OBGYN osce

1. Abnormal Pap Smear

1.1. Stats

1.1.1. HPV implicated in almost all cases

1.2. Notes

1.3. Abnormal Results

1.3.1. Atypical Squamous Cells of Unknown Significance (ASCUS)

1.3.1.1. Do HPV DNA test

1.3.1.1.1. (+)

1.3.1.1.2. (-)

1.3.2. Atypical Squamous Cells, Cannot Exclude High Grade Squamous Intraepithelial Lesion (ASC-H)

1.3.2.1. Colposcopy

1.3.3. Low-grade Squamous Intraepithelial Lesion

1.3.3.1. Colposcopy

1.3.4. High-grade Squamous Intraepithelial Lesion

1.3.4.1. Colposocpy

1.3.5. Over 35 years old or risk factors for endometrial cancer?

1.3.5.1. Get endometrial biopsy

1.4. Consequences

1.4.1. HPV usually causes squamous cell carcinoma of the cervix (typically at the transition zone)

1.4.2. Many pap smear abnormalities (ASCUS, ASCH, and LSIL) may regress over the next year

1.5. Colposcopy

1.5.1. Looking for acetowhite epithelium (turns white with acetate wash), mosaicism, punctuations, and atypical vessels

1.5.1.1. Biopsy these areas

1.5.1.1.1. CIN I

1.5.1.1.2. CIN II

1.5.1.1.3. CIN III = all the way through from basal cells to surface

1.5.1.1.4. Squamous Cell Carcinoma in Situ (all the way through the basement membrane)

1.6. Cervical Cancer Risk Factors

1.6.1. HPV

1.6.1.1. Detectable in 99.7% of cervical cancers

1.6.2. Low SE status

1.6.3. OCP use

1.6.4. Smoking (squamous specifically)

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. Preterm Labor

3.1. Definition

3.1.1. Delivery from 20-37 weeks of EGA

3.1.2. Labor = contractions + cervical changes

3.2. Stats

3.2.1. Contributes to 35% of 1st year of life mortalitiy

3.2.2. 70% of neonatal demise

3.3. Newborn Complications

3.3.1. Respiratory Distress

3.3.2. Infection

3.3.3. Intraventricular Hemorrhage

3.4. Risk Factors

3.4.1. Prior h/o preterm birth

3.4.2. Short cervical length <2.5 cm

3.4.3. Cervical surgery

3.4.4. Smoking

3.4.5. Drinking

3.4.6. Low maternal BMI

3.4.7. Adolescence

3.4.8. Chorioamnionitis

3.4.9. Preeclampsia

3.5. Clinical Features

3.5.1. Often PROM

3.5.1.1. Always start antibiotics if PPROM (ampicillin)

3.6. Treatment/management

3.6.1. 24-34 weeks EGA

3.6.1.1. Corticosteroids

3.6.1.1.1. Dexamethasone

3.6.1.2. Short-term tocolytics

3.6.1.2.1. CCBs

3.6.1.2.2. NSAIDs

3.6.1.2.3. ß-agonists

3.6.1.2.4. Magnesium sulfate

3.6.1.2.5. Contraindications

3.6.1.3. Magnesium sulfate if <32 weeks

3.6.1.4. Goal is to try to make it to 34 weeks if possible, otherwise reduce risk of RDS

3.6.2. >34 weeks EGA

3.6.2.1. Admit for potential delivery

3.6.2.1.1. If stable and no labor progression, d/c home w/ close followup

3.6.2.1.2. If progresses, go ahead and deliver

3.6.3. Progesterone Therapy

3.6.3.1. Inhibits cervical ripening

3.6.3.2. Can give to women w/ h/o preterm birth or short cervix

3.6.4. GBS

3.6.4.1. If PPROM or GBS unknown, start penicillin prophylaxis

4. Abnormal Uterine Bleeding

4.1. Normal Cycle

4.1.1. 21-35 days (avg 28d ±7 days)

4.1.2. Menses 3-5 days

4.1.3. Avg menstrual blood loss 35 mL

4.2. :led_blue: Definition AUB

4.2.1. Any departure from the normal amount/duration of bleeding whether too much or too little

4.2.2. interval of <21 days or >35 days

4.3. Types of AUB

4.3.1. Heavy Menstrual Bleeding

4.3.1.1. >80 mL/cycle or >7d bleeding or >1 pad/hr

4.3.1.2. Usually due to fibroids, adenomyosis, or polyps

4.3.2. Hypomenorrhea

4.3.2.1. Regular periods but very light flow

4.3.2.2. Usually HPA dysfunction (e.g., exercise, anorexia) or birth control

4.3.3. Oligomenorrhea

4.3.3.1. Cycles >35d-6 mos. apart

4.3.3.2. **Definition:** Infrequent uterine bleeding

4.3.3.3. Usually PCOS, pregnancy, chronic anovulation, thyroid disease

4.3.4. Polymenorrhea

4.3.4.1. Cycles <21d apart

4.3.4.2. Usually a type of anovulation

4.3.5. Metrorrhagia

4.3.5.1. Bleeding between periods or intermenstrual spotting/bleeding

4.3.5.2. Consider cervical cancer or polyps

4.3.6. Secondary Amenorrhea

4.3.6.1. Cessation of cycles for **6-12 mo** after previously normal cycles

4.3.7. Primary Amenorrhea

4.3.7.1. No menses by age **16.5 or 5 years** after breast development (thelarche @13yo)

4.4. DDX

4.4.1. Dysfunctional Uterine Bleeding

4.4.1.1. Refers to AUB w/o identifiable cause

4.4.1.2. 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.

4.4.1.2.1. Most often happens around periods that are commonly anovulatory, such as menarche, pregnancy, breastfeeding, perimenopause.

4.4.1.3. Diagnosis of exclusion so r/o thyroid, abnormal prolactin levels, POI

4.4.1.3.1. Workup

4.4.1.4. Treatment

4.4.1.4.1. NSAIDs (1st line)

4.4.1.4.2. OCPs (1st line)

4.4.1.4.3. Surgery if needed

4.4.2. PALM COEIN

4.4.2.1. Polyps

4.4.2.1.1. Pathophysio

4.4.2.1.2. Risks

4.4.2.1.3. Symptoms

4.4.2.1.4. Treatment

4.4.2.1.5. Notes

4.4.2.2. Adenomyosis

4.4.2.2.1. Pathophys

4.4.2.2.2. Risks

4.4.2.2.3. Symptoms

4.4.2.2.4. Treatment

4.4.2.2.5. Notes

4.4.2.3. Leiomyomas

4.4.2.3.1. Pathophys

4.4.2.3.2. Risks

4.4.2.3.3. Symptoms

4.4.2.3.4. Treatment

4.4.2.3.5. Notes

4.4.2.3.6. Diagnosis

4.4.2.4. Malignancy

4.4.2.4.1. Pathophys

4.4.2.4.2. Risks

4.4.2.4.3. Symptoms

4.4.2.4.4. Treatment

4.4.2.4.5. Notes

4.4.2.5. Coagulopathy

4.4.2.5.1. Pathophys

4.4.2.5.2. Risks

4.4.2.5.3. Symptoms

4.4.2.5.4. Treatment

4.4.2.5.5. Notes

4.4.2.6. Ovulatory Dysfunction

4.4.2.6.1. Pathophys

4.4.2.6.2. Risks

4.4.2.6.3. Symptoms

4.4.2.6.4. Treatment

4.4.2.6.5. Notes

4.4.2.7. Endometrial dysfunction

4.4.2.7.1. Pathophys

4.4.2.7.2. Risks

4.4.2.7.3. Symptoms

4.4.2.7.4. Treatment

4.4.2.8. Iatrogenic

4.4.2.8.1. Pathophys

4.4.2.8.2. Risks

4.4.2.8.3. Symptoms

4.4.2.8.4. Treatment

4.4.2.8.5. Notes

4.4.2.9. Not otherwise specified

4.5. General Workup

4.5.1. Hx&PE

4.5.1.1. History

4.5.1.1.1. Chief Complaint (S-O-C-R-A-T-E-S)

4.5.1.1.2. Observed (Clinical Eye)

4.5.1.1.3. Associated symptoms

4.5.1.1.4. Medical/Surgical history

4.5.1.1.5. Family history

4.5.1.1.6. ObGyn History

4.5.1.1.7. Medications

4.5.1.1.8. Allergies

4.5.1.1.9. Social history

4.5.1.2. Physical/ROS

4.5.1.2.1. Signs of anemia

4.5.1.2.2. B-symptoms

4.5.1.2.3. Pelvic Exam

4.5.2. Tests

4.5.2.1. Pap smear

4.5.2.2. Biopsy anything suspicious (r/o cancer)

4.5.2.3. Pelvic/TV US

4.5.2.3.1. Mass = f/u sonohysterogram or hysterosalpingogram

4.5.2.3.2. EMT (if abnormal do EMB)

4.5.3. Labs

4.5.3.1. ß-hCG (pregnancy and malignancy)

4.5.3.2. CBC with platelets

4.5.3.3. Prolactin

4.5.3.4. TSH

4.5.3.5. FSH

4.5.3.6. STI panel

4.5.3.7. Hyperandrogenism?

4.5.3.7.1. Total testosterone

4.5.3.7.2. Early morning 17-hydroxyprogesterone

5. Normal Prenatal Care

5.1. Vaccines

5.1.1. Flu (IM) okay during pregnancy

5.1.2. Hep B okay during pregnancy

5.1.3. MMRV (most important to get before pregnancy, cannot be given during!)

5.2. Scheduled Visits (Uncomplicated)

5.2.1. Visit Schedule

5.2.1.1. q4w until 28 weeks

5.2.1.2. q2w from 28-36 weeks

5.2.1.3. q1w from 36w-delivery

5.2.2. 1st Trimester

5.2.2.1. 10 week visit (initial prenatal encounter)

5.2.2.1.1. Baselines

5.2.3. 3rd Trimester

5.2.3.1. Gestational DM

5.2.3.1.1. High risk patients screen earlier

5.2.3.1.2. 1-hr GTT 140 or higher

5.2.3.2. Alloimmunization

5.2.3.2.1. Type & Screen

5.2.3.3. Maternal Anemia

5.2.3.3.1. Low-end of Normal Maternal Hgb at 28 weeks is 10

5.2.3.3.2. Usually iron deficiency anemia

5.2.3.3.3. Get iron studies w/ ferritin

5.2.3.3.4. Tx is iron supplement

5.2.3.4. Infectious

5.2.3.4.1. GBS Screen at 35w

6. Preventative Care/Maintenance

6.1. Breast

6.1.1. Stats

6.1.1.1. 2nd most common malignancy in women

6.1.1.2. 2nd most common cause of cancer death

6.1.2. Risk Factors

6.1.2.1. #1 Age

6.1.2.1.1. Lifetime risk 1 in 8

6.1.2.2. FHx and Genetics

6.1.2.2.1. 1st degree relative

6.1.2.3. Early menarche / late menopause

6.1.2.4. Nulliparity

6.1.2.5. Radiation

6.1.2.6. Dense breasts

6.1.3. Screenings

6.1.3.1. Start mammograms at 40yo, annually (ACOG)

6.2. GU

6.2.1. Contraception

6.2.2. STI Screening

6.2.2.1. <25 = chlamydia/gonorrhea screen

6.2.2.2. HPV typically transient, do NOT screen under age 30 (unless good reason)

6.2.2.3. Cervicitis then test for:

6.2.2.3.1. PID

6.2.2.3.2. Chlamydia

6.2.2.3.3. Gonorrhea

6.2.2.3.4. Trichomoniasis

6.2.2.3.5. HIV

6.2.2.3.6. HBV and HCV if at risk population

6.2.3. Cervical Cancer

6.2.3.1. Risk Factors

6.2.3.1.1. Immunosuppression

6.2.3.1.2. HPV

6.2.3.1.3. Smoking

6.2.3.1.4. Early coitarche

6.2.3.2. Screenings

6.2.3.2.1. Pap w/ cytology alone| begin at 30 y.o. every 3 years

6.2.3.2.2. Pap w/ co-testing for 30-65 y.o. every 5 years (or cytology alone every 3)

6.2.3.2.3. 65+ y.o **discontinue** if: 3 or more negative cytology test, and normal paps in the last 10 years

6.2.3.2.4. Special Population

6.2.3.3. Prevention

6.2.3.3.1. HPV vaccine given between ages 9-26

6.2.4. Pap smears

6.2.4.1. Remember that endometrial cells are not reported until age 45, at which point they are an abnormal finding

6.2.4.2. Bethesda System (2014)

6.2.4.2.1. Specimen type

6.2.4.2.2. Specimen Adequacy(mandatory)

6.2.4.2.3. General categorization (optional)

6.2.4.2.4. Interpretation / result (mandatory)

6.3. Other

6.3.1. Domestic Violence

6.3.2. Colorectal Disease

6.3.2.1. Start colonoscopies at 50, every 10 years (45 if AA)

7. 3rd Trimester Bleeding

7.1. Generally

7.1.1. RhoGam recommended if mom is RhD(-)

7.1.2. If bleeding is severe

7.1.2.1. IV access

7.1.2.2. Type & Screen

7.1.2.3. Notify blood bank of need for tfx

7.1.2.4. IVF resuscitation

7.1.2.5. RhoGam

7.1.2.5.1. KB test can tell you how much is needed

7.1.2.6. Prepare OR for possible delivery/lap

7.2. DDX

7.2.1. Placenta Previa (or vasa previa)

7.2.1.1. Risk Factors

7.2.1.1.1. Prior c-section

7.2.1.1.2. Uterine surgery

7.2.1.1.3. Multiparity

7.2.1.1.4. Smoking

7.2.1.1.5. AMA

7.2.1.1.6. Prior previa

7.2.1.2. Symptoms

7.2.1.2.1. Sudden and profuse painless vaginal bleeding in 3rd trimester

7.2.1.3. Diagnostics

7.2.1.3.1. DO NOT DO A VAGINAL EXAM UNTIL PLACENTAL LOCATION CONFIRMED BY ULTRASOUND

7.2.1.3.2. TAUS/Pelvic US --> TVUS (if dx early, get another one in 3rd trimester as some spontaneously resolve)

7.2.1.4. Treatment/Management

7.2.1.4.1. Fetal distress

7.2.1.4.2. Stable

7.2.2. Placental abruption

7.2.2.1. Risk Factors

7.2.2.1.1. Chronic HTN

7.2.2.1.2. Preeclampsia

7.2.2.1.3. Cocaine

7.2.2.1.4. H/o abruption

7.2.2.1.5. Meth

7.2.2.1.6. Trauma

7.2.2.1.7. Rapid decompression of an overdistended uterus

7.2.2.1.8. Elevated AFP in 2nd trimester

7.2.2.2. Symptoms

7.2.2.2.1. Severe abdominal pain

7.2.2.2.2. Vaginal bleeding

7.2.2.2.3. +/- strong contractions

7.2.2.2.4. Abnormal FHT

7.2.2.3. Diagnostics

7.2.2.3.1. Often clinical

7.2.2.3.2. TAUS/TVUS

7.2.2.3.3. Confirmed by placental exam after delivery (retroplacental clot + placental necrosis)

7.2.2.4. Treatment

7.2.2.4.1. Small and Asymptomatic

7.2.2.4.2. Big or Symptomatic

7.2.3. Uterine Rupture

7.2.3.1. Risk Factors

7.2.3.1.1. Prior C-section (especially classical)

7.2.3.1.2. Overuse of oxytocin

7.2.3.1.3. External cephalic version

7.2.3.1.4. Ehlers Danlos Syndrome

7.2.3.2. Symptoms

7.2.3.2.1. Sudden, severe abdominal pain

7.2.3.2.2. Vaginal bleeding

7.2.3.2.3. Abnormal FHT

7.2.3.2.4. Regression of fetal parts

7.2.3.3. Treatment/Management

7.2.3.3.1. Immediate laparotomy for repair + c-section delivery

7.2.3.3.2. UAE and hysterectomy if bleeding can't be controlled

8. Adnexal Mass

8.1. Ovarian

8.1.1. Cancer

8.1.1.1. Notes

8.1.1.1.1. Most lethal gynecological cancer

8.1.1.1.2. 3rd most common gynecological cancer

8.1.1.2. Pathophys

8.1.1.2.1. Originate from epithelial cells (most common), germ cells, or ovarian stroma

8.1.1.3. Risk Factors

8.1.1.3.1. BRCA 1/2 (biggest risk)

8.1.1.3.2. Other FHx (1st degree relative)

8.1.1.3.3. H/o breast cancer

8.1.1.3.4. Early menarche

8.1.1.3.5. Late menopause

8.1.1.3.6. Nulliparity

8.1.1.3.7. Late 1st pregnancy

8.1.1.4. Protective Factors

8.1.1.4.1. OCPs

8.1.1.4.2. Breastfeeding

8.1.1.4.3. Multiparity

8.1.1.4.4. Chronic anovulation

8.1.1.4.5. Hysterectomy

8.1.1.4.6. Tubal ligation

8.1.1.5. Diagnostics

8.1.1.5.1. Pelvic US

8.1.1.5.2. Labs

8.1.1.6. Treatment/Management

8.1.1.6.1. Surgery

8.1.1.6.2. Chemo in some cases

8.1.2. Cyst

8.1.2.1. Types

8.1.2.1.1. Follicular cyst

8.1.2.1.2. Corpus luteum cyst

8.1.2.1.3. Theca lutein cyst

8.1.2.2. Complications

8.1.2.2.1. Torsion (waxing and waning pain and nausea)

8.1.2.2.2. Rupture (acute abdominal pain)

8.1.2.3. Diagnostics

8.1.2.3.1. Pelvic US

8.1.2.3.2. Pelvic exam

8.1.2.4. Treatment/Management

8.1.2.4.1. Premenarchal/Postmenopausal

8.1.2.4.2. Otherwise

9. Ectopic Pregnancy

9.1. Pathophys

9.1.1. Extrauterine pregnancy, 96% of the time in the fallopian tube

9.2. Risk Factors

9.2.1. IVF

9.2.2. Prior ectopic pregnancy

9.2.3. PID or other genital infections

9.2.4. Infertility

9.2.5. Tubal surgery

9.2.6. Prior sterilization w/ sterilization failure

9.2.7. Smoking (dose-dependent)

9.2.8. In utero DES exposure

9.2.9. Vaginal douching

9.2.10. Advanced age

9.3. Symptoms

9.3.1. 1st trimester vaginal bleeding w/o apparent intrauterine pregnancy

9.3.2. abdominal pain

9.3.3. may be asymptomatic!

9.3.4. amenorrhea

9.3.5. hemodynamic instability + acute abdomen not otherwise explained

9.3.6. other pregnancy signs/symptoms

9.4. Workup

9.4.1. TVUS

9.4.1.1. Looking for

9.4.1.1.1. Intrauterine/extrauterine mass or pregnancy

9.4.1.1.2. Intraperitoneal bleeding

9.4.1.1.3. Confirm location of extrauterine pregnancy if present

9.4.2. ß-hCG

9.4.2.1. If the patient is stable, repeat in two days. If ß-hCG has risen <35% then likely ectopic pregnancy.

9.4.3. Uterine aspiration w/o products of conception (ancillary diagnostic)

9.4.4. Type & Screen

9.4.5. CBC

9.5. Treatments

9.5.1. Stable

9.5.1.1. First-line

9.5.1.1.1. Methotrexate

9.5.1.2. Second-line

9.5.1.2.1. Laparoscopic Surgery

9.5.2. Unstable

9.5.2.1. Transfer to hospital for resuscitation and stabilization

9.5.2.1.1. May need to stabilize there and then w/ IV access, IV fluids, blood products

9.5.2.2. Emergent laparoscopic surgery

9.5.2.2.1. Salpingostomy

9.5.2.2.2. Salpingectomy

9.5.2.3. Type & Screen + RhoGam if RhD(-)

9.5.2.4. FAST

9.5.2.4.1. If (-) then unlikely to be a ruptured ectopic

9.5.3. Follow-up

9.5.3.1. Must track ß-hCG post-treatment/surgery weekly to confirm that levels decline

9.5.3.1.1. If ß-hCG fails to decline, treat with methotrexate until resolved

9.6. Notes

9.6.1. Almost all spontaneous pregnancies following surgical treatment of ectopic pregnancy occur in the first 18 mo following the procedure

9.7. DDX

9.7.1. Physiologic (actual pregnancy w/ implantation bleeding)

9.7.2. Spontaneous abortion

9.7.3. Other pathology like a polyp

9.7.4. Subchorionic hematoma

9.7.5. Gestational trophoblastic disease

10. Endometriosis

10.1. Pathophys

10.1.1. Endometrial glands outside the uterus (often ovaries, peritoneum, pelvis)

10.1.2. Frequent cause of pelvic pain of women in 30s

10.1.3. Retrograde menstrual flow

10.1.4. Estrogen-dependent

10.2. Risk Factors

10.2.1. FHx

10.2.2. Nulliparity

10.2.3. Prolonged exposure to exogenous estrogen

10.2.4. Early menarche

10.2.5. Late menopause

10.2.6. Short menstrual cycles (<27 days)

10.2.7. Heavy menstrual bleeding

10.2.8. Obstructions to menstrual outflow

10.2.9. Physical/Sexual abuse in childhood/adolescence

10.2.10. Trans unsaturated fats

10.2.11. Atherosclerotic disease

10.3. Symptoms

10.3.1. Endometrioma

10.3.1.1. Ovarian cyst ("chocolate cyst") made of ectopic endometrial tissue filled with old blood

10.3.2. Pelvic pain (dysmenorrhea or dyspareunia)

10.3.2.1. Often, but not always, cyclic

10.3.2.2. Tenderness on physical exam

10.3.3. Infertility

10.3.4. Urinary/GI symptoms

10.3.5. "Powder burn" lesions

10.3.6. Often subside during pregnancy

10.3.6.1. But increases risk of preterm birth

10.4. Diagnosis

10.4.1. Definitively diagnosed by histology of laparoscopic biopsy

10.4.2. Can achieve presumptive diagnosis based on symptoms, signs, and imaging

10.4.3. TVUS/Pelvic US

10.4.4. Visual inspection

10.4.5. Staged I-IV by severity

10.4.6. Bimanual pelvic exam

10.5. Treatment

10.5.1. Mild-moderate pain but no evidence of endometrioma

10.5.1.1. NSAIDs + OCPs for medical management as long as possible

10.5.1.2. Reassess 3-4 mo after start of tx

10.5.1.2.1. If still symptomatic, consider oral northindrone or depot medroxyprogesterone

10.5.2. Severe pain interfering with daily life or that is refractory

10.5.2.1. Trial of GnRH analog (leuprolide) + hormonal therapy

10.5.2.1.1. If still refractory, only then try aromatase inhibitors

10.5.2.2. Offer laparoscopic diagnosis and treatment

10.5.2.2.1. OCPs afterward to suppress recurrence

10.5.2.2.2. Hysterectomy + BSO and excision of extrauterine lesions is definitive, but consider ablation + local excision for more conservative management (esp. if fertility is at issue)

10.5.3. Endometriomas

10.5.3.1. Symptomatic or expanding endometriomas should be surgically removed

10.5.3.2. Asymptomatic and small endometriomas can be left in place w/ medical management

10.6. Notes

10.6.1. Affects ~10% of women

10.6.2. Increases risk of epithelial ovarian cancer (EOC)

11. Contraception

11.1. Progestin Only Birth Control

11.1.1. Progestin Side Effects

11.1.1.1. Irregular uterine bleeding/spotting

11.1.1.2. Amenorrhea

11.1.1.3. Weight gain

11.1.1.4. Mood changes

11.1.1.5. Bone loss (w/ long-term depot medroxyprogesterone)

11.1.2. Progestin IUD

11.1.2.1. Contraindications

11.1.2.1.1. Pregnancy

11.1.2.1.2. Endometrial or cervical cancer/hyperplasia

11.1.2.1.3. Unexplained vaginal bleeding

11.1.2.1.4. Gestational trophoblastic disease

11.1.2.1.5. Distorted endometrial cavity

11.1.2.1.6. Acute pelvic infection

11.1.2.1.7. Active liver disease

11.1.2.1.8. Active breast cancer

11.2. Combined Hormone Contraception

11.2.1. Combined Estrogen-Progestin Side Effects

11.2.1.1. Nausea

11.2.1.2. Breast tenderness

11.2.1.3. Headache

11.2.1.4. Unscheduled bleeding

11.2.1.5. Amenorrhea

11.2.1.6. Mild BP increase

11.2.1.7. Increased VTE risk (3x-5x)

11.2.1.8. MI and Stroke

11.2.1.9. Increase triglycerides

11.2.2. Contraindications

11.2.2.1. Age 35+ and smoking

11.2.2.2. 2 or more CV disease risk factors (old age, smoking, diabetes, HTN)

11.2.2.3. HTN (sys 140+ or dia 90+)

11.2.2.4. Prior hx of VTE

11.2.2.5. Known thrombogenic mutations

11.2.2.6. Prior MI/Stroke or complicated heart disease

11.2.2.7. Breast cancer

11.2.2.8. Cirrhosis

11.2.2.9. Migraine w/ aura

11.2.2.10. Hepatocellular adenoma or malignant hepatoma

11.2.3. Notes

11.2.3.1. Works by increasing estrogen and progesterone so HPA axis is inhibited, resulting in less LH/FSH which normally trigger ovulation

11.2.3.2. Most effective if taken at the same time every day

11.3. Non-hormone Contraception

11.3.1. Copper IUD

11.3.1.1. Contraindications

11.3.1.1.1. Wilson Disease

11.3.1.1.2. Pregnancy

11.3.1.1.3. Endometrial or cervical cancer/hyperplasia

11.3.1.1.4. Unexplained vaginal bleeding

11.3.1.1.5. Distorted cavity

11.3.1.1.6. Acute pelvic infection

11.4. Plan B

11.4.1. Big dose of progesterone that prevents ovulation and alters the lining of the uterus to make implantation less favorable

11.4.2. Must be taken within 72 hours to work

12. Preeclampsia

12.1. Criteria (Uncomplicated PreE)

12.1.1. 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:

12.1.1.1. New onset proteinuria (>300 mg in 24 hours or urine protein:Cr ratio >0.3)

12.1.1.2. Any other sign of end organ damage

12.1.1.2.1. Thrombocytopenia

12.1.1.2.2. Impaired LFTs

12.1.1.2.3. Renal Insufficiency (Cr >1.1)

12.1.1.2.4. Pulmonary Edema

12.1.1.2.5. New Onset Cerebral or Visual Disturbance

12.2. Criteria (Severe PreE)

12.2.1. Systolic BP 160 or higher or diastolic 110 or higher on two occasions 4 hours apart

12.2.2. Any other sign of end organ damage

12.2.2.1. Also may see severe epigastric/RUQ pain

12.2.2.2. AMS

12.2.2.3. Dyspnea

12.2.2.4. Stroke (hemorrhagic)

12.3. Risk Factors

12.3.1. Nulliparity

12.3.2. AMA

12.3.3. African American

12.3.4. Prior h/o preeclampsia or family h/o

12.3.5. Chronic HTN

12.3.6. Chronic renal disease

12.3.7. Obesity

12.3.8. Antiphospholipid Syndrome

12.3.9. Diabetes

12.3.10. Multifetal pregnancy

12.4. Routine Workup

12.4.1. Establish baseline BP and urine protiein

12.4.1.1. Get BP and protein at first visit

12.4.1.2. Record BP at every visit

12.4.1.3. Urine dipstick at every visit for protein and signs of infection

12.4.1.4. Repeat any high BP reading to confirm

12.4.2. Detailed H&P

12.4.2.1. Screen for PreE symptoms (HA, abdominal pain, visual disturbances)

12.4.2.2. Personal history of HTN and CVD issues

12.4.2.3. Family history of HTN and CVD issues

12.4.2.4. Risk factors (smoking, drugs, lifestyle, etc.)

12.4.3. Prevention

12.4.3.1. Low dose ASA from 12 weeks

12.4.4. Normal routine screenings and perinatal care

12.5. Management of Preeclampsia

12.5.1. Uncomplicated Preeclampsia

12.5.1.1. Close observation

12.5.1.1.1. Are baby and mom stable?

12.5.1.1.2. Regular checks

12.5.1.2. Deliver at term ~37 weeks

12.5.1.3. Consider magnesium sulfate on case-by-case basis

12.5.1.3.1. Note: Magnesium is eliminated by the kidneys and should be stopped 24 hours postpartum

12.5.2. Severe (Complicated) Preeclampsia

12.5.2.1. Stabilize maternal status

12.5.2.1.1. BP > 160 SBP or > 110 DBP

12.5.2.2. Assess for maternal/fetal threats

12.5.2.2.1. PulseOx, Labs, Fetal Strip

12.5.2.2.2. Review of symptoms

12.5.2.3. Assess fetal weight, FHR pattern, and/or BPP

12.5.2.4. Assess for potential delivery window

12.5.2.4.1. 34 weeks or more GA = give magnesium and deliver

12.5.2.4.2. Less than 34 weeks

12.6. Complications

12.6.1. Maternal Complications

12.6.1.1. End organ damage

12.6.1.1.1. AKI

12.6.1.1.2. Liver damage

12.6.1.1.3. Coagulopathy

12.6.1.2. Seizure

12.6.1.3. Stroke

12.6.2. Fetal Complications

12.6.2.1. IUGR

12.6.2.2. Preterm birth

12.7. DDX

12.7.1. Chronic HTN

12.7.1.1. BP 140/90+ before pregnancy or at less than 20 weeks, or persisting more than 12 weeks postpartum

12.7.1.2. Risk of IUGR, fetal demise, placental abruption, and preeclampsia

12.7.2. Gestational HTN

12.7.2.1. HTN w/o proteinuria or other features of preeclampsia at > 20 weeks gestation

12.7.3. Eclampsia

12.7.3.1. PreE + seizures

12.7.4. HELLP Syndrome

12.7.4.1. Hemolysis, Elevated Liver enzymes, Low Platelets, thought to be a subset of severe PreE

12.7.5. Posterior Reversible Encephalopathy Syndrome

12.7.6. Superimposed Preeclampsia

12.7.6.1. Preeclampsia in a patient with preexisting chronic HTN

12.7.7. Superimposed Preeclampsia with Severe Features

12.7.7.1. Preeclampsia w/ severe features in a patient with preexisting chronic HTN

12.7.8. Preeclampsia with Severe Features

12.7.8.1. Worsening vasospasm results in end organ damage usually requiring delivery of the baby regardless of GA

12.8. Stats

12.8.1. 90% of cases occur late in pregnancy (>34 weeks)

12.8.2. 10-25% of Gestational HTN cases go on to become preeclampsia

12.8.3. Overall incidence rate of preeclampsia in the US is ~5%

12.8.4. ~25% of women with preeclampsia develop severe features