Repro Final

FELTON: Genital Flora/Vaginosis/Toxic Shock/STIs

1. Toxic Shock Syndrome: S. aureus. TSST-1 exotoxin. Fever, diffuse macular rash, desquamation of palms & soles (1-2 wks after onset), severe hypotension <90 systolic. Also:
myalgia, dizziness, vomiting.
2. Group B strep: S. agalactiae. G+ cocci in chains. weakly -hemolytic. CAMP test +, hippurate hydrolysis, Lancefield antigen, 7 serotypes. Early onset (1 week to 1 month
old) neonatal sepsis, pna, meningitis (w/ neurologic sequelae-blindness etc). Risk w/ PROM, UTI, preterm labor, or fever during delivery. Tx & Prophylaxis: Penicillin.
3. Group A strep: S. pyogenes. BacitrAcin susceptible. Postpartum infections (childbirth or abortion), puerperal sepsis. Tx broad spectrum abx. Also may cause streptococcal toxic
shock syndrome; bug is found in BLOOD (vs not in blood if S. aureus TSS)
4. Clostridium sordellii: After medical abortion uterine gas gangrene & septic abortion. Also causes TSS (with Lethal Toxin).
5. Chancroid: H. ducreyi, small coccobacilli, hard to grow. Soft, suppurative, painful inguinal adenopathy (Bubo). Poor socioeconomic. no immunity. Tx: azith or ceftriax
6. Klebsiella granulomatis: Granuloma inguinale (Donovanosis) short G- rod. "Safety-Pin" looking. Bipolar staining. Infectious form has capsule. Macrophage vacuoles full of
Donovan bodies. irregularly outlined ulcers on genitalia.
7. N. gonorrhoeae: G- diplococci, cytochrome C, Ox+, pinkpurple on chocolate agar (w/CO2, obligate aerobe). Glucose fermenting. Pili for attachement/evasion. Protein Iforms porins/endocytosis. Protein II (aka Opa)-for adherence/adhesion. LOS endotoxin for local cytotoxicity & inflammation, fever & systemic toxicity. Causes PID.
8. Chlamydia: elementary body (extracellular, infectious!) & reticulate body (intracellular, divides). In men, causes Nongonococcal Urethritis (NGU), Epididymitis (most
common cause), reiter's syndrome, etc. Tx: azithromycin
9. Lymphogranuloma Venereum (LGV): caused by C. trachomatis L1-L3 serotypes. tropical. unilateral LAD/Bubo/scarring. Proctocolitis & colorectal fistulas. Can break down,
form a chronically draining sinus or become fibrotic. Dx: Complement Fixation titers 1:64 Tx: Doxycycline.
10. Congetinal syphilis: rhinitis (snuffles), diffuse macropapillar desquamative rash, vesicular rash w/ highly infectious bullas. Osteitis of nasal bones lead to saddle-nose.
centrally-notched peg teeth (Hutchinson's teeth), B/L knee effusions (Clutton's Joints) & interstitial keratitis.
SAVIOLA: TORCH infections
1. Rubella: +strand RNA virus, enveloped. Togavirus. Resp droplets. "blueberry muffin" appearance due to extramedullary hematopoesis. Congenital Rubella Syndrome: small
baby, early cataracts, PDA, deafness, microcephaly, spastic dysplegia, chorioretinis & glaucoma. Can isolate organism in CSF.
2. Toxoplasmosis: obligate intracellular protozoa, meningoencephalomyelitis w/ necrosis, calcifications, cysts & vascular changes in retina: (1) chorioretinitis (2) hydrocephalus
(3) intracranial calfications.
3. Parvovirus B19: "Slapped cheek" fifth disease. naked ssDNA @ erythrocyte precursors. Neonates: hydrops fetalis
4. CMV: large enveloped herpesvirus. in utero infxn. SZs, sensorineural hearing loss. microcephaly, psychomotor retartation.
5. HSV-2: dsDNA enveloped via secretions; STD. Infant acquires at birth neonatal encephalitis (60% fatal), ocular & neurological sequelae.
CASTRO: Gyn Infections & CDC Guidelines
1. Amsel's Critera bacterial vaginosis (req 3 of 4): (1) homogenous discharge; (2) whiff test + amine odor; (3) pH > 4.5; (4) "clue cells" (epith cells covered in bacteria). Etiol:
Gardnerella, peptostreptococci, Bacteroides, etc. Ferment amino acids, increases pH, fishy odor. Tx: Methimazole.
2. Trichomoniasis: itching, pain, inflammation, strawberry patches on vag/cervix. Yellow-green frothy, pH >4.5. Tx Pt+ Sexual partner! Metronidazole or Tinidazole. Advise to
avoid EtOH-Disulfiram rxn. (can increase susceptibility to HIV infxn)
3. Atrophic vulvovaginitis: post-menopausal. thin vaginal mucosa. yellowish discharge with pH >4.5 (expected in postmenopausals). will see ROUNDED PARABASAL cells.
4. LESION on vulva that doesn't improve w/ treatment, could be a Squamous Cell Carcinoma MUST GET A BIOPSY.
5. Lichen Sclerosis (atrophic dystrophy): postmenopausal, white-ish cigarette paper appearance. Hyperkeratosis & chronic inflamm. Very itchy. Tx: steroids/testosterone cream
6. Herpes Simplex: Asx shedding. Primary-prodrome, parasthesias, painful ulcers, fever (can be systemic). Recurrent infxn-milder. Dx: PCR or viral culture of base of lesion.
7. Primary Syphilis-painless firm chancre. Secondary Syphilis-Diffuse macropapular rash, condylomata Lata (very infectious). Tertiary Syphilis-gummas, aortitis, iritis,
granulomas. Neurosyphilis (at any stage)-dx requires positive VDRL test of CSF. Tx: IV penicillin G.
8. Syphilis Dx: VDRL/RPR with reflex FTA-ABS/TPA or Darkfield of ulcer. BOTH have to be positive (nontreponemal-VDRL/RPR & treponemal FTA-ABS) Tx: Penicillin .
Caution: Jarische-Herxheimer Rxn (HA, myalgia, fever). Use VDRL and RPR titers to monitor disease progression & treatment if 4-fold, then FAILED tx or REINFECTED
9. Fitz-Hugh-Curtis syndrome intra-abdominal spread of N. gonorrhoeae, adhesions on liver surface, very painful. Dx: GC culture or NAAT. Tx: Ceftriaxone (for GC) and add
Azithromycin (for Chlamydia).
10. PID-polymicrobial upper genital infection (ascending from endocervix). Complications: infertility, adhesions, pain/tubal pregnancy. Minimum criteria: Pelvic pain in sexually
active woman AND one or more of: cervical motion tenderness, uterine tenderness, or adnexal tenderness. (more likely w/ fever). Tx: broad spectrum abx covering aerobes,
anaerobes, GC and chlamydia.
FOSTER: Well Preventative Care/Anatomy
1. Lymph drainage: Ovaries/EndometrPara-aortic & Pelvic LNs; CervixPelvic LNs (hypogastric/obturator/ext iliac); Lower Vagina/Vulva Inguinofemoral/Ext Iliac LNs
2. Screening: chlamydia age 25 and younger. GC all sexually active adolescents. HIV all sexually active adolescents + age 19-64. and w/ developmental disabilities
3. RADAR, Universal screening for domestic abuse: Remember to ask, Ask directly, Document. Assess patient's safety, Review options/Referral.
4. age 40-64: mammogram, colorectal screening (colonoscopy every 10 year after age 50), Hep C if born b/w 1945-65. If Paps negative for 10 years, can d/c after age 65.
FOSTER: Approach to Gyn Pt; Pap smears/Dysplasia
1. When medical error occurs, inform the patient and their family. Disclosure is the right thing to do and decreases risk of a lawsuit.
2. "time out" or surgical checklist is a mandatory "moment of truth" to discuess patient and procedure. This involves the entire team.
3. Cytology alone every 3 yrs for age 21-29. Cytology + HPV screen every 5 yrs for >30 yrs. Stop screening at age 65 if no hx of anything worse than CIN1.
4. Glandular abnormalities more concerning bc more likely to have a significant pathology (adenocarcinoma). Do colposcopy + endometrial biopsy in > 30 yrs or risk factors.
5. HPV types 16, 18, etc CIN1 (many regress spontaneously) vs CIN 3 severe neoplasia (don't wanna miss this on Pap smears) squamous cell cervical cancer.
FOSTER: Prolapse
1. Stress Incontinence loss of support of urethrovesical junction (UVJ), bladder pressure exceeds urethral pressure when pt coughs or sneezesurine leakage.
2. Urethral Diverticulaunk etiology. Exam findings: suburethral mass, tenderness @ urethra, expressed pus from urethral massage.
3. Symptoms of uterine prolapse: vary according to what's falling and how far. Diffuse "pressure", backache, dyspareunia, worse w/ standing, voiding problems, UTI, incont,
constipation ("splinting" for BM) or fecal incontinence.
NELSON: Contraception/CDC guidelines [2Qs on statistics]
1. 400K die yearly due to pregnancy & childbirth. 50K abortions attempted daily (which accounts for 90K annual deaths).
2. NO contraceptives for 1 year will result in 85% pregnancy. 51% U.S. pregnancies are unintended. 30% of don't know risks of pregnancy (thrombosis, diabetes, HTN).
3. Copper IUD: interferes w/ sperm motility from cervix to fallopian tube.
4. Levonorgestrel-Releasing Intrauterine System (LNG IUS): lowest level of hormones of any contraceptive. Thickens cervical mucus, impairs sperm motility, inhibits ovulation,
used to reduce excessive menstrual bleeding. Side effect: amenorrhea.
5. Absolute Contraindications for OCPs: hx DVT, PE, MI, stroke, chirrosis, HA with aura (migraines), HTN, SLE, IBS/crohn's, smoking, <21 days postpartum.
6. Ulipristal Acetate (morning after pill) is preferred for overweight and obese (higher failure rates in this population with LNG emergency contracteption).
7. ONLY Contraceptive method for those who have active breast cancer (within 5 years) is the COPPER-IUD.

NELSON: Abortion/1st Tri Bleeding

1. Threatened Abortion: woman presents w/ bleeding, contractions and CLOSED cervix, can see baby on ultrasound, has HR. No risks. Tx: rest, reassure the . Normal
ultrasound appearances will should a gestational sac ~3 wks after implantation.
2. Incomplete Abortion: woman presents w/ bleeding, contractions, OPEN cervix & PASSAGE of some products. Risks: maternal hemorrhage, infxn, perforation, asherman's. Tx:
Misoprostol or manual vacuum suction +/- curettage. MUST evacuate uterus completely.
3. Complete Mole whole placenta is neoplastic, NO embryo. 46 XX - both chromosomes are from sperm that replicated. Findings: hCG, painless vaginal bleeding,
oversized uterus, "snowstorm" on ultrasound. RISK of malignant conversion, choriocarcinoma, etc.
4. Incomplete Molepart of placenta is neoplastic. Embryo present. triploidy or quadriploidy. Findings: hCG, u/s shows "fetal parts", NO risk of malignant conversy.
5. Ectopic Pregnancy: risk factors-prior ectopic, PID, tobacco use, tubal ligation. hCG levels plateau & fall, low progesterone (non-viable is <5ng/mL). Tubal ectopic pregnancy
is medical emergency, risk of rupture & shock. Management: don't waste any time, transfuse some Hb, give anesthesia, emergent laparotomy.
WAGNER: Fertilization/Implantation
1. Acrosomal Rxn: sperm meets 2' oocyte, binds two different ZP3 receptorsreleases acrosin (zona pellucida-penetrating protease) Ca2+ influx in acrosome, actin depolym,
vesicle formation and exocytosis. Fertilin & Integrin assist in fusion of sperm head to 2' oocyte membrane after acrosomal rxn, this depolarizes the 2' oocyte membrane & induces
exocytosis of oocyte granules that prevent polyspermy. Spermatozoan head contact with 2' oocyte triggers 2nd meiotic event and completes fertilization into zygote.
2. ZyoteBlastomere (3d)Morula arrives & floats in uterus(6d)Blastocyst implants in endometrium (1wk): made up of (1) inner cell mass (2) trophoblast (3) blastocoele
3. Trophoblast adheres via E-Cadherin & secretes anticoagulants/proteolytic enzymes to embed itself into endometrium. Divides into inner edge Cytotrophoblast that mitotically
divides and an outer edge syncytiotrophoblast (multinucleated cytoplasmic space w undulating membrane, stimulates prostaglandins & increased vascularization), depends on
cAMP for formation.
WAGNER: Placentation/Pregnancy (too much info. see primer)
1. Uteroplacental circulation (5wks): fetal heartchorionic villi/fetal tissues(now deoxygenated) umbilical arteriesplacentamaternal circulation (gets
oxygenated)placentaumbilical vein-->fetus.
2. Placental hormone secretion: hCG, Estriol, Progesterone, hCS, PTHrP, Relaxin, CRH, Prostaglandins & leukotrienes.
3. Pregnancy Phys: blood vol, plasma fibrinogen, CO, SVR, RPF, GFR, urinary output, clearance of Creatine & BUN, plasma osmolarity (compensated by RAAS
system), GI motility, GI transit time, hypomotile gallbladder. Liver: cholesterol, ALP, Fibrinogen, SHBPs, albumin. tidal volume, minute ventilation, O2 uptake. residual
volume and TPR.
4. hCS: promotes function of mammary glands for impending lactation. Also decreases maternal glucose util & increases lipolysis fo more glucose and FFAs can get to fetus.
5. Hyperemesis Gravidarum: increased hCG (most responsible), also increased T4, Estriol and Prolactin.
6. Placental CRH: "placental clock" for gestational length, increases throughout pregnancy, sharp increase in last 5 wks. Stimulates fetal ACTH/DHEA/cortisol secretion which
stimulates placental estrogen production that will sensitive yometrium for parturition. Cortisol stimulates surfactant production. Plays role in postpartum depression due to
modulation of maternal stress axis.
WAGNER: Lactation
1. Promotes breast development in pregnancy: Estrogen, Progesterone, Prolactin, hCS, Cortisol, GH & Insulin
2. Regulation of Prolactin: Estrogen stimulates ant pit to release prolactin. Dopamine @ ant pit D2 receptorshyperpolarizes lactotrophs tonic inhibition of prolactin
3. Suckling: Prolactin from Ant Pit (partly by dopamine); Oxytocin from Post Pit. (via supraoptic/paraventric nuc)elicits myoepithelial/nipple contractionmilk ejection
4. Effect of breastfeeding: Sucklingepisodic prolactin inhib reprod via GnRH release & antagonism ( FSH & LH); Oxytocin hastens involution of myometrium.
5. Milk: IgA, mucus, lactoferrin, bifidus factor (for intestinal flora), water/carb/fat/protein/minerals. Colostrum @ first 5 days more minerals, immunoprotection, less fat/lactose.
CASTRO: Antepartum Care
1. Accurately dating delivery using Naegel's rule:

[ ( first day of LMP +7 days )3 months=EDD ]

2. Pregnancy Dx: hCG > 5 IU/mL, first detectable 6-8 d after ovulation. Softening of uterus/cervix, blue-ish vagina @ 6 wks; Palpable uterus on abd exam/heart tones @ 12 wks.
3. Fundal Height: defined as distance from symphysis to top of uterine fundus. Between 18-36 wks it should be equal to the gestational age in cm's (+ or - 2 cm).
4. Quad Screen: (2nd tri aneuploidy test): AFP, -hCG, Estriol, inhibin A.AFP: NTDs, Gastrochesis, Omphocele, fetal death. AFP in trisomy 18 or 21 or inaccurate dating
5. Vaginal Culture at 35-37 wks for Group B Strep if c/s is positive, give prophylactic penicillin in labor (to prevent early onset neonatal grp B strep sepsis)
CASTRO: Teratology/Prenatal Dx
1. Pregestational Diabetes: (uncontrolled glucose=teratogenic). Target goals: HbA1c < 6.5, FBS 70-90 mg/dL, and 1 hr PPBS 100-130 mg/dL. Assess for end-organ damage.
2. Hemoglobin Bart (a fetal thalassemia): deletion of all 4 alpha chain genes fetal anemiahigh output failurenon-immune hydrops fetalisfetal death.
3. Prenatal Screening: 1st tri-u/s for nuchal tanslucency, serum hCG, PAPP-A plus maternal agepos? offer diagnostic CVS. 2nd trim Screening: Quad Screen. Integrative
screening combines 1st tri & 2nd tri tests (95% detection of aneuploidy with 5% false positive rate)
4. maternal serum AFP: Open NTD (anencephaly, spina bifida, encephalocele)get amniocentesis (for acetylcholinesterase), gastroschisis, omphalocele, placental abruption,
fetal demise, multiple gestation or INCORRECT gestational age dating.
5. Valproic Acid teratogenic class X or D: causes NTDs (open spina bifida) and facial dysmorphisms.
6. Dilantin: Fetal Hydantoin Syndrome: craniofacial abn (clefts, hypertelorism), hypoplastic digits, cardiac abn, growth restrictions, mental deficiencies & neonatal coagulopathy
CASTRO: Normal/Abnormal Labor/Delivery & Post-partum Care
1. Engagement: biparietal diameter has entered plane of the inlet (aka "zero station"-lowest part of presenting baby is at ischial spine level).
2. True Labor: repetitive contractions w/ progressive effacement & dilation of the cervix (max dilation is usually 10 cm)
3. Active Phase of Labor: more rapid cervical dilation, assume if 4 cm dilated. q2hr exams to monitor. Give Penicillin for Group B strep prophylaxis. Avoid narcotics!
4. Active Phase Arrest: no change in dilation for 2 or more hrsdo Amniotomy w/ intrauterine pressure catheter (measures contraction strength) inadequate contractions if
<200 montevideos (contractions too weak) give Pitocin to induce (if this doesn't work, must do C-section)
5. Third Stage of Labor: b/w baby delivery & placenta deliv ~30 mins. Delivering Placenta: gentle traction on umbilical cord (lengethening of cord, sudden gush of blood,
globular configuration of uterus); if you pull on cord before placental separationuterine inversion ( hemorrhage & shock). After placenta delivery, watch out for uterine atony
w/ hemorrhage (avoid w/ oxytocin & uterine massage).
6. Endometritis -few days postpartum: fever, uterine tenderness, foul-smell. Polymicrobial. Tx: broad-spectrum antibiotics (Ampicillin & Gentamycin +/- Clindamycin)
7. Septic Pelvic Vein Thrombophlebitis - postpartum, variable timing. SPIKING fevers despite abx, right-sided uterine pain, ADD heparin. increased risk w/ c-sections.
CASTRO: Intra/Antepartum Care/Fetal Assessment
1. Non-Stress test (NST) is REACTIVE if has two instances of 15 beat accelerations lasting for 15 seconds within 20 minutes. This is NORMAL and reassuring. Safe to continue.
2. Biophysical Profile-in utero apgar score, amniotic fluid level. Umbilical Artery Doppler-reverse diastolic flow suggests lack of placental perfusion, indicates need for delivery.
3. Assess fetal lung maturity diagnostic amniocentesis for L:S ratio. (if Lecithin/Sphingomyelin ratio is > 2.0, means lungs are mature).

4. Fetal Heart Decelerations: Early Deceleration-(normal) benign head compression causing vagal reflex; vs Late DecelerationsUteroplacental Insufficiency (smooth slowing
of FHR that starts after contraction starts and ends after contraction finishes--seen in HTN, preeclampsia, abruption, IUGR and cocaine use.
CASTRO: OB clinical Cases
1. Class A-NO risk. Class B-no evidence of risk in humans (animal studies w/o risk & no controlled human studies); Class C-risk cannot be ruled out (animals w/ adverse, no
human studies; or no studies at all); Class D-positive evidence of risk (only use if benefit>known risk; eg Valproate, ACEi, Warfarin, Aminoglycosides), Class X-contraindicated
2. Definition of spontaneous abortion (miscarriage) is loss of fetus before 20 weeks.
3. Missed Abortion - Fetus has died & retained in the uterus (usually for more than 6 wks). Declining hCG levels. Closed cervical os. No heartbeat. No bleeding or contractions.
CASTRO: Med & Surg Complications of Pregnancy I & II
1. Preeclampsia: BP 140/90 AFTER 20 wks gestation (in without chronic HTN) PLUS Proteinuria 0.3 gm/24 hrs (30 mg/dL or 1+ on dipstick). Sx: edema @ hands/face
2. Severe features of preeclampsia: HA/visual disturbances, thrombocytopenia (or HELLP), Cr > 1.1 or doubled, LFTs/hepatic abnormalities (N/V/RUQ pain), pulm edema
3. HELLP syndrome: Hemolysis, Elevated Liver function(LDH>900, bilirubin>1.2), Low Platelets (<100,000), and usually drop in hbg/hct.
4. Eclampsia: grand mal seizures on top of preeclampsia sx, 50% occur intrapartum. tx: Magnesium Sulfate (caution if renal impairment).
5. Hypertensive Emergency in pregnancy: 160/105 tx: IV hydralazine or Labetalol. For tx of Chronic HTN in pregnancy: Methyldopa, Labetalol or Nifedipine.
6. Screening for Gestational Diabetes50g oral glucose challenge in 1st trimester; if abnormal3 hr glucose tolerance test (this step is diagnostic). Post-partum, do 75g GTT 2
months after delivery to see if persisting gestational diabetes or overt diabetes.
7. Diabetes effects on FETUS: hyperglycemia, hyperinsulinemia, surfactant, macrosomia, polyhydramnios, shoulder dystocia; Pregestational Diabetes increase risk of
miscarriage, congenital anomalies (cardiac & NTD), IUGR.
8. Diabetes effects on NEONATE: hypoglycemia (when cord is cut), hypocalcemia, delayed maturation, RDS, hyperbilirubin, polycythemia, cardiomyopathy.
CASTRO: Med & Surg Complications of Pregnancy III
1. Eisenmenger's Syndrome: primary pulmonary HTN and pregnancy is associated with 50% mortality rate! (are in danger of undergoing decompensation in pregnancy)
2. UTI: get UA, c/s. Tx: Nitrofurantoin or Cephalexin [AVOID sulfonamides in 3rd tri (bilirubin displacement); AVOID FQs (cartilage abn)] Pyelonephritis (Hematuria, flank
pain, CVA tender), risk of SEPTIC SHOCK, pulmonary edema, ARDS & preterm labor. Tx: Hospitalization, IV abx, hydration. If >1 infxn- supressive therapy.
3. Anti-phospholipid Syndome: at least 1 Ab assoc w thrombosis (anti-cardiolipin &/or lupus Ab) PLUS adverse obstetrical event (eg fetal demise). Tx: Heparin & lo dose aspirin
4. Intrahepatic Cholestasis of Pregnancy (Benign): diffuse pruritis (itching) without rash, +/- jaundice, no pain. Risks: fetal demise, preterm labor. Dx: increased Bile Acids. Tx:
Ursodeoxycholic Acid, antihistamines, freq antepartum testing, delivery baby at 37 wks.
5. Hyperthyroid pregnant: PTU at LOWEST dose (want to avoid thyroid storm), but since CAN cross placenta, will cause fetal goiter. Can also cause transient neonatal
thyrotoxicosis or hypothyroidism.
CASTRO: Obstetrical Complications I (IUGR, IUFD)
1. Diagnosis of IUGR: accurate GA, est fetal weight by u/s, population-specific growth curves. Clinical assessment: Do Fundal Height Assessment (screening) between 18-36
wks, cm's equal to GA. But get an U/S femur length/head circumference, etc of for more accurate dx.
2. Deliver IUGR fetus when: (1) fetal testing is non-reassuring (deceleration, oligohydramnios, abn umbilical doppler), fetus near term/fully mature, or no growth in 3 weeks.
3. LGA/Macrosomia: (wt > 4,000 grams) causes: maternal obesity, excessive wt gain, diabetes, gestational diabetes. Diagnose to avoid delivery problems (cephalopelvic
disproportion/shoulder dystocia)
4. IUFD: death in utero after 20 wks (stillbirth). Dx: u/s shows no cardiac activity. Tx: induce labor/operate. CAUTION: DIC can result from a retained fetus > 6 wks
CASTRO: Obstetrical Complications II (Pre-term, PROM, Post-term)
1. Preterm Labor prevention: modifiable factors, physical activity, Progesterone Supplementation (daily vaginal suppositories or IM injections 2nd trimester until 36 wks).
Tocolytics: MgSO4, Terbuatline/Ritodrine, Nifedipine, PG synthetase inhibitor (Indomethacin-caution: can cause premature closure of ductus, renal abn w/ oligohydramnios)
2. PROM: ruptured chorioamniotic membranes prior to labor onset, eg Chorioamnionitis- w/ fever, uterine tenderness, maternal/fetal tachycardia, poss purulent discharge-usually POLYMICROBIAL--Tx: broad spectrum antibiotics for aerobes/anaerobes PLUS must deliver baby!
4. PPROM: rupture chorioamniotic membr <37 weeks. Fetal complic: contraction deformity, amniotic band syndrome, pulm hypoplasia (2nd tri PPROM). Dx: Clear watery d/c
from cervical os & vaginal pooling NITRAZINE test "Ferning" pattern confirms it is cervical mucusruptured membranes confirmed send for GC/Chlamydia/GBS, U/S
for AFI/fetal lie/est fetal wt, external fetal HR monitoringBetamethasone if <34 wks, AVOID digital cervical unless in labor (risk infection)
5. Post-term Labor: after 42 wks. most common cause is INACCURATE DATING. Rare Causes: anencephaly, fetal adrenal hypoplasia, steriod sulfatase deficiency (XR, male w/
congenital ichthyosis). Complications: fetal postmaturity syndrome, macrosomia, placental dysfxn, Meconium Aspiration Syndrome (persistent pulm HTN, neurodev probs)
6. Oligohydramnios (AFI <5) caused by: PROM, renal/bladder anomalies, Uteroplacental insufficiency (eg IUGR, HTN, preeclampsia, maternal drug use), post-term pregnancy
CASTRO: Obstet Complications III (3rd Tri Bleeding/Rh Disease)
1. RhD Neg & Ab screen Posget Antibody ID & Titer (to determine if Anti(D) vs benign)if AntiD positive (Rh Neg sensitized) check Dad's Rh status/zygosityif fetus
RhD positiverecheck Ab titer every 4 wks after 20 wks GA if antiD titer 1:16Serial MCA Doppler on fetus to check for anemia [early sign of hydrops fetalis]
2. Give Rho-GAM to: (1) RhD Neg, Unsensitized (AntiD neg) @ 28 wks & IF RhD Pos baby, give it AGAIN 72 hrs from delivery; (2) to any RhD neg, unsensitized (antiD neg)
w/ abortion, ectopic, vaginal bleeding, abd trauma, amniocentesis or external/cephalic version. (also partial molar pregnancy, give to any molar bc often can't determine type)
3. Kleihauer Betke test used to determine extent of fetal maternal hemorrhage (estimate # fetal cells in maternal circulation)
4. Placenta Previa: placenta covers internal os; (Prev C-section STRONGLY assoc w/ Placenta Accreta) get Ultrasound if previa, NO VAGINAL EXAM in 3rd trim; always
deliver by another C-section! (presents w/ painless vaginal bleeding)
5. Abruptio Placentae: premature separation of a normally placed placenta. Risk factors: Maternal vascular disease. Findings: PAINFUL vaginal bleeding, uterine contractions,
signs of fetal hypoxia, hypovolemic shock.
FUCHS: Oxytocics/Tocolytics
1. Oxytocin: Gq/PLC/IP3/Ca2+ release/MLCKUterine Contractions (& local prostaglandins). USE: induce labor, stop postpartum bleed/adjunct to abortion. ADVERSE to
NEONATE: PVCs, bradycardia, CNS dmg, SZs, jaundice, retinal hemorrhage, death. ADVERSE to : PVCs, HTN/HoTN, N/V, pelvic hematoma, uterine
hypertonicity/spasm/rupture, fatal afibrinogenemia. SAH, severe water intox, SZs, coma & death (assoc w/ slow oxytocin infusion over 24 hrs). CONTRAINDICATIONS:
cephalopelvic disproportion, transverse fetal lie, c-section preferred, hypertonic uterine patterns, severe toxemia, cord prolapse, total placenta previa, casa previa.
2. Dinoprostone: prostaglandin E2. Cervix softening, ripening & dilation. USE: induce labor; abortion wk 12-20; or evacuation up to 28 wks. Dino preferred if Pt is asthmatic
(over carboprost). CAUTION: hx of glaucoma/asthma, CV/Renal/Liver dz; or if contraindications for vaginal delivery. (generally, a 2nd line therapy if can't use oxytocin)
3. Mifepristone (RU-486): Progesterone receptor blocker. progesterone production from CL, prostaglandins contracts uterus for expulsion of detached blastocyst in Rxinduced abortions thru day 49. (also used for hyperglycemia 2' to hypercortisolism in Cushing syndrome)
4. Methylergonovine (Ergot Alkaloid): -receptors/serotonin receptors, inhibits NO release vasoconstriction, uterine/cervical contractions. USE: tx postpartum hemorrhage.
SIDES: HTN, acute MI, stroke, HA/hallucinations, Ergotism (vascular ischemia & gangrene)
5. Magnesium Sulfate: inhibits Ca2+ influx uterine smooth mm relaxes uterus. USE: DELAYS labor; or Tx Eclampsia. CAUTION: bleeding disoders (slow blood clotting),
SIDES: heart block, renal failure, confusion/coma.
6. Terbutaline: -adrenergic/AC/cAMP relaxation of bronchial & uterine smooth mm. USE: Asthma & off-label inhibition of contractions. SIDES: nervousness/increased
glucose/decreased K. Tachycardia/HTN, musc cramps/dizziness/HA/insomnia/dry mouth/N/V.

MISC:
1. Betamethasone: given to accelerate development of fetal lungs if < 34 weeks preterm, to decrease risk of neonatal resp distress syndrome (RDS)
2. Right-sided hydronephrosis (mild) in pregnancy is a NORMAL finding because uterus is dextro-rotated (doesn't necessarily mean renal stone)
3. Diastolic murmurs--always ABNORMAL findings in pregnant women (systolic murmurs can be normal)
4. Normal fetal HR is 110-160 bpm.
5. Much higher risk of placenta accreta (when placenta grows too deeply into uterus) in with previous C-section (bc scarred uterine walls).

CAN CROSS PLACENTA: Coumadin/Warfarin, PTU, Methimazole, SLE Ab's (Anti-SSA/Anti-Ro; Anti-SSB/Anti-La), AntiD Ab's, IgG, Iodine, cortisol, glucose
Dilantin (phenytoid), DES, OCPs, Tetracyclines, Doxycycline, Valproate, Diazepam, Lithium, Toxoplasma, Thyroid stimulating immunoglobulin (from Graves), TRH
CANNOT CROSS PLACENTA: IgM, insulin, glucagon, free T3 or T4, thyroxine, Heparin, TSH
Causes of IUGR: Tobacco, Cocaine, Methamphetamine, EtOH, chemotherapy (methotraxate), Dilantin, Carbamazepine, Cystic Fibrosis, SLE, Congenital Rubella, Congenital
VZV, polyhydramnios, uteroplacental insufficiency, in utero infection, CMV, nutritional, multiple gestations, maternal hypertension, low maternal BMI
Tx of Pregnant Conditions:
- ALL young : 400 mcg/day (0.4 mg/d) of Folic Acid; but if AT RISK for NTDs: 4 g/day of Folic Acid (@ 1 month preconception & 1st trimester)
- Chronic/Essential HTN pregnant pt: Methyldopa, Nifedipine or labetalol (and monitor for IUGR)
- Pregestational Diabetes (pre-existing): Insulin (gold-standard) or Glyburide.
- Endometritis (puerperium complication): broad-spectrum antibiotics (Ampicillin + Gentamycin, with or without Clindamycin)
- Septic Pelvic Vein Thrombophlebitis: antibiotics + heparin
- Hypertensive emergency: IV Hydralazine
- Eclampsia: Magnesium Sulfate
- Pulmonary Embolism: Heparin
- Intrahepatic Cholestasis of Pregnancy: Ursodeoxycholic Acid & Antihistamines
Rx Treatments:
- Bacterial Vaginosis: Metronidazole (oral or topical) or Clindamycin (cream); [note: if hx of preterm or symptomatic-oral metro or oral clinda]
- Candida infection: topical -azoles (or 1 time oral fluconazole)
- Vagina Trichomonas: Metronidazole + treat partner
- Cervicitis: Ceftriaxone + Azithromycin
- Outpatient PID: Ceftri + Doxy +/- Metronidazole.
- Inpatient PID: IV Ceftriaxone + PO Doxycycline
- GBS prophylaxis/tx: Penicillin
- incomplete abortion: Misoprostol (or surgically vacuum)
- prevent recurrent genital HSV: daily acyclovir, famciclovir or valacyclovir (suppressive therapy)
- Chlamydia in pregnancy: azithromycin or amoxicillin
Statistics [2 questions]
- Fetal Death Rate: approx 7/1000
- 1 million pill users get pregnant in U.S. each year.
- NO contraceptives for 1 year will result in 85% pregnancy rate.
- 400K die yearly due to pregnancy & childbirth complications
- 51% of U.S. pregnancies are unintended
- 50K abortions are attempted daily.
- 30% of don't know how dangerous pregnancy is (risk of thrombosis, diabetes & HTN)

Clinical Case Vignettes:

1. Pregnant who is Rh Negative with positive AntiD antibodies.
2. Closed cervical os, vaginal bleeding.
3. Quad screen of expecting mother at 18 weeks gestation comes back with elevated AFP levels, which fetal conditions can you reasonably exclude? (remember dating error can
result in false pos)
4. Prenatal counseling for old maternal age, if age 35, your chance of ANY chromosomal abnormalities is 1:178. Older paternal age assoc w skeletal dysplasias.
5. A nonreactive stress test is obtained, next best step?
6. Woman is in labor and dilated 5 cm's for over 2 hours, what is this called? What's the next best step in evaluation?
7. Woman 2 days post-partum presents with fever and tender uterus, dx? tx?
8. Woman 3 weeks post-partum (c-section) presents with spiking fever and right-sided uterine pain. dx? tx?
9. 35 week pregnant woman presents with clear watery vaginal discharge coming from cervical os, and vaginal pooling; what test do you run? what do you look for?
10. Woman complaining of "vaginal discharge"
11. Sexually active woman c/o RUQ pain Fitz-Hugh-Curtis syndrome intra-abdominal spread of N. gonorrhoeae, adhesions on liver surface, very painful. Tx: Ceftriaxone (for
GC) and add Azithromycin (for Chlamydia).
12. Woman presents with mucopurulent discharge from endocervix, what is the most common cause? (chlamydia or gonorrhea) Next best step: give empirical ceftriaxone and
azithromycin
13. Genital Ulcers: syphilis, herpes, chancroid, LGV (NOT gonorrhea!)