Endometrial CA:

-requires Estrogen exposure! Pre-pubertal girls .005% of having endo cancer! old lady highest
risk.

UWISE QBANK:

pt has a bicornuate uterus is at risk for: preterm labor and delivery.

Pregnancy: plasma-osmolarity, SVR = Risk of pulm edema . CO (due to HR SV.)

total T3, T4, and TBG.

FOLIC ACID : .6mg normally 4mg if high risk.

1st trimester tests: CBC, U/A, STDs(chlam/gonor,VDRL,HIV) Hep B, Rubella, PAP,

Blood type (type and screen)

Optional: trisomy 21 test: nuchal translucency, PAPP-A, hCG

2nd trimester: triple or quad screen (15-20 weeks). Confirm w Amniocenti (PAPP-A (alpha
fet), hCG, uEstriol, + Inhibin A).

3rd trimest: 1hr sugar(24-28wks)comfrm w 3hr sugar, CBC, indirect coombs if rh-, GBS(35 37wks)

GROUP B STREP test done at 35-37 weeks. If past pregnAncy complicated with B strep,
dont do test for current pregnancy and just give Abx during birth!

Sequential screen: combined test (1st trimester screen) + quad screen (2nd trimester screen).
Chorionic villus sampling detects karyotype and mutations, not neural tube defects.

AMNIOTOMY- artificial rupture of membranes

Hb electrophoresis is best to detect

Best to detect Parental carrier state. Heme C trait and Thalasemia minor.

blood smear can only ID sickle disease.

NSAIDS are safe until 32weeks gest, when premature PDA clsoure becomes an issue.

Meconium amnio fluid? do nothing! intubate trachea and suction meconium from beneath glottis
immediately after delivery only IF baby is depressed

MISSED ABORTION - fetus dies but mom's body doesnt realize it, so body acts pregnant. If during
suction and currette fatty tissue is noted, stop suction and move to Laparotomy (open surgery) [vs
laparoscopy], you may have mom bowels!!
 UTERINE INVERSION: globular mass at introitus

#1 risk factor is excessive (iatrogenic) traction on the umbilical cord during the third stage of
delivery

#2 risk: Uterine DISTENSION ( Grand multiparity, multiple gestation, polyhydramnios,

macrosomia)

Retained products of conception- causes profuse vag bleeding and can cause sepsis.

Suction and curettage risks: anesthesia; uterine perforation; bowel, bladder or cervical injury.

In pregnancy plasma osmolality is less (as well as SVR) which increases risk of pulm edema.
TOCOLYTICS, specially when given with isotonic fluid can cause lung edema. magnesium sulfate
(also used to avoid eclamptic seizures) and nifedipine (calciumCB) are tocolytics.

Diastolic murmors are always abnormal

MOLAR PREGNANCY metastasizes to lungs so chest xray is appropriate.

weight gain in pregnancy:

10-20lbs if obese

15-25 if overweight

25-35 if normal

30-40 if underweight

cell-free dna screen has the highest detection rates for trisomy 21 and 18. can be done 9weeks!

FETAL SCALP ELECTRODE If the fetal heart rate cannot be confirmed using external methods, then
this is the most reliable way to document fetal well-being.

DECELERATIONS :

early decelerations assoc w Head compression!

Variable - cord compression

Severe variable deceleration hint to placental insuff (fetal acidosis)

late decelerations- Placental insufficiency,

Tachycardia and sign of sinusoidal pattern on the fetus = fetal anemia. suspect placenta
abruption.

Management of bad fetal tracing

Identify nonhypoxic causes that can explain the abnormal ndings. (Most common are
 medications, particularly -agonists or -blockers.)

Begin intrauterine resuscitation as follows:

Discontinue medications (e.g., oxytocin)

Give IV normal saline bolus

Provide high- flow oxygen

Change patients position (left lateral)

Vaginal exam to rule out prolapsed cord

Perform scalp stimulation to observe for accelerations (reassuring)

Prepare for delivery if the EFM tracing does not normalize. Posibly operative vag delivery
or C/S

C/S indicated when: Uterine scar (Prior myomectomy ( fibroid)) or prior classic incision c-section

External Cephalic Version

attempted in patients with transverse lie or breech presentation.

optimum time for external version is 37 weeks gestation, and success rates are 6070
percent.

Both U/S and MRI can be done in pregnancy. If CT-scan had to be done in preg it could be,
specially in 3rd trimester, but it is NEVER the 1st choice.

CHORIOAMNIONITIS: is an intra-amniotic infection that can occur with PREMATURE rupture of

membranes. Mom-fever, painful uterus. fetus-lethargic pale fever; tachycardia and minimal
variability in heart rate are warning signs for Infant sepsis.

Tx. get cervical cultures; then start IV antibiotics; then schedule delivery.

PPROM:

Tx: if contxns dont give Tocolytics

Before viability (< 24 weeks): Manage patient with bed rest at home.

Preterm viability (2433 weeks): Hospitalize. Give IM betamethasone if < 32 weeks. Obtain
cervical cultures. Begin prophylactic ampicillin and erythromycin for 7 days.

34 weeks: Initiate delivery.

ENDOMETRITIS : risks- prolongued rupture of mem, multiple vag exams, C/S.

fever, painful uterus

 Tx. Gentamycin + Clindamycin

Give a positive pressure airway and naloxone to treat NARCOTIC INDUCED CNS or respiratory
depression in newborns. Do not give naloxone if mom has a history of substance abuse.

If mom has HIV treat newborn with Zidovudine (azt) right after delivery, do HIV testing in 24 hours.

4100gr = 9 lbs

UTERINE ATONY

Mcc of postpartum hemorrhage(PPH) PPH= >500ml in vag delivery or 1000ml in C/S.

Risk F:
Anesthesia
Uterine over distention Prolonged labor
Laceration
Retained placenta (can occur with placenta accreta)

Coagulopathy

Tx. Uterine Massage or Uterotonics (oxytocin, methylergonovine, carboprost, Misoprostol).

breast feeding decreases risk of OVARY CA.

Progestin is the only contraception that can be used while breast- feeding. And started right after delivery

Combined hromones- wait 3 wks after delivery to avoid DVT. IUD-wait 6wk

ECTOPIC PREG- The #1 thing that ^ risk is a past ECTOPIC PREG !

absence of an adnexal mass does not rule out ectopic pregnancy.

Unruptured: Methotrexate or salpingostomy

Ruptured: Salpingectomy (Remove tube!!)

by 5 weeks or hCG>1500 an Vag U/S should see baby, if not it may be ectopic. Abd U/S:
6weeks and hCG >6,500

HCG should double every 48hrs until 8 weeks!! use this to find ectopics (which wont double in
48hrs).

CERVICAL INSUFF

SHORT CERVIX BUT NO HX OF 2ND TRIM LOSES: MONITOR

>2 2ND TRIMES L OSES: CERCLAGE AT 14-16 WEEKS

Smoking , alcohol, radiation increase risk of SPONTA ABORTIONS.

 DIABETES:

Normally screen for GESTATIONAL DIABETES between 24 and 28 weeks. but if patient is
obese with Strong family history screen as soon as four weeks!!

Target: Fasting <90 1hr after food <120

Congen Malform assoc w A1c>8.5 in 1st trimester

Gestational Diabetes mostly appears in 3rd trimester! So it doesnt cause cong malf

pre-eclampisa and polyhadramnios are assoc with gestational diabetes.

Routine for diabet mother: check A1c e/trimester, monthly sonos and biophs prof,

Start weekly Nonstress tests and AFI(amnFindx):

At 26weeks if poor sugar contrl

At 32 weeks if using insuling, microsomia, htn

Target delivery is 40weeks (due to delayed fetal maturity)

Induce earlier if poor sugar cntrl OR fetus is >4500g

HTN AND PRECLAMP:

Gestational HTN- must develop after 20weeks!!. Otherwise its chronic HTN

mild preeclampsia = >300 prot and >140bp

severe= >500 prot or >160bp or warning signs (headac, vision chang, pulm edem, oliguria, v
Platelets, ^Liver enz )

Severe preeclampsia remote from term(<32 weeks) you can try expectant management
instead of immidiate C/S only if you DON'T have:

Thrombocytopenia <100,000 , inability to control blood pressure with maximum doses

of two antihypertensive medications, non-reassuring fetal surveillance, liver function
test elevated more than two times normal, eclampsia, persistent CNS

Monitoring:

Serial sonograms (evaluate for [IUGR])

Serial BP monitoring and urine protein

ONLY TX SEVERE HTN >160/100

Maintenance:
 Methyldopa or labetalol: 1st line best, preserves placentl blood f.

2nd line nifedipine (CCB)

Acute tx for severe preclamp or eclamp and during labor:

IV Hydralazine or Labetalol

If PREECLAMPSIA give magnesium during labor and for 24 hours after

MAGNESIUM OVERDOSED can cause respiratory depression, give calcium gluconate.

Magnesium overdose causes loss of deep tendon reflex then respiratory depression and
eventually cardiac arrest. Levels should be <7.

Nulliparity is risk f for preeclamp

Mom w HTN: give Misoprostol! Methylergonovine and Carbopost are C/I in HTN!

HYDROPS FETALIS = fluid in 2 cavities (ascites, pleural effusion, etc..)

Rhogam: at 28 weeks; within 3days after birth; after fetus loss; w amnio, Chorio; w heavy vag
bleeding.

preterm labor cant occur before 20 weeks!

GROWTH RESTRICTIONS

Asymmetric: Uteroplacental insufficiency

Symmetric fetal growth restriction= infxn, congenital dfct, early event of organ prob.

PARTIAL MOLE : part of a mole (not a full mole) cause it has fetal parts and mom genes. the uterus
doesnt enlarge. XXY. hCG doesnt super increase. abd pain.

MASTITIS - if fever remains after Abx or if theres fluctuant mass its an abscess > do drainage

endometrial POLYP includes the following: observation, medical management with progestin,
curettage, surgical removal (polypectomy) via hysteroscopy, and hysterectomy. Observation is
not recommended if the polyp is > 1.5 cm. In women with infertility and Polyps polypectomy is
the treatment of choice.

Rapid growth of a pregnacy looking mass inside uterus: think Leiomyosarcoma

CERVIX:

21-65
 Pap q 3yrs

30yrs can do pap +HPV q 5yrs

Pap with ASCUS: repeat in 12mo or do HPV (HPV pos or repeat pap abnorm= do copolscopy) if
not resume routine.

24yr with ASCUS or CIN 1, 2 : Observe with serial Paps. if u get ASCUS again keep observing
colposcopy performed only if the repeat cytology reveals ASC-H (atypical squamous cell cannot rule out
high grade squamous intraepithelial lesion), AGC (atypical glandular cells) or HSIL (high-grade squamous
intraepithelial lesion).

Women who have a history of cervical cancer, are infected with HIV, have a weakened immune
system, or who were exposed to DES before birth should not follow these routine guidelines.

CRYOTHERAPY and more invasive LEEP are tx for dysplasia, not cancer.

CERVICAL CA when metastatic causes hydronephrosis> flank pain> edema.

Post Coital bleeding is Cervical CA until proven otherwise!

2DRY AMENORRHEA : (= 6 months without periods)

Check: 1-pregnancy, 2-Prolactin, TSH, 3-Progestin challenge, 4-Estradiol, FSH, LH.

Progestin challenge: (oral pills x 7 days)

+ bleeding: its PCOS

Estradiol, FSH, LH:

nl Estradiol = outflow tract problm

Low Estradiol

Low FSH/LH = Hypoth or Pit problm

High FSH/LH= Premature Ovary Failure

ENDOMETRIAL HYPERPLASIA - due to Estrogen. Its an of Glandular (monthly shedding) tissue.

CA risk

young woman with anovolatory cycles can have endometrial hyperplasia (dx with biopsy)

80-90% of women with ENDOMETRIAL CARCINOMA present with vaginal bleeding or discharge.

40s w INTERMENSTRUAL BLEEDING think- endomet hyperplasia, endomet polyp, endome CA,
and Fibroids.

THIRD TRIMESTER BLEEDING: ABRUPTIO, PLAC PREVIA, VASA PREVIA, UTERINE RUPTURE
 Only abruption and uterine rupture are painful bleeding

Place ext fetal monitor, IV fluids, PTT,, U/S to r/o PLAC PREVIA!!

DONT do finger or speculum exam until Placent Previa is r/o

VASA PREVIA: umbilical veins over os. Triad: ROM, painless bleed, fetal bradycard

UTERINE PERFORATION: Sudden onset of extreme abdominal pain

Abnormal bump in abdomen
No uterine contractions, Regression of fetus

1. ENLARGED UTERUS: Pregnancy, Leiomyoma(fibroid), Adenimyosis

a. Leiomyoma
i. ASYMMETRIC, firm, PAINLESS uterus, menorrhagia.

ii. GnRH agonist (Leuprolide) can shrink fibroid temporarily to make surgery easier or
correct anemia.

iii. IF Pregnancy is Desired do MYOMECTOMY (just removing fibroid)

1. C/S all pregnancies after a myomectomy!

iv. Submucosal fibroid causes abortions. Subserosa-blocks ureters.

b. Adenomyosis:
i. SYMMETRIC, soft, PAINFUL uterus, not affected by estrogen.
ii. Tx.
1. Levonorgestrel IUD
2. Hysterectomy- best!
2. PELVIC PAIN: Cervicitis; acute salpingo-oophoritis; chonic PID; tuboovarian abcess
i. WORKUP:
a. Pelvic Exam; Carvical culture; ESR and WBC; Sonogram.
2. Abx: azythromycin and Ceftriaxone for chlam and gono
b. Acute Salpingo-oophoritis
i. Cervical Motion tenderness,
ii. Lower pelvic pain after menses
iii. Dx.
1. + culture, ^^ WBC ^^ ESR
2. r/o abcess with U/S
c. PID
i. Dyspareunia; infertility; hx of ectopic or abnorm bleeding
ii. culture
iii. U/S: bilat cystic masses
 d. Tuboovar abcesses (advanced severe PID)
i. Ill-looking; sever Lower pain; back pain, rectal pain,
ii. ^^ WBC ^^ESR U/S unilat pelvic mass
BREAST:

Fribrocystic disease: PAINFUL, CYCLICAL, COLLAPSES W FNA

Fibroadenoma: PAINLESS, firm, MOBILE
Observation with repeat exam in 68 weeks:
(i) Cyst disappears on aspiration, and the fluid is clear.
(ii) Needle biopsyand imaging studies are negative.
Routine mamography only >50yrs
Mamography as Dx. only after >40yrs
Non bloody discharge: intraductal papill, or CA
Do Lumpectomy unless:
(i) >5cm or 2 sites in diff quadrants
(ii) PREGNANCY
(iii) Prior irradiation of breast

OVARY:

Symple Cyst: (luteal or follicular)

ASYMPTOMATIC
If big can cause torsion so..
Complex Cyst: teratoma (dermoid)
FNA of a complex cyst never correct answer!!!

WORK-UP: for MENSTRUATING Women

hCG
Ultrasound
Laparoscopy/Laparotomy
IF complex or simple thats >7cm
Ovary CA:
ANOVULATORY cycles are PROTECTIVE
WORK-UP: for PRE-pubertal or POST-menopausal women
Ultrasound (and CT for post women)
Biopsy
Tumor markers