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APGO & World Study guide

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Unit 1: Patient

Unit 2: OB
MFM
Pulmonary changes:
o Increases: inspiratory capacity, tidal volume, minute ventilation, total body o2
consumption
o Decreases: FRC, ERC (expiratory reserve volume), RV decrease, total lung capacity
o Respiratory rate does NOT increase, but respiratory alkalosis (from progesterone)
comes from increases in tidal volume and inspiratory reserve volume
MAIN PONT OF RESP ALKALOSIS IS TO FACILITATE CO2 FROM FETUS, WHICH
MAKES FETAL HGB MORE AVID FOR O2
o Tocolytics increase risk of pulm edema during pregnancy
o CXR: prominent pulm vasculature, normal, 2/2 increased circulating blood volume
Cardiac changes: CO increases up to 33% 2/2 both increases in SV and HR; SVR decreases;
most women get systolic murmur 2/2 increases in volume (diastolic murmurs are always
abnormal); if a VSD, and pulm vascular resistance exceeds SVR, rL shunt develops and
cyanosis develops
o Colloid pressure decreases edema
o Increase in HR (and SV increase in CO)
o Fibrinolytic activity decreases and plasminogen activity increases
o DIC when fibrinogen hits normal (~200) b/c increase fibrinogen levels in pregnancy; D-
dimers also always present
o IVC syndrome: supine, get lightheaded, dizzy, faint, b/c of insufficient shunting from the
paravertebral circulation when the uterus impinges on IVC return
o Normal: increased second heart sound split with inspiration, distended neck veins, low-
grade systolic ejection murmur
Heme:
o Increases: Fibrinogen, fibrin split products, 7,8,9,10
o Decreases: protein C and S
o Same: prothrombin (II), 5, 12, PT and PTT
o Left shift of Hb curve
o Thromboembolism risk doubles
o Hgb <11 is anemia, leukocyte count can go high as well 2/2 stress
Urinary: hydronephrosis from compression by uterus and R ovarian vein 2/2
dextrorotation of uterus R>L; residual volume in bladder is also increased b/c P decreases
bladder tone
o Trace glucose normal b/c increased solute filtration thru kidneys
o RAAS increased affects pts with prior HTN
o Hydronephrosis is considered normal on imaging
GI:
o Portal vein enlarges (live and biliary tract do NOT) from increased blood flow
o GERD increases, increased transit time of food, less GB contraction
o Estrogen effects: inhibition of bile acid transport gallstones, purutitis
o Constipation: enlarging bowel, reduced motility, increased H20 resorption
o Gums: more edematous and bleed easily
o Increased hemorrhoids
o Alk phos doubles b/c of placenta production

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o Cholesterol increases
o Albumin increases, but looks lower b/c of hemodiluation
Endocrine:
o DHEA decreases b/c liver converts to E, serum cortisol increases
o Increases insulin, reduced tissue response to insulin, hyperglycemia, maternal hypoG
during fasting b/c taken by fetus
o Increased bone turnover, increased PTH, no bone loss however
Thyroid: increased levels of TBG from increased estrogen increased total t4 and t3 with
stable levels of free t4/3; thyroid can increase in size in pregnancy by up to 10%
Hair: increases in anagen (growth) and decreases in telogen phases
Leucorrhea of pregnancy: heavier vaginal d/c during pregnancy that some women may
mistaken for ROM
Eyes: edema in cornea (blurry vision) and decreased IOP dont change prescription for
women b/c goes away after pregnancy
In molar pregnancy: always do CXR b/c MC site of mets of gestational trophoblastic dz
Weight gain: >30 bmi, 11-20 pounds; if underweight (bmi<18.5), gain 28-40lbs
Preconception Care
Screening for blood dyscrasias: routine in AA with CBC and Hb electrophoresis
Downs screening
o Sequential screen: highest detection rate for trisomy 21; quad screen plus NT and
PAPP-A
o First tri: NT, PAPP-A and free beta-hCG
o Second tri: quad test (AFP, bHCG, estroil, inhibin A)
Risk of miscarriage 2/2 CVS is not related to prior miscarriages from unknown causes
Antepartum
DM2 a/w: shoulder dystocia, metabolic disturbances, PED, polydyraminois, fetal macrosomnia,
NOT with IUGR
Intrapartum
Ketone in urine: dehydration, can be secondary to hyperemesis g.
Must confirm fetal HF and status before placing an epidural. If FHR cannot be found, apply fetal
scalp electrode
Intrauterine pressure cath: info on strength and frequency of patients contractions
o If blood comes when placing: withdraw, monitor fetus and replace if reassuring;
possible sources could be placenta separation or uterine perforation
Operative-assisted vaginal delivery: forceps or vacuum; if pt cannot deliver infant with one or
two pushes during +2 fully dilated stage
Variable decel: umbilical cord compression>>umbilical cord prolapse
Umbilical cord prolapse tx: even if reassuring heart tones and status with baby coming down,
elevate the fetal head and perform a c-section
Prophylactic episiotomy is NOT recommended
Stage
Characteristics
Nulligravida
Multigravida
First
Onset of true labor to <20h
<14h
full cervical dilation
Latent Phase
0-3/4 cm dilation
Variable
Variable
Active Phase
to full dilation
>1cm/hr
>1.2cm/hr
Second
Full dilation to birth
30m to 3hrs
5 to 30m
Third
From delivery of baby 0-30m
0-30m
to delivery of placenta
Arrest of descent: mgmt. is usually C-section

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o Nulli: no change in 2 hrs (add another if epidural in place)

o Multi: no change in 1 hr (add another hour if epi in place)
o MC from cephlopelvic disproportion esp if prominent ischial spines
Bloody show: results as cervix beings thinning/effacement
Start pushing once 2nd stage of labor begins
MCC overestimation of amt of descent (station): molding and caput succedaneum
(edema of fetal scalp caused by pressure on head from cervix)
Signs that placenta is coming: 1) cord lengthening, 2) gush of blood, 3) uterus becomes
more firm and globular (shrinks)
C-section indications: uterine rupture, cord prolapse, hemorrhage from placenta previa
or abruption
Immediate Care of Newborn
Mg use during PEC: check baby for respiratory distress after birth
Large babies: gestational DM; small babies: DM1; both at risk for hypoG
DM babies: hypoG, polycythemia, hyperbili, hypoCa, respiratory distress
Chorio baby: fetal tachy in response to maternal fever, lethargic, pale baby with high temp at
birth
Naloxone to infant could put them at life-threatening withdrawal
HIV mother: AZT immediately, test for HIV at 24h, do NOT breastfeed
Postpartum
Sheehans: anterior pit loss of THS, ACTH, gonadotropins
Endometritis: higher in c-section births, prolonged labor, prolonged rupture of membranes,
internal fetal monitoring, mult vag exams
Endometritis: MCC postpartum fever
Postpartum depression: w/in 2-6mos delivery, >2 weeks
o 2 weeks: postpartum blues
Breastfeeding decreases the risk of ovarian CA
Lactation
Pain and cracking during b-feeding: from malposition of baby
Prolactin stimulates milk production, E & P inhibit lactation, oxytocin stimulates ejection
o Nipple stimulation: milk ejection from release of oxytocin
Mastitis tx: Abs and continue b-feeding
Candidiasis: from babys oral cavity, pink and shiny nipples with peeling at the periphery
Signs baby is getting sufficient milk: 3-4 stools in 24h, 6 wet diapers in 24h, sounds of
swallowing and weight gain
Postpartum Infection
Fever differential: endometritis, cystitis, mastitis, thrombophlebitis (rare)
o Thrombo is a dx of exclusion; mgmt. is with anticoag and antibiotics
C-section erythematous site: drainage always to evaluate for fascia dehiscence and heal from
bottom up
Can also get nec-fascitis from c-dif which requires debridement and ABs; characterized by loss
of sensation and necrotic tissue

Uworld
Uterine atony:
o Risk factors: overdistension (multiple gestation, polyhydraminos, macrosomnia),
uterine fatigue (prolonged labor)
o 80% of PPH within 24h

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o Mgmt: oxytocin infusion, fundal massage, IV access, infusion if BP<90 systole if

oxytocin doesnt control carboprost, ergot alkaloid pack uterus with gauze, foley,
sengstaken-blakemore tube, bakri postpartum balloon
Endometritis:
o MCC post-partum fever 2nd and 3rd day
o RFs: prolonged rupture of membranes (>24h), prolonged labor (>12h), c-section, fetal
scalp electrodes used
o Sx: fever, tender nipples, tender uterus, foul-smelling lochia
o Mgmt: Broad-spec Abs (clinda and genta) to cover polymicrobial infection
PID would be ceftriaxone (gonorrhea) and azithromycin (chlamydia)
BPP scoring:
o Used in high-risk preg, decreased FM, after a nonreactive nonstress test and still
nonreactive after vibroacoustic stimulation (b/c common cause of abnormal NST is
sleeping baby)
o 5 parameters assessed by US:
NST (reactive)
Fetal tone (flexion or extension of extremity)
Fetal mvmt (2 in 30m)
Fetal breathing (20 sec in 30 minutes)
Fluid volume (single pocket greater than 2cm in vertical axis)
o 8-10 is normal, 2 or less is severe fetal asphyxia
if 8 and dec fluid, delivery
4 or less, delivery if >26w old
o Contraction stress test: used in setting of equivocal NST or BPP test
o NST: normal if in 20 min at least 2 accelerations at least 15 bpm increase for at least 15
seconds
Screening tests:
o For all: cervical cytology, rhesus type and AB, H&H, MCV, rubella immunity, varicella
immunity, urine culture, syphilis testing, hepBAg, chlamydia testing (not gon, only if
RF), HIV, influenza vaccine during any flu season, offer CF and Downs genetic tests
Breech:
o Majority correct by 37th week, no correction before then
Attempt ECV beyond 37th week w/o contraindications: placental abnormalities,
hyperextended fetal head, fetopelvic disproportion
SAB mgmt
o Inevitable or incomplete: hospitalize, give IV fluids, prevent DIC, extensive hemorrhage,
sepsis, RhoGAM administration
o Inevitable: suction curettage
o Missed and after 16th week: induction of labor
IUFD (>20w): induction of labor esp to prevent DIC, coag consumption
represented by decreasing fibrinogen, platelet levels, and increasing PT/PTT
o Complete: serial bHCG testing to ensure nothing remains in uterus
DM during pregnancy
o Goals: </= 95 fasting, </= 140 1h post prandial, </= 120 2h post prandial
o Tx: subQ insulin b/c doesnt cross placenta
Changes during pregnancy:
o Renal
GFR increases, RPF increases, so BUN and Cr decrease (early in first trimester)
o Thyroid:
If hypoT, increase dose of Rx

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T3 and T4 total are increased b/c increase in thyroid binding globulin

Increased AFP: from inaccurate dating, NTD (then do amniotic fluid analysis to also find
increased aceylcholinesterase), abd wall defects (gastrochisis, omphalocele)
o Decreased AFP: downs and Edward syndrome
o Downs: low AFP, increased bHCG, low estriol, elevated inhibin A
o Edwards: low AFP, very low bHCG, low estriol, normal inhibin A
Post-partum low grade fever:
o Blood clots still coming, small leukocytosis
o VERY common in first 24 h PP and mgmn is REASSURANCE
o Lochia rubra lochia serosa lochia alba
Fetal heart tones:
o Tx in recurrent variable decels (non-reassuring in general tx): improve oxygenation by
administering O2 to mom and changing maternal position then amnioinfusion
(AROM and infusion of saline into amniotic cavity)
o Variable decel: <30 second; intermittent (<50% of uterine contractions) vs recurrent;
etiology: cord compression, cord prolapse, oligo
PEC:
o Severe features: thrombocytopenia, renal insufficiency (>=1.1 Cr or doubling Cr),
impaired liver function, neuro sx, pulm edema, very high BP (>=160 OR >=110)
o Hypertensive emergency (>=160 OR >=110) tx: hydralazine IV or labetalol IV
False labor:
o Last 4-8w of pregnancy
o Contraction are in lower abd and irregular w/o increase in intensity, relieved by
sedation, no cervical changes
o True contraction: increase in intensity, shortening intervals btwn regular contractions
GBS prophylaxis when unknown status:
o Del <37w, PPROM (<37w)
o Membrane ruptured for >/=18 hours
o BGS bacteriuria during current pregnancy
o Prior hx of delivery of infant with GBS sepsis
Renal colic/flank pain evaluation: US to see renal stones
o Dont do CT or IV pyelogram in pregnancy
IUGR:
o Symmetric: insult from fetus, begin <28w usually
o Asymmetric: insult from mom, normal length but decreased girth
HTN, hypoxemia, smoking, vascular dz, PEC
Better Px than symmetric
HELLP syndrome mgmt.: DELIVERY IMMEDIATELY (labor induction or c-section)
CVS: aspiration from CV of placenta during 10-12w; offers earlier dx, can do FISH, ; do in
women >35 after US (for instance, if US shows nuchal translucency)
o Amnio: 16-18w
o Risks of CVS: limb reduction, fetal death; increased when done before 9-10w gestational
age
bHCG: alpha unit common among TSH, LH, FSH; promotes male sex differentiation, stimulates
maternal thyroid, peaks at 6-8w gestational age (a/w nausea?)
Progesterone: inhibits uterine contractions during pregnancy; preps endometrium for
implantations of fertilized ovum
Estrogen: induces prolactin production during pregnancy
Acreta: 2/3 need hysterectomy to stop bleeding; previa: 25% risk for accreta after c-section

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When to do hysterosalpingogram for infertility workup: when ovulation you know if not
an issue, and past hx of PID fallopian tubes, endometriosis, DES, congenital things
No breastfeeding tx: ice packs and tight-fitting bra
Previa: painless bleeding in 3rd tri; US to dx; tx: if mom and fetus stable scheduled c-section;
do NOT induce labor b/c could make bleeding worse; if massive bleeding or unstable ER c-
section
Appendicitis dx: US offers least amt of rads < xray < CT
CTS: increased in pregnancy 2/2 estrogen-mediated depolymerization of ground substance
edema in tissues CTS (carpal tunnel syndrome)
Intrahepatic cholestasis of pregnancy: mgmt. for baby is early delivery once fetal lung
maturity is established 2/2 risk for demise and meconium-stained amnio fluid
Placenta previa and prior c-sections: increased risk for placenta acreta
PEC increased risk for placental abruption (b/c of association btwn HTN and abruption)
o If bleeding controlled during abruption, can proceed with vaginal and augmentation of
labor if necessary
o Similarly in PEC pt who just had seizures, but is now stabilized, can also do induction of
labor
Isoimmunization: recommends testing at 28w for ABs if Rh(-) if at risk, give rhoGAM at 28w
and at time of delivery
Bacteruria screening: 12-16w
Luteoma of pregnancy: benign solid lesions on both ovaries, from bHCG, Sx include hirsutism
and virilization
Post pregnancy low-grade fever: common after pregnancy along w/moderate leukocytosis;
also normal is lochia rubra
Graves dz: IgG crosses placenta and can cause toxicosis in baby goiter, tachypnea,
tachycardia, cardiomegaly, restlessness, diarrhea, poor weight gain
Cervical incompentence dx: gold std is transvaginal US
Fetal demise: IUFD after 20w gestation; should perform autopsy to determine cause
Chorio: maternal tachy (>100), fetal tachy (>160), uterine tenderness, leukocytosis; a/w
PPROM
Vasa previa: mothers vitals remain stable while babies decrease from tachy to brady to
sinusoidal pattern. Can occur during AROM; fetus exsanguinates immediate c-section
All pregnant women should be offered vaccines: flu and TDaP for transplacental immunization
Good for UTI in pregnancy: nitrofurantoin, amoxicillin, first gen ceph no fluoroquinolones,
no Bactrim

Unit 3: GYN
Contraception & Sterilization
Depo-Provera: can cause unpredictable bleeding that resolves usually in 2-3 months; after one
year of use, 50% have amenorrhea
Plan B: levonorgestrel, not an abortifacient, not terotogenic effects, can give it and start OCPs
immediately
Contraindications to combined estrogen pills: thromboembolic dz hx (DVT), lactating women
(decreases protein in milk), women over 35 who smoke, or women who get severe nausea on
pill
OCPs decrease ovarian and endo CA, but may inc b-CA risk if high dose and used for extended
time period; slightly higher risk of CIN
Tubal ligation: slight decrease in ovarian CA
IUD lower risk of endometrial CA b/c of progestin release

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Patch is less effective in heavier women (obese)

Abortion
17-OH progesterone is only for prior Hx of preterm labor (20w to 37w)
Recurrent miscarriage is 2 or more consecutive losses or 3 more losses <20w
Antiphospholipid syndrome tx: aspirin and heparin in order to get pregnant
Medical abortion is a/w more blood loss than surgical
o Manual vacuum: <8 weeks
o d/c <16w and dilation & evacuation >16w
o Intact fetus for autopsy: must do medical abortion induction with intravaginal PGs
o Medical abortion with heavy bleeding tx: D/C
Vulvar & Vaginal Disease
Lichen sclerosis: chronic inflmm skin changes in post-meno and pre-menarche pts; sx: vulvar
pruritis that is extreme, burning pain and introital dyspareunia; skin changes: polygonal ivory
papules (white patches confused with thrush), hypopigmentation, erosions and fissures from
scratching, introital stenosis, phimoisis (absorption of clitoris), and labia minora are resorbed;
tx: hi potency topical steroids; 5% SCC
Lichen planus: in FA, involves skin, scalp, nails, oral mucus membranes and vulva; vulva gets
itchy, burning, bleeds, dyspareunia; skin shows lacy reticular pattern with or without scaring
and erosions; tx: topical steroids
Vulvar vestibulitis: tenderness, erythema, painful intercourse, pain wearing tight pants, pain
during tampon insertion
Lichen simplex chronicus: rubbing and itching that leads to loss of protective barrier
lichenified, rubor, with or without edema; tx: corticosteroids topical
Pelvic organ prolapse 1st line: Pessary
STIs and UTIs
Can have b/l tubo-ovarian abscesses with more aggressive PID 2/2 polymicrobial cause
Hospitalize for PID if: high fever, n/v such that cannot tolerate oral meds
o Cefotetan or cefoxitin PLUS doxy
o Or clindamycin PLUS gentamicin
o Outpatient: ceftriaxone, cefoxitin or third-gen ceph PLUS doxy with or w/o
metronidazole
Pelvic Relaxation and Urinary Incontinence
Urge test: bladder contractions while filling

o Mainstay of urge tx: anti-chol oxy
Stress: 2/2 urethral hypermobility (straining Q-tip angle >30 degrees) and/or intrinsic
sphincter deficiency (ISD); or both!; tx: urethropexy
o Tx: kegels
Urethral bulking procedure: for intrinsic sphincter def (ISD that causes stress incontinence)
but little to no mobility of urethra (drain pipe urethra)
Vaginal prolapse surgery: colpocleisis (also for uterine prolapse)
Pessary: first-line, noninvasive tx for POP (can also use pessary for incontinence)
Breast
Best prolactin levels are when patient is fasting
If FNA bloody and mass shrinks excisional biopsy of mass is necessary
o If FNA clear and mass shrinks reexamine in 2 months to make sure cyst hasnt
recurred
o If FNA negative exicisional biopsy b/c high rate of false negatives w/FNA
If no breast-feeding desired: ice packs and tight bra
Mastitis: MCC s. aureus, so first-line tx is dicloxacillin; erythromycin if penicillin allergy

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Endometriosis
Older women with endo Hx, who has complex ovarian cyst needs work-up in case its ovarian
CA EXPLORATORY SURGERY
Definitive tx: hysterectomy with BSO b/c 60% who dont get BSO need to go for re-operation
Danazol is NOT first-line b/c it causes weight gain, increased body hair/acne and adverse
blood lipid levels decrease LDL and increase HDL
o OCPs first-line b/c of decrease in estrogen
o OCPs induce a decidual reaction in the functioning endometrium OCPs can also be
given continuously to prevent secondary dysmenorrhea
o Can also give DMPA (osteoporosis though) or implants
Hemorrhagic cyst: in older women, aSx, mass-like, repeat US b/c will likely resolve so no
radical workup is required
Trying to get pregnant: clomiphene citrate (similar to PCOS and trying to get pregnant)
Gross: clear white lesions, small dark red or mulberry or brown or powder burn lesions, dark
brown chocolate, dark red or blue domes that are 15-20cm in size at largest
Histo: endo glands, stroma, epithelium, hemosiderin-laden macs
Chronic Pelvic Pain
Chronic pelvic pain in teen dx: dx laproscopy
Rx:
o GnRH: down-regulates axis
o Danazol: suppresses mid-cycle LH and FSH surges
o OCPs: assume pseudopregnancy state
Women with PID can develop chronic pelvic pain
o Salpingectomy if persistent pain and there is some type of mass
Ilioinguinal N: pain worse with thigh adduction (obturator injury would be that she cant
adduct), numbness over the right inguinal area and right medial thigh groin, symphysis,
labium, upper inner thigh
Iliohypogastric N: groin and skin overlying the pubis
Gynecological Problems
LSIL colpo (unless pregnant, teen, or post-meno) [20% of LSIL on pap have HSIL on colpo-
directed biopsy]
After above scenario, colpo shows HSIL (CINIII) & ECC is negative LEEP to send tissue to
path to fully evaluate dysplasia; if invasive cervical CA Ia2 though IIa radical hysterectomy
ACOG on mammos: annual starting at 50, and at least q2y from 40-50yo
LSIL, colpo then showed CIN-I, ECC was negative f/u pap in 6 and 12 mos. Or HPV testing at
12 mos
o Excisional or ablative procedures are not indicated for LSIL
o Cold knife/LEEP if: positive ECC, HSIL too large for LEEP, cant see on colpo
Can do hysteroscopy in office or OR
New breast mass in 42-yo who drinks a lot of caffeine, mass is mobile, no LAD, rubbery:
FNA!!!!!!!!!!!
Adnexal mass felt on PE: transvag US is best way to being workup
Dysmenorrhea (book ch32)
dysmenorrhea and infertility: chronic PID or endometriosis
UWORLD
Urinary incontinence:
o Stress
Pelvic floor muscle weakness

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Dx: history and PE showing prlvic floor weakness such as uterine prolapse
and/or cystocele; UA, cystometry and post-void are normal
Also increased urethral mobility dx by cotton-swab that shows >30 degree
angle when there is an increase in abd pressure
Tx: Kegel exercises, pessaries, estrogen replacement
Surgery: Burch or sling or urethropexy

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o Urge:
Causes: detrusor instability, bladder irritation from neoplasm, interstitial cystitis
Sx: more urinary freq than stress b/c they have the urge to go when detrusor is
contracting
Tx: oxybutynin
o Overflow:
Tx: bethanechol and alpha-blockers
Vaginismus:
o Involuntary contraction of perineal muscles
o Cause: psychological
o Tx: relation, kegels (to relex muscles), insert dilators/fingers
Atrophic vaginitis:
o Vag dryness, pruritis, dyspareunia, dysuria, urinary frequency, negative urine dip
o Tx: lubricants, low-dose vag estrogen cream
Interstitial cystitis (painful bladder syndrome)
o Chronic condition of bladder of unknown etiology disruption of GAG layer that coats
bladder epi
o Triad: urge and frequency with chronic pelvic pain that is made worse by intercourse,
bladder filling, exercise, spicy foods; also get nocturia
o Pain improves with voiding; bimannual exam: anterior pain
o Cystoscopy: submucosal petechiae or ulcerations
o Dx: bladder distension w/h20 or K sensitivity testing
o Versus cystocele: herniation of bladder making an vaginal wall herniate; similar sx of
freq, urge but usually aSx
o Tx: dimethyl sulfoxide, NSAIds, antihistamines, TCAs, pentosan polysulfate (a GAG)
POF dx: increased FSH and >/= 3 months of amenorrhea in women <40yo; FSH higher than LH
b/c FSH takes longer to clear from blood
EMB: if >35 with recurrent anovulation, <35 with RF for endo CA (prolonged estrogen
exposure, obesity, DM2) and irregular bleeding, excessive bleeding unresponsive to Rx
therapy ; if normal PELVIC US
HypoT a/w galactorrhea: TRH stimulates prolactin secretion
Candida: pseudohyphae; tx with oral fluconazole; can also use topical nystatin; oral nystatin is
used for candida of mouth (thrush) and of esophagus (esophagitis)
Amsel critieria for BV: 1) thin, gray-white d/c 2) pH >4.5 3) whiff test of fishiness when KOH
added 4) Clue cells on wet mount (vag epi cells on coccobacilli)
Up to 90% of periods within first year will be anovulatory causes irregular and longer
periods
Precocious puberty: before age 8 in girls with the development of secondary sexual
characteristics; tx: GnRH agonist

Unit 4: REI
Puberty
Thelarche adrenarche growth spurt menarche
o Breasts around 10yo, menarche is 12.7yo; earlier for fatter, less active girls

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Body weight 85-101 needed for menses to occur; need sleep, weight and optic sunlight
exposure
Rokitansky-Kuster-Hauser Syndrome: agenesis of vaginal and uterine components, normal
ovaries so therefore normal secondary sexual characteristics
Kallmans: suspect when no development of secondary sexual characteristics (2/2 no GnRH
from arcuate nucleus of hypothal) tx: pulsatile GnRH
Normal menarche: between 9 and 17, normal esp if normal secondary sex characteristics
Mullerian agenesis: absence of uterus and cervix (blind pouch vagina); normal ovaries so
therefore normal secondary sexual characteritistics; do RENAL US b/c renal anomalies occur
25-30% of time in females with mullerian agenesis
Amenorrhea
Ashermans can cause amenorrhea
Do prolactin before LH and FSH in work-up of amenorrhea; prolactinoma is the MC pit tumor
causing amenorrhea
OCP cessation: may lead to amenorrhea if prior to pill, pt had irregular menses (i.e. oligo-
ovulatory cycles)
Hirsutism and virilization
Late onset 21-hydroxylase deficiency: measure 17-OH-progesterone
Sertoli-leydig cell tumor: 20-40yo, acne, hirsutism, amenorrhea, clitoral hypertrophy,
deepened voice, adnexal mass
Causes of virilization: PCOS, hypoT, androgen producing tumors (ovary, adrenal gland,
pituitary), anabolic steroid use
Spironolactone: aldosterone antagonist
Normal and AUB
Medroxyprogesterone acetate mechanism: converts endometrium from proliferative (done by
estrogen) to secretory; progestins inhibits further endo growth, convert to secretory, then
withdrawal mimics the involution of CL endo sloughing
Endo Polyp: do not observe is >1.5cm tx is polypectomy via hysteroscopy
OCPs contraindicated in SMOKING >35 YO!!!!!!!!!!!!!
Dysmenorrhea
Mechanism in OCPs for painful periods: progestin in OCPS causes endo atrophy less PGs
from endometrium are produced therefore
Screening: chlam and gon for all sexually active pts </=25 yo.
Laparoscopy: after trials of meds for dysmenorrhea to dx endometriosis and exlude other
causes of secondary dysmenorrhea (some may say first try GnRH agonist)
Endometriosis: finding in surgery is blue-black powder burn lesions in pelvis; path shows
endometrial glands/stroma and hemosiderin-laden macrophages
Fibroids path: well-circumscribed, non-encapsulated myometrium
o If fibroids with irregular bleeding in woman >40yo, do EMB to r/o CA
Osteoporosis: best to rate if also know risk factors
o Prior fracture, family Hx, race, dmentia, hx of falls, poor nutrition, smoking, low BMI,
estrogen def, alcoholism, insufficient physical activity
Estrogen endogenous: from circulating androgens that are converted to E by aromatization
Menopause
Contraindication to meno tx: vaginal bleeding must first do EMB or pelvic US with
endometrial stripe <4mm
Bone fracture alone is evidence enough to begin tx for osteoporosis with bisphosphonates
after a DEXA scan

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MCC of women stopping HRT: vaginal bleeding which happens during initiation of HRT in first
6 months
Estrogen: best way to stop hot flashes (use for littlest amt of time); also increases HDL while
lowering LDL
Infertility
Primary if inability to conceive for one year w/o contraception
Hysterosalpingogram: evaluate for tubal dz from PID after one salpingitis episode, 15% pts
experience infertility
Evaluate PCOS first with testosterone test; then can do LH/FSH ratio, which will be increased
Imipramine: causes hyperprolactinemia
hypoT also causes infertility increased prolactin no ovulation; confirm with serum TSH
and free t4
exercise-induced hypothalamic amenorrhea: normal FSH and LOW estrogen; if change in daily
habits doesnt cure, can use exogenous gonadotropins (FSH and LH)
ovarian reserve: determine with clomiphene challenge test
Males are the issue in 35% of cases semen analysis if everything is normal
o Tests before: pelvic exam, weight/BMI, cycle length and regularity, thyroid function
tests, prolactin levels
PMS & PMDD
PMS: exercise helps, vita A, E and B6 also help
PMS and PMDD: occur during luteal phase (not follicular)
Tx: OCPs are beneficial as well as SSRIs
PMS is a/w family Hx, lack of B6, calcium and magnesium, as well as other mental illnesses

UWORLD
Ovarian torsion:
o RFs: ovarian mass (>/= 5cm, reproductive age, pregnancy, infertility tx)
o Sx: sudden onset pelvic pain (right more common than left b/c of ligament length),
adnexal mass, n/v (dont usually get with ovarian cyst rupture), possible low-grade
fever esp if necrosis, vaginal bleeding NOT common
o Dx: color Doppler US
o Tx: laparoscopy w/detorsion, possible SO-ectomy if necrosis or malignancy
o Pathophys: twisting of suspensory ligament of the ovary (has vessels in it) aka
infundibulopelvic ligament, and also the utero-ovarian ligament
Rupture ovarian cyst:
o Sudden onset lower pain following sex or strenuous activity; sometimes light bleeding;
no n/v usually
o Cullens sign: periumbilical ecchymoses 2/2 significant intraperitoneal bleeding from
rupture
o Dx: pelvic US showing ovarian mass with moderate amt of free fluid
Mittelschmerz: recurrent mild, unilateral midcycle pain from normal follicular enlargement
prior to ovulation, pain lasts hours to days, US normal (not needed)
Ectopic: amenorrhea, cramp ab pain, vag bleeding, +bHCG, no intraU preg
o Dx: transvaginal US b/c transabdominal cannot see gestational sac at bHCG <6500 but
transvag can see one (or not see one) as low as 1500.
Elevated prolactin: causes anovulation and galactorrhea
Turners: cause of anovulation, low FSH, low inhibin (marker of ovary function), normal GH
levels (even though short), low estrogen (ovarian dysgenesis)
Aromatase deficiency:

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o XX, normal internal genitalia, but ambiguous external genitalia

o Later get polycystic ovaries, hi levels of testosterone, hi FSH and LH, no estrogen
o Cause of primary amenorrhea, sexual infantilism, clitoromegaly
McCune Albright triad: caf au lait spots, polyostotic fibrous dysplasia, autonomous endocrine
hyperfunction, most commonly precocious puberty,
o Menses before breast and pubic hair
Precocious puberty: early breast, menarche, dx of exclusion b/c work-up is normal; tx: GnRH
agonist; from a premature secretion of GnRH in a pulsatile manner
CAH: usually leads to precocious adrenarche
Kallmans syndrome: hypogonadotrpic hypogonadism with anosmia, low FH, FSH, delayed
puberty
MIF: in XY (from the Y, or the testes), prohibits uterus, f-tubes and upper vagina formation
Androgen insensitivity syndrome: defect/absence of androgen-receptors, blind pouch vagina,
MIF so no female sex organs, breasts b/c test is converted to estrogen, but no axillary or pubic
hair b/c these are dependent on testosterone
POF: <40 yo, increased FSH, LH and decreased estrogen, a/w addisons, DM1, pernicious
anemia, Hashimotos, only option for future pregnancy is IVF with donor oocyte
In anovulation, FSH and LH levels are normal (just dont get progesterone release, and dont
get sloughing of endometrium b/c that is caused by P-withdrawal); so if person not getting
periods, and progresterone withdrawal causes period, it must be 2/2 anovulation and NOT a
physical barrier
Primary amenorrhea from Turners: FIRST TEST IS measure FSH to see if its central OR
peripheral if high, its peripheral (like Turners) karyotyping; if central pit MRI
Unit 5: Neoplasia
Gestational Torphoblastic Dz:
Molar incidence: higher in Asians, women <20yo or >40yo, less consumption of beta carotene
and folic acid, increased in women with 2 or more miscarriages, prior molar pregnancy (20X
more common, and 100X more common if 2 prior moles); no association with obesity, fetal
aneuploidy
Snowstorm is the result of: multiple hydropic villi; also find multiple internal echoes
Can get tachy and HTN in molar pregnancy
bHCG >1mil is dx for molar
Mole also a/w elevated bHCG and uterus size greater than gestational dates
o Whenever there is a discrepancy btwn dates and uterine size, dx: PELVIC US excludes
multiple gestations, uterine abnormalities, moles
Molar mgmt.: SUCTION CURETTAGE, follow with serial bHCG, only chemo is noncompliant or
GTD that persists
Molar types:
o Partial: fetal parts maybe, triploidy (69XXX, 69XXY, 69XYY; egg fertilized by 2 sperm of
sperm that reduplicates), show marked villi swelling, lower bHCG than complete, older
pts, longer gestations, often dx as missed or incomplete abortions
o Complete: no fetal parts, diploid (sperm fertilizes an empty egg, 1 sperm that
duplicates is 46XX in 90% or 2 sperm that make 46XY in 10%); show trophoblastic
proliferation w/hydropic degeneration; present usually with larger uterus, PEC, greater
likelihood of post-molar GTD (choriocarcinoma)
Further mgmt.: serial bHCG to ensure regression after evacuation, NO pregnancy for 6 months
after negative bHCG levels
Chorio dx: DO NOT BIOPSY as in the std with other malignancies, b/c very vascular and cld
track; dx by QUANTITATIVE bHCG in a woman with recent term, miscarriage, termination or
mole is sufficient to make dx of choriocarcinoma

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Vulvar Neoplasms:
Lichen sclerosis: carries risk of SCC; responds to steroid use
o Mgmt. of SCC on vulva: RADICAL VULVECTOMY AND GROIN NODE DISSECTION; only
microinvasive SCC can be tx with wide local excision
Vulvar CA: SCC accounts for 90%, melanoma is 5%
Pagets dz of vulva: an in situ carcinoma; looks like: white, lacey, plaque-like lesions poorly
demarcated erythema (not a mass), hyperkeratosis areas
VIN from HPV: dark spots, multicentric, sometimes itchy, maybe past Hx of HPV
o Mgmt.: local superficial wide excision; likelihood of recurrence is high however; not a
full out CA, so dont do radical surgeries
o If widespread can also do CO2 laser ablation
Bartholins neoplasm: in region, firm, nontender, somewhat fixed; typically adenocarcinoma,
more common post-menopausal women (cysts are not very common in post-meno women)
Condyloma tx: trichloroacetic acid, imiquimod cream
Cervical dysplasia tx: cryotherapy
Cervical Dz and Neoplasia:
Biggest RF for development: HPC and condyloma
o Others: early-onset sexual activity, mult partners, previous STDs, immunosuppression,
smoking, low SES, lack of regular Pap smears; 6 and 11 a/w warts while 16 and 18 a/w
with high-grade dysplasia and cervical cancer
Pap recommendations
o ASCUS positive either HPV testing or repeat pap (cytology) in 1 year
If HPV negative routine screening (next pap in 3 years)
If HPV positive or repeat cytology 1 year later shows ASCUS or higher
colposcopy
HOWEVER: if 21-24 and HPV positive, then do repeat cytology in 1 year, and
follow with colpo only if ASC-H (H means cannot r/o high grade sq intraepi)
Screening:
o Starts at 21
o 21-29 pap q3y
o 30-65 pap and HPV q5 or pap q3
o stop after >/=65yo if no hx of mod/severe dysplasia or cancer and 3 negative paps in a
row or 2 negative co-tests within past 10 years, with most recent performed within past
5y
o immune compromised: start screening at onset of sex, every 6 mos for 2 times then q1y
o 21-24:
AUCUS or LSIL repeat pap in 1y
If in 1 y: ASC-H, AGC, HSIL colpo
If in 1 y: ASCUS or LSIL or negative repeat in 1 year if ASCUS again (three
times ASCUS so far), colpo; or negative pap times 2 after first ASCUS
routine screening
Leukoplakia on cervix: white plaque; shld be biopsied
Cervix most concerning: atypical vessels, mosaisicm (new bl vessels on sides), punctations
(new vessels on their ends)
Case: HSIL, colpo shows acetowhite lesion with punctations and unsuccessful visualization of
entire lesion ECC is negative (high amt of false negatives though) cervical conization
o Conization is done after ECC to obtain path specimen and r/o cancer (cryo would
destroy specimen); done with cold knife cone or LEEP
o Indications for conization with knife or LEEP:

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Unsuccessful colpo inc ability to see entire transformation zone

Positive ECC
Pap smear indicating adenocarcinoma in situ
Cervical biops that cant r/o invasive CA
Discrepancy btwn pap smears and biopsy results: i.e. HSIL on pap and three
negative biops on colpo
Uterine Leiomyomas
Sx MC a/w fibroids: menorrhagia; 2/2 1) inc in uterine cavity size means greater SA for
endometrium; 2) congestion in myo/endometrium resulting in hypermenorrhea
Dx: pelvic US
o Pelvic US has higher sensitivity than CT for uterine and ovarian pathology
Estrogen makes fibroids grow
o Tx: GnRH agonist for medical therapy (relieves pain and excess bleeding)
If suspected fibroids and menstrual abnormalities, do ENDOMETRIAL SAMPLING to r/o endo
hyperplasia or CA
Adenomyosis: boggy uterus, menorrhagia + dysmenorrhea
Fibroid compromise fertility: tx = myomectomy (like in our patient)
o If do not desire fertility: uterine A embolization or hysterectomy
Sx: dysmenorrhea, menorrhagia, urinary frequency, constipation (compression effects), back
pain
Endometrial Carcinoma
Top 5 CA in women: breast, lung, colon, uterine, ovarian
Top 5 gyn CA: uterine, ovarian, cervical, vulva, vaginal
RFs for endometrial CA: late meno, early menarche, nulli, obesity, Tamoxifen, DM (a/w
obesity)
D/C: when pt has Sx of CA (bleeding) and endo sample (what you do first) reveals atypical cells
Routine eval shld include CXR b/c lungs is the MC site of mets
Surgical Tx: TAH, BSO, b/l pelvic and para-aortic LN-ectomy
A theca-lutein cyst is seen in presence of molar pregnancy and often b/l
Pt on Tamoxifen: no screening or intervention for monitoring of endometrium ONLY if
symptomatic
Ovarian Neoplasms
Functional ovarian cyst: adnexal mass that is +/- symptomatic
Endometrioma: endometriosis isolated to the ovary
After optimal debulking, common practice is chemo with combo of taxane and platinum
adjunct
Dermoid tumors: solid and cystic components, teeth/hair/sweat glands/cartilage/bone/fat

Unit 6: Sexuality
Unit 7: Violence
Comprehensive Exams

UWORLD NOTES
If fetal anomaly is incompatible with life and she goes into PTL, just allow for spont delivery;
i.e. b/l renal agenesis
If known gonorrhea negative at visit, then can just treat for chlamydia with single dose
azithromycin 1g
CDC on chlamydia: annual test for sexually active women </= 25 and >25 if they have
RFs such as new or multiple sex partners

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Hypovolemia in patient with worsening vitals who was just in MVA: uterine
rupture>>placental abruption; more likely to exsanguinate with rupture
o Uterine rupture: distended abd with irregular contour
N/V: torsion>>cyst rupture
Gestational DM tx: 1st line: diet and exercise; 2nd-line: insulin
Mittelschmerz: think of middle meaning midcycle pain 2/2 normal follicular enlargement
that occurs prior to ovulation unilateral, mild pain, lasts a few hrs
PPROM: best med to prolong labor onset is antibiotics! Which prolongs for 5-7 days, longer
than tocolytics and steroids
In persistent chronic pelvic pain 2/2 PID: take the chronically inflamed fallopian tube, leave
the ovary and take down adhesions
Breastfeeding protects against ovarian CA (along with OCPs)
PID tx inpatient/outpatient:
o Cefotetan or cefoxitin PLUS doxy or clinda PLUS genta (b/c clinda doesnt do GNs)
o Ceftriaxone, cefoxitin or ceph PLUS doxy with or without metronidazole
Terb = beta agonist to relax uterus and stop contractions; dont use >48h; can cause
tachycardia, hypotension, anxiety, chest tightening and pain
Post-term pregnancy a/w placental sulfatase deficiency, fetal adrenal hypoplasia, anencephaly,
extrauterine pregnancy
If one twin dies, must r/o coagulopathy by measuring maternal fibrinogen levels
Cervical cerclage: place in second trimester
PPROM at 36w tx: augment labor b/c benefits of delivery outweigh risks of expectant
management, namely chorioamnionitis
1st: vag mucosa
2nd: vag fascia and perineum
3rd degree lac: partial or complete rectal sphincter transection
4th: ext anal sphincter, internal anal sphincter, or rectal mucosa
o Do medial-lateral epi to avoid ext anal sphincter
Tocolysis
o Terb and ritodrine are contraindicated in DM
o Mg sulfate is contraindicated in MG
Lowest pregnancy rates: Depo-Provera, IUD, Implanon
LSIL colpo next
Amnioinfusion decreases repetitive, variable decels
Management of lupus during pregnancy: steroids
RF for uterine atony: chorio (think of vasodilation), twins, prolonged labor, multiparity,
precipitous labor, hydraminos, macrosomnia, general anesthesia, tocin in labor
Prolonged latent phase: >20 in nulli and >14 in multi
Primary amenorrhea eval: look for uterus on US if present do FSH, if absent do karyotype; if
FSH is increased, do karyotype; if FSH is decreased, do cranial MRI
Variables decel: prolapse of cord, nuchal cord, low amniotic fluid levels; recurrent if >/=50% of
contractions, progressively lower nadir and longer duration with each subsequent contraction
o 1st-line mgmt.: improve fetal O2 by changing maternal position and adding suppl O2
o 2nd-line mgmt.: amnioinfusion AROM and saline injection into cavity
Placental abruption: can be no bleeding b/c concealed in 20% of cases, and US doesnt see it
either US is just to r/o previa; uterus also becomes hypertonic during abruption (just as if it
would during third-stage of pregnancy)
FGR estimates: abdominal circumference on US is the most reliable predictor for weight

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Androgen-insensitivity syndrome tx: gonads removed after puberty is complete b/c of breast
and height extra testosterone is turned into estrogen responsible for breast development;
after gonad removal, estrogen therapy ensues w/o progesterone b/c there is no uterus
o MIF they have b/c XY and it is produced by tests responsible for prohibiting
formation of uterus, FT and upper vagina (blind-pouch vagina)
5-alpha-reductase deficiency: XY, dont have DHT b/c cant convert it; female external genitalia
but virilize at puberty
both above ^^ are XY and phenotypically female
In IUFD with threatened DIC, tx: induce labor; if DIC, transfuse
o Abruption is the MCC of coagulopathy during pregnancy
PID and pregnant: inpt tx
PTL: intermittent pain (no pain btwn contractions) distinguish from other etiologies causes
constant pain
Bleeding in a hemodynamically teen tx (AUB acutely): hi-dose estrogen
HPV vac: girls 9 -26; boys 9 21
US for renal stones YES!
Paps in immunocompromised, SLE, organ transplant recipients: start them at onset of sexual
intercourse, do q6months just twice, then annually thereafter.
Increases risk for PTL: multifetal gestation, polyhydraminos, uterine issues i.e. bicornate
uterus (uterine distension), abruption of placenta (decidual hem), chorio, maternal/fetal
stress, idiopathic
Bloody show is a/w cervical dilation during pregnancy if not cervical dilating, then its NOT
bloody show
If vaginal bleeding and pregnant, dx: transvaginal US to r/o previa

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