best_study_guide_for_obgyn.doc

8/12/2019 best_study_guide_for_obgyn.doc

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OB/GYN Student Study Guide

Abbreviation and DefinitionsLMP: last menstrual period

PMP: previous menstrual periodEDC: estimated date of confinementGP: gravida !ara:Gravida is how many pregnancies; Para is the number of

times the uterus is emptiedTPAL: (Tennessee Power and Light!: Term ("! (the numberof term pregnancies # twins count as $ pregnancy%! Preterm("! Abortions (elective or spontaneous "! Living " (all childrencounted here!

G$P$&&' Twins

C"C: cold )nife coni*ation LEEP: loop electrocautery e+cision procedureB#L: bilateral tubal ligation D$C: dilation and currettage POC: products of conception%ystero: uterus #&%: transvaginal hysterectomy #A%: transabdominal hysterectomy

LA&%: laparoscopic assisted vaginal hysterectomy #L%: total laparoscopic hysterectomyBSO: bilateral salpingoopherectomy

O'igo: few tra()e'o: cervi+%y!er: too much (u'!o: vagina%y!o: not enough e(to*y: removal ofMeno: menses ooto*y: incisionMetr:uterus osto*y: ma)ing a new opening+r)ea: flow (entesis: needle into something+r)agia: e+cess flow !o'y*enorr)ea: cycle every '& days

P+OM: premature rupture of membranes PP+OM: preterm premature rupture of membranesS&D: spontaneous vaginal delivery L#CS: low transverse cesarean section+ L#CS: repeat LT,- ,A&D: forceps assisted vaginal delivery &BAC:vaginal birth after c.s&A&D: vacuum assisted vaginal delivery &M-: viable male infant &,-: viable female infantSAB:spontaneous abortion (miscarriage! EAB: elective abortion-.,D: /ntrauterine fetal demise

ASC.S: atypical s0uamous cells of undetermined significanceLGS-L: low grade s0uamous intra epithelial lesion%GS-L: high grade s0uamous intra epithelial lesion

1stTrimester: w& # w$' gestational age2ndTrimester: w$' # '13rdTrimester: w'1 # 2&Previable: less than '& wee)s; if delivered considered Abortion3 not -45Preterm: '2678 w

Term: 78 # 2' wEmbryo: fertili*ation to 1 wee)sFetus: 1 wee)s to birthInfant: delivery to $ yearPost Dates: 9 2$62' wee)s


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Pregnan(y and Prenata' Care

Diagnosis: home PT: highly sensitive at the time of missed cycle (positive at 16 d!; b At that point your b @hen the ?

,%#: seen at B wee)s on -; 5oppler C ,hadwic)Is -ign6blue hue of cervi+b> GoodellIs -ign # softening and cyanosis of c+ at 2 wee)sc> LaddinIs -ign # softening of uterus after wee)sd> ?reast swelling and tenderness

e> Linea nigraf> Palmar erythemag> Telangiectasiash> Jauseai> Amenorrhea3 obviously

K> uic)ening


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Nor*a' C)anges in Pregnan(y:

$> ,4 #a> ,M inc by 7&6=&N O ma+ '& # 2& wee)sb> -4H dec secondary to inc> progesterone and therefore smooth muscle rela+ationc> ?P dec: systolic down = # $&. diastolic down $& # $= until '2 wee)s then slowly

returns>'> Pulmonary:

a> T4 inc 7& # 2&Nb> Dinute 4ent inc 7& # 2&Nc> TL, dec =N secondary to elevation of diaphragmd> PA M' and pa M' inc; dec pA ,M' and pa ,M'

7> G/:a> Jausea and vomiting in 8&N 6 inc> estrogen3 progesterone and Heflu+ # dec> GE sphincter tonec> 5ec lower intestinal motility3 inc water reabsorption and therefore constipation

2> Henala> idneys increase in si*eb> reters dilate # increased ris) of pyelonephritis

c> GCH inc =&N 6 ?J3 ,rt dec '=N=> Plasma volume inc by =&N3 H?, vol inc '& # 7&N 6 drop in @?, still nl at $& # '& in laborc> /nc> fibrinogen3 inc factors 8 # $&3 dec $$ # $7e> -light dec in plt3 slight dec in PT.PTT

> Endocrinea> /nc estrogen from palcenta; dec from ovaries # low estrogen levels assn with

fetal death and anencephalyb> Progesterone is produced by corpus luteum then the palcentac> 7& mg of elemental iron isrecommended

i> folate is necessary early on to prevent nueral tube defect (spina bifida! #2&& mcg per day is recommended in women without sei*ure meds orprevious infant with neural tube defect (2g are recommended then!

ii> '& # 7& lb weight gain is M3 obese women do not have to gain weight>


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Prenata' Care

,irst #ri*ester: ,?,3 ?lood Type and -creen3 HPH3 Hubella3 /tIs normal to have mucus or a pin) discharge in the wee)s preceding yourlabor>

+outine Prob'e*s of Pregnan(y:?ac) Pain GEH5 ,onstipation


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,eta' Lung Maturity:

Lecithin.-phingomyelin Hatio: over '>& indicates fetal lung maturity

CLD: Clouresence Polari*ation: 9==mg.g is mature; good for use in diabetics

Phosphatidyl glycerol: comes bac) pos or neg: best for diabetics because is last test toturn positive; hyperglycemia delays lung maturity


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Clinic Survival GuideCopy and put in your pocket!

Clinic note:

21 yo G2P1001 at 28 2/7 by 8 week ultrasound (always include dating criteria) coplaining o inguinalpain on walking" #enies contractions$ %aginal bleeding$ rupture o ebranes$ and &as etalo%eent (t&e cardinal 'uestions o obstetrics)"

P 110/8 *rine+ trace protein (pregnant woen usually &a%e trace protein) neg glucose,undal -eig&t(,-)+ (easured ro t&e pubic syp&ysis to undus. correlates wit&in 1.2 c unless obese) 2c,etal -eart ones (,-)+ 10s (count t&e out on your watc& in t&e beginning noral 120s.10s)34treities+ no cal tenderness (any results o recent ultrasounds$ lab work &ere)5/P+ 1" 6*P at 28 2/7+ sie appropriate or dates 2" ound 9igaent Pain+ recoended aternity belt

:" - ;eg+ &oga :00 cg 6< today:" Continue P;=/ ,e$ discussed preter labor precautions" > ?ulli%an today

6"


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S!ontaneous Abortions 9 4;

o @: )aryotype for balanced trans3 antiphospholipid ab3 hysterosalpinography for

abn uterus (septate uterus most common!

-n(o*!etent Cervi3 Sd: AbIs between $7 # '' wee)s because cervi+ canIt hold PM, in:see painless dilation and effacement in 'ndtrimester; inf+ is common b.c oftrauma.vaginal flora

#7: Dc5onaldIs ,erclage: a pursestring nonabsorpable suture aroundcervi+: remove at term; also could manage e+pectantly; ?E5HE-T # give steroids and

Ab+ to dec inf+ and inc fetal lung maturity and tocoly*e contractions; ?oth Dc5onald and-hirod)ar are near the internal os # -hirod)ar stitch Kust tunnels under the cervicalepithelium>

Causes of 4nd#ri*ester Abs: inf+3 mat anat defects3 cervical defects3 systemic d*3fetoto+ic agents3 trauma (chromosomes occur in second trimester3 but not as fre0uentlyas first trimester!

C)ro*oso*e Stuff

Trisomies: $7 Edwards3 $1 Patou3 '$ 5ownIs

Autosomal 5ominant 5*: Jeurofibromatosis3 von @illebrandIs3 Achondroplasia3Msteogenesis imperfecta

R Lin)ed 5*: Duscular 5ystrophy3 GP5 5ef3 hemophilia

Hecessive 5*: $' M< Adrenal hyperplasia

Dc,une Albright: polyostotic fibrous dysplasia: degeneration of long bones3 se+ualprecocity3 caf au lait spots (t+ precocious puberty with medro+yprogesterone acetate!

Statisti(a' Stuff

Daternal Dortality mat death.$&&3&&& live births

Certility rate " live births.$&&& females $= # 22

?irth rate " live births . $&&& people


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Ante!artu* ,eta' Survei''an(e

NS# Jon -tress Test: to be reactive need ' a((e'erations of 5 beats !er *inutefor 5 se(onds in 4; *inute stri!; if nonreactive3 baby can be sleeping # give mom

Kuice # do a ?PP (thin) about sedatives3 narcotics3 ,J-.,4 abnormalities!

BPP biophysical profile; on .- 1 pts good. 2 pts bad

Give ' points Give & points

J-T Heactive U ' accels

AC/ (amniotic Cluid /nde+! one ' by ' cm poc)et no poc)et seen

Cetal ?reathing Dovements Last over 7& seconds U 7& seconds

Cetal E+tremity Dovements 7 or more episodes nder 7 episodes

Cetal Tone E+tension to fle+ion; fle+ at rest E+tended at rest

Modified BPP J-T and AC/

Contra(tion stress test 9CS#!: nipple stimulation or o+ytocin # shows 7 uterinecontactions in $& minutes to be good; negative no late decelerations

%O #O +EAD #%E S#+-P:o Heassuring things # normal behavior3 beat to beat variation3 reactive strip

(above!o Early decels # they begin and end with the contraction # a sign of head

compression # Mo 4ariable decels # are more Kagged and loo) li)e a 4 # a sign of cord compression

# we may start amnioinfusiono Late decels # begin at pea) of contraction and end after contaction is finished # a

sign of uteroplacental insufficiency # are bad> (nonreassuring!

,SE fetal scalp electrode6 placed usually with /P, when a more accurate recording ofheart tones is needed; do not use in moms with

,eta' S(a'! !%; ta)e blood from scalp for nonreassuring factors3 fetal hypo+ia (not reallydone anymore!

P< over 8>'= is reassuring 8>' # 8>'= indeterminate U8>' bad


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Labor

DA#-NG

Denstrual C'> 7 wee)s since PT positive>7> - of ,HL at 6$$ wee)s ma)es gestational

age 97 wee)s>2> - of under '& wee)s supports gestationalage 97 wee)s>

S#AGES O, LABO+

,irst: beginning of contractions to complete cervical dilationo Latent # to appro+> 2 cm (or acceleration in dilation!

o Active # to $& cm complete; prolonged if slower than 54 (*/)r nu''/5 (*/)

*u'ti!; if prolonged3 do amniotomy3 start pitocin3 place /P, to evaluatecontraction strength

o ,ai'ure to !rogress# no change despite ' hours of ade0uate labor (D4 9'&&!

Se(ond: complete dilation to the delivery of babyo Prolonged if 4 )ours *u'ti!/ )ours nu''i! 9with epidural! or ' hours nullip.$

hour multip (no epid! #)ird: delivery of baby to delivery of placenta

o ,an ta)e up to 7& mins

o -igns include increase in cord length3 gush of blood3 uterine fundal rebound

,ourt): one hour post delivery

P0S O, LABO+$> Po /nlet: 5iagonal ,onKugate # symphysis to sacral promontory $$>= cm

Mbstetrical ,onKugate # shortest diameter $& cmb> Didplane: spines felt as prominent or dullc> Mutelt: ?ituberous 5iameter 1>= cm

-ubpubic Angle less than 2& degrees


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,O+CEPS

Mutlet forceps: re0uirements #

visible scalp

-)ull on pelvic floor

Mcciput Anterior or Posterior

Cetal head on perineum : can see without separating labia

Ade0uate anesthesia; bladder drained

Da+imum 2= degrees of rotation

Low forceps:

station ' but s)ull not on pelvic floor

Didforceps: station higher than ' with engaged head (not done!

&ACC..M E7#+AC#-ON: can cause cephalophematoma and lacerations -ame re0uirements for outlet forceps

-ND.C#-ON:

-ndi(ations: PreEclampsia at term3 PHMD3 ,horioamnionitis3 fetal Keopardy.demise392'w3 /GH

Bis)o! S(oring Syste*: if induction is favorable: 91 vaginal delivery without inductionwill happen same as if with induction: U 2 usually fail induction: U = # =&N fail induction

-core ,m Effacement -tation ,onsistency Position of c+

& & &67&N 67 Cirm Post

$ $6' 7&6=&N 6' Ded Did

' 762 &68&N 6$3& -oft Ant

7 26= 91&N F$3 F'

Prostag'andins: dilate cervi+ and inc contractions: Prepidil3 ,ervidil3 ,ytotec:contraindicated in prior ,-3 nonreassuring fetal monitoring

La*inaria: an osmotic dilator3 is actually seaweed%

A*nioto*y: speeds labor; beware of prolapsed cord%

O3yto(in: $& in $&&& ml /4 piggybac) on pump O ' m .min; if over 2& m.min areused watch for -/A5 -uprapubic Pressure (not fundal pressure%!'> DcHobertIs # mom fle+es hips # )nees to chin level7> GEJTLE traction2> @oodIs ,or)screw # pressure behind post shoulder to dislodge the ant shoulder=> Hubin maneuver # pressure on accessible shoulder to push it to ant chest of

fetus to decrease biacromial diameter> Cracture clavicle away from baby8> try to deliver posterior arm

CA+D-NAL MO&EMEN#S

Engagement # fetal head enters pelvis

Cle+ion # smallest diameter to pelvis

5escent # verte+ to pelvis

/nternal Hotate # sag suture is parallel to AP

E+tend at pubic symphysis

E+ternally rotate after head delivery

-ND-CA#-ONS ,O+ C8SEC#-ON

Cailure to progress (PIs of labor!

?reech presentation with labor

-houlder presentation

Placenta Previa

Placental Abruption

Cetal distress: = minutes of decal U& bpm; repetitive late decals unresponsive toresusitation

,ord Prolapse


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Prolonged second stage of labor

Cailed forceps

Active herpes

Prior classical ,.- (has to do with incision on uterus not s)in%!

' prior low transverse c.s (4?A,s are controversial!

.'trasound

5oppler 4elocimetry: systolic.diastolic ratio in the umbilical cord

/nc -.5 ratio: pre6eclampsia3 /GH3 nicotine3 maternal tobacco

/f end diastolic flow absent or reversed3 delivery is indicated

4elocimetry is done in cases of suspected /GHThe first ultrasound is the only one that can change dates> Accept .- date if over LDP date by

2d # $ w: first trimester

'w: second trimester

7 w: third trimester5ating is done by a biparietal diameter3 head circumference3 femur length and abdominalcircumference>

Anest)esiaE!idura' anest)esia: lengthens second stage # may need o+ytocin

/nKected into L7.L2 interspace: use the techni0ue of least resistance (the epidural spacehas a negative atmospheric pressure so the syringe you place over the needle willsuddenly lose its resistance as you advance it into the epidural space3 inKect test dose!

,an cause hypotension after dosage because the autonomic nervous system is bloc)edand all blood pools in e+tremities; can see late decals3 but usually resolve with hydrationand blood pressure increase>

Para(ervi(a' b'o(2: not really done because can inKect into fetus easily and cause fetal

bradycardiaS!inal: one time dose3 shorter duration of action3 used in repeat c.sPudenda' B'o(2: ,an be done with vaginal delivery3 inKect analgesic into post6ischial spine andsacrospinous ligament (ta)es = # $& mins to set up: good for forceps delivery without epidural!

,eta' Co*!'i(ations of Pregnan(y

SMALL ,O+ GES#A#-ONAL AGE

U $&N percentile for growth

can be symmetric or asymmetric

has higher rates of mort.morbidity

HC: 5ecreased growth potential

o ,ongenital abn: Tri $73 $13 '$3 Turnerso ,D43 Hubella

o Teratogens3 smo)ing3 EtM Tobacco!; femur length is usually spared


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5oppler velocimetry with end diastolic flow reversed or absent or nonreassuring fetalheart tracing necessitates delivery>

MAC+OSOM-A: 9 &N percentile: 9 2=&&g

age

,.: u.s 0 ' wee)s to assess si*e; however - is not that accurate in diagnosis

#7: tight control of diabetes; wt loss before conception; induce3 prepare for dystocia;consider c.s if over =&&&g

OL-GO%YD+AMN-OS:

Amniotic Cluid inde+: divide momIs belly into 2 0uadrants # measure the largest poc)et offluid in each U=: Mligohydramnios 9'&: Polyhydramnios

Absence of Hange of Dotion # 2&R increase in Perinatal mortality

Assn with abnormalities of G (renal agenesis PotterIs -d3 polycystic )idney d*3obstruction!3 and /GH

Cetal idney.lungamniotic fluid resorbed by placeta3 swallowed by fetus3 or lea)ed

out into vagina> Dost common cause: HMD (rupture of membranes!

5+: -

TR: /f preterm3 hydrate if fetus stable; /f term3 deliver

POLY%YD+AMN-OS:

AC/ 9 '& or '=; '67N of pregnancies; assn with JT defects; obst mouth3 hydrops3 multgest

Donitor with serial ultrasounds> ,an do therapeutic amniocentesis>

Antenata' %e*orr)age

PLACEN#A P+E&-A: Abnormal implantation of placenta over the internal os

Three types$> ,omplete (completely over os!'> Partial (little over os!7> Darginal (barely over os!

SS:painless vaginal bleeding # d+ by ultrasound # 5MJIT ERAD/JE @/T< SMH

+,: previous placental previa3 prior uterine scars3 multiparous3 adv mat age3 largeplacenta

#7: ,- if lungs mature.fetal distress.hemorrhage

P'a(enta a((reta: superficial invasion of placenta into wall of uterus

P'a(enta in(reta: invasion into the myometrium

P'a(enta !er(reta: invasion into the serosaT+ for above 7: '.7 get hysterectomy after c.s

PLACEN#AL AB+.P#-ON: premature separation of a normally implanted placenta


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SS: usually painful vaginal bleeding (uterus is contracting! . hemm between wall andplacenta

+,:htn3 prior abruption3 trauma3 smo)ing3 drugs # cocaine3 vascular disease

D7: inspection of placenta at delivery for clots; can see retroplacental clot on ultrasoundor a drop in serial hematocrits

#7: deliver if fetal status nonreassuring

Co*!'i(ations: hypovolemia3 5/,3 couvalaire uterus (brown boggy!3 PTL

.#E+-NE +.P#.+E: maKor cause of maternal death

2&N assn with a prior uterine scar (,-3 uterine surgery!

&N not assn with scarring but abd trauma (D4A!3 improper o+ytocin3 forceps3 inc> fundalpressure3 placenta percreta3 mult gest3 grand multip3 choriocarcinoma.molar pregnancy

SS: severe abd pain3 vag bleeding3 int bleeding3 fetal distress #7: immediate laparotomy3 hysterectomy with cesarean

,E#AL &ESSEL +.P#.+E: occurs usually with a velamentous cord insertion between amnionand chorion; may pass over osvasa previa (Perinatal mortality =&N!

SS: vag bleeding3 sinusoidal variation of


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CON#+A-ND-CA#-ONS #O #OCOLYS-S: acute fetal distress3 chorioamnionitis3eclampsia.pre e3 fetal demise3 fetal maturity3 hypersensitivity to tocolytics3 heart disease3/GH

O+" .P:


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CA.SES:inf+3 hydramnios3 incompetent cervi+3 abruptio placenta3 amniocentesis

Labor usually follows shortly

D7: -terile speculum e+am # ferning (on slide!3 pooling (in fornices!3 nitra*ine paper(turns blue! 6 gc3 chl3 strep ? culture .- # loo)s for AC/ (oligohydramnios!

MGM#: 9 7w delivery

Pretermpen G for ? strep3 e+pectant management vs> delivery for any signs

of infection or fetal compromise3 ?PPs vs> J-Ts

C)orioa*nionitis

Def: infection of amniotic fluid

He0uires delivery; increased ris) with inc> length of rupture of membranes

SS: fever 9 71 c3 inc @?,3 tachycardia3 uterus tender3 foul discharge

#7: Ampicillin and Gentamycin3 add ,lindamycin if c.s3 5EL/4EHS

Dost common cause of neonatal sepsisEndo*etritis

+,: prolonged labor3 PHMD3 more c.s than vag delivery O+GS: polymicrobial anerobes.aerobes li)e E ,oli.Group ? -trep.?acteroides

SS: uterine tenderness3 foul lochia

TR : gentamycin and clindamycin (continue until '2621 h afebrile!

Ce!)a'o!e'vi( Dis!ro!ortion

,ommon indication for c.s

Types of pelvis:

Gynecoid: $' cm widest3 sidewalls straight

Android: $' cm diam3 sidewalls convergent

Anthropoid: U$' cm3 sidewalls narrow

Platypelloid: $' cm3 sidewalls wide

Mbstetric conKugate diameter: sacral promontory to midpoint symphysis pubis: shortestAP diameter >= # $$>=

Ma'!resentationBree(): 762N

HC: previous breech3 uterine anomalies3 polyhydramnios3 oligohydramnios3multigestation3 hydro.anencephaly

Cran): fle+ed hips3 e+tended )nees (feet near head!

,omplete: fle+ed hips3 one or both )nees fle+ed

/ncomplete.Cootling: one or both foot down

5R: LeopoldIs maneuver3 vaginal e+am (feel sacrum and anus!

TR: , -ection is the preferred management3 e+ternal version (manipulation intoverte+ position!3 trial of delivery if '&&&67=&&g and multip (has a proven pelvis!

,a(e: chin is anterior for delivery3 many anencephalics have a face presentation; d+ on e+amBro


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Co*!ound: fetal e+tremity with verte+ or breech cord prolapse; part will reduce as laboroccurs

PP %e*orr)age

5efined as 9 =&& ml blood loss following vag delivery3 9 $&&& ml blood loss following c.s

Causes

o terine atony coagulopathy

o Corceps uterine rupture

o Dacrosomia uterine inversion

#7o 4igorous fundal massage M+ytocin '& in $&&& ml J-

o Hepair laceration Dethergine &>' mg /D (contra: htn!

o Ta)e out placental remnants PgC' # alpha (


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Jote: the delta M5 2=& is prognostic3 not the titeritselfVone '.7 TR: intrauterine blood transfusion through umbilical A of H< neg blood

E+#%+OBLAS#OS-S ,E#AL-S: heart failure3 diffuse edema3 ascites3 pericardial

effusion3 bilirubin brea)down Kaundice3 neuroto+ic effects>

-ntrauterine ,eta' De*ise

/C5 assn with abruption3 congenital anomalies3 post dates3 infection3 but usually isune+plained>

Hetained /C5 over 7 # 2 w leds to hypofibrinogenemia secondary to the release of

thromboplastic substance of decomposing fetus sometimes D-Ccan result>

D7: no C 5ichorionic diamniotic: ' chorions. ' amnions: separation before trophoblast on

embryonic dis) (splits before 8' hours!'> Donochorionic diamniotic: has one placenta; when twins occur d> =6$& before

amnion forms7> Donochorionic monoamniotic: one chorion and amnion; can be conKoined twins

DiFygoti( # /nc in Africa (Jigeria!7> ' sperm. ' eggs

D7: u.s3 inc


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De'ivery of #= # =>& g1 # 1>2 mg.ml: therapeutic1 ,J- depression$& Loss of dtrIs$= Hespiratory depression.paralysis$8 ,oma

'& ,ardiac Arrest


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C nephropathyH retinopathyD cardiomyopathyT renal transplant

Etio'ogy: impairment in carbohydrate metabolism that manifests during pregnancy ;=&N in subse0uent preg ; many get 5D later in life>

+is2 ,a(tors: 9'= yo3 obesity3 family history3 prev infant 92&&& g3 prev> stillborn3 prev>polyhydramnios3 recurrent Ab

Assn

Causes: -taph saprophyticus3 ,hlamydia3 E ,oli3 lebsiella3 Pseudomonas3Enterococcus3 Proteus3 ,oag # staph3 group ? strep

SS .#-: dysuria3 fre0uency3 urgency D3 .#-: .A F nitrite3 @?, esterase3 bacteria (contaminated if inc> epithelial cells!

#3 .#-: (pregnancy!: Dacrodantin

SS Pye'one!)ritis: ,4A tenderness3 fever3 dirty A (need '.7 of criteria to diagnose!

#7 Pye'one!)ritis: /4 Ancef until afebrile + 21 hours then 86$2 d po efle+

Pyelo is more li)ely to occur on the H because the uterus is de+trorotated>ProgesteroneIs effects cause urinary stasis3 which can predispose to pyelonephritis>

-nfe(tions and Pregnan(y

Ba(teria' &aginosis: Gardnerella vaginalis

ss: gray.yellow malodourous discharge # clue cells on wet prep

t+: Detronida*ole (flagyl! in second or third trimester

Grou! B Stre!: Assn with T/3 ,horioamnionitis3 endometritis3 neonatal sepsis

'67.$&&& live births assn with G??- sepsis

/4 pen G or ampicillin in delivery

%er!es Si*!'e3 &irus: a 5JA virus (


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&ari(e''a oster &irus

4ertical transmission possible

/f mom gets chic)en po+ during pregnancy the baby could die

#7: varicella *oster immune globulin given to mom within 8' hours of e+posure; can alsogive to infant>

CM&

SS baby: hepatosplenomegaly3 thrombocytopenia3 Kaundice3 cerebral calcifications3chorioretinitis3 interstitial pneumomitis3 DH3 sensorineural hearing loss3 neuromusculard.o

+ube''a

SS adu'ts: maculopapular rash3 arthralgia3 lymphadenopathy for '62 d

SS infant: deafness3 ,4 anomalies3 cataracts3 DH

D3: /gD titers in infant

5o not give DDH vaccine to pregnant woman

Jo t+ for rubella

#o3o!'as*osis

,irst tri*ester infe(tion: chorioretinitis3 microcephaly3 Kaundice3 hepatosplenomegaly

Adu't SS: fever3 malaise3 lymphadenopathy3 rash

D3: percutaneous umbilical cord sampling3 /gD ab

#3: pyrimethamine (U$2 w!3 spiramycin (less teratogenic!

%e!atitis B

#rans*: se+3 blood products . transplacental; can cause mild to fulminant hepatitis

D3: ab mar)ers:


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%y!ere*esis Gravidaru*

Dorning sic)ness is found in 1&N of women3 but usually resolves by $w

#3: maintain nutrition3 J- with =N de+trose3 compa*ine3 phenergan3 reglan /4./D; if

needed TPJ (total parenteral nutrition!

Coagu'ation Disorders

A hypercoaguable state can be due to inc> coag factors (all e+cept $$3 $'3 dec turnovertime for fibrinogen!3 endothelial damage3 and venous stasis (uterus compresses /4, and

pelvic veins! increased deep venous thromboses3 septic pelvic thromboses andpulmonary emboli>

Se!ti( !e'vi( t)ro*bosis: postpartum3 prolonged fever on antibiotics; usually due toovarian veins; not li)ely to lead to emboli; t3is heparin3 ab+

Dee! &enous #)ro*boses: --: edema3 erythema3 palpate venous cord3 tender3

different calf si*es; 5+: 5oppler of e+tremity3 venography; T+: heparin /4 (PTT + '! thensub heparin or loveno+ in pregnancy (JM ,MDA5/J /J PHEGJAJ,S: s)eletalanomalies3 nasal hypoplasia!; coumadin M if post partum>

Pu'*onary E*bo'us: 54T right atrium H4pulmonary arteries pulm htn3

hypo+ia3 H--: sob3 pleuritic chest pain3 hemoptysis3 with signs of 54T5R: 5oppler e+t3 ,RH3 E,G3 4 -can3 -piral ,T Pulmonary AngiographyTR: /4 heparin then - heparin or loveno+ (coumadin M postpartum!

Substan(e Abuse

EtO%: Cetal Alcohol -d: growth retardation3 ,J- effects3 abnormal facies3 cardiac

defects#3: alcoholism: aggressive counseling; ade0uate nutrition

Caffiene: 1&N e+posed in first trimester

#oba((o: /nc> -ab3 preterm birth3 abruption3 dec> birth weight3 -/5s3 resp disease

Co(aine: inc> abruption (from vasoconstriction!3 /GH3 inc PTL; as a child3developmental delay

O!iates: (heroin.methadone!; the danger is heroin withdrawal3 not use miscarriage3PTL3 /C5; t3:enroll in methadone program; do not restart methadone if patient has notused for 21 hours>

Post!artu* Care

&agina' de'ivery: pain care.perineal care (ice pac)s3 chec) for hemorrhage3 stoolsoftener Pelvic rest + w (no douching3 tampons3 se+!; J-A/5-

C Se(tion: local wound care3 narcotics for pain3 stool softeners3 J-A/5-

Breast Care: Dil) letdown occurs at '2 # 8' hr; if not breast feeding use ice pac)s3 tightbra3 analgesia (breast feeding gives relief!

Mastitis: oral or s)in flora enter a crac) in breast s)in; can be treated with diclo+acillin;"ontinue to breast feed-

Contra(e!tion: no diaphragms3 caps until w; if breast feeding depo3 micronor; not

breastfeedingM,P3 norplant3 depo3 Mrthoevra


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Post Partu* %e*orr)age:o ?lood loss vag delivery =&& cc; c.s $&&&cc (normal # remember3 momIs

plasma volume e+pands Kust for this reason%!o Causes:

terine atony (HC: multip3 h.o atony3 fibroids! t+: pitocin3 methergine3 etc>

Hetained products of conception: find on manual e+ploration of uterus

Placenta accreta: placenta is stuc) in uterine wall ,erv.4ag lacs: repair with ade0uate anesthesia

terine rupture ($.'&&&! ss: abd pain3 pop t+: laparotomy and repair ifpossible>

terine /nversion ($.'1&&! HC: fundal placenta3 atony3 accreta3 e+cesscord traction t3:*anua''y revert3 JTG3 Laparotomy

Post Partu* de!ression:o Post partum blues: =&N; changes in mood3 appetite3 sleep3 will resolve

o Post Partum depression: =N; decreased energy3 apathy3 insomnia3 anore+ia3

sadness; can get better or proceed to psychosis; t+: antidepressants (--H/s!

Endo*etritis:a polymicrobial infection invading the uterine wall after delivery;o --: fever3 inc @?,3 uterine tenderness (O =6$& d pp!3 foul discharge

o Loo) for retained products do a d Q c

o T+: triple antibiotics until afebrile + 21 hours and pain gone>

GYNECOLOGY

Benign Disorders of Lo


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o --: dysuria.parunia3 pruritus3 4ulvodynia3 lichen sclerosis et atrophicus

o T+ : 'N testosterone cream3 hydrocortisone cream

Benign Cysts:o Epidermal ,yst: occlusion of pilosebaceous duct.hair follicle

T+: incision and drainageo -ebaceous cyst: duct bloc)ed # sebum accumulates

TR: / Q 5 if infectedo Apocrine -weat Gland ,yst: on mons or labiaoccludes glands

superinfectionhidradentitis suppurative / Q 53 5o+ycyclineo ?artholinIs gland ,yst: 2 or 1 oIcloc) on labia maKora

TR: sit* baths3 inf+ # / Q 5 . word catheter

Cervi(a' Lesionso ,ongenital anomalies: 5E- e+posure in utero '=N congenital anomalies3 clear

cell adenocarcinoma $No ,ervical ,ysts: dilated retention cysts: nabothian cysts bloc)age of

endocervical gland O $ cm # as+3 no TRo Desonephric ,ysts: (remnants of wolfian.mesonephric ducts! deeper in stroma

o Polyps: broad based can have intermittent.post coital bleeding; usually

removed cervical fibroids intermenst bleeding3 dysparunia3 bladder.rectalpressure. r.o cerv cano ,ervical -tenosis: congenital or after scarring (surgery.radiation! or secondary to

neoplasm or polyp; if asymptomatic3 leave alone; if causes menstrual problems3remove; gently dilate scarring>

,ibroids

Cibroids Estrogen dependant local proliferation of smooth muscle cells3 usually occur inwomen of child bearing age and regress at menopause; African American are at higherris); has a pseudocapsule of compressed muscle cells; are found in '&67&N Americanwomen at age 7&

SS: menorrhagia (submucous!3 metrorrhagia (subserous3 intramural!3 pressure s+ (frompressing against bladder!3 infertility; =&N are asymptomatic>

Parasitic fibroids: get their blood supply from the omentum>

%isto'ogi( C)anges:o


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Surg #3: momectomy(only for fertility purposes!3 )ystere(to*y indi(ated

Pe'vi( Endo*etriosis: presence of endometrial glands outside of endometriumo Theories

-ampsonIs reflu+ menstruation: most li)ely

,oelomic metaplasia: irritant to peritoneum

Camily history . genetic

/mmunologic

Lymphatic and vascular mets

/atrogenic dissemination (ie:you see it on the other side of a c sectionscar!

o /nduces fibrosis which causes pelvic pain

o

SS: pain3 infertility3 bleeding.ovarian dysfunction3 hematoche*ia. hematuria3dyspareunia (pain with se+!o ,an be on peritoneum3 ovary (chocolate cysts!3 round ligament3 tube3 sigmoid

colono D7: laparoscopy

o #7:

J-A/5

M,P.Provera

Lupron (GJH< agonist! # pseudomenopause

Laser surgery.coagulation of implants3 TA


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#7: if premenopausal3 can observe if under 1cm; /f postmenopausal (any si*e! orpremenopausal need laparoscopy vs> laparotomy for cystectomy or oopherectomy

#reat*ent of S#Ds

C)'a*ydia tra()o*atis:o

5R # 5irect fluorescent Abo #3: do+ycycline $&& mg bid + 8 d or A*ithromycin $ g po (one dose!

N Gonorr)ea:o 5R: gram stain3 culture

o HC: low -E-3 urban3 nonwhite3 early se+3 prev gon inf+

o Treat both partners

o #7: Hocephin '=& mg /D or ,ipro =&& mg po or Clo+in 2&& mg po

o sually transfers male to female more than female to male>

Sy!)i'is: Treponema pallidumo 5R: dar) field microscopy

o #7: (U$ yr duration! Pen G '>2 million /D (9$yr duration! '>2 mill /D + 7

doses (see ob section for full description!

%er!es Si*!'e3 &irus: first episode # Acyclovir.Camciclovir.4alcyclovir; N

Ly*!)ogranu'ona veneru*: primary papules.shallow ulcer; secondary painfulinflammation of inguinal nodes with fever3 h.a3 malaise3 anore+ia; Tertiary rectalstricture.rectovaginal fistula. elephantiasis #7: do+ycycline $&& mg po bid + '$ d

Mo''us(u* (ontagiosu*: po+ virus from close contact; $6= mm umbilicated lesionanywhere but the palms or soles; are asymptomatic and resolve on their own

P)t)ris !ubis/sar(o!tes s(abei: Lice and scabies3 respectively; TR: lindane.well

&aginitis

Candida:o HC: Ab+3 5D3 Pregnancy3 immunocompromised

o --: burning3 itching3 vulvitis3 cottage cheese discharge3 dysparunia

o 5R: wet prep M< branching hyphae

o E+am: white pla0ues with or without satellite lesions

o #7: over the counter creams wor) well (monistat!; if resistant3 5iflucan $=& mg

po + once

#ri()o*onas: unicellular flagellated proto*oano --: itching3 inc> discharge (yellow.gray.green!3 frothy

o E+am: strawberry cervi+3 foamy discharge

o 5R: see the buggers *ipping all over your wet prep


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o #7: Clagyl =&& mg po bid + 8 d. partner condom + ' w

o Jote: avoid flagyl in frist trimester

Ba(teria' vaginosis: Gardnerella vaginaliso --: odorous discharge

o 5R: whiff test by adding M


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D7: mostly PE : called a PMP 3 which is a graph on which certain points corresponding tolengths of the vagina and where it moves on valsalva are graphed> This tells you where the defectis3 so you )now the appropriate therapy from it>S7: pain3 pressure3 dyspareunia3 incontinence3 bowel or bladder dysfunctionCauses: anything that will cause chronically increased abdominal pressure: cough3 straining3ascites3 pelvic tumors3 heavy lifting+,: aging3 menopause3 traumatic delivery3 associated with multiparityPE: pelvic e+am shows the amount of descent of the structure into the vagina and thusdetermines the degree of rela+ation: (PMP !

-tage $ # upper '.7 of vagina-tage ' # to the level of the introitus-tage 7 # outside of the vagina

#7: )egels (contraction of levator ani muscle3 instructed by physician!3 estrogen replacement3vaginal pessaries3 surgery

-NCON#-NENCE:

.+GE -NCON#-NENCE: a)a detrussor instabilityS7: urgency3 often can not ma)e it to the bathroomCauses: foreign body3 T/3 stones3 ,A3 diverticulitis

D3: based on history3 can be shown on urodynamics (which is a catheter in the bladder3 rectumand a machine to measure the difference> The bladder is filled with normal saline and response tothat is measured>!.rodyna*i(s s)o


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$> Adrenarche (61 yo!: regenerates *ona reticularis that produces 5 Growth spurt: (6$7 yo!: increase G< and somatomedian # , result in pea) height velocity3increase estrogen levels3 fusion of growth plate> Denarche: ($' # $7 yo!: anovulatory period up to $ year3 may ta)e ' years to have regularcycle3 delayed in athletes

Two pneumonics: (pic) your favorite! breast hair grow bleed or boobs pubes pits and pads

#ANNE+ S#AGES?reast Prepubertal $> prepubertal'> ?reast bud '> prese+ual hair 7> ?reast elevation 7> -e+ual hair 2> Areolar Dound 2> Did6escutcheon=> Adult ,ontour => Cemale escutcheon

MENOPA.SE: cessation of menstruationOnset # usually =&6 =$ years

6 if U2& yrs premature menopause6 if U7= premature ovarian failure (idiopathic3 send genetic studies!

S7: irregular menses3 hot flashes secondary to decreased estrogen3 mood changes3 depression3lower urinary tract atrophy3 genital changes3 osteoporosisLABS: C-< 9 2&3 elevated L


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b> C-< low: insufficient GnH

'> Breast @ uterus: estrogen F D/Ca> +o2itans2y "uster %auser: uterovaginal agenesis with other anomalies 2++b> Androgen insensitivity: 2+y3 testicular femini*ation3 no receptors for

testosterone3 D/C secreted therefore no mullerian structures>7> @Breast @ uterus: +y (no steroids! but phenotypically female3 no internal female organs>

a> 5 )ydro3y'ase def(steroid synthesis! in RS2> Breast @ uterus:

a> /mperforate hymen # solid membrane across introitus3 pelvic.abd pain fromaccumulation of menstrual fluid # hemato colpos>

b> Trans vaginal septum # failure to fuse mullerian determined upper vagina andG sinus found at mid vagina t+: surgery

c> 4aginal agenesis H T+:surgery>

SECONDA+Y AMENO++%EA:

Dust do a good


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$$> Edema$'> @eight gain$7> ?reast Tenderness

T?: avoid "affeine! etoh! toba""o! lo, sodium diet! ,ei$ht redu"tion! stress mana$ement-Dru$s& @S:IDS! %CPs! lasi0! "al"ium! vit E! SS/I

DYSMENO++%EA:pain and cramping during menstruation that interferes with the acts of dailyliving>Primary # presents U'& years b.c of increased PG occurs with Mvulatory cycles-econdary # Endometriosis3 Adenomyosis3 fibroids3 cervical stenosis (congenital3 trauma3surgery3 infection!3 adhesions (h.o infection P/53 TMA3 e+ lap LMA!

MENO++%AG-A


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5R: inspection on PE3 pap3 rectal3 ED?3


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or2 .!:-perm count6 must be done firstT-


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6false negative pap 2&6=&N

benign (e''u'ar ()angesH: thin) infection so wet prep3 cultures

2oi'o(ytosis: pathologic description associated with


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Ib=IIa radiation! radi"al hystere"tomy ( ta)es uterus3 cervi+3 parametrium3 LJ!IIb=III=I. e0tensive radiation!"hemo

O&A+-AN #.MO+S+,: family h+3 uninterrupted ovulation3 nulitips3 low fertility3 delayed childbearing3 late onsetmenopause (M,s have protective effect!S7: asymptomatic until advanced stages3 urinary fre0uency3 dysuria3 pelvic pressure3 ascites3 6 6#y!es:

Nonneo!'asti(: only operate if postmenopausal or if theyIre over 1 cmo Collicle cyst

o ,orpus luteum


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// # with e+tension to pelvic structures/// # peritoneum/4 6 distant mets

AdKuvant ,hemo: cisplatin and ta+olRHT in //.///Collow ,A$'= because increased in 1&N

CA O, ,ALLOP-AN #.BES6adeno ,A from mucosa6disease progresses li)e ovarian ,A6peritoneal spread6ascites6bilateral in $&6'&N results from mets often6primary in very rare6asymptomatic but may have vague lower abdominal pain and dischargeTR: TA


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HhythmCertility awareness.abstinences==61&N effectiveovulation assment ??Tmenstrual cycle trac)ingcervical mucus e+am

,oitus /nteruptus@ithdrawal before eKaculation$=6'=N failure

Lactational AmenorrheaJursing delays ovulation by hypothalamic suppressionDa+ of months=&N ovulate by 6$' months$=6==N get pregnant while nursing

?arrierDale and female condom3 diaphragm3 cervical cap sponge3 spermacide

/5-permicidal inflammatory response. inhibition of implantationsed when M,Ps contraindicatedPatient is a low -T5 ris),ontraindicated in pregnancy3 abnormal vaginal bleeding3 infectionHelative contraindication: nullip3 prior ectopic3 h.o -T53 mod.sev dysmenorrheaCailure rate U'N

Jorplant: not sold anymore for monetary reasons only-ustained release6 = years&>'N failurenot many side effects b.c no estrogen only progesteronesi+ fle+ible rods (7mg progesterone! - upper arm

side effects: /rregular vaginal bleeding3 7N failure rateside effects: irregular menstrual bleeding3 depression3 weight gain98&N get irregular menses3 eventually have amenorrhea

4asectomy

Ligation of the vas deferensU$N failure ratemust use condom for 26 w)s until a*ospermia confirmed on semen analysis8&N reanastomose resulting in pregnancy $16&N=&N ma)e anti6sperm antibodies

Tubal -terili*ationDost used method of birth control2N failure rateJo side effects


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Permanent although $N see) reversal which is successful in 2$612N$.$3=&& ris) of ectopic2.$&&3&&& mortality rate

Ora' Contra(e!tive Pi''s:MEC%: Pulsatile release of C-< and L< suppresses ovulation

,hange in cervical in cervical mucus,hange in Endometrium

#YPES:Donophasic # fi+ed dose of estrogen and progesteroneDultphasic varies progesterone dose each wee) and lower overall estrogen.progProgesterone progestin only not as effective as combination M,Ps

COMPL-CA#-ONS:Thromboembolism ( do not give in women with family history of 54T or PE!3 PE3 ,4A3

D/3

#%E+AP.#-C AB

'=N of pregnancies end in therapeutic ab

His) of death U $.$&&3&&& (anesthesia!

4aginal evacuation # suction curettage3 5 Q ,.E

/nduction of labor

Dedical TR :o Antiprogestin agent (H621 # mifepristone : bloc)s effects of progesterone! $st

X of $st trimester>o Post coital pill # high doses of estrogen that either suppresses ovulation or

accelerates ovum thru tube so no fertili*ation se: J.4

4nd#er*

,ongenital anomalies

4aginal prostaglandin

5 Q E

/nduction of labor w. hypertonic solution (saline3 urea3 PGC3 PGE vaginal suppositories!

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