GSUI - Cause: Trauma, childbirth; Mechanism: proximal urethra falls below pelvic diaphragm so intrabdominal pressure only transmits to bladder; History: No urge to void, urine loss with valsalva; Dx: Cystometric exam; Treatment: Pelvic floor strengthening (Kegel) then urethropexy. 

UI - Cause: Detrusor spasm; Mech: Overactive detrusor; History: Urge to void; Dx: Cytometry shows uninhibited contractions. Treatment: anticholinergics (NO SURGERY).

Cancer: Pap smear ~3yr post onset of sex

Immunizations: Tetanus booster 1x btwn ages 11-16; Hep B; HPV between ages 9-26.

Other: MVA advice, Depression screen, firearms.

Most common mortality: MVA, malignancy, homocide

Cancer: Annual pap smear after age 21 or ~3yr after sex onset. Pap smears every 2-3 years after age 30 if three consecutive negatives.

Immunizations: Tetanus every 10y; HPV from 9-26 years.

Other: Cardiovascular disease.

Most common mortality: Malignancy, accidents, cardiovascular.

Cancer: Pap smears; after age 50: stool for occult blood, barium enema with flexible sigmoidoscopy q5y or colonoscopy q10y, mammography.

Immunizations: Tetanus q10y; Age 50: Annual influenza; Age 60: Zoster vaccine.

Other: Cholesterol screen q5y after age 45; Fasting blood sugar q3y at age 45; TSH q5y after age 50.

Most common mortality: Cancer, Cardiovascular.

Cancer: Annual stool for occult blood, Colonoscopy q10y or sigmoidoscopy with barium enema q 5y, annual mammography, pap smears until age 65-70.

Immunizations: Tetanus q10y, Pneumococcal vaccine, annual influenza vaccine.

Other: Cholesterol screen q5y, Fasting blood sugar q3y, Bone mineral density at age 65.

Most common mortality: Heart disease, cancer, CVA.

• If, after 30 minutes in stage 3 of labor, the uterus hasn't delivered attempt a manual extraction.

• Uterine inversion can cause hemorrhage.

• Treat inverted uterus by using a relaxing agent such as halothane or magnesium sulfate, then manual reduction, then oxytocin to prevent hemorrhage by clamping down on spiral arteries with uterine contraction.

Menopause...go!

Age of onset?

Symptoms and mechanism?

Treatment and risks?

Age of onset is between 40 and 51.

Symptoms include irregular menses due to anovulatory cycles, vasomotor symptoms like flushing and sweating, sleeplessness, feelings of inadequacy, vaginal atrophy and dryness. Ovarian inhibin levels are decreased so FSH and LH levels rise before estrogen falls.

Treat with short-term (<6mo) hormone replacement with estrogen or estrogen with progesterone if patient still has her uterus. Raloxifene is ineffective in treating hot flashes. Hormone replacement carries a risk of breast cancer, heart disease, PE and stroke. Bone loss is reduced with Calcium, vit D and hormone replacement.

Labor:

What is latent phase?

More rapid dilation >4cm.

Normal rate of dilation is ≥1.2 cm/h for nulliparous and ≥1.5 cm/h for a woman with at lease one vag delivery. 

If rate is slower than above, it is protraction of active phase. If no progress is made it is arrest of active phase.

1st: Onset of labor (cervical change with regular uterine contractions) to complete dilation of cervix (usu 10cm).

2nd: Complete cervical dilation to delivery of infant.

3rd: Delivery of infant to delivery of placenta.

Powers, passenger, pelvis.

Powers: adequate contractions occur every 2-3 mins, last 40-60sec and are firm on palpation. They are greater than 200 montevideo units (add each mmHg above baseline for 10 minute window). If inadequate treate with oxytocin.

Passenger: in cephalopelvic disproportion must consider c-section.

Normal baseline is 110 - 160 with accelerations and variability. 

Variable decelerations: caused by cord compression. If intermittent and abrupt, they can be observed.

Early decelerations: Caused by fetal head compression - benign.

Late decelerations: Onset after onset of contraction with the nadir following contraction peak and return to baseline after contraction is complete. Suggestive of fetal hypoxia which can lead to acidemia if prolongued.

The HCG level at which transvaginal sonography should reveal an intrauterine pregnancy--typically between 1500 and 2000 mIU/mL.

If ultrasound is negative after HCG threshold has been reached, suspect ectopic pregnancy (~85% chance). Next step is laparoscopy to visualize and treat ectopic pregnancy.

Risk factors are macrosomia, gestational diabetes.

Complications include injury to fetal C4, C5 nerve roots (Erb's palsy, waiter's tip) resulting in deltoid, infraspinatous and flexor forearm muscle weakness which leaves the arm internally rotated and hanging limply.

Intervention includes McRobert's maneuver (maternal thighs sharply flexed) and suprapubic pressure.

Endometrial cancer (20% not on hormonal repl), do endometrial sampling followed with biopsy if positive.

Most common cause is atrophic endometrium. Also vaginitis can cause this.

Placenta previa (painless, significant bleeding)

Placenta abruption (painful contractions)

Rule out with ultrasound--may have to do transvaginal.