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Ulcerative Infections
? Syphilis (primary) ? Pediculosis
? Herpes genitalis ? Scabies
? Chancroid
? Pyoderma
? Lymphogranuloma
? Trauma
venereum
? Excoriations
? Granuloma inguinale ? Bechet's disease
(donovanosis)
? Fixed drug eruption
? Mol uscum
? Yeast infection
contagiosum
? Genital warts
2



Famous People in History
Diagnosed with Syphilis
3

Just to Name a Few!
? Columbus
? Al Capone
? Henry VIII
? Beethoven
? Charles VIII
? Toulouse-Lautrec
? Merriweather Lewis
? Vincent Van Gogh
? Lenin
? James Joyce
? Hitler
? Baudelaire
? Idi Amin
? Paul Gauguin
? Ivan the Terrible
? Scott Joplin
? Benito Mussolini
? Edouard Manet
? Ben Franklin
? Franz Schubert
? Abraham and Mary Todd ? Tolstoy
Lincoln
? Nietzsche
? Robert Schumann
? Karen Blixen
4
? Howard Hughes

Syphilis
"The Great Imitator"
? Treponema pal idum (spirochete)
? 1o Syphilis ? genital ulcers (chancre)
?Painless, indurated, sharply demarcated, red smooth
base
?Heals spontaneously in 4-8 weeks
?Incubation period ? 9-90 days (2?4 weeks average)
?Dark field microscopy is 80% sensitive (operator
dependent)
?The VDRL and RPR tests detect nonspecific
treponemal antibodies
Serology (VDRL / RPR) is Often Negative
5
In Early Primary Syphilis



Primary Syphilis (1)
Chancre (Painless)
Spirochete
6



Primary Syphilis (2)
Chancre (Painless)
7
Logical Images Inc.

Syphilis (2)
? 2o: Onset 2-10 weeks after the chancre, rash
(maculopapular rash that often includes palms and
soles), fever, arthralgias, condyloma lata, painless
lymphadenopathy
? Latent
? 3o: 3-25 years after infection (immunocompetent)
?Neurosyphilis
?Meningitis, dementia, neuropathy
?Cardiovascular syphilis
?Thoracic aortic aneurysm, aortic insufficiency
?Skin lesions (gummas)
?Bone and joint disease (Charcot's joint)
8


Secondary Syphilis (1)
9

Secondary Syphilis (2)
10
Med-Chal enger ? EM


Secondary Syphilis (3)
11


Secondary Syphilis (4)
12


Condyloma Lata
?Secondary
syphilis
?Smooth, moist,
flat warts
Med-Chal enger ? EM
?Genital, perianal
?Fluid positive for
spirochetes (dark
field)
13

Syphilis (4)
? Positive darkfield microscopy for primary and
secondary lesions
? Non-treponemal tests
?RPR, VDRL (not specific for syphilis)
?Positive 14 days after chancre in most
?Occasional false positives
?Follow titers to assure cure
? Treponemal (MHA-TP and FTA-ABS)
?Best sensitivity / specificity
?Expensive and difficult to perform
?Titers not predictive of cure
14


Tertiary Syphilis (Charcot's Joint)
15

Tertiary Syphilis (Gummas)
16


Tertiary Syphilis (Gummas)
17

Syphilis (5)
? Test for HIV
? Jarisch-Herxheimer reaction: release of
endotoxin from spirochete death (fever,
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
?Penicil in strongly preferred first line agent
? Desensitization recommended
?Doxycycline, tetracycline, ceftriaxone, azithromycin
possible alternatives
18



Genital Herpes Simplex
19

Genital Herpes Simplex (1)
? HSV-2 (more common in U.S.) or HSV-1
? Prodrome: Burning, itching, paresthesias
? Fever, malaise, headache, myalgias,
adenopathy
?Common in first episode
? 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
weeks to heal
20

Genital Herpes Simplex (2)
? Symptomatic recurrences are the rule (60%
to 90%)
? 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
21

Genital Herpes Simplex (3)
? Diagnosis
?Usual y clinical
?Viral tissue culture (3-10 days, false
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
sensitivity
22

Genital Herpes
23
Logical Images Inc.

Genital Herpes Simplex (4)
? Complications: meningitis (10% if primary),
encephalitis, hepatitis, transverse myelitis,
erythema multiforme, urinary retention
(sacral root ganglia)
? Treatment: Acyclovir / valacyclovir /
famciclovir
? Controls symptoms, decreases relapses,
shortens course
? C-section if active genital herpes
? Neonatal herpes
?Acquired at birth
?High mortality
24

Perianal Herpes
25
Logical Images Inc.


Chancroid (1)
26

Chancroid (2)
? Haemophilus ducreyi (Gram negative
bacil us)
? More common in developing countries, rare
in USA
? Incubation period is 3-6 days
? Vesiculopustular lesion, then painful genital
ulcer or ulcers
? Tender unilateral adenopathy, bubo
formation with spontaneous rupture
? Diagnosis: Clinical; r/o HSV, syphilis
? Treatment: Ceftriaxone, azithromycin,
ciprofloxacin, erythromycin
27
Distinguish from non-painful lesion of primary syphilis


Chancroid (3)
"Kissing lesion"
Autoinnoculation
28

Lymphogranuloma Venereum
29

Lymphogranuloma Venereum (LGV)
? Chlamydia trachomatis (only certain serotypes)
? Endemic in some regions, seen only sporadical y in
USA
? Incubation 1-3 weeks
? Shal ow, painless, genital vesicles and papules heal
in 2-3 days
? Painful inguinal nodes ("buboes") weeks to months
later, "groove sign"
? Fever, chil s, arthralgias, E. nodosum
? Diagnosis: Complement fixation titer, culture of
aspirate
? Treatment: Doxycycline or erythromycin x 3 weeks
30

Lymphogranuloma Venereum
31


Lymphogranuloma Venereum
"Groove Sign"

32

Ulcerative Lesions
STD
Ulcer
Adenopathy
Systemic
Symptoms

Syphilis
Single
Minimal
None
(primary)
Painless
Starts as papule
Syphilis
None
Generalized
Generalized rash
(secondary)
Nontender
Mucous patches
Nonfluctuant
Condyloma lata
Herpes
Multiple
Shotty
Flu-like
Shal ow
Bilateral
Precedes lesions
Painful
Minimal y tender
Starts as vesicle
Chancroid
Single or multiple
Unilateral
None
Painful
Fluctuant
Purulent base
LGV
Evanescent
Groove sign
Sometimes
Multiple
Painless
33
Starts as vesicle

Nonulcerative Infections
? Chlamydia
? Gonorrhea
? Nongonococcal urethritis
? Pelvic inflammatory disease
? Secondary/tertiary syphilis
? Candidal vaginitis
? Trichomonas
? Bacterial vaginosis
? Endometriosis
34


Chlamydia
35

Chlamydia Trachomatis
? Number one STD
? Major cause of female infertility/PID
? Co-infection common
? Symptoms of local disease
?Penile or vaginal discharge
?Dysuria
?Females: Cervicitis, urethritis, PID
?Males: Epididymitis, urethritis, proctitis
?Abnormal vaginal bleeding
?Abdominal, pelvic pain, testicular pain
36

Chlamydia Trachomatis
? 1-3 week incubation period
? Often asymptomatic
? Highest rate in sexual y active adolescent
females
? Consider with sterile pyuria
? Diagnosis: Cultures low yield, indirect
methods (DNA probes or nucleic acid
amplification tests)
? Treatment: Azithromycin or doxycycline
37

Gonorrhea
? Incubation of 1 to 14 days
? 20% of women with untreated gonorrhea
develop PID
? Symptoms of localized disease
?Penile or vaginal discharge
?Dysuria
?Females: Cervicitis, urethritis, proctitis, PID
?Males: Epididymitis, urethritis, proctitis,
prostatitis
?Abdominal and pelvic pain
?Asymptomatic (most frequent in women) 38

Gonorrhea
39

Gram Negative Diplococci
40

Gonorrhea
? Diagnosis: Gram stain, culture or nucleic
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)
?Cefixime PO no longer an alternative (no
longer a treatment option per the CDC)
41

Gonorrhea
Non-Genital GC
? Rectal GC: Proctitis with purulent discharge
? GC conjunctivitis (purulent discharge)
? Pharyngitis
? Pelvic inflammatory disease (PID)
? Disseminated gonococcal disease
?Skin lesions
?Arthritis, tenosynovitis
?Endocarditis
?Meningitis
** Most common cause of septic
arthritis in pts. <50 y.o.**
42

Gonococcemia
? Fever, polyarthritis or monarthritis (knees,
ankles), tenosynovitis (wrists, ankles); often
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
? Genital and pharynx cultures
? Rule out syphilis, Chlamydia
? Treatment: Ceftriaxone, cefotaxime, cefoxitin
with probenecid

Disseminated Gonococ
Gonococcemia c
emia

Gonococcemia
45

Gonococcal Pustule
Gonococcemia
Logical Images Inc.


GC Conjunctivitis
47

Pelvic Inflammatory Disease
48

Pelvic Inflammatory Disease (1)
? Neisseria gonorrhoeae, Chlamydia
trachomatis (most common)
? Polymicrobial infections (including
anaerobes) are also common 30-40%
? Risk factors: Prior STD/PID, IUD in 1st
month of insertion, young age, multiple
partners
? Decreased risk of PID
?Pregnancy
?Barrier contraceptives
49

Pelvic Inflammatory Disease (2)
? 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
? Additional criteria improve specificity
?Temp >101 (38.3)
?Abnormal cervical or vaginal mucopurulent
discharge
?Elevated ESR/CRP
?Lab confirmation of gonorrhea or chlamydia 50

Pelvic Inflammatory Disease (3)
51

Pelvic Inflammatory Disease (4)
? Admission criteria
?Toxic (e.g. intractable nausea / vomiting,
fever)
?Pregnancy
?Surgical emergency not ruled out
?Outpatient compliance issues
?Failed outpatient therapy
?TOA (tubo-ovarian abscess)
?Consider in nul iparous females
52

Pelvic Inflammatory Disease (5)
? Inpatient treatment ? 2 regimens
?Cefotetan or cefoxitin; plus doxycycline
?Clindamycin plus gentamicin
?Alternative: Ampicil in/sulbactim PLUS doxycycline
? Outpatient treatment: 3 regimens
?Ceftriaxone plus doxycycline + /- metronidazole
?Cefoxitin and probenecid plus doxycycline +/-
metronidazole
?Other parenteral third generation cephalosporin
(ceftizoxime or cefotaxime) plus doxycycline +/-
metronidazole
53

Pelvic Inflammatory Disease (6)
? Remove IUD if in place
? Treat partner
? Complications
?Ectopic
?Infertility
?Adhesions
?Tubo-ovarian abscess (1/3 of hospitalized
patients)
?Chronic pelvic pain
?Dyspareunia
54




Fitz-Hugh-Curtis Syndrome
55

Pelvic Inflammatory Disease (6)
? Fitz-Hugh-Curtis syndrome
?Purulent material spil s from tubes into
abdomen
?Direct or lymphatic spread
?Bacterial perihepatitis
?LFTs usually normal
?Right upper quadrant and shoulder pain
?"Violin string" adhesions around the liver
56

Vulvovaginitis
? 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
prepubertal girls
? Normal vaginal pH 4.0-4.5
57


Trichomoniasis (1)
58

Trichomoniasis (2)
? Vaginitis
?Flagel ated protozoan
?Yel ow-green, frothy, malodorous discharge;
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
59


Trichomoniasis (3)
?Diagnosis: Wet mount
(motile trichomonads),
spun urine, cultures
?Treatment: Metronidazole or tinidazole
(single dose), topical not recommended
?Disulfiram-like reaction with alcohol
?Transmitted sexual y - treat partner
?Associated with PROM, preterm delivery,
low birth weight
60


Bacterial Vaginosis (1)

? Most common cause of vaginal discharge
? Normal vaginal flora (lactobacil i) replaced by
Gardnerel a and anaerobes
? 3 of 4 criteria per CDC:
?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)
whiff test
61

Clue Cells
62


Bacterial Vaginosis (2)

? Treatment: Metronidazole PO or gel,
clindamycin cream
? Risk of preterm labor, PROM, preterm
birth, postpartum endometritis
? All symptomatic women need treatment
? All pregnant patients should be treated
63

Candidal Vaginitis (1)
? Candida albicans 85-92%
? Part of normal flora
? Risk factors: Diabetes, oral contraceptives,
antibiotics, pregnancy
? Symptoms: Vulvar pruritis (most common),
vaginal discharge, dyspareunia, and dysuria
? Exam: Vulvar erythema, edema or
excoriation
? Cottage cheese non-odorous discharge
64


Candidal Vaginitis (2)
65

Candidal Vaginitis (3)
? Diagnosis
?KOH wet mount: pseudohyphae,
budding yeast
?Normal pH
? Treatment: Fluconazole 150mg po once;
Multiple OTC and prescription topical
agents
? Topical imidazoles more effective than
nystatin
? Pregnancy: Topical imidazoles only x 7d
66

Hyphae
67

Vulvovaginitis
Clinical Findings
Diagnostic Testing
BV
Trich
Candida
pH > 4.5
Yes
Yes
No
WBCs
++
+++
No
Clue cel s
Yes
No
No
Trichomonads
No
Yes
No
Yeast forms
No
No
Yes
Sexual y transmitted?
No
Yes
No
Treat sexual partners?
No
Yes
No


Bartholin Gland Abscess
69


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

Condyloma Accuminata (1)
71

Condyloma Accuminata (2)
? Human papil oma virus (DNA virus), also cal ed
venereal warts
? 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
? Direct contact
? Painless (location and size may cause discomfort)
? Treatment
?Condylox (podofilox topical)
?Aldara (imiquimod topical)
?Cryotherapy
72

Condyloma Accuminata (3)
73
Logical Images Inc.

Ovarian Cyst
? Symptomatic cysts >3 cm
? Fol icular cyst occurs first 2 weeks of menstrual
cycle
? Mittelschmerz: Transient ovulatory mid-cycle
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
?Hemorrhage can occasional y cause shock and
require emergent surgery
? Diagnosis: Ultrasound, CT, laparoscopy
74



Ovarian Follicular Cyst
76


Ovarian Cyst
77

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
? Severe abdominal pain, constant, unilateral
? Nausea, vomiting, usual y afebrile
? Vaginal bleeding is uncommon
? Exam: Unilateral tenderness, rebound or mass
? Diagnosis: Ultrasound, laparoscopy
? Rule out ectopic, appendicitis, PID
78


Endometriosis (1)
79

Endometriosis (2)
? Endometrium outside of the uterus
? Ovaries, fal opian tubes, bladder, abdominal
cavity, lung (catamenial pneumothorax)
? Constant pelvic pain associated with menses
? Dyspareunia, hypermenorrhea, infertility
? Exam: Adherent uterus, ovarian mass (chocolate
cyst), pelvic tenderness and nodularity
? Diagnosis: Laparoscopy
? Treatment: Analgesics, hormones, surgery
Endometriosis most commonly involves the
ovaries
80


Leiomyomas (Fibroids) (1)
81

Leiomyomas (Fibroids) (2)
? Benign tumors of uterine muscle
? Most common pelvic tumor; most common in
African American women
? Pelvic pain, abnormal bleeding
? Pregnancy can result in rapid growth and
loss of blood supply (degeneration)
? Diagnosis: Ultrasound
? Treatment: NSAIDs, hormonal therapy,
surgery
82

Uterine Cancer
? Most common gynecologic cancer
?Adenocarcinoma most common type
?Sarcoma (aggressive, worst prognosis)
? Average age 58
? Risk: Continuous estrogen, obesity, diabetes,
hypertension, nul iparity, early menses, late
menopause
? Abnormal bleeding, painless uterine
enlargement
? Diagnosis: D&C or uterine biopsy
Postmenopausal women with bleeding
83


Uterine Cancer
84

Ovarian Cancer
? Peak incidence age 55-65
? 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
? Exam: Fixed unilateral mass
? Diagnosis: CT scan, pelvic ultrasound
Ascites in females is a gynecologic neoplasm
until proven otherwise (e.g., ovarian cancer)
85

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

Abnormal Vaginal Bleeding
(Non-Pregnant)
? Non-uterine: Cervix, vagina, urinary, GI,
coagulation disorders
? Ovulatory: Menorrhagia (heavy bleeding),
metrorrhagia (outside cycle); polyps, tumors,
cancer, infection, fibroids, endometriosis,
dyscrasias
? Anovulatory (DUB): Prolonged amenorrhea with
intermittent menorrhagia; endocrine disorders,
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


Obstetrics
88


What is the age of the oldest
woman to give birth?


67 years / In vitro / Twin Boys
90

Normal Pregnancy
? Breast tenderness, "morning sickness"
? Fundus at umbilicus: 20 weeks
? Chadwick's sign (blue, soft cervix)
? Increased blood volume, coagulation factors, cardiac
output
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
91



Weight of Largest Viable Baby
Born?
?22.8 pounds !!
92

Abortions (1)
? Threatened
? Incomplete
?Bleeding, pain
?Bleeding
?Closed os
?Tissue at os
?<20 weeks
?Products of
?Vaginal rest, normal
conception
activities
?D&C
? Inevitable
?Includes 1st or 2nd
?Bleeding
trimester fetal
?
demise or
Open os
anembryonic
?<20 weeks
gestation
?D&C
93

Abortions (2)
? Complete
?Passed al tissue with
pain, bleeding
?Closed os
?Ultrasound
?May need D&C
? Septic
?Polymicrobial
?Endometritis,
peritonitis, sepsis
?IV antibiotics
94
?D&C

Ectopic Pregnancy
95

Ectopic Pregnancy (1)
? Risk factors
? Location
?Previous ectopic
?Distal fal opian tube most
?PID / IUD
common
?
?
Tubal ligation, pelvic
Indicates IUP on US
surgery
? Double gestational sac
?Infertility treatment
? Yolk sac or fetal pole
?Half have NO risk factor
? Fetal heart activity
?
? HCG
Characteristics
?Slower than normal
?5-8 weeks after LNMP,
increase in HCG
pain, abnormal bleeding
?Level correlated with US
?Relative bradycardia may
results improves predictive
be associated with occult
value
blood loss
96



ED Ultrasound: 1st Trimester
Pregnancy
Yolk Sac
Gestational Sac
(double Ring)

97
IUP

Ectopic Pregnancy (2)
? Transvaginal US: Most sensitive, diagnostic in
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
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
Consider a heterotopic pregnancy (IUP & 98
ectopic) in fertility assisted patients


Ectopic Pregnancy (3)
99

Ectopic Pregnancy (4)
? Diagnosis
?IUP on US: High probability no ectopic
?Diagnostic for ectopic
? Empty uterus, embryonic cardiac activity
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
? Consultation, admit or close fol ow up
? Ectopic precautions
100
? Serial HCG & ultrasound



Ectopic Pregnancy
101

Ectopic Pregnancy (4)
Treatment
? Surgical
?Laparoscopic salpingostomy if unruptured
?Laparotomy if hemodynamical y unstable,
ruptured
? Medical: Methotrexate
?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
?Significant failure rate (up to 36%)
102


Laparoscopy
103

RhoGAM
? RhoGAM = IgG anti-D antibodies
? Destroy Rh+ fetal red cel s in the maternal
circulation
? If RhoGAM not given, mother develops
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,
trauma (even relatively minor)
? Dose: 50 mcg if <12 weeks, 300 mcg if >12
104
weeks

Molar Pregnancy (1)
Gestational Trophoblastic Disease
? Proliferation of chorionic vil i; no fetus =
Complete hydatidiform mole, if fetal tissue
incomplete
? 1st and 2nd trimester bleeding,
hyperemesis gravidarum,
no fetal heart tones
? Passage of "grape-like clusters"
? Uterine size > gestational age
? HCG level greater than expected
? Complications: Neoplasm, preeclampsia, PE 105


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


Molar Pregnancy (3)
107

Abruptio Placentae
? 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,
contractions, uterine tenderness
? Ultrasound is not sensitive for diagnosis
? Fetal monitoring for fetal distress
? Misdiagnosed as preterm labor
?Complications: Fetal and maternal death, DIC
? May or may not be associated with painful dark
108
red bleeding


109

Placenta Previa
? Implantation of placenta over the cervical os
? Increased incidence: Older, multiparity, smoking,
prior c-section
? Diagnosis: Ultrasound highly accurate
Painless third trimester bright red bleeding
Pelvic exam contraindicated
110


111


Placenta Previa
112


Pregnancy-Induced
Hypertension
? Classification
?Chronic hypertension
?Preeclampsia superimposed
on chronic hypertension
?Transient hypertension
?Preeclampsia, eclampsia
? Transient hypertension
?Mid-trimester
?140/90 or greater without signs of preeclampsia
?No compromise to pregnancy
?Regresses postpartum
113

Preeclampsia
? Hypertension: 140/90,SBP >20 or DBP > 10
over baseline, proteinuria, +/- edema after 20
weeks
? If <20 weeks, consider molar pregnancy
? Vasospastic disease with end organ damage,
cause unknown
? Symptoms: Headache, vision changes,
edema, abdominal pain
? Risk: Primigravidas, DM, HTN, age <20 or
>40, multiple gestation, obesity, renal disease,
molar pregnancy, family history
114


115

Eclampsia
? Preeclampsia + seizure
? Headache, CNS, visual changes, hyperreflexia
? Treatment
?Hydralazine for DBP >105 (labetalol, nitro,
nitroprusside)
Eclampsia possible
?MgSO for seizures
4
up to 4-8 weeks
?Definitive: Delivery
postpartum
?Monitor for hypermagnesemia
- reflexes, respiration
?Treatment: Calcium gluconate
? Complications: Liver or splenic hemorrhage, end 116
organ failure, intracranial bleed, abruption


117

HELLP Syndrome
? Clinical variant of preeclampsia
? Multigravida
? Diagnosed by lab tests
? Hemolysis, Elevated Liver enzymes, Low
Platelets (<100,000)
? Common complaint: Epigastric or right upper
quadrant pain
? Hemolysis: Schistocytes (fragmented red cel s)
on peripheral smear
? Treatment: Same as preeclampsia
?Bedrest, delivery of fetus, magnesium, control BP
if DBP >105
118
?No diuretics or ACE inhibitors

Appendicitis
? Most common surgical emergency in pregnancy
? Incidence in pregnancy is the same
? 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
trimester
? Diagnosis: Ultrasound helpful; MRI; CT scan
Pyelonephritis is a common misdiagnosis in
missed appendicitis in pregnancy
119

Urinary Tract Infections
? Asymptomatic pyuria or bacteruria should be
treated aggressively
? Increased incidence during pregnancy
? Obtain urine culture
? Consider inpatient treatment for pyelonephritis
? Increased risk of bacteremia, septic shock
? Can precipitate preterm labor
? Treatment: Cephalosporin, amoxicil in,
nitrofurantoin x 7-10 days
120

Drugs in Pregnancy
? FDA safety category
?A: safe
?B: presumed safe
?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
? 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)
? Antibiotics
? Antiemetics
?Penicil ins
?Promethazine
?Cephalosporins
(Phenergan)
?Nitrofurantoin
?Prochlorperazine
?Clindamycin
(Compazine)
?Erythromycin (except
?Metoclopramide
esteolate)
(Reglan)
?Anti-TB drugs
?Ondansetron (Zofran)
?Sulfonamides
? Vaccines
(except 3rd
?Td
trimester)/bilirubin
?
?
Trimethoprim (except
Influenza
1st trimester)/neural
?Hep B
tube and cardiac
?Rabies
defects
122

Safe Drugs for Pregnancy (2)
? Asthma
? Antivirals
?Corticosteroids
?Acyclovir
?Albuterol
?Zidovudine (AZT)
?Terbutaline
? Miscel aneous
?Theophylline
?Diphenhydramine
? Hypertension
(Benadryl)
?Methyldopa
?Amitriptyline (Elavil)
?Hydralazine
?Fluoxetine (Prozac)
?Beta blockers
?Famotidine (Pepcid)
?Calcium channel
?Ranitidine (Zantac)
blockers
? Anticoagulants
?Heparin
123
?Enoxaparin

Contraindicated Drugs in Pregnancy
? ASA
? Ergot alkaloids
? NSAIDs (3rd trimester) ? Anticonvulsants
? Tetracycline
(Neuro/OB GYN
? ACE inhibitors
?
consult)
Aminoglycosides
? Warfarin (Coumadin)
? Isotretinoin (Accutane)
? Live vaccines (MMR)
124

APGAR Score
? Indicator of neonatal depression
? Measured at 1 and 5 minutes
? Appearance (color), Pulse, Grimace
(reflex), Activity (tone), Respiratory
effort
? Score 0-2 each
0
1
2
Color
Pale or blue
Pink body, blue
Pink body and
extremities
extremities
Heart Rate
Absent
< 100 bpm
> 100 bpm
Respiration
Absent
Slow and irregular Good, with crying
Reflex Response
Absent
Grimace or
Coughs, sneezes
noticeable facial
or pul s away
movement
Muscle tone
Absent
Some flexion of
Active,
the extremities
spontaneous limb
125
movement


Preterm Labor
? Labor before 37 weeks
? Sterile speculum and bimanual
exam
? Risk factors: PROM, abruption,
cocaine, amphetamines,
multiple births, infection
? Admit, bed rest, tocolytics
(terbutaline)
126


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

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
? Diagnosis: Examine vaginal fluid
?Nitrazine test: blue (positive) pH > 6.5
?Sterile speculum exam (ferning), avoid bimanual
? Complications: Premature labor, prolapsed
cord, infection (chorioamnionitis)
? Admit
128


129

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

Amniotic Fluid Embolism
? 2nd and 3rd trimesters
? Release of amniotic fluid into maternal circulation
resulting in an immunologic maternal response,
simulating anaphylaxis
? Rare
? Occurs with labor, C-section, abruptio placentae,
abortion, amniocentesis, trauma
? Sudden cardiovascular col apse, usual y soon
after delivery, seizures
? Shock, dyspnea, hypoxemia, ARDS, DIC
? High mortality (50% at one hour); supportive care
131

Postpartum Hemorrhage (1)
? Uterine atony

?Most common in first 24 hrs
?Enlarged "doughy" uterus
?Risks: Prolonged or precipitous labor,
multiparity, multiple gestations
?Treatment: Fundal massage, oxytocin, IV fluids
? Uterine rupture
?Prior C-section, trauma, cocaine, high doses of
oxytocin
?Shock, bleeding, absent heart tones, tender
boggy uterus that expands
?Fluid resuscitation, immediate C-section
132

Postpartum Hemorrhage (2)
? Retained products of conception

?Early or delayed postpartum hemorrhage
?Sudden, brisk, painless bleeding
?Globular, firm uterus
?Oxytocin, D&C, fluid resuscitation
? Laceration of lower genital tract
? Coagulopathy
? Uterine inversion
?Excessive traction on umbilical cord
?Vaginal mass, uterus not palpable on exam
?Obstetrical emergency (IV, O2, tocolytic drugs)
?Do not separate placenta
133
?Manual reduction or emergent laparotomy

Trauma in Pregnancy
(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
? Fetal monitoring >20 weeks
?Minimum of 4 hours
?Signs of fetal distress
?>8 contractions/hr suggest abruption
? Kleihauer-Betke test (controversial)
? For hypotension: Turn on left side (displace
uterus off IVC), fluid bolus
Maternal stabilization is the most important
factor in determining fetal survival
134

Peri-mortem C-Section
? Maternal cardiopulmonary arrest
? Indicators of fetal survival
?Cause of maternal death
?Quality of CPR
?Gestational age (>24 weeks)
?Arrest to delivery time (survival unlikely after 20
minutes)
? Vertical abdominal and uterine incision
135

Endometritis
? Risk factors: C-section, PROM, prolonged labor,
chorioamnionitis, multiple exams, internal
monitoring
? Fever, abdominal pain, foul-smel ing lochia
? Usual y polymicrobial
? Admit, broad spectrum IV antibiotics
Mastitis/Breast Abscess
? Pain, erythema, fever, edema
? Engorged duct becomes blocked, then
infected
? Staphylococcal infection
? Continue breast feeding
136
? Antibiotics (dicloxacil in, cephalexin) or I&D



137

OB GYN QUESTIONS
138

An Rh-negative patient with a
spontaneous abortion at 15 weeks
should be treated with:

A. 25 ug RhoGAM
B. 50 ug RhoGAM
C. 100 ug RhoGAM
D. 300 ug RhoGAM
E. 250 ug RhoGam
OBG 1

Which of the following is
associated with abruptio placenta?

A. Maternal shock without fetal distress
B. Uterine hypotonicity
C. Maternal hypertension
D. Placental coverage of the internal os
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
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
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
reveals the left breast to be erythematous
and very tender. Appropriate treatment
for this disease includes which of the
following?
A. Cephalosporin
B. Immediately stop milk expression / breast
feeding
C. Hospitalization
D. Aminoglycosides
E. Surgical debridement
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
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
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
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
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:
A. Hypertension and seizures
B. Elevated platelet count
C. Hypertension, proteinuria and edema
D. Hypertension, proteinuria and seizures
E. Roth spots and Janeway lesions
OBG 7

Which is true about abruptio
placentae?

A. Occurrence in the second trimester
B. Abruptions tend to be painless
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
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
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
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
factor is associated with the most likely
diagnosis?

A. Previous intrauterine pregnancy
B. Cholecystectomy
C. Condyloma acuminata
D. Tubal ligation
E. Abdominal trauma
OBG 10

A 28 y/o patient presents with an abrupt
onset of severe, right lower quadrant pain,
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
C. Pain management and outpatient pelvic
ultrasound
D. Pelvic ultrasound
E. Ceftriaxone IM and doxycycline PO
OBG 11

Which drug has been determined safe
during pregnancy?

A. Tetracycline
B. Chloramphenicol
C. Heparin
D. Coumadin
E. Ibuprofen in the third trimester
OBG 12

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

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

A 20 y/o ill-appearing female presents with
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
C. IV Ceftriaxone, doxycycline, metronidazole
and admission
D. IM Benzathine Penicil in G
E. IV Ceftriaxone and IV doxycycline and
discharge
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
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
D. Does not freak people out
E. Sensitive to acyclovir
OBG 16

Which of the following is true about
chancroid?
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
D. It causes painless ulcers
E. It is less common in developing countries
OBG 17

A 37 y/o female reports pain and swelling in
her groin. She reports a small ulcer in the
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
B. Etiology is C. trachomatis
C. Endemic in the U.S.
D. Treated with Cetriaxone
E. Associated with + VDRL
OBG 18

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?

A. Positive serum ketones
B. Hypobilirubinemia
C. Metabolic acidosis
D. Thrombocytosis
E. Hemolysis
OBG 19

Which of the following is most
consistent with ectopic pregnancy?
A. + HCG 2 weeks post-partum with adnexal
tenderness on bimanual examination
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
identified on ultrasound
E. + HCG and no fetal heart tones detected by
doppler
OBG 20

OB GYN Answer Key
1. D
11.D
2. C
12.C
3. E
13.C
4. A
14.A
5. C
15.C
6. E
16.A
7. C
17.C
8. E
18.B
9. B
19.E
10.D
20.B

This post was last modified on 24 July 2021