1. Abnormal Uterine Bleeding
1.1. Normal Cycle
1.1.1. 21-35 days (avg 28d)
1.1.2. Menses 3-5 days
1.1.3. Avg blood loss 30-50 mL
1.2. Definition
1.2.1. Any departure from the normal amount/duration of bleeding whether too much or too little
1.3. Types of AUB
1.3.1. Menorrhagia
1.3.1.1. >80 mL/cycle or >7d bleeding or >1 pad/hr
1.3.1.2. Usually due to fibroids, adenomyosis, or polyps
1.3.2. Hypomenorrhea
1.3.2.1. Regular periods but very light flow
1.3.2.2. Usually HPA dysfunction (e.g., exercise, anorexia) or birth control
1.3.3. Oligomenorrhea
1.3.3.1. Cycles >35d apart
1.3.3.2. Usually PCOS, pregnancy, chronic anovulation, thyroid disease
1.3.4. Polymenorrhea
1.3.4.1. Cycles <21d apart
1.3.4.2. Usually a type of anovulation
1.3.5. Metrorrhagia
1.3.5.1. Bleeding between periods
1.3.5.2. Consider cervical cancer or polyps
1.3.6. Secondary Amenorrhea
1.3.6.1. Cessation of cycles for 6 mo after previously normal cycles
1.3.7. Primary Amenorrhea
1.3.7.1. No menses by age 16 or 4 years after breast development
1.4. DDX
1.4.1. Dysfunctional Uterine Bleeding
1.4.1.1. Refers to AUB w/o identifiable cause
1.4.1.2. Thought to be related to chronic anovulation resulting in endometrial proliferation that never sheds as part of a cycle. As it grows, it slowly outgrows its blood supply and you get random bleeding.
1.4.1.2.1. Most often happens around periods that are commonly anovulatory, such as menarche, pregnancy, breastfeeding, perimenopause.
1.4.1.3. Diagnosis of exclusion so r/o thyroid, abnormal prolactin levels, POI
1.4.1.3.1. Workup
1.4.1.4. Treatment
1.4.1.4.1. NSAIDs (1st line)
1.4.1.4.2. OCPs (1st line)
1.4.1.4.3. Surgery if needed
1.4.2. PALM COEIN
1.4.2.1. Polyps
1.4.2.1.1. Pathophys
1.4.2.1.2. Risks
1.4.2.1.3. Symptoms
1.4.2.1.4. Treatment
1.4.2.1.5. Notes
1.4.2.2. Adenomyosis
1.4.2.2.1. Pathophys
1.4.2.2.2. Risks
1.4.2.2.3. Symptoms
1.4.2.2.4. Treatment
1.4.2.2.5. Notes
1.4.2.3. Leiomyomas
1.4.2.3.1. Pathophys
1.4.2.3.2. Risks
1.4.2.3.3. Symptoms
1.4.2.3.4. Treatment
1.4.2.3.5. Notes
1.4.2.4. Malignancy
1.4.2.4.1. Pathophys
1.4.2.4.2. Risks
1.4.2.4.3. Symptoms
1.4.2.4.4. Treatment
1.4.2.4.5. Notes
1.4.2.5. Coagulopathy
1.4.2.5.1. Pathophys
1.4.2.5.2. Risks
1.4.2.5.3. Symptoms
1.4.2.5.4. Treatment
1.4.2.5.5. Notes
1.4.2.6. Ovulatory Dysfunction
1.4.2.6.1. Pathophys
1.4.2.6.2. Risks
1.4.2.6.3. Symptoms
1.4.2.6.4. Treatment
1.4.2.6.5. Notes
1.4.2.7. Endometrial dysfunction
1.4.2.7.1. Pathophys
1.4.2.7.2. Risks
1.4.2.7.3. Symptoms
1.4.2.7.4. Treatment
1.4.2.7.5. Notes
1.4.2.8. Iatrogenic
1.4.2.8.1. Pathophys
1.4.2.8.2. Risks
1.4.2.8.3. Symptoms
1.4.2.8.4. Treatment
1.4.2.8.5. Notes
1.4.2.9. Not otherwise specified
1.5. General Workup
1.5.1. H&P
1.5.1.1. History
1.5.1.1.1. When it started
1.5.1.1.2. Associated symptoms
1.5.1.1.3. Medical/Surgical history
1.5.1.1.4. Family history
1.5.1.1.5. ObGyn History (paps, pregnancies, etc.)
1.5.1.1.6. Medications
1.5.1.1.7. Allergies
1.5.1.1.8. Social history
1.5.1.2. Physical/ROS
1.5.1.2.1. Signs of anemia
1.5.1.2.2. B-symptoms
1.5.1.2.3. Pelvic Exam
1.5.2. Tests
1.5.2.1. Pap smear
1.5.2.2. Biopsy anything suspicious (r/o cancer)
1.5.2.3. Pelvic/TV US
1.5.2.3.1. Mass = f/u sonohysterogram or hysterosalpingogram
1.5.3. Labs
1.5.3.1. ß-hCG (pregnancy and malignancy)
1.5.3.2. CBC
1.5.3.3. Prolactin
1.5.3.4. TSH
1.5.3.5. FSH
1.5.3.6. STI panel
1.5.3.7. Hyperandrogenism?
1.5.3.7.1. Total testosterone
1.5.3.7.2. Early morning 17-hydroxyprogesterone
2. Vulvar/vaginal Benign Disease
2.1. Infectious
2.1.1. Bacterial Vaginosis
2.1.1.1. Pathophys
2.1.1.1.1. Decreased lactobacilli results in increased anaerobes like gardnerella and bacteroides
2.1.1.2. Risks
2.1.1.2.1. Smoking
2.1.1.2.2. Douching
2.1.1.2.3. New sexual partner
2.1.1.2.4. Recent BSA
2.1.1.3. Symptoms
2.1.1.3.1. Most common cause of vaginal discharge (grey, thin)
2.1.1.3.2. Fishy odor
2.1.1.3.3. 50-75% are asymptomatic
2.1.1.3.4. Does not generally cause inflammatory symptoms by itself (book says ~25% will have vulvar irritation)
2.1.1.4. Treatment
2.1.1.4.1. Metronidazole 500mg BID for 7 days
2.1.1.4.2. Alternatively topical clindamycin
2.1.1.5. Notes
2.1.1.5.1. Potential Complications of Untreated BV
2.1.1.5.2. No need to treat partner
2.1.1.5.3. "Gold standard" for diagnosis is gram stain, but diagnosis is more often made clinically
2.1.2. Trichomoniasis
2.1.2.1. Pathophys
2.1.2.1.1. Protozoan STI
2.1.2.2. Risks
2.1.2.2.1. Multiple sex partners
2.1.2.3. Symptoms
2.1.2.3.1. Frothy, copious discharge that is foul smelling and sometimes green
2.1.2.3.2. Itching
2.1.2.3.3. Burning
2.1.2.3.4. Dyspaerunia
2.1.2.3.5. Dysuria
2.1.2.3.6. Vulvar edema/erythema
2.1.2.3.7. "Strawberry" cervix
2.1.2.3.8. Petechiae (uncommon)
2.1.2.3.9. Often asymptomatic
2.1.2.4. Treatment
2.1.2.4.1. Metronidazole 2 grams, PO, once; or 500mg BID for 7 days
2.1.2.4.2. Treat partner also
2.1.2.4.3. Re-test in two weeks or so (NAAT)
2.1.2.5. Notes
2.1.2.5.1. Left Untreated
2.1.2.5.2. During pregnancy
2.1.2.5.3. Diagnostics
2.1.3. Candidiasis
2.1.3.1. Pathophys
2.1.3.1.1. Typically due to candida albicans
2.1.3.1.2. Candida is part of normal vaginal flora in ~25% of women
2.1.3.1.3. Not typically due to opportunistic infection
2.1.3.2. Risks
2.1.3.2.1. Multiple sexual partners
2.1.3.2.2. Diabetes
2.1.3.2.3. Recent antibiotic use (loss of lactobacillus)
2.1.3.2.4. Increased estrogen levels
2.1.3.2.5. Immunosuppression
2.1.3.2.6. Genetic predisposition
2.1.3.2.7. Obesity
2.1.3.2.8. Tight clothing/panty liners
2.1.3.3. Symptoms
2.1.3.3.1. Vulvar Itching
2.1.3.3.2. Vulvar Erythema
2.1.3.3.3. Cottage cheese/white discharge (but sometimes thin, watery, loose)
2.1.3.3.4. Soreness
2.1.3.3.5. Vulvar excoriation/fissures
2.1.3.3.6. Dyspaerunia
2.1.3.4. Treatment
2.1.3.4.1. Uncomplicated
2.1.3.4.2. Complicated
2.1.3.4.3. Pregnancy
2.1.3.5. Notes
2.1.3.5.1. Specific Diagnostics
2.1.3.5.2. Boric acid tablets are used in some specific types of candidal infections, but are used vaginally. Taking these orally can be fatal!
2.1.3.5.3. Oral Fluconazole associated with miscarriage at high doses, but is safe for pregnant women at the low therapeutic dose used for candidiasis
2.1.4. Pelvic Inflammatory Disease
2.1.4.1. Pathophys
2.1.4.1.1. Acute and subclinical infection of upper genital tract (fallopian tubes)
2.1.4.1.2. Spectrum of infection, no single diagnostic gold standard
2.1.4.1.3. Can lead to tuboovarian abscess
2.1.4.1.4. May lead to scarring or Fitz-Hugz Syndrome
2.1.4.2. Risks
2.1.4.2.1. Sexual activity
2.1.4.2.2. Prior history of PID
2.1.4.2.3. Prior/current history of STD
2.1.4.2.4. First 12 weeks of pregnancy
2.1.4.2.5. Anything that increases risk of infection
2.1.4.3. Symptoms
2.1.4.3.1. Lower abdominal pain
2.1.4.3.2. Dyspareunia
2.1.4.3.3. AUB
2.1.4.3.4. Lower abdominal tenderness
2.1.4.3.5. Acute cervical motion, uterine, and adnexal tenderness on bimanual pelvic exam
2.1.4.3.6. Purulent discharge
2.1.4.3.7. Fitz-Hugh Curtis Syndrome (perihepatitis)
2.1.4.3.8. Infertility
2.1.4.3.9. Pelvic organ tenderness is a defining symptom of acute PID
2.1.4.3.10. Fever
2.1.4.3.11. WBCs on microscopy
2.1.4.4. Treatments
2.1.4.4.1. Ceftriaxone/Cefoxitin + Doxycycline (10-14d) = "Foxy Doxy"
2.1.4.4.2. F/u within 48-72 hours if treating outpatient
2.1.4.4.3. If pregnant, use azithromycin instead of doxycycline ("Foxy Zee at the Metro")
2.1.4.5. Notes
2.1.4.5.1. Specific Diagnostics
2.1.4.5.2. Indications for Hospitalization
2.1.4.5.3. Permanent Complications
2.1.5. General Workup
2.1.5.1. Swab + wet prep
2.1.5.2. Swab + KOH slide
2.1.5.3. pH test
2.1.5.4. UA + culture + microscopy
2.1.5.5. Vaginal discharge culture + gram stain
2.1.5.6. NAAT
2.1.6. STI Screenings
2.1.6.1. <25 screen for gonorrhea/chlamydia
2.1.6.2. >25 screen if new/multiple partners or partner w/ new confirmed STI
2.1.6.3. Pregnant = screen for syphilis, gonorrhea, chlamydia, HIV, and HBV in 1st trimester
2.1.6.3.1. Repeat 3rd trimester for high risk patients
2.1.6.4. Age 13-64 screen for HIV at least once, repeat annually if high risk
2.1.6.5. Men who have sex w/ men = annual gonorrhea/chlamydia screen
2.1.6.6. Injection drug use or unsafe sex = screen for HIV annually
2.1.7. Herpes Simplex Virus
2.1.7.1. HSV1
2.1.7.1.1. Oral or genital lesions
2.1.7.2. HSV2
2.1.7.2.1. Genital lesions
2.1.7.3. Symptoms
2.1.7.3.1. Pain + Urinary retention
2.1.7.4. Treatment
2.1.7.4.1. Acyclovir, Famciclovir, or valacyclovir
2.2. Noninfectious
2.2.1. Lichen Sclerosis
2.2.1.1. Symptoms
2.2.1.1.1. White, thin skin
2.2.1.1.2. Shrinkage of labia
2.2.1.1.3. +/- pruritis
2.2.1.2. Complications
2.2.1.2.1. 10-15% risk to turn into cancer in postmenopausal women
2.2.1.3. Diagnostics
2.2.1.3.1. Biopsy, always
2.2.1.4. Treatment
2.2.1.4.1. Potent topical corticosteroids
2.2.1.4.2. Topical antihistamines
2.2.2. Lichen Planus
2.2.2.1. Symptoms
2.2.2.1.1. Multiple shiny, flat, purple papules
2.2.2.1.2. Pruritis
2.2.2.1.3. Adhesions
2.2.2.1.4. Vaginal stenosis
2.2.2.1.5. Wickham striae
2.2.2.1.6. Dyspaerunia
2.2.2.2. Treatment
2.2.2.2.1. Potent topical steroid (sometimes systemic steroids), applied nightly, is first-line
2.2.2.2.2. Estrogen cream
2.2.2.2.3. No cure, so education/support important
2.2.2.2.4. F/u in 3-4 weeks
2.2.2.3. Diagnostics
2.2.2.3.1. Biopsy
2.2.3. Lichen Simplex Chronicus
2.2.3.1. Pathophys
2.2.3.1.1. Reactive change to chronic itching, typically only one side
2.2.3.2. Symptoms
2.2.3.2.1. Severe itching, worse at night
2.2.3.2.2. Thick white skin w/ scaling
2.2.3.3. Treatment
2.2.3.3.1. Topical steroids
2.2.4. Adenosis
2.2.4.1. Pathophys
2.2.4.1.1. Extracervical lesion consisting of columnar epithelium, often associated with DES exposure
2.2.4.2. Symptoms
2.2.4.2.1. Palpable red spots/patches in upper third of vagina
2.2.4.2.2. Otherwise asymptomatic
2.2.4.3. Treatment
2.2.4.3.1. None
2.2.4.4. Management
2.2.4.4.1. Biopsy to rule out cancer
3. Abnormal Pap Smear
3.1. Stats
3.1.1. HPV implicated in almost all cases
3.2. Notes
3.3. Abnormal Results
3.3.1. Atypical Squamous Cells of Unknown Significance (ASCUS)
3.3.1.1. Do HPV DNA test
3.3.1.1.1. (+)
3.3.1.1.2. (-)
3.3.2. Atypical Squamous Cells, Cannot Exclude High Grade Squamous Intraepithelial Lesion (ASC-H)
3.3.2.1. Colposcopy
3.3.3. Low-grade Squamous Intraepithelial Lesion
3.3.3.1. Colposcopy
3.3.4. High-grade Squamous Intraepithelial Lesion
3.3.4.1. Colposocpy
3.3.5. Over 35 years old or risk factors for endometrial cancer?
3.3.5.1. Get endometrial biopsy
3.4. Consequences
3.4.1. HPV usually causes squamous cell carcinoma of the cervix (typically at the transition zone)
3.4.2. Many pap smear abnormalities (ASCUS, ASCH, and LSIL) may regress over the next year
3.5. Colposcopy
3.5.1. Looking for acetowhite epithelium (turns white with acetate wash), mosaicism, punctuations, and atypical vessels
3.5.1.1. Biopsy these areas
3.5.1.1.1. CIN I
3.5.1.1.2. CIN II
3.5.1.1.3. CIN III = all the way through from basal cells to surface
3.5.1.1.4. Squamous Cell Carcinoma in Situ (all the way through the basement membrane)
3.6. Cervical Cancer Risk Factors
3.6.1. HPV
3.6.1.1. Detectable in 99.7% of cervical cancers
3.6.2. Low SE status
3.6.3. OCP use
3.6.4. Smoking (squamous specifically)
4. Preterm Labor
4.1. Definition
4.1.1. Delivery from 20-37 weeks of EGA
4.1.2. Labor = contractions + cervical changes
4.2. Stats
4.2.1. Contributes to 35% of 1st year of life mortalitiy
4.2.2. 70% of neonatal demise
4.3. Newborn Complications
4.3.1. Respiratory Distress
4.3.2. Infection
4.3.3. Intraventricular Hemorrhage
4.4. Risk Factors
4.4.1. Prior h/o preterm birth
4.4.2. Short cervical length <2.5 cm
4.4.3. Cervical surgery
4.4.4. Smoking
4.4.5. Drinking
4.4.6. Low maternal BMI
4.4.7. Adolescence
4.4.8. Chorioamnionitis
4.4.9. Preeclampsia
4.5. Clinical Features
4.5.1. Often PROM
4.5.1.1. Always start antibiotics if PPROM (ampicillin)
4.6. Treatment/management
4.6.1. 24-34 weeks EGA
4.6.1.1. Corticosteroids
4.6.1.2. Short-term tocolytics
4.6.1.2.1. CCBs
4.6.1.2.2. NSAIDs
4.6.1.2.3. ß-agonists
4.6.1.2.4. Magnesium sulfate
4.6.1.2.5. Contraindications
4.6.1.3. Magnesium sulfate if <32 weeks
4.6.1.4. Goal is to try to make it to 34 weeks if possible, otherwise reduce risk of RDS
4.6.2. >34 weeks EGA
4.6.2.1. Admit for potential delivery
4.6.2.1.1. If stable and no labor progression, d/c home w/ close followup
4.6.2.1.2. If progresses, go ahead and deliver
4.6.3. Progesterone Therapy
4.6.3.1. Inhibits cervical ripening
4.6.3.2. Can give to women w/ h/o preterm birth or short cervix
4.6.4. GBS
4.6.4.1. If PPROM or GBS unknown, start penicillin prophylaxis
5. Preeclampsia
5.1. Criteria (Uncomplicated PreE)
5.1.1. New onset, 20 wk+ BP of 140/90 or higher (either SBP or DBP) on two separate readings 6 hours apart + any of the following:
5.1.1.1. New onset proteinuria (>300 mg in 24 hours or urine protein:Cr ratio >0.3)
5.1.1.2. Any other sign of end organ damage
5.1.1.2.1. Thrombocytopenia
5.1.1.2.2. Impaired LFTs
5.1.1.2.3. Renal Insufficiency (Cr >1.1)
5.1.1.2.4. Pulmonary Edema
5.1.1.2.5. New Onset Cerebral or Visual Disturbance
5.2. Criteria (Severe PreE)
5.2.1. Systolic BP 160 or higher or diastolic 110 or higher on two occasions 4 hours apart
5.2.2. Any other sign of end organ damage
5.2.2.1. Also may see severe epigastric/RUQ pain
5.2.2.2. AMS
5.2.2.3. Dyspnea
5.2.2.4. Stroke (hemorrhagic)
5.3. Risk Factors
5.3.1. Nulliparity
5.3.2. AMA
5.3.3. African American
5.3.4. Prior h/o preeclampsia or family h/o
5.3.5. Chronic HTN
5.3.6. Chronic renal disease
5.3.7. Obesity
5.3.8. Antiphospholipid Syndrome
5.3.9. Diabetes
5.3.10. Multifetal pregnancy
5.4. Routine Workup
5.4.1. Establish baseline BP and urine protiein
5.4.1.1. Get BP and protein at first visit
5.4.1.2. Record BP at every visit
5.4.1.3. Urine dipstick at every visit for protein and signs of infection
5.4.1.4. Repeat any high BP reading to confirm
5.4.2. Detailed H&P
5.4.2.1. Screen for PreE symptoms (HA, abdominal pain, visual disturbances)
5.4.2.2. Personal history of HTN and CVD issues
5.4.2.3. Family history of HTN and CVD issues
5.4.2.4. Risk factors (smoking, drugs, lifestyle, etc.)
5.4.3. Prevention
5.4.3.1. Low dose ASA from 12 weeks
5.4.4. Normal routine screenings and perinatal care
5.5. Management of Preeclampsia
5.5.1. Uncomplicated Preeclampsia
5.5.1.1. Close observation
5.5.1.1.1. Are baby and mom stable?
5.5.1.1.2. Regular checks
5.5.1.2. Deliver at term ~37 weeks
5.5.1.3. Consider magnesium sulfate on case-by-case basis
5.5.1.3.1. Note: Magnesium is eliminated by the kidneys and should be stopped 24 hours postpartum
5.5.2. Severe (Complicated) Preeclampsia
5.5.2.1. Stabilize maternal status
5.5.2.1.1. BP > 160 SBP or > 110 DBP
5.5.2.2. Assess for maternal/fetal threats
5.5.2.2.1. PulseOx, Labs, Fetal Strip
5.5.2.2.2. Review of symptoms
5.5.2.3. Assess fetal weight, FHR pattern, and/or BPP
5.5.2.4. Assess for potential delivery window
5.5.2.4.1. 34 weeks or more GA = give magnesium and deliver
5.5.2.4.2. Less than 34 weeks
5.6. Complications
5.6.1. Maternal Complications
5.6.1.1. End organ damage
5.6.1.1.1. AKI
5.6.1.1.2. Liver damage
5.6.1.1.3. Coagulopathy
5.6.1.2. Seizure
5.6.1.3. Stroke
5.6.2. Fetal Complications
5.6.2.1. IUGR
5.6.2.2. Preterm birth
5.7. DDX
5.7.1. Chronic HTN
5.7.1.1. BP 140/90+ before pregnancy or at less than 20 weeks, or persisting more than 12 weeks postpartum
5.7.1.2. Risk of IUGR, fetal demise, placental abruption, and preeclampsia
5.7.2. Gestational HTN
5.7.2.1. HTN w/o proteinuria or other features of preeclampsia at > 20 weeks gestation
5.7.3. Eclampsia
5.7.3.1. PreE + seizures
5.7.4. HELLP Syndrome
5.7.4.1. Hemolysis, Elevated Liver enzymes, Low Platelets, thought to be a subset of severe PreE
5.7.5. Posterior Reversible Encephalopathy Syndrome
5.7.6. Superimposed Preeclampsia
5.7.6.1. Preeclampsia in a patient with preexisting chronic HTN
5.7.7. Superimposed Preeclampsia with Severe Features
5.7.7.1. Preeclampsia w/ severe features in a patient with preexisting chronic HTN
5.7.8. Preeclampsia with Severe Features
5.7.8.1. Worsening vasospasm results in end organ damage usually requiring delivery of the baby regardless of GA
5.8. Stats
5.8.1. 90% of cases occur late in pregnancy (>34 weeks)
5.8.2. 10-25% of Gestational HTN cases go on to become preeclampsia
5.8.3. Overall incidence rate of preeclampsia in the US is ~5%
5.8.4. ~25% of women with preeclampsia develop severe features
6. 3rd Trimester Bleeding
6.1. Generally
6.1.1. RhoGam recommended if mom is RhD(-)
6.1.2. If bleeding is severe
6.1.2.1. IV access
6.1.2.2. Type & Screen
6.1.2.3. Notify blood bank of need for tfx
6.1.2.4. IVF resuscitation
6.1.2.5. RhoGam
6.1.2.5.1. KB test can tell you how much is needed
6.1.2.6. Prepare OR for possible delivery/lap
6.2. DDX
6.2.1. Placenta Previa (or vasa previa)
6.2.1.1. Risk Factors
6.2.1.1.1. Prior c-section
6.2.1.1.2. Uterine surgery
6.2.1.1.3. Multiparity
6.2.1.1.4. Smoking
6.2.1.1.5. AMA
6.2.1.1.6. Prior previa
6.2.1.2. Symptoms
6.2.1.2.1. Sudden and profuse painless vaginal bleeding in 3rd trimester
6.2.1.3. Diagnostics
6.2.1.3.1. DO NOT DO A VAGINAL EXAM UNTIL PLACENTAL LOCATION CONFIRMED BY ULTRASOUND
6.2.1.3.2. TAUS/Pelvic US --> TVUS (if dx early, get another one in 3rd trimester as some spontaneously resolve)
6.2.1.4. Treatment/Management
6.2.1.4.1. Fetal distress
6.2.1.4.2. Stable
6.2.2. Placental abruption
6.2.2.1. Risk Factors
6.2.2.1.1. Chronic HTN
6.2.2.1.2. Preeclampsia
6.2.2.1.3. Cocaine
6.2.2.1.4. H/o abruption
6.2.2.1.5. Meth
6.2.2.1.6. Trauma
6.2.2.1.7. Rapid decompression of an overdistended uterus
6.2.2.1.8. Elevated AFP in 2nd trimester
6.2.2.2. Symptoms
6.2.2.2.1. Severe abdominal pain
6.2.2.2.2. Vaginal bleeding
6.2.2.2.3. +/- strong contractions
6.2.2.2.4. Abnormal FHT
6.2.2.3. Diagnostics
6.2.2.3.1. Often clinical
6.2.2.3.2. TAUS/TVUS
6.2.2.3.3. Confirmed by placental exam after delivery (retroplacental clot + placental necrosis)
6.2.2.4. Treatment
6.2.2.4.1. Small and Asymptomatic
6.2.2.4.2. Big or Symptomatic
6.2.3. Uterine Rupture
6.2.3.1. Risk Factors
6.2.3.1.1. Prior C-section (especially classical)
6.2.3.1.2. Overuse of oxytocin
6.2.3.1.3. External cephalic version
6.2.3.1.4. Ehlers Danlos Syndrome
6.2.3.2. Symptoms
6.2.3.2.1. Sudden, severe abdominal pain
6.2.3.2.2. Vaginal bleeding
6.2.3.2.3. Abnormal FHT
6.2.3.2.4. Regression of fetal parts
6.2.3.3. Treatment/Management
6.2.3.3.1. Immediate laparotomy for repair + c-section delivery
6.2.3.3.2. UAE and hysterectomy if bleeding can't be controlled
7. Adnexal Mass
7.1. Ovarian
7.1.1. Cancer
7.1.1.1. Notes
7.1.1.1.1. Most lethal gynecological cancer
7.1.1.1.2. 3rd most common gynecological cancer
7.1.1.2. Pathophys
7.1.1.2.1. Originate from epithelial cells (most common), germ cells, or ovarian stroma
7.1.1.3. Risk Factors
7.1.1.3.1. BRCA 1/2 (biggest risk)
7.1.1.3.2. Other FHx (1st degree relative)
7.1.1.3.3. H/o breast cancer
7.1.1.3.4. Early menarche
7.1.1.3.5. Late menopause
7.1.1.3.6. Nulliparity
7.1.1.3.7. Late 1st pregnancy
7.1.1.4. Protective Factors
7.1.1.4.1. OCPs
7.1.1.4.2. Breastfeeding
7.1.1.4.3. Multiparity
7.1.1.4.4. Chronic anovulation
7.1.1.4.5. Hysterectomy
7.1.1.4.6. Tubal ligation
7.1.1.5. Diagnostics
7.1.1.5.1. Pelvic US
7.1.1.5.2. Labs
7.1.1.6. Treatment/Management
7.1.1.6.1. Surgery
7.1.1.6.2. Chemo in some cases
7.1.2. Cyst
7.1.2.1. Types
7.1.2.1.1. Follicular cyst
7.1.2.1.2. Corpus luteum cyst
7.1.2.1.3. Theca lutein cyst
7.1.2.2. Complications
7.1.2.2.1. Torsion (waxing and waning pain and nausea)
7.1.2.2.2. Rupture (acute abdominal pain)
7.1.2.3. Diagnostics
7.1.2.3.1. Pelvic US
7.1.2.3.2. Pelvic exam
7.1.2.4. Treatment/Management
7.1.2.4.1. Premenarchal/Postmenopausal
7.1.2.4.2. Otherwise
8. Ectopic Pregnancy
8.1. Pathophys
8.1.1. Extrauterine pregnancy, 96% of the time in the fallopian tube
8.2. Risk Factors
8.2.1. IVF
8.2.2. Prior ectopic pregnancy
8.2.3. PID or other genital infections
8.2.4. Infertility
8.2.5. Tubal surgery
8.2.6. Prior sterilization w/ sterilization failure
8.2.7. Smoking (dose-dependent)
8.2.8. In utero DES exposure
8.2.9. Vaginal douching
8.2.10. Advanced age
8.3. Symptoms
8.3.1. 1st trimester vaginal bleeding w/o apparent intrauterine pregnancy
8.3.2. abdominal pain
8.3.3. may be asymptomatic!
8.3.4. amenorrhea
8.3.5. hemodynamic instability + acute abdomen not otherwise explained
8.3.6. other pregnancy signs/symptoms
8.4. Workup
8.4.1. TVUS
8.4.1.1. Looking for
8.4.1.1.1. Intrauterine/extrauterine mass or pregnancy
8.4.1.1.2. Intraperitoneal bleeding
8.4.1.1.3. Confirm location of extrauterine pregnancy if present
8.4.2. ß-hCG
8.4.2.1. If the patient is stable, repeat in two days. If ß-hCG has risen <35% then likely ectopic pregnancy.
8.4.3. Uterine aspiration w/o products of conception (ancillary diagnostic)
8.4.4. Type & Screen
8.4.5. CBC
8.5. Treatments
8.5.1. Stable
8.5.1.1. First-line
8.5.1.1.1. Methotrexate
8.5.1.2. Second-line
8.5.1.2.1. Laparoscopic Surgery
8.5.2. Unstable
8.5.2.1. Transfer to hospital for resuscitation and stabilization
8.5.2.1.1. May need to stabilize there and then w/ IV access, IV fluids, blood products
8.5.2.2. Emergent laparoscopic surgery
8.5.2.2.1. Salpingostomy
8.5.2.2.2. Salpingectomy
8.5.2.3. Type & Screen + RhoGam if RhD(-)
8.5.2.4. FAST
8.5.2.4.1. If (-) then unlikely to be a ruptured ectopic
8.5.3. Follow-up
8.5.3.1. Must track ß-hCG post-treatment/surgery weekly to confirm that levels decline
8.5.3.1.1. If ß-hCG fails to decline, treat with methotrexate until resolved
8.6. Notes
8.6.1. Almost all spontaneous pregnancies following surgical treatment of ectopic pregnancy occur in the first 18 mo following the procedure
8.7. DDX
8.7.1. Physiologic (actual pregnancy w/ implantation bleeding)
8.7.2. Spontaneous abortion
8.7.3. Other pathology like a polyp
8.7.4. Subchorionic hematoma
8.7.5. Gestational trophoblastic disease
9. Endometriosis
9.1. Pathophys
9.1.1. Endometrial glands outside the uterus (often ovaries, peritoneum, pelvis)
9.1.2. Frequent cause of pelvic pain of women in 30s
9.1.3. Retrograde menstrual flow
9.1.4. Estrogen-dependent
9.2. Risk Factors
9.2.1. FHx
9.2.2. Nulliparity
9.2.3. Prolonged exposure to exogenous estrogen
9.2.4. Early menarche
9.2.5. Late menopause
9.2.6. Short menstrual cycles (<27 days)
9.2.7. Heavy menstrual bleeding
9.2.8. Obstructions to menstrual outflow
9.2.9. Physical/Sexual abuse in childhood/adolescence
9.2.10. Trans unsaturated fats
9.2.11. Atherosclerotic disease
9.3. Symptoms
9.3.1. Endometrioma
9.3.1.1. Ovarian cyst ("chocolate cyst") made of ectopic endometrial tissue filled with old blood
9.3.2. Pelvic pain (dysmenorrhea or dyspareunia)
9.3.2.1. Often, but not always, cyclic
9.3.2.2. Tenderness on physical exam
9.3.3. Infertility
9.3.4. Urinary/GI symptoms
9.3.5. "Powder burn" lesions
9.3.6. Often subside during pregnancy
9.3.6.1. But increases risk of preterm birth
9.4. Diagnosis
9.4.1. Definitively diagnosed by histology of laparoscopic biopsy
9.4.2. Can achieve presumptive diagnosis based on symptoms, signs, and imaging
9.4.3. TVUS/Pelvic US
9.4.4. Visual inspection
9.4.5. Staged I-IV by severity
9.4.6. Bimanual pelvic exam
9.5. Treatment
9.5.1. Mild-moderate pain but no evidence of endometrioma
9.5.1.1. NSAIDs + OCPs for medical management as long as possible
9.5.1.2. Reassess 3-4 mo after start of tx
9.5.1.2.1. If still symptomatic, consider oral northindrone or depot medroxyprogesterone
9.5.2. Severe pain interfering with daily life or that is refractory
9.5.2.1. Trial of GnRH analog (leuprolide) + hormonal therapy
9.5.2.1.1. If still refractory, only then try aromatase inhibitors
9.5.2.2. Offer laparoscopic diagnosis and treatment
9.5.2.2.1. OCPs afterward to suppress recurrence
9.5.2.2.2. Hysterectomy + BSO and excision of extrauterine lesions is definitive, but consider ablation + local excision for more conservative management (esp. if fertility is at issue)
9.5.3. Endometriomas
9.5.3.1. Symptomatic or expanding endometriomas should be surgically removed
9.5.3.2. Asymptomatic and small endometriomas can be left in place w/ medical management
9.6. Notes
9.6.1. Affects ~10% of women
9.6.2. Increases risk of epithelial ovarian cancer (EOC)
10. Contraception
10.1. Progestin Only Birth Control
10.1.1. Progestin Side Effects
10.1.1.1. Irregular uterine bleeding/spotting
10.1.1.2. Amenorrhea
10.1.1.3. Weight gain
10.1.1.4. Mood changes
10.1.1.5. Bone loss (w/ long-term depot medroxyprogesterone)
10.1.2. Progestin IUD
10.1.2.1. Contraindications
10.1.2.1.1. Pregnancy
10.1.2.1.2. Endometrial or cervical cancer/hyperplasia
10.1.2.1.3. Unexplained vaginal bleeding
10.1.2.1.4. Gestational trophoblastic disease
10.1.2.1.5. Distorted endometrial cavity
10.1.2.1.6. Acute pelvic infection
10.1.2.1.7. Active liver disease
10.1.2.1.8. Active breast cancer
10.2. Combined Hormone Contraception
10.2.1. Combined Estrogen-Progestin Side Effects
10.2.1.1. Nausea
10.2.1.2. Breast tenderness
10.2.1.3. Headache
10.2.1.4. Unscheduled bleeding
10.2.1.5. Amenorrhea
10.2.1.6. Mild BP increase
10.2.1.7. Increased VTE risk (3x-5x)
10.2.1.8. MI and Stroke
10.2.1.9. Increase triglycerides
10.2.2. Contraindications
10.2.2.1. Age 35+ and smoking
10.2.2.2. 2 or more CV disease risk factors (old age, smoking, diabetes, HTN)
10.2.2.3. HTN (sys 140+ or dia 90+)
10.2.2.4. Prior hx of VTE
10.2.2.5. Known thrombogenic mutations
10.2.2.6. Prior MI/Stroke or complicated heart disease
10.2.2.7. Breast cancer
10.2.2.8. Cirrhosis
10.2.2.9. Migraine w/ aura
10.2.2.10. Hepatocellular adenoma or malignant hepatoma
10.2.3. Notes
10.2.3.1. Works by increasing estrogen and progesterone so HPA axis is inhibited, resulting in less LH/FSH which normally trigger ovulation
10.2.3.2. Most effective if taken at the same time every day
10.3. Non-hormone Contraception
10.3.1. Copper IUD
10.3.1.1. Contraindications
10.3.1.1.1. Wilson Disease
10.3.1.1.2. Pregnancy
10.3.1.1.3. Endometrial or cervical cancer/hyperplasia
10.3.1.1.4. Unexplained vaginal bleeding
10.3.1.1.5. Distorted cavity
10.3.1.1.6. Acute pelvic infection
10.4. Plan B
10.4.1. Big dose of progesterone that prevents ovulation and alters the lining of the uterus to make implantation less favorable
10.4.2. Must be taken within 72 hours to work
11. Normal Prenatal Care
11.1. Vaccines
11.1.1. Flu (IM) okay during pregnancy
11.1.2. Hep B okay during pregnancy
11.1.3. MMRV (most important to get before pregnancy, cannot be given during!)
11.2. Scheduled Visits (Uncomplicated)
11.2.1. Visit Schedule
11.2.1.1. q4w until 28 weeks
11.2.1.2. q2w from 28-36 weeks
11.2.1.3. q1w from 36w-delivery
11.2.2. 1st Trimester
11.2.2.1. 10 week visit (initial prenatal encounter)
11.2.2.1.1. Baselines
11.2.3. 3rd Trimester
11.2.3.1. Gestational DM
11.2.3.1.1. High risk patients screen earlier
11.2.3.1.2. 1-hr GTT 140 or higher
11.2.3.2. Alloimmunization
11.2.3.2.1. Type & Screen
11.2.3.3. Maternal Anemia
11.2.3.3.1. Low-end of Normal Maternal Hgb at 28 weeks is 10
11.2.3.3.2. Usually iron deficiency anemia
11.2.3.3.3. Get iron studies w/ ferritin
11.2.3.3.4. Tx is iron supplement
11.2.3.4. Infectious
11.2.3.4.1. GBS Screen at 35w
12. Preventative Care/Maintenance
12.1. Breast
12.1.1. Stats
12.1.1.1. 2nd most common malignancy in women
12.1.1.2. 2nd most common cause of cancer death
12.1.2. Risk Factors
12.1.2.1. #1 Age
12.1.2.1.1. Lifetime risk 1 in 8
12.1.2.2. FHx and Genetics
12.1.2.2.1. 1st degree relative
12.1.2.3. Early menarche / late menopause
12.1.2.4. Nulliparity
12.1.2.5. Radiation
12.1.2.6. Dense breasts
12.1.3. Screenings
12.1.3.1. Start mammograms at 40yo, annually (ACOG)
12.2. GU
12.2.1. Contraception
12.2.2. STI Screening
12.2.2.1. <25 = chlamydia/gonorrhea screen
12.2.2.2. HPV typically transient, do NOT screen under age 30 (unless good reason)
12.2.2.3. Cervicitis then test for:
12.2.2.3.1. PID
12.2.2.3.2. Chlamydia
12.2.2.3.3. Gonorrhea
12.2.2.3.4. Trichomoniasis
12.2.2.3.5. HIV
12.2.2.3.6. HBV and HCV if at risk population
12.2.3. Cervical Cancer
12.2.3.1. Risk Factors
12.2.3.1.1. Immunosuppression
12.2.3.1.2. HPV
12.2.3.1.3. Smoking
12.2.3.1.4. Early coitarche
12.2.3.2. Screenings
12.2.3.2.1. Pap w/ cytology from 21-30 every 3 years
12.2.3.2.2. Pap w/ cytology + HPV from 30-65 every 5 years (cytology alone every 3)
12.2.3.2.3. 65+ w/ 3 normal paps in the last 10 years = stop screening
12.2.3.3. Prevention
12.2.3.3.1. HPV vaccine given between ages 9-26
12.2.4. Pap smears
12.2.4.1. Remember that endometrial cells are not reported until age 45, at which point they are an abnormal finding
12.3. Other
12.3.1. Domestic Violence
12.3.2. Colorectal Disease
12.3.2.1. Start colonoscopies at 50, every 10 years (45 if AA)