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Obstetrics and Gynecology Review

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Vaginitis

Vaginitis	Discharge	Treatment
Bacterial Vaginosis	Thin white, Fish odor with KOH, itching, pH >4.5	Metronidazole PO Clindamycin or Flagyl IntraVag
Candidal Vaginitis	Thick white discharge, pseudohyphae, budding yeast, pH <4.5 (normal)	Fluconazole, OTC vaginal creams
Trichomoniasis	Yellow-green frothy discharge, strawberry cervix, flagellated motile protozoa	Metronidazole PO x1

What do you give Prego ladies?

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Genital Ulcer Infections

INFECTION	PRESENTATION	DIAGNOSIS	TREATMENT
HSV	PAINFUL, cluster of vesicles on red base	Clinical, Tzank	Acyclovir or Valacyclovir
Primary Syphilis	PAINLESS CHANCRE	Darkfield microscopy	PCN 2.4 mil IM x 1
Chancroid	PAINFUL +/- Bubo, Pustule → Necrotic	Clinical dx GNR Bacilli (Fish)	Azithro 1 g PO OR Rocephin 250 mg IM
Lymphogranuloma venereum	PAINLESS + U/L tender LAD “groove sign”	Chlamydia L1-3	Doxycycline 100 mg BID x 3 weeks. Prego - Erythromycin
Granuloma Inguinale	PAINLESS, Beefy, red, bleeds easily Can autoamputate	Culture - Donovan bodies Klebsiella	Azithromycin OR Doxycycline OR Ciprofloxacin
Human Papillomavirus	Flat papules or pedunculated skin colored lesions	Clinical	Refer Imiquimod OR Podofilox

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PID

Most common causes:	N gonorrhoeae and C trachomatis
CDC Criteria for TX:	Pelvic pain +: cervical motion tenderness, uterine tenderness, adnexal tenderness
Criteria to increase specificity:	Temp > 38.3, abnormal discharge, abundant WBC on wet prep, increased ESR or CRP, lab evidence of STI
Outpatient Treatment:	Rocephin 250 IM + doxy 100 mg BID x14 days +/- metro 500 mg BID x14 days
Who needs admission:	Pregnant, febrile, unable to tolerate PO, failed outpatient tx, concern for TOA, WBC >15K, poor outpatient f/u
Inpatient Treatment:	Cefoxitin or cefotetan IV + doxy IV
Complications:	TOA, Fitz-Hugh-Curtis, ectopics, infertility

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Bartholin Abscess

Where do the ducts exit? 4 and 8 o’clock labia minora
MC Bugs? E coli, S. aureus
CP? Pain, tenderness, dyspareunia, tender fluctuance
Tx? Word catheter, Marsupilization, Sclerotherapy, Excision

How long does a Word catheter stay in? 4-6 weeks minimum, up to 3 mo

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Ovarian Torsion

Causes: ovarian mass or hypermobility of ovary
Twist causes venous/lymph obstruction congestion → edema → arterial compromise → ischemia/necrosis

Dual blood supply prevents complete arterial obstruction most of the time

What 2 arteries?

Ovarian & Uterine

CP: U/L severe pain, can be intermittent, nausea, +/-fever
Dx: Doppler ultrasound

Gold Std: laparoscopy
Size most likely to torse? >4cm

Tx: Surgery

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GYN CANCER

Ovarian CA - Age 55-65 peak, often advanced at dx

Present: subacute abdominal pain, BLOATING, weight loss, ASCITES, pleural effusion
Dx: US and CT scan, CA-125 serum tumor markers

Cervical CA - Risk factor HPV

HPV vaccine - age 9-26
AIDS defining illness in pt with HIV
Vaginal bleeding in postmenopausal women is CA
Dx: pelvic exam, biopsy

Endometrial/Uterine CA - Post menopausal bleeding

Needs OBGYN referral for endometrial biopsy
Adenocarcinoma
Risk: Continuous estrogen, obesity, DM, HTN, early menses/late menopause

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Physiologic changes in pregnancy

Cardiac Output:	Increase	Blood volume	Increases
Heart rate	Increase	Hematocrit	Decreases (low 30% range by 30th week)
Blood pressure	Decrease in 2nd, return to normal in 3rd	WBC	Increases (increase PMNs)
Tidal Volume	Increases	Fibrinogen level	Increased (avg 400-450)
Functional residual volume	Decreases (due to elevation of diaphragm)	Factors VII, VII, IX, X and XII	Increased
Respiratory Rate	Slight increase	PT/PTT	Normal
pCO2	Decreases to ~30	Safe dose of radiation?	5 rad = .05 gy = 50msv

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Ectopic Pregnancy

Most common location:	Fallopian tube (Ampulla)
Presentation	Triad: Pain, Bleeding, Missed period
Risk factors:	Previous ectopic, PID, tubal/abdominal surgery, IUD, ART
Discriminatory zone:	HCG ~1500
What do you need to dx IUP?	YOLK SAC (5.5-6 wks)
TX:	Methotrexate: early, stable Surgery F/U HCG is key

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Trophoblastic disease

Presentation:	Abnormal vaginal bleeding, uterus bigger than dates, hyperemesis
hCG Levels:	>100,000
Complete:	Grape like vesicles, snowstorm on US, empty egg, 20% malignancy
Partial	Nonviable fetus present; <5% malignancy
Tx:	-D&C, close f/u of B-hCG titers to exclude carcinoma -Rho-GAM

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First Trimester Bleeding

Threatened Abortion	Bleeding + closed os
Inevitable Abortion	Bleeding + open os + IUP
Incomplete Abortion	Bleeding + open os + POC
Complete Abortion	Bleeding slow + os closed + All POC
Missed Abortion	Os closed + Fetal Death
Management	Pelvic rest, Rho-gam Cytotec, Cervidil, Methotrexate Evacuation

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PLacenta Previa

2nd trimester PAINLESS bleeding
Placenta partially or completely covering cervical os
NO PELVIC EXAM
Risk factors

Advanced maternal age, smoking, high parity, scarring

Diagnosis: ultrasound
Can be seen <20 weeks but 50% will resolve and move up uterine wall
Tx: expectant management, C-section

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Abruptio Placentae

Risk factors	cocaine/meth use, trauma, smoking, HTN, EtOH, previous abruption, advanced maternal age, high parity
Complications	DIC, fetal demise
Apparent vs concealed	Apparent: seen on US, presents with vag bleeding Concealed: not see on US, no bleeding
Sx	Painful vaginal bleeding, back and abd pain
Diagnosis	Fetal stress testing, US- not sensitive enough
Treatment	C section

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Hypertension in Pregnancy

Chronic HTN if < 20 weeks

Treat with methyldopa or labetalol

Pregnancy induced HTN

If >20 weeks with NO other symptoms
Same treatment as above

Pre-eclampsia/Eclampsia

If >20 weeks and symptoms

HTN Moms Love Nifedipine & Chocolate

Hydralazine, Methyldopa, Labetalol, Nifedipine, Clonidine

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Preecclampsia/Eclampsia

Risk factors - 1st pregnancy, age extremes (<20 or >35), multiple gestation, HTN, DM
Classic triad - HTN, proteinuria, edema
Mild preeclampsia - BP 140-160/90-110, Proteinuria >300mg/24hr
Severe preeclampsia

SBP 160-180 or >110 diastolic
Proteinuria 5g/24hr or dip with 4+ protein
End organ dysfunction (renal/liver)
CP: HA, blurred vision, RUQ pain, clonus

Tx: Delivery

HTN Mom Love Nifedipine and Chocolate
Corticosteroids if <34wk (Betamethasone x 2 doses, 12 hr apart)
Magnesium - 6gm load then continuous 1-3g/hr

Toxicity Signs? Tx?

Eclampsia → + Seizures

How long can eclampsia/pre-eclampsia last post partum? 4 weeks
Long term sequelae? ICH, retinal detachment, transient cortical blindness, edema/infarct of parieto-occipital lobes

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HELLP

Presentation	epigastric/RUQ pain
Diagnosis	Hemolysis, elevated liver enzymes, low platelets (<100k), schistocytes on smear (fragmented RBCs)
Treatment	Bedrest, delivery, control BP, corticosteroids if <34 weeks

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Premature/Preterm Labor

Definition:	Regular contractions and cervical changes <37 weeks
Braxton Hicks Contractions:	Mild intensity, irregular and no cervical changes
Treatment	Tocolytics (consult OB) - Magnesium sulfate and terbutaline
Less than 34 weeks add:	Corticosteroids for lung maturity

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Premature Rupture of Membranes (PROM)

Definition:	Rupture of membranes before onset of labor at >37 weeks
PPROM:	PROM at < 37 weeks
Diagnosis:	Nitrazine test (amniotic fluid alkaline, pH >7), Fern test
Treatment: >37 weeks, <37 weeks	>37 weeks - delivery within 12-24H <37 weeks - steroids, watch for infection
Complications:	Chorioamnionitis

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Stages of Labor

STAGE	DEFINITION	TIMING
FIRST	Regular contractions to full cervical dilation	Nulliparous: 6-20H Multiparous: 2-14
SECOND	Full dilation to delivery of infant	Nulliparous: 30 min - 3H Multiparous: 5-60 min
THIRD	Delivery of infant to delivery of placenta	Lasts 0-30 min
FOURTH	Hour after delivery	Treat lacs, tears and hemorrhage

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Delivery Complications

Nuchal Cord Management:	Loose: reduce manually Tight: Clamp and cut (need rapid delivery), or deliver with somersault out (keep head close to perineum)
Breech Delivery:	C section! Complication is head entrapment; If head entrapment, use terbutaline or nitro for uterine relaxation
Cord Prolapse	Need to elevate presenting part to prevent compression. Immediate C section
Shoulder Dystocia	Anterior shoulder impacted -Turtle sign
Shoulder Dystocia Management	Call for help (OB, neonatology, anesthesia) McRoberts Suprapubic Pressure Rubins Woods Maneuver Episiotomy Deliver posterior arm Zavanelli Maneuver Roll to all fours position Break Clavicle

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Postpartum Hemorrhage - 4 T’s

Blood loss requiring transfusion OR 10% drop in hematocrit

>1000cc C section, >500 Vaginal Delivery

Causes: 4T’s → Tone, Trauma, Thrombin, Tissue
Early: < 24 hours after delivery, Late: >24 hours after delivery- retained products
Tx:

Uterine atony- MCC Tx: uterine massage, oxytocin, IV fluids
Lacerations- surgical repair
Retained POC- diagnose with US, surgical removal
DIC - FFP

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Rh Incompatibility

Rhesus factor most common blood incompatibility
15% of population is Rh negative
Rh (-) mom and Rh (+) baby can make antibodies to baby’s blood= hemolysis
Tx:

Rhogam
Give at 28-29 weeks to Rh (-) moms and with any chance that fetal blood entered mom’s circulation (vaginal bleeding)
Also give at delivery again if baby is Rh (+)

Complications:

Fetal hydrops if antibodies attack baby’s RBCs

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Mastitis/Breast Abscess

Cause	Blocked duct with engorgement → infection (staph/strep)
Sx	Breast pain, fever, redness, swelling
Treatment	Warm compresses, I&D, antibiotics (dicloxacillin, Keflex)

Do you need to stop breastfeeding? NO - CONTINUE breastfeeding/pumping

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Endometritis

Infection of the endometrial lining of the uterus
Risk factors: c-section, prolonged ROM, prolonged labor, internal monitoring, no prenatal care
Sx: fever, abdominal pain, foul smelling lochia
2-3 days postpartum
Tx: Clindamycin (Ampicillin) + Gentamicin until afebrile 48 hours

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Ovarian Thrombosis

Ovarian vein dilates → valvular incompetence → birth → blood flow decreases leading to venous collapse and stasis + hypercoaguable → clot
Risk Factors: BV, manual placental removal, prolonged labor, multiple cervical exams
CP: abrupt onset, pain, usually 5-10 days PP, +/- mass in right iliac fossa
Which side is MC?
Dx:CT with contrast
Tx: anti-coagulation, antibiotics +/- IVC filter +/- thrombectomy
Cx: up to ⅓ embolize and cause PE

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Cardiac Arrest/Perimortem Cesarean Section

Purpose of Peri-Mortem C-Section (PCS):

Primary goal is improvement of maternal, not fetal, resuscitation
PCS decreases uterine compression on the IVC thus increasing venous return, resulting in improved maternal cardiac filling pressure.
PCS also allows for improved respiratory mechanics, as the diaphragm is lowered after the procedure
Perform at 24+ weeks

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Peri-Mortem C-section

How to perform a PCS:

Make a vertical incision from xiphoid to the pubis using a scalpel (ideally #10 Blade)
Cut through subcutaneous tissue to get to peritoneal wall
Use fingers to bluntly dissect to the peritoneum
Cut through peritoneum vertically (ideally with scissors or use a scalpel to initiate an opening inferiorly)
Deliver the uterus, then cut into the lower half of the uterus vertically to avoid the placenta and then use scissors to extend the incision upwards until you reach the baby
Deliver the baby (neonate will likely need resuscitation)
Clamp and cut the umbilical cord
Place packing/towels in the opened uterus and abdomen