Endometrial CA:

-requires Estrogen exposure! Pre-pubertal girls .005% of having endo cancer! old lady highest
risk.

UWISE QBANK:

Pregnancy: plasma-osmolarity, SVR = Risk of pulm edema . CO (due to HR SV.) total T3,
T4, and TBG.

1st trimester tests: CBC, U/A, chlam/gonor, VDRL, HIV, Hep B, Rubella, PAP, Blood type (type
and screen)

Optional: trisomy 21 test: nuchal translucency, PAPP-A, hCG

2nd trimester: triple or quad screen (15-20 weeks). Comfrm w Amniocenti (PAPP-A (alpha fet), hCG,

3rd trimest: 1hr sugar(24-28wks), comfrm w 3hr sugar, CBC, indirect coombs if rh-, GBS(35
37wks)

uEstriol, + Inhibin A).

B STREP test done at 35-37 weeks. If past pregnAncy complicated with B

strep, dont do test for current pregnancy and just give Abx during birth!
GROUP

SequEntial screen: combined test (1st trimester screen) + quad screen (2nd trimester screen).

chorionic villus sampling detects karyotype and mutations, not neural tube defects.

AMNIOTOMY- artificial rupture of membranes

Hb electrophoresis is best to detect sickle c carrier state. It also detects Heme C trait and
thalasemia minor. blood smear can only ID sickle cell disease (not carrier!)
.6mg normally 4mg if high risk.

FOLIC ACID :

NSAIDS are safe until 32weeks gest, when premature PDA clsoure becomes an issue.

Meconium amnio fluid? do nothing! intubate trachea and suction meconium from beneath glottis
immediately after delivery only IF baby is depressed

severe preeclampsia remote from term(<32 weeks) you can try expectant management instead of
immidiate C/S only if you DON'T have:
Thrombocytopenia <100,000 , inability to control blood pressure with maximum doses of two
antihypertensive medications, non-reassuring fetal surveillance, liver function test elevated
more than two times normal, eclampsia, persistent CNS

MISSED ABORTION- fetus dies but mom's body doesnt realize it, so body acts pregnant. If during
suction and currette fatty tissue is noted, stop suction and move to Laparotomy (open surgery)
[vs laparoscopy], you may have mom bowels!!

Grand multiparity, multiple gestation, polyhydramnios macrosomia: are all uterine distention
risk factors for UTERINE INVERSION. The most common risk factor, however, is excessive
(iatrogenic) traction on the umbilical cord during the third stage of delivery. CCP: globular
mass at introitus

UTERINE PERFORATION would cause small (scant) vaginal bleeding. Cervical laceration would
cause heavier bleeding

Retained products of conception- causes profuse vag bleeding and can cause sepsis.

Suction and curettage risks: anesthesia; uterine perforation; bowel, bladder or cervical injury.

In pregnancy plasma osmolality is less (as well as SVR) which increases risk of pulm edema.
TOCOLYTICS, specially when given with isotonic fluid can cause lung edema. magnesium
sulfate (also used to avoid eclamptic seizures) and nifedipine (calciumCB) are tocolytics.

Diastolic murmors are always abnormal

MOLAR PREGNANCY

weight gain in pregnancy:

metastasizes to lungs so chest xray is appropriate.

10-20lbs if obese
15-25 if overweight
25-35 if normal
30-40 if underweight

cell-free dna screen has the highest detection rates for trisomy 21 and 18. can be done 9weeks!

pre-eclampisa and polyhadramnios are assoc with gestational diabetes.

A speculum exam with a nitrazine test to confirm rupture of membranes is indicated if the
patients history suggests this, or if a patient is uncertain as to whether she has experienced
leakage of amniotic fluid.

FETAL SCALP ELECTRODE

If the fetal heart rate cannot be confirmed using external methods,

then this is the most reliable way to document fetal well-being.

DECELERATIONS :
early decelerations assoc w Head compression!
Variable - cord compression
1

Severe variable deceleration hint to placental insuff (fetal acidosis)

late decelerations- Placental insufficiency,

Tachycardia and sign of sinusoidal pattern on the fetus = fetal anemia. suspect
placenta abruption.

Management of bad fetal tracing

Identify nonhypoxic causes that can explain the abnormal ndings. (Most common
are medications, particularly -agonists or -blockers.)
3. Begin intrauterine resuscitation as follows:
a. Discontinue medications (e.g., oxytocin)
b. Give IV normal saline bolus
c. Provide high- flow oxygen
d. Change patients position (left lateral)
e. Vaginal exam to rule out prolapsed cord
f. Perform scalp stimulation to observe for accelerations (reassuring)
4. Prepare for delivery if the EFM tracing does not normalize. Posibly operative
vag delivery or C/S

C/S indicated when: Uterine scar: Prior myomectomy ( fibroid) or prior classic incision c-section

External Cephalic Version

attempted in patients with transverse lie or breech presentation.
optimum time for external version is 37 weeks gestation, and success rates are 60
70 percent.

check when episiotomies are recommended!! Current data does not demonstrate these
theoretical maternal and fetal benefits of episiotomies and there are insufficient objective
evidence-based criteria to recommend episiotomy, and especially routine use of episiotomy.

Both U/S and MRI can be done in pregnancy. If CT-scan had to be done in preg it could be,
specially in 3rd trimester, but it is NEVER the 1st choice.

CHORIOAMNIONITIS : is an intra-amniotic infection that can occur with PREMATURE rupture of

membranes. Mom-fever, painful uterus. fetus-lethargic pale fever; tachycardia and minimal
variability in heart rate are warning signs for Infant sepsis.
Tx. get cervical cultures; then start IV antibiotics; then schedule delivery.

PPROM:
Tx: if contxns dont give Tocolytics
- Before viability (< 24 weeks): Manage patient with bed rest at home.
- Preterm viability (2433 weeks): Hospitalize. Give IM betamethasone if < 32
weeks. Obtain cervical cultures. Begin prophylactic ampicillin and erythromycin for
7 days.

 > 34 weeks): Initiate delivery.

ENDOMETRITIS : risks- prolongued rupture of mem, multiple vag exams, C/S.

fever, painful uterus
Tx. Gentamycin + Clindamycin

Give a positive pressure airway and naloxone to treat NARCOTIC INDUCED CNS or respiratory
depression in newborns. Do not give naloxone if mom has a history of substance abuse.

If mom has HIV treat newborn with Zidovudine (azt) right after delivery, do HIV testing in 24
hours.

4100gr = 9 lbs

THIRD

TRIMESTER BLEEDING :

ABRUPTIO , PLAC PREVIA, VASA PREVIA, UTERINE RUPTURE

Only abruption and uterine rupture are painful bleeding

Place ext fetal monitor, IV fluids, PTT,, U/S to r/o PLAC PREVIA!!
DONT do finger or speculum exam until Placent Previa is r/o
VASA PREVIA: umbilical veins over os. Triad: ROM, painless bleed, fetal bradycard

Mcc of postpartum hemorrhage(PPH) is a uterine atony!

PPH= >500ml in vag delivery or 1000ml in

C/S.

Manage with Uterine Massage or Uterotonics (oxytocin, methylergonovine,

carboprost, Misoprostol).

Mom w HTN: give Misoprostol! Methylergonovine and Carbopost are C/I in HTN!

breast feeding decreases risk of OVARY CA.

Progestin is the only contraception that can be used while breast- feeding. And started right after delivery

Combined hromones- wait 3 wks after delivery to avoid DVT. IUD-wait 6wk

ECTOPIC PREG -

The #1 thing that ^ risk is a past

ECTOPIC PREG !

absence of an adnexal mass does not rule out ectopic pregnancy.

Unruptured: Methotrexate or salpingostomy
Ruptured: Salpingectomy (Remove tube!!)

by 5 weeks or hCG>1500 an Vag U/S should see baby, if not it may be ectopic. Abd U/S: 6weeks
and hCG >6,500

HCG

CERVICAL INSUFF

should double every 48hrs until 8 weeks!! use this to find ectopics (which wont double in
48hrs).
SHORT CERVIX BUT NO HX OF 2ND TRIM LOSES: MONITOR

 >2 2ND TRIMES L OSES: CERCLAGE AT 14-16 WEEKS

Smoking , alcohol, radiation increase risk of

DIABETES:

SPONTA ABORTIONS.

Normally screen for GESTATIONAL

DIABETES

between 24 and 28 weeks. but if

patient is obese with Strong family history screen as soon as four weeks!!
Target:

Fasting <90 1hr after food <120

Congen Malform assoc w A1c>8.5 in 1st trimester

Gestational Diabetes mostly appears in 3rd trimester! So it doesnt cause cong malf
Routine for diabet mother: check A1c e/trimester, monthly sonos and biophs prof,
Start weekly Nonstress tests and AFI(amnFindx):

At 26weeks if poor sugar contrl

At 32 weeks if using insuling, microsomia, htn

Target delivery is 40weeks (due to delayed fetal maturity)

Induce earlier if poor sugar cntrl OR fetus is >4500g

HTN AND PRECLAMP:

Gestational HTN- must develop after 20weeks!!. Otherwise its chronic HTN
mild preeclampsia = >300 prot and >140bp

severe= >500 prot or >160bp or warning signs (headac, vision chang, pulm edem,

oliguria, v Platelets, ^Liver enz )

Monitoring:
Serial sonograms (evaluate for [IUGR])
Serial BP monitoring and urine protein
ONLY TX SEVERE HTN >160/100
Maintenance:

Methyldopa or labetalol: 1st line best, preserves placentl blood f.

2nd line nifedipine (CCB)

Acute tx for severe preclamp or eclamp and during labor:

IV Hydralazine or Labetalol

If PREECLAMPSIA give magnesium during labor and for 24 hours after

MAGNESIUM

OVERDOSED

can cause respiratory depression, give calcium gluconate.

 Magnesium overdose causes loss of deep tendon reflex then respiratory depression
and eventually cardiac arrest. Levels should be <7.
Nulliparity is risk f for preeclamp

HYDROPS

FETALIS =

fluid in 2 cavities (ascites, pleural effusion, etc..)

Rhogam: at 28 weeks; within 3days after birth; after fetus loss; w amnio, Chorio; w heavy vag
bleeding.

preterm labor cant occur before 20 weeks!

GROWTH

RESTRICTIONS

Asymmetric: Uteroplacental insufficiency

Symmetric fetal growth restriction= infxn, congenital dfct, early event of organ
prob.

PARTIAL MOLE: part of a mole (not a full mole) cause it has fetal parts and mom genes. the
uterus doesnt enlarge. XXY. hCG doesnt super increase. abd pain.

MASTITIS -

2DRY

if fever remains after Abx or if theres fluctuant mass its an abscess > do drainage

AMENORRHEA :

(= 6 months without periods)

Check: 1-pregnancy, 2-Prolactin, TSH, 3-Progestin challenge, 4-Estradiol, FSH, LH.

Progestin challenge: (oral pills x 7 days)
+ bleeding: its PCOS
Estradiol, FSH, LH:
nl Estradiol = outflow tract problm
Low Estradiol
Low FSH/LH = Hypoth or Pit problm
High FSH/LH= Premature Ovary Failure

FIBROIDS(leiomyomata): 30-40s w Chronic menorrhagia after previous normal periods.

GnRH agonist (Leuprolide) can shrink fibroid temporarily to make surgery easier
or correct anemia.
Hysterectomy is Tx of choice if symptoms persist despite medical therapy.
IF Pregnancy is Desired do MYOMECTOMY (just removing fibroid)
Submucosal fibroid causes abortions. Subserosa-blocks ureters.

40s w INTERMENSTRUAL BLEEDING think- endomet hyperplasia, endomet polyp, endome

CA, and Fibroids.

ENDOMETRIAL
tissue.

HYPERPLASIA -

due to Estrogen. Its an of Glandular (monthly shedding)

CA risk
young woman with anovolatory cycles can have endometrial hyperplasia (dx with biopsy)

Management of an endometrial POLYP includes the following: observation, medical management

with progestin, curettage, surgical removal (polypectomy) via hysteroscopy, and hysterectomy.
Observation is not recommended if the polyp is > 1.5 cm. In women with infertility and
Polyps polypectomy is the treatment of choice. While her inability to get pregnant may be more
complicated than just her polyp, removal of the polyp should occur prior to infertility
treatments.

Rapid growth of a pregnacy looking mass inside uterus: think Leiomyosarcoma

21-65
Pap q 3yrs
30yrs can do pap +HPV q 5yrs
Pap with ASCUS: repeat in 12mo or do HPV (HPV pos or repeat pap abnorm= do copolscopy) if
not resume routine.
24yr with ASCUS or CIN 1, 2 : Observe with serial Paps. if u get ASCUS again keep
observing
colposcopy performed only if the repeat cytology reveals ASC-H (atypical squamous cell cannot rule out high
grade squamous intraepithelial lesion), AGC (atypical glandular cells) or HSIL (high-grade squamous
intraepithelial lesion).

Women who have a history of cervical cancer, are infected with HIV, have a weakened immune
system, or who were exposed to DES before birth should not follow these routine guidelines.

CRYOTHERAPY and more invasive LEEP are tx for dysplasia, not cancer.

CERVICAL CA when metastatic causes hydronephrosis> flank pain> edema.

Post Coital bleeding is Cervical CA until proven otherwise!

80-90% of women with ENDOMETRIAL

CARCINOMA

present with vaginal bleeding or discharge.