C8GN

hyslcal exam and pelvlc exam durlng renaLal vlslLs & lnvesLlgaLlons ApproprlaLe for Lhe gesLaLlonal age
- hys|ca| Lxam
- 8ase||ne 8|ood ressure
l. lmporLanL for lnLerpreLlng changes ln Lhe fuLure, l.e. pre-eclampsla.
- WelghL
- e|v|c exam
l. ap smear (lf none wlLhln 6 monLhs),
ll. CulLure for GC and ch|amyd|a
- Gestat|ona| age (CA)
- lf regular perlods and sure LM daLe ! use flrsL day of Lhe LM ! unLll now
- lf uncerta|n LM ! daLlng uslng u|trasound (besL beLween weeks 8-12)

ASM1CMA1IC 8AC1LkIUkIA IN A kLGNAN1 WCMAN
- Ur|ne AsympLomaLlc bacLerlurla? MCC: L. co||
- lf unLreaLed 23-30 ! U1I (rlsk of pye|onephr|t|s) ! ^ r|sk of preterm |abor.

GLNL1IC SCkLLNING
- Serum a|pha fetoprote|n (AI): beLween 16-20 weeks for older or oLher hlgh-8lsk paLlenLs.
- oslLlve 1r|p|e screen (low Al, Low esLrlol, hlgh PCC) - means llkely Down's syndrome.
- uad screen tr|p|e screen + |nh|b|n A (h|gh)








Ieta| heart 1CNLS & cardlac acLlvlLy can be deLecLed wlLh:
- 1ransvag|na| U]S aL 7-8 weeks
- Dopp|er aL 10-12 weeks
- Stethoscope aL 16-20 weeks.

Culckenlng (when Lhe moLher 1
sL
deLecLs feLal movemenLs):
- rlmlgravlda: usually occurs aL 18 Lo 20 weeks &
- MulLlgravlda: 16 Lo 18 weeks

Ieta| neart kate Norma|: 120-160 bpm (Any value ouLslde Lhls range ! worrlsome.)

Ieta| 1ACnCAkDIA: lf hearL raLe >160 bpm - ofLen assoclaLed wlLh:
- CxyLocln admlnlsLraLlon,
- MaLernal fever or
- lnLrauLerlne lnfecLlon.

Ieta| neart Mon|tor|ng:

8ouLlne durlng labor-dellvery Lo deLecL early feLal dlsLress from feLal hypoxla/ Closer assessmenL of hlgh-rlsk moLhers.


er|od|c Ieta| neart kate Changes:
- Acce|erat|ons:
o 1ranslenL lncrease of 13 bpm, lasLlng for 13 seconds,
o 8esponse Lo feLal movemenL or uLerlne conLracLlon
- keassur|ng s|gn of feta| we||-be|ng.
- Non-stress test (NS1):
o Screenlng LesL
o keact|ve ! normal - 2 acceleraLlons wlLhln a 20 mln perlod.
o Non-react|ve: less Lhan 2 ! sleep?
- Dece|erat|ons ! 3 Lypes:
o Lar|y - head compress|on (normal)
" deceleraLlon nadlr and uLerlne conLracLlon peak ! maLch up.
" shape wlLh onseL early ln conLracLlon
" robably d/L vagal response from head compress|on.
" normal
o Late - uterop|acenta| |nsuff|c|ency
" CnseL: laLe ln conLracLlon, feLal deceleraLlon nadlr occurs afLer peak of uLerlne conLracLlon, and reLurn Lo basellne
afLer end of conLracLlon. nadlr may as low as 40 bpm
" lndlcaLes a uterop|acenta| |nsuff|c|ency.
" 1he mosL worrlsome paLLern!
o Var|ab|e - cord compress|on
" varlable ln shape, onseL, and duraLlon
" MosL common Lype of perlodlclLy seen durlng labor
" uue Lo cord compress|on.

Symphys|s-funda| he|ght (SlP) measuremenL:
MeasuremenL beLween 20 and 33 weeks (ln cm) should equal Lhe number of weeks of gesLaLlon
12 weeks: publc symphysls
20 weeks: umblllcus
33 weeks: sLernum

ln obsLeLrlcs, card|otocography (C1G) ls a Lechnlcal means of recordlng of Lhe feLal hearLbeaL and Lhe uLerlne conLracLlons (!"#$#!)
durlng pregnancy, Lyplcally ln Lhe Lhlrd LrlmesLer. 1he machlne used Lo perform Lhe monlLorlng ls called a card|otocograph, more
commonly known as an e|ectron|c feta| mon|tor (LIM).
8asellne lP8 varlablllLy ls deflned as flucLuaLlons ln Lhe basellne lP8 LhaL are lrregular ln ampllLude and frequency.
1he flucLuaLlons are vlsually quanLlLaLed as Lhe ampllLude of Lhe peak- Lo-Lrough ln bpm.
In|t|a| renata| V|s|t
1. ]L:
a) WelghL & PelghL measuremenL
b) 8 measuremenL
c) LxamlnaLlon of Lhyrold, hearL, lungs, breasLs, abd, exLremlLles & opLlc fundus
d) LxamlnaLlon of ankles for edema
e) CompleLe pelvlc examlnaLlon
f) LxamlnaLlon Lo deLermlne pelvlc capaclLy
g) LxamlnaLlon of uLerus slze and feLal poslLlon
h) LvaluaLlon for feLal hearL sounds
2. 8|ood test:
a) C8C, 8lood Lyplng and 8h
0
(u) anLlbody levels,
b) Serologlc LesLs for hepaLlLls 8, rubella and syphllls
3. Cerv|ca| tests:
a) CulLures for CC and chlamydla
b) apanlcolaou (ap) LesL.
4. Ur|ne tests:
a) urlne culLure,
b) urlne proLeln and glucose
3. CLher LesLs:
a) Screenlng for 18 (lf aL rlsk)
6. CeneLlc screenlng
7. elvlc u/S (ldeally bLw 16-20 wks),
buL noL rouLlnely.

Io||ow-Ups
1. WelghL
2. 8
3. Ldema
4. uLerus slze & feLal pos
3. PearL snd
6. 8epeaL: 8h Ab. aL 28 wk (ln 8h neg. women) and PcL ln 3
rd
LrlmesLer
7. ln hlgh rlsk woman: repeaL CC & Chlam aL 36 wks
8. urlne: proLeln & glucose

kLMA1UkL kU1UkL CI 1nL MLM8kANL
1. 8upLure of membrane prlor Lo Lhe onseL of uLerlne conLracLlon (noL a normal progresslon of labor!)
2. ln Lerm-pregnancy buL unfavorable cervlx ! Lo decrease rlsk of lnfecLlon ! 1x: expedlLed dellvery w/ oxyLocln & prosLaglandln.

1
st
& 2
nd
tr|mester b|eed|ng Abort|on, Abnorma| regnancy
A8Ck1ICN: (LhreaLened, lnevlLable, compleLe & lncompleLe). - < 3 of LhreaLened aborLlons go on Lo aborL
1. 1hreatened abort|on
a. llrsL LrlmesLer bleedlng
b. leLal pole wlLh a hearLbeaL
c. lf Lhere ls a hearLbeaL Lhere ls less Lhan 10 chance of mlscarrlage
2. Inev|tab|e abort|on
a. ueformaLlon and/or descenL of gesLaLlonal sac wlLh a dllaLed cervlx
3. Comp|ete abort|on
a. roducLs of concepLlon compleLely expelled
4. M|ssed abort|on
a. lnLrauLerlne pregnancy wlLh an embryo, buL no cardlac acLlvlLy by 8 weeks gesLaLlon













Abnorma| pregnancy:
S. Lctop|c pregnancy
a. regnancy ouLslde Lhe uLerlne cavlLy. MC locaLlon: ln lalloplan Lube (Lubal pregnancles), buL can be ln Lhe cervlx,
ovarles, and abd. cavlLy
b. oLenLlally medlcal emergency, can lead Lo deaLh
c. 1-8 wk afLer a mlssed perlod. SSx of pregnancy ! poslLlve (n/ v, breasL Lenderness). lncldence: 1 ln 100 pregnancles.
d. 8lsk facLors: prevlous Px of lu or ecLoplc pregnancy, use of luu,
uLS exposure, and prlor pelvlc surgery.
e. S & S: abdomlnal paln, vaglnal bleedlng (d/L Lubal aborLlon). 8lmanual elvlc Lxam: a boggy/ poorly dellneaLed pelvlc
mass, and cervlcal moLlon Lenderness (CM1) ls poslLlve.
f. lf rupLures ! hemoperlLoneum ! may presenL wlLh slgns of shock, and Lhe paln may radlaLe Lo Lhe shoulder (d/L
lrrlLaLlon of Lhe dlaphragm)
g. Adler slgn: Lhe presence of flxed" abdomlnal Lenderness on Lurnlng Lhe paLlenL Lo Lhe LLu or 8Lu. 1hls ls Lo uu wlLh
acuLe appendlclLls.
6. Mo|ar pregnancy
a. A gesLaLlonal LrophoblasLlc dlsease
b. A non-vlable ferLlllzed egg lmplanLs ln Lhe uLerus
and converLs lnLo a mass ln Lhe uLerus
(swollen chorlonlc vllll, whlch grow ln clusLers, resemble grapes).
c. Mole ls caLegorlzed lnLo: parLlal mole (wlLh some developmenL of a malformed embryo/ feLus) or compleLe mole (no
embryo/ feLus).
d. CharacLerlzed by: Lhe presence of a hydaLldlform mole (= hydaLld mole, mola hydaLldosa), and wlll end up as a mlssed
aborLlon/ mlscarrlage.
e. SSx: palnless vaglnal bleedlng ln Lhe fourLh Lo flfLh monLh of pregancy
f. Lab: Plgh level of beLa hCC,
ux: uSC ! "clusLer of grapes/ "honeycombed uLerus/ "snow-sLorm. ueflnlLlve ux: PlsLo-A
g. 1x: succLlon curreLage and hCC follow up.
h. Cnly 2-3 develop lnLo chorlo Ca.
7. 1rauma (posL-colLal)
8. hyslologlc bleedlng (due Lo placenLal developmenL)
9. CenlLal leslon (e.g. cervlcal polyp, neoplasms)
3
rd
tr|mester b|eed|ng - lacenLa prevla, AbrupLlo placenLae, vasa prevla, uLerlne rupLure
******1h|rd semester b|eed|ng ! a|ways do an u|trasound before a pe|v|c exam.
1. Cervlcal causes: - CervlclLls, polyp, cervlcal eroslon (ecLroplon), cervlcal cancer/8loody show (sheddlng of cervlcal mucous plug)
2. vaglnal cause - varlcoslLles, laceraLlons
3. lacenLal causes:
1. LACLN1A kLVIA
l. Abnormal placenLa lmplanLaLlon aL or near Lhe cervlcal os
1. *alnless vaglnal bleedlng ln Lhlrd LrlmesLer* - Cesarean dellvery wlll be done.
ll. Marglnal: wlLhln 2 cm of os buL does noL cover any parL of os
lll. arLlal: placenLa parLlally covers lnLernal os
lv. 1oLal: placenLa compleLely covers Lhe lnLernal os
2. A8kU1IC LACLN1AL
v. remaLure separaLlon of a normally lmplanLed placenLa afLer 20 weeks gesLaLlon
3. VASA kLVIA
vl. velamenLous lnserLlon of cord lnLo membranes of placenLa.
vll. unproLecLed feLal vessels pass over Lhe cervlcal os
vlll. Vasa prev|a ls an obsLeLrlc compllcaLlon deflned as "feLal vessels crosslng or runnlng ln close proxlmlLy Lo Lhe
lnner cervlcal os".
lx. normally, Lhe umblllcal cord lnserLs lnLo Lhe mlddle of Lhe placenLa as lL develops. ln velamenLous cord
lnserLlon, Lhe umblllcal cord lnserLs lnLo Lhe feLal membranes (chorlamnloLlc membranes), Lhen Lravels wlLhln
Lhe membranes Lo Lhe placenLa (beLween Lhe amnlon and Lhe chorlon). 1he exposed vessels are noL proLecLed
by WharLon's [elly and hence are vulnerable Lo rupLure. 8upLure ls especlally llkely lf Lhe vessels are near Lhe
cervlx, ln whlch case Lhey may rupLure ln early labor, llkely resulLlng ln a sLlllblrLh.
4. U1LkINL kU1UkL
x. CompleLe separaLlon of Lhe wall of Lhe pregnanL uLerus wlLh or wlLhouL expulslon of Lhe feLus LhaL can
endanger Lhe llfe of Lhe moLher & feLus.
xl. Sudden exLreme paln, profuse vaglnal bleedlng, hypoLenslon or shock ln Lhe moLher & feLal bradycardla. leLal
parLs may be palpaLed ln Lhe abdomen, or abdomlnal conLour mlghL change.
xll. 8lsk facLors: revlous uLerlne surgery, Lrauma, excesslve oxyLocln, grand mulLlparlLy.

reec|amps|a] Lc|amps|a and regnancy Induced n1N
1. MILD 8L-LCLAMSlA:
a. SusLalned 8 elevaLlon > 140]90 mm ng
b. AfLer 20Lh week of pregnancy
c. urlnalysls wlLh 2+ or more proLelnurla (> 300 mg/ 24 hrs) or > 1+ urlne dlpsLlc
d. Cllgurla
e. Swelllng of hands and/or face noLe: Some swelllng of Lhe feeL and ankles ls consldered normal wlLh pregnancy
f. 8apld welghL galn
g. MgmnL: lf < 36 wks expecLanL (dlscharge wlLh close monlLorlng of feLal & maLernal survelllance).
lf > 36 - 37 wks ! dellvery.
2. SLVLkL 8LLCLAMSlA:
a. Mlld preeclampsla plus one of Lhe followlng:
l. SusLalned 8 elevaLlon >160]110 mm ng
ll. 3+ roLelnurla (> 3 g/ 24 hrs)
lll. rescence of *warnlng slgns* - n/v, Peadache, vlsual dlsLurbances, Abdomlnal paln,
lv. PLLL syndrome = hemolysls, elevaLed llver enzymes & low plaLeleLs.
3. LCLAMSIA:
a. reeclamsla + Lonlc-clonlc selzures:
unexplalned grand mal selzures ln a hyperLenslve and or proLelnurlc pregnanL women ln Lhe lasL half of pregnancy.
b. A llfe-LhreaLenlng condlLlon.
c. 1reaLmenL:
l. Magneslum sulfaLe for eclampLlc selzures
ll. Lower blood pressure Lo 143/100 wlLh hydralazlne l.v.
lll. uellvery ls Lhe only deflnlLlve LreaLmenL for eclampsla (eclampsla ! assoclaLed wlLh preLerm dellvery, ln 30)
4. kLGNANC INDUCLD n1N - MANAGLMLN1
a. uellvery ls Lhe LreaLmenL, lf Lhe paLlenL ls aL Lerm.
b. lf premaLure & pLn has mlld P1n ! LreaL wlLh labeLalol or hydralazlne, and bedresL.
c. Cbserve Lhe paLlenL carefully.
d. lf Lhe paLlenL has severe dlsease (ollgurla, menLal sLaLus changes, PA, blurred vlslon, PLLL syndrome, blood pressure
>160/110mmPg, or progresslon Lo eclampsla) ! dellver Lhe baby, regardless of gesLaLlonal age.
CS1 Ak1UM nLMCkknAGL - 8lood Loss > S00m| dur|ng vag|na| de||very & >1000m| dur|ng C-Sect|on / (MCC - uLerlne ALony)
1. U1LkINL A1CN
a. caused by overdlsLenslon of Lhe uLerus (mulLlple gesLaLlon), prolonged labour, grand mulLlparlLy (hlsLory of 3 or more
dellverles).
b. 1x. - ulluLe oxyLocln & blmanual massage of Lhe uLerus. Can also Lry llgaLlng uLerlne vessels.
l. lf Lhls falls Lry prosLaglandln. lf LhaL falls - hysLerecLomy.
2. U1LkINL INVLkSICN:
a. 1he uLerus lnverLs and can be seen ouLslde Lhe vaglna, usually as a resulL of pulllng Loo hard on Lhe cord.
b. uL Lhe uLerus back ln place manually (anesLhesla may be needed) and glve lv flulds and oxyLocln.


ISSULS IN CS1 Ak1UM LkICD - ulmonary embollsm, sychlaLrlc condlLlons, lever ln posL parLum, breasL feedlng condlLlons.
1. ULMCNAk LM8CLISM:
1. Cne of Lhe MC causes of MorLallLy osL-parLum
2. due Lo hyper-coagulable sLaLe, amnloLlc fluld embollsm
2. SCnIA1kIC CCNDI1ICNS
1. osLparLum blues (80): mood swlngs & Learfulness, buL predomlnanLly [oy.
2. osLparLum depresslon (10-20): predomlnanLly sadness. CharacLerlsLlcs: welghL loss, sleeplessness, anhedonla, anxleLy,
and oLher depresslon sympLoms. MngmnL: refer Lo psychlaLrlsL (psycho1x & anLldepresslon)
3. osLparLum psychosls ( 1): blzarre LhoughL & behavlours, vlsual and audlLory halluclnaLlons. MngmnL: hosplLallzaLlon &
anLlpsychoLlc
3. ILVLk
1. usually endometr|t|s: loul smelllng dlscharge, fever & uLerlne Lenderness.
2. lf a posL-parLum fever does noL resolve wlLh broad specLrum anLlbloLlcs, Lhere are 2 maln posslblllLles:
1. e|v|c abscess: C1 scan wlll show Lhe abscess. lf presenL, draln lL or
2. e|v|c thromboph|eb|t|s: manlfesLs as splklng fevers (fence posL fever).
4. 8kLAS1 ILLDING:
1. lf a woman does wanL Lo breasLfeed, waLch for masLlLls, whlch usually develops ln Lhe flrsL Lwo monLhs posLparLum.
2. 8reasLs are red, lnduraLed, and palnful and nlpple cracks or flssurlng may be seen.
1. LacLaLlon masLlLls Lends Lo affecL only one breasL - noL boLh breasLs.
3. SLaphylococcus aureus ls Lhe usual cause.
4. MasLlLls 1reaLmenL:
1. Analgeslcs (l.e. aceLamlnophen, lbuprofen)
2. Apply molsL heaL Lo affecLed breasL for 13 mlns 4x/day
3. ConLlnue breasLfeedlng Lo relleve breasL engorgemenL (use pump lf needed).
4. AnLlsLaphylococcal anLlbloLlc ls usually glven for more Lhan mlld sympLoms.
3. lf a flucLuanL mass develops or Lhere ls no response Lo anLlbloLlcs wlLhln a few days, an abscess ls llkely presenL and musL
be dralned.
GNLCCLCG
1yplcal cllnlcal presenLaLlon, Lhe sympLoms and slgns
Pow Lo make ux and know Lhe uu
1he rlsk facLors, Lhe common causes and Lhe posslble long Lerm effecL
1he LreaLmenL (flrsL 1x/ besL 1x/ mosL effecLlve 1x, eLc)

Secondary amenorrhea
- Absence of mensLruaLlon for: 3-months |f prev|ous|y regu|ar cyc|es or 6-months |f prev|ous|y |rregu|ar cyc|es
- 1
sL
- 8ule ouL pregnancy (Lhe MCC) ! geL a beta hCG
- CLher cause - Cvarlan dlsease - 40 (!) / PypoLhalamlc dysfuncLlon - 33/ lLulLary dlsease/ uLerlne dlsease
- hyslologlc causes - regnancy / LacLaLlon / Menopause
- Secondary causes - Low body welghL (malnuLrlLlon, anorexla nervosa = 8Ml <17.3 kg/m
2
))/ SLress/ Chronlc lllness
- hyslcal Lxam
l. PelghL & welghL, 8Ml
ll. Any evldence of sysLemlc lllness or cachexla
lll. 8reasL exam - check for galacLorrhea
lv. Check for hlrsulLlsm, acne, sLrlae, acanLhosls nlgrlcans, vlLlllgo.
- Labs - urlne or serum -hCC/ Serum prolacLln, 1SP, lSP/ 1esLosLerone lf lndlcaLed
- AlgorlLhm for Workup
l. uo a pregnancy LesL
ll. Check prolacLln level (Lo 8/C plLulLary Lumor) & 1SP (Lo 8/C hypoLhyroldlsm).
lll. AdmlnlsLer progesLerone - lurLher LesLlng depends on resulLs of progesLerone challenge:
l. lf vaglnal bleedlng wlLhln 2 weeks = sufflclenL esLrogen.
1. nexL, check LP.
a. lf hlgh, Lhlnk CCS.
b. lf low ! hypoLhalamlc dysfuncLlon (secondary causes? Look for drug (8L ! under consLanL suppresslon by
dopamln), sLress or exerclse lnduced depresslon of Cn8P).
lv. lf Lhere ls no vaglnal bleedlng afLer progesLerone challenge LesL, means Lhere ls noL sufflclenL esLrogen.
1. Check lSP
a. Plgh = menopause (premaLure ovarlan fallure)
b. Low or normal lSP = check for CnS Lumor or ouLleL obsLrucLlon

6
SLCCNDAk DSMLNCkknLA:
- MensLrual paln due Lo an underlylng organlc dlsease - 8eglns ln women who are ln Lhelr 20s - Worsens wlLh age
- AssoclaLed dyspareunla, abnormal bleedlng, lnferLlllLy

a. LNDCML1kICSIS
- rollferaLlon & funcLlonlng of endomeLrlal Llssue ouLslde of Lhe uLerlne cavlLy.
- AffecLs 1-2 of women, peak age 20-30's up Lo 30 ln lnferLlle women
- MC Locat|on: CVAkILS (60) 2
nd
MC: cul de sac (uLero-sacral llgamenL)/ 8uL can be anywhere ln perlLoneum
- CC - e|v|c pa|n ! 3 D's: Dysmenorrhea, Dyspareun|a, & Dyschez|a ] lnferLlllLy
- 8ecLovaglnal exam ! uLerosacral nodularlLles
- ulagnosls: Laparoscopy: - 1yplcal leslons have a "powder burn" or "mu|berry" ||ke appearance (dark b|ue
or brown|sh-b|ack) on the uterosacra| ||gaments, cul-de-sac, or anywhere ln Lhe pelvls.
- 1x. Conservat|ve ! surgery
- Lxclslon, cauLerlzaLlon, or ablaLlon of endomeLrlal lmplanLs wlLh preservaLlon of ovarles and uLerus .
- Danazo|: lnhlblLs ovarlan sLeroldogenesls
- ! LsLrogen secreLlon, buL |t has androgen|c effect ! acne and h|rsut|sm ! not very popu|ar now
- Gnkn agon|st: Lg.: Leupro||de, 8usere||n
- lnlLlally lncreases LP & lSP, buL afLer appr 10 days ! down regulaLes recepLors ! suppresses secreLlon of LP &
lSP ! hypogonadal effecL. - ! more popu|ar now for a wlde varleLy of gyn. problems

b. Adenomyos|s
- LndomeLrlal glands found wlLhln uLerlne musculaLure (focal or dlffuse).
- usually t. |s > 40 yrs and presenLs wlLh menorrhagla & dysmenorrhea.
- elvlc exam reveals a |arge boggy uterus.
- lnvesLlgaLlons:
- M8l (mosL accuraLe)
- e|v|c U|tra-Sound (not very sens|t|ve, but h|gh|y spec|f|c)
- D&C to ru|e out Lndometr|a| Ca.
- 1x. - lron supplemenLs as necessary / Analgeslcs/ nSAlus/ Cn8P agonlsLs
- Conslder LoLal abdomlnal hysLerecLomy (1AP), & 8SC lf > 43 yo, lf paLlenL has severe sympLoms.

c. I|bro|d (Le|omyoma = Uter|ne f|bro|ds = I|bro|d)
- 8en|gn Lumors LhaL develop ln uLerus.
- Common ! l.e.: 1 ln 3 women durlng ch||dbear|ng age = 8y age 30 ! half of women have flbrolds.
- Look for kap|d growth dur|ng pregnancy or use of ora| contracept|ves, w|th regress|on after menopause
- Lstrogen Dependant 1umor
- llbrolds can cause |nfert|||ty, menometrorrhag|a, dysmenorrhea
- Symptoms
- elvlc cramplng or paln wlLh perlods
- MeLrorrhagla (bleedlng beLween perlods).
- Menorrhagla (heavy mensLrual bleedlng).
- Anem|a due to |e|omyoma = |nd|cat|on for hysterectomy.
- Invest|gat|ons
- elvlc exam ! changes ln shape of uLerus. - Can be dlfflculL Lo dx. lf pL ls exLremely overwelghL.
- U|trasound conf|rms the d|agnos|s.
- D&C ! Lo rule ouL endomeLrlal cancer and mallgnanL LransformaLlon. 8are (<1).
- 1x. f|bro|dectomy (= myomectomy)
- 1hls can resLore ferLlllLy. (8emember: Lo prevenL uLerlne rupLure durlng labour and dellvery ! CS)
- llbrold ls Lhe MC lndlcaLlon for hysLerecLomy.
- May noL need Lo be removed lf Lhey are noL causlng paln, bleedlng excesslvely, or growlng rapldly.

DSIUNC1ICNAL U1LkINL 8LLLDING (DU8)
- MCC Abnormal uLerlne bleedlng
- alnless, lrregular & lnLermlLLenL, noL assoc. wlLh Lumor (lnvesLlgaLe wlLh PSC), lnflammaLlon or pregnancy (ulagnosls of excluslon)
- usually assoclaLed wlLh anovulaLory cycles (unopposed esLrogen), such as ln polycysLlc ovarlan syndrome,
- More common afLer menarche and prlor Lo menopause
- 8/C endometr|a| cancer w|th a D&C (d||at|on & curettage)!
- Check for anemla (Pb or PcL).
- 1x - Cycllc progesLlns (aL days 14-23 of Lhe cycle) or CC + lron lf anemlc
LLVIC INILAMMA1Ck DISLASL (ID)
- Age 13-3S yrs resenLlng wlLh Abdom|na| pa|n (|ower quadrants)
+ Adnexa| tenderness] mass, (usua||y UL can be 8L)
+ Cerv|ca| mot|on tenderness
+ one of Lhe followlng: - Iever (> 38 C or > 100.4 I) / uru|ent cerv|ca| d|scharge. / LeukocyLosls, LlevaLed LS8 (> 13) or C8
- Caused by: Chlamydla, Conorrhea, L. coll, AcLlnomyces (lf wlLh luu Px).
- CompllcaLlons - lnferLlllLy d/L scarrlng of Lhe falloplan Lubes
- 1x. - Ceftr|axone + Doxycyc||ne.

e|v|c ke|axat|on] Vag|na| ro|apse
- Caused by a weakness of Lhe pelvlc floor" muscles & llgamenLs.
- PlsLory of several vaglnal dellverles.
- Sx - SensaLlon of fullness/ heavlness ln pelvlc area worsened wlLh sLandlng and relleved by lylng down.

1. CS1CCLLL 8LADDLk bulges lnLo ULk AN1LkICk vaglnal wall
2. UkL1nkCCLLL - UkL1nkA bulges lnLo |ower AN1LkICk vaglnal wall
3. LN1LkCCLLL - 8CWLL bulges lnLo ULk CS1LkICk vaglnal wall
4. kLC1CCLLL - kLC1UM bulges lnLo |ower CS1LkICk vaglnal wall

CLCS1IC CVAkIAN SNDkCML (CCS)
- Most Common hormona| d|sorder among women of reproduct|ve age.
- MosL llkely cause of |nfert|||ty |n a woman younger than 30 w|th abnorma| menstruat|on.
- Classlc presenLaLlon ls an overwe|ght, h|rsut|sm, amenorrhea & |nfert|||ty.
- Women wlLh CCS are more llkely Lo be overwe|ght or obese (30).
- Plgh LP & androgen excess. Ln to ISn rat|o |s > 2 or 3 : 1.
- lnfrequenL ovulaLlon or a lack of ovulaLlon (chronlc unovulaLlon) ! lnferLlllLy. (1he MCC of female lnferLlllLy).
- unopposed esLrogen ! lncreases rlsk for endometr|a| ca.
- red|abetes or type 2 d|abetes
- d/L Insu||n res|stant ! whlch lmpalrs Lhe body's ablllLy Lo use lnsulln effecLlvely Lo regulaLe blood sugar ! resulLs ln hlgh blood
sugar and Lype 2 dlabeLes.
- Acanthos|s n|gr|cans.
- brown Lo black, poorly deflned, velveLy hyperplgmenLaLlon of Lhe skln. lL ls usually found ln body folds,

such as Lhe posLerlor and
laLeral folds of Lhe neck, Lhe axllla, groln and oLher areas.
- Invest|gat|ons - Mu|t|p|e ovar|an cysts as vlewed by u|trasound:
- 1reatment of CCS:
- LndomeLrlal proLecLlon: CC or cycllc progesLerone.
- AnovulaLlon & lnferLlllLy LreaLmenL: C|om|phene

CVAkIAN CANCLk
- Llfe Llme lncldence: 1.4 (1 ln 70 women)
- MC sympLom: |ncrease abdom|na| g|rth d]t asc|tes
- MC flndlng: pelvlc mass (C1 scan)
- MC (80) of all Cvarlan Ca ! derlved from ovary eplLhellum (^ CA 12S |eve| ! CA=Cancer AnLlgen, marker for eplLhel.)
- MC gynecologlc cancer leadlng Lo deaLh
- Screenlng LesL - 8lmanual pelvlc exam u/S ! good for flndlng pelvlc mass, buL noL very speclflc

MLNCAUSL
- CessaLlon of menses for > 6 monLhs, due Lo ovarlan fallure - Average age = 31
- SympLoms: ! malnly assoclaLed w|th estrogen def|c|ency:
- PoL flashes
- ALrophy of vaglna & bladder - dyspareunla & urlnary frequency /urgency or lnconLlnence.
- CsLeoporosls
- uecreased breasL slze, skln Lhlnnlng & loss of elasLlclLy.
- Mood dlsLurbances and lrrlLablllLy
- Conf|rmat|on of Menopause - ^ ISn, and ! estrogen
- 1reaLmenL:
- P81: LsLrogen & rogesLln ! Lhe mosL effecLlve 1x, buL conLroverslal (see below)
- hyslcal exerclse, relaxaLlon
- Calclum + vlL u (Lo prevenL bone loss)
- 8lsphosphonaLes for osLeoporosls
- SelecLlve LsLrogen 8ecepLor ModulaLors (SL8Ms)

CS1-MLNCAUSAL 8LLLDING
- Any bleedlng occurs > 1 year afLer menopause - Suspect endometr|a| cancer unt|| proven otherw|se (MCC: ALrophlc vaglnlLls)
- lnvesLlgaLlons
o Lndometr|a| samp||ng - b|opsy or D&C
o SonohysLerogram for endomeLrlal Lhlckness and polyps
o PysLeroscopy
- 1x: 1AP & 8SC (1oLal Abdomlnal PysLerecLomy and 8llaLeral Saphlngo-CophorecLomy)

VAGINAL DISCnAkGL] INILC1ICN
- Most appropr|ate Next step |n Dx M|croscop|c eva|uat|on ! on g|ass-s||de: one drop of sa||ne & one drop of kCn
- Cand|d|as|s: prurlLus, coLLage-cheese ! pseudo hyphe
o 1op|ca| or ora| anLlfungal l.e. I|uconazo|e
- 8acter|a| vag|nos|s (Gardnere||a): MC, pP>3.0, Lhln, graylsh, flshy odor, no vaglnal lnflammaLlon, Clue cells
o Cnly lf symptom pos|t|ve ! Metron|dazo|e (safe for pregnancy, even 1
st
tr|mester), or c||ndamyc|n.
- 1r|chomon|as|s: cuplous, gray-green, lLchy-burnlng, sLrawberry cervlx, froLhy dlscharge ! moLlle organlsm
o Metron|dazo|e p.o., treat partner too.
- Ch|amyd|a: mlld, only abnormal vaglnal dlscharge or a burnlng sensaLlon when urlnaLlng, MCC of bacLerlal S1u
o Az|thromyc|n (slngle oral dose) or oral Dox|cyc||n for 7 days
- Gonorrhea: MucopurulenL dlscharge from cervlx/vaglna
o S|ng|e dose Cef|x|me + az|thromyc|n. (when LreaL pLn wlLh CC, also LreaL for Chlamydla )
- hys|o|og|ca| d|scharge ! no sympLom
o 1x wlLh CC LhaL conLaln progesLln ! mucus wlll become Lhlck.

S1LS IN LkAMINA1ICNS CI INILk1ILL CCULL
- Couple ! lnablllLy Lo achleve pregnancy afLer 12 mLhs of unproLecLed and frequenL lnLercourse.
- 2/3 female problem, 1/3 male problem
- lf noLhlng apparenL on Px & L ! nexL sLep ls: SLMLN ANALSIS (non-lnvaslve & economlcal).
o normospermla - L[aculaLe vol. >2 ml, pP 7.2-7.8/ Sperm con.c >20 mll/mL / lorward moLlllLy + norm. Morph. >30 sperm
o If abnorma| ! repeat SA (qua||ty var|ed from t|me to t|me)
- nexL , DCCUMLN1 CVULA1ICN: basal body Lemp, luLeal phase progesLerone levels or endomeLrlal blopsy. normal cycles?
o PysLerosalplngogram: checks falloplan Lubes & uLerus.
o Cervlx: cervlclLls, cone blospy, Lrauma? LvaluaLe mucus.
o Laparoscopy: ! lasL resorL. LndomeLrlosls, Px of lu?
- 1reaLmenL - Clomlphene clLraLe, human Menopausal ConadoLropln (lSP & LP).
o lf all else falls: ln vlLro ferLlllzaLlon (lvl) & lCSl.

8Ik1n CCN1kCL ML1nCDS
- Cra| contracept|ves (Lst +rog): besL cholce for healLhy young woman. 8uL lL does noL reduce rlsk of S1u's.
- rogest on|y (ln[ecLable: Depoprovera, subdermal lmplanL): LacLaLlng, cannoL use LsLrogen, smoker or >33 yo
- Intrauter|ne dev|ce (IUD): besL for older monogamous women, mulLlparous. May lncrease rlsk for lu & ecLoplc pregnancy
- 8arr|er method (ulaphragm, condoms, cervlcal cap): besL for moLlvaLed woman, noL very ferLlle, has mulLlple parLner.
o Condoms - boLh prevenL S1u & pregnancy.
- Natura| (8asal body Lemp, colLus lnLerupLus, perlodlc absLlnence, lacLaLlon) ! noL rellable. 8ellglous reasons
- 1uba| ||gat|on: permanenL conLracepLlon
CLkVICAL CANCLk 1nL NLWLS1 CLIC ICk CLkVICAL SCkLLNING
- 1he easlesL-Lo-prevenL cancer ln women. - revenLlon: wlLh regular cervlcal screenlng LesL (ap smear) and Pv LesL.
- 1he ap LesL: recommended for all women beLween Lhe ages of 21 and 63 years old, every 3 - 3 years + Pv LesL > age 30
- 8lsk facLors - Smoklng/ Larly Age Sex/ MullLple arLners/ S1u/ CC/ Afrlncan/Plspanlc/ oor
- 1here are 2 Lypes of LesLs used for cervlcal cancer screenlng.
o 1he ap LesL can flnd early cell changes and LreaL Lhem before Lhey become cancer.
o 1he Pv (human papllloma vlrus) LesL flnds cerLaln lnfecLlons LhaL can lead Lo cell changes and cancer.
1. All women should 8LGIN cervlcal cancer screenlng aL AGL 21.
2. 8eLween 21 and 29 should have a A LesL LVLk 3 LAkS.
- no need Pv LesL unless lL ls needed (eg. afLer an abnormal ap LesL resulL).
3. 8eLween 30 and 6S should have 8C1n a ap test and an nV test LVLk S LAkS.
- 1hls ls Lhe preferred, buL lL ls also Ck: ap LesL alone, every 3 yrs.
4. CVLk AGL 6S who had regular screenlngs wlLh normal resulLs shou|d not be screened anymore.
- Women who have been dlagnosed wlLh cervlcal pre-cancer should conLlnue Lo be screened.
3. Women who have had Lhelr uLerus and cervlx removed and have no hlsLory of cervlcal cancer or pre-cancer should noL be screened.
6. Women who have had Lhe Pv vacclne should sLlll follow Lhe screenlng recommendaLlons for Lhelr age group.
7. Plgh rlsk for cervlcal ca woman may need screenlngs more ofLen.

CCMMCN 8kLAS1 CCNDI1ICNS ACCCkDING 1C AGL
< 3S ears
a. II8kCADLNCMA
l. alnless, dlscreLe, sharply clrcumscrlbed, rubbery, moblle mass.
ll. MosL common benlgn Lumor of female breasL.
lll. Cbserve Lhe paLlenL for one or more mensLrual cycles ln Lhe absence of sympLoms.
lv. regnancy or ora| contracept|ves can st|mu|ate growth, menopause causes regress|on (estrogen-dependant
growths).
v. Lxclslon ls curaLlve buL noL requlred (unless paLlenL deslres lL or Lhere ls cllnlcal concern for cancer).
8. II8kCCS1IC DISLASL
l. 8llaLeral, mulLlple, Lender (especlally premensLrual) cysLlc leslons.
ll. MosL common of all breasL dlseases.
lll. Genera||y, no further work-up |s needed - [ust rout|ne fo||ow-up.
lv. rogesLerone for one week aL end of each monLh or danazol mlghL help relleve sympLoms.
C. MAS1I1IS Ck A8SCLSS
u. IA1 NLCkCSIS
l. PlsLory of Lrauma Lo Lhe breasL.
ll. *noLe: avo|d mammography |n women younger than 30 b/c breasL Loo dense Lo glve lnLerpreLable lmage.
e. lf susplclous of CANCLk (exceedlngly rare ln Lhls age group), use UL1kASCUND for evaluaLlon.

>3S ears
l. II8kCCS1IC DISLASL
l. As ln younger female
ll. AsplraLlon of cysL fluld & basellne mammography are recommended.
lll. lf Lhe cysL fluld ls non-bloody & Lhe mass resolve afLer asplraLlon, Lhe paLlenL needs only reassurance, follow-up & a
basellne mammogram.
lv. lf Lhe f|u|d |s b|oody or the cyst recurs qu|ck|y, do a b|opsy to ru|e out cancer.
g. II8kCADLNCMA
l. Get base||ne mammogram. Cbserve brlefly lf Lhe mass ls small and seems benlgn cllnlcally and Lhe woman ls
premenopausal and she has no rlsk facLors for breasL cancer. CLherwlse, do a blopsy.
h. Iat necros|s
|. Mast|t|s & abscess

8kLAS1 CANCLk
- C|ass|c presentat|on: n|pp|e retract|on, peau d'orange |n a nu|||par|ous woman w|th a strong fam||y h|story.
- ln every pa|pab|e breast mass |n woman > 3S y.o. ! musL be lnvesLlgaLed, Lo r/o cancer!
- Do a mammography, fo||owed by b|opsy of the mass.
- ln Lhe absence of a classlc benlgn presenLaLlon, regardless of Px of recenL breasL Lrauma (faL necrosls) or bllaLerallLy wlLh
premensLrual masLalgla ! a|ways cons|der b|opsy.
- Also geL a d|agnost|c mammogram (1
st
|mag|ng study) & poLenLlally ulLrasound and/or breasL M8l.