OBGYN study guide

Health maintenance
1.Contraception
2.Abortion
3.Typical health screening guidelines
Teens: Tanner staging
- <24 y/o, chlamydia and gonorrhea, HIV
Young adult: breast exam @20, pelvic exam @21, HPV @21
40-64: colonoscopy (50 y/o, q10y), DM test (45y, q3y), Mammogram (40 y/o, q1y), lipids (45 y, q5y)
65+: bond mineral density (65 y/o, q2)

HPV guidelines
Start age 21: every 3 years, cytology alone
>30: Co-test cytology with HPV every 5 yrs
>65: stop if 3 consec neg cytology or 2 consec neg co-test, neg in past 10 yrs; no history of CIN2 or higher. Most recent, within 5y.

OB
Pregnancy Screening
hCG (detect 6d), double x 2 days before 10 w
TVUS: hcg>1500, can detect gestational sack
Visits- <28w every month, 28-36w every 2-3w, 36-31 every week
1st trimester screen (11-13w): for Down’s mostly; Nuchal translucency, PAPP-A, bHCG; incrs NT, decrs PAPP-A, incrs bHCG
Quad screen (15-21w): For down’s, edward’s, NTD. AFP, inhibin A, bHCG, Estriol. FP- confirm GA
AFP- high levels: NTD, abdominal wall defect, fetal death, placental abruption, multi gestations, cystic hygroma, sacrococcygeal teratoma, oligo; low levels:
trisomy, molar preggo
Targeted US Anatomy scan (18-20w), every 4 w for growth

Estriol- low levels w/ 21, 18, 13

CVS (9-12w)- greater risk limb, can’t detect NTD
Amniocentesis (15-20w)- fetal anomaly on US, abn quad, FHx congenital abnormalities, lung maturity
Cordocentesis (>17w):
FISH- sensitive, karyotype- not as sensitive
GTT one hour, 50g (26-28w)
Recheck AB screen, admin Rhogham (28w)
GBS (36w), HIV testing (some states)
Fetal movements (10 over 2 hr)-> NST-> 2 accelerations for 15 sec over 20 min, redo 1-2 hr
 CST (negative- no decel, pos- late decal >50%, equivocal-intermittent late or variable, unsatisfactory- <3 contractions 10 min). C/I- PROM, preterm
labor, prior C/S, placenta previa
 BPP: NST, breathing >30 sec, moving x 3, tone (ext + flex), AFI (>5, pocket >2)
Oligohydramnios: ROM, IUGR, GU malformation
Poly: malformation (anencephaly, GI), DM, multiple gestation, anemia, virus
1.Postpartum hemorrhage
DDX: Primary- uterine atony, placenta accrete, uterine inversion, lacs, rupture
Secondary- retained products of conception, infection, inherited coags
CARPIT- coag, atony, rupture, placenta, implantation, trauma to GU
RF: prolonged, augmented, or rapid labor, hx PPH, operative + episiotomy (esp ML), PEC, overdistended uterus, chorioamnionitis
Hx: uterine atony- soft & boggy uterus -> lacs
Dx: US- normal endometrial stripe (<5mm); CBC, PT, PTT, fibrinogen, T&S
Tx: uterine massage, 2 large bore IV, crystalloids, T&S, vials, I&O’s
uterotonic agents- oxytocin (s/e hypotension), methergine (c/i-HTN), hemabate/PGF2a (c/I asthma), dinoprostone/ PE2 (suppository, s/e hypotension),
misoprostol/PGE1 (rectal)
Tamponade- packing, bakri balloon
Exploratory lap w/ B-lynch suture (uterine atony)
Worst case- UAE, hysterectomy, hypogastric aa ligation, ligation utero-ovarian lg
POC- D&C
VWF-
What to do? Prevention- oxytocin infusion, fundal massage
Stage 1: IV access x 2, fluids, oxytocin, fundal, 1-methergine, 2-hemabate or misopristol, empty bladder, T&S x 2PRBC
Stage 2: vaginal-balloon, repair tears, UAE; c-section: B-lynch, balloon

2.Cerclage
Hx: 1+ 2nd trimester loss w/ painless cervical dilation w/o labor or abruption placentae; prior cerclage
P/E: painless dilation cervix
US: short cervical length before 24 weeks
Indication: singleton, PROM <34w, short cervix <24w- w/o cervical insufficiency, cerclage recommended. For no history PROM- vaginal progesterone
Transvaginal cerclage- 2nd trimester add, remove at 36-37 w
Transabdominal- 10-14 w, non-pregnant state
3. HTN in preggo
cHTN- prior to 20 weeks;
Complications: superimposed preeclampsia- +proteinuria; abruptio placenta, IUGR, preterm
Tx- labetalol, a-methyldopa, hydralazine, nifedipine
gHTN
PEC >140/90 x2 after 20 w or >160/110 short term, + proteinuria
sPEC: PEC+/- proteinuria: thrombocytopenia (<100), renal (incrs BUN, Cr, C:P ratio), LFT’s, pulmonary edema, cerebral or visual symptoms
HTN crisis>160/110 BP
1st line- IV labetalol, hydralazine, nifedipine; 1st line EC- Mg (<48 hr use, neuroprotection <32, prolong preg for steroids for those delivery w/in 7 d)
S/E- labetalol (neonatal brady, avoid in asthma, HD, CHF)
 Hydralazine (hypotension), Nifidepine (maternal tachy, overshoot hypotension)
2nd line- labetalol or nicardipine by infusion pump. Nitroprusside last resort (cyanide tox)
Note: tocolysis not recommended <24 and >34 w

4.Late-term + Post-term
postterm: >42w; late term: 41-42
RF: nulliparity, prior post-term, obesity, carrying M fetus, anencephaly + placental insufficiency
C: neonatal convulsions, meconium aspiration, macrosomia, post-maturity syndrome, oligo,
-lac, infection, PPH, C/S
Tx: BPP 41 w +, can induce 41-42 week, def 42+
Delivery- oligo 41w+

Episiostomy
Indication: FHR, shoulder dystocia, operative delivery, potential for large lac (short perineal body, previous lac, LGA. (does not provide peritoneal
protetction, helped op delivery, improved neonatal outcome
GA- LMP, 1st sem US- crown rump length, 2nd sem- BPD, FL, AC. If 1st sem> 1 week, or 2nd sem > 2 weeks use

5.IOL
Indications: postterm, PROM >12 hr, HTN series, fetal demise, DM, FGR, twins, chorioamnonitis, abruptio placentae, oligo, cholestasis of pregnancy, IUGR,
abn fetal testing, prolonged labor. + Bishop score<6, verification >39 w (US’s atleast 39w, 36 w +hcG, FHT >30w)

C/I: high risk C/S, uterine rupture, placenta previa, vasa previa, herpes, transverse lie, invasive cervical cancer, FHT III, <39 w, prior myomectomy
SE: uterine hypertonus, tachysystole, rupture. Fetal hypoxia. Prolapsed cord. Precipitous labor.
FHR III- discontinue oxytocin, turn side, give O2 and IV fluid. 2- terb
Cervical ripening: <6w, mechanical or chemical (misoprostol/PGE1 or PGE2/dipnoprostone)
IOL: oxytocin, membrane stripping, AROM, nipple stimulation
Note: before 28w, vMisoprostol most effective. Avoid misoprostol for IOL 3rd trimester
TOLAC
Candidates: one lTCS, no scars, no previous rupture
C/I: classical C/S, inability to form emergency CS

6. Placenta accreta (increta-myometrium only, percreta-myometrium + serosa)

RF: C-section w/ previa over scar
Dx: US- irregular shaped placenta lacunae, turbulent flow, thinning myometrium, loss of clear space
Tx: C/S 34w, leave placenta. 2-UAE, hysterectomy

7. Preterm birth (20-37w)

Tx: definite history- 17-a hydroxyprogesterone caproate IM 15-36w, singleton birth, TVUS every 2 w, <25mm before 23w, consider cerclage. Maybe history
w/ TVUS<20mm, vaginal progesterone

8. Preterm labor
Tx: hydration (decrs ADH), BM therapy- repeat steroids if >7d, no abx unless GBS
C/I: IUFD, fetal anomaly, nonreassuring FHT, PEC/EC, maternal bleed, chorioamnionitis, PPROM (unless for steroid admin),

9. Shoulder dystocia
RF: abn pelvic anatomy, GDM, post-term, short, obese, macrosomia, protracted labor
Dx: turtle sign, failure of external rotation, resistance delivery of anterior shoulder
Tx: Call for help, 1-Mc robert’s maneuver (incrs AP), suprapubic pressure obliquely, episiostomy
2-delivery of posterior arm, woods corkscrew (posterior shoulder rotate 180), rubin (push shoulder anterior toward fetal chest) 3-fracture of clavicle,
zavanelli maneuver, abdominal rescue, symphiosotomy
Complications:b rachial plexus injury, fetal humeral/clavicle fx, hypoxia/death

10.C/S indication- labor dystocia, FHR, malpresentation, multiple gestation, macrosomia, HSV
Prolonged 1st stage (NP >20, MP>14h), oxytocin >4h
Prolonged 2nd stage (NP>3, MP>2h)

11. Thrombophilia
Prior DVT- prophylactic dose LMWH or UFH
Low risk: heterozygous factor V or prothrombin; protein C or S deficit
Surveillance unless prior VTE, LMWH
High risk: antithrombin deficit; heterozygous prothrombin and factor V
Surveillance or prophylactic- no VTE
 Prior VTE or 1st degree relative- prophylactic LMWH/UFH
Warfarin, LMWH,hep- ok for breast feeding
Testing for inherited b/c recurrent loss, placental abruption, PEC, FGR not recommended. MTHFR screening not recommended- not related to neg preggo
outcomes
Screen for factor V leiden, PT g20210A, antithrombin, protein C and S deficits

12. Thrombocytopenia
DDx: gestational thrombocytopenia (no incrs risk maternal or fetal bleeding), pseudothrombocytopenia, HIV, drug-induced, PIH, HELLP, TTTP, HUS, DIC,
SLE, APL, pregnancy induced HTN
Neonatal alloimmune thrombocytopenia- tx IVIG
ITP C/S not helpful to prevent IC hemorrhage-> tx prednisone, short-platelet transfusion, 2-IVIG, 3-splenectomy. Additionally, insufficient data recommend
med therapy for fetal indications
Epidural safe >100
ITP avoid NSAIDs, aspirin, trauma; Vax Hflu
Mild thrombodytopenia (<70), monthly platelet counts

13. DM
Type 1- IUGR, caudal regression, cardiac anomalies, NTD, still births, perinatal death
Type II- macrosomia, preterm, neonatal hypoglycemia, hypocalcemia, hyperbili, polycythemia
Tx- A1 diet controlled; A2 and all else is insulin
Goal: <100 preprandial, <140 and <120 postprandial, HbA1C, folic acid, ECG, optho exam, P:Cr ratio,
At 32-34 w for A2: BPP, US every 4 weeks
A1: delivery 41-42 2; A2: delivery 39-42w, insulin drip during labor

14. Twins
Incrs risk for fetal anomalies
Monochorion- TTSS=> serial amniocentesis, laser coagulation
IOL at 38w

15. Bleeding during pregnancy + abortions

1TM bleeding- spontaneous abortion, ectopic, hyadtiform mole, CA, trauma
Hx- vaginal bleeding +/- abd pain
PE- VS, pelvic exam; hCG, CBC, T&S, Rh antibody, US

Periviable birth (20-26 w)

Ectopic pregnancy
Non-ruptured
- Beta <50% rise in 48 hrs
- Fetal pole outside uterus, discriminatory level (beta >2000)
- MTX
Ruptured
- Hx: severe acute pain
- Labs: CBC (anemia)
- TVUS: no IUP, free fluid
FHR baseline- 2 minutes/10 mins mean, >10 min is new baseline
Tachy- hypoxia, infxn, maternal fever, drugs
BTBV: decrs- acidemia (maternal and fetal), asphysxia, narcotics, Mg, barbituates, neuro abnormality. Incrs- mild fetal hypoxemia.
Accelerations- 30 sec +, greater than 15 sec above baseline
Decelerations- 30 sec +
Variable decel: <30 sec, greater than 15 bpm; give amnioinfusion
Prolonged decal 2-10 min, maternal hypotension, cord compression, cervical exam, uterine hyperactivity
Sinusoidal: 3-5 cycles per minute, >20 min
GYN
1.Pelvic organ prolapse (POP)
Anterior compartment- hernia of anterior vagina, assoc w/ cystocele
Posterior “ -hernia of posterior vagina, assoc w/ rectocele
Enterocele- hernia of intestines through vaginal wall
Uterine prolapse/vaginal vault prolapse- uterus, cervix, vagina (uterine procidentia is all 3)
RF: parity, advancing age, obesity, hysterectomy, race (Latina + white>AA)
Hx: “bulge, falling out of vagina,” Stress incontinence, constipation or incomplete emptying
Tx: expectant management, conservative- vaginal pessary (obstetric conjugate- ring + donut, cube, gellhorn), pelvic floor muscle training, estrogen, surgery
(recurrence 30%), biofeedback, functional electrical stimulation
C/I: noncompliant
S/E: irritation of vaginal mucosa, ulcers, necrosis, migration

2.Adnexal masses
DDx- GYN: CA, ectopic, leiomyoma, TOA, hydrosalpinx, torsion, corpus luteum cyst, theca lutein cyst
Non-GYN
RF malignancy: age, post menopause, nulliparity, early menarche, late menopause, FHx
Hx: constitutional, lymphadenopathy, ascites, mass characteristics- irregular, fixed, nodular, firm
DX: 1-TVUS, 2-CBC, bHCG, Ca-125- only PM, AFP, LDH
TOA- aspiration C/I for suspected CA

bHCG AFP LDH CA-125

Dysgerminoma + - + -

Choriocarcinoma + - - -

Immature teratoma - + + +

Embryonal carcinoma + + - -
 Probably Benign Likely Malignant

Patient Characteristics +pregnant +age >60s

+pre-menopausal +post-menopausal
+constitutional sx (early satiety, weight loss)

Physical Exam +lymphadenopathy

+ascites
Mass characteristics:
+irregular, firm, fixed, nodular

Imaging +simple appearing +cyst size >10cm

+no solid components +papillary/solid
+no internal blood flow +irregularity
+ascites
++Doppler flow

Serum markers *CA-125 may be elevated in certain benign CA-125

conditions bHCG, AFP, LDH if less common pathology suspected

3.Premenopausal bleeding
P/E:
(1)myoma- abdominal mass, irregularly enlarged uterus;
(2)symmetric enlarged- adenomyosis, endometrial CA
(3)visualization of lesions (vulva, vagina, cervix)
(4)iatrogenic- IUD, OCPs, DMPA, anticoag, trauma/FB
(5)endometritis- listeria, BV, mycoplasma, Neisseria, chlamydia, Staph, GBS, anaerobes, TB
(6)Ovulatory disorders- PCOS, perimenopause/premature ovarian failure, stess/exercise
(7)Pregnancy- miscarriage, ectopic, hyadtiform mole, physiologic- ectropian, implantation bleeding
Dx: sonohysterography, endometrial biopsy, hysteroscopy, D&C
4.Postmenopausal bleeding
Etiology: CA (6%), hyperplasia, polyp (37%), fibroid (6%), proliferative/secretory (14%), AVM
NonGYN: thyroid, coagulopathy- uremia, liver dysfnx, congenital, , rectal bleed, urologic
(1)Atrophy (30%)- spotting, dyspareunia, itch, burn -> POP. Tx- HRT, vaginal estrogen cream (isolated)
(2) Polyps (30-40%)- RF age, tamoxifen, obesity, HRT, lynch, cowden
Hx-intermenstrual bleeding
Dx- TVUS, sonohysterography or hysteroscopy
Tx- polypectomy. Give IUD if on tamoxifen
(3) Uterine leiomyomas (fibroids- submucosal cause bleed)
PE: enlarged, mobile uterus w/ irregular counter
DX: pelvic US, saline infusion sonography
Tx: OTC, raloxifene, aromatase inhibitors; hysterectomy, myomectomy, endometrial ablation, UAE
(4) Adenomyosis
Hx: dysmenorrhea, menorrhagia, also PM on hormone therapy
PE: symmetrically enlarged uterus
Tx: hysterectomy
()Endometrial hyperplasia- hx bleeding. Prolonged or heavy
RF: unopposed estrogen- obesity, age, estrogen, tamoxifen, early menarche, late menopause, nulliparity. FHx- lynch, cowden, endometrial,
ovary, breast, colon. DM, estrogen secreting tumor.
Dx: TVUS, f/u biopsy if >4mm thick, heterogeneous echo, endometrium not visualized
Tx: w/o atypia- MPA; w/atypia- progestin, IUD. Definitive tx- hysterectomy
()Endometrial CA
RF: type I (estrogen dep, 90%, hypertrophic), type II (estrogen ind, PM, atrophy)
Hx: isolated vaginal bleeding (80-90%), enlarged uterus
Dx: TVUS, endometrial biopsy or D&C, Ca-125 pre and post
Tx: staging, hysterectomy +BSO + para-aortic LN dissection
Sarcoma of uterus- hysterectomy for dx
Fallopian tube or ovarian
Cervical and vaginal CA
Vulvar (nor associared w/ bleeding until advanced)
Choriocarcinoma
(7) Iatrogenic cause- perimenopausal combined HRT, tamoxifen, Post radiation therapy, steroids, anticoags, SSRI, TCA, antispychotics

Endomyometritis- TSS
Endometritis