Topnotch Ob Gyne Supplement Handout 2019

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TOPNOTCH MEDICAL BOARD PREP OB-GYNE SUPPLEMENT HANDOUT BY NIÑA KATRINA BANZUELA, MD For inquiries visit or email us at [email protected] Labia Majora

OBSTETRICS SUPPLEMENT HANDOUT TABLE OF CONTENTS Maternal Anatomy Events Post-conception Placenta Fetal Development Fetal Imaging Breech Postpartum Changes Guidelines for Cesarean Section Other Important Obstetric Information Urinary Tract Infection in Pregnancy Other Important Gynecologic Concepts Gynecologic problems in pre-pubertal children Family Planning

1 6 7 8 10 11 13 15 16 19 20 29 29

Labia Minora

Clitoris Vestibule

Vestibular Glands

Urethral opening








Labia Majora

Ventral portion of the penis Penis

Labia Minora

Urinary bladder Prostate gland

Urinary bladder Urethral and Paraurethral glands Vagina Greater vestibular glands Hymen

Prostatic Utricle Bulbourethral glands Seminal colliculus Appendix of testes



Hydatid of Morgagni Uterus and Cervix Fallopian Tubes Upper ¼ of the vagina FEMALE

Appendix of Appendix of epidydymis vesiculosis Ductus of Duct of epididymis epoophoron Ductus deferens Gartner’s Duct Ejaculatory duct Seminal Vesicle Ureter Renal Pelvis Calyces Collecting system Glomerulus Renal Collecting Tubules Testes Ovary Seminiferous tubules Rete Testis Gubernaculum testis

Ovarian Follicles Rete Ovarii Round ligament of uterus

VULVA (PUDENDA) • External structues from the symphysis pubis to the perineal body • Includes mons pubis, labia majora and minora, Structure Mons Pubis escutheon

Vestibular bulbs

Vaginal opening/hymen

7-8x2-3x1-1.5cm round ligaments terminate at their upper borders connective tissue with many vessels, elastin fibers, and some smooth muscle fibers points downward and inward toward the vaginal opening; rarely exceeds 2 cm functionally mature female structure derived from the embryonic urogenital membrane perforated by six openings: urethra, the vagina, two Bartholin gland ducts, and two ducts of the Skene glands Bartholin glands, paraurethral glands (Skene glands→ diverticulum) minor vestibular glands lower two thirds of the urethra lie immediately above the anterior vaginal wall. 1 to 1.5 cm below the pubic arch lie beneath the bulbocavernosus muscle on either side of the vestibule vulvar hematoma. Hymenal caruncles Impreforate hymen

DIFFERENCE OF LABIA MAJORA AND LABIA MINORA LABIA MAJORA LABIA MINORA HOMOLOGY Scrotum Ventral portion of the penis Skin of the penis LINING Outer- KSSE NKSSE EPITHELIUM Inner- NKSSE NULLIPAROUS Lie in close Not visible behind WOMEN apposition the non-separated Inner surface labia majora resembles the mucous membrane MULTIPAROUS Gape widely Project beyond the WOMEN Inner surface labia majora become skin like GLANDS (+) Hair follicles No hair follicles (+) Sweat glands No sweat glands (+) Sebaceous (+) Sebaceous glands glands VESTIBULE • Functionally mature female structure of the urogenital sinus of the embryo. Extends from clitoris to forchette STRUCTURES IN THE VESTIBULE HYMEN ▪ Non keratinized Stratified squamous epithelium ▪ During first coitus, first that ruptures is usually at the 6 o’clock position ▪ Caruncle Myrtiformes: Remnants of hymen in adult female GLANDULAR Periurethral Glands “ Skene’s Glands” STRUCTURES Vulvovaginal Glands “Bartholin’s Glands” 6 OPENINGS: ▪ Vaginal introitus ▪ Urethral opening ▪ Paired Para urethral glands opening ▪ Paired Bartholin ducts opening GLANDULAR STRUCTURES PERIURETHRAL GLANDS “ Skene’s glands” Other name Lesser vestibular glands Male Prostate homology Type of Tubulo alveolar gland Location Adjacent to the


VULVOVAGINAL GLANDS “Bartholin’s glands” Greater vestibular glands Bulbourethral gland Compound alveolar/ compound acinar 4 and 8 o clock of the Page 1 of 31

TOPNOTCH MEDICAL BOARD PREP OB-GYNE SUPPLEMENT HANDOUT BY NIÑA KATRINA BANZUELA, MD For inquiries visit or email us at [email protected] Pathology

urethra Urethral diverticulum

vagina Bartholins’s cyst/ abscess

Triangle Anterior → Superficial and deep

Urogenital triangle Boundaries: Superior- pubic rami Lateral-ischial tuberosities Posterior: superficial transverse perineal muscle


Anal triangle ischiorectal fossa, anal canal, anal sphincter complex, and branches of the internal pudendal vessels and pudendal nerve

Urogenital (Anterior) Triangle: SUPERFICIAL SPACE Anterior Triangle (SUPERFICIAL SPACE) closed compartment

bounded deeply by the perineal membrane and superficially by Colles fascia ischiocavernosus, bulbocavernosus, and superficial transverse perineal muscles; Bartholin glands; vestibular bulbs; clitoral body and crura; and branches of the pudendal vessels and nerve

ischiocavernosus muscle

clitoral erection

bulbocavernosus muscles

Bartholin gland secretion Clitoral erection

superficial transverse perineal muscles

may be attenuated or even absent Contributes to the perineal body

Urogenital (Anterior) Triangle: DEEP SPACE Anterior Triangle (DEEP SPACE) PERINEUM

Continuous space with the pelvis

lies deep to the perineal membrane and extends up into the pelvis Contents: compressor urethrae and urethrovaginal sphincter muscles, external urethral sphincter, parts of urethra and vagina, branches of the internal pudendal artery, and the dorsal nerve and vein of the clitoris

Ishorectal fossae

wedge-shaped spaces found on either side of the anal canal and comprise the bulk of the posterior triangle Continuous space


Clinical Significance


Anterior rami of the 2nd to 4th sacral nerve


between the piriformis and coccygeus muscles and exits through the greater sciatic foramen in a location posteromedial to the ischial spine → obturator internus muscle → pudendal canal (Alcock Canal) → enter the perineum and divides into three terminal branches

Terminal Branches:




pubic symphysis


ischiopubic rami and ischial tuberosities


sacrotuberous ligaments



dorsal nerve of the clitoris

skin of the clitoris

perineal nerve

muscles of the anterior triangle and labial skin

inferior rectal

external anal sphincter, the mucous membrane of the anal canal, and the perianal skin

Landmark for pudendal nerve block

Ischial spine


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TOPNOTCH MEDICAL BOARD PREP OB-GYNE SUPPLEMENT HANDOUT BY NIÑA KATRINA BANZUELA, MD For inquiries visit or email us at [email protected] Blood Supply

• • • • • • • •

internal pudendal artery

VAGINA H-shaped lower portion of the vagina is constricted (urogenital hiatus in the levator ani) Stratified squamous non keratinized epithelium without glands Upper part is more capacious It extends from the vulva to the cervix. Ruggae that has an accordion like distensability Vaginal length: – Anterior wall: 6-8 cm – Posterior wall: 7-10 cm Potential space: Lower third

CERVIX ENDOCERVIX Supravaginal portion Extends from the isthmus (Internal Os) to the ectocervix and contains the endocervical canal

EXOCERVIX Portio vaginalis Extends from the squamo columnar junction to the external orifice Single layer of mucous secreting Non keratinized highly ciliated columnar epithelium stratified squamous which is thrown into folds forming epithelium complex glands and crypts Hormone Sensitive Extensive amount of nerves Few nerves only Blood supply: Cervicovaginal branch of uterine artery located at the lateral walls Cervix: SQUAMO-COLUMNAR JUNCTION

• • •

Vesicovaginal septum – Separates the vagina from the bladder and urethra Rectovaginal septum – Separates the lower portion of the vagina from the rectum Rectouterine pouch of Douglas – Separates the upper fourth of the vagina from the rectum

• •

• • •

Upper vaginal vaults – Subdivided into anterior, posterior, and two lateral fornices by the uterine cervix Internal pelvic organs usually can be palpated through their thin walls Posterior fornix provides surgical access to the peritoneal cavity

Prepubertal women o Original SCJ at or near the exocervix Reproductive Age women o Eversion of endocervical epithelium and exposure of columnar cells to the vaginal environment o Relocation of SJC down the Exocervix Late adulthood / Post menopausal women o SCJ at the endocervical canal o Formation of transformation zone with regrowth of the squamous epithelium



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Nulliparous: 6 to 8 cm (fundus=cervix) , 50-70 g multiparous: 10 cm (cervix 1/3), 80 g or more


Lower uterine portion

Fallopian tubes

Attaches at the cornua

Posterior wall

Completely covered by visceral peritoneum

Anterior wall

Only upper portion with peritonem → vesicouterine pouch




STRATUM FUNCTIONALE • Shed during menstruation • Supplied by the Spiral Arteries • Superficial 2/3 STRATUM BASALE • Source of Stratum Functionale after menstruation • Supplied by the Straight arteries • Basal 1/3 • lympathics Inner Longitudinal Middle oblique Outer longitudinal lymphatics

Zona Spongiosa Zona compacta

LIGAMENTS OF THE UTERUS Broad • Two wing-like structure that extend from ligament the lateral margins of the uterus to the pelvic walls • Divide the pelvic cavity into anterior and posterior compartments Reproductive Fallopian tubes structures ovaries Vessels: Ovarian arteries Uterine arteries Ligaments: Ovarian ligament Round ligament of uterus Cardinal • AKA Transverse Cervical Ligament or ligament Mackenrodt Ligament • Originated form the densest portion of the broad ligament • Medially united to the supravaginal wall of the cervix • Provide the major support of the uterus and cervix • Maintain the anatomic position of the cervix and upper part of the vagina Uterosacral • From posterolateral to the supravaginal ligament portion of the cervix encircling the rectum • Insert into the fascia over S2 and S3 Round • Extend from the lateral portion of the uterus, Ligament arising below and anterior to origin of the oviducts, that is continuous with the broad ligament, outward and downward to the inguinal canal terminating at upper portion of labium majus


SEGMENTS OF THE FALLOPIAN TUBE Intramural Embodied within 2% of ectopic pregnancy Interstitial the muscular Ectopic pregnancy at this wall of the uterus area result in severe maternal morbidity Isthmus The narrow Most highly developed portion of the musculature tube that adjoins Narrowest portion the uterus, Preferred portion for passes gradually applying clips for female into the wider, sterilization lateral portion. Preferred portion for tubal ligation 12% of ectopic pregnancy Ampulla Widest and most Site of fertilization tortuous area 80% of ectopic pregnancy Infundibulum Fimbriated 5% of ectopic pregnancy extremity Tunnel shaped opening of the distal end of the fallopian tube

• •

OVARIES Lies on the posterior aspect of the broad ligament, in the ovarian fossa o lateral to the uterus in the pelvic sidewall where the common iliac artery bifurcates o ovarian fossa of Waldeyer Are attached to the broad ligament by the mesovarium. They are not covered by peritoneum.

Ovaries: LAYERS OUTER Innermost CORTEX portion


Primordial and Graafian follicles in various stages of development Outermost ▪ Tunica Albuginea- dull and portion whitish fibrous connective tissue covering the surface of the ovary ▪ Germinal epithelium of Waldeyer- a single layer of cuboidal epithelium over the Tunica Albuginea ▪ Composed of loose connective tissue that is continuous with that of the mesovarium. ▪ Smooth muscle fibers that are continuous with those in the suspensory ligament. ▪ Contains the stroma and blood vessels of the ovary ▪

PELVIS Pelvic Organs: BLOOD SUPPLY MAJOR BLOOD SUPPLY TO THE FEMALE REPRODUCTIVE SYSTEM Pudenda Internal Pudendal artery Vagina Vaginal Artery of the Uterine Artery Cervix Cervicovaginal branch of Uterine artery Uterus Uterine Artery Fallopian tubes Ovarian Artery Ovaries PARTICIPANTS IN THE COLLATERAL CIRCULATION OF THE FEMALE PELVIS Branches from the ▪ Ovarian artery Aorta ▪ Inferior mesenteric ▪ Lumbar and vertebral ▪ Middle sacral arteries Branches from the ▪ Deep iliac circumflex External Iliac Artery ▪ Inferior epigastric artery Branches from the ▪ Medial femoral circumflex artery Femoral Artery ▪ Lateral femoral circumflex artery

FALLOPIAN TUBES single layer of columnar cells, some of them ciliated and others secretory. • No submucosa • supplied richly with elastic tissue, blood vessels, and lymphatics • Sympathetic innervation TOPNOTCH MEDICAL BOARD PREP OBSTETRICS HANDOUT BY NIÑA KATRINA BANZUELA, MD For inquiries visit or email us at [email protected]

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ANT: lower abdomen POST: lumbar vertebra LATERAL: iliac fossa



Inclined neither anterior ly nor posterio rly

SUPERIOR BOUNDARY: Pelvic inlet INFERIOR BOUNDARY: Pelvic outlet ANTERIOR: Pubic Bones, Ascending Rami Of Ischial Bones, Obturator Foramina LATERAL: Ischial Bones and Sacrosciatic Notch


Good prognos is for vaginal delivery

Forward and straight with little curvatur e Increase d incidence of Deep Transver se Arrest Limited posterior space for fetal head, poor prognosi s

Straight = pelvis deeper than other 3 types

Well curved and rotated backward

Increased incidence of Face Delivery Good prognosis for vaginal delivery

Poor prognosis for vaginal delivery

EMBRYOLOGIC STRUCTURES AND DERIVATIVES EMBRYOLOGIC STRUCTURES LABIOSCROTAL SWELLING UROGENITAL FOLDS PHALLUS (GENITAL TUBERCLE) UROGENITAL SINUS PELVIC JOINTS • Anterior: symphysis pubis/arcuate ligament of the pubis • Posterior: sacroiliac • Hormonal changes during pregnancy cause laxity of these joints • By 3-5 months POST PARTUM, laxity has regressed • Symphysis Pubis increase in width also Increase mobility and displacement of the sacroiliac joint WHY THE DORSAL LITHOTOMY POSITION? • Upward gliding of sacroiliac joint is GREATEST in the DORSAL LITHOTOMY POSITION • Outlet increase by 1.5 -2.0 cm







Labia Majora

Ventral portion of the penis Penis

Labia Minora

Urinary bladder Prostate gland

Urinary bladder Urethral and Paraurethral glands Vagina Greater vestibular glands Hymen

Prostatic Utricle Bulbourethral glands Seminal colliculus Appendix of testes


Hydatid of Morgagni Uterus and Cervix Fallopian Tubes Upper ¼ of the vagina

Appendix of Appendix of epidydymis vesiculosis Ductus of Duct of epididymis epoophoron Ductus deferens Gartner’s Duct Ejaculatory duct Seminal Vesicle Ureter Renal Pelvis Calyces Collecting system Glomerulus Renal Collecting Tubules Testes Ovary

PELVIC TENDENCY AND TYPE • Anterior – dictates the tendency of the pelvis • Posterior – dictates the type or character of the pelvis Seminiferous Ovarian Follicles GYNEANDROI ANTHROP PLATYtubules COID D OID PELLOID MEDULLA Rete Testis Rete Ovarii GUBERNACULUM Gubernaculum Round ligament FREQUENCY 50% 20% 25% 5% rarest testis of uterus Vertically INLET Heart Horizontally Round oriented SHAPE Shaped oriented oval oval EVENTS POST-CONCEPTION Divergent, Converge SIDEWALLS Straight Convergent then nt POST CONCEPTION: WEEK 1 convergent 1. Cleavage Non ISCHIAL Promine Non 2. Blastocyst formation promin Prominent SPINES nt prominent 3. Implantation ent TOPNOTCH MEDICAL BOARD PREP OBSTETRICS HANDOUT BY NIÑA KATRINA BANZUELA, MD Page 5 of 31 For inquiries visit or email us at [email protected]

TOPNOTCH MEDICAL BOARD PREP OB-GYNE SUPPLEMENT HANDOUT BY NIÑA KATRINA BANZUELA, MD For inquiries visit or email us at [email protected] Cartilages CVS Urogenital System RBC EMBRYONIC PERIOD Order of Formation CNS Heart Upper limb Lower limb External genitalia

First to develop and continues post natal Completed by 8 weeks Completed by 8 weeks Completed by 8 weeks Completed by 9 weeks


CLEAVAGE • Zygote cytoplasm is successively cleaved to form a blastula, which consists of increasing smaller blastomeres • At 32 -cell stage, the blastomeres form a morula, which consists of an inner cell mass and outer cell mass • The morula enters the uterine cavity at about 3 days post conception BLASTOCYST FORMATION • Occurs when fluid secreted within the morula forms the blastocyst cavity • Inner cell mass – future embryo, is now called the Embryoblast • The outer cell mass – future placenta, is now called the Trophoblast IMPLANTATION • Blastocyst implants at around 7 days post conception within the posterior superior wall of the uterus • This is during the secretory phase of the menstrual cycle, so implantation occurs within the functional layer of endometrium. POST CONCEPTION: WEEK 2 EMBRYOBLAST • Differentiates into two distinct cell layers, the Epiblast and Hypoblast, forming a Bilaminar Embryonic Disk o Epiblast -clefts develop within the Epiblast to form the amniotic cavity o Hypoblast -form the yolk sac TROPHOBLAST • Cytotrophoblast divide mitotically • Syncytiotrophoblast o Does not divide mitotically o Produces the HCG o Continues its growth into the endometrium to make contact with the endometrial blood vessels

• • • •

EMBRYO PERIOD: WEEK 3-8 The beginning of the development of major organ systems Coincides with the first missed menstrual period Period of high susceptibility to teratogen Gastrulation is a process that establishes the 3 primary germ layers, forming a trilaminar embryonic disk o Ectoderm o Endoderm o Mesoderm

DERIVATIVES LAYER Ectoderm Endoderm Mesoderm

DERIVATIVES CNS and PNS Sensory organs of seeing and hearing Integument layer Lining of the GIR and Respiratory tract Muscles







Adequate and well-controlled human studies have failed to demonstrate a risk to the fetus Folic acid in the first trimester of pregnancy (and there is no evidence of risk in later trimesters). Animal reproduction studies have failed to demonstrate a risk to the fetus and there are no adequate and well-controlled studies in Paracetamol, pregnant women OR Animal studies have amoxicillin, shown an adverse effect, but adequate and cephalexin, well-controlled studies in pregnant women have failed to demonstrate a risk to the fetus in any trimester. Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in paroxetine humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks. There is positive evidence of human fetal risk based on adverse reaction data from Phenytoin, investigational or marketing experience or tetracyclne, studies in humans, but potential benefits may aspirin, warrant use of the drug in pregnant women despite potential risks. Studies in animals or humans have demonstrated fetal abnormalities and/or there is positive evidence of human fetal risk based on adverse reaction data from Thalidomide, investigational or marketing experience, and isotretinoin the risks involved in use of the drug in pregnant women clearly outweigh potential benefits.

PLACENTA FETAL TO MATERNAL MEMBRANES • Amnion o Avascular; provides tensile strenght; first identifiable at 7th to 8th day of life; from fetal ectoderm • Chorion • Decidua parietalis (endometrium) • Myometrium • Serosa


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TOPNOTCH MEDICAL BOARD PREP OB-GYNE SUPPLEMENT HANDOUT BY NIÑA KATRINA BANZUELA, MD For inquiries visit or email us at [email protected] AMNIOTIC FLUID • Normal amniotic fluid volume o By 12 weeks = 60ml o By 34-36 weeks = 1L o By term = 840 ml o By 42 weeks = 540 ml • Production of amniotic fluid o Initially by amniotic epithelium o Fetal kidneys and urine production *Amniotic fluid volume is also dependent on the extent of maternal plasma expansion • Removal and regulation of amniotic fluid volume o Fetal swallowing o Fetal aspiration o Exchange through skin and fetal membranes THE PLACENTA AT TERM • Volume 497 Ml • Weight 508 grams (450-500 grams) • Surfaces o Fetal ▪ Covered with amniotic membrane giving it white, glistening appearance ▪ Where the umbilical cord arises o Maternal ▪ Attached to the decidua ▪ Deep, bloody appearance arranged into 15-20 irregular lobes, cotyledons • Hofbauer cells

Progesterone Aldosterone Deoxycorticosterone Cortisol hCG • • • •

• • • •

0.1–40 0.05–0.1 0.05–0.5 10–30

250–600 0.250–0.600 1–12 10–20

Almost exclusively produced by the placenta Glycoprotein Alpha and beta subunit Functions: rescue and maintenance of function of the corpus luteum, stimulates fetal testicular testosterone secretion, materanl thyroid gland stimulation (chorionic thyrotropins), promotion of relaxin secretion detectable in plasma of pregnant women 7 to 9 days after the midcycle surge of LH that precedes ovulation. Plasma levels increase rapidly, doubling every 2 days, with maximal levels being attained at 8 to 10 weeks At 10 to 12 weeks, plasma levels begin to decline, and a nadir is reached by about 16 weeks Clearance: mainly hepatic, renal (30%)

hPL • Similar to hCG • detected in maternal serum as early as 3 weeks • Maternal plasma concentrations are linked to placental mass, and they rise steadily until 34 to 36 weeks • production rate near term: approximately 1 g/day • Functions: Maternal lipolysis , anti-insulin or "diabetogenic”, potent angiogenic PROGESTERONE • Source: o First 6-7 weeks of pregnancy: Corpus luteum (ovary) o After 8 weeks: Placenta (Syncytiotrophoblast) • Function: o Affects tubal motility, the endometrium, uterine vasculature, and parturition o Inhibits T lymphocyte–mediated tissue rejection • Preferred precursor of progesterone biosynthesis by the Trophoblast: Maternal plasma LDL cholesterol

Circulation in the Mature Placenta

ESTROGEN • Pregnancy near term is hyperestrogenic • Produced exclusively by Syncytiotrophoblasts • Placenta produce all types of estrogen •

Fetal surface covered by amnion beneath which the fetal chorionic vessels course chorionic villi →intervillous space →decidual plate → myometrium

FUNIS • Umbilcal cord • Two artery, one vein (left or right?) • Ave lenght: 55 cm • Wharton jelly- extracellular matrix of specialized connective tissue • Anticlockwise spiral is present in 50 to 90 percent of fetuses PLACENTAL HORMONES • Trophoblast • Steroid hormones • hPL, hCG, parathyroid hormone–related protein (PTH-rP), calcitonin, relaxin, inhibins, activins, and atrial natriuretic peptide • hypothalamic-like releasing and inhibiting hormones: thyrotropin-releasing hormone (TRH), gonadotropinreleasing hormone (GnRH), corticotropin-releasing hormone (CRH), somatostatin, and growth hormone– releasing hormone (GHRH). PLACENTAL STEROID HORMONES Steroid Nonpregnant Estradiol-17 0.1–0.6 Estriol 0.02–0.1

ESTROGEN Estradiol



SOURCE Maternal ovaries for weeks 1 through 6 of gestation After T1, the placenta is the major source of circulating estradiol. Maternal ovaries, adrenals, and peripheral conversion in the first 4 to 6 weeks of pregnancy The placenta subsequently secretes increasing quantities Produced almost exclusively by the placental syncytiotrophoblast Continued production depends on the living fetus Marker of fetal well being

Pregnant 15–20 50–150


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TOPNOTCH MEDICAL BOARD PREP OB-GYNE SUPPLEMENT HANDOUT BY NIÑA KATRINA BANZUELA, MD For inquiries visit or email us at [email protected] Placental Estrogen Production

Ovulation age/post conceptional age o Measures the actual age of the embryo from the time of fertilization/ovulation *A fetus that is 18 weeks AOG. What is the ovulation age? DETERMINING THE AGE OF THE FETUS • Naegele’s Rule • Crown Rump Length (CRL) o Measured from the superior to inferior pole of the fetus preferably in extended position o Used for First trimester • Biparietal Diameter (BPD) o Measured at the outer to outer aspect of the skull at the level of the occipitofrontal plane o Used during the second and third trimester

Conditions that Affect Hormone Levels in Pregnancy Condition


Fetal Demise

dec estrogen

Fetal anencephaly

Dec estrogen (estriol)

Fetal adrenal hypoplasia

absence of C19-precursors

Fetal-Placental Sulfatase Deficiency

very low estrogen levels in otherwise normal pregnancies

Fetal-Placental Aromatase Deficiency

virilization of the mother and the female fetus

Trisomy 21—Down Syndrome

serum unconjugated estriol levels were low

Fetal Erythroblastosis


Glucocorticoid Treatment

Dec estrogen

Maternal Adrenal Dysfunction

Dec estrogen

Gestational Trophoblastic Disease

placental estrogen formation is limited to the use of C19-steroids in the maternal plasma estrogen produced is principally estradiol



The uterus usually is just palpable above the symphysis pubis, crown-rump length is 6 to 7 cm. Centers of ossification have appeared in most of the fetal bones fingers and toes have become differentiated Skin and nails have developed and scattered rudiments of hair appear. external genitalia are beginning to show definitive signs of male or female gender spontaneous movements.


fetal crown-rump length is 12 Gender can be determined by experienced observers by inspection of the external genitalia by 14 weeks. Quickening by multiparas


fetus now weighs somewhat more than 300 g, and weight begins to increase in a linear manner. fetus moves about every minute and is active 10 to 30 percent of the time downy lanugo covers its entire body


canallicular period of lung development is nearly completed fat deposition begins fetus born at this time will attempt to breathe, but many will die because the terminal sacs have not yet formed


crown-rump length is approximately 25 cm skin is red and covered with vernix caseosa pupillary membrane has just disappeared from the eyes born at this age has a 90-percent chance of survival


CRL of 32 deposition of subcutaneous fat


average crown-rump length is about 36 cm weight is approximately 3400 g

Terms Perinatal period

Period beginning 20 weeks AOG and ending up to 28 completed days after birth It is recommended that this period be defined as commencing at BW of 500 grams

Neonatal period

Period after birth of an infant up to 28 completed days after birth

Fetal period

Begins from 8 weeks after fertilization or 10 weeks after onset of last menses

Embryonic period

Commences beginning of the 3rd week after ovulation and fertilization and lasts up to 8 weeks AOG 8 weeks period from the time of fertilization 10 weeks period from the time of the last menstrual cycle/Ovulation


Fetus or embryo removed or expelled from uterus during the first half of gestation 20 weeks or less, or in the absence of accurate dating criteria, born weighing less than 500 grams

HEAD DIAMETERS • Bitemporal diameter (8.0cm) o Greatest TRANSVERSE diameter of the head • Biparietal diameter (9.5 cm) • Occipitomental ( 12.5 cms) • Occipitofrontal (11.5 cms) o The plane that corresponds to the greatest CIRCUMFERENCE o 34.5 cm • Suboccipitobregmatic ( 9.5 cms) o The plane that corresponds to the smallest circumference of the head o 32 cm

GESTATIONAL AGE vs. OVULATION AGE FETAL CIRCULATION • Gestational age/menstrual age • 3 vessels (AVA) o The time elapsed since the last menstruation o 2 arteries o Precedes fertilization/ovulation by 2 weeks TOPNOTCH MEDICAL BOARD PREP OBSTETRICS HANDOUT BY NIÑA KATRINA BANZUELA, MD For inquiries visit or email us at [email protected]

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o 1 vein Three Shunts: o Ductus venosus o Foramen ovale o Ductus arteriosus

Surfactant is formed in the type II pneumocytes that line the alveoli Starts to appear in the amniotic fluid at 28-32 weeks. 90% lipid and 10% proteins o Phosphatidylcholines (lecithin) account for 80% of the glycerophospholipids o Most active component – dipalmitoylphosphatidylcholine (DPPC) o 2nd most active - phosphatidylglycerol Alveolar development = just before birth – 8 years old

• •


Fetal Blood • HEMATOPOIESIS o yolk sac – first site of hematopoiesis. embryonic period o Liver takes over up to near term o Bone marrow starts at 4 mos AOG and remains as the major site of blood formation during adulthood • Erythrocytes – nucleated and have a shorter life span due to their large volume and are more easily deformable • Fetal blood volume (125 ml/kg) o Term infants = 80 ml/kg body weight o Placenta = 45 ml/kg body weight • Fetal Hemoglobin o Hemoglobin F o Hemoglobin A (adult hgb) o Hemoglobin A2

Genetic/Chromosomal Sex o XX or XY? o Dependent on the presence of Y chromosome Gonadal Sex o testes or ovaries? o Dependent on the presence of SRY gene present on the Y chromosome or the Testes Determining region Phenotypic Sex o Is it a penis or a vagina? o Dependent on the hormones produced

Fetal Circulation: CHANGES AFTER BIRTH • Foramen ovale – functionally closed w/in several minutes; anatomically fused 1 year after birth • Ductus arteriosus – functionally closed by 10-12 hours after birth; anatomically closed by 2-3 weeks • Ductus venosus constrict and becomes the ligamentum venosum Kleihauer-Betke test • Rationale: o Fetal RBC’s are resistant to denaturating effects of alkali. o Mother’s RBC are sensitive, thus may hemolyze FETAL PULMONARY SYSTEM FETAL IMAGING


Presence of surfactant in the amnionic fluid is evidence of fetal lung maturity (after 34 weeks)


FIRST TRIMESTER SONOGRAPHY Sonography before 14 weeks Ealy pregnancy can be evaluated using TAS or TVS, or both CROWN-RUMP LENGTH- most accurate biometric predictor of gestational age (variance of 3 to 5 days) 5 weeks- gestational sac 6 weeks- embryo with cardiac activity; MEAN SAC DIAMETER should be visible via TVS has reached 20mm, otherwise pregnancy is said to be anembryonic 5mm- cardiac motion visible <7mm and no cardiac activity is seen, a subsequent examination is recommended in 1 week


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TOPNOTCH MEDICAL BOARD PREP OB-GYNE SUPPLEMENT HANDOUT BY NIÑA KATRINA BANZUELA, MD For inquiries visit or email us at [email protected] INDICATIONS 1. Confirm an intrauterine pregnancy 2. Evaluate a suspected ectopic pregnancy 3. Define the cause of vaginal bleeding 4. Evaluate pelvic pain 5. Estimate gestational age 6. Diagnose or evaluate multifetal gestations (optimal time to determine CHORIONICITY) 7. Confirm cardiac activity 8. Assist chorionic villus sampling, embryo transfer, and localization and removal of an intrauterine 9. device 10. Assess for certain fetal anomalies such as anencephaly, in high-risk patients 11. Evaluate maternal pelvic masses and/or uterine abnormalities 12. Measure nuchal translucency when part of a screening program for fetal aneuploidy 13. Evaluate suspected gestational trophoblastic disease NUCHAL TRANSLUSCENCY a component of first-trimester aneuploidy screening, has had a major impact on the number of pregnancies receiving late first-trimester ultrasound examination It represents the maximum thickness of the subcutaneous translucent area between the skin and soft tissue overlying the fetal spine at the back of the neck It is measured in the sagittal plane between 11 and 14 weeks If increased, the risk for fetal aneuploidy and various structural anomalies—including heart defects—is significantly elevated Components of a Standard Ultrasound Examination by Trimester First Trimester Second and Third Trimester 1. Gestational sac, size, 1. Fetal Number, including location, and number amnionicity and 2. Embryo, and/or yold sac chorionicity of multifetal identification gestations 3. Crown-Rump Length 2. Fetal Cardiac Activity 4. Fetal Number, including 3. Fetal Presentation amnionicity and 4. Placental location, chorionicity of multifetal appearance and gestations relationship to the 5. Embryonic/fetal anatomy internal cervical os, with appropriate for all the documentation of first trimester placental cord insertion 6. Evaluation of the maternal site uterus, adnexa and cul-de- 5. Amniotic Fluid Volume sac 6. Gestational Age 7. Evaluation of the fetal Assessment nuchal region, with 7. Fetal Weight estimation consideration of fetal 8. Fetal Anatomical survey nuchal transluscency 9. Evaluation of the maternal assessment uterus, adnexa and cervix, when appropriate

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

Gestational age estimation Fetal-growth evaluation Significant uterine size/clinical date discrepancy Suspected multifetal gestation Fetal anatomical evaluation Fetal anomaly screening Assessment for findings that may increase the aneuploidy risk Abnormal biochemical markers Fetal presentation determination Suspected hydramnios or oligohydramnios Fetal well-being evaluation Follow-up evaluation of a fetal anomaly History of congenital anomaly in prior pregnancy Suspected fetal death Fetal condition evaluation in late registrants for prenatal care

Three Types of Examination (Congenital Anomaly Scan) 1. STANDARD 2. SPECIALIZED 3. LIMITED STANDARD


Most commonly performed May be adequately assessed after 18 weeks Elements: o Head, face, and neck: Lateral cerebral ventricles, Choroid plexus, Midline falx, Cavum septum pellucidi, Cerebellum, Cisterna magna, Upper lip, Consideration of nuchal fold measurement at 15–20 weeks o Chest: Four-chamber view of the heart, Left ventricular outflow tract, Right ventricular outflow tract o Abdomen: Stomach—presence, size, and situs, Kidneys, Urinary bladder, Umbilical cord insertion into fetal abdomen, Umbilical cord vessel number o Spine: Cervical, thoracic, lumbar, and sacral spine o Extremities- Legs and arms o Fetal sex- In multifetal gestations and when medically indicated




Targeted examination- a detailed anatomical survey performed when an abnormality is suspected on the basis of history, screening test result, or abnormal findings from a standard examination includes the anatomical structures in the standard type along with additional views of the brain and cranium, neck, profile, lungs and diaphragm, cardiac anatomy, liver, shape and curvature of the spine, hands and feet, and any placental abnormalities also fetal echocardiography and Doppler studies performed to address specific clinical question amnionic fluid volume assessment, placental location, or evaluation of fetal presentation or viability


SECOND AND THIRD TRIMESTER SONOGRAPHY MATERNAL INDICATIONS 1. Vaginal bleeding 2. Abdominal/pelvic pain 3. Pelvic mass 4. Suspected uterine abnormality 5. Suspected ectopic pregnancy 6. Suspected molar pregnancy 7. Suspected placenta previa and subsequent surveillance 8. Suspected placental abruption 9. Preterm premature rupture of membranes and/or preterm labor 10. Cervical insufficiency 11. Adjunct to cervical cerclage 12. Adjunct to amniocentesis or other procedure 13. Adjunct to external cephalic version FETAL INDICATIONS



DOPPLER EXAMINATION used to evaluate flow within blood vessels Umbilical Artery


Amount of flow during diastole increases as gestation advances Abnormal is S/D ratio is above 95th percentile for gestational age Useful adjunct in the management of of pregnancies complicated by IUGR


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Extreme cases of IUGR: absent or reversed As long as fetal surveillance remain reassuring: o Absent: managed expectantly at 34 weeks o Reversed: managed expectantlyat 32 weeks



reversed Ductus arteriosus



Uterine artery


Middle cerebral artery


to monitor fetuses exposed to indomethacin and other NSAIDs INDOMETHACIN: for tocolysis, may cause ductal constriction or closure, particularly when used in the third trimester. The resulting increased pulmonary flow may cause reactive hypertrophy of the pulmonary arterioles and eventual development of pulmonary hypertension NSAIDs: may cause ductal constriction, hence administration is typically limited to less than 72 hours, discontinued if ductal constriction is identified Diastolic notch: associated with gestational hypertension; preeclampsia and growth restriction For fetal anemia Adjunct evaluation for fetal growth restriction Fetal hypoxemia→ end diastolic flow in the MCA “brain sparing”: misnomer, as it is not protective for the fetus but associated with perinatal morbidity and mortality BREECH

TYPES OF BREECH FRANK Lower extremities are flexed at the hips and extended to the knee, feet lie in close proximity to the face


Lower extremities are flexed at the hips and one or both knees are flexed


One or both hips are NOT flexed and one or both feet or knees lie below the breech A foot or knee is lowermost in the birth canal Footling breech- incomplete breech with one or both feet below the breech

RISK FACTORS 1. Early gestational age 2. Abnormal amniotic fluid volume 3. Multifetal gestation 4. Hydrocephaly 5. Anencephaly 6. uterine anomalies 7. placenta previa 8. fundal placental implantation 9. pelvic tumors 10. high parity with uterine relaxation 11. prior breech delivery 12. Prior cesarean delivery 13. Smoking COMPLICATIONS 1. Perinatal mortality and morbidity from difficult delivery 2. Low birthweight from preterm delivery 3. Cord prolapse 4. Placenta previa 5. Fetal anomalies DIAGNOSIS • Abdominal examination – Leopold’s Maneuver – L1: the hard, round, ballottable fetal head may be found to occupy the fundus. – L2: the back to be on one side of the abdomen and the small parts on the other – L3: (not engaged)- the breech is movable above the pelvic inlet – L4 (after engagement): shows the firm breech to be beneath the symphysis • Vaginal examination – With a frank breech during vaginal examination, no feet are appreciated, but the fetal ischial tuberosities, sacrum, and anus are usually palpable. – In some cases, the anus may be mistaken for the mouth and the ischial tuberosities for the malar eminences. Breech Cephalic • the finger • firmer, less encounters yielding jaws are muscular felt through the resistance with mouth the anus • The mouth and • The finger, upon malar eminences removal from form a triangular the anus, may be shape stained with meconium • the ischial tuberosities and anus lie in a straight line complete breech- the feet may be felt alongside the buttocks footling presentations- one or both feet are inferior to the buttocks • Ultrasound – Confirm the diagnosis of breech METHODS OF VAGINAL DELIVERY Spontaneous Infant is expelled entirely without any breech delivery traction other than support Partial breech Breech is allowed to deliver spontaneously extraction as far as the umbilicus, but the remainder of the body is assisted


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TOPNOTCH MEDICAL BOARD PREP OB-GYNE SUPPLEMENT HANDOUT BY NIÑA KATRINA BANZUELA, MD For inquiries visit or email us at [email protected] Total breech extraction

Entire body is extracted by the OB Hand is introduced through the vagina, and both fetal feet are grasped. The ankles are held with the second finger lying between them With gentle traction, the feet are brought through the introitus both feet are grasped and pulled through the vulva simultaneously

CS DELIVERIES PREFERRED • Chronic fetal distress; IUGR • A large fetus • Any degree of CPD • Hyperextended head • Footling breech • Prematurity • A request for sterilization METHODS USED IN BREECH DELIVERY: Delivery of the shoulder Delivery of the aftercoming head

Delivery of an entrapped aftercoming head

Lovesets maneuver Mauriceau maneuver Prague maneuver Piper’s forceps Bracht maneuver Pinard Duhrssen incision Zavanelli maneuver Symphysiotomy

DELIVERY OF THE SHOULDER LOVESETS maneuver – Delivery of the POSTERIOR shoulder ahead of the anterior – The OB’s hand is passed along the humerus towards the elbow – LOVE? Kiss me at the POSTERIOR area of my SHOULDER, down to my HUMERUS and to my ELBOW DELIVERY OF THE AFTERCOMING HEAD MAURICEAU MANEUVER • The index and the Middle finger are placed over the baby’s Maxilla to maintain flexion. • The other hand on the baby’s shoulder to provide traction • The assistant applies suprapubic pressure PIPER’S FORCEPS • This is the preferred (PIPERED) method • Occiput should be anterior • Blades applied to the sides of the head PRAGUE MANEUVER • Used when the baby fails to rotate trunk from occiput posterior to occiput anterior • Used when there is persistent fetal back • Fingers are placed over the shoulders and upward traction is made • Legs are grasped and body is swung over abdomen BRACHT MANEUVER • Breech is allowed to deliver spontaneously up to the navel • Suprapubic pressure is applied PINARD’S MANEUVER • Breech decomposition • From frank breech to be delivered as footling • The fingers are pressed in the baby’s popliteal fossa causing flexion of the knee • Foot is grasped and delivered as footling

▪ VERSION Version 2 types of version

vaginal delivery may be achieved. Done when there is no facility for Caesarean section

Procedure in w/c fetal presentation is altered by physical manipulation from a less favorable to a more favorable position External ▪ for breech presentation cephalic recognized prior to labor and version has reached 36 weeks ▪ Should be carried at between 32-34 weeks Internal ▪ used only for the delivery of podalic the second of twin version ▪ converts a fetus from a transverse/oblique/ cephalic into double footling

EXTERNAL CEPHALIC VERSION Indication for external ▪ For breech presentation cephalic version recognized prior to labor and has reached 36 weeks Contraindication to 1. Any history of bleeding external version 2. Presence of multiple pregnancy 3. Associated major malformation 4. Plan for the manner of delivery Factors associated with 1. Multiparity- most consistent successful version and most important factor associated with success 2. Fetal presentation 3. Amount of amniotic fluid

POSTPARTUM CHANGES BREASTS & LACTATION I. How breast milk protects babies against infection. (DOH, 1991) 1. Breastfed babies have less diarrhea than artificially-fed babies. 2. Fewer respiratory and middle ear infection. 3. Fewer infections because of the following: a. Breast milk is clean and free of bacteria b. Contains antibodies (immunoglobulin) to many common infections, until he can make his own antibodies. c. Contains white blood cells to help fight infection. d. Contains bifidus factor which helps special bacteria called Lactobacillus bifidus to grow in the baby’s intestine. Lactobacillus bifidus prevents other harmful bacteria from growing and causing diarrhea. e. Contains lactoferrin which binds iron. Prevents the growth of some harmful bacteria which need iron. II. Other advantages of breastfeeding. (DOH, 1991) 1. Breast milk contains lipase which digests fat. Breast milk is quickly and easily digested and a breastfed baby may want to feed again more quickly than an artificially-fed baby. 2. Breast milk is always ready to feed to the baby and it needs no preparation. 3. Breast milk never goes sour or bad in the breast even if a woman does not feed her baby for some days. 4. Breastfeeding helps to stop bleeding after delivery. 5. Breastfeeding on demand helps to protect against another pregnancy. 6. It helps them to bond, become attached to each other and love each other. 7. It is free. You don’t have to buy it. 8. It is exclusively for your baby and cannot be served to other adults.

DELIVERY OF AN ENTRAPPED AFTERCOMING HEAD DUHRSSEN ▪ Incisions in the cervix at 2-, 6-, and INCISION 10-o’clock positions ZAVANELLI ▪ Replacement of the fetus higher into MANEUVER the vagina and uterus, followed by cesarean delivery SYMPHYSIOTOMY ▪ Surgical incision into the fibrocartilage of the symphysis pubis in order to allow the fetal head to pass into the pelvis (engage), so that a TOPNOTCH MEDICAL BOARD PREP OBSTETRICS HANDOUT BY NIÑA KATRINA BANZUELA, MD For inquiries visit or email us at [email protected]

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TOPNOTCH MEDICAL BOARD PREP OB-GYNE SUPPLEMENT HANDOUT BY NIÑA KATRINA BANZUELA, MD For inquiries visit or email us at [email protected] • Protective Effects on Infants of Human Milk and Breast Feeding (AAP, 1997) Decreased Incidence/Severity Possible protective effects Diarrhea Sudden infant death Lower respiratory infection syndrome Otitis media Type-1 Diabetes Bacteremia Inflammatory bowel disease Bacterial meningitis Lymphoma Botulism Allergies Necrotizing enterocolitis Chronic digestive diseases Urinary infections III. Composition of Human Breast Milk Component Human milk Water Enough (87.2% to 87.5%) Bacterial None contamination Anti-infection Antibodies, substances leucocytes, lactoferrin, bifidus factor Protein (Total) 1% 0.5% • Casein 0.5% • lactalbumin Amino acids Enough for growing Cysteine brain Enough • Taurine Fats (Total) 4% average • Saturation Enough UNsaturated Fatty acids – Enough for growing linoleic acid brain (essential) Enough • Cholesterol Lipase to digest fat Present Lactose (sugar) 7% (enough) Salts (mEq/L) – Sodium • Chloride • Potassium Iron – colostrum • Mature milk

6.5 12 14

Cow milk More required

4% too much 3% too much 0.5% Not enough Not present






None 3% - 4% (not enough) 25 (too much) 29 (too much) 35 (too much)


0.5 – 0.8 mg/L 0.2 – 0.3 mg/L

V. How should breastfeeding begin. (DOH, 1991) 1. First feed • First feed should be on the delivery table. • Cover both mother and baby to keep them warm. • Let the mother hold the baby close and let him suck at the breast. • Sucking stimulates the production of oxytocin which helps to deliver the placenta and stop hemorrhage. • Baby gets valuable colostrums. • More likely to breastfeed for a long time. A delay of even a few hours will result in failure to breasfeed. •

4% Too much saturated Not enough Not enough

IV. Some Myths about Breastfeeding: (Thomson Medical Center, Singapore. 2004) 1. It is painful & difficult to learn. 2. Breastfed babies cry more than bottle-fed babies. 3. Breastfeeding tends to isolate mother and baby from the rest of the family members. 4. It is embarrassing. 5. Spoils a baby and weaning is difficult. 6. Quality of breast milk depends on your mood. 7. Breastfeeding mother may have to give up food she likes, become tied down and be unable to work. 8. Breastfed babies need more water. 9. Breast milk lack iron.


Duration of feeds More babies finish in 5-10 minutes, but some like to take much longer, perhaps half an hour. It does not matter. • Slow feeders take the same total amount of milk as fast feeders. • Sucking in the wrong position causes sore nipples. •

Likely Antibodies not active, absent lactoferrin

Rooming-in There is no need for a mother and baby to rest separately after a normal delivery. Demand feeding

Let the mother pick up her baby and feed him whenever he cries and she feels a need to feed him. Frequent sucking stimulates the production of prolactin which helps the milk to come in sooner. It prevents engorgement of breasts.

Feeding from both breasts Let the baby finish the first breast to make sure that he gets the hindmilk. Let him take the second breast if he wants to, but do not force him.

Prelacteal feeds Prelacteal feeds (e.g. formula, glucose water, ampalaya juice, diluted honey) are NOT necessary and they can be harmful. • Small amount of colostrum is ALL that a normal baby needs at this time. •

Extra water Normal baby is born with a store of water which keeps him well hydrated until the milk comes in. He does not need drinks of water, they interfere with breasfeeding.

Night breastfeeds It is better if the mother breastfeeds the baby at night as long as he wants to. • Night feeding helps to keep up the milk supply because the baby sucks more. • Night feeds are especially useful for working mothers. • Night feeds are important for child spacing. •

Early weight changes A baby may lose weight for the first few days after delivery. He may lose up to 10% of his birth weight. • When breastfeeding is started, the baby should regain his birth weight in ten days. •

10. Cleaning the breast • Frequent washing, especially with soap, removes the natural oil from the nipple. • The skin becomes dry and is more easily damaged and fissured. DELAYED CORD CLAMPING WHO recommedations Delayed umbilical cord clamping (not earlier than 1 minute after birth) is recommended to due both improved maternal and infant health and nutition outcomes Delayed cord clamping Performed approximately 1-3 minutes after birth is recommended for all births UNLESS the neonate is asphyxiated and needs to be moved immediately for resuscitation Benefits Pre-Term/Low Birth Weight

Immediate Benefits Decrease the risk of intraventricular hemorrhage, necrotizing enterocolitis, lateonset sepsis

Decreases the need for blood 3. transfusuions for anemia, surfactant, TOPNOTCH MEDICAL BOARD PREP OBSTETRICS HANDOUT BY NIÑA KATRINA BANZUELA, MD For inquiries visit or email us at [email protected]

Long-Term Benefits Increases hemoglobin at 10 weeks of age May be a benefit to neurodevelopmental outcomes

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TOPNOTCH MEDICAL BOARD PREP OB-GYNE SUPPLEMENT HANDOUT BY NIÑA KATRINA BANZUELA, MD For inquiries visit or email us at [email protected] mechanical ventilation

Full-Term infants

Increases hematocrit, hemoglobin, blood pressure, cerebral oxygenation, RBC flow Provides adequate blood volume and birth iron stores Increases hematocrit and hemoglobin

Laceration of the cervix, vagina or perineum

Improves hematological status (hematocrit and hemoglobin) at 2-4 months of age Improves iron status up to 6 months of age

POST-PARTUM HEMORRHAGE (PPH) Definition The following are suggested definitions but there is a lack of agreement on what constitutes excessive blood loss: 1. Blood loss >500 ml for vaginal delivery and 1,000 ml for cesarean section (CS). 2. Blood loss >500 ml in the first 24 hours following delivery. 3. Ten percent (10%) decrease in hemoglobin or hematocrit level. 4. Need for transfusion. Problems with the above definitions: 1. Clinical estimation of blood loss is frequently inaccurate and the brisk nature of blood loss during delivery or the presence of amniotic fluid can make this more difficult. 2. Delay in obtaining laboratory results. Information from laboratory tests would not reflect the patient’s current hemodynamic status. 3. Any definition based on the need for transfusion is difficult as there are differences in provider practice patterns regarding transfusion. Definition of obstetric hemorrhage combining clinical and objective data (Bonnar, 2000) Blood Systolic EBL Heart volume BP Signs & symptoms (ml) rate (%) (mmHg) 50010-15 <100 Normal None 1000 1000 100Slight Vasoconstriction, 15-25 1500 120 decrease weakness, sweating 1500 120Restlessness, pallor, 25-35 80-100 2000 140 oliguria 2000Anuria, altered 35-45 >140 60-80 3000 consciousness

TRAUMA (Genital tract trauma)

Extension/laceration at CS Uterine rupture Uterine inversion

THROMBIN (Abnormaliti es of coagulation)

Preexisting clotting abnormalities (e.g. hemophilia, vonWillebrands disease, hypofibrinogenemia) DIC HELLP Anticoagulation

ry lobe Precipitous delivery Macrosomia Shoulder dystocia Operative delivery Episiotomy (e.g. mediolateral) Deep engagement Malposition Malpresentation Prior uterine surgery Fundal placenta Grand multiparity Excessive traction on umbilical cord History of Coagulopathy or liver disease

Sepsis Intrauterine demise Hemorrhage

General Management of PPH: 1. Initial management approach to obstetric hemorrhage: a. Assessment: constant awareness of the hemodynamic status as well as evaluation to determine the cause of bleeding. b. Breathing: administration of oxygen c. Circulation: obtaining intravenous (IV) access and adequate circulating blood volume through infusion of crystalloid and blood products. Second large-bore IV catheter is needed 2. Notify the blood bank. 3. Simultaneous, coordinated, multi-disciplinary management (OB-GYN, anesthesiologist, hematologists, radiologists, nurses, laboratory and blood bank technicians) to concur timely management in the presence of obstetric hemorrhage. 4. Preoperative preparedness is important especially for patients identified as high risk. Important Causes of PPH: 1. Uterine atony 2. Retained placenta 3. Uterine rupture 4. Genital tract trauma 5. Uterine inversion

GUIDELINES FOR CESAREAN SECTION INDICATIONS Maternal Prior cesarean delivery Abnormal placentation Maternal request Prior classical hysterotomy Unknown uterine scar type Uterine incision dehiscence Etiology and Risk Factors Prior full-thickness myomectomy Etiology Pathophysiology Risk Factors Genital tract obstructive mass Multiple gestation Invasive cervical cancer Overdistended uterus Polyhydramnios Prior trachelectomy Macrosomia Permanent cerclage Prolonged labor Prior pelvic reconstructive surgery Uterine muscle fatigue Augmented labor TONE Pelvic deformity Prior PPH (Abnormal HSV or HIV infection uterine Prolonged rupture of Chorioamnionitis Cardiac or pulmonary disease contractility) membranes (ROM) Cerebral aneurysm or arteriovenous malformation Uterine Fibroids (myoma), Pathology requiring concurrent intraabdominal distortion/abnormality placenta previa surgery B-mimetics, MgSO4, Uterine relaxing drugs Perimortem cesarean delivery anesthetic drugs MaternalCephalopelvic disproportion Prior uterine surgery Accreta/Increta/Percre Fetal Failed operative vaginal delivery Placenta previa TISSUE ta Placenta previa or placental abruption Multiparity (Retained Fetal Nonreassuring fetal status products of Manual placenta Retained Malpresentation conception) removal placenta/membranes Macrosomia Succinturiate/accesso Congenital anomaly TOPNOTCH MEDICAL BOARD PREP OBSTETRICS HANDOUT BY NIÑA KATRINA BANZUELA, MD Page 14 of 31 For inquiries visit or email us at [email protected]

TOPNOTCH MEDICAL BOARD PREP OB-GYNE SUPPLEMENT HANDOUT BY NIÑA KATRINA BANZUELA, MD For inquiries visit or email us at [email protected] Abnormal umbilical cord Doppler study Thrombocytopenia Prior neonatal birth trauma 1. •

• 2. ▪ ▪ ▪ ▪ ▪ ▪

3. • •

• •

4. ▪

Previous uterine scar In the presence of scarred uterus, the following are ABSOLUTE INDICATIONS for elective CS: (Level III, Grade C) o Previous classical or inverted T-uterine scar o Uncertainty of type of previous CS scar o Previous multiple low transverse segment uterine scars o Previous hysterotomy or myomectomy entering the uterine cavity or extensive transfundal uterine surgery o Previous uterine rupture o Presence of a contraindication to labor, such as placenta previa/accreta, or malpresentation o No informed consent for VBAC Failed trial of labor during VBAC. Abnormalities of the reproductive tract Presence of gynecologic tumors in pregnancy, such as uterine myoma and/or adnexal masses, are NOT ABSOLUTE indications for CS, unless they cause dystocia CS performed for those with a history of surgical repair of obstetric and anal sphincters, urinary incontinence and pelvic organ prolapse because of risk of recurrences Genital warts and genital cancers may be an indication for CS if it obstructs the birth canal, or if it is excessively bleeding, or in order to prevent profuse bleeding Presence of cervical stenosis is NOT A CONTRAINDICATION to attempted vaginal delivery. There is increased risk for CS. Vaginal delivery for corrected imperforate hymen. CS performed for those with history of complete transverse vaginal septum and vaginal agenesis due to risk of vaginal soft tissue dystocia and lateral vault laceration Abnormalities of the placenta, cord, membranes and amniotic fluid Vasa previa o Elective CS between 35-37 weeks AOG o Emergency CS for bleeding vasa previa Placenta previa o Any degree of placental overlap (>0 mm) at the internal os after 35 weeks is an indication for CS o Previa within 1 cm of the internal os is an indication for CS o Elective CS for asymptomatic woman with previa >37 weeks and for suspected accreta >36 weeks Abruptio placenta o Emergency CS for abruptio placenta with fetal compromise, severe uterine hyprtonus, life threatening bleeding or DIC, and remote from vaginal delivery. Cord prolapse o Emergency CS for cord prolapse o Cord prolapse with poor chances of viability, vaginal delivery may be tried with informed consent o Ultrasound finding suggestive of forelying cord or funic presentation is NOT an absolute indication for CS o Digital diagnosis of funic/cord presentation in labor is an indication for CS Chorioamnionitis or intra-amniotic infection o Presence of clinical chorioamnionitis or intra-amniotic infection is NOT an absolute indication for CS. Oligohydramnios o Uncomplicated oligohydramnios is NOT an absolute indication for CS Infection in pregnancy Herpes simplex virus o CS for those who develop primary genital herpes within 6 weeks of delivery

CS for those with active genital lesions or prodromal symptoms (e.g. vulvar pain or burning) at the time of delivery Hepatitis B virus o Scheduled CS at 39 weeks with HBV profile as follows: ▪ HbeAg positive ▪ HBV DNA copies >1,000,000 ▪ Not received oral antiretroviral therapy Human papilloma virus o Only for those with very large genital warts causing pelvic outlet obstruction or potential for excessive bleeding during vaginal delivery HIV o Elective CS at 39 weeks to reduce risk of MTCT provided: ▪ Currently on highly active antiretroviral therapy (HAART) ▪ Viral load <400 copies/ml ▪ On any ARV with viral load <50 copies/ml o

5. •

• • • • • 6. • •

7. •

8. • • • 9.

Maternal medical conditions Hypertensive complications o Maternal indications ▪ Deteriorating maternal condition ▪ Uncontrolled hypertension despite drug therapy ▪ HELLP syndrome ▪ Placental abruptio o Fetal indications ▪ Severe IUGR/FGR ▪ Non-reassuring FHR pattern, repeated Category II or III, refractory with resuscitation, remote from delivery ▪ BPP <4, done 6 hours apart ▪ Doppler studies: ARED Severe bronchial asthma o CS is rarely needed. Cardiac disease o CS reserved for high-risk cardiac patients. Gestational DM Obesity o Increased risk for CS Macrosomia IUGR/FGR Deterioration in the fetal condition or when there is an unripe cervix or when there are indications of additional fetal compromise during labor Viable fetus with IUGR when there is: o deterioration in the BPP o loss of variability on NST o severe oligohydramnios, and o failure to grow on serial biometry in the presence of abnormal umbilical artery or venous Doppler studies. Fetal congenital anomalies Fetuses with the following anomalies may benefit from CS: o Neural tube defects with fetus in breech o Neural tube defects with sac >6 cm o Cystic hygromas o Sacrococcygeal teratomas >5 cm o Hydrocephalus with BPD >10 cm or HC >36 cm Elective CS o Fetus with hypoplastic left heart syndrome o Transposition of great arteries with intact intraventricular septum that require urgent neonatal atrial septostomy Maternal request (CDMR) If without clear indication or there is fear of childbirth, the OB should provide counseling to the patient. Well-written informed consent with proper approval by the hospital’s ethics committee should be secured before performing the CS. Should be performed >39 weeks AOG, unless there is documentation of fetal lung maturity. Multiple pregnancy


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TOPNOTCH MEDICAL BOARD PREP OB-GYNE SUPPLEMENT HANDOUT BY NIÑA KATRINA BANZUELA, MD For inquiries visit or email us at [email protected] 10. Fetal malpresentation (Refer to Section III) 11. Abnormal labor patterns (Refer to Section II) 12. Abnormal FHR patterns (Refer to Section I) Operative Recommendations Timing of planned CS • Scheduled at 39 weeks Pre-operative preparation for CS • Hemoglobin determination • Antimicrobial prophylaxis within 60 minutes preoperatively with either penicillins or cephalosporins (1st or 2nd gen) – Cefazolin 2g/IV (1st gen), Cefuroxime 1.5 g/IV (2nd gen) • Alternative (if allergic): Clindamycin 600 mg/SIV • Morbid obese (BMI>35): double dose of antibiotic • Routine shaving not recommended. Clippers are recommended than razors for excessive hair. Techniques of CS • Transverse abdominal incision or Joel-Cohen incision is preferred. • Placental delivery by controlled cord traction rather than manual extraction • Blunt dissection of uterus was associated with reduced mean blood loss compared to sharp dissection. • Single layer closure was associated with significant reduction in mean blood loss, duration of operative time, post-operative pain but more likely to result in uterine rupture. • Closure of both visceral and parietal peritoneum after CS lead to LESS adhesions • Closure of subcutaneous tissue for >2 cm subcutaneous fat. • Indwelling FC may be removed <24 hours after CS Anesthesia in CS • Uncomplicated elective CS may have modest amounts of clear liquids up to 2 hours prior to induction of anesthesia • Patient undergoing elective surgery should have a fasting period for solids at least 6-8 hours prior to induction. • Aspiration prophylaxis: non-particulate antacids, H2 receptor antagonists, metoclopramide Post-CS care • No evidence to recommend a policy of delaying oral fluids and food after CS • Remove the dressing 24 hours after the CS. • No evidence of adverse outcomes associated with early postnatal discharge (3-4 days) • Sexual intercourse may be resumed as early as 2 weeks postpartum for as long as the patient feels comfortable. *Notes: Placenta previa is one of the main indications for delivery during late preterm or early term. We do not want uterine contractions, hence labor, to ensue with placenta previa due to possible bleeding OTHER IMPORTNANT OBSTETRIC INFORMATION DERMATOSES IN PREGNANCY

PITUITARY DESTRUCTION Damage or necrosis of the pituitary gland caused by anoxia, thrombosis, or hemorrhage. It is called Sheehan’s syndrome when related to pregnancy and Simmonds’ disease when unrelated to pregnancy. OBSTETRICAL HEMORRHAGE

Uterine Atony The most frequent cause of obstetrical hemorrhage is failure of the uterus to contract sufficiently after delivery and to arrest bleeding from vessels at the placental implantation site Uterine Inversion Puerperal inversion of the uterus is considered to be one of the classic hemorrhagic disasters encountered in obstetrics. Unless promptly recognized and managed appropriately, associated bleeding often is massive. Risk factors include alone or in combination: 1. Fundal placental implantation, 2. Delayed-onset or inadequate uterine contractility after delivery of the fetus, that is, uterine atony, 3. Cord traction applied before placental separation, and 4. Abnormally adhered placentation such as with the accrete syndromes OLIGOHYDRAMNIOS Causes of Oligohydramnios ▪ Fetal abnormality o Congenital abnormalities ▪ By 18 weeks the fetal kidneys are the main contributor to amniotic fluid volume ▪ Severely decreased amniotic fluid volume beginning in early in gestation are secondary to genitourinary abnormalities ▪ Other organ system anomalies can also indirectly cause oligohydramnios ▪ Uteroplacental insufficiency ▪ Post term pregnancies (most common) ▪ Exposure to medications o Associated with exposure to drugs that block the renin-angiotensin system (ACE inhibitors and NSAIDs) Pregnancy Outcomes Increased risk of adverse pregnancy outcomes o More likely to have malformations o Higher levels of fetal stillbirth, growth restriction, non-reassuring heart rate pattern, meconium aspiration syndrome were also noted o Increased spontaneous/medically indicated preterm birth o Increased risk for CS for fetal distress and risk for APGAR <7 o Pulmonary hypoplasia Management Target the underlying etiology


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TOPNOTCH MEDICAL BOARD PREP OB-GYNE SUPPLEMENT HANDOUT BY NIÑA KATRINA BANZUELA, MD For inquiries visit or email us at [email protected] o o o

Evaluate fetal abnormalities and growth Close fetal surveillance Amnioinfusion – may be used intrapartum in the setting of variable fetal heart rate decelerations, NOT considered a treatment or a standard of care

DYSTOCIA Difficult labor, characterized by abnormally slow labor progress o Expulsive forces may be abnormal ▪ Contractions are insufficiently strong or inappropriately coordinated to efface and dilate the cervix ▪ Inadequate voluntary maternal muscle effort o Fetal abnormalities of presentation, position or development may slow labor o Abnormalities of the maternal body pelvis may create a contracted pelvis o Soft tissue abnormalities of the reproductive tract may form an obstacle to fetal descent


Influenza Mumps Measles/Rubeola

German Measles/ Rubella

Congenital varicella syndromechorioretinitis, microphthalmia, cerebral cortical atrophy, growth restriction, hydronephrosis, limb hypoplasia, and cicatricial skin lesions No firm evidence that it causes congenital malformations Women who develop mumps in the first trimester may have an increased risk of spontaneous abortion The virus does not appear to be teratogenic. However, an increased frequency of abortion, preterm delivery, and low-birthweight neonates is noted with maternal measles Rubella infection in the first trimester, however, poses significant risk for abortion and severe congenital malformations. Rubella is one of the most complete teratogens, and sequelae of fetal infection are worst during organogenesis. Congenital Rubella Syndrome • Eye defects—cataracts and congenital glaucoma • Congenital heart defects—patent ductus arteriosus and pulmonary artery stenosis • Sensorineural deafness—the most common single defect • Central nervous system defects— microcephaly, developmental delay, mental retardation, and meningoencephalitis • Pigmentary retinopathy • Neonatal purpura • Hepatosplenomegaly and jaundice • Radiolucent bone disease

Parvovirus B19 Cytomegalovirus


Group A Streptococcus Group B Streptococcus

Associated with abortion, nonimmune hydrops and still birth Growth restriction, microcephaly, intracranial calcifications, chorioretinitis, mental and motor retardation, sensorineural deficits, hepatosplenomegaly, jaundice, hemolytic anemia, and thrombocytopenic purpura Late onset sequelae include hearing loss, neurological deficits, chorioretinitis, psychomotor retardation, and learning disabilities Remains the most common cause of severe maternal postpartum infection and death worldwide May cause preterm labor, prematurely ruptured membranes, clinical and subclinical chorioamnionitis, and fetal infections. GBS can also cause maternal bacteriuria, pyelonephritis, osteomyelitis, postpartum mastitis, and puerperal infections.

MRSA Listeriosis



Skin and soft tissue infections are the most common presentation of MRSA in pregnant women Discolored, brownish, or meconiumstained amnionic fluid is common with fetal infection, even preterm gestations Maternal listeriosis causes fetal infection


Page 17 of 31

TOPNOTCH MEDICAL BOARD PREP OB-GYNE SUPPLEMENT HANDOUT BY NIÑA KATRINA BANZUELA, MD For inquiries visit or email us at [email protected] that characteristically produces disseminated granulomatous lesions with microabscesses



Management o Prevent seizure – prevent seizure provoking stimuli, compliance o Anticonvulsants are given at lowest dosage

Chorioamnionitis is common with maternal infection, and placental lesions include multiple, well-demarcated macroabscesses. Clinically affected neonates usually have generalized disease expressed as low birthweight, hepatosplenomegaly, jaundice, and anemia. Some primarily have neurological disease with intracranial calcifications and with hydrocephaly or microcephaly. Many eventually develop chorioretinitis and exhibit learning disabilities. TRIAD: Chorioretinitis, intracranial calcifications and hydrocephalus

APPENDICITIS IN PREGNANCY Suspected appendicitis is one of the most common indications for abdominal exploration during pregnancy When appendicitis is suspected, treatment is prompt surgical exploration. Although diagnostic errors may lead to removal of a normal appendix, surgical evaluation is preferable to postponed intervention and generalized peritonitis o Appendicitis increases the likelihood of abortion or preterm labor, especially if there is peritonitis PANCREATITIS IN PREGNANCY Medical treatment is the same as that for nonpregnant patients and includes analgesics, intravenous hydration, and measures to decrease pancreatic secretion by interdiction of oral intake. LEIOMYOMAS IN PREGNANCY Can regress after pregnancy May cause pain or pressure May outgrow their blood supply and hemorrhagic infarct follows- Red or Carneous Degeneration Treatment is analgesic medication, myomectomy has resulted in good outcomes Pedunculated subserosal myosmas will undergo torsion—can be managed with laparoscopy or laparotomy Complications o Preter labor o Placental abruption o Fetal malpresentation o Obstructed labor o Cesarian delivery o Postpartum hemorrhage SEIZURE DISORDERS IN PREGNANCY Women with epilepsy have increased seizure risks with mortality risks and fetal malformations o Often associated with decreased and subtherapeutic anticonvulsant serum levels, lower seizure threshold, or both Medications o Fetus of an epileptic mother who takes anticonvulsant medications has increased risk for congenital malformations o Monotherapy has lower birth defect rate compared to multiagent o Phenytoin and phenobarbital increase the risk for malformations (two-to-threefold above the baseline). Valproate may increase four-toeightfold risk o Newer antiepileptic mediations are reported to have no associations with a markedly increased risk of major birth defects

UTI IN PREGNANCY (Summary of Recommendations from the UTI in Pregnancy and ASB in Adults Subgroup) ASYMPTOMATIC BACTERIURIA






Who: Screen ALL pregnant women for ASB once early during pregnancy between 9th to 17th weeks, preferably on the 16th week age of gestation Test of Choice: Urine culture of clean-catch midstream urine. Alternative: Urine gram stain of at least one organism per oil immersion field *Urinalysis, Urine dipsticks for leukocyte esterase and/or nitrite tests are not recommended as an initial screening test Two consecutive voided or one catheterized urine specimen with isolation of the same bacterial strain in quantitative counts ≥ 100,000 cfu/mL In settings where obtaining two consecutive urine cultures are not feasible or difficult, one urine culture is an acceptable alternative In settings where dipslide culture technique is available, it may be used as an alternative to urine culture Antibiotic treatment for asymptomatic bacteriuria is indicated to reduce the risk of acute cystitis and pyelonephritis in pregnancy as well as the risk of LBW neonates Among the drugs that can be used are Nitrofurantoin, (not for near term) coamoxiclav, cephalexin, fosfomycin, cotrimoxazole (not on the first and third trimester) depending on the sensitivity results of the urine isolate Duration of treatment will depend on the antibiotics that will be used but shortcourse (7 days) treatment is preferred over single-dose regimen A follow up urine culture should be done one week after completing the course of treatment Monitoring should be done every trimester until delivery RECOMMENDED DOSE AND DURATION 500 mg BID x 7 days



TOPNOTCH MEDICAL BOARD PREP OB-GYNE SUPPLEMENT HANDOUT BY NIÑA KATRINA BANZUELA, MD For inquiries visit or email us at [email protected] Cefuroxime Fosfomycin trometamol Amoxicillinclavulanate Nitrofurantoin TMP-SMX

500 mg BID x 7 days 3 g in single dose


Cefadroxil Cefuroxime

1 g BID for 7 days 500mg BID for 7 days 500mg TID for 7 days 200mg BID for 7 days 100mg BID for 7 days 100 mg BID for 7 days

625 mg BID x 7 days



100 mg BID x 7 days 160/800 mg BID x 7 days

B C (avoid in 1st and 3rd trimester)







Fosfomycin trometamol Pivmecillina m Amoxicillinclavulanate

3 gms single dose


Hemolytic anemia Anopthalmia Hypoplastic left heart syndrome Asd Cleft lip & palate None

400 mg BID for 7 days 625mg BID for 7 days



Trimethopri msulfamethox azole

800/160 mg BID for 7 days


Cefpodoxim e Nitrofurant oin

ACUTE CYSTITIS IN PREGNANCY urinary frequency, urgency, dysuria and Symptoms bacteriuria without fever and costovertebral angle tenderness. +/- Gross hematuria -

Diagnosis -

Treatment -



Monitoring -

In pregnant women suspected to have acute uncomplicated cystitis, obtain a pretreatment urine culture and sensitivity test of a midstream clean catch urine specimen In the absence of a urine culture, the laboratory diagnosis of acute cystitis can be determined by the presence of significant pyuria defined as a) > 8 pus cells/mm3 of uncentrifuged urine OR b) > 5 pus cells/hpf of centrifuged urine, and c) a positive leukocyte esterase and nitrite test Treatment should be instituted immediately to prevent the spread of the infection to the kidney Since E. coli remains to be the most common organism isolated, antibiotics to which this organism is most sensitive and which are safe to give during pregnancy should be used A 7-day treatment with an oral antimicrobial agent that is safe for use in pregnancy is recommended except for fosfomycin which is given as a single dose In the absence of a urine culture and sensitivity, empiric therapy should be based on local susceptibility patterns of uropathogens In cases where the result of a urine culture shows an organism resistant to the empirically started antibiotic in a clinically improving patient, no adjustment is necessary. Adjust antibiotic therapy based on urine culture results ONLY when there is no improvement in the clinical signs and symptoms and laboratory results or there is worsening of condition Post-treatment urine culture 1 – 2 weeks after completion of therapy should be obtained to confirm eradication of bacteriuria and resolution of infection Pregnant patients with pyelonephritis, recurrent UTIs, concurrent gestational DM, concurrent nephrolithiasis or urolithiasis, and pre-eclampsia, should be monitored at monthly intervals until delivery to ensure that urine remains sterile during pregnancy




500 mg QID for 7 days










May be given on the second trimester of pregnancy until 32 weeks AOG Only use in first trimester of pregnancy is appropriate when no other suitable alternative antibiotics are available avoid in women at risk of preterm labor may be given on the second and third trimester of pregnancy use in first trimester pregnancy is appropriate when no other suitable alternative antibiotics are available use only for culture proven susceptible uropathogens due to high level of resistance



Diagnosis -


Neonatal necrotizing enterocolitis Anencephaly Hypoplastic left heart syndrome Choanal atresia Transverse limb defect Diaphragmatic hernia

fever (T> 38°C) chills flank pain costo-vertebral angle tenderness nausea and vomiting with or without signs and symptoms of lower urinary tract infection Urinalysis: Pyuria (> 5 wbc/hpf of centrifuged urine) Urine culture: bacteriuria with counts of > 10,000 cfu of uropathogen per ml on urine culture Urinalysis and Gram stain are recommended Urine culture and sensitivity test should also be performed routinely to facilitate cost-effective use of antimicrobial agents and because of the potential for serious sequelae if inappropriate antimicrobial agent is used. Blood cultures are NOT routinely recommended except in patients with signs of sepsis


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Indications for Admission


Treatment -


Monitoring -


Routine renal ultrasound is of limited clinical benefit and should be reserved for women who fail to respond to initial treatment. inability to maintain oral hydration or take medications concern about compliance presence of possible complicating (comorbid) conditions severe illness with high fever, severe pain, marked debility signs of preterm labor signs of sepsis In the absence of a urine culture and sensitivity, empiric therapy should be based on local susceptibility patterns of uropathogens. Since E. coli remains to be the most common organism isolated, antibiotics to which this organism is most sensitive and which are safe to give during pregnancy should be used The recommended duration of treatment is 14 days Intravenous antimicrobial therapy is usually continued until the patient is afebrile for 48 hours and symptoms have improved; afterward, the patient is treated with oral antibacterials. The course of oral therapy lasts for 10–14 days. If the patient fails to respond clinically by 72 hours, further evaluation should ensue for bacterial resistance to the antibacterial used, urolithiasis, perinephric abscess formation or urinary tract abnormalities, and the antibacterial agent should be changed to include an aminoglycoside Post-treatment urine culture should be obtained after completion of antibiotic treatment to confirm resolution of the infection (“test of cure”) Patient should be followed up for symptoms of recurrent infection and monthly urine culture should be performed until delivery Recurrence of symptoms requires antibiotic treatment based on urine culture and sensitivity test results, in addition to assessing for underlying genitourologic abnormality The duration of re-treatment in the absence of a urologic abnormality is 2 weeks For patients whose symptoms recur and whose culture shows the same organism as the initial infecting organism, a 4-6 week regimen is recommended







• •

• •

Rare malformations of blood vessesls than true neoplasms. Usually discovered intitially during childhood. It is usually single, 1-2 cm in diameter, flat, soft and colors range from brown, red or purple. These tumors range in size and not encapsulated The most common benign solid tumors of the vulva. It occurs in all age groups and commonly found in the labia majora. Majority are 1-10 cm in diameter. Benign, slow-growing, circumscribed tumors or fat cells arising from the sub cutaneous tissue of the vulva

VAGINA Urethral diverticulum- permanent, epithelialized, sac-like projection that arises from the posterior urethra, present at a mass of the anterior vaginal wall. It is a common problem discovered in 1-3% of women Inclusion cysts- the most common cystic structures of the vagina Dysontogenic cysts- thin walled, soft cysts of embryonic origin o Gartner’s duct cysts – from the mesonephros o Mullerian cysts – from the paramesonephricum o Vestibular cysts – fromt he urogenital sinus CERVIX Endocervical and Cervical Polyps – Most common benign neoplastic growth of the cervix. It is most common in multiparous women in their 40s-50s. Majority are smooth, soft, reddish purple to cherry red. They are fragile and readily bleed when touched. It may arise to endocervical canal or ectocervix Nabothian cysts- retention cysts that are very common that they are considered a normal feature of the adult cervix. Aymptomatic and no treatment is necessary Cervical myoma- usually a solitary growth, small and most are asymptomatic ASCCP GUIDELINES FOR MANAGEMENT OF ABNORMAL CERVICAL CANCER SCREENING TESTS AND CANCER PRECURSORS 1.

Unsatisfactory cytology – take in account the age and HPV status

*Notes: Notice that as one goes from ASB to Pyelonephritis (asymptomatic to development of symptoms), the criteria for diagnosis somewhat becomes lenient IMPORTANT GYNECOLOGIC CONCEPTS VULVA Urethral Caruncles


Small, single, sessile but may be pedunculated, 1-2 cm in diameter. Occurs frequently in post-menopausal women, and may be secondary to infection or 2. Negative Cytology (Pap smear)/NILM (Negative for chronic irritation Intraepethelial lesion or malignancy) but Insufficient or absent TZ (Transformation zone) Cysts The most common large cyst of the vulva is HPV testing is UNACCEPTABLE for women aged 21-29 a cystic dilatation of an obstructed years old Bartholin’s duct. The most common small vulvar cysts are epidermal inclusion cysts or sebacious cysts. Nevus Vulvar nevi are one of the most common benign neoplasms in females; generally asymptomatic TOPNOTCH MEDICAL BOARD PREP OBSTETRICS HANDOUT BY NIÑA KATRINA BANZUELA, MD Page 20 of 31 For inquiries visit or email us at [email protected]



Women more than 30 years old, cytology negative, HPV positive Co-testing: Cytology (Pap smear) and determination of HPV DNA

Reflex HPV testing: ASCUS in Pap smear warrants HPV DNA determination 6.

Management of Women with Low-grade Squamous Intraepithelial Lesions (LSIL)* †

Management of Pregnant Women with Low-grade Squamous Intraepithelial Lesion (LSIL) Preferred: Colposcopy Acceptable: Defer colposcopy 6 weeks postpartum 7. -

Management of Women with Atypical Squamous Cells: Cannot Exclude High-grade SIL (ASC-H) Colposcopy regardless of HPV status 8.


ASCUS- repeat cytology at 1 year: acceptable; HPV TESTING: PREFERRED


Management of Women Ages 21-24 years with either Atypical Squamous Cells of Undetermined Significance (ASC-US) or Low-grade Squamous Intraepithelial Lesion (LSIL)

Management of Women Ages 21-24 yrs with Atypical Squamous Cells, Cannot Rule Out High Grade SIL (ASCH) and High-grade Squamous Intraepithelial Lesion (HSIL)


Page 21 of 31


Management of Women with High-grade Squamous Intraepithelial Lesions (HSIL) Immediate loop resection OR Colposcopy with endocervical assessment

Signs and Symptoms


10. Initial Workup of Women with Atypical Glandular Cells (AGC)


11. Subsequent Management of Women with Atypical Glandular Cells (AGC)




UTERUS Endometrial polyps – localized overgrowths of endometrial glands and stroma beyond the surface of the endometrium. Majority are asymptomatic, but those who are symptomatic are associated with a wide range of bleeding patterns Hematometra – uterus distended with blood and secondary to gynatresia. Common symptoms include amennorrhea and cyclic lower abdominal pain


Leiomyomas/Myomas/Uterine Fibroids (lifted from POGS CPG on Myoma and adnexal masses, 2010) Definition


Risk Factors


Etiologies (Theories)


Benign monoclonal tumors arising from smooth muscle cells of the myometrium Contain large amount of extracellular matrix surrounded by a thin pseudocapusule of areolar tissue or compressed muscle fibers Become more common as women age, especially from 30s to 40s through menopause. After menopause, myomas usually shrink Most common in women with a higher BMI There appears to be a familial tendency Pregnancy decreases the risk of myomas OCP and smoking decreases the risk Early menarche, high dat and eating large amounts of red meat has been associated with increased risk Steroid hormones: estrogen and progesterone were considered most important regulators of myoma growth High mobility group proteins HMGI (C) and HMGI (Y) code for proteins that help control cell growth by indirectly regulating DNA transcription. Mutations in these genes are probably secondary changes in already genetically susceptible cells.


Most myomas are asymptomatic and may not require intervention Common presentations: AUB, pressure symptoms and pain AUB is usually characterized by heavy bleeding Myomas rarely cause pelvic pain Pressure symptoms depend on the location of the myome (i.e. anterior- bladder symptoms, posterior- bowel symptoms). Dyspareunia may arise due to mass effect Palpation of a mass: uterus is enlarged with irregular contour Prolapsed Mass: may present with vaginal bleeding, urinary flow obstruction, UTI, pelvic heaviness and acute pain Dysmenorrhea: dyspareunia and noncyclic pelvic pain are more associated with myoas compared with dysmenorrhea Infetility: submucous myoma and intramural myomas which impine the fallopian tube have impact on infertility. Subserous myomas do not affect infertility Asymptomatic/Quiescent Myoma: majority of myomas are asymptomatic and would not require therapy. Classified by their location in the uterus sice it affects the symptoms they may cause and how they can be treated Most myomas span more than one anatomic location (Hybrids) Parasitic myomas: occur spontaneously as pedunculated subserosal myomas, lose their blood supply and parasitize other organs Seedling myomas: diameter of less than or equal to 4mm Tumors in the subserosal and intramural locations comprise the majority (95%) of all leiomyomas, submucous leiomyomas make up the remaining 5% Subserous myomas: outside wall of the uteruus thus may give the uterus its “knobby” contour on PE. They may be connected by a stalk (pedunculated myoma) or may be broad based (sessile). They do not need treatment unless they grow large. However, those on a stalk can twist and cause pain. Easiest to remove by laparoscopy Intramural myomas- within the uterine myometrium and can range in size from microspic to larger ones. Most do not cause problems unless they become quite large distorting the uterine cavity or cause irregular external uterine contour. A sufficiently enlarged myoma can cause pressure symptoms. They often do not need any treatment unless infertility and AUB are concerns Submucous myomas: proximate to the endometrium and grow toward and bulge into the endometrial cavity. They may either be pedunculated or sessile. They can cause heavy menstrual period, as well as intermenstrual bleeding. Distortion of the endometrial cavity milieu by these myomas may diminish implantation and sperm transport thus producing infertility or abortion. They may transform intro intracavitary myomas, and may prolapse through the cervix

Differential Diagnosis for Myoma 1. Adenomyosis and Adenomyoma Definition Adenomysosis: presence of endometrial tissue within the myometrium, at least 1 hpf from the base of the endometrium Adenomyoma: an adenomyosis tha appears as a focal mass Symptoms Often asymptomatic Symptoms include: heavy menstrual bleeding,


Page 22 of 31







dyspareunia, dychezia, dysmenorrhea Symptoms begin a week before the onset of menstrual flow and may not resolve until after the cessation od menses Uterus is diffusely enlarged but usually never exceeds 14cm in size soft and tender uterus particularly at the time of menses Mobility of the uterus is not restricted Adenomyosis is a clinical diagnosis and can only be confirmed by pathologic review Imaging studies, although helpful, are not definitive Sonographic criteria for the diagnosis of adenomyosis include: • Heterogenous myometrial areas that are not encapsulated and containing anechoic lacunae measuring 1-3mm in diameter and an area characterized by irregular cystic spaces measuring 1-7mm in diameter (honeycomb pattern) and disrupting the normal fine speckled pattern of the uterus Sonographic criteria for the diagnosis of adenomyosma include: • Nonhomogenous circumscribed area in the myometrium with indistinct margin, containing hypoechoic areas larger than 5mm • Circumscribed nodular aggregate of smooth muscle and endometrial glands seen together with compensatory hypertrophy of the myometrium surrounding the site of ectopic endometrium Hysterosalpingography in general gives poor diagnostic sensitivity and specificity Transabdominal ultrasound exhibits higher degree of sensitivity but poor specificity Transvaginal ultrasound exhibits satisfactory predictive value in the diagnosis

2. Leiomyosarcoma Definition A rare gynecologic malignancy May arise in a previously existing benign leiomyoma (sarcomatous transformation) or independently from smooth muscle cell of the mymetrium Clinical Median Age: 44-57 years old History May be associated with a history of prior pelvic radiation therapy Symptoms Non-specific Abnormal vaginal bleeding Pelvic pain or pressure Enlarging abdomen (pelvic mass is the principal finding) Abnormal vaginal discharge Signs A uterine mass increasing in size in postmenopausal woman Single large uterine mass tends to be softer due to tissue necrosis, internal cystic degeneration and hemorrhage Mass is difficult to separate from the surrounding myometrium at attempted myomectomy Diagnosis Preop diagnosis is difficult Endometrial sampling and ultrasound including color Doppler have not found to be reliable There is insufficient evidence to support routin biopsy of uterine fibroids MRI is promising in distinguishing between benign and malignant smooth muscle tumors. An ill-defined margin of uterine smooth muscle tumor on MRI is more in keeping with a malignant process 3.






Most common benign, solid neoplasm of the ovary Often present in postmenopausal women Smaller tumors are asymptomatic Bogger tumors can cause abdominal enlargement secondary to the size of the tumor and ascites Does not change the pattern of menstrual flow May be pedunculated and therefore easily palpated during one examination yet difficult to palpate on subsequent examination Size varies from 6-30cm The amount of ascites is directly proportional to the size of the tumor Usually misdiagnosed as myoma prior ro operation based on physical examination alone Ovarian fibromas can have signal intensities similar to that of a pedunculated myoma and ultrasound may not be able to differentiate the two MRI can demonstrate continuity of a presumed adnexal mass with the adjacent myometrium this establishing the diagnosis of myoma or adnexal mass surrounded by ovarian stroma and follicles thus establishing the ovarian origin of the mass





Degenerative Changes The eventual fate of myomas is determined by its blood supply Type of degeneration Hyaline

Carneous or red




Cystic or hydropic






Diagnosis of Myoma Pelvic Examination

65% Mildest form of degeneration characterized by loss of smooth muscle cells that are replaced by fibrous connective tissue Occurs in 5-10% of pregnant women Can cause severe pain and peritoneal irritation Characterized by extensive coagulative necrosis Due to the deposition of calcium phosphates and carbonates brought about by the continued diminished blood supply and ischemic necrosis of tissue Characterized by accumulation of edema fluid and often associated with collagen deposition Result from adipose metaplasia in myomas. It contains an admixture of smooth muscle and mature adipose tissue May be a misnomer. It is unknow whether myomas degenerate into leiomyosarcomes or whether they arise spontaneously -





Ovarian fibroma


Manual palpation and estimation of the size of the uterus is an important part of routine gynecological examination, as it is necessary to exclude abnormal growth of this reproductive organ due to beign or malignant tumors Uterine size, as assessed by bimanual examination, correlates well with uterine size and weight at pathologi examination, even in most obest women Typically ised to confirm the diagnosis of myomas A complementary transabdominal ultrasound evaluation may be of value in selected cases such as large volume uteri Sonohysterography or saline infusion sonograhy (SIS) provides additional informaltion over TVS Page 23 of 31










CT scan






alone and is an important adjunct in women with known or suspected myomas, particularly before surgical or medical therapy Office hysteroscopy and SIS are equivalent diagnostic tools for the detection of intrauterine myomas and polups All patients with submucous myoma who are candidates for hysteroscpic removal should undergo SHG for accurate preoperative grading Real time US and Doppler are used complementary to each other to enhance the differentiation between benign and malignant endometrial lisons Color doppler SHG may be usedul in distinguishing polyp from submucsal myomas based on the vascularity of the lesions (polyps typicall contained a single feeding vessel, whereas myomas had several vessels, which arose from the inner myometrium HSG obtains limited accuracy but because of the valuable information it provides about the cavity and tubes, it remains mandatory in the evaluation of infertility Diagnostic hysteroscopy and SIS are equivalent diagnostic too;s for the detection of intrauterine myomas and polyps Not currently a primary imaging modality for uterine myoma TVS is as efficient as MRI in detecting myoma presence. However, MRI is more accurate for exact myoma mapping and should be preferred when such mapping is important Recommended for preop evaluation when advanced surgery of myomas is planned especially for patients who want to preserve fertility MRI is superior to TVS for the diagnosis of adenomyosis

Treatment of Myomas Hysterectomy


Conservative Surgical Therapies




In women who do not wish to preserve fertility and who have been counseled regarding the alternatives and risks, hysterectomy may be offered as the definitive treatment Myomectomy: option for women who wish to preserve their uterus but women should be counseled regarding the risk of requiring futher intervention (ie. There is a 15% recurrence and 10% of women undergoing a myomectomy since it is dependent on the intraoperative fidings and the course of surgery) Abdominal myomectomy: most suggest a laparotomy for myomas exceeding 5-8cm, multiple myomas or when deep intramural myomas are present Laparoscopic myomectomy Laparoscopic myolysis: alternative to myomectomy or hysterectomy for selected women who wish to preserve their uterus but do not desire future fertility Hysteroscopic myomectomy: first line conservative surgical therapu for the

Medical Management

management of symptomatic intracavitary myomas Selective Uterine artery occlusion - Selective Progesterone Receptor Modulators (Ulipristal) - GnRH-agonist ± add-back

ADNEXA (POGS CPG on adnexal Masses, November 2018) -

Masses arise from the ovaries, fallopian tubes and surrounding connective tissue

Fuctional cysts – All are benign and usually does not cause symptoms or require surgical management o Follicular cysts- most frequent cystic structures in normal ovaries. Mostly asymptomatic o Corpus luteum cysts- minimum of 3 cm in diameter, associated with normal, delayed menses or amenorrhea. It may cause intraperitoneal bleeding o Theca lutein cysts- least common of the 3 physiologic ovarian cyts, almost always found bilaterally, and can produce enlargement of the ovaries. It is caused by prolonged or excessive stimulation of the ovaries to gonadotropins. USUALLY OCCUR WITH PREGNANCY, INCLUDING MOLAR PREGNANCY. Benign neoplams o Benign cystic teratoma (Dermoid cyst)- cystic structures that on histologic examination contain elemetns of the three germ cell layers. Benign teratomas are among the most common ovarian neoplasms, and are the most common neoplasms in prepubertal females and teenagers. When opened, sebacous fluid along with hair, cartilage and teeth can be found o Endometriomas (Chocolate cyst) – usually associated with endometriosis, and one of the most common causes of the enlargement of the ovary. It range to small (1-5 mm) to 5-10 cm in diameter hemorrhagic cysts. Symptoms include pelvic pain, dyspareunia and infertility o Fibromas- most common benign, solid neoplasms of the ovary. Associated with Meig’s syndome (Ovarian fibroma + ascites + hydrothrorax) o Brenner tumors (Transitional cell tumor)- rare, small, smooth, fibroepithelial ovarian tumors that are generally asymptomatic. 1-2% undergo malignant changes. Histologically, it is composed of solid masses/nests of epithelial cells (similar to transition cells of the urinary bladder) and surrounding fibrous stroma o Adenofibroma and Cystadenofibroma – benign, firm tumors, consists of fibrous and epithelial components Differential Diagnosis for Pelvic masses Gynecologic Non-Gynecologic Benign Malignant Benign Malignant Functional Cyst Epithelial Diverticular GI cancers cell abscess carcinoma Endometrioma Germ cell Appendiceal Metastatic tumors abscess cancer Tubo-ovarian Sex cord/ Nerve sheath Retroperito abscess stromal tumors neal tumors sarcomas Mature teraoma Metastatic Ureteral carcinoma diverticulum Serous Bladder cystadenoma diverticulum Hydrosalpinx Pelvic kidney Paratubal cysts Leiomyoma Mullerian anomalies

In newborns, small functional cysts measuring <1-2cm may be found secondary to the influence of maternal hormones. These cysts usually regress after the first few months of life TOPNOTCH MEDICAL BOARD PREP OBSTETRICS HANDOUT BY NIÑA KATRINA BANZUELA, MD Page 24 of 31 For inquiries visit or email us at [email protected] -



With increasing age, the incidence of malignancy rises

Dysgerminoma Endodermal Sinus Tumor Choriocarcinoma Immature Teratoma Embryonal Carcinoma

History and PE Patient should be questioned about pain, particularly its location, quality and time of onset Pain in the presence of an adnexal mass is often secondary to the distention of the ovarian capsule or compression of adjacent structure Time of Onset/Quality of Pain Midcycle pain Post-coital pain Dyspareunia Sudden onset with postive prenancy test Sudden onset of severe or intermittent severe pain associated with nausea and vomiting Menstrual Disturbance Severe dysmenorrhea and menorrhagia Prolonged amenorrhea followed by menorrhagia, hyperandrogenism and PCO on UTS Bleeding in premenarchal or postmenopausal patient with solid ovarian mass Vague GI symptoms (dyspepsia, early satiety, sensation of abdominal bloeating or fullness, constipation or a change in quality of stool)

Probable cause Ovulation Ruptured follicular or corpus luteum cyst Endometriosis Ectopic pregnancy Ovarian torsion

Endometriosis or leiomyomas Polycystic Ovarian Syndrome

Granulosa cell tumor Ovarian carcinoma

Laboratory Tests and Serum Biomarkers Laboratory tests Pregnancy Test to be requested Serial quantitative B-HCG to evaluate should be based suspected ectopic pregnancy on associated CBC: elevated WBC may indicate PID or symptoms TOA, or pelvic abscess from volonic or appendiceal pathology Serum cancer Does not need to be measured on all antigen (CA)-125 premenopausal women with simple ovarian cyst on ultrasound Not recommended for differentiating between benign and malignant adnexal mass LDH, AFP and Should be measured in all women under hCG the age of 40 with complex ovarian mass because of the likelihood of germ cell tumors An estimation of the risk of malignancy is essential in the assessment of an ovarian mass (RMI: Risk of malignancy index) Imaging Primary imaging modality: Grey scale, high frequency, 2D transvafinal ultrasound with color Doppler imaging UTS should be used to identify specific diagnosis, differentiate from a non-gynecologic pathologies, differentiate benign from malignant masses, or to evaluate extent of the disease CT scan and MRI should be used as an afjunct to ultrasound for uncertain or problematic cases and to determine the extent of the disease


+ -


+ -


+ -








Children with simple ovarian cyst <10cm with no malignant features should be manage expectantly. Otherwise, surgery is preferred. Laparoscopy is preferred over open surgery in benign ovarian tumors. For malignany diseases, surgical staging is recommended but with preservation of the uterus and contralateral ovary even in advance disease.

Management of Adnexal Masses in Reproductive Aged Women Asymptomatic with simple cysts <5cm Asymptomatic with simple cysts 5-7cm


Expectant management Timing of ultrasound during the first half of the follicular phase (days 4-6) Yearly ultrasound follow-up Consider further imaging (MRI) or surgical intervention Persistent: repeat ultrasound at 6 months with CA-125 determination Surgical management

Persistent asymptomatic ovarian cyst or with suspicion of malignancy Functional ovarian cyst should not be prescribed with OCP Observation should be advised for the asymptomatic woman when the evaluation shows Ca-125 levels <200U/mL and no TVS finding suspicious for cancer Observation may also be advised for women with ovarian cysts who are at high risk for surgical morbidity and mortality Surgical management • Benign masses may be removed laparoscopically or through laparotomy • Ovarian cystectomy if the preoperative suspicion for malignancy is low, the mass appears beign intraoperatively, and there is no evidence of metastatic disease • Aspiration of ovarian cyst SHOULD NOT be done Management of Adnexal Masses in Postmenopausal women Postmenopausal women who have adnexal masses with low risk of malignany (normal CA 125 <35IU/ml, asymptomatic, simple, unilateral, unilocular simple cysts, less than of equal to 7cm in diameter) may be offered surveillance every 3-6 months If there is no increase in size, and if the Ca-125 remains normal, frequency of surveillance may be decreased or may be done annually Surgery • Symptomatic • Suspicious or persistent complex adnexal mass regardless of size • Asymptomatic with simple adnexal cyst >7cm in diameter

Management of Fallopian Tube Masses Hydrosalpinx Desirous of Salpingostomy may be done in younger pregnancy patients with mild to moderate hydrosalpinx to achieve natural conception Management of Adnexal Masses in Premenarchal Women Laparoscopic salpingectomy must be done in A complete pediatric examination should include a complete women with severe hydrosalpix who will history and thorough inspection and palpation of the undergo invitro fertilization to improve involved sites and possible related areas pregnancy rates TRANSABDOMINAL ULTRASONOGRAPHY should be the first Laparoscopic proximal tubal ligation/tubal line of imaging to asses the abdomen and reproductive tract occlusion should be done in patients with of premarcheal patients severe hydrosalpinx with extensive adhesions Serum markers and distorted pelvic anatomy B-HCG AFP LDH Ca-125 Not May not require surgical removal or TOPNOTCH MEDICAL BOARD PREP OBSTETRICS HANDOUT BY NIÑA KATRINA BANZUELA, MD Page 25 of 31 For inquiries visit or email us at [email protected]

TOPNOTCH MEDICAL BOARD PREP OB-GYNE SUPPLEMENT HANDOUT BY NIÑA KATRINA BANZUELA, MD For inquiries visit or email us at [email protected] desirous of monitoring pregnancy Antibiotics should be started in women with hydrosalpinx to prevent progressive damage to the tubes Tuboovarian Abscess Broad spectrum antibiotics should be initiated in women with TOA until clinical improvement is achieved for 24-48 hours. Antibiotics include IV Clindamycin, Metronidazole or Cefoxitin. Once clinical improvemt is noted and the fever has resolved, antibiotics should be changed to oral preparation and continued for 14 days Surgical intervention should be done in patients suspected of ruptured TOA, abscess size larger than 8cm, and no clinical response after initiation of antibiotics within 48 hours Surgical drainage using laparoscopy within 24 hours after initiation of antibiotic therapy should be done in women desirous of pregnancy with a TOA to maximize fertility, minimize complications, shorter hospitalizations and faster response rate Management of Paraovarian/Paratubal Cysts Asymptomatic paraovarian/paratubal simple cysts measuring 10 cm or less can be managed expectantl Surgery, preferably laparoscopy, should be advised based on the presence/severity of symptoms, size and radiologic characteristics of the mass and the risk of malignancy To prioritize fertility preservation, cystectomy (enucleation from the mesosalpix) of the cyst should be done Aspiration of cyst fluid should be avoided Adnexal Masses in Special Populations: Pregnancy The most frequent types of ovarian masses are corpus luteum cysts, endometriomas, benign cystadenomas, and mature cystic teratomas (dermoids) Diagnosis Ultrasound must be the primary diagnostic tool MRI may be used in cases where there is difficulty in distinguishng the nature of the mass The use of tumor markers as an adjunctin evaluating the mass should be individualized Treatment May be observed if there are no options complications during the course of pregnancy Elective surgical intervention should be done in the second trimester of pregnancy (14-16 weeks) In cases of complications such as rupture or torsion, or when malignancy is suspected, surgical intervention must be performed regardless of age of gestation For ovarian torsion in a patient still desirous of pregnancy, it should be managed by reduction of the torsion with concomittant ovarian cystectomy


Atrophic vaginitis Cervicitis

Pelvic Inflammatory Disease

Description Most common cause of vaginitis in the US

Metronidazole, 2g oral single dose

Women with this infection should also be tested for other STDs 75% of women may experience this in their lifetime. Predisposing factors: pregnancy, diabetes, antibiotic use. Discharge may be varied from watery to thick Common in menopausal women Presents with purulent cervical discharge

Topical azoles (Butoconazole, Clotrimazole, Miconazole, Tioconazole, Nystatin, Fluconazole) Estrogen cream

Diagnosis implies that the patient has upper genital tract infection and inflammation (ascended to the endometrium and fallopian tubes) Commonly caused by N. gonorrhoea and C. trachomatis Triad: pelvic pain, cervical motion and adnexal tenderness and fever

Tubo-ovarian Abscess

End stage process of PID

Genital Ulcers

Those with genital ulcers may have HSV or syphilis or chancroid

Genital warts

Manifestation of HPV 51 (external) Non-oncogenic HPV 6 and 11 also cause external genital warts

Treatment Metronidazole Clindamycin

Highly contagious

Women with BV are at risk for PID, Pregnant women are at risk for PROM, preterm labor and delivery, chorioamnionitis


Diagnosis: fishy vaginal odor; clue cells in histology Profuse, purulent, malodorous vaginal discharge with pruritus;

GonorrheaCeftriaxone 250 mg IM single dose or Cefixime 400 mg oral single dose ChlamydiaDoxycycline 100 mg BID x 7 days Or Azithromycin 1 g oral single dose Outpatient treatment: Cefoxitin or Ceftriaxone PLUS Doxycycline or Azithromycin Inpatient treatment: Cefoxitin or Cefotan PLUS Doxycline Or Clindamycin PLUS Cefrtriaxone or Gentamicin Medical treatment or Abscess Drainage Chancroid: Azithromycin, Ceftriaxone, Ciprofloxacin, Erythromycin HSV: Acyclovir, Famciclovir, Valacyclovir

GENITOURINARY INFECTIONS and STDs Diagnosis Bacterial Vaginosis

Strawberry cervix may be observed


E.coli is the most common pathogen for acute cystitis

Metronidazole, 500mg/tab BID x 7 days or


Syphilis: Pen G Goal of treatment is to remove the warts but it is not possible to eradicate the infection Cryotherapy, Imiquimod cream, Podophyllin, Podofilox, Trichloroacetic acid, Cautery, Laser, Interferon Acute Cystitis: TMP-SMX, Nitrofurantoin Pyelonephritis: TMP-SMX, Page 26 of 31

TOPNOTCH MEDICAL BOARD PREP OB-GYNE SUPPLEMENT HANDOUT BY NIÑA KATRINA BANZUELA, MD For inquiries visit or email us at [email protected] Levofloxacin, Cetriazone, Ampicillin, Gentamicin VULVAR PAIN SYNDROMES Vulvodynia or vulvar pain is one of the most common gynecologic problems, and was noted that 15% of women will develop this in their lifetime Other terms include vulvar pain syndrome, or vulvar vestibulitis Described as a triad of severe pain to touch, localized to the vaginal vestibule and dyspareunia; pain and tenderness localized to the vestibule and mild-tomoderate erythema Categorized into: o Vestibulodynia- usually younger women (shortly after puberty to mid-20s); usually involves allodynia (hyperesthesia, pain is present without stimulation), pain is neurogenic in origin, Intolerance to pressure may be caused by use of tampon, sexual activity, or tight clothing o Dysesthetic vulvodynia – most common on peri-and post-menopausal women; pain is non-localized Therapy-similar to chronic pain syndromes o Tricyclic anti-depressants o Gabapentin (300-3600 mg daily) – 2/3 to ¾ of women has response to treatment




Characterized by a combination of hyperandrogenism (either clinical or biochemical), chronic anovulation, and polycystic ovaries. It is frequently associated with insulin resistance and obesity It is the most common cause of hyperandrogenism, hirsutism, and anovulatory infertility in developed countries Criteria: o Oligoovulation or anovulation o Clinical and/or biochemical signs of hyperandrogenism o Polycystic ovaries and exclusion of other etiologies (congenital adrenal hyperplasia, androgen-secreting tumors, Cushing’s syndrome)


Metabolic Syndrome Diagnostic Criteria o Female waist >35 inches o Triglycerides >150 mg/dL o HDL <50 mg/dL o Blood pressure >130/85 mmHg o Fasting glucose: 110–126 mg/dL o Two-hour glucose (75 gm OGTT): 140–199 mg/dL Treatment o Hormonal contraception or ovulation induction o Hirsutism: Weight loss, Oral contraceptives, medroxyprogesterone, GnRH analogues, glucorticoids, ketoconazole, finasteride, spironolactone, flutamide, metformin

AMBIGUOUS GENITALIA AND CONGENITAL ADRENAL HYPERPLASIA Ambiguous genitalia will be found in 1 in 14,000 newborns Females with masculinized external genitalia will be identified as female pseudohermaphrodites Most common cause is Congenital Adrenal Hyperplasia You may see clitoral enlargement and labial fusion CONGENITAL ADRENAL HYPERPLASIA (CAH) May be demonstrated at birth by the presence of ambiguous genitalia in genetic females or present later in childhood Significant proportions of newborns with this condition are also at risk for the development of life-threatening neonatal adrenal crises as a result of sodium loss because of absent aldosterone. In milder disease, delayed diagnosis may result in abnormalities of accelerated bone maturation, leading to short stature. The development of premature secondary sexual characteristics in males and further virilization in females may also occur Treatment and Management o Replacement of cortisol – suppresses ACTH output and decreases the stimulation of the cortisol producing pathways in the adrenal cortex o For females at risk – dexamethasone o Corrective surgery o Psychosocial support and counseling


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TOPNOTCH MEDICAL BOARD PREP OB-GYNE SUPPLEMENT HANDOUT BY NIÑA KATRINA BANZUELA, MD For inquiries visit or email us at [email protected] Vulvovaginitis Most common gynecologic problem in the prepubertal children Classic symptoms: introital irritation (discomfort/pruritus) or discharge Major factor of childhood vulvovaginitis – poor perineal hygiene because of the proximity to the rectum Treatment – improvement of local perineal hygiene – keeping vulvar skin clean, dry and cool as well as avoiding irritants Labial Adhesions (Adhesive Vulvitis) Mean that the labia minora have adhered or agglutinated together at the midline PE finding: a translucent vertical midline line visible at the site of agglutination. The thin line in a vertical direction is pathognomonic for labial adhesions Often partial and only involve either upper or lower aspect of the labia Most common in girls ages 2-6 because estrogen is at its lowest at this time No treatment is absolutely necessary UNLESS the child is symptomatic o Symptoms- voiding difficulties, recurrent vulvovaginitis, discomfort from labia pulling at the site of adhesion, and rarely bleeding Treatment – dabbing of topical estrogen 2x/day at the site of fusion

FAMILY PLANNING POGS CPG ON FAMILY PLANNING, 2ND EDITION (NOVEMBER 2017) Reversible- temporary prevention of fertility; “active” method Permanent- sterilization; “terminal method” FERTILITY AWARENESS-BASED METHODS 1. Calendar Calculation (Rhythm) 2. Standard Days Method (SDM) 3. Basal Body Temperature (BBT) 4. Cervical Mucus Method or Billings Ovulation Method 5. Symptothermal Method (STM) 6. Two-Day Method 7. Saliva Ovulation Monitor 8. Lactation Amenorrhea Method (LAM) IMPERFORATE HYMEN Hymen should establish a connection between the lumen of the vaginal canal and the vestibule May result to primary amenorrhea May cause hydrocolpos or mucocolpos- caused by collection of secretions behind the hymen, and in rare cases may build up to form a mass that obstructs the urinary tract May develop hematocolpos and hematometrium overtime Fallopian tubes can also be distended because the menstrual flow may back up through the tubes VAGINAL AGENESIS Also called Mullerian agenesis or Mullerian aplasia Usually associated with the Mayer-Rokitansky-KusterHauser (MRKH) syndrome o congenital absence of the vagina and uterus (in 75% of patients), although small masses of smooth muscular material resembling a rudimentary bicornuate uterus are not uncommon o Some patients have rudimentary uterine horns o 50% have concurrent urinary tract anomalies o Presents with primary amenorrhea o PE findings shows a short vaginal pouch and inability to palpate a uterus GYNECOLOGIC PROBLEMS IN PRE-PUBERTAL CHILDREN

Proper Use FAB Method may be used by regularly menstruating women and highly motivated couples Calendar Rhythm Method


Standard Days Method (SDM)


Basal Body Temperature (BBT)



Cervical Mucus Method or Billings Ovulation Method



Woman records the length of her cycles for several months FERTILE PERIOD: Previous shortest cycle – 18=_____ Previous longest cycle- 11= ____ the couple abstains from coitus during this calculated fertile period The couple should abstain from vaginal intercourse from menstrual days 8-19 among women with cycles of 26-32 days BBT is recommended for any reproductive age woman who is willing to take and chart her BBT daily and practice abstinence during her fertile days The couple should refrain from vaginal intercourse from the first day of menses until 3 days after the temperature rise of 0.2 to 0.5 C Recommended for any reproductive age woman without evidence of vaginal infections or abnormal vaginal discharge The couple should refrain from vaginal


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Symptothermal Method (STM)

Two-Day Method

Saliva Ovulation Monitor

Lactation Amenorrhea Method (LAM)

intercourse once the presence of a clear, wet and slippery mucus secretion is observed until the 4th day after her peak day of wetness STM is recommended for any reproductive age woman who is willing to take and chart her BBT daily, has the diligence to chart her daily observations of her cervical mucus, make a daily record of all these, and willing to practice abstinence during the fertile period Couple should refrain from vaginal intercourse when the woman senses cervical secretions and the 3rd full day after the rise in BBT Woman should have no evidence of vaginal infection or abnormal discharge Once she notices any secretions of any type, color or consistency, the couple should refrain from vaginal intercourse on that day and the day after Monitoring of ovulation using the saliva should be started at the end of the menses Couple should refrain from vaginal intercourse on the days that a ferning pattern is observed. Criteria: presence of amenorrhea exclusive breast-feeding (no supplements) performed up to 6 months after delivery Special consideration: 1. Women who is positive for HIV should avoid breastfeeding 2. Women with active/untreated TB should not breastfeed. She may resume breastfeeding if she is on TB medications for at least 2 weeks and is verified noninfectious 3. Women with active herpes lesions on the breast should not breastfeed.

Discontinuation Advise the client that the discontinuation rates with FAB methods are high. These are mainly due to trouble learning a particular method, difficulty of using it, challenge of sexual abstinence, lack of confidence, dissatisfaction and shifting to another family planning method HORMONAL CONTRACEPTION Progesterone inhibit ovulation thickening of the cervical mucus Estrogen maintains thin endometrium prevent unscheduled bleeding inhibit follicular development COMBINED HORMONAL CONTRACEPTIVES taken daily and on time to prevent conception Formulation classified into generations depending upon their introduction in the United States market, amount of estrogen and the type of progestin used COC classification according to the amount of Estrogen (EE) used: Generation Amount of Estrogen First 50 mcg or more Second Less than 50 mcg Third Doses are now even lower ranging from 20-35mcg

Generation First

Amount of Estrogen Contain up to 10 times the dose of progestins compared to later generations Include: norethindrone, norethindrone acetate and ethynodiol diacetate Second More potent and at lower doses produce and Anovulatory effect Levonorgestrel (LNG) and norgestimate Third Contain gonane progestins, such as desogestrel or gestodene, and have reduced androgenic and metabolic side effects Fourth Drosperinone, dienogest or nomegestrol acetate Third and second generation COCs are better tolerated than first generation Phasic Pills developed to reduce the total progestin per cycle without compromising the contraceptive efficacy or cycle control Type Monophasic same amount of Estrogen and progesterone in every hormonal pill Biphasic The first 10 pills with one dosage and the next 11 pills having another level of estrogen and progestin Triphasic The first 7 pills with one dosage and the next 7 pills have another level of estrogen and progestin and the last 7 pills with yet another dosage Quadriphasic pills Contains a bioidentical synthetic estrogen, estradiol valerate and dienogest. The product offers 4 progestin/estrogen dosing combinations during each 28-day cycle Monophasic pills should be the first choice for women staring oral contraceptive use Mechanism of action Low dose COC’s prevent pregnancy by the following processes: 1. Estrogen prevents ovulation by suppressing FSH release 2. Progestins prevent ovulation by supressing LH release. Cervical mucus is thickened thereby preventing sperm passage Proper Use Monthly COCs 1. 21 pills-21 active tablets taken every day followed by 7 pill-free days 2. 22 pills- 22 active tablets taken every day followed by 6 pill-free days 3. 24 pills- 24 active tablets taken every day followed by 4 pill-free days 4. 28 pills- 21 active pills taken every day followed by 7 inactive or reminder pills of different color. The reminder pills do not contain hormones. No pill-free or rest days Continuous COCs Active pills are taken for 365 days of each year Extended cycle preparations Active pills are taken for 12 weeks followed by a one-week pill free period for withdrawal bleeding How to Take COCs Take one pill regularly, preferably at the same time every day Start within the first 5 days of the menstrual period. However if the client is certain that she is not pregnant, it can be started anytime but a backup method is required for 7 days if started after the 7th day of menses Start the COCs as prescribed (Quick Start). This method may improve the initiation of use but a backup method is required for 7 days if started after the 7th day of menses. Missed Pills

COC classification according to the type of progestin used: TOPNOTCH MEDICAL BOARD PREP OBSTETRICS HANDOUT BY NIÑA KATRINA BANZUELA, MD For inquiries visit or email us at [email protected]

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TOPNOTCH MEDICAL BOARD PREP OB-GYNE SUPPLEMENT HANDOUT BY NIÑA KATRINA BANZUELA, MD For inquiries visit or email us at [email protected] She should take a missed hormonal pill as soon as possible then keep taking pills as usual, one each day (She may take 2 pills at the same time or on the same day) 1 pill missed or new pack started 1 day late

Take hormonal pill asap No back-up required

2 pills missed or new pack started 2 days late

1 hormonal pill asap No back-up required

3 pills missed in a row in the first or second week or new pack started 3 days late

1 hormonal pill asap Use back up for the next 7 days (+) intercourse in the past 5 days→ emergency contraception

3 pills missed in the 3rd week

Discard current pack and start new pack right away Use back-up method for the next 7 days (+) intercourse in the past 5 days→ emergency contraception

Safety COCs do not disrupt an existing pregnancy COCs do not cause birth defects and will not harm the fetus even if the woman becomes pregnant while taking the pills or accidentally starts the pill when she is already pregnant Drug Interaction Effectiveness of COCs are reduced with rifampicin, phenytoin, phenobarbital, carbamazepine, primidone and ethosoximide Side effects Spotting, amenorrhea, nausea, breast tenderness, headaches and depression Return to Fertility There is no delay of return to fertility after COCs are discontinued Special Groups Smokers Women older than 40 Postpartum/ Breastfeeding women

Obesity Hypertension


Diabetes Mellitus

Should not be used for women who are older than 35 years old and who smoke 15 sticks or more per day Healthy, non-smoking women doing well on COCs can continue their method until menopause after weighing the risks and benefits Started any time after 3 weeks postpartum if the client is NOT breastfeeding and do not have any other risk for venous thrombosis COCs are not recommended as the first choice for breastfeeding women For those who are fully or nearly fully breastfeeding for 6 months, COCs are started anytime if still amenorrheic but should be started within the first 5 days of menses, if menstruation has resumed COCs can be started immediately after an abortion. No back up contraceptive is needed if begun within the first 7 days following abortion Should be used with caution in obese women older than 35 years old because of the increased risk of VTE May be prescribed for healthy nonsmoking clients who are 35 years old or younger with well-controlled and monitored hypertension with no signs of end-organ vascular disease May be appropriate for healthy nonsmoking women with known dyslipidemia without other known cardiovascular risk factors Should be limited to healthy, nonsmoking women who are younger than 35 years and with no evidence of





Migraine headaches


hypertension, nephropathy, retinopathy or other vascular disease A personal history of benign disease or a family history of breast cancer is NOT a contraindication to COCs COCs reduces the risk for both endometrial and ovarian cancer Not recommended for women with documented history of VTE Can be considered for women with migraine headache without aura provided they are healthy, nonsmoking and younger than 35 years

Follow-up The client should be advised to return to the clinic 3 months after the initiation then annually thereafter. However, the client should return to the clinic anytime for any problem or questions that may arise LONG ACTING HORMONAL CONTRACEPTIVE Contraceptive Three layers: Patch 1. an outer protective layer of polyester 2. an adhesive middle layer containing 75 mcg ethinyl estradiol and 6.0 mg norelgestromin 3. a polyester release liner that is removed prior to placement on the skin delivers 150 mcg norelgestromin and 20 mcg ethinyl estradiol into the circulation each day at a fairly constant rate for at least 9 days Contraceptive Flexible soft colorless ring-shaped device Vaginal Ring made of ethylene vinyl acetate copolymers Each ring contains 2.7 mg of ethinyl estradiol and 11.7 mg of etonogestrel Injectables Depo-MedroxyProgesterone Acetate (DMPA) Given every 3 months MPA: 17-acetoxy-6-methylprogestin that has progestogenic activity in the human inhibits ovulation keeps endometrium thin keeps cervical mucus thin Non-contraceptive benefits (DEFINITIVE: salpingitis, endom CA, Iron deficiency anemia, Sickle cell anemia; PROBABLE: Ovarian cysts, dysmenorrhea, endometriosis, epileptic seizure, vaginal candidiasis) Resumption of ovulation after DMPA is varied and may last up until 1 year In cycling women: Days 0-5 of the cycle Nonlactating women: 5 days postpartum Exclusive BF : should not be given until at least 6 weeks postpartum Norethindrone Enanthate (NET-EN) Given every 60 days for at least the 1st 6 months then every 12 weeks Progestin-Estrogen (once monthly injectable) 25mg MPA, 5mg estradiol enanthate Subdermal Implant

Norplant -made of polydimethylsiloxane (Silastic) containing levonorgestrel Norplant II Implanon Third generation duration of action of 3 years Extremely effective, and is much easier to insert and remove than the multiple levonorgestrel-releasing implants. Contains 68 mg of the progestin Etonogestrel Adverse Reactions:


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TOPNOTCH MEDICAL BOARD PREP OB-GYNE SUPPLEMENT HANDOUT BY NIÑA KATRINA BANZUELA, MD For inquiries visit or email us at [email protected] 1. 2.

Bleeding irregularities Acne

introitus and the base of the penis during intercourse Advantages: 1. female controlled 2. can be inserted prior to the onset of sexual activity 3. can be left in place for a longer time after ejaculation 4. offer greater protection against the transfer of certain sexually transmitted organisms (Herpes and HPV) 5. polyurethane is stronger and thicker making it less likely to rupture Disadvantages: 1. cost (about three times higher) 2. ease of use

EMERGENCY CONTRACEPTION Steroids most effective if treatment begins within 72 hours after an isolated midcycle act of coitus Eg. A regimen of four tablets of ethinyl estradiol, 0.05 mg, and dl-norgestrel, 0.5 mg, combination oral contraceptive (Ovral), given in doses of two tablets 12 hours apart Copper effective for 7 days after coitus IUD INTRAUTERINE DEVICE (IUD) Mechanism of Action: induce a local inflammatory reaction of the endometrium, and the cellular and humoral components expressed in the tissue and the fluid fill the uterine cavity to create an environment that is toxic to sperm, so fertilization of the ovum does not occur Benefits - a high level of effectiveness, - a lack of associated systemic metabolic effects - the need for only a single act of motivation for long-term use Contraindications 1. Pregnancy or suspicion of pregnancy 2. Acute PID 3. Postpartum enometritis of inflicted abortion in the past 3 months 4. Known or suspected uterine or cervical malignancy 5. Genital bleeding of unknown origin 6. Untreated acute cervicitis 7. Previously inserted IUD that has not been removed

STERILIZATION Male sterilization Female sterilization

Vasectomy 13 to 20 ejaculations are required after the procedure Bilateral tubal Ligation *Fimbriectomy (supposed protection from ovarian Ca)

COITUS RELATED METHODS Spermicides Active Ingredient: NANOXYL-9 (surfactant that immobilizes or kills sperm on contact by destroying the sperm cell membrane. Carriers: gels, foams, creams, tablets, films, and suppositories Spermicides need to be placed into the vagina before each coital act BARRIER METHODS Diaphragm Thin, dome-shaped membrane of latex rubber or silicone with a flexible spring modelled into the rim. The spring allows the device to be collapsed for insertion and then allows for expansion within the vagina to seat the rim against the vaginal wall to create a mechanical barrier between the vagina and the cervix Should be used with a spermicide and be left in place for at least 8 hours after the last coital act. If repeated intercourse takes place, additional spermicide should be used vaginally Cervical cap a cup-shaped silicone or rubber device that fits around the cervix concern about a possible adverse effect of the cap on cervical tissue, it has been recommended that cap users not keep the cap in place for more than 48 hours speculum exam and repeat cervical cytologic examination 3 months after starting to use this method Male latex, polyurethane, and animal tissue Condom Some condoms come pre-packaged with either N9 spermicide or lubricants. N9 has been associated with an increased risk of HIV acquisition in high-risk women Female consists of a soft, loose-fitting polyurethane Condom sheath with two flexible rings: One ring lies at the closed end of the sheath and serves as an insertion mechanism and internal anchor for the condom inside the vagina. The outer ring forms the external edge of the device and remains outside the vagina after insertion, thus providing protection to the TOPNOTCH MEDICAL BOARD PREP OBSTETRICS HANDOUT BY NIÑA KATRINA BANZUELA, MD For inquiries visit or email us at [email protected]

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