Download MBBS Obstetrics and Gynecology Lecture Notes

Ulcerative Infections
? Syphilis (primary) ? Pediculosis
? Herpes genitalis ? Scabies
? Chancroid
? Pyoderma

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? Lymphogranuloma
? Trauma
venereum
? Excoriations
? Granuloma inguinale ? Bechet's disease

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(donovanosis)
? Fixed drug eruption
? Mol uscum
? Yeast infection
contagiosum

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? Genital warts
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Famous People in History

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Diagnosed with Syphilis
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Just to Name a Few!
? Columbus
? Al Capone

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? Henry VIII
? Beethoven
? Charles VIII
? Toulouse-Lautrec
? Merriweather Lewis

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? Vincent Van Gogh
? Lenin
? James Joyce
? Hitler
? Baudelaire

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? Idi Amin
? Paul Gauguin
? Ivan the Terrible
? Scott Joplin
? Benito Mussolini

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? Edouard Manet
? Ben Franklin
? Franz Schubert
? Abraham and Mary Todd ? Tolstoy
Lincoln

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? Nietzsche
? Robert Schumann
? Karen Blixen
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? Howard Hughes

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Syphilis
"The Great Imitator"
? Treponema pal idum (spirochete)
? 1o Syphilis ? genital ulcers (chancre)
?Painless, indurated, sharply demarcated, red smooth

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base
?Heals spontaneously in 4-8 weeks
?Incubation period ? 9-90 days (2?4 weeks average)
?Dark field microscopy is 80% sensitive (operator
dependent)

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?The VDRL and RPR tests detect nonspecific
treponemal antibodies
Serology (VDRL / RPR) is Often Negative
5
In Early Primary Syphilis

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Primary Syphilis (1)
Chancre (Painless)
Spirochete

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Primary Syphilis (2)
Chancre (Painless)

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Syphilis (2)
? 2o: Onset 2-10 weeks after the chancre, rash
(maculopapular rash that often includes palms and

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soles), fever, arthralgias, condyloma lata, painless
lymphadenopathy
? Latent
? 3o: 3-25 years after infection (immunocompetent)
?Neurosyphilis

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?Meningitis, dementia, neuropathy
?Cardiovascular syphilis
?Thoracic aortic aneurysm, aortic insufficiency
?Skin lesions (gummas)
?Bone and joint disease (Charcot's joint)

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Secondary Syphilis (1)
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Secondary Syphilis (2)

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10
Med-Chal enger ? EM

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Secondary Syphilis (3)
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Secondary Syphilis (4)
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Condyloma Lata

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?Secondary
syphilis
?Smooth, moist,
flat warts
Med-Chal enger ? EM

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?Genital, perianal
?Fluid positive for
spirochetes (dark
field)
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Syphilis (4)
? Positive darkfield microscopy for primary and
secondary lesions
? Non-treponemal tests
?RPR, VDRL (not specific for syphilis)

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?Positive 14 days after chancre in most
?Occasional false positives
?Follow titers to assure cure
? Treponemal (MHA-TP and FTA-ABS)
?Best sensitivity / specificity

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?Expensive and difficult to perform
?Titers not predictive of cure
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Tertiary Syphilis (Charcot's Joint)

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Tertiary Syphilis (Gummas)
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Tertiary Syphilis (Gummas)

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Syphilis (5)
? Test for HIV
? Jarisch-Herxheimer reaction: release of
endotoxin from spirochete death (fever,

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arthralgias, headache, myalgias; several hours
after antibiotics)
? 50% in primary; 90% in secondary
?Also seen treating in Lyme disease (14%)
? Treatment: Benzathine PCN 2.4 mil ion units

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?Penicil in strongly preferred first line agent
? Desensitization recommended
?Doxycycline, tetracycline, ceftriaxone, azithromycin
possible alternatives
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Genital Herpes Simplex
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Genital Herpes Simplex (1)

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? HSV-2 (more common in U.S.) or HSV-1
? Prodrome: Burning, itching, paresthesias
? Fever, malaise, headache, myalgias,
adenopathy
?Common in first episode

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? Primary lesion at 2-7 days after contact
(shal ow, painful vesicles clustered on
erythematous base, then ulcerations, may
coalesce)
? Local symptoms peak 8 to 10 days, 2 to 4

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weeks to heal
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Genital Herpes Simplex (2)
? Symptomatic recurrences are the rule (60%
to 90%)

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? Can shed virus during recurrences as wel as
during asymptomatic periods
? 1 in 5 sexual y active adults infected
? HSV lesions increase acquisition and
transmission of HIV

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Genital Herpes Simplex (3)
? Diagnosis
?Usual y clinical
?Viral tissue culture (3-10 days, false

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negatives common but stil gold
standard), antigen testing, serologic
testing (may take 6 weeks)
?Tzanck smear (nucleated giant cel s) no
longer recommended due to low

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sensitivity
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Genital Herpes
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Genital Herpes Simplex (4)
? Complications: meningitis (10% if primary),
encephalitis, hepatitis, transverse myelitis,
erythema multiforme, urinary retention
(sacral root ganglia)

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? Treatment: Acyclovir / valacyclovir /
famciclovir
? Controls symptoms, decreases relapses,
shortens course
? C-section if active genital herpes

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? Neonatal herpes
?Acquired at birth
?High mortality
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Perianal Herpes

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Chancroid (1)
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Chancroid (2)
? Haemophilus ducreyi (Gram negative
bacil us)
? More common in developing countries, rare
in USA

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? Incubation period is 3-6 days
? Vesiculopustular lesion, then painful genital
ulcer or ulcers
? Tender unilateral adenopathy, bubo
formation with spontaneous rupture

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? Diagnosis: Clinical; r/o HSV, syphilis
? Treatment: Ceftriaxone, azithromycin,
ciprofloxacin, erythromycin
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Distinguish from non-painful lesion of primary syphilis

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Chancroid (3)
"Kissing lesion"
Autoinnoculation
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Lymphogranuloma Venereum
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Lymphogranuloma Venereum (LGV)
? Chlamydia trachomatis (only certain serotypes)
? Endemic in some regions, seen only sporadical y in

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USA
? Incubation 1-3 weeks
? Shal ow, painless, genital vesicles and papules heal
in 2-3 days
? Painful inguinal nodes ("buboes") weeks to months

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later, "groove sign"
? Fever, chil s, arthralgias, E. nodosum
? Diagnosis: Complement fixation titer, culture of
aspirate
? Treatment: Doxycycline or erythromycin x 3 weeks

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Lymphogranuloma Venereum
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Lymphogranuloma Venereum

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"Groove Sign"

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Ulcerative Lesions
STD

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Ulcer
Adenopathy
Systemic
Symptoms
Syphilis

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Single
Minimal
None
(primary)
Painless

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Starts as papule
Syphilis
None
Generalized
Generalized rash

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(secondary)
Nontender
Mucous patches
Nonfluctuant
Condyloma lata

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Herpes
Multiple
Shotty
Flu-like
Shal ow

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Bilateral
Precedes lesions
Painful
Minimal y tender
Starts as vesicle

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Chancroid
Single or multiple
Unilateral
None
Painful

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Fluctuant
Purulent base
LGV
Evanescent
Groove sign

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Sometimes
Multiple
Painless
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Starts as vesicle

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Nonulcerative Infections
? Chlamydia
? Gonorrhea
? Nongonococcal urethritis
? Pelvic inflammatory disease

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? Secondary/tertiary syphilis
? Candidal vaginitis
? Trichomonas
? Bacterial vaginosis
? Endometriosis

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Chlamydia
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Chlamydia Trachomatis

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? Number one STD
? Major cause of female infertility/PID
? Co-infection common
? Symptoms of local disease
?Penile or vaginal discharge

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?Dysuria
?Females: Cervicitis, urethritis, PID
?Males: Epididymitis, urethritis, proctitis
?Abnormal vaginal bleeding
?Abdominal, pelvic pain, testicular pain

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Chlamydia Trachomatis
? 1-3 week incubation period
? Often asymptomatic
? Highest rate in sexual y active adolescent

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females
? Consider with sterile pyuria
? Diagnosis: Cultures low yield, indirect
methods (DNA probes or nucleic acid
amplification tests)

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? Treatment: Azithromycin or doxycycline
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Gonorrhea
? Incubation of 1 to 14 days
? 20% of women with untreated gonorrhea

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develop PID
? Symptoms of localized disease
?Penile or vaginal discharge
?Dysuria
?Females: Cervicitis, urethritis, proctitis, PID

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?Males: Epididymitis, urethritis, proctitis,
prostatitis
?Abdominal and pelvic pain
?Asymptomatic (most frequent in women) 38

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Gonorrhea

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Gram Negative Diplococci
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Gonorrhea
? Diagnosis: Gram stain, culture or nucleic

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acid amplification test
? Treatment: Single dose therapy
?Ceftriaxone 250 mg IM PLUS azithromycin
1 gm PO once (treats resistant gonorrhea in
addition to Chlamydia coinfection)

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?Cefixime PO no longer an alternative (no
longer a treatment option per the CDC)
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Gonorrhea
Non-Genital GC

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? Rectal GC: Proctitis with purulent discharge
? GC conjunctivitis (purulent discharge)
? Pharyngitis
? Pelvic inflammatory disease (PID)
? Disseminated gonococcal disease

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?Skin lesions
?Arthritis, tenosynovitis
?Endocarditis
?Meningitis
** Most common cause of septic

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arthritis in pts. <50 y.o.**
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Gonococcemia
? Fever, polyarthritis or monarthritis (knees,
ankles), tenosynovitis (wrists, ankles); often

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seen weeks after initial exposure
? Necrotic pustules on an erythematous base;
may be hemorrhagic (<20 lesions total)
? Joint fluid and blood often negative for
organism

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? Genital and pharynx cultures
? Rule out syphilis, Chlamydia
? Treatment: Ceftriaxone, cefotaxime, cefoxitin
with probenecid

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Disseminated Gonococ

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Gonococcemia c
emia

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Gonococcemia
45

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Gonococcal Pustule

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Gonococcemia
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GC Conjunctivitis
47

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Pelvic Inflammatory Disease
48

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Pelvic Inflammatory Disease (1)
? Neisseria gonorrhoeae, Chlamydia
trachomatis (most common)

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? Polymicrobial infections (including
anaerobes) are also common 30-40%
? Risk factors: Prior STD/PID, IUD in 1st
month of insertion, young age, multiple
partners

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? Decreased risk of PID
?Pregnancy
?Barrier contraceptives
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Pelvic Inflammatory Disease (2)

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? Diagnostic tests: US, CT scan, laparoscopy
? CDC - empiric treatment if no other etiology
to explain these findings:
?Uterine tenderness or adnexal tenderness
?Cervical motion tenderness

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? Additional criteria improve specificity
?Temp >101 (38.3)
?Abnormal cervical or vaginal mucopurulent
discharge
?Elevated ESR/CRP

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?Lab confirmation of gonorrhea or chlamydia 50

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Pelvic Inflammatory Disease (3)
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Pelvic Inflammatory Disease (4)
? Admission criteria

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?Toxic (e.g. intractable nausea / vomiting,
fever)
?Pregnancy
?Surgical emergency not ruled out
?Outpatient compliance issues

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?Failed outpatient therapy
?TOA (tubo-ovarian abscess)
?Consider in nul iparous females
52

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Pelvic Inflammatory Disease (5)

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? Inpatient treatment ? 2 regimens
?Cefotetan or cefoxitin; plus doxycycline
?Clindamycin plus gentamicin
?Alternative: Ampicil in/sulbactim PLUS doxycycline
? Outpatient treatment: 3 regimens

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?Ceftriaxone plus doxycycline + /- metronidazole
?Cefoxitin and probenecid plus doxycycline +/-
metronidazole
?Other parenteral third generation cephalosporin
(ceftizoxime or cefotaxime) plus doxycycline +/-

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metronidazole
53

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Pelvic Inflammatory Disease (6)
? Remove IUD if in place
? Treat partner

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? Complications
?Ectopic
?Infertility
?Adhesions
?Tubo-ovarian abscess (1/3 of hospitalized

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patients)
?Chronic pelvic pain
?Dyspareunia
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Fitz-Hugh-Curtis Syndrome
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Pelvic Inflammatory Disease (6)

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? Fitz-Hugh-Curtis syndrome
?Purulent material spil s from tubes into
abdomen
?Direct or lymphatic spread
?Bacterial perihepatitis

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?LFTs usually normal
?Right upper quadrant and shoulder pain
?"Violin string" adhesions around the liver
56

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Vulvovaginitis

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? Inflammation of vulva and vaginal tissues
? Vaginal discharge / itching / irritation
? Causes: Infection, irritant or al ergic
contact, vaginal FB, atrophic vaginitis
? Most common gynecological complaint in

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prepubertal girls
? Normal vaginal pH 4.0-4.5
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Trichomoniasis (1)

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Trichomoniasis (2)
? Vaginitis
?Flagel ated protozoan
?Yel ow-green, frothy, malodorous discharge;

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pruritus, irritation, abdominal pain
?"Strawberry" cervix on exam (punctate
submucosal hemorrhages) ? seen in 2% to 10%
?Typical y asymptomatic especial y males
?Increases risk of HIV, HSV

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Trichomoniasis (3)
?Diagnosis: Wet mount
(motile trichomonads),

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spun urine, cultures
?Treatment: Metronidazole or tinidazole
(single dose), topical not recommended
?Disulfiram-like reaction with alcohol
?Transmitted sexual y - treat partner

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?Associated with PROM, preterm delivery,
low birth weight
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Bacterial Vaginosis (1)

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? Most common cause of vaginal discharge
? Normal vaginal flora (lactobacil i) replaced by
Gardnerel a and anaerobes
? 3 of 4 criteria per CDC:

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?Copious thin white homogenous discharge
?Clue cel s (vaginal epithelial cel s with adherent
bacteria) on wet prep
?pH > 4.5
?A fishy odor with potassium hydroxide (KOH)

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whiff test
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Clue Cells
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Bacterial Vaginosis (2)

? Treatment: Metronidazole PO or gel,
clindamycin cream
? Risk of preterm labor, PROM, preterm

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birth, postpartum endometritis
? All symptomatic women need treatment
? All pregnant patients should be treated
63

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Candidal Vaginitis (1)

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? Candida albicans 85-92%
? Part of normal flora
? Risk factors: Diabetes, oral contraceptives,
antibiotics, pregnancy
? Symptoms: Vulvar pruritis (most common),

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vaginal discharge, dyspareunia, and dysuria
? Exam: Vulvar erythema, edema or
excoriation
? Cottage cheese non-odorous discharge
64

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Candidal Vaginitis (2)
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Candidal Vaginitis (3)
? Diagnosis

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?KOH wet mount: pseudohyphae,
budding yeast
?Normal pH
? Treatment: Fluconazole 150mg po once;
Multiple OTC and prescription topical

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agents
? Topical imidazoles more effective than
nystatin
? Pregnancy: Topical imidazoles only x 7d
66

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Hyphae
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Vulvovaginitis
Clinical Findings
Diagnostic Testing

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BV
Trich
Candida
pH > 4.5
Yes

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Yes
No
WBCs
++
+++

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No
Clue cel s
Yes
No
No

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Trichomonads
No
Yes
No
Yeast forms

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No
No
Yes
Sexual y transmitted?
No

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Yes
No
Treat sexual partners?
No
Yes

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No

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Bartholin Gland Abscess
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Bartholin Cyst/Abscess
? Cyst: Painless, I&D, Word
catheter
? Abscess
?Painful

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?Anaerobic/aerobic bacteria ? Bacteroides,
E.coli, also N.gonorrhea, Chlamydia
?I&D ? Iodoform, Word catheter
?Recurrent - Marsupialization
70

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Condyloma Accuminata (1)
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Condyloma Accuminata (2)
? Human papil oma virus (DNA virus), also cal ed
venereal warts

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? Incubation period 1-3 months
? Rule out other STDs. Increased risk of cervical
carcinoma
? Rectal, penile and perineal (most common); occur
in soft, vegetating clusters

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? Direct contact
? Painless (location and size may cause discomfort)
? Treatment
?Condylox (podofilox topical)
?Aldara (imiquimod topical)

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?Cryotherapy
72

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Condyloma Accuminata (3)
73
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Ovarian Cyst
? Symptomatic cysts >3 cm
? Fol icular cyst occurs first 2 weeks of menstrual
cycle
? Mittelschmerz: Transient ovulatory mid-cycle

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pain, unilateral, last <1day
? Corpus luteal cyst occurs during last 2 weeks
? Abdominal pain, bleeding, vomiting
?Tender adnexal mass, cervical motion tenderness
?Fluid in the cul-de-sac

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?Hemorrhage can occasional y cause shock and
require emergent surgery
? Diagnosis: Ultrasound, CT, laparoscopy
74

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Ovarian Follicular Cyst
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Ovarian Cyst
77

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Ovarian or Adnexal Torsion
? Ovary twists on pedicle
? Most associated with benign tumors or cysts
? Dermoid cyst most common
? Malignant tumors usual y fixed, torsion rare

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? Severe abdominal pain, constant, unilateral
? Nausea, vomiting, usual y afebrile
? Vaginal bleeding is uncommon
? Exam: Unilateral tenderness, rebound or mass
? Diagnosis: Ultrasound, laparoscopy

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? Rule out ectopic, appendicitis, PID
78

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Endometriosis (1)
79

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Endometriosis (2)
? Endometrium outside of the uterus
? Ovaries, fal opian tubes, bladder, abdominal
cavity, lung (catamenial pneumothorax)
? Constant pelvic pain associated with menses

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? Dyspareunia, hypermenorrhea, infertility
? Exam: Adherent uterus, ovarian mass (chocolate
cyst), pelvic tenderness and nodularity
? Diagnosis: Laparoscopy
? Treatment: Analgesics, hormones, surgery

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Endometriosis most commonly involves the
ovaries
80

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Leiomyomas (Fibroids) (1)

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81

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Leiomyomas (Fibroids) (2)
? Benign tumors of uterine muscle
? Most common pelvic tumor; most common in
African American women

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? Pelvic pain, abnormal bleeding
? Pregnancy can result in rapid growth and
loss of blood supply (degeneration)
? Diagnosis: Ultrasound
? Treatment: NSAIDs, hormonal therapy,

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surgery
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Uterine Cancer
? Most common gynecologic cancer
?Adenocarcinoma most common type

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?Sarcoma (aggressive, worst prognosis)
? Average age 58
? Risk: Continuous estrogen, obesity, diabetes,
hypertension, nul iparity, early menses, late
menopause

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? Abnormal bleeding, painless uterine
enlargement
? Diagnosis: D&C or uterine biopsy
Postmenopausal women with bleeding
83

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Uterine Cancer
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Ovarian Cancer
? Peak incidence age 55-65

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? Risk factors: Infertility, low parity, high fat diet,
history of breast or colon cancer, family history
? Advanced stage at diagnosis common
? Abdominal pain, bloating, weight loss, pleural
effusion

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? Exam: Fixed unilateral mass
? Diagnosis: CT scan, pelvic ultrasound
Ascites in females is a gynecologic neoplasm
until proven otherwise (e.g., ovarian cancer)
85

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Cervical Cancer
? Average age at diagnosis 54
? Risk factors: Early coitus, multiple partners,
smoking, HPV, high-risk male partners
? In HIV patients is an AIDS-defining il ness

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? Squamous type ~ 90%
? Symptoms: Postmenopausal bleeding, abnormal
vaginal bleeding, postcoital bleeding, vaginal
discharge, pain
? Diagnosis: Cervical biopsy

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? Human papil oma virus vaccine ? protects against 4
types of virus (2 types cause 70% of cervical
cancers and 2 types cause 90% of genital warts
? Licensed for males and females aged 9 - 26
86

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Abnormal Vaginal Bleeding
(Non-Pregnant)
? Non-uterine: Cervix, vagina, urinary, GI,
coagulation disorders
? Ovulatory: Menorrhagia (heavy bleeding),

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metrorrhagia (outside cycle); polyps, tumors,
cancer, infection, fibroids, endometriosis,
dyscrasias
? Anovulatory (DUB): Prolonged amenorrhea with
intermittent menorrhagia; endocrine disorders,

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OCPs, liver/renal diseases, polycystic ovary,
extremes of reproductive age, eating disorders.
Treatment: OCP, NSAIDs or D&C
? Peri- & postmenopausal: Cancer should be 87
considered

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Obstetrics
88

---

What is the age of the oldest

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woman to give birth?

---

67 years / In vitro / Twin Boys
90

---

Normal Pregnancy

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? Breast tenderness, "morning sickness"
? Fundus at umbilicus: 20 weeks
? Chadwick's sign (blue, soft cervix)
? Increased blood volume, coagulation factors, cardiac
output

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Human Chorionic Gonadotropic Hormone (HCG)
? Doubles every 2-3 days for first 7-8 weeks
? May be positive 8-9 days after ovulation
? Routinely positive after 1st missed period
? Detectable up to 2-3 weeks post AB or delivery

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91

---

Weight of Largest Viable Baby
Born?

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?22.8 pounds !!
92

---

Abortions (1)
? Threatened
? Incomplete

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?Bleeding, pain
?Bleeding
?Closed os
?Tissue at os
?<20 weeks

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?Products of
?Vaginal rest, normal
conception
activities
?D&C

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? Inevitable
?Includes 1st or 2nd
?Bleeding
trimester fetal
?

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demise or
Open os
anembryonic
?<20 weeks
gestation

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?D&C
93

---

Abortions (2)
? Complete
?Passed al tissue with

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pain, bleeding
?Closed os
?Ultrasound
?May need D&C
? Septic

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?Polymicrobial
?Endometritis,
peritonitis, sepsis
?IV antibiotics
94

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?D&C

---

Ectopic Pregnancy
95

---

Ectopic Pregnancy (1)
? Risk factors

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? Location
?Previous ectopic
?Distal fal opian tube most
?PID / IUD
common

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?
?
Tubal ligation, pelvic
Indicates IUP on US
surgery

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? Double gestational sac
?Infertility treatment
? Yolk sac or fetal pole
?Half have NO risk factor
? Fetal heart activity

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?
? HCG
Characteristics
?Slower than normal
?5-8 weeks after LNMP,

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increase in HCG
pain, abnormal bleeding
?Level correlated with US
?Relative bradycardia may
results improves predictive

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be associated with occult
value
blood loss
96

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---

ED Ultrasound: 1st Trimester
Pregnancy
Yolk Sac
Gestational Sac

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(double Ring)
97
IUP

---

Ectopic Pregnancy (2)
? Transvaginal US: Most sensitive, diagnostic in

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80% of stable patients
? Sonographic discriminatory zone: The level of
HCG at which a developing IUP should be
seen
?Transvaginal 1500-3000 mIU/ml; should

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see a gestational sac
?Transabdominal 6000mIU/ml; should see a
fetal pole
?An US should be ordered if patient at risk
for ectopic despite low HCG levels

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Consider a heterotopic pregnancy (IUP & 98
ectopic) in fertility assisted patients

---

Ectopic Pregnancy (3)
99

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---

Ectopic Pregnancy (4)
? Diagnosis
?IUP on US: High probability no ectopic
?Diagnostic for ectopic
? Empty uterus, embryonic cardiac activity

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outside the uterus
? Empty uterus, -hCG > 1500 mIU/ml
?High probability of ectopic
? Adnexal mass, free pelvic fluid with no IUP
?Indeterminate: No definitive IUP or ectopic

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? Consultation, admit or close fol ow up
? Ectopic precautions
100
? Serial HCG & ultrasound

---

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Ectopic Pregnancy
101

---

Ectopic Pregnancy (4)
Treatment

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? Surgical
?Laparoscopic salpingostomy if unruptured
?Laparotomy if hemodynamical y unstable,
ruptured
? Medical: Methotrexate

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?Inhibits cel division in rapidly dividing fetal cel s
?Tubal mass < 4 cm and no fetal cardiac activity
?Abdominal pain most common side effect
?Presume ruptured ectopic as opposed to
treatment side effect

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?Significant failure rate (up to 36%)
102

---

Laparoscopy
103

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---

RhoGAM
? RhoGAM = IgG anti-D antibodies
? Destroy Rh+ fetal red cel s in the maternal
circulation
? If RhoGAM not given, mother develops

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antibodies to Rh+ fetal blood which cross the
placenta and cause a hemolytic anemia in the
fetus, splenomegaly, erythroblastosis, death
? Indications: Rh- and abortion (any type),
abruption, ectopic, antepartum hemorrhage,

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trauma (even relatively minor)
? Dose: 50 mcg if <12 weeks, 300 mcg if >12
104
weeks

---

Molar Pregnancy (1)

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Gestational Trophoblastic Disease
? Proliferation of chorionic vil i; no fetus =
Complete hydatidiform mole, if fetal tissue
incomplete
? 1st and 2nd trimester bleeding,

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hyperemesis gravidarum,
no fetal heart tones
? Passage of "grape-like clusters"
? Uterine size > gestational age
? HCG level greater than expected

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? Complications: Neoplasm, preeclampsia, PE 105

---

Molar Pregnancy (2)
Ultrasound = "snowstorm appearance"
106

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IUP

---

Molar Pregnancy (3)
107

---

Abruptio Placentae

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? Separation of the placenta from the uterine wal
? Causes: Spontaneous, abdominal trauma
? Risk factors for spontaneous abruption:
Hypertension, older, parity, smoking, cocaine
? May have bleeding, abdominal pain,

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contractions, uterine tenderness
? Ultrasound is not sensitive for diagnosis
? Fetal monitoring for fetal distress
? Misdiagnosed as preterm labor
?Complications: Fetal and maternal death, DIC

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? May or may not be associated with painful dark
108
red bleeding

---

109

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---

Placenta Previa
? Implantation of placenta over the cervical os
? Increased incidence: Older, multiparity, smoking,
prior c-section
? Diagnosis: Ultrasound highly accurate

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Painless third trimester bright red bleeding
Pelvic exam contraindicated
110

---

111

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---

Placenta Previa
112

---

Pregnancy-Induced

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Hypertension
? Classification
?Chronic hypertension
?Preeclampsia superimposed
on chronic hypertension

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?Transient hypertension
?Preeclampsia, eclampsia
? Transient hypertension
?Mid-trimester
?140/90 or greater without signs of preeclampsia

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?No compromise to pregnancy
?Regresses postpartum
113

---

Preeclampsia
? Hypertension: 140/90,SBP >20 or DBP > 10

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over baseline, proteinuria, +/- edema after 20
weeks
? If <20 weeks, consider molar pregnancy
? Vasospastic disease with end organ damage,
cause unknown

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? Symptoms: Headache, vision changes,
edema, abdominal pain
? Risk: Primigravidas, DM, HTN, age <20 or
>40, multiple gestation, obesity, renal disease,
molar pregnancy, family history

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114

---

115

---

Eclampsia
? Preeclampsia + seizure

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? Headache, CNS, visual changes, hyperreflexia
? Treatment
?Hydralazine for DBP >105 (labetalol, nitro,
nitroprusside)
Eclampsia possible

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?MgSO for seizures
4
up to 4-8 weeks
?Definitive: Delivery
postpartum

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?Monitor for hypermagnesemia
- reflexes, respiration
?Treatment: Calcium gluconate
? Complications: Liver or splenic hemorrhage, end 116
organ failure, intracranial bleed, abruption

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---

117

---

HELLP Syndrome
? Clinical variant of preeclampsia
? Multigravida

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? Diagnosed by lab tests
? Hemolysis, Elevated Liver enzymes, Low
Platelets (<100,000)
? Common complaint: Epigastric or right upper
quadrant pain

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? Hemolysis: Schistocytes (fragmented red cel s)
on peripheral smear
? Treatment: Same as preeclampsia
?Bedrest, delivery of fetus, magnesium, control BP
if DBP >105

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118
?No diuretics or ACE inhibitors

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Appendicitis
? Most common surgical emergency in pregnancy
? Incidence in pregnancy is the same

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? Diagnosis is often delayed, rate of perforation
results in:
? fetal mortality and maternal morbidity
? Symptoms and WBC count are unreliable
? Appendix may be pushed upward (RUQ) in the third

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trimester
? Diagnosis: Ultrasound helpful; MRI; CT scan
Pyelonephritis is a common misdiagnosis in
missed appendicitis in pregnancy
119

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---

Urinary Tract Infections
? Asymptomatic pyuria or bacteruria should be
treated aggressively
? Increased incidence during pregnancy
? Obtain urine culture

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? Consider inpatient treatment for pyelonephritis
? Increased risk of bacteremia, septic shock
? Can precipitate preterm labor
? Treatment: Cephalosporin, amoxicil in,
nitrofurantoin x 7-10 days

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120

---

Drugs in Pregnancy
? FDA safety category
?A: safe
?B: presumed safe

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?C: possible adverse effects (animal studies),
use if benefit outweighs risk
?D: use only in life-threatening emergencies with
no alternative
?X: do not use

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? Teratogenic risk is greatest at 4-12 weeks
? Use drugs only when medical y necessary
? Health of the mother takes precedence
121

---

Safe Drugs for Pregnancy (1)

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? Antibiotics
? Antiemetics
?Penicil ins
?Promethazine
?Cephalosporins

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(Phenergan)
?Nitrofurantoin
?Prochlorperazine
?Clindamycin
(Compazine)

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?Erythromycin (except
?Metoclopramide
esteolate)
(Reglan)
?Anti-TB drugs

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?Ondansetron (Zofran)
?Sulfonamides
? Vaccines
(except 3rd
?Td

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trimester)/bilirubin
?
?
Trimethoprim (except
Influenza

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1st trimester)/neural
?Hep B
tube and cardiac
?Rabies
defects

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122

---

Safe Drugs for Pregnancy (2)
? Asthma
? Antivirals
?Corticosteroids

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?Acyclovir
?Albuterol
?Zidovudine (AZT)
?Terbutaline
? Miscel aneous

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?Theophylline
?Diphenhydramine
? Hypertension
(Benadryl)
?Methyldopa

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?Amitriptyline (Elavil)
?Hydralazine
?Fluoxetine (Prozac)
?Beta blockers
?Famotidine (Pepcid)

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?Calcium channel
?Ranitidine (Zantac)
blockers
? Anticoagulants
?Heparin

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123
?Enoxaparin

---

Contraindicated Drugs in Pregnancy
? ASA
? Ergot alkaloids

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? NSAIDs (3rd trimester) ? Anticonvulsants
? Tetracycline
(Neuro/OB GYN
? ACE inhibitors
?

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consult)
Aminoglycosides
? Warfarin (Coumadin)
? Isotretinoin (Accutane)
? Live vaccines (MMR)

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124

---

APGAR Score
? Indicator of neonatal depression
? Measured at 1 and 5 minutes
? Appearance (color), Pulse, Grimace

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(reflex), Activity (tone), Respiratory
effort
? Score 0-2 each
0
1

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2
Color
Pale or blue
Pink body, blue
Pink body and

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extremities
extremities
Heart Rate
Absent
< 100 bpm

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> 100 bpm
Respiration
Absent
Slow and irregular Good, with crying
Reflex Response

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Absent
Grimace or
Coughs, sneezes
noticeable facial
or pul s away

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movement
Muscle tone
Absent
Some flexion of
Active,

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the extremities
spontaneous limb
125
movement

---

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Preterm Labor
? Labor before 37 weeks
? Sterile speculum and bimanual
exam
? Risk factors: PROM, abruption,

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cocaine, amphetamines,
multiple births, infection
? Admit, bed rest, tocolytics
(terbutaline)
126

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---

Premature Rupture of Membrane (PROM)
Mucus plug
Ruptured amniotic sac
127

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---

Premature Rupture of Membrane (PROM)
? Rupture prior to onset of labor
? Digital pelvic exams associated with
increased frequency
? Limit digital exams and use sterile gloves

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? Diagnosis: Examine vaginal fluid
?Nitrazine test: blue (positive) pH > 6.5
?Sterile speculum exam (ferning), avoid bimanual
? Complications: Premature labor, prolapsed
cord, infection (chorioamnionitis)

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? Admit
128

---

129

---

Umbilical Cord Prolapse

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? High perinatal mortality
? Knee-to-chest position
? Immediate C-section
Impede delivery and elevate presenting part
130

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---

Amniotic Fluid Embolism
? 2nd and 3rd trimesters
? Release of amniotic fluid into maternal circulation
resulting in an immunologic maternal response,
simulating anaphylaxis

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? Rare
? Occurs with labor, C-section, abruptio placentae,
abortion, amniocentesis, trauma
? Sudden cardiovascular col apse, usual y soon
after delivery, seizures

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? Shock, dyspnea, hypoxemia, ARDS, DIC
? High mortality (50% at one hour); supportive care
131

---

Postpartum Hemorrhage (1)
? Uterine atony

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?Most common in first 24 hrs
?Enlarged "doughy" uterus
?Risks: Prolonged or precipitous labor,
multiparity, multiple gestations

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?Treatment: Fundal massage, oxytocin, IV fluids
? Uterine rupture
?Prior C-section, trauma, cocaine, high doses of
oxytocin
?Shock, bleeding, absent heart tones, tender

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boggy uterus that expands
?Fluid resuscitation, immediate C-section
132

---

Postpartum Hemorrhage (2)
? Retained products of conception

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?Early or delayed postpartum hemorrhage
?Sudden, brisk, painless bleeding
?Globular, firm uterus
?Oxytocin, D&C, fluid resuscitation

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? Laceration of lower genital tract
? Coagulopathy
? Uterine inversion
?Excessive traction on umbilical cord
?Vaginal mass, uterus not palpable on exam

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?Obstetrical emergency (IV, O2, tocolytic drugs)
?Do not separate placenta
133
?Manual reduction or emergent laparotomy

---

Trauma in Pregnancy

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(see also Trauma lecture)
? Initial trauma care same as in non-pregnant
? RhoGAM if Rh negative and abdominal trauma
? No radiologic test should be withheld if needed for
maternal evaluation

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? Fetal monitoring >20 weeks
?Minimum of 4 hours
?Signs of fetal distress
?>8 contractions/hr suggest abruption
? Kleihauer-Betke test (controversial)

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? For hypotension: Turn on left side (displace
uterus off IVC), fluid bolus
Maternal stabilization is the most important
factor in determining fetal survival
134

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---

Peri-mortem C-Section
? Maternal cardiopulmonary arrest
? Indicators of fetal survival
?Cause of maternal death
?Quality of CPR

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?Gestational age (>24 weeks)
?Arrest to delivery time (survival unlikely after 20
minutes)
? Vertical abdominal and uterine incision
135

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---

Endometritis
? Risk factors: C-section, PROM, prolonged labor,
chorioamnionitis, multiple exams, internal
monitoring
? Fever, abdominal pain, foul-smel ing lochia

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? Usual y polymicrobial
? Admit, broad spectrum IV antibiotics
Mastitis/Breast Abscess
? Pain, erythema, fever, edema
? Engorged duct becomes blocked, then

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infected
? Staphylococcal infection
? Continue breast feeding
136
? Antibiotics (dicloxacil in, cephalexin) or I&D

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---

137

---

OB GYN QUESTIONS
138

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---

An Rh-negative patient with a
spontaneous abortion at 15 weeks
should be treated with:
A. 25 ug RhoGAM
B. 50 ug RhoGAM

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C. 100 ug RhoGAM
D. 300 ug RhoGAM
E. 250 ug RhoGam
OBG 1

---

Which of the following is

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associated with abruptio placenta?
A. Maternal shock without fetal distress
B. Uterine hypotonicity
C. Maternal hypertension
D. Placental coverage of the internal os

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E. Painless bleeding
OBG 2

---

30 y/o female in her third trimester
presents with a headache, a BP of 180/110,
and pitting pre-tibial edema. Which of the

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following is characteristic of the most
likely cause of these findings?
A. Polycythemia
B. Most often seen in multi-gravidas
C. Is not associated with HELLP syndrome

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D. Cannot occur post-delivery
E. Delivery is usual y curative
OBG 3

---

A 36 y/o female who is breast feeding
complains of breast pain. Examination

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reveals the left breast to be erythematous
and very tender. Appropriate treatment
for this disease includes which of the
following?
A. Cephalosporin

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B. Immediately stop milk expression / breast
feeding
C. Hospitalization
D. Aminoglycosides
E. Surgical debridement

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OBG 4

---

A 36 y/o is 2 hours post-partum. She
reports an acute onset of shortness of
breath. VS: BP: 90/60; RR: 40; HR: 112;
POx is 92%. Which of the following is

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characteristic of the most likely cause of
her clinical condition?
A. Usual y occurs in the 1st trimester
B. Frequently experience abdominal pain
C. 50% mortality at 1 hour

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D. Associated with hypertension
E. Usual y have a swol en, tender calf
OBG 5

---

A term pregnant female is brought in in
spinal precautions after a serious motor

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vehicle collision. Her blood pressure is
80/60 and her heart rate is 120. What should
be done first?
A. Administer one liter normal saline bolus
B. Perform a FAST ultrasound

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C. Start 2 large bore IVs
D. Transfuse 2 units O positive blood
E. Turn the patient onto her left side
OBG 6

---

Pre-eclampsia is characterized by:

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A. Hypertension and seizures
B. Elevated platelet count
C. Hypertension, proteinuria and edema
D. Hypertension, proteinuria and seizures
E. Roth spots and Janeway lesions

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OBG 7

---

Which is true about abruptio
placentae?
A. Occurrence in the second trimester
B. Abruptions tend to be painless

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C. Due to placental insertion over the cervical os
D. May occur without visible bleeding
E. Pelvic examinations are not contraindicated
OBG 8

---

RhoGAM should be given to which of

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the following patients?
A. An RH-positive patient with an incomplete
abortion at 14 weeks
B. An RH-negative patient with an incomplete
abortion at 5 weeks

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C. An RH-positive patient with an ectopic
pregnancy
D. An RH-negative patient with a GSW to the
shoulder
E. An RH-negative patient with non-traumatic

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pelvic pain
OBG 9

---

A 19 y/o female presents following a
syncopal episode and an onset of
abdominal pain. Her UHCG is +. Which risk

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factor is associated with the most likely
diagnosis?
A. Previous intrauterine pregnancy
B. Cholecystectomy
C. Condyloma acuminata

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D. Tubal ligation
E. Abdominal trauma
OBG 10

---

A 28 y/o patient presents with an abrupt
onset of severe, right lower quadrant pain,

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UHCG is negative. She has a history of
uterine fibroids. What is the most
appropriate next step?
A. CT of the abdomen
B. Surgical consult for emergent appendectomy

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C. Pain management and outpatient pelvic
ultrasound
D. Pelvic ultrasound
E. Ceftriaxone IM and doxycycline PO
OBG 11

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---

Which drug has been determined safe
during pregnancy?
A. Tetracycline
B. Chloramphenicol
C. Heparin

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D. Coumadin
E. Ibuprofen in the third trimester
OBG 12

---

A 22 y/o female presents with a chief
complaint of vaginal discharge.

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Examination reveals a copious, gray,
vaginal discharge with a "fishy" odor.
Which is consistent with this etiology?
A. "Strawberry" cervix on exam
B. It is an STD

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C. The presence of clue cel s
D. Treated with Ampicil in
E. Treated with Fluconazole
OBG 13

---

A 40 y/o female presents with a papulo-

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squamous rash involving the trunk and
palms. The rash is non-pruritic and
annular in shape. She reports a labial ulcer
2 months ago. Which of the following is
characteristic of the most likely disease?

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A. Incubation period is 21 days
B. Both the dark-field microscopy and the
serology are negative at this stage
C. The painless ulcer persists in this stage
D. These lesions are typical y seen one week

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after sexual contact
E. The rash is unique and specific for this
disease
OBG 14

---

A 20 y/o ill-appearing female presents with

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a fever, vaginal discharge, cervical motion
and adnexal tenderness. Which of the
following is the most appropriate action?
A. Floxin 400 mg PO
B. IV Ceftriaxone and doxycycline PO

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C. IV Ceftriaxone, doxycycline, metronidazole
and admission
D. IM Benzathine Penicil in G
E. IV Ceftriaxone and IV doxycycline and
discharge

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OBG 15

---

A 30 y/o female presents to the ED with a
chief complaint of painful urination.
Examination reveals verrucous lesions at
the labia majora. Which is true regarding

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the most likely etiology?
A. Cannot be reliably distinguished from
secondary syphilis visual y
B. Should be treated with excision in the ED
C. Is not associated with cervical cancer

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D. Does not freak people out
E. Sensitive to acyclovir
OBG 16

---

Which of the following is true about
chancroid?

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A. It is caused by a gram positive bacil us
B. It is caused by the sole pathogen
responsible for inguinal bubo formation
C. It may be treated with ceftriaxone or
erythromycin

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D. It causes painless ulcers
E. It is less common in developing countries
OBG 17

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A 37 y/o female reports pain and swelling in
her groin. She reports a small ulcer in the

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same location 3 months ago. She has a
tender area in the groin, draining purulent
fluid. Which is true regarding this disease?
A. Incubation period fol owing the initial lesion is
up to 12 months

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B. Etiology is C. trachomatis
C. Endemic in the U.S.
D. Treated with Cetriaxone
E. Associated with + VDRL
OBG 18

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A 34 y/o G4 P3 patient presents with right
upper quadrant pain, bleeding gums and
early petechiae on her extremities. Which
of the following is consistent with this
syndrome?

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A. Positive serum ketones
B. Hypobilirubinemia
C. Metabolic acidosis
D. Thrombocytosis
E. Hemolysis

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OBG 19

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Which of the following is most
consistent with ectopic pregnancy?
A. + HCG 2 weeks post-partum with adnexal
tenderness on bimanual examination

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B. + HCG above discriminatory zone and no
IUP on ultrasound
C. - HCG and adnexal mass on bimanual
examination
D. + HCG and yolk sac and gestational sac

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identified on ultrasound
E. + HCG and no fetal heart tones detected by
doppler
OBG 20

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OB GYN Answer Key

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1. D
11.D
2. C
12.C
3. E

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13.C
4. A
14.A
5. C
15.C

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6. E
16.A
7. C
17.C
8. E

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18.B
9. B
19.E
10.D
20.B

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