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Unit 1 The Patient a. Pap smear and cultures i. Syphilis serologic testing by non-treponemal tests (VDRL or RPR) are nonspecific tests but treponemal antibody can confirm infection 1. Dark field microscopy 2. Macular rash on palms and soles copper penny lesions ii. High risk for cervical cancer do cervical biopsy 1. Tabacco use, poor screening history 2. Postmenopausal and postcoital bleeding 3. Fixation of uterus and thickening of rectovaginal septum and back pain = parametria involvement (stage II) possible extension into sidewall (stage III) iii. Trichonomiasis erythematous patches on cervix = strawberry cervicitis 1. Unicellular protozoans 2. Frothy, yellow-green vaginal discharge with a strong odor iv. Acute salpingitis (PID) = lower abdominal pain, adnexal tenderness, fever, cervical motion tenderness, and vaginal discharge v. HPV typing = initial triage after finding atypical swuamous cells of undetermined significance (ASCUS) on a pap smear. 1. If high risk is found do colposcopy with biopsy 2. Or you can do pap smear in 6 and 12 months and return to annual if those are negative 3. Need a biopsy confirmed diagnosis of cervical dysplasia before getting a cone biopsy, LEEP or cryotherapy vi. Pap smear screening is NOT needed in patient with hysterectomy unless it was done for cervical cancer or high grade cervical cancer precursor 1. Patients with uterus can stop cervical cancer screening between 65-70 if had 3 negative smears and no history of cervical cancer 2. Still need bimanual and ractovaginal exam yearly and mammogram annually 3. Colon cancer screening at age 50 4. Dowagers hump = exaggerated thoracic spine curvature -> likely from thoracic compression fractures secondary to osteoporosis vii. Classic primary herpes = painful genital ulcerations, fever, dysuria 1. If you have one STI do screening for the other STIs viii. Hyperthyroidism symptoms 1. TSH and pregnancy test

2. Thin, tachycardic, frequent irregular menses, temperature instability, anxiety, sleep problems ix. Screen for gonorrhea and chlamydia by DNA probes x. Herpes diagnosis gold standard is culture 1. Very early is best 2. Serum antibody screening = shows lifetime exposure 3. DNA studies with PCR can be done 4. Herpes cultures have a 10-20% false negative rate b. Legal issues and ethics i. Doctors did not violate ethics because they did not state patients name ii. Patient privacy is physicians responsibility so they can be fined iii. Informed consent needs to be obtained if patient is fully alert 1. Exception is emergency situations iv. Anencephalic infant cant survive it would be more harm than good to do a C-section = non-maleficence to the patient v. If person is still competent she can make her own choices regardless of who is power of attorney vi. Justice requires to treat all cases alike regardless whether or not a patient is able to afford treatment vii. Dont start a procedure without patient consent viii. Pharm companies can have conferences in which physicians get CME credit and participation is not based on use or advocacy of product 1. An investigator may own stock in a company if he/she does research for that company as long as they declare the conflict of interest ix. Power of attorney should make decisions based on what patient would have wanted for themselves regardless of best interests x. Patients wanting abortion should be counseled regardless of insurance status and no consent is needed from partner c. Preventative care and health management i. No family history of breast cancer = mammogram every 1-2 years from age 40-49 then every year starting at age 50 ii. Male condom = protects against STIs iii. Folate lower homocysteine levels 1. Fever nonfatal MIs and fatal coronary events and prevents neural tube defects 2. Women of reproductive age should take daily 400microgram supplement a. Important prior to pregnancy and during first 4 weeks of fetal development iv. Contraceptive methos with <1% pregnancy rates 1. Depo-provera, IUD, sterilization, implanon a. OCPs = 3% pregnancy rate

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b. Male condom = 12% pregnancy rate c. Contraceptive ring = 8% in a year d. Diaphragm with spermicide = 18% v. Pregnancy or possibility of pregnancy within 4 weeks is a contraindication to MMR and varicells vaccinations 1. You can use tetanus, hep B, polio, pneumococcal vaccinations vi. High risk for breast cancer do mammogram 1. As adjuvtive after mammo do ultrasound or MRI vii. Obese, acanthosis nigricans from insulin resistance = velvety, hyperpigmented skin usually on neck and underarms 1. Do a diabetes screen viii. Pap smear starting at 21 regardless of sex 1. Due to low incidence of cancer in younger women 2. Adverse effects from follow up on young women ix. Level of physical activity is inverse to death from coronary disease 1. Exercise is best first step for coronary heart disease especially if patients BMI is normal x. Osteoporosis risk factors = early menopause, glucocorticoid therapy, sedentary lifestyle, alcohol consumption, hyperthryroidism, hyperparathryroidism, anticonfulsant therapy, vitamin D deficiency, family history of early or severe osteoporosis, chronic liver or renal disease Unit 2 Obstetrics a. Maternal-Fetal Physiology i. Molar pregnancy 1. Chest x-ray would be next step because lungs are the most common site of metastasis 2. Repeat beta-hcg is done weekly for post-op value ii. Physiologic dyspnea of pregnancy 1. 75% of women by 3rd trimester 2. peripartum cardiomyopathy = idiopathic, heart failure secondary to left ventricular systolic dysfunction towards the end of pregnancy or several months after delivery a. fatigue, SOB, palpitations, edema iii. Resp rate does NOT change during pregnancy 1. TV is increased which increase minute ventilation causing respiratory alkalosis 2. Diaphragmatic excirsion is increased during pregnancy and not limited by enlarging uterus 3. Uterus cases 4cm elevation of diaphragm 4. Total lung capacity decreases slightly from compensatory widening of the chest iv. Weight gain in pregnancy

1. BMI <18.5 = 28 to 40 pounds 2. BMI 18.5 to 24.9 = 25 to 35 pounds 3. BMI 25-29.9 = gain 15 to 25 lbs 4. BMI > 30 = 11 to 20 lbs v. Hemodilution of pregnancy 1. 36% increase in maternal blood volume max is reached around 34 weeks 2. Plasma volume increases 47% and RBC mass increases 17% 3. Dilution effect lowers hemoglobin but no change in MCV vi. Tocolysis with terbutaline or other beta agonists = increase susceptibility to pulmonary edema especially with isotonic fluid use 1. Systemic vascular resistance decreases during pregnancy 2. Chorioamnionitis = more likely to get pulmonary edema but not usually main cause unless patient is in septic shock vii. Compensated respiratory alkalosis 1. Increased minute ventilation during pregnancy causes compensated respiratory alkalosis viii. Thyroid during pregnancy 1. Thyroid binding globulin is increased due to increased circulation estrogens with an increase in total thyroxine 2. Free thyroxine = constant 3. T3 also increase in pregnancy while T4 doesnt change ix. Urinary system dilatation 1. Right dilation more because right has dextroroation of uterus and left side has sigmoid colon cushioning 2. Right ovarian vein is dilated and lies obliquely over the right ureter right uretral dilatation 3. High levels of progesterone can have some little effect on smooth muscle of the ureter x. Cardiac output 1. Increases up to 33% due to higher HR and SV 2. SVR falls during pregnancy 3. Up to 95% of women have systolic murmur from increased volume a. Diastolic murmurs are always abdmornal 4. Systemic vascular resistance is normally greater than pulmonary vascular resistance a. If pulmonary resistance becomes higher then right to left shunt will happen and cyanosis will occur with VSD b. Preconception Care

i. Chorionic villus = 10-12 weeks, sample chorionic frondosum (mostly mitotically active villi in the placenta), transabdominal or transcervical approach 1. Fetal chromosomal abnormalities, biochemical or DNA based studies 2. CANT detect neural tube defects a. Omphaloceles and neural tube defects are diagnosed with prenatal ultrasound ii. Screening for sickle cell is best by hemoglobin electrophoresis because its definitive and thalassemia minor and hemoglobin C trait can be picked up aswell iii. Tay-Sachs = 1/30 for Ashkenazi Jews 1. 1/300 in other populations 2. Frequency of disease = 1/3000 3. Cystic fibrosis = most likely inherited disease in the population iv. Inhibin A = quad screen for more sensitivity for down syndrome 80% detection and 5% FP 1. 15 and 18 weeks should be offered to patients, but can be done up to 22 weeks 2. Triple screen = down, trisomy 18, neural tube defects a. AFT, beta HCG and unconjugated estriol b. 69% detection for downs 3. PAPP A = effective marker for screening for down in first trimester v. Valproic acid = increased risk for neural tube defects, hydrocephalus and craniofacial malformations vi. Chorionic villus sampling 1% miscarriage 1. Not related to prior miscarriages vii. Sickle cell anemia husband 1/10 chance and wife has a brother with sickle cell anemia 1. 2/3 X 1/10 X = 1/60 2. Wife has 1/3 chance of NOT being a carrier and 2/3 chance of being a carrier viii. Fragile X syndrome = most common form of INHERITED mental retardation 1. 1/3600 males 2. 1/4000 to 6000 females 3. Down syndrome is genetic but in majority of cases its not inherited. ix. Poorly controlled diabetes immediately pripr to conception and during organogenesis = 4 to 8 fold increase in structural anamoly 1. Majority are CNS (neural tube defects) and cardiovascular system 2. Genitourinary and limb defects have also been reported

x. Prenatal screening for Jewish 1. Do fanconi anemia, tay sachs, cystic fibrosis and neimann pick disease all autosomal recessive in Jews and Ashkenazi descent 2. Beta thalassemia = mainly Mediterranean c. Antepartum Care i. Valproic acid = 1 to 2% incidence of neural tube defects mainly lumbar meningomyelocele 1. Fetal u/s at 16 to 18 weeks 2. Fetal valproic syndrome = spina bifida, cardiac defects, facial clefts, hypospadias, craniosynostosis, and limb defectsparticularly radial aplasia 3. Cuadral regression syndrome = rare syndrome in poorly controlled diabetics 4. Some associated with omphalocele and lung hypoplasia ii. 3 hour glucose tolerance test fasting blood sugar less than or equal to 95 1. 1 hour less than or equal to 180 2. 2 hour less than or equal to 155 3. 3 hour less than or equal to 140 4. Initial management = teach patient how to monitor blood glucose levels at home a. Fasting blood sugar and 1 or 2 hour post prandial values after all three meals, daily b. Maintain fasting below 90 and hour post meal below 120 5. Risk factors for gestational diabetes = previous large baby (greater than 9lbs), history of abnormal glucose tolerance, pre-pregnancy weight of 110% or more of idea body weight and member of an ethnic group with higher rates of DMII like American Indian or Hispanic iii. Confirming gestational age = dating ultrasound iv. Gestational diabetes complications 1. Shoulder dystocia, metabolic disturbances, preeclampsia, polyhydramnios, getal macrosomia 2. Intrauterine growth restriction = seen in pre-existing diabetes NOT gestational diabetes v. Pregnant BMI 42 with poor nutrition, pale no fresh veggies 1. Folic acid supplementation 2. Evaluate for iron, protein and other nutrients 3. 70 grams of protein a day vi. Quadruple test = maternal serum AFP, unconjugated estriol, hCG, inhibin A = most effective screening in 2nd trimester 1. 1/800 births without prenatal intervention

2. Combined test = nuchal translucency measurement with maternal serum PAPP-A and free Beta-hCG 1st semester screening a. 85% detection and 5% false positive rates vii. Thickened nuchal translucency associated with fetal chromosomal and structural abnormalities and genetic syndromes 1. Schedule for detailed fetal u/s and echo at 18-20 weeks to rule out anomalies viii. Methyldopa = no associated birth defect ix. Obese women weight gain 1. 11-20 lbs gain mainly in 2nd half of pregnancy x. Previous fetal neural tube defect 1. Take 4mg of folic acid daily before conception and through 1st trimester a. Reduced incidence by 85% 2. Non high risk patient = 0.4mg/day d. Intrapartum Care i. Uterine perforation assume this if intrauterine pressure catheter is place and significant vaginal bleeding is noted 1. Withdraw the catheter, monitor the fetus and observe for any signs of fetal compromise 2. If fetal status is reassuring then attempt to place another catheter ii. Assisted operative vaginal delivery 1. If infant cant come out with one or two pushes next best choice given fetal station and presentation is to do emergency outlet forceps or vacuum assisted delivery iii. Initial evaluation for labor patient 1. Review prenatal records focusing on antenatal complications and dating criteria 2. Focused history 3. Limited physical exam vital signs and fetal HR with ab and pelvic exam 4. Nitralazine test = done to confirm rupture of membranes if patient has history for this or if patient is uncertain wheter she has experience leakage of amniotic fluid iv. Braxton hicks contractions = short, less intense than true labor and discomfort in lower abdomen and groin area 1. Active labor would be strong, regular uterine contractions that cause cervical change 2. Intra-amniotic infection = fever, fundal tenderness, maternal and fetal tachycardia v. Return to the hospital for suspected labor if: 1. Contractions every 5 minutes for 1 hour

2. Fetal movement less than 10 per two hours 3. Vaginal bleeding vi. Fourth stage of labor = immediate postpartum period of 2 hours after delivery of placenta 1. First stage = onset of labor and full cervical dilatation 2. 2nd stage = complete cervical dilatation through delivery of infant 3. Third stage = after delivery to end of delivery of placenta vii. Episiotomy = enlarges vaginal outlet for delivery 1. Indicated for instrumental deliveries, protracted or arrest of descent 2. Midline episotomy = less pain, ease of repair, less blood loss a. Increased risk of 3rd and 4th degree tears viii. Variable decelerations = cord compression and theyre most common decels in labor 1. Late decelerations = placental insufficiency 2. Early decelerations = head compression 3. Oligohydramnios can increase patients risk of having umbilicord compression but it doesnt by itself cause variable decels 4. Umbilical cord prolapse = 0.2 to 0.6% of births 5. VEAL CHOP a. Variable = cord compression b. Early = head compression c. Accelerations = okay d. Late = placental insufficiency ix. Late decelerations = associated with uterine contractions 1. Onset, nadir and recovery of decelerations occur AFTER the beginning/peak and end of contraction 2. Associated with uteroplacental insufficiency x. If the fetal heart rate cant be confirmed by using external methods then do fetal scalp electrode 1. Epidural without fetal status = dangerous e. Immediate Care of the Newborn i. Infants born to diabetic mothers = increased risk for hypoglycemia, polycythemia, hyperbilirubinemia, hypocalcemia and respiratory distress 1. Thrombocytopenia = NOT a risk ii. Diabetes type 1 moms have babies that are = SMALL and hypoglycemic 1. Gestational diabetes = large infants iii. Chorioamnionitis and foul smell on delivery is warning sign that infant can be septic 1. Septic infant = pale, lethargic and high temperature

iv. Infant w/ no resp effort and mom does mepridine and marijuana 1. Give positive pressure ventilation and prepare to intubate 2. Naloxone can cause life-threatening withdrawal because mother has poor social history of narcotic use v. Pre-eclampsia given magnesium 1. Make sure neonate is being oxygenated; may need bag mask 2. Hypoglycemia = not first concern vi. Flattened nasal bridge 1. Flattened nasal bridge, small size and small rotated cup shaped ears can be associated with Downs look for other down syndrome signs a. Sandal gap toes, hypotonia, protruding tongue, short broad hands, Simian creases, epicanthic folds, oblique palpebral fissures b. Dont share concerns until full exam 2. Amniocentesis to a 19yo is not done unless there are specific risk factors vii. Positive pressure ventilitation in newborn 1. Adjust head to sniffing position a. Head is in flex position for adult CPR 2. Secure mask for good seal 3. Compress bag just until chest rise is seen 4. Have O2 flow at minimum 10 L/min viii. Twin-twin transfusion syndrome 1. Polycythemia = complication for plethoric twin 2. Complication of monochorionic pregnancies imbalance of blood flow through communicating vessels across a shared placenta leading to underperfusion of the donor twin which becomes anemia and overperfusion of the recipient which becomes polycythemic 3. Donor twin often gets IUGR and oligohydramnios 4. Recipient twin gets volume overload and polyhydramnios can lead to heart failure and hydrops ix. APGAR scoring 1. Heart rate, resp rate, reflex, activity, color x. HIV positive mother = start AZT zidovudine immediately after delivery 1. Testing begins at 24hours 2. No reason to isolate the infant 3. Breast feeding would NOT be encouraged with mother with HIV

f. Postpartum Care i. Preventing lactation 1. Hormonal interventions predispose to thromboembolic events a. Risk of rebound engorgement 2. Bromocriptine = associated with hypertension, stroke and seizures 3. Safest method = breast binding, ice packs and analgesics 4. Patient should avoid breast stimulation or other means of milk expression so that natural inhibition of prolactin secretion can result in breast involution ii. Postpartum hemorrhage = obstetric emergency that can follow vaginal or C-section 1. Uterine atony = most common cause of PPH and happens in 1/20 deliveries 2. Can lead to hypovolemia, hypotension, tachycardia or oligouria 3. PPH = estimated blood loss of greater than or equal to 500ml after vaginal birth or greater than or equal to 1,000ml after C-section iii. Endometritis 1. Most common cause of postpartum fever = endometritis a. Differentials = UTI, lower genital tract infection, wound infections, pulmonary infections, thrombophlebitis, and mastitis b. Occurs in 2% after vaginal delivery c. Occurs in 10 to 15% after Ceasarean d. Increased rate of infection with vaginal birth = prolonged labor, prolonged rupture of membranes, multiple vaginal examinations, internal fetal monitoring, removal of the placenta manually and low socioeconomic status e. Uterine fundal tenderness = common in endometriosis iv. Endometriosis = related to mode of delivery 1. Less than 3% of vaginal births 2. 5-10 times higher incidence after Cesarean 3. Increased rates of infection in vaginal birth = prolonged labor, prolonged rupture of membranes, multiple vaginal examinations, internal fetal monitoring, removal of the placenta manually and low socioeconomic status v. Breastfeeding is recommended for first 6months exclusively 1. Benefits = increased uterine contraction due to oxytocin release during milk let down and decreased blood loss 2. Major source of IgA = decreased newborn GI infections 3. Low in iron = supplementation is needed for babies

vi. Postpartum depression 1. Sense of incapability of loving her family ambivalence toward infant vii. Postpartum blues 1. Lasts less than 2 weeks 2. In 40-85% of women in immediate postpartum period 3. Milder and self-limited 4. Postpartum depression = longer than 2 weeks viii. Sheehan syndrome 1. Rare 2. Significant blood loss anterior pituitary necrosis leads to loss of gonadotropin, TSH and ACTH production 3. Slow mental function, weight fain, fatigue, difficulty staying warm, no milk production, hypotension, amenorrhea 4. Treatment = estrogen and progesterone replacement and supplementation with thyroid and adrenal hormones ix. Endometritis 1. Bacterial isolated are usually polymicrobial mix of aerobes and anaerobes in genital tract a. Most causative agents = staph aureus and strep x. Post partum depression 1. Most significant risk factor = prior history of depression 2. Other risk factors = marital conflict, lack of perveived social support, contemplated terminating the pregnancy, stressful life events in the 12 months, sick leave in past 12 months related to hyperemesis, uterine irritability or psychiatric disorder g. Lactation h. Ectopic Pregnancy i. Spontaneous Abortion j. Medical and Surgical Conditions in Pregnancy k. Medical and Surgical Complications in Pregnancy i. Obesity classifications 1. Class 1 = 30-34.9 2. Class 2 = 35-39.9 3. Class 3 = 40+ 4. Increased maternal morbidity is from obesity and includes chronic hypertension, gestational diabetes, preeclampsia, fetal macrosomia, higher rates of Csection and postpartum complications 5. BMI over 38 = 7 fold increase in preeclampsia and 3 fold increase for hypertension ii. Renal infection = most common serious medical complication of pregnancy

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1. First do IV hydration to ensure adequate urinary output 2. After diagnosis give antibiotics 3. Majority of patients are afebrile by 72 hours but if no improvement by then do further evaluation sonography to look for urinary tract obstruction or calculi a. Obstruction = relieved by cystoscopic placement of double J uretral stent unless long term stenting is foreseen then do nephrostomy b. If nothing works do surgical exploration Pruritis gravidarum = mild variant of intrahepatic cholestasis of pregnancy 1. Retention of bile salt and as serum levels increase theyre depositived in the dermis pruritis 2. Skin lesions = secondary to scratching and excoriation 3. Antihistamines and topical emollients can provide some relief and should be used initially 4. Ursodeoxycholic acid = relieved prutitis and lowers serum enzyme levels 5. Opiod antagonist naltrexone = also relieved itching Pneumonia cough, dyspnea, sputum, pleuritic chest pain 1. Mild URI and malaise with mild leukocytosis 2. Chest radiography = essential for diagnosis 3. Uncomplicated pneumonia = DONT need pulmonary function tests, sputum culture, serological testing, cold agglutinin identification and bacterial antigen tests Mitral valve prolapse 1. Anxiety, palpitations, atypical chest pain, syncope 2. Beta blocker can decrease sympathetic tone, relieved chest pain and palpitations and reduce risk of lifethreatening arrhythmias Breast Cancer during pregnancy 1. Surgical treatment may be definitive during pregnancy 2. In the absence of metastatic disease a wide excisional biopsy, modified radical mastectomy, or total mastectomy with axiallary node staging 3. Non-pregnant women get adjunctive radiotherapy with breast conserving surgery NOT recommended during pregnancy because fetus will be at risk for excessive radiation Suspected appendicitis = most common indication for surgical abdominal exploration 1. Enlarged uterus shifts appendix upward and outward toward the flank so pain/tenderness may be located on the right lower quadrant

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2. Easily confused with preterm labor, pyelonephritis, renal colic, placental abruption, degeneration of a uterine myoma 3. Peritonitis and appendiceal rupture = more common during pregnancy 4. Diagnosis = clinical findings, graded compression ultrasonography sensitive and specific before 35 weeks gestation 5. Selective imaging can have radiation exposure to fetus viii. Classic depression 1. SSRI paroxetine (paxil) = category D increased fetal cardiac malformations and persistent pulmonary hypertension 2. Fluoxetine and sertraline = no pregnancy problems 3. Tricyclic antidepressants no fetal malformations 4. Bupropion = no unusual reports ix. Lupus patient 1. Malaise, fever, arthritis, rash, pleuropericarditis, photosensitivity, anemia, cognitive dysfunction 2. Renal involvement 3. No cure 4. NSAIDS = treats arthralgia and serositis 5. Severe disease = corticosteroids 6. Hydroxychloroquine = controls skin manifestations and may be associated with lupus flares if discontinued x. Anemia during pregnancy and puerperium 1. Iron deficiency and acute blood loss = major causes 2. Iron deficiency = hypochromia and microcytosis with low ferritin level and no stainable bone marrow iron 3. Spotting would not lead to blood loss anemia Preeclampsia-Eclampsia Syndrome i. Incidence of pre-eclampsia 1. Influence by parity 2. Related to race and ethnicity and genetic predisposition with environmental factors 3. Previous history of disease, chornic hypertension, miltifetal pregnancy, molar pregnancy 4. Extreme maternal age, diabetes, chornic renal disease, antiphospholipid antibody syndrome, vascular or connective tissue disase or triploidy 5. Previous spontaneous abortion = NOT increased risk ii. Treatment of choice for eclampsia = magnesium sulfate 1. Second agents or if magnesium is contraindicated = valium, hydantoin, tiagabine, barbituates iii. Magnesium toxicity 1. Therapeutic level = 4-7

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Loss of deep tendon reflexes = 7-10 Respiratory depression = above 12 Cardiac arrest = 15 Pulmonary edema can occur but is not related to toxicity from the drug Severe pre-eclampsia 1. Thrombocytopenia <100,000 = contraindication to expectant management of secere preeclampsia remote from term <32 weeks a. Other contraindications = inability to control BP w/ a max dose of 2 antihypertensive medications, non-reassuring fetal surveillance, liver function test elevated more than 2X normal, eclampsia, persistent CNS syntoms, oligouria b. Delivery is NOT based on degree of proteinuria, elevated uric acid and hemoconcentration Placental abruption 1. Tachysystole and fetal anemia (tachycardia and sinusoidal HR pattern) 2. Hypertension and preeclampsia = risk factors for abruption 3. No history of cervical trauma HELLP syndrome 1. Hemolysis, elevated liver enzymes, low platelets 2. Swelling of liver capsule liver rupture 3. Right uppe quadrant pain can happen 4. Symptoms over several days = malaise, anorexia, nausea, vomiting, epigastric pain, progressive jaundice 5. Persistent vomiting in late pregnancy 6. have hypertension, proteinuria and edema 7. Usually have severe liver dysfunction with hypofibrinogenmia, hypoalbuminemia, hypocholesteriemia, prolonged clotting times a. AFL worsens = hypoglycemia Pre-eclamsia definitive therapy = delivery of fetus and placenta 1. Delayed in stable disease at early gestational age 2. Fluid management must be closely monitored 3. Magnesium sulfate = during labor and for 24 hours postpartum to lower the seizure threshold 4. Low dose aspirin = some benefit in decreasing risk of preeclampsia in a subset of high risk patients 5. Hydralazine = antihypertensive agent of choice for controlling elevated blood pressures in the acute setting Mild preeclampsia 1. Elevation of BP and 24 hour urine results 2. 24 hour urine protein values greater than 300mg

2. 3. 4. 5.

3. Protein greater than 5,000mg = needed for diagnosis of severe preeclampsia 4. BP between 120/80 and 139/89 = prehypertension indicative of developing hypertension in the future ix. Antihypertensive meds for higher then 160/105 1. Hydralazine direct vasodilator 5mg IV followed by 510mg IV at 20min intervals (max dose 40mg) a. OR labetalol combined alpha and beta adrenergic antagonist 10-20mg IV followed by 20mg then 40mg then 80mg IV every 10 minutes (max dose 220mg) 2. Goal= not normal BP but reduce diastolic BP into safe range 90-100mmHg = prevent maternal stroke or abruption without compromising uterine perfusion x. Gestational hypertension 1. Normal labs, no proteinuria, no symptoms 2. BP was normal prior to visit chronic hypertension is excluded 3. Up to of women with gestational hypertension develop preeclampsia m. Isoimmunization i. RhoGAM Anti-D-immunoglobulin = given to Rh-negative women to prevent isoimmunization 1. Each dose has 300ug of De antibody and given to the Dnegative non-sensitized mother to prevent sensitization after any pregnancy related events to stop fetalmaternal hemorrhage 2. Rh-negative women without evidence of Rh immunization = prophylactic dose of RhoGAM IM within 72 hours of delivering the Rh-positive baby, following spontaneous or induced abortion, following antepartum hemorrhage, following amniocentesis or chorionic villus sampling and prophylactically at 28 weeks gestation after an indirect Coombs test 3. Father is known to be Rh-negative, RhoGAM is not necessary since fetus will be Rh-negative and not risk for hemolytic disease 4. Rhogam = not indicated following gyn procedures ii. Severe hemolytic disease 1. Values in Zone 3 of Liley curve 2. Hydrops and fetal death withing 7-10days 3. Immediate delivery OR fetal transfusion 4. At 30 weeks gestation fetus needs more time in utero so correct underlying anemia a. Intravascular transfusion into umbilical vein

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5. Do intraperitoneal transfusion = when intravascular transfusion is technically impossible 6. Fetal hydrops present then reversal of fetal anemia is slower via intraperitoneal transfusion 7. Maternal plasmapheresis = severe disease when intrauterine transfusions are not possible Transplacental hemorrhage 1. 60% have <0.1cc of fetal blood 2. Less than 1% have >5cc 3. Less than 0.25% have >30cc 4. Incidence of size of transplacental hemorrhage increases as pregnancy advances 5. 2nd month of gestation 5-15% have feto-maternal hemorrhage 6. 3rd trimester 45% have it 7. Less than 0.1cc of fetal blood can sensitize a patient Kleihauer-Betke test = accurate and sensitive acid elution test 1. Great value for incidence and size of fetal transplacental hemorrhage 2. Acid elution makes mothers RBCs very pale and fetal cells remain stained a. Simple comparative counts = estimation of whether a signification feto-maternal transfusion has occurred 300ug dose of RhoGAM = 30cc of fetal blood neutralized 1. Equivalent to 15cc of fetal RBCs 2. 28 weeks 300 micrograms of Rh-immune globin = given after testing for sensitization w/ indirect Coombs test 3. Also given at any gestational age following amniocentesis Delta OD450 measurement 1. Presence of serverly erythroblastic fetus amniotic fluid is stained yellow a. Yellow piment = bilirubin quantified by 420nm and 460nm wavelength 2. Deviation of reading at 450nm is due to the presence of heme pigment = indicator of severe hemolysis Rarely, Rh-negative woman can be sensitized despite prophylaxis 1. Protection is dose-dependent a. 1 dose prevents Rh sensitization to an exposure of as much as 30cc of Rh+ RBCs b. greater exposure = partial protection and Rh sesniziation may occur from failure to diagnose massive transplacental hemorrhage

2. Latter part of pregnancy or soon after delivery before post-delivery prophylaxis dose is given 3. Inadvertent maternal transfusion of Rh+blood can lead to Rh sensistization to D or another RBC antigen 4. If patient didnt get RhoGAM following antenatal bleeding or after invasive procedure (amniocentesis or CVS) 5. RhoGAM = protection against D antigen so patient can be sensitized to other RBC antigens viii. Noninvasive diagnosis of fetal anemia = Doppler u/s 1. Use middle cerebral artery peak systolic velocity in the management of fetuses b/c of red cell alloimmunization is best test a. Amniocentesis and cordocentesis = invasive and have many complications ix. Fetal hydrops = easily diagnosed on u/s 1. Decresed hepatic protein production 2. Folloection of fluid in two or more body cavities ascites, pericardial and/or pleural fluid and scalp edema 3. Extramedullary hematopoiesis hepatosplenomegaly 4. Placentomegaly and polyhydramnios x. Patient was sensitized during first pregnancy that was complicated by abruption and required C-section 1. Transplacental hemorrhage of fetal Rh-positive RBC into circulation of Rh-negative mother may occur following amniocentesis, CVS, spontaneous/threatened abortion, ectopic pregnancy, dilatation and evacuation, placental abruption, antepartum hemorrhage, preeclampsia, C-section, manual removal of the placenta and external version n. Multifetal Gestation i. Congenital anomalies = increased in twins mainly monozygotic 1. Deliver earlier 35-37 weeks 2. Weight less but usually in normal range a. Macrosomnia is uncommon ii. Preterm delivery = increased risk of mobirity and mortality 1. Increases w/ higher order of multiples a. Over 50% of twins, 90% of triplets and almost all quadruplets 2. Increased risk of RDS, intracranial hemorrhage, cerebral palsy, blindness, low birth weight 3. Also can have intrauterine death, miscarriage, congenital anomalies, preeclampsia, diabetes and placental abnormalities iii. Twin infant death rate = 5X higher than singletons

1. Cerebral palsy = 5-6X than singletons 2. Twins = higher incidence of IUGR 3. 58% of twins delivery prematurely at average of 35 weeks a. 12% of twins are very premature iv. Twin-twin tansfusion syndrome = intrauterine blood transfusion from one twin to the other 1. In monochorionic, monozygotic twins a. If they have dichorionic placentation = no risk b. Monochorionic, diamnionic or monochorionic, monoamnioc placentation = at risk 2. Donor twin = smaller and anemic at birth 3. Recipient twin = larger and plethoric 4. Large weight discordance, polyhydramnious around recipient, oligohydramnios around donor twin 5. Diamniotic dichorionic placentation = prior to morula state within 3 days post fertilization 6. Diamniotic monochorionic = between days 4 and 8 post fertilization 7. Monoamnionic, monochorionic between 8 and 12 days post fertilization 8. Division on or after day 13 = conjoined twins 9. Cardiac twinning = vascular anastomoses in combo with partial or complete lack of cardiac development in one of the twins 10. Superfecundation = fertilization of 2 or more ova form the same cycle by sperm from separate acts of sexual intercourse v. Assisted reproduction = increases in number of multiple gestations 1. In vitro fertilization rates of twins veries a. More likely in younger women 2. Frequency increases with drugs 3. Dizygous twinning from ovulation of multiple follicles and rate of multiple gestation = increases w/ maternal age 4. Elevated FSH = dizygous multiple births 5. Higher prior pregnancies and pervious multiple births = increases chances 6. Dizygous twinning has genetic component and ethnicity effects rates of dizygous twins = but NOT related to paternal family history vi. Delivery for twins when A is in breech and B is vertex = Csection 1. Problems = head entrapment and umbilical cord prolapse

vii. AFP levels in twin gestations are elevated = 2X that of singleton pregnancies 1. Fundal height exceeds gestational age in weeks 2. Other causes of increased AFP = dating errors, neural tube defects, pilonidal cysts, cystic hygroma, sacrococcydeal teratoma, fetal abdominal wall defects, and fetal death viii. Untreated severe twin-twin transfusion syndrome = poor prognosis perinatal mortality rates of 70-100% 1. Death in utero of either twin = common 2. Surviving infants = increased rates of neurological morbidity w/ increased risk of cerebral palsy 3. Excessive volume = cardiomegaly, tricuspid regurgitation, ventricular hypertrophy, hydrops fetalis of recipient twin a. Recipient twin = plethoric, hypervolemic, macrosomic 4. Donor twin = anemic and hypovolemic and poor growth a. Donor becomes hydropic from anemia and high output heart failure 5. Hydrops fetalis = can happen in either twin ix. Interventions for preterm twin delivery 1. Adequate weight gain in first 20-24 weeks = important to reduce risk of preterm and low birth weight babies a. Aids in development of placenta helps pass more nutrients to babies 2. Recommended to gain at least 24lbs by 24th week 3. Bed rest = thromboembolic complications, no improvement in preterm birth 4. Not effective = tocylytics, home uterine activity, prophylactic cerclage x. Ultrasound for dizygotic twins = dividing membrane thickness greater than 2mm, twin peak lambda sign, different fetal genders, two separate placentas (anterior and posterior) 1. Dizygotic = always have dichorionic placentas o. Fetal Death i. Microcephaly and severe mental retardation = greatest between 8 and 15 weeks gestation 1. No risk of mental retardation has been documents at less than 8 weeks or greater than 25 weeks with doses even exceeding 50 rad ii. Couples w/ news of fetal birth defect or loss - coping response 1. Varies with severity, treatability, coping level 2. Start to understand situation anger to spouse, child, caregiver

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3. Denial anger bargaining depression acceptance Uncontrolled diabetes during organogenesis = high rate of birth defects 1. Spine and heart are commonly affected 2. High level of glucose transplacentally = increased growth and polyuria increased amniotic fluid a. Infection = placentomegaly and polyhydramnios BUT normal or decreased growth b. Severe hypertension and active antiphospholipid syndrome = oligohydramnios and IUGR c. Hyperthyroidism = risk of miscarriage and stillbirth increased if untreated i. Risk to mother and baby are further increased if disease persists or its diagnosed late in pregnancy Autosomal trispomy = most common abnormal karyotype in spontaneous abortuses 40 to 50% of cases 1. Most commonly trisomy 16 2. Triploidy = 15% and tetraploidy for 5% 3. Monosomy X (45,XO) = 15 to 25% losses Autosomal dominant Factor V Leiden mutation based on history 1. Most common inherited thrombophillic disorder - 5% of Caucasian woman in USA 2. Point mutation altering factor 5 making it resistant to inactivation by protein C 3. Thrombophillic effect of FVL mutation has been clearly established 4. Heterozygosity = 5-10 fold increased risk of thrombosis 5. Homozygosity = 80 fold incased risk of thrombosis 6. Obstetric complciations = stillbirth, preeclampsia, placental abruption and IUGR Fibrinogen levels may decrease w/ dead fetus of 3-4 weeks coagulopathy 1. Nosebleed = common finding 2. Induction should be considered but can be delayed after death of a twin to allow viable twin to mature 3. Fibrinogen levels should be monitored to detect progressive coagulopathy a. Weekly or biweekly 4. Spalding sign = overlapping of fetal skull bones suggests fetal demise Fundal height = measurement of lower abdominal organs uterus, fallopian tubes, ovaries

1. Demise several weeks prior to visit or with decrease in fetal growth leading to demise = decrease in fundal height measurement 2. Increased fundal height = increase in size of these structures leiomyomata, tubal abscess, ovarian cyst 3. Rupture of membrane and earlier gestational age = associated with size less than dates viii. Vaginal bleeding with pregnancy = check maternal blood type 1. Patients blood type is Rh-negative = RhoGAM is given to prevent Rh sensitization ix. Tissue consistent with omental tissue can include segments of bowel suction should be turned off and gently removed from curette 1. Laparoscopy allows closer examination and if bowel is involved, surgeon should consider laparotomy or closer evaluation of bowel for damage x. Uncontrolled glucose = adverse fetal outcome 1. Type 1 DM = many pregnancy complications fetal death, macrosomnia, maybe fetal growth restriction a. Increased risk for polyhydramnios, congenital malformation (cardio, neral tube defects, caudal regression syndrome), preterm birth, hypertensive complication p. Abnormal Labor i. Continued monitoring of labor = if fetus is not macrosomic or no fetopelvic disproportion 1. If this were ture = DO C-section ii. Breech presentation is associated with = prematurity, multiple pregnancy, genetic disorder, polyhydramnios, hydrocephaly, anencephaly, placenta previa, uterine anomalies, uterine fibroids iii. Multiparous at term waiting until 42 weeks = increased risk of perinatal mortalitiy 1. Uncomfortable with back pain 2. Cervix unfavoration so cytotec administration is appropriate prior to Pitocin 3. Foley bulb or artificial rupture of membranes cant be achieved w/ closed cervix iv. Arrest of dilatation in active phase of labor 1. Contractions every 5-6 minutes start Pitocin to increase frequency and strength a. If theres no change add intrauterine pressure catheter to asses strength of contractions v. Shoulder dystocia risk factors = fetal macrosomia, maternal obesity, DM, posterm pregnancy, prior shoulder dystocia, prolonged 2nd sage of labor

1. Gestational diabetes! vi. Major cause of higher C-section deliveries = less women have vaginal births after C-section 1. Increased risk of complications uterine rupture 2. Rate of breech presenation = stable vii. Amniotomy 1. Patient has secondary arrest of dilataion no change in cervix over 2 hours 2. Multiparious woman = 1.5cm/hour dilatation in active phase 3. Amniotmoy is done and if that doesnt work Pitocin can be attempted after careful evaluation viii. Breech presentation = 3-4% of women in labor, more frequently in preterm 1. Frank breech = most common type, occurs in 48-73% of cases and buttocks are the presenting part 2. Complete breech = 5-12% of cases 3. Incomplete breech = footling breeches is 12-38% of cases ix. Latent phase of labor since active phase is more than 4cm 1. Prolonged latent phase = >20hours for nulliparas a. >14 hours for multiparas 2. Treat with rest or augmentation of labor 3. If baby is premature = do C-section 4. Artificial rupture of membranes = not recommended in latent phases b/c it places the patient at increased risk of infection x. Vaginal birth after C-section 1. After 1 previous C-section = 70-80% chance of success 2. Risk of uterine rupture = 1% or less if they had 1 previous C-section a. Data if 2 previous C-sections is unknown 3. Indication for C-section has an affect a. Nonrecurring indication like placenta previa or breech = more success b. Secondary to cephalopelvic disproportion = less success q. Third-Trimester bleeding i. Patient is near term with 2nd episode of active bleeding from placenta previa 1. Next step = C-section 2. No contractions = so tocolysis is not necessary and not used with heavy vaginal bleeding 3. Catastrophic bleeding could occur due to disruption of blood vessels as cervix dilates if vaginal delivery is pursued and induction of labor = contraindicated

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iii. iv.

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4. Even though patient is NOT at term delivery is indicated due to 2nd episode of heavy bleeding Abnormal placentation must be checked by u/s 1. Placenta previa must be ruled out before proceeding with vaginal examination b/c risk of injury to placenta and catastrophic bleeding a. Bleeding from placenta previa = without warning or pain 2. If delivery was imminent then give steroid Smoking = increased risk of placental abruption, placental previa, fetal growth restriction, preeclampsia and infection During pregnancy cervix is extremely vascular and with dilatation a small amount of bleeding may occur bloody show = not of clinical significance and often occurs with normal labor 1. Serious causes of bleeding need to be ruled out like placental abruption and placenta previa Placental abruption 1. Presenting signs = abdominal pain, bleeding, uterine hypertonus, fetal distress 2. Risk factors = smoking, cocaine use, chronic hypertension, trauma and prolonged premature rupture of membranes and history of prior abruption 3. Treatment = emergent C-section w/ appropriate resuscitation, including IV fluids and blood products as needed Placental abruption with deteriorating fetal condition 1. Do emergency C-section 2. Mother risks excessive blood loss, DIC, possible hysterectomy 3. Fetus risks = neuro injury from anoxia or death 4. Risk factors for abruption = smoking, cocaine use, abdominal trauma, chronic hypertension, multiparity and prolonged premature rupture of membranes Cervical cancer can complicate pregnancies and present with bleeding 1. Rule out threatened abortion, infection or trauma 2. Treatment = based on stage, appropriate therapy, maternal and fetal welfare Placenta accrete = placenta grows into the myometrium 1. Risks = history of previous C-sections and low anterior placenta a. Scar from previous surgery prevents proper implantation of placenta and it grows into the muscle

2. Vasa previa = rare and umbilical cord inserts into membranes 3. Placental abruption = premature separation of normally implanted placenta ix. Correcting coagulation deficiencies = replace all necessary components 1. Fresh frozen plasma has fibrinogen and factors 5 and 8 2. Cryoprecipitate = fibrinogen, factor 8 and von willebrands factor 3. RBC and platelets are given separately x. Cervicitis = caused by chlamydia, gonorrhea, trichomonas or other infections can present with vaginal bleeding 1. Cervix = more vascular during pregnancy and inflammation can lead to bleeding r. Preterm Labor i. Magnesium sulfate = competes with calcium entry into cells acts like a tocolytic 1. Beta adrenergic agents = increase cAMP in the cell = less calcium 2. Prostaglandin synthetase inhibitors like indomethacin = decrease prostaglandin by blocking conversion of free arachidonic acid to prostaglandin 3. Ca2+ channel blockers block calcium entry into muscle cells by inhibiting calcium transport ii. 50% of preterm contractions have spontaneous resolution 1. Preterm labor = regular contractions leading to cervical chance would need prompt treatment 2. Betamethasone = given if patient is at increased risk of delivering preterm iii. Amniocentesis = rules out intra-amniotic infection 1. Patient has fever and increased WBC 2. Steroids = not given until intra-amniotic infection has been ruled out iv. Terbutaline = beta adrenergic agent 1. Side effects = tachycardia, hypotension, anxiety and chest tightening or pain 2. Prostaglandin synthetase inhibitors like indomethacin = premature constriction of ductus arteriosus usually after 24 weeks gestation 3. Magnesium sulfate may cause resp depression in high doses a. Flushing and headache can happen v. Betamethasone treatment from 24-34 weeks gestation = increase pulmonary maturity and reduce incidence of severity of RDS in the newborn

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vii.

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1. Decrease intracerebral hemorrhage and necrotizing enterocolitis in newborn 2. NOT associated with infection or enhanced frowth Fibronectic = extracellular matrix protein that acts as an adhesive between fetal membranes and underlying deciduous 1. Normally found in cervical secretions in first half of pregnancy 2. Presence between 22-34 weeks = indicated disruption or injury to maternal-fetal interface 3. FDA approved for women with preterm labor symptoms from 24-35 weeks and during routine screening of asymptomatic patients from 22-30 weeks gestation 4. Negative predictive value of 99.2% in symptomatic a. In asymptomatic = 96.7% for delivery before 35 weeks 5. Positive predictive value = 16.7% Magnesium sulfate toxicity 1. Resp depression = 12-15mg/dl 2. Cardiac depression = >15 3. Before resp depression = absent deep tendon reflexes 4. Beta-adrenergic agents like terbutaline = hypotension and tachycardia 5. Indomethacin = prostaglandin synthetase inhibitor = fetal bradycardia 6. Fetal tachycardia = infection or increased maternal temperature Most cases preterm labor = idiopathic 1. Dehydration and uterine distortion (from uterine fibroids or structural malformation) can be associated with preterm labor a. Sometimes iatrogenic causes = inducing a patient with severe preeclampsia 2. Fetal movement does NOT cause preterm labor Maternal indomethacin exposure = premature constriction of ductus arteriosus especially if used after 34 weeks gestation 1. Skeletal anomalies and polyhydramnios are not associated with indomethacin 2. Indomethacin = oligohydramnios 3. Ca2+ channel blocker like Nifedipine = fetal hypoxia and decreased uteroplacental blood flow Diabetic patient with myasthenia gravis at 33 weeks 1. Terbutaline and ritodrine = contraindicated in diabetic patients 2. Magnesium sulfate = contraindicated for myasthenia gravis

3. Indomethacin = contraindicated at 33 weeks due to risk of premature ductus arteriousus closure s. Premature Rupture of Membranes i. Methods to confirm rupture of membranes = testing vaginal fluid for ferning and Nitrazine testing 1. Important to test fluid from vagina and not test cervical mucus because of false positive ferning patterns 2. Avoid digital exam because of high risk of introducing bacteria into uterine cavity chorioamnionitis 3. U/s can show oligohydramnios and support diagnosis but doesnt confirm it ii. Premature rupture occurs in 10-15% of all pregnancies and preterm premature rupture of membranes between 16-26 weeks in 1% 1. Preterm premature rupture of membranes = 1/3 of all preterm deliveries 2. Recurrence rate for pre-PROM = 32% iii. Preterm rupture of membranes amniocentesis can be performed to detect amniotic infection 1. Lowest predictive value for chorioamnionitis = amniotic leucocytes 2. Interleukin 6 would be increased in chorioamnionitis 3. Low amniotic fluid glucose = indicated intra-amniotic infection iv. Antibiotic therapy is given to patient with preterm premature rupture of membranes can prolong latency by p to 5-7 days and reduce incidence of maternal amnionitis and neonatal sepsis 1. Corticosteroids and tocolytics can also prolong pregnancy but not 7 days v. Time from premature rupture of membranes to labor = inversely related to gestational age 1. At term 90% will go into labor within 24 hours of PROM 2. At GA 28-34 weeks 50% go into labor within 24 hours and 80% within 48 hours vi. Role of tocolysis with preterm rupture = controversial 1. Can be used in limited settings 2. Good to attempt to prolong interval to delivery to gain time for steroids to obtain maximum benefit for the fetus a. Reasonable if theres no infection or advanved preterm labor i. But low success rate, but benefits to fetus outweight any costs to the mother in this situation

vii. Primary risk factor for preterm rupter of membranes = genital tract infection especially bacterial vaginosis 1. Risk factors = multiple gestations, smoking (2X), shortened cervical length, previous preterm rupture, oligohydramnios viii. Premature rupture of membranes at 36 weeks 1. Benefits of delivery outweight risk of expectant management 2. Tocolytics is controversial not after 34 weeks 3. Benefits to neonate outweigh the potential risks of intra-amniotic infection prior to 32 weeks, but only in absence of evidence of intra-amniotic infection 4. Steroids after 32 weeks are controversial ix. Maternal signs of chorioamnionitis or other intra-amniotic infection are indications for delivery 1. Tender gundus = chorioamnionitis sign 2. Labor at 32 weeks would be allowed to progress and prolonged non-rassuring fetal testing would prompt delivery 3. No criteria for amniotic fluid index or degree of oligohydramnios as an indication for delivery x. Preterm premature rupture of membranes before viability = significant risk of poor outcome 1. Neonatal survival when rupture occurs between 20 and 23 weks = 25% 2. Complications = structural abnormalities mainly deformations (abnoromalities due to insult after structure has already formed) rather than malformation (abnormal development of structure itself) 3. Pulmonary hypoplasia = seen when rupture of membranes occurs before 25 weeks gestation due to lack of amniotic fluid so theres problem with normal intrautering breathing process t. Intrapartum Fetal Surveillance i. Non-stress test = assess fetal well being and measures HR responses to fetal movement 1. Normal or reactive non stress test occurs when there are 2 fetal HR accelerations of 15 beast/minute for 15 seconds within 20 minutes. 2. Vibroacoustic stimulation = not indicated unless NST is nonreactive 3. Contraction stress tests = asses uteroplacental insufficiency and looks for persistent late deceleration after contraction 3/10 minutes a. Not necessary to perform since non-stress test will asses fetal well being

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4. If no abnormal testing found labor would be induce or C-section Variable deceleration = acute fall in FHR with a rapid down slope and variable recovery phase 1. Variable in duration, intensity and timing and may not bear a constant relationship to uterine contractions 2. Early decels = physiologic caused by fetal head compression during uterine contraction vagal stimulation slower HR a. Uniform shape with slow onset that coincided with start of contraction and slow return to baseline that coincides with end of contraction b. Mirror image of the contraction 3. Late decal = symmetric fall in fetal HR, beginning at or after the peak of the uttering contraction and returning to baseline only after the contraction has ended a. Associated with uteroplacental insufficiency 4. Sinusoidal pattern = regular, smooth, undulating form typical of a sine wave occurring w/ frequency of two to 5 cycles/min and amplitude range of 5-15 beats/min a. Stable baseline HR of 120-160 b. Absent beat to beat variability See above Initial measures to evaluate and treat fetal hypoperfusion = change in maternal position to left lateral positon increases perfusion to uterus, maternal supplemental oxygenation, treatment of maternal hypotension, discontinue oxytocin, consider intrauterine resuscitation with tocolytics and IV fluids, fetal acid-base assessment with fetal scalp capillary blood gas or pH measurement 1. Amniofusion = used to treat patients with variable decels 2. Measures to improve uteroplacental blood flow should be attempted prior to C-section 3. Augmentation of labor may accentuate the late decels Variable decels = umbilical cord compression from cord wrapped around fetal part, fetal anomalies or oligohydramnios Late decels = uteroplacental insufficiency as a result of decreased uterin perfusion or placental function fetal hypoxia and academia 1. Common causes = chronic hypertension and postdate pregnancies 2. Uterine hyperstimilation = prolonged bradycardia FH monitor with normal baseline and regular contractions Regular contractions with fetal tachycardia with prolonged ruptured membranes = due to infection like chorioamnionitis

1. In the presence of nuchal cord or oligohydramnios = fetal HR tracing may show variable decels ix. Early decal tracing x. Tracing with tachycardia and regular contractions 1. Prolonged period of fetal tachycardia = maternal fever or chorioamnionitis u. Postpartum Hemorrhage i. Retained placental risks = prior C-section, uterine leiomyomas, prior uterine curettage and succenturiate lobe of placenta ii. Prostaglandin F2 alpha = IM or directly into uterine muscle 1. Cant ever administer prostaglandin F2-alpha nor methylergonovine IV severe bronchoconstriction and stroke 2. Oxytocin = given as short time, rapid infusion of dilute solution and not as IV push 3. Misoprostol can be given to women with hypertension or asthma iii. Methergine, prostaglandins and oxytocin = uterotonics used to increase uterine contractions and decrease uterine bleeding 1. Methylergonovine = ergot alkaloid potent SM constrictor a. Also a vasoconstrictive agent so it should bt WITHHELD from women with hypersion and/or preeclampsia 2. Misoprostol = non-FDA approved use for cervical ripening and labor induction iv. Ligation of a number of pelvic vessels = reduction in vascular pressure in pelvis controlling hemorrhage 1. Internal iliac artery or hypogastric artery ligation 2. Ovarian artery ligation should not be primary approach 3. External iliac artery ligation devascularization of leg = DONT DO THIS 4. If conservative methods fail do hysterectomy v. Low lying anterior placenta in patient with history of multiple C-sections = the diagnosis of placenta accrete should be considered 1. Placenta accrete = abnormally firm attachment of placenta to uterine wall a. Increasing incidence due to increased C-sections b. Serious obseteric complication leading to retained placenta and severe postpartum hemorrhage 2. Hysterectomy = frequently required due to intractable hemorrhage at delivery vi. Uterine inversion = uncommon cause of postpartum hemorrhage

1. Factors that lead to an over-distended uterus = risk factors a. Grant multiparity, multiple gestation, polyhydramnios, macrosomnia b. Most common risk factor = excessive iatrogenic traction on umbilical cord during 3rd stage of delivery 2. Leiomyomas can spontaneously prolapse = unlikely during peripartum period vii. Uterine atony = most common cause of postpartum hemorrhage 1. Risk factors = precipitous labor, multiparity, general anesthesia, oxytocin use in labor, prolonged labor, macrosomnia, hydramnios, twins and chorioamnionitis 2. Patients are risk for genital tract lacerations = precipitous labor, macrosomnia, instrument assisted delivery or manipulative delivery 3. Retained placenta = prior C-section, uterine leimyomas, prior uterine cureattage, succenturiate lobe of placenta 4. Over-distened uterus = uterine inversion, grand multiparity, multiple gestation, polyhydramnios, macrosomnia 5. Most common etiology of uterine inversion = excessive traction of umbilical cord during 3rd stage of delivery iatrogenic cause viii. After backup, IV access and stabilizing the patient, the first step in postpartum hemorrhage = make sure uterus is well contracted, no retained placental tissue and look for lacerations 1. Patient has firm fundus = contracted uterus 2. Placenta = complete ruled out retained placental tissue so its important to rule out lacerations which can lead to hemorrhage 3. B-lynch suture = used at time of laparotomy for uterine atony 4. Uterine artery emobolization can be considered after other sources of bleeding like laceration are ruled out. ix. Postpartum hemorrhage = bleeding in excess of 500 cc after a vaginal delivery OR in excess of 1000 cc after a C-section x. Prostaglanding F2 alpha = potent SM constriction which has bronchoconstrive effects 1. Used with caution in asthma patients 2. Contraindicated in poorly controlled or severe asthma v. Postpartum Infection i. Breast engorgement = exaggerated response to lymphatic and venous congestion associated with lacatation

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1. Milk let down generally occurs on postpartum day 2 or 3 2. If the baby is not feeding well then breast can become engorged low grade fever 3. Lactating women are told to feed frequently and use breast pump to prevent painful engorgement and mastitis 4. Postpartum fever differential = endometritis, cystitis, mastitis a. Vaginitis = no fever b. Septic pelvic thrombophlebitis = rare, high fever not responsive to antibiotics and is a diagnosis of exclusion Acute cystitis = common complication after vaginal delivery 1. Increased risk with use of indwelling catheter 2. Most common cause = gram negative bacteria a. Major pathogens = E.coli 75%, P. mirabilis 8%, S. faecalis <5%, and S. agalactiae Pregnancy puts women at risk for cholelithiasis cholecystitis 1. Classic symptoms = nausea, vomiting, dyspepsia and upper abdominal pain after fatty foods a. Treatment = depends on severity but often involved cholecystectomy laparoscopically 2. Endometritis symptoms = fever and maternal tachycardia, uterine tenderness and no other localizing signs of infection Aggressive debridement of necrotic area = prevents further spread of infection 1. Extend it until vital tissue with good blood supply is found 2. Repair of the defect = delayed until infection has completely resolved 3. Incision and drainage of perineal laceration is appropriate if it was an uncomplicated abscess Epidural = pain relief during labor 1. Complications = spinal headache, localized back pain and meningitis a. Meningitis = progress rapidly, required aggressive treatment with antibiotics i. Diagnosis = CSF from lumbar puncture Endomyometritis = common complication of prolonged labor, prolonged rupture of membranes, multiple vaginal examinations 1. Infection = polymicrobial, mostly anaerobic 2. Give broad spectrum antibiotics until patient is afebrile for 24 hours

3. Adding gentamicin to amplicillin = covers gram negative a. Erythromycin = good for URI b. Vanco = s. auerus and penicillin resistant gram + c. Ciprofloxacin = excellent coverage for gram pathogens like pseudomonas vii. C-sectoin infection wound= mixed bacteria from skin, uterus and vagina 1. Treatment = open the wound, check for fascia dehiscence and drainage of purulent material 2. Packing the wound until its healed form bottom up prevents persistent infection 3. Broad spectrum antibiotics are started but alone wont treat abscess viii. Necrotizing fasciitis = dangerous infection by gas forming organisms like Clostridium, can quickly cause sepsis and death 1. Classical clinical manifestation = fever, pain and induration of wound 2. Treatment = early recognition, antibiotics and debridement of necrotic tissue 3. Endomyometritis = fever and maternal tachycardia, uterine tenderness and no other localizing signs of infection 4. Cellulitis = swollen, erythematous, tender + warm area without grey necrtotic edges 5. Hemotoma = swollen, tender and painful area that may be expanding ix. Septic thrombophlebitis = thrombosis of venous system of the pelvis 1. Diagnosis of exclusion of other cuases but sometimes a CT scan will reveal thrombosed veins 2. Treatment = addition of anticoagulation to antibiotics and resolution of fevers is generally rapid 3. Anticoagulation treatment = short term x. Septic thrombophlebitis w. Anxiety and Depression i. Suicidal ideatation = inpaitent management 1. SSRI = hasten recovery to fully functioning state ii. History of psychiatric illness = risk for postpartum depression 1. 1/3 with postpartum psych problem report a prior history 2. Need follow up carefully = early appointment for postpartum visit, question about mood and thoughts iii. Sertraline = category C iv. Postpartum blues 1. Affects 50% of women at 5-6 days postpartum

a. Symptoms = insomnia, easy crying, depression, poor concentration, irritability or labile affect and anxiety b. Symptoms last a few hours per day and are mild and transient c. Blues = related to biochemical changes of puerperium 2. Postpartum depression = mood changes, insomnia, phobias and irritability = more pronounced v. Fluoxetine, SSRI antidepressant medication 1. Side effects = fatigue, sleep problems, headache, irritability, agitation, sexual dysfunction like decreased libido and delary or absent orgasm a. MOST COMMON = insomnia i. Significant insomnia can effect 1/5 patients vi. Most depressed patients who are suicidal are relieved to be asked about it 1. Most important topic = suicide risk vii. SSRI medications can be safely used during lactation 1. SSRIs are secreted in breast milk but no detectible levels of drug were found in the infants serum 2. Also no adverse effects were noted in the infant by either their parents or pediatricians viii. Most women with stress dont develop major depression 1. Treatment is necessary when it interferes with patients ability to function 2. However its important to establish good support systems ix. Premenstrual dysphoric disorder = luteal phase and are absent in the beginning of follicular phase 1. Important to document timing of symptoms each month to diagnose PDD 2. Also important to make sure symptoms are not an exacerbation of an underlying psychiatric disorder before initiating therapy x. Postpartum depression = mood changes, insomnia, phobias, irritability that are all more pronounced than blues 1. Postpartum psychosis = visual or auditory hallucinations x. Postterm Pregnancy i. Postpartum pregnancies = associated with placental sulfatase deficiency, fetal adrenal hypoplasia, anencephaly, inaccurate or unkown dates and extrauterine pregnancy ii. Incidence of infants with dysmaturity = 10% when the gestational age exceeds 43 weeks

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1. Infants = withered, meconium stained, long nailed, small placenta 2. Great risk for still birth Unfavorable cervix at 42 weeks gestation = arguable 1. F/u with antepartum fetal testing = twice weekly nonstress tests with amniotic fluid index 2. Risk of fetal death = 1-2/1000 high risk pregnancies with a reassuring NST, contraction stress test or biophysical profile 3. Addition of amniotic fluid assessment = can improve the predicitce value of a reactive NST and reduce the risk of antepartum fetal demise to even lower levels 4. U/S for gestational age determination in the 3rd trimester = no usedful since measurement error is +/- 3 weeks 5. Alloweing spontaneous onset of labor is OK but not without some type of antepartum testing Postterm pregnancies = macrosomnia, oligohydramnios, meconium aspiration, uteroplacental insufficiency and dysmaturity 1. Gestational diabetes = macrosomnia but is not alone a risk factor for post term pregnancies Postterm pregnancy = past 42 completed weeks or 294 days Management of posterm pregnancy 1. Patient records fetal kick counts 2. Begin fetal surveillance at 42 weeks 3. NST, CST, biophysical profile and delievery for nonreassuring testing 4. Is favorable cervix = induce at 42 weeks and if cervix is unfavorable do cervical ripening a. Prostaglanding E1 tablet = most commonly used cervical ripening agents Unfavorable cervix at 42 weeks gestation = controversial 1. Induction of labor in patient with reactive tracing and unfavorable cervix = minimize any risk antepartum fetal demise a. Risk of C-section = increased compared to patient who goes into spontaneous labor b. At 41 weeks = reasonable to follow with antepartum fetal testing like 2X weekly NSTs with amniotic fluid assessment c. Risk of fetal death = 1-2/1,000 in higih risk with a reassuring nonstress test, contraction stress test or biophysical profile i. Addiction of amniotic fluid assessment can improve predictive value and reactive

viii. Amniofusion 1. Meconium staining of amniotic fluid = 3-4X most common in postterm pregnancy a. Likely due to greater length of time in utero allowing for activation of a more mature vagal system or fetal hypoxia 2. Amniofusion = normal saline is infused into intrauterine cavity a. If used for thick meconium it doesnt decrease incidence of meconium aspiration syndrome or even have an impact on neonatal outcomes b. Routine prophylactic amniofusion for meconium-stained amniotic fluids = not recommended c. Its a reasonable approach to treatment of repetitive variable decelerations, regardless of amniotic fluid meconium status ix. Favorable cervix greater than 4cm at 41 weeks = induction x. About 50% of patients with history of postterm pregnancy have prolonged pregnancy with the next gestation 1. Diagnosis of postterm = based on accurate gestational age 2. In patients with irregular menses = do ultrasound prior to 20 weeks 3. If theres reasonable fetal surveillance its reasonable to go past 41 weeks gestation a. But since she had prior C-section it should be considered before 41 weeks delivery y. Fetal Growth Abnormalities i. Patient with gestational diabetes = MOST likely to have macrosomic infant 1. Diabetic pregnancys, macrosomia = result of high maternal blood sugars a. In mothers with little or no end-organ damage (vasculopathy), high blood sugars will also occur in the fetal system i. As result of increased glucose load = fetus secretes more insulin ii. Increased insulin = increased fetal growth since its a growth factor 2. Type 2 diabeteic patient with nephropathy and retinopathy = more likely to have growth restricted infant due to uteroplacental insufficiency ii. Fetal growth restriction = assesement

NST and reduce risk of antepartum fetal demise to even lower levels

1. Growth restricted pregnancy = oligohydramnios is usually found a. Due to reduced fetal blood volume, renal blood flow and urinary output b. Chronic hypoxia = divers blood from from kidney to more critical organs i. 90% of oligohydramnios delivery growth restricted infants 1. infants have high rate of fetal compromise 2. Systolic/diastolic ratio of umbilical artery = Doppler u/s a. Increased ratio = increased vascular resistance i. Common finding in IUGR fetuses b. Normal ratio = fetal well-being c. Vascular resistance increases S/D ratio increases d. Severe resistance = absence and reversal of enddiastolic flor i. Increased rate of perinatal morbitity and mortality and higher likelihood of long term poor neurologic outcomes 3. Antenatal testing = nonstress test, contraction stress test, biophysical profile used in growth restricted fetus to detect possible fetal asphyxia iii. Alterations in uteroplacental perfusion = affects growth and status of fetus as well as placenta 1. This patient has medical disease that affect the vasculature limited substrave availability to the fetus a. Vascular disease = retinopathy and proteinuria iv. Fetal growth restriction = risk factor for cardio, chronic hypertension, COPD, and diabetes 1. Osteoporosis risk factor = family history, slender body composition, prior history, Asian/Caucasian, alcohol, smoking, sedentary lifesylte, excess thyroid or corticosteroids, use of anticonvulsant medications v. Decreased fetal movement a nonstress test was done and reassuring 1. NST = based on principle that when fetus moves the heartbeat normally accelerates a. It assesses fetal health through monitoring accelerations of HR in response to babys own movements b. Amniotic fluid volume = important because a decreased amount raises possibility that baby must be under stress

i. Since theres no growth restriction and fetal status was reassuring, there are no indications for Doppler studies or delivery c. Since there were dramatic decreases in growth = follow patient with weekly non-stress tests vi. Uteroplacental insufficiency = asymmetric growth restriction 1. They have normal length but weight is below normal 2. On u/s the head is spared from reduced blood fluw so fetal abdomen is below normal 3. Usually deted during 3rd trimester and reflects uteroplacental insufficiency 4. Symmetric restriction = all measurments are below normal a. Intrinsic growth failure or early event secondary to one or more organ system anomalies, fetal aneuploidy or chronic intrauterine infection b. Infections = rubella, CMV, syphilis, varicella, toxoplasmosis c. Usually detected in mid trimester vii. Intrauterine growth restriction detected = check fetal well being until delivery is deemed necessary 1. Once or twice weekly testing a. NST fetal heart beat is recorded over a period of atleast 30 minutes looking for accelerations with fetal movement and biophysical profile u/s for fetal movement, fetal tone, amniotic fluid and breathing plus nonstress test b. NSTs = twice weekly with atleast a weekly AFI c. BPP = can be performed weekly d. U/S for fetal growth is not useful if more frequent than every 2 weeks e. Amniocentesis for fetal lung maturity = considered at more advances gestational age viii. Intrauterine growth restriction can be complicated by fetal demise, perinatal demise, meconium aspiration and polycythemia 1. Polyhydramnios = involves production and removal so urinary and swallowing a. Increase fetal urinary output with hyperglycemia and increased renal osmotic load = polyhydramnios b. Abonormal fetal swallowing result of CNS or GI tract abnormalities like anencephaly, esophageal or duodenal atresia, diaphragmatic hernia or primary muscular disease

c. Polyhydramnios = not associated with asymmetric growth restriction b/c assymetric reflects poor blood flow and limited substrate availability i. Oligohydramnios = frequently identified in pregnancies complicated by fetal growth restriction ix. Fetus with enhanced general growth or macrosomnia = weight above 90th percentile for gestational age 1. Can be ascribed to = enhanced growth potential (5060%), normal maternal glucose homeostasis (35-40%), underestimation of fetal age (5%) a. Macrosomic newborns of diabetes mothers experience excessive rate of neonatal morbidity, including birth trauma including shoulder dystocia and brachial plexus injury 2. These infants have higher rates of severe hypoglycemia and neonatal jaundice a. Neonatal acidosis = with poor glycemic control, thus increasing the incidence of fetal demise 3. Poorly controlled pre-existing diabetes = increased risk of congenital anomalies, gestational diabetes is not associated with increased risk of congenital anomalies x. To confirm gestational age need 1 of the following criteria 1. Fetal heart tones have been documented for 20 weeks by a non-electronic fetoscope or for 30 weeks by Doppler 2. It has been 36 weeks since a positive serum or urine HCG pregnancy test was performed by a reliable laboratory 3. U/S measurement of crown rump length = at 6-12 weeks supports gestational age of at least 39 weeks 4. Ultrasound at 13-20 weeks confirms the gestational age of at least 39 weeks, determined by clinical history and physical examination z. Obstetrics Procedures i. Lacerations after episiotomy 1. 1st degree = vaginal mucosa 2. 2nd degree = vaginal fascia and perineum 3. 3rd degree = rectal partial or complete transection of rectal sphincter 4. 4th degree = external anal sphincter, internal anal sphincter and the rectal mucosa 5. mediolateral episiotomy avoids external anal sphincter ii. Requirements for operative vaginal delivery

iii.

iv.

v.

vi.

vii.

1. Forceps applications = cervical dilatation, head engagement, vertex presentation, clinical assessment of fetal size and maternal pelvis, known position of fetal head, adequate maternal pain control and rupture of membranes a. Strict adherence for low forceps delivery does not increase fetal or maternal risks when performed by an experienced operator Placenta previa = placenta covering the os 1. Posterm pregnancies, chorioamnionitis, oligohydramnios and term premature rupture of membranes = indicators for induction and delivery if patient and her baby are candidates Chorionic villus sampling = prenatal test that can detect genetic and chromosomal abnormalitites of a fetus 1. Loss rate of amniocentesis is 0.5% while 1-3% for CVS 2. CVS = 10-12 weeks wihlie amniocentesis after 15 weeks 3. Early CVS <10 weeks gestation = increase in rare limb abnormalities 4. CVS = more attempts, failure in adequate sampling and repeat test later on 5. Pregnancies complicated by isoimmunization can be followed by serial assessment of amniotic fluid for bilirubin Breech infants delivered vaginally = higher risk for neonatal complications 1. Recoment C-section especially since its her first pregnancy 2. External cephalic version = contraindicated in active labor Ultra sounds of crown-rump length = most reliable +-4to5 days in first trimester 1. Fetal heart tones for 20 weeks by non electrionic fetoscope 2. 30 weeks by Doppler Newer vacuum extractors = less maternal discomfort b/c applied to vertex of fetal head and dont take up additional space in pelvis 1. Decreased maternal lacterations 2. Complications of vacuum = lacerations at edges of the vacuum cup particularly if torsion is applied a. Torsion = separation of fetal scalp from underlying structures cephalohematoma and places the fetus at risk for jaundice 3. Transient neonatal lateral rectus paralysis = more requently in vacuum-assisted deliverier, but because

III.

the paralysis resolves spontaneously unlikely to be of clinical importance viii. Early decal = head compression during contraction ix. Amniocentesis = to obtain fetal karoyotype 1. Symmetric fetal growth restriction w/ polyhydramnios = trisomy 18 maybe a. Amniotic fluid should be obtained for FISH testing detects aneuploidy conditions i. FISH takes 48 hours ii. Fetal karyotype 10-14 days 2. Therapeutic amniocentesis = would be used if there were respiratory compromise or preterm labor, both caused by polyhydramnios 3. Maternal fibrinogen levels and Kleihauer-Betke levels are useful in assessing abruption 4. Contraction stress test = fetal well being x. Uterine fibroids in lower uterine segment may obstruct labor by preventing fetal head form entering pelvis 1. Macrosomnia = higher than 4000g in diabetic and higher than 4500 in non-diabetic Gynecology a. Contraception and Sterilization i. OCP = decrease ovarian and endometrial cancer 1. Earlier, higher dose OCP = slight increase in breast cancer but not the most recent lower dose pills 2. OPC = slightly higher risk of CIN but decreased risk for PID, endometriosis, benign breast changes and ectopic pregnancy 3. Side effect = hypertension and thromboembolic disorders ii. Strong risk for cardiac disease = smoking 1. OCPs are contraindicated in women with coronary vascular disease, past use of pill doesnt increase current risk iii. Levonorgesteral IUD = lower failure rates 1. Most disruption in menstrual bleeding amenorrheic 2. Protective against endometrial cancer from progestin release iv. Tubal sterilization post regret = age 1. About 10% of women = regret based on young age a. 20% under 30 and 40% under 25 2. Also high in women not married at tubal ligation age, less than a year after delivery and if there was a conflict between a woman and her partner v. Depo-Provera = unpredictable bleeding that resolved in 2-3 months

1. After 1 year of using it 50% have amenorrhea vi. Vasectomy for husband can be better sterilization 1. Both are 99.8% effective 2. Vasectomy = local anesthesia so less risk 3. Patient is morbidly obese so anesthesia and surgery risks are increased and chronic medical problems = more complications from surgery vii. Patch = comparable efficiency to pill but higher failure rate in women over 198 lbs 1. Patch = transdermal system placed in upper arm or torso and slowly releases ethinyl estradiol and norelgestromi steady serum for 7 days 2. Apply 1 patch in different area each week for 3 weeks then have a patch free week for withdrawl bleed 3. Risks = higher estrogen levels (60% more than 35mcg pill) and increased risk of thromboembolic events viii. Emergency contraceptive pills = not abortifacient no teratogenic effect 1. More effective the sooner they are taken 72 hours and no later than 120 hours 2. Plan B, leconorgesteral pill taken in 1 or 2 doses has few side effects 3. Can be used anytime during womans cycle but may impact the next cycle can be earlier or later with bleeding from light, normal to heavy ix. Ideal candidate for progestin only pills = contraindications to combined pills 1. Contraindications to combo = thromboembolic disease, lactating women, women over 35 who smoke or women who develop severe nausea 2. Progestins should be used with caution in women with history of depression x. Tubal ligation = slight reduction in ovarian cancer 1. No reduction in endometriosis, STI, endometrial cancer, menstrual blood flow b. Abortion i. Septic abortion 1. Fever and bleeding + dilated cervix = septic 2. Threatened abortion = vaginal bleeding, pos preg test and cervical os closed or unaffected 3. Missed abortion = retention of nonviable intrauterine pregnancy for extended period of time dead fetus or blighted ovum 4. Normal pregnancy = closed cervix 5. Ectopic pregnancy = bleeding, abdominal pain and adnexal mass maybe and closed cervix typically

ii. Postoperative endometritis due to introduction of bacteria into uterine cavity at time of D+C 1. Begin antibiotics immediately then do u/s to look for products of conception a. If found do repeat D+C 2. Beta hCG levels wont be helpful 2 days after termination 3. Hysterosonogram = contraindicated when infection is present 4. No indications for laparoscopy iii. Septic abortion management 1. Give broad spectrum antibiotics and uterine evacuation a. Single agent antimicrobials = not enough coverage b. Do laparoscopy if ectopic is suspected c. Medical termination = not best since prompt evacuation of the uterus is indicated in this case iv. Medical abortion = higher blood loss than surgical abortion 1. Early in pregnancy (less than 49 days) both medical and surgical procedures can be offered a. Mifeprisone (antiprogestin) = can be given followed by misoprostol (prostaglandin) to include uterine contractions to expel the products of conception b. Approach = effective 96% and safe and doesnt affect future fertility c. Surgical termination is required in event of failure or excessive blood loss d. Either surgical or medical can have psychological sequelae v. Antiphospholibid antibody syndrome 1. Prolonged dilute Russell viper venom is suggestive 2. Treatment = aspirin + heparin a. 75% success rate with this combo 3. Conflicting evidence for steroid used vi. Patient at 20 weeks requesting abortion and autopsy of fetus = do induction with intravaginal prostaglandins 1. For autopsy = need medical abortion to have intact fetus 2. Abortion is legal up to 24 weeks unless anomaly inconsistent with extrauterine life 3. Dilation and curettage = fetus less than 16 weeks 4. Dilation and evacuation = after 16 weeks 5. Induction with hypertonic saline = high morbitity so not longer performed vii. Patient reports being pregnant but is asymptomatic with no gestational sac in the uterus 1. First step = obtain beta-hCG to confirm pregnancy

viii. Heacy bleeding due to complication of medical termination of pregnancy 1. Managed by D+C 2. Since shes not symptomatic for anemia dont transfuse blood at this time ix. Antiphospholipid antibodies = recurrent pregnancy loss 1. Work up = anticardiolipin antibody status, PTT, and Russell viper venom time 2. Reccurent pregnancy loss = >2 consecutive or >3 spontaneous losses before 20 weeks gestation 3. Etiologies = anatomic causes, endocrine abnormalities like hyper or hypothyroidism and luteal phase deficiency, prenatal chromosomal anomalies, immune factors like lupus antigoaculant and idiopathic factors 4. Cervical incompetence diagnosis = history, PE, and other tests like u/s a. Treatment = cerclage x. Manual vacuum aspiration at 11 weeks GA 1. More than 99% effective in early pregnancy less than 8 weeks 2. Age, partiy, and medical illness = not contraindications 3. Ashermans syndrome = increased risk with subsequent pregnancy termination 4. Complications of pregnancy termination increases with increased gestational age c. Vulvar and Vaginal Disorders i. Recurrent HSV-2 episode 1. Two serotypes of HSV 1 and 2 2. Most recurrent genital herpes = HSV 2 3. Up to 30% of first episode cases = HSV-1 but recurrences are less frequent for HSV1 than 2 4. Classified as initial primary, initial nonprimary, recurrent and asymptomatic a. Initial primary or first episode primary = true primary infection (no history of previous genital herpetic lesions and seronegative for HSV antibodies) i. Systemic symptoms = fever, headache, malaise and myalgias, and usually precedes onset of genital lesions ii. Vulvar lesions = tender grouped vesicles that progress into exquisitely tender, superficial, small ulcerations on an erythematous base b. Initial non primary first recognized episode of herpes with seropositive HSV antibodies

i. Prior HSV 1 infection = partial immunity to HSV 2 infection lessens severity ii. Severity and duration = intermediate between primary and recurrent disease less pain, fewer lesions, more rapid resolution of clinical lesions and shorter duration of viral shedding iii. Systemic symptoms = rare c. Recurrent infections = reactivation of latent genital infections usually HSV2 i. Episodic prodromal symptoms and outbreaks of lesions at verying intervals and varying severity 5. Clinical diagnosis = confirmed by viral culture, antigen detection or serologic tests a. Treatment = antiviral therapy with acyclovir, famciclovir, valacyclovir ii. Trichomoniasis T. Vaginalis 1. Symptoms = diffuse, malordorous, yellow-green discharge with vulvar irritation a. Some women have minimial or no symptoms 2. Diagnosis = saline microscopy of vaginal secretions a. 60-70% sensistivity 3. Treatment = metronidazole 2 grams orally in a single dose a. Alternative = 500mg orally 2X a day for seven days 4. Sexual partner should also undergo treatment prior to resuming sexual relations iii. Lichen sclerosus = chronic inflammatory skin condition mostly in Caucasian premenarchal girls and postmenopausal women 1. Exact etiology is unknown but likely multifactorial 2. Patients have extreme vulvar pruritus and may also present with vulvar burning, pain, introital dyspareunia 3. Early skin changes = polygonal ivory papules involving vulva and perianal areas, waxy sheen on labia minor and clitoris and hypopigmentation 4. Advanced skin changes = fissures and erosions due to chronic itch-scratch-itch cycles, mucosal edema, surface vascular changes and ultimately scarring with loss of normal architecture like introital stenosis and resoprtion of the clitoris (phimosis) and labia minora 5. Treatment = high potency topical steroids 6. Less than 5% chance of developing squamous cell cacner iv. Lichen simplex chronicus

1. Common vulvar non-neoplastic disorder from chronic scratching and rubbing damages skin and leads to loss of protective barrier a. Perpetual itch-scratch-itch cycle develops = susceptibility to infection, ease of irritation and more itching b. Symptoms = severe vulvar pruritis can be worse at night c. Thick, lichenified, enlarged and rugose labia with or without edema i. Localized or generalized changes d. Diagnosis = clinical history and findings + vulvar biopsy e. Treatment = short-course of high-potency topical corticosteroids and antihistamines to control pruritus v. Mucopurulent Cervicitis MCP = mucupurulent exudate visible in the endocervical canal or in an endocervical swab specimen 1. MPC = asymptomatic but some can have abnormal discharge or bleeding 2. Can be caused by Chlamydia trachomatis or Neisseria gonorrhea most cases neither organism can be isolated a. Thus test for both i. Results determines need of treatment unless the likelihood is high or the patient wouldnt return back for treatment 3. Antibiotics should cover both = azithromycin and doxycycline for chlamydia and a cephalosporin or quiniolone for gonorrhea a. Uncomplicated cervicitis need 125mg of ceftriaxone in a single dose b. Ceftriaxone 250mg = upper genital tract infection or PID vi. Lichen planus = chonric dermatologic disorder involving the hair-bearing skin and scalp, nails, oral mucous membranes and vulva 1. Inflammatory mucocutaneous eruptions characterized by remissions and flares 2. Exact etiology = unknown; multifactorial 3. Vulvar symptoms = irriation, burning, pruritus, contact bleeding, pain and dyspareunia 4. Clinical findings = very with a lacy, reticulated pattern of the labia and perineum with or without scarring and erosions as well

5. Well progressive adhesion formation and loss of normal architecture, the vagina can become obliterated 6. Can have oral lesions, alopecia and extragenital rashes 7. Treatment = challenging, supportive therapy and topical super potent corticosteroids vii. Vulvar vestibulitis syndrome 1. Severe pain on vesibular touch or attempted vaginal entry, tenderness to pressure and erythema of various degrees 2. Abrupt onset and its sharp, burning and rawness sensation 3. Pain with tampon inserting, biking, tight pants and avoid sex because of intraoital dyspareunia 4. Vestibular findings = exquisite tenderness to light tough with/without focal or diffuse erythematous macules 5. Primary or inciting event cant be determined 6. Treatment = TCAs to block sympathetic afferent pain loops, pelvic floor rehabilitation, biofeedback and topical anesthetics 7. Surgery with vestibuloectomy = recommended for patients who dont respond to therapy and unable to tolerate intercourse viii. Vulvovaginal candidiasis = caused by C. albicans occasionally cased by other Candida species or yeasts 1. Symptoms = pruritus and discharge a. Other = soreness, vulvar burning, dyspareunia and external dysuria 2. Clincaly suggestion of diagnosis by vulvovaginal pruritus and erythema with or without associated vaginal discharge 3. Need one of the following a. Wet preparation of salie or 10% KOH, gram stain of vaginal discharfe demonstrating yeasts or pseudohyphae b. Vaginal culture or other tests yields a positive result of yeast species i. Micrscopy = may be negative in up to 50% of confirmed cases 4. Treatment for uncomplicated VVC = short course topical Azole formulations (1-3 days) can result in relief of symptoms and negative cultures in 80-90% of patients who complete therapy ix. Genital condylomata or warts = HPV 6 or 11 1. Other HPV types have been associated with cancer like 16,18,31,33,35

2. Vulvar intraepithelial neoplasia = possibility given cervical dysplasia, tobacco use, HIV status 3. Gential condylomata that doesnt respond to topical therapy should be biopsies a. Likewise, vulvar biopsy is indicated to evaluate the hyperkeratoic lesion in this patient and rule out the possibility of vulvar neoplasia x. Bacterial vaginosis = most common cause of vaginitis 1. Infection arises from a shift in the vaginal flora from hydrogen peroxide producing lactobacilli to nonhydrogen peroxide producing lactobacilli allows proliferation of anaerobic bacteria a. Majority of women = asymptomatic, but patients may have thin gray discharge with fishy odor that is worse following menses and intercourse 2. Modified Amsei criteria need 3/4: a. Thin, gray homogenous vaginal discharge b. Positive whiff test i. Addition of KOH release characteristic amine odor c. Present of clue cells on saline micrscocopy d. Elevated vaginal pH > 4.5 3. Treatment = metronidazole 500mg orally BID for 7 days or vaginal metronidazole 0.75% gel QHS for 5 days d. Sexually Transmitted Infections and Urinary Tract Infections i. Patient with STI and high fever = in patient admission for aggressive IV antibiotic therapy to prevent scarring of fallopian tubes and future infertility ii. Hep B screening = blood sample screening to detect outer shell of Dane particles HBsAg 1. Chlamydia = urine or endocervival swab 2. Gonorrhea = endocervical swab 3. HPV = cervival dysplais and genital warts a. Abnormal pap or visualization of condylomatous lesions by biopsy or by HPV DNA hybridization 4. Spirochetes of syphilis from ulcerated lesions can be visualized under darkfield microscopy during primary and secondary infection a. Latent phase = serological testing and for screening do RPR or VDRL 5. Herpes = culture or antibodies in the blood iii. Mildly asymptomatic or asymptomatic UTI = common in females 1. Considered in patients who present with low pelvic pain, urinary frequency, urinary urgency, hematuria or new issues with incontinence

2. Routine screening of pregnant patients for asymptomatic UTI at each prenatal visit is recommended in order to prevent UTI can cause preterm labor 3. Pelvic u/s not indicated at this point iv. Acute salpingitis 1. Symptoms = vary and very subtle mild pain and tenderness or can be dramatic with high fever, mucopurulent cervical discharge and severe pain 2. Diagnostic criteria = lower abdominal tenderness, uterine/adnexal tenderness and mucopurulent cervicitis v. Acute cystitis in healthy, non pregnant women = uncomplicated 1. E.coli = 80 to 85% of cases 2. Other pathogens = staph saprophyticus, klebsiella pneumonia, and proteus mirabilis with citrobacter and enterococci causing only occasional cases 3. Physician must consider antibiotic resistant when determining treatment vi. Herpes simplex virus 1. Highly contagious DNA virus 2. Initial = viral like symptoms preceding appearance of vesicular genital lesions 3. Protrome = burning or irritation may occur before lesions appear 4. Primary infection = dysuria due to vulvular lesions can cause significant urinary retention requiring catheter drainage 5. Treatment = care of local lesions and symptoms a. Sitz baths, perineal care and topical Xylocaine jellies or creams can be helpful b. Antiviarl meds like acyclovir can decrease viral shedding and shorten course of outbreak i. Topical or oral 6. Syphillis = chronic, treponem pallidum, direct contact with infectious lesion a. Early syphilis = primary, secondary and early latent staged during first year of infection b. Latent phase = after that and patient has normal physical exam with positive serology c. Primary syphilis = painless papule appears at site of inoculation i. Then it ulcerates = chancre ii. If left untreated, 25% will develop systemic symptoms of secondary syphilis

IV. V. VI. VII.

low grade fever, malaise, headache, generalized lymphadenopathy , rash, anorexia, weight loss and myalgias 7. HIV = RNA retrovirus transmitted via sexual contact or sharing IV needles a. Many signs/sympstoms 8. Trichomonas = protozoan that is transmitted via sexual contact a. Non-specific discharge and no systemic manifestations vii. Young, nulliparous patient with N/V = inpatient IV antibiotics for acute salpingitis 1. Sexual contacts should be informed and treated 2. Vefotetan or Cefoxitin PLUS doxycycline or clindamycin PLUS gentamicin 3. Outpatient = ceftriaxone, cefoxitin or another 3rd generation cephalosporin like ceftizoxime or cefotaxime PLUS doxycycline with/without metronidazole viii. Trichomonas = flagellated protozoan seen on microscopy 1. Slighterly larger than PNM WBC 2. Seen after KOH to a wet smear of vag secretion 3. Clue cells are vaginal epithelial cells that appear stippled with adherent bacteria bacterial vaginosis 4. Pseudohyphae are seen with candida species ix. Salpingitis = 15-30% of women with inadequately treated gonococcal or chlamydial infections 1. Long term problems = chronic pelvic pain, hydrosalpinx, tubal scarring and ectopic pregnancy 2. Important to do aggressive screening and treatment for STI and counseling for safe sex x. Salpingitis = can be any ascending infection from genitourinary tract or GI tract 1. Aerobic and anerobic organisms like E. coli, klebsiella, G vaginalis, prevotella, group B strep and enterococcus 2. Bilateral tubo-ovarian abscesses e. Pelvic Relaxation and Urinary Incontinence f. Endometriosis g. Chronic Pelvic Pain h. Disorder of the Breast i. Gynecological Problems REI Neoplasia Sexuality Violence