OB II

19. List the incidence of neural tube defects in the US.

1/1000

Diagnosis

Vaginal examination is facilitated by using a single-blade speculum. While depressing the posterior vaginal wall, the patient is asked to strain down. This demonstrates the descent of the anterior vaginal wall consistent with prolapse and urethral displacement. Similarly, retraction of the anterior vaginal wall during straining will accentuate posterior vaginal defects and uncover enterocele and rectocele if present. Rectal-vaginal examination is often useful to demonstrate a rectocele and to distinguish it from an enterocele.

20. Discuss the use of folic acid in the prevention of neural tube defects.

should take vitamins plus 4 mg of folic acid daily before conception. Because neural tube closure is complete by 28 days postconception, initiating folic acid after the first 28 days has no prophylactic value.

Screening

- Any palpable breast mass should be evaluated with ultrasonography - If ultrasound shows simple cyst, it can be either closely observed or aspirated - For a palpable lesion that shows a solid component on ultrasonography, biopsy should be done, even in the presence of a normal mammogram - Current recommendations for screening MRI confined to women at very high risk of breast cancer based on family hx or prior exposure to radiation therapy & possibly women with very dense breast tissue on mammography - finds more lesions

2. Explain the uses and limitations of Cancer Antigen 125 [CA12].

- Cancer antigen 125 (CA 125) is expressed by ~85% of epithelial ovarian tumors & released into the circulation. - However, it is detectable in only 50% of patients with stage I disease. - The highest serum levels of CA 125 are found in patients with ovarian cancer, but the serum CA 125 level also may be increased in other malignancies & in pregnancy, endometriosis, & menstruation. - The level of CA 125 is clearly of value for monitoring the course of ovarian cancer, but there is as of yet no clear role for use of CA 125 for screening purposes.

2. Describe the evaluation of a patient with a testicular mass

- Evaluation includes determination of -hCG & -fetoprotein values & computed tomography of the abdomen (retroperitoneal nodes) & chest (mediastinal or pulmonary nodules

1. List the risk factors and screening tests for cervical cancer.

- First intercourse at early age, greater # of sexual partners, smokers, history of STD (especially herpes virus or HPV), lower socioeconomic class Screening tests - If cytologic smear shows dysplasia or malignant cells, colposcopy with directed biopsy should be done. -The Papanicolauo smear has limited sensitivity (20% false-negative rate

1. Define dysfunctional uterine bleeding (DUB).

• Dysfunctional uterine bleeding (DUB) is defined as abnormal uterine bleeding (AUB) in women between menarche and menopause that cannot be attributed to medications, blood dyscrasias, systemic diseases, trauma, uterine neoplasms, or pregnancy. This form of AUB is almost always caused by aberrations in the hypothalamic-pituitary-ovarian hormonal axis resulting in anovulation

5. Define endometrial hyperplasia. (245)

• Endometrial hyperplasia represents an overabundant growth of the endometrium generally caused by persistent levels of estrogen unopposed by progesterone. • Hyperplasia is more frequently seen at the extremes of a woman's reproductive years when ovulation is infrequent.

3. List the risk factors for ectopic pregnancy

• History of tubal infection • Cigarette smoking (increased relative risk, 1.26) • Prior ectopic pregnancy • History of tubal sterilization within the past 1-2 years (higher incidence if cauterization was used) • History of tubal reconstructive surgery • Pregnancy with current intrauterine device, depot medroxyprogesterine acetate or emergency contraceptive pill use • Infertility due to tubal factors • Use of assisted reproductive technologies

1. Discuss the staging for ovarian cancer.

- Stage I confined to the ovary - Stage II confined to the pelvis - Stage III Includes spread to the upper abdomen - Stage IV includes spread to distant sites

Discuss the complications associated with macrosomia and dystocia.

Erb's which can be caused by excessive traction on the brachial plexus by the delivery attendant. This is an important cause of malpractice in obstetrics. If Erb's palsy occurs on the posterior shoulder, the damage could not have been caused by excessive traction, but was most likely caused by abnormalities of the sacral promontory applying pressure on the brachial plexus before delivery. Klumpkes

Health promotion

Family planning, healthy weight and nutrition ( folic acid), healthy behaviors, stress resilience, healthy environments

7. Discuss the treatment of endometrial hyperplasia

Simple hyperplasia without atypia should be treated initially with a progestin Complex hyperplasia with atypia is best treated by hysterectomy after carcinoma has been excluded. Complex hyperplasia must be evaluated with a fractional D&C and should be initially treated with daily progestin therapy for 3-6 months. Test of cure with another biopsy is then needed

1. State the BP value that is considered hypertensive during pregnancy.

The diagnosis of hypertension should be reserved for patients with a systolic blood pressure of greater than or equal to 140 mm Hg or a diastolic pressure of greater than or equal to 90 mm Hg

13. Discuss the thromboembolitic diseases associated with pregnancy - superficial thrombophlebitis

This is more common in patients with varicose veins, obesity, or limited physical activity. In most patients, superficial thrombophlebitis is limited to the calf area, and symptoms include swelling and tenderness of the involved extremity. On physical examination, there is erythema, tenderness, warmth, and a palpable cord over the course of the involved superficial veins.

7. Discuss the use of glucocorticoids for fetal pulmonary maturation

a. Antenatal corticosteroid therapy for fetal pulmonary maturation reduces mortality and the incidence of RDS and intraventricular hemorrhage (IVH) in preterm infants. These benefits extend to a broad range of gestational ages (24 to 34 weeks) Treatment consists of 2 doses of 12 mg of betamethasone, given intramuscularly 24 hours apart, or 4 doses of 6 mg of dexamethasone, given intramuscularly 12 hours apart. Optimal benefit begins 24 hours after initiation of therapy and lasts 7 days

33. State the treatment for syphilis.

a. Penicillin G is the therapy of choice.

19. Recall clinical infection with Rubella

a. Rubella results from infection with a single-stranded RNA togavirus transmitted through the respiratory route, with the highest attack rates occurring between March and May. It is highly contagious, with 75% of those infected becoming clinically ill. The incubation period is 14-21 days

34. Sate the incidence and modes of transmission for Toxoplasma gondi in the US

a. The organism is acquired by ingesting undercooked meat or unpasteurized goat's milk, drinking contaminated water, exposure to feces from an infected cat, or rarely by tachyzoites from blood transfusion. b. The incidence of primary infection in pregnancy is 1 in 1000.

5. Define fetal malpresentation

a. The term malpresentation encompasses any fetal presentation other than vertex, including breech, face, brow, shoulder, and compound presentations.

29. State the rate of vertical transmission of GBS

a. Transmission rates of 35-70% have been reported, with the highest transmission rates occurring in women with heavy vaginal colonization.

3. Describe the antepartum management of multiple fetuses in the 1st - 3rd trimesters.

etween 16 and 22 weeks, the patient is seen every 2 weeks for ultrasonographic cervical length assessment because incompetent cervix is more common with multiple gestations. A suture (cerclage) can be placed in the cervix if marked shortening is noted in the absence of contractions Third trimester - i. During the third trimester, prevention of prematurity is of utmost importance. The cervix is monitored closely with ultrasonographic measurements for early effacement and dilation that may precede frank premature labor. A cervical length of less than 25 mm at 24 to 28 weeks is associated with doubling of the risk for premature birth.

6. List the different tocolytic agents and how they are used to manage preterm labor

magnesium sulfate is frequently the drug of choice for initiating tocolytic therapy. Magnesium acts at the cellular level by competing with calcium for entry into the cell at the time of depolarization Because magnesium is excreted by the kidneys, adjustments must be made in patients with an abnormal creatinine clearance . Once successful tocolysis has been achieved, the infusion is continued for at least 12 hours, and then the infusion rate is weaned over 2 to 4 hours and then discontinued feeling of warmth and flushing on first administration i. Nifedipine as an oral agent is very effective in suppressing preterm labor with minimal maternal and fetal side effects. It works by inhibiting the slow, inward current of calcium ions during the second phase of the action potential of uterine smooth muscle cells and may gradually replace intravenous magnesium sulfate. The only side effects are headache, cutaneous flushing, hypotension, and tachycardia. The latter two side effects can be partially avoided by making certain the patient is well hydrated Prostaglandin synthetase inhibitors - These agents are used on a short-term basis in special circumstances when prostaglandin production may be the inciting factor in preterm labor, such as with the presence of uterine fibroids. In the United States, indomethacin is the most commonly used prostaglandin inhibitor; it can be administered both orally and rectally, with some slight delay in absorption from rectal administration as compared with the oral route. oxytocin receptor antagonist - atosiban, not approved in US Efficacy of Tocolytic Therapy - neonatal survival, decreased respiratory distress syndrome (RDS), and increased the birth weight of infants Thus the use of prophylactic antibiotics in women with preterm labor may prevent the progression of a subclinical infection to clinical amnionitis.

Inevitable abortion

, a clinical pregnancy is complicated by both vaginal bleeding and cramp-like lower abdominal pain. The cervix is frequently partially dilated

1. Define infertility

- A couple is considered infertile after unsuccessfully attempting to achieve pregnancy for 1 year. - Infertility is termed primary when it occurs without any prior pregnancy & secondary when it follows a previous conception.

10. Discuss the uterine or tubal factor infertility.

- Abnormalities of the uterine cavity are seldom the cause of infertility. Large submucosal myomas or endometrial polyps may be associated with infertility and first-trimester spontaneous abortions Fimbrial occlusion is by far the most common. Prior salpingitis is a common cause of tubal occlusion - mucus plugs, endometriosis, tubal adenomyosis, or prior infection. Mid-segment occlusion can be seen after surgery or infection with tuberculosis. Tubal abnormalities may be diagnosed by HSG or laparoscopy

8. Discuss the main cause(s) of cervical factor infertility

- During the few days before ovulation, the cervix produces profuse watery mucus (spinnbarkeit) that exudes out of the cervix to contact the seminal ejaculate The mucus should extend in a thread to at least 6 cm. The pH should be 6.5 or greater. A postcoital (Sims-Huhner) test is performed 2 to 12 hours after intercourse to assess the number and motility of spermatozoa that have entered the cervical canal.

11. List the treatment options for uterine of tubal factor infertility.

- In most circumstances, microsurgical tuboplasty is more effective than conventional surgical techniques for reversal of tubal occlusion - When performed for fimbrial occlusion, neosalpingostomy is associated with a success rate of 20% to 30%, although it has reached 40% with long-term follow-up - For an isthmic-cornual occlusion caused by disease, clearing the obstruction with oral danazol has been reported when the occlusion coexists with peritoneal endometriosis. Selective catheterization has restored patency in most proximal occlusions and should be the first line of therapy. Microsurgical resection and reanastomosis are associated with a 50% to 60% pregnancy rate. If the intramural portion of the tube is occluded, reimplantation is required, with a new opening being made into the endometrial cavity conception is usually ectopic in the next preggers

12. Discuss the peritoneal factor infertility.

- Laparoscopy identifies previously unsuspected pathologic conditions in 30% to 50% of women with unexplained infertility. Endometriosis is the most common finding Periadnexal adhesions may be found and may hold the fimbriae away from the ovarian surface or entrap the released oocyte. - Endometriosis may interfere with tubal motility, cause tubal obstruction, or cause adhesions that directly disturb the pick-up of the oocyte by the fimbriae. - Treatment of endometriosis depends on its extent. If substantial adhesions or endometriomas are present, laparoscopic surgery is preferable because these conditions generally do not respond to medical management. With advanced operative laparoscopic techniques, most endometriosis can be removed or ablated without laparotomy by using advanced instrumentation, lasers, or fulguration - Danazol, GnRH agonists, and oral medroxyprogesterone acetate are effective treatments for symptomatic disease, with continuous oral contraception therapy being generally inferior If ovarian reserve is low, IVF is preferable to removal of an endometrioma, because of the compromised ovarian function that often results from ovarian surgery.

2. Explain the uses and limitations of Prostate Specific Antigen [PSA

- PSA is a serine protease produced by normal & neoplastic prostatic ductal epithelium. Its concentration is proportional to the total prostatic mass. - The inability to differentiate benign prostatic hyperplasia from carcinoma on the basis of the PSA level renders it inadequate as the sole screening method for prostate cancer. - The PSA level is useful for monitoring response to therapy in cases of known prostate cancer, particularly after radical prostatectomy, when PSA should be undetectable.

Anthropoid

1. A much larger anteroposterior than transverse diameter, creating a long narrow oval at the inlet , inclination of the sacrum

13.Discuss the management for spontaneous abortion - threatened

1. A threatened abortion is best managed by an ultrasonic examination to determine whether the fetus is present and, if so, whether it is alive Once a live fetus has been demonstrated to the couple on ultrasonography, management consists essentially of reassurance; however, they should be encouraged to undergo first trimester screening for chromosome abnormalities such as trisomy 13, 18, or 21. There is no need for admission to hospital nor is there any evidence that bed rest improves the prognosis.

14. Explain how to calculate the estimated date of confinement (EDC).

2. Estimated date of confinement (EDC) or "due date" may be determined by adding 9 months and 7 days to the first day of the last menstrual period

26. State when a fetus is most susceptible to a teratogen.

2. The most vulnerable stage is from day 17 to day 56 postconception (or day 31 to day 71 by gestational age), during the period of organogenesis

16. State the risk of vertical transmission of HIV from infected mother to infant

20-30%

3. Define the White's classification A1 and A2 and list the drugs that should be used to control A2

A1 - gestational diabetes - glucose intolerance developing during pregnancy; fasting blood glucose and postprandial plasma glucose normal - diet alone A2 - gestational diabetes with fasting plasma glucose greater than 105 or 2 hr postprandial plasma glucose greater than 20, or 1 hr prostprandial plasma glucose greater than 140 treatment is diet and insulin Oral hypoglycemic agents have traditionally not been recommended for pregnant women because of the risks for teratogenesis and neonatal hypoglycemia. However, oral hypoglycemic agents (e.g., glyburide), which do not appear to enter the fetal circulation in appreciable quantities, have been used successfully to treat gestational diabetes after the first trimester. Insulin use is the gold standard to maintain euglycemia in pregnancy A combination of rapid-acting or short-acting (lispro or regular) and intermediate-acting (NPH) insulin is usually given in split morning and evening doses or more frequently to achieve euglycemia

10. List the clinical manifestations of preeclampsia.

ANGII sensitivity - One of the earliest signs of developing preeclampsia is a lowering of the effective pressor dose of infused angiotensin II. In normal pregnancy, the amount of angiotensin necessary to increase the diastolic pressure 20 mm Hg is increased, whereas in patients destined to develop preeclampsia, the effective pressor dose is lower. Weight gain and edema - Abnormal weight gain and edema occur early and reflect an expansion of the extravascular fluid compartment. This expansion is related to the endothelial injury and increased capillary permeability that allows fluid to diffuse from the intravascular to the extravascular space. Thus, many preeclamptic patients have an increase in total body fluid volume but are intravascularly volume depleted. The hematocrit may also increase, reflecting the relative hypovolemia and hemoconcentration. For this reason, diuretic therapy is generally not advised unless there is evidence of pulmonary edema Blood pressure elevation - diastolic especially, mirrors changes in peripheral vascular resistance Proteinuria -The proteinuria of preeclampsia/eclampsia is likely due to afferent arteriolar constriction with increased glomerular permeability to proteins. Renal function - The earliest change may be an increase in serum uric acid concentration. Creatinine clearance may decrease, and serum creatinine and blood urea nitrogen levels may rise. Renal involvement may progress to significant oliguria and frank renal failure Coagulation - Thrombocytopenia is the most common abnormality. Although platelet counts tend to decline even in normal pregnancies, a value of less than 100,000 cells/mm3 is clearly pathologic and, if accompanied by other signs of preeclampsia, is evidence of severe disease. DIC may occur especially if there is a placental abruption. The specific combination of hemolysis (H), elevated liver function tests (EL), and low platelet levels (LP-the HELLP syndrome)can occur without clinical manifestations of DIC and is a sign of severe preeclampsia even if blood pressures are normal or only minimally elevated Liver function - In the liver, vasospasm may result in focal hemorrhages and infarctions leading to right upper quadrant or epigastric pain and elevated serum enzyme levels Elevated alkaline phosphatase levels are frequently seen in pregnancy and are usually not of clinical significance because they are mostly due to placental production of this enzyme. Placental function - Vasospasm in the uteroplacental vascular bed may cause placental infarction and decreased uteroplacental perfusion. This ultimately leads to fetal compromise in the form of intrauterine growth restriction (IUGR), oligohydramnios, or fetal heart rate abnormalities. Extensive placental infarctions can result in retroplacental hemorrhage or abruption, which is an important cause of perinatal morbidity and mortality. CNS - CNS EFFECTS Visual disturbances, such as blurred vision, spots, and scotomata, represent degrees of retinal vasospasm. Sudden loss of vision (cortical blindness) is due to occipital lobe ischemia. If the mother is expeditiously stabilized and delivered, full restoration of vision is likely to occur. A new-onset headache and increased reflex irritability or hyperreflexia are extremely concerning signs of CNS involvement and may connote imminent seizures.

4. State the percentage of females who have bleeding during early pregnancy.

About 30% to 40% of all pregnant women will have some bleeding during early pregnancy (e.g., implantation bleeding), which may be mistaken for a period

1.Define, diagnose and list the treatments for the various types of pelvic organ prolapse. Include cystocele, enterocele, rectocele, uterine and vaginal vault prolapsed. - Cystocele

Anterior vaginal prolapse • The anterior vagina is the most common site of vaginal prolapse. Women with this type of defect describe symptoms of vaginal fullness, heaviness, pressure, and discomfort that often progress over the course of the day and are most noticeable after prolonged standing or straining. Women may have to apply manual pressure to empty their bladder completely. Other symptoms include stress urinary incontinence (SUI), urinary urgency, frequency, and nocturia. Significant anterior vaginal wall prolapse that protrudes beyond the vaginal opening (hymen) can cause urethral obstruction due to kinking, resulting in urinary retention

12. Discuss the treatment of hypertension during pregnancy.

Arterial blood pressure greater than or equal to 160 mm Hg systolic or 105 mmHg diastolic must be treated promptly. The safest, most efficacious drugs for the acute control of severe hypertension complicating preeclampsia are labetalol and hydralazine. Although hydralazine has theoretical advantages over labetalol (don't use in asthmatics, heart block) in that it is a direct vasodilator and does not induce bronchospasm, rapid bolus infusions are potentially more likely to induce precipitous hypotension Intravenous sodium nitroprusside has the advantage of providing minute-to-minute control of blood pressure but may cause fetal cyanide toxicity with prolonged administration, so the use of this medication is generally limited to the postpartum period.

Past reproductive history-risk assessment

Ask about past medical history such as rheumatic heart disease, thromboembolism, or autoimmune diseases that could affect future pregnancy. Screen for ongoing chronic conditions such as hypertension and diabetes.

Reproductive life plan-risk assessment

Ask your patient if she plans to have any (more) children and how long she plans to wait until she (next) becomes pregnant. Help her develop a plan to achieve those goals within 1-2 years, bring her back for full assessment, more than 2 years, effective contraception

26. Define asymptomatic bacteriuria.

By definition, asymptomatic bacteriuria is the presence of at least 100,000 organisms/mL in a clean urine specimen from an asymptomatic patient

2. Lost the potential causes of antepartum bleeding

Common • Placenta previa • Abruptio placentae • Preterm labor Uncommon - cancer, uterine rupture

Compare and contrast ductal carcinoma and lobular carcinoma - ductal

Ductal carcinoma - 95 pct of all breast cancers DCIS - noninvasive, local therapy, SERMS after resection of estrogen/progesterone receptor positive ininvasive - most common type of invasive breast cancer

Define eclampsia.

Eclampsia is the presence of tonic-clonic seizures in a woman with preeclampsia that cannot be attributed to other causes. Tx - MgSO4 - most seizures were before preggers

Perineal lacerations

First degree: A laceration involving the vaginal epithelium or perineal skin Second degree: A laceration extending into the subepithelial tissues of the vagina or perineum with or without involvement of the muscles of the perineal body Third degree: A laceration involving the anal sphincter Fourth degree: A laceration involving the rectal mucosa

1. List the risk factors and describe the screening process for breast cancer.

High risk (greater than 4.0) - older age, personal hx of breast cancer, known BRCA mutation, familial cancer syndrome, breast biopsy showing proliferative disease with atypia, dense breast tissue on mammography Moderate risk 2-4 - first degree relative, personal hx of ovarian or endometrial cancer, age at first full term pregnancy, nulliparous, obesity, upper class, prior hx of radiation therapy, HL Low Risk - 1-2 early menarche, late menopause, white, alcohol, long duration ERT.

5. Define hyperemesis gravidarum

Hyperemesis gravidarum is defined as persistent nausea and vomiting in pregnancy that is associated with ketosis and weight loss (>5% of prepregnancy weight).

35. Describe congenital Toxoplasmosis and list the treatments.

If fetal infection is identified, therapy with pyrimethamine and sulfadiazine plus folinic acid should be given and has been shown to reduce the severity of fetal damage

7. Describe what occurs with hCG levels in the 1st 30 days of normal gestation. Compare this to non-viable pregnancies.

In the first 30 days of a normal gestation, the level of hCG doubles every 2.2 days. In patients whose pregnancies are destined to abort, the level of hCG rises more slowly, plateaus, or declines.

intrauterine disorders

Intrauterine adhesions result from trauma to the basal layer of the endometrium from previous surgery or infection. When most of the uterine cavity has been obliterated (Asherman's syndrome), amenorrhea results

13. List the etiologies of IUGR

Maternal -Poor nutrition, smoking, drugs, alcohol, antiphospolipid syndrome Placental insufficiency due to EH, CRD Fetal - TORCHES

4. Recognize the landmarks of the fetal skull.

Nasion (the root of the nose) Glabella (the elevated area between the orbital ridges) Sinciput (brow) (the area between the anterior fontanelle and the glabella) Anterior fontanelle (bregma)-diamond shaped Vertex (the area between the fontanelles and bounded laterally by the parietal eminences) Posterior fontanelle (lambda)-Y or T shaped Occiput (the area behind and inferior to the posterior fontanelle and lambdoid sutures

Discuss the management of the various types of post partum hemorrhage.

Resuscitation with normal saline usually requires a volume of 3 times the estimated blood loss 1. Uterine atony If uterine atony is determined to be the cause of the postpartum hemorrhage, a rapid continuous intravenous infusion of dilute oxytocin (40 to 80 U in 1 L of normal saline) should be given to increase uterine tone. If the uterus remains atonic and the placental site bleeding continues during the oxytocic infusion, ergonovine maleate or methylergonovine, 0.2 mg, may be given intramuscularly. The ergot drugs are contraindicated in patients with hypertension because the pressor effect of the drug may increase blood pressure to dangerous levels. Analogues of prostaglandin F2α given intramuscularly are quite effective in controlling postpartum hemorrhage caused by uterine atony - IM takes 20 min, myometrium takes 4 min Failing these pharmacologic treatments, a bimanual compression and massage of the uterine corpus may control the bleeding and cause the uterus to contract. Although packing the uterine cavity is not widely practiced, it may occasionally control postpartum hemorrhage and obviate the need for surgical intervention. Alternatively, a large-volume balloon catheter has been developed that performs a similar function while maintaining a channel into the uterine cavity, allowing further bleeding to be monitored. If uterine bleeding persists in an otherwise stable patient, she can be transported to the angiocatheterization laboratory, where radiologists can place an angiocatheter into the uterine arteries for injection of thrombogenic materials to control blood flow and hemorrhaging. Hysterectomy or ligation of uterine arties is last resort 2. Genital tract trauma - When repairing genital tract lacerations, the first suture must be placed well above the apex of the laceration to incorporate any retracted bleeding arterioles into the ligature. Cervical lacerations need not be sutured unless they are actively bleeding. The intraoperative laceration of the ascending branch of the uterine artery during delivery through a low transverse incision can be easily controlled by the placement of a large suture ligature through the myometrium and broad ligament below the level of the laceration. A uterine rupture usually necessitates subtotal or total abdominal hysterectomy, although small defects may be repaired 3. Retained products of conception When the placenta cannot be delivered in the usual manner, manual removal is necessary (Figure 10-3). This should be performed urgently if bleeding is profuse. Otherwise, it is reasonable to delay 30 minutes to await spontaneous separation 4. Uterine inversion - The patient rapidly goes into shock, and immediate intravascular volume expansion with intravenous crystalloids is required An anesthesiologist should be present. When the patient's condition is stable, the partially separated placenta should be completely removed and an attempt made to replace the uterus by placing a cupped hand around the fundus and elevating it in the long axis of the vagina. o If this is unsuccessful, a further attempt should be made using IV nitroglycerin (100 μg) or general anesthesia to relax the uterine muscle. Once replaced, a dilute oxytocin infusion should be started to cause the uterus to contract before removing the intrauterine hand. Rarely, the uterus cannot be replaced from below, and a surgical procedure may be required. At laparotomy, a vertical incision should be made through the posterior portion of the cervix to incise the constriction ring and allow the fundus to be replaced into the peritoneal cavity. Suturing of the cervical incision completes this procedure 5. Amniotic fluid embolus - The principal objectives of treatment for amniotic fluid embolism are to support the respiratory system, correct the shock, and replace the coagulation factors 6. Coagulopathy Patients with thrombocytopenia require platelet concentrate infusions; those with von Willebrand's disease require factor VIII concentrate or cryoprecipitate.

Define shoulder dystocia

Shoulder dystocia means difficult delivery of the shoulder. It has been defined as delivery of the shoulder requiring the use of procedures in addition to gentle downward traction on the fetal head or a prolonged head-to-body delivery interval of more than 60 seconds. Most important risk factors - macrosomia, diabetes

5. List the common causes of male coital factor infertility

Some medications, such as furantoins and calcium channel blockers, reduce sperm quality or function. - A semen analysis should be performed following a 2- to 4-day period of abstinence Low levels of gonadotropins and testosterone may indicate hypothalamic-pituitary failure. An elevated prolactin concentration may indicate the presence of a prolactin-producing pituitary tumor. An elevated level of follicle-stimulating hormone (FSH) generally indicates substantial parenchymal damage to the testes

Substance abuse - risk assessment

T-ACE (tolerance, annoyed, cut down, eye opener) or CAGE (cut down, annoyed, guilt, eye opener)

Define amniotic fluid index

The AFI represents the sum of the linear measurements (in centimeters) of the largest amniotic fluid pockets noted on ultrasonic inspection of each of the four quadrants of the gestational sac less than 5 cm is oligo (cord compression), greater than 23 is poly - diabetic preg/fetal anomaly

28. State the normal reservoirs for GBS and discuss the mode of transmission to women.

The GI tract is the major reservoir, although the organism has been isolated from the vagina, cervix, throat, skin, urethra, and urine of healthy individuals b. GBS may be transmitted to the genital tract by fecal contamination or sexual transmission from a colonized partner.

amniotomy

The artificial rupture of fetal membranes may provide information on the volume of amniotic fluid and the presence or absence of meconium. In addition, rupture of the membranes may cause an increase in uterine contractility. Amniotomy incurs risks for chorioamnionitis if labor is prolonged and for umbilical cord compression or cord prolapse if the presenting part is not engaged The amniotic fluid is rich in a hormone called prostaglandin, and the bathing of the cervix by this fluid increases the strength and frequency of uterine contractions To enable the doctor or midwife to monitor the baby's heartbeat internally .To avoid having the baby aspirate the contents of the amniotic sac at the moment of birth

platypelloid

a flattened gynecoid pelvis 1. A short anteroposterior and wide transverse diameter creating an oval-shaped inlet

17. List the etiology of intrauterine fetal demise (IUFD).

a. Intrauterine fetal demise (IUFD) is fetal death after 20 weeks' gestation but before the onset of labor. b.In more than 50% of cases, the etiology of antepartum fetal death is not known or cannot be determined. Associated causes - HTN, DM, erythroblastosis fetalis, antiphospholipid syndromes, hereditary thrombophilas

12. Define intrauterine growth retardation (IUGR

a. Intrauterine growth restriction (IUGR) by definition occurs when the birth weight of a newborn infant is below the 10th percentile for a given gestational age SGA merely indicates that a fetus or neonate is below a defined reference range of weight for a gestational age, whereas IUGR refers to a small group of fetuses or neonates whose growth potential has been limited by pathologic processes in utero, with resultant increased perinatal morbidity and mortality. c. Growth-restricted fetuses are particularly prone to problems such as meconium aspiration, asphyxia, polycythemia, hypoglycemia, and mental retardation, and they are at greater risk for developing adult-onset conditions such as hypertension, diabetes, and atherosclerosis

5. Describe the symptoms of lichen sclerosis and the type of patient most likely affected.

a. Lichen sclerosis often causes intense pruritus, dyspareunia, and burning pain. Although it can develop in any body area in any aged person, it is most frequently found on the vulva of menopausal women. On examination, the skin is thin, inelastic, and white, with a crinkled, tissue paper appearance

17. State when during pregnancy the transmission of HIV is the highest

a. More than 50% of transmissions occur near the time of or during labor and delivery. b. (Extra): Breastfeeding may increase the risk for transmission 10-20%.

8. Define premature rupture of membranes (PROM).

a. Premature rupture of the membranes (PROM) is defined as amniorrhexis (spontaneous rupture of membranes as opposed to amniotomy) before the onset of labor at any stage of gestation

Discuss the diagnosis of CMV

a. Serologic testing is possible, with an elevation of IgM that peaks 3-6 months after infection and resolves by 1-2 years. IgG elevates rapidly and persists for life b. Problems with serologic testing include: 1) the prolonged elevation in levels of IgM, making delineation of timing of infection difficult, and 2) a 20% fals-negative rate in IgM testing. In addition, the presence of IgG does not rule out the presence of persistent disease

25. Describe the impact of HBV and HCV during pregnancy. - HBV

a. The course of acute hepatitis is unaltered in pregnancy. Fetal infection may occur and is most likely if maternal infection occurs in the 3rd trimester. Chronic active hepatitis is associated with an increased risk for prematurity, low birth weight, and neonatal death. Maternal prognosis is very poor if the disease is complicated by cirrhosis, varices, or liver failure Women who are asymptomatic HBsAg carriers are at no higher risk for antepartum complications than are the general population. However, newborns delivered to mothers positive for HBsAg have a 10% risk for developing acute infection at birth c. This is in contrast to those delivered to mothers positive for both HBsAg and hepatitis Be antigen (HBeAg), in which the infant's risk increases to 70-90%. Infection in the infant may be fulminant and lethal. d. If the infant survives, it has an 85-90% chance of becoming a chronic hepatitis carrier and a 25% chance of developing liver cirrhosis, hepatocellular carcinoma, or both. Therefore, it is recommended that all pregnant women be screened for HBsAg carriage during pregnancy. Women in high-risk groups should be rescreened in the third trimester if the initial screen is negative. f. Transmission to the infant is believed to occur by direct contact during delivery. Therefore, the newborn is given hepatitis immune globulin and hepatitis vaccine soon after delivery, which reduces the risk for infection to less than 10%.

16. Define post term pregnancy and discuss the management of it

a. The prolonged or postterm pregnancy is one that persists beyond 42 weeks (294 days) from the onset of the last normal menstrual period b. Perinatal mortality is 2 to 3 times higher in these prolonged gestations. Much of the increased risk to the fetus and neonate can be attributed to development of the fetal postmaturity (dysmaturity) syndrome, which occurs when a growth-restricted fetus remains in utero beyond term. Occurring in 20% to 30% of postterm pregnancies, this syndrome is related to the aging and infarction of the placenta

Define urethral caruncle.

a. Urethral caruncles appear as small, fleshy out-growths of the distal edge of the urethra. In children, this results from spontaneous prolapse of the urethral epithelium. ON the other hand, in post-menopausal women, the caruncle occurs when the hypoestrogenicvaginal epithelium contracts and everts the urethral epithelium.

2. Define urinary incontinence and stress urinary incontinence (SUI

a. Urinary incontinence is defined as the involuntary loss of urine that is objectively demonstrable and is a social or hygiene problem. b. SUI is involuntary leakage of urine in response to physical exertion, sneezing or coughing. is urethral hypermobility due to vaginal wall relaxation, displacing the bladder neck and proximal urethra downward. When this occurs, increased intraabdominal pressure from coughing, sneezing, or physical exertion is no longer transmitted equally to the bladder and proximal urethra. The normal urethral resistance is overcome by the increased bladder pressure and leakage of urine results.

Define leiomyoma

a. Uterine leiomyomas ("fibroids") are benign tumors derived from the smooth muscle cells of the myometrium. They are the most common neoplasm of the uterus. Estimates are that more than 45% of women have leiomyomas by the fifth decade of life, but most are asymptomatic.

7. Define vulvar vestibulitis, vaginismus and imperforate hymen.

a. Vulvar vestibulitis (vestibular adenitis) is a relatively rare condition in which one or more of the minor vestibular glands becomes inflamed. This condition is characterized by severe introital dyspareunia and, occasionally, vulvar pain. On examination, the lesions may be visualized as 1- to 4-mm erythematous dots that are exceedingly tender when gently touched with a cotton-tipped swab. Although described as an "itis," vestibulitis is not an infectious process and does not respond to antibiotic therapy. Topical estrogen creams or hydrocortisone may be tried, but surgical therapy to remove the glandular area may ultimately be required.

2. Define testicular feminization (complete androgen insensitivity syndrome).

a. When the genetic sex is male (46 XY), there may be external phenotypic development along female lines. This occurs in the complete androgen insensitivity syndrome (testicular feminization), a genetic abnormality most commonly inherited as an X-linked recessive disorder. Because of a genetic deficiency of androgen receptors, the external genital development occurs along female lines. Testes are usually undescended and are located in the inguinal canals or the labial areas. After puberty, external genitalia are generally normal for females on examination, with the exception that the public hair is scanty or absent. In many cases, there is sufficient vaginal development to allow adequate coital activity. In utero, müllerian inhibiting substance is produced by the 46 XY fetus, which results in a lack of müllerian duct development and explains the absence of uterus or fallopian tubes. After puberty, the testes must be removed because malignant neoplastic transformation is possible. Ambiguous genitalia in an XY child can occur with partial androgen insensitivity

31. Discuss the screening for syphillis during pregnancy.

a.All pregnant women should be screened for syphilis at the first prenatal visit with either Venereal Disease Research Laboratory (VDRL) c.Specific treponemal tests such as the fluorescent treponemal antibody absorption test (FTA-ABS) are performed to confirm diagnosis

7. State the major factors predisposing to breech presentations

a.Prematurity b.Fetal structure anomalies (hydrocephalus) c.Uterine anomalies (bicornuate uterus) d.Multiple gestation ePlacenta previa f.Hydramnios gContracted maternal pelvis

1. Define and state the incidence of preterm labor. Which patients are at highest risk?

a.Preterm birth is usually defined as one occurring after 20 weeks and before 37 completed weeks of gestation. b.Preterm births in the United States have increased from 9.8% in 1981 to 12.7% in 2005. c.Prematurity is the leading cause of infant mortality d.In the United States, the incidence of preterm deliveries in the black population is twice as high as that in the white population. e.When one preterm birth has occurred, the relative risk for preterm delivery in the next pregnancy is 3.9, and the risk increases to 6.5 with two previous preterm deliveries. f.Second-trimester abortions seem to carry an increased risk for subsequent preterm delivery

18. Discuss the management of HIV during pregnancy.

administration of the nucleoside reverse-transcriptase inhibitor zidovudine to the mother during pregnancy and labor and to the infant for 6 weeks post-partum reduced the maternal transmission to the newborn from 25.5% to 8.3%, with a 68% reduction in vertical transmission c. The current management for pregnant women involves the use of multiple agents to minimize the development of drug resistance, and unless contraindicated, all drug regimens should include zidovudine. f. Pregnant women with HIV infection on nucleoside analogues should have liver enzymes and electrolytes monitored in the third trimester. Pregnant women on protease inhibitors should be screened for gestational diabetes at the initial visit in addition to the usual time at 2 to 28 weeks because these drugs can cause hyperglycemia. For women who are immunocompromised, with CD4 counts less than 200, prophylaxis against PCP, Mycobacterium avium complex infection, and others should be offered. TMP-SMX is relatively safe for use in pregnancy and is the first choice for PCP prophylaxis i. Women who have viral loads greater than 1000 should be offered a cesarean delivery, which may reduce vertical transmission under these conditions. This should be done at about 38 weeks of gestation to reduce the chance of labor or rupture of membranes. k. All procedures should be avoided that may increase the risk for fetal HIV infection, including artificial rupture of membranes, invasive fetal heart monitoring, fetal blood sampling, assisted delivery (forceps or vacuum), or episiotomy o. Breastfeeding is not recommended and should be discouraged.

4. List the most common locations of EP's

ampulla of fallopian tube, isthmus 12 pct

2. List and describe the abnormalities of the twinning process

conjoined twins - If division of the embryo occurs very late (after 13 days, when the embryonic disk has completely formed), cleavage of the embryo will be incomplete, resulting in conjoined twins. 1.thoracopagus (anterior) interplacental vascular anastomoses i. Interplacental vascular anastomoses occur almost exclusively in monochorionic twins at a rate of 90% or more. The most common type is arterial-arterial, followed by arterial-venous and then venous-venous. ii. Vascular communications between the two fetuses through the placenta may give rise to a number of problems, including abortion, hydramnios, TTTS, and fetal malformations Twin-twin transfusion - i.The presence of unbalanced anastomoses in the placenta (typically arterial-venous connections) leads to a syndrome in which one twin's circulation perfuses the other (i.e., TTTS) in about 10% of monozygotic twins iii. Fetal complications include hypovolemia, hypotension, anemia, oligohydramnios, and growth restriction in the donor twin, and hypervolemia, hydramnios, hyperviscosity, thrombosis, hypertension, cardiomegaly, polycythemia, edema, and congestive heart failure in the recipient twin. iv. Both twins are at risk for demise from the circulatory derangement, and the pregnancy is predisposed further for preterm delivery due to uterine overdistention with hydramnios. v. TTTS is diagnosed using ultrasound. Typically the donor twin is smaller and may have oligohydramnios, absent bladder, and anemia. The recipient, on the other hand, is larger with possible polyhydramnios, cardiomegaly, and ascites or hydrops. vi. Given the poor prognosis of untreated TTTS (about 50% survival of either twin), treatment with either serial amniocentesis and fluid reduction from the recipient twin's sac or laser photocoagulation of the anastomotic vessels on the surface of the placenta is performed in specialized centers. Fetal malformation - i. Arterial-arterial placental anastomoses can result in fetal structural malformations. In this situation, the arterial blood from the donor twin enters the arterial circulation of the recipient twin, and the reversed blood flow may cause thrombosis within critical organs or atresias due to trophoblastic embolization. The recipient twin, being perfused in a reverse direction with relatively poorly oxygenated blood, fails to develop normally. This so-called acardiac twin typically has no anatomic structures cephalad of the abdomen but often has fully formed lower extremities umbilical cord abnormalities - most in monochorionic twins, associated with renal agenesis (that is absence of one umbilical artery) retained dead fetus syndrome - the retained dead fetus syndrome can develop, which involves disseminated intravascular coagulopathy in the mother as a result of transfer of nonviable fetal material with thromboplastin-like activity into her circulation. In such cases, the maternal platelet count and fibrinogen level should be checked once a week to identify possible coagulation abnormalities. The dead fetus is reabsorbed if the demise occurs before 12 weeks' gestation. Beyond this time, the fetus shrinks and becomes dehydrated and flattened (fetus papyraceus).

9. Define puerperal sepsis and list the organisms associated.

defined as a temperature of 100.4°F (38°C) or higher that occurs for more than 2 consecutive days (exclusive of the first postpartum day) during the first 10 postpartum days. After parturition, the pH of the vagina changes from acidic to alkaline because of the neutralizing effect of the alkaline amniotic fluid, blood, and lochia, as well as the decreased population of lactobacilli. This change in pH favors an increased growth of aerobic organisms. About 48 hours postpartum, progressive necrosis of the endometrial and placental remnants produces a favorable intrauterine environment for the multiplication of anaerobic bacteria. About 70% of puerperal infections are caused by anaerobic organisms. Most of these are anaerobic cocci (Peptostreptococcus, Peptococcus, and Streptococcus), although mixed infections with Bacteroides fragilis are encountered in up to one third of cases. Of the aerobic organisms Mycoplasma organisms have been shown to contribute to puerperal endometritis.

pelvic outlet

formed by two triangular planes with a common base at the level of the ischial tuberosities. The anterior triangle is bordered by the subpubic angle at the apex, the pubic rami on the sides, and the bituberous diameter at the base. The posterior triangle is bordered by the sacrococcygeal joint at its apex, the sacrotuberous ligaments on the sides, and the bituberous diameter at the base. This plane is the site of a low pelvic arrest.

14. Differentiate between symmetrical and asymmetrical growth restriction.

i. In fetuses with symmetrical growth restriction, growth of both the head and the body is inadequate. The head-to-abdominal circumference ratio may be normal, but the absolute growth rate is decreased. Symmetrical growth restriction is most commonly seen in association with intrauterine infections or congenital fetal anomalies Assymetrical - i. When asymmetrical growth restriction occurs, usually late in pregnancy, the brain is preferentially spared at the expense of abdominal viscera. As a result, the head size is proportionally larger than the abdominal size. The liver and fetal pancreas undergo the most dramatic anatomic and biochemical changes, and these changes are now thought to play an important role in programming the fetus for a greater risk for obesity and diabetes later in life.

HCV infection

k. There is currently no safe treatment for HCV infection during pregnancy. Given the lack of measures to prevent transmission and to treat the infection efficiently, universal screening in pregnancy is currently not recommended.

Describe the symptoms of leiomyoma

majority are asymptomatic, • She may complain of pelvic pressure, congestion, bloating, a feeling of heaviness in the lower abdomen, or lower back pain. She may note frequency of urination. • Prolonged or heavy menstrual bleeding may be associated with intramural or submucosal myoma • Fibroids are not generally painful, but severe pain may be associated with red degeneration (acute infarction) within a fibroid. This most commonly occurs during pregnancy

gynecoid

most common - transverse diameter only slightly greater than the anteroposterior diameter 5. Well-curved sacrum 6. Spacious subpubic arch, with an angle of about 90 degrees

Second Stage of Labor

o At the beginning of the second stage, the mother usually has a desire to bear down with each contraction. This abdominal pressure, together with the uterine contractile force, combines to expel the fetus. During the second stage of labor, fetal descent must be monitored carefully to evaluate the progress of labor Length - Primis 30 min - 3 hr, multi 5-30 min

29. List and describe the test used to determine the adequacy of fluid volume.

real-time ultrasonography

Allostasis

refers to the body's ability to maintain stability through change If a woman enters pregnancy with worn-out allostatic systems (e.g., dysregulated stress or inflammatory response), she may be more vulnerable to a number of pregnancy complications, including preterm birth.

imperforate hymen

represents the mildest form of canalization abnormalities. It occurs at the site where the vaginal plate contacts the urogenital sinus. After birth, a bulging, membrane-like structure may be noticed in the vestibule, usually blocking egress of mucus. If not detected until after menarche, an imperforate hymen may be seen as a thin, dark bluish or thicker, clear membrane blocking menstrual flow at the introitus

3. List the characteristics of normal semen

semen volume - 2-5 mL sperm count, greater than 20 million/mL sperm motility greater than 50 pt, normal forms - greater than 30 pct standard morphology, more than 14 pct strict morphology WBCs - few than 10 per high power field or 1x10^6 ml

8. State the most common cause of vaginal trauma

sexual assault

Threatened abortion

when a pregnancy is complicated by vaginal bleeding before the 20th week Vaginal examination at this stage usually reveals a closed cervix 25% to 50% of threatened abortions eventually result in loss of the pregnancy.

2. Sate the age most DUB occurs

• Most DUB occurs during the years around the menarche (11-14 years of age) or menopause (45-50 years of age).

5. Describe the triad of symptoms associated with EP

• The classic triad consists of prior missed menses, vaginal bleeding, and lower abdominal pain

Incomplete abortion

1.In addition to vaginal bleeding, cramp-like pain, and cervical dilation, an incomplete abortion involves the passage of products of conception, often described by the woman as looking like pieces of skin or liver.

27. List the most commonly associated organisms associated with UTI's during pregnancy.

a. E. coli is the organism most frequently isolated (60%) b. Other organisms encountered are P. mirabilis, enterococci, Klebsiella pneumonia, and group B streptococci.

15. Define puerperium.

The puerperium consists of the period following delivery of the baby and placenta to about 6 weeks postpartum. During the puerperium, the reproductive organs and maternal physiology return toward the prepregnancy state, although menses may not return for much longer

15. List some additional methods besides EDC to measure gestations age.

2.Measurement of fetal crown-rump length the average of multiple measurements (e.g., biparietal diameter, femur length, abdominal and head circumferences

caput

Caput is a localized, edematous swelling of the scalp caused by pressure of the cervix on the presenting portion of the fetal head. The development of both molding and caput can create a false impression of fetal descent.

1.Define labor.

It is defined as progressive cervical effacement and dilation resulting from regular uterine contractions that occur at least every 5 minutes and last 30 to 60 seconds

1. Define preconception care and state why it is considered so important?

Organogenesis begins early in pregnancy, and placental development starts with implantation at 7 days postconception Allostasis refers to the body's ability to maintain stability through change

Define adenomyosis

extension of endometrial glands and stroma into the uterine musculature more than 2.5 mm beneath the basalis layer

11. Discuss the treatment and management of PROM.

ii. For preterm fetuses with PPROM, the risks associated with preterm delivery must be balanced against the risks for infection and sepsis that may make in utero existence even more problematic. For the mother, the risks include not only the development of chorioamnionitis but also the possibility of failed induction in the presence of an unfavorable cervix, resulting in subsequent cesarean birth. iii. Management is dictated to a large extent by the gestational age at the time of membrane rupture, although the quantity of amniotic fluid remaining after PPROM may be as important as gestational age in determining pregnancy outcome. v. Oligohydramnios associated with PROM in the fetus at less than 24 weeks' gestation may lead to the development of pulmonary hypoplasia. Factors that may be responsible include fetal crowding with thoracic compression, restriction of fetal breathing, and disturbances of pulmonary fluid production and flow. vi. If PROM occurs at 36 weeks or later and the condition of the cervix is favorable, labor should be induced after 6 to 12 hours if no spontaneous contractions occur. In the presence of an unfavorable cervical condition with no evidence of infection, it is reasonable to wait 24 hours before induction of labor to decrease the risk for failed induction and maternal febrile morbidity. The following discussion applies when premature membrane rupture occurs before 36 weeks' gestational age. vi. If PROM occurs at 36 weeks or later and the condition of the cervix is favorable, labor should be induced after 6 to 12 hours if no spontaneous contractions occur. In the presence of an unfavorable cervical condition with no evidence of infection, it is reasonable to wait 24 hours before induction of labor to decrease the risk for failed induction and maternal febrile morbidity. The following discussion applies when premature membrane rupture occurs before 36 weeks' gestational age. Because the risk for infection appears to increase with the duration of membrane rupture, the goal of expectant management is to continue the pregnancy until the lung profile is mature iii. The presence of bacteria by Gram stain or culture of amniotic fluid obtained at amniocentesis correlates with subsequent maternal infection in about 50% of cases and with neonatal sepsis in about 25%. iv. Ampicillin or erythromycin significantly prolongs the interval to delivery in patients with PPROM Managment of chorioamnionitis i. Once chorioamnionitis is diagnosed, antibiotic therapy should be delayed only until appropriate cultures have been taken. Ampicillin and gentamycin in combination are the drugs of choice. In the penicillin-sensitive patient, cephalosporins may be indicated, noting the 12% incidence of crossover sensitivity. Once antibiotics have been started, labor should be induced. If the condition of the cervix is unfavorable and there is evidence of fetal involvement, it may be necessary to perform a cesarean delivery Tocolytic therapy - i. The use of tocolytics to control preterm labor in patients with PROM is controversial. The arguments against their use are that they may mask evidence of maternal infection (e.g., tachycardia) and that contractions associated with the membrane rupture may be indicative of uterine infection. Arguments for their use are that PROM is sometimes initially associated with evidence of uterine contractions, and time is gained for pulmonary maturation. In the presence of infection, tocolysis is usually unsuccessful Corticosteroids - i. There is a decreased incidence of RDS in infants who are born with PPROM 16 to 72 hours after membrane rupture, presumably owing to the endogenous release of corticosteroids from the stress of decreased amniotic fluid. Perhaps for this reason, the National Institutes of Health (NIH) guidelines for glucocorticoid therapy recommend they be given to patients with PPROM only up to 32 weeks' gestation, Outpatient - i. After inpatient observation for 2 to 3 days without any evidence of infection, outpatient management can be considered in an attempt to reduce the incidence of late preterm births (34 to 37 weeks). To be eligible for such management, the patient should be reliable, fully informed regarding the risks involved, and prepared to participate in her own care. The fetus should be presenting as a vertex, and the cervix should be closed to minimize the chance of cord prolapse. At home, restricted physical activity is advised, no coital activity should occur, and the patient must monitor her temperature at least 4 times per day. Instructions should be given to return immediately if the temperature exceeds 100°F (37.8°C). The patient should be seen weekly, at which time her temperature should be taken, nonstress testing performed after 28 weeks Any patient with oligohydramnios is not a candidate for outpatient management. i. The same considerations discussed under preterm labor apply to patients with PROM. The decrease in amniotic fluid that is sometimes seen can result in early cord compression and the presence of variable fetal heart decelerations. This is true of both vertex and breech presentations; therefore, there is a necessity for abdominal delivery in a large number of cases unless fluid replacement can be instituted by amnioinfusion.

Define endometriosis

• Endometriosis is a bengin condition in which endometrial glands and stroma are present outside the uterine cavity and walls.

4. State the most common treatment option for SUI

• Pelvic floor muscle exercises (PFMEs) also known as Kegel exercises, are proven first-line therapy to improve or cure mild to moderate forms of SUI

8. Define low lying placenta.

A patient with a low-lying placenta, when the placental margin is within 2 cm of the endocervical os, may present in the same way as a patient with placenta previa. It may be difficult to distinguish a low-lying placenta from a marginal placenta previa, but a transvaginal ultrasound is typically diagnostic. Although vaginal delivery is not contraindicated, the same level of monitoring should be maintained for maternal hemodynamic stability and fetal well-being

9. Compare abrupt placentae with palcenta previa based on symptoms.

Abruptio placentae, or premature separation of the normally implanted placenta, complicates 0.5% to 1.5% of all pregnancies (1 in 120 births). Abruption severe enough to result in fetal death occurs in 1 per 500 deliveries. Risk factors - maternal hypertension - most important most common (due or not due to preeclampsia), tobaccos use, DIC Placental separation is initiated by hemorrhage into the decidua basalis with formation of a decidual hematoma. The resulting separation of the decidua from the basal plate predisposes to further separation and bleeding as well as to compression and destruction of placental tissue. The inciting cause of placental separation is unknown. It may be due to an inherent weakness or anomaly in the spiral arterioles Clinically, the diagnosis of a placental abruption is entertained if a patient presents with painful vaginal bleeding in association with uterine tenderness, hyperactivity, and increased tone - CLINICAL DIAGNOSIS In the setting of placental abruption, the use of tocolytics or uterine relaxants is not advised

10. Discuss the maternal fetal risks associated with placental abruption.

Abruption places the fetus at significant risk for hypoxia and, ultimately, death. The perinatal mortality rate due to placental abruption is 35%, Placental abruption is the most common cause of DIC in pregnancy. This results from release into the maternal circulation of thromboplastin from the disrupted placenta and subplacental decidua, causing a consumptive coagulopathy. o Hypovolemic shock and acute renal failure due to massive hemorrhage may be seen with a severe abruption if hypovolemia is left uncorrected. Sheehan's syndrome (amenorrhea as a result of maternal postpartum pituitary necrosis) may be a delayed complication resulting from coagulation within the portal system of the pituitary stalk.

3. State the most accurate method for the determination of antepartum bleeding

An important and accurate method for determining the cause of third-trimester bleeding is ultrasonography

5. State which hormone is used for pregnancy tests and when it is first detectable in the serum.

2.The hCG molecule is first detectable in serum 6 to 8 days after ovulation

6. Describe the criteria used for staging and the clinical implications of each

Tumor Size less than 1 cm ER or PR positive, Grade 1 equals low risk, 1-2 cm ER or PR receptor positive, Grade 1-2, High tumor size greater than 2 cm ER or PR -, Grade, 2-3

Screening - risk assessment

Cystic fibrosis

9. List the treatment options for cervical factor infertility

- Any cervical infection is treated by prescribing a 10-day course of doxycycline, 100 mg twice daily, for both partners

4. Differentiate between normal pregnancy associated edema and edema associated with preeclampsia.

Preeclampsia is often preceded by, or associated with, the development of generalized edema. Dependent edema (edema of the lower extremities) is very common in normal pregnancies. Hand and facial edema are more likely to be associated with preeclampsia, but if unaccompanied by hypertension and proteinuria, they are not diagnostic of the preeclampsia syndrome.

8. Define Ashman syndrome. (247)

Most commonly, the scarring results from curettage in high-risk settings, although vigorous scraping under any circumstances can result in the loss of the endometrium and consequent adhesion of opposing myometrial surfaces. Endometrial ablation procedures are designed to deliberately destroy the endometrium and create such scarring

2. List the etiologies of preterm labor

Spontaneous (number one), multiple pregnancies, PROM, HTN, cervical incompetence, antepartum hemorrhage, IUGR

4. Describe the surgical treatment and pain management for endometriosis

• Surgical intervention is required for an endometrioma larger than 3 cm, gross distortion of pelvic anatomy, involvement of bowel or bladder, and adhesive disease. Surgery may improve fertility for women with severe endometriosis. • The most comprehensive surgery includes total abdominal hysterectomy, bilateral salpingo-oophorectomy with destruction of all peritoneal implants, and dissection of all adhesions. Usually, an appendectomy is also preferred. Because of extensive adhesions, this surgery is often technically very challenging there is a 20% recurrence rate for endometriosis, usually involving the bowel. Can obstruct, ureter, bladder, and sigmoid colon, may require resection of these organs If you want future fertility - laparoscopic or open surgery is designed to destroy all endometriotic implants and remove all adhesive disease. This usually involves excision (not lysis) of all adhesions and laser ablation or electrocautery of suspected implants. Large endometriomas (>3 cm) are amenable only to surgical resection For residual disease diagnosed at surgery - Depot medroxyprogesterone acetate (DMPA), continuous oral contraceptives, and the levonorgestrel-releasing intrauterine device (IUD) are all attractive long-term options. • Medical therapy is generally the first line to treat other symptomatic women. There is no convincing evidence that treatment improves fertility in women with mild endometriosis. Medical Tx • For relief of non-cyclic pelvic pain, short-term medical treatment may be used. NSAIDs, oral contraceptives, and progestins (e.g., medroxyprogesterone acetate) should be considered the appropriate first-line medical treatments for symptomatic endometriosis. When an inadequate response occurs, second-line medical treatment with either a GnRH agonist, higher-dose progestins, or danazol appears to be equally effective. • Danazol (decreases estradiol secretion) is an androgenic derivative that may be used in a "pseudomenopause" regimen to suppress symptoms of endometriosis if fertility is not a present concern. It is given over a period of 6 to 9 months, and doses of 600 to 800 mg daily are generally necessary to suppress menstruation. Through its weak androgenic properties, danazol decreases the plasma levels of sex hormone-binding globulin. The resulting increase of free testosterone may cause hirsutism and acne. GnRH agonists - • GnRH agonists cause a temporary medical castration, thereby bringing about a marked, albeit temporary, regression of endometriosis. Treatment of women with endometriosis with GnRH agonists usually produces relief of pain and involution of implants. The disadvantages of these agonists are related to cost, hot flashes, and side effects, including vaginal dryness. They also cause calcium loss from bone and an unfavorable lipid profile. If treatment with a GnRH agonist is effective in relieving chronic pelvic pain and surgery is not indicated, low-dose estrogen-progestin add-back therapy can permit longer-term use of GnRH agonists by mitigating the adverse impact of estrogen deficiency without reducing the efficacy of GnRH agonists. •Oral contraceptives and oral medroxyprogesterone acetate are more effective in treating endometriosis-

General anesthesia agents

Induction agents for general anesthesia include propofol (most commonly), thiopental, etomidate (when cardiovascular stability is particularly desired), and ketamine (for hypovolemic or asthmatic patients). The muscle relaxant used to facilitate intubation is succinylcholine (unless contraindicated), owing to its rapid onset and brief duration of action. If contraindicated, vecuronium or rocuronium may be used. o Oxygen delivery is maintained at 50% to 100% until delivery if the baby is stressed. Nitrous oxide may be added. After induction, a potent inhalational agent is administered and at a modest level (0.5 minimum alveolar concentration [MAC]) to minimize myometrial relaxation. Narcotics may be administered after the delivery of the baby to reduce the need for inhalational anesthesia and provide postoperative pain relief. The patient must be extubated only when fully awake to minimize the risk for aspiration. Patients who receive epidural analgesia for labor pain have a similar duration of the first stage of labor, but the second stage may be prolonged by 15 minutes on average . Prolongation of the second stage could also be due to impaired ability to push (unlikely as long as motor block is avoided by appropriate adjustment of the epidural infusion), or decreased maternal urge to push due to sensory blockade. Cerebrospinal fluid leaks through the hole in the dura, resulting in low intracranial pressure. The hallmark is a severe positional headache-little or no headache supine, sudden onset of severe headache when sitting upright or standing

Anesthesia C-section

The type of anesthesia selected for cesarean delivery is determined by the urgency of the surgery, the presence or absence of a preexisting epidural catheter for labor, and the patient's medical condition, pregnancy-related complications If the history or the physical examination suggests that the intubation will be difficult (Box 8-2), the patient must have a regional anesthetic or an awake intubation, or the operation must be started under local anesthesia. All patients are premedicated with a nonparticulate antacid. Routine monitors are placed, including noninvasive blood pressure monitors, electrocardiograph, and pulse oximeter, and adequate left uterine displacement must be instituted. Supplemental oxygen is provided. A crystalloid preload (bolus over 30 to 60 minutes) of 10 to 15 mL/kg is given before regional anesthesia o For elective or urgent cesarean delivery (nonemergency), regional anesthesia is preferred because the airway is maintained. Complications involving loss of the airway are the leading causes of anesthetic-related maternal mortality and are usually associated with general anesthesia If no epidural is in place, a spinal block is frequently used. A comparison of the characteristics of spinal and epidural anesthesia is shown in Table 8-8 General anesthesia is employed for cesarean delivery in three situations: (1) there is extreme urgency without a preexisting, functional epidural catheter; (2) there is a contraindication to regional anesthesia; or (3) regional anesthesia has failed. When a relative contraindication to regional anesthesia is present, the benefits of regional anesthesia frequently outweigh the risks in the pregnant patient The protocol for general anesthesia for cesarean birth includes oral administration of nonparticulate antacid (sodium citrate), routine monitoring and left uterine displacement, preoxygenation for at least four vital capacity breaths, and rapid sequence induction of anesthesia with cricoid pressure followed by intubation to prevent regurgitation and pulmonary aspiration of gastric contents. Once the correct position of the endotracheal tube has been confirmed by end-tidal CO2 and auscultation of the lungs, surgery may begin Anesthesia related deaths - aspiration, cardiac arrest, intubation problems are MCCs of death

13. List and discuss the causes of post partum hemorrhage

Most of the blood loss occurs from the myometrial spiral arterioles and decidual veins that previously supplied and drained the intervillous spaces of the placenta. As the contractions of the partially empty uterus cause placental separation, bleeding occurs and continues until the uterine musculature contracts around the blood vessels and acts as a physiologic-anatomic ligature. Failure of the uterus to contract after placental separation (uterine atony) leads to excessive placental site bleeding Most postpartum hemorrhages (75% to 80%) are due to uterine atony. The factors predisposing to postpartum uterine atony are listed in Box 10-4 2. Genital tract trauma - second most common 3. Retained placental tissue In about half of patients with delayed postpartum hemorrhage, placental fragments are present when uterine curettage is performed with a large curette. Bleeding occurs as the uterus is unable to maintain a contraction and involute normally around a retained placental tissue mass 4. Low placental implantation Low implantation of the placenta can predispose to postpartum hemorrhage because the relative content of musculature in the uterine wall decreases in the lower uterine segment, which may result in insufficient control of placental site bleeding 5. Coagulation disorders - TTP, amniotic fluid embolus - This syndrome is characterized by a fulminating consumption coagulopathy, intense bronchospasm, and vasomotor collapse 6. ITP, Von Willebrand's disease is an inherited coagulopathy characterized by a prolonged bleeding time due to factor VIII deficiency. During pregnancy, these patients are likely to have a decreased bleeding diathesis because pregnancy elevates factor VIII levels. In the postpartum period, they are susceptible to delayed bleeding as factor VIII levels fall 7. Uterine inversion - Uterine inversion is the "turning inside-out" of the uterus in the third stage of labor. Just after the second stage, the uterus is somewhat atonic, the cervix open, and the placenta attached. Improper management of the third stage of labor can cause an iatrogenic uterine inversion. 8. If the inexperienced physician exerts fundal pressure while pulling on the umbilical cord before complete placental separation (particularly with a fundal implantation of the placenta), uterine inversion may occur As the fundus of the uterus moves through the vagina, the inversion exerts traction on peritoneal structures, which can elicit a profound vasovagal response. The resulting vasodilation increases bleeding and the risk for hypovolemic shock. If the placenta is completely or partially separated, the uterine atony may cause profuse bleeding, which compounds the vasovagal shock

7. Discuss the clinical management of placenta previa

Once the diagnosis of placenta previa is established, management decisions depend on the gestational age of the fetus and the extent of the vaginal bleeding. With a preterm pregnancy, the goal is to attempt to obtain fetal maturation without compromising the mother's health. If bleeding is excessive, delivery must be accomplished by cesarean birth regardless of gestational age. When the bleeding episode is not profuse or repetitive, the patient is managed expectantly in the hospital on bed rest. o With expectant management, 70% of patients will have recurrent vaginal bleeding before completion of 36 weeks' gestation and will require delivery. If the patient reaches 36 weeks, fetal lung maturity should be determined by amniocentesis and the patient delivered by cesarean birth if the fetal lungs are mature. Elective delivery is preferable because spontaneous labor places the mother at greater risk for hemorrhage and the fetus at risk for hypovolemia and anemia.

12. Define post partum hemorrhage for a vaginal vs. C-section delivery.

Postpartum hemorrhage is defined as blood loss in excess of 500 mL at the time of vaginal delivery. There is normally a greater blood loss following cesareandelivery; therefore, blood loss in excess of 1000 mL is considered a postpartum hemorrhage in these patients. The excessive blood loss usually occurs in the immediate postpartum period but can occur slowly over the first 24 hours.

17. Define APGAR score. What are normal values? List the 5 signs assessed in the test.

The Apgar score is an excellent tool for assessing the overall status of the newborn soon after birth (1 minute) and after a 5-minute period of observation (Table 8-9). A normal Apgar score is 7 or greater at 1 minute and 9 or 10 at 5 minutes HR - less than 100, Respiratory effort - good strong cry, Muscle tone- active motion, Reflex irritability - strong cry Color - completely pink

android

The android pelvis is the typical male type of pelvis, and it is found in less than 30% of women 1. Triangular inlet with a flat posterior segment and the widest transverse diameter closer to the sacrum than in the gynecoid type 3. Shallow sacral curve 5. Narrow subpubic arch

6. State the most common symptoms of placenta previa.

The classic presentation of placenta previa is painless vaginal bleeding in a previously normal pregnancy. The mean gestational age at onset of bleeding is 30 weeks

Stages of labor - 1

The first stage is from the onset of true labor to complete dilation of the cervix. The second stage is from complete dilation of the cervix to the birth of the baby. The third stage is from the birth of the baby to delivery of the placenta. The fourth stage is from delivery of the placenta to stabilization of the patient's condition, usually at about 6 hours postpartum. The first stage of labor consists of two phases: a latent phase, during which cervical effacement and early dilation occur, and an active phase, during which more rapid cervical dilation occurs (Figure 8-9). Although cervical softening and early effacement may occur before labor, during the first stage of labor, the entire cervical length is retracted into the lower uterine segment The active phase begins when the cervix is 3 to 4 cm dilated in the presence of regularly occurring uterine contractions Duration of stage - primipara - 6-18 hr, multipara 2-10 hr, rate of dilation primis 1 cm/hr, 1.2 cm/hr in multiparas maternal monitoring - Maternal pulse rate, blood pressure, respiratory rate, and temperature should be recorded every 1 to 2 hours in normal labor and more frequently if indicated. Fluid balance, particularly urine output and intake, should be monitored carefully. Fetal monitoring - The fetal heart rate should be evaluated either by auscultation with a De Lee stethoscope, by external monitoring with Doppler equipment, or by internal monitoring with a fetal scalp electrode ( not necessary in uncomplicated preggers ) no ob risk factors - monitored every 30 min in stage 1 and 15 min in stage two risk factors 15 and 5

1. List the most common causes of maternal death.

The most common causes of maternal death are hemorrhage, embolism, hypertensive disease, and infection

Plane of least diameter

The plane of least diameter is the most important from a clinical standpoint because most instances of arrest of descent occur at this level. It is bordered by the lower edge of the pubis anteriorly, the ischial spines and sacrospinous ligaments laterally, and the lower sacrum posteriorly. Low transverse arrests generally occur in this plane.

11. Define uterine rupture

Uterine rupture implies complete separation of the uterine musculature through all of its layers, ultimately with all or a part of the fetus being extruded from the uterine cavity A prior uterine scar is associated with 40% of cases. Typically, rupture is characterized by the sudden onset of intense abdominal pain and some vaginal bleeding The most consistent clinical finding is an abnormal fetal heart rate pattern. In most cases, total abdominal hysterectomy is the treatment of choice, The associated fetal mortality rate is still about 30%.

tamoxifen

- Nonsteroidal compound that on selected tissues acts like an antiestrogen (breast tissue) but on other tissues acts like an estrogen (bones, lipids, uterus) o Antitumor effects on breast cancer cells, decreased risk (by 40%) of contralateral breast cancer, improved bone density, & favorable effects on lipid profiles increased risk of endometrial cancer Aromatase Inhibitors - Newer class of hormonal agents known as the aromatase inhibitors being used for treatment of postmenopausal women with breast cancer - These drugs include: o anastrozole (Arimidex), exemestane (Aromasin), & letrozole (Femara) - more superior, less endometrium effects, but are more expensive - A monoclonal antibody directed against HER2/neu (trastuzumab, Herceptin) has been shown to have activity against breast cancers that overexpress HER2/neu. - Adverse effects include: o myocardial dysfunction, & should not be used in conjunction with cardiotoxic chemotherapy agents such as doxorubicin - Lapatinib (Tykerb) is an oral agent that also interferes with the HER2 signaling pathway. - As opposed to Herceptin, which acts on the membrane-bound, extracellular domain of the HER2/neu pathway, lapatinib acts intracellularly & is effective in women with Herceptin-refractory HER2/neu-positive breast cancer. - It is currently approved for use in women with recurrent Herceptin-refractory breast cancer & in combination with capecitabine chemotherapy. Zoledronic Acid (Zometa) & Pamidronate (Aredia) - Use of bisphosphonates can reduce the need for palliative radiation, bone fixation, & pain medicine in women with lytic bone metastases. Recent data also show that zoledronic acid may lead to a decrease in the recurrence rate of breast cancer

7. List the treatment options for ovulatory factor infertility.

- Pituitary insufficiency requires the injection of hMG (follicle-stimulating hormone [FSH] and LH). Hypothalamic amenorrhea is caused by infrequent or absent pulsatile release of gonadotropin-releasing hormone (GnRH). GnRH is highly effective when administered in small pulses subcutaneously or intravenously in these patients every 90 to 120 minutes by a small portable infusion pump. Because this treatment is not currently as available in the United States, hMG is used, but with a much higher risk for multiple pregnancy. Hyperprolactinemia and its suppressive effect on the hypothalamus are specifically treated by use of the dopamine agonists bromocriptine (Parlodel) and cabergoline (Dostinex). - Most of the remaining patients with anovulation have some form of polycystic ovarian syndrome (PCOS) and generally respond to clomiphene, an orally active antiestrogen Anovulation occurs in patients with polycystic ovaries because of chronic, mild suppression of FSH release Clomiphene, by inhibiting the negative feedback effect of endogenous estrogen, causes a rise of FSH and stimulation of follicular maturation - Other treatments used to induce ovulation in PCOS are laparoscopic "ovarian drilling," in which multiple small craters are created with laser or cautery, and dexamethasone, which increases the ovarian response to clomiphene Assessment by serial pelvic ultrasonography and carefully timed hCG administration may lead to normal ovulation. If follicular maturation is not occurring, ovulation induction will require low-dose FSH or hMG. Current use of a low-dose regimen of hMG or pure FSH reduces the overall risk for multiple pregnancy to about 5 Multiple pregnancy occurs in 6% to 8% of clomiphene citrate conceptions, with less than 1% of cases exceeding twin The hyperstimulation syndrome is a critical illness associated with marked ovarian enlargement and exudation of fluid and protein into the peritoneal cavity

3. Discuss the prognostic factors and current management of prostate cancer

- Prognostic factors for prostate cancer include stage of disease, grade of tumor, & pretreatment PSA level - In general, patients with T1A prostate tumors are observed without treatment. - For organ-confined prostate cancer (T1B, T1C, & T2 tumors), both radiation therapy & radical prostatectomy are equally viable options. Recently, it has been proposed that observation alone & treatment with hormonal agents at the time of progression because the rate or death from prostate cancer is low for well-differentiated early-stage disease. - For stage 3 (T3 or T4) disease (locally advanced), radiotherapy is generally used. A trial combining androgen deprivation with local radiation therapy showed improved local control & overall survival in this patient cohort. Some centers use androgen deprivation to downstage tumors before an aggressive surgical approach. - For stage D1 disease (positive pelvic nodes), the management is controversial. Divergent approaches include androgen deprivation alone, x-ray therapy with or without androgen deprivation, close observation with androgen deprivation at progression, or, infrequently, prostatectomy with androgen deprivation.

Differentiate the types of testicular cancer

- Seminomas (40%) - Nonseminomas o Embryonal carcinoma, mature & immature teratoma, choriocarcinoma, yolk sac tumor, & endodermal sinus tumor o There is often an admixture of several cell types within nonseminomas o Any nonseminomatous component plus seminoma is treated as a nonseminoma

4. Explain the current treatment and describe the expected outcomes in ovarian cancer

- Subsequently, patients are treated with 6 cycles of platinum- & paclitaxel-based chemotherapy, cisplatin - Outcome depends on stage of disease. - Ninety percent of patients with stage I disease are alive at 5 years, versus 80% of those with stage II disease. - Unfortunately, survival with advanced disease is poor: 15% - 20% of patients with stage III disease are alive at 5 years & only 5% of patients with stage IV disease are alive.

4. Discuss the treatment options for male coital factor infertility

- The couple should be advised to have intercourse about every 1 to 2 days during the periovulatory period (e.g., days 12 through 16 of a 28-day cycle). When a high semen volume coexists with a low count, infertility may result because a lower density of sperm contacts the cervical mucus. At present, these abnormalities of volume are most commonly treated with sperm washing and intrauterine insemination (IUI). - If low sperm density (oligospermia) or low motility (asthenospermia) is caused by hypothalamic-pituitary failure, injections of human menopausal gonadotropin (hMG) may be effective. The suppressive effects of hyperprolactinemia on hypothalamic function can be reversed by the administration of bromocriptine, a dopamine agonist. When low semen quality coexists with a varicocele (dilation and incompetence of the spermatic veins), improved semen quality, particularly motility, may occur with ligation of this venous plexus - If semen quality cannot be improved, IUI with close timing of the insemination to the precise point of ovulation is effective Accurate timing may be accomplished either by measurement of daily luteinizing hormone (LH) concentrations or by controlled stimulation of the cycle with clomiphene or hMG, followed by administration of hCG when follicular diameter, as seen by ultrasonography, indicates maturity. Insemination may then be carried out within a few hours of ovulation, which occurs about 36 hours following the onset of the LH surge or hCG injection - IVF is an effective treatment for the male factor because with intracytoplasmic sperm injection (ICSI), only one motile sperm for each egg is required. Finally, insemination with donor sperm is effective when the male factor is refractory to treatment

13. Discuss the options for infertile couples as far as assisted reproductive technologies.

- The last resort for infertile couples with any of the aforementioned factors and failure of lesser treatments is the procedure of IVF and embryo transfer - In most cases of tubal occlusion in which the rate of success with tubal repair is low (<30%), IVF is preferable to surgery because of the more rapid conception rate and the lower ectopic pregnancy rate. Even severe male factors can be effectively treated with IVF by using intracytoplasmic sperm injection, with high fertilization rates of injected oocytes and pregnancy rates similar to those of non-male-factor IVF (30% to 35%). - A GnRH agonist is given to prevent premature LH release. It is commonly started in the mid-luteal phase or overlapped with an oral contraceptive. After ovarian suppression (with GnRH agonist), the ovaries are stimulated with FSH, hMG, or both, on the second or third day of the next cycle. Follicle size is assessed by transvaginal ultrasonic scanning. - A GnRH agonist is given to prevent premature LH release. It is commonly started in the mid-luteal phase or overlapped with an oral contraceptive. After ovarian suppression (with GnRH agonist), the ovaries are stimulated with FSH, hMG, or both, on the second or third day of the next cycle. Follicle size is assessed by transvaginal ultrasonic scanning. - An injection of hCG (usually 10,000 U) is given based on follicular size and estradiol levels to induce the resumption of meiosis and completion of oocyte maturation. Thirty-five hours after the hCG injection, multiple oocytes are aspirated under transvaginal ultrasonic guidance. After a further period of in vitro maturation, washed sperm are added, or a single sperm is injected (ICSI) into each oocyte. Fertilization may be identified 14 to 18 hours after insemination by the visualization of two pronuclei. The conceptus is then transferred to the uterine cavity 2 to 5 days after oocyte retrieval by means of a tiny catheter. In some cases, the hatching process is aided by making an artificial opening in the zona pellucida ("assisted hatching"). Surplus embryos not transferred at the time of the IVF treatment can be frozen, stored, and transferred in a later menstrual cycle in the event of failure or for additional pregnancies The mean live delivery rate per retrieval with IVF currently approximates 30%, with about 1% of clinical pregnancies being ectopic - It is possible to achieve pregnancy with IVF and embryo transfer using donor eggs, with a higher success rate than in regular IVF (about 40%). The eggs generally come from young fertile women (known or anonymous volunteers

6. Discuss the ovulatory factor and its role in infertility

- The simplest screening tests to confirm reasonably normal ovulation are serial measurement of urinary LH, which assesses the duration of luteal function, and the mid-luteal level of serum progesterone, which assesses the level of luteal function

3. Describe the screening guidelines for ovarian Cancer

- The tools evaluated thus far, namely, pelvic ultrasonography & determination of serum CA 125 value, are inadequate for screening the general female population. - Screening for this disease is difiicult for several reasons. The incidence of ovarian cancer is relatively low, & there are no recognized pre-invasive lesions. Moreover, pelvic ultrasonography & the CA 125 level lack sufficient sensitivity & specificity. - However, it seems reasonable to apply these techniques on a period basis to women at a particularly high risk of ovarian cancer, for example, those with a strong family history of the disease (2 or more affected relatives) or known carriers of BRCA gene mutation

7. List the treatment options for ovulatory factor infertility

- Use of fertility drugs such as clomiphene citrate or gonadotropins will correct any luteal insufficiency in women with unexplained infertility - In women whose menses are less frequent than every 35 days (oligomenorrhea), it is helpful to induce more frequent ovulation, thus increasing the opportunity for pregnancy and improving the ability to time coitus

3. Discuss the natural history of breast cancer and list the prognostic factors associated with the disease

-The # of involved axillary nodes is the most i- Patients with estrogen-receptor-positive tumors have a better prognosis (however, difference in recurrent rates at 5 years is only 8-10% when compared with receptor-negative disease). - Extent of hormone positivity may be very important in treatment outcome; patients with more than 90% of tumor cells staining positive for estrogen receptor respond very well to hormonal therapies & may be able to avoid adjuvant chemotherapy, whereas those whose tumors are weakly positive or negative for estrogen receptor may benefit from adjuvant chemotherapy. mportant predictor of outcome - HER2/neu is a transmembrane protein that is overexpressed in ~30% of breast cancers. - HER2/neu positive tumors are associated with a higher risk of recurrence & an overall worse prognosis - In addition, use of therapies directed against the HER2/neu pathway such as trastuzaumab (Herceptin) greatly improve the prognosis. - Most bread cancers are high-grade

Complications of oxytocin induction

. First, an excessive infusion rate can cause hyperstimulation and thereby cause fetal distress from ischemia. In rare situations, a tetanic contraction can occur and lead to rupture of the uterus. Second, because oxytocin has a similar structure to antidiuretic hormone, it has an intrinsic antidiuretic effect and will increase water reabsorption from the glomerular filtrate. Severe water intoxication with convulsions and coma can occur rarely when oxytocin is infused continuously for more than 24 hours. Third, prolonged infusion of oxytocin can result in uterine muscle fatigue (nonresponsiveness) and postdelivery uterine atony (hypotonus), which can increase the risk for postpartum hemorrhage

9. State the incidence of early pregnancy loss and within what time frame they are usually lost.

. Spontaneous abortion occurs in 10% to 15% of clinically recognizable pregnancies. 2.The term biochemical pregnancy refers to the presence of hCG in the blood of a woman 7 to 10 days after ovulation but in whom menstruation occurs when expected. In other words, conception has occurred, but spontaneous loss of the gestation takes place without prolongation of the menstrual cycle. 3.When both clinical and biochemical pregnancies are considered, evidence would suggest that more than 50% of all conceptions are lost, the majority in the 14 days following conception

General management considerations

1. When the patient is Rh negative and does not have Rh (anti-D) antibodies, prophylactic Rho (D) immune globulin (Rho-GAM) should be administered

5. State the 2 transverse diameters of the fetal skull and list their approximate size

1. Biparietal (9.5 cm), the largest transverse diameter; it extends between the parietal bones. 2. Bitemporal (8 cm), the shortest transverse diameter; it extends between the temporal bones

31. Describe the umbilical Doppler assessment.

1. During the ultrasonic assessment, it is easy to assess fetal umbilical artery vascular resistance as an index of fetal health performing pulse wave Doppler assessment. 2. A normal systolic-to-diastolic (S/D) ratio suggests normal flow when the S/D ratio is low, indicating low fetal-placental vascular resistance. When flow becomes abnormal, there is complete loss of flow in the umbilical artery during diastole from the fetus to the placenta. When the fetus is very ill, there can be reversed flow during diastole, whereby the deflection during diastole is negative (downward, - cm/second) and blood in the umbilical artery flows backward from the placenta to the fetus in the umbilical artery. Under the latter condition, the fetus should be delivered expeditiously

11.Discuss the maternal risk factors for spontaneous abortions. Include infections, medical disorders and local maternal factors.

1. Infection with Mycoplasma, Listeria, or Toxoplasma should be specifically sought in women with recurrent abortions because despite being found infrequently, they are all treatable with antibiotics. (1) diabetes mellitus, (2) hypothyroidism, and (3) systemic lupus erythematosus (SLE) Local - maternal factors -cervical incompetence - due to trauma This occurs most frequently from mechanical dilation of the cervix at the time of termination of pregnancy, but it may also occur at the time of curettage. The diagnosis of cervical incompetence is usually made when a mid-trimester pregnancy is lost with a clinical picture of sudden unexpected rupture of the membranes, followed by painless expulsion of the products of conception congenitally abnormal uterus - fibroids -The most commonly acquired abnormalities of the uterus with the potential to affect fecundity are submucous fibroids. Although these tend to occur more frequently in women in their late 30s

4. Describe the potential pathways leading to preterm labor

1. Infection-Cervical Pathway treating women in preterm labor with antibiotics significantly prolongs the time from the onset of treatment to delivery, compared with that in patients who do not receive antibiotics ii. There is a link between vaginal-cervical infections and progressive changes in the cervical length, shorter cervixes have more infections iii. The most recent test to be developed is cervical and vaginal fetal fibronectin. This substance is a basement membrane protein produced by the fetal membranes. When the fetal membranes are disrupted, as with repetitive uterine activity, shortening of the cervix, and in the presence of infection, fibronectin is secreted into the vagina and can be tested. A positive fetal fibronectin test at 22 to 24 weeks predicts more than half of the spontaneous preterm births that occur before 28 weeks Placental vascular switch from a TH1 type of immunity, which may be embryotoxic, to TH2 antibody profile, in which blocking antibody production is thought to prevent rejection Stress-strain pathway i. Both mental (cognitive) and work-related stress and strain are postulated to initiate a stress response that increases release of cortisol and catecholamines. Cortisol from the adrenal gland initiates early placental corticotrophin-releasing hormone (CRH) gene expression, and elevated levels of CRH are known to initiate labor at term. Catecholamines released during the stress response not only affect blood flow to the uteroplacental unit but also cause uterine contractions (norepinephrine). Poor nutrition in the form of reduced calories or abnormal patterns of intake (fasting) are known stressors and have been associated with a significantly increased risk for preterm birth. uterine Stretch i. Uterine stretch as a result of increasing volume during normal and abnormal gestations is an important physiologic mechanism that facilitates the process of emptying the uterus. This pathway is common in patients with polyhydramnios and those with multiple gestations, both of which have an increased risk for preterm birth.

Discuss the diagnosis of DUB

• The diagnosis of DUB is usually made by excluding other causes of AUB. A possible unexpected pregnancy should always be ruled out initially. A pelvic examination must be performed to verify that the source of bleeding is uterine and not the result of a cervical, rectal, vaginal, vulvar, or urethral lesion • Two investigations are most useful for confirming DUB: a pelvic ultrasound and an endometrial biopsy

10. Describe the clinical features of puerperal sepsis.

1. Puerperal infection presents with a rising fever and increasing uterine tenderness on postpartum day 2 or 3. With the development of parametritis (pelvic cellulitis), the temperature elevation will be sustained, and signs of pelvic peritonitis may develop. Erratic temperature fluctuations and severe chills suggest bacteremia and dissemination of septic emboli, with the particular likelihood of spread to the lungs. 2. When the usual relative pelvic venous stasis is combined with a large inoculum of pathogenic anaerobic bacteria, a pelvic vein thrombophlebitis is likely to develop, usually on the right side of the pelvis. The clinical picture of pelvic thrombophlebitis is characterized by a persistent spiking fever for 7 to 10 days after delivery, despite antibiotic therapy.

missed abortion

1. Suspected missed abortion should be confirmed by ultrasound. Once the diagnosis has been made, it is appropriate to evacuate the retained products of conception surgically to minimize the risk for sepsis and DIC and to reduce the extent of hemorrhage and the degree of pain that accompanies the spontaneous expulsive process

17. State the most common autosomal recessive disorder in North American Whites.

1. The most common gene carried by North American whites is the cystic fibrosis (CF) gene (carrier frequency, 1/25).

incomplete abortion

1. Until bleeding has stopped or is minimal, it is best to insert an intravenous line and take blood for grouping and crossmatching because shock may occur from hemorrhage or sepsis Once the patient's condition is stable, the remaining products of conception should be evacuated from the uterus under appropriate pain control Delay in treatment may result in overwhelming sepsis that may lead to renal and hepatic failure, disseminated intravascular coagulation (DIC), and even death.

teratogen

1.A teratogen is any agent or factor that can cause abnormalities of form or function (birth defects) in an exposed fetus.

6. Discuss the values of hCG that constitute a negative pregnancy test, positive pregnancy test and the concentration detectable in the urine.

1.A titer of less than 5 IU/L is considered negative 2.A level above 25 IU/L is a positive result Most qualitative urine pregnancy tests can detect hCG above 25 IU/L.

23. Discuss the use of integrated and sequential screening.

1.In an attempt to improve the detection rate and minimize the screen positive rate and the number of invasive procedures, a few studies have been conducted to evaluate the concept of combining first- and second-trimester screening 1.With integrated screening, the first- and second-trimester results are combined into a single risk calculation and are not reported until after the second-trimester results are available. This approach has been found to have the highest sensitivity and to be the most cost effective 2.Sequential screening involves performance of both first- and second-trimester screening with disclosure of the first-trimester results for clinical management.

complete abortion

1.In complete abortion, after passage of all the products of conception, the uterine contractions and bleeding abate, the cervix closes, and the uterus is smaller than the period of amenorrhea would suggest. In addition, the symptoms of pregnancy are no longer present, and the pregnancy test becomes negative.

28. Describe the non-stress test in assessment of fetal well-being

1.The first step in the assessment of fetal well-being is the nonstress test. With the mother resting in the left lateral supine position, a continuous fetal heart rate tracing is obtained using external Doppler equipment. The mother reports each fetal movement, and the effects of the fetal movements on heart rate are determined 2.A normal fetus responds to fetal movement with an acceleration in fetal heart rate of 15 beats/minute or more above the baseline for at least 15 seconds. If at least two such accelerations occur in a 20-minute interval, the fetus is regarded as being healthy, and the test is said to be reactive.

12. State the most common cause of spontaneous abortion

1.The most common cause of spontaneous abortion is a significant genetic abnormality of the conceptus. most are trisomies

missed abortion

1.The term missed abortion is used when the fetus has died but is retained in the uterus, usually for more than 6 weeks. Because coagulation problems may develop, fibrinogen levels should be checked weekly until the fetus and placenta are expelled (spontaneously) or removed surgically.

recurrent abortion

1.Three successive spontaneous abortions usually occur before a patient is considered as a recurrent aborter.

22. List the tests included in the second trimester screening and state which disease they are used to predict.

1.Traditionally, a woman was offered the serum triple screening test that measures alpha fetoprotein (AFP), hCG, and unconjugated estriol (UE3) at 16 to 20 weeks of gestation. Approximately 80% to 85% of all open neural tube defects can be detected by maternal serum AFP - also detects gastroschisis or omphalocele AChE). Acetylcholinesterase is a protein that is present only if there is an open neural tube defect. The combination of low MSAFP, elevated hCG, and low UE3 levels (triple screen) has a detection rate for Down syndrome of about 70% 4. Low MSAFP, low hCG, and low UE3 levels can also be used to screen for trisomy 18

21. List the tests included in the first trimester screening and state which disease they are used to predict.

2. A combination of maternal age, fetal nuchal translucency (NT) (echo free area at back of fetal neck) thickness, and maternal serum-free β-human chorionic gonadotrophin (β-hCG) and pregnancy-associated plasma protein-A (PAPP-A) are included in the first-trimester screen. They screen for fetal aneuploidy Elevated levels of free β-hCG and low levels of plasma protein-A Are associated with an increased risk for Down syndrome.

8. Discuss the use of transvaginal ultrasonography in predicting early pregnancy viability.

2. Using transvaginal ultrasonography, the gestational sac should be seen at 5 weeks of gestation or a mean hCG level of about 1500 IU/L (1st IRP). The presence of a gestational sac of 8 mm (mean sac diameter) without a demonstrable yolk sac, 16 mm without a demonstrable embryo, or the absence of fetal cardiac motion in an embryo with a crown-rump length of greater than 5 mm indicates probable embryonic demise

18. List the common sex linked disorders.

2.Duchenne Muscular Dystrophy - Children present with a waddling gait or language delay and have to mount stairs one by one. Although the average age of diagnosis remains 5.5 years, children often become symptomatic much earlier 3.Fragile X syndrome 1.Fragile X syndrome is an X-linked disorder that is the second most common form of mental retardation after Down syndrome,

lobular carcinoma

25 pct of breast cancers - bilateral, orderly row of cells

11. Discuss the management of a patient with mild preeclampsia vs. severe preeclampsia or eclampsia.

? Delivery is the only definitive cure for preeclampsia The goal of management is to decrease or prevent the maternal complications of severe preeclampsia, while minimizing the neonatal complications arising from prematurity A woman with mild preeclampsia, without evidence of fetal compromise, whose disease does not appear to be progressing, will generally not be delivered unless the gestational age is 37 weeks or older, whereas a woman with severe preeclampsia or eclampsia should usually be delivered after a period of stabilization, regardless of the gestational age of the fetus The patient should be delivered before she reaches 38 weeks, if she develops signs or symptoms of worsening disease, or if there is evidence of fetal compromise. If the initial evaluation is consistent with the diagnosis of severe preeclampsia, the patient should remain hospitalized for the remainder of the pregnancy For those patients younger than 32 weeks with severe preeclampsia, the decision regarding delivery needs to be individualized after carefully weighing the risks to the neonate of prematurity vs. the potential maternal and fetal risks of continuing the pregnancy Deterioration in clinical status (e.g., uncontrollable hypertension, deteriorating renal function, pulmonary edema, evidence of HELLP or coagulopathy, CNS symptoms, abruption, or abnormal fetal testing) requires delivery MgSO4 - excreted via kidney, SEs - lose patellar reflex, warmth and flushing, slurred speech, paralysis and respiratory difficulty

Define HELLP syndrome.

A variant of severe preeclampsia with particularly high morbidity is the HELLP syndrome. This syndrome occurs in preeclamptic women with evidence of hemolysis, elevated liver enzymes, and low platelets (thrombocytopenia). In contrast to more typical presentations of preeclampsia, the patient with HELLP syndrome is more likely to be multiparous, older than 25 years, and at less than 36 weeks' gestation

List and briefly describe the analgesia and anesthesia which can be used during labor. Include C- section as well - labor

Acupuncture decreases pain in most studies. These techniques tend to work best early in the first stage of labor when the pain is least intense and may decrease pharmacologic use at that time. Pharmacologic treatment options include parenteral narcotics, regional analgesia (epidural, spinal, combined spinal-epidural, paracervical, caudal, and pudendal nerve blocks), and inhalational analgesia. Parenteral narcotics have very limited efficacy for the relief of labor pain. They work best in the early first stage when the pain is primarily visceral and less intense. All opioids readily cross the placental barrier and may cause neonatal respiratory depression depending on the dose and timing relative to delivery. They may also cause decreased fetal heart rate variability (not necessarily due to fetal acidosis) and impair neonatal breastfeeding. Fentanyl and nalbuphine have the shortest neonatal half-lives of the commonly used parenteral narcotics. Neuraxial analgesia (medication injected into the spinal column) is undoubtedly the most effective form of labor pain relief. Lumbar epidural analgesia is the most common form of neuraxial analgesia used to treat labor pain, and its use has been steadily increasing to 60% nationally. It may be used to provide pain relief for the first and second stages of labor, and, by injecting a higher concentration of local anesthetic Modern epidural management includes an initial bolus of local anesthetic (bupivacaine, ropivacaine, or lidocaine) and narcotic (fentanyl or sufentanil) to achieve a T10 sensory level, followed by an infusion of a dilute solution of the same agents until delivery. Pain during the first stage of labor is conducted along the sympathetic fibers, entering the spinal cord between T10 and L2. Dilute solutions can be used that permit ambulation, or the "walking epidural." The goal is to avoid motor block to minimize any adverse effects on maternal expulsive efforts in the second stage. A pudendal nerve block anesthetizes somatic afferent nerve fibers entering the spinal cord at sacral segments S2 to S4. It is usually effective at relieving the perineal pain of the second stage of labor, along with the pain of episiotomy and episiotomy repair. It does not affect the ongoing pain of uterine contractions.

11. Define acute fatty liver or pregnancy. List the incidence.

Acute fatty liver of pregnancy is a serious complication that is peculiar to pregnancy. It is associated with diffuse microvesicular fatty infiltration of the liver resulting in hepatic failure. The incidence is about 1 per 10,000 pregnancies It most commonly occurs in the third trimester of pregnancy or the early postpartum period Although the cause is unknown, it may in some instances result from an inborn error of metabolism, possibly a deficiency of long-chain 3-hydroxyl coenzyme A dehydrogenase. Presentation is variable, with abdominal pain, nausea and vomiting, jaundice, and increased irritability Hypertension and proteinuria are present in about half of patients, raising the issue of coexisting preeclampsia. Invariably, patients suffer hepatic coma and renal failure

List the common teratogens

Alcohol, anxiety agents (fluoxetine is drug of choice is preggers), methotrexate, bulsfan, cyclophosphamide, nitrogen ureas, chlorambucil (alklyating agents), warfarin, Dilantin D, valproic acid, carbazepine, phenobarbital, DES, retinoids

13. Define induction and augmentation. Include both mechanical and pharmacologic approaches.

All for cervical ripening Induction of labor is the process whereby labor is initiated by artificial means; augmentation is the artificial stimulation of labor that has begun spontaneously. Currently approved pharmacologic treatments include intravaginal application of prostaglandin E2 (dinoprostone) using a vaginal insert called Cervidil (on a string), which can be removed quickly if the medication causes hyperstimulation. Cytotec, a synthetic prostaglandin E1 (alprostadil) analogue, has been approved for cervical ripening. One 25-μg tablet placed intravaginally effectively initiates cervical ripening. Although prostaglandin administration has been demonstrated to shorten the duration of labor induction, the impact on cesarean birth rates due to failed induction has been minimal. Other methods of cervical ripening may include intrauterine placement of catheters or the use of osmotic dilators Oxytocin is identical to the natural pituitary peptide, and it is the only drug approved for induction and augmentation of labor. Pitocin is the synthetic preparation. The physician must be fully aware of the indications and the contraindications for the use of oxytocin (Table 8-3). In general, induction of labor before term is indicated only when the continuation of pregnancy represents a significant risk to the fetus or mother. In some situations, induction may be indicated at term, as in the case of premature rupture of the membranes In general, any condition that makes normal labor dangerous for the mother or fetus is a contraindication to induction or augmentation of labor. The most common contraindication has been prior uterine surgery in which there has been complete transection of the uterine wall Induction of labor before term for maternal or fetal indications must not be undertaken without the assessment of fetal pulmonary maturity, provided that a delay will not jeopardize the mother or fetus. Fetal lung maturity can most often be accelerated within 24 to 48 hours by the use of glucocorticoids

8. Define intrahepatic cholestasis of pregnancy

Although the pathogenesis of this syndrome is not known, some distinctive features are present: (1) cholestasis and pruritus in the second half of pregnancy without other major liver dysfunction, (2) a tendency to recurrence with each pregnancy, (3) an association with oral contraceptives and multiple gestations, (4) a benign course in that there are no maternal hepatic sequelae, and (5) an increased rate of meconium-stained amniotic fluid and fetal demise.

apical vaginal and uterine prolapse

Although vaginal prolapse can occur without uterine prolapse, the uterus cannot descend without carrying the upper or apical portion of the vagina with it. Although vaginal prolapse can occur without uterine prolapse, the uterus cannot descend without carrying the upper or apical portion of the vagina with it. Complete procidentia (uterine prolapse through the vaginal hymen) represents failure of all the vaginal supports (Figure 23-2). Hypertrophy, elongation, congestion, and edema of the cervix may sometimes cause a large protrusion of tissue beyond the hymen, which may be mistaken for a complete procidentia. Vaginal vault prolapse or eversion of the vagina may be seen after vaginal or abdominal hysterectomy and represents failure of the supports around the upper vagina.

Recurrent abortions

it is appropriate to rule out the presence of systemic disorders such as diabetes mellitus, SLE, and thyroid disease, and it is also necessary to test for the presence of a lupus anticoagulant rule out the presence of Mycoplasma, Listeria, Toxoplasma, Treponema, cytomegalovirus, and Brucella Many of the congenital abnormalities of the uterus can now be diagnosed using pelvic ultrasonography and may no longer require laparotomy for repair. 2. More than half of couples with recurrent losses will have normal findings during an evaluation.

Labs - risk assessment

Check complete blood count, urinalysis, type and screen, rubella, syphilis, hepatitis B, HIV, cervical cytology; screen for gonorrhea, chlamydia, and diabetes in selected populations. Consider thyroid-stimulating hormone

4. List the predisposing factors associated with placenta previa.

Bleeding from a placenta previa accounts for about 20% of all cases of antepartum Factors that have been associated with a higher incidence of placenta previa include (1) multiparity, (2) increasing maternal age, (3) prior placenta previa, and (4) multiple gestation. Patients with a placenta previa have a 4% to 8% risk for having placenta previa in a subsequent pregnancy

Fourth stage of labor

Blood pressure, pulse rate, and uterine blood loss must be monitored closely. It is during this time that postpartum hemorrhage commonly occurs, usually because of uterine relaxation, retained placental fragments, or unrepaired lacerations. An increase in pulse rate, often out of proportion to any decrease in blood pressure, may indicate hypovolemia

11. Describe the management of puerperal sepsis

Broad-spectrum antibiotics, such as ampicillin and the cephalosporins, are effective first-line drugs for mild and moderate cases of puerperal infection The major pelvic pathogen resistant to this combination is Bacteroides fragilis, which is usually sensitive to clindamycin. The use of clindamycin with either an aminoglycoside or ampicillin will provide the best first-line coverage Pelvic thrombophlebitis UFH 2-3 weeks for pevlis, 4-6 weeks for femoral If the patient does not respond to heparin therapy and the clinical course is one of unrelenting fever and pelvic tenderness, a diagnosis of pelvic abscess must be considered The presence of a pelvic abscess requires surgical drainage.

11. Define brow and compound presentations

Brow presentation occurs when the presenting part of the fetus is between the facial orbits and anterior fontanelle (Figure 13-8). This type of presentation arises as the result of extension of the fetal head such that it is midway between flexion (vertex presentation) and hyperextension (face presentation). The incidence is about 1 in 1400 deliveries. With a brow presentation, the presenting diameter is the supraoccipitomental diameter, which is much longer than the presenting diameter for a face or a vertex presentation. The intrapartum management is expectant because the brow presentation is an unstable one. Fifty percent to 75% will convert to either a face presentation, through extension, or a vertex presentation, through flexion, and will subsequently deliver vaginally. With a persistent brow presentation, the large presenting diameter makes vaginal delivery impossible, unless the fetus is very small or the maternal pelvis is very large, and delivery must be accomplished by cesarean birth. Compound presentation - A compound presentation occurs when a fetal extremity (usually the hand) prolapses alongside the presenting part (the head) and both parts enter the maternal pelvis at the same time. This presentation occurs more frequently with premature gestations. The incidence of a hand or arm prolapsing alongside the presenting fetal head is 1 in 700 deliveries, and management is expectant. Usually, the prolapsed part of the fetus does not interfere with labor. If the arm prolapses, it is best to wait to see if it moves out of the way as the head descends. If it does not, the arm may be gently pushed upward while the head is simultaneously pushed downward by fundal pressure. If the complete extremity prolapses and the fetus then converts to a shoulder presentation (Figure 13-9), delivery must be accomplished by cesarean birth

Second Stage of labor - Movements

Descent is brought about by the force of the uterine contractions, maternal bearing-down (Valsalva) efforts, and, if the patient is upright, gravity. Flexion - cause further flexion of the cervical spine, with the baby's chin approaching its chest. In the occipitoanterior position, the effect of flexion is to change the presenting diameter from the occipitofrontal to the smaller suboccipitobregmatic Internal Rotation - rotates so that the occiput turns anteriorly toward the symphysis pubis Extension - The flexed head in an occipitoanterior position continues to descend within the pelvis. Because the vaginal outlet is directed upward and forward, extension must occur before the head can pass through it. As the head continues its descent, there is bulging of the perineum followed by crowning External rotation -the delivered head now returns to its original position at the time of engagement to align itself with the fetal back and shoulders. Expulsion - anterior should delivers first

5. List and describe the types of placenta previa

Complete placenta previa implies that the placenta totally covers the cervical os. A complete placenta previa may be central, anterior, or posterior, depending on where the center of the placenta is located relative to the os. Partial placenta previa implies that the placenta partially covers the internal cervical os. A marginal placenta previa is one in which the edge of the placenta extends to the margin of the internal cervical os

Define molding

Cranial bones are thin, and weak - These features allow them to overlap under pressure and to change shape to conform to the maternal pelvis, a process known as "molding."

crowning

Crowning occurs when the largest diameter of the fetal head is encircled by the vulvar ring. At this time, the vertex has reached station +5

Deep venous thrombosis

DVT is much more common in the left than the right leg. Pain in the calf in association with dorsiflexion of the foot (positive Homans' sign) is a clinical sign of DVT in the calf veins. Dull ache, tingling, tightness, or pain in the calf or leg, especially when walking, may be present. Acute swelling and pain in the thigh area and tenderness in the femoral triangle are suggestive of iliofemoral thrombosis. Compression ultrasonography with Doppler flow studies is a noninvasive technique that has high sensitivity and specificity and is currently the primary mode of diagnosis used for D-Dimers can be used in nonpregnant women

5. Explain how to diagnose and manage preterm labor.

Diagnosis - i. The diagnosis of preterm labor occurring between 20 and 37 weeks is based on the following criteria in patients with ruptured or intact membranes: (1) documented uterine contractions (four per 20 minutes) and (2) documented cervical change (cervical effacement of 80% or cervical dilation of 2 cm or more). Uterine contractions are not a good predictor of preterm labor, but cervical changes are Management - i. Provided that membranes are not ruptured and there is no contraindication to a vaginal examination (e.g., placenta previa), an initial assessment must be done to ascertain cervical length and dilation and the station and nature of the presenting part. ii. With adequate hydration and bed rest, uterine contractions cease in about 20% of patients , cultures should be taken for group B streptococcus Other organisms that may be important are Ureaplasma, Mycoplasma, and Gardnerella vaginalis. The latter is associated with bacterial vaginosis, a diagnosis that can be made by the presence of three of four clinical signs (vaginal pH > 4.5, amine odor after addition of 10% potassium hydroxide [KOH], and presence of clue cells or milky discharge). iv. Antibiotics should be administered to patients who are in preterm labor. For patients who are not allergic to penicillin, a 7-day course of ampicillin, erythromycin, or both can be given. Those allergic to penicillin can be given clindamycin If the patient does not respond to bed rest and hydration, tocolytic therapy is instituted, provided there are no contraindications

15. List the diagnosis of HIV during pregnancy

ELISA, western blot, HIV PCR for indeterminate cases and to measure effect of drug therapy on viral load f. All pregnant women should be tested for HIV unless they refuse. Rapid HIV testing should be offered to pregnant women presenting intrapartum whose HIV status is unknown. If the rapid test is positive, zidovudine prophylaxis should be administered and confirmatory testing sent

13. Describe the management of eclampsia.

Eclampsia is a true obstetric emergency . Eclamptic seizures often induce a fetal bradycardia that usually resolves after maternal stabilization and correction of hypoxia. It is very important to stabilize the mother before any attempt is made to deliver the infant. Induction of labor or cesarean birth during the acute phase may aggravate the course of the disease. Once hypoxia is corrected, convulsions controlled, and the diastolic blood pressures brought down to the 90- to 100-mm Hg range, delivery should be expedited, preferably by the vaginal route.

10. Define face presentation. What is the recommendation on how these fetuses should be delivered?

Face presentation occurs when the fetal head is hyperextended such that the fetal face, between the chin and orbits, is the presenting part. The incidence is about 1 in 500 deliveries. Because anencephalic fetuses uniformly present face first, anencephaly should be ruled out when face presentation is suspected The mechanism of labor with a face presentation is similar to the vertex presentation in that the longest diameter (mentum to brow) enters the pelvis transversely. As labor proceeds and the face descends to the midplane, internal rotation occurs into the vertical axis. If the mentum rotates anteriorly under the symphysis pubis, vaginal delivery should be expected. Forceps, but not vacuum, can be applied to assist if prerequisites are met. However, if the mentum rotates posteriorly, the fetal head will be unable to extend farther to complete the expulsive process. Thus, mentum posterior cases and those with persistent mentum transverse must be delivered by cesarean birth.

15. List and describe the 3 types of breech presentations

Frank breech occurs when both fetal thighs are flexed and both lower extremities are extended at the knees. A complete breech has both thighs flexed and one or both knees flexed (sitting in a "squat" position). An incomplete (or footling) breech has one or both thighs extended and one or both knees or feet lying below the buttocks. At term, 65% of breech fetuses are frank, 25% are complete, and 10% are incomplete. Most are frank.

1. Define gestational diabetes mellitus (GDM).

GDM is defined as glucose intolerance with onset or first recognition during pregnancy. Pregnancy is associated with progressive insulin resistance.Human placental lactogen, progesterone, prolactin, cortisol, and tumor necrosis factor are associated with increased insulin resistance during pregnancy. Studies suggest that women who develop GDM have chronic insulin resistance and that GDM is a "stress test" for the development of diabetes in later life

35. Describe congenital Toxoplasmosis and list the treatments.

Highest risk of transmission in 3rd semester, severity the most in 1st trimester . A classic triad of hydrocephalus, intracranial calcifications, and chorioretinitis is described b. Toxoplasmosis is a self-limiting infection. Owing to the fetal risk, spiramycin is used for treatment of maternal primary infection

Management post term preg

However, if the gestational age is firmly established at 42 weeks, the fetal head is well fixed in the pelvis, and the condition of the cervix is favorable, labor usually should be induced. 42 weeks unripen cervix - deliver if AFI below 5 or spontaneous HR decelerations are found on NST So long as these parameters of fetal well-being are reassuring, labor need not be induced unless the cervical condition becomes favorable, the fetus is judged to be macrosomic, or there are other obstetric indications for delivery. At 42 weeks' gestation with firm dates, delivery is initiated by the appropriate route, regardless of other factors, in view of the increasing potential for perinatal morbidity and mortality. 5. When the patient presents very late in gestation for initial assessment of prolonged pregnancy, but the gestational age is in question and fetal assessment is normal, an expectant approach is often acceptable. intrapartum - . The fetal membranes should be ruptured as early as is feasible in the intrapartum period so that internal electrodes can be applied and the color of the amniotic fluid assessed

10. Describe the third stage of labor. Include the signs of placental separation and the 4 types of perineal lacerations.

Immediately after the baby's delivery, the cervix and vagina should be thoroughly inspected for lacerations and surgical repair performed if necessary. The cervix, vagina, and perineum may be more readily examined before the separation of the placenta because no uterine bleeding should be present to obscure visualization. Placental separation-Separation of the placenta generally occurs within 2 to 10 minutes of the end of the second stage of labor Signs of placental separation are as follows: (1) a fresh show of blood from the vagina, (2) the umbilical cord lengthens outside the vagina, (3) the fundus of the uterus rises up, and (4) the uterus becomes firm and globular. Only when these signs have appeared should the assistant attempt traction on the cord. With gentle traction and counterpressure between the symphysis and fundus to prevent descent of the uterus into the pelvis, the placenta is delivered. It is routine to add 20 U of oxytocin to the intravenous infusion after the baby has been delivered

7. Discuss the use of hCG testing in the diagnosis of EP

In the 1st trimester of normal pregnancies, serum titers of hCG increase exponentially following a nonlinear model • . Healthy, normally developing pregnancies generally can be detected by a normal rate of increase of maternal serum hCG levels. Over 66% of normal pregnancies show doubling of hCG levels every 48 hours in the first several weeks of pregnancy. • A normal range exists, and the slowest rise for a normal pregnancy in 2 days is 53%. If the hCG levels rise by less than 53%, the differential diagnosis includes an abnormal IUP or an ectopic pregnancy • After a spontaneous pregnancy loss, the minimal decline in hCG is 21% to 35% in 2 days. Therefore, if the hCG levels are declining more slowly than 20%, an ectopic pregnancy is likely. Lower levels of hCG (<500) clear from the circulation more slowly that do higher levels.

pulmonary embolism

It is one of the most common causes of pregnancy-related deaths in the United States. In about 70% of cases, DVT is the instigating factor. Suggestive symptoms include pleuritic chest pain, shortness of breath, air hunger, palpitations, hemoptysis, and syncopal episodes An electrocardiogram can show sinus tachycardia with or without premature heartbeats or right ventricular axis deviation Pulmonary embolism is ultimately a radiologic diagnosis. Three algorithms may be used: (1) If bilateral compression ultrasonography of the lower extremities is positive for DVT, a pulmonary embolism may be assumed in a symptomatic patient. (2) A ventilation-perfusion scan has minimal risk to the fetus, but it cannot be used in patients with an abnormal chest x-ray or in patients with asthma or chronic obstructive pulmonary disease. (3) Helical computed tomography has the advantage that the presence of a thrombus can be visualized by a noninvasive technique. It has comparative sensitivity to conventional pulmonary angiography and has been shown to be a cost-effective technique in pregnancy

12. Discuss the management of acute fatty liver disease of pregnancy

Laboratory findings include an increase in prothrombin time (PT) and partial thromboplastin time (PTT), hyperbilirubinemia, hyperammonemia, hyperuricemia, and a moderate elevation of the transaminase levels. Hematemesis and spontaneous bleeding become manifest as disseminated intravascular coagulation (DIC) develops. Liver failure is indicated by elevated blood ammonia levels. Termination of pregnancy and intensive supportive care are indicated on diagnosis. Treatment is mainly directed at supportive measures, such as administration of intravenous fluids with 10% glucose to prevent dehydration and severe hypoglycemia replace coagulation factors with vitamin K and/or fresh frozen plasma In those who survive, recovery is complete, with no signs of chronic liver disease.

10. Discuss the management of intrahepatic cholestasis of pregnancy.

Local measures such as cold baths, bicarbonate washes, or phenol (0.5% to 1% in water-soluble creams) may be of some help. The best results have been obtained with ursodeoxycholic acid. It significantly ameliorates the pruritus and reduces serum levels of bile acids, aminotransferases, and bilirubin. Serial fetal surveillance is performed in the third trimester, with delivery at term if testing remains reassuring

2. State the CDC's aims for preconception care.

Major components of preconception care include risk assessment, health promotion, and medical and psychosocial interventions and follow-up

List the common factors associated with infertility

Male (coital) - 40 pct - get semen analysis Ovulatory - 20 pct, get LH, progesterone tests Cervical - postcoital test Uterine, tubule - 30 pct hysterosalpinogram/laparoscopy Peritoneal 40 pct laparoscopy

9. List the proposed etiologies of intrahepatic cholestasis of pregnancy

Most probably, genetic, geographic, or environmental factors are involved. A mutation in the MDR3 gene may be associated with up to 15% of cases The main symptom is itching, without abdominal pain or a rash, which may occur as early as 20 weeks of gestation. Jaundice is rarely observed.Laboratory tests show elevated levels of serum bile acids

Discuss the principals (the principal is your pal, dumbass) of oxytocin induction in augmentation and the potential complications of augmentation.

Oxytocin - induction/augmentation of labor 1. Oxytocin must be given intravenously to allow it to be discontinued quickly if a complication such as uterine hypertonus or fetal distress develops. Because oxytocin has a half-life of 3 to 5 minutes, its physiologic effect will diminish quickly (within 15 to 30 minutes) after discontinuation. 2. A dilute infusion must be used and "piggybacked" into the main intravenous line so that it can be stopped quickly if necessary, without interrupting the main intravenous route. 3. The drug is best infused with a calibrated infusion pump that can be easily adjusted to effect the required infusion rate accurately. 4. The induction of labor for a specific indication generally should not exceed 72 hours. In patients with a low Bishop score, it is not unusual for an induction to progress slowly. If the cervix effaces and dilates, it is recommended that the membranes be ruptured on the third day. If adequate progress is not made within 12 hours of rupturing the membranes, a cesarean delivery may be performed. 5. If adequate labor is established, the infusion rate and the concentration may be reduced, especially during the second stage of labor. This principle avoids the risks of hyperstimulation and fetal distress, which frequently occur once labor has been established

IUGR Management

Pre-pregnancy - For women with antiphospholipid antibodies associated with the delivery of a prior IUGR infant, low-dose aspirin (81 mg/day) in early pregnancy may reduce the likelihood of recurrent IUGR. iii. For patients with one of the hereditary thrombophilias, low-dose heparin (5000 U twice daily) Antepartum - ii. The working woman who becomes fatigued is more likely to have a low-birth-weight infant. Work leave, or in some cases of maternal disease, hospitalization, will increase uterine blood flow and may improve the nutrition of the fetus at risk. iii. The objective of clinical management is to expedite delivery before the occurrence of fetal compromise, but after fetal lung maturation has been achieved In the presence of severe oligohydramnios, amniocentesis may not be safe or feasible. Delivery should be strongly considered without assessing lung maturity because these fetuses are at great risk for asphyxia, and the stress associated with IUGR usually accelerates fetal pulmonary maturity l. Doppler-derived umbilical artery systolic-to-diastolic ratios are abnormal in IUGR fetuses. Fetuses with growth restriction tend to have increased resistance to flow and to demonstrate low, absent, or reversed diastolic flow

Blood products used to correct coagulation defects

Platelets 1 unit increases 25K, Cryoprecipitate - supplies fibrinogen, VIII, and XIII, fresh frozen plasma supplies all factors except platelets, packed RBC increases hct by 3 pct

Posterior vaginal prolapse (rectocele and enterocele)

Posterior vaginal defects occur when there is weakness in the rectovaginal septum. Symptoms can be indistinguishable from other types of prolapse because the discomfort, pressure, and sense of a vaginal bulge are nonspecific However, when difficulties with bowel function and defecation occur, lower posterior vaginal prolapse is likely. Straining or the need to manually splint for complete bowel elimination may occur. Upper posterior vaginal wall prolapse is nearly always associated with herniation of the pouch of Douglas, and because this is likely to contain loops of bowel, it is called an enterocele.

24. Describe the impact of VZV infection during pregnancy.

Potential maternal complications include preterm labor, encephalitis, and varicella pneumonia. Maternal management should be symptomatic, but a CXR should be considered to rule out pneumonia Diagnosis of the syndrome is based on IgM-positive cord blood and clinical findings in the newborn, which include limb hypoplasia, cutaneous scars, chorioretinitis, cataracts, cortical atrophy, microcephaly, and symmetrical IUGR The risk for this fetal syndrome is 2% if maternal infection occurred between 3-20 weeks and 0.4% if infection occurred before 13 weeks of gestation. Only rarely have cases been identified as a result of maternal infection past 20 weeks gestation. However, if maternal infection occurs between 5 days before delivery and 2 days after delivery, transplacental transfer of maternal protective antibodies to the fetus has not occurred, and the infant is at great risk for developing a fulminant infection with a 30% mortality rate. Varicella-zoster immune globulin (VZIG) should be given to these infants at birth, and they should be placed in contact isolation. The placenta and fetal membranes should be considered infectious h. For the exposed gravid woman who has no knowledge of a prior infection, a varicella IgG titer should be obtained immediately. If the patient proves to be non-immune, VZIG should be administered within 6 days of exposure, although it is unclear whether this therapy modifies the disease course and risk to the fetus. k. Varicela vaccine is composed of a live attenuated virus and , therefore, is contraindicated in pregnancy. l. Herpes zoster does not occur more frequently in pregnancy. If it does occur, it poses no risk to the fetus. If zoster develops close to deliver, varicella may be transmitted through contact with a lesion, so this should be avoided

4. Discuss the goals of intrapartum management for the treatment of preterm labor and vertex-vertex presentations

Pre term labor - . Relative contraindications to tocolysis in these pregnancies include a gestational age of 34 weeks or more, growth failure of one or more fetuses, concerning fetal status on biophysical monitoring, and preeclampsia ii. In the special case of monoamniotic twins, delivery by cesarean birth is usually accomplished by 34 to 36 weeks because of the increased risk for lethal cord entanglement. vertex-vertex presentations - i. To choose the safest route of delivery for mother and babies, the presentations of the fetuses must be accurately known. By convention, the presenting twin is designated as twin A and the second twin as twin B. Vertex (twin A)-vertex (twin B) presentation occurs most frequently (50% of the time), followed by vertex-breech ii. Vertex-vertex twins are managed similarly to a singleton vertex presentation After delivery of the first twin, the cord is clamped (identified as twin A) and cut, but cord blood samples are not obtained until the second fetus has been delivered to prevent potential hemorrhage from the undelivered fetus through placental vascular anastomoses. A vaginal examination is then performed to assess the presentation and station of the second twin. If the second twin is still in a vertex presentation, spontaneous delivery is expected. If necessary, forceps or vacuum can be used to assist delivery of a vertex second twin. Because the second twin is at increased risk for cord prolapse, abruptio placentae, and malpresentation, careful attention to fetal heart monitoring is necessary.

2. Define preeclampsia. In the early second trimester, what complications should be considered?

Preeclampsia is a syndrome unique to pregnancy, characterized by the new onset of hypertension and proteinuria in the latter half of gestation. Preeclampsia is classically considered to be a disease affecting the first pregnancy, but it also occurs in multiparas, especially if there are predisposing risk factors such as twins, diabetes mellitus, chronic hypertension, or a change in husband/partner. When it arises in the early second trimester (14 to 20 weeks), a hydatidiform mole or choriocarcinoma should be considered.

8. Define superimposed preeclampsia

Preeclampsia may become superimposed on chronic hypertensive disease. Superimposed preeclampsia can be very difficult to distinguish from poorly controlled chronic hypertension, especially if the woman is not seen until after the 20th week of gestation, but the two conditions are managed differently. In general, superimposed preeclampsia carries a worse prognosis than does either condition alone. The diagnosis of superimposed preeclampsia should be reserved for those women with chronic hypertension who develop new-onset proteinuria (≥0.3 g in a 24-hour collection) after the 20th week of gestation. In pregnant women with preexisting hypertension and proteinuria, the diagnosis of superimposed preeclampsia should be considered if they experience sudden significant increases in blood pressure or proteinuria or any of the other signs and symptoms consistent with severe preeclampsia (160/110, 5 g proteinuria, oliguria, visual disturbanches, pulmonary edema)

5. Explain the surgical and chemotherapeutic treatment of breast cancer.

Primary or Local-Regional Treatment - Primary local treatment for invasive breast cancer is either lumpectomy (also known as wide local excision or breast conservation) followed by radiation or mastectomy. - Several trials show that therapeutic equivalence for breast conservation compared with mastectomy in terms of overall survival, whereas mastectomy has a slightly lower local recurrence rate. - Chemotherapy has been shown to decrease the risk of recurrence & improve overall survival in both node-negative & node-positive cancer, but it is associated with more toxicity than hormonal therapy. - Sequential therapy with chemotherapy followed by hormonal therapy does offer additive effect against the cancer in women with hormonally sensitive disease. Treatment of Advanced Disease - We currently lack curative therapy for recurrent metastatic breast cancer - Because treatment is not curative, the initial systemic treatment for patients with estrogen-receptor-positive advanced disease is usually hormonal. - Chemotherapy is used once disease has progressed while receiving hormonal therapy or in women with estrogen-receptor-negative breast cancer o Common combination regiments are CMF, CAF, & AC. Cyclophosphamide, MTX, 5-FU, Adriamycin (doxorubicin)

Describe the staging of breast cancer

Primary tumor (tumor size in cm) T1 less than 2, T2 2-5, T3 greater than 5, T4 any size with extension to chest wall or skin Regional nodes N - N0 - none, N1, movable ipsilateral axillary nodes, N2 fixed nodes or in apparent mam nodes, N3 infraclavicular node Distant metastasis M0 - none, M1 distant metastasis Stage 1 T1N0 Stage 2A T0N1, T1 N1, T2 N0 Stage 2B, T2 N1 T3 N0 Stage IIIA T0 -T2 (N2), T3, N1, N2 (stage I, and II are operable), Stage IIIB T4, any N (stage III is ocally advanced) stage IIIC Any T N3 = advanced Stage IV Any T Any N M1 - advance or metastatic

Medications - risk assessment

Review current medication use. Avoid category X drugs and most category D drugs unless potential maternal benefits outweigh fetal risks

6. Recall the structure of the bony pelvis

The pelvis is divided into the false pelvis above and the true pelvis below the linea terminalis (pelvic inlet. The false pelvis is bordered by the lumbar vertebrae posteriorly, an iliac fossa bilaterally, and the abdominal wall anteriorly. Its only obstetric function is to support the pregnant uterus. The true pelvis is a bony canal and is formed by the sacrum and coccyx posteriorly and by the ischium and pubis laterally and anteriorly. Its internal borders are solid and relatively immobile. The posterior wall is twice the length of the anterior wall. The true pelvis is the area of concern to the obstetrician because its dimensions are sometimes not adequate to permit passage of the fetus

4. Discuss the screening tests for GDM.

Screening for gestational diabetes is generally performed between 24 and 28 weeks of gestation with a 50-g 1-hour oral glucose challenge test(GCT), given without regard to last oral intake Screening is advised at the first prenatal visit in pregnant women with risk factors such as maternal age greater than 25 years, previous macrosomic infant, previous unexplained fetal demise, previous pregnancy with GDM, family history of diabetes, history of polycystic ovarian disease, and obesity. ). If the 1-hour screening (50-g oral glucose) plasma glucose exceeds 200 mg/dL, a glucose tolerance test is not required and may dangerously elevate blood glucose values. . If the first-trimester screen is negative, it should be repeated at 24 to 28 weeks. Glucose values above 130 to 140 mg/dL on a GCT are considered abnormal and have an 80% to 90% sensitivity in detecting GDM. An abnormal screening GCT is followed with a diagnostic 3-hour 100-g oral glucose tolerance test. This involves checking the fasting blood glucose after an overnight fast, drinking a 100-g glucose drink, and checking glucose levels hourly for 3 hours. If there are two or more abnormal values on the 3-hour GTT, the patient is diagnosed with GDM Three hour oral glucose tolerance test fasting is 95, 1 hr is 180, 2 hr is 155, 3 hr is 140

Spinal vs. Epidural anesthesia

Spinal advantages - faster, easier, more reliable, defined end point, minimal chance of patchy block, denser block, lower drug exposure for mom and fetus, no chance of systemic toxicity Epidural advantages - lower chance of postdural headache, slower onset, beneficial in pts with cardiac and HTN disorder, faster offset, discharge to room sooner Spinal disadvatnages -post dural headache Epidural - higher risk for systemic toxicity due to accidental intravenous injection, risk for patchy block

Explain the staging and management

Staging - Stage I confined to testes - Stage II Includes infradiaphragmatic nodal metastases - Stage III spread beyond retroperitoneal nodes - ~85% of nonseminomas are associated with an increased -hCG or -fetoprotein value. ~10% of seminomas are associated with an increased -hCG level. The -fetoprotein value is never increased in pure seminoma; if it is increased, the tumor is nonseminoma & should be treated as such - Radial inguinal orchiectomy is the definitive procedure for both pathologic diagnosis & local control after orchiectomy - management depends on type, Stage one seminoma XRT, non seminoma observe Stage II seminoma XRT, non seminoma chemo Stage III seminoma and non is chemo

List the incidence of GDM

The prevalence of diabetes mellitus has greatly increased in the last 20 years. Reports show a rate of 3% to 8% of gestational diabetes mellitus (GDM).

pelvic inlet diameters

The true conjugate (anatomic conjugate) is the anatomic diameter and extends from the middle of the sacral promontory to the superior surface of the pubic symphysis . The obstetric conjugate represents the actual space available to the fetus and extends from the middle of the sacral promontory to the closest point on the convex posterior surface of the symphysis pubis.

14. Discuss the management of superficial thrombophlebitis, DVT and PE

Superficial thrombophlebitis does not lead to pulmonary embolization. Bed rest, pain medications, and local application of heat are often sufficient treatment. There is no need for anticoagulants, but antiinflammatory agents may be considered. When symptoms disappear, patients may gradually begin to ambulate. They should be instructed to wear support hose to help avoid a repeat episode DEEP VENOUS THROMBOSIS When a clinical diagnosis of DVT is made, anticoagulant therapy should be started pending the results of a diagnostic workup unfractionated heparin or subcutaneous low-molecular-weight heparin (enoxaparin sodium) to achieve full anticoagulation. Intravenous anticoagulation should be maintained for at least 5 to 7 days, after which treatment is converted to subcutaneous heparin, which must be continued for the duration of pregnancy and up to 6 weeks postpartum with weekly monitoring of the aPTT Both forms of heparin may be associated with thrombocytopenia and osteoporosis. Supplemental calcium and vitamin D are advised along with periodic platelet counts. Warfarin is a vitamin K antagonist, which crosses the placenta, carries the risks for fetal hemorrhage and teratogenesis and, with few exceptions, should only be used in the postpartum period pulmonary embolism - Tests to order include those for acquired (lupus anticoagulant, anticardiolipin antibody) and inherited thrombophilias (factor V Leiden mutation, protein C, protein S and antithrombin III deficiencies, and the prothrombin G20210A mutation). In pregnant patients with a history of a pulmonary embolus or DVT during a previous pregnancy, prophylactic doses of heparin or low-molecular-weight heparin are given during pregnancy and the immediate postpartum period. Minidose heparin (10,000 to 15,000 U/day) or enoxaparin sodium (40 mg once daily) provides sufficient prophylaxis for most patients, although some pregnant women may require full anticoagulation

Discuss the diagnosis and Tx of leiomyomas

The bladder should be emptied before examination to avoid the confusion of urinary retention. • Very large fibroids can be palpated abdominally on bimanual pelvic examination a firm, irregularly enlarged uterus with smoothly rounded or bosselated protrusions may be felt if the tumors are subserosal or intramural • In general, the myomatous masses are in the midline, but sometimes a large portion of the tumor lies in the lateral aspect of the pelvis and may be indistinguishable from an adnexal mass. If the mass moves with the cervix, it is suggestive of a leiomyoma Treatment - • A small, asymptomatic fibroid does not need treatment. Unless the gibroid uterus is excessively large (>12 week gestational size) or is implicated as a cause of infertility in a woman seeking pregnancy, the first line treatment is targeted to her symptoms. • Heavy or prolonged menstruation caused by fibroids may be managed hormonally in many cases. • First therapeutic options are: o Progestin-only therapies oral or injected medroxyprogesterone acetate, progestin-only oral contraceptive pills, or levonorgestrel-releasing intrauterine devices GnRH limited to treatments such as endometrial ablation, hysterectomy GnRH agonists with lose dose progestins or estrogen/progestin comboniations minimizes hypoestrogenism. mifeprostone - antiprogesterone antagonist Surgery options - if desired fertility, get myomectomy/uterine artery embolization (for a limited number of leiomyomas) if deserived uterine preservation or poor surgical risk - endometrial ablation or UAE Hysterectomy - only definitive therapy rapidly growing uterus - exploratory laparotomy, abdominal hysterectomy • For women who desire uterine preservation and possible future fertility, uterine artery embolization (UAE) may be an option when a few small to moderate-sized tumors are present. UAE is a procedure performed under conscious sedation in which microspheres or small coils are introduced into the uterine artery by a transcutaneous femoral approach. These coils and particles occlude the artery feeding the fibroid, leading to necrosis of the fibroid. Fibroids often shrink 40% to 60% in size, and bleeding is reduced. After UAE is performed, pregnancy is still possible but is higher risk. • Hysterectomy provides definitive therapy. About 200,000 hysterectomies are done annually in the United States to treat fibroids. If the uterus is large or bulky, laparotomy is generally the preferred approach

7. List the criteria required for a diagnosis of chronic hypertension

The diagnosis of chronic hypertension requires at least one of the following: known hypertension before pregnancy, development of hypertension before 20 weeks' gestation, or, in cases in which hypertension is first noted during pregnancy, persistence of elevated blood pressures greater than 12 weeks' postpartum

9. Define gestational hypertension

The diagnosis of gestational hypertension is made if hypertension without proteinuria first appears after 20 weeks' gestation or within 48 to 72 hours after delivery and resolves by 12 weeks postpartum The diagnosis of gestational hypertension can only be made in retrospect, if the pregnancy has been completed without the development of proteinuria and if the blood pressure has returned to normal before the 12th week postpartum

20. Discuss the diagnosis of Rubella

The diagnosis of rubella is best made by serologic testing The diagnosis can be made by the presence of a fourfold rise in the hemagglutination-inhibiting (HAI) antibody titer in paired sera obtained 2 weeks apart or by the presence of IgM a. Between 10-15% of adult women are susceptible to rubella. In a review of all cases of infants with congenital rubella syndrome (CRS) reported, 83% were born to Hispanic mothers and 91% were born to foreign-born mothers. b. The disease course is unaltered by pregnancy, and the mother may or may not exhibit the full clinical disease. The severity of the mother's illness does not have an impact on the risk for fetal infection. Rather it is the trimester in which the infection occurs that has the greatest impact on fetal risk. i. Infection I the first trimester carries up to 80% risk for development of CRS, where s the risk for CRS drops to 30-50% later in pregnancy. CRS rarely occurs after 20 weeks of gestation. c. The components of CRS include the following: i. Symmetrical IUGR; Congenital deafness (Detected after age 1); Cardic malformations; Patent ductus areteriosus; Pulmonary artery hypoplasia; Eye lesions; Cataracts; Retinopathy; Microphthalmia; Hepatosplenomegaly; CNS involvement; Microcephaly; Panencephalitis; Brain calcifications; Psychomotor retardation; Hepatitis; Thrombocytopenic purpura Routine rubella susceptibility testing should be performed in all pregnant women with a single IgG level. Those who are nonimmune should be vaccinated in the immediate postpartum period. It is recommended that women not become pregnant for at least 3 months after vaccination. Women should be screened for rubella susceptibility at each pregnancy because immunity can wane. Rubella is not a contraindication to breastfeeding. There is no specific treatment for rubella.

3. Describe the criteria for the diagnosis of preeclampsia.

The following two criteria are essential for the diagnosis of preeclampsia: (1) the development of hypertension (systolic blood pressure ≥ 140 mm Hg or diastolic blood pressure ≥ 90 mm Hg), in a woman whose blood pressures were previously normal, after the 20th week of pregnancy; (2) the development of new-onset proteinuria after the 20th week of gestation. Proteinuria is defined as more than or equal to 0.3 g protein in a timed 24-hour urine collection

2. Recall the structure of the fetal skull

The lambdoid suture extends from the posterior fontanelle laterally and serves to separate the occipital from the parietal bones. The coronal suture extends from the anterior fontanelle laterally and serves to separate the parietal and frontal bones. The frontal suture lies between the frontal bones and extends from the anterior fontanelle to the glabella (the prominence between the eyebrows). The posterior fontanelle closes at 6 to 8 weeks of life, whereas the anterior fontanelle does not become ossified until about 18 months The anterior fontanelle (bregma) is found at the intersection of the sagittal, frontal, and coronal sutures. It is diamond shaped and measures about 2 × 3 cm, and it is much larger than the posterior fontanelle. The posterior fontanelle is Y- or T-shaped and is found at the junction of the sagittal and lambdoid sutures

16. List the most common chromosomal abnormalities among LIVE infants. What happens to the incidence of these with increased maternal age

The most common chromosomal abnormalities among liveborn infants are sex chromosomal aneuploidy (e.g., Turner syndrome [45 XO], Klinefelter syndrome [47 XXY]), balanced Robertsonian translocations (translocations within group D or between groups D and G), and autosomal trisomies (e.g., Down syndrome) In women 35 to 39 years of age, the rate is about 1 in 125; in those 40 to 45, it is about 1 in 20 The overall risk for Down syndrome (trisomy 21) is 1 per 800 live births

27. Describe the "kick count" method of assessing fetal well-being

The mother assesses fetal movement (kick counts) each evening on her left side. She should recognize 10 movements in 1 hour, and if she does not, she should retest in 1 hour

List the incidence of hyperemesis gravidarum

The overall incidence is about 1%. The disorder appears more frequently with first pregnancies, multiple pregnancies, and those with trophoblastic Significant abdominal pain and tenderness are generally absent

7. Discuss the management of hyperemesis gravidarum

Treatment is symptomatic, but if outpatient management fails, patients must be admitted for intravenous administration of fluids, electrolytes, glucose, vitamins, and medical therapy. Vitamin B6 (pyridoxine), doxylamine, antihistamines, antiemetics of the phenothiazine class, and promotility agents (e.g., metoclopramide), and droperidol are used

32. Describe congenital syphilis.

Transmission rates for primary and secondary disease are between 50% and 80% b. Components of early congenital syphilitic infection include nonimmune hydrops, hepatosplenomegaly, profound anemia and thrombocytopenia, skin lesions, rash, osteitis and periostitis, pneumonia, and hepatitis. The perinatal mortality rate from congenital syphilis is roughly 50%. c. Late congenital syphilis (diagnosed after 2 years of age) is a multisystem disease characterized by dental abnormalities (Hutchinson's teeth, mulberry molars); saber shins; saddle nose deformity; interstitial keratitis; eighth nerve deafness; and failure to thrive

2. Explain current treatment and the methods available for prevention

Treatment - Treatment for carcinoma in situ of the cervix is usually total hysterectomy - For patients with higher-end disease, a combo of chemotherapy (cisplatin-based) & radiation therapy is recommended. A recently approved vaccine (Gardasil) can provide protection against the 4 most common strains of the virus & has shown efficacy in decreasing the risk of cervical cancer.

9. List the etiologies and risk factors associated with PROM

including vaginal and cervical infections, abnormal membrane physiology, incompetent cervix, and nutritional deficiencies

episiotomy

When necessary, an incision in the perineum (episiotomy) may aid in reducing perineal resistance, although current management is to allow the fetus to deliver without an episiotomy. The head is born by rapid extension as the occiput, sinciput, nose, mouth, and chin pass over the perineum.

4. List and describe the non-infectious conditions associated with vulvar pruritis (18-1).

Women with psoriasis may complain of vulvar pruritus and burning with minimal or no apparent lesions in the vulvar area. b. Chronic, Noninfectious conditions ssociated with Vulvar Pruritus: i. Dermatosis: 1. Atopic and contact dermatitis; lischen sclerosus, lichen planus; lichen simplex chronicus; psoriasis; genital atrophy ii. Neoplasia: 1. Vulvar intraepithelial neoplasia, vulvar cancer 2. Paget's Disease iii. Vulvar manifestations of Sysemic disease 1. Crohn disease

Cervical effacement

o Before the onset of parturition, the cervix is frequently noted to soften as a result of increased water content and collagen lysis. Simultaneous effacement, or thinning of the cervix, occurs as it is taken up into the lower uterine segment (Figure 8-8B). Consequently, patients often present in early labor with a cervix that is already partially effaced. As a result of cervical effacement, the mucous plug within the cervical canal may be released. The onset of labor may thus be heralded by the passage of a small amount of blood-tinged mucus from the vagina ("bloody show").

6. Define breech presentation and list the incidence

a. Breech presentation occurs when the fetal buttocks or lower extremities present into the maternal pelvis. b.The incidence of breech presentation is 4% of all deliveries.

False labor

o During the last 4 to 8 weeks of pregnancy, the uterus undergoes irregular contractions that normally are painless In the last month of pregnancy, these contractions may occur more frequently, sometimes every 10 to 20 minutes, and with greater intensity. These Braxton Hicks contractions are considered false labor in that they are not associated with progressive cervical dilation or effacement

22. Discuss congenital CMV infections and the impact on pregnancy.

a. CMV is the most common congenital viral infection in the US b. CMV may be transmitted transplancentally, or at delivery by direct contact c. Fetal infection can occur when the mother does not exhibit symptoms. There is a 40-50% maternal-infant transmission rate d. About 10-15% of infected infants are symptomatic at birth, exhibiting nonimmune hydrops, symmetrical IUGR, chorioretinitis, microcephaly, cerebral calcifications, hepatosplenomegaly, and hydrocephaly. e. About 80-90% are asymptomatic at birth but may later exhibit mental retardation, visual impairment, progressive hearing loss, and delayed psychomotor development. f. Sensorineural hearing loss is the most frequent sequel of congenital CMV infection. h. Patients with a confirmed primary infection should have a detailed ultrasonic examination. Ultrasonic findings include fetal growth restriction, hydrocephaly, intracranial calcifications, microcephaly, echogenic bowel, hepatosplenomegaly, and nonimmune hydrops. i. If the ultrasound is normal, an amniocentesis should be performed to test for CMV by PCR. j. If the ultrasound shows signs of fetal anomalies, or the PCR test is positive, patients should be advised of options. k. Recently, hyperimmune anti-CMV globulin has been shown to be effective and can be offered. Ganciclovir has also been used in pregnancy with resolution of fetal CMV infection. The patient should also be advised of the option of termination

4. Define cephalopelvic disproportion (CPD).

a. Cephalopelvic disproportion (CPD) exists if the maternal bony pelvis is not of sufficient size and of appropriate shape to allow the passage of the fetal head. This problem may occur as a result of contraction of one of the planes of the pelvis. Relative CPD may exist with a normal pelvis, if the fetal head is excessively large or if it is in an abnormal position. Contraction of the maternal pelvis may occur at the level of the inlet or midpelvis, but contraction of the outlet is extremely unusual unless it is found in association with a midpelvic contraction The finding of an unengaged head in a nulliparous patient at the start of labor indicates an increased likelihood of CPD at the pelvic inlet, but an unengaged fetal head in a multiparous patient in labor is not an unusual occurrence Relative CPD can occur in the multiparous patient (the "multip trap"), however, and should be kept in mind. The occurrence of CPD at the level of the midpelvis occurs more frequently than inlet dystocia because the capacity of the midpelvis is smaller than that of the inlet and also because deflection or positional abnormalities of the fetal head are more likely to occur at that level.

6. Discuss the diagnosis and treatment of lichen sclerosis.

a. Diagnosis is important because this is a chronic, progressive disease with the potential to constrict and destroy the normal genital architecture. When untreated, there is the possibility of progression to vulvar intraepithelial neoplasia (VIN), differential type. In the long term, the labia minora are lost, the labia majora flatten, the introitus becomes severely constricted, and the clitoris becomes inverted and trapped. b. Treatment of lichen sclerosis involves the use of potent topical steroids such as 0.05% clobetasol.

10. Describe the diagnosis of PROM.

a. Diagnosis of PROM is based on the history of vaginal loss of fluid and confirmation of amniotic fluid in the vagina. Episodic urinary incontinence, leukorrhea, or loss of the mucous plug must be ruled out Because of the risk for introducing infection and the usually long latency period from the time of examination until delivery, the examiner's hands should not be inserted into the vagina of a patient who is not in labor, whether preterm or term Confirmation of the diagnosis can be made by (1) testing the fluid with Nitrazine paper, which will turn blue in the presence of the alkaline amniotic fluid, and (2) placing a sample on a microscopic slide, air drying, and examining for ferning

1. Define female psedohermaphrodism

a. Female pseudohermaphroditism is caused by masculinization occurring in utero, the infant presenting with ambiguous genitalia. Masculinization of the genetically female fetus occurs secondary to the endogenous hormonal milieu, as in congenital adrenal hyperplasia, or as a result of exogenous hormonal ingestion by the mother. Androgen-producing tumors of the ovary or adrenal gland, although rare, also cause this problem. Enlargement of the clitoris is the most conspicuous abnormality.

1. List the risk factors and screening guidelines for prostate cancer

o Older age, race (African American), family history (first-degree relative), & possibly dietary fat - The American Cancer Society recommends a digital rectal exam in men 40 years or older & determination of the prostate-specific antigen (PSA) value in men 50 years or older

Plane of greatest diameter

o The plane of greatest diameter is the largest part of the pelvic cavity. It is bordered by the posterior midpoint of the pubis anteriorly, the upper part of the obturator foramina laterally, and the junction of the 2nd and 3rd sacral vertebrae posteriorly. The fetal head rotates to the anterior position in this plane.

Pelvic planes - pelvic inlet

o The plane of the inlet is bordered by the pubic crest anteriorly, the iliopectineal line of the innominate bones laterally, and the promontory of the sacrum posteriorly. The fetal head enters the pelvis through this plane in the transverse position.

Ritgen maneuver

o To facilitate delivery of the fetal head, a Ritgen maneuver may be performed (Figure 8-11). The right hand, draped with a towel, exerts upward pressure through the distended perineal body, first to the supraorbital ridges and then to the chin. This upward pressure, which increases extension of the head and prevents it from slipping back between contractions, is counteracted by downward pressure on the occiput with the left hand. A recent (2008) randomized trial from Sweden found simple manual perineal support to be equally effective

1. Discuss the etiology and classification of twinning

a. Multiple gestation occurs as the result of either the splitting of an embryo (i.e., identical or monozygotic twinning) or the fertilization of two or more eggs produced in a single menstrual cycle (i.e., fraternal or dizygotic twinning). b. Because dizygotic twins arise from separate eggs, they are structurally distinct pregnancies coexisting in a single uterus, each with its own amnion, chorion, and placenta. c. Monozygotic twins arise from cleavage of a single fertilized egg at various stages during embryogenesis, and thus the arrangement of the fetal membranes and placentas will depend on the time at which the embryo divides (Table 13-1). d. The earlier the embryo splits, the more separate the membranes and placentas will be. i. If division occurs within the first 72 hours of fertilization, the membranes will be dichorionic, diamniotic with a thick, four-layered intervening membrane. ii. If division occurs after 4 to 8 days of development, when the chorion has already formed, monochorionic, diamniotic twins will evolve with a thin, two-layer septum. iii. If splitting occurs after 8 days, when both amnion and chorion have already formed, the result will be monochorionic, monoamniotic twins residing in a single sac with no septum. Most are monochorionic diamniotic

1. Recognize the different variations of uterine development.

a. The upper vagina, cervix, uterine corpus, and fallopian tubes are formed from the paramesonephric (müllerian) ducts. The absence of a Y chromosome and the resultant absence of müllerian inhibiting substance lead to the development of the paramesonephric system, with the regression of the mesonephric system. The paramesonephric ducts first arise at 6 weeks' gestation lateral to the cranial pole of the mesonephric duct and expand caudally. By 9 to 10 weeks, they fuse in the midline at the urogenital septum to form the uterovaginal primordium. Later, dissolution of the septum between the fused paramesonephric ducts leads to the development of a single uterus and cervix. b. The most common anomalies of the uterus result from either incomplete fusion of the paramesonephric ducts, incomplete dissolution of the midline fusion of those ducts, or formation failures Failure of fusion is most evident in uterus didelphys, which presents with two separate uterine bodies, each with its own cervix and attached fallopian tube and vagina. A bicornuate uterus with a rudimentary horn also represents a fusion failure. Less complete fusion failure is seen in the bicornuate uterus with or without double cervices. Incomplete dissolution of the midline fusion of the paramesonephrica explains the septate uterus. Failure of formation can be seen in the unicornuate uterus. In müllerian agenesis, there is complete lack of development of the paramesonephric system. The affected woman generally has incomplete development of the fallopian tubes associated with the absence of the uterus and most of the vagina. All these conditions occur in normal karyotypic and phenotypic females but can be associated with important anomalies of the urinary system such as a horseshoe or pelvic kidney. c. The most common congenital cervical anomalies are the result of malfusion of the paramesonephric (müllerian) ducts with varying degrees of separation, as seen in the didelphys cervix or septate cervix. Women with fusion anomalies may present with menstrual blood trapped in a noncommunicating uterine horn or vagina. A DES-exposed female infant has an increased risk for a small, T-shaped endometrial cavity or cervical collar deformity. DES exposure in utero can also produce fallopian tube abnormalities, although it does not appear to cause abnormalities of the urinary tract.

7. Discuss the physiologic events that prepare a woman for labor. Include, lightening, false labor and cervical effacement - lightening

o Two or more weeks before labor, the fetal head in most primigravid women settles into the brim of the pelvis. In multigravida, this often does not occur until early in labor. Lightening may be noted by the mother as a flattening of the upper abdomen and an increased prominence of the lower abdomen

vaginismus

b. Vaginismus is an involuntary contraction of the vaginal introital and levator ani muscles. Vaginismus may preclude, or render very painful, vaginal penetration during coitus, pelvic examination, or tampon use. Often a history of sexual abuse or phobias about vaginal trauma is associated with vaginismus

30. Compare and contrast early and late congenital GBS.

b.Late Onset GBS infection has been linked to a nosocomial source in the nursery, occurs after the first week of life (mean onset, 4 weeks), and usually is exhibited as meningitis (80%) or another type of focal infection c.Early Onset GBS infection is characterized by its rapid onset and fulminant course, with presentation typically within the first 48 hours of life. ii. he infant presents with respiratory distress and pneumonia, and 30% of infants develop meningitis. Septicemia, shock, and death may result even when antibiotics are begin expediently. iii. The overall infant mortality rate from early-onset disease is 50%. Preterm infants account form more than 90% of deaths. The risk for sepsis developing in a full-term infant with bacterial colonization is 1-2% compared with 8-10% in the preterm infant.

Management

induction of labor - i. Justifications for such intervention include the emotional burden on the patient associated with carrying a dead fetus, the slight possibility of chorioamnionitis, and the 10% risk for disseminated intravascular coagulation when a dead fetus is retained for more than 5 weeks in the second or third trimester. ii. Vaginal suppositories of prostaglandin E2 (dinoprostone [Prostin E2]) can be used from the 12th to the 28th week of gestation. There have been reported cases of uterine rupture and cervical lacerations, . Dinoprostone use in this range is contraindicated in patients with prior uterine incisions (e.g., cesarean, myomectomy) because of the unacceptable risk for uterine rupture. 1. Furthermore, prostaglandins are contraindicated in patients with a history of bronchial asthma or active pulmonary disease, although the E series drugs act primarily as bronchodilators. 2. Misoprostol (Cytotec, a synthetic prostaglandin E1 analogue) vaginal tablets have been found to be quite effective with little or no gastrointestinal side effects, and they are less expensive than dinoprostone. c. After 28 weeks' gestation, if the condition of the cervix is favorable for induction and there are no contraindications, misoprostol followed by oxytocin is the treatment of choice i. Regardless of the mode of therapy chosen, weekly fibrinogen levels should be monitored during the period of expectant management, along with a hematocrit and platelet count. If the fibrinogen level is decreasing, even a "normal" fibrinogen level of 300 mg/dL may be an early sign of consumptive coagulopathy in cases of fetal demise. An elevated prothrombin and partial thromboplastin time, the presence of fibrinogen-fibrin degradation products, and a decreased platelet count may clarify the diagnosis. ii. If laboratory evidence of mild disseminated intravascular coagulation is noted in the absence of bleeding, delivery by the most appropriate means is recommended. If the clotting defect is more severe or if there is evidence of bleeding, blood volume support or use of component therapy (fresh-frozen plasma) should be given before intervention.

15. Discuss the diagnosis and management of IUGR

c. Serial uterine fundal height measurements should serve as the primary screening tool for IUGR. A more thorough sonographic assessment should be undertaken when (1) the fundal height lags more than 3 cm behind a well-established gestational age or (2) the mother has a high-risk condition such as preexisting hypertension; chronic renal disease; advanced diabetes with vascular involvement; preeclampsia d. Recently, interest has focused on the prediction of patients at risk for IUGR at mid-pregnancy. Patients with abnormal triple screens (alpha-fetoprotein, human chorionic gonadotropin [hCG], and estriol [E3]) who do not have abnormal fetuses by ultrasound and amniocentesis may be at risk for IUGR. In addition, elevations of umbilical artery and uterine artery Doppler assessments (increased resistance) as early as mid-pregnancy are associated with a greater risk for IUGR as pregnancy progresses the abdominal circumference is the single most effective parameter for predicting fetal weight because it is reduced in both symmetrical and asymmetrical IUGR. f. During advancing gestation, the head circumference remains greater than the abdominal circumference until about 34 weeks, at which point the ratio approaches 1 (Figure 12-2). After 34 weeks, the normal pregnancy is associated with an abdominal circumference that is greater than the head circumference. When asymmetrical growth restriction occurs, usually in the third trimester, the BPD is essentially normal, whereas the ratio of head to abdominal circumference is abnormal. With symmetrical growth restriction, the head-to-abdominal circumference ratio may be normal, but the absolute growth rate is decreased, and estimated fetal weight is reduced. g.From 50% to 90% of infants with manifestations of IUGR at birth can be identified with serial prenatal ultrasonography

Define macrosomia.

fetus weighing 4500 g or more Because the risk for shoulder dystocia and possible fetal injury increases significantly as the upper extremes of fetal weight are reached, however, ACOG recommends cesarean delivery for an estimated fetal weight of 5000 g or more in women without diabetes, and 4500 g or more in women with diabetes Maternal morbidity associated with macrosomia includes labor dystocia, shoulder dystocia, and genital trauma, with a corresponding increase in the cesarean delivery rate. There is also an increase in postpartum hemorrhage and puerperal infection

16. Describe the pregnancy and labor management for breeches. In the description include the external cephalic version and for labor management, vaginal delivery, assisted breech delivery and c-section.

vaginal delivery - Until the publication of randomized trials demonstrating that vaginal breech delivery is associated with increased perinatal mortality compared with planned cesarean birth, vaginal breech deliveries were performed in selected centers in patients who met strict criteria. These criteria are summarized in Box 13-4.The standard of care now in most practices is to deliver all breeches by cesarean birth to avoid the potential morbidities of umbilical cord prolapse, head entrapment, birth asphyxia, and birth trauma. Assisted breech delivery - Because the breech presentation can present in a setting in which cesarean birth is impossible or unsafe, vaginal delivery of the breech continues to be an important practitioner skill. Once the fetus has delivered spontaneously to the umbilicus gentle downward traction is exerted until the scapulae appear at the introitus After delivery of the scapulae, the shoulders are delivered by sweeping each arm in turn across the fetal chest until only the fetal head remains undelivered). Once the shoulders have been delivered, the head is delivered by manual flexion of the fetal head with one hand flexing the head at the base of the skull while the operator's other hand is applied to the fetal maxilla for downward flexion Some obstetricians use Piper forceps routinely because this method has been shown to result in delivery of the head with the least amount of trauma to the fetus Cesarean delivery - During the process of breech vaginal delivery, successively larger parts of the fetus deliver, with the largest part, the fetal head, delivering last. In the very premature infant whose abdomen is much smaller than the head, the lower extremities, abdomen, and trunk may deliver through an incompletely dilated cervix, leaving the fetal head trapped and leading to fetal asphyxia and birth trauma. Premature breech fetuses are thus preferentially delivered by cesarean birth because of the head-abdominal size disparity. Cesarean delivery is currently preferred for both preterm and term breech infants, although significant trauma can still occur if care is not taken with delivery of the arms and head.

8. Discuss the repair of vesicovaginal and ureterovaginal fistulas

vesicovaginal fistula - • The vaginal approach (Latzko's operation) is the procedure of choice. A bulbocavernosus muscle flap or fat pad (Martius graft) may be interposed between the bladder and vagina to provide support, vascularity, and strength to the suture line, ureterovaginal fistula - Small fistulas usually close spontaneously after placement of a ureteric stent (double J), • If the fistula is close to the ureterovesical junction, the ureter proximal to the fistula can be reimplanted into the bladder (ureteroneocystostomy). If the fistula is several centimeters from the bladder, a Boari flap may be useful, a segment of ileum may be interposed between the proximal ureter and the bladder, or rarely a transureteroneoureterostomy, may be employed.

6. Discuss the symptoms and treatment of adenomyosis

• Although many women are asymptomatic, those who suffer from this condition typically complain of severe secondary dysmenorrhea and menorrhagia. Conservative management with NSAIDs and hormonal control of the endometrium are mainstays of therapy. Combination oral contraceptives or hormone-containing patches and vaginal rings may be used to reduce cyclic blood loss and menstrual pain

8. Discuss the surgical management of EP

• Laparotomy is the preferred surgical approach for women who are hemodynamically unstable because rapid access to the bleeding site is critical. o Laparotomy is also appropriate whenever it is anticipated that laparoscopy would not be successful, such as when the patient has significant intraperitoneal adhesions from prior surgeries, infection, or endometriosis. • For hemodynamically stable patients, laparoscopy is the preferred surgical approach because patients require fewer days of postoperative hospitalization, suffer less postoperative pain, and recover more quickly. o Laparoscopy also offers the potential to reduce overall treatment costs. If it is determined intraoperatively that laparoscopy is not possible, the surgery can always be converted to laparotomy. • Salpingectomy (removal of the entire fallopian tube) is recommended when there has been significant damage to the tube, when removal of the damaged elements would leave less than 6 cm of functional tube, or when a patient who previously has been sterilized verifies that she still does not desire future fertility. • Partial salpingectomy (removal of a portion of the tube) is generally done only if the ectopic pregnancy is implanted in the ampullary portion • Salpingotomy and salpingostomy are both procedures in which the ectopic pregnancy site is identified and vasoconstrictive agents are injected beneath the implantation prior to an incision. With salpingotomy, the incision is closed, where as it is left open in salpingostomy. An incision is made parallel to the axis of the tube along its antimesenteric border over the site of implantation. The products of conception are removed by gentle dissection or hydrodissection. Bleeding is controlled by judicious use of electrocoagulating instruments. The tube and pelvis are copiously irrigated. Most studies have shown that salpingostomy (incision is left open) results in better long-term tubal function. • There is a 10% to 20% risk of residual trophoblastic tissue whenever the products of conception are separated from the tube (i.e., when salpingostomy or salpingotomy are performed). Women who do not have resection of the affected tubal areas should have repeat hCG titers 3 to 7 days postoperatively to confirm that no hormone-producing cells remain behind to reinvade the tube. If repeat hCG titers fail to decline appropriately, methotrexate (MTX) therapy can be started o . If there is any concern about significant tubal damage or a high likelihood of retained products of conception, salpingectomy should be performed.

Possible

• Lower abdominal pain is present in most cases. Amenorrhea or a history of an abnormal last menstrual period is obtained in 75% to 90% of ectopic pregnancies. Abnormal vaginal bleeding is seen in over half the patients, ranging from spotting to the equivalent of a normal menstrual period. This spotting or bleeding results from an abnormally low production of hCG by the ectopic trophoblastic tissue. Distinguishing patients with ectopic pregnancy from those with an early threatened abortion or a spontaneous abortion can be challenging. On ultrasound, there is a thickened endometrial stripe, while histologically, there is almost always a localized hyperplasia of the uterine lining (Arias-Stella reaction), due to hCG stimulation. There may be a small amount of fluid in the cul-de-sac representing some slight intraperitoneal hemorrhage.

5. Define overactive bladder and urge incontinence

• Overactive bladder (OAB) is associated with detrusor muscle instability, is a more descriptive symptom-based term and more accurately encompasses the common clinical presentation. OAB is defined as "urgency, with or without urge incontinence, usually with frequency and noturia." OAB has become the preferred term because it comprises symptoms of urgency, urge urinary incontinence, frequency, and nocturia. • Urge urinary incontinence (UUI) is defined as the involuntary leakage of urine accompanied by or immediately preceded by urgency. UUI can be associated with small losses of urine between normal micturitions or large volume losses with complete bladder emptying. • These two terms are often used interchangeably to describe a problem with bladder control that is associated with a strong desire to pass urine with a decreased ability to control it.

7. State the incidence of urinary fistulas in the US and the most common causes

• Pelvic surgery, irradiation or both now account for 95% of vesicovaginal fistulas in the US. More than 50% occur after simple abdominal or vaginal hysterectomy.

6. Describe the 5 parameters that can also cause endometrial hyperplasia with unopposed estrogen stimulation. (246)

• Polycystic ovary syndrome • Estrogen producing tumors such as granulosa-theca cell tumors • Obesity because of peripheral conversion of androgen to estrogen in adipose cells • Prolonged use of exogenous estrogens without progestins • Use of tamoxifen

Management

• Prophylactic measures to mitigate the symptoms of POP include identifying and treating chronic respiratory and metabolic disorders, correction of constipation and intraabdominal disorders that may cause repetitive increases in intraabdominal pressure, and administration of estrogen to menopausal women. Failure to recognize and treat significant support defects at the time of concomitant gynecologic surgery may lead to progression of existing prolapse and the development of urinary incontinence or retention and urinary tract infections (UTIs). • When only a mild degree of pelvic relaxation is present, pelvic floor muscle exercises may improve the tone of the pelvic floor musculature. Pessaries, which provide intravaginal support, may be used to correct prolapse by "propping up" the vagina. They can be considered when the patient is medically unfit or refuses surgery or during pregnancy and the postpartum period. Repair of vaginal prolapse - • Anterior colporrhaphy corrects anterior vaginal wall prolapse and helps support the urethra. It involves plication of the pubocervical fascia to support the bladder and urethra. • When the anterior prolapse involves a direct detachment of lateral vaginal support, it is considered a paravaginal defect. Paravaginal defect repairs involve exposure of the retropubic space. Interrupted permanent sutures are used to reattach bilaterally the anterosuperior vaginal sulci to the arcus tendineus fasciae ("white line") extending from the ischial spine to the lower edge of the pubic ramus • Posterior colporrhaphy corrects a posterior vaginal wall prolapse and is similar in principle to anterior colporrhaphy. Repair of Apical prolapse - The repair of apical defects may require peritoneal entry for the repair of an enterocele. After identification of the enterocele, the contents are reduced, the neck of the peritoneal sac is ligated, and the defect is repaired by approximating the uterosacral ligaments and levator ani muscles to restore continuity in the endopelvic fascia. • For women with advanced vaginal prolapse who no longer desire coital function, there are less invasive surgical options. A LeFort colpocleisis involves suturing the partially denuded anterior and posterior vaginal walls together in such a way that the uterus remains in situ and is supported above the partially occluded vagina. In women with posthysterectomy prolapse, a complete colpocleisis involves total obliteration of the vagina. These "obliterative" procedures are traditionally reserved for elderly women who are not likely to tolerate more invasive reparative surgery.

6. Discuss the behavioral and pharmacologic treatment for overactive bladder

• Reducing fluid intake and avoiding liquids during the evening hours are good initial behavior changes. Gradually increasing the intervals between voidings and doing pelvic floor muscle strengthening exercises, such as Kegel exercises, are effective for attaining better bladder control. • Antimuscarinics or anticholinergics have become the mainstays of drug treatment of OAB. • The mainstays of drug therapy include oxybutynin choloride and tolterodine. Oxybutrynin chloride has been shown to improve symptoms of urgency in about 70% of patients. Tolterodine also has anticholinergic activity. Because of its bladder specificity, tolterodine has a more favorable side-effect profile than oxybutynin. • Trospium chloride, solifenacin and darifenacin are newer agents

3. Describe the triad of symptoms associated with endometriosis

• The characteristic triad of symptoms associated with endometriosis is dysmenorrhea, dyspareunia, and dyschezia Premenstrual and postmenstrual spotting is a characteristic symptom of endometriosis Early in the clinical course, women tend to have cyclic pelvic pain, which starts 1 to 2 days before the menstrual flow and resolves at the end of the menses

2. Discuss the 3 theories of the etiology of endometriosis

• The retrograde menstruation theory of Sampson proposes that endometrial fragments transported through the fallopian tubes at the time of menstruation implant and grow in various intraabdominal sites. Endometrial tissue, which is normally shed at the time of menstruation, is viable and capable of growth in vivo or in vitro. To explain some rare examples of endometriosis in distant sites, such as the lung, forehead, or axilla, it is necessary to postulate hematogenous spread. • The müllerian metaplasia theory of Meyer proposes that endometriosis results from the metaplastic transformation of peritoneal mesothelium into endometrium under the influence of certain, generally unidentified stimuli. • The lymphatic spread theory of Halban suggests that endometrial tissues are taken up into the lymphatics draining the uterus and are transported to the various pelvic sites where the tissue grows ectopically. Endometrial tissue has been found in pelvic lymphatics in up to 20% of patients with the disease

6.Differentiate between probable and possible EP's - Probable

• Women who present with lower pelvic pain and vaginal spotting or bleeding, with or without amenorrhea, can be rapidly tested for pregnancy. The differential diagnosis includes threatened abortion or ectopic pregnancy. The patient generally has other clinical signs, such as tenderness of the abdomen with adnexal or cervical motion tenderness. The diagnosis of ectopic pregnancy may be confirmed by the absence of intrauterine pregnancy (IUP) on ultrasound in a woman with a level of hCG sufficient to identify an IUP.

1. Define ectopic pregnancy (EP).

•An ectopic pregnancy is a gestation that implants outside the endometrial cavity

2. State the incidence of ectopic pregnancy

•An ectopic pregnancy is estimated to occur in 1 of every 80 spontaneously conceived pregnancies