Endometrial CA: -requires Estrogen exposure! Pre-pubertal girls .005% of having endo cancer! old lady highest risk.
UWISE QBANK: •
Pregnancy: ↓ plasma-osmolarity,↓ SVR = Risk of pulm edema . ↑ CO (due to ↑ HR ↑ SV.) ↑ total T3, T4, and ↑ TBG.
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1st trimester tests: CBC, U/A, 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). Comfrm w Amniocenti (PAPP-A (alpha fet), hCG,
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3rd trimest: 1hr sugar(24-28wks), comfrm w 3hr sugar, CBC, indirect coombs if rh-, GBS(35 37wks)
uEstriol, + Inhibin A).
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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! GROUP
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SequEntial screen: combined test (1st trimester screen) + quad screen (2nd trimester screen).
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chorionic villus sampling detects karyotype and mutations, not neural tube defects.
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AMNIOTOMY- artificial rupture of membranes
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Hb electrophoresis is best to detect sickle c carrier state. It also detects Heme C trait and thalasemia minor. blood smear can only ID sickle cell disease (not carrier!) ≥ .6mg normally 4mg if high risk.
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FOLIC ACID :
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NSAIDS are safe until 32weeks gest, when premature PDA clsoure becomes an issue.
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Meconium amnio fluid? do nothing! intubate trachea and suction meconium from beneath glottis immediately after delivery only IF baby is depressed
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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
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MISSED ABORTION- fetus dies but mom's body doesn’t 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!!
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Grand multiparity, multiple gestation, polyhydramnios macrosomia: are all uterine distention risk factors for UTERINE INVERSION. The most common risk factor, however, is excessive (iatrogenic) traction on the umbilical cord during the third stage of delivery. CCP: globular mass at introitus
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UTERINE PERFORATION would cause small (scant) vaginal bleeding. Cervical laceration would cause heavier bleeding
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Retained products of conception- causes profuse vag bleeding and can cause sepsis.
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Suction and curettage risks: anesthesia; uterine perforation; bowel, bladder or cervical injury.
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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.
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Diastolic murmors are always abnormal
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MOLAR PREGNANCY
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weight gain in pregnancy:
metastasizes to lungs so chest xray is appropriate.
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!
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pre-eclampisa and polyhadramnios are assoc with gestational diabetes.
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A speculum exam with a nitrazine test to confirm rupture of membranes is indicated if the patient’s history suggests this, or if a patient is uncertain as to whether she has experienced leakage of amniotic fluid.
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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 1
Severe variable deceleration hint to placental insuff (fetal acidosis) ◦ late decelerations- Placental insufficiency,
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Tachycardia and sign of sinusoidal pattern on the fetus = fetal anemia. suspect placenta abruption.
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Management of bad fetal tracing ◦ Identify nonhypoxic causes that can explain the abnormal ndings. (Most common are medications, particularly β-agonists or β-blockers.) ◦ 3. Begin intrauterine resuscitation as follows: a. Discontinue medications (e.g., oxytocin) b. Give IV normal saline bolus c. Provide high- flow oxygen d. Change patient’s position (left lateral) e. Vaginal exam to rule out prolapsed cord f. Perform scalp stimulation to observe for accelerations (reassuring) 4. Prepare for delivery if the EFM tracing does not normalize. Posibly operative vag delivery or C/S
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C/S indicated when: Uterine scar: Prior myomectomy ( fibroid) or prior classic incision c-section
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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 60– 70 percent.
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check when episiotomies are recommended!! Current data does not demonstrate these theoretical maternal and fetal benefits of episiotomies and there are insufficient objective evidence-based criteria to recommend episiotomy, and especially routine use of episiotomy.
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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.
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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.
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PPROM: ◦ Tx: if contxns don’t give Tocolytics ◦ - Before viability (< 24 weeks): Manage patient with bed rest at home. ◦ - Preterm viability (24–33 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
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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.
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If mom has HIV treat newborn with Zidovudine (azt) right after delivery, do HIV testing in 24 hours.
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4100gr = 9 lbs
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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!! ◦ DON’T do finger or speculum exam until Placent Previa is r/o ◦ VASA PREVIA: umbilical veins over os. Triad: ROM, painless bleed, fetal bradycard •
Mcc of postpartum hemorrhage(PPH) is a uterine atony!
PPH= >500ml in vag delivery or 1000ml in
C/S.
◦ Manage with Uterine Massage or Uterotonics (oxytocin, methylergonovine, carboprost, Misoprostol). ◦
Mom w HTN: give Misoprostol! Methylergonovine and Carbopost are C/I in HTN!
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breast feeding decreases risk of OVARY CA.
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Progestin is the only contraception that can be used while breast- feeding. And started right after delivery
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Combined hromones- wait 3 wks after delivery to avoid DVT. IUD-wait 6wk
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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
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HCG
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CERVICAL INSUFF
should double every 48hrs until 8 weeks!! use this to find ectopics (which wont double in 48hrs). ◦ 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
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DIABETES:
SPONTA ABORTIONS.
◦ 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 doesn’t cause cong malf ◦ 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
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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 )
• 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.
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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 •
HYDROPS
FETALIS =
fluid in 2 cavities (ascites, pleural effusion, etc..)
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Rhogam: at 28 weeks; within 3days after birth; after fetus loss; w amnio, Chorio; w heavy vag bleeding.
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preterm labor cant occur before 20 weeks!
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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 doesn’t enlarge. XXY. hCG doesnt super increase. abd pain.
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MASTITIS -
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2DRY
if fever remains after Abx or if theres “fluctuant mass” its an abscess > do drainage
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 •
FIBROIDS(leiomyomata): 30-40’s w Chronic menorrhagia after previous normal periods. ◦ GnRH agonist (Leuprolide) can shrink fibroid temporarily to make surgery easier or correct anemia. ◦ Hysterectomy is Tx of choice if symptoms persist despite medical therapy. ◦ IF Pregnancy is Desired do MYOMECTOMY (just removing fibroid) ◦ Submucosal fibroid causes abortions. Subserosa-blocks ureters.
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40’s w INTERMENSTRUAL BLEEDING think- endomet hyperplasia, endomet polyp, endome CA, and Fibroids.
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ENDOMETRIAL tissue.
HYPERPLASIA -
due to ↑↑↑Estrogen. It’s an ↑↑of Glandular (monthly shedding)
↑ CA risk young woman with anovolatory cycles can have endometrial hyperplasia (dx with biopsy) • •
Management of an 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. While her inability to get pregnant may be more complicated than just her polyp, removal of the polyp should occur prior to infertility treatments.
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Rapid growth of a pregnacy looking mass inside uterus: think Leiomyosarcoma
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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.
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CERVICAL CA when metastatic causes hydronephrosis> flank pain> edema. • Post Coital bleeding is Cervical CA until proven otherwise!
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80-90% of women with ENDOMETRIAL
CARCINOMA
present with vaginal bleeding or discharge.
