Obstetrics and Gynecology Flashcards

Endometriosis

  • Uterus not enlarged, bleeding into the peritoneal cavity.

  • Symptoms: Dysmenorrhea and dyspareunia (painful sex, especially during menstruation).

  • May displace cervix, causing cervical motion tenderness.

  • Risk factors: Nulliparity and low BMI.

  • Can cause infertility by disrupting pelvic anatomy, oocyte release, and sperm entry.

  • Treatment: NSAIDs, oral contraceptives, Mirena, GnRH agonists, cauterization, or removal of ovaries.

Uterine Polyps

  • Light abnormal uterine bleeding (AUB) with a normal-sized uterus.

  • Pedunculated fleshy growth that may be calcified.

  • Hyperechoic.

  • Doesn't affect ovulation; menses are regular with light intermenstrual bleeding due to friability and vascularity.

Fibroids

  • Irregular-sized, bulky, enlarged uterus due to smooth muscle proliferation within the myometrium.

  • Typically cause regular (ovulatory) but heavy, prolonged menses (menorrhagia), can cause AUB.

  • Growth increased by estrogen, pregnancy, and OCPs.

  • Globular masses can cause breech presentation.

Adenomyosis

  • Symmetrically (diffusely) enlarged, boggy (soft) uterus.

  • Endometrial glands within the myometrium.

  • Menorrhagia and dysmenorrhea, but no intermenstrual bleeding.

  • Treatment for AUB: IV estrogen or high-dose OCPs to stabilize the endometrium; high-dose progestin if estrogen is contraindicated.

Third Trimester Bleeding

Placenta Previa

  • Abnormal implantation where the placenta grows across the os.

  • Cervical dilation causes placental tearing.

  • Initial reassuring fetal monitoring.

  • Diagnosis: Transabdominal followed by TVUS.

  • Management: No sex, no digital cervical exam, inpatient admission for bleeding episodes.

  • Risk factors: Previous placenta previa, prior caesarean, multiple gestation, advanced maternal age.

  • Most cases resolve spontaneously by trimester 3; persistent cases require caesarean delivery at 36-37 weeks.

Vasa Previa

  • Blood vessels connect the uterus to an accessory lobe and lie across the os.

  • Tearing during cervical dilation leads to fetal exsanguination.

  • Diagnosis: NST showing fetal distress, bradycardia, and sinusoidal pattern.

  • Treatment: Urgent C-section.

Uterine Rupture

  • Risk factors: Previously scarred uterus (C-section), oxytocin-induced forceful contractions.

  • Loss of fetal station.

  • Fetal HR: Uterine rupture if 80 bpm at nadir; peak to nadir >30 sec.

  • Sudden decrease in HR with prolonged fetal HR deceleration.

  • Mother experiences increasing lower abdominal pain; vaginal bleeding is not always present.

  • Fetal parts may partially expel into the maternal abdomen, causing a palpable irregular abdominal protuberance.

  • Treatment: Crash C-section.

Vaginal Hematoma

  • Risk factors: Operative vaginal delivery, infant >8.8lb, nulliparity, prolonged 2nd stage of labor.

  • Vaginal purplish mass +/- hypovolemic shock.

  • Minimal external bleeding but significant blood loss as blood collects in the paravaginal potential space.

  • Treatment: Observation for non-expanding hematomas; embolization or surgery for expanding hematomas.

Uterine Inversion

  • Risk factors: Nulliparity, macrosomnia, placental accreta, rapid labor and delivery.

  • Due to excessive fundal pressure and traction on the umbilical cord before placental separation.

  • Smooth round mass protruding through the vagina/cervix; massive postpartum hemorrhage and hypovolemic shock with lower abdominal pain.

  • Uterine fundus no longer palpable transabdominally.

  • Management: Aggressive fluid replacement, manual replacement of uterus, placental removal, and uterotonic drugs after replacement.

Placental Abruptio

  • Placenta tears off the endometrium but remains in place.

  • Pain can be in the back or abdomen.

  • Firm uterus with unusually low-amplitude high-frequency contractions.

  • Concealed bleeding can cause uterine distension.

  • Large force needed to tear placenta off: HTN/cocaine use; MVA.

  • Tender, hypertonic uterus.

  • Diagnosis: US/NST.

  • Kleihauer-Betke test for fetomaternal hemorrhage to determine the necessary dose of anti-D Ig after delivery of Rh+ fetus to Rh- mother.

Fetal Heart Rate Decelerations

VEAL CHOP

  • Early decelerations: Head compression.

  • Late decelerations: Fetal hypoxemia and forceful contractions; stop oxytocin, give mother O2, change position (left lateral with legs raised), IV fluids.

  • Variable decelerations: Cord compression/abnormal position; abrupt decline and return to baseline.

  • Cord compression with <50% contractions well tolerated; maternal repositioning to reduce cord compression, amnioinfusion if no improvement.

  • Most ominous when repetitive and severe (below 60 bpm); if recurrent, perform Caesarian.

  • Prolonged deceleration: Decrease of 15 bpm below baseline for 2-10 minutes.

  • Sinusoidal tracing: Severe hypoxia (e.g., in Vasa Previa and Rh disease).

Umbilical Cord Prolapse

  • Abrupt, prolonged deceleration or bradycardia.

Contraception

Long Acting Reversible Contraception (LARC)

  • Most effective, even compared to tubal ligation/vasectomy.

  • Non-IUD: Subcutaneous etonogestrel arm implant (lasts 3 years); irregular bleeding/spotting common initially.

IUD

  • CI: Acute pelvic infection, severe uterine cavity distortion, AUB, Wilson disease.

  • Hormonal (5 years): CI in current breast cancer; can cause irregularity.

  • Copper (10 years): Longest acting.

Moderate Efficacy

  • Injections (3 months).

  • Patches (E+P): Highest risk of DVT/PE.

  • Rings (E+P): Minimal breakthrough bleeding.

  • OCPs: Inhibit LH surge -> no ovulation; metabolized via P450; used in AUB/choriogestational trophoblastic disease/molar pregnancy.

  • Mini Pill (Progesterone only): Daily compliance is crucial.

Low Efficacy

  • Condoms and diaphragms (diaphragm > cup).

Hysteroscopic Sterilisation

  • Insertion of nickel into FTs causing gradual scarring (backup birth control for 3 months until occlusion confirmed via hysterosalpingogram).

  • CI: Previous tubal ligation; allergy to contrast media/nickel; uterine/FT pathologies; recent/active pelvic infection.

OCP Combo Pills

  • Inhibits LH surge.

  • CI: >35 if smoking >15 cigarettes per day; SLE; migraine with aura; breast cancer; cirrhosis; RF for CV disease; thromboembolism; Hx of stroke, hepatocellular adenoma.

  • Oestrogen containing contraceptives CI <1 month postpartum (increased risk of thromboembolism).

Medroxyprogesterone Acetate Injection

  • Thickens cervical mucus; decidualises endometrium -> atrophy; impairs Tubal peristalsis.

  • Osteoporosis risk in over 35s.

  • Progestin only IUD does not affect thrombotic state -> systemic forms still not used in high risk pt.

  • Protective against endometrial cancer.

  • Oestrogen only contraception is CI in breastfeeding as can decrease milk production.

Emergency Contraception

  • Copper IUD: 0-120hr, >99% effective.

  • Ulipristal (Progestin R blocker): 0-120hr, 98-99% effective (delays ovulation).

  • Levonorgestrel: 0-72hr.

  • High dose OCPs: 0-72hr.

Oestrogen-progestin Contraceptive

Pros

  • Endometrial and ovarian cancer risk reduction, menstrual regulation, hyperandrogenism tx.

Cons

  • Thromboembolism; HTN; Stroke; MI, hepatic adenoma, cervical cancer, moderate breast cancer risk, mood changes (mainly due to progesterone).

Primary Amenorrhea

  • Absence of menarche in girls aged 13 or older with no secondary sexual characteristics or absence of menarche by 15 w secondary sexual characteristics

  • Absent Uterus? Go to Karyotype

    • 46 XY = AI

    • 46 XX = Mullerian Agenesis

  • Uterus Present? Check FSH

    • Low FSH = Central cause: Hypothyroidism, Prolactinoma, Functional Hypothalamic Amenorrhea (FHA), Cushings Syndrome

    • Norm FSH = Imperforate Hymen

    • High FSH = Peripheral cause: Primary Ovarian Insufficiency or Turners

  • Mullerian Agenesis (Mayer-Rokitansky-Kuster-Hauser Syndrome): MCC, normal secondary sexual characteristics, absent uterus and upper vagina (46XX with intact ovaries - hormonally normal), management includes renal tract evaluation and vaginal dilation.

  • Androgen Insensitivity Syndrome (defect in androgen receptor): Normal appearing female, decreased pubic and axillary hair, increased height, 46XY, presence of intraabdominal testicles, increased testosterone and LH and estrogen (aromatase conversion of testosterone)

  • 5-alpha reductase deficiency: Virilisation at puberty, 46XY, phenotypically F at birth, impaired testosterone to DHT conversion; normal male testosterone and estrogen levels, male internal genitalia, blind ending vagina, maternal virilisation (aromatase deficiency in foetus).

  • Turners Syndrome: Increased risk of aortic dissection d/t bicuspid AV; short stature; webbed neck; scoliosis; micrognathia; cubitus valgus renal and ovarian disorders common.

Abnormal Uterine Bleeding

  • Immature HPO Axis: Anovulatory, painless irregular heavy bleeding, unopposed estrogen, Tx with progesterone or combined oral pill.

  • Progesterone Challenge: Withdrawal bleeding suggests anovulation, Estrogen challenge if progesterone challenge negative (withdrawal bleeding signifies lack of Estrogen).

  • Maternal Oestrogen Effects in Newborns: Breast Hypertrophy, Swollen Labia, Physiologic Leukorrhea, Uterine withdrawal bleeding are all normal and transient.

  • Testes: Should descend by 6 months

  • Hypospadias (inferior): Ventrally displaced urethral opening, Karyotype and US analysis if severe.

  • Torsion of appendix testes: Classic ‘blue dot’ pathognomic sign, conservative Tx.

  • Peyronie Disease: Penile pain, curvature and dorsal nodules/plaques resolves spontaneously in 1-2 yrs in most; NSAIDs for pain and surgery.

Penile Cancer

  • Bowen disease: Cutaneous SCC in situ can progress to cancer (painless ulcer/nodule with inguinal LAD)

  • Varicocele: Decreased fertility and testicular atrophy, check for left renal cell cancer - Tx gonadal vein ligation.

  • Spermatocele: Cystic epididymis accumulations of sperm; usually asymptomatic.

  • Hydrocele: Transilluminates, collection of serous fluid;

    • Non communicating in adults - cancer/infection/trauma

    • Communicating in kids: Incomplete closure of processes vaginalis.

  • Hematocele: Testicular trauma Blood accumulation in tunica vaginalis; Pain.

  • Erectile Dysfunction Causes: Vascular, Neurological, Psychogenic (Norm non sexual nocturnal/morning erections), Endocrine (TSH/Prolactin - Hypogonadism), Medications.

  • Breast Mastitis: Flu like sx + fever; wedge shaped redness; purulent discharge, Dicloxacillin to cover MRSA and penicillin resistant Staph.

  • Breast fibroadenomas: Work up with US (less than 30) and Mammogram (more than 30).

  • Fibrocystic Changes of Breast: Diffuse, bilateral premenstrual tenderness - OCPs; danazol; NSAIDs

  • Galatocele: Benign milk retention cyst Can occur during lactation and Tri3; soft, mobile nontender mass as large as 5 cm

  • Phyllodes tumour - larger and greater metastatic potential

  • Paget’s disease of Breast - Erythematous, scaly or vesicular rash affecting nipple and areola Intraductal papilloma: No associated mass or LAD

  • Physiological Galactorrhea - Bilateral and guaiac negative w/o signs of malignancy

  • Inflammatory Breast Carcinoma - Edema, diffusely warm, dimpling, peau d’orange.

  • Tx of Breast cancer: SERMs - Risk of venous thromboembolism; endometrial cancer, Raloxifene - Risk of venous thromboembolism

  • Breastfeeding CI - Active untreated TB; HIV infection; Active varicella infection; Herpetic breast lesions

Pregnancy

Exercise CI

  • Increased risk antepartum bleeding eg placenta previa, Risk of preterm delivery eg insufficiency and Cardioresp Disease.

  • Shoulder Dystocia: Failure of usual obstetric manoeuvres to deliver fetal shoulders

  • Cephalopelvic disproportion: Failure to progress in labour

  • Hypotonic Contractions: Failure to progress in Labour

  • HTN and short interpregnancy interval risk of growth restriction

  • Oligohydramnios- Complications- Meconium aspiration; Preterm delivery; Umbilical cord compression

  • Polyhydramnios- Complications- Fetal malposition; Umbilical cord prolapse; Preterm labour; PPOM

  • Monochorionic gestation:- Risk of TTTS and Dichorionic gestation: LAMBDA SIGN

  • Patients at <32 gestation in preterm labour need: Indomethacin; Bethamethasone; Magnesium sulfate; Penicillin

  • External cephalic version: >/=37 wks gestation If breech/transverse

  • Preeclampsia: New onset HTN and proteinuria and/or end-organ damage at >20wks gestation Can present up to 6 wks postpartum - Delivery at 37wks

  • Preeclampsia with severe features —-> delivery >34wks Indication- obstetrical indications (failed induction); fetal HR abnormalities; Baby >5000g/4500 if gestational diabetes

  • HELLP Syndrome: Hemolysis, elevated liver enzymes, low platelets - Life threatening - Delivery (warranted at 34 wks or deteriorating maternal/fetal status)

  • Intrahepatic cholestasis of pregnancy: Generalised pruritusDevelops in third trimester Pruritus worse on hands and feet Complications- Intrauterine demise, preterm delivery, meconium stained amniotic fluid, neonatal RDS Management: Deliver at 37 wks

  • Acute fatty liver of pregnancy- RUQ pain, mildly elevated transaminases and resultant intrauterine demise Liver failure; Platelets </= 100,000; Immediate delivery

  • Maternal fever d/t intraamniotic infection (IAI) -> fetal tachycardia (>160 bpm)

  • Erythroblastosis fetalis- ABO Incompatabilty and Rh Incompatability RhoD IgG normally given at 28 wks and within 72 hrs

Pregnancy 2

  • PPROM: Rupture of membranes w/o onset of labour External Cephalic Version: Indicated for breech or CI - vaginal delivery, prior classical C Section Complications: Abruptio placentae and Intrauterine fetal demise

  • Vaginal delivery CI - incomplete or footling breech

  • Primary Dysmenorrhea- can be accompanied by n/v, diarrhoea or back pain Menopause- Need 12 months no bleeding to dx menopause - clinical dx.

  • Prolapse can occur post menopause, tx with hysterectomy, bladder tape for stress incontinence,

  • HRT- Treats vasomotor sx; mood and dryness in F < 60 and Topical estrogen used if mainly vaginal sx

  • Genitourinary syndrome of menopause- Urinary incontinence, recurrent UTI, Narrowed introitus, Loss of labial volume - Tx: Vaginal moisturiser and lubricant; Topical vaginal oestrogen

  • Vesicovaginal Fistula: Continuous clear vaginal discharge - Bladder dye testing used to confirm Dx

  • (Vulvar) Lichen Sclerosus: Vulvar pruritus and Hypopigmented (white) labial lesions Dx - Clinical with punch biopsy to confirm + rule out vulvar cancer and Tx - Superpotent topical corticosteroids eg Clobetasol

  • Pelvic Inflammatory Disease- Constant Pelvic pain, tenderness of cervix Purulent discharge Complications: Tubo-ovarian abscess; Infertility; Ectopic Pregnancy, Tx : IM Ceftriaxone + ORAL doxycycline if outpatient or IV Cefoxitin/cefotetan + oral doxy if inpatient.

  • Secondary dysmenorrhea: Sx onset >25yrs, pain is Unilateral and Secondary Amenorrhea- MCC is pregnancy Pregnancy test ==> Serum FSH/TSH/Prolactin

  • Ectopic Pregnancy Most common site is FT RFs: PID, smoking, presence of IUD; Amenorrhea; Syncope; Intraabdo bleeding Quantitative, Beta hCG Inappropriate rise Beta hCG points to ectopic Progesterone lever US: Use serial beta hCGs Laparotomy in hemodynamically unstable Medical management: Methotrexate - CI Blood dyscrasias Surgical Management:

  • Exposure to teratogens - Viruses (rubella, CMV) Mercury, alcohol

  • Ruptured ovarian cyst- Peritoneal signs and referred pain to shoulder Amnioinfusion CI if hx of uterine surgery

  • Recurrent Pregnancy Loss: Genetic Factors Chromosomal (normal couple; Bal translocations and Trisomies) Causes- Uterine and Cervical Abnormalities