Introduction (Liantonio)

Introduction (Liantonio)

Screening

• PAP – annually upon onset of activity or age 18. Age ≥ 30 + 3 normal consecutive PAP, may screen q2-3 yrs.

• Age ≥ 40 mammography q2 yrs, breast exam q1 yr by professional, sigmoidoscopy q3-5 yrs

• GYN includes gynecology, urogynecology, pelvic reconstructive surgery, gynecologic oncology, reproductive-endocrinology infertility

Anatomy

• Fallopian Tubes: broad ligament, fimbriae, lining of ciliated smooth muscle, mucus-producing epithelial layer
• Fertilization occurs in middle to outer portion of fallopian tube
• Ovaries: fully developed 3rd mo fetal life – oogenesis begins 6th wk fetal life, ovaries present at birth

Obstetric Definitions

• Gravida: is or has been prego
• Primigravida: 1st preg
• Multigravida: has been preg ≥ 2x
• Nulligravida: never been preg

• Primipara: delivered > 20wks
• Multipara: delivered ≥ 2x

/

• Nullipara: never delivered (either never been preg or had past abortions)
• Parturient: actively in labor
• Puerpera: recently given birth < 3wks
• Spontaneous Abortion: ≤ 20wks
• Miscarriage: spontaneous abortion ≥ 20wks
• Infertility: failure > 1 yr
• DES – diethylstilbestrol, previously used for nausea but teratogenic – reproductive cancer in offspring

OB/GYN Physical Exam

• Height, weight, BP
• Breast exam
• Exam of ab, back, lymphatics
• Pelvic exam: vulva, clitoris, BUS, vagina, cervix, uterus, adnexa, rectovaginal
• Children, sexual abuse + assault, contraceptive Hx

Reproductive Cycle

• Phase I: Menstruation and follicular phase

• Phase 2: Ovulation

• Phase 3: Luteal Phase

• Pregranulosa cells -> granulose cells -> surround oocyte -> theca cells

• Theca Cells: secrete androgens – precursor to estradiol production by granulose cells

Hormonal Effects

Estradiol / Progesterone
Endometrium / Stimulates cell growth, thickens and reaches maximal thickness at ovulation / Converts proliferative endometrium to secretory endometrium
Endocervix / Thin, clear, watery cervical mucus / Thick, opaque, resistant to sperm capture
Breasts / Ductal elements of breasts, nipples, areolae / Stimulates acinar (milk producing glands)
Vagina / Vaginal thickening and maturation, facilitates lubrication for intercourse / Retention of epithelial thickness, diminished secretory changes

Perimenopause + Menopause

-Ovarian follicles diminish in number

-Less sensitive to FSH

-Ovulatory process becomes inefficient

-Menopause leads to total resistance to FSH

-Process of ovulation ceases entirely and cyclic hormone production ends

Diagnosis of Pregnancy (Beysolow)

• Other causes of amenorrhea include: emotional stress, chronic dz, endocrine disorders(hyper/hypothyroidism), malnutrition, excessive exercise, opiods, obesity, psychiatric disturb.

• Presumptive sx: amenorrhea, N/V(2-12 wks gestation), fatigue, mastodynia(breast tenderness)

• *Always R/O pregnancy in females w/ UTI*

• Skin changes:
• Chloasma- “mask of pregnancy” darkening of the skin over the forehead, nose, cheekbones(16wks

• Linea nigre- darkening of nipples and lower midline of abdomen due to incr. in melanocytes

• Stretch marks- caused by sep. of underlying collagen, adrenocorticoid response

• Spider telangectases- blanch when compressed due to high levels of estrogen

• Probable signs:
• Chadwick’s sign- congestion of pelvic vasculature; bluish/purplish discol. vagina and cervix

• Leukorrhea- incr. in vaginal discharge consist. of epithelial cells and cervical mucus

• Goodell’s sign- softening and cyanosis of cervix

• Ladin’s sign- softening of uterus in anterior midline along uterocervical junct. (6 wks gest.)

• Hegar’s sign- widening of the softened area of uteral isthmus

• McDonald’s sign- uterus becomes flexible at uterocervical junct.(7-8 wks gest.)

• Von Fernwald’s sign- irregular softening of fundus at site of implantation(4-5 wks gest.)

• Probable manif:
• Abd. enlargement(7-28th wk)
• Braxton-Hicks contr.(painless contr. disappears w/ exercise),
• uterine soufflé- auscultation of rushing sounds in area of uterus, synchronous to maternal pulse

• Positive manif: Fetal heart tones (10-12 wks), palp. of fetus, U/S, + HCG(will appear as early as 10 days)

• Pregnancy Testing
• Immunologic pregnancy testing- most are + 4-7 days after first missed period; cross reactive w/ LH, results can be altered by proteinuria, immunologic dz, menopause, and hypothyroidism

• Radioimmunoassay pregnancy testing- *sensitive and specific* can detect before missed period; does not cross react

• Radioreceptor assay pregnancy- highly sensitive and accurate; does cross react w/ LH

• Drugs that can cause false +: anticonvulsants, anti parkinsonism meds, hypnotics, and tranquilizers)

• Drugs that can cause false -: diuretics and promethazine

Prenatal Care/Prenatal H&P(Sanassi)

• *Nagele’s Rule: LMP + 9months + 7 days= estimated date of delivery*
• Previous pregnancy: G1P2345;
• 1= total preg.

• 2= full term;

• 3= preterm(<37wks)

• 4= abortions;

• 5=living

• Surgical Hx: Previous C-section may/may not be candidates for vaginal deliv. (horizontal-V-bac; vert. can’t

• 1st trimester: up to 12 wks
• Measure HCG- doubles every 2-3 days then levels off in 2nd and 3rd trimest.; low levels that slowly rise indicate ectopic pregnancy

• High levels of glucose- gestational diabetes; high levels of protein- UTI
• Cx: pre-eclampsia, macrosomia(large baby), pretermed labor

• Chorionic villus sampling(optional)
• May be done at 10-12 wks to analyze chromosomal disorders(Down), and metabolic(CF)

• 2nd trimester: 13-27 wks
• Urine screen for glucose and protein:

• Glucose Tolerance test

• Alfa-fetoprotein levels- 15-18 wks;

• high levels indicate NTD(spina bifida, anencephaly),

• low levels indicate trisomies(Edward’s syndrome- trisomy 18, Down’s- trisomy 21)

• Amniocentesis- optional 15-20 wks; chromosomal abnorm., metabolic dis., NTDs, and AFP levels

• 3rd trimester: 28 wks-delivery
• Urine screen for glucose and protein
• Pre-eclampsia(HTN + proteinuria); systolic >30 and diastolic >15 from baseline
• Sudden weight gain, vision changes; RF: African American, 1st preg., DM

• Eclampsia- pre-eclampsia + seizures

• Antibody screen (indirect antiglobulin test)
• Performed on pregnant women who are Rh-negative
• Given RhoGAM

• Fetal fibronectin(26-34 wks)
• Fluid released when “water breaks”
• Performed if pt. is having signs of premature labor during these weeks

• Group B strep- 35-37 wks (do before delivery) swab external canal and send for culture

• Subsequent visits: 0-32 wks(q 4wks); 32-36 wks(q2 wks); 36-deliv. (q wk)

• Leopold’s Maneuver:
• First maneuver- determine what fetal part is at uterine fundus; palpating upper pole
• Second maneuver- Assess which side is the spine and which is the extremities; palpating sides
• Third maneuver- assess fetal descent by palpating above the symphysis pubis
• Fourth maneuver- assessing for cephalic vs. breech pres. by putting downw. pressure on fundus
• Fundal Height: recorded at each visit after 20 wks; fundal ht. is roughly gestational age; 20 wks- at umbilic.

• Nutrition: average woman req. 2300kcal/day, an additional 300kcal/day needed in pregnancy
• Common concerns during pregnancy:
• Ptyalism- excessive salivation Tx; belladonna extract
• Pica- ingestion of substances that have no value as food
• STDs, Candidiasis, varicose veins; leg cramps Tx: incr. calcium intake w/o phosphorus, aluminum hydroxide; Acrodysesthesia(Hand discomfort) periodic numbness and tingling of fingers only!

Medical Disease Of Pregnancy(Podd)

Iron Deficiency Anemia

• *MC form of anemia in pregnancy* due to Hgb <10, hematocrit <30

• Often hx of Pica-eating dirt or clay

• MCV <80, MCHC <30; hypochromic microcytic anemia

• Tx: Ferrous sulfate or fumurate

Folate Deficiency Anemia

• 2nd MC due to: fetal demand and growth, phenytoin, nitrofurantoin, trimethoprim, methotrexate, alcohol
• Macrocytic anemia w/ hypersegmented neutrophils

• Tx: Oral folate Cx: NTDs

Vitamin B12 deficiency Anemia

• Rare in pregnancy usually due to malabsorption syndromes: Crohn’s dz, ulcerative colitis, parasitic infx.
• Macrocytic anemia; Serum B12 <70ng/ml

• Tx: IV Cyanocobalamin(Vitamin B12)

Sickle Cell Dz

• Hemoglobin SS: vaso-occlusive crises, uteroplacental insuffic., intrauterine growth restriction, preterm labor

• Dx: Hgb electrophoresis, reticulocyte count is increased

UTI

• Asx bacteruria is more likely to cause cystitis and pyelonephritis in pregnant then non pregnant
• Etiology: urinary stasis due to progesterone, SEEKS PP, *E.coli MCC*

• Tx: Cystitis: ampicillin, nitrofurantoin, sulfisoxazole; pyelonephritis: IV fluids + ampicillin or ceph
• Cx: Pyelonephritis: *MC serious medical complication of preg.* can cause preterm labor and sepsis

Pneumonia

• Etiology: Strep. Pneumo *MC*, H.flu, Klebsiella, atypical: Mycoplasma

• Dx: Basic metabolic panel, CXR, ABG, sputum gram stain and culture
• Tx: hospitalize all pregnant pts.; strep pneumo: Pen G; atypical: erythromycin

Asthma

• Tx: albuterol and *terbutaline-* used for pregnancy to hold contractions to delay premature labor

TB

• Active TB: INH and Rifampin x 9 months

Smoking during pregnancy

• Risks include decreased fertility, spontaneous abortion, ectopic pregnancy, decr. birth weight, preterm deliv., PROM, abruption placentae, SIDS, asthma, and resp. infx.

Hyperthyroidism

• Dx: decr. TSH, incr. T3 and T4
• Tx: PTU(propylthiouracil)DOC

Maternity Blues

• 1-5 days PP; duration 2-3 days; Sx: mild insomnia, tearfulness, fatigue, poor concent., leads to PPD

Diabetes Mellitus

• Etiology: human placental lactogen(HPL)- anti insulin, estrogen and progesterone, and insulinase

• Screening: 1 hr. Glucola(50gm glucose) load test done at weeks 24 -28; levels should be <126; if >140 perform oral glucose tolerance test

• OGTT: administration of 100gm load for 3 hours; fasting: 95; 1 hr: 180; 2hr: 155; 3 hr: 140; Dx is made if two or more hour marks are equal to or greater than the reference values

• Tx: NPH and regular insulin (recommended if fasting level >105 or 2 hr post-prandial glucose >120

• Cx: Maternal: DKA, pre-eclampsia and eclampsia; Fetal: hypoglycemia(incr. insulin at birth), shoulder dystocia and Erb’s palsy, neural tube anomalies

Superficial Thrombophlebitis

• *MC thromboembolic disorder in pregnancy*; Most occur w/in 72 hrs postpartum(3 days)
• Sx: erythema, tenderness, and *palpable veins*

• Tx: leg elevation, rest, analgesia

DVT

• Leading cause of morbidity during pregnancy, and leading cause of nonobstetric maternal mortality
• Dx: Doppler U/S, Homan sign-pain on dorsiflexion
• Tx: heparin, LMW heparin, coumadin(ONLY post partum)

PE (Pulmonary embolism)

• Sx: tachypnea, dyspnea, tachycardia, hemoptysis and chest pain

• Dx: pulmonary angiography(gold standard), spiral CT scan
• Tx: anticoagulants

Epilepsy

• Etiology: neurologic injury, brain lesion, idiopathic, and estrogen- exacerbates neuronal excitement

• Tx: carbamazepine- causes bone marrow suppression so you give Folate and Vitamin K

Post Partum Psychosis

• 2-3 days PP; sx include confusion, attention deficit, distractibility, clouded sensorium

• Tx: antidepressants

Postpartum depression(PPD)

• 2 wks-12 months PP; duration 3-14 months; Sx: irritability, diffic. falling asleep, phobias, anxiety, worsen in evening;

• Tx: antidepressants

Appendicitis

• *MC surgical emergency in pregnancy*

Cholelithiasis/Cholecystitis

• Caused by estrogen and progesterone increase which helps increase cholesterol and stone formation

• Dx: U/S
• TX: cholecystectomy in 1st and 2nd trimesters only; nasogastric suction, Abx for biliary colic

Pruritic Urticarial Papules and Plaques of Pregnancy(PUPPP)

• *MC pruritic dermatosis of pregnancy* more commonly occurs in primigravidas and 3rd trimester
• Sx: pruritic, erythematous papules or plaques in abdominal striae, may extend to trunk and extrem.; *Spares the periumbilical, palms, face, and soles*

• Tx: topical steroids- prednisone

Selected Cardiac Disease in Pregnancy(Podd)

Mitral Valve Prolapse- mid-systolic click;

• Tx: not needed, but can use beta blockers

Mitral Stenosis- Accentuated S1 w/ an opening snap; diastolic murmur heard at apex;

• Tx: beta blockers, diuretics

Rheumatic Heart Disease

• *MCC of acquired cardiac dz in pregnancy*; may affect any valve but most assoc. w/ mitral stenosis

• Cx: incr. risk of maternal thromboembolic dz, subacute bacterial endocarditis, CHF, A-fib, pulm. Edema

• *MC dysrrhythmia in pregnancy is paroxysmal atrial tachycardia* and A-fib is assoc. w/ mitral stenosis

Peripartum Cardiomyopathy(PPCM)

• Etiology: Viral myocarditis
• Occurs either last month of pregnancy or w/in first six months postpartum

• Dx: Echo- cardiomegaly, and decr. Ejection fraction (picture of a dilated cardiomyopathy)
• Tx: Bed rest, digoxin, diuretics, anticoagulation

Marfan’s Syndrome

• inherited autosomal dominant trait resulting in connective tissue abnorm. (fibrolyn 1)

• Manif: aortic aneurysm, long extremities, ectopia lentis(dislocation of lens), dyspnea, chest pain, aortic regurg, mitral prolapse, and pectus excavatum(caved in chest)

Fetal Medicine/Monitoring(Leshinsky)

• Ultrasound can determine gestational age based on abdominal circumference, head circumference, biparietal diameter, femur length, and crown to rump length(1st trimester), all of the fetus

• External fetal monitoring- use of U/S and gel to detect fetal heart rates and tones

• Internal fetal monitoring- use of intrauterine devices to detect fetal heart rates and tones

• Baseline fetal HR: 110-160; baseline variability: *6-10 is perfect*; 5 or less indicates premi; moderate 6-25; marked >25 indicates asphyxia; absent signifies hypoxia; check it for 10 min then divide by 10.

• Accelerations: seen w/ fetal movement or stimulation; ≥ 15 bts/min above baseline lasting ≥ 15s

• Early decelerations: decr. in response to contractions, duration is length of contraction; should not go< 100

• Variable decelerations: rapid decr. in fetal HR not assoc. w/ contractions, w/ incr. baseline; due to umbilical cord compression and serious if FHR goes <70 and stays for >1 min

• Late decelerations: gradual onset of decreased FHR and gradual return to norm. Onset starts later than beginning of contraction. Return to normal after completion of contraction. Late mirror image due to uteral placental insufficiency

• Tx of non-reassuring fetal monitoring: Incr. fetal oxygenation by- O2 admin, decr. uterine contractions, correcting maternal hypotension; Delivery

• Biophysical profile (5 parameters, 2 points each)
• NST reactivity- accelerations; Extremity tone; chest wall mvmts; gross body mvmts.; amniotic fluid
• Gross body movements- 3 mvmts in arm, leg, or body in 1 min.
• 8-10 is reassuring, 4-6 should deliver if >36 wks or repeat in 24 hrs, 0-2 fetal jeopardy

Complications in Pregnancy (Leshinsky)

Most pregnancy losses occur in first 13 wks of pregnancy

Spontaneous Abortion

• Typically prior to 20 wks; ovum becomes detached from uterine wall leading it to be sloughed
• Risks: incr. parity, and >35 years of age
• Etiology: monosomy, trisomy; maternal factors- herpes, rubella, fibroids, progest. defic., smoking

1. Threatened abortion: bleeding w/o loss of fetus
2. Sx: bleeding(brown/bright red), possible uterine contractions, pain is not severe, *cervix is closed and not effaced*

• Tx: call if sx continue, follow HCG levels

1. Missed abortion:
2. Retention of a failed intrauterine pregnancy due to hormone problems
3. Sx: loss of pregnancy sx, decr. uterine size, possible brown vaginal discharge(not seen), cervix is closed and not effaced

• Dx: Beta HCG (decr)
• Tx: 1st trim: suction curettage, 2nd trim: dilate+ evacuate, prostaglandin

1. Inevitable abortion:
2. Rupture of membranes and/or *cervical dilation during first half of pregnancy*
3. Sx: effacement of cervix, cervical dilation, ROM, vaginal bleeding/cramps

• Tx: dilate and evacuate, RhoGAM if Rh + fetus

1. Incomplete abortion:
2. Gestational sac becomes deflated causing partial expulsion of pregnancy tissue
3. Sx: passage of products of conception, continuous bleeding, dilated os, *boggy uterus*

• Tx: dilate and evacuate, RhoGAM

1. Complete Abortion:
2. Documented pregnancy that spontaneously passes ALL products of conception
3. Sx: passage of all products of conception, uterus is small for gestat. age and nontender

1. Septic Abortion:
2. Abortion in the presence of endometritis due to products of conception
3. Sx: *severe abd. pain*, fever, uterine tenderness, *brown/bloody foul smelling discharge*

• Dx: CBC- leukocytosis, cultures
• Tx: broad spectrum Abx (IV), D+E

1. Recurrent Abortion: two or more consecutive abortions or total of 3;
2. Tx: cerclage- tie cervix shut

1. Blighted Ovum: no embryo in the sac
2. Usually occurs in 1st trimester before woman knows she is pregnant; placenta grows w/o embryo

Hydratidiform Mole/Molar Pregnancy

• Benign gestational trophoblastic dz;
• abnormal proliferation of placenta and trophoblast w/o embryo

• Complete Molar Pregnancy: *MC*
• Dispermic fertilization of an anuclear ovum resulting in paternally derived normal 46XX
• Dx: U/S- grape like vesicles w/o fetus (assoc. w/ malignancy)

• Incomplete Molar Pregnancy:
• Dispermic fertilization of a normal ovum resulting in *69XXY*
• Focal trophoblastic prolif. and degeneration of placenta
• Dx: U/S- no vesicles, *fetus visualized* however grossly abnormal; HCG elevated

• Sx: bleeding <16 wks, preeclampsia, N/V, proteinuria
• PE: cervix dilated, pass tissue of trophoblast as vesicles, absent fetal heart tones, *painless vag. bleeding*

• Dx: U/S- snow storm appearance indicates malignancy

• Tx: Suction dilate and curettage w/ oxytocin, contraception(make sure pt. is NOT pregnant), methotrexate or Actinomycin D for rising HCG levels

Ectopic Pregnancy

• *Leading cause of pregnancy death*; implantation of fertilized ovum outside uterine cavity
• RF: intratubal adhesions, intrauterine contraception, in vitro fertilization
• Sx: triad of amenorrhea, vaginal bleeding, and abdominal pain; if it ruptures can cause hypotension, tachycar

• Dx: plateau of HCG(slowly rise), culdocentesis- non clotting blood, surgical laparoscopy- to identify loc.
• Tx: methotrexate(if <4cm) and HCG titers( if >5000 surgery); laparoscopy, salpingostomy, salpingectomy

Incompetent Cervix

• Premature cervical dilation in 2nd trimester
• Etiology: previous procedure such as colposcopy; or trauma
• Sx: recurrent 2nd trimester loss, expulsion of normal sac and fetus b/wn 18-32 wks, *no pain or bleeding*

• PE: dilation of cervix, bulging of membranes, visualization of fetal tissue
• Dx: HCG is consistent, cervical funneling, shortened cervix leading to effacement
• Tx: Trendelenburg position to reduce bulging; cerclage of cervix till ready to give birth

Hyperemesis Gravidarum

• Etiology: incr. HCG hormone
• Sx: severe N/V, weight loss, dehydration, acidosis from starvation, metabolic alkalosis(vomiting)

• Tx: IV fluids, antiemetics

Rh Incompatibility/Erythroblastosis Fetalis

• Sx: fetal hemolysis and erythropoiesis leading to further hemolysis, fetal anemia, fetal hepatosplenomegaly and ascites, fetal heart failure, fetal icterus, hydrops fetalis- ascites w/ anasarca

• Dx: maternal blood Rh type, fetal blood type, Kleihauer-Betke test- detects fetal RBC in mat. Circulation
• Tx: RhoGAM at 28 weeks gestation and w/in 72 hrs post delivery

Pre-eclampsia

• Can lead to DIC; due to incr. prod. of thromboxane and decr. prod. of prostacyclin
• Sx: systolic ≥ 140 or diastolic ≥90 or rise in diastolic of 15mm Hg or systolic 30mmHg from baseline, proteinuria, pitting edema, weight gain;

• Severe: >160/110 or any of the following: proteinuria, oliguria, HA, pulmonary edema, elevated LFT
• Tx: severe: methyldopa and labetalol, beta blockers and diuretics 2nd line; ACE is CI in 2nd and 3rd trimesters; otherwise managed w/ hydralazine and labetalol

Eclampsia

• Etiology: cerebral vasospasm, ischemia, edema, hypertensive encephalopathy
• Sx: seizure(tonic clonic) + pre-eclampsia sx

• Tx: ICU w/ MgSO4

Multiple Gestations (2 or more fetuses)

• Types of Twining
• Dizygotic- two separate ova; placentation is diamniotic and dichorionic (2 separate sacs)

• Monozygotic- single ovum splits; diamniotic and dichorionic placenta or monoamniotic

• Cx: twin-twin transfusion- 1 is receiving nutrition while other isn’t, intrauterine growth retardation, vanishing twin- 1 gets reabsorbed

• Management: C section best course of action if monoamniotic and monochorionic or breech

Post-term pregnancy

• Can lead to macrosomia due to placental fx remaining, dysmaturity syndrome due to placental aging

• Appearance of newborn would be long, thin, desquamation of skin, meconium staining

• Management: if dates certain and cervix favorable induce labor; if otherwise C-section

Labor and Delivery (Leshinsky)

True labor: products of conception expelled from uterus; uterine contractions lead to effacement and dilation; pain in the abdomen radiating to lower back, increased intensity of contractions w/ shorter intervals b/wn contractions

Evaluation for Labor: advise pt. to come to hospital if:

• contractions five minutes apart for at least 1 hr
• ROM, any bleeding, decrease in fetal movements

Vaginal Exam: