positive RPR or BDRL test. next step
confirmation with a treponemal test, such as MHATP (microhemagglutination assay for antibodies to treponema pallidum) or FTA-ABS (fluorescent treponema antibody absorbed)
screen for gest diabetes when
at 26 to 18 wks; 50g oral glucose lead, assesment of serum glucose after 1 hr
menorrhagia due to uterine fibroids. next step labs
CBC, endometrial biopsy (for endometrial cancer), Pap smear (for cervical dysplasia or cancer)
woman55 yr or older with an adnexal mass. next step labs
CA-125 and CEA tumor markers for epithelial ovarian tumors
thickened endometrial strip in postmenopausal woman may indicate; fluid in cul-de-sac may indicate
malignancy; ascites (corr w malig)
us exam of uterus, inject saline into endometrial cavity. can identify endometrial polyps or submucous myomata (tumor composed of mm tiss)
IDs soft tissue planes and can help define mullerian defects, such as vaginal agenesis or uterine didelphys. maybe helpful in establishing the location of a pregnancy
why intravenous pyelogram (IVP)
asses concentrating ability of the kidneys, patency of the ureters, integrity of the bladder
why hysterosalpingogram (HSG)
this uses dye, injected thru cervix, and radiographs are taken. usedful for the detection of intrauterine abnormalities and patency of the fallopian tubes
most common cause of postpartum hemorrhage, and next step
uterine atony. first step- uterine massage to check if the uterus is boggy. if uterus is firm, consider genital tract laceration
what to look out for w/ tubo-ovarian abscess (life threatening)
rupture! clinical present- shock with hypoTN (see hypotension, confusion, apprehension , and tachycardia), IMMEDIATE SURGERY
most common cause of a nontender infectious ulcer of the vulva, tx
syphilis. painless adenopathy is usually associated. IM penicillin
how to test for syphilis
serology (RPR or VDRL) and specific treponemal test. However a patient with primary sypilis may not have developed an antibody response yet so confirm with DARKFIELD MICROSCOPY
signs of placental separation
cord lengthening, gush of blood, globular uterine shape, uterus lifting up to the anterior abdominal wall
what is the mechanism of hemorrhage for inverted uterus
inability for adequate MYOMETRIAL contraction effect. myometrial fibers do not exert their normal tourniquet effect on spiral arteries
best therapy for patient whose uterine fundus cannot be repositioned after uterine inversion (because the cervix is tightly contracted and physician can't get in there)
Duhrssen incisions of the cervix are used to
treat the entrapped fetal head of a breech vaginal delivery
perimenopause/climacteric. when does it start. next step
between 40 and 51 yrs measure FSH and LH to check for elevation
premature ovarian failure
menopause before age 40 (ovarian follicular atresia). At ages below 30, consider autoimmune diz or karyotypic abnormalities
in menopause ovarian inhibin levles are decreased what's the consequence of this
FSH and LH levels rise before estradiol levels fall
An 18 y/o adolescent female with infantile breast development has not started her menses. She has some webbing of the neck region, streaked ovaries, adn elevated gonadotropin (LH. FSH) levels. What is this condition
Turner syndrome 45 XO, this pt likley has decreased estrogen which predisposes her to osteoporosis and other conditions later in life
Excessive exercise may lead to ___ dysfunction, but many times simple weight gain will lead to its restoration of function. What to do (apart from gaining weight)?
put pt on OCPs to maintain normal hypothalamic fcn
What two endocrine states may cause hypothalamic dysfunction, inhibit GnRH pulsations, and thus inhibit pituitary FSH and LH release
hypothyroidism and hyperprolactinemia. These cause HYPOESTROGENIC AMENORRHEA
a common cause of hyperprolactinemia in a 22 y/o girl is
prolactinoma. pt will likely be amenorrheic
amenorrhea due to hyperprolactinemia causes a ____ state due to decreased GnRH release, and decreased FSH and LH secretion
continuous estrogen-progestin therapy may be associated with a small but significnat risk of what 2 conditions
cardiovascular diz and breast cancer
pathophysiology of septic shock
vasodilation usu due to endotoxins, although Staph aureus has exotoxins as causative
clinically adequate uterine contractions
contractions everey 2 to 3 min, firm on palpation, and lasting for at least 40 to 60 secs OR 200 Montevideo units in 10 mins
what pelvis type predisposes to the persistent fetal occiput posterior position
anthropoid- AP diameter greater than transverse diameter with prominent ischial spines and narrow anterior segment
1500 to 2000 mIU/ml. should be able to see an intrauterine pregnancy with this hCG level, which should be achieved by 5 wk GA
most significant risk factor for the development of an ectopic pregnancy
prior chlamydial cervical infection
RH-negative women with threatened abortion, spontaneous abortion, or ectopic pregnancy should get what
Rhogam to prevent isoimmunization
threatened abortion. hCG level is greater than us threshold. you did TVUS and see no intrauterine pregnancy, what do you do next?
laparoscopy. DO NOT GIVE METHOTREXATE BECAUSE THERE COULD BE A BABY IN THERE (15% of time)
threatened abortion. hCG level is lower than us threshold. what next?
measure hCG in 48 h it should rise by 66%
threatened abortion. hCG level is lower than us threshold. you measured hCG 48 h later and it rose by 66%. what next?
probably a viable IUP, so repeat sonogram when hCG exceeds threshold
threatened abortion. hCG level is lower than us threshold. you measured hCG 48 h later and it did not rise by 66%. in fact it only rose by 20%what next?
probably nonviable pregnancy. UTERINE CURETTAGE
threatened abortion. hCG level is lower than us threshold. you measured hCG 48 h later and it did not rise by 66%. in fact it only rose by 20%so you did a uterine curettage and found chorionic villi on pathology. what next?
this is a MISCARRIAGE aka SPONTANEOUS ABORTION. three choices- (1) expectant management, (2) D&C, (3) vaginal misoprostol
threatened abortion. hCG level is lower than us threshold. you measured hCG 48 h later and it did not rise by 66%. in fact it only rose by 20%so you did a uterine curettage and found NO chorionic villi on pathology. what next?
this is an ECTOPIC PREGNANCY. If it's asymptomatic, small (<3.5 cm) then do IM methotrexate
Woman at 5 wks gestation with severe lower abdominal pain who is hypotensive and tachycardic, TVUS shows free fluid in cul-de-sac what next?
RUPTURED ECTOPIC PREGNANCY likely, she is in shock, do surgery immediately. Forget about methotrexate
risk factors for placenta accreta
placenta previa, implantation over the lower uterine segment, prior c/s scar or other uterine scar, uterine curettage, FETAL DOWN SYNDROME
pt has placenta previa or low-lying placenta dx in 2nd trimester. what to do?
do another us in 3rd trimester, because it may resolve as the lower uterine segment grows more rapidly, this is known as transmigration of the placenta
what is the most likely complication after high ligation of umbilical cord and IV methotrexate therapy as a management option of placenta accreta, in order to avoid hysterectomy?
the next complication is infection because necrosis of the placental tissue can be a nidus for infection
tx gonococcal cervicitis
IM ceftriaxone for GC + oral azithromycin or doxycycline for chlamydia. If it's GC treat G and C. If it's C only treat C.
yellow exudative discharge arising from the endocervix with 10 or more PMNs per high power field on microscopy
Why is Chalmydia not a common cause of pharyngitis like Neisseria is?
b/c Neisseria has pili that allow it to adhere to surface of columnar epithelium at back of throat. Chlamydia doesn't
clinical picture of completed abortion
passage of tissue, resolution of crampling and bleeding, closerd cervical ox
pregnancy less than 20 weeks gestation assoc with vaginal bleeding, w/o cervical dilation
pregnancy less than 20 weeks gestation assoc with cramping, bleeding, and cervical dilation. No passage of tissue
pregnancy less than 20 weeks assoc with crampling, vaginal bleeting, open cervical os, and some passage of tissue but also some retained tissue. Cervix remains open due to continued uterine contractions
pregnancy less than 20 weeks with embryonic or fetal demise but no bleeding or crampling
difference between inevitable abortion and incompetent cervix
inevitable abortion- uterine contractions lead to cervical dilation
incompetent cervix- cervix opens spontaneously without uterine contractions. Painless cervical dilation.
pt has complete molar pregnancy, undergoes uterine suction curettage, what next
follow pt with weekly hCG levels because sometimes gestational trophoblastic diz persists after evacuation of the molar pregnancy
pt has complete molar pregnancy, undergoes uterine suction curettage, pt is followed with weekly hCG levels and they stay elevated showing that the gestational trophoblastic diz is persistent. what next?
two most common causes of antepartum (at or after 20 wks gest) bleeding
placenta previa and placental abruption
Erb palsy, how is it usually caused, what nerve roots are affected, what muscles are weak, appearance of affected arm
downward traction of anterior shoulder, C5-6, deltoid infraspinatus forearm flexors, limp by side and internally rotated (waiter's tip)
maneuvers for shoulder dystocia
McRoberts (hyperflex maternal thighs against abdomen) and suprapubic pressure- first ones to try
then Wood's corkscrew (progressively rotate posterior shoulder 180 degrees in a corkscrew fashion), delivery of posterior arm, Zavanelli maneuver (cephalic replacement and immediate c/s)
how does the McRoberts maneuver work
causes anterior rotation of symphysis pubis and flattening of lumbar spine. This relieves the anterior shoulder from impaction
how does the suprapubic pressure maneuver work
moves fetal shoulders from AP to oblique plane, allowing the shoulder to slip out from under the symphysis pubis
ureteral injury after hysterectomy. best exam
intravenous pyelogram (IVP). (CT scan of abdomen with IV contrast is okay)
placement of a stent into the renal pelvis through the skin under radiologic guidance to relieve urinary obstruction
risk factors for ureteral injury
cancer, extensive adhesions, endometriosis, tubo-ovarian abscess, residual ovaries, interligamentous leiomyomata
most common location for ureteral injury
at the CARDINAL LIGAMENT where the ureter is only 2-3 cm lateral to the cervix (water under the bridge)
overdissection of the ureter may lead to
devascularization injury. urine can be leaked into abdominal cavity and cause irritation to the intestines, inducing n/v
66 y/o woman with postmenopausal vaginal bleeding what are you concerned about? what should you do?
postmenopausal bleeding REQUIRES you to do what?
endometrial biopsy to assess for endometrial cancer
postmenopausal bleeding. pt has many risk factors for endometrial cancer. however endometrial biopsy/sampling is negative for cancer. what next?
hysteroscopy to directly visualize endometrial cavity
how is endometrial sampling (biopsy) done
a thin catheter is introduced through the cervix into the uterine cavity under some suction to aspirate endometrial cells. It is doe in the office
msot common cause of postmenopausal bleeding
atrophic endometrium 2/2 low estrogen levels (HOWEVER anytime there is postmenopausal bleeding you must biopsy and test for endometrial cancer)
what type of younger woman can be affected with endometrial cancer?
woman with h/o PCOS or other chronic anovulation
risk factors for endometrial cancer
too much or unopposed estrogen (early menarche and late menopause, obesity, chronic anovulation, estrogen-secreting ovarian tumors, ingestion of unopposed estrogen)
personal or family hx of breast or ovarian cancer
staging procedure for endometrial cancer includes
TAHBSO, omentectomy, lymph node sampling, peritoneal washings
what is the primary tx for endometrial cancer. how do you treat when staging shows high suspicion of spread? how do you treat when staging shows metastasis? what is the role of progestin in tx?
surgical (also is done for staging). radiotherapy. chemotherapy. no role- ineffective once endometrial cells become complex and atypical, because even though it is effective in shedding the endometrial lining it cannot inhibit cellular proliferation
placental previa. next step? long term management?
ultrasound exam; expectant management as long as bleeding is not excessive, c/s at 36 to 37 weeks' gestation after an amniocentesis is done to establish fetal lung maturity
risk factors for placenta previa
grand multip, prior c/s, prior uterine curettage, previous placenta previa, multiple gestation
woman presents with a placenta previa picture. What is the order of examinations?
us exam (rule out previa), speculum exam (Assess cervix and look for lacerations), digital exam (dont do a blind digital exam you could further separate the placenta from the uterus and cause more bleeding)
major risk factors for placental abruption aka abruptio placentae
trauma such as motor vehicle accident (MOST SIGNIFICANT), HTN- chronic and preeclampsia, cocaine use.
other risk factors for placental abruption
short umbilical cord, uteroplacental insufficiency, submucous leiomyomata, sudden uterine decompression (hydramnios), cigarette smoking, PPROM (preterm premature rupture of membranes)
bleeding into the myometrium of uterus giving a reddish discolored appearance to the surface. occurs in placental abruption
other things that may present with placental abruption (it has a variable presentation and is thus hard to diagnose)
preterm labor, stillbirth, FHR abnormalities
lab tests for placental abruption
serial hemoglobin levels
Kleihauer-Betke (Apt) test- tests for fetal erythrocytes from maternal blood because fetal-to-maternal hemorrhage is more common with abruption
how does the Kleihauer-Betke (Apt) test work?
Fetal Hgb is resistant to base, adult is not. Expose blood to NaOH, adult Hgb will be denatured (yellow-brown) and fetal will not (pinkish)
woman has abnormal vaginal bleeding, flank tenderness, and leg swelling what do you think of?
advanced cervical cancer (metastasis)
risk factors for cervical cancer
early age of coitus and childbearing, STDs, poor, HPV, HIV, smoking, multiple sex partners
tx early cervical cancer; advanced cervical cancer
surgery (radical hysterectomy) or radiation therapy; radiotherapy (brachy and teletherapy) + cis-platimum chemotherapy to sensitize tissue to radiotherapy
how does cervical cancer spread to the ureters
through the cardinal ligaments toward the pelvic sidewalls
staging procedure for cervical cancer
examination under anesthesia, IVP, CXR, barium enema or proctoscopy (examination of anus and rectum), cystoscopy
Pap smear. you see LSIL or HSIL. what next?
colposcopy-directed biopsy with endocervical currettage (LEEP or cone biopsy). HPV typing is not indicated
adolescent or pregnant woman. Pap smear. You see ASCUS, what next?
can observe, or can do HPV testing
most appropriate initial test for amenorrhea in the reproductive years (premenopausal)
pregnancy test (beta hCG)
positive progestin withdrawal bleed (vaginal bleeding after the ingestion of a progestin such as medroxyprogesterone acetate or Provera) is consistent with
When women are hypoestrogenic, two broad categories of causes are common. What are they and how to distinguish?
FSH level. FSH is elevated in ovarian failure
treatment of Sheehan syndrome
replace hormones- thyroxine, cortison, mineralocorticoid, estrogen and progestin therapy
two most common causes of secondary amenorrhea after postpartum hemorrhage
Sheehan syndrome and intrauterine adhesions
artificial ROM, fetal bradycardia ensues. what next?
vaginal exam to assess for umbilical cord prolapse
what factors predispose to cord prolapse?
unengaged presenting part
transverse fetal lie or footling breech with ROM
umbilical cord prolapse. what next?
pt should be taken for emergent c/s, pt should be placed in Trendelenburg position and physician's hand should be kept in vagina to elevate the presenting part
maneuvers to improve maternal oxygenation and cardiac output delivery to the uterus in the case of fetal bradycardia
1. Distinguish maternal from fetal pulse with fetal scalp electrode or ultrasound (confirm the problem)
2. Identify umbilical cord prolapse with vaginal exam
(Note these 2 steps are the first steps in assessing fetal brady after artificial ROM)
3. place pt on her side to move uterus from great vessels
4. IV fluid bolus if pt is possibly vol depleted, give ephedrine a pressor if needed (hypoTN due to epidural catheter)
5. give 100% oxygen by face mask
6. Stop oxytocin and give terbutaline to relax uterus
the most common sign of uterine rupture is
a fetal heart rate abnormality, such as fetal bradycardia, deep variable decels, or late decels. immediate c/s is indicated
prolonged fetal decels or fetal bradycardia assoc with misoprostol cervical ripening is usu assoc with
uterine hyperstimulation- defined as more than 5 contr in 10 min
galactorrhea due to hypothyroidism (can be consequence of Graves diz treatment). what next
check serum prolactin and TSH
likely mechamism of hypothyroidism inducing galactorrhea
hypothyroidism causes elevated TRH which acts as a prolactin-releasing hormone. hyperprolactinemia causes galactorrhea
labs to expect in primary hypothyroidism (inducing galactorrhea). Treat
elevated TRH and TSH, elevated prolactin, inhibited GnRH pulsation leading to oligomenorrhea (consequence of elevated prolactin)
Treat- thyroxine, estrogen, bromocriptine (for pts desiring fertility) or cabergolamine if not bromocriptine responsive- dopamine agonists can be given vaginally or orally
women with oligomenorrhea and galactorrhea should have what imaging?
AP and lateral coned-down view of sella turcica. Skull MRI will confirm empty sella
treat women with hyperprolactinemia (with or without microadenoma) who have adequate estrogen level (>40 pg/ml) and don't care about fertility
periodic progestin withdrawal (give em progestin so they bleed)
treat patient with pituitary adenoma (and thus hyperprolactinemia) who wants to be fertile
medical management (estrogen, bromocriptine, cabergolamine) v. surgery
pts with mildly elevated prolactin levels (20-60 ng/ml), think about...
pts with markedly elevated prolactin levels, think about...
hypothroidism (check TRH)
pituitary adenoma (do MRI)
complications of pituitary adenoma removal
transient diabetes insipidus, hemorrahge, meningitis, CSF leak, panhypopituitarism. Can reduce size of macroadenoma with bromocriptine before surgical removal
pregnant woman with microadenoma of pituitary gland. complains of headaches and visual disturbances. what next?
oral bromocriptine (no surgery)
pruritic urticartial papules and plaques of pregnancy (PUPP)
erythematous papules and hives (surrounded by a pale halo) beginning the in the abdominal area and spreading to the thighs and sometimes the buttocks and arms; a cause of pruritus unique to pregnancy. histology- normal epidermis + superficial perivascular infiltrate of lymphocytes and hisiocytes assoc with edema of papillary dermis. tx- topical steroids, antihistamines
erythematous blisters (VESICLES) on abdomen and extremities (more on LIMBS than trunk); another cause of pregnancy-related pruiritus. Newborns can have transient neonatal herpes gestationis (it resolves) Thought to be related to IgG autoantibody directed at basement membrane leading to classic complement pathway activation. dx- immunofluorescent examination of biopsy specimens. tx- oral corticosteroids
cholestasis of pregnancy. how to dx
intrahepatic cholestasis- bile salts are incompletely cleared by the liver, accumulate in the body, and are deposited in the dermis, causing pruritus- usu begins in 3rd trimester. +/- jaundice. no skin rash. may recur with ingestion of oral contraceptives and in subsequent pregnancies, common in Swedes.
dx- increased levels of circulating bile acids
cholestasis of pregnancy. increased risk of
prematureity, fetal distress, fetal loss
esp when jaundice is present
tx cholestasis of pregnan
antihistamines adn cornstarch baths; ursodeoxycholic acid
cholestyramine (bile salt binder) BUT assoc with vit K deficiency
most common cause of generalized pruritus in pregnancy in the absence of skin lesions
cholestasis of pregnancy
common outpt tx of PID
IM ceftriaxone as a singe injection, and oral doxycycline, 2x/day for 10-14 days
differential dx of salpingitis
pyelonephritis, appendicitis, cholecytitis, diverticulitis, pancreatitis, ovarian torsion, gastroenteritis
dx of acute salpingitis
made clinically by abdominal tenderness, cervial motion tenderness, adnexal tenderness
a complication of salpingitis, RUQ pain when perihepatic adhesions are present
criteria for outpt managment of salpingitis; inpt mngment
low-grade fever, tolerance of oral medication, absence of peritoneal signs, compliance; fails outpt therapy, pregnancy, extremems of age, can't tolerate oral meds- IV cefotetan and oral/IV doxycycline
tx tuboovarian abscess
clindamycin or metronidazole for anaerobes. note that you do not have to drain a TOA
IUD ___ risk for PID. OCPs ___ risk of PID because progestin thickens the cervical mucus
gold standard for dx salpingitis
laparoscopy- look for purulent d/c exuding from the fimbriae of the tubes
sulfur granules are classic for ____, which occurs more often in the presence of an IUD
Actinomyces. Actinomyces israelii is a gram + anaerobe, sensitive to penicillin
Concern for PE in pregnancy (acute onset of pleuritic chest pain and severe dyspnea and tachypnea). what test?
(MRA of lungs is ok)
(Also get tests for other causes of thrombosis- hyperhomocysteinemia, protein S and C, antithrombin III, factor V Leiden, antiphospholipid syndr, etc)
imaging confirms PE now what
anticoagulation- IV heparin for 5 to 7 days, then switch to subq heparin to maintain aPTT at 1.5 to 2.5 times control for at least 3 months. Can alwo use LMWH. Ater 3 months, can do low dose heparinization for remainder of pregnancy and 6 weeks postpartum
dx of PE may be made presumptively on:
1. clinical presentation
2. hypoxemia on arterial blood gas
3. clear cxr
pregnant woman has what normal acid-base alteration
respiratory alkalosis with partial metabolic compensation (renal excr of bicarbonate). Since serum bicarb is lower the pregnant woman is more prone to metabolic acidosis
most common EKG abnormality assoc with pulm embolism
can also see S wave in lead I, Q wave in lead III, and R-axis deviation
why give oral acyclovir therapy at the primary outbreak? what is the rationale?
decrease viral shedding and duration of infection. Acyclovir DOES NOT affect likelihood of future recurrence, change pt's immune response
what is this: lesions with ragged edges, necrotic base, adenopathy in inguinal region
Chancroid. Caused by gram - Haemophilus ducreyi
most common symptom of uterine fibroids
menorrhagia- excessive bleeding during menses. Maybe due to 1. increased endometrial surface area, 2. disruption of hemostatic mechanisms during menses, 3. ulceration of submucosal fibroid surfaces
intermenstrual bleeding, what dx to consider?
endometrial hyperplasia, endometrial polyp, uterine cancer, uterine leiomyomata
signs of uterine leiomyomata degenerating into leiomyosarcoma, risk factor, what to do?
rapid growth (i.e., increase of more than 6 wks size in 1 yr). h/o radiation to pelvis is a risk factor. exploratory laparotomy with hysterectomy
typical physical exam of leiomyomata
irregular, midline, firm nontender mass that moves contiguously with cervix
medical tx of fibroids
NSAIDS, progestin therapy (medroxyprogesterone acetate- Provera); GnRH agonists cause decrease in size over 3 mos (used before surgery because tumor regrows when drug is stopped)
surgical tx of fibroids
future pregnancy not desired- hysterectomy (you can try uterine artery embolization); pregnancy desired- myomectomy
signs of severe preeclampsia
BP criteria (160/110 or greater), proteinuria (24 h urine protein of more than 5 g), epigastric tenderness (2/2 ischemia to liver), elevated LFTs
feared complication of severe preeclampsia
rupture of hepatic hematoma --> immediate laparotomy and blood product replacement
HTN with proteinuria (>300 mg/24h) at gest age above 20 wks, caused by vasospasm. Nondependent edema (face, hand) is usu present. 2 elevated BPs meausred 6 hr apart, taken in seated position are needed for dx. tx- (mag sulfate &) delivery
CBC- plt & Hct, UA, 24h urine protein, LFTs, LDH (rises w/ hemolysis), UA test (usu increased w preeclampsia), fetal testing to evaluate uteroplacental insufficiency
when is chronic HTN diagnosed
when pregnant woman has HTN prior to 20 wks gestation or if HTN persists beyond 12 wks postpartum
firm, mobile, nontender, rubbery mass
fibroadenoma- does not change with menstrual cycle. if pt is low risk for brca, fine needle aspiration (FNA) is acceptable. Most common cause of breast mass in adolescent-20s
3 breast biopsy methods
FNA, core needle stereotactic biopsy, excisional biopsy (removes entire lesion). the latter 2 remove more tissue but cause more bruising and pain
most common benign breast change
fibrocystic changes- multiple irregular diffuse breast lumpiness. an exagerrated response to ovarian hormones. common in premenopausal women
tx- decrease caffeine, NSAIDS, tight bra, OCPs or oral progestin; severe cases- danazol (weak antiestrogen and androgenic) or mastectomy
woman with red tender indurated breast who is nonlactating, what must be ruled out
inflammatory breast cancer (agressive. skin changes due to cancer cells within subdermal lymph channels. more in YOUNGER pts)
5 main causes of infertility
ovulatory (progesterone and LH increased around ovulation, also body temp); uterine; tubal; semen abnormalities (vol >2 ml, sperm conc > 20 mil/ml, motility >50%, morphology >30% normal); peritoneal factor/endometriosis (3 D's- dysmenorrhea, dyspareunia, dyschezia).
Cervical factor is an infrequent etiology, may be susbected with thick cervical mucus before ovulation. Can bypass with intrauterine insemination.
endometriosis is best diagnosed by; tubal factor infertility is best diagnosed by
laparoscopy (HSG is not helpful since endometriosis manifests outside of the uterus/tubes/ovaries); laparoscopy
how can a pt assess whether ovulation occurs or the adequacy of the corpus luteum
what is this? 12h h/o colicky R lower abd pain and n/v, significant involuntary guarding. tx? when likely to occur?
torsion of ovary, surgery, 14 wk or after delivery
appendicitis in pregnancy
pain is superior and lateral to McBurney's pt b/c uterus pushes appendix up & out. can mimick pyelonephritis
how to dx cholelithiasis in pregnancy. why is this common?
abd us; increase in gallbladder vol and biliary sludge esp after 1st trimester
tx cholecystitis (bladder inflamm -> biliary colic RUQ pain), biliary obstr, or pancreatitis in pregnancy
most frequent and serious compl of a benign ovarian cyst
ovarian torsion; pregnancy is a rsk factor esp around 14 wk and after delivery. acute onset of colicky pain. surgical tx with ovarian conserve if possible- cystectomy if untwisting results in reperfusion, oophorectomy if not
ectopic pregn risk factors
salpingitis esp with Chlamydia, tubal adhesive diz, infertility, progesterone-secreting IUD, tubal surgery, prior ectopic pregn, ovulation induction, congenital abnormalities of the tube
pregn woman tx w nitrofurantoin for UTI, gets dark colored urine (bilirubinemia), jaundice, and fatigue. what is teh dx
G6Pd deficiency- hemolytic anemia triggered by sulfonamids, nitrofurantoin, antimalarial agents
elevated A2 hgb level is suggestive of ___; elevated hgb F level is sugg of ___
cervical change assoc with uterine contr AFTE 20 wks and PRIOR to 37 wks. in nullip- uterine contr, cervical exam with 2 cm dil and at least 80% eff
BM protein that helps bind placental membranes to the decidua of the uterus. if assay neg- no delivery within 1 week
what cervical length --> increased risk of preterm deliv
less than 25 mm (by TVUS. if there's funneling or beaking its worse)
preterm labor what to do
tocolysis if GA is less than 34-35. steroids if GA is less than 34. UDS for cocaine
side effect of terbutaline
pulmonary edema (and the other tocolytics have this effect too but the beta-agonists MOST); tachycardia, widened pulse pressure, hyperglycemia, hypokalemia
role ofcorticosteroids in early GA and in GA >28 wks
lower IVH risk, lower respiratory distress syndr risk
tocolytic agent causes repeat variable decels of FHR which one was used
indomethacin, because increased variable decels can indicate decreased amniotic fluid and oligohydramnios (indomethacin is assoc with this)
pt on tocolytic gets pulmonary edema (dyspnea, tachypnea, low o2 sat)
d/c tocolytic, give furosemide
OCP- two tabs of ovral oral contraceptives (0.1 mg ethinyl estradiol and 0.5 mg levonorgestrel) at time 0 and 2 tabs after 12 hrs
oCPs best suited for sickle cell disease and epilepsy
injectables (depo-medroxy progesterone acetate)- note that it decreases bone density
main risks combined hormonal contraception
due to estrogen component. venous thromboembolism, strokes in patients with migraines with aura, myocardial infarction in women smokers age 35 adn older, increased risk of cholelithiasis, benign hepatic tumors
main positives OCPs
decreases risk of ovarian and endometrial cancer, shortens duration and decreases blood loss of menses, improves pain from dysmenorrhea and endometriosis, decreases dysfunctional uterine bleeding adn menrrhagia, improves acne
depot medroxyprogesterone acetate (DepoProvera) is associated with what serious side effect particularly in adolescents
loss of bone mineral density
dx DVT in pregnancy, tx
Dopper us, heparin IV for 5 to 7 days, then sq to maintain aPTT at 1.5 to 2.5 times control for at least 3 mos, then prophylactic or full heparinization (coumadin may cause congenital abnormalities adn is more difficult to reverse)
what does heparin do
potent thrombin inhibitor, that blocks conversion of fibrinogen to fibrin. it combines with antithrombin III, stabilizing the clot
most common ovarian tumors in women younger than 30, tx
benign cystic teratomas (Dermoid cysts). ovarian cystectomy
young child with precocious puberty, what type of ovarian tumor?
granulosa-theca cell (Estrogen-secreting) tumor
struma ovarii; appearance on MRI. tx.
a teratomy in which thyroid tissue has overgrown the other elements, usu unilateral more frequent in R. usu measure less than 10cm in diameter, can rarely produce enough thyroid hormone to cause hyperthyroidism. on MRI- complex multilobulated masses with thick septa, thought to represent multiple large thyroid follicles. tx- cystectomy or salpingo-oophorectomy
rupture of mucinous epithelial ovarian tumor
pseudomyxoma peritonei; mucinous material spills out into intra-abdominal cavity
superficial separation of subcutaneous tissue
red tender indurated incision and fever 4-10 days postoperatively. tx- open wound and drain purulence. Also broad-spectrum antimicrobial with wet-to-dry dressing changes
fascial disruption (separation fo the fascia but not the peritoneum)
profuse drainage from teh incision 5 to 14 days after surgery. repair ASAP and broad-spectrum abx
evisceration- protrusion of bowel or omentum through incision.
sterile sponge wet with saline should be placed over bowel and pt taken to OR. immediately start abx
causes of a hemoperitoneum in pregnancy (2)
1- ruptured ectopic pregnancy
2- ruptured corpus luteum (less common)
endometrial tissue that floats with a "frond pattern" is almost always diagnostic for
an intrauterine pregnancy
a physiologic ovarian cyst formed from mature graafian follicles following ovulation, which secretes progesterone. usu less than 3 cm in diameter
why do corpus luteum cysts tend to rupture more during pregnancy
1. increased incidence and friability of corpus lutea in pregnancy
2. anticoagulation therapy
confirm dx of ruptured corpus luteum cyst. tx.
laparoscopy, secure hemostasis (stop bleeding) if bleeding continues do cystectomy
earliest indicator of hypovelemia
decreased urine output. THen positive tilt test, then tachycardia, then hypotension (30% of blood vol would be lost at this point in a young healthy pt)
pt comes in with heavy vaginal bleeding and hypotension and tachcardia what next?
IV isotonic fluids
nonclotted blood obtained from culdocentesis is consistent with
intraabdominal hemorrhage (as seen in ectopic pregnancy rupture or corpus luteum rupture)
suspect Asherman's syndr what next
hysterosalpingogram (and confirmed by hysteroscopy- gold standard)
when should intrauterine adhesions be suspected
if a woman presents with secondary amenorrhea, a negative pregnancy test, and does not have progestin-induced withdrawal bleeding
tx intrauterine adhesions/Asherman's
operative hysteroscopy. post op management may include inserting IUD or pedriatric Foley catheter to prevent adhesions from reforming. also consider conjugated estrogens and progesterone (medroxyprogesterone acetate)
how can cervical conization (aka cone biopsy of the cervix) cause secondary amenorrhea and how will it present
causes cervical stenosis, which leads to retrograde menstruation, which will present as crampy abdominal pain
signs of breast cancer, suspicious on mammogram
isolateed cluster of tiny irregular calcifications esp if LINEAR and WISPY
if brca suspected, then what?
stereotactic biopsy OR needle-localization biopsy. Similar miss rate, but latter procedure excises more tissue which is helpful in borderline ca
2 most common causes of primary amenorrhea when there is normal breast development and absent uterus. how to differentiate
1. mullerian agenesis
2. androgen insensitivity. (46 XY but phenotypically female, high testosterone- in the male range)
differentiate with serum testosterone level or karyotype. (also the former have normal pubic and axillary hair)
when to remove gonads of androgen insensitivity person and why
around age 16-18 after puberty is completed, because the gonads are at high risk of malignancy after puberty (fyi- they aren't descended and are intra-abdominal)
when should androgen insensitivity syndrome be suspected
when a pt has primary amenorrhea, an absent uterus, normal breast development, and scant/absent pubic and axillary hair (the body every vain and "insensitive" woman wants)
describe women with mullerian agenesis
46XX karyotype, no uterus or fallopian tubes, short or absent vagaina. Have normally functioning ovaries since ovaries are not mullerian structures and therefore normal breast development (Effect of estrogen). normal pubic and axillary hair growth since there's no defect in their androgen receptors. 1/3 have congenital renal abnormalities, like pelvic kidneys
why do pts with androgen insensitivity usu have full breast development? where is that estrogen coming from?
peripheral conversion of androgens to estrogens
most common cause of delayed puberty (Absent breast tissue after age 14 yrs)
gonadal dysgenesis, which can occur with 46XX and 46XY and 45XO (Turner, most common karyotype)
tx septic abortion
maintain BP (IV fluids or dopamine/pressors), monitor BP oxygenation and urine output (b/c oliguria is an early sign of septic shock), start abx (GENTAMICIN & CLINDAMYCIN), uterine curettage. (if there's shock may want to put in a central venous pressure catheter)
most likely mechanism of septic infection
ascending infection with polymicrobial bacteria (include anaerobes that have ascended from lower genital tract)
woman has septic abortion, pockets of air seen in uterine mm on CT scan what next?
hysterectomy. she's got a necrotizing metritis like Clostridum
common way of acquiring Listeria monocytogenes, esp among Hispanics
unpasteurized milk products such as soft goat cheese. GI infection spreads to fetus through placenta causing chorioamnionitis. will see gram positive rods
is delivery necessary in Listeria chorioamnionitis? if not then what do you do?
no. IV ampicillin tx.
tx uterine atony
IM methylergonovine (Methergine)- avoid in HTN due to risk of stroke,
IM prostaglandin F2 alpha (Hemabate)- avoid in asthma due to risk of bronchoconstriction,
rectal misoprostol- the preferred agent due to low cost, high efficacy, and low side effects
Surgical therapy if above fails- exploratory lap with uterine artery ligation or internal iliac (aka hypogastric) artery ligation, B lynch stitch, or hysterectomy if all else fails
Late PPH (occurs after first 24 hrs) may be caused by? tx?
subinvolution of the uterus/placental site- eschar over the placental bed falls off- bleed 2 wks after delivery. tx- oral methylergonovine and f/u (or oxygocin, prostaglandin F2alpha)
PPH case to suspect with uterine crapming, fever, foul-smelling lochia
retained products of conception (POC)
characteristic physical findings of Turner syndrome
short stature, webbed neck, shield chest, increased carrying angle at the elbow
hypogonadotropic hypogonadism (low FSH, low estrogen) causes
a central defect- poor nutrition or eatin d/o, extreme exercise, chronic illness or stress, primary hypothyroidism, Cushing syndrome (increased cortisol), pituitary adenomas, and craniopharyngiomas (hyperPRL)
most common etiology in postpartum mastitis
S aureus. tx- dicloxacillin, continued breast-feeding or pumping
when to suspect that mastitis is complicated by abscess. how to confirm. how to tx.
persistent fever after 48 h of abx therapy or presence of fluctuant mass. us exam. surgical drainage or us-guided aspiration, antistaph abx
nulliparous woman with tender, red breast and enlarged tender axillary lymph nodes, what do you think and what do you do?
inflammatory brca, biopsy
what does a galactocele (milk retention cyst) look like, tx?
nonerythematous fluctuant mass (so it's also fluctuant like an abscess, but it's NOT red); aspiration
how to distinguish fever of breast engorgement and fever of abscess
breast engorgement fever will not be longer than 24 hr
why don't we want to use methimazole in pregnancy
has been assoc with aplasia cutis congenital (skin or scalp defects)
symptoms suggestive of thyroid storm
altered mental status, hyperthermia, HTN, diarrhea. can also have CHF
drugs to tx thyroid storm
admit pt to ICU. PTU, beta blockers for tachycardia (be careful in CHF patients), acetaminophen or cooling blankets for hyperthermia, corticosteroids to prevent peripheral conversion of T4 to T3
subclinical maternal hypothyroidism may be associated with
adverse neurological development and decreased childhood intelligence
most likely cause of hyperthyroidism in POSTpartum period, what antibodies are often present
destructive lymphocytic thyroiditis aka postpartum thyroiditis. High corticosteroid levels in pregnancy suppress autoimmune antibodies, a flare occurs postpartum when these levels fall. OFten antimicrosomal and anti-peroxidase antibodies are present
parvovirus B19 infection (5th disease- pregnant mom can have a younger child with high fever and slapped cheeks who gave it to her) may lead to
fetal abortion, stillbirth, and HYDROPS (pregnancies less than 20 wks are esp at risk for hydrops)
excess fluid located in 2 or more fetal body cavities, and many times is associated with hydramnios
how does parvovirus B19 cause hydrops?
1. severe anemia may cause heart failure
2. induction fo the hematopoietic centers in the liver to replace normal liver tissue, leading to low serum protein
tx fetuses affected by parvovirums
intrauterine transfusion if severe v. observation if not so severe.
causes of fetal anemia
parvovirus B19 inf, isoimmunization, large fetal-to-maternal hemorrhage, thalassemia
if person is IgM and IgG negative for parvovirus B19, what does this mean?
it means they're susceptible but we don't know infection status. we have to know how far back their exposure was. if more than 20 days then they're not infected.
etiology of endomyometritis
ascending infection of polymicrobial vaginal organisms (mostly anaerobes like Bacteroides but also gram negative rods)
after c/s: IV abx w/anaerobic coverage, such as gentamicin and clindamycin
after vaginal: don't need anaerobic coverage, ampicillin and gentamicin is fine
septic pelvic thrombophlebitis. tx?
bacterial infection at the placental implantation site, spreads to pelvic venous thrombi usu involving the ovarian vein. can also spread to common iliac veins or involve IVC.
tx- abx and heparin
one reason fever of endomyometritis may not improve after 48 hr of therapy and next step
enterococcal infection. Add ampicillin
what to do if fever of endomyometritis persists despite triple antibiotic therapy (gentamicin, clindamycin, ampicillin) for 48-72 hr
CT scan of abdomen and pelvis to look for abscess or infected hematoma
signs of wound infection after c/s
fever on postop day 4, +/- erythema or drainage
tx- surgical opening of wound, dressing changes, antimicrobial agents, inspect fasia for nec fasc (surgical debridement if necessary)
which syphilis tests' titers will fall with treatment?
which will remain positive for life?
2 most common infectious causes of vulvar ulcers in teh US
(chancroid is much less common)
Haemophilus ducreyi gram stain. tx?
small Gram negative rod. looks like "school of fish"
tx- oral azithromycin and IM ceftriaxone
alternative tx for syphilis in the case of penicillin allergy (but NOT in a pregnant person)
pt undergoes therapy for syphilis but RPR titer doesnt fall what is one reason why, and how to diagnose
neurosyphilis, Lumbar puncture
PROM + tender uterine fundus + FETAL TACHYCARDIA; best tx? etiology?
intra-amniotic infection (chorioamnionitis). best tx- ampicillin and gentamycin & induction of labor. etiology- ascending infection from vaginal organisms
before 32 weeks give steroids for fetal lung maturity (in the absence of overt infection) then deliver when lungs are mature (presence of PHOSPHATIDYL GLYCEROL- PG- on vaginal pool amniotic fluid) using induction if necessary, can give broad-spectrum abx which can delay delivery; after 34-35 wks- delivery. When infection is apparent (even if before 32 weeks), start IV amp and gent and induce labor.
what organism may induce chorioamnionitis without rupture of membranes, since the mechanism is transplacental spread?
bacterial vaginosis on speculum exam, microscopy
homogenous, white vaginal discharge and fishy odor. no erythema or lesions of vagina; clue cells- coccoid anaerobic bacteria attached to surface of epithelial cells
metronidazole orally or vaginally (alternative clindamycin)
the 3 common infectious causes of vaginitis or vaginosis
bacterial vaginosis, Trichomoniasis (flagellated protozoan, yellow-green to gray frothy vaginal discharge, STRAWBERRY CERVIX), Candida vulvovaginitis
which organism that causes vaginitis/vaginosis can be isolated from a wet surface 6 hrs later
elevated morning hasting 17-hydroxyprogesterone level is high suggestive of
CAH- congenital adrenal hyperplasia caused by 21-hydroxylase deficiency
decrease DHT- inhibit adrenal or ovarian androgen secretion, wt loss, OCPs, spironolactone (is an androgen antagonist)
6 y/o girl with breast development and vaginal spotting, no abnormal hair growth. 10 cm ovarian mass palpated on rectal exam. what is it?
granulosa-theca cell tumor (secreting estrogen)
most common neonatal endocrine cause of death (2/2 salt wasting). also the most common cause of ambiguous genitalia in the newborn
congenital adrenal hyperplasia (21-hydroxylase deficiency)
suspicious Down's findings on us
thickened nuchal fold, shortened femur length, echogenic bowel (double bubble of duodenal atresia
elevated unexplained MSAFP is associated with increased for
stillbirth, growth restriction, preeclampsia, placental abruption
primary management of PCOS
use insulin-lowering agents (such as metformin) to reduce hyperinsulinism and limit risk of developing cardiovascular diz and DM
pts desiring pregnancy- clomiphene citrate
endometrial cancer in PCOS woman who wants children
high dose progestin therapy and repeat of endometrial biopsy in 2-3mos. then hysterectomy after childbirth
timing of division--> resulting chorionicity and amnioicity
first 72 hr, day 4-8, day 8, after day 8
di/di, monochorionic/diamniotic, mono/mono, conjoined twins
when there is no dividing membrane between the twins (mono, di) what can occur
cord entanglement --> 50% perinatal mortality rate
management of vasa previa
planned c/s before ROM, at 35-36 wks gestation. digital vaginal exam contraindicated.
lichen sclerosis clinical presentation and tx
cigarette paper skin (crinkled, fragile, thin, atrophic), figure 8 pattern around vulva and anus, itching which can be worse at night. can be retraction of clitoris and constriction of introitus with some bruising. tx- avoid skin irritants, don't scratch, wear cotton white underwear. Clobetasol and other steroids
inflammed Bartholin aka greater vestibular glands, tx
incision and placement of a small balloon (Word) catheter into gland OR
marsupialization- surgical fixation of the cyst wall everted against the mucosa of the vulva
both techniques allow infection drainage for several weeks
BIOPSY for cancer in women over 40
suspicious lesion of vulva what should you do
BIOPSY especially in postmenopausal woman. if vulvar cancer- surgical staging, remove primary lesion and adjacent inguinal lymph nodes