CARDIOLOGY

Cardiomyopathy
-A group of diseases of the myocardium associated with mechanical or electrical dysfunction that usually exhibit ventricular hypertrophy or dilation
-Current major society definitions of cardiomyopathies exclude heart disease secondary to CV disorders such as HTN, CAD, or valvular disease
-Etiologies may be genetic, inflammatory, metabolic, toxic, or idiopathic
Type Info Signs & Symptoms Workup Management Prognosis
Dilated Cardiomyopathy: -Common etiologies: viral, -CHF -Treat CHF symptoms
dilation and impaired contraction genetic, alcoholism -Arrhythmias -ICDs
of one or both ventricles -Systolic dysfunction -Sudden death -Eval for transplant
-Exercise intolerance
-Fatigue or weakness
-Dyspnea
Hypertrophic Cardiomyopathy: -Caused by genetic mutations -Varied presentation, may be asymptomatic -Differential: athlete’s -β-blockers to reduce O2 -Annual
disorganized hypertrophy of left -Diastolic dysfunction -CHF heart (physiologic LVH), demand mortality of 1%
ventricle and occasionally right -Usually asymptomatic until -DOE: the most common sx HTN, aortic stenosis -CCB to reduce -May progress
ventricle childhood or adolescence -Orthopnea and PND -Valsalva will increase contractility and improve to dilated
-Athletes with underlying -Exertional chest pain HCM murmur and diastolic relaxation cardiomyopathy
HOCM at greater risk for lethal -Atypical chest pain decrease aortic stenosis -Pacer or AICD
arrhythmia during exertion -Syncope and presyncope murmur -Surgical myectomy,
-May have abnormal SAM -Palpitations -EKG: prominent Q mitral valve surgery, or
movement of mitral valve -Postural hypotension waves, P wave ethanol ablation to
-Fatigue abnormalities, LAD destroy thickened
-Edema -Echo septum
-Arrhythmias -Holter monitor
-Harsh crescendo systolic murmur ± mitral -Exercise stress test
regurg -Screen relatives
-S4
-Displaced apical impulse or thrill
-Sudden death
-Stroke
Restrictive Cardiomyopathy: -Etiologies: scleroderma, -R CHF as pulmonary pressures must increase to -Differential: constrictive
diastolic dysfunction  normal amyloidosis, genetic, HOCM, deliver blood pericarditis
contractility but rigid and stiff DM, chemo, HIV
ventricular walls -Uncommon in US
Arrhythmogenic Right -Genetic cause -Ventricular arrhythmias
Ventricular
Cardiomyopathy/Dysplasia: RV
wall replaced with fibrous tissue
Unclassified Cardiomyopathies -Includes stress-induced
cardiomyopathy and left
ventricular noncompaction

1
 Pregnancy-Induced Hypertension
Signs & Symptoms Management
-Defined as BP > 140/90 after 20th week of pregnancy WITHOUT proteinuria in a previously -Weekly prenatal visits
normotensive woman -Delivery at 37-39 weeks for frequent mildly elevated BPs, or earlier for severe HTN
-No symptoms of preeclampsia, such as HA, vision changes, RUQ pain -Antihypertensives if severe to reduce risk of maternal stroke

Workup Prognosis
-Differentiate from preeclampsia: urine dip for protein may not be 100% reliable, so need to do -Generally favorable, not associated with morbidity and mortality of preeclampsia, however
24 hour urine or spot urine:creatinine women with gestational HTN are at increased risk of developing preeclampsia
-Assess fetal wellbeing with biophysical profile or NST with amniotic fluid estimation -Associated with development of HTN later in life
Deep Venous Thrombosis
Signs & Symptoms
-Palpable cord
-Calf pain
-Ipsilateral edema, warmth, tenderness,
erythema

Workup
-Homan’s is only + 50% of the time
-Determine probability with Well’s criteria  <
2 indicates unlikely, > 6 highly likely
-Further investigation using D-dimer
-US for at least moderate Well’s score

Management
-Immediate anticoagulation with heparin,
LMWH, or fondaparinux
-Lytics or thrombectomy for select cases
-3 months of anticoagulation for initial distal
DVT or consider IVC filter if not a good
candidate

2
 PULMONOLOGY
Pulmonary Embolism
Etiologies Differential Management
-Most arise from LE DVT -Pneumonia -Supplemental O2 if hypoxic
-Stasis: surgery, heart failure, chronic venous stasis, immobility -Infection -Give empiric heparin while
-Blood vessel injury: fractures, surgery -Obstructive lung disease waiting for imaging results
-Hypercoagulability: postpartum, malignancy, OCPs, protein C/S/antithrombin III -CHF (depending on level of suspicion
deficiency, lupus anticoagulant, factor V Leiden, prothrombin gene mutations, -Msk disease as well as timeframe to get test
hyperhomocysteinemia -Acute MI results back)
-Anxiety -IVC filter for repeat clots or
Classification poor anticoagulant candidates
-Massive = sustained hypotension, pulselessness, persistent bradycardia, or need for Workup -Consider lytics for massive PE
inotropic support -D-dimer is only useful if PE is very unlikely! Otherwise risk is too great -Consider surgical embolectomy
-Submassive = pt is normotensive with myocardial necrosis that there will be a false negative for failed or contraindicated
-Minor/nonmassive = normotensive with no myocardial necrosis -PE highly unlikely in ED if pt meets these criteria: age < 50, HR < 100, anticoagulation or lytic therapy
SpO2 ≥ 95%, no hemoptysis, no estrogens, no prior h/o DVT or PE, no -Can be managed outpatient for
Signs & symptoms unilateral leg swelling, no surgery or hospitalization in past 4 weeks select stable patients with no
-Onset does not have to be sudden! -ABG if respiratory distress present: will usually show respiratory comorbidities
-Dyspnea, pleuritic or anginal chest pain, cough, wheezing alkalosis, overall not very useful in diagnosing PE -Continue outpatient
-Leg swelling or pain -Troponin anticoagulation for at least 3
-Hemoptysis -EKG sometimes shows S1Q3T3 months
-Palpitations, syncope -Troponins: May be + in moderate to large PEs from acute R heart
-Tachycardia and tachypnea, loud P2 from pulmonary HTN overload Prognosis
-Diaphoresis -May have concomitant DVT detected by US -30% are fatal without treatment
-Fever -CXR may show edema, cardiomegaly, prominent pulmonary vein, left -Less than 10% mortality if
-Homan’s sign sided pleural effusion, or atelectasis treated by anticoagulation
-Orthopnea -VQ scan, spiral CT pulmonary angiography (test of choice), or
-↓ Breath sounds pulmonary angiography (gold standard but hi morbidity, requires femoral
-JVD cath)
-“Massive PE”  hypotension -Pregnant? VQ scan vs CTA and radiation dose is debated

-Carb intolerance induced by human placental lactogen
-Occurs in 3-5% of all pregnancies
-Classification via White’s classification (A1 = nutritional controlled;
A2 = insulin requiring
Screening
-Oral glucose tolerance test administered at 28 weeks, when HPL
begins to have most effect
-Positive results followed up with 3 hour glucose tolerance test
ENDOCRINOLOGY
Gestational Diabetes
Management
-Diet + exercise, insulin if needed (preferred over orals)
-BG monitoring 4x daily, with goal FBG < 95 and 1 hour postprandial BG < 130
-Early NSTs with amniotic fluid index for fetal monitoring of insulin-requiring mothers d/t higher rates of placental
insufficiency, with biweekly NSTs after 32 weeks for type A2
-Single 3rd trimester US to screen for macrosomia
-Deliver by 40 weeks or earlier if fetus is nearing 8.8 lb
-Rescreen mother at 6 weeks postpartum for glucose intolerance
Prognosis
-Increased risk of having DM postpartum, as well as preeclampsia, bacterial infection, macrosomia, neonatal complications,
polyhydramnios, preterm labor, and ketoacidosis
-Child will be predisposed to developing DM later in life
3

-Highly genetic predisposition
Signs & Symptoms
-Oligomenorrhea
-Hyperandrogenism  acne, hirsutism, male-pattern hair
loss, DUB due to endometrial hyperplasia
-Obesity
-Glucose intolerance
-Dyslipidemia
-OSA
-NASH
Subacute Thyroiditis
-AKA de Quervain’s thyroiditis
Causes
-Radioiodine therapy
-Viral or infectious cause
-Trauma
Signs & Symptoms
-Painful thyroid, neck pain, or
goiter
Workup
-TSH, free T3 & T4, ESR
-Radioiodine imaging (uptake
will be low)
Management
-Pain control with NSAIDs or
prednisone if refractory
-Monitor thyroid panel every 2-8
weeks to confirm resolution of
thyroid imbalance and
normalization of function
-β-blockers for palpitations
Polycystic Ovarian Syndrome
Workup Management
-Diagnose with 2/3 Rotterdam -Weight loss and exercise
criteria: oligomenorrhea, -Follow fasting lipids and glucose regularly
hyperandrogenism, polycystic -Assess for depression, eating disorders, and sleep apnea regularly (hi prevalence in this
ovaries on US population)
-Also can check total testosterone -Fertility evaluation if desired
-Rule out other causes of irregular -Hirsutism and other androgenic symptoms  OCPs, adding spironolactone later if needed (has
menses: bHCG, prolactin, TSH, antiandrogenic effects)
FSH -Endometrial protection against hyperplasia  OCPs or intermittent progestins to induce bleeding
-Glucose intolerance  metformin especially helpful if infertility also present
-Infertility  weight loss, consider clomiphene
Thyroiditis
Painless Thyroiditis Acute (Suppurative) Riedel’s (Fibrous)
Thyroiditis Thyroiditis
Causes -Rare! Signs & Symptoms
-Usually autoimmune: Hashimoto’s (aka chronic lymphocytic thyroiditis) or a variant, can be postpartum -Painful, stony, hard
-From exposure to drugs like Li Cause thyroid
-Precipitating factors: infection, stress, sex steroids, pregnancy, iodine intake, and radiation exposure -Suppurative bacteria -Dysphagia
-Dyspnea
Signs & Symptoms Signs & Symptoms -Hoarseness
-Painless thyroiditis; typically involves 2-6 weeks of hyperthyroidism followed by transient -Painful, red, tender
hypothyroidism, then euthyroid thyroid Management
-Postpartum presentation can occur up to 1 year after giving birth and has a longer course than typical -Short-term steroids
painless thyroiditis Management -Long-term tamoxifen
-Hashimoto’s typically causes a goiter -Antibiotics therapy
-Surgical drainage if
Workup needed
-TSH, free T3 & T4
-Differentiate from Grave’s disease with technetium scan or radioiodine uptake scan
Management
-Monitor thyroid panel every 2-8 weeks to confirm resolution of thyroid imbalance and normalization of
function
-β-blockers for palpitations
-Hyperthyroid phase is generally mildly symptomatic and does not require treatment
-Treatment of symptomatic hypothyroid phase with thyroxine
Prognosis
-May have recurrent episodes
-20% develop permanent hypothyroidism
4

Differential
-Infection: UTI, hepatitis, meningitis, gastroenteritis,
appendicitis, cholecystitis, pancreatitis
-Other GI: PUD, fatty liver, SBO
-Metabolic: thyrotoxicosis, Addison’s disease, DKA,
hyperparathyroidism
-Drugs: antibiotics, iron supplements
Signs & Symptoms
-Severe vomiting in pregnancy with dehydration and weight loss
GASTROENTEROLOGY
Hyperemesis Gravidarum
Management
-Diet changes: avoid spicy, fatty, or odorous foods, taking multivitamin with folate
-Lifestyle changes: frequent naps, shortening work day
-CAM: acupressure, ginger
-Initial pharmacologic therapy with pyridoxine + doxylamine
-Add antihistamine or 5HT3 agonist if needed: Benadryl, meclizine, Dramamine, Zofran
-Add dopamine agonist if needed: Compazine, Reglan
-Glucocorticoids only for refractory cases after the 1st trimester
-Hospitalization with IVF + thiamine for dehydration
-Enteral or parenteral nutrition may be required

Workup Prognosis
-UA -Symptoms typically resolve by midpregnancy
-Labs: CBC, CMP, thyroid panel -Infants of others who gain less than 15 lb during pregnancy tend to be of lower birth weight, small for gestational age, and preterm
-No significant difference in neonatal mortality rate between infants born to mothers with hyperemesis gravidarum compared to
other mothers

GENITOURINARY
Dysfunctional Uterine Bleeding
-Bleeding outside normal parameters of menses (24-35 days, < Differential Workup Management
80 mL per cycle) found in the absence of demonstrable -Abnormal uterine -A diagnosis of exclusion -Treat underlying cause if due to abnormal
structural or organic pathology that is unrelated to another bleeding (known -Pregnancy test uterine bleeding
underlying illness pathology): miscarriage, -Malignancy workup if postmenopausal -Adolescent mild DUB can be treated with iron
-Classified as ovulatory or anovulatory gestational trophoblastic -Coagulopathy workup: PT/aPTT, CBC, supplements and observation
-Some providers consider DUB to be a subset of abnormal disease, IUD, meds, -Assess ovulatory status: biphasic body temp, -Adolescent mod-severe DUB can be treated
uterine bleeding trauma, coagulopathy, progesterone levels, urine LH with OCPs or progestin only regimen
adrenal disorder, stress, -Pelvic exam with pap -Patients with contraindication to estrogen
Causes pituitary adenoma, -May need endometrial biopsy or hysteroscopy therapy can consider symptomatic management
-Usually a hormonal disturbance: menopause, premature smoking, infections, -Consider US evaluation for fibroids, polyps, or with NSAIDs, progestin-only regimen, or
ovarian failure, PCOS, prolactinoma, anovulation, immature HP fibroids, malignancy, adenomyosis Mirena IUD
axis (adolescents), perimenopause atrophic vaginitis -Consider testosterone and DHEAS levels in -Endometrial ablation an option for women not
-Anovulation causes DUB b/c there is no corpus luteum women with signs of virilization wishing to conceive (although will still need
formation  no progesterone to oppose estrogen-induced contraception)
hyperplasia of the endometrium -Hysterectomy is the definitive treatment

5
 Endometriosis & Adenomyosis
Endometriosis Signs & Symptoms Workup
-Location of endometrial tissue any place outside of the uterus -Endometriosis typically occurs in young, tall, thin, -US or MRI
-May be caused by retrograde menstruation, where sloughed off nulliparous Caucasian women -Laparoscopy for definitive diagnosis (implants will have variable
endometrial tissue escapes through the fallopian tubes to implant -Adenomyosis typically occurs in women ages 40-50 coloration and appearance)
outside of uterus -Associated with early menarche and late menopause
-Could also be caused by Mullerian cell remnants, direct surgical -May be asymptomatic Management
transplantation, altered immune response, genetics, or increased -Dysmenorrhea -Endometriosis improves with suppression of ovulation and medical
estrogen stimulation -Dyspareunia therapy is first line: OCPs, NSAIDs for cyclical pain, GnRH
-Usually occurs in the pelvis, but can occur in the ovary, cul de -Pelvic pain agonists for severe pain (create a hypoestrogenic state)
sac, uterine ligaments, fallopian tubes, bladder, rectum, bowel -Sacral backache -Surgical excision for failed medical management
cervix, vagina, omentum, umbilicus, vulva, ureter, spinal cord, -Pelvic mass -Adenomyosis is treated with hysterectomy
nasopharynx, breast, lung, and kidney -Tenesmus and diarrhea with painful BMs
-Urinary frequency Prognosis
Adenomyosis -Infertility -Associated with epithelial ovarian cancer but NOT endometrial
-Endometriosis within the uterine muscle -Lateral displacement of cervix or stenosed os cancer
-Recurrence is common
Pelvic Organ Prolapse
-Herniation of pelvic organs to or beyond the vaginal walls Signs & Symptoms Workup Management
-Can be a cystocele, rectocele, enterocele, uterus, vaginal vault, fibroid -Feeling a bulge or something falling out -Pelvic and rectovaginal exam to -No treatment needed if
-Classified via the Pelvic Organ Prolapse Quantitation system of vagina determine location and source of asymptomatic
-Urinary, defecatory, or sexual dysfunction prolapse -Symptomatic prolapse may be
Risk Factors -Neuromuscular exam: treated conservatively (pessaries or
-Multiparity bulbocavernosus and anocutaneous Kegels) or surgically
-Advancing age reflexes, sharp/dull touch, strength
-Obesity
-Hysterectomy
-Chronic constipation
-Heavy lifting
Cervicitis
Etiologies Signs & symptoms Workup
-Infectious: chlamydia, gonorrhea, HSV, HPV, trichomoniasis, -Postcoital spotting -STI testing
Mycoplasma genitalium, CMV, BV -Intermenstrual spotting -Wet prep
-Noninfectious: cervical cap, pessary or diaphragm use, -Dyspareunia -Pap & pelvic
chemical or latex allergy, cervical trauma -Unusual vaginal discharge
-If chronic  cervical stenosis, leukorrhea, granular redness, Treatment
erythema, vulvar irritation -Chlamydia  single azithromycin dose, or doxycycline
-Salpingitis -Gonorrhea  ceftriaxone IM or single cefixime oral dose
-Edematous or friable cervix -HSV  acyclovir
-Trichomoniasis  single metronidazole

6
 Cervical Dysplasia

-After HPV infection, epithelia can develop active or latent infection or undergo neoplastic
transformation
-HPV types 16 and 18 are more likely to undergo malignant transformation
-Most women will clear HPV infection within 2 years
-CIN = cervical intraepithelial neoplasia (aka cervical dysplasia); premalignant squamous
transformation cells (not glandular)
-Bethesda system: ASCUS, LSIL, or HSIL
-Women over 30 who are being screened no more frequently than every 3 years will have HPV
testing done automatically with their cytology

Screening
-Begin at age 21 or within 3 years of first sexual contact
-Every 3 years if low risk with 3 consecutive normal paps
-D/c after age 65 if last 3 paps were normal
-Women who have had a total hysterectomy for benign reasons do not need paps

Management
-Differs based on age of patient, as younger women tend to clear the infection before progression to
dysplasia
-If ASCUS is detected, specimen will be tested for HPV as well if woman is over 21, or repeat
cytology in 6 months if woman is under 21
-LSIL or HSIL or AGC will need referral for colposcopy, where biopsies will be taken
-Biopsies give corresponding histology grade of CIN 1, 2, or 3
-CIN 1 generally observed or may be ablated (cryotherapy or laser)
-CIN 2 or 3 have 5-15% chance of progressing to cervical cancer and these lesions need to be
excised via LEEP or conization procedure (↑ risk of preterm labor in future pregnancies)

7
 Incompetent Cervix (Cervical Insufficiency)
-Painless cervical changes in the 2nd trimester leading to recurrent pregnancy Screening Workup Management
loss, stillbirth, or preterm delivery -UpToDate recommends routine TVUS screening for -Transvaginal US showing -No evidence for bedrest
-Short cervix is defined as < 25 cm from external to internal os short cervix in singleton pregnancies at 16-28 weeks shortened endocervical -Progesterone supplements
canal and funneling of -Indomethacin
Causes Signs & Symptoms fetal membranes into -Prophylactic cerclage or
-Congenital: short cervix, Mullerian abnormalities, collagen abnormalities, -Vaginal fullness or pressure endocervix pessary
FH -Spotting or watery or brown discharge -Early US surveillance for
-Trauma: cervical laceration, instrument dilation, cone biopsy, LEEP -Vague abdominal and back pain women not meeting criteria
-Elevated serum relaxins (higher in multiple gestations) -Premature cervical effacement and dilation for cerclage
Vaginitis
Etiology Bacterial vaginosis Trichomoniasis Yeast vaginitis Atrophic vaginitis
Info -Polymicrobial overgrowth of normal flora -Usually sexually transmitted -Agent is Candida albicans -Inflammation of the vagina due to
-May be ppt by hormonal changes, thinning and shrinking of tissues and
oral steroids or abx, nylon panties, decreased lubrication
hot weather, obesity -Seen in women with decreased
estrogen
Signs & -Fish odor -Copious vaginal discharge -Pruritus -Pruritus
symptoms -Heavy bubbly discharge that is white or gray -Pruritus -Burning -Burning
-Dysuria -Nonfoul cottage cheese discharge -Vaginal dryness
-Dyspareunia -Dyspareunia -Dyspareunia
-Abdominal pain -Vaginal or vulvar erythema -Spotting
-Vaginal and cervical inflammation -May be asymptomatic -Pale, thin vaginal mucosa
with punctate hemorrhages =
strawberry cervix
Workup -Wet prep: clue cells, alkaline pH -Wet prep: look for motile -KOH wet prep -Must r/o infectious cause
-Whiff test trichomonads -Negative wet prep
Treatment -1st line is metronidazole or clindamycin cream -Single dose of metronidazole -Single dose of butoconazole or -Estrogen replacement therapy
fluconazole -Regular sexual activity
-1st trimester pregnancy use -Lubricants and vaginal moisturizers
8
 itraconazole
-OTC Monistat only treats Candida
albicans and not other 2 species
Picture

Dysmenorrhea
Primary = painful menses with normal anatomy Secondary = a result of disease or pathology
-Leading cause of school absences Causes
-Incidence decreases after age 20 -GYN: endometriosis, uterine fibroids, adenomyosis, STIs, endometrial polyps, ovarian
cysts, pelvic adhesions, chronic PID, cervical stenosis
Cause -Non-GYN: IBD, IBS, uteropelvic junction obstruction, psychogenic
-Usually prostaglandins and uterine vasoconstriction
Signs & Symptoms
Signs & Symptoms -Usually begins well after menarche
-Cramping pain radiating to back or inner thighs
-May have associated heavy flow, n/v/d, HA, dizziness Workup
-Refer for laparoscopy
Management
-NSAIDs beginning 1-2 days before expected menses Management
-OCPs -Treat underlying cause
-Progesterone -NSAIDs
-Mirena IUD -OCPs
-Acupuncture -IUD
-Thiamine supplementation -Refer to OB-GYN for uterine artery embolization and evaluation for hysterectomy
Breast Cancer
-Usually arises from ducts or lobules Screening Workup
-Most commonly diagnosed female cancer -Mammography is USPSTF grade C for women 40-49, grade B for women 50- -Biopsy of suspicious lesion
-Only 5-10% are due to genetic mutations 74 every 2 years -Pathology and genomic marker assay
-Clinical breast exam
Risk Factors
-Obesity or inactivity -Breast self exam is USPSTF grade D Management
-Use of hormone therapy -Dedicated breast MRI for high risk populations -Women with high risk can consider chemoprevention with
-Nulliparity tamoxifen or raloxifene
-First birth after age 30 Signs & Symptoms -Chemo is typically 3-6 months and is initiated for visceral
->1 alcoholic drink per day -Early: single, nontender firm mass with ill-defined margins or possibly no mets, failed endocrine therapy, or ER-/PR- tumors
-Not breastfeeding palpable mass but an abnormality is detected on mammogram -Endocrine therapy with tamoxifen (premenopausal)or
-Increasing age -Later: skin or nipple retractions, axillary adenopathy, breast enlargement, aromatase inhibitors (postmenopausal)
-White
erythema, peau d’orange, edema, pain, fixation of mass to chest wall -Surgical: breast-conserving vs mastectomy
-Hx of chest irradiation
-Hx of atypical hyperplasia on previous biopsy -Very late: ulceration, supraclavicular adenopathy, arm edema, mets to bone, -Radiation therapy as an adjuvant
-FH of breast cancer or inherited mutations liver, lung, or brain

9
 Breast Cancer Type
Ductal Carcinoma in Situ
Invasive Ductal Carcinoma
Lobular Carcinoma in Situ
Invasive Lobular Carcinoma
Medullary Carcinoma
Comedocarcinoma
Paget’s Disease of the Breast
-Common benign neoplasm in young women
composed of fibrous and glandular tissue
Info S/S Management
-Arises from ductal hyperplasia and fills ductal lumen -Typically asymptomatic -Lumpectomy followed by
-Very early malignancy without basement membrane penetration and discovered on radiation is most common
-Less than 30% recurrence rate following lumpectomy screening mammogram as -Tamoxifen or aromatase
calcifications inhibitor therapy for 5 years if
receptor+ tumor
-The most common breast cancer -Pt is typically -Chemo with Herceptin and
-Worst and most invasive postmenopausal Tykerb for HER2+ tumors
-Mammogram detects
spiculated margins
-Firm, fibrous, rock-hard
mass with sharp margins
and small, glandular, duct-
like cells
-Contains signet ring cells
-2nd most common breast cancer -Orderly row of cells in -Assessment with US preferred
stroma that are fluid and over mammography
mobile
-Often bilateral
-Fleshy, cellular, lymphocytic infiltrate -Mammogram detects
-Good prognosis although it is a rare subtype of invasive ductal carcinoma linear crystallization
pattern
-Subtype of DCIS
-Ductal caseating necrosis
-Subtype of ductal carcinoma -Presents as eczematous
lesions on the nipple
-May also be seen on the
vulva
Fibroadenoma
Signs & Symptoms Workup Management
-Pt is usually in teens to 30s -Consider malignancy or fibrocystic changes in -Observation if malignancy has been ruled out
-Firm, round, nontender, mobile 1-5 cm nodule women > 30 -Surgical excision if unable to r/o malignancy
that is solitary and unilateral -US for younger women or if large
-Growth is hormonally affected and can be -FNA or needle biopsy for confirmatory
rapid during pregnancy diagnosis Prognosis
-Can recur after excision
10
 Vulvar Neoplasia
-Vulvar intraepithelial neoplasia (VIN) is a Differential Workup
premalignant lesion that is difficult to distinguish or -Flesh-colored lesion: sebaceous gland, vestibular papillae, -Any lesion not previously known on the vulva warrants biopsy via physical
may exist in association with invasive squamous skin tag, cyst, wart, molluscum contagiosum exam or colposcopy
cell carcinoma, lichen sclerosus, or lichen planus -White lesion: lichen sclerosus, lichen simplex chronicus,
-Malignant lesions include squamous cell vitiligo Management
carcinoma (90% of vulvar cancers), melanoma, and -Brown, red, or black lesion: could be anything, need to -Wide local excision of VIN if high risk based on lesion characteristics and pt age
basal cell carcinoma biopsy -Laser ablation or topical therapy with imiquimod for VIN lesions that would
cause significant vulvar mutilation if excised
Risk Factors Signs & Symptoms -Excision of malignant lesions with inguinofemoral lymph node evaluation ±
-HPV infection -Vulvar pruritus chemo or radiation
-Immunosuppression -Visible or palpable abnormality, may be in multiple
-Cigarette smoking locations Prognosis
-Lichen sclerosus (can transform to SCC) -Pain -VIN recurs in 30% of women and 4-8% will go on to develop locally invasive
-Dysuria vulvar cancer
Leiomyomas (Uterine Fibroids)
-Benign tumors arising from the myometrium Signs & Symptoms Workup
-Varying locations -Dysmenorrhea and AUB -TVUS is diagnostic
-Menorrhagia and possible subsequent anemia -Consider malignancy workout with rapid growth
Risk Factors -Dyspareunia
-Black -Urinary frequency Management
-Obese -Infertility -Only if symptomatic or pursuing pregnancy
-Over age 40 -Irregular feeling uterus -Surgical myomectomy (should be hysteroscopic if desiring future pregnancy)
-Nulliparity -Abdominal mass -Hysterectomy only for extremely large, painful fibroids with intractable bleeding
-Bloating -Mirena IUD or Depo injections to reduce bleeding
Protective -Pelvic pain or pressure or feeling of fullness -Menopause-mimicking agent such as ulipristal
-Multigravida -Acute pain with torsioned pedunculated -Uterine artery embolization to starve off fibroids
-Postmenopausal fibroid -Consider shrinking large fibroids with GnRH agonists prior to surgical removal
-Smoker -Miscarriage with submucosal fibroids
-Prolonged OCP use intruding on fetus Prognosis
-Depo use -Can be asymptomatic -Not associated with malignant transformation
-Symptoms improve after menopause
Ovarian Neoplasia
-Vary from annoying and benign to invasive and malignant Malignant Ovarian Neoplasms Signs & Symptoms Management
-Functional ovarian cysts (corpus luteum cyst or follicular cysts) are NOT -Adenocarcinoma -Thyrotoxicosis with dermoid tumor -Malignancy: local excision vs
considered to be neoplasms because they are a result of a normal physiologic -Granulosa cell tumor -Torsioned ovary or cyst  signs of acute abdomen total hysterectomy and bilateral
process -Dysgerminoma
-Malignancy symptoms are nonspecific like pelvic SO vs partial bowel resection
-Ovarian neoplasms are derived from neoplastic growth of ovarian cell layers -Clear cell carcinoma
-Endometrioid carcinoma pain and bloating depending on stage of cancer,
Benign Ovarian Neoplasms usually followed by radiation ±
-Mucinous cystadenoma Risk Factors Workup chemo
-Serious cystadenoma -Nulliparity -Transvaginal US: signs indicative of malignancy -Benign neoplasms will persist
-Endometrioma (chocolate cyst) -Fertility treatments include large amounts of free fluid in the abdominal unless excised, which is usually
-Fibroma -FH of breast or ovarian cancer cavity, solid ovarian enlargement or mixed cystic done to prevent ovarian torsion
-Brenner tumor and solid enlargement, thick-walled or complex -Simple cysts in a
-Thecoma Protective Factors
ovarian cysts postmenopausal woman may be
-Sertoli-Leydig cell tumors -Prolonged OCP use
-Dermoid cyst (teratoma): can contain hair, teeth, sebaceous glands, and thyroid -Pregnancy -Serum CA-125: will also be elevated in infection, followed by serial US and CA-
cells producing TH -Tubal ligation or hysterectomy endometriosis, ovulation, and trauma 125s
-Uterine leiomyoma -Staging and grading of malignancies

11
 Endometrial Neoplasia
-Endometrial neoplasia involves proliferation Signs & Symptoms Workup Management
of the endometrial glands that can progress to -Abnormal uterine bleeding -Endometrial biopsy can be done in clinic and -Benign pathology on biopsy watched, no
or coexist with endometrial carcinoma -Postmenopausal bleeding is 99.6% sensitive in premenopausal women action warranted unless bleeding persists
-Endometrial carcinoma is the most common -Abnormal pap cytology and 91% in postmenopausal women -Endometrial hyperplasia on pathology without
GYN cancer in the US and is usually -Transvaginal US to assess endometrial stripe: atypia is treated with progesterone cream,
adenocarcinoma Differential for Postmenopausal Bleeding thin stripe < 4-5 mm associated with low risk ovulation induction, or IUD to induce massive
-Atrophy (59%) of cancer while stripe > 5 mm warrants biopsy menses and endometrial sloughing
Risk Factors -Endometrial polyps -Atypical endometrial hyperplasia needs D&C
-Age > 50 -Endometrial cancer or hysterectomy + BSO
-Uopposed estrogen use -Endometrial hyperplasia
-PCOS -Hormonal effects
-DM -Cervical cancer
-Obesity
-Nulliparity
-Late menopause
-Tamoxifen use
-HNPCC
Menopause
Climacteric = a phase in women transitioning from a Signs & Symptoms Workup Management
reproductive state to a non-reproductive state; includes -Begin up to several years before cessation of menses and -Diagnosis is usually clinical -Dressing in layers, avoiding food
perimenopause as well as a time before and after can last for 2-9 years after menopause -FSH > 35 is diagnostic (FSH triggers, regular exercise
-Dry hair and mouth, facial hirsutism is ↑in response to low -Estrogen replacement therapy for
Perimenopause = ~4 years before menopause when -Menstrual irregularlity, postcoital bleeding, intermenstrual estrogen) moderate to severe symptoms of
cycles become irregular and there are increased spotting -Check TSH if there are vasomotor instability: use lowest dose
climacteric symptoms -Loss of adiposity and collagen in vulva, loss of protective symptoms of hyperthyroidism for shortest amount of time possible
covering of clitoris, thinner vaginal surface, vaginal dryness -For women under 45, do -Vaginal moisturizers and lubricants for
Menopause = time during cessation of menses for 1 year; and atrophy, genital itching or burning, dyspareunia, pale or oligo/amenorrhea workup: vaginal atrophy symptoms, may need
can be natural due to loss of ovarian estrogen activity, shiny vaginal epithelium with loss of rugae, spare pubic hCG, prolactin, TSH, FSH vaginal estrogen
induced via surgery or radiation, temporary due to diet or hair, introital stenosis, fusion of labia minora, pelvic organ -Women under 40 need -SSRIs
GnRH therapy, premature if before age 40, or late if after prolapse, vulvar dermatoses, stress incontinence, urinary comple premature ovarian -Biofeedback
age 55 frequency, decreased libido failure workup -Acupuncture
-Hot flashes, vasomotor instability, sleep and mood
Postmenopause = time following cessation of menses for disruptions
1 year -Reduced breast size and loss of ligamentous supports

-Average age of natural menopause in US is 51.4 years

12
 Amenorrhea
Primary Amenorrhea Secondary Amenorrhea
-Failure to menstruate by age 16 in presence of Workup -Cessation of menses for a period of time = to Workup
2˚ sex characteristics or failure to menstruate -Physical exam for sex characteristics and 3 cycles or 6 months in a woman who -Physical exam for hirsutism, acanthosis
by age 14 in absence of 2˚ sex characteristics normal anatomy (breast development indicates previously had menses nigricans, vitiligo, galactorrhea, and signs of
estrogen effects and functioning ovaries) estrogen deficiency or eating disorder
Etiologies -US to look for presence of uterus Etiologies -Serum hCG, FSH, LH, PRL, TSH,
-Chromosomal abnormality  gonadal -FSH level to determine whether cause is -Pregnancy progesterone, ?DHEAS (false negs)
dysgenesis central or ovarian -Functional hypothalamic amenorrhea: -Serum total testosterone with signs of
-Central: tumors, infiltration of hypothalamus -Karyotype if breast development not present excessive exercise, eating disorder, systemic hyperandrogenism
or pituitary, congenital GnRH deficiency, -Normal FSH, signs of breast development, illness, psychological stress -Other workup based on clinical findings
hypoprolactinemia, disrupted GnRH pulsations and presence of uterus indicate further workup -Hyperprolactinemia: pituitary tumor,
-PCOS for secondary causes of amenorrhea medications, hypothyroidism Management
-Anatomic abnormality or absence of uterus, -PCOS -All depend on desire for fertility
cervix, or vagina Management -Premature ovarian failure -Hypothalamic amenorrhea: sufficient calorie
-Treat underlying pathology -Endometrial scarring (Asherman’s) intake, CBT, leptin administration
-Achieve fertility if desired -Hyperprolactinemia: dopamine agonist or
-Prevent complications of disease process surgical treatment
-Premature ovarian failure: OCPs to prevent
bone loss
-PCOS treatment
-Hysteroscopic lysis of intrauterine adhesions
remenstrual Syndrome
-More severe form is premenstrual dysphoric disorder Workup Management
-PMDD defined by 5+of the following: sadness, despair, suicidal -Exercise
Signs & Symptoms ideatio, tension, anxiety, panic attacks, irritability affecting others, -Regular sleep
-Symptoms begin with ovulation and last 2 weeks until menses mood wings, crying, disinterest in daily activities, binge eating, -Stress management
-Acne, breast swelling, fatigue, GI upset, insomnia, bloating, cravings -Healthy eating habits
HA, food cravings, depression, anxiety, irritability -Avoiding caffeine, sugar, and salt
-OCPs for severe symptoms
-Consider antidepressants or counseling for PMDD
Fibrocystic Breasts
-The most common benign condition of the Signs & Symptoms Workup Management
breast -Patients are usually ages 30-50 -Differentiate from fibroadenoma or -Counseling to wear supportive bra
-Uncommon in postmenopausal women unless -Pain or tenderness in the breasts malignancy by the presence of multiple -Avoiding trauma and caffeine
on HRT -Cysts or multiple transient lumps that are firm, transient lesions -Danazol for severe persistent pain
mobile, and tender -Further workup via US or mammogram -Evening primrose oil
-Changes are related to menstrual cycle and indicated for lesions that persist throughout
can be worsened by caffeine menstrual cycle

13
 Pelvic Inflammatory Disease
-Inflammation of the uterus, Signs & Symptoms Workup Management
fallopian tubes, and/or ovaries, -Pelvic or abdominal pain -Testing for GC, Chlamydia, -If no other cause of pelvic or abdominal pain can be found in a sexually active
and possibly surrounding pelvic -Painful defecation HIV, hep B, syphilis woman at risk for STIs, always treat for PID
organs -Abnormal vaginal bleeding -Cervical cultures -Begin antibiotic before cultures come back
-Usually polymicrobial, with -Dyspareunia -hCG -Admit for inpatient management if there is pregnancy, nonresponse to oral
STIs + endogenous organisms -Uterine, adnexal, or cervical motion -Pelvic US if concern for antibiotics, inability to take PO, severe illness, or tubo-ovarian abscess
tenderness abscess -Outpatient treatment of mild-mod PID: ceftriaxone IM + doxycycline
Risk Factors -RUQ pain (from perihepatitis) -CBC -Inpatient treatment of severe or complicated PID: IV cefoxitin + PO doxycycline
-Multiple sex partners -Signs of STI infection -UA -Treat partners
-Douching
-Smoking Prognosis
-Risk for infertility increases with each episode
Mastitis
Agents Workup Management
-Staph aureus, increasingly MRSA -Malignancy workup if occurring in a non-lactating -Continue breastfeeding or pumping
woman -Ibuprofen
Signs & Symptoms -US to differentiate from abcess if needed -Cold compresses
-Usually unilateral -Oral dicloxacillin, 1st generation cephalosporin, or erythromycin if not
-Fever and flulike symptoms suspecting MRSA
-Erythema, warmth, tenderness, and hardness of affected -Severe infection with MRSA risk  Bactrim, clindamycin, or linezolid
breast
Contraceptive Methods
Misc. Methods Info Failure Rate Cost
Withdrawal 4-27%
Fertility Awareness -Includes rhythm method, natural family planning, and symptothermal method 9-25%
-Based on consistent symptoms of ovulation
-Effective if regular cycles
-Must be committed, motivated, vigilant
-Control of fertility
-No chemicals, hormones or foreign objects
-Inexpensive
-Accepted by religious organizations
-Use alternate methods or alternate forms of pleasure during ‘unsafe’ days
-Decreases spontaneity
-Unreliable if irregular cycles
-Perimenopausal years more difficult
Barrier Methods Info Failure Rate Cost
Spermicide -Only kind available in US is nonoxyl-9 10-29% $0.50-$1.50 per application
-Natural alternatives: lemon juice, vinegar, neem oil
-Comes as a vaginal film, suppository, cream, gel, or lubricant
-No STI protection, can acually cause allergies an irritation  ↑ risk of STIs
Cervical Cap -Silicone cap filled with spermicide 7.6-14% $89 + exam & fitting
-Only kind approved in US is the FemCap (others associated with abnormal paps) Free for insured under new ACA
-Requires prescription and fitting legislation
-Can be inserted up to 24 hours before sex and worn for up to 48 hours
-No STI protection
-Increased risk of nonmenstrual toxic shock

14
 Diaphragm -Rubber that is filled with spermicide 10-20% $15-$75 + exam & fitting
-Requires prescription and fitting Free for insured under new ACA
-No STI protection legislation
-Increased risk of UTIs, vaginitis, and nonmenstrual toxic shock
Female Condom -Synthetic nitrile 5-20% $2-$4 each
Male Condom -Latex, polyurethane, natural, or “spray on” 3-15% $0.25-$2 each
-Often prelubricated with spermicide
-Can cause UTIs in female partners
-No STI protection with natural condoms

Sponge -Polyurethane with spermicide $13-$19 for 3

-Does not prevent STIs
Hormonal Methods
-Absolute contraindications to all estrogen-containing BC (per CDC): -Relative contraindications to all estrogen-containing BC:
• Age > 35 and smoking > 15 cigs/day • Gall bladder disease
• Known CAD • H/o cholestatic jaundice in pregnancy
• Multiple risk factors for CAD: DM, HTN, smoking • Epilepsy
• HTN • Clot risks: leg injury or cast, elective surgery, sickle cell disease
• H/o DVT, PE, stroke, or migraine with aura • Obesity
• Known coagulopathy
• Complicated valvular heart disease: pulm HTN, afib, h/o bacterial endocarditis
• SLE
• Breast cancer
• Cirrhosis, hepatocellular adenoma, or malignant hepatoma
Hormonal Method Info Failure Rate Cost
Combined OCPs -Estrogen portion suppresses the FSH surge by negative feedback  ovulation inhibition, also alters endometrium 3-9% $15-$30 per month
and causes degeneration of the corpus luteum Free for insured under new
-Progestin portion suppresses LH surge  inhibited ovulation, also thickens cervical mucus to inhibit implantation ACA legislation
-Benefits: improvement of acne, DUB, mittelschmerz pain, endometriosis, ovarial failure, ovarian cysts, uterine
fibroids, fibroadenomas or fibrocystic breasts, iron deficiency anemia; decreases risk of ovarian and endometrial
cancers, ectopic pregnancy, and acute PID
-Adverse effects: nausea, vomiting, weight changes, spotting, migraines, edema, rash, depression, decreased libido, ?
↑ risk of breast cancer, ↑ risk benign liver tumors, worsening gallbladder problems, blood clots, stroke
-Need to adjust strength and estrogen/progesterone formulation if adverse effects are present
-Most to least androgenic progestins: norgestrel, levonorgestrel, norethindrone, norethindrone acetate, ethynodiol,
norgestimate, desogestrel, drospirenone
-Ethynodiol is the only highly estrogenic estrogen, all others have lower estrogenic effects
-No protection against STIs
Adverse Effect Causes Management
Breakthrough Need higher progestin content to - Monophasic formulation with a higher progestin dose
bleeding increase endometrial support - Triphasic formulation with increasing dose of progestin
- higher dose of estrogen
Acne, oily skin, and Side effects from progestins Product with lower risk of androgenic effects
hirsutism
GI complaints Estrogen and progesterone - Estrogen – induces nausea and vomiting via the CNS
- Progesterone – slows peristalsis, causing constipation and feelings of bloating and distention
Headaches - discontinue the oral contraception
- lower the dose of estrogen
- lower the dose of progestin

15
 - eliminate the pill-free interval for 2-3 consecutive cycles
Decreased libido and Low levels of estrogen ↓ vaginal Use of the NuvaRing may help with lubrication disorders
depression lubrication
Dyslipidemias Estrogen Replace an androgenic progestin with a more estrogenic progestin
Mastalgia Estrogen component - lower-dose estrogen pills
- if tenderness occurs prior to menses, switch to a contraceptive that offers extended cycle length
Weight gain High estrogen content Switch to an estrogen product with <35 mcg of ethinyl estradiol
Visual changes/ Estrogen stimulation of - progestin-only products
contact lens melanocyte production - use sunscreen
disturbances - refer to ophthalmologist if normal saline eye drops do not help
Hormonal Method Info Failure Rate Cost
Progestin-Only Pill -Must be taken with obessive regularity 1-13% Free for insured under new ACA
-Can have irregular bleeding legislation
-A good option for breastfeeding women, smokers > 35, or those who can’t tolerate estrogen
Vaginal Ring -May be removed for up to 3 hours during intercourse without backup protection 1-2% $15-$70 per month
-Adverse effects: vaginitis, HA, leukorrhea, FB sensation, device expulsion, feeling it during sex Free for insured under new ACA
legislation
Transdermal Patch -Can bathe, swim, or exercise with patch in place 0.3-8% Free for insured under new ACA
-Must use back-up if patch falls off > 1 day legislation
Medroxyprogesteron -IM injection q 3 months 1-2% $35-$75 per injection
e Injection -Results in amenorrhea after a year or so of use Free for insured under new ACA
-Can use if smoker or nursing legislation
-Decreased risk of PID and endometrial cancer
-AEs: bleeding abnormalities, weight gain, lipid changes, depression, acne, HA, delay in return to
fertility
-Black box warning for ↑ risk osteoporosis related to duration of use = should only use < 2 years
-No protection against STIs
Progesterone -Must be trained by company-approved provider to insert and remove 1-4% $400-$800 for insertion
Implantable Rod -Good option for smokers or those who have contraindications to estrogen $75-$150 for removal
-May be less effective in obese patients Free for insured under new ACA
-AEs: menstrual irregularity, amenorrhea, weight gain, acne, depression legislation
Mirena IUD -Changes mucus and sets up hostile environment for sperm 0.2%
-Questionable use in individuals at risk for STIs
-Often used in later reproductive years before menopause
-Decreased risk of endometrial cancer
-Can be in place up to 5 years
-Women may become amenorrheic after a year of use
-Less bleeding and cramping than with copper IUD
-Increased risk of ovarian cysts
-May want to culture IUD for Actinomyces after removal
Surgical Methods Info Failure Rate Cost
Vasectomy -Cutting and sealing the vasa deferentia 0.15% $350-$1000
-Clinic procedure under local anesthesia
-Recovery period of 2-3 days
-Men will still be fertile for several ejaculations afterwards, need to have semen analysis in 1 month to
confirm sterility
Tubal Ligation -An outpatient surgery under general anesthesia 0.5% $1500-$6000
-Recovery period of 1 week
-Benefits: ↓ risk ovarian cancer and possibly breast cancer, can be done immediately postpartum

16
 -Increased risk of ectopic pregnancy
-Need to confirm blockage with hysterosalpingogram
Other Methods Info Failure Rate Cost
Paragard IUD -Changes mucus and sets up hostile environment for sperm 0.6-1.0%
-Questionable use in individuals at risk for STIs
-Often used in later reproductive years before menopause
-Decreased risk of endometrial cancer
-Can be in place for up to 10 years
-Can cause heavy bleeding and cramping
-May want to culture IUD for Actinomyces after removal
Lactation -Most effective if infant is not taking any supplemental formula and mother is nursing at least every 4 10%
hours
Emergency Methods Info Failure Rate Cost
Morning After Pill -Not an abortifacient = won’t work if already implanted
(Plan B One-Step, -No evidence of teratogenic effects
Next Choice) -Best if initiated within 72 hours of unprotected sex but can be taken for up to 5 days afterward
-Rare risks or AEs, but may need prophylactic antiemetics before taking
-Available without a prescription for ages 17+
Ulipristal acetate -Selective progesterone receptor modulator
(Ella) -Rx only
Mifepristone -Use within 72 hours of unprotected sex 15%
(RU486) -An abortifacient = will dislodge implanted embryo
-Also inhibits ovulation and changes endometrium
Infertility
-Failure to achieve Signs & Symptoms Management
pregnancy within one year -Men: genital infection, hernia, absence of vas deferens, signs -Treat underlying problem
of frequent, unprotected sex of androgen deficiency, testicular mass, varicocele -Bromocriptine for hyperprolactinemia
if < 35 or within 6 months if -Women: breast formation, galactorrhea, genitalia, signs of -Treat ED
> 35 hyperandrogenism -Varicocele repair
-Referral to fertility specialist for semen abnormality
Etiologies Workup -Ovulatory dysfunction treatment: ovulation-inducing meds or hormone injections
-Male issues: 1° -CBC and CMP for both partners -Tubal repair
hypogonadism (androgen -GC/Chlamydia -Laparoscopic ablation of endometriosis
insensitivity, cryptorchidism, -UA -Fertility monitoring: timed intercourse with fertility awareness methods will result in pregnancy in
meds, varicocele, genetic -Men: consider post-ejaculatory UA for retrograde ejaculation, 90% of couples
defect), 2° hypogonadism scrotal US, FSH and testosterone levels, sperm studies, -For unexplained infertility, 3-4 cycles of clomiphene followed by intrauterine insemination is
(androgen excess, infiltrative transrectal US recommended
disorder, meds, pituitary -Women: consider FSH, prolactin, TSH levels, antral follicular -IVF results in the highest per cycle pregnancy rate in the shortest time interval but is most costly
adenoma) count via US, hysterosalpingography, pelvic US, hysteroscopy, and has a high rate of high order multiple pregnancy
-Female issues: ovulatory laparoscopy
dysfunction, tubal damage, Prognosis
endometriosis, cervical -Overall likelihood of successful treatment is 50%
factor

17
 Normal Labor & Delivery
Stages of Labor Signs & Symptoms Management
-1st stage: onset of labor to full dilation of 10 cm -Sequential changes within the -Measurement of uterine contractions via tocodynamometer
-2nd stage: interval between full dilation and delivery of fetus myometrium and cervix take place over -Continuous fetal HR monitoring
-3rd stage: time from fetal delivery to expulsion of placenta days to weeks -Adequate labor for delivery is 3-5 contractions in a 10 minute period
-Loss of mucus plug  “bloody show” -IV placement
Factors Influencing Course of Labor -Progressive cervical dilation and -Pain management: parenteral analgesics vs epidural anesthesia
-Powers: uterine contractions effacement: should dilate at > 1.2 cm/hr -Clear liquid diet during labor
-Passenger: fetal size and number, lie, presentation, station, for nulliparous women and > 1.5 cm/hr -Consider C-section for labor dystocia (“failure to progress”)
presence of any fetal anomalies (ideally fetus is small and in for multiparous women -Consider operative vaginal delivery (use of forceps or vacuum assistance) for fetal
vertex position, longitudinal lie, with head flexed and in -Fetal head can be observed to rotate as it distress, maternal exhaustion, or prolonged 2nd stage of labor
anterior position and passing through pelvic inlet) navigates the birth canal (“cardinal -Routine episiotomy not recommended, instead repair lacerations if they present
-Passage: pelvis and surrounding soft tissues movements of labor”) -Deliver placenta within 30 minutes of birth of fetus and examined to be sure it is intact
Abruptio Placentae (Placental Abruption)
-Partial or complete separation of the Risk Factors Management
placenta from the uterine wall prior to -High: cocaine use, trauma, polyhydramnios, eclampsia, prior abruption, chronic -Fetal HR abnormality on NST suggests impending distress and
delivery of the fetus HTN, PROM, chorioamnionitis, fetal growth restriction, smoking emergency management
-Moderate: AMA, multiparity, male fetus -Stabilization of maternal hypovolemia with large bore IV
access with blood replacement
Signs & Symptoms -Expeditious delivery for nonreassuring fetal HR, maternal
-Painful vaginal bleeding instability, or gestational age > 36 weeks (should be C-section if
-Tender uterine fundus unstable or with malpresentation)
-Contractions -Expectant management of select cases in pregnancies < 36
-Abdominal pain weeks with administration of glucocorticoids in fetuses 23-34
-Can be asymptomatic weeks
-Can be chronic: light, intermittent vaginal bleeding, oligohydramnios, fetal growth
restriction, and preeclampsia Prognosis
-Separation > 50% usually leads to acute DIC and fetal death
Workup -Increased risk of abruption in all future pregnancies
-US to eval for retroplacental hematoma but sensitivity is only 25-50% = diagnosis is
clinical
-Blood type and Rh status
-NST
Placenta Previa
-When placenta implants Risk Factors Signs & Symptoms
abnormally in the lower -Multiparity -Painless vaginal bleeding
uterine segment  partial or -AMA
total blockage of cervical os -Asian Workup
-Prior placenta previa -Avoid pelvic exam which can rupture the placenta
-Smoking -Transvaginal US to assess placental location
-H/o C-section
-Multiple gestation Management
-Total placenta previa  refer to high risk OB
Screening -Marginal previa  f/u with serial US, avoid cervical US and sex,
-Usually detected in 1st or 2nd trimester US activity restrictions, deliver via C-section at 36-37 weeks
-Active bleeding  hospitalization with close monitoring, may need
emergency C-section

18
 Ectopic Pregnancy
-Most occur in the fallopian tube Risk Factors
-Others are cornual (interstitial), cervical, fimbrial, ovarian, -High: tubal obstruction or injury (PID, tubal ligation),
abdominal previous ectopic, DES use, current IUD use
-Rarely heterotrophic (intrauterine and ectopic at the same time) -Moderate: infertility, smoking, older age, non-white
-The leading cause of pregnancy-related deaths in the 1st trimester ethnicities, previous cervicitis
Signs & Symptoms
-Abdominal or pelvic pain
-Amenorrhea or vaginal bleeding
-Usual pregnancy symptoms
-Shoulder pain from blood pooling under diaphragm
-Urge to defecate from blood pooling in cul-de-sac
-Orthostatic BP
-Fever
-Rebound tenderness
-Adnexal pain on bimanual exam
-Cervical motion tenderness
Workup
-Quantitative serum hCG
-Transvaginal US to examine uterine contents: diagnostic if true
gestational sac, yolk sac, or embryo is detected inside or outside of
the uterus (should be able to visualize if hCG > 1500 which is the
limit of US detection)
Management
-If hCG is < 1500 and US is nondiagnostic, need to repeat US and
hCG in 3 days or when hCG level reaches US limit
-Surgical if unable to comply with nonsurgical management,
ruptured, or hCG > 5000: best outcome with salpingostomy, but will
need salpingectomy if ruptured
-Medical management is the treatment of choice for women who are
hemodynamically stable with hCG < 5000 and tubal size < 3-4 cm:
methotrexate IM followed by serial hCG measurements
-Expectant management only for asymptomatic women with small
tubal pregnancy and low hCG levels who are willing to accept the
risk of rupture or hemorrhage

Molar Pregnancy (Hydatiform Mole) and Gestational Trophoblastic Disease

-Occurs when an extra set of paternal chromosomes is Signs & Symptoms Management
incorporated into a fertilized egg, transforming the placenta -Vaginal bleeding -Suction uterine curettage with testing of tissue by a
into a growing mass of cysts -Enlarged uterus excessive for gestational age pathologist
-A complete molar pregnancy means there is no embryo or -Pelvic pressure or pain -Weekly hCG levels until normal
normal placental tissue -Theca lutein cysts -May need prophylactic chemotherapy for high risk disease
-A partial molar pregnancy means there is an abnormal -Anemia
nonviable embryo and possible some normal placental tissue -Hyperemesis gravidarum Prognosis
-Can coexist with a viable fetus -Hyperthyroidism -Risk of developing malignancy with uterine invasion or
-Preeclampsia before 20 weeks’ gestation metastatic disease if tissue is retained: persistent or invasive
Risk Factors -Vaginal passage of hydropic vesicles gestational trophoblastic neoplasia, choriocarcinoma, or
-Extremes of age Workup placental site trophoblastic tumor
-Prior molar pregnancy -Quantitative hCG: will be higher than expected
-Pelvic US
Premature Rupture of Membranes (PROM) & Preterm Premature Rupture of Membrans (PPROM)
PROM Signs & Symptoms Management
-Rupture of membranes at full term but before onset of labor (normally amniotic -Feeling “leaking urine” or increased vaginal secretions -If term, good evidence that labor should be induced
sac ruptures well into labor) -Sx of chorioamnionitis: odor, fundal tenderness, low after this in order to prevent NICU placement; GBS
-Occurs in 10% of normal pregnancies grade fever, fetal tachycardia prophylaxis if > 18 hours since rupture, or with
colonization or fever
PPROM Workup -If preterm, need inpatient monitoring, treatment of
-Refers to rupture of membranes before 37 weeks -Visual exam for pooling of amniotic fluid in vagina infection if present, deliver if > 34 weeks or with fetal
-Usually caused by maternal infection with test for ferning of sampled fluid distress, otherwise expectant management with steroids
-Risk factors: intra-amniotic infection, prior h/o PPROM, lower SES, teen mom, -GC/Chlamydia testing if needed for fetal lung maturation
smoker, h/o STD, h/o cervical cerclage, multiple gestation, polyhydramnios

19
 Preterm Labor
-Regular, painful uterine contractions with Prevention Workup Management
cervical dilation or effacement before 37 weeks -Treating infections has not been shown to improve -Check fetal fibronectin, has good -Progesterone: maintains cervical integrity,
outcomes NEGATIVE predictive value for opposes oxytocin, and is anti-inflammatory
Possible Etiologies -ID of high risk women with early care and enhanced assessing risk of delivering in next -Tocolytics (anti-contractants like terbultaline,
-Dental disease prenatal services also has failed to improve outcomes 7-14 days (can be inaccurate with mag sulfate, CCBs, indomethacin): no
-Bacterial vaginosis -Can follow women with h/o preterm labor with frequent recent cervical disruption like sex or evidence that they improve outcomes but they
-Inflammatory response US to assess cervical length TVUS) do buy time to administer steroids or transport
-ACOG recommends offering progesterone to women -US measurement of cervical to NICU facility
Risk Factors with cervical length < 15 mm or with h/o preterm delivery length; preterm labor likely if < 20 -Steroids to mature fetal lungs
-Smoking -Cervical cerclage or pessary an option mm -GBS prophylaxis if needed or if culture not
-Black -Evaluation of fetal lung maturity recently done
-Extremes of age Signs & Symptoms (amniotic fluid specimen): -Bed rest, pelvic rest, and hydration have no
-Low SES, poor housing, or other social stress -Contractions: back pain, abdominal pain, cramping lecithin/sphingomyelin ratio, foam evidence to back them up
-Multiple gestation -Diarrhea stability index, -Avoid sex and strenuous physical activity
-Intergestational period < 6 mos -Leaking fluid phosphatidylglycerol, or -Outpatient follow-up feasible for reliable
-H/o cervical surgery or short cervix fluorescence polarization patients
-Infection: bacteriuria or UTI, BV
Rh Incompatibility
-Maternal immunization can occur as a result Screening Differential Management
of transplacental fetomaternal hemorrhage or -Maternal Rh status and antibody screening -RBC membrane defects: hereditary -Emergent neonatal transfusion at delivery for
blood transfusion with Rh+ blood done at first prenatal visit and at delivery spherocytosis infants with signs of shock
-RBC enzyme defects: G6PD deficiency, -Later transfusions for symptomatic anemia
Prevention pyruvate kinase deficiency -EPO and iron for mild anemia
-Rhogam given to all Rh- mothers at 28 weeks, -Gilbert’s syndrome
again just after delivery if neonate is
determined to be Rh+, and anytime during Workup
pregnancy when there is risk of fetomaternal -Maternal and infant blood T&S
hemorrhage -Coombs test
-Infant peripheral smear
Signs & Symptoms -Antibody titers during pregnancy for mothers
-Rh incompatibility causes a spectrum of with known Rh sensitization and Rh+ fetus
disease from hyperbilirubinemia to hydrops
fetalis
Induced Abortion
-98% of unsafe induced abortions occur in the developing world Management
-Many US states have limits on abortions after 20 weeks -Antibiotic prophylaxis: doxycycline
-Rhogam if indicated
Methods
-Surgical: D&C, vacuum Prognosis
-Medical: for women < 63 days since LMP -Surgical complications: cervical laceration, hemorrhage, uterine perforation, incomplete abortion,
Workup sepsis
-Confirm pregnancy and gestational age -Psychological complications? Studies show women post-abortion have no higher incidence of
-CBC and T&S mental health disorders

20
 Prenatal Care
Week(s) Initial visit: 8-12 16 20 24 28 30 32 & 34 36 37 38 & 39 40+ Postpartum
Discussion -History -Begin fetal -Importance -Pregnancy ROS: -Signs of -Pregnancy -Postterm -1 week incision check for C-sections
highlights -Counseling movements of daily fetal cramping, bleeding, n/v, true ROS once > 42 -2 week check for vaginal deliveries
-Anticipatory guidance -Round ligament movements constipation, fetal contractions weeks, -4-6 week f/u for everyone
-Genetic screening options spasms  flank pain from here on movement, leakage, -Loss of discuss -Adjustment, breastfeeding,
-Discuss contractions, preeclampsia mucus plug induction postpartum depression, return to sex,
preterm sx (HA, vision ∆, edema, -Pregnancy contraception, bowel movements,
labor RUQ pain, ↓ urine output) ROS lochia
Complete PE 
Pap & pelvic  
Weight, BP
check, fetal
heart tones
Measure Follow up with US for height > 3 cm discrepancy from gestational age
fundal height
Leopold’s
maneuvers
Cervical
checks
Imaging TVUS for dating 20 week US to assess Consider additional US for select high risk pregnancies or inability to measure accurate fundal
fetal anatomy and size heights: h/o preterm labor (cervical length), obesity, DM, multiple gestation
NST Consider for high risk women: IDDM, AMA, maternal heart defect, intrauterine
growth restriction, multiple gestation

Biweekly
Genetic 10-13 weeks: CVS 15-22 weeks: window for quad screen and
screen 11-14 weeks: PAPP-A, NT amniocentesis
bHCG 
CBC  
T&S 
GC/C  
RPR  
HIV  
Hep B surface
antigen
 
Varicella &
rubella titers

Vit D level 
Glucose
tolerance test
Consider for select high
risk individuals

HSV, TB, If hypothyroid need to follow TSH q 8 weeks with goal TSH 2-3
TSH, urine
drug screen
Urine dip  Consider repeat or frequent UAs for certain high risk individuals: UTI at initial visit, h/o pyelonephritis or kidney problem, symptoms
of preeclampsia or diabetes  culture if + and f/u with test of cure
F/u proteinuria with preeclampsia labs: 24 hour urine, CMP, PT/PTT, uric acid
Rhogam
administration
Only give for abnormal
bleeding during this time
 Before leaving hospital
GBS swab 
21
 Spontaneous Abortion
-Pregnancy that ends spontaneously before fetus has reached age of viability ( = Signs & Symptoms Workup
before 22 weeks) -Vaginal bleeding -US: no cardiac activity in a fetus with CRL > 6 mm or no growth of
-80% occur in the first trimester -Abdominal pain or cramping pregnancy over one week are diagnostic for miscarriage; bad signs
-Occurs in up to half of all pregnancies, although only half of these are diagnosed -Open cervical os indicated miscarriage include yolk sac abnormalities, fetal HR < 100,
-Products of conception visualized in and large subchorionic hematoma
Causes the vagina or cervical os -Serial quantitative hCGs: normal doubling is reassuring
-Chromosomal abnormalities, esp trisomy 16 -Signs of hemodynamic instability and
-Fibroids, polyps, or scarring fever if septic Management
-Thrombosis or other placental complication -Follow quantitative hCG to zero
-Infection Differential -May need surgical intervention: D&C
-Fetal exposure -Physiologic bleeding from -Medical management (90% efficacy): mifepristone or misoprostol
implantation -Expectant management is an option as long as there is minimal
Risk Factors -Ectopic pregnancy bleeding or discomfort, pt is < 13 weeks, stable VS, and no evidence
-Maternal or paternal age -Cervical polyp of infection (80% efficacy but can take days to weeks)
-Increasing parity -Cervical infection or neoplasia -Administer Rhogam if mother is Rh-
-Smoking -Recent sex -Methylergonovine maleate to control bleeding
-Cocaine or caffeine -Broad spectrum abx if septic abortion (clindamycin + gentamicin or
-High BMI Zosyn)
-Submucosal fibroids or other uterine abnormality -Grief counseling
-Asherman’s syndrome -Pelvic rest for 2 weeks
-DM -No evidence for avoiding pregnancy for 2-3 cycles
-Thyroid disease -Contraception if desired
-PCOS
-H/o spontaneous abortion
Shoulder Dystocia
-When shoulders of infant can’t fit Prevention Management
through pubic symphysis because -Routine prophylactic C-section not indicated for -Get help
they are wider than the pelvic outlet suspected macrosomia but can be considered in mothers -Episiotomy
with h/o shoulder dystocia and brachial plexus injury -McRobert’s maneuver
Risk Factors -Drain bladder and disimpact bowel
-Maternal obesity Signs & Symptoms
-DM -Prolonged 2nd stage of labor Prognosis
-H/o or current macrosomic infant -Recoil of infant head on perineum (“turtle sign”) -Fetal complications: brachial plexus injury, clavicular or
-H/o shoulder dystocia -Lack of spontaneous restitution (translation: no natural humeral fracture, increased risk of asphyxia
head turning) -Maternal complications: hemorrhage, 4th degree tear
Fetal Distress
Causes Prevention Signs & Symptoms Management
-Cord compression -Continuous fetal HR monitoring vs -Prolonged abnormalities on fetal HR monitoring -Correct underlying abnormality
-Placental abruption intermittent auscultation during labor: -Outpatient: monitor with repeat NSTs
-Cord prolapse no evidence one is better than the other Workup -Improve fetal oxygenation
-Maternal medication -High risk women should have -Outpatient: NST -Rapid operative intervention if needed
-Rapid descent of fetal head continuous fetal monitoring during labor -Inpatient: fetal scalp stimulation (FHR acceleration in response is
reassuring), fetal ST analysis, fetal scalp blood sampling

22

-Failure of labor to progress as Signs & Symptoms
anticipated -Labor not following the norms of the Friedman
curve (although these values are now debated)
Causes and Risk Factors -Uterine contractions < 200 Montevideo units
-Hypocontractile uterine activity
-Inadequate pelvis
-Fetal malpresentation or macrosomia
-AMA
-Maternal medical issues: DM, HTN,
obesity
-Prolonged rupture of membranes
-Chorioamnionitis
-Short maternal stature
-High station at complete dilation
-Defined as blood loss > 1000 mL (or > 1500
for C-section)
-Avg vaginal delivery EBL is 500 mL (or 1000
mL if section)
-Occurs in 5% of deliveries
-Can be early (within 24 hours of delivery) or
late (up to 6 weeks after delivery)
Causes
-Uterine atony (causes 70% of cases)
-Retained placental tissue
-Infection
-Blood vessel damage during C-section
-Congenital coagulopathy
-Fetal growth < 10%ile for gestational age and
gender
-Multiples share the same growth curve as
singletons up to 22-24 weeks
Causes
-Congenital malformations
-Chromosomal abnormalities
-Damage during organogenesis
-Infection: rubella, CMV
-Placenta previa
-Placental infarction or single umbilical artery
-Small placenta
-Multiple gestation
Labor Dystocia
Management
-Administer oxytocin and monitor for 4-
6 hours before considering operative
delivery
-Intervention not indicated as long as
labor is progressing and fetal HR
reassuring
Postpartum Hemorrhage
Risk Factors Signs & Symptoms Management
-Chorioamnionitis -Signs of shock and hypovolemia -Treat underlying cause
-Uterine distension -Delivery of placenta > 30 min after infant -Uterine atony  uterine
-Prolonged or induced labor -Uterine atony massage, oxygen, large-bore IV
-Use of mag sulfate -Signs of uterine rupture: hypotension greater than access, oxytocin,
-General anesthesia expected for EBL, increasing abdominal girth methylergonovine
-Multiparity -Uterine inversion  manual
-Previous hemorrhage Workup reduction of uterus, laparotomy
-Placenta previa or abruption -Check for retained placenta: inspect delivered -Uterine rupture  surgical
-Operative delivery placenta for missing parts, explore uterus intervention
-Look for traumatic cause of hemorrhage: tear, -Embolization of uterine or
Prevention hematoma, uterine inversion hypogastric arteries
-Active management of 3rd stage of labor -Coagulopathy workup: PT/aPTT, fibrinogen, -Hysterectomy is last resort
-Use of oxytocin after delivery of the anterior shoulder antithrombin III
Intrauterine Growth Restriction
Risk Factors Signs & Symptoms Management
-Chronic maternal vascular disease -Fundal height consecutively < 2 than expected -Delivery with maturity or by 37 weeks if
-Smoking evidence of compromise or poor growth
-Fetal abnormalities Workup
-Poor maternal weight gain or malnutrition -US to evaluate fetal growth and %ile, with Prognosis
-Vaginal bleeding during pregnancy Doppler of umbilical cord to assess blood flow -High infant mortality within first 2 years of
-Low pre-pregnancy weight -Symmetrically small growth may just indicate life
-Prior fetal growth restriction small baby -Risk of intellectual deficits
-Prior stillbirth -Asymmetrically small growth indicates
-Alcohol, cocaine, or heroin use placental insufficiency (brain will be larger
-Elevated AFP during 2nd trimester screen than body)
-NST and biophysical profile
Screening -Fetal karyotyping if polyhydramnios present
-Fundal height measurement
23
 Preeclampsia (Toxemia) & Eclampsia
-Pregnancy-induced Screening Differential
HTN with significant -Urine dip for symptomatic women -Exacerbation of underlying renal disease
proteinuria ± -Acute fatty liver of pregnancy
pathologic edema Signs & Symptoms -TTP/HUS
-Can also have -Lies on a spectrum from mild & -Exacerbation of lupus
preeclampsia asymptomatic to severe
superimposed on -Only appears after 20 weeks, with Workup
chronic HTN majority of cases after 28 weeks -24 hour urine
-Irritability -CBC
Risk Factors -Hyperreflexia -CMP
-Multiple gestation -End-organ damage: frontal HA, -Uric acid
-Obesity photophobia and visual changes, -Coags: PT, aPTT
-Chromosomal or epigastric pain, oliguria, -NST
congenital fetal nondependent edema -Diagnose with BP > 140/90 + proteinuria > 0.3 g in a 24 hour urine
anomalies -Eclampsia: all s/s of preeclampsia + specimen
-Pregestational DM seizures due to neurologic irritability
-First pregnancy -HELLP syndrome: preeclampsia + Management
-Age < 20 or > 40 signs of hemolysis, elevated liver -Deliver if severe preeclampsia or eclampsia
enzymes, and low platelets -Expectant management with frequent monitoring with delivery at 37
weeks if mild
-Seizure prophylaxis with mag sulfate if severe
-Labetalol or hydralazine only for BPs > 150/100 to reduce risk of stroke

MUSCULOSKELETAL
Osteoporosis
Causes Prevention Signs & Symptoms Management
-Meds: steroids, anticoagulants, -1200 mg Ca daily (diet + supplements) -Low trauma fracture -Meds recommended for both osteopenia and osteoporosis
anticonvulsants, aromatase inhibitors, -Vitamin D (800-1000 IU daily) -Decreasing height treatment
cyclosporine, tacrolimus, GnRH agonists, -Exercise -Bisphosphonates inhibit bone resorption and are 1st line
barbiturates, Li, Depo, chemo, TPN -Smoking cessation Workup treatment: alendronate, ibandronate, etc.
-Avoidance of heavy alcohol use -DEXA: diagnostic if BMD is < 2.5 -Calcitonin nasal spray
Risk Factors SD below the young normal mean at -Estrogens like raloxifene
-Advancing age Screening the hip or spine -Estrogen agonists
-Prior fx or parental h/o hip fx -Screen women > 65 with DEXA -If premenopausal, also need to check -PTH for severe cases
-Steroid therapy -Screen men with DEXA only with CMP, CBC, Ca, P, vit D, TSH, 24 -Recheck osteopenic pts in 2 years (T-score
-Low body weight clinical manifestations of low bone mass: hour urine for Ca and Cr -2.00 to -2.49), low bone mass pts in 3-5 years (T-score -1.50
-Current cigarette smoking radiographic osteopenia, h/o low trauma to -1.99), and normal density pts in 10 years
-Excessive alcohol consumption fx, loss of > 1.5 in height, long-term -OCPs for premenopausal women taking steroids who become
-Rheumatoid arthritis steroids, prostate cancer treatment, amenorrheic
-Premature menopause hypogonadism, hyperthyroidism, etc.
-Malabsorption
-Chronic liver disease
-IBD

24
 PSYCHIATRY
Intimate Partner Violence (Domestic Violence)
-Refers to actual or threatened psychological, Signs & Symptoms Management
physical, or sexual harm by a current or former -Inconsistent explanation of injuries -Provider expression of empathy and continued ability to support and assist
partner or spouse -Delay in seeking treatment or missed appointments patient
-May begin or escalate during pregnancy -Frequent ED visits -Consult domestic violence advocate to explore resources
-Late prenatal care -Caution with providing written materials that may be seen by perpetrator
-Inappropriate affect -Don’t confront perpetrator
-Overly attentive partners -Restraining orders have inconsistent effectiveness
-Reluctance to be examined
-Somatization
Postpartum Depression
-Can occur in women or men Screening Workup
-Mood changes will develop in 40-80% of women postpartum -Edinburgh Postnatal Depression Scale -DSM-IV criteria is depression symptoms > 2 weeks with onset
and are normal as long as duration is < 2 weeks within 4 weeks of childbirth
Signs & Symptoms
Risk Factors -Sadness and crying episodes Management
-Formula feeding -Fatigue -Attention to infant by other family members or friends
-H/o depression -Changes in sleeping and eating habits -Support groups or counseling, home visits
-Cigarette smoking -Reduced libido -Psychotherapy
-Childcare stress or low social support -Irritability -Healthy diet and sleep patterns
-Infant colic -Feelings of hopelessness and low self-esteem -Meds recommended only if support and adequate rest fail to
-Low SES -Guilt improve symptoms: sertraline or paroxetine
-Unplanned pregnancy -Feeling overwhelmed and inadequate in caring for infant
-Inability to be comforted Prognosis
-Anhedonia and social withdrawal -Can last several months to a year if untreated
-Anxiety and panic attacks
-Anger spells

DERMATOLOGY
Melasma
-Disorder of hyperpigmentation affecting sun-exposed areas of skin Signs & Symptoms
-Usually appears on the face
Causes -More pronounced in those with darker complexions
-Pregnancy (occurs in up to 75% of pregnant women)
-OCPs
-Genetics Workup
-Sun exposure -Diagnosis is clinical
-Cosmetics
-Thyroid dysfunction Management
-Antiepileptics -Broad spectrum sun protection
-Hydroquinone 4% cream

25
 HEMATOLOGY
Normocytic Anemia
-Can occur in pregnancy due to hemodilution with increased circulating volume
-Hb can range from 9.5-11.6 depending on trimester
Microcytic Anemia = MCV < 80
Iron Deficiency Anemia Chronic Inflammation Anemia Sideroblastic Anemia
Etiology Etiology Etiology
-In an adult, this is due to blood loss, likely GI, until proven -Usually from reduced erythropoietin stimulation of bone -Inherited, acquired, or idiopathic heme synthesis from alcohol,
otherwise marrow lead, myelodysplasia, leukemia, TB, or drugs

Signs & symptoms Workup Workup

-Fatigue -A disease of exclusion -BM biopsy showing ringed sideroblasts
-Dyspnea on exertion
-Tachycardia Management Management based on cause
-Cheilosis -Treat only it pt is symptomatic with folate, iron, EPO
-Spoon-shaped nails
-Pica
-Dysphagia due to webbing of the esophagus

Management
-Treat blood loss
-Oral iron with stool softeners, continue 3-6 months post Hb
recovery
-Consider parenteral therapy by heme if pt does not tolerate oral
therapy or it is not rapid enough
-Recheck CBC in 3-4 weeks and ferritin in 8 weeks
Macrocytic Anemia = MCV > 100
Vitamin B 12 Deficiency Folate Deficiency
Etiology Etiology
-Inadequate diet: vegetarians -Inadequate diet: alcoholics
-Malabsorption -Dialysis
-Drugs -Malabsorption
-Impaired metabolism
Signs & symptoms
-Abnormal sensation and peripheral neuropathy in stocking-glove pattern Signs & symptoms
-Glossitis -Glossitis
-Pallor -Diarrhea
-Anorexia -Malnourishment
-Diarrhea -Cheilosis
-No neuropathies

26
 INFECTIOUS DISEASE
Chlamydia
-Most commonly reported STI in US Signs & symptoms Workup
-Frequent coinfection with gonorrhea -May be asymptomatic -Cervical swab with PCR is best
-Vaginal discharge -Urine test for men
Screening -Dysuria
-Every year for women < 26 -Cervical friability or ectropion Treatment
-When there is a new sex partner in last 60 days -Pelvic or lower abdominal pain -1st line is azithromycin or doxycycline
-With > 2 new sex partners in a year -Ectopic pregnancy -2nd line is erythromycin or levofloxacin
-Perihepatitis -Sexual abstinence for 7 days from initiation of therapy
-Lymphogranuloma venereum with L serotypes -Treat for gonorrhea as well

Prognosis
-Need retesting 3 months after treatment
-Complications: PID, epididymitis, urethritis, sterility

Gonorrhea
Screening Signs & symptoms Workup
-Every year for women < 26 -Vaginal discharge -Cervical swab with PCR is best
-When there is a new sex partner in last 60 days -Abdominal pain -Urine test for men
-With > 2 new sex partners in a year -Cervicitis -May need to culture rectum
-Most men will be symptomatic with purulent discharge,
dysuria, urethritis Treatment
-Pharyngitis -1st line is ceftriaxone injection
-2nd line is cephalosporin
-If pharyngitis is present add azithromycin or doxycycline
-Treat for chlamydia as well

Prognosis
-Complications: PID, tubo-ovarian abscess, perihepatitis,
vertical transmission

-Agent is parasite Toxoplasma gondii
-Transmission is through ingestion of
contaminated meat or produce, vertical, via
blood transfusion or organ transplantation, or
by handling contaminated animal feces (cats)
Toxoplasmosis
Signs & Symptoms Differential Management
-Infections are generally asymptomatic -Lymphoma -Usually not required in adults
-Fevers, chills, sweats -Primary HIV -Congenital toxoplasmosis  treat with
-Cervical lymphadenopathy -Mono pyrimethamine + sulfadiazine for 1 year
-Congenital toxoplasmosis: chorioretinitis,
intracranial calcifications, seizures, jaundice, Workup Prognosis
HSM, lymphadenopathy, anemia, -Toxo IgG antibodies will be present in pts -Infection will persist in latency for lifetime of
thrombocytopenia, abnormal CSF, hearing previously exposed/immunized, while IgM infected host but can reactive in times of
loss, intellectual disability, motor indicates active infection immunosuppression
abnormalities, hydrocephalus -Treated infants remain at risk for long-term
sequelae

27
 Syphilis
-Treponema pallidum Signs & symptoms Workup
-Most cases are MSM -Primary/acute infection lasts 5-6 weeks: contagious chancre, painless rubbery regional -Remember that negative tests do not exclude a diagnosis of
-Can be transmitted lymphadenopathy, followed by generalized lymphadenopathy syphilis
vertically from mother to -Secondary infection 6 weeks-6 months after exposure (not all pts will develop this): fever, malaise, -Darkfield microscopy of chancre sample
fetus HA, arthralgias, bilateral papulosquamous rash on the palms and soles, alopecia, denuded tongue, -LP for neurosyphilis
condyloma lata -Direct fluorescent antibody testing
-Tertiary infection occurs in disease > 4 years’ duration: end organ manifestations, CV symptoms, -Serology: RPR (has a 3-6 week latency period)
gummas, neurosyphilis -HIV test recommended as syphilis facilitates this infection
-Latent infection has no clinical manifestations but serology will be reactive
-Congenital syphilis of infant: stillbirth, prematurity, low birth weight, hydrops fetalis, large or pale Management
placenta, inflamed umbilical cord, fever, HSM, lymphadenopathy, failure to thrive, edema, syphilitic -Mandatory reporting within 24 hours
rhinitis, maculopapular rash, condyloma lata, jaundice, anemia, thrombocytopenia, leukopenia or -Penicillin G
leukocytosis, pneumonia -Recheck serologies at 6 and 12 months after treatment to look
for fourfold reduction in titer
Screening
-Recommended for pregnant women at the first prenatal visit, with repeat at 28 weeks
Human Papilloma Virus
-Small DNA viruses that are sexually or contact transmitted Prevention Workup
-Sexually transmitted strains are associated with squamous neoplasia of the -HPV vaccines cover most of the sexually transmitted subtypes -Pap cytology
anogenital region and oropharynx -Colposcopy
Signs & Symptoms Management
Risk Factors -Condyloma acuminata: caused by HPV type 6 and 11, can also -Most sexually transmitted HPV infections will
-Multiple sex partners be 16 or 18 self-resolve
-Young age at first sexual activity -Cervical dysplasia and oropharyngeal lesions: usually HPV 16 -Follow resolution of infection with sequential
-H/o STDs and 18 Paps
-Multiparity -Common cutaneous warts: HPV types 1, 2, 4
-Immunosuppresion -Anal carcinoma in MSM
-Uncircumcised male partner
Herpes Simplex
-Over 85% of adults will be + for HSV-1 and 20% will be + for HSV-2 by serology Complications
-Precipitating factors: sunlight, dental surgery, cosmetic surgery, wind, trauma, fever, stress -Eczema herpeticum: severe infection in the immunocompromised
-Transmission can be through asymptomatic shedding -Herpetic whitlow: fingernail or hand infection
-First outbreak will be the worst and can last up to 21 days -Herpes gladiatorum: infection anywhere not covered by underwear
-Pyoderma
Signs & symptoms -Proctitis, esophagitis
-Prodrome of burning or neuralgia -Keratitis
-Swollen regional lymph nodes -Encephalitis
-Pain with urination
Management
Differential: chancroid, syphilis, pyoderma, trauma -Acyclovir
-Valacyclovir
Workup -Famciclovir
-Viral culture is gold standard -Topical corticosteroid for orolabial herpes
-Serology is questionable, as not all + cultures will have + serology and vice versa, and many -7-10 days for first outbreak and 3-5 days for subsequent outbreaks
are asymptomatically + -Suppressive therapy if needed

28