• women of reproductive age should take a daily 400μg (0.4 mg) supplement.
• adequate levels are especially important prior to pregnancy and during the 1st four weeks of fetal development.
• ↓ fatal MIs and fatal coronary artery events.
• if there is a prior hx of fetal neural tube defects supplement w/ 4 mg/day.

apgo U1T7, U2T10

• biennial mammograms starting at age 50; USPSTF.
• yearly at age 40 (American Cancer Society & ACOG)

U1T7 q. 2

• first-degree relative with postmenopausal BC.
• combination of 1st degree and second degree relatives on the same side of the family dx with breast and ovarian cancer (one cancer type per person) ↑ of BRCA mutation in non-Ashkenazi women.
• screen with mammogram.

U1T7 q. 3

• < 1% pregnancy rate - Depo-Provera
• 3-5% - oral contraceptive
• 12% - condom

U1T7 q. 5

• early menopause, glucocorticoid thx, sedentary lifestyle, etOH consumption, hyperthryoidism, hyperPTH, anticonvulsant thx, vit D def, fam hx of early or severe osteoporosis, chronic liver disease, or renal disease.
• bone density scan for women w/ no pre-existing risk factors at age 65 (DEXA scan).

U1T7 q. 6

• upper displacement of diaphragm by 4 cm.
• TLC ↓ only slightly b/c of compensatory a/p widening of chest.
• Respiratory rate does NOT change; however, TV is ↑ → ↑ minute ventilation → respiratory alkalosis.
• minute ventilation = RR x TV

U2T8 q. 2

• CXR - lungs are the most common site of metastatic disease in pts w/ gestational trophoblastic disease.
• w/ a complete mole → u/s sound will reveal a heterogenous cystic tissue (snowstorm pattern from multiple hydropic villi).

U2T8 q. 9

• ↑ estrogen → ↑ thyroid binding globulin → ↓ free T₄ (thyroxine) → ↑ TSH → normal levels of free T₄, but ↑ total thyroxine.

U2T8 q. 10

• underweight: BMI < 18.5, gain 28-40 lbs
• normal: BMI 18.5-24.9, gain 25-35 lbs
• overweight: BMI 25-29.9, gain 15-25 lbs
• obese: BMI > 30, gain 11-20 lbs
• majority of weight gain occurs during 2nd half of pregnancy.
• adequate weight gain in first 20-24 weeks is especially important in multiton pregnancies → ↓ risk of preterm infants (early weight gain ↑ placental development; 24 lbs by 24 weeks is recommended)

U2T8, U2T20

• medications used to suppress premature labor/contractions (β₂-agonists-terbutaline or ritodrine, oxytocin antagonists, CCBs-nifedipine).
• use of β₂-agonists ↑ susceptibility to pulmonary edema b/c plasma osmolality is ↓ & SVR is ↓ during pregnancy.
• women with chorioamnionitis are also more likely to develop pulmonary edema.
• abx can be used to prolong latency period by approx. 5-7 days, as well as ↓ incidence of maternal amnionitis & neonatal sepsis.

U2T8, T25

• approx. 1%
• performed during weeks 10-12 of gestation.
• chorionic frondosum is sampled.
• CVS < 10 weeks associated w/ rare limb abnormalities.
• amniocentesis fetal loss risk: 0.5%; performed after 15 weeks (FYI-good for dx fragile-X).

U2T9, T32

• PAPP A (pregnancy associated plasma protein A) + nuchal translucency + β-hCG; aka combined test.
• triple screen - β-hCG, AFP, unconjugated estriol
• add Inhibin A for quad screen → ↑ sensitivity; employed during 2nd trimester (both triple and quad screens).
• βhCG ↑, AFP ↓, estriol ↓, inhibin A ↑
• remember: maternal serum AFP is sampled.
• if screens are (+), further testing should be pursued.

U2T9, U2T10, UW 2569

• shoulder dystocia (difficult passage of shoulder during delivery), metabolic disturbances, preeclampsia, polyhydramnios, fetal macrosomia.
• intrauterine growth restriction is seen more commonly in women with pre-existing diabetes (longterm diabetes → vascular damage → ureteroplacental insufficiency).
• infants born to diabetic mothers are at ↑ risk of developing hypoglycemia, polycythemia, hyperbilirubinemia, hypocalcemia, and respiratory distress.

U2T10, T12

• neural tube defect is the most common; specifically, lumbar meningomyelocele.
• cardiac defects, hypospadius, craniosynostosis, limb defects (particularly radial aplasia).
• case reports: omphalocele and lung hypoplasia.

• start zidovudine (AZT) immediately.
• azithromycin prophylaxis @ 6 weeks (Pneumocystic jirovecii).
• HIV testing at 24 hours.
• for mother start HAART during pregnancy
• risk of vertical transmission w/o HAART or w/o c-section is 25%.
• attempt c-section at 38 weeks, before labor or membrane rupture (these ↓ benefit of c-section)

U2T12, T17a, Kap Q0428, Q0426m

• if you are not familiar with the mother's prenatall hx (eg, opiate/heroine use) you can precipitate life-threatening withdrawal.
• even if respiratory depression 2° to perinatal meds is suspected administer positive pressure ventilation & prepare for intubation; NO naloxone.

U2T12

• aka intra-amniotic infection
• mom: tender fundus, fever, tachycardia
• if amniotic fluid is sampled → ↑ IL-6, ↓ glucose
• foul smell upon delivery is a warning sign that infant can be septic.
• a septic infant will appear pale, lethargic, and be febrile.
• tx: IV abx and prompt delivery (vaginal is fine) regardless of gestational age; abx is most commonly ampicillin + gentamicin.

U2T12, T25, p. 214

• stage 1: interval btw onset of labor and full cervical dilation; latent phase and active phase (> 3 cm).
• stage 2: complete cervical dilation through delivery of infant.
• stage 3: begins after delivery of baby and ends w/ delivery of placent (allow 30 minutes for delivery of placenta; then proceed to manual removal of placenta).
• stage 4: immediate postpartum period, approx 2 hours after delivery of placenta.
• stage 1 is divided into latent phase and active phase; active phase is > 3cm; arrest of labor is no Δ in cervical dilation > 2 hours. 

U2T11, Kap m001020

• assess respiratory effort
• tocolytic mechanism: competes w/ Ca²⁺ for entry into cell.

U2T24

• it is not standard of care to offer amniocentesis to a 19-year-old.

U2T12

1. Heart Rate: absent (0), < 100 (1), ≥ 100 (2)
2. Respiratory Rate: absent (0), weak/gasping (1), strong cry  (2)
3. Reflex Irritability: absent (0), grimace (1), cry/pull away/gags (2)
4. Activity (muscle tone): absent (0), some flexion (1), flexed arms/legs that resist extension (2)
5. Skin Color: blue all over (0), blue extermities (1), pink (2)

• endometritis (vaginal 2%, caesarean 10-15%)
• Ddx: UTI, lower genital tract infxn, wound infxn, pulm infxn, thrombophlebitis, mastitis.
• ↑ risk w/ vaginal: prolonged labor, prolonged rupture of membranes, multiple vaginal exams, internal fetal monitoring, manual removal of placenta, ↓ socioeconomic status.
• polymicrobial infxn (aerobes & anaerobes); most common - staph and strep. 

U2T13

• HTN, stroke, seizure
• safest method to prevent lactation → breast binding, ice packs, and analgesics.

U2T13

• ambivalence toward newborn or sense of incapability of loving her family.

U2T13

• uterine atony
• PPH is defined as estimated blood loss ≥ 500 ml after vaginal birth or ≥ 1000 ml after caesarean.
• occurs in 1 in 20 deliveries

U2T13

• significant blood loss (PPH) → anterior pituitary infarction (necrosis).
• ↓ FSH/LH, ↓TSH, ↓ ACTH
• slow mental fxn, weight gain, difficulty staying warm, no milk production, hypotension, amenorrhea.
• tx: estrogen & progesterone replacement + thyroid and adrenal hormones.

U2T13

• fetal status
• if fetal heart rate cannot be assessed externally → fetal scalp electrode.
• measuring intrauterine pressure and epidural are 2° concerns.
• before epidural fetal status must be assessed.

U2T13

• early decelerations - head compression (uterus contracts → compression of head → vagal stimulation → ↓ HR).
• late decelerations - assocated w/ uterine contractions (onset, nadir, recovery of decels occurs after the beginning, peak, and end of contractions); assoc w/ uteroplacental insufficiency.
• variable decelerations = cord compression; most common decelerations and have no relationship to uterine contractions. breech presentation or oligohydramnios can ↑ risk of cord compression. sustained fetal bradycardia is usually observed; must perform emergent c-section (do not attempt to push cord back, as it can damage it).
• accelerations are always reassuring and indicate fetal well-being.

U2T11, T26, Kap m000973m

• Braxton-Hicks contractions
• short duration, less intense than true labor
• active labor is defined by strong, regular regular contractions that cause cervical Δ.

U2T11

1. contractions every 5 minutes for 1 hour
2. rupture of membranes
3. fetal movement < 10 per 2 hours
4. vaginal bleeding

U2T11

• it is indicated after a non-reactive NST.
• 2 parts to BPP - non-stress test (NST) and u/s evaluation.
• NST - record fetal HR for 30 min while looking for accelerations w/ fetal movement; reactive = 2 episodes of ↑ HR of 15 beats/min for duration of at least 15 seconds within a 20 min period.
• 5 components make up the BPP (1 NST & 4 u/s) for a total of 10 points; ≤ 2 points → labor induction, 4 points → labor induction if > 32 weeks, repeat test same day if < 32 weeks & deliver if < 6 points.

1. Nonstress test (fetal heart rate)
2. fetal movement
3. fetal tone
4. fetal breathing
5. amniotic fluid volume (vertical pocket ≤ 2 cm → 0 points, > 2 cm → 2 points). 

wikipedia, U2T26,31, UW 3112

• ischial tuberosity = 0
• arrest of descent is defined as lack of Δ for 2 hours in nulliparous & 1 hour for multoparous women.
• add 1 hour if epidural has been administered.

UW 3116

• oxytocin
• responsible for milk ejection
• suckling works better than breast pump for stimulating secretion of milk.
• prolactin → milk production (present throughout pregnancy, but suppressed by estrogen & progesterone).

U2T14

• candidiasis
• check infant's oral cavity.

U2T14

• 3-4 stools in 24 hours
• 6 wet diapers in 24 hours
• weight gain
• sounds of swallowing

U2T14

• progestin-only are the preferred form of hormonal contraception in lactating mothers.
• IUD is safe and does not affect milk production.
• tubal ligation and essure (permanent, non-surgical transcervical sterilization procedure) are not reversible and not recommended in women that may change their mind; even if they state adamantly that they don't ever want children again, reversible is the best alternative.

U2T14, UW3339

• engorgement commonly occurs with milk comes in.
• frequent nursing (1.5-3 hours around the clock)
• warm shower or warm compresses to enhance milk flow.
• massaging breast
• hand expressing milk to soften breast.
• wearing a good support bra
• using analgesics 20 min before breast feeding.

U2T14

• fetal pole visualized outside the uterus on u/s.
• βhCG > 2000 mIU/ml (discriminatory zone); at this level intrauterine pregnancy should be seen on u/s.
• or the pt has inappropriately ↑ βhCG level (<50% ↑ in 48 hrs) and has levels which do not fall down following diagnostic dilation & curettage.
• w/ heterotopic preg, there should be a visible pregnancy in uterus
• w/ a missed abortion there should also be some visible tissue or a fetal pole w/in the uterus.
• in a normal pregnancy βhCG ↑ by at least 50% every 48 hours until pregnancy is 42 days old.
• progesterone < 5 ng/ml suggests an abnormal or extrauterine pregnancy; > 25 ng/ml suggests a healthy pregnancy.

U2T15

• serial βhCG levels (at least every 48 hours until a trend is established, usually 3 levels).

U2T15

• hemodynamic stability
• non-ruptured ectopic pregnancy
• size of ectopic mass < 4 cm w/o fetal HR or
• < 3.5 cm in presence of fetal HR
• normal liver enzymes
• normal renal fxn
• normal WBC
• ability of pt to f/u rapidly if condition Δ (access to car).

U2T15

1. threatened abortion
2. incomplete abortion
3. missed abortion
4. inevitable abortion
5. recurrent abortion
6. septic abortion

1. threatened: vaginal bleeding before 20 weeks w/o passage of any products; cervix is closed. tx: reassurance and outpatient follow-up (bedrest and no sex is recommended only for psychological benefit to parents).
2. incomplete: passed some, but not all, of the products of conception; cervical dilation.
3. missed: fetal demise w/o cervical dilatation or passage of products of conception; if pt stable 1st tri - expectant management (no ↑ in risk of hemorrhage/infection), 2nd tri - dilation & evacuation.
4. inevitable: vaginal bleeding, dilated cervix; u/s → ruptured or collapsed gestational sac w/ absence of fetal cardiac motion.
5. recurrent: 3 successive spontaneous abortions; test for SLE, DM, thyroid disease, maternal/paternal chrom, uterine imaging w/ hysteroscopy or hysterography NOT CT/MRI.
6. septic abortion: fever, bleeding w/ dilated cervix, tender uterus.

U2T16, U3T34, UW4804

• dilation & suction curettage
• products of conception need to be evacuated to control the bleeding.

U2T16

• DM
• chronic renal disease
• lupus
• HTN, hx of pre-eclampsia, prior termination of pregnancy DO NOT ↑ risk of 1st trimester loss.

U2T16

• incompetent cervix.
• tx: cervical cerclage after 1st trimester; suturing of cervix at 12-14 weeks.
• risk factors: cone bx for tx of abnormal Pap.

U2T16, U2T21

• pulmonary HTN; these women are at greatest risk w/ ↓ venous return & ↓ R. ventricular filling (assoc. w/ most maternal deaths).
• similar mortality rates are seen in aortic coarctation w/ valve involvement and Marfan syndrome w/ aortic involvement.

U2T17a

• propylthiouracil
• propranolol
• sodium iodide
• dexamethasone
• contraindicated in pregnancy: radioactive iodoine (I-131); concentrates in fetal thyroid → congenital hypothyroidism.

U2T17a

• pyelonephritis

U2T17a

• amitriptyline (TCA)
• good safety profile
• unrelated to migraines, but also safe: levothyroxine, labetalol, acyclovir.

U2T17a

• even if pt is allx (anaphylaxis) to penicillin, it is still the #1 choice; no proven alternatives to penicillin during pregnancy (doxycycline is contraindicated in pregnancy).
• desensitization followed by IM benzathine penicillin G.
• also, all pregnant women should be screened for syphilis regardless of risk factors.
• screen with RPR or VDRL; if (+) confirm w/ fluorescent treponemal antibody-absorption test (FTA-ABS).

U2T17a, UW 4530

• if no risk factors assess at 24-28 weeks (performed in 2 steps: 50g, 1-hour oral glucose challenge; if abnormal (>140 mg/dl) → diagnostic 100g, 3-hour oral glucose tolerance test (≥ 2 abnormal 100 g glucose results = gestational diabetes).
• 1-hour: < 180, 2-hour: < 155, 3-hour: < 140
• target is fasting glucose < 95 mg/dl, 1-hour postprandial 130-140 mg/dl, or 2-hour postprandia < 120 mg/dl.
• tx  - diet, but insulin may be required; insulin does not cross placenta.
• pt at low risk are not routinely screened.
• if high risk, screen as soon as possible; risk - obesity, FHx DM, previous GDM.

U2T17a, acog p. 156

• CXR is essential for dx
• PFTs, sputum cultere, serologic testing, cold agglutin identification, and bacterial Ag testing is not recommended in uncomplicated pneumonia.

U2T17b

• surgical excision and chemothx
• chemothx after first trimester
• radiation thx is NOT recommended!
• when breast cancer is dx during pregnancy, it has been reported that microscopic metastases to regional lymph nodes are likely.

U2T17b, Kap Q0099m

• paroxetine (SSRI) → fetal cardiac anomalies & persistent pulmonary HTN.
• sertraline and fluoxetine are permissible SSRIs.

U2T17b

• appendicitis
• difficult to dx - anorexia, N&V are commonly associated w/ pregnancy.
• uterus can displace appendix upwardly and laterally.
• dx: graded compression ultrasonography (↑ sensitivity & specificity, esp < 35 weeks).
• ddx: preterm labor, pyelonephritis, renal colic, placental abruption, degeneration of a uterine myoma.

U2T17b

• HTN
• gestational DM
• preeclampsia
• fetal macrosomia
• postpartum complications
• ↑ rates of caesarean delivery

U2T17b

• aggressive hydration
• abx (should improve w/in 72 hours).
• if no improvement → u/s evaluation looking for obstruction.
• relieve obstruction w/ cystoscopic placement of double-J ureteral stent, unless long-term stents are foreseen (then, percutaneous nephrostomy).

U2T17b

• mild variant of intrahepatic cholestasis → jaundice → pruritis.
• tx: ursodeoxycholic acid

U2T17b

• α-methyldopa (first-line medication for tx HTN in pregnancy); centrally acting α₂-adrenergic agonist.
• hydralazine (direct vasodilator)
• labetalol
• the goal is to lower the diastolic to a safe range (90-100 mmHg), and not a normal BP. This is to prevent maternal stroke or abruption, but maintain adequate placental perfusion.

U2T18, UW 4780

• 4-7 mEq/L
• loss of deep tendon reflexes occur at 7-10.
• respiratory depression at 12
• cardiac arrest >15.
• magnesium prevents seizures (tx of choice for eclampsia); administered during labor & 24 hrs postpartum to prevent seizures.
• tx MgSO₄ toxicity w/ calcium gluconate.

U2T18, UW2561

• thrombocytopenia < 100,000
• uncontrollable HTN w/ 2 anti-hypertensives.
• non-reassuring fetal surveillance (look for growth restriction or oligohydramnios).
• ↑ LFTs (2x normal)
• eclampsia
• CNS symptoms
• oliguria
• FYI: uric acid and hemoconcentration are markers for preeclampsia.

U2T18

• mild: persistent elevation of BP (> 140/90) & 24 hour urine protein > 300 mg (1-2+ on dipstick) after 20th week of gestation; manage with bedrest & observation; deliver if fetal lungs are mature.
• severe: mild preeclampsia + 24 hour urine protein > 5000 mg (3-4+ on dipstick) or BP > 160/110.
• if HTN is detected and is new w/ normal lab values and no proteinuria → gestational HTN.
• if gestational age is adequate (>34 weeks) → deliver; only cure for preeclampsia.

U2T18, Kap Q0774m, UW 2557

• it is w/in the spectrum of severe preeclampsia.
• hemolysis, elevated liver enzymes, low platelets.
• HELLP can lead to swelling of liver capsule and rupture of liver (w/ or w/o RUQ pain); can be due to centrilobular necrosis, hematoma formation, and formation of thrombi in portal capillary system.
• can be w/ of w/o hemolysis (↑ bilirubin & anemia).

U2T18, UW 4781

• occurs late in pregnancy.
• symptoms develop over days to weeks and include malaise, anorexia, N&V, epigastric pain, and progressive jaundice.
• 50% associated with HTN, proteinuria, and edema, signs suggestive of preeclampsia.
• ↑ LFTs
• thrombocytopenia and abnormal coagulation studies
• may or may not have DIC.
• Renal Failure
• severe liver dysfxn w/ hypofibrinogenemia, hypoalbuminemia, hypocholesterolemia, prolonged clotting times.
• as AFL worsens → hypoglycemia.
• tx - must deliver baby.
• High Yield: renal failure, hypoglycemia, hyperbilirubinemia, and coagulopathy helps distinguish this syndrome from HELLP.
• believed to be due to long-chain 3-hydroxyacyl-conenzyme A deficiency.

U2T18, Kap m000986

• middle cerebral artery peak systolic velocity
• also great way to monitor Kell antigen, which does not cause hemolysis, but → destruction & suppression of hematopoietic precursor cells.
• amniotic fluid surveillance for bilirubin would not be useful for Kell-sensitized pregnancies (linear deviation from OD 450nm does not work).
• if anti-Kell is detected in mother, test father for anti-Kell Ag (Kell sensitization usually occurs via transfusion). 

U2T19, O&G p. 200

• intrauterine intravascular fetal transfusion, directly into umbilical vein.
• if this is not feasible (inaccessible or hydrops fetalis) → intraperitoneal transfusion.
• maternal plasmapheresis when disease is severe and intrauterine transfusions are not possible.

U2T19

• severe anemia
• hydrops fetalis is the collection of fluid in 2 or more spaces (ascites, pericardial effusion, pleural effusion, edema of scalp, polyhydramnios, placentomegaly.

U2T19

• Rosette test, if (+) → Kleihauer-Betke test; acidic solution turns mother's RBCs pale, while fetal RBC resists Δ.
• RhoGAM dose can then be determined (1 dose [300 μg] covers up to 30cc of feto-maternal hemorrhage; most of the time only 0.1 cc are transferred; 0.1 cc can sensitize mother).
• RhoGAM only desensitizes to D-antigen.
• Current recommendations for RhoGAM (Rh+ baby) in mother w/o evidence of Rh immunization: IM prophylactivally w/in 72 hours of delivery (if no evidence of fetomaternal hemorrhage), spontaneous or induced abortion, following antepartum hemorrhage, following amniocentesis or chorionic villus sampling, and prophylactically at 28 weeks gestation (first tested w/ indirect Coomb's test).

U2T19

• dividing membrane thickness > 3mm, peak (lambda) sign, different fetal genders, and 2 separate placentas (anterior & posterior) always.

1. ---

   Diamniotic dichorionic placentation occurs w/ division prior to morula state (w/in 3 days of fertilization).
2. Diamniotic monochorionic: division btw day 4-8.
3. Monoamniotic monochorionic: division between 8-12.
4. Conjoined twins: division ≥ day 13.

U2T20

• fertilization of multiple ova from the same cycle, but from separate acts of sexual intercourse.

U2T20

• autosomal trisomy (40-50% of cases); most commonly trisomy 16.

U2T21

• 8-15 weeks
• no risk < 8 weeks & > 25 weeks.

U2T21

• when a dead fetus has been in utero for 3-4 weeks fibrinogen levels may ↓.
• pt may experience a nose bleed (common in pregnancy, but can be 2° to coagulopathy).
• consider induction of viable fetus, but may be delayed; check fibrinogen levels weekly/bi-weekly.

U2T21

• prematurity
• multiple pregnancy
• genetic disorders
• polyhydramnios
• hydrocephaly
• anencephaly
• placenta previa
• uterine anomalies & uterine fibroids

U2T22

• multiparous women: at least 1.5 cm/hour.
• if secondary arrest of dilatation occurs → amniotomy; no Δ for 2 hours.
• after amniotomy and contraction pattern is still not adequate → pitocin.
• after pitocin and no cervical Δ, place intrauterine pressure catheter to assess strength of contractions.
• fetus must be stable.

U2T22

• prostaglandin
• cervical ripening & labor induction (↑ uterine contractions).
• prevention & tx of postpartum hemorrhage

UpToDate

• prolonged latent phase: nulliparas - > 20 hours, multiparas - > 14 hours; tx w/ rest or augmentation of labor.
• treat prolonged latent phase w/ rest; Do NOT rupture membranes during latent phase → ↑ risk of infection.
• active phase: cervical dilation > 4 cm
• artificial rupture of membranes during latent phase is not recommended as it ↑ risk of infxn.

U2T22

• cervicitis: caused by chlamydia, gonorrhea, trichomonas. cervix is much more vascular during preg and inflammation can → bleeding. can have no pain, cramping, or dysuria; friable cervix.
• bloody show: cervix extremely vascular during pregnancy. dilation → small amount of bleeding; normal labor; friable cervix.

U2T23

• placenta accreta: placenta grows into myometrium.
• hx of caesarean section & low anterior placenta.
• scar tissue from previous surgery prevents proper implantation of placenta and it can grow into muscle.

U2T23

• in a near term pt, if second episode of bleeding from a placenta previa develops → c-section.
• do not perform vaginal exam w/o ruling out placenta previa w/ abdominal u/s; not transvaginal and withold digital exam till after u/s.
• bleeding from placenta previa can occur w/o warning or pain; classically painless bleeding.
• placenta previa w/ past hx of c-section → ↑ risk of placenta accreta.

U2T23, Kap Q0861

• smoking, cocaine, abdominal trauma, chronic HTN, multiparity, and prolonged premature rupture of membranes.
• painful bleeding
• lack of vaginal bleeding does not rule out placental abruption (can bleed retroplacentally).
• normal u/s (only catches 25% of placental abruptions).
• ↑ uterine contractions/spasms.

U2T23, UW 2407

• presence of regular uterine contractions leading to cervical change.
• this must be treated promptly.

U2T24

• terbutaline and ritodrine: diabetes
• MgSO₄: myasthenia gravis
• indomethacine: contraindicated in preterm > 33 weeks (↑ risk of closure of ductus arteriosus at 34 weeks).

U2T24

• genital tract infection
• esp. bacterial vaginosis
• also multiple gestations, smoking, prior preterm rupture, short cervical length, and oligohydramnios.

U2T25

• it is a uterotonic and used to ↑ uterine contractions & ↓ uterine bleeding.
• since methylergonovine is a potent smooth muscle constrictor, do not use in women w/ HTN and preeclampsia.
• other uterotonics: prostaglandins (misoprostol) and oxytocin (pitocin).

U2T27

• potent smooth muscle constrictor (uterotonic)
• but also has a bronchio-constrictive effect; contraindicated in asthma pts.

U2T27

• prostaglandin F2-α IV → bronchoconstriction; can be directly injected into uterus.
• methylergonovine IV → stroke.
• oxytocin, never as IV push, but as rapid infusion of a dilute solution.

U2T27

• breast engorgement; it is an exagerrated response to the lymphatic and venous congestion associated with lactation.
• milk "let-down" usually occurs on postpartum day 2 or 3; if the baby is not feeding well the breast can become engorged.

U2T28

• cholelithiasis → cholecystitis
• pregnancy puts women at risk for cholelithiasis.

U2T28

• septic thrombophlebitis (thrombosis of venous system of pelvis).
• tx: abx & anticoagulation → rapid resolution of fever.
• anticoagulation is short-term.

U2T28

• form of PMS with severe emotional symptoms (angry, depressed, irritable, labile).
• most common symptom is abdominal bloating (90%), then breast tenderness and headaches.
• occurs in the luteal phase.
• absent in the beginning of the follicular phase.
• tx - fluoxetine (SSRI) QD or only during symptomatic phase.

U2T29, Kap s2s323m

• affects 50% of women w/in 3-6 days postpartum.

U2T29

• 42 completed weeks
• associated with placental sulfatase deficiency, fetal adrenal hypoplasia, anencephaly, inaccurate or unknown dates, and extrauterine pregnancy.
• complications of postterm: macrosomia, oligohydramnios, meconium aspiration, uteroplacental insufficiency, dysmaturity.
• 2x/week monitoring with U/S to evaluate for oligohydramnios (vertical pocket < 2cm or AFI < 5 cm); amniotic fluid can become drastically ↓ in 24-48 hrs.

U2T30, UW3281

• NST (non-stress test) and AFI (amniotic fluid index) 2x a week w/ induction of labor for a nonreactive NST or oligohydramnios; even @ 42 weeks if gestation is uncertain (gestation should be determined by u/s prior to 20 weeks)
• induction of an unfavorable cervix (no cervical Δ) → ↑ risk of caesarean sedtion.

U2T30

• no benefit
• it is the infusion of normal saline into the intrauterine cavity.
• used to tx repetitive variable decelerations.

U2T30

• complex of symptoms occurring in an infant, such as a relative absence of subQ fat, skin wrinkling, prominent fingernails and toenails, meconium staining of skin and placental membranes.
• incidence of dysmaturity approaches 10% when gestational age > 43 weeks.

U2T30

• use cervical ripening agents.
• prostaglandin E1 applied locally is the most commonly-used cervical riepning agent.

U2T30

• ↑ systolic/diastolic ratio of the umbilical artery (sign of ↑ vascular resistance).

U2T31

• crown-rump length (dates pregnancy w/in 5-7 days).
• crown-rump at 6-12 weeks supports gestational age of at least 39 weeks.
• crown-rump at 13-20 weeks confirms gestational age of at least 39 weeks determined by clinical hx and physical exam.

U2T31

• head-sparing effect w/ an asymmetric growth pattern.
• head/brain is spared ↓ blood flow (head size remains very close to normal).
• fetal abdomen measues below normal.

U2T31

• cardiovascular disease
• chronic HTN
• COPD
• diabetes

U2T31

• hyperglycemia → ↑ renal osmotic load
• abnormal fetal swallowing (CNS: anencephaly or GI abnormalities: esophageal aresia, duodenal atresia, diaphragmatic hernia)

U2T31

• the intrauterine device is protective against uterine cancer b/c of release of progestin in the endometrial cavity.
• also "Plan B": effective for up to 120 hours after intercourse, and delays ovulation.

U2T33, UW 2393

• first-degree: only vaginal mucosa
• second-degree: vaginal fascia and perineum.
• third-degree: rectal partial or complete transection of the rectal sphincter.
• fourth-degree: external anal sphincter, the internal anal sphincter, and the rectal mucosa.

U2T32

• caesarean NOT indicated for macrosomia (> 4000 g), 42 weeks gestation, and polyhydramnios.
• consider c-section > 5000 g in woman without diabetes, 4500 g in woman with diabetes.
• fetal head > 12 cm could benefit from c-section.

U2T32

• fetal lacerations at edge of vacuum cup particularly if torsion is applied (maternal laceration occurs w/ forceps delivery).
• torsion can also → separation of fetal scalp from underlying structures → cephalohematoma → ↑ risk of jaundice.

U2T32

• breech position
• breech infants delivered vaginally are at higher risk for neonatal complications → caesarean section.
• external cephalic version is contraindicated in active labor.

U2T32

• hx of thromboembolic disease
• lactating women
• smokers of age > 35
• severe nausea w/ combine OCP
• the above are ideal candidates for progetin-only pills

U3T33

• chronic HTN
• smokers > 35 years old
• impaired liver fxn, hepatic neoplasm
• known or suspected breast cancer
• thrombophlebitis, thromboembolic disease
• undiagnosed abnormal vaginal bleeding
• cerebral vascular disease
• known or suspected pregnancy
• congenital hyperlipidemia
• can worsen diabetes (↑ insulin resistance).
• can cause cholestasis or cholecystitis.
• OCPs ↑ risk of cervical cancer

U3T33, p. 227, UW 2392, 3359

• slight ↓ in risk of ovarian cancer.

U3T33

• unpredictable bleeding for 2-3 months (resolves)
• after 1 year of depo-provera, nearly 50% of users have amenorrhea.
• progestin → endometrial thinning & suppresses secretion of FSH/LH.

U2T33

• adhesions or fibrosis of endometrium
• associated w/ D&C

wikipedia

• < 8 weeks

U3T34

• D&C if fetus < 16 weeks.
• dilation & evacuation can be performed after 16 weeks by those trained in procedure.
• induction w/ intravaginal prostaglandins (intact fetus for autopsy).
• abortion is legal until viability is reached (24 weeks).

U3T34

• mifepristone is an antiprogestin
• misoprostol (a prostaglandin) → uterine contractions to expel products of conception.
• medical abortion (vs. surgical) is associated w/ higher blood loss.

U3T34

• uterine evacuation + broad-spectrum abx
• medical termination is not a good option since prompt evacuation is indicated.

U3T34

• manifests as inflammatory mucocutaneous eruptions characterized by remissions and flares.
• involves hair-bearing skin and scalp, nails, oral mucous membranes, and vulva.
• vulvar symptoms: irritation, burning, pruritis, contact bleeding, pain & dyspareunia.
• Clinical findings: lacy, reticulated pattern of labia and perineum.

U3T35

• TCA to block sympathetic afferent pain loops, pelvic floor rehabilitation, biofeedback, and topical anesthetics.
• surgery w/ vestibulectomy is recommended for non-responsive pts.
• vulvar vestibulitis - severe pain on vestibular touch or attempted vaginal entry (sexual intercourse and tampon placement → exquisite pain). Abrupt onset of symptoms, and are sharp, burning, and produces a raw sensation. May have focal or diffuse erythematous macules.
• primary or inciting event cannot be determined.

U3T35

• a shift in vaginal flora from hydrogen peroxide producing lactobacilli to non-hydrogen peroxide producing lactobacilli → proliferation of anaerobic bacteria.

  ---

• thin, gray homogenous vaginal discharge
• positive whiff test (KOH → release of amines)
• clue cells on saline microscopy
• ↑ vaginal pH (> 4.5)
• tx - metronidazole

U3T35

• caucasian premenarchal girls and postmenopausal women.
• present w/ extreme vulvar pruritis
• early skin Δs include polygonal ivory papules involving vulva and perianal areas, waxy sheen on labia minora and clitoris, hypopigmentation.
• vagina is NOT involved.
• scarring w/ loss of normal architecture (introital stenosis, resorption of clitoris [phimosis] & labia minora).
• tx: high-potency topical steroids (clobetasol or halobetasol).
• can progress to non-HPV vulvar carinoma (< 5%); must punch bx.

U3T35, Kap m001008, UW4810

• mucopurulent exudate visible in endocervical canal
• usually asymptomatic, but can have abnormal discharge or abnormal vaginal bleeding.
• Chlamydia (most common cause) or N. gonorrhoeae
• tx: azithromycin or doxycycline (chlamydia) & cephalosporin or quinolone (gonorrhea).

U3T35, UW 4158

• abdominal pain w/ exquisite tenderness during pelvic examination; can be more severe w/ fever and mucopurulent d/c as well; this is PID.
• u/s may reveal complex masses, possibly bilateral (tuboovarian abscess).
• this is an ascending infxn; polymicrobial (E. coli, , Klebsiella, Prevotella, G. vaginalis, GBS)
• dx criteria: lower abdominal tenderness, uterine/adnexal tenderness, mucopurulent cervicitis.
• tx - cefoxitin/doxycyline, cefotetan/doxy, clindamycin/gentamicin.

U2T36, UW 2416

• UTIs can be mild or even asymptomatic.
• low pelvic pain, ↑ urinary frequency, urinary urgency, hematuria, or new issues w/ incontinence.
• pregnant pts should be routinely screened for UTIs; it can cause preterm labor.
• tx w/ Nitrofurantoin, cephalexin, or amoxicillin (some E. coli are resistant) ; always confirm resolution w/ urine culture 10 days after tx.
• if second UTI occurs during pregnancy after tx first UTI, place pt on prophylactic abx (nitrofurantoin or sulfisoxazole); all women w/ UTI during pregancy should be rescreened periodically.

U3T36, Kap Q0777, UW 4472

• endometritis
• salpingitis (bilateral pain)
• oophoritis
• can progress to tuboovarian abscess, peritonitis, and sepsis.
• tx: clindamycin & gentamicin, cefoxitin/doxy, or cefotetan/doxy; d/c with doxycycline.
• most commonly caused by chlamydia or gonorrhea, but it is actually a polymicrobial infxn.

U3T36, UW 2416

• to prevent scarring of fallopian tubes and infertility.
• admit and tx w/ IV abx if pt is N&V or ↑ fever (102 °F/38.9 °C).
• tx: azithromycin (chlamydia) & ceftriaxone (gonorrhea)

U3T36, Kap m000138.seq

• colpocleisis: procedure involving closure of vagina (remove strips from anterior & posterior walls, w/ closure of margins of the anterior and posterior wall to each other; a septum will then divide the vaginal canal into 2).

U3T37

• central & lateral cystoceles: fix defect in pubocervical fascia.
• pessary is a device inserted into vagina to provide structural support (to correct urinary incontinence, uterine prolapse, or cystocele).

U3T37

• incomplete emptying of the bladder due to underactive detrusor muscle.
• post-void residual volume is > 300 cc; normal PVR is 50-60 cc.
• urge incontinence (detrusor overactivity incontinence or detrusor instability); uninhibited contraction of bladder with filling, tested w/ cytometrogram.

U3T37

• urethral hypermobility (straining Q-tip angle > 30° from horizon); tx - kegel exercises (strengthening pelvic floor), retropubic urethropexy, and sling procedures.
• intrinsic sphincteric deficiency of the urethra ("drain pipe" urethra; tx - urethral bulking procedure.

U3T37, UW 2398

• first-line thx - kegel exercise and bladder training.
• anticholinergic agent - oxybutynin; contraindicated in glaucoma.
• urge incontinence - secondary to detrusor instability.

U3T37

• endometrial glands embedded in the wall of the uterus → soft boggy uterus.
• MRI may demonstrate globular uterus w/ cystic areas seen in myometrial wall.
• grows during menstrual cycle, but cannot shed and becomes trapped → uterine pain.
• for women > 35, it is mandatory to perform endometrial curettage to rule out endometrial carcinoma.

U4T46, Kap s2s119, UW 3120

• dysmenorrhea
• dyspareunia
• pelvic masses: nodularity on back of uterus, u/s may reveal cysts on ovaries (simple or complex); endometrial glands and stroma outside uterus.
• most common site is the ovaries.
• tx - OCP → provide negative feedback to pituitary-hypothalamic axis → sotps stimulating ovaries to produce sex hormones; less commonly- GnRH agonist → initial ↑ FSH/LH → desensitization → suppression of hypothalamic-pituitary axis.
• endometrioma (chocolate cyst) - caused by endometriosis within the ovaries.

U3T38

• selective estrogen receptor modulator (SERM)
• depletes hypothalamic estrogen receptors → inhibiting negative feedback of estrogen → ↑ pulsatile secretion of GnRH → ↑ FSH/LH release → growth of ovarian follicle → follicular rupture.

U3T38

• first tx based on clinical presentation (NSAIDs and OCPs)
• exploratory laparoscopy to dx.
• if NSAIDs & OCPs fail → diagnostic laparoscopy, even in an adolescent (common in teens w/ chronic pelvic pain).

U3T38

• exploratory surgery
• the mass may be an old endometrioma (chocoloate cyst), but cannot be assumed.

U3T38

• u/s
• MRI and CT will not provide much more information.

U3T38

• indication for TAH/BSO?

U3T38

• sudden onset of abdominal pain
• cyst on u/s (cyst predisposes to torsion)
• right ovary more likely to torse
• causes: cyst, strenuous exercise, sudden ↑ in abdominal pressure.
• doppler is not useful b/c flow does not rule out torsion.
• ddx - endometriosis (but will not be sudden, and menses should correlate), ectopic preg (β-hCG), appendicitis (will not be sudden).
• tx - surgical exploration.

U3T38

• chronic inflammatory condition of bladder.
• recurrent irritative voiding symptoms of urgency & frequency.
• chronic pelvic pain in 70% (can be chief complaint); pain typically relieved by voiding.
• pain exacerbated by sexual intercourse, filling of bladder, exercise, spicy foods, and certain beverages.
• cystoscopy deminstrates submucosal petechiae or ulcerations.

U3T39, UW 4807

• nafarelin
• goserelin
• leuprolide

U3T39

• androgen (17-α-ethinyl testosterone)
• suppresses pituitary output of FSH/LH → regression of normal and ectopic endometrial tissue.

• combined estrogen/progestin thx

U3T39

• pelvic varicosities → chronic pelvic pain
• pain aggravated by standing, fatigue, and coitus.
• pain described as pelvic "fullness" or "heaviness," and may extend to vulvar area and legs.
• also associated w/ vaginal d/c, backache, and urinary frequency.

U3T39

• fasting prolactin level (manipulation of breast during exam → ↑ prolactin levels.
• if fasting prolactin is ↑ → brain MRI.

U3T40

• caffeine
• fibrocystic disease (most common benign breast condition) often associated w/ cyclic mastalgia (breast pain).

U3T40

• reexamine in 2 months to ensure that cyst has not recurred.
• Note: breast mass age < 30 → u/s; > 30 → u/s & mammogram (suspicious for malignancy → core bx).

UW2345

• most common pathogen is staph aureus
• use dicloxacillin (penicillin-type)
• if allx to penicillins, use erythromycin.

U3T40

• excisional bx
• false-negative FNA is possible.
• no need to repeat mammogram in 2 months.

U3T40

• LSIL - colposcopy directed bx. If bx confirms CIN-I → Pap smear at 6 & 12 mos or HPV DNA testing at 12 mos. No need to excise of ablate for LSIL.
• HSIL - LEEP (loop electrosurgical excision procedure, like a bovie); removes entire transformation zone and dysplastic areas identified via colposcopy.

U3T41

1. breast budding (thelarche, age 10)
2. hair growth (adrenarche)
3. growth spurt
4. menarche (age 12-13)

   ---

   normal age for menarche is btw 9 and 17. if 2° sex characteristics are present (buds and pubic hair) and pt is 15, just wait; no tests.

U4T42

1. adequate body weight (85-106 lbs is necessary)
2. sleep
3. optic exposure to sunlight

U4T42

• olfactory tract hypoplasia (anosmia)
• color blindness
• facial deformities
• no GnRH secretion → no 2° sex characteristics
• tx: pulsatile GnRH thx

U4T42, Kap Q0513

• DHEA → androstenedione/androstenediol → testosterone → dihydrotestosterone
• DHEA via sulfotransferase → DHEAS
• DHEAS levels 300x ↑ than DHEA
• DHEA peaks in early morning; DHEAS has no diurnal variation (levels are more stable).
• DHEA produced in adrenals, gonads (ovary/testes), and brain.
• DHEA → DHEAS in adrenals, liver, small intestine.
• for rapid onset virilization suspect ovarian or adrenal tumor.

wikipedia, UW2170

• if precocious by a few months observation.
• otherwise tx w/ GnRH agonists to suppress pituitary secretion of FSH/LH.
• precocious puberty (puberty before ages 6 or 7)
• GnRH dependent (central, ↑ FSH/LH) or GnRH independent (peripheral production of androgen or estrogen via ovarian cysts/tumors, adrenal tumors, congenital adrenal hyperplasia - 21-hydroxylase deficiency → ↑ androgens → testosterone and estradiol; ↓ FSH/LH).

U4T42, acog p. 310, UW 3868

• GnRH dependent and leads to precocious puberty, but with the normal order of pubertal events.
• thelarche → pubarche → growth spurt → menarche

U4T42

1. functional (weight loss, obesity, excessive exercise)
2. drugs (marijuana and tranquilizers)
3. neoplasia (pituitary adenoma)
4. psychogenic (chronic anxiety and anorexia nervosa)

• excessive exercise → ↓ GnRH and ↓ LH → ↓ estrogen. 

U4T43

• genital tract infections (bacterial vaginosis)
• smoking during pregnancy, ↑ 2x
• prior PROM, ↑ 2x (normal risk is 15%; hx → 30%)
• short cervical length
• prior preterm delivery
• hydramnios
• multiple gestations
• bleeding in early pregnancy
• PROM - membrane rupture prior to onset of uterine contractions.

Ob/Gyn p. 213, U2T25

• nitrazine test
• amniotic fluid pH > 7.1
• vaginal secretions (pH 4.5-6.0)
• urine (pH < 6.0)
• fern test - allow fluid to dry, and pattern resembles the leaves of a fern.
• never perform digital exam if PROM is supected; introduce bacteria → chorioamnionitis.

p. 214

• at term (≥ 37 weeks): 90% will go into labor, waiting 12-24 hrs for spontaneous is appropriate as long as no risk factors (eg, previous or current GBS infection), or induction w/ oxytocin if cervix is unfavorable.
• preterm: assess fetal lung maturity and chorioamnionitis.
• at 34 weeks or beyond deliver (steroids not recommended to ↑ fetal maturity after 34 weeks).
• PROM at 24-31 weeks: care for pt expectantly until 33 weeks; abx and corticosteroids.

p. 215

• OCPs

U4T43

• intrauterine synechiae or adhesions from trauma to basal layer of endometrium → amenorrhea.
• caused by curettage or endometritis.

U4T43

• hirsutism and acne
• check 17-hydroxyprogesterone levels

U4T44

• PCOS
• Cushing
• late-onset 21 hydroxylase deficiency
• hyperinsulinemia
• idiopathic hirsutism
• Sertoli-Leydig tumor

U4T44

• ↑ estrogen during pregnancy → synchrony of hair growth; therefore, hair grows in the same phase and is shed at the same time.
• non-pregnant state → asynchronous hair growth.

U4T44

• occurs most commonly in women btw the ages of 20-40)
• rapid onset of hirsutism and virilizing signs
• acne, hirsutism, amenorrhea, clitoral hypertrophy, deepening of voice.
• suppression of FSH/LH, ↑ testosterone, ovarian mass (usually unilateral).

U4T44

• spironolactone in addition to OCPs
• lupron and depo-provera are good 2nd line thx

U4T44

• coagulopathy can present with mentstrual symptoms in young women.
• Von Willebrand disease is most comon.

U4T45

• < 1.5 cm → observation
• > 1.5 cm → curettage, polypectomy, hysterectomy
• women w/ infertility → polypectomy is preferred.

U4T45

• ↓ FSH, ↑ LH (LH/FSH ratio will be ↑; both must be tested)
• ↑ normal testosterone or slightly above normal.
• free testosterone is ↑ b/c sex hormone binding globulin is ↓ by ↑ androgens.
• ↑ LH → ↑ androgens (theca cells) → hirsutism
• male pattern baldness
• stigmata of insulin resistance (acanthosis nigricans).

U4T45, T48, pathoma p. 144, UW 2414

• dysfxnl: irregular or increased menstrual bleeding w/o identified etiology; hormonal imbalance, eg anovulation (tx - high-dose estrogen & high-dose progesterone combination orally).
• mid-cycle: occurs at time of ovulation and is due to drop in estrogen.

U4T45, Kap m001007

• OCPs
• progestin in OCP → endometrial atrophy, improving dysmenorrhea.

U4T46

• primary dysmenorrhea (no abnormalities on physical exam).
• endometriosis
• PID → secondary dysmenorrhea
• adenomyosis
• leiomyomas (bx age > 40, r/o endometrial carcinoma)

U4T46

• before initiating hormone thx, must rule out endometrial carcinoma.
• either tissue dx or pelvic u/s w/ endometrial stripe < 4 mm.

U4T47

• < 40
• ↑ FSH/LH, FSH:LH ratio > 1
• ↑ FSH ≥ 3 mos
• developing follicles → estrogen secretion
• estrogen → suppresses FSH/LH
• symptoms: amenorrhea, hot flashes, vaginal & breast atrophy, anxiety, depression, irritability.

U4T47, UW 4136, 3814

• 1200 mg

U4T47

• irregular vaginal bleeding
• women that are amenorrheic for a period do not like the resumption of any vaginal bleeding/spotting.

U4T47

• estrogen
• use lowest dose for the shortest duration of time.

U4T47

• ↓ LDL, ↑ HDL (not recommended for 1° prevention of heart disease). 
• minimize hot flashes
• ↓ bone loss

• ---

  breast cancer
• MI
• cerebrovascular accidents
• thromboembolic events
• endometrial cancer w/ intact uterus

U4T47

• osteopenia (-1 to -2.5)

• ---

  prior fracture
• Fhx osteoporosis
• race
• dementia
• hx of falls
• poor nutrition
• smoking
• low BMI
• estrogen deficiency
• alcoholism
• insufficient physical activity

U4T47

• most important for pt to lose weight
• first-line thx: metformin and ovulation inducing agents.

U4T48

• ↑ prolactin
• hypothyroidism can also → hyperprolactinemia.

U4T48

• deficiency of vitamin A, E, and B6.

U4T49

• clarify if the symptoms are cyclic or constant.
• people can ascribe symptoms to their menstrual cycle, when in fact they are suffering from depression.
• PMS (mild to moderate; tx OCPs), PMDD (severe symptoms).
• SSRI (fluoxetine) for PMS & PMDD, can be taken everyday or for 10 days during luteal phase.

U4T49

• suction curettage
• methotrexate is reserved for development of post-molar gestational trophoblastic disease (GTD).
• after evacuation, serial β-hCG monitoring to ensure spontaneous regression. pregnancy should be avoided intil 6 months after β-hCG has normalized; effective contraception (OCPs) highly recommended during this period.

U5T50

• folic acid deficiency
• supplementation w/ folic acid may↓ risk of molar pregnancy.
• asian race associated w/ higher incidence of molar pregnancy.
• < 20 y.o and > 40 y.o.
• β-carotene deficiency (vit A precursor)
• ≥ 2 miscarriages
• after having 1 molar pregnacy, risk of another is only 1-2% (higher than normal, but still ↓).

U5T50

• vaginal bleeding is universal in molar pregnancies.
• uterine size > than gestational age in 25-50% of moles.
• complete mole - no fetus visualized on u/s; 46,XX or 46,XY w/ ↑↑↑↑ β-hCG, 2% → choriocarcinoma, 15-20% malignant trophoblastic disease. 2 sperm + empty egg.
• partial mole - fetus may be present, but grossly abnormal; 69,XXX, 69,XXY, 69,XYY w/ ↑ β-hCG, choriocarcinoma rare, < 5% risk of malignancy. 2 sperm + 1 egg.

U5T50, FA p. 540

• hypothyroidism → ↑ TRH or TSH → stimulation of lactotrophs (↑ prolactin) → amenorrhea.
• hyperthyroidism is associated with vaginal bleeding.

UW 4221

• gestational age ≥ 10 weeks.

U5T50

• β-hCG level in a reproductive aged woman w/ recent hx of pregnancy (term, miscarriage, termination, mole) is all that is required to establish dx.
• metastatic choriocarcinoma is quite vascular, so it is best not to bx.
• tissue dx is not done in choriocarcinoma.
• risk factors: advanced maternal age, hx of molar pregnancy.
• presentation after delivery of a term fetus: irregular vaginal bleeding lasting > than the expected postpartum time (4-6 weeks), N&V, abdominal fullness, enlarged uterus, bilateral ovarian cysts (theca-lutein cysts).

U5T50, Kap m000978

• invasive → radical vulvectomy w/ groin node dissection.
• microinvasive SCCA → wide local excision; must be < 2 cm, well-differentiated, w/ invasion < 1.0 mm.

U5T51

• squamous cell carcinoma (90%)
• mean age is 65 years
• smoking ↑ risk
• chronic itch-scratch cycle of lichen sclerosis → SCCA.

U5T51

• erythematous with a lacy white mottling of the surface.
• hyperkeratotic areas w/o a distinct lesion.
• psoriasis is a possible dx, but consider the age of the pt; it should not present late in life.

U5T51

• to tx genital warts
• not VIN
• tx VIN w/ CO₂ laswer ablation or skinning vulvectomy; however, the tx is disfiguring.

U5T51

• white plaque is called leukoplakia
• regardless of the Pap result → bx lesion.

U5T51

• adolescent - repeat Pap in 12 mos.
• older women - HPV DNA testing, repeat cytology at 6 & 12 mos, or colposcopy; if HPV (-) then repeat cytology in 12 mos.

U5T52

• normal Pap → repeat Pap in 6 months.
• if both Paps are normal, annual surveillance.

U5T52

• new blood vessels on end and on their sides.
• ectropion - area of columnar epithelium that has not yet undergone squamous metaplasia (reddish ring of tissue surrounding the external os).
• acetowhite epithelium - can represent dysplasia.

U5T52

• unsatisfactory colposcopy.
• inability to visualize entire squamocolumnar jxn.
• bx shows severe dysplasia.
• (+) endocervical curettage.
• bx shows carcinoma in situ.
• adenocarcinoma in situ on Pap; as opposed to atypical glandular cells (AGC).
• substantial discrepancy btw Pap and bx results.

U5T52

• perimonopausal women that do not ovulate regularly.

U5T53

1. obesity, confers greatest risk (peripheral conversion of androgens to estrogen or anovulation/PCOS)
2. nulliparity
3. late menopause
4. HTN
5. exposure to unopposed estrogen (combination thx does not ↑ risk, actually ↓ risk w/ OCPs)
6. DM
7. Herediatary Non-polyposis Colorectal Cancer

U5T54, Kap Q0862m

• 28%
• 30% of women w/ complex atypical hyperplasia will have invasive endometrial carcinoma on final pathology.

U5T54

• 80-90% of women w/ endometrial carcinoma present w/ vaginal bleeding or discharge as their only presenting symptom; < 5% are asymptomatic.
• abnormal vaginal discharge
• lower abdominal discomfort
• ↑ uterine size

U5T54

• endometrial sampling
• if atypical cells are found → dilation & curettage
• fi pathologic dx is confirmed → CXR (most commonly spreads to lungs).

U5T54

• in the setting of pregnancy (molar) or choriocarcinoma
• due to gonadotropin stimulation
• often bilateral

U5T54

• atrophy of the endometrium

U5T54

• surface epithelial tumors
• germ cell tumors
• sex cord-stromal tumors

1. endometrioma - isolated collection of endometriosis involving an ovary.
2. functional ovarian cyst - result of normal ovulation.
3. serous cystadenoma - larger than fxnl ovarian cyst and pt may present w/ ↑ abdominal girth; cystadenocarcinoma (malignant).
4. mucinous cystadenoma - tend to be multilocular and large; cystadenocarcinoma (malignant)
5. dermoid (bening cystic teratoma) - contain solid components, appear echogenic on u/s, may contain teeth, cartilage, bone fat, and hair.

U5T55, pathoma p. 145-147

• family hx
• nulliparity
• early menarche
• late menopause
• caucasian
• ↑ age
• residence in North America and Northern Europe
• smoking is NOT a risk

• ---

  long term suppression of ovulation is protective (OCPs that cause anovulation are protective).

U5T55

• estrogen cream
• long term use of estrogen cream may require addition of progestin to prevent endometrial carcinoma.
• water based lubricants can be helpful
• DO NOT recommend petroleum jelly; irritates vaginal mucosa.

U6T56

• estrogen antagonist in breast
• agonist in endometrium → endometrial carcinoma; therefore, only used for 5 years.
• raloxifene does not ↑ risk for endometrial cancer; ↑ risk of VTE.

UW2408

• breast cancer
• ovary and fallopian tube
• BRCA2 has a ↓ incidence of early-onset breast cancer and a much ↓ risk of ovarian cancer.

pathoma p. 145, acog p. 290

• female pseudohermaphrodite (XX) - ovaries present, but external genitalia are virilized or ambiguous. due to excessive androgens (congenital adrenal hyperplasia).
• male pseudohermaphrodite (XY) - testes present, but external genitalia are female or ambiguous. most common form is androgen insensitivity. no upper 1/3 of vagina, uterus, or ovaries; gonadectomy after completion of puberty (completion of breast development and attainment of adult height); breasts develop b/c testosterone (peripheral conversion) → estrogen. no pubic or axillary hair b/c it is dependent on testosterone.
• Müllerian agenesis (Mayer-Rokitansky-Küster-Hauser syndrome, 46XX) - idiopathic absence of Müllerian duct → absent female internal organs (ovaries present, not derived from duct system). Normal external genitalia and development of 2° sex characteristics (estrogen-mediated).
• Aromatase Deficiency - similar to CAH, but absence of estrogen.

FA p. 539, Kap m001017, UW 4217, 3913

• protrusion of the anteroinferior vaginal wall (a cystocele).

Kap m001015

• face first presentation w/ infants chin oriented towards the pubic symphisis.
• normal vaginal delivery is possible with this position; fetus can flex its head → delivery.
• also compound presentation (extremity prolapses alongside fetal head) can be delivered vaginally.

Kap Q0101, Q0102

• during labor uterine contractions → ↓ placental perfusion → hypoxia → anaerobic metabolism → fetal acidemia.
• fetus can counter hypoxia by lowering heart rate (diving reflex).
• electronic fetal monitoring is used to determine, indirectly, if the fetus is acidemic or "stressed."
• however, many normal fetuses can have non-reassuring fetal heart rate tracings and are not acidemic or in distress; tracings are not specific.

Kap Q0119

• presents a couple of days after delivery; cesarean section is the major risk factor.
• endometritis is the most common cause of puerperal fever on 2nd and 3rd day postpartum.
• fever, lower abdominal pain/uterine tenderness, foul-smelling vaginal d/c, malaise, leukocytosis.
• abx must cover anaerobes, gram (-) & gram (+).
• clindamycin-gentamicin.

UW 4799

• low-molecular-weight heparin
• longer half-life and more predictable dose-response relationship when compared to unfractionated heparin.
• also ↓ risk of thrombocytopenia
• warfarin is contraindicated during pregnancy (nasal hypoplasia, stippled vertebral & femoral epiphyses, hydrocephaly, microcephaly, IUGR, developmental delay).

Kap Q0112

• fetal bradycardia
• decreased intensity of uterine contractions

Kap m001001

• evaluate uterus and uterine cavity
• allows for visualization of internal contours
• provides information on tubal patency
• part of a work-up for recurrent pregnancy loss
• additional studies include anticardiolipin-Ab, lupus anticoagulant, TSH, thyroid perixidase-Ab, parental karyotype, fetal karyotype.

Kap m000254

• ↑ progesterone (smooth muscle relaxant)
• before administering any anesthetics or blocks, administer antacid to prevent apiration pneumonitis.

Kap Q0110

• dysfunctional uterine bleeding is ofthen the presenting symptom.
• autosomal dominant, and the most common inherited bleeding disorder.
• usually presents w/ heavy bleeding in adolescent during their first episode of menses.
• normal PT, normal to slightly ↑ PTT, ↑ BT

Kap s2s126m

• occurs with artificial or natural rupture of membranes.
• painless vaginal bleeding (test for fetal blood with Apt test)
• fetal tachycardia → bradycardia
• maternal vital signs stable
• immediate c-section!!!

Kap m000990, UW 2533

• hospitalization and IV clindamycin and gentamicin.
• indications for inpatient clindamycin & gentamicin thx: 1) pregnancy 2) Temp > 39 °C 3) Pt w/ IUD, or 4) evidence of pelvic abscess.
• For acute PID w/o evidence of TOA oral ofloxacin for 14 days.

Kap s2s317m

• endometrial thickness > 10 mm
• or an intrauterine mass
• tx: ampicillin + gentamicin + clindamycin or metronidazole.

Kap m000969

• aka Albright hereditary osteodystrophy, McCune-Albright syndrome, polyostotic fibrous dysplasia.
• ↓ Ca²⁺, ↑ PO₄ (same problem as hypoparathyroidism)
• ↑ PTH w/ unresponsiveness of renal tubules to PTH.
• other features: brachydactyly (short fingers/toes) of 4th & 5th digits, obesity w/ round facies, short neck, cafe-au-lait spots, precocious puberty,  subcapsular cataracts, cutaneous/subcutaneous&perivascular calcifications of basal ganglia.
• Cushing's syndrome can occur with this disease.
• the 3 P's: precocious puberty, pigmentation, polyostotic fibrous dysplasia.

PT-peds.10e p. 354, UW 3871

• known hx of DUB, evidence of iron deficiency anemia, and moderate amount of prolonged/active bleeding → high-dose estrogen and high-dose progesterone combination orally.
• must be hemodynamically stable.
• BUT, if pt presents for first time with DUB (no structural or organic disease), and pt is > 35, obese, chronically HTN, or diabetic → endometrial bx.

Kap m001007, UW2391

• caused by Klebsiella granulomatis
• found in tropical or subtropical regions
• recurrent painless ulcers, well defined bases w/ exuberant (beefy red) granulation tissue.
• no lymphadenopathy
• lymphogranuloma venerum also assoc. w/ painless ulcers, then 10-30 days later lymphadenitis and lymphangitis (painful).
• syphilis is also painless and painless lymphadenopathy.

Kap s2s125m, UW 4791

• must suspect bone metastasis
• radionuclide scan (sensitive)
• X-ray films if radionuclide scan is (+) to rule out false-postive scans.

Kap Q0410m

• lochia - normal shedding of endometrium after delivery of placenta.
• bright red blood (lochia rubra) → pinkish-brown (lochia serosa) → yellowish-white (lochia alba)
• 4 weeks duration, but may last up to 6-8 weeks.

Kap m001002

• IM influenza vaccine is recommended
• MMR, varicella, intranasal flu vaccines are all contraindicated b/c they are live attenuated vaccines (do not use during pregnancy).
• However, the risk to the fetus is theoretical and if pt received MMR shortly before or after conception there is no need to terminate pregnancy; not a good reason.

Kap Q0230m, Q0500m

• fetal scalp sampling is used to determine acid-base status of fetus when fetal heart rate tracing is not reassuring.
• pH > 7.25 → expectant management.
• pH 7.20 - 7.25 → reevaluate in 15-30 min.
• pH < 7.20 → c-section.

Kap Q0501

• aka condyloma acuminata
• verrucous (cauliflower-like or warty) appearance
• tx: cryothx, laser thx, chemical destruction (trichloroacetic acid), or imiquimod.
• Pap smear should also be done w/ complete physical exam.

Kap Q0508

• Volume > 2 ml
• pH 7.2 - 7.8
• Density > 20 million/ml
• Motility > 50%
• Morphology > 50%
• 2 samples 1-2 weeks apart must be obtained before dx male factor infertility.

Kap m001011

• 1° - lack of spontaneous uterine bleeding by age 16.
• 2° - absence of a menstrual period for 3 cycles (if menses was regular) or 6 months in a woman who previously had irregular periods.
• causes of 2° - pregnancy, hyperprolactinemia, thyroid dysfunction (hypothyroidism → anovulation).
• if progesterone withdrawal test is (+), then endogenous estrogen is present and anovulaton is cause of amenorrhea. 
• if progesterone withdrawal test is (-), then administer 21 days of estrogen and 7 days of progesterone → no bleeding →outflow tract obstruction or Asherman syndrome.

Kap Q0761, m001012m

• preeclampsia
• low birth-weight
• preterm labor
• placental abruption

Kap s2s016

• umbilical hernia
• distended abdomen
• large head & large fontanelles
• hypothermic
• feeding difficulties
• generalized hypotonia
• coarse facial features
• macroglossia
• constipation and jaundice
• bradycardia
• most common cause is thyroid dysgenesis

PT-peds.10e p. 103, Kap q. s2s347m, UW 3662

• jaundice
• constipation
• sluggishness
• poor feeding
• apnea
• macroglossia
• excessive sleepiness

PT-peds.10e p. 346

• infants born to diabetic moms are frequently macrosomic, BUT can have other anomalies.
• congenital heart disease (asymmetric septal hypertrophy).
• caudal regression (hypoplastic lower extremities).
• vertebral defects
• single umbilical artery
• jaundice
• small left colon
• renal vein thrombosis
• hyaline membrane disease (aka infant respiratory distress syndrome) → tachypnea, retractions → progressively worsens to include  grunting, nasal flaring, cyanosis.
• polycythemia (↑ glucose → ↑ metabolic rate → hypoxia → ↑ EPO → hyperviscosity).

PT-peds p. 357, Kap q. m000420, UW 4831, 4794

• clinical dx - consistent hx and loss of 5% or more of pre-pregnancy weight; associated w/ ↑ βhCG (eg, twin pregnancies); presents during weeks 4-10.
• first check βhCG levels to rule out molar pregnancies (also a cause of hyperemesis).
• can be associated with mild elevations of liver enzymes; amylase & lipase also ↑ (from salivary gland 2° to vomiting).
• initial tx - avoidance of triggers, ginger lollipops, tea, acupressure/puncture, and saltines w/ small, frequent meals.
• if above measures are ineffective & nausea is the only complaint then pyridoxine (effective for nausea.
• pyridoxine-doxylamine (B₆-antihistamine combo) works for N&V.
• if N&V still persists → promethazine.

Kap m00997, UW 4789

• systolic
• diastolic murmurs must be worked up!
• diastolic murmurs indicate structural abnormalities (mitral stenosis 2° rheumatic fever)

Kap Q0607m

• > 36 weeks
• otherwise manage expectantly
• at < 36 weeks the fetus still has enough room to move around.

Kap m000976

• doxycycline
• fluoroquinolones
• streptomycin
• TMP-SMX during 1st trimester (folate antagonist) & 3rd trimester (↑ risk of kernicterus).

Kap Q0768, UW 4472

Mittelschmerz

Spinnbarkeit

• at ovulation, an ovarian follicle can rupture, releasing blood into the peritoneal cavity → peritoneal irritation and pain.
• occurs for 1-2 days midcycle in menstruating females; aka midcycle pain.
• spinnbarkeit: vaginal d/c w/ egg-like consistency, which is associated w/ ovulation.

Kap Q0378, UW 3365, 3480

• mitral valve stenosis
• valasalva maneuver should be avoided

Kap Q0286

• most often occurs in pts undergoing ovulation induction w/ gonadotropins; also can occur w/ clomiphene.
• Mild: ovaries < 5 cm and pt has mild weight gain and pelvic discomfort.
• Moderate: ovaries can be up to 12 cm and pt has at least 10 lb weight gain, N&V.
• Severe: ovaries > 12 cm, ascites, hydrothorax, hemoconcentration, and oliguria.
• Do not perform pelvic or abdominal exam → rupture of ovarian capsule.
• Severe OHSS is tx w paracentesis, thoracentesis, or surgery.

Kap Q0125

• aka cholasma
• disorder of pigmentation most commonly seen in darker skinned people (esp Asians).
• common in women, particularly during pregnancy or menopause, and in pts taking OCPs.
• worsens w/ subsequent pregnancies.
• avoid exposure to sunlight.
• tx - bleaching creams w/ hydroquinone.

Kap Q1034

1. more than 5 contractions in 10 minutes
2. contractions lasting 2 minutes or more
3. contractions of normal duration occuring w/in 1 minute of each other

• AND a non-reassuring fetal heart rate tracing (2° to uterine hyperstimulation).
• discontinue oxytocin (short half-life, 3-5 min).
• if still no response → tocolytics (MgSO₄ or terbutaline).

Kap Q0121m

• dx w/ TSH (<0.1) + free T₄
• if values are normal, but clinical picture suggests hyperthyroidism check free T₃.
• remember TBG is naturally ↑ during pregnancy.
• tx - propylthiouracil or methimazole (safe during pregnancy).

Kap m000998

• alpha₂-adrenergic agonist (centrally acting alpha adrenergic agonist → ↓ sympathetic outflow tract).
• safe in pregnancy (category B)
• anti-hypertensive

UW 4780

• recent hx of STD; wait 3 months.
• copper (paragard, non-hormonal) disrupts sperm motility and viability; good for 10 years.
• levonorgestrel (progestin) thins endometrium and inhibits secretion of FSH/LH → ↓ bleeding or amenorrhea; good for 5 years.

Kap s2s320m

• greenish-gray, frothy discharge
• malodorous (fishy)
• colposcopy → petechial cervical lesions (strawberry cervix).
• sexual partner must be tx as well.
• remember: white to gray discharge is Gardnerella vaginalis; sexual partner does not need to be tx.
• both conditions are tx w/ metronidazole.

Kap Q0559

• neonatal infections results when passing through vagina.
• asymptomatic → acyclovir 3x daily from 36 weeks to prevent outbreak prior to labor.
• c-section if genital herpes lesions or symptoms are present.

Kap s2s008

• Stage I and II, < 2 cm → surgical resection; Stage I and II, > 2 cm → radiation thx.
• Stage I and II: no extension to pelvic wall and no metastases.
• SCCA of vagina is highly responsive to radiation thx.

UW 3745

• prolactinoma, dopamine suppression (anti-Ψ), imipramine (TCA), overstimulation of nipples, OCPs.
• hypothyroidism → ↑ TSH → stimulation of lactotrophs → amenorrhea.
• color of discharge can range from white to yellow, brown, or green.

UW 4543

• trisomy 18, Edwards syndrome
• karyotype analysis via FISH is warranted.

• one of the following criteria must be met:

  ---

• fetal heart tones have been documented for 20 weeks by a non-electronic fetoscope or for 30 weeks by doppler.
• it has been 36 weeks since a (+) serum or urine hCG was performed by a reliable lab.
• u/s measurement of crown-rump length obtained at 6-12 weeks.
• u/s at 13-20 weeks confirms gestational age of at least 39 weeks.
• attempting to determine gestational age during the 3rd trimester is not useful; error = +/- 3 weeks.

 U2T30

• 41 weeks (although not postterm): twice weekly NSTs and AFIs, if abnormal → deliver.
• management at 42 weeks is controversial.
• at 42 weeks consider induction of labor; however, if cervix is unfavorable (long & closed), chances for cesarean are ↑ when compared to postterm pts that go into spontaneous labor.
• at 42 weeks w/ long & closed cervix → cervical ripening agent (misoprostol) → oxytocin.

U2T30

• finbronectin is an extracellular matrix protein that acts as an adhesive btw the fetal membranes and underlying deciduus.
• normally found in cervical secretions during the first half of pregnancy.
• however, its presence during weeks 22 and 34 indicates disruption or injury to the maternal-fetal interface.
• has a negative predictive value of 99.2%.

U2T24

• both can be caused by trauma.
• uterine rupture: severe pain, vaginal bleeding can range from spotting to massive hemorrhage, signs of hypovolemia and shock from rapid exsanguination, retraction of presenting parts on pelvic exam, abdominal findings (irregular contour - fetal parts become more palpable).

UW 2531

• developing follicles

UW 3814

• tx w/ penicillin, ampicillin, clindamycin, cefazolin, or vancomycin.

• ---

  tx prophylactically if GBS status unknown AND:
• delivery at < 37 weeks.
• duration of membrane rupture is ≥ 18 hours.
• GBS bacteriuria in any concentration during current pregnancy.
• prior hx of delivery of an infant w/ GBS sepsis.

UW 4757

• adolescent: open and closed comedones and inflammatory nodules in differing stages of evolution primarily affecting the face, chest, and back.
• steroid: aka steroid-induced folliculitis, monomorphous pink papules and absence of comedones.

UW 4812

• lower abdominal pain that radiates to the thighs legs, and occurs a couple hours before the onset of menstruation is classic for 1° dysmenorrhea.
• women with this condition have ↑ levels of prostaglandins.
• tx: NSAIDs

UW 2395

• clear cell adnocarcinoma of vagina or cervix.
• cervical anomalies.
• uterine malformations.

UW 2575

• used to determine ovulatory reserve.
• the lower the level the less the reserve.

UW 3365

• if HTN is noted before 20 weeks it is either chronic HTN or a hydatidiform mole.
• if HTN occurs after 20 weeks or during L&D with no urine protein or proteinuria < 300mg/day.

UW 4777

• tx with clomiphene
• this can be with or without intrauterine insemination.

U3T38

1. nulliparity (think about semen exposure theory).
2. age > 35
3. obesity
4. diabetes
5. race (African American)

Kap Ob assessment

• if patient has an infection

U5T52

• a form a conversion disorder, a woman will present with all signs and symptoms of pregnancy (amenorrhea, morning sickness, abdominal distension, and self-reported (+) home pregnancy test).
• u/s will reveal a normal endometrial stripe and negative pregnancy test.

UW 2552

• epidurals can block nearby sympathetic fibers → lower extremity vasodilation.

UW 4146

• midfacial hypoplasia
• microcephaly
• cleft lip and palate
• digital hypoplasia
• hirsutism
• developmental delay
• commonly caused by phenytoin or carbamazepine

UW2572