Khaled khalilia 1

Gynecology & Obstetrics

Khaled khalilia
IMLE

2016

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Menstrual disorders
Amenorrhea Primary Amenorrhea Secondary Amenorrhea
Def: Def:
 Absence of menes for X ≥ 3 Months - No Menes at Age 14 without secondary sexual - No Menes for X> 6 months or 3 cycles I a
 Injury to arcuate nucleus development. women with a previous normal cycle.
 - No Menes at Age 16 with/without secondary
ET:
sexual development.
- Pregnancy (pregnancy should be ruled out first)
- Functional hypothalamic (stress, exercise)
ET:
 Normal menes:  With secondary sex development: - Sheehan Syndrome ( Ant. Pituitary Necrosis)
- Frequency  21-35 day - Müllerian agenesis - Asherman Syndrome (intrauterine scarring following
- Duration  3-7 day - Androgen insensivity syndrome (Morris)
D&C)
- Arcuate nucleus injury
- Volume  30-80 ml - Imperforate Hymen
- Ovarian Failure
 Oigomenorrhea: bleeding > 35 day - Hyperprolactinemia ↑
- Hyperprolactinemia ↑
 Polymenorrhea: bleeding < 21 day - Hypothyroidism ↓
- polycystic ovarian syndrome
 Metrorrhagia: bleeding at irregular interval - Polycystic Ovary Syndrome ( PCOS )
-
 Hypomenorrhea: low intensity bleeding ↓ - Cushing Syndrome
 Hypermenorrhea: high intensity bleeding ↑ - Anorexia Nervosa
 - Congenital Adrenal Hyperplasia
- Pituitary Tumor
 without secondary sex development:
- Kallman Syndrome
- Turner Syndrome XO (Gonadal Dysgenesis)
- Diabetes Mellitus (DM)

Virilization Hirsutism Dysmenorrhea

Primary Secondary
Def: excessive growth of androgen-responsive hair in
women. (Face) Menstrual pain in absence of Menstrual pain due to organic
organic disease. disease.

ET:
 Idiopathic  Allergic/  PID
 POS psychogenic  Uterine Myoma
 Acromegaly  Ovulatory cycle  Adenomyosis
 Danazol, Cyclosporine, Phenytoin, Corticosteroids  Normal pelvic exam  Endometriosis
 Prolactin ↑   Adhesion
 Cushing Syndrome  Cervical stenosis
 Ovarian Tumor  Uterine polyps
Premenstrual Syndrome  Von-Hipel-lindau
 Cong. Adrenal Hyperplasia
 Aromatase Deficiency
Tx:
 Sulfatase Deficiency
- Antiprostaglandins (Naproxen)
 21-Hydroxylase Deficiency
- NSAIDs (first line)
 11-Hydroxylase Deficiency
 - Combined oral contraceptive
Tx: - Progestin (IM,oral,IUD)
 GnRH-Agonist - Endometrial ablation (increase the risk of infertility,
 Cyproterone Acetate miscarriage, preterm labor, antepartum hemorrhage, and
 Combined Oral Contraceptive abnormal placental attachment. It is therefore con-
traindicated in women who wish to maintain the possibility
of fertility.)

Development + Puberty
 The age of onset of puberty varies and is correlated with osseous maturation
 The breast bud (thelarche) is the 1st sign of puberty (10-11 yr), followed by pubic hair (pubarche) 6-12 mo later.
 Precocious puberty  pubertal changes before age 8 or menarche before age 10.
 precocious puberty Tx  long-acting GnRH agonist leuprolide (Lupron)
 The production of sex steroids induces secondary sex characteristics, endometrial proliferation (leading to menstruation), vaginal cornification, and growth of
long bones.

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Menstrual disorders
Menopause Hormone Replacement Therapy Dysfunctional uterine Bleeding (DUB)

 Decline of ovarian function, which signals the end of  Estrogen, Progesterone and Progestin  Unexplained abnormal Bleeding.
reproductive life span  cessation of menstruation at age Indication:
50 +/- 5 years.  Relief menopausal symptoms ET:
 ↓ Estrogen  Premenstrual ( Trauma, Sexual abuse)
 Prevent + Tx of Osteoporosis
 ↑ FSH  Post-menopausal (Atrophy,Neoplasm)
 Prevent Cardiovascular diseases (↓LDL)
 Systemic disease
 Decrease dementia
S+S:  Vasomotor symptoms  Drugs (HRT, Anti-coagulants)
Complication:
 Hot flush (Red skin) + sweats  Pregnancy related
 endometrial Cancer / breast
Vagina  Ovulatory:
 Amenorrhea  DVT
 Smaller
 Osteoporosis  Lesion (Polyps, Fibroid, Adenomyosis)
 Atrophy  Uterine Bleeding
 Sleep Disturbances (Insomnia)  Infection
 Dry  Edema
 Pale/dry epithelia  Urinary incontinence Contraindication:  Trauma
 Ligament ↓Tone  Dysuria  ↓Prostaglandin (vasoconstrictive)
 Liver Disease
Bone  Dyspareunia  Undiagnosed vaginal Bleeding  Anovulatory:
 ↓Ca  Atrophic vaginitis  PCOS
 Breast cancer
 Osteoporosis   ↑ prolactin
 ↓Estrogen  Uterine cancer
Fractures
 ↓Gonadotropin  DVT  Thyroid dysfunction
Uterus
 Petechial  Cardiovascular disease  Estrogen-producing Tumor
Hemorrhage Menopausal Syndrome  Liver Disease
 ↓ Size Dx:
 Thin endometrial  Irritability ,palpitation  TSH (rule out Thyroid dysfunction)
mucosa  ↓ libido  Prolactin (rule out Hyperprolactinemia)
Hair
 Insomnia
 Endometrial Biopsy (All X > 35 to exclude
 ↑ Body hair cancer).
 Fatigue
Breast  Β-HCG ( rule out pregnancy)
 Headache
 ↓ Turgor  Coagulation profile ,exclude Von Willebrand
 Depression
 ↓Form/Fullness  FSH, LH
 US (Fibroid, Polyp)
 Day 21  progesteroneconfirm ovulation

Tx:
 Resuscitation (if unstable)
 Oral contraceptive
 Clomiphene Citrate ( want children)
 D&C (stop bleeding)
 Endometrial Ablation (x children)
 Hysterectomy (x children) definitive Tx


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Menstrual disorders
Endometriosis Bartholin Gland Cyst

 The presence of functioning endometrial tissue (glands and stroma) outside  secrete mucous and become obstructed  cyst or abscess
their usual location in the uterine cavity.  lateral side of the Vulva ( 1 - 4 cm)
 Benign disease  affect women in their reproductive years.
 Gunmetal, powder burns, chocolate cyst Tx:
 Drainage  catheter (done at the office)
Risk factors: S+S:  Recurrence  Marsupialization
 Family History
 Dysmenorrhea
 Single women 
 Dyspareunia Pain
 Marry late
 Dyschezia (painful defecation)  Tenderness
 ↓ or X children
 Pelvic pain  Dyspareunia
Dx:  Infertility  Edema
 CA-125: correlate with disease degree, response to treatment, marker of 
recurrence.
 Laparoscopy (Biopsy)
 Gun shoot powder Polycystic Ovarian Syndrome
 Chocolate cyst
Tx: Dx:  Amenorrhea
 NSAIDs  US: bilateral enlarged ovaries + multiple cysts  Irregular Menes
 Oral Contraceptive (Estrogen-progestin)  ↑ Androgen (Testosterone)  virilization  Hirsutism
 Medroxyprogesterone (Depo-provera)  ↑Estrogen (outside ovary):
 Danazol (induce Pseudomenopause) Side effects: Hypoestrogenism  Obesity
 ↑LH secretion  Acne
 Leuprolide (GnRH-agonist)
 ↓FSH secretion
 Surery:  DM-Type 2
 Conservative: Laseor, Electrocautery,ablation  LH:FSH ratio > 3:1
 Infertility
 Radical: Total Hysterectomy +/- bilateral salpingo-oophorectomy. Tx:
(good for patient who don’t want children, Severe)  Lifestyle (↑Excercuise, ↓ BMI)
Best time to become Pregnant is immediately after conservative surgery  Oral Contraceptive (prevent Endometrial Hyperplasia).
 Clomiphene Metformine (induct ovulation)

Adenomyosis pelvic organ prolapse

 Invasion of Endometrial Glands into the myometrium.

 MRI  most accurate test
 Hysterectomy  only definitive Treatment
 Tx: NSAIDS

Nabothian Cyst

 mucus-filled cyst on the surface of the cervix

 Blockage of crypts in the uterine cervix
 harmless and usually disappear on their own
 Dx: colposcopyor biopsy (exclude cancer)
 Tx: electrocautery and cryofreezing

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Syndromes
Asherman Syndrome Sheehan Syndrome Klinefelter Syndrome Kallman Syndrome

 Trauma to the Endometrium, after  Postpartum pituitary gland necrosis.  47,XXY  Hypogonadotropic hypogonadism
a dilation and curettage (D&C)  Hypopituitarism ↓ S+S:  X/Delayed pubertal Development
 ChildbirthBlood loss  Hypovolemic  Large Breast
performed after: miscarriage,  ↓Poor secondary sexual characteristic
 Small Penis
delivery, surgical termination of
Shock  Ischemic Necrosis (Ant.Lobe)
 Small Testicle
 Normal Stature
S+S:
 ↓ Facial/Body hair  Female phenotype
pregnancy can lead to the  agalactorrhea (X lactation,X Prolactin)
 Infertility ̊
development of Intrauterine scars  Amenorrhea 2 ̊  Amenorrhea 1̊ ̊̊̊
 Osteoporosis
resulting in adhesions.  ↓ Loss of pubic / Axillary hair
 ↑FSH,↑LH,↓Testosteron  Anosmia
 Fatique (↓TSH)
 endometrium fail to respond Dx:  ↓FSH, ↓LH
 ↓BP
to estrogen  secondary  Karyotype  ↓Testosterone
Tx:
Amenorrhea, hypomenorrhea  ↓Sperm count
 Testosterone
Tx:  Short Stature
Dx: Hysteroscopy
 Cortisone acetate  Hormone Therapy (Osteoporosis)
Tx: removal of adhesions  Infertility
 Estrogen  menstruation
 HMG  induce ovulation Tx: Hormoe Replacement
 Female: Estrogen
 Male: Testpsterone

Turner Syndrome Ovarian Hyper-stimulation Synd Müllerian agenesis Female Athletic Syndrome

 45 X, XO Karyotype ET: occur after using injectable hormone  Mayer-Rokitansky-Kuster-Hauser 1. Ammenorhea

 Gonadal Dysgenesis medications during in vitro fertilization syndrome. 2. Eating Disorders
 Amenorrhea 1 ̊ (Infertility Tx). ↑HCG  congenital malformation 46XX 3. Osteopenia/Osteoporosis
 Infertility  failure of the Müllerian duct to
 Sexual infantilism S+S:
develop, resulting in:
 NO secondary sex characteristics  abdominal pain  Menstrual Bleeding following
 X uterus
 Short stature  bloating Administration of Estrogen and
 X cervix
 Nausea/ Vomiting Progesterone.
 and/or vagina vaginal hypoplasia
Dx:  Diarrhea
 Amniocentesis 2/3 upper portion.
 Tenderness (ovaries)
 US Cx:  primary Amenorrhea 15%
 Karyotype  ovarian torsion normal development of breasts, sexual
Tx: hair, ovaries, tubes, and external genitalia.
 ovarian rupture
 thrombophlebitis
 renal insufficiency
 Venous thrombosis

Hypogonadotropic Hypogonadism Help Syndrome

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Gynecological Infection
Candida Bacterial Vaginosis Trichomoniasis Chlamydia

ET: Candida Albicans (Fungus) ET: Gardenerella vaginalis ET: Trichomonas Vaginalis ET: Chlamydia Trachomatis

S+S: S+S: S+S: S+S:

 Discharge: Thick/white  Gray, thin discharge  Discharge: Yellow/Green  Asymptomatic
 Pruritus  Fish Odor  Strawberry spots  Muco-purulent discharg
 ↑ before Menes  X no vaginal irritation  Pruritus  Dysuria
 ↑ during pregnancy  Dysuria  Frequency
 Beef-Red-Appearance Dx:  Frequency  Bleeding
 Cheesy material  Clue cells  Symptomatic partner
 Fish odor Dx: Dx:
Dx:  Cervical culture
Tx:  Nucleic acid amplification test
Tx:  Mitronidazole (2gr single dose) Tx:
 Doxycycline or
 Azithromycin (pregnant)
Tx:  Amoxicillin (pregnant)
Antifungal: Extra:  Treat Gonorrhea
 Econazole  ↑increased risk for preterm  Treat partner
 Miconazole labor Extra:
 Fluconazole (oral)  Associated with N.gonorrhea

Syphilis Herpes Simplex Gonorrhea Human Papilloma Virus (HPV)

Et: Treponema pallidum Et: ET: N.Gonorrhea ET:

 90% HSV-2(Genital)  6, 11  condyloma
S+S:  10% HSV-1 (Oral) S+S:  16, 18, and 31  cervical neoplasia
1. Painless ulcer: vulva, vagina,
cervix. S+S: Dx: S+S:
2. Maculopapular rash: palms,  Tingling, Burning  Gram stain  Asymptomatic
soles, Limbs, condylomata lata  Pruritus  Culture (cervical/throat)  Wart like lesion
3. Optic atrophy, tabes dorsalis,  Ulceration + Vesicle Tx:  Hyperkeratotic
aortic aneurysm, Gumma  Ceftriaxone(1) +  Edema
Dx: Dx: Azithromycin(1) /Doxycycline  Macular lesion
 Aspiration: Ulcer/Node  Viral culture  Treat chlamydia (coinfection) Dx:
 Darkfield microscopy (most  Cytologic smear  Cytology
sensitive, specific)
 HSV DNA PCR  Colposcopy (Biopsy)
 + VDRL
Tx: Tx:
 FTA-ABS (specific anti treponemal
 Acyclovir
antibody test)  Confirmation
 Active infection during labor 
C-Section
Tx:
 Penicillin G (IM) Pelvic inflammatory Disease Toxic shock Syndrome Sexually transmitted Diseases
 Treat Partner

Extra: ET:
 gumma: soft, non-cancerous growth
rd
3 stage.
 C.Trachomatis
 FTA-abs are diagnostic even in the  N.Gonorrhea
presence of SLE
 E-coli
 penicillin allergy: Desensitization with
phenoxymethyl penicillin
 Staphlococcus
 Streptococcus
 Actinomyces israelii
S+S:

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Gynecology Disorders
Gestational Trophoblastic Disease Leiomyoma (Fibroids)

1. Complete / Partial vesicular mole  Fibromyoma, Fibroid, Leiomyoma, Myoma

2. Invasive mole (chorio-adenoma destruens )
 Uterine myoma  most common benign Tumor of Female Genital Tract.
3. Placental-site trophoblastic tumor
4. Chorio-carcinoma  Not detectable before Puberty. (↑ during reproductive years x> 35)
 Have rich vascular supply
 Anemia  most common complication
 Types:
 Summucous:
 Intramural: within uterine wall  prolonged bleeding + Dysmenorrhea
 Sunserous: bladder symptoms, constipation, back pain

S+S:
 Asymptomatic
 Uterine Bleeding
 Dysmenorrhea
 Pelvis pain
 Pelvis Pressure
 Urinary frequency + urgency
 Urinary retention
 Constipation
 Infertility
 Compression of ureter, Bladder, Rectum.
Dx:
 Pelvis examination
 US (confirm + location)
 CBC (Anemia)
 Biopsy (exclude cancer)
 IV Urography
Complication:
 Anemia (most common)
 Inflammation (Endometritis, salpingitis)
 Torsion
 Obstruction (Bowel, urinary)
 Malignancy

Tx:
 Only if symptomatic, rapidly enlarging, menorrhagia, intracavitary.
 Treat anemia if present.

• Conservative :(watch and wait) if:

 symptoms absent or minimal
 fibroids <6-8 cm or stable in size
 Currently pregnant due to increased risk of bleeding (follow-up U/S if
symptoms progress).

 Medical:
 NSAIDS
 OCC /Depo-provera
 GnRH-analouges: (Leuprolide, Danazol)
 Short term (6 months)
 Before myomectomy,Hysterectomy  reduce fibroid size
 Reduce bleeding
 Progesterone
 Mifepristone

 Surgery:
 Myomectomy (preserve fertility)
 Hysterectomy

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Conditions during pregnancy

Placenta Previa Placental Abruption

Def: Def: Separation of Placenta from it’s site of implantation before the delivery of the Fetus.
 Placental insertion over/near internal os of cervix.
 Obstacle in front of the Fetal presenting part. Dx:
 Clinical *
Types: total, partial, marginal, lateral  Us

Risk Factors : ET: ET: S+S:

 Previous C-Section  Endometrium (inflammation, Atrophy)  Preeclampsia  rd
PAINFULL vaginal Bleeding (3 Trimester)
 Multiparity  Endometritis  Drugs  Uterine: contracted, Tender, Hard
 Previous D&C  Trauma  PROM  Pain
 Smoking  Submucous myoma  Choriamnionitis  Shock/ Anemia
 Age ↑  Twin Pregnancy  Trauma  Coagulopathy (Consumptive)
 Uterine myoma  Hb↓, WBC↑
 Fetal Distress

S+S: Complication:
 PAINLESS Bleeding (bright red)  Fetal death
 Shock / Anemia Placenta Previa + accreta:  Premature
 Soft uterus  Hysterectomy  Intrauterine Hypoxia
 Artery Ligation (Bilateral)  DIC
Dx:
 Gauze Packing  Anemia
 Do not perform vaginal exam untel  Oversewing implantation  Sheehan Syndrome
placenta praevia has been ruled out by US
site with sutures.  Life threatening (Emergency)
 US
Tx:
Tx:
 Stabilize mother: O2, IV Fluid, RBC
 GA < 37 + minimal Bleeding:
 Fibrinoge 4 gr
 Hospital Admission
 Furosemide (pulmonary congestion)
 Corticosteroid (Lung maturity)
 Fresh Frozen Plasma
 Limited physical activity
 Cryoprecipitate
 GA ≥ 37, Profuse Bleeding, L/S ratio > 2:1  C-Section
 Delivery:
 C-section: Fetal Distress, Maternal Distress, Labor fail to progress, Bleeding↑↑).
 Vaginal Delivery: mature Baby without Fetal Distress/Bleeding/ dead Fetus
 Hysterectomy: severely damaged uterus or absence of hemostasis

C-Section: Vaginal Delivery:

Placenta Previa Placental Abruption
 Patient in Labor  X < 28 wk (Little surviving chance)
Bleeding Painless + Painful
 Mature Fetus + Bleeding  Dead Fetus (minimal Bleeding, cervix
Blood Bright Red Dark
 Immature Fetus + severe Bleeding ↑↑ = soft + effaced)
First Bleeding slight↓ Perfuse↑
 Total placenta pravia + Dead Fetus
Fetus Felt easy Difficult to feel
 Fetal Distress
Uterus Soft, non tender Firm, Tender
Premature + Bleeding (few)  Observe Placenta felt X felt
clotting X no clotting defect Clotting defect
Associated conditions:
 placenta accreta → abnormally firm adherence to the uterine wall
 placenta increta → placental villi invade the myometrium
 placenta percreta → placental villi penetrate through the myometrium

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Conditions during pregnancy

Pre-term Labor Post-term Labor

Def: Delivery between 24-37 WK ( ↑Mortality x < 34 wk ) Def: X > 42 Wk

ET: Complication: ET: Dx:

 idiopathic  Death  Date Error  Gestational age (LMP)
 infection  RDS  Prior post-term pregnancy  US (CRL)
 Chronic Lung disease/ Pneumonia  Prima-parity  Quickening
 chorioamnionitis
 PPROM  Metabolic acidosis
 Polyhydramnios  Persistent Pulmonary HTN
 Placenta Previa  Necrotizing Enterocolitis Maternal Complication: Fetal Complication:
 Hemorrhage  Death
 Placental abruption  Retinopathy of prematurity
 Infection  Fetal distress
 ↑ BP  Growth retardation
 Perineum injury (Vagina,Rectum)  Oligohydramnios
 Fibroids  Forceps/ Vacuum  Hypoxia
 Trauma/Surgery  Meconium aspiration
 Multiple Gestation  Macrosomia
 Cervical incompetence  Shoulder dystocia
 Congenital anomaly

Dx: Tx:
 US (cervical length + Dilation)  Wait for spontaneous Labor/ripening
 Fetal Fibronectin  Induction of Labor  PG-Gel for cervical ripening.
 E3 (Estriol)
1. 40 – 41 GA
Tx: o Healthy, uncomplicated pregnancy:
1. Tocolytics (Suppression of Labor):  Indomethacin  X No induction of Labor
o Doesn’t inhibit preterm labor completely (X<48 hrs.) to give Betamethasone  Fetal monitoring
(steroid for Lung maturity.) o Maternal Risk / Fetal distress:
o Preterm, live, immature fetus, intact membrane, cervical dilation <4cm  Cervical ripening (PG) + induction of Labor
2. At 41 GA
2. Induce Lung maturity: Betamethasone, Dexamethasone
3. Cervical Cerclage (placement of cervical sutures at the level of internal Os and o Healthy, uncomplicated pregnancy:
removed in the 3rd Trimester)  Cervical Incompetence  Labor induction (Ask mother)
 Bishop Score + ripening (PG)
o If mother doesn’t want:
 Fetal movement count (daily)
 Non-stress test
 Amniotic Fluid index
 If these are abnormal  induce Labor
3. At 42 GA
o Induce Labor (even if everything is normal)

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Conditions during pregnancy

PROM (Premature rupture of membrane) Spontaneous Abortion

Def: Def:
 Spontaneous rupture of the membrane at any time of GA before the onset of Labor.  The termination of pregnancy by any means before the fetus is sufficiently
Et: developed to survive.
 Multiple Previous pregnancy  The termination of pregnancy before 20 weeks gestation based upon the date of the
 UTI first day of the LMP.
 Vaginal Infection: C.Trachomatis  Delivery of product of conception that weighs less than 500g. \
 STD  Chromosomal abnormality = 70 %
 ↓Nutrition
 Twin pregnancy ET:
 Placenta previa  mechanical causes: (incompetent cervix, uterine malposition, Asherman Syndrome)
 Hydramnios  infections: ( CMV, Toxoplasmosis, malaria)
 Abnormal presentation  genetic causes: ( Aneuploid, Euploid , Antiphospholipid syndrome)
 endocrine causes: ( Combined deficiency of E and P )
S+S:  immunological causes: (Antiphospholipid antibody IgG, IgM)
 Sudden gush of Fluid / continuous leake  maternal systemic conditions: (Endocrine, Blood incompatibility, Toxin)
 Color / consistency of fluid
 ↑ increased prominence of fetal palpation  Aneuploidy: (abnormal no. of chromosomes )
 Euploidy: (abnormal chromosom component)
Complication:
 Intrauterine infection Dx:
 Chorioamnionitis  Ultrasound: differentiate between types
 Placental abruption
 Preterm Labor Tx:
 Cord prolapse
 Abnormal \Presentation
Signs +
Type Diagnosis Treatment
Dx: Symptom
 Sterile speculum exam Bleeding,  Open Cervix Follow up
 Nitrazine Paper  Amniotic Fluid turn paper BLUE Complete  US: No conception
 fern test (air-dry a drop of the fluid on a slide ► examine for arborization) Complete passage of products
 cervical aspect (degree of effacement and dilatation) placenta + sac  Only during first 6wk
 check for cord prolapse
 Culture ↑↑ Bleeding  Open Cervix  Watch + wait
 determination = L/S ratio Incomplete +/- passage of  US: products of  Misoprostol
tissue Conception  D&C +/- oxytocin
Tx: No Bleeding  Cervix Closed  Watch + wait
 depends on Fetal GA and the presence of Chorioamnionitis.  US: SGA, all product  Misoprostol
 Chorioamnionitis or Fetal Distress  DELIVERY IMMEDIATELY Missed of Conception  D&C +/- oxytocin
present.
 GA > 33 (or mature) + Amnionitis  Delivery  Dead Fetus
↑ Bleeding,  Dilation of Cervix  Watch + wait
 GA > 36  Induction (Oxytocin) (if latent period exceeds 8-12 Hrs) Inevitable Rupture of  Intact product of  Misoprostol
Membran Conception  D&C +/- oxytocin
 GA 34 – 36  wait 24-48 hrs for surfactant production (Lung maturity)  Induction Bleeding  Cervix= closed + Soft  Watch + wait
Cramps  Intact product of  Rest
 GA 26 – 34  Threatened
Conception
 Intrauterine Bleeding
o Chorioamnionitis or Lung Maturation  Induction of Labor Infection of  D&C
o X No Chorioamnionitis or Immature Lung  give Corticosteroid ( uterus +  AB 
Betamethasone) for Lung maturation. Septic
surrounding Metronidazole
area Levofloxacin
 GA < 26 maternal Risk

diagnosis of amnionitis:

 Physical examination → signs of infection (fever, tachycardia).

 Laboratory tests:
o maternal leukocytosis (> 16,000),
o amniotic fluid C-reactive protein measurements,
o aerobic or anaerobic culture.
 US examination → fetal size.

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Conditions during pregnancy

Polyhydramnios Macrosomia
th
Def: Def: infant weight > 90 percentile for a particular GA or X > 4000 gr
 source  amniotic epithelium.
 associated with fetal malformations  CNS and GIT Et/ Risk factors: Complications:
 present when swallowing is inhibited  esophageal atresia.
 anencephaly and spina bifida  increased transudation of fluid from the exposed  Obesity (maternal)  Shoulder dystocia
meninges into the amniotic cavity .  Gestational DM  Laceration
 enlarged placenta may contribute to increased amniotic fluid  History of macrosomic infant  Hemorrahge
 Prolactin control its volume.  Prolonged pregnancy  Uterine Rupture
 Maternal conditions associated with hydramnios are heart disease, preeclampsia,  Multiparity  ↓ Blood sugar
severe anemia, Toxoplasma or CLMV infections, Syphilis  Beckwith–Wiedemann syndrome Dx: Us
Tx: X > 4500 gr  C-Section
 ACUTE: severe Symptoms, Rapid accumulation, Obstetrical Emergency
 Chronic: not severe Symptoms, slow accumulation

Et: S+S:
 Idiopathic  Dyspnea
 DM Type 1  Palpitation
 Multiple Gestation  Abdominal Enlargement
 Rh+ Isoimmunization  Edema
 Anemia  Pain
 Preeclampsia  Varicose vein
 Infection  Uterus: large, ↑Tone
 CNS Anomaly: Spina  Fetal parts: cant be felt
befidia,Anencephalus,  FHR: difficult to hear
Hydrocephalus Cant define presentation
 TTTTS
 Esophageal atresia
 Duodenal atresia

Complication: Dx:
 Placental rupture Ultrasound
 Postpartum hemorrhage
 PROM Tx:
 Erythroblastosis  Bed rest
 Fetal malformation  NSAIDs
 Umbilical Cord Prolapse  Amniocenthesis
 Amniotomy

Oligohydramnios

Def: ↓ decrease Amniotic Fluid

ET:
 Idiopathic
 Preeclampsia
 ACE-I
 PG-inhibitors
 Congenital Urinary Tract anomalies (Renal agenesis, obstruction)
 Hypoxemia
 IUGR
 Ruptured membrane
 chromosomal anomalies

S+S:
Complication:
 smaller symphysiofundal height
 fetal malpresentation (Breech)  Cord compression
 prominence of fetal parts  pulmonary hypoplasia
 ↓amniotic fluid.  IUGR
 Potter syndrome

Tx: Amnioinfusion

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Conditions during pregnancy

Ectopic Pregnancy Umbilical Cord prolapse
Umbilical Cord: 2x Artery, 1X Vein
Def: Embryo implants outside of the Endometrial (uterine) Cavity 40 % Fetal cardiac output
Artery: fetal Blood(↓o2) Placenta
Et: Vein: Placenta (↑o2)  Fetus
 factors that causes delayed transport of the fertilised ovum through the Fallopian
tube (tubal ectopic pregnancy). Def: descent of the cord to a level adjacent to or below the presenting part, causing cord
 tubal hypoplasia compression between presenting part and pelvis. Short <35, Long >70
 tortuosity
 congenital diverticula Et:
 accessory ostia  Fetal malpresentation
 partial stenosis  Polyhdramnios
 Inflammatory: PID ( 50%), septic abortion, puerperal sepsis, medical termination →  Multiple Gestation
intraluminal / peritubal adhesions  CPD
 Surgical: tubal reconstructive surgery, recanalisation of tubes  PROM
 Tumor: broad ligament myoma, ovarian tumor  Prematurity
 Miscellaneous causes: IUD, endometriosis, ART, hormonal perturbations → tubal
dysfunctions S+S:
 Visible/palpable Cord
 FHR changes ( variable deceleration, Bradycardia)
Risk Factors: Sites of ectopic pregnancy:
 Previous ectopic pregnancy  Ruptured membranes
 IUD  Tube: ( ↑ recurrence rate) o occult cord prolapse (descent of the umbilical cord alongside) lie adjacent to the
 Infertility o isthmic (25%) presenting part
 Smoking o ampullary (55%) o overt cord prolapse (umbilical cord past the presenting part). Lie below the
 Uterine Leiomyoma o fimbrial (17%) presenting part
 Abnormal uterine anatomy o interstitial (2%)  NO ruptured membranes
 Adhesion  Uterine o Funic presentation = cord presentation = procubitus → one or more loops of
 Abdominal surgery o Corneal umbilical cord between the fetal presenting part and the cervix,. ( characterized
o Cervical by prolapse of the umbilical cord below the level of the presenting partbefore
 Fallopian tube surgery
 Clomiphene Citrate (induction of  Intraligamentous rupture of the membranes occurs(procubitus)
 Ovarien o If the cervix is opened the cord can be easily palpated through the membranes.
ovulation)
 Salpingitis (Luimen narrowing)  Abdominal
o Primary  If compression is complete and prolonged  it induces asphyxia, metabolic acidosis
 Septic abortion
o Secondary and death.
 heterotopic  Benckiser Syndrome 

Tx:
S+S:  C-section (Emergency)
 Asymptomatic (until it ruptured)
 Abdominal pain
 Amenorrhea Uterine Rupture
 Syncope
 Vaginal Bleeding
 Pelvis mass Et:
Dx:  Previous uterine scar
 US ( Vaginal )  Grand multiparity
 Β-HcG  several or combined with Sonography  Hyperstimulation with oxytocin
 Progesterone < 5ng/ml  During Labor
 Culdocentesis: confirm diagnosis  Classical incision
 Laoaroscopy  Perforation with D&C
 Trauma
Tx:  Uterine abnormalities
 Methotrexat + Folinic Acid
 Salpingectomy / Salpingo-oophorectomy S+S:
 Prolonged Fetal Bradycardia (most common)
 Abdominal pain
 Uterine contraction (Hyper, Hypo )
 Vaginal Bleeding

Complication:
 Maternal death
 Hemorrhage
 DIC
 amniotic fluid Embolus
 Fetal Distress
Tx:
 Rule out placental abruption
 Immediate delivery
 Hysterectomy ( uncontrolled Hemorrhage)

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Conditions during pregnancy

Postpartum Hemorrhage Multiple Gestation

Def: S+S: Dx:

 Bleeding more than 500 ml after delivery  ↑ uterus Size  US
 Early  within 24 hrs. after delivery  Edema  Twin-peak sign (Lambada Sign)  2 Amnion, 2
 Late  24 hr. – 6 Weeks later.  Varicose vein Chorion
 HR: 2x different fetal HR  T-Sign
Et:  ↑ Β-HcG
1. Uterine Atony (80%) (without contraction): multiparty, over distention, macrosomia,  ↑AFP
Placenta Previa/abrupture, Anesthesia, Infection, induced/prolonged labor.  ↑Estriol
2. Retained Placenta (remnants): placenta acreta, increta, percreta
3. Trauma: Laceration, Episiotomy, Hematoma Risk Factors:
4. Coagulation Disorders: Hemophilia, DIC, Aspirin, ITP, TTP vWF (most common) Complication:  IVF
 Fetal Death  ↑ Maternal Age
Tx:  Spontaneous abortion  African
 ABCs, IV Fluids  Premature labor/Delivery
 Local Control:  Placenta previa
o Bimanual Compression (massage the uterus)  Placental abruption  Most common Presentation:
o Uterine Packing (mesh + Ab)  Anemia  Cephalic-cephalic 60%
o Balloon Tamponade  Cord Prolapse  Cephalic-Breech 20%
 Medical:  TTTTS
o Oxytocin: contract uterus, constrict Blood vessels, ↓Blood flow  Malformation
o Ergotamine  ↑ BP
o Prostaglandin  Post-partum Hemorrhage
o Misoprostol
 Surgical:
o D&C
o Uterine Artery Ligation (Bilateral)
o Internal iliac Artery Ligation Monozygotic Dizygotic
o Hysterectomy
o Angiographic Embolization
1 Egg 2 Eggs
1 Sperm 2 Sperm
Note: Normally, Postpartum, the uterine Contraction compresses the Blood Vessels to stop
Blood Loss. In uterine atony this does not occur  Identical Twins  Fraternal Twins
 Same Gender  Different/same Sex
 Same Blood Type  2 Amnion, 2 Chorion
 Different Fingerprint  No vascular Anastomosis
 30 %  Normal Amniotic Fluid
 TTTS  70%
 Hydrations
 Malformation
 2 Amnion, 2 chorion
 2 Amnion, 1 chorion
 1 Amnion, 1 chorion
Twin-to-twin transfusion syndrome (TTTTS)

 Arterial blood from donor twin passes through placenta into vein of recipient twin Tx:
 Vascular Anastomosis (only in Monochorionic):  Vaginal Delivery  if Twin A present as Vertex
 Perfused: (Take)  C-Section
o ↑ Hypervolemia, ↑BP o if first Twin not in Vertex
o Heart Failure, Edema o Hypotonic uterine dysfunction
o Polyhydramnios o Fetal distress
o Hepatosplenomegaly o Cord prolapse
o ↑Bilirubin (Kernicterus) o Prematurity
 Hypo perfused: (give) o Placenta previa
o Hypoxemia  Twin A (vaginal delivery)  Twin B (C-Section)
o Oligohydramnios
o IUGR
o Hypovolemia, ↓BP
o Anemia
Tx:
 Amniocenthesis
 Intrauterine Blood Transfusion
 Laparoscopy: occlusion of placenta vessels

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Conditions during pregnancy

Gestational Diabetes Rh+ Incompatibility

Risk Factors: Def:

 occurs when the mother is Rh negative and the baby is Rh positive
 Age > 25  not a problem in the first pregnancy  mother has not developed Antibodies to
 Obesity the foreign Rh+.
 Previous history of GDM  When first baby is deliveredfetal Blood cells croos the placenta into mothers
 Previous overweight child X> 4 kg Blood she make antibodies against Rh+ Blood.
 Polycystic Ovarian Syndrome  When the Mother gets pregnant for the second time her antibodies attack the
 Glucocorticosteroide use second Rh+ Baby  Hemolysis (Hemolytic Disease).
 HTN
Dx:
Complication:  Antibody Screen  done to see if mother Rh- or Rh+
 Preterm Birth  Antibody titer  done to see how many antibodies to Rh+ blood the mother has.
 Birth injuries o A positive titer (x≥1:16)  inicate ↑Risk of fetal hemolytic anemia
 DM-2 after delivery  Kleihauer–Betke test  can confirm that fetal blood has passed into the maternal
 Preeclampsia circulation and estimate the amount of fetal blood that has passed into the
 Polyhydramnios maternal circulation.
 Spontaneous abortion  indirect Coombs test screen blood from antenatal women for IgG antibodies
 IUGR that may pass through the placenta and cause hemolytic disease of the newborn.
 Infant Risk:  direct Coombs test is used to confirm that the fetus or neonate has an immune
o Polycythemia mediated hemolytic anemia.
o Hypoglycemia  Bilirubin
o Macrosomia
o ↑ Bilirubin (jaundice) Prophylaxis:
o Fetal Lung immaturity  Exogenous Rh IgG (Rhogam)  to all Rh- and antibody screen negative women in
o Congenital anomalies the following scenarios:
o Hypocalcemia ↓Ca²  Routinely at 28 wk GA (protection)
Dx:  Within 72h of the birth of Rh+ fetus
 All pregnant women between 24-28 wk. GA  + kleinhauer-Betke test
 Random non-fasting 50 gr Glucose load  serum measurement of Glucose (1 hr.  Invasive Procedures
later).  Ectopic pregnancy
o X<140 mg/dl  Normal
o X>140 mg/dl  do OGTT (Oral Glucose Tolerance Test): Complication:
 Fetal RBC Hemolysis
 diagnosis of gestational diabetes is made if X ≥ 2 of the four values meet or exceed the  Fetal Anemia
following:  Edema
o Fasting serum glucose concentration >95 mg/dL (5.3 mmol/L)  Ascites
o 1-hour serum glucose concentration >180 mg/dL (10 mmol/L)  Fetal Hydrops
o 2-hour serum glucose concentration >155 mg/dL (8.6 mmol/L)  Erythroblastosis fetalis
o 3-hour serum glucose concentration >140 mg/dL (7.8 mmol/L)
Tx:
Tx:  Intrauterine blood transfusion
 Lifestyle modification (first line)  At Delivery, if the Baby is Rh+  give the mother anti-D Rh immunoglobulin again.
 Insulin (if glycemic target not achieved within 2 wk.)
 Never tell the pregnant women to lose weight: /
 Glycemic Target:
o FPG < 95 mg/dl
o 1h PG < 140
o 2h PG < 120

Notes:
 50% Risk of developing DM-Type 2
 most
of glucose.

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Tumors
Ovarian Tumor Endometrial Cancer
 Benign: cystic, smooth, unilateral, mobile  Adenocarcinoma: x > 80% (most common)
 Malignant: Solid, nodular, Bilateral, Fixed  ↑Estrogen, X progesterone  Endometrium HyperplasiaAdenocarcinoma
 Protective Factors: OCP, Pregnancy, Breastfeeding  most endometrial cancers are diagnosed as Stage I
 Serous: most common ovarian cancer 50 % (Postmenopausal)
 Most common in Young patient (20s)  Germ Cell origin (Teratoma,dysgerminoma↑)

Dx: S+S: Dx: S+S:

 CA-125  Asymptomatic  Endometrial Sample:  ↑Age (60-70)
 US  Abd. discomfort (Nausea,  Endometrial Biopsy (office)  Uterine Bleeding (postmenopausal).
 Labaroscopy (Biopsy)
Dyspepsia)  D&C +/- Hysteroscopy  Uterus: enlarged, soft
 Pelvic mass  Compression  US  Hematuria
 Pelvic ultrasound findings of: ovarian papillary
 Constipation  X-ray, CT, MRI, Urography
vegetations, ovarian > 10 cm, ascites, ovarian
 Urinary frequency  Risk Factors:
torsion, or solid ovarian lesions  Do
 Menstrual irregularities  Any Genital Bleeding during post  Age postmenopausal ↑↑
exploratory laparotomy.
 Ascites menopause must be investigated to  obesity ↑↑
 Transvaginal Ultrasaunde with Doppler color flow rule out Endometrial Carcinoma.  Estrogen replacement Therapy
imagining  detect Neuvascularity of tumor
Risk Factors:  nulliparity
blood supply.
 ↑Age > 40
 late menopause (after 52)
 Nulliparity
 Family History (BRCA-1)  polycystic ovarian syndrome
 estrogen-producing tumors
 Tamoxifen

Stage: Stage: FIGO Classification ↗

Stage 1: Growth limited to ovaries

1A 1 ovary Stage 1: Limited to Uterine Fundus
1B 2 ovary 1A X No myometrial invasion
1C 1 or 2 ovaries + Ruptured capsule/capsule 1B Myometrial invasion X≤ 50 %
involvement/malignant Ascites 1C Myometrial invasion X > 50 %
Stage 2: Ovaries (one or both) + Pelvic Extension
Stage 2: Extend to Cervix  Stromal invasion
2A Extension to Tube/ Uterus Stage 3: Local/Regional spread
2B Extension to pelvic structures (Bladder, Rectum, Vagina
3A Invade serosa / Adnexa
2C
3B Vaginal metastasis
Stage 3: Ovaries + outside pelvic + Positive Nodes
3C Pelvis metastasis / para-aortic LN metastasis
3A Microscopic peritoneal metastasis outside pelvis
Stage 4: invade Bladder/Bowel mucosa + Distant metastasis
3B Macroscopic peritoneal metastasis outside pelvic (X<2cm)
4A Invade Bladder/Rectum (confirmed by Biopsy)
3C Implant > 2cm / Retroperitoneal/ inguinal Nodes 4B Distant metastasis
Stage 4: Distant Organ Involvement (Liver, Lung)

Tx: Tx:
Early Stage Disease: Stage I:
 X want children: Total Hysterectomy + Bilateral Salpingo-oophorectomy.  Total Hyterectomy
 Want children:  + Bilateral Salpingo-oophorectomy
 surgery + preserve ( uterus, opposite Tube + Ovary ) if they are free of Tumor  + peritoneal cyto. Examination
 Remove remaining reproductive Organs after Childbearing.
Advanced Stage Disease: Stages 2 + 3 , grade 1 with deep myometrial invasion:
 III or IV (large pelvis mass, Ascites)  Total Hyterectomy + Bilateral Salpingo-oophorectomy
 Total Hysterectomy + Bilateral Salpingo-oophorectomy + Omentectomy + pelvic and para-aortic lymphadenectomy.
 Procedures may be necessary: Resection of Colon, intestine, retroperitoneal LN.  Extended-field radiation for extra pelvic cancer (depending on the site and extent)
Chemotherapy: Cisplastin + Cyclophosphamide
Stage 4: systemic chemotherapy

Recurrence: high-dose progestins (Depo-Provera)

Endometrial Hyperplasia
Extra: It is considered weakly premalignant because it progresses to
 ovarian endodermal sinus tumor  Schiller-duval body endometrial carcinoma in approximately 1% of women.
 mucinous ovarian tumors  Usually very large.
 Intestine  first affected by spread and encroachment of ovarian cancer.
 the leading cause of gynecological cancer deaths
 Androgen-secreting tumors  produce Hirsutism (Sertoli-leydig cell tumors, Luteoma)

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Tumors
Invasive Cervical Carcinoma Cervical intraepithelial neoplasia (CIN)
 85% squamous cell carcinoma
S+S: Dx:  15% adenocarcinoma arising from endocervical glands
 Vaginal Discharge (thin, watery)  Pap-smear
 Metrorrhagia  Lahm-Shiller-Test Risk Factors:
 Pain (flank, Leg)  Colposcopy S+S:  ↑ Age (x>40)
 Asymptomatic  HPV (16.18)
 Dysuria  Biopsy
 postcoital bleeding  Herpes simplex type 2
 Hematuria  IV Pyelography (Hydroureter)  malodorous discharge  Immunosupression
 Edema (Foot)  pelvic pain  multiple sexual partners
 ulceration  Smoking
Stage:
Dx:
 Pap-smear
Stage 1: Carcinoma limited to Cervix  Colposcopy
 Biopsy
1A Microscopic
1B Macroscopic  Confined to cervix
Stage 2: beyond cervix (not to pelvis wall), vagina (not lower third)
2A X no parametrial involvement
2B Parametrial involvement
Stage 3: pelvis wall/ vagina (Lower third)
3A Vagina (lower third)
3B Pelvis wall, Hydronephrosis
Stage 4: beyond pelvis/ mucosa of Bladder, Rectum
4A Spread to adjacent organs
4B Distant Organs
Tx:
 Excisional Treatment:
 Cone Biopsy
 LEEP
TX:  Hysterectomy
 Surgery: Hysterectomy (uterus, ovary, ligaments , upper vagina) +  Ablative Treatmeny:
Bilateral pelvis lymphadenectomy.  Cryosurgery
 Radiotherapy  Laser Vaporisation
 Chemotherapy (Cisplastin,Doxorubicin)  Electrocautery

Cone Biopsy: remove tissue in depth and diameter (30mm)

Hysterectomy: x children, (in case of CIN + Pelvis pathology)

 Cervical squamous cell carcinoma: 70%

 Cervical Adenocarcinoma: 15% associated with exposure to dietylsilbestrol (DES)

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Tumors
Uterine Sarcoma Vulvular Cancer
 Arise from Stromal components (Endometrial stroma, mesenchymal).
 Bad prognosis 1) squamous cell carcinoma:
 Types:
most common after age 40  most common type 90%
 rapidly enlarging uterus  Pain  Leiomyosarcoma Squamous cell carcinoma staging
S+S:
 Vaginal Bleeding: most common symptom  Endometrial stroma 0
 Pruritus Carcinoma in situ
 vaginal discharge. carcinoma
 Bloody vaginal discharge I Limited to vaginal wall x<2cm
 Adenosarcoma
 Postmenopausal bleeding II Limited to vulva/perineum X>2cm
 carcinosarcoma
 Ulcerated lesion III Spread to lower
urethra/anus/Unilateral LN
 cauliflowerlike lesion
Lichen Sclerosus Dx: Biopsy (always) IV Invade into
Bladder/rectum/bilateral LN
IVa Distant metastasis
 White, thin skin extending from labia to perianal area. Risk factors:
 Most common in postmenopausal women (can occur at any age)
 HPV 16 positivity
 associated with a higher risk of cancer  Vulvar carcinoma
 smoking
S+S:  immunosuppression
 Pruritus
 Dyspareunia Staging: done during surgery
 Burning
 Tx:
Tx: Topical steroid (clobetasol)
 Unilateral lesion without LN involvement  modified radical vulvectomy
 Bilateral  radical vulvectomy
Squamous cell Hyperplasia
 Involved LN must undergo Lymphadenectomy
 Surface thickened and hyperkeratotic
 Postmenopausal women ↑ lymphatic drainage : superficial inguinal lymph nodes  deep femoral nodes
 Pruritus (most common symptom) external iliac lymph nodes.
 Dx: Biopsy
 Tx: corticosteroid
2) Paget Disease: Intraepithelial neoplasia

S+S:
 Soreness
 Pruritus
 Red lesion + superficial white coating

Dx: Biopsy (always)

Tx:
 Bilateral Lesion: radical vulvectomy
 Unilateral Lesion: modified Vulvectomy

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Labor & Delivery

Normal Labor and Delivery Stages Of Labor
True Labor: False Labor:  First Stage: (4-12hr)
 Contraction:  Contraction: o Latent phase:
o painful o Braxton-Hicks contraction  Uterine contraction  infrequent and irregular
o Regular interval o Irregular interval  Slow cervical dilation and effacement (3-4 cm)
o Interval shorten ↓ o Long interval o Active phase:
o Intensity increase ↑ o Unchanged intensity  Rapid cervical dilation to full dilation  1.2 cm/h (multipara 1.5)
 Cervix dilation  No Cervix dilation  Painful, regular contraction 2-3 min, lasting 1 min
 Discomfort: Back, Abdomen  Discomfort: Lower Abdomen  Second Stage: (20-50 min)
 Discomfort doesn’t stop by Sedation  Discomfort relieved by sedation o Full Dilation  Delivery
 Progressive dilation & effacement of o Fetal Head descent
cervix o Steps:
 Descent of presenting part (progression  Engagement
of station)  Descent
 Flexion
 Internal rotation
 Extension
 External rotation
Fetal Lie: relation of long  Delivery of Anterior shoulder
axis of the Fetus to the  Delivery of Posterior shoulder
mother.
 Third Stage: (5-30 min)
o Immediately after Delivery
 Longitudinal o Separation and expulsion of the placenta (Blood, uterus rise, uterus  Firm
 Transverse and globular, umbilical cord protrude)
 Oblique o May last up to 30 min
o Give oxytocin (reduce risk of PPH)

Attitude: Posture of the

Fetus.

 Flexion
Station
 Deflexion
 Extension

Presentation: the portion of fetal body that foremost within the Birthcanal or in closest proximity to it.

Cephalic presentation

 Vertex
 Sinciput
 Brow
 Face

Breech Presentation

 Complete
 Frank
 Footling

Shoulder
presentation

Position: relationship
of presenting part to
maternal pelvic

most common: OA (Left)

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Fetal Monitoring
Fetal Distress

 Baseline FHR
o normal range is 110-160 bpm  Fetal Heart Rate:
o parameter of fetal well-being vs. distress o Normal: 110 – 160
 Variability: o Bradycardia: X < 110
 physiologic variability is a normal characteristic of FHR o Tachycardia: X > 160
 variability is measured over a 15 min period and is described as:
 absent, minimal (<6 bpm), moderate (6-25 bpm), marked (>25 bpm)  FHR measured by Doppler
 normal variability indicates fetal acid-base status is acceptable  contractions measured by tocometer
 can only be assessed by electronic fetal monitoring (CTG)
 Normal variability is between 10-25 bpm³ Factors affecting Fetal Oxygenation:
 Variability can be categorized as:  ↓ uterine Blood flow (↓BP, Blood loss, Anesthesia, maternal position)
o Reassuring ≥ 5 bpm  ↓ maternal Oxygen ( Anemia, Smoking)
o Non-reassuring < 5bpm for between 40-90 minutes  Chronic conditions ( SLE, HTN, DM-1, COPD, Antiphospholipid syndrome)
o Abnormal < 5bpm for >90 minutes  Uterine Hypertonus (Placental abruption, oxytocin Hyperstimulation)
 Periodicity:  Uteroplacental dysfunction
 accelerations: increase of ≥15 bpm lasting ≥15 s, in response to fetal movement  Cord compression (Oligohydramnios, Cord prolapse)
or uterine contraction (or ≥10 bpm lasting ≥10 s if <32 wk GA)

 decelerations: 3 types, described in terms of shape, onset, depth, duration

recovery, occurrence, and impact on baseline FHR and variability

Late Deceleration: (Dangerous)

Nonstress Test (NST)
 Begin at Peak of Uterine contraction
 Recover after contraction ends  Check for Fetal well-being while still in the Uterus  measure Fetal movementsand
 Decrease in HR after contraction started assesses the FHR.
 No return to Baseline until contraction ends  Reactive NST:
 Insufficient Blood flow through uterus o Detection of 2 Fetal movements
 Cause: Hypoxia, Acidosis, maternal ↓BP, o Acceleration of FHR > 15 bpm ( lasting 15-20 Seconds) over 20 min.
uterine Hypertonus ↑  Reactive NST  Fetus is doing well  no further examination is needed.

Early deceleration: (not dangerous)

Biophysical Profile
 Start when uterine contraction begin
 Recover when uterine contraction stop Def: Us assesment of the Fetus +/- NST Consist of:
 (Mirror contraction)  Fetal HR
 Decrease in HR that occurs with contraction Indication:  Fetal Tone
 Vagal response to head compression  Abnormal NST  Fetal Breathing
 ↑ intracranial pressure (Fetal)  Post-term pregnancy  Fetal Movements
 physiological  ↓ fetal movements  Amniotic Fluid level
 Fetal Distress
BPP:
 8 – 10  Normal
 4 – 8  Inconclusive
Acceleration: (Not dangerous)  X < 4  Abnormal
 ↑HR > 15 ( for x > 15 Sec )
 At least 2 accelerations every 15 min.
 Alongside uterine contraction
Notes
 The presence of accelerations is reassuring
 Healthy Fetus

Variable deceleration:
 rapid fall in HR with a variable recovery
phase
 Variable in shape, onset, duration
 Most common type during labor
 can sometimes resolve if the mother changes
position
 Cord Compression, Forceful pushing, 2nd
stage. Hydramnios

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Physiological Change during Pregnancy Screening

↑ Increased ↓ Decreased General
Β-hCG
 ↑ HR  ↓ BP  Heart L.Axis
 ↑Cardiac output 40%  ↓ Htk  Split S1  Produced by Placental trophoblastic cells.
 ↑ Plasma Volume 40%  ↓ Creatinine  Holosystolic murmur  + in Serum  9 d post-conception
 ↑ Blood volume  ↓ Ca²  Prolonged murmur  + in Urine  28 d after first day of LMP.
 ↑ TBG  ↓TLC, RV  Palmar erythema  Peak at 8 – 10 Wk  then fall until Delivery
 ↑ Total urinary output  Varicose vein  ↓ Levels: Ectopic pregnancy, Abortion, inaccurate dates
 ↑GFR  Hemorrhoids  ↑ Levels: multiple gestation, molar pregnancy, Trisomy 21, inaccurate dates.
 Anemia  Best initial Test when suspecting pregnancy

 Linea nigra midline abdominal pigmentation

 Chloasma  Hyperpigmentation change under eye and bridge of nose.
 Spider Angioma 
 Striae gravidarum  connective tissue change
 ↑ Areola pigmentation  Screening Tests:
 Chadwick sign  Blue Discoloration of Vagina & Cervix.  Β-hCG
 Goodel sign  softening of Cervix  US (8-12wk)  CRL
 Triple Screen: Maternal Serum α-Fetoprotein, β-hCG, Estriol. Done at 15 – 20 Wk. ↑
MSAFP: dating error, Neural tube defect, abdominal wall defect.
 CBC: (27wk) if ↓Hb  give Iron (oral) + stool softener
 Glucose Load: ( 24-28wk ) X > 140  Do OGT (Oral Glucose Tolerance test)
 Cervical culture: (36wk)  chlamydia, Gonorrhea
 Rectovaginal culture: (36 wk)  Group B Streptococcus culture
 Chorionic villus sampling: Fetal karyotype (10-13wk)
 Amniocentesis: Fetal karyotype (11-14wk), L/S Ratio
 Fetal Blood sampling: (umbilical cord sample).patient with Rh isoimmunization.

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Pelvimetry
Pelvis Types
Gynecoid Anthropoid Android Platepelloid
Dating:
GA: Number of days/weeks since the last menstrual period.
 Nägele Rule: Estimation of the day of Delivery by: Last menstrual period – 3 months +7
Days.
 Measurement of Uterus heigh
 Ultrasound


Preterm: 25 – 37 Wk  1 First Trimester: 0 - 12 Wk

Term: 38 – 42 Wk  2 Second Trimester: 12 – 28 Wk
Posterm: X > 42 Wk  3 Third Trimester: 28 – 40 Wk

Gravidity (G): Total Nr. Of pregnancies of any Gestation (include: current pregnancy,
abortion, Ectopic pregnancy, moles).  multiple gestation = one pregnancy.

Parity: (TPAL):
o T: Nr. Of Term infants
o P: Nr. Of premature infants
o A: Nr. Of Abortions
o L: Nr. Of living children

Quickening: ( feeling fetal movements)

Primapara:
Multipara:

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Contraindicated Drugs:
 ACE-Inhibitors
 Tetracycline
 Retinoids
 Misoprostol

↑↑ adverse Effects:
 Phenytoin
 Valproate
 Lithium
 Carbamazepine
 Warfarin
 Erythromycin
 Chloramphenicol

Vaccine:
 Contrindicated: (MMR) Rubella, Mumps, measles + oral typhoid
 Safe: Tetanus, Diphteria, Influenxa, Hepatitis B, Pertusis

Termination of Pregnancy:
 Medical:
o X < 9 wk  methotrexat + Misoprostol
o X > 12 wk  Prostaglandins or Misoprostol
 Surgical:
o X < 12 dilation + vacum aspiration +/- curettage
o X > 12 dilation and evacuation

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Contraception
Hormones Barrier methods Surgical Natural Postcoital

 Diaphragm condom  Male Sterilization  Coitus Interruptus  Estrogen

 Combined Oral
 Spermicides  Female Sterilization  Period  Estrogen/progestin
Contraceptive
 Breast feeding (Lactation)  Cooper IUD (after)
 Progestin-only-pill
 Danazol
 Mirena IUD
 Mifepristone (Emergency)
 Transdermal
 Nuva Ring
 Depo-Provera

Combined Oral Contraception

Absolute contraindication Relative Contraindication
 M.o.a:  Cigarette smoking
 inhibit LH,FSH  ovulatory Supression  Ischemic Heart Disease  Dubi-johnson Syndrome  Controlled HTN
 Decidualization of Endometrium  Vulvular Heart disease  Rotor syndrome  Obesity
 Cardiovascular disease  Liver Adenoma  DM
 Thickening of cervical mucous ↓ sperm
 Transient ischemic attack  Hepatic Carcinoma  Family history of Arterial disease
penetration.
 Angina  Melanoma  Hyperprolactinemia
 Mixture of Estrogen & Progestagen.  
Hyperlipidemia Gallstones  Depression
 Drug interaction: Rifampin, Phenobarbital,  Hypertension (uncontrolled)  Infectious Hepatitis  Chronic systemic Disease (SLE,
Phenytoin.  Coagulation abnormality  Hemolytic uremic syndrome  Sickle cell disease
 Reduce Endometrial/Ovarian Cancer  Fibrinolysis  Trophoblastic disease
 Reduce PID and menstrual Disorders  Before/after major surgery  Undiagnosed vaginal Bleedin
 Pulmonary HTN/Embolism  Breast Cancer
 Migraine (focal,ergotamine Tx)  Endometrial Cancer
 Active Liver Disease  Smoker, Age > 35
 Recurrent cholestatic jaundice  Pregnancy
 A/V Thrombosis
 DVT

Surgical Intrauterine Device (IUD) progesterone-only oral contraceptives

 Taken daily without breaks.
 Male / Female Sterilization m.o.a: A sterile inflammatory response of the  Missing pill: limited to 3 hours
 Most effective (X children ) endometrium (foreign body)  prevents
 ↓ complication implantation. Indication: Do it again
 Male Sterilization:  X > 35 smoker
 Vasectomy (vas deference).  Cooper Device (Must be removed every 6 years).  Postpartum women (doesn’t affect breastmilk supply)
 examination of the ejaculate for sperm-free  Progesterone Device (MiRNA) (replaced every year).  Women with contraindication to combined OCP.
on two successive occasions  Effective  Women intolerant to side effects of combined OCP.
 ↓ failure (pregnancy) rate Complication:
M.O.A:
 Female Sterilization:  Bleeding, cervical shock, perforation
 Prevent LH surge
 uterine Tube ligation  Infection (in case of PID: remove + AB)
 Endometrial Decidualization
 can be performed immediately postpartum.  Ectopic pregnancy
 Thickening of cervical mucous
 can be performed at any time of the ovarian  Expulsion
Risk of PIS doesn’t increase beyond first  ↓ tubal motility
or endometrial cycle
month
Depo-Provera (DMPA)
Contraindication:
Vaginal Diaphragm Absolute  Relative  Medroxy-progesterone-acetate (150mg)
 Injectable
 Pregnancy  X<20 age
 Initiate within 5 days of beginning of normal Menes.
 Prevent Sperm from entering the cervical canal.  Undiagnosed  Null parity
 Postpartum  immediately
 held in place over the cervix by suction. vaginal Bleeding  Anemia
 Restoration of fertility  not immediately (up to 1-2y)
 Complication: Toxic shock syndrome  PID  Menorrhagia 
  STD  Multiple sexual part.
 Wilson disease  Bacteremia risk
 Cooper allergy  Dysmenorrhea
 GIT Bleeding  Prosthesis

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Hypertension (HTN)
Pregnancy induced HTN Preeclampsia Eclampsia Chronic Hypertension

Def: Def: Hypertension + Proteinuria after 20 WK Def: Preeclampsia + Convulsion/Coma without

Neurological conditions. (Grand mal, Tonic-Clonic).
 Hypertension that develops as a S+S:
consequence of pregnancy and regress Stages:
 ↑ BP (Diastolic ≥ 90)
postpartum.  Premonitory (10 sec)  eye rolled up
 First time after 20 Wk  ↑ weight gain (rapid)  Tonic Convulsion (10-20 sec)  Tonic
 Disappear 12 Wk (Postpartum)  Headache contraction, Cyanosis
 Epigastric pain (RUQ)  Clonic (1 min) 
 Proteinuria  Coma 
Risk Factors:
Hellp Syndrome Risk Factors: like Preeclampsia
 Chronic HTN
 a life-threatening pregnancy complication  Renal Disease S+S:
usually considered to be a variant of  DM  Preeclampsia (↑BP, Proteinuria)
preeclampsia.  Polyhdraminos  Tonic – clonic seizure (Hyperreflexia)
 Age > 40, <18
 Consist of:  Previous Preeclampsia Dx:
 Hemolysis  Urine 24 Hrs
Dx:
 Elevated Liver Enzymes ↑  Kidney Function (Urea, creatinine, uric acid).
 Low Platelet Count ↓  Anemia/ Thrombocytopenia
 Liver function Test (ALT, AST)
 ↑ uric acid  Coagulation profile
S+S:  Roll-over Test: ↑Diastolic pressure > 20 mmHg
 Epigastric pain (RUQ) in supine position. Tx:
 Malaise Tx:  Stabilize the mother -> then deliver the Baby.
 Nausea  Hospitalization  prevent recurrent seizure  Mg²-sulfate
 Mild: (BP >140/90), Proteinuria ( +1 , +2)  Control BP  (Hydralazine, Labetalol)
Tx:
 At Term  Induce delivery  Delivery (only definitive treatment)
 Delivery
 Blood transfusion (red cells, platelets,  Preterm:  C-Section: Fetal distress, x respond to TX,
plasma).  Betamethasone (mature fetus lungs) retinal hemorrhage.
 Control BP (Hydralazine, Labetalol)  Mg²-Sulfate (Seizure prophylaxis)  Vaginal:
 Mg²SO4 : controversial +/-
 Severe: (BP>160/110), proteinuria (3+, 4+)
 Prevent Eclampsia (Mg²-sulfate)
 Control BP (Hydralazine, Labetalol)
 Delivery:
 At term  induce delivery
 Preterm 
 Betamethasone (mature fetus Lung)
 Mg²-sulfate (Seizure prophylaxis)

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Gynecological Infection
Candida Trichomoniasis Bact. Vaginosis Chlamydia Gonorrhea Herpes Simplex Syphilis HPV
Fungus
 Candida Albicans  Trichomonas  Gardenerella  Chlamydia Trachomatis  N.Gonorrhea  90% HSV-2(Genital)  Treponema pallidum  6+11  condyloma
Vaginalis vaginalis  10% HSV-1 (Oral)  16, 18, and 31 
Etiology

cervical neoplasia

 Discharge:  Discharge: Yellow/Green  Gray, thin discharge  Asymptomatic   Tingling, Burning 1. Painless ulcer: vulva,  Asymptomatic
Thick/white  Strawberry spots  Fish Odor  Muco-purulent discharg   Pruritus vagina, cervix.  Wart like lesion
 Pruritus   X no vaginal irritation    Ulceration + Vesicle 
Symptoms

Pruritus Dysuria 2. Maculopapular rash: Hyperkeratotic

 ↑ before Menes  Dysuria   Frequency  palms, soles, Limbs,  Edema
 ↑ during pregnancy  Frequency  Bleeding  condylomata lata  Macular lesion
 Beef-Red-   Symptomatic partner  3. Optic atrophy, tabes
Appearance  dorsalis, aortic
 Cheesy material aneurysm, Gumma


 ↑↑ WBC  Clue cells  Cervical culture  Gram stain  Viral culture  Aspiration: Ulcer/Node  Cytology
Investigation

 Inflammatory cells  Fish odor  Nucleic acid amplification  Cytologic smear  Darkfield microscopy  Colposcopy (Biopsy)
 Culture
(PMN) test  HSV DNA PCR (most sensitive, specific)
 (cervical/throat)  + VDRL

 FTA-ABS (specific anti
treponemal antibody
test)  Confirmation


 Antifungal:  Mitronidazole  A  Doxycycline or  Ceftriaxone(1) +  Acyclovir  Penicillin G (IM)
 Econazole (2gr single dose)  Mitronidazole  Azithromycin (pregnant)   Treat Partner
Treatment

Azithromycin(1)
 Miconazole  Amoxicillin (pregnant) /Doxycycline
 Fluconazole (oral)  Treat Gonorrhea
 Treat chlamydia
 Treat partner
(coinfection)


 Sexual Transmission  ↑increased risk for  Associated with  Associated with  Active infection  gumma: soft, non-
preterm labor N.gonorrhea Chlamydia
during labor  C- cancerous growth 3rd
stage.
Section
  Neurosyphilis: Penicillin
Extra

(IV)
 penicillin allergy:
Desensitization with
phenoxymethyl penicillin
 FTA-abs are diagnostic
even in the presence of
SLE.

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Gynecological Infection
Candida Trichomoniasis Bact. Vaginosis Chlamydia Gonorrhea Herpes Simplex Syphilis HPV
Fungus
 Candida Albicans  Trichomonas  Gardenerella  Chlamydia Trachomatis  N.Gonorrhea  90% HSV-2(Genital)  Treponema pallidum  6+11  condyloma
Vaginalis vaginalis  10% HSV-1 (Oral)  16, 18, and 31 
Etiology

cervical neoplasia

 Discharge:  Discharge: Yellow/Green  Gray, thin discharge  Asymptomatic   Tingling, Burning 4. Painless ulcer: vulva,  Asymptomatic
Thick/white  Strawberry spots  Fish Odor  Muco-purulent discharg   Pruritus vagina, cervix.  Wart like lesion
 Pruritus   X no vaginal irritation    Ulceration + Vesicle 
Symptoms

Pruritus Dysuria 5. Maculopapular rash: Hyperkeratotic

 ↑ before Menes  Dysuria   Frequency  palms, soles, Limbs,  Edema
 ↑ during pregnancy  Frequency  Bleeding  condylomata lata  Macular lesion
 Beef-Red-   Symptomatic partner  6. Optic atrophy, tabes
Appearance  dorsalis, aortic
 Cheesy material aneurysm, Gumma


 ↑↑ WBC  Clue cells  Cervical culture  Gram stain  Viral culture  Aspiration: Ulcer/Node  Cytology
Investigation

 Inflammatory cells  Fish odor  Nucleic acid amplification  Cytologic smear  Darkfield microscopy  Colposcopy (Biopsy)
 Culture
(PMN) test  HSV DNA PCR (most sensitive, specific)
 (cervical/throat)  + VDRL

 FTA-ABS (specific anti
treponemal antibody
test)  Confirmation


 Antifungal:  Mitronidazole  A  Doxycycline or  Ceftriaxone(1) +  Acyclovir  Penicillin G (IM)
 Econazole (2gr single dose)  Mitronidazole  Azithromycin (pregnant)   Treat Partner
Treatment

Azithromycin(1)
 Miconazole  Amoxicillin (pregnant) /Doxycycline
 Fluconazole (oral)  Treat Gonorrhea
 Treat chlamydia
 Treat partner
(coinfection)


 Sexual Transmission  ↑increased risk for  Associated with  Associated with  Active infection  gumma: soft, non-
preterm labor N.gonorrhea Chlamydia
during labor  C- cancerous growth 3rd
stage.
Section
  Neurosyphilis: Penicillin
Extra

(IV)
 penicillin allergy:
Desensitization with
phenoxymethyl penicillin
 FTA-abs are diagnostic
even in the presence of
SLE.

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