TOPNOTCH Ob-Gyne Supplement Handout by Joan Cabanting and Nina Banzuela - UPDATED DECEMBER 2017 PDF

TOPNOTCH MEDICAL BOARD PREP OB SUPPLEMENT HANDOUT BY THE TOPNOTCH TEAM
For inquiries visit www.topnotchboardprep.com.ph or https://web.facebook.com/topnotchmedicalboardprep

Structure
OBSTETRICS SUPPLEMENT HANDOUT Mons Pubis escutheon
Labia Majora 7-8x2-3x1-1.5cm
TABLE OF CONTENTS round ligaments terminate at their upper
Maternal Anatomy 1 borders
Events Post-conception 6 Labia Minora connective tissue with many vessels, elastin
Placenta 7 fibers, and some smooth muscle fibers
Fetal Development 8
Fetal Imaging 10 Clitoris points downward and inward toward the
Breech 11 vaginal opening; rarely exceeds 2 cm
Postpartum Changes 13 Vestibule functionally mature female structure
Guidelines for Cesarean Section 15 derived from the embryonic urogenital
Other Important Obstetric Information 16 membrane
Urinary Tract Infection in Pregnancy 19 perforated by six openings: urethra, the
Other Important Gynecologic Concepts 21 vagina, two Bartholin gland ducts, and two
Family Planning 24 ducts of the Skene glands
Vestibular Glands Bartholin glands, paraurethral glands
(Skene glands→ diverticulum) minor
MATERNAL ANATOMY vestibular glands
Urethral opening lower two thirds of the urethra lie
EXTERNAL GENITALIA immediately above the anterior vaginal
wall.
EMBRYOLOGIC MALE FEMALE 1 to 1.5 cm below the pubic arch
STRUCTURES Vestibular bulbs lie beneath the bulbocavernosus muscle on
LABIOSCROTAL Scrotum Labia Majora either side of the vestibule
SWELLING vulvar hematoma.
UROGENITAL FOLDS Ventral portion Labia Minora Vaginal Hymenal caruncles
of the penis opening/hymen Impreforate hymen
PHALLUS (GENITAL Penis Clitoris
TUBERCLE) DIFFERENCE OF LABIA MAJORA AND LABIA MINORA
UROGENITAL SINUS Urinary bladder Urinary bladder LABIA MAJORA LABIA MINORA
Prostate gland Urethral and HOMOLOGY Scrotum Ventral portion of
Paraurethral the penis
glands Skin of the penis
Prostatic Utricle Vagina LINING Outer- KSSE NKSSE
Bulbourethral Greater EPITHELIUM Inner- NKSSE
glands vestibular glands NULLIPAROUS Lie in close Not visible behind
Seminal Hymen WOMEN apposition the non separated
colliculus Inner surface labia majora
PARAMESONEPHRIC Appendix of Hydatid of resembles the
DUCT testes Morgagni mucous membrane
Uterus and MULTIPAROUS Gape widely Project beyond the
Cervix WOMEN Inner surface labia majora
Fallopian Tubes become skin like
Upper ¼ of the GLANDS (+) Hairfollicles No hair follicles
vagina (+) Sweat glands No sweat glands
(+) Sebaceous (+) Sebaceous
EMBRYOLOGIC MALE FEMALE glands glands
STRUCTURE
MESONEPHRIC DUCT Appendix of Appendix of VESTIBULE
epidydymis vesiculosis • Functionally mature female structure of the urogenital
Ductus of Duct of sinus of the embryo. Extends from clitoris to forchette
epididymis epoophoron
Ductus deferens Gartner’s Duct STRUCTURES IN THE VESTIBULE
Ejaculatory duct HYMEN ▪ Non keratinized Stratified squamous
Seminal Vesicle epithelium
METANEPHRIC DUCT Ureter ▪ During first coitus, first that ruptures is
URETERIC BUD Renal Pelvis usually at the 6 o’clock position
Calyces ▪ Caruncle Myrtiformes: Remnants of hymen
Collecting system in adult female
METANEPHRIC Glomerulus GLANDULAR Periurethral Glands “ Skene’s Glands”
MESENCHYME Renal Collecting Tubules STRUCTURES Vulvovaginal Glands “Bartholin’s Glands”
UNDIFFERENTIATED Testes Ovary 6 OPENINGS: ▪ Vaginal introitus
GONAD ▪ Urethral opening
CORTEX Seminiferous Ovarian Follicles ▪ Paired Para urethral glands opening
tubules ▪ Paired Bartholin ducts opening
MEDULLA Rete Testis Rete Ovarii
GUBERNACULUM Gubernaculum Round ligament
testis of uterus
VULVA (PUDENDA)
• External structues from the symphysis pubis to the
perineal body
• Includes mons pubis, labia majora and minora,
TOPNOTCH MEDICAL BOARD PREP OBSTETRICS HANDOUT BY THE TOPNOTCH TEAM Page 1 of 27
GLANDULAR STRUCTURES
Boundary Landmark
PERIURETHRAL VULVOVAGINAL
GLANDS GLANDS Anterior pubic symphysis
“ Skene’s glands” “Bartholin’s glands”
Other name Lesser vestibular Greater vestibular glands Anterolateral ischiopubic rami and ischial tuberosities
glands
Male Prostate Bulbourethral gland Posterolateral sacrotuberous ligaments
homology posterior coccyx
Type of Tubulo alveolar Compound alveolar/
gland compound acinar
Location Adjacent to the 4 and 8 o clock of the Triangle
urethra vagina
Pathology Urethral Bartholins’s cyst/ Anterior Urogenital triangle
diverticulum abscess → Superficial Boundaries:
and deep Superrior- pubic rami
Lateral-ischial tuberosities
Posterior: superficial transverse perineal
muscle
Posterior Anal triangle

ischiorectal fossa, anal canal, anal sphincter
complex, and branches of the internal
pudendal vessels and pudendal nerve
Urogenital (Anterior) Triangle: SUPERFICIAL SPACE

Anterior Triangle (SUPERFICIAL SPACE)
closed bounded deeply by the perineal

compartment membrane and superficially by Colles
fascia
ischiocavernosus, bulbocavernosus, and
superficial transverse perineal muscles;
Bartholin glands; vestibular bulbs; clitoral
body and crura; and branches of the
pudendal vessels and nerve
ischiocavernosus clitoral erection

muscle
bulbocavernosus Bartholin gland secretion

muscles Clitoral erection
superficial may be attenuated or even absent

transverse perineal Contributes to the perineal body
muscles
Urogenital (Anterior) Triangle: DEEP SPACE

Anterior Triangle (DEEP SPACE)
Continuous lies deep to the perineal membrane and

space with extends up into the pelvis
PERINEUM the pelvis Contents: compressor urethrae and
urethrovaginal sphincter muscles, external
urethral sphincter, parts of urethra and vagina,
branches of the internal pudendal artery, and
the dorsal nerve and vein of the clitoris
Ishorectal wedge-shaped spaces found on either side of

fossae the anal canal and comprise the bulk of the
posterior triangle
Continuous space
PUDENDAL NERVE AND VESSELS

Roots Anterior rami of the 2nd to 4th sacral nerve
Course between the piriformis and coccygeus

muscles and exits through the greater sciatic
Clinical Significance foramen in a location posteromedial to the
ischial spine
→ obturator internus muscle → pudendal
canal (Alcock Canal) → enter the perineum
and divides into three terminal branches
Terminal Branches:
dorsal nerve of skin of the clitoris

the clitoris
perineal nerve muscles of the anterior triangle and labial

skin
inferior rectal external anal sphincter, the mucous

membrane of the anal canal, and the perianal
skin
Landmark for Ischial spine

pudendal nerve
block
• Upper vaginal vaults
Blood Supply internal pudendal artery – Subdivided into anterior, posterior, and two lateral
fornices by the uterine cervix
• Internal pelvic organs usually can be palpated through their
VAGINA
thin walls
• H-shaped • Posterior fornix provides surgical access to the peritoneal
• lower portion of the vagina is constricted (urogenital hiatus cavity
in the levator ani)
• Stratified squamous non keratinized epithelium without
glands
• Upper part is more capacious
• It extends from the vulva to the cervix.
• Ruggae that has an accordion like distensability
• Vaginal length:
– Anterior wall: 6-8 cm
– Posterior wall: 7-10 cm
• Potential space: Lower third
CERVIX
ENDOCERVIX EXOCERVIX
Supravaginal portion Portio vaginalis
Extends from the isthmus (Internal Extends from the
Os) to the ectocervix and contains the squamo columnar
endocervical canal junction to the external
orifice
Single layer of mucous secreting Non keratinized
highly ciliated columnar epithelium stratified squamous
which is thrown into folds forming epithelium
complex glands and crypts Hormone Sensitive
Extensive amount of nerves Few nerves only
Blood supply: Cervicovaginal branch of uterine artery located at
the lateral walls
Cervix: SQUAMO-COLUMNAR JUNCTION
• Vesicovaginal septum
– Separates the vagina from the bladder and urethra
• Rectovaginal septum
– Separates the lower portion of the vagina from the
rectum
• Rectouterine pouch of Douglas
– Separates the upper fourth of the vagina from the
rectum
• Prepubertal women
o Original SCJ at or near the exocervix FALLOPIAN TUBES
• Reproductive Age women • single layer of columnar cells, some of them ciliated and
o Eversion of endocervical epithelium and exposure of others secretory.
columnar cells to the vaginal environment • No submucosa
o Relocation of SJC down the Exocervix • supplied richly with elastic tissue, blood vessels, and
• Late adulthood / Post menopausal women lymphatics
o SCJ at the endocervical canal • Sympathetic innervation
o Formation of transformation zone with regrowth of • Diverticula
the squamous epithelium
SEGMENTS OF THE FALLOPIAN TUBE
UTERUS Intramural Embodied within 2% of ectopic pregnancy
Interstitial the muscular Ectopic pregnancy at this
SIZE Nulliparous: 6 to 8 cm (fundus=cervix) , 50-70 g wall of the uterus area result in severe
multiparous: 10 cm (cervix 1/3), 80 g or more maternal morbidity
Isthmus The narrow Most highly developed
Isthmus Lower uterine portion portion of the musculature
tube that adjoins Narrowest portion
Fallopian Attaches at the cornua the uterus, Preferred portion for
tubes passes gradually applying clips for female
into the wider, sterilization
Posterior Completely covered by visceral peritoneum
lateral portion. Preferred portion for tubal
wall
ligation
Anterior wall Only upper portion with peritonem → 12% of ectopic pregnancy
vesicouterine pouch Ampulla Widest and most Site of fertilization
tortuous area 80% of ectopic pregnancy
Infundibulum Fimbriated 5% of ectopic pregnancy
ENDOMETRIUM STRATUM FUNCTIONALE Zona extremity
• Shed during Spongiosa Tunnel shaped
menstruation Zona opening of the
• Supplied by the Spiral compacta distal end of the
Arteries fallopian tube
• Superficial 2/3
STRATUM BASALE OVARIES
• Source of Stratum • Lies on the posterior aspect of the broad ligament, in the
Functionale after ovarian fossa
menstruation o lateral to the uterus in the pelvic sidewall where the
• Supplied by the Straight common iliac artery bifurcates
arteries o ovarian fossa of Waldeyer
• Basal 1/3
• Are attached to the broad ligament by the mesovarium.
• lympathics
• They are not covered by peritoneum.
MYOMETRIUM Inner Longitudinal
Middle oblique Ovaries: LAYERS
Outer longitudinal OUTER Innermost ▪ Primordial and Graafian follicles
SEROSA lymphatics CORTEX portion in various stages of
development
LIGAMENTS OF THE UTERUS Outermost ▪ Tunica Albuginea- dull and
Broad • Two wing-like structure that extend from portion whitish fibrous connective
ligament the lateral margins of the uterus to the pelvic tissue covering the surface of
walls the ovary
• Divide the pelvic cavity into anterior and ▪ Germinal epithelium of
posterior compartments Waldeyer- a single layer of
Reproductive Fallopian tubes cuboidal epithelium over the
structures ovaries Tunica Albuginea
Vessels: Ovarian arteries INNER ▪ Composed of loose connective tissue that is
Uterine arteries MEDULLA continuous with that of the mesovarium.
Ligaments: Ovarian ligament ▪ Smooth muscle fibers that are continuous with
Round ligament of uterus those in the suspensory ligament.
Cardinal • AKA Transverse Cervical Ligament or ▪ Contains the stroma and blood vessels of the
ligament Mackenrodt Ligament ovary
• Originated form the densest portion of the
broad ligament PELVIS
• Medially united to the supravaginal wall of
the cervix Pelvic Organs: BLOOD SUPPLY
• Provide the major support of the uterus and MAJOR BLOOD SUPPLY TO THE FEMALE REPRODUCTIVE
cervix SYSTEM
• Maintain the anatomic position of the cervix Pudenda Internal Pudendal artery
and upper part of the vagina Vagina Vaginal Artery of the Uterine
Uterosacral • From posterolateral to the supravaginal Artery
ligament portion of the cervix encircling the rectum Cervix Cervicovaginal branch of
• Insert into the fascia over S2 and S3 Uterine artery
Round • Extend from the lateral portion of the uterus, Uterus Uterine Artery
Ligament arising below and anterior to origin of the Fallopian tubes Ovarian Artery
oviducts, that is continuous with the broad Ovaries
ligament, outward and downward to the
inguinal canal terminating at upper PARTICIPANTS IN THE COLLATERAL CIRCULATION OF THE
portion of labium majus
FEMALE PELVIS FREQUENCY 50% 20% 25% 5% rarest
Branches from the ▪ Ovarian artery Vertically
INLET Heart Horizontally
Aorta ▪ Inferior mesenteric Round oriented
SHAPE Shaped oriented oval
▪ Lumbar and vertebral oval
▪ Middle sacral arteries Divergent,
Converge
Branches from the ▪ Deep iliac circumflex SIDEWALLS Straight Convergent then
nt
External Iliac Artery ▪ Inferior epigastric artery convergent
Branches from the ▪ Medial femoral circumflex artery Non
ISCHIAL Promine Non
Femoral Artery ▪ Lateral femoral circumflex artery promin Prominent
SPINES nt prominent
ent
Forward
False ANT: lower abdomen Inclined
and Straight =
neither
POST: lumbar vertebra straight pelvis Well curved
anterior
SACRUM with deeper than and rotated
ly nor
LATERAL: iliac fossa little other 3 backward
posterio
curvatur types
L INEA TERMINALIS rly
e
Increase
True SUPERIOR BOUNDARY: Pelvic inlet
d
INFERIOR BOUNDARY: Pelvic outlet incidence
of Deep Increased
ANTERIOR: Pubic Bones, Ascending Rami Of Ischial Transver incidence of
Good
Bones, Obturator Foramina se Arrest Face Poor
prognos
SIGNIFICAN Limited Delivery prognosis for
LATERAL: Ischial Bones and Sacrosciatic Notch is for
CE posterior Good vaginal
vaginal
space for prognosis delivery
delivery
fetal for vaginal
head, delivery
poor
prognosi
s
EMBRYOLOGIC STRUCTURES AND DERIVATIVES
EMBRYOLOGIC MALE FEMALE

STRUCTURES
LABIOSCROTAL Scrotum Labia Majora
SWELLING
UROGENITAL FOLDS Ventral portion Labia Minora
of the penis
PHALLUS (GENITAL Penis Clitoris
TUBERCLE)
UROGENITAL SINUS Urinary bladder Urinary bladder
Prostate gland Urethral and
PELVIC JOINTS Paraurethral
• Anterior: symphysis pubis/arcuate ligament of the pubis glands
• Posterior: sacroiliac Prostatic Utricle Vagina
• Hormonal changes during pregnancy cause laxity of these
Bulbourethral Greater
joints
glands vestibular glands
• By 3-5 months POST PARTUM, laxity has regressed
Seminal Hymen
• Symphysis Pubis increase in width also Increase mobility
colliculus
and displacement of the sacroiliac joint
PARAMESONEPHRIC Appendix of Hydatid of
DUCT testes Morgagni
WHY THE DORSAL LITHOTOMY POSITION?
• Upward gliding of sacroiliac joint is GREATEST in the Uterus and
DORSAL LITHOTOMY POSITION Cervix
• Outlet increase by 1.5 -2.0 cm Fallopian Tubes
Upper ¼ of the
vagina
MESONEPHRIC DUCT Appendix of Appendix of

epidydymis vesiculosis
Ductus of Duct of
epididymis epoophoron
Ductus deferens Gartner’s Duct
Ejaculatory duct
Seminal Vesicle
METANEPHRIC DUCT Ureter
URETERIC BUD Renal Pelvis
Calyces
Collecting system
METANEPHRIC Glomerulus
MESENCHYME Renal Collecting Tubules
PELVIC TENDENCY AND TYPE
• Anterior – dictates the tendency of the pelvis UNDIFFERENTIATED Testes Ovary
• Posterior – dictates the type or character of the pelvis GONAD
GYNE- ANDROI ANTHROP PLATY- CORTEX Seminiferous Ovarian Follicles
COID D OID PELLOID tubules
MEDULLA Rete Testis Rete Ovarii
GUBERNACULUM Gubernaculum Round ligament DERIVATIVES
testis of uterus LAYER DERIVATIVES
Ectoderm CNS and PNS
Sensory organs of seeing and hearing
EVENTS POST-CONCEPTION Integument layer
Endoderm Lining of the GIR and Respiratory tract
POST CONCEPTION: WEEK 1 Mesoderm Muscles
1. Cleavage Cartilages
2. Blastocyst formation CVS
3. Implantation Urogenital System
RBC
EMBRYONIC PERIOD
Order of Formation
CNS First to develop and continues post natal
Heart Completed by 8 weeks
Upper limb Completed by 8 weeks
Lower limb Completed by 8 weeks
External genitalia Completed by 9 weeks
PERIOD OF TERATOGENICITY
CLEAVAGE
• Zygote cytoplasm is successively cleaved to form a blastula,
which consists of increasing smaller blastomeres
• At 32 -cell stage, the blastomeres form a morula, which
consists of an inner cell mass and outer cell mass
• The morula enters the uterine cavity at about 3 days post
conception
BLASTOCYST FORMATION DRUGS IN PREGNANCY

• Occurs when fluid secreted within the morula forms the
blastocyst cavity Category Examples
• Inner cell mass – future embryo, is now called the Adequate and well-controlled human studies
Embryoblast have failed to demonstrate a risk to the fetus
A Folic acid
• The outer cell mass – future placenta, is now called the in the first trimester of pregnancy (and there
Trophoblast is no evidence of risk in later trimesters).
Animal reproduction studies have failed to
IMPLANTATION demonstrate a risk to the fetus and there are
• Blastocyst implants at around 7 days post conception no adequate and well-controlled studies in
Paracetamol,
within the posterior superior wall of the uterus pregnant women OR Animal studies have
B amoxicillin,
• This is during the secretory phase of the menstrual cycle, so shown an adverse effect, but adequate and
cephalexin,
implantation occurs within the functional layer of well-controlled studies in pregnant women
endometrium. have failed to demonstrate a risk to the fetus
in any trimester.
POST CONCEPTION: WEEK 2 Animal reproduction studies have shown an
EMBRYOBLAST adverse effect on the fetus and there are no
• Differentiates into two distinct cell layers, the Epiblast and adequate and well-controlled studies in
C paroxetine
Hypoblast, forming a Bilaminar Embryonic Disk humans, but potential benefits may warrant
o Epiblast -clefts develop within the Epiblast to form the use of the drug in pregnant women despite
amniotic cavity potential risks.
o Hypoblast -form the yolk sac There is positive evidence of human fetal risk
based on adverse reaction data from
TROPHOBLAST Phenytoin,
investigational or marketing experience or
• Cytotrophoblast divide mitotically D tetracyclne,
studies in humans, but potential benefits may
aspirin,
• Syncytiotrophoblast warrant use of the drug in pregnant women
o Does not divide mitotically despite potential risks.
o Produces the HCG Studies in animals or humans have
o Continues its growth into the endometrium to make demonstrated fetal abnormalities and/or
contact with the endometrial blood vessels there is positive evidence of human fetal risk
based on adverse reaction data from Thalidomide,
EMBRYO PERIOD: WEEK 3-8 X
investigational or marketing experience, and isotretinoin
• The beginning of the development of major organ systems the risks involved in use of the drug in
• Coincides with the first missed menstrual period pregnant women clearly outweigh potential
• Period of high susceptibility to teratogen benefits.
• Gastrulation is a process that establishes the 3 primary
germ layers, forming a trilaminar embryonic disk
o Ectoderm PLACENTA
o Endoderm FETAL TO MATERNAL MEMBRANES
o Mesoderm • Amnion
o Avascular; provides tensile strenght; first identifiable
at 7th to 8th day of life; from fetal ectoderm PLACENTAL STEROID HORMONES
• Chorion Steroid Nonpregnant Pregnant
• Decidua parietalis (endometrium) Estradiol-17 0.1–0.6 15–20
• Myometrium Estriol 0.02–0.1 50–150
• Serosa
Progesterone 0.1–40 250–600
AMNIOTIC FLUID Aldosterone 0.05–0.1 0.250–0.600
• Normal amniotic fluid volume Deoxycorticosterone 0.05–0.5 1–12
o By 12 weeks = 60ml Cortisol 10–30 10–20
o By 34-36 weeks = 1L
o By term = 840 ml hCG
o By 42 weeks = 540 ml • Almost exclusively produced by the placenta
• Production of amniotic fluid • Glycoprotein
o Initially by amniotic epithelium • Alpha and beta subunit
o Fetal kidneys and urine production • Functions: rescue and maintenance of function of the
*Amniotic fluid volume is also dependent on the extent of corpus luteum, stimulates fetal testicular testosterone
maternal plasma expansion secretion, materanl thyroid gland stimulation (chorionic
• Removal and regulation of amniotic fluid volume thyrotropins), promotion of relaxin secretion
o Fetal swallowing • detectable in plasma of pregnant women 7 to 9 days after
o Fetal aspiration the midcycle surge of LH that precedes ovulation.
o Exchange through skin and fetal membranes • Plasma levels increase rapidly, doubling every 2 days, with
maximal levels being attained at 8 to 10 weeks
THE PLACENTA AT TERM • At 10 to 12 weeks, plasma levels begin to decline, and a
• Volume 497 Ml nadir is reached by about 16 weeks
• Weight 508 grams (450-500 grams) • Clearance: mainly hepatic, renal (30%)
• Surfaces
o Fetal hPL
▪ Covered with amniotic membrane giving it • Similar to hGH
white, glistening appearance • detected in maternal serum as early as 3 weeks
▪ Where the umbilical cord arises
• Maternal plasma concentrations are linked to placental
o Maternal
mass, and they rise steadily until 34 to 36 weeks
▪ Attached to the decidua
• production rate near term: approximately 1 g/day
▪ Deep, bloody appearance arranged into 15-20
• Functions: Maternal lipolysis , anti-insulin or
irregular lobes, cotyledons
"diabetogenic”, potent angiogenic
• Hofbauer cells
PROGESTERONE
• Source:
Circulation in the Mature Placenta
o First 6-7 weeks of pregnancy: Corpus luteum (ovary)
o After 8 weeks: Placenta (Syncytiotrophoblast)
• Function:
o Affects tubal motility, the endometrium, uterine
vasculature, and parturition
o Inhibits T lymphocyte–mediated tissue rejection
• Preferred precursor of progesterone biosynthesis by the
Trophoblast: Maternal plasma LDL cholesterol
ESTROGEN
• Pregnancy near term is hyperestrogenic
• Produced exclusively by Syncytiotrophoblasts
• Placenta produce all types of estrogen
ESTROGEN SOURCE
• Fetal surface covered by amnion beneath which the fetal
Estradiol Maternal ovaries for weeks 1 through 6 of
chorionic vessels course chorionic villi →intervillous space
gestation
→decidual plate → myometrium
After T1, the placenta is the major source of
circulating estradiol.
FUNIS
Estrone Maternal ovaries, adrenals, and peripheral
• Umbilcal cord
conversion in the first 4 to
• Two artery, one vein (left or right?)
6 weeks of pregnancy
• Ave lenght: 55 cm
The placenta subsequently secretes increasing
• Wharton jelly- extracellular matrix of specialized connective
quantities
tissue
Estriol Produced almost exclusively by the placental
• Anticlockwise spiral is present in 50 to 90 percent of
syncytiotrophoblast
fetuses
Continued production depends on the living fetus
Marker of fetal well being
PLACENTAL HORMONES
• Trophoblast
• Steroid hormones
• hPL, hCG, parathyroid hormone–related protein (PTH-rP),
calcitonin, relaxin, inhibins, activins, and atrial natriuretic
peptide
• hypothalamic-like releasing and inhibiting hormones:
thyrotropin-releasing hormone (TRH), gonadotropin-
releasing hormone (GnRH), corticotropin-releasing
hormone (CRH), somatostatin, and growth hormone–
releasing hormone (GHRH).
Embryonic Commences beginning of the 3rd week after

period ovulation and fertilization and lasts up to 8 weeks
AOG
8 weeks period from the time of fertilization
10 weeks period from the time of the last
menstrual cycle/Ovulation
Abortus Fetus or embryo removed or expelled fro uterus

during the first half of gestation
20 weeks or less, or in the absence of accurate
dating criteria, born weighing less than 500 grams
GESTATIONAL AGE vs. OVULATION AGE

• Gestational age/menstrual age
o The time elapsed since the last menstruation
o Precedes fertilization/ovulation by 2 weeks
Placental Estrogen Production
• Ovulation age/post conceptional age
o Measures the actual age of the embryo from the time
of fertilization/ovulation
*A fetus that is 18 weeks AOG. What is the ovulation age?
DETERMINING THE AGE OF THE FETUS

• Naegele’s Rule
• Crown Rump Length (CRL)
o Measured from the superior to inferior pole of the
fetus preferably in extended position
o Used for First trimester
• Biparietal Diameter (BPD)
o Measured at the outer to outer aspect of the skull at
the level of the occipitofrontal plane
o Used during the second and third trimester
Conditions that Affect Hormone Levels in Pregnancy

FETAL PERIOD
Condition Findings
Fetal Demise dec estrogen AOG

Fetal anencephaly Dec estrogen (estriol) 12 The uterus usually is just palpable above the symphysis
pubis,
Fetal adrenal hypoplasia absence of C19-precursors crown-rump length is 6 to 7 cm.
Fetal-Placental Sulfatase very low estrogen levels in Centers of ossification have appeared in most of the
Deficiency otherwise normal pregnancies fetal bones
fingers and toes have become differentiated
Fetal-Placental Aromatase virilization of the mother and the Skin and nails have developed and scattered rudiments
Deficiency female fetus of hair appear.
external genitalia are beginning to show definitive signs
Trisomy 21—Down serum unconjugated estriol levels of male or female gender
Syndrome were low spontaneous movements.
Fetal Erythroblastosis Elevated 16 fetal crown-rump length is 12

Gender can be determined by experienced observers by
Glucocorticoid Treatment Dec estrogen inspection of the external genitalia by 14 weeks.
Quickening by multiparas
Maternal Adrenal Dec estrogen
Dysfunction 20 fetus now weighs somewhat more than 300 g, and
weight begins to increase in a linear manner.
Gestational Trophoblastic placental estrogen formation is
fetus moves about every minute and is active 10 to 30
Disease limited to the use of C19-steroids
percent of the time
in the maternal plasma
downy lanugo covers its entire body
estrogen produced is principally
estradiol 24 canalicular period of lung developmentis nearly
completed
fat deposition begins
fetus born at this time will attempt to breathe, but many
FETAL DEVELOPMENT will die because the terminal sacs have not yet formed
Terms 28 crown-rump length is approximately 25 cm

skin is red and covered with vernix caseosa
Perinatal Period beginning 20 weeks AOG and ending up to pupillary membrane has just disappeared from the eyes
period 28 completed days after birth born at this age has a 90-percent chance of survival
It is recommended that this period be defined as
commencing at BW of 500 grams 36 CRL of 32
deposition of subcutaneous fat
Neonatal Period after birth of an infant up to 28 completed
period days after birth 40 average crown-rump length is about 36 cm
weight is approximately 3400 g
Fetal Begins from 8 weeks after fertilization or 10
period weeks after onset of last menses
HEAD DIAMETERS FETAL PULMONARY SYSTEM
• Bitemporal diameter (8.0cm)
o Greatest TRANSVERSE diameter of the head
• Biparietal diameter (9.5 cm)
• Occipitomental ( 12.5 cms)
• Occipitofrontal (11.5 cms)
o The plane that corresponds to the greatest
CIRCUMFERENCE
o 34.5 cm
• Suboccipitobregmatic ( 9.5 cms)
o The plane that corresponds to the smallest
circumference of the head
o 32 cm
FETAL CIRCULATION
• 3 vessels (AVA) • Presence of surfactant in the amnionic fluid is evidence of
o 2 arteries fetal lung maturity (after 34 weeks)
o 1 vein • Surfactant is formed in the type II pneumocytes that line
• Three Shunts: the alveoli
o Ductus venosus • Starts to appear in the amniotic fluid at 28-32 weeks.
o Foramen ovale • 90% lipid and 10% proteins
o Ductus arteriosus o Phosphatidylcholines (lecithin) account for 80% of the
glycerophospholipids
o Most active component –
dipalmitoylphosphatidylcholine (DPPC)
o 2nd most active - phosphatidylglycerol
• Alveolar development = just before birth – 8 years old
SEXUAL DIFFERENTIATION
• Genetic/Chromosomal Sex
Fetal Blood o XX or XY?
• HEMATOPOIESIS o Dependent on the presence of Y chromosome
o yolk sac – first site of hematopoiesis. embryonic • Gonadal Sex
period o testes or ovaries?
o Liver takes over up to near term o Dependent on the presence of SRY gene present on
o Bone marrow starts at 4 mos AOG and remains as the the Y chromosome or the Testes Determining region
major site of blood formation during adulthood • Phenotypic Sex
• Erythrocytes – nucleated and have a shorter life span due o Is it a penis or a vagina?
to their large volume and are more easily deformable o Dependent on the hormones produced
• Fetal blood volume (125 ml/kg)
o Term infants = 80 ml/kg body weight
o Placenta = 45 ml/kg body weight
• Fetal Hemoglobin
o Hemoglobin F
o Hemoglobin A (adult hgb)
o Hemoglobin A2
Fetal Circulation: CHANGES AFTER BIRTH

• Foramen ovale – functionally closed w/in several
minutes; anatomically fused 1 year after birth
• Ductus arteriosus – functionally closed by 10-12 hours
after birth; anatomically closed by 2-3 weeks
• Ductus venosus constrict and becomes the ligamentum
venosum
Kleihauer-Betke test
• Rationale:
o Fetal RBC’s are resistant to denaturating effects of
alkali.
o Mother’r RBC are sensitive, thus may hemolyze
SECOND AND THIRD TRIMESTER SONOGRAPHY

FETAL IMAGING
MATERNAL INDICATIONS
FIRST TRIMESTER SONOGRAPHY 1. Vaginal bleeding
- Sonography before 14 weeks 2. Abdominal/pelvic pain
- Ealy pregnancy can be evaluated using TAS or TVS, or 3. Pelvic mass
both 4. Suspected uterine abnormality
- CROWN-RUMP LENGTH- most accurate biometric 5. Suspected ectopic pregnancy
predictor of gestational age (variance of 3 to 5 days) 6. Suspected molar pregnancy
- 5 weeks- gestational sac 7. Suspected placenta previa and subsequent surveillance
- 6 weeks- embryo with cardiac activity; MEAN SAC 8. Suspected placental abruption
DIAMETER should be visible via TVS has reached 20mm, 9. Preterm premature rupture of membranes and/or
otherwise pregnancy is said to be anembryonic preterm labor
- 5mm- cardiac motion visible 10. Cervical insufficiency
- <7mm and no cardiac activity is seen, a subsequent 11. Adjunct to cervical cerclage
examination is recommended in 1 week 12. Adjunct to amniocentesis or other procedure
13. Adjunct to external cephalic version
INDICATIONS
1. Confirm an intrauterine pregnancy FETAL INDICATIONS
2. Evaluate a suspected ectopic pregnancy 1. Gestational age estimation
3. Define the cause of vaginal bleeding 2. Fetal-growth evaluation
4. Evaluate pelvic pain 3. Significant uterine size/clinical date discrepancy
5. Estimate gestational age 4. Suspected multifetal gestation
6. Diagnose or evaluate multifetal gestations (optimal time 5. Fetal anatomical evaluation
to determine CHORIONICITY) 6. Fetal anomaly screening
7. Confirm cardiac activity 7. Assessment for findings that may increase the
8. Assist chorionic villus sampling, embryo transfer, and aneuploidy risk
localization and removal of an intrauterine 8. Abnormal biochemical markers
9. device 9. Fetal presentation determination
10. Assess for certain fetal anomalies such as anencephaly, 10. Suspected hydramnios or oligohydramnios
in high-risk patients 11. Fetal well-being evaluation
11. Evaluate maternal pelvic masses and/or uterine 12. Follow-up evaluation of a fetal anomaly
abnormalities 13. History of congenital anomaly in prior pregnancy
12. Measure nuchal translucency when part of a screening 14. Suspected fetal death
program for fetal aneuploidy 15. Fetal condition evaluation in late registrants for
13. Evaluate suspected gestational trophoblastic disease prenatal care
NUCHAL TRANSLUSCENCY Three Types of Examination (Congenital Anomaly Scan)

- a component of first-trimester aneuploidy screening, has 1. STANDARD
had a major impact on the number of pregnancies 2. SPECIALIZED
receiving late first-trimester ultrasound examination 3. LIMITED
- It represents the maximum thickness of the
subcutaneous translucent area between the skin and soft STANDARD - Most commonly performed
tissue overlying the fetal spine at the back of the neck - May be adequately assessed after 18
- It is measured in the sagittal plane between 11 and 14 weeks
weeks - Elements:
- If increased, the risk for fetal aneuploidy and various o Head, face, and neck: Lateral
structural anomalies—including heart defects—is cerebral ventricles, Choroid plexus,
significantly elevated Midline falx, Cavum septum
pellucidi, Cerebellum, Cisterna
Components of a Standard Ultrasound Examination by magna, Upper lip, Consideration of
Trimester nuchal fold measurement at 15–20
First Trimester Second and Third Trimester weeks
1. Gestational sac, size, 1. Fetal Number, including o Chest: Four-chamber view of the
location, and number amnionicity and heart, Left ventricular outflow tract,
2. Embryo, and/or yold sac chorionicity of multifetal Right ventricular outflow tract
identification gestations o Abdomen: Stomach—presence,
3. Crown-Rump Length 2. Fetal Cardiac Activity size, and situs, Kidneys, Urinary
4. Fetal Number, including 3. Fetal Presentation bladder, Umbilical cord insertion
amnionicity and 4. Placental location, into fetal abdomen, Umbilical cord
chorionicity of multifetal appearance and vessel number
gestations relationship to the o Spine: Cervical, thoracic, lumbar,
5. Embryonic/fetal anatomy internal cervical os, with and sacral spine
appropriate for all the documentation of o Extremities- Legs and arms
first trimester placental cord insertion o Fetal sex- In multifetal gestations
6. Evaluation of the maternal site and when medically indicated
uterus, adnexa and cul-de- 5. Amniotic Fluid Volume
sac 6. Gestational Age
7. Evaluation of the fetal Assessment
nuchal region, with 7. Fetal Weight estimation
consideration of fetal 8. Fetal Anatomical survey
nuchal transluscency 9. Evaluation of the maternal
assessment uterus, adnexa and cervix,
when appropriate
SPECIALIZED - Targeted examination- a detailed Uterine artery - Diastolic notch: associated with
anatomical survey performed when an gestational hypertension;
abnormality is suspected on the basis of preeclampsia and growth restriction
history, screening test result, or Middle cerebral - For fetal anemia
abnormal findings from a standard artery - Adjunct evaluation for fetal growth
examination restriction
- includes the anatomical structures in the - Fetal hypoxemia→ end diastolic flow
standard type along with additional in the MCA
views of the brain and cranium, neck, - “brain sparing”: misnomer, as it is not
profile, lungs and diaphragm, cardiac protective for the fetus but associated
anatomy, liver, shape and curvature of with perinatal morbidity and
the spine, hands and feet, and any mortality
placental abnormalities
- also fetal echocardiography and
Doppler studies BREECH
LIMITED - performed to address specific clinical
question TYPES OF BREECH
- amnionic fluid volume assessment, FRANK Lower extremities are
placental location, or evaluation of fetal flexed at the hips and
presentation or viability extended to the knee, feet
lie in close proximity to the
DOPPLER EXAMINATION face
- used to evaluate flow within blood vessels
Umbilical Artery - Amount of flow during diastole COMPLETE Lower extremities are
increases as gestation advances flexed at the hips and one or
- Abnormal is S/D ratio is above 95th both knees are flexed
percentile for gestational age
- Useful adjunct in the management of
of pregnancies complicated by IUGR
- Extreme cases of IUGR: absent or
reversed INCOMPLETE One or both hips are NOT
- As long as fetal surveillance remain (FOOTLING) flexed and one or both feet
reassuring: or knees lie below the
o Absent: managed breech
expectantly at 34 weeks A foot or knee is lowermost
o Reversed: managed in the birth canal
expectantlyat 32 weeks Footling breech- incomplete
breech with one or both feet
below the breech
RISK FACTORS
1. Early gestational age
2. Abnormal amniotic fluid colume
normal 3. Multifetal gestation
4. Hydrocephaly
5. Anencephaly
6. uterine anomalies
7. placenta previa
8. fundal placental implantation
9. pelvic tumors
10. high parity with uterine relaxation
absent 11. prior breech delivery
12. Prior cesarean delivery
13. Smoking
COMPLICATIONS
1. Perinatal mortality and morbidity from difficult delivery
2. Low birthweight from preterm delivery
reversed 3. Cord prolapse
4. Placenta previa
Ductus arteriosus - to monitor fetuses exposed to 5. Fetal anomalies
indomethacin and other NSAIDs
- INDOMETHACIN: for tocolysis, may DIAGNOSIS
cause ductal constriction or closure, • Abdominal examination
particularly when used in the third – Leopold’s Maneuver
trimester. The resulting increased – L1: the hard, round, ballottable fetal head may
pulmonary flow may cause reactive be found to occupy the fundus.
hypertrophy of the pulmonary – L2: the back to be on one side of the abdomen
arterioles and eventual development and the small parts on the other
of pulmonary hypertension – L3: (not engaged)- the breech is movable
- NSAIDs: may cause ductal above the pelvic inlet
constriction, hence administration is – L4 (after engagement): shows the firm breech
typically limited to less than 72 hours, to be beneath the symphysis
discontinued if ductal constriction is • Vaginal examination
identified – With a frank breech during vaginal
examination, no feet are appreciated, but the
fetal ischial tuberosities, sacrum, and anus are • The assistant applies suprapubic pressure
usually palpable. PIPER’S FORCEPS
– In some cases, the anus may be mistaken for • This is the preferred (PIPERED) method
the mouth and the ischial tuberosities for the • Occiput should be anterior
malar eminences. • Blades applied to the sides of the head
Breech Cephalic PRAGUE MANEUVER
• the finger • firmer, less • Used when the baby fails to rotate trunk from occiput
encounters yielding jaws are posterior to occiput anterior
muscular felt through the • Used when there is persistent fetal back
resistance with mouth • Fingers are placed over the shoulders and upward
the anus • The mouth and traction is made
• The finger, upon malar eminences • Legs are grasped and body is swung over abdomen
removal from form a triangular BRACHT MANEUVER
the anus, may be shape • Breech is allowed to deliver spontaneously up to the
stained with navel
meconium • Suprapubic pressure is applied
• the ischial PINARD’S MANEUVER
tuberosities and • Breech decomposition
anus lie in a • From frank breech to be delivered as footling
straight line • The fingers are pressed in the baby’s popliteal fossa
- complete breech- the feet may be felt alongside the buttocks causing flexion of the knee
- footling presentations- one or both feet are inferior to the • Foot is grasped and delivered as footling
buttocks
• Ultrasound DELIVERY OF AN ENTRAPPED AFTERCOMING HEAD
– Confirm the diagnosis of breech DUHRSSEN ▪ Incisions in the cervix at 2-, 6-, and
INCISION 10-o’clock positions
METHODS OF VAGINAL DELIVERY ZAVANELLI ▪ Replacement of the fetus higher into
Spontaneous Infant is expelled entirely without any MANEUVER the vagina and uterus, followed by
breech delivery traction other than support cesarean delivery
Partial breech Breech is allowed to deliver spontaneously SYMPHYSIOTOMY ▪ Surgical incision into the fibro-
extraction as far as the umbilicus, but the remainder of cartilage of the symphysis pubis in
the body is assisted order to allow the fetal head to pass
Total breech Entire body is extracted by the OB into the pelvis (engage), so that a
extraction - Hand is introduced through the vagina, vaginal delivery may be achieved.
and both fetal feet are grasped. ▪ Done when there is no facility for
- The ankles are held with the second Caesarean section
finger lying between them
- With gentle traction, the feet are VERSION
brought through the introitus Version Procedure in w/c fetal presentation is altered by
- both feet are grasped and pulled physical manipulation from a less favorable to a
through the vulva simultaneously more favorable position
2 types of External ▪ for breech presentation
CS DELIVERIES PREFERRED version cephalic recognized prior to labor and
• Chronic fetal distress; IUGR version has reached 36 weeks
• A large fetus ▪ Should be carried at between
• Any degree of CPD 32-34 weeks
• Hyperextended head Internal ▪ used only for the delivery of
• Footling breech podalic the second of twin
• Prematurity version ▪ converts a fetus from a
• A request for sterilization transverse/oblique/ cephalic
into double footling
METHODS USED IN BREECH DELIVERY:
Delivery of the shoulder Lovesets maneuver EXTERNAL CEPHALIC VERSION
Delivery of the aftercoming head Mauriceau Indication for external ▪ For breech presentation
maneuver cephalic version recognized prior to labor and
Prague maneuver has reached 36 weeks
Contraindication to 1. Any history of bleeding
Piper’s forcep
external version 2. Presence of multiple pregnancy
Bracht maneuver
3. Associated major malformation
Pinard
4. Plan for the manner of delivery
Delivery of an entrapped aftercoming Duhrssen incision
Factors associated with 1. Multiparity- most consistent
head Zavanelli maneuver
successful version and most important factor
Symphysiotomy associated with success
DELIVERY OF THE SHOULDER 2. Fetal presentation
LOVESETS maneuver 3. Amount of amniotic fluid
– Delivery of the POSTERIOR shoulder ahead of the
anterior
– The OB’s hand is passed along the humerus towards the
elbow
– LOVE? Kiss me at the POSTERIOR area of my
SHOULDER, down to my HUMERUS and to my ELBOW
DELIVERY OF THE AFTERCOMING HEAD

MAURICEAU MANEUVER
• The index and the Middle finger are placed over the
baby’s Maxilla to maintain flexion.
• The other hand on the baby’s shoulder to provide
traction
Lipase to digest fat Present None
Lactose (sugar) 7% (enough) 3% - 4% (not
POSTPARTUM CHANGES enough)
Salts (mEq/L) – 6.5 25 (too much)
BREASTS & LACTATION Sodium 12 29 (too much)
I. How breast milk protects babies against infection. (DOH, • Chloride 14 35 (too much)
1991) • Potassium
1. Breastfed babies have less diarrhea than artificially-fed Iron – colostrum 0.5 – 0.8 mg/L
babies. • Mature milk 0.2 – 0.3 mg/L
2. Fewer respiratory and middle ear infection.
3. Fewer infections because of the following: IV. Some Myths about Breastfeeding: (Thomson Medical
a. Breast milk is clean and free of bacteria Center, Singapore. 2004)
b. Contains antibodies (immunoglobulin) to many 1. It is painful & difficult to learn.
common infections, until he can make his own 2. Breastfed babies cry more than bottle-fed babies.
antibodies. 3. Breastfeeding tends to isolate mother and baby from the
c. Contains white blood cells to help fight infection. rest of the family members.
d. Contains bifidus factor which helps special bacteria 4. It is embarrassing.
called Lactobacillus bifidus to grow in the baby’s 5. Spoils a baby and weaning is difficult.
intestine. Lactobacillus bifidus prevents other 6. Quality of breast milk depends on your mood.
harmful bacteria from growing and causing 7. Breastfeeding mother may have to give up food she likes,
diarrhea. become tied down and be unable to work.
e. Contains lactoferrin which binds iron. Prevents the 8. Breastfed babies need more water.
growth of some harmful bacteria which need iron. 9. Breast milk lack iron.
II. Other advantages of breastfeeding. (DOH, 1991) V. How should breastfeeding begin. (DOH, 1991)
1. Breast milk contains lipase which digests fat. Breast milk 1. First feed
is quickly and easily digested and a breastfed baby may • First feed should be on the delivery table.
want to feed again more quickly than an artificially-fed • Cover both mother and baby to keep them warm.
baby. • Let the mother hold the baby close and let him suck at
2. Breast milk is always ready to feed to the baby and it the breast.
needs no preparation. • Sucking stimulates the production of oxytocin which
3. Breast milk never goes sour or bad in the breast even if a helps to deliver the placenta and stop hemorrhage.
woman does not feed her baby for some days. • Baby gets valuable colostrums.
4. Breastfeeding helps to stop bleeding after delivery. • More likely to breastfeed for a long time. A delay of even
5. Breastfeeding on demand helps to protect against another a few hours will result in failure to breasfeed.
pregnancy.
6. It helps them to bond, become attached to each other and 2. Rooming-in
love each other. •
There is no need for a mother and baby to rest
7. It is free. You don’t have to buy it. separately after a normal delivery.
8. It is exclusively for your baby and cannot be served to 3. Demand feeding
other adults.
• Let the mother pick up her baby and feed him whenever
he cries and she feels a need to feed him.
Protective Effects on Infants of Human Milk and Breast
• Frequent sucking stimulates the production of prolactin
Feeding (AAP, 1997)
which helps the milk to come in sooner.
Decreased Incidence/Severity Possible protective effects
• It prevents engorgement of breasts.
Diarrhea Sudden infant death
Lower respiratory infection syndrome 4. Duration of feeds
Otitis media Type-1 Diabetes
• More babies finish in 5-10 minutes, but some like to
Bacteremia Inflammatory bowel disease
take much longer, perhaps half an hour. It does not
Bacterial meningitis Lymphoma
matter.
Botulism Allergies
• Slow feeders take the same total amount of milk as fast
Necrotizing enterocolitis Chronic digestive diseases
feeders.
Urinary infections
• Sucking in the wrong position causes sore nipples.
III. Composition of Human Breast Milk
5. Feeding from both breasts
Component Human milk Cow milk
• Let the baby finish the first breast to make sure that he
Water Enough (87.2% to More required
gets the hindmilk. Let him take the second breast if he
87.5%)
wants to, but do not force him.
Bacterial None Likely
contamination 6. Prelacteal feeds
Anti-infection Antibodies, Antibodies not • Prelacteal feeds (e.g. formula, glucose water, ampalaya
substances leucocytes, active, absent juice, diluted honey) are NOT necessary and they can be
lactoferrin, bifidus lactoferrin harmful.
factor
• Small amount of colostrum is ALL that a normal baby
Protein (Total) 1% 4% too much needs at this time.
• Casein 0.5% 3% too much
• lactalbumin 0.5% 0.5% 7. Extra water
Amino acids - Enough for growing Not enough • Normal baby is born with a store of water which keeps
Cysteine brain Not present him well hydrated until the milk comes in. He does not
• Taurine Enough need drinks of water, they interfere with breasfeeding.
Fats (Total) 4% average 4%
• Saturation Enough Too much 8. Night breastfeeds
UNsaturated saturated • It is better if the mother breastfeeds the baby at night as
Fatty acids – Enough for growing Not enough long as he wants to.
linoleic acid brain Not enough • Night feeding helps to keep up the milk supply because
(essential) Enough the baby sucks more.
• Cholesterol • Night feeds are especially useful for working mothers.
• Night feeds are important for child spacing.
9. Early weight changes POST-PARTUM HEMORRHAGE (PPH)

• A baby may lose weight for the first few days after
delivery. He may lose up to 10% of his birth weight. Definition
• When breastfeeding is started, the baby should regain The following are suggested definitions but there is a lack of
his birth weight in ten days. agreement on what constitutes excessive blood loss:
1. Blood loss >500 ml for vaginal delivery and 1,000 ml for
10. Cleaning the breast cesarean section (CS).
• Frequent washing, especially with soap, removes the 2. Blood loss >500 ml in the first 24 hours following delivery.
natural oil from the nipple. 3. Ten percent (10%) decrease in hemoglobin or hematocrit
• The skin becomes dry and is more easily damaged and level.
fissured. 4. Need for transfusion.
DELAYED CORD CLAMPING Problems with the above definitions:

WHO recommedations 1. Clinical estimation of blood loss is frequently inaccurate
- Delayed umbilical cord clamping (not earlier than 1 and the brisk nature of blood loss during delivery or the
minute after birth) is recommended to due both presence of amniotic fluid can make this more difficult.
improved maternal and infant health and nutition 2. Delay in obtaining laboratory results. Information from
outcomes laboratory tests would not reflect the patient’s current
hemodynamic status.
Delayed cord clamping 3. Any definition based on the need for transfusion is difficult
- Performed approximately 1-3 minutes after birth is as there are differences in provider practice patterns
recommended for all births UNLESS the neonate is regarding transfusion.
asphyxiated and needs to be moved immediately for
resuscitation Definition of obstetric hemorrhage combining clinical and
objective data (Bonnar, 2000)
Benefits Blood Systolic
EBL Heart
Immediate Long-Term Benefits volume BP Signs & symptoms
(ml) rate
Benefits (%) (mmHg)
Pre-Term/Low Decrease the risk Increases 500-
10-15 <100 Normal None
Birth Weight of intraventricular hemoglobin at 10 1000
hemorrhage, weeks of age 1000 - 100- Slight Vasoconstriction,
15-25
necrotizing 1500 120 decrease weakness, sweating
enterocolitis, late- May be a benefit to 1500 - 120- Restlessness, pallor,
25-35 80-100
onset sepsis neurodevelopmental 2000 140 oliguria
outcomes 2000- Anuria, altered
35-45 >140 60-80
Decreases the 3000 consciousness
need for blood
transfusuions for Etiology and Risk Factors
anemia, surfactant, Etiology Pathophysiology Risk Factors
mechanical Multiple gestation
ventilation Overdistended uterus Polyhydramnios
Macrosomia
Increases Prolonged labor
hematocrit, TONE Uterine muscle fatigue Augmented labor
hemoglobin, blood (Abnormal Prior PPH
pressure, cerebral uterine Prolonged rupture of
oxygenation, RBC Chorioamnionitis
contractility) membranes (ROM)
flow Uterine Fibroids (myoma),
Full-Term infants Provides adequate Improves distortion/abnormality placenta previa
blood volume and hematological status B-mimetics, MgSO4,
birth iron stores (hematocrit and Uterine relaxing drugs
anesthetic drugs
hemoglobin) at 2-4 Prior uterine surgery
Increases months of age Accreta/Increta/Percre
Placenta previa
hematocrit and TISSUE ta
Multiparity
hemoglobin Improves iron status (Retained
Manual placenta
up to 6 months of products of
Retained removal
age conception)
placenta/membranes Succinturiate/accesso
ry lobe
Precipitous delivery
Macrosomia
Laceration of the
Shoulder dystocia
cervix, vagina or
Operative delivery
perineum
Episiotomy (e.g.
mediolateral)
Deep engagement
Extension/laceration at
Malposition
TRAUMA CS
Malpresentation
(Genital tract
Uterine rupture Prior uterine surgery
trauma)
Fundal placenta
Grand multiparity
Excessive traction on
umbilical cord
Uterine inversion
Preexisting clotting History of o Previous uterine rupture
abnormalities (e.g. Coagulopathy or liver o Presence of a contraindication to labor, such as
hemophilia, disease placenta previa/accreta, or malpresentation
THROMBIN o No informed consent for VBAC
vonWillebrands
(Abnormaliti disease, • Failed trial of labor during VBAC.
es of hypofibrinogenemia)
coagulation) 2. Abnormalities of the reproductive tract
DIC Sepsis
HELLP Intrauterine demise ▪ Presence of gynecologic tumors in pregnancy, such as
Anticoagulation Hemorrhage uterine myoma and/or adnexal masses, are NOT ABSOLUTE
indications for CS, unless they cause dystocia
General Management of PPH: ▪ CS performed for those with a history of surgical repair of
1. Initial management approach to obstetric hemorrhage: obstetric and anal sphincters, urinary incontinence and
a. Assessment: constant awareness of the hemodynamic pelvic organ prolapse because of risk of recurrences
status as well as evaluation to determine the cause of ▪ Genital warts and genital cancers may be an indication
bleeding. for CS if it obstructs the birth canal, or if it is excessively
b. Breathing: administration of oxygen bleeding, or in order to prevent profuse bleeding
c. Circulation: obtaining intravenous (IV) access and ▪ Presence of cervical stenosis is NOT A
adequate circulating blood volume through infusion of CONTRAINDICATION to attempted vaginal delivery. There
crystalloid and blood products. Second large-bore IV is increased risk for CS.
catheter is needed ▪ Vaginal delivery for corrected imperforate hymen.
2. Notify the blood bank. ▪ CS performed for those with history of complete
3. Simultaneous, coordinated, multi-disciplinary management transverse vaginal septum and vaginal agenesis due to
(OB-GYN, anesthesiologist, hematologists, radiologists, risk of vaginal soft tissue dystocia and lateral vault
nurses, laboratory and blood bank technicians) to concur laceration
timely management in the presence of obstetric hemorrhage.
4. Preoperative preparedness is important especially for 3. Abnormalities of the placenta, cord, membranes and
patients identified as high risk. amniotic fluid
• Vasa previa
Important Causes of PPH: o Elective CS between 35-37 weeks AOG
1. Uterine atony o Emergency CS for bleeding vasa previa
2. Retained placenta • Placenta previa
3. Uterine rupture o Any degree of placental overlap (>0 mm) at the
4. Genital tract trauma internal os after 35 weeks is an indication for CS
5. Uterine inversion o Previa within 1 cm of the internal os is an indication
for CS
GUIDELINES FOR CESAREAN SECTION o Elective CS for asymptomatic woman with previa >37
weeks and for suspected accreta >36 weeks
INDICATIONS • Abruptio placenta
Maternal Prior cesarean delivery o Emergency CS for abruptio placenta with fetal
Abnormal placentation compromise, severe uterine hyprtonus, life
Maternal request threatening bleeding or DIC, and remote from vaginal
Prior classical hysterotomy delivery.
Unknown uterine scar type • Cord prolapse
Uterine incision dehiscence o Emergency CS for cord prolapse
Prior full-thickness myomectomy o Cord prolapse with poor chances of viability, vaginal
Genital tract obstructive mass delivery may be tried with informed consent
Invasive cervical cancer o Ultrasound finding suggestive of forelying cord or
Prior trachelectomy funic presentation is NOT an absolute indication for
Permanent cerclage CS
Prior pelvic reconstructive surgery o Digital diagnosis of funic/cord presentation in labor is
Pelvic deformity an indication for CS
HSV or HIV infection
• Chorioamnionitis or intra-amniotic infection
Cardiac or pulmonary disease
o Presence of clinical chorioamnionitis or intra-amniotic
Cerebral aneurysm or arteriovenous malformation
infection is NOT an absolute indication for CS.
Pathology requiring concurrent intraabdominal
• Oligohydramnios
surgery
o Uncomplicated oligohydramnios is NOT an absolute
Perimortem cesarean delivery
indication for CS
Maternal- Cephalopelvic disproportion
Fetal Failed operative vaginal delivery
4. Infection in pregnancy
Placenta previa or placental abruption
▪ Herpes simplex virus
Fetal Nonreassuring fetal status
o CS for those who develop primary genital herpes
Malpresentation
within 6 weeks of delivery
Macrosomia
o CS for those with active genital lesions or prodromal
Congenital anomaly
symptoms (e.g. vulvar pain or burning) at the time of
Abnormal umbilical cord Doppler study
delivery
Thrombocytopenia
▪ Hepatitis B virus
Prior neonatal birth trauma
o Scheduled CS at 39 weeks with HBV profile as follows:
▪ HbeAg positive
1. Previous uterine scar
▪ HBV DNA copies >1,000,000
• In the presence of scarred uterus, the following are ▪ Not received oral antiretroviral therapy
ABSOLUTE INDICATIONS for elective CS: (Level III, Grade C) ▪ Human papilloma virus
o Previous classical or inverted T-uterine scar o Only for those with very large genital warts causing
o Uncertainty of type of previous CS scar pelvic outlet obstruction or potential for excessive
o Previous multiple low transverse segment uterine bleeding during vaginal delivery
scars ▪ HIV
o Previous hysterotomy or myomectomy entering the o Elective CS at 39 weeks to reduce risk of MTCT
uterine cavity or extensive transfundal uterine provided:
surgery
▪ Currently on highly active antiretroviral therapy • Routine shaving not recommended. Clippers are
(HAART) recommended than razors for excessive hair.
▪ Viral load <400 copies/ml Techniques of CS
▪ On any ARV with viral load <50 copies/ml • Transverse abdominal incision or Joel-Cohen incision is
preferred.
5. Maternal medical conditions • Placental delivery by controlled cord traction rather than
• Hypertensive complications manual extraction
o Maternal indications • Blunt dissection of uterus was associated with reduced
▪ Deteriorating maternal condition mean blood loss compared to sharp dissection.
▪ Uncontrolled hypertension despite drug therapy • Single layer closure was associated with significant
▪ HELLP syndrome reduction in mean blood loss, duration of operative time,
▪ Placental abruptio post-operative pain but more likely to result in uterine
o Fetal indications rupture.
▪ Severe IUGR/FGR • Closure of both visceral and parietal peritoneum after
▪ Non-reassuring FHR pattern, repeated Category CS lead to LESS adhesions
II or III, refractory with resuscitation, remote • Closure of subcutaneous tissue for >2 cm subcutaneous
from delivery fat.
▪ BPP <4, done 6 hours apart • Indwelling FC may be removed <24 hours after CS
▪ Doppler studies: ARED
• Severe bronchial asthma
o CS is rarely needed. Anesthesia in CS
• Cardiac disease • Uncomplicated elective CS may have modest amounts of
o CS reserved for high-risk cardiac patients. clear liquids up to 2 hours prior to induction of anesthesia
• Gestational DM • Patient undergoing elective surgery should have a fasting
• Obesity period for solids at least 6-8 hours prior to induction.
o Increased risk for CS • Aspiration prophylaxis: non-particulate antacids, H2
• Macrosomia receptor antagonists, metoclopramide
Post-CS care
6. IUGR/FGR • No evidence to recommend a policy of delaying oral fluids
• Deterioration in the fetal condition or when there is an and food after CS
unripe cervix or when there are indications of additional • Remove the dressing 24 hours after the CS.
fetal compromise during labor • No evidence of adverse outcomes associated with early
• Viable fetus with IUGR when there is: postnatal discharge (3-4 days)
o deterioration in the BPP • Sexual intercourse may be resumed as early as 2 weeks
o loss of variability on NST postpartum for as long as the patient feels comfortable.
o severe oligohydramnios, and *Notes: Placenta previa is one of the main indications for delivery
o failure to grow on serial biometry in the presence of during late preterm or early term. We do not want uterine
abnormal umbilical artery or venous Doppler studies. contractions, hence labor, to ensue with placenta previa due to
possible bleeding
7. Fetal congenital anomalies
• Fetuses with the following anomalies may benefit from CS:
o Neural tube defects with fetus in breech
OTHER IMPORTNANT OBSTETRIC
o Neural tube defects with sac >6 cm INFORMATION
o Cystic hygromas
o Sacrococcygeal teratomas >5 cm DERMATOSES IN PREGNANCY
o Hydrocephalus with BPD >10 cm or HC >36 cm
• Elective CS
o Fetus with hypoplastic left heart syndrome
o Transposition of great arteries with intact
intraventricular septum that require urgent neonatal
atrial septostomy
8. Maternal request (CDMR)

• If without clear indication or there is fear of childbirth, the
OB should provide counseling to the patient.
• Well-written informed consent with proper approval by
the hospital’s ethics committee should be secured before
performing the CS.
• Should be performed >39 weeks AOG, unless there is
documentation of fetal lung maturity.
9. Multiple pregnancy
10. Fetal malpresentation (Refer to Section III)
11. Abnormal labor patterns (Refer to Section II)
12. Abnormal FHR patterns (Refer to Section I)
PITUITARY DESTRUCTION
Operative Recommendations
Damage or necrosis of the pituitary gland caused by anoxia,
Timing of planned CS thrombosis, or hemorrhage. It is called Sheehan’s syndrome
• Scheduled at 39 weeks when related to pregnancy and Simmonds’ disease when
Pre-operative preparation for CS unrelated to pregnancy.
• Hemoglobin determination
• Antimicrobial prophylaxis within 60 minutes pre-
operatively with either penicillins or cephalosporins (1 st or
2nd gen) – Cefazolin 2g/IV (1st gen), Cefuroxime 1.5 g/IV
(2nd gen)
• Alternative (if allergic): Clindamycin 600 mg/SIV
• Morbid obese (BMI>35): double dose of antibiotic
OBSTETRICAL HEMORRHAGE o Increased risk for CS for fetal distress and risk
for APGAR <7
o Pulmonary hypoplasia
Management
- Target the underlying etiology
o Evaluate fetal abnormalities and growth
o Close fetal surveillance
o Amnioinfusion – may be used intrapartum in
the setting of variable fetal heart rate
decelerations, NOT considered a treatment or
a standard of care
DYSTOCIA
- Difficult labor, characterized by abnormally slow labor
progress
o Expulsive forces may be abnormal
▪ Contractions are insufficiently strong
or inappropriately coordinated to
efface and dilate the cervix
▪ Inadequate voluntary maternal
muscle effort
o Fetal abnormalities of presentation, position
or development may slow labor
o Abnormalities of the maternal body pelvis may
create a contracted pelvis
o Soft tissue abnormalities of the reproductive
tract may form an obstacle to fetal descent
Uterine Atony
The most frequent cause of obstetrical hemorrhage is failure of
the uterus to contract sufficiently after delivery and to arrest
bleeding from vessels at the placental implantation site
Uterine Inversion
Puerperal inversion of the uterus is considered to be one of the
classic hemorrhagic disasters encountered in obstetrics. Unless
promptly recognized and managed appropriately, associated
bleeding often is massive. Risk factors include alone or in
combination:
1. Fundal placental implantation,
2. Delayed-onset or inadequate uterine contractility after
delivery of the fetus, that is, uterine atony,
3. Cord traction applied before placental separation, and
4. Abnormally adhered placentation such as with the accrete
syndromes
OLIGOHYDRAMNIOS
Causes of Oligohydramnios
▪ Fetal abnormality
o Congenital abnormalities
▪ By 18 weeks the fetal kidneys are the
main contributor to amniotic fluid
volume
▪ Severely decreased amniotic fluid
volume beginning in early in
gestation are secondary to
genitourinary abnormalties
▪ Other organ system anomalies can
also indirectly cause
oligohydramnios
▪ Uteroplacental insufficiency
▪ Post term pregnancies (most common)
▪ Exposure to medications
o Associated with exposure to drugs that block
the renin-angiotensin system (ACE inhibitors
and NSAIDs)
Pregnancy Outcomes
- Increased risk of adverse pregnancy outcomes
o More likely to have malformations
o Higher levels of fetal stillbirth, growth
restriction, non-reassuring heart rate pattern,
meconium aspiration syndrome were aslo
noted
o Increased spontaneous/medically indicated
preterm birth
INFECTIOUS DISEASES IN PREGNANCY Late onset sequelae include hearing
loss, neurological deficits, chorioretinitis,
psychomotor
retardation, and learning disabilities
Group A Remains the most common
Streptococcus cause of severe maternal postpartum
infection and death
worldwide
Group B May cause preterm labor, prematurely
Streptococcus ruptured membranes, clinical
and subclinical chorioamnionitis, and fetal
infections.
GBS can also cause maternal bacteriuria,

pyelonephritis, osteomyelitis,
postpartum mastitis, and puerperal
infections.
MRSA Skin and soft tissue infections are the most

common presentation of MRSA in
pregnant women
Listeriosis Discolored, brownish, or meconium-
stained amnionic fluid is common with
fetal infection, even preterm gestations
Diagnosis Effects Maternal listeriosis causes fetal infection
Varicella Congenital varicella syndrome- that characteristically produces
chorioretinitis, microphthalmia, cerebral disseminated granulomatous lesions with
cortical atrophy, growth restriction, microabscesses
hydronephrosis, limb hypoplasia,
and cicatricial skin lesions Chorioamnionitis is common with
Influenza No firm evidence that it causes congenital maternal infection, and placental lesions
malformations include multiple, well-demarcated
Mumps Women who develop mumps in the first macroabscesses.
trimester may have an increased risk of Toxoplasmosis Clinically affected neonates
spontaneous abortion usually have generalized disease
Measles/Rubeola The virus does not appear to be expressed as low birthweight,
teratogenic. hepatosplenomegaly, jaundice, and
However, an increased frequency of anemia. Some primarily
abortion, preterm delivery, have neurological disease with
and low-birthweight neonates is noted intracranial calcifications and
with maternal measles with hydrocephaly or microcephaly. Many
German Rubella infection in eventually develop
Measles/ Rubella the first trimester, however, poses chorioretinitis and exhibit learning
significant risk for abortion and disabilities.
severe congenital malformations.
TRIAD: Chorioretinitis, intracranial
Rubella is one of the most complete calcifications and hydrocephalus
teratogens, and sequelae
of fetal infection are worst during APPENDICITIS IN PREGNANCY
organogenesis. - Suspected appendicitis is one of the most common
indications for abdominal exploration during pregnancy
Congenital Rubella Syndrome - When appendicitis is suspected, treatment is prompt
• Eye defects—cataracts and congenital surgical exploration.
glaucoma - Although diagnostic errors may lead to removal of a
• Congenital heart defects—patent ductus normal appendix, surgical evaluation is preferable to
arteriosus and postponed intervention and generalized peritonitis
pulmonary artery stenosis o Appendicitis increases the likelihood of
• Sensorineural deafness—the most abortion or preterm labor, especially if there is
common single defect peritonitis
• Central nervous system defects—
microcephaly, developmental PANCREATITIS IN PREGNANCY
delay, mental retardation, and - Medical treatment is the same as that for nonpregnant
meningoencephalitis patients and includes analgesics, intravenous hydration,
• Pigmentary retinopathy and measures to decrease pancreatic secretion by
• Neonatal purpura interdiction of oral intake.
• Hepatosplenomegaly and jaundice
• Radiolucent bone disease LEIOMYOMAS IN PREGNANCY
- Can regress after pregnancy
Parvovirus B19 Associated with abortion, nonimmune - May cause pain or pressure
hydrops and still birth - May outgrow their blood supply and hemorrhagic
Cytomegalovirus Growth restriction, microcephaly, infarct follows- Red or Carneous Degeneration
intracranial calcifications, chorioretinitis, - Treatment is analgesic medication, myomectomy has
mental and motor retardation, resulted in good outcomes
sensorineural deficits, - Pedunculated subserosal myosmas will undergo
hepatosplenomegaly, jaundice, hemolytic torsion—can be managed with laparoscopy or
anemia, and thrombocytopenic purpura laparotomy
- Complications
o Preter labor - In settings where dipslide culture
o Placental abruption technique is available, it may be used as
o Fetal malpresentation an alternative to urine culture
o Obstructed labor - Antibiotic treatment for asymptomatic
o Cesarian delivery bacteriuria is indicated to reduce the risk
o Postpartum hemorrhage of acute cystitis and pyelonephritis in
pregnancy as well as the risk of LBW
SEIZURE DISORDERS IN PREGNANCY neonates
- Women with epilepsy have increased seizure risks with - Among the drugs that can be used are
mortality risks and fetal malformations Treatment nitrofurantoin, (not for near term) co-
o Often associated with decreased and amoxiclav, cephalexin, fosfomycin,
subtherapeutic anticonvulsant serum levels, cotrimoxazole (not on the first and third
lower seizure threshold, or both trimester) depending on the sensitivity
- Medications results of the urine isolate
o Fetus of an epileptic mother who takes - Duration of treatment will depend on the
anticonvulsant medications has increased risk antibiotics that will be used but short-
for congenital malformations course (7 days) treatment is preferred
o Monotherapy has lower birth defect rate over single-dose regimen
compared to multiagent Monitoring - A follow up urine culture should be done
o Phenytoin and phenobarbital increase the risk one week after completing the course of
for malformations (two-to-threefold above the treatment
baseline). Valproate may increase four-to- - Monitoring should be done every trimester
eightfold risk until delivery
o Newer antiepileptic mediations are reported
to have no associations with a markedly ANTIBIOTICS RECOMMENDED DOSE PREGNANCY
increased risk of major birth defects AND DURATION CATEGORY
- Management Cefalexin 500 mg BID x 7 days B
o Prevent seizure – prevent seizure provoking Cefuroxime 500 mg BID x 7 days B
stimuli, compliance Fosfomycin 3 g in single dose B
o Anticonvulsants are given at lowest dosage trometamol
Amoxicillin- 625 mg BID x 7 days B
clavulanate
Nitrofurantoin 100 mg BID x 7 days B
TMP-SMX 160/800 mg BID x 7 days C
(avoid in 1st
and 3rd
trimester)
ACUTE CYSTITIS IN PREGNANCY

- urinary frequency, urgency, dysuria and
Symptoms bacteriuria without fever and
costovertebral angle tenderness.
+/- Gross hematuria
- In pregnant women suspected to have

acute uncomplicated cystitis, obtain a
pretreatment urine culture and
sensitivity test of a midstream clean catch
Diagnosis urine specimen
- In the absence of a urine culture, the
laboratory diagnosis of acute cystitis can
be determined by the presence of
significant pyuria defined as a) > 8 pus
UTI IN PREGNANCY cells/mm3 of uncentrifuged urine OR b) >
(Summary of Recommendations from the UTI in Pregnancy 5 pus cells/hpf of centrifuged urine, and c)
and ASB in Adults Subgroup) a positive leukocyte esterase and nitrite
test
ASYMPTOMATIC BACTERIURIA
Who: Screen ALL pregnant women for ASB

once early during pregnancy between 9th to
17th weeks, preferably on the 16th week age of
gestation
Screening Test of Choice: Urine culture of clean-catch
midstream urine.
Alternative: Urine gram stain of at least one
organism per oil immersion field
*Urinalysis, Urine dipsticks for leukocyte
esterase and/or nitrite tests are not
recommended as an initial screening test
- Two consecutive voided or one
catheterized urine specimen with
isolation of the same bacterial strain in
quantitative counts ≥ 100,000 cfu/mL
Diagnosis - In settings where obtaining two
consecutive urine cultures are not feasible
or difficult, one urine culture is an
acceptable alternative
- Treatment should be instituted Nitrofurantoin - May be given on the second trimester
immediately to prevent the spread of the of pregnancy until 32 weeks AOG
infection to the kidney - Only use in first trimester of
- Since E. coli remains to be the most pregnancy is appropriate when no
common organism isolated, antibiotics to other suitable alternative antibiotics
which this organism is most sensitive and are available
Treatment which are safe to give during pregnancy Co-Amoxiclav - avoid in women at risk of preterm
should be used labor
- A 7-day treatment with an oral TMP-SMX - may be given on the second and third
antimicrobial agent that is safe for use in trimester of pregnancy
pregnancy is recommended except for - use in first trimester pregnancy is
fosfomycin which is given as a single dose appropriate when no other suitable
- In the absence of a urine culture and alternative antibiotics are available
sensitivity, empiric therapy should be - use only for culture proven
based on local susceptibility patterns of susceptible uropathogens due to high
uropathogens level of resistance
- In cases where the result of a urine culture
shows an organism resistant to the
empirically started antibiotic in a clinically ACUTE UNCOMPLICATED PYELONEPHRITIS
improving patient, no adjustment is
necessary. Adjust antibiotic therapy based - fever (T> 38°C)
on urine culture results ONLY when there Symptoms - chills, flank pain
is no improvement in the clinical signs and - costo-vertebral angle tenderness
symptoms and laboratory results or there - nausea and vomiting
is worsening of condition - with or without signs and symptoms of
lower urinary tract infection
- Post-treatment urine culture 1 – 2 - Urinalysis: Pyuria (> 5 wbc/hpf of
weeks after completion of therapy should centrifuged urine)
be obtained to confirm eradication of - Urine culture: bacteriuria with counts of
Monitoring bacteriuria and resolution of infection > 10,000 cfu of uropathogen per ml on
- Pregnant patients with pyelonephritis, Diagnosis urine culture
recurrent UTIs, concurrent gestational DM, - Urinalysis and Gram stain are
concurrent nephrolithiasis or urolithiasis, recommended
and pre-eclampsia, should be monitored at - Urine culture and sensitivity test should
monthly intervals until delivery to ensure also be performed routinely to facilitate
that urine remains sterile during cost-effective use of antimicrobial agents
pregnancy and because of the potential for serious
sequelae if inappropriate antimicrobial
agent is used.
ANTIBIOTICS RE- PREG- BIRTH DEFECTS - Blood cultures are NOT routinely
COMMENDED NANCY / NEONATAL recommended except in patients with
DOSE AND CATEGORY COMPLICATIONS
signs of sepsis
DURATION
- Routine renal ultrasound is of limited
clinical benefit and should be reserved for
Cefalexin 500 mg QID women who fail to respond to initial
for 7 days B NONE treatment.
Cefadroxil 1 g BID for 7 Indications - inability to maintain oral hydration or take
days for medications
Cefuroxime 500mg BID for Admission - concern about compliance
7 days - presence of possible complicating (co-
Cefaclor 500mg TID for morbid) conditions
7 days B NONE
- severe illness with high fever, severe pain,
Cefixime 200mg BID for
7 days
marked debility
Cefpodoxime 100mg BID for B NONE - signs of preterm labor
7 days - signs of sepsis
Nitrofurantoin 100 mg BID for B Hemolytic anemia - In the absence of a urine culture and
7 days Anopthalmia sensitivity, empiric therapy should be
Hypoplastic left based on local susceptibility patterns of
heart syndrome uropathogens. Since E. coli remains to be
Asd the most common organism isolated,
Cleft lip & palate
antibiotics to which this organism is most
Fosfomycin 3 gms single B None
trometamol dose
Treatment sensitive and which are safe to give during
Pivmecillinam 400 mg BID for B None pregnancy should be used
7 days - The recommended duration of treatment
Amoxicillin- 625mg BID for Neonatal is 14 days
clavulanate 7 days necrotizing - Intravenous antimicrobial therapy is
enterocolitis usually continued until the patient is
Trimethoprim- 800/160 mg C Anencephaly afebrile for 48 hours and symptoms have
sulfamethoxazole BID for 7 days Hypoplastic left improved; afterward, the patient is treated
hert syndrome with oral antibacterials. The course of oral
Choanal atresia
therapy lasts for 10–14 days. If the patient
Transverse limb
defect fails to respond clinically by 72 hours,
Diaphragmatic further evaluation should ensue for
hernia bacterial resistance to the antibacterial
used, urolithiasis, perinephric abscess
formation or urinary tract abnormalities,
and the antibacterial agent should be
changed to include an aminoglycoside
- Post-treatment urine culture should be
obtained after completion of antibiotic Uterus
treatment to confirm resolution of the • Endometrial polyps – localized overgrowths of endometrial
infection (“test of cure”) glands and stroma beyond the surface of the endometrium.
- Patient should be followed up for Majority are asymptomatic, but those who are symptomatic
symptoms of recurrent infection and are associated with a wide range of bleeding patterns
Monitoring monthly urine culture should be • Hematometra – uterus distended with blood and secondary
performed until delivery to gynatresia. Common symptoms include amennorrhea and
- Recurrence of symptoms requires cyclic lower abdominal pain
antibiotic treatment based on urine • Leiomyomas/Myomas – most frequent pelvic tumor and the
culture and sensitivity test results, in most common tumor in women. More prone to grow and
addition to assessing for underlying symptomatic to nulliparous women, highest occuring in 5th
genitourologic abnormality decade. May cause miscarriage.
- The duration of re-treatment in the o Types
absence of a urologic abnormality is 2 ▪ Intramural
weeks ▪ Subserous- just beneath the serosa
- For patients whose symptoms recur and ▪ Submucosal- just below the endometrium, may be
whose culture shows the same organism associated with abnormal bleeding and distortion
as the initial infecting organism, a 4-6 of the uterine cavity that may produce infertility or
week regimen is recommended abortion
▪ Broad ligaement
*Notes: Notice that as one goes from ASB to Pyelonephritis ▪ Parastic
(asymptomatic to development of symptoms), the criteria for o Myomas often enlarge during pregnancy
diagnosis somewhat becomes lenient o Most common symptoms
▪ Pelvic pain or pressure
▪ Enlarging pelvic mass
IMPORTANT GYNECOLOGIC CONCEPTS ▪ Abnormal uterine bleeding (30%)
o Management
BENIGN GYNECOLOGIC LESIONS BASED ON LOCATION ▪ Judicious observation- for small asymptomatic
myomas
Vulva ▪ Myomectomy
• Urethral Caruncles – small, single, sessile but may be • Persistent pain/pressure
pedunculated, 1-2 cm in diameter. Occurs frequently in post- • Enlargement to more than
menopausal women, and may be secondary to infection or 8 cm to a woman who has
chronic irritation not completed childbearing
• Cysts- the most common large cyst of the vulva is a cystic • CONTRAINDICATION:
dilatation of an obstructed Bartholin’s duct. The most Pregnancy
common small vulvar cysts are epidermal inclusion cysts or ▪ Hysterectomy
sebacious cysts. • Persistent pain/pressure
• Nevus- vulvar nevi are one of the most common benign • Size reached the size of a
neoplasms in females; generally asymptomatic 14-16 week gestation
• Hemangioma- rare malformations of blood vessesls than ▪ Medical Management – decrease the circulating
true neoplasms. Usually discovered intitially during level of estrogen and progesterone
childhood. It is usually single, 1-2 cm in diameter, flat, soft • Adenomyosis – from aberrant glands of the basalis layer
and colors range from brown, red or purple. These tumors of endometrium. 50% are asymptomatic, but those who
range in size and not encapsulated are symptomatic present with dysmentorrhea,
• Fibroma- the most common benign solid tumors of the vulva. menorrhagia ages 35-50
It occurs in all age groups and commonly found in the labia
majora. Majority are 1-10 cm in diameter. Oviduct
• Lipoma- Benign, slow-growing, circumscribed tumors or fat • Leiomyomas
cells arising from the sub cutaneous tissue of the vulva • Angiomyomas
• Paratubal cysts – if pedunculated and near the fimbrial end
Vagina of the oviduct, they are called hydatid cysts of Morgagni
• Urethral diverticulum- permanent, epithelialized, sac-like
projection that arises from the posterior urethra, present at Ovary
a mass of the anterior vaginal wall. It is a common problem • Fuctional cysts – All are benign and usually does not cause
discovered in 1-3% of women symptoms or require surgical management
• Inclusion cysts- the most common cystic structures of the o Follicular cysts- most frequent cystic structures in
vagina normal ovaries. Mostly asymptomatic
• Dysontogenic cysts- thin walled, soft cysts of embryonic o Corpus luteum cysts- minimum of 3 cm in diameter,
origin associated with normal, delayed menses or
o Gartner’s duct cysts – from the mesonephros amenorrhea. It may cause intraperitoneal bleeding
o Mullerian cysts – from the o Theca lutein cysts- least common of the 3 physiologic
paramesonephricum ovarian cyts, almost always found bilaterally, and can
o Vestibular cysts – fromt he urogenital sinus produce enlargement of the ovaries. It is caused by
prolonged or excessive stimulation of the ovaries to
Cervix gonadotropins. USUALLY OCCUR WITH PREGNANCY,
• Endocervical and Cervical Polyps – Most common benign INCLUDING MOLAR PREGNANCY.
neoplastic growth of the cervix. It is most common in
multiparous women in their 40s-50s. Majority are smooth,
soft, reddish purple to cherry red. They are fragile and
readily bleed when touched. It may arise to endocervical
canal or ectocervix
• Nabothian cysts- retention cysts that are very common that
they are considered a normal feature of the adult cervix.
Aymptomatic and no treatment is necessary
• Cervical myoma- usually a solitary growth, small and most
are asymptomatic
• Benign neoplams Management

o Benign cystic teratoma (Dermoid cyst)- cystic • Laboratory
structures that on histologic examination contain o Pregnancy test, CBC, Prothrombin time, PTT,
elemetns of the three germ cell layers. Benign teratomas VWF
are among the most common ovarian neoplasms, and • Imaging
are the most common neoplasms in prepubertal females o Ultrasound
and teenagers. When opened, sebacous fluid along with • Endometrial Sampling
hair, cartilage and teeth can be found o Performed for women at risk for endometrial
o Endometriomas (Chocolate cyst) – usually associated pathology (polyps, hyperplasia or carcinoma)
with endometriosis, and one of the most common • Management
causes of the enlargement of the ovary. It range to small o Mefenamic Acid and other NSAIDs
(1-5 mm) to 5-10 cm in diameter hemorrhagic cysts. o Tranexamic Acid
Symptoms include pelvic pain, dyspareunia and o Mild bleeding: combination low-dose oral
infertility contraceptive
o Fibromas- most common benign, solid neoplasms of the o Acute moderate bleeding: combination
ovary. Associated with Meig’s syndome (Ovarian monophasic oral contraceptives every 6 hours
fibroma + ascites + hydrothrorax) for 4-7 days
o Brenner tumors (Transitional cell tumor)- rare, small, o Emergency management:
smooth, fibroepithelial ovarian tumors that are ▪ Hormonal therapy: Estrogen-
generally asymptomatic. 1-2% undergo malignant progestin therapy 1-2 pills 2x/day
changes. Histologically, it is composed of solid for 7 days effective for 12-24 hours
masses/nests of epithelial cells (similar to transition OR conjugated estrogens 25-40 mg
cells of the urinary bladder) and surrounding fibrous IV every 6 hrs or 2.5 mg oral every 6
stroma hours
o Adenofibroma and Cystadenofibroma – benign, firm ▪ If intrauterine clots are detected D&C
tumors, consists of fibrous and epithelial components is indicated
In relation to pregnancy:
The most frequent types of ovarian masses are corpus
luteum cysts, endometriomas, benign cystadenomas, and GENITOURINARY INFECTIONS and STDs
mature cystic teratomas (dermoids)
Diagnosis Description Treatment
TUMOR MARKERS Bacterial Most common cause of Metronidazole
Vaginosis vaginitis in the US Clindamycin
Marker Description
Serum CA125 Antigenic determinant, elevated in 80% of Women with BV are at risk for
patients with advanced epithelial ovarian PID, Pregnant women are at
cancers, is elevated in most patients with risk for PROM, preterm labor
advanced or metastatic endometrial cancers and delivery, chorioamnionitis
Also useful for monitoring epithelial ovarian Diagnosis: fishy vaginal odor;
cancer. Seen in 50% with stage 1 ovarian clue cells in histology
cancer Trichomonas Profuse, purulent, malodorous Metronidazole
Serum CA125 levels are useful in vaginal discharge with
distinguishing malignant from benign pelvic pruritus; Strawberry cervix
masses may be observed
Alfafetoprotein Both α -fetoprotein (AFP) and human chorionic
and hCG gonadotropin (hCG) are secreted by some Women with this infection
germ cell malignancies should also be tested for other
Most endodermal sinus tumor (EST) lesions STDs
secrete AFP Candidiasis 75% of women may Topical azoles
The mixed germ cell lesions may secrete either experience this in their (Butoconazole,
AFP, hCG, or both or neither of these markers, lifetime. Predisposing factors: Clotrimazole,
depending on the components pregnancy, diabetes, antibiotic Miconazole,
Inhibin Inhibin is secreted by some granulosa cell use. Discharge may be varied Tioconazole,
tumors from watery to thick Nystatin,
Fluconazole)
Atrophic Common in menopausal Estrogen
MANAGEMENT OF AUB/DUB vaginitis women cream
Cervicitis Presents with purulent Treatment –
Dysfunctional Uterine Bleeding cervical discharge for lower
- Describes abnormal bleeding for which no specific genital tract
cause was found; often a diagnosis of exclusion infection with
both
Causes of Bleeding Per Age Group chlamydia and
gonorrhea
Cefexime,
Azithromycin,
Doxycycline,
Ofloxacin,
Levofloxacin
Pelvic Diagnosis implies that the Outpatient involves allodynia (hyperesthesia, pain is
Inflammatory patient has upper genital tract treatment: present without stimulation), pain is
Disease infection and inflammation Cefoxitin or neurogenic in origin, Intolerance to pressure
(ascended to the endometrium Ceftriaxone may be caused by use of tampon, sexual
and fallopian tubes) PLUS activity, or tight clothing
Doxycycline or o Dysesthetic vulvodynia – most common on
Commonly caused by N. Azithromycin peri-and post menopausal women; pain is
gonorrhoeae and C. non-localized
trachomatis Inpatient - Therapy-similar to chronic pain syndromes
treatment: o Tricyclic anti-depressants
Triad: pelvic pain, cervical Cefoxitin or o Gabapentin (300-3600 mg daily) – 2/3 to ¾ of
motion and adnexal Cefotan PLUS women has response to treatment
tenderness and fever Doxycline
POLYCYSTIC OVARY SYNDROME
Or
- Characterized by a combination of hyperandrogenism
Clindamycin (either clinical or biochemical), chronic anovulation,
PLUS and polycystic ovaries. It is frequently associated with
Cefrtriaxone or insulin resistance and obesity
Gentamicin - It is the most common cause of hyperandrogenism,
Tubo-ovarian End stage process of PID Medical hirsutism, and anovulatory infertility in developed
Abscess treatment or countries
Abscess - Criteria:
Drainage o Oligoovulation or anovulation
Genital Those with genital ulcers may Chancroid: o Clinical and/or biochemical signs of
Ulcers have HSV or syphilis or Azithromycin, hyperandrogenism
chancroid Ceftriaxone, o Polycystic ovaries and exclusion of other
Ciprofloxacin, etiologies (congenital adrenal hyperplasia,
Erythromycin androgen-secreting tumors, Cushing’s
syndrome)
HSV: Acyclovir,
Famciclovir,
Valacyclovir
Syphillis: Pen
G
Genital warts Manifestation of HPV 51 Goal of
(external) treatment is to
remove the
Non-oncogenic HPV 6 and 11 warts but it is
also cause external genital not possible to
warts eradicate the
infection
Highly contagious
Cryotherapy,
Imiquimod
cream,
Podophyllin,
Podofilox,
Trichloroacetic
acid, Cautery,
Laser,
Interferon
UTI E.coli is the most common Acute Cystitis:
pathogen for acute cystitis TMP-SMX,
Nitrofurantoin
Pyelonephritis:
TMP-SMX,
Levofloxacin,
Cetriazone,
Ampicillin, - Metabolic Syndrome Diagnostic Criteria
Gentamicin o Female waist >35 inches
o Triglycerides >150 mg/dL
o HDL <50 mg/dL
VULVAR PAIN SYNDROMES o Blood pressure >130/85 mmHg
- Vulvodynia or vulvar pain is one of the most common o Fasting glucose: 110–126 mg/dL
gynecologic problems, and was noted that 15% of o Two-hour glucose (75 gm OGTT): 140–199
women will develop this in their lifetime mg/dL
- Other terms include vulcar pain syndrome, or vulvar - Treatment
vestibulitis o Hormonal contraception or ovulation
- Described as a triad of severe pain to touch, localized to induction
the vaginal vestibule and dyspareunia; pain and o Hirsutism: Weight loss, Oral contraceptives,
tenderness localized to the vestibule and mild-to- medroxyprogesterone, GnRH analogues,
moderate erythema glucorticoids, ketoconazole, finasteride,
- Categorized into: spironolactone, flutamide, metformin
o Vestibulodynia- usually younger women
(shortly after puberty to mid 20s); usually
AMBIGUOUS GENITALIA AND CONGENITAL ADRENAL
HYPERPLASIA
- Ambiguous genitalia will be found in 1 in 14,000
newborns
- Females with masculinized external genitalia will be
identified as female pseudohermaphrodites
- Most common cause is Congenital Adrenal Hyperplasia
- You may see clitoral enlargement and labial fusion
CONGENITAL ADRENAL HYPERPLASIA (CAH)

- May be demonstrated at birth by the presence of
ambiguous genitalia in genetic females or present later
in childhood
- Significant proportions of newborns with this condition
are also at risk for the development of life-threatening
neonatal adrenal crises as a result of sodium loss
because of absent aldosterone.
- In milder disease, delayed diagnosis may result in
abnormalities of accelerated bone maturation, leading
to short stature.
- The development of premature secondary sexual
characteristics in males and further virilization in
females may also occur
- Treatment and Management
IMPERFORATE HYMEN
o Replacement of cortisol – suppresses ACTH
- Hypen should establish a connection between the
output and decreases the stimulation of the
lumen of the vaginal canal and the vestibule
cortisol producing pathways in the adrenal
- May result to primary amenorrhea
cortex
- May cause hydrocolpos or mucocolpos- caused by
o For females at risk – dexamethasone
collection of secretions behind the hymen, and in rare
o Corrective surgery
cases may build up to form a mass that obstructs the
o Psychosocial support and counseling
urinary tract
- May develop hematocolpos and hematometrium
overtime
- Fallopian tubes can also be distended because the
menstrual flow may back up through the tubes
VAGINAL AGENESIS
- Also called Mullerian agenesis or Mullerian aplasia
- Usually associated with the Mayer-Rokitansky-Kuster-
Hauser (MRKH) syndrome
o congenital absence of the vagina and uterus
(in 75% of patients), although small masses of
smooth muscular material resembling a
rudimentary bicornuate uterus are not
uncommon
o Some patients have rudimentary uterine horns
o 50% have concurrent urinary tract anomalies
o Presents with primary amenorrhea
o PE findings shows a short vaginal pouch and
inability to palpare a uterus
GYNECOLOGIC PROBLEMS IN PRE-

PUBERTAL CHILDREN
Vulvovaginitis
- Most common gynecologic problem in the prepubertal
children
- Classic symptoms: introital irritation
(discomfort/pruritus) or discharge
- Major factor of childhood vulvovaginitis – poor perineal
hygiene because of the proximity to the rectum
- Treatment – improvement of local perineal hygiene –
keeping vulvar skin clean, dry and cool as well as
avoiding irritants
Labial Adhesions (Adhesive Vulvitis)

- Mean that the labia minora have adhered or
agglutinated together at the midline
- PE finding: a transluscent vertical midline line visible at
the site of agglutination. The thin line in a vertical
direction is pathognomonic for labial adhesions
- Often partial and only involve either upper or lower
aspectis of the labia
- Most common in girls ages 2-6 because estrogen is at its
lowest at this time
- No treatment is absolutely necessary UNLESS the child 2. ease of use
is symptomatic
o Symptoms- voiding difficulties, recurrent PERIODIC ABSTINENCE
vulvovaginitis, discomfort from labia pulling at Calendar - Woman records the length of her cycles
the site of adhesion, and rarely bleeding Rhythm Method for several months
- Treatment – dabbing of topical estrogen 2x/day at the - FERTILE PERIOD:
site of fusion Previous shortest cycle – 18=_____
Previous longest cycle- 11= ____
- the couple abstains from coitus during
FAMILY PLANNING this calculated fertile period
Natural - Temperature Method: the woman is
Reversible- temporary prevention of fertility; “active” method Family Planning required to abstain from intercourse
Permanent- sterilization; ”terminal method” (Rhythym) from the onset of the menses until the
third consecutive day of elevated basal
COITUS RELATED METHODS temperature
Spermicides - Active Ingredient: NANOXYL-9 (surfactant - Cervical Mucus Method: slippery
that immobilizes or kills sperm on mucus is observed to be present.
contact by destroying the sperm cell Abstinence is required every day
membrane. thereafter until 4 days after the last day
- Carriers: gels, foams, creams, tablets, films, when the characteristic mucus is
and suppositories present (the “peak mucus day”)
- Spermicides need to be placed into the - Require a great amount of motivation
and training
vagina before each coital act
- Pregnancy rates with use of these
methods are relatively high and
BARRIER METHODS
continuation rates are low.
Diaphragm - Thin, dome-shaped membrane of latex
Coitus - Removal of the penis from the vagina
rubber or silicone with a flexible spring
Interruptus prior to ejaculation to prevent
modeled into the rim. The spring allows the
(Withdrawal pregnancy is an ancient male-
device to be collapsed for insertion and then
Method) controlled method of contraception
allows for expansion within the vagina to
- Major drawback: No protection
seat the rim against the vaginal wall to
against STIs
create a mechanical barrier between the
Lactation Criteria:
vagina and the cervix
Amenorrhea 1. presence of amenorrhea
- should be used with a spermicide and be
Method (LAM) 2. exclusive breast-feeding (no
left in place for at least 8 hours after the last
coital act. If repeated intercourse takes supplements)
place, additional spermicide should be used 3. performed up to 6 months after
vaginally delivery
Cervical cap - a cup-shaped silicone or rubber device
that fits around the cervix HORMONAL CONTRACEPTION
- concern about a possible adverse effect of Progesterone - inhibit ovulation
the cap on cervical tissue, it has been - thickening of the cervical mucus
recommended that cap users not keep the Estrogen - maintains thin endometrium
- prevent unscheduled bleeding
cap in place for more than 48 hours
- inhibit follicular development
- speculum exam and repeat cervical
cytologic examination 3 months after
Oral Contraceptive Pills (OCPs)
starting to use this method
Pharmacology 1. fixed dose (monophasic)
Male - latex, polyurethane, and animal tissue 2. multiphasic (biphasic, triphasic,
Condom - Some condoms come prepackaged with quadphasic): lower total dose of
either N9 spermicide or lubricants. steroid without increasing
- N9 has been associated with an increase incidence of unscheduled bleeding
risk of HIV acquisition in high-risk 3. daily Progestin Only (POPs) aka
women minipills
Female - consists of a soft, loose-fitting polyurethane Physiology MOA: inhibits ovulation by by interfering
Condom sheath with two flexible rings: One ring lies with the release of gonadotropin
at the closed end of the sheath and serves as releasing hormone (GnRH) from the
an insertion mechanism and internal anchor hypothalamus
for the condom inside the vagina. The outer Estrogen: prevents rise in the FSH
ring forms the external edge of the device
Progestin: inhibits LH; changes in the
and remains outside the vagina after
cervical mucus (which prevent sperm
insertion, thus providing protection to the
transport into the uterus), the fallopian tube
introitus and the base of the penis during
(which interfere with gamete transport),
intercourse
and the endometrium (which reduce the
Advantages:
likelihood
1. female controlled
of implantation)
2. can be inserted prior to the onset of
ovulation inhibition dose: lowest amount of
sexual activity
a progestin needed to suppress LH
3. can be left in place for a longer time
*This dual actions of Estrogen and
after ejaculation
Progesterone lead to inhibition of follicle
4. offer greater protection against the
development and ovulation
transfer of certain sexually
transmitted organisms (Herpes and
HPV)
5. polyurethane is stronger and thicker
making it less likely to rupture
Disadvantages:
1. cost (about three times higher)
Metabolic Effects - directly related to dosage and potency 2. Systemic disease that may affect the
- Estrogen: nausea, breast tenderness, vascular system (SLE, diabetic
fluid retention (weight gain 3-4lbs), retinopathy and nephropathy)
melisma, depression (due to decrease 3. Cigarette Smoking older than 35 years
tryptophan →dec serotonin); decrease old
sebum production 4. Uncontrolled hypertension
- Progestin: increase sebum; acne and 5. Undiagnosed Uterine Bleeding
weight gain 6. Elevated triglycerides level
- Others: unscheduled, breakthrough 7. Pregnancy
bleeding (insufficient estrogen, too 8. Functional heart disease (CHF)
much progestin); headache (estrogen 9. Active Liver Disease
withdrawal) Relative
Hepatic Effects - Ethinyl Estradiol: Increase Factos V, 1. Heavy cigarette smoking younger than
VIII, X and fibrinogen; venous and 35
arterial thrombosis 2. Migraine headaches
- Progestin: decreased Steroid Hormone 3. Amenorrhea
Binding Globulin 4. Genital bleeding
1. Carbohydrate: The effect of OCs on Galactorhea
glucose metabolism is mainly Beginning Oral Adolescents: As long as she has
related to the dose, potency, and Contra demonstrated maturity of the
chemical structure of the Ceptives hypothalamic-pituitary-ovarian axis with at
progestin (Estrogen+Progestin: least three regular, presumably ovulatory,
impaired glucose tolerance) menstrual cycles
2. Lipids After Pregnancy
Estrogen: increase HDL, - Abortion (ovulation occurs 2-4 weeks)
cholesterol, total cholesterol and - less than 12 weeks: start immediately
triglycerides, decrease LDL - 21-28 weeks: 1 week later
Progesterone: decrease HDL, - 28 weeks and not nursing: 2-3 weeks
increase LDL, increase TG after delivery
3. Coagulation Parameters *When woman breastfeeds every 4 hours
Estrogen: increase risk of including nighttime, ovulation occurs 10
thrombosis weeks after delivery
Cardiovascular - Thrombosis, not atherosclerotic
Effects - Venous thromboembolism: increased
risk LONG ACTING HORMONAL CONTRACEPTIVE
- Myocardial infarctions there is no Contraceptive Three layers:
increased risk of myocardial Patch 1. an outer protective layer of polyester
infarction (MI) 2. an adhesive middle layer containing
(Cigarette smoking of more than 25 75 mcg ethinyl estradiol and 6.0 mg
sticks per day with OCPs has a 30-fold norelgestromin
MI risk) 3. a polyester release liner that is
- Stroke: no increased risk removed prior to placement on the
- Smoking is a risk factor for arterial skin
but not venous thrombosis. - delivers 150 mcg norelgestromin and 20
Combination OCs should not be mcg ethinyl estradiol into the circulation
prescribed to women older than the each day at a fairly constant rate for at
age of 35 who smoke cigarettes or use least 9 days
alternative forms of nicotine Contraceptive - Fllexible soft colorless ring-shaped device
Obesity - BMI greater than 30 with OCs: 3-fold Vaginal Ring made of ethylene vinyl acetate copolymers
increase in venous thrombosis; affects - Each ring contains 2.7 mg of ethinyl
OC efficacy estradiol and 11.7 mg of etonogestrel
Neoplastic 1. Breast- increased risk, however OC Injectables Depo-MedroxyProgesterone Acetate
effects with less than 50mcg of Estrogen does (DMPA)
not pose any increase risk for - Given every 3 months
developing breast Ca MPA: 17-acetoxy-6-methylprogestin that has
2. Cervical Ca- conflicting progestogenic activity in the human
3. Endometrium- strong protective - inhibits ovulation
effect; related to duration of use with - keeps endometrium thin
40% reduction in 2 years and 60% in 4 - keeps cervical mucus thin
years - Non-contraceptive benefits (DEFINITIVE:
4. Ovarian Ca- reduces risk with 30% salpingitis, endom CA, Irone deficiency
reduction in 1 year, 40% in 4 years, anemia, Sickle cell anemia; PROBABLE:
53% in 8 years and 60% in 12 years Ovarian cysts, dysmenorrhea,
5. Liver adenoma and Ca- should not be endometriosis, epileptic seizure, vaginal
used in patients with active liver candidiasis)
disease - Resumption of ovulation after DMPA is
6. Pituitary adenoma-mask symptoms aried and may last up until 1 year
produced by prolactinoma - In cycling women: Days 0-5 of the cycle
(amenorrhea and galactorrhea) - Nonlactating women: 5 days postpartum
7. Malignant Melanoma- does not alter - Exclusive BF : should not be given until at
the risk least 6 weeks postpartum
8. Colorectal Ca- decreases the risk of Norethindrone Enanthate (NET-EN)
developing both colon and rectal - Given every 60 days for at least the 1st 6
cancer months then every 12 weeks
Contra- Absolute
Indications To 1. History of vascular disease Progestin-Estrogen (once monthly
Ocp Use (thromboembolism, thrombophlebitis, injectable)
atherosclerosis, and stroke) - 25mg MPA, 5mg estradiol enanthate
Subdermal Norplant
Implant -made of polydimethylsiloxane (Silastic)
containing levonorgestrel
Norplant II
Implanon
- Third generation
- duration of action of 3 years
- extremely effective, and is much easier to
insert and remove than the multiple
levonorgestrel-releasing implants.
- Contains 68 mg of the progestin
Etonogestrel
Adverse Reactions:
1. Bleeding irregularities
2. Acne
EMERGENCY CONTRACEPTION
Steroids - most effective if treatment begins within 72
hours after an isolated midcycle act of coitus
- eg. A regimen of four tablets of ethinyl estradiol,
0.05 mg, and dl-norgestrel, 0.5 mg, combination
oral contraceptive (Ovral), given in doses of two
tablets 12 hours apart
Copper - effective for 7 days after coitus
IUD
INTRAUTERINE DEVICE (IUD)

Mechanism of Action: induce a local inflammatory reaction
of the endometrium, and the cellular and humoral
components expressed in the tissue and the fluid fill the
uterine cavity to create an environment that is toxic to sperm,
so fertilization of the ovum does not occur
Benefits
- a high level of effectiveness,
- a lack of associated systemic metabolic effects
- the need for only a single act of motivation for long-term use
Contraindications
1. Pregnancy or suspicion of pregnancy
2. Acute PID
3. Postpartum enometritis of inflicted abortion in the
past 3 months
4. Known or suspected uterine or cervical malignancy
5. Genital bleeding of unknown origin
6. Untreated acute cervicitis
7. Previously inserted IUD that has not been removed
STERILIZATION
Male sterilization Vasectomy
- 13 to 20 ejaculations are required
after the procedure
Female - Bilateral tubal Ligation
sterilization - *Fimbriectomy (supposed
protection from ovarian Ca)
This OB-Gyne Supplement handout was created by Marie Jo-An

Cabanting MD and subsequent updated by Niña Katrina
Banzuela, MD. Thank you so much Joan and Niña! =)

TOPNOTCH Ob-Gyne Supplement Handout by Joan Cabanting and Nina Banzuela - UPDATED DECEMBER 2017 PDF

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TOPNOTCH MEDICAL BOARD PREP OB SUPPLEMENT HANDOUT BY THE TOPNOTCH TEAM

For inquiries visit www.topnotchboardprep.com.ph or https://web.facebook.com/topnotchmedicalboardprep

Posterior Anal triangle

Urogenital (Anterior) Triangle: SUPERFICIAL SPACE

closed bounded deeply by the perineal

ischiocavernosus clitoral erection

bulbocavernosus Bartholin gland secretion

superficial may be attenuated or even absent

Urogenital (Anterior) Triangle: DEEP SPACE

Continuous lies deep to the perineal membrane and

Ishorectal wedge-shaped spaces found on either side of

PUDENDAL NERVE AND VESSELS

Course between the piriformis and coccygeus

dorsal nerve of skin of the clitoris

perineal nerve muscles of the anterior triangle and labial

inferior rectal external anal sphincter, the mucous

Landmark for Ischial spine

Cervix: SQUAMO-COLUMNAR JUNCTION

EMBRYOLOGIC STRUCTURES AND DERIVATIVES

EMBRYOLOGIC MALE FEMALE

MESONEPHRIC DUCT Appendix of Appendix of

BLASTOCYST FORMATION DRUGS IN PREGNANCY

Embryonic Commences beginning of the 3rd week after

Abortus Fetus or embryo removed or expelled fro uterus

GESTATIONAL AGE vs. OVULATION AGE

DETERMINING THE AGE OF THE FETUS

Conditions that Affect Hormone Levels in Pregnancy

Fetal Demise dec estrogen AOG

Fetal Erythroblastosis Elevated 16 fetal crown-rump length is 12

Terms 28 crown-rump length is approximately 25 cm

Fetal Circulation: CHANGES AFTER BIRTH

SECOND AND THIRD TRIMESTER SONOGRAPHY

NUCHAL TRANSLUSCENCY Three Types of Examination (Congenital Anomaly Scan)

DELIVERY OF THE AFTERCOMING HEAD

9. Early weight changes POST-PARTUM HEMORRHAGE (PPH)

DELAYED CORD CLAMPING Problems with the above definitions:

8. Maternal request (CDMR)

GBS can also cause maternal bacteriuria,

MRSA Skin and soft tissue infections are the most

ACUTE CYSTITIS IN PREGNANCY

- In pregnant women suspected to have

Who: Screen ALL pregnant women for ASB

• Benign neoplams Management

CONGENITAL ADRENAL HYPERPLASIA (CAH)

GYNECOLOGIC PROBLEMS IN PRE-

Labial Adhesions (Adhesive Vulvitis)

INTRAUTERINE DEVICE (IUD)

This OB-Gyne Supplement handout was created by Marie Jo-An

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