Chapter 1 History

o Age o Birth history

G - # total pregnancies (includes miscarriages, abortions, etc.) P - # pregnancies carried past 20 weeks A - # ended before 20 weeks TPAL system: e.g., G2P1001 (P, # term, # preterm, # abortus, # live births)

o LMP Used to calculate estimated gestational age (EGA) Estimated Due Date = LMP 3 months + 7 days

o Chief Complaint o Past GYN History:

Menstrual history Age of menarche (nl is 9-16 years) Interval first day of 1 cycle to first day of next cycle (nl is 28 7 days, or

between 21-35 days) Quantity of menses flow should last < 7 days (< 80 mL total), if excessive

-> menorrhagia o Irregular and heavy menses = Menometrorrhagia

o Contraceptive history Duration, type, last use of contraception, any side effects

o STIs History of HSV, Syphilis, GC, HIV, HPV, PID # of sexual partners, recent change in partners, use of barrier contraception

o Obstetric history Date and gestational age of each pregnancy + outcome If induced abortion, ask gestational age and method If delivered, ask method. If applicable, vacuum or forceps deliver, or type of C-

section (low-transverse vs classical) Complications of pregnancy

o PMH, PSH HTN, hepatitis, diabetes, cancer, heart disease, pulmonary disease, thyroid disease

o Allergies, Meds o Drug/Alcohol/Tobacco o ROS

Preeclampsia headache, visual disturbance, epigastric pain, facial swelling Always ask about preeclampsia symptoms for all pregnancies > 20 weeks!

Labs

o CBC assess for anemia and thrombocytopenia o Blood type, Rh, Coombs

For Rh-neg, Rhogam given at 28 weeks and at delivery (if baby is Rh+) o HBsAg if pos, newborn must be given HBIG and HepB vaccine o Rubella titer if not immune, must be vaccinated postpartum (live-attenuated so not given

during pregnancy) o RPR or VDRL positive needs to be confirmed (MHATP or FTA-ABS)

Treatment during pregnancy is crucial (penicillin) o HIV test screen with ELISA, confirm with western blot o Urine culture & U/A look for bacteriuria o Pap smear o GC endocervical assays

Timed Prenatal Tests

o 16-20 weeks NTDs and Down o 1st trimester trisomies via PAPP-A, NT, B-hCG o 26-28 weeks screen for gestational diabetes (50 g glucose load, watch glucose after 1 hour) o 3rd trimester optional repeat CBC, cervical cultures, RPR o 35-37 weeks GBS cultures (introital)

Gyn Patient labs for common scenarios:

o Threatened abortion Quantitative hCG and/or progesterone levels to help establish viability of pregnancy

and risk of ectopic pregnancy o Menorrhagia due to uterine fibroids

CBC, endometrial biopsy (look for endometrial cancer), pap smear (cervical dysplasia/cancer)

o Woman > 55 with adnexal mass CA-125 and CEA markers for epithelial ovarian cancer

Sonohysterography US of the uterus after injecting saline to give better definition Postmenopausal bleeding concern is endometrial cancer

o Risk factors: HTN, diabetes, anovulation, early age of menarche, late age of menopause, obesity, infertility, nulliparity

CASE 1 (INCONTINENCE) Case: Incontinence following stressor: cough/sneezing/lifting/Valsalva.

DDX: o Genuine Stress Urinary Incontinence (GSUI)

Incontinence due to sudden increase in intra-abdominal pressure (without bladder muscle contractions)

Normally, bladder and proximal urethra are both in intra-abdominal space, with urethra having more pressure. If for some reason (trauma, multiple births) proximal urethra goes infra-abdominal from weakening of pelvic diaphragm, coughing or some other stressor increases intra-abdominal pressure and causes urine to leak out

No urge, immediate incontinence following cough o Urge Urinary Incontinence (UUI)

Uninhibited spasms of bladder detrusor muscle -> overcomes urethral pressure May see dysuria and urge Delay (a few seconds) between cough and leaking (cough takes time to trigger

spasm) Treat with anticholinergic (Ditropan i.e., Oxybutynin)

o Overflow incontinence (Neurogenic Bladder) History of diabetes/spinal cord issue/MS No urge Post-void catheterization will show large amounts of urine Overdistended bladder, cough will further increase bladder pressure and lead to small

dribbling Treat with intermittent self-catheterization (or maybe Bethanechol to stimulate

contractions?) o Fistula

Post-surgery or prolonged labor Diagnose with dye in bladder

Work-up: U/A, post-voidal residual Phys: hypermobile urethra, cystocele, loss of urethrovesical angle

o Cystocele bladder bulging into anterior vagina (sign of pelvic relaxation, associated with anatomic problem of GSUI)

o Cysturethrocele proximal urethra below intra-abdominal cavity Differentiate between GSUI and UUI Cystometric Examination Treatment

o GSUI pelvic floor strengthening exercises (Kegel exercises) If that doesnt work urethropexy (surgical fixation of proximal urethra above pelvic

diaphragm in intra-abdominal space) or transvaginal fixation Transvaginal tape and Transobturator tape procedures install a hammock to support

the urethra with the assumption that part of disease path involves pubourethral ligament insufficiency

CASE 2: Health-Maintenance of 66-yo woman Most common cause of mortality in elderly women is cardiovascular disease Health maintenance test (3 parts):

1. Cancer Screening annual mammography, colon cancer (occult blood test, intermittent colonoscopy)

2. Immunizations Tdap q10 years, Pneumococcal vaccine at 65, yearly flu shot 3. Common diseases of this age group screen cholesterol q5 years up to 75 yo, thyroid function

test q5 years, and fasting blood sugar levels q3 years

CASE 3: Red mass bulging in introitus After vaginal delivery, a reddish mash is noted bulging in the introitus next to the placenta after slight lengthening of the cord DDX:

Uterine inversion (most likely) o A turning inside out of the uterus o Caused by undue traction of the cord before placental separation (might be due to placenta

taking too long to separate, and pulling occurs) o Reddish mass next to the placenta is the endometrial surface o Fundus is most common placental spot before inversion (cord is straight line out the canal,

easier to pull) o Rough/shaggy appearance o Complication: massive postpartum hemorrhage (almost always happens regardless of

treatment) Inverted uterus position makes it so uterine muscles cannot contract to stop

bleeding from spiral arteries (i.e., reason is uterine atony) o Treatment: reposition uterus back with fingers

If not, need anesthesiology (halothane for uterine relaxation) or surgery Get two IV lines in (in anticipation of shock) Terbutaline or Mg sulfate may help relax uterus too After putting uterus back to location, discontinue relaxants and start oxytocin

(uterotonic causes uterus to contract to stop bleeding) Prolapse of other masses/organs (vaginal or cervical tissue)

o Smooth appearance BACKGROUND INFO:

Stages of labor o 1st stage contractions and crowning o 2nd stage cervix fully dilated, baby delivered o 3rd stage placental delivery

Abnormally retained placenta = if third stage lasts > 30 minutes o Try manual extraction (if you wait too long, might cause hemorrhage)

Evidence of placental separation 1) Gush of blood 2) Lengthening of the cord 3) Globular and firm shape of uterus 4) Uterus rises up to the anterior abdominal wall

CASE 4: PERIMENOPAUSE Woman complains of irregular menses, feelings of inadequacy, sleeplessness, episodes of warmth and sweating DDX:

Climacteric state (Perimenopause) o Essentially symptoms of hypo-estrogen state (40-50 years) usually a 2-4 year transition

period before menopause Hot flash skin temp elevation and sweating for 2-4 min Low estrogen -> decreases epithelial thickness of vagina -> atrophy and dryness

o Test FSH and LH should be elevated here (because estrogen and androgen are low) Note: FSH cannot be used to titrate estrogen therapy, because it responds to inhibin,

not estrogen (may be high even if enough estrogen is given) o Treatment: estrogen replacement therapy with progestin

If woman still has uterus, progestin is important to prevent endometrial cancer in chronic estrogen use

Treats menopause and osteoporosis (fewer fractures) but increases risk of breast cancer and heart disease in long-term use

Note: The SERM raloxifene does not treat hot flashes, only for bone Osteoporosis prevention includes weight-bearing exercise, Ca and VitD supplements,

and estrogen therapy with progestin BACKGROUND INFO

Premature ovarian failure cessation of ovarian function due to follicular atresia (like in menopause), but prior to 40 years old

o If < 30 yo, think autoimmune or karyotypic anomalies Prolactinemia is a hypothalamus issue (prolactinoma)

o High prolactin -> low GnRH -> low estrogen -> low bone density o Will see low bone density on DEXA scan!! o Most common site of osteoporosis bone fracture is the thoracic spine (compression fracture)

PCOS obese, hirsute, anovulation, insulin resistance due to estrogen excess! o Prescribe progesterone or OCPs!

Marathon runner with amenorrhea excessive exercise leads to hypothalamic dysfunction! (weight gain can restore normal function)

o Prescribe OCPs to maintain normal hypothalamic function. Sheehan Syndrome Anterior pituitary hemorrhage associated with postpartum hemorrhage

o Cant breastfeed! No prolactin release from anterior pituitary. Hypoestrogen state.

CASE 5: NECROTIZING FASCIITIS 28-yo woman has fever, myalgia, vomiting, hypotension, and infected skin incision (underlying tissue brawny and has crepitus) 1 week following a C-section DDX:

Necrotizing fasciitis o Usually multiple organisms or anaerobes (rarely, GAS as flesh-eating bacteria) o Key feature: gas in tissue (crepitus) o If sunburn-like rash or desquamation, think S. aureus (nafcillin / methicillin, unless MRSA

-> Vanc) o Treatment: IV fluids, broad-spectrum antibiotics, immediate surgical debridement

Penicillin, Gentamicin, and Metronidazole Dopamine or Dobutamine (vasoconstrictors) are used if blood pressure cannot be

maintained by fluids alone o Goal is to keep MAP > 65 mm Hg for adequate organ / cerebral perfusion

BACKGROUND INFO:

Group A Strep Toxic Shock Syndrome rapidly progressing infection of episiotomy or C-section MAP = [2 x Diastolic + Systolic ] / 3

CASE 6: NORMAL ACTIVE LABOR NORMAL LABOR:

Normal term is 37-42 weeks since LMP Active phase of labor: 4 cm dilation

o If nulliparous, cervix will dilate at rate of > 1.2 cm/h during active phase o Normalcy of labor is dictated by cervical dilation, not uterine contraction pattern

Labor o Latent phase initial part of labor, cervix effaces (thins) rather than dilates o Active phase dilation occurs more rapidly, cervix > 4 cm dilation o First Stage complete dilation of cervix (latent + active phases) o Second stage delivery of infant o Third stage delivery of placenta

Protraction of active phase rate of cervical dilation in active phase is less than expected (should be > 1.2 cm/h for a nulliparous woman, or > 1.5 cm/h for those with at least one vaginal delivery)

Arrest of active phase no cervical dilation in active phase for 2 hours C-section is only for arrest of active phase or cephalopelvic disproportion! If labor abnormality, assess the three Ps: Powers, Passenger, Pelvis

o Powers If inadequate power, give oxytocin for increased contraction strength/frequency Normal contractions: once every 2-3 min, firm on palpation, and lasting 40-60

seconds (or measured as > 200 Montevideo units is adequate) o Passenger

Baseline fetal heart rate: 110-160 (bradycardia is < 110), helps assess fetal status Accelerations and variability are normal

Acceleration can be caused by maternal fever. (Early) deceleration by fetal head compression mirror images of uterine contractions; or (variable) cord compression quick in onset/decline; or (later) fetal hypoxia offset (see next page).

o Pelvis If there is a cephalopelvic disproportion (pelvis too small for fetus), then C-section

Even if mom is Rubella-nonimmune, it is a live attenuated vaccine, so do not give until after delivery

Bloody show is normal (mucus + vaginal bleeding), a sign of impending labor vs. placenta previa, abruption, vasa previa all just bleeding with no mucus

CASE 7: THREATENED ABORTION Definition of threatened abortion: vaginal spotting during first half of pregnancy. 18-yo female at 7 weeks gestation by LMP presents with 2-day history of vaginal spotting and lower abdominal pain. Physical exam: 4-week-sized uterus. -hCG = 700. No intrauterine gestational sac noted on ultrasound. Recommended action: Follow up on -hCG in 48 hours! Rule of thumb: if f/u -hCG levels rise by at least 66%, then most likely normal pregnancy. If < 66% rise (especially if 25 = normal; < 5 = nonviable pregnancy)

o Nonviable pregnancy = spontaneous abortion or ectopic pregnancy If -hCG level > 1500, then transvaginal sonogram (if intrauterine gestational sac is seen, then

discharge with close follow-up) o Miscarriage still possible, but not ectopic pregnancy o If -hCG level > 1500 but no evidence of intrauterine pregnancy, ectopic pregnancy

likelihood is HIGH!! Do laparoscopy to diagnose and treat.

CASE 8: PLACENTA ACCRETA Placenta accreta - Placenta will be very adherent to the uterus, attached to myometrium without

penetrating it Path: defect in decidua basalis layer placental villi are attached to the myometrium Treatment: hysterectomy (attempts to pull it will cause hemorrhage)

o Alternative: ligation of umbilical cord with IV methotrexate (not very successful) Risk factors: prior C-section, placenta previa, prior myomectomy Presentation: no separation of placenta, may have antepartum bleeding

BACKGROUND INFO:

Placenta increta abnormally implanted placenta penetrates myometrium Placenta percreta perforates - abnormally implanted placenta penetrates past

myometrium to serosa (often invades bladder too) Placenta abruption placenta has detached prematurely (may cause hemorrhage) Placenta previa placenta covering the uterus opening, not letting baby out

CASE 9: VAGINAL DISCHARGE Patient comes in with mucopurulent vaginal discharge and postcoital spotting DDX:

Gonococcal cervicitis o Treat: IM ceftriaxone + oral azithromycin (or doxycycline) for concurrent Chlamydia o Complications:

Salpingitis -> infertility or increased risk of ectopic pregnancy Disseminated gonorrhea is also possible

o Gonorrhea always at least affects cervix o Check for salpingitis (tubal infection, i.e., PID) adnexal tenderness? o Check for uterine involvement abdominal tenderness, heavy menses (indicative of upper

GU infection) o Check for dissemination signs of Gonococcal septic arthritis, or painful skin pustules

Bugs that can infect cervix and cause discharge o Chlamydia (most common), Gonorrhea, HSV (like urethra in men) o fishy odor = Gardnerella vaginalis (bacterial vaginosis) o foul-smelling green discharge = Trichomonas o cottage cheese discharge = Candida

For abnormal vaginal bleeding, always rule out: o Ectopic pregnancy o Threatened abortion

BACKGROUND INFO:

Lower genital tract vulva, vagina, cervix Upper genital tract uterus, fallopian tubes, ovaries

CASE 10: COMPLETED SPONTANEOUS ABORTION 35-yo at 8 weeks gestation lower abdominal pain, vaginal bleeding; after passing what looked like liver, her pain subsided DDX:

Completed abortion o Key signs: abd pain and bleeding that resides after expulsion of tissue, with a closed

cervical os on exam o Management: follow hCG levels to zero (to confirm all the tissue has been expelled)

Should halve every 2-3 days If plateaus instead of falling, then there is residual pregnancy tissue (incomplete

abortion or ectopic pregnancy) o Spontaneous abortions are usually due to chromosomal anomalies

BACKGROUND INFO:

Threatened abortion pregnancy < 20 weeks, with vaginal bleeding (no cervical dilation) Inevitable abortion pregnancy < 20 weeks, with cramping, bleeding, and cervical dilation but no

passage of tissue Incomplete abortion pregnancy < 20 weeks, with cramping, bleeding, and open cervical os, and

some passage of tissue, but also some tissue retained in utero o Cervix remains open due to continued uterine contractions (trying to expel rest of

tissue) o Vs. incompetent cervix (painless cervical dilation without contractions! -> cerclage) o Management of an incomplete abortion is dilatation and curettage

Completed abortion pregnancy < 20 weeks with complete passage of tissue and closed cervical os Missed abortion pregnancy < 20 weeks with embryonic/fetal demise but no symptoms Molar pregnancy trophoblastic (placental) tissue, but without a fetus

o Presents with vaginal spotting, absent fetal heart tones, size greater than gestational date, and very high hCG levels

o Diagnosis is by ultrasound snow storm appearance o Treatment is curettage, and then follow hCG to make sure no remaining trophoblastic tissue

CASE 11: Shoulder Dystocia Obese woman delivering at 42 weeks, average fetal weight of 3700 g, head delivers but shoulder does not come out

Shoulder dystocia o Definition: shoulder not coming out, stuck behind pubic symphysis o Management: McRoberts maneuver (hyperflexion of maternal hips onto abdomen)

and/or suprapubic pressure (push on suprapubic region to try to push fetal shoulder down into an oblique position and thus get out from under pubic symphysis)

o Complications: likely postpartum hemorrhage and neonatal brachial plexus injury o Risk factors: maternal gestational diabetes (increases weight of fetal shoulders /

abdomen), maternal obesity, multiparous, post-term

Erb Palsy C5-C6 brachial plexus injury due to downward traction of anterior shoulder o Weakness of Deltoid, infraspinatus muscles, and forearm flexors (biceps) o Arm hands limply on side and is internally rotated

CASE 12: URETERAL INJURY AFTER HYSTERECTOMY Woman had a hysterectomy two days ago for endometriosis, now has right flank pain tenderness, fever, and R costovertebral angle tenderness. DDX:

Flank pain/fever after a hysterectomy/oophorectomy, think ureteral injury Right ureteral obstruction/injury following pelvic surgery

o Management: IV pyelogram (IVP), or CT scan of abdomen IVP = IV dye is injected and radiographs are taken of kidneys, ureters, bladder If IVP shows obstruction, then antibiotics + cystoscopy to attempt retrograde stenting

(assuming ureter is kinked but not occluded) i.e., percutaneous nephrostomy Whether to immediately surgically repair or percutaneous nephrostomy first with

repair at a later date is case dependent o Hydronephrosis would suggest obstruction

Pyelonephritis o Less likely given history of recent pelvic surgery o Management: IV antibiotics and urine culture

BACKGROUND INFO:

Cardinal ligament attaches uterus sides to pelvic side walls (contains uterine arteries) o Most common site for ureteral injury is at cardinal ligament! (ureter is only 2-3 cm next to

the cervix here) Percutaneous nephrostomy placement of stent into renal pelvis through skin under radiologic

guidance to relieve urinary obstruction water under the bridge = ureter is just under uterine artery Over-dissection of ureter can lead to devascularization injury Other injuries from hysterectomies can include vesicovaginal fistula (urine leaking into vagina)

CASE 13: Postmenopausal Bleeding 66-yo diabetic nulliparous woman has post-menopausal vaginal bleeding (menopause at 55) DDX

Always think endometrial cancer here o Diagnosis: endometrial biopsy (via catheter) o Risk factors: obesity, diabetes, HTN, prior anovulation (irregular menses), early

menarche, late menopause, nulliparity, unopposed estrogen therapy, family hx Atrophic endometrium most common cause of postmenopausal bleeding friable tissue of

endometrium / vagina due to low estrogen levels Endometrial polyps growth of endometrial glands and stroma, which projects into the uterine

cavity (usually on a stalk) can cause postmenopausal bleeding Endometrial hyperplasia premalignant state Vaginal spotting can occur secondary to hormonal therapy But endometrial carcinoma must always be ruled out! (may occur concurrently with some of these)

BACKGROUND INFO:

Endometrial stripe sonographic assessment of endometrial thickness o Thickness > 5 mm is abnormal in postmenopausal women

Persistent postmenopausal bleeding warrants further investigation (such as hysteroscopy) even after a normal endometrial sampling.

CASE 14: ANTEPARTUM BLEEDING I (PREVIA) G5P4 woman at 32 weeks complains of painless vaginal bleeding. Abdomen is soft and nontender. Fetal heart tones are 140-150 bpm (normal) DDX

Placenta previa o Classic presentation: painless vaginal bleeding after mid-second trimester o Diagnosis: ultrasound

Do this before vaginal exam, because it can induce bleeding in previa o Management: expectant management! C-section at 36-37 weeks (if its just the first

episode of bleeding, we want to avoid delivering a premature baby) Second or third episode of bleeding, deliver with C-section!

o Previa is a risk factor for placenta accreta! o Risk factors for placenta previa: multiparous, prior C-section, prior uterine curettage, prior

placental previa Placental abruption

o Classic presentation: painful contractions with bleeding Lacerations

o Check with speculum exam for cervical lacerations (thats why you do that after ultrasound)

Most commonly placenta previa or placental abruption o Abruption usually has severe abdominal pain (painful contractions), previa does not o Ultrasound to rule out previa first, and if negative, then speculum exam and assessment

for abruption

BACKGROUND INFO: Antepartum bleeding (bleeding > 20 weeks) Complete placenta previa completely covers (vs. partial) Marginal placenta previa placenta abuts against internal os

o Marginal or low-lying placentas often self-resolve via transmigration of the placenta Low-lying placenta edge of placenta is within 2-3 cm of internal os Vasa previa the umbilical cord vessels that insert into the membranes overlying the internal

cervical os, thus vulnerable to fetal exsanguination upon rupture of membranes CASE 15: ANTEPARTUM BLEEDING II (PLACENTAL ABRUPTION) 22-yo G2P1 cocaine user at 35 wks with abd pain and vaginal bleeding. BP is 150/90. DDx:

Placental abruption o Presents as vaginal bleeding with pain o Risk factors: cocaine use, HTN, trauma (like car accident) o Complications: postpartum hemorrhage, fetomaternal bleeding, coagulopathy (causes fetal

death via DIC, will see low fibrinogen), preterm delivery o Management: Delivery o Diagnosis: cannot be diagnosed by US (not effective), b/c blood clot behind placenta

looks the same as placenta No one diagnostic test, must use clinical picture as a whole!

Placenta previa BACKGROUND INFO

Antepartum bleeding + Coagulopathy => think abruption!! Concealed abruption bleeding is completely behind placenta, so no external bleeding Fetomaternal hemorrhage fetal blood enters maternal circulation Couvelaire uterus bleeding into myometrium of uterus, gives reddish discolored appearance

to uterine surface CASE 16: Cervical Cancer 50-yo G5P5 has a 6-month history of postcoital spotting and malodorous vaginal discharge. Prior history of Syphilis and smoking. Speculum shows 3-cm exophytic lesion on anterior lip of cervix. DDX

Cervical cancer o Post-coital spotting is a sign of cervical cancer! o Average age of cervical cancer is 51 o Malodorous discharge is due to necrotic tumor o If flank pain in cervical cancer, likely metastatic obstruction of ureter (leads to

hydronephrosis) o Diagnose with cervical biopsy (pap smear is screening only) o Risk factors: multiparity, smoking, history of STI

o Management Early cervical cancer contained in cervix, can treat with surgery or radiation therapy

(both are good) Advanced cervical cancer best treated with radiotherapy (brachytherapy +

teletherapy) + chemotherapy (cisplatin) o Cervical cancer can spread via cardinal ligaments to pelvic walls

Can obstruct one or both ureters -> hydronephrosis

BACKGROUND INFO: Cervical cancer 80% squamous, 20% adeno Radiation brachytherapy radioactive implants near the tumor bed (iridium, cesium) Radiation teletherapy external beam radiation Colposcopy cervical intraepithelial lesions will turn white with addition of acetic acid (acetowhite

change) HPV typing

o HPV typing plays a role in the management of Atypical Squamous Cell (ASC) readings as only about 50% of these patients are actually infected with a high risk viral type

o Not useful in HSIL, too many people positive Pap Smears

o Pap smear (cytology) can detect normal, LSIL, HSIL, or suspicious for invasive cancer. o Next step is colposcopy, look for acetowhite change and take for biopsy (histology), which

can stage at CIN I-III (CIN III = CIS) or cancer. o If CIN I observe. If CIN III LEEP (excise area of lesion) or cervical cone biopsy, both

excisions but cone can go deeper looking for margins

CASE 17: Postpartum Amenorrhea 24-yo G2P2 has amenorrhea after vaginal delivery complicated by postpartum hemorrhage. She is not able to lactate DDX of post-partum amenorrhea:

Sheehan syndrome (anterior pituitary necrosis) o Caused by hypotension in postpartum period (e.g., postpartum hemorrhage) ->

hemorrhagic necrosis of anterior pituitary o May see hypothyroidism or monophasic basal body temp (no LH surge) o Management: hormone replacement of all anterior pituitary hormones

Intrauterine adhesions (Asherman syndrome) o Scar tissue formation in endometrium, caused by uterine curettage, which damages the

decidua basalis layer of the endometrium (thus amenorrhea) o Management: surgical resection of scar tissue

Note that amenorrhea is normal for 2-3 months postpartum (breastfeeding inhibits hypothalamic function, so may be longer)

o But in a non-lactating woman, suspect pathology like Sheehan or Asherman To differentiate, check whether pituitary is functioning, and whether uterus is responsive to

hormonal therapy o If unable to breast-feed, lack of prolactin -> pituitary issue o If the patient could breast-feed, more likely intrauterine adhesions o If there is bleeding in response to estrogen + progesterone OCP, then Sheehan

PCOS if obese with history of irregular cycles o Will see vaginal bleeding after ingestion of progestin (like Provera) o Characterized by high estrogen without progesterone, obesity, hirsutism, and glucose

intolerance. LH:FSH > 2:1 Pregnancy always check this in secondary amenorrhea!

BACKGROUND INFO

If women are hypoestrogenic, two categories of causes: o Hypothalamic/pituitary failure o Ovarian failure o High FSH indicates ovarian failure

General immediate workup o Pregnancy test (always!) o Prolactin and thyroid levels o Maybe FSH and estrogen

CASE 18: FETAL BRADYCARDIA (CORD PROLAPSE) 22-yo G3P2 at term is in labor, cervical dilation = 5 cm, vertex is at -3 station. Upon AROM, persistent fetal bradycardia to the 70-80 bpm range is noted for 3 minutes.

DDx o Cord prolapse

rope-like cord on vaginal exam, often with pulsations NEXT STEP: vaginal exam to assess for cord prolapse (sticking out) MANAGEMENT: Elevate legs, C-section immediately Risk factors: fetal head is unengaged (here, vertex is -3 station), or transverse fetus,

or breech This presentation is typical of cord prolapse, where cord protrudes from cervical os

(normally, fetal head will take over the whole pelvis and prevent prolapse of cord) It is not unusual for a multiparous woman to have an unengaged fetal head in early

labor, so do not AROM with an unengaged presentation o Uterine hyperstimulation (e.g., Oxytocin, Misoprostol) Terbutaline

> 5 contractions in 10 minutes Too many contractions -> vasoconstriction of uterine vessels -> less blood to fetus

o Hypotension due to epidural catheter IV fluids o Uterine rupture

Immediate management of fetal bradycardia 1. Differentiate fetal heart beat from maternal pulse just to be sure can use fetal scalp electrode

(only after presentation during labor, needs > 4 cm dilation) or ultrasound 2. Turn mom on her side (removes compression of great vessels by uterus, better VR) 3. IV fluid bolus if volume depleted 4. 100% oxygen face mask 5. Stop Oxytocin

a. If there is oxytocin hyperstimulation, you can give Terbutaline (beta-agonist) to relax uterus muscles

CASE 19: Breast discharge 30-yo woman with irregular menses has watery milky-white breast discharge. Positive history of Graves disease. Negative pregnancy test. DDx:

Galactorrhea due to hypothyroidism o Hypothyroid has higher TRH, which increases prolactin release -> galactorrhea o Diagnosis: check serum prolactin and TSH levels o High prolactin will also inhibit GnRH -> oligomenorrhea o Management: thyroxine

Pregnancy always check pregnancy test first! Pituitary adenoma (prolactinoma) headaches, peripheral vision defects? get MRI

o Macroadenoma surgery o Microadenoma Bromocriptine (safe in pregnancy)

Empty Sella skull MRI Psychotropic medications

CASE 20: ITCHING IN PREGNANCY 24-yo G1P0 at 28 weeks has 2-wk history of general pruritus. No rash. Normal fetal heart tones. DDx:

Cholestasis o Bile salts are incompletely cleared by liver, accumulates in dermis causes itching o Diagnose with increased levels of circulating bile acids (usually no elevated LFTs) o Usually third trimester o Unknown etiology o Management first line is oral antihistamine, and corn starch baths! o Associated with increased fetal morbidity

Contact dermatitis less likely since its generalized Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP) erythematous papules/hives start in

abdominal area (at abdominal striae) and often spreads to buttocks, but this patient has no rashes o Unknown etiology o Management: topic steroids and antihistamines

Herpes gestationis causes itching and blisters on abdomen and extremities o Due to autoimmune (IgG?) o NOT due to HSV! Just a skin disease that looks like herpes o Management: oral corticosteroids

CASE 21: PID (Acute Salpingitis) 23-yo G0P0 has abdominal pain, fever, heavier menses than usual, and dyspareunia. Exam shows cervical motion tenderness and adnexal tenderness. DDx:

PID (i.e., salpingitis) o Common presentation: young woman with pelvic pain and vaginal discharge o Key feature: cervical motion tenderness and adnexal tenderness o Usually due to bacteria of endocervix that ascend the tubes (e.g., Chlamydia, GC, or

anaerobes usually polymicrobial) o Diagnosis: laparoscopy is gold standard (differentiates from appendicitis! For

salpingitis, will see purulent drainage from fallopian tubes) o Treatment: IM ceftriaxone and oral doxycycline o Complications: infertility, ectopic pregnancy

Fitz-Hugh-Curtis syndrome when perihepatic adhesions form from salpingitis o May see tubo-ovarian abscess (abscess around distal tube and ovary, is treatable with

antibiotics unlike normal abscess) Treat with Clindamycin or Metronidazole (usually anaerobes) May appear as a complex ovarian mass on US TOA rupture is a surgical emergency

Other ddx includes pyelonephritis, appendicitis, cholecytitis, diverticulitis, pancreatitis, ovarian torsion (colicky pain, associated with ovarian cyst on US), and gastroenteritis

Sulfur granules think Actinomyces! Treat with penicillin. CASE 22: PE in Pregnancy 19-yo G1P0 at 20 weeks has pleuritic chest pain and dyspnea DDx:

PE of pregnancy o Pregnant women are predisposed to DVTs and PE due to venous obstruction (leads to venous

stasis) and hypercoagulable state (more fibrinogen) o Diagnosis: spiral CT or MR angiography o Management: IV heparin to stabilize DVT

If PE, full IV anticoagulation therapy for 5-7 days, and then subcutaneous Can use LMWH, less bleeding complications and less need to check for

anticoagulation Prophylactic low-dose heparin for rest of pregnancy

o On EKG, most likely just to show tachycardia with no other abnormalities Thromboembolism is the most common cause of maternal death! In normal maternal physiology, there is respiratory alkalosis with metabolic compensation

CASE 23: HSV in Labor 31-yo G3P2 at 39 wks is in labor, ROM 2 hours ago history of HSV taking acyclovir. 1 day h/o tingling in perineal area.

HSV with prodromal symptoms o Herpes prodrome burning, itching, tingling o Complications: encephalitis or infections of eyes/skin/mucosa o Transfer: mostly through exposure to fluids/secretions in genital tract rather than

transplacentally o Diagnosis: during prenatals, PCR or culture can help. During labor, must use clinical exam. o Management: C-section delivery (if prodromal or active lesions)

HSV active lesions during pregnancy can be treated with Acyclovir, which reduces shedding and duration of infection but does not decrease likelihood of future outbreaks

Chancroid can also cause vulvar ulcers, with painful lymphadenopathy Case 23: Uterine fibroids (leiomyoma) 40-yo G5P5 with a h/o enlarged uterus has menorrhagia and anemia. Prior D&C showed benign pathology. Exam shows non-tender irregular midline mass attached to cervix.

Uterine fibroids o Presentation: menorrhagia o Management: hysterectomy (best for symptomatic fibroids if no future pregnancy desired)

If uterus was smaller, then maybe treat with Provera (progesterone) or GnRH agonist (can shrink temporarily to make surgery easier)

Uterine artery embolization cannulize femoral artery and catheterize both uterine arteries, infusing embolization particles that preferentially target fibroid vessels

o Very rarely, can progress to leiomyosarcoma (increase > 6 wks gestational size in 1 year) Ovarian mass

o Less likely since mass moved with the cervix (attached to) and is midline rather than lateral Endometrial hyperplasia, polyp, or cancer

o Consider if there is intermenstrual bleeding

Anovulatory process o Consider if there are irregular cycles

(menomerorrhagia) TOA, pelvic kidney, endometrioma

Submucosal fibroids can lead to recurrent

abortions

Myomectomies for uterine fibroids can predispose to uterine rupture (sometimes require C-section deliveries to avoid pressure of labor) may see fetal bradycardia

CASE 25: Preeclampsia and Hepatic Rupture 19-yo G1P0 delivered at 29 wks has severe preeclampsia, epigastric tenderness, and elevated LFTs. Shortly after delivery, she had severe abdominal pain/distension, syncope, hypotension, and tachycardia. DDx:

Hepatic rupture secondary to preeclampsia o Hepatic rupture is a serious sequelae of severe preeclampsia

Other complications of preeclampsia: placental abruption, eclampsia, coagulopathies, uteroplacental insufficiency

o Preeclampsia: often see HTN, proteinuria, elevated LFTs, epigastric tenderness (due to ischemia of liver)

Presentation headache, RUQ/epigastric pain, vision changes Sudden increase in weight may indicate edema!

Hepatic hematoma may form -> ruptures -> hemorrhage o Management: laparotomy to explore and blood transfusions to manage temporarily

But definitive treatment is delivery!! If severe preeclampsia, deliver regardless of term. If mild, can monitor for

worsening disease until risk of prematurity has decreased During labor and 24 h after, patients are at high risk for eclampsia, so give

magnesium sulfate (anticonvulsant) during labor! Side effect of Mg sulfate are pulmonary edema and loss of DTRs!

o First sign is loss of DTRs! If severe HTN, control with hydralazine or labetalol

BACKGROUND INFO:

Chronic HTN BP > 140/90 before pregnancy or < 20 weeks (predisposes to preeclampsia) Gestational HTN HTN without proteinuria > 20 weeks Preeclampsia HTN + proteinuria (> 300 mg over 24 hrs) at > 20 weeks Eclampsia Preeclampsia + seizures

o Most common cause of death is intracerebral hemorrhage due to the seizures Severe Preeclampsia BP > 160/110, or 24-h proteinuria > 5 g. Vasospasm associated with

preeclampsia so bad that maternal organs are threatened necessitates delivery of baby o During labor, proteinuria can be estimated with urine dipstick (protein 3+ or 4+ is severe, 1+

or 2+ is mild) Superimposed preeclampsia Preeclampsia + baseline chronic HTN HELLP Syndrome complication/variant of preeclampsia, composed of hemolysis, elevated liver

enzymes, and low platelets (hence HELLP)

CASE 26: Breast Mass I 22-yo has a 1-cm firm, mobile, nontender, rubbery breast mass in upper outer quadrant, no adenopathy DDx:

Next step: biopsy of the mass (fine needle or core needle biopsy) o Any 3D-dominant breast mass needs a biopsy!

Fibroadenoma o Classic description: firm, non-tender, rubbery, mobile o A benign smooth muscle tumor of the breast, usually in young women in 20s o Does not change with menstrual cycle (vs. fibrocystic change), b/c do not respond to ovarian

hormones Fibrocystic change

o Classic presentation: multiple, irregular, lumpy o Most common benign breast condition just an exaggerated response to ovarian hormones o Usually in premenopausal women o Changes with menstrual cycle! More painful/engorged just before menstruation o Treatment: drink less caffeine, take NSAIDs and use a tight-fitting bra (maybe OCPs or

progestin therapy) Breast cancer

o More worried about this if the mass was fixed or if there were nipple retraction or blood nipple discharge

Blood nipple discharge with no mass think intraductal papilloma!!

o Also called serosanguineous discharge o Usually small benign tumors in the milk ducts o Second most common cause of bloody nipple discharge is malignancy

Nipple retraction of skin dimpling think malignancy! Red tender indurated breast think inflammatory breast cancer!

BACKGROUND INFO:

Core needle biopsy needle extracts tissue, preserves architecture (histology) Fine needle aspiration small needle with vacuum to aspirate fluid/loose cells (cytology) Excisional biopsy surgery to remove entire lesion If a woman under 30, best way to image the breast is by US (dense fibrocystic changes can interfere

with mammograms)

CASE 27: Infertility Infertile woman with regular menses, biphasic basal body temperature, no STIs, and HSG shows patent tubes and normal uterine cavity. Semen analysis of partner is normal. BACKGROUND INFO:

Infertility = unable to conceive after 1 year of trying Five basic factors of infertility:

1. Ovulatory a. E.g., PCOS, hypothalamic disturbances (e.g., hypothyroid, hyperprolactinemia ->

decreases GnRH pulses), or premature ovarian failure i. PCOS obesity, anovulation, hirsutism, glucose intolerance

b. Thus always check TSH and prolactin levels! c. Two things to check for: regular menses and basal body temperature (should be rise of

0.5 degF after ovulation due to rise of progesterone thus normally biphasic) d. Elevated FSH suggests premature ovarian failure e. Here is regular menses with biphasic temp, unlikely to be anovulatory f. Treatment: Clomiphene citrate (especially good for PCOS)

2. Uterine unlikely with normal HSG a. E.g., uterine submucosal leiomyoma causes recurrent abortions (interferes with

implantation) b. History of fibroids suggest this

3. Tubal unlikely with normal HSG a. History of chlamydia or GC cervicitis/salpingitis may suggest tubal disease b. Gold standard for diagnosis is laparoscopy (similar to peritoneal) c. Management is IVF (similar to male factor management)

4. Male factor unlikely with normal semen analysis 5. Peritoneal factor endometriosis 6. RARELY may consider cervical factor if history of prior cryotherapy

a. Suspect if thick cervical mucus before ovulation b. Management: use intrauterine insemination (catheter injects sperm, bypasses cervix)

Hysterosalpingogram (HSG) dye is placed into uterus via catheter for radiologic study Fecundability probability of achieving pregnancy within one menstrual cycle (usually 20-25%) Ovulation normally occurs 36 hours after LH surge

DDx:

Endometriosis o 3 Ds of endometriosis

dysmenorrhea, dyspareunia, dyschezia

o Can cause infertility by inhibiting ovulation, inducing adhesions

o Diagnosis: laparoscopy is the gold standard, also allows surgical ablation

CASE 28: Abdominal Pain in Pregnancy 23-yo G2P1 at 29 wks with a h/o a 8-cm ovarian cyst presenting with 12-hr colicky, right lower abdominal pain with n/v. Abdomen is tender on right lower quadrant with guarding. DDx:

Ovarian torsion o Presentation acute colicky pain o Management: surgery (laparoscopy if not pregnant)

First try to unwind to see if reperfusion (if so, just remove cyst, if not, complete oophorectomy)

o Often secondary to benign ovarian cyst, and pregnancy is also a risk factor (most commonly ~14 weeks or after delivery)

Acute appendicitis actually upward and lateral to McBurneys point (sometimes mimics Pyelo as flank pain

o Treat with surgery and IV antibiotics o Note: Pyelo should have pyuria!

Cholecystitis physiologic effect of pregnancy is gallstones (due to biliary sludge) o Worse following a meal o Complications include pancreatitis and ascending cholangitis o If pancreatitis is diagnosed, check US for gallstones first! (most common cause)

Pancreatitis has pain radiating to the back! o Biliary colic = gallstones without fever, just the colicky pain (often radiates to shoulder)

Placental abruption most common cause of third-trimester bleeding! o Cocaine use, trauma, HTN are risk factors o Presents with vaginal bleeding and cramping

Ectopic Pregnancy o Leading cause of maternal mortality in first two trimesters o Presents with amenorrhea with vaginal spotting and lower abdominal pain (sharp and

tearing) o Possible adnexal mass o If ectopic rupture -> syncope or hypovolemia o Check hCG levels to diagnose ectopic. Treatment is surgery.

CASE 29: Ectopic Pregnancy 19-yo G2A1 at 7 weeks has vaginal spotting. H/O prior pelvic infection. Abdomen is non-tender. Pelvic exam shows a closed and non-tender cervix, a uterus of 4-weeks size, and no adnexal tenderness. hCG is 2300 mIU/mL, and transvaginal sonogram reveals empty uterus with no adnexal masses. DDx:

Note that spotting and lower abdominal pain can be normal in early pregnancy. Ectopic pregnancy

o Triad of abdominal pain, amenorrhea, and vaginal spotting. But even without pain, any woman with amenorrhea + vaginal spotting should get hCG test for ectopic!

o Tests: hCG level and transvaginal ultrasound (@hCG > 1500, IUP can be seen) Usual strategy is to check for intrauterine pregnancy after hCG > 1500 Ultrasound may show intra-abdominal fluid (blood) or extrauterine embryo

(intrauterine sac, if not seen, high likelihood of ectopic) o Diagnosis

If hCG < 1500 and no severe pain/hypotension/adnexal tenderness or mass, then repeat hCG in 48 hours expect to see >66% rise in normal pregnancies (otherwise, suspect abnormal non-viable pregnancy, location unclear so not necessarily ectopic just non-viable)

Some use progesterone levels to check, so progesterone > 25 ng/mL is normal (< 5 ng/mL is abnormal, i.e., non-viable)

o Management: Can be surgical or medical Laparoscopy: Salpingectomy (removal of tube) is performed for gestations too large

for conservative therapy or when rupture has occurred For those who want to preserve fertility with no rupture, salpingostomy (just

removing the ectopic) can be performed do not close incision (let heal without) due to risk of stricture formation

Medical: Methotrexate (anti-folate) Given as a single IM shot, only for ectopics < 4 cm 3-7 days after therapy, may have some abdominal pain due to tubal abortion

(or possibly rupture) must be observed for hypotension or worsening pain Should not be used if there is a chance of viable pregnancy, because it

destroys the intrauterine pregnancies too o You can see enlarged uterus from ectopic due to high hCG levels o Sometimes will palpate adnexal mass (but only 50% of the time) o Complication: ectopic rupture

Pain gets a lot worse, may have syncope Shoulder pain if blood is irritating the diaphragm

Risk factors for ectopic pregnancy o Salpingitis (especially Chlamydia) o Tubal surgery / adhesive disease / congenital abnormalities o Prior history o Progesterone IUDs

BACKGROUND INFO:

hCG is made by syncytiotrophoblasts of placenta, assayed by pregnancy tests

CASE 30: Anemia in Pregnancy 29-yo G2P1 at 20 weeks has a Hb of 9.5 g/dL. MCV = 70. Ferritin = 90 (nl 30-100), Iron = 140 (nl 50-150), Hb electrophoresis showed Hb A1 at 95% and HbA2 at 5%. Management of Anemia:

Usually first try a therapeutic trial of iron (if microcytic), reassess in 3-4 weeks If Hb does not improve, then iron studies + Hb electrophoresis

DDx:

-Thalassemia (most likely here) o Due to decreased -globin chain production o Elevated HbA2 strongly suggests beta-thalassemia! o Elevated Hb F level would suggest alpha-thalassemia! o -thalassemia minor less production of -globin, generally safe for mom and baby

(asymptomatic) o -thalassemia major may appear healthy at birth, but as Hb F falls and no -chains to

replace it, the infant can become severely anemic Iron-deficiency anemia most common etiology Folate/B12 deficiency macrocytic

o Usually folate def, because it runs out faster Sickle cell point mutation in -globin (Glu->Val)

o Women with sickle cell tend to have more intense anemia during pregnancy and episodes of vasoocclusive crises

G6PD deficiency hemolytic anemia triggered by sulfonamides, nitrofurantoin, and anti-malarials o May see dark urine due to bilirubinuria; may also see jaundice

HELLP Syndrome o In pregnant women with hemolysis, elevated liver enzymes, and low platelets must treat

with immediate delivery! Physiologic anemia of pregnancy due to physiologic hemodilution

CASE 31: Preterm Labor 19-yo G1P0 at 29 weeks has intermittent abdominal pain. Vitals are normal, fetal heart tracing showed baseline HR at 120 bpm and is reactive. Uterine contractions every 3-5 minutes, cervix 3 cm dilated, 90% effacted, and fetal vertex is at -1 station. Preterm labor (< 37 weeks but > 20 weeks)

Next step: Tocolysis, try to identify cause for preterm labor, antenatal steroids, GBS antibiotics o Tocolysis = meds to suppress preterm labor (e.g., Terbutaline, Nifedipine, Indomethacin) o Steroids are needed for < 34 weeks gestation

Diagnosis: in a nulliparous woman, 2 cm dilation and 80% effacement is sufficient to diagnose preterm labor

o Fetal Fibronectin Assay: Can assess preterm delivery risk by swabbing posterior vaginal fornix for fetal fibronectin (if pos, there is risk; if negative, def no delivery within 1 week)

o Can also assess by transvaginal cervical length ultrasound measures cervix (< 25 mm is concerning), or funneling or beaking of amniotic cavity into cervix is worrisome for preterm labor

Causes of preterm labor o UTI, cervical infection, bacterial vaginosis, generalized infection

Most common is GC infection! o Trauma or abruption o Hydramnios

Indomethacin can cause oligohydramnios -> cord compression -> variable fetal decelerations

CASE 32: UTI 29-yo with 2-day h/o dysuria, urgency, and frequency. No fever, no abdomen/back tenderness.

DDx for UTIs o Cystitis (>100,000 CFUs in midstream catch specimen)

Presentation: dysuria, urgency, frequency, hesitancy, hematuria (from hemorrhagic cystitis). Fever is uncommon!

But if there is gross hematuria, also suspect nephrolithiasis Next step: urinalysis and/or urine culture Most likely etiology: E. coli (or less likely, Klebsiella and Proteus) Management: Sulfa drugs (TMP-SMX - Bactrim), cephalosporins, quinolones

(ciprofloxacin), or nitrofurantoin are all acceptable (aimed at E. coli) If urine culture shows no organism -> think Chlamydia (urethritis), do urethral

swabbing for trachomatis May also be Candidal vulvovaginitis or Urethral Syndrome (urethral

inflammation of unknown etiology

In pregnancy, asymptomatic bacteriuria (seen on culture) leads to acute infection in 25% of untreated women and so should always be treated!

o Pyelonephritis flank tenderness, fever, chills, n/v (often ill-appearing) Treat with TMP-SMX or fluoroquinolone, re-examine in 48 hours Need suppressive antibiotics (nitrofurantoin) for rest of pregnancy

o Urethritis also urgency, frequency, dysuria Suspect in UTI symptoms but with sterile (negative) culture and no response to

cystitis antibiotics! Do not use Doxycycline in pregnant women

May see purulent drainage Usually due to Chlamydia, GC, or Trichomonas

If GBS bacteriuria in pregnancy -> need IV ampicillin to decrease risk of neonatal GBS sepsis

CASE 33: Contraception IUDs

Contraindications: o Recent STIs, abnormal size/shape of uterus o If heavy menses, do not use Paragard o If Wilsons disease, do not use Paragard!

Mirena o Slow release of progestin decreases menses (amount and frequency) o Causes mucus thickening and endometrial thinning (thus less bleeding) o Lasts 5 years

OCPs Mechanism

o Progesterone inhibits ovulation, causes cervical mucus thickening o Estrogen maintains endometrium, prevents unscheduled bleeding, and inhibits follicular

development Contraindications:

o History of thromboembolism/DVTs, migraines, smoker > 35, breast/endometrial cancer, undiagnosed vaginal bleeding, diabetes with peripheral vascular disease, HTN

Benefits reduces risk of ovarian and endometrial cancer, decreases menses, improves endometriosis, and improves acne

Side-effects primarily n/v Risks are due to estrogen: thromboembolism, stroke (in migraine patients), MI (in > 35 smokers),

cholelithiasis, benign hepatic tumors Others include patch, ring, Depo shots (q3 months), Levo implants (Implanon)

Breastfeeding use Progestin-only oral (Minipill) Sickle cell / epilepsy use Depo (side effect: osteopenia) Patch has 2x risk of DVT vs. OCP

Morning after (must be given within 72 hours) Plan B Progestin only (0.75 mg Levonorgestrel taken at 0 and 12 hours) Yuzpe method 0.1 mg estrogen + 0.5 mg levo in two doses, 12 hours apart IUD can be inserted up to 5 days post-unprotected sex for emergency contraception

CASE 34: Unresponsive Pyelonephritis 20-yo G1P0 at 29 wks has received IV Amp + Gent for 48 hours for pyelo, now she has shortness of breath (SOB). Urine culture shows E. coli sensitive to Ampicillin. Pyelonephritis

Presentation: dysuria, frequency, urgency, costovertebral tenderness, fever/chills, n/v Diagnosis: >100,000 CFU by clean catch

o Usually E. coli, but may also be Klebsiella, Staph, or Proteus Primary treatment is IV antibiotics (Amp + Gent, or a Cephalosporin)

o Acute pyelo in pregnant women should be hospitalized! o Treat until symptoms have significantly improve, and then switch to oral antibiotics and

suppressive therapy for remainder of pregnancy (otherwise risk recurrent UTI) o If no clinical improvement after 48-72 hours, suspect a urinary tract obstruction (e.g.,

nephrolithiasis) OR a perinephric abscess!! Endotoxins from pyelo can cause pulmonary damage ARDS!

o Commonly occurs post-antibiotic therapy o CXR may show patchy infiltrates or may be normal if disease is early o Management: supportive measures (oxygenation and fluid management)

The most common cause of septic shock in pregnancy is pyelonephritis! Asymptomatic bacteriuria is checked at the first prenatal visit and U/A at every OB visit

CASE 35: DVT in Pregnancy 31-yo G1P0 at 24 wks has been walking more than usual and complains of a 2-day h/o right calf soreness (which is tender and swollen). DVT

Pregnancy is a hypercoagulable state and can predispose to thrombosis Diagnosis: Doppler flow study (Duplex Ultrasound Flow Study) of lower extremity Treatment: Heparin with extremity elevation Side effect: Osteoporosis (anticoagulants, even Heparin, can inhibit Vit K, which is involved in bone

metabolism), thrombocytopenia CASE 36: Dominant Breast Mass (Pt. I was Case 26)

Any palpable dominant breast mass needs biopsy, even with negative mammogram/US o Dominant = on palpation, felt to be separate from rest of breast tissue

If older, then removal of entire mass is preferred over FNA biopsy, as age is the biggest risk factor for breast cancer

Skin dimpling is suspicious for malignancy BRCA1 (higher risk) and BRCA2 increase risk of breast and ovarian cancer

o Autosomal dominant! One mutation increases risk! If fluid drained is straw-colored or clear and the mass disappears, then you can discard the fluid and

no more therapy is needed. But if the fluid is bloody, then it must be sent for cytology. Unilateral serosanguineous (bloody) nipple discharge = most common cause is intraductal

papilloma! Most common histological type of breast cancer = infiltrating intraductal carcinoma

CASE 37: Ovarian Tumor

Presentation: weight loss, palpitations, sweating, nervousness, but normal thyroid palpation. No proptosis or lid lag. Mobile, non-tender, 9-cm mass with both solid and cystic components.

o Normally, most common hyperthyroidism is Graves disease, but normal thyroid here o Both solid and cystic components = complex

Hyperthyroidism can be caused by a benign cystic teratoma containing thyroid tissue (struma ovarii)!!!

Most common ovarian tumor < 30 yo = dermoid cysts (benign cystic teratomas) o Cystic teratoma is a benign germ cell tumor that may contain all 3 germ cell layers o Dermoid cysts can contain thyroid tissue -> hyperthyroidism

Struma ovarii On MRI, look like multilobulated masses with thick septa, thought to represent

multiple large thyroid follicles o Treatment = laparoscopy with ovarian cystectomy (just removing the cyst), if benign, or

more extensive surgery if malignant Excised cyst is sent for pathology to determine if benign or malignant

o Ultrasound: echoic band in hypoechoic area or cystic structure with fat-fluid level o Most common complication: ovarian torsion (severe abdominal pain) o Another complication: rupture shock/hemorrhage -> peritonitis

If contains neural elements = malignant teratoma Epithelial ovarian tumor most common ovarian malignancy, usually in older women

o E.g., serous (most common, esp in women > 30 yo), mucinous (large size) o If mucinous bursts, will see pseudomyxoma peritonei (mucinous material in intra-

abdominal cavity) -> repeated bouts of bowel obstruction o Treatment is combination chemotherapy o Commonly presents with ascites (common sign of ovarian malignancy!!) o Often spreads to small bowel and omentum o Tumor marker: CA-125, elevated in most epithelial tumors, more specific in post-

menopausal women Functional ovarian cyst physiologic cyst of ovary of follicular, corpus luteal, or theca lutein in

origin, found in reproductive-aged women Presentation of a germ cell malignancy = pelvic mass with pain due to rapidly enlarging size

Workup of Adnexal Masses

At extremes of age, few are functional cysts, so management is straightforward o Prepubertal, if adnexal mass > 2 cm, OPERATE o Menopausal, if adnexal mass > 5 cm, OPERATE

Otherwise: o Adnexal mass > 8 cm = likely tumor o Adnexal mass < 5 cm = likely functional cyst o Between 5-8 cm, use ultrasound to distinguish (simple cyst suggests functional cyst)

Precocious puberty + pelvic mass, think estrogen-secreting tumor (e.g., granulosa-theca cell tumor) Granulosa-theca (estrogen) and Sertoli-Leydig (androgen) tumors are usually solid on ultrasound!

CASE 38: Fascial Disruption 45-yo obese woman has 4-hr h/o profuse serosanguineous drainage from abdominal incision site. She had undergone staging surgery for ovarian cancer 7 days ago. DDx:

Most likely a surgical site infection (deep incisional) with fascial disruption o Presentation: profuse drainage o Next step: immediate surgical closure and broad-spectrum antibiotics o Because the rectus fascia is interrupted, the peritoneal fluid can escape through the wound o If this was just a superficial fascial issue (e.g., due to seroma or small fluid collection in

subcutaneous fat tissue), then patient would only have limited amount of drainage rather than profuse

o No intestinal contents penetrating incision, so evisceration is not suspected o Usually occurs 7-10 days post-op

Anterior to fascia separations (superficial wound separation) o Usually occurs due to infection or hematoma! o Presents as redness/tenderness around incision with fever 4-10 days post-op o Treatment is opening wound and draining mucus, wet-to-dry dressing changes, and broad-

spectrum antibiotics Evisceration

o Protrusion of bowel or omentum through incision (so all layers of incision disrupted) o Significant mortality due to sepsis o Treatment: sterile sponge wet with saline should be placed over bowel, and patient taken to

OR. Immediate antibiotics. BACKGROUND INFO:

Wound dehiscence separation of surgical incision but with intact peritoneum Fascial disruption separation of fascial layer, usually leading to communication of peritoneal

cavity with skin Evisceration disruption of all layers of incision, with omentum or bowel protruding through

incision Surgical site infection (SSI) infection within 30 days post-op at incision site Urine vs. lymphatic drainage:

o Creatinine is a lot higher in urine than lymph, so thats how to differentiate CASE 39: Abdominal Pain in Pregnancy 25-yo at 10 wks has severe abdominal pain and lightheadedness, with heavy vaginal bleeding and passed some tissue that floated in a frond pattern. Cervix is closed. DDx:

Ruptured corpus luteum cyst with hemoperitoneum (most likely) o Presentation: symptoms of hypovolemia and sudden abdominal pain (lkikely due to

hemoperitoneum blood in abdomen) May have unilateral cramping or abd pain for 1-2 weeks before rupture Earliest sign of hypovolemia is decreased urine output (oliguria)

o Next step: secure hemostasis, but if bleeding continues, cystectomy

If you remove corpus luteum < 10 weeks, need to give exogenous progesterone (placenta takes over after 10-12 weeks)

o Hemiperitoneum in pregnancy is usually caused by a ruptured ectopic pregnancy, and less commonly, a ruptured corpus luteum (can mimic ectopic)

o Endometrial tissue that floats like a frond pattern is almost ALWAYS an intrauterine pregnancy (so not ectopic, likely ruptured corpus luteum)

Float test shows chorionic villi o Hemorrhagic corpus luteum occurs more commonly in patients with bleeding disorders

(vWD) or on Warfarin Ectopic pregnancy Ruptured endometrioma Appendicitis Ovarian torsion Splenic rupture

CASE 40: Amenorrhea (Intrauterine Adhesions) 33-yo has 6 months of amenorrhea after a D&C for a spontaneous abortion. Menstrual period was normally previously. Pregnancy test was negative. DDx:

Intrauterine adhesions (Asherman syndrome) o Caused by uterine curettage damaging endometrial lining, causing intrauterine adhesions

Often due to postpartum curettage (2-4 weeks after delivery) o Hypothalamus, pituitary, and ovaries are working normally, but endometrial tissue is not

responsive! Normal hormonal status (should have normal estrogen, FSH, etc.)

o No progestin-induced withdrawal bleeding when tested! o Hysterosalpingogram to diagnose (injected dye, most commonly used way) shows

obliteration of endometrial cavity But gold standard is hysteroscopy (confirm after HSG)

o Management: operative hysteroscopy + post-op IUD to prevent adhesion reformation Hypothyroidism, hyperprolactinemia

o Unlikely without galactorrhea Pituitary issue (Sheehan syndrome) Ovarian causes (premature ovarian failure) Cervical stenosis due to cervical conization (also post-procedural!!)

o Cramping abdominal pain due to retrograde menstruation (risk for endometriosis) BACKGROUND INFO:

Secondary amenorrhea = at least 6 months of no menses Hysteroscopy = direct visualization of endometrial cavity Uterine sounding = assessing depth and direction of cervical/uterine cavity with a thin blunt probe

CASE 41: Abnormal Mammogram 59-yo with abnormal mammogram (calcifications around a small mass), but breasts is non-tender and no masses on palpation

In this high-risk age group, a core biopsy or excisional biopsy is preferable to FNA Suspicious mammogram findings:

o Cluster of calcifications o Masses with irregular borders (e.g., spiculated mass)

Other signs of breast cancer o Skin thickening

Diagnose with core biopsy via stereotactic guidance or via needle-localization excision Other possibilities

o Fat necrosis due to trauma to breast, looks identical to breast cancer (calcifications) on mammogram (but do biopsy anyway to evaluate!)

CASE 42: Primary Amenorrhea due to Mullerian Agenesis 17-yo nulliparous female with only one kidney has primary amenorrhea. Normal height and weight and vitals. Thyroid is normal. Normal female genitalia, pubic hair, and breasts. Approach always check for breast development and uterus development (present or not?)

Breast development suggests normal estrogen, and axillary/pubic hair suggests normal androgens. Thus, its not a hormonal issue here.

MAIN DIFFERENTIATING FACTOR: PUBIC/AXILLARY HAIR DEVELOPMENT!!! FIRST TEST IS ALWAYS PREGNANCY TEST HERE! Primary amenorrhea no menses by age 16

DDx for Primary Amenorrhea (given normal breast development):

Mullerian (or vaginal) agenesis 46XX o Congenital absence of development of uterus, cervix, and fallopian tubes in a female o Next step: serum testosterone, karyotype (can see XX vs XY)

Testosterone is normal in Mullerian agenesis and high in androgen insensitivity! o Most likely this because many with Mullerian agenesis have congenital urinary tract

abnormalities (such as only one kidney or a pelvic kidney) o Have normally functioning ovaries (ovaries are not Mullerian structures!) o Androgens are normal = normal pubic/axillary hair (vs AIS)

Androgen insensitivity 46XY o Defective androgen receptors

External genitalia remain female, but no internal female organs Breasts still develop because some estrogen + no androgen opposition No androgens = no pubic hair

o Usually has breasts but not much pubic/axillary hair o Intra-abdominal gonads are at increased risk for malignancy, need gonadectomy

If absence of breast development, think hypoestrogenic state like gonadal dysgenesis o E.g., Turner Syndrome (karyotype) 45X o Gonadal dysgenesis (can be 46XY too) also has higher risk of malignancy (like in AIS)

Kallman syndrome = delayed puberty with anosmia o No GnRH secreted by hypothalamus

CASE 43: Septic Abortion 23-yo post-D&C for an incomplete abortion now has continued vaginal bleeding, lower abdominal cramping, fever, and chills. Low BP, cervix os open with uterine tenderness. DDx:

Septic abortion o Retained products of conception, infection by vaginal bacteria ascending o Retained products present as open cervical os, abdominal cramping, and bleeding

(trying to get rid of it), and infection as fever, chills, low BP o First trimester bleeding suggests abortion o Next step: broad-spectrum antibiotics followed by D&C again

Clindamycin + Gentamicin D&C 4 hours after antibiotics are begun, to allow serum levels to be achieved

o Infection is usually polymicrobial o Oliguria is the first sign of septic shock! o If pockets of gas on CT, then likely necrotizing metritis -> need hysterectomy

Chorioamnionitis o Complication of pregnancies with rupture of membranes

Treat with immediate delivery o One exception is Listeria, acquired via unpasteurized milk products like goat cheese, which

can cause chorio without rupture of membranes Treat with IV ampicillin, does not need to be delivered

CASE 44: Postpartum Hemorrhage 29-yo G5P4 at 39 weeks with preeclampsia delivers vaginally. No FH of bleeding diathesis. After placental delivery, there is significant vaginal bleeding (1000 cc).

Postpartum hemorrhage is defined by > 500 mL loss by vaginal delivery of > 1000 mL by C-section Postpartum hemorrhage is defined as early (first 24 hours) or late (> 24 hours)

o Early: usually uterine atony (bleeding from placenta) Other: genital tract laceration, uterine inversion, placenta accreta, retained placenta,

coagulopathy o Late: subinvolution of the placental site

Usually 10-14 days after delivery Eschar over placental bed falls off and leads to bleeding Late may also be retained products of conception (smelly lochia, fever)

DDx:

Uterine atony o Uterine atony is the most common cause of postpartum hemorrhage o Presents as postpartum hemorrhage and a boggy uterus on palpation o Myometrium has not contracted to cut off uterine spiral arteries that are supplying the

placenta o Risk factor of uterine atony: preeclampsia (due to MgSO4 use) o Treatment: Oxytocin and uterine massage

Or if this doesnt work, then PGF2-alpha or rectal misoprostal If meds fail, surgery (uterine artery ligation, internal iliac artery ligation)

Genital tract laceration o If uterus palpation is found to be firm (no atony) yet bleeding continues

Firm contracted uterus Uterine inversion Placenta accreta Retained placenta Coagulopathy

CASE 45: PUBERTAL DELAY GONADAL DYSGENESIS 16-yo with primary amenorrhea, and short. Breasts and pubic hair are both Tanner Stage I. No development of external genitalia.

If no secondary sex characteristics by age 14, then it is delayed puberty Four stages of puberty: thelarche, adrenarche, growth spurt, and menarche Again, always do a pregnancy test!

DDx:

Gonadal dysgenesis (Turner Syndrome) o Most common cause of delayed puberty! Usually due to Turners. o Next step: Check FSH

Determines whether a CNS issue (low FSH) or an ovarian problem (high FSH) i.e., hypogonadotropic vs. hypergonadotropic hypogonadism

o If 46 XY, the Y predisposes to malignancy, need gonadectomy Ionizing radiation, chemotherapy, etc. can also cause hypergonadotropic hypogonadism Hypogonadotropic hypogonadism (low FSH)

o Due to hypothalamic dysfunction e.g., poor nutrition / eating disorders, extreme exercise, chronic illness

o May also be due to primary hypothyroidism, Cushings, pituitary adenomas, and craniopharyngioma

CASE 46: Breast Abscess and Mastitis 20-yo breastfeeding woman 3-weeks postpartum has right breast pain and 2-day h/o fever. Redness of right breast with fluctuance (pus). DDx:

Postpartum mastitis o Usually 3-4 weeks postpartum o Presentation: fever, chills, redness of breast o Management: antibiotics (dicloxacillin, an anti-staph agent), continue breastfeeding o Etiology: Staph aureus o Complication: abscess formation

Management: I&D Suspect if persistent fever 48 hours after starting antibiotic, or if there is a fluctuant

mass Galactocele

o Non-infected collection of milk due to a blocked mammary duct, non-red!! o Presents as a palpable mass and symptoms of breast pain o Management: Aspiration (to prevent it turning into an abscess)

Breast engorgement o Breast pain and low fever o Due to milk accumulation, presents 1 week postpartum just breast feeding and pumping

will alleviate

CASE 47: Thyroid Storm in Pregnancy 18-yo G2P1 at 35 wks is taking PTU for Graves disease. She has a 1-day history of palpitations, nervousness, sweating, and diarrhea. BP is 150/110, HR is 140, RR is 25, temperature is 100.8 F. Thyroid is tender and enlarged. There is leukocytosis. DDx:

Thyroid storm (due to Graves disease) o Definition: thyroid storm is extreme thyrotoxicosis that leads to CNS dysfunction

(coma/delirium) and autonomic instability (hyperthermia, high/low BP) High vitals due to autonomic instability are a hallmark of thyroid storm!

o Presentation: hyperthyroid symptoms + painless enlarged thyroid, possible proptosis (Graves)

Leukocytosis is important to note, because PTU can sometimes cause bone marrow aplasia (so you would see low WBCs and possibly sepsis)

o Management: a beta-blocker (e.g., Propanolol), corticosteroids, and PTU In non-pregnant patients or very sick ones, you can use a saturated solution of

potassium iodide (which may affect the fetal thyroid gland) Both PTU and Methimazole can cross the placenta and cause some transient neonatal

hypothyroidism (PTU is drug of choice in pregnancy) Remember that corticosteroids also decrease T4-T3 peripheral conversion

o Complications: Fetal hypo/hyper-thyroidism due to maternal hyperthyroidism

Need to treat with maternal PTU or intraamniotic thyroxine (for fetal hypothyroidism), or risk non-immune hydrops and fetal death

Physiology o Pregnancy causes increase in thyroid-binding globulin and thus total T4 (since free T4 is

regulated to remain constant). TSH is constant since free T4 is constant. Pregnancy is generally a euthyroid state.

High TBG, high total T4 Normal free T4 and TSH

o In the postpartum state, the cause of hyperthyroidism is most likely to be lymphocytic thyroiditis rather than Graves disease (most common overall)

High steroid levels in pregnancy suppress autoimmune antibodies, and postpartum there is a flare

Screening o TSH is the best screening test for hyperthyroidism (low TSH suggests hyperthyroid)

confirm with high free T4 Usually 1-4 months postpartum Associated with antimicrosomal antibodies

CASE 48: Chlamydia Cervicitis and HIV in Pregnancy 18-yo G1P0 at 22 weeks has a positive Chlamydia test. No pain, afebrile. GC is negative.

Next step: oral azithromycin/amoxicillin (erythromycin causes biliary sluding no pregnant) o Note: Tetracycline is contraindicated in pregnancy, cant use for Chlamydia here o Also test for HIV o If HIV positive, assess stage and treat with HAART offer C-section o Give Zidovudine to neonate

Babies with documented chlamydial ophthalmic infecitons are given oral erythromycin for 14 days (erythromycin eye drops only prevents GC!)

Chlamydia generally does not cause complications in pregnancy (but may cause postpartum endometritis)

o GC can complicate pregnancy abortion, preterm labor, PPROM, chorioamnionitis, neonatal sepsis, and postpartum infection

o GC can also disseminate -> skin lesions, septic arthritis HIV

o HIV should be tested at the initial prenatal visit and again during labor/delivery o Symptoms are like mono o Antibodies to HIV are detectable within 1 month after infection and definitely within 3

months of infection o Viral loads and CD4 T cell monitoring during pregnancy, get viral load to undetectable

levels to minimize vertical transmission (< 1000 RNA/ml) o Treat with HAART monitor LFTs o Offer C section, give ZDV to mother during labor and baby afterwards, no breastfeeding o If labor has already started (ROM happened), then C-sections will not decrease risk

CASE 49: Parvovirus Infection in Pregnancy 24-yo G2P1 at 22 wks had myalgia and low fever a month ago (gotten better). 2-yo son also had a high fever and red cheeks. Fundal height is 28 cm and fetal parts are difficult to palpate. DDx:

Parvovirus B19 - Polyhydramnios with probable hydrops fetalis o Causes fetal anemia due to parvovirus infection, inhibits bone marrow erythrocyte

production in baby Fetal anemia -> hydrops fetalis (presents early as polyhydramnios)

Mechanism unknown Hydramnios presents as increased fundal height and difficult to palpate fetus

o Adults vs. children present differently with parvovirus infections (myalgia vs. slapped cheeks in children fifth disease; low vs. high fever in children)

o Hydrops fetalis = excess fluid in body cavities (ascites, skin edema, pericardial effusion, pleural effusion, etc.0

o Sinusoidal heart rate pattern sine wave with cycles of 3-5 per minute, indicative of severe fetal anemia or fetal asphyxia

o If pregnant woman is positive for parvovirus B19 -> weekly ultrasounds to assess for hydrops fetalis (if positive, consider intrauterine transfusion)

o Causes of fetal anemia include parvovirus B19, isoimmunization (e.g., Rh), fetal-to-maternal hemorrhage, or thalassemia

Parvovirus B19 test results:

Causes of hydramnios: parvovirus B19, gestational diabetes, isoimmunization, syphilis, fetal cardiac arrhythmias, and fetal intestinal atresias

CASE 50: Postpartum Endomyometritis 24-yo G1P1 underwent C-section two days ago, now has fever of 102 F. No cough or dysuria, no other abnormalities, but uterine fundus is tender.

DDx: o Endomyometritis

The most common cause of fever in a woman s/p C-section is endomyometritis! Can have some uterine tenderness

Caused by ascending infection of polymicrobial vaginal organisms (usually anaerobes, may have gram-negative rods)

Basically, an infection of the decidua, myometrium, and sometimes the parametrial tissues usually at the incision site of the uterus

Usually occurs at post-op day 2 May present with pain, foul-smelling lochia, and fever Management: IV antibiotics w/ anaerobe coverage Clindamycin + Gentamicin

Usually responds within 48 hours. IF fever persists, suspect enterococcus infection give ampicillin

If fever persists even after that, get CT to check for abscess! In contrast, endometritis s/p vaginal delivery does not need anaerobe coverage

(amp + gent is good enough) o Other ddx includes:

Mastitis breast exam (breast engorgement) Wound infection especially if no response to antibiotics, same organisms involved

but will require drainage Inspect fascia for necrotizing fasciitis If fever in first 24 hours, think Group A Strep (flesh-eating bacteria)

need immediate surgery! Pyelonephritis costovertebral/flank tenderness, leukocytes in urine

Septic pelvic thrombophlebitis bacterial infection of thrombosed pelvic veins, usually the ovarian vein

o Treat with antibiotics and maybe Heparin CASE 51: Syphilis Chancre 31-yo has a non-tender 1-cm ulcerated lesion on vulva raised borders and indurated base. Also bilateral non-tender inguinal lymphadenopathy DDx:

Syphilis (primary chancre) o Management: test with RPR or VDRL, and if negative, darkfield microscopy

RPR and VDRL may not be positive in early syphilis! These are non-specific non-treponemal tests

o Treat with IM Penicillin If allergic, use oral erythromycin or doxycycline in non-pregnant women In pregnant women, desensitize and try Penicillin again After treatment, follow RPR or VDRL (should see four-fold fall in 3 months and

negative in 1 year) If RPR titers fall and then rise again, suspect reinfection

o Tests such as MHA-TP or FTA-ABS are specific tests that will be positive for life after infection! They are next step after positive RPR/VDRL.

o Stages of Syphilis Primary indurated, non-tender chancre Secondary systemic: maculopapular rash on palms/soles, or flat lesion of

condylomata on vulva Latent varying duration between secondary and tertiary stages Tertiary CNS and cardiac issues (e.g., tabes dorsalis, aortic aneurysms, optic

atrophy) Diagnose neurosyphilis with lumbar puncture! Suspect if RPR levels are

not going down! Neurosyphilis classicaly presents as ataxia and Argyll-Robertson pupils

Squamous cell carcinoma of the vulva if the patient were order (post-menopausal) HSV if lesions were painful

Chancroid (H. ducreyi) should have painful ulcers and adenopathy o Ragged edges with necrotic base o If painless and negative RPR/VDRL and dark-field microscopy, suspect chancroid! o Treat with IM ceftriaxone or oral azithromycin

Chlamydia lymphogranuloma venereum painless ulcers, painful adenopathy (buboes) CASE 52: Intra-amniotic Infection 24-yo G2P1 at 30 wks had PROM two days ago. Her temperature is 100.8 F and the uterus is tender. There is persistent fetal tachycardia (170-175 bpm). DDx:

Intra-amniotic infection (i.e., chorioamnionitis) o Presentation: fever, tender uterus, fetal tachycardia, malodorous vaginal discharge

An early sign is fetal tachycardia! (>160) o Diagnosis: best way to diagnose is via amniocentesis o Due to ascending infection from vaginal organisms (most commonly GBS and gram-

negs like e. coli) Listeria can cause chorio without ROM!! (e.g., from eating goat cheese)

o Management: IV Ampicillin and Gentamicin, and induction of labor (delivery) BACKGROUND INFO:

The two most common complications of PPROM are infection (chorio) and labor (most common!)

o May also see neonatal RDS due to prematurity, placental abruption, and necrotizing enterocolitis

If presenting with PPROM o First check for infection o If no infection, give corticosteroids to reduce risk of neonatal RDS (if < 32 weeks) and

antibiotics to reduce risk of chorio (always) Premature rupture of membranes (PROM) rupture of membranes before onset of labor Preterm PROM (PPROM) rupture of membranes when < 37 weeks, prior to onset of labor

o On physical, will see pooling of amniotic fluid in posterior vaginal vault, and alkaline changes of vaginal fluid

o Ultrasound shows oligohydramnios o Half of PPROM patients will go into labor within 48 hours, and 90% within a week

Latency period duration of time from ROM to onset of labor

CASE 53: Vaginal Discharge 18-yo has fishy vaginal discharge, worse after intercourse. Speculum exam shows homogenous white vaginal discharge with fishy odor. DDx for vaginal discharge:

Bacterial Vaginosis o Presentation: white vaginal discharge with fishy odor. No inflammation (no swelling or

erythema). o Management: Metronidazole (or alternative: Clindamycin) o Due to excessive anaerobes in vagina (not an STI), leads to alkaline discharge o Associated with endometritis, PID, preterm delivery, and PPROM

Trichomoniasis o Presentation: frothy green discharge, intense inflammation (strawberry cervix) o An STI o Treat with Metronidazole

Candida vulvovaginitis o Antibiotics may decrease lactobacilli in vagina, which normally inhibits Candida growth o Diabetes can suppress immune function and also predispose to Candida o NOT an STI

CASE 54: Hirsutism, Sertoli-Leydig Cell Tumor 42-yo with 8 month h/o increasing hirsutism and irregular menses. No steroid meds, weight changes, or family history. Pelvic exam shows an 8-cm right adnexal mass. DDx:

Hirsutism likely due to excess androgens. Adrenal or ovarian tumors are possibilities, and given the adnexal mass, its probably ovarian. Irregular menses are due to androgen effect inhibiting ovulation.

o Other signs of androgen excess include virilization (clitoromegaly, deepening voice, balding, increased muscle mass), acne, oily skin, increased libido

o Hirsutism has a number of causes, virilization is usually due to androgen-secreting tumors! Sertoli-Leydig Cell Tumor (ovarian tumor)

o Androgen counterpart of the Granulosa-Theca cell stromal tumor o Fast onset of hirsutism suggests ovarian/adrenal tumor! o Will see high testosterone level (testosterone mostly made by ovaries)

Adrenal tumor/hyperplasia (e.g., late-onset CAH) o Will see high DHEA-S tumor o CAH will see increase in 17-hydroxyprogesterone

Cushing disease no HTN, buffalo hump, abdominal striae, central obesity, or other stigmata of the disease

Steroid use denied it Anovulation (e.g., PCOS) usually has a more gradual onset of hirsutism and irregular menses since

menarche. Treat with Clomiphene, spironolactone, or OCPs. Thyroid disease, hyperprolactinemia, medications

BACKGROUND INFO:

DHEA-S is adrenal DHT is metabolized from testosterone by 5-alpha-reductase

CASE 55: Serum Screening in Pregnancy 20-yo G1P0 at 16 wks has a maternal AFP that is 2.8x the median (normal upper limit is 2-2.5x)

Next step: OB ultrasound to assess dates and multiple gestation o Most common causes of abnormal serum screening are dating errors and multiple

gestations! If ultrasound dating/gestation is normal, try amniocentesis!

o Other causes: Elevated AFP may be associated with a NTD

Or abdominal wall defects, sometimes oligohydramnios If no obvious etiologies, there is an increased risk of stillbirth and IUGR

Low AFP is associated with Down syndrome Or molar pregnancy, fetal death

o Down Syndrome: low AFP, low estriol, high hCG, high inhibin-A First trimester low PAPP-A, high hCG, and thicken nuchal translucency

o Trisomy 18: all four are low! First trimester screen PAPP-A, hCG, nuchal translucency

o Ultra screen o If positive, proceed with amniocentesis

Trisomy screen AFP, hCG, inhibin-A, unconjugated estriol o Quad screen

CASE 56: PCOS 23-yo with long h/o irregular menses, obesity, hirsutism, and acne DDx:

PCOS o Presentation: irregular menses, obesity, hirsutism, LH:FSH > 2:1 o Definition: hyperandrogenic state of chronic anovulation (due to ovarian secretion of

testosterone) associated with excess estrogen o Diagnostic criteria

Anovulation (oligomenorrhea) Hyper-androgenism Small cysts on ovary via transvaginal ultrasound (can occur with any anovulation, not

necessarily PCOS) o Work up: TSH, prolactin, serum testosterone, DHEA-S, 17-hydroxyprogesterone, pelvic US o Therapy: OCPs, screen for metabolic abnormalities o Complications: diabetes, metabolic syndrome, CAD, endometrial cancer

Chronic estrogen exposure without progesterone increases risk of endometrial cancer!

Usually stage I normal treatment is hysterectomy If desire children, then do progestin therapy for 2-3 months and then repeat

sampling

CASE 57: Pelvic Organ Prolapse 55-yo G3P3 with a h/o a total abdominal hysterectomy, now has a 1-mo h/o pelvic pressure and a sensation of something falling out of her vagina. On exam, there is vulvar atrophy and mucosal bulging through the introitus. DDx:

Vaginal vault prolapse o Small bowel pushes uterus/cervix into vagina o Management: Surgical fixation of vagina to a sturdy structure (e.g., sacrospinous ligament or

sacrum) Or Pessary (synthetic device acting as hammock to suspend pelvic organs)

o Risk factors include multiple vaginal deliveries and spacious cul-de-sac (surgical obliteration of the cul-de-sac, i.e., culdoplasty, can reduce risk)

Types of pelvic organ prolapse:

o Cystocele (anterior), enterocele (central), rectocele (posterior), paravaginal (lateral) o Cystocele defect of pelvic floor support of bladder, allows bladder to fall down into vagina

(urethra is often hypermobile) an anterior POP defect If urethra is not well supported, Valsalva maneuver causes urethral Q-tip to rotate

through a large angle (Q-tip test) Presentation may include urinary incontinence and hypermobile urethra

o Enterocele defect of pelvic support of uterus and cervix (if still present) or the vaginal cuff (if hysterectomy). Small bowel and/or omentum pushes organs into vagina

Central POP defect o Rectocele defect of pelvic support of rectum, allows rectum to impinge into vagina

May have constipation posterior POP defect Patient may say that she needs to push in vagina to have bowel movement!

o Paravaginal defect defect in levator ani attachment to lateral pelvic side wall no support for vagina (lateral pelvic defect) surgical repair (reattachment of levator ani to side wall)

CASE 58: Twin Gestation with Vasa Previa 31-yo G4P3 at 36 wks with a twin pregnancy presents in labor. Upon ROM, there is moderate vaginal bleeding. Twin A has fetal tachycardia and now a sinusoidal HR pattern. DDx:

Twin gestation with vasa previa o Vasa previa is when a fetal vessel (not protected by cord/membranes) overlies the internal

cervical os can cause rapid exsanguination of fetus after ROM Associated with velamentous cord insertion (umbilical vessels separate before

reaching placenta, protected only by a thin fold of amnion instead of by cord or placenta itself, thus susceptible to tearing) and accessory placental lobes

o Next step: Stat C-section and alert pediatricians for likelihood of anemia in twin A o Diagnosis: Ultrasound with color Doppler

BACKGROUND INFO:

Chorionicity number of placentas (monochorionic vs. dichorionic) o Dizygotic twins are always dichorionic

Amnionicity number of amniotic sacs (monoamnionic vs. diamnionic) o Dizygotic twins are always diamnionic

Complications of twin gestation preterm delivery, higher rate of congenital malformations, 2x increased risk of preeclampsia and postpartum hemorrhage, and twin-twin transfusion

o If preeclampsia with SOB think pulmonary edema! Give Furosemide! Clomiphene induces ovulation and promotes maturation of multiple follicles more eggs available

for fertilization - increases likelihood of dizygotic twins o IVF also increases likelihood o All dizygotic twins are di/di

Maternal AFP may be increased in twin gestation, especially in the case of a vanishing twin where only one fetus is seen on US

In twin gestation, more volume than single gestation, but RBC mass increases less, so more physiologic anemia!

o Also greater increase in BP compared to single gestation! Twin-twin transfusion syndrome one twin is donor and the other is a recipient such that one twin is

larger with more amniotic fluid and the other is smaller with oligohydramnios o Treat with laser ablation of shared anastomotic vessels, or serial amniocentesis for

decompression If no dividing membrane between the twins, cord entanglement can occur (50% mortality rate)

o Thus, it is important to look for dividing membrane on US exams

Case 59: Prenatal Care

BACKGROUND INFO:

Advanced Maternal Age - >35 yo at estimated date of delivery Normal findings in pregnancy:

o Glycosuria due to increased GFR de