OBGYN Objectives / Module Notes

Updated Objectives 2020

Info is based off of:

- Module links (youtube APGO videos and ACOG Articles)
- VCOM OBGYN Powerpoints linked in the objectives (and posted on the VCOM website)
- Textbook referenced in Syllabus (Beckmann OBGYN)
- UpToDate when all other sources fail

BOLD headings = Objective topics

GREEN highlights = topic is featured in the Module

MODULE 1: Labor & Delivery

APGO Educational Videos:
- Uterine Atony
- Uterine arterioles run through uterus to give blood flow, and after delivery the uterus should contract to
close them off and prevent hemorrhage
- Higher Risk for hemorrhage:
- Low-lying placenta (bc less smooth muscle at the lower part of uterus to contract and close off
arterioles)
- Uterine Atony
- Magnesium (blocks calcium channels >> Ca can’t activate muscle contraction)
- Causes of Atony:
- Uterine Overdistension (interferes with contraction)
- By fetal macrosomia, multiple fetuses, polyhydramnios, distension with blood clots
- Anesthesia
- (causes hypotension >> decreased oxytocin >> decreased contraction)
- Exhausted Myometrium
- By rapid labor, prolonged labor with oxytocin stimulation, chorioamnionitis
- Tx
- Uterine Massage
- Evacuates clots and augments uterine contraction
- Uterine artery ligation
- B-Lynch Stitch over the uterus like suspenders
- Bakri Balloon (inside uterus to give counterpressure against uterine wall)
- Uterotonics
- Oxytocin (Pitocin)
- Released by posterior pituitary
- Given IV (immediate effect) or IM (3-7 minutes to effect)
- Methylergonovine (Methergine)
- 5-HT2 agonist in uterine smooth muscle
- IM (2-5 minutes) or oral (5-10 minutes to effect)
- AE = hypertension (bc causes vasoconstriction; don’t use in hypertensive patients)
- Carboprost (Hemobate)
- Increases free Ca++ >> augments uterine contraction
- AE = diarrhea, bronchospasms (don’t give to asthmatics)
- Misoprostol (Cytotec)
- Physiology of Labor
1. Quiescence (from conception to initiation of parturition)
- Uterine muscle relaxes
 - Mediated by Progesterone
- (giving woman weekly Progesterone injections reduces risk preterm labor)
2. Activation (from start of parturition to onset of labor)
- Cervical softening + uterus preps for labor
- Mediated by Estrogen, Progesterone, Uterine stretch
3. Stimulation (from onset of labor to delivery)
- Uterine Contraction + Cervical dilation + fetal / placental expulsion
- Mediated by Prostaglandins, Oxytocin, Relaxin
4. Involution (delivery to restoration of fertility)
- Uterine involution + cervical repair + breastfeeding
- Mediated by Oxytocin (stimulates uterus to contract back and prevent hemorrhage)

Module Notes:
- Articles:
- Azithromycin Prophylaxis in C-sections reduce the risk of post-op infections
- More effective than placebos
- Prevention of GBS early-onset in Neonates
- Screen all women for GBS at 36-38 weeks
- Give all GBS+ women at 36-38 weeks prophylactic antibiotics
- IV intrapartum PCN prophylaxis works the best (not oral or IM)
- Or IV Ampicillin
- PCN allergy >> 1st Gen Cephalosporins (Cefazolin)
- But best to verify via allergy screening and give PCN if possible
- High risk anaphylaxis >> Clindamycin
- IV Vanco if GBS isolate is not susceptible to Clindamycin
- Bloody Show = thick vaginal discharge of mucus and blood from the cervix, caused by rupture of small blood
vessels in the cervix as it effaces and dilates
- Normal part of pregnancy

Intrapartum Fetal Surveillance

- Basic EFM Patterns using Systemic Approach
- Fetal HR (FHR) measured by
- Doppler / Toco externally (measures frequency)
- or Fetal Scalp Electrode / IUPC internally (measures frequency + strength)
- Fetal Heart Monitory (FHT)
- systematically comments on the following in order:
- Baseline
- Variability (absent, minimal, moderate, marked)
- Presence of Accelerations
- Presence of Decelerations (Variable, Early, Late)
- Contraction Frequency
- “Reactive” means:
- ≥ 2 accelerations within 20 minutes
- + moderate variability
- + No decelerations
- Variability = fluctuations in FHR of 2 cycles / minute or more
- Amplitude of peak-to-trough in bpm
- Absent = no amplitude range
- Minimal (DECREASED) = < 5 bpm amplitude
- Causes = hypoxemia, acidosis, sleep cycles, drugs, prematurity, arrhythmias, fetal
tachycardia, etc
- Moderate (NORMAL) = 6-25 bpm amplitude
- Marked (INCREASED) = > 25 bpm amplitude
 - Causes = fetal stimulation, transient hypoxemia, sympathomimetic drugs
- Acceleration = abrupt increase in FHR from most recently calculated baseline (onset to peak in < 30s)
- Duration of accel = time from initial change in FHR from baseline to return to baseline
- < 32 weeks: acme (peak) of 10+ bpm above basline with duration 10 seconds - 2 minutes
- > 32 weeks: acme 15+ bpm above baseline for 15 seconds - 2 minutes
- Prolonged Acceleration = lasts 2 - 10 minutes (> 10 minutes = baseline change)
- Variable Deceleration = abrupt decrease in FHR ≥ 15 bpm, lasting 15 seconds - 2 minutes
- that takes < 30 seconds from onset of decel to nadir (lowest point)
- Causes
- Cord compression
- Rapid vagal stimulation (like head compression)
- Cord prolapse (if immediately after rupture of membranes)
- Hypoxemia / Acidosis (if associated with diminished or absent FHR variability)
- Prolonged Deceleration = lasts 2 - 10 minutes
- (can be bad...need immediate response)
- By cord compression, maternal hypotension / hypoxemia, head compression, amniotic fluid
embolism
- Early Deceleration = gradual decrease in FHR with onset to nadir ≥ 30 seconds, and Nadir matches the
peak of the contraction
- Good finding; no response needed
- Causes = head compression, vasovagal response
- Never hypoxemia/acidosis
- Late Deceleration = gradual decrease with onset to nadir ≥ 30 seconds, and nadir is after the peak of the
contraction
- Not reassuring
- Causes = uteroplacental insufficiency (UPI), decreased uterine perfusion / tone, decreased
placental function, maternal hypotension / hypertension, IUGR, maternal diabetes, tobacco
use
- Tachycardia = > 160 bpm
- By maternal fever, fetal hypoxemia, sepsis, chorioamnionitis, fetal anemia, hydrops, maternal
hyperthyroidism, drugs
- Bradycardia = < 110 bpm
- If < 90 bpm, need prompt investigation + resolution or delivery
- Hypoxemia, maternal hypotension / hypoglycemia, cord compression, amniotic fluid embolism,
hypothermia, congenital heart block
- Sinusoidal Pattern = regular, smooth, undulating, sine-like wave in FHR baseline with frequency of 3-5 cycles /
minute persisting ≥ 20 minutes
- By severe fetal anemia, Rh isoimmunization, hemolytic disease, acute blood loss, fetal
hypoxemia/acidosis, maternal narcotic use
- Pseudosinusoidal Pattern = transient, less uniform, and not associated with adverse outcomes
- Contraction Frequency = # contractions in 10 minutes, averaged over 30 minutes
- Normal: ≤ 5 contractions in 10 minutes (averaged over 30 minutes)
- Montevideo Units (MVU) = total intensity of each contraction in a 10 minute period
- MVU > 200 is adequate for most labors to progress

- Standardized Terminology to appropriately document patterns

- Management of EFM Patterns
 - NICHD Categories of FHR Tracings
- Category 1 = NORMAL acid-base status (no intervention required)
- Baseline normal (110-160)
- Variability Moderate
- +/- accelerations
- NO late/variable decelerations (early are ok)
- Category 2 = INDETERMINATE (>> surveillance and reevaluation)
- Include:
- Baseline: bradycardia or tachycardia
- Variability: minimal, absent, marked
- Accelerations: absent after fetal stimulation
- Decelerations: variable, prolonged
- Category 3 = ABNORMAL acid-base status (>> prompt evaluation / intervention)
- Include:
- Absent variability + any of:
- late decelerations
- recurrent variable decelerations
- Bradycardia
- Sinusoidal pattern

Intrapartum Care
- True v. False Labor Signs / Symptoms
 - True Labor = painful uterine contractions + cervical dilation
- Braxton Hicks contractions = painful contractions felt, but no cervical dilation (false labor)
- When to see OB for evaluation of contractions:
- Leakage of fluid
- Vaginal bleeding
- Painful contractions every 5 minutes for 1 hour
- Decrease in fetal movements
- Pain Management Approaches during Labor
- Stage 1: pain from contraction of uterus / cervix dilation (visceral pain from T10 - L1)
- Stage 2: pain from fetal head descending to lower birth canal and peritoneum (somatic pain from
S2-4)
- Epidural Block
- infusion of anesthetic into epidural space
- Benefits = covers labor AND delivery; maintain sense of touch / motor ability for participation
in labor
- Risk = post-dural puncture headache
- Spinal Block = single injection of local anesthetic (lasts 2 hours)
- Benefit = limited duration for C-section / rapidly-progressing vaginal deliveries
- Risk = postdural puncture headache
- Local Block = local injection into perineum or vagina
- Benefit = enough for episiotomy or laceration repair
- General Anesthesia = inhaled / IV anesthetic >> maternal loss of consciousness
- Only for emergency C-sections
- Risk = maternal aspirations, Neonatal depression
- IV Narcotics (Opioids and Opioid agonists)
- But are systemic, so pain relief is via sedation in this method
- Initial Assessment of Laboring Patient
- Fetal Heart Tones (by EFM or intermittent auscultation)
- Presentation (vertex or breech)
- By abdominal US or exam
- Sterile Vaginal Exam
- For dilation, effacement, and station
- Dilation = opening of internal os of cervix
- Complete dilation = 10 cm
- Effacement = distance between internal and external os
- Non-effaced = about 4 cm thick
- 50% effaced = 2 cm
- Completely effaced = 0 cm thick
- Station = fetal presenting part in relation to ischial spine
- 0 station = presenting at level of ischial spines
- +1, +2, +3 station = 1, 2, 3 cm below ischial spine (to +5)
- -1, -2 station = still 1, 2 cm above ischial spine
- External Tocometer (to assess uterine activity)
- 4 Stages of Labor + Steps of Vaginal Delivery
- Stage 1 = Cervical Dilation (onset to 10 cm)
- Latent Phase = from cervical dilation to 4 cm dilated
- Active Phase = from 4 cm dilation to more rapid dilation (1.2-1.5 cm/hr)
- Walking more comfortable than supine
- Decreased GI motility (so limit solid food intake or else >> nausea/vomiting)
- Mom may feel urge to push when the fetal had descends to put pressure on the
perineum, but don’t push until the cervix is completely dilated
- Stage 2 = Complete Dilation to Delivery of infant
- Pushing can begin, at onset of each contraction
 - First delivery, may push for 2-3 hours
- Shorter if laboring without an epidural
- Shorter on subsequent vaginal deliveries
- If low-risk, mom can rest 1-2 hours if she doesn’t yet feel the urge to push
- Delivery
- imminent when half-dollar sized vertex is visible in between pushes
- Steps:
- Ritgen Maneuver = support perineum with one hand and vertex of head with
other hand
- and facilitate extension of the head
- Restitution (head realigns with shoulders)
- Delivery of anterior shoulder then posterior shoulder
- Skin to skin contact with baby on maternal chest
- Stage 3 = Delivery to Placental Delivery
- Active Management Immediately Postpartum:
- Fundal Massage
- Gentle Cord Traction (avoid inversion of the uterus)
- IV / IM Oxytocin
- Placenta Delivery
- can take up to 30 minutes (can wait for uterus to spontaneously expel placenta)
- 2 signs of placenta separating from uterus:
- Gush of Blood
- Lengthening of Umbilical Cord
- Stage 4 = first 2 hours after delivery of placenta
- Palpate uterus to make sure it’s firm/contracted
- Uterine Massage, Oxytotic agents prn
- Examine Placenta to make sure it’s intact and completely removed
- Inspect Birth Canal
- Repair Lacerations with absorbable sutures
- Monitor amount of blood loss via perineal pads, BP, pulse
- Operative Delivery
- = forceps or vacuum retraction
- Indications
- Prolonged / arrested Stage 2 (complete dilation until delivery)
- Suspicion of immediate or potential fetal compromise
- Shortening of Stage 2 for maternal benefit
- Contraindications
- < 34 weeks (risk fetal hemorrhage)
- Fetal bone demineralization condition (osteogenesis imperfecta)
- Bleeding disorder (hemophilia, vWD, thrombocytopenia)
- Fetal head unengaged or in unknown position
- Common Complications
- Maternal Deaths
- 99% maternal deaths occur in developing countries
- Highest risk = adolescent girls
- Major Complications (accounting for 75% maternal death)
- Bleeding
- Infection
- High BP
- Delivery Complications
- Unsafe abortion
- Lacerations
Complications of Pregnancy
- (I) Abnormal Labor
- Causes / Methods of evaluating abnormal labor patterns
- External Tocometer (tells frequency of contractions)
- IUPC (tells frequency + Strength of contractions)
- Fetal Heart Tones
- Montevideo Unit (MVU) = amplitudes above the baseline added together for 10 minutes
- Normal = MVU > 200
- Normal Labor requires:
- Power of regular uterine contractions (to dilate cervix and push fetus down)
- Progression of Labor
- Nulliparous women: > 1.2 cm / hour in active labor
- Multiparous woman: > 1.5 cm / hour in active labor
- Passenger (fetus)
- Not too big
- Good position (so can fit through pelvis)
- Palpate Anterior fontanelle (diamond shape) and Posterior fontanelle (triangular
shape) + sagittal suture
- Occiput Anterior (best position bc smallest part of head coming through first)
- Posterior fontanelle (triangle) palpated at anterior of mom’s body
- Passage (nothing obstructing the birth canal)
- Abnormal Labor Patterns
- Protraction Disorder (slow labor)
- Stage 1 slow (cervix not dilating)
- Nulliparous > 20 hours
- Or rate < 1 cm/hour
- Multiparous > 14 hours
- Rate < 1.2-1.5 cm / hour
- Management:
- Observation or Sedation
- Stage 2 slow (pushing too long)
- > 3 hours with regional anesthetic
- > 2 hours without regional anesthetic (or descending rate < 1 cm/hour)
- Mx:
- Observation, Amniotomy, Oxytocin, augmentation
- C-section if maternal or fetal status becomes nonreassuring
- Arrest Disorder (halted labor)
- Stage 1: no dilation for > 2 hours (or 4 hours with regional anesthetic)
- Stage 2: no descend after 1 hour of pushing

- Failure to Progress = arrest of dilation

- Nulliparous woman < 1.2 cm / hour; or multiparous < 1.5 cm / hour
- Augmentation = stimulation of uterine contractions
- Amniotomy = rupture of amniotic membranes
- Can >> prostaglandin release to help contractions
- Oxytocin
- But titrate so you don’t cause uterine tachysystole
- Arrest of Descent
- Fetal size > 4500 grams
- >> greater risk shoulder dystocia / labor dystocia
- Suboptimal Presentations
- Occiput Transverse = (baby’s head sideways)
- occiput on one side and anterior fontanelle on opposite side
- Occiput Posterior
- Face presentation
- Compound presentation
- Cephalopelvic Disproportion (baby’s head not proportionate to mother’s pelvic size)
- Uterine Tachysystole = 5 contractions / 10 minutes for 30 minutes
- Shoulder Dystocia = Baby’s shoulder caught behind pubic symphysis
- Have 5 minutes to deliver well-oxygenated term infant
- Risk = brachial plexus injury
- Turtle Sign = baby’s head comes out then goes back in (bc shoulders stuck)
- Emergent Management:
- McRoberts Maneuver = hyperflexion + abduction of hips
- Suprapubic pressure downward on anterior shoulder
 - Try to deliver posterior arm of fetus
- Episiotomy to open up space posteriorly
- Woodscrew/Rubin maneuver = rotation of fetus to reduce the shoulder
- Move patient to hands/knees
- Last ditch effort:
- Intentional clavicular fracture
- Zavenelli Procedure = push head back in and go to C-section
- Cord Prolapse (umbilical cord prolapsed through the cervix)
- Causes:
- Fetus is not vertex
- SROM or AROM before vertex is well engaged
- SROM = spontaneous rupture of membranes
- AROM = artificial rupture of membranes
- Risk = compression of blood vessels in the cord
- Emergent Management
- Push baby’s head back up, and reduce the cord back into the cavity
- Then go to immediate C-Section
- Leave hand in place on baby’s head with cord inside until immediate C-section
delivery
- Breech Delivery (feet first)
- Three kinds
- Frank = feet near the head
- Complete = legs crossed
- Incomplete = one or both feet are extended

- Emergent Management
- C-Section preferred if available
- Breech Extraction
- Physician reaches hand into uterus and grabs lower extremities of fetus to
gently deliver breech infant

- Avoid traction on fetus (don’t pull the baby out...let mom push it out)
- to avoid fetal head extension, which can make delivery more difficult
- Suprapubic pressure (once baby is delivered to level below umbilicus)
- External Cephalic Version = put pressure on mom’s abdomen to turn the fetus into vertex
presentation (50% success rate)
- Best after 36 weeks gestation (bc spontaneous vertex presentation usually happens
by 36 weeks, and also after 36 weeks they’re less likely to revert back to breech)
 - Trial of Labor after Cesarean Delivery (TOLAC)
- Possible Outcomes:
1. Successful TOLAC / VBAC (vaginal birth after cesarean)
2. Scheduled repeat C-Section
3. Failed TOLAC >> end up having to do C-section
- Highest morbidity, bleeding, infection
- Risks
- Uterine rupture (up to 10% risk with hx of classical C-section)
- Difficult labor without assurance of vaginal delivery
- Benefits
- Avoid surgery (less infection, shorter recovery periods)
- Decrease future abnormal placental risks
- Rates of Success:
- Higher rate of success with:
- Prior vaginal birth
- Spontaneous labor
- Higher Failure risk:
- Higher maternal age
- Non-white ethnicity
- Obesity
- Recurrent indication for initial C-section
- higher birth weight
- Gestational age > 40 weeks
- Preeclampsia
- Shorter inter-pregnancy interval
- Complications of Abnormal Labor
- Oxytocin Administration
- For stimulation of uterine contractions
- And post-delivery to prevent uterine atony
- (O) Obstetric Procedures (Indications + Complications)
- Premature Rupture of Membranes = rupture of membranes before onset of labor
- Tests for Rupture of Membranes
- Nitrazine Test = drop of vaginal fluid onto paper strips of Nitrazine dye
- Uses pH to distinguish urine from vaginal secretions
- Amniotic fluid = alkaline (pH > 7.1)
- Will turn dark blue on paper
- Vaginal secretions and Urine = acidic (pH < 6)
- Fern Test = amniotic fluid dries on a slide and causes a fern pattern (due to NaCl in the fluid)
 - Ultrasound = if there is less fluid than expected around the fetus, then PROM is possible
- If there’s lots of fluid left, may question if membranes have ruptured
- Dye Injected into Amniotic Sac
- If ROM, then dye will be seen in the vagina within 30 minutes
- Induction / Augmentation of labor
- Indications
- Elective Induction (39+ weeks)
- Postterm pregnancy
- CVD, chronic HTN, Diabetes, Eclampsia, Pre-eclampsia
- Hepatic / Pulmonary / Renal diseaseAsx HIV infection, coagulopathy
- Abnormal FHR, fetal abnormality, fetal growth restriction
- Multiple gestation, Oligohydramnios, Polyhydramnios, PROM, Placental abruption
- Intra-amniotic infection (IAI, chorioamnionitis)
- Poor reproductive history, Prior delivery of stillborn
- Intrauterine death
- Methods:
- Oxytocin
- Cervical Ripening:
- Misoprostol or Prostaglandin E2
- Mechanical dilation using Laminara
- “Sweeping” the amniotic membrane
- Risk of infection, accidental ROM, or bleeding from undiagnosed placenta previa
- Artificial ROM
- Cesarean Delivery
- Prophylactic Antibiotics before C-section
- Cefazolin single dose 60 minutes before skin incision
- Or Azithromycin 500 mg IV if in labor or with ruptured membranes
- Leopold’s Maneuvers
 - Epidural / Spinal Anesthesia Placement
- Below L2 (to avoid damaging the SC)
- Vaginal Birth after Cesarean Section
- Spontaneous Vaginal Delivery
- Ultrasound
- Chorionic Villous Sampling / Amniocentesis
- Episiotomy
- Forceps Delivery
- Newborn Circumcision

MODULE 2: Postpartum Care, Fetal Death, Trophoblastic Disease

Module Articles:
- Postpartum Hemorrhage
- ACOG:
- Uterotonic Agents = first line for PPH caused by uterine atony
- Lancet:
- Tranexamic Acid administration in PPH reduces deaths due to bleeding with no adverse effects or
complications

Postpartum Care
- Normal Postpartum Physiology / Care
- Maternal Physiologic Changes of Postpartum Period
- Uterus Contracts down
- To Pelvis in 2 weeks
- Normal size in 6 weeks
- Afterbirth pains (hypertonic uterine contractions in first 3 days)
- Lochia = bloody vaginal discharge, bright red and gets lighter/clearer over 10 days
 - Lochia Rubra = menses-like blood (few days)
- Lochia Serosa = more watery-like discharge (few weeks)
- Lochia Alba = yellowish-white discharge (6-8 weeks)
- Vaginal / Vulva soreness
- OTC analgesia
- Pelvic Floor weakness (will improve but may never reach pre-pregnancy state)
- Kegel exercises
- Increased urinary output (due to increased blood flow to the kidneys)
- Normalizes in 2-3 weeks
- Weight Loss
- Immediate 12-15 lbs
- Non-pregnant weight in 6 months
- Menses returns
- in 6-8 weeks if not breastfeeding
- 2-18 months if breastfeeding
- Coagulation
- Pregnancy is procoagulant >> increased risk VTE
- Back to normal in 6-8 weeks
- Normal Postpartum Care
- Monitor: BP, uterine tone (bleeding), urine output (involuntary retention)
- Encourage ambulation (reduce DVT / PE risk)
- Perineal pain (ice packs, sitz baths)
- Breastfeeding support
- Discharge from Hospital:
- 48 hours post-vaginal delivery
- 72 hours post-Cesarean
- Postpartum Patient Counseling
- Breast v. Bottle
- Encourage breast as much as possible for at least 6 months
- Bladder
- Urinary retention
- All women should urinate within 6 hours of delivery or 6 hours of catheter removal
- Urinary incontinence also common
- Bowel: offer stool softeners (especially with lacerations)
- Bleeding / discharge expectations
- “Bottom” (Perineal pain / irritation)
- Blues (postpartum depression history, warning signs)
- Birth Control
- Expect mood changes
- Immunizations
- RhoGAM for Rh- women
- Rubella, Tetanus, Measles, HepB
- Follow up with OB in 6 weeks (physical exam + pap smear)
- Postpartum Contraception
- A new mom CAN get pregnant before she has her first period
- Lactational Amenorrhea < 6 months postpartum if breastfeeding exclusively
- Failure rate 2-5%
- Hormonal Contraception
- Estrogen + Progesterone (ok once milk supply has been established)
- May begin progesterone only at 6 weeks postpartum
- Nexplanon
- Progesterone IUD
- Sterilization (bilateral tubal ligation)
- Postpartum Hemorrhage
- Definition:
- Vaginal > 500 cc
- Cesarean > 1000 cc
- Early v. Late
- Early/Primary PPH within first 24 hours
- By uterine atony, retained placenta, placenta accreta, defective coagulation, uterine
inversion, lacerations
- Late/Secondary PPH 24 hours to 6 weeks
- By retained products of conception, infection, inherited coagulation defects, subinvolution of
placenta site
- Risk Factors
- Polyhydramnios / Multiple gestations
- Prolonged labor / Oxytocin augmentation
- Fast labor
- Chorioamnionitis
- Hx of PPH
- Asian / Hispanic ethnicity
- Causes (4 T’s)
- Uterine Atony (90%)
- Risk Factors
- Fast OR prolonged labor
- Oxytocin induction or augmentation
- Magnesium sulfate prophylaxis
- Chorioamnionitis
- multiple gestation, polyhydramnios, macrosomia, myomas
- Presentation
- SOFT/BOGGY uterus on exam
- Tx:
- Oxytocin + Fundal Massage + Gentle cord traction
- Uterotonics prn (Methergine, Oxytocin, Prostaglandins)
- Bakri balloon, Uterine packing
- Surgery / Hysterectomy (last resort)
- Lacerations (6%)
- Risk Factors:
- Foreceps / vacuum delivery
- Macrosomia
- fast labor/delivery
- Breech
- Retained Placenta (3%)
- RF: placental abnormality (succenturiate, accreta, increta, percreta)
- Risk for accreta: prior Cesarean
 - Examine placenta for completeness after delivery
- Remove what’s left digitally

- Coagulation defects
- ITP, TTP, vWF, Hemophilia, HELLP Syndrome, DIC
- Exam: note if blood is clotting, blood oozing from IV punctures, skin wounds / bruising
- Dx:
- CBC, Blood type + cross match, Clot observation test (blood should clot in tube within
8-10 minutes)
- Coag studies (platelets, PT/INR, PTT, Fibrinogen, D-dimer)
- Tx:
- Monitor volume, coag status, replace blood components
- Recombinant Factor VIIa, Clot-promoting drugs
- Uterine Inversion
- PPH + can’t feel uterus (bc it’s involuted)
- Mx = bimanual reduction of uterus
- +/- tocolytics, surgery
- Immediate Management
- Active Management after Delivery
- Fundal massage
- IV / IM Oxytocin
- Gentle Traction on Cord
- Bimanual compression
- Methergine, Prostaglandins
- Intrauterine packing
- Bakri Tamponade Balloon Catheter (puts pressure in inside of uterus)
- Surgical (last resort)
- Uterine / hypogastric artery ligation
- Uterine compression sutures
- Hysterectomy
- Inspection for Lacerations
- And suture / repair
- Coagulopathy management
- FFP + platelets + packed RBCs in 1:1:1 ratio
- rFVIIa
- Sheehan Syndrome (ischemic pituitary necrosis due to severe postpartum hemorrhage)
- >> failure to breastfeed, failure to return to menses
- Postpartum Depression
- Edinburgh Postnatal Depression Scale
- Score > 10 suggests depression may be present
- Postpartum Blues (40-80%)
- Transient symptoms peaking in first 5 days, resolving in 2 weeks
- Rapid mood swings, anxiety, decreased concentration, crying
- Postpartum Depression (5-10%)
- Onset within 4 weeks postpartum
- Symptoms present most of the day, almost every day, for 2 weeks, and impair normal
functioning in life
- All the same criteria of major depressive episode (need 5 including depressed mood)
 - Physiology
- Estradiol and Cortisol rise during pregnancy then drop promptly after birth
- Postpartum Psychosis (< 0.5%)
- Severe insomnia, delusions, hallucinations within 2 weeks of delivery
- Treatment
- Psychotherapy (first line)
- Adequate sleep + exercise
- SSRIs first line pharmacotherapy (Sertraline)
- Keep on the same antidepressant if they are already on one and it works well
- Benefits of antidepressants outweigh risks
- Minimal levels reached in breast milk
- Refer to psych if depression worsens (or suicidal / psychosis)
- Postpartum Infection
- Endometritis = infection of endometrium, myometrium, and/or parametrial tissues
- 5% vaginal, 10% cesarean deliveries
- Risk Factors
- C-section
- PROM, Prolonged labor, Retained Placental tissues
- Multiple vaginal exams, especially postmembrane rupture
- Common infections
- MULTIBACTERIAL
- GAS, GBS, Enterococcus, Staphylococcus
- E. coli, Klebsiella, Proteus
- Evaluation
- Abdominal pain
- Foul smelling lochia
- FEVER + UTERINE TENDERNESS
- CBC: Leukocytosis
- Management
- IV Antibiotics until afebrile x 24 hours
- Prevention:
- antibiotics pre-cesarean (Azithromycin)
- GBS prophylaxis
- Minimize vaginal exams after rupture of membranes
Gestational Trophoblastic Disease
- Abnormal proliferations of trophoblasts from the placenta
- Risk Factors
- Advanced maternal age
- History of previous GTD
- Asian, Native American, African
- Molar Pregnancy v. GTN
- Gestational Trophoblastic Neoplasia (GTN)
- Choriocarcinoma = neoplastic syncytiotrophoblast / cytotrophoblast without chorionic villi
- Placenta site trophoblastic tumor = absence of villi with proliferation of intermediate trophoblastic
cells
- Invasive mole = edematous chorionic villi with trophoblastic proliferation that invade into myometrium
- Hydatidiform Moles (Molar Pregnancies)
- Non-invasive tumors from proliferation of trophoblastic tissues (due to abnormal fertilization events)
- Partial = two sperm fertilize haploid ovum
- Karyotype 69XXX or 69XXY
- Fetal components often present (“partial” molar)
- Uterine size normal or smaller than expected
- Complete = 2 sperm fertilize empty ovum
- 46XX or 46 XY
- Absent fetus (“completely” molar)
- Associated with theca-lutein cysts
- Uterine size larger than expected
- Presentation
- Abnormal vaginal bleeding
- High beta-hCG
- Hyperemesis gravidarum
- Large uterus, large cystic ovaries
- No fetal heart tones
- Diagnostic Methods
- Complete Mole = diffuse echogenic snowstorm pattern on ultrasound
- High beta-hCG + exclusion of pregnancy
- Treatment
- D&C
- Hysterectomy (if don’t want to preserve childbearing)
- Follow Up
- Check beta-hCG levels at:
- 48 hours post-evacuation
- Every 1-2 weeks while elevated
- Monthly for 6 months
- Malignant GTD:
- Refer to specialist
- Evaluate for metastases
- No mets: Chemotherapy +/- hysterectomy
- Mets: refer to cancer specialist + chemo, surgery, +/- radiation

Fetal Death
- Common Causes in each Trimester
- T1: chromosomal abnormalities
- T2: anatomical abnormalities (septate uterus, fibroids, cervical insufficiency)
- Presentation
- Diagnostic Methods
 - Management (Medical + Psychosocial)
- Module Articles
- Office Management of Early Pregnancy Loss
- Up to 15% pregnancies end in miscarriage (80% in first trimester)
- Virtually no therapies proven to eliminate miscarriage
- Dx of miscarriage:
- Ultrasound
- Product of conception seen
- beta-hCG levels
- Management
- Expectant management (“wait and see” approach)
- 90% successful passage of products of conception without intervention (though may
take weeks)
- effective for incomplete abortions
- Misoprostol
- Uterine aspiration (preferred over D&C for early pregnancy loss)
- Manual vacuum
- Managing Adverse Birth Outcomes: Helping Parents and Families Cope
- Offer counseling
- Assess for postpartum depression / anxiety
- Physicians may need to seek their own coping support

MODULE 3: STIs, Vaginal Disease, Infertility

Vulvar / Vaginal Disease
- Normal vaginal appearance / secretions
- pH ≈ 4.5

- Vulvovaginitis DDx
- Bacterial Vaginosis (25%)
- Thin white discharge + fishy odor
- pH > 4.5
- + whiff test
- Clue cells
- Treatment = Metronidazole (or Clindamycin)
- Candidiasis (40%)
- Thick white discharge + itching
- Risk Factors: Pregnant, Diabetic, Obese, Antibiotics, Corticosteroids, OCPs
- Anything that keeps vaginal area warm/moist (swimming, panty liners)
 - Wet Mount:
- Blastospores
- Pseudohyphae
- + Yeast culture
- Tx = Vaginal Miconazole, Clotrimazole, Terconazole (or oral
- Trichomoniasis (35%)
- Yellow frothy discharge + odor
- By sexual contact (but can survive in swimming pools and hot tubs)
- Screen patients for STDs (gonorrhea, chlamydia)
- Wet Mount (organism)
- Tx = Metronidazole, Tinidazole
- Wet Mount interpretation
- pH
- Normal 4.5
- < 4.5: Yeast
- > 4.5: BV or Trich
- KOH “Whiff” Test
- Add a few drops of KOH to vaginal discharge >> fishy odor (Bacterial Vaginosis)

- Classification of Vulvar Dysplasia

- VIN 1 = lower 1/3 (mild)
- VIN 2 = 1/3 - 2/3 dysplasia (moderate)
- VIN 3 = > 2/3 to full thickness displasia (severe)
- = Carcinoma-in-situ (but not “cancer” yet, as has not broken through to invade other tissues)
- Vulvar Dermatitis
- Contact Dermatitis
- Common irritants
- Shampoo and body wash irritants
- Maxi pads, panty liners
- Creative underwear (cotton underwear is best)
- If itching not better with steroids, then >> biopsy (for dysplasia, cancer)
- Lichen Simplex Chronicus
- Itch-scratch cycle
- Scratching >> mechanical irritation >> epidermal thickening + inflammation
- red/reddish-brown plaques
- Tx = Corticosteroids + education on irritants and avoiding itch-scratch cycle
- Lichen Sclerosus
- Marked inflammation + epithelial thinning
- Itching and burning
- ONLY on VULVA
- Cigarette/Parchment paper skin
- Perianal halo / keyhole distribution
 - Tx = topical corticosteroids
- Increases risk for SCC of vulva
- Lichen Planus
- Can affect skin, oral cavity, Vulva OR VAGINA (whereas sclerosis only affects vulva)
- >> vulvar burning/itching, Insertional dyspareunia, Vaginal discharge
- Wickham striae (white lacy network)
- Atrophy
- Bartholin’s Gland Disease
- Vulvodynia

STIs
- STI Screening and Partner Notification Guidelines
- Annually screen all sexually active females < 25
- + annually screen older females with risk factors
- Bacterial Vaginosis
- Presentation
- Discharge odor worse after intercourse
- May be asymptomatic
- Evaluation
- Wet mount: Clue cells, decreased lactobacilli, high WBC
- Fishy odor (especially after KOH added)
- Management
- Metronidazole (or Clindamycin)
- Chlamydia
- Presentation
- Often asx
- Urethritis
- Mucopurulent cervicitis
- Dx = culture, ELISA, PCR
- Tx = Azithromycin (or amoxicillin)
- NOT Doxy in pregnancy
- Gonorrhea
- Presentation
- Often asymptomatic (+/- discharge)
- Dx = NAAT
- Tx = Ceftriaxone + Azithromycin
- + REPORT all cases to health department
- Syphilis
- By Treponema pallidum
- Presentation
- 1˚ = chancre
- 2˚ = rash on hands/soles
- 3˚ = gummas, CNS sxs, ophthalmic / auditory symptoms (neurosyphillis)
- Dx
- Dark field microscopy (spirochetes)
- VDRL, RPR
- LP for neurosyphillis
- Tx = PENICILLIN G (always; if allergic, desensitize)
- Chancroid
- By Haemophilus ducreyi
- Presentation = painful genital ulcer + tender suppurative inguinal LAD
- Dx = clinical
 - Tx = Ceftriaxone, Erythromycin, Azithromycin
- Tricomoniasis
- Presentation
- Yellow frothy discharge
- Vulvar itching / burning (strawberry cervix)
- Dx = Wet Mount: trich organisms
- Tx = Metronidazole (or Tinidazole)
- HSV
- Presentation
- Flu-like symptoms (initial infection)
- Painful vesicles >> crust and lyse before healing
- Tx = Acyclovir 7-10 days
- Donovanosis / Granuloma Inguinale
- By Klebsiella granulomatis
- Presentation = painless vascular ulcerative lesions that bleed easily on contact
- Tx = Doxycycline or TMP-SMX
- Lymphogranuloma Venereum
- By Chlamydia trachomatis
- Presentation
- Inguinal / femoral LAD
- (if anal transmission) anal bleeding, constipation, anal spasms
- Can >> abscesses/fistulas if untreated
- Tx = Tetracycline, Erythromycin, Doxycycline

Pelvic Inflammatory Disease

- PID
- Pathophysiology
- Infection of upper genital tract, mostly by Chlamydia trachomatis or Neisseria gonorrhea
- Diagnosis
- 1+ of:
- Cervical motion tenderness
- Uterine tenderness
- Adnexial tenderness
- AND 1+ of:
- Fever > 101
- cervical/vaginal mucopurulent discharge
- High WBC on microscopy of vaginal fluid
- High ESR or CRP
- Lab documentation of cervical infection with Neisseria gonorrhea or Chlamydia
- Management
- Ceftriaxone IM + oral Azithromycin
- Salpingitis
- Pathophysiology
- Presentation
- Diagnosis
- Management
- Long-term Sequelae
- Tubo-ovarian abscess
- Chronic salpingitis
- Pelvic adhesions
Pelvic Pain
- Dysmenorrhea
- Primary v. Secondary
- Causes
- Evaluation
- Management
- Endometriosis
- Presence of endometrial glands + stroma in sites outside the uterus
- Pathogenesis theories
- Retrograde Flow
- During menstruation, glands implant in peritoneum, posterior cul de sac, and ovaries
- Vascular and Lymphatic Dissemination
- Endometrial cells travel through lymphatic/vascular system to distant sites (kidneys, pleural
cavities)
- Coelomic Metaplasia
- Multipotent stem cells in peritoneal cavity develop into functional endometrial tissue
- Explains endometriosis in adolescents prior to onset of menstruation
- Common sites
- Bilateral Ovaries
- Posterior Cul-de-sac (uterosacral ligaments, Rectovaginal septum)
- Round ligament, Fallopian Tubes, Sigmoid Colon
- Presentation
- Dysmenorrhea
- Dyspareunia
- Infertility more common in women with endometriosis
- Dyschezia or Hematochezia
- Exam (may be benign)
- Fixed, non-mobile uterus
- Ovarian endometriomas
- Uterosacral nodularity
- Diagnosis
- Direct Visualization + Tissue biopsy in OR
- Confirmed by 2+ of:
- Endometrial epithelium
- Endometrial stroma
- Endometrial glands
- Hemosiderin-laden macrophages
- scarring and adhesions
- Clear, white lesions
- Powder-burn lesions
- Dark red or blue domes
- Management
- OCP (first line)
- Progesterone therapy
- GnRH agonist (induces menopause)
- Danazol
- Surgery
- Excision, Cauterization, Ablation of visible lesions, Lysis of adhesions
- Hysterectomy or Salpingo-oophorectomy
- Chronic Pelvic Pain
- 10% all referrals to gynecologist
- More prevalent than migraines or asthma in women
- Definition
 - Noncyclic pain lasting > 6 months severe enough to cause functional disability or medical care, and
localizes to:
- Pelvis
- Abdominal wall below umbilicus
- Lumbosacral back
- Causes
- Gyn:
- Endometriosis, Malignancies, Ovarian retention syndrome
- PID (18-35% PID patients will develop chronic pelvic pain)
- Adhesions, Leiomyomatas, benign cystic mesotheliomas
- Adenomyosis, Cervical stenosis, Chronic emdometritis
- IBS
- Interstitial Cystitis (pelvic pain, urgency, frequency, dyspareunia)
- Presentation
- Evaluation
- History (symptoms, medical, surgical, menstrual, sexual, psychosocial)
- Ask about depression (significant indicator of response to treatment)
- Carnett Sign = tensing of abdominal wall while raising legs or chin
- Signifies myofascial component to pain
- Cervical Cultures
- Management
- Multidisciplinary: Psychotherapy, Gastroenterology, Urology, PT, Anesthesia
- Treat cause (if known)
- If cause unknown, focus on pain relief
- OCP, GnRH agonists (suppress ovulation)
- Hysterectomy (if non-gynecological causes have been ruled out)
- Psychosocial issues
- *correlation between chronic pain and history of abuse*

Infertility
- Definition
- Infertility = failure of conception after 12 months of frequent unprotected intercourse
- Fecundability = probability of achieving pregnancy in one menstrual cycle (20-25%)
- Subfertile = reduced chances of getting pregnant
- Normal Fertility couples with regular sexual intercourse have 20-25% chance of getting pregnant each
month
- Hypothalamus >> GnRH >> Pituitary >> LH/FSH >> Ovaries >> Estradiol/Progesterone >> Reprod. tract
- Causes (Male v. Female)
- Ovulation Failure (25%)
- Amenorrhea, Oligomenorrhea (irregular)
- Primary ovarian failure
- By infection, surgery, radiation, medication, autoimmunity, Turner syndrome, Menopause
- >> high FSH + low estrogen
- Pituitary Failure (trauma, ischemia)
- Hyperprolactinemia can be sign of pituitary adenoma
- Polycystic Ovaries
- Cystic ovaries
- High LH + low FSH
- excessive androgens (produced by follicles bc of highLH)
- Hirsutism, Acne, Obesity
- Anovulation, menstrual irregularity
- Tx = OCPs, gonadotropins, GnRH analog (suppress LH)
 - Age
- Tubal Disease
- Often caused by infection, PID
- Uterine Problems (endometriosis, fibroids, previous surgery)
- Cervical Problems (abnormal mucus quality, damage)
- Evaluation
- Male infertility (need to have good sperm production)
- Semen analysis via masturbation after 2-3 days of abstinence
- Volume, sperm concentration, motility, morphology
- If semen analysis abnormal >> repeat
- If persistently abnormal >> Urologist or Reproductive endocrinologist
- Female Infertility
- Need good oocyte production
- History of regular menstrual cycles?
- Monthly ovulation (daily temperature, LH measuring kits)
- Hysterosalpingogram (for fallopian tube patency)
- Inject dye into uterine cavity, and should see it exit through both tubes
- Pregnancy Test (is the patient already pregnant?)
- FSH, LH, Estrogen
- Prolactin Levels (from pituitary adenoma)
- Ultrasound (for PCOS)
- Laparoscopy (of uterus, tubes, ovaries, adhesions, fibroids, endometriosis)
- Hysteroscopy of uterus (for fibroids, endometriosis)
- Management
- Clomiphene (a selective estrogen modulator)
- Stimulate follicular development in the ovaries
- Purified Gonadotropins (stimualtes follicular development)
- Intrauterine Insemination
- Semen sample is washed, suspended in medium, and injected via catheter through cervix into
uterine cavity
- Assistive Reproductive Technology (ART)
- IVF (99% ART)
- Process
- Stimulate ovaries to produce multiple follicles, then retreive oocytes
- Fertilize and incubate the oocytes
- Transfer embryo(s) to uterus
- 30% risk multiple gestations
- Indications
- Blocked / absent fallopian tubes
- Tubal sterilization
- Severe pelvic adhesions
- Severe endometriosis
- Poor ovarian response to stimulation
- Severe male factor infertility
- Failed treatment with less aggressive therapies
- Pre-implantation Genetic Diagnosis
- Tests embryos for genetic disease (CF, Tay-Sachs) prior to implantation
- Psychosocial issues
- Decreased social support (more common in black women than white / asian women)
- Stress

Sexual Assault / Domestic Violence

- Sexual Assault ACOG Article in Module:
- Screen all women for history of sexual assault
- Medical and Legal requirements exist for physicians evaluating survivors of sexual assault in the acute
phase (specimens, history, emergency contraception prn, STI prophylaxis, documentation, chain of
evidence)
- Recognize consequences of sexual assault (infection, pregnancy, mental health conditions)
- Sexual Assault
- Risk Factors
- Presentation:
- Chronic pelvic pain, Dysmenorrhea, Vaginismus
- Nonspecific vaginitis, Menstrual cycle disturbances, Sexual dysfunction
- Types of Sexual Assault
- Marital Rape = within marital relationship without consent
- Date / Acquaintance Rape = coitus without consent (may have consented to sexual play)
- Or with impaired cognitive function (alcohol, sleep, drugs, etc)
- Aggravated Criminal Sexual Assault = weapons used, lives endangered, physical violence inflicted,
physically / mentally handicapped
- Management of sexual assault
- Screen all patients for history of sexual assault
- Acute care:
- Advise to go immediately to ED or medical facility and not to change clothes, bathe, douche,
urinate, defecate, wash out her mouth, clean her fingernails, smoke, eat, or drink
- Medical
- Informed Consent, Chaperone during pelvic exams (or support person present)
- STD testing, Serology
- STI Prophylaxis prn
- Ceftriaxone IM single dose
- + Azithromycin oral single dose
- + Metronidazole single dose (2 hours after the others)
- (covers Gonorrhea, Chlamydia, and Trich)
- HIV >> 28 day HAART + consult with HIV specialist
- Emergency contraception
- Counseling, Follow up, Referrals prn
- Psychosocial
- Legal:
- DOCUMENT injuries, recording of events
- Collect samples (fingernail scrapings, vaginal secretions, pubic hair, saliva, blood-stained
clothing, etc)
- Reporting to authorities, Security of chain of evidence
- Domestic Violence
- PREGNANCY = period of greatest risk for physical abuse
- RADAR Model
MODULE 4: Antenatal Care
Maternal-Fetal Physiology
- Fetal / Neonatal Circulation (powerpoint in Objectives)
- Formation
- 3rd week: blood vessels + heart begins to form
- 4th week: first heart beat
- 5th week: atria + ventricles form
- Supplies oxygen to organs with high demand (heart, brain, upper body)
- Bypasses organs with lower metabolic demand (liver, lungs, lower body)
- Adult v. Fetal Circulation:
- Fluids/gases move from high to low pressure
- Adult:
- High Pressure in systemic circulation (L heart)
- Low Pressure in Pulmonary circulation (R heart)
- Fetus:
- High Pressure in pulmonary circulation
- Collapsed lungs, constricted vascular tree, high vascular resistance
- To shunt blood to heart / system
- Low Pressure in systemic circulation
- 4 Shunts:
- Placenta
- Low resistance organ (so blood flows there)
- Replaces 4 organs:
- Lungs (gas exchange)
- GI system (nutrition / fluid regulation)
- Liver (Nutrition / waste removal)
- Kidneys (fluid excretion / ion regulation)
- Uterine arteries = mother >> placenta
- Uterine veins = placenta >> mother
- Umbilical arteries (2) = fetus >> placenta
- Deoxygenated blood
- Umbilical vein = placenta >> fetus
- Oxygenated blood
 - Ductus Venosus
- Oxygenated blood from Umbilical Vein >> IVC
- Bypasses LIVER
- Lower IVC deoxygenated blood mixes with oxygenated DV
- Lower IVC carries blood from lower extremities (deoxygenated)
- IVC >> Right atrium
- Foramen Ovale
- Between R/L Atria
- R >> L Shunt
- Oxygenated blood from IVC >> Left Ventricle and aorta (via foramen ovale)
- Ductus Arteriosus
- Pulmonary artery >> Aorta
- R >> L Shunt
- High resistance in pulmonary arteries (collapsed lungs) >> low resistance in aorta

- Fetal Hb can carry more O2 than adult Hb (due to gamma chains)

- First Breath caused by:
- Physical stress during birth
- Sudden exposure to external temperature
- Post-birth Hypoxia + Hypercapnia
- Connection with placenta is severed
- CO2 builds up >> signals breath
- Shift from Fetal to Adult Circulation by:
- Newborn Breathing (decreases pulmonary resistance)
- Expansion of lungs >> decreased resistance
- Removal of placenta (increases aortic systemic resistance)
- Closure of Shunts:
- Foramen Ovale:
- High pressure in L atrium pushes back on low pressure R atrium
- Ductus Venosus:
- Cutting umbilical vein >> pressure rises and blood backs up from portal vein
- 1-3 hours after birth, DV smooth muscle contracts to close DV
- >> increased portal vein pressure >> increased liver perfusion
- Ductus Arteriosus:
- Increased O2 and decreased PGE2 >> closure (no more PGE to keep it open)
- Indomethacin if it doesn’t close by itself
 - Remnants of Fetal Circulation in Adults:

- Patent Ductus Arteriosus (PDA)

- L >> R shunt (initially)
- No cyanosis in early life, but growth >> late cyanosis
- Eisenmenger syndrome
- L>R shunt >> pulmonary HTN >> R>L shunt (reversal)
- Machinery murmur
- Tx = Indomethacin
- Tetralogy of Fallot
- R >> L shunt
- Pulmonary artery stenosis
- RV enlargement
- Overriding aorta
- VSD
- Early cyanosis (skipping lungs)
- Boot shaped heart
- Tx = dilate pulmonary stenosis + close VSD + reconstruct aorta
- Physiology of Pregnancy (powerpoint in objectives)
- Fertilization
- Sperm moves past follicular cells and attaches to zona pellucida
- Acrosomal Reaction = local digestion of zona pellucida >> sperm can access ovum
- Cortical Reaction = glycoproteins in zona pellucida cross-link and become impermeable to other
sperm
- Oocyte + sperm fuse >> meiotic division
- After Fertilization
- Zygote divides inside zona pellucida and becomes Morula
- Morula stays inside fallopian tube 3-4 days while Progesterone readies the Endometrium for
implantation
- Implantation
- Blastocyst implants 5-7 days after fertilization
- Trophoblasts >> Syncytiotrophoblasts + Cytotrophoblasts >> Chorion that will become placenta
- Syncytiotrophoblasts produce hCG by day 7
- Hormones in Pregnancy
- Estrogen, Progesterone (increased)
- Prolactin
- AFP produced by yolk sac
- Too high: think neural tube defects
- Too low: think Down Syndrome or other genetic defects
- hCG: peaks in first trimester
- hPL (human Placental Lactogen)
- hCS (human Chorionic Sommatolactotropin)
 - Hormonal Termination of Pregnancy
- Levonorgesterel (Plan B)
- Protestin-only pill taken right after intercourse (mechanism unknown)
- Stops implantation
- Mifepristone (RU-486)
- Progesterone antagonist + PGE >> induces myometrial contractions
- Up to 49 days after pregnancy
- Parturition
- Oxytocin during labor (contractions)
- Milk Synthesis begins at delivery
- Prolactin (from anterior pituitary)
- Suckling required to keep Prolactin levels high
- Oxytocin >> milk ejection
- Maternal Physiologic / Anatomic Changes @ Pregnancy
- EDD = 40 weeks after LMP
- First Trimester = 0-13 weeks
- Second Trimester = 14-27 weeks
- Third Trimester = 28-40 weeks
- Thyroid
- Overall Euthyroid state, despite changes in thyroid regulation
- beta-HCG
- Thyrotropin-like activity >> rise in free T4 in first trimester
- peaks in first trimester (10 weeks) and decreases until term
- Estrogen
- Thyroxine-binding globulin activity >> rise in total T4 / T3
- But doesn’t change free T4/T3
- CVS
- Increased circulating blood volume (to 45% at 32 weeks)
- Increased CO (HR x SV)
- Increased SV in first half of pregnancy
- Increased HR in second half of pregnancy
- Low BP
- Progesterone smooth muscle relaxation
- Increased vasodilatory substances from placenta
- Supine Hypotension Syndrome
- Low BP when supine, due to growing baby impeding Vena Cava when supine
- Advise women not to lay on back while sleeping, but instead on side
- Heart displaced upward; apex moved laterally (bc diaphragm elevated)
- Exam:
- Distended neck veins (increased volume)
- Systolic ejection murmurs (diastolic needs evaluation)
- S2 split with inspiration
- Respiratory:
- Changes mediated by Progesterone
- Thorax:
- Elevated Diaphragm (growing fetus)
- Increased chest diameter / circumference
- Increased O2 consumption
- Increased Minute ventilation = volume of air taken in per minute
- Increases 30-40%
- Compensated Respiratory Alkalosis
- Bc increased ventilation >> increased CO2
- >> increased bicarb excretion to compensate (normal pH)
 - All >> DYSPNEA of pregnancy
- Hematologic:
- Increased blood volume
- Physiologic Anemia
- Bc plasma volume increases 45%, but RBC volume only increases 35%
- Average Hg 12.5 in pregnancy (v. 14 in non-pregnant)
- >> Iron supplements
- 60 mg elemental iron / day
- or 300 mg Ferrous Sulfate / day
- VTE Risk
- Increased clotting factors (fibrinogen)
- Decreased Protein C/S
- >> Edema
- GI
- Progesterone relaxes smooth muscle
- GERD (relaxed LES)
- Gallstones (relaxed gallbladder motility)
- Constipation (less GI motility)
- Nausea / Vomiting
- Related to Progesterone and beta-HCG (highest in first trimester)
- Decreases in 2nd trimester as beta-HCG levels decline
- Hyperemesis Gravidarum = severe N/V in pregnancy
- Growing baby displaces stomach upward >> more GERD
- Dietary cravings
- Generalized Pruritus from cholestasis / increased bile acids
- Hemorrhoids
- Gingival disease
- Renal:
- Enlargement / Dilation of Kidneys + collecting system
- Progesterone >> relaxation of ureters >> dilation
- Mechanical compression of distal ureters >> dilation
- Decreased Bladder Capacity (as uterus enlarges)
- Increased renal plasma flow / GFR
- Increased urinary glucose excretion
- Trace glucose on urinary “dipstick” is normal (but monitor for glucosuria)
- >> urinary frequency, stress incontinence
- MSK:
- Lumbar Lordosis (center of gravity over the legs)
- >> low back pain
- Unsteady gait
- Skin:
- Spider angiomata (torso, face, arms)
- Palmar erythema
- Striae Gravidarum, Hyperpigmentation, Darkened Linea Alba (>> Linea Nigra)
- Melasma (“Mask of Pregnancy”)
- Increased skin nevi (may resolve after pregnancy)
- Increased Sweat + Sebum production
- Hair growth
- Breasts:
- Increase in size in first 8 weeks, then steadily thereafter
- Nipples deeply pigmented
- Tenderness / tingling
- Estrogen/Progesterone >> ductal growth + alveolar hypertrophy
 - Colostrum = thick yellow fluid expressed from nipples in latter pregnancy
- Fetal/Placental Physiology
- Umbilical Cord:
- 2 umbilical arteries = fetus >> placenta (deoxygenated)
- 1 umbilical vein = placenta >> fetus (oxygenated)
- Fetal Circulation:
- Umbilical vein >> portal system
- Ductus Venosus (bypasses LIVER)
- Umbilical vein >> portal system >>
- 50% to liver
- 50% >> DV >> shunted to IVC >> R atrium
- Foramen Ovale (bypasses LUNGS)
- Some blood from R atrium >> L atrium >> L ventricle >> aorta (bypasses lungs)
- Rest of blood >> R ventricle >> pulmonary arteries
- Ductus Arteriosus (bypasses LUNGS)
- From pulmonary arteries >> ductus arteriosus >> Aorta (bypasses lungs)
- Aorta >> common ileacs >> internal ileacs >> Umbilical arteries >> placenta
- Placenta: Exchange of O2, glucose, amino acids between mom / fetus
- Effect of Pregnancy on common diagnostic studies

Preconception / Antepartum Care

- Preconception Care
- ACOG Prepregnancy Counseling Article (in Module)
- Ask “Would you like to become pregnant in the next year?”
- Optimize health, address modifiable risk factors, educate about pregnancy
- Manage medical conditions that affect pregnancy (diabetes, HTN, psychiatric illness, Thyroid)
- Review all medications, supplements, herbal products
- Offer screen for genetic conditions
- Immunizations (especially for live ones that can’t be given once pregnant)
- Tetanus, Diphtheria, Pertussis, MMR, HepB, Varicella
- Annual Flu Vaccine
- STI screening
- Infectious Disease exposure (like Zika)
- Alcohol, Tobacco, Drugs, Opioids, etc
- Intimate Partner Violence screen
- Folic Acid supplementation (0.4 mg/day)
- Calcium, Iron, Vitamin A, B12, B, D, other nutrients (need RDA)
- BMI goal in normal range before pregnancy
- Certain Medical Conditions’ effect on pregnancy
- Diabetes (high A1c)
- higher rates fetal malformations (25% if A1c > 11.2)
- Heart, brain, renal, GI, skeletal malformations
- Miscarriage risk (44% if A1c 11)
- Maternal risks: nephropathy, retinopathy,
- SLE (increased risk complications)
- Hypertension
- Risk: Preeclampsia, placental Abruption, IUGR
- Treat severe HTN > 160/90
- Don’t want to lower BP too much or else risk lowering placental perfusion
- Tx:
- CONTRAINDICATED: ACEI, ARBs, direct renin inhibitors
- Methyldopa
 - Labetalol
- Screen for HIV, STDs in preconception visit
- Genetic Screening Options in pregnancy
- Screen for:
- Sickle Cell (african descent)
- Beta Thalassemia (mediterranean, southeast asian, african descent)
- Alpha Thalassemia (mediterranean, southeast asian, african descent)
- Tay-Sachs (Ashkenazi Jewish, French canadians, Cajun descent)
- Canavan / Familial Dysautonomia (Ashkenazi Jewish)
- CF (Caucasians of European / Ashkenazi descent)
- If Positive for carrier gene:
- Test father: if both are carriers, then 25% risk of fetus having disease
- (50% chance that they will be a carrier)
- Preimplantation Genetic Diagnosis
- Can test embryos for genetic diseases before implantation
- Chorionic Villus sampling / Amniocentesis
- Test fetus for genetic defect (after conceiving naturally)
- Risk of Advanced Maternal Age in pregnancy
- Medications, Immunizations, and Environmental Hazards in pregnancy
- Vaccines
- No live vaccines during pregnancy (Varicella, Rubella, Pertussis, HepB)
- Give these during preconception visit
- Toxoplasmosis (cat feces)
- Intimate Partner Violence
- Smoking in Pregnancy
- Antepartum Care
- Diagnose Pregnancy
- beta-HCG > 25 can cause positive pregnancy test
- N/V, fatigue, breast tenderness
- Prenatal Visits for low-risk women:
- Timing:
- Intake at < 8 weeks
- First prenatal visit < 12 weeks
- 4 week interval visits until 28 weeks (second trimester)
- 2 week interval visits 28-36 weeks (third trimester)
- Weekly visits > 36 weeks to delivery
- Weight, BP
- Diabetes Screen: 1 hour glucose tolerance test at 24-28 weeks
- Or at initial prenatal visit for obese women
- Fetal Assessment
- FHR (via doppler starting at 12 weeks)
- Chromosomal Screening
- 1st Trimester screen: for Trisomy 18 / 21
- Fetal US (18-20 weeks)
- Non-stress tests (NST)
- If concerned for maternal diabetes, HTN, IUGR
- Measures FHR and accelerations for at least 20 minutes
- Maternal Kick Counts
- Lay on side and should feel:
- 5 movements in 1 hour
- 10 movements in 2 hours
- Fetal Growth
- Fundal Height Measurement (from pubic symphysis to top of fundus)
 - Approximates # weeks gestation
- Amniotic Fluid Volume
- Low: if fetus shunts fluid away from kidneys to brain >> decreased urine output
- Fetal Lung Maturity
- Determine Gestational Age
- EDD = 40 weeks after LMP
- Naegele Rule = first day of LMP + 7 days - 3 months
- Gestational age = # weeks elapsed between first date of LMP and estimated date of delivery
- Ultrasound
- Confirms EDD if patient’s cycles are regular
- Or determines EDD if patient’s cycles are irregular
- At 5 weeks: normal gestational sac (transvaginal)
- @ hcg 1000-5000
- 18-22 weeks is best time if only one ultrasound will be done
- Confirms presence of pregnancy; diagnose multiple gestations
- Estimates gestational age
- Confirm cardiac activity
- Evaluate pelvic masses / abnormalities, vaginal bleeding, pelvic pain
- Nuchal Translucency (lucent area behind head in nuchal region)
- Too much = Trisomy 13/18/21, Turner, etc
- Diagnostic Studies/Timing
- Chorionic Villus Sampling
- Done > 10 weeks to provide prenatal diagnosis in first trimester
- Risks / Complications
- Vaginal spotting / bleeding
- Cannot diagnose amniotic fluid disorders (like neural tube defects)
- Benefits
- Can be performed earlier in pregnancy (> 10 weeks)
- Rate of pregnancy loss is the same as midtrimester amniocentesis
- Amniocentesis
- Procedure
- Indications
- Complications
- “Soft Markers” for Down Syndrome on Ultrasound
- Nuchal fold
- Intracardiac echogenic focus
- Mild ventriculomegaly
- Echogenic bowel
- Shortened femur / humerus
- Absent nasal bone
- Pyelectasis
- How to screen for Neural Tube Defects?
- High AFT
- Amniocentesis
- Risk Factors for pregnancy complications
- Smoking (miscarriage, placental abruption, IUGR, preterm, birth defects, SIDS)
- Alcohol (MR, developmental delay, birth defects)
- Drugs, Environmental hazards, Seat belt use
- Excessive weight gain (macrosomia, postpartum obesity)
- Inadequate weight gain (preterm, IUGR, low birthweight)
- Nutritional Needs of Pregnant Woman
- Folic Acid: 0.4 mg/day
- Or 4 grams / day if previous pregnancy with neural tube defects
- Weight Gain Recommendations: based on pre-pregnancy BMI
- BMI < 19.8: 28-40 lbs
- BMI 19.8-26: 25-35 lbs
- BMI 26-29: 15-25 lbs
- BMI > 29: 11-20 lbs
- Avoid:
- Unpasteurized milk, dairy, cold lunch meat products (Listeriosis >> fetal demise)
- Tuna, Shark, King macerel (mercury)
- Herbal remedies (lack of regulation)
- Answers to commonly asked questions about pregnancy, labor, and delivery
- Exercise:
- Avoid exercises with risk of falling / trauma (horseback, wrestling, football), or strenuous
exercise that she did not do prior to pregnancy
 - Sex:
- Ok unless Placenta Previa, PROM
- Find comfortable positions
- Travel:
- Airlines allow up to 36 weeks
- Avoid prolonged sitting
- Walk every 1-2 hours for good circulation
- Caution with seatbelts worn low on hip bones
- Teratogenic Meds to avoid:
- ACIEs
- Coumadin
- Isotretinoin
- Ionizing radiation > 5 rads
- CT scan abdomen/pelvis = 3.5 rads (CT head is < 1)
- AXR = 100 - 200 millirads (CXR is 0.02 millirads)
- ACOG Routine Tests during Pregnancy (article in Module)
- CBC, Blood type, UA, Urine culture
- Rubella, Hep B/C, STIs, HIV, TB
- Rh antibody test, Glucose screening test, GBS
- Genetic screens
- Ultrasound exams
- Amniocentesis, Chorionic villous testing (to diagnose birth defects)
- Screening for Infectious Diseases that impact Pregnancy:
- Urine Culture / Bacteremia:
- Can >> preterm birth
- Tx = Ampicillin, Cefalexin, or Nitrofurantoin (for all asymptomatic bacteriuria in pregnancy)
- Hepatitis B:
- 90% risk infection of fetus (>> chronic fatal liver disease)
- Tx
- HepB (-): vaccinate mom during pregnancy
- HepB (+): HBIg to mom
- HBIg + vaccination to newborn
- Hepatitis C:
- There’s no good treatment for this...you can’t do much about it
- (C-section doesn’t prevent transmission; HCIg is no good)
- VDRL / RPR:
- For Syphilis (>> abortion, stillbirth, neonatal death)
- Rash, hepatosplenomegaly, saddle nose, Hutchinson teeth, mulberry molars, saber shins
- Tx = PENICILLIN (ALWAYS...if allergic, then desensitize and still give PCN)
- HIV:
- Tx = HAART + C-section at 38 weeks
- Avoid breastfeeding if possible (developed countries)
- Gonorrhea:
- REPORT all cases
- >> gonococcal ophthalmia
- Tx = Ceftriaxone + Azithromycin (can’t give Doxy in pregnancy)
- + Erythromycin prophylaxis eye drops to newborn
- Chlamydia:
- >> Conjunctivitis, Ophthalmia, Pneumonia (in neonate)
- + endometritis, infertility in mom
- Tx = Azithromycin or Amoxicillin
Ectopic Pregnancy
- DDx of First Trimester Bleeding
- Non-viable Intrauterine Pregancy
- Spontaneous abortion
- Molar pregnancy
- Viable intrauterine Pregnancy
- Physiologic implantation bleeding
- Sub-chorionic hemorrhage
- Ectopic Pregnancy

- Evaluation of First Trimester Bleeding:

- TVUS
- hCG (low = failed pregnancy)
- Hematocrit (if perfuse bleeding)
- Ectopic Pregnancy
- Ectopic implantation outside of endometrial cavity
- 1.5% all US pregnancies
- 98% in fallopian tube
- 70-80% in ambullary portion of fallopian tube
- Risk Factors
- Fallopian tube scarring
- History of Ectopic pregnancy (#1 risk factor)
- Tubal surgeries (ligation)
- Chlamydial infections, PID
- Smoking (slows cilia in fallopian tube)
- Diagnostic Protocols
- High index of suspicion
- Classic Sxs
- Amenorrhea
- Vaginal bleeding
- Abdominal pain
- Serum beta-hCG at 48-hour intervals
- Should increase by 50% over 48 hours
- Vaginal US
- Intrauterine pregnancy should be seen when beta-hCG is 1500-2000
- Treatment Options
- Methotrexate
- Indications
- Must be SAFE for mom
- SUCCESS must be likely
- B-hCG < 5000 ideal
- mass < 3.5 cm
- Absolute Contraindications to Methotrexate:
- Hemodynamic instability
- Liver/Kidney abnormalities
- Active lung disease
- Breastfeeding
- Inability to comply with required follow up beta-hCG testing
- Relative Contraindications (that indicate MTX may not be successful)
- Fetal cardiac activity
- High beta-hCG > 5000
- Large ectopic size > 3.5 cm
- Adverse Effects
 - N/V, diarrhea, gastric distress, stomatitis
- Dizziness
- Monitoring Required
- MUST follow up for B-hCG level 4-7 days after procedure (must go down)
- Surgical
- Salpingectomy = removal of entire fallopian tube
- No need for follow up bc the entire pregnancy is removed with the tube
- Salpingostomy = hole made in fallopian tube and pregnancy is removed
- Requires beta-hCG follow up

Spontaneous Abortion
- Spontaneous Abortion
- Abortion = pregnancy loss < 20 weeks gestation
- Miscarriage / Spontaneous Abortion = pregnancy loss in absence of any medical or surgical intervention
- Causes:
- First Trimester: Chromosomal abnormalities
- Second Trimester: maternal systemic disease, abnormal placentation, anatomic anomalies
- Often preventable/treatable causes
- Types
- Inevitable = bleeding / ROM + open cervix
- Incomplete = bleeding + open cervix + passage of some tissue (some may remain in uterus)
- Threatened = bleeding without loss of fluid or tissue (closed cervix)
- No treatment necessary (Reassurance as long as US looks ok)
- Missed = retention of a failed intrauterine pregnancy for some time (often asx)
- Complete = documented pregnancy + spontaneous passage of all contents of uterus
- No intervention needed (the abortion is complete)
- Management
- Threatened and Complete:
- No management needed
- Incomplete, Inevitable, and Missed:
- Expectant (watch + wait)
- Medical (Prostaglandins)
- Surgical
- Curettage
- Vacuum
- RhoGAM for Rh- mothers
- Counseling
- Emotional support (short and long-term) for both patient and spouse
- Reassurance
- that the loss was not precipitated by anything they did / didn’t do
- That a single loss does not significantly increase risk of future losses
- Follow up 2-6 weeks
- Recurrent Abortion = 2+ losses
- First trimester = usually genetic/autoimmune factors
- Can consider chromosomal evaluation if recurrent first trimester losses
- Second trimester = usually anatomic abnormalities
- Septic Abortion
- Causes
- Complications
MODULE 5: Reproductive Physiology; Breast and Cervical Disorders
Female Reproductive Physiology
- Hypothalamic-Pituitary-Ovarian axis
- Hypothalamus >> [GnRH] >> Pituitary
- Pituitary >> [LH, FSH] >> Ovaries
- Ovaries >> Estrogen / Progesteron >> reproductive tract / organs
- Natural Suppression of HPO axis:
- Before puberty
- Lactation
- Diet-induced (Anorexia, Malnutrition)
- Excessive Exercise
- Estradiol Production
- LH signals Theca cells to produce Androgens
- Granulosa cells convert androgens to estradiol
- Oocyte Development
- Primordial Germ Cells (oogonia) >> Mitosis that stops in fetal life
- Then all enter meiosis and arrest in meiosis 1 at puberty
- FSH stimulates development from Meiosis 1 to Meiosis 2 (halted again until fertilization)
- Phases of Menstrual Cycle
- Day 1 = onset of menstruation
- Follicular Phase
- Early follicular phase:
- low Estrogen/Progesterone feeds back >> increase GnRH >> increase FSH/LH
- Mid Follicular phase
- Granulosa cell hypertrophy >> lots of Estrogen (by FSH)
- Eventually Estrogen will negatively feedback to hypothalamus / pituitary to lower
FSH/LH
- Late follicular phase
- Estrogen causes thickened endometrium + change in cervical mucus consistency
- Estrogen changes from positive to NEGATIVE feedback
- Dominant follicle is selected
- 30-50 follicles start growing 2-3 months before start of each menstrual cycle, but only
1 is selected and becomes the “dominant” follicle that will ovulate
- As each follicle grows, it produces increasing amounts of estradiol
- Increased amounts of estradiol sends negative feedback to pituitary
- Inhibin >> suppresses FSH from the pituitary
- As follicles grow, FSH levels fall due to negative feedback
- Small follicles are very dependent on FSH, so only the largest will
survive as FSH levels fall (and will ovulate)

- Polycystic Ovaries
- Pituitary >> high LH + low FSH >> disturbed follicle growth
- String of follicles/pearls in ovaries
 - Anovulation
- High LH >> androgen secretion
- Hirsutism
- Ovulation (after LH spike)
- with high enough estradiol levels from ovary, pituitary secretes LH surge
- Ovulation happens 36 hours after LH surge
- Oocyte completes Meiosis 1 and arrests in Meiosis 2
- Spike in Body Temp right after ovulation
- Luteal Phase (Progesterone + estradiol)
- Always 14 days (fixed)
- The Ruptured follicle becomes the corpus luteum which secretes Progesterone
- LH >> Progesterone secretion

- LH secreted in the luteal phase keeps signaling the CL to secrete Progesterone

- Steroid negative feedback from CL keeps LH/FSH relatively low
- Eventually CL’s sensitivity to LH decreases, and CL breaks down
- >> loss of negative feedback
- >> FSH and LH on the rise again to start new cycle / Follicular development
- Phases of Endometrium
- Proliferative
- Estradiol causes increase in thickness
- Secretory
- Increased secretion from glands
- Onset of Menstruation = when Progesterone levels fall
- Gradual reduction in blood flow to superficial layers >> hypoxia and damage >> constriction of spiral
arteries (that eventually reopen and rupture)
- Menopause
- Absence of menses for 12 months
- High FSH, LH
- Average age 51.4
- Premature Ovarian Failure = < 41 years old
- Presentation
- Hot flashes, mood lability, vaginal dryness, dyspareunia, urinary symptoms

Embryology and Pelvic Anatomy

- Define:
- Perineum = surface of the trunk between the thighs and buttocks, extending from the coccyx to the pubis
- Vulva = labia majora, labia minora, mons pubis, clitoris, vestibule, and ducts of glands that open into the
vestibule
- Labia majora = folds of skin with underlying adipose tissue fused anteriorly with mons pubis at the perineum
- Labia minora = narrow skin folds lying inside the labia majora
- Clitoris = anterior to labia minora; embryologic homologue of the penis
 - Urogenital Diaphragm = triangular shaped diaphragm that lies on the anterior part of the pelvis between
ischiopubic rami

- Embryology/Development of External Female Genitalia

- Cloaca is formed from dilatation of caudal end of hindgut, and covered by cloacal membrane
- Urorectal septum separates the cloaca into the urogenital sinus (anteriorly) and anorectal canal (posteriorly)
- Septum forms mesoderm in pelvic floor that grows down to reach the cloacal membrane
- Genital tubercle develops at cranial end of cloacal membrane
- Labioscrotal swellings + urogenital folds appear on each side of cloacal membrane
- ESTROGEN presence + ABSENT ANDROGENS >> external female genitalia
- Genital tubercle >> clitoris
- Unfused urogenital folds >> labia minora
- Labioscrotal swellings >> labia majora
- Embryology/Development of Ovary
- 5th week of gestation: Primary sex cords project from surface of gonadal/genital ridges in embryo
- 6th week: primarordial germ cells migrate into gonadal ridges and associate with sex cords
- Primordial germ cells will become oogonia
- 10th week: gonad has developed into an identifiable ovary
- Primary sex cords degenerate, and secondary sex cords appear (“cortical cords”)
- 16th week: cortical cords organize into primordial follicles (each with an oogonium)
- Uterus
- lies between the bladder + rectum
- Components of the Uterus
- Cervix
- Body of Uterus
- Endometrium (simple columnar epithelium)
- Myometrium (smooth muscle)
- Serosa (connective tissue)
- Uterine Ligaments
- Round Ligament: travels through the inguinal canal
- Suspensory Ligament: holds ovarian artery + vein
- Ovarian Ligament (proper ovarian ligament)
- Broad Ligament: extension of parietal peritoneum
- Covers body of the uterus
- Blood supply to Pelvis
- Iliac artery >> internal/external iliac artery (at pelvic brim)
- Anterior division of internal iliac:
Internal pudendal Obturator
Inferior gluteal Uterine
Vesical Vaginal
Middle rectal
- External iliac artery ultimately >> Femoral artery
- Inferior epigastric artery branches in pelvis and traverses abdomen
- Need to avoid at laparoscopy port placement
- Path of Ureter in Pelvis
- Under ovarian vessels at pelvic brim
- Then crosses uterine artery as it enters the uterus
- Watch out for ureter during pelvic surgeries
- Muscles of Pelvic Floor
- Pelvic Diaphragm
- Levator Ani (critical to support pelvis and prevent organ prolapse)
- Puborectalis + Pubococcygeus + Ileococcygeus
- Coccygeus
- Perineal membrane + Perineal body (inferior to pelvic diaphragm)

- Bony Pelvis
 - Greater (False) Pelvis
- Distributes weight of abdominal organs, and supports uterus at term
- Formed by:
- Lumbar vertebrae
- Posterior iliac fossa
- Abdominal wall
- Lesser (True) Pelvis
- Contains pelvic organs (uterus, vagina, bladder, fallopian tubes, ovaries, rectum, anus)
- Formed by:
- Sacrum / coccyx (posterior)
- Ischium / pubis (anterior)
- Pelvic Measurements:
- True Conjugate (Obstetric) Diameter = sacral promontory >> widest part of pubic symphysis
- Narrowest distance through which baby has to traverse
- Should be at least 11 cm to ensure delivery of fetal head
- Diagonal (false) Conjugate Diameter = sacral promontory >> inferior margin of pubic symphysis (pelvic
exam)
- Anatomical Conjugate Diameter = sacral promontory >> superior margin of pubic symphysis

- Pudendal Block:
- Pudendal artery = at level of ischial spines
- So give block below the ischial spines to avoid pudendal nerve and arteries
- Vulvar innervation
- Mostly by pudendal nerve
- But anterior to the urethra: ilioinguinal + genitofemoral nn.
- MC site of Ectopic Pregnancy
- Ampulla (bc past the ampulla is the isthmus which is very narrow and fetus can’t fit as well there)
- Ovarian Torsion
- Ovary twists on IP Ligament (infundibulopelvic ligament) >> cuts off main blood supply
- IP ligament carries:
- Ovarian arteries (branch of abdominal aorta)
- Ovarian veins (drain to IVC on R, into left renal vein on left)

OBGyn History and Exam

- Thorough OBGyn History
- Assess Health Risks
- Unintended pregnancy, STIs, cervical pathology, breast/gyn malignancy
- Domestic Violence
- Health Literacy
- Assess compliance with Screening
- Gyn exam (cervix + ovaries)
- Breast exam, imaging
- Osteoporosis
- Cholesterol / Diabetes
- Colon Cancer
- OB History
- G’s and P’s:
- Gravida = # pregnancies
- Nulli-, Prima-, Multi-, Grand multi-gravida
- Parity = # births
- Nulli-, Prima-, Multi-para
- TPAL
- Full Term
- Preterm
- Abortion
- Living
- Examples:
- if 4 pregnancies, 3 born full term, and 1 miscarriage: G4 P3013
- Currently pregnant; 1 prior ectopic pregnancy: G2 P0010
- 3 pregnancies; 1 was miscarriage and others were full term and living: G3 P2012
- 1 prior pregnancy that was full term and is living: G1 P1001 (or G1P1)
- 1 prior pregnancy of twins born at term and living: G1 P1002
- Parturient = currently in labor
- Puerpera = recently gave birth
- Outcomes of Pregnancy
- Full Term = ≥ 37 weeks
- Preterm = < 37 weeks
- Abortion (induced, spontaneous, Ectopic, Molar)
- Living currently
- Gyn History
- Menstrual history
- Normal Cycle: q21-35 days with flow ≤ 7 days (average flow < 60 mL)
- Menorrhagia = flow > 7 days,or > 80 mL
- Metrorrhagia = irregular
- Menometrorrhagia = heavy, irregular
- Polymenorrhea = < 21 days between periods
- Dysmenorrhea = painful menses
- Age of menarche + Age of Menopause
- Current cycle characteristics
- First day of LMP
- Frequency, Duration, Amount estimate of flow
- Symptoms associated
- Pap smear History
- Date + Results of most recent
- Prior abnormal results (+ evaluation, diagnosis, treatment, follow up)
- Contraceptive history
- Methods + dates
- Complications
- Reasons for changes
- Sexual history
- Gyn infections (STIs, risk factors, results of screening tests)
- Dyspareunia
 - Current/past abuse or assault
- Sexually active? Men, women, or both? Condoms?
- How many lifetime partners?
- History of STI?
- Infertility history
- Gyn surgical procedures
- Hysteroscopy, Laparoscopy, Hysterectomy, Oophorectomy, Myomectomy
- Bilateral tubal ligation
- Documentation and Oral Reporting of Results
- Gain Patient’s confidence and cooperation, and assure comfort and modesty
- Quiet, private, well lit room
- With patient dressed whenever possible
- Cover intimidating instruments possibly
- Presence of family members may impede interview
- Painless Exam
- Can tell patient to breathe in through nose and out through mouth, and relax muscles
- “Try to relax as much as you can, although I know that is alot easier for me to say than for you to do”
- “Let me know if anything is uncomfortable, and I will stop and we will try to do it differently”
- Talk before you touch: “I am going to touch you now” to alleviate surprises
- Education regarding Breast self-examination
- Encouraged so that women know what their normal breasts feel like (can lead to earlier detection of masses
/ abnormalities)
- Pap Smear + DNA Probes / Culture (APGO video)
- Cervical cancer worldwide:
- 5th leading cause of cancer
- 4th leading cause of cancer death in women
- Declined 50% in US due to screenings
- Liquid Cytology
- Pap test, HPV PCR, Gonorrhea, Chlamydia
- Nucleic Acid Amplification Testing (NAAT)
- Separate swab of endocervix (or first catch urine sample)
- Pap Smear Guidelines
- Initiation of Pap testing = age 21 (regardless of first sexual activity)
- Age 21-30:
- Pap test + Cytology q 3 years
- Age 30-65:
- Pap test q3 years
- OR Pap + HPV q5 years
- But still need visual and bimanual genital exam regularly
- Age > 65 OR Hysterectomy:
- No pap test required anymore
- History of CIN 2 or higher: screen for 20 years after regression or treatment of lesion
- Annual Health Maintenance Visit (APGO video)
- Screen for:
- Diet, Nutrition, Exercise
- Seat belt use, Sun exposure
- Alcohol / substance use, Tobacco
- Depression
- Contraception, STIs
- Intimate Partner Violence
- Breast Cancer
- Risk Factors
- Age
 - FH, Genetics
- Early menarche, Late menopause, late childbearing
- Hodgkin disease, Enlarged thymus
- Dense breast
- Mammogram Screening initiation: 40 years old q2 years
- Colorectal Cancer
- 3rd cause of cancer death in women
- Risk Factors
- Inflammatory Bowel Disease (Crohns, UC)
- FH colorectal cancer or polyps
- Genetic syndromes
- Lifestyle (low fruit/veggies, low exercise, low fiber diet, overweight/obesity)
- Screening Colonoscopy
- Age 50 and q 10 years
- Age 45 for african american women
- Cervical Cancer
- HPV vaccine given from age 9 - 26
- Screening Pap:
- Age 21+
- Age 21-30 by cytology alone q3 years
- Age 30-65 by cytology + HPV q5 years
- Age 65+ or hysterectomy: no longer needed
- History of CIN2 or higher: screen 20 years after regression or treatment of lesion
- Osteoporosis
- Risk Factors:
- Caucasian
- Age
- Low body weight
- FH
- Alcohol, Tobacco use
- Screening DEXA scan
- Age 65
- Or < 65 if:
- Medical history of fragility fracture
- < 127 lbs
- Medical causes of bone loss
- Parental history of hip fracture
- Current smoker
- Alcoholism
- Rheumatoid arthritis
- Dx = T-score < -2.5
- “Low bone mass” = -1 to -2.5
- Normal = > -1
- Skin Cancer
- Risk Factors
- FH
- Atypical nevi; high nevus count
- Sun / UV exposure
- Phenotypic Traits: light skin, red/blonde hair color, high density freckling, light eye color
- Skin Lesion Exam: (ABCDE)
- Asymmetry
- Border irregularities
- Color variations
 - Diameter > 6 mm
- Enlargement / Evolution
- Coronary Heart Disease
- Check Cholesterol: LDL, HDL, Triglycerides, Total cholesterol
- Risk Factors for CHD
- FH of hyperlipidemia, Peripheral vascular disease, or premature CVD (< 50 men or <60
women)
- Obesity, Diabetes, Hypertension
- Tobacco
- Dyslipidemia
- high LDL, Triglycerides, and Total cholesterol
- OR low HDL
- Screening Cholesterol assessment
- Age 45 in women, q5 years (unless risk factors)

Breast Disorders
- Breast Anatomy
- Terminal Duct Lobular Unit (TDLU) = lobule of acini that drain milk into terminal duct
- Ducts surrounded by myoepithelial cells to allow for milk ejection
- Standards of Surveillance of an adult woman
- Breast self-exam
- Physical Exam
- Performance of Clinical Breast Exam
- Include inspection of both axillae + entire chest wall
- Mammogram
- For 40+ yo
- Detects lesions 2 years before palpable
- Ultrasound
- For women < 40
- Or for inconclusive mammography findings
- MRI for very high risk women (like BRCA)
- Approach to woman with:
- Nipple discharge
- Bilateral or unilateral? Spontaneous or expressed? Uniductal or multiductal? Color? Mass?
- Cancer more concerning if:
- Bloody discharge
- Unilateral
- >> breast ductography
- Breast pain (Mastalgia)
- Cyclic: associated with Luteal phase of menstrual cycle
- Pain more in outer breasts
- Non-cyclic: no association with cycle
- Drugs, mastitis, tumors, cysts, surgery, idiopathic
- Extramammary pain
- Chest trauma, fibromyalgia, rib fractures, shingles, etc
- Tx
- Tight bra; weight reduction; Exercise
- Danazol (but has lots of side effects)
- Breast mass
- Signs concerning of malignancy:
- Size > 2 cm
- Immobility
 - Poorly defined margins
- Firm
- Skin dimpling or color changes
- Retraction or changes in nipple
- Bloody nipple discharge
- Ipsilateral Lymphadenopathy
- BIOPSY suspicious breast masses
- Non-Proliferative Breast Disorders
- Breast Cysts
- Common in women 35-50
- round/ovoid in shape
- Fibrocystic Change
- Cyclic pain
- Nodular tissue
- Dilation of acini and ducts, with dense stroma
- Fibrosis, Adenosis
- Proliferative Breast Disorders WITHOUT Atypia (increase risk BCa by 1.5-2)
- Intraductal Papilloma
- serous/bloody nipple discharge
- < 2 cm from the nipple
- Tx = surgical excision
- Fibroadenoma
- Common age 15-35
- Well defined, mobile mass
- Dense stroma with compressed ducts; well circumscribed
- Tx = observation or excision
- Usual Ductal Hyperplasia
- Increased duct cells, but retain cytological features of benign cells
- No tx needed
- Epithelial Hyperplasia, Sclerosing Adenosis, Sclerosing lesions, Papillomas
- Proliferative Lesions WITH Atypia (Cancer risk 3.7-5.3)
- Atypical Ductal Hyperplasia (ADH)
- Atypical Lobular Hyperplasia (ALH)
- Lobular Carcinoma in-situ (7-10x increased risk BCa)
- Management
- If biopsy shows ADH, ALH, or LCIS >> surgical excision
- Ductal Carcinoma in Situ (DCIS)
- Cells invade ducts but don’t invade basement membrane
- Cohesive, low grade cells
- Microcalcifications on mammogram
- Comedo necrosis = necrosis in the middle of cancer cells
- Tx = excision
- Breast Cancer
- Risk Factors for Breast Cancer
- Age
- Personal history of BCa
- BRCA, FH of early BCa
- High breast tissue density
- Early menarche; Late menopause
- No term pregnancies; First pregnancy after age 30; never breastfed
- Types
- Invasive Ductal Carcinoma
- 70% are Ductal
 - DCIS that has invaded the basement membrane
- Invasive Lobular Carcinoma
- “Single file” of cells
- Paget’s Disease of the nipple
- Eczematous patch on the nipple
- Associated with DCIS or invasive breast cancer
- Paget cells: large, pale cells with clear halo
- Presentation
- Mass
- Mammogram abnormality
- Her-2/neu
- Promotes growth of cancer cells (in 25% BCa)
- Good prognosis bc highly responsive to therapy
- Estrogen / Progesterone receptors
- ER+ = better prognosis than ER-
- Metastasis
- Regional LNs, brain, bone, liver, lung, ovaries
- Treatment
- Surgical: Lumpectomy or Mastectomy
- Radiation to reduce local recurrence
- Chemotherapy if high-risk characteristics of the tumor
- Hormone therapy if ER+
- Selective Estrogen Receptor Modulators (SERMs)
- Aromatase inhibitors
- Mastitis

Cervical Disease and Neoplasia

- HPV
- Causes 99.9% cervical cancer worldwide
- HPV 6/11 = more genital warts
- HPV 16/18 = more cervical cancer
- Epidemiology / Risk Factors
- Young (20-24 peak)
- # lifetime sex partners
- Early age of first intercourse
- Male partner sexual behavior
- Smoking
- Uncircumcised males
- Clinical Burden
- Infects 6 million annually in the US
- 75-90% lifetime likelihood of getting genital HPV
- HPV Vaccine
- Options
- Gardasil: quadravalent vaccine that prevents HPV 6, 11, 16, 18
- Cervarix: bivalent vaccine to prevent HPV 16/18
- ACOG Recommendation:
- Routine vaccination for females and males age 9-26
- First dose before age 15 + one dose 6-12 months apart
- OR if first dose is ≥ 15 yo:
- + 1 dose 1-2 months after first dose
- + 1 dose 6 months after first dose
- STILL SCREEN with Pap Smear even if had the vaccine
- Cervical Cancer
- Pathogenesis
- Squamocolumnar Junction = between squamous and columnar cells of cervix
- Descends in menarche to be visible
- Then ascends back up cervix with age
- Neoplasia almost always develops in the Transformation Zone
- Area of immature metaplasia between original and current squamocolumnar junction
- Risk Factors
- HPV (99.9% cervical cancers worldwide)
- OCPs, DES
- FH cervical cancer
- Hispanic, African American
- Immunosuppression (HIV, drugs, autoimmune disorders)
- SMOKING
- Low SES
- Lack of regular cancer screening
- Presentation
- Watery vaginal discharge; intermittent spotting; postcoital bleeding
- +/- visible cervical lesion
- Guidance for Cervical Screening
- First Pap = 21 yo
- < 30 yo: every 3 years
- > 30 yo: every 3 years OR every 5 years with cytology and HPV testing
- STOP screening:
- At 65
- Post hysterectomy with removal of cervix, without prior abnormal Pap
- History of CIN 2 or higher:
- Screen for 20 years after regression or treatment of lesion (even if over 65)
- Annually for high risk patients:
- DES in utero exposure
- Immunocompromised
- History of CIN II / III

- Initial Management for Abnormal Pap test

- >> COLPOSCOPY (biopsy) for diagnosis
- Acetic acid applied to cervix to make dysplastic cells appear white
- Treatment
- LLETZ
- Cryotherapy
- Ablation or Excision
- Closer screening
- Classification Terminology for Cervical Cytology
- Cervical Intraepithelial Changes (CIN)

- CIN1 / LSIL
- Mild atypical changes in the lower 1/3 of cervical epithelium
- Tx
- Observation (if good colposcopy)
- (likely resolves on its own)
- Colposcopy + cytology q6 months until 2 consistent negative Paps (says VCOM
powerpoint)
- Or Repeat Pap smear in 1 year (says ACOG video)
- CIN2 / CIN3
- CIN 2
- Covers lower 1/3 - 2/3 of the cervical epithelium
- HSIL if it’s p16 (+)
- LSIL if it’s p16 (-)
- CIN 3 = HSIL
- Change in > 2/3 epithelium
- 12-40% progress to cancer
- Tx usually recommended
- Ablation (Cryotherapy or Laser ablation)
- Excision (Cone or LEEP)
- Invasive Cervical Carcinoma
- Follows CIN3
MODULE 6: Pregnancy Complications
Preeclampsia / Eclampsia Syndrome
- Types of HTN in pregnancy
- Preeclampsia
- new-onset HTN ≥ 20 weeks
- + proteinuria OR end-organ dysfunction
- Gestational Hypertension
- HTN > 20 weeks without symptoms of preeclampsia
- Chronic Hypertension
- HTN before pregnancy, OR diagnosed ≤ 20 weeks
- Hypertension with Superimposed Preeclampsia
- chronic HTN + symptoms of preeclampsia
- Preeclampsia-Eclampsia
- Eclampsia = seizure onset in a woman with preeclampsia
- Pathophysiology
- By Maternal vasospasm
- Risk Factors for Preeclampsia
- History of Preeclampsia in previous pregnancy
- FH of preeclampsia (first degree relative)
- Primiparity
- Multiple Gestation
- Pre-exiting HTN, DM, Obesity
- Renal disease, hypercoagulability, SLE
- > 40 yo
- Presentation / Diagnosis
- Dx requires:
- High BP
- > 140/90 on two occasions > 4 hours apart after 20 weeks gestation
- + Proteinuria
- > 300 mg/24 hour urine
- Protein/Cr ratio > 0.3
- Dipstick 1+
- OR high BP + systemic findings of end-organ dysfunction
- Platelets < 100K
- Cr > 1.1
- LFTs 2x normal
- Pulmonary edema
- Cerebral / visual symptoms
- Management
- Preeclampsia
 -Delivery at 37 weeks if no severe features
-Close surveillance until 37 weeks gestation
- BP, serum, urine (for progression)
- BP meds if > 160/110
- Hydralazine, Labetalol, or Nifedipine
- US for fetal growth / evidence of restriction
- NSTs twice a week
- Betamethasone if < 34 weeks (for fetal lung maturity)
- Preeclampsia with Severe Features
- Delivery at 34 weeks if severe features (or even earlier if worsening symptoms)
- C-section not necessarily required
- determined by presentation, FGA, cervical status, maternal/fetal conditions
- “Severe Features”:
- Uncontrollable severe HTN
- Eclampsia
- Pulmonary edema
- Abruptio placentae
- DIC
- Nonreassuring fetal status, Intrapartum fetal demise, Nonviable fetus
- Magnesium Sulfate (for seizure prophylaxis)
- Eclampsia
- STABILIZE MOM first (will help to stabilize fetus)
- IV Magnesium sulfate (for seizures)
- Delivery Now (again, C-section is not required)
- Complications
- Maternal:
- Morbidity / Mortality (a leading cause, 50-60K / year worldwide)
- Eclampsia (before, during, or after labor)
- HELLP syndrome
- Placental abruption
- Stroke, Liver damage, Kidney injury, ARDS
- Fetal:
- Growth restriction
- Preterm labor
- Placental abruption
- HELLP Syndrome
- Hemolysis + Elevated Liver enzyme + Low Platelets
- Presentation
- Persistent edema unresponsive to resting in supine position
- May involve upper extremities, sacral region, face
- RUQ pain/tenderness (liver)
- Nausea / vomiting (nonspecific viral-like syndrome)
- Hyperreflexia on DTRs
- Clonus at ankle is worrisome
- Diagnosis Criteria
- Microangiopathic hemolysis (Hemolysis)
- Hepatocellular dysfunction (high LFTs)
- Thrombocytopenia (low platelets)
- Management
- Platelets if < 20K
- If < 34 weeks
- try Corticosteroids + Delay Delivery 24-48 hours after Corticosteroids if possible
- If labs or fetal status worsens, go straight to Delivery
 - If > 34 weeks, DELIVER

Gestational / Pregestational Diabetes

- Gestational Diabetes = carbohydrate intolerance starting with onset of pregnancy
- A1 = diet controlled
- A2 = medication/insulin controlled
- Pregestational Diabetes = diabetic before pregnancy
- Risk Factors
- Prior pregnancy with GDM
- BMI > 30
- Previous macrosomic fetus
- Impaired glucose metabolism (like PCOS)
- Family history
- Asian / Hispanic women
- Screening Protocol
- 50g 1 hour GTT > 200 (done at 24-28 weeks)
- If > 130, do 3 hour GTT
- (don’t need to be fasting)
- HbA1c
- Diagnostic Protocol
- 100g 3 hour GTT:
- Fasting > 95
- 1 hour > 180
- 2 hour > 155
- 3 hour > 140
- Need 2+ abnormal results to diagnose GDM
- Management / Monitoring
- Monitor Glucose:
- Morning + pre- and post-prandial levels throughout the day/evening
- Goals:
- Fasting < 95 (morning)
- 1-hour postprandial < 140
- 2-hour postprandial < 120
- DIET first: 30 kcal/kg per day
- Meds (if uncontrolled by diet)
- Insulin
- Fast-acting (Regular, Lispro, Aspart)
- Intermediate -acting (NPH)
- Long-Acting (Detemir, Glargine)
- Glyburide
- Stimulates insulin secretion from beta cells in peripheral tissues
- *not for sulfa allergic patients*
- Metformin
- Biguanide that improves insulin sensitivity in liver and peripheral tissues
- Delivery induced at 39 weeks if there are no complications
- C-section considered if fetal weight > 4500g
- Consider earlier delivery if indicated
- Constant glucose infusion (5% Dextrose) to maintain glucose at 100 mg/dL
- Glucose drops during delivery
- +/- paired with insulin infusion
- Complications
- Increased Fetal Growth
 - Shoulder Dystocia
- Cesarean Delivery
- Severe Perineal Laceration
- Preeclampsia
- Type 2 Diabetes
- Polyhydramnios
- In Neonate:
- Hypoglycemia
- Hypercalcemia, Hyperbilirubinemia
- Polycythemia
- Childhood Obesity
- Adult Type 2 Diabetes

Alloimmunization
- Pathophysiology
- RBCs contain surface antigens (antibodies will attack foreign antigens)
- ABO: Lewis Antigen (“Lewis Lives”)
- ABO Incompatibility >> mild hemolytic response / fetal Hyperbilirubinemia
- RhD: Kell antigen (“Kell Kills”)
- Rh- mom will mount antibody response to Rh+ fetus if exposed to fetal blood during delivery
- Antibodies will attack Rh+ fetus RBCs in subsequent pregnancies
- (antibodies can freely cross the placenta)
- >> fetal hemolytic anemia
- Modes of Sensitization
- Abortion, Ectopic Pregnancy, External Cephalic Version, Hydatidiform Mole
- CVS, Amniocentesis
- Abdominal Trauma
- Abruption / Bleeding Previa
- Childbirth, Delivery of placenta
- Consequences
- Severe anemia >> high output fetal cardiac failure
- >> FETAL HYDROPS
- Skin edema
- Ascites
- Pleural / Pericardial effusions
- Diagnosis
- Indirect Coombs Test
- Coombs+ means the patient has received sufficient antibody (anti-D Ig)
- Blood type screening for every pregnancy
- Doppler Ultrasound (for peak velocity of Middle Cerebral Artery flow)
- in Fetal Anemia, blood will be less viscous due to fewer cells
- So velocity of flow will increase in MCA
- Amniotic Fluid Assessment (for fetal anemia)
- Management / Prophylaxis
- RhoGAM to Rh- women
- RhoGAM = anti-D Ig
- 300 µg given at:
- 28 weeks (or earlier if sensitization even happens)
- 40 weeks if she still hasn’t delivered
- After delivery
- 300 mcg protects Rh- mother from 15 mL RBCs or 30 mL whole fetal blood
- (average fetal blood volume = 350 ccs (like a 12 oz can of soda)
Third Trimester Bleeding
- By Term:
- Blood volume increased 40%
- CO increased 30%
- 20% of this goes to gravid uterus (bad if it starts bleeding)
- Causes
- Serious:
- Placenta Previa, Placental Abruption
- Vasa Previa
- Preterm Labor
- Uterine rupture
- Benign: Vaginal / Cervical Tear, Cervical polyp, Severe Cervicitis
- Evaluation
- ABCs (+ evaluate Baby)
- Fetal Heart Rate
- PPQRST History
- Pain with bleeding?
- Placental location
- Quantity of bleeding
- Recreational drug use
- Sex recently?
- Timing
- Exam
- Vitals (Maternal + Fetal heart signs)
- Petechiae on skin?
- Palpate Uterus (soft, hard, tender?)
- Speculum Exam (for visual examination of cervix)
- NO DIGITAL CERVICAL EXAM until placental location is confirmed
- Placenta Previa = placenta covers the internal os
- Complete or Marginal coverage
- >> painless vaginal bleeding
- Dx
- Ultrasound (placenta seen between fetal head and cervix)
- NO DIGITAL EXAM

- Management
- Volume resuscitation (if heavy bleeding)
- +/- Betamethasone (for lung maturity if < 34 weeks)
- C-section delivery
- Complications
- Bleeding from lower uterine segment
- Abnormal extension of Placental tissue (Accreta, Increta, Percreta)
 - Types
- Accreta = into superficial myometrium
- Increta = into myometrium
- Percreta = through myometrium into surrounding tissues
- Risk Factors
- Placental previa
- Previous myomectomy
- Prior C-section or endometrial ablation
- Cesarean Hysterectomy required
- ALL of these can >> significant bleeding / morbidity
- Placental Abruption = abnormal separation of placenta
- MC cause of coagulopathy in pregnancy
- Presentation = vaginal bleeding + abdominal pain (painful)
- Risk Factors
- Trauma
- COCAINE
- HTN
- Multiple gestations
- Dx = clinical exam
- Mx
- Monitor vital signs
- Fluid administration (make up for bleeding)
- Monitor fetal heart rates
- DELIVERY if severe hemorrhage
- Complications
- blue/purple uterus serosa (if blood penetrates uterus)
- Hemorrhage
- RhD hemolytic anemia in neonate
- DIC, depleted serum fibrinogen, low platelets
- Management of Acute Blood Loss / Hemorrhage
- IVF
- 1:1:1 ratio (to avoid dilution of clotting proteins)
- 1 unit FFP
- 1 unit PRBCs
- 1 unit Platelets
- Massive Blood Transfusion = > 10 units PRBCs in 24 hours
- 1 unit PRBCs = 200 ccs RBCs
- Should raise Hct by 3-4%
- When to give Transfusion
- Massive Hemorrhage (yes)
- Maternal Hb 6-7 (transfusion recommended)
- Hb 7-8 (consider it)
- Hb 8-10 (only give if symptomatic anemia or ACS)
- Risks of Transfusion
- Infection
- Allergic / Immune reaction
- Volume Overload
- RhoGAM for Rh- moms
- Trauma in Pregnancy
- Causes
- motor vehicle accident (most common)
- Physical violence against women (second most common cause)
- Risks:
 - maternal injury/death, placental abruption, uterine rupture, hemorrhage, PROM, preterm labor
- Management
- STABILIZE MOM
- If < 20 weeks, place mother in lateral decubitus tilt position
- Monitor vitals, FHTs (Doppler)
- Ultrasound
- Tocometry at least 4 hours if ≥ 23 weeks
- Then 24 hours if there are any signs of uterine tenderness, contractions, ROM,
nonreassuring fetal status
- Fetal-Maternal Hemorrhage
- Determine Rh status
- If Cardiopulmonary Arrest:
- Attempt resuscitation
- Emergent C-section after 4 minutes of failed resuscitation if in third trimester
- maternal resuscitation is easier after baby is delivered
- Fetal survival not likely if maternal vital signs absent for > 15 minutes
- More favorable if delivered within 5 minutes of loss of maternal circulation
- Uterine Rupture
- Complications

Premature Rupture of Membranes

- Definitions
- Premature Rupture of Membranes (PROM) = ROM before uterine contractions
- Preterm Premature ROM (PPROM) = ROM before 37 weeks (“preterm”)
- Leading cause of neonatal morbidity / mortality
- Prolonged ROM = ROM > 24 hours, regardless of gestational age
- Risk Factors for PROM
- (often there are no risk factors present)
- (anything that weakens chorioamniotic membrane)
- Prior preterm delivery (risk repeat PROM 15-30%)
- Vaginal infection (bacterial vaginosis, STI, etc)
- Uterine distension (multiple gestation, polyhydramnios, myomas)
- Placental Abnormalities (accreta, previa)
- Uterine abnormalities (fibroids, didelphys, short cervix)
- Invasive Procedures (Amniocentesis, Cervical cerclage)
- African American
- Low SES
- Low BMI
- Tobacco / Smoking
- Confirm ROM:
- Presentation
- Leaking fluid (big gush, or steady leaking)
- Confusing...could be urine, vaginal secretions, cervical discharge, semen, perineal sweat
- Diagnostic Methods
- Speculum Exam
- Pooling of clear fluid in vaginal vault
- Ferning
 - Nitrazine positive
- amniotic fluid is basic/alkaline (pH > 7.1) = appears BLUE on pH paper
- v. vaginal secretions pH 4.5-6

- + swab for gonorrhea, chlamydia, GBS

- Do NOT do digital exam if membranes are ruptured and mom is not in active labor
- Minimize infection risk
- Other Evaluation
- Non Stress Test (for Fetal Status)

- Ultrasound
- Fetal Presentation / Position
- Biophysical Profile (0-2 points each)
- (Normal = score 8-10)
- Amniotic Fluid Index
- Fetal breathing movements
- Gross motor movement
- Tone
- Non-stress test
- Management
- Expectant management or Delivery?
- Delivery Indications:
- > 34 weeks
- Signs of fetal / maternal infection
- Fetal distress
- Advanced labor
- Evidence of fetal lung maturity
- Expectant Management
- Risk/Benefits of Expectant Management based on Gestational Age
- > 37 weeks (90% will go into labor within the next 24 hours)
- Wait it out
- Or Induce (via Oxytocin)
- Reduces time to delivery
- Decreases Chorioamnionitis, Endometritis, Admission to NICU
- < 37 weeks: need to weigh Risk of Prematurity v. Uterine Infection
- Late Preterm (34 - 36.6 weeks)
 - Induce labor once ROM is confirmed
- C-Section for Breech fetus
- Early Preterm (< 34 weeks)
- Risk prematurity > uterine infection
- If infection is present >> DELIVERY
- Uterine tenderness, fevers, or high WBC
- No infection:
1. Admit to inpatient
- Ultrasound (amniotic fluid volume)
- Non-stress testing
2. Corticosteroids (to enhance lung maturity)
3. Antibiotics
- to increase latency between ROM and spontaneous labor
- NOT to treat an infection (they’re given bc they’re proven to
increase latency)
4. Induce Delivery at 32-34 weeks
- But if ever see uterine infection, >> DELIVERY
- Antibiotics
- GBS prophylaxis (stop if GBS culture comes back negative)
- Broad spectrum antibiotics (like Erythromycin + Ampicillin)
- Corticosteroids
- Why? (matures lungs, stimulate surfactant release)
- Reduces Respiratory Distress Syndrome
- Reduces Intravascular Hemorrhage
- Indications for CS:
- < 32 weeks PPROM
- Or < 34 weeks without PPROM
- No signs of chorioamnionitis
- Tocolytics (Muscle relaxants)
- decrease contractions to promote latency
- Goal = delay delivery for 48 hours to allow steroids to promote lung maturity
- Tocolytic Options + AE + Contraindications
- Beta agonists (Terbutaline, Ritodrine)
- AE: hyperglycemia (don’t use in diabetics)
- CCBs (Nifedipine, Verapamil)
- AE: hypotension
- Prostaglandin Synthetase Inhibitors (Indomethacin)
- AE in Mom: Thrombocytopenia, Anemia
- AE in Baby: Necrotizing Enterocolitis (NEC)
- Death of intestinal tissue (survival of 70-80%)
- Magnesium Sulfate
- Also prevents seizures
- Contraindicated in myasthenia gravis
- AE: depressed reflexes, flushing, SOB, Pulmonary edema
- Fetal Monitoring
- Kick Counts
- Fetal Tracings
- Ultrasound (interval growth, Biophysical profile, Presentation)
- Potential Complications
- Fetal Mortality (⅓ < 26 weeks, 15% > 26 weeks)
- Pulmonary Hypoplasia
- Cord prolapse
- MSK deformities
 - Placental abruption
- Maternal Postpartum Endometritis

Preterm Labor
- 3 Criteria for “Preterm Labor”
- 20-37 weeks
- Regular contractions
- Cervical change (Effacement, Dilation)
- Risk Factors
- Prior Preterm delivery (20-30% recurrence)
- Multifetal Gestation
- Vaginal infection
- Uterine distension
- Placental abnormalities
- Uterine abnormalities
- Low SES
- Low BMI
- Tobacco
- Presentation
- Menstrual-like cramps, Low dull backache, Abdominal pressure, Pelvic pressure
- Increase/change in vaginal discharge (mucous, watery, light bloody)
- Uterine contractions (often painless)
- Evaluation
- Speculum Exam for ROM
- Ferning? Pooling of fluid? Nitrazine positive?
- Cervix open or closed?
- Digital Cervical exam (dilation?)
- Labs
- Lung Maturity
- Lecithin:Sphingomyelin Ratio > 2
- Lecithin increases ≈ 35 weeks while sphingo stays constant
- Phosphatidylglycerol present (if present, < 5% will develop RDS)
- Lamellar body number density (LBND)
- Best if LBND > 50K (fetal lung maturity)
- Gestational Age:
- < 34 weeks: 32% chance ARDS
- 34-36 weeks: 14%
- > 36 weeks: 2%
- Predict Risk of Preterm Delivery
- LOW likelihood of delivery in the next week IF:
- Fetal Fibronectin (fFN) negative
- Protein produced by trophoblasts and chorioamniotic membranes (“glue” to
maintain integrity of membranes)
- Will be positive when it breaks down and is found in cervical-vaginal fluids
- Cervical length ≥ 30 mm
- GBS
- Abdominal Ultrasound
- Presentation + Position
- Biophysical Profile (including amniotic fluid volume)
- Cervical Length
- Prevention
- 17-a-hydroxyprogesterone caproate
- Weekly injections from 20 - 36 weeks gestation
 - Management
- Corticosteroid Use Indications (to develop lungs, decrease hemorrhage risk)
- No signs chorioamnionitis
- ≤ 32 weeks with PPROM
- Or < 34 weeks without PPROM
- Tocolytics
- To delay delivery 48 hours until Corticosteroids can mature the lungs
- Beta agonists, CCBs, Magnesium Sulfate, Indomethacin
- Antibiotic Indications
- GBS Prophylaxis
- Adverse Outcomes
- Significant disabilities
- Mortality (60% if < 25 weeks)
- Cardiovascular abnormalities
- Intracranial hemorrhage
- Hypoglycemia
- Necrotizing Enterocolitis
- Infection
- Retinopathy of prematurity / Blindness
- Fetal Lung Development
- Type II pneumocytes line alveoli and produce phospholipids packaged into lamellar bodies
- Surfactant released from lamellar bodies >> reduces surface tension
- Components: Lecithin + Sphingomyelin + Phosphatidylglycerol
- Phosphatidylglycerol appears later in gestation
- Braxton-Hicks Contractions = painless intermittent contractions without cervical dilation
- Increase in frequency throughout gestation

Fetal Growth Abnormalities

- Macrosomia = > 4500 g
- Large for Gestational Age = > 90th percentile for gestational age
- Intrauterine Growth Restriction = weight < 10th percentile for gestational age
- Detection Methods
- ULTRASOUND
- Fetal Biometry Measurements
1. Biparietal diameter
2. Head circumference
3. Abdominal circumference
4. Femur length
- Fundal height
- Maternal weight gain / size (limited value)
- Doppler Velocimetry of fetal vessels
- Management
- Surveillance
- Delivery when fetal death risk > neonatal death risk (difficult to assess)
- Offer C-Section if estimated fetal weight > 4500 g

Medical / Surgical Conditions in Pregnancy

- Anemia
- Physiologic Anemia happens naturally in pregnancy
- bc plasma volume increases 45% in pregnancy, but RBC volume only increases 35%
- Average Hg 12.5 in pregnancy (v. 14 in non-pregnant)
- Diagnosis by Trimester
- T1: Hb < 11 Hct < 33%
 - T2: Hb < 10.5 Hct < 32%
- T3: Hb < 11 Hct < 33%
- Mx
- Iron supplements (if iron deficiency)
- 60 mg elemental iron / day
- or 300 mg Ferrous Sulfate / day
- Folate supplement (if folate deficiency / high MCV)
- 0.4 mg/day (Rx prenatal vitamins contain 1 mg)
- (or 4 g/day if history of NTD)
- When to give Transfusion
- For Massive Hemorrhage
- Maternal Hb 6-7 (transfusion recommended)
- Hb 7-8 (consider it)
- Hb 8-10 (only give if symptomatic anemia or ACS)
- Impact
- Baby: diminished iron stores
- Mother: regular adult anemia (fatigue, etc)
- Preexisting Renal Disease
- Risk associated with:
- High Creatinine > 1.5
- HTN present
- Complications
- Hypertensive complications
- IUGR
- Urinary Tract Disorders
- Asymptomatic Bacteriuria >> Ampicillin, Cephalexin, or Nitrofurantoin 7-10 days
- Acute Cystitis >> same (Amp, Ceph, or Nitrofurantoin)
- Pyelonephritis >> IV hydration + Antibiotics (Cephalosporin, Ampicillin, or Gentamycin)
- Acutely ill (fever, CVA tenderness, malaise, dehydration)
- Impact
- Preterm labor
- Septic Shock in mom
- ARDS
- Nausea/Vomiting of Pregnancy (NVP)
- DDx
- Pregnancy-Related
- Acute fatty liver of Pregnancy
- Preeclampsia, HELLP
- NOT Pregnancy-related
- GI: gastroenteritis, gastroparesis, gallbladder, bowel obstruction, hepatitis, PUD,
pancreatitis, appendicitis
- GU: pyelonephritis, ovarian torsion, kidney stones
- Metabolic: DKA, Porphyria, Addison, Hyperthyroidism
- Neuro: migraines, CNS tumors
- Exam Findings that point to NOT pregnancy related
- Abdominal pain / tenderness (other than mild epigastric discomfort
- Fever, headache
- Abnormal neuro exam
- Goiter
- Management
- DIET: frequent small meals, high carb, low fat, bland/salty diet, clear liquids, rest, fresh air
- Vitamin B6 (Pyridoxine) +/- Doxylamine (first line)
- Antihistamines (H1 blockers), Promethazine, Dimenhydrinate
 - Dopamine antagonists (Phenothiazines, Benzamides)
- IVF for dehydration
- Chlorpromazine, Metoclopramide, Odanzetron
- DDx of R Side Abdominal Pain in pregnancy
- Appendicitis (RLQ)
- Good outcome if early diagnosis and treatment
- Evaluation
- WBC, CRP
- Abdominal Ultrasound (imaging of choice, since CT has radiation)
- Tx = prompt appendectomy (delay increases risk of perforation, which increases fetal complications)
- RUQ = cholecystitis, cholelithiasis, hepatic hemorrhage, liver dysfunction (HELLP)
- IBD, Adnexal pain
- Cardiac Disease
- Respiratory Disorders
- Surgical Abdomen

Post-Term Pregnancy
- Normal Period of Gestation
- Complications of Prolonged Gestation
- Evaluation
- Management

Multifetal Gestation
- Risk Factors
- Embryology
- Diagnosis
- Management
- Complications (Fetal / Maternal)

MODULE 7: Menstruation + Contraception

Normal and Abnormal Bleeding
- Normal Menstrual Cycle
- Normal = predictable and regulated
- 21-35 day cycles
- Flow 4-6 days
- Loss of ≈ 30 cc menstrual blood
- Physiology
- Ovarian dominant follicle secretes estradiol
- Follicular Phase
- LH levels increase >> LH surge on day 11-13
- >> ovulation
- After ovulation, dominant follicle becomes corpus luteum
- Luteal Phase
- Corpus luteum produces Progesterone (+ some estrogen)
- Negatively feeds back to decrease FSH/LH
- Progesterone develops the secretory uterine lining
- FSH/LH are at lowest levels by the end of the luteal phase
 - Feedback >> rise in preparation for next cycle
- No fertilization:
- Corpus luteum breaks down >> decreased Progesterone >> uterine wall breaks down
- >> Menses
- Abnormal Uterine Bleeding
- Definition = menstrual flow outside of normal regularity, frequency, volume, or duration
- Most cases in 5-10 years before menopause
- Pathophysiology
- Causes
- PALM-COEIN
- Polyps
- Adenomyosis
- Leiomyoma
- Malignancy
- Coagulopathy (like vWF)
- Ovarian dysfunction (PCOS, perimenopausal anovulation)
- Endometrial processes
- Iatrogenic
- Not yet classified
- Pregnancy
- Gonorrhea, Chlamydia
- Evaluation
- History: heaviness of periods; pattern of bleeding
- Exam:
- Excessive weight gain
- Signs of:
- PCOS (hirsutism, acne)
- Thyroid disease
- Insulin resistance
- Bleeding Disorder (petechiae, ecchymosis, skin pallor, swollen joints)
- Pelvic Exam (including bimanual)
- Endometrial Biopsy
- Low index of suspicion to rule out endometrial cancer for:
- Women > 40 yo
- Risk factors present (obesity, diabetes, etc)
- Labs:
- CBC (for anemia)
- TSH (rule out thyroid disease)
- PREGNANCY TEST in reproductive age women
- Pelvic Ultrasound
- Management
- Initial Options
- OCPs, Cyclic Progesterone
- Levonorgestrel IUD
- Endometrial Ablation (but rule out endometrial hyperplasia first with endometrial biopsy)
- Surgical Options
- Possibly needed if due to anatomic source, like Polyp or Fibroid
- Hysterectomy if all else fails
- Leiomyoma (Fibroids) (was case in module)
- Evaluation
- Exam + Ultrasound
- +/- CT or MRI
- Hysteroscopy
 - Treatment
- Medical:
- Progestin supplementation
- Iron if anemic
- GnRH agonists before planned hysterectomy (to reduce fibroid size)
- Surgical
- Myomectomy (if may still want children)
- Hysterectomy (if don’t want more children)
- Articles in Modules
- Mx of AUB due to Ovulatory Dysfunction (ACOG)
- Progestin-only Contraception
- Combined hormonal contraception
- Endometrial ablation or Hysterectomy if all else fails
- Mx of Acute AUB in Non-pregnant Reproductive-Aged Women (ACOG)
- Classify Cause by PALM-COEIN system
- Management
- Initially Medical
- IV conjugated equine estrogen
- OCPs, Oral Progestins
- Tranexamic acid
- Surgical Treatment based on stability, bleeding severity, contraindications to medications,
lack of response to medications, underlying medical conditions, and desire for future fertility
- Transition to long-term maintenance therapy after acute bleeding is controlled

Uterine Leiomyoma
- Prevalence
- Presentation
- Diagnosis
- Management

Amenorrhea
- Amenorrhea = absence of menstruation
- Primary Amenorrhea = no menarche by 16 years old
- Secondary Amenorrhea = no menstruation for 3-6 months or 3 cycles
- Oligomenorrhea = bleeding less frequently than every 35 days
- Pathophysiology
- Causes
- Pregnancy (MC cause)
- Hypothalamic-Pituitary dysfunction
- Functional (weight loss, excessive exercise, obesity)
- Drugs, Psychogenic causes (anxiety, anorexia nervosa), head injury, chronic illness
- Neoplastic (Prolactin-secreting pituitary adenoma, Craniopharyngioma, Hypothalamic hamartoma)
- Ovarian dysfunction
- Turner syndrome; X chromosome deletion
- Gonadotropin-resistant ovary syndrome (Savage syndrome)
- Premature natural menopause
- Autoimmune ovarian failure
- Altered Genital outflow tract
- Imperforate hymen, transverse vaginal septum
- Asherman Syndrome (MC cause of secondary amenorrhea)
- Scarring of endometrium after D&C to remove products of pregnancy, or adhesions
- Evaluation
- H&P (including Tanner staging, hirsutism)
 - TSH (rule out subclinical hypothyroidism)
- FSH (high in women < 40 can mean primary ovarian insuficiency)
- Prolactin
- Autoimmune antibodies
- Progesterone Challenge test (give 10-14 days progesterone, and it should induce withdrawal bleeding a
week after completing the oral course)
- Yes bleeding = no problem with estrogen’s effect on the endometrium
- Cause probably anovulatory or oligo-ovulatory
- No bleeding = hypoestrogenic, Asherman syndrome, outflow tract obstruction
- Amenorrhea Dx / Mx (ACOG Article in Module)
- Metformin for PCOS patients (A recommendation)
- C Recommendations
- Exclude Pregnancy
- Weight restoration, nutritional rehab, and decreased exercise for patients with functional
hypothalamic amenorrhea (and female athlete triad)
- Evaluate overweight PCOS patients for glucose intolerance, dyslipidemia, and overall cardiovascular
risk
- Diagnosis
- H&P, Pregnancy test, LH, FSH, TSH, Prolactin, Ultrasound, etc
- Pregnant = pregnancy test +
- Thyroid dysfunction = abnormal TSH
- Pituitary Adenoma = abnormal prolactin level >> MRI
- No Uterus
- Androgen insensitivity syndrome, Mullerian agenesis
- Functional Amenorrhea (Energy deficit) = low FSH/LH
- Primary Ovarian Deficiency = high FSH/LH
- Turner syndrome
- PCOS = hyperandrogenism, high LH, low FSH
- Outflow Tract Obstruction = normal FSH/LH and all other causes excluded

PMS / PMDD
- Criteria for Diagnosis
- PMS Criteria (at least 1 symptom during 5 days before menses for last 3 menstural cycles)

- PMDD Criteria
- For majority of menstrual cycles, at least 5 symptoms present in week before menses, and improve
in first days of menses
- 1+ of the following:
- Marked affective lability (mood swings, sad/tearful, increased sensitivity to rejection)
- Marked irritability, anger, or increased interpersonal conflicts
- Marked depressed mood, feeling of hopelessness, or self-depreciating thoughts
- Marked anxiety, tension, and/or feelings of being keyed up or on edge
- AND 1+ of the following:
- Decreased interest in usual activities (work, school, friends, hobbies)
 - Subjective difficulty concentrating
- Lethargy, easy fatiguability, marked lack of energy
- Marked change in appetite, overeating, or specific food cravings
- Hypersomnia or insomnia
- Treatment Options
- Nonpharm:
- Fruits, vegetables (limit sugars, fats, salt, caffeine, alcohol)
- Aerobic exercise
- Calcium or Magnesium supplements
- Pharm:
- NSAIDs for dysmenorrhea, breast pain, leg edema in PMS
- OCPs
- SSRIs for PMDD (GOLD STANDARD for PMDD)
- ACOG Article in Module (PMD/PMDD)
- SSRIs for first line treatment in PMS / PMDD (A recommendation)
- OCPs are effective for PMS / PMDD (A recommendation)
- Calcium supplements 1000 - 1200 mg/day may help PMS (B)
- CBT may improve PMS / PMDD (B)
- Daily Record of Severity of Problems is a useful tool to help diagnose PMS / PMDD (C)

Contraception / Sterilization
- Pathologic basis for contraception
- Mechanisms of Methods:
- Prevent Ovulation
- Combined OCPs, Medroxyprogesterone acetate injections (Depo), Etonogesterel implants
- Lactational amenorrhea (infant suckling interrupts GnRH secretion >> low LH/FSH >> low
follicle development)
- Prevent Fertilization
- Keeping millions of sperm from contacting the oocyte
- Physical Barriers:
- condoms, diaphragms, sterilization
- thickened cervical mucus (pills, implants, injections, progestin-only IUDs)
- Chemical Barriers:
- Spermicide (deposited near cervix before sex and needs to be in place for at least an
hour afterwards
- Copper IUD (causes local inflammation that’s toxic to sperm and egg)
- Temporal methods
- Fertility Awareness (avoid intercourse for 5 days before to 1 day after ovulation)
- Emergency contraceptives (purely a temporal barrier and doesn’t interact with
established pregnancy)
- Ulipristal acetate (a selective progesterone receptor modulator)
- Copper IUD can be used up to 5 days after unprotected sex as emergency
contraception
- Prevent Implantation
- Copper IUD
- Levonorgestrel IUD
- Progestin
- Etonorgestrel, Levonorgestrel, Norgestimate
- Mechanism
- Causes negative feedback on Hypothalamus >> inhibits LH and LH surge >> inhibits
ovulation
- Thickens cervical mucous
- Creates thin resting endometrium
 - May interfere with egg transport via tubal peristalsis
- Estrogen
- Ethanol Estradiol, or Estradiol valerate
- Mechanism
- Negative feedback >> FSH suppression >> Prevents follicle recruitment, maturation, and
ovulation
- Potentiates concentration of progesterone receptors
- Balanced endometrial proliferation (minimizes irregular bleeding)
- Methods
- Hormonal
- Estrogen / Progesterone
- OCPs, Transdermal Patch, Vaginal ring
- Progesterone Only
- Progesterone pills
- Etonogestrel implant, Medroxyprogesterone injections (Depo-Provera)
- Levonorgestrel IUD
- Non-Hormonal
- Lactational amenorrhea
- Fertility awareness methods
- Barrier methods (condoms, diaphragms, spermicide)
- Sterilization
- Copper IUD
- Comparing Methods (Effectiveness, Benefits/Risk, Financial considerations)
- Male:
- Condom (18 / 2% failure rate)
- Withdrawal (22 / 4)
- Female
- LARC
- IUD (Copper 0.6%; LNG 0.2%)
- Implantable (0.05)
- Injectable (6 / 0.2)
- Hormonal (ALL 9 / 0.3%)
- OCP Combined or Progestin only
- Patch, Ring
- Barriers
- Condom (21 / 5)
- Sponge (24 / 20)
- Diaphragm (12 / 6), Spermicide (28 / 18)
- Couple
- Fertility Awareness (24 / 0.4 - 5%)
- Coitus Interruptus (22%)
- Permanent Option
- Sterilization
- Emergency Contraception
- Progesterone
- Ulipristal
- Copper IUD
- Methods of Sterilization
- Male = Vasectomy (compromise of vas deferens)
- Safer, less expensive, and more effective than female sterilization
- More reversible than female sterilization
- 1% failure rate
- Must confirm azoospermia by semen analysis (98% at 6 months)
 - Female = hysterectomy, fallopian cautery / clips / rings / ligation / etc
- Reversal is high cost and low success rate
- Risks / Benefits of Procedures
- Potential surgical complications
- Failure rates
- Reversibility

Hirsutism / Virilization
- Normal Variations of Secondary Sex Characteristics
- Hirsutism = presence of coarse pigmented hair on the face, chest, upper back, or abdomen in a female as a result
of excessive androgen production (hyperandrogenism)
- Virilization =
- Physiology
- Types of Androgens: Testosterone, DHEAS, Androstenedione
- Androgens are produced in the:
- Adrenal glands
- Ovaries (in theca cells)
- extraglandular tissue
- Hyperandrogen + PCOS Causes
- Increased number theca cells, or increased LH receptors on theca cells
- High LH stimulation of theca cells, or increased sensitivity of theca cells to LH
- Potentiation of LH by hyperinsulinemia
- Causes
- Ovarian
- PCOS = most common cause of excess androgens and hirsutism in women
- Oligomenorhea / amenorrhea, acne, hirsutism, infertility, obesity
- Excess androgens, high LH, low FSH, high Testosterone
- Ovarian tumors
- Adrenal
- Congenital Adrenal Hyperplasia (2nd most common cause behind PCOS)
- Cushing Syndrome, Adrenal neoplasms
- Pituitary
- Pharm
- Danazol (used for suppression of pelvic endometriosis)
- OCPs (Progestins)
- Evaluation
- H&P + Pelvic Exam
- Hyperandrogenic symptoms?
- New constitutional symptoms?
- Onset?
- Normal Exam + Mild Symptoms >>
- Trial medication 6 months
- If no improvement, >> Testosterone testing
- Moderate symptoms concerning for PCOS >>
- Total Testosterone level
- High > 200: order Hormone testing + Imaging
- Not high < 200: order TSH, Prolactin, 17-OHP, +/- Cushing testing
- Rapid onset palpable mass >>
- Hormonal Workup
- Imaging
- Management
- Non-Medical
- Shaving, plucking, waxing, depilatory creams
 - Electrolysis / Laser hair removal
- Combined OCPs
- Decrease adrenal / ovarian androgens (>> decrease hair growth)
- Desogestrel, Gestodene, Norgestimate
- PCOS management If she wants to become pregnant:
- Not OCPs obviously if she wants pregnancy, so:
- Weight reduction
- Ovulation induction with Clomiphene
- Exogenous gonadotropins
- Ovarian surgery
- Other options
- Oral Progestins (suppress LH)
- Oral Estrogens
- increases sex hormone binding globulin in the liver >> decreased testosterone
- Medroxyprogesterone
- Decreases GnRH >> decreases testosterone
- Glucocorticoid (For Adrenal Hyperandrogenism)
- Ketoconazole
- Spironolactone

MODULE 8: Menopause, Oncology, Pelvic Support

Pelvic Support Defects and Urinary Incontinence
- Primary Support of Pelvic Floor
- Levator Ani muscles (Iliococcygeus, Pubococcygeus, and Puborectalis)
- Endopelvic Fascia (secondary support)
- Uterosacral ligaments, Cardinal ligaments, and Arcus tendineus
- Levels of Support
- 1: Apical support
- Cardinal-Uterosacral ligaments (apical attachment to uterus and sacrum)
- Defect >> uterovaginal prolapse
- 2: Mid-vaginal
- Arcus tendinous fascia (overlying levator ani)
- Support upper ⅔ of the vagina laterally
- Defect >> cystocele
- 3: Distal Vaginal
- Urogenital diaphragm + Perineal body
- Defect >> distal rectocele
- Pelvic Organ Prolapse = descent of pelvic structure(s) to or through the vaginal opening
- Risk Factors
- AGING and VAGINAL DELIVERY (most common)
- Menopause (less collagen)
- Chronic increased abdominal pressure, Constipation, Obesity
- Pelvic floor trauma, Connective tissue disorders
- Presentation
- Bulge symptoms
- Incontinence
- Dyspareunia
- Types
 - Cystocele = bladder prolapse through vagina
- Rectocele = rectum prolapse through vagina
- Vaginal Vault Prolapse = descent of vaginal vault post-hysterectomy
- Uterine Prolapse = uterine descent through vagina
- Treatment
- Expectant Management (treat only if symptomatic or causing problems)
- Pelvic floor Physical Therapy
- Vaginal pessaries
- Surgical Management (but there is risk of recurrent prolapse with surgery)
- Hysterectomy
- Reconstruction
- Incontinence
- Involuntary leakage of urine
- Physiology
- Urine Storage = Sympathetic
- Contraction of sphincter by pudendal nerve
- Contraction of smooth muscle at neck of uterus to keep it closed
- Micturition = Parasympathetic
- Relaxation of sphincter by pudendal nerve
- Contraction of smooth muscle of the bladder and relaxation of smooth muscle at the neck of
the baldder (hypogastric nerve)
- Types of Incontinence
- Stress Incontinence
- Happens with increased abdominal pressure (coughing, sneezing, laughing, weight lifting,
etc)
- Causes
- Urethral hypermobility (insufficient support tissue)
- Intrinsic sphincter deficiency (loss of urethral mucosal and muscular tone)
- Tx
- Kegel exercises, PT
- Pessaries, Urethral bulking agents, Mid-urethral sling
- ACOG Article in Module
- Evaluation:
- H&P + assess for Pelvic Organ Prolapse
- Urinalysis, Postvoid residual urine volume
- Cough stress test, Urethral mobility
- Urge = “Overactive Bladder”
- Urge to urinate followed by involuntary leakage
- Cause = Detrusor overactivity >> involuntary detrusor contractions
- Tx
- Bladder training
- Prompted voiding
- Beta agonists (act on beta receptors to enhance detrusor relaxation)
- Antimuscarinics (decrease detrusor contractions)
- AE = dry mouth, blurred vision, tachycardia, constipation, drowsiness
- Mixed = stress + urge incontinence symptoms
- Overflow
- Incomplete bladder emptying
- Cause:
- Detrusor underactivity (spinal nerve damage, neuropathy, etc)
- Bladder outlet obstruction (fibroids, pelvic prolapse, etc)
- Tx
- Treat cause
 - Intermittent straight catheterization (to empty the not-emptying bladder)
- Evaluation
- History + Exam (evaluate for pelvic organ prolapse)
- Postvoid residual urine volume
- Urodynamic testing (measure pressure/volume of bladder filling and flow rate of emptying)
- Cystourethroscopy (for lesions, foreign bodies, malformations, strictures)
- Treatment for ALL Types:
- Weight loss
- Normalize fluid intake
- Decrease bladder irritants
- Minimize constipation
- Smoking cessation
- UTI
- Risk Factors
- Upper UTI
- Diagnosis
- Treatment
- Lower UTI
- Diagnosis
- Treatment

Menopause
- Menopause = 12 months of amenorrhea (on depletion of ovarian follicles)
- Perimenopause = transition from reproductive age to menopause (about 4 years before final period)
- Physiologic Changes in the HPO axis in perimenopause / menopause
- Hypothalamus >> [GnRH] >> Pituitary >> [LH/FSH] >> Ovary >> Estrogen + inhibin
- Inhibin >> negative feedback to hypothalamus and pituitary
- Perimenopause
- First part of follicular phase shortens
- Increased anovulatory cycles >> abnormal uterine bleeding
- Increased risk endometrial hyperplasia and cancer (unopposed estrogen due to anovulation)
- Menopause:
- Depletion of ovarian follicles
- >> low estrogen production
- Feedback >> GnRH release >> high FSH/LH
- Presentation
- Vasomotor symptoms
- Hot Flashes, Sweating
- Palpitations
- Anxiety
- Sleep disturbances
- Increased risk bone loss
- Due to RANK-L, osteoclasts, bone resorption
- Increased LDL, Cardiovascular disease
- Mastalgia
- Vulvovaginal atrophy
- Dryness, itching, dyspareunia
- By low estrogen and decreased collagen and adipose tissue
- Incontinence, UTIs
- Depression
- Management
- Menopausal Hormone Therapy
- Estrogen AND Progesterone (to prevent uterine cancer)
 - If no uterus, then don’t need Progesterone; can just use Estrogen
- Minimal dose for shortest amount of time possible
- Contraindications to HT:
- Undiagnosed genital bleeding
- Known estrogen-dependent neoplasia
- Active DVT, PE, or history of those
- Active stroke, MI
- Liver disease / dysfunction
- Known / suspected pregnancy
- Gabapentin
- Clonidine
- SSRIs / SNRIs
- Vaginal Estrogen (for vaginal symptoms)
- Risks of Treatments:
- Combined HT: breast cancer, stroke, CVD, VTE risk
- Estrogen only: uterine cancer risk
- Progesterone only: depression, weight gain
- ACOG Module Articles:
- Tx of Menopause Symptoms
- Vasomotor Treatment
- Systemic Hormone Therapy +/- Progestin
- But raises risk for VTE and breast cancer
- Transdermal Estrogen may have lower risk VTE than oral estrogen
- DON’T routinely discontinue HT at age 65
- individualize therapy, bc some women may still need it after 65
- Estrogen + SERM (Bazedoxifene) for women with uterus
- Paroxetine = the only FDA-approved med for VMS management
- Though venlafaxine, clonidine, and gabapentin are all more effective than placebo
- Botanicals, natural products, herbs, etc have not been shown to be more effective
than placebo
- Vulvovaginal Atrophy
- Vaginal Estrogen (if no indications for systemic HT)
- Oral SERM Ospemifene = for dyspareunia associated with VVA
- Bioidentical Hormone Therapy
- = plant- or animal-derived hormones
- Lack of evidence to support bioidentical hormones over conventional menopause hormone therapy
- Conventional hormone therapy is preferred
- No good evidence to support individualized hormone therapy based on salivary, serum, or urine
testing

Gynecological Neoplasia
- Cervical Cancer
- (discussed in earlier module)
- Vulvar Cancer
- 90% SCC (then melanoma)
- Risk Factors
- Age
- HPV
- Smoking
- Lichen Sclerosus
- Presentation
- Vulvar pruritus
- red/white ulcerative or exophytic lesion
 - Evaluation
- Vulvar BIOPSY (Punch biopsy, colposcopy)
- Indications for Vulvar Biopsy
- Complaint of vulvar symptoms (cancer won’t always have an exophytic lesion)
- Persistent pruritus, burning, or pain
- Visible lesions
- Lymph Nodes involved:
- Inguinal, Femoral nodes
- Deep Pelvic nodes (if from anterior 1/3 of vulva)
- Treatment Options
- Radical Vulvectomy with bilateral node dissections (if very invasive)
- Or more conservative operations for unifocal lesions
- Postop radiation to decrease groin recurrence
- Uterine Cancer
- Usually Adenocarcinoma
- Risk Factors
- UNOPPOSED ESTROGEN
- Tamoxifen
- Obesity, Older age, Nulliparity, Infertility history
- Early menarche, Late Menopause
- Presentation
- Abnormal uterine bleeding + risk factors
- Often postmenopausal bleeding
- Causes of Endometrial hyperplasia / Cancer
- Diagnosis
- BIOPSY
- Transvaginal Ultrasound
- +/- CA-125 (often elevated)
- Management
- HYSTERECTOMY +/- Radiation
- Staging Impact on Management / Prognosis
- Endometrial Hyperplasia:
- D&C sample of endometrium to exclude coexisting cancer
- Progestins high-dose (for women who desire future fertility)
- Levonorgestrel IUD
- Hysterectomy = definitive therapy (after completion of childbearing)
- Stage 1 Cancer:
- Hysterectomy only
- Radiation may reduce recurrence, but doesn’t improve survival
- Stage 3c - 4 (Metastasis):
- Hysterectomy + RADIATION
- Recurrent Disease:
- Hysterectomy + RADIATION
- Progestin can also help
- Ovarian Cancer
- Growth Factors Associated
- Fibroblast Growth Factor (FGF)
- Platelet Derived GF (PDGF)
- Vascular Endothelial GF (VEGF)
- Risk Factors
- Older Age, Nulliparity, Infertility history
- Endometriosis
- BRCA, Lynch syndrome
- OCPs decrease risk of ovarian cancer
- Early Warning Signs of Ovarian Cancer
- Increased abdominal size, abdominal bloating / pain
- Fatigue, unexplained weight loss
- Indigestion, constipation, urinary frequency, incontinence
- Back pain
- Evaluation
- Ultrasound suspicious masses
- (+/- MRI, CT)
- CA125 Ovarian Biomarker
- But can be falsely elevated in other conditions that cause inflammation:
- Endometriosis, Uterine Fibroids, PID
- Cirrhosis, Pleural/Peritoneal fluid
- Cancer of uterus, breast, lung, pancreas
- HE4 another biomarker
- Associations:
- BRCA 1 / 2
- Can consider bilateral salpingo-ophorectomy to reduce risk
- Peutz Jegers Syndrome (+ mucocutaneous pigmented lesions)
- Lynch Syndrome (risk colon, uterine, ovarian, and stomach cancer)
- Histologic Categories
- Epithelial tumors (from fallopian tubes and surface epithelium)
- 60% High Grade Serous Carcinoma (@ TP53 or BRCA)
- 10% Endometroid Carcinomas (@ Lynch syndrome)
- 10% Clear Cell Carcinoma (@ endometriosis)
- 10% Mucinous Carcinoma (@ perimenopausal women)
- 3% Low Grade Serous Carcinoma
- Hyalinized stroma with psammoma bodies

- Germ Cell tumors (from primordial germ cells of the ovary)

- 95% Mature Teratoma / Dermoid (benign)
- Contains ectoderm, endoderm, and mesoderm
- Malignant:
- Immature Teratomas (2%)
- Ectodermal component undergoes malignant transformation
- Dysgerminomas (like seminomas; have LDH)
- Yolk Sac Tumors (young girls; Schiller Duval bodies; AFP)
- Mixed Germ Cell Tumors
- Sex Cord Stromal tumors (from ovarian stroma or follicles)
- Granulosa Cell Tumors
- Secrete estrogen
- biomarkeres inhibin A/B
- Call-Exner bodies
- Sertoli Leydig
- Secrete androgens or androgen precursors
- Fibromas (benign)
 - MC stromal tumor
- +/- Meig’s Syndrome: ascites, pleural effusions, fibroma
- Thecomas (usually benign)
- Solid, often very large tumors
- 90% Epithelial types
- Most common type of ovarian cancer = Serous cystadenocarcinoma
- Impact of Staging on Management
- Most commonly diagnosed at stage 3/4 (since earlier stages are asymptomatic)
- SURGERY + CHEMO usually (Paclitaxel + Carboplatin or Cisplatin)
- With cytoreductive surgery or “TUMOR DEBULKING” to decrease tumor size before chemo
- Staging of Ovarian Cancer

- Treatment of
- Simple Ovarian Cyst (Follicular Cyst):
- Resolves in 6 weeks spontaneously
- OCP may prevent recurrence