OB/GYN Student Study Guide

Abbreviation and Definitions LMP: last menstrual period PMP: previous menstrual period EDC: estimated date of confinement GP: gravida !ara: Gravida is how many pregnancies; Para is the number of times the uterus is emptied TPAL: (Tennessee Power and Light !: Term ("! (the number of term pregnancies # twins count as $ pregnancy%! Preterm ("! Abortions (elective or spontaneous "! Living " (all children counted here! G$P$&&' ( Twins C"C: cold )nife coni*ation LEEP: loop electrocautery e+cision procedure B#L: bilateral tubal ligation D$C: dilation and currettage POC: products of conception %ystero: uterus #&%: transvaginal hysterectomy #A%: transabdominal hysterectomy LA&%: laparoscopic assisted vaginal hysterectomy #L%: total laparoscopic hysterectomy BSO: bilateral salpingoopherectomy O'igo: few %y!er: too much %y!o: not enough Meno: menses Metr: uterus +r)ea: flow +r)agia: e+cess flow tra()e'o : cervi+ (u'!o: vagina e(to*y: removal of ooto*y: incision osto*y: ma)ing a new opening (entesis: needle into something !o'y*enorr)ea: cycle every '& days

P+OM: premature rupture of membranes PP+OM: preterm premature rupture of membranes S&D: spontaneous vaginal delivery L#CS: low transverse cesarean section + L#CS: repeat LT,- ,A&D: forceps assisted vaginal delivery &BAC: vaginal birth after c.s &A&D: vacuum assisted vaginal delivery &M-: viable male infant &,-: viable female infant SAB: spontaneous abortion (miscarriage! EAB: elective abortion -.,D: /ntrauterine fetal demise ASC.S: atypical s0uamous cells of undetermined significance LGS-L: low grade s0uamous intra epithelial lesion %GS-L: high grade s0uamous intra epithelial lesion 1st Trimester: w& # w$' gestational age 2nd Trimester: w$' # '1 3rd Trimester: w'1 # 2& Previable: less than '& wee)s; if delivered considered Abortion3 not -45 Preterm: '2678 w Term: 78 # 2' w Embryo: fertili*ation to 1 wee)s Fetus: 1 wee)s to birth Infant: delivery to $ year Post Dates: 9 2$62' wee)s

Pregnan(y and Prenata' Care Diagnosis: home :PT: highly sensitive at the time of missed cycle (positive at 16; d!; b<,G rises to $&&3&&& by $& wee)s and levels off at$&3&&& at term; can get gestational sac as early as = wee)s> At that point your b<,G should be $=&& to '&&&> Dis(ri*inatory /one: This means that when ?<,G is $'&&6$=&&3 evidence of a pregnancy should be seen on transvaginal ultrasound> @hen the ?<,G is A&&&3 you can see evidence on a transabdominal ultrasound> ,%#: seen at BA wee)s on :-; 5oppler C<T at $' w Gestationa' Age: days and wee)s from LDP Dating Age (not used e+cept on tests%!: wee)s and days from fertil*ation; GA ' wee)s greater than 5A Naeg'e0s +u'e: Cor E5,: LDP # 7 months F 8 days F $ year .'trasound: can be $ wee) off in the first trimester3 ' wee)s off in the second trimester3 7 wee)s in the third trimester soG if your US differs from the EDC by L P more than this! a""e#t the US datin$ over the L P datin$> /n the first half of the first trimester3 use the ,rown Hump Length (,HL! which is within 7 # = days of accuracy> Do!!'er: can get C<T (fetal heart tones! at $' wee)s 1ui(2ening: at $A # '& wee)s (mom feels the baby move! Signs and S3 of Pregnan(y: a> ,hadwic)Is -ign6blue hue of cervi+ b> GoodellIs -ign # softening and cyanosis of c+ at 2 wee)s c> LaddinIs -ign # softening of uterus after A wee)s d> ?reast swelling and tenderness e> Linea nigra f> Palmar erythema g> Telangiectasias h> Jausea i> Amenorrhea3 obviously K> Luic)ening

Nor*a' C)anges in Pregnan(y: $> ,4 # a> ,M inc by 7&6=&N O ma+ '& # 2& wee)s b> -4H dec secondary to inc> progesterone and therefore smooth muscle rela+ation c> ?P dec: systolic down = # $&. diastolic down $& # $= until '2 wee)s then slowly returns> '> Pulmonary: a> T4 inc 7& # 2&N b> Dinute 4ent inc 7& # 2&N c> TL, dec =N secondary to elevation of diaphragm d> PA M' and pa M' inc; dec pA ,M' and pa ,M' 7> G/: a> Jausea and vomiting in 8&N 6 inc> estrogen3 progesterone and <,G; resolves by $2 # $A w b> Heflu+ # dec> GE sphincter tone c> 5ec lower intestinal motility3 inc water reabsorption and therefore constipation 2> Henal a> Pidneys increase in si*e b> :reters dilate # increased ris) of pyelonephritis c> GCH inc =&N 6 ?:J3 ,rt dec '=N => <eme a> Plasma volume inc by =&N3 H?, vol inc '& # 7&N 6 drop in <ct b> @?, still nl at $& # '& in labor c> <ypercoaguability d> /nc> fibrinogen3 inc factors 8 # $&3 dec $$ # $7 e> -light dec in plt3 slight dec in PT.PTT A> Endocrine a> /nc estrogen from palcenta; dec from ovaries # low estrogen levels assn with fetal death and anencephaly b> Progesterone is produced by corpus luteum then the palcenta c> <,G # doubles roughly every 21 hours; pea)s at $& # $' wee)s; the alpha subunit loo)s li)e L<3 C-< and T-< but the beta subunit differs d> /nc in thyroid binding globulins 8> Dusculos)eletal.5erm # -pider angiomata3 melasma3 linea nigra3 palmar erythema a> ,hange in the center of gravity # low bac) pain> 1> Jutrition # '&&& # '=&& cal.day need to increase #rotein! "al"ium and iron6 an iron su!!'e*ent is needed in the second trimester> 7& mg of elemental iron is recommended i> folate is necessary early on to prevent nueral tube defect (spina bifida! # 2&& mcg per day is recommended in women without sei*ure meds or previous infant with neural tube defect (2g are recommended then! ii> '& # 7& lb weight gain is MP3 obese women do not have to gain weight>

Prenata' Care ,irst #ri*ester: ,?,3 ?lood Type and -creen3 HPH3 Hubella3 <ep ? s Ag3 </43 :A.,+3 G,3 ,hl3 PP53 Pap -mear (without cytobrush! Appt 0 mo> 5oppler C<T O $& # $' w MP 5rugs: Tylenol3 ?enadryl3 Phenergan Houtine labs 0 visit: C<T3 Cundus height3 :rine dip (prt3 bld3 glucose3 etc!3 weight3 ?P Se(ond #ri*ester: D-ACP.Triple -creen O $= # $1 w)s3 MI-ullivan O '2 # '1 wee)s Luic)ening at $8 # $; wee) Glucose Tolerance Test 4alues: %Sullivan& =& g glucose normal: under $2&; if over then perform $&& g $lu"ose toleran"e test Casting $&= $ hour $;& ' hours $A= 7 hours $2= Hhogam O '1 wee)s #)ird #ri*ester: HPH3 ,?,3 Group ? -trep 7=678 wee)s (if not scheduled for repeat cesarean!3 cervical e+am every wee) after 78 wee)s or the onset of contractions Labor #re"autions& Go to LQ5 if you have contractions every = minutes3 if you feel a sudden gush of fluid3 if you donIt feel the baby move for $' hours3 or if you have bleeding li)e a period> /tIs normal to have mucus or a pin) discharge in the wee)s preceding your labor> +outine Prob'e*s of Pregnan(y: ?ac) Pain GEH5 <emorrhoids 4aricose 4eins Pica (cravings! 5ehydration Edema Cre0uency ,onstipation ?ra+ton <ic)s Hound ligament pain (inguinal pain3 worse on wal)ingTR: Tylenol3 heating pad3 Daternity belt!

MSA,P: produced by placenta: goes through amniotic fluid mom /nc D-ACP: neural tube defects3omphalocele3gastroschisis3 mult gest3 fetal death3 in(orre(t dates 5ec D-ACP: 5ownIs3 certain trisomies TH/PLE -,HEEJ: D-ACP3 Estriol3 ?<,G6 ris) for defects is calculated> /f it comes bac) abnormal3 ma'e sure datin$ is a""urate3 then counsel patient and consider amniocentesis> #ri!'e S(reen #ri 45 #ri 56 MSA,P dec dec Estrio' /J, dec B%CG /J, dec Amniocentesis can be done to get babyIs )aryotype if abn :-3 aberrant D-ACP3 Adv Daternal Age or Camily history of abnormalities ,an do a ,horionic 4illi -ampling O ; # $$ wee)s if you need a )aryotype sooner3 have inc> ris) of PPHMD3 previable delivery3 fetal inKury however> P.BS: percutaneous umbilical blood sampling: gets fetal blood to test for degree of fetal anemia.hydops in Hh disease3 etc>

,eta' Lung Maturity: Lecithin.-phingomyelin Hatio: over '>& indicates fetal lung maturity CLD : Clouresence Polari*ation: 9==mg.g is mature; good for use in diabetics Phosphatidyl glycerol: comes bac) pos or neg: best for diabetics because is last test to turn positive; hyperglycemia delays lung maturity

Clinic Survival Guide Copy and put in your pocket! Clinic note: 21 yo G2P1001 at 28 2/7 by 8 week ultrasound (always include dating criteria) co plaining o! inguinal pain on walking" #enies contractions$ %aginal bleeding$ rupture o! e branes$ and &as !etal o%e ent (t&e cardinal 'uestions o! obstetrics)" (P 110/)8 *rine+ trace protein (pregnant wo en usually &a%e trace protein) neg glucose ,undal -eig&t(,-)+ ( easured !ro t&e pubic sy p&ysis to !undus. correlates wit&in 1.2 c unless obese) 2/c ,etal -eart 0ones (,-0)+ 110s (count t&e out on your watc& in t&e beginning2 nor al 120s.1)0s) 34tre ities+ no cal! tenderness (any results o! recent ultrasounds$ lab work &ere) 5/P+ 1" 6*P at 28 2/7+ si7e appropriate !or dates 2" 8ound 9iga ent Pain+ reco ended aternity belt :" 8- ;eg+ 8&oga :00 cg 6< today :" Continue P;=/ ,e$ discussed preter labor precautions 1" > ?ulli%an today 6"<" ?tudent$ 9: Co plaints+ #isc&arge do cultures$ wet prep (look !or tric&)2 ucus nor al at ter 0&e baby doesn@t o%e at ti es babies go t&roug& nor al sleep cycles" 5s long as it o%es e%ery couple o! &ours$ t&at@s !ine" Aick counts. lie on side and count t&e a ount o! kicks in one &our a!ter dinner. s&ould be o%er 10" E(to!i( Pregnan(y Dost common place # ampulla of the fallopian tubes; also located in ovary3 abd wall3 cervi+3 bowel +is2 fa(tors: /nf+ of tube3 P/53 /:5 use3 previous tubal surgery3 assited reproduction Mccur in $.$&& pregnancies SS: episodic lower abd pain o Abnormal bleeding: due to inade0uate progesterone support o <,G decreased: normally3 <,G doubles every other day; in ectopics it doesnIt o :nilateral tenderness o F.6 mass o ,ullenIs sign (periumbical <ematoma! o :.- finding6 comple+ adene+al mass3 can see sac or fetus3 even #7: Dethotre+ate =& mg.m' if () "m! unru#tured: follow serial <,Gs 2 and 8 days later> Sou want the value to drop $=N between days 2 and 8> /f it doesnIt3 you give another dose of methotre+ate> If the mass is * ) "m then salpingostomy or salpingectomy (if patient is stable3 can do this laparoscopically; if not needs emergent laparotomy! Arias8Ste''a +3n: assn with ectopic pregnancy; endometrial change that loo)s li)e clear cell carcinoma (but is not cancerous!

S!ontaneous Abortions 9 :4; <ee2s= Mccur in $= # '=N of pregnancies A&N assoc with abn chromosomes ("$ cause: Trisomy $A3 "': Donosomy R! +, if re(urrent: inf+3 maternal anatomic defects3 Antiphospholipid -d; endocrine problems (of mom!3 previous miscarriage LABS to do: b<,G3 ,?,3 type and screen3 :-; give Hhogam if Hh 6 5efinitions: o #)reatened AB # intrauterine pregnancy with bleeding; ('osed (ervi3 needs initial obstetric visit o Missed AB # Cetal death without passage of products of conception; no C<T by 1 wee)s o -nevitab'e AB # dilated cervi+3 proceeds to complete or incomplete o -n(o*!'ete AB # products not all out do a 5Q, o Co*!'ete AB # Products all out; need to follow ?<,G until & to ma)e sure it was not a hydatidiform mole or choriocarcinoma SS: bleeding3 crampy abdominal pain (always as) if clot or whitish tissue was passed! Abortion > ? @ 6 <ee2: $> Trisomies '> TurnerIs -d (2=R! %abitua' Ab : 7 AbIs in a row o ,auses: balanced translocation of parents3 autoimmune d*3 abn uterus3 etc> o @:: )aryotype for balanced trans3 antiphospholipid ab3 hysterosalpinography for abn uterus (septate uterus most common! -n(o*!etent Cervi3 Sd: AbIs between $7 # '' wee)s because cervi+ canIt hold PM, in: see painless dilation and effacement in 'nd trimester; inf+ is common b.c of trauma.vaginal flora #7: Dc5onaldIs ,erclage: a pursestring nonabsorpable suture around cervi+: remove at term; also could manage e+pectantly; ?E5HE-T # give steroids and Ab+ to dec inf+ and inc fetal lung maturity and tocoly*e contractions; ?oth Dc5onald and -hirod)ar are near the internal os # -hirod)ar stitch Kust tunnels under the cervical epithelium> Causes of 4nd #ri*ester Abs : inf+3 mat anat defects3 cervical defects3 systemic d*3 fetoto+ic agents3 trauma (chromosomes occur in second trimester3 but not as fre0uently as first trimester! C)ro*oso*e Stuff Trisomies: $7 Edwards3 $1 Patou3 '$ 5ownIs Autosomal 5ominant 5*: Jeurofibromatosis3 von @illebrandIs3 Achondroplasia3 Msteogenesis imperfecta R Lin)ed 5*: Duscular 5ystrophy3 GAP5 5ef3 hemophilia Hecessive 5*: $' M< Adrenal hyperplasia Dc,une Albright: polyostotic fibrous dysplasia: degeneration of long bones3 se+ual precocity3 cafT au lait spots (t+ precocious puberty with medro+yprogesterone acetate! Statisti(a' Stuff Daternal Dortality ( mat death.$&&3&&& live births Certility rate ( " live births.$&&& females $= # 22 ?irth rate ( " live births . $&&& people

Ante!artu* ,eta' Survei''an(e NS# ( Jon -tress Test: to be reactive need ' a((e'erations of 5A beats !er *inute for 5A se(onds in 4; *inute stri!; if nonreactive3 baby can be sleeping # give mom Kuice # do a ?PP (thin) about sedatives3 narcotics3 ,J-.,4 abnormalities! BPP ( biophysical profile; on :.- 1 pts good. 2 pts bad J-T AC/ (amniotic Cluid /nde+! Cetal ?reathing Dovements Cetal E+tremity Dovements Cetal Tone Give ' points Heactive one ' by ' cm poc)et Last over 7& seconds 7 or more episodes E+tension to fle+ion; fle+ at rest Give & points U ' accels no poc)et seen U 7& seconds :nder 7 episodes E+tended at rest

Modified BPP ( J-T and AC/ Contra(tion stress test 9CS#!: nipple stimulation or o+ytocin # shows 7 uterine contactions in $& minutes to be good; negative ( no late decelerations %OB #O +EAD #%E S#+-P: o Heassuring things # normal behavior3 beat to beat variation3 reactive strip (above! o Early decels # they begin and end with the contraction # a sign of head compression # MP o 4ariable decels # are more Kagged and loo) li)e a 4 # a sign of cord compression # we may start amnioinfusion o Late decels # begin at pea) of contraction and end after contaction is finished # a sign of uteroplacental insufficiency # are bad> (nonreassuring! ,SE ( fetal scalp electrode6 placed usually with /:P, when a more accurate recording of heart tones is needed; do not use in moms with </4 -.PC ( /ntra :terine Pressure ,atheter # placed in uterus to monitor contractions; a good baseline is $&6$= mm <g; ,t+ in labor inc> '& # 7& mm<g or even to 2& # A&; can amnioinfuse through the /:P, with normal saline6 +ou "annot tell ho, stron$ a "ontra"tion is ,ith the to"ometer- +ou need an IUPC to "ount onte.ideoUnits- Mver '&& D4:s is considered ade0uate> ,eta' S(a'! !%; ta)e blood from scalp for nonreassuring factors3 fetal hypo+ia (not really done anymore! P< over 8>'= is reassuring 8>' # 8>'= indeterminate U8>' bad

Labor DA#-NG Denstrual <istory: 2& wee)s from LDP (JaegleIs rule: LDP F 8 days # 7 months! :terine -i*e: o $& @ee)s grapefruit si*e o '& wee)s is at umbilicus o '& # 77 wee)s matched dates F6 ' cm of Cundal <eight o may not match at term due to descent :ltrasound: is most accurate at 1 # $' wee)s 5ating ,riteria for delivery: determines whether lungs are considered mature for delivery $> C<T documented 7& wee)s by 5oppler> '> 7A wee)s since :PT positive> 7> :- of ,HL at A6$$ wee)s ma)es gestational age 97; wee)s> 2> :- of under '& wee)s supports gestational age 97; wee)s> S#AGES O, LABO+ ,irst: beginning of contractions to complete cervical dilation o Latent # to appro+> 2 cm (or acceleration in dilation! o Active # to $& cm complete; prolonged if slower than 5C4 (*/)r nu''/5CA (*/) *u'ti!; if prolonged3 do amniotomy3 start pitocin3 place /:P, to evaluate contraction strength o ,ai'ure to !rogress # no change despite ' hours of ade0uate labor (D4: 9'&&! Se(ond: complete dilation to the delivery of baby o Prolonged if 4 )ours *u'ti!/ D )ours nu''i! 9with epidural! or ' hours nullip.$ hour multip (no epid! #)ird: delivery of baby to delivery of placenta o ,an ta)e up to 7& mins o -igns include increase in cord length3 gush of blood3 uterine fundal rebound ,ourt): one hour post delivery D P0S O, LABO+ $> Po<er: nl contractions felt best at fundus; last 2=6=& seconds; 7 in $& minutes '> Passenger: a> Presentation # what is at the cervi+ (head (verte+!3 breech! b> Position # MA3 MP3 LMT3 HMT c> Attitude # relationship of baby to itself d> Lie # long a+is of baby to long a+is of mom e> Engagement # biparietal diameter has entered the pelvic inlet f> -tation # presenting partIs relationship to ischial spine (673 6'3 6$3 &3 $3 '3 7! 7> Pe'vi*etry: a> /nlet: 5iagonal ,onKugate # symphysis to sacral promontory ( $$>= cm Mbstetrical ,onKugate # shortest diameter ( $& cm b> Didplane: spines felt as prominent or dull c> Mutelt: ?ituberous 5iameter ( 1>= cm -ubpubic Angle less than 2& degrees

,O+CEPS Mutlet forceps: re0uirements # visible scalp -)ull on pelvic floor Mcciput Anterior or Posterior Cetal head on perineum : can see without separating labia Ade0uate anesthesia; bladder drained Da+imum 2= degrees of rotation Low forceps: station ' but s)ull not on pelvic floor Didforceps: station higher than ' with engaged head (not done! &ACC..M E7#+AC#-ON: can cause cephalophematoma and lacerations -ame re0uirements for outlet forceps -ND.C#-ON: -ndi(ations: PreEclampsia at term3 PHMD3 ,horioamnionitis3 fetal Keopardy.demise3 92'w3 /:GH Bis)o! S(oring Syste*: if induction is favorable: 91 vaginal delivery without induction will happen same as if with induction: U 2 usually fail induction: U = # =&N fail induction -core & $ ' 7 ,m & $6' 762 26= Effacement &67&N 7&6=&N A&68&N 91&N -tation 67 6' 6$3& F$3 F' ,onsistency Cirm Ded -oft Position of c+ Post Did Ant

Prostag'andins: dilate cervi+ and inc contractions: Prepidil3 ,ervidil3 ,ytotec: contraindicated in prior ,-3 nonreassuring fetal monitoring La*inaria: an osmotic dilator3 is actually seaweed% A*nioto*y: speeds labor; beware of prolapsed cord% O3yto(in: $& : in $&&& ml /4 piggybac) on pump O ' m :.min; if over 2& m:.min are used watch for -/A5< Augmentation of labor needed in inade0uate ct+3 prolonged phases

DEL-&E+Y ,rowning 6 HitgenIs maneuver (hand pressure on perineum to fle+ head! <ead out:3 chec) for nuchal cord (cord around nec)! # delivery anterior shoulder gently by pulling straight down6 suction nares and mouth with bulb # deliver posterior shoulder # clamp cord with ' Pellys3 cut with scissors3 hand off baby # get cord blood# gentle traction on cord with suprapubic pressure3 massage momIs uterus # retract placenta out and inspect it # inspect mom for tears3 visuali*e complete cervi+ Episiotomy repair ($ # ' degree midline! ' # & ,hromic or 4icryl loc)ing suture superiorly to repair vaginal mucousa # interrupted chromics to repair deep fascia if needed # simple running to repair mid fascia # sub L stitch inferiorly and superficially A t)ird degree tear involves the rectal sphincter; a fourt) degree tear involves rectal mucousa Didline episiotomy: can e+tend3 but has less dyspareunia; Dediolateral episiotomy is done at = or 8 oIcloc)3 but has more pain and inf+ but less chance of e+tension (consider if shoulder dystocia! S)oud'er Dysto(ia HC: macrosomia3 5D3 obese3 post dates3 prolonged second stage> ,ompl: fracture3 brachial ple+us inKury3 hypo+ia3 death Treatment: $> -uprapubic Pressure (not fundal pressure%! '> DcHobertIs # mom fle+es hips # )nees to chin level 7> GEJTLE traction 2> @oodIs ,or)screw # pressure behind post shoulder to dislodge the ant shoulder => Hubin maneuver # pressure on accessible shoulder to push it to ant chest of fetus to decrease biacromial diameter A> Cracture clavicle away from baby 8> try to deliver posterior arm CA+D-NAL MO&EMEN#S Engagement # fetal head enters pelvis Cle+ion # smallest diameter to pelvis 5escent # verte+ to pelvis /nternal Hotate # sag suture is parallel to AP E+tend at pubic symphysis E+ternally rotate after head delivery -ND-CA#-ONS ,O+ C8SEC#-ON Cailure to progress (PIs of labor! ?reech presentation with labor -houlder presentation Placenta Previa Placental Abruption Cetal distress: = minutes of decal U;& bpm; repetitive late decals unresponsive to resusitation ,ord Prolapse

Prolonged second stage of labor Cailed forceps Active herpes Prior classical ,.- (has to do with incision on uterus not s)in%! ' prior low transverse c.s (4?A,s are controversial!

.'trasound 5oppler 4elocimetry: systolic.diastolic ratio in the umbilical cord /nc -.5 ratio: pre6eclampsia3 /:GH3 nicotine3 maternal tobacco /f end diastolic flow absent or reversed3 delivery is indicated 4elocimetry is done in cases of suspected /:GH The first ultrasound is the only one that can change dates> Accept :.- date if over LDP date byG 2d # $ w: first trimester 'w: second trimester 7 w: third trimester 5ating is done by a biparietal diameter3 head circumference3 femur length and abdominal circumference> Anest)esia E!idura' anest)esia: lengthens second stage # may need o+ytocin /nKected into L7.L2 interspace: use the techni0ue of least resistance (the epidural space has a negative atmospheric pressure so the syringe you place over the needle will suddenly lose its resistance as you advance it into the epidural space3 inKect test dose! ,an cause hypotension after dosage because the autonomic nervous system is bloc)ed and all blood pools in e+tremities; can see late decals3 but usually resolve with hydration and blood pressure increase> Para(ervi(a' b'o(2: not really done because can inKect into fetus easily and cause fetal bradycardia S!inal: one time dose3 shorter duration of action3 used in repeat c.s Pudenda' B'o(2: ,an be done with vaginal delivery3 inKect analgesic into post6ischial spine and sacrospinous ligament (ta)es = # $& mins to set up: good for forceps delivery without epidural! ,eta' Co*!'i(ations of Pregnan(y SMALL ,O+ GES#A#-ONAL AGE U $&N percentile for growth can be symmetric or asymmetric has higher rates of mort.morbidity HC: 5ecreased growth potential o ,ongenital abn: Tri $73 $13 '$3 Turners o ,D43 Hubella o Teratogens3 smo)ing3 EtM< -.G+: ,auses: <tn3 5D3 renal d*3 malnutrition3 plac previa3 abruption3 ,D43 To+o3 Hubella and mult gest -ymmetric: insult was early in gestation ie> 4iral Asymmetric: late onset (ie> Tobacco!; femur length is usually spared

 5oppler velocimetry with end diastolic flow reversed or absent or nonreassuring fetal heart tracing necessitates delivery> MAC+OSOM-A: 9 ;&N percentile: 9 2=&&g <igher ris) of shoulder dystocia and birth trauma (brachial ple+us inKuries!3 low APGAH3 hypoglycemia3 polycythemia3 hypocalcemia3 Kaundice E#-O: 5D3 obesity3 post term3 multiparity3 inc> age ,.: u.s 0 ' wee)s to assess si*e; however :- is not that accurate in diagnosis #7: tight control of diabetes; wt loss before conception; induce3 prepare for dystocia; consider c.s if over =&&&g OL-GO%YD+AMN-OS: Amniotic Cluid inde+: divide momIs belly into 2 0uadrants # measure the largest poc)et of fluid in each U=: Mligohydramnios 9'&: Polyhydramnios Absence of Hange of Dotion # 2&R increase in Perinatal mortality Assn with abnormalities of G: (renal agenesis ( PotterIs -d3 polycystic )idney d*3 obstruction!3 and /:GH Cetal Pidney.lung amniotic fluid resorbed by placeta3 swallowed by fetus3 or lea)ed out into vagina> Dost common cause: HMD (rupture of membranes! 5+: : TR: /f preterm3 hydrate if fetus stable; /f term3 deliver POLY%YD+AMN-OS: AC/ 9 '& or '=; '67N of pregnancies; assn with JT defects; obst mouth3 hydrops3 mult gest Donitor with serial ultrasounds> ,an do therapeutic amniocentesis>

Antenata' %e*orr)age PLACEN#A P+E&-A: Abnormal implantation of placenta over the internal os Three types $> ,omplete (completely over os! '> Partial (little over os! 7> Darginal (barely over os! SS: painless vaginal bleeding # d+ by ultrasound # 5MJIT ERAD/JE @/T< SM:H <AJ5- % Avoid speculum e+am% /f patient presents complaining of vaginal bleeding3 ma)e sure an ultrasound for placental location is performed first> +,: previous placental previa3 prior uterine scars3 multiparous3 adv mat age3 large placenta #7: ,- if lungs mature.fetal distress.hemorrhage P'a(enta a((reta: superficial invasion of placenta into wall of uterus P'a(enta in(reta: invasion into the myometrium P'a(enta !er(reta: invasion into the serosa T+ for above 7: '.7 get hysterectomy after c.s PLACEN#AL AB+.P#-ON: premature separation of a normally implanted placenta

 SS: usually painful vaginal bleeding (uterus is contracting! . hemm between wall and placenta +,: htn3 prior abruption3 trauma3 smo)ing3 drugs # cocaine3 vascular disease D7: inspection of placenta at delivery for clots; can see retroplacental clot on ultrasound or a drop in serial hematocrits #7: deliver if fetal status nonreassuring Co*!'i(ations: hypovolemia3 5/,3 couvalaire uterus (brown boggy!3 PTL

.#E+-NE +.P#.+E : maKor cause of maternal death 2&N assn with a prior uterine scar (,-3 uterine surgery! A&N not assn with scarring but abd trauma (D4A!3 improper o+ytocin3 forceps3 inc> fundal pressure3 placenta percreta3 mult gest3 grand multip3 choriocarcinoma.molar pregnancy SS: severe abd pain3 vag bleeding3 int bleeding3 fetal distress #7: immediate laparotomy3 hysterectomy with cesarean ,E#AL &ESSEL +.P#.+E: occurs usually with a velamentous cord insertion between amnion and chorion; may pass over os(vasa previa (Perinatal mortality =&N! SS: vag bleeding3 sinusoidal variation of <H +,: mult gestation ($N singleton3 $&N twins3 =&N triplets! NON OBS#E#+-C CA.SES O, AN#EPA+#.M %EMO++%AGE ,ervictis3 polyps3 neoplasms3 vag laceration3 vag varicies3 vag neoplasms3 abd pelvic trauma3 congenital bleeding d.o Preter* Labor +,: low -E-3 nonwhite3 U$1 yo3 mult gest3 h.o preterm birth3 smo)ing3 cocaine3 no PJ, uterine malformation3 h.o ,P,3 Group ? strep3 ,hlamydia3 Gonorrhea3 ?4 S.+&-&AL: '7 w &61N '2w $=6'&N '=w =&6A&N 'A6'1w 1=N ';w ;&N ALGO+-#%M: Good 5ates U'2w '2672w 972w

-ab

Tocoysis3 -teroids

E+pectant management

 CON#+A-ND-CA#-ONS #O #OCOLYS-S: acute fetal distress3 chorioamnionitis3 eclampsia.pre e3 fetal demise3 fetal maturity3 hypersensitivity to tocolytics3 heart disease3 /:GH BO+" .P: <QP3 chec) cervi+ visually by speculum3 wet prep3 :A3 cervical length3 fetal fibronectin #OCOLY#-CS: MgSOE: wor)s as membrane stabili*er3 competitive inhibition of ,a; therapeutic at 268 mE0.L -E: flushing3 nausea3 lethargy3 pulm edema To+icity: cardiac arrest (t+: calcium gluconate!3 slurred speech3 loss of patellar refle+ (O 8 6$&!3 resp problems (O$=6$8!3 flushed.warm (O;6$'!3 muscle paralysis (O$=6$8!3 hypotn (O$&6$'! Nifedi!ine: calcium channel bloc)er: $& mg 0 A h; se: nausea and flushing B4 agonist: ritodrine/ terbuta'ine: dec> uterine stimulation; may cause 5PA in hyperglycemia3 pulm edema3 n.v3 palpitations (avoid with h.o cardiac disease or if vaginal bleeding! &>'= mg s0 0 '&67& min + 7 then = mg 0 2 po -ndo*et)a(in/!rostag'andin synt)esis in)ibitor: =& mg po.$&& mg pr -E: premature closure of P5A in an hour3 oligohydramnios ADDG o ?etamethasone or 5e+amethasone (to increase fetal lung maturity! o ?edrest with bathroom priviledges o Pen G (Group ? -trep prophyla+is! P+E#E+M BABY +-S"S o Low birth weight o /ntraventricular hemorrhage o -epsis o Jecroti*ing enterocolitis

P+OM Preter* P+OM U78w (usually 7'67A w! ( PPHMD Pro'onged P+OM : rupture 9 '2 hours

 CA.SES: inf+3 hydramnios3 incompetent cervi+3 abruptio placenta3 amniocentesis Labor usually follows shortly D7: -terile speculum e+am # ferning (on slide!3 pooling (in fornices!3 nitra*ine paper (turns blue! 6 gc3 chl3 strep ? culture :.- # loo)s for AC/ (oligohydramnios! MGM#: 9 7Aw delivery Preterm pen G for ? strep3 e+pectant management vs> delivery for any signs of infection or fetal compromise3 ?PPs vs> J-Ts

C)orioa*nionitis Def: infection of amniotic fluid He0uires delivery; increased ris) with inc> length of rupture of membranes SS: fever 9 71 c3 inc @?,3 tachycardia3 uterus tender3 foul discharge #7: Ampicillin and Gentamycin3 add ,lindamycin if c.s3 5EL/4EHS Dost common cause of neonatal sepsis Endo*etritis +,: prolonged labor3 PHMD3 more c.s than vag delivery O+GS: polymicrobial anerobes.aerobes li)e E ,oli.Group ? -trep.?acteroides SS: uterine tenderness3 foul lochia TR: gentamycin and clindamycin (continue until '2621 h afebrile!

Ce!)a'o!e'vi( Dis!ro!ortion ,ommon indication for c.s Types of pelvis: Gynecoid: $' cm widest3 sidewalls straight Android: $' cm diam3 sidewalls convergent Anthropoid: U$' cm3 sidewalls narrow Platypelloid: $' cm3 sidewalls wide Mbstetric conKugate diameter: sacral promontory to midpoint symphysis pubis: shortest AP diameter ;>= # $$>= Ma'!resentation Bree(): 762N HC: previous breech3 uterine anomalies3 polyhydramnios3 oligohydramnios3 multigestation3 hydro.anencephaly Cran): fle+ed hips3 e+tended )nees (feet near head! ,omplete: fle+ed hips3 one or both )nees fle+ed /ncomplete.Cootling: one or both foot down 5R: LeopoldIs maneuver3 vaginal e+am (feel sacrum and anus! TR: , -ection is the preferred management3 e+ternal version (manipulation into verte+ position!3 trial of delivery if '&&&67=&&g and multip (has a proven pelvis! ,a(e: chin is anterior for delivery3 many anencephalics have a face presentation; d+ on e+am Bro<: must convert to occiput for delivery OP: usually rotate to MA (manually! S)ou'der: transverse lie do c section

Co*!ound: fetal e+tremity with verte+ or breech cord prolapse; part will reduce as labor occurs PP %e*orr)age 5efined as 9 =&& ml blood loss following vag delivery3 9 $&&& ml blood loss following c.s Causes o :terine atony coagulopathy o Corceps uterine rupture o Dacrosomia uterine inversion #7 o 4igorous fundal massage M+ytocin '& : in $&&& ml Jo Hepair laceration Dethergine &>' mg /D (contra: htn! o Ta)e out placental remnants PgC' # alpha (<emabate! (contra: asthma! o ,ytotec 1&& mg rectal <ysterectomy if medical therapy fails

+) -n(o*!atibi'ity Dom is Hh neg (Hh is an antigen on the H?,: ,5E family! F Dad is /h #os ( baby is be /h #os: during first pregnancy (usually at delivery but can occur with -ab3amniocentesis3 trauma3 ectopic3 etc!3 mom develops antibodies against Hh positivity (because she lac)s the antigen! which can cross the palacenta and cause a hemolysis in the newborn which may cause death> "'ei)auer Bet2e #est: assess amt of fetal blood passed into maternal circulation Mn first visit: blood type3 also screen for other antibodies: o Lewis # lives o Pell # )ills o 5uffy # dies +%OGAM: given as passive immuni*ation to prevent sensiti*ation: given O '1 w; chec) baby at delivery3 if HhF give Hhogam again to mom within 8' hours /f multip not sensiti*ed t+ as above SensitiFed: mom has developed antibodies against baby chec) a titer: if over $:13 do fetal survey on :- and amniocentesis at $A # '& w to measure the M5 2=& with the spectrophotometer (you )now3 that machine you used in general biology! reading for the L/LES ,:H4E Vone 7 <5J

Vone ' ffffsdfffollfollowfollclosely

Vone $ M)ay @ee)s gestation

Jote: the delta M5 2=& is prognostic3 not the titeritself Vone '.7 TR: intrauterine blood transfusion through umbilical A of H< neg blood E+#%+OBLAS#OS-S ,E#AL-S: heart failure3 diffuse edema3 ascites3 pericardial effusion3 bilirubin brea)down Kaundice3 neuroto+ic effects>

-ntrauterine ,eta' De*ise /:C5 assn with abruption3 congenital anomalies3 post dates3 infection3 but usually is une+plained> Hetained /:C5 over 7 # 2 w leds to hypofibrinogenemia secondary to the release of thromboplastic substance of decomposing fetus sometimes D-C can result> D7: no C<T on ultrasound #7: delivery Postdates :O 2$ w: do J-T: if nonreassuring do induction o 2'w: do ?PP and J-T ' 0 w): if nonreassuring do induction o inc ris) of macrosomia: oligohydramnios3 Deconium aspiration3 /:C5 o 5R: by LDP3 u.s consistent with LDP in first trimester o /nduce after 2' w Mu'ti!'e Gestation: $.1& twins Q $.8&&& # 1&&& triplets Co*!'i(ations: PTL3 placenta previa3 cord prolapse3 pp hemorrhage3 pre E ,eta' (o*!'i(ations: preterm3 congenital abnormalities3 -GA3 malpresentation De'ivery: usually occurs at 7A # 78 w if twins; Triplets # 77 # 72 w Monoygoti( #<ins: Gidenti(a'H $> 5ichorionic diamniotic: ' chorions. ' amnions: separation before trophoblast on embryonic dis) (splits before 8' hours! '> Donochorionic diamniotic: has one placenta; when twins occur d> =6$& before amnion forms 7> Donochorionic monoamniotic: one chorion and amnion; can be conKoined twins DiFygoti( #<ins: Gfraterna'H $> 5ichorionic diamniotic '> /nc in Africa (Jigeria! 7> ' sperm. ' eggs D7: u.s3 inc <,G3 inc D-ACP #7: managed as high ris)

 De'ivery of #<ins: o 2&N verte+ vaginally (only if reassuring C<T3 '=&& # 7=&& g! o '&N vt+ . br or br . vt+ '&N controversial3 usually c.s o '&N br . br cs o Triplets cs Pre8E('a*!sia / E('a*!sia / C)roni( %tn ?P 5ip Prt '2h :rine <.a3 vision changes H:L pain <ELLP3 LCT increased Nor*a' U$2&.;& TH U$=& mg Jo Jo Jo Mi'd Pre E $2&6$=;.;&6$&; F$3F' 7&& mg no no no Severe Pre E 9$A&.$$& F73F2 7>= # =>& g yes yes yes

E#-OLOGY: vasospasm; inc> thrombo+ane; trophoblast invasion of spiral arteries recurrence of pre E in subse0uent pregnancy is 4A @ DDI ,eta' Co*!'i(ations: prematurity3 dec blood flow to placenta; abruption.fetal distress3 /:GH3 oligohydramnios SS: htn3 proteinuria in third trimester B)en severe3 can get severe h.a3 vision changes3 sei*ures (eclampsia! +,: nulliparous3 92& yo3 African American3 chronic htn3 chronic renal d*3 antiphospholipid sd3 twin gestation3 angiotensin gene T'7=3 -LE #7: de'ivery is t)e G(ureH MgSOE (always chec) refle+es and respirations when on Dg3 need good :MP! 2>1 # 1>2 mg.ml: therapeutic 1 ,J- depression $& Loss of dtrIs $= Hespiratory depression.paralysis $8 ,oma '& ,ardiac Arrest <ydrala*ine to control ?P over $A&.$$& ECLAMPS-A: pre eclampsia plus sei*ures o ,an have cerebral herniation3 hypo+ic encelphalopathy3 aspiration3 thromboembolic events o -ei*ures are tonic clonic: '=N prelabor. =&N labor . '=N after labor (even 86$& days! o T+ of sei*ures: Dg-o2 (membrane stabili*ation!3 4alium /4 %ELLP: hemolysis3 elevated liver en*ymes3 low platelets o :sually in the severe pre E classification o T+: delivery3 Dg-o23 hydrala*ine C)roni( %tn: U'&w EGA3 9Aw post partum; $.7 can get superimposed pre E; inc ris) of abruption3 5/, acute tubular necrosis3 inc> prematurity . /:GH o #7: procardia (,,?!3 methyldopa3 ? bloc)ers3 J-Ts at 72 wee)s Diabetes in Pregnan(y Priscilla @hite ,lassification: not used as much anymore A$ diet controlled G5D (gestational diabetes mellitus! A' G5D controlled with insulin; polyhydramnios3 macrosomia3 prior stillbirth ? 5D onset 9 '& yo; duration U $&y , onset $&6$; yo; duration U '& y 5 Kuvenile onset dur 9 '& y

C nephropathy H retinopathy D cardiomyopathy T renal transplant Etio'ogy : impairment in carbohydrate metabolism that manifests during pregnancy ; =&N in subse0uent preg ; many get 5D later in life> +is2 ,a(tors: 9'= yo3 obesity3 family history3 prev infant 92&&& g3 prev> stillborn3 prev> polyhydramnios3 recurrent Ab Assn <it): 2+ more pre e3 '+ more - Abs3 inc> inf+3 inc> hydramnios3 c.s3 pp hemorrhage3 fetal death ,eta' ano*a'ies:Transpostion of the great vessels3 sacral agenesis3 macrosomia3 still birth D7: MI-ullivan (=& g glucose! O'1 w over $2&: fasting U$&=3 $ hr U$;&3 ' hr U$A=3 7 hr U$2= Manage*ent: A5A $1&& # ''&& )cal.d diet; glucose chec)s3 insulin if necessary3 deliver O 7162& w oral glucose tolerance test after delivery in si+ wee)s Antenata' testing: O 7&67' w :- 0 2w (loo) for /:GH3 polyhydramnios!3 )ic) counts3 J-T3 ?PP @atch for neonatal hypoglycemia

.#- $ Pye'one!)ritis Asy*!to*ati( Ba(turia: 9 $&&3&&& colonies =N of pregnancies; increased susceptibility to cystitis and pyelonephritis ($=N complicated by bacteremia3 sepsis3 AH5-!; treat as bacturia because of ris)s of preterm labor assn with pyelonephritis> Causes: -taph saprophyticus3 ,hlamydia3 E ,oli3 Plebsiella3 Pseudomonas3 Enterococcus3 Proteus3 ,oag # staph3 group ? strep SS .#-: dysuria3 fre0uency3 urgency D3 .#-: :.A F nitrite3 @?, esterase3 bacteria (contaminated if inc> epithelial cells! #3 .#-: (pregnancy!: Dacrodantin SS Pye'one!)ritis: ,4A tenderness3 fever3 dirty :A (need '.7 of criteria to diagnose! #7 Pye'one!)ritis: /4 Ancef until afebrile + 21 hours then 86$2 d po Pefle+ Pyelo is more li)ely to occur on the H because the uterus is de+trorotated> ProgesteroneIs effects cause urinary stasis3 which can predispose to pyelonephritis> -nfe(tions and Pregnan(y Ba(teria' &aginosis: Gardnerella vaginalis ss: gray.yellow malodourous discharge # clue cells on wet prep t+: Detronida*ole (flagyl! in second or third trimester Grou! B Stre!: Assn with :T/3 ,horioamnionitis3 endometritis3 neonatal sepsis '67.$&&& live births assn with G??- sepsis /4 pen G or ampicillin in delivery %er!es Si*!'e3 &irus: a 5JA virus (<-4 $ and '! /f mom has lesions can give baby viral sepsis on the way out herpes encephalitis #3: /4 Acyclovir3 , -E,T/MJ if active lesions

&ari(e''a /oster &irus 4ertical transmission possible /f mom gets chic)en po+ during pregnancy the baby could die #7: varicella *oster immune globulin given to mom within 8' hours of e+posure; can also give to infant> CM& SS baby: hepatosplenomegaly3 thrombocytopenia3 Kaundice3 cerebral calcifications3 chorioretinitis3 interstitial pneumomitis3 DH3 sensorineural hearing loss3 neuromuscular d.o +ube''a SS adu'ts: maculopapular rash3 arthralgia3 lymphadenopathy for '62 d SS infant: deafness3 ,4 anomalies3 cataracts3 DH D3: /gD titers in infant 5o not give DDH vaccine to pregnant woman Jo t+ for rubella #o3o!'as*osis ,irst tri*ester infe(tion: chorioretinitis3 microcephaly3 Kaundice3 hepatosplenomegaly Adu't SS: fever3 malaise3 lymphadenopathy3 rash D3: percutaneous umbilical cord sampling3 /gD ab #3: pyrimethamine (U$2 w!3 spiramycin (less teratogenic! %e!atitis B #rans*: se+3 blood products . transplacental; can cause mild to fulminant hepatitis D3: ab mar)ers: <bs Ag 4accinated at birth now Sy!)i'is 4ertical transmission possible in primary and secondary syphilis SS baby: hepatosplenomegaly3 hemolysis3 LA53 Kaundice3 saber shins D3: /gD antitreponemal ab %-& 4ertical transmission possible; AVT decreases chances GHEATLS /nc transmission with inc viral burden.adv disease Neisseria gonorr)ea Transmitted during birth to eye3 oropharny+3 e+t ear3 anorectal mucousa 5isseminates arthritis3 meningitis -creening in early pregnancy #3: ceftria+one3 -upra+ po C)'a*ydia 2&N babies get conKunctivitis $&N babies get pneumonitis #3: Vithroma+3 erythromycin

%y!ere*esis Gravidaru* Dorning sic)ness is found in 1&N of women3 but usually resolves by $Aw <yperemesis: more pernicious vomiting assn with weight loss3 electrolyte imbalances3 dehydration3 and if prolonged3 hepatic and renal damage> #3: maintain nutrition3 J- with =N de+trose3 compa*ine3 phenergan3 reglan /4./D; if needed TPJ (total parenteral nutrition!

Coagu'ation Disorders A hypercoaguable state can be due to inc> coag factors (all e+cept $$3 $'3 dec turnover time for fibrinogen!3 endothelial damage3 and venous stasis (uterus compresses /4, and pelvic veins! increased deep venous thromboses3 septic pelvic thromboses and pulmonary emboli> Se!ti( !e'vi( t)ro*bosis: postpartum3 prolonged fever on antibiotics; usually due to ovarian veins; not li)ely to lead to emboli; t3 is heparin3 ab+ Dee! &enous #)ro*boses: --: edema3 erythema3 palpate venous cord3 tender3 different calf si*es; 5+: 5oppler of e+tremity3 venography; T+: heparin /4 (PTT + '! then sub L heparin or loveno+ in pregnancy (JM ,M:DA5/J /J PHEGJAJ,S: s)eletal anomalies3 nasal hypoplasia!; coumadin MP if post partum> Pu'*onary E*bo'us: 54T right atrium H4 pulmonary arteries pulm htn3 hypo+ia3 H<C death> --: sob3 pleuritic chest pain3 hemoptysis3 with signs of 54T 5R: 5oppler e+t3 ,RH3 E,G3 4L -can3 -piral ,T Pulmonary Angiography TR: /4 heparin then -L heparin or loveno+ (coumadin MP postpartum! Substan(e Abuse EtO%: Cetal Alcohol -d: growth retardation3 ,J- effects3 abnormal facies3 cardiac defects #3: alcoholism: aggressive counseling; ade0uate nutrition Caffiene: 1&N e+posed in first trimester #oba((o: /nc> -ab3 preterm birth3 abruption3 dec> birth weight3 -/5s3 resp disease Co(aine: inc> abruption (from vasoconstriction!3 /:GH3 inc PTL; as a child3 developmental delay O!iates: (heroin.methadone!; the danger is heroin withdrawal3 not use miscarriage3 PTL3 /:C5; t3: enroll in methadone program; do not restart methadone if patient has not used for 21 hours>

Post!artu* Care &agina' de'ivery: pain care.perineal care (ice pac)s3 chec) for hemorrhage3 stool softener Pelvic rest + A w (no douching3 tampons3 se+!; J-A/5 C Se(tion: local wound care3 narcotics for pain3 stool softeners3 J-A/5 Breast Care: Dil) letdown occurs at '2 # 8' hr; if not breast feeding use ice pac)s3 tight bra3 analgesia (breast feeding gives relief! Mastitis: oral or s)in flora enter a crac) in breast s)in; can be treated with diclo+acillin; "ontinue to breast feed Contra(e!tion: no diaphragms3 caps until A w; if breast feeding depo3 micronor; not breastfeeding M,P3 norplant3 depo3 Mrthoevra

 Post Partu* %e*orr)age: o ?lood loss vag delivery ( =&& cc; c.s ( $&&&cc (normal # remember3 momIs plasma volume e+pands Kust for this reason%! o Causes: :terine atony (HC: multip3 h.o atony3 fibroids! t+: pitocin3 methergine3 etc> Hetained products of conception: find on manual e+ploration of uterus Placenta accreta: placenta is stuc) in uterine wall ,erv.4ag lacs: repair with ade0uate anesthesia :terine rupture ($.'&&&! ss: abd pain3 pop t+: laparotomy and repair if possible> :terine /nversion ($.'1&&! HC: fundal placenta3 atony3 accreta3 e+cess cord traction t3: *anua''y revert3 JTG3 Laparotomy Post Partu* de!ression: o Post partum blues: =&N; changes in mood3 appetite3 sleep3 will resolve o Post Partum depression: =N; decreased energy3 apathy3 insomnia3 anore+ia3 sadness; can get better or proceed to psychosis; t+: antidepressants (--H/s!

Endo*etritis: a polymicrobial infection invading the uterine wall after delivery; o --: fever3 inc @?,3 uterine tenderness (O =6$& d pp!3 foul discharge o Loo) for retained products do a d Q c o T+: triple antibiotics until afebrile + 21 hours and pain gone>

GYNECOLOGY Benign Disorders of Lo<er Genita' #ra(t Congenita' ano*a'ies: Labia' fusion: assn with e+cess androgens develop abnormal genitalia t3: estrogen cream -*!erforate )y*en: the Kunction between the sinovaginal bulbs and the :G sinus is not perforated obstructs outflow o --: primary amenorrhea at puberty3 hematocolpos (blood behind hymen! o TR: surgery &agina' se!tu*s: when vagina forms3 the sinovaginal bulbs and mullerian tubercle must be canali*ed> /f not you get a transverse vaginl septum between lower '.7 and upper $.7 primary amenorrhea o TR: surgery &agina' agenesis: Ho)itans)y6Puster6<auser -d: mullerian agenesis.dysgenesis; may have rudimentary pouch from sinovaginal bulb; Testosterone /nsensitivity: 2A +y with no sensitivity to testosterone (may have undescended testes! o TR: surgical creation of vagina &u'var dystro!)y: <ypertrophic: from chronic vulvar irritation ( raised white lesions o TR: cortisone cream bid o Atrophic: dec estrogen to local tissues (postmenopausal!

o --: dysuria.parunia3 pruritus3 4ulvodynia3 lichen sclerosis et atrophicus o T+ : 'N testosterone cream3 hydrocortisone cream Benign Cysts: o Epidermal ,yst: occlusion of pilosebaceous duct.hair follicle T+: incision and drainage o -ebaceous cyst: duct bloc)ed # sebum accumulates TR: / Q 5 if infected o Apocrine -weat Gland ,yst: on mons or labia occludes glands superinfection hidradentitis suppurative / Q 53 5o+ycycline o ?artholinIs gland ,yst: 2 or 1 oIcloc) on labia maKora TR: sit* baths3 inf+ # / Q 5 . word catheter Cervi(a' Lesions o ,ongenital anomalies: 5E- e+posure in utero ( '=N congenital anomalies3 clear cell adenocarcinoma $N o ,ervical ,ysts: dilated retention cysts: nabothian cysts ( bloc)age of endocervical gland O $ cm # as+3 no TR o Desonephric ,ysts: (remnants of wolfian.mesonephric ducts! deeper in stroma o Polyps: broad based ( can have intermittent.post coital bleeding; usually removed cervical fibroids ( intermenst bleeding3 dysparunia3 bladder.rectal pressure. r.o cerv can o ,ervical -tenosis: congenital or after scarring (surgery.radiation! or secondary to neoplasm or polyp; if asymptomatic3 leave alone; if causes menstrual problems3 remove; gently dilate scarring>

,ibroids Cibroids ( Estrogen dependant local proliferation of smooth muscle cells3 usually occur in women of child bearing age and regress at menopause; African American are at higher ris); has a pseudocapsule of compressed muscle cells; are found in '&67&N American women at age 7& SS: menorrhagia (submucous!3 metrorrhagia (subserous3 intramural!3 pressure s+ (from pressing against bladder!3 infertility; =&N are asymptomatic> Parasitic fibroids: get their blood supply from the omentum> %isto'ogi( C)anges: o <yaline ,hange o ,ystic ,hange o ,alcific change o Catty ,hange o Hed.white infarcts o -arcomatous change (most rare! /n pregnancy are at increased ris) for -ab3 /:GH3 PTL3 5ystocia; may grow during pregnancy Med #7: 5epo provera3 Lupron (GnH< agonist!3 5ana*ol

 Surg #3: momectomy(only for fertility purposes!3 )ystere(to*y indi(ated <)en ane*i( fro* b'eeding severe !ain siFe J 54 < urinary freKuen(y gro<t) after *eno!ause3 new role for emboli*ation by interventional radiology Endo*etria' %y!er!'asia Endometrial hyperplasia: abnormal proliferation of gland.stromal elements; overabundance of histologically normal epithelium o -imple without atypia: $N cancer6 Provera o ,omple+ without atypia: 7N cancer6 Provera o -imple with atypia: ;N cancer6 Provera vs> TA< o ,omple+ with atypia: '8N cancer6 TA< o HC: unopposed estrogen3 P,M3 granulosa.theca tumors o 5R: endometrial biopsy Endo*etriosis Adeno*yosis: Endometrium in myometrium o :susally a 7& yo multiparous woman with heavy #ainful #eriods3 enlg tender uterus described either as boggy.soft or woody.firm and pelvic heaviness o H+: hysterectomy . analgesics o The tissue does not undergo proliferation phase of cell cycle> Pe'vi( Endo*etriosis: presence of endometrial glands outside of endometrium o Theories -ampsonIs reflu+ menstruation: most li)ely ,oelomic metaplasia: irritant to peritoneum Camily history . genetic /mmunologic Lymphatic and vascular mets /atrogenic dissemination (ie:you see it on the other side of a c section scar! o /nduces fibrosis which causes pelvic pain o SS: pain3 infertility3 bleeding.ovarian dysfunction3 hematoche*ia. hematuria3 dyspareunia (pain with se+! o ,an be on peritoneum3 ovary (chocolate cysts!3 round ligament3 tube3 sigmoid colon o D7: laparoscopy o #7: J-A/5 M,P.Provera Lupron (GJH< agonist! # pseudomenopause Laser surgery.coagulation of implants3 TA<.?-M Ovarian Cysts :sually follicular from failure of follicle rupture; disappear in A& d 7 # 1 cm Types: o ,orpus luteum cysts (firm.solid! o ,ystic.hemorrhagic (hemoperitoneum! o Theca lutein (bilateral3 filled with straw fluid; high b<,G! D7: ultrasound3 ,A$'= in cases suspect for epithelial ovarian cancer DiffD7: ectopic3 tuboovarian abscess3 torsion3 endometriosis3 neoplasm

 #7: if premenopausal3 can observe if under 1cm; /f postmenopausal (any si*e! or premenopausal need laparoscopy vs> laparotomy for cystectomy or oopherectomy #reat*ent of S#Ds C)'a*ydia tra()o*atis: o 5R # 5irect fluorescent Ab o #3: do+ycycline $&& mg bid + 8 d or A*ithromycin $ g po (one dose! NC Gonorr)ea: o 5R: gram stain3 culture o HC: low -E-3 urban3 nonwhite3 early se+3 prev gon inf+ o Treat both partners o #7: Hocephin '=& mg /D or ,ipro =&& mg po or Clo+in 2&& mg po o :sually transfers male to female more than female to male> Sy!)i'is: Treponema pallidum o 5R: dar) field microscopy o #7: (U$ yr duration! Pen G '>2 million : /D (9$yr duration! '>2 mill : /D + 7 doses (see ob section for full description! %er!es Si*!'e3 &irus: first episode # Acyclovir.Camciclovir.4alcyclovir; AAN <-46' 77N <-46$ of genital herpes; vesicles rupture in $&6'' d leaving a painful ulcer; can use antivirals also as suppressing agents as the virus hangs out in the dorsal root ganglion> %P&: o Types A.$$ ( genital warts o Types: $A3$137$ ( cervical cancer o TR: podofilo+3 cyrotherapy3 podophyllin rein3 T,A3 Aldara cream C)an(roid: casued by <aemophilus ducreyi; is a painful soft ulcer with inguinal lymphadenopathy; t3 with ,eftria+one '=& /D + once or A*ithromycin $ g once po or Erythromycin; treat partner> Ly*!)ogranu'ona veneru*: primary ( papules.shallow ulcer; secondary ( painful inflammation of inguinal nodes with fever3 h.a3 malaise3 anore+ia; Tertiary ( rectal stricture.rectovaginal fistula. elephantiasis #7: do+ycycline $&& mg po bid + '$ d Mo''us(u* (ontagiosu*: po+ virus from close contact; $6= mm umbilicated lesion anywhere but the palms or soles; are asymptomatic and resolve on their own P)t)ris !ubis/sar(o!tes s(abei: Lice and scabies3 respectively; TR: lindane.Pwell

&aginitis Candida: o HC: Ab+3 5D3 Pregnancy3 immunocompromised o --: burning3 itching3 vulvitis3 cottage cheese discharge3 dysparunia o 5R: wet prep PM< ( branching hyphae o E+am: white pla0ues with or without satellite lesions o #7: over the counter creams wor) well (monistat!; if resistant3 5iflucan $=& mg po + once #ri()o*onas: unicellular flagellated proto*oan o --: itching3 inc> discharge (yellow.gray.green!3 frothy o E+am: strawberry cervi+3 foamy discharge o 5R: see the buggers *ipping all over your wet prep

o #7: Clagyl =&& mg po bid + 8 d. partner condom + ' w o Jote: avoid flagyl in frist trimester Ba(teria' vaginosis: Gardnerella vaginalis o --: odorous discharge o 5R: whiff test by adding PM<; see clue cells on wet prep (spotty s0uamous cells! o TR: flagyl =&&mg bid + 8 d o Jot an -T5 Atro!)y o --: burning d.c on se+ o HC: post menopausal o TR: estrogen P-D Organis*s: Jeisseria3 ,hylamadia3 Dycoplasmia3 :reaplasma3 ?acterioides3 among others S7: diffuse lower abdominal pain3 vaginal discharge3 bleeding3 dysuria3 dyspareunia3 ,DT3 adne+al tenderness3 G/ discomfort D7: Cervi(a' Motion #enderness Adene3a' tenderness dis()arge fever e'evated BBC ES+ Lab: cultures3 pelvic :.- if mass palpated3 rise in @?, count #7: Ceftia0one 2 $ I. 1 12! Do0y"y"line 122 m$ I. or Clindamy"in 3 4entamy"in Usually t0 for )5 hrs I. then if afebrile "han$e to Do0y"y"lin 122 m$ #o bid 0 1) d #OA: Tubo Mvarian Abcess: persistent P/5 progresses to TMA in 76$AN of the time Adne+al mass.fullness (not walled off li)e true absess! 5R: :.-3 Pelvic ,T if obese3 increase @?, with a shift to the left3 increase E-H TR: 6os#itali7e for I. antibioti"s 8Tri#les& am#i"illin! $entamy"in! "lindamy"in9 if T%: ru#tures or doesn;t resolve ,ith antibioti"s then sur$eryENDOME#+-#-S: usually after some type of instrument disruption of the uterus: ,6section3 vaginal delivery3 5 Q E.,3 /:5! 5R: endometrial or endocervical culture will result in s)in3 G/3 repro flora TR: Do0y"y"line vs- I. ab0 #O7-C S%OC" SYND+OME: vaginal infection that is not associated with menstruation ,an be assoc with delivery3 c6sections3 post partum Endometritis3 sab or laser t+ of coac Sta!) aureus !rodu(es e!ider*a' #SS #85 t)at !rodu(es fever eryt)e*a ras) desKua*ation of !a'*er surfa(es and )y!otension> Also see G/ disturbances3 myalase; mucus membrane hyperemia3 change in mental status Labs: increased ?:J.,H3 decreases plt; but neg b'ood (u'tures TR: al,ays hos#itali7e< may need ICU and $ive I. fluids and = or #ressors- :>? do not shorten the len$th of the a"ute illness but does de"rease the ris' or re"urren"eBLADDE+ ANA#OMY 6 5etrusser and urethra ( smooth muscle 6 /nternal spincter is at urethrovesical K+n 6 /ncontinence ( intraurethral U intravesical pressure 8 PSNS (-'3732! allows micturition : ,<ML/JEHG/, HE,EPTMH8 SNS # hypogastric n> T $& # L' prevents urination by contracting bladder nec) and internal spincter : JE HE,EPTMH6 -omatic controls e+ternal spincter (pudendal nerve! PEL&-C +ELA7A#-ON: damage to the anterior vaginal wall leading to cystocele3 endopelvic fascia leading to rectocele or enterocele or stretching of cardinal ligaments which can lead to uterine prolapse

D7: mostly PE : called a PMP L3 which is a graph on which certain points corresponding to lengths of the vagina and where it moves on valsalva are graphed> This tells you where the defect is3 so you )now the appropriate therapy from it> S7: pain3 pressure3 dyspareunia3 incontinence3 bowel or bladder dysfunction Causes: anything that will cause chronically increased abdominal pressure: cough3 straining3 ascites3 pelvic tumors3 heavy lifting +,: aging3 menopause3 traumatic delivery3 associated with multiparity PE: pelvic e+am shows the amount of descent of the structure into the vagina and thus determines the degree of rela+ation: (PMP L! -tage $ # upper '.7 of vagina -tage ' # to the level of the introitus -tage 7 # outside of the vagina #7: )egels (contraction of levator ani muscle3 instructed by physician!3 estrogen replacement3 vaginal pessaries3 surgery -NCON#-NENCE: .+GE -NCON#-NENCE: a)a detrussor instability S7: urgency3 often can not ma)e it to the bathroom Causes: foreign body3 :T/3 stones3 ,A3 diverticulitis D3: based on history3 can be shown on urodynamics (which is a catheter in the bladder3 rectum and a machine to measure the difference> The bladder is filled with normal saline and response to that is measured>! .rodyna*i(s s)o<s: involuntary.uninhibited bladder contractions #7: Pegle e+ercises3 anticholerginics (ditropan3 amytriptaline!3 muscle rela+ants3 beta agonists3 estrogen replacement6 surgery is not used here3 more medical therapy is appropriate S#+ESS -NCON#-NENCE: S7: involuntary loss of urine when there is an increased abdominal pressure mostly from snee*ing3 coughing3 laughing which transmits pressure to the urethra Me(): /ntrinsic spincter defect3 hypemobile bladder nec)3 pelvic rela+ation Causes: trauma3 neurologic dysfunction3 associated with multiparity #7: Peglele+ercises3 alpha agonists3 estrogen cream3 retropubic urethrope+y (which is a surgery where the periurethral tissue is Koined with the ,ooperIs ligament # called a Bur()! or #rans &agina' #a!e procedure (the periurethral tissues are raised towards the abdominal wall using a mesh sling6 placed under local anesthesia! O&E+,LOB -NCON#-NENCE: S7: dribbling3 urgency3 stress Me(): underactive detrussor leading to poor or absent bladder contractions Cause: 5D3 drugs3 fecal impaction3 D-3 neurologic #7 : treat underlying cause3 <ytrin3 bethanechol3 intermittient cath3 dantroleen D7: urodynamics3 post void residual (after you pee3 you place a catheter to see how much urine is left in the bladder6 over $&& cc is abnormal! .+-NA+Y ,-S#.LA: produces continuous urine lea)age commonly seen following pelvic surgery.radation HC: P/53 radiation3 endometriosis3 prior surgery 5R: Dethylene blue dye inKection into the bladderWplace a tampon in the vagina6 if itIs a vesicovaginal fistula the tampon will be blue3 indigo carmine dye given /4 with a tampon in vagina Wif itIs a ureterovaginal fistula the tampon will be blue TR: surgery but must wait 7 # A months to repair postsurgical fistulas ENDOC+-NOLOGY P.BE+#Y: secondary se+ characteristics3 growth spurt3 achievement of fertility

$> Adrenarche (A61 yo!: regenerates *ona reticularis that produces 5<EA6-3 5<EA3 androsteinone '> Gonadarche (yo!: pulsatile GnH< secretion goes to ant pituitary to secrete L<3 C-< 7> Thelarche (breast3 $$ yo!: Tanners stages 2> Pubarche ($' yo!: pubic hair3 A+illary hair => Growth spurt: (;6$7 yo!: increase G< and somatomedian # , result in pea) height velocity3 increase estrogen levels3 fusion of growth plate A> Denarche: ($' # $7 yo!: anovulatory period up to $ year3 may ta)e ' years to have regular cycle3 delayed in athletes Two pneumonics: (pic) your favorite! breast hair grow bleed or boobs pubes pits and pads #ANNE+ S#AGES ?reast $> Prepubertal '> ?reast bud 7> ?reast elevation 2> Areolar Dound => Adult ,ontour <air $> prepubertal '> prese+ual hair 7> -e+ual hair 2> Did6escutcheon => Cemale escutcheon

MENOPA.SE: cessation of menstruation Onset # usually =&6 =$ years 6 if U2& yrs premature menopause 6 if U7= premature ovarian failure (idiopathic3 send genetic studies! S7: irregular menses3 hot flashes secondary to decreased estrogen3 mood changes3 depression3 lower urinary tract atrophy3 genital changes3 osteoporosis LABS: C-< 9 2&3 elevated L<3 decreased estrogen resulting in decreased negative feedbac) D7: < Q P (PE shows decreased breast si*e with vaginal3 urethral3 and cervical atrophy ' to decreased estrogen! #7: <ormone replacement (<HT! primarily estrogen and progesterone if pt has uterus; calcium3 4it 53 e+ercise to counter the decreased osteoclast activity: Estrogen cream to counter act vaginal atrophy> Contraindi(ations: 4aginal bleeding3 thromboembolic d*3 breast ca3 uterine ca Uno##osed estro$en 8estro$en ,ithout #ro$esterone in ,omen ,ithout a uterus9 results in endometrial hy#er#lasia and C:ConseKuenses of de(reased estrogen: 6 unfavorable lipid profile that could result in stro)e and D/ 6 /ncreased bone resorption b.c estrogen decreases osteoclast activity predisposing to hip fract> 6 Atrophy of s)in and muscle tone> WHI Study: What are all these questions about estrogen and progesterone on the news? /n women with active heart disease3 estrogen and progesterone (prempro! increases the remote ris) of stro)e and 54T> There were problems with this study3 however> There are no problems ta)ing estrogen alone when you donIt have a uterus> P+-MA+Y AMENO++%EA: Estrogen gives breasts; S chromosome ma)es Dullerian /nhibitory Cactor6 no uterus if D/C present> $> No Breasts L uterus: no estrogen a> C-< high: ovarian failure (hypergonadotropic hypogonadism! i> #urner0s : ovaries undergo rapid atresia ii> Dosaic iii> 5M )ydro3y'ase def : D/C produced so no female internal organs ivC Pure Gonada' dysgenesis

b> C-< low: insufficient GnH<3 hypo pituitarism3 -wyerIs -d: Gonadal agenesis3 2A+y3 testes do not develop b.c D/C not released3 infertility3 e+ternal female genitalia3 no breast> '> LBreast @ uterus: estrogen F D/C a> +o2itans2y "uster %auser: uterovaginal agenesis with other anomalies 2A++ b> Androgen insensitivity: 2A+y3 testicular femini*ation3 no receptors for testosterone3 D/C secreted therefore no mullerian structures> 7> @Breast @ uterus: +y (no steroids! but phenotypically female3 no internal female organs> a> 5M )ydro3y'ase def (steroid synthesis! in RS 2> LBreast @ uterus: a> /mperforate hymen # solid membrane across introitus3 pelvic.abd pain from accumulation of menstrual fluid # hemato colpos> b> Trans vaginal septum # failure to fuse mullerian determined upper vagina and :G sinus found at mid vagina t+: surgery c> 4aginal agenesis HP<3 mullerian agenesis.dysgenesis uterial of partial vaginagenesis3 no patent vagina3 2A++3 and ovaries and uterus on :.-> T+: surgery> SECONDA+Y AMENO++%EA: Dust do a good <QP to chec) for stresses3 wt loss.gain3 drugs3 e+ercise3 upt3 Estradiol level3 progesterone challenge Enough estrogen (bleeds with progesterone challenge! chec) C-<3 L<3 PHL o L< high thin) P,M o L< wni thin) hypothalamic amenorrhea so stress3 e+ercise3 post pill o PHL increased thin) prolactinoma3 hypothyroidism3 prenothra*ines3 pregnancy Jo estrogen (no bleed with progesterone challenge! chec) C-<3 L<3 PHL o C-< high thin) ovarian failure3 resistant ovarian syndrome o C-< low # wnl chec) DH/.,T for pituitary tumors3 -heehanIs -immans syndrome o ,ould also be post surgery problems: AshermanIs following 5Q, ,ervical stenosis following ,P, S<yer0s Syndro*e: 2A+y3 gonadoagenesis3 w.o testes no D/C yielding female genitalia but no estrogen so no breasts> "a''*an0s Syndro*e: absence of GnH< and anosomia> Pts have breast and uterus Testicular Cemini*ation: 2A+y insensitive to testosterone> D/C so no internal female genital structures F estrogen so has breasts> PMS 'nd X of cycle Probable ,auses: abnormal estrogen.progesterone balance3 increase PG production3 decrease endogenous endorphins; disturbance in renin6angiotensin6aldosterone system 5R: = of $' symptoms (including $ of the first four! -R: $> 5ecreased mood '> An+iety 7> Affective Liability 2> 5ecrease interest => /rritability A> ,oncentration difficulty 8> 5ecreased energy 1> ,hange in appetite ;> Mverwhelmed $&> Edema

$$> Edema $'> @eight gain $7> ?reast Tenderness T?: avoid "affeine! etoh! toba""o! lo, sodium diet! ,ei$ht redu"tion! stress mana$ementDru$s& @S:IDS! %CPs! lasi0! "al"ium! vit E! SS/I DYSMENO++%EA: pain and cramping during menstruation that interferes with the acts of daily living> Primary # presents U'& years b.c of increased PG occurs with Mvulatory cycles -econdary # Endometriosis3 Adenomyosis3 fibroids3 cervical stenosis (congenital3 trauma3 surgery3 infection!3 adhesions (h.o infection P/53 TMA3 e+ lap LMA! MENO++%AG-A <eavy prolonged menstrual bleeding; over 1& cc. cycle Avg 7= ml of blood loss 9 '2 pads per day Estrogen increases endometrial thic)ness Progesterone matures Endometrium and withdrawal of leads to secretion Denstruation at regular intervals usually indicates ovulation Abnor*a' .terine B'eeding/D.B a)a irregular periods indicate anovulation ,auses: fibroids3 Adenomyosis3 endometrial hyperplasia3 endometrial polyps3 cancer3 pregnancy complication 6 Puberty # give Cergon3 J-A/5- premarin until bleeding stops3 chec) 4on @illebrand Cactor 6 $A # 2& yo thin) endometriosis3 Adenomyosis3 fibroids T0& E >! %CPs 6 92& yo thin) endometrial cancer T?& E >! de#o #rovera! DAC! T:6

ME#+O++%AG-A: intermenstral bleeding thin) endometrial polyps3 endometrial.cervical cancer3 pregnancy complication POLYMENO++%EA: cycles U'$ d between periods ( anovulation OL-GOMENO++%EA: 97= d apart ( disruption of pit.Gonadal a+is3 pregnancy D.B: abnormal uterine bleeding in absence of organic causes O&.LA#O+Y D.B: Early spotting # estrogen no increasing fast enough Did spotting # estrogen drop off at ovulation Late spotting # Progesterone def TR: @S:IDS de" blood loss by 22BC2D

POS# MENOPA.SAL BLEED-NG 6 9$' months after menopause 6 lower.upper genital tract Dech: e+ogenous hormones Jon gyn causes: rectal bleeding3 prolapse3 fissures3 tumors vaginal atrophy3 ,A (endometrial and cervical!3 endometrial <yperplasia3 Polyps

5R: inspection on PE3 pap3 rectal3 ED?3 <-G3 <.<3 :.T?& ref all $i #roblems! sur$ery! estro$en re#la"ement! b0 all lesions %-+S.-#-SM / &-+-L-SM Diagnosis/ Bor2 u!: assess body hair systematically Cree testosterone6 ovary produces the most testosterone 5<EA-6 adrena' produces the most 5<EA-6 screens for adrenal tumors $8 hydro+y progesterone6 congenital adrenal hyperplasia %air ty!e: 4illus hairs # cover entire body Terminal hairs # thic) ( A+illary3 pubic3 = reductase converts testosterone to dihydrotestosterone to stimulate terminal hair development %irsuitis* # increase of terminal hairs esp on face3 chest bac)3 diamond shaped escutcheon (male! increase = reductase &iri'is* # male features3 deepening of voice3 balding3 increase muscle mass3 clitormegaly3 breast atrophy3 male body habitus Causes: Adrenal tumor3 ovarian tumor3 P,M ,ushingIs syndrome: increase A,T<3 cortisol ,ongenital Adrenal <yperplasia # '$ and $$ hydro+ylase def Po'y(ysti( Ovarian Syndro*e: This is a syndrome which can include numerous ovarian cysts3 but really is more than that> /t includes G /nsulin Hesistance: diagnosed by Casting Glucose. /nsulin ratio U2>= T+: etformin <irsuitism: from hyperandrogenemia Anovulation: irregular3 heavy periods; if desires fertility treat with metformin and "lomid C-< : L< ratio is over '>=:$ -N,E+#-L-#Y: inability to achieve pregnancy after $' months of unprotected intercourse3 '&N of population 6 /diopathic6 $&N 6 Dale and Cemale6 $&N 6 ,e*a'e Causes # 2&N Ovu'atory # Anovulation3 endocrine3 P,M3 premature ovarian failure TR& ovulation indu"tion 8&N success Clomid: antiestrogen that results in increased C-<3 more mature follicies and ovulation se: hot flashes3 emotional liability3 depression and mult gestations Per$onal: purified C-<.L< <DG /D inKection in follicular phase 1= # ;&N effective /4C3 G/CT3 V/CT: ovulation induction3 harvest oocytes add sperm fertili*e place in uterus> #uba': adhesions3 endometriosis3 P/53 salpingitis TR: tubal reconstruction Peritonea': endometriosis3 adhesions3 P/5 .terine: ashermanIs3 fibroids TR: myomectomy Lutea' P)ase Defe(t TR: #ro$esterone durin$ and after "on"e#tion Ma'e Causes: 2&N TR: for all intrauterine insemination DE5- that affect sperm analysis: cimetidine3 colchicines3 sulfasala*ine3 allopurinol3 erythromycin3 steroids3 tetracycline ,yptorcidism 4aricocele Epidydimitis Prostatitis

Bor2 .!: -perm count6 must be done first T-<3 Prolactin <-G6hysterosalpingogram6 assesses patency of tubes and diagnoses intrauterine defects Post ,oital test6 loo)s at 0uality of mucus and sperm3 done 5"$'6$2 ??T6 temperature curve6 spi)e predictive of ovulation Progesterone level on day '$6 assess ovulation 5iagnostic -cope6 loo)s for endometriosis C%ANGES -N &.L&A Li()en S('erosis # thin s)in3 hyalini*ed collagen t+: "lobetasol 8a hi$h #oten"y steroid9 E3tra*a**ary Paget0s # intraepithelial neoplasia of the s)in 9A& yrs w.vulvar purities pale atypical cells with mitotic figure '&N have adeno ca underneath -R: pruitus unrelieved by antifungals 5R: biopsy T?& ,ide lo"al e0"ision! Col#o Assoc with other cancers: gi3 breast3 cv+ c.w chronic inflammatory changes -car yields red velvet and white pla0ues on labia /nfranodal spread li)ely to be fatal &-N - -- --- : &.L&A+ -N#+AEP-#%EL-AL NEOPLAS-A: dysplasia of the vulva 6atypia3 thic)ened s)in 6degree proportioned to " of mitotic fig 6can see s0uamouspearls 6postmenopausal late =&6A&s 6correlated with <P4 1& # ;&N 6diffused focal raised3 flat3 white3 red3 brown3 blac) -R: 4ulvodynia3 pruitus TR:e0"ision ,ith s"al#el or laser3 f.u ,olpo 0 7 mo until disease free then 0 A mo &.L&A+ CA # =N gyn malignancy 6associated with 5D3 <TJ3 obesity vulvardystrophies -R: 4ulvodynia3 purities3 mass erythemia 5R: b+ : see epidermoid ;&N of cases3 melanoma =6 $&N3 basal '67N3 cauliflower hard indurated -TAG/JG: / U'cm in si*e3 no nodes3 no mets /a U$mm /b 9$mm // 9'cm3 no nodes3 no mets but can progress to perineum3 urethra and anus /// unilateral nodes with any si*e /4 bilateral nodes TR: based on sta$e! from ,ide lo"al e0"ision to vulve"tomy to radi"al vulve"tomy=lym#h node disse"tion

&AG-NAL CA 6women in their =&Is 65E- e+posure in utero resulting in clear cell adenocarcinoma 6asymptomatic for the most part but may have d.c3 bleeding3 purities 6TR: pap # ,olpo # pathologic d+ ABNO+MAL PAP SMEA+

6false negative pap 2&6=&N Gbenign (e''u'ar ()angesH : thin) infection so wet prep3 cultures 2oi'o(ytosis: pathologic description associated with <P4 GASC.S : Atypical -0uamous ,ell <yperplasia of :ndetermined -ignificance: o AI hide underlying severe lesions o re#eat #a# in 3 months! Col#os"o#y if 2 :SCUSs o consider <P4 typing GLGS-LH: Low Grade -0uamous /ntraepithelial Lesion: T+: Col#os"o#y G%GS-LH : <igh Grade -0uamous /ntraepithelial Lesion: T+: Col#os"o#y

Co'!os(o!y: magnifies region of cervi+ after stained with acetic acid> Areas of dysplasia stain @</TE (aceto white focal lesion! and are biopsied> An endocervical curettage is also done> #reat*ent of dysplasia is based on the bio!sy and ECC resu't> As a general ruleG Dild dysplasia: observation3 cryotherapy Doderate dyplasia: cryotheraphy or LEEP (loop electrosurgical e+cision procedure! -evere dysplasia: LEEP or ,old Pnife ,oni*ation /f E,, has dysplasia: ,P, or LEEP E indi(ations for C"C: o Mi(roinvasion on bio!sy o ECC <it) dys!'asia o Pa! (o'!o dis(re!an(y: /f the pap smear does not correlate with the biopsy results: ie> <G-/L with normal biopsy results3 you may have missed something and need to do a ,P, o -nadeKuate (o'!o: means that there is a lesion e+tending into the os or that you could not visuali*e the whole lesion on colpo6 there may be something more e+tensive there

CE+&-CAL CANCE+ Dost cancer occurs in transformation *one Poilocyte: has viral particle <P4 oncogenic 773 7=3 ='3$A3 $1 ordinary wart A3$$ S7: vaginal bleeding3 d.c3 pelvic pain3 growth on cervi+ may palpate.see mass on e+am ,lassic presentation: post coital bleeding3 pelvic pain.pressure3 abnormal vaginal bleeding rectal.bladder s+ #y!es: -0uamous large cell3 )eratini*ing3 non6)eratini*ing3 small cell (worse prog! Adenocarcinoma Di+ed carcinoma Glassy cell # occurs in pregnant women usually fatal +,: tobacco " of se+ partners3 age of onset of se+3 " -T5s3 </4 (cervical ,A an A/5- defining illness! Staging # based on microinvasion so *ust do a (one : staged ,L/J/,ALLS M carcinoma in situ / contained to cervi+ // carcinoma beyond cervi+3 no sidewall // pelvic sidewall3 hydronephrosis /4 e+tends beyond pelvis #7: IaE "one bio#syF hystere"tomy 122D "ure

Ib=IIa E radiation! radi"al hystere"tomy ( ta)es uterus3 cervi+3 parametrium3 LJ! IIb=III=I. E e0tensive radiation!"hemo O&A+-AN #.MO+S +,: family h+3 uninterrupted ovulation3 nulitips3 low fertility3 delayed childbearing3 late onset menopause (M,s have protective effect! S7: asymptomatic until advanced stages3 urinary fre0uency3 dysuria3 pelvic pressure3 ascites3 6 6 #y!es: Nonneo!'asti(: only operate if postmenopausal or if theyIre over 1 cm o Collicle cyst o ,orpus luteum <ematoma o P,M o Theca lutein cysts: assn with <,G and L< o Endometrioma o Para ovarian cysts (mullerian! E!it)e'ia' (1&N! o -erous cystadenoma: papillary cystic malignant bilateral3 psammonma bodies o Endometroid: solid o Ducinous: cystic o ,lear cell: associated with <obnail ,ells on path3 assn with 5Eo ?runner: loo) li)e transitional epithelium: @althard Jests ;;N benign o -:ET: solid undiff Ger* Ce'' o 5ysgerminoma: younger people3 solid radiosensitive3 lymphocytic infiltrate o Teratoma: ectoderm endoderm mesoderm3 Hoti)ans)yIs protuberance3 complications: medi"al& struma ovarii3 autoimmune hemolytic anemia3 carcinoid sur$ery: torsion3 acute abdomen o Primary choriocarcinoma of the ovary false3 F :PT3 increased <,G o Sol) -ac Tumor.Endodermal -inus: FACP.L5<3 F-chuller 5uval ?odies o Di+ed germ cell: <,G3 ACP3 L5<3 ,A $'= Stro*a' 6older women (=&61&! 6-e+ cords hormone production o Cibroma: DeigIs syndrome: ovarian tumor3 r hydrothora+3 ascites o Granulosa Theca # femini*ing3 late recurrence3 ,all E+ner ?odies3 produce large amounts of estrogen> o -ertoli Leidig # masculini*ing3 secrete testosterone3 ,rystaloids of Hein)e secrete androgens o Gynandroblastoma6 components of male and female Ot)er o <ilar ,ell: hillus3 androgenic3 small o Pru)enberg: G/ metastasis bilateral enlarged solid ovaries signet ring cell associated with mucus assn with gastric cancer Ovarian Can(er Staging: / 6 growth to one.both ovaries

// # with e+tension to pelvic structures /// # peritoneum /4 6 distant mets AdKuvant ,hemo: cisplatin and ta+ol RHT in //./// Collow ,A$'= because increased in 1&N CA O, ,ALLOP-AN #.BES 6adeno ,A from mucosa 6disease progresses li)e ovarian ,A 6peritoneal spread 6ascites 6bilateral in $&6'&N results from mets often 6primary in very rare 6asymptomatic but may have vague lower abdominal pain and discharge TR: TA<.?-M cisplatin3 cyclophosphomide RHT #+OP%OBLAS#-C D-SEASE Doles Co*!'ete: 6U'& yrs or 92& yrs3 1&N of molar pregnancies 6,omplete E?33 (both + from sperm! 6worse b.c can transform into malignant6 '& N malignant 6no baby parts -n(o*!'ete: Triploid (usually RRS! 6Day have baby parts S7: early abnormal bleeding 6Large for dates 6F.6 grape tissue 6bilateral enlarged ovaries 6increased in Asians 1.$&&& 6early to+emia 6threatened A? 6hyperemesis3 hyperthyroid3 <TJ +,: maternal age3 h.o hydatidiform mole3 recurrent -A?3 low social economic status3 poor nutrition #7: dilation and "uretta$e! "onsider hystere"tomy ,/.: monitor <,G for one year3 contraception for one year (b.c donIt want to confuse rising <,G titers of a new pregnancy with those from molar pregnancy!3 pelvic e+ams 0 ' w)s until uterus clear ,hemo: if increased <,G at A months3 lung or other mets3 recurrence C%O+-OCA+C-NOMA: malignanancies in assn with pregnancy 6maKority follow trophoblastic moles3 but can follow normal pregnancy also 6$.'&3&&& pregnancies HC: as above (A! women mating with (M! men -R: abnormal bleeding after any pregnancy TR: Chemothera#y 1- T? 2- Eto#oside=a"tinomy"in D= T? 3- Cy"lo#hos#hamide=.in"ristine DAC CON#+ACEP#-ON

Hhythm Certility awareness.abstinences ==61&N effective ovulation assment ( ??T menstrual cycle trac)ing cervical mucus e+am ,oitus /nteruptus @ithdrawal before eKaculation $=6'=N failure Lactational Amenorrhea Jursing delays ovulation by hypothalamic suppression Da+ of A months =&N ovulate by A6$' months $=6==N get pregnant while nursing ?arrier Dale and female condom3 diaphragm3 cervical cap sponge3 spermacide /:5 -permicidal inflammatory response. inhibition of implantation :sed when M,Ps contraindicated Patient is a low -T5 ris) ,ontraindicated in pregnancy3 abnormal vaginal bleeding3 infection Helative contraindication: nullip3 prior ectopic3 h.o -T53 mod.sev dysmenorrhea Cailure rate U'N Jorplant: not sold anymore for monetary reasons only -ustained release6 = years &>'N failure not many side effects b.c no estrogen only progesterone si+ fle+ible rods (7Amg progesterone! -L upper arm side effects: /rregular vaginal bleeding3 <A3 wt change3 mood changes

5eproprovera Dedo+yprogesterone acetate /D slow release of over 7 months >7N failure rate side effects: irregular menstrual bleeding3 depression3 weight gain 98&N get irregular menses3 eventually have amenorrhea 4asectomy Ligation of the vas deferens U$N failure rate must use condom for 26A w)s until a*ospermia confirmed on semen analysis 8&N reanastomose resulting in pregnancy $16A&N =&N ma)e anti6sperm antibodies Tubal -terili*ation Dost used method of birth control 2N failure rate Jo side effects

Permanent although $N see) reversal which is successful in 2$612N $.$3=&& ris) of ectopic 2.$&&3&&& mortality rate Ora' Contra(e!tive Pi''s: MEC%: Pulsatile release of C-< and L< suppresses ovulation ,hange in cervical in cervical mucus ,hange in Endometrium #YPES: Donophasic # fi+ed dose of estrogen and progesterone Dultphasic varies progesterone dose each wee) and lower overall estrogen.prog Progesterone progestin only not as effective as combination M,Ps COMPL-CA#-ONS: Thromboembolism ( do not give in women with family history of 54T or PE!3 PE3 ,4A3 D/3 <TJ MEDS t)at De(rease Effi(a(y of OCPS: P,J3 tetracycline3 rifampin3 ibuprofen3 dilantin3 barbiturates3 sulfonamide OCP de(rease t)e effi(a(y of folates3anticoagulants3 insulin3 methyldopa3 phenothia*ine Benefits of OCP: 5ecrease ovarian.endometrial ca 9BY A;INNN=3 ectopic3 anemia3 pid3 cysts3 benign breast d*3 osteoporosis> #%E+AP.#-C AB '=N of pregnancies end in therapeutic ab His) of death U $.$&&3&&& (anesthesia! 4aginal evacuation # suction curettage3 5 Q ,.E /nduction of labor Dedical TR : o Antiprogestin agent (H:621A # mifepristone : bloc)s effects of progesterone! $st X of $st trimester> o Post coital pill # high doses of estrogen that either suppresses ovulation or accelerates ovum thru tube so no fertili*ation se: J.4 4nd #er* ,ongenital anomalies 4aginal prostaglandin 5QE /nduction of labor w. hypertonic solution (saline3 urea3 PGC3 PGE vaginal suppositories!