Ob Gyn

Braxton-Hicks Contractions

Braxton Hicks contractions are characterized as short in duration, less intense than true labor, and the discomfort as being in the lower abdomen and groin areas. True labor is defined by strong, regular uterine contractions that result in progressive cervical dilation and effacement. This patient's history does not suggest she is in the first stage of labor. Patients with appendicitis usually present with fever, decreased appetite, nausea and vomiting. Gestational diabetes is diagnosed based on glucose challenge tests. The first test with a 50 gram load is typically performed at 24-28 weeks gestation. It is not abnormal for patients to have glucosuria. This finding is not diagnostic for gestational diabetes. Patients with dehydration frequently present with maternal tachycardia and have ketonuria.

What is normal uterine activity

With an IUPC in place, quantitative data can be measured, most commonly using Montevideo units (MVU). A Montevideo Unit is the sum of the intensity of each contraction in a 10 minute period (in mmHG). Adequate uterine activity is defined as a contraction pattern that generates greater than 200 MVUs.

Screening in HIV + patient

Yearly pap smear (twice in 1st year of diagnosis) CD4 cell count 3-6 m (12m if stable) BP yearly Fasting glucose every 6-12m Fasting lipids every 6-12m AA screen once in men 65-75 who ever smoked Depression annually, Cognition annual Colonoscopy at 50 Syphilis, Chlamydia, Gonorrhea, Trichomonas serology annually for sexually active

Retained Placenta RF: preterm labor placenta accreta

>30 min in Stage 3 labor

APGAR

Activity Active, Arms/legs flexed, none Pulse Over 100, less than 100, none Grimace Sneeze pull cough, Grimace, none Appearance Pink all over, pink w/ blue extrem, blue Resp Good/crying, slow irreg, none

Breast development is Tanner stage 1, and axillary and pubic hair development are Tanner stage 3. Dark facial hair + Acne. Short vaginal canal, significant clitoromegaly, posterior labioscrotal fusion, and no cervix or palpable uterus. - US shows bilateral gonads without follicles; there is no uterus.

Androgen insensitivity

Genetics

Autodominant Auto-recessive X-linked recessive X-linked dominant

Forceps Delivery -higher rates of 3rd and 4th degree perineal lacs

Conditions required: -full dialated cervix -engaged head at +2 station -absolute knowledge of fetal position - no CPD -adequate anesthesia - empty bladder Complications: bruising, laceration to fetal head cervix vagina, perineum, facial nerve palsy, skull fracture or intracranial damage

ROM --> fetal bradycardia

CHECK MEMBRANE STATUS WITH SPECULUM / PELVIC EXAM, NOT DIGITAL EXAM

Screening for sickle cell = Electrophoresis

Screening for carriers of both alpha and beta thalassemia is possible by evaluation of red cell indices. Although solubility tests for hemoglobin S or sickle cell preparations can be used for screening, hemoglobin electrophoresis is definitive and preferable because other hemoglobinopathies can also be detected including hemoglobin C trait and thalassemia minor.

Women G3P2 w/ Type 2 diabetes at 38 weeks, the cervix is 2cm dialated, membranes are intact, fundal height 42 cm, 4hrs after admission the cervix is completely dialated and the vertix is occiput anterior at -1 station. Over next hr contractions occur at 2 min, last 60 s, and are 60mm Hg in insensity but cervix and station remain unchanged. FHT are normal and reactive. 1 hr later her condition is unchanged why?

Cephalopelvic disporportion Contraction of outlet fetal malposition Hypotonic uterine activity shoulder dystocia

Disruptions

Deformations - fetal structural anomalies due to EXTRINSIC MECHANICAL FORCES Disruptions - secondary breakdown of previously normal structure ( amniotic band syndrome--> compression amputation) Malformation: primary defect in cells or tissues that form an organ (intrinsic developmental abnormality ) like Holoprosencephaly

Fetal Injuries NTRACRANIAL HEMORRHAGE — Intracranial hemorrhages (ICH) as a consequence of birth injury include subdural, subarachnoid, epidural, intraventricular hemorrhages, and less frequently, intracerebral and intracerebellar hemorrhages (table 3). The risk of ICH increases with operative delivery, as shown by the reported incidences per 10,000 deliveries of intracranial hemorrhage of 3.7, 17, and 16.2 for unassisted, forceps-assisted, or vacuum-assisted delivery, respectively (table 2) [2]. This may be an underestimation as illustrated by a reported incidence of intracranial hemorrhages of 26 percent in spontaneous vaginal birth in a prospective study of neonatal brain development that screened asymptomatic neonates by magnetic resonance imaging (MRI) [29]. Subdural hemorrhage — Although the overall incidence is rare, subdural hemorrhage (SDH), or hematoma, is the most common type of intracranial hemorrhage noted in neonates. SDH forms between the dura mater and subarachnoid membrane (figure 1). In one study based upon a California database of 583,340 live-born singleton infants born to nulliparous women between 1992 and 1994, the reported incidences per 10,000 deliveries were 2.9, 8, and 9.8 for spontaneous unassisted vaginal, vacuum-assisted, and forceps-assisted deliveries, respectively [30]. As would be expected, the sequential use of vacuum and forceps increased the risk to 21.3 per 10,000 deliveries [30]. The location of SDH is most often tentorial and/or interhemispheric, and is best diagnosed by computed tomography (CT) of the head [31]. The diagnosis may be made incidentally in asymptomatic neonates [29,32]. Symptomatic infants usually present within the first 24 to 48 hours of life. Presenting symptoms or findings generally include respiratory depression, apnea, and/or seizures [31,33]. Other symptoms include signs of neurologic dysfunction such as irritability and altered tone and level of consciousness. Rarely, SDH is associated with increased intracranial pressure resulting in an increase in head circumference, tense fontanelle, apnea, bradycardia, and coma. The management of SDH depends upon the location and extent of the bleed. Most cases can be managed with conservative therapy without surgical intervention. This is likely due to the plasticity of the neonatal skull, which allows for some degree of expansion without development of increased intracranial pressure [33]. Surgical evacuation is necessary for infants with SDH and signs of increased intracranial pressure. SDH that occurs in the posterior fossa, an area of the brain with less skull plasticity, may cause brainstem compression that requires emergent surgical evacuation. Serial hematocrits should be performed to assess for ongoing blood loss. In patients with significant blood loss resulting in signs of hypovolemia, normal saline is initially administered for volume replacement, followed by whole blood transfusion. Investigation of a congenital coagulopathy should be considered for infants with an extensive SDH in the absence of overt birth trauma. Seizure disorders should be treated with antiepileptic drug therapy (AED). We prefer to use phenobarbital (loading odes of 20 mg/kg) as the initial AED. (See "Treatment of neonatal seizures".) Subarachnoid hemorrhage — Subarachnoid hemorrhage (SAH) represents the second most commonly detected neonatal intracranial hemorrhage. It is most often caused by rupture of bridging veins in the subarachnoid space or small leptomeningeal vessels. Although SAH can occur with normal, spontaneous vaginal deliveries [29,31], the risk of SAH is higher with operative vaginal deliveries, with reported incidences per 10,000 deliveries of 1.3, 2.3, 3.3, and 10.7 for spontaneous, vacuum-assisted, forceps-assisted, and combined vacuum- and forceps-assisted vaginal deliveries, respectively (table 3) [30]. As with subdural hemorrhage, newborns with SAH most often present at 24 to 48 hours of life with apnea, respiratory depression, and seizures [34]. The diagnosis is made by CT of the head. Treatment is usually conservative. Rarely, a large SAH can cause posthemorrhagic hydrocephalus. Epidural hemorrhage — Epidural hemorrhage (EDH) is very rare in neonates and is found between the dura and inner table of the skull (figure 1). Usually caused by injury to the middle meningeal artery, the rarity of neonatal EDH is attributed to the absence of the middle meningeal artery groove in the neonatal cranial bones, thus making it more difficult to injure the artery. EDH is often accompanied by a linear skull fracture, and is usually located in the parietotemporal area. Like the other types of intracranial birth injuries, EDH is often associated with operative deliveries and primiparous mothers [35]. EDH and cephalohematoma can coexist when accompanied by an underlying skull fracture due to communication through the skull fracture (figure 1) [36]. Neonates with EDH present with nonspecific neurologic symptoms, such as seizures and hypotonia. Increased intracranial pressure may develop and is manifested as a bulging fontanelle, changes in vital signs, and level of consciousness. The diagnosis of EDH is made by CT or MRI of the head, which may differentiate it from subdural hemorrhage. This condition has the potential to deteriorate quickly because of the arterial source of bleeding. As a result, frequent serial studies are required, and the infant should be followed closely with neurosurgery. Patients with very small lesions and a stable clinical course may be managed with supportive therapy. Surgical evacuation is necessary when there is evidence of increased intracranial pressure and/or the EDH is large. In one case series, surgical treatment was reserved for infants with large hematomas (greater than 1 cm thick and 4 cm long), depressed skull fractures, hydrocephalus, and/or shifting of the brain parenchyma [35]. When accompanied by a cephalohematoma, needle aspiration of the cephalohematoma may result in the resolution of the EDH [37]. Intraventricular hemorrhage — Although intraventricular hemorrhage (IVH) is usually associated with premature delivery, IVH is also reported as a consequence of birth injury in term infants. In a study of 505 healthy asymptomatic term infants who underwent head ultrasonography within 72 hours of life, the incidence of IVH was 4 percent [38]. All the hemorrhages were subependymal in location (grade 1 IVH). The risk of IVH increases with operative deliveries, with reported incidences per 10,000 deliveries of 1.1, 1.5, 2.6, and 3.7 for spontaneous, vacuum-assisted, forceps-assisted, and combined vacuum- and forceps-assisted deliveries, respectively (table 3) [30]. In the absence of a clotting disorder or severe asphyxia, most IVH in term infants will resolve spontaneously with no long-term sequelae. For infants with IVH due to significant birth trauma, close monitoring is required due to the risk of extension of the hemorrhage into the surrounding parenchyma and the development of post-hemorrhagic hydrocephalus. (See "Clinical manifestations and diagnosis of intraventricular hemorrhage in the newborn".) FRACTURES Clavicle — Clavicular fractures are the most commonly reported fractures in neonates (image 2). Based upon data from large case series, the incidence of clavicle fractures due to birth trauma ranges from 0.5 to 1.6 percent [39-41]. Fractured clavicles are often associated with difficult vaginal delivery; however, clavicular fractures also occur in infants who are products of a normal spontaneous vaginal or cesarean delivery.

EXTRACRANIAL INJURIES — Extracranial injuries occur during delivery and are due to edema or bleeding into various locations within the scalp and skull (figure 1). Caput succedaneum — Caput succedaneum is an edematous swelling of the scalp above the periosteum, which is occasionally hemorrhagic (figure 1). It presents at birth after prolonged engagement of the fetal head in the birth canal or after vacuum extraction. Unlike cephalohematoma, it extends across the suture lines. Caput succedaneum is generally a benign condition, and it usually resolves within a few days and requires no treatment. There are reported complications in infants with caput succedaneum that include necrotic lesions resulting in long-term scarring and alopecia [13]. Halo scalp ring is an annular alopecic ring that occurs in infants after a prolonged or difficult labor due to compression from the bony prominence of the maternal pelvis. [14]. Rarely, systemic infection may occur as a complication of an infected caput succedaneum [15]. Cephalohematoma — Cephalohematoma is a subperiosteal collection of blood caused by rupture of vessels beneath the periosteum (usually over the parietal or occipital bone), which presents as swelling that does not cross suture lines (figure 1). The swelling may or may not be accompanied by discoloration, rarely expands after delivery, and does not generally cause significant blood loss. Cephalohematoma is estimated to occur in 1 to 2 percent of all deliveries and is much more common when forceps or vacuum delivery is performed (table 2). (See "Operative vaginal delivery", section on 'Risks'.) The majority of cephalohematomas will resolve spontaneously over the course of a few weeks without any intervention. However, calcification of the hematoma can occur with a subsequent bony swelling that may persist for months. Significant deformities of the skull may occur when calcification or ossification of the cephalohematoma occurs (image 1). Case reports have demonstrated successful surgical excision of these calcified or ossified hematomas [16,17]. Other complications of cephalohematoma include infection and sepsis, with Escherichia coli being the most commonly reported causative agent. Infected cephalohematomas present as erythematous, fluctuant masses that may have expanded from their baseline size. Imaging with computed tomography (CT) or magnetic resonance imaging (MRI) is helpful in making the diagnosis. Needle aspiration and culture of the hematoma are considered to be mandatory for suspected cases [18]. Osteomyelitis is a reported complication of an infected cephalohematoma [19]. In these affected infants, treatment includes incision and drainage of the abscess with debridement of the necrotic skull, and a prolonged course of parenteral antibiotics (eg, vancomycin, gentamicin, and cefotaxime). Subgaleal hemorrhage — Subgaleal hemorrhage (SGH) develops when blood accumulates in the loose areolar tissue in the space between the periosteum of the skull and the aponeurosis (figure 1). The injury occurs when the emissary veins between the scalp and dural sinuses are sheared or severed as a result of traction on the scalp during delivery. The incidence of SGH has been estimated to occur in 4 of 10,000 spontaneous vaginal deliveries and 59 of 10,000 vacuum-assisted deliveries [20]. The potential for massive blood loss (20 to 40 percent of a neonate's blood volume resulting in a loss of 50 to 100 mL [21]) into the subgaleal space contributes to the high mortality rate associated with this lesion. The subgaleal space extends from the orbital ridges anteriorly to the nape of the neck posteriorly and to the level of the ears laterally. In infants with SGH, the reported mortality is about 12 to 14 percent [22,23]. Infants who died had massive volume loss resulting in shock and coagulopathy [23]. SGH presents as a diffuse, fluctuant swelling of the head that may shift with movement. Expansion of the swelling due to continued bleeding may occur hours to days after delivery. Affected neonates may have tachycardia and pallor due to blood loss, although blood loss may be massive before signs of hypovolemia become apparent. Early recognition of this injury is crucial for survival [24]. Infants who have experienced a difficult operative delivery or are suspected to have a SGH require ongoing monitoring including frequent vital signs (minimally every hour), and serial measurements of hematocrits and their occipital frontal circumference, which increases 1 cm with each 40 mL of blood deposited into the subgaleal space. Head imaging, using either CT or MRI, can be useful in differentiating subgaleal hemorrhage from other cranial pathologic conditions. Coagulation studies are required to detect coagulopathy that may be associated with the bleeding. Treatment includes volume resuscitation with packed red blood cells, fresh frozen plasma, and normal saline as appropriate for ongoing bleeding and coagulopathy correction. Rarely has brain compression been reported that required surgical evacuation of the hematoma.

Types of Birth Control Combination including suppression of hypothalamic gonadotropin-releasing hormone (GnRH) and pituitary gonadotropin secretion. The most important mechanism for providing contraception is inhibition of the midcycle luteinizing hormone (LH) surge, so that ovulation does not occur Another mechanism of contraceptive action is suppression of ovarian folliculogenesis (via suppression of pituitary follicle-stimulating hormone [FSH] secretion) -use back up for 1st month Contraindicated in: ●Age ≥35 years and smoking ≥15 cigarettes per day ●Multiple risk factors for arterial cardiovascular disease (such as older age, smoking, diabetes, and hypertension) ●Hypertension (systolic ≥160 mmHg or diastolic ≥100 mmHg) ●Venous thromboembolism ●Known thrombogenic mutations ●Known ischemic heart disease ●History of stroke ●Complicated valvular heart disease (pulmonary hypertension, risk for atrial fibrillation, history of subacute bacterial endocarditis) ●Systemic lupus erythematosus (positive or unknown antiphospholipid antibodies) ●Migraine with aura at any age ●Breast cancer ●Cirrhosis ●Hepatocellular adenoma or malignant hepatoma DRUG INTERACTIONS — The metabolism of oral contraceptives (OCs) is accelerated by any drug that increases liver microsomal enzyme activity such as phenobarbital, phenytoin, griseofulvin, and rifampin. As a result, the contraceptive efficacy of an OC is likely to be decreased in women taking these drug Antibiotics - Rifampin is the only antibiotic proven to decrease serum ethinyl estradiol and progestin levels in women taking OCs Menstrual cramps and premenstrual symptoms appear to be decreased with continuous, compared with cyclic, regimens [82]. Thus, women choosing extended-cycle regimens should be aware of potential breakthrough bleeding in early cycles, but they should be reassured that this decreases over time and does not represent a decrease in contraceptive efficacy. The patient should be reassured since initially after Depo-Provera injection there may be unpredictable bleeding. This usually resolves in 2-3 months. In general, after oone year of using Depo-Provera, nearly 50% of users have amenorrhea. Ex: LMP 14 days. Had sex last night. Wants contraception. Ans = Provide emergency contraception, then begin oral contraceptives immediately. Emergency contraceptive pills are not an abortifacient, and they have not been shown to cause any teratogenic effect if inadvertently administered during pregnancy. They are more effective the sooner they are taken after unprotected intercourse, and it is recommended that they be started within 72 hours, and no later than 120 hours. Plan B, the levonorgestrel pills, can be taken in one or two doses and cause few side effects. Emergency contraceptive pills may be used anytime during a woman's cycle, but may impact the next cycle, which can be earlier or later with bleeding ranging from light, to normal, to heavy. Ideal candidates for progestin-only pills include women who have contraindications to using combined oral contraceptives (estrogen and progestin containing). Contraindications to estrogen include a history of thromboembolic disease, women who are lactating, women over age 35 who smoke or women who develop severe nausea with combined oral contraceptive pills. Progestins should be used with caution in women with a history of depression. Tubal ligation has not been shown to reduce the risk of breast, cervical, or endometrial cancers, nor is there a decrease in menstrual blood flow in women who have undergone a tubal ligation. There is a slight reduction in the risk of ovarian cancer, but the mechanism is not yet fully understood. Approximately 10% of women who have been sterilized regret having had the procedure with the strongest predictor of regret being undergoing the procedure at a young age. Fat asthmatic woman...whats her best permanent contraception? Husband vasectomy. Both vasectomy and tubal ligation are 99.8% effective. Vasectomies are performed as an outpatient procedure under local anesthesia, while tubal ligations are typically performed in the operating room under regional or general anesthesia; therefore carrying slightly more risk to the woman, assuming both are healthy. She is morbidly obese, so the risk of anesthesia and surgery are increased. In addition, she has chronic medical problems that put her at increased risk of having complications from surgery. The levonorgestrel intrauterine device has lower failure rates within the first year of use than does the copper containing intrauterine device. It causes more disruption in menstrual bleeding, especially during the first few months of use, although the overall volume of bleeding is decreased long-term and many women become amenorrheic. The levonorgestrel intrauterine device is protective against endometrial cancer due to release of progestin in the endometrial cavity. She is not a candidate for oral contraceptive pills because of her poorly controlled chronic hypertension. The progestin only pills have a much higher failure rate than the progesterone intrauterine device. She is not a candidate for the copper-containing intrauterine device because of her history of Wilson's disease. 20yr BMI is 29 Long-acting reversible contraceptives (LARC) methods such as contraceptive implants and intrauterine devices are a good option for this patient. Despite high up-front costs and the need for office visits for insertion and removal, LARC methods provide many distinct advantages over other contraceptive methods as Depo-Provera and oral contraceptives. While Depo-Provera is an effective form of contraception, it may not be the best choice in this woman with a high BMI. For this young mother who desires a reversible, but reliable form of contraception, the high effectiveness, continuation rate and user satisfaction of LARC methods would be of most benefit.

IUDs Candidates for intrauterine contraception — Ideal candidates for intrauterine contraception are women who: ●Desire one of the most effective methods of contraception; ●Are at low risk of acquiring sexually transmitted infections, since such infections may require removal of the IUD; ●Are not planning a pregnancy for at least one year, since attempting pregnancy also requires removal of the IUD; ●Want to use a reversible contraceptive; ●Want or need to avoid estrogen-based methods. Possible mechanisms of action of intrauterine devices Changes in cervical mucus that inhibit sperm transport (eg, increased copper concentration, thickening, glandular atrophy or decidualization) Chronic inflammatory changes of the endometrium and fallopian tubes, which have spermicidal effects and inhibit fertilization and implantation Thinning and glandular atrophy of the endometrium, which inhibits implantation Direct ovicidal effects CI to IUD: Wilsons or Copper allergy, Pregnant, PID, unknown DUB TCu380A (copper) IUD — The TCu380A (Paragard) The device is latex-free and clinically relevant allergy to copper is extremely rare approved to remain in place for 10 years (proper usage .5% risk of pregnancy) Copper IUD The free copper and copper salts released by in utero oxidation of copper-containing IUDs enhance the cytotoxic inflammatory reaction within the endometrium (eg, local prostaglandin production is increased), which is toxic to sperm and ova. In vitro, copper interferes with sperm migration, viability, and acrosomal reaction [28]. Postfertilization effects also appear to contribute as a secondary contraceptive mechanism Depot medroxyprogesterone Diaphragm *Norethindrone pills (Only Progestin pill available)* Progestin-only contraceptive pills (POPs) work by thickening cervical mucus, suppressing ovulation, and thinning the endometrium. In contrast to estrogen-progestin oral contraceptive pills and desogestrel POPs, ovulation is not consistently suppressed with norethindrone POPs - POPs are a good option for women in whom an estrogen-containing contraceptive is either contraindicated or causes additional health concerns (eg, migraine with aura, ≥35 years of age and smoking ≥15 cigarettes/day) We suggest that POPs be initiated on the first day of menses; back-up contraceptive is not necessary if POPs are started within the first five days of start of menses . Because of the short duration of action and the short half-life of POPs, it is essential that the pill be taken at the same time each day to maximize contraceptive efficacy A back-up contraceptive (eg, condoms) should be used or the woman should abstain from sex for at least two days if the POP is taken more than three hours late or missed on any given day. Unscheduled bleeding and changes in menses are the most common side effects associated with progestin-only contraceptive pills (POPs); an increased prevalence of follicular cysts [18] and acne flare -PoPs represent a reasonable contraceptive choice for women at high risk of, or known, coronary artery disease, cerebrovascular disease, venous thromboembolic disease, hypertension, or other conditions in which use of contraceptive doses of estrogen are contraindicated Progesterone IUD Triphasic oral contraceptives (type of Combined OCP) Triphasic preparations contain varying doses of progestin or estrogen plus progestin across the 21 days. One multiphasic preparation is an "estrophasic" OC (Estrostep) that contains a fixed dose of norethindrone acetate (1 mg) and a gradually increasing dose of ethinyl estradiol (20 mcg on cycle days 1 to 5, 30 mcg on days 6 to 12, and 35 mcg on days 13 to 21) in an effort to minimize estrogen-related side effects Oral contraceptives will decrease a woman's risk of developing ovarian and endometrial cancer. The earlier, higher dose oral contraceptive pills have been linked to a slight increase in breast cancer, but not the most recent lower dose pills. Women who use oral contraceptive pills have a slightly higher risk of developing cervical intraepithelial neoplasia, but their risk of developing PID, endometriosis, benign breast changes and ectopic pregnancy are reduced. Both hypertension and thromboembolic disorders can be a potential side effect from using oral contraceptive pills. Progestin Androgenic levels --High-- Norgestrel Levonorgestrel --Middle-- Norethindrone Norethindrone acetate --Low-- Ethynodiol Norgestimate Desogestrel Drospirenone Dienogest The patch is a transdermal system that is placed on a woman's upper arm or torso (except breasts). The patch (Ortho Evra) slowly releases ethinyl estradiol and norelgestromin, which establishes steady serum levels for seven days. A woman should apply one patch in a different area each week for three weeks, then have a patch-free week, during which time she will have a withdrawal bleed. PATCHES FAIL IN FATTYS

ashsenki jews

Fanconi anemia, Tay-Sachs disease, Cystic Fibrosis, and Niemann-Pick disease are all autosomal recessive conditions that occur at an increased incidence in Jews of Ashkenazi descent.

Shoulder Dystocia

Fetal macrosomia, maternal obesity, diabetes mellitus, postterm pregnancy, a prior delivery complicated by a shoulder dystocia, and a prolonged second stage of labor are all associated with an increased incidence of shoulder dystocia. Although a family history can be indicative of large babies which might place her at additional risk, her gestational diabetes represents her largest risk factor.

ITP Primary ITP - Primary ITP is acquired thrombocytopenia due to autoimmune platelet destruction, not triggered by an associated condition. Secondary ITP - Secondary ITP is ITP associated with another condition (eg, human immunodeficiency virus [HIV], hepatitis C virus [HCV], systemic lupus erythematosus [SLE], chronic lymphocytic leukemia [CLL]). By convention, the associated condition is noted in parenthesis, as in "secondary ITP (lupus-associated)." we suggest that children with moderate or severe thrombocytopenia (eg, platelet count <30,000/microL) avoid contact and collision sports (such as football, boxing, lacrosse, and hockey), and also consider restricting activities that have a significant risk for traumatic injury (such as baseball, squash, skiing, or gymnastics

For all patients with severe bleeding (eg, intracranial, gastrointestinal) and a platelet count <30,000/microL, we recommend immediate platelet transfusion along with ITP-specific therapy with intravenous immune globulin (IVIG) and glucocorticoids For patients who require therapy, we suggest glucocorticoids rather than IVIG For Children: NO pharmacologic intervention ("watchful waiting") for most children with no bleeding or mild bleeding (defined as skin manifestations only, such as bruising and petechiae), regardless of platelet count. The main options for initial pharmacologic intervention include glucocorticoids, intravenous immunoglobulin (IVIG), or intravenous anti-D immune globulin (anti-D, also known as anti-Rho immune globulin) IVIG toxicity side effects include headache (can be severe, eg, aseptic meningitis); nausea, vomiting, fever, chills, body aches. These side effects can be minimized by prolonged infusion time and premedicationΔ (see topic text). Transient neutropenia also may occur Corticosteroid toxicity Behavioral change, sleep disturbance, hypertension, impaired glucose tolerance. Increased appetite and weight gain; osteopenia and growth failure with prolonged usage. Rituixmab for chronic ITP Urticarial rash, headache, fever, and chills (mild and transient). Serum sickness in up to 10 percent of children

Donovonosis Calymmatobacterium granulomatis

Haemophilus Ducreyi

Question w/ woman Boggy Enlarged Uterus Hyperthyroid symptoms peri-menopausal age no period in last 4 years

Hydatidiform Mole -test B-hcg this was attempted to come off as hyperthyroidism

Kallmann Syndrome

Kallmann syndrome is characterized by olfactory tract hypoplasia and the arcuate nucleus does not secrete GnRH. Therefore, these females have no sense of smell and do not develop secondary sexual characteristics. The diagnosis is often one of exclusion found during the workup of delayed puberty. The presence of anosmia with delayed puberty should suggest Kallmann syndrome. Treatment is pulsatile GnRH therapy.

Preventative medicine

Lipid Screen

Mullerian Agenesis vs Congential Uterine Abnormalities

MA: Mayer-Rokitansky-Küster-Hauser syndrome failure of the Müllerian duct to develop, resulting in a missing uterus and variable degrees of vaginal hypoplasia of its upper portion Congential Uterine Abnormalities

Klein-Waardenburg Syndrome -pax 3 gene mutation

Major: sensorineural hearing loss iris pigmentary abnormality ( heterochromia iridum- different colors of iris in two eyes or heterochromia iridis - two different colors of iris in same eye or characteristic brilliant blue iris) hair hypopigmentation (white forelock or white hairs at other sites on the body) (poliosis) dystopia canthorum (lateral displacement of inner canthi) first‐degree relative previously diagnosed with Waardenburg syndrome Minor: skin hypopigmentation (congenital leukoderma/white skin patches - Vitiligo ) medial eyebrow flare (synophrys) broad nasal root (dystopia canthorum) hypoplasia alae nasi premature graying of the hair (before age 30

Acute Thyroid Storm tx

acute treatment of thyroid storm may include thioamides (i.e. PTU), propranolol, sodium iodide and dexamethasone. Oxygen, digitalis, antipyretics and fluid replacement may also be indicated. Maternal mortality with thyroid storm exceeds 25%.

Elevated Maternal AFP

Multigestation, neural tube defects, pilonidal cysts, cystic hygroma, sacrococcygeal teratoma, fetal abdominal wall defects, and fetal death.

Woman comes in with no prenatal care. blood pressure of 170/105 and 3+ proteinuria. Fundal height is 28 cm. FHR Tachysystole (170 bpm) on tocometer and evidence of fetal anemia (tachycardia and sinusoidal heart rate pattern) on the heart rate tracing. She has Hypertension and preeclampsia. Active labor.

Placental Abruptio

Breech Presentation

Prematurity, multiple gestation, genetic disorders, polyhydramnios, hydrocephaly, anencephaly, placenta previa, uterine anomalies and uterine fibroids are all associated with breech presentation -if you feel a body part its the buttocks

Contraindication to induction

Prior classic or high risk c-section prior uterine rupture prior transmural uterine incision active gential herpes placenta previa vasa previa umbilical cord prolapse persistant funic presentation transverse fetal lie invasive cervical cancer Cat 3 fetal heart rate tracing

Nonreassuring Fetal Status

Repetitive Late Decels Bradycardias Loss of Variability Tx: O2, turned onto left side to decrease IVC compression and increase uterine perfusion, DC oxytocin until reassured if prolonged decel due to hypertonus (single contraction over 2 min) or Tachysystole (greater than 5 contractions in 10min peroid) the patient can be given a dose of terbutaline to help relax the uterus.

Ruptured ovarian cyst

Rupture of an ovarian cyst is often accompanied by sonographic evidence of hematoperitoneum or free fluid in the pelvis

PPROM -BEWARE that infection is number 1 risk factor! A history of PPROM in a previous pregnancy, genital tract infection, antepartum bleeding, and cigarette smoking have a particularly strong association with PPROM Same RF as preterm birth Risk factors for preterm birth No partner Low socioeconomic status Anxiety Depression Life events (divorce, separation, death) Abdominal surgery during pregnancy Occupational issues (upright posture, use of industrial machines, physical exertion, mental or environmental stress related to work or working conditions) Multiple gestation Polyhydramnios Uterine anomaly, including diethylstilbestrol-induced changes in uterus and leiomyomas Preterm premature rupture of membranes History of second trimester abortion History of cervical surgery Premature cervical dilatation or effacement (short cervical length) Sexually transmitted infections Systemic infection, pyelonephritis, appendicitis, pneumonia Bacteriuria Periodontal disease Placenta previa Placental abruption Vaginal bleeding, especially in more than one trimester Previous preterm delivery Substance abuse Smoking Maternal age (<18 or >40) African-American race Poor nutrition and low body mass index Inadequate prenatal care Anemia (hemoglobin <10 g/dL) Excessive uterine contractility Low level of educational achievement Maternal first degree family history of spontaneous preterm birth, especially if the pregnant woman herself was born preterm Fetal anomaly Fetal growth restriction Environmental factors (eg, heat, air pollution) As a general rule, tocolytics should not be administered for more than 48 hours. They also should not be administered to patients who are in advanced labor (>4 cm dilation) or who have any findings suggestive of subclinical or overt chorioamnionitis. A course of antenatal corticosteroids consists of betamethasone suspension 12 mg intramuscularly every 24 hours for two doses or four doses of 6 mg dexamethasone intramuscularly 12 hours apart Methods to confirm rupture of membranes include testing the vaginal fluid for ferning and nitrazine testing. It is important to test the fluid from the vagina and not to test cervical mucus because of false positive ferning patterns While the role of tocolysis in the setting of preterm rupture of membranes is controversial, it may be appropriate in limited settings (before 34 weeks). Tocolysis may be administered in an attempt to prolong the interval to delivery to gain time for steroids to obtain maximum benefit for the fetus. The risks of chorioamnionitis with continuing tocolytics beyond 48 hours outweighs the benefit of awaiting lung maturity. Most authors agree that the achievement of fetal lung maturity (i.e. positive phosphatidylglycerol or 34 weeks gestational age) is the threshold at which the risk of morbidity and mortality of maintaining the pregnancy in utero outweighs the benefits of prolonging the pregnancy. In some cases of preterm rupture of the membranes, amniocentesis may be performed to detect intra-amniotic infection. look for Low glucose (under 20) High IL-6 High WBC (but this has a poor predictive value) Example: Pt at 36 w has PPROM - and is not having contractions, you do not wait, you INDUCE!

Sterile speculum examination is done to verify PROM, estimate cervical dilation, collect amniotic fluid for fetal maturity tests, and obtain samples for cervical cultures. NOT DIGITIAL. Digital pelvic examination, particularly multiple examinations, increases risk of infection and is best avoided unless imminent delivery is anticipated Patient presentation — The classic clinical presentation of PPROM is a sudden "gush" of clear or pale yellow fluid from the vagina. However, many women describe intermittent or constant leaking of small amounts of fluid or just a sensation of wetness within the vagina or on the perineum. Findings on physical examination — Direct observation of amniotic fluid coming out of the cervical canal or pooling in the vaginal fornix is pathognomonic of PPROM. If amniotic fluid is not immediately visible, the woman can be asked to push on her fundus, Valsalva, or cough to provoke leakage of amniotic fluid from the cervical os. For patients who are not in active labor, examination of the cervix and vagina is performed using a sterile speculum. Digital examination should be avoided because it may decrease the latency period (ie, time from rupture of membranes to delivery) and increase the risk of intrauterine infection -Nitrazine paper. Amniotic fluid usually has a pH range of 7.0 to 7.3 compared to the normally acidic vaginal pH of 3.8 to 4.2 -Fluid from the posterior vaginal fornix is swabbed onto a glass slide and allowed to dry for at least 10 minutes. Amniotic fluid produces a delicate ferning pattern Expeditious delivery of women with PPROM is clinically appropriate if intrauterine infection, abruptio placentae, nonreassuring fetal testing, or a high risk of cord prolapse is present or suspected 23-34 weeks (delivery at 34 w after checking lung maturity) Step 1: Admit to L and D, Confirm w/ Pooling, Nitazine, Ultrasound Stable Maternal and Fetal Sstatus, hospitialize until delivery. (Corticosteroids, 7 days of ampicillin -->amoxicillin and 1 dose of azithromyocin) [if low allergic cefazolin or clindamyacin if high] We hospitalize women with PPROM who have a viable fetus from the time of diagnosis until delivery, with few exceptions. Activity is limited to using the bathroom and sitting up in a bedside chair. Thromboprophylaxis should be considered for all hospitalized pregnant women at bedrest Diagnosis and treatment of overt infection — Overt chorioamnionitis is usually easily diagnosed clinically because of maternal fever, particularly when associated with leukocytosis, maternal and fetal tachycardia, uterine tenderness, and/or malodorous amniotic fluid. Diagnosis of subclinical chorioamnionitis requires amniocentesis to identify microorganisms in the amniotic fluid (gram stain and culture) and document an abnormally low amniotic fluid glucose concentration. A rapid test for interleukin-6 (IL-6), which is perhaps the most sensitive marker for microbial invasion of the amniotic cavity, is available in some countries The time from premature rupture of membranes to labor is inversely related to gestational age. At term, 90% will spontaneously go into labor within 24 hours of PROM. At 28 weeks to 34 weeks, 50% will go into labor within 24 hours and 80% within 48 hours Best way to delay delivery in PPROM? Antibiotic therapy given to patients with preterm premature rupture of the membranes has been found to prolong the latency period by 5-7 days, as well as reduce the incidence of maternal amnionitis and neonatal sepsis. Corticosteroids (betamethasone) and tocolytics may also prolong the pregnancy for various lengths of time, but generally not seven days. Complications that may be found in the developing fetus in PPROM include structural abnormalities that are primarily deformations (abnormalities that occur due to an insult after a structure has already formed) rather than malformations (abnormal development of the structure itself). Pulmonary hypoplasia is seen when rupture of membranes occurs before 25 weeks gestation because the lack of amniotic fluid interferes with the normal intrauterine breathing process. The result is failure of normal development and growth of the respiratory tree.

Antiphospholipid Syndrome

Tx aspirin and heparin?

Overflow Incontinence -can present with dribbling and sx of stress + urge incontinence

UNDERACTIVE or ACONTRACTILE BLADDER BLADDER OUTLET OBSTRUCTION ASENSITILE BLADDER Tx: -reduce urethral closing pressure (prazosin, terazosin, phenoxybenzamine) -decrease straited muscle tone to reduce bladder outlet resistance (diazepam, dantrolene) -increase contractility of bladder (cholinergics - bethanecol)

Post-term Pregnancy ●Nulliparity ●Male fetus ●Maternal obesity ●Older maternal age ●Maternal or paternal personal history of postterm birth ●Maternal race/ethnicity (African-American women, Latina, and Asian women are at lower risk than Caucasians) Fetal and neonatal risks — Postterm fetuses tend to be larger than term fetuses, with a higher incidence of macrosomia (≥4500 g) In contrast, up to 20 percent of postterm fetuses have "fetal dysmaturity (postmaturity) syndrome," a term used to describe infants with characteristics of chronic intrauterine malnutrition [32-34]. These fetuses are at increased risk of umbilical cord compression due to oligohydramnios, and nonreassuring antepartum or intrapartum fetal heart rate patterns due to placental insufficiency or cord compression. Meconium passage is common and may be related to physiological maturation of the gut or fetal hypoxia. Neonates have a long thin body, long nails, and are small for gestational age. Their skin is dry (vernix caseosa is decreased or absent), meconium stained, parchment-like, and peeling; it appears loose, especially over the thighs and buttocks, and has prominent creases; lanugo hair is sparse or absent, while scalp hair is increased. These fetuses/neonates are at risk for the short- and long-term morbidity typically seen in intrauterine growth restriction/small for gestational age infants Postterm pregnancies are associated with placental sulfatase deficiency, fetal adrenal hypoplasia, anencephaly, inaccurate or unknown dates and extrauterine pregnancy Postterm pregnancies are associated with macrosomia, oligohydramnios, meconium aspiration, uteroplacental insufficiency and dysmaturity. Although postterm infants are larger than term infants and have an increased incidence of fetal macrosomia, there is no evidence to support induction of labor as a preventive measure for macrosomia in these cases. There is no associated risk for preeclampsia in postterm gestations. Optimal management for the patient with a favorable cervix at greater than or equal to 41 weeks gestation is delivery. Her dilation and effacement make it likely her induction will be successful. Induction of labor in a patient with an unfavorable cervix increases the risk of Cesarean section significantly, compared to a patient who goes into spontaneous labor. It is not advisable to follow a patient who is >42 weeks with antepartum fetal testing, such as twice weekly non-stress tests with amniotic fluid index, if the gestational age is certain. daughter's skin appears to be peeling and has a green/yellow hue, and her fingernails are very long. Overall both parents are concerned, as the baby appears to be thin and fragile = FETAL DYSMATURITY dysmaturity approaches 10% when the gestational age exceeds 43 weeks. Infants are described as withered, meconium stained, long-nailed, fragile and have an associated small placenta. These infants are at great risk for stillbirth. The diagnosis of dysmaturity is more common in women with unknown last menstrual periods and unsure dating. While low birth weight is a common finding in infants with Trisomy 18, overlapping fingers, micronathia, and cardiac defects are the most common findings. Trisomy 21 can be associated with low birth weight, but the syndrome is characterized by a constellation of facial findings (low set ears, flattened bridge of the nose, and almond shaped eyes) and nearly 50% are associated with cardiac defects

We favor induction of well-dated postterm pregnancies at or shortly after 410/7ths weeks of gestation, irrespective of cervical status We utilize cervical ripening agents in women with unfavorable cervices. In women wishing to avoid pharmacologic agents for cervical ripening and induction, membrane sweeping (also called stripping) can be performed if the cervix is sufficiently dilated, and reduces the proportion of patients who remain undelivered at 42 weeks. Expectant management — Postterm pregnancy is a universally accepted indication for antenatal fetal monitoring because the risk of antepartum fetal demise increases with advancing gestational age. Postterm pregnancies should be followed with antepartum fetal surveillance because perinatal morbidity and mortality increases beginning at 41 weeks of gestation. Many practitioners use *twice-weekly testing with some evaluation of amniotic fluid volume beginning at 41 weeks of gestation. A non-stress test and amniotic fluid volume assessment (a modified BPP) should be adequate.* The non-stress test is an assessment of fetal well-being that measures the fetal heart rate response to fetal movement. The normal or reactive non-stress test occurs when there are two fetal heart rate accelerations of 15 beats/minute for 15 seconds within 20 minutes. Contraction stress test assesses uteroplacental insufficiency and looks for persistent late decelerations after contractions (3/10 minutes); however, it is not necessary to perform, as the non-stress test will assess fetal well-being, as well. An ultrasound to assess fetal growth is not indicated as the patient's fundal height is appropriate for her gestational age and she does not have any other indication to assess fetal growth such as a history of chronic hypertension or diabetes. Observation alone would not be proper care as the patient is postterm. Delivery is indicated if there is evidence of fetal compromise or oligohydramnios. The diagnosis of postterm pregnancy is based on the establishment of an accurate gestational age. In a patient with irregular menses, it is important to obtain an ultrasound prior to 20 weeks to accurately date the pregnancy. It is reasonable to allow a patient with reassuring fetal surveillance to go past 41 weeks gestation if her gestational age is accurately known. Amnioinfusion is a procedure where normal saline is infused into the intrauterine cavity. Amnioinfusion remains a reasonable approach in the treatment of repetitive variable decelerations, regardless of amniotic fluid meconium status. Meconium staining of the amniotic fluid is three to four times more common in the postterm pregnancy. This is likely due to two reasons: 1) greater length of time in utero allows for activation of a more mature vagal system; and 2) fetal hypoxia. Routine prophylactic amnioinfusion for thick meconium does not appear to decrease the incidence of meconium aspiration syndrome or have an impact on neonatal outcomes If cervix unfavorable....no change etc use Prostoglandin analogues (Prostaglandin E1 tablet)

Short Luteal Phase

What phase of menstrual cycle is constant?

Random

Wilson disease (WD) is the most common metabolic condition associated with PALF in children over five years of age. It is characterized by a Coombs negative hemolytic anemia, marked hyperbilirubinemia, low serum ceruloplasmin, and a low serum alkaline phosphatase

VBAC

if prior hysterotomy was a low transverse or low vertical incision

GBS

in unknown status when to give

Labor Warnings

labor warnings: contractions every five minutes for one hour, rupture of membranes, fetal movement less than 10 per two hours or vaginal bleeding. A reactive non-stress test and normal AFI (modified biophysical profile) are sufficient to assess fetal well being at this time

Previous c-section puts you at risk for

placentra preva placenta accreta

Non-reassuring status

repetitive late decels bradycardias loss of variability Tx: Face Mask O2, turned on left side, stop oxytocin, give IV fluids -if station is above 0 --> C/S

Vaccum Delivery

same conditions required for forceps: complications: Scalp laceration and cephalohematoma, subgaleal hemorrhage, shoulder dystocia

Abortion Woman with recurrent losses before 14w Antiphosphospholipid antibodies are associated with recurrent pregnancy loss. The workup for antiphospholipid syndrome includes assessment of anticardiolipin and beta-2 glycoprotein antibody status, PTT, and Russell viper venom time. There are multiple etiologies for recurrent pregnancy loss, which is defined as > two consecutive or > three spontaneous losses before 20 weeks gestation. Etiologies include anatomic causes, endocrine abnormalities such as hyper or hypothyroidism and luteal phase deficiency, parental chromosomal anomalies, immune factors such as lupus anticoagulant and idiopathic factors. Her history is not consistent with cervical insufficiency which is diagnosed typically in the second trimester by history, physical exam and other diagnostic tests, such as ultrasound. Serial cervical lengths or placement of a cerclage are not indicated in this patient. Treatment with 17-hydroxyprogesterone is indicated in patients with a history of prior preterm birth. Tx for ALA = aspirin and heparin CI for Manual Vacuum = Gestational AGE Manual vacuum aspiration is more than 99% effective in early pregnancy (less than eight weeks). Age, parity and medical illnesses are not contraindications for manual vacuum aspiration. Although the risk of Asherman's syndrome increases with each subsequent pregnancy termination, this patient may still undergo surgical termination as long as she understands risks and benefits. Complications of pregnancy termination increase with increasing gestational age. Pt w medical term of preg presents with heavy bleeding. This patient is having heavy bleeding as a complication of medical termination of pregnancy. This is managed best by performing a dilation and curettage.

29 year-old G2P1 woman with six weeks amenorrhea presents with lower abdominal pain and vaginal bleeding. Her temperature is 102.0°F (38.9°C) and the cervix is 1 cm dilated. Uterus is eight-week size and tender. Ans: The patient has a septic abortion. She has fever and bleeding with a dilated cervix which are findings seen with septic abortion. Threatened abortions clinically have vaginal bleeding, a positive pregnancy test and a cervical os closed or uneffaced, while missed abortions have retention of a nonviable intrauterine pregnancy for an extended period of time (i.e. dead fetus or blighted ovum). - The management of septic abortion includes broad-spectrum antibiotics and uterine evacuation. Single agent antimicrobials do not provide adequate coverage for the array of organisms that may be involved and therefore are not indicated. Medical abortion is associated with higher blood loss than surgical abortion. Early in pregnancy (less than 49 days) both medical and surgical procedures can be offered. Mifepristone (an antiprogestin) can be administered, followed by misoprostol (a prostaglandin) to induce uterine contractions to expel the products of conception. This approach has proven to be effective (96%) and safe. A surgical termination is required in the event of failure or excessive blood loss. Medical termination seems to be more desirable by some patients since they do not have to undergo a surgical procedure. It does not affect future fertility. Any termination of pregnancy, whether medical or surgical, can have psychological sequelae. Woman wants abortion w/ autopsy. Both medical and surgical abortions are options for this patient, depending on her personal preferences. However, if she desires an autopsy, she must undergo a medical abortion in order to have an intact fetus. Example" Pt had elective termination now presents with fever and abdominal pain. This patient has postoperative endometritis that could be due to introduction of bacteria into the uterine cavity at the time of dilation and curettage. It is important to begin antibiotics immediately. After starting antibiotics, an ultrasound should be obtained to look for products of conception. If found, the patient would then require a repeat dilation and curettage

PPV in newborn

Adjusting the head to a modified flex position is typically used in adult CPR. The sniffing position (tilting the neonate's head back and lifting the chin) is the correct position for application of positive pressure ventilation in a newborn infant. It is important to also secure the mask to the infant's face and to observe an initial chest rise. A recommended rate of oxygen flow is 10 L/minute.

Peripartum Cardiomyopathy -pulm edema, pleural effusions -cardiomegaly -global or local hypokensis

Heart failure w/i the last month of pregnancy to 5m post partum LV dysfx (EF under 45 percent Tx: B-blockers (okay to use implantable defib in preg) -pain control with epidural (dec cardiac work and decrease tachycardia) 1/2 will demonstate resolution of LV dialation

Chorioamnionitis IAI is polymicrobial and usually results from migration of cervicovaginal flora through the cervical canal in women with ruptured membranes. Other causes include transplacental infection associated with bacteremia and bacterial contamination during invasive procedures IAI cannot be cured without delivery. We suggest prompt induction or augmentation of labor, as appropriate, with cesarean delivery reserved for standard obstetrical indications

Maternal Fever + symptoms (leukocytosis, maternal and fetal tachycardia, uterine tenderness, malodorous amniotic fluid). A positive amniotic fluid culture is diagnostic, but takes too long to be clinically useful. The fetal tachycardia may be in response to the maternal fever. Fetal tachycardia coupled with minimal variability is a warning sign that the infant can be septic. A septic infant will typically appear pale, lethargic and have a high temperature. Tx: Broad Specs ampicillin (2 g intravenously every six hours) plus gentamicin (1.5 mg/kg intravenously every eight hours for patients with normal renal function). Clindamycin (900 mg intravenously) is added to this regimen to reduce postsurgical infections related to anaerobes in patients undergoing cesarean delivery.

Appendicitis in pregs

The diagnosis of appendicitis is more difficult to make in pregnancy because anorexia, nausea, and vomiting that accompany normal pregnancy are also common symptoms of appendicitis. In addition, the enlarged uterus shifts the appendix upward and outward toward the flank, so that pain and tenderness may not be located in the right lower quadrant. Appendicitis is easily confused with preterm labor, pyelonephritis, renal colic, placental abruption, or degeneration of a uterine myoma. Peritonitis and appendiceal rupture are more common during pregnancy. The diagnosis is made based on clinical findings and *graded compression ultrasonography *that is sensitive and specific especially before 35 weeks gestation

Small for Gestational Age Fetal Growth Restriction is this the same as Intrauterine Growth Restriction Asymmetric IUGR (after 20 weeks) * Caused by placental insufficiency* -the placenta cannot provide all of the nutrients required for optimal fetal growth secondary to intrinsic placental problems or decreased maternal nutrient delivery to the placenta - as a result the fetus selectively shunts blood flow to the most critical developmental areas (e.g. brain) and away from less critical areas (e.g. limbs, abdomen) Causes: Hypertension, anemia, chronic renal disease, APhosL syn, SLE, Malnutrition, severe diabetes or Placental factors (previa, abruption, infarction, multi gest) Dx: Increased Head to Abdominal Measurements Tx: lose dose aspirin Symmetric IUGR (before 20 weeks) -Caused by a global perturbation in fetal growth as a result of intrinsic fetal problems trisomy 18 (any genetic conditions) renal agenesis infection (CMV, rubella) rubella infection toxoplasmosis radiation pregnancy at high altitudes

The general sequence of Doppler and biophysical changes in FGR is: ●A reduction in umbilical venous flow is the initial hemodynamic change. Venous flow is redistributed away from the fetal liver and towards the heart. Liver size decreases, causing a lag in fetal abdominal circumference, which is the first biometric sign of fetal growth restriction. ●Umbilical artery Doppler index increases (diminished end diastolic flow) due to increased resistance in the placental vasculature. ●Middle cerebral artery Doppler index decreases (increased end diastolic flow), resulting in preferential perfusion of the brain (brain-sparing effect). ●Increasing placental vascular resistance results in absent and then reversed end diastolic flow in the umbilical artery. ●Middle cerebral artery Doppler index normalizes or abnormally increases as diastolic flow falls due to loss of brain-sparing hemodynamic changes. ●As cardiac performance deteriorates due to chronic hypoxia and nutritional deprivation, absent or reversed end diastolic flow in the ductus venosus and pulsatile umbilical venous flow may develop. These can be preterminal events.

Mastitis 42-year-old G5P4 woman is exclusively breastfeeding her two-month-old baby when she develops a fever and a red tender wedge-shaped area on the outer quadrant of her left breast.

The patient has a classic picture of mastitis that is usually caused by streptococcus bacteria from the baby's mouth. Mastitis is easily treated with antibiotics. The initial choice of antimicrobial is influenced by the current experience with staphylococcal infections at the institution. Most are community-acquired organisms, and even staphylococcal infections are usually sensitive to penicillin or a cephalosporin. If the infection persists, an abscess may ensue which would require incision and drainage. However, this patient's presentation is that of simple mastitis. There is no need for the mother to stop breastfeeding because of the mastitis.

a missed abortion on ultrasound, along with a retroverted uterus. She elects to undergo suction dilation and curettage. During the procedure, "fatty appearing tissue" is noted to be coming through the curette.

The tissue is consistent with omental tissue and may include segments of bowel. The suction should be turned off and the tissue gently removed from the curette. Laparoscopy will allow closer examination and should bowel appear to be involved, the surgeon should consider laparotomy for closer evaluation of the bowel for damage.

Cervical Insufficiency Congenital and acquired cervical abnormalities increase the risk of cervical insufficiency; acquired risk factors are more common. Cervical trauma may occur during labor or delivery (spontaneous, forceps- or vacuum-assisted, cesarean) rapid mechanical cervical dilation before a gynecologic procedure, or treatment of cervical intraepithelial neoplasia. Congenital abnormalities include genetic disorders affecting collagen (eg, Ehlers-Danlos syndrome), uterine anomalies [7,8], in utero diethylstilbestrol (DES) exposure [9], and biologic variation Physical examination — The initial clinical examination may reveal a soft, somewhat effaced cervix, with no or minimal dilation [10]. Provocative maneuvers such as suprapubic or fundal pressure or the Valsalva maneuver may reveal fetal membranes in the endocervical canal or vagina; this is always an abnormal finding. Tocodynamometry shows no or infrequent contractions at irregular intervals. Late clinical presentation is characterized by advanced dilation and effacement (eg, ≥4 cm dilated and ≥80 percent effaced), spotting, unprovoked grossly prolapsed membranes or ruptured membranes, or contractions that seem inadequate to explain the advanced effacement and dilation.

This patient has an incompetent cervix and should have a cervical cerclage at 14 weeks. A Pregnancy loss in the late second trimester is not usually related to genetic abnormality of the conceptus and most clinicians delay placement of a cerclage until after the first trimester, given the high background prevalence of first trimester pregnancy wastage. Although some clinicians use prophylactic progesterone to prevent recurrent abortion, as well as preterm labor, no controlled trials support the use of prophylactic progesterone in the treatment of cervical incompetence. Tx: Women with: ≥2 consecutive prior second-trimester losses*, or ≥3 early (<34 weeks) preterm births -Transvaginal cerclage at 12 to 14 weeks and -Hydroxyprogesterone caproate 250 mg IM weekly from 16 to 36 weeks Women with: One prior second-trimester loss*, or One or two preterm births -Hydroxyprogesterone caproate 250 mg IM weekly from 16 to 36 weeks -Serial measurement of cervical length beginning at 14 to 16 weeks and ending at 24 weeks -If cervical length <25 mm before 24 weeks, place transvaginal cerclage

Mother is tx w/ mepiridine during preggers -used cannabis during pregnancy -infant born limp and unresponsive, HR greater than 90 bpm...no resp effort

You should give positive pressure ventilation and prepare to intubate the infant, if necessary. Any history of substance abuse may be a relative contraindication to the use of naloxone (Narcan) because the mother may have used narcotics during the pregnancy and administration of naloxone to the infant can cause life-threatening withdrawal. Stimulation may not be sufficient for this infant. Suction will not necessarily stimulate a respiratory effort. The signs of NAS are due to dysfunction of autonomic regulation, state control capacities, and sensory and motor functioning. They include a high pitched cry, irritability, sleep/wake disturbances, alterations in tone or movement, feeding difficulties, gastrointestinal and autonomic disturbances, and failure to thrive. Tx: morphine phenobarb

Asherman Syndrome

adhesions may cause amenorrhea (lack of menstrual periods), repeated miscarriages, and infertility. However, such symptoms could be related to several conditions. They are more likely to indicate Asherman syndrome if they occur suddenly after a D&C or other uterine surgery.

Subchorionic Hematoma

believed to result from partial detachment of the chorionic membranes from the uterine wall, in contrast to abruption, which is due to detachment of the placenta from the uterine wall Patients are asymptomatic or experience light vaginal bleeding. In contrast to abruption, abdominal pain is typically absent, a minority of patients experience cramping or contractions, and the diagnosis is usually made before rather than after 20 weeks of gestation ultrasound findings of a hypoechoic or anechoic crescent-shape area behind the fetal membranes, which may also elevate the edge of the placenta

Postpartum contraception She desires long-term effective contraception, because she doubts she wants more children. She also desires to breastfeed exclusively for six months and has had trouble with this in the past. (Doubts she wants them but doesnt say FOR SURE NO CHILDREN)

concerns that hormones, especially estrogen, may have a negative impact on the quantity or quality of breast milk. Although Depot medroxyprogesterone is a progesterone only contraceptive, it is known to cause weight gain and would not be a good choice in this patient. The IUD is the best choice because it is long term but reversible, and does not affect milk production. Tubal ligation and Essure are permanent sterilization and would not be best for a patient who may desire more children.

Hypermagnesiemia Toxicity is related to serum magnesium concentration: loss of deep tendon reflexes occurs at 7 to 10 mEq/L (8.5 to 12 mg/dL or 3.5 to 5.0 mmol/L), respiratory paralysis at 10 to 13 mEq/L (12 to 16 mg/dL or 5.0 to 6.5 mmol/L), cardiac conduction is altered at >15 mEq/L (>18 mg/dL or >7.5 mmol/L), and cardiac arrest occurs at >25 mEq/L (>30 mg/dL or >12.5 mmol/L). Calcium gluconate (1 gram intravenously over 5 to 10 minutes) should be administered to counteract life-threatening symptoms of magnesium toxicity At a magnesium level of 11 mEq/L, respiratory depression is most likely to occur. A therapeutic magnesium level is between 4-7 mEq/L. Seizures are prevented by the use of magnesium. Loss of deep tendon reflexes occurs at a level of 7-10 mEq/L. Cardiac arrest may occur at a level of 15 mEq/L. Pulmonary edema can occur with magnesium therapy, but is not related to toxicity from the drug. High levels of magnesium sulfate may cause respiratory depression (12-15 mg/dl) or cardiac depression (>15 mg/dl). Prior to developing respiratory depression the patient should have diminished or absent deep tendon reflexes (areflexia).

neuromuscular toxicity is the most common complication of hypermagnesemia. Symptoms range from diminished deep tendon reflexes when the plasma magnesium concentration reaches 4 to 6 meq/L (4.8 to 7.2 mg/dL or 2 to 3 mmol/L) to somnolence, loss of deep tendon reflexes, and muscle paralysis. (See 'Neuromuscular effects' above.) BEWARE RESPIRATORY DISTRESS ●Bradycardia and hypotension may occur at a plasma magnesium concentration above 4 to 5 meq/L (4.8 to 6 mg/dL or 2 to 2.5 mmol/L). Observed electrocardiogram changes include prolongation of the P-R interval, an increase in QRS duration, and an increase in Q-T interval. Complete heart block and cardiac arrest may occur at a plasma magnesium concentration above 15 meq/L (18 mg/dL or 7.5 mmol/L). (See 'Cardiovascular effects' above.) ●Hypermagnesemia may inhibit the secretion of parathyroid hormone (PTH), causing transient hypocalcemia. (See 'Hypocalcemia' above.) ●Hypermagnesemia may also cause nonspecific symptoms such as nausea, vomiting, and flushing.

Candidia of the breast

22-year-old G2P1 woman comes to your clinic today with her three-month-old daughter. She was breastfeeding without problems until about two weeks ago, when she began to experience sore nipples. The nipples are very sensitive and there is a burning pain in the breasts, which is worse when feeding. The tips of the nipples are pink and shiny with peeling at the periphery. This presentation is classic for candidiasis and should prompt an inspection of the baby's oral cavity. Candida of the nipple is associated with severe discomfort and pain

Cat 2 Tracing

Baseline Changes w/ Tachycardia : medication, maternal anxiety, infection, fever [general measures] w/ Bradycardia: rupture of membranes, occipitoposterior position, post-term pregnancy, congenital anomalies [consider deliv]

Postpartum Thyroiditis subacute lymphocytic thyroiditis.

Common during pregnancy, this disorder usually produces a tender goiter during or after a respiratory infection. Transient, symptomatic hyperthyroidism with elevated T 4 can occur, often resulting in misdiagnosis as Graves disease. Usually, treatment is unnecessary.

TB in pregnancy ≥5 HIV infection Close contact of active contagious case Abnormal chest radiograph with fibrotic changes consistent with old TB Immunosuppressed patients: TNF-alpha inhibitors, chemotherapy, organ transplantation, glucocorticoid treatment (equivalent of ≥15 mg/day prednisone for ≥1 month) ≥10 Persons with clinical conditions that increase the risk of reactivation, including silicosis¶, chronic renal failure requiring dialysis¶, diabetes mellitus, some malignancies (leukemias, lymphomas, carcinoma of the head, neck, or lung), underweight (≥10 percent ideal body weight), jejunoileal bypass, injection drug users Children less than 4 years of age Foreign born from countries with incidence >25/100,000Δ Residents and employees in high-risk settings, such as prisons, jails, healthcare facilities, mycobacteriology labs, and homeless shelters ≥15 Healthy individuals age 4 years and older with low likelihood of true TB infection◊

Do not screen everyone: Appropriate groups for testing include those at high risk for progression of LTBI to active disease, especially those who are significantly immunocompromised (eg, HIV infection, immunosuppressive therapy) or those who have been infected with TB recently Diagnostic tools for latent tuberculosis include tuberculin skin testing (TST) and interferon-gamma release assays (IGRAs). Tuberculin skin testing can be performed safely in pregnant women, and pregnancy does not alter the response to the TST Patients with positive LTBI screening results (table 1) must undergo clinical evaluation to rule out active tuberculosis. This includes evaluation for symptoms (eg, fever, cough, weight loss) and radiographic examination of the chest (with appropriate shielding). Testing and treatment for latent tuberculosis infection should be pursued during pregnancy only if there is an indication for prompt management of LTBI (usually in recent infection or immunocompromised hosts); a decision to test presupposes a decision to treat promptly if the test is positive (even during the first trimester). Therefore, patients appropriately targeted for LTBI screening with positive TST results should initiate treatment during pregnancy However, if a skin test has been performed in the absence of an indication for prompt LTBI management and is positive, a chest radiograph (with shielding) should be performed, regardless of gestational age; it can be deferred if delivery is imminent. The regimen of choice for treatment of LTBI is isoniazid (5 mg/kg up to 300 mg daily) for nine months (table 2). This should be combined with pyridoxine supplementation (25 mg daily)

Side effects of different forms of anesthesia

Neuraxial - Spontaneous CSF leak - A CSF leak is most often characterized by orthostatic headaches — headaches that worsen in a vertical position and improve when lying down. Other symptoms can include* neck pain or stiffness, nausea, vomiting, dizziness, fatigue, and a metallic taste in the mouth* (indicative of a cranial leak), among others. A CT scan can identify the site of a cerebrospinal fluid leakage. Once identified, the leak can often be repaired by an epidural blood patch, an injection of the patient's own blood at the site of the leak, fibrin glue injection or surgery Intravascular injection of anesthetic - leads to instant signs of toxicity like tinnitus and metallic taste in mouth

Herpes Gestationis / Pemphigoid Gestationis

Skin disorders of pregnancy

Emanicpated minors

The following are the categories of minors authorized to consent to medical care emancipated minors (sometimes defined as those who are married, who are pregnant, who are parents, who have served in armed forces, are living apart and financially independent from their parents)

Turner Syndrome

The genetic defect of Turner syndrome is the absence of one of the X chromosomes. These females have failure to establish secondary sexual characteristics, short stature and characteristic physical features: pterygium colli, shield chest and cubitus valgus. Partial deletions of the long arm of the X chromosome also cause premature ovarian failure

Stress incontinence The majority of GSI is due to urethral hypermobility (straining Q-tip angle >30 degrees from horizon). Some (<10%) of GSI is due to intrinsic sphincteric deficiency (ISD) of the urethra. Mixed incontinence occurs when increased intra-abdominal pressure causes the urethral-vesical junction to descend causing the detrusor muscle to contract. 70-year-old G3P3 woman presents with a four-year history of constant leakage of urine. Her history is significant for abdominal hysterectomy and bilateral salpingo-oophorectomy for endometriosis. She had four anterior repairs in the past for recurrent cystocele. The leakage started six months after her last anterior repair. Pelvic exam showed no evidence of pelvic relaxation. The vagina was well-estrogenized. Q-tip test revealed a fixed, immobile urethra. Cystometrogram showed no evidence of detrusor instability. Cystourethroscopy showed no evidence of any fistula and revealed a "drain pipe" urethra. Which of the following is the best first treatment for this patient? This is a classic example of intrinsic sphincteric deficiency. Urethral bulking procedures are minimally invasive and have a success rate of 80% in these specific patients.

involuntary leakage of urine that occurs with increases in intra-abdominal pressure (eg, with exertion, sneezing, coughing, laughing) in the absence of a bladder contraction -Urethral Hypermobility - insufficent support of pelvic floor musculature and vaginal ct, causing the urethra and bladder neck to loss ability to close -Intrinsic Sphincteric Deficiency - loss of urethral tone Tx: initial therapy (lifestyle mod: caffiene restriction, fluid mang, bladder training, pelvic muscle exercises, topical estrogen) -Pessaries -Surgery (slings, resuspend the hypermobile urethra) Retropubic urethropexy such as tension-free vaginal tape and other sling procedures have the best five-year success rates for patients with GSI due to hypermobility Urethral bulking procedures are best for patients with ISD, but with little to no mobility of the urethra. Colpocleisis is one option to treat uterine prolapse, and is not indicated for urinary incontinence

Fetal HBV We obtain liver biochemical tests every three months during pregnancy and for six months postpartum The infection rate among infants born to HBeAg-positive mothers who do not receive any form of prophylaxis is as high as 90 percent. The high protective efficacy (95 percent) of neonatal vaccination suggests that most infections occur at birth when maternal secretions in the birth canal come in contact with the infant's mucosal membranes -Test for HBsAg on all women at 1st prenatal visit HBsAg-negative mother, birth weight ≥2 kg — If the mother is HBsAg negative and the birthweight is ≥2 kg (4.4 pounds), the preferred schedule for HepB vaccine is as follows (table 2A) [1,20]: ●First dose - During the birth hospitalization ●Second dose - at one to two months of age ●Third dose - At 6 to 18 months of age (must be given at ≥24 weeks of age) If HBsAg + give monovalent HepB vaccine + HBIg w/in 12 hrs of delivery The schedule for subsequent doses depends upon the infant's birth weight: ●Birth weight ≥2 kg (4.4 pounds) - The second and third doses should be given one and six months of age, respectively. ●Birth weight <2 kg (4.4 pounds) - Three additional doses should be given (at one, two to three, and six months of age or at two, four, and six months of age).

Acute HBV infection during pregnancy is usually not severe and is not associated with increased mortality or teratogenicit Risk factors for perinatal transmission — The most important risk factor for transmission despite proper administration of prophylaxis (HBIG and first dose of HBV vaccine given within 12 hours of birth and completion of HBV vaccine series) appears to be high maternal HBV viral load. The obstetrical approach should not be influenced by the HBV status of the mother. (vag vs c/s) Breastfeeding — Breastfeeding does not appear to increase the risk of transmission Newborns of carrier mothers should receive passive-active immunization In addition to standard passive-active immunization, antiviral therapy should be offered to mothers with high HBV DNA levels since it can further reduce the risk of perinatal transmission We generally offer prophylaxis to women who have a high viral load (more than 7 log10 IU/mL), although some clinicians recommend using lower cutoff (approximately 6 log10 IU/mL) with Tenofovir or telbivudine infants of HBsAg-positive mothers should receive monovalent HepB vaccine and HBIG 0.5 mL as soon after delivery as possible (preferably within 12 hours), regardless of birth weight Clinical manifestations and course — Newborn infants with HBV infection rarely show clinical or biochemical signs of disease at birth. Affected newborns remain asymptomatic, and develop chronic antigenemia with mild and often persistent liver enzyme elevations beginning at two to six months of age (immune tolerant phase) (figure 1) [1,16,17]. A small number of patients will develop acute hepatitis by two months of age and present with icteric, and occasionally fulminant, hepatitis [17-20]. Most patients develop chronic infection, which may progress to cirrhosis and hepatocellular carcinoma.

Acute Fatty Liver of Pregnancy occurs typically in the third trimester or postpartum microvesicular fatty infiltration of hepatocytes inherited enzyme deficiency in beta-oxidation that predisposes the mother to this disorder evidence of hepatic insufficiency such as hypoglycemia or encephalopathy and abnormalities in coagulation studies is more consistent with acute fatty liver of pregnancy. All women with acute fatty liver of pregnancy and their children should undergo molecular testing for long-chain 3-hydroxyacyl coenzyme A dehydrogenase (LCHAD) deficiency, at least for the most common G1528C mutation Tx: maternal stabilization and prompt delivery of the fetus, regardless of gestational age. Maternal stabilization requires glucose infusion and reversal of coagulopathy (eg, administration of fresh frozen plasma, cryoprecipitate, packed red blood cells and platelets), as needed

Acute fatty liver of pregnancy — The clinical presentation of AFLP commonly includes nausea and vomiting, abdominal pain, malaise, polydipsia/polyuria, jaundice/dark urine, encephalopathy, and hypertension/preeclampsia [24]. HELLP may be difficult to distinguish clinically from AFLP since both occur at the same time in gestation and share several clinical features (figure 1). In fact, in one study approximately half of AFLP patients based on the Swansea criteria (which identify the most severe spectrum of the disease) also fulfilled criteria for HELLP syndrome [25]. (See "Acute fatty liver of pregnancy", section on 'Clinical manifestations'.) It is important to differentiate between the two disorders because women with AFLP can rapidly develop liver failure and encephalopathy. Additional laboratory testing can be helpful: prolongation of the prothrombin (PT) and activated partial thromboplastin time (aPTT), severe hypoglycemia, and elevated creatinine concentration are more common in women with AFLP than in those with HELLP. Hypertension is more common in HELLP than in AFLP (in one review: 80 to 100 percent of cases versus 26 to 70 percent of cases [24]). Of note, women with AFLP are more likely than women with HELLP to have offspring with an inherited defect in mitochondrial beta-oxidation of fatty acids, such as long-chain 3-hydroxyacyl-coenzyme A dehydrogenase deficiency, short-chain acyl-coenzyme A dehydrogenase deficiency, or carnitine palmitoyltransferase I deficiency [12,13,15,26,27]. However, this information is not typically available during differential diagnosis, and is not highly sensitive or specific. (See "Acute fatty liver of pregnancy", section on 'Pathogenesis'.) AFLP can be confirmed by diagnostic liver biopsy, but this is rarely performed because the clinical diagnosis is usually reasonably certain, the information gained would not change management (ie, delivery of the fetus), and the procedure exposes the mother and pregnancy to additional risks (picture 2). Furthermore, AFLP and HELLP share several common histological features

Noonan Syndrome

Clinically, patients with Noonan syndrome typically have normal puberty and fertility. They may have short stature, webbed neck, heart defects, and abnormal faces. Individuals with Noonan syndrome have a normal karyotype.

Quad Screen

Down syndrome Quad Screen • + quad screen o ↓ α-fetoprotein o ↓ estriol o ↑ inhibin A o ↑ β-hCG o remember: high (hCG, inhibin); deficit (estriol, fetoprotein) • + ultrasound shows o high amount of fluid behind the neck ↑ nuchal translucency Elevated AFP with ultrasound showing viable single gestation of accurate age is a reason to do a 2nd trimester aminocentesis Chorionic Villous Sampling = sampling of placental villi as a means of prenatal genetic testing based on assumption that the placenta has same genetic make up as the fetus DONE AT 10-12 WEEK Complications transverse limb abnormality, risk greatest when performed < 9 weeks, rupture of membranes, chorioamnionitis Aminocentesis = based on capture of free-floating fetal cells in the amniotic fluid DONE AT OVER 15 Weeks

IUPC

If an intrauterine pressure catheter is placed, and a significant amount of vaginal bleeding is noted, the possibility of placenta separation or uterine perforation should be considered. In this case, withdrawing the catheter, monitoring the fetus and observing for any signs of fetal compromise would be the most appropriate management. If the fetal status is found to be reassuring, then another attempt at placing the catheter may be undertaken

Postpartum hem After ensuring appropriate backup, establishing intravenous access and stabilizing a patient as needed, the first steps in the management of postpartum hemorrhage are to make sure the uterus is well-contracted, there is no retained placental tissue and to look for lacerations. This patient has a firm fundus, which indicates a contracted uterus. Her placenta is complete, which typically rules out retained placental tissue, so it is important to rule out lacerations, which can lead to hemorrhage The following are associated with retained placenta: prior Cesarean delivery, uterine leiomyomas, prior uterine curettage and succenturiate lobe of placenta. Prostaglandin F2-alpha should be administered intramuscularly. It could also be injected directly into the uterine muscle. A uterine compression suture such as a B-Lynch has been shown to be effective in the management of unresponsive uterine atony. Ligation of a number of pelvic vessels can lead to reduction in the vascular pressure in the pelvis thus controlling hemorrhage. This is especially true with internal iliac artery (hypogastric artery) ligation. However, ligation of the ovarian arteries should not be undertaken as a primary approach

Methergine, prostaglandins and oxytocin are all uterotonics and used to increase uterine contractions and decrease uterine bleeding. Methylergonovine is an ergot alkaloid, which is a potent smooth muscle constrictor. It is also a vasoconstrictive agent and should be withheld from women with hypertension and/or preeclampsia. Prostaglandin F2-alpha (Hemabate) is a potent smooth muscle constrictor, which also has a bronchio-constrictive effect. As such, it should be used with caution in any patient with a reported history of asthma. It is absolutely contraindicated in patients with poorly controlled or severe asthma Placental abruption and uterine atony are both common, but, in the presence of a low-lying anterior placenta in a patient with a history of multiple Cesarean births, the diagnosis of the placenta accreta must be entertained. Placenta accreta is an abnormally firm attachment of the placenta to the uterine wall. The incidence of placenta accreta may be increasing because of the rise in the number of women with previous Cesarean sections. This is a serious obstetric complication leading to retained placenta and severe postpartum hemorrhage. Hysterectomy is frequently required due to intractable hemorrhage at delivery.

Breast Abscess / Mastitis DIFFERENTIAL DIAGNOSIS ●Plugged duct - A plugged duct is a localized area of milk stasis within the milk duct that causes distention of mammary tissue. Symptoms include a palpable lump with tenderness. A plugged duct may be distinguished from mastitis and breast abscess by the absence of systemic findings. Severe engorgement - Engorgement occurs due to interstitial edema with onset of lactation or at other times with accumulation of excess milk. Mastitis may be distinguished from severe engorgement in that engorgement is bilateral, with generalized involvement [1]. Severe engorgement is not typically associated with systemic symptoms of fever and myalgias. ●Galactocele - A galactocele (also known as a milk retention cyst) is a cystic collection of fluid that is usually caused by an obstructed milk duct. Galactoceles present as soft cystic masses; they are not tender and are not associated with systemic manifestations. Ultrasonography may demonstrate a simple milk cyst or a complex mass. The diagnosis can be made on the basis of the clinical history and needle aspiration, which yields a milky substance. (See "Common problems of breastfeeding and weaning", section on 'Galactoceles'.) ●Inflammatory breast cancer - Inflammatory breast cancer (IBC) should be considered if a breast infection does not resolve with appropriate treatment. Clinical manifestations include skin thickening due to edema, erythema, and peau d'orange appearance (picture 1). It is often associated with axillary lymphadenopathy. The diagnosis is established via biopsy.

Patients with *primary breast abscess* present with localized, painful inflammation of the breast associated with fever and malaise, along with a FLUCTUANT, tender, PALPABLE MASS *Lactational mastitis * typically presents as a firm, red, tender, swollen area of one breast associated with fever >38.3ºC in a nursing mother. Systemic complaints may include myalgia, chills, malaise, and flu-like symptoms. In the early stages, the presentation can be subtle with few clinical signs; patients with advanced infection may present with a large area of breast swelling with overlying skin erythema. Reactive lymphadenopathy may be associated with axillary pain and swelling. Most primary breast abscesses are caused by Staphylococcus aureus. Methicillin-resistant S. aureus (MRSA) is becoming an increasingly important pathogen in cases of lactational and nonlactational mastitis Tx: Needle aspiration is an appropriate initial approach for abscess drainage when the overlying skin is intact . The use of ultrasound guidance ensures complete drainage and facilitates aspiration of loculated areas as well as collections that may not be appreciated on physical exam The patient should be reexamined every two to three days and the cavity imaged with ultrasound and aspiration repeated in a similar manner until there is no further fluid visible in the abscess cavity or the fluid aspirated is serous In the setting of nonsevere infection in the absence of risk factors for methicillin-resistant S. aureus (MRSA), outpatient therapy may be initiated with *dicloxacillin or cephalexin, pending culture results if allergic = clindamycin* -if MRSA risk factors (diabetic) use TMP-SMX or clindamycin Women should be encouraged to continue breastfeeding following breast infection, even in the setting of incision and drainage. If there is difficulty with breastfeeding because the incision interferes with nursing on the affected breast, the infant cannot relieve breast fullness, or there is concern about spreading infection to the baby, hand expression or breast pumping can be effective for maintaining the milk supply until breastfeeding can resume

Autosomal Dominant Conditions

Porphyrias Tuberous sclerosis Marfan syndrome Neurofibromatosis Huntington's disease Retinoblastoma Waardenburg syndrome Myotonic dystrophy Familial hypercholestrolemia (LDL receptor defect Type IIa) Adult polycystic kidney disease von Hippel Lindau Familial adenomatous polyposis and Peutz Jeghers Syndrome Hereditory spherocytosis Achondroplasia Ehlor's Danlos (vascular type) Hypertrophic Obstructive Cardiomyopathy (HOCM) Von Willebrand Disease Polydactyly Osteogenesis Imperfecta (Except Type VII) Hereditary hemorrhagic telengiactasia (Osler-weber-rendu syndrome) Osteopetrosis Type II (Adult type) Hypokalemic Periodic Paralysis

*Secondary Dysmenorrhea* Important findings on pelvic examination may include: •Imperforate hymen (hematometrocolpos) •Vulvar, anal, and/or vaginal trauma (sexual assault) •Vaginal discharge (PID) •Vaginal bleeding (ectopic pregnancy, acute abruption, spontaneous abortion, normal labor) •Cervical motion tenderness (PID) •Uterine tenderness (PID, acute abruption, dysmenorrhea, uterine rupture) •Adnexal tenderness (PID, ectopic pregnancy, ovarian torsion) •Adnexal mass (ovarian mass [cyst, abscess, or tumor], ectopic pregnancy, PID, endometriosis) •Tenderness of the posterior cul-de-sac, rectovaginal septum, or uterosacral ligaments on rectovaginal examination (endometriosis)

Secondary dysmenorrhea has the same clinical features, but occurs in women with a disorder that could account for their symptoms, such as endometriosis, adenomyosis, or uterine fibroids. -onset after 25 -AUB -nonmidline pain -absence of N/V/D backpain, dizziness, headache during menses -dysparenia or dyschezia -progression of symptoms *Pelvic inflammatory disease* is most common in women 15 to 25 years of age. It is characterized by lower abdominal pain, which is usually BILATERAL and ranges from mild to severe. The onset of pain is often during or shortly after menses, and may worsen during coitus or with jarring movement. •Purulent endocervical discharge •Acute cervical motion and adnexal tenderness Women with *endometriosis* typically report pelvic pain that is both related to menses and occurs at times other than menses. They may have premenstrual spotting, dyspareunia, dyschezia, poor relief of symptoms with NSAIDs, progressively worsening symptoms, and inability to attend work or school during menses. •Uterosacral ligament abnormalities, such as nodularity, thickening, or focal tenderness •Lateral displacement of the cervix due to asymmetric involvement of one uterosacral ligament by endometriosis, causing it to shorten (figure 2) • Retroverted uterus •Cervical stenosis •Adnexal enlargement from an endometrioma Women with *adenomyosis* typically present with dysmenorrhea after age 35 years •bulky globular mildly tender uterus *Fibroids* are rare in adolescents but are common after 35yr • enlarged, irregularly-shaped, nontender uterus, which may also be palpable abdominally. Ruptured ovarian cyst - Sudden onset of lateralizing pain, especially in association with exercise or sexual intercourse

Syphilis Tests Primary syphilis: chancre Solitary, painless ulcer with indurated border Secondary syphilis: condyloma latum -Slightly raised or flat, round or oval papules covered by gray exudate Venereal warts Soft, usually painless skin-colored or red papules Human papillomavirus

Sphyilis Screening: RPR or VDRL (they gave a 1:4 postivitity on the exam - what does this mean?) Confim with specific test: Fluorscent Treponemal Antibody Absorption Test (FTA-abs) or EIA for anti-treponemal IgG, the T. pallidum hemagglutination (TPHA) test, the microhemagglutination test with T. pallidum antigen, and the enzyme-linked immunosorbent assay.

Classic symptoms and findings for pneumonia.

The typical symptoms include cough, dyspnea, sputum production, and pleuritic chest pain. Mild upper respiratory symptoms and malaise usually precede these symptoms, and mild leukocytosis is usually present. Chest radiography is essential for diagnosis, although radiographic appearance does not accurately predict the etiology of the pneumonia.

Valproic Acid

Valproic acid use during pregnancy is associated with a 1 to 2% incidence of neural tube defects, specifically lumbar meningomyelocele. Fetal ultrasound examination at approximately 16 to 18 weeks gestation is recommended to detect neural tube defects. Other malformations have been reported in the offspring of women being treated with valproic acid and a fetal valproate syndrome has been described which includes spina bifida, cardiac defects, facial clefts, hypospadius, craniosynostosis, and limb defects, particularly radial aplasia

Tubo-ovarian Abscess

characteristic sonographic appearance of an abscess is a complex, multilocular mass

Overflow incontinence

failure to empty the bladder adequately. This is due to an underactive detrusor muscle (neurologic disorders, diabetes or multiple sclerosis) or obstruction (postoperative or severe prolapse). A normal post-void residual (PVR) is 50-60 cc. An elevated PVR, usually >300 cc, is found in overflow incontinence.

Cervical Cancer RF Early onset of sexual activity Multiple sexual partners A high-risk sexual partner (eg, a partner with multiple sexual partners or known HPV infection) History of sexually transmitted infections (eg, Chlamydia trachomatis, genital herpes) History of vulvar or vaginal squamous intraepithelial neoplasia or cancer Immunosuppression Early age at first birth (younger than 20 years old) and increasing parity (3 or more full term births) are also associated with an increased risk of cervical cancer; these are also likely due to exposure to HPV through sexual intercourse Low socioeconomic status

pelvic ultrasound reveals a fundal placenta and a fetus measuring 18 weeks with normal cardiac activity. Vaginal examination reveals a 3-centimeter lesion arising off the posterior lip of the cervix. It easily bleeds with palpation and is hard in consistency

Chronic Pelvic Pain

-year-old G0 female presents with a three-year history of severe dysmenorrhea shortly after menarche at age 14. Her menstrual cycles are regular with heavy flow. She has been treated with ibuprofen and oral contraceptives for the last year without significant improvement. She misses 2-3 days of school each month due to her menses. She has never been sexually active. Physical examination is remarkable for Tanner Stage IV breasts and pubic hair. Pelvic examination is normal, as is a pelvic ultrasound Next step = Laparoscopy Chronic pelvic pain is the indication for at least 40% of all gynecologic laparoscopies. Endometriosis and adhesions account for more than 90% of the diagnoses in women with discernible laparoscopic abnormalities, and laparoscopy is indicated in women thought to have either of these conditions. Often, adolescents are excluded from laparoscopic evaluation on the basis of their age, but several series show that endometriosis is as common in adolescents with chronic pelvic pain as in the general population. Therefore, laparoscopic evaluation of chronic pelvic pain in adolescents should not be deferred based on age. Laparoscopy can be both diagnostic and therapeutic in this patient in whom you suspect endometriosis. None of the other imaging modalities listed will help in the further workup of this patient.

Fetal Herpes HSV is transmitted to an infant during birth, primarily through an infected maternal genital tract. The risk of transmission is greater with primary HSV infection acquired during pregnancy, compared with reactivation of previous infection. Dx: isolation of HSV in culture, detection of HSV DNA using polymerase chain reaction (PCR) assays, and detection of HSV antigens using rapid direct immunofluorescence assays or enzyme immunoassays. Negative HSV cultures, PCR, and rapid tests do not exclude neonatal HSV. Electroencephalography and neuroimaging should be performed in all neonates with suspected HSV-associated CNS involvement Tx: Acyclovir Localized skin, eye, and mouth (SEM) disease should be treated for a minimum of 14 days. Disseminated and central nervous system (CNS) disease should be treated for a minimum of 21 days Neonates with ocular HSV involvement should receive a topical ophthalmic solution (eg, 1 percent trifluridine, 0.1 percent iododeoxyuridine, or 3 percent vidarabine) in addition to systemic acyclovir therapy We suggest oral acyclovir suppressive therapy for six months immediately following parenteral acyclovir for neonatal herpes simplex virus (HSV) disease Tx for moms: Acyclovir Cesarean delivery is protective, and recommended in the setting of active genital infection

Most newborns with perinatally acquired HSV appear normal at birth, although many are born prematurely. HSV infection in newborns usually develops in one of three patterns, which occur with roughly equal frequency: ●Localized to the skin, eyes, and mouth (SEM) ●Localized CNS disease ●Disseminated disease involving multiple organs The initial manifestations of CNS disease frequently are nonspecific and include temperature instability, respiratory distress, poor feeding, and lethargy; they may progress quite rapidly to hypotension, jaundice, disseminated intravascular coagulation (DIC), apnea, and shock. Vesicular skin lesions may or may not be present and develop late in some patients; the absence of skin lesions complicates recognition of the infection ●Mucocutaneous vesicles ●Sepsis-like illness (fever or hypothermia, irritability, lethargy, respiratory distress, apnea, abdominal distension, ascites) ●CSF pleocytosis ●Seizures ●Focal neurologic signs ●Abnormal neuroimaging ●Respiratory distress, apnea, or progressive pneumonitis ●Thrombocytopenia ●Elevated liver transaminases, viral hepatitis, or acute liver failure ●Conjunctivitis, excessive tearing, or painful eye symptoms

Large for Gestational Age -Diabetes -AMA -Multiparity -Post-term preg -Male infants -BWS (pancreatic islet cell hyperplasia)

low apgars hypoglycemia, polycythemia, hypocalcemia, jaundice -increased risk for leukemia, wilms tumors, osteosarcoma

Papular Urticarial Papules and Plaques of Pregnancy (PUPPP)

A 33 year old G4P3 presents at 30 weeks gestation with periumbilical itching associated with a rash that later spread to her thighs and buttocks. Most common pruritic dermatosis of pregnancy Unknown etiology Presentation Symptoms severe itching in the periumbilical region which spreads to the extremities Physical exam periumbilical erythematous papules and hives that spreads to the extremities

Antepartum Care The quadruple test (maternal serum alpha fetoprotein, unconjugated estriol, human chorionic gonadotropin, and inhibin A) is the most effective screening test for Down syndrome in the second trimester. Down syndrome occurs in about 1 in 800 births in the absence of prenatal intervention. The efficacy of screening for Down syndrome is improved when additional components are added to the maternal serum alpha fetoprotein screening. The addition of unconjugated estriol and human chronic gonadotropin (the Triple Screen) results in a 69% detection rate for Down syndrome. Adding inhibin A to produce a quadruple screen achieves a detection rate of 80-85%. An amniotic fluid alpha fetoprotein level is unnecessary. Nuchal translucency measurement with maternal serum PAPP-A and free Beta-hCG (known as the combined test) is a first trimester screen for Down syndrome. It detects approximately 85% of cases of Down syndrome at a 5% false positive rate. Shoulder dystocia, metabolic disturbances, preeclampsia, polyhydramnios and fetal macrosomia are all associated risks of gestational diabetes 70g of protein a day, in a vegetarian we need folic acid supps and iron

An ultrasound performed between 14 and 20 weeks gestation should be used to date the pregnancy if there is greater than a 10 day discrepancy from the menstrual dates. First trimester ultrasound provides the most accurate assessment of gestational age and can give an accurate estimated date of confinement (EDC) to within 3-5 days. This patient has three values on the three-hour glucose tolerance test that were abnormal. Initial management should include teaching the patient how to monitor her blood glucose levels at home on a schedule that would include a fasting blood sugar and one- or two-hour post-prandial values after all three meals, daily. Goals for blood sugar management would be to maintain blood sugars when fasting below 90 and one- and two-hour post-meal values below 120. A repeat glucose tolerance test would not add any value, as an abnormal test has already been documented. Oral hypoglycemic agents and insulin are not indicated at this time, as the patient may achieve adequate glucose levels with diet modification alone. recommended that all women with a previous pregnancy complicated by a fetal neural tube defect ingest 4 mg of folic acid daily before conception and through the first trimester .4 for nonrisk pts A thickened NT may be associated with fetal chromosomal and structural abnormalities as well as a number of genetic syndromes. Patients who desire non-invasive assessment of their risk for aneuploidy can have first trimester screen (a fetal nuchal translucency (NT) measurement and a maternal serum PAPP-A) and a second trimester quadruple screen. The sequential screen yields a 95% detection rate for Down syndrome at a 5% false-positive rate. Since the fetus in this case had a thickened NT, this patient should be scheduled to have a detailed fetal ultrasound and echocardiogram at 18-20 weeks to rule out anomalies

Intrauterine Synechiae

Asherman's syndrome (AS) or Fritsch syndrome, is a condition characterized by adhesions and/or fibrosis of the endometrium most often associated with dilation and cutterage - adhesions or scar tissue that form inside the cavity of the uterus. Symptoms associated with intrauterine adhesions include: ●Abnormal uterine bleeding, including amenorrhea, hypomenorrhea ●Infertility ●Cyclic pelvic pain ●Recurrent pregnancy loss Dx: Hysteroscopy w/ tx being resection followed by itrauterine balloon or IUD (w/ estrogens)

Delayed Puberty

Delayed puberty is defined clinically by the absence or incomplete development of secondary sexual characteristics bounded by an age at which 95 percent of children of that sex and culture have initiated sexual maturation. In the United States, the upper 95th percentile in the United States for boys to initiate puberty is 14 (an increase in testicular size being the first sign) and for girls is 12 (breast development being the first sign) -Primary hypogonadism is characterized by high levels of luteinizing hormone (LH) and follicle-stimulating hormone (FSH). Secondary hypogonadism is characterized by low to normal concentrations of LH and FSH, and typically is caused by impaired secretion of hypothalamic gonadotropin-releasing hormone (GnRH)

Lactation Suppression

Hormonal interventions for preventing lactation appear to predispose to thromboembolic events, as well as a significant risk of rebound engorgement. Bromocriptine, in particular, is associated with hypertension, stroke and seizures. The safest method to suppress lactation is breast binding, ice packs and analgesics. The patient should avoid breast stimulation or other means of milk expression, so that the natural inhibition of prolactin secretion will result in breast involution.

Postpartum emotions

Materinity Blues 2-3 days, resolves within 10 days Tearfulness, fatigue, depressed affect irritiability Tx: Reassurance, watchful waiting, 20% develop depression in 1 year Postpartum Depression 2w- 12m Depressed affect, anxiety, symyptoms worse at night, poor concentration, decreased libido Tx: Antidepressant Medications, psychotherapy Postpartum Psychosis Variable: days to 4-6 weeks Delusions, confusion, sleep disturbances, unusual behavior, emotional liability Tx: Antipsychotics

Choronic Villus Sampling

Preformed earlier than aminocentesis Chorionic villus sampling (CVS) is a prenatal test that can detect genetic and chromosomal abnormalities of a fetus. The loss rate with amniocentesis is quoted as 0.5% vs. ~1 to 3% for chorionic villus sampling. CVS is performed between 10 and 12 weeks gestation, while amniocentesis is performed after 15 weeks. Early CVS (<10 weeks gestation) is associated with an increase in rare limb abnormalities. It is more likely that a CVS will involve multiple attempts - a failure to obtain an adequate sample of cells and the woman requiring a repeat test later on - when compared with amniocentesis. Pregnancies complicated by isoimmunization can be followed by serial assessment of the amniotic fluid for bilirubin.

When to begin oxytocin

The patient is in the latent phase of labor and has not yet reached the active phase (more than 4 cm). A prolonged latent phase is defined as >20 hours for nulliparas and >14 hours for multiparas, and may be treated with rest or augmentation of labor. Artificial rupture of membranes is not recommended in the latent phase as it places the patient at increased risk of infection. Cervical dilation or laminaria placement are not indicated. 38 w, contractions every 2 min, membranes intact, 7/100/0 unchanged for 4 hrs. Cat 1 This patient has secondary arrest of dilation, as she has not had any further cervical change in the active phase for over four hours. Amniotomy is often recommended in this situation. After it is performed, if the patient is still not in an adequate contraction pattern, augmentation with oxytocin can be attempted after careful evaluation. Although the patient requires close monitoring, it is too early to proceed with a Cesarean delivery. An internal scalp electrode is not necessary, since the fetal heart monitoring is reassuring.

Type 1 Diabetes in Pregnancy Tx for diabetic neuropathy For patients with diabetic neuropathy, foot care is important to prevent ulceration, infection, and amputation. For patients with painful diabetic neuropathy, we suggest initial therapy using either amitriptyline or venlafaxine (Grade 2B), or duloxetine or pregabalin (Grade 2A). Among these options, we prefer to start with amitriptyline, particularly in younger healthier patients, because of its effectiveness and low cost. For patients who do not improve on one drug, we suggest combination therapy employing two drugs from different medication classes Gastroparesis - syndrome of objectively delayed gastric emptying in the absence of a mechanical obstruction and cardinal symptoms of nausea, vomiting, early satiety, bloating, and/or upper abdominal pain -gastric scintography -blenderize foods (consume small frequent meals which are low in fat and contain only soluble fiber) 1st line= metoclopramide --> domperidone and subsequently oral erythromycin Metoclopramide: bind to dopamine D2 receptors with where it is a receptor antagonist (decrease nausea), and is also a mixed 5-HT3 receptor antagonist/5-HT4 receptor agonist (increase motility) CI: epilepsy Patients with a history of ADHD, restless legs syndrome, hyperprolactinaemia, and Parkinson's disease should be closely monitored when using dopamine antagonists for treatment of emesis. Patients who take antipsychotics are recommended not to take metoclopramide. AE: restlessness (akathisia), and focal dystonia. Infrequent ADRs include hypertension, hypotension, hyperprolactinaemia leading to galactorrhea, constipation, depression, headache, and extrapyramidal effects such as oculogyric crisis.

The patient with type 1 diabetes is at risk for many pregnancy complications. In women with insulin-dependent diabetes, the rates of spontaneous abortion and major congenital malformations are both increased. The risk appears related to the degree of metabolic control in the first trimester. Overt diabetic patients are also at an increased risk for fetal growth restriction, although fetal macrosomia may also occur. The former becomes a greater concern as in this patient, with longer-term diabetes and vascular complications, such as retinopathy. Diabetics also have increased risk for polyhydramnios, congenital malformations (cardiovascular, neural tube defects, and caudal regression syndrome), preterm birth and hypertensive complications. Small babies are more common with type 1 diabetes than with gestational diabetes, and the blood sugar level of all newborns of diabetic mothers should be monitored closely after delivery, as they are at increased risk for developing hypoglycemia. Macrosomic (large) infants are typically associated with gestational diabetes. A mother with a large baby in 1st preg is more likely to have GA diabetes in 2nd preg

Lichen Sclerosis -steps (when to biopsy) -tx -diff increased risk of squamous cell cancer of the vulva -proper hygiene AVOID (substitute with) -pantyhose (wear stockings), synthetic underwear (wear cotton or none), jeans or other tight pants (wear loose pants skirts and dresses), swimsuits thongs leotards (wear loose cotton), pantyliners (wear tampons or cotton pas), scented soaps or shampoos (use fragrance free pH neutral soap), bubble baths (tub baths in morning and night w/o additives), scented detergents (unscented), washcloths (fingers), douches, powders, sprays, dyed toilet paper, high dryers (patting)

benign, chronic, progressive dermatologic condition characterized by marked inflammation, epithelial thinning, and distinctive dermal changes accompanied by pruritus and pain. -classic appearance is thin, white, wrinkled skin localized to the labia minora and/or labia majora -areas of epithelial hyperplasia from chronic rubbing are often seen. Fissuring is frequently present perianally, in the intralabial folds, or around the clitoris. At the end-stages, the vulva is pallid and featureless due to midline fusion -Vulvar pruritus is a common symptom of vulvar lichen sclerosus and can be so intense that it interferes with sleep. Other symptoms include pruritus ani, painful defecation, rectal bleeding, dyspareunia, and dysuria. Dx: Clinical + Biopsy Histology Tx: Educate + Topical Corticosteroids (clobetasol or halobetasol) daily for 6 - 12 w then taper (if thickened plaques may inject corticosteroids) 64-year-old G2P2 woman 12m of vulvar pruritus. No discharge. No OTC med helps. Dysparunia. Hx of HTN and allergic rhinitis. loss of the labia minora with resorption of the clitoris (phimosis). The vulvar skin appears thin and pale and involves the perianal area as in the picture below. No ulcerations are present. The vagina is mildly atrophic, but appears uninvolved. Which of the following is the most likely diagnosis in this patient? Lichen sclerosus is a chronic inflammatory skin condition that most commonly affects Caucasian premenarchal girls and postmenopausal women. The exact etiology is unknown, but is most likely multifactorial. Patients typically present with extreme vulvar pruritus and may also present with vulvar burning, pain and introital dyspareunia. Early skin changes include polygonal ivory papules involving the vulva and perianal areas, waxy sheen on the labia minora and clitoris, and hypopigmentation. The vagina is not involved. More advanced skin changes may include fissures and erosions due to a chronic itch-scratch-itch cycle, mucosal edema and surface vascular changes. Ultimately, scarring with loss of normal architecture, such as introital stenosis and resorption of the clitoris (phimosis) and labia minora, may occur. Treatment involves use of high-potency topical steroids. There is less than a 5% risk of developing squamous cell cancer within a field of lichen sclerosus.

Lichen Simplex Chronicus 0-year-old G1P1 woman presents with a history of chronic vulvar pruritus. The itching is so severe that she scratches constantly and is unable to sleep at night. She reports no significant vaginal discharge or dyspareunia. She does not take antibiotics. Her medical history is unremarkable. Pelvic examination reveals normal external genitalia with marked lichenification (increased skin markings) and diffuse vulvar edema and erythema as shown in picture below. Saline microscopy is negative. Potassium hydroxide testing is negative. Vaginal pH is 4.0. The vaginal mucosa is normal

common vulvar non-neoplastic disorder, results from chronic scratching and rubbing, which damages the skin and leads to loss of its protective barrier. Over time, a perpetual itch-scratch-itch cycle develops, and the result is susceptibility to infection, ease of irritation and more itching. Symptoms consist of severe vulvar pruritus, which can be worse at night. Clinical findings include thick, lichenified, enlarged and rugose labia, with or without edema. The skin changes can be localized or generalized. Diagnosis is based on clinical history and findings, as well as vulvar biopsy. Treatment involves a short-course of high-potency topical corticosteroids and antihistamines to control pruritus.

Large for Gestation Age RF obese, who have diabetes, and with excessive gestational weight gain Metheylation of placental glucocorticoid receptor and upregulation of placental growth hormone / choronic somatomammotropin genes Beckwith Wideman, Sotos, Weave

complications -resp distress -shoulder dystocia -hypoglycemia -polycythemia -perinatal asphyxia These infants have significantly higher rates of severe hypoglycemia and neonatal jaundice

uterine cord prolapse

umbilical cord prolapse. Although fetal surveillance is reassuring, the most appropriate management is to continue to elevate the fetal head with a hand in the patient's vagina and call for assistance to perform a Cesarean delivery. It is important to elevate the fetal head in an attempt to avoid compression of the umbilical cord. Once an umbilical cord prolapse is diagnosed, expeditious arrangements should be made to perform a cesarean section. It is not appropriate to replace the umbilical cord into the uterus or allow the patient to continue to labor or perform a forceps-assisted vaginal delivery

Depression in Pregnancy

One SSRI, Paroxetine (Paxil) has recently been changed to a category D drug because of the increased risk of fetal cardiac malformations and persistent pulmonary hypertension. The older SSRI compounds, fluoxetine and sertraline, have not been reported to cause early pregnancy loss or birth defects in animals or in humans. Because these agents have few side effects compared with other antidepressants, they are a good choice for pregnant women. Tricyclic antidepressants have a long record of use in pregnancy and there is no increase in the rate of fetal malformation. Bupropion is not an MAO inhibitor, nor is it an SSRI and a report by the Bupropion Pregnancy Registry reports no unusual effects in 90 exposed pregnancies.

Menstrual Cycle

The average adult menstrual cycle lasts 28 to 35 days, with approximately 14 to 21 days in the follicular phase and 14 days in the luteal phase [1,2]. There is relatively little cycle variability among women between the ages of 20 and 40 years. In comparison, there is significantly more cycle variability for the first five to seven years after menarche and for the last 10 years before cessation of menses (figure 3) [1]. In general, menstrual-cycle length peaks at about age 25 to 30 years and then gradually declines so that women in their forties have slightly shorter cycles. Changes in intermenstrual interval are primarily due to changes in the follicular phase; in comparison, the luteal phase remains relatively constant

Caudal Regression Syndrome

incomplete development of the sacrum and sometimes of the lumbar vertebrae. This syndrome, whether associated with either occult or open spinal dysraphism, seems to occur with increased incidence in children of mothers with insulin-dependent diabetes -abnormal development of the caudal cell mass affecting all tissues that derive from it, including the neural, gastrointestinal, urogenital and musculoskeletal tissues of the caudal vertebral column and lower extremities -Affected infants may appear to have a small pelvis, neurogenic bladder, and variable degrees of limb deformity, depending on the level of the defect

Lupus and Pregnancy

malaise, fever, arthritis, rash, pleuropericarditis, photosensitivity w/ malar rash and oral lesions, anemia, and cognitive dysfunction. A significant number of patients have renal involvement. There is no cure, and complete remissions are rare. Mild disease may be disabling because of pain and fatigue. *Nonsteroidal anti-inflammatory drugs are used to treat arthralgia and serositis. Severe disease is managed with corticosteroids. *Hydroxychloroquine is used to help control skin manifestations and may be associated with lupus flares if discontinued.

Lesson from nbme

pyuria does not indicate UTI Infection related - A recently (within last 2 weeks) treated urinary tract infection (UTI) - Current antibiotics - even one dose of antibiotic before collection of urine specimen - Urine dilution by high fluid intake - Extreme frequency of urine - Use of an antiseptic to clean urethra prior to collection of MSU (false negative result) - Vulvo-vaginitis - infectious causes with contamination of sample with vulvo-vaginal leucocytes - Chlamydial urethritis - Urethritis - other infectious aetiologies e.g N. gonorrhoea - Prostatitis - Balanitis - Appendicitis - if appendix lies close to ureter or bladder - UTI with 'fastidious' or slow growing atypical organism (an organism that grows only in a specially fortified artificial culture media under specific culture conditions) - Viral infections of the lower genitourinary tract - Renal tract tuberculosis - consider in patients with fever, weight loss, night sweats, anorexia with no other obvious cause - Adenovirus - in immunocompromised patients - Schistosoma haematobium - concurrent eosinophilia is common, history of possible exposure? Non infection related - Presence of catheter or recent catheter - Recent cystoscopy and urinary tract surgery - Urinary tract stones - Physiological pyuria of pregnancy - Vulvo-vaginitis - non infectious causes with contamination of sample with vulvo-vaginal leucocytes - Urethritis - non infectious causes - Urinary tract neoplasm - Pelvic irradiation - Interstitial nephritis: analgesic nephropathy, sarcoidosis ( lymphocytes not neutrophils) -Renal papillary necrosis: diabetes, sickle cell disease, analgesic nephropathy - Polycystic kidneys - Interstitial cystitis - similar symptoms to UTI with sterile pyuria; cystoscopy shows inflammation, sometimes with ulceration; may progress to cause contracture of bladder; cause is unknown - Drugs - NSAIDS, steroids, cyclophosphamide, indinavir, - Malignant hypertension - Other reported associations include SLE and other systemic inflammatory diseases, Kawasaki disease

Congenital Toxoplasmosis ost newborns with congenital toxoplasmosis are asymptomatic. Among those who are symptomatic, clinical findings are nonspecific and may include chorioretinitis, intracranial calcifications, seizures, jaundice, hepatosplenomegaly, lymphadenopathy, anemia, thrombocytopenia, and abnormal cerebrospinal fluid.

subclinical disease is the rule, signs present at birth may include fever, maculopapular rash, hepatosplenomegaly, microcephaly, seizures, jaundice, thrombocytopenia, and, rarely, generalized lymphadenopathy the so-called classic triad of congenital toxoplasmosis consists of chorioretinitis, hydrocephalus, and intracranial calcifications Tx: if symptomatic or + serology pyrimethamine plus sulfadiazine (or sulfamerazine or sulfamethazine) and folinic acid (leucovorin) Complete blood counts should be monitored during therapy to evaluate drug-induced neutropenia, and hemolysis (for patients with G6PD deficiency)

Fetal Varicella Dx: Characteristic vesicular lesions Tx: Varicella-zoster immune globulin (VariZIG) postexposure prophylaxis - Newborns with severe infection should be treated with acyclovir -The use of aspirin should be avoided because of the increased risk of developing Reye syndrome. Use of acetaminophen may prolong the illness -encourage breast feeding A mother with active VZV lesions must be isolated. The infant is isolated from the mother until she is not infectious. Maternal exposure 6 to 21 days before hospitalization − A seronegative mother exposed to VZV 6 to 21 days before hospital admission should be isolated from other patients and the nursery because she may develop varicella while hospitalized. Her infant, if born at term, should be isolated with the mother. The mother and infant should be cared for only by staff with immunity to VZV. Nursery exposure — An infant who develops varicella in the nursery or NICU should be isolated

*Congenital varicella syndrome* occurs in infants whose mothers are infected between 8 and 20 weeks gestation. Clinical manifestations vary and include Cicatricial skin lesions, ocular defects (eg, cataracts, chorioretinitis, Horner syndrome, microphthalmos, and nystagmus), and abnormalities of the limb (eg, hypoplasia of bone and muscle) and central nervous system (eg, cortical atrophy, seizures, and cognitive impairment). neonatal varicella - mothers exposed within 2 weeks of delivery Fever may develop within the first days after birth, followed by a vesicular eruption. In mild cases, the lesions heal within 7 to 10 days. However, disseminated disease may ensue, with varicella pneumonia, hepatitis, and meningoencephalitis being the most common visceral manifestations. NOTE Postexposure prophylaxis with varicella-zoster immune globulin (VariZIG) is recommended for infants born to symptomatic mothers around the time of delivery, preterm infants with gestational age (GA) ≥28 weeks born to mothers without immunity, and preterm infants <28 weeks. We recommend a 10-day course of acyclovir (30 mg/kg per day in 3 divided doses IV) to treat neonatal varicella

Stages of Labor Normal labor progress is slower before 6 cm than after 6 cm, and this should be considered when making a diagnosis of a protraction disorder. Most common cause of protraction / arrest -Hypocontractile Uterine Activity other reasons: -Cephalopelvic Disproportion this diagnosis is often based upon observation of protracted or arrested labor during the active phase. In this setting, it is often due to fetal malposition (eg, extended or asynclitic fetal head) or malpresentation (mentum posterior, brow) rather than a true disparity between fetal size and maternal pelvic dimensions Occiput posterior (OP) position — Persistent OP position is associated with longer duration of first and second stages of labor, as well as a higher risk of arrest of descent requiring operative delivery Neuraxial anesthesia (epidural, spinal) Obesity

*First Stage* (avg 10-12hrs null, 6-8 multi) : onset of contraction to complete cervical dilation -Latent: gradual cervical change -Active: Rapid cervical change (>1 cm dilation/hr) *Protraction*: Friedman considered the minimum rate of acceptable cervical dilation during the active phase of the first stage of labor to be 1.2 cm/hour for nulliparous patients and 1.5 cm/hour for multiparous patients. A slower rate of cervical dilation was diagnostic of protracted labor. *Arrest of labor *is diagnosed at cervical dilation ≥6 cm dilation in a patient with ruptured membranes and: ●No cervical change for ≥4 hours despite adequate contractions ●No cervical change for ≥6 hours with inadequate contractions Tx: start Oxytocin and evaluate cervical change after four hours of adequate uterine contractions with oxytocin or six hours of inadequate uterine contractions with oxytocin prior to making a diagnosis of labor arrest and performing a cesarean delivery ( under 200 MVUs) *Second Stage* : cervical dilation to fetus expulsion -Passive: from dilation to pushing -Active: pushing to expulsion a second stage longer than two hours in nulliparas (three hours when regional analgesia is used), and longer than one hour in multiparas (two hours when regional analgesia is used) ●Nulliparous women: No progress (descent, rotation) after ≥4 hours with epidural anesthesia and ≥3 hours without epidural anesthesia ●Multiparous women: No progress (descent, rotation) after ≥3 hours with epidural anesthesia and ≥2 hours without epidural anesthesia *Third Stage* Expulsion of fetus to expulsion of placenta

Preterm Labor

*Risk Factors * No partner Low socioeconomic status Anxiety Depression Life events (divorce, separation, death) Abdominal surgery during pregnancy Occupational issues (upright posture, use of industrial machines, physical exertion, mental or environmental stress related to work or working conditions) Multiple gestation Polyhydramnios Uterine anomaly, including diethylstilbestrol-induced changes in uterus and leiomyomas Preterm premature rupture of membranes History of second trimester abortion History of cervical surgery Premature cervical dilatation or effacement (short cervical length) Sexually transmitted infections Systemic infection, pyelonephritis, appendicitis, pneumonia Bacteriuria Periodontal disease Placenta previa Placental abruption Vaginal bleeding, especially in more than one trimester Previous preterm delivery Substance abuse Smoking Maternal age (<18 or >40) African-American race Poor nutrition and low body mass index Inadequate prenatal care Anemia (hemoglobin <10 g/dL) Excessive uterine contractility Low level of educational achievement Maternal first degree family history of spontaneous preterm birth, especially if the pregnant woman herself was born preterm Fetal anomaly Fetal growth restriction Environmental factors (eg, heat, air pollution)

Pre-eclampsia RF: Hx of Pre-eclampsia 1st Pregnancy FHx GA-DM Blood pressure ≥130/80 mm Hg BMI over 26 Antiphospholipid antibodies CKD Multigestations AMA or Very Young Age Molar or Multifetal preg Diabetes Triploidy HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) probably represents a severe form of preeclampsia, but this relationship remains controversial; HELLP may be an independent disorder. As many as 15 to 20 percent of affected patients do not have concurrent hypertension or proteinuria, leading some experts to believe that HELLP syndrome is a separate disorder from preeclampsia. (See "HELLP syndrome".) ●Chronic/preexisting hypertension - Chronic/preexisting hypertension is defined as systolic pressure ≥140 mmHg and/or diastolic pressure ≥90 mmHg that antedates pregnancy or is present before the 20th week of pregnancy (on at least two occasions) or persists longer than 12 weeks postpartum. It can be primary (primary hypertension, formerly called "essential hypertension") or secondary to a variety of medical disorders. (See "Overview of hypertension in adults".) ●Preeclampsia superimposed upon chronic/preexisting hypertension - Superimposed preeclampsia is defined by the new onset of either proteinuria or end-organ dysfunction after 20 weeks of gestation in a woman with chronic/preexisting hypertension. For women with chronic/preexisting hypertension who have proteinuria prior to or in early pregnancy, superimposed preeclampsia is defined by worsening or resistant hypertension (especially acutely) in the last half of pregnancy or development of signs/symptoms of the severe spectrum of the disease (table 2). ●Gestational hypertension - Gestational hypertension refers to hypertension without proteinuria or other signs/symptoms of preeclampsia that develops after 20 weeks of gestation . It should resolve by 12 weeks postpartum. If hypertension persists beyond 12 weeks postpartum, the diagnosis is revised to chronic/preexisting hypertension that was masked by the physiologic decrease in blood pressure that occurs in early pregnancy. If hypertension resolves postpartum, the diagnosis is revised to transient hypertension of pregnancy.

-eclampsia is not an indication for C-section Caused by Abnormalities in the development of the placental vasculature early in pregnancy (hypoperfusion) Systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg on two occasions at least four hours apart after 20 weeks of gestation in a previously normotensive patient If systolic blood pressure is ≥160 mmHg or diastolic blood pressure is ≥110 mmHg, confirmation within minutes is sufficient and Proteinuria ≥0.3 grams in a 24-hour urine specimen or protein (mg/dL)/creatinine (mg/dL) ratio ≥0.3 Dipstick 1+ if a quantitative measurement is unavailable In patients with new-onset hypertension without proteinuria, the new onset of any of the following is diagnostic of preeclampsia: (Also criteria for SEVERE) Platelet count <100,000/microliter Serum creatinine >1.1 mg/dL or doubling of serum creatinine in the absence of other renal disease Liver transaminases at least twice the normal concentrations Pulmonary edema Cerebral or visual symptoms Tx: SEVERE: prepartum and postpartum MgSO4 and it is indication for delivery, regardless of gestational age, given the high risk of serious maternal morbidity. However, prolonged antepartum management in a tertiary care setting or in consultation with a maternal-fetal medicine specialist is an option for selected women remote from term (<34 weeks of gestation) -betamethasone if under 34 weeks For women with preeclampsia without features of severe disease, we suggest expectant management with delivery at ≥37 weeks of gestation - frequent laboratory monitoring (platelet count, liver and renal function tests), assessment of maternal blood pressure and symptoms, and evaluation of fetal growth and well-being. In most patients, antihypertensive therapy is not indicated for systolic blood pressure <160 mmHg or diastolic blood pressure <110 mmHg -

Bleeding During Pregnancy Uterine size larger than expected for dates suggests a multiple gestation, possibly with miscarriage of one of the multiples, gestational trophoblastic disease (molar pregnancy), or other uterine pathology (fibroids can cause an irregularly enlarged uterus)

1st trimester -ectopic preg -miscarriage (MCC) -implantation of normal pregnancy -polyps, ectriopion, infection/inflammation, trophoblastic disease Steps: Stabalize (+CBC) --> HPI, Physicial + Speculum +TV- US 2nd and 3rd trimester ●Bloody show associated with cervical insufficiency or labor (by definition, labor occurs after 20 weeks) ●Miscarriage (by definition, miscarriage occurs before 20 weeks) ●Placenta previa ●Abruptio placenta ●Uterine rupture ●Vasa previa Bleeding before 20 weeks The presence of only light, intermittent, painless bleeding suggests bloody show from cervical insufficiency, a small marginal placental separation, or a cervical or vaginal lesion (eg, polyp, infection, cancer). Heavier bleeding, particularly when associated with pain, is more consistent with impending miscarriage or a larger placental separation (ie, abruption) Bleeding After 20 weeks ●Placenta previa (20 percent) ●Abruptio placenta (30 percent) ●Uterine rupture (rare) ●Vasa previa (rare) In contrast to bleeding in the first half of pregnancy, digital examination of the cervix should be avoided in women presenting with bleeding in the second half of pregnancy until placenta previa has been excluded.

Breast 68yr breast tenderness, sister just diagnosed with breast cancer at 70. = Reassurance Genetic testing is not indicated in this case as there is no strong family history and the sister with breast cancer was postmenopausal at time of diagnosis. 43yo w/ dominant 2cm mass in breast. MRI normal. Multiple relatives w/ breast cancer. Next Step? Fine Needle Aspiration Any solid dominant breast mass on exam should be evaluated cytologically, with a fine needle aspiration (FNA), or histologically, with an excisional biopsy. In this scenario, an MRI should not be part of the initial work-up for the patient's palpable breast mass. Testing for genetic mutations is indicated for patients with a strong family history of breast cancer, but diagnosis is the most important next step in the management of this patient. A normal mammogram does not rule out the presence of cancer, and there is no reason to repeat the mammogram in two months, especially considering that the first one was normal. The first noticeable symptom of breast cancer is typically a lump that feels different from the rest of the breast tissue. More breast cancer cases are discovered when the woman feels a lump. Breast cancer can also present with a spontaneous bloody nipple discharge. Even though the mass decreased in size after aspiration, the bloody discharge obtained obligates an excisional biopsy be performed to rule out breast cancer. If clear discharge is obtained on aspiration and the mass resolves, reexamination in two months is appropriate to check that the cyst has not recurred. Any solid mass left after aspiration should always be excised. A specimen obtained on fine-needle aspiration (FNA) is examined both histologically and cytologically. An excisional biopsy should be performed when the results are negative, due to the possibility of a false-negative result. FNA can, however, prevent the need for other diagnostic testing and is the appropriate first step in the evaluation of a palpable breast mass. Breast ultrasound can be used to distinguish between a cyst and a solid mass. Fine needle aspiration under ultrasound guidance can help distinguish a fibroadenoma from a cyst and exclude cancer in certain situations.

23-year-old nulliparous woman presents with a painful nodule in her axilla for three days. In the axillary area, shaved skin is noted and an erythematous raised 1 cm lesion is palpated and is slightly tender to touch. = This is a typical presentation for folliculitis which can occur with shaving the axillary hair Woman finished breast feeding 6m ago...has a white watery nipple discharge for last 4m which can be expressed during PE. Serum prolactin after this is 45 (norm 40) what is next step? Obtain a fasting prolactin level Stimulation of the breast during the physical examination may give rise to an elevated prolactin level. Accurate prolactin levels are best obtained in the fasting state. If still elevated, then a TSH level and brain MRI would be indicated to rule out a pituitary tumor. Post partum women may continue to produce milk for up to two years after cessation of breastfeeding. Although pathologic factors such as hypothyroidism, hypothalamic disorders, pituitary disorders (adenomas, empty sella syndrome), chest lesions (breast implants, thoracotomy scars, and herpes zoster) and renal failure can elevate prolactin levels, a non-significant benign elevation needs to be ruled out first. A ductogram is usually indicated in patients who have bloody discharge from a single breast duct. Fibrocystic breast changes are the most common type of benign breast conditions and occur most often during the reproductive years. Fibrocystic disease is often associated with cyclic mastalgia, possibly related to a pronounced hormonal response. Caffeine intake can increase the pain associated with fibrocystic breast changes, so recommending that she decrease her caffeine intake may be helpful. Bilat nipple itchiness = chemical irriation Febrile woman nursing 2.5w baby w/ breast pain not relieved by APAP w/ erythema on the upper outer quadrant of the left breast which is tender to touch -start antibiotics + NSAID puerperal mastitis which most often occurs during the second to fourth week after delivery and the most appropriate next step in her management is to use ibuprofen in addition to acetaminophen for pain relief. She should be encouraged to continue breastfeeding or expressing their milk during treatment. ost postpartum mastitis is caused by staphylococcus aureus, so a penicillin-type drug is the first line of treatment. Dicloxacillin is used due to the large prevalence of penicillin resistant staphylococci. Erythromycin may be used in penicillin allergic patients.

Amenorrhea Thin w/ normal Prolactin and TSH Test: FSH and LH The causes of hypothalamic-pituitary amenorrhea are functional (weight loss, obesity, excessive exercise), drugs (marijuana and tranquilizers), neoplasia (pituitary adenomas), psychogenic (chronic anxiety and anorexia nervosa), and certain other chronic medical conditions. In this case, the next step to make a diagnosis is to obtain FSH and LH levels, which would be expected to be in the low range. Oral contraceptives (OCPs) are the most appropriate treatment for this patient who most likely has the diagnosis of polycystic ovarian syndrome (PCOS). The constellation of findings support this clinical diagnosis (irregular cycles, obesity, and hirsutism). Because she is using condoms for contraception and is sexually active, OCPs would help regulate her cycles and further provide effective contraception. Asherman's syndrome can be caused by curettage or endometritis. The intrauterine synechiae or adhesions result from trauma to the basal layer of the endometrium, which causes amenorrhea. Chronic endometritis may be associated with abnormal uterine bleeding and not amenorrhea.

24-year-old nulliparous woman comes into the office because she has not had her menses for six months. She is in good health and not taking any medications. She is not sexually active. She does well in graduate school, despite her demanding new program. Her height is 5 feet 6 inches and her weight is 104 pounds. Her vital signs are normal. Her physical examination, including a pelvic examination, is completely normal. What is the most likely reason for her amenorrhea? = Hypothalamic-pituitary dysfunction Anorexia nervosa or significant weight loss may cause hypothalamic-pituitary dysfunction that can result in amenorrhea. A lack of the normal pulsatile secretion of gonadotropin releasing hormone (GnRH) leads to a decreased stimulation of the pituitary gland to produce follicle stimulating hormone (FSH) and luteinizing hormone (LH). This leads to anovulation and amenorrhea. Dysparunia + abnormal menses....no other findings = Premature Ovarian failure (vaginal dryness is prob cause of dysparunia) The history, physical exam and labs make the other possibilities less likely: psychogenic disorder (no chronic anxiety or anorexia nervosa), outflow obstruction (previously had periods), Asherman's syndrome (no history of pregnancy or intrauterine procedures), or a pituitary tumor (normal labs). Measurement of serum prolactin level is part of the initial laboratory assessment for a patient with amenorrhea and no other symptoms or findings on physical exam. A prolactinoma is the most common pituitary tumor causing amenorrhea. Galactorrhea may be present when hyperprolactinemia is the cause of anovulation and amenorrhea.

Inferitility Use ovulation predictor kits and attempt intercourse after it turns positive The basal body temperature charts tell when a patient ovulated retrospectively, so it cannot be used to time intercourse to conceive, as the egg is only viable for about 24 hours. Although having intercourse more frequently will increase her likelihood of conceiving, it is not a practical solution for a working person to stop their work in order to conceive.

45 yr old This patient, most likely, has decreased ovarian reserve due to her age. A clomiphene challenge test, which consists of giving clomiphene citrate days five to nine of the menstrual cycle and checking FSH levels on day three and day 10, will help determine ovarian reserve. History of PID Hysterosalpinogram Overall algorithm Female - Pelvix Exam TSH and Prolactin Male - semen test Female - Hysterosalpinogram

Premenstrual Dysphoric Disorder

5 or more of following the week prior to mense declining w/in a few days after the onset of menses w/ 1 of them being a core symptom Core: Affective Liability, Irritability, markedly depressed mood, marked anxiety Non-core: anhedonia, dc concentration, lethargy, appetite changes, sleep changes, overwhelmed feeling, physical sx (breast tenderness, bloating, muscle jx pt, HA) fxal life difficulties -exclude other psych paths first MUST OCCUR FOR AT LEAST 2 CYCLES Tx: SSRIs -Fluoxetine -{Paroxetine - Citalopram - Sertraline

Lichen Planus Lichen planus is a chronic dermatologic disorder involving the hair-bearing skin and scalp, nails, oral mucous membranes and vulva. This disease manifests as inflammatory mucocutaneous eruptions characterized by remissions and flares. The exact etiology is unknown, but is thought to be multifactorial. Vulvar symptoms include irritation, burning, pruritus, contact bleeding, pain and dyspareunia. Clinical findings vary with a lacy, reticulated pattern of the labia and perineum, with or without scarring and erosions as well. With progressive adhesion formation and loss of normal architecture, the vagina can become obliterated. Patients may also experience oral lesions, alopecia and extragenital rashes. Treatment is challenging, since no single agent is universally effective and consists of multiple supportive therapies and topical superpotent corticosteroids.

52-year-old nulliparous woman presents with long-standing vulvar and vaginal pain and burning. DYSPARUNIA, painful sitting and clothing. Gums bleed. Products on genitals hurt. Her physical examination is remarkable for inflamed gingiva and a whitish reticular skin change on her buccal mucosa. A fine papular rash is present around her wrists bilaterally. Pelvic examination reveals white plaques with intervening red erosions on the labia minora as shown in below picture. A speculum cannot be inserted into her vagina because of extensive adhesions.

Ovarian Torsion 1 The sudden onset of pain and nausea, as well as the presence of a cyst on ultrasound suggest ovarian torsion. 26-year-old G0 presents to the emergency room with eight hours of severe right lower quadrant pain associated with nausea w/ paplable adnexal mass Tx = surgical exploration ( A Doppler ultrasound to check the blood flow to the ovaries is controversial, as normal flow does not rule out ovarian torsion. )

A 26-year-old G0 woman presents with severe right lower quadrant pain associated with nausea for the last six hours, which began shortly after she finished her aerobic exercises. On abdominal examination, she has moderate tenderness to palpation in the right lower quadrant. On pelvic exam, she has no lesions or discharge. A thorough bimanual exam was difficult to perform due to her discomfort. Beta-hCG <5 mIU/ml and WBC is 8,500 /microliter. A pelvic ultrasound showed a 6 cm right ovarian mass. The uterus and left ovary appeared normal. There was a moderate amount of free fluid in the pelvis.

Down Syndrome

A flattened nasal bridge, small size and small rotated, cup-shaped ears may be associated with Down syndrome and should prompt a survey looking specifically for other features seen with Down syndrome that include sandal gap toes, hypotonia, a protruding tongue, short broad hands, Simian creases, epicanthic folds, and oblique palpebral fissures. The initial physical findings may be a variant of normal, therefore, you should not share any concerns with the mother until you perform a detailed physical examination. Wide-spaced nipples and lymphedema are associated with Turner syndrome. It is not standard of care to offer amniocentesis to a 19-year-old, unless she has specific risk factors.

Autosomal Recessive Non-Hispanic white individuals, including Ashkenazi Jews, are at increased risk for being carriers for cystic fibrosis. The carrier frequency is approximately 1/25 in the non-Hispanic white population. Since the patient's husband is not of Ashkenazi Jewish or French Canadian descent, he is not at increased risk for being a carrier for Tay-Sachs disease. The carrier frequency for Tay-Sachs disease is estimated at 1/30 for Ashkenazi Jews. The gene occurs at a much lower frequency (1 in 300) in most other populations. Canavan disease, Bloom syndrome and Gaucher's disease occur at an increased incidence in the Ashkenazi Jewish population. The carrier frequency for Gaucher's disease is approximately 1/15 for Ashkenazi Jews. The frequency of the disease is 1/900 in this population.

Abetalipoproteinemia. Acute fatty liver of pregnancy. Alkaptonuria. Bernard-Soulier syndrome. Bloom syndrome. Carpenter syndrome. Chediak-Higashi syndrome. Chondrodystrophy. CAH. Congenital hepatic fibrosis. Cystic Fibrosis. Cystinosis, Cystinuria. Dubin-Johnson syndrome. Endocardial Fibroelastosis. Familial Mediterranean Fever. Fanconi Anemia. Friedrech's Ataxia. Gastroschisis. Gaucher's disease. Glanzman's Thromasthenia. Glycogen storage diseases. Hartnup Disease. Krabbe Disease. Leukocyte Adhesion Defect. Nieman Pick Disease. Rotor syndrome. Shwaman Diamond syndrome. Situs Inversus. Sickle cell Disease and Trait. Tay-Sachs. Thalasemia. Werner syndrome. Wilson's Disease. Xeroderma pigmentosa.

Spontaneous Abortion Risk Factors Advancing maternal age is the most important risk factor for spontaneous miscarriage in healthy women. Previous spontaneous abortion rolonged ovulation to implantation interval — Early losses have been related to delayed implantation (ie, >10 days between ovulation and implantation) Prolonged time to conceive Smoking Alcohol Cocaine NSAIDs (not APAP) low folate Extremes of maternal weight (overweight/under) Untreated Celiacs Uterine Structural Issues Maternal Infection First trimester abortions: main cause is genetic fetal abnormalities Autosomal trisomy is the most common abnormal karyotype encountered in spontaneous abortuses, accounting for approximately 40-50% of cases. Triploidy accounts for approximately 15%, tetraploidy 5% of cases, and Monosomy X (45X, 0) identified in 15-25% of losses Systemic diseases such as diabetes mellitus, chronic renal disease and lupus are associated with early pregnancy loss. In women with insulin-dependent diabetes, the rates of spontaneous abortion and major congenital malformations are both increased. This patient has an incompetent cervix (RF cone biposy) and should have a cervical cerclage at 14 weeks. A positive fetal fibronectin does not indicate incompetent cervix and is used later in pregnancy as a negative predictor of preterm delivery. Pregnancy loss in the late second trimester is not usually related to genetic abnormality of the conceptus and most clinicians delay placement of a cerclage until after the first trimester, given the high background prevalence of first trimester pregnancy wastage The clinician should reassure this patient that first trimester spontaneous abortion is a common occurrence and that she has not caused this missed abortion. No increased risk The risk of developing microcephaly and severe intellectual disability is greatest between eight and 15 weeks gestation. No risk under 8 weeks or above 25.

Actively bleeding patient G1p0 w/ dialated cervical os *This patient is actively bleeding and is anemic. She, therefore, requires immediate surgical treatment consisting of dilation and suction curettage*. Although clinicians increasingly utilize both expectant management and various drug regimens to treat spontaneous abortion, a prerequisite for either is that the patient is hemodynamically stable and reliable for follow-up care. Endometrial ablation will not work in this case, as the products of conception need to be evacuated to control the bleeding Regardless of method chosen, the patient's blood type should be checked and rhogam administered as indicated. if b-hcg under 2000, no need for us just do a bhcg again in 48hrs b-hcG does not double in 48hrs and progesterone level is 4. The pregnancy is abnormal based on the abnormal Beta-hCG levels and the progesterone level. In a normal pregnancy, the level should rise by at least 50% every 48 hours until the pregnancy is 42 days old (after that time, the rise in level may not follow the curve). A progesterone level of <5 ng/ml suggests an abnormal or extrauterine pregnancy. In this instance, the pregnancy is intrauterine because of the presence of a yolk sac. Dilation and curettage is an option for treatment. Other options include expectant management, misoprostol or manual vacuum aspiration. Laparoscopy and methotrexate are not indicated as this is a confirmed intrauterine pregnancy. Patients experiencing early pregnancy loss can safely consider several different treatments, including expectant management, medical treatment to assist with expulsion of the pregnancy or surgical evacuation. Provided the patient is hemodynamically stable and reliable for follow-up, expectant management is appropriate therapy. It is important to rule out systemic disease in a patient with recurrent abortion (three successive first trimester losses). Testing for lupus anticoagulant, diabetes mellitus and thyroid disease are commonly performed. Maternal and paternal karyotypes should also be obtained. Infectious causes should also be considered. Uterine imaging to exclude a septum or other anomaly is routinely done using hysteroscopy or hysterography and not CT or MRI scanning no increased risk in subsequent pregnancies

Bacterial Vaginosis postcoital musty odor and increased milky, gray-white discharge for the last week Pertinent labs: wet mount pH >4.5 and whiff test positive. Microscopic exam reveals clue cells, but no trichomonads or hyphae.

All symptomatic pregnant women should be tested and treatment should be not be delayed because treatment has reduced the incidence of preterm delivery. The optimal regimen for women during pregnancy is not known, but the oral metronidazole regimens are probably equally effective. Once treated antepartum, there is no need to treat during labor unless she is reinfected.

Menopausal 48yo w/ 3 skipped periods is most likely perimenopausal Although there has been a decline in the average age of menarche with the improvement in health and living conditions, the average age of menopause has remained stable. The Massachusetts Women's Health Study reports that the average age of menopause is 51.3. This patient is most likely perimenopausal and will probably have more menstrual periods in the future. Take 1200 Calcium daily The most important lipid effects of postmenopausal hormone treatment are the reduction in LDL cholesterol and the increase in HDL cholesterol. Estrogen increases triglycerides and increases LDL catabolism, as well as lipoprotein receptor numbers and activity, therefore causing decreased LDL levels. Hormones inhibit hepatic lipase activity, which prevents conversion of HDL2 to HDL3, thus increasing HDL levels. Estrogen production by the ovaries does not continue beyond menopause. However, estrogen levels in postmenopausal women can be significant due to the extraglandular conversion of androstenedione and testosterone to estrone

Although the patient's worsening symptoms make treatment an important consideration, the specific organic cause(s) of abnormal bleeding must be ruled out prior to initiating therapy. A tissue diagnosis consistent with normal endometrium or a pelvic ultrasound with an endometrial stripe of <4 mm ought to be documented. This patient has many of the major risk factors for osteoporosis including history of fracture as an adult, low body weight and being a current smoker. Patients who already have had an osteoporotic fracture may be treated on this basis alone. Prior to beginning treatment with bisphosphonates, a bone mineral density (BMD) should be documented and repeated at two-year intervals to monitor treatment The World Health Organization (WHO) defines osteopenia (low bone mass) as -1 to -2.5. The American College of Obstetricians and Gynecologists (ACOG) Committee Opinion recommends that physicians interpret T scores between −1.0 and −2.5 in combination with the patient's risk factors for fracture Some of the risk factors for fracture include prior fracture, family history of osteoporosis, race, dementia, history of falls, poor nutrition, smoking, low body mass index, estrogen deficiency, alcoholism, and insufficient physical activity.

Gestational Diabetes RF isk factors — Pregnant women with any of the following characteristics appear to be at increased risk of developing gestational diabetes; the risk increases when multiple risk factors are present [32]: ●Personal history of impaired glucose tolerance or gestational diabetes in a previous pregnancy ●Member of one of the following ethnic groups, which have a high prevalence of type 2 diabetes: Hispanic-American, African-American, Native American, South or East Asian, Pacific Islander ●Family history of diabetes, especially in first degree relatives [33] ●Prepregnancy weight ≥110 percent of ideal body weight or BMI >30 kg/m2, significant weight gain in early adulthood and between pregnancies [34], or excessive gestational weight gain [35-37] ●Maternal age >25 years of age ●Previous delivery of a baby >9 pounds (4.1 kg) ●Previous unexplained perinatal loss or birth of a malformed infant ●Maternal birthweight >9 pounds (4.1 kg) or <6 pounds (2.7 kg) ●Glycosuria at the first prenatal visit ●Medical condition/setting associated with development of diabetes, such as metabolic syndrome, polycystic ovary syndrome (PCOS), current use of glucocorticoids, hypertension

Always screen at 24-28 weeks The terminology for diabetes diagnosed in pregnancy is in flux. The terms "overt" and "gestational diabetes" are based primarily on gestational age at diagnosis. Diagnosis of diabetes at 24 to 28 weeks of gestation is consistent with gestational diabetes, while diagnosis at the first prenatal visit (in early pregnancy) is more consistent with overt diabetes

Maternal Pulmonary Hypertension

Among women with cardiac disease, patients with pulmonary hypertension are among the highest risk for mortality during pregnancy, a 25-50% risk for death. Management of labor and delivery is particularly problematic. These women are at greatest risk when there is diminished venous return and right ventricular filling which is associated with most maternal deaths. Similar mortality rates are seen in aortic coarctation with valve involvement and Marfan syndrome with aortic involvement. The baby is not at increased risk of pulmonary hypoplasia or Marfan's due to the mother's condition.

Eating Disorders DSM-5 diagnostic criteria for anorexia nervosa A. Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected. B. Intense fear of gaining weight or of becoming fat or persistent behavior that interferes with weight gain, even though at a significantly low weight. C. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weigh anemia, 38.6%; leukocytopenia, 34.4%; hyponatremia, 19.7%; hypokalemia, 19.7%; bradycardia, 41.3%; hypotension, 16.1%; hypothermia, 22.4%; elevation of alanine aminotransferase concentration, 12.2%; osteopenia, 51.7%; osteoporosis, 34.6%; and primary amenorrhea, 14.8%. DSM-5 diagnostic criteria for bulimia nervosa A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 1) Eating, in a discrete period of time (eg, within any two-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances. 2) A sense of lack of control over eating during the episode (eg, a feeling that one cannot stop eating or control what or how much one is eating). B. Recurrent inappropriate compensatory behavior to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise. C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for three months. D. Self-evaluation is unduly influenced by body shape and weight. E. The disturbance does not occur exclusively during episodes of anorexia nervosa. UMINATION DISORDER Epidemiology — The prevalence of rumination disorder is not clear [1]. Diagnosis — The DSM-5 diagnosis of rumination disorder requires each of the following [1]: ●Repeated regurgitation of food, which may be rechewed, reswallowed, or spit out; the eating disturbance occurs for at least one month ●Regurgitation of food is not due to a general medical condition, such as gastroesophageal reflux disease or pyloric stenosis. (See "Clinical manifestations and diagnosis of gastroesophageal reflux in adults" and "Approach to the infant or child with nausea and vomiting", section on 'Pyloric stenosis'.) ●Regurgitation does not occur solely during the course of avoidant/restrictive food intake disorder, anorexia nervosa, binge eating disorder, or bulimia nervosa ●If the eating behavior occurs in the context of another mental disorder (eg, intellectual disability) or general medical condition (including pregnancy), the severity of the eating behavior warrants additional clinical attention Little is known about the course of illness in rumination disorder

Anorexia Nervosa -core features of anorexia nervosa are persistent restriction of energy intake that leads to an abnormally low body weight; intense fear of gaining weight or becoming fat, or persistent behavior that prevents weight gain; and distorted perception of body weight and shape. Other features include perfectionism, cognitive and behavioral rigidity, feelings of ineffectiveness, inhibited expression of emotions, social withdrawal, poor insight, resistance to treatment, restlessness or hyperactivity, as well as symptoms and signs related to food and eating, such as preoccupation with food and rituals related to meals -emaciation, hypothermia, bradycardia, hypotension, hypoactive bowel sounds, dry skin, brittle hair, and hair loss. Common laboratory findings include leukopenia, elevated blood urea nitrogen, hypercholesterolemia, low triiodothyronine, low estrogen levels in females and low testosterone concentrations in males, and low bone mineral density with osteopenia and osteoporosis - vomiting after eating, which can erode dental enamel and cause hypertrophy of the parotid glands and "puffy" cheeks. Regular vomiting can also cause dehydration, hypokalemia, hypochloremia, and metabolic alkalosis Binge Eating Disorder The DSM-5 diagnosis of binge eating disorder requires each of the following [1]: ●Episodes of binge eating, defined as consuming an amount of food in a discrete period of time (eg, two hours) that is definitely larger than what most people would eat in a similar amount of time under similar circumstances. During episodes, patients feel they lack control over eating (eg, patients feel they cannot stop eating or control the amount or what they are eating). ●Binge eating episodes are marked by at least three of the following: •Eating more rapidly than normal •Eating until feeling uncomfortably full •Eating large amounts of food when not feeling physically hungry •Eating alone because of embarrassment by the amount of food consumed •Feeling disgusted with oneself, depressed, or guilty after overeating ●Episodes occur, on average, at least once a week for three months ●No regular use of inappropriate compensatory behaviors (eg, purging, fasting, or excessive exercise) as are seen in bulimia nervosa ●Binge eating does not occur solely during the course of bulimia nervosa or anorexia nervosa

Preterm labor 20-year-old G1P0 woman at 28 weeks gestation presents to triage with uterine contractions every four minutes. On exam, her cervix is long, closed and posterior. Her urinalysis is normal. Fetal fibronectin is negative. In addition to hydration, which of the following is the most appropriate next step in the management of this patient? -Observations 20-year-old G2P1 28w. Toco q4. Temp = 100.5°F (38.0°C); heart rate 120; respiratory rate 18, and blood pressure 110/65. Her uterine fundus is tender, dilated 1 cm, 50% effaced. Baby is in vertex presentation. Fetal heart tones are in the 150s with a category I tracing. Her white blood cell count (WBC) is 18,000/mcL. This patient has a fever, a tender fundus, and elevated white blood cell count, which are concerning for an intra-amniotic infection. Delivery is warranted and in the case of reassuring heart tones, there are no contraindications for labor induction and a Cesarean section is not indicated at this time

Approximately 50% of patients with preterm contractions have spontaneous resolution of abnormal uterine activity. The patient should be observed until a correct diagnosis is made. If there is evidence the patient is dehydrated and she is unable to tolerate PO fluids, then IV hydration would be indicated. Preterm labor, which is defined as the presence of regular uterine contractions leading to cervical change, needs to be promptly treated. Tocolysis is not necessary in this case because a diagnosis of preterm labor has not been made (no cervical change). The patient should not be sent home until diagnosis and treatment plans are determined. Since fetal fibronectin is negative and the patient is not in labor, she can be expectantly managed. Cerclage is not necessary, since she does not have an incompetent cervix. Treatment with betamethasone is not indicated unless there is evidence that the patient is at increased risk of delivering preterm. Bedrest is not indicated and has not been shown to reduce preterm birth. ibronectin is an extracellular matrix protein that is thought to act as an adhesive between the fetal membranes and underlying decidua. It is normally found in cervical secretions in the first half of pregnancy. Its presence in the cervical mucus between 22 and 34 weeks is thought to indicate a disruption or injury to the maternal-fetal interface. Fetal fibronectin is FDA approved for use in women with symptoms of preterm labor from 24 to 35 weeks and during routine screening of asymptomatic patients from 22 to 30 weeks gestation. Fetal fibronectin has a negative predictive value of 99.2% in symptomatic women — 99 out of every 100 patients with a single negative test result will not deliver in the next 14 days. The positive predictive value in symptomatic women is 16.7% — 17 out of 100 women with a positive test will deliver within 14 days. In asymptomatic women, a negative fetal fibronectin test has a negative predictive value of 96.7% for delivery before 35 weeks.

Asthma in Pregnancy Step1: PRN SABA Step 2: low dose Inhaled glucocorticoids (alt = Cromolyn, LTRA, or Theophylline) Step3: low dose inhaled glucocorticoids + LABA (or medium dose inhaled glucocorticoids, alts = low dose cort + LRTA, Theophylline, or Zileuton)

Asthma generally worsens in 40% of pregnant patients. One of the indications for moving to the next line of treatment includes the need to use beta agonists more than twice a week. The appropriate choice for her treatment would be inhaled corticosteroids or cromolyn sodium. Theophylline would be used in more refractory patients. Subcutaneous terbutaline and systemic corticosteroids would be used in acute cases. Zafirlukast, a leukotriene receptor antagonist, is not effective for acute disease. There is little experience with their use in pregnancy, thus the safety of zafirlukast in pregnancy is not well established. Antibiotic treatment is only used when a pulmonary infection is diagnosed.

Endometrial Biopsy results Tx Oral contraceptive pills (OCPs) suppress endometrial development, reestablish predictable bleeding patterns, decrease menstrual flow, and lower the risk of iron deficiency anemia. OCPs can be used effectively in a cyclic or continuous regimen to control dysfunctional bleeding. Acute episodes of heavy bleeding suggest an environment of prolonged estrogenic exposure and buildup of the lining. Bleeding usually is controlled within the first 24 hours, as the overgrown endometrium becomes pseudodecidualized. Seek alternate diagnosis if flow fails to abate in 24 hours. The type of OCP and underlying patient factors may be important determinants of potential risk for complications associated with OCPs. Studies have shown an increased risk of nonfatal venous thromboembolic events (blood clots) associated with contraceptives that contain drospirenone as compared with those that contain levonorgestrel. Estrogen Estrogen alone, in high doses, is indicated in certain clinical situations. Prolonged uterine bleeding suggests the epithelial lining of the cavity has become denuded over time. In this setting, a progestin is unlikely to control bleeding. Estrogen alone will induce return to normal endometrial growth rapidly. Hemorrhagic uterine bleeding requires high-dose estrogen therapy. If bleeding is not controlled within 12-24 hours, a D&C is indicated. Beginning progestin therapy shortly after initiating estrogen therapy to prevent a subsequent bleeding episode from treatment with prolonged unopposed estrogen is wise.

Benign endometrial histology includes atrophy (absence of a hormonal effect), proliferative endometrium (estrogen effect), secretory endometrium (progestin effect), disordered or dyssynchronous endometrium (implies irregular shedding of the endometrium secondary to unopposed estrogen), and endometritis. Further endometrial assessment should also be considered when the endometrial biopsy is nondiagnostic, but a high suspicion of cancer remains Normal endometrium — During the normal menstrual cycle, proliferative endometrium is found during the follicular phase, and secretory endometrium is found during the luteal phase (figure 1). Normal proliferative endometrium exhibits no crowding of glands within the stroma (<50 percent ratio of glands to stroma). Normal secretory endometrium may have >50 percent gland to stroma ratio. Although they exhibit crowding, these glands are organized, and cells comprising the glands are spaced and are not mitotically active. Normal proliferative and secretory endometrium is shown in the picture

Fat and Pregnant

Body mass index (BMI) is equal to a person's weight divided by their height. The National Heart, Lung, and Blood Institute identify a normal BMI is 18.5 to 24.9 kg/m2; overweight is a BMI of 25 to 29.9 kg/m2; and obesity is a BMI of 30 kg/m2 or greater. Obesity is further categorized as class I (BMI: 30 to 34.9 kg/m2), class II (BMI: 35 to 39.9 kg/m2), and class III (BMI: 40-plus kg/m2). Increased maternal morbidity results from obesity and includes *chronic hypertension, gestational diabetes, preeclampsia, fetal macrosomia, as well as higher rates of Cesarean delivery and postpartum complications.* This patient's BMI is over 38 so she is a class II and has over a 7-fold increase risk for preeclampsia and a 3-fold risk for hypertension.

BV

Bacterial vaginosis is the most common cause of vaginitis. The infection arises from a shift in the vaginal flora from hydrogen peroxide-producing lactobacilli to non-hydrogen peroxide-producing lactobacilli, which allows proliferation of anaerobic bacteria. The majority of women are asymptomatic; however, patients may experience a thin, gray discharge with a characteristic fishy odor that is often worse following menses and intercourse. Modified Amsel criteria for diagnosis include three out of four of the following: 1) thin, gray homogenous vaginal discharge; 2) positive whiff test (addition of potassium hydroxide releases characteristic amine odor); 3) presence of clue cells on saline microscopy; and 4) elevated vaginal pH >4.5. Treatment consists of Metronidazole 500 mg orally BID for seven days, or vaginal Metronidazole 0.75% gel QHS for five days.

Breast Feeding Although the side lying position is a good one for breastfeeding, it is important for mother and baby to be belly-to-belly in order for the infant to be in a good position to latch on appropriately, taking a large part of the areola into its mouth. The pain experienced by the patient from her tubal may be interfering with appropriate position and she should be counseled about a different, more comfortable position. Hospital policies that promote breastfeeding include getting the baby on the breast within a half hour of delivery and rooming-in for the baby to ensure frequent breastfeeding on demand (i.e. unlimited access). Signs that a baby is getting sufficient milk include 3-4 stools in 24 hours, six wet diapers in 24 hours, weight gain and sounds of swallowing. While prolactin is responsible for milk production, oxytocin is responsible for milk ejection. Production of oxytocin is stimulated by suckling which works better than a breast pump for stimulating the secretion of milk. Cortisol and insulin act in concert with other hormones to stimulate the growth and development of the milk-secreting apparatus.

Benefits to the mother include increased uterine contraction due to oxytocin release during milk let down and decreased blood loss. Breastfeeding is associated with a decreased incidence of ovarian cancer. Some studies have reported a decreased incidence of breast cancer. Breastfeeding has not been shown to decrease the risk for developing coronary artery disease, cervical dysplasia and cervical cancer or colon cancer in the mother. Breast milk is a major source of Immunoglobulin A which is associated with a decrease of newborn's gastrointestinal infections. Prolactin is responsible for the synthesis of milk, but although present in large quantities during gestation, its action is inhibited by the hormones of pregnancy, particularly estrogen and progesterone. After delivery, large amounts of prolactin continue to be secreted, milk is produced after the inhibitory action of estrogen and progesterone is lifted. With delivery, there is a rapid and profound decrease in the levels of progesterone and estrogen, which removes the inhibitory influence of progesterone on the production of alpha-lactalbumin by the rough endoplasmic reticulum. The increased alpha-lactalbumin serves to stimulate lactose synthase and ultimately to increase milk lactose. Progesterone withdrawal allows prolactin to act unopposed in its stimulation of alpha-lactalbumin production. This may take up to two days.

Postpartum Infections Mixed bacteria originating from the skin, uterus and vagina cause wound infections after a Cesarean section. Prior to establishing a diagnosis of surgical site infection, evaluation requires opening the wound, checking for fascial dehiscence, drainage and assessment of the fluid. Packing the wound until it has healed from the base of the wound facilitates the healing process. Broad spectrum antibiotics are indicated if you suspect cellulitis or abscess. Non-pregnancy related conditions must be considered when evaluating women in the postpartum period. Pregnancy puts women at risk for cholelithiasis and, therefore, cholecystitis. Classic symptoms include nausea, vomiting, dyspepsia and upper abdominal pain after eating fatty foods. Treatment would be dependent on the severity of symptoms, but often involves cholecystectomy that is usually performed laparoscopically. Example: Her laceration was repaired in layers in the customary fashion. She now complains of increasing pain in her perineal area, fever, chills and weakness. Her vital signs are: blood pressure 90/50; pulse 120; and temperature 102.2° F (39° C). Her abdomen is soft, nontender and her uterine fundus is firm and nontender. Her perineum is erythematous, swollen, but the laceration edges have separated and are grey. Tx: Antibiotics + Aggressive debridement of the necrotic areas is required to prevent further spread of the infection. Debridement should extend until vital tissue with good blood supply is encountered. Repair of the defect should be delayed until the infection has completely resolved

Breast engorgement is an exaggerated response to the lymphatic and venous congestion associated with lactation. Milk "let-down" generally occurs on postpartum day two or three. If the baby is not feeding well, the breast can become engorged, which can cause a low-grade fever. Lactating women are encouraged to feed their baby frequently, and use a breast pump to prevent painful engorgement and mastitis. Postpartum fever differential includes endometritis, cystitis and mastitis. These are easy distinguished, based on clinical findings. Vaginitis is not accompanied by fever. Septic pelvic thrombophlebitis is a rare condition and characterized by high fever not responsive to antibiotics and is a diagnosis of exclusion. Septic thrombophlebitis involves thrombosis of the venous system of the pelvis. Diagnosis is often one of exclusion of other causes, but sometimes a CT scan will reveal thrombosed veins. Treatment requires addition of anticoagulation to antibiotics and resolution of fevers is rapid. Anticoagulation treatment is short-term Example: You are called to evaluate her because her temperature is 102.0° F (38.9° C). The patient does not have any specific complaints. She has experienced intermittent chills. Her exam is non-focal. There is no uterine tenderness. A urine analysis shows no WBCS and is nitrate and leukocyte estrase negative. Fever continues at 102. Next step? Chest Xray. The lungs are the most common source of fever on the first postpartum day, particularly if the patient had general anesthesia. Atelectasis may be associated with a postpartum fever. Aspiration pneumonia should be considered in patients who had general anesthesia

Hashimotos

Cytotoxic T cells destroy parenchyma (type IV hypersensitivity reaction [HSR]) • Initial thyrotoxicosis, eventual hypothyroidism (2) Blocking antibodies against TSH receptor (type II HSR) • Decrease hormone synthesis; type II hypersensitivity (3) Helper T cells release cytokines attracting macrophages that damage tissue (type IV HSR) (4) Antimicrosomal and antithyroglobulin antibodies destroy parenchyma (type II HSR) c. Gross and microscopic (1) Enlarged, gray gland (2) Lymphocytic infiltrate with prominent germinal follicles (Fig. 23-7A) d. Clinical findings (1) Most common cause of primary hypothyroidism (2) Initial thyrotoxicosis from gland destruction • Known as hashitoxicosis (3) Signs of hypothyroidism (see later discussion) (4) Risk factor for primary B-cell malignant lymphoma of the thyroid

Erbs Palsy The signs of Erb's Palsy include loss of sensation in the arm and paralysis and atrophy of the deltoid, biceps, and brachialis muscles.[8] "The position of the limb, under such conditions, is characteristic: the arm hangs by the side and is rotated medially; the forearm is extended and pronated. The arm cannot be raised from the side; all power of flexion of the elbow is lost, as is also supination of the forearm".[6] The resulting biceps damage is the main cause of this classic physical position commonly called "waiter's tip

C5-C6 ventri rami The paralysis can be partial or complete; the damage to each nerve can range from bruising to tearing. The most commonly involved root is C5 (aka Erb's point: the union of C5 & C6 roots)[8] as this is mechanically the furthest point from the force of traction, therefore, the first/most affected.[6] Erb-Duchenne palsy presents as a lower motor neuron syndrome associated with sensibility disturbance and vegetative phenomena.[9] The most commonly involved nerves are the suprascapular nerve, musculocutaneous nerve, and the axillary nerve

Indications for C-section

CPD Failed Induction of Labor Active Genital Herpes Untreated HIV [women whose viral load remains >1000 copies/mL prior to 38 weeks gestation (eg, women not taking ARV agents, women presenting late in pregnancy, or women not responding to their current ARV regimen), pre-labor cesarean section significantly decreases the risk of transmission to the child.] Cervical Cancer Prior Uterine Surgery (c-section, full thickness myomectomy) Prior Uterine Rupture Obstruction of canal (Fibroids, ovarian tumors) Non-reassuring fetal testing (bradycardia, absence of FHR variability, Scalp pH under 7.2) Cord Prolapse Fetal malpresentations (breech, transverse lie, brow) Multiple gestatations (nonvertex 1st twin, higher-order multiples) Fetal Anomalies (hydrocephalus, OI) Placental (Placenta previa, Vasa previa, abruptio placetae)

Mucopurulent Cervicitis

Ceftriaxone and azithromycin

Pelvic Prolapse Tx Pessary fitting is the least invasive intervention for this patient's symptomatic prolapse. Although a sacrospinous ligament suspension would be an appropriate procedure for this patient, it is invasive and not an appropriate first step.

Central and lateral cystoceles are repaired by fixing defects in the pubocervical fascia or reattaching it to the sidewall, if separated from the white line. Defects in the rectovaginal fascia are repaired in rectoceles. Uterine prolapse is surgically treated by a vaginal hysterectomy, but this patient already had a hysterectomy 90yr patient with symotpmatic prolapse Because of the hydronephrosis due to obstruction, intervention is required. Colpocleisis is a procedure where the vagina is surgically obliterated and can be performed quickly without the need for general anesthesia. Anterior and posterior repairs provide no apical support of the vagina. She will be at high risk of recurrent prolapse. The sacrospinous fixation (cuff to sacrospinous-coccygeus complex) or sacrocolpopexy (cuff to sacral promontory using interposed mesh) require regional or general anesthesia and is not the best option for this patient with high surgical morbidity.

Infertility testing Infertility is defined as the inability to achieve pregnancy after one year of regular, unprotected intercourse. A menstrual cycle length of 22 to 35 days suggests ovulatory cycles, as does the presence of mittelschmerz and premenstrual symptoms The following tests are useful in most couples with infertility: ●Semen analysis to assess male factors ●Menstrual history, assessment of LH surge in urine prior to ovulation, and/or luteal phase progesterone level to assess ovulatory function ●Hysterosalpingography to assess tubal patency and the uterine cavity. ●Day 3 serum FSH and estradiol levels. In select couples, the following additional tests may be warranted: ●Pelvic ultrasound to assess for uterine myomas and ovarian cysts ●Laparoscopy to identify endometriosis or other pelvic pathology ●Assessment of ovarian reserve in women >35 years of age; this may involve a clomiphene challenge test, ultrasound for early follicular antral follicle count, day 3 serum inhibin B level, or antimüllerian hormone measurement. ●Assessment of thyroid function. Day 3 FSH and CCCT — Both the day 3 FSH level (where day 1 is the first day of full menstrual flow) and the CCCT, which is a provocative test for measurement of FSH, are widely used for screening ovarian reserve.

Cervical cultures are negative. Her husband's semen analysis is within normal limits. Which of the following is the most appropriate next step in diagnosis? 1) H and P 2) Ovulation Assessment Serum Progesterone (preferred) See Mid-Luteal Serum Progesterone for protocol Obtain Serum Progesterone on Day 21 of cycle (or 7 days before anticipated Menses onset) Serum Progesterone > 5 ng/ml (15.8 nmol/L) suggests Ovulation Other measures to confirm Ovulation Basal Body Temperature (not recommended, unreliable) Urine Luteinizing hormone 3) Hysterosalpinogram 4) Age over 35: FSH day 3 Anti-müllerian hormone (AMH) — Anti-müllerian hormone (AMH) is a member of the TGF-beta family and is expressed by the small (<8 mm) preantral and early antral follicles. The AMH level reflects the size of the primordial follicle pool, and may be the best biochemical marker of ovarian function across an array of clinical situations Assessment of fallopian tube patency — We perform HSG as the first-line test for evaluation of tubal patency because of its therapeutic, as well as diagnostic, benefits Chlamydia antibodies — Chlamydia trachomatis IgG antibody testing is a simple, inexpensive, noninvasive test with some evidence supporting its use as a method for predicting the presence of tubal disease

Gestational Landmarks on US

Gestational sac - 4.5 to 5 weeks Yolk sac - 5 weeks Cardiac activity - 5.5 to 6 weeks Measurable crown-rump length - 6 weeks

Urge Incontinence worsening urinary incontinence for the last three months. She reports an increase in urinary frequency, urgency and nocturia. On examination, she has a moderate size cystocele and rectocele. A urine culture is negative. A post-void residual is 50 cc. A cystometrogram shows two bladder contractions while filling. -Though the testing may be simple (using a Foley catheter and attached large syringe without the plunger, filling with 50-60 cc of water at a time) or complex (using computers and electronic catheters), the uninhibited contraction of the bladder with filling makes the diagnosis.

DETRUSOR OVER ACTIVITY -most idiopathic (UTIs, bladder stones , bladder cancer, urethral divertiulua, foreign bodies, stroke, spinal cord injury, parkinson disease, MS, diabetes) Tx: initial therapy (lifestyle mod: caffiene restriction, fluid mang, bladder training, pelvic muscle exercises, topical estrogen) -Antimuscarinics (KNOW THIS!!!) (Oxybutynin, Toleterdine, Fesoterodine, Solifenancin, Trospium, Darifenacin) -Mirabegron (b3 agonist - ae elevated BP, xerostomia) -Sacral neuromodulation -Posterior Tibial Nerve Stimulation -Botulinum Toxin

Embrogenesis time line Down syndrome quad screen: high (hCG, inhibin); deficit (estriol, fetoprotein) abnormal migration of primitive germ cells Saccrococcygeal Teratoma - persistence of primitive streak or abnormal migration of primitive germ cells Pregnancy-associated plasma protein A (Pappalysin-1 aka PAPPA) Low plasma level of this protein has been suggested as a biochemical marker for pregnancies with aneuploid fetuses low PAPPA may be seen in prenatal screening for Down syndrome.[1] Low levels may alternatively predict issues with the placenta, resulting in adverse complications such as intrauterine growth restriction, preeclampsia, placental abruption, premature birth, or fetal death.

Day 0 - conception • Embryogenesis begins -sperm fertilized ovum in ampulla -all mitochondria are maternal in origin Week 1 • Cleavage and blastocyst formation -zygote undergoes mitotic divisions to form blastomeres → morula → blastocyst w/ cavity -blastocyst cavity forms two cell masses -->inner cell mass = embryoblast which will become embryo IF ICM Divides --> Identical Twins! -->outer cell mass = trophoblast which becomes placenta • hCG secretion o begins after implantation of blastocyst o syncytiotrophoblast invades uterine wall and secretes hCG o hCG detected in blood at day 8 and in urine at day 10 (pregnancy test) -↓ hCG: ectopic pregnancy or a sign for spontaneous abortion -↑ hCG: multiple pregnancy, hydatidiform mole, or gestational trophoblastic neoplasia Week 2 • Bilaminar disk formation WEEK 2 and 2's -consists of 2 germ layers: epiblast and hypoblast, -2 cavities are present: amniotic cavity and yolk sac -placenta has 2 components: cytotrophoblast and synctiotrophoblast -notochord forms Week 3 • Gastrulation -establishment of three embryonic germ layers (ectoderm, mesoderm, and endoderm) -initiated by formation of primitive streak • Formation of notochord and neural plate -Notochord (mesoderm) induces its overlying ectoderm to become neuroectoderm - neuroectoderm will form neural plate, fully closes by week 4 (hence why folic acid should be taken BEFORE pregnancy to make a difference -neural plate forms neural tube and neural crest cells o notochord will become adult nucleus pulposus in the vertebral column

Forming the Chorion and Amnion • hCG secretion -begins after implantation of blastocyst -syncytiotrophoblast invades uterine wall and secretes hCG -hCG detected in blood at day 8 and in urine at day 10 (pregnancy test) ↓ hCG: ectopic pregnancy or a sign for spontaneous abortion ↑ hCG: multiple pregnancy, hydatidiform mole, or gestational trophoblastic neoplasia

Day 3 - chorion (forms part of placenta) forms Day 8 - amnion (amniotic sac) forms *Twins that separate before day 3 (morula)? * Dichorionic, 2 placentas, diamniotic, This format includes Dizygotic, or monozygotic that split before day 3. Logic: separation has occured before formation of chorion, placenta, and amniotic sac (so each twin will have its own) *Twins that separate after day three but before day 8 (blastocyst)? * Monochorionic, 1 placenta, diamniotic Logic: separation has occurred after formation of chorion and placenta, but before formation of amniotic sac. Twins that separate after day 8, before day 13 (epiblast/hypoblast)? Monochorionic, 1 placenta, monoamniotic (twins share 1 chorion, 1 placenta, 1 amniotic sac) Risk for conjoined twins THIS WAS ASKED ABOVE! Twins that separate after day 13? Conjoined

HELLP (systemic inflammatory disorder) Magnesium sulfate is given intravenously to patients on the labor and delivery unit to prevent convulsions, and for fetal/neonatal neuroprotection in pregnancies between 24 and 32 weeks of gestation The most common clinical presentation is abdominal pain and tenderness in the midepigastrium, right upper quadrant, or below the sternum. Many patients also have nausea, vomiting, and malaise, which may be mistaken for a viral illness. Hypertension and proteinuria are present in approximately 85 percent of cases. Most cases of HELLP are diagnosed between 28 and 36 weeks of gestation, but symptoms may present up to 7 days postpartum. (See 'Patient presentation' above.) ●We base the diagnosis of HELLP on the presence of all of the following laboratory findings in pregnant women of appropriate gestational age (see 'Diagnosis' above): •Microangiopathic hemolytic anemia with schistocytes on blood smear (picture 1). Other signs suggestive of hemolysis include an elevated indirect bilirubin level and a low serum haptoglobin concentration (≤25 mg/dL). •Platelet count <100,000 cells/microL. •Total bilirubin >1.2 mg/dL. •Serum aspartate aminotransferase (AST) >70 IU/L.

Delivery if: ●Pregnancies ≥34 weeks of gestation ●Nonreassuring tests of fetal status (eg, biophysical profile, fetal heart rate testing) ●Presence of severe maternal disease: multiorgan dysfunction, disseminated intravascular coagulation (DIC), liver infarction or hemorrhage, pulmonary edema, renal failure, or abruptio placenta. When both the maternal and fetal status are reassuring, we administer a course of corticosteroids before delivering pregnancies complicated by HELLP syndrome at less than 34 weeks of gestation Actively bleeding patients with thrombocytopenia should be transfused with platelets. Platelet transfusion may be indicated to prevent excessive bleeding during delivery if the platelet count is less than 20,000 cells/microL If c/s keep platelets over 50,000

Placenta

Development of the placenta and fetus is a continuous process that begins at the time of fertilization. The first three days of development occur within the fallopian tube. Four days after fertilization, the morula (a solid mass of blastomere cells) enters the uterus. On the fifth day after fertilization, the morula becomes a blastocyst as fluid accumulates and polarization of the cells occurs. The blastocyst has an outer layer of cells (trophoblast) that will form the placenta and fetal membranes, an inner cell mass at one pole that will form the embryo, and a fluid filled cavity. The inner and outer cell masses multiply and the fluid cavity enlarges until the expanded blastocyst hatches out of the zona shell. Initially it is bathed in uterine secretions that provide oxygen and metabolic substrates; however, these secretions soon become inadequate for support of further development. Therefore, within 24 hours of hatching (about day 6 after fertilization), the blastocyst implants in the uterine lining, which provides access to substrates (glycogen filled stromal cells) necessary for continued growth. Implantation involves movement of the blastocyst to an optimal location (typically the mid to upper anterior or posterior wall of the uterus), adhesion, and invasion. As the trophoblast erodes deeper into the decidua, vacuoles form and become confluent to form lacunae by day 13 after fertilization. The lacunar space eventually becomes the intervillous space. The progenitor cytotrophoblast cell is the stem cell of the placenta. These cells proliferate throughout gestation, differentiating along two pathways to form either villous cytotrophoblast which ultimately can become syncytiotrophoblasts (outer cellular layer) or extravillous cytotrophoblasts (inner cellular layer) Syncytiotrophoblast is a specialized epithelium that has several functions, including transport of gases, nutrients, and waste products and synthesis of peptide and steroid hormones that regulate placental, fetal, and maternal systems. Extravillous trophoblast (EVT) has a proliferative component and an invasive component. There is also a migratory EVT, which is neither invasive nor proliferative. These cells populate the cell islands, septum, chorionic plate and chorion laeve

Contraindications to beta blockers

Disease-related concerns: • Bronchospastic disease: In general, patients with bronchospastic disease should not receive beta-blockers; if used at all, should be used cautiously with close monitoring. • Conduction abnormality: Consider pre-existing conditions such as sick sinus syndrome before initiating. • Diabetes: Use with caution in patients with diabetes mellitus; may potentiate hypoglycemia and/or mask signs and symptoms. May also reduce release of insulin in response to hyperglycemia; dosage of antidiabetic agents may need to be adjusted. • Heart failure (HF): Use with extreme caution in patients with compensated heart failure and monitor for a worsening of the condition. • Hepatic impairment: Use with caution in patients with hepatic impairment; bioavailability is increased due to decreased first-pass metabolism. • Myasthenia gravis: Use with caution in patients with myasthenia gravis. • Peripheral vascular disease (PVD) and Raynaud's disease: May precipitate or aggravate symptoms of arterial insufficiency in patients with PVD and Raynaud's disease; use with caution and monitor for progression of arterial obstruction. • Pheochromocytoma (untreated): If possible, obtain diagnostic tests for pheochromocytoma prior to use. Labetalol has been shown to be effective in lowering blood pressure and relieving symptoms in patients with pheochromocytoma. However, some patients have experienced paradoxical hypertensive responses; use with caution in patients with pheochromocytoma. Additional alpha-blockade may be required during use of labetalol. • Psoriasis: Beta-blocker use has been associated with induction or exacerbation of psoriasis, but cause and effect have not been firmly established. • Psychiatric disease: Use with caution in patients with a history of psychiatric illness; may cause or exacerbate CNS depression. • Thyroid disease: May mask signs of hyperthyroidism (eg, tachycardia). If hyperthyroidism is suspected, carefully manage and monitor; abrupt withdrawal may exacerbate symptoms of hyperthyroidism or precipitate thyroid storm. Pregnancy Antihypertensives ACE inhibitors are contraindicated because risk of fetal urinary tract abnormalities is increased. ARBs are contraindicated because they increase risk of fetal renal dysfunction, lung hypoplasia, skeletal malformations, and death. Aldosterone antagonists (spironolactone and eplerenone) should be avoided because they may cause feminization of a male fetus.

Drugs associated with isolated thrombocytopenia

Drug Mechanism(s) Abciximab DITP Acetaminophen DITP with antibodies to a drug metabolite; the antibodies do not react with the unmodified parent compound Alemtuzumab ITP-like syndrome* Amiodarone DITP Beta-lactam antibiotics (eg, penicillins, cephalosporins) DITP Carbamazepine DITP Eptifibatide DITP Ethambutol DITP Furosemide DITP Gold compounds Bone marrow suppression Haloperidol DITP Heparin Drug-dependent antibodies that also activate platelets and cause endothelial injury Ibuprofen DITP in some patients; in other patients only antibodies to a drug metabolite that do not react with the unmodified parent compound Irinotecan DITP Levofloxacin DITP Linezolid Bone marrow suppression (dose-dependent) Measles-mumps-rubella (MMR) vaccine ITP-like syndrome Naproxen DITP with a antibodies to a drug metabolite; the antibodies do not react with the unmodified parent compound Oxaliplatin DITP Phenytoin DITP Piperacillin DITP Quinidine DITP Quinine¶ DITP Ranitidine DITP Rifampin DITP Simvastatin DITP Sulfonamides DITP Tirofiban DITP Trimethoprim-sulfamethoxazole DITP Valproic acid Bone marrow suppression (dose-dependent) Vancomycin DITP

breast mass Breast Cancer Risk Factors Age 50 or older Benign breast disease, especially cystic disease, proliferative types of hyperplasia, and atypical hyperplasia Exposure to ionizing radiation First childbirth after age 20 Higher socioeconomic status History of breast cancer History of breast cancer in a first-degree relative Hormone therapy Nulliparity Obesity (i.e., BMI ≥ 30 kg per m2)* Alcohol consumption Did not breastfeed Elevated endogenous estrogen levels High BMI* Hormonal contraception therapy Increased mammographic density of breast tissue Menarche before age 12 Menopause after age 45 Mutations in BRCA 1 and BRCA 2 genes

Mammography — A diagnostic mammogram is the first imaging study performed for a woman with a new, palpable breast mass, and should be performed even if a recent mammogram was negative. ●Fibroadenoma - A simple fibroadenoma is a benign solid mass. It typically is identified in young women, but can also be identified as a calcified mass in older women. The mass is firm, and described as "mobile" as it can be rolled onto an edge. A fibroadenoma may be solitary, multiple, and bilateral. (See "Overview of benign breast disease", section on 'Simple fibroadenomas'.) ●Cyst - A simple cyst is a benign fluid-filled mass that can be palpated as a component of fibrocystic changes of the breast or as a discrete, compressible, or ballotable solitary mass. Breast cysts are commonly found in premenopausal, perimenopausal, and occasionally postmenopausal women. (See "Breast cysts: Clinical manifestations, diagnosis, and management".) ●Fibrocystic changes - Fibrocystic changes in the breast are common, particularly in premenopausal women, and may be prominent and organized. However, the breast tissue tends to be more diffuse and tender, and generally does not form a discrete or well-defined mass. Most patients present with breast pain that may be cyclical or constant, bilateral or unilateral or focal. The breast tissue, particularly in the upper outer quadrants, may increase in size prior to the onset of menses, then return to baseline after the onset of the menstrual flow. On the clinical examination, the breast tissue frequently is nodular. (See "Overview of benign breast disease", section on 'Nonproliferative breast lesions'.) ●Galactocele - A galactocele is a milk retention cyst common in women who are breast feeding. ●Fat necrosis - Fat necrosis is a benign breast mass that can develop after blunt trauma to the breast; injection of native or foreign substances such as fat [25], paraffin, or silicone [26,27]; an operative procedure such as breast reductive surgery [28] or autologous breast reconstruction [29]; and radiation therapy [30,31] to the breast. Fat necrosis from trauma is generally associated with skin ecchymosis. Fat necrosis can often be clinically difficult to distinguish from a malignant mass

Pulmonary Hypertension Increased RA, RV and PA pressure increased PVR, decreased CO, nml PCWP

Patients with pulmonary hypertension (PH) initially present with exertional dyspnea and fatigue, that progress to develop the signs and symptoms of severe PH or right ventricular failure (eg, exertional chest pain or syncope, and congestion including peripheral edema, ascites, and pleural effusion) 1st Test: Echocardiogram Diagnosis of PH requires right heart catheterization (RHC).*PH is confirmed when the mean pulmonary artery pressure is ≥25 mmHg at rest.* Tx: Fluid retenion = LOOP diuretic Hereditary = Anticoagulant

Methyldopa

Edema: May produce clinical edema; discontinue if edema worsens or signs of heart failure arise. Mild edema may be controlled with the concomitant use of diuretic therapy. • Hematologic effects: Rare cases of reversible granulocytopenia and thrombocytopenia have been reported. May rarely produce hemolytic anemia; positive Coombs' test occurs in 10% to 20% of patients usually occurring between 6 and 12 months of therapy; perform CBC periodically. If Coombs'-positive hemolytic anemia occurs during therapy, discontinue use and do not reinitiate; Coombs' test may not revert back to normal for weeks to months following discontinuation. • Hepatic effects: May rarely produce liver disorders including fatal hepatic necrosis; use with caution in patients with previous liver disease or dysfunction. Periodically monitor liver function during the first 6-12 weeks of therapy or when unexplained fever occurs; discontinue use if fever, abnormal liver function tests, or jaundice is present. • Neuromuscular effects: Patients with severe bilateral cerebrovascular disease have exhibited involuntary choreoathetotic movements (rare); discontinue use if these symptoms develop. • Sedation: Usually transient, sedation may occur with initiation or whenever the dose is increased.

Post-surgical complications -seroma post- C/S endometritis thrombophlembitis atlectasis wound infection The white blood cell count is elevated, but this can be a normal finding in postpartum women secondary to the physiologic leukocytosis of pregnancy and the effects of labor. A left shift and a rising rather than falling neutrophil count postpartum is suggestive of an infectious process. Some degree of malodorous yellow-red lochia is normal after any delivery.

Endometritis: is based upon clinical criteria of fever and uterine tenderness occurring in a postpartum woman (+midline lower abdominal pain, purulent lochia, chills, HA, malaise) . Other signs and symptoms which support the diagnosis include foul lochia, chills, and lower abdominal pain. The uterus may be soft and subinvoluted, which can lead to excessive uterine bleeding. Sepsis is an unusual presentation Differential diagnosis of postpartum fever includes surgical site infection, mastitis/breast abscess, urinary tract infection, pneumonia, and pelvic vein thrombosis Patients with Deepn Septic Pelvic Thrombophlembitis - usually present with fever in the early postpartum or postoperative period (usually within three to five days), although the onset may be delayed to up to three weeks following delivery [14-16]. Patients usually do not appear clinically ill; fever or chills may be the only symptoms, and patients appear clinically well between fever spikes [17]. Abdominal or pelvic tenderness is notably absent. DSPT is frequently a diagnosis of exclusion; it should be suspected in patients with persistent postpartum fever despite antibiotic therapy. Surgical site infection (cesarean delivery incision, episiotomy incision, perineal lacerations) is typically evident on physical examination of the surgical site (eg, local erythema, edema, and/or tenderness). Pyelonephritis is characterized by fever (>38ºC), chills, flank pain, costovertebral angle tenderness, and possibly lower urinary tract symptoms. Pyuria and/or a positive urine culture support the diagnosis Aspiration pneumonia presents with fever, dyspnea, and possibly hypoxemia. Lung auscultation may reveal diffuse crackles and a chest radiograph will show infiltrates Unexplained fever with significant back pain after a neuraxial anesthetic, especially when accompanied by neurologic symptoms, may be due to infection or inflammation of the spinal cord

Estrogen Effects

Estradiol: Is the young female's hormone of femininity. It's also called E2. It's prododuced by aromatization of Testosterone in the Graafian follicle (granulosa cell). It's the most potent estrogen with the highest effect on receptors. Estrone: Is the estrogen of the menopause. It's produced by aromatization of androstenedione in peripheral (fatty) tissue. It's also called E1. It's less potent than Estradiol. Estriol: Is the placental estrogen and it's only seen during pregnancy and it's high levels reflects fetal well being. It's also called E3. It's the least potent of all estrogens. It originates from the fetal adrenal gland in the form of DHEA Sulfate and then is finally transformed to Estriol in the placenta by the sulfatase enzyme.

Fetal Hydrops The placenta may appear thickened due to intravillous edema (image 6). In general, a placental thickness ≥4 cm in the second trimester and ≥6 cm in the third trimester is considered abnormal and should prompt further investigation [11,12]. However, massive polyhydramnios can cause the placenta to appear thinned or compressed. Maternal Findings: Mirror Syndrome DIAGNOSIS — The prenatal diagnosis of hydrops fetalis is based on ultrasound examination that shows two or more of the following fetal findings: ●Ascites ●Pleural effusion ●Pericardial effusion ●Skin edema (>5 mm) Maternal immunoglobulin M (IgM) and immunoglobulin G (IgG) serologies are obtained for the most common infectious causes of NIHF: parvovirus B19, cytomegalovirus (CMV), and toxoplasmosis. Parvovirus B19 is the most common of these and causes fetal anemia and myocardial dysfunction (see "Parvovirus B19 infection during pregnancy"). The typical sonographic finding of fetal CMV infection is bilateral periventricular hyperechogenicities (calcifications) (image 7) (see "Cytomegalovirus infection in pregnancy", section on 'Prenatal diagnosis'). Intracranial hyperechogenic foci or calcifications and ventricular dilatation are the most common findings of fetal toxoplasmosis (see "Toxoplasmosis and pregnancy", section on 'Fetal infection'). Hydrops is a characteristic finding of congenital syphilis; therefore, a nontreponemal antibody test (eg, Venereal Disease Research Laboratory [VDRL] test, Rapid Plasma Reagin [RPR] test) should be obtained if not recently performed as part of routine prenatal care. Complete blood count with red blood cell indices. A mean corpuscular volume (MCV) <80 femtoliters (fL) in the absence of iron deficiency suggests thalassemia. The father's MCV should be determined. If both parents have MCV <80 fL, additional studies are required. Hemoglobin electrophoresis will identify carriers of hemoglobin variants and beta-thalassemia. In Asian couples, however, DNA-based genotyping is generally necessary to rule out alpha-thalassemia (hemoglobin electrophoresis is not recommended because it is nondiagnostic of alpha-thalassemia). Cardiovascular abnormalities — Abnormalities of the cardiovascular system are responsible for as many as 40 percent of cases of NIHF [38]. Numerous cardiac lesions have been implicated (table 2), the three major subgroups are structural anomalies, arrhythmias, and vascular abnormalities. Structural — The most commonly encountered cardiac lesions associated with hydrops are atrioventricular septal defect, hypoplastic left and right heart, and isolated ventricular or atrial septal defects. Other less common anomalies include Tetralogy of Fallot and premature closure of the ductus arteriosus. Many of these lesions are also associated with aneuploidy. Fetal cardiac tumors are rare, but are often associated with hydrops, ventricular obstruction, and/or arrhythmia [39]. Most structural lesions are not amenable to in utero therapy and, in the setting of early-onset hydrops, the prognosis for these pregnancies is poor, with a mortality rate close to 100 percent [40]. Patients should be offered genetic counseling, as the recurrence risk of congenital cardiac defects is as high as 2 to 5 percent [41]. Arrhythmias — Both tachyarrhythmias and bradyarrhythmias can lead to hydrops. The mechanism is believed to be high output cardiac failure with progressive venous congestion in the former, and low cardiac output in the latter. ●Tachyarrhythmias - Tachyarrhythmias associated with NIHF include supraventricular tachycardia (most commonly), followed by atrial flutter, reentrant tachycardias (eg, Wolf-Parkinson-White syndrome), long QT, and ventricular tachycardia. Fetal tachyarrhythmias can often be treated by maternal administration of rate controlling agents; however, in cases of hydrops, disturbances in the placental transfer may render maternal therapy inadequate [40,42]. In such cases, the drugs can be administered directly to the fetus. (See "Overview of the general approach to diagnosis and treatment of fetal arrhythmias".) In women with Graves' disease, fetal tachycardia, particularly in combination with goiter, advanced bone age, poor growth, or craniosynostosis, suggests fetal hyperthyroidism from transplacental passage of maternal thyroid-stimulating hormone receptor antibody. Cardiac failure and hydrops may occur with severe disease. Maternal treatment with propylthiouracil or methimazole is an effective transplacental treatment of affected fetuses. (See "Hyperthyroidism during pregnancy: Treatment", section on 'Fetal hyperthyroidism'.) ●Bradyarrhythmias - One-half of persistent bradyarrhythmias are caused by structural abnormalities [42]. Complex congenital lesions that affect the AV nodal region result in anatomic interruptions in the conduction system leading to atrioventricular dissociation and bradycardia. The other one-half of persistent bradyarrhythmias are related to maternal autoimmune disorders in which maternal immunoglobulin G (IgG) antibodies cross the placenta and cause direct damage to fetal bundle of His and Purkinje fibers

Fetal findings — NIHF is defined by fetal findings. Two or more of the following findings should be present on ultrasound examination: ●Ascites - In its early stage, fetal ascites appears as a rim of echolucent fluid just inside the abdominal wall (image 1) or surrounding the bladder or liver. Pseudoascites, which is a hypoechoic band comprised of abdominal wall muscles, should not be mistaken for ascites. If there is a large amount of ascites, the bowel may appear compressed (image 2) and its walls may be accentuated due to increased ultrasound transmission afforded by the excess intraabdominal fluid [4,7]. Isolated fetal ascites can result from several disorders and is not considered true hydrops since only one compartment is affected, but may progress to hydrops. (See 'General approach' below.) ●Pleural effusions - Pleural effusions appear as a rim of echolucent fluid just inside the chest wall, outlining the lungs. The effusion may be unilateral or bilateral, and may compress the lung tissue (image 3A-C). Persistent effusions that develop before 20 weeks of gestation may retard the growth and development of the lungs, leading to pulmonary hypoplasia, which may be fatal in the neonatal period. A variety of techniques for prenatal diagnosis of severe pulmonary hypoplasia have been reported, but none are consistently reliable. ●Pericardial effusions - Pericardial effusions appear as a rim of echolucent fluid surrounding the heart (image 4), but may be difficult to visualize with standard two-dimensional images. It is important not to mistake physiologic pericardial fluid or the hypoechoic myocardium for an abnormal effusion. Use of M-mode helps in measuring pericardial effusions accurately and differentiating between physiologic and pathologic pericardial fluid when the diagnosis is uncertain [2]. During second-trimester fetal ultrasonographic examination, visualization of pericardial fluid up to 2 mm thick is common and should not be regarded as pathologic [8], and even fluid up to 7 mm thick may be benign [9]. Pericardial fluid greater than 2 mm thick that increases on serial examinations suggests a pathologic etiology. ●Skin edema - Skin edema is a late sign of fetal hydrops (image 5). Pathologic skin edema has been defined as subcutaneous tissue thickness on the chest or scalp greater than 5 mm [10]. Fat under the scalp or in the posterior nuchal region should not be mistaken for skin edema. NIHF may be associated with polyhydramnios and placental thickening. Polyhydramnios is generally defined as an amniotic fluid index greater than 24 cm or a maximum vertical pocket greater than 8 cm [10]. It is present in up to 75 percent of pregnancies complicated by NIHF

Pregnant HIV Mom tx PI w/ 2-nrti backbone Tenofovir/ emtricitabine or lamivudine or Abacavir/lamivudine or Zidovudine/lamivudine PLUS ATAZANAVIR + RITONAVIR fetal tx All infants of HIV mothers should receive 6 weeks of zidovudine (add Nevirapine if the mother did not recieve antepartum prophylaxis)

For treatment-naïve pregnant women who have advanced HIV disease and/or CD4 cell count <350 cells/microL, we recommend prompt initiation of antiretroviral therapy regardless of gestational age For treatment-naïve pregnant women with higher CD4 cell counts, we suggest that the antiretroviral regimen be initiated prior to the 14th week of gestation Women who present later in pregnancy should initiate an antiretroviral regimen without delay Treatment-experienced women on a virologically suppressive antiretroviral regimen that they tolerate can continue that regimen, even if the individual agents are not preferred in pregnancy.

Thrombocytopenia in pregnancy

Gestational thrombocytopenia - This condition is associated with mild and asymptomatic thrombocytopenia, no past history of thrombocytopenia, occurrence during late gestation, no association with fetal thrombocytopenia, and spontaneous resolution after delivery. For both mother and infant, routine obstetric management is appropriate. Epidural anesthesia is considered to be safe in women with gestational thrombocytopenia who have platelet counts above 50,000 to 80,000/microL. (See 'Gestational thrombocytopenia' above.) ●Immune thrombocytopenia (ITP) - Early in pregnancy, the management of ITP is the same as if the patient were not pregnant. It is important to discuss options for neuraxial analgesia/anesthesia with the consulting anesthesiologist prior to delivery because therapies to raise the platelet count may take time to be effective (table 4). If needed, treatment with glucocorticoids or IVIG should be initiated approximately one week prior to a scheduled delivery. Communication with the pediatrician is important because thrombocytopenia can occur in the infant, and platelet counts can continue to decrease several days after delivery (table 3). (See 'Immune thrombocytopenia (ITP)' above.) ●Preeclampsia and HELLP syndrome - Severe thrombocytopenia (platelet counts <50,000/microL) occurs in <5 percent of preeclamptic women. Its severity increases in those with the hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome or full-blown eclampsia in whom disseminated intravascular coagulation may be a contributing factor. Delivering the fetus is the most effective method of treating preeclampsia, eclampsia, and the HELLP syndrome. Recovery within three days following delivery is consistent with the diagnosis of preeclampsia. If severe thrombocytopenia and hemolysis persist for longer than three days, the clinical picture becomes indistinguishable from thrombotic thrombocytopenic purpura-hemolytic uremic syndrome (TTP-HUS). (See 'Preeclampsia and HELLP syndrome' above and "HELLP syndrome".) ●TTP-HUS - Thrombotic thrombocytopenic purpura-hemolytic uremic syndrome (TTP-HUS) can be life-threatening if not diagnosed and treated appropriately. Congenital TTP is more common than acquired TTP-HUS. Congenital TTP is treated with plasma infusion, and acquired TTP-HUS is treated with plasma exchange therapy; if the distinction has not been made at the time of presentation, plasma exchange should be used. Recurrence during subsequent pregnancies is expected to be high for congenital TTP and low for acquired TTP-HUS. (See 'TTP-HUS' above.) ●HIT - Heparin-induced thrombocytopenia (HIT) is a complication of heparin use that is rare in pregnant women. HIT is associated with potentially life-threatening arterial and venous thrombosis; it is suspected in patients who develop thrombocytopenia 5 to 10 days after beginning heparin.

Hypertension in Pregnancy

HTN is treated at 160 SYS or 110 dia Acute: labetalol IV (fastest) or hydralazine IV Chronic: methyldopa or labetalol Preeclampsia-eclampsia - Preeclampsia refers to the syndrome of new onset of hypertension and either proteinuria or end-organ dysfunction (table 1) most often after 20 weeks of gestation in a previously normotensive woman [1]. Eclampsia is diagnosed when seizures have occurred. ●Chronic (preexisting) hypertension - Chronic hypertension is defined as systolic pressure ≥140 mmHg and/or diastolic pressure ≥90 mmHg that antedates pregnancy, is present before the 20th week of pregnancy, or persists longer than 12 weeks postpartum. ●Preeclampsia-eclampsia superimposed upon chronic hypertension - Preeclampsia-eclampsia superimposed upon chronic hypertension is diagnosed when a woman with chronic hypertension develops worsening hypertension with new onset proteinuria or other features of preeclampsia (eg, elevated liver enzymes, low platelet count). ●Gestational hypertension - *Gestational hypertension refers to elevated blood pressure first detected after 20 weeks of gestation* in the absence of proteinuria or other diagnostic features of preeclampsia. Any history of hypertension - start aspirin prior to week 16, low dose

DUB 41-year-old G3P3 woman reports heavy menstrual periods occurring every 26 days lasting eight days. The periods have been increasingly heavy over the last three months. She reports soaking through pads and tampons every two hours. She has a history of three uncomplicated spontaneous vaginal deliveries and a tubal ligation following the birth of her last child A pelvic ultrasound would image the endometrium and assess for endometrial pathology such as polyps or submucosal fibroids Management of an endometrial polyp includes the following: observation, medical management with progestin, curettage, surgical removal (polypectomy) via hysteroscopy, and hysterectomy. Observation is not recommended if the polyp is > 1.5 cm. In women with infertility polypectomy is the treatment of choice. 34-year-old G2P2 Her urine pregnancy test is negative; an endometrial biopsy is negative for hyperplasia. Intermenstrual bleeding is frequently caused by structural abnormalities of the endometrial cavity, such as myomas, polyps or malignancy. An ultrasound would be helpful as the next step in diagnosis. Although an HSG might reveal structural abnormalities, it is too invasive as the next step. Vaginal spotting for 2 weeks. Regular cycles. On OCPS started 3m ago. Normal findings except paplable tender mass on right adnexa. 1st test? Urine Preg is vitally important to rule out pregnancy in the evaluation of abnormal uterine bleeding. Pelvic ultrasound could be considered as a next step if the pregnancy test is negative in order to evaluate the adnexal finding

How does MPA control peroids tients with anovulatory bleeding have predominantly proliferative endometrium from unopposed stimulation by estrogen. Progestins inhibit further endometrial growth, converting the proliferative to secretory endometrium. Withdrawal of the progestin then mimics the effect of the involution of the corpus luteum, creating a normal sloughing of the endometrium. Stimulation of rapid endometrial growth, conversion of proliferative to secretory endometrium, and regeneration of the functional layer describe effects of estrogen on the endometrium. 15year-old G0 female reports menarche six months ago, with increasingly heavy menstrual flow causing her to miss several days of school. Three months ago, her pediatrician started her on oral contraceptives to control her menstrual periods, but she continues to bleed heavily. Disorders of clotting may present with menstrual symptoms in young women, with Von Willeberand disease being most common. Persistent bleed in 35 yr morbidly obese pt Endometrial biopsy should be performed to rule out endometrial hyperplasia or carcinoma given the history of irregular bleeding, coupled with the increased risk of these diagnoses in morbidly obese patients. PCOS This patient likely has polycystic ovarian syndrome (PCOS). PCOS patients have testosterone levels at the upper limits of normal or slightly increased. Free testosterone (biologically active) is elevated often because sex hormone binding globulin is decreased by elevated androgens. LH is increased in response to increased circulating estrogens fed by an elevation of ovarian androgen production. Insulin resistance and chronic anovulation are hallmarks of PCOS 42 yr old with menstrual pain, irreg periods and intermenstraul bleeding This patient has classic symptoms of leiomyomata, including menorrhagia. An endometrial biopsy should be performed on all women over age 40 with irregular bleeding to rule out endometrial carcinoma.

PID Outpatient First-line regimens — The CDC recommends any of the following outpatient regimens, with or without metronidazole (500 mg twice a day for 14 days) [1]: ●Ceftriaxone (250 mg intramuscularly in a single dose) plus doxycycline (100 mg orally twice a day for 14 days) ●Cefoxitin (2 g intramuscularly in a single dose) concurrently with probenecid (1 g orally in a single dose) plus doxycycline (100 mg orally twice a day for 14 days) ●Other parenteral third-generation cephalosporins, such as cefotaxime (1 gram intramuscularly in a single dose) or ceftizoxime (1 gram intramuscularly in a single dose) plus doxycycline (100 mg orally twice a day for 14 days) Of the cephalosporins listed, ceftriaxone has the overall best activity against gonococcal infection. We prefer ceftriaxone plus doxycycline in patients with mild to moderate PID. Metronidazole should be added for patients with Trichomonas vaginalis or in those women with a recent history of uterine instrumentation.

INDICATIONS FOR HOSPITALIZATION — Recommended indications for hospitalization and parenteral antibiotics include [1]: ●Pregnancy ●Lack of response or tolerance to oral medications ●Nonadherence to therapy ●Inability to take oral medications due to nausea and vomiting ●Severe clinical illness (high fever, nausea, vomiting, severe abdominal pain) ●Complicated PID with pelvic abscess (including tuboovarian abscess) ●Possible need for surgical intervention or diagnostic exploration for alternative etiology (eg, appendicitis) Tx: Cefoxitin or Cefotetan plus doxycycline or Clindamycin plus gentamicin

Post Op fever Obstetric and gynecologic surgery — Postpartum endometritis, manifested by fever, pelvic pain and purulent vaginal discharge, is more common in patients with preexisting medical problems, after premature rupture of membranes, difficult deliveries, and after the use of internal fetal monitoring. The differential diagnosis of fever after gynecologic surgery includes urinary tract infection (UTI), cellulitis, necrotizing fasciitis, superficial abscess, deep abscess, and pelvic thrombophlebitis. As with other major surgeries, fever in the first day or two after gynecologic surgery usually resolves spontaneously Wind (POD 1-2) the lungs, i.e. pneumonia, aspiration, and pulmonary embolism. Once attributed to atelectasis, but a recent review suggests that is not supported by existing clinical evidence Water (POD 3-5) urinary tract infection, related to indwelling catheter (during surgery or currently i.e. Foley catheter ) Walking (POD 4-6) DVT, PE, Thrombophlembitis - often cyclical fevers Wound (5-7) Surgical Site Infection Wonder Drugs (7+) Central venous line or Drugs Surgical site infection — Wound infection is diagnosed in 2.5 to 16 percent of patients after cesarean delivery [17], generally four to seven days after the procedure Endometritis — Endometritis is more common following cesarean birth than following vaginal birth. The diagnosis of endometritis is largely based upon clinical criteria: fever; uterine tenderness; foul lochia; and leukocytosis, which develop within five days of delivery. A temperature ≥100.4 ºF (38 ºC) in the absence of other causes of fever, such as pneumonia, wound cellulitis, or urinary tract infection, is the most common sign Endometritis can be found in less than 3% of vaginal births and this is contrasted by a 5-10 times higher incidence after Cesarean deliveries. Factors related to increased rates of infection with a vaginal birth include prolonged labor, prolonged rupture of membranes, multiple vaginal examinations, internal fetal monitoring, removal of the placenta manually and low socioeconomic status. POLYMICROBIAL The most common cause of postpartum fever is endometritis. The differential diagnosis includes urinary tract infection, lower genital tract infection, wound infections, pulmonary infections, thrombophlebitis, and mastitis. Question gives uncomplicated Csection, fever on the 3rd day w/ mild breast engorgement and mild uterine fundal tenderness (no incision tenderness)

Immediate (in OR or w/in hrs) medications or blood products to which the patient was exposed during preoperative care either in the operating room or in the recovery area; trauma suffered prior to surgery or as part of surgery; infections that were present prior to surgery; and rarely malignant hyperthermia. Acute — (onset within the first week after surgery) There are many causes of fever in the first week after surgery. Nosocomial infections are common during this period. Occasionally, fever or other symptoms predate surgery and are manifestations of community-acquired infection, such as a viral upper respiratory tract infection UTI is a frequent cause of postoperative fever in patients with indwelling urethral catheters. The risk of UTI increases with the duration of catheterization Subacte (1 week + after) Central Venous Catheters C. Diff Febrile Drug Ractions Thrombophlembitis if impaired motility SSIs due to more indolent microorganisms (eg, coagulase-negative staphylococci) can cause delayed fever, especially in patients with implanted medical devices or grafts. These devices generally need to be removed in order to cure the infection. Septic pelvic thrombophlebitis — The postpartum state is the major risk factor for development of septic pelvic thrombophlebitis, which occurs in the setting of pelvic vein endothelial damage and is usually associated with endomyometritis, venous stasis, and hypercoagulability

Fetal Syphilus All pregnant women should be screened for syphilis at the first prenatal visit (Grade 1B). The screening test should be repeated during the third trimester (28 to 32 weeks of gestation) and again at delivery in women who are at high risk for syphilis, live in areas with high prevalence of syphilis, are previously untested, or had a positive screening test in the first trimester. fever, hepatomegaly, generalized lymphadenopathy, edema Late Stigmata Facial features Frontal bossing, saddle nose, short maxilla, protuberant mandible Ophthalmologic Interstitial keratitis, chorioretinitis, secondary glaucoma, corneal scarring, optic atrophy Ears Sensorineural hearing loss Oropharynx Hutchinson teeth, mulberry molars, perforation of hard palate Cutaneous Rhagades (fissures, cracks, or linear scars in the skin,) , gummas Central nervous system Intellectual disability, arrested hydrocephalus, seizures, optic atrophy, juvenile general paresis Skeletal Saber shins (anterior bowing of the tibia), Higoumenakis sign (enlargement of the sternoclavicular portion of the clavicle), Clutton joints (painless arthritis), scaphoid scapula Mother should be given penicillin on dx and

Infection can result in stillbirth, hydrops fetalis, or prematurity and associated long-term morbidity. Placenta is large, thick and pale Inflamed Umbilical Cordwith abscess-like foci of necrosis within Wharton's jelly, centered around the umbilical vessels (necrotizing funisitis); barber-pole appearance *Syphilitic rhinitis ("snuffles")* -Can be an early feature, developing after the first week of life; contains spirochetes and is infectious (use contact precautions) *Maculopapular Rash* 1 -2 w after rhinitis -pink --> copper brown w/ desquamation or scaling on palms and soles - contains spirochetes *Vesicular rash (pemphigus syphiliticus)* same as above *Condylomata lata* Single or multiple, flat, wartlike, moist lesions around the mouth, nares, and anus and other areas of the skin where there is moisture or friction; lesions contain spirochetes and are infectious (use contact precautions) *Jaundice and Hemolysis --> Anemia, Thrombocytopenia, Leukopenia* *pseudoparalysis of parrot* - pain w/ movement leads to decreased movement *Periositis* irreg perisoteal thickening *wegner sign* metaphyseal serration (sawtooth) *wimberger sign* demineralization and oseeous destruction of upper medial tibia Dx: VDRL / RPR + Direct fluroscent antibody staining or darkfield microscopy Tx: We recommend that infants with proven or highly probable congenital syphilis be treated with 10 days of parenteral penicillin PENICILLIN, if allergy desenstitization! Treatment of early maternal syphilis at least 30 days before delivery is the most important factor influencing the risk of congenital infection.

Endometriosis Endometrioma The classical example is of an unilocular cyst with acoustic enhancement with diffuse homogeneous ground-glass echoes as a result of the haemorrhagic debris it also is a common cause of an elevated CA125 level in the premenopausal patient with an adnexal mass

Pelvic examination findings consistent with endometriosis include: posterior vaginal fornix tenderness; palpable tender nodules in the posterior cul-de-sac, uterosacral ligaments, or rectovaginal septum; lateral displacement of the cervix; fixation of adnexa or uterus in a retroverted position; and/or a tender adnexal mass Tx: NSAIDS + Low dose cyclical E+P or P only

Normal Pregnancy Physiology Right sided hydronephrosis Some degree of dilation in the ureters and renal pelvis occurs in the majority of pregnant women. The dilation is unequal (R > L) due to cushioning provided by the sigmoid colon to the left ureter and from greater compression of the right ureter due to dextrorotation of the uterus. The right ovarian vein complex, which is remarkably dilated during pregnancy, lies obliquely over the right ureter and may contribute significantly to right ureteral dilatation. High levels of progesterone likely have some effect but estrogen has no effect on the smooth muscle of the ureter. Thyroid binding globulin (TBG) is increased due to increased circulating estrogens with a concomitant increase in the total thyroxine. Free thyroxine (T4) remains relatively constant. Total triiodothyroxine (T3) levels also increase in pregnancy while free T3 levels do not change. In a pregnant patient without iodine deficiency, the thyroid gland may increase in size up to 10%. This patient's thyroid function is normal for pregnancy, and her symptoms of fatigue can be explained by other physiologic changes in pregnancy, including anemia, difficulty with sleep, and increase metabolic demand. Hyperthyriodism, large uterus, fleshy protrusion This patient's presentation is classic for a molar pregnancy. Beta-hCG levels in normal pregnancy do not reach one million. A chest x-ray would be the most appropriate step, as the lungs are the most common site of metastatic disease in patients with gestational trophoblastic disease

Inspiratory Capacity (IC) increased Tidal volume (TV) increased Minute ventilation increased Functional reserve capacity (FRC) decreased Expiratory reserve capacity (ERC) decreased Residual volume (RV) decreased (Note in obesity FRC is decreased and RV is increased due to air trapping however in pregs both are decreased) TV is increased which increases the minute ventilation, which is responsible for the respiratory alkalosis in pregnancy Plasma osmolality is decreased during pregnancy which increases the susceptibility to pulmonary edema. Common causes of acute pulmonary edema in pregnancy include tocolytic use, cardiac disease, fluid overload and preeclampsia Use of multiple tocolytics increases the susceptibility of pulmonary edema, especially with the use of isotonic fluids. Systemic vascular resistance is decreased during pregnancy. The cardiac output increases up to 33% due to increases in both the heart rate and stroke volume. The SVR falls during pregnancy. Up to 95% of women will have a systolic murmur due to the increased volume. Diastolic murmurs are always abnormal. The systemic vascular resistance (SVR) is normally greater than the pulmonary vascular resistance.

Placental Abruption RF History of Abruption (also in sisters) Abdominal Trauma Cocaine or other drugs Polyhydroaminos Chronic HTN Pre-eclampsia, Eclampsia, GA HTN PROM Chorioamnionitis Previous Ischemic Placental disease (FGR, SFGA) Maternal Age Parity Smoking during preg Male infant Uterine abnormalities, cocaine use, and smoking are additional less common causes of abruption. Uterine anomalies (eg, bicornuate uterus), uterine synechiae, and leiomyoma are mechanically and biologically unstable sites for placental implantation; abruption at these sites may be due to inadequate decidualization and/or shear. Suboptimal trophoblastic implantation may also explain the increased risk of abruption among women with a prior cesarean

Intense contractions, dark flowing vaginal bleed, preterm labor = Abruption (Nbme q) abrupt onset of vaginal bleeding, mild to moderate abdominal and/or back pain, and uterine contractions. Back pain is prominent when the placenta is on the posterior wall of the uterus. The uterus is often firm, and may be rigid and tender. Contractions are usually high frequency and low amplitude, but a contraction pattern typical of labor is also possible and labor may proceed rapidly. Imaging — Identification of a retroplacental hematoma is the classic ultrasound finding of placental abruption Dx: Clinical Tx: unstable at any gestational age (eg, significant coagulopathy, hypotension, and/or ongoing major blood loss), or the fetal heart rate tracing is nonreassuring at any gestational age, or the gestational age is ≥36 weeks, we suggest *expeditious delivery via c/s*

Cholestasis of Pregnancy

Intrahepatic cholestasis of pregnancy (ICP) occurs in the second and third trimester and is characterized by pruritus and an elevation in serum bile acid concentrations. The onset of ICP is typically heralded by the development of pruritus, which may be intolerable. It is often generalized but predominates on the palms and the soles of the feet and is worse at night. ●The diagnosis of ICP is based upon the presence of pruritus associated with elevated levels of serum bile acids and/or aminotransferases, and the absence of diseases that may produce similar symptoms. ●ICP carries an increased risk of fetal complications. The most concerning complication is the increased risk for sudden fetal death. Although pruritus is bothersome, the maternal prognosis in ICP is good. ●Treatment for ICP focuses on reducing pruritus and preventing maternal and fetal complications. We suggest treatment with ursodeoxycholic acid (ursodiol or UDCA, a synthetic bile acid) (Grade 2B). The optimal dose has yet to be determined; we usually prescribe 300 mg three times a day (or 15 mg/kg per day) until delivery. ●For most women diagnosed with ICP, we suggest delivery at 36 weeks of gestation (Grade 2B). If ICP is diagnosed at ≥37, we initiate delivery upon diagnosis.

Nbme question with a girl w/ stage 5 pubic but stage 2 breasts w/ amenorrhea -no reassurance for delayed puberty under 8 years old. Could be normal but investigate! The earliest detectable secondary sexual characteristic on physical examination in most girls is breast/areolar development (thelarche) (picture 1A), although about 15 percent have pubic hair as the initial manifestation (pubarche) (picture 1B) [32]. Ovarian enlargement and growth acceleration typically precede breast development but are not apparent on a single physical examination. Estrogen stimulation of the vaginal mucosa causes a physiologic leukorrhea, which is a thin, white, non-foul-smelling vaginal discharge that typically begins 6 to 12 months before menarche. Menarche occurs, on average, 2 to 2.5 years after the onset of puberty for girls right after peak growth spurt --> menarche

Know that this is most likely low estrogen state Thelarche is the appearance of breast tissue, which is primarily due to the action of estradiol from the ovaries Menarche is the time of first menstrual bleed. The first menstrual bleed is often not associated with ovulation; it typically is caused solely by the effects of estradiol on the endometrial lining. Menstrual bleeding in regular menstrual cycles after maturity is caused by the interplay of estradiol and progesterone produced by the ovaries Pubarche is the appearance of pubic hair, which is primarily due to the effects of androgens from the adrenal gland. The term is also applied to first appearance of axillary hair, apocrine body odor, and acne. The median length of time between the onset of puberty (breast tanner stage 2) and menarche is 2.6 years, and the 95th percentile is 4.5 years.

Multigestation Ultrasound markers suggestive of dizygotic (non-identical) twins include -a dividing membrane thickness greater than 2 mm, -twin peak (lambda) sign, -different fetal genders -two separate placentas (anterior and posterior) The twin infant death rate is five times higher than that of singletons. The epidemic of multiple gestations resulting from assisted reproductive techniques is of great significance to individual parturients and to society because of the major morbidities associated with twinning as well as with triplets and higher order multiples. The risk for development of cerebral palsy in twin infants is five to six times higher than that of singletons. One study, with dichorionic twins, monochorionic twins and singletons, showed that twins had a higher incidence of IUGR (intrauterine growth restriction) than singletons. Fifty-eight percent of twins deliver prematurely, with an average gestational age at delivery of 35 weeks. Twelve percent of twins deliver very prematurely. The optimal mode of delivery for twins in which the first twin is in the breech presentation is by Cesarean section. Similar to singletons, if the first twin is breech problems can occur including head entrapment and umbilical cord prolapse. When the presenting twin is vertex and twin B is not vertex, controversy exists as to the optimal mode of delivery. A small randomized study comparing Cesarean delivery with vaginal delivery for vertex-non-vertex twins failed to show an advantage for Cesarean delivery

LMP is 16 weeks, 3 days. She reports no complaints and is not yet feeling fetal movement. Her fundal height is 22 cm. The MSAFP (maternal serum alpha fetoprotein) result is elevated Monozygotic conceptions may have either monochorionic or dichorionic placentation, depending upon the time of division of the zygote. Diamniotic dichorionic placentation occurs with division prior to the morula state (within three days post fertilization). Diamniotic monochorionic placentation occurs with division between days four and eight post-fertilization. Monoamniotic, monochorionic placentation occurs with division between days eight and 12 post fertilization. Division at or after day 13 results in conjoined twins Best way to decrease preterm deliv? Studies show that an *adequate weight gain in the first 20 to 24 weeks of pregnancy is especially important for women carrying multiples and may help to reduce the risk of having preterm and low-birth weight babies. *These pregnancies tend to be shorter than singleton pregnancies, and studies suggest that a good early weight gain aids in development of the placenta, possibly improving its ability to pass along nutrients to the babies. Assisted reproduction has led to an increase number of multiple gestations. The rates of multiple births after IVF (in-vitro fertilization) vary according to maternal age and the number of embryos transferred. Transfer of multiple embryos is more likely to result in multiple gestations in younger women than in older women. The frequency of multiple gestations increases with the use of ovulation inducing drugs. The risk is in the 5-6% range, but varies depending on the drug and dosage regimen used. Dizygous twinning results from the ovulation of multiple follicles and the rate of multiple gestation increases with advancing maternal age. Elevated follicle-stimulating hormone correlates with dizygous multiple births. A higher number of prior pregnancies and previous history of multiple births increases the chance of having a multiple gestation. Dizygous twinning appears to have a genetic component and rates of dizygous twins vary according to ethnicity, but are not related to paternal family history.

Gyn Procedures CIN 3 in 34 yo --> LEEP This patient has cervical dysplasia (not invasive cancer) and therefore needs cervical conization by a LEEP procedure or cold knife cone Complications from a LEEP include infection, bleeding, cervical stenosis, persistent disease, and possibly risk for preterm delivery.

LSIL in 23 yr on pap smear --> Colposcopy The most recent consensus guidelines (ASCCP-2013) state that management of LSIL is initial colposcopic examination (unless the woman is pregnant, postmenopausal or an adolescent). An excisional procedure, such as cold knife biopsy or LEEP, is not warranted without a tissue diagnosis of dysplasia. CIN1 = observation The patient does not require treatment at this time. She requires follow up Pap smear in one year. Excisional or ablative procedures are not indicated for LSIL. Indications for cold knife conization (CKC) include: positive endocervical curettage; HSIL lesion too large for LEEP; patient not tolerant of examination in office; lesion extending into the endocervical canal beyond vision; or to rule out invasive cancer (classify the depth of invasion if biopsy shows invasion). It is unusual to manage low grade lesions by CKC. Indications for LEEP are similar to CKC.

Go over these Anterior compartment prolapse - Hernia of anterior vaginal wall often associated with descent of the bladder (cystocele) Paravaginal attachments along the length of the vagina to the superior fascia of the levator ani muscle and the arcus tendineus fascia pelvis (also referred to as the "white line"). Loss of level 2 support contributes to anterior vaginal wall prolapse (cystocele). Posterior compartment prolapse - Hernia of the posterior vaginal segment often associated with descent of the rectum (rectocele) Enterocele - Hernia of the intestines to or through the vaginal wall. Pelvic floor defects are created as a result of childbirth and are caused by the stretching and tearing of the endopelvic fascia and the levator muscles and perineal body. Genital atrophy and hypoestrogenism also play important contributory roles in the pathogenesis of prolapse In the majority of cases, labor and childbirth are thought to be the primary factors responsible for pelvic neuropathies and tissue damage that predispose to the development of POP. Other medical conditions that may result in prolapse are those associated with increases in intra-abdominal pressure (eg, obesity, chronic pulmonary disease, smoking, constipation). Certain rare abnormalities in connective tissue (collagen), such as Marfan disease, have also been linked to genitourinary prolaps

Look out for fcked up question that states pt has uterus consistent with 5 months gestation and she has fibroids, how do you treat? (She's not actually pregnant, just has a big uterus, but wording makes you think she's preg) -Picture of uterine prolapse in older woman, asking mechanism of prolapse (Established risk factors for POP include parity, advancing age, and obesity - -Late 40's with possible menopause (no period for months) first step? (bHCG) -Having a baby w/macrosomia associated with what? GDM in future -Teen with PID and high fever, mgmt? Admit and IV ABX -PCOS peripheral conversion of? (Androstenedione to estrone) -Growth of cervix into parametrium? (CA) -What OCP is C/I in smoker? (triphasic) -Pt with pigmented skin over axilla at risk for? (DM) -Classic presentation of TSS (Tampon left in, etc...) -Placenta previa, placenta abruptio, placenta accreta classic presentations (1 question each) -Cord prolapse management -Painless, pruritic, ulcerated lesion in old lady? (Vulvar CA) -Uterus large for dates, first consideration? (Multiple gestation) -Breastfeeding mom, tender upper outer quadrant, fever, dx? (Mastitis) -Purulent cervical dc, motion tenderness, diplococci, what bug? (N. Gonorrhea) -MCC of serosanguinous dc and normal mammo? (Intraductal papilloma) -Amenorrhea after DnC? (Ashermann) -Amenorrhea in avid runner? (Low FSH and estrogen) -Recent pubic hair development indicative of? (Menarche) -Non-reducible uterus tx? (Halothane) -Kid with no evidence of trauma and green vag dc? (Foreign body) -Karyotype of pt w/ facial hair, no tits, blind vag, clitoromegaly? (46XY) -OCP causing decrease in breast milk protein -MCC of post-partum hemorrhage? (Atony) -Bicornuate uterus risk for? (Preterm labor) -Achondroplasia inheritance pattern? (AD) -What causes variable decels? (Cord compression) -What do you do after positive VDRL? (FTA-ABS) -Know presentations of all types of incontinence (including mechanism and tx) -Teen, never menstruated, blue bulge? (Hematocolpos) -Yellow/gray frothy discharge, wet mount shows? (Flagellated protozoa) -Big uterus w/correct dates? (Polyhydramnios) -Lady with irregular and smooth uterus, what type of leiomyoma? (Submucosal) -Know how to treat hyperthyroidism is pregnancy -Screen ages (mammo, dexa, pap) -Know when to use Rhogam -Know pre-eclampsia vs. severe vs. eclampsia -Presentation of bartholin gland abscess

Diabetes and pregnancy

Management of complications Although diabetic retinopathy, nephropathy, and mild neuropathy are not contraindications to pregnancy, they require preconception counseling and close management before and during pregnancy. Retinopathy requires that an ophthalmologic examination be done every trimester. If proliferative retinopathy is noted at the first prenatal visit, photocoagulation should be used as soon as possible to prevent progressive deterioration. Nephropathy , particularly in women with renal transplants, predisposes to pregnancy-induced hypertension. Risk of preterm delivery is higher if maternal renal function is impaired or if transplantation was recent. Prognosis is best if delivery occurs ≥ 2 yr after transplantation. Congenital malformations of major organs are predicted by elevated Hb A 1c levels at conception and during the first 8 wk of pregnancy. If the level is ≥ 8.5% during the 1st trimester, risk of congenital malformations is significantly increased, and targeted ultrasonography and fetal echocardiography are done during the 2nd trimester to check for malformations. If women with type 2 diabetes take oral hypoglycemic drugs during the 1st trimester, fetal risk of congenital malformations is unknown

Hep C Genotypes 2 and 3 — For most children and adolescents with genotype 2 or 3, we suggest deferring treatment until an interferon-free regimen is available. For adults with these genotypes, the current preferred treatment is the combination of sofosbuvir (a HCV polymerase inhibitor) with ribavirin The goal of treatment is to eradicate hepatitis C virus (HCV) RNA, which is predicted by the achievement of a sustained virologic response (SVR), defined by the absence of HCV RNA by polymerase chain reaction six months after stopping treatment.

Maternal vertical transmission — The risk of transmitting the virus from a HCV-infected woman to her infant is approximately 5 percent. Transmission rates are higher if the mother is coinfected with HIV Breastfeeding not contraindicated — Although HCV RNA has been detected in breast milk and colostrum of viremic mothers [24], breastfeeding does not appear to increase the rate of HCV transmission in asymptomatic mothers -abstain if cracked or bleeding

Ectopic Pregnancy Methotrexate Expectant Managment (missed on nbme) -actually the question was on a woman who had a thickened endometrial stripie but no fetal pole (possibly intrauterine nonviable pregnancy) w/ bhg of 450 1 week ago. -she is stable w/ a closed cervix w/ 6 week gestation size. Her hemoglobin is stable but the bhcg is no TX: expectant management -remember methotrexate is only for ectopics Examples: LMP 7week ago. Vitals WNL. Cramping, vaginal bleed, RLQ pain but no acute abdomin. Scant blood in vagina. No cervical motion tenderness. Beta-hCG is 2500 mIU/ml; progesterone 6.2 ng/ml; hematocrit 34%. The transvaginal ultrasound shows an empty uterus with endometrial thickening, a mass in the right ovary measuring 3 x 2 cm and a small amount of free fluid in the pelvis. Ans: Methotrexate LMP 8 weeks ago, stable vitals, Ab Exam normal, Pelvic examination reveals old blood in the vaginal vault, closed cervix without lesions, slightly enlarged uterus and no adnexal tenderness. Pertinent labs: Quantitative Beta-hCG is 1000 mIU/ml; urinalysis normal; hematocrit = 32%. Transvaginal ultrasound shows no intrauterine pregnancy, no adnexal masses, no free fluid in pelvis. -Ans: b-HCG in 48hrs Inappropriately rising Beta-hCG levels (less than 50% increase in 48 hours) or levels that either do not fall following diagnostic dilation and curettage would be consistent with the diagnosis of ectopic pregnancy. Alternatively, a fetal pole must be visualized outside the uterus on ultrasound LMP 6 weeks ago. Spotting this morning. No pain. Vitals WNL. On pelvic exam, her cervix is normal; uterus is small and nontender; and no masses are palpable. Initial labs show quantitative Beta-hCG 2000 mIU/ml and hematocrit 38%. A repeat Beta-hCG level 48 hours later is 2100 mIU/ml. A transvaginal ultrasound shows an empty uterus with a thin endometrial stripe and no adnexal masses The patient clearly has an abnormal pregnancy, as demonstrated by the slowly increasng Beta-hCG levels. Since the Beta-hCG level is above 2000 mIU/ml, and she has a thin endometrial stripe, this rules out an intrauterine pregnancy and the diagnosis is an ectopic pregnancy. She is a good candidate for medical treatment with methotrexate Acute abdomen + Ultrasound shows no intrauterine pregnancy, a right adnexal mass that measures 6 x 2 cm, and a moderate amount of free fluid in the cul de sac. Her vital signs, examination and anemia are consistent with an intra-abdominal bleed. Exploratory laparoscopy/laparotomy is indicated at this point. 19-year-old G2P1 woman presents with vaginal spotting and uterine cramping. On pelvic examination, she has no cervical motion tenderness, her uterus is normal size and non-tender; no adnexal masses are palpable. Quantitative Beta-hCG 48 hours ago was 1500 mIU/ml. Currently, Beta-hCG is 3100 mIU/ml. Progesterone is 26 ng/ml; Transvaginal ultrasound will most likely show an intrauterine pregnancy. The Beta-hCG level is above the discriminatory zone for ultrasound (2000 mIU/ml), and the level has doubled in 48 hours. Additionally, the progesterone level is within expected range for a normal pregnancy (>25 ng/ml suggests healthy pregnancy) and up to 30% of all normal pregnancies experience first trimester spotting/bleeding 20-year-old G1P0 woman has vaginal spotting and mild cramping for the last three days. LMP 7w ago. Quantitative Beta-hCG 48 hours ago was 750 mIU/ml; today, current Beta-hCG 760 mIU/ml; progesterone 3.2 ng/ml; hematocrit 37%. Transvaginal ultrasound shows a fluid collection in the uterus with a yolk sac but no fetal pole. A 3x3 cm cyst is seen on the left ovary. There is no free fluid in the pelvis. he pregnancy is abnormal based on the abnormal Beta-hCG levels and the progesterone level. In a normal pregnancy, the level should rise by at least 50% every 48 hours until the pregnancy is 42 days old (after that time, the rise in level may not follow the curve). A progesterone level of <5 ng/ml suggests an abnormal or extrauterine pregnancy. In this instance, the pregnancy is intrauterine because of the presence of a yolk sac. Dilation and curettage is an option for treatment. Other options include expectant management, misoprostol or manual vacuum aspiration. Laparoscopy and methotrexate are not indicated as this is a confirmed intrauterine pregnancy. Mifepristone is a progestin receptor antagonist and can be used as emergency contraception to prevent ovulation and blocks the action of progesterone which is needed to maintain pregnancy

Methotrexate therapy — The optimal candidates for MTX treatment of ectopic pregnancy are hemodynamically stable, willing and able to comply with post-treatment follow-up, have a human chorionic gonadotropin (hCG) concentration ≤5000 mIU/mL, and no fetal cardiac activity. Ectopic mass size less than 4 cm is also commonly used as a patient selection criterion; - no fetal heart rate, normal liver enzymes and renal function, normal white cell count, and the ability of the patient to follow up rapidly (reliable transportation, etc.), if her condition changes. Contraindications — Some women are not appropriate candidates for medical therapy and should be managed surgically, including women with the following characteristics [7,8]: ●Clinically important abnormalities in baseline hematologic, renal, or hepatic laboratory values: MTX is renally cleared, and in women with renal insufficiency, a single dose of MTX can lead to death or severe complications, including bone marrow suppression, acute respiratory distress syndrome, and bowel ischemia. Dialysis does not provide normal renal clearance [9,10]. Renal and liver disease may slow metabolism of MTX and result in pancytopenia and skin and mucosal damage [11]. MTX, especially with chronic administration such as for those with psoriasis or rheumatoid arthritis, can be hepatotoxic. Similarly, it can cause suppression of the bone marrow. ●Immunodeficiency, active pulmonary disease, peptic ulcer disease. MTX could be associated with pulmonary toxicity, and the various toxicity of MTX is enhanced in women with immune impairment. Similarly, in those with peptic ulcers, MTX may worsen the condition. ●Hypersensitivity to MTX. ●Heterotopic pregnancy with coexisting viable intrauterine pregnancy. (See "Abdominal pregnancy, cesarean scar pregnancy, and heterotopic pregnancy", section on 'Heterotopic pregnancy'.) ●Breastfeeding. ●Unable or unwilling to complete MTX protocol: •Not able or willing to comply with medical therapy post-treatment follow-up •Lack of timely access to a medical institution for management of tubal rupture The transvaginal ultrasound shows an empty uterus with endometrial thickening, a mass in right ovary measuring 3.8 x 2 cm, and a small amount of free fluid in the pelvis. What is the most likely diagnosis in this patient? The diagnosis of ectopic pregnancy is made when either: 1) a fetal pole is visualized outside the uterus on ultrasound; 2) the patient has a Beta-hCG level over the discriminatory zone (the level at which an intrauterine pregnancy should be seen on ultrasound, usually 2000 mIU/ml) and there is no intrauterine pregnancy (IUP) seen on ultrasound; or 3) the patient has inappropriately rising Beta-hCG level (less than 50% increase in 48 hours) and has levels which do not fall following diagnostic dilation and curettage.

Myasthenia Gravis in pregnancy Because weakness due to myasthenia lessens in cooler temperature, patients with ptosis can be tested using the ice pack test. For this test, an icepack is applied to a patient's closed eyes for 2 min, then removed. A positive result is full or partial resolution of ptosis. The ice pack test usually does not work if patients have ophthalmoparesis. Patients with opthalmoparesis can be tested using the rest test. For this test, patients are asked to lie quietly in a dark room for 5 min with their eyes closed. If ophthalmoparesis resolves after this rest, the result is positive. Pearls & Pitfalls Try the ice pack or rest test before the anticholinesterase test. Do the anticholinesterase test only if patients have obvious ptosis or ophthalmoparesis (to get unequivocal results). Even if a bedside test is unequivocally positive, serum AChR antibody levels, electromyography (EMG), or both are required to confirm the diagnosis. AChR antibodies are present in 80 to 90% of patients with generalized myasthenia but in only 50% with the ocular form. Antibody levels do not correlate with disease severity. Up to 50% of patients without AChR antibodies test positive for anti-MuSK antibodies. EMG using repetitive stimuli (2 to 3/sec) shows a significant decrease in amplitude of the compound muscle action potential response in 60% of patients

Myasthenia gravis varies in its course during pregnancy. Frequent acute myasthenic episodes may require increasing doses of anticholinesterase drugs (eg, neostigmine), which may cause symptoms of cholinergic excess (eg, abdominal pain, diarrhea, vomiting, increasing weakness); atropine may then be required. Sometimes myasthenia becomes refractory to standard therapy and requires corticosteroids or immunosuppressants. During labor, women may need assisted ventilation and are extremely sensitive to drugs that depress respiration (eg, sedatives, opioids, Mg sulfate). Because the IgG responsible for myasthenia crosses the placenta, transient myasthenia occurs in 20% of neonates, even more if mothers have not had a thymectomy.

Tocolysis Magnesium sulfate works by competing with calcium entry into cells. Beta-adrenergic agents work by increasing cAMP in the cell, thereby decreasing free calcium. Prostaglandin synthetase inhibitors, such as Indomethacin, work by decreasing prostaglandin (PG) production by blocking conversion of free arachidonic acid to PG. Calcium channel blockers prevent calcium entry into muscle cells by inhibiting calcium transport. Maternal indomethacin exposure can result in premature constriction of the ductus arteriosus, especially if used after 32 weeks gestation. Polyhydramnios is not associated with indomethacin. In fact, indomethacin is associated with oligohydramnios. Fetal hypoxia and decreased uteroplacental blood flow have been associated with the use of calcium channel blockers, such as Nifedipine.

Nifedipine, a calcium channel blocker is the best option for her as she has contraindications to the other agents listed. Terbutaline and ritodrine are contraindicated in diabetic patients and the FDA made a formal announcement in 2011 warning against using terbutaline to stop preterm labor stating that terbutaline is both ineffective and dangerous if used for longer than 48 hours; magnesium sulfate is contraindicated in myasthenia gravis; and indomethacin is contraindicated at 33 weeks due to risk of premature ductus arteriosus closure. Terbutaline is a beta-adrenergic agent. Side effects include tachycardia, hypotension, anxiety and chest tightening or pain. Treatment with betamethasone from 24 to 34 weeks gestation has been shown to increase pulmonary maturity and reduce the incidence and severity of RDS (respiratory distress syndrome) in the newborn. It is also associated with decreased intracerebral hemorrhage and necrotizing enterocolitis in the newborn. It has not been associated with increased infection or enhanced growth.

External otitis (conductive hearing loss) The most common symptoms of external otitis are ear pain, pruritus, discharge, and hearing loss [2]. In addition to symptoms, patients should be asked about any known tympanic membrane perforation, previous ear infections, any prior ear surgery, recent ear instrumentation, and water exposure. On physical examination, the auricle and tragus should be examined for erythema or signs of trauma (figure 1). Tenderness with tragal pressure or when the auricle is manipulated or pulled are indicative findings of external otitis

Otoscopy is critical for distinguishing between external otitis, otitis media, and other ear pathology. The ear canal usually appears edematous and erythematous in external otitis. Debris or cerumen is typically yellow, brown, white, or gray. Otomycosis, a fungal infection of the external canal, may take on different appearances (eg, fine, dark coating with Aspergillus; white, sebaceous-like material with Candida). (See 'Otomycosis' below.) The tympanic membrane may be erythematous in external otitis and only partially visible due to canal edema. The presence of an air-fluid level along the tympanic membrane is indicative of a middle ear effusion and underlying otitis media

Virilization

PCOS Peripubertal onset of symptoms, oligomenorrhea, obesity, polycystic ovaries on ultrasound Idiopathic hirsutism Normal menstrual cycles, normal serum androgens, and no other identifiable cause for the hirsutism Nonclassic 21-hydroxylase deficiency Similar presentation to PCOS, high serum 17-hydroxyprogesterone concentration, more common in certain ethnic groups Classic 21-hydroxylase deficiency Diagnosed during infancy, ambiguous genitalia Androgen-secreting ovarian tumors: (Sertoli-Leydig cell, Granulosa-theca cell, Hilus cell) Onset in third decade or later (usually postmenopausal), rapidly progressive hirsutism, virilization Androgen-secreting adrenal tumors Some women with adrenocortical cancer present with just virilization, but a mixed Cushing's and virilization syndrome is more common Ovarian hyperthecosis Onset in third decade or later (usually postmenopausal), rapidly progressive hirsutism, virilization Severe insulin resistance syndromes Virilization, amenorrhea, infertility, and the ovary shows histologic changes of hyperthecosis Cushing's disease Corticotroph adenoma secreting ACTH results in excess cortisol and adrenal androgens Drugs Use of exogenous androgens (testosterone or DHEA) can cause hirsutism and acne Acromegaly Enlarged jaw (macrognathia) and enlarged, swollen hands and feet, which results in increasing shoe, glove, and ring sizes. Patients with large pituitary tumors may have headaches, visual field defects, and cranial nerve palsies. Drugs that cause hirsutism or have other androgenic effects include anabolic steroids and danazol (which was often given in the past for endometriosis). Valproate has been associated with the development of PCOS

Placenta Accreta RF risk increases w/ previous C-sections Placenta Previa history of uterine surgery (eg, myomectomy entering the uterine cavity, hysteroscopic removal of intrauterine adhesions, cornual resection of ectopic pregnancy, dilatation and curettage, endometrial ablation), cesarean scar pregnancy, maternal age greater than 35 years history of pelvic irradiation

Placenta accreta refers to an abnormality of placental implantation in which the anchoring placental villi attach to myometrium rather than decidua, resulting in a morbidly adherent placenta. Placenta increta (chorionic villi penetrate into the myometrium) and placenta percreta (chorionic villi penetrate through the myometrium to the uterine serosa or adjacent organs) are related, but more severe, abnormalities of placental implantation The first clinical manifestation of placenta accreta is usually profuse, life-threatening hemorrhage that occurs at the time of attempted manual placental separation. Part, or all, of the placenta remains strongly attached to the uterine cavity, and no plane of separation can be developed Dx: 2nd/3rd trimester US - loss of placental homogeneity (mulitple sonolucent spaces = venous lakes in mymoetrium) or loss / thinning of normal hypoechoic area behind placenta w/ retroplacental myometrium thickness less than 1mm or loss of bladder line w/ uterine serosa (bulging of placenta into the posterior wall of bladder) -1st trimester suspicious w/ gestational sac in lower uterine segment (instead of fundus) near scar Summary: US showing multiple vascular lacunae within the placenta, loss or disruption of the retroplacental clear space and bladder line) Tx: Betamethason at 34 weeks deliver within 48 hrs. Place balloon catheters into the internal iliac arters prior to hysterectomy leaving the placenta undisturbed in situ

Endometritis

Postpartum endometritis is a common cause of postpartum febrile morbidity (defined as an oral temperature of ≥38.0 degrees Celsius [≥100.4 degrees Fahrenheit] or more on any 2 of the first 10 days postpartum, exclusive of the first 24 hours). The infection begins in the decidua, and then may extend into the myometrial and parametrial tissues. (See 'Introduction' above.) ●The infection is polymicrobial, usually involving a mixture of two to three aerobes and anaerobes from the lower genital tract. (See 'Microbiology' above.) ●Cesarean delivery is the most important risk factor for development of postpartum endometritis. (See 'Risk factors' above.) ●The diagnosis of postpartum endometritis is based upon clinical criteria of fever and uterine tenderness occurring in a postpartum woman. Other signs and symptoms which support the diagnosis include foul lochia, chills, and lower abdominal pain. The uterus may be soft and subinvoluted, which can lead to excessive uterine bleeding. Sepsis is an unusual presentation

Postpartum Hemorrhage -risk factors LARGE BABY uterine overdistention (eg, multiple gestation, polyhydramnios, macrosomia), uterine infection, uterine inversion, inherited bleeding diathesis, acquired bleeding diathesis (eg, amniotic fluid embolism, abruptio placenta, sepsis, fetal demise), and use of some drugs, such as uterine relaxants and drugs that affect coagulatio

Postpartum hemorrhage (PPH) is an obstetrical emergency that can follow vaginal or Cesarean delivery. Uterine atony is the most common cause of PPH and occurs in one in every twenty deliveries. It is important to detect excessive bleeding quickly and determine an etiology and initiate the appropriate treatment as excessive bleeding may result in hypovolemia, with associated hypotension, tachycardia or oliguria. The most common definition of PPH is an estimated blood loss of greater than or equal to 500 ml after vaginal birth, or greater than or equal to 1000 ml after Cesarean delivery.

Primary Dysmenorrhea RF: age <30 years, body mass index <20 kg/m2, smoking, menarche before age 12, longer menstrual cycles/duration of bleeding, irregular or heavy menstrual flow, and history of sexual assault Pathogenesis: Prostaglandins released from endometrial sloughing at the beginning of menses play a major role in inducing contractions. These contractions are nonrhythmic or incoordinate, occur at high frequency (more than 4 or 5 per 10 minutes), often begin from an elevated basal tone (more than 10 mmHg), and result in high intrauterine pressures (frequently more than 150 to 180 mmHg, sometimes exceeding 400 mmHg) [15]. When uterine pressure exceeds arterial pressure, uterine ischemia develops and anaerobic metabolites accumulate, which stimulate type C pain neurons resulting in dysmenorrhea. Tx: Nonsteroidal antiinflammatory agents and hormonal contraceptives are the mainstays of therapy ( NSAIDS before APAP ie Ibuprofen or mefenamic acid ) then both estrogen-progestin and progestin-only methods are effective. -if refractory for 3m w/ both we try a laparoscopy

Primary dysmenorrhea refers to the presence of recurrent, crampy, lower abdominal pain that occurs during menses in the absence of demonstrable disease that could account for these symptoms. Nausea, diarrhea, fatigue, headache, and a general sense of malaise often accompany the pain The majority of women with primary dysmenorrhea do not have any risk factors for the disorder. The pain starts one to two days before or with the onset of menstrual bleeding and then gradually diminishes over 12 to 72 hours. It is recurrent, occurring in most, if not all, menstrual cycles. The pain is usually crampy and intermittently intense, but may be a continuous dull ache. It is usually confined to the lower abdomen and suprapubic area. Although the pain is usually strongest in the midline, some women also have severe back and/or thigh pain. Nonmidline pain, especially if unilateral, suggests a uterine anomaly or alternative diagnosis

DONOR TWIN in TTTS Small (IUGR), Oligohydramnios Underperfusion of blood Anemic

RECIPIENT TWIN LARGE (Plethoric), volume overload w/ polyhydroaminos, heart failure --> hydrops Polycythemia monochorionic diaminoinic Death in utero of either twin is common. Surviving infants have increased rates of neurological morbidity, with increased risk of cerebral palsy for the surviving twin. Excessive volume can lead to cardiomegaly, tricuspid regurgitation, ventricular hypertrophy and hydrops fetalis for the recipient twin. Although the recipient twin is plethoric, it is not macrosomic.

Small for Gestational Age -cause for small size unknown fundal height less than 3cm of expected --> US -re-examine the dating -serial US every 2-3 weeks -if pre-eclampsia, placental insuffiencey, collagen vascular disorders or vascular disease --> Tx w/ low dose aspirin Example: Smoker, Diabetic, has consistently a small fetus starting at week 32- why? alterations in uteroplacental perfusion affect the growth and status of the fetus, as well as the placenta. This patient has significant medical diseases that are affecting her vasculature and, ultimately, limiting the substrate availability to the fetus with resultant uteroplacental insufficiency. The vascular disease is evidenced by retinopathy and proteinuria. Ex: A 36-year-old G1 with type 1 diabetes is diagnosed with intrauterine growth restriction at 33 weeks gestation. What is the most appropriate next step in management? Ans = Antenatal testing of fetal well-being Uteroplacental insufficiency can lead to asymmetric growth restriction. Asymmetric growth restricted infants typically have a normal length, but their weight is below normal. On ultrasound, there is a head-sparing effect, meaning that the head/brain is spared of the reduced blood flow that is a result of uteroplacental insufficiency. Thus, the fetal abdomen measures below normal and the head remains very close to normal. There is an asymmetrical growth pattern that is usually detected during the third trimester and reflects uteroplacental insufficiency. Symmetric fetal growth restriction indicates that all fetal measurements are below normal. As a general rule, such a finding indicates an intrinsic growth failure or an "early event" secondary to one or more organ system anomalies, fetal aneuploidy or chronic intrauterine infection Small babies increase risk of Fetal demise Perinatal demise Meconium aspiration Polycythemia cardiovascular disease, chronic hypertension, chronic obstructive lung disease and diabetes

Risk factors *decreased growth potentional* Genetic and chromosomal abnormalities (Trisomies) Intrauterine infections Tetragenics Substance abuse Radiation exposure Small Maternal Stature Pregnancy at high altitudes Female fetus *Intrauterine Growth Restricted* (symmetric if before 20w, asym after) - confirmed by increased head - abdominal measurements Maternal: HTN, Anemia, CRF, Malnutrition, Severe diabetes, anti-phospholipid, SLE Placental: Placenta Previa, chronic abruption, placental infarction, multiple gestation Example: Diabetic w/ cHTN @ 35w GA ultrasound reveals limited fetal growth over the past three weeks. Biometry is consistent with 32-5/7, EFW 2175 g, <10th percentile. What is the most appropriate next test indicated in the management of this patient? Ans = Amniotic fluid volume, umbilical artery Doppler systolic: diastolic ratio, non-stress test When a pregnancy is complicated by fetal growth restriction, various fetal physiologic parameters require assessment. In growth-restricted pregnancies, oligohydramnios is frequently found. This finding is presumably due to reduced fetal blood volume, renal blood flow and urinary output. Chronic hypoxia is responsible for diverting blood flow from the kidney to organs that are more critical during fetal life. The significance of the amniotic fluid volume with respect to fetal outcome has been well documented. Ninety percent of patients with oligohydramnios delivered growth restricted infants. These infants experienced a high rate of fetal compromise. The systolic/diastolic (S/D) ratio of the umbilical artery is determined by Doppler ultrasound. An increase in the S/D ratio reflects increased vascular resistance. It is a common finding in IUGR fetuses. A normal S/D ratio indicates fetal well-being. As vascular resistance increases, the S/D ratio increases. With severe resistance, there is absence and ultimately reversal of end-diastolic flow. These findings are associated with an increased rate of perinatal morbidity and mortality, and a higher likelihood of a long-term poor neurologic outcome. SFGA baby, The non-stress test is reactive and the amniotic fluid index is 10. What is your next step in management? Ans= Continue with weekly non-stress tests There is reverse end diastolic flow and the amniotic fluid volume is decreased. The AFI is 1.1 cm. Ans = Induction of labor

Gestational Diabetes Hypoglycemia LARGE polycythemia hyperbilirubinemia hypocalcemia

Screening should be performed between 24 and 28 weeks in those women not known to have glucose intolerance earlier in pregnancy. This evaluation can be done in two steps: a 50-g oral glucose challenge test is followed by a diagnostic 100-g oral glucose tolerance test (OGTT) if initial results exceed a predetermined plasma glucose concentration. Patients at low risk are not routinely screened. For those patients of average risk screening is performed at 24 - 28 weeks while those at high risk (severe obesity and strong family history) screening should be done as soon as feasible. Infants born to diabetic mothers are at increased risk for developing hypoglycemia, polycythemia, hyperbilirubinemia, hypocalcemia and respiratory distress. Thrombocytopenia is not a risk.

Postpartum Lochia — The basal portion of the decidua remains after the placenta separates. This decidua divides into two layers: the superficial layer is shed and the deep layer regenerates new endometrium, which covers the entire endometrial cavity by the 16th postpartum day [7]. Normal shedding of blood and decidua is referred to as lochia rubra (red, red brown), and lasts for the first few days following delivery. Vaginal discharge then becomes increasingly watery, called lochia serosa (pinkish brown), which lasts for two to three weeks. Ultimately, the discharge turns yellowish-white, the lochia alba. Microscopically, lochia consists of serous exudate, erythrocytes, leukocytes, decidua, epithelial cells, and bacteria. Malodorous lochia — The most common cause of malodorous lochia is a retained gauze sponge inadvertently left in situ after repair of an episiotomy or laceration. Chloasma resolves in the postpartum period, although the exact timing is not known. APAP is safe for breast feeding

Shivering (Chills, rigors) 25 - 50% of women after normal deliveries Tx: warm blanket Uterine involution — Immediately after delivery of the placenta, the uterus begins to involute (ie, contract). Myometrial retraction is a unique characteristic of the uterine muscle that enables it to maintain its shortened length following successive contractions On examination, the fundus should be nontender, firm, and more globular than in its pregnant state. A soft, boggy uterus in the presence of heavy vaginal bleeding suggests inadequate contraction of the uterus (ie, atony). Cervix — After delivery, the cervix is soft and floppy and there are small lacerations at the margins of the external os, which remains dilated. The cervix contracts slowly, remaining two to three centimeters dilated for the first few postpartum days, and less than 1 centimeter dilated at one week. The external os never resumes its pregravid shape; the small, smooth, regular circular opening of the nulligravida becomes a large, transverse, stellate slit after childbirth Breast engorgement — Breast engorgement refers to swelling of the breast and can occur early or late in the postpartum period. The breast becomes firm, enlarged, tender, and may be warm to the touch. Early engorgement is secondary to edema, tissue swelling, and accumulated milk, while late engorgement is due solely to accumulated milk. Early engorgement typically occurs between 24 and 72 hours postpartum, with a normal range of one to seven days. Peak symptomatology averages three to five days postpartum. Breast engorgement is uncomfortable and may give rise to a mild temperature elevation for a short period of time; however, any fever should prompt an investigation to rule out an infectious source -Engorgement commonly occurs when milk comes in. Strategies that may help include frequent nursing, taking a warm shower or warm compresses to enhance milk flow, massaging the breast and hand expressing some milk to soften the breast, wearing a good support bra and using an analgesic 20 minutes before breast feeding. (Answer to q was to decrease symptoms feed every 1.5-3hrs round the clock)

Post Partum Care Lochia

Shivering - postpartum chills and rigors are normal and last up to an hour possibly due to hemorrhage or placental serpation. Tx w/ warm blanket Uterine Involution -

Postpartum blues She delivered four weeks ago and tearfully reports that she is not sleeping, feels anxious and has thoughts of jumping out her 15th floor window. symptoms of depression. Symptoms such as mood changes, insomnia, phobias and irritability are more pronounced than with the "blues." She has not described any of the even more advanced psychotic symptoms of visual or auditory hallucinations. A patient's history of a psychiatric illness is a risk factor for the development of a postpartum depression. Patients with a prior history of depression, either situational or spontaneous, are at very high risk for postpartum depression. In fact, one-third of patients with a postpartum psychiatric problem report a prior history. These patients need careful follow up after delivery, which should include an early appointment for a postpartum visit SI = offered thoughts of suicidal ideation, thus inpatient management is the most appropriate choice. While behavioral psychotherapy is necessary to establish long-term strategies for coping skills, newer regimens for postpartum depression include the use of SSRI medication. SSRI medications have been shown to hasten recovery to a fully functioning state. Antipsychotic medication is not indicated without an established diagnosis. Electroconvulsive therapy may be indicated for patients who don't respond to standard depression treatments. -With Category A drugs, there are adequate, well-controlled studies in pregnant women that have not shown an increased risk of fetal abnormalities to the fetus in any trimester of pregnancy. -With Category B, animal studies have revealed no evidence of harm to the fetus; however, there are no adequate and well-controlled studies in pregnant women or animal studies that have shown an adverse effect, but adequate and well-controlled studies in pregnant women have failed to demonstrate a risk to the fetus in any trimester. -Category C drugs have animal studies that show an adverse effect and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks. -Category D drugs have adequate well-controlled or observational studies in pregnant women and are known risks to the fetus. - Category X drugs should not be used in pregnancy, because adequate well-controlled or observational studies in animals or pregnant women have demonstrated positive evidence of fetal abnormalities or risks.

Signs and symptoms of depression which last for less than two weeks are called postpartum blues. It occurs in 40-85% of women in the immediate postpartum period. It is a mild disorder that is usually self-limited. This patient does not have signs/symptoms of anxiety disorder or bipolar disorder. Which of the following signs or symptoms of postpartum depression are most useful to distinguish it from postpartum blues and normal changes that occur after delivery? -Ambevilance towards the Newborn In addition to the more common symptoms of depression, the postpartum patient may manifest a sense of incapability of loving her family and manifest ambivalence toward her infant. Anhedonia is an inability to experience pleasure from normally pleasurable life events such as eating, exercise, and social or sexual interaction. -The most significant risk factor for developing postpartum depression is the patient's prior history of depression. Other risk factors for postpartum depression include marital conflict, lack of perceived social support from family and friends, having contemplated terminating the current pregnancy, stressful life events in the previous twelve months, and a sick leave in the past twelve months related to hyperemesis, uterine irritability or psychiatric disorder. While all the side effects listed are reported in patients on fluoxetine, an SSRI antidepressant medication, the most common side effect is insomnia. Significant insomnia may affect one in five patients taking SSRIs. In addition to sleep disturbances, sexual dysfunction, such as decreased libido and delayed or absent orgasm, are common. Breastfeeding is beneficial to both mother and infant. Current recommendations state that SSRI medications can be safely used during lactation. Several studies show that SSRIs are secreted in breast milk, however no detectable levels of the drug were found in the infants' serum. In addition, no adverse effects were noted in the infants by either their parents or pediatricians following the infants. Third trimester maternal use of SSRIs including Fluoxetine (neonatal agigitation and poor feeding) has been associated with abnormal muscle movements (extrapyramidal signs or EPS) and withdrawal symptoms which may include agitation, abnormally increased or decreased muscle tone, tremor, sleepiness, severe difficulty breathing, and difficulty in feeding. In some newborns, the symptoms subside within hours or days and do not require specific treatment; other newborns may require longer hospital stays. SSRI use during pregnancy is not associated with newborn seizures, intracranial hemorrhage or temperature instability. The FDA has concluded that, given the conflicting results from different studies, it is premature to reach any conclusion about a possible link between SSRI use in pregnancy and persistent pulmonary hypertension. Woman comes in with problems towards end of cycle ( tension, depressed mood) Ascertaining the timing of her symptoms each month is an important first step in establishing the proper diagnosis. Symptoms of Premenstrual Dysphoric Disorder occur in the luteal phase and are absent in the beginning of the follicular phase. It is therefore important to document the timing of symptoms each month when considering a diagnosis of Premenstrual Dysphoric Disorder. Additionally, it is important to ascertain that these symptoms are not an exacerbation of an underlying psychiatric disorder before initiating therapy as this potentially can have more consequences during her pregnancy and postpartum period.

Adnexal Masses If premenopausal In the absence of pain or intraperitoneal bleeding, observation for a time period between two weeks and three months and possibly therapy with oral contraceptive pills is appropriate. The oral contraceptive pills will keep a new cyst from forming so as to decrease confusion at the follow-up ultrasound, but do not help the current cyst regress According to aafp if premenopausal 1st test = pregnancy test then US if -internal echos, septae, exrecrescenes, papillations or over 10 cm then surg - if less than 10cm do trial of NSAIDs and serial tv- us 4 - 6 weeks if postmenopausal any mass over 10cm is surgical if under do ultrasound for malignant clues if negative check CA 125 if over 35 units/mL its surgical if not...serial ultrasound every 4-6 w ●High risk - Solid component that is not hyperechoic and is often nodular or papillary Septations, if present, that are thick (>2 to 3 mm) Color or power Doppler demonstration of flow in the solid component Presence of ascites (any peritoneal fluid in postpostmenopausal women and more than a small amount of peritoneal fluid in premenopausal women is abnormal) Peritoneal masses, enlarged nodes, or matted bowel (may be difficult to detect) ●Intermediate risk - Not anechoic and/or unilocular, but no features of malignancy (eg, a mass with thin septations or low level echoes) ●Low risk - Anechoic unilocular fluid filled cysts with thin walls

Simple cysts less than 2 cm in diameter are considered physiologic. Larger and complex cysts are more likely to be nonphysiologic. asymptomatic simple cysts <6 cm on ultrasound examination can be observed with or without administration of oral contraceptive pills. A solid ovarian mass in childhood is always considered malignant until proven otherwise by histological examination. ●Alpha-fetoprotein (AFP) is an oncofetal antigen that is a glycoprotein. It is produced by endodermal sinus tumors, mixed germ cell tumors, and immature teratomas. ●Lactate dehydrogenase (LDH) is elevated with dysgerminomas ●CA-125 is a marker for epithelial ovarian cancer that is highly sensitive, but not very specific, since it is elevated with many intraperitoneal processes (eg, endometriosis, pelvic inflammatory disease, pregnancy, Crohn's disease) ●Human chorionic gonadotropin (hCG) is produced by trophoblastic cells and thus will be elevated with pregnancy, hydatidiform moles, placental site tumors, nongestational choriocarcinoma, and embryonal ovarian carcinomas ●Carcinoembryonic antigen (CEA) can be produced by epithelial or germ cell tumors ●Inhibin and mullerian inhibiting substance (MIS) concentrations are elevated in children with granulosa-theca cell tumors ●Thrombocytosis has been associated with ovarian malignancies in girls and adolescents [52]. Because it is readily available, the platelet count is useful in the emergency evaluation of a torsed ovary with suspicion for malignancy. Theca Lutein Cyst: luteinized follicle cysts that form as a result of overstimulation from high hCG levels or extreme sensitivity to hCG. Bilateral multiseptated cystic adnexal masses in a woman with gestational trophoblastic disease, multiple gestation, ovarian hyperstimulation, or a pregnancy complicated by fetal hydrops are likely to represent theca lutein cysts, rather than malignancy. Most are asymptomatic, but maternal virilization, hyperemesis gravidarum, preeclampsia, or thyroid dysfunction may occur. The cysts gradually resolve weeks to months after the source of hCG is eliminate Corpus luteum of pregnancy - An early intrauterine pregnancy is always associated with a corpus luteum cyst, which is typically less than 2.5 cm in diameter. However, the corpus luteum may occasionally become enlarged and painful due to hemorrhage. Luteoma - Luteoma is a nonneoplastic ovarian change associated with pregnancy that can simulate a neoplasm on clinical, gross, or microscopic examination [10]. Luteomas involute spontaneously after delivery or are adequately treated by a conservative surgical approach. The diagnosis should be suspected in the presence of a solid adnexal mass and maternal hirsutism or virilization

Postoperation The diagnosis of wound infection is clinical. Symptoms include localized erythema, induration, warmth, and pain at the incision site. Purulent wound drainage and separation of the wound may occur. Some patients will have systemic evidence of their infection such as fever and leukocytosis. Infected wounds are opened, explored, drained, irrigated, debrided, and dressed open. If fascial disruption is suspected, drainage should be performed in the operating room. Once the infection has cleared and granulation tissue is apparent, the wound can be closed secondarily. Wound dressings — Dressings that maintain moisture and warmth facilitate healing Negative pressure wound therapy (also called vacuum-assisted wound closure) can be used for wounds that have a clean, granulating base. The negative pressure reduces excess fluid accumulation and, with time, the size of large complex wounds Cellulitis: Antibiotics Open wound: none Systemic signs: Antibiotics

Small hematomas and seromas can be managed expectantly, while large collections should be drained. For symptomatic hematomas, the wound is opened partially or completely under sterile conditions. If there is no evidence of infection, the wound can be closed immediately. For suspected seroma, aspiration under sterile conditions may be all that is required. (obesity is a risk factor) risk factors for fascial disruption in one risk model included age, male sex, chronic pulmonary disease, ascites, anemia, emergency surgery, postoperative coughing, wound infection -Herniation is more common when the incision length exceeds 18 cm Sx: profuse serosanguinous drainage, often preceded by a popping sensation and an incisional bulge exacerbated by Valsalva maneuvers. Most dehiscences occur 4 to 14 days after surgery, with a mean of 8 day The absence of a healing ridge in a laparotomy incision by postoperative day five can be a sign of impaired healing and impending disruption Tx: Wound exploration in OR (place moist dressing in meantime)

Emergency Contraception We suggest administering emergency contraception as soon as possible, but up to 120 hours, after an episode of unprotected intercourse in women who wish to prevent pregnancy levonorgestrel and estradiol plus levonorgestrel regimens are most effective when given as soon as possible after unprotected intercourse ulipristal is only drug licensed for use b/t 3 days and 5 days The copper IUD as an emergency contraceptive is effective up to five days after ovulation because of its post-fertilization effects

The WHO has concluded that there are no contraindications to the oral combination method of emergency contraception except pregnancy. The American College of Obstetricians and Gynecologists states that emergency oral contraception should not be used in a patient with a known or suspected pregnancy, hypersensitivity to any component of the product, or undiagnosed abnormal genital bleeding. Nausea and vomiting are the most common side effects of the oral hormonal drugs. Single- and split-dose levonorgestrel regimens have similar rates of nausea and vomiting (nausea: up to 24 percent, vomiting: up to 9 percent) [54]; antiemetics are not typically required. Split-dose levonorgestrel causes significantly less nausea and vomiting than standard dose estrogen-progestin (nausea: up to 68 percent, vomiting: up to 25 percent) and slightly less nausea than ulipristal (nausea 29 percent). Irregular bleeding is not uncommon in the month after treatment, and has been reported in 16 percent of patients in the first week after use [29,55]. Uncommon side effects include dizziness, fatigue, headache, breast tenderness, and lower abdominal pain.

3 days after c/s a 27yo has temperature 101.8 and mild pain with urination. No urinary urgency or frequency. She is bottle feeding. Incision is clean and intact. Breasts are tense, erythmatous, and tender. Uterus is firm, nontender and consistent in size with 20wk. Leukocyte: 6500 Urine: RBC: 10-15/hpf and WBC: 1-2/hpf Most likely diagnosis? A. breast engorgement B. Cystitis C. ENdometritis D. Mastitis E. wound cellulitis Answer is not B. Is is A? If so why? How can you rule out cystitis? Is it because of the normal WBC in the urine? Is mild pain with urination normal post c/s?

The answer is A. The timeline and presentation does not follow with mastitis. Mastitis is often a couple weeks or so postpartum. Mastitis is also unilateral and often only one section of that single breast. Breast engorgement is very very common, can cause a temp, etc. Timeline is perfect, as it often happens when the milk comes in (around day 3). The RBCs in the urine are likely from lochia, we see blood in urine all the time postpartum, and it's very hard to get a clean catch once a foley is out (should have been out PostOp day 1). There are practically no WBCs, which, from the info given, makes a UTI unlikely.

Ectopic Pregnancy Risk Factors Previous ectopic pregnancy Previous tubal surgery Tubal ligation Tubal pathology In utero DES exposure Current IUD use Infertility Hx of Cervicitis Hx of PID Multiple Sexual Partners Smoking Previous ab or pelvic surg Douching Early age of intercourse if hemodynamically stable w/ bhcg around a 1000 but no other indications - do a serial bhcg in 48hrs

The diagnosis of ectopic pregnancy is made when either: 1) a fetal pole is visualized outside the uterus on ultrasound; 2) the patient has a Beta-hCG level over the discriminatory zone (the level at which an intrauterine pregnancy should be seen on ultrasound, usually 2000 mIU/ml) and there is no intrauterine pregnancy (IUP) seen on ultrasound; or 3) the patient has inappropriately rising Beta-hCG level (less than 50% increase in 48 hours) and has levels which do not fall following diagnostic dilation and curettage Tx: MTX if •Hemodynamically stable •Have no renal, hepatic, or hematologic disorders •Able and willing to comply with post-treatment monitoring •Pretreatment serum hCG concentration less than 5000 mIU/mL •Tubal size of less than 3 cm and no fetal cardiac activity (these are not independent predictors of MTX treatment success) In single-dose protocols, intramuscular MTX is given followed by a hCG level on treatment Day 4 and 7 and then weekly. Additional doses of MTX are given if the hCG does not decline sufficiently. The hCG is followed until the level is undetectable Note: In normal pregnancy the Beta-hCG level is above the discriminatory zone for ultrasound (2000 mIU/ml), and the level has doubled in 48 hours. Additionally, the progesterone level is within expected range for a normal pregnancy (>25 ng/ml suggests healthy pregnancy) and up to 30% of all normal pregnancies experience first trimester spotting/bleeding

Herpes course primary lesion lasts 20 days recurrent last around 10 days 50 percent of patients with symptomatic recurrences have prodromal symptoms before eruption such as local mild tingling or shooting pains in the buttocks, legs, and hips Tx with acylcovir does not decrease recurrance rates Dx: A clinical diagnosis of genital herpes should be confirmed with laboratory testing The classical presentation with multiple vesicles on an erythematous base is often absent in many patients viral culture, polymerase chain reaction (PCR), direct fluorescence antibody, and type-specific serologic tests. The choice of test varies with the clinical presentation [60]. Cell culture and PCR-based testing are the preferred tests for a patient presenting with active lesions, although PCR-based testing has the greatest overall sensitivity and specificity.

The initial presentation can be severe with painful genital ulcers, dysuria, fever, tender local inguinal lymphadenopathy, and headache. In other patients, however, the infection is mild, subclinical, or entirely asymptomatic Dysuria can lead to reluctance to void because of the passage of acidic urine on open and inflamed vesicles; this is best managed with Sitz baths. However, acute urinary retention with loss of sacral sensation can occur due to lumbosacral radiculomyelitis secondary to severe primary HSV infection Tx: Acyclovir, famciclovir, and valacyclovir all have similar antiviral activity against HSV, although famciclovir and valacyclovir have improved bioavailability versus acyclovir Genital HSV infections are classified as initial primary, initial nonprimary, recurrent and asymptomatic. Initial, or first-episode primary genital herpes is a true primary infection (i.e. no history of previous genital herpetic lesions, and seronegative for HSV antibodies). Systemic symptoms of a primary infection include fever, headache, malaise and myalgias, and usually precede the onset of genital lesions. Vulvar lesions begin as tender grouped vesicles that progress into exquisitely tender, superficial, small ulcerations on an erythematous base. Initial, nonprimary genital herpes is the first recognized episode of genital herpes in individuals who are seropositive for HSV antibodies. Prior HSV-1 infection confers partial immunity to HSV-2 infection and thereby lessens the severity of type 2 infection. The severity and duration of symptoms are intermediate between primary and recurrent disease, with individuals experiencing less pain, fewer lesions, more rapid resolution of clinical lesions and shorter duration of viral shedding. Systemic symptoms are rare. Recurrent episodes involve reactivation of latent genital infection, most commonly with HSV-2, and are marked by episodic prodromal symptoms and outbreaks of lesions at varying intervals and of variable severity. Clinical diagnosis of genital herpes should be confirmed by viral culture, antigen detection or serologic tests. Treatment consists of antiviral therapy with acyclovir, famciclovir or valacyclovir.

Androgen Insensitivity Syndrome Symptoms of CAIS do not appear until puberty, which may be slightly delayed, but is otherwise normal except for absent menses and diminished or absent secondary terminal hair. Axillary hair (i.e. armpit hair) fails to develop in one third of all cases. External genitalia is normal, although the labia and clitoris are sometimes underdeveloped. The vaginal depth is widely variable, but is typically shorter than unaffected women The gonads in these women are not ovaries, but instead, are testes; during the embryonic stage of development, testes form in an androgen-independent process that occurs due to the influence of the SRY gene on the Y chromosome.[25][26] They may be located intra-abdominally, at the internal inguinal ring, or may herniate into the labia majora, often leading to the discovery of the condition.[1][27][28][29] Testes in affected women have been found to be atrophic upon gonadectomy.[30] Testosterone produced by the testes cannot be directly used due to the mutant androgen receptor that characterizes CAIS; instead, it is aromatized into estrogen, which effectively feminizes the body and accounts for the normal female phenotype observed in CAIS The Müllerian system (the fallopian tubes, uterus, and upper portion of the vagina) typically regresses due to the presence of anti-Müllerian hormone originating from the Sertoli cells of the testes.[18] These women are thus born without fallopian tubes, a cervix, or a uterus,[18] and the vagina ends "blindly" in a pouch -increased risk of osteoporosis -increased risk of gonadal tumors Physical exam rudimentary vagina presents with no sexual hair cryptorchid testes often found in labia majora or inguinal canal surgically removed to prevent malignancy 5-a reductase def Physical exam internal gonads are normal male -prepubescence ambiguous genitalia -pubescence (↑ testosterone production) masculinization/↑ growth of external genitalia "penis at 12"

The main differentials for CAIS are complete gonadal dysgenesis (Swyer syndrome) and Müllerian agenesis (Mayer-Rokitansky-Kuster-Hauser syndrome or MRKH). Both CAIS and Swyer syndrome are associated with a 46,XY karyotype, whereas MRKH is not; MRKH can thus be ruled out by checking for the presence of a Y chromosome, which can be done either by fluorescence in situ hybridization (FISH) analysis or on full karyotype.[1] Swyer syndrome is distinguished by poor breast development and shorter stature Mullerian Dysgenesis - An individual with this condition is hormonally normal; that is, they will enter puberty with development of secondary sexual characteristics including thelarche and adrenarche (pubic hair). Their chromosome constellation will be 46,XX. Ovaries are intact and ovulation usually occurs. Typically, the vagina is shortened and intercourse may, in some cases, be difficult and painful. Medical examination supported by gynecologic ultrasonography demonstrates a complete or partial absence of the cervix, uterus, and vagina.

TTP/HUS in pregnancy -in ADULTS HUS in kids HUS had been divided into diarrhea-positive and diarrhea-negative HUS. The former, also referred to as typical HUS, primarily resulted from STEC infections, and less frequently from Shigella dysenteriae type 1 infection Patients with HUS can become profoundly and rapidly anemic. Based upon clinical experience, packed red blood cells (RBC) should be transfused when the hemoglobin (Hgb) level is <6 g/dL A post-transfusion goal of an Hgb level between 8 and 9 g/dL is recommended to prevent cardiac and pulmonary complications resulting from high output cardiac failure HTN (increased renin) Antihypertensive drugs used in patients with HUS include calcium channel blockers (1st line) and angiotensin converting enzyme (ACE) inhibitors Electrolyte disturbances are common usually due to acute renal insufficiency or failure. They include hyperkalemia, hyperphosphatemia, and metabolic acidosis. the indications for dialysis in children with HUS are similar to those in children with other forms of AKI. These include the following: ●Signs and symptoms of uremia ●Azotemia defined as BUN ≥80 to 100 mg/dL (29 to 36 mmol/L) ●Severe fluid overload (eg, cardiopulmonary compromise and/or hypertension) that is refractory to medical therapy ●Severe electrolyte abnormalities (eg, hyperkalemia and acidosis) that are refractory to medical therapy ●Need for nutritional support in a child with oliguria or anuria Eculizumab — Eculizumab, a monoclonal antibody to complement factor C5 that blocks complement activation, has been used in the treatment of patients with complement-mediated HUS. we suggest plasma exchange be used in patients with significant neurologic symptoms, such as seizures or strokes -95% recover with no sequalea - if there is renal sequale give ACEi

The mainstay of treatment for most patients with TTP-HUS is plasma exchange, which in the context of this syndrome refers to the removal of the patient's plasma by pheresis and the replacement with donor plasma rather than another replacement fluid such as albumin Plasma exchange should be initially performed daily until the platelet count has normalized and hemolysis largely ceased, as evidenced by a return of the serum lactate dehydrogenase (LDH) concentration to normal or near normal (algorithm 1). Plasma exchange may be discontinued in patients found to have an ADAMTS13 activity ≥10 percent if the patient's clinical presentation and course suggest an etiology other than severe acquired ADAMTS13 deficiency, and where plasma exchange therapy would not be potentially beneficial. •If plasma exchange is not immediately available, plasma infusion may serve as temporary treatment until the patient can be transferred to a medical center capable of performing plasma exchange. (See 'Plasma exchange versus plasma infusion' above.) •Exceptions to the use of plasma exchange include postdiarrheal HUS in children

Thyroid Disorders pregnancy Iodine requirements — Iodine requirements are higher in pregnant than in nonpregnant women due to the increase in maternal T4 production required to maintain maternal euthyroidism and increased renal iodine clearance. radioiodine administration is contraindicated Rarely, newborns with congenital hypothyroidism present with lethargy, hoarse cry, feeding problems, often needing to be awakened to nurse, constipation, puffy (myxedematous) facies, macroglossia, umbilical hernia, large fontanels, hypotonia, dry skin, hypothermia, and prolonged jaundice. Signs and symptoms in newborns — Birth length and weight typically are within the normal range; birth weight often is at a relatively higher percentile than birth length owing to myxedema [69]; head circumference also may be increased. The knee epiphyses often lack calcification, and this is more likely to occur in males than females (40 versus 28 percent, respectivel

The major changes in thyroid function during pregnancy are an increase in serum thyroxine-binding globulin (TBG) concentrations and stimulation of the thyrotropin (TSH) receptor by human chorionic gonadotropin (hCG). -This transient, usually subclinical, hyperthyroidism should be considered a normal physiologic finding (does not need tx!) -mild graves or toxic adenoma = supportive -symptomatic = 1st term PTU (hepatotoxic), 2nd and 3rd term methimazole (agranulocytosis) Surgery if cannot do above Monitor w/ free T4 tests High fetal heart rate (>160 beats/minute), fetal goiter, advanced bone age, poor growth, and craniosynostosis are manifestations of fetal hyperthyroidism. Cardiac failure and hydrops may occur with severe disease. Neonatal Graves' disease develops in about 1 to 5 percent of infants born to mothers with Graves' hyperthyroidism, and is caused by the transplacental passage of maternal stimulatory antibodies binding to the thyroid stimulating hormone receptor (TSHR-Ab) -Neonatal Graves' hyperthyroidism resolves spontaneously within 3 to 12 weeks after birth as the maternal TSHR-Ab disappears from the infant's circulation Dx: TSH and free t4 levels + measurement of antibodies in mother (Thyroid Stimulating Immunoglobulin) We recommend that these infants be treated with a combination of the antithyroid drug methimazole and a beta adrenergic blocker such as propranolol or atenolol, rather than no treatment

Neuraxial Analgesia The likelihood of systemic toxicity can be reduced by aspirating the catheter before injecting to help ascertain that its distal aperture(s) is (are) not located within a blood vessel. Other measures to reduce the risk of toxicity include adding epinephrine to the solution to delay intravascular absorption, using a test dose, injecting a local anesthetic with a lower toxicity profile, reducing the total dose injected, and administering the dose incrementally. Maternal hypotension resulting from local anesthetic-induced sympathetic block may reduce placental perfusion. The placental bed is not autoregulated and, therefore, its perfusion is entirely dependent upon maternal systolic blood pressure. A decrease in perfusion pressure will result in decreased fetal oxygenation, which is manifested by deterioration in the fetal heart rate pattern (eg, bradycardia, repetitive late decelerations).

The most common etiology is accidental injection of local anesthetic into a blood vessel. Systemic toxicity manifests in the central nervous system (CNS) as tinnitus, metallic taste in mouth, disorientation, and (ultimately) seizures; in the cardiovascular system toxicity manifests as hypotension, dysrhythmias, and cardiac arrest. CNS toxicity typically precedes cardiovascular toxicity, thus patients may experience cerebral signs without hemodynamic compromise. Bupivacaine toxicity does not follow this sequence; cardiac toxicity may occur in the absence of CNS toxicity Amiodarone, a primary drug in the ACLS arrhythmia treatment algorithm, is the favored treatment for severe bupivacaine-induced arrhythmias; Pruritis is common, tx w/small dose naloxone (not antihistamine)

17-year-old nulliparous sexually active female presents to the emergency department with pelvic pain that began 24 hours ago. She reports menarche at the age of 15 and coitarche soon thereafter. She has had four male partners, including her new boyfriend of a few weeks. Her blood pressure is 100/60, pulse 100, and temperature 102.0°F (38.9°C). On speculum examination, you note a foul-smelling mucopurulent discharge from her cervical os and she has significant tenderness with manipulation of her uterus Although the patient had a LEEP, risk for cervical stenosis is low. She is having regular cycles; therefore, anovulation and luteal phase defect is less likely.

The most likely cause of the symptoms and signs in this patient is infection with a sexually transmitted organism. The most likely organisms are both N. gonorrhoeae and chlamydia, and the patient should be treated empirically for both after appropriate blood and cervical cultures are obtained. Since the patient also has a high fever, inpatient admission is recommended for aggressive intravenous antibiotic therapy in an effort to prevent scarring of her fallopian tubes and possible future infertility. Although some patients can be treated with an outpatient regimen, this patient should be hospitalized for IV treatment, as she has nausea and vomiting so she might not be able to tolerate oral medications. She is also at risk for non-compliance with an outpatient treatment regimen. It is important to treat aggressively in order to prevent the long-term sequelae of acute salpingitis. You would not wait for culture results before initiating treatment. Her recent sexual contacts should also be informed (by her and/or with her consent) and treated. According to the 2010 CDC treatment guidelines, there are two options for parenteral antibiotics covering both gonorrhea and chlamydia. Cefotetan or cefoxitin PLUS doxycycline or clindamycin PLUS gentamicin. For outpatient treatment, the 2010 CDC guidelines recommend ceftriaxone, cefoxitin, or other third-generation cephalosporin (such as ceftizoxime or cefotaxime) PLUS doxycycline WITH or WITHOUT metronidazole. There are alternative oral regimens as well. http://www.cdc.gov/std/treatment/2010/pid.htm

Acog gives a situation where there is vaginal bleeding but the patient is stable, there is small amount of fluid in the cavity and old blood introitus and states that the proper tx is methotrexate Another patient Beta-hCG level is above 2000 mIU/ml, and she has a thin endometrial stripe, this rules out an intrauterine pregnancy and the diagnosis is an ectopic pregnancy. She is a good candidate for medical treatment with methotrexate -nothing seen in tubes or ovaries.

The next best step in management is methotrexate administration. Certain conditions must be met prior to initiating methotrexate therapy for treatment of an ectopic pregnancy. These include: hemodynamic stability, nonruptured ectopic pregnancy, size of ectopic mass <4 cm without a fetal heart rate or <3.5 cm in the presence of a fetal heart rate, normal liver enzymes and renal function, normal white cell count, and the ability of the patient to follow up rapidly (reliable transportation, etc.), if her condition changes. There is no indication for antibiotics in this scenario. Offering observation delays treatment and pain control would not address the underlying cause of the patient's problem.

Puberty Ameronorrhea in 16yo, 5 feet 1 inch tall and weighs 80 pounds -Inadequate body weight Tx of true precious puberty treatment would include GnRH agonist to suppress pituitary production of follicular-stimulating hormone and luteinizing hormone. Observation is acceptable if the precocious puberty is within a few months of the routinely expected puberty year-old female is being evaluated for premature hair growth in the pubic area. She has no breast development and has not had any menstrual bleeding. Laboratory evaluation revealed high DHEA and DHEAS levels and low levels of LH and FSH. Congenital adrenal hyperplasia of the 21-hydroxylase type results in the adrenal being unable to produce adequate cortisol as a result of a partial block in the conversion of 17-hydroxyprogesterone to desoxycorticosterone, with the accumulation of adrenal androgens. This leads to precocious adrenarche. Treatment includes steroid replacement. Idiopathic isosexual precocious puberty is GnRH dependent and leads to an appropriate (although early) order of pubertal events. Primary Amenorrhea - blind pouch vagina, no uterus. Whats next step? Renal Ultrasound

The normal and predictable sequence of sexual maturation proceeds with breast budding, then adrenarche (hair growth), a growth spurt and then menarche THELARCHE ADENARCHE GROWTH SPURT MENARCHE TAGM! Example: 7-year-old female is undergoing evaluation for vaginal bleeding. On physical examination, she has Tanner stage III breasts, tall stature and an otherwise normal examination. An MRI of the brain and a pelvic ultrasound are normal. LH and FSH levels are in the pubertal levels and she has normal DHEAS and androgen levels. = Tue precocious puberty is a diagnosis of exclusion where the sex steroids are increased by the hypothalamic-pituitary-gonadal axis, with increased pulsatile GnRH secretion. CNS abnormalities associated with precocious puberty include the following: tumors (e.g., astrocytomas, gliomas, germ cell tumors secreting human chorionic gonadotropin [hCG]); hypothalamic hamartomas; acquired CNS injury caused by inflammation, surgery, trauma, radiation therapy, or abscess; or congenital anomalies (e.g. hydrocephalus, arachnoid cysts, suprasellar cysts). These conditions are not likely in the presence of a normal work-up in this patient. Congenital adrenal hyperplasia usually presents in the neonatal period and is associated with ambiguous genitalia. McCune Albright Syndrome is characterized by premature menses before breast and pubic hair development. An ovarian neoplasm is unlikely with a normal pelvic ultrasound.

Thrombophilias in pregnancy Most laboratories screen 'at risk' patients with either a snake venom (e.g. dilute Russell's viper venom time) based test or an aPTT based test. In both methods, the time it takes for blood to clot is decreased in the presence of the factor V Leiden mutation.

The prothrombin gene mutation is a guanine to adenine transition at nucleotide 20210 in the 3' untranslated region of prothrombin Activated protein C (APC) is a potent natural anticoagulant that acts by cleaving and thus inactivating the activated forms of factor V and factor VIII (factors Va and VIIIa). *Factor V Leiden (AD)* results from a point mutation that causes an amino acid change (an arginine to glutamine substitution) at position 506 in factor V. This abolishes a cleavage site of APC, making the molecule less susceptible to inactivation. -the major manifestation is venous thromboembolism (VTE), which can include deep venous thrombosis, pulmonary embolus, and cerebral vein thrombosis. - case-control and retrospective cohort studies have generally reported an association, particularly for late fetal loss -They also may have a small increased risk of preeclampsia, may have a small increased risk of low birth weight babies, may have a small increased risk of miscarriage and stillbirth due to either clotting in the placenta, umbilical cord, or the fetus (fetal clotting may depend on whether the baby has inherited the gene) or influences the clotting system may have on placental development.

Molar Pregnancy The recurrent risk for molar pregnancies ranges from 1 to 2%, which is a 20-fold increase from background risk. The risk of recurrence after two molar pregnancies is 10%. A complete mole has a characteristic "snowstorm" appearance on ultrasound. This is due to the presence of multiple hydropic villi. This patient has a classic presentation for a molar pregnancy. Vaginal bleeding is universal in molar pregnancies. Uterine size greater than dates (weeks from LMP) can be seen in 25-50% of moles, although size less than dates can be seen in 14-33% of moles. There is no fetus seen in cases of a complete mole. There can be a fetus, which is usually grossly abnormal, in cases of a partial mole. There is detectable Beta-hCG in molar pregnancies. The Beta-hCG values are generally higher than the values observed in normal pregnancy. Tachycardia from hyperthyroidism (10% serum diagnosis; 1% clinical diagnosis) and hypertension from preeclampsia (12-25%) can occur in molar pregnancy. Partial Mole = Karyotype 69XXY, fetus present, lower risk of developing post-molar GTD The risk of developing another molar pregnancy is approximately 1-2% (higher than compared to women who have never had a molar pregnancy). Therefore, full-term pregnancy is considered very plausible, even in women with repeated molar pregnancies.

There is a much higher incidence among Asian women in the United States (1/800.) Molar pregnancy occurs more frequently in women less than 20 or older than 40 years of age. The incidence is higher in areas where people consume less beta-carotene and folic acid. There is no known association between molar pregnancy and obesity, a previous history of fetal aneuploidy, chronic hypertension and parity. The risk of having a molar pregnancy is increased in women with two or more miscarriages. In the face of discrepancy between dates and uterine size, a pelvic ultrasound in indicated to confirm dates, exclude multiple gestation, uterine abnormalities, and molar pregnancy. There is no single Beta-hCG value that is diagnostic for a molar pregnancy. A quantitative Beta-hCG, though, is crucial at determining whether or not a pelvic (transvaginal) ultrasound will confirm a very early gestation. With a Beta-HCG above the discriminatory zone (>1500), an IUP should be easily identified on transvaginal ultrasound. Suction curettage is the standard management for molar pregnancies. Hysterectomy is an option as this particular patient has completed childbearing, however, the morbidity of a hysterectomy is still considered greater than suction curettage Once evacuation has been accomplished, patients must be followed regularly with serial Beta-hCG levels to insure spontaneous regression. Pregnancy should be avoided during this follow-up period, and for the following six months. Effective contraception (OCP or other hormonal contraception) is strongly recommended to prevent confusion in interpreting a rising Beta-hCG as a post-molar recurrence/progression versus a new, spontaneous pregnancy.

57-year-old woman, G2P2 , px w / pelvic pressure and a feeling of a mass in the vagina for 2 months. worse while standing for long periods of time and are relieved by lying down. Hx of vaginal hysterectomy 10 yr ago. No urinary or bowel sx. Examination shows no anterior vaginal relaxation (CYSTOCELE) . Valsalva maneuver produces a bulging posterior vaginal mass that has its origin high in the vaginal vault. Which of the following is the most likely diagnosis

Think anatomy -Enterocele cystoceles are more promixal and anterior in the vaginal cavity

Endometerosis 1 The complex ovarian cyst is most likely an endometrioma. Painful sex, some cul de sac tenderness Tx = NSAIDS --> OCPs Definitive diagnosis is based on exploratory surgery and biopsies, although endometriosis is usually initially treated based on the clinical presentation. In addition, this patient can benefit from laparoscopy, since she has failed the two most common treatments for endometriosis, NSAIDs and OCPs LMP 3 weeks ago. Complex Cyst on left ovary. This patient most likely has a hemorrhagic cyst (not endometrioma), considering her history and where she is in her menstrual cycle. Her mother's history of endometriosis does increase her risk; however, it is unlikely since she has never had any symptoms herself. A repeat ultrasound in 2m is the most appropriate next step, as this is most likely a hemorrhagic cyst which will resolve on its own.

This patient has typical symptoms of endometriosis, including dysmenorrhea and dyspareunia. In addition, the nodularity on the back of the uterus is suggestive of endometriosis Complex CYST in 68 yr old = Exploratory Surgery A complex ovarian mass in a postmenopausal patient needs to be surgically explored. Although this could be an old endometrioma which never resolved, this cannot be assumed. If this is ovarian cancer, waiting three months can change this patient's prognosis. Pt w/ hx of endometrosis has 18m infertility, SIS shows patent tubes, she has cycles reg....whats next step A patient with a known history of endometriosis who is unable to conceive and has an otherwise negative workup for infertility, benefits from ovarian stimulation with clomiphene citrate, with or without intrauterine insemination.

Rh Isoimmunization While 75% of all gravidas have evidence of transplacental hemorrhage during pregnancy or immediately after delivery, 60% of these patients have <0.1 cc of fetal blood in the maternal circulation, which is enough to sensitize a patient. The incidence and size of transplacental hemorrhage increases as pregnancy advances. During the second month of gestation, 5-15% of women will have evidence of feto-maternal hemorrhage. By the third trimester, this number increases to 45% of patients. The risk of isoimmunization is 2% antepartum, 7% after full term delivery, and 7% with subsequent pregnancy. Fetal hydrops is easily diagnosed on ultrasound. It develops in the presence of decreased hepatic protein production. It is defined as a collection of fluid in two or more body cavities, such as ascites, pericardial and/or pleural fluid and scalp edema. On occasion, when extramedullary hematopoiesis is extensive, there will be evidence of hepatosplenomegaly. Placentomegaly (placental edema) and polyhydramnios are also seen on ultrasound. RhoGAM (Anti-D-immunoglobulin) is administered to Rh-negative women to prevent isoimmunization. Each dose provides 300 micrograms of D-antibody and is given to the D-negative non-sensitized mother to prevent sensitization after any pregnancy-related events that could result in fetal-maternal hemorrhage. Up to 2 percent of women with a spontaneous abortion and 5 percent of those undergoing elective termination become isoimmunized without D-immunoglobulin. The current recommendations for Rh-negative women without evidence of Rh immunization is prophylactically at 28-weeks gestation (after an indirect Coombs' test) and within 72 hours of delivering an Rh-positive baby, following spontaneous or induced abortion, following antepartum hemorrhage and following amniocentesis or chorionic villus sampling. If the father of the fetus is known to be Rh-negative, RhoGAM is not necessary, since the fetus will be Rh-negative and not at risk for hemolytic disease. Values in Zone 3 of the Liley curve indicate the presence of severe hemolytic disease, with hydrops and fetal death likely within 7-10 days, thus demanding immediate delivery or fetal transfusion. At 30 weeks gestation, the fetus would benefit from more time in utero. An attempt should be made to correct the underlying anemia. Intravascular transfusion into the umbilical vein is the preferred method. Intraperitoneal transfusion is used when intravascular transfusion is technically impossible. If fetal hydrops is present, the reversal of the fetal anemia occurs much more slowly via intraperitoneal transfusion. Percutaneous umbilical blood sampling should not be used as a first-line method to evaluate fetal status. Maternal plasmapheresis is used in severe disease when intrauterine transfusions are not possible.

This patient was sensitized during her first pregnancy that was complicated by abruption and required Cesarean delivery. Transplacental hemorrhage of fetal Rh-positive red blood cells into the circulation of the Rh-negative mother may occur following a number of obstetric procedures and complications, such as amniocentesis, chorionic villus sampling, spontaneous/threatened abortion, ectopic pregnancy, dilation and evacuation, placental abruption, antepartum hemorrhage, preeclampsia, cesarean section, manual removal of the placenta and external version. Noninvasive tests to detect anemia Middle cerebral artery peak systolic velocity Noninvasive diagnosis of fetal anemia has been performed with Doppler ultrasonography. The use of middle cerebral artery peak systolic velocity in the management of fetuses at risk for anemia because of red cell alloimmunization has emerged as the best test for the noninvasive diagnosis of fetal anemia. 30 cc of fetal blood is neutralized by the 300 micrograms dose of RhoGAM. This is equivalent to 15 cc of fetal red blood cells. At 28-weeks gestation, 300 micrograms of Rh-immune globulin is routinely administered after testing for sensitization with an indirect Coombs' test. Administration is given following amniocentesis at any gestational age. Most appropriate method of determining dose of RhoGam after placental abruption? -Kleihauer-Betke test The routine dose of RhoGAM neutralizes 30 cc of fetal blood. The Kleihauer-Betke test is an accurate and sensitive acid elution test. It has great value in determining the incidence and size of fetal transplacental hemorrhage. In this test, using acid elution, the mother's red blood cells become very pale, while fetal cells, which contain a different form of hemoglobin, remain stained In a Rh hemolytic disease mother at 24w what should be measured in AF to see severity of disease? BILIRUBIN In the presence of a severely erythroblastotic fetus, the amniotic fluid is stained yellow. The yellow pigment is bilirubin, which can be quantified most accurately by spectrophotometric measurements of the optical density between 420 and 460nm, the wavelength absorbed by bilirubin. The deviation from linearity of the optical density reading at 450nm is due to the presence of heme pigment, an indicator of severe hemolysis. If mom got rhogam last preg but is still sensitizied it is most likely due to The amount of fetal maternal hemorrhage was more than previously estimated

HTN HELLP syndrome is a disease process in the spectrum of severe preeclampsia. The acronym stands for "hemolysis, elevated liver enzymes, low platelets" and can lead to swelling of the liver capsule and possibly, liver rupture. It may or may not be accompanied by right upper quadrant pain. It is possible to only have thrombocytopenia and elevated transaminases, without clear hemolysis (elevated bilirubin and anemia) - especially if a diagnosis is made early. This patient does not have seizures and, therefore, does not have eclampsia. The clinical scenario is not consistent with hepatitis or cholecystitis. Acute fatty liver almost always manifests late in pregnancy. Symptoms develop over several days to weeks and include malaise, anorexia, nausea and vomiting, epigastric pain, and progressive jaundice. In many women, persistent vomiting in late pregnancy is the major symptom. About half of all women have hypertension, proteinuria, and edema signs suggestive of preeclampsia. There is usually severe liver dysfunction with hypofibrinogenemia, hypoalbuminemia, hypocholesterolemia, and prolonged clotting times. As acute fatty liver worsens there is marked hypoglycemia.

Thrombocytopenia <100,000 is a contraindication to expectant management of severe preeclampsia remote from term. Delivery is recommended for patients diagnosed with severe preeclampsia when gestational age is at or beyond 34 0/7 weeks. Additional contraindications to expectant management prior to 34 weeks gestation include pulmonary edema, renal failure, abruption- placentae, disseminated intravascular coagulation, persistent cerebral symptoms, non-reassuring fetal testing, or fetal demise. Women with these conditions should be delivered irrespective of gestational age. Other contraindications include: inability to control blood pressure with maximum doses of two antihypertensive medications, non-reassuring fetal surveillance, liver function test elevated more than two times normal, eclampsia, persistent CNS (central nervous system) symptoms and oliguria. Delivery should not be based on the degree of proteinuria. Although elevated, uric acid and hemoconcentration are markers of preeclampsia, they are not part of the diagnostic or management criteria. Treatment with an antihypertensive is indicated for blood pressures persistently greater than 160 systolic and 110 diastolic. First-line agents include hydralazine (a direct vasodilator) 5mg IV followed by 5-10mg doses IV at 20-minute intervals (maximum dose = 40mg) or labetalol (combined alpha & beta-adrenergic antagonist) Goal Diastolic is 90-100 mmHg

Transverse fetal lie

Transverse lie should be suspected when the firm resistance typical of the fetal head is not appreciated upon palpation of the uterus above the symphysis pubis. Additional palpation will detect the fetal head in one of the mother's flanks, confirming the diagnosis. The location of the fetal back up or down is more difficult to determine, especially if the patient is obese. Confirm with US Before onset of labor — When the diagnosis of singleton fetus in transverse lie is made before the onset of labor and in the absence of contraindications to a vaginal delivery, we suggest external version to cephalic presentation at 38 to 39 weeks of gestation, followed by artificial rupture of the membranes while the vertex is held in position, and induction of labor Early Labor - For patients in early labor with a singleton fetus in transverse lie, intact membranes, and a live fetus, we suggest external version to cephalic presentation followed by artificial rupture of the membranes while the vertex is held in position Active Labor or PROM - C-section Transverse lie of second twin after delivery of first twin — After delivery of the first twin, the second twin may assume a transverse lie, regardless of its original position in the uterus. We perform internal podalic version to breech presentation and breech extraction of the non-vertex second twin Transverse lie with fetal demise or previable fetus — In cases of fetal demise or previable fetus in transverse lie before labor or in early labor, we suggest external version to achieve a longitudinal lie followed by induction of labor or augmentation, if appropriate.

Fetal STDs

Treatment of chlamydia during pregnancy prevents transmission of C. trachomatis to infants during passage through the birth canal. The recommended regimens for treatment of the pregnant female is azithromycin (1 gram orally given as a single dose) if cannot - use amoxicillin or erythromyocin Trichamonas - Symptomatic pregnant women — Metronidazole is the drug of choice for treatment of symptomatic trichomoniasis in pregnancy. Some clinicians avoid its use in the first trimester because it crosses the placenta, thus there is a potential for teratogenicity Asymptomatic pregnant women — We suggest not treating asymptomatic infections during pregnancy because randomized trials have found that it does not prevent, and in some trials even increased, the risk of preterm delivery -This patient has signs and symptoms of trichomoniasis, which is caused by the protozoan, T. vaginalis. Many infected women have symptoms characterized by a diffuse, malodorous, yellow-green discharge with vulvar irritation. However, some women have minimal or no symptoms. Diagnosis of vaginal trichomoniasis is performed by saline microscopy of vaginal secretions, but this method has a sensitivity of only 60% to 70%. The CDC recommended treatment is metronidazole 2 grams orally in a single dose. An alternate regimen is metronidazole 500mg orally twice daily for seven days. The patient's sexual partner also should undergo treatment prior to resuming sexual relations.

Indications for cs She is 10 cm dilated with left sacrum anterior at +2 station. Recommend a Cesarean section External cephalic version and internal versions are contraindicated in active labor. Note : The most likely complication after tubal ligation is a future pregnancy. The failure rate associated with surgical sterilization is approximately one percent. Approximately one-third of pregnancies after tubal ligation are ectopic.

Uterine fibroids located in the lower uterine segment may obstruct labor by preventing the fetal head from entering the pelvis. A fetal head with measurements greater than 12 cm could benefit from delivery by Cesarean section. Cesarean delivery is indicated in this patient because of a placenta previa (placenta covering the internal os). A vaginal delivery is contraindicated in patients with a placenta previa. Post-term pregnancies, chorioamnionitis, oligohydramnios, and term premature rupture of membranes are all acceptable indications for induction of labor and delivery if the patient is a good candidate for initiation of labor.

Pulmonary Embolism / DVT INFERIOR VENA CAVA FILTERS — Inferior vena cava (IVC) filters have been used during pregnancy. Indications for insertion of an IVC filter are the same in pregnant and non-pregnant patients ●Conventional anticoagulation is contraindicated, such as during active bleeding, following recent surgery, or following a hemorrhagic stroke. ●Conventional anticoagulation has proven ineffective, such as in patients who develop new VTE despite being anticoagulated. ●A complication of anticoagulation develops (eg, significant bleeding), which prohibits continuation of anticoagulant therapy. ●The pulmonary vascular bed is already significantly compromised (eg, massive pulmonary embolism, chronic thromboembolic pulmonary hypertension) and unlikely to tolerate another insult Treatment with SC LMWH should be discontinued at least 24 hours prior to delivery if the delivery time is predictable (eg, induction of labor, planned cesarean section). This allows the effect of heparin to resolve, which is particularly important for patients who desire neuraxial anesthesia because anticoagulation during insertion (or removal) of a neuraxial anesthesia catheter increases the risk for spinal hematoma PE: The most common presenting symptom is dyspnea followed by pleuritic pain and cough. In patients with suspected PE, arterial blood gases (ABG), brain natriuretic peptide (BNP), and troponin and D-dimer levels, as well as electrocardiography (ECG) and chest radiography should be performed. Clinical symptoms of DVT (leg swelling, pain with palpation) 3.0 Other diagnosis less likely than pulmonary embolism 3.0 Heart rate >100 1.5 Immobilization (≥3 days) or surgery in the previous four weeks 1.5 Previous DVT/PE 1.5 Hemoptysis 1.0 Malignancy 1.0 Despite its poor diagnostic accuracy, a chest radiograph should be performed in every pregnant patient in whom a PE is suspected -however, the algorithm states that if PE is suspected and you have dvt symptoms + compression US shows thrombosis --> Tx In patients in whom PE is unlikely (modified Wells ≤4), we prefer sensitive D-dimer testing to determine whether or not diagnostic imaging is indicated. if over 4 or + D-dimer (5oo+ ng) : computed tomographic pulmonary angiography (CTPA) [CI for CTPA renal insufficiency [estimated glomerular filtration rate <60 mL/min/1.73 m2], contrast allergy, or morbid obesity] -if contraindicated or inconclusive: V/Q scan (test of choice in pregs) -if V/Q contraindicated or inconclusive: Magnetic Resonance Contrast-enhanced Angiography Lower-extremity proximal vein compressive ultrasound (CUS) and echocardiography are not diagnostic of PE, but may also be used to facilitate the decision to empirically treat for PE when definitive testing is inconclusive

Tx: LWH We suggest that anticoagulant therapy continue at least six weeks postpartum COMPLICATIONS — Heparin has several side effects, including bleeding, thrombocytopenia, skin necrosis, and osteoporosis. These adverse effects can occur even at prophylactic doses and are more likely with long-term use. ●Bleeding - The management of bleeding during heparin therapy depends upon the location and severity of the bleeding, the degree of anticoagulation (ie, the anti-Xa level or aPTT), and the risk of discontinuing the anticoagulant. In many cases, the heparin can be stopped and restarted after the bleeding is controlled. However, insertion of an inferior vena caval (IVC) filter should be considered if the bleeding is sufficiently severe to prohibit resumption of anticoagulant therapy. Clinicians should NOT resume anticoagulant therapy if the bleeding is related to a placenta previa or abruption, although this recommendation is based on low quality evidence. ●Thrombocytopenia - Heparin-induced thrombocytopenia (HIT) is a potentially fatal complication of heparin therapy. The diagnosis and management of HIT are discussed in detail separately. ●Skin necrosis - Heparin-induced skin necrosis is a manifestation of HIT and may occur in the absence of thrombocytopenia. The diagnosis and management of HIT are discussed in detail separately. ●Osteoporosis - Long-term heparin therapy (longer than seven weeks) can reduce bone mineral density by reducing bone formation. This effect appears to be more common with unfractionated heparin than low molecular weight heparin. Absolute contraindications to Thrombolytic Therapy (Emblectomy is then used) Prior intracranial hemorrhage Known structural cerebral vascular lesion Known malignant intracranial neoplasm Ischemic stroke within three months (excluding stroke within three hours*) Suspected aortic dissection Active bleeding or bleeding diathesis (excluding menses) Significant closed-head trauma or facial trauma within three months Persistent hypotension or shock (ie, a systolic blood pressure <90 mmHg or a decrease in the systolic blood pressure by ≥40 mmHg from baseline) due to acute PE is the only widely accepted indication for systemic thrombolysis -Recombinant tissue type plasminogen activator (tPA, alteplase), streptokinase (SK), and recombinant human urokinase (UK)

Fibroids The size of the myomatous uterus is described in menstrual weeks, as with the gravid uterus. As an example, a 20-week size myomatous uterus is not unusual, and is often associated with heavy menses, increasing abdominal girth, and a sense of abdominal fullness similar to pregnancy. Submucosal myomas that protrude into the uterine cavity (eg, types 0 and I) (figure 3) are most frequently related to significant menorrhagia. However, women with intramural myomas also commonly experience heavy or prolonged menstrual bleeding. Leiomyomas that distort the uterine cavity (submucosal or intramural with an intracavitary component) result in difficulty conceiving a pregnancy and an increased risk of miscarriage Pelvic examination — A thorough pelvic examination should be performed. On bimanual pelvic examination, an enlarged, mobile uterus with an irregular contour is consistent with a leiomyomatous uterus For women with abnormal uterine bleeding related to leiomyomas who wish to undergo the least invasive procedure, we suggest a trial of placement of a levonorgestrel-releasing intrauterine contraception over other drug therapie

Types of fibroids Intramural Parasitic Pedunculated Submucosal Subserosal Heavy and/or prolonged menses is the typical bleeding pattern with myomas and the most common fibroid symptom [60]. Intermenstrual bleeding and postmenopausal bleeding are NOT characteristic of myomas Leiomyoma degeneration or torsion Pain may be associated with a low grade fever, uterine tenderness on palpation, elevated white blood cell count, or peritoneal signs. The discomfort resulting from degenerating fibroids is self-limited, lasting from days to a few weeks, and usually responds to nonsteroidal antiinflammatory drugs. Ultrasound is used for the primary diagnosis of fibroids. Degeneration can be suggested when pain is present when scanning directly over the fibroid We suggest expectant management of asymptomatic women, except in the case of a woman with moderate or severe hydronephrosis or a woman with a hysteroscopically-resectable submucous leiomyoma who is pursuing pregnancy We recommend hysteroscopic myomectomy for women with appropriate submucosal leiomyomas that are symptomatic (eg, bleeding, miscarriage) Laparoscopic myomectomy is an option for women with a uterus less than 17 weeks' size or with a small number of subserosal or intramural leiomyomas. Future childbearing is possible; however, the integrity of the uterine incision during pregnancy has not been evaluated adequately and may be inferior to abdominal myomectomy Hysterectomy is the definitive procedure for relief of symptoms and prevention of recurrent leiomyoma-related problems. (See 'Hysterectomy' above.) We suggest use of GnRH agonists prior to a potentially complicated hysterectomy (or myomectomy) if the surgeon feels reduction in uterine/myoma volume will significantly facilitate the procedure or if there is significant anemia which has not responded to iron therap

Subchorionic Hemorrhage

Ultrasound -crescentic collection with elevation of the chorionic membrane (depending on the time elapsed since bleeding, the collection will have variable echotexture) - acute: hyperechoic and may be difficult to differentiate from adjacent chorion -subacute-chronic: decreasing echogenicity with time in almost all cases there is extension of the haematoma towards the margin of the placenta

Missed Abortion

Ultrasound criteria for a missed abortion are a Crown Rump L of > 7 mm with no cardiac activity. Medical induction using misoprostol has been shown to be efficacious and associated with less complications when compared to surgical evacuation. Checking a serum progesterone and following serial Beta-hCG may be indicated in confirming a viable pregnancy.

Uterine Rupture RF grand multiparity, advancing maternal age, dystocia resulting in protracted labor, macrosomia, multiple gestation, and abnormal placentation (eg, placenta accreta, increta, or percreta) inherent or acquired weakness of the myometrium, disorders of the collagen matrix (Ehlers-Danlos type IV) [9-12], and abnormal architecture of the uterine cavity (bicornuate uteri, uterus didelphys, "blind uterine horns") Rupture of an unscarred uterus has also been associated with trauma (eg, traffic accident, domestic violence, gunshot wound) and obstetric maneuvers (eg, internal version and breech extraction, instrumental delivery, manual removal of the placenta). -higher incidence in TOLAC

Uterine rupture is most common in women with a prior hysterotomy. Signs of uterine rupture may include the sudden onset fetal heart rate (FHR) abnormalities (FETAL BRADYCARDIA) , vaginal bleeding, constant abdominal pain, cessation of uterine contractions, recession of the presenting part (loss of station), and maternal hypotension and tachycardia Postpartum, uterine rupture is characterized by pain and persistent vaginal bleeding despite use of uterotonic agents. Tx = definitive is hysterectomy

Operational Vaginal Deliv This patient meets all the requirements for an operative vaginal delivery. Forceps application requires complete cervical dilation, head engagement, vertex presentation, clinical assessment of fetal size and maternal pelvis, known position of the fetal head, adequate maternal pain control and rupture of membranes

Vacuum less likely to have maternal lacerations than forceps Fetal and neonatal complications related to vacuum use include lacerations at the edges of the vacuum cup, particularly if torsion is applied. Torsion may also lead to separation of the fetal scalp from the underlying structures can cause a cephalohematoma and places the fetus at risk of jaundice. Transient neonatal lateral rectus paralysis has been found to occur more frequently in vacuum-assisted deliveries, but, because the paralysis resolves spontaneously, it is unlikely to be of clinical importance.

Intrapartum fetal monitoring 160s with minimal variability and late decelerations despite resuscitation with oxygen, fluids and left lateral position This fetus is clearly not tolerating labor. Unfortunately, there is no good way to assess fetal status at this point. A biophysical profile is not of any value in labor. Amnioinfusion may be used for repetitive variable decelerations and not for recurrent lates. The presence of late decelerations in a patient with diabetes and oligohydramnios is not reassuring and unlikely to recover. Late decelerations when viewed as repetitive and/or with decreased variability are an ominous sign. The can be associated with uteroplacental insufficiency as a result of decreased uterine perfusion or placental function, thus leading to fetal hypoxia and acidemia. Common causes include chronic hypertension and postdate pregnancies. Variable decelerations are associated with cord compression. Uterine hyperstimulation may cause prolonged bradycardia.

While the patient is contracting every four minutes, it is not clear if her contractions are adequate. An intrauterine pressure catheter (IUPC) will help determine if her contractions are adequate and if oxytocin augmentation is appropriate. Prostaglandins are used for cervical ripening and are contraindicated in patients with history of previous Cesarean section. While a vacuum assisted delivery is not contraindicated in a patient with prior history of C-section, it should not be performed in a patient who is not completely dilated. A C-section is not indicated yet because it is unclear if the patient is having adequate strength contractions. Maternal drugs may cause loss of variability. Variable decelerations are reflex mediated usually associated with umbilical cord compression as a result of cord wrapped around fetal parts, fetal anomalies or oligohydramnios Initial measures to evaluate and treat fetal hypoperfusion include a change in maternal position to left lateral position which increases perfusion to the uterus, maternal supplemental oxygenation, treatment of maternal hypotension, discontinue oxytocin, consider intrauterine resuscitation with tocolytics and intravenous fluids, fetal acid-base assessment with fetal scalp capillary blood gas or pH measurement

Subacute granulomatous thyroiditis

a. Viral infection (e.g., coxsackievirus, mumps) b. Occurs most often in women 40 to 50 years old c. Granulomatous inflammation with multinucleated giant cells d. Clinical findings (1) Most common cause of a painful thyroid gland (2) Often preceded by an upper respiratory infection (3) Cervical adenopathy is not prominent. (4) Initial thyrotoxicosis from gland destruction • Increased serum T4, decreased serum TSH (5) Permanent hypothyroidism is uncommon. e. Decreased 123I uptake f. Self-limited; does not require treatment

Lipid Screening Increased Risk - Diabetes. - Previous personal history of CHD or non-coronary atherosclerosis (e.g., abdominal aortic aneurysm, peripheral artery disease, carotid artery stenosis). - A family history of cardiovascular disease before age 50 in male relatives or age 60 in female relatives. - Tobacco use. - Hypertension. - Obesity (BMI ≥30). The preferred screening tests for dyslipidemia are total cholesterol and HDL-C on non-fasting or fasting samples. There is currently insufficient evidence of the benefit of including TG as a part of the initial tests used to screen routinely for dyslipidemia. Abnormal screening test results should be confirmed by a repeated sample on a separate occasion The optimal interval for screening is uncertain. On the basis of other guidelines and expert opinion, reasonable options include every 5 years, shorter intervals for people who have lipid levels close to those warranting therapy, and longer intervals for those not at increased risk who have had repeatedly normal lipid levels. An age to stop screening has not been established. Screening may be appropriate in older people who have never been screened; repeated screening is less important in older people because lipid levels are less likely to increase after age 65. However, because older adults have an increased baseline risk for coronary heart disease, they stand to gain greater absolute benefit from the treatment of dyslipidemia, compared with younger ad

Women 20 and older at Increased Risk for CHD The USPSTF recommends screening women aged 20-45 for lipid disorders if they are at increased risk for coronary heart disease. Men 35 and Older The USPSTF strongly recommends screening men aged 35 and older for lipid disorders. The USPSTF recommends the service. There is high certainty that the net benefit is substantial. Men 20-35 at Increased Risk for CHD The USPSTF recommends screening men aged 20-35 for lipid disorders if they are at increased risk for coronary heart disease U2D: In primary prevention patients who are not at higher risk, we suggest screening for lipid abnormalities starting at age 35 in male patients and age 45 in female patients

Endometrial Carcinoma Risk Factors Major risk factors are Obesity Diabetes Hypertension Other risk factors include Unopposed estrogen Tamoxifen use for > 5 yr Previous pelvic radiation therapy A personal or family history of breast or ovarian cancer Family history of hereditary nonpolyposis colorectal cancer or possibly, among 1st-degree relatives, endometrial cancer We recommend total extrafascial hysterectomy with bilateral salpingo-oophorectomy performed either via laparotomy or laparoscopy for staging and initial management of endometrial carcinoma (Grade 1B). (See 'Surgical staging overview' above and 'Laparoscopy' above.) ●Women with apparent stage IA grade 1 endometrial carcinoma who wish to preserve fertility can opt to avoid TAH-BSO and undergo progestin therapy, but the optimum surveillance of these women is not known and they are at risk for recurrent and synchronous disease. Thus, we recommend that these women undergo TAH-BSO after completion of childbearing, even in cases with demonstrated tumor regression

Women who should undergo evaluation for endometrial hyperplasia or endometrial cancer Abnormal uterine bleeding Postmenopausal women - Any uterine bleeding, regardless of volume (including spotting or staining). Further evaluation of a sonographic finding of an endometrial thickness >4 mm (even if the patient has no uterine bleeding). Age 45 years to menopause - Any abnormal uterine bleeding, including intermenstrual bleeding in women who are ovulatory. Abnormal uterine bleeding in any woman that is frequent (interval between the onset of bleeding episodes is less than 21 days), heavy (total volume of >80 mL), or prolonged (longer than seven days). Younger than 45 years - Abnormal uterine bleeding that is persistent, occurs in the setting of a history of unopposed estrogen exposure (obesity, chronic anovulation) or failed medical management of the bleeding, or in women at high risk of endometrial cancer (eg, tamoxifen therapy, Lynch syndrome, Cowden syndrome). In addition, endometrial neoplasia should be suspected in premenopausal women who are anovulatory and have prolonged periods of amenorrhea (six or more months). Cervical cytology results Presence of atypical glandular cells (AGC)-endometrial. Presence of AGC-all subcategories other than endometrial - If ≥35-years-old OR at risk for endometrial cancer (risk factors or symptoms). Presence of benign-appearing endometrial cells in women ≥40 years of age who also have abnormal uterine bleeding or risk factors for endometrial cancer. Other indications Monitoring of women with endometrial pathology (eg, endometrial hyperplasia). Screening in women at high risk of endometrial cancer (eg, Lynch syndrome).

X-linked Disorders Dominant All males are hemizygous while all females are heterozygous. There's no homozygous females (because of the random inactivation of one of the X chromosomes). The inheritance follows one of two patterns: Both males and females are affected and the typical example is X linked hypophosphotemic rickets. Manifested only in females and is lethal in utero in males. Examples include incontinenta pigmenti, focal dermal hypoplasia, and orofaciodigital syndrome.

Xlinked Dominant -Hypophosphotemic Rickets -Rhett Syndrome -Incontinenta Pigmenti charcot marie tooth disease fragile-X syndrome alport syndrome Xlinked Recessive Lesch-Nyhan Syndrome Duchene Muscular Dystrophy Hunter's Disease Menkes Disease (Kinky hair syndrome) Glucose 6 Phosphate Dehydrogenase Deficiency Hemophilia A and B Fabry's Disease Wiskott-Aldrich Syndrome Bruton's Aggamaglobulinemia Color Blindness Complete Androgen Insensitivity Congenital Aqueductal stenosis (hydrocephalus) Inherited Nephrogenic Diabetes Insipidus

Vulvar vestibulitis

a constellation of symptoms and findings limited to the vulvar vestibule, which include severe pain on vestibular touch or attempted vaginal entry, tenderness to pressure and erythema of various degrees abrupt onset and are described as a sharp, burning and rawness sensation. Women may experience pain with tampon insertion, biking or wearing tight pants, and avoid intercourse because of marked introital dyspareunia. Vestibular findings include exquisite tenderness to light touch of variable intensity with or without focal or diffuse erythematous macules. - Treatment includes use of tricyclic antidepressants to block sympathetic afferent pain loops, pelvic floor rehabilitation, biofeedback, and topical anesthetics. Surgery with vestibulectomy is recommended for patients who do not respond to standard therapies and are unable to tolerate intercourse.

Mifprestone

a progestin receptor antagonist and can be used as emergency contraception to prevent ovulation and blocks the action of progesterone which is needed to maintain pregnancy. In the US, Mifepristone is also used with misoprostol for pregnancy termination.

Hydatidiform Mole -gestational trophoblastic disease (GTD) The two main risk factors for GTD are extremes of maternal age (over age 35 or under 20) and previous GTD

aberrant fertilization and have the potential to locally invade the uterus and metastasize. Malignant GTD is referred to as gestational trophoblastic neoplasia (GTN) and includes invasive mole, choriocarcinoma, placental site trophoblastic tumor, and epithelioid trophoblastic tumor -HM presents with an elevated serum hCG concentration and is often accompanied by vaginal bleeding, an enlarged uterus, and pelvic discomfort. - Serum hCG is often much higher in patients with GTD than in those with intrauterine or ectopic pregnancies. hCG is >100,000 mIU/mL in approximately 40 percent of complete moles and 6 percent of partial moles Dx: US complete mole (46XX) is a central heterogeneous mass with numerous discrete anechoic spaces (referred to as a "snowstorm or swiss cheese pattern"). The ultrasound is more likely to be indeterminate in a partial mole (69XXY), but abnormalities of the gestational sac or a placenta with cystic spaces may be seen. In partial mole, a fetus is present. Tx: Suction + Cutterage For women with HM who are age ≥40 years and have completed childbearing, we suggest hysterectomy rather than uterine evacuation -follow up is weekly serum hcG -Following evacuation of a complete or partial molar pregnancy, if hCG levels rise or remain elevated over several weeks, the patient is classified as having gestational trophoblastic neoplasia (GTN). -use contraception during tx

pH of vaginitis

above 4.5 Trichomonas (oral metro/tinidazole) BV (cream metro or oral) below 4.5 candidia (butoconazole cream or clotrimazole)

Ovarian Torsion RF ovarian mass 5cm or greater reproductive age pregnancy Torsion is more likely to occur with benign cysts or neoplasms rather than malignant lesions, possibly because malignant masses are more likely to be fixed in place. Ovulation induction Prior Torsion Tx: Laparoscopy For most premenopausal patients with ovarian torsion, we recommend detorsion and ovarian conservation rather than salpingo-oophorectomy. Ovarian cystectomy is often performed if a benign mass is present. Patients with an ovarian mass that is suspicious for malignancy require salpingo-oophorectomy. Ovaries that are hemorrhagic and/or edematous are most likely viable and, thus, oophorectomy should be reserved for necrotic/gelatinous/dead tissue (black and atrophic). Salpingo-oophorectomy is also reasonable for postmenopausal women. -prevent recurrance w/ high dose oral contraceptions if cysts

acute onset of moderate to severe pelvic pain, often with nausea and possibly vomiting, in a woman with an adnexal mass WAXING AND WANING "waves" of n/v low grade fever Dx: U/S -edematous enlarged ovary compared to contralateral - Multiple small peripheral follicles ("string of pearls") - similiar to PCOS appearance -Abnormal ovarian location - The normal location of the ovaries is lateral to the uterus, but in torsion, they may be located anterior to the uterus -Decreased or absent Doppler flow within the ovary or Whirlpool sign (concentric hypoechoic stripes) A definitive diagnosis of ovarian torsion is made by direct visualization of a rotated ovary at the time of surgical evaluation. The decision to proceed with surgery is based upon a clinical diagnosis, which is often based upon the presence of acute pelvic pain and an adnexal mass with a sonographic appearance consistent with torsion Note: The embryological ovary migrates from the level of the 10th thoracic vertebrae and descends to the true pelvis by puberty. Thus, in early life, the ovary is an abdominal organ and more susceptible to torsion.

Toxic Shock Syndrome 80 % have antibody to TSST-1 by the late teenage years, and by the fourth decade 90 to 95 percent have such antibody. Patients with clinical TSS lack antibody to TSST-1 and often fail to develop appropriate antibodies in convalescent serum

approximately half of reported TSS cases are menstrual, associated with highly absorbent tampons. Nonmenstrual TSS has been associated with surgical and postpartum wound infections, mastitis, septorhinoplasty, sinusitis, osteomyelitis, arthritis, burns, cutaneous and subcutaneous lesions (especially of the extremities, perianal area, and axillae), and respiratory infections following influenza. Patients with TSS commonly have fever, hypotension, and skin manifestations (maculopapular desquamative rash particularly palms and soles), Vomiting and diarrhea at onset of illness, myalgia, conjunctivial hyperemia, decreased platelets The mainstay of treatment for TSS is supportive while hypotension is present. clindamyacin and vancomyocin or naxicillin

Oligohydraminos Fetal urination, lung fluid, and swallowing all make important contributions to fluid movement in late gestation, with minimal contributions from other sources. Fetal disorders that affect any of these processes will affect the amniotic fluid volume Maternal -Medical or obstetrical conditions associated with uteroplacental insufficiency (eg, preeclampsia, chronic hypertension, collagen vascular disease SLE [nbme], nephropathy, thrombophilia) -Medications (eg, angiotensin converting enzyme inhibitors, prostaglandin synthetase inhibitors, trastuzumab) Placental -Abruption -Twin to twin transfusion (ie, twin polyhydramnios-oligohydramnios sequence) -Placental thrombosis or infarction Fetal -Chromosomal abnormalities -Congenital abnormalities, especially those associated with impaired urine production -Growth restriction -Demise -Postterm pregnancy -Ruptured fetal membranes (check nitralizine and pH) Idiopathic

amniotic fluid volume that is less than expected for gestational age. It is typically diagnosed by ultrasound examination and may be described qualitatively (eg, normal, reduced) or quantitatively (eg, amniotic fluid index [AFI] ≤5). Second Trimester - Therefore, disorders related to the fetal renal/urinary system begin to play a prominent role in the etiology of oligohydramnios. Maternal and placental factors, as well as rupture of the fetal membranes, are also common causes of oligohydramnios in the second trimester. Third trimester (29-40) — Oligohydramnios first diagnosed in the third trimester is often associated with PPROM or with uteroplacental insufficiency due to conditions such as preeclampsia or other maternal vascular diseases. Oligohydramnios frequently accompanies fetal growth restriction related to uteroplacental insufficiency. Fetal anomalies and abruptio placentae also play a role at this gestational age. Amniotic fluid volume normally decreases postterm and oligohydramnios can develop in these pregnancies Dx: Although use of an objective criterion is generally preferable (amniotic fluid index ≤5; single deepest pocket <2 cm) Tx: 2nd trimester - anatomic survey Infants may have anatomical and functional abnormalities, such as skeletal deformations, contractures, and pulmonary hypoplasia. 3rd tx - delivery if at term, if early hospitialization w/ nonstress tests, maternal hydration

Fetal CMV Common laboratory findings in the symptomatic neonate include thrombocytopenia, elevated transaminases, and elevated direct and indirect serum bilirubin. Imaging of the brain often shows periventricular intracranial calcifications, periventricular leukomalacia, ventriculomegaly, vasculitis, or polymicrogyria -chorioretinitis The timing of primary maternal infection is the most important determinant of perinatal sequelae. First trimester maternal infection results in both higher frequency and greater severity of perinatal sequelae compared with infection later in pregnancy During pregnancy, there is no treatment proven to be effective for prevention of fetal disease or reduction in risk of sequelae.

associated with long-term neurodevelopmental disabilities, including sensorineural hearing loss (SNHL), cerebral palsy, intellectual disability, vision impairment, and seizures. It is the leading cause of nonhereditary SNHL Clinical findings are nonspecific and include petechiae, jaundice, hepatosplenomegaly, small size for gestational age, and microcephaly. Dx: Laboratory diagnosis of congenital CMV infection is accomplished by isolation or molecular detection of CMV from urine or saliva samples collected within the first three weeks of life (table 1). Both viral culture and polymerase chain reaction (PCR) tests have high sensitivity and specificity for detection of CMV in infected neonates Tx: We recommend antiviral treatment for symptomatic infants with virologically-proven CMV infection and at least one end-organ symptom ganciclovir (life threatening disease) and valganciclovir (nonlifethreat) has been shown to improve long-term audiologic and neurodevelopmental outcomes.

Fetal Demise Uncontrolled diabetes during organogenesis is associated with a high rate of birth defects. The most common sites affected are the spine and the heart of the fetus, although all birth defects are increased. Fetuses in utero exposed to high levels of glucose transplacentally have increased growth and polyuria resulting in an increase in the amniotic fluid. While some viral infections are also associated with placentomegaly and polyhydramnios, the fetus will have normal or decreased growth depending on the timing of the infection. Severe hypertension and active APAS is often associated with oligohydramnios and intrauterine growth restriction. a missed abortion and should be offered uterine evacuation. Ultrasound criteria for a missed abortion are a CRL of > 7 mm with no cardiac activity. Medical induction using misoprostol has been shown to be efficacious and associated with less complications when compared to surgical evacuation. Allowing the parents when to decide to deliver can help the bereavement process.

autosomal dominant Factor V Leiden (FVL) mutation based on her history. FVL is the most common inherited thrombophilic disorder affecting approximately 5% of Caucasian women in the United States. It is a point mutation which alters factor V making it resistant to inactivation by protein C. The thrombophilic effect of a FVL mutation has been clearly established. Heterozygosity for FVL is associated with a five- to ten-fold increased risk of thrombosis, while homozygosity is associated with an 80-fold increased risk. The FVL mutation is associated with obstetric complications including stillbirth, preeclampsia, placental abruption and IUGR. Fetuses with Trisomy 18 are likely to have congenital anomalies that are detectable on prenatal ultrasound. Over 90% of cases of trisomy 21 and 18 may be detected with the quad screen. A congenital parvovirus infection associated with a fetal demise would likely cause hydrops in the fetus which would be identified on ultrasound Methotrexate is used in the treatment of selected ectopic pregnancies and can be used to induce medical terminations of pregnancies if the LMP was < six weeks ago.

Menopause Menopause before age 40 years is considered to be abnormal and is referred to as primary ovarian insufficiency (premature ovarian failure). Hot flashes typically begin as the sudden sensation of heat centered on the upper chest and face that rapidly becomes generalized. The sensation of heat lasts from two to four minutes, is often associated with profuse perspiration and occasionally palpitations, and is sometimes followed by chills and shivering, and a feeling of anxiety. -arousal from sleep -depression -vaginal driness -breast pain -migraines -bone loss -decreased risk of cardiac disease

defined as the permanent cessation of menstrual periods, determined retrospectively after a woman has experienced 12 months of amenorrhea without any other obvious pathological or physiological cause. It occurs at a median age of 51.4 years in normal women, and is a reflection of complete, or near complete, ovarian follicular depletion, with resulting hypoestrogenemia and high FSH concentrations In the late reproductive years before the onset of the menopausal transition, serum inhibin B begins to decrease, serum follicle-stimulating hormone (FSH) increases slightly, estradiol levels are preserved, but luteal phase progesterone levels decrease as fertility potential begins to decline. Menstrual cycles are ovulatory, but the follicular phase (the first half of the menstrual cycle before ovulation occurs) begins to shorten (eg, 10 versus 14 days) Menopausal Transition (follicular depletion) -lengthening of intermenstrual interval (in constrast to shortening in late reproductive years Normal intermenstrual interval during the reproductive years is 25 to 35 days; during the menopausal transition, this may increase to 40 to 50 days. Then increases amenorrhea / anovulatory cyles -decreased estrogen, increased FSH, a progressive decrease in serum inhibin B, as well as a decrease in antimüllerian hormone (AMH), another product of the granulosa cell.

Weight Gain during pregnancy

developed guidelines (2009) on weight gain in pregnancy. Historical data show that women who gained within the IOM guidelines experienced better outcomes of pregnancy than those who did not. The recommendations are: underweight (BMI < 18.5 kg/m2) total weight gain 28 - 40 pounds; normal weight (BMI 18.5 - 24.9 kg/m2) total weight gain 25 - 35 pounds; overweight (BMI 25 - 29.9 kg/m2) total weight gain 15 - 25 pounds; and obese (BMI > 30 kg/m2) total weight gain 11 - 20 pounds.

Congenital Rubella Preventive measures include immunization of girls before they reach child-bearing age; testing pregnant women for rubella immunity and providing counseling regarding avoidance of exposure to rubella for those who are nonimmune Category A: Cataracts/congenital glaucoma, congenital heart disease (most commonly patent ductus arteriosus or peripheral pulmonary artery stenosis), hearing impairment, pigmentary retinopathy Category B: Purpura, hepatosplenomegaly, jaundice, microcephaly, developmental delay, meningoencephalitis, radiolucent bone disease

ensorineural deafness, cataracts, cardiac malformations (eg, patent ductus arteriosus, pulmonary artery hypoplasia), and neurologic and endocrinologic sequelae. Neonatal manifestations may include growth retardation, radiolucent bone disease (not pathognomonic of congenital rubella), hepatosplenomegaly, thrombocytopenia, purpuric skin lesions (classically described as "blueberry muffin" lesions that represent extramedullary hematopoiesis), and hyperbilirubinemia Dx: The diagnosis of CRI is confirmed by isolation of rubella virus in culture, demonstration of rubella-specific IgM antibodies, demonstration of rubella-specific IgG antibodies that persist at a higher concentration or longer duration than expected from passive transfer of maternal antibody, or detection of rubella virus RNA by polymerase chain reaction Tx: Supportive

Hepatitis B

hepatitis B cases worldwide are acquired from sexual transmission. Post-exposure prophlaxis should be inititated as soon as possible but not later than 7 days after blood contact and within 14 days after sexual exposure. In individuals who are unvaccinated but exposed to persons who are HBsAG positive, recommendations are to receive a dose of HBIG (Hepatitis B Immune Globulin) and the HBV (Hepatitis B Vaccine Series). If the source is HBsAG negative or unknown status, then only the HBV series is used. If the exposed individual has been vaccinated and is a responder then no further treatment is necessary. If the exposed individual is vaccinated and a non-responder, then HBIG plus HBV or HBIG times two doses is used. B

Previous DVT and now Fetal Demise Uncontrolled diabetes during organogenesis is associated with a high rate of birth defects. The most common sites affected are the spine and the heart of the fetus, although all birth defects are increased. Fetuses in utero exposed to high levels of glucose transplacentally have increased growth and polyuria resulting in an increase in the amniotic fluid Denial, Anger, Bargaining, Depression, Acceptance.

his patient is most likely to have the autosomal dominant Factor V Leiden (FVL) mutation based on her history. FVL is the most common inherited thrombophilic disorder affecting approximately 5% of Caucasian women in the United States. It is a point mutation which alters factor V making it resistant to inactivation by protein C. The thrombophilic effect of a FVL mutation has been clearly established. Heterozygosity for FVL is associated with a five- to ten-fold increased risk of thrombosis, while homozygosity is associated with an 80-fold increased risk. The FVL mutation is associated with obstetric complications including stillbirth, preeclampsia, placental abruption and IUGR. Fetuses with Trisomy 18 are likely to have congenital anomalies that are detectable on prenatal ultrasound. Over 90% of cases of trisomy 21 and 18 may be detected with the quad screen. A congenital parvovirus infection associated with a fetal demise would likely cause hydrops in the fetus which would be identified on ultrasound.

Csections INDICATIONS AND CONTRAINDICATIONS — Cesarean delivery is performed when the clinician and/or patient believe that abdominal delivery is likely to provide a better maternal and/or fetal outcome than vaginal delivery. Indications for cesarean delivery fall into two general categories: "medically/obstetrically indicated" or "on maternal request." (See "Cesarean delivery on maternal request".) Approximately 70 percent of cesarean deliveries in the United States are primary (first) cesareans. The three most common indications for primary cesarean delivery in the United States account for almost 80 percent of these deliveries [1]: ●Failure to progress during labor (35 percent) ●Nonreassuring fetal status (24 percent) ●Fetal malpresentation (19 percent) Additional, less common indications for cesarean delivery include, but are not limited to: ●Abnormal placentation (eg, placenta previa, vasa previa, placenta accreta) ●Maternal infection with significant risk of perinatal transmission during vaginal birth ●Some fetal bleeding diatheses ●Funic presentation or cord prolapse ●Suspected macrosomia (typically 5000 grams in women without diabetes, 4500 grams in women with diabetes) ●Mechanical obstruction to vaginal birth (eg, large fibroid, severely displaced pelvic fracture, severe fetal hydrocephalus) ●Uterine rupture

increased due to Less women are having vaginal births after Cesarean Women attempting a vaginal birth after Cesarean (VBAC) after one previous low transverse Cesarean delivery have a 70-80% chance of having a successful VBAC and approximately 70% with two previous cesarean sections. The risk of uterine rupture with a history of one previous low transverse Cesarean section is approximately 1 percent or less. Patients who had a prior Cesarean delivery for a nonrecurring indication, such as placenta previa or breech presentation are more likely to have a successful VBAC compared to patients whose previous Cesarean delivery was performed secondary to cephalopelvic disproportion. Smoking increases the risk of several serious complications of pregnancy, including placental abruption, placenta previa, fetal growth restriction, preeclampsia and infection

Aminotic fluid max at 28 weeks

less than 5 AFI is oligohydroaminos -if previous to prom --> 40x risk of death due to umbilical cord compression MCC: ROM AFI great than 25 is used to diangose polyhydraminos -increased risk of CORD PROLAPSE (hydrops secondary to high output cardic failure)

Uterine Inversion Examination through the dilated cervix reveals a mass (ie, fundus) in the uterine cavity; on abdominal examination, a cup-like defect (fundal notch) may be palpated in the area of the normally globular fundus. Ultrasound examination of uterine inversion shows an abnormal uterine fundal contour with a homogeneous globular mass (ie, inverted fundus) within the uterus Dx: vaginal bleeding potentially resulting in shock, lower abdominal pain, and the presence of a smooth round mass protruding from the cervix or vagina. On abdominal examination, lack of palpation of a normally positioned fundus is the key finding Factors that lead to an over-distended uterus are risk factors for uterine inversion. Grand multiparity, multiple gestation, polyhydramnios and macrosomia are all risk factors. The most common etiology of uterine inversion, however, is excessive (iatrogenic) traction on the umbilical cord during the third stage of delivery. Although the patient is at risk for uterine dehiscence and uterine rupture because of her history of a prior Cesarean section, these are infrequent occurrences so the most likely cause of postpartum hemorrhage in this patient is uterine atony.

mild to severe vaginal bleeding, mild to severe lower abdominal pain, the presence of a smooth, round mass protruding from the cervix or vagina, and possibly urinary retention. The most common presentation is complete uterine inversion with severe postpartum hemorrhage, often leading to hypovolemic shock. Shock out of proportion to blood loss has been described and attributed to increased vagal tone from stretching of the pelvic parasympathetic nerves (neurogenic shock), Tx: dc uterotonic drugs, IV access w/ aggressive fluids, tx bradycardia w/ atropine, do not remove placenta, immediately attempt to manually replace the inverted uterus through vagina then give uterine relaxants 1) AGGRESSIVE IV FLUIDS 2) DO NOT REMOVE PLACENTA 3) IMMEDIATELY MANUALLY REPLACE INVERTED UTERUS (push fundus toward umbilicus) 4) UTERINE RELAXANTS -Nitroglycerin -Terbutaline -MgSO4 - Inhalational Anesthetic Agents (Sevoflurane, Desflurane, Isoflurane, while Halothane and enflurane are effective they have serious side effects) 5) Laparotomy (Huntington or Haultain procedure) or Hydrostatic reduction After reduction Oxytocin infusion ●Carboprost tromethamine (15-methyl prostaglandin F2 alpha) 250 mcg intramuscularly, may be repeated every 15 to 90 minutes for a maximum of eight doses. ●Misoprostol 800 micrograms intravaginally. Rectal administration is acceptable, especially if there is heavy vaginal bleeding. ●Dinoprostone 20 mg rectally. ●Methylergonovine 200 mcg intramuscularly up to every six hours for a maximum of four doses. Reactive airway disease is a contraindication to the use of prostaglandin F analogues and ergonovine. Poorly controlled hypertension is also a contraindication to use of methylergonovine.

Heart disease in pregnancy The most common cause of *aortic stenosis *among women of childbearing age is congenital bicuspid aortic valve disease. Aortic stenosis due to rheumatic heart disease is an uncommon cause and is generally accompanied by mitral stenosis -If symptoms develop during pregnancy, restricted activities are a reasonable first step. Pulmonary edema should be treated with diuretics -Severe = Vmax >_ 4m/s or P>_40 mmHg recommend valve replacement for severe AS asymptomatic + LVEF under 50 if undergoing any other cardiac surg symptomatic TAVR is recommended in patients with AS who have an indication for AVR who have a prohibitive surgical risk and a predicted post-TAVR survival >12 months or high surgical risk Coronary angiography is indicated before valve intervention in patients with symptoms of angina, objective evidence of ischemia, decreased left ventricular systolic function, history of coronary artery disease (CAD) or coronary risk factors (including men >40 years of age and post-menopausal women)

mitral valve prolapse (systolic ejection murmur w/ click) are asymptomatic and diagnosed by routine physical examination or as an incidental finding at echocardiography. A small percentage of women with symptoms have anxiety, palpitations, atypical chest pain, and syncope. For women who are *symptomatic, B-blocking drugs are given to decrease sympathetic tone, relieve chest pain and palpitations, and reduce the risk of life-threatening arrhythmias*. Because she is symptomatic, the option of no treatment is not correct. Mitral stenosis: Beta blockers are the mainstay of therapy for pregnant patients with mitral stenosis; they act by controlling heart rate and increasing the diastolic filling time. Pregnant women with mitral stenosis who have or develop atrial fibrillation should receive anticoagulation (LMW Heparin, UFH if CR under 30)

Thirty-six hours ago a 23-year-old G1P1 woman delivered vaginally and sustained a 2nd-degree laceration. She had a prolonged first stage of labor, ruptured membranes for 26 hours and received penicillin for group B Strep prophylaxis. She now complains of increasing abdominal pain, cramping and heavy, foul-smelling lochia. Her vital signs reveal a temperature of 100.0° F (37.8° C); pulse 80; blood pressure 120/60; and respirations 18. She has a tender uterine fundus that measures at the umbilicus. Her extremities reveal mild bilateral edema; no erythema or tenderness. Blood work reveals a white count of 12.2; hematocrit of 34%; and normal chemistries. Her urinalysis is positive for blood and negative for WBCs, leukocyte esterase and nitrites. In addition to ampicillin, which of the following would be the best antibiotic choice?

ndomyometritis is a common complication of prolonged labor, prolonged rupture of membranes and multiple vaginal examinations. The infection is polymicrobial, mostly anaerobic and requires broad-spectrum antibiotics for treatment until the patient is afebrile for 24 hours. By adding Gentamicin, you are covering the spectrum of gram-negative organisms. Erythromycin provides good coverage for upper respiratory infections. Vancomycin provides good coverage for S. aureus and penicillin-resistant gram-positive bacteria. Ciprofloxacin provides excellent coverage for gram-negative pathogens, including Pseudomonas.

VIN Examination of the external genitalia reveals an elevated, firm, erythematous, ulcerated lesion arising from the left labia, measuring 2.5 cm in greatest dimension =uamous cell carcinoma accounts for approximately 90% of vulvar cancers. Patients commonly present with a lump and they commonly have a long-standing history of pruritus. The chronic itch-scratch cycle of untreated lichen sclerosus, or any other chronic pruritic vulvar disease, is thought to stimulate the development of squamous carcinoma. The mean age of squamous cell carcinoma is 65 years and smoking is known to increase the risk of development of vulvar cancer, especially in the setting of HPV infection. With lichen sclerosus, the skin appears thin, inelastic and white, with a "crinkled tissue paper" appearance. Paget's disease of the vulva is associated with white plaque-like lesions and poorly demarcated erythema, not a discrete mass. Verrucous carcinoma has cauliflower-like lesions t! VIN III should be treated with local superficial excision. Even with complete removal of all gross disease, recurrence is still possible and the patient will need close surveillance Example: 58-year-old G2P2 woman presents to your office complaining of two years of a vulvar rash. She has seen multiple physicians without a clear definitive diagnosis. The patient has experienced intermittent pruritus for one year. She has been prescribed "every yeast medication known" and has also used multiple over-the-counter products. She was recently given topical steroid cream, which did not alleviate her symptoms. She is a breast cancer survivor and was diagnosed and treated one year ago. She is presently on tamoxifen. No vaginal bleeding has occurred since her menopause. On examination, her vulva is fiery red mottled background with whitish hyperkeratotic areas. A distinct lesion is not seen. No nodularity or tenderness is noted This is a typical description of Paget's disease of the vulva. Paget's is an in situ carcinoma of the vulva. The association with breast cancer is significant, but not as high as Paget's disease of the nipple. It would be unlikely for psoriasis to present this late in life.

radical vulvectomy and groin node dissection Only microinvasive squamous cell carcinoma of the vulva can be treated by wide local excision, but it is a diagnosis that is only made after pathology evaluation of a small (<2 cm), well-differentiated lesion, with invasion <1.0 mm. This lesion may be melanoma and a biopsy must be done to exclude this diagnosis. The concerning features are the size and irregularity of the lesion. Melanoma represents 5% of vulvar cancer On examination, multicentric brown-pigmented papules are noted on the perineum, perianal region and labia minora. No induration or groin adenopathy is noted. =human papilloma virus (HPV) related vulvar intraepithelial neoplasia Molluscum, a poxvirus, is characterized by multiple shiny non-pigmented papules with a central umbilication. Paget's disease, although multicentric, does not have brown pigmentation. Hidradenitis is a chronic, unrelenting skin infection causing deep, painful scars and foul discharge. 74-year-old G2P2 post-menopausal woman She notes the new onset of a lump in her vagina, but denies any pain, abnormal bleeding or vaginal discharge. She has well-controlled diabetes mellitus and hypertension. She is recently sexually active with a new partner since the death of her husband three years ago. She smokes a half-pack per day, and has done so since age 18. On examination, she is noted to have a somewhat firm and fixed non-tender 4 cm mass in her labia majora at the level of the Bartholin gland on the right. There is no associated erythema or discharge, and the remaining vulvar exam and pelvic exam are unremarkable. Her groin examination reveals no adenopathy The finding of a mass in the Bartholin gland is highly suspicious for malignancy and requires excision/biopsy, especially in a post-menopausal women. Primary vulvar adenocarcinomas most likely arise from the Bartholin gland, but other histologies such as squamous cell, transitional, adenosquamous, and adenoid cystic carcinomas can also arise from this location A vulvar lesion unresponsive to treatment needs a biopsy no matter what age

Placenta Previa RF ●Previous placenta previa ●Previous cesarean delivery ●Multiple gestation ●Multiparity ●Advanced maternal age ●Infertility treatment ●Previous abortion ●Previous intrauterine surgical procedure ●Maternal smoking ●Maternal cocaine use ●Male fetus ●Non-white race Prelabor cesarean delivery may increase previa risk in a subsequent delivery, more than previous intrapartum cesarean or vaginal delivery

refers to the presence of placental tissue that extends over or lies proximate to the internal cervical os. Sequelae include the potential for severe bleeding and preterm birth, as well as the need for cesarean delivery. Placenta previa should be suspected in any woman beyond 20 weeks of gestation who presents with painless vaginal bleeding. For women who have not had a second trimester ultrasound examination, antepartum bleeding after 20 weeks of gestation should prompt sonographic determination of placental location before digital vaginal examination is performed because palpation of the placenta can cause severe hemorrhage. Dx: TA -US --> TV-US f the placental edge covers the internal os, the placenta is labeled a previa . If the placental edge is <2 cm from, but not covering, the internal os, the placenta is labeled as low-lying Tx: *asymptomatic placenta previa*, we monitor placental position with ultrasound examination as an outpatient and counsel these patients to avoid excess physical activity and to call their provider promptly if bleeding or labor occurs. We perform cesarean delivery at 36 to 37 weeks *Women with active bleeding* are hospitalized for close maternal and fetal monitoring and supportive care. Indications for emergency cesarean delivery include refractory life threatening maternal hemorrhage, nonreassuring fetal status, and significant vaginal bleeding after 34 weeks of gestation. *Give Anti-D Ig for symptomatic Rh - moms* *Csection at 36-37 weeks but if placenta edge is more than 10mm from internal os you may attempt vaginal delivery*

Bleeding in 3rd trimester Pt with 4 prev CS and a anterior placenta partially covering the cervical os At risk for Placenta accreta occurs when the placenta grows into the myometrium. This patient is at risk for this condition due to her history of four previous Cesarean deliveries, and the low anterior placenta. The scar tissue from the previous surgery prevents proper implantation of the placenta and it subsequently grows into the muscle This patient is undergoing a placental abruption, with a deteriorating fetal condition. An emergent Cesarean delivery is necessary. The mother risks excessive blood loss, DIC and possible hysterectomy. The fetus risks neurological injury from anoxia or death. Risk factors for abruption include smoking, cocaine use, abdominal trauma, chronic hypertension, multiparity and prolonged premature rupture of membranes Double set-up examination A two-team approach for a high-risk procedure—e.g., a planned vaginal delivery of a placenta previa—in which the 1st team is prepared for a normal—i.e., uneventful—vaginal delivery, while the 2nd team—which includes a gynaecologist, anesthaesiologist, several nurses, etc.—is on alert, ready to perform an immediate cesarean section if necessary

ultrasound should be performed to check for abnormal placentation. A biophysical profile is not appropriate in this patient. Placenta previa must be ruled out before proceeding with digital cervical examination because of the risk of injury to the placenta and hemorrhage -remember in PREVIA digital exam is CI The placenta delivered with a significant clot attached to the maternal surface. The patient continues to bleed from the placental bed. Estimated blood loss is 1500 ml. The operative team decides to give her fresh frozen plasma (FFP) to replace which of the following components? FIBRINOGEN Correcting coagulation deficiencies requires replacing all necessary blood components. Fresh frozen plasma contains fibrinogen, as well as clotting factors V and VIII. Cryoprecipitate contains fibrinogen, factor VIII and von Willebrand's factor. Neither of these preparations contains red blood cells or platelets, which must be given separately.

Dysmenorrhe The US Preventive Services Task Force recommends chlamydia and gonorrhea screening for all sexually active patients, age 25 and younger. Since pelvic inflammatory disease is a cause of secondary dysmenorrhea, it needs to be evaluated as a potential cause of her symptoms. Although HPV screening is common, it can be used as an adjunct to cytology in primary screening in women 30 years or older, and is not indicated in a 20 year old. Pap smears are not indicated in women under 21 years of age regardless of sexual history. A hysterosalpingogram is used for infertility work-up and will not necessarily help determine the cause of her pain.

using OCPs after NSAIDS has what effects The progestin in oral contraceptives causes endometrial atrophy. Since prostaglandins are produced in the endometrium, there would be less produced. Dysmenorrhea should be improved. This patient has hyperprolactinemia due to imipramine. The patient has to be weaned off imipramine (instead of abrupt discontinuation to minimize withdrawal symptoms) and placed on a more appropriate medication. Once she is off imipramine and the cause of her elevated prolactin levels is confirmed, her normal menses should resume

Vulvovaginal candidiasis (VVC)

usually is caused by C. albicans, but is occasionally caused by other Candida species or yeasts. Typical symptoms include pruritus and vaginal discharge. Other symptoms include vaginal soreness, vulvar burning, dyspareunia and external dysuria. None of these symptoms are specific for VVC. The diagnosis is suggested clinically by vulvovaginal pruritus and erythema with or without associated vaginal discharge. The diagnosis can be made in a woman who has signs and symptoms of vaginitis when either: a) a wet preparation (saline or 10% KOH) or Gram stain of vaginal discharge demonstrates yeasts or pseudohyphae; or b) a vaginal culture or other test yields a positive result for a yeast species. Microscopy may be negative in up to fifty percent of confirmed cases. Treatment for uncomplicated VVC consists of short-course topical Azole formulations (1-3 days), which results in relief of symptoms and negative cultures in 80%-90% of patients who complete therapy.

DUB Pelvic ultrasound is the first-line imaging study in women with AUB. Transvaginal examination should be performed, unless there is a reason to not perform the vaginal study (eg, virginal patient). Transabdominal sonography should also be performed if transvaginal imaging does not allow adequate assessment of the uterus or adnexa or if a large pelvic mass is present. Ultrasound is effective at characterizing uterine and adnexal lesions. As noted above, assessment of endometrial thickness is not a useful test in premenopausal women. If intracavitary pathology (lesions that protrude into the uterine cavity, ie, endometrial polyps, submucosal myomas, intramural myomas with an intracavitary component) is suspected based upon the initial ultrasound, the patient may be evaluated with either saline infusion sonohysterography or hysteroscopy.

● If patient ovulates, may be due to inadequate proliferative phase, inadequate secretory phase, irregular shedding or membranous dysmenorrhea ● Inadequate proliferative phase: disparity between clinical menstrual cycle date and microscopic changes (usually delayed morphologic changes of proliferation) ● Inadequate secretory phase: discrepancy of 2+ days between microscopy and clinical cycle date; biopsy shows underdeveloped secretory endometrium or secretory and proliferative endometrium in same specimen; also irregular shedding; due to low progesterone; associated with infertility, amenorrhea; treat with hormones ● Irregular shedding: bleeding 7+ days due to lag in shedding of secretory endometrium, which is normally completed by day 4 of menstruation; should do biopsy on day 5+ of menstruation; biopsy shows retained secretory endometrium, fragmented menstrual endometrium, proliferative endometrium; occurs in 10-17% of DUB cases; associated with luteal phase defect ● Membranous dysmenorrhea: rare, endometrial cast passed during menstruation, resembles decidua; may be due to exogenous progesterone ● Anovulatory cycle: proliferative endometrium during chronological secretory phase; usually causes endometrial hyperplasia

Puberty The earliest detectable secondary sexual characteristic on physical examination in most girls is breast/areolar development (thelarche) (picture 1A), although about 15 percent have pubic hair as the initial manifestation (pubarche) (picture 1B) [32]. Ovarian enlargement and growth acceleration typically precede breast development but are not apparent on a single physical examination. Estrogen stimulation of the vaginal mucosa causes a physiologic leukorrhea, which is a thin, white, non-foul-smelling vaginal discharge that typically begins 6 to 12 months before menarche. Menarche occurs, on average, 2 to 2.5 years after the onset of puberty Earlier menarche (before 12 years of age) is associated with higher BMI during adulthood as compared with later menarche

●Gonadarche is the activation of the gonads by the pituitary hormones follicle-stimulating hormone (FSH) and luteinizing hormone (LH). ●Adrenarche is the activation of production of androgens by the adrenal cortex. While puberty encompasses changes due to both gonadarche and adrenarche, the term "puberty" is often used to refer specifically to gonadarche and associated changes, particularly in the phrases "precocious puberty" and "delayed puberty." Adrenarche is discussed in detail separately. (See "Normal adrenarche" and "Premature adrenarche".) A number of other terms describe specific components of puberty: ●Thelarche is the appearance of breast tissue, which is primarily due to the action of estradiol from the ovaries. ●Menarche is the time of first menstrual bleed. The first menstrual bleed is often not associated with ovulation; it typically is caused solely by the effects of estradiol on the endometrial lining. Menstrual bleeding in regular menstrual cycles after maturity is caused by the interplay of estradiol and progesterone produced by the ovaries. ●Spermarche is the time of the first sperm production (heralded by nocturnal sperm emissions and appearance of sperm in the urine), which is due to the effects of FSH and LH, via testosterone [1]. ●Pubarche is the appearance of pubic hair, which is primarily due to the effects of androgens from the adrenal gland. The term is also applied to first appearance of axillary hair, apocrine body odor, and acne. (if this is first sign of puberty --> 3x risk of pre-eclampsia)