ĐĎॹá>ţ˙ ÂÄţ˙˙˙žżŔÁ˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙ěĽÁ5@ đż´bjbjĎ2Ď2 3p­X­XĆË7˙˙˙˙˙˙ˆ˘˘˘˘˘˘˘śŢTŢTŢT8U$:XÔśŃÓzYY(BYBYBYBYBYBY$Ď&Ď&Ď&Ď&Ď&Ď&Ď$KŐR×zJĎA˘_]BYBY_]_]JϢ˘BYBY‹Ó7Ş7Ş7Ş_]b>˘BY˘BY$Ď7Ş_]$Ď7Ş$7Ş[ŞRtČô˘˘TËBYY đV”5ĹŢTÁ›ž hÉ$ĎĄÓ0ŃӆÉÎŘ_§ÂŘ<TËśś˘˘˘˘آTËĐBYô6ZŽ7ŞäZŒp[ďBYBYBYJĎJĎśś¤PZR„!ŞśśZRGravida - Pregnancy G5(#preg), P1(term), 0(preterm), 0(miscarriage), 2(child living) Para  @& who has delivered a child Parity  used to summarize preg hx (TPAL) Puberty  when reproduxn becomes possible Menarche  1st period Catamenia  menarche x cycle x duration (10 x 30 x 5) Count  # of wks in preg; a 24 wks, considered an abortion. P 24, or 500gm, preterm birth. Determine wks preg, go by size of baby (est size on US). Perinatal  28 wks ’! end of neonatal period Neonatal  1st 29d p birth Infant - 1st yr of life Term -37 completed wks of preg. Preterm/Premie - before 37 wks Post-term  p 42 wks Abortion  termination of preg prior to age of fetal viability Puerpera - @& who just delivered Stillbirth - no sx of life @ or p birth EDC: Naegel s Rule: (LMP + 7d  3mo) Menstrual Cycle Nml 21-35d; duration 4-6d. Ask what was 1std of LMP Hypothal ’! GnRH ’! pit (FSH turns on ovary + estrogen produx; FSH selects follicle that s mature, LH) ’! ovary (estrogen prod by follicle in ovary) estrogen turns off FSH (via neg fdbk), FSH maturation of follicle + turns on LH (cauzing prolif). ‘!estrogen levels, LH surge ’! ovulation, formation of CL (progesterone). CL dies, progesterone levels “! = menstrual period begins “! progesterone stim GnRH again. Estrogen: Cauz grwth of breasts, ‘!grwth of epithelium, prolif of endometrial glands, ‘!ciliated cells of fallopian tubes, grwth of milk apparatus, fat + stroma in breast. Abundance, ferning + spinnbarkheit of cervical mucus; watery + clear. On endometrial glands ’! prolif + thickening Spinnbarkheit: If cervical mucus is thin, stretchable + watery, sperm can get thru Progesterone  secretory ” in endometrial gland, preps 4 implant Preovulatory - follicular phase, same as prolif in uterus Postovulatory - progesterone,  Luteal phase same as secretory in uterus Menses  “! estrogen + progesterone If persistent estrogen, endometrium building ‘!c estrogen, `" ovulation, `" progesterone, `" cdrawal of both hormones, `" menstrual period. Effects of progesterone  prolif of breast alveolar cells, cauz them to become secretory, incr in body temp, PMS brest tender, bloating, decr uterine contraxn. Progesterone help prevent premature delivery. Preg Trophoblast ’! outer layer of cells of embryo, invade endometrium d7-14. Egg fertilized in fallopian tube, during travel “! to uterus; ÷ many x s, remains same size. In uterus, same size, many cells. Not getting bigger = has to fit thru fallopian tube. d14& completed its implantation. Yolk sac  food source during embryonic stage; provides nutrition until can get nutrition fr mom. Chorion  contains structures called villi; purpose:‘! surf ra; absorption btn mother/baby. Gives ‘!placenta  waste + nutrient x" takes place. Amnion  membranes holding fetus + fluid. 2 Umbilical arteries  bring blood fr fetus ’! placenta arteries have “!O2 blood Umbilical Vein- blood fr placenta bk to fetus. (‘!O2) Villus membrane  nutrient + waste x" takes place, `" mixing of meternal/fetal blood) hCG  detectable in blood p 8d , preg test measures ˛ subunit. Quantitative or qualitative. Might want 2 do quantitative ’! ectopic preg, ‘!twin conditions, molar preg, incr in“! s syndrome ’! Nmlly double q 2d; @ 80d drop some? + remain steady for rest of preg ’! takes place of LH + replace the CL PRL  milk produx, acts as ADH for fetus, reduces permeability of the amnion HPL  detecable at 6wks gestation, Human Placenta Lactagen  cauz mother not to take glucose in2 her own musc cells ’! reserve glucose 4 baby, allow mom to use fat 4 energy instead. Similar ’! type 2 DM. AFP  prod by fetal liver & yolk sac, can determine if baby has pblms  Down s + neural tube defects. Fetal anomalies Oxytocin - rel by pituitary, contraxn + milk rel. (let-“!reflex) (milk prod in alveolar cells in breast) Possible Sx of preg - N/V, urinary freq, quickening (erly mvmts of baby, felt 16-18 wks for 1st time, if 1st preg, won t feel till 17-19 wks), amenorrhea, breast "s (bigger, Montgomery glands become lrgr, drkr areola, striae), skin pigment, chadwick s sign (bluish cervix). Probably sx: abd enlgmt, " in uterine size, shape, softer, Hegar s sign (softening of isthmus of uterus), Braxton hicks contraxn (usually `" painful, soften + open cervix a little bit), ballottement of fetus, ’!palpable fetus, preg test: urine & blood. Positive sx: auscu. of fetal e&, 120-160/min; 12-14 wks by Doppler, visualization via US, perception of fetal mvmts. Uterus: myometrium grows, hypertrophy of musc, wt incr, Braxton hicks, contraxn, @ 12 wks becomes an abd organ, 16 wks dextrorotates, 20 wks @ umbilicus Cervix  function is 2 hold product of conception inside uterus ‘!vascularity + edema, Goodell s sign  softening, Chadwick s sign, endocervical gland hyperplasia (ectropion), mucus plug – barrier to infxn, cervical softening, effacement (thin out + soften) + dilation, mucus plug expelled at end of preg. Effacement is when cervix gets pulled up into uterus as whatever is coming out pushes out. Can efface or dilate 1st . Station – where the head is, how hi or lo it is, judged fr ischial spines of pelvis. Put fingers in + feel ischial spines (0 station) + feel where the head is, vaginal introitus (+3) Fully dilated = can’t feel cervix ~ baby’s head; `" effacement 2 feel for. Ovary  function maintain CL until placenta takes ovr; maintained by hCG, CL secretes progesterone + relaxin, possible pain fr ovarian cyst Breast "s Hypertrophy of the alveoli + ducts ‘!nipple size, Montgomery glands postpartum colostrums secretin milk prod in resp to PRL milk ejection in resp to Oxytocin [“!] of drugs in breast milk "s in Urinary tract:‘! renal blood flow in 1st + 2nd tri, “!3rd urinary stasis leading to infxn Skin " - abd & breast striae, linea nigra, ‘!areola pigment., melasma Endocrine "s -‘!in size & blood flow of pituitary, ‘!PRL levels, Oxytocin secretion c labor/suckling, ‘!size/vascularity of thyroid, ‘!parathormone to mobilize Ca2+ for fetus GI "s - ‘! + outward intest displacement “! intest. Mobility + tone, delayed gastric emptying cauz reflux “! gastric pH, relax of LES ’! cauz reflux, gingival hyperplasia cholestatic jaundice, ‘! bile viscosity, ‘! tendenecy for cholecystitis, subdermal deposition of bile pigment cauz pruritis Respiratory "s - Elevation of diaphragm reduces TLC. Progesterone incr respiratory rate. Incr tidal vol, pulm blood flow & airway conductance, “!pulm resistance & residual vol. e&vascular - Nml vital "s, "s becauz of preg. Venous pressure usually ‘!in lo-r extremities, enough to cauz incr in venous pressure ’! edema; varicosities Hematological - Incr in the amt of blood vol. Need to prod blood, 1st is plasma. RBCs take longr to catch ‘!, anemia fr being diluted. RBCs will ‘!, 1st will c ‘! reticulocyte count. Lose blood during delivery, need to tx. Nml blood loss btn 400-600cc. 500 + above considered xcessive blood loss. FA needed for grwth of trophoblast. Wt gain  recommended ~ 25-30 lbs Ca2+- for fetal grwth 1500mg/d, absorption ‘!c vit D B12 - xcessive vit C intake may result in B12“! Fat soluble: Vit A CONTRAINDICATED Techniques for evaluating fetal well-being US Visualization of IUP, rate + grwth Anomilaes, twins, placenta location + age Gestaional age based on: Head & Abd circumference Biparietal diameter Femur length Crown-rump length (1st trimester) Amniocentesis – chromosomal testing, fetal lung maturity, lecithin/sphingomyelin 2:1 (PG positive) complications: inj to fetus, placenta or cord. Can also get AFP levels in amniotic fluid, more accurate than mother’s serum Non-stress test - Transducer placed on mother’s abd + record baby’s HR + reactivity. Nml FHR 120-160, NST is reactive if at least 2 accel in 20 mins. Accel is rise in FHR of at least 15 BPM lasting at least 15 sec Biophysical Profile - 5 parameters, 2 pts ea. Reactive non-stress test, amniotic fluid pocket 2 cm >, fetal tone/mvmt/breathing Scalp/noise stimulations – loud noise near mother’s abd, rub or pinch baby’s head, watch for accel in fetal HR. Prenatal Care Hx: make sure pt is preg: UCG, hCG (8d p conception), US Determine gestational age: LMP/Naelgel’s rule, uterine size, US (crown rump length, head circumference, length of femur) Comprehensive database Preg test - +/- results; Blood- can titer & find how much preg hormone in blood. By 12d should be (+) in blood. PE: complete exam (1st visit), check uterine size, cervix, adnexal masses, feel size of bony pelvis. Full hx + physical, lab tests, instructions (preprinted helpful) CBC, urine culture, need to tx STDs. E-lytes only if there’s an issue, rubella is to see if pt is immune (if not, need to immunize p birth). VDRL routine, hep B (baby gets immunoglobulin when born, if mother not infected, baby gets vaccine), Pap smear, GC, Chlamydia (RFs then test), type & Rh, AB screen to see if Rh Abs present, HIV test is offered to all pts in USA (push for this test), sickle screen or Hb electrophoresis (offer genetic counseling). Initial Instrux -Nutrition, smoking, etoh, drug use. Meds allowed to take for common pblms (HA, C). Ok to travel as long as no hi RFs, take freq brks, walk ~, adequate hydration. Dehydration common c flying, bathing, sexual activity unless restricted mvmt. No heavy lifting, `" > 10lbs Nutrition  prenatal vit, Fe + Ca2+ supps; foods to avoid during preg: raw fish, raw meat, raw eggs, deli meat, dairy needs 2b pasteurized, fish hi in mercury. Solid white tuna should b ltd to 1can/wk. Chunk like, 2 cans/wk. Warning Sx  vaginal bleed, leakage of H2O, baby not moving; ‘!BP = facial edema Interval visits - answer pt concerns, ask if baby is moving? Any problems? Explain mechanics of preg, lordosis, sciatic nerve compression; measure fundal ht Fundal Ht: 12 wks at pubic symphysis 16 wks- midway b/t pubic sym + umb 20wks – umbilicus 20-36 – cm = gestational age 36 wks – fetus descends into pelvis lrgr fundal ht c twins + fibroids; may LMP wrong, xs fluid, or maybe very lg baby Sm- grwth restriction, dates r wrong, oligohydro – low fluid, fetal demise (spontaneous abortion) Leoplods Maneuver – determines fetal position’! performed near end of preg. ?s at the fundus, fetal position & presentation Cervical Exam  effacement is shortening & thinning of the cervix, dilation or opening of the cervical OS, firm ’! soft, station is where the level of the head is in the ischial spine in mother’s pelvis. Prepreg planning - Hx + PE, folic acid, screen for STDs, rubella, hep B, varicella, genetic carrier testing, wt nmlization, optimize cntl of chronic dz (easier to manage dz during preg) ex: out of cntl DM can cauz miscarriage, want to take off harmful meds, lifestyle "s depending on risk behaviors. Preg hx + outcomes, gestational ages of delivery; GYN Hx: LMP, catamenia (menarche, cycle interval, duration = 12 x 28 x 5) STDs, HIV PMHx, meds, supps, c-sxns, GYN procedures; Maternal FHx is MIP b/c mother s side determines risk factors (mult gestations, genetic pblms, hx of baby born + then died) Social Hx: nicotine, etoh, drugs, xercise, domestic violence PE: Vitals, thyroid, breast (mass can cauz delay in dx + tx b/c of tx in preg; grwth of tissue during preg), Pelvic (Pap, cultures, uterine anomalies, masses), Cardiac (check for murmurs) Medical & Surgical Issues during Preg Elective vs. emergent? Trimester, risk to preg, type of anesthesia, reluctance of surgeon. Ex: hernia or strangulated hernia; breast mass + breast Ca c 20 wks of preg; schedule & do. 1st trimester, unlikely will physically be interfered c, meds more likely to harm baby in 1st trimester. 3rd trimester, least likely to be affected by meds, baby might get in way. General anesthesia most harmful, will sedate baby. Trauma in preg make sure `" domestic violence shoulder/lap belt, lap belt alone more dangerous than `" belt. As uterus rises, injury is more likely ‘!uterine vasculature " in organ location "s in Hct (lo-r) + blood gases (more alkalotic) Always tx mother; fetal survival depends on tx of mother; routine ABCs, tx injuries b4 preg, unless life-threatening preg complication arises. Physiologic "s ’! tachycardia, hypoten, significant blood loss needs to occur b4 sx of shock r apprnt. Fetal resuscitation O2 via mother uterine rupture or abruption placenta (separating b4 baby’s born) check FHR, do US + see EGA, decide if baby can be saved + survive emergent C-sxn c imminent maternal death Postmortem C-sxn *Salvagable is 24 wks or 500gms Listeriosis - Contracted thru unpasteurized dairy/deli meats. Preg more susceptible ’!flu-like illness. Prevention is MIP Rubella  most famous for deafness; cataracts, glaucoma, micropthalmia, PDA, septal defects, pulm aortic stenosis, sensory neural deafness, hepatitis, HSM, jaundice, TTP (blueberry muffin baby), anemia Herpes - Disseminated infxn in baby ’! CNS/ophthalmic dmg, skin or mucous membrane dz, c-sxn for 10 infxn or recurrent lesion at time of delivery. Avoid invasive monitoring c vaginal delivery, don t brk H2O, don t prick baby s scalp for pH. PostPartum Depression  fits criteria 4 major depression, tx c antidepressants. Sx include guilt. PRLomas  usually been put on bromocriptine, stop once preg; assess for HA, visual field defects ’! assume PRLoma is growing. Sx ’! MRI. Gestational DM  insulin resistance that dvps during preg. Due to " in HPL; during preg usually no sx; don t depend on sx for dx. Screen pts whether or not sx. If dvp GDM, > likely to dvp DM2, esp A2 (insulin-dependend). A1  gestational, mgmd c diet Dx: glucose challenge test, 24-28 wks; earlier if suspicion. Upper limits of nml: 95,180, 155, 140. 2 > abnl values = DM during preg Thromboembolic dz -‘!risk in preg, venous stasis, tend to clot more due to XS estrogen. Thrombophilias  tend to throw clot to placenta; antiphospholipid syndrome Dx: US, Doppler lo-r extrems for DVT, spiral for PE Clues to hypercoag – 1st thrombosis < 45, idiopathic venous thrombosis, FHx, recurrent venous thrombosis Tx: heparin or lo molecular wt heparin, bed rest, analgesia, AVOID ORAL ANTICOAGS Chronic Pelvic Pain May be cauzd by structural pblm, idiopathic Some things that have been attributed include pelvic adhesions fr surgery, still do w/u. Infxn: recurrent or incomplete. Urinary/bowel dz, endometriosis Dysmenorrhea  lo-r abd cramp, sweating, tachy, tremulousness, HA, N/V/D, occurs prior to or during menses. 10 dysmenorrhea - “!in smokers, parous @& Related to endogenous PGs, begins c onset of ovulatory cycles Tx: NSAIDS, reduce uterine contrax, related to endogenous PGs, quantity of flow to degree of dysmen 2nd dysmenorrhea: Pelvic infxn, intrauterine adhesions, endometriosis, cervical stenosis Endometriosis – presence of endometrium other than uterine cavity. Adenomyosis: endometrial tiss ci uterine myometrium Eti: retrograde menstruation c seeding of endometrial cells Common locations: ovaries, peritoneum, cul-de-sac, pelvic ligs, LNs, rectosigmoid, vulva, cervix, vagina Uncommon: skin, umbilicus, eyes, lungs, extrems, surgical scars, perineum, bladder, kidneys Appearance: sm raised blebs, red blood-filled lesions, chocoloate cysts, powder burn areas, puckered scars, adhesions Sx: asymp, infertility, chronic pelvic pain, prior to menses, relieved as menses begin. Dysprunia, sx relating to location. PE: fixed, retroverted uterus, scarring & tenderness of cul-de sac, nodularity of ligs, enlarged, tender Adnexa Dx: Lap, bx, peritoneal bx c absence of macroscopic dz Tx: surgery; remove implants, provera oral/IM –induce amenorrhea, OC – anovulation, Danazol – amenorrhea + endometrial atrophy, GNRH agonists – leuprolide PMS Eti: occur in luteal phase Somatic Sx: bloating, wt gain, breast pain, acne, HA, "s in bowel habits Dx: only in luteal phase. R/O med/psychiatric illness Tx: diuretics & NSAIDs Leiomyomas (fibroids)  benign sm musc tumor of uterus Eti: may grow under hormonal influence, area prior to menarche, regress p menopause Sx: pelvic pain, dysmenorhea, abnl bleed, urinary urgency, anemia Degeneration of fibroids: outgrow blood supply, hyaline-musc replaced by fibrous tissue. Myxomatous, calcific, cystic, fatty, red (carneous) painful acute infarctn Dx: enlgd, hard, irreg uterus on exam, US, hysterogram or hysteroscopy for submucous myoma Tx: sm + asymt- no tx, Lg + desires preg – do myomectomy If no desire for fertility ’!hysterectomy Birth Cntl ’! Contraception Copper Intrauterine Device (IUD)  interferes c sperm transport, fertilization + implantation. Cu enhances sterile inflamatory rxn, spermicidal + toxic 2 blastocyst cell. Lasts 10y Mirena  progesterone releasing IUD, thickens cervical mucus to prevent sperm penetration. Slows tubal motility, atrophic endometrium inhibits implantation. Lasts ~ 5y. Recommended pt: parous @&, stable, mutually monogamous relationship, no hx of PID or STDs. Adv: easy to put in, little user dependency, no systemic SEs + lasts a long time. CI: preg/suspicion, irreg uterine cavity, hx PID, postpreg PID, undx vaginal bleed, un-tx vaginitis, cervicitis, adnexal pain, uterine/cervical Ca, unresolved abnl pap, Wilsons dz, Cu allergy, multi partners, susceptibility to infxn. Has progesterone pblm CI. Best time to put in IUD is during menstrual period, immediately p an abortion, any day of cycle if preg can be xcluded. > 4 wks postpartum when uterus is involuted. Removal + replacement at same visit. Insertion during menses – avoids preg, cervix slightly dilated, insertion bleeding not noticed by pt, more likely to be xpelled. Pre-insertion guidelines – medical + social hx, uterus position, Pap smear, STDs, consent form, prophylx NSAIDs (about 1h a procedure, cuts “!on cramping) + abx (endocarditis), cleanse cervix, stabilize, sound uterus (6-9 cm). Post insertion  onset of protection is immediate, check in 6-12 wks, then annually, check for strings. If don t feel strings, should let provider know. Nml to heavy menses + incr dysmenorrhea, will resolve. If any serious sx  fever & foul discharge ’! PID. If think preg, not effective at preventing ectopic preg. At risk for septic abortion, must remove IUD. Risks: expulsion, PID, uterine perforation, difficult removal, Difficult removal/missing strings  locate IUD c sono, if in endometrial cavity, retrieve c hook. If not, hysteroscopy, if `" in uterus, do KUB to locate c/i peritoneal cavity, remove laparoscopically. If `" located, probably expelled. Spermicide  creams, jellies, foams, suppositories, films. Easily available, OTC, inexpensive, protects against STDs, must apply c each coital event. Not a substitute for a condom. Diaphragm – have to be fitted in the office, needs 2b used c spermicide, not > 6h but < 24h. Has ‘!failure rate + interferes c spontaneous intercourse. @& & B&condoms inexpensive, protect STDs, compliance + motivation 2 use @& Sterilization  surgical, need extensive counseling, not reversible. Need to document + verbal, offer all temporary methods 1st. More at risk for ectopic preg. Tubal ligation  either laparo, or mini laparotomy Essure  transvaginal thru cervix c a coil in tube, scar tissue forms around it. New method B&sterilization  hi 1 time cost, regret, need for trained surgeon Adv: lo complication rate, no compliance necessary, no follow-up cost, ambulatory surgery c minimal discomfort, perm for @& who have med CI to preg. Depo Provera  long-acting progestin inj, q3mo. Progesterone does the work, has 3 effects, inhibits ovulation by suppressing FSH, LH. Thickens cerv mucus. Start ci 5d of LMP & wait > 6wks postpartum if breast feeding. ADRs  irreg bleeding, amenorrhea, bone density " wt gain, depression, breast tenderness. Ideal candidate  @& desiring long-lasting, reversible contraception. @& who should avoid estrogen, breastfeeding @& preprd to accept menstrual "s & noncompliance c pill CI: known or suspected preg, unDx vaginal bleed, known or suspected malign of the breast, active thrombophlebitis, current or past Hx of thrombus or cerbrovasc dz, liver dysfunct dz NuvaRing – E & P; insert for 3wks, removed for a wk. Can remove for up to 3h, but not necessary. RU-486: anti-progestational agent that causes decidual necrosis, used c misoprostol ’! cervical softening & uterine contraxn, requires 3 visits. Use up to 49d gestation Postcoital contraception   morning p pill, 72h later, 75% Complications of preg Hyperemesis Gravidarum: wt loss, dehydration, hypoK, hypoNa, hypoCl. PE: dry coated tongue, poor skin turgor, sunken eyeballs Mngmt: eval for hosp admit, IV fluids & e-lyte replacement, NPO, advance diet slowly, social & psycho support Tx: vit B12, metoclopramide, odansetron, ginger, steroids, acupressure Premature rupture of membranes –leakage/gush of water, pooling of vaginal fluid, nitrazine (pH – if dk blue its basic and amniotic fluid), ferning (crystal pattern on slide looks like fern leaves – amniotic fluid), amniotic fluid index. Mngmt: steroids, tocolysis (meds to stop contrax), vaginal culture (GBS + abx & watch for infxn), avoid vaginal contamination, monitor cbc, temp, fundal tenderness, prompt delivery in case of chorioamnionitis. Complications – preterm delivery, chorioamnionitis, fetal malformations, failure of lung dvpmt (need amniotic fluid to dvp lungs) Rh incompatibility – Rh neg mom, Rh pos baby. Isoimmunization – IgM is initial, baby not affected b/c doesn’t cross. Next preg IgG, crosses placenta’! hemolysis of fetal RBCs, anemia, incr erythpoiesis, heart failure, fetal hydrops, effusions, & placental edema, jaundice Tx: give Rhogam at 28-30 wks, given 4 invasive procedures during preg, for miscarriage & ectopics. Postterm preg  Htn, long labor, macrosomia, shoulder dystocia, meconium, fetal distress, oligohydraminos, ‘!risk for c-sxn Interventional  fetal surveillance, cervical ripening, labor induction Preterm L&D  prior to 37wks. Lo bwt: < 2500gms; very lo bwt 1000-1500 gms, Impact – expense of NICU, decision for heroic efforts, long-term phys & mental disabilities, immature lungs, intraventricular hemorrhage. Eti: – unk; placenta previa or abruption, pelvic infxn, trauma, surgery. Autoimmune dz, cerv incompetence, uterine pathology, maternal dz or drug use, fetal anomalies, idiopathic. @& at risk  those who ve been preterm a, Progesterone inj can reduce risk. Cervical "s , contraxns, pelvic press, water/bloody discharge. Fetal fibronectin  located b/t deciduas & chorion, if detected by vaginal swab. Placenta previa  placenta, implanted ovr lo-r uterine segment. Total, partial, marginal. Lo vol – placenta in lo-r uterine segmt, near cervix. Total is worse b/c no way for baby to get out until placenta comes out--- if out 1st = baby has lost all its O2. Sx: bright red vaginal bleeding, no abd pain, bleeding in 3rd tri, or end of 2nd. Earlier, worse the prognosis. Dx: US – the key if you have pt c 3rd tri bleed, don’t do pelvic exam unless do US. If you find placenta & is previa don’t touch cervix, can make the bleeding worse & become life-threatening hemorrhage ci mins, may not have time to go to OR & deliver baby. Mgmt: bed rest, fluid replacemt, blood transfusion, CBC, type & cross, coag profile. Klehauer-Betke test ’! Rh test to see how much fetal blood got in2 circulation. If significant, another dose of Rhogam. Placetal abruption – completely or partially separates fr its implantation. MCC – HTN, trauma, cocaine, idiopathic Sx: uterine pain due to titanic contraxns, fetal distress/demise, shock, vaginal bleeding, incr fundal ht. Mgmt: tx shock, delivery, conservative if premature. Postpartum hem >500 cc in 1st 24h preg Eti: coagulopathy, cervical, vulvar, or vaginal lacerations, uterine atony – overdisten, oxytocin use during labor, uterine exhaustion, retained placenta or blood clots, uterine infxn. Check for placenta 4 missing pieces, feel fundus for consistency, evaluate for coag, inspect for lacerations, uterine exploration Mgmt: of atonic uterus – bimanual massage, oxytocin, manual removal of clots or placenta, methergine, vasopressin, PGs, angiography, selective arterial embolization/ligation HTN in preg – 140/90 or higher Chronic, transient gestational, pre-eclampsia, eclampsia, chronic Htn c superimposed preeclampsia. Chronic HTN  dx prior to preg or 1st 20 wks. Preg may cauz/exacerbate e& or renal complications of HTN. Lo Na diet, meds may not b needed (`" ACE or CCB), methyldopa is preferred tx. Transient HTN  devp during preg, no proteinuria, BP rtns to nml ci 12 wks p delivery. Cant b differentd fr chronic HTN dx during preg until 12 wks Mild preeclampsia – HTN <160/110. proteinuria: 2+ or more on dipstick, > 300 mg/24 hrs, but < 5g/day. Asympt. Nml blood tests Severe preeclampsia – BP > 160/110; protein > 5gm/d, oliguria < 500 ml/24h; cerebral/visual disturb, TTP, cyanosis, grwth restriction in baby. Sx: HA, scotomas, flashes, epigastric, RUQ pain. Multiorg dysfunction, HELLP syndrome- hemolysis, elevated LFTs, lo platelets. >34 wks, deliver; < 34 weigh risk & benefits. Pathophys  vasospasm, ‘!arteriolar resistance, “!GFR due to constriction of afferent arteriole, cauzs oliguria. Eclampsia  Sz involved RF for pre-eclampsia – nulliparity, teen preg, multiple gestation, DM, renal dz, chronic HTN, molar preg Consequences – abruption placenta, Sz, hem stroke, DIC, pulm edema, liver hem, acute renal failure, fetal growth restriction. Mgmt: hydralazine or labetalol if BP very hi (goal 140/90 – 150/105). Steroids 4 fetal lung maturity, MgSO4 for Sz prophylx, continue 24 hrs pp, monitor levels. Delivery is definitive Mgmt: Termination of Preg Surgical D&C – D&C ’! vacuum Ru-486  works by blocking progesterone receptors. Used c misoprostol, cervical softening and uterine contraxns. D&C - dilate cervix c laminaria (seaweed stics) day prior to the procedure. Cervix can b dilated under anesthesia c tapered dilators. Curette loosens uterine contents. Vacuum extraction of POC. D&E – 2nd trimester abortion – when fetus is removed in pieces p cervix is dilated. Grasp fetal parts and remove manually. Cervical Ca Premalignant dz, very common, screening is easy & can detect treatable premalig dz. Screening guidelines - begin PAP @18 or p sexual begins. P 3 consec. nml, discretion of provider. RF: Infxn c HPV (strains 16,18,31,33 r hi risk types) early 1st coitus, smoking, lo socioeconomic strains, HIV infxn or other immunodeficiency. Pap smear method – not during menses, avoid intercourse, douches, lubricants, tampons 24h prior. Do pap b4 bimanual, sample endocervix & ectocervix Cysts & Neoplasms Endometrial hyperplasia Some types of endometrial prolif may ’! carcinoma. Sx: irreg or postmenopausal bleeding Dx: endometrial bx; < 35 don t need if `" RF, > 40 bx c abnl bleeding, +/- RF Hyperplasia Simple (cystic)  inactive endometrium, no malignant potential,  Swiss cheese Complex (adenomatous): ‘! # of glands, gland crowding Hyperplasia c atypia: irreg nuclei, may ’! malignancy Tx: depends on age, < 40 D&C; rpt bx in 3-6mo. Give progesterone, then stop, will shed endometrium. If childbearing complete, do hysterectomy Endometrial Ca RF ‘! estrogen, early menarche, PCO, obesity, nulliparity, HTN, DM, FHx, late menopause @& ovulates ’! prod progesterone. In PCO, `" ovulating, producing unopposed E. Obesity  more body fat ’! more E produced Nulliparity  amenses at least a year for ea preg, cuts “!on # x s prod estrogen Endometrial Ca Sx: peri/postmenopsl bleeding Dx: bx, US 4 endometrial thickness, consistency, hysteroscopy & D&C if EMBx unsuccessful or `" correlated c TVS (transvaginal sono), or sx persist. Need 2 do both endometrial bx & US, b/c may miss the lesion, US will show how thick endometrium is. Tx: surgical staging, TAH/BSO (total abd hysterectomy, bilat salpingo oophorectomy), omentectomy, LN, disxn, radiation, chemotx Dermoid cysts Neoplasms of ovary c many types of epithelium, diff cells, have hair & teeth often. Strange looking Torsion – twists on itself, surgical emergency, if don’t repair, ovary becomes ischemic ’! necrotic p a few hours. Most likely to happen c dermoid cysts b/c they re heavy. Acute presentation, agony, have had pain b4 & went away on its own. Sometimes ovary will twist & then untwist itself. RF: nulliparity, BRCA1 or BRCA2 gene mutations, FHx, advancing age Tx: un-ruptured : follow conservatively. ruptured c lg amt of free fluid – drain surgically Surgery - 8cm, or if 5-8 cm s spontaneous regression Ovarian Ca RF: nulliparity, BRCA 1 & BRCA 2, FHx, advancing age Sx: most stage III – IV @ time of dx, abd enlgmt, pain, early satiety, menstrual irreg, late in the dz abd fullness b/c sx of ascites. Dx: pelvic exam, US, CT, markers: CA-125, AFP, HCG, false +, follow dz p surgery, screening in hi risk pts. Sx on US which raise suspicion – solid, septation, papillations, size, adhesions, bilateral, ascites. Do tumor markers b4 & p monitor tx Tx: TAH/BSO, omentectomy, L. node disxn, peritoneal washing (fluid, suxn & c if malignant cells) radiation, chemotx, tumor debulking, 2nd look – laparoscopy later, or if tumor markers ‘!, see if recurrence of dz. Screening & Prevention: referral 4 genetic counseling, CA 125, Pelvic US, prophlx oophorectomy Benign Disorders of the Vulva Vulvar Neoplasia vulvar intraepithelial neoplasia (VIN) I, II, III invasive carcinoma pruritis, pigmentations, ulceration, bx suspicious tx: local excision, tx invasive c vulvectomy Vaginal neoplasia – VAIN I, II, III Invasive vaginal Ca, incidental finding on colposcopy. Tx: local excision, invasive c vaginectomy Perimenopause - Prior to & following menopause Climacteric - transition fr repro yrs in2 menopause Menopause - loss of ovarian funct ’! cessation of menses Physiology  fewer ovarian follicles cauz ‘!FSH levels, ‘!in stromal component of ovary leads to shift in ratio of androgens:estrogens. Postmenopausal estrogen prod is a product of periph conversion of adrenal androstenedione Dx: not necess to test; day 2 or 3 serum FSH level > 50 IU/ml, serum estradiol < 50 pg/ml; amenorrhea for at least 1 year Eval of abnl bleeding - pelvic exam/US, PAP, endometrial bx, hysteroscopy, D&C CVD  2x as many @& die of CVD > Ca, MCC death in @& > 50. Onset in @& 10 yrs later than in B& RF: smoking, HTN, hyperlipid, DM, obesity, estrogen def. 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ˇˇ¸¸¸¸"¸f¸h¸l¸’¸Â¸Ä¸Ć¸Ň¸Ô¸î¸šš*šHšTšĚšţšş,ş@şFşPşVşhşjş’ş şşşźşŇşÔşŘşźčÚĎÇź´Ç§ź´™Çź™źÇźÇźÇźÇ‚™źÇźÇ™źzźzźÇ™Çź§źÇ™ÇhR…CJaJhż>=h'<56CJaJh'<>*CJaJhż>=h'<6>*CJaJh'<CJaJnHo(tHhWţCJaJhăgKh'<CJaJh'<CJaJh'<h'<CJaJh'<h'<56CJaJ.halšh 2ˆ56>*B*CJaJnHph˙tH,ź4źôźöźv˝„˝Ś˝Ş˝Ę˝â˝:ž<ž˜žśžşžňžöžřžúžPżzżĐżŇżčżŔ-ŔCŔiŔˆŔŠŔ§Ŕ¨ŔŤŔ­ŔŽŔąŔ˛ŔżŔŔŔĘŔËŔĚŔÔŔŐŔňęćęŘĐĂęŘęśę¨ŘęŘęĐęĐęœĐęĐęĐęŽę‚ęznznznzę‚ę‚hUkhUk5CJaJhUkCJaJhUkh'<5CJaJhçuh'<6>*CJaJhlWíh'<>*CJaJhlWíh'<56CJaJh'<CJaJnHo(tHhR…CJaJnHo(tHhR…CJaJhlWíh'<6>*CJaJh'<h'<CJaJhps@h'<56CJaJ+4źÜźv˝Ę˝Fž–ž˜žśžňžˆŔÁÁ#Á‡Á˜ĂľĜÄÁÄöĉĹýĹsƖĆ<Č É ÉHÉjÉúúúúúúúúúúőőđđđđđđđđđđđđđőđđgdI~gd„agd'<ŐŔßŔÁÁÁ"Á6Á7Á†Á‡ÁŽÁŁÁľÁÂÂÂÂbÂd˜ÜĂÄÄOÄPĜĝĶÄÁÄřđřčÚčÎčƸ°˘°•°‰°}°o°˘°}°f°Xh:IhI~56CJaJhI~>*CJaJh]hI~6>*CJaJhlWíhI~>*CJaJh•> hI~>*CJaJhI~CJaJnHo(tHhDhI~6>*CJaJhI~CJaJh•> hI~56CJaJhđH*CJaJhlWíh„a>*CJaJh•> h„a56CJaJh„aCJaJhUkCJaJh'<CJaJÁÄĂÄŇÄčÄöÄřÄ Ĺ,Ĺ-Ĺ.ŢŝĹŘĹŮĹsƉƊƕƖƘĆŕĆäĆçĆčĆýĆÇ$Ç(Ç*Ç,ÇQÇČČČČ<ČhČjČÉ É ÉňęâęňęÚęÚęňęÎęšĹęňęŻęÚęŻęŻęŁŻę—ęŻę‰~ę‰vh„aCJaJhI~6>*CJaJhoŇhI~6>*CJaJhI~CJaJnHtHh:IhI~CJH*aJhŁoCJaJh•> hI~6>*CJaJhI~6CJaJh•> hI~>*CJaJhUkCJaJh­U‚CJaJhI~CJaJh:IhI~6>*CJaJ( ÉHÉjÉlÉxÉzɘɚÉPĘQĘ^ĘoʂʗʺʻʽĘŘĘŮĘçĘôĘË!Ë1Ë2ËJËSËVËĚĚ(Ě*Ě,ĚěŢŇĘŇĘŇĘžĘŢʜʜ¨ĘœĘŽ†Ž†~†pś~c~[~h CJaJh.3@CJaJnHo(tHhÖđh.3@56CJaJh.3@CJaJh{@CJaJhÖđh{@56CJaJhlWíhI~>*CJaJhÖđhI~6>*CJaJhŁoCJaJhÖsËhI~>*CJaJhI~CJaJhĽG–hI~5CJaJhĽG–hI~56CJaJ&halšhI~56>*B*CJaJph˙ jÉÎÉöÉ!Ę0Ę]Ę^ʂʻĘćĘçĘËJË,ĚîÍđÎÚĎÜĎŹĐќŃlŇmŇ~ҟŇvx÷÷÷÷÷ňňňňňííčăăăăăăăăŢŢŢŢgd-(‘gd gd.3@gd{@gdI~ & FgdI~,Ě@ĚB̀̂̚ĚĐĚÍÍ Í"Í8ÍÂÍÔÍîÍňÍîÎđÎřÎĎ*ĎśĎÚĎÜĎâĎĐĐ@ĐBĐDĐhĐŹĐňäÜĎÜĎœϪϪśŞ˜ŞŒ}kŞśŞÜYŞśŞśŞśŞ"h†ryh 56CJaJnHtH"h mÄh 56CJaJnHtHhŁo56CJaJnHtHhI~CJaJnHtH"hŤsh 6>*CJaJnHtHh CJaJnHtHhŁoCJaJnHtHhŁoCJaJnHo(tHh CJaJnHo(tHh CJaJhŁ'Žh 56CJaJh h 6>*CJaJŹĐ°ĐŃBќѴŃŇŇ+ŇWŇYŇ[Ň\ŇlŇmŇ}Ň~ҁҟҧŇÔx^xîâîâîâÖâÖâƹ⤌weYGYEYU"hçPśh-(‘6>*CJaJnHtHh-(‘CJaJnHtH"hçPśh-(‘56CJaJnHtH(halšh-(‘>*B*CJaJnHph˙tH.halšh-(‘56>*B*CJaJnHph˙tH(h 56>*B*CJaJnHph˙tHh CJH*aJnHtHh†ryh CJH*aJnHtHhŁoCJaJnHtHh CJaJnHtH"h†ryh 6>*CJaJnHtHopposed estrogen (only for @& s a uterus) Benefits: imprvmt menopausal sx. Prevent osteo. colon Ca Estrogen effects: improves lipid profile, antioxidant,‘! fibrinolytic potential, “!fibrinogen & factor VII. insulin, vasodilation & antispasmodic effects, “!BP ADRs  breast tenderness, bloating, depression, vaginal bleed, appetite ", insomnia, N, HA, fatigue, libido " s, PMS, nervousness Risks - breast Ca, MI, DVT, stroke, PE Pt selection: young pts c hot flushes, sz possible decline in sz cntl. Migraines, high risk breast cancer CI  breast Ca or undx breast mass; uterine Ca or undx vaginal bleed; hypertrigly, familial hyperlipidemias, clot disorder, stroke, thrombophlebitis, liver dz, E dependent dz Breast Dz Lg modified sebaceous glands, Axillary xtensions (Tail of Spence), ea. Breast weighs 2-300g, glandular tissue, mostly adipose & CT, 12-20 lobes radiating fr nipple  ea. Lobe contains 10-100 lobules Milk Ejexn - Originates in secretory cells of alveoli. Branching collecting ducts ’! lactiferous sinuses ’! terminate in excretory duct ’! nipple "s c menstrual cycle - tender during luteal phase, ‘! blood flow, vasc engorgement, H2O retention, ‘!size/density/nodules Benign Breast Dz Fibrocystic "s - irreg in contour, cyclically painful, exaggeration of nml tissue response to hormonal "s, benign, ‘!engrgmt & density, xcessive nodularity, ‘!tenderness, occasional nipple discharge, bilat, poorly localized pain, sx most prominent premenstrually Sx: nodular  plate of peas, rubbery, fluid-filled cysts Dx: H&P, aspiration cytology 4 cysts, FNA or excision bx Mgmt: support bra, diuretics, “!methylxanthines (coffee, chocolate, tea, cola, OTC meds), “!tobacco use, OCPs, bromocriptine, danazole, tamoxifen Fibroadenomas - adolescents & @& in 20s. Self-discovered, slo-growing, solitary, multiple, `" painful, `" cycle "s, may regress of shrink. Rubbery, firm texture, solid. Freely mobile, may recur p reoval, US differ cystic fr solid. Dx: FNA or excisional bx. Intraductal Papilloma - Spontaneous, intermittent discharge fr 1 nipple. Watery, serous, serosanguinous. Perimenopausal age grp, 75% beneath areola, sm, soft & diff 2 palpate. Tx: excision fr involved duct & small tissue margin Nipple Discharge - Benign or malignant dz; 2b medically significant ’! spontaneous & persistent in non-lactating. Color doesn t diff benign or malignant. Cytology ’! but `" dx. Mammogram, possible excisional bx Breast Ca - US 1 of hi-est rates. 1/8 lifetime risk 4 American @&, 1/17 risk if no other RFs, other than age. RF: Age - ‘!directly c age, nonexistent b4 puberty Estrogen xposure: oophorectomy prior to age 35 “!risk 70%, obesity ‘!risk, early menarche, late menopause, nulliparity, 1st child p age 30 Genetic predisposition: BRCA-1 & BRCA-2, FHx, genetic testing & prophyx oophorectomy & mastectomy Radiation xposure: Jap. survivors of ATOM ’! Hi doses of tx radiation Misc: breast dz (benign or malignant), etoh use, estrogen tx, hi dietary fat Screening & Dx - BSE, clinical breast exam, mammo, US, needle asp BSE  majority Ca disc. by Pt. Several days following menses, inspect/palp. Technique: arm at side, behind head, massage c pads of 2, 3 ,4 fingers. Begin at nipple, work outward in concentric circles Clinical exam: 3-5 min, inspect & palpate sitting & supine; sitting: hands above head & on hips; examine breast, axilla, Cx wall & supraclavicular ras Inspect  vascular, symmetry, contour, skin, nipple, erythema Palpate  compress areola to see discharge, masses: record findings as face of clock, describe quadrant Mammography  most accurate & earliest detection, most sensitive, detects nonpalpable lesions, lo radiation xposure, annual begin age 40. Directs decisions  annual f/u; rpt films, US, bx US  diff cystic fr solid; `" radiation. `" 4 lesions < 2mm; can t detect microCa2+, can t diff benign vs. malignant. For guidance of needle bx or asp Needle Asp  aspirate all fluid, cdraw needle, maintain pressure 5-10 min avoid hematoma, If asp. is bloody or residual mass, do bx Bx When - bloody aspirate, mass p asp, suspicious mammo, PE findings, sm mass  needle bx, lg; incisional/excisional bx Breast Ca Classification Ductal carcinoma: in situ, infiltrating Lobular ca  in situ, infiltrating, inflammatory, Paget s dz Tx: cntl local dz, tx metastases. Improve quality of life, Cntl of local dz: radiation, lumpectomy, quadrantectomy, mastectomy, sentinel LN bx Vaginitis & STDs Many @& already tried OTC tx; R/O physiologic discharge  nml discharge vagina produces, nml lactobacilli produce LA & H2O2 which r protective Bact Vaginosis  aka hemophilus vaginalis, Gardnerella; overgrwth of nml vaginal anaerobes ’! “!lactobacilli. Cauz minor PAP abnl, cervicitis, PID, preterm labor,  sexually assoc ‘!risk of other infxn Sx: irriation or pruritis, thin, gray or wht discharge, fishy or musty odor worsens p intercourse. Dx: discharge, vaginal pH > 4.5, clue cells (nml vaginal epithelial cells), whiff test (KOH mixed c vaginal secretion to amplify the fishy odor) Tx: topical or oral metronidazole/clindamycin. Alternatives oral clindamycin or metronidazole (preg) Recurrent BV: tx 10-14d, suppressive tx c metronidazoel gel. Don t use clindamycin due to resistance. Trichomonas  single celled parasite c 2-5 flagellate. Sex Tx; ‘!multiple partners Sx: itching, dysuria, yl-grn or gray frothy discharge, foul fishy odor Dx: erythema,  strawberry cervix (my angry cervix!) Culture is most accurate, detected on pap, bubbles Tx: PO metronidazole, single dose, tx partner. If Tx failures: metronidazole 2g; combo tinidazole & metronidazole Genital herpes Counseling  abt t-mission, asympt viral sheding: use condom, avoid intercorse c lesion, if active lesion at time of L&D ’!csxn Tx: PO acyclovir, valacyclovir, famcyclovir. Labor & Delivery 1st: onset of contraxns until full cervical dilatation. 2nd: full dilatation until delivery, up to 1h in multipara, & 2h for primipara; pt is pushing q contraxn until baby is born. Delivery happens here. 3rd: delivery of infant ’! delivery of placenta, (~30mins) False labor: felt as abd tightening, irregular, long intervals True labor : felt in the bk also. 1st stage latent: until 4cm; not sure if real or not, going fr irreg contraxns ’! true labor, may b widely spaced apart Active: 4 cm ’!7 or 8cm Transition: 7-8 cm until full dilatation, labor more intense In active phase, primipara should dilate a minimum of 1.2 cm/hr. Multiparas should dilate at least 1.5 cm/hr. Classical c-sxn  `" vaginal deliveries p b/c uterus can rupture., only when lo-r segment isn t lg enough to get baby thru. Usually lo-r segment transverse Sx of labor - Lightening - descent of fetal head in2 pelvic inlet. Blood show  extrusion of blood tinged cervical mucus plug Rupture of membranes  gush or leakage of clear fluid (unless meconium). Some @& will deliver co ruptures; H2O break? Mngmt: presenting in labor - Onset of contraxns, interval, rupture of membranes, color of fluid, vital sx, pelvic exam for cervical effacement, dilatation, station; Pelvic architecture. Fetal position & presentation; monitor contraxns & Fetal HR. Mngmt of 2nd stage Encourage pushing when fully dilated episiotomy as baby crowns cntrl delivery of head suxn nasopharynx check for nuchal cord “!ward traction on head to deliver ant shoulder, upward for post shoulder Double clamp & cut cord Count to 10 slowly as pt is bearing “!, long pushes r more effective c pushing the baby “!. Short pushes result in conehead. Epidural  encourage mom & remind her to push“!below; if arching bk & turning red, not pushing effectively. Flex head fwd & something to hold on to behind her knees will help push effectively. Crowns  baby s head is bulging out, perineum is stretched & thin; episiotomy is done now. Not too early, perineum `" stretched more sensitive & will bleed more. Give local anesthesia a episiotomy. Mgmt: of 3rd stage - Signs of placental separation uterus becomes globular & rises gush of blood fr vagina, umbilical cord lengthens. Watch 4 sx placenta is separating ’! gives a gush of blood, a uterus starts to contract. Gentle traxn on cord c suprapubic pressure. Pull on clamp, keep 1 hand over suprapubic area or else you can invert the uterus. Pull “!until see placenta at vagina, twist placenta, see membranes come out, its own wt will gently deliver membranes. Give oxytocin (contract uterus), bleeding ceases. Repair episiotomy. Check placenta & birth canal  cervix, vagina, genitalia make sure no lacerations; unrepaired will bleed, Episiotomy Median: easy repair, good healing < painful, < dysprunia, good anatomic restoration, chance of extension to anal sphincter. Like to do median  disadv; Mediolateral: diff to repair, faulty healing, > painful, > dysprunia, occasional faulty anatomic restoration, grtr blood loss, < extension. if short perineum or lg baby, do mediolateral General anesthesia: may cross placenta, cauzin decr reactivity of fetal HR, & lo Apgar. Risk of asp pna; deleterious effect on maternal expulsive efforts. Mainly for C-sxn. Sedation: stadol or Demerol, c phenergan. Doesn t completely eliminate pain, falls asleep in btn contraxns. May prolong labor or precipitate delivery, crosses placenta, reversible c narcan; deleterious effect on maternal expulsive efforts. If sedation given very early, may slow “! contraxns, give ~ 4-5cm, having a tough labor; seems to relax pt & may deliver in the next contraxn or 2. Pblm: mom might not push effectively if still sedated. Crosses the placenta, if monitoring placenta & HR not too great, monitor. If fetal HR < reactive, lo Apgar ’! Narcan. Pudendal block: pudendal nerve supplies perineum, clitoris, anus, & medial/inferior portions of vulva. Helps pain c cervix dilation & pain episiotomy. Used at time of delivery to “!vaginal pain; INJ near ischial spines, effective for episiotomy; no effect on fetus or contraxns Local anesthesia: lido at site of episiotomy or laceration, `" effect on fetus or contraxns. If don t have time to give anesthetic, do anyway, but when repairing, will need anesthetic. Spinal anesthesia  subarachnoid space, single INJ; CI c coagulopathy, hypovolemia, severe HTN, hemorrhage. Used 4 C-sxn, if need longer-acting, give epidural. Easier to give & quick. Complications: hypoten, resp paralysis, anxiety & discomfort, bladder dysfunc, spinal HA. If“!BP, placenta doesn t perfuse ’! bradycardic baby. Leakage of spinal fluid  every time pt sits‘!, brain will sag & pull on meninges, painful. HA everytime sits ‘!’!spinal HA. Epidural block - 85% effective for painfree labor; CI c HTN, hemorrhage, platelets <80,000; spinal deforminity, neuro disease, or infxn at INJ site Adequate for c-sxn; may decr contraxns in early labor, reduce ability to push. Complications: hypotension, CNS stimulation, inadvertent spinal Give topoffs thru cathether; if pt needs c-sxn, have anesthesia there already; give additional dose thru Care of mother p delivery: freq vitals, palpate fundus, early ambulation, vulvar & perineal hygiene, watch 4 urinary retention (prob c epidural or c-sxn c foley) & constipation. Analgesia, rubella vaccination & Rho Gam. Hygiene  given a squirt bottle, sanitary napkins, p 24h, bleeding should slow “!, shouldn t be bleeding more than a period, Instruct if sees heavier bleeding, she s doing too much and should get back into bed. Uterine involution: uterus is 18-20wk size immediately p delivery. Uterus is non pregnant size 4wks later. Cervix dilated & effaced p delivery; cervix 2 cm a few days later; cervix never returns to pre-gravid state. "s in Mammary glands: 1st 5d colostrums is secreted; colostrums hi in protein & mineral. Colostrum lo in sugar & fat content; Ig s secreted in colostrums. Mature milk hi-r in fat & sugar, contain all vit. except vit K. Breast milk ideal 4 baby Hunger motions: licking lips, rooting, sucking motions Endocrinology of Lactation: hi oxytocin levels, drop in estro. & progest. allows milk rel. Suckling triggers rel of PRL, cauz further milk prod. CI breastfeeding; active TB, HIV infxn, chronic hep B, CMV, some meds Breast care: keep clean, ice packs & analgesics if `" breastfeeding; well supported bra, warm packs if breastfeeding Milk supply, proper feeding, encourage breast feeding, engrgmnt, blocked ducts, mastitis, abscess Failure of dilatation or descent: abnl or sm bony pelvis; asynclitism, macrosomic baby, fetal anomalies, conjoined twins, uterine or cervical pathology, inadequate complications Mngmt: re-evaluate bony pelvis in relation to estimated fetal wt; eval position, rotate if possible, intrauterine pressure catheter, determine strength of contraxns; oxytocin Shoulder dystocia: occurs when body size incr relative to size of head, often occurs c GDM and/or macrosomia, head delivers, then retracts; shoulders don t deliver easily. Ant. shoulder impacted above pubic symphysis. Mngmt: call 4 back‘! & anesthesia, episiotomy, McRobert s position (knees to Cx), suprapubic & intravaginal pressure. `" fundal pressure, wood s screw maneuver, deliver post arm, Fx clavicle. Prolapsed Cord  occurs when the umbilical cord falls below presenting part of fetus & presents thru birth canal a delivery of head. Contraxn compresses cord b/t bony structure of pelvis, death of fetus will occur quickly if blood can t flow thru cord. Operative vaginal delivery  vacuum extractor; forceps Indications for C-sxn failure of dilatation or descent malpresentation, dystocia umbilical cord prolapse previous uterine surgery placenta previa failed induction of labor deterioration of maternal or fetal condition *VBAC: counsel pt on risks & benefits of VBAC vs. rpt c-sxn. CI  unk scar, need for induction, pt request for repeat c-sxn. Any CI for vaginal delivery. Dysfunctional uterine bleeding Anovulatory bleeding in the absence of reproductive tract pathology or medical illness. Common in adolescents & perimenopausal @& Metrorrhagia  irreg intervals, xcessive 3 factors cntl bleeding in the nml cycle: almost simultaneous histological "s in all areas of endometrium. Orderly, progressive waves of vasocon. cauz ischemic endometrial disintegration. Mechanism which initiates flow is the same mechanism to stop flow. Vasocon  bv s to heal ‘!& reconstruct Estrogen breakthru bleeding (DUB) Lo cont levels of E cauz intermitten spotting. Hi E endometrial builds ‘!& prolif; resulting in amenorrhea followed by menometrorrhagia. Not an orderly brkd“!,`" cntld. Cauzd by anovulation, when progesterone `" present to induce a secretory endometrium c eventual shedding. E cdwl bleeding (`" DUB)  when have cont bleeding & then stop it; nml  a ovulation, E levels peak & then drop ’! may result in spotting. Same thing would happen if took out ovaries or destroyed follicle. Progesteron breakthru bleeding (`" DUB)  endometrium becomes atrophic ’! irreg spotting Progesterone challenge test  give P, when stop, should get a period; bleeding = +, means she had anovulation. Eval of DUB  hx, pelvic exam, pap, endometrial bx (age & rf) Amenorrhea 10  no menses by age 14, combined c absence of 2ndry sex characteristics, or no menses by age 16 regardless of dvpmt of sex characteristics. 20  in a @& who has previously menstruated, absence of menses for 6mo or 3 cycle intervals Asherman s syndrome  endometrial destruxn fr infxn or D&C. Amenorrhea, infertility, habitual abortions, dysmenorrheal. Dx: Hysterogram or hysteroscopy (can tx at same time, if wrong Dx, pointless. Put in IUD to prevent wall fr sticking together, give E for endometrium to grow again) Tx; D&C hysteroscopy, IUD, estrogen Premature ovarian failure  when ovaries stop functioning b4 menopause Eti: idiopathic, familial, autoimmune, gonadal dysgenesis, infxn, radiation, chemotx. Sometimes seemed like ovaries have failed, then come bk to life. 10 vs. 20 amenorrhea c absence of partial, full sexual dvp. Dx: FSH level (elevated), autoimmune investigation Tx: HRT; may reverse PCOS  Common, un-tx ’! serious illness. Glucose intolerance, hyperinsulinemia to compensate, hyperandrogenism, anovulation cauzs amenorrhea, oligomenorrhea, DUB, hirsutism, acne, obesity, alopecia, ovarian cysts on US b/c of hi insulin, stim ovaries to prod more androgens, won t ovulate, dvp dysfunct. uterine bleed or amenorrhea  E builds‘!, becomes unstable, won t get period. 2 thick to be stable, will shed irreg ’! DUB Dx: clinical features, r/o ovarian or adrenal tumors, Cushing syndrome/dz, medication effects, hyperPRL, acromegaly. Hormonal charact - ‘!testosterone & androstenedione cauz masculinization. ‘!E cauzs (-) fdbk of FSH & + fdbk of LH (‘!LH: FSH ratio). “!insulin sensitivity ’!‘!insulin secretion. Elevated fasting insulin levels Implications: In addition to direct effects; ‘!risk for MI, HTN, dyslipidemia, endometrial carcinoma, IGT or type 2 DM, GDM MC cauz of amenorrhea not due to preg or menopause Mgmt: cycle cntl, fertility, sx cntl, prevention of DM and CVD Tx: lifestyle "s  xercise, diet, wt loss, Antiandrogen (spironolactone) for acne & hirsutism. Metformin: corrects underlying pblm, helps sx, prevents sequellae Clomiphene for infertility (+dexamethasone for adrenal suppression if DHEAS elevated) Pituitary adenoma  almost always benign, lg adenoma can cauz visual field defects fr pressure on optic chiasm. Galactorrhea & menstrual abnl if it is PRL-secreting. Dx: PRL level, xray of sella tursica, MRI - microadenoma (< 10 mm)  observation & bromocriptine. - macroadenoma  surgery & radiation; postsurgical hypopituitarism may dvp Sheehan s Syndrome  postpartum pituitary necrosis due to obstetrical hemorrhage & shock. Failure of lactation & loss of body hair. Hypothalamic Disorders  hypogonadotropic hypogonadism  deficiency in pulsatile GnRH secretion, Lo FSH Dx: exclusion. Due to stress, anorexia, wt loss, overexercising, lo body fat. Tx cauz, often self-resolving. HRT vs ovulation induction Eval of Amenorrhea  r/o preg; exclude menopause, ask about meds Initial w/u: TSH level - ‘!=hypothy PRL ‘! = pituitary adenoma Progestational challenge  wthdrwl bleed = anovulation/PCO Next step: If no wthdrwl bleed, give cycle of E and progesterone. FSH level  low or nml = hypothalamic ‘! = ovarian failure If doesn t bleed = end organ problem W/U: TSH, PRL, Progesteron challenge, E/P cycle, FSH, imaging of sella tursica. Abortions Spontaneous  RFs ‘!parity, ‘!maternal/paternal age, conception c/i 3 mo of a live birth, abnl dvp is pathological finding. Maternal factors; infxus, systemic, envmtl & uterine Paternal; chromosomal, fetal, immunologic abnlty Inevitable  rupture of the membranes or cervical dilation during the 1st ˝ of preg such that preg loss is unavoidable. Uterine contraxns follow ’! expel fetus Complete- documented preg that spont passes all of the products of conception Incomplete- partial expulsion of preg tissue, bleeding and pain result, suction and curettage necessary. Missed  retention of a failed uterine preg for an xteneded period (more than 2 periods) Pt present c absence of uterine growth, lost early Sx of preg. Evac of uterus c suction 1st tri, D&E for 2nd tri Molar  proliferation of  other tissue. Replacement of nml placental tissue by hydropic placental villi. Complete moles don t have fetal formation so fetal membranes r absent. 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