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First Aid For The Obstetrics & Gynecology Clerkship
First Aid For The Obstetrics & Gynecology Clerkship
INTRODUCTION
Be on Time
Most OB/GYN teams begin rounding between 6 and 7 A.M. If you are expected
to “pre-round,” you should give yourself at least 10 minutes per patient that
you are following to see the patient and learn about the events that occurred
overnight. Like all working professionals, you will face occasional obstacles to
punctuality, but make sure this is occasional. When you first start a rotation,
try to show up at least 15 minutes early until you get the routine figured out.
Try to look interested to attendings and residents. Sometimes this stuff is bor-
ing, or sometimes you’re not in the mood, but when someone is trying to
teach you something, look grateful and not tortured.
Always treat patients professionally and with respect. This is crucial to prac-
ticing good medicine, but on a less important level if a resident or attending
spots you being impolite or unprofessional, it will damage your grade and eval-
uation quicker than any dumb answer on rounds ever could. And be nice to
the nurses. Really nice. Learn names; bring back pens and food from pharma-
ceutical lunches and give them out. If they like you, they can make your life a
lot easier and make you look good in front of the residents and attendings.
2
your subject prior to asking attendings medical questions. But please don’t ask
a question just to transparently show off what you know. It’s annoying to
everyone. Show off by seeming interested and asking real questions that you
INTRODUCTION
have when they come up.
If you have the opportunity to make a resident look good, take it. If some new
complication comes up with a patient, tell the resident about it before the at-
tending gets a chance to grill the resident on it. And don’t hesitate to give
credit to a resident for some great teaching in front of an attending. These
things make the resident’s life easier, and he or she will be grateful and the re-
wards will come your way.
Volunteer to do things that will help out. So what if you have to run to the
lab to follow up on a stat H&H. It helps everybody out, and it is appreciated.
Observe and anticipate. If a resident is always hunting around for some tape
to do a dressing change every time you round on a particular patient, get some
tape ahead of time.
3
More Volunteering
Be self-propelled, self-motivated. Volunteer to help with a procedure or a diffi-
cult task. Volunteer to give a 20-minute talk on a topic of your choice. Volun-
INTRODUCTION
teer to take additional patients. Volunteer to stay late. The more unpleasant
the task, the better.
Be a Team Player
Help other medical students with their tasks; teach them information you
have learned. Support your supervising intern or resident whenever possible.
Never steal the spotlight, steal a procedure, or make a fellow medical student
look bad.
Be Honest
If you don’t understand, don’t know or didn’t do it, make sure you always say
that. Never say or document information that is false (for example, don’t say
“bowel sounds normal” when you did not listen).
Some patients have extensive histories. The whole history can and probably
should be present in the admission note, but in ward presentation it is often
too much to absorb. In these cases, it will be very much appreciated by your
team if you can generate a good summary that maintains an accurate picture
of the patient. This usually takes some thought, but it’s worth it.
4
HOW TO ORGANIZE YOUR LEARNING
INTRODUCTION
The main advantage to doing the OB/GYN clerkship is that you get to see pa-
tients. The patient is the key to learning, and the source of most satisfaction
and frustration on the wards. One enormously helpful tip is to try to skim this
book before starting your rotation. Starting OB/GYN can make you feel like
you’re in a foreign land, and all that studying the first two years doesn’t help
much. You have to start from scratch in some ways, and it will help enor-
mously if you can skim through this book before you start. Get some of the
terminology straight, get some of the major points down, and it won’t seem so
strange.
This review book, First Aid for the Clinical Clerkship in Obstetrics & Gy-
necology
A full-text online journal database, such as www.mdconsult.com (sub-
scription is $99/year for students)
A small pocket reference book to look up lab values, clinical pathways,
and the like, such as Maxwell Quick Medical Reference (ISBN
0964519119, $7)
A small book to look up drugs, such as Pocket Pharmacopoeia (Tarascon
Publishers, $8)
5
H O W T O P R E PA R E F O R T H E C L I N I C A L C L E R K S H I P E X A M
If you have read about your core illnesses and core symptoms, you will know a
INTRODUCTION
great deal about medicine. To study for the clerkship exam, we recommend:
2 to 3 weeks before exam: Read the entire review book, taking notes.
10 days before exam: Read the notes you took during the rotation on
your core content list and the corresponding review book sections.
5 days before exam: Read the entire review book, concentrating on lists
and mnemonics.
2 days before exam: Exercise, eat well, skim the book, and go to bed
early.
1 day before exam: Exercise, eat well, review your notes and the
mnemonics, and go to bed on time. Do not have any caffeine after 2 P.M.
6
RECT,” “ALWAYS,” and “NEVER.” If you find one of these words, cir-
cle or underline it for later comparison with the answer.
Evaluate each answer as being either true or false. Example:
INTRODUCTION
Which of the following is least likely to be associated with pelvic pain?
A. endometriosis T
B. ectopic pregnancy T
C. ovarian cancer ? F
D. ovarian torsion T
By comparing the question, noting LEAST, to the answers, “C” is the best an-
swer.
Terminology
G (gravidity) 3 = total number of pregnancies, including normal and ab-
normal intrauterine pregnancies, abortions, ectopic pregnancies, and hy-
datidiform moles (Remember, if patient was pregnant with twins, G = 1.)
P (parity) 3 = number of deliveries > 500 grams or ≥ 24 weeks’ gestation,
stillborn (dead) or alive (Remember, if patient was pregnant with twins,
P = 1.)
Ab (abortion) 0 = number of pregnancies that terminate < 24th gesta-
tional week or in which the fetus weighs < 500 grams
LC (living children) 3 = number of successful pregnancy outcomes (Re-
member, if patient was pregnant with twins, LC = 2.)
Or use the “TPAL” system if it is used at your medical school:
T = number of term deliveries (3)
P = number of preterm deliveries (0)
A = number of abortions (0)
L = number of living children (3)
S A M P L E O B S T E T R I C A D M I S S I O N H I S T O RY A N D P H Y S I C A L
Date
Time
Identification: 25 yo G3P2
Estimated gestational age (EGA): 38 5/7 weeks
Last menstrual period (LMP): First day of LMP
Estimated date of confinement: Due date (specify how it was determined)
by LMP or by ____ wk US (Sonograms are most accurate for dating EGA
when done at < 20 weeks.)
Chief complaint (CC): Uterine contractions (UCs) q 7 min since 0100
History of present illness (HPI): 25 yo G3P2 with an intrauterine preg-
nancy (IUP) at 38 5/7 wks GA, well dated by LMP (10/13/99) and US at
10 weeks GA, who presented to L&D with CC of uterine contractions q 7
min. Prenatal care (PNC) at Highland Hospital (12 visits, first visit at 7
wks GA), uterine size = to dates, prenatal BP range 100–126/64–83. Prob-
lem list includes H/o + group B Streptococcus (GBS) and a +PPD with sub-
sequent negative chest x-ray in 5/00. Pt admitted in early active labor
with a vaginal exam (VE) 4/90/−2.
7
Past Obstetric History
’92 NSVD @ term, wt 3,700 g, no complications
’94 NSVD @ term, wt 3,900 g, postpartum hemorrhage
INTRODUCTION
Allergies: NKDA
Medications: PNV, Fe
Medical Hx: H/o asthma (asymptomatic × 7 yrs), UTI × 1 @ 30 wks s/p
Macrobid 100 mg × 7 d, neg PPD with subsequent neg CXR (5/00)
Surgical Hx: Negative
Social Hx: Negative
Family Hx: Mother—DM II, father—HTN
ROS: Bilateral low back pain
PE
General appearance: Alert and oriented (A&O), no acute distress
(NAD)
Vital signs: T, BP, P, R
HEENT: No scleral icterus, pale conjunctiva
Neck: Thyroid midline, no masses, no lymphadenopathy (LAD)
Lungs: CTA bilaterally
Back: No CVA tenderness
Heart: II/VI SEM
Breasts: No masses, symmetric
Abdomen: Gravid, nontender
Fundal height: 36 cm
Estimated fetal weight (EFW): 3,500 g by Leopold’s
Presentation: Vertex
Extremities: Mild lower extremity edema, nonpitting
Pelvis: Adequate
VE: Dilatation (4 cm)/effacement (90%)/station (−2); sterile speculum
exam (SSE)? (Nitrazine?, Ferning?, Pooling?); membranes intact
US (L&D): Vertex presentation confirmed, anterior placenta, AFI = 13.2
Fetal monitor: Baseline FHR = 150, reactive. Toco = UCs q 5 min
Labs
Blood type: A+
Antibody screen: Neg
Rubella: Immune
HbsAg
VDRL: Nonreactive
FTA
GC
Chlamydia
HIV: See prenatal records
1 hr GTT: 105
3 hr GTT
PPD: + s/p neg CXR
CXR: Neg 5/00
AFP: Neg x 3
Amnio
PAP: NL
Hgb/Hct
Urine: + blood, − protein, − glucose, − nitrite, 2 WBCs
GBS: +
8
Assessment
1. Intrauterine pregancy @ 38 5/7 wks GA in early active labor
2. Group B strep +
INTRODUCTION
3. H/o + PPD with subsequent − CXR 5/00
4. H/o UTI @ 30 wks GA, s/p Rx—resolved
5. H/o asthma—stable × 7 yrs, no meds
Plan
1. Admit to L&D
2. NPO except ice chips
3. H&H, VDRL, and hold tube
4. D5 LR TRA 125 cc/hr
5. Ampicillin 2 g IV load, then 1 g IV q 4 hrs (for GBS)
6. External fetal monitors (EFMs)
7. Prep and enema
S A M P L E D E L I V E RY N O T E
S A M P L E P O S T PA R T U M N O T E
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S A M P L E P O S T- N S V D D I S C H A R G E O R D E R S
1. D/c pt home
INTRODUCTION
10
SECTION IIA
High-Yield Facts
in Obstetrics
Normal Anatomy
Diagnosis of Pregnancy
Physiology of Pregnancy
Antepartum
Intrapartum
Postpartum
Medical Conditions and
Infections in Pregnancy
Complications of
Pregnancy
Spontaneous Abortion,
Ectopic Pregnancy, and
Fetal Death
Induced Abortion
11
NOTES
12
HIGH-YIELD FACTS IN
Normal Anatomy
V U LVA
The vulva consists of the labia majora, labia minora, mons pubis, clitoris,
vestibule of the vagina, vestibular bulb, and the greater vestibular glands. Ba-
sically, it is the external female genitalia (see Figure 2-1).
Blood Supply
From branches of the external and internal pudendal arteries
13
Lymph
Medial group of superficial inguinal nodes
Nerve Supply
Anterior parts of vulva: Ilioinguinal nerves and the genital branch of the
genitofemoral nerves
Posterior parts: Perineal nerves and posterior cutaneous nerves of the thigh
VA G I N A
Blood Supply
HIGH-YIELD FACTS
Nerve Supply
Hypogastric plexus—sympathetic innervation
Pelvic nerve—parasympathetic innervation
UTERUS
Normal Anatomy
Histology
Mesometrium: The visceral layer of the peritoneum reflects against the
uterus and forms this outmost layer of the organ (the side that faces the
viscera).
Myometrium: The smooth muscle layer of uterus. It has three parts:
1. Outer longitudinal
2. Middle oblique
3. Inner longitudinal
Endometrium: The mucosal layer of the uterus, made up of columnar ep-
ithelium
14
Blood Supply
Uterine arteries—arise from internal iliac artery
Ovarian arteries
Nerve Supply
Superior hypogastric plexus
Inferior hypogastric plexus
Common iliac nerves
L I G A M E N T S O F T H E P E LV I C V I S C E R A
Broad ligament: Extends from the lateral pelvic wall to the uterus and ad-
HIGH-YIELD FACTS
nexa. Contains the fallopian (uterine) tube, round ligament, uterine and
ovarian blood vessels, lymph, utererovaginal nerves, and ureter (see Figure
2-2).
Round ligament: The remains of the gubernaculum; extends from the
corpus of the uterus down and laterally through the inguinal canal and
terminates in the labia majora.
Cardinal ligament: Extends from the cervix and lateral vagina to the
pelvic wall; functions to support the uterus.
FA L L O P I A N ( U T E R I N E ) T U B E S
The fallopian tubes extend from the superior lateral aspects of the uterus
Normal Anatomy
through the superior fold of the broad ligament laterally to the ovaries.
15
Parts, from Lateral to Medial
Infundibulum: The lateralmost part the uterine tube. The free edge is
connected to the fimbriae.
Ampulla: Widest section
Isthmus: Narrowest part
Intramural part: Pierces uterine wall
Blood Supply
From uterine and ovarian arteries
Nerve Supply
Pelvic plexus (autonomic) and ovarian plexus
HIGH-YIELD FACTS
O VA R I E S
The ovaries lie on the posterior aspect of the broad ligament, and are attached
to the broad ligament by the mesovarium. They are not covered by peri-
toneum.
Blood Supply
Ovarian artery, which arises from the aorta at the level of L1. Veins drain into
the vena cava on the right side and the left renal vein on the left.
Normal Anatomy
Nerve Supply
Derived from the aortic plexus
16
Histology
Ovaries are covered by tunica albuginea, a fibrous capsule. The tunica albu-
ginea is covered by germinal epithelium.
HIGH-YIELD FACTS
Normal Anatomy
17
Normal Anatomy HIGH-YIELD FACTS
18
NOTES
HIGH-YIELD FACTS IN
Diagnosis of Pregnancy
History
The majority of women have amenorrhea from the last menstrual period
(LMP) until after the birth of their baby. Some women experience
vaginal bleeding in
pregnancy, and therefore
Symptoms fail to recognize their
condition.
Although not specific to pregnancy, these symptoms may alert the patient to
the fact that she is pregnant:
Breast enlargement and tenderness from about 6 weeks’ gestational age
(GA)
Areolar enlargement and increased pigmentation after 6 weeks’ GA
Colostrum secretion may begin after 16 weeks’ GA
Nausea with or without vomiting, from about the date of the missed pe- Nausea and/or vomiting
riod occurs in approximately
Urinary frequency, nocturia, and bladder irritability due to increased 50% of pregnancies, most
bladder circulation and pressure from the enlarging uterus notably at 2 to 12 weeks’
GA, and typically in the A.M.
Signs
Some clinical signs can be noted, but may be difficult to quantify:
Breast enlargement, tension, and venous distention—particularly obvi-
ous in the primigravida
Bimanual examination reveals a soft, cystic, globular uterus with en- Hyperemesis gravidarium-
largement consistent with the duration of pregnancy (see Table 3-1) persistent vomiting that
Chadwick’s sign: Bluish discoloration of vagina and cervix, due to con- results in weight loss,
gestion of pelvic vasculature dehydration, acidosis from
starvation, alkylosis from
loss of HCl in vomitus, and
PREGNANCY TESTING hypokalemia.
How?
The beta subunit of human chorionic gonadotropin (hCG) is detected in ma-
ternal serum or urine.
hCG is a glycoprotein produced by the developing placenta shortly af-
ter implantation hCG is a glycoprotein
hormone composed of
alpha and beta subunits.
19
TABLE 3-1. Fundal Height During Pregnancy
When?
Diagnosis of Pregnancy
20
False negatives may occur if:
The test is performed too early
The urine is very dilute
False positives may occur if:
Proteinuria (confirm with plasma hCG)
Urinary tract infection (UTI)
Plasma hCG
Used when quantitative information is needed:
Diagnosing ectopic pregnancy
Monitoring trophoblastic tumors
Screening for fetal abnormalities
HIGH-YIELD FACTS
I N D I C AT I O N S
Diagnosis of Pregnancy
The electronic Doppler device can detect fetal heart tones as early as 8 weeks’
GA, albeit with difficulty.
If FHTs are not auscultated
by 11 weeks’ GA, an
U LT R A S O N I C S C A N N I N G ( U S ) ultrasonic evaluation should
be performed to document
a viable intrauterine
Not generally used to diagnose pregnancy, but can do so once a gestation sac
pregnancy.
is present within the uterus.
When?
To confirm an intrauterine pregnancy (if it is suspected to be ectopic)
To confirm the presence of a fetal heartbeat in a patient with a history
of miscarriage
To diagnose multiple pregnancy
To estimate gestational age Scan dating is useful up to
To screen for fetal structural anomalies
20 weeks’ GA when
menstrual data is unreliable
Limitations or conflicts with clinical
findings.
Scan dating becomes progressively less accurate and should be utilized only up
to 20 weeks’ GA:
US measures the size of the fetus, not the gestational age.
Biologic variation in size increases as gestation advances.
21
Diagnosis of Pregnancy HIGH-YIELD FACTS
22
NOTES
HIGH-YIELD FACTS IN
Physiology of Pregnancy
TERMS TO KNOW
23
Oocyte: The primitive ovum before it has completely developed
Primary: The oocyte at the end of the growth period of oogonium and
before the first maturation division has occurred
Secondary: The larger of two oocytes resulting from the first maturation
division
Oogenesis: Formation and development of the ovum
Oogonium: The primordial cell from which an oocyte originates
Organogenesis: Occurs between 4 and 8 weeks after conception
Polar body: The small cell produced in oogenesis resulting from the divi-
sions of the primary and secondary oocytes
Preembryonic period: The first 2 weeks after fertilization
Pregenesis: The time period between the formation of germ cells and the
union of sperm and egg
Puerperium: The period of up to 6 weeks after childbirth, during which
the size of the uterus decreases to normal
Residual volume (RV): The volume of gas contained in the lungs after a
maximal expiration
HIGH-YIELD FACTS
Tidal volume (TV): The volume of air that is inhaled and exhaled during
normal quiet breathing
Total lung capacity (TLC): The volume of gas contained in the lungs af-
ter a maximal inspiration
Vital capacity (VC): The volume of gas that is exhaled from the lungs in
going from TLC to RV
Joint changes (i.e., pubic Zona pellucida: Inner, solid, thick membranous envelope of the ovum
symphysis) + postural (vitelline membrane, zona radiata)
changes secondary to
change in center of gravity
results in backaches and GENERAL EFFECTS OF PREGNANCY ON THE MOTHER
other aches that are
Physiology of Pregnancy
common in pregnancy.
Table 4-1 summarizes maternal physiologic changes during pregnancy.
Energy Requirements
Ideal weight gain: Energy requirements increase gradually from 10 weeks to 36 weeks by 50 to
100 kcal/day. In the final 4 weeks, requirements increase by 300 kcal/day.
T1: 1.5 to 3 lbs. gained
T2 and T3: 0.8 lbs./wk
24
TABLE 4-1. Summary of Changes in the Body During Pregnancy
T3 (28 wks–
T1 T2 term) Term =
(1–14 wks) (14–28 wks) 37–42 wks During Labor 9-Month Period
Body water ↑ by 8.5 L
Energy requirements ↑ by 50–100 ↑ by 300 kcal/d
kcal/d
Body weight ↑ (primarily ↑ (primarily ↑ (primarily ↑ by 25–35 lb
reflects reflects reflects fetal
maternal maternal growth)
growth) growth)
Tidal volume ↑ ↑ by 200 mL
Vital capacity ↑ ↑ by 100–200 mL
HIGH-YIELD FACTS
Cardiac output ↑ by 60% ↑ by 30% during ↑
each
contraction
May ↑ further in
` second stage
of labor
Blood pressure (BP) ↓ ↑ by 10–20 mm
Hg during each
contraction
May ↑ further in
second stage
of labor
Systolic BP ↔
Physiology of Pregnancy
Diastolic BP ↓ ↓ by 15 mm Hg ↑ to T1 level
at 16–20 wks
Heart rate ↑ by 10–15%/min ↔
Stroke volume ↑ by 10% ↑ During each
contraction
Central venous ↔ ↑ of 3–5 mm Hg
pressure during each
contraction
Systemic vascular ↓ from pre- ↓↓ from pre- ↑, but not to ↑ with each
resistance pregnancy pregnancy prepregnancy contraction
level level level
Glomerular filtration ↑ ↑ to 60% ↑
rate (GFR) above
nonpregnant
levels by
16 wks
Renal plasma flow ↑ ↑ to 30–50% Peaks at 30 wks ↑
above
nonpregnant
levels by
20 wks
Plasma aldosterone ↑ w/in 2 wks ↑ 3–5 times the ↑ 8–10 times the ↑
of conception nonpregnant nonpregnant
level level
(Continued)
TABLE 4-1. Summary of Changes in the Body During Pregnancy (continued)
T3 (28 wks–
T1 T2 term) Term =
(1–14 wks) (14–28 wks) 37–42 wks During Labor 9-Month Period
Serum alkaline ↑
phosphatase
Plasma prolactin ↑ ↑ 10–20 times
nonpregnant
level
Cortisol and other ↑ from 12 wks ↑ ↑ ↑ to 3–5 times
corticosteroids nonpregnant
levels
Glucagon ↑
Insulin sensitivity ↑ ↓ at 20 wks ↓
HIGH-YIELD FACTS
First 20 Weeks
Insulin sensitivity increases in first half of pregnancy.
Fasting glucose levels are lower.
This favors glycogen synthesis and storage, fat deposition, and amino Pregnancy is an anabolic
acid transport into cells. state.
HIGH-YIELD FACTS
After 20 weeks
After 20 weeks, insulin resistance develops and plasma insulin levels rise.
A carbohydrate load produces a rise in plasma insulin 3 to 4 times
greater than in the nonpregnant state, but glucose levels also are higher.
This reduces maternal utilization of glucose and induces glycogenolysis,
gluconeogenesis, and maternal utilization of lipids as energy source. The optimal time to screen
Despite these high and prolonged rises in postprandial plasma glucose, for glucose intolerance/
the fasting level in late pregnancy remains less than nonpregnant levels. diabetes mellitus (DM) in
the pregnant female is at
AMINO ACIDS 26 to 28 weeks’ GA.
Plasma concentration of amino acids falls during pregnancy due to he-
modilution.
Physiology of Pregnancy
Urea synthesis is reduced.
LIPIDS
All lipid levels are raised, with the greatest increases being in the Normal pregnancy is a
triglyceride-rich component. hyperlipemic, as well as a
Lipids cross the placenta. glucosuric, state.
Hyperlipidemia of pregnancy is not atherogenic, but may unmask a
pathologic hyperlipidemia.
Fat
Early in pregnancy, fat is deposited.
By midpregnancy, fat is the primary source of maternal energy.
Postpartum, lipid levels return to normal. The increase in cholesterol
May take 6 months excretion results in
increased risk of gallstones.
Cholesterol
There is an increased turnover of cholesterol from lipoproteins, creating
an increased supply to most tissues and increased supply for steroid pro-
duction.
Total cholesterol is raised postpartum in all mothers, but can be reduced
by dieting after delivery.
27
DRUGS/OTHER SUBSTANCES
Plasma levels of phenytoin fall during pregnancy.
The half-life of caffeine is doubled.
Antibiotics are cleared more rapidly by the kidney.
Respiratory System
Fetal PCO2 must be greater than maternal PCO2; thus, the maternal respira-
tory center must be reset. This is done in several ways:
During pregnancy, progesterone reduces the carbon dioxide threshold at
which the respiratory center is stimulated and increases the respiratory
center sensitivity. This may lead to hyperventilation of pregnancy.
Physiology of Pregnancy
Cardiovascular System
CARDIAC OUTPUT
Cardiac output (CO) increases by 40% by week 10, due to a 10% in-
crease in stroke volume and increase in pulse rate by 10 to 15% per
minute.
Generalized enlargement of the heart and enlargement of left ventricle
Heart is displaced anterolaterally secondary to rise in level of diaphragm
→ alters electrocardiogram (ECG) and may produce changes that
mimic ischemia.
Physical Exam
At end of T1—both components of S1 become louder, with exaggerated
Healthy women must be splitting.
treated as potential cardiac After midpregnancy—90% of pregnant women demonstrate a third
patients during pregnancy heart sound or S3 gallop.
and the puerperium until Systolic ejection murmurs along the left sternal border occur in 96% of
functional murmurs resolve pregnant patients (due to increased flow across aortic and pulmonic
and the cardiovascular valves).
system returns to baseline Diastolic murmurs are never normal, and their presence warrants evalu-
status. ation by a cardiologist.
28
During Labor
CO increases by 30% during each contraction with an increase in
stroke volume, but no increase in heart rate.
VENOUS SYSTEM
Patients with hypertensive
Venous dilation results from: heart disease or cardiac
Relaxation of vascular smooth muscle disease may develop
Pressure of enlarging uterus on inferior vena cava and iliac veins progressive or sudden
deterioration.
Gastrointestinal System
Reflux esophagitis (heartburn):
Enlarging uterus displaces the stomach above the esophageal sphincter
Increased distensibility and
and causes increased intragastric pressure. pressure of veins →
Progesterone causes a relative relaxation of the esophageal sphincter.
predisposition to
There may also be reflux of bile into the stomach due to pyloric incom-
HIGH-YIELD FACTS
petence. development of varicose
Constipation may occur secondary to progesterone, which relaxes in- veins of legs, vulva,
testinal smooth muscle and slows peristalsis. rectum, and pelvis.
GALLBLADDER
Increases in size
Empties more slowly
Cholestasis, probably due to a hormonal effect since it also occurs in
some users of oral contraceptives (OCs) and hormone replacement Decreased GI motility may
therapy (HRT) be responsible for the
increased absorption of
LIVER
Physiology of Pregnancy
water, Na+, and other
Hepatic function increases. substances.
Plasma globulin and fibrinogen concentrations increase.
Synthetic rate of albumin increases → total albumin mass increases by
19%, plateauing at 28 weeks.
Velocity of blood flow in hepatic veins decreases.
Serum alkaline phosphatase increases largely due to placental produc- The superior rectal vein is
tion part of the portal system
and has no valves, hence
the high pressure within the
Genitourinary System system is communicated to
Urinary stasis secondary to decreased ureteral peristalsis and mechani- the pelvic veins and
cal uterine compression of the ureter at pelvic brim as pregnancy pro- produces hemorrhoids.
gresses
Asymptomatic bacteruria occurs in 5 to 8% of pregnant women.
Urinary frequency increases:
During first 3 months of pregnancy due to bladder compression by en-
larging uterus
The increase in cholestasis
During last week of pregnancy as the fetal head descends into pelvis
Nocturia: plus increase in lipids and
Physiologic after T1
cholesterol lead to higher
Passing urine four times per night is normal incidence of gallstones,
Fetal movements and insomnia contribute to the nocturia cholecystitis, and biliary
Stress incontinence: obstruction.
Occurs frequently during normal pregnancy
29
Due to relaxation of the bladder supports
The urethra normally elongates during pregnancy, but not in those
who develop stress incontinence.
BLADDER
Albumin concentration falls
by 22% despite the Bladder tone decreases, but bladder capacity increases progressively during
increase in synthetic rate pregnancy.
due to hemodilution.
URETERS
Ureters undergo progressive dilatation and kinking in > 90% of pregnant
women at ≥ 6 weeks
Accompanied by a decreased urine flow rate
Dilatation is greater on right secondary to dextrorotation of the uterus,
Bacteruria + urinary stasis and does not extend below the pelvic brim.
predispose patients to Dilatation is secondary to the physical obstruction by the pregnant
pyelonephritis, the most uterus and the effects of pregnancy hormones.
HIGH-YIELD FACTS
common nonobstetric cause Ureteric dilatation extends up to the calyces → increased glomerular
for hospitalization during size and increased interstitial fluid → enlarged kidneys (length increases
pregnancy. by 1 cm and weight increases by 20%).
RENAL FUNCTION
Renal plasma flow increases from T1, reaching 30 to 50% above non-
pregnant levels by 20 weeks. Flow remains elevated until 30 weeks and
then slowly declines to nonpregnant levels postpartum.
Glomerular filtration rate (GFR) increases soon after conception. It
If frequency occurs in reaches 60% above nonpregnant level by 16 weeks and remains ele-
conjunction with dysuria, vated for remainder of pregnancy.
Physiology of Pregnancy
hematuria,urgency/
hesitancy, flank pain, or RENAL TUBULE CHANGES
suprapubic pain, the patient Tubular function changes:
should be evaluated for a Tubules lose some of their resorptive capacity—amino acids, uric acid,
UTI/cystitis +/pyelonephritis. and glucose are not as completely absorbed in the pregnant female.
Results in an increase in protein loss of up to 300 mg/24 hr
Renal retention of Na+ results in water retention. Mother and conceptus in-
crease their Na+ content by 500 to 900 nmol (due to increased reabsorption
In pregnancy, the increased by renal tubules).
rate of renal clearance →
reduced effective dose of
Hematologic
antibiotics.
PLASMA VOLUME
Plasma volume increases by 50% during pregnancy due to increase in both red
blood cells (RBCs) and plasma, but proportionately more plasma. This results
GFR increases → quantity in hemodilution.
of glucose filtered in urine Greater in multigravids than primigravids
is greater than in Greater in multiple pregnancies than in single pregnancies
nonpregnant state → Positively correlated with birth weight
tubular threshold for Increase in plasma volume is less in patients with recurrent abortions.
Advantage of increased circulating volume:
glucose is exceeded →
Helps to compensate for increased blood flow to uterus and kidneys
glycosuria is detected in
Reduces viscosity of blood and increases capillary blood flow
50% of pregnant women.
30
RED BLOOD CELLS
Circulating RBC mass increases progressively during pregnancy:
By 18% in women not given Fe supplements Tubules are presented with
By 30% in women on Fe supplementation increased quantities of
Reticulocyte count increases by ≥ 2%. urine because of the
Mean corpuscular volume (MCV) usually increases. increased GFR.
HEMOGLOBIN
Fetal Hgb (HbF) concentration increases 1 to 2% during pregnancy,
secondary to an increase in the number of RBCs with HbF
HIGH-YIELD FACTS
An ESR = 100 mm/hr is not uncommon in normal pregnancy. increased aldosterone,
mineralocorticoids, and
WHITE BLOOD CELLS prostaglandins.
Neutrophils
Neutrophil count increases in T1 and continues to rise until 30 weeks.
Neutrophilic metabolic activity and phagocytic function increases.
Lymphocytes
Counts remain unchanged, but function is suppressed.
Hemodilution is not due to
PLATELETS a fall in total circulating
Physiology of Pregnancy
hemoglobin.
Platelet reactivity is increased in T2 and T3 and returns to normal at 12
weeks postpartum
In 8 to 10% of normal pregnancies, the platelet count falls below 150 ×
103 without negative effects on the fetus.
PITUITARY GLAND
Pituitary gland increases in weight and sensitivity.
Prolactin
Plasma levels rise within a few days postconception.
At term, levels are 10- to 20-fold higher than nonpregnant state.
31
Follicle-Stimulating Hormone
Blunted response to gonadotropin-releasing hormone (GnRH)
Shows a progressive decreased response → no response at 3 weeks after
ovulation
Luteinizing Hormone
Response to GnRH diminishes and finally disappears.
ADRENAL GLAND
Plasma cortisol and other corticosteroids increase progressively from 12
weeks to term and reach 3 to 5 times nonpregnant levels.
Half-life of plasma cortisol is increased, while its clearance is reduced.
THYROID GLAND
The following changes are thought to be due to the increase in estrogen dur-
ing pregnancy:
HIGH-YIELD FACTS
PLASMA PROTEINS
Concentrations of proteins in maternal serum fall markedly by 20 weeks,
mostly due to a fall in serum albumin. This fall reduces the colloid osmotic
pressure in the plasma → edema in pregnancy.
PANCREAS
Size of islets of Langerhans increases during pregnancy.
The number of beta cells increases during pregnancy.
The number of insulin receptor sites increases during pregnancy.
Insulin
Serum levels rise during second half of pregnancy, but insulin resistance
increases as well.
This insulin resistance may be due to presence of hPL, prolactin, or
other pregnancy hormones that have anti-insulin activity.
32
TABLE 4-2. Pruritic Dermatologic Disorders Unique to Pregnancy
Increased
Incidence
Fetal
Morbidity/
Disease Onset Pruritis Lesions Distribution Incidence Mortality Intervention
Pruritic urticarial T2–T3 Severe Erythematous Abdomen, Common No Topical
papules and urticarial thighs, (0.25–1%) steroids,
plaques of papules buttocks, antipruritic
pregnancy and occasionally drugs
(PUPPP) plaques arms and (hydroxy-
legs zine,
phenhy-
dramine)
HIGH-YIELD FACTS
Papular eruptions T2–T3 Severe Excoriated No area of Uncommon Unlikely Systemic/
(prurigo papules predilection (1:300– topical
gestationis and 1:2,400) cortico-
papular steroids, an-
dermatitis) tipruritics
Pruritis T3 Severe Excoriations Generalized Common Yes Antipruritics,
gravidarum common (1–2%) cholestyra-
mine
Impetigo T3 Minimal Pustules Genitalia, Rare Yes (maternal Systemic
herpetiformis medial sepsis cortico-
thighs, common) steroids and
umbilicus, antibiotics
Physiology of Pregnancy
breasts, for sec-
axillae ondary
infection
Herpes gestationis T2– Severe Erythematous Abdomen, Rare Yes Mild—topical
post- papules, extremities, (1:10,000) steroids,
partum vesicles, generalized antihista-
bullae mines
More severe—
systemic
cortico-
steroids
33
ESTROGEN EFFECTS
Spider nevi are common (branched growths of dilated capillaries on the
Thyroid-stimulating skin).
hormone, iodide, thyroid- Palmar erythema
releasing hormone, and T4
cross the placenta. TSH CORTICOSTEROID EFFECTS
does not. Striae on the abdomen, breasts, etc., develop in response to increased circulat-
ing corticosteroids.
FINGERNAILS
Grow more rapidly during pregnancy
N O R M A L A N AT O M I C A L A D A P TAT I O N S I N P R E G N A N C Y
Vagina
Vaginal epithelium hypertrophies and quantity of glycogen-containing
cells shed into vagina increase.
Connective tissue decreases in collagen content and there is an increase
in water content (like the cervix—see below).
Physiology of Pregnancy
Uterus
Hypertrophy and hyperplasia of myometrial smooth muscle secondary
to:
Action of steroid hormones
Uterine distention and wall thinning with the growing fetus, pla-
centa, amniotic fluid
Term uterus weighs 1,100 g with a 20-fold increase in mass (nonpreg-
nant, parous uterus weighs 70 g).
ROUND LIGAMENT
Round ligament increases in length, muscular content, and diameter:
During pregnancy, the ligaments may contract spontaneously or in re-
sponse to uterine movement.
In labor, contractions of the ligaments pulls the uterus forward → ex-
pulsive force is directed as much into the pelvis as possible.
34
During pregnancy, the ovarian arteries contribute 20 to 30% of the
blood supply in 70% of women.
Uterine arteries dilate to 1.5 times their nonpregnant diameter.
The uterus is composed of
UTERINE CERVIX smooth muscle, whose
myometrial cells contain
Amount of collagen within cervix is reduced to one third of nonpreg- estrogen and progesterone
nant amount. receptors.
The duration of spontaneous labor is inversely proportional to cervi-
cal collagen concentration at the beginning of dilation.
Accumulation of glycosaminoglycans and increase in water content and vas-
cularity in the cervix results in softening and cyanosis = characteristic cervix
of gravid female:
Results in increased compliance to stretch
This process is called “cervical ripening” and takes place gradually over
the last few weeks of gestation.
In early T1, squamous epithelium of ectocervix becomes hyperactive,
HIGH-YIELD FACTS
endocervical glands become hyperplastic, and endocervical epithelium
proliferates and grows out over the ectocervix.
The resulting secretions within the endocervical canal create the an-
tibacterial mucous plug of the cervix.
UTERINE ISTHMUS
The uterine isthmus is normally a small region of the uterus that lies be-
tween the uterine corpus and cervix.
Beginning at 12 weeks of pregnancy, the isthmus enlarges and thins sec-
ondary to hormonal influences of pregnancy and uterine distention.
During labor, the isthmus expands and is termed the lower uterine seg-
ment.
Physiology of Pregnancy
Cervical effacement and
CONCEPTION dilation occur in the already
ripened cervix.
Ovulation
Ovulation is necessary for normal fertilization to occur:
The ovum must leave the ovary and be carried into the fallopian tube.
The unfertilized ovum is surrounded by its zona pellucida.
This oocyte has completed its first meiotic division and carries its first
Cervical effacement causes
polar body.
expulsion of the mucous
plug as the cervical canal is
Fertilization shortened during labor.
35
Preimplantation
Fertilized ovum remains in the ampulla for 80 hours after follicular rup-
ture and travels through isthmus of fallopian tube for 10 hours.
The fertilized egg divides to form a multicellular blastomere.
The blastomere passes from the fallopian tube into the uterine cavity.
The embryo develops into a blastocyst as it freely floats in endometrial
cavity 90 to 150 hours after conception (see Table 4-3).
Implantation
On day 5 to 6 of development, the blastocyst adheres to the en-
dometrium with the help of adhesion molecules on the secretory en-
dometrial surface.
After attachment, the endometrium proliferates around the blastocyst.
HIGH-YIELD FACTS
Placentation
During week 2, cells in the outer cell mass differentiate into tro-
phoblasts.
Fetal Development
Human chorionic
gonadotropin (hCG) is 12 Brain configuration rougly complete, internal sex organs now specific, uterus
now no longer bicornuate, and blood forming in marrow. External geni-
detectable in maternal
talia forming (9–12 weeks).
serum after implantation
has taken place, 16 Fetus is active now, sex determination by visual inspection (ultrasound) is
approximately 8 to 11 days possible due to the formed external genitalia. Myelination of nerves, heart
after conception. muscle well developed, vagina and anus open, and ischium ossified.
20 Sternum ossifies.
24 Primitive respiratory movements.
28 Nails appear and testes at or below internal inguinal ring.
Trophoblasts 36 Earlobe soft with little cartilage, testes in inguinal canals, and scrotum small
(trophoectoderm) are the with few rugae.
precursor cells for the 40 Earlobes stiffen by thick cartilage, and scrotum well developed.
placenta and membranes.
Reproduced, with permission, from Lindarkis NM, Lott S. Digging Up the Bones: Obstetrics and
Gynecology. New York: McGraw-Hill, 1998: 6.
36
A trophoblastic shell forms the initial boundary between the embryo
and the endometrium.
The trophoblasts nearest the myometrium form the placental disk; the
other trophoblasts form the chorionic membranes.
The decidua produces
Postimplantation maternal steroids and
synthesizes proteins that
The endometrium or lining of the uterus during pregnancy is termed de- are related to the
cidua.
maintenance and protection
Maternal RBCs may be seen in the trophoblastic lacunae in the second
week postconception. of the pregnancy from
immunologic rejection.
The Placenta
The placenta continues to adapt over T2 and T3. It is the primary producer
of steroid hormones after 7 weeks’ gestational age.
HIGH-YIELD FACTS
BLOOD SUPPLY
Flow in the arcuate and radial arteries during normal pregnancy is high with
low resistance (resistance falls after 20 weeks).
Developmental Ages
Postconception Day Tissue/Organ Formation
4 Blastula
7–12 Implantation
13 Primitive streak
Physiology of Pregnancy
16 Neural plate
19–21 First somite
23–25 Closure of anterior neuropore
25–27 Arms bud
Closure of posterior neuropore
28 Legs bud
44 Sexual differentiation
PREGNANCY PROTEINS
37
Dizygotic Twins
Nonidentical or Fraternal Twins
(Always have 2 chorions and 2 amnions,
and sexes may be different.)
Chorion
Amnion
HIGH-YIELD FACTS
Monozygotic Twins
Identical or Maternal Twins
Physiology of Pregnancy
Monochorionic Monochorionic
Monoamnionic (rare) Diamnionic (< 1/3)
(Siamese twins) Twins are in separate cavities
Twins share single cavity
38
Prolactin
Source: Decidualized endometrium
Function: Regulates fluid and electrolyte flux through the fetal membranes
Alpha-Fetoprotein (AFP)
Source: Yolk sac, fetal gastrointestinal tract, and fetal liver Amniotic fluid AFP and
Function: Regulates fetal intravascular volume (osmoregulator) maternal serum (MSAFP)
MSAFP peaks between 10 and 13 weeks’ gestational age, then de- are elevated in association
clines thereafter. with neural tube defects
Detectable as early as 7 weeks’ gestation and low in trisomy 21.
PREGNANCY STEROIDS
HIGH-YIELD FACTS
Function: Estrogens affect uterine vasculature, placental steroidogenesis, pregnancies with Down’s
and parturition. syndrome.
Estradiol
Source:
Maternal ovaries for weeks 1 through 6 of gestation
Subsequently, the placenta secretes increasing quantities of estradiol
synthesized from the conversion of circulating maternal and fetal
In women with threatened
DHEA-S.
After T1, the placenta is the major source of circulating estradiol.
T1 abortions, estradiol
concentrations are
Estrone abnormally low for
Physiology of Pregnancy
Source: gestational age.
Maternal ovaries, adrenals, and peripheral conversion in the first 4 to
6 weeks of pregnancy
The placenta subsequently secretes increasing quantities.
Estriol
Source:
During T3, low estradiol
Placenta
Continued production is dependent on the presence of a living fetus.
levels are associated with
poor obstetrical outcomes.
Progesterone
Source:
Corpus luteum before 6 weeks’ gestational age
Thereafter, the placenta produces progesterone from circulating ma-
ternal low-density lipoprotein (LDL) cholesterol.
Function:
Affects tubal motility, the endometrium, uterine vasculature, and par-
Abortion will occur in 80%
turition of women with
Inhibits T lymphocyte–mediated tissue rejection progesterone levels under
10 ng/mL.
Cortisol
Source: Decidual tissue
Function: Suppresses the maternal immune rejection response of the im-
planted conceptus
39
LDL Cholesterol
Source: Fetal adrenal gland
Function:
Principal regulatory precursor of corpus luteum progesterone produc-
tion
Progesterone concentrations Principal lipoprotein utilized in fetal adrenal steroidogenesis
of < 5 ng/mL are
diagnostic of fetal death in
T1. Prompt diagnostic
studies should be performed
to distinguish between
ectopic pregnancy and
intrauterine fetal demise.
HIGH-YIELD FACTS
Protesteronr concentrations
are significantly elevated in:
women with hydratidiform
mole complications of Rh
isoimmunization.
Physiology of Pregnancy
40
HIGH-YIELD FACTS IN
Antepartum
P R E N ATA L C A R E
Goal
To increase the probability of a healthy baby without maternal compromise
Definitions
Gravidity: The number of times a woman has been pregnant
Parity: The number of times a woman has had a pregnancy that led to a
birth after 20 weeks’ gestation or an infant > 500 g
The above indicates that a woman has been pregnant 3 times, has had 1 term
birth, 2 preterm births, 0 abortions, and has 1 live child.
41
TABLE 5-1. Prenatal Visits
Fetal position Fetal position Fetal position Fetal position Fetal position
3. Urine analysis/ 3. Urine analysis/ 3. Urine analysis/ 3. Urine analysis/ 3. Urine analysis/
culture culture culture culture culture
4. Group B strep 4. Cervical exam 4. Fetoplacental
culture (frequency is functional tests (if
controversial) indicated)
42
A S S E S S M E N T O F G E S TAT I O N A L A G E
Definitions
Gestational age (GA): The time of pregnancy counting from the first day
of the last menstrual period
Developmental age: The time of pregnancy counting from fertilization
First trimester: 0 to 14 weeks
Second trimester: 14 to 28 weeks
Third trimester: 28 weeks to birth
Embryo: Fertilization to 8 weeks
Fetus: 8 weeks until birth
Previable: Before 24 weeks
Preterm: 24 to 37 weeks
Term: 37 to 42 weeks
HIGH-YIELD FACTS
Nägele’s Rule
Nägele’s rule is used to calculate the estimated date of confinement
(i.e., due date) +/− 2 weeks Nägele’s rule
First day of patient’s last normal menstrual period − 3 months + 7 days + assumes two things:
1 year 1. A normal gestation is
280 days.
2. Patients all have a 28-
Abdominal Exam and Fundal Height day menstrual cycle.
As the fetus grows, the location of the uterus, or fundal height, grows superi-
orly in the abdomen, toward the maternal head. The location in the abdomen
that the fetus and uterus are located is described in terms of weeks (see Figure
5-1).
Fetus at the level of umbilicus: 20 weeks
Example:
Fetus at level of pubic symphysis: 12 weeks
Antepartum
Fetus between pubic symphysis and umbilicus: 16 weeks If LMP = July 20, 2001,
then EDC = April 27, 2002
T H E T R I P L E S C R E E N : M AT E R N A L S E R U M S C R E E N I N G
43
36 weeks
40 weeks
32 weeks
28 weeks
24 weeks
20 weeks
16 weeks
12 weeks
HIGH-YIELD FACTS
Estradiol
Low levels are associated with:
Trisomy 21 (Down’s syndrome)
Trisomy 18 (Edward’s syndrome)
Possibly low in trisomy 13 (Patau’s syndrome)
Antepartum
R h I N C O M PAT I B I L I T Y A N D P R E G N A N C Y
What Is Rh?
The surface of the human red blood cell (RBC) may or may not contain
a Rhesus (Rh) antigen. If so, that person is said to be Rhesus + (for ex-
ample, if someone with blood type A has a Rhesus antigen, the blood
type is A+. If that person has no Rhesus antigen, he is A−).
Half of all antigens in a fetus come from the father, and half come from
the mother.
44
The Problem with Rh Sensitization
The parental combination you must worry about: Mother Rh− and father
Rh+. Erythroblastosis fetalis
If the pregnant female is Rh− and her fetus is Rh+, then she may be-
Hemolytic disease of the
come sensitized to the Rh antigen and develop antibodies (Figure 5-2). newborn/fetal hydrops
These antibodies cross the placenta and attack the fetal RBCs → fetal
occurs when the mother
RBC hemolysis.
lacks an antigen present in
the fetus → fetal RBCs
Sensitization trigger an immune
response when they reach
Sensitization may occur during: the mother’s circulation →
Amniocentesis
maternal antibodies cause
Miscarriage/threatened abortion
Vaginal bleeding
fetal RBC hemolysis and
Placental abruption/previa anemia → fetal
hyperbilirubinemia →
HIGH-YIELD FACTS
Delivery
Abdominal trauma kernicterus → heart
Cesarean section failure, edema, ascites,
External version pericardial effusion.
Antepartum
In each pregnancy, a woman should have her Rh type determined and an an- mother accordingly (see
tibody screen performed at the initial visit with an indirect Coombs’ test. RhoGAM below).
– S –
+ S + –+ – S
+ + –
– – S + – – + –
– – + – – – S – +
– + + – – S
– – – S + + – – S S
+ – S + –
– + + + – S
A B C D E
45
Managing the Unsensitized Rh− Patient (The Rh− Patient Who Has
a Negative Antibody Screen)
1. Antibody screen should be done at 0, 24 to 28 weeks.
2. If negative, give 300 µg of RhIgG to prevent maternal development of
RhoGAM is administered to antibodies.
Rh− mothers exposed to 3. At birth, determine if baby is Rh+; if so, give postpartum RhIgG.
fetal blood.
Management of the Sensitized Rh− Patient (If on Initial Visit the Antibody
Screen for Rh Is Positive)
1. Perform antibody screen at 0, 12 to 20 weeks.
In a first sensitized 2. Check the antibody titer.
gestation, the risk of fetal If titer remains stable at < 1:16, the likelihood of hemolytic disease
involvement is low. of the newborn is low.
If the titer is > 1:16 and/or rising, the likelihood of hemolytic disease
HIGH-YIELD FACTS
F E TA L I M A G I N G
Amniocentesis
Amniocentesis is the most extensively used fetal sampling technique and is
typically performed at 15 weeks’ GA when the amniotic fluid is 200 mL.
Indications
Fetal anomaly suspected on US
Abnormal MSAFP
Family history of congenital abnormalities
Offered to all patients ≥ 35 years of age
Procedure
Thirty milliliters of amniotic fluid is removed via a 20- to 22-gauge nee-
dle using a transabdominal approach with US guidance.
Biochemical analysis is performed on the extracted fluid:
Amniotic fluid AFP levels
Fetal cells can be grown for karyotyping or DNA assays.
Risks
Pain/cramping
Vaginal spotting/amniotic fluid leakage in 1 to 2% of cases
46
Symptomatic amnionitis in < 1/1,000 patients
Rate of fetal loss ≤ 0.5%
Risks
0.5% rate of complications
Preterm delivery
Premature rupture of membranes
Fetal injury
HIGH-YIELD FACTS
Cordocentesis
Cordocentesis is a procedure in which a spinal needle is advanced transpla-
centally under US guidance into a cord vessel to sample fetal blood. Typically
performed after 17 weeks.
Indications
Fetal karyotyping because of fetal anomalies
To determine the fetal hematocrit in Rh isoimmunization or severe fetal
anemia
To assay fetal platelet counts, acid–base status, antibody levels, blood
chemistries, etc.
Fetal abdominal measurements: Taken to determine their proportion-
ality to the fetal head (head-to-abdominal circumference ratio) and as- The fetal head is normally
Antepartum
sess fetal growth.
larger than the body in T2
Amniotic fluid index (AFI): Represents the total of linear measure-
ments (in centimeters) of the largest amniotic fluid pockets in each of and early T3.
the four quadrants of the amniotic fluid sac.
Reduced amniotic fluid volume (AFI < 5) = oligohydramnios
Excessive fluid (AFI > 20) = polyhydramnios
Indications
Advanced maternal age
Previous child with abnormal karyotype Polyhydramnios (AFI > 20)
Parental chromosome rearrangements may signify poor control in
Fetal structural abnormality on sonogram a diabetic pregnancy or a
Unexplained intrauterine growth retardation (IUGR) fetal anomaly.
Abnormally low MSAFP
47
NUTRITIONAL NEEDS OF THE PREGNANT WOMAN
Weight Gain
Weight gain for normal BMI = 25 to 35 lb
Optimal weight gain for an underweight teenager carrying a singleton
pregnancy = 40 lb or 5 lb every 4 weeks in second half of pregnancy
An obese woman may need to gain only 15 lb.
Diet
The average woman must consume an additional 300 kcal/day beyond
baseline needs.
Vitamins
HIGH-YIELD FACTS
Vegetarians
Lactoovovegetarians in general have no nutritional deficiencies, except
possibly Fe and Zn.
Vegans must consume sufficient quantities of vegetable proteins to pro-
vide all essential amino acids normally found in animal protein.
Antepartum
Pica
Occasionally seen in pregnancy, pica is the compulsive ingestion of nonfood
substances with little or no nutritional value:
Ice
Clay (geophagia)
Starch (amylophagia)
A N S W E R S T O C O M M O N LY A S K E D Q U E S T I O N S
Caffeine in Pregnancy
Contained in coffee, tea, chocolate, cola beverages
Currently no studies have shown deleterious fetal effects with custom-
ary amounts
48
Adverse maternal effects include:
Insomnia
Acid indigestion
Reflux
Urinary frequency
Exercise
No data exist to indicate that a pregnant woman must decrease the in-
tensity of her exercise or lower her target heart rate.
Women who exercised regularly before pregnancy should continue:
Exercise may relieve stress, decrease anxiety, increase self-esteem, and
shorten labor.
The form of exercise should be one with low risk of trauma, particularly
abdominal.
Exercise that requires prolonged time in the supine position should be
HIGH-YIELD FACTS
avoided in T2 and T3.
Exercise should be stopped if patient experiences oxygen deprivation →
extreme fatigue, dizziness, or shortness of breath.
Contraindications to exercise include:
Evidence of IUGR
Persistent vaginal bleeding
Incompetent cervix
Risk factors for preterm labor
Rupture of membranes
Pregnancy-induced hypertension
Antepartum
trition “Morning sickness” can
Management of mild cases includes: occur day or night.
Avoidance of fatty or spicy foods
Eating small, frequent meals
Inhaling peppermint oil vapors
Drinking ginger teas
Management of severe cases includes:
Discontinuation of vitamin/mineral supplements until symptoms sub-
side
Antihistamines
Promethazine
Metoclopramide
Intravenous droperidol
Heartburn
Common in pregnancy
Treatment consists of:
Elimination of spicy/acidic foods
Small, frequent meals
Decrease amount of liquid consumed with each meal
Limit food and liquid intake a few hours prior to bedtime
49
Sleep with head elevated on pillows
Utilize liquid forms of antacids and H2-receptor inhibitors
Constipation
Common in pregnancy
Management includes:
Increase intake of high-fiber foods
Increase liquids
Psyllium-containing products
VARICOSITIES
Enemas, strong cathartics,
and laxatives should be
Common in pregnancy, particularly in lower extremities and vulva
avoided.
HIGH-YIELD FACTS
Hemorrhoids
Varicosities of the rectal veins are common in pregnancy
Management includes:
Cool sitz baths
If thrombosis of a Stool softeners
Increase fluid and fiber intake to prevent constipation
hemorrhoid occurs, clot
excision should be
attempted to alleviate pain Leg Cramps
Antepartum
and swelling.
Occur in 50% of pregnant women, typically at night and in T3
Most commonly occur in the calves
Massage and stretching of the affected muscle groups is recommended.
Backache
Typically progressive in pregnancy
Management includes:
Minimize time standing.
Rhythmic cramping pains Wear a support belt over the lower abdomen.
originating in the back may Acetaminophen
Exercises to increase back strength
signify preterm labor.
Supportive shoes and avoidance of high heels
50
Sexual Relations
There are no restrictions during the normal pregnancy.
Nipple stimulation, vaginal penetration, and orgasm may → release of
oxytocin and prostaglandins → uterine contractions.
Contraindications:
If membranes have ruptured
If + placenta previa
Employment
Work activities that increase risk of falls/trauma should be avoided.
Exposure to toxins/chemicals should be avoided.
Travel
HIGH-YIELD FACTS
If prolonged sitting is involved, the patient should attempt to stretch
her lower extremities and walk for 10 minutes every 2 hours. Hypercoaguable
The patient should bring a copy of her medical record. state and mechanical
Wear seat belt when riding in car.
compression of venous
Airplane travel in pressurized cabin presents no additional risk to the
pregnant woman. blood flow to extremities
In underdeveloped areas or when traveling abroad, the usual precau- → increased risk of
tions regarding ingestion of unpurified water and raw foods should be thrombosis.
taken.
Immunizations
Vaccines safe in pregnancy:
There is no evidence of fetal risk from inactivated virus vaccines, bacterial • Hep B
vaccines, toxoids, or tetanus immunoglobulin, and they should be adminis- • Oral polio
tered as appropriate. Safe vaccines: • Tetanus
Antepartum
Yellow fever • Yellow fever
Oral polio
• Diphtheria
Hepatitis B
Diphtheria
Tetanus
51
Progressive and prolonged abdominal pain
Fever and chills
Dysuria
Prolonged vomiting with inability to hold down liquids or solids for >
24 hours
Progressive, severe headache, visual changes, or generalized edema
Pronounced decrease in frequency or intensity of fetal movements
HIGH-YIELD FACTS
Antepartum
52
HIGH-YIELD FACTS IN
Intrapartum
T H R E E S TA G E S O F L A B O R
First Stage
The first stage of labor begins with onset of labor (uterine contractions of suf- Duration of labor is
ficient frequency, intensity, and duration to result in effacement and dilation
typically shorter in the
of the cervix), and ends when the cervix is fully/completely dilated to 10 cm.
multiparous woman than in
The first stage of labor consists of two phases: nulliparous women.
1. Latent phase: Begins with the onset of labor and ends at approxi-
mately 4 cm cervical dilatation.
Average Duration
Nulliparous—20 hours
Multiparous—14 hours
There are three stages of
2. Active phase: Rapid dilation. Begins at 4 cm dilation and ends at 10 labor, and two phases
cm. of stage 1.
Active phase is further classified according to the rate of cervical dilation: Ac-
celeration phase, phase of maximum slope, and deceleration phase.
Fetal descent begins at 7 to 8 cm of dilation in nulliparas and becomes most
rapid after 8 cm.
Average duration of cervical dilation from 4 to 10 cm: Remember the three “Ps”
Nulliparous: 1.2 cm/hr that affect the duration of
Multiparous: 1.5 cm/hr the Active Phase:
Power (strength and
53
First stage
10 +4
Second stage
Deceleration phase
6
eration
Accel-
phase
2
0
Hours of labor
Delivery
Third Stage
The main event of the third stage is placental separation. It begins immedi-
ately after the delivery of the fetus and ends with the delivery of the fetal and
placental membranes.
protraction or arrest of
descent (the fetal head The three signs of placental separation are:
descends < 1 cm/hr in a
nullip and < 2 cm/hr in a 1. Gush of blood from vagina
multip). 2. Umbilical cord lengthening
3. Fundus of the uterus rises up and becomes firm
T R U E L A B O R V E R S U S FA L S E L A B O R
54
B L O O D FA C T S A B O U T T H E U T E R U S
Bloody Show
Discharge of small amount of blood-tinged mucus from vagina (mucous plug)
HIGH-YIELD FACTS
Spontaneous rupture of
Rupture of Membranes (ROM)
membranes (SROM) most
ROM is characterized by sudden gush of nearly colorless fluid. ROM can be often occurs during the
diagnosed with pool, nitrazine, and fern tests (described in PROM section). course of active labor.
A S S E S S M E N T O F T H E L A B O R I N G PAT I E N T
Initial Assessment
History and Physical
Patients without prenatal care require a complete H&P and those with
prenatal care require an update and focused physical. Prenatal record
Intrapartum
should be obtained when possible.
Labs
Patients without prenatal care require:
Complete blood count (CBC)
Blood typing
Rh determination
Urine testing
Patients who have had antepartum care require:
Urine test for protein or glucose
CBC
A specimen of blood in the event that subsequent crossmatching is
required
55
History of allergies
How long ago did patient consume food or liquids and how much
Use of medications
Risk status assignment (high or low)
Vaginal infections with A sterile speculum is used to look for fluid in the posterior vaginal fornix
Trichomonas vaginalis (pool test), which determines if ROM has occurred.
Blood Fluid may be collected on a swab for further study if the source of fluid is un-
Semen clear:
Ferning test (high estrogen content of amniotic fluid causes fern pat-
tern on slide when allowed to air dry):
Crystallization/arborization is due to interaction of amniotic fluid
proteins and salts.
Confirms ROM in 85 to 98% of cases
Nitrazine test—nitrazine paper is pH sensitive and turns blue in pres-
ence of amniotic fluid:
Amniotic fluid (pH = 7.15) is more alkaline than vaginal secretions.
Vernix: The fatty 90 to 98% accurate
substance consisting of
desquamated epithelial cells Fluid should also be examined for vernix or meconium.
Intrapartum
and sebaceous matter that The presence of meconium in the amniotic fluid may indicate fetal
covers the skin of the fetus. stress.
Meconium: A dark green Meconium staining is more common in term and postterm pregnancies
fecal material that than in preterm pregnancies.
Meconium aspiration syndrome (MAS) can occur → infant tachypnea,
accumulates in the fetal
costal retractions, cyanosis, coarse breath sounds, etc.
intestines and is discharged
Prevent MAS via amnioinfusion intrapartum and DeLee suction post-
at or near the time of birth. partum
CERVICAL EXAM
There are four parameters of the cervix that are examined: effacement, consis-
tency, dilation, and position.
EFFACEMENT
Effacement describes the length of the cervix. With labor, the cervix thins
out and softens, and the length is reduced. The normal length is 3 to 4 cm.
Know this cervical exam Terminology: When the cervical length shrinks by 50% (to around 2
stuff cold for the wards!! cm), it is said to be 50% effaced. When the cervix becomes as thin as
the adjacent as the lower uterine segment it is 100% effaced.
56
Determination of effacement: Palpate with finger and estimate the length
from the internal to external os.
DILATION
Dilation describes the size of the opening of the cervix at the external os.
Ranges: Ranges from closed or zero to fully dilated (10 cm). The pre-
senting part of a term-sized infant can usually pass through a cervix that
is fully dilated.
Determination of dilation: The examining finger is swept from the margin
of the cervix on one side to the opposite side.
CERVICAL POSITION
Position describes the location of cervix with respect to the fetal presenting
part. It is classified as one of the following:
Posterior—difficult to palpate because it is behind the fetus, and usually
high in the pelvis
HIGH-YIELD FACTS
Midposition
Anterior—easy to palpate, low down in pelvis
During labor, the cervical position usually progresses from posterior to ante-
rior.
CERVICAL CONSISTENCY
Consistency ranges from firm to soft. Soft indicates onset of labor.
Vaginal prostaglandins
are inserted for ripening of
Bishop Score cervix.
A scoring system that helps determine the status of the cervix—is it fa- IV pictocin is used to
vorable or unfavorable for successful delivery? increase and intensify
If induction of labor is indicated, the status of the cervix must be evalu- contractions.
Intrapartum
ated to help determine the method of labor induction that will be uti-
lized.
A score of ≥ 8 indicates that the probability of vaginal delivery after labor in-
duction is similar to that after spontaneous labor.
57
ASSESSMENT OF THE FETUS
Leopold Maneuvers
Leopold maneuvers are begun in midpregnancy through labor to assess the fe-
tus and maternal abdomen (Figure 6-2). Consist of four parts:
First maneuver answers the question: “What fetal part occupies the fun-
dus?”
Second maneuver answers the question: “On what side is the fetal back?”
Third maneuver answers the question: “What fetal part lies over the pelvic
inlet?”
Fourth maneuver answers the question: “On which side is the cephalic
prominence?”
Five aspects of the fetus are described from the Leopold maneuvers:
Station
HIGH-YIELD FACTS
Lie
Presentation
Position
Attitude
Intrapartum
FIGURE 6-2. Leopold maneuvers. Determining fetal presentation (A and B), position (C), and
engagement (D).
(Reproduced, with permission, from Pernoll ML. Benson & Pernoll’s Handbook of Obstetrics and Gynecology, 10th ed. New
York: McGraw-Hill, 2001: 159.)
58
STATION
Station describes the degree of descent of the fetal head (or presenting part)
in relation to ischial spines.
HIGH-YIELD FACTS
the level of the introitus, and +1 is 1 cm past the ischial spines. presenting part should be
measured at the biparietal
LIE
diameter (BPD), not at the
Lie describes the relation of the long axis of the fetus to that of the mother. tip-top of the head, which
Can be either: may simply be caput and
Longitudinal (99% of term or near term births). This can be vertex not the head at all. So
(head first) or breech (buttocks first). when the BPD is at the
Transverse (0.4% of term or near term births)
level of the ischial spines,
PRESENTATION/PRESENTING PART the station is 0.
Presentation describes the portion of the fetus that is foremost within the
birth canal. It is normally determined by palpating through the cervix on
vaginal examination.
If the lie is longitudinal, the presentation is either the head (cephalic)
or buttocks (breech). One type of cephalic presentation is the vertex
Intrapartum
presentation in which the posterior fontanel is the presenting part.
This is considered normal. Anterior fontanel: bigger
If the lie is transverse, the shoulder is the presenting part. diamond shape
Posterior fontanel: smaller
THE FETAL SKULL triangle shape
The top of the fetal skull is composed of five bones: two frontal, two parietal,
and one occipital. The anterior fontanel lies where the two frontal and two
parietal meet, and the posterior fontanel lies where the two parietal meet the
occipital bone.
FETAL POSITIONS
Position refers to the relation of the presenting part to the right (R) or left (L)
side of the birth canal and its direction anteriorly (A), transversely (T), or
posteriorly (P).
For a cephalic occipital presentation, the position can be described in the fol-
lowing ways:
Occipital anterior (OA)
Occipital posterior (OP)
Left occipital anterior (LOA)
Left occipital posterior (LOP)
59
LOP ROP
LOA ROA
Intrapartum
Normal Presentation
VERTEX PRESENTATION (OCCIPITAL PRESENTATION)
Vertex presentation is usual (96% of at or near term presentations). The head
is flexed so that the chin is in contact with the chest. The posterior fontanel
is the presenting part.
60
Malpresentations
FACE PRESENTATION
In face presentation (0.3% of presentations at or near term), the fetal neck is
sharply extended so the occiput is in contact with the fetal back. The face is Vaginal delivery is possible
the presenting part. Diagnosis is made by palpation of the fetal face on vaginal
only if the fetus is mentum
exam.
anterior; mentum posterior
SINCIPUT PRESENTATION cannot deliver vaginally →
cesarean section.
The fetal head assumes a position between vertex presentation and face pre-
sentation so that the anterior fontanel presents first.
BROW PRESENTATION
The fetal head assumes a position such that the eyebrows present first. This
forces a large diameter through the pelvis; usually, vaginal delivery is possible
HIGH-YIELD FACTS
only if the presentation is converted to a face or vertex presentation.
Sinciput and sinciput
BREECH PRESENTATIONS presentation are usually
transient and almost always
In breech presentations, the presenting fetal part is the buttocks. Normally, convert to vertex or face.
the delivery is C-section. Incidence: 3.5% at or near term but much greater in
early pregnancy (14%). Those found in early pregnancy will often sponta-
neously convert to vertex as term approaches.
Risk Factors
Low birth weight (20 to 30% of breeches)
Congenital anomalies such as hydrocephalus or anencephaly
Uterine anomalies
Multiple gestation
Placenta previa
Diagnosis can be made by:
Intrapartum
Leopold maneuvers
Ultrasound
Types of Breech
Frank breech (65%): The thighs are flexed (bent forward) and the legs
are extended (straight) over the anterior surfaces of the body (feet are
in front of the head or face).
Complete breech (25%): The thighs are flexed (bent) on the abdomen
and the legs are flexed (folded) as well.
Incomplete (footling) breech (10%): One or both of the hips are not
flexed so that a foot lies below.
Management
Normally, C-section is the form of delivery.
External cephalic version: This is maneuvering the infant to a vertex
position. Can be done only if breech is diagnosed before onset of labor Why is pelvimetry and
and the GA > 37 weeks. The success rate is 75%, and the risks are pla- head position so important
cental abruption or cord compression. in frank breech vaginal
Trial of breech vaginal delivery: This is the attempt at a vaginal deliv- delivery? Because the head
ery. It can be done only in a frank breech, GA > 36 weeks, fetal weight doesn’t have time to mold
2,500 to 3,800 g, fetal head flexed, and favorable pelvis. Risks are in order to fit through the
greater for birth trauma (especially brachial plexus injuries) and pro- birth canal.
lapsed cord that entraps the aftercoming head.
61
SHOULDER DYSTOCIA
Shoulder dystocia occurs when, after the fetal head has been delivered, the fe-
tal shoulder is impacted behind the pubic symphysis.
Risk Factors
Macrosomia
Gestational diabetes
Maternal obesity
Post-term delivery
Prolonged stage 2 of labor
Complications
Fetal humeral/clavicular fracture
Brachial plexus nerve injuries
Hypoxia/death
HIGH-YIELD FACTS
Treatment
Several maneuvers can be done to displace the shoulder impaction:
Suprapubic pressure on maternal abdomen
McRoberts maneuver: Maternal thighs are sharply flexed against ma-
ternal abdomen. This decreases the angle between the sacrum and spine
and may dislodge fetal shoulder.
Woods corkscrew maneuver: Pressure is applied against scapula of pos-
terior shoulder to rotate the posterior shoulder and “unscrew” the ante-
rior shoulder.
Posterior shoulder delivery: Hand is inserted into vagina and posterior
arm is pulled across chest, delivering posterior shoulder and displacing
anterior shoulder from behind pubic symphysis.
Break clavicle or cut through symphysis
Engagement indicates that Zavanelli maneuver: If the above measures do not work, the fetal head
the pelvic inlet of the can be returned to the uterus. At this point, a C-section can be per-
maternal bony pelvis is formed.
Intrapartum
The cardinal movements of labor are changes in the position of the fetal head
during passage through the birth canal. The movements are as follows: en-
gagement, flexion, descent, internal rotation, extension, and external rota-
Engagement is measured tion.
by palpation of the
presenting part of the
occiput. Engagement
Engagement is the descent of the biparietal diameter (the largest transverse di-
ameter of the fetal head, 9.5 cm) to the plane of the pelvic inlet (Figure 6-4):
Often occurs before the onset of true labor, especially in nulliparas
62
FIGURE 6-4. Engagement.
(Reproduced, with permission, from DeCherney AH, Pernoll ML. Current Obstetric & Gynecologic Diagnosis & Treatment. Nor-
walk, CT: Appleton & Lange, 1994: 211.)
HIGH-YIELD FACTS
Flexion
Flexion refers to the chin-to-chest position that the fetus takes. This passive
motion facilitates the presentation of the smallest possible diameter of the fe-
tal head to the birth canal.
Internal Rotation
Internal rotation refers to the fetal occiput gradually rotating toward the pubic
symphysis (Figure 6-6).
Extension
Extension moves the occiput to the fetal back (Figure 6-7):
Intrapartum
Occurs after the fetus has descended to the level of the maternal vulva
This descent brings the base of the occiput into contact with the infe-
rior margin of the symphysis pubis, where the birth canal curves up-
ward.
The fetal head is delivered by extension from the flexed to the extended
position, thus curving under and past the pubic symphysis.
63
A B
Expulsion
The anterior shoulder is the After external rotation, further descent brings the anterior shoulder to the
Intrapartum
one closest to the superior level of the pubic symphysis. The shoulder is delivered under the pubic sym-
portions of the vagina, physis and then the rest of the body is quickly delivered (Figures 6-9 and
while the posterior shoulder 6-10).
is closest to the perineum
and anus.
64
FIGURE 6-8. External rotation.
(Reproduced, with permission, from DeCherney AH, Pernoll ML. Current Obstetric & Gynecologic Diagnosis & Treatment. Nor-
walk, CT: Appleton & Lange, 1994: 212.)
HIGH-YIELD FACTS
S TA N D A R D M E T H O D O F D E L I V E RY
It is done during a contraction when the head distends the vulva and per-
ineum enough to open the vaginal introitus to ≥ 5 cm in diameter.
Intrapartum
Checking for Nuchal Cord
A nuchal cord is when the umbilical cord wraps around the fetal neck. To
check for this condition, following delivery of the head, a finger should be
passed along the fetal neck to ascertain the presence of the cord.
If so, a finger should be slipped under the cord and, if loose enough, it
should be slipped over the infant’s head.
If the cord is wrapped tightly around the infant’s neck, it should be cut
between two clamps.
The infant should then be delivered.
Typically, the rest of the body rapidly follows the delivery of the shoulders
without effort.
Delivery of Shoulders
Most frequently, the shoulders appear at the vulva just after external ro-
tation and are born spontaneously (see Figures 6-9 and 6-10).
65
HIGH-YIELD FACTS
Vaginal Lacerations
Intrapartum
The perineum and anus become stretched and thin, which results in increased
risk of spontaneous laceration and anterior tears involving the urethra and
labia.
66
FIRST DEGREE
Involve the fourchette, perineal skin, and vaginal mucosa, but not the under-
lying fascia and muscle
Repair: Absorbable sutures (e.g., 3-0 vicryl)
SECOND DEGREE
First degree plus the fascia and muscle of the perineal body but not the rectal
sphincter
Repair: Done in layers, sometimes using a crown stitch to bring the perineal
body together (e.g., with 3-0 vicryl)
THIRD DEGREE
Second degree plus involvement of the anal sphincter
Repair: Repair anal sphincter with interrupted sutures (e.g., 2-0 vicryl) and re-
HIGH-YIELD FACTS
pair vagina as in second-degree laceration.
Proper repair of 4th-
FOURTH DEGREE degree laceration is
important to prevent
Extend through the rectal mucosa to expose the lumen of the rectum future maternal
Repair: Same as third-degree repair plus careful repair of anal mucosa (e.g., problems (e.g., fecal
with 4-0 vicryl) incontinence).
Episiotomy
An episiotomy is the incision of the perineum and/or labia to aid delivery.
There are two types:
Intrapartum
2. Mediolateral: The incision is oblique starting from 5 o’clock or 7
o’clock position of the vagina. Causes more infection and pain.
Indications
Risk of perineal rupture
Shoulder dystocia
Breech delivery
Forceps/vacuum delivery
Postdelivery Tasks
1. Clear the nasopharynx:
To minimize infant aspiration of amniotic fluid debris and blood that
may occur once the thorax is delivered and the baby can inspire
Use a bulb syringe to aspirate the mouth and nares. Squeeze the bulb-suction
2. Clamping and cutting the cord: between fingers first, then
The umbilical cord is clamped by two instruments and cut in be- place in fetal mouth/nares.
tween.
The infant is handed to the pediatrician/nurse/assistant for examina-
tion.
A sample of cord blood is taken from the umbilical cord that re-
mains attached to the placenta.
67
Postdelivery Uterine Exam
The height and consistency of the uterine fundus are ascertained.
A moderate amount of bleeding is normal.
must be achieved:
The primary mechanism is myometrial contraction → vasoconstriction.
Oxytocin (Pitocin) is administered in the third stage of labor → my-
ometrial contractions → reduces maternal blood loss.
Dystocia
Dystocia literally means difficult labor and is characterized by abnormally
slow progress of labor.
Causes
1. Abnormalities of the expulsive forces:
Uterine dysfunction → uterine forces insufficiently strong or inap-
propriately coordinated to efface and dilate cervix
Inadequate voluntary muscle effort during second stage of labor
2. Abnormalities of presentation, position, or fetal development
3. Abnormalities of the maternal bony pelvis
4. Abnormalities of the birth canal
68
M A N A G E M E N T O F L O W - R I S K PAT I E N T S
HIGH-YIELD FACTS
Contractions in the second stage increase further (aided by maternal bearing
down) to 80 to 100 mm Hg, and the frequency increases to five to six per 10
minutes.
Vaginal Exams
Vaginal examinations should be kept to the minimum required for the evalua-
tion of a normal labor pattern, for example, VE q 4 hours in latent phase and
q 2 hours in active phase. Sterile glove and lubricant should be utilized.
Intrapartum
sonic device
2. Continuous electronic monitoring of the FHR and uterine contrac-
tions
69
MANAGEMENT OF HIGH-RISK PREGNANCIES
Nonstress Test
If fetal compromise is suspected, the nonstress test (NST) is the first assess-
ment of fetal well-being:
The mother is placed in a left lateral, supine position.
A continuous FHR tracing is obtained using external Doppler equip-
ment.
The heart rate changes that result from the fetal movements are deter-
mined:
A normal fetal response during each fetal movement is an accelera-
tion in fetal heart rate of ≥ 15 bpm above the baseline for at least 15
seconds.
If at least two such accelerations occur in a 20-minute interval, the
Intrapartum
Biophysical Profile
A BPP uses ultrasonography and cardiotocography to ascertain fetal well-
being by assessing the following five parameters:
The physiologic basis for 1. Fetal breathing movements (chest wall movements)
using the BPP lies in the 2. Fetal activity (gross trunk or limb movements)
fact that coordinated fetal 3. Amniotic fluid index
activities (i.e., breathing 4. Fetal tone (flexion and extension of an extremity)
5. Reactivity (nonstress test)
and movement) require an
intact, nonhypoxic central A score of 0 or 2 is given for each parameter and a normal profile equals 8 to
nervous system. 10.
70
Amniotic fluid index (AFI) is examined in the BPP and reflects the volume of
amniotic fluid. The calculation of AFI is as follows: The maternal abdomen is
divided into quadrants, and with ultrasound, the maximum vertical pocket of
each quadrant is measured in centimeters and added.
HIGH-YIELD FACTS
F E TA L H E A R T R AT E PAT T E R N S
Intrapartum
variations above and below termed accelerations (increases in HR) and decel-
erations (decreases in HR) (Figure 6-11).
71
Baseline Baseline
FHR FHR
160
FHR
100
Reactive: 15-bpm A normally reactive fetal tracing has two accelerations of at least 15 bpm
increase of 15-second greater than the baseline, lasting for at least 15 seconds, in 20 minutes. It rep-
duration 2×/20 minutes. resents intact neurohumoral cardiovascular control mechanisms and indicates
that the fetus is unstressed.
Early Decelerations
Early decelerations are normal and due to head compression during contrac-
tions. The timing of onset, peak, and end coincides with the timing of the
contraction. The degree of deceleration is proportional to the contraction
strength. The effect is regulated by vagal nerve activation.
NO intervention necessary!!
Late Decelerations
Late decelerations are abnormal and are due to uteroplacental insufficiency
(not enough blood) during contractions. They begin at the peak of contrac-
The lateral recumbent tion and end slowly after the contraction has stopped.
position (either side) is best
Intervention
for maximizing cardiac Change maternal position to the lateral recumbent position.
output and uterine blood Give oxygen by face mask.
flow. (In the supine Stop oxytocin (Pitocin) infusion.
position, the vena cava and Provide an IV fluid bolus.
aortoiliac vessels may be Give an IV tocolytic drug (MgSO4).
compressed by the gravid Monitor maternal blood pressure.
uterus.) If persist longer than 30 minutes, fetal scalp blood pH should be ob-
tained and C-section considered.
72
Variable Decelerations
Variable decelerations are abnormal and can be mild or severe. They are due to
cord compression and sometimes head compression. They can occur at any
time. If they are repetitive, suspicion is high for the cord to be wrapped
around the neck or under the arm of the fetus. Variable decelerations are
abnormal.
Intervention They are classified as:
Amnioinfusion: Infuse normal saline into the uterus through the in- Mild
trauterine pressure catheter to alleviate cord compression. Lasts < 30 sec and depth
Change maternal position to side/Trendelenburg position.
> 70 to 80 bpm
Deliver fetus with forceps or C-section.
Moderate
Lasts 30 to 60 sec and
FETAL TACHYCARDIA
depth < 70 to 80 bpm
Mild = 161 to 180 bpm OR
Severe = ≥ 181 Lasts > 60 sec and depth
HIGH-YIELD FACTS
Fetal tachycardia may indicate intrauterine infection, severe fetal hypoxia, = 70 to 80 bpm
congenital heart disease, or maternal fever. Severe
Lasts > 60 sec and depth
BEAT-TO-BEAT VARIABILITY (BTBV) < 70 bpm
The single most important characteristic of the baseline FHR May signify fetal
Variation of successive beats in the FHR BTBV is controlled primarily acidemia.
by the autonomic nervous system, thus an important index of fetal cen-
tral nervous system (CNS) integrity
At < 28 weeks’ GA, the fetus is neurologically immature; thus, de-
creased variability is expected.
Intrapartum
tracing tachycardia is present.
May be decreased/absent due to alterations in the CNS or inadequate
fetal oxygenation
Increases in BTBV
BTBV (beat to beat
Beat-to-beat variability increases with mild fetal hypoxemia. variability) can be reliably
determined only with
internal FHR monitoring
(fetal scalp electrode).
73
Prolonged Decelerations
Isolated decelerations that last 2 to 10 minutes. Causes include:
Cervical examinations
Uterine hyperactivity
Short-term variability Maternal hypotension → transient fetal hypoxia
is thought to be the Umbilical cord compression
most important
predictor of fetal Management
outcome. Stop Pitocin/prostaglandins.
Change maternal position.
Administer IV fluids.
If mother is hypotensive, administer ephedrine/terbutaline.
Administer maternal O2.
Rule out cord prolapse.
HIGH-YIELD FACTS
A B N O R M A L L A B O R PAT T E R N S
INDUCTION OF LABOR
Intrapartum
Indications
If a deceleration has Generally any condition that makes normal labor dangerous to mother or fe-
occurred without recovery tus is an indication.
after 2 minutes, an
emergency C-section is Maternal
required. Premature ROM
Diabetes mellitus
Heart disease
Prolonged labor
Prolonged pregnancy
Fetal
IUGR
Abnormal fetal testing
Infection
Rh incompatibility
Contraindications
Maternal
Contracted pelvis
Prior uterine surgery (controversial)
74
TABLE 6-3. Abnormal Labor Patterns
Diagnostic Diagnostic
Criterion: Criterion:
Labor Pattern Nulliparas Multiparas Preferred Treatment Exceptional Treatment
Prolongation disorder > 20 hrs > 14 hrs Therapeutic rest (may be Oxytocin stimulation or
(prolonged latent phase) unrecognized false labor) cesarean delivery for
urgent problems
Protraction disorder
1. Protracted active phase < 1.2 cm/hr < 1.5 cm/hr
dilatation
2. Protracted descent < 1 cm/hr < 2 cm/hr Expectant and support Cesarean delivery for
(cephalopelvic
disproportion) CPD
Arrest disorders
HIGH-YIELD FACTS
1. Prolonged deceleration > 3 hrs > 1 hr Without CPD: Oxytocin Rest if exhausted
phase
2. Secondary arrest of > 2 hrs > 2 hrs
dilatation
3. Arrest of descent > 1 hr > 1 hr With CPD: Cesarean Cesarean delivery
delivery
4. Failure of descent (no > 1 hr > 1 hr
descent in deceleration
phase or second stage
of labor)
Intrapartum
Fetal Scalp stimulation is done
Lung immaturity
between decelerations to
Acute distress
Abnormal presentation elicit a reactive acceleration
and rule out metabolic
Induction Drugs acidosis.
OXYTOCIN
A synthetic polypeptide hormone that stimulates uterine contraction:
Acts promptly when given intravenously
Should not be employed for more than a few hours
The term CPD (cephalopelvic
Complications disproportion) has been used
Potent antidiuretic effects of oxytocin (oxytocin is related structurally to describe a disparity
and functionally to vasopressin or antidiuretic hormone) can cause wa- between the size of the
ter intoxication, which can lead to convulsions, coma, and death. maternal pelvis and the fetal
Risk of uterine tetanic contractions (overstimulation)
head that precludes vaginal
PROSTAGLANDINS delivery. This condition can
rarely be diagnosed with
Misoprostol, a synthetic PGE1 analog: certainty and is often due to
Can be administered intravaginally or orally malposition of the fetal head
Used for cervical ripening and induction
(i.e., asynclitism).
75
PGE2 gel and vaginal insert:
Both contain dinoprostone
Used for cervical ripening in women at or near term
2. Classical:
Vertical incision made in uterine corpus
Done when:
Lower uterine segment not developed
Fetus is transverse lie with back down
Indications
Repeat cesarean (elective; patient does not desire a trial of labor)
Dystocia or failure to progress in labor
Breech presentation
Transverse lie
Concern for fetal well-being (i.e., fetal distress)
76
Contraindications for VBAC
Prior classical or T-shaped incision or other transfundal uterine surgery
Contracted pelvis
Medical/obstetric complication that precludes vaginal delivery
Inability to perform emergency C-section because of unavailable sur-
geon, anesthesia, sufficient staff, or facility
HIGH-YIELD FACTS
PREREQUISITES FOR FORCEPS DELIVERY
A fully dilated cervix, ROM, engaged fetal head, > +2 station, no cephalo-
pelvic disproportion, empty bladder, and vertex presentation
PA I N C O N T R O L D U R I N G L A B O R A N D D E L I V E RY
Three essentials of obstetrical pain relief are simplicity, safety, and preserva-
tion of fetal homeostasis.
Pain relief during labor is a
benefit-versus-risk trade-
Uterine Innervation off.
Pain early in the first stage of labor is largely generated from uterine contrac-
Intrapartum
tions. Visceral sensory fibers from the uterus, cervix, and upper vagina traverse
through the Frankenhäuser ganglion (lies just lateral to the cervix) → pelvic
plexus → middle and superior internal iliac plexus → lumbar and lower tho-
racic sympathetic chains → enter the spinal cord through the white rami
communicantes associated with the 11th and 12th thoracic and first lumbar
nerves.
77
An understanding of pregnancy and the birth process
Appropriate antepartum training in breathing
Appropriate psychological support (e.g., by a friend or family member)
Considerate obstetricians and labor assistants who instill confidence
INTRAMUSCULAR (IM)
HIGH-YIELD FACTS
Meperidine + Promethazine:
Small doses given more frequently are preferable to large boluses less of-
Uterine contractions and ten.
cervical dilation cause Analgesia is maximal 45 minutes post injection.
discomfort.
INTRAVENOUS (IV)
Meperidine + Phenergan:
A more rapid effect is produced by this route––the maternal analgesic
and fetal depressant effects are immediate post injection.
NARCOTIC ANTAGONISTS
Naloxone hydrochloride:
Displaces the narcotic from receptors in the CNS
0.1 mg/kg of body weight of the newborn injected into the umbilical
vein
Acts within 2 minutes
78
INHALATION ANESTHESIA
Nitrous oxide (N2O) is the only anesthetic gas in current use in the intra-
partum in the United States:
Provides pain relief during labor and delivery
Produces an altered consciousness Prophylactic measures
Does not prolong labor or interfere with uterine contractions against aspiration include
Self-administered N2O in a 50% mixture with 50% O2 (face mask) pro- fasting for at least 6 hours
vides excellent pain relief in the second stage of labor. prior to anesthesia and
Also used for cesarean delivery and some forceps deliveries with IV ad-
antacid administration
ministration of a short-acting barbituate (e.g., thiopental) and a muscle before induction.
relaxant (e.g., succinylcholine)
Regional Analgesia
Nerve blocks that provide pain relief for women in labor and delivery without
loss of consciousness (anesthesia)
HIGH-YIELD FACTS
PUDENDAL BLOCK
Local infiltration of the pudendal nerve with a local anesthetic agent
(e.g., lidocaine)
Allows pinching of the lower vagina and posterior vulva bilaterally
without pain
Effective, safe, and reliable method of providing analgesia for sponta-
neous delivery
Can be used along with epidural analgesia
Complications
Inadvertant intravascular injection will cause systemic toxicity, hematoma,
infection.
PARACERVICAL BLOCK
Intrapartum
Lidocaine or chloroprocaine is injected at the 3 o’clock and 9 o’clock
positions around the cervix.
Provides good relief of pain of uterine contractions during first stage of
labor
Requires additional analgesia for delivery because the pudendal nerves
are not blocked
Complications
Fetal bradycardia (usually transient)
79
Provides excellent relief of pain from uterine contractions
Proceeded by infusion of 1 L of crystalloid solution → prevents hy-
potension
Cesarean Delivery
A higher level of spinal blockade is necessary to at least the level of the
eighth thoracic dermatome (just below the xiphoid process of the ster-
num).
A larger dose of anesthetic agent is required to anesthetize the larger
area → increased frequency and intensity of toxic reactions.
Bladder dysfunction
EPIDURAL ANALGESIA
Injection of local anesthetic into the epidural or peridural space:
Lumbar epidural analgesia—injection into a lumbar intervertebral space
Caudal epidural analgesia—injection through the sacral hiatus and sacral
canal
eighth thoracic level and extends to first sacral dermatome) or vaginal deliv-
ery (block begins from the tenth thoracic to the fifth sacral dermatome)
Effects on Labor
Increased duration of labor
Increased incidence of:
Chorioamnionitis
80
Low-forceps procedures
Cesarean deliveries
Maternal pyrexia
Contraindications
Actual/anticipated serious maternal hemorrhage
Infection at or near sites for puncture
Suspicion of neurological disease
LOCAL INFILTRATION
Employed for delivery:
Before episiotomy and delivery
After delivery in the site of lacerations to be repaired
Around the episiotomy wound if there is inadequate analgesia
HIGH-YIELD FACTS
P E LV I C T Y P E S
Frequency In 50% of all females One third of white One fourth of white Rarest, < 3% of women
women; one sixth of women; one half of
nonwhite women nonwhite women
Inlet shape Round Heart shaped Vertically oriented Horizontally oriented
oval oval
Intrapartum
Sidewalls Straight Convergent Convergent Divergent, then
convergent
Ischial spines Not prominent Prominent (diameter Prominent (diameter Not prominent
(diameter ≥ 10 cm) < 10 cm) < 10 cm) (diameter > 10 cm)
Sacrum Inclined neither Forward and straight Straight = pelvis Well curved and
anteriorly nor with little curvature deeper than other rotated backward;
posteriorly three types short = shallow pelvis
Significance Good prognosis for Limited posterior space Good prognosis for Poor prognosis for
vaginal delivery for fetal head → poor vaginal delivery vaginal delivery
prognosis for vaginal
delivery
81
Intrapartum HIGH-YIELD FACTS
82
NOTES
HIGH-YIELD FACTS IN
Postpartum
T H E P U E R P E R I U M O F T H E N O R M A L L A B O R A N D D E L I V E RY
The period of confinement during birth and 6 weeks after. During this time,
the reproductive tract returns anatomically to a normal nonpregnant state.
Uterine Changes
INVOLUTION OF THE UTERINE CORPUS
Immediately after delivery, the fundus of the contracted uterus is slightly be-
low the umbilicus. After the first 2 days postpartum, the uterus begins to
shrink in size. Within 2 weeks, the uterus has descended into the cavity of the
true pelvis.
83
TABLE 7-1. Lochia
appearance:
Before childbirth, the os is
a small, regular, oval Changes in the Vagina and Vaginal Outlet
opening.
After childbirth, the orifice Gradually diminishes in size, but rarely returns to nulliparous dimensions:
Rugae reappear by the third week.
is a transverse slit.
The rugae become obliterated after repeated childbirth and menopause.
HIGH-YIELD FACTS
thase → increased milk lactose.
Colostrum is a deep yellow-
COLOSTRUM colored liquid secreted by
the breasts that contains
Colostrum can be expressed from the nipple by the second postpartum day minerals, protein, fat,
and is secreted by the breasts for 5 days postpartum. antibodies, complement,
macrophages, lymphocytes,
MATURE MILK AND LACTATION
lysozymes, lactoferrin, and
Colostrum is then gradually converted to mature milk by 4 weeks postpartum. lactoperoxidase.
Subsequent lactation is primarily controlled by the repetitive stimulus of nurs-
ing and the presence of prolactin.
Postpartum
due to the absence of
Suckling stimulates the neurohypophysis to secrete oxytocin in a pulsatile prolactin.
fashion → contraction of myoepithelial cells and small milk ducts → milk ex-
pression
By 1 week postpartum, the blood volume has returned to the patient’s non-
pregnant range.
CARDIAC OUTPUT
Milk letdown may be
The cardiac output remains elevated for ≥ 48 hours postpartum.
provoked by the cry of the
By 2 weeks postpartum, these changes have returned to nonpregnant
levels. infant or inhibited by stress
or fright.
85
Elevation of plasma fibrinogen and the erythrocyte sedimentation rate re-
main for ≥ 1 week postpartum.
R O U T I N E P O S T PA R T U M C A R E
FIRST HOUR
Take BP and HR at least every 15 minutes.
Monitor the amount of vaginal bleeding.
Palpate the fundus to ensure adequate contraction:
If the uterus is relaxed, it should be massaged through the abdominal
wall until it remains contracted.
Postpartum
If Episiotomy/Laceration Repair
An ice pack should be applied for the first several hours to reduce
edema and pain.
Periodic application of a local anesthetic spray can relieve pain as well.
At 24 hours postpartum, moist heat (e.g., via warm sitz baths) can de-
crease local discomfort.
The episiotomy incision is typically well healed and asymptomatic by
week 3 of the puerperium.
86
BLADDER FUNCTION
Ensure that the postpartum woman has voided within 4 hours of delivery. If
not:
This typically indicates further trouble voiding to follow.
An indwelling catheter may be necessary, with a prohylactic antibiotic
after catheter removal.
Consider a hematoma of the genital tract as a possible etiology.
HIGH-YIELD FACTS
If Fourth-Degree Laceration
Fecal incontinence may result, even with correct surgical repair, due to injury
to the innervation of the pelvic floor musculature.
DISCOMFORT/PAIN MANAGEMENT
During the first few days of the puerperium, pain may result due to:
Afterpains
Episiotomy/laceration repair
Breast engorgement
Postspinal puncture headache
Postpartum
ABDOMINAL WALL RELAXATION
Exercise may be initiated any time after vaginal delivery and after abdominal
discomfort has diminished after cesarean delivery.
DIET
There are no dietary restrictions/requirements for women who have delivered
vaginally. Two hours postpartum, the mother should be permitted to eat and
drink.
IMMUNIZATIONS
The nonisoimmunized D-negative woman whose baby is D-positive is
given 300 µg of anti-D immune globulin within 72 hours of delivery.
Woman not previously immunized against/immune to rubella should be
vaccinated prior to discharge.
Unless contraindicated, woman may receive a diphtheria–tetanus tox-
oid booster prior to discharge.
87
P O S T PA R T U M PAT I E N T E D U C AT I O N
in Postpartum
Blood can accumulate Combined oral contraceptive hormones reduce the amount of breast milk, al-
within the uterus without though very small quantities of the hormones are excreted in the milk.
visible vaginal bleeding:
Watch for: Palpable uterine Progestin-only oral contraceptive pills are virtually 100% effective without
enlargement during the substantially reducing the amount of breast milk.
initial few hours
postpartum.
Coitus in Postpartum
After 6 weeks, coitus may be resumed based on patient’s desire and comfort. A
vaginal lubricant prior to coitus may increase comfort.
Infant Care
Prior to discharge:
Follow-up care arrangements should be made
88
All laboratory results should be normal, including:
Coombs’ test
Bilirubin
Hgb and Hct
Blood glucose
Maternal serologic tests for syphilis and HbsAg should be nonreactive. Urinary retention with
Initial HBV vaccine should be administered. bladder overdistention is a
All screening tests required by law should be done (e.g., testing for common complication of
phenylketonuria [PKU] and hypothyroidism). the early puerperium.
Patient education regarding infant immunizations and well-baby care
Discharge
VAGINAL DELIVERY
One to two days post hospitalization, if no complications
HIGH-YIELD FACTS
CESAREAN SECTION
Three to four days post hospitalization, if no complications
M AT E R N A L F O L L O W - U P C A R E
Breast Feeding
Human milk is the ideal food for neonates for the first 6 months of life.
Postpartum
Department of Health and Human Services/U.S. Department of Agriculture.
BENEFITS
Uterine Involution
Nursing accelerates uterine involution.
Immunity
Colostrum and breast milk contain secretory IgA antibodies against Esch-
erichia coli and other potential infections.
Milk contains memory T cells, which allows the fetus to benefit from mater-
nal immunologic experience.
Nutrients
All proteins are absorbed by babies, and all essential and nonessential amino
acids available.
89
GI Maturation
Milk contains epidermal growth factor, which may promote growth and matu-
ration of the intestinal mucosa.
Cyclophosphamide
Cyclosporine
Doxorubicin
Ergotamine
Lithium
Breast-fed infants are less Methotrexate
prone to enteric infections
than are bottle-fed babies. Mothers ingesting the following medications with unknown effects on the infant:
Psychotropic drugs
Antianxiety drugs
Antidepressants
Chloramphenicol
Metoclopramide
Metronidazole
CMV, HBV, and HIV are
Tinidazole
excreted in breast milk.
Postpartum
Drug Abuse
Mothers who abuse the following drugs:
Amphetamines
Cocaine
A common misperception: Heroin
Mothers who have a Marijuana
common cold should not Nicotine
Phencyclidine
breast feed (FALSE).
Radiotherapy
Mothers undergoing radiotherapy with:
Gallium
Indium
Iodine
Radioactive sodium
Most drugs given to the Technetium
mother are secreted in
breast milk. The amount of
drug ingested by the infant
is typically small.
90
P O S T PA R T U M P S Y C H I AT R I C D I S O R D E R S
Maternity/Postpartum Blues
A self-limited, mild mood disturbance due to biochemical factors and psycho-
logical stress:
Affects 50% of childbearing women
Begins within 3 to 6 days after parturition
May persist for up to 10 days
SYMPTOMS
Similar to depression, but milder (see below)
TREATMENT
Supportive—acknowledgement of the mother’s feelings and reassurance
Thirty percent of adolescent
HIGH-YIELD FACTS
Monitor for the development of more severe symptoms (i.e., of postpar-
tum depression or psychosis). women develop postpartum
depression.
Postpartum Depression
Similar to minor and major depression that can occur at any time:
Classified as “postpartum depression” if it begins within 3 to 6 months
after childbirth
Eight to 15% of postpartum women develop postpartum depression
within 2 to 3 months. Criteria for major
depression/post-
SYMPTOMS partum depression:
Symptoms are the same as major depression. Two-week period of
depressed mood or
NATURAL COURSE anhedonia nearly every
Postpartum
Gradual improvement over the 6 months postpartum day plus one of the
The mother may remain symptomatic for months → years. following:
1. Significant weight loss
TREATMENT or weight gain without
effort (or ↑ or ↓ in
Pharmacologic intervention is typically required:
appetite)
Antidepressants
Anxiolytic agents
2. Insomnia or
Electroconvulsive therapy
hypersomnia
Mother should be co-managed with a psychiatrist (i.e., for psychother- 3. Psychomotor
apy to focus on any maternal fears or concerns). agitation/retardation
4. Fatigue or loss of
energy
Postpartum Psychosis 5. Feelings of
Mothers have an inability to discern reality from that which is unreal worthlessness/excessive
(can have periods of lucidity). or inappropriate guilt
Occurs in 1 to 4/1,000 births 6. Decreased ability to
Peak onset—10 to 14 days postpartum, but may occur months later concentrate/think
7. Recurrent thoughts of
suicide/death
91
RISK FACTORS
History of psychiatric illness
Family history of psych disorders
Younger age
If these drugs are Primiparity
prescribed to nursing
mothers, infant blood COURSE
concentrations of the drug Variable and depends on the type of underlying illness; often 6 months
should be monitored.
TREATMENT
Psychiatric care
Pharmacologic therapy
Hospitalization (in most cases)
Usually remits
HIGH-YIELD FACTS
after 2 to 3 days.
Postpartum
92
HIGH-YIELD FACTS IN
Medical Conditions
and Infections in Pregnancy
S O C I A L R I S K FA C T O R S
Alcohol
Alcohol is teratogenic.
An occasional drink during pregnancy carries no known risk. There is no consensus on
Fetal alcohol syndrome (FAS) may occur with chronic exposure to al- the quantity of alcohol that
cohol in the later stages of pregnancy. Features may include: leads to adverse fetal
Growth retardation outcomes. Hence, the best
Facial anomalies: maternal advice is to
Small palpebral fissures discontinue alcohol use
Indistinct/absent philtrum when trying to become
Epicanthic folds
pregnant and during
Flattened nasal bridge
pregnancy.
Short length of nose
Thin upper lip
Low-set, unparallel ears
Retarded midfacial development
Central nervous system (CNS) dysfunction:
Microcephaly
Mental retardation
Abnormal neurobehavior (e.g., attention deficit hyperactivity dis-
order)
Tobacco
The leading preventable cause of low birth weight in the United
States Smoking by pregnant
Smoking is associated with decreased birth weight and increased prema- women and all household
turity. members should be stopped
There is a positive association between sudden infant death syndrome and not resumed
(SIDS) and smoking.
postpartum.
Use of nicotine patch is controversial
93
Illicit Drugs
MARIJUANA
Derived from the plant Cannabis sativa; active ingredient, tetrahydrocannabi-
nol:
No evidence of significant teratogenesis in humans
Metabolites detected in urine of users for days to weeks
Commonly used by multiple substance abusers; thus, its presence in
urine may identify patients at high risk for being current users of other
substances as well
COCAINE
Pregnancy does not increase one’s susceptibility to cocaine’s toxic effects
Complications of pregnancy:
Spontaneous abortion and fetal death in utero
Preterm labor and delivery (25%)
HIGH-YIELD FACTS
OPIATES
Heroin
Three- to sevenfold increase in incidence of stillbirth, fetal growth re-
Conditions and Infections
Newborn infants born to narcotic addicts are at risk for severe, potentially fa-
tal narcotic withdrawal syndrome, characterized by:
High-pitched cry
Poor feeding
Hypertonicity/tremors
Irritability
Sneezing
Sweating
Vomiting/diarrhea
Seizures
HALLUCINOGENS
No evidence that lysergic acid diethylamide (LSD) or other hallucino-
gens cause chromosomal damage or other deleterious effects on human
pregnancy
There have been no studies on the potential long-term effects on
neonatal neurodevelopment.
94
AMPHETAMINES
Crystal methamphetamine (“ice,” “blue ice”), a potent IV stimulant, has been
associated with:
Decreased fetal head circumference
Placental abruption
Intrauterine growth retardation (IUGR)
Fetal death in utero
EXPOSURE TO VIOLENCE
Twenty percent of all pregnant women are battered during preg-
nancy.
For some women, the violence is initiated at the time of pregnancy.
One half of women who are physically abused prior to pregnancy con-
HIGH-YIELD FACTS
tinue to be battered during pregnancy.
Ask: “Are you in a relationship in which you are being hit, kicked,
slapped, or threatened?”
All abused patients should be given information regarding their imme-
diate safety and referrals for counseling and support.
C O N T R A I N D I C AT I O N S T O P R E G N A N C Y
Pulmonary hypertension:
Associated with a 50% maternal mortality rate and a > 40% fetal
RISK INTERVENTIONS
Nutritional Recommendations
Folic acid supplementation:
If previous pregnancies: 4 mg/day starting 4 weeks prior to concep-
tion, through T1 Folic acid supplementation
If nulligravida, 0.4 mg (400 µg) qd reduces the risk of neural
tube defects (NTDs).
Physical Activity Recommendations
Women who exercise regularly before pregnancy are encouraged to con-
tinue.
For the normal healthy woman, a low-impact exercise regimen may be
continued throughout pregnancy.
95
T E R AT O L O G Y A N D D R U G S
The placenta permits the passage of many drugs and dietary substances:
Lipid-soluble substances readily cross the placenta.
Water-soluble substances cross less well because of their larger molecu-
Drug exposure is
responsible for 2 to 3% of lar weight.
The greater degree to which a drug is bound to plasma protein, the less
birth defects.
likely it is free to cross.
The minimal effective dose should be employed.
CATEGORY B
Conditions and Infections
CATEGORY C
Uncertain safety—animal studies show an adverse effect, no human studies.
CATEGORY D
Unsafe—evidence of risk that may in certain clinical circumstances be justifi-
able
CATEGORY X
Highly unsafe—risk outweighs any possible benefit.
Vitamin A Derivatives
Isotretinoin (Accutane):
For treatment of cystic acne
25% risk of anomalies
Malformed infants have characteristic craniofacial, cardiac, thymic,
and CNS anomalies.
Etretinate (Tegison):
For treatment of psoriasis
Similar teratogenic effects to that of isotretinoin
96
Vitamin A:
No evidence that normal doses are teratogenic
Large doses (≥ 25,000 IU/day) should be avoided because birth de-
fects have been reported at these dosages.
Antineoplastics
Methotrexate and aminopterin are folic acid derivatives. They cause IUGR,
mental retardation, and craniofacial malformations.
Anticoagulants
Warfarin (Coumadin) crosses the placenta and is associated with chon-
drodysplasia punctata, presumably due to microhemorrhages during de-
velopment.
Fetal and maternal hemorrhage has also been reported, but incidence
HIGH-YIELD FACTS
can be reduced with careful control of the prothrombin time.
Heparin, an alternative to Coumadin, has a large negative charge and
Heparin is the drug of
does not cross the placenta.
Does not have any adverse fetal effects
choice in pregnant
Heparin-induced osteoporosis with fracture occurs in 1 to 2% of patients who require
women in whom full anticoagulation has been achieved during preg- anticoagulation.
nancy.
Low-molecular-weight heparins (LMWH):
May have substantial benefit over standard unfractionated heparin
Molecules do not cross placenta
Psychotropics
ANTICONVULSANTS
Phenytoin decreases absorption of folate and decreases serum folate and
causes craniofacial, limb, and mental defects.
Valproic acid and carbamazepine use is associated with a 1% risk of
neural tube defects.
ANTIDEPRESSANTS
Imipramine (Tofranil):
Tricyclic antidepressant
Associated with fetal cardiac anomalies
Fluoxetine (Paxil):
No increased risk of major malformations or developmental abnor-
malities has been observed.
97
TRANQUILIZERS
Chlordiazepoxide (Librium) is associated with congenital anomalies.
Diazepam use perinatally has been associated with fetal hypothermia,
hypotonia, and respiratory depression.
Analgesics
Aspirin:
No teratogenic effects seen in T1
Significant perinatal effects seen, such as decreased uterine contrac-
tility, delayed onset of labor, prolonged duration of labor
Increases risk of antepartum bleeding and bleeding at delivery
NSAIDs:
Ibuprofen (Motrin, Advil) and naproxen (Naprosyn) have not
demonstrated any negative fetal effects with short-term use.
Nonpharmacologic
HIGH-YIELD FACTS
should be used only when are affected between 26 weeks’ GA and infant age of 6 months.
clearly indicated. Doxycycline has no teratogenic risk in T1.
Quinolones (Ciprofloxacin, Norfloxacin) have a high affinity for carti-
lage and bone tissue → may cause arthropathies in children.
Antiasthmatics
Epinephrine (sympathomimetic amine) exposure after T1 has been as-
sociated with minor malformations.
Terbutaline (Brethine) is not associated with birth defects.
Long-term use has been associated with increased risk of glucose in-
tolerance.
Isoproterenol (Isuprel) and Albuterol (Ventolin) are not teratogenic.
Corticosteroids are inactivated by the placenta when maternally admin-
istered → < 10% of maternal dose is in the fetus.
Cardiovascular Drugs
Angiotensin-converting enzyme inhibitors (Vasotec, Capoten) can
cause fetal renal tubular dysplasia in T2 and T3 → oligohydramnios, fe-
tal limb contractures, craniofacial deformities, hypoplastic lung devel-
opment.
Propranolol (Inderal) shows no evidence of teratogenicity:
Fetal bradycardia has been seen as a direct dose effect when given to
mother 2 hours prior to delivery.
Increased risk of IUGR seen with maternal use
98
Androgens/Progestins
Androgens may masculinize a developing female fetus
Progestational agents (e.g., Danazol) (often synthetic testosterone de-
rivatives) may cause clitoromegaly and labial fusion if given prior to 13
weeks’ GA. Pregnancy testing is
recommended before
prescribing hormonal
MEDICAL CONDITIONS AND PREGNANCY
medications in patients with
anovulatory symptoms and
menstrual irregularities.
Endocrine Disorders in Pregnancy
DIABETES MELLITUS
See Table 8-1.
Pregestational diabetes—patient had DM before pregnancy
HIGH-YIELD FACTS
Gestational diabetes—patient develops diabetes only during pregnancy.
Gestational diabetes is classified as type A according to White classifi-
cation.
White classification A1—controlled with diet
White classification A2—requires insulin
Screening
Screening is controversial, but tests often used are:
Fasting 2-Hour
Plasma Postprandial Vascular
Class Onset Glucose Glucose Duration (yrs) Disease Therapy
A1 Gestational < 95 mg/dL < 120 mg/dL — — Diet and exercise
A2 Gestational < 95 mg/dL > 120 mg/dL — — Insulin
Vascular
Class Onset Duration (yrs) Disease Therapy
B > 20 yrs old < 10 None Insulin
C 10–19 yrs old 10–19 None Insulin
D Before age 10 > 20 Benign Insulin
retinopathy
F Any Any Nephropathy Insulin
(pronounced
“neFropathy”)
R Any Any Proliferative Insulin
Retinopathy
H Any Any Heart Insulin
99
> 140 is high (a 3-hour glucose tolerance test is then required to di-
agnose GDM).
If ≥ 200, patient is diagnosed with GDM type A1 and a diabetic diet
is initiated.
2. 3-Hour glucose tolerance test—if glucose challenge test is > 140 and
Diabetes is the most < 200
common medical Draw fasting glucose level; normal(n) < 95
complication of pregnancy. Give 100-g glucose load.
Draw glucose levels at 1 hour (n < 180), at 2 hours (n < 155), and at
3 hours (n < 140).
Positive for gestational diabetes if 2/4 high values
Risk Factors
Be extra careful to test:
Gestational diabetes Previous or family history of gestational diabetes
probably results from Obesity
placental lactogen History of large babies
HIGH-YIELD FACTS
secreted during pregnancy, History of full-term stillbirth or child with cardiac defects
which has large glucagon-
like effects. Effects of Gestational Diabetes
Maternal Effects
Four times increased risk of preeclampsia
Increased risk of bacterial infections
Higher rate of C-section
Increased risk of polyhydramnios
Increased risk of birth injury
Fetal Effects
Increased risk of perinatal death
Conditions and Infections
Thirty percent of women Three times increased risk of fetal anomalies (renal, cardiac, and CNS)
with gestational diabetes Two to three times increased risk of preterm delivery
develop other diabetes Fetal macrosomia increases risk of birth injury.
later. Metabolic derangements (hypoglycemia, hypocalcemia)
Management
The key factors involved in successful management of these high-risk preg-
nancies include:
Good glucose control:
Prepregnancy glucose levels should be maintained during pregnancy
The CNS anomaly most with insulin.
specific to DM is caudal Glucose control should be checked at each prenatal visit.
regression.
Starting at 32 to 34 weeks:
Fetal monitoring:
Ultrasonography to evaluate fetal growth, estimated weight, amniotic
fluid volume, and fetal anatomy at 16 to 20 weeks’ GA
Nonstress test and amniotic fluid index testing weekly to biweekly
depending on disease severity
Biophysical profile
Contraction stress test (oxytocin challenge test)
Early elective delivery:
Fetal macrosomia must be ruled out with ultrasonography.
100
If fetal weight is > 4,500 g, elective cesarean section should be considered to avoid
shoulder dystocia. Unless there is an obstetric complication, induction of labor
and vaginal delivery are done.
HYPERTHYROIDISM/GRAVES’ DISEASE
Thyrotoxicosis complicates 1 in 2,000 pregnancies.
Graves’ disease is the most common cause of thyrotoxicosis in preg-
nancy.
Treatment is propylthiouricil or methimazole or surgery. Radioactive io- In normal pregnancy, total
dine is contraindicated in pregnancy. T3 and T4 are elevated but
free thyroxine levels do not
Thyroid Storm change.
Thyroid storm is a major risk. Precipitating factors are infection, labor, and
C-section.
Treatment
HIGH-YIELD FACTS
Beta blocker
Sodium iodide
Parathyroid hormone (PTH)
Dexamethasone Propylthiouracil (PTU) is the
drug of choice over
25% mortality rate methimazole for treating
thyrotoxicosis in pregnancy.
Complications
1% risk of neonatal thyrotoxicosis
Fetal goiter/hypothyroid, usually from PTU
Preterm delivery
Preeclampsia
Hypothyroidism
Overt hypothyroidism is
Subclinical hypothyroidism is more common than overt hypothyroidism, and often associated with
often goes unnoticed. Diagnosed by elevated TSH. infertility.
Postpartum Thyroiditis
Transient postpartum hypothyroidism or thyrotoxicosis associated with au-
toimmune thyroiditis is common:
Between 1 and 4 months postpartum, 4% of all women develop tran-
sient thyrotoxicosis.
Between 4 and 8 months postpartum, 2 to 5% of all women develop hy-
pothyroidism. In women with type 1 DM,
25% develop postpartum
Sheehan Syndrome thyroid dysfunction.
Pituitary ischemia and necrosis associated with obstetrical blood loss leading
to hypopituitarism. Patients do not lactate postpartum due to low prolactin.
101
Pregnant epileptics are more prone to seizures due to the associated
stress and fatigue of pregnancy.
The fetus is at risk for megaloblastic anemia.
The pregnant female and her fetus are at risk for hemorrhage due to a
deficiency of vitamin K–dependent clotting factors induced by anticon-
Folic acid supplementation vulsant drugs.
is increased in the epileptic Management of the epileptic female should begin with prepregnancy
patient to 5 mg/day. counseling.
Anticonvulsant therapy should be reduced to the minimum dose of the
minimum number of anticonvulsant medications.
Folic acid supplementation (5 mg/day) should be taken by those women
taking anticonvulsants.
Once pregnant, the patient should be screened for NTDs and congeni-
tal malformations.
Blood levels of anticonvulsant medications should be checked at the
beginning of pregnancy to determine the drug level that controls
epileptic episodes successfully.
HIGH-YIELD FACTS
102
MITRAL STENOSIS (MS)
Pathophysiology
Increased preload due to normal increase in blood volume results in left
atrial overload and backup into the lungs resulting in pulmonary hy-
pertension. Cardiac output increases by
30 to 50% by midpregnancy.
Sequelae
Tachycardia associated with labor and delivery is exacerbates the pul-
monary HTN because of decreased filling time.
Postpartum period is the most hazardous time.
Treatment
Antibiotic prophylaxis
Blood volume increases
MITRAL VALVE PROLAPSE 50% by 30th week.
These patients are normally asymptomatic and have a systolic click on physi-
HIGH-YIELD FACTS
cal exam. They will generally have a safe pregnancy. Antibiotics should be
give for prophylaxis against endocarditis.
Prolapse = okay to be
Pulmonary Disease Pregnant
The adaptations to the respiratory system during pregnancy must be able to Stenosis = Sick in
satisfy the increased O2 demands of the hyperdynamic circulation and the fe- pregnancy
tus. Advanced pregnancy may worsen the pathophysiological effects of many
acute and chronic lung diseases.
ASTHMA
Epidemiology
One to four percent of pregnancies are complicated by asthma:
25% of asthmatics worsen in pregnancy.
25% improve.
50% have no change.
103
Management of Status Asthmaticus
Give oxygen.
Give SQ terbutaline.
Give IV corticosteroids.
Two to seven percent of pregnant women have UTIs; 25% are asymptomatic.
PYELONEPHRITIS
Pyelonephritis in pregnant
women is on the right side Acute pyelonephritis is the most common serious medical complication of pregnancy
and occurs in 1 to 2% of pregnant women. Management includes:
86% of the time.
Hospitalization
IV antibiotics (ampicillin or cefazolin)
Monitor fluids
Conditions and Infections
APPENDICITIS
Appendicitis is the most common surgical condition in pregnancy (oc-
curs 1 in 2,000 births).
Has usual symptoms
Uterus displaces the appendix superiorly and laterally. Pain and tender-
ness may not be found at McBurney’s point (RLQ).
Increased estrogens cause Incidence is same throughout pregnancy, but rupture is more frequent
increase in cholesterol in T3 (40%) than T1 (10%).
saturation, which, in Management is appendectomy.
addition to biliary stasis,
leads to more gallstones
in pregnant women.
104
CHOLELITHIASIS AND CHOLECYSTITIS
Incidence of cholecystitis is 1 in 4,000 pregnancies (more common
than nonpregnant). Persistent nausea and
Same clinical picture as nonpregnant vomiting in late pregnancy
Medical management unless common bile duct obstruction or pancre- should prompt a search for
atitis develops, in which case a cholescystectomy should be perfomed. underlying pathology (e.g.,
High risk of preterm labor gastroenteritis, cholecystitis,
pancreatitis, hepatitis,
Anemia peptic ulcer, pyelonephritis,
Physiologic anemia is normal anemia in pregnancy because of hemodilu- fatty liver of pregnancy,
tion due to volume expansion. and psychological or social
Anemia for a pregnant woman is a drop in Hgb by 10 g/dL or Hct by issues).
30%.
Incidence: 20 to 60% of pregnant women, 80% is iron-deficiency type
Risks: Preterm delivery, IUGR, low birth weight
HIGH-YIELD FACTS
Therapy is 325 mg tid of FeSO4 (prophylaxis is q d)
Intrapartumb
Maternal HSV Gonorrhea
exposure Papillomavirus Chlamydia
HIV GBS
HBV TB
External HSV Staphylococcus
contami- Coliforms
nation
105
TABLE 8-2. Perinatal Infections (continued)
Neonatal
Human HSV Staphylococcus
trans-
mission
Respirators Staphylococcus
and Coliforms
catheters
a Bacteria, viruses, or parasites may gain access transplacentally or cross the intact membranes.
b Organisms may colonize and infect the fetus during L&D.
106
TABLE 8-3. Viral Infections and Their Potential Fetal Effects (continued)
HIGH-YIELD FACTS
Chorioretinitis
Mental retardation
Jaundice
107
TABLE 8-4. Bacterial Infections and Their Potential Fetal Effects (continued)
a Antimicrobials prolong the carrier state and are not given in uncomplicated infections.
Conditions and Infections
108
HIGH-YIELD FACTS IN
Complications
of Pregnancy
HYPERTENSION IN PREGNANCY
In Pregnancy-Hypertensive States
The balance is thought to be tipped toward the thromboxane pathway.
109
Diagnose HTN
BP > 140/90 at rest, measured at
least twice, and > 6 hours apart.
(sustained ↑ in BP)
History of HTN
before pregnancy
Yes No
HTN
Check onset prior
Baseline to 24 weeks?
Labs
Yes No
Consider
Molar
HIGH-YIELD FACTS
Pregnancy
Chronic Hypertension
BP > 160/110
If conditions worsen,
Like: ↑ HTN, Proteinuria,
Yes No
DIC, ↑ Fetal growth,
other signs/symptoms
Severe
Preeclampsia
Check
24-hr Urine
Protein
Complications of Pregnancy
>5g
> 0.3 g
<5g
Deliver Baby
≥ 36 Yes No
weeks’
gestation
Mild Preeclampsia
110
Management
Mild: Early and serial ultrasounds, biophysicals
Severe:
Serial ultrasounds and biophysicals
Antihypertensives (methyldopa or nifedipine) In PIH, you must monitor
for intrauterine growth
PREGNANCY-INDUCED HYPERTENSION (PIH) retardation (IUGR) and
Defined as hypertension during pregnancy in a previously normotensive progression to
woman (the patient had normal blood pressure prior to 20 weeks’ gestation): superimposed preeclampsia
Mild: Systolic ≥ 140 mm Hg and/or diastolic ≥ 90 mm Hg (15 to 25% incidence).
Severe: Systolic > 160 mm Hg and/or diastolic > 110 mm Hg (same as
chronic HTN)
Subsets of PIH
1. PIH (simple) Severe PIH usually occurs
HIGH-YIELD FACTS
2. Preeclampsia: Renal involvement leads to proteinuria. in the third trimester.
3. Eclampsia: Central nervous system involvement leads to seizures.
4. HELLP syndrome: The clinical picture is dominated by hematologic
and hepatic manifestations.
Complications
Heart failure Symptoms of severe
Cerebral hemorrhage disease include:
Placental abruption Headache
Fetal growth restriction Visual disturbances
Fetal death Epigastric pain
Complications of Pregnancy
Management
Mild: Observe, bed rest
Severe: Always hospitalize + antihypertensive pharmacotherapy (hy-
dralazine or labetalol short term, nifedipine or methyldopa long term)
The only definitive
Generally, for all pregnancy-hypertensive states: treatment for PIH is
Plus the following: delivery.
If > 36 weeks/fetal lung maturity: Induce labor.
If < 34 weeks/fetal lung immaturity: Steroids plus expectant manage-
ment
If fetal or maternal deterioration at any gestational age, induce labor
PREECLAMPSIA
Preeclampsia is pregnancy-induced hypertension with proteinuria +/− patho-
logical edema. It is classified as mild or severe.
Preeclampsia rarely develops before 20 weeks and usually occurs in a first preg-
nancy.
Criteria for Mild Preeclampsia
BP: ≥ 140 systolic or ≥ 90 diastolic
Proteinuria: 300 mg to 5 g/24 hrs (norm: < 300 mg/24 hrs in pregnancy, Preeclampsia is usually
< 150 mg/24 hrs in nonpregnant state) asymptomatic; it is crucial
to pick up during routine
Manifestations of Severe Disease prenatal visits.
BP: > 160 systolic or > 110 diastolic
111
Proteinuria: > 5 g/24 hrs
Elevated serum creatinine
Oliguria (< 500 mL/24 hrs)
Symptoms suggesting end organ involvement:
Headache
Visual disturbances
Epigastric/right upper quadrant pain
Pulmonary edema
Hepatocellular dysfunction (elevated aspartate transaminase [AST],
alanine transaminase [ALT])
Thrombocytopenia
IUGR or oligohydramnios
Microangiopathic hemolysis
Grand mal seizures (eclampsia)
Predisposing Factors
HIGH-YIELD FACTS
Nulliparity
HTN may be absent in 20% Family history of preeclampsia–eclampsia
Multiple fetuses
of women with HELLP and
Diabetes
severely elevated in 50%. Chronic vascular disease
Renal disease
Hydatidiform mole
Fetal hydrops
HELLP SYNDROME
HELLP syndrome is a manifestation of preeclampsia with hemolysis, elevated
liver enzymes, and low platelets. In contrast to typical presentations of
Complications of Pregnancy
Diagnosis of Preeclampsia
Once preeclampsia is suspected, the following tests should be done:
Know which labs to order. Blood: Electrolytes, blood urea nitrogen (BUN), creatinine, liver func-
tion tests (LFTs) (ALT, AST), complete blood count (CBC), uric acid,
and platelet count
Urine: Sediment, 24-hour protein, 24-hour creatinine
Fetal: Ultrasound, nonstress test, biophysical profile
Management
Varies depending on severity of disease and gestational age of fetus:
112
Plus the following:
If > 36 weeks/fetal lung maturity: Induce labor.
If < 34 weeks/fetal lung immaturity: Steroids plus expectant manage-
ment
If fetal or maternal deterioration at any gestational age: Induce labor.
25% of seizures are
The only cure is delivery. before labor.
50% of seizures are
ECLAMPSIA during labor.
25% of seizures are
Criteria
post-labor (may be
Mild or severe preeclampsia encountered up to 10
Generalized seizures days postpartum).
Management
1. Control of the convulsions (magnesium sulfate IV and IM)
HIGH-YIELD FACTS
2. Correction of hypoxia and acidosis
3. BP control (hydralazine or labetalol)
4. Delivery after control of convulsions
Complications of Pregnancy
Long-Term Control
Methyldopa: PO, false neurotransmitter
Side effects: Postural hypotension, drowsiness, fluid retention
Nifedipine: PO, calcium channel blocker
Side effects: Edema, dizziness
Atenolol: PO, selective beta-1 blocker
Side effect: breathlessness
PRETERM LABOR
Criteria
Gestational age (GA) < 37 weeks with regular uterine contractions and:
Progressive cervical change
Braxton Hicks contractions
or (irregular, nonrhythmical,
A cervix that is 2 cm dilated usually painless contractions
or that begin at early gestation
A cervix 80% effaced and increase as term
or approaches) may make it
Ruptured membranes difficult to distinguish
between true and false
labor.
113
Epidemiology
Preterm labor has been associated with the following findings:
1. Infection:
The common denominator Systemic
among these fetal and Pyelonephritis urinary tract infection (UTI)/sexually transmitted
maternal conditions that disease (STD)
may induce preterm labor Chorioamnionitis
has not been determined. 2. Maternal factors:
Low socioeconomic status
Coitus
Long work hours
Youth
Grand multiparity
ETOH/smoking/narcotics
Previous preterm labor
HIGH-YIELD FACTS
Previous abortion
Most infants born after 34 Preeclampsia/eclampsia/HTN
weeks’ GA will survive (the 3. Anomalies:
survival rate is within 1% Uterine (septated uterus, fibroids)
of the survival rate beyond Cervical incompetence
Multifetal pregnancy
37 weeks).
Polyhydramnios
Fetal anomalies
Placenta previa/abruptio
Assessment
Complications of Pregnancy
TOCOLYTIC THERAPY
Hydration often stops
Tocolysis is used if < 34 weeks.
contractions during preterm
labor. Tocolytic Agents
IV magnesium sulfate—suppresses uterine contractions
Oral calcium channel blocker (nifedipine)
Beta mimetics (ritodrine, terbutaline)—stimulate beta-2 receptors on
myometrial cells → increase cyclic adenosine monophosphate (cAMP)
→ decrease intracellular Ca → decrease contractions
Side effects: Pulmonary edema, tachycardia, headaches
114
Prostaglandin inhibitors (indomethacin)
Side effects: Premature constriction of ductus arteriosus, pulmonary
HTN, and interventricular hemorrhage
Contraindications to Tocolysis
Severe Bleeding from any cause Mnemonic for
Severe Abruptio placentae contraindications to
Fetal Death/life-incompatible anomaly tocolysis: BAD CHU
Chorioamnionitis Severe Bleeding from
Severe pregnancy-induced Hypertension any cause
Unstable maternal hemodynamics Severe Abruptio
placentae
Action Fetal Death/life-
Acts as Ca2+ antagonist and reduces actin–myosin interaction (at 7 incompatible anomaly
mg/100 mL) Chorioamnionitis
Severe pregnancy-
Side Effects
HIGH-YIELD FACTS
Decreases deep tendon reflexes (at 8 to 10 mg/100 mL)
induced Hypertension
Unstable maternal
Respiratory/cardiac depression (at > 12 mg/100 mL)
Flushing, warmth, headaches, nystagmus, dizziness, dry mouth, hypocal- hemodynamics
cemia
Complications of Pregnancy
Mg Level Side Effect
4–7 mg Uterine contractions decreased
8–12 mg Depressed deep tendon reflexes
> 12 mg Respiratory/cardiac depression
CORTICOSTEROIDS
Given to patients in preterm labor from 24 to 35 weeks unless they
have chorioamnionitis
Reduce fetal mortality: Accelerate fetal lung maturity (decreases respi-
ratory distress syndrome [RDS]), reduce intraventricular hemorrhage,
and reduce necrotizing enterocolitis
LECITHIN–SPHINGOMYELIN RATIO
An amniocentesis may be performed to assess fetal lungs for risk of RDS. Fetal
lungs are mature if:
Phosphatidylglycerol is present in amniotic fluid
or
Lecithin–sphingomyelin ratio is > 2
115
P R E M AT U R E R U P T U R E O F M E M B R A N E S
Risks
Prolonged rupture of membranes: The rupture of membranes > 18 to 24
hours before labor. Patients who do not go into labor immediately will
Prolonged rupture of have prolonged rupture of membranes and are at increasing risk of in-
HIGH-YIELD FACTS
116
Specific Management for PROM at Term
Ninety percent of term patients go into spontaneous labor within 24 hours af-
ter rupture:
Patients in active labor should be allowed to progress.
If labor is not spontaneous, it should be induced or cesarean delivery If nitrazine and pooling are
should be performed. nonconfirmatory, ferning
test is useful.
Specific Management of PPROM
Fifty percent of preterm patients go into labor within 24 hours after rupture.
Generally, one needs to balance the risks of premature birth against the risk of
infection (which increases with the time that membranes are ruptured before
birth). Management is aimed at assessing these risks and acting accordingly:
Gram stain and culture of amniotic fluid to assess for chorioamnionitis
If chorioamnionitis is suspected, begin ampicillin and/or erythromycin
HIGH-YIELD FACTS
prophylaxis.
Amniotic fluid assessment of lecithin–sphingomyelin ratio for lung ma-
turity
Perform ultrasound to assess gestational age, position of baby, and level
of fluid.
If < 34 weeks, give steroids to decrease incidence of RDS.
Expectant management
ROM: Rupture of membranes
PROM: Premature rupture of membranes (ROM before the onset of la-
bor)
PPROM: Preterm (< 37 weeks) premature rupture of membranes
Don’t get the ROMs mixed
up!
Complications of Pregnancy
Prolonged rupture of membranes: Rupture of membranes that lasts
> 18 hours
THIRD-TRIMESTER BLEEDING
INCIDENCE
Occurs in 2 to 5% of pregnancies
Golden rule:
WORKUP Never initially do a pelvic
History and physical exam in a third-trimester
Vitals bleed.
Labs: CBC, coagulation profile, type and cross, urine analysis
117
Possible
Reposition Mother Sucessful fetal
No Check blood pressure, No Vasa
resuscitation?
IV, tocolytics Previa
Is the EMF strip Yes
reassuring? No Abruptio
Placenta Conservative
No
Yes Is placenta Management
low implant? Observation
Placenta
Yes
No Previa
Heavy
bleeding?
(prompt delivery)
Stabilize Mother,
Acquire
Baseline Labs
CBC, T&C, DIC panel
Consider
No ruptured
uterus
DIFFERENTIAL
Obstetric Causes
Placental abruption
Placenta previa
Placenta previa and Vasa previa/velamentous insertion
Uterine rupture
abruption are most common.
Circumvillate placenta
Extrusion of cervical mucus (“bloody show”)
Nonobstetric Causes
Cervicitis
Polyp
Neoplasm
MORTALITY
Maternal: 1 to 5%
Fetal: 50 to 80%
118
HIGH-YIELD FACTS
FIGURE 9-3. Placental abruption.
(Reproduced, with permission, from Cunningham FG, MacDonald PC, Gant NF, et al. Williams Obstetrics, 20th ed. Stamford,
CT: Appleton & Lange, 1997: 747.)
RISK FACTORS
Trauma (usually shearing, such as a car accident), preeclampsia (and maternal
HTN), smoking, cocaine abuse, high parity, previous history of abruption Pregnant woman + car
Complications of Pregnancy
accident + back pain =
CLINICAL PRESENTATION
abruption.
Vaginal bleeding (maternal and fetal blood present)
Constant and severe back pain or uterine tenderness
Irritable, tender, and typically hypertonic uterus
Evidence of fetal distress
Maternal shock
Bleeding is present in 50
DIAGNOSIS to 80% of cases.
Ultrasound will show retroplacental hematoma only part of the time.
Clinical and pathological findings
MANAGEMENT
Correct shock (packed RBCs, fresh frozen plasma, cryoprecipitate,
platelets).
Expectant management: Close observation of mother and fetus with
ability to intervene immediately
If there is fetal distress, perform C-section.
Placenta Previa
A condition in which the placenta is implanted in the immediate vicinity of
the cervical canal. It can be classified into three types:
119
Complete placenta previa: The placenta covers the entire internal cer-
vical os.
Partial placenta previa: The placenta partially covers the internal cer-
vical os.
Marginal placenta previa: One edge of the placenta extends to the
edge of the internal cervical os.
INCIDENCE
0.5 to 1%
ETIOLOGY
Unknown, but associated with:
Increased parity
Older mothers
HIGH-YIELD FACTS
Previous abortions
Previous history of placenta previa
Fetal anomalies
CLINICAL PRESENTATION
Painless, profuse bleeding in T3
Postcoital bleeding
Spotting during T1 and T2
Painless bleeding = Cramping (10% of cases)
Placenta Previa
Complications of Pregnancy
A B
let
Pl
Pl
Pelvic in
Ce ix
Ce ix
cm
cm
acenta
acenta
rv
rv
10
10
120
DIAGNOSIS
Transabdominal ultrasound (95% accurate)
Double set-up exam: Take the patient to the operating room and prep
for a C-section. Do speculum exam: If there is local bleeding, do a
C-section; if not, palpate fornices to determine if placenta is covering
the os. The double set-up exam is performed only on the rare occasion
that the ultrasound is inconclusive.
MANAGEMENT
Cesarean section is always the delivery method of choice for placenta pre-
via. The specific management is geared toward different situations.
For Preterm
If there is no pressing need for delivery, monitor in hospital or send
home after bleeding has ceased.
Transfusions to replace blood loss, and tocolytics to prolong labor to 36
HIGH-YIELD FACTS
weeks if necessary
Even after the bleeding has stopped, repeated small hemorrhages may cause
IUGR.
Complications of Pregnancy
If Severe Hemorrhage
C-section regardless of fetal maturity
Incidence
0.03 to 0.05%
Presentation
Rapid vaginal bleeding and fetal distress (sinusoidal variation of fetal heart
rate)
Management
Correction of shock and immediate C-section
121
VELAMENTOUS CORD INSERTION
The velamentous insertion of the umbilical cord into the fetal membranes: In
other words, the fetal vessels insert between amnion and chorion. This leaves
them susceptible to ripping when the amniotic sac ruptures.
Epidemiology
1% of single pregnancies
10% of twins
50% of triplets
Clinical Presentation
Vaginal bleeding with fetal distress
Management
HIGH-YIELD FACTS
Uterine Rupture
The ripping of the uterine musculature through all of its layers, usually with
part of the fetus protruding through the opening
Incidence
0.5%
Risk Factors
Complications of Pregnancy
All pregnant patients with a Prior uterine scar is associated with 40% of cases:
previous cesarean section Vertical scar: 5% risk
must be consented for an Transverse scar: 0.5% risk
elective “trial of labor”
(vaginal delivery) with Presentation and Diagnosis
knowledge of the risk of Sudden cessation of uterine contractions with a “tearing” sensation
uterine rupture: Recession of the fetal presenting part
< 1% if previous low Increased suprapubic pain and tenderness with labor (may not be read-
transverse C-section × 1 ily apparent if analgesia/narcotics are administered)
< 2% if previous low Vaginal bleeding (or bloody urine)
transverse C-section × 2 Sudden, severe fetal heart rate decelerations
10% if previous classical Sudden disappearance of fetal heart tones
C-section × 1 Maternal hypovolemia from concealed hemorrhage
Management
Total abdominal hysterectomy is treatment of choice (after delivery).
If childbearing is important to the patient, rupture repair is possible but
risky.
122
Extrusion of cervical mucus (“bloody show”): A consequence of efface-
ment and dilation of the cervix, with tearing of the small veins → slight
shedding of blood. Treatment is rarely necessary.
A B N O R M A L I T I E S O F T H E T H I R D S TA G E O F L A B O R
CAUSES
HIGH-YIELD FACTS
Coagulation defects
Uterine atony (myometrium cannot contract postpartum)
Ruptured uterus
Degrees of retained placental tissue Incidence of excessive
Bleeding from the placental implantation site blood loss following vaginal
Trauma to the genital tract and adjacent structures delivery is 5 to 8%.
Most common cause is uterine atony. Normally the uterus contracts, com-
pressing blood vessels and preventing bleeding.
RISK FACTORS
Complications of Pregnancy
Blood transfusion/hemorrhage during a previous pregnancy CARPIT (pronounced
Coagulopathy “carpet”)
Vaginal birth after cesarean (VBAC) Coagulation defect
High parity Atony
Large infant Rupture
Midforceps delivery
Placenta retained
MANAGEMENT Implantation site
Trauma
1. Manually compress and massage the uterus—controls virtually all cases
of hemorrhage due to atony.
2. Obtain assistance.
3. Give oxytocin (20 units in 1 L of lactated Ringer’s) or mether-
gonovine or prostaglandins if oxytocin is ineffective.
4. If not previously done, obtain blood for typing and crossmatching/be-
gin fluid or blood replacement.
5. Carefully explore the uterine cavity to ensure that all placental parts The cause of the
have been delivered and that the uterus is intact. postpartum bleeding should
6. Inspect the cervix and vagina. be sought out and treated
7. Place Foley and monitor urine output. immediately.
If all this fails:
Hysterectomy
or
Radiographic embolization of pelvic vessels
or
Uterine artery ligation or hypogastric artery ligation
123
Abnormal Placentation
The abnormal implantation of the placenta in the uterus: These conditions
can cause retention of the placenta after birth.
Placenta previa
Previous C-section
Previous dilation and curettage (D&C)
Grand multiparity
MANAGEMENT
All of these conditions often result in postpartum hemorrhage (third stage of
labor hemorrhage) and require hysterectomy.
Uterine Inversion
Complications of Pregnancy
INCIDENCE
1 in 2,200 deliveries
MANAGEMENT
Call for assistance.
An anesthesiologist should anesthetize.
Separate placenta from uterus and replace inverted uterus by pushing
on the fundus toward the vagina.
Oxytocin is given after uterus is restored to normal configuration and
anesthesia is stopped.
Macrosomia
Defined as birth weight > 4,500 g:
Risk factors for macrosomia: Diabetes, obesity, previous history, post-term
pregnancy, multiparity, and advanced maternal age
Macrosomic infants are at risk for: Birth trauma, jaundice, hypoglycemia,
low Apgar scores, childhood tumors
124
P O S T PA R T U M I N F E C T I O N
HIGH-YIELD FACTS
Risk Factors commonly responsible for
Prolonged rupture of membranes female genital infections.
C-section
Colonization of the lower genital tract with certain microorganisms
(i.e., group B streptococci, C. trachomatis, M. hominis, and Gardnerella
vaginalis
Premature labor
Frequent vaginal exams
Diagnosis
Complications of Pregnancy
Fever > 100.4°F (38°C)
Soft, tender uterus
Lochia has a foul odor.
Leukocytosis (WBC > 10,000/µL)
Malaise
Management
Identify source of infection (i.e., perform urinalysis). Endometritis is relatively
Identify the cause of infection (i.e., culture the lochia). uncommon following
Assess the severity of the infection. vaginal delivery, but a
Treat (i.e., with antibiotics). major problem after
C-section.
Types of Postpartum Infections
ENDOMETRITIS
A postpartum uterine infection involving the decidua, myometrium,
and parametrial tissue
Also called metritis with pelvic cellulitis, endomyometritis, and endopara-
metritis Following delivery, the
Typically develops postpartum day 2 to 3 bladder and lower urinary
Treat with IV antibiotics (gentamicin and clindamycin) until patient is tract remain somewhat
afebrile for 24 to 48 hours.
hypotonic → residual urine
and reflux.
125
URINARY TRACT INFECTION
Caused by catheterization, birth trauma, conduction anesthesia, and
frequent pelvic examinations
Presents with dysuria, frequency, urgency, and low-grade fever
Rule out pyelonephritis (costovertebral angle tenderness, pyuria, hema-
turia).
Obtain a urinalysis and urinary culture (E. coli is isolated in 75% of
postpartum women).
Wound infection occurs in 4 Treat with appropriate antibiotics.
to 12% of patients
CESAREAN SECTION WOUND INFECTION
following C-section.
Fever that persists to the fourth or fifth postoperative day suggests
wound infection.
Wound erythema and tenderness several days after surgery
Obtain Gram stain and cultures from wound material.
HIGH-YIELD FACTS
EPISIOTOMY INFECTION
Antibiotic prophylaxis with
IV cefazolin is commonly Look for pain at the episiotomy site, disruption of the wound, and a
employed. necrotic membrane over the wound.
Rule out the presence of a rectovaginal fistula with a careful rectovagi-
nal exam.
Open, clean, and debride the wound to promote granulation tissue for-
mation.
Sitz baths are recommended.
Reassess for possible closure after granulation tissue has appeared.
Complications of Pregnancy
MASTITIS
The more extensive the
laceration/incision, the Affects 1 to 2% of postpartum women
Two types: Epidemic (nosocomial) and nonepidemic:
greater the chance of
Epidemic mastitis is caused by infant acquiring Staphylococcus aureus
infection and wound in his nasopharynx from the hospital. Mother presents on day 2 to 4
breakdown. with fever and breast tenderness. Treat with penicillin and isolate
from other patients.
Endemic (nonepidemic) mastitis presents weeks or months after de-
livery, usually during period of weaning. Mother presents with fever,
systemic illness, and breast tenderness. Treat with penicillin or di-
cloxacillin. Continue breast feeding.
Breast engorgement
(painful, swollen, firm
breasts) is not mastitis (due
to infection) and is normal
during the second to fourth
postpartum day. Treat with
supportive bra, 24-hour
demand feedings, and ice
packs if not breast feeding.
126
HIGH-YIELD FACTS IN
Spontaneous Abortion,
Ectopic Pregnancy,
and Fetal Death
F I R S T- T R I M E S T E R B L E E D I N G
DIFFERENTIAL DIAGNOSIS
Spontaneous abortion Over 50% of pregnancies
Ectopic pregnancy result in spontaneous
Hydatidiform mole abortion.
Benign and malignant lesions (i.e., choriocarcinoma, cervical cancer)
WORKUP
Vital signs (rule out shock/sepsis/illness)
Pelvic exam (look at cervix, source of bleed)
Beta-human chorionic gonadotropin (hCG) level, complete blood
count (CBC), antibody screen
Ultrasound (US) (assess fetal viability; abdominal US detects fetal heart A fetus of < 20 weeks’
motion by ≥ 7 weeks’ gestational age [GA]) gestational age (GA) or
weighing < 500 g that is
See Figure 10-1 for management algorithm. aborted = an “abortus.”
S P O N TA N E O U S A B O R T I O N
127
Missed
Internal No Abortion
cervical os
Severe open?
No Normal
Cramps? No
Sonogram?
Threatened
No Yes Observation
Abortion
Yes
Yes
Heavy
Bleeding? Inevitable
No Perform
Abortion D&C
Yes
Complete Observation
No
Vaginal Abortion
HIGH-YIELD FACTS
Tissue
Flow?
Production of
Yes Conception
in Uterus?
Incomplete
Yes
Abortion
ETIOLOGIES
Spontaneous Abortion
Chromosomal Abnormalities
Top etiologies of Majority of abnormal karyotypes are numeric abnormalities as a result
spontaneous abortion: of errors during gametogenesis, fertilization, or the first division of the
1) Chromosomal fertilized ovum.
abnormalities Frequency:
Trisomy—50 to 60%
2) Unknown
Monosomy (45,X)—7 to 15%
3) Infection
Triploidy—15%
4) Anatomic defects Tetraploidy—10%
5) Endocrine factors
Infectious Agents
Infectious agents in cervix, uterine cavity, or seminal fluid can cause abor-
tions. These infections may be asymptomatic:
Toxoplasma gondii
Herpes simplex
Ureaplasma urealyticum
Mycoplasma hominis
Uterine Abnormalities
Septate/bicornuate uterus—25 to 30%
Cervical incompetence
Leiomyomas (especially submucosal)
Intrauterine adhesions (i.e., from curettage)
128
Endocrine Abnormalities
Progesterone deficiency
Polycystic ovarian syndrome (POS)—hypersecretion of luteinizing hor- Ninety-four percent of
mone (LH) abortions occur in T1.
Diabetes—uncontrolled
Immunologic Factors
Lupus anticoagulant
Anticardiolipin antibody (antiphospholipid syndrome)
Environmental Factors
Tobacco––≥ 14 cigarettes/day increases abortion rates
Alcohol
Irradiation
Environmental toxin exposure
HIGH-YIELD FACTS
T H R E AT E N E D A B O R T I O N
Threatened abortion is vaginal bleeding that occurs in the first 20 weeks of Twenty to 50% of
pregnancy, without the passage of products of conception (POC) or rupture of
threatened abortions lead
membranes. Pregnancy continues, although up to 50% result in loss of preg-
nancy. to loss of pregnancy.
DIAGNOSIS
Speculum exam reveals blood coming from a closed cervical os, without am-
niotic fluid or POC in the endocervical canal.
Spontaneous Abortion
MANAGEMENT
Threatened abortion:
Bed rest with sedation and without intercourse Vaginal bleeding in first 20
weeks of pregnancy without
passage of POC and without
I N E V I TA B L E A B O R T I O N rupture of membranes
Inevitable abortion is vaginal bleeding, cramps, and cervical dilation. Expul-
sion of the POC is imminent.
DIAGNOSIS
Speculum exam reveals blood coming from an open cervical os. Menstrual- Inevitable abortion is
like cramps typically occur. different from threatened
abortion because it has
MANAGEMENT cervical dilation.
Surgical evacuation of the uterus
Rh typing—D immunoglobulin (RhoGAM) is administered to Rh-
negative, unsensitized patients to prevent isoimmunization.
INCOMPLETE ABORTION
Incomplete abortion is the passage of some, but not all, POC from the cervi-
cal os.
129
DIAGNOSIS
Cramping and heavy bleeding
Enlarged, boggy uterus
Dilated internal os with POC present in the endocervical canal or
vagina
MANAGEMENT
Stabilization (i.e., IV fluids and oxytocin if heavy bleeding is present)
Blood typing and crossmatching for possible transfusion if bleeding is
brisk or low Hgb/patient symptomatic
Rh typing
POC are removed from the endocervical canal and uterus with ring for-
ceps. Suction dilation and curettage (D&C) is performed after vital
signs have stabilized.
Karyotyping of POC if loss is recurrent
HIGH-YIELD FACTS
COMPLETE ABORTION
MISSED ABORTION
Missed abortion is when the POC are retained after the fetus has expired.
DIAGNOSIS
The pregnant uterus fails to grow, and symptoms of pregnancy have dis-
appeared.
Intermittent vaginal bleeding/spotting/brown discharge and a firm,
closed cervix
Decline in quantitative beta-hCG
US confirms lack of fetal heartbeat.
MANAGEMENT
Although most women will spontaneously deliver a dead fetus within 2 weeks,
the psychological stress imposed by carrying a dead fetus and the dangers of
coagulation defects favor the practice of labor induction and early delivery:
Check fibrinogen level, partial thromboplastin time (PTT), antibody
screen, and ABO blood type.
Evacuate the uterus (suction D&C in first trimester) or induce labor
with IV oxytocin and cervical dilators or prostaglandin E2 suppositories.
Administer RhoGAM to Rh-negative, unsensitized patients.
130
SEPTIC ABORTION
Septic abortion results from a maternal infection leading to sepsis, fetal infec-
tion, and fetal death. The infection is usually polymicrobial, often with E. coli
and other gram-negative organisms.
If POC are retained in
DIAGNOSIS septic abortion, a severe
coagulopathy with bleeding
Generalized pelvic discomfort, pain, and tenderness
often occurs; otherwise,
Signs of peritonitis
Fever of 37.8 to 40.6°C (100 to 105°F) prognosis is good.
Malodorous vaginal and cervical discharge
Leukocytosis
MANAGEMENT
Cultures of uterine discharge and blood Consumptive coagulopathy
Check CBC, urinalysis (UA), serum electrolytes, liver function tests is an uncommon, but
HIGH-YIELD FACTS
(LFTs), blood urea nitrogen (BUN), creatinine, and coagulation panel. serious, complication of
Abdominal and chest films to exclude free air in the peritoneal cavity septic abortion.
→ helps determine the presence of gas-forming bacteria or foreign body
Prompt uterine evacuation (D&C), IV antibiotics, IV fluids
RECURRENT ABORTION
Three or more successive clinically recognized pregnancy losses prior to 20 Recurrent abortion is three
weeks’ GA constitutes recurrent abortion. or more successive
abortions.
Women with two successive spontaneous abortions have a recurrence risk of
25 to 45%.
Spontaneous Abortion
ETIOLOGY
Parental chromosomal abnormalities (balanced translocation is the
most common)
Anatomic abnormalities (congenital and acquired) Women with a history of
Endocrinologic abnormalities recurrent abortion have a
Infections (e.g., Chlamydia, Ureaplasma) 23% chance of abortion in
Autoimmunity subsequent pregnancies
Unexplained (majority of cases)
that are detectable by
MANAGEMENT ultrasound.
Investigate possible etiologies.
Potentially useful investigative measures include:
131
TABLE 10-1. Types of Abortions
Complete abortion Complete expulsion of POC before 20 weeks’ gestation; cervix dilated
Incomplete abortion Partial expulsion of some POC before 20 weeks’ gestation; partially dilated cervix
Threatened abortion No cervical dilatation or expulsion of POC; intrauterine bleeding before 20 weeks’
gestation occurs
Inevitable abortion Threatened abortion with a dilated cervical os
Missed abortion Retention of nonviable POC for 4–8 weeks or more; often proceeds to complete abortion
Recurrent spontaneous Three or more consecutive spontaneous abortions
abortion
Septic abortion Abortion associated with severe hemorrhage, sepsis, bacterial shock, and/or acute renal
failure
Therapeutic abortion Termination of pregnancy before the period of fetal viability in order to protect the life
HIGH-YIELD FACTS
Isthmic Abdominal
(12%) Cornual (2%) (< 1%)
Ampullary
(78%)
Fimbrial
(5%)
Cervical
(1%)
Ovarian
(4%)
132
Etiology/Risk Factors
Fallopian tube transport malfunction due to:
Infection such as Chlamydia and gonorrhea (50%)
Previous ectopic pregnancy
Previous tubal surgery The primary causes of
Abdominal surgery resulting in adhesions ectopic pregnancy include
Endometriosis conditions that either
Congenital abnormalities (often from diethylstilbestrol [DES] expo- prevent or impede passage
sure) of a fertilized ovum
Pregnancy with intrauterine device in place
through the fallopian tube.
Assisted reproduction:
Ovulation-inducing drugs
In vitro fertilization
HIGH-YIELD FACTS
Amenorrhea followed by irregular vaginal bleeding Classic triad of ectopic
Adnexal tenderness or mass
pregnancy:
US evidence of an adnexal mass without intrauterine gestation or an
Amenorrhea
adnexal gestational sac with a fetal pole and cardiac activity
Less-than-normal increase in hCG Vaginal bleeding
A serum progesterone level lower than normal for patients with an in- Abdominal pain
trauterine pregnancy (i.e., < 25 ng/mL) These usually indicate
Laparoscopy shows an adnexal mass or abdominal gestation. rupture.
Signs of Rupture
Shock
Spontaneous Abortion
Bleeding
Increased abdominal pain
Management
There are two options of treatment:
Operative
Laparoscopy or laparotomy with salpingostomy or segmental resection if
the tube is to be retained and salpingectomy if the tube requires re-
moval
Medical
Intramuscular methotrexate (prevents DNA synthesis via its antifolate
actions)
Patient is monitored as an outpatient.
67 to 100% effective Always do a β-hCG level on
a premenopausal woman
with abdominal pain.
133
If ruptured, always stabilize with IV fluids, blood replacement, and pressors if
necessary. Operative repair is used.
F E TA L D E AT H
T1 (1 TO 14 WEEKS)
Chromosomal abnormalities
Environmental factors (e.g., medications, smoking, toxins)
Infection (e.g., herpes simplex virus, human papillomavirus, mumps,
Mycoplasma)
Antiphospholipid antibodies (after 10 weeks)
Maternal anatomic defects (e.g., maternal müllerian defects)
Endocrine factors (e.g., progesterone insufficiency, thyroid dysfunction)
Maternal systemic disease (e.g., diabetes)
Unknown
T2 (14 TO 28 WEEKS)
Spontaneous Abortion
Anticardiolipin antibodies
Antiphospholipid antibodies
Chromosomal abnormalities
Anatomic defects of uterus and cervix
Infection (e.g., BV, syphilis)
Erythroblastosis
Up to 35% of fetal deaths Placental pathological conditions (e.g., circumvallate placentation, pla-
are associated with the centa previa)
presence of congenital
malformation. T3 (28 WEEKS TO TERM)
Anticardiolipin antibodies
Placental pathological conditions (e.g., circumvallate placentation, pla-
centa previa, abruptio placentae)
Infection
TIME NONSPECIFIC
Trauma
Cord entanglement
Electric shock
Maternal systemic disease
Maternal infection
134
D I S S E M I N AT E D I N T R AVA S C U L A R C O A G U L AT I O N ( D I C )
Pathophysiology
In pathologic states (i.e., via thromboplastin production from dead POC), the
coagulation cascade is activated, which results in consumption of platelets
and coagulation factors. Fibrin deposition in small vessels results in bleeding
HIGH-YIELD FACTS
and circulatory obstruction. Pregnancy normally
induces:
Increases in coagulation
Diagnosis
factors I (fibrinogen),
Physical exam may reveal multiple bleeding points associated with pur- VII, VIII, IX, and X
pura and petechiae. Increased activation of
Lab evaluation reveals thrombocytopenia, hypofibrinogenemia, an ele- platelet clotting
vated prothrombin time, and increased fibrin split products.
Management
Supportive therapy to correct/prevent shock, acidosis, and tissue ischemia
and, if applicable, prompt termination of pregnancy. Ultimately, the only care
Spontaneous Abortion
is to correct the underlying cause.
In any obstetric
complication, obtain a
coagulation panel and
fibrin split-product levels to
monitor for DIC.
135
Spontaneous Abortion HIGH-YIELD FACTS
136
NOTES
HIGH-YIELD FACTS IN
Induced Abortion
DEFINITION
I N D I C AT I O N S F O R T H E R A P E U T I C A B O R T I O N
Maternal Indications
Cardiovascular disease
Genetic syndrome (e.g., Marfan’s)
Hematologic disease (e.g., TTP)
Metabolic (e.g., proliferative diabetic retinopathy)
Neoplastic (e.g., cervical cancer; mother needs prompt chemotherapy)
Neurologic (e.g., Berry aneurysm; cerebrovascular malformation)
Renal disease
Intrauterine infection
Severe preeclampsia/eclampsia
137
Fetal Indications
Major malformation (e.g., anencephaly)
Genetic (e.g., Tay–Sachs disease)
METHODS OF ABORTION
First Trimester
MEDICAL
Antiprogesterones such as mifepristone (RU 486) or epostane; used
only before 9 weeks’ gestation. Without progesterone, the uterine lining
sloughs off.
Methotrexate IM + intrauterine misoprostol 1 week later; used only be-
fore 9 weeks’ gestation. Methotrexate is a folic acid antagonist that in-
HIGH-YIELD FACTS
SURGICAL
Cervical dilation followed by aspiration curettage (D&C): Risks include cer-
vical/uterine injury and Asherman’s syndrome.
Second Trimester
MEDICAL
Intravaginal prostaglandin E2 (PGE2) or PGF2α with urea
Medical methods of
abortions can only be used SURGICAL
in first 9 weeks.
Dilation and evacuation
Induced Abortion
138
LESS COMMON METHODS OF ABORTION
Medical
Intra-amnionic infusion of hyperosmolar fluid (saline + urea) Infection is the most
High-dose IV oxytocin (induces uterine contractions) common complication of
hysterectomy.
Surgical
Hysterotomy is used only if other methods have been unsuccessful.
A hysterotomy is a C-section of a preterm fetus.
Hysterectomy
HIGH-YIELD FACTS
than the risk of death from
giving birth.
Induced Abortion
139
Induced Abortion HIGH-YIELD FACTS
140
NOTES
SECTION IIB
High-Yield Facts
in Gynecology
Contraception
Sterilization
Infertility
Menstruation
Abnormal Uterine
Bleeding
Pelvic Pain
Endometriosis
Pelvic Masses
Cervical Dysplasia
Cervical Cancer
Endometrial Cancer
Ovarian Cancer
Vulvar Dysplasia
and Cancer
Gestational Trophoblastic
Neoplasias (GTN)
Sexually Transmitted
Diseases (STDs)
and Vaginitis
Vulvar Disorders
Menopause
Pelvic Relaxation
Women’s Health
141
NOTES
142
HIGH-YIELD FACTS IN
Contraception
Barrier
Hormonal
Intrauterine device (IUD)
Sterilization
BARRIER METHODS
FEMALE CONDOM
Rarely used because of expense and inconvenience (it must not be removed
for 6 to 8 hours after intercourse). It offers labial protection, unlike the male
condom.
MALE CONDOM
Types
Latex (cheapest and most common)
Polyurethane (newest, sensitive, expensive)
Animal skins (sensitive, least protection against sexually transmitted
diseases [STDs])
Efficacy
88 to 98%, depending on if used properly
Drawbacks
Interruption of coitus
Decreased sensation
DIAPHRAGM
A flexible ring with a rubber dome that must be fitted by a gynecologist: It
forms a barrier from the cervix to the anterior vaginal wall. It must be inserted
with spermicide and left in place after intercourse for 6 to 8 hours.
143
Types
Flat or coil spring type (for women with good vaginal tone)
Arcing type (for poorer tone or vaginal/uteral irregularities such as cys-
toceles or long cervices)
Wide seal rim
Efficacy
82 to 94%
Complications
If left in for too long, may result in Staphylococcus aureus infection
(which may lead to toxic shock syndrome)
CERVICAL CAP
A smaller version of a diaphragm that fits directly over the cervix; more likely
to cause irritation or toxic shock syndrome. It is more popular in Europe.
HIGH-YIELD FACTS
Efficacy
82 to 94%
SPERMICIDE
Foams, gels, creams placed in vagina up to 30 minutes before intercourse
Types
Nonoxynol-9 and octoxynol-3; effective for only about 1 hour
Efficacy
80 to 97%
SPONGE
Contraception
Efficacy rates for A polyurethane sponge containing nonoxynol-9 that is placed over the
spermicides are much cervix: It can be inserted up to 24 hours before intercourse.
higher when combined with
Efficacy
other barriers (e.g., 84%
condoms, diaphragms).
Risk
Toxic shock syndrome
HORMONAL AGENTS
ORAL CONTRACEPTIVES
Efficacy
97 to 99.9%
144
Mechanism (there are several)
Estrogen suppresses follicle-stimulating hormone (FSH) and therefore
prevents follicular emergence.
Progesterone suppresses the midcycle gonadotropin-releasing hormone In combination oral
(GnRH) surge, which suppresses luteinizing hormone (LH) and there- contraceptives, at the time
fore prevents ovulation. of desired/expected
Causes thicker cervical mucus
menstruation, a placebo, or
Causes decreased motility of fallopian tube
Causes endometrial atrophy
“sugar-pill,” is given to
simulate the natural
Progestin-Only Pills progesterone withdrawal.
Contain only progestin: There is LH suppression and therefore no ovulation.
The main differences from combination pills are:
A mature follicle is formed (but not released).
No “sugar-pill” is used.
HIGH-YIELD FACTS
Lactating women (progestin, unlike estrogen, does not suppress breast nutshell:
milk) Estrogen inhibits FSH.
Women > 40 years old
Progestin inhibits LH.
Women who cannot take estrogens for other medical reasons (e.g., es-
trogen-sensitive tumors)
Contraception
Risks of Oral Contraceptives
Increases risk of venous thromboembolism/stroke (3/10,000)
Increases risk of myocardial infarction (in smokers over 35 years old)
Depression
Oral contraceptives’ link to
Contraindications of Oral Contraceptives an increase in breast cancer
is not proven.
Thromboembolism
Cerebrovascular accident (CVA) or coronary artery disease (CAD)
Breast/endometrial cancer
Cholestatic jaundice
Undiagnosed vaginal bleeding
Hepatic disease
Known/suspected pregnancy
Concomitant anticonvulsant therapy Why is estrogen a
Some antibiotics procoagulant? Estrogen
Relative contraindications: Migraines, hypertension (HTN), lactation
increases factors VII and X
and decreases antithrombin
III.
145
Side Effects of Oral Contraceptives
Breakthrough bleeding
Breast tenderness
Nausea (10 to 30% of women)
Efficacy
99.7%
Mechanism of Action
Sustained high progesterone level to block LH surge (and hence ovulation).
Thicker mucus and endometrial atrophy also contribute. There is no FSH
HIGH-YIELD FACTS
suppression.
Indications
Systemic lupus erythematosus (SLE)
Migraines
Headaches
Heavy bleeding
Efficacy
99.8%
Mechanism of Action
Suppression of LH surge
Thickened mucus
Endometrial atrophy
146
Side Effects
Irregular bleeding
Acne
Decreased libido
Adnexal enlargement
Possible difficult removal
Indications
Oral contraceptives contraindicated/intolerated
Smokers over 35 years old
Women with diabetes mellitus, HTN, CAD
Contraindications
Thrombophlebitis/embolism
Known/suspected pregnancy
HIGH-YIELD FACTS
Liver disease/cancer
Breast cancer
Concomitant anticonvulsant therapy
INTRAUTERINE DEVICE
Efficacy
97%
Types
Contraception
Paragard––made with copper and lasts 10 years
Progestasert––releases progesterone and lasts 1 year
Mechanism of Action
Prevents fertilization by creating a hostile environment (a sterile in-
flammatory reaction) for sperm and for a fertilized ovum
Prevents ovulation and causes endometrial atrophy (Progestasert only)
Contraindications
Multiple sexual partners
History of PID
Immunocompromised (e.g., HIV, sickle cell disease)
Known/suspected pregnancy
Complications
PID
Uterine perforation
147
Ectopic pregnancy
Menorrhagia and metrorrhagia
IUD expulsion
P O S T C O I TA L / E M E R G E N C Y C O N T R A C E P T I O N
Efficacy
> 95%
148
HIGH-YIELD FACTS IN
Sterilization
VA S E C T O M Y
Sperm can still be found proximal to the surgical site, so to ensure sterility one
must:
Have two consecutive negative sperm counts
or
Use contraception for 6 weeks or 15 ejaculations
T U B A L L I G AT I O N
ELECTROCAUTERY
This involves the cauterization of a 3-cm zone of the isthmus. It is the most
popular method (very effective but most difficult to reverse).
149
CLIPPING
The Hulka clip, similar to a staple, is applied at a 90° angle on the isthmus. It
is the most easily reversed method but also has the highest failure rate.
PARKLAND METHOD
Similar to the Pomeroy but without the lifting, a segment of isthmus is tied
proximally and distally and then excised.
MADLENER METHOD
Similar to the Pomeroy but without the excision, a segment of isthmus is
lifted and crushed and tied at the base.
IRVING METHOD
The isthmus is cut, with the proximal end buried in the myometrium and the
distal end buried in the mesosalpinx.
KROENER METHOD
Sterilization
Resection of the distal ampulla and fimbrae following ligation around the
proximal ampulla
UCHIDA METHOD
Epinephrine is injected beneath the serosa of the isthmus. The mesosalpinx is
pulled back off the tube, and the proximal end of the tube is ligated and ex-
cised. The distal end is not excised. The mesosalpinx is reattached to the ex-
cised proximal stump, while the long distal end is left to “dangle” outside of
the mesosalpinx.
LUTEAL-PHASE PREGNANCY
150
R E V E R S I B I L I T Y O F T U B A L L I G AT I O N
Around one third of tubal ligations can be reversed such that pregnancy can
result. Some types of sterilization (i.e., banding, clipping) are more reversible.
Even pregnancies after reversal are ectopic until proven otherwise, and
therefore reversal does not preclude a full ectopic workup.
C O M P L I C AT I O N S O F T U B A L L I G AT I O N
HIGH-YIELD FACTS
uterus.
O T H E R M E T H O D S O F S T E R I L I Z AT I O N
Colpotomy
Utilizes entry through the vaginal wall near the posterior cul-de-sac and oc-
cludes the fallopian tubes by employing methods similar to those performed in
laparoscopy and laparotomy
Hysterectomy
Removal of the uterus, either vaginally or abdominally; rarely performed for
Sterilization
sterilization purposes
151
Sterilization HIGH-YIELD FACTS
152
NOTES
HIGH-YIELD FACTS IN
Infertility
DEFINITION
F E M A L E FA C T O R S A F F E C T I N G I N F E R T I L I T Y
Tubal disease—20%
Anovulation—15%
Unexplained—10%
Multifactorial—40%
INFERTILITY WORKUP
Semen Analysis
Performed after at least 48 hours of abstinence, with examination maximum 2
hours from time of ejaculation (for those who prefer to donate at home)
153
Intrauterine insemination (sperm injected through cervix)
Intracytoplasmic sperm injection
Artificial insemination
ovulation
temperature of month
POSSIBLE CAUSES AND TREATMENTS OF ANOVULATION
Pituitary insufficiency: Treat with intramuscular luteinizing hormone/
follicle-stimulating hormone (LH/FSH).
Hypothalamic dysfunction: Treat with bromocriptine (a dopamine ago-
nist)
Clomiphene: An Polycystic ovary syndrome: Treat with clomiphene or human
antiestrogen that inhibits menopausal gonadotropin (hMG).
negative feedback on the Other causes: Hyper/hypothyroid, androgen excess, obesity/starvation,
central nervous system galactorrhea
If ovulation analysis and semen analysis are normal, analysis of the internal
architecture is performed to determine if there is an anatomical impediment
to pregnancy.
Infertility
Exploratory Laparoscopy
Endometriosis is found in
about one third of infertile A laparoscope is inserted transabdominally to visualize the pelvis:
women. Check for adhesions.
Check for endometriosis.
154
TREATMENT
Laparoscopic lysis of adesions
Laparoscopic endometriosis ablation
Medical treatment of endometriosis
Definition
Directly retrieving eggs from ovary followed by manipulation and replace-
ment: Generally employed for inadequate spermatogenesis. The following
are examples.
HIGH-YIELD FACTS
In Vitro Fertilization (IVF) and Embryo Transfer
Fertilization of eggs in a lab followed by uterine placement: Intracytoplasmic
sperm injection is a subtype of IVF to aid severe male factors. Success rate of
IVF is about 20%.
Infertility
155
Infertility HIGH-YIELD FACTS
156
NOTES
HIGH-YIELD FACTS IN
Menstruation
DEVELOPMENT
Puberty
Puberty is the transition from childhood to reproductive potential. More com-
monly, it refers to the final stage of maturation known as adolescence.
Precocious Puberty
Appearance of the secondary sexual characteristics before 8 years of age is re-
ferred to as precocious puberty.
Causes Manifestation
Idiopathic (most common) Thelarche/pubarche/menarche Tanner stages:
Stage 1: Prepubertal child
Tumors (of the hypothalamic– Thelarche/pubarche/menarche
Stages 2–4: Developmental
pituitary stalk; prevent negative
stages
feedback)
Stage 5: Adult
Inflammation of the hypothalamus Thelarche/pubarche/menarche
(leads to ↑ GnRH)
21-Hydroxylase deficiency (cortisol Pubarche
pathway is blocked, leading to excess
androgens)
157
Causes Manifestation
Excess estrogens from: Thelarche and menarche
Exogenous sources (e.g., oral
contraceptives)
Estrogen-secreting tumors
The menstrual cycle is the cyclical changes that occur in the female reproductive
system (see Figure 15-1): The hypothalamus, pituitary, ovaries, and uterus interact
to cause ovulation approximately once per month (average 28 days [+/− 7 days]).
cycle E2
more estradiol so that its
positive feedback causes an
LH surge. LH
FSH
Ovarian
histology
Follicular Corpus
recruitment Dominant follicle luteum
37.0
Body
temperature 36.5
(° C)
36.0
158
Follicular Phase (Proliferative Phase)—Days 1 Through 14
The follicular phase begins on the first day of menses. Now that progesterone
levels have fallen with the death of the corpus luteum, all hormone levels are
low. Without any negative feedback, GnRH from the hypothalamus causes
follicle-stimulating hormone (FSH) levels to rise. Main event of
menstruation: Absence of
FSH released from the pituitary stimulates maturation of granulosa cells in progesterone causes
the ovary. The granulosa cells secrete estradiol in response. endometrial sloughing.
Two main events in
Estradiol causes luteinizing hormone (LH) to be released from the pituitary follicular phase:
while at the same time inhibiting FSH release. In the meantime, the estradiol
FSH causes follicle
secretion also causes the endometrium to proliferate.
maturation and estrogen
LH acts on the theca cells to increase secretion of androgens (which are con- secretion.
verted to estradiol), prepare the cells for progesterone secretion, and cause fur- Estrogen causes
ther granulosa maturation. endometrial
HIGH-YIELD FACTS
proliferation.
Main event of
Ovulation—Day 14 ovulation: LH surge
The LH surge causes the oocyte to be released from the follicle. What re- causes oocyte to be
mains is the corpus luteum, which secretes progesterone. released.
Main events of luteal
phase: Corpus luteum
Luteal Phase—Days 14 Through 28 secretes progesterone,
which causes:
The effect of LH on the follicle was to change its secretion from estradiol to
Endometrial maturation
progesterone. This happens before ovulation.
↓ FSH, ↓ LH
The corpus luteum survives only about 11 days in the absence of hCG, during
which time it continues progesterone secretion.
Menstruation
Progesterone causes the endometrium to mature in preparation for possible
implantation. It becomes highly vascularized with increased gland secretion.
Progesterone also causes inhibition of FSH and LH release. The corpus luteum would
be maintained after
If fertilization does not occur, the corpus luteum dies, progesterone levels fall, fertilization by human
and the cycle begins again. chorionic gonadotropin
(hCG) released by the
embryo.
AMENORRHEA
Etiologies
Etiologies of amenorrhea are categorized by where in the hormone cascade the
lesion is.
159
HYPOTHALAMIC CAUSES OF AMENORRHEA
All hypothalamic causes result in ↓ FSH/LH levels:
Kallman’s syndrome: Congenital lack of GnRH
Pituitary stalk compression: Tumors, granulomas, irradiation
↓ GnRH release: Stress, anorexia, hyperprolactinemia, severe weight
loss, extreme exercise
Evaluation of Amenorrhea
I. Is it primary or secondary?
First step to evaluating amenorrhea is to determine if it is primary or sec-
ondary (see Figure 15-2).
160
Uterus
Yes No
HIGH-YIELD FACTS
Yes No
Work up as Work up as
secondary amenorrhea progestin-negative
secondary amenorrhea
Menstruation
If the progestin challenge results in menses, then the diagnosis is
one of the following
PCOD
Ovarian or adrenal tumor Prolactin inhibits GnRH
Hypothalamic dysfunction pulsations, and therefore
If progestin challenge is negative: inhibits ovulation.
a) Heteroscopy to determine if Asherman’s syndrome is the cause
b) Check FSH level:
If ↑, suspect ovarian causes.
If ↓, suspect hypothalamic–pituitary failure.
2. Amenorrhea + galactorrhea:
Check TSH levels. If low, hypothyroidism is the cause.
If TSH is normal, check prolactin levels. Prolactin levels are high,
perform a CT/MRI of the brain to confirm a prolactinoma.
161
Progestin
challenge
Negative Positive
TSH
Normal Elevated
Treat hypothyroidism
Cone view normal Cone view abnormal
and or
prolactin 50–100 ng/mL prolactin over 50–100 ng/mL
or
visual symptoms
Microadenoma, Macroadenoma
hyperplasia
162
Treatment of Amenorrhea
Hypothalamic Causes
Tumor removal
Weight gain
Stress relief Early menopause is
Exogenous pulsatile GnRH idiopathic.
Pituitary Causes
Tumor removal
Bromocriptine (dopamine agonist inhibits prolactin release)
Exogenous FSH/LH
Ovarian Causes
Ovarian failure—in vitro fertilization, oral contraceptives
PCOD—clomiphene (an antiestrogen)
HIGH-YIELD FACTS
Uterine Causes
Obstruction—surgery
PCOD patients are usually
obese and have hirsutism
HYPERPROLACTINEMIA and insulin resistance. It is
the most common cause of
Elevated prolactin levels could be due to: hirsutism.
Hypothyroidism—check TSH level (hypothyroidism causes a rise in
prolactin).
Central nervous system (CNS) tumors—perform head CT/MRI.
Drugs:
Dopamine antagonists
Methyldopa
Serotonin agonists
Menstruation
Spinal cord lesions—perform spinal CT/MRI.
PMS refers to a group of symptoms experienced during the luteal phase of the
menstrual cycle. Symptoms are cyclic in nature with resolutions and exacerba-
tions.
Management of PMS
Diet—luteal-phase reductions in alcohol, caffeine, fats, tobacco, refined
sugars: Decreases irritability by decreasing fluctuation in blood sugar
levels
Sodium restriction—decreases edema
Oral contraceptive pills—cause anovulation, and this improves symptoms
163
Nonsteroidal anti-inflammatory drugs (NSAIDs)—decrease inflamma-
tion found in PMS
Selective serotonin reuptake inhibitors (SSRIs)
GnRH agonists
Androgens
Androgens are steroid hormones produced in the gonads (ovaries in women,
the testes in males) and in the adrenal glands.
Excess androgen in women will also result in these changes as well. In this
context, these effects are termed hirsutism and virilism.
Hair Types
Vellus hairs are fine hairs found on most parts of the body. They are barely
visible. Terminal hairs are the coarse, darker hairs found, for example, in the
axilla and pubic region. Androgens facilitate the conversion of vellus to ter-
minal hairs.
PRODUCTION OF ANDROGENS
In women, androgens are produced in two locations: The adrenals and the
ovaries (in males, they are produced in the adrenals and testes).
164
ADRENAL PRODUCTION OF ANDROGENS
The zona fasciculata and the zona reticularis of the adrenal cortex produce
androgens, as well as cortisol. ACTH regulates production.
A third layer of the adrenal cortex, the zona glomerulosa, produces aldos- Cortisol production in
terone and is regulated by the renin–angiotensin system. the adrenals:
Where? zonas fasciculata
All three hormones––cortisol, androgens, and aldosterone––are derived from and reticularis
cholesterol. Androgen products from the andrenal are found mostly in the Regulated by? ACTH
form of dehydroepiandrosterone (DHEA) and dehydroepiandrosterone-sulfate Derived from?
(DHEAS). Elevation in these products represents increased adrenal androgen
Cholesterol
production.
HIGH-YIELD FACTS
vert these androgens to estrone and estradiol. When LH levels become dispro- DHEA and DHEAS are
portionately greater than FSH levels, androgens become elevated. androgen products from the
adrenals. Increased levels
PATHOLOGIES of these indicate that the
source is adrenal.
Excess androgen can be either ovarian etiology or adrenal, neoplastic, or be-
nign.
ADRENAL ETIOLOGIES
Cushing’s Syndrome and Cushing’s Disease
High LH:FSH ratio in the
Cushing’s syndrome is a general term meaning hypercortisolism along with context of androgen excess
the clinical picture that goes with it—moon face, buffalo hump, weakness, indicates that ovary is the
etc. Exogenous or endogenous cortisol can be the cause. source.
Menstruation
Cushing’s disease is a subset of Cushing’s syndrome, in which the increased
cortisol level is due to ACTH hypersecretion by the pituitary, usually sec-
ondary to a benign pituitary adenoma. It accounts for 70% of Cushing’s syn-
dromes. Virilism and hirsutism are associated with this condition because the
ACTH stimulates androgen production as well.
165
21-Hydroxylase deficiency––this is the most common congenital adrenal hy-
perplasia. The condition has various levels of severity. Affected individuals
lack an enzyme crucial to cortisol and mineral corticoid production. There-
21-Hydroxylase
fore, hormone synthesis is shunted to excessive production of androgens. Ele-
deficiency typical vated serum 17-hydroxyprogesterone levels are found as well. In the severe
scenario: form, affected females have ambiguous genitalia at birth, along with severe
A baby with ambiguous salt wasting and cortisol insufficiency. A milder form presents simply with vir-
genitalia, dangerously ilization and hirsutism of females after puberty.
hypotensive, and with
elevated 17- 11β-Hydroxylase deficiency––this condition is associated with decreased
hydroxyprogesterone. cortisol, but increased mineral corticoids and androgens. The resultant pic-
ture is a severe hypertension with virilization/hirsutism (which results in
pseudohermaphroditism of female babies). 11-Deoxycortisol levels are high.
OVARIAN ETIOLOGIES
11β-Hydroxylase Polycystic Ovarian Syndrome (PCOS)
HIGH-YIELD FACTS
deficiency:
PCOS is a common condition (affecting 5% of reproductive age women) and
Low cortisol, high mineral
is characterized by hirsutism, virilization, amenorrhea, obesity, and diabetes
corticoids (hypertensive) (sometimes). Ovaries are found to have multiple inactive cysts with hyper-
and high androgens. plastic ovarian stroma. The LH:FSH ratio is often greater than 3:1. The cause
11-Deoxycortisol is elevated is unknown, and the treatment is oral contraceptives.
vs.
21-Hydroxylase deficiency: Hyperthecosis
Low cortisol and mineral
Hyperthecosis is when an area of luteinization occurs in the ovary, along with
corticoids (hypotensive), stromal hyperplasia. The luteinized cells produce androgens and hirsutism and
high androgens. virilization may result.
17-Hydroxyprogesterone is
elevated. Theca Lutein Cysts
As described above, theca cells produce androgens and granulose cells trans-
form the androgens to estrogens. Theca lutein cysts produce abnormally high
Menstruation
166
HIGH-YIELD FACTS IN
Abnormal Uterine
Bleeding
DEFINITIONS
167
Bleeding per vagina
Premenopausal Postmenopausal
β-hCG level
Endometrial biopsy
Consider cervical or
(+) (−) endometrial cancer.
Do ultrasound
(Intrauterine pregnancy –Check PT/PTT for coagulopathy.
shows at > 7 weeks; alternatively, –Physical exam or CT/ultrasound might
you might see ectopic or nothing.) show pelvic mass or neoplasia.
–Consider laparoscopy to diagnose endometriosis.
HIGH-YIELD FACTS
Threatened/inevitable/incomplete
abortion or ectopic pregnancy
Surgery
Abnormal Uterine Bleeding
D I F F E R E N T I A L D I A G N O S E S F O R P R E M E N O PA U S A L M E T R O R R H A G I A
168
DYSFUNCTIONAL UTERINE BLEEDING
DUB is a diagnosis made by exclusion after workup for other causes of abnormal
uterine bleeding (caused by anatomical lesions) is negative.
CLASSIFICATION OF DUB
DUB is classified as either anovulatory or ovulatory, though it is most often
caused by anovulation:
Anovulatory DUB: Anovulation results in constant endometrial prolif-
eration without progesterone-mediated maturation and shedding. The
“overgrown” endometrium continually and irregularly sheds. Causes of Tumors (benign and
anovulatory DUB include: malignant) often present
Polycystic ovaries (polycystic ovarian disease [PCOD]) with menorrhagia or
HIGH-YIELD FACTS
Obesity metrorrhagia.
Unopposed exogenous estrogen
EVALUATION OF DUB
Postcoital bleeds suggest
History trauma, infections, or
Thorough menstrual and reproductive history cervical cancer.
Signs of systemic disease (thyroid, liver, kidney)
TREATMENT OF DUB
High-dose oral contraceptive pills
or
Medroxyprogesterone acetate ≥ 10 days
169
P O S T M E N O PA U S A L B L E E D I N G
Studies to Get
HIGH-YIELD FACTS
170
HIGH-YIELD FACTS Abnormal Uterine Bleeding
171
NOTES
Abnormal Uterine Bleeding HIGH-YIELD FACTS
172
NOTES
HIGH-YIELD FACTS IN
Pelvic Pain
C H R O N I C P E LV I C PA I N
173
STS (serotest for syphilis)
Urinalysis (UA)
Occult blood
Blood culture
Mittelschmerz is pelvic pain
5. Radiographic studies:
associated with ovulation. Abdominal and vaginal sonogram
Computed tomography (CT)
Magnetic resonance imaging (MRI)
Barium enema
Laparoscopy is the final, Bone scan
Renal sonogram/intravenous pyelogram (IVP)
conclusive step in
6. Colonoscopy and/or cystoscopy (should be perfomed if all above are
diagnosing pelvic pain, but
inconclusive)
it should only be done once 7. Rule out psychosomatic pain.
psychogenic causes are 8. Diagnostic laparoscopy
considered carefully.
HIGH-YIELD FACTS
A C U T E P E LV I C PA I N
Etiologies
Pelvic Pain
174
CBC (PID or appendicitis might give elevated WBCs)
UA (leukocytes indicate possible UTI)
4. Pelvic sonogram (will show cysts and possibly torsion)
5. Diagnostic laparoscopy
Ruptured cyst is the most
common cause of acute
pelvic pain.
HIGH-YIELD FACTS
Clinical and Laboratory Findings
Pelvic Pain
count occasionally many white spiking ileus
present blood cells
and some
bacteria
Hemorrhagic Hematocrit Normal Usually Hematocrit No Rare
ovarian cyst may be low negative generally
after < 10%
treatment
of
hypovolemia
Torsion of Normal Normal Generally Minimal clear No Rare
adnexa negative fluid if
obtained
early
Degenerating Normal or Normal Generally Normal clear Possibly Rare
leiomyoma elevated negative fluid
white blood
cell count
Reproduced, with permission, from Pearlman MD, Tintinalli JE, eds. Emergency Care of the Woman. New York: McGraw-Hill,
1998: 508.
175
Pelvic Pain HIGH-YIELD FACTS
176
NOTES
HIGH-YIELD FACTS IN
Endometriosis
DEFINITION
P R E VA L A N C E
PAT H O P H Y S I O L O G Y
Tissue in endometriosis is
The ectopic endometrial tissue is functional. It responds to hormones and goes viable and behaves
through cyclic changes, such as menstrual bleeding. normally.
The result of this ectopic tissue is “ectopic menses,” which causes peritoneal
inflammation, pain, fibrosis, and, eventually, adhesions.
SITES OF ENDOMETRIOSIS
Exam scenario:
Common 37-year-old female
Ovary (bilaterally) complains of hemoptysis
Cul-de-sac with each period.
Fallopian tubes Diagnosis: Endometriosis of
Uterosacral ligaments nasopharynx or lung
Bowel
Less Common
Cervix
Vagina
Bladder
Rare
Nasopharynx
Lungs
177
ADHESIONS
C L I N I C A L P R E S E N TAT I O N
SIGNS
DIAGNOSIS
178
CLINICAL COURSE
30% asymptomatic
If left untreated, most lead to increasing pain and possible bowel com-
plications. Maximum time on estrogen
Often, there is improvement with pregnancy secondary to temporary suppression should be 6
cessation of menses. months due to adverse
effects.
T R E AT M E N T
Medical
All of these treatments suppress estrogen:
Gonadotropin-releasing hormone (GnRH) agonists—suppress follicle- The pulsatile fashion of
HIGH-YIELD FACTS
stimulating hormone (FSH); creates a pseudomenopause endogenous GnRH
Progesterone (with or without estrogen)—creates a pseudopregnancy stimulates FSH secretion.
Danazol—an androgen derivative that suppresses FSH/LH, thus also GnRH agonists are not
causing pseudomenopause pulsatile and therefore end
up suppressing FSH.
Surgical
Conservative (if reproductivity is to be preserved): Laparoscopic lysis
of adhesions and implants
or
Definitive: Total abdominal hysterectomy and bilateral salpingo-
oophorectomy (TAH/BSO)
Pseudomenopause—
↓ FSH/LH rather than ↑
ADENOMYOSIS FSH/LH as seen in “real”
Endometriosis
menopause.
Definition
Adenomyosis is endometrial tissue found within the myometrium. Adenomyosis
and endometriosis rarely coexist.
Treatment
GnRH agonist
Mifepristone (RU 486)—a progesterone antagonist
TAH/BSO if severe
179
ADENOMYOSIS VS. ENDOMETRIOSIS
Adenomyosis Endometriosis
Found in older women Found in young women
Doesn’t respond to hormonal Tissue is responsive to estrogen.
stimulation
Noncyclical Cyclical
HIGH-YIELD FACTS
Endometriosis
180
HIGH-YIELD FACTS IN
Pelvic Masses
DIFFERENTIAL DIAGNOSES
Leiomyoma
Pregnancy
Endometriosis/adenomyosis
Ovarian neoplasm Leiomyomas are the most
Tubo-ovarian abscess (TOA) common causes of
Ovarian cyst undiagnosed pelvic masses.
Adhesions (to uterus)
Also, congenital anomalies, other carcinomas/sarcomas
In different contexts, pelvic masses are more likely to carry different diag-
noses. The following are contexts and the likely diagnosis:
181
D I A G N O S T I C T E S T S F O R VA R I O U S C A U S E S O F P E LV I C M A S S E S
ECC is endocervical
curettage—scraping of the BENIGN OVARIAN MASSES
endocervical canal with
HIGH-YIELD FACTS
subsequent cytological
examination. F U N C T I O N A L O VA R I A N C Y S T S
Follicular Cysts
Follicular cysts are the most common functional ovarian cysts.
PHYSIOLOGY
KUB x-ray is x-ray of the Failure of rupture or incomplete resorption of the ovarian follicle results in a
kidneys, ureters, and cyst. Just like the original follicle, the ovarian cyst is granulosa cell lined and
bladder (portions of the contains a clear to yellow estrogen-rich fluid.
intestines are also
visualized). SIGNS AND SYMPTOMS
Pelvic Masses
Asymptomatic
Oligomenorrhea
Polymenorrhea
Unilateral abdominal pain
Acute pelvic pain (usually signifies rupture)
TREATMENT
No treatment may be necessary, since most cysts resolve spontaneously
within 2 months.
Oral contraceptives may aid in the symptomatic patient.
If the cyst is unresolved after 2 months, laparotomy/scopy is indicated
to evaluate/rule out neoplasia.
Lutein Cysts
There are two types of lutein cysts: Corpus luteum cysts and theca lutein
cysts.
182
CORPUS LUTEUM CYST
The corpus luteum cyst is an enlarged and longer living, but otherwise normal,
corpus luteum. It can produce progesterone for weeks longer than normal.
Signs/symptoms: Unilateral tenderness + amenorrhea
Diagnosis: History and physical/pelvic exam (once ectopic pregnancy has Pregnancy test must be
been ruled out), sonogram performed to rule out
Treatment (only if symptomatic): Analgesics, oral contraceptives, laparot- ectopic pregnancy!
omy/scopy if ruptured
HIGH-YIELD FACTS
production.
Conditions that cause elevated hCG levels:
Gestational trophoblastic disease (molar pregnancy)
Polycystic ovarian disease
Ovulation-inducing agents (clomiphene or hCG)
Multiple gestation:
Signs/symptoms: Signs and symptoms are usually due to the accompany-
ing condition that causes the elevated hCG.
Diagnostic finding: Elevated hCG levels
Treatment: One must treat the underlying condition; theca lutein cyst
will resolve once hCG levels come down.
LEIOMYOMAS (FIBROIDS)
Pelvic Masses
Leiomyomas are localized, benign, smooth muscle tumors of the uterus. They
are hormonally responsive and therefore become bigger and smaller correspond-
ing to the menstrual cycle.
Extremely rarely do
EPIDEMIOLOGY leiomyomas progress
to malignancy
Leiomyomas are found in 25 to 33% of reproductive-age women and in up to
50% of black women. (leiomyosarcoma).
183
SYMPTOMS
Asymptomatic in > 50% of cases
Bleeding +/− anemia—one third of cases present with bleeding. Bleed-
ing is usually menorrhagia, caused by:
Abnormal blood supply
Pressure ulceration
Abnormal endometrial covering
Pain—secondary dysmenorrhea
Pelvic pressure
Infertility
DIAGNOSIS
Physical exam (bimanual pelvic and abdominal exams): Fibroids are
smooth, firm, and usually midline.
Sonography (may also be visualized by x-ray, magnetic resonance imag-
HIGH-YIELD FACTS
Submucosal and intramural ing (MRI), CT, hysterosalpingogram (HSG), hysteroscopy, or intra-
types of fibroids usually venous urogram)
present as menorrhagia. Pap, ECC, and D&C can be done to rule out malignancy.
Subserous type often
presents with torsion. TREATMENT
No treatment is indicated for most women, as this hormonally sensitive tumor
will likely shrink with menopause.
Pregnancy is usually uncomplicated. Bed rest and narcotics are indicated for
pain with red degeneration. Tocolytics can be given to control/prevent prema-
Pregnancy with fibroids ture contractions.
does carry increased risk
for preterm labor and Treatment is usually initiated when:
fetal malpresentation. Tumor is > 12 to 14 weeks’ gestation size.
Hematocrit falls.
Pelvic Masses
184
HIGH-YIELD FACTS IN
Cervical Dysplasia
OVERVIEW
R I S K FA C T O R S F O R C E R V I C A L D Y S P L A S I A A N D C E R V I C A L C A N C E R
L O C AT I O N O F C E R V I C A L D Y S P L A S I A : T R A N S F O R M AT I O N Z O N E
The transformation zone is the area between the old and the new squamo-
columnar junctions.
The adolescent cervix is
The squamo-columnar junction exists between the squamous epithelium of more susceptible to
the vagina and ectocervix and the columnar epithelium of the endocervix. carcinogenic stimuli.
With age, metaplasia occurs, transforming columnar cells to squamous cells
and thereby advancing the squamo-columnar junction proximally toward the
185
endocervix. The area between the original junction and the new junction is
the transformation zone.
Technique
A speculum is placed in the vagina to expose the uterine cervix (no
digital exams or lubricants in the vagina prior to the Pap).
Cells are scraped from the ectocervix with a spatula, then from the en-
docervix using an endocervical brush.
Two things to remember
The cells are smeared on a glass slide, fixative spray is applied, and the
about Pap smear: cells are examined.
HIGH-YIELD FACTS
1. It is a screening tool.
2. It provides cytologic
information, not Success Rate of Pap
histologic.
Decreases incidence and mortality rate of invasive cervical cancer by
90%
80% sensitivity
99% specificity
186
1. Modern Classification System A.K.A. CIN (cervical intraepithelial
neoplasia): Describes the degree of abnormality of the cells
2. Bethesda system (SIL, squamous intraepithelial lesion): Describes
three things: (1) the adequacy of the Pap test performed, (2) the de-
gree of abnormality, and (3) a description of the cells
HIGH-YIELD FACTS
Atypical cells, possible inflammatory Reactive cellular changes
Atypical squamous cells of undetermined
significance (ASCUS)
CIN I—mild dysplasia: Neoplastic cells Low-grade squamous intraepithelial lesion
confined to lower one third of epithelium (LGSIL)
(60% spontaneously regress)
CIN II—moderate dysplasia: Involvement of High-grade squamous intraepithelial lesion
two thirds of epithelium (43% regress) (HGSIL)
CIN III—severe dysplasia (carcinoma in situ):
Involvement up to the basement membrane
of the epithelium (33% regress, 12% advance
to invasive cancer)
Squamous cell carcinoma Squamous cell carcinoma
Cervical Dysplasia
Glandular lesions Atypical glandular cells Atypical glandular cells of undetermined
significance (AGCUS)
AGCUS divides into endocervical or
endometrial
187
COLPOSCOPY WITH CERVICAL BIOPSY AND ECC
Definition
Low-magnification microscopic viewing with green filter light of cervix,
vagina, and vulva
Indications
Abnormal finding on Pap smear:
HGSIL and sometimes LGSIL
Any other suspicious lesions
Ninety percent of women
with abnormal cytologic
findings can be adequately Procedure
HIGH-YIELD FACTS
188
Indications for Cone Biopsy/LEEP
1. Inadequate view of transformation zone on colposcopy
2. Positive ECC
3. ± 2 grade discrepancy between colposcopic biopsy and Pap
4. Treatment for HGSIL
5. Treatment for adenocarcinoma-in-situ
LEEP as Treatment
LEEP can also be used to diagnose and treat CIN and VIN (vulvar intraep-
ithelial neoplasia).
HIGH-YIELD FACTS
When treating, ablate entire transformation zone.
Always excise keratinizing lesions.
C RY O T H E R A P Y
Cervical Dysplasia
LASER THERAPY
189
Cervical Dysplasia HIGH-YIELD FACTS
190
NOTES
HIGH-YIELD FACTS IN
Cervical Cancer
EPIDEMIOLOGY
Frequency
Cervical cancer is expected to account for 12,800 new cancer cases in
the United States in the year 2000.
Cervical cancer is expected to account for 4,600 cancer deaths in the
United States in the year 2000.
Age Affected
Peak incidence between ages 45 and 55
Fifteen percent of women develop it before age 30.
Increasing percentage of women diagnosed before 20 years of age (per-
haps due to early screening)
Race Prevalence
More prevalent in African American (AA) women and urban Hispanic
women than white women Cervical cancer is the third
AA mortality rate = two times greater than whites most common gynecologic
malignancy (breast cancer
SYMPTOMS is first; ovarian cancer is
second).
Early Stages
None
Irregular/prolonged vaginal bleeding/pink discharge
Postcoital bleeding (brownish discharge)
Middle Stages
Postvoid bleeding Symptoms of cervival
Dysuria/hematuria cancer become evident
when cervical lesions are of
Advanced Stages moderate size; looks like
Weight loss “cauliflower.”
Bloody, malodorous discharge
Severe pain, due to spread to sacral plexus
191
DIFFERENTIAL DIAGNOSIS
Eversions
Polyps
Papillary endocervicitis/papillomas
Tuberculosis, syphilitic chancres, and granuloma inguinale can also cause cer-
vical lesions.
be visible.
Types of Squamous Cell Carcinoma
Keratinizing
Nonkeratinizing:
Well-demarcated tumor-stromal borders
Small-cell carcinoma:
Small, round, or spindle-shaped cell with poorly defined tumor-
Adenocarcinoma is stromal borders
relatively resistant to radio-
and chemotherapy
Adenocarcinoma
compared to squamous cell
carcinoma. Accounts for 10 to 20% of all invasive cervical cancers
Arises from columnar cells lining the endocervical canal and glands
Early diagnosis is difficult → 80% false-negative rate with Pap smear
Cervical Cancer
S I T E S O F D I S TA N T O R G A N M E TA S TA S E S ( I N O R D E R O F F R E Q U E N C Y )
1. Lung
2. Liver
3. Bone
192
C L I N I C A L S TA G I N G O F I N VA S I V E C E R V I C A L C A N C E R
Modes of Staging
Pelvic and rectal exam (under anesthesia)
Chest x-ray
Liver function tests
Evaluate genitourinary tract via intravenous pyelogram or computed to-
mography (CT) with intravenous contrast dye.
Evaluate lymph node enlargements or abnormalities with external CT-
guided biopsies.
T R E AT M E N T O F I N VA S I V E C E R V I C A L C A N C E R
HIGH-YIELD FACTS
Radical surgery—radical hysterectomy with lymph node dissection Radical hysterectomy
Radiation therapy—high-dose delivery to the cervix and vagina, and
requires removal of:
minimal dosing to the bladder and rectum:
External beam whole pelvic radiation
Uterus
Transvaginal intracavitary cesium—transvaginal applicators allow
Cervix
significantly larger doses of radiation to surface of cervix. Parametrial tissue
Upper vagina
+ Pelvic lymphadenectomy
from the bifurcation of the
T R E AT M E N T F O R B U L K Y C E N T R A L P E LV I C D I S E A S E
iliac vessels to the level of
Hysterectomy after radiation therapy the inguinal ligament
Tumor cytoreduction:
Use of cytotoxic chemotherapy before definitive treatment with radi-
ation or radical surgery
Cervical Cancer
RECURRENT CERVICAL CARCINOMA
193
Cause of Death
Uremia and pyelonephritis are major causes of death in cervical cancer.
Found in 50% of patients
Treatment
Similar to treatment of squamous cell carcinoma of cervix
Preferred treatment is radical hysterectomy and pelvic lymph node dis-
section for stage I or IIA.
Vaginectomy if vagina is involved
Disease Recurrence
Most DES-related clear cell carcinomas recur ≤ 3 years of initial treat-
ment.
Pulmonary and supraclavicular nodal metastasis common → yearly
screening chest x-ray recommended
194
TABLE 21-1. Staging of Invasive Cervical Cancer
International Federation
of Gynecologists and 5-Year Survival Rate
Obstetricians (FIGO) Stage Description of Carcinoma Post Treatment
0 In situ; intraepithelial carcinoma
I Confined to cervix; preclinical 65–90%
IA Preclinical
(Diagnosis only by microscopy)
Minimal microscopic invasion of stroma:
Max of 7-mm horizontal spread
HIGH-YIELD FACTS
Preclinical greater than IA-2
Cervical Cancer
Tumor involves lower one third of vagina
Hydronephrosis or nonfunctioning kidney
195
TABLE 21-2. TNM Category Staging
M Distant Metastasis
MX Presence of distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis (excludes peritoneal metastasis)
4 Undifferentiated
196
HIGH-YIELD FACTS Cervical Cancer
197
NOTES
Cervical Cancer HIGH-YIELD FACTS
198
NOTES
HIGH-YIELD FACTS IN
Endometrial Cancer
G E N E R A L FA C T S
Pap smears are not diagnostic, but a finding of AGCUS (abnormal glandular
cells of unknown significance) leads to further investigation.
D I F F E R E N T I A L D I A G N O S I S O F P O S T M E N O PA U S A L B L E E D I N G
Exogenous estrogens
Atrophic endometritis/vaginitis
Endometrial cancer
Endometrial/cervical polyps Postmenopausal bleeding
always requires an
endometrial biopsy as the
Etiologies of Endometrial Cancer first step in the workup.
All etiologies (except radiation) result in chronic elevations in circulating
levels of estrogen:
Ovarian failure (i.e., polycystic ovarian disease [PCOD])
Exogenous estrogens
Estrogen-producing tumors (i.e., granulosa cell tumors)
Liver disease (a healthy liver metabolizes estrogen)
Previous radiation (leading to sarcomas)
199
Risk Factors
Obesity
Early menarche/late menopause
Nulliparity
Any agent/factor that PCOD
raises the level or time of Diabetes mellitus
exposure to estrogen is a Hypertension
risk factor for endometrial Endometrial hyperplasia
cancer. Tamoxifen treatment for breast cancer (increases risk two to three times)
Protective Factors
Combined oral contraceptives
Cigarette smoking
Multiparity
HIGH-YIELD FACTS
ENDOMETRIAL HYPERPLASIA
Endometrial Cancer
200
Pathology
Chest x-ray
Labs
CA-125
HIGH-YIELD FACTS
S TA G I N G O F E N D O M E T R I A L C A N C E R
Endometrial Cancer
spread and/or positive peritoneal cytology survival
IIIB—invasion of vagina
IIIC—mets to pelvic/para-aortic lymph nodes
IV—distant IVA—invasion of bladder and/or bowel 10% 5-year
spread IVB—distant invasion, including intra- survival
abdominal and/or inguinal lymph nodes
GRADING
201
T R E AT M E N T
Basic treatment for all stages (surgical staging is always the first step):
Total abdominal hysterectomy (TAH)
Bilateral salpingo-oophorectomy (BSO)
Nodal sampling
Peritoneal washings
Adjuvant Therapy
After the above steps in treatment, adjuvant therapy depends on the stage.
Stages I–II Brachytherapy (intracavitary radiation)
Side effects:
Stages III–IV External beam radiation
Doxyrubicin––cardiotoxicity
Hormone therapy: Progestin therapy is often used as adjuvant
Cisplatin––nephrotoxicity
hormonal therapy:
If the cancer is progesterone receptor positive—70% have a
HIGH-YIELD FACTS
5-year survival.
If the cancer is receptor negative—15 to 20% have a 5-year
survival.
Chemotherapy is used only for cancers that recur outside the
pelvis.
Doxorubicin
Cisplatin
UTERINE SARCOMA
Poor prognosis
Most cases are diagnosed with exploratory surgery for what was thought to be
a uterine myoma (fibroid).
Types
Leiomyosarcoma (LMS)
Mixed mesodermal (MMD)
Endometrial stromal sarcoma (ESS)
Diagnosis
≥ 10 mitosis/high-power field
Usually diagnosed from specimen sent after hysterectomy
Staged just like endometrial cancer
Treatment
Surgical (TAH/BSO, nodes, washings)
Plus adjuvant:
LMS—doxorubicin and cisplatin
Ifosphamide can cause MMD—ifosphamide and cisplatin
hemorrhagic cystitis. ESS—progestin therapy
202
HIGH-YIELD FACTS IN
Ovarian Cancer
203
Signs and Symptoms
Pelvic mass
Typical scenario: Abdominal mass (“omental caking”) (widening abdominal girth)
A postmenopausal woman Pleural effusion (dyspnea)
with widening girth notices Ascites
that she can no longer Ventral hernia (due to ↑ intra-abdominal pressure)
button her pants.
Diagnosis: Ovarian cancer. CA-125
CA-125 is a tumor marker elevated in 80% of cases. It is useful in tracking the
progression of the disease and the response to treatment.
Risk Factors
Omental caking is a fixed Advanced age
pelvic and upper abdominal Family history
HIGH-YIELD FACTS
O VA R I A N C A N C E R W O R K U P
Large ovarian tumors can 1. As with any pelvic mass, the first step of evaluation is ultrasound.
cause bowel obstruction 2. Definitive identification of adnexal mass by laparoscopy/laparotomy fol-
and other GI symptoms. lows.
Screening Recommendations
Women with standard risk (fewer than two first-degree relatives with
ovarian cancer): No routine screening recommended
Women with high risk (two or more first-degree relatives with ovarian
About 25% of ovarian cancer): Genetic testing and counseling
cancers occur in association
with endometriosis.
204
If testing shows one of the hereditary syndromes, perform:
Annual CA-125
Annual transvaginal ultrasound
Annual pelvic exam
HIGH-YIELD FACTS
Stage II—pelvic IIA—involvement of uterus/tubes 70% 5-year survival
spread IIB—involvement of other pelvic
structures CA-125 is elevated in 80%
IIC—IIA or IIB plus tumor on ovary of cases of ovarian cancer,
surface, capsule ruptures, ascites but only in 50% of stage I
with malignant cells, or positive
cases. It is most useful as a
peritoneal washings
tool to gauge progression/
Stage III—spread IIIA—positive abdominal peritoneal 25% 5-year survival regression of disease.
to the abdominal washings
cavity IIIB—< 2-cm implants on abdominal
peritoneal surface
IIIC—> 2-cm implants on abdominal
peritoneal surface and/or positive
retroperitoneal or inguinal nodes
Ovarian Cancer
Stage IV—distant Parenchymal liver/spleen spread 5% 5-year survival
metastasis Pleural effusion, skin or Ovarian and endometrial
supraclavicular nodes tumors are staged
surgically, whereas cervical
cancer is staged clinically.
T R E AT M E N T
Postop Management
First-line chemotherapy: Paclitaxel and cisplatin or paclitaxel and carboplatin:
Stage I–II Only chemotherapy if stage I/IIC or high-grade tumor
Stage III–IV Chemotherapy, plus:
Radiation if residual tumor < 2 cm
Interval debulking if tumor > 2 cm (internal debulking means
additional surgery after chemotherapy)
205
Poor Prognostic Indicators
Short disease-free interval
Mucinous or clear cell tumor
Multiple disease sites
High CA-125
N O N E P I T H E L I A L O VA R I A N C A N C E R
Histologic Types
Germ cell—8% of all ovarian cancers; include teratomas, dysgermino-
mas, choriocarcinomas
HIGH-YIELD FACTS
Clinical Presentation
Abdominal pain with rapidly enlarging palpable pelvic/abdominal mass
Acute abdomen
Fever
Vaginal bleeding
Usually found in children or young women
Ovarian Cancer
206
Mixed GCTs
10% of GCTs
Dysgerminoma and endodermal sinus tumor is the most common com-
bination.
LDH, AFP, and β-hCG may be elevated.
HIGH-YIELD FACTS
Prognosis of Ovarian GCTs
Prognosis is generally good because most are discovered early. Five-year sur-
vival is 85% for dysgerminomas, 75% for immature teratomas, and 65% for
endodermal sinus tumors.
Ovarian Cancer
Secretes estrogens that can cause feminization, precocious puberty, or
postmenopausal bleeding
Association with endometrial cancer
Inhibin is the tumor marker.
Adjuvant Therapy
Data are inconclusive, but chemotherapy and radiation play a small role
at present.
207
TABLE 23-1. Ovarian Tumors and Their Serum Markers
FA L L O P I A N C E L L C A R C I N O M A
HIGH-YIELD FACTS
208
HIGH-YIELD FACTS IN
Vulvar Dysplasia
and Cancer
V U LVA R I N T R A E P I T H E L I A L N E O P L A S I A ( V I N )
Risk Factors
Like cervical cancer, vulvar cancer risk factors include HPV types 16, 18, 31,
and 33, and the precancerous lesions are classified as intraepithelial neoplasia
(termed VIN as opposed to CIN).
Risk factors for vulvar
dysplasia include HPV,
Presentation herpes simplex virus type II
Pruritus and/or irritation (recent or long-standing), raised white lesions (HSV-II), lymphogranuloma
venereum (LGV),
pigmented moles, and poor
Diagnosis hygiene.
Biopsy
Colposcopic exam (must include cervix, vagina, perineal and perianal
skin)
Staging
Most common site of vulvar
As in cervical dysplasia, VIN is based on degree of epithelial spread: dysplasia is labia majora.
VIN I—involvement of < 1⁄2 epithelium.
VIN II—involvement of > 1⁄2 epithelium
VIN III—full-thickness involvement (carcinoma-in-situ)
Treatment
Treatment is according to the size of the lesion:
Small, well-circumscribed VIN → wide local excision
Multifocal lesions → laser vaporization
Extensive lesions → vulvectomy
209
V U LVA R C A N C E R
Diagnosis
Biopsy of the suspicious lesion
Staging
Vulvar Dysplasia
Treatment
Stages I–II
Radical vulvectomy and lymphadenectomy (wide local excision is some-
times possible for certain small lesions < 1 cm)
Stages III–IV
As above, plus removal of affected organs and adjunct radiation therapy
210
VA G I N A L C A N C E R
HIGH-YIELD FACTS
Diagnosis
Biopsy of suspicious lesion
Staging
Stage I: Limited to vaginal mucosa Survival ≈ 75%
Stage II: Beyond mucosa but not Survival ≈ 70%
involving pelvic wall
Stage III: Pelvic wall involvement Survival ≈ 35%
Stage IV: Involvement of bladder, Survival < 15%
rectum, or distant mets
Vulvar Dysplasia
Treatment
Stages I–II
Surgical resection and radiation
Stages III–IV
Radiation only
211
Vulvar Dysplasia HIGH-YIELD FACTS
212
NOTES
HIGH-YIELD FACTS IN
Gestational Trophoblastic
Neoplasias (GTN)
DEFINITION OF GTN
H Y D AT I D I F O R M M O L E
Partial Mole
A mole with a fetus or fetal parts. Women with partial (incomplete) molar
pregnancies tend to present later than those with complete moles: DNA of a partial mole is
Karyotype: Usually 69XXY, and contains both maternal and paternal both maternal and
DNA paternal.
Epidemiology: 1 in 50,000 pregnancies in the United States
213
Invasive Mole
A hydatidiform mole that invades the myometrium: It is by definition malig-
A young woman who passes nant, and thus treatment involves complete metastatic workup and appropri-
grape-like vesicles from her ate malignant/metastatic therapy (see below).
vagina should be diagnosed
with hydatidiform mole. HISTOLOGY OF HYDATIDIFORM MOLE
Trophoblastic proliferation
Hydropic degeneration (swollen villi)
Lack/scarcity of blood vessels
DIAGNOSIS
hCG > 100,000 mIU/mL
Absence of fetal heartbeat
GTN secrete human chorionic Ultrasound- “snowstorm” pattern
gonadotropin (hCG), Pathologic specimen—grapelike vesicles
lactogen, and thyrotropin. Histologic specimen (see above)
Nonmetastatic malignancy
has almost a 100%
remission rate following
chemotherapy.
214
Treatment for metastatic molar pregnancy is the same as for choriocarcinoma
(see below)
CHORIOCARCINOMA
Diagnosis
Increased hCG
HIGH-YIELD FACTS
Absence of fetal heartbeat
Uterine size/date discrepancy
Specimen (sheets of trophoblasts, no villi)
GTN
Treatment of Metastatic Choriocarcinoma, Metastatic Invasive Mole,
or Metastatic Hydatidiform Mole
Treatment is determined by the patient’s risk (high or low) or prognostic
score.
High risk: Opposite of above (i.e., hCG > 100,000 IU/24-hr urine, more than
4 months from pregnancy, brain or liver mets, etc.)
215
World Health Organization (WHO) Prognostic Scoring System
SCORE
Risk Factor 0 1 2 4
Age (years) ≤ 39 > 39
Pregnancy H. mole Abortion Term
Interval from <4 4–6 7–12 > 12
pregnancy
event to
treatment
(in months)
hCG (IU/mL) < 103 103–104 104–105 > 105
ABO blood O×A B
HIGH-YIELD FACTS
group A×O AB
(female ×
male)
Number of 1–4 5–8 >8
metastases
Site of Spleen GI Brain
metastasis Kidney Liver
Size of largest 3–5 >5
tumor (cm)
Prior Single Multiple
chemotherapy
agent
216
P L A C E N TA L S I T E T R O P H O B L A S T I C T U M O R ( P S T T )
Treatment
Total abdominal hysterectomy: Prognosis is poor if there is tumor recurrence
or metastasis.
HIGH-YIELD FACTS
GTN
217
GTN HIGH-YIELD FACTS
218
NOTES
HIGH-YIELD FACTS IN
Sexually Transmitted
Diseases and Vaginitis
P E LV I C I N F L A M M AT O RY D I S E A S E ( P I D )
Definition
Inflammation of the female upper genital tract (uterus, tubes, ovaries, liga- PID affects 10% of women
ments) caused by ascending infection from the vagina and cervix in reproductive years.
Lab Results and Other Possible Exam Signs Requirement for diagnosis
+/− Fever
of PID:
Gram-positive staining
Pelvic abscess 1) Abdominal tenderness
Elevated white count 2) Adnexal tenderness
Purulent cervical discharge 3) Cervical motion
tenderness
Laparoscopy Positive lab tests are not
This is the “gold standard” for diagnosis, but it is usually employed only in necessary for diagnosis.
cases unresponsive to medical treatment.
Risk Factors
Multiple sexual partners
New sex partner(s) Chandelier sign—when
Unprotected intercourse you touch the cervix, there
Concomitant history of sexually transmitted disease is so much pain that she
jumps to the chandelier.
219
Criteria for Hospitalization
Pregnancy
Peritonitis
Gastrointestinal (GI) symptoms (nausea, vomiting)
Criteria for hospitalization Abscess (tubo-ovarian or pelvic)
for PID: Uncertain diagnosis
GU PAP
GI symptoms
Uncertain diagnosis Treatment
Peritonitis Inpatient
Cefotetan + doxycycline (preferred for chlamydia)
Abscess
Clindamycin + gentamicin (preferred for abscess)
Pregnancy
Outpatient
Ofloxacin + metronidazole
Ceftriaxone + doxycycline (preferred for chlamydia (because of doxycycline)
HIGH-YIELD FACTS
GONORRHEA
There is a 50 to 90%
chance of transmission Presentation
after one exposure to Asymptomatic
gonorrhea.
STDs and Vaginitis
Dysuria
Endocervicitis
Vaginal discharge
Pelvic inflammatory disease (PID)
Diagnosis
Fifteen percent of women Culture in Thayer–Martin agar (gold standard)
with gonorrhea will Gonazyme (enzyme immunoassay)
progress to PID if
untreated.
Treatment
Ceftriaxone
or
Ciprofloxacin + doxycycline
or
Azithromax
When treating gonorrhea,
empirical treatment of Treat partners.
chlamydial co-infection is
also given.
220
CHLAMYDIA
SEROTYPES A–K
Serotypes A–K of Chlamydia trachomatis can have the following presentation:
Asymptomatic
Mucopurulent discharge
HIGH-YIELD FACTS
Cervicitis
Urethritis Fitz-Hugh–Curtis
PID perihepatitis presents as
Trachoma—conjunctivitis resulting in eyelash hypercurvature and right upper quadrant pain,
eventual blindness from corneal abrasions fever, nausea, and vomiting.
Fitz-Hugh–Curtis syndrome It can be caused by
gonorrhea or chlamydia.
SEROTYPES L1–L3
Serotypes L1–L3 of Chlamydia trachomatis cause lymphogranuloma venereum.
This is a systemic disease that can present in several forms:
Primary lesion—painless papule on genitals
Secondary stage–lymphadenitis
Tertiary stage—rectovaginal fistulas, rectal strictures
SYPHILIS
221
ally appearing 1 to 6 months after primary chancre: Spontaneous re-
gression after about 1 month
Tertiary syphilis—presents years later with skin lesions, bone lesions
(gummas), cardiovascular lesions (e.g., aortic aneurysms), central ner-
vous system (CNS) lesions (e.g., tabes dorsalis).
Diagnosis
Screening is done via rapid plasma reagin (RPR) or Venereal Disease
Research Laboratory (VRDL). These are nonspecific and can give posi-
tive results for many conditions.
Pregnancy may give false- Treponemal test (FTA-ABS) is a very specific test, performed if RPR is
positive RPR. positive.
Visualization of spirochetes on darkfield microscopy is an additional test
available.
HIGH-YIELD FACTS
Treatment
Penicillin G for all stages, though in differing doses
Doxycycline, if penicillin allergic
G E N I TA L H E R P E S
Presentation
Patients with herpes can be asymptomatic, in addition to the following:
Primary infection: Painful multiple vulvar vesicles, associated with
fever, lymphadenopathy, malaise, usually 1 to 3 weeks after exposure
Recurrent infection: Recurrence from viral stores in the sacral ganglia,
resulting in a milder version of primary infection including vesicles.
Initial primary infection: This is defined as initial infection by HSV-II
These patients present very in the presence of preexisting antibodies to HSV-I. The preexisting anti-
ill. bodies to HSV-II can make the presentation of HSV-I milder.
Major Risks
Cervical cancer
Neonatal infection
222
Treatment
Treatment for HSV is palliative and not curative.
Primary outbreak—acyclovir Cesarean delivery is
Recurrent infection—one half original dose of acyclovir indicated for active herpes
Pregnancy—acyclovir during third trimester infection.
HIV is an RNA retrovirus and causes AIDS. The virus infects CD-4 lympho-
cytes and other cells and causes decreased cellular immunity. Treatment of AIDS is
palliative and not curative.
Presentation
HIGH-YIELD FACTS
Initial infection: Mononucleosis-like illness occurring weeks to months af-
ter exposure—fatigue, weight loss, lymphadenopathy, night sweats. This is
followed by a long asymptomatic period lasting months to years.
AIDS: Opportunistic infections, dementia, depression, Kaposi’s sarcoma,
wasting
Risk Factors
Intravenous drug use
Blood transfusions between 1978 and 1985
Prostitution
Multiple sex partners/unprotected sex Risk factors for HIV include
Bisexual partners intravenous drug use, blood
transfusions (1978–1985),
Treatment
Two antiretroviral agents plus one protease inhibitor has been common treat-
ment.
H U M A N PA P I L L O M AV I R U S ( H P V )
Presentation
Warts of various sizes (sometimes described as cauliflower-like) on the exter-
nal genitalia, anus, cervix, or perineum
223
Diagnosis
Warts are diagnosed by visualization.
Cervical dysplasia caused by HPV infection is screened via Pap smear.
Treatment
Condylomata acuminata are treated with cryosurgery, laser ablation, or
trichloroacetic acid.
See cervical dysplasia chapter for treatment of cervical dysplasia.
CHANCROID
Presentation
Chancroid presents as a papule on external genitalia that becomes a painful ulcer
(unlike syphilis, which is painless) with a gray base. Inguinal lymphadenopathy
HIGH-YIELD FACTS
also is possible.
Etiology
Haemophilus ducreyi
Diagnosis
Gram stain of ulcer or inguinal node aspirate showing gram-negative rods
Treatment
Ceftriaxone, erythromycin, or azithromycin
STDs and Vaginitis
Presentation
Pruritus in genital area from parasitic saliva
Etiology
Pediculosis is a parasite.
Diagnosis
Visualization of crabs, history of pruritus
Treatment
Permethrin cream or Lindane shampoo
224
Etiology
Antibiotics—destabilize the normal balance of flora
Douche—raises the pH
Intercourse––raises the pH
Foreign body––serves as a focus of infection and/or inflammation
There are several common organisms that cause vaginitis: Bacterial (Gard-
nerella), Candida, and Trichomonas. The distinguishing features are described
with the following characteristics.
Diagnostic Characteristics
Clinical characteristics
Quality of discharge
pH—secretions applied to test strip reveal pH of discharge.
“Whiff” test—combining vaginal secretions with 10% KOH: Amines
HIGH-YIELD FACTS
released will give a fishy odor, indicating a positive test.
Microscopic findings
Physiologic
(Normal) Bacterial Vaginosis Candidiasis Trichomoniasis
Clinical Complaints None Malodorous Pruritus, erythema, Copious, frothy
discharge, edema, odorless discharge,
especially after discharge, malodorous,
menses, intercourse dyspareunia pruritus, urethritis
Quality Clear or white, no Homogenous gray or White, “cottage Green to yellow,
of Discharge odor white, thin, sticky cheese-like” sticky, “bubbly”
225
TOXIC SHOCK SYNDROME
Suspect TSS
–mucous membranes
–GI
–liver If criteria not met,
–renal pursue alternative
–skin diagnoses.
–cardiac
HIGH-YIELD FACTS
–muscular
–hematologic
–skin rash
–fever > 38.9° C
–CNS
1) Assess hemodynamics.
Any potential site for Staphylococcus aureus?
2) Replace volume and electrolytes.
(Infection or colonization)
3) Intravenous antibiotics
A) Anti-staph beta-lactam
(e.g., nafcillin 1–2 g q4h)
B) Clindamycin
Male Female
C) Vancomycin
Surgical wound, Vaginal, tampon, contraceptive
STDs and Vaginitis
Positive
Remove any FB*; culture site and blood
* Foreign body
226
HIGH-YIELD FACTS IN
Vulvar Disorders
V U LVA R D Y S T R O P H I E S
PSORIASIS
Treatment
Steroid cream
Coal tar with ultraviolet light therapy or topical vitamin D
227
VESTIBULITIS
CYSTS
Bartholin’s Abscess
Bartholin’s abscesses occur when the main duct draining Bartholin’s gland is
occluded, which usually occurs due to infection. Inflammatory symptoms gen-
erally arise from infection and can be treated with antibiotics.
TREATMENT
Incision and drainage and marsupialization (suturing the edges of the
Bartholin’s glands are incised cyst to prevent reocclusion)
analogous to the male or
Cowper’s gland Ward catheter (a catheter with an inflatable tip left in the gland for 10
Vulvar Disorders
Hidradenomas
Hidradenomas (apocrine sweat gland cysts) also occur beneath the labia ma-
jora as a result of ductal occlusion. These cysts tend to be more pruritic than
sebaceous cysts. They are also treated by incision.
228
I N F E S TAT I O N S
Pthirus pubis
Crab lice (“crabs”) are blood-sucking parasites that are transmitted through
sexual activity or fomites. Adults lay eggs, which hatch into the lice that
cause intense itching.
DIAGNOSIS
A magnifying glass will aid in revealing small brown lice and eggs attached to
hair shafts.
TREATMENT
Treat with Permethrin cream or Kwell shampoo (contraindicated in pregnant
or lactating women), as well as washing all garments.
HIGH-YIELD FACTS
Sarcoptes scabei
“Scabies” are also parasitic infections (more contagious) spread by person-to-
person contact or via fomites. Patients may present with papular and/or vesic-
ular eruptions on genitals or extremities, as well as with intractable itching.
Close observation reveals that the source of itching is the site where adult
parasites have burrowed into skin and laid eggs. Adults, larvae, or eggs may be
seen.
TREATMENT
Kwell cream or lotion from the neck down, overnight. Crotamiton is applied
similarly in pregnant/lactating women and children under 10 years of age.
Vulvar Disorders
229
Vulvar Disorders HIGH-YIELD FACTS
230
NOTES
HIGH-YIELD FACTS IN
Menopause
DEFINITIONS
FA C T O R S A F F E C T I N G A G E O F O N S E T
Genetics
Smoking (decreases age by 3 years) Cigarette smoking is the
Chemo/radiation therapy only factor shown to
significantly reduce age of
menopause (3 years).
P H Y S I O L O G Y D U R I N G T H E P E R I M E N O PA U S A L P E R I O D
Oocytes Die
Women’s immature eggs, or oocytes, begin to die precipitously and be-
come resistant to follicle-stimulating hormone (FSH), the pituitary
hormone that causes their maturation.
FSH levels rise for two reasons:
231
Estrogen Levels Fall
Estrogen (estradiol-17β) levels begin to decline, resulting in hot flashes
(may also be due to increased luteinizing hormone [LH]). Hot flashes usually
occur on the face, neck, and upper chest and last a few minutes, followed by
intense diaphoresis.
P H Y S I O L O G Y D U R I N G T H E M E N O PA U S A L P E R I O D
The most important physiological change that occurs with menopause is the
decline of estradiol-17β levels that occurs with the cessation of follicular
maturation. Table 28-1 lists the organ systems affected by those decreased
estradiol levels.
TABLE 28-1.
232
T R E AT M E N T O F T H E A D V E R S E E F F E C T S O F M E N O PA U S E
HIGH-YIELD FACTS
Coronary artery
RISKS OF HRT/ERT
disease is the most
Increase incidence in breast cancer common cause of mortality,
Increase incidence in endometrial cancer (ERT only) accounts for about 500,000
Thromboembolism deaths/yr.
Cholecystitis/cholelithiasis
Risks can be reduced by beginning therapy years after menopause and/or treat-
ment for only a few years.
CONTRAINDICATIONS TO HRT/ERT
Unexplained vaginal bleeding
Breast carcinoma (relative, not absolute, contraindication)
Metastatic endometrial carcinoma
Liver disease
Menopause
History of thromboembolic disease
History of MI (ERT/HRT has not shown to be effective in cardioprotec-
tion after an MI has occurred)
Estrogen creates a
hypercoagulable state due
to increased production of
hepatic coagulation factors.
233
Menopause HIGH-YIELD FACTS
234
NOTES
HIGH-YIELD FACTS IN
Pelvic Relaxation
A N AT O M Y O F P E LV I C F L O O R S U P P O R T
Several crucial structures make up the support of the female pelvic floor. Dis-
turbance of any of the following can result in prolapse:
Bony structure
Broad and round ligaments
The pelvic diaphragm is
Endopelvic fascia made up of the levator ani
Pelvic diaphragm and coccygeal muscles.
Urogenital diaphragm
Perineum
PROLAPSE
Types of Prolapse
Prolapses can be classified according to the location of the protruding struc-
ture: Anterior, apical, and posterior.
Anterior
Cystocele (bladder)—see Figure 29-1
Cystourethrocele
235
FIGURE 29-2. Rectocele.
(Reproduced, with permission, from Pernoll ML. Benson & Pernoll’s Handbook of Obstetrics and Gynecology, 10th ed. New
York: McGraw-Hill, 2001: 807.)
Apical
HIGH-YIELD FACTS
Uterocele
Vaginal prolapse
Posterior
Rectocele—see Figure 29-2
Enterocele (intestine)—see Figure 29-3
Grading of Prolapse
Organ displacement:
In general, think of
To the level of the ischial spines Grade I
prolapse as either limited to
the upper vagina, to the Between ischial spines and introitus Grade II
introitus, or protruding Within introitus Grade III
from the body.
Pelvic Relaxation
236
Loss of levator ani function—postpartum
Disturbance of parts—postsurgical
Loss of innervation—amyotrophic lateral sclerosis (ALS), paralysis
Loss of connective tissue—spina bifida, myelomeningocele
HIGH-YIELD FACTS
Diagnosis
Diagnosis is made by direct visualization of prolapsed organ during complete
pelvic examination: Patient should be examined in the standing position.
Treatment of Prolapse
Asymptomatic Prolapse
Usually requires follow-up but no immediate intervention
Pelvic-strengthening exercises (i.e., Kegel maneuvers) and/or
HRT/ERT may benefit.
Symptomatic Prolapse
Can be treated with a pessary or surgically
Pelvic Relaxation
Pessary
A pessary is an object placed in the upper vagina designed to help maintain
support of the pelvic organs. Types include:
Smith-Hodge—an oval ring
Doughnut (ring)
Inflatable
Gehrung—U-shaped
Surgical Treatment
These are several types of surgical repairs for each type of prolapse.
CYSTOCELE
Kelly plication (anterior vaginal repair)—endopelvic fascial reinforce-
ment via vaginal approach
Lefort procedure/colpocleisis—surgical obliteration of the vaginal canal
Burch/Marshall–Marchetti–Krantz procedures—urethrovescicular sus-
pension via abdominal approach
Sling procedure—elevation of bladder neck and urethra via vaginal and
abdominal approaches
RECTOCELE
Posterior repair—posterior vaginal wall reinforcement with levator ani
muscles via vaginal approach
237
ENTEROCELE
Moschovitz repair—approximation of endopelvic fascia and uterosacral
ligaments via abdominal approach to prevent an enterocele
UTERINE PROLAPSE
Hysterectomy—a uterine prolapse often occurs in conjunction with an-
other prolapse, and so combined repairs are usually performed.
U R I N A RY I N C O N T I N E N C E
Definition
Reversible causes of
urinary incontinence: Involuntary loss of urine that is a symptom of a pathological condition. Incon-
tinence can be due to reversible or irreversible (but treatable) causes.
“DIAPPERS”
HIGH-YIELD FACTS
Delerium
Infection Reversible Causes of Urinary Incontinence
Atrophic vaginitis Delerium, infection, atrophic vaginitis, drug side effects, psychiatric illness,
Pharmacologic causes excessive urine production, restricted patient mobility, and stool impaction
Psychiatric causes are reversible causes of urinary incontinence.
Excessive urine production
Restricted mobility It is helpful to search out these easily correctable causes before moving on to
Stool impaction the more expensive and invasive workup for the irreversible causes.
URGE INCONTINENCE
Sudden feeling of urgency followed by complete emptying of bladder: Caused
by unopposed detrusor contraction
OVERFLOW INCONTINENCE
Constant dribbling +/− urgency with inability to completely empty the blad-
der: Caused by detrusor underactivity (due to a neuropathy) or urethral ob-
struction
MIXED INCONTINENCE
Combinations of above
Evaluation
HISTORY
Ask about aforementioned symptoms, medications, medical history (diabetes
mellitus, neuropathies)
238
PHYSICAL
Pelvic exam: Check for cystoceles, urethroceles, and atrophic changes.
Rectal exam: Check for impaction, and rectocele; assess sphincter tone.
Neuro exam: Assess for neuropathy.
Remember to examine for
LABS prolapse while patient is
Urinalysis and culture to rule out urinary tract infection standing.
Q-TIP TEST
A cotton swab is placed in the urethra. The change in angle between the
Q-tip and the woman’s body is measured upon straining. Normal upward
change is < 30°, and a positive test is one with > 30° change. A positive test
indicates stress incontinence.
Q-tip test: Increased
CYSTOMETRY upwards motion of the Q-tip
HIGH-YIELD FACTS
is caused by loss of support
Cystometry provides measurements of the relationship of pressure and vol- from the urethrovesicular
ume in the bladder. Catheters that measure pressures are placed in the blad- (UV) junction, indicating
der and rectum, while a second catheter in the bladder supplies water to cause
stress incontinence.
bladder filling. Measurements include residual volume, pressures at which desires
to void occur, bladder compliance, flow rates, and capacity. Diagnoses: Stress,
urge, and overflow incontinence.
URODYNAMIC STUDIES
A set of studies that evaluate lower urinary tract function. Studies may in-
clude cystometry (see above), bladder filling tests, cystoscopy, uroflowmetry
leak-point pressure tests, to name a few. Can help diagnose all types of in-
continence.
Pelvic Relaxation
Treatment
STRESS INCONTINENCE
Kegel exercises strengthen urethral muscles.
Estrogen therapy
Alpha-adrenergic drugs
Surgical repair (usually Burch procedure or Kelly plication)
URGE INCONTINENCE
Medications:
Anticholinergics
Calcium channel blockers
Tricyclics
Timed voiding: Patient is advised to urinate in prescribed hourly inter-
vals before the bladder fills.
Surgery is rarely used to treat urge incontinence.
OVERFLOW INCONTINENCE
Due to Obstruction
Relieve obstruction.
239
Due to Detrusor Underactivity
Treat possible neuro causes:
Diabetes mellitus
B12 deficiency
HIGH-YIELD FACTS
Pelvic Relaxation
240
HIGH-YIELD FACTS IN
Women’s Health
H E A LT H M A I N T E N A N C E A N D S C R E E N I N G T O O L S
Pap Smear
Yearly beginning at age 18 or when sexually active
After three consecutive normal Paps in a healthy, low-risk female,
screening may be done every 2 to 3 years.
Mammography
Annually beginning at age 35 if there is family history of breast cancer
Annually beginning at age 40 for all others
241
Laboratory Testing
THYROID-STIMULATING HORMONE (TSH)
Test:
At age 65 and older, check every 3 to 5 years
Periodic screening (age 19 to 64) if strong family history of thyroid dis-
ease and if autoimmune disease
CHOLESTEROL
Test:
Every 5 years beginning at age 20
Every 3 to 5 years between ages 65 and 75
History of CAD
LIPIDS
Periodic screening if:
Elevated cholesterol
History of parent or sibling with blood cholesterol ≥ 240 mg/dL
History of sibling, parent, or grandparent with premature (< 55 years)
CAD
Diabetes mellitus (DM)
Smoker
Obese
FASTING GLUCOSE
Test:
Women’s Health
242
HIV Testing
Recommended for:
Women seeking treatment for STDs
History of prostitution/intravenous drug abuse
History of sex with an HIV+ partner
Women whose partners are bisexual
Women transfused between 1978 and 1985
Women in an area of high prevalence of HIV infection
Women with recurrent genital tract disease
Women < 50 years of age who have invasive cervical cancer
Women who are pregnant or planning to become pregnant
BACTERIURIA TESTING/URINALYSIS
Periodically for women with DM and women ≥ 65 years of age
During routine prenatal care
HIGH-YIELD FACTS
Immunizations
Tetanus–diphtheria booster once between 13 and 16 years
Tetanus–diphtheria booster every 10 years
Measles, mumps, rubella (MMR) for all nonimmune women
Hepatitis B vaccine for those not previously immunized
Varicella vaccine if not immune
Hepatitis A vaccine if at high risk
Influenza vaccine annually beginning at age 55
Give influenza vaccine prior to age 55 if:
Residents of chronic care facilities
Immunosuppression
Hemoglobinopathies
Women who will be in T2 or T3 during the endemic season
Women’s Health
Pneumococcal vaccine if 65 years of age or sooner if:
Sickle cell disease
Asplenia
Alcoholism/cirrhosis
Influenza vaccine risk factors
P R E V E N T I V E H E A LT H I N F O R M AT I O N
1. Puberty
2. Pregnancy
3. Menopause
243
2. Nutrition
3. Physical activity and exercise
GOALS
High-fat diets have adverse 1. Maintain a healthy diet consisting of small frequent meals (i.e., four to
effects on lipid metabolism, six instead of two to three):
insulin sensitivity, and body Utilize the Food Guide Pyramid as a tool in making food choices in
Alcohol
Women experience more accelerated and profound medical consequences of
excessive alcohol than men (a phenomenon called “telescoping”):
Cirrhosis
Peptic ulcers that require surgery
Alcohol: Myopathy
Accounts for 100,000
Cardiomyopathy
deaths per year in the When combined with cigarette smoking → oral and esophageal cancers
United States. Fetal alcohol syndrome:
Excessive use for women Teratogenic effects are dose related.
Women’s Health
is about one half the Includes growth retardation, facial anomalies, mental retardation
quantity considered
excessive for men.
When compared to men, Cigarettes
women have relatively Linked to lung cancer and CAD
reduced activity of Most common factor in chronic obstructive pulmonary disease
gastric alcohol Endocrine effects: Smokers reach menopause earlier and have increased
dehydrogenase to begin risk of osteoporosis.
alcohol metabolism and Obstetric effects: Reduced fertility, increased rates of spontaneous abor-
have less body water in tion, premature delivery, low-birth-weight infants, reduced head cir-
which to distribute cumferences
unmetabolized alcohol. Children who grow up exposed to secondhand smoke have higher rates
of respiratory and middle ear illness.
S E AT B E LT U S E
244
SAFER SEX PRACTICES
Improved and successful prevention of pregnancy and STDs by more adoles- Lung cancer is the most
cents requires counseling that includes: common cause of cancer
Encouragement to postpone sexual involvement
death in women.
Provision of information about contraceptive options, including emer-
gency contraception and side effects of various contraceptive methods Related to 400,000
deaths per year
HIGH-YIELD FACTS
Begins in the brain with perception of erotogenic stimuli via the special
States are higher than in
senses or through fantasy
any other developed
Arousal country.
Clitoris becomes erect.
Labia minora become engorged.
Blood flow in the vaginal vault triples.
Upper two thirds of the vagina dilate.
Lubricant is secreted from the vaginal surface.
Lower one third of vagina thickens and dilates.
Plateau
The formation of transudate (lubrication) in the vagina continues in
conjunction with genital congestion.
Occurs prior to orgasm
Women’s Health
Orgasm
Rhythmic, involuntary, vaginal smooth muscle and pelvic contractions
→ pleasurable cortical sensory phenomenon (“orgasm”)
It is normal for children <
6 years of age to be
Sexuality During Prenatal Through Childhood
curious about their own or
Resolution others’ bodies, and they
Sexual development begins prenatally when the fetus differentiates into may engage in observable
a male or female. sexual behaviors.
Sexual behavior, usually in the form of masturbation, is common in
childhood.
As children grow older, they are socialized into cultural emphases on
privacy and sexual inhibition in social situations.
Between ages 7 and 8, most children engage in childhood sexual games,
either same-gender or cross-gender play.
Unlike men, women have
no refractory period and
Adolescence can experience multiple
Gender identity and sexual preferences begin to solidify as puberty begins. orgasms without a time lag
in between.
245
Menstrual Cycle
The menstrual cycle can affect sexuality (i.e., in some women, there is a peak
in sexual activity in the midfollicular [postmenstrual] phase).
After somatosensory
stimulation, orgasm is an Pregnancy
adrenergic response. For some women, intercourse is avoided during pregnancy due to fear of harm-
ing the baby or a self-perception of unattractiveness.
Postpartum
Women often experience sexual problems within the first 6 months of
delivery.
Problems may include:
Perineal soreness
HIGH-YIELD FACTS
Excessive fatigue
Disinterest in sex
Menopause
A decrease in sexual activity is most frequently observed.
Hormonal Changes
Estrogen decrease → decreased vaginal lubrication, thinner and less elastic
vaginal lining
246
General Evaluation Strategies
Differentiate between the following possible etiologies:
Medical illnesses
Menopausal status
Medication use (antihypertensives, cardiovascular meds, antidepres- Sexual intercourse during
sants, etc.) pregnancy is NOT related to
bacterial vaginosis or
Rule out other psychiatric/psychological causes: preterm birth in normal,
Life content (stress, fatigue, relationship problems, traumatic sexual his- healthy pregnancies. But
tory, guilt) there are certain obstetrical
Major depression
conditions in which coitus
Drug abuse
should be avoided (i.e.,
Anxiety
Obsessive–compulsive disorder
placenta previa, abruptio
placentae, premature labor,
and premature rupture of
HIGH-YIELD FACTS
General Management Strategies membranes).
Medical illnesses need evaluation and specific treatment.
Screen for and treat depression with psychotherapy or medication.
Reduce dosages or change medications that may alter sexual interest
(i.e., switch to antidepressant formulations that have less of an impact
on sexual functioning such as bupropion [Wellbutrin] or nefazodone
[Serzone]).
or Little is known about how
Combine buspirone (Buspar), an antianxiety agent, with a selective being a new mother affects
serotonin reuptake inhibitor to counteract the sexual side effects. sexual desire and response.
Address menopause and hormonal deficiencies.
Women’s Health
Hypoactive sexual desire disorder—persistent or recurrent absence or
deficit of sexual fantasies and desire for sexual activity
Sexual aversion disorder—persistent or recurrent aversion to and Complaints of sexual
avoidance of genital contact with a sexual partner arousal disorder are
typically accompanied by
complaints of dyspareunia,
Sexual Arousal Disorder lack of lubrication, or
orgasmic difficulty.
Partial or total lack of physical response as indicated by lack of lubrica-
tion and vasocongestion of genitals
Persistent lack of subjective sense of sexual excitement and pleasure
during sex
MANAGEMENT
Treat decreased lubrication with KY Jelly or Astroglide.
Menopausal symptoms may respond to oral or topical estrogen. Lack of orgasm during
Sildenafil (Viagra) may be helpful. intercourse is considered a
Referral for psychosocial consultation or therapy if psychological issues normal variation of female
exist sexual response if the
woman is able to
experience orgasm with a
partner using other,
noncoital methods.
247
Orgasmic Disorder
Persistent delay or absence of orgasm
EVALUATION
Sildenafil citrate (Viagra)
Differentiate between the following:
and other vasodilators are
Take sexual experience into account—women often become more or-
currently undergoing gasmic with experience.
clinical trials with women Physical factors that may interfere with neurovascular pelvic dysfunc-
for sexual dysfunction tion (i.e., surgeries, illnesses, or injuries)
treatment. Psychological and interpersonal factors are very common (i.e., growing
up with messages that sex is shameful and men’s pleasure only).
Partner’s lack of sexual skills
MANAGEMENT
For lifelong, generalized orgasmic disorder, there is rarely a physical cause.
HIGH-YIELD FACTS
Evaluation
Differentiate between:
Physical disorder
Exogenous administration
Vaginismus
of estrogen improves
Lack of lubrication
vaginal lubrication, atrophic
conditions, hot flashes,
Women’s Health
Management
headaches, and insomnia.
If due to vaginal scarring/stenosis due to history of episiotomy or vagi-
nal surgery, vaginal stretching with dilators and massage
If postmenopausal, vaginal estrogen cream to improve vaginal pliability
Low-dose tricyclic antidepressants may be helpful.
Pelvic floor physical therapy (Kegel exercises)
Coital position changes
VAGINISMUS
Recurrent involuntary spasm of the outer third of the vagina (perineal and le-
vator ani muscles) interfering with or preventing coitus
Evaluation
Obtain history.
Rule out organic causes (i.e., vaginitis, endometriosis, pelvic inflamma-
tory disease, irritable bowel syndrome, urethral syndrome, interstitial
cystitis, etc.).
Examine the pelvis for involuntary spasm.
Rule out physical disorder or other psychiatric disorder.
248
Management
Treat organic causes.
Psychotherapy
Provide reassurance.
Physical therapy (i.e., Kegel exercises, muscle relaxation massage, and Menopause and sexual
gradual vaginal dilatation) (the woman controls the pace and duration) dysfunction:
Menopause → vaginal
atrophy and lack of
DOMESTIC VIOLENCE adequate lubrication →
painful intercourse →
Domestic violence refers to a relationship in which an individual is victimized decreased sexual desire
(physically, psychologically, or emotionally) by a current or past intimate or
romantic partner.
HIGH-YIELD FACTS
Injuries to the head, eyes, neck, torso, breasts, abdomen, and/or genitals
Bilateral or multiple injuries
Many antidepressants alter
A delay between the time of injury and the time at which treatment is
sought sexual response by
Inconsistencies between the patient’s explanation of the injuries and increasing the availability
the physician’s clinical findings of serotonin and decreasing
A history of repeated trauma dopamine.
The perpetrator may exhibit signs of control over the the health care
team, refusal to leave the patient’s side to allow private conversation,
and control of victim.
The patient calls or visits frequently for general somatic complaints.
In pregnant women: Late entry into prenatal care, missed appoint-
ments, and multiple repeated complaints are often seen in abused preg-
nant women.
Women’s Health
Estrogen improves overall
sense of well-being––
Assessment probably secondarily
improves sexual desire.
See Table 30-1.
Source: Nursing Research Consortium on Violence and Abuse, 1989. Reproduced, with permis-
sion, from Seltzer VL, Pearse WH. Women’s Primary Health Care, 2nd ed. New York: McGraw-
Hill, 2001: 659.
249
Reaction to Domestic Violence
Listen in a nonjudgmental fashion, and assure the patient that it is not
her fault, nor does she deserve the abuse.
Assess the safety of the patient and her children.
If the patient is ready to leave the abusive relationship, connect her
with resources such as shelters, police, public agencies, and counselors.
If the patient is not ready to leave, discuss a safety or exit plan and pro-
vide the patient with domestic violence information.
Carefully document all subjective and objective findings. The records
can be used in a legal case to establish abuse.
S E X U A L A S S A U LT
Sexual assault occurs when any sexual act is performed by one person on an-
HIGH-YIELD FACTS
Reorganization Phase
Phobias
Flashbacks
Nightmares
Gynecologic complaints
MANAGEMENT
Physician’s Medical Responsibilities
Obtain complete medical and gynecologic history.
Assess and treat physical injuries in the presence of a female chaperone
(even if the health care provider is female).
Obtain appropriate cultures.
Counsel patient and provide STD prophylaxis.
Provide preventive therapy for unwanted pregnancy.
Assess psychological and emotional status.
Provide crisis intervention.
Arrange for follow-up medical care and psychological counseling.
250
Physician’s Legal Responsibilities
Obtain informed consent for treatment, collection of evidence, taking
of photographs, and reporting of the incident to the authorities.
Accurately record events.
Accurately describe injuries.
Collect appropriate samples and clothing. In general, where the
Label photographs, clothing, and specimens with the patient’s name; performance of one duty
seal and store safely. conflicts with the other, the
preferences of the patient
TREATMENT prevail.
Infection Prophylaxis
Gonorrhea, chlamydia, and trichomonal infections:
Ceftriaxone 125 mg IM + azithromycin 1 g PO in a single dose
or
Doxycycline 100 mg PO bid for 7 days + metronidazole 2 g PO in a
single dose Sexual abuse occurs in
HIGH-YIELD FACTS
Offer the hepatitis B vaccine. approximately two thirds of
Administer tetanus–diphtheria toxoid when indicated. relationships involving
physical abuse.
Postcoital Regimen
Combined estrogen–progestin pills: Ovral (50 ug ethinyl estradiol, 0.5
mg norgestrel): 2 tabs PO STAT, then 2 more tabs 12 hours later:
75% effective
Mifepristone (RU 486): A single dose of 600 mg PO:
99.9% effective
Any injury during
pregnancy, especially one
to the abdomen or breasts,
ETHICS
is suspicious for abuse.
It is the physician’s responsibility to:
Women’s Health
Determine the patient’s preferences.
Honor the patient’s wishes when the patient can no longer speak for
herself.
251
Reproductive Issues
The ethical responsibility of the physician is:
To identify his or her own opinions on the issue at hand
To be honest and fair to their patients when they seek advice or services
The greatest risk of danger in this area
of spousal abuse is around To explain his or her personal views to the patient and how those views
a threat or attempt to leave may influence the service or advice being provided
the relationship.
Informed Consent
A legal doctrine that requires a physician to obtain consent for treatment ren-
dered, an operation performed, or many diagnostic procedures
1. Must be voluntary
2. Information:
Risks and benefits of the procedure are discussed.
Alternatives to procedure are discussed.
Consequences of not undergoing the procedure are discussed.
Physician must be willing to discuss the procedure and answer any
questions the patient has.
3. The patient must be competent.
Exceptions
The following are certain cases in which informed consent need not be ob-
tained:
Patient Confidentiality
The annual incidence of The information disclosed to a physician during his or her relationship with
sexual assault is 73 per the patient is confidential.
100,000 females.
The physician should not reveal information or communications without the
express consent of the patient, unless required to do so by law.
Exceptions
A patient threatens to inflict serious bodily harm to herself or another
person.
Communicable diseases
Seventy-five percent of Gunshot wounds
rape victims knew the Knife wounds
252
Where the law does not require otherwise, the physician should permit a com-
petent minor to consent to medical care and should not notify the parents
without the patient’s consent.
If the physician feels that without parental involvement and guidance the mi-
nor will face a serious health threat, and there is reason to believe that the
parents will be helpful, disclosing the problem to the parents is equally justi-
fied.
O F F I C E H E A LT H M A I N T E N A N C E T E S T S
HIGH-YIELD FACTS
≥ Age 18 (or before Pap Annually
if sexually active) Manual breast exams
CBC, BUN, creatinine, Periodically
hemoglobin
≥ Age 20 Cholesterol Every 5 years
≥ Age 40 Mammogram Annually
Fecal occult blood testing
Women’s Health
≥ Age 65 TSH Every 3–5 years
Cholesterol
Urinalysis Periodically
Pneumococcal vaccine Once
253