Gravida – preg



Gravida - Pregnancy

G5(#preg), P1(term), 0(preterm), 0(miscarriage), 2(child living)

Para – ♀ who has delivered a child

Parity – used to summarize preg hx (TPAL)

Puberty – when reproduxn becomes possible

Menarche – 1st period

Catamenia – menarche x cycle x duration (10 x 30 x 5)

Count – # of wks in preg; a 24 wks, considered an abortion. P

24, or 500gm, preterm birth. Determine wks preg, go

by size of baby (est size on US).

Perinatal – 28 wks → end of neonatal period

Neonatal – 1st 29d p birth

Infant - 1st yr of life

Term -37 completed wks of preg.

Preterm/Premie - before 37 wks

Post-term – p 42 wks

Abortion – termination of preg prior to age of fetal viability

Puerpera - ♀ who just delivered

Stillbirth - no sx of life @ or p birth

EDC: Naegel’s Rule: (LMP + 7d – 3mo)

Menstrual Cycle

Nml 21-35d; duration 4-6d. Ask what was 1std of LMP

Hypothal → GnRH → pit (FSH turns on ovary + estrogen produx; FSH selects follicle that’s mature, LH) → ovary (estrogen prod by follicle in ovary) estrogen turns off FSH (via neg fdbk), FSH maturation of follicle + turns on LH (cauzing prolif). ↑estrogen levels, LH surge → ovulation, formation of CL (progesterone). CL dies, progesterone levels ↓ = menstrual period begins

↓ progesterone stim GnRH again.

Estrogen: Cauz grwth of breasts, ↑grwth of epithelium, prolif of endometrial glands, ↑ciliated cells of fallopian tubes, grwth of milk apparatus, fat + stroma in breast. Abundance, ferning + spinnbarkheit of cervical mucus; watery + clear. On endometrial glands → prolif + thickening

Spinnbarkheit: If cervical mucus is thin, stretchable + watery,

sperm can get thru

Progesterone – secretory Δ in endometrial gland, preps 4

implant

Preovulatory - follicular phase, same as prolif in uterus

Postovulatory - progesterone, “Luteal phase” same as secretory

in uterus

Menses – ↓ estrogen + progesterone

If persistent estrogen, endometrium building ↑c estrogen, ≠ ovulation, ≠ progesterone, ≠ cdrawal of both hormones, ≠ menstrual period.

Effects of progesterone – prolif of breast alveolar cells, cauz them to become secretory, incr in body temp, PMS brest tender, bloating, decr uterine contraxn. Progesterone help prevent premature delivery.

Preg

Trophoblast → outer layer of cells of embryo, invade endometrium d7-14. Egg fertilized in fallopian tube, during travel ↓ to uterus; ÷ many x’s, remains same size. In uterus, same size, many cells. Not getting bigger = has to fit thru fallopian tube. d14…completed its implantation.

Yolk sac – food source during embryonic stage; provides

nutrition until can get nutrition fr mom.

Chorion – contains structures called villi; purpose:↑ surf ra;

absorption btn mother/baby. Gives ↑placenta –

waste + nutrient x∆ takes place.

Amnion – membranes holding fetus + fluid.

2 Umbilical arteries – bring blood fr fetus → placenta arteries

have ↓O2 blood

Umbilical Vein- blood fr placenta bk to fetus. (↑O2)

Villus membrane – nutrient + waste x∆ takes place, ≠

mixing of meternal/fetal blood)

hCG – detectable in blood p 8d , preg test measures β subunit.

Quantitative or qualitative. Might want 2 do

quantitative → ectopic preg, ↑twin conditions, molar

preg, incr in↓’s syndrome

→ Nmlly double q 2d; @ 80d drop some? + remain steady for

rest of preg

→ takes place of LH + replace the CL

PRL – milk produx, acts as ADH for fetus, reduces permeability

of the amnion

HPL – detecable at 6wks gestation, Human Placenta Lactagen –

cauz mother not to take glucose in2 her own musc cells

→ reserve glucose 4 baby, allow mom to use fat 4

energy instead. Similar → type 2 DM.

AFP – prod by fetal liver & yolk sac, can determine if baby has

pblms – Down’s + neural tube defects. Fetal anomalies

Oxytocin - rel by pituitary, contraxn + milk rel. (let-↓reflex)

(milk prod in alveolar cells in breast)

Possible Sx of preg - N/V, urinary freq, quickening (erly mvmts of baby, felt 16-18 wks for 1st time, if 1st preg, won’t feel till 17-19 wks), amenorrhea, breast ∆s (bigger, Montgomery glands become lrgr, drkr areola, striae), skin pigment, chadwick’s sign (bluish cervix).

Probably sx: abd enlgmt, ∆ in uterine size, shape, softer, Hegar’s sign (softening of isthmus of uterus), Braxton hicks contraxn (usually ≠ painful, soften + open cervix a little bit), ballottement of fetus, →palpable fetus, preg test: urine & blood.

Positive sx: auscu. of fetal ♥, 120-160/min; 12-14 wks by Doppler, visualization via US, perception of fetal mvmts.

Uterus: myometrium grows, hypertrophy of musc, wt incr, Braxton hicks, contraxn, @ 12 wks becomes an abd organ, 16 wks dextrorotates, 20 wks @ umbilicus

Cervix – function is 2 hold product of conception inside uterus

↑vascularity + edema, Goodell’s sign – softening, Chadwick’s sign, endocervical gland hyperplasia (ectropion), mucus plug – barrier to infxn, cervical softening, effacement (thin out + soften) + dilation, mucus plug expelled at end of preg. Effacement is when cervix gets pulled up into uterus as whatever is coming out pushes out. Can efface or dilate 1st .

Station – where the head is, how hi or lo it is, judged fr ischial spines of pelvis. Put fingers in + feel ischial spines (0 station) + feel where the head is, vaginal introitus (+3)

Fully dilated = can’t feel cervix ~ baby’s head; ≠ effacement 2 feel for.

Ovary – function maintain CL until placenta takes ovr; maintained by hCG, CL secretes progesterone + relaxin, possible pain fr ovarian cyst

Breast ∆s

1. Hypertrophy of the alveoli + ducts

2. ↑nipple size, Montgomery glands

3. postpartum colostrums secretin

4. milk prod in resp to PRL

5. milk ejection in resp to Oxytocin

6. [↓] of drugs in breast milk

∆s in Urinary tract:↑ renal blood flow in 1st + 2nd tri, ↓3rd

urinary stasis leading to infxn

Skin ∆ - abd & breast striae, linea nigra, ↑areola pigment.,

melasma

Endocrine ∆s -↑in size & blood flow of pituitary, ↑PRL levels, Oxytocin secretion c labor/suckling, ↑size/vascularity of thyroid, ↑parathormone to mobilize Ca2+ for fetus

GI ∆s -

↑ + outward intest displacement

↓ intest. Mobility + tone, delayed gastric emptying cauz reflux

↓ gastric pH, relax of LES → cauz reflux, gingival hyperplasia

cholestatic jaundice, ↑ bile viscosity, ↑ tendenecy for cholecystitis, subdermal deposition of bile pigment cauz pruritis

Respiratory ∆s - Elevation of diaphragm reduces TLC. Progesterone incr respiratory rate. Incr tidal vol, pulm blood flow & airway conductance, ↓pulm resistance & residual vol.

♥vascular - Nml vital ∆s, ∆s becauz of preg. Venous pressure usually ↑in lo-r extremities, enough to cauz incr in venous pressure → edema; varicosities

Hematological - Incr in the amt of blood vol. Need to prod blood, 1st is plasma. RBCs take longr to catch ↑, anemia fr being diluted. RBCs will ↑, 1st will c ↑ reticulocyte count. Lose blood during delivery, need to tx. Nml blood loss btn 400-600cc. 500 + above considered xcessive blood loss.

FA needed for grwth of trophoblast.

Wt gain – recommended ~ 25-30 lbs

Ca2+- for fetal grwth 1500mg/d, absorption ↑c vit D

B12 - xcessive vit C intake may result in B12↓

Fat soluble: Vit A CONTRAINDICATED

Techniques for evaluating fetal well-being

US

• Visualization of IUP, rate + grwth

• Anomilaes, twins, placenta location + age

• Gestaional age based on:

o Head & Abd circumference

o Biparietal diameter

o Femur length

o Crown-rump length (1st trimester)

Amniocentesis – chromosomal testing, fetal lung maturity, lecithin/sphingomyelin 2:1 (PG positive)

complications: inj to fetus, placenta or cord. Can also get AFP levels in amniotic fluid, more accurate than mother’s serum

Non-stress test - Transducer placed on mother’s abd + record baby’s HR + reactivity. Nml FHR 120-160, NST is reactive if at least 2 accel in 20 mins. Accel is rise in FHR of at least 15 BPM lasting at least 15 sec

Biophysical Profile - 5 parameters, 2 pts ea. Reactive non-stress test, amniotic fluid pocket 2 cm >, fetal tone/mvmt/breathing

Scalp/noise stimulations – loud noise near mother’s abd, rub or pinch baby’s head, watch for accel in fetal HR.

Prenatal Care

Hx:

1. make sure pt is preg: UCG, hCG (8d p conception), US

2. Determine gestational age: LMP/Naelgel’s rule, uterine size, US (crown rump length, head circumference, length of femur) Comprehensive database

Preg test - +/- results; Blood- can titer & find how much preg

hormone in blood. By 12d should be (+) in blood.

PE: complete exam (1st visit), check uterine size, cervix,

adnexal masses, feel size of bony pelvis. Full hx + physical, lab tests, instructions (preprinted helpful) CBC, urine culture, need to tx STDs. E-lytes only if there’s an issue, rubella is to see if pt is immune (if not, need to immunize p birth). VDRL routine, hep B (baby gets immunoglobulin when born, if mother not infected, baby gets vaccine), Pap smear, GC, Chlamydia (RFs then test), type & Rh, AB screen to see if Rh Abs present, HIV test is offered to all pts in USA (push for this test), sickle screen or Hb electrophoresis (offer genetic counseling).

Initial Instrux -Nutrition, smoking, etoh, drug use. Meds allowed to take for common pblms (HA, C). Ok to travel as long as no hi RFs, take freq brks, walk ~, adequate hydration. Dehydration common c flying, bathing, sexual activity unless restricted mvmt. No heavy lifting, ≠ > 10lbs

Nutrition – prenatal vit, Fe + Ca2+ supps; foods to avoid during preg: raw fish, raw meat, raw eggs, deli meat, dairy needs 2b pasteurized, fish hi in mercury. Solid white tuna should b ltd to 1can/wk. Chunk like, 2 cans/wk.

Warning Sx – vaginal bleed, leakage of H2O, baby not moving;

↑BP = facial edema

Interval visits - answer pt concerns, ask if baby is moving? Any problems? Explain mechanics of preg, lordosis, sciatic nerve compression; measure fundal ht

Fundal Ht: 12 wks at pubic symphysis

16 wks- midway b/t pubic sym + umb

20wks – umbilicus

20-36 – cm = gestational age

36 wks – fetus descends into pelvis

lrgr fundal ht c twins + fibroids; may LMP wrong, xs fluid, or maybe very lg baby

Sm- grwth restriction, dates r wrong, oligohydro – low fluid, fetal demise (spontaneous abortion)

Leoplods Maneuver – determines fetal position→ performed

near end of preg. ?s at the fundus, fetal position & presentation

Cervical Exam – effacement is shortening & thinning of the cervix, dilation or opening of the cervical OS, firm → soft, station is where the level of the head is in the ischial spine in mother’s pelvis.

Prepreg planning - Hx + PE, folic acid, screen for STDs, rubella, hep B, varicella, genetic carrier testing, wt nmlization, optimize cntl of chronic dz (easier to manage dz during preg) ex: out of cntl DM can cauz miscarriage, want to take off harmful meds, lifestyle ∆s depending on risk behaviors.

Preg hx + outcomes, gestational ages of delivery; GYN Hx: LMP, catamenia (menarche, cycle interval, duration = 12 x 28 x 5) STDs, HIV

PMHx, meds, supps, c-sxns, GYN procedures; Maternal FHx is MIP b/c mother’s side determines risk factors (mult gestations, genetic pblms, hx of baby born + then died)

Social Hx: nicotine, etoh, drugs, xercise, domestic violence

PE: Vitals, thyroid, breast (mass can cauz delay in dx + tx b/c of tx in preg; grwth of tissue during preg), Pelvic (Pap, cultures, uterine anomalies, masses), Cardiac (check for murmurs)

Medical & Surgical Issues during Preg

Elective vs. emergent? Trimester, risk to preg, type of anesthesia, reluctance of surgeon.

Ex: hernia or strangulated hernia; breast mass + breast Ca c 20

wks of preg; schedule & do.

1st trimester, unlikely will physically be interfered c, meds more likely to harm baby in 1st trimester. 3rd trimester, least likely to be affected by meds, baby might get in way. General anesthesia most harmful, will sedate baby.

Trauma in preg

1. make sure ≠ domestic violence

2. shoulder/lap belt, lap belt alone more dangerous than ≠ belt.

3. As uterus rises, injury is more likely

4. ↑uterine vasculature

5. ∆ in organ location

6. ∆s in Hct (lo-r) + blood gases (more alkalotic)

Always tx mother; fetal survival depends on tx of mother; routine ABCs, tx injuries b4 preg, unless life-threatening preg complication arises.

Physiologic ∆s → tachycardia, hypoten, significant blood loss

needs to occur b4 sx of shock r apprnt.

Fetal resuscitation

1. O2 via mother

2. uterine rupture or abruption placenta (separating b4 baby’s born) check FHR, do US + see EGA, decide if baby can be saved + survive

3. emergent C-sxn c imminent maternal death

4. Postmortem C-sxn

*Salvagable is 24 wks or 500gms

Listeriosis - Contracted thru unpasteurized dairy/deli meats. Preg more susceptible →flu-like illness. Prevention is MIP

Rubella – most famous for deafness; cataracts, glaucoma,

micropthalmia, PDA, septal defects, pulm aortic stenosis, sensory neural deafness, hepatitis, HSM, jaundice, TTP (blueberry muffin baby), anemia

Herpes - Disseminated infxn in baby → CNS/ophthalmic dmg, skin or mucous membrane dz, c-sxn for 10 infxn or recurrent lesion at time of delivery. Avoid invasive monitoring c vaginal delivery, don’t brk H2O, don’t prick baby’s scalp for pH.

PostPartum Depression – fits criteria 4 major depression, tx c antidepressants. Sx include guilt.

PRLomas – usually been put on bromocriptine, stop once preg; assess for HA, visual field defects → assume PRLoma is growing. Sx → MRI.

Gestational DM – insulin resistance that dvps during preg. Due to ∆ in HPL; during preg usually no sx; don’t depend on sx for dx. Screen pts whether or not sx. If dvp GDM, > likely to dvp DM2, esp A2 (insulin-dependend). A1 – gestational, mgmd c diet

Dx: glucose challenge test, 24-28 wks; earlier if suspicion.

Upper limits of nml: 95,180, 155, 140. 2 > abnl values =

DM during preg

Thromboembolic dz -↑risk in preg, venous stasis, tend to clot

more due to XS estrogen.

Thrombophilias – tend to throw clot to placenta;

antiphospholipid syndrome

Dx: US, Doppler lo-r extrems for DVT, spiral for PE

Clues to hypercoag – 1st thrombosis < 45, idiopathic

venous thrombosis, FHx, recurrent venous thrombosis

Tx: heparin or lo molecular wt heparin, bed rest, analgesia,

AVOID ORAL ANTICOAGS

Chronic Pelvic Pain

May be cauzd by structural pblm, idiopathic

Some things that have been attributed include pelvic adhesions fr surgery, still do w/u. Infxn: recurrent or incomplete. Urinary/bowel dz, endometriosis

Dysmenorrhea – lo-r abd cramp, sweating, tachy, tremulousness, HA, N/V/D, occurs prior to or during menses.

10 dysmenorrhea - ↓in smokers, parous ♀

Related to endogenous PGs, begins c onset of ovulatory cycles

Tx: NSAIDS, reduce uterine contrax, related to endogenous

PGs, quantity of flow to degree of dysmen

2nd dysmenorrhea: Pelvic infxn, intrauterine adhesions, endometriosis, cervical stenosis

Endometriosis – presence of endometrium other than uterine cavity. Adenomyosis: endometrial tiss ci uterine myometrium

Eti: retrograde menstruation c seeding of endometrial cells

Common locations: ovaries, peritoneum, cul-de-sac, pelvic ligs,

LNs, rectosigmoid, vulva, cervix, vagina

Uncommon: skin, umbilicus, eyes, lungs, extrems, surgical

scars, perineum, bladder, kidneys

Appearance: sm raised blebs, red blood-filled lesions, chocoloate cysts, powder burn areas, puckered scars, adhesions

Sx: asymp, infertility, chronic pelvic pain, prior to menses,

relieved as menses begin. Dysprunia, sx relating to location.

PE: fixed, retroverted uterus, scarring & tenderness of cul-de

sac, nodularity of ligs, enlarged, tender Adnexa

Dx: Lap, bx, peritoneal bx c absence of macroscopic dz

Tx: surgery; remove implants, provera oral/IM –induce

amenorrhea, OC – anovulation, Danazol – amenorrhea +

endometrial atrophy, GNRH agonists – leuprolide

PMS

Eti: occur in luteal phase

Somatic Sx: bloating, wt gain, breast pain, acne, HA, ∆s in

bowel habits

Dx: only in luteal phase. R/O med/psychiatric illness

Tx: diuretics & NSAIDs

Leiomyomas (fibroids) – benign sm musc tumor of uterus

Eti: may grow under hormonal influence, area prior to menarche, regress p menopause

Sx: pelvic pain, dysmenorhea, abnl bleed, urinary urgency,

anemia

Degeneration of fibroids: outgrow blood supply, hyaline-musc

replaced by fibrous tissue. Myxomatous, calcific, cystic,

fatty, red (carneous) painful acute infarctn

Dx: enlgd, hard, irreg uterus on exam, US, hysterogram or

hysteroscopy for submucous myoma

Tx: sm + asymt- no tx, Lg + desires preg – do myomectomy

If no desire for fertility →hysterectomy

Birth Cntl → Contraception

Copper Intrauterine Device (IUD) – interferes c sperm transport, fertilization + implantation. Cu enhances sterile inflamatory rxn, spermicidal + toxic 2 blastocyst cell. Lasts 10y

Mirena – progesterone releasing IUD, thickens cervical mucus to prevent sperm penetration. Slows tubal motility, atrophic endometrium inhibits implantation. Lasts ~ 5y.

Recommended pt: parous ♀, stable, mutually monogamous

relationship, no hx of PID or STDs.

Adv: easy to put in, little user dependency, no systemic SEs +

lasts a long time.

CI: preg/suspicion, irreg uterine cavity, hx PID, postpreg PID,

undx vaginal bleed, un-tx vaginitis, cervicitis, adnexal

pain, uterine/cervical Ca, unresolved abnl pap, Wilsons

dz, Cu allergy, multi partners, susceptibility to infxn. Has

progesterone pblm CI. Best time to put in IUD is during

menstrual period, immediately p an abortion, any day of

cycle if preg can be xcluded. > 4 wks postpartum when

uterus is involuted. Removal + replacement at same visit.

Insertion during menses – avoids preg, cervix slightly dilated, insertion bleeding not noticed by pt, more likely to be xpelled.

Pre-insertion guidelines – medical + social hx, uterus position, Pap smear, STDs, consent form, prophylx NSAIDs (about 1h a procedure, cuts ↓on cramping) + abx (endocarditis), cleanse cervix, stabilize, sound uterus (6-9 cm).

Post insertion – onset of protection is immediate, check in 6-12 wks, then annually, check for strings. If don’t feel strings, should let provider know. Nml to heavy menses + incr dysmenorrhea, will resolve. If any serious sx – fever & foul discharge → PID. If think preg, not effective at preventing ectopic preg. At risk for septic abortion, must remove IUD.

Risks: expulsion, PID, uterine perforation, difficult removal,

Difficult removal/missing strings – locate IUD c sono, if in endometrial cavity, retrieve c hook. If not, hysteroscopy, if ≠ in uterus, do KUB to locate c/i peritoneal cavity, remove laparoscopically. If ≠ located, probably expelled.

Spermicide – creams, jellies, foams, suppositories, films.

Easily available, OTC, inexpensive, protects against STDs, must apply c each coital event. Not a substitute for a condom.

Diaphragm – have to be fitted in the office, needs 2b used c spermicide, not > 6h but < 24h. Has ↑failure rate + interferes c spontaneous intercourse.

♀ & ♂condoms

inexpensive, protect STDs, compliance + motivation 2 use

♀ Sterilization – surgical, need extensive counseling, not reversible. Need to document + verbal, offer all temporary methods 1st. More at risk for ectopic preg.

1. Tubal ligation – either laparo, or mini laparotomy

2. Essure – transvaginal thru cervix c a coil in tube, scar tissue forms around it. New method

♂sterilization – hi 1 time cost, regret, need for trained surgeon

Adv: lo complication rate, no compliance necessary, no follow-up cost, ambulatory surgery c minimal discomfort, perm for ♀ who have med CI to preg.

Depo Provera – long-acting progestin inj, q3mo. Progesterone does the work, has 3 effects, inhibits ovulation by suppressing FSH, LH. Thickens cerv mucus. Start ci 5d of LMP & wait > 6wks postpartum if breast feeding.

ADRs – irreg bleeding, amenorrhea, bone density ∆ wt gain,

depression, breast tenderness.

Ideal candidate – ♀ desiring long-lasting, reversible

contraception. ♀ who should avoid estrogen, breastfeeding

♀ preprd to accept menstrual ∆s & noncompliance c pill

CI: known or suspected preg, unDx vaginal bleed, known or

suspected malign of the breast, active thrombophlebitis,

current or past Hx of thrombus or cerbrovasc dz, liver

dysfunct dz

NuvaRing – E & P; insert for 3wks, removed for a wk. Can remove for up to 3h, but not necessary.

RU-486: anti-progestational agent that causes decidual necrosis, used c misoprostol → cervical softening & uterine contraxn, requires 3 visits. Use up to 49d gestation

Postcoital contraception – “morning p” pill, 72h later, 75%

Complications of preg

Hyperemesis Gravidarum: wt loss, dehydration, hypoK, hypoNa, hypoCl.

PE: dry coated tongue, poor skin turgor, sunken eyeballs

Mngmt: eval for hosp admit, IV fluids & e-lyte replacement,

NPO, advance diet slowly, social & psycho support

Tx: vit B12, metoclopramide, odansetron, ginger, steroids,

acupressure

Premature rupture of membranes –leakage/gush of water, pooling of vaginal fluid, nitrazine (pH – if dk blue its basic and amniotic fluid), ferning (crystal pattern on slide looks like fern leaves – amniotic fluid), amniotic fluid index.

Mngmt: steroids, tocolysis (meds to stop contrax), vaginal culture (GBS + abx & watch for infxn), avoid vaginal contamination, monitor cbc, temp, fundal tenderness, prompt delivery in case of chorioamnionitis.

Complications – preterm delivery, chorioamnionitis, fetal malformations, failure of lung dvpmt (need amniotic fluid to dvp lungs)

Rh incompatibility – Rh neg mom, Rh pos baby.

Isoimmunization – IgM is initial, baby not affected b/c doesn’t cross. Next preg IgG, crosses placenta→ hemolysis of fetal RBCs, anemia, incr erythpoiesis, heart failure, fetal hydrops, effusions, & placental edema, jaundice

Tx: give Rhogam at 28-30 wks, given 4 invasive procedures

during preg, for miscarriage & ectopics.

Postterm preg – Htn, long labor, macrosomia, shoulder dystocia, meconium, fetal distress, oligohydraminos, ↑risk for c-sxn

Interventional – fetal surveillance, cervical ripening, labor

induction

Preterm L&D – prior to 37wks. Lo bwt: < 2500gms; very lo

bwt 1000-1500 gms,

Impact – expense of NICU, decision for heroic efforts, long-term phys & mental disabilities, immature lungs, intraventricular hemorrhage.

Eti: – unk; placenta previa or abruption, pelvic infxn, trauma, surgery. Autoimmune dz, cerv incompetence, uterine pathology, maternal dz or drug use, fetal anomalies, idiopathic.

♀ at risk – those who’ve been preterm a, Progesterone inj can reduce risk. Cervical ∆s , contraxns, pelvic press, water/bloody discharge. Fetal fibronectin – located b/t deciduas & chorion, if detected by vaginal swab.

Placenta previa – placenta, implanted ovr lo-r uterine segment.

Total, partial, marginal. Lo vol – placenta in lo-r uterine segmt, near cervix. Total is worse b/c no way for baby to get out until placenta comes out--- if out 1st = baby has lost all its O2.

Sx: bright red vaginal bleeding, no abd pain, bleeding in 3rd tri,

or end of 2nd. Earlier, worse the prognosis.

Dx: US – the key if you have pt c 3rd tri bleed, don’t do pelvic exam unless do US. If you find placenta & is previa don’t touch cervix, can make the bleeding worse & become life-threatening hemorrhage ci mins, may not have time to go to OR & deliver baby.

Mgmt: bed rest, fluid replacemt, blood transfusion, CBC, type & cross, coag profile. Klehauer-Betke test → Rh test to see how much fetal blood got in2 circulation. If significant, another dose of Rhogam.

Placetal abruption – completely or partially separates fr its implantation. MCC – HTN, trauma, cocaine, idiopathic

Sx: uterine pain due to titanic contraxns, fetal distress/demise,

shock, vaginal bleeding, incr fundal ht.

Mgmt: tx shock, delivery, conservative if premature.

Postpartum hem >500 cc in 1st 24h preg

Eti: coagulopathy, cervical, vulvar, or vaginal lacerations,

uterine atony – overdisten, oxytocin use during labor,

uterine exhaustion, retained placenta or blood clots,

uterine infxn. Check for placenta 4 missing pieces, feel

fundus for consistency, evaluate for coag, inspect for

lacerations, uterine exploration

Mgmt: of atonic uterus – bimanual massage, oxytocin, manual

removal of clots or placenta, methergine, vasopressin, PGs,

angiography, selective arterial embolization/ligation

HTN in preg – 140/90 or higher

Chronic, transient gestational, pre-eclampsia, eclampsia, chronic Htn c superimposed preeclampsia.

Chronic HTN – dx prior to preg or 1st 20 wks. Preg may

cauz/exacerbate ♥ or renal complications of HTN. Lo

Na diet, meds may not b needed (≠ ACE or CCB),

methyldopa is preferred tx.

Transient HTN – devp during preg, no proteinuria, BP rtns to

nml ci 12 wks p delivery. Cant b differentd fr chronic

HTN dx during preg until 12 wks

Mild preeclampsia – HTN 300 mg/24 hrs, but < 5g/day. Asympt. Nml

blood tests

Severe preeclampsia – BP > 160/110; protein > 5gm/d, oliguria < 500 ml/24h; cerebral/visual disturb, TTP, cyanosis, grwth restriction in baby.

Sx: HA, scotomas, flashes, epigastric, RUQ pain. Multiorg

dysfunction, HELLP syndrome- hemolysis, elevated LFTs,

lo platelets. >34 wks, deliver; < 34 weigh risk & benefits.

Pathophys – vasospasm, ↑arteriolar resistance, ↓GFR due to

constriction of afferent arteriole, cauzs oliguria.

Eclampsia – Sz involved

RF for pre-eclampsia – nulliparity, teen preg, multiple gestation, DM, renal dz, chronic HTN, molar preg

Consequences – abruption placenta, Sz, hem stroke, DIC, pulm edema, liver hem, acute renal failure, fetal growth restriction.

Mgmt: hydralazine or labetalol if BP very hi (goal 140/90 –

150/105). Steroids 4 fetal lung maturity, MgSO4 for

Sz prophylx, continue 24 hrs pp, monitor levels.

Delivery is definitive Mgmt:

Termination of Preg

Surgical D&C – D&C → vacuum

Ru-486 – works by blocking progesterone receptors. Used c

misoprostol, cervical softening and uterine contraxns.

D&C - dilate cervix c laminaria (seaweed stics) day prior to the procedure. Cervix can b dilated under anesthesia c tapered dilators. Curette loosens uterine contents. Vacuum extraction of POC.

D&E – 2nd trimester abortion – when fetus is removed in pieces p cervix is dilated. Grasp fetal parts and remove manually.

Cervical Ca

Premalignant dz, very common, screening is easy & can detect treatable premalig dz. Screening guidelines - begin PAP @18 or p sexual begins. P 3 consec. nml, discretion of provider.

RF: Infxn c HPV (strains 16,18,31,33 r hi risk types) early 1st

coitus, smoking, lo socioeconomic strains, HIV infxn or

other immunodeficiency.

Pap smear method – not during menses, avoid intercourse, douches, lubricants, tampons 24h prior. Do pap b4 bimanual, sample endocervix & ectocervix

Cysts & Neoplasms

Endometrial hyperplasia

Some types of endometrial prolif may → carcinoma.

Sx: irreg or postmenopausal bleeding

Dx: endometrial bx; < 35 don’t need if ≠ RF, > 40 bx c abnl

bleeding, +/- RF

Hyperplasia

Simple (cystic) – inactive endometrium, no malignant

potential, “Swiss cheese”

Complex (adenomatous): ↑ # of glands, gland crowding

Hyperplasia c atypia: irreg nuclei, may → malignancy

Tx: depends on age, < 40 D&C; rpt bx in 3-6mo. Give

progesterone, then stop, will shed endometrium. If

childbearing complete, do hysterectomy

Endometrial Ca RF

↑ estrogen, early menarche, PCO, obesity, nulliparity, HTN, DM, FHx, late menopause

♀ ovulates → prod progesterone. In PCO, ≠ ovulating, producing unopposed E.

Obesity – more body fat → more E produced

Nulliparity – amenses at least a year for ea preg, cuts ↓on #

x’s prod estrogen

Endometrial Ca

Sx: peri/postmenopsl bleeding

Dx: bx, US 4 endometrial thickness, consistency, hysteroscopy

& D&C if EMBx unsuccessful or ≠ correlated c TVS

(transvaginal sono), or sx persist. Need 2 do both

endometrial bx & US, b/c may miss the lesion, US will

show how thick endometrium is.

Tx: surgical staging, TAH/BSO (total abd hysterectomy, bilat

salpingo oophorectomy), omentectomy, LN, disxn,

radiation, chemotx

Dermoid cysts

Neoplasms of ovary c many types of epithelium, diff cells, have hair & teeth often. Strange looking

Torsion – twists on itself, surgical emergency, if don’t repair, ovary becomes ischemic → necrotic p a few hours. Most likely to happen c dermoid cysts b/c they’re heavy. Acute presentation, agony, have had pain b4 & went away on its own. Sometimes ovary will twist & then untwist itself.

RF: nulliparity, BRCA1 or BRCA2 gene mutations, FHx,

advancing age

Tx: un-ruptured : follow conservatively.

ruptured c lg amt of free fluid – drain surgically

Surgery - 8cm, or if 5-8 cm s spontaneous regression

Ovarian Ca

RF: nulliparity, BRCA 1 & BRCA 2, FHx, advancing age

Sx: most stage III – IV @ time of dx, abd enlgmt, pain, early

satiety, menstrual irreg, late in the dz abd fullness b/c sx of

ascites.

Dx: pelvic exam, US, CT, markers: CA-125, AFP, HCG,

false +, follow dz p surgery, screening in hi risk pts.

Sx on US which raise suspicion – solid, septation,

papillations, size, adhesions, bilateral, ascites.

Do tumor markers b4 & p monitor tx

Tx: TAH/BSO, omentectomy, L. node disxn, peritoneal

washing (fluid, suxn & c if malignant cells) radiation,

chemotx, tumor debulking, 2nd look – laparoscopy later, or

if tumor markers ↑, see if recurrence of dz.

Screening & Prevention: referral 4 genetic counseling, CA

125, Pelvic US, prophlx oophorectomy

Benign Disorders of the Vulva

Vulvar Neoplasia

1. vulvar intraepithelial neoplasia (VIN) I, II, III

2. invasive carcinoma

3. pruritis, pigmentations, ulceration,

4. bx suspicious

5. tx: local excision, tx invasive c vulvectomy

Vaginal neoplasia – VAIN I, II, III

Invasive vaginal Ca, incidental finding on colposcopy.

Tx: local excision, invasive c vaginectomy

Perimenopause - Prior to & following menopause

Climacteric - transition fr repro yrs in2 menopause

Menopause - loss of ovarian funct → cessation of menses

Physiology – fewer ovarian follicles cauz ↑FSH levels, ↑in stromal component of ovary leads to shift in ratio of androgens:estrogens. Postmenopausal estrogen prod is a product of periph conversion of adrenal androstenedione

Dx: not necess to test; day 2 or 3 serum FSH level > 50 IU/ml,

serum estradiol < 50 pg/ml; amenorrhea for at least 1 year

Eval of abnl bleeding - pelvic exam/US, PAP, endometrial bx,

hysteroscopy, D&C

CVD – 2x as many ♀ die of CVD > Ca, MCC death in ♀ > 50.

Onset in ♀ 10 yrs later than in ♂

RF: smoking, HTN, hyperlipid, DM, obesity, estrogen def.

Protective factors: xercise, etoh, antioxidants, lo fat intake

Pt education: ♀ focus on short-term sx, diet, xercise, sexuality,

drug/alcohol abuse, smoking, caffeine, domestic/elder abuse,

Ca2+ supplementation

Health screening

HRT - oral, transdermal, topical

Regimens: cont’ combined, cyclic, pulsed estrogen, cont’

progesterone, cont’ unopposed estrogen (only for ♀

s a uterus)

Benefits: imprvmt menopausal sx. Prevent osteo. colon Ca

Estrogen effects: improves lipid profile, antioxidant,↑

fibrinolytic potential, ↓fibrinogen & factor VII.

insulin, vasodilation & antispasmodic effects, ↓BP

ADRs – breast tenderness, bloating, depression, vaginal bleed,

appetite ∆, insomnia, N, HA, fatigue, libido ∆’s, PMS,

nervousness

Risks - breast Ca, MI, DVT, stroke, PE

Pt selection: young pts c hot flushes, sz possible decline in sz

cntl. Migraines, high risk breast cancer

CI – breast Ca or undx breast mass; uterine Ca or undx vaginal

bleed; hypertrigly, familial hyperlipidemias, clot disorder,

stroke, thrombophlebitis, liver dz, E dependent dz

Breast Dz

Lg modified sebaceous glands, Axillary xtensions (Tail of Spence), ea. Breast weighs 2-300g, glandular tissue, mostly adipose & CT, 12-20 lobes radiating fr nipple – ea. Lobe contains 10-100 lobules

Milk Ejexn - Originates in secretory cells of alveoli. Branching collecting ducts → lactiferous sinuses → terminate in excretory duct → nipple

∆s c menstrual cycle - tender during luteal phase, ↑ blood flow, vasc engorgement, H2O retention, ↑size/density/nodules

Benign Breast Dz

Fibrocystic ∆s - irreg in contour, cyclically painful, exaggeration of nml tissue response to hormonal ∆s, benign, ↑engrgmt & density, xcessive nodularity, ↑tenderness, occasional nipple discharge, bilat, poorly localized pain, sx most prominent premenstrually

Sx: nodular “plate of peas,” rubbery, fluid-filled cysts

Dx: H&P, aspiration cytology 4 cysts, FNA or excision bx

Mgmt: support bra, diuretics, ↓methylxanthines (coffee,

chocolate, tea, cola, OTC meds), ↓tobacco use,

OCPs, bromocriptine, danazole, tamoxifen

Fibroadenomas - adolescents & ♀ in 20s. Self-discovered, slo-growing, solitary, multiple, ≠ painful, ≠ cycle ∆s, may regress of shrink. Rubbery, firm texture, solid. Freely mobile, may recur p reoval, US differ cystic fr solid.

Dx: FNA or excisional bx.

Intraductal Papilloma - Spontaneous, intermittent discharge fr 1 nipple. Watery, serous, serosanguinous. Perimenopausal age grp, 75% beneath areola, sm, soft & diff 2 palpate.

Tx: excision fr involved duct & small tissue margin

Nipple Discharge - Benign or malignant dz; 2b medically significant → spontaneous & persistent in non-lactating. Color doesn’t diff benign or malignant. Cytology → but ≠ dx. Mammogram, possible excisional bx

Breast Ca - US 1 of hi-est rates. 1/8 lifetime risk 4 American ♀, 1/17 risk if no other RFs, other than age. RF:

1. Age - ↑directly c age, nonexistent b4 puberty

2. Estrogen xposure: oophorectomy prior to age 35 ↓risk 70%, obesity ↑risk, early menarche, late menopause, nulliparity, 1st child p age 30

3. Genetic predisposition: BRCA-1 & BRCA-2, FHx, genetic testing & prophyx oophorectomy & mastectomy

4. Radiation xposure: Jap. survivors of ATOM → Hi doses of tx radiation

5. Misc: breast dz (benign or malignant), etoh use, estrogen tx, hi dietary fat

Screening & Dx - BSE, clinical breast exam, mammo, US,

needle asp

BSE – majority Ca disc. by Pt. Several days following menses, inspect/palp.

Technique: arm at side, behind head, massage c pads of 2, 3 ,4 fingers. Begin at nipple, work outward in concentric circles

Clinical exam: 3-5 min, inspect & palpate sitting & supine; sitting: hands above head & on hips; examine breast, axilla, Cx

wall & supraclavicular ras

Inspect –vascular, symmetry, contour, skin, nipple, erythema

Palpate – compress areola to see discharge, masses: record

findings as face of clock, describe quadrant

Mammography – most accurate & earliest detection, most

sensitive, detects nonpalpable lesions, lo radiation xposure,

annual begin age 40. Directs decisions – annual f/u; rpt

films, US, bx

US – diff cystic fr solid; ≠ radiation. ≠ 4 lesions < 2mm;

can’t detect microCa2+, can’t diff benign vs.

malignant. For guidance of needle bx or asp

Needle Asp – aspirate all fluid, cdraw needle, maintain

pressure 5-10 min avoid hematoma, If asp. is bloody or

residual mass, do bx

Bx When - bloody aspirate, mass p asp, suspicious mammo, PE

findings, sm mass – needle bx, lg; incisional/excisional bx

Breast Ca Classification

1. Ductal carcinoma: in situ, infiltrating

2. Lobular ca – in situ, infiltrating, inflammatory, Paget’s dz

Tx: cntl local dz, tx metastases. Improve quality of life, Cntl of

local dz: radiation, lumpectomy, quadrantectomy,

mastectomy, sentinel LN bx

Vaginitis & STDs

Many ♀ already tried OTC tx; R/O physiologic discharge – nml discharge vagina produces, nml lactobacilli produce LA & H2O2 which r protective

Bact Vaginosis – aka hemophilus vaginalis, Gardnerella; overgrwth of nml vaginal anaerobes → ↓lactobacilli. Cauz minor PAP abnl, cervicitis, PID, preterm labor, “sexually assoc” ↑risk of other infxn

Sx: irriation or pruritis, thin, gray or wht discharge, fishy or

musty odor worsens p intercourse.

Dx: discharge, vaginal pH > 4.5, clue cells (nml vaginal

epithelial cells), whiff test (KOH mixed c vaginal

secretion to amplify the fishy odor)

Tx: topical or oral metronidazole/clindamycin. Alternatives

oral clindamycin or metronidazole (preg)

Recurrent BV: tx 10-14d, suppressive tx c metronidazoel gel.

Don’t use clindamycin due to resistance.

Trichomonas – single celled parasite c 2-5 flagellate. Sex Tx;

↑multiple partners

Sx: itching, dysuria, yl-grn or gray frothy discharge, foul

fishy odor

Dx: erythema, “strawberry cervix” (my angry cervix!)

Culture is most accurate, detected on pap, bubbles

Tx: PO metronidazole, single dose, tx partner. If Tx failures:

metronidazole 2g; combo tinidazole & metronidazole

Genital herpes

Counseling – abt t-mission, asympt viral sheding: use condom,

avoid intercorse c lesion, if active lesion at time of L&D →csxn

Tx: PO acyclovir, valacyclovir, famcyclovir.

Labor & Delivery

1st: onset of contraxns until full cervical dilatation.

2nd: full dilatation until delivery, up to 1h in multipara, & 2h

for primipara; pt is pushing q contraxn until baby is born.

Delivery happens here.

3rd: delivery of infant → delivery of placenta, (~30mins)

False labor: felt as abd tightening, irregular, long intervals

True labor : felt in the bk also.

1st stage

latent: until 4cm; not sure if real or not, going fr irreg

contraxns → true labor, may b widely spaced apart

Active: 4 cm →7 or 8cm

Transition: 7-8 cm until full dilatation, labor more intense

In active phase, primipara should dilate a minimum of 1.2 cm/hr. Multiparas should dilate at least 1.5 cm/hr.

Classical c-sxn – ≠ vaginal deliveries p b/c uterus can rupture.,

only when lo-r segment isn’t lg enough to get baby thru. Usually lo-r segment transverse

Sx of labor - Lightening - descent of fetal head in2 pelvic inlet.

Blood show – extrusion of blood tinged cervical mucus plug

Rupture of membranes – gush or leakage of clear fluid (unless meconium). Some ♀ will deliver co ruptures; H2O break?

Mngmt: presenting in labor - Onset of contraxns, interval, rupture of membranes, color of fluid, vital sx, pelvic exam for cervical effacement, dilatation, station; Pelvic architecture. Fetal position & presentation; monitor contraxns & Fetal HR.

Mngmt of 2nd stage

1. Encourage pushing when fully dilated

2. episiotomy as baby crowns

3. cntrl delivery of head

4. suxn nasopharynx

5. check for nuchal cord

6. ↓ward traction on head to deliver ant shoulder, upward for post shoulder

7. Double clamp & cut cord

Count to 10 slowly as pt is bearing ↓, long pushes r more effective c pushing the baby ↓. Short pushes result in conehead.

Epidural – encourage mom & remind her to push↓below; if arching bk & turning red, not pushing effectively. Flex head fwd & something to hold on to behind her knees will help push effectively.

Crowns – baby’s head is bulging out, perineum is stretched & thin; episiotomy is done now. Not too early, perineum ≠ stretched more sensitive & will bleed more. Give local anesthesia a episiotomy.

Mgmt: of 3rd stage - Signs of placental separation uterus becomes globular & rises gush of blood fr vagina, umbilical cord lengthens. Watch 4 sx placenta is separating → gives a gush of blood, a uterus starts to contract. Gentle traxn on cord c suprapubic pressure. Pull on clamp, keep 1 hand over suprapubic area or else you can invert the uterus. Pull ↓until see placenta at vagina, twist placenta, see membranes come out, its own wt will gently deliver membranes. Give oxytocin (contract uterus), bleeding ceases. Repair episiotomy. Check placenta & birth canal – cervix, vagina, genitalia make sure no lacerations; unrepaired will bleed,

Episiotomy

Median: easy repair, good healing < painful, < dysprunia,

good anatomic restoration, chance of extension

to anal sphincter. Like to do median – disadv;

Mediolateral: diff to repair, faulty healing, > painful,

> dysprunia, occasional faulty anatomic

restoration, grtr blood loss, < extension.

if short perineum or lg baby, do mediolateral

General anesthesia: may cross placenta, cauzin decr reactivity of fetal HR, & lo Apgar. Risk of asp pna; deleterious effect on maternal expulsive efforts. Mainly for C-sxn.

Sedation: stadol or Demerol, c phenergan. Doesn’t completely eliminate pain, falls asleep in btn contraxns. May prolong labor or precipitate delivery, crosses placenta, reversible c narcan; deleterious effect on maternal expulsive efforts. If sedation given very early, may slow ↓ contraxns, give ~ 4-5cm, having a tough labor; seems to relax pt & may deliver in the next contraxn or 2. Pblm: mom might not push effectively if still sedated. Crosses the placenta, if monitoring placenta & HR not too great, monitor. If fetal HR < reactive, lo Apgar → Narcan.

Pudendal block: pudendal nerve supplies perineum, clitoris, anus, & medial/inferior portions of vulva. Helps pain c cervix dilation & pain episiotomy. Used at time of delivery to ↓vaginal pain; INJ near ischial spines, effective for episiotomy; no effect on fetus or contraxns

Local anesthesia: lido at site of episiotomy or laceration, ≠ effect on fetus or contraxns. If don’t have time to give anesthetic, do anyway, but when repairing, will need anesthetic.

Spinal anesthesia – subarachnoid space, single INJ; CI c coagulopathy, hypovolemia, severe HTN, hemorrhage. Used 4 C-sxn, if need longer-acting, give epidural. Easier to give & quick. Complications: hypoten, resp paralysis, anxiety & discomfort, bladder dysfunc, spinal HA. If↓BP, placenta doesn’t perfuse → bradycardic baby.

Leakage of spinal fluid – every time pt sits↑, brain will sag & pull on meninges, painful. HA everytime sits ↑→spinal HA.

Epidural block - 85% effective for painfree labor; CI c HTN, hemorrhage, platelets ................
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