Obgyn UWISE Notes (and Master the boards)

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( 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 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 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.