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Ob Gyn Notes

UWOLRD Notes
 Preeclampsia
o Systolic 140 or more, diastolic 90 or more, on 2 occasions 4 hrs apart
 If 160 or 110, only need 1 occurrence
o Proteinuria of 300mg per 24 hrs
 Or protein:creatinine ratio greater than or equal to 0.3
 Dipstick of 1+ if no other option
o If no proteinuria:
 Thrombocytopenia (less than 100k)
 Cr over 1.1
 Elevated transaminases
 Pulm edema
 Cerebral or visual symptoms
 Decels
o Early= fetal head compression
 REI:
o
 Preterm labor: <32 weeks:
o Cervical length <2 = concern
o >3 = not concern
o 2-3 unclear, send FFN
 Urinary incontinence:
o Menopause can lead to urinary incontinence: low estrogen causes dryness
urgency, leakage, UTIs but no issues with Valsalva or nothing.
o Postpartum overflow incontinence is due to local anesthetic causing bladder
atony.
 Tx: self limited, just cath while necessary
 Contraception
o Persistent HTN in patient with OCPs, you have to d/c OCPS
 AUB
o Fibroids will cause firm nontender uterus, where adenomyosis is boggy tender
uterus
o Endometriosus is the one that’s worse just before menses. Also worse with
exercise.
o Endometriosus also leads to thickened uterosacral ligaments and immobile
uterus
o Endometriosus causes infertility. Surgical resection can help.
o Intrauterine synechiae= asherman syndrome
 Placental abruption vs previa: previa is painless bleeding after 20 weeks, abruption is
constant abdominal pain and abnormal fetal heart tracings
o Placental abruption risk factors: tobacco use, pre-e, cocaine use, abdominal
trauma
o Placental abruption can lead to DIC
 Tyoe II osteogenesis imperfect = IUFD with limb fractures, hypopastic thoracic cavity,
short femur, IUGR.
o Type I OI is mild, 3-4 are moderate, 2 is lethal.
 Infections
o Endometritis= clinda and gent
o TOA= complex multiloculated adnexal mass
o HSV can cause sterile pyruria
o HPV= acuminata= clusters of fleshy lesions, exophytic, dry, verrucous. Usually
asymptomatic but may be friable or pruritic
o Syphilis = lata= raised, gray-white, broader bases
 HELLP: hemolysis, elevated liver enzymes, low platelets= severe form of pre-e
o RUQ abdominal pain!
o Tx: delivery, Mg for seizure ppx, anti HTN drugs
 In utero exposure
o Hydantoin syndrome = exposure to anti-epileptic = cleft lip and palate, wide
anterior fontanelle, distal phalange hypoplasia, microcephaly
 Lichen sclerosis- vulvar itching and burning, thick white vulvar plaques, clitoral hood
retraction
o Dx: clinical or vulval punch biopsy
o Tx: topical steroids
o Px: May progress to vulvar cancer
 Psuedocyesis- woman thinks she’s pregnant and stops having period, starts having
breast fullness and weight gain etc. Consult psych
 Septic Pelvic Thrombophlebitis
o Thrombosis of deep pelvic or ovarian veins that becomes infected
o Risk: C-section, pelvic surgery, endometritis, PID, pregnancy, malignancy
o Dx: of exclusion. Fever unresponsive to antibiotics, no localizing signs/symptoms
 Staph toxic shock: fever, hypotension, macular rash including palms and soles, vomiting,
diarrhea, altered mentation
 Asymptomatic bacteria is common after multiparity and DM- must treat in pregnant
women
o Tx: cephalexin, amoxicillin-clavulanate, or nitrofurantoin
o Comp: pylo, preterm delivery, low birth weight
 Tumor markers
o CA125= glycoprotein
 Elevated in >80% nonmucinous epithelial ovarian cancers, as well as
some others
 Useful in postmenopausal women with adnexal mass
o CEA and CA19-9 elevated in mucinous ovarian cancers and endometroid cancers
o AFP (endodermal sinus tumor or embryonal carcinoma), hCG (embryonal
carcinoma or choriocarcinoma), LDH (dysgerminoma) sometime elevated in
malignant germ cell tumors
o Inhibin A and B elevated in granulosa cell tumors
 Rectovaginal fistula risk factors include long 2nd stage of labor, 3rd degree lacs,
inadequate repair.
o Dark red velvety rectal mucosa seen in vagina
 PMS diagnosed with 2 month symptom diary and treated with SSRIs (or OCPs)
 Nonclassic CAH= 21-hydroxylase def
o Irregular menses, acne, hirsutism in adolescence
o High testosterone, high bone age, high 17-hydroxyprogesterone level
 Cervical conization preterm labor, risk is assessed with TVUS
 Oxytocin excess can lead to hyponatremia (so seizures), hypotension, tachysystole (too
many contractions)
 Mg toxicity is hyporeflexia, lethargy, HA, respiratory failure but the therapudic range is
5-8.
 Preterm labor = regular contractions before 37 weeks
o At greater than 34 weeks gestation, tocolytics are contraindicated
o Always give betamethasone
o Always give penicillin if GBS is positive of unknown
o At earlier than 32 weeks, give magnesium sulfate
 Placenta previa c-section that ish!
 Menopause looks like hyperthyroidism, so if a patient comes in with vasomotor
symptoms, get the TSH and FSH levels
 If other signs of puberty are present, amenarche is permissible up to age 15
 Breast fat necrosis= fixed mass, skin or nipple retraction, calcifications, foamy
macrophages and fat globules, spiculed hyperechoic mass
 Cancer
o If granulosa cell tumor is identified, get an EMB, because that tumor produces
estrogen which could fuck up the endometrium
o Epithelial ovarian cancer
 Lab: elevated ca125
 US: solid mass, thick septations, ascites
o Enlarged uterus with bilateral enlarged ovaries = concern for complete mole,
which makes a shitload of betaHCG which stimulate giant bilateral Theca Lutein
Cysts
o Mammary paget disease= persistent, eczematous, ulcerating nipple rash. Pain,
itching, burning. ADENOCARCINOMA.
 Facts
o Delay in removing a demised fetus for weeks can lead to a coagulopathy
o hCG secreted by syncytiotrophoblast to preserve corpus luteum
o Obesity estrone GnRH (high freq, short interval) LH no LH surge
anovulation
o BetaHCG looks like TSH so drives T3 and T4 up (although free T4 is unchanged
because Estrogen stimulate TBG)
o OCPs contraindicated in patients who have migraine with aura
o Oligohydramnios Deepest pocket <2cm or AFI<5
o Abdominal imaging: US MRI
o If you’re over 35 and you have atypical glandular cells on pap, you get an EMB
o Loss of fetal station is pathognomonic for uterine rupture
o Raloxifene decreases breast cancer but increases venous thromboembolism
o In their first year of menses, girls can have many annovulatory cycles causing
heavy flow including clots and shit
o ABO incompatibility only affects the babies and is usually pretty mild, just like 24
hrs of anemia and jaundice, nbd. Follow with serial bilis and use phototherapy as
necessary
o Mag is also given for preterm deliveries as it decreases rate of cerebral palsy
o Monochorionic twins= intertwine membrane meets placenta as T. dichorionic
twins= lambda sign (2 placentas)
o Bartholin cysts are at 4 and 8
o Epidural can lead to hypotension via venous pooling due to sympathetic
blockade. Treat with fluid bolus.
o Beta cell hyperplasia leads to higher insulin, but human placental lactogen
causes insulin resistance.
o At ovulation a cervical mucus is produced reminiscent of discharge
o Progesterone mediated smooth muscle relaxation leads to urethral relaxation
which makes UTIs more common
o HG can cause thiamine deficiency  ataxia, nystagmus, encephalopathy,
elevated AST ALT.
o Downs is not down (BetaHCG and Inhibin A both up)
o Women over 35 are offered cell-free DNA testing
o Pre-E + joint pain, malar rash = Lupus flare.
o After uterine inversion, replace the uterus first, then remove placenta and give
uterotonics
o Score of 0-4 on BPP means placental insuf. \
o Myomectomies that enter the uterine cavity put a woman at greater risk of
uterine rupture needs c-section
o PID tx: IV cefoxitin/cefotetan + oral doxy
o Pharyngitis with fever and lower abdominal pain in sexually active female is GC
pharyngitis with PID
o Progesterone IUD contraindicated in BC cause of systemic absorption
o PCOS ovulation can be induced with wt loss of clomphene citrate (blocks
estrogen receptors at hypothamalmus so they still release LH)
o A or B infants with O mothers have mild hemolytic response
o Disparity between cytology and colpo bx LEEP
o If you get everything on LEEP you can just stop
o Primary ovarian insuf can be a result of chemo =(
o Intrahepatic cholestatis of pregnancy is treated with ursodeoxycholiccacid
o Arrest of second satge of labor = no change in station for 3 hours if nullip, 2
hours if multip
 Tx: vacuum, c-section
o Assymptomatic Bartholin cysts can just be watched, as with most asymptomatic
stuff in obgyn
o Tx of PID: cephalosporin + azithro or doxy
o Symmetric growth restriction= chromosomal abnormalities or congenital
infection, asymmetric is due to uteroplacental insuf, or maternal malnutrition
o Postpartum thyroiditis= hyperthyroid phase followed by hypothyroidism.
Elevated anti-TPO antibodies are seen
 Usually self limited
o Abruption can lead to DIC
o Don’t forget about oxytocin and hyponatremia
o Uterine synechiae are enough to cause amen
o Appy would have fever where torsion would not
o HSV mom should get antivirals at 36 weeks. Then if symptomatic at delivery she
needs c-section!
o HELLP leads to distension of liver capsule and RUQ pain without rebound
o Vaginal pH over 5 can confirm hypoestrogen state
o Sex can rupture ovarian cyst
o Ketones in urine indicate HG and not just regular n/v
o Sexually active women <25 should do GCCT testing annually
o Use vacuum when cervix is 10cm and labor is protracted
o DES vaginal clear cell adenocarcinoma. SCC is cause by smoking or HPV
o Toxic shock= erythematous macular rash over entire body
o Recurrent variable reposition mom amnioinfusion
o Embryonal carcinoma= elevated bhcg, abdominal mass, teens, ascites.
o Hytidaform mole can cause pre-e in a patient
o Luteoma or theca-lutean cysts have bilateral ovarian masses and maternal
virilization in pregnancy
o
UWISE Notes Maybe

Gyn
 Paps
o ASCUS HPV test. If positive colpo. If negative repeat co-testing in 3 years
 Except women 21-24, if they have ASCUS and HPV, just repeat the pap in
1 year. In fact, don’t look for HPV in the first place. Only do colpo if they
have ASCUS for >2 years
o Co-test every 5 years, or pap every 3.
o Ghonnorhea is often worse with menses
o Thich= yellow frothy discharge and strawberry cervicitis
 Preventative care and health management
o Colonoscopies start at age 50 every 10 years or flexible sigmoidoscopy every 5
years, or hemoccult testing every year.
 If 1st degree relative has colon cancer before 60, then start screening at
40 or 10 years before they go it
o Mammograms start at 40 and are yearly, US as adjunct
o MMR and varicella are contraindicated in pregnancy
o Family history predicts osteoporosis
o Prevent osteoporosis with weight bearing exercise 4 times a week
 Amen
o Get an FSH level, unless there is hyperandrogensim, then get DHEAS and 17-OH
o PCOS treat with weight loss and OCPs
o Get Upreg, then I think TSH, then I think…
o Ashermans can cause amen
o PCOS endometrial cancer. Clomiphene use ovarian cancer. Fat breast
cancer.
o Irregular menses before OCPs can lead to amen after OCPs
 Hirsutism
o Late onset 21 hydroxylase deficiency: high 17-hydroxyprogesterone?
o Cushings= dexamethasone suppression test for dx
o DM poorly controlled can cause irregular men and hirsutism
o Sertoli Leydig cell tumors are testosterone secreting ovarian tumors. Ages 20-40,
rapid onset of virilization.
o Hyperthecosis= severe PCOS= balding, deep voice, acne, etc.
o Spironolactone is androgen antagonist
 AUB
o If polyp is causing infertility and greater than 1.5 cm, polypectomy is way to go.
o If fibroid is in the ute, and lady wants to have baby, hysteroscopic myomectomy
is best
o Nexplanon can lead to irregular bleeding/ spotting
 Dysmen
o First line is OCPs
o The progestin in OCPs lead to atrophy, preventing pain
o If it persists through NSAIDs and OCPs, do laparoscopy to confirm endometriosus
o Remember: SSRIs treat PMS, not dysmen
o IUDs or endometrial ablation are options for dysmen but not definitive
(hysterectomy)
o Primary dysmen is when there are no abnormal exam finding at all. Secondary
dysmen is due to like endometriosus or adenomiosus or something.
o ALL WOMEN OVER 40 WITH AUB GET EMB
o Fibroids= well-circumscribed, nonencapsulated.
 Meno
o Women should take 1200 mg of Ca per day
o Women with risk for osteoporosis: Dexa scan every 2 years and bisphosphonates
o HRT should be for shortest possible time on smallest does
o Ovaries produce androgens after meno, so post-meno women who have BSO
can go through meno again due to androgen removal
o HRT safe within 10 years of meno or under 60.
o Contraindications to HRT: CAD, breast cancer, prior DVT or stroke, liver disease
o HRT increases risk of BC more than anything and decreases risk of Colon cancer
 Endometrial cancer risk can be eliminated with progesterone added,
ovarian risk increase is not sig.
o HRT increases HD, decreases LDL
o Osteopenia is -1 to -2.5. Before treating osteopenia, evaluate risk factors for
fracture.
 Infertility
o Testosterone levels confirm the diagnosis of PCOS
o Quetiapine cane be antidopaminergic which means it can be high prolactin
which means infertility.
o Exercise induce amen is diagnosed by normal FSH and low E2.
o Anti-mullerian hormone is used to determine ovarian reserve don’t forget that
shit
o They actually recommend ovulation prediction kits
o PCOS weight loss, metformin, ovulation induction are first line.
o Hypothyroidism can lead to hyperprolactinemia, leading to infertility. Just start
treating with T4.
 PMS
o Use a diary
o Tx: NSAIDS/ OCPs SSRIS (either every day or just luteal phase) leupron
o Hypothyroid= mood, bloating, fatigue
o Endorphins from exercise can help
o Family history is strongest risk factor
o B6, Ca, Mg deficiency
o Ca supplementation demonstrates benefit
 Gestational trophoblastic disease
o Risk factor: Asian! Low consumption of beta-carotene, folic acid
o Tx: suction curettage
o Complete= 46XX= higher risk of malignancy
o Partial= 69XXX/XYY/XXY
o Never give phophylactic MTX, it works when the disease is discovered later
o Choriocarcinoma (after delivery) is dx with elevated bhcg
o TSH levels are suppressed and patients become hyperthyroid
o Ovaries produce bilateral theca lutein cysts in response
 Vulvar neoplasms
o Lichen sclerosus squamous cell carcinoma
o SCC tx: radical vulvectomy and groin node dissection
o Could also be melanoma
o Bartholin gland malignancy= painess, no LAD, short onset
o VIN2 Laser ablation
o VIN3 wide local excision
o Trichloroacetic acid (TCA) treats warts
o Pagets disease of the vulva is associated with breast cancer
 Cervical cancer
o Leukoplakia= white cervical lesion. Biopsy that shit.
o Age 21-29: pap every 3 years
o Age 30-65 pap and HPV every 5 years
 Leiomyomas
o Most commonly cause HMB.
o No treatment necessary with pregnancy
o Submucosal lesions are the worst for infertility
o Consider EMB to rule out endometrial cancer for AUB
o Tx: OCPs, NSAIDs Lupron hysterectomy?
o Take away Lupron and they grow back just as big
o Dx with pelvic US if unsure
 Endometrial cancer
o Obesity is greatest risk
o AUB is biggest concern
o +EMB directly to TAH, BSO
o EMB is NOT a screen
 Ovarian Neoplasms
o 5 years of OCPs cuts ovarian cancer risk in half
o BRACA testing is done on the relative that has the cancer, not the pt
o Endometriomas appear different than simple cyst on US
o Functional ovarian cysts are normal. Look like simple cysts
o Chest x ray or CT are good to determine extent
o Dermoid cyst= mature cystic teratoma
o Younger patients get germ cell tumors
 STIs and UTIs
o Itching and irritation = herpes
o Itching and thick white discharge = candida
o After contact with Hep B, administer HBIG and start vaccine series
o Salpingitis= uterine pain and bilateral adnexal pain, fever, mucopurulent
discharge
o Tubal infertility is 12% after 1 episode of PID
o Pylo: tx= aminoglycoside+ amp/piperacillin/cephalosporins/aztreonam/pip-
tazo/fluoroquins
 Prenatal care
o 1st visit: H&P
 CBC, rubella titer, hepatitis surface antigens, RPR, GCCT, UCx, type and
screen, HIV
o 1st trimester
 Sequential screen= blood from 1st trime and blood from 2nd trime
combined
o 2nd trimester
 anatomy US
 24-28wks 1hr glucose tolerance test
 if positive, 3 hr fasting glucose tolerance test
 27 weeks tdap vaccine (even if they just got it)
 flu vaccine at any point
 28 weeks Rho gam. Also give any time they bleed.
 Visit OB 1/month until 28 weeks, then every 2 weeks to 36. Then every
week to 42. Induce at 41 weeks though.
o 3 trime
rd

 CBC, RPR, HIV, quant


 35-37 weeks: GBS, good for 5 weeks if negative
 Induce at 41 weeks.

 Baby moving around 20 weeks
 Fundus is at umbilicus at 20 weeks
 36 weeks scan for orientation ECV
 Vulvar and vaginal disorders
o Lichen sclerosus can affect premenarchal girls
o Lichen planus= scalp, nails, oral mucosa, vulva. Remissions and flares. Related to
cell-mediated immunity. Lacy, reticular pattern with or without scarring and
erosions
o Lichen simplex chronicus= results from chronic scratching. Pruritis worse at
night.
o Vulvodynia= severe pain on vulvar touch. Tx: tricyclic antidepressants, pelvic
floor rehab, topical anesthetics, clobetasol (steroid)
 Urinary Incontinence
o Cystocele can lead to overflow incontinence due to outflow obstruction
o Stress incontinence Tx: mid-urethral sling
 Positive q-tip test
 Qtip moves because bladder drops down when she valsalvas
 Tx: birch procedure, 2 types of suburethral sling
 1. Transvaginal-
 2. transobturator
o Intrinsic sphincter deficiency tx: urethral bulking procedure. Best for fixed,
immobile urethra
o Detrusor overactivity urge incontinence. Tx: Beta-3 agonist.
 Oxybutinin, imipramine,
o Urge incontinence can also be caused by vaginal dryness from estrogen absence
o Do not treat asymptomatic prolapse
o Kegels DO NOT HELP pelvic organ prolapse
 Endometrioses
o Uterosacral ligament nodularity= endometrioses
o Tx: NSAIDS OCPS GnRH agonists (short term), danazol (SEs), Surgery if
laparoscopic resection doesn’t fix it, TAH, BSO will.
o Dx: Dx lap
o Endometriomas= painful, or asymp ovarian cyst on US “ground glass”
appearance, echogenic but homogenous
o If patient is infertile, you can try to remove some via surgery or try to stimulate
the ovaries and do intrauterine insemination
 Chronic pelvic pain
o Interstitial cystitis= chronic inflammation of the bladder, with UTI symptoms but
clean UA (make sure its not herpes sterile pyuria). Pelvic pain. Autoimmune?
Associated with endometriosus
o History of sexual abuse associated with chronic pelvic pain
o Pelvic congestion syndrome: pelvic varicositied in broad ligament. Cause
unknown. Soe women have pain. Aggravated by standing, fatigue, and sex. Pelvic
“fullness or heaviness”
o Nerve entrapment syndrome
 Iliohypogastric: skin of groin and pubis
 Ilioinguinal: medial thigh and muscles of leg adduction
o Fibromyalgia: constant, refractory to hormones, reproducible with palpation. Tx:
physical therapy and exercise
 Carnets sign= pain with abdominal flexion
 Breast
o Palpation of breast during exam may lead to elevated prolactin
o Cyclic mastalgia is due to fibrocystic breast changes
o BF mastitis tx: antibiotics, NSAIDs
o FNA is not enough, do excisional biopsy as well
o BRCA mutation pts and 1st degree relatives, Li-Fraumeni pts, and pt who had
chest wall radiation all need breast MRI screening
o Massmamogram+/-USFNAexcisional bx tx
 Gyn procedures
o LEEP complications: infection, stenosis, preterm delivery
o Vulval lesion unresponsive to TCA treatment needs bx
o Can’t get IUD out? Hysteroscopy!
o

OB
 Physiology of pregnancy
o Increased minute vent compensated resp alk
o Tocolytics can cause pulmonary edema
o Uterus and R ovarian vein compress the right ureter leading to hydronephrosis
o In patient with gestational trophoblastic disease, get a chest x-ray to looks for
mets
o Everyone must gain weight during pregnancy, even obese
 Ectopics
o If concerned for ectopic, repeat b-hcg in 48 hrs before treating with MTX
o At bhcg of 2k you can see intrauterine preg
o Even if bhcg is not rising fast enough but you can see a yolk sac, just do
expectant management, don’t even repeat US
o Before you can give MTX: dx of nonruptured ectopic, <4cm w/o HR or <3.5cm
with HR, hemodynamic stable, normal LFTs
o If ectopic is ruptured, do salpingectomy, repair of the tube is not appropriate
 Spontaneous abortion
o Diabetes, renal disease, and lupus all associated with increased spontaneous
abortions
o Also smoking, alc, radiation
o If patient is aborting and hemo unstable, you have to d&c
o 3 or more 1st trime losses test for lupus anticoag, anticardiolipin, DM, thyroid
 Complications in Preg
o DM1 growth restriction, polyhydramnios
o HIV HAART during preg and IV zidovudine in labor. C-section for women with
viral loads over 1k
o Pylo is most common cause of sepsis
o Athsma  if using beta ag more than 2 time per week, go up to inhaled
corticosteroid
o Treat thyroid storm with: PTU, propranolol, iodide, dexamethasone. NO
radioidodine.
o Women with risk factors for GDM are tested at first visit, everyone else at 24-28
weeks
o No evidence to screen for bv
o Symptomatic mitral valve prolapse beta blockers
o Symptoms of PNA chest x-ray for dx tx.
o High BMI increases risk of HTN, Pre-E
o Lupus Tx w/ NSAIDS, then steroids, then azathioprine and cyclophosphamide
o Paroxetine is contraindicated
o Itching due to gall bladder, give ursodeoxycholic acid
 Pre-eclampsia and eclampsia
o Mg toxicity respiratory depression, treat with calcium gluconate
 4-7 is therepudic, 7-10 loss of reflexes, cardiac arrest above 15
o Proteinuria >300mg/dl for pre-e, >5000 for severe pre-e
o Abruption= tachysystole, fetal anemia
o Goal to reduce diastolic pressure to 90-100
o Hydralazine, labetalol first line for HTN
o Chronic HTN, obesity, family history, and parity all predict pre-e. But chronic
renal disease predicts it most of all.
 Rh nonsense
o Risk of isoimmunization is 2% antepartum, 7% after full term delivery
o Fetal anemia can be detected by middle cerebral artery peak systolic velocity via
Doppler.
o Hydrops is dx by US: fluid in 2 or more cavities: ascites, pericardial fluid, pleural
fluid, scalp edema.
o 30cc of fetal blood is neutralized by the standard rho gam dose of 300
o Lewis lives, duffy dies, kell kills (lewis Antibody does not matter)
o Bilirubin in the amniotic fluid is best indicator of rh hemolytic disease severity
o Tx: transfusion to the fetus via the cord or immediate delivery
 Multigestation
o 2 placentas= fraternal
o twin death rate is 5x higher
o congenital anomalies are more common in twins
o early weight gain reduces premature deliver
o Twin twin transfusion syndrome occurs in mono-di
o Preterm birth occurs in 50% of twins and 90% of triplets.
o When twin A is breech, do c-section
o Division by day 3= di di, 4-8 = mono di, after 9 = mono mono
 Fetal death
o Risk of microcephaly and ID (especially due to radiation) is highest at 8-15 weeks)
o Factor V Leiden= thrombophilia= stillbirth, pre-e, abruption, IUGR
o Uncontrolled DM macrosomia, oligo, neural tube defects AND FETAL DEATH
o
o ^^Results of quad screen^^
o Always check maternal blood type in the case of bleeding and pregnancy
 Abnormal labor
o Arrest of dilation during active phase  oxytocin
o Misoprostal makes cervix more favorable
o Breach risks: prematurity, multiple gestations, genetic disorders,
polyhydramnios, hydrocephaly, anencephaly, previa, anomalies, uterine fibroids
o Prolonged laten phase is >20 for hulls, >14 for mults. Tx is induction or rest.
o Arrest of dilated (no cervical change for 4 hours) is treated with amniotomy,
then oxytocin if necessary, then c-section if necessary.
o Category III and remote from labor c-section
o Cord prolapse occurs with back up transverse lie. Also with ROM,
polyhydramnios, preme, SGA
o Retraction of fetal head= shoulder dystocia McRobert maneuver (hyperflexing
mother’s legs to abdomen
 rd
3 trime bleeding
o cervical ripening =prostaglandin E2
o polyhydramnios+ water breaking loss of intrauterine pressure, abruption
o Previa + hemo unstable c-section
o Prior C-section +low anterior placenta= placenta acreta
o Abruption= pain, bleeding, uterine hypertonus, fetal distress
 Risks: smoking, coacaine, HTN, trauma, PPROM, hx
o Bloody show basically just has stable fetus
o Friable cervix= cervicitis
o Cervical cancer is also friable lesion
 Preterm labor
o Usually idiopathic. Dehydration and uterine distortion can be factors.
o Tocolytics: nifedipine, indomethicin
 Terbutaline is a tocolytic but not recommended
o Even at 28 weeks, with intra-amniotic infection, you gotta deliver (augmentation
is fine, don’t need to c-sect). Tocolysis is contraindicated
o Steroids decrease RDS, intracerebral hemorrhage, and NEC
o Magnesiu sulfate works by competing with Ca for entry into cells.
o Smoking increases risk
 PROM
o PPROM low amniotic fluid cord compression variables!!
o Give amp and erythromycin to prolong latency period by 5-7 days and reduce
chorio
o PPROM: Clinda and gent are indicated only if chorio is suspected
o Magnesium sulfate is used for neuroprotection in labor
o PPROM low AFI pulmonary hypoplasia
o 17-alpha hydroxyprogesterone reduces the risk of Plabor
o cerclage only if history of incompetent cervix
o weeks 34-36&6, delivery is worth it because otherwise you risk chorio
o You don’t need to redose steroids
o Abruption +PPROM = expectant (somehow) (as long as everyone is stable) (you’d
do c-section if maternal or fetal status worsened)
 Intrpartum fetal monitoring
o Prostaglandins are used for cervical ripening but are contraindicated in women
with prior c-section due to increased risk of rupture
o Intrauterine pressure catheter can help determine in pt is making adequate
contractions or if oxytocin is appropriate
o Cervadil = PGE2
o Biophysical profile is never the right answer during labor
o Cord compression variable
 Variables may be treated with amnioinfusion
o Uteroplacental insufficiency late decels
 Lates may be treated with L lateral decubitus position, STOP oxytocin,
and treat any materal hypotension
o When baby has minimal variability with no acels for too long, best stimulation is
digital scalp stim! Then acoustic, then clamp
 Postpartum Hem
o Uterine atony is most common cause
o Methylergonovine is an ergot used to constrict uterus, but is vasoconstrictor so
is contraindicated in HTN
o Prostaglandin F2= hemabate= used to constrict uterus but also
bronchoconstricts, contraindicated in asthma
o PPH = 500cc after NSVD or 1000cc after c-section
o Placental lakes= acreta
o Unresponsive uterine atony  B-lynch suture (uterine compression)
o vWD delayed postpartum hem
o clot on the placenta= abruption
 Postpartum infection
o Endometritis amp and gent OR apparently clinda and gent per Uworld
o E coli is most likely cause of foley UTI
o Breast engorgement can cause a low fever
o Incision infection? Open and drain
o Septic thrombophlebitis= dx of exclusion, CT can show thrombosed veins. Tx:
anticoagulation and antibiotics
o Atelectasis (chest xray) is most common source of fever on PPD1.
o Gent and clinda can also tx endometritis? Especially following c-section
 Anxiety and depression
o SI admit
o Fluoxetine has a SE of insomnia
o SSRIs are fine for BF
o Pregnant women taking SSRIs baby may have agitation and poor feeding,
tremor, sleepiness, difficulty breathing
 Post-term preg
o Beginning at 41 weeks, 2x weekly testing with NST and AFI
 Don’t go beyond 42 weeks if you’re certain of the gestational age and
patient has favorable cervix
 If patient has unfavorable cervix, keep following with twice weeklies.
o Postterm pregs associated with placental sulfatase deficiency, adrenal
hypoplasia, and anencephaly
o Associated with macrosomia, oligo, mec aspiration, uteroplacental insuf,
dysmaturity
o If patient has prior c-section, deliver them before 41 weeks
o Dysmaturity= infants are withered, meconium stained, long finger nailed, fragile.
Risk for stillbirth
 Get plactal path and mom utox to try to figure out why IUGR occured
o Induction in patient with closed cervix starts with PGE1
o Risk factors: previous late term, nulliparity, AMA, obesity, male fetus, white
mom
 Fetal growth abnormalities
o Vasuclar disease like HTD and DM  uteroplacental insuf SGA
o If fetal growth restriction is present, begin twice weekly: AFI, systolic/diastolic
ratio of umbilical cord, NST
 As vasucalr resistance increases, S/D ratio increases
o Fetuses with growth restriction later in life develop: HTN, CV disease, DM2,
COPD
o IUGR + abnormal Doppler umbilical + oligo= deliver now! Prefer induction of
labor vs c-section
 Obstetric procedures
o CR length by US in 1st trimester is most accurate estimation of gestational age
o Fatty tissue on D&C likely corresponds to omental due to perf
o Fibroids in lower uterine segment may obstruct labor c-section
o Macrosomia greater than 4000 grams c-section?
o BPD>12cm c-section
o Placenta previa c-section always
o Chorio induction of labor, you don’t have to c-sect
o ECV and ICV are contraindicated in active labor, but you can still c-sect a baby
out during active labor
o BTL decreases ovarian cancer
o CVS is performed earlier than amniocentesis
 CVS loss rate 1-3%
 Amnio loss rate 0.5%
 CVS has lower success rate, higher limb deformities
o Patient with history of cervical insuf should have propho cerclage
 Contraception
o Depo shot unpredictable bleeding for 2-3 months
o The patch doesn’t work if you’re more than 198 lbs
o Plan B must be within 72 hrs, copper IUD can be within 5 days
 Abortion
o Medical termination has higher blood loss
o Vaccuum aspiration is okay up to 8 weeks
o Patient with bleeding after medical abortion D&C
o Give doxycycline prior to AND after a D&C

Review Lecture
 Folic acid sup
o No risk factors 400mcg
o Risk factors (previous neural tube defects) 4mg
 Phenytoin nail and digital hypoplasia, oral cleft, cardiac abnormalities
 Heartbeat appears at 6-6.5 weeks
 Threatened abortion tx: just send them home, let it pass
 Cocaine  abruption