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Disease/Etiology PROM/PPROM (premature rupture w/o contraxns before or after 37 wks) (infexn) (VS preterm labor= early ut contraxns)

Sx -early vaginal fluid leakage -no ut contraxns -ROM w/o contraxns < 37 wks DDI: normal vaginal secretions, incontinence, infection and associated discharge, or fluids such as semen or blood.

Diagnosis -sterile speculum exam (NO DIGITAL EXAM- decs latency) verify fluid pooling -Nitrazine paper test (yellow --> blue) cuz pH amn fluid alkaline blue 7.1-7.3 [false + - semen, blood, basic urine, cervical mucus is thicker, trich vaginitis) false - minimal leakage) -Ferning on slide (thin branches due to NaCl)

Management ALL PTS -informed consent -if chorioamnionitis fetal infexn then IV Abs and immed delivery! PROM -Before 24 weeks, expectant mngmt + latency Abs - 24-31 weeks gestation, GBS prophylaxis + single-course of steroids and latency antibiotics. - From 32-33 weeks GBS prophy + latency antibiotics (delivery if lung mat) -At 34 wks delivery + GBS prophy ->37 wks -90% spont delivery in 24 hrs, if not watch 12-24 then induce -if PPROM -anovaginal GBS culture -cervical G/C culture 1 dose steroids if 24-34 weeks -inpt observation: continuous FHT, contraxns -US: AFI + height -signs of chorio: fever, tachy (WBC unreliable esp w/steroid use) -watch 4 cord comprexn: esp if not vertex (hard 2 tell by FHT always) - standard latency drug regimen (7 days)IVamp 2 g IV + erythro 250 mg IV q 6 hours for 2 days, then oral amox 250 mg + erythromycin 330 mg q 8 hours (for 5 days.)

Risk Factors/ Sequelae -Tocolytics CIed -Fetal sequelae: RDS, sepsis, umb cord prolapse, demise, amniotic band -Maternal seq: chorioamn endometritis, sepsis, infexn, retained placental tissue, postpart hemmorhage, abrupxn

Preterm Labor

-preterm regular contraxns b4 37 wks + cervical -contraxns w/o ROM < 37 wks

1) Recognize Sx -> prompt 2 doc -cramp, backache, abdl P/D, vagl D/C (mucus/water/blood), painless ut contraxns/tightening 2) Fetal fibronectin (EC glycoprotein in cervical mucus) (hi NPV- preterm birth in next 7-14 days OR likelihood of birth b/w 22-34 wks) 3) Transvagl US (cervical length)(<2.5 cm) 4) Treat BV in preg (Flagyl) 5) Monitoring during immed premie @ Triage: -Extl toco (freq of contraxns) -sterile speculum (cervix ) -monitor bleeding (previa/abrup) -UA/culture (check if UTI) -GBS anovaginal cultures (give intrapartum Ab prophy) -G/C cultures (if nec) -US (GA, AFI, plac, prez, anomalies) -amniocentesis (chorioamn -> bac, WBC, low gluc, hi LDH-> immed deliver regardless of GA) (chorioamn = CI tocolysis- need 2 expel NOT retain)

Goal: delay delivery til maturity Tocolytics to extend 48 hrs so can allow steroid Tx x2 Tx: 1) Prophylactic bed rest, hydraxn, sedaxn, tocolytics 2) weekly IM prog (17ahydroxyprog) (4m 16/20-36 wks) OR vagl prog supplements 3) Tocolytics (=delay delivery) (until at least steroids can be admined)(MSO4 > nifedipine) 4) Steroids optimal if: Single dose @ 24-34 wks (betamethasone or dexa) + can do rescue Types of Tocolytics: #1) MgSO4 (compete Ca) (preecl seizure + tocolytic) 4-7: Therapeutic levels (HA/ flush) 7-10: Loss of DTRs >12: Resp deprexn 15: Cardiac arrest CI: HypoCa or myas gravis 2) Nifedipine(Procardia) (CCB) (hypoTN/HA/fetal UPI = CO202) (- may worsen Mg tox) 3) B-agonists (cAMP-> Ca) (terbutaline/ritodrine) (HypoTN, tachy, anxiety, chest tight, EKG, pulm edema-esp w/IVF) (relative CI: CAD + CRF) 4) Indomethacin (PG) (premature PDA, renaltox, oligo) [Vs. Epilepsy #1 Phenytoin]

Premie RFs: #1 Twins -Large ut (twin/poly/ fibroid/septate) -Prev premie -AA/ smoker -Cervical insuff -Infexn (BV/UTI) -Plac (previa/abrup) MOA: 4 p.ws 1. HPA activaxn (4m stress) 2. Inflammxn (infexn 3. Decidual hemorr (abrupxn) 4. Pathologic ut overdistexn (twins, poly) -Fetal sequelae: -NRDS (ground glass) (-> BPD) -IVH (cerebr palsy) (transcranial US) -NEC (ischemia) -Sepsis/neuro/seizure -Poor T control -CI 2 Tocolysis: chorioamn, advanced labor/dil, mature fetus, severe anomalies, severe bleeding/abrupxn, severe preecl, fetal distress/plac insuffic

Disease/Etiology Preeclampsia (HTN + proteinuria after 20 weeks) [systemic vasospasm due to placental factors release)

Sx Criteria: 1) HTN (>140/90 2xs b/w 6hrs-1 wk) 2) Proteinuria [>300 mg/24-hr urine or 2 random samples >1+) -ALSO: nondependent face/hand edema (NOT part of criteria) DDI: -Chronic HTN <20 wks gestaxn or >12 wks postpartum -Gestaxnl HTN (no proteinuria

Diagnosis -Labs: -CBC: hi Hct (= worse constrixn/ low intravasc volume), platelet count, -Liver: LFTs -Kidney: 24-hour urine protein, creatinine clearance, serum uric acid (prop 2 progrexn) AST, and creatinine levels. -Coag: PT/PTT Fetus: -US: confirm age, AFI (oligo), weight (IUGR < 10th) -NST/BPP (placenta)

Management -Mild preeclampsia =Outpatient setting if BP< 160/100, there are no maternal Sx, compliant, no abnormal labs, urine protein < 1000 mg in 24 hours, fetal statusnormal. -No HTN meds cuz might mask preeclamp progrexn - Do watch outpt : mothers daily weight, watching for symptoms of severe preeclampsia, biweekly prenatal visits, weekly 24-hour urine dipstick for protein, and labs 1-2 times a week (such as LFTs, platelets, and hematocrit). Fetal monitoring should include daily movement, NST twice a week or BPP once a week, and US once a month. -Severe preeclampsia= (>160/110 give HTN meds) Inpatient mngmnt -routine labs -can induce after 34 wks if maternal Sx still (vagl delivery unless other risks) -Drugs (maintain sys 140-160 diastolic 90-100 (cuz still need enuf fetal blood flow + dont want maternal ischemia) -labetalol (a1 + b1b2) CI in pts w/CHF or asthma (aes: tremor, HA, low CO)(neonatal hypogly + iugr) -hydralazine (peripheral art vasodil) (aes: hypoTN, lupus-like, fluid retention, tachy,HA, palpitations and neonatal TCP -nifedipine (Ca-ch blocker) -methyldopa (false nt) -thiazide (less plasma vol) -MgSO4 for seizure prophy (seizure + tocolytic to prevent ut contraxns) (competitively inhibs Ca) (TOXICITY: lose DTRs, flush/somnolence, muscle paralysis, resp deprexn, cardiac arrest)

Risk Factors/Sequelae Fetal sequelae: IUGR, premie, oligo, hypoxia, cardio, demise. Mother: renal failure, pulmonary edema, placental abruption, liver failure, eclampsia, HELLP sx, stroke, cardiovascular compromise and death. -Eclampsia (+ seizures) -HELLP hemolysis, elev liver enzs and low platelets. hemolysis high LDH (>600), elev bilirubin, or aberrant peripheral blood smears; elev liver enzs AST > 70 U/L, and low platelets < 100,000/mm3. Risk factors 4 preecl: Nulliparity, multigestaxn, AMA, chronic HTN, chronic HTN/DM, Ehler-Danlos, APL, obesity, AA race

Severe preeclampsia Criteria: -HTN [2 BPs> 160/110, -Proteinuria > 5 g in 24 hours (or two random samples of 3+), -oliguria, -TCP (<100,000 uL), -inced LFTs with RUQ/ epigastric pain, -pulmonary edema severe visual or CNS changes.

Gestational DM (inced placental hormones cause insulin resistance: hPL, P/E, PRL, cortisol, TNF-a) (GLUT-1) (normal glucosuria: 300 mg/day so urine glucose less reliable) (HbA1c/blood glucose)

Screening 24-28 weeks Screening: 50 g 1-hr OGTT >140 Diagnosis: 100 g 3-hr (2/4) Fasting: 95 1-hour: 180 2-hour: 155 3-hour: 140 Preg F/U: Q1-2 wkly glucose + q1 monthly US fetalsize (esp 18-20 US cong -> ECHO if abnormal) /HbA1c + wkly NST (>32) Induce at: Term (39) >4,500 g = C/S Postpartum F/U: 50% get T2DM -75 g 2-hr OGTT (6wks-2mos): 140 -annual glucose checks -Caution w/ hi-dose OCP (glu) (IUD + lo-dose ok) Glucose goals: Fasting < 95 1-hr < 180 2-hr < 155 3-hr < 120

T1DM: -Optho 1xs 1st trim -Watch for progrexn of CRF (watch Cr etc) -may not need much insulin few days postpartum

Tx: strict glucose control 1) Home glucose checks: 4xs Goals: fasting < 95 1-hr post prandial <130-140 2-hr < 120 2) Drugs: A1- diet-ctrlled (30-35 kcal/kg lean body wt)(45% CHO, 35% fat, 20% protein) (=+good outcomes) -if obese: only 30% calorie-restrixn ok A2- insulin, glyburide, metformin (1st trim only) (start insulin if (cant do goal: fasting<105 or 2-hr <120) -NPH (medium) + lispro or regular insulin (fast) (insulin reqts inc: 28-32 wks) 3) Fetal lung maturity testing: L/S not as accurate -Phosphatidyl glycerol levels or fluorescence polarization instead 4) Labor mngmnt: -if well-ctrlled: induce at term (38-39 wks) -if not: 37 wks C/S (macrosomia) -delivery: strict glucose ctrl: goal 100 or give D5W or fast-insulin -if give beta: need insulin to counteract steriod hypergly

Maternal sequelae: Premie, poly, preecl/HTN, worse DKA/nephron/retino; UTI/pyelo/infexns (poly -> abrup, PPH ut atony) Fetal sequelae: GDM: (Macrosomia) -Macrosomia (<4500 g or >90th) -shoulder dystocia, prolonged labor, CPD, brachial plexus (Erbs + Klumpkys) -clavicle fracture -caudal regrexn -meconium/NRDS - hypoCa, hyperbili, and polycythemia. Preexisting DM: (IUGR)(UPI) Cong anomalies (organogenesis) -#1 Cardiac (VSD/PDA/TOV) CNS, GI, GU, skel - matl DKA/nephro/retino BOTH (ppor ctrl) -neonatal hypogly -spont AB/IUFD/mis -LT: DM/obesity/psy RFs: (earlier screen) -age>25 yr, obesity (BMI > 30), hx of GDM, delivery of a prev LGA infant, previous IUFD, nonwhite, or strong FH of diabetes.

Third Trimester Bleeding

DDI: #1 plac abrupxn #2 plac previa -vasa previa -ut rupture -vagl laceraxns/ vulvar varicosities -cervical ca/ cervicitis/polyps/normal friable tissue in preg

Workup: 1) History & Physical (Hx of coagulo - petechiae, cervical CA, hemorrhoids) (PE: vitals, FHT Doppler, resp + cardio Sx, IV access) 2) Pelvic US r/o previa! (before digital exam) -sterile speculum: vag/cervix 3) IF LOTTA HEMORR: a) 2 large-bore IV for crystalloid fluid b) Blood: CBC, coag, type & crossmatch 4 units PRBCs + if Rh neg: Kleihauer-Betke test to det RhoGAM dose c) staff ready for urgent C/S OR admit to hospital for obs PLACENTA PREVIA (painless bleeding, soft nontender uterus) (C/S) Sx: (sentinel bleed @ 28 wks when lower ut stretches and thins--> usually resolves by 3235 wks) Dx: 1) transvagl US (>abdl US FP if post placenta) 2) Bleeding usually stops in 1-2 hrs: observaxn, IVF, bed rest, maturity steroids 3) if severe bleed or at term: deliver 4) if stable can do outpt if compliant: schedule C/S at 36-37 wks + amnio for fetal lung maturity RFs: -prev previa, prior C/S ut surgery, multip, AMA, cocaine, smoke. Sequelae: -plac accreta (exts 2 myo)( if prev C/S) -> r hysterec -3rd trim bleeding -premie/-cong anomalies(card, CNS, GI,resp)

PLACENTAL ABRUPXN (painful bleeding, hyperT tender uterus, rapid delivery)(vagl -> C/S) (retroperitl concealed hemorr) (bleeding in decidua basalis -> prem sep of placenta) (--continus bleed, FHT tachy -> brady, decels, minl var, IUFD) Dx: 1) US 2 r/o previa 2) =CLINICAL EXAM Tx: 1) Monitor vitals, fluids, C/S delivery if severe hemorr or term, fetal transfuxn if anemic, RhoGAM if Rh neg AEs: Couvelaire uterus (serosa purple from blood pening ut) -TCP, hi Pt/PTT, low fibrinogen/DIC -> check D-dimers) RFs: -prior abrupxn, preecl/chronic HTN, twins, AMA, multip, cocaine, smoke, chorioamn, trauma, poly. VASA PREVIA (fetal BVs over intl os below presenting fetal parts) (velamentous cord inserxn b/w chorion + amnion) (fetal BV rupture) Dx: 1) Watch for pulsating vessels on digital exam, speculum exam, during AROM 2) If mixed blood: do Apt test (NaOH)(Mom: yellow-brown + Baby: stays pink) UTERINE RUPTURE #1 urgent C/S!! 2) urgent lap -> or else hysterec if cant save uterus RF:prev C/S ut scar

Postpartum Hemorrhage

>500 cc vagl >1000 mL C/S -ALSO Sx 10% drop in Hct -need 4 transfus -tachy/cap refill/ ortho hypoTN/ narrow pulse P DDI: #1) ut atony 4 Ts #1) Tone -ut atony #2) Trauma -ut laceraxns -stretched ut (twins/poly) #3) Tissue -retained plac -accreta #4) Thrombin -hemophilia -heparin Tx severe bleeds

Genl Workup Genl Measures -Call for help -Eval blood loss/pt status -Have OR on standby Genl ABCs 1) 2 large-bore IV access 2) Rapid crystalloid infuxn 3)Blood type/cross-match-> administer PRBCs (impt) (PRBC= RBC, WBC, plasma) 4) Periodic H&H and coag 5) Monitor oliguria Genl Rapid Eval (for DDI) 1) Immed bimanual massage (until other Tx ready)
-palpate soft boggy uterus (atony) -paplate for retained plac frag/rup -inspect perineum, vagina, cervix (laceraxns, ut inverxn, hematoma) -reinspect placenta for missing (R/O laceraxns -> try bimanual massage/ oxy uterotonic --> if fails, OR for D/C -> if PPH inflatable balloon/packing -> lap

Retained Placenta (x cleavage b/w zona basalis/spongiosa) (plac accreta/increta/percreta) 1) Manual removal (2 fingers) 2) Manage any ut atony as above 3) US (2 confirm complete removal) 4) Suction curettage or large sharp curettage (OR w/ US guidance) (Watch out ASHERMAN!) 5) Watch out for accreta (FATAL HEMORR- OR 4 explor lap) 6) If accreta-related hemorr: Try packing --> often Hysterectomy Genital laceraxn/hematoma 1) Immed laceraxn repair (no blind sutures)(can use packing) 2) Hematoma (lotta pain)(watch H&H can be occult): observe stable <5 cm hematoma , vitals, oliguria, ice packs) 3) If large/hemorr: Get help, go to OR -assistance 4 adeq exposure -drainage/ligaxn/niterlocking sutures -> vaginal packs [Carefully watch out for hemodynamic status: occult bleeding into retroperitoneal hematomalow back/rectal pain-> CT/US: dissecting tissue planes like ischiorectal fossa) Coagulopathy 1) Collect blood in tube to see if clotting ->Replace factors 2) ID cause w/labs: PT/FVL/AT3 3) Watch out for infexn, hemorr, amn fluid embolism Amn Fluid Embolism (5 findings: RDS -> cyanosis -> CV collapse -> hemorr -> coma) (severe coagulopathy/DIC) (Tx: cardio/lung support)

AEs -Asherman Sx (vigorous D&C) -Sheehan Sx (pituitary hemorr)no lactaxn/amenorrhea

Plac Accreta Rf: -previa -prev C-sexns

#1 Ut atony 1) Immed bimanual massage -palpate soft boggy uterus (atony) 2) Uterotonics: (only if ut soft/boggy) -oxy prophy infuxn -> methylergonovine (x HTN/heart/lung/kid/liver pts) or PGs: misoprostol (PGE1) + dinoprostone (PGE2) + Hemabate (15-methyl PGF-2a) (x if asthma/CHF /glaucoma pts) 3) IU comprexn/tamponade: ut packing or Bakri balloon (+ fast, retain fertility, less aes) 4) Surgery Tx: 5) Uterine comprexn sutures (B-Lynch) (OLeary sutures: bilatlly tie off uterine arts) 6) Sequenxl art ligaxn/embolizxn (uterine, ut-ov, then intl iliac art) 7) Hysterec(r/o retained plac w/D&C 1st)

Uterine Inverxn 1) Manual replacement (under halothane anesthesia/uterine relaxers: terbutaline, MgSO4, nitroglycerin) 2) Surgical under anes Prevexn Active management of stage 3 of labor (immediate plac removal + admin oxy uterotonic)

First Trimester Bleeding (Reproduc-age woman w/: amenorrhea -> unilatl abdl pain + vagl bleeding regardless of OCP)

DDI: AGE -Ectopic preg (tubal/ov/interstixl/cervic al /heterotropic/abdl) -Spont abortion (threatened, inev, incomplete, complete, missed)(recurrent preg loss) -Induced AB -Gestaxnl Trophobl Ca [-hemorrhagic corpus luteal cyst -placental polyp -appendicitis/caliculi] [implantaxn bleeding embryo implantaxn into endometrium causes bleed] Initial Workup 1) #1 R/O ectopic 1st (can rupture)-> US!

ECTOPIC PREG (improper blastocyst implaxn) (#1 fallopian tube- ampulla) Dx: 1a) Preg test (serum- 5 days, urine: 14day) 1) low or plateau B-hCG (normal: double q 48 hrs, 100K @ 10 wks,then 20-30k) 2) Pelvic US (adnexal mass: cyst w/echogenic ring) 3) Transvagl US: r/o heterotropic preg (IUP + ectopic at same time) Transvagl US @ 5 wks (IUP Dx: IUP can be seen @ hCG 1,500-2000 or FHR @ hCG >5,000) Transvagl US for IUP: -4.5-5 wk: gestaxnl sac (1,500-2000 B-hCG) -5-6 wk: yolk sac -fetal pole: 5.5-6 wks Transabdominal US: (l8r) 5-6,000 hCG (IUP= transvagl US +chorionic villi in tissue)

Other Ectopic Sites: Ovary (US echogenic cyst on ovary) vs. Interstixl/cornual preg (presents wks l8r cuz more space for expaxn) (proxl tube w/in uterine wall)(swelling latl to round lig)(-moassive hemorr -> hysterec) vs Cervical Preg (Hx of D&C)(MTX ok) vs Abdominal Preg (can continue preg or remove surgically, only 10% survive --> ALWAYS leave placenta behind cuz massive hemorr otherwise) vs IF TRUE HETEROTROPIC PREG (IUP + ectopic more w/IVF now)(try to preserve IUP:CI 2 use MTX + use KCl) SPONT AB: (dont need karyotyping unless recurrent Ab) (will not lead to future spont ab) -Types: -Threatened (bleeding)(ae: premie/ LBW) (Sx: bleeding -> THEN abdl cramping)(Tx--> none, reassure back to normal life) -Inevitable (open os/dilaxn) -incomplete (some POC)(suxn D&C or expectant if no bleed) -complete (no POC)(US to confirm empty uterus or D&C/ oral methylergonovine for hemostasis/ut contraxn + vaginal rest-> mild analgesic + RhoGAM) -missed (all POC retained) Recurrent Preg Loss (= now karyotype)(=r risk future loss) (>2 ABs)(Early loss= chroml) (Late loss= anatomic/autoimm/ Asherman) Asherman: IU synechiae after D&C denudes past basalis -> scar tissue--> Dx: webbed scar pattern on hysteroscopy--> Tx: synechiae scar lysis + postop E to reprolif endometrial lining) APLA: Dx: (Lupus ANA + anti-cardiolipin --> anti-Smith + anti-dsDNA) --> Tx: low-dose aspirin + hep

Sx: -Reproduc-age woman w/: amenorrhea -> unilatl abdl pain + vagl bleeding regardless of OCP -adnexal mass/cervical motion tenderness -pelvic mass posterolatl to ut -abdl bleeding/tenderness/ distexn

4) Low P (prog <5) = only 4 screening =nonviable preg (doesnt tell u locaxn if ectopic) (>20 = viable preg. IUP or ectopic tho) 5) Definitive #1= lap = direct visualizaxn (FN: early ectopic vs FP: hematosalpinx) 6) Curretage of uterus once u rule out IUP: can help r/o ectopic 7) Culdocentesis: positive culdo ID hemoperitoneum (due to ruptured ectopic or even ruptured corpus luteum) vs clear

fluid (=unruptured ectopic or no ectopic) vs purulent fluid (appendicitis or salpingitis infexs) Tx: surgical or MTX Large, ruptured ectopic 1) IVF/blood/pressors 2) lap: salpingostomy if possible -> salpingectomy (remove fallop tubes) (follow serial hCG) (give RhoGAM) Small <4 cm, unruptured ectopic (B-hCG <5,000 most successful 92%): 1) IM MTX (folate antag) x1 (monitor ALT, Cr, serial B-hCG should dec in 4-7 days or give another dose) (RhoGAM if Rh neg) (common ae: abdl pain- give NSAID) MTX aes: -N/V/D/Dizzy/stomatitis CI to MTX: Absolute: -BF/HIV/alcoholic liver Dx/ anemia-TCPblood dyscrasia/ active lung dx/ peptic ulcers/hepatic-renal Relative -Gestaxnl sac >3.5 cm -Embryonic cardiac activity Ectopic RF: (=Inflammaxn theory) #1 Prior ectopic preg -Hx of PID/STD (chlamydia indolent vs gonor rapid onset) (salpingitis) -prev tubal/pelvic surgery (adhexns) -Endometriosis -IVF / smoking/AMA -IUD/DES/exog E/P/preg after sterilizaxn

Dx: 1) Karyotype 2) Late loss- hysteroscopy, lap (septate uterus/anatomic) Elective Aborxn: -(1st trim: vacuum suction curetage)(2nd trim: PG/suxn/ extraxn forceps thru cervix) (Outpt if < 49 days: => ut contraxns-> mifepristone ( Prog) + MTX ( folate) + misoprostol (PG- directly stim myometrium) aes: -ut perforaxn, cervical laceraxn, hemorr, incomplete, infexn --> oral Abs + antipyretics --> suxn D&C if incomplete -Septic aborxn (illegal aborxns): shock/hemorr/renal failure --> broad Abs + IVF + hysterec -Post-Abortal Syndrome: ut atony after aborxn-> hematometra (blood in ut) ->open cerxiv/bleed/ softer uterus (looks like incomplete Ab picture) -> Do suxn D&C either way -> Ab + ergot derivative afterward

UTI/Renal Disease

BgrO -(more ureter dilaxn/stasis -> ProgSM dilaxn + mechanical ut comprexn + hier urine pH bacl media) -R>L cuz ut dextrorotaxn + L-sided cushioning by sigmoid colon) Order: Asymp bac.UTI -> cystitis/pyelo -> sepsis/ARDS

ASYMP BACTERURIA(> 100,000 colonies)/UTI Dx: -UA/culture -> LE, nitrates, hematuria, WBC (E. Coli-PEEKSS(G-aers)-> NACTS 7 days + pyridium analgesic for dysuria ORANGE PEE --> test of cure in 1-2 wks) (nitrofurantoin, amp, cephalexin) AEs: premie, LBW (<2500 g) PYELONEPHRITIS (R>L) Tx: CAG --> N (Sx: CVA, fever, dehy) (premie, ARDS, sepsis) 1) Hospitalize for IV Abs 2) IVF + IV Abs until asymp for 24-48 hrs (ceftriax/cefotetan/cefazolin + amp/genta) 3) then oral Abs (10-14 days total) 4) Supprexn Tx for rest of preg: w/ nitrofurantoin 5) If no improvt/recurrent: r/o UT obstruxn/caliculi (US) or new Abs. F/U 6 wks PP for urology workup (pyelo can also inc contraxns= premie: give tocolytics ( contraxns cuz fever, E Coli phospholipase A-> PGs)

NEPHROLITHIASIS (Sx like pyelo, NO FEVER + hematuria)(less renal colic in preg cuz ureteral dilaxn) Tx: 1) Hydraxn + expectant mng 2) Strain urine for stones 3) If infexn: urology consult for drainage w/ureteral stent PREEXISTING RENAL Dx ( IUGR, HTN) (OK if mild Dx (Cr < 1.5)/ transplant)(BAD if mod/severe CRD) (outcome prop 2 Cr/HTN levels) Inced screening in preg: 1) serial fetal assessments indicated

FetalGrowthRestrixn -IUGR -Macrosomia

IUGR (<10th)

Dx: 1) Serial fundal hts: If size<date discrep >2 cm -> do US (#1 confirm correct GA) 2) US: biparietal diam, head circum, abdl circum, femur length (AC or EFW < 10th = suggests IUGR) 3) Serial US q2-3 wks + anatomy too (cuz lotta congl defects) + AFI (r/o oligo too) [ SGA always small Trisomy 21/18/Turner VS IUGR fall off growth curve] 4) Doppler umb art / MCA velocimetry: (+reduce intervexns nec) -S/D ratio = plac resistance mmnt - plac resist = S/( = 1.8-2 normal r r D) -absent/reversed flow =bad 5) Other: Amnio: for fetal lung maturity if near-term, karyotype, viral PCR

Tx: 1) Serial biometry monitoring q3-4 wks: movement cts, NST, BPP, Doppler 2) Deliver if fetal distress or reved/ab Doppler flow (stop smoking, start aspirin if APLA) 3) Prep 4 delivery: steroids + prep 4 AEs NRDS, hyothermia, hypogly, hyperviscosity/ polycythemia (thrombi/CHF/hyperbili)

RF: Maternal RF (asymm IUGRhead>abd- late): HTN, CRF, Restrictive lung dx/ cyanotic HD, DM, APLA, collagen-vasc dx, Hgopathies, smoking, cocaine/heroin/methadone, alcohol/FAS, malnutrixn, multigestaxn, infexn (rubella, varicella, CMV) (early=organo), genetic dx, teratogens like warfarin/ folate antags/ seizures drugs, hi altitude, AMA or YMA, plac dx- previa/thrombi , ut fibroids/ septum Fetal RF: (symm IUGR early <28 wks) Female, chroml (BeckwithWiedman), twins

Multiple Gestation (36-37 wks) (DiDi: 2 sep ova + 2 sep sperm/ <3 days split) (DiMo: 4th-8th:1 chorion + 2 amnions) (MoMo: after 9th day)

Dx: 1) Size discrep > 4 cm on serial fundal hts --> do US 2) US-> #1 confirm accurate dating, twins, poly etc) --> if twins, confirm chorionicity 3) Diff mngmnt in preg: discuss warning signs of premie labor (cervical checks q1-2 wks midtrimester + serial US q4 wks @ 1618 wks for cervical lengths+discordant growth (15-25% dec in smaller twin)/bedrest @ 24-26 wks/FFN) + need more nutrixn (add 300 kcal/add folate/iron (more anemia) + more HTN (BP checks-> urine protein checks)

Labor mngmnt: (Watch out for: cord prolapse + after ut atony + PPH) (-Vagl birth: vertex/vertex Or presenting twin is vertex -C/S: v/b or b/b or presenting twin nonvertex) 1) Monitor both FHR separately 2) If vertex/breech after deliver 1st vertex twin can try 2 convert: a) extl cephalic version (breech -> vertex) b) breech extraxn by pulling legs (if not, C/S ) TTTS: -art-venous anastomoses (Tx: serial AF removal 4m recipient OR IU laser anas ablaxn) -Donor (hypovolemia, anemia, oligo) -Recipient (hypervol, poly, polycythemia, HTN, CHF, hydrops)( urine output-> poly)

AEs: -#1 premie -cord prolapse -IUGR -plac previa/abrupxn/AB -PPH -GDM/preecl -poly -cervical incomp -congenital (renal ag + single umb artery) -SGA -malprez RF -IVF (both) -DiDi -clomiphene (DiDi) -genetics (DiDi)(Africans) -AMA + multip

Prenatal Care p. 73

**Weight gain in Preg: underwt <19.8-> 28-40 normal 19.8-26 -> 25-35 overwt (26.1-29) ->15-25 obese (>29.0) -> 11-15 [ALWAYS NEED TO GAIN WT EVEN IF OBESE!]

Gynecology Disease Endometriosis


(endol tissue outside uterus) (bilatl)(ov > post- culde-sac/ uterosacral lig/ Douglas/broad/ rectosig/lungs/brain) (horlly resp: E) (+ w/menopause) (- w/E so remove ovaries)

Dx Diagnostic criteria: 1) Only by direct visualizaxn w/ laparoscopy or laparotomy + tissue biopsy (early white/clear ->dark brown powder burns or raised blue mulberry lesions-> reactive fibrosis/adhexns) (ovarian endometrioma chocolate cyst thick dark old blood/fixed adnexal mass) 2) Dx criteria: (2/4) -endol epi / glands/stroma/ Hemosiderin -m 3) Alternative Dx: -Pelvic US: ovarian endometriomas (cysts w/old blood= homog intl echoes = ground glass) -MRI: deep endometriosis in uterosacral ligs or cul-de-sac -CA-125
Theories: (more than one true) 1)Retrograde menstruaxn- transtubal regurg during menstruaxn (=pelvic-dept sites) 2)Immunologic theory (cant clear)(=lupus) 3) coelemic epithelium metaplasia (undiffed multipot cells become endometrial cells)(= can occur b4 menarche in adolescents) 4)Lymphatic/vascular disseminaxn (=lungs)

Tx Workup: 1) H&P timing of sx, FH 2) Physical exam during early menses (implants most tender/largest): fixed retroverted uterus, uterosacral tenderness 3) Empiric Tx OR direct lap visualizaxn + biopsy Temporizing measures (=recur) 4) Expectant: if mild; trying to conceive; perimenopl wait it out NSAIDs (Tx of endo help concepxn) 5) Hormonal: 1st line) Pseudopregnancy: (mild endo + wanna conceive) 1) NSAID + combo OCP (continuous or cyclic) (decidualizes endol implants/ + suppress ovulaxn/menstruaxn) (continuous= no 2 dysmenorr) 2. Depo MPA(prog)--xbone loss (gonadotropins -> ov steroids) ( endol implants) -2nd line) Pseudomenopause -Danazol (weak androgen)( E + T) -GnRH ag (Leuprolide)(E) + add-back therapy if wanna use > 6 mos (or else bone loss) (+ add lil E/ OCP= same effic + aes) ( LH/FSH -> ov E-> endol implants atrophy/no new/amen) (aes: E/T -> osteo, hot flash, atrophic vag, deep voice, facial hair, acne)(+ hi HDL low LDL) 6) Surgical: Conservative (retain concepxn)(leave ut/ovaries)(BEST time 4 preg after this: - Lap + fulguration -Lap endometrioma cystectomy -Laser/electrocoagulaxn Definitive: BSO TAH -adhesiolysis/remove lesions

RF/Aes RFs: (E) -nulliparous -FH -genital obstruxn -age > 25 -autoimmune (lupus) -Age: reprod age women ~25-30 yrs (regress w/meno) -Pain amount of endometriosis ( depth of invaxn more so) Sequelae: -infertility (30%) adhexns Classic Sx: -tender nodularity at back of uterus/post cul-de-sac/uterosacral ligament -fixed, retroverted uterus -Classic Triad: progressive dysmenorrhea, deep dyspareunia (post cul de sac/uterosacral) dyschezia (+ rectosigmoid) -deep dyspareunia -cyclic pain 1-2 days b4 menses -spotting/hematochezia -acute abdl pain (endometrioma torxn/rupture)

DDI:(recurrent pelvic pain)(CPP/infert/AUB) -Chronic PID/ recurrent salpingitis -Adenomyosis/Fibroids/ov ca -Hemorrhagic corpus luteum -Adhexns (surgical) -Ectopic preg ( B-hCG) -Appendicitis (WBCs) -Adnexal mass torsion/rupture -Sudden abdl pain -endometrioma adnexal torxn/rupture

Infertility

-corpus luteum cyst rupture -ectopic/ acute PID Defixn: (<35 12 mos)(>35 6 mos)(>40 immed) (Normal: 75%- 6 mos, 85% - 2yrs, 90%-3 yrs)

Male Factors -Etiology varicocele (>40%) idiopathic (>20%) obstruction (-15%) cryptorchidism (-8%) immunologic (-3%) -Investigations semen analysis and culture post-coital (Hubner) test: rarely done Normal semen analysis Must be obtained .tier 48-72 hours of abstinence 1. Volume 2-5 cc 2. Count > 20 millior/cc 3. Motiity >50% forward progrexn 4. Morphology >30% normal 5. Absence of pyospermia, hyparviscosity, agglutination

Dx: ovnlatory day 3: FSH, LH, TSH, PRL DHEA, free testosterone(hirsute) day 21-23: serum progesterone to confirm ovulation initiate basal body temperature monitoring (biphasic pattern) postcoital test: evaluate mucus for clarity, pH, spinnbarkeit tubal factors HSG (can be therapeutic- opens fallopian tube) SHG laparoscopy with dye insufflation peritoneaUuterine factors HSG/SHG, hysteroscopy other karyotype Tx -Education (sex 2 days b4 and after ovulation) - Medical ovulation induction clomiphene citrate ( Clomid): estrogen antagonist that causes a perceived decreased estrogen state, resulting in increased pituitary gonadotropins; causes increased FSH and LH, leading to ovulation induction (better if anovulatory) human menopausal gonadotropin [HMG (Pergonal)], urofollitropin [FSH (Metrodin)] - FSH and LH extracted from urine of postmenopausal women followed by beta-hCG for stimulation of ovum release may add bromocriptinc: (dopamine agonist) if elevated prolactin dexamethasone for hyperandrogenism (adult onset congenital adrenal hyperplasia), metformin (PCOS) luteal phase progesterone supplementation for luteal phase defect ASA (81 mg PO OD) daily for women with a history of recurrent spontaneous abortions

surgical/procedural tuboplasty lysis of adhesions artificial insemination sperm washing IVF (in vitro fertilization) intrafallopian transfers GIFT (gamete intrafallopian transfer): immediate transfer with sperm after oocyte retrieval ZIFT (zygote intrafallopian transfer): transfer after 24 hour culture of oocyte and sperm TET (tubal embryo transfer): transfer after >24 hour culture ICSI (intracytoplasmic sperm injection) lUI (intrauterine insemination) oocyte or sperm donon IVM (in vitro maturation)

Ovarian/Pelvic Mass (Ovarian/Adnexal CA) DDI Pelvic Mass: Ovary: Functional cysts (benign) -Follicular cyst -Corpus luteum cyst -Theca lutein cyst Hemorrhagic cyst Neoplasm -(benign) #1 Dermoid cyst -(malig) #1 Epithelial ov ca (>40) or Germ cell (<20) Also PCOD, Endometrioma, TOA, luteoma of preg -Uterus -Leiomyoma/Leiomyosarcoma (asymm) -(symm) preg, adenomyosis, endol ca, hematometra -Other -Ectopic, pelvic adhexns, hydrosalpinx, FP ca -GI: diverticular abscess, CRC, bladder ca Abnormal Pap Smear (Cervical CA) Contraception Menopause Mngmnt Post Menol Bleeding (Endol CA) AUB Leiomyoma/Fibroids (benign SM tumor) (regress after menopause) (x post-menol enlarging ut/fibroids = leiomyosarcoma)(>40 do endol biopsy)

NO CHILD RFs (E) + protective Nulliparity OCP, preg/breast-feeding, tubal ligaxn, hysterectomy (protective) Caucasian Family History (BC, ov ca, endo ca, crc) Increasing age ( > 40) Late menopause/early menarche Delayed mild-bearing

PCOD/Hirsutism (excess androgens + E) (Hirsutism: terminal thick pig hair in male pattern -> androgens or 5-ar -> DHT) (face, chest, low abd, back, inner thighs) (Virilism: free T hirsute + voice deepening, clitoromegaly, frontal balding, muscles, breast atrophy)

Dx Criteria: (2/3) -oligo/anovulaxn irregular cycles (6 mos) -clinical/lab evidence of hyperandrog -r/o other causes or polycystic ovaries MOA: Androgens: -DHEA-S (adrenals) -androstene (adr + ovaries) -testost (adr + ovaries + adipose) Normal Adrenal Cortex: GFR ACT -glomerulosa (aldo) RAAS -fasciculata (ACTH 17-OH)) cortisol -reticularis (ACTH 17-OH) testost -Ovary: LH:theca -> T or androstene FSH:granulosa estradiol or estrone respect (LH/FSH androstene/T PCOS) ( adipose androstene -> estrone -> positive feedback leads to more LH produxn T) - E -> hep enzs -> SHBG -> free T -cortisol -> ACTH precursors -> androgs ( aldo/cortisol) salt-loss DDI: -#1) Familial idiopathic (50%) (normal labs) (5ar: genital hair follicles do T DHT) -#1) PCOS -#2) CAH (17-OH)( fasting morning 17-OH > 2 or >4 random ACTH stimulaxn test) ( 17-OH/ DHEA) -Ovarian tumor Sertoli-Leydig tumors -Adrenal neoplasms ( DHEA-S) -Cushings (cortisol)(ACTH supprexn test; moon facies, buffalo hump, ez bruising, proxl myopathies)

PCOD Workup: 1) Physical: - signs of insulin resist/hyperandro: acne, hirsutism, acanthosis nigricans, alopecia, clitoromegaly - CV risk factors/Metab Sx (BP, BMI, waist circum >35) 2) Labs: a. Document hyperandro: (free T or total T + SHBG) (LH/FSH>2:1 + free testost/DHEAS/androstene + SHBG + estrone>estradiol) b. Exclude DDI: TSH, PRL, 17-OH (random < 4 or morning fasting <2 ng/mL) c. Metabolic Sx: fasting glucose (<110 normal, 110-125 impaired, >126 Type 2 DM) 75-g 2-hr OGTT (<140) (140199 impaired, >200 Type 2 DM) d. Fasting lipids (total choles, HDL >50, Trig <150) 3)Transvaginal US: ID polycystic ovary: string of pearls (>12 follicles with >2-9 mm or ovarian volume >10 cm) (also any endol thickening) 4)Optional: -Lap (nec 4 diag) -> white, smooth sclerotic ovary with white capsule, multiple follicular cysts, hyperplastic theca/stroma -If other Sx: Cushing (24-hr urine free-cortisol or low dose dexamethasone supprexn test) Beckman Hirsutism/Anovulaxn WorkFlow: ATTACHED SHEET!! Tx: (Goal: interrupt positive-feedback cycle) 1) Cycle control: (no wanna conceive) -Lifestyle: lose weight (dec peripheral estrone formaxn- adipose) -Monthly OCP or intermittent Provera withdrawal bleeding (prevent endol hyperplasia due 2 unopposed E)(OCP -> LH -> ov theca produxn of androstene/T) VS.HYPOTSH/or HYPERTHECOSIS(REFRACTORY 2 OCP) -Metformin(oral hypogly)(glucose ctrl/ insulin/ free androgen /ovulaxn) 2) Infertility (wanna conceive) -induce ovulaxn: 1st line) clomiphene citrate (antiestrogen) + metformin ( can check prog -> 2 see if ovuling) -2nd line) human menopausal gonadotropins (recomb FSH) +

RF: -FH diabetes -FH early-onset CVD AE: unopposed E: -endol hyperplasia/ca, AUB Long-term sequelae: -hyperlipidemia -T2DM -Infertility -Obesity -Sleep apnea (wt-related)

-HyperPRL -HypoTSH (hi TSH-> low free T4)(+ PRL) (synthroid) -exog androgens/steroids -acromegaly Metabolic Sx Dx Criteria -BP > 130/85 (HTN) -waist circum >35 -fasting glucose >100 -low HDL (<50) -hi trig (>150) *Constitutional Hirsutism (normal labs)( 5a-reductase) Tx: (+ take OCP cuz teratogens + SHBG) Androgen blockers: -Spironolactone 100 mg/day (androgen blockade)(inhibs T production by the ovary + 5-r) -Flutamide -cyproterone acetate Direct 5-r inhibor: -finasteride -Topical Eflornithine (irrev inhibor of L-ornithine decarboxylase) ->slows and shrinks hair) *Medication-induced Hirsutism/Viriliz (Iatrog) Danazol (Tx 4 endometriosis) (attenuated androgen hirsute/acne/irrev voice ) (Do preg test b4 danazol -> virilize fetus) Progestin-OCP (impeded androgens) (r/o late-onset CAH cuz similar Sx)

metformin -2nd line: ovarian drilling (laser perforates stroma) wedge resexn -bromocriptine (if hyperPRL) 3) Hirsutism -OCP (Yasmin = spironolactone analog- inhibs AR) -mechanical removal + eflornithine topical cream (ornithine decarboxy inhibor) -finasteride (5ar-inhibor) vs flutamide (androgen reup inhibor) *Ovarian Neoplasms: [=SUDDEN RAPID ONSET viriliz < 6 mos] -Sertoli-Leydig Cell Tumors (androblastoma)(90% survive): (sec testost -> unilatl, 10 cm (ages 20-40) (2 overlapping stages: defeminiz + masculinizaxn) Dx: Pelvic exam (palpable ov mass) labs ( LH + FSH + low plasma androstene + testost) pelvic US immed surgical removal of ovary (inspect contralatl ovary -> if enlarged bisect 4 inspexn) Sequelae after surgical removal: improved ov cycles/hirsutism/ temporal hair/fem body shape VS worsened (clitoromegaly & existing terminal hair mechanical hair) -Gyandroblastoma:( T->masculiniz + E->endolhyper/AUB) -Both granulosa cell and arrhenoblastoma components -Lipid (lipoid) cell tumors ( 17-ketosteroids) -unique histo: sheets of round, clear, pale-staining cells (DDI: Sertoli, hilar, luteoma of preg) -Hilar Cell Tumors (POST-MENOL WOMEN) (overgrowth of mature hilar cells/ov mesenchyme) (analogs to male Leydig cells) -pathognomonic Reinke albuminoid crystals (always small, unilateral, and benign) surgical removal

*Adrenal Androgens CAH (#1 cause) 21-OH deficiency: ( DHEA ) progesterone + 17a-hydroxyprogesterone NO desoxycorticosterone + compound S) (chrom 6: AR + var penetrance) (also 11B-OH defic: desoxycorticosterone)(mild hirsutism + HTN)( androgens) (no desoxy -> cortisol) -Dx: - 17-OH progesterone in plasma (follicular phase)(fasting) (also DHEA-S + androstene) Tx: (goals: normalize cortisol level) prednisone, 2.5 mg daily (hirsutism) -Severity types: -Severe: (17-OH > 2000 ng/dL) Newborn female infant Virilized (ambiguous genitalia), or virilized w/ life-threatening salt wasting -Mild: (adult-onset too) (>200 ng/dL) (w/ACTH stim test -> inc to 1000 ng/dL) Frequently associated with terminal body hair, acne, subtle alterations in menstrual cycles and infertility Patients can also have sonographic evidence of polycystic-appearing ovaries. - Manifested at puberty Adrenarche may precede thelarche. History of pubic hair growth occurring before the onset of breast Defixn: 1 Amenorrhea menses/2sex by 13 menses + 2 sex by 15

Cushings Sx ( cortisol) (24-hr urine cortisol -> dexa supprexn test) (adrenal tumor/ACTH-tumor corticosteroid excess -> truncal obesity, moonlike facies, glucose intol, skin thinning with striae, osteo, proxl muscle weakness, hyperandrogenism, and menstrual irreg) Adrenal neoplasms [SUDDEN RAPID ONSET] (DHEA-S > 6 mg/mL)(CT/MRI surgery) -rapid onset of hirsutism, severe acne, amen

Amenorrhea

[vs. oligo(>35 days-6mos) vs hypomenorrhea (less days or flow, same freq)] DDI 2 amenorrhea:

2amenorrhea menses 3-6 mos or 3 cycles Urinary Incont + Pelvic Relaxn Breast Disease Pelvic Pain/STI STI Vulvovaginitis

-#1 pregnancy -HPA dysfxn

PREG s Organ System Cardiovascular ( CO)

MOA -enlarging uterus -> diaph elevated->heart elevated -CO 33% ( plasma vol + SVR) SV + HR -P (SM dilaxn) + vasodil (PG, NO, ANP) -> SVR -> BP -Always: SVR > PVR (unless Eisenmenger R-> L shunt)

Normal findings -low-grade systolic ejection murmur -inced S2 w/insp -distended neck veins -S3 gallop -IVC syndrome (enlarged ut compresses IVC ) dizzy/syncope when lie down -dyspnea (response 2 low art PCO2) -mucosal hyperemia/sinusitis

Respiratory (compensated resp alk) ( total body oxygn) ( Vm= minute vent)

-enlarging ut -> diaph elevated -> RV/FRC/ERC/TLV + same resp rate + (IC/IRV ->) TV -> (same RR* ->) Vm -> resp alkalosis TV -[AGAIN: same RR* TV -> Vm --> resp alkalosis!] -Prog -> CO2 chemorec sensitivity -> ventilaxn + art PCO2 -> compensatory resp alkalosis -> inced renal bicarb excrexn -> normal maternal pH + normal bicarb -comp resp alk -> Bohr L-shift -> total oxy-carrying capacity -> Hb-02 affinity (maternal lungs) -> CO2 grad (plac- picks up from fetus) - coag factors (=hypercoag state preg + PP) ( fibrinogen)(same clotting time) - WBCs -slightly platelets - GFR/RPF -> Cr/BUN -R hydronephorosis OK Prog + enlarged ut -> ureters dilaxn/stasis -> R ureter dilated more (uterus dextrorotaxn/R ovarian vein dilaxn/L sigmoid colon cushioning) -> asymp bac/UTI/R pyelo (R flank pain) - RAAS (normally no inc in HTN unless chronic HTN already) - tone/motility -> GERD + constipaxn + hemorrhoids ( venous P) - GB contractility -> gallstones + cholestasis (pruritus) - E -> hepatic synthesis of proteins ( fibrinogen, clotting factors, ceruloplasmin, TBG, SHBG, CBG, Vit D) -Liver changes: alk P, serum choles + total albumin but less free albumin (hemodiluxn) -THYROID: (euthyroid overall) E-> hep syn of TBG-> thyroid slightly enlarges + TBG/Total T4/T3 + same free T4/T3

Hematologic (diluxnl anemia: (>11) RBC vol 30%/ plasma 50% = Hct) -Need 60 mg elemenFe Renal

GI

Urine OK -glucosuria -not proteinuria (F/U 4 preecl) -lose aas/folate/B12 -freq/stress incont -bladder protrudes into vagina -OK if -gums bleed/edema (epulis gravidum=pyog granulomas)

Beckmans Hirsutism WorkFlow

Endometrial CA Staging