Hey, there, chief!!!

Its Your Unofficial Guide to Success on the OSU-COM Med III OB/GYN Oral Examination

Table of Contents
#1. A 25 year-old presents to the ER with complaints of abnormal vaginal bleeding................................... 3 #2. A 19 year old presents to the office in referral for treatment and counseling of abnormal Pap smear. . 4 #3. 27 year old presents to the office with complaints of abnormal vaginal bleeding................................... 5 #4. 17 yo presents to the ER with RLQ pain................................................................................................. 6 #5. -- 17 yo presents with mother for evaluation of amenorrhea. ................................................................. 7 #6. 45 yo presents to the office with complaints of bladder problems........................................................ 8 #7. 52 year old presents in referral from her PCP for postmenopausal bleeding....................................... 10 #8. 63 year old presents in referral for incidental finding on CT scan after MVA of right adnexal mass.... 11 #9. A 16 year old presents to the ER with abdominal pain. US reveals 10x12x8cm mass. ...................... 12 #10. A 19 year old presents to the office for routine "annual" exam and to start hormonal birth control.... 13 #11. A 16 yo pregnant female comes to L&D complaining of severe HA and persistent n/v. .................... 18 #12. A 25 y/o G1P0 presents with complaints of 2 yrs infertility. ................................................................ 18 #13. 35 y/o presents to office c/o pelvic pain and abnormal cycles............................................................ 19 #14. 25 y/o presents to ER 4 days after hysterectomy with c/o severe pelvic pain, N/V............................ 20 #15. A 54 year old presents with complaints of 3 yr h/o hot flushes/night sweats and difficulty concentrating. Previously, a physician talked to her about HRT and she would like to re-discuss her options......................................................................................................................................................... 21 #16. A 21 yr old with known IUP presents to the ER with vaginal bleeding. .............................................. 22 #17. A 25-year-old presents for preconceptual counseling and at this visit finds out she is pregnant. ...... 23 #18. 24yo @ 32wks c/o abd pain & bleeding............................................................................................. 24 #19. 24yo @ 38wks c/o decreased fetal movement ................................................................................... 26 #20. A 26 y/o @ 16 wks by LMP is sent for an ultrasound for size greater than dates and is found to have a twin gestation on ultrasound. She is concerned about the potential risks, please counsel..................... 27 #21. A 35 y/o presents for routine prenatal care at 28 weeks, what needs to be done? Answer in italics . 28 #22. A 24 y/o presents to L&D with ROM at term with unknown GBBS. How do you manage her labor?29 #23. You have a patient on post partum who delivered 2 hours ago and is presenting with heavy vaginal bleeding....................................................................................................................................................... 30 #24. A 21 y/o presents to the office with complaints of vaginal discharge. ................................................ 31 #25. A 50 y/o presents with complaints of vulvar pain and pruritis............................................................. 32

#1. A 25 year-old presents to the ER with complaints of abnormal vaginal bleeding. Ok so there are numberous causes I will try to limit this discussion to the ones not discussed extensively in other questions and the ones most pertinent for this patient. Differential diagnoses: Broad Bleeding from other sites, Trauma, Infection, Dysfunction of menses, Obstetric causes, Benign gynecologic causes, Malignancy, Coagulopathy, Atrophy Explained: Bleeding from other sites- Make sure the person is actually bleeding from the vagina. Other sites may be rectum, urine, vulva in the case of lichen sclerosis, or even the blood in the semen of the man they just regretted having sex with. o Rule out- Check UA, occult blood, pelvic. Trauma- Circumstances regarding bleeding will rule this out. After sex only, consider an over enthusiastic partner to be the cause. Infection- Cervicitis, vaginal infections, as well as PID can cause bleeding especially if they are chronic. Quick review of infections and how to differentiate them follows below. o Bacterial Vaginosis- +whiff, pH5-6, clue cells, Tx- Metro or Clinda for 7days and warn about antabuse qualities. o Candidal vaginitis- More pruritis in Hx, white creamy discharge, pH4-5, Pseudohyphae on KOH prep, Tx- Diflucan, OTC azoles, Suspect DM, HIV, immunodifficiency if recurrent. o Trichomonas- High vol. odorous green/yellow D/C, pH6-7, Strawberry cervix, Trichomonad seen in wet prep. Tx- Metronidazole single dose. o Gonorrhea and Chlamydia- Cause CervicitisCervical motion tenderness with no other signs of PID. Gonorrhea- Purulent D/C, Gram stain shows kissing kidneys. Tx- Ceftriaxone IM. Chlamydia- Tx- Doxycycline or Azithromycin, Erythromycin for pregnant women. Dysfunction of menses: Ask about menstrual cycles. Do you have them? Are they regular? How long? How much bleeding? Etc o Menorrhagia- Heavy or prolonged menstrual bleeding. Ave. blood loss is 35ml. >80ml=Menorrhagia. Caused by a number of causes to be discussed Fibroids, Adenomyosi, Hyperplasia/Ca, dysfunc. Uterine bleeding. CK TSH, PRL if you suspect hypo or visual field defects, headaches, are reported. Often treating the hypothyroidism will relieve the PRL elevation. o Metorrhagia and Menometrorrhagia- Bleed between periods. Etiologies as above. o Polymenorrhea- Bleeding in a perior <21 days. Anovulation. o Oligomenorrhea- Bleeding>35 days apart. Investigate hormonal abnormalities. Pregnancy, PCOS, Chronic anovulation. o Dysfunctional Uterine Bleeding- Diagnosis of exclusion if other causes of dysfunction of menses are ruled out. Tx- OCPs, NSAIDS, Excessive blood loss Conjugated Estrogens. Benign Gynecologic Causes: o Fibroids- Benign tumors of smooth muscle. Dx- Physical exam shows enlarged lumpy uterus, Ultrasound shows hypogenic areas. Tx- Young pt- Medroxyprogesterone, danazol, lupron will shrink fibroid in many cases. Uterine artery embolization, Myomectomy. With definitive therapy being a hysterectomy. o Endometriosis- Cyclic pelvic pain around time of menses with associated dysmenorrhea, dysparunia, bleeding, infertility.

Dx- Uterosacral nodularity on rectovag. Exam or retroverted fixed uterus, Adenexal mass with ovary involvement. Tx- OCPs, Provera, Nsaids, Danazol or Lupron for FSH and LH supression. Surgery Ablate endometrial implants or TAH/BSO with LOA. total abdominal hysterectomy; bilateral o Adenomyosis- Patients complain of Menorrhagia, in addition they have dysmenorrhea salpingo-oophorectomy and may have bowel or bladder symp. Due to the enlargement of the uterus. Dx- Enlarged globular uterus Tx- OCPs, Nsaids, Menstrual supression with progestins, Hysterectomy o Cervical Polyps- Painless bleeding after sex. Tx- Remove in office or D&C in OR. Obstetric causes- Pregnancy, If pt is pregnant then consider placenta previa, abruption, Molar pregnancy, Spontaneous abortion, Ectopic pregnancy. o Get a B-HCG on everyone presenting with abnormal bleeding and F/U with US if positive. Do not do a bimanual exam on a previa pt. Always look for ectopic prrgnancy as this can be fatal if tubal rupture were to occur. Uterine size not consistent with dates will direct you towards molar pregnancy. In that case also get a Quant and consider D&C for pathology specimen. Malignancy- Cervical, Uterine, Abdominal o Get a Pap, consider Bx if endometrial stripe >5mm, consider abdominal if other symptoms accompany N/V, Bowel or bladder problems, chachectic pt etc. Coagulopathy- Consider if menorrhagia was reported at menarche. Atrophy- Premature ovarian failure, Turners pts, Overall if a pt presents with abnormal bleeding the history will rule out a majority of causes. The physical with a PAP and culture will r/o others. Diagnostic testing should include CBC and Heme studies and B-HCG to start along with TSH, PRL if this sounds like menstual cycle dysfunction. From there the further testing is as described for individual conditions.

---------------------------------------------------------------------------------------------------------------#2. A 19 year old presents to the office in referral for treatment and counseling of abnormal Pap smear. Definition: A pap smear involves scraping the cells from the internal os of the cervix to acquire cells from the transformation zone. Recommended for 18yr olds or those that Bendo has corrupted. History: Investigate other symptoms such as post coital bleeding, pelvic pain, pressure, urinary changes etc. Then we must determine what this pts pap demonstrated. Below are the cytologic classifications used to describe Paps. o Atypical squamous cells (ASC), ASC of undetermined significance (ASC-US) and ASC cannot rule out High-grade squamous intreaepithelial lesion (ASC-H) o Low grade squamous intraepithelial lesion (LSIL) o High grade squamous intraepithelial lesion (HSIL) o Squamous cell carcinoma. Now what do we tell the pt her smear means. o ASC-US- Get HPV testing If high risk HPV is demonstrated then proceed to Colposcopy guided biopsies. No high risk HPV then F/U with another pap in one year. If at one year they continue to have an abnormal Pap then they proceed to colpo. 80-85% of ASC and LSIL lesions do resolve o LSIL, HSIL proceed to colposcopy guided biopsy. In addition to the cytologic description there is also a histologic system. o CIN I- Mild dysplasia, repeat pap every 6 months for one year, LEEP if persistant dysplasia. o CIN II- Moderate dysplasia, LEEP or CONE o CIN III- Severe dysplasia, Carcinoma in situ. LEEP or CONE Cervical Cancer-

o o

Staged clinically- May use Exam under anesthesia, X-ray, cystoscopy, proctoscopy, IVP, and barium enema. Stage I- Confined to the cervix Ia- Microscopic Ib- Macroscopic Stage II- Vagina and parametrium IIa- Upper third of the vagina involved IIb- Parametrium involved, not out to pelvic walls Stage III- Lower third and pelvic side wall IIIa- Lower third of vagina involved IIIb- Extention to pelvic side walls, hydronephrosis, or non functioning kidney. o Note cervical cancer pts often die of kidney failure. Think of the proximity of the cervix to the ureters. IV- Outside repro tract, distant involvement o IVa- Bowel or bladder involvement o IVb- Distant mets. Survival: I-85-90% II-60-75% III-35-45% IV-15-20 Tx- Surgery is only indicated for stage Ia,Ib, and IIa. Beyond this we use chemo (Platin) and radiation (external beam and Interperitoneal) therapy. If disease recurs after radiation then pelvic exenteration (removal of all pelvic organs) is sought. Note: realize if on bimanual exam you feel tumor in the adenexa this is automatically a stage IIB and you can assure the pt with no further workup that an operation will not be an option.

--------------------------------------------------------------------------------------------------------------#3. 27 year old presents to the office with complaints of abnormal vaginal bleeding 1. H&P a. History of vaginal bleeding: frequency/duration/volume/bleeding history/relationship to cycle i. Menorrhagia: Prolonged menses ii. Metrorrhagia: Bleeding in between menses iii. Oligomenorrhea: >35 days b/w cycles iv. Polymenorrhea: <24 days b/w cycles v. Spotting: light bleeding; assoc with premenstrual or postcoital b. Use of hormone therapy in for of OCP, IUD, replacements c. Signs/Symptoms i. Discharge, fever, abdominal pain, hirsutism, obesity, virilization, signs of hypothyroid, trauma, bloody urine, bloody stools d. Physical: ID source of bleed (gyn/gi) ; identify genital tract lesions, masses, discharge 2. Differential (Structural vs. Hormonal ) a. Hormonal: Ovulation not taking place or erratic i. Pregnancy (ectopic; SAb), OCP (breakthrough nl), hypothyroidism, PCOS, adrenal or ovarian tumors b. Structural i. Uterine: Endometrial polyp, fibroid, adenomyosis, cancer (rarely seen before 35yo), endometritis ii. Cervical: cervicitis, cancer iii. Vaginal: vaginitis (BV); trauma; cancer

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Evaluation a. b. c. d. e. Pregnancy Test H/H: Check when bleeding heavy, prolonged. Pap smear; GC; Chlamydia If h&p warrant: Thyroid Function Tests, Coagulation studies Ultrasound i. Used to assess for structural lesions and to assess endometrium and myometrium ii. Hysteroscopy: To further evaluate abnormalities found by u/s; used to biopsy or excise lesions Endometrial Biopsy: After pregnancy excluded. Biopsy if patient has risk factors of endometrial cancer, family history of gyn cancer, estrogen therapy. Would definitely biopsy if patient over 35. Hormonal: Trial of oral contraceptive pills. Infection: Treat according to pathogen Abnormal pap: further evaluation based on results Fibroid/Polyp: Surgical removal PCOS: Progestin

f. 4. Treatment a. b. c. d. e.

#4. 17 yo presents to the ER with RLQ pain 1. H&P a. The usual start: Onset, Location, Radiation, Relationship to meals, fevers, chills, weight loss or gain, nausea, vomiting, diarrhea, constipation, hematochezia, melena, jaundice, change in the color of urine or stool, change in the diameter of stool, vaginal bleeding/discharge; sexual/ob/gyn history b. Physical i. Specifics of Abd exam: BS, tenderness, rebound, masses, is McBurneys point hurting like a mofo. ii. Pelvic Exam: looking for cervical motion tenderness 2. Differential a. GI i. Appendicitis; Obstruction; Diverticulitis; cholecystitis, constipation, gastroenteritis, inflammatory bowel disease b. GU i. Renal: Stones ii. Urinary: Stones, Infection. iii. Genital: 1. Ectopic pregnancy (missed/late cycle, vaginal bleeding) 2. Adnexal cysts or masses with bleeding, torsion, or rupture 3. Pelvic inflammatory disease (fever, leukocytosis) 4. Leiomyomas (abnormal uterine bleeding) 3. Evaluation a. b. c. d. 4. Treatment a. Ectopic pregnancy: Laproscopic resection b. PID: Cephalosporin & Doxycycline c. Ovarian cyst: i. Depends on size 1. <6cm: observe; try OCP to stop further growth; prevent new ones; >8: Ex-lap; cystectomy ii. Palpable Mass: Ex-lap; oopherectomy Chem/CBC/LFTs/Pancreatic enzymes/UA/Pregnancy Test/Stool Guaiac U/S if positive pregnancy test GC/Chlamydia; culture vaginal/cervical secretions CT: R/o nephrolithiasis, appendicitis

d. Ovarian torsion: i. Stable: using laparoscopy uncoil, surgical fixation ii. Vascular compromise/necrosis: USO e. Leiomyomas: i. Decrease estrogen: medroxyprogesterone; gnrh ii. Myomectomy ----------------------------------------------------------------------------------------------------------#5. -- 17 yo presents with mother for evaluation of amenorrhea. OK, 17 is not a legal adult, so save the pregnancy question for when mom is out of the room. Tricky buggers. First step is to take a full H+P, need to see if this is primary vs. secondary amenorrhea. Primary amenorrhea - lack of menses by the age of 16, or 4 years after onset of breast development: 3 categories Outflow tract abnormalities: 1) Imperforate hymen- causes the back-up of menses in the vagina and uterus, causes symptoms of abdominal pain and later swelling of the uterus. Treatment is surgically incising and sewing open the hymen 2) Transverse vagina septum- caused by failure of Mullerian and urogenital sinus derived components to fuse. Treatment is surgical resection 3) Vaginal agenesis- failure of mullerian system to develop partially or completely. Pts are 46XX, have ovaries, may or may not have uterus. A neo-vagina may be created using serial dilators or surgery. 4) Testicular feminization- phenotypic females who are 46XY, but lack functional testosterone receptors. Mullerian inhibiting factor secreted by the testes prevent the development of the uterus and inner 2/3 of the vagina. Often have a blind pouch vagina. Treatment is creation of a neo-vagina 5) Vaginal atresia- female reproductive tract is present, but distal vagina is composed of fibrosed tissue. Treatment is creation of a neo-vagina connected to the upper genital tract, these patients are capable of reproduction. Central disorders: 1) Kallmann Syndrome- hypogonadotrophic hypogonadism caused by a congenital absence of GnRH. Usually associated with anosmia. 2) Other causes of hypogonadotrophic hypogonadism- can be caused by tumors, trauma, sarcoid, tuberculosis, or other disruption of the pituitary outflow tract. Loss of GnRH pulsatility can be caused by anorexia, extreme stress, hyperprolactinemia, or delayed puberty. 3) Pituitary dysfunction- very rare, caused by lack of FSH and LH. Can be caused by tumors, surgery, irradiation, or hemosiderosis causing iron deposits in the pituitary. End-organ disorders: 1) Ovarian failure- will have hypergonadotropic hypogonadism. a) Savage Syndrome- failure of ovaries to respond to FSH and LH due to receptor defect b) Turner syndrome- ovaries undergo rapid atresia 2) Gonadal agenesis- 46XY with defect in testicular enzyme for steroid production, typically 17a-hydroxylase. Differentiated from testicular feminization by lack of breasts because of lack of estrogens. 3) Swyer syndrome- congenital absence of testes in 46XY, have internal and external female genitalia, no estrogen

Work up of primary amenorrhea: 1) Physical exam to determine presence of uterus, patency of the hymen and vagina, presence of breasts 2) Karyotype, followed by testosterone and FSH assays Secondary amenorrhea- absence of menses for three menstrual cycles, or a total of 6 months in someone who previously had normal menstruation. Most common cause is pregnancy. Anatomic: 1) Asherman syndrome- intrauterine synechiae or adhesions, usually due to surgery or infection 2) Cervical stenosis- usually caused by scarring of os by surgery or trauma (i.e. a kid with a giant brain, Im looking at you Bendo) Ovarian Failure: caused by ovarian torsion, surgery, infection, radiation, or chemo. Premature ovarian failure (POF) is usually idiopathic, happening before age 40. Pts. With POF are treated with estrogens to lower cardiac and osteoporosis risks. Polycystic Ovarian Disease (PCOD): Chronic anovulation leads to elevated estrogens and androgens, the androgens are converted peripherally by adipose tissue to estrogen. The hyperestrogenic state leads to an increased LH:FSH, which causes further anovulation and increased androgen production. Signs and symptoms- amenorrhea, hirsuitism, obesity, polycystic ovaries, insulin resistence, hyperinsulinemia. Treatment is with ovulation induction using clomiphene. Losing weight, corticosteroids, and treating hyperinsulinemia with metformin can all raise the success of ovulation induction. If pt. not currently interested in fertility, can give progestins to lower risk of endometrial cancer secondary to unopposed estrogen. Hyperprolactinoma: Excess prolactin cause amenorrhea and milk production. 1) Primary hypothyroidism- TRH also stimulates prolactin secretion 2) Empty sella syndrome- dopamine secreted by the hypothalamus inhibits the secretion of prolactin, if the hypothalamus is prevented from secreting dopamine, prolactin levels will rise. Diagnosed by MRI 3) Drugs- dopamine antagonists (haldol, raglan, phenothiazines), TCAs, estrogen, MAOIs, and opiates. Hypogonadotrophic hypogonadism- see above Work-up: 1) Always get a B-hCG first. 2) TSH and prolactin levels 3) H and P with drug history, cranial nerve test, breast exam (attempt to express milk) 4) Progesterone challenge test- attempts to assess adequacy of estrogen levels, will have menses upon withdrawal of progestin if estrogen present in sufficient quantities and outflow tract normal. 5) FSH and LH levels to assess for hypothalamic/pituitary disorder (low/normal FSH and LH levels) vs. ovarian failure (high FSH and LH due to loss of estrogen feedback) --------------------------------------------------------------------------------------------------------------#6. 45 yo presents to the office with complaints of bladder problems Want to get a full H and P, focusing on OB/GYN history, such as vaginal births (including episiotomies) and any other genital surgeries. Also get history of any conditions that cause chronically increased abdominal pressure (cough, straining, ascites, pelvic tumors). Ask for signs and symptoms of incontinence, pelvic pain and pressure, or feelings of incomplete voids. On physical exam, be sure to

check for a cystocele, an anterior bulge in the vagina as well as doing a thorough neurological exam. Send a urinalysis and urine culture. Pelvic relaxation can lead to urinary incontinence. Treatments for pelvic relaxation include: hormonal therapy to improve tissue tone and reversal over vaginal mucosa atrophy, kegel exercises to strengthen the pelvic musculature, Vaginal pessaries to mechanically support the interior of the vagina. Surgical treatment includes a colporrhaphy to repair the fascial defects the bladder or other structure is herniating through. Also want to treat any underlying conditioning that causes increased intraperitoneal pressure. Urinary incontinence: Occurs when pressure in the bladder is greater than the pressure in the urethra. Pressure in the urethra is maintained by the internal and external sphincters, and the junction of the internal sphincter and bladder (urethrovesical junction) is located anatomically so that any increase in the intra-abdominal pressure will be translated equally to the bladder and urethra, so no pressure gradient will be created. The sympathetic nervous system (delivered via the hypogastric nerve, T10 to L 2) provides resting tone to the bladder neck and internal sphincter, providing continence. The parasympathetic system (via the pelvic nerve, S2-4) controls relaxation of the sphincter and bladder neck, and contraction of the detrusor muscle of the bladder. Finally, the external sphincter is under somatic, voluntary control. Incontinence specific tests: 1)Standing stress test- pt. With full bladder stands over towel and coughs, physician observes and verifies loss of urine, pt. Then said to have genuine stress incontinence. 2) Cotton swab test- lubricated cotton swab is inserted into urethra to the urethrovesical junction, when pt. strains to urinate the change in the angle of the cotton swab is noted. Normal is less than 30 degrees, 3060 degrees is associated with a hypermobile bladder neck. 3) Cystometrogram- uses pressure sensor to determine detrusor stability while bladder is filled, used to distinguish stress incontinence vs. detrusor instability. 4) Uroflowmetry- measure rate of urine flow in pts complaining of hesitencey, incomplete voiding, and poor stream. Stress incontinence: Caused by increase in intra-abdominal pressure. This is usually a result of descent of the bladder neck with an unequal transfer of pressure to the blader vs. the urethra. In some cases it is caused by weakness of the internal sphincter and is called intrinsic sphincter deficiency. Pts will describe involuntary loss of urine with coughing, laughing, sneezing, and straining. In severe cases it can also be with minor pressure changes caused by walking or changing position. Three main risk factors are pelvic relaxation, increased intra-abdominal pressure, and menopause. There are no good medical treatments, but Kegel exercises to strengthen the pelvic muscles, pessaries for mechanical support of the bladder neck, alpha-adrenergic agents to increase sphincter tone and increase closure, and topical and systemic estrogen to increase vaginal mucosa quality. Surgical treatments aim to suspend the bladder neck in its usual anatomic position, such as slings. Detrusor instability: Also called urge incontinence, it is caused by involuntary and uninhibited detrusor contractions. Most cases are idiopathic, but it can also be caused by UTIs, bladder stones, cancer, suburethral diverticula, and foreign bodies. Pts describe urgency, frequency (>8 times a day), stress incontinence, and nocturia. May lose continence just seeing or thinking of the bathroom Can be treated with behavior modifications (regularly scheduled voids with gradually lengthening intervals until cortical control is reestablished). Medical therapy aims to increase storage capability. Anticholinergics block the parasympathetic relaxation of the sphinters (Pro-Banthine, oxybutynin). Smooth muscle relaxants decrease frequency of bladder contractions (detrol, tolterodine). Imiprimine has both anticholinergic activity and alpha-adrenergic activity which activates the sympathetic system, promoting contraction of the bladder neck and internal sphincter. There are no effective surgeries for detrusor instability. Total incontinence: Caused by urinary fistulas between the urinary system and the GI system or vagina. Often caused by obstetric trauma, pelvic radiation ,and pelvic surgery. Pts. Have a painless and continuous loss of urine. Methylene blue dye injected into the bladder will leak from a bladder or urethral fistula. Indigo carmie injected i.v. will filter through the kidney and will

reveal any fistulas involving the ureters. Cystourethroscopy can be used to locate and identify fistulas, as can intravenous pyelogram and retrograde pyelogram. Surgical repair is treatment of choice. Obstetric fistulas can be repaired immediately, but it is typical to wait 3 to 6 months to fix surgical fistulas. Antibiotics are commonly given during this waiting period. Overflow incontinence: caused by detrusor insufficiency or areflexia is usually secondary to another process such as: fecal compaction, medications, neurological diseases, autonomic neuropathy (diabetes), spinal cord injuries, and MS. It can also be due to outflow obstruction form urethra stenosis or kinking caused by surgery. Pts complain of constant dribbling, stress incontinence, and urge incontinence. Obstruction symptoms include retention, straining to void, and poor stream. Treatment focuses on reducing urethral closure pressure (prazosin, terazosin, and phenoxybenzamine), striated muscle relaxants (diazepam, dantrolene). Cholinergic agents (bethanechol) can be used to increase bladder contractility. Self catheterization can also be used to relieve symptoms. In the event of an obstruction, surgery to correct the obstruction should be employed. ---------------------------------------------------------------------------------------------------#7. 52 year old presents in referral from her PCP for postmenopausal bleeding. -Definition = vaginal bleeding occurring more than 12 months after menopause (some sources say anything persisting for more than 6 months should be investigated) -Is ALWAYS abnormal and should be investigated to R/O cancer Differential Non-GYN causes: -Rectal bleeding from hemorrhoids, anal fissures, rectal prolapse, and lower GI tumors -Urethral caruncles Lower genital tract bleeding: -Vaginal atrophy = most common source -Lesions of vulva, vagina, or exocervix Upper genital tract bleeding (pathologic) - what we are generally most worried about -Cervical polyps or cancer -Endometrial atrophy, polyps, hyperplasia, and cancer - the most common cause of bleeding in these women is atrophy of the vaginal mucosa or endometrium Diagnosis: -H&P, with careful inspection of the external anogenital region, vagina, and cervix history - trauma? bleeding diathesis? meds (e.g. tamoxifen, coumadin?) physical - we want to know where the bleeding is coming from - pelvic exam essential - general exam to look for signs of systemic illness Digital Rectal Exam and occult blood screening -Pap Smear - All women need cervical cytology testing (eg, Papanicolaou (Pap) smear) as part of the evaluation of abnormal bleeding as it can be difficult to distinguish between cervical and upper uterine bleeding. Any visible lesion needs to be biopsied, even if the Pap smear is normal. -Endometrial biopsy if there is no obvious non-GYN or lower genital tract etiology - Endometrial biopsy is the standard technique for endometrial monitoring. Office-based endometrial biopsy is preferred to D&C (dilation and curettage) because it is less invasive and more cost-effective, with comparable sensitivity and specificity.

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-Transvaginal ultrasound (TVS) can identify polyps and examine thickness of endometrial stripe (NL < 5 mm) - important to note that if thickness of endometrium is less than 5 mm the likelihood of hyperplasia is very low so question - to biopsy or to use TVS as initial step? Either transvaginal sonography or endometrial biopsy can be used safely and effectively as the first diagnostic step. Whether sonography or endometrial biopsy is used initially depends on the physician's assessment of patient risk, the nature of the physician's practice, the availability of high-quality sonography, and patient preference. Similar sensitivities for detecting endometrial carcinoma are reported for transvaginal sonography when an endometrial thickness of greater than 5 mm is considered abnormal and for endometrial biopsy when "sufficient" tissue is obtained. -Hysteroscopy and/or D&C - indications for D&C include: Px's with a nondiagnostic office biopsy who are at high risk of endometrial carcinoma Px's with insufficient tissue for analysis on office biopsy cervical stenosis prevents the completion of an office biopsy Treatment: -endometrial biopsy or D&C may be curative. Simple endometrial hyperplasia calls for cyclic progestin therapy for 21 days of each month for 3 months. A repeat endometrial biopsy should be performed. If endometrial hyperplasia with atypical cells or carcinoma of the endometrium is found, hysterectomy is necessary. -If systemic or medication related treat underlying cause or remove/alter underlying drug -Referral if suspected GI etiology -Biopsy lesions of vulva and vagina -Repair mucosal lacerations -Estrogen cream for vaginal atrophy -H/H if heavy bleeding - stabilize patient if neccesary -Endometrial hyperplasia -Simple = monitor with repeat endometrial biopsies -Complex or Atypical = progestin therapy; hysterectomy if no reversal or if recurrence -Removal of endometrial polyps by hysteroscopy or D&C -----------------------------------------------------------------------------------------------------------------------#8. 63 year old presents in referral for incidental finding on CT scan after MVA of right adnexal mass. a. Age: older think stromal tumors or epithelial tumors (most common) b. Must rule out cancer c. To do: i. US ii. Pelvic exam iii. Colonoscopy iv. Tumor markers d. Dermoid: this is the most likely according to Dr. Evans, my preceptor. Refer to question 9 for more detail. Since this is an incidental finding, the dermoid would most likely have been there since she was little, would show lots of calcifications, and would not need to be removed. In a younger patient, as I describe in the next question, the dermoid cyst would get removed. e. Epithelial tumors: i. Risk factors: white, obesity, high fat, nulliparity ii. Protective: tubal ligation, hysterectomy, breast feeding, ocps

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Most commonly sporadic disease- tumor suppressor 10% inherited- BRCA1, BRCA2, HNPCC No good screening/prevention Generally asymptomatic at beginning, then can experience pain, urinary and bowel changes, pelvic mass, and fluid wave vii. Serous most common histologic type. Other types: mucinous, endometriod, clear cell, brenner viii. Risk for primary peritoneal carcinoma because same lining as ovary ix. Management: 1. diagnose with laparotomy/laparascopy, stage, and cytoreduction (debulk) 2. stage 1A-1B, grade 1-2 need no adjuvant therapy 3. stage 1 grade 3 and higher need chemo (taxol and cisplatin) 4. advanced, can add radiation 5. ip chemo with optimal resection 6. follow with CA-125 f. stromal tumors: see question 9 g. Metastasis from another primary cancer..must be treated obviously h. Colon cancer: It is hard to differentiate adnexal masses vs. colon masses on a CT. Do colonoscopy to rule out colon cancer. i. Fibroids: homogenous on scan, also made of calcium, take out if becomes symptomatic -------------------------------------------------------------------------------------------------------------------#9. A 16 year old presents to the ER with abdominal pain. US reveals 10x12x8cm mass. j. AGE: young think germ cell tumors or stomral tumors, old think epi cell tumors or stromal tumors k. H&P: find associated signs/symptoms/physical exam findings i. ****have u ever had a period? If not think obstruction or weird stuff like testicular feminization l. Vitals: look for febrile, htn, tachycardia m. US will help decide benign vs malignancy i. Help define etiology by components: benign vs malignancy 1. benign simple cyst 2. malignant: septations, solid componenets, growth on surface or inner lining of ovary n. lab tests- guided from h&p findings i. pregnancy test-ectopic ii. B-HCG level- ectopic iii. Tumor markers 1. CA-125 (more for older women), AFP, LDH, hCG iv. CBC- increased wbcs point to infection v. ESR- elevated in TOA vi. Blood cultures- sepsis from ruptured TOA vii. Endocervical swabs- look for infection o. Germ cell tumori. Presents as pelvic mass and pelvic pain, ascites, pleural effusion ii. Tumor markers, karyotype iii. Complications: torsion- more common in younger patients, rupture-rare iv. Dysgerminoma- most common malignant germ cell tumor 1. risk of bilateral disease 2. LDH 3. abnormal karyotope (risk) 4. txt: unilateral oopherectomy, staging, chemo for recurrent of metastatic (BEP), sensitive to radiation but causes ovarian failure v. Mature Teratoma (dermoid cyst) 1. Benign cystic teratoma, struma ovarii, carcinoid 2. 1-2% risk of malignancy

iii. iv. v. vi.

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3. txt: unilateral oopherectomy with staging vi. primitive germ cell tumors 1. immature teratomas- immature neural elements 2. endodermal sinus tumor- AFP 3. embryonal carcinoma 4. ovarian choriocarcinoma 5. all receive oophorectomy and chemo except stage Ia, grade 1 immature teratoma does not need chemo p. stromal tumors i. granulose cell tumor secrete estrogen, menstrual irregularities, endometrial hyperplasia, follow inhibin 1. uni oophorectomy and staging and sample endometrium ii. sertoli-leydig tumors- secrete androgens 1. usually women 30-40 2. virilization 3. txt: uni oophorectomy with eval of contra ovary q. Endometriosis- most common site is ovary i. 7x increased risk with first degree relatives with this ii. Associated with autoimmune diseases iii. Reproductive age iv. Hallmark is cyclic pelvic pain, also presents with dysmenorrhea, dyspareunia, abnormal bleeding, and infertility v. Definitive diagnosis is with direct visualization: laparoscopy/laparotomy vi. chocolate cysts vii. Txt: 1. medical with nsaids, ocps danazol, GnRH agonists 2. surgically: ablation or TAHBSO and removal of lesions r. TOA i. Persistent pid can lead to this ii. Increased WBCs, increased ESR, adnexal or post cul-de-sac mass iii. Cultures: endocervical swab and blood cultures, rule out sepsis iv. Can diagnose with US, may need CT, or definitively with laparatomy/laparascopy v. Txt: if ruptured, OR, but if not can txt with iv broad spectrum antibiotics (cefoxitin and doxycycline) (amp, gent and clinda or metro) until about 48 hrs after being afebrile, then pelvic exam preformed to look for resolution of symptoms, then can switch to PO meds as outpatient to finish course of 10-14 days of antibiotics. s. Testicular feminization: i. Karyotype XY ii. Very feminine, very pretty, lots are models..(according to Dr. evans!) iii. Must take out testes because high risk of cancer

Ectopic pregnancy i. Risk factors: assisted fertility, stds, pid, prior ab surgery, prior ectopic ii. H&P: unilateral pelvic pain or lower ab pain, vaginal bleeding, adnexal mass, small uterus for GA iii. Low b-hcg level for GA iv. Transvaginal US v. Txt: stabilize patient if rupture occurs and take to OR, if stable and not ruptures watch for signs of rupture, can txt with laparascopic resection or use methotrexate for nonthreatening, uncomplicated ectopics. ---------------------------------------------------------------------------------------------------------------#10. A 19 year old presents to the office for routine "annual" exam and to start hormonal birth control. I approached this question first by looking at the components of a standard gynecologic history and physical and then reviewing birth control options.

t.

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Normal PMH/PSH/FH/SH/PE/ROS is a given for every patient: I will highlight the importance of the gyencolgic history and physical - but do not forget the following! for any woman about to go on birth control ask about history of clots, bleeding issues, smoking, etc - anything that points to an increased risk of hypercoagulability... GYNECOLOGIC HISTORY maintain a sensitive and nonjudgmental approach during this encounter Basic history The basic information required by the gynecologist: menstrual history (age of menarche, cycle length and regularity, history nonmenstrual bleeding, dysmenorrhea, any postcoital bleeding, date of LMP, date of prior normal LMP) sexual history obstetrical history (history of all pregnancies, make sure to ask specific questions about miscarriages/terminations as some women will not include these type of contraception, past or current pap smear history (date and result of last smear; diagnosis and follow-up of abnormal Pap smears) history of gynecologic procedures (eg, endometrial biopsy, laparoscopy, curettage) history of STD's or other pelvic/vaginal/vulvar infections; treatments Genitourinary and breast ROS (abnormal vaginal bleeding, amenorrhea, pelvic pain, vaginal dryness, discharge, h/o UTI's, urinary changes) GYNECOLOGIC EXAMINATION Clinically, the pelvic examination is often linked to cervical cancer screening. Guidelines advise the first test be performed within three years of coitarche or at age 21, whichever comes first. The American College of Obstetricians and Gynecologists (ACOG) continues to recommend annual pelvic examinations for adult women. This examination may be performed in association with cervical screening. so the definitive answer if asked should you give a Pap smear on this 19 year old patient would be to state that The ACOG recommends that cervical cancer screening should be started approximately three years after the onset of sexual activity, but no later than age 21. So if she just started intercourse at age 18 for example, it is not indicated. Now keep in mind, ACOG recommends annual PELVIC exams, so do not trip up when differentiating the two. components of the gynecologic exam: A complete gynecologic examination consists of evaluation of the breasts, abdomen, internal and external genitalia, and rectum. It is generally performed cephalad to caudad with examination of external organs before internal ones. always remember the importance of noting patient anxiety, and the need for a chaperone breast exam - questionable utility in a young woman such as this, but good to introduce the technique and importance of regular exams external genitalia - inspection and palpation, hair distribution, skin, labia minora and majora, clitoris, introitus, perineal body, and urethral meatus are evaluated for developmental abnormalities, skin lesions (eg, discoloration, ulcers, plaques, verrucous changes, excoriation), masses, and evidence of trauma or infection. vagina - speculum exam. If abnormal discharge is identified it should be evaluated for volume, color, consistency, and odor. The pH of normal discharge is less than 4.5, an elevated pH can be due to infection (eg, bacterial vaginosis) or exogenous substances bimanual exam - The vagina, cervix, uterus, adnexa, and cul-de-sac are palpated after the speculum examination, so that the glove lubricant will not interfere with cultures or cytologic samples. The abdominal hand should be used to sweep the pelvic organs downward, while the vaginal hand is

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simultaneously elevating them. It should only take a moment to determine the size, shape, symmetry, mobility, position, and consistency of the uterus. If you have worked with Dr. Hull you know he will ask you about the 5 components of the bimanual exam. The adnexal areas are checked for the presence of appropriately sized, mobile ovaries (eg, about 2 by 3 cm), which are normally somewhat tender. Palpable ovaries in postmenopausal women (postmenopausal ovary syndrome) are not a "normal" finding (detectable in about 30 percent of postmenopausal women and require investigation, although most are associated with benign or no disease. When adnexal masses are detected, they should be described as to location, size, consistency, mobility, and degree of tenderness. Rectovaginal examination - The final component of the gynecologic assessment is the rectovaginal examination. This allows optimal palpation of the cul-de-sac and uterosacral ligaments, as well as the uterus and adnexae. OVERVIEW OF Hormonal CONTRACEPTION so before reviewing the types of combined and progesterone only OCP's, it is important to always note that while they will help prevent pregnancy sexually transmitted diseases are not prevented by use of non-condom contraceptive methods go over the methods available and the individual side effects and method of delivery of each as well as advantages and disadvantages of each option here are 10 questions to ask anyone considering contraception. 1. What are your contraceptive goals? Do you ever plan to get pregnant? When? 2. Are you currently having sex with a male partner? 3. Have you tried any contraceptive methods? If so, which one(s)? 4. What did you like/dislike about the method(s)? 5. Are you a good pill taker? 6. For user-controlled methods, how often did you forget to use the method? 7. Are there any methods you have heard about and would like to try? 8. How important is spontaneity of use? 9. Is protection from sexually transmitted infections important considering your life situation? 10. Is cost an issue? Does your health insurance plan cover any contraceptive method? Now to the overview: Hormonal contraceptives may be taken orally, injected, or released from a subdermal implant, transdermal patch, or intrauterine or intravaginal contraceptive device. Combined method: OCP's - come in either combination progesterone and estrogen or estrogen only forms - 1/3 of sexually active women in US use OCP's - MOA - place body in pseudopregnancy state by interfering with pulsatile FSH/LH release, this suppresses ovulation preventing pregnancy...because the FSH and LH surge is suppressed in the middle of the menstrual cycle, follicle growth, recruitment, and hence ovulation do not occur. Monophasic vs Multiphasic Pills - difference is that monophasic pills have a fixed dose of estrogen/progesterone while multiphasic have varying doses leading to the advantage of providing a lower level of estrogen and progestin overall How to pick from the dozens of pills? base it upon the side effect profiles and risk factors of the individual patient, not all ocps have the same S/E's - OCP's when used perfectly have a failure rate after 1 yr of use of less than 1%; in real life this is closer to 3% as some patients miss pills and many medications can interact with and alter the pills effectiveness Side effects of OCP's? cardiovascular - thromboembolism, PE, CVA, MI, HTN - note that these complications tend to occur mainly in smokers on OCP's other - benign hepatic tumors, gallbladder disease OCP's are contraindicated in women over age 35 who smoke cigarettes

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weight gain, bleeding, breast pain, menorrhagia - all may lead to px non-compliance Advantages and disadvantages? adv - high efficacy rates, reduced incidence of ovarian cancer, endometrial cancer, ectopic pregnancy, PID, and benign breast disease. Other health benefits of OCP's include alleviation of quality of life problems such as dysmenorrhea, and osteoporosis. Disadvantages include the discussed side effects and the lack of protection offered from STD's when not used with condoms. Combined method: Monthly Injectable same end MOA as ocp's (pseudopregnancy state) - must visit doctor once a month, no long-term studies available as it has only been around since 2000, but has been shown to have .2% 1 year failure rate - advantages include not having to remember to take pill everyday, but does require monthly visit to doc., this may be considered advantage or disadvantage depending on px preference...same health benefits as ocps -disadvantages include same s/e's as OCP's Combined method: Transdermal Patch change patch weekly with patch free week every 4th week; same MOA as ocp's 1% failure rate same primary s/e's and health benefits of OCP's but can cause skin irritation Progesterone Only Contraceptives include: progestin-only OCP's, Injectable Prog (Depo-Provera) MOA - makes cervical mucous less permeable to sperm, endometrtium also becomes less appropriate for implantation via progesterone-induced atrophy PROG-ONLY OCP's another pill taken daily; high failure rate compared to combination pills (as high as 3-6%) side effects - irregular ovulatory cycles, breakthrough bleeding, ectopic pregnancy advantages - because they do not contain estrogen, ideal for nursing mothers and women for whom estrogens are contraindicated (i.e. 35+ y.o. smokers) disadvantages - failure rate much much higher Injectiable Progesterone-Only - DEPO injected IM once every 3 months - suppresses ovulation, thickens cervical mucus, makes endometrium unsuitable for implantation effectiveness - 1st year failure rate .3% (so very effective) side effects - irregular menstrual bleeding (>70% experience spotting and irregular menses during 1st year of use, so primary method of discontinued use), depression, wt gain, hair loss, breast tenderness advantages/disadvantages - highly effective, only requires injection 4 x a year - disadv = irregular bleeding, wt gain, mood changes discouraged in women with depression bleeding problems tend to go away after abuot the 3rd or 4th injection discontinuation of depo may result in a delay in the return of regular menses (6 to 18 months) after which time fertility returns to normal levels

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summary quick and dirty table of gyn history from up2date The gynecologic history I. Menstruation A. Menarche B. Last menstrual history (LMP) C. Menstrual pattern - cycle, interval, duration of flow, amount of flow, moliminal symptoms, dysmenorrhea, intermenstrual bleeding D. If postmenopausal - age at last menses, recent vaginal bleeding, vasomotor symptoms, hormone replacement therapy II. Obstetric history A. Gravidity B. Description of each pregnancy - date, outcome, complications III. Birth control A. If sexually active, current method - satisfaction, problems, need for change B. Past methods C. If sterilized, date and method IV. Sexual history A. Type B. Orgasmic C. Dyspareunia D. Problems, concerns, questions V. Infertility A. Ever difficulty conceiving? B. Ever evaluated or treated for this problem? If so, describe VI. Pap smear history A. Last Pap test B. Usual frequency C. Any abnormals? - diagnosis, treatment, follow-up VII. Infection A. Vaginal discharge - onset, pattern, color, odor, symptoms B. Prior vaginal infections - type, frequency, treatment C. Sexually transmitted diseases D. Pelvic inflammatory disease VIII. Pelvic relaxation A. Prolapse B. Vaginal relaxation C. Urinary retention D. Urinary incontinence - description, duration, severity

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#11. A 16 yo pregnant female comes to L&D complaining of severe HA and persistent n/v. Differential: Preeclampsia Just about anything else - meningitis/encephalitis, hepatitis, TTP, ITP, sepsis, appendicitis, acute fatty liver of pregnancy, pylo, etc. Preeclampsia: Wks 20+ with BP > 140 or > 90 and protein > 300 mg/24h...+/- edema. non-criteria but may encounter - oliguria, SOB, RUQ pain, N/V, spontaneous bleeding, HA, visual disturbance/scotoma Why: Endothelial damage? Consider: Often asymptomatic. Prenatal checkup screenings! Consider: May be symptomatic 4-6 wks postpartum What next: H&P - Risks are primigravida, obesity, pre-existing HTN, multigestational, extremes of age, underlying medical condition, prior preeclampsia PE/VS CBC/Chemistry/LFTs/UA if suspect HELLP also hepatic U/S or CT Then: Labetolol/hydralizine Magnesium Possibly transfuse if hemolysis **Delivery** - If baby mature or steroid candidate - If mother well or not very well D/C to home with antihypertensive if indicated Complications: Stroke Seizure Heart failure Hepatic rupture Kidney damage Placental abruption ---------------------------------------------------------------------------------------------------------------------------------#12. A 25 y/o G1P0 presents with complaints of 2 yrs infertility. Infertility - have tried to get pregnant for one year Primary - never conceived Secondary - one year since last conception H&P - medical, surgical, gyn/obst, sexual, social, menstruation, therapy trials What goes wrong: Sperm, Ovary, Uterus/tubes, Cervix Sperm: Why: Endocrine (hypothal, pit, thy, adrenal), radiation, sexual dysfx, cryptorchidism, antisperm antibodies How to know: Semen analysis, post coital test, endocrine tests

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What to do: coital technique, IVF/GIFT, donor sperm Ovary: Why: Hypothal-pit-ovarian axis for any reason, tumor, premature failure, obesity/anorexia How to know: Meticulous menstrual history, temp vs LH kit vs *serum progesterone*, hirsute/obese, EMB, progestin challenge What to do: Clomiphen citrate (increase pulsatile GnRH), gonadotropins +/- IVF/GIFT, egg donation/surrogacy Uterus/tubes: Why: Endometriosis, fibroids, PID, prior surgery, Asherman's, congenital How to know: HSG, hysteroscopy, L/S What to do: Hysteroscopy w/ LOA, myomectomy, tuboplasty, IVF Cervix/mucous: Why:stenosis/scarring, mucous quality How to know: mucous studies, post coital test What to do: mechanical dilation (a cause and a treatment), IUI Probably should seek specialist if cause is not readily apparent.... --------------------------------------------------------------------------------------------------------------------------#13. 35 y/o presents to office c/o pelvic pain and abnormal cycles. a. First obtain History. Ask pt how long she has had abnormal cycles and about menstrual cycle bleeding pattern including timing of bleeding, quantity of bleeding and menstrual history with menarche, recent periods, and associated symptoms (dyspareunia, infertility, etc.). Make sure to also include family h/o bleeding d/o including menorrhagia appearing at menarche. Determine if pt has menorrhagia, metrorrhagia, or menometrorrhagia. Also make sure to find out if pt pelvic pain is associated with menstrual cycle or when pain occurs. b. Next perform PE. Make sure to r/o rectal, urethral, vaginal, and cervical causes of bleeding. ( hemorrhoids, lacerations, cervical cancer) On bimanual exam feel for any uterine, or adnexal masses or uterine or adnexal tenderness. On rectovaginal exam make sure to feel for any uterosacral nodularity or a fixed or retroverted uterus. Perform a pap smear in order to screen for cervical cancer and obtain cervical cultures to r/o infection. c. Next order labs/tests. Include hcg, CBC, TSH, and prolactin. Any woman age 35 or older with abnormal uterine bleeding should receive an endometrial biopsy to help r/o endometrial hyperplasia and cancer. Pelvic U/S can be obtained to identify fibroids, adenomyosis, hyperplasias, cancers, adnexal masses, and endometrial polyps. MRI can be used to distinguish between fibroids and adenomyosis. If intrauterine pathology is suspected on pelvic U/S HSG can be done to show intrauterine defects. Hysteroscopy will allow direct visualization of the intrauterine cavity. Laparoscopy or laparotomy is the only way to definitively diagnose endometriosis. D&C can provide tissue for diagnosis. d. Finally there is treatment. Table 22-2 Bleeding Disorder Bleeding Amount Typical Treatment Uterine fibroids Heavy Myomectomy vs. Hysterectomy Adenomyosis Heavy Hormonal management vs. hysterectomy Cervical polyps Light Polypectomy in office Endometrial polyps Heavy Hysteroscopy, polypectomy +/- D&C Endometrial hyperplasia Varies Progestin therapy vs.

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Endometrial Cancer Pregnancy problems Pregnancy Miscarriage Ectopic Pregnancy Hormonal problems Hypothyroidism Hyperprolactinemia Anovulation

Heavy Varies Heavy Varies Varies None Varies

hysterectomy Hysterectomy, BSO, radiation Expectant management vs. delivery Expectant management vs. D&C MTX vs. Surgical removal Thyroid hormone replacement DA agonists Cyclic OCPs or progestins

e. If none of these produce diagnoses to explain abnormal uterine bleeding then consider DUB. In a woman of this age who is still in her reproductive years there is increased risk of structural and hormonal causes of uterine bleeding which should be eliminated. An effort should be made to determine if pt is ovulating (BBT/ovulation prediction kits). Should also consider pathologic anovulation such as hypothyroidism, hyperprolactinemia, hyperandrogenism, and PMOF. Treatment for DUB depends on cause and age of pt. Nonhormonal treatment with NSAIDs can decrease menstrual blood loss by 20% to 50%. This therapy is reserved for ovulatory women with DUB. This may be used alone or in conjunction with estrogen and progesterone therapy. If pt is not responsive to medical management surgical intervention with D&C can help diagnosis and be therapeutic. Endometrial ablation can also be used but hysterectomy is the definitive surgery for DUB. ---------------------------------------------------------------------------------------------------------------#14. 25 y/o presents to ER 4 days after hysterectomy with c/o severe pelvic pain, N/V. f. First obtain history. Find out when the onset of this severe pain was, duration, nature including sharp/stabbing/dull, intensity, and location of pain and what makes it better or worse. Find out when N/V started and how many episodes have occurred. Find out if it occurs after intake of food or in association with medications. Ask about any other associated symptoms including heavy vaginal bleeding or leakage of fluid from wound site or fevers. Also ask if pt has had any flatus or BMs. Also ask how often pt has been urinating and if they have noticed any difficulties with this. g. On PE examine the incision site. Look for any signs of wound infection, dehiscence, or evisceration. Make sure to localize the pain and look for any abdominal distension or abd/pelvic areas of swelling. Make sure to note any flank and groin pain vs. abdominal pain. Also look for signs of dehydration. Make sure to listen for decreased or absent bowel sounds. Check for excess amounts of blood on pelvic exam. h. Next think about labs/tests. Obtain CBC to look for any signs of sig blood loss and chem. 7 to look at electrolytes for any signs of metabolic alkalosis (maybe associated with vomiting secondary to bowel obstruction) or elevation of creatinine which could suggest ureteral injury (>0.3mg/dL above preoperative values). Cystoscopy/IVP/ Ultrasound can be done to help try and r/o ureteral injury. U/S of pelvis or CT could also help to identify a seroma/hematoma or abscess formation. Can obtain Abdominal films/Abd pelvic CT/Barium enema to r/o bowel obstruction. Abdominal films and CT could also show evidence of any retained foreign objects from surgery. i. If pt has ureteral injury, bowel obstruction, vaginal cuff evisceration, or retained foreign object these would be surgical emergencies requiring immediate transport to the OR. If pt has a wound infection/hematoma/seroma then treatment will include opening the wound and draining the purulence/fluid. Could also closely observe seroma/hematoma and follow with imaging to see if it resolves. If pt has a fascial disruption then this would also require immediate repair. If pt has a pelvic abscess then U/S guided drainage can be done for treatment. All situations predisposing or related to infection would require treatment with a broad-spectrum antibiotic.

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---------------------------------------------------------------------------------------------------------------#15. A 54 year old presents with complaints of 3 yr h/o hot flushes/night sweats and difficulty concentrating. Previously, a physician talked to her about HRT and she would like to re-discuss her options. Menopausal transition begins mid-late 40s, avg age of menopause 51 Symptoms Hot flashes exact etiology unknown, ? estrogen withdrawal, involves anterior hypothalamus (cooling system) Vaginal Atrophy estrogen necessary for maintenance of vaginal Epithelium Sleep Disturbance Physiology ovulation ceases, decreased estrogen/progesterone from ovary, increased FSH (lack of negative feedback); ovaries still produce testosterone, small amounts of estrone from peripheral conversion of adrenal steroid precursors **obese pts likely have less symptoms b/c of increased peripheral conversion to estrone in adipose tissue Vasomotor Symptoms 65% of menopausal females, resolve within 3-5 yrs in 85-90%; small percentage 10-15% have longer lasting symptoms Options for Vasomotor symptoms of menopause: *Hormone Replacement Therapy *SSRIs (paxil, venlafaxine) *Clonidine *Herbal black cohosh, soy, vitamin E (mixed results, minimally effective) - venlafaxine, paxil, clonidine with inconsistent results may be somewhat effective - by far the most effective tx is HRT which is >90% effective So why the controversy over HRT and what are the current recommendations? Womens Health Initiative (WHI) *15 yr long randomized controlled trial involving 162,000 postmenopausal females *multiple study arms included under this broad initiative Results: A. Estrogen + Progestin in women with a uterus - stopped early in 2002 due to adverse outcomes in tx arm of study - showed > risk CAD events ( relative risk (RR) 1.29), stroke (RR 1.41), pulmonary embolism (RR 2.13), and breast CA (RR 1.26) B. Estrogen alone in women with hysterectomy - stopped early in 2004 due to adverse outcomes - showed > risk of stroke (RR 1.39), but no increase in breast CA or CAD **critics have raised several issues with the study **of note the average age of women in the trial was 63 years old much older than typically started on for menopausal sx (avg age 51) could account for increased risks observed Current recommendations: *not recommended in women with CAD or at high risk for CAD, breast CA or active liver disease *DO NOT give estrogen only to women with a uterus must give combined estrogen + progesterone or will substantially increase risk of endometrial CA *HRT highly effective, safe if given for short period of time and in lowest effective dose - do not give for extended period of time (i.e. >5 yrs) *Another key point while HRT is recommended for relief of hot flashes b/c it is the only highly effective tx, it is not recommended to give long term for the prevention of osteoporosis with the advent of newer bisphosphanates/raloxifene with much safer side effect profiles, these are the better tx for long-term osteoporosis management

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-------------------------------------------------------------------------------------------------------------#16. A 21 yr old with known IUP presents to the ER with vaginal bleeding. A. History and Physical Important HOPI questions: *amount of bleeding quantify by asking amount of pads used/ how often pads changed? *duration of bleeding? *associated leakage of fluid? *depending on gestational age contractions and fetal movements? *trauma? PMH *von willebrands or other bleeding disorder? Physical Exam: *assess hemodynamic stability blood pressure, heart rate, volume status at bedside - if pt is unstable, i.e. from rapidly hemorrhaging ruptured ectopic, this needs to be addressed FIRST *assess uterine size appropriate for dates, large for dates, small for dates? *abdominal pain, adnexal masses (e.g. ectopic pregnancy)? *Sterile Speculum Exam assess vaginal vault for sources of bleeding, examine cervix for dilation (i.e. dilated in complete/incomplete SABs) B. Differential Diagnosis **categorize into First Trimester and Second Trimester causes (being able to list this differential is probably the most important part of the question and this question can pretty much be taken in any direction from here) First Trimester Bleeding *Spontaneous Abortion - Complete - Incomplete - Threatened - Missed *Ectopic Pregnancy *Molar Pregnancy Non-Uterine Causes: - cervicitis (evaluated for G&C, etc.) - bleeding cervical polyps - previously undx cervical malignancy - vaginal or cervical lacerations, post-coital Systemic Causes bleeding disorders Second Trimester Bleeding Placenta Previa Abruptio Placenta Vasa Previa Non-Uterine Causes: same for 1st trimester

C. Work-Up Labs: *Type and screen know maternal and fetal RhD status, as there is risk of materno-fetal hemorrhage with vaginal bleeding during pregnancy *CBC with diff evaluate Hgb, WBC can indicate infection (which may be a cause of pregnancy loss) * Coag Studies INR/PTT, evaluating for bleeding disorders/coagulopathy *B-hCG this is important for the evaluation of ectopic pregnancy and molar pregnancy can follow serial measurements - should double every 48 hrs -discriminatory zone = B-hCG level at which an intrauterine pregnancy can be Identified on ultrasound, usually ~1500-2000 mIU/mL *screen for maternofetal hemorrhage to assess RhoGam necessity erythrocyte rosette test (screen), if positive follow with Kleihauer-Betke test to quantify hemorrhage

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Imaging: *Transvaginal U/S Ectopic no IUP, suggestive if B-hCG above discriminatory zone Molar Preg Snowstorm pattern of hydropic villi in grapelike clusters Placental abnormalities can identify abnormal location, i.e. placenta previa C. Treatments (brief descriptions) General Measures: * Stabilize any hemodynamically unstable pt. * RhoGham to any RhD negative mother. 1) Ectopic pregnancy stable, unruptured tx with methotrexate vs L/S removal Unstable, ruptured tx with open laparotomy 2) Molar pregnancy evacuation with D&C or D&E **follow with serial B-hCG as complete moles have 15-25% chance of persisting as malignancy and incomplete moles have 4% chance if B-hCG decreases after D&C and begins to rise again, this is a persistent mole and should be regarded as malignant (invasive mole vs choriocarcinoma vs PSST) 3) SAB Complete SABs may be monitored with expectant management, incomplete/missed SABs do D&C to ensure complete removal of POC; >14 wks often require D&E 4) Placenta Previa typically delivery by C-Section -------------------------------------------------------------------------------------------------------------#17. A 25-year-old presents for preconceptual counseling and at this visit finds out she is pregnant. Since she is seeing you for preconception counseling, I think its safe to assume that this is a desired pregnancy. Here are some things to cover: 1. Detailed H & P including OB/GYN history. Specific things to ask about might include: - LMP (figure out EDC), nutrition, vitamins, Drug/EtOH/Tobacco - Any new symptoms she is experiencing like bleeding, discharge, leakage of fluid, urinary sx, N/V (if she is experiencing any bleeding or cramping then get a beta HCG quant to r/o ectopic/miscarriage) - if >20wks estimated GA then ask about contractions and fetal movement - OB/GYN hx including Gs and Ps (gestational ages, complications, SAB, TAB, mode of del, birth weight, length of time in labor, Rh antibodies) 2. Determine Gestational age: Best determined by accurate LMP, U/S is most accurate in 1st trimester using crown-rump length. U/S can be used in 2nd and 3rd trimesters using calculations based on measurements of the BPD, AC, femur length. U/S becomes less accurate with increasing GA. 2. Physical Exam: - Pap (unless already done in last 6 mo.), GC/Chlamydia - Bimanual exam. Size of uterus should be appropriate for GA. Uterus becomes palpable at 20wks 3. Tests to order (for 1st trimester) - (I am assuming beta HCG is already done) - CBC, Type and Screen, Ab screen, RPR, Rubella antibody screen, HepB surface Ag, UA, UCx - If no h/o chickenpox then draw a titer for VZV antibodies - PPD - Toxo titers (some order it, some dont. . .its not required) - Offer HIV - Depending on the estimated GA you could also get FHT (>12wks), Fundal Height (>16wks), Nuchal Translucency (11-14wks, this isnt standard but should be offered), triple screen (16-18 wks) - CF or Sickle Cell screen if at risk 4. Discuss the new symptoms that she will be experiencing as she progresses in pregnancy

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-Diet - only need to increase daily intake by 300kcal (one extra snack a day -Exercise - No situps, all other safe forms of exercise permitted and recommended -Pretanal Vitamins, Avoidance of alcohol, cigarettes, radiation, etc -Discussion about what to expect the next few months (morning sickness, fetal movement, etc) -- Warning signs (bleeding, LOF, decreased fetal movement, etc) 5. Schedule follow up appt. Monthly during 1st trimester Bi-weekly during 2nd trimester Weekly during 3rd trimester

Additional info: Parameters to Follow Each Visit: Weight (ideal gain: 20-30 pounds, 10-15 if patient is overweight to begin with), Blood pressure (red flag if over 140/90), UA (red flags: Protein 1+, glucosuria, signs of UTI), Fundal height starting around week 20 (uterus should be at umbilicus, after week 20 it should be equal to GA +/- 2cm), Doppler heart tones starting around week 11-12 (normal:120-160), Fetal presentation after 32 weeks, Repeat antibody screen around 28 wks and administer RhoGAM at 28 weeks and delivery, GBBS culture at 36 wks, Cervial exam is somewhat controversial, but many people begin checking once the fetus is at term. ------------------------------------------------------------------------------------------------------------#18. 24yo @ 32wks c/o abd pain & bleeding This is what we call antepartum hemorrhage DDx: OB causes Placental: Previa, abruption, vasa previa Uterine: uterine rupture, preterm labor Fetal: fetal vessel rupture NonOB causes Cervical: severe cervicitis, polyps, cervical cancer Vaginal/vulvar: lacerations, varices, cancer Other: hemorrhoids, congenital bleeding d/o, trauma, hematuria Steps to take: 1. take Hx: abnl Pap? Coitus? Recent pelvic exam? Pain? Contractions? 2. monitor vitals (maternal & fetal check for decelerations) 3. transvag U/S to determine placental location 4. speculum exam to determine location & extent of bleeding (unless theres a previa) 5. CBC, type & cross 6. place IV if need IVF or drug or transfusion 7. Rhogam if Rh(-) mom. (can do Kleihauer-Betke test to determine extent of fetomaternal transfusion so approp amt of Rhogam can be given) 8. d-dimer, fibrin split products if suspect abruption 9. prepare for preterm delivery betamethasone, tocolysis This is most likely ..Abruption: hemorrhage into decidua basalis leads to premature separation and further bleeding **normal U/S does not r/o abruption!**

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Risk factors: *Prior abruption *HTN Multip Smoking *Cocaine *Trauma Coagulation d/o Painful VB in 3rd trimester 50% occur b/t 30th wk and labor, 15% during labor, 30% postpartum upon inspection of placenta Bigtime maternal complication = CONSUMPTIVE COAGULOPATHY (DIC) Concealed hemorrhage: bleeding confined w/in uterine cavity 20% (no vag bleeding) Revealed/external hemorrhage: blood dissects down twd cervix 80%. b/c there is an egress for blood, revealed hemorrhages are less likely to result in larger retroplacental clots, which are assoc w/ fetal demise Couvelaire uterus: bluish appearance of uterus at time of c/s caused by extravasation of blood beneath uterine serosa Tx: expectant mgt if mom & baby stable. If at term prompt delivery. Pitocin augmentation & NVD is preferred to c/s unless fetal distress or hemodynamic instability. (remember: placenta previa & vasa previa require c/s!!) Although this chick is painful.could also be Previa: abnl implantation of placenta over internal os (complete, partial, marginal) May be complicated by accreta (abnl adherence to uterine wall), increta (invades myometrium), or percreta (invades to serosa). Risk factors for previa: Prior previa Prior uterine scars Uterine anomalies Mult gestation Multip AMA Smoking Many previa noted on early U/S will move up & away from cervix during 3rd trimester as lower uterine segment develops. Painless VB as lower uterine segment develops and thins, placental attachments are disrupted resulting in bleeding. Vag exam CONTRAINDICATED!! May cause further separation of placenta Dx: transvag U/S Tx: pelvic rest (no intercourse), modified bed rest If unstoppable labor, fetal distress or life-threatening hemorrhage immed c/s

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If preterm, can do expectant mgt, but 70% will have recurring bleeding episode & have to deliver before 36 wks. While this usually happens during labor, it could be..uterine rupture: uterus blows up. 90% assoc w/ prior uterine scar Also assoc w/ trauma, improper use of oxytocin, excessive fundal pressure, placenta percreta, mult gest, grand multip, invasive mole or choriocarcinoma Sudden onset intense abd pain, various VB Nonreassuring fetal monitoring, disappearance of FHTs, regression of presenting part Tx: immed ex lap & delivery. May require TAH. Discouraged to attempt future pregs. And this is rather rare but could also be..fetal vessel rupture: velamentous cord insertion vessels insert b/t amnion & chorion away from placenta instead of inserting directly into chorionic plate. Run unprotected, so vulnerable to hurt. Vasa previa: when these vessels cross over the os Succenturiate placenta: accessory lobe implanted in a different part than rest of placenta the vessels connecting the parts are unprotected Risk factors for weird vessels: Abnl placentation Mult gest (1% risk in singletons, 10% risk in twins, 50% risk in triplets) VB assoc w/ sinusoidal variation of FHT indicative of fetal anemia Dx usually made after lots of bleeding and fetal compromise. Can do Apt test (examine blood for fetal RBCs. Combine supernatant w/ NaOH if pink, theres fetal blood. If yellow-brown, its just mom) May be able to dx antepartum w/ color Doppler -----------------------------------------------------------------------------------------------------------------#19. 24yo @ 38wks c/o decreased fetal movement 1. Kick counts: 10 movements w/in 2 hrs is reassuring. If less NST 2. NST: If reactive looking good. Reassure pt of likelihood of well-being of fetus. If at term and the cervix inducible, can induce if you want 3. if NST nonreactive or inconclusive have pt drink orange juice (glucose load babies like to move it with sweet treats). 4. if still no accelerations contraction stress test or BPP 5. if still nothing need to weigh the risks/benefits of delivery vs. continuing preg based on gestational age, lung maturity, fetal compromise, etc. NST = nonstress test: pretty much just a fetal heart monitor formally reactive if: 2 accels of fetal HR in 20 min that are at least 15 beats above baseline HR and last for at least 15 seconds Contraction stress test: external monitoring after oxytocin or maternal breast stimulation. formally reactive by same criteria as NST, get at least 3 contractions in 10 min

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BPP = biophysical profile: U/S Looks at 5 categories and gives score of 0 (absent) or 2 (normal) for each: normal = 8-10 amniotic fluid vol: single vertical pocket >2cm fetal tone: 1+ episodes of extension of fetal extremity w/ return to flexion or open/close of hand fetal activity: 3+ discrete body or limb movements w/in 30min fetal breathing movements: 1+ episodes lasting 30sec or more w/in 30 min fetal heart rate (NST) score 0-2 imminent delivery b/c fetal asphyxia possible score 4-6 repeat testing, delivery if persistent score 8-10 normal Doppler study: uterine and umbilical artery waveform .im not really sure what this is? Usually end diastolic flow velocity is relative to peak systolic velocity systolic: diastolic ratio w/ advancing gestation elevated systolic:diastolic ratio = increased resistance in placental vasculature (pre-e, IUGR) systolic:diastolic ratio s as fetal condition deteriorates usually used to assess twin-twin transfusion, but apparently also for general how is fetus today queries? --------------------------------------------------------------------------------------------------------------#20. A 26 y/o @ 16 wks by LMP is sent for an ultrasound for size greater than dates and is found to have a twin gestation on ultrasound. She is concerned about the potential risks, please counsel. Types of twins Diamniotic,dichorionic division with 3 days post fertilization Diamniotic, monochorionic division days 4-8 Monoamniotic, monchorionic division days 8-12 - division after 13 days results in conjoined twins - division beyond day 15 will result in singleton Dizygotic twins are more common than monozygotic Increased chances of twinning o Use of fertility drugs o Race/geographic area ( Africa 1/30, Asians 1/100) o AMA o Parity o Family hx correlates to mothers family hx o Maternal weight and height overweight tall women Suggestions of twin pregnancy -Uterine size - inc. MSAFP, Human Placetal Lactogen, BhCG - U/S - Excessive maternal weight gain - Palpation of >3 fetal large parts (i.e cranium) Accurate estimation of gestational age is important b/c twins are inc. risk for: o Preterm delivery o IUGR o Twin-twin transfusion o Cord entanglement & Intrauterine fetal demise Mono-mono twins o Cord Prolapse o Placenta previa and abruption o Cervical incompetence o Pre eclampsia o GDM

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o Post partum hemorrhage o Congenital abnormalities o Malpresentation *An U/S done in 1st 20 wks most reliable Nutrition o Should inc. daily caloric intake by ~600 kcal o Expect 35-45 lb weight gain Fetal Growth o Growth of twin close to singleton growth until 3rd trimester for noncomplicated twin pregnancies Prenatal care o Managed as high risk pregnancy o Mono-mono twins should be examined every 2 to 3 wks starting in 2nd trimester - may be managed with antenatal corticosteriods, earlier delivery or C-section o Di twins- should be examined every 4-6 wks after 20 wks gestation Delivery o Vertex/vertex- Undergo trial of labor with C/S reserved o Vertex/nonvertex can also undergo trial of labor is twins are concordant or the present twin in larger o Both breech or nonvertex /vertex C/S indicated o Twins should be between 2000g 3500g but delivery safe above 1500g ---------------------------------------------------------------------------------------------------------------#21. A 35 y/o presents for routine prenatal care at 28 weeks, what needs to be done? Answer in italics Frequency of prenatal visits Every 4-5 wks until 28 wks Every 2-3 wks 28-36 wks Every week >36 wks until delivery Initial Prenatal Visit History identify women at inc. risk of maternal medical complications, pregnancy complications, or fetal abnormalities - be sure to include past medical and surgery hx past obstetrical hx family medical hx (including genetic hx) menstrual and gynecologic hx assess for domestic violence and social situation *NOTE: This pt is considered Advanced for Maternal Age (AMA)- inc. risk Physical Vitals (BP, weight, height) Uterine size Pelvic and bimanual exam (examine cervix, perform smear if pt. symptomatic i.e. discharge, odor) Obtain Estimated Date of Delivery (EDD) o Naegeles rule: Add 7 days to 1st day of LMP then subtract 3 months o U/S estimation of EDD if menses irregular or unknown LMP Fetal heart tones(FHT) can be heard by 9-12 wks using Doppler Transvaginal U/S can visulize fetal cardiac motion as early as 5.5 6 wks Initial Prenatal Labs (1st trimester labs) B-hCG if not sure pt. is pregnant Blood type Rh factor & Antibody screen H&H Pap Smear Rubella titer UA & Urine Cx RPR Hep B antigen

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 Gonorrhea/ Chlamydia HIV offered Varicella if no or unsure of chickenpox PPD Can also test for CF, Sickle cell, HSV, Hep C and obtain nuchal translucency by U/S Other tests for high risk groups found in Blueprints p.7 *NOTE the pt could be offered prental genetics referral Routine prenatal vists vitals, UA, fundal height, FHT >10 wks, ask about symptoms related to pregnancy.

2nd Trimester labs (12 wks 27wks) screens for NTDs and Down Syndrome* Triple screen- Maternal serum alpha fetal protein(MSAFP), estradiol, BhCG Quad screen add inhibin A Anatomy Screening U/S fetal anatomic survey, amniotic fluid volume, placental location, and gestational age. *NOTE: Offer Amniocentesis to AMA pt 3rd Trimester Labs (28 wks until delivery) *NOTE: pt @ 28 wks Start off the visit by asking her about any vaginal bleeding, loss of fluids, contractions, and address any other problems that have arisen since her last visit or are ongoing throughout the pregnancy, i.e. tobacco use, PPBC, social work issues, etc. A cervical exam should be done to check for signs of preterm labor. H&H- hemocrit getting close to nadir Start Iron if Hct <32% If Rh neg. should get RhoGAM @ 28 wks Glucose loading test(GLT) SCREENING TEST - 50 g oral glucose - > 140 after 1 hour need a GTT Glucose tolerance test (GTT) 100g oral glucose Fasting- 95 1hr 180 2hr 155 3hr 140 - Gestational DM if 2 or more values exceeded 36 wks Group B Strep if + tx during labor w/ penicillin Repeat RPR, Gonorrhea/Chlamydia for high risk pts. Also should discuss route of delivery, PP contraception, breast/bottle feeding, and labor management (i.e. epidural) -----------------------------------------------------------------------------------------------------------#22. A 24 y/o presents to L&D with ROM at term with unknown GBBS. How do you manage her labor? As you rotated through OB clinic, you probably discovered that it is standard to screen expectant women at about 36-37 weeks for Group B strep, and patients Group B strep status has its own little spot on the L&D Resident Board. This is because GBS is commonly responsible for perinatal infections of both mom and baby, including chorioamnionitis, endomyometritis, and really bad neonatal sepsis which carries a mortality rate of about 25%. GBS is found in about 25% of womens perineal or rectal areas, and gold standard for diagnosis is that culture the resident made you do in clinic. In this case, the patients GBS status is unknown. Therefore, it is necessary to treat the mom with prophylactic antibiotics if there is a known risk factor for early-onset neonatal sepsis. These risk factors are: Preterm labor (which is not applicable in this case), especially with PPROM

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Intrapartum maternal fever (chorioamnionitis) Prolonged rupture of membranes, defined as greater than 12-18 hours (not sure how long its been in this case, but youd know by the history) Previous delivery of infected infant

They use ampicillin at OSU L&D. Other choices are erythromycin, clinda, or vanc, say, if the patient had a Pen allergy. Also, the antibiotics should be ideally delivered at least 4 hours prior to delivery. Although these are the recommendations from an obstetrics textbook and ACOG guidelines, you could probably make an argument to just go ahead and treat the patient with unknown status as if she were GBS +. Other things to consider are to watch both mother and baby for signs and symptoms of infection throughout the peripartum and postpartum time periods. --------------------------------------------------------------------------------------------------------------#23. You have a patient on post partum who delivered 2 hours ago and is presenting with heavy vaginal bleeding. In this case, you would consider this to be early onset postpartum hemorrhage, or hemorrhage occurring within the first 24 hours after delivery. The amount of blood loss to be considered PP hemorrhage is 500 mL for a vaginal birth and 1000 mL for C/S. The first thing you would need to do is to evaluate the patients stability and extent of blood loss; while you begin to form a differential diagnosis for the bleeding you may need to begin fluid resuscitation and think about getting blood transfusion or FFP ready depending on the circumstances. Youd obviously want to have the L&D summary and report to know how the birth went, what type, complications, etc. to give you clues does the patient have risk factors for certain things on the differential, like for uterine atony (a history of atony, chorioamnionitis, macrosomic fetus). The major diagnoses to consider are: Uterine atony Retained products of conception (POCs) Missed vaginal and/or cervical lacerations Placenta accreta Uterine rupture Maternal coagulopathy

A helpful mnemonic for PP hemorrhage to remember if you blank during the exam is to remember the four Ts: Tone (uterine atony), Tissue (retained POCs), Trauma (lacerations during birth, etc), Thrombin (coagulopathy) Uterine atony would be considered the most common cause of postpartum hemorrhage, although with active management of the third stage of labor weve cut down on it as being a problem. Youve probably seen the residents mention that the uterus is kinda boggy during deliveries and sections and notice that they massage it to help firm up the uterus, which helps to firm it up maybe start a little Pit those are all things that are active management of the third stage of labor to help cut down on this problem. Uterine atony is certainly something that could happen in this patient, even at 2 hours postpartum, as the uterus could firm up initially and become boggy once again. In the case of atony, youd want to possibly attempt to give some procontractile agents again, such as Pitocin, methergen or some prostaglandins to see if this helps alleviate the issue youd diagnose uterine atony in this patient if there was no overt site of lacerations and in the presence of a boggy uterus but youd also have to rule out other things on the differential as well. Retained POCs is a possibility as well. If there was no inspection of the placenta, it could have been easily missed and can contribute to PP hemorrhage. Abdominal U/S may help evaluate for changes in the uterine wall that would demonstrate this, but it may require that you do a manual evaluation of the uterus or a D&C depending on the state of the cervix to diagnose. If hemorrhage continues in the suspected case of retained POCs and you cannot get the bleeding to stop, you may have an accreta. In this case it could be that the patient clotted up around the site and

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then passed this clot and started bleeding. Accreta will not respond to contractile agents you tried for the suspected diagnosis of uterine atony, and may require surgical intervention to treat. Its also certainly possible that lacerations were missed, if they were tucked away under the cervix on the deep vaginal walls or on the cervix somewhere they missed it. In that case a thorough exam and repair would be appropriate. Consider the possibility of uterine rupture as well if the patient had risk factors like prior uterine surgeries, like myomectomy or is having a VBAC, etc. and Its rare, but consider a coagulopathy if theres continual bleeding without evidence of significant source. --------------------------------------------------------------------------------------------------------------#24. A 21 y/o presents to the office with complaints of vaginal discharge. Overview: The major differential is STD vs. non-STD infection. Of great importance is distinguishing between lower reproductive tract vs. upper due to the ability of PID to cause more serious illness (more below). The overall differential includes: o Vaginal infections Bacterial vaginosis Symbiotic infection of Gardnerella vaginalis with anaerobic bacteria Trichomonas vaginitis Candida vulvovaginitis (the major non-STD) o Cervicitis Is caused by bacterial infection, most commonly Chlamydia and Gonorrhea (often together) o PID Infection that has ascended from the vagina/cervix Includes "endometritis", "salpingitis" (fallopian tube infection), "oophoritis" (ovarian infection), as well as infections of the broad ligaments and pelvic peritoneum Complications include infertility, ectopic pregnancy risk, adhesions (and associated chronic pelvic pain), and tubo-ovarian abscess PID is the biggest risk factor for tubo-ovarian abscesses TOA pts are very ill with severe pelvic pain, n/v, and high fever; our pt probably doesn't have this, but if you get pimped on it, image the ovaries with ultrasound and give IV antibiotics, the same as used for PID (see below) History Keys -- Run through the differential in your head o Bacterial vaginosis -- Is there a fishy odor? o Candida -- Recent abx, diabetes?, immunodeficiency?, dysuria, clumpy discharge o Trich -- Itchy vulva? o PID Pelvic pain? o General STD risks Sexual history including # of partners and method of contraception Pap history Physical Exam Keys o PID physical exam findings are a little different because the discharge is less important (discharge may not be present at all) The "3 cardinal symptoms of PID" (required for diagnosis) Pelvic tenderness Chandelier sign Uterine/adnexal adhesions or pain on bimanual

o Fun with discharge Visualize

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 "Frothy green"suggests Trichomonas (remember, the flagella froth it up) Clumpy = candidiasis Actually ON the cervix suggests cervicitis, as does a friable/erythematous cervix Prepare a saline wet smear with discharge Clue cells (vaginal epithelial cells with bacterial clusters) = bacterial vaginosis Flagellated critters = Trichomonas Add KOH Fishy odor = bacterial vaginosis Pseudohyphae/filaments under microscope = Candidiasis Take a swab for GC/Chlamydia testing Treatment Keys o Bacterial vaginosis = metronidazole o Trichomoniasis = metronidazole (remember, its Flagyl as in flagella) and treat partner o Candidiasis = fluconazole (Diflucan) o Cervicitis Chlamydia = azithromycin or doxy (I think they like doxy here at OSU, but make sure pt isn't pregnant) Gonorrhea = cephalosporin (e.g. ceftriaxone) o PID Triple antibiotics: Cover both chlamydia and gonorrhea as noted above and ADD METRO for ANAEROBIC COVERAGE (it's almost always polymicrobial) May require hospitalization if suspected tubo-ovarian abscess, pregnant pt, n/v precluding oral abx Follow-up Keys o Consider treating the partner if it's an STD o Advise her to get tested for HIV, Hep B ------------------------------------------------------------------------------------------------------------------------#25. A 50 y/o presents with complaints of vulvar pain and pruritis. Overview/differential Yeast infections are the most common reason for vulvar pruritis. The workup is as listed above in #24, HOWEVER, per Dr. Cohn, if ANYTHING DOESNT SEEM RIGHT (not the classic appearance of candidiasis, or doesnt respond to therapy), BIOPSY THAT SHIT Crucial because physical exam cannot always distinguish candidiasis from lichen sclerosus from lichen planus from neoplastic lesions (the latter are discussed below) In addition, the same vaginal infections mentioned in question #24 are also apt to cause vaginal pruritis and irritation: Bacterial vaginosis Trichomoniasis So use the same H&P/dx/tx stuff from up there. Also in the differential: Vaginal atrophy secondary to estrogen deficiency (usually only a concern in the post-menopausal) Contact dermatitis secondary to laundry detergents, perfumed soaps, vaginal hygiene products The lichens Vulvar neoplastic lesions Discussing these more in depth ... Vaginal atrophy Is she post-menopausal?

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 Dyspaerunia? Tx = Estrogen cream (avoids systemic estrogen side effects) Contact dermatitis As above, usually from laundry detergents, soaps, etc. Treatment "Healthy vulvar and vaginal hygiene" ... avoiding tight-fitting clothes, no scented soaps, no bubble baths, no douches Topical steroids (it is, after all, an immune reaction) The Lichens Lichen sclerosus Autoimmune disease of unknown etiology Thinning/atrophy of the labia will appear crackly white 5-15% risk of cancer Lichen planus Also autoimmune with unknown etiology Rash is rememembered by the 5 Ps: Purple, pruritic, planar, polygonal papules Diagnosis of both = biopsy Treatment of both Vulvar hygiene Topical steroids Neoplastic lesions of the vulva All can cause pruritis 3 categories: 1. Paget's disease; 2. Vulvar Intraepithelial Neoplasia ("VIN"; this is considered pre-invasive cause its intraepithelial only); and 3. Vulvar cancer Paget's disease of the vulva Usually benign, but will have underlying adenocarcinoma in 20% Velvety-red appearance that will later scar into white plaques Diagnose by biopsy Tx = Wide local excision If no associated adenoCA, this is curative Though it has a high recurrence rate and should be followed closely If associated with adenoCA, it's usually metastatic at presentation and fatal VIN 80% of pts will have HPV DNA Will progress to cancer if not treated Classic presentation = vulvar pain/pruritis that is refractory to multiple antifungal trials Lesions take on a wide variety of morphology, therefore you MUST BIOPSY Just like cervical histology, VIN-I = mild dysplasia, VIN-II = moderate dysplasia, and VIN-III = severe dysplasia Just like cervical biopsies, throw some acetic acid up on that vulva to look for acetowhite changes outlining possible dysplastic cells Treatment = wide local excision or laser ablation (VulvaBlaster 3000) Vulvar cancer Presentation similar to VIN

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 90% are squamous cell (others include malignant melanoma and basal cell CA; basically the big 3 skin cancers) Diagnosis Again, biopsy If squamous cell, it needs surgical staging As it spreads via lymphatics, this must include groin lymphadenectomy (it likes the inguinal nodes) Most important prognostic factor is # of positive nodes Melanoma and basal cell CA don't spread via nodes as often, therefore no lymphadenectomy Treatment Wide local excision for local disease Add pelvic radiation if it's squamous cell and it's in the nodes

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