Increased risk of molar pregnancy in Asians

Recurrent risk of molar preg 1-2%; recurrent risk after two molar pregnancies 10%
Complete mole: empty egg with one sperm that duplicates or two sperm (49 XX or
XY); snowstorm appearance/multiple internal echoes; multiple hydropic villi; no
fetus; very high B-hcg; enlarged uterus; vaginal bleeding; tachycardia due to
hyperthyroidism (B-hcg); hypertension from preecmplasia; treat by suction
curettage; f/u 6 mo with negative B-hcg and birth control; if metastases to lungs or
vagina etc present, then do CT scan; associated with theca lutein cysts
Partial mole: egg+2 sperm; fetus, placenta/cord present; treat by suction curettage;
69XXX, XXY, XYY; lower risk of post molar GTD; villi swelling; f/u 6 mo with negative
B-hcg and birth control
Choriocarcinoma: diagnosis by quant B-hcg; do not biopsy b/c its vascular! Hx of
pregnancy/mole/miscarriage/termination
Discrepancy between dates and uterine size: pelvic U/S to confirm date
Do chest xray because lungs are most common site of gestational trophoblastic
disease

Vulvar lesion: BIOPSY!

Vulvar SCC: radical vulvectomy with node dissection; itchy, firm red ulcer lump;
smoking and HPV (warty like papules; pigmented brown)
VIN III: wide local excision
VIN II: lase ablation
Condyloma: trichloroacetic acid and iquimod
Lichen sclerosis: thin, inelastic and white with a crinkled tissue paper skin
Pagets: white plaque like lesion and erythema; itchy; fiery red mottled background
with whitish hyperkeratotic areas
Verrucous carcinoma: cauliflower lesion
Melanoma: pigmented
Bartholin gland: firm mass (malignancy)

Cervical Cancer: condyloma puts at really high risk b/c HPV has been acquired (low
6,11 and high 16,18,30s,45); due to exposure to high risk HPV
Risk factors: early sex, lots of sex partners; other STIs, age, tobacco, poor screening
hx
Post coital bleeding!
ASCUS: repeat at 12 months or HPV test
-

If HPV negative or repeat normal: routine screen at 3 yrs

HPV positive or repeat test reveals ASCUS or higher: colposcopy
Cervical mass/white plaque leukoplakia: biopsy
Most concerning finding on colposcopy: disorderly atypical vessels- great degree of
angiogenesis
Ectropion: columnar epithelium; not undergone squamous metaplasia red ring
around external os
Cannot visualize entire lesion esp endocervical: unsatisfactory coloposcopy; DO
CERVICAL CONIZATION
Cervical dysplasia: only in epithelial layer
CIS: entire epithelium
Cancer: cells invade beyond the basement membrane
High grade lesion that involves ENDOCERVIX: conization
Screening: 21 yrs start; 21-29 yr (every 3 yrs); 30-65 (HPV+pap every 5 yrs or pap
every 3 yrs)
-

Can stop at 65 if: no hx or moderate/severe dysplasia/cancer OR 3

negative pap tests in a row OR 2 negative cotests of HPV+pap within past
10 years
Same guidelines for those vaccinated

Fibroids: most common symptom is menorrhagia (heavy periods) due to bigger

uterus=more sloughing
Fibroids located below the fetus (lower uterine segment or cervix): soft tissue
dystocia; deliver by C-section
Miscarriages, lower pregnancy or implantation rate: SUBMUCOSAL fibroid

GnRH treatment only for 3-6 months before hysterectomy to shrink them by
inhibiting the HPO axis or if pt is close to menopause when estrogen effects will be
lost; only short term treatment; can cause menopause like symptoms such as hot
flashes
Estrogen stimulates fibroid growth
Asymptomatic, small fibroids: do not treat
Always rule out endometrial cancer through biopsy in late repro age pts esp if there
is menorrhagia/irregular bleeding
Young pt with infertility and fibroid: myomectomy

Endometrial CA risk factors: estrogen exposure (nulliparity, obesity, late

menopause, HRT, atypical hyperplasia); greatest risk factor (excluding atypical
hyperplasia) is obesity
No symptoms of endometrial CA (bleeding): just do regular annual exams
Vaginal bleeding: endometrial biopsy or D/C
Most common: breast, lung, colorectal; Gyn: uterine, ovarian, cervical
U/S with 5mm lining; endometrial sample with rare atypical cells: do D&C
Endometrial adenocarcinoma: do X-ray to look for metastasis
For CA, do abdominal hysterectomy + bilateral salpingo-oophorectomy and
lympahdectomy (pevlix and paraaortic)
Adnexal mass with endometrial hyperplasia/atypia/CA/vaginal bleeding: granulosa
cell tumor (release of estrogen; heterogenous mass with solid component)

Increased risk of ovarian cancer: family hx is greatest; othrs: nulliparity, early

menarche/late menopause, white race, increase age
OCPs: decrease risk of endometrial and ovarian CA (suppression of ovulation)
Affected individual with ovarian CA should be tested for BRCA mutation
No routine screening for ovarian CA
Functional ovarian cyst: due to normal ovulation; unilocular simple cyst
To check for involvement of peritoneal cavity or retroperitoneum: do CT scan

Ovarian CA prognosis: depends on Tumor Stage

Advanced ovarian CA: surgery + chemo
Dermoid: solid and cystic; all three germ layers

Depo: unpredictable bleeding; resolves in 2-3 months; most are amenorrhea; weight
gain
Unprotected sex: emergency contraception and then oral contraceptives
immediately
Contraindications to estrogen: DVT/VTE, over 35 and smoke, migraine with aura,
breast CA, lactating women
OCP: decrease risk of ovarian and endometrial CA; increased risk of cervical CA; old
ones increased risk of breast CA
Strongest predictor of regret after sterilization: age
Patch: high failure rates in overweight women (over 198 lbs)
Copper IUD: not for Wilsons disease or anemic pts

Septic abortion: fever, bleeding, dilated cervix; prompt uterine evacuation +

antibiotics
Threatened abortion: bleeding, closed cervix
Missed abortion: retention of nonviable IUP; expectant management with
misoprostol or D/C or manual vacuum aspiration
Ectopic: bleeding, abd pain, adnexal mass, closed cervix
Antiphospholipid Ab: recurrent preg loss 1 st trimester; anticardioplipin/lupus
anticoagulant/beta2 glycoprotein; prolonged Russell viper venom test; treat with
heparin + aspirin
Medical abortion (mifepristone and misoprostol): increased blood loss
Manual vacuum aspiration: less than 8 wks
Mifepristone kills; misoprostol pushes it out
Heavy bleeding after medical termination: do D/C b/c there are retained products of
conception

Bacterial vaginosis: thin, gray homogenous discharge with fishy odor; positive whiff
test with KOH; pH>4.5, no inflammation/erythema; clue cells on saline microscopy;
oral metronidazole or vaginal metronidazole
Trichomoniasis: protozoa trichomonas vaginalis; diffuse malodorous green-yellow
discharge; vulvar irritation; strawberry cervix-multiple petechiae;
erythema/inflammation of vagina; pH>4.5; saline microscopy shows motile trich;
oral metronidazole for pt and partner
Vulvovaginal candidiasis: candida albicans; itching, thick curdish white discharge;
erythema/inflammation of vagina; wet prep shows yeast or pseudohyphae; pH<4.5;
topical azole or oral azole
Lichen sclerosus: itching; white papules-thin and pale vulvar skin; vagina NOT
involved; introital stenosis, resorption of the clitoris; high dose steroids; risk of SCC
in area of LS
Lichen planus: involves hairy skin such as scalp, nails, oral mucous membranes,
vulva; lacy, reticulated pattern; itching/burning/bleeding; adhesions formation/loss
of normal architecture; high dose steroids
Lichen simplex chronicus: chronic itching and rubbing- damage skin; lichenificationincreased skin markings; vulvar redness and edema; high dose steroids and
antihistamines
Vestibulodynia: pain on vestibular touch or vaginal entry (tampons or sex); tx:
tricyclic antidepressants to block sympathetic afferent pain loops, pelvic floor rehab,
topical anesthetic, biofeedback
Mucopurulent cervicitis: yellow endocervical discharge; Chlamydia trachomatis or
Neisseria gonorrhea; culture or NAAT; C-azithromycin or doxycycline; G-ceftriazone
Vaginal estrogen: helps with urgency to pee

HSV: initial infection: cold like symptoms; prodrome of burning/irritation before

lesions; primary can cause dysuria requiring cath
Primary HSV: fever, headache, malaise, myalgia and then lesions
initial infection: cold like symptoms; prodrome of burning/irritation
before lesions; primary can cause dysuria requiring cath
Recurrent: shorter duration; less pain; fewer lesions; tx: acyclovir, famciclovir,
valacyclovir; shortens the course and decreases viral shedding

Syphilis
Primary: painless papule, ulcerates, chancre
Secondary: fever, malaise, headache, lymphadenopathy, rash (soles of
hands/feet), myalgia,
Anorexia, weight loss
Tertiary: gummas, neuro, aortitis
Hepatitis B: no vaccination or history of infection then give HBIG and HEP B VACCINE
PID: Chl or Gon; high fever (102), n/v, unstable
Inpatient treatment with IV Ab; IV cefotetan/cefoxitin+
doxycycline/clindamycin + gentamicin
Outpatient: cefotaxime/ceftizoxime + doxycycline +/- metronidazole
Salpingitis: Chl or Gon or ascending infection; usually polymicrobial; tenderness on
bimanual exam; fever, tenderness of uterus and adnexa; mucopurulent discharge;
can cause pelvic pain, hydrosalpinx, tubal scarring
Tuboovarian abscess: mass on U/S
Tubal disease: infertility
Acute cystitis: urinary frequency/urgency/hematuria; E coli; also Staph Saph, Kleb
Pneumo, Entero Fae, Proteus Mir

Urge incontinence: detrusor overactivity; parasympathetic releases Ach-contract by

muscarinic receptors; cystometrogram reveals uninhibited detrusor contractions;
Tx: oxybutynin-anticholinergic
Overflow: failure to empty the bladder; underactive detrusor
(neurologic/diabetes/MS) or obstruction; normal post void residual 50-60 cc
Stress incontinence: bladder pressure>urethral pressure; incontinence due to
increased intraabdominal pressure; urethral hypermobility >30 degrees; also due to
intrinsic sphincter deficiency
Retropubic urethropexy is best: tension free vag tape or sling procedure
Intrinsic sphincter deficiency: drainpipe urethra; urethral bulking
Pelvic organ prolapse: family history, increased parity/age, obesity, chronic
constipation; vaginal delivery

Cystocele repair by pubocercival fascia or reattaching to the sidewall/laterally/arcus

tendinous fascia (white line)
Asymptomatic prolapse: observe
Colpocleisis: closure of vagina for prolapse of anterior and posterior wall that causes
hydronephrosis
Initial treatment for prolapse: pessary
Interstitial cystitis: inflammation of bladder; urgency/frequency/nocturia;
dyspareunia

Endometriosis: dysmenorrhea, dyspareunia; adnexal tenderness; uterosacral

ligament nodularity; cul de sac tenderness; endometrioma in ovary as chocolate
complex cyst; endometrial glands outside the uterus; uterosacral nodularity; fixed
uterus
Confirm diagnosis: diagnostic laparoscopy
Infertility: ovarian stimulation with clomiphene citrate
Tx: OCP and NSAIDS; inhibits estrogen stimulation of endometrium (no
placebo pills to inhibit withdrawal bleed)
Gold standard: surgery with laparoscopic ablation/excision of implant or
definite total hys/BSO
Premenstrual dysphoric disorder: severe depression, irritability and tension before
menstruation
Hemorrhagic cyst: complex ovarian cyst; repeat U/S after 2 months
Ovarian torsion: sudden pain/nausea/vomiting; ovarian cyst on U/S; free fluid in
pelvis; surgical exploration (Doppler is controversial)

Irritable bowel syndrome: chronic abd pain; constipation/diarrhea; relief with

defecation; change in frequency of stool; change in stool form or appearance
Chronic pelvic pain disorder: possible abuse; new partner
TVUS: abdomino-pelvic symptoms, postmenopausal, FH of ovarian CA
Pelvic adhesive disease: chronic pelvic pain after a surgery

Pelvic congestion: due to pelvic varicosities (dilated vessels); pain worsened by

standing/fatigue/sex; pelvic fullness or heaviness
Ilioinguinal n: decreased sensation inguinal area and medial thigh
Obturator n: cant adduct thigh

Pagets disease: appearance of eczema

Fibroadenoma: firm, painless, mobile
Supernumerary nipple: nipple line; nontender
Clogged milk duct: breastfeeding woman;
White watery nipple discharge: get fasting prolactin level (also get TSH level and
then brain MRI)
Fibrocystic changes: cyclic mastalgia; caffeine can cause pain
Bloody discharge: excisional biopsy to rule out breast CA
Clear discharge on aspiration: reexamine in 2 months
Mastitis: redness and tenderness (might or might not have fever); ibuprofen and
continue breastfeeding and antibiotics (dicloxacillin for staph aureus)

LSIL/HSIL: colposcopy; HSIL: can also jump to LEEP

Cervical dysplasia (CIN) on biopsy: LEEP, cervical conization or cold knife cone
CIN I: Pap smear in 1 year?
LEEP complications: infection, bleeding, cervical stenosis, preterm delivery
Invasive cervical cancer IA-IIA: radical hysterectomy
ASCUS and HPV + or repeat 1 yr +: colposcopy
Pap + HPV after 30 yrs=every 5 yrs
Pap at 21 yrs old and stop at 65 (if 3 negative pap smears; 2 neg cotests in last 10
years + no hx of high grade CIN- still need annual bimanual and rectovaginal)
Colonoscopy at 50 and every 10 yrs
DEXA: risk factors for osteoporosis before age 65; or start at age 65

Mammogram: age 40; every year

Thelarche (breast buds), adrenarche/pubarche (hair growth), growth spurt and

menarche
Delayed puberty: after 16
Precocious puberty: age 8 (menarche); GnRH agonist to suppress pituitary
Turner: XO; no secondary sex char, short, shield chest; ovarian failure
Rokitansky-Kuster-Hauser: Mullerian agenesis (blind pouch vagina, no uterus, no
cervix); renal ultrasound due to renal anomalies
Kallmann syndrome: olfactory hypoplasia and no secretion of GnRH; delayed
puberty
Congenital adrenal hyperplasia: usually 21-hhydroxylase; no cortisol and salt
wasting (aldosterone); increased DHEA and DHEAS;
Imperforate hymen: amenorrhea, abdominal pain, bluish mass; normal breast and
hair development
Transverse vaginal septum: normal vaginal opening; short blind vagina; pelvic mass;
normal breast and hair development

Secondary amenorrhea: no periods for 6 months

Anorexia: HPO axis off; lack of pulsatile GnRH low FSH/LH- anovulation and
amenorrhea
Functional HPO amenorrhea (hypothalamic): weight loss, obesity, exercise, drugs,
neoplasia, psychogenic; check estrogen
PCOS: irregular cycle, obesity, hirsutism; Tx: OCP and weight loss and metformin;
increased risk of endometrial hyperplasia/CA; elevated LH and free testosterone;
low sex hormone binding globulin; increased LH/FSH ratio
Pregnancy: enlarged uterus with amenorrhea
Premature ovarian failure: amenorrhea, dyspareunia due to vaginal dryness (lack of
estrogen)
Ashermans syndrome: after D/C or endometritis; causes uterine adhesions and
trauma to basal layer of endometrium; amenorrhea

Adrenal tumor: elevated DHEAS; hirsutism; irregular menses

Cushings syndrome: hirsutism, obesity, irregular menses; striae on abdomen;
overnight dexamethasone suppression test
Acanthosis nigricans: get fasting insulin
Postpartum telogen effluvium: hair loss due to high estrogen
Sertoli Leydig tumor: hirsutism, acne, deep voice, missed periods, enlarged clit,
adnexal mass due to testosterone production; low FSH/LH; high testosterone
Sudden onset: think tumor
Endometrial polyp: can cause infertility; lots of bleeding; hysteroscopic polypectomy
vs observation vs medical management with progestin vs curettage
Irregular bleeding and obesity: get endometrial biopsy
Intermenstrual bleeding: structural abnormality in endometrial cavity like
myoma/polyp/cancer; get pelvic U/S
Fibroids: bleeding; seen on U/S; myomectomy (if submucosal use hysteroscopy; if
serosal use laparoscopic)
Adenomyosis: menstrual pain; heavy flow; soft, boggy uterus; endometrial tissue
trapped in myometrium; definite treatment is hysterectomy
Over 40 with irregular bleeding: endometrial carcinoma

Menopause: hot flashes, vaginal dryness;

Contraindication to hormone therapy: vaginal bleeding (could be endometrial
CA); lowest dose for shortest time (most effective treatment); increases risk
of breast CA, CVA, VTE, endometrial CA if estrogen only
Most effective treatment for hot flashes: estrogen; HRT causes HDL up and
LDL down and triglyceride up
Osteoporosis: vit D, calcium, bisphosphonates; risk factors: fracture, low
weight, smoker
Bone mineral density repeated at 2 years by DEXA
Estrogen post menopausal is from peripheral conversion only

Perimenopause: loss of periods and some symptoms of menopause

Premature ovarian failure: less than 40 yrs old

Infertility: unable to conceive within 12 months

Tubal disease: hx of pelvic infection; hysterosalpingogram; infertility
PCOS: ovulation induction agents
Clomphine challenge test: give clomiphene and check FSH; helps determine ovarian
reserve and ovulation induction

Premenstrual dysphoric disorder: severe; last week of luteal phase; interference

with social function; Tx: SSRI
Premenstrual syndrome: symptoms the week before menstrual cycle like mood
swings; Tx: exercise and Vit A, E, B6, OCPs, SSRI (fluoxetine); risk factor family
history
Get prospective symptom calendar

Elective C-section at 39 weeks

Postpartum depression: over 2 weeks; crying, loss of appetite, sleeping difficulty,
low self worth; most important risk factor is hx of depression
Postpartum blues: less than 2 weeks

Anemia: hemodilutional (normal MCV); iron deficiency and thalassemia (low MCV);
folate deficiency (macrocytic)
Physiologic dyspnea of pregnancy: short of breath with normal physical exam
Pulmonary emboli: tachycardia, tachypnea, hypoxia, chest pain, signs of DVT
Mitral stenosis: strep infection- rheumatic heart disease; diastolic murmur; heart
failure signs
Peripartum cardiomyopathy: heart failure due to decreased LV systolic function
towards end of pregnancy; fatigue, SOB, palpitations, edema

Respiratory alkalosis in pregnancy: increased minute ventilation- increased PO2,

decreased PCO2, compensate with decrease Bicarb
Normal: increased inspiratory capacity, tidal volume, minute ventilation; decreased
functional reserve capacity, expiratory reserve capacity and residual volume
Pulmonary edema: due to tocolytic use, fluid overload, preeclampsia, cardiac
disease
SVR and plasma osmolality decreased in pregnancy
CO increases in pregnancy first b/c of stroke volume and then heart rate
Right ureter dilation>left; due to progesterone smooth muscle relaxation and
compression by uterus- mild hydronephrosis
Thyroid binding globulin increases which causes increased in total T4 and T3; free
T4 and T3 remain unchanged
Poorly controlled diabetes: cardiac malformation
Trisomy 21: best test: cell free DNA screen
Most common inherited mental retardation: fragile X
Preexisting diabetes: IUGR (not in gestational diabetes)

Braxton hicks: low abdomen and groin; irregular; short; less intense; no cervical
change
No GBS culture if 1) GBS bacterinuria in current pregnancy or 2) previous pregnancy
with GBS neonate
Otherwise do a rectovaginal culture at 35-37 weks for all women; if + then treat at
labor
Confirm fetal heart rate before epidural (if external monitoring is not working well,
put in fetal scalp electrode)

Down syndrome: fat nasal bridge, small size and rotated ears, sandal gap toes,
hypotonia, protruding tongue, epicathanic foolds, palpebral fissure oblique
Turner: wide spaced nipples and lymphedema
Meconium stained amniotic fluid: intubate trachea, suction meconium beneath
glottis if infant is depressed; if strong newborn then no need for tracheal suctioning

Type 1 diabetes: small and hypoglycemic baby

Gestational diabetes: large and hypoglycemic baby; polycythemia,
hyperbilirubinemia
Chorioamnionitis: fever and tachycardia in mom; tachycardia in baby with minimal
variability; baby will be lethargic, pale and high temperature b/c of sepsis
Twin-twin transfusion: large, plethoric, polycythemic twin A (heart failure,
polyhydramnios, fluid overload, hydrops) and small, pale twin B (IUGR,
oligohydramnios)
Infant with no respiratory effort: positive pressure ventilation + prepare to intubate
HIV+ mom: treat baby with AZT immediately after delivery

Increased rate of infection: prolonged labor/ROM, multiple vaginal exams, internal

fetal monitoring, remove placenta manually, low socioeconomic
Endometritis: postpartum fever; and risk factors listed above; uterine tenderness
(other causes of fever: UTI, lower genital tract infxn, wound infxn, pulm,
thrombophlebitis, mastitis); due to anaerobic and aerobic bacteria of genital tract
(mostly Staph aureus and strep)

Lactation suppression: breast binding, ice packs, analgesics

Breastfeeding: exclusive for 6 mo atleast; decreased risk of ovarian CA; decreased
GI infxn in baby b/c of IgA
Mastitis: strep bacteria from babys mouth; fever, erythema, tenderness; antibiotics
and feed more
Withdrawal of estrogen and progesterone allows breast milk to come in
Engorgement: tenderness; frequent nursing, warm compress, massage breast, good
support bra, analgesic
Suckling stimulates milk ejection by oxytocin

Abnormal pregnancy but intrauterine: expectant management

Unsure if ectopic: repeat Bhcg in 48 hrs
Methotrexate: if pt stable, nonrupture ectopic, <3.5cm ectopic, no heart tones

Spontaneous abortion: active bleeding, anemic, unstable do D/C

Incompetent cervix: cerclage at 14 weeks
Diabetes screening between 24-28 wks unless have risk factors like being fat or
family history should be screened asap

If Mag toxicity, low respiratory rate then give calcium gluconate

Asymmetric IUGR: uteroplacental insufficiency (some form of systemic disease like
hypertension)
Symmetric IUGR: infection, aneuploidy/chromosomal abnormality