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HPAO
Hereditary Progressive Arthro-Ophthalmopathy
Stickler’s Syndrome
5 A’s
Ask
Advise
Assess
Assist
Arrange
Stages of Change Model To Assess Readiness
Precontemplation
Contemplation
Preparation
Active
Maintenance
Stages of bereavement and grief
Shock 2w
Awareness/Anger
Bargaining
Depression 6mos
Resolution 1-2 y
Primary amenorrhea
No secondary sex characteristics by 13
No menses by 16
WHI Study

For the group of women on HT. CEE/MPA

Small but significant increased risk of:
DVT
Invasive Breast Cancer
Stroke
Heart Attack (MI)
Behcets triad:
Immigrant
Genitalia
Eyes
Oral
effect of Pagets of vulva
“Cake for the Pageant”
Cake icing
Bisphophonate
B = Both prevents and treats

I= Inhibits osteoclasts

sph = spine and hip
SAIL THE FEMORAL TRIANGLE
Sartorius
Adductor longus
Inguinal
Ligament
PEACH Study
PID Evaluation And Clinical Health
PID treated as inpatient v. outpatient
No diff in CPP, infertility, TOA, ectopic, IUP, recurrence, persistent infection
High risk level for DVT in gyn surgery
>40yo

DVT/PE
Immobilization postop/Inherited thrombophilic disease
Malignancy
ERT

Varicose Veins
Obesity
Prolonged Surgery
Chorioamnionitis pathogens
Bacteroides
Prevotella
E. Coli
GBS
Cholecystitis pathogens
BEcK Serratia (Ec,Enc)
Postpartum hemorrhage
Management
Assess/Stabilize
Mechanical
Pharmacological
Blood products
Surgery
Emergent measures
Carpenter-Coustan
95, 180, 155, 140
5-year survival by stage for Cervical Carcinoma
85, 65, 35, 12%
cho,fat,prot
DM in pregnancy
50, 30, 20
Ecclampsia
MgSO4
4g to 6g load in 100 mL IV over 15–20 minutes
maintain at 2 g/hr IV

6g IV/IM over 15 – 20 minutes.
Maintain 2g/hr IV
Eclampsia management
Injury – prevent maternal
Stabilize medically
Convulsions – treat/prevent (Mg or phenobarb)
Antihypertensive
Respiratory/cardiac
Fetus
An abdominal circumference within the normal range reliably excludes growth restriction with a false-negative rate of less than ___%
10%
A measurement of what abdominal circumference identifies more than 90% of newborns with a birth weight greater than 4000.
AC >35 cm
TAH v. TVH
S Size uterus
S Shape uterus
C Caliber vagina
L Length vagina
I Infrapubic angle
P Parity/SVD#/birth weights
Prolapse
PID/endometriosis/pelvic surgery

and⬦ Malignancy and other abdominal surgery needs to be done
APPY
Dissect/ligate mesoappendix/vessels
Clamp/cut base
Purse string suture at base
Paint stump with betadine
Invert (before finish purse) and embed
Perform u/s in ECV for:
D Dorsum
V vaginal exam
T Type breech

P placenta location
E extended or flexed

P position
A AFI
C cord length/nuchal
U uterine anomalies
Leopold’s
North pole what’s at fundus
South pole what’s in pelvic pole
Back where is back
Attitude extended or flexed head?
WHI
For the group of women on HT. CEE/MPA
Small but significant increased risk of: DISH
DVT ***same for ET
Invasive breast cancer (8 per 10,000 women) ***no significance in ET
Strokes ***same for ET
Heart attacks ***ET did not “prevent”

HT offered health benefits as well.
Lower risk of spine and hip fractures. ***same for ET with Hip
Reduced risk of colon cancer
FFN requirements:
Intact membranes
<3 cm
24-35 weeks
Pneumonia types
F Flu
A Atypical
V Varicella
A Aspiration
B Bacterial
Velocimetry?
Assess Vascular Impedance.
Seizure etiology
Idiopathic/Infection/Injury
Congenital
Tumors - glioma, hamartoma
Alzheimers/Degenerative/Alcohol/Drugs - buproprion,clonidine, lidocaine
Lytes/Metabolic
Incontinence History
F Frequency
U Urgency
N Nocturia
D Dysuria
A Aggravating Factors

Timing Coincident = GSUI
Delayed = DI
Meds causing incontinence
R Reserpine
A Aldomet
D Digitalis

M Major tranquilizers
C Caffeine
Urological Physical Exam
O Obesity
P Prolapse evidence
I Impulsivity of cough

D Degree of estrogenization of pelvic tissue
N Neuro exam
Q Q-tip test
Postmenopausal mass work up
C CT
U u/s
T tumor markers

B Bowel prep
I IVP
G GI work up
Clinical Pelvimetry
inlet

D Diagonal conjugate
R Retropubic space
P Pectineal line

Mid

H Hollow of sacrum
I Ischial spines
S Sacrospinous ligament

Outlet

Coccyx
Infrapubic angle
COHOSH sides
COntractions
HypotensiOn
Seizures
Increases Prolactin
C Craniophayrngioma/adenoma
H Hypothyroid
A Antipsychotic/Haldol
N Nipple stim
T TCA and Reglan
Bacterial Pneumonia
Acute fever/chills, productive cough, lobar pattern CXR

Streptococcus
rusty sputum gram+ diplococci

Hemophilus gram-coccobacillus
Uck (productive)
Klebsiella gram- rods
Staphylococcus gram+ cocci
Dilantin
Maternal Side effects
Gummy, Hairy/hypertrichosis, Acne, Rickety (osteomalacia/vit D def) neuropathy/NTD
Fetal effects of epilepsy in pregnancy:
Stillbirth
IUGR
Preeclampsia
Conditions associated with Uterine Rupture
S Scars - c/s, myomectomy
T Trauma
R Rupture history
I Instrumentation,TOP,Forceps
P Perforation,accreta/increta

C Cocaine
A Anomaly
M malpresentation/molar
P Prostaglandin/Pitocin

M Multiple gestation
O Obstructed labor
E Endometritis prior pregnancy
What are the benefits of Autologous Blood transfusion?
SPA

Safety..... no risk of transfusion reactions due to incompatibility.
Purity..... no risk of transmitted disease, such as, among others, HIV/AIDS,
Hepatitis B& C, HTLV/ Human T-cell Lymphotropic Virus 1&2, & Syphilis.
Availability..... instantly available and requires no cross matching.
Treatment option for Obesity
DEB MS

Diet (usually requires 500-1000 kcal/day reduction. Refer to nutritionist)
Exercise (first focus on exercise consistency, then increase duration and intensity)
Behavior therapy ( stress management, stimulus control, problem solving, social support)
Medications
Surgery
Initial Management of hypertension
Document and classify hypertension
Evaluate for end organ damage
Assess overall cardiovascular risk factors
Rule out secondary and reversible causes
Pheochromocytoma Symptoms
Palp Pallor Pers Pain Pressure⬦Pancreas

Palpitation
Pallor
Perspiration
Pain (chest, head, abdomen)
Pressure (HBP)
Pancreas (hyperglycemia)
Treatment of H. Pylori
omeprazole
Clairithromyin
ampiciilin
Thromboprophylaxis in pregnancy. Candidates for therapeutic anticoagulation
V Valves mechanical
I inherited thrombophilia homozygous FVL, Prothrombin mutation, ATIII deficiency
A APS
G
A Active DVT
R Recurrent DVT
A Afib from RHD


Conditions are at highest risk and should have adjusted-dose heparin prophylaxis
The Physician’s Responsibility to Victims of Domestic Violence

What must the physician do?
SAD SORE

S Screen
A Assess safety/suicide/Acknowledge it’s not her fault
D Document

S Support subsequent
O Offer help/lists/groups
R Refer
E Escape plan

Implement universal screening
Acknowledge the trauma
Assess immediate safety
Help establish an Escape plan
Offer educational materials
Offer list of community and local resources
Provide referrals
Document interactions with patient
Provide ongoing support at subsequent visits
Classification of Sexual Dysfunction
- Desire disorders
- Orgasm disorders
- Pain disorders
- Arousal disorders
Melanoma findings
A asymmetry
B Border irregularity
C Color variagation
D Diameter > 5mm
E enlargement/elevation
Canavan’s Disease (auto recessive)

Enzyme?
Aspartoacylase deficiency (storage disease)
What are Symptoms of Hepatitis?
FARM
Fatigue
Anorexia
RUQ pain
Malaise

Jaundice
Dark urine/stool
Coagulopathy
Encephalopathy
Treatment of Thyroid Storm
βIG TRIP

β B Blocker
I Iodine
G Glucocorticoids

T Thermoregulation
R Rehydration
I Iodinated Radiocontrast agent
P PTU
How do you counsel a patient regarding VBAC?
Sequelae of rupture hyster/death
Rupture rates

Success rates of VBAC
Failure factors of VBAC

Risk rupture 1% with prior LTCS
Risk of rupture 7% prior classical
Risk of death to mother and baby if rupture
Possible need for hysterectomy if rupture and unable to stop hemorrhage.
Success rate 66% prior CPD
Success rate 75% not for CPD
Lower success if obese, >4000g, >40 weeks, prior labor required ind/aug
Congenital CMV “symptoms and sequelae”
90% of infected neonates asymptomatic at birth, 10% will develop late sequelae
10% of infected neonates symptomatic at birth, 90% of survivors have permanent sequelae
Amsel’s criteria: BV
Clue POD

Need at least three of four.
pH >4.5,
amine odor on the application of KOH base,
appearance of a thin homogeneous vaginal discharge
clue cells on wet mount.
Gardnerella vaginalis
what are they on path?
gram-negative rods
-Adnexal Mass -What are the criteria that assist you determining whether to observe or treat surgically?
SAC BAGS
S Size
A Age
C Characteristics

B Bilaterality
A Ascites
G Growth
S Symptoms
-Discuss post operative bladder care in this patient?
USO

Ureteral integrity

Subjectively - Indwelling catheter for 1-3 days dome and at least 7d if trigone

Objectively - Obtain a cystogram/VCUG to confirm the injury has healed before removing the catheter
What is the lymphatic drainage of the cervix?
Common iliac
External iliac
Internal iliac
Obturator – think Point B
Presacral – think origin of USL
Parametrial – think Stage II
Paracervical
Define DUB:
Disabling Uterine Bleeding
Disruptive Uterine Bleeding
Drugs with Uterine Bleeding

Disabling uterine bleeding that Disrupts lifestyle (ACOG)
DUB “Disabling!” “Disrupts!” (ACOG)
Unexplained bleeding on HRT (ACOG)
DUB “Unexplained!”
B = Bleeding
Monopolar devices require what type of media if using electrical current?
Electrolyte-poor fluids.
MSG

Mannitol/Sorbitol/Glycine

Monopolar=Mannitol MSG
What are complications of Dextran 70?
Dextran = DIC
Anaphylaxis

Glycine = ammonia toxicity
-Discuss (in detail) how you would exhaust conservative options of treatment prior to taking the patient to the OR
MRS

Multiple visits
Relationship doc-pt
Secondary gain none

Marriage disruption
Children – unable to care for
Work interference
Risks of BTL:
REF

Regret
Ectopic
Failure
BTL counseling
Risks REF Regret/Failure/Ectopic

Benefit Permanent – not intended to be reversible

Alternatives/Anesthesia Vasectomy/IUD/short term reversible

Anticipated outcome

Informed refusal

STD
Amenorrhea -How would you work-up a patient with amenorrhea? First rule out the obvious!
LMP
Lactation
Menopause
Pregnancy
-Hirsutism -Discuss the life cycle of a hair follicle
Life cycle of a hair follicle: ACT


Anagen actively growing last 3 years

Catagen breakdown/transitional phase 3 weeks

Telogen resting phase 3 months, then falls out
3 steps to classify individual CHD risk category:

Coronary heart disease (CHD)
1)Obtain a fasting lipid profile
2)Identify presence of CHD or CHD equivalents (risk factor that places patient at same risk for CHD event as CHD itself)
Multiple risk factors that confer 10 year risk of > 20%
3) Identify major CHD risk factors other than increased LDL
CHD or CHD equivalents
(risk factor that places patient at same risk for CHD event as CHD itself)
Diabetes
Symptomatic carotid disease
Peripheral arterial disease
Aortic abdominal aneurysm
major CHD risk factors other than increased LDL
Smoking
Hypertension
Low HDL (<40)
Family hx of premature CHD (1st degree male relative with CHD < 55yo, 1st degree female relative with CHD <65
Age > 55 yo
HDL > 60 subtract one risk factor
-What is the contraceptive mechanism of action of both the estrogen and progesterone component in the OCP?
MAOI

Mucus – thickened cervical
Atrophy of endometrium
Ovulation Inhibition




PCOS – give low dose monophasic – study showed may reduce risk endometrial cancer
100 µg LEvonorgestrel and 20 µg Ethinyl estradiol (ALEsse)
Failure rate of OCPs.
obesity?
0.1% failure (4.5% failure in obesity)
Causes of recurrent pregnancy loss:
-MULIGI (eulogy)

M Metabolic poorly controlled DM/PCO (no therapy for PCO)/TSH

U Uterine anomalies Septum-poor vascularization, unicornuate , fibroids, ashermans

L Luteal phase defect
I Immune disorders APS, alloimmune hydrops, SLE
G Genetic Balanced Translocation
I Infection TORCH, Parvo, ureaplasma, syphilis

LFD Not proven
Initial incision of VH
Incise Supravaginal septum SVS

entry into the Cervicovesical space CVS

Grasping the Vesicouterine peritoneal fold VPF
Simple screening tool for depression:
Ask two questions:

‘During the past month,
Have you often been bothered by feeling down, depressed or hopeless?’

‘During the past month,
Have you often been bothered by having little interest or pleasure in doing things?’
Diagnostic Criteria for depression
Diagnosis of depression requires 5 distinct criteria be present:
o Concomitantly
o For most of the day
o On consecutive days
o For at least 2 weeks

At least one of the criteria must be either:
Depressed mood
o
Markedly diminished interest or pleasure in almost all activities

At least 4 other neurovegetative symptoms must be present
Diagnostic Criteria for depression:
neurovegetative symptoms
GUILT SPACE

Guilt feelings of worthlessness or inappropriate guilt

Suicide thoughts of death or suicide

Sleep insomnia or sleeping too much

Psychomotor psychomotor retardation or agitation

Appetite significant change in appetite or weight

Concentration diminished ability to think, concentrate or make decisions

Energy fatigue or loss of energy
Depression:
preferred agent for Pregnancy
Fluoxetine/Prozac
Don’t forget to rule out postpartum thyroiditis
Depression:preferred agent for Breastfeeding
Sertraline/Zoloft
PP Depression:
Don’t forget to rule out what?
postpartum thyroiditis
Hypoactive sexual desire may be due to other causes
SAVED Negative Experiences

S Stress
A Anxiety
V Vaginismus
E Etoh
D Depression/drugs

Negative Experiences
meds that cause hypoactive sexual desire
BBlockers
OCPs
Antidepressants/antiandrogens
Tamoxifen
ROME II SYMPTOM CRITERIA FOR IBS
At least 3 months or more, which need not be consecutive, in the preceding 12 months of abdominal discomfort or pain that has II out of three features:

RELIEF
FREQUENCY
FORM

1) Relieved with defecation; and/or
2) Onset associated with a change in frequency of stool; and/or
3) Onset associated with a change in form of stool.
PMS tx: ACOG
FIRST LINE
SANDS
First line:

Supportive

Aerobic exercise

Nutrition (Ca Mg Vit E) CME

Dietary avoid salt, caffeine, fatty food, alcohol

Spironolactone
PMS tx: ACOG
Second line:
SSRI (either fluox, Sert),

Anxiolytic /Alprazolam if needed
PMS tx: ACOG
Third line:
Suppression (OCPs, GnRH)
Congenital Toxoplasmosis clinical presentation:
Cats (chorioretinitis)
eat liver (HSM),
drink milk (calcifications) and water (ascites/hydrops), have small head(microcephaly)
Meds that decrease libido
B B Blocker
O OCP/antiandroges
A Antidepressants
T Tamoxifen
Other Causes of headache
VMI

Vascular -
Aneurysm,
AVM
Subarachnoid hemorrhage
Intracranial hemorrhage
Cavernous venous thrombosis

Mass lesions –
constant, slowly progressive
Tumor
Abscess
Intracranial hematoma

Infectious Meningitis/Encephalitis
PseuDOtumor cerebri – Headache
PseuDOtumor cerebri – HEADACHE
P-DO TUMOR CEREBRI

Pregnancy, Obesity, Diabetes
Frequent and prolonged headache
Diagnosis with LP (Opening Pressure > 250 mmH20)
Optic nerve damage
Treatment is with Diuretics
Spironolαctone
Diuretic and Aldosterone antagonist
Direct inhibition of 5-α-reductase activity
Flutamide
– Flute receptor

Antiandrogen - blocks testosterone at the receptor
Finasteride
(inhibits the enzyme 5- -reductase) –
better tolerated FINER, FINAST than Flutamide
vestibulitis. Describe your management and treatment.
CLEAST
C Calcium Citrate and low oxalate diet
L Lubricate/Lidocaine
E Eliminate irritants Estrogen cream
A Amitriptyline
S Surgery
T Therapy-biofeedback/sex
Erythema and edema of the vulva
PDS CV


Psoriasis – calcipotriene, steroid
Dermatitis – Irritant, Contact, Seborrheic
Steroid overuse (sebaceous hyperplasia)

Candida
Vaginitis (GBS) - PCN or Clinda
Diagnose PCOS Need 2 of 3
P Phasting GIR>4.5, Waist to hip ratio >.85 predictive
C Clinical
O Ovulation disturbance
S Sono
Contact vulvar dermatitis allergens
Immunogic causes (hypersensitivity reaction)
Poison SLK

Poison oak

Semen
Latex
KY Jelly
Met formin should not be used with what meds?
Cimet idine, trimet hoprim
Vulvar psoriasis. What are the clinical manifestations?
Treatment?
SILVER SCALES & PITTING NAILS! Hold breast.

Calcipotriene - synthetic vitamin D3,
Steroid
Phototherapy UVB light Psoralen PUVA
Cystometry

Test of detrusor function and can be used to assess:
Sensation
Capacity
Compliance
Contractions - presence and magnitude of both voluntary and involuntary detrusor
Differential Diagnosis of Urinary Incontinence in Women
FILLING
FISTULA
FUNCTIONAL
CONGENITAL

Filling and storage disorders

Urodynamic stress incontinence
UVJ Hypermobility
ISD
Detrusor overactivity (idiopathic)
Detrusor overactivity (neurogenic)
Mixed types

Fistula
Vesical
Ureteral
Urethral

Congenital
Ectopic ureter
Epispadias

Functional incontinence etiology
DIAPPERS
Who requires cystoscopy and cytology to exclude bladder neoplasm:
Microscopic hematuria (2-5 red blood cells per high-power field),
> 50 yo with persistent hematuria
Acute onset of irritative voiding symptoms in the absence of UTI
Lifestyle interventions that may help modify incontinence:
Curb pounds
Caffeine reduction
Carrying physical forces (eg, work, exercise),
Cessation of smoking
Constipation relief
Why is estrogenization important in incontinence?
Urethra and bladder contain a rich supply of estrogen receptors
atrophy and replacement of the submucosa (vascular plexus) by fibrous tissue.

Important for anatomic repair
Bulking agents provide what effect to the periurethra?
Washer effect
Defined as the involuntary loss of urine coincident with increased intra-abdominal pressure in the absence of uninhibited detrusor contraction.
SUI
Urinary Incontinence w/u in office:
Urinalysis and urine culture: UTIs
Urine cytology: Carcinoma in situ of the urinary bladder
Chem 7 profile: Blood urea nitrogen and creatinine levels are checked if compromised renal function is suggested.
Voiding diary
Pad test documents urine loss. Intravesical methylene/ Pyridium
Cotton-swab test
Cough stress test or Marshall test
Standing pelvic examination
PVR volume
Uroflow test evaluating bladder outlet obstruction.
To properly diagnose bladder outlet obstruction, perform pressure-flow studies.
Filling cystometrogram
The only test able to help assess bladder contractility and the extent of a bladder outlet obstruction.
voiding cystogram VCUG

aka detrusor "pressure-flow study"

simultaneously records the voiding detrusor pressure and the urinary flow rate.
Can help identify a urethral diverticulum, urethral obstruction, and vesicoureteral reflux.
VCUG
GTN Therapy depends on low or high risk category
Met CHAP

Mets Lung/vagina

Chemo prior
HCG < 40,000
Antecedent preg < 4 months ago
pregnancy term v SAB
Sexually abused children may develop the following:
ABUSE


A Avoidance or interest of all things of a sexual nature
B Bodies are dirty or damaged

U Unusual aggressiveness
S Sleep problems/Seductiveness/Suicidal/Secretiveness
E Examples of sexual molestation in drawings/games/fantasies
PEP 4 weeks
Post Exposure Prophylaxis
PEP 4 weeks
Post Exposure Prophylaxis
Combivir BID
CPP DDx
CPP DDx

GUM Gyn

G GI
U Uro
M Musculoskeletal

Gyn
Spigelian hernia?
“Spigel semilunaris”

Ventral hernia through the linea semilunaris,


Line where the sheaths of the lateral abdominal muscles fuse to form the lateral rectus sheath
Sperm analysis
50 50% mobility forward within 60 min of ejaculation
40 40 million count/ejaculate
30 30% morphology
20 20 million concentration/ml
2 2 ml
Lichen Sclerosis also found where?
Lichen on my back.
Parchment
Memory loss DDx
Memory loss = ICTAL Depression

Think of ICTAL, Add Tumor/Trauma/TIA
Add depression

Hypothyroid!
Zoloft traits and sides
GI side effects n/v
Most activating of all three SSRI. Zoloft = Zest! Zeal!
Amitriptyline sides
Trippy/drowsy/confusion/dizzy
Depression Meds with less sexual sides
bupropion
reuptake inhibitor of DA NE SE
Medical abortion
What regimen?

95-99% effective

decreased rate of continuing pregnancies

decreased time to expulsion

fewer side effects - vaginal, and lower mife dose

improved complete abortion
EBR 63 days better than FDA ladder 49 days

Mifepristone 200 mg po, then in 24 hours⬦ miso 800 pv⬦in 2 weeks sono.

Mifepristone (RU-486)

derivative of norethindrone

binds to the progesterone receptor with an affinity greater than progesterone but does not activate the receptor, thereby acting as an antiprogestin

necrotizing the decidua, softening the cervix, and increasing both uterine contractility and prostaglandin sensitivity
How would you counsel for medical TOP?
TOP CEASES


Compliance Importance of compliance and follow up
Effective 95-99% effective
Access Need access to care
Sides Pain, bleeding, septic abortion
Early Can be done early
Surgery May need surgical procedure anyway/ No anesthesia or surgical risk
Oft Forgotten risks of D&E
R Retained POC
A Ashermans
S Stenosis
H Hematometra –D&C/methergine
Memory loss
= ICTAL Depression
Think of ICTAL,
Add Tumor/Trauma/TIA
Add depression elder abuse
Communicating hydrocephalus - dizziness, unsteady walking, increased frequency of urination, and forgetfulness
Dizziness
mad stamp cabin

M Meds - neuroleptics, antidepressants, hypnotics/sedatives, loop diuretics, antihypertensives
A Anemia/arrhythmia/aortic stenosis/abuse/acoustic neuroma
D dehydration/Disequilibrium of aging/diverticulitis/diverticulosis

S Shy Drager
T tumor/trauma/TIA
A Acoustic neuroma
M Meniere’s
P postural hypotension/panic attack/PUD

C cervical spondylosis/constipation (valsalva)/communicating hydrocephalus/Colon cancer
A Abuse
B BPPV
I infection (flu)
N nutrition
Hernia repair
Hernias < 3 cm
Mesh plug or Suture repair with primary fascia-to-fascia closure
Bowel Burn injury? What do you do?
Call general surgery
If > 2mm blanching burn area, resect 5 cm both sides
If < 2mm blanching, bury area with one or two stitches
Oft forgotten vulvar ulcers
Behcets
Pagets
HIV/Mono/Cicatricial Pemphigoid
Lichens Simplex Chronicus
Describe:
PIPA (post inflammatory pigment alteration) pickers nodule, chronic itch-scratch cycle
Lichen Planus
PRURITIC PURPLE PAPULES

wickhams striae, look at mouth/tooth loss, obliterates vagina. Purple papules in hair steroids, neovagina, retinoids
Modified McCall Culdoplasty
Approximates the USL in the midline, incorporating posterior vaginal fornix in the stitch.
Securely close pubocervical and RV fascia, one or two layers across vag apex.
Permanent 2-0 through full thickness of peritoneum post fornix/post vag wall, and then bring it through US ligaments
PEACH Study
PID Evaluation And Clinical Health
PID treated as inpatient v. outpatient

No diff in CPP, infertility, TOA, ectopic, IUP, recurrence, persistent infection


No difference in outcome with mild to mod PID, clinical sxs. Cefoxitin/Doxy.
Outpatient PID: 14 day therapy
Oflaxacin/Flagyl

Ceftriaxone/Rocephin and doxy with or without Flagyl
Inpatient PID x 14 days
Mefoxin/Doxy
Gent/Clinda
Inpatient TOA:
Meds 75% effective x 14 days
Baseline imaging for size and location
Amp/Gent/Flagyl
Mefoxin/Doxy
Why Probenecid? “For Good Killing”
A uricosuric (treats gout by lowering uric acid levels)

Blocks urinary excretion, and thereby increases the blood levels and action of many medications
Laparoscopic Myomectomy
Two major concerns with laparoscopic myomectomy are:
LAVH R&R

Removal of large myomas through small abdominal incisions

Repair of the uterus.
What are the vessels at risk during a sacrospinous ligament fixation?
In Pouring Gusts

Internal pudendal vessels coursing posterior to sacrospinous ligament

Inferior Gluteal vessels
What is Adenomyosis?
Stroma and/or heterotopic endometrial glands are located deeper than the endometrial-myometrial junction by more than 1 high-power field.
Cervical Ca; describe how the radiation is given.
Transfuse if Hg <12

Teletherapy 5040 cGy
Brachytherapy 3,000 cGy

four field technique.
7000 cgy Point A
5000 cgy Point B
How is cisplatin given / dosed?
Cross links DNA
Weekly cisplatin

40 mg/m2 IV weekly for 5 wk
Benefits of chemosensitization
Synchronizes cycle/reduces hypoxia/direct effect/higher growth fraction
How long after MI can you do a surgery?
Duke’s activity risk – best predictor of cardiac risk. Greater than 4 is moderate function.

6 weeks, need stress test/echo

Scar formation and infarct healing is usually completed within six weeks of MI
Will be intermediate risk
How do you treat Crohns disease
Combination of corticosteroids and Immunosuppressants:

6-mercaptopurine and azathioprine

Ceph/Flagyl – bacterial overgrowth

Surgery

IV Infliximab Moderate to severe Crohns disease that does not respond to standard therapies Anti –TNF also tx for RA Treatment of open, draining fistulas.
History Work up for prolapse
S Symptoms Urinary/Colorectal/Protrusion/Pain/Sexual/Defecation dysfunction
O Ongoing Risks Constipation/Occupationalstress/Obesity/Chronic cough/Future childbearing/Young age
M Medical condition smoking/COPD/arthritis
E Estrogen status
Complications/problems with SSLF:
Resultant fixed vaginal retroversion predisposes to anterior prolapse –

SSLF cystocele risk 16-90%
Options for prolapse repair
Anatomic repair –
good EPF. Repair site EPF to USL/CL complex AP repairs
Compensatory repair –
bad EPF – SSLF, ASCP, Sling, graft
Complications/problems with b/l US suspension:
Ureters!

Cystoscopy mandated
Abdominal route surgery methods to repair apical prolapse include:
B/L Uterosacral Suspension
ASCP
Complications/problems with b/l iliococcygeus suspension:
Apical recurrence rate high

Limits vaginal depth
How do you do a sacro colpopexy?
Suspending strap (fore and aft) after hyst (autologous/donor fascia, porcine dermis)

Into anterior longitudinal ligament over the promontory
How do you repair the bowel?
Close in 2 layers

First layer full thickness interrupted 3-0 vicryl for mucosa. 0.25 cm apart
Second layer running seromuscular stitch 3-0 silk 0.5 cm apart
PE The classic radiographic findings
Hamptons hump -wedge-shaped, pleura-based triangular opacity with an apex pointing toward the Hilus = Hamptons Hump
Westermark sign - decreased vascularity
Management of Acute Coronary Syndrome (ACS)

Within first 10 minutes:
A Airway
B Breathing/Oxygen
C Circulation/IV access

M Morphine
A Aspirin
D Draw Enzymes
E EKG
For all ACS: Acute Coronary Syndrome
H BANG - MI

Heparin or LMWH

B-blockers
Aspirin
Nitroglycerin
GP (Glycoprotein) IIa/IIIb if percutaneous intervention (PCI)/Stents anticipated
Discuss Cardiac Enzymes:
Test Onset Peak Duration
CPK 3-12 h 18-24 h 36-48 h
Troponin 3-12 h 18-24h 10d
Spiral CT is advantageous for a number of reasons:
Faster 15-25 secs total. Patient can hold their breath for the entire study, reducing motion artifacts,

More optimal use of IV contrast enhancement

Higher resolution than conventional CT

Can detect other chest pathology

Less fetal than radiation than V/Q

angiography may miss central mural thrombus
Determine if anovaginal or rectovaginal fistula
Within 3 cm of anus is anovaginal
Simple RVF
No need for colostomy, may heal spontaneously in 6 months

Low to mid vag septum <2.5 cm diameter

Traumatic/infectious etiology
Complex RVF
Requires 2nd stage procedure/need for colostomy

High vaginal septum 2.5 cm or more in diameter

IBD/Crohns, radiation or neoplasm
Recurrent vaginitis/cystitis may be what?
RVF
Anal u/s evaluates what?
Sphincters
Most helpful test for RVF?
fistulagram/fluoroscopy
Gene mutations involved in SPORADIC ovarian cancer?
TP53 (tumor suppressor)

HER-2-neu (oncogene)
Common Causes of Transient (Functional) Urinary Incontinence
DIAPPERS

Delirium
Infection
Atrophic
Pharmacological
Psychologic – depression, psychogenic polydipsia
Pregnancy
Excessive fluid (DM, CHF/vol overload, hypercalcemia, intake)
Restricted mobility, Radiation
Stool impaction, Surgery
AMA screening
STAMP AMA

S Screening Parents
T Testing
A Abortion
M Maternal Risks
P Pre-embyro analysis/selection
Etiology of Early Pregnancy Loss
M Medical Thyroid, DM
I Immune/Infection APL/Rh/RPR/Ureaplasma
C Chromosomal Balanced translocation
U Uterine Mullerian/Leiomyoma
Infertility workup
UTERINE STOPS OBESITY

Uterine Avascular septum, ashermans
Sperm
Tubal PID, adhesive disease
Ovary/Osis
PCOS/Anovulation/endometriosis
Pituitary PRL, TSH
Social
Infertility history
Coital frequency
Obesity

Depo Provera

Etoh/smoking/Coffee>4 cups/day


Drugs (THC/CCB)

heat/sauna exposure
Contraindications to ECV (ACOG)
MAOIugr

Multifetal pregnancy
Abruption/previa
Oligo/marked
IUGR
Failure rate condoms when used correctly?
3%
Failure rate condoms when used INCORRECTLY?
12%
A patient presents with PROM at 18 versus 24 versus 26 versus 34 weeks gestation. Overall survival
18(30%)
24(50-75%)
26(80%)
34 (98%)
Most common adverse effects from high-dose radiation:
IUGR
Microcephaly
Mental retardation
Risk of CNS effects is greatest with exposure at ______of gestation, with no proven risk at less than 8 weeks of gestation or at greater than 25 weeks of gestation
8–15 weeks
A threshold for this adverse effect may exist in the range of _____rads.
Even multiple diagnostic X-ray procedures rarely result in ionizing radiation exposure to this degree.
20–40 rad.

Even multiple diagnostic X-ray procedures rarely result in ionizing radiation exposure to this degree.
Ionizing radiation can result in the following 3 harmful effects:
GCC

1) Cell death and teratogenic effects
2) Carcinogenesis
3) Genetic effects or mutations in germ cells
Mastitis pathogens?
Staph aureus,
Staph epidermis. Streptococcus,
E.Coli
How do you treat mastitis?
Dicloxacillin 500 Qid x 10-14 days
If no response to Dicloxacillin in 24-48 hrs,
Keflex,
Augmentin (B Lactamase inhibitor)
AGC favor Neoplasia
Chance AIS?
Chance invasive adenocarcinoma?
Chance of coexisting Squamous cell lesion?
Counsel patient that 5% chance AIS
2% chance invasive adenocarcinoma
R/o coexisting squamous lesion (50%)
A patient presents at 26 weeks with back pain and fever. What's the differential diagnosis?
Pyelonephritis
Labor
Perinephric abscess
Pancreatitis
Renal stones
Cholelithiasis
Cholecystitis
PUD
How a CXR appears in ARDS.
Diffuse bilateral alveolar infiltrates/ opacities (consolidation)
Consolidation with air-bronchograms
Normal appearing
Why CXR normal appearing sometimes with ARDS?
Changes seen on x-ray often lag many hours behind functional changes, so hypoxemia may seem disproportionately severe compared with the edema observed on chest x-ray
Pathophysiology ARDS
Inflammation, then fibrosis
Capillary and alveolar epithelial injury
Plasma and blood leak
Alveolar flooding and atelectasis
Refractory to O2 therapy
A patient presents with Size > Dates. Don’t forget this in your differential:
Uterine fibroid
Adnexal mass
How is TTT caused?
Placental AV shunt

most common is AA shunt!!! TTT=AA
Is 20% discordance always pathologic?
which twin type see discordance in?
No.
If two fetuses are discordant but both have normal estimated weights and grow appropriately on their own growth curves, the discordance may not indicate a pathologic process

Discordance=Dizygotic
Management: Vaginal Delivery if First Twin Vertex
Monitor first twin by internal scalp electrode
In pregnancy, exertion at altitudes of up to ____appears to be safe
6,000 feet
SCUBA in pregnancy –
Compression sickness in fetus,
Barotrauma (lungs, ears, sinus) risky if taking anticoagulants
Absolute Contraindications to Aerobic Exercise During Pregnancy
Hemodynamically significant heart disease
Restrictive lung disease
Incompetent cervix/cerclage
Multiple gestation at risk for premature labor
Persistent second- or third-trimester bleeding
Previa after 26 weeks of gestation
PTL during the current pregnancy
ROM
Preeclampsia/Gestational Hypertension
What is T&S?
ABO & Rh, and minor antigens (c,e,Kell,Kidd)
Blood exposed to O, see what antibodies are made
What is T&C?
T&S and crossmatch
Donor red cells exposed to recipient serum to check compatibility
⬢ How long does it take to get blood?
ASAP: type, screen and crossmatch time is 30 minutes
STAT: un-crossmatched blood can be released in 10 minutes
GB stones diagnosis in pregnancy:
GB ultrasound
ERCP
Why would someone have recurrent pyelonephritis?
Resistant organism pseudomonas
Other pathogen not treated Proteus, mycoplasm
Vesicoureteral reflux -VCUG
Renal calculi
Fistula
Perinephric abscess
Obstruction
Diabetes
ovarian cyst during pregnancy.
Luteoma 2/3 regress postpartum
Dysgerminoma midline vertical at 18 weeks, sample ipsi nodes
Dermoid
Serous Cystadenoma
Corpus Luteum Cyst resolves by 16 weeks
Theca lutein cysts regress in 6 months
Torsion PP due to rapid involution
In pregnancy, which masses should be surgically excised?
> 6 cm beyond first trimester

Large masses can be observed if not highly suspicious for malignancy by u/s evaluation
Cervical length <______is PTL
< 20mm
Cervical length >_____can exclude PTL
>30mm
Pt presents with contractions and 2cm dilated, don’t forget to do three things:
r/o infection
cervical length
FFN
FFN, what is it?
CHORION GLUE

Glue that holds chorion to maternal endometrium
Indicates membrane/decidua disruption
GBS Would you give any antibiotics and why?
Reduce “early-onset” neonatal GBS disease.
GBS sepsis, meningitis, neurological damage (CP in chorio)
If PCN allergic, but not at high risk for anaphylaxis, what is next choice?
Cefazolin 2g IV then 1 q 8 hours
98% susceptibility
Poor cerclage outcomes after how many weeks gestation?
22 weeks
Who gets cerclage?
13 – 16 weeks


3 mid-trimester losses
3 preterm deliveries
What are early and late symptoms of GBS in the neonate?
Early (24 - 48 hours) respiratory symptoms/Pneumonia.
Late (2 weeks) Meningitis, bacteremia/seizures
When do you not use GBS cultures/treat?
GBS negative within last 4 weeks per ACOG
Planned c/s, not in labor and no ROM
A patient is positive culture GBS and is not sensitive to clindamycin or erythromycin. What would you give her?
PCN - risk of fatal anaphylaxis has been estimated at 1 per 100,000

Cefazolin 2g IV then 1 q 8h 98% susceptibility

Vancomycin 1g q 12h
What are the signs of Mg toxicity?
CRAPO
Cardiac arrest
Respiratory depression
Absent reflexes
Paralysis Muscular
Oliguria
Treatment Mg toxicity. How to you mix it? How slow do you inject?
I’m not in love with Mg toxicity 10cc
10cc 10% 10 min

1g Calcium Gluconate IV
Calcium Gluconate (10 cc of 10% solution over 10 minutes) by slow intravenous injection
How would you apply Piper forceps?
Maintains the head in a flexed position.
Applied to bimalar biparietal region
Supports the fetal body in a horizontal plane - savage maneuver by assistant.
Direction of the pelvic axis
reverse pelvic curve
LEFT blade first
How do you avoid head extension?
Suprapubic pressure
Mariceaux-Smellie-Veit maneuver - fetal maxillary prominences.
Upper hand on the fetal back
Assistant to maintain horizontal while applying forceps
Piper forceps
nuchal arm and how do you deal with it? Breech delivery.
Lovset’s maneuver – deliver posterior arm, rotate 180 degrees, deliver new posterior arm.
or rotate the infant so that the fetal face rotates toward the symphysis pubis; this reduces the tension holding the arm around the back of the fetal head.
Or:Duhrrsen’s incision 2,6, and 10 o’clock

must press antecubital.
If press on humerus, will get radial nerve palsy - wrist drop.
Twin B breech - deliver vaginally if:
>1500 g, <36 weeks? Controversial
When to do ECV:
COMPLETED 36 weeks
Most of the evidence pertaining to ECV comes from recent studies that selected patients near term.
Why not induce successful ECV right away?
There is no support for routine practice of immediate induction of labor to minimize reversion.

except possibly in persistent transverse lie to avoid cord prolapse, after verting successfully.
What are the risk factors for ECV failure?
Marked oligohydramnios
Small fetus
Nulliparity harder
Anterior placenta
Maternal obesity
fetus fixed in pelvis
frank breech
Most common complication of ECV?
Fetal/maternal bleed
ECV tocolytic? Epidural? What studies say:
Support the use of a tocolytic agent during ECV attempts, particularly in nulliparous patients.

There is not enough consistent evidence to make a recommendation favoring spinal or epidural anesthesia during ECV attempts
Can VBACs can get oxytocin for augmentation/induction?
Yes.
In VBAC, the rate of uterine rupture was not different between those who received oxytocin and those who labored spontaneously.
Post partum for preeclampsia and develops severe oliguria <10cc/hr. What is the role of a CVP line insertion?
Evaluate intravascular volume
If the CVP rises and stays high (14-16mmHg) then volume loading is complete
Insert CVP, if low, give IVF
If CVP normal, give nitroglycerin to dilate renal artery
CVP does not mirror PCWP in severe Preeclampsia
Can push PCWP to 12-14mmHg
How is true preload measured?
Pulmonary artery catheter
If urinary flow is still poor, and the blood pressure is low or marginal, then what?
vasopressor, such as norepinephrine.
to increase renal perfusion pressure
more potent inotrope, such as dobutamine
What is the risk of Asherman’s syndrome after D&C?
69%
• What surgical techniques might increase or decrease risk of Asherman’s syndrome?
Antibiotics prior to procedure

Gentle curettage
A patient doesn’t bleed after given estrogen and progestin. DDX?
Asherman’s
Pelvic TB
Outlet obstruction
Transverse vaginal septum
Imperforate hymen
What values appear to be most effective at determining the likelihood of macrosomia and other adverse pregnancy outcomes in patients with GDM?
Postprandial glucose values
Besides R/N 2/3 ½ R/N ½ ½ , what is another GDM method to initiate with:
Can start with 10 R or Lispro, 20 NPH in AM , and 5/5 in pm
10/20 5/5
Which GDM regimen is best?
No particular insulin regimen or insulin dose has been demonstrated to be superior for GDM.
What can be used instead of Regular, and will improve postprandial?
Lispro instead of Regular (1:1) to improve postprandial
More rapid onset of action than regular insulin
Obese pregnant women (body mass index >30) may do well with moderate caloric restriction of what %?
Caloric restriction of 30%
With caloric restriction, what is important to check daily?
Should check morning urine ketones

Possibility that it may cause starvation ketosis –
Definition of mild and severe CHTN in pregnancy:
mild (BP >140/90 mmHg) or as severe (BP >=180/110 mmHg)
Are diuretics okay in pregnancy?
Diuretics are okay except in settings in which uteroplacental perfusion is already reduced (preeclampsia and IUGR).
Do women with mild hypertension (140–179 mmHg systolic or 90–109 mmHg diastolic pressure) need meds?
No.
Generally do well during pregnancy and do not, as a rule, require antihypertensive medication.
There is, to date, no scientific evidence that antihypertensive therapy will improve perinatal outcome.
HTN Therapy could be increased or reinstituted for:
Blood pressures > 150–160 mmHg systolic or 100–110 mmHg diastolic
antihypertensive therapy should be initiated or continued in:
Severe chronic hypertension (systolic pressure >=180 mmHg or diastolic pressure >=110 mmHg),
Gestational hypertension
⬢ How would you manage?
140/90, no proteinuria

Manage like mild HTN
PP HTN treatment:
Labetalol PO 200 mg every 8 hours (maximum dose of 2,400 mg/d)
Nifedipine is 10 mg orally every 6 hours (maximum dose of 120 mg/d)
In Eclampsia, deliver if FHR decels don’t resolve after how many minutes?
10 minutes
The patient with eclampsia should be delivered in a timely fashion.
Once the Eclamptic patient is stabilized, should base delivery on what factors?
Age
Fetal condition decels - greater than 10 minutes
Labor
Bishop/cervix

<30weeks or Bishop < 5 should CD
Regional anesthesia contraindicated at what platelet level?
plt<50,000
Besides anterior shoulder entrapment, what other shoulder dystocia is there?
Impaction of the posterior fetal shoulder on the sacral promontory. ACOG.
Severe shoulder dystocia may result in:
hypoxic-ischemic encephalopathy and even death
What percent of Erb’s palsy victims heal completely within a year.
90%

Usually takes up to three months
What percent of Klumpke’s palsy recover in 1 year?
40%
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