OBGYN STUDY GUIDE

Oral Health Online Module

Gingivitis is inflammation of the gingiva without destruction of the periodontal ligament or bone, which
distinguishes it from periodontitis. Pregnancy-related gingivitis affects 2575% of pregnant F. It likely
occurs because immunosuppresion and hormonal changes cause an altered response to bacterial plaque.

The Relationship between Peridontal Disease and Preterm Birth
Numerous studies have documented an association between maternal periodontal disease and preterm birth
and low birth weight. There are several potential explanations for this association. Periodontal dz may have
direct effects on the uterus through bacteremia causing direct infection of the chorioamnion. However, it is
more likely that an indirect mechanism mediated by a systemic inflammatory response occurs.
At present, studies do not demonstrate that tx of periodontal dz during pregnancy improves pregnancy
outcomes. However, the studies demonstrate that periodontitis improved w/ tx & that tx is safe during
pregnancy.
Bacteremia: Direct Mechanism
Periodontal infection in the mouth may have direct effects on the uterus through bacteremia
causing direct infection of the chorioamnion. However, bacteria have not been found in amniotic
fluid cultures.
Systemic Inflammatory Response: Indirect Mechanism
It is more likely that preterm birth results from a systemic inflammatory response to periodontal
infection that increases prostaglandins and interleukins and affects labor initiation.
Inflammatory response may lead to placental blood flow restrictions, placental necrosis, and
consequent low birth weight.
A similar mechanism has been proposed to explain the association seen b/w periodontitis and
increased rates of heart dz & diabetes.
Caries are transmissible disease!
Mothers are the main source of passing streptococci mutans, the bacteria responsible for causing caries,
to their infants.
Transmission occurs via saliva contact such as tasting or pre-chewing food.
The higher mom's bacterial level, the more likely the child will acquire the bacteria.
If colonization is delayed until after age two, then the child will have fewer caries.
Caregivers with caries also often pass on bad habits (high sugar intake, poor oral hygiene).
Fathers can pass on the bacteria, but studies show this is less common

Pregnancy Granuloma
Pregnancy granuloma may be found in 5% of pregnant F. It is indistinguishable from pyogenic granuloma,
and is a rapidly growing, tumor-like lesion that develops as a response to local irritation such as poor
hygiene, overhanging restorations, or trauma. Increasing estrogen and progesterone levels during pregnancy
exacerbate the condition. Usually appear between 2
nd
and 8
th
month of pregnancy- bleeds easily. Treat by
offering reassurance as they often spontaneously resolve after delivery.

Dental Treatment in Pregnancy
First Trimester
In states where F only have access to dental insurance while pregnant, care should begin early especially if
extensive care is needed.
Scheduling visits in the afternoon can avoid the nausea of morning sickness that many F experience.
Second Trimester
Organogenesis is complete, thereby reducing the risk of any necessary medication exposures.
The fetus is not large, making it easier for mothers to recline in the dental chair for prolonged periods.
Third Trimester
Late in term, position woman slightly on left side with a towel prop to avoid vena cava syndrome.
Encourage her to stand and walk periodically if it is a long appointment.
Elevating her head helps avoid shortness of breath induced by abdominal contents pushing up on already
compressed lungs.
Dental radiographs offer so little radiation it is not an issue in pregnancy if proper procedure is followed.

Common ABX for dental procedures are category B: Penicillin, Amoxicillin, Cephalexin, Erythromycin base,
Clindamycin, and Metronidazole (not during 1
st
trimester).

Common analegesics:
Acetaminophen category B
Ibuprofen category B in 2
nd
, category D in 1
st
and 3
rd

Oxycodone Category B in 1
st
and 2
nd
, category D in 3
rd

Hydrocodone & Codeine Category C in 1
st
and 2
nd
, category D in 3
rd

Common Anesthetics:
Lidocaine category B
Procaine category C
Epinephrine category C
Nitrous Oxide No rating but controversial
Avoid Benzos
Preventative Agents:
Fluoride Safe to use
Xylitol No harm found
Chlorhexidine No harm to fetus
Postpartum Interventions
Promote breast feeding
Ensure children are not put to bed with a bottle
Parents gently clean infants gums and teeth after breast feeding
Children seen dentist at 12 months of age
Promote high dose xylitol gum or brief chlorhexidine rinse programs for mom until kid is 2y/o
During menopause, the decrease in hormones leads to atrophy of gums & other oral changes such as dry
mouth & altered taste sensation. HRT may improve these sxs, but these sxs alone are not an indication for
HRT use.

UTERUS
MENSTURAL CYCLE
Follicular phase
o Day 1 begins with menses
o Estrogen increases causing uterine lining to thicken
o Secondary to an increase in FSH
follicles are stimulated
o On day 2 or 3 of the cycle one follicle
in the ovary becomes dominant
Ovulation
o A surge in LH causes dominant follicle to release its egg
Luteal Phase
o The follicle changes into the corpus luteum which
o secretes progesterone
o The high level of progesterone and estrogen are
important for creating the thickened lining of the
uterus for implantation of the fertilized egg.
o If no implantation takes place within 2 wks there is a
dramatic drop in progesterone and estrogen resulting
in the shedding of the uterine lining.
Reproductive Hormones
FSH- stimulates ovaries to make estrogen and to mature follicles.
LH- prepares follicle wall for breakdown & release of ovum= ovulation
Estrogen- dominant female hormone, produced by ovary, causes
maturing of follicle and thickening or proliferation of uterine lining.
Progesterone- produced by corpus luteum after ovulation, responsible for
holding uterine lining in place for implantation. Suppresses LH and FSH.

ENDOMETRIAL CANCER
MC gynecologic malignancy.
Postmenopausal F make up 75% of pts; Median age at presentation is 58 y/o.
Adenocarcinomas make up 75% of cancer cell types.
RFs: obesity, nullparity, infertility, late menopause, DM, unopposed estrogen stimulation, HTN,
gallbladder dz and chronic Tamoxifen use.
Oral Contraceptives seem to have a protective effect.
Presentation
BUZZ inappropriate uterine bleeding (90% of pts).
Obesity, HTN, and DM may also be present.
Dx:
Pap smear, endocerival curettage and endometrial biopsy.
Endometrial biopsy has an accuracy rate of 90-95%
Fractional D & C and transvaginal US.
Tx:
Total hysterectomy combined with bilateral salpingo-oopherectomy for tx and staging.
Radiation therapy may be indicated. Chemotherapy is used at advanced stages.
Recurrence is treated with high-dose progestins or antestrogens.
Prognosis depends on histologic appearance, age (older F have poorer outcomes) & extent of metastases.

ENDOMETRIOSIS
presence of ectopic implants of tissue that look and act like endometrium, and are found outside the
uterine cavity
Endometriosis can occur very rarely in post-menopausal F, it is almost exclusively in F of reproductive
age. MC occurs in nulliparous F (50%) median age at dx is 25-29 y/o
The lesions are usually found on the peritoneal surfaces of the reproductive organs and adjacent
structures of the pelvis, but they can occur anywhere in the body.
Infertility is common. Found in 20-35% of infertile F. 70%-85% of F with chronic pelvic pain
RFs: Family hx, early menarche, long duration of menstrual flow, heavy bleeding during menses and
shorter cycles.
Presentation: Endometriosis is common among F of reproductive age 15-44 y/o.
Dysmenorrhea; Dyspareunia (Deep penetration); Dyschezia (difficulty passing bowel mvmt); Infertility
Pelvic pain or a low sacral backache that occurs premenstrually and subsides after menses begins.
Lesions on the urinary tract or bowel may result in bloody urine or stool in the perimenstrual interval.
Other: bowel and bladder sxs, premenstrual spotting, menorrhagia, tender uterus on pelvic exam,
adnexal mass, or utero-sacral ligament nodularity.
PE: Tender nodularity of the cul-de-sac and uterine ligaments and a fixed uterus.
Diagnosis Laparoscopy
Treatment
OCPs, Danazol, Depo-Provera, GnRH agonists or progestin.
Surgery may be conservative or definitive; Large must be resected.

LEIOMYOMATA UTERI (FIBROIDS)
MC tumor in female pelviso 20% of reproductive age F, 50% in autopsy series.
o Neoplasms of smooth muscle cells contained w/n pseudocapsules of fibrous connective tissue
o Most common indication for pelvic surgery (30% of cysts for nonmalignant reasons)
MC occurs in the 4th decade & MC in black F and those with a family history.
Etiology:
Fibroids depend on estrogen and appear with increased frequency in F who have endometrial
hyperplasia, anovulatory states and estrogen-producing ovarian tumors.
Stimulant: GH, human placental lactogen (HPL)
Inhibitors: progestins, Danazol, GnRH agonists (Leuprolide)
Classified by their location: 95% in uterine fundus, usually multiple
o Subserous: deforming external serosa.
o Intramural: within uterine wall.
o Submucous: deforming uterine cavity; type that causes uterine bleeding.
Presentation
Asymp; but do have a firm, enlarged, irregular uterine mass.
BUZZ: AUB & Pelvic pain or pressure/fullness in pelvis
Urinary frequency or urgency, hydroureter
Mass at cerival os
Infertility 2-3%
Risk of spontaneous abortion is increased.
Dx
History & PE, Pelvic Exam, US, MRI, saline hysteroscopy, hysterosalpingography and laparoscopy.
Tx
Expectant management with pelvic or ultrasound examination
o Pregnant pt-caution regarding pain, SAB, PTL, placental abruption, fetal malpresentation, uterine
rupture, cesarean delivery, PPH
Medical
o Progestins (Depo-Provera)
o Danazol
o GnRH agonists-reduce uterine volume by 40-50%. Treat 3-6 months
o Surgery
Laparoscopic and/or hysteroscopic myomectomy
Laparotomy with myomectomy (transfusion risk of 10 to 15%)
Hysterectomy with transfusion risk of 5 to 10%
Pregnancy after surgery
o Superficial- 6 wks
o Deep (penetrating near or into endomcavity), or multiple-4 to 6 months

ADENOMYOSIS
Definition: ectopic endom glands and stroma within myometrium
o Downward growth of basalis layer of endometrium
o Often asymp-multiple serial sections show presence in 60% in F 40-50 y/o
o Associated with fibroids 50% of the time and endometriosis, 20%
o Two presentations: Diffuse, focal (adenomyomas)
o No progesterone receptors, few estrogen receptors
Sxs
o 80% Parous, usually aged 35 to 50
o Secondary dysmenorrhea (15-30%), menorrhagia (40-50%), dyspareunia (7%)
o Pelvic examination: uterus diffusely enlarged, 2 to 3 times normal, boggy, perhaps tender
Dx
o Only dxed 25% of the time preoperatively
o Transvaginal US may demonstrate irregular cystic spaces in myometrium
o MRI more definitive
Tx:
o Oral contraceptives; Prostaglandin synthetase inhibitors; Depo-Provera; Hysterectomy

UTERINE PROLAPSE
Typically occurs after pregnancy, labor, and vaginal delivery but may also occur in nulliparas. Risk
increases 50% after menopause
MC in white F, less common in African & Asian F.
Any condition that increases intra-abdominal pressure may predispose a F to prolapse including,
obesity, chronic cough or constipation, and repetitive heavy lifting.
Systemic problems such as obesity, asthma and COPD and local factors, such as pelvic tumors and
ascites predispose to prolapse.
Presentation
Sxs are usually worse after prolonged standing or late in the day and are relieved by lying down.
Vaginal fullness, lower abdominal aching or low back pain.
Moderate prolapse, patients describe a falling-out-sensation or a feeling of sitting on a ball.
Most prolapses are accompanied by a cystocele, rectocele or enterocele.
Dx Clinical
Uterine prolapse is graded as 0 (no descent) to 4 (through the hymen)
Tx
Wt loss, smoking cessation, pelvic muscle exercises & use of a vaginal pessary.
Surgical tx: relieves sxs, restores normal anatomic relationships and visceral fxn & allow sexual
intercourse.


OVARY
CYSTS
FOLLICULAR
MC functional cysts.
Thin-walled cysts with clear fluid, 5-6 cm or less; Very in diameter from 3-8 cm.
Etiology: Result from a failure in ovulation, most likely secondary to disturbances in the release of
the pituitary gonadotropins. The fluid of the incompletely developed follicle is not reabsorbed,
producing an enlarged follicular cyst.
Presentation
Asymptomatic, although bleeding and torsion can occur.
Large cysts may cause aching pelvic pain, dyspareunia, and occasionally abnormal uterine bleeding
associated with a disturbance of the ovulatory pattern.
Diagnosis: Clinical Diagnosis
History, PE, Labs, Imaging (US, SCT scan, MRI)
Treatment
Most follicular cysts disappear spontaneously within 60 days without treatment.
Use of OCPs has often been recommended to help establish a normal rhythm.

THECA LUTEIN
Etiology: Elevated levels of chorionic gonadotropin can produce theca lutein cysts and thus are seen
in pts with hydatidiform ole or choriocarcinoma and in patients undergoing chorionic gonadotropin
or clomiphene therapy.
Rarely, they are seen in normal pregnancy.
Presentation
Abdominal SXS are minimal, although a sense of pelvic heaviness or aching may be described.
Rupture of the cyst may result in intraperitoneal bleeding.
Continued signs & sxs of pregnancy, especially hyperemesis and breast paresthesias are reported.
Dx:
may or may not be luteinized and they may or may not have granulosa cells.
Bilateral and filled with clear, straw-colored fluid.
Tx:
The cysts disappear spontaneously after termination of the molar pregnancy, treatment of the
choriocarcinoma or discontinuation of fertility therapy.
Resolution may take months to occur.
Surgery is reserved for complications such as torsion and hemorrhage.

ENDOMETRIOMES (ENDOMETRIOMAS)
In F with endometriosis, endometriotic foci on the ovarian surface may develop a fibrous enclosure
and manifest cyst formation as a result of accumulation of fluid and blood.
These endometrial cysts vary from several mm to even 10 cm in size.
Referred to as chocolate cysts because they contain thick, brown blood debris inside.
Filmy or fibroid adhesions from these cysts to the pelvic sidewall, cul-de-sac and fallopian tubes are
common & may obscure visualization of the cyst.
Presentation
chronic pelvic pains, dyspareunia, dysmenorrhea and infertility.
Dx: Clinical Diagnosis
Tumor marker CA-125 is commonly elevated in these forms of cysts, which creates a serious clinical
problem in distinguishing these cysts from malignant epithelial tumors.

POLYCYSTIC OVARIAN SYNDROME (PCOS)
Characterized by persistent anovulation that can lead to clinical manifestations including:
o Enlarged polycystic ovaries; Secondary amenorrhea or Oligomenorrhea; Obesity; Hirsuitism;
Infertility
The syndrome has a prevalence of 5-10% with variance among races and ethnicities.
Approx. 50% of patients are hirsute, and 30-75% are obese.
Anovulation is identified in F with persistently high concentrations of LH and low concentrations of
FSH, a low day-21 progesterone level, or on sonographic follicular monitoring.
PCOS is presumably related to hypothalamic pituitary dysfunction & insulin resistance (DM)
Dx
A presumptive dx of PCOS often can be made based on the history and initial exam
PCOS can be dx if at least 2 of the following conditions are present:
o Amenorrhea or Oligomenorrhea
o Hyperandrogenism
o Polycystic ovaries on US.
Polycystic ovaries have been called oyster ovaries bc they are enlarged & sclerocystic w/ smooth,
pearl-white surfaces w/o indentations. Many small, fluid-filled follicle cysts lie beneath the thickened
fibrous surface cortex.
Labs: mildly elevated serum androgens levels, an increased ratio of LH/FSH, lipid abnormalities, and
insulin resistance.
Tx
Most pts with PCOS seek tx for either hirsutism or infertility.

OVARIAN NEOPLASMS:
May arise from any histologic element of ovary & are most often benign, esp in premenopausal F.
Characteristics of the mass and the age of pt are the most important factors guiding dx & tx.
The overall risk of malignancy of an ovarian cyst is 13% in premenopausal F vs. 45% in a
postmenopausal F.
EPITHELIAL
Serous, Mucinous, Endometrioid, Clear cell, Transitional cell (Brenner), and Undifferentiated
Accounts for >60% of ovarian neoplasms and for >90% of ovarian malignant neoplasms, most often
occurs in 50s years of life
Mucinous cystadenomas= 20% of neoplasms
o Most frequent ages 30 to 50, but comprise 50% of
o epithelial tumors in patients less than 20
o 5% bilateral
o Usually large(15-30 cm) and multiloculated
o Cyst wall usually smooth but may see papillary projections
SEX-CORD STROMAL TUMORS
Only accounts for 5-8% of all ovarian malignancies with the Granulosa cell tumors being most common
Associated w/ hyperestrogenism (bc the granulosa cells in the stroma produce estrogen) & may cause
precocious puberty in young F and adenomatous hyperplasia & vaginal bleeding in postmenopausal F
Sertoli-stromal cell tumors are uncommon and present with virilizing around age 25
GERM-CELL TUMORS
Dermoids or benign (mature) cystic teratomas=25% of benign neoplasms
Most common tumor in young women-80% of tumors before age 20
10-25% are bilateral. Often in anterior position
Derivatives of all three germ cell layers
Chance of malignancy is 1 to 3%. Malignant teratomas contain immature, embryonal types of tissue
Interesting variant-Struma ovarii- thyroid tissue
Diagnosis Transvaginal US; MRI, CT; Labs: CBC, pregnancy test, CA-125; Laparoscopy or laparotomy

Neoplasms Metastatic to the Ovary: Only accounts for 5-6% of all ovarian malignancies coming from the
genital tract, breast, GI tract
Presentation: Most present with few warning sign or symptoms until the disease is widely disseminated
throughout the abdominal cavity, some will present with GI complaints (dyspepsia, change in stool caliber,
abdominal pain or pressure, nausea) ascites is a poor prognosis, some have abnormal uterine bleeding. In
general, the prepubescent child and the postmenopausal woman are at greatest risk for a malignant ovarian
neoplasm. The reproductive age woman is more likely to have a functional ovarian cyst or endometrioma.
Demographics: mainly postmenopausal F and highest in 65-74 y/o
Treatment:
US is the best tool but is non-specific, CA-125 is a good tumor marker but is not used to dx, Pelvic
screening is poor and do not catch small lesion but you still need to do it.
BRCA1 and BRCA2 are RFs for ovarian cancer. So known family hx of these genes in a patient, they
should get yearly transvaginal ultrasounds of their ovaries starting at age 25-35, plus a CA-125 level.
Oral contraceptives can be PROTECTIVE in pts with BRCA genes against ovarian cancer.
There is no standardized system for evaluation of ovarian masses but if there is mass during a repeat US
4-6 weeks later you need to do investigation
CT or MRI may be useful but because of the high cost and questionable benefits it is used infrequently
CBC, electrolytes, hCG, AFP, LDH should be looked at- particularly if surgery is going to be performed
(looking for anemia, pregnancy, etc)
Surgery is cornerstone of tx for ovarian cancer, regardless of cell type or stage of disease
CXR when malignant masses are found in the ovaries
Barium enema when there are GI abnormalities looking for GI cancer and a mammogram because
ovarian and breast are related sometimes


CERVIX
BENIGN NEOPLASMS
POLYPS
Cause
An abnormal response to increased levels of the female hormone, estrogen
Chronic inflammation
Clogged blood vessels in the cervix
Cervical polyps are common, especially in F > age 20 who had kids. Polyps are rare in young F who have
not started their period
Presentation
Abnormally heavy periods (menorrhagia)
Abnormal vaginal bleeding After douching; After intercourse; After menopause; Between periods
White or yellow mucus (leukorrhea)
Dx
Pelvic exam:smooth, red or purple, fingerlike growths on the cervix. A cervical biopsy will most often
show cells that are consistent w/ a benign polyp. Rarely there may be abnormal, precancerous, or cancer
cells in a polyp.
Tx
Remove polyps during a simple, outpt procedure. Gentle twisting of a cervical polyp may remove it.
Larger polyps may require removal with electrocautery.
Although most cervical polyps are benign, the removed tissue should be sent to a lab & checked further.

PAPILLOMAS
HPV infection is found in 1-2% of cytology screened F.
HPV casues papillomas
Presentation
Benign neoplasms found on portio vaginalis of the cervix. Usually discovered on routine vaginal exams
Diagnosis
asymptomatic; papillary projection from the exocervix; the presence of koilocytes with or without
cytologic atypia; and colposcopic identification



LEIOMYOMAS
Uncommon
Presentation
smooth muscle leiomyomas of the cervix are uncommon. Most are solitary and may be large enough to
fill the pelvic cavity
Treatment
Small, asymptomatic leoimyomas do not require tx
Removal if the become symptomatic

CERVICAL INFECTIONS
ACUTE & CHRONIC CERVICITIS
An infection of the cervix which is similar to urethritis in men.
Acute cervicitis
Vaginal discharge, postcoital bleeding, intermenstrual bleeding, mucopurulent exudate, cervical friability
Higher incidence of STIs, so do lab studies
RX: usually associated with specific organism, So treat specifically
Chronic cervicitis
Not generally associated with specific infection
Surgical procedures may be appropriate-cryosurgery, electrocautery, laser therapy

CERVICAL INTRAEPITHELIAL NEOPLASIA
As low as 1.05% in FP clinics to as high as 13.7% in STD clinics.
CIN is MC detected in F in their 20s
Risk factors: multiple sex partners, HPV infection, lower genital tract neoplasia, hx of STDs, smoking, HIV,
AIDS, multiparity and long term OCP use.
Presentation
SSx: usually no symptoms or signs
Dx based on biopsy
Diagnosis
The cervix often appears grossly normal.
Infection with the HPV is present.
Dysplastic or carcinoma in situ cells are noted in a cytologic smear preparation (traditional Pap smear or
liquid based cytology)
Colposcopic examination reveals an atypical TX with thickened acetowhite epithelium and ocarse
punctuate or mosaic patterns of surface capillaries.
Iodine-nonstaining area of squamous epithelium is typical.
Biospy diagnosis of CIN (dysplasia or carcinoma in situ)
Treatment
Depending on level of CIN and ASC-US/HPV results, various tx options are indicated.
Cryotherpay
LEEP
Cold Knife conization

CANCER OF THE CERVIX
Risk Factors
Sexual activity increases risk
The younger the age of first intercourse the greater the risk
Risk increases with the number of sexual partners
Risk increases with sexual partners who have multiple sexual partners
Use of condoms or a diaphragm decreases risk
MC cause is --Exposure to HPV
HPV exposed patient should be monitored closely
Gardasil & Cervarix are vaccines for pts not previously exposed to HPV. Recommended: 9-26 y/o
ALSO- Low socioeconomic status; African America; LT use of oral contraception; Smoking
Presentation
Routine pap smear. Unless very advanced invasive disease there will be no sxs
DX
Step one is routine Papanicolaou Smear
Normal
Mild cervical intraepithelial neoplasia (CIN-1)
Moderate dysplasia (CIN-2)
Severe dysplasia (CIN-3), about one third of these will progress to CIS
Carcinoma in situ (CIS)
Colposcopy
Schiller test paint the cervix with Lugol iodine. Cells that do not stain should be biopsied
Biopsy Punch biopsy
Endocervical curettage
Conization
For CIN-3 or CIS The removal of a cone shaped area of the cervix including the entire
transformation zone. This can be done w/ a scalpel, laser or as a loop electrosurgical excision
procedure (LEEP)
Treatment
Conization may be used to treat preinvasive CIN
Hysterectomy with pelvic lymphadenectomy for more advanced disease
Possible radiation treatment

VAGINA/VULVA
VULVAR DISORDERS
WHITE/RED/DARK LESION, ULCER
White lesions-
LICHEN SCLEROSUS
Usually postmenopausal women
Untreated, 3-5% go on to develop squamous cell cancer. Do multiple bxs
Acute phase erythema, edema, development of white plaques (lichenification&HK), coalescence.
Intense pruritus leads to scratch-itch cycle, leading to erosions, fissures, and ulcerations
Chronic phase Atrophic white skin (sometimes accompanied by islands of hyperplastic epithelium),
agglutination, contraction, involvement of the perianal region
Rx: Break the scratch-itch cycle, reduce inflammation-antihistamines at hs, potent topical steroids with
tapering for maintenance. If poor response, then trial of tacrolimus cream, retinoid, antimalarial agents,
photodynamic therapy.
VULVAR LICHEN SIMPLEX CHRONICUS; LICHEN PLANUS
Red lesions-PSORIASIS, Candida, Pagets, Seborrheic dermatitis, lupus, VIN
Dark lesions-MELANOSIS OR LENTIGO; CAPILLARY HEMANGIOMA; Nevus, hemangioma, melanoma
(complete excision)
Melanosis-areas of irregular, deeply pigmented macules and patches on the vulvar mucosa. Not
palpable, as with melanoma. If concerned, do biopsy
Ulcerative lesions-Herpes, syphilis, LV, Behcets- CHART

BEHCETS SYNDROME
Rare in U.S. Genital and oral ulcerations along with ocular inflammation

WHITE LESIONS
VULVAR INFLAMMATORY CONDITIONS
Contact dermatitis-probably the MC benign disorder of the vulva
o Irritant (nonimmunologic, or chemical); Allergic (immunologic); Irritants; Sxs-pruritus, rash
o Rx- elimination of causative agent, loose-fitting clothing, cotton underwear, steroid creams,
Burrows solution (1:20 dilution) compresses QID, antihistamines, sedatives
Intertrigo
o Increased moisture: genitocrural folds, abdominal panniculus, breasts
o Early-erythematous, white (maceration)
o Later-linear fissuring, lichenification, hyperkeratosis, hyperpigmentation
Other- Seborrheic dermatitis, psoriasis, neurodermatitis, lichen planus

LARGE TUMORS
BARTHOLINS DUCT CYST
Common vulvar disorder
Etiology: Obstruction of the main duct of Bartholins gland (gland neck) results in retention of
secretions & cystic dilation. Infection, congenital stenosis/narrowing of the duct, inspissated mucus,
& mechanical trauma.
Secondary infection may result in recurrent abscess formation.
The gland and duct are located deep in the posterior third of each labium major, w/ the duct opening
into the vestibule. Enlargement in the postmenopausal pt reflect a malignant process (although rare,
<1%); biopsy should be considered.
Sxs: Acute SXS generally result from infection, which leads to:
Pain, tenderness, dyspareunia, and even difficulty in walking with adducted thighs.
The surrounding tissues become edematous and inflamed.
A fluctuant, tender mass is usually palpable.
Unless an extensive inflammatory process if present, systemic sxs or signs of infection are unlikely.
Tx: Drainage of the infected cyst or abscess by: Marsupialization or Word catheter.

BARTHOLINS DUCT ABSCESS
Acute process
Primary versus secondary
Organisms: N. gonorrhea, E. coli, S.aureus, T. Vaginalis, M. hominis, C. trachomatis, Strep, Bacteroides
May rupture in 72 hours
Tx
I & D, packing versus Word catheter. Rest, analgesics, sitz bath, possible antibiotics

BARTHOLINS CARCINOMA
Rare. Only 0.001% of female genital tract malignancies

HIDRANENITIS SUPPURATIVA
Not uncommon, usually postpubertal
Resistant infection of apocrine sweat glands- staph or strep.
Axilla frequently involved
Pain, pruritus: Multiple pruritic subcutaneous nodules, develop abscesses, rupture.
PE- Suppurative lesions, draining sinuses, lymphedema, widespread scarring, pitting, induration.
Tx:
After gram stain/culture, give TCN 250 mg po QID or amoxacillin-clavulanate 250 mg po TID.
Warm, moist compresses; OCs of some value.; Surgical excision in severe cases.


SMALL TUMOR
MOLLUSCUM CONTAGIOSUM
Etiology: Benign, epithelial poxvirus-induced tumors. Spread by direct & indirect contact
Lesions are often multiple and are mildly contagious.
Mild local irritation, small bumps.
Presentation
Multiple, slow-growing dome-shaped lesions 0.1-1.0 cm, w/ umbilicated center. Gritlike, milky material
can be expressed
Tx
Open lesion (needle, curettage) & express material, (+/-) chemical cautery. Also cryocautery or BCA.


HERPES SIMPLEX
Etiology: HSV-2 but increasingly also caused by HSV-1
Chronic, life-long, relapsing condition
Transmittable even in the absence of lesions
Presentation
BUZZ: multiple, painful vesicular or ulcerative lesions on the genitals.
Pt is asymp & lesions are absent are absent in many cases, particularly in infections caused by HSV-1.
After the initial infection, the virus remains dormant, but can be reactivated at a future time, which
manifests as a recurrent, symptomatic episode with painful ulceration.
Diagnosis
Most pts with HSV-2 have not been diagnosed with genital herpes. Many of these patients have mild
or unrecognized infections but shed virus intermittently in the genital tract
o As a result, the majority of genital herpes infections are transmitted by persons who
unaware that they have the infection or who are asymptomatic when transmission occurs.
Viral culture and PCR are for definitive dx
DDX: Includes others causes of genital ulceration such as syphilis and chancroid among infectious causes
and drug eruptions and Behcets disease among noninfectious causes.
Treatment
Systemic antivirals improve sXs, speed healing of lesions, and may decrease asymptomatic viral
shedding. They may also be used as daily suppressive therapy.
First Clinical Episode of Genital Herpes Recommended Regimens:
o Acyclovir 400 mg PO TID for 7-10 days
o Acyclovir 200 mg PO PID for 7-10 days
o Famciclovir 250 mg PO TID for 7-10 days
o Valacyclovir 1 g BID for 7-10 days.
Tx can be continued for longer than 10 days if lesions are not resolved.

CONDYLOMA ACUMINATA (GENITAL WARTS) -HPV
Etiology: HPV, mainly types 6 & 11.Also types 16 & 18
~30-60% of the pop has been infected with HPV at some point in their lives, but SXS present in < 1%.
Sexually transmitted & infects both partners.
Prevention: 2 vaccines against HPV are available: Both are intended to protect against cerival cancer
and high-grade cervical intraepithelial neoplasia (CIN).
Condyloma Acuminata may grow rapidly during pregnancy. Warts on the vaginal introitus may bleed
during delivery and predispose newborn to genital warts or recurrent respiratory papillomatosis (RRP).
Vulvar, vaginal and cervical HPV lesions are NOT CIs to a vaginal delivery, but rather require tx during
pregnancy. Warts that are recognized early in pregnancy should be treated at 30-32 wks to allow healing
before delivery.
Presentation:
Asymptomatic, white, exophytic or papillomatous growth.
White papillary growths, small at first, tend to coalesce and form large cauliflower-like masses that
may proliferate profusely.
May affect the vulva, vagina, and cervix in F; penis and scrotum in men; and the pubis, perineum and
oropharynx in both sexes.
Dx: Clinical Diagnosis
Colposcopy is indicated to identify small and flat lesions.
Biopsy may be needed to R/O neoplasia.
Tx: During tx, the pt should keep the area as clean as possible and abstain from sex or have her partner use a
condom. Tx is based on patient preference and convenience.
Examination of entire lower genital tract w/ the colposcope & a cytologic smear taken from cervix.
Applied by healthcare provider:
o Bichloracetic acid or trichloroacetic acid 50-80% solution.
o Podophyllin 10-25% in tincture of benzoin
o Cryosurgery, electrosurgery, simple surgical excision, laser vaporization, injectable.
Applied by pt:
Podofilox 0.5% solution or gel
Imiquimod 5% cream (topically active immune enhancer that simulates production of interferon and
other cytokines). Not indicated for mucosal warts.


Pregnancy:
Electrocoagulation, Cryotherapy or CO2 laser therapy should be administered at approx. 32 weeks to
avoid, on one hand, post-treatment necrosis, which may last as long as 4-6 wks. and to prevent, on
the other hand, recurrence if treated too early.
Podophyllin, Podofilox, and imiquimod are contraindicated in pregnancy.


EPIDERMAL CYSTS

SEBACEOUS CYSTS

APROCRINE SWEAT GLAND CYSTS

ACROCHORDON

NEVI (MELANOMA), HEMANGIOMA


VUVLODYNIA (LPV)
Sxs: burning, irritation, dryness, hyperpathia; 15% F have experienced
Localized provoked vulvodynia (LPV)
o 20-30 y/o, entry dyspareunia, vestibular tenderness
o Mast cell proliferation, hyperinnervation
o May be prior hx of sx, infection, interstitial cystitis
o RX: 5% lidocaine cream, topical estrogen, low-oxalate diet, calcium citrate, tricyclic
antidepressants, sx
Generalized unprovoked vulvodynia
o Pt in her 60s, unknown cause
o Dx of exclusion
o RX: similar

VULVOVAGINAL CANDIDIASIS (YEAST INFECTION)
Etiology: Candida albicans.
~75% of F will have at least one episodes and 40-45% will have two or more episodes.
Presentation
Pruritus; Vaginal soreness; Dyspareunia; External dysuria; White, curd-like, cheesy vaginal
discharge
Uncomplicated VVC
Sporadic or infrequent VVC
Mild-moderate VVC
Likely to be Candida albicans
Nonimmunocomprimised F

Complicated VVC
Recurrent VVC
Severe VVC
Nonalbicans candidiasis
F w/ uncontrolled diabetes, debilitation or are
immunosuppression or those who are pregnant.
Dx
Uncomplicated VVC
o Clinical features: external dysuria and vulvar pruritus, pain, swelling and redness. Vulvar edema,
fissures, excoriations or thick curdy vaginal discharge.
o Demonstration of Candidial mycelia: Wet prep or gram stain of vaginal discharge demonstrates
years or pseudohyphae OR culture or other test yields a positive result for yeast species.
o Normal vaginal pH <4.5
Tx
1
st
line: short-course topical azole drugs (Butoconazole 2%, Clotrimazole 1% or Miconazole 2%) (single
dose and regimens of 1-3 days) or Oral agent (Fluconazole 150 mg PO tablet, one tablet in single dose).




CANCER OF THE VULVA & VAGINA p. 797-806
RFS:
Endometrium
Unopposed estrogen therapy without progestin, tamoxifen, late menopause, PCOS, estrogen-
secreting ovarian tumors, nulliparity, obesity, long hx. AUB
Family history, BRCA mutations
Other malignancies: ovary, breast, colon
Ovary
Low parity, decreased fertility, delayed childbearing
Family history, BRCA mutations
No history of OC use
Cervix
Early onset of sex, multiple partners, OCs?: persistent HPV.. CIN II-III
Cigarette smoking
Vulva
Chronic vulvar irritation, non-neoplastic epithelial disorders (LSA, LSC, etc)
HPV- Condylomata, VIN
Granulomatous lesions
Immunosuppression (HIV, drugs,other)
Smoking
Premalignant Dz of the Vulva
Terminology: 2004 change from VIN 1-2-3 to VIN only, representing the high-grade lesions VIN 2-3
90% of VIN is HPV associated
HR-HPV associated with multicentric VIN. Recall embryonic origin of lower genital tract
Low risk HPV associated with condyloma time and low-grade VIN
Long-term risk of vulvar cancer with treated VIN three equals 3-7%.

VIN:
Dx: colposcopy and BX
Tx: individualized
o Wide local excision
o Laser ablation
o 5-FU, imiquimod
o Superficial vulvectomy (microinvasion found in 10 to 20%)
Follow-up is long-term. Colposcopy every 3 to 4 months for two years, then every 6 to 12 months


VAGINITIS/ VAGINOSIS
Vaginitis is an inflammation of the vagina that can result in discharge, itching and pain.
Etiology: Is usually a change in the normal balance of vaginal bacteria or an infection. Vaginitis can also
result from reduced estrogen levels after menopause.
MC types of vaginitis are:
o BV results from overgrowth of one of several organisms normally present in vagina
o Yeast infxn usually caused by a naturally occurring fungus called Candida albicans
o Trichomoniasis caused by a parasite & is commonly transmitted by sexual intercourse
o Vaginal atrophy results from reduced estrogen levels after menopause



VULVOVAGINAL CANDIDIASIS (YEAST INFECTION)
Aka a yeast infection Etiology: Candida albicans.
~75% of F will have at least one episodes and 40-45% will have two or more episodes.
Presentation
Pruritus; Vaginal soreness; Dyspareunia; External dysuria; White, curd-like, cheesy vaginal
discharge
Uncomplicated VVC
Sporadic or infrequent VVC
Mild-moderate VVC
Likely to be Candida albicans
Nonimmunocomprimised F

Complicated VVC
Recurrent VVC
Severe VVC
Nonalbicans candidiasis
F with uncontrolled diabetes, debilitation or are
immunosuppression or those who are pregnant.
Dx
Uncomplicated VVC
o Clinical features: external dysuria and vulvar pruritus, pain, swelling and redness. Vulvar edema,
fissures, excoriations or thick curdy vaginal discharge.
o Demonstration of Candidial mycelia: Wet prep or gram stain of vaginal discharge demonstrates
years or pseudohyphae OR culture or other test yields a positive result for yeast species.
o Normal vaginal pH <4.5
Tx
1
st
line: short-course topical azole drugs (Butoconazole 2%, Clotrimazole 1% or Miconazole 2%) (single
dose & regimens of 1-3 days) or Oral agent (Fluconazole 150 mg PO tablet, 1 tablet in single dose).

BACTERIAL VAGINOSIS (BV)
BV is the MC vaginal infection in F ages 15-44 y/o, although ~50% of affected F are asymptomatic.
BV refers to the changes of vaginal bacterial flora with a loss of lactobacilli, an increase in vaginal pH, and an
increase in multiple anaerobic and aerobic bacteria.
Polymicrobial infection resulting from replacement of the normal
H202-producing Lactobacillus sp. with high concentrations of anaerobic bacteria esp.:
o G. Vaginalis the predominant
organism involves is a small,
nonmotile nonencapsulated
pleomorphic rod.
o Gardnerella vaginalis, Ureaplasma
mycoplasma, Prevotella spp. and
Mobiluncus spp. G. Vaginalis the
predominant organism involves is a
small, nonmotile nonencapsulated
pleomorphic rod.
BV is associated w/ mult/new sex partners, douching, no condom use & lack of vaginal lactobacilli.
Presentation
Discharge, Leukorrhea, pruritus, burning and dyspareunia.
Homogenous, thin, white discharge that smoothly coats the vaginal walls; malodorous fishy
odor of vaginal discharge.
Dx
BV can be diagnosed by the use of clinical criteria or Gram stain (gram + nonmotile coccobacillus that
normally inhabits the vagina).
Clinical criteria require 3 of the following SXS or signs:
o White, thin, homogenous, noninflam vaginal discharge that smoothly coats vaginal walls,
o Presence of clue cells (epithelial cells w/ border obscured by small bacteria) on wet prep,
o Vaginal pH of >4.5
o Fishy odor of vaginal discharge before or after addition of 10% KOH. (the wiff test)
Tx
All F who have symptomatic disease require treatment.
Recommended regimens for nonpregnant F:
o Metronidazole 500 mg PO BID for 7 days OR
o Metronidazole gel 0.75% one full applicator intravaginally daily for 5 days OR
o Clindamycin cream 2% intravaginally at HS for 7 days
Pregnant F: Follow-up evaluation 1 month after completion of tx
o Metronidazole 250 mg PO TID for 7 days OR
o Clindamycin 300 mg PO BID for 7 days





TRICHOMONA VAGINITIS
Etiology: protozoan T. vaginalis
Presentation
50% are asymptomatic
BUZZ: Diffuse, Persistent purulent, malodorous thin vaginal discharge (profuse, frothy, yellow-
greenish, foul smelling)
Vaginal itching, irritation, burning & pain/soreness
Patchy redness of the labia & vagina.
Frequent, painful dysuria, if urine touches inflamed tissue.
Generalized vaginal erythema w/ multiple small petechiae.
Sxs can be worse during pregnancy or right before or after a menstrual period.
Dx
Wet prep microscopy of vaginal secretions is MC. Culture is the most sensitive & specific test for dx.
Tx
Metronidazole (Flagyl) 2 g PO in a single dose (Cure rate 90-95%)- okay for pregnancy cat B
Tinidazole 2 g PO in a single dose
In resistant cases PO metronidazole may be repeated after 4-6 wks.
Sex partners of patients with T. vaginalis should be treated and sexual activity should be avoided until
they and their sex partners are cured.

N. GONORRHEA
Etiology: Gram-negative bacterium, Neisseria gonorrhoeae. Incubation period is 2-8 days.
It is a very common infection, especially among young people ages 15-24 years.
Transmission: MC during anal, vaginal, or oral sex with someone who has gonorrhea.
A pregnant F w/ gonorrhea can spread the infection to her baby during childbirth. In babies, gonorrhea
MC affects the eyes. Other complications include PID & infertility.
Presentation: May be asymptomatic
Infections in the urethra, cervix, anal canal, or pharynx.
Womens sXs can include:
Vaginal discharge, urinary frequency & dysuria,menstrual irregularity, & bilateral lower abdominal
pain.
Infections in other mucosal sites, i.e. oropharynx & anorectal are usually asymptomatic, but may
present with pain or discharge.
Asymptomatic carriers can develop systemic infection, a triad of
Polyarthralgia, tenosynovitis and dermatitis or purulent arthritis without dermatitis.
Dx
Cultures (2-14d)
NAATs- Nucleic Acid Amplification Tests (1-3d)
PCR (polymerase chain reaction)
Probes- nucleic hybridization tests
GC/CT Trach test, BD Probe (1-3d)
ELISA- Enzyme linked immunosorbent assay (2-24hr)
LCR- ligase chain reaction
DFR- direct flourescent antibody
Serologic testing for syphilis , HIV, HBV & HCV are recommended.
Chlamydia testing should be done with GC- therefore, typically do GC/CT probe
Sites- endocervix, vagina, urine, oropharynx, rectum
Tx
Uncomplicated gonorrhea: Ceftriaxone IM + either azithromycin or doxycycline PO (non-pregnant F).
Patients partner should also undergo testing and treatment for gonorrhoeae even if he or she has no
signs or symptoms; Partner receives the same treatment as the patient. Patient should abstain from
sexual relations for the 7 days after therapy is initiated.
Without therapy, 10-17% of F with gonorrhea develop pelvic infection.
Major complication is salpingitis, which may result in tubal scarring, infertility & increased risk for
ectopic pregnancy.

CHLAMYDIA
Chlamydia is a common STD that can infect both men and F and can easily be cured.
Etiology: Chlamydia trachomatis; Chlamydiae.
MC seen in people under the age of 25 y/o.
Transmission: MC during anal, vaginal, or oral sex with someone who has chlamydia.
Presentation
Most patients are asymptomatic.
F w/ cervical infection may have a mucopurulent discharge with hypertrophic cervical inflammation.
Salpingitis may cause pelvic pain or be asymptomatic.
Dx:
UA; Swab and collection of specimens from the endocervix or vagina.
Swab of affected areas (Routine pap test to swab the discharge from the cervix for culture or antigen
testing; slim swab into the end of the penis to get a sample from the urethra).
Tx:
C. Trachomatis Therapy Regimen:
o Ceftriaxone 250 mg IM in a single dose, or
o Cefixime 400 mg PO in a single dose (For N. Gonorrhea coverage), PLUS
o Azithromycin (Pregnant F & Amoxicillin 500 mg PO TID for 7 days) 1 g PO in a single dose, or
o Doxycycline (Non-pregnant F) 100 mg PO BID for 7 days
If left untreated, chlamydia can cause serious permanent damage to a Fs reproductive tract, making it
difficult for a F to get pregnant.
Chlamydia can also cause a potentially fatal ectopic pregnancy

C. TRACHOMATIS
A bacterial intracellular parasite that causes a wide range of infections: cervicitis, salpingitis,
perihepatitis and urethritis.
15 serotypes: genital infections are D to K strains, lymphogranuloma venereum- L strain.
In US 4%-5% of sexually active F carry Chlamydia in their cervix. CDC recs annual screening in F <26
Complications- PID, infertility
Presentation
Frequently asymptomatic, however purulent discharge may be found.
Dysuria and frequency may be present
Neonates born to infected mothers have a 60-70% risk of infection.
PE & Investigational Procedures
Cervix may appear normal
Often cervical ectopy, erythema and friablility.
Mucopurulent cervicitis is caused by chlamydia in approximately 50% of cases.
Chlamydia testing: variety, although NAATs may be best (FDA-approved for urine)
Tx
Same combo regimen as GC
Alternative regimens use erythromycin or levofloxacin or ofloxacin, and in pregnancy, amoxacillin is rec
in place of azithromycin
No test of cure in 3-4 weeks, except in pg, but pts should be rescreened in 3 months for new disease
Screening
All sexually active F age 24 or younger
Women older than 24 with high-risk sexual behaviors
All pregnant F in the first trimester and third trimester
All F with PID
All F with symptoms of cervicitis found on pelvic exam

ATROPHIC VAGINITIS
Vaginal dryness, spotting, serosanguineous or watery discharge, dyspareunia
pH of vagina is 5.0-7.0
Decreased estrogen in pre-pubertal, lactating, and postmenopausal F
TX: topical estrogen (estrogen cream, estradiol vaginal ring, Vagifem tablets) or systemic estrogen

FOREIGN BODY VAGINITIS
TSS (toxic shock syndrome) rare (1: 100,000), but serious
Tampon use, staph aureus exotoxins
High fever, headache, sore throat, myalgia, vomiting, diarrhea, palmar erythema, skin rash.
TX: cultures, cleansing of vagina, supportive measures, beta-lactamase resistant PCN or vancomycin


MENSTRUAL DISORDERS
TERMS:
Menorrhagia excessive, heavy menstrual flow
Metrorrhagia- bleeding which occurs at any time during the menstrual cycle
Menometrorrhagia heavy bleeding which occurs at any time during the menstrual cycle
Dysmenorrhea menstrual pain which interferes with activities of daily living (ADLs)
Hypomenorrhea extremely light menstrual flow
Oligomenorrhea menstrual periods which occur at intervals greater than 35 days

ABNORMAL UTERINE BLEEDING (AUB)
Normal volume: Less than 80, averages 30 mL
Normal interval: 21-35 days (28 days)
Duration of flow: 2-7 days
AUB
o 10 different bleeding patterns
o General etiologies:
Dysfunctional uterine bleeding-no evidence of organic lesions. Caused by a loss of
coordinated cyclic hormonal changes
Pregnancy and its complications
Organic pelvic lesions, benign or malignant
Extragenital problems (coagulopathies, endocrinopathies, iatrogenic)
Age categories
o Prepubertal: not DUB
o Menarche-20 years: majority is anovul DUB
o Age 20-40 years: less than 20% is anovul DUB. Rest is pregnancy and its complications, PID, IUDs,
OCs, neoplasia, thyroid disease, endometriosis, adenomyosis
o Age over 40: anovulatory bleeding again a prominent cause, but neoplasia must be ruled out
Dx
Workup of AUB:
o Age, history- meds? Contraception? STI hx? Abnl PAPs?
o Pelvic exam
o Imaging studies-transvaginal ultrasound, SIS
o Possible hysteroscopy or laparoscopy
o Possible labs-CBC, pregnancy test, TSH, Prolactin, coag studies, etc.



DYSFUNCTIONAL UTERINE BLEEDING (DUB)
Most common cause is fibroids and can be dx by pelvic utz.
Most common cause of iron deficiency anemia in females
Get worse after menopause and reduce in size with OCPs.








AMENORRHEA
Amenorrhea is a sx not a dx: Absence or cessation of menses.
Regular bleeding at intervals of 21-45 days implies an intact hypothalamic-pituitary-ovarian system, as
well as responsiveness of the endometrium and patency of the outflow tract.

Primary amenorrhea: Rare disorder. Absence of menses by 13 y/o in the absence of normal growth or
secondary sexual development OR absence of menses by age 15 years in the setting of normal growth and
secondary sexual development.
Etiology MC cause involves gonadal failure, congenital absence of uterus & vagina & constitutional
delay. Errors in development of gonads, mullerian and wolffian system are MC causes. Nearly all
individuals w/o secondary sex characteristics have a genetic basis for primary amenorrhea.

Secondary Amenorrhea: absence of menses for >3 cycle intervals or 6 consecutive months, in previously
menstruating F. The evaluation is organized around the disruption of the cycles at the levels of the
hypothalamus, pituitary and ovary.
Etiology: MC physiologic causes are pregnancy, breastfeeding, and menopause. Non-physiologic causes
maybe due to chronic anovulation, hypothyroidism, hyperprolactinemia, wt loss or anorexia, sever
stress. Hormone excess symptoms-Excess estrogen secretion of PCOS is most common.

Dx: -hCG for pregnancy, TSH, & Prolactin & Serum FSH, Estrogen, LH, & Testosterone Levels may be
necessary to make a diagnosis.
Algorithm for W/U of Amenorrhea.
Signs of pregnancy (-hCG), estrogen deficiency, galactorrhea, abnormalities on pelvic exam particularly
adnexal masses. (Steps 1-3 of the algorithm reflect standard workup).
Progesterone Challenge: to assess functionality outflow tract and reactive endometrium. Determines
the presence or absence of sufficient estrogen.
o Medroxyprogesterone (Provera) 10mg PO for 5 days is given
o Withdrawal bleed 2-7 days after last dose.
o Any amount of bleeding=positive. No further testing needed
o Negative withdrawal implies inadequate follicular estrogen priming of endometrium and can be
found in anovulatory state (athlete, severe stress, anorexia).
Estrogen/progesterone Withdrawal Test (if Progesterone challenge is negative).
o Conjugated estrogen (Premarin) 1.25mg PO is given for 25 days with Provera, 10mg dose added
during last 5 days. Ethinyl estradiol 10mg day may be substituted.
o Withdrawal bleed indicates that the uterus is capable of responding given appropriate hormonal
stimuli; therefore uterus is eliminated as cause.
Confirmation of uterine causes such as intrauterine adhesions made by hysteroscopy.
Tx
Primary Amenorrhea: Modalities can consist of HRT, ovulation induction and counseling.
o 1
st
line: Low dose OCPs best method or can use Estrogen/Progesterone similar to the challenge.
Hormone replacement-creating normal cyclic hormone pattern, preventing osteoporosis and
resulting in development of sex characteristics.
o Ovulation induction requires gyn fertility consult and/or referral
o Surgery- Need for surgical intervention should be infrequent. An example would be corrective
surgery for ambiguous genitalia, correctable uterine anomalies or vaginal agenesis.
o Counseling- Every patient deserves counseling and adequate education about problem and all
available treatments and associated risks.
Secondary Amenorrhea:
o Hormone replacement is necessary in all cases of ovarian failure.
o Ovulation induction is used when fertility is desired.
o Hirsutism management depends on source of elevated androgens and end-organ sensitivity. Can
involve suppression of adrenal glands or ovary, tumor removal, ovulation induction in PCOS or
Spironolactone for end-organ suppression.
o Surgery- endometrial biopsy or rarely the removal of a steroid secreting tumor
o OCPs may be used to provide estrogen and may create a cycle with a withdrawal bleed.

ATHLETIC TRIAD
Hypoestrogenic condition
Refers to an interrelationship of eating disorder, osteoporosis and amenorrhea.
Endurance athletes, ballet dancers and college females.
Critical Weight Concept of Frisch-onset and regularity of menses necessitates maintaining wt & body fat
above a critical level. Losing 10-15% of normal wt for height may result in abnormal menstrual function.
History, nutritional assessment, increase in caloric intake, reduction of training intensity, BMD and
estrogen replacement in the form of OCPs

DYSMENORRHEA
One of MC gynecological D/O. Single greatest cause of lost work an school days among young F.
Risk Factors: Parous F have less, Nulliparous, single, well-educated more likely. Obesity may increase
severity. Early menarche, fam hx & heavy menses appear to increase risk.
Etiology: Increased uterine prostaglandin production and release. Increased prostaglandin cause
abnormal uterine activity resulting in ischemia.
Presentation
Symptoms appear 24-48 hrs. before or at onset of menses.
Painful menstruation, but also refers to a syndrome complex that may encompass N/V, HA,
nervousness, fatigue, diarrhea, syncope, lower abdominal cramping, bloating, breast tenderness,
mood changes, backache and dizziness.
PRIMARY: Two types
Spasmodic- pain begins w/ onset of menses & is experienced as severe cramping in lower abdomen &
back.
Congestive- usually occurs prior to onset of bleeding an is also characterized by general discomfort in
lower abdomen as well as in other areas of the body.
Presentation
Usually lower midline, dull abdominal ache or cramping, may radiate to back that generally occurs with
ovulatory menstruation.
May begin 2 days before onset or at onset of menses
Can be severe on first day and usually lasts no more than 48 hrs.
May be accompanied by increased flow and clots.
Usually increase in severity over the years followed by a decrease after age 27 or pregnancy. A few may
experience at menarche but not typically ovulatory that early. Generally show up in clinic in early 20s.
Dx
Complete gyn exam including abdomen: A pelvic exam w/ negative findings strongly suggests primary .
No investigative procedures are necessary. Dx is suggested by appropriate hx, negative pelvic exam, & a
therapeutic response to ovulation-blocking agents or prostaglandin synthetase inhibitors
Any positive finding requires further evaluation for secondary dysmenorrhea.
Tx
Individualized based on severity, contraception desired and existence of concurrent medical disease.
NSAIDS: Ibuprofen, Ponstel, or Naprosyn (TOC for F who do not use OC. Can also be used with OCPs).
Patients can be advised to start NSAIDS the day before or day of onset if they have a regular cycle or
are taking OCPs. Should take at earliest sign before pain intensifies.
SECONDARY:
Menstrual pain due to pathologic process.
Causes are numerous and differential diagnosis should include adenomyosis, endometriosis, fibroids,
polyps, IUD, PID, congenital abnormalities, ovarian cysts, true cervical stenosis, endometrial carcinoma
and pelvic adhesions.
Determine age of onset of pain, duration in years, associated sxs, character of discomfort & relationship
in time to cycle.
Adenomyosis- ingrowth of endometrium into uterine musculature. Common in multiparous middle
aged women. Pt present with c/o labor like pain only during menses. Often c/o heavy menses. Final
diagnosis not usually made until pathologic exam of uterus post hysterectomy.
Endometriosis- Growth of endometrium outside of uterine cavity. More common in nulliparous women.
Pt present with c/o pain increasing in severity over the years. Begins 2-3 days before menses, peaks at
heaviest day of flow. Often associated with painful intercourse, painful bowel movements and backache.
Myomas-Uterine myomas usually cause dysmenorrhea only when they are submucosal or protrude into
the uterine cavity. They can cause heavy and prolonged bleeding.
IUD- Especially in days after insertion and in first few cycles following insertion. NSAIDs generally help.
Removal necessary or desired for some women.

PREMENSTRUAL SYNDROME (PMS)
Diverse constellation of cyclic physical & emotional sxs, occurring during the luteal phase of menstrual
cycle. This phase is followed by a sx free period of at least 1 wk beginning after the onset of menses.
Occurrence during the luteal phase is the distinctive characteristic that aides your diagnosis.
PMDD is a classification for American Psych Association Premenstrual Dysphoric Disorder requires the
presence of at least 1 of 4 core SXS (irritability, dysphoria, labile mood, tension) & at least 5 other sxs.
SXS must markedly interfere with normal activity.
Incidence:
o It has been reported that 70% to 90% of Fs will admit to recurrent menstrual problems.
o 20-40% report some degree of temporary mental and physical dysfunction.
o 2-5% may be incapacitated. (PMDD)
Etiology: Abnormal neurotransmitter response to normal ovarian function. (Women with PMS have
normal estrogen, progesterone, prolactin and thyroid levels and are not vitamin or mineral deficient).
Presentation- may last 3-21 days
Physical sxs:
Neurologic: migraines and other headaches, syncope, vertigo
Metabolic: breast tenderness, edema
Cardiovascular: palpitations, ectopic beats, and paroxysmal tachycardia.
GI: nausea, bloating, flatulence,
Constipation, diarrhea
Urinary: oliguria, urethritis, cystitis, urinary retention
Dermatologic: acne, urticaria
Musculoskeletal: pain and swelling in joints and muscle
Behavioral Sxs:
Depression; Irritability; Tension; Lethargy ; Mood swings; Anger; Uncontrolled crying; Aggression; Panic
attack; Anxiety; Social withdrawal; Change in memory and concentration; Change in libido; Poor impulse
control
Dx:
Complete physical exam with pelvic exam.; PHQ9
Complete mental status to R/O psychopathology may be necessary
There are no characteristic physical findings in PMS
PMS-Investigative Procedures
Menstrual chart. SXS charted against cycles
Diagnosis depends on the temporal relationship of psychological and somatic SXS with menstrual cycle.
Should show length of cycles, duration of bleeding, regularity or irregularity. By definition PMS
ONLY occurs during OVULATORY CYCLES.
Each symptom along with its severity is charted each day along with eating patterns.
A full 3 cycles are optimal for evaluation.
Post-hysterectomy pts with ovaries may have PMS.
Tx
Goals: Altering the cycle, changing the bodys response to the cycle, and treating SXS themselves.
Education is the most helpful. Knowledge of cycle and menstrual chart.
Exercise 3-4 times per week seems to help sxs.
Stress management: Meds, relaxation techniques, time management.
Diet & nutrition: Aim at increasing complex carbs, decrease sugars, & eliminate caffeine.
Supplements: Vit B6, Vit E, Calcium & Magnesium.
Pharmacotherapy:
o 1
st
Line: OCPs- monophasic may be more effective. Psychological sxs may worsen
o SSRIs- Fluoxetine, Paroxetine
o Anxiolytics like Alprazolam (Xanax) or Lorazepam can help control anxiety and irritability if
given during symptomatic period. Always limit use and advise about dependency.
MENOPAUSE & POSTMENOPAUSE
Menopause= spontaneous absence of menstruation for 12 mths w/ elevated FSH & no pathologic cause.
Induced (or surgical) menopause is defined as permanent cessation of menses after BSO, or ablation
of ovarian function due to radiation or chemo.
Premature menopause is defined as menopause reached at or before 40 & can be natural or induced.
At age 40, frequency of ovulation decreases causing menstrual irregularities heralding
perimenopause or the menopause transition.
Average age of completion 51.5 years.
Presentation
Symptoms are due to hormonal changes.
There are receptors for estrogen throughout the body and 400 different bodily functions are affected
by estrogen decrease, so SXS are numerous and head-to-toe.
2 Stages of Menopause Transition
Early: Older follicles produce less progesterone leaving F in a state of estrogen dominance.
Pt present with c/o PMS like SXS such as bloating, cramping, moodiness and breast tenderness
throughout the cycle.
Feeling agitated, angry and tearful are typical SXS that cause F to seek care.
Increasing estrogen stimulation of endometrium and lower progesterone cause menses to be
heavier, prolonged & closer together. Cycle length shorten by 5-7 days. T
Late: Estrogen levels decline leading to hot flashes, memory and concentration problems, heart
palpitations, migraine headaches, vaginal dryness, sleep disturbance. Some F will experience anxiety, and
depression. Pts. Present to clinic c/o being up all night and feeling like they are losing their minds.
Serotonin, dopamine, acetylchonie are decreased & norepinephrine increased
Presentation
Early (40s) Irregular periods; PMS; Heart palpitations; Mood swings, irritability; Weight gain, waistline;
Joint pain; Irritable bowel; Night sweats
Late (late 40s early 50s) Hot flashes, night sweats; Insomnia, fatigue; Migraine headaches; Memory
and concentration issues; Dry skin, brittle hair& nails; Weight gain, waistline; Depression/Anxiety;
Dyspareunia; Vaginal dryness; Vaginal and Urinary infections; Loss of libido
PE
PE with speculum and pelvic exam Ovaries should not be palpable in menopausal female- U/S.
Menstrual Chart: Including detail of spotting or heavy bleeding. Most helpful along with history of
SXS in determining stage of menopause transition & possible need for evaluation & tx options.
FSH: Useful to confirm menopause.
Tx
Early Transition Management
Irregular menses can be managed with low dose OCP if no contraindications.
Heavy menses can be managed with low dose OCP, Mirena IUD or ablation
Uterine myomas- referral for evaluation and treatment.
PMS symptoms- Vit B 6 50-100mg, Vit E 400-800IU, Calcium 1200mg, Mag 600mg
Late Transition Management
Hot flashes- Black Cohosh (Remifen) most researched. Estroven Max. Soy products. May help in early
stages. ERT, HRT and SSRIs. Acupuncture.
Sleep disruption- Calcium at bedtime, time release Melatonin, Good sleep hygiene, relaxation
techniques. Limited use of sleep medications.
Depression- Referral and treatment. Reassurance that this can be time limited and antidepressants
can be a good bridge over this transition period.
Atrophic vaginal changes/ dyspareunia- Vaginal estrogen creams, rings, inserts. OTC
lubes/moisturizers.
Hormone Replacement Therapy:
HRT= estrogen and progesterone. Should be thought of as hormone maintenance for best
results. FDA approved for hot flashes, osteoporosis prevention.
ERT= estrogen only (no uterus) Same as above
Progesterone only= May be helpful for hot flashes for F who cannot use estrogen
Vaginal Estrogen products= FDA approved for vulvovaginal atrophy
Transdermal preferable to avoid 1
st
pass through liver. Lower thromboembolic risk.

BREAST
ABSCESS
Etiology: Staph. aureus
Occur primarily in lactating F. During lactation and nursing, an area of redness, tenderness and
induration may develop in the breast.
In its early stages the infection can often be resolved while continuing nursing with the affected breast
and administering an antibiotic.
Presentation
Unilateral breast erythema, tenderness, heat, significant fever, chills and other flu-like symptoms.
Usually, one quadrant or a lobule of one breast is affected.
If the lesion progresses to form a palpable mass with local and systemic signs of infection, an abscess has
developed and need to be drained by I & D.
Even in this setting, breastfeeding or pumping can help in controlling the pain and discomfort associated
with the infection as well as shorten the duration of the infection.
Diagnosis: Clinical Diagnosis
Tx
Surgical (Surgical Drainage; I & D).

BREAST CANCER
Mammogram after age 50
Mutation in the BRCA1 or BRCA2 gene is present

Risk Factors
Female, older age
Hx of breast cancer
Breast cancer in 1st deg relative
BRCA1 and BRCA2 mutations
High fat, low fiber diet
History of fibrocystic change with atypical cells
Increased exposure to estrogen (nulliparous, early menarche, late menopause)
1st full term pregnancy after 35
Presentation
MC in ductal located upper outer quadrant
Hard non-tender mass
Diagnosis
Any solid lump that has been present >4 months = BIOPSY!
Tx
Raloxifene (Evista) and Tamoxifen commonly used in treatment

FIBROADENOMA
2
nd
MC benign neoplasm of the breast.
MC occurs in young F, usually within 20 years of puberty; MC in black F.
Etiology: Idiopathic/unknown. Hormonal relationship is likely since they can increase in size during
pregnancy or with estrogen therapy and usually regress after menopause.
Multiple tumors in 1 or both breasts are found in 10-15% of patients.
Presentation
Round, firm, smooth, discrete, relatively mobile and nontender mass 1-5 cm in diameter.
Dx/Tx
The tumor is usually discovered accidently.
Clinical diagnosis in young patients is generally not difficult.
Fibroadenomas typically present as well-defined solid masses with benign imaging feature on US & can
be managed with core needle biopsy or ST (3-6 mo.) follow-up w/ repeat US & breast exam.
Treatment of Fibroadenoma may be by local excision of the mass with a margin of surrounding normal
breast tissue or managed expectantly.
In a F <25 y/o, a Fibroadenoma should be biopsied.
FIBROCYSTIC BREAST CHANGES
MC benign condition of the breasts- includes cysts, papillomatosis, fibrosis, adenosis and ductal epithelial
hyperplasia.
MC occurs in F 30-50 y/o
Etiology: Appears to represent an exaggerate response of breast stroma and epithelium to hormones and
growth factors.
Presentation
May present as asymptomatic glandular or nodular breast tissue.
Breast lumps or areas of thickening that tend to blend into the surrounding breast tissue, generalized
bilateral breast pain or tenderness, bilateral pain and size fluctuation during the menstrual cycle.
Multiple lesions distinguish fibrocystic changes from carcinoma.
Monthly inrease in breast pain or tenderness just prior to menstruation.
Dx: Clinical Diagnosis & Clinical Breast Exam.
US or Mammogram to confirm findings.
In suspected cysts:
o FNA is both diagnostic and therapeutic.
o Cysts usually contain straw colored fluid.
Tx
F who are asymptomatic or have mild SXS require no treatment except a supportive bra.
F who have severe pain or large cysts associated w/ fibrocystic breasts may require tx: FNA or Surgical
Excision.
OTC pain relievers/OCs may be used to treat breast pain and tenderness.

MASTITIS
Bacterial infection of the breast tissue that occurs primarily in lactating F.
Generally confined to the first 2 months of lactation.
Etiology: Staph. aureus; blocked milk duct.
Bacteria from the pt.s skins surface and the babys mouth can enter the milk ducts through a break or
crack in the skin of the nipple or through a milk duct opening.
Presentation
Unilateral breast pain and tenderness, heat, swelling, erythema, significant fever, chills and other
flu-like SXS (malaise, fatigue & myalgia).
Usually, one quadrant or a lobule of one breast is affected.
Dx: Clinical
Tx:
Penicillinase-resistant abx (Cloxacillin, dicloxacillin, nafcillin) or a cephalosporin & hot compresses.
Breast feeing may continue bc the source is likely to be the infants oropharynx and the bacteria is a
normal bacterial source found in the body that is just not suppose to be in the breast tissue.
Self-care: Rest, continue breast-feeding and drink extra fluids.




Sexually Transmitted Infections/ Pelvic Infections
TOXIC SHOCK SYNDROME
Rare (1: 100,000), but serious
Tampon use, staph aureus exotoxins
High fever, headache, sore throat, myalgia, vomiting, diarrhea, palmar erythema, skin rash.
RX: cultures, cleansing of vagina, supportive measures, beta-lactamase resistant penicillin or vancomycin

PELVIC INFLAMMATORY DISEASE
Inflammation of upper female genital tract. 2/3 are <25 y/o
combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis.
Etiology: Sexually transmitted organisms, particularly N. gonorrhea and C. trachomatis,
Usually Polymicrobial including GC, Chlamydia, endogenous aerobes and anaerobes, occasionally
Mycoplasma species.
Presentation
Acute PID
Insidious or acute onset of lower abdominal pain and pelvic pain, which is usually bilateral.
Sensation of pelvic pressure or back pain.
Purulent vaginal discharge
Nausea may occur, w/wo vomiting
HA and general lassitude are common complaints.
Abdominal tenderness, usually in both lower quadrants; the abdomen may be somewhat distended
and bowel sounds may be hypoactive and absent
Pelvic Exam: May demonstrate inflammation of the periurethral (Skene) or Bartholins glands as well
as a purulent cervical discharge. Pelvic tenderness.
Bimanual: May demonstrate or elicit extreme tenderness on mvmt of the cervix & uterus & palpation
of the parametria. Swelling or true mass of the adnexa

Diagnosis: Clinical based on the presence of cervical motion tenderness or uterine or adnexa tenderness.
Difficult to dx due to a wide variation in signs & sxs. Many F have subtle or mild sxs.
Delay in diagnosis & tx contributes to inflammatory sequelae in the upper reproductive tract
Cultures- rapid enzyme tests
Pregnancy testing- 4% admitted for PID have ectopic preg. ALWAYS RULE OUT PREGNANCY
WBC and Sed Rate- <50% have elevated WBC, 24% have normal Sed rate.
U/S- 95% accurate for detecting pelvic abscesses.
Tx
Empiric, BS coverage of likely pathogens and should be given as soon as a presumptive dx is made.
Outpatient Therapy Regimen: bed rest, abstinence & repeat cultures in 2 wks after finishing tx.
RPR, HIV and HBsAG should be obtained.
o Ceftriaxone 250 mg IM in a single dose, plus
o Doxycycline 100 mg PO BID for 14 days, with or without
o Metronidazole 500 mg PO BID for 14 days.
OR
o Cefoxitin 2 g IM in a single dose and probenecid 1 g PO in a single dose administered
concurrently, plus
o Doxycycline 100 mg PO BID for 14 days, with or without
o Metronidazole 500 mg PO BID for 14 days.
Inpatient Therapy Regimen:if dx uncertain, pelvic abscess, adolescent or believe unreliable, generalized
periotonitis or severe illness, outpt tx fails, clinical reevalu in 48-72 hrs cant be arranged, pt has HIV
o Cefotetan 2 g IV every 12 hours or Cefoxitin 2 g IV every 6 hours, plus
o Doxycycline 100 mg PO or IV every 12 hours.
OR
o Clindamycin 900 mg IV every 8 hours, plus
o Gentamicin loading dose IV or IM (2mg/kg body weight), followed by a maintenance dose (1.5
mg/kg) every 8 hours. Single daily dosing (3-5 mg/kg) can be substituted.

VULVAR LESIONS & GENITAL ULCERS
CHANCROID
ulcerating disease of the genital region caused by Haemophilus ducreyi. Its exact incidence is unknown;
clinical infection is rare in women.
Tx all sexual partners regardless of sxs, if they had sexual contact in the 10 days preceding pts sx onset

SYPHILIS
Infective agent is a spirochete-Treponema pallidum.
Spread by sexual intercourse or intrauterinetransmission (congenital syphilis)
Incubation period- 2-6 wks, with primary sore (chancre) appearing at the site of infection & remaining
for 1-6 wks.

LYMPHANOGRANULOMA VENEREUM
A granulomatous dz of the genital tract that is sexually transmitted. Incidence is rare in women.

CONTRACEPTIVE METHODS
*** 49% of pregnancies in the US are unintended
Negative consequences associated with unintended pregnancies Maternal depression; Increased risk
of physical violence; Delays or lack of prenatal care birth defects and low birth wt

Efficacy: how well a method works inherently
Effectiveness: how well a method works in actual practice
Perfect use: effectiveness when following directions for use
Typical use: effectiveness during actual use, including inconsistent or incorrect use

Fertility Awareness Method
Natural family planning and periodic abstinence
Avoid intercourse or use another method during fertile phase
o Fertile phase: includes several days before and after ovulation
Failure rate of 1-25%
May be acceptable for cultural or religious reasons
Nonhormonal
Needs regular menstrual cycles
Restricts sexual spontaneity
Requires ongoing effort and commitment
Calendar Method
Record menstrual cycle on a calendar for 6-12 cycle
Calculate fertile period
o Earliest day of fertile period=shortest cycle length minus 18
o Latest day of fertile period=longest cycle length minus 11
If cycle range is 27-32 days fertile period=days 9-21
Standard Day Method
Ideal for F with menstrual cycles 26-32 days long
On the 1
st
day of cycle, place rubber ring on red bead move ring one bead per day
Abstain from unprotected intercourse during white beads (days 8-19)
Cervical Mucus Method
Check and chart character of mucus on the vulva or at the introitus
Changes throughout cycle
At ovulation, is clear, wet, stretchy, and slippery
Non-safe days: begin 2 or 3 days before first sign of slippery mucus and last for 3 days after
Two-Day Method
Much simpler form of cervical mucus method
2 Questions: Did I have cervical mucus today? & Did I have cervical mucus yesterday?
o If answer is no to both questions, it is a safe day to have intercourse
Basal Body Temperature
Record daily temperature first thing when you wake up
Read it to the 1/10 degree: best to have large-scale thermometer that only registers 96-100 F
Temperature will increase 0.4-0.8F with ovulation
Good at telling when ovulation has happened, but cant predict
o Best to consider 1
st
part of cycle as unsafe days
o Better in combination with other methods
Coitus Interruptus/ Withdrawal or Pull-Out Method
Failure rate: 4-27%
Withdrawal of the penis out of the vagina before ejaculation
Free, no hormones, readily available
Need to have great self-control and must use with every intercourse
Doesnt protect against STIs
Lactational Amenorrhea Method
98-99% effective
Lasts for up to 6 months
Must be exclusively breastfeeding
Not going 5 hours or more without pumping or breastfeeding
No menstrual cycle since birth
Prevents ovulation
Male Condom
Thin latex or plastic. Readily available & cost-effective. Dry or lubricated & can use w/ or w/o spermicide
Block sperm from entering vagina
Failure rate of 2-18%
Reduce risk of STIs
Pull out penis before loss of erection
Store in cool, dry placE
Female Condom
Pouch with flexible rings on both end. Barrier to sperm
Inner ring inside vagina
Outer ring outside vagina
Place with lubricant or spermacide
Failure rate: 5-21%
May prevent STIs
Readily available. Cost ~$4
Diaphragm
Dome-shaped cup
Silicone
Failure rate of 6-16%
Inserted into the vagina, covers the cervix barrier to sperm
Use with spermicide
Insert up to 6 hours before intercourse, leave in place between 6-24 hours after
Multiple sizes, requires fitting
No oil-based lubricants
May increase UTIs
Essure
>99.5% effective, permanent
Outpatient: no incision or anesthesia, hysteroscope inserted through the cervix
Microinserts in fallopian tubes, natural tissue grows around blocking tubes
Hysterosalpingogram 3 months after insertion
Female Sterilization
>99.5% effective. PERMANENT
Laparoscopy, mini-laparotomy, or laparotomy
Interruption of fallopian tubes
Risks: infection, bleeding, reaction to anesthetic, ectopic pregnancy
Permanent
Vasectomy
>99.5% effective. Use back-up method for 3 months.
Interrupts vas deferens prevents sperm into seminal fluid
Less complicated and less expensive than female sterilization
Combined Hormonal Contraceptives
Mechanism of Action:
o Primary: Preventing Ovulation
o Secondary: Thickens cervical mucus, thins endometrium, slows motility
Combined Contraceptives-Prescribing Precautions
Pregnancy
Current or Hx: HTN, MI Stroke, Blood Clot, Diabetes, Liver Dz, Gallbladder Dz, Breast Ca, HAs w/ Aura
Cigarette smoking in F 35 and older
Postpartum and lactation- Do not want to give estrogen during breast feeding.
Unexplained vaginal bleeding
Severe diarrhea, malabsorption, or other bowel disorders
Awareness of meds that interfere with effectiveness (i.e. St. Johns Wort, antiretroviral therapy, rifampin,
rifabutin, carbamazepine, phenytoin, etc.)
Warning Signs (ACHES): Abdominal pain; Chest pain; HAs that are severe; Eye problems: blurred vision
or loss of vision; Severe leg pain
Cyclic, Extended, or Continuous?
o Cyclic: 21 days of a combined contraceptive followed by a med-free interval (usually 7 days)
o Extended: Medication-free interval observed less often than every month
o Continuous: Medication-free interval is omitted completely
Start Options
Quick start: day of visit is recommended Back up method for 7 days
Sunday start (no bleeding on weekends) Back up method for 7 days
1st day of next menstrual period
92-99% effective
Therapeutic Uses
o Dysmenorrhea, Irregular Menses, Iron-deficiency anemia, Acne, PCOS, Menstrual
migraines without aura
The Pill
Stress importance of taking pill at the same time every day
Missed Pills:
o 1 pill: Take next pill ASAP and continue next pill as usual
o 2+: Same as above, Use a back up for 7 days
Breakthrough bleeding
o If within first three months, encourage to keep taking
o After three months, try different pill (more estrogen)
Transdermal Patch- OrthoEvra
Worn weekly for 3 weeks then removed for 1 week
Can bathe, swim and do other activities. Check patch daily to ensure all edges are adherent
Nuva Ring
Placement location is not critical, absorption occurs as long as it is anywhere in the vagina
Teach insertion in the office
Leave in for 3 weeks, then remove for one week
Removal for intercourse is not recommended, but can be done for no more than 3 hours per day
Check placement daily
Progestin Only Pills
92-99% effective
Lower dose of progestin, no estrogen
Thickens cervical mucus
Taken continuously
Require punctual dosing: if >3 hours late, use back up method for 48 hours
When starting, use back up method for at least 48 hours
Can be used when breastfeeding
Irregular bleeding, spotting
Birth Control Shot (Depo-Provera)
97-99% effective
Shot every 3 months. If >7 days from LMP, use back up method for 7 days
Thickens cervical mucus, prevents ovulation
Irregular bleeding, amenorrhea, weight gain, depression
Delay in return to fertility
Implant (Nexplanon)
99% effective
Progestin only
Thickens cervical mucus- prevents ovulation
Must be inserted by a provider with additional training
If >7 days from LMP, use back up method for 7 days
SE: Irregular bleeding, amenorrheaEducate!
Cost effective if you keep it in for 3 or more years.
Mirena and Skyla (Progestin IUD)
99% effective
Thickens cervical mucus
Effective for 5 years (Mirena) & 3 years (Skyla)
Irregular bleeding/spotting common for up to 6 months
Lighter menstrual cycles or amenorrhea
If >7 days from LMP, use back up method for 7 days
ParaGard (Copper IUD)
99% effective
Non-hormonal
Spermicidal
Effective for up to 12 years
Menstrual cycle remains heavier, may cause heavier bleeding and more cramping
No back up method required
IUD Considerations
Immediately Reversible
Cost-effective with long-term placement
May use while breastfeeding
Provider must insert and remove-timing of placement?
Risk of expulsion or perforation of uterus
Precautions Current STI; Recent endometritis; Uterine anomaly; Unexplained vaginal bleeding
Monthly string check
Signs to watch for: late period, abdominal pain, infection, change in string
Emergency Contraception
11% of sexually experienced F have used EC
Prevent pregnancy up to 5 days after unprotected sex, take as soon as possible
Women under 17 need a prescription for some brands
May be expensive
SE: N&V
Morning-after pill (Plan B, Ella, etc.) ~85% effective
o Delay or inhibition of ovulation
ParaGard IUD-99.9% effective
o Implantation occurs 6-12 days following ovulation
o Prevent sperm from fertilizing egg

INFERTILITY
Infertility The inability of a couple to conceive after 1 year of regular intercourse
Primary vs. Secondary
Sterility Intrinsic inability to achieve pregnancy
4 key aspects: Sperm; Ovulation; Transport; Implantation
MALE EVALUATION
25-40% of infertility cases due to male causes
Most often due to testicular pathology
Physical Exam
Hormonal abnormalities Hair pattern; Breast changes (gynecomastia)
Genitalia Development; Bilaterally descended testes; Varicocele
Semen Analysis
Normal excludes any important male factor
Abnormal need for further evaluation
o Repeat semen analysis in 4 weeks to confirm
o Draw T, FSH, LH
o Endocrine, urological or genetic cause? Consider referral
FEMALE Infertility
Ovulation
Transport Cervical factor; Tubal factor
Implantation Uterine factor
Physical Exam
BMI; Distribution of body fat; Thyroid; Breast formation/galactorrhea; Hair pattern (Hirsuitism or
Virilization); Acanthosis nigricans
Pelvic exam Speculum & Bimanual
Initial Female Laboratory Testing
NG/CT & Ureaplasma
FSH/E2 CD 3
Mid-luteal progesterone (>2ng/ml)
Prolactin (<20)
TSH, free T4
Insulin (<12.4)
Blood glucose
DHEA-s
Testosterone (<0.6)
Pap smear
Confirming Ovulation (irregular menses)
o Draw mid-luteal progesterone, 3rd week of cycle Want >2ng/ml
o Home LH predictor kits
o Cervical mucus
o Basal body temps
Clomid Challenge Test
o Evaluating ovarian reserve (pt >35)
o Draw FSH & Estradiol (E2) levels on cycle day 3 Want FSH <10ng/ml, & E2 < 80ng/ml
o Give Clomid on cycle days 5-9
o Repeat FSH and E2 on cycle day 10 or 11
Want FSH to be about the same as day 3
Want E2 to be rising approximately 250 ng/ml
Imaging
o Ultrasound
o Hysterosalpingogram
o Laparoscopy with chromotubation GS for evaluating tubal factor
Diagnosis
20% - several factors may be suboptimal
Unexplained infertility:
Normal uterine cavity; Bilateral, patent tubes; Normal semen analysis; Evidence of ovulation
Treatment
Promoting fertility + cycle awareness
Medications
* Addresses the ovulatory factor*
*Clomiphene Citrate
Ex: Clomid 50-100mg on cycle days 3-7 or 5-9
8% chance of twins
Aromatase Inhibitors
Ex: Letrozole 5mg cycle days 3-7 or 5-9
Treat pituitary and/or thyroid conditions as needed
*Consider laparoscopic ovarian drilling in PCOS
Intrauterine insemination (IUI)
Mild to moderate disease
Sperm is injected into the uterus through the cervix
Typically combined with Clomid
Assisted Reproductive Technology (ART)
In vitro fertilization (IVF) Indications Unexplained infertility, blocked fallopian tubes,
unsuccessful IUI
Intra-cytoplasmic sperm injection (ICSI) Indications poor semen analysis, IVF failure, vasectomy,
inability to have erection or ejaculate
1-3 embryos per cycle 15-35% success each time

Protecting Fertility
Men:: Minimize Hot tub use; Biking; Briefs /Constricting pants; Laptop use on lap. Zinc 25mg/Vit C 500iu
per day
Women Healthy wt (nutrition & exercise); Give up alcohol, cigarette, drug use; Reduce stress; Consider
counseling; Take prenatal vits!
Both Men and F Minimize lubricant use

UNCOMPLICATED/ COMPLICATED PREGNANCY
Preconception Counseling
Health Promotion Nutrition; Exercise; Smoking, alcohol, drug use; Decrease stressors
Optimize Current Medical Conditions
Medication Review Start Prenatal Vitamins >3 months before planned conception
Menstrual Cycle Awareness
Vaccines Hepatitis B, Rubella, Varicella cannot be given in pregnancy
Social Environment

NEW OB:
Initial Obstetric Visit New OB
Pregnancy History
Gravida & Parity
Gravida: # of times a woman has been pregnant
Para: # of pregnancies resulting in birth of fetus at viability (~20 weeks)
T: Term (37-42 weeks)
P: Preterm (<37 weeks)
A: Abortion
L: Living
Primip first baby, Multip 2+, Grand multip 5+
H.R. is a 28 year old G4P2012 here for her NOB
Evaluation of past pregnancies/births/abortions
Abortions-weeks gestation, methods used, complications
Complications during pregnancy or birth (GDM, HTN, Pre-eclampsia, Hemorrhage, etc.)
Weeks gestation
Newborn weight
Onset of labor
Length of labor
Medications during labor (epidural, etc.)
Current Pregnancy History
Last Menstrual Period (LMP)
Naegeles Rule
o Start with 1
st
day of LMP + 7 days Subtract 3 mths =Estimated Date of Delivery (EDD)
Pregnancy Wheel
1
st
trimester ultrasound?
Review of Systems Full ROS (How are you feeling?)
New OB-Physical Exam
Full Head to Toe
Pelvic Exam
o Bimanual-Estimate gestational age based on uterine size
Lemon-6 weeks, orange-8 weeks, tomato-10 weeks, graperfruit-12 weeks
o Pelvimetry
o Chadwicks sign
Breast Exam Nipple assessment
Abdominal
o FHTs (audible 10-12 weeks, 110-160bpm = NL)
o Palpate Uterine Fundus

New OB-Labs
CBC
Blood Type & Rh Factor
Antibody Screen
RPR, HIV, HBsAG
Rubella titer
GC/CT
Pap Smear
UA/UC
Consider: varicella, Vit D, glucose, HcG
New OB-Genetic Screening
1
st
trimester screen
Cell Free DNA Testing; Chorionic Villus Sampling; Quad Screen (AFP); Amniocentesis; Level 2 US
New OB-Education
Nutrition
Weight Gain
BMI: <18.5 28-40lbs BMI: 18.5-24.9 25-35lbs
BMI: 25-29.915-25lbs BMI: 30 and greater 11-20lbs
**Pattern important. 5-10lbs by 20wk, then 1lb/wk. average
o Avoid swordfish, shark, king mackerel, tile, unpasteurized cheeses, deli meats, >300mg
caffeine/day
o Good, regular protein sources with lots of fruits/veggies; Supplementations; WIC; Diet log
Lifestyle Exercise; Sexual Activity; Avoid alcohol, smoking, drugs; Reduce stressors; Meds-
Category: A, B, C, D, X
1
st
trimester warning signs Vaginal bleeding; Cramping; Abdominal Pain; Fever

1
St
Trimester Prenatal Visits
Every 4-6 weeks
Physical Exam Weight, BP; FHT (110-160); Fundal Height
Genetic Screening?
Address Questions and Concern
2
nd
Trimester
Every 4-6 weeks
PE Wt, BP; FHT (110-160); Fundal Height (+or- 3cm)- Start measuring ~20 wks; Fetal movement
Level 2 Ultrasound 18-20 weeks
Labs
o GDM: 26-28 weeks
1 Hour: >130-140 mg/dl
3 Hour:
Fasting 95 1 Hour180 2 Hour 155 3 Hour 140
GDM Diagnosis: 2 or more
o Hgb
o Antibody Screen
Rhogam (if Rh-)
Warning Signs
o Preterm labor ( >6 contractions in one hour); Vaginal bleeding; Leaking fluid; Decreased Fetal
Movement
Childbirth Education
3rd Trimester
Every 2-4 weeks until 36 weeks, then weekly
Physical Exam Weight, BP; Fundal Height (+or- 3cm); FHT (110-160); Leopolds Maneuvers;
Edema; Optional cervical exam
Labs
GBS: 35-37 weeks
Recheck Hgb if low

PREGNANCY CHANGES:
CV
Increased CO
Decreased peripheral vascular resistance
Vasodilation, decreased valve tone
Mild cardiomegaly
Leads toPalpitations; SOB; Bleeding gums; Spider nevi; Varicosities (Legs, Vulva, Hemorrhoids);
Hypercoagulable state; Congestion; Edema
Respiratory
Unchanged rate
Increased 02 requirements and inspiratory capacity
Decreased expiratory reserve and total capacity
Rib cage expands while uterus pushes up
Leads toConstant state of hyperventilation and shortness of breath
GI
Decreased gastric motility
Increased gastric acid secretion
Lax esophageal sphincter
Leads to. Heartburn; Bloating; Constipation; Gas; N/V
Renal
Increased kidney size, dilated ureters
GFR increase
Uterus and fetal head cause pressure on bladder
Decreased pelvic floor support for urethra
Leads to Urinary frequency; Mild glucose and protein excretion; Increased UTI risk; Incontinence risk
Reproductive
Increased uterine size
Cervical vascularity
Breast Size
Leads to Cervical bleeding; Galactorrhea; Back pain; Sex
Skin
Hyperpigmentation (Nevi changes)
Transparent
Linea nigra
Striae
Leads toUrticaria, rash; Cholasma; Linea nigra
MSK
Relaxin
Lordosis
Leads to hypermobility, back/joint pain, mild carpal tunnel d/t swelling, pregnancy waddle

ABNORMAL EXAM FINDINGS
Size/Date Discrepancy (x2)
o Size < Dates
Intrauterine Growth Restriction (IUGR)
Oligohydramnios
o Size > Dates
Multiples; Polyhydramnios; Macrosomia
U/S Growth Scan
Also consider Maternal body habitus; Incorrect pregnancy dating
Leopolds not head down by 34ish weeks
o Ultrasound Confirmation
o Spinningbabies.com
o External cephalic version

ADDITIONAL PREGNANCY TESTING
Indications:
o
o HTN
o Measuring large or small (x2 visits) Growth scan
Nonstress Test (NST) Reactive = 20 mins normal baseline fetal HR, moderate variability, no
decelerations, 2 accelerations
Biophysical Profile (BPP) Breathing, gross movement, tone, amniotic fluid index, NST
Amniotic Fluid Index (AFI)
o Oligohydramnios <5
o Polyhydramnios >20
Growth Scan (U/S)

GESTATIONAL DIABETES
Classification: A1, A2, B
Lifestyle=key!! Diet; Exercise
Check Blood Sugar 4x per day Fasting (<95) vs. Post-Prandial (2 Hour: <120)

Complications Macrosomia, Shoulder Dystocia, Newborn Hypoglycemia, DM2 increased risk for life

PREECLAMPSIA
Dx: Hypertension: >140/90 + Proteinurea, onset after 20wk
Warning Signs Change in Vision; HA; Right Upper Gastric Pain; Swelling in hands and feet
Labs ALT/AST; Platelets; BUN/Creatinine; Uric Acid; 24 hour urine/Serum Protein Creatinine Ratio
HELLP Hemolysis, elevated liver enzymes, low platelets
PE: reflexes, clonus
Tx: delivery

NORMAL LABOR/DELIVERY
STAGES OF LABOR
Prelabor?
1
st
Stage
Latent Phase Onset of contractions Contractions consistently 3-5min apart lasting 60+ secs,
cervix is 5-6cm. NO timeline. Considered prolonged if >24hr (still not abnormal, but consider
maternal energy, options for therapeutic rest include Morphine, Ambien, Benadryl, or Vistaril)
Active Phase
o Cervix is 5-6cm Fully dilated cervix (10cm)
o Admission to hospital at the start of active phase
2
nd
Stage
Pushing
Fully dilated cervix Birth of newborn
3
rd
Stage
Birth of newborn Delivery of placenta
4
th
Stage
Post Partum
Labor Considerations
Mobility? Food/Drink Intake? No Routine IV Continuous Support
Ongoing assessment
FHTs (continuous vs. intermittent based on risk)
EARLY DECALS
Definition Gradual decrease in FHR with onset of deceleration to nadir >30 seconds. The
nadir occurs with the peak of a contraction.
Normal finding, no intervention needed
Due to fetal head compression (baby is stressed during contraction, but can immediately
bounce back once its over)

LATE DECALS
Definition: Gradual decrease in FHR with onset of deceleration to nadir >30 seconds. Onset of
the deceleration occurs after the beginning of the contraction, and the nadir of the
contraction occurs after the peak of the contraction.
Abnormal due to decrease in uterine blood flow or placental dysfunction
Vital signs (q4h)
Contractions (frequency, duration, strength)

Cervical Exams Dilation; Effacement; Station; Fetal position

INTRAUTERINE RESUSCIATION
Goal: Get more oxygenated blood to baby
Stop pitocin (if its running) Contractions limit babys access to placental flow
Maternal position change (left side, hands and knees) Lifts uterus off of the abdominal aorta
Give IV fluid bolus Increases blood volume carrying oxygen to baby
Give mom oxygen via nasal canula or mask Increases oxygen in the blood being carried to baby
Natural Pain Relievers
Freedom of movement; WATER!; Massage, effleurage; Guided imagery, meditation; Breathing techniques;
Therapeutic presence; TENS unit; Sterile water injections; Hot and cold; Back pressure;
Acupuncture/acupressure; Homeopathy; Aromatherapy; Vocalizations; Music; Prayer
Laboring Positions & Birthing Positions

Pharmacologic Options
IV
o Fentanyl
Short-acting synthetic opioid
50-100 mcg every hour
Analgesia and sedation
Rapidly crosses placentafewer body movements between contractions
Newborn effects: respiratory depression (narcan available)
Epidural
o Local anesthetics in epidural space interrupt sensation of pain, touch, movement in nerves as
they enter & leave spinal cord
o Hypotension (maternal position, ephedrine), maternal fever, headache
o Slow cervical dilation, increased second stage, malposition of fetus
Nitrous Oxide
o Widespread outside of US
o No IV, patient controlled
o Less effective than epidural, more potent than opioids
o No known adverse effects on infant
o SE: N&V, light-headedness

2
nd
Stage-Pushing
Multip FAST! 5 minutes up to 2 hours if epidural
Primip ~1-2 hours typically, 3 hrs. if epidural
2 phases
Honor the lull phase
Passive fetal decent
Active pushing effort
Directed vs. physiologic pushing
o Physiologic = less fatigue, perineal injury, fetal acidosis & need for instrument assisted birth
2
nd
Stage-Birth
Keep head flexed until head has emerged, check for nuchal cord, allow head to restitute, downward
traction, upward traction, lift newborn to mother
No routine episiotomies or aggressive vaginal stretching
Newborn dried and stimulated with warm blankets
Baby skin to skin with mom
Clamp & cut cord (FOB?) Delayed
3rd Stage- Placenta
Placental delivery 5-30 min after birth
Wait for detachment
Lengthening of the cord
Uterus rises up, globular shape (Mom may report cramping)
Fresh blood
Guard the uterus and apply gentle traction
Inspect placenta for completeness

Initial Postpartum
Assess:
Vaginal bleeding; Fundal height (at umbilicus; Cramping/Pain; Vitals; Ability to void; Breastfeeding;
Family bonding
Newborn exam Full head to toe including hip dysplasia check + length, wt, head and chest
circumference
Newborn Medications
Antibiotic eye ointment
Vitamin K IM injection
Postpartum
Day 1 and 2 in hospital
Birth Story
Education Warning Signs; Postpartum depression; Exercise; Contraception; 6-8 week in clinic
PE:
o BUBBLE HE: Breasts, Uterus, Bowel, Bladder, Lochia, Episiotomy, Homans Sign, Education
o Abdomen-Diastisis
Labs: Hemoglobin & GDM2 hr glucose at 6 week postpartum
Medications Pain Relievers; Stool Softeners; Iron

INDUCTION
Indications
Safer for baby to be out Non-reassuring fetal status; IUGR; Post term pregnancy (>42wk)- Typically
offered at 41wk
Safer for mom to be done Preeclampsia
Elective (not a true indication)
Risks
Iatrogenic prematurity
Neonatal respiratory problems
Higher use of pharmacologic pain management
Cesarean
Chorioamnionitis
Induction-Bishop Score
Bishop score:
o Multiparous: 5-6unfavorable cx, ripen
o Nulliparous: 7-9
Cervical Ripening AROM; Cytotec; Cervadil; Foley bulb/catheter
Inducing Contractions Pitocin

DELIVERY COMPLICATIONS
CESAREAN
Malpresentation
vertex = normal head down
transverse highest risk of cord prolapse
breech butt down
o frank breech hips flexed, knees extended
o complete breech hips flexed, knees flexed
o footling breech leg extended with foot down either single or double
Fetal Distress
Placenta Previa, Placenta Abruptio
Cord Prolapse
The concern with cord prolapse is that the cord can be stretched during delivery or it can become
compressed between the birth canal and the fetus. Hypoxia is the biggest concern
Size of baby/Shape of Pelvis

PREECLAMPSIA
Goal: Optimize birth timing without incurring maternal or fetal adverse outcomes
Give Magnesium Sulfate
Effective anticonvulsant (NOT treating HTN)
Evaluate Pulmonary edema, urine output, DTRs/Clonus, HTN
Give calcium gluconate if signs of toxicity
S/E: I feel weak, walk like a noodle, and just overall feel gross
Hypertensive Crisis Labetalol, Hydralazine, Nifedipine
Can compromise fetal perfusion, so dont let diastolic BP <90-100
Fluid therapy (Lactated Ringers)

ECLAMPSIA
Preeclampsia onset of generalized, tonic-clonic seizures = eclampsia
Before, during or after birth
2-3% of severe preeclampsia patients
Prodromal symptoms
Care during seizures Prevent injury; Protect airway/prevent aspiration; Oxygenation (O2 by face
mask); Tx severe HTN; Prevent recurrent seizures (give magnesium sulfate); Evaluate for prompt
delivery


CHORIOAMIONITIS
Acute inflammation of the membranes and chorion of the placenta
SXs Maternal Fever: >100.4; Uterine Tenderness; Maternal or Fetal Tachycardia; Foul smelling
amniotic fluid
Management Prompt initiation of antibiotics

SHOULDER DYSTONIA
Maneuvers for resolution
Downward head traction, evaluate if episiotomy is needed
McRoberts (lie on back with knees back) + Suprapubic Pressure (assistant)
Rubins (turn anterior shoulder)
Barnums (reach and pull out posterior arm)
Gaskins (move mom to hands and knees)
Woodscrew and Reverse woodscrew (rotate shoulders so that whatever was anterior is now
posterior, if unsuccessful, rotate back)
Zavonellis (rotate head back into pelvis in preparation for Cesarean RARE)
Increases risk forHypoxic injury; Neonatal resuscitation; Cerebral palsy; Brachial plexus injury;
Increased vaginal laceration; Emotional trauma

POSTPARTUM HEMORRHAGE
**Leading cause of pregnancy related deaths worldwide**
Risk Factors
Tone Uterine atony (#1)- Prolonged or rapid labor, macrosomic fetus, grand multiparity,
chorioamnionitis
Tissue Retained placental fragments
Trauma Cervical or vaginal lacerations, uterine rupture
Thrombin
Dx: Vaginal Birth >500ml EBL; Cesarean >1000ml EBL
Prevention Pitocin given routinely after birth; Routine fundal massage
Management for uterine atony
Uterine massage; Pitocin (IM or IV); Cytotec; Methergine; Bimanual compression


PRENATAL & PERINATAL CARE
EARLY PREGNANCY RISK
SPONTANEOUS ABORTION
MC complication of pregnancy & is defined as the passing of a pregnancy at < 20 wks of gestation. It
implies the spontaneous loss of an embryo or fetus weighing <500g.
Expectant Management
Medication Management Cytotec
Surgical Management D&C
Ongoing Management Monitor serial HCGs
THREATENED ABORTION
Approx 25% of F experience 1
st
trimester bleeding. In most cases, its caused by implantation into
endometrium. 1
st
trimester bleeding has also been associated w/ preterm premature rupture of
membranes & preterm labor. Other causes, such as ectopic pregnancy & molar gestation should also be
considered.
COMPLETE ABORTION
All the products of conception have passed from the uterine cavity & the cervix is closed. Slight bleeding
& cramping may continue for several weeks.
MISSED ABORTION
Pregnancy has been retained w/n the uterus after embryonic or fetal demise. Cramping or bleeding may
be present, but often there are no other sxs. The cervix is closed, & products of conception remain in situ.
INEVITABLE ABORTION
Bleeding w/ cervical dilation, often w/ back or abdominal pain, indicate impending abortion. Unlike an
incomplete abortion, the products of conception have not passed form the uterine cavity.

THIRD-TRIMESTER VAGINAL BLEEDING
ABRUPTIO PLACENTAE:
(Placental abruption) is defined as the premature separation of the normally implanted placenta
from the uterine wall after 20 wks. of gestation but prior to the delivery of the infant.
PLACENTA PREVIA
Low-lying: near the cervical opening
Partial: covers part of the opening
Complete: covers and blocks the cervical opening
Frequently observed earlier in pregnancy, usually resolves
Risk for blood loss for motherc-section
PLACENTA ACCRETA
Part or all of the placenta invade and is inseparable from the uterine wall
Diagnosed by ultrasound
Complications: hemorrhage, hysterectomy
Risk factors: previous c-sections (myometrial damage), maternal age, multiparity
o
1/3 of all antepartum bleeding in the third trimester is due to placental abruption, and it will occur in
1 in 75-225 deliveries. About 1 in 830 abruption ends in fetal demise.
Etiology: Idiopathic/unknown in most cases. It has been linked to several risk factors including:
Mechanical force or trauma (Domestic violence, MVA), maternal hypertension (>140/90) has been
strongly associated, smoking, increasing parity, acquired or inherited thrombophilia, preterm
premature rupture of the membranes and cocaine abuse.
Presentation
Clinical triad (Most placental abruptions will present with the clinical triad-although many will not
fill all 3 of the following categories).
o Fetal distress or fetal death
o Tetanic uterine activity (Contractions)
o Uterine bleeding, external or concealed.
Diagnosis
It is diagnosed retrospectively, evident only when the inspection of the placenta reveals a clot over
the placental bed with disruption of the underlying placental tissue.
Bleeding from vagina, uterine cavity, fetal HR abnormalities & changes in maternal hemodynamic
status.
Treatment


VASA PREVIA

HTN IN PREGNANCY
Normal pregnancy is associated with decreased maternal sensitivity to endogenous vasopressors.
Apparently early in gestation, this effect leads to expansion of the maternal intravascular space and a
decline in blood pressure throughout the first half of pregnancy, with a nadir at midgestation.
Thereafter, continued expansion of intravascular volume leads to a gradual rise in the BP to
prepregnancy levels by term.
Women destined to develop preeclampsia do not exhibit normal refractoriness to endogenous
vasopressors. As a result, normal expansion of the intravascular space does not occur, and the
normal decline in BP during the first half of pregnancy may be absent or attenuated. Despite normal
to elevated blood pressure, intravascular volume is reduced.

PREECLAMPSIA
Hypertension that occurs after 20 wks. of gestation in a F with previously normal BP, systolic BP
>140 mmHg or diastolic BP >90 mmHg on 2 occasions at least 6 hrs apart.
Proteinuria, defined as urinary excretion of >0.3g (300mg) protein in a 24-hour urine specimen. This
finding usually correlates with a finding of 1+ or greater on a dipstick.
Risk Factors MC in young, nulliparous F (Bimodal age distribution Age <20 or >35); Family hx;
Multiple gestatio; Hydatidiform mole; DM, thyroid dz,; Chronic HTN; Renal dz; Collagen vascular dz;
Antiphospholipid dz.
Etiology: Idiopathic/Unknown
Classified into mild or severe based on degree of HTN & proteinuria and the presence of other sxs.
Presentation
Scotomata
Blurred vision
Pain in the epigastrium or RUQ
PE: Brisk patellar reflexes and clonus.
Diagnosis
Diagnosis is based on 2 criteria:
o Elevated maternal blood pressure of
o Proteinuria >300 g in a 24-hour urine specimen.
Laboratory:
o Elevated levels of Hct, lactate dehydrogenase, serum transaminases and uric acid and
thrombocytopenia.
Treatment
Mild Preeclampsia
F with mild preeclampsia are hospitalized for further evaluation and, if indicated, delivery.
If mild preeclampsia is confirmed & the gestational age is 40 wks. or greater, delivery is indicated.
At 37-40 wks., cervical status is assessed & if favorable induction is initiated; If the cervical status is
unfavorable, preinduction cervical ripening agents are used as needed.
F with very unfavorable cervical exams b/w 36-40 wks. may be managed expectantly for a limited
time w/ bed rest, antepartum fetal surveillance and close monitoring of maternal condition including
BP measurement Q4-6 hours & daily assessment of patellar reflexes, wt gain, proteinuria & sxs.
o CBC, lactate dehydrogenase, and uric acid should be checked weekly to twice weekly.
o Delivery is indicated if the cervical status becomes favorable, antepartum testing is abnormal;
the gestational age reaches 40 wks. or evidence of worsening preeclampsia is see.

ECLAMPSIA
Tonic-clonic seizures in a pregnant woman.
Treatment
In most cases eclamptic seizures are self-limited, lasting 1-2 minutes.
The first priorities are to ensure that the airway is clear and to prevent injury and aspiration of
gastric contents.
Diazepam or Lorazepam should be used only if the seizures are sustained.
Nearly all tonic-clonic seizures are accompanied by prolonged fetal heart rate deceleration that
resolves are the seizure has ended.
Once the patient has been stabilized, delivery is indicated.
If possible, a 10-20 minute period of in utero resuscitation should be permitted before delivery.
Convulsions along to not constitute an indication for caesarean section. However, if vaginal birth is
not possible within a reasonable period of time, caesarean delivery is performed in most cases.

HELLP SSYNDROME
Variant of preeclampsia characterized by Hemolysis elevated liver enzymes, and low platelets.
Complicates ~10% of cases of severe preeclampsia and up to 50% of cases of eclampsia.
Presentation RUQ Pain; N/V; Malaise
Diagnosis
Hypertension and proteinuria are variable.
The hallmark of the disorder is microangiopathic hemolysis leading to elevation of serum lactate
dehydrogenase level and fragmented RBCs on peripheral smear.
Transaminase levels are elevated, thrombocytopenia is present and DIC may be evident.
Treatment