Topnotch Ob Gyne Supplement Handout 2019

TOPNOTCH MEDICAL BOARD PREP OB-GYNE SUPPLEMENT HANDOUT BY NIÑA KATRINA BANZUELA, MD
For inquiries visit www.topnotchboardprep.co.nr or email us at topnotchboardprep@yahoo.com
OBSTETRICS SUPPLEMENT HANDOUT Labia Majora 7-8x2-3x1-1.5cm

round ligaments terminate at their upper
borders
TABLE OF CONTENTS
Maternal Anatomy 1 Labia Minora connective tissue with many vessels, elastin
Events Post-conception 6 fibers, and some smooth muscle fibers
Placenta 7
Fetal Development 8 Clitoris points downward and inward toward the
Fetal Imaging 10 vaginal opening; rarely exceeds 2 cm
Breech 11 Vestibule functionally mature female structure
Postpartum Changes 13 derived from the embryonic urogenital
Guidelines for Cesarean Section 15 membrane
Other Important Obstetric Information 16 perforated by six openings: urethra, the
Urinary Tract Infection in Pregnancy 19 vagina, two Bartholin gland ducts, and two
Other Important Gynecologic Concepts 20 ducts of the Skene glands
Gynecologic problems in pre-pubertal children 29 Vestibular Glands Bartholin glands, paraurethral glands
(Skene glands→ diverticulum) minor
Family Planning 29
vestibular glands
Urethral opening lower two thirds of the urethra lie
MATERNAL ANATOMY
immediately above the anterior vaginal
wall.
EXTERNAL GENITALIA 1 to 1.5 cm below the pubic arch
Vestibular bulbs lie beneath the bulbocavernosus muscle on
EMBRYOLOGIC MALE FEMALE either side of the vestibule
STRUCTURES vulvar hematoma.
LABIOSCROTAL Scrotum Labia Majora Vaginal Hymenal caruncles
SWELLING opening/hymen Impreforate hymen
UROGENITAL FOLDS Ventral portion Labia Minora
of the penis DIFFERENCE OF LABIA MAJORA AND LABIA MINORA
PHALLUS (GENITAL Penis Clitoris LABIA MAJORA LABIA MINORA
TUBERCLE) HOMOLOGY Scrotum Ventral portion of
UROGENITAL SINUS Urinary bladder Urinary bladder the penis
Prostate gland Urethral and Skin of the penis
Paraurethral LINING Outer- KSSE NKSSE
glands EPITHELIUM Inner- NKSSE
Prostatic Utricle Vagina NULLIPAROUS Lie in close Not visible behind
Bulbourethral Greater WOMEN apposition the non-separated
glands vestibular glands Inner surface labia majora
Seminal Hymen resembles the
colliculus mucous membrane
PARAMESONEPHRIC Appendix of Hydatid of MULTIPAROUS Gape widely Project beyond the
DUCT testes Morgagni WOMEN Inner surface labia majora
Uterus and become skin like
Cervix GLANDS (+) Hair follicles No hair follicles
Fallopian Tubes (+) Sweat glands No sweat glands
Upper ¼ of the (+) Sebaceous (+) Sebaceous
vagina glands glands
EMBRYOLOGIC MALE FEMALE VESTIBULE

STRUCTURE • Functionally mature female structure of the urogenital
MESONEPHRIC DUCT Appendix of Appendix of sinus of the embryo. Extends from clitoris to forchette
epidydymis vesiculosis
Ductus of Duct of STRUCTURES IN THE VESTIBULE
epididymis epoophoron HYMEN ▪ Non keratinized Stratified squamous
Ductus deferens Gartner’s Duct epithelium
Ejaculatory duct ▪ During first coitus, first that ruptures is
Seminal Vesicle usually at the 6 o’clock position
METANEPHRIC DUCT Ureter ▪ Caruncle Myrtiformes: Remnants of hymen
URETERIC BUD Renal Pelvis in adult female
Calyces GLANDULAR Periurethral Glands “ Skene’s Glands”
Collecting system STRUCTURES Vulvovaginal Glands “Bartholin’s Glands”
METANEPHRIC Glomerulus 6 OPENINGS: ▪ Vaginal introitus
MESENCHYME Renal Collecting Tubules ▪ Urethral opening
UNDIFFERENTIATED Testes Ovary ▪ Paired Para urethral glands opening
GONAD ▪ Paired Bartholin ducts opening
CORTEX Seminiferous Ovarian Follicles
tubules GLANDULAR STRUCTURES
MEDULLA Rete Testis Rete Ovarii PERIURETHRAL VULVOVAGINAL
GUBERNACULUM Gubernaculum Round ligament GLANDS GLANDS
testis of uterus “ Skene’s glands” “Bartholin’s glands”
Other name Lesser vestibular Greater vestibular glands
VULVA (PUDENDA) glands
• External structues from the symphysis pubis to the Male Prostate Bulbourethral gland
perineal body homology
• Includes mons pubis, labia majora and minora, Type of Tubulo alveolar Compound alveolar/
Structure gland compound acinar
Mons Pubis escutheon Location Adjacent to the 4 and 8 o clock of the
TOPNOTCH MEDICAL BOARD PREP OBSTETRICS HANDOUT BY NIÑA KATRINA BANZUELA, MD Page 1 of 31
urethra vagina Triangle
Pathology Urethral Bartholins’s cyst/
diverticulum abscess Anterior Urogenital triangle
→ Superficial Boundaries:
and deep Superior- pubic rami
Lateral-ischial tuberosities
Posterior: superficial transverse perineal
muscle
Posterior 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 bounded deeply by the perineal

compartment 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 clitoral erection

muscle
bulbocavernosus Bartholin gland secretion

muscles Clitoral erection
superficial may be attenuated or even absent

transverse perineal Contributes to the perineal body
muscles
Urogenital (Anterior) Triangle: DEEP SPACE

Anterior Triangle (DEEP SPACE)
Continuous lies deep to the perineal membrane and

PERINEUM space with extends up into the pelvis
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 wedge-shaped spaces found on either side of

fossae the anal canal and comprise the bulk of the
posterior triangle
Continuous space
PUDENDAL NERVE AND VESSELS

Roots Anterior rami of the 2nd to 4th sacral nerve
Course between the piriformis and coccygeus

Clinical Significance 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:
dorsal nerve of skin of the clitoris

the clitoris
Boundary Landmark perineal nerve muscles of the anterior triangle and labial
skin
Anterior pubic symphysis
inferior rectal external anal sphincter, the mucous
Anterolateral ischiopubic rami and ischial tuberosities membrane of the anal canal, and the perianal
skin
Posterolateral sacrotuberous ligaments
Landmark for Ischial spine
posterior coccyx
pudendal nerve
block
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 CERVIX
– Posterior wall: 7-10 cm
• Potential space: Lower third ENDOCERVIX EXOCERVIX
Supravaginal portion Portio vaginalis
Extends from the isthmus (Internal Extends from the
Os) to the ectocervix and contains the squamo columnar
endocervical canal 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
• 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
• 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 UTERUS
SIZE Nulliparous: 6 to 8 cm (fundus=cervix) , 50-70 g • Diverticula

multiparous: 10 cm (cervix 1/3), 80 g or more
SEGMENTS OF THE FALLOPIAN TUBE
Isthmus Lower uterine portion Intramural Embodied within 2% of ectopic pregnancy
Interstitial the muscular Ectopic pregnancy at this
Fallopian Attaches at the cornua wall of the uterus area result in severe
tubes maternal morbidity
Isthmus The narrow Most highly developed
Posterior Completely covered by visceral peritoneum
portion of the musculature
wall tube that adjoins Narrowest portion
Anterior wall Only upper portion with peritonem → the uterus, Preferred portion for
vesicouterine pouch passes gradually applying clips for female
into the wider, sterilization
lateral portion. Preferred portion for tubal
ligation
ENDOMETRIUM STRATUM FUNCTIONALE Zona 12% of ectopic pregnancy
• Shed during Spongiosa Ampulla Widest and most Site of fertilization
menstruation Zona tortuous area 80% of ectopic pregnancy
• Supplied by the Spiral compacta Infundibulum Fimbriated 5% of ectopic pregnancy
Arteries extremity
• Superficial 2/3 Tunnel shaped
STRATUM BASALE opening of the
• Source of Stratum distal end of the
Functionale after fallopian tube
menstruation
• Supplied by the Straight OVARIES
arteries • Lies on the posterior aspect of the broad ligament, in the
• Basal 1/3 ovarian fossa
• lympathics o lateral to the uterus in the pelvic sidewall where the
MYOMETRIUM Inner Longitudinal common iliac artery bifurcates
Middle oblique o ovarian fossa of Waldeyer
Outer longitudinal • Are attached to the broad ligament by the mesovarium.
SEROSA lymphatics • They are not covered by peritoneum.
Ovaries: LAYERS
OUTER Innermost ▪ Primordial and Graafian follicles
LIGAMENTS OF THE UTERUS CORTEX portion in various stages of
Broad • Two wing-like structure that extend from development
ligament the lateral margins of the uterus to the pelvic Outermost ▪ Tunica Albuginea- dull and
walls portion whitish fibrous connective
• Divide the pelvic cavity into anterior and tissue covering the surface of
posterior compartments the ovary
Reproductive Fallopian tubes ▪ Germinal epithelium of
structures ovaries Waldeyer- a single layer of
Vessels: Ovarian arteries cuboidal epithelium over the
Uterine arteries Tunica Albuginea
Ligaments: Ovarian ligament INNER ▪ Composed of loose connective tissue that is
Round ligament of MEDULLA continuous with that of the mesovarium.
uterus ▪ Smooth muscle fibers that are continuous with
those in the suspensory ligament.
Cardinal • AKA Transverse Cervical Ligament or
▪ Contains the stroma and blood vessels of the
ligament Mackenrodt Ligament
ovary
• Originated form the densest portion of the
broad ligament
• Medially united to the supravaginal wall of PELVIS
the cervix
• Provide the major support of the uterus and Pelvic Organs: BLOOD SUPPLY
cervix MAJOR BLOOD SUPPLY TO THE FEMALE REPRODUCTIVE
• Maintain the anatomic position of the cervix SYSTEM
and upper part of the vagina Pudenda Internal Pudendal artery
Uterosacral • From posterolateral to the supravaginal Vagina Vaginal Artery of the Uterine
ligament portion of the cervix encircling the rectum Artery
• Insert into the fascia over S2 and S3 Cervix Cervicovaginal branch of
Round • Extend from the lateral portion of the uterus, Uterine artery
Ligament arising below and anterior to origin of the Uterus Uterine Artery
oviducts, that is continuous with the broad Fallopian tubes Ovarian Artery
ligament, outward and downward to the Ovaries
inguinal canal terminating at upper PARTICIPANTS IN THE COLLATERAL CIRCULATION OF THE
portion of labium majus FEMALE PELVIS
Branches from the ▪ Ovarian artery
Aorta ▪ Inferior mesenteric
FALLOPIAN TUBES ▪ Lumbar and vertebral
• single layer of columnar cells, some of them ciliated and ▪ Middle sacral arteries
others secretory. Branches from the ▪ Deep iliac circumflex
• No submucosa External Iliac Artery ▪ Inferior epigastric artery
• supplied richly with elastic tissue, blood vessels, and Branches from the ▪ Medial femoral circumflex artery
lymphatics Femoral Artery ▪ Lateral femoral circumflex artery
• Sympathetic innervation
False ANT: lower abdomen Forward

Inclined
and Straight =
neither
POST: lumbar vertebra straight pelvis Well curved
anterior
SACRUM with deeper than and rotated
ly nor
LATERAL: iliac fossa little other 3 backward
posterio
curvatur types
L INEA TERMINALIS rly
e
Increase
True SUPERIOR BOUNDARY: Pelvic inlet
d
INFERIOR BOUNDARY: Pelvic outlet incidence
of Deep Increased
ANTERIOR: Pubic Bones, Ascending Rami Of Ischial Transver incidence of
Good
Bones, Obturator Foramina se Arrest Face Poor
prognos
SIGNIFICAN Limited Delivery prognosis for
LATERAL: Ischial Bones and Sacrosciatic Notch is for
CE posterior Good vaginal
vaginal
space for prognosis delivery
delivery
fetal for vaginal
head, delivery
poor
prognosi
s
EMBRYOLOGIC STRUCTURES AND DERIVATIVES
EMBRYOLOGIC MALE FEMALE

STRUCTURES
LABIOSCROTAL Scrotum Labia Majora
SWELLING
UROGENITAL FOLDS Ventral portion Labia Minora
of the penis
PHALLUS (GENITAL Penis Clitoris
TUBERCLE)
UROGENITAL SINUS Urinary bladder Urinary bladder
Prostate gland Urethral and
PELVIC JOINTS Paraurethral
• Anterior: symphysis pubis/arcuate ligament of the pubis glands
• Posterior: sacroiliac
Prostatic Utricle Vagina
• Hormonal changes during pregnancy cause laxity of these
Bulbourethral Greater
joints
glands vestibular glands
• By 3-5 months POST PARTUM, laxity has regressed
Seminal Hymen
• Symphysis Pubis increase in width also Increase mobility
colliculus
and displacement of the sacroiliac joint
PARAMESONEPHRIC Appendix of Hydatid of
WHY THE DORSAL LITHOTOMY POSITION? DUCT testes Morgagni
• Upward gliding of sacroiliac joint is GREATEST in the Uterus and
DORSAL LITHOTOMY POSITION Cervix
• Outlet increase by 1.5 -2.0 cm Fallopian Tubes
Upper ¼ of the
vagina
MESONEPHRIC DUCT Appendix of Appendix of

epidydymis vesiculosis
Ductus of Duct of
epididymis epoophoron
Ductus deferens Gartner’s Duct
Ejaculatory duct
Seminal Vesicle
METANEPHRIC DUCT Ureter
URETERIC BUD Renal Pelvis
Calyces
Collecting system
METANEPHRIC Glomerulus
MESENCHYME Renal Collecting Tubules
PELVIC TENDENCY AND TYPE UNDIFFERENTIATED Testes Ovary
• Anterior – dictates the tendency of the pelvis GONAD
• Posterior – dictates the type or character of the pelvis CORTEX Seminiferous Ovarian Follicles
GYNE- ANDROI ANTHROP PLATY- tubules
COID D OID PELLOID MEDULLA Rete Testis Rete Ovarii
FREQUENCY 50% 20% 25% 5% rarest GUBERNACULUM Gubernaculum Round ligament
Vertically testis of uterus
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
Non 1. Cleavage
ISCHIAL Promine Non 2. Blastocyst formation
promin Prominent
SPINES nt prominent 3. Implantation
ent
Cartilages
CVS
Urogenital System
RBC
EMBRYONIC PERIOD
Order of Formation
CNS First to develop and continues post natal
Heart Completed by 8 weeks
Upper limb Completed by 8 weeks
Lower limb Completed by 8 weeks
External genitalia Completed by 9 weeks
PERIOD OF TERATOGENICITY
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
DRUGS IN PREGNANCY
• Inner cell mass – future embryo, is now called the
Embryoblast Category Examples
• The outer cell mass – future placenta, is now called the Adequate and well-controlled human studies
Trophoblast have failed to demonstrate a risk to the fetus
A Folic acid
in the first trimester of pregnancy (and there
IMPLANTATION is no evidence of risk in later trimesters).
• Blastocyst implants at around 7 days post conception Animal reproduction studies have failed to
within the posterior superior wall of the uterus demonstrate a risk to the fetus and there are
• This is during the secretory phase of the menstrual cycle, so no adequate and well-controlled studies in
implantation occurs within the functional layer of Paracetamol,
pregnant women OR Animal studies have
endometrium. B amoxicillin,
shown an adverse effect, but adequate and
cephalexin,
well-controlled studies in pregnant women
POST CONCEPTION: WEEK 2 have failed to demonstrate a risk to the fetus
EMBRYOBLAST in any trimester.
• Differentiates into two distinct cell layers, the Epiblast and Animal reproduction studies have shown an
Hypoblast, forming a Bilaminar Embryonic Disk adverse effect on the fetus and there are no
o Epiblast -clefts develop within the Epiblast to form the adequate and well-controlled studies in
amniotic cavity C paroxetine
humans, but potential benefits may warrant
o Hypoblast -form the yolk sac use of the drug in pregnant women despite
potential risks.
TROPHOBLAST
There is positive evidence of human fetal risk
• Cytotrophoblast divide mitotically based on adverse reaction data from
• Syncytiotrophoblast Phenytoin,
investigational or marketing experience or
o Does not divide mitotically D tetracyclne,
studies in humans, but potential benefits may
o Produces the HCG aspirin,
warrant use of the drug in pregnant women
o Continues its growth into the endometrium to make despite potential risks.
contact with the endometrial blood vessels
Studies in animals or humans have
demonstrated fetal abnormalities and/or
EMBRYO PERIOD: WEEK 3-8
there is positive evidence of human fetal risk
• The beginning of the development of major organ systems based on adverse reaction data from Thalidomide,
• Coincides with the first missed menstrual period X
investigational or marketing experience, and isotretinoin
• Period of high susceptibility to teratogen the risks involved in use of the drug in
• Gastrulation is a process that establishes the 3 primary pregnant women clearly outweigh potential
germ layers, forming a trilaminar embryonic disk benefits.
o Ectoderm
o Endoderm
o Mesoderm
PLACENTA
FETAL TO MATERNAL MEMBRANES
DERIVATIVES • Amnion
LAYER DERIVATIVES o Avascular; provides tensile strenght; first identifiable
Ectoderm CNS and PNS at 7th to 8th day of life; from fetal ectoderm
Sensory organs of seeing and hearing • Chorion
Integument layer • Decidua parietalis (endometrium)
Endoderm Lining of the GIR and Respiratory tract • Myometrium
Mesoderm Muscles • Serosa
Progesterone 0.1–40 250–600
AMNIOTIC FLUID Aldosterone 0.05–0.1 0.250–0.600
• Normal amniotic fluid volume
Deoxycorticosterone 0.05–0.5 1–12
o By 12 weeks = 60ml
o By 34-36 weeks = 1L Cortisol 10–30 10–20
o By term = 840 ml
o By 42 weeks = 540 ml hCG
• Production of amniotic fluid • Almost exclusively produced by the placenta
o Initially by amniotic epithelium • Glycoprotein
o Fetal kidneys and urine production • Alpha and beta subunit
*Amniotic fluid volume is also dependent on the extent of • Functions: rescue and maintenance of function of the
maternal plasma expansion corpus luteum, stimulates fetal testicular testosterone
• Removal and regulation of amniotic fluid volume secretion, materanl thyroid gland stimulation (chorionic
o Fetal swallowing thyrotropins), promotion of relaxin secretion
o Fetal aspiration • detectable in plasma of pregnant women 7 to 9 days after
o Exchange through skin and fetal membranes the midcycle surge of LH that precedes ovulation.
• Plasma levels increase rapidly, doubling every 2 days, with
THE PLACENTA AT TERM maximal levels being attained at 8 to 10 weeks
• Volume 497 Ml • At 10 to 12 weeks, plasma levels begin to decline, and a
• Weight 508 grams (450-500 grams) nadir is reached by about 16 weeks
• Surfaces • Clearance: mainly hepatic, renal (30%)
o Fetal
▪ Covered with amniotic membrane giving it hPL
white, glistening appearance • Similar to hCG
▪ Where the umbilical cord arises • detected in maternal serum as early as 3 weeks
o Maternal • Maternal plasma concentrations are linked to placental
▪ Attached to the decidua mass, and they rise steadily until 34 to 36 weeks
▪ Deep, bloody appearance arranged into 15-20 • production rate near term: approximately 1 g/day
irregular lobes, cotyledons • Functions: Maternal lipolysis , anti-insulin or
• Hofbauer cells "diabetogenic”, potent angiogenic
PROGESTERONE
Circulation in the Mature Placenta • 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
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 ESTROGEN SOURCE
chorionic vessels course chorionic villi →intervillous space Estradiol Maternal ovaries for weeks 1 through 6 of
→decidual plate → myometrium gestation
After T1, the placenta is the major source of
FUNIS circulating estradiol.
• Umbilcal cord Estrone Maternal ovaries, adrenals, and peripheral
• Two artery, one vein (left or right?) conversion in the first 4 to
• Ave lenght: 55 cm 6 weeks of pregnancy
• Wharton jelly- extracellular matrix of specialized connective The placenta subsequently secretes increasing
tissue quantities
• Anticlockwise spiral is present in 50 to 90 percent of Estriol Produced almost exclusively by the placental
fetuses syncytiotrophoblast
Continued production depends on the living fetus
PLACENTAL HORMONES Marker of fetal well being
• 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), gonadotropin-
releasing hormone (GnRH), corticotropin-releasing
hormone (CRH), somatostatin, and growth hormone–
releasing hormone (GHRH).
PLACENTAL STEROID HORMONES

Steroid Nonpregnant Pregnant
Estradiol-17 0.1–0.6 15–20
Estriol 0.02–0.1 50–150
• Ovulation age/post conceptional age
Placental Estrogen Production 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
FETAL PERIOD
Conditions that Affect Hormone Levels in Pregnancy
Condition Findings
AOG
Fetal Demise dec estrogen
12 The uterus usually is just palpable above the symphysis
Fetal anencephaly Dec estrogen (estriol) pubis,
crown-rump length is 6 to 7 cm.
Fetal adrenal hypoplasia absence of C19-precursors Centers of ossification have appeared in most of the
fetal bones
Fetal-Placental Sulfatase very low estrogen levels in fingers and toes have become differentiated
Deficiency otherwise normal pregnancies Skin and nails have developed and scattered rudiments
of hair appear.
Fetal-Placental Aromatase virilization of the mother and the external genitalia are beginning to show definitive signs
Deficiency female fetus of male or female gender
spontaneous movements.
Trisomy 21—Down serum unconjugated estriol levels
Syndrome were low 16 fetal crown-rump length is 12
Fetal Erythroblastosis Elevated Gender can be determined by experienced observers by
inspection of the external genitalia by 14 weeks.
Glucocorticoid Treatment Dec estrogen Quickening by multiparas
Maternal Adrenal Dec estrogen 20 fetus now weighs somewhat more than 300 g, and
Dysfunction weight begins to increase in a linear manner.
fetus moves about every minute and is active 10 to 30
Gestational Trophoblastic placental estrogen formation is percent of the time
Disease limited to the use of C19-steroids downy lanugo covers its entire body
in the maternal plasma
estrogen produced is principally 24 canallicular period of lung development is nearly
estradiol 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
FETAL DEVELOPMENT
28 crown-rump length is approximately 25 cm
Terms skin is red and covered with vernix caseosa
pupillary membrane has just disappeared from the eyes
Perinatal Period beginning 20 weeks AOG and ending up to born at this age has a 90-percent chance of survival
period 28 completed days after birth
It is recommended that this period be defined as 36 CRL of 32
commencing at BW of 500 grams deposition of subcutaneous fat
Neonatal Period after birth of an infant up to 28 completed 40 average crown-rump length is about 36 cm
period days after birth weight is approximately 3400 g
Fetal Begins from 8 weeks after fertilization or 10

period weeks after onset of last menses
HEAD DIAMETERS
Embryonic Commences beginning of the 3rd week after • Bitemporal diameter (8.0cm)
period ovulation and fertilization and lasts up to 8 weeks o Greatest TRANSVERSE diameter of the head
AOG • Biparietal diameter (9.5 cm)
8 weeks period from the time of fertilization • Occipitomental ( 12.5 cms)
10 weeks period from the time of the last • Occipitofrontal (11.5 cms)
menstrual cycle/Ovulation o The plane that corresponds to the greatest
CIRCUMFERENCE
Abortus Fetus or embryo removed or expelled from uterus o 34.5 cm
during the first half of gestation • Suboccipitobregmatic ( 9.5 cms)
20 weeks or less, or in the absence of accurate o The plane that corresponds to the smallest
dating criteria, born weighing less than 500 grams circumference of the head
o 32 cm
GESTATIONAL AGE vs. OVULATION AGE
• Gestational age/menstrual age FETAL CIRCULATION
o The time elapsed since the last menstruation • 3 vessels (AVA)
o Precedes fertilization/ovulation by 2 weeks o 2 arteries
o 1 vein • Surfactant is formed in the type II pneumocytes that line
• Three Shunts: the alveoli
o Ductus venosus • Starts to appear in the amniotic fluid at 28-32 weeks.
o Foramen ovale • 90% lipid and 10% proteins
o Ductus arteriosus 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
SEXUAL DIFFERENTIATION
Fetal Blood
• HEMATOPOIESIS
o yolk sac – first site of hematopoiesis. embryonic • Genetic/Chromosomal Sex
period o XX or XY?
o Liver takes over up to near term o Dependent on the presence of Y chromosome
o Bone marrow starts at 4 mos AOG and remains as the • Gonadal Sex
major site of blood formation during adulthood o testes or ovaries?
• Erythrocytes – nucleated and have a shorter life span due o Dependent on the presence of SRY gene present on
to their large volume and are more easily deformable the Y chromosome or the Testes Determining region
• Fetal blood volume (125 ml/kg) • Phenotypic Sex
o Term infants = 80 ml/kg body weight o Is it a penis or a vagina?
o Placenta = 45 ml/kg body weight o Dependent on the hormones produced
• Fetal Hemoglobin
o Hemoglobin F
o Hemoglobin A (adult hgb)
o Hemoglobin A2
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
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
• Presence of surfactant in the amnionic fluid is evidence of - <7mm and no cardiac activity is seen, a subsequent
fetal lung maturity (after 34 weeks) examination is recommended in 1 week
INDICATIONS 1. Gestational age estimation
1. Confirm an intrauterine pregnancy 2. Fetal-growth evaluation
2. Evaluate a suspected ectopic pregnancy 3. Significant uterine size/clinical date discrepancy
3. Define the cause of vaginal bleeding 4. Suspected multifetal gestation
4. Evaluate pelvic pain 5. Fetal anatomical evaluation
5. Estimate gestational age 6. Fetal anomaly screening
6. Diagnose or evaluate multifetal gestations (optimal time 7. Assessment for findings that may increase the
to determine CHORIONICITY) aneuploidy risk
7. Confirm cardiac activity 8. Abnormal biochemical markers
8. Assist chorionic villus sampling, embryo transfer, and 9. Fetal presentation determination
localization and removal of an intrauterine 10. Suspected hydramnios or oligohydramnios
9. device 11. Fetal well-being evaluation
10. Assess for certain fetal anomalies such as anencephaly, 12. Follow-up evaluation of a fetal anomaly
in high-risk patients 13. History of congenital anomaly in prior pregnancy
11. Evaluate maternal pelvic masses and/or uterine 14. Suspected fetal death
abnormalities 15. Fetal condition evaluation in late registrants for
12. Measure nuchal translucency when part of a screening prenatal care
program for fetal aneuploidy
13. Evaluate suspected gestational trophoblastic disease Three Types of Examination (Congenital Anomaly Scan)
1. STANDARD
NUCHAL TRANSLUSCENCY 2. SPECIALIZED
- a component of first-trimester aneuploidy screening, has 3. LIMITED
had a major impact on the number of pregnancies
receiving late first-trimester ultrasound examination STANDARD - Most commonly performed
- It represents the maximum thickness of the - May be adequately assessed after 18
subcutaneous translucent area between the skin and soft weeks
tissue overlying the fetal spine at the back of the neck - Elements:
- It is measured in the sagittal plane between 11 and 14 o Head, face, and neck: Lateral
weeks cerebral ventricles, Choroid plexus,
- If increased, the risk for fetal aneuploidy and various Midline falx, Cavum septum
structural anomalies—including heart defects—is pellucidi, Cerebellum, Cisterna
significantly elevated magna, Upper lip, Consideration of
nuchal fold measurement at 15–20
Components of a Standard Ultrasound Examination by weeks
Trimester o Chest: Four-chamber view of the
First Trimester Second and Third Trimester heart, Left ventricular outflow tract,
1. Gestational sac, size, 1. Fetal Number, including Right ventricular outflow tract
location, and number amnionicity and o Abdomen: Stomach—presence,
2. Embryo, and/or yold sac chorionicity of multifetal size, and situs, Kidneys, Urinary
identification gestations bladder, Umbilical cord insertion
3. Crown-Rump Length 2. Fetal Cardiac Activity into fetal abdomen, Umbilical cord
4. Fetal Number, including 3. Fetal Presentation vessel number
amnionicity and 4. Placental location, o Spine: Cervical, thoracic, lumbar,
chorionicity of multifetal appearance and and sacral spine
gestations relationship to the o Extremities- Legs and arms
5. Embryonic/fetal anatomy internal cervical os, with o Fetal sex- In multifetal gestations
appropriate for all the documentation of and when medically indicated
first trimester placental cord insertion
6. Evaluation of the maternal site SPECIALIZED - Targeted examination- a detailed
uterus, adnexa and cul-de- 5. Amniotic Fluid Volume anatomical survey performed when an
sac 6. Gestational Age abnormality is suspected on the basis of
7. Evaluation of the fetal Assessment history, screening test result, or
nuchal region, with 7. Fetal Weight estimation abnormal findings from a standard
consideration of fetal 8. Fetal Anatomical survey examination
nuchal transluscency 9. Evaluation of the maternal - includes the anatomical structures in the
assessment uterus, adnexa and cervix, standard type along with additional
when appropriate views of the brain and cranium, neck,
profile, lungs and diaphragm, cardiac
anatomy, liver, shape and curvature of
SECOND AND THIRD TRIMESTER SONOGRAPHY the spine, hands and feet, and any
placental abnormalities
MATERNAL INDICATIONS - also fetal echocardiography and
1. Vaginal bleeding Doppler studies
2. Abdominal/pelvic pain LIMITED - performed to address specific clinical
3. Pelvic mass question
4. Suspected uterine abnormality - amnionic fluid volume assessment,
5. Suspected ectopic pregnancy placental location, or evaluation of fetal
6. Suspected molar pregnancy presentation or viability
7. Suspected placenta previa and subsequent surveillance
8. Suspected placental abruption DOPPLER EXAMINATION
9. Preterm premature rupture of membranes and/or - used to evaluate flow within blood vessels
preterm labor
10. Cervical insufficiency Umbilical Artery - Amount of flow during diastole
11. Adjunct to cervical cerclage increases as gestation advances
12. Adjunct to amniocentesis or other procedure - Abnormal is S/D ratio is above 95th
13. Adjunct to external cephalic version percentile for gestational age
- Useful adjunct in the management of
FETAL INDICATIONS of pregnancies complicated by IUGR
- Extreme cases of IUGR: absent or INCOMPLETE One or both hips are NOT
reversed (FOOTLING) flexed and one or both feet
- As long as fetal surveillance remain or knees lie below the
reassuring: breech
o Absent: managed A foot or knee is lowermost
expectantly at 34 weeks in the birth canal
o Reversed: managed Footling breech- incomplete
expectantlyat 32 weeks 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
normal
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
absent 12. Prior cesarean delivery
13. Smoking
COMPLICATIONS
1. Perinatal mortality and morbidity from difficult delivery
2. Low birthweight from preterm delivery
3. Cord prolapse
reversed 4. Placenta previa
5. Fetal anomalies
Ductus arteriosus - to monitor fetuses exposed to
indomethacin and other NSAIDs DIAGNOSIS
- INDOMETHACIN: for tocolysis, may • Abdominal examination
cause ductal constriction or closure, – Leopold’s Maneuver
particularly when used in the third – L1: the hard, round, ballottable fetal head may
trimester. The resulting increased be found to occupy the fundus.
pulmonary flow may cause reactive – L2: the back to be on one side of the abdomen
hypertrophy of the pulmonary and the small parts on the other
arterioles and eventual development – L3: (not engaged)- the breech is movable
of pulmonary hypertension above the pelvic inlet
- NSAIDs: may cause ductal – L4 (after engagement): shows the firm breech
constriction, hence administration is to be beneath the symphysis
typically limited to less than 72 hours, • Vaginal examination
discontinued if ductal constriction is – With a frank breech during vaginal
identified examination, no feet are appreciated, but the
Uterine artery - Diastolic notch: associated with fetal ischial tuberosities, sacrum, and anus are
gestational hypertension; usually palpable.
preeclampsia and growth restriction – In some cases, the anus may be mistaken for
Middle cerebral - For fetal anemia the mouth and the ischial tuberosities for the
artery - Adjunct evaluation for fetal growth malar eminences.
restriction Breech Cephalic
- Fetal hypoxemia→ end diastolic flow • the finger • firmer, less
in the MCA encounters yielding jaws are
- “brain sparing”: misnomer, as it is not muscular felt through the
protective for the fetus but associated resistance with mouth
with perinatal morbidity and the anus • The mouth and
mortality • The finger, upon malar eminences
removal from form a triangular
BREECH the anus, may be shape
stained with
TYPES OF BREECH meconium
FRANK Lower extremities are • the ischial
flexed at the hips and tuberosities and
extended to the knee, feet anus lie in a
lie in close proximity to the straight line
face - complete breech- the feet may be felt alongside the buttocks
- footling presentations- one or both feet are inferior to the
buttocks
COMPLETE Lower extremities are • Ultrasound
flexed at the hips and one or – Confirm the diagnosis of breech
both knees are flexed
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
Total breech Entire body is extracted by the OB vaginal delivery may be achieved.
extraction - Hand is introduced through the vagina, ▪ Done when there is no facility for
and both fetal feet are grasped. Caesarean section
- The ankles are held with the second
finger lying between them VERSION
- With gentle traction, the feet are Version Procedure in w/c fetal presentation is altered by
brought through the introitus physical manipulation from a less favorable to a
- both feet are grasped and pulled more favorable position
through the vulva simultaneously 2 types of External ▪ for breech presentation
version cephalic recognized prior to labor and
CS DELIVERIES PREFERRED version has reached 36 weeks
• Chronic fetal distress; IUGR ▪ Should be carried at between
• A large fetus 32-34 weeks
• Any degree of CPD Internal ▪ used only for the delivery of
• Hyperextended head podalic the second of twin
• Footling breech version ▪ converts a fetus from a
• Prematurity transverse/oblique/ cephalic
• A request for sterilization into double footling
METHODS USED IN BREECH DELIVERY: EXTERNAL CEPHALIC VERSION

Delivery of the shoulder Lovesets maneuver Indication for external ▪ For breech presentation
Delivery of the aftercoming head Mauriceau cephalic version recognized prior to labor and
maneuver has reached 36 weeks
Prague maneuver Contraindication to 1. Any history of bleeding
Piper’s forceps external version 2. Presence of multiple pregnancy
Bracht maneuver 3. Associated major malformation
Pinard 4. Plan for the manner of delivery
Delivery of an entrapped aftercoming Duhrssen incision Factors associated with 1. Multiparity- most consistent
head Zavanelli maneuver successful version and most important factor
Symphysiotomy associated with success
DELIVERY OF THE SHOULDER 2. Fetal presentation
LOVESETS maneuver 3. Amount of amniotic fluid
– 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
POSTPARTUM CHANGES
DELIVERY OF THE AFTERCOMING HEAD
MAURICEAU MANEUVER BREASTS & LACTATION
• The index and the Middle finger are placed over the
I. How breast milk protects babies against infection. (DOH,
baby’s Maxilla to maintain flexion.
1991)
• The other hand on the baby’s shoulder to provide
1. Breastfed babies have less diarrhea than artificially-fed
traction
babies.
• The assistant applies suprapubic pressure
2. Fewer respiratory and middle ear infection.
PIPER’S FORCEPS
3. Fewer infections because of the following:
• This is the preferred (PIPERED) method
a. Breast milk is clean and free of bacteria
• Occiput should be anterior
b. Contains antibodies (immunoglobulin) to many
• Blades applied to the sides of the head
common infections, until he can make his own
PRAGUE MANEUVER
antibodies.
• Used when the baby fails to rotate trunk from occiput
c. Contains white blood cells to help fight infection.
posterior to occiput anterior
d. Contains bifidus factor which helps special bacteria
• Used when there is persistent fetal back
called Lactobacillus bifidus to grow in the baby’s
• Fingers are placed over the shoulders and upward
intestine. Lactobacillus bifidus prevents other
traction is made
harmful bacteria from growing and causing
• Legs are grasped and body is swung over abdomen
diarrhea.
BRACHT MANEUVER
e. Contains lactoferrin which binds iron. Prevents the
• Breech is allowed to deliver spontaneously up to the
growth of some harmful bacteria which need iron.
navel
• Suprapubic pressure is applied
II. Other advantages of breastfeeding. (DOH, 1991)
PINARD’S MANEUVER
1. Breast milk contains lipase which digests fat. Breast milk
• Breech decomposition
is quickly and easily digested and a breastfed baby may
• From frank breech to be delivered as footling
want to feed again more quickly than an artificially-fed
• The fingers are pressed in the baby’s popliteal fossa
baby.
causing flexion of the knee
2. Breast milk is always ready to feed to the baby and it
• Foot is grasped and delivered as footling
needs no preparation.
3. Breast milk never goes sour or bad in the breast even if a
DELIVERY OF AN ENTRAPPED AFTERCOMING HEAD
woman does not feed her baby for some days.
DUHRSSEN ▪ Incisions in the cervix at 2-, 6-, and
4. Breastfeeding helps to stop bleeding after delivery.
INCISION 10-o’clock positions 5. Breastfeeding on demand helps to protect against another
ZAVANELLI ▪ Replacement of the fetus higher into pregnancy.
MANEUVER the vagina and uterus, followed by 6. It helps them to bond, become attached to each other and
cesarean delivery love each other.
SYMPHYSIOTOMY ▪ Surgical incision into the fibro- 7. It is free. You don’t have to buy it.
cartilage of the symphysis pubis in 8. It is exclusively for your baby and cannot be served to
order to allow the fetal head to pass other adults.
into the pelvis (engage), so that a
• Let the mother pick up her baby and feed him whenever
Protective Effects on Infants of Human Milk and Breast he cries and she feels a need to feed him.
Feeding (AAP, 1997) • Frequent sucking stimulates the production of prolactin
Decreased Incidence/Severity Possible protective effects which helps the milk to come in sooner.
Diarrhea Sudden infant death • It prevents engorgement of breasts.
Lower respiratory infection syndrome
Otitis media Type-1 Diabetes 4. Duration of feeds
Bacteremia Inflammatory bowel disease • More babies finish in 5-10 minutes, but some like to
Bacterial meningitis Lymphoma take much longer, perhaps half an hour. It does not
Botulism Allergies matter.
Necrotizing enterocolitis Chronic digestive diseases • Slow feeders take the same total amount of milk as fast
Urinary infections feeders.
• Sucking in the wrong position causes sore nipples.
III. Composition of Human Breast Milk
Component Human milk Cow milk 5. Feeding from both breasts
Water Enough (87.2% to More required • Let the baby finish the first breast to make sure that he
87.5%) gets the hindmilk. Let him take the second breast if he
Bacterial None Likely wants to, but do not force him.
contamination
Anti-infection Antibodies, Antibodies not 6. Prelacteal feeds
substances leucocytes, active, absent • Prelacteal feeds (e.g. formula, glucose water, ampalaya
lactoferrin, bifidus lactoferrin juice, diluted honey) are NOT necessary and they can be
factor harmful.
Protein (Total) 1% 4% too much • Small amount of colostrum is ALL that a normal baby
• Casein 0.5% 3% too much needs at this time.
• lactalbumin 0.5% 0.5%
Amino acids - Enough for growing Not enough 7. Extra water
Cysteine brain Not present • Normal baby is born with a store of water which keeps
• Taurine Enough him well hydrated until the milk comes in. He does not
Fats (Total) 4% average 4% need drinks of water, they interfere with breasfeeding.
• Saturation Enough Too much
UNsaturated saturated 8. Night breastfeeds
Fatty acids – Enough for growing Not enough • It is better if the mother breastfeeds the baby at night as
linoleic acid brain Not enough long as he wants to.
(essential) Enough • Night feeding helps to keep up the milk supply because
• Cholesterol the baby sucks more.
Lipase to digest fat Present None • Night feeds are especially useful for working mothers.
Lactose (sugar) 7% (enough) 3% - 4% (not • Night feeds are important for child spacing.
enough)
Salts (mEq/L) – 6.5 25 (too much) 9. Early weight changes
Sodium 12 29 (too much) • A baby may lose weight for the first few days after
• Chloride 14 35 (too much) delivery. He may lose up to 10% of his birth weight.
• Potassium • When breastfeeding is started, the baby should regain
Iron – colostrum 0.5 – 0.8 mg/L his birth weight in ten days.
• Mature milk 0.2 – 0.3 mg/L
10. Cleaning the breast
IV. Some Myths about Breastfeeding: (Thomson Medical • Frequent washing, especially with soap, removes the
Center, Singapore. 2004) natural oil from the nipple.
1. It is painful & difficult to learn. • The skin becomes dry and is more easily damaged and
2. Breastfed babies cry more than bottle-fed babies. fissured.
3. Breastfeeding tends to isolate mother and baby from the
rest of the family members. DELAYED CORD CLAMPING
4. It is embarrassing. WHO recommedations
5. Spoils a baby and weaning is difficult. - Delayed umbilical cord clamping (not earlier than 1
6. Quality of breast milk depends on your mood. minute after birth) is recommended to due both
7. Breastfeeding mother may have to give up food she likes, improved maternal and infant health and nutition
become tied down and be unable to work. outcomes
8. Breastfed babies need more water.
9. Breast milk lack iron. Delayed cord clamping
- Performed approximately 1-3 minutes after birth is
V. How should breastfeeding begin. (DOH, 1991) recommended for all births UNLESS the neonate is
1. First feed asphyxiated and needs to be moved immediately for
• First feed should be on the delivery table. resuscitation
• Cover both mother and baby to keep them warm.
• Let the mother hold the baby close and let him suck at Benefits
the breast. Immediate Long-Term Benefits
• Sucking stimulates the production of oxytocin which Benefits
helps to deliver the placenta and stop hemorrhage. Pre-Term/Low Decrease the risk Increases
• Baby gets valuable colostrums. Birth Weight of intraventricular hemoglobin at 10
• More likely to breastfeed for a long time. A delay of even hemorrhage, weeks of age
a few hours will result in failure to breasfeed. necrotizing
enterocolitis, late- May be a benefit to
2. Rooming-in onset sepsis neurodevelopmental
outcomes
• There is no need for a mother and baby to rest
Decreases the
separately after a normal delivery.
need for blood
3. Demand feeding
transfusuions for
anemia, surfactant,
mechanical ry lobe
ventilation Precipitous delivery
Macrosomia
Laceration of the
Increases Shoulder dystocia
cervix, vagina or
hematocrit, Operative delivery
perineum
hemoglobin, blood Episiotomy (e.g.
pressure, cerebral mediolateral)
oxygenation, RBC TRAUMA
Deep engagement
flow (Genital tract Extension/laceration at
Malposition
trauma) CS
Full-Term infants Provides adequate Improves Malpresentation
blood volume and hematological status Uterine rupture Prior uterine surgery
birth iron stores (hematocrit and Fundal placenta
hemoglobin) at 2-4 Grand multiparity
Increases months of age Uterine inversion
Excessive traction on
hematocrit and umbilical cord
hemoglobin Improves iron status Preexisting clotting History of
up to 6 months of abnormalities (e.g. Coagulopathy or liver
age hemophilia, disease
THROMBIN vonWillebrands
(Abnormaliti
disease,
es of
POST-PARTUM HEMORRHAGE (PPH) hypofibrinogenemia)
coagulation)
DIC Sepsis
Definition HELLP Intrauterine demise
The following are suggested definitions but there is a lack of Anticoagulation Hemorrhage
agreement on what constitutes excessive blood loss:
1. Blood loss >500 ml for vaginal delivery and 1,000 ml for General Management of PPH:
cesarean section (CS). 1. Initial management approach to obstetric hemorrhage:
2. Blood loss >500 ml in the first 24 hours following delivery. a. Assessment: constant awareness of the hemodynamic
3. Ten percent (10%) decrease in hemoglobin or hematocrit status as well as evaluation to determine the cause of
level. bleeding.
4. Need for transfusion. b. Breathing: administration of oxygen
c. Circulation: obtaining intravenous (IV) access and
Problems with the above definitions: adequate circulating blood volume through infusion of
1. Clinical estimation of blood loss is frequently inaccurate crystalloid and blood products. Second large-bore IV
and the brisk nature of blood loss during delivery or the catheter is needed
presence of amniotic fluid can make this more difficult. 2. Notify the blood bank.
2. Delay in obtaining laboratory results. Information from 3. Simultaneous, coordinated, multi-disciplinary management
laboratory tests would not reflect the patient’s current (OB-GYN, anesthesiologist, hematologists, radiologists,
hemodynamic status. nurses, laboratory and blood bank technicians) to concur
3. Any definition based on the need for transfusion is difficult timely management in the presence of obstetric hemorrhage.
as there are differences in provider practice patterns 4. Preoperative preparedness is important especially for
regarding transfusion. patients identified as high risk.
Definition of obstetric hemorrhage combining clinical and Important Causes of PPH:

objective data (Bonnar, 2000) 1. Uterine atony
Blood Systolic 2. Retained placenta
EBL Heart 3. Uterine rupture
volume BP Signs & symptoms
(ml) rate 4. Genital tract trauma
(%) (mmHg)
500- 5. Uterine inversion
10-15 <100 Normal None
1000
1000 - 100- Slight Vasoconstriction, GUIDELINES FOR CESAREAN SECTION
15-25
1500 120 decrease weakness, sweating INDICATIONS
1500 - 120- Restlessness, pallor, Maternal Prior cesarean delivery
25-35 80-100
2000 140 oliguria Abnormal placentation
2000- Anuria, altered Maternal request
35-45 >140 60-80
3000 consciousness Prior classical hysterotomy
Unknown uterine scar type
Etiology and Risk Factors Uterine incision dehiscence
Etiology Pathophysiology Risk Factors Prior full-thickness myomectomy
Multiple gestation Genital tract obstructive mass
Overdistended uterus Polyhydramnios Invasive cervical cancer
Macrosomia Prior trachelectomy
Prolonged labor Permanent cerclage
TONE Uterine muscle fatigue Augmented labor Prior pelvic reconstructive surgery
(Abnormal Prior PPH Pelvic deformity
uterine Prolonged rupture of HSV or HIV infection
Chorioamnionitis Cardiac or pulmonary disease
contractility) membranes (ROM)
Uterine Fibroids (myoma), Cerebral aneurysm or arteriovenous malformation
distortion/abnormality placenta previa Pathology requiring concurrent intraabdominal
B-mimetics, MgSO4, surgery
Uterine relaxing drugs Perimortem cesarean delivery
anesthetic drugs
Prior uterine surgery Maternal- Cephalopelvic disproportion
Accreta/Increta/Percre Fetal Failed operative vaginal delivery
TISSUE Placenta previa
ta Placenta previa or placental abruption
(Retained Multiparity
products of Manual placenta Fetal Nonreassuring fetal status
Retained Malpresentation
conception) removal
placenta/membranes Macrosomia
Succinturiate/accesso
Congenital anomaly
Abnormal umbilical cord Doppler study o CS for those with active genital lesions or prodromal
Thrombocytopenia symptoms (e.g. vulvar pain or burning) at the time of
Prior neonatal birth trauma delivery
▪ Hepatitis B virus
1. Previous uterine scar o Scheduled CS at 39 weeks with HBV profile as follows:
• In the presence of scarred uterus, the following are ▪ HbeAg positive
ABSOLUTE INDICATIONS for elective CS: (Level III, Grade C) ▪ HBV DNA copies >1,000,000
o Previous classical or inverted T-uterine scar ▪ Not received oral antiretroviral therapy
o Uncertainty of type of previous CS scar ▪ Human papilloma virus
o Previous multiple low transverse segment uterine o Only for those with very large genital warts causing
scars pelvic outlet obstruction or potential for excessive
o Previous hysterotomy or myomectomy entering the bleeding during vaginal delivery
uterine cavity or extensive transfundal uterine ▪ HIV
surgery o Elective CS at 39 weeks to reduce risk of MTCT
o Previous uterine rupture provided:
o Presence of a contraindication to labor, such as ▪ Currently on highly active antiretroviral therapy
placenta previa/accreta, or malpresentation (HAART)
o No informed consent for VBAC ▪ Viral load <400 copies/ml
• Failed trial of labor during VBAC. ▪ On any ARV with viral load <50 copies/ml
2. Abnormalities of the reproductive tract 5. Maternal medical conditions

▪ Presence of gynecologic tumors in pregnancy, such as • Hypertensive complications
uterine myoma and/or adnexal masses, are NOT ABSOLUTE o Maternal indications
indications for CS, unless they cause dystocia ▪ Deteriorating maternal condition
▪ CS performed for those with a history of surgical repair of ▪ Uncontrolled hypertension despite drug therapy
obstetric and anal sphincters, urinary incontinence and ▪ HELLP syndrome
pelvic organ prolapse because of risk of recurrences ▪ Placental abruptio
▪ Genital warts and genital cancers may be an indication o Fetal indications
for CS if it obstructs the birth canal, or if it is excessively ▪ Severe IUGR/FGR
bleeding, or in order to prevent profuse bleeding ▪ Non-reassuring FHR pattern, repeated Category
▪ Presence of cervical stenosis is NOT A II or III, refractory with resuscitation, remote
CONTRAINDICATION to attempted vaginal delivery. There from delivery
is increased risk for CS. ▪ BPP <4, done 6 hours apart
▪ Vaginal delivery for corrected imperforate hymen. ▪ Doppler studies: ARED
▪ CS performed for those with history of complete • Severe bronchial asthma
transverse vaginal septum and vaginal agenesis due to o CS is rarely needed.
risk of vaginal soft tissue dystocia and lateral vault • Cardiac disease
laceration o CS reserved for high-risk cardiac patients.
• Gestational DM
3. Abnormalities of the placenta, cord, membranes and • Obesity
amniotic fluid o Increased risk for CS
• Vasa previa • Macrosomia
o Elective CS between 35-37 weeks AOG
o Emergency CS for bleeding vasa previa 6. IUGR/FGR
• Placenta previa • Deterioration in the fetal condition or when there is an
o Any degree of placental overlap (>0 mm) at the unripe cervix or when there are indications of additional
internal os after 35 weeks is an indication for CS fetal compromise during labor
o Previa within 1 cm of the internal os is an indication • Viable fetus with IUGR when there is:
for CS o deterioration in the BPP
o Elective CS for asymptomatic woman with previa >37 o loss of variability on NST
weeks and for suspected accreta >36 weeks o severe oligohydramnios, and
• Abruptio placenta o failure to grow on serial biometry in the presence of
o Emergency CS for abruptio placenta with fetal abnormal umbilical artery or venous Doppler studies.
compromise, severe uterine hyprtonus, life
threatening bleeding or DIC, and remote from vaginal 7. Fetal congenital anomalies
delivery. • Fetuses with the following anomalies may benefit from CS:
• Cord prolapse o Neural tube defects with fetus in breech
o Emergency CS for cord prolapse o Neural tube defects with sac >6 cm
o Cord prolapse with poor chances of viability, vaginal o Cystic hygromas
delivery may be tried with informed consent o Sacrococcygeal teratomas >5 cm
o Ultrasound finding suggestive of forelying cord or o Hydrocephalus with BPD >10 cm or HC >36 cm
funic presentation is NOT an absolute indication for • Elective CS
CS o Fetus with hypoplastic left heart syndrome
o Digital diagnosis of funic/cord presentation in labor is o Transposition of great arteries with intact
an indication for CS intraventricular septum that require urgent neonatal
• Chorioamnionitis or intra-amniotic infection atrial septostomy
o Presence of clinical chorioamnionitis or intra-amniotic
infection is NOT an absolute indication for CS. 8. Maternal request (CDMR)
• Oligohydramnios • If without clear indication or there is fear of childbirth, the
o Uncomplicated oligohydramnios is NOT an absolute OB should provide counseling to the patient.
indication for CS • Well-written informed consent with proper approval by
the hospital’s ethics committee should be secured before
4. Infection in pregnancy performing the CS.
▪ Herpes simplex virus • Should be performed >39 weeks AOG, unless there is
o CS for those who develop primary genital herpes documentation of fetal lung maturity.
within 6 weeks of delivery
9. Multiple pregnancy
10. Fetal malpresentation (Refer to Section III) PITUITARY DESTRUCTION
11. Abnormal labor patterns (Refer to Section II) Damage or necrosis of the pituitary gland caused by anoxia,
12. Abnormal FHR patterns (Refer to Section I) thrombosis, or hemorrhage. It is called Sheehan’s syndrome
when related to pregnancy and Simmonds’ disease when
Operative Recommendations unrelated to pregnancy.
Timing of planned CS
• Scheduled at 39 weeks OBSTETRICAL HEMORRHAGE
Pre-operative preparation for CS
• Hemoglobin determination
• Antimicrobial prophylaxis within 60 minutes pre-
operatively 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, Uterine Atony
post-operative pain but more likely to result in uterine The most frequent cause of obstetrical hemorrhage is failure of
rupture. the uterus to contract sufficiently after delivery and to arrest
bleeding from vessels at the placental implantation site
• Closure of both visceral and parietal peritoneum after
CS lead to LESS adhesions
Uterine Inversion
• Closure of subcutaneous tissue for >2 cm subcutaneous
Puerperal inversion of the uterus is considered to be one of the
fat.
classic hemorrhagic disasters encountered in obstetrics. Unless
• Indwelling FC may be removed <24 hours after CS
promptly recognized and managed appropriately, associated
bleeding often is massive. Risk factors include alone or in
Anesthesia in CS
combination:
• Uncomplicated elective CS may have modest amounts of 1. Fundal placental implantation,
clear liquids up to 2 hours prior to induction of anesthesia 2. Delayed-onset or inadequate uterine contractility after
• Patient undergoing elective surgery should have a fasting delivery of the fetus, that is, uterine atony,
period for solids at least 6-8 hours prior to induction. 3. Cord traction applied before placental separation, and
• Aspiration prophylaxis: non-particulate antacids, H2 4. Abnormally adhered placentation such as with the accrete
receptor antagonists, metoclopramide syndromes
Post-CS care
• No evidence to recommend a policy of delaying oral fluids OLIGOHYDRAMNIOS
and food after CS Causes of Oligohydramnios
• Remove the dressing 24 hours after the CS. ▪ Fetal abnormality
• No evidence of adverse outcomes associated with early o Congenital abnormalities
postnatal discharge (3-4 days) ▪ By 18 weeks the fetal kidneys are the
• Sexual intercourse may be resumed as early as 2 weeks main contributor to amniotic fluid
postpartum for as long as the patient feels comfortable. volume
*Notes: Placenta previa is one of the main indications for delivery ▪ Severely decreased amniotic fluid
during late preterm or early term. We do not want uterine volume beginning in early in
contractions, hence labor, to ensue with placenta previa due to gestation are secondary to
possible bleeding genitourinary abnormalities
▪ Other organ system anomalies can
OTHER IMPORTNANT OBSTETRIC INFORMATION also indirectly cause
oligohydramnios
DERMATOSES IN PREGNANCY ▪ 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
o Evaluate fetal abnormalities and growth Varicella Congenital varicella syndrome-
o Close fetal surveillance chorioretinitis, microphthalmia, cerebral
o Amnioinfusion – may be used intrapartum in cortical atrophy, growth restriction,
the setting of variable fetal heart rate hydronephrosis, limb hypoplasia,
decelerations, NOT considered a treatment or and cicatricial skin lesions
a standard of care Influenza No firm evidence that it causes congenital
malformations
Mumps Women who develop mumps in the first
DYSTOCIA trimester may have an increased risk of
- Difficult labor, characterized by abnormally slow labor spontaneous abortion
progress Measles/Rubeola The virus does not appear to be
o Expulsive forces may be abnormal teratogenic.
▪ Contractions are insufficiently strong However, an increased frequency of
or inappropriately coordinated to abortion, preterm delivery,
efface and dilate the cervix and low-birthweight neonates is noted
▪ Inadequate voluntary maternal with maternal measles
muscle effort German Rubella infection in
o Fetal abnormalities of presentation, position Measles/ Rubella the first trimester, however, poses
or development may slow labor significant risk for abortion and
o Abnormalities of the maternal body pelvis may severe congenital malformations.
create a contracted pelvis
o Soft tissue abnormalities of the reproductive Rubella is one of the most complete
tract may form an obstacle to fetal descent 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 Associated with abortion, nonimmune

hydrops and still birth
Cytomegalovirus Growth restriction, microcephaly,
intracranial calcifications, chorioretinitis,
mental and motor retardation,
sensorineural deficits,
hepatosplenomegaly, jaundice, hemolytic
anemia, and thrombocytopenic purpura
INFECTIOUS DISEASES IN PREGNANCY Late onset sequelae include hearing

loss, neurological deficits, chorioretinitis,
psychomotor
retardation, and learning disabilities
Group A Remains the most common
Streptococcus cause of severe maternal postpartum
infection and death
worldwide
Group B May cause preterm labor, prematurely
Streptococcus ruptured membranes, clinical
and subclinical chorioamnionitis, and fetal
infections.
GBS can also cause maternal bacteriuria,

pyelonephritis, osteomyelitis,
postpartum mastitis, and puerperal
infections.
MRSA Skin and soft tissue infections are the most

common presentation of MRSA in
pregnant women
Listeriosis Discolored, brownish, or meconium-
stained amnionic fluid is common with
fetal infection, even preterm gestations
Diagnosis Effects Maternal listeriosis causes fetal infection
that characteristically produces - Management
disseminated granulomatous lesions with o Prevent seizure – prevent seizure provoking
microabscesses stimuli, compliance
o Anticonvulsants are given at lowest dosage
Chorioamnionitis is common with
maternal infection, and placental lesions
include multiple, well-demarcated
macroabscesses.
Toxoplasmosis 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 UTI IN PREGNANCY
surgical exploration. (Summary of Recommendations from the UTI in Pregnancy
- Although diagnostic errors may lead to removal of a and ASB in Adults Subgroup)
normal appendix, surgical evaluation is preferable to
postponed intervention and generalized peritonitis ASYMPTOMATIC BACTERIURIA
o Appendicitis increases the likelihood of
abortion or preterm labor, especially if there is Who: Screen ALL pregnant women for ASB
peritonitis once early during pregnancy between 9th to
17th weeks, preferably on the 16th week age of
PANCREATITIS IN PREGNANCY gestation
- Medical treatment is the same as that for nonpregnant Screening Test of Choice: Urine culture of clean-catch
patients and includes analgesics, intravenous hydration, midstream urine.
and measures to decrease pancreatic secretion by Alternative: Urine gram stain of at least one
interdiction of oral intake. organism per oil immersion field
*Urinalysis, Urine dipsticks for leukocyte
LEIOMYOMAS IN PREGNANCY esterase and/or nitrite tests are not
- Can regress after pregnancy recommended as an initial screening test
- May cause pain or pressure - Two consecutive voided or one
- May outgrow their blood supply and hemorrhagic catheterized urine specimen with
infarct follows- Red or Carneous Degeneration isolation of the same bacterial strain in
- Treatment is analgesic medication, myomectomy has quantitative counts ≥ 100,000 cfu/mL
resulted in good outcomes Diagnosis - In settings where obtaining two
- Pedunculated subserosal myosmas will undergo consecutive urine cultures are not feasible
torsion—can be managed with laparoscopy or or difficult, one urine culture is an
laparotomy acceptable alternative
- Complications - In settings where dipslide culture
o Preter labor technique is available, it may be used as
o Placental abruption an alternative to urine culture
o Fetal malpresentation - Antibiotic treatment for asymptomatic
o Obstructed labor bacteriuria is indicated to reduce the risk
o Cesarian delivery of acute cystitis and pyelonephritis in
o Postpartum hemorrhage pregnancy as well as the risk of LBW
neonates
SEIZURE DISORDERS IN PREGNANCY - Among the drugs that can be used are
- Women with epilepsy have increased seizure risks with Treatment Nitrofurantoin, (not for near term) co-
mortality risks and fetal malformations amoxiclav, cephalexin, fosfomycin,
o Often associated with decreased and cotrimoxazole (not on the first and third
subtherapeutic anticonvulsant serum levels, trimester) depending on the sensitivity
lower seizure threshold, or both results of the urine isolate
- Medications - Duration of treatment will depend on the
o Fetus of an epileptic mother who takes antibiotics that will be used but short-
anticonvulsant medications has increased risk course (7 days) treatment is preferred
for congenital malformations over single-dose regimen
o Monotherapy has lower birth defect rate Monitoring - A follow up urine culture should be done
compared to multiagent one week after completing the course of
o Phenytoin and phenobarbital increase the risk treatment
for malformations (two-to-threefold above the - Monitoring should be done every trimester
baseline). Valproate may increase four-to- until delivery
eightfold risk
o Newer antiepileptic mediations are reported
ANTIBIOTICS RECOMMENDED DOSE PREGNANCY
to have no associations with a markedly
AND DURATION CATEGORY
increased risk of major birth defects
Cefalexin 500 mg BID x 7 days B
Cefuroxime 500 mg BID x 7 days B Cefadroxil 1 g BID for 7 days
Fosfomycin 3 g in single dose B Cefuroxime 500mg BID for 7
trometamol days
Amoxicillin- 625 mg BID x 7 days B Cefaclor 500mg TID for 7
clavulanate days
Nitrofurantoin 100 mg BID x 7 days B Cefixime 200mg BID for 7 B NONE
TMP-SMX 160/800 mg BID x 7 days C days
(avoid in 1st Cefpodoxim 100mg BID for 7 B NONE
and 3rd e days
trimester) Nitrofurant 100 mg BID for 7 B Hemolytic
oin days anemia
ACUTE CYSTITIS IN PREGNANCY Anopthalmia
- urinary frequency, urgency, dysuria and Hypoplastic left
Symptoms bacteriuria without fever and heart
costovertebral angle tenderness. syndrome
+/- Gross hematuria Asd
Cleft lip &
- In pregnant women suspected to have palate
acute uncomplicated cystitis, obtain a Fosfomycin 3 gms single dose B None
pretreatment urine culture and trometamol
sensitivity test of a midstream clean catch Pivmecillina 400 mg BID for 7 B None
Diagnosis urine specimen m days
- In the absence of a urine culture, the Amoxicillin- 625mg BID for 7 Neonatal
laboratory diagnosis of acute cystitis can clavulanate days necrotizing
be determined by the presence of enterocolitis
significant pyuria defined as a) > 8 pus Trimethopri 800/160 mg BID C Anencephaly
cells/mm3 of uncentrifuged urine OR b) > m- for 7 days Hypoplastic left
5 pus cells/hpf of centrifuged urine, and c) sulfamethox heart
a positive leukocyte esterase and nitrite azole syndrome
test Choanal atresia
Transverse
- Treatment should be instituted limb defect
immediately to prevent the spread of the Diaphragmatic
infection to the kidney hernia
- Since E. coli remains to be the most
common organism isolated, antibiotics to Nitrofurantoin - May be given on the second trimester
which this organism is most sensitive and of pregnancy until 32 weeks AOG
Treatment which are safe to give during pregnancy - Only use in first trimester of
should be used pregnancy is appropriate when no
- A 7-day treatment with an oral other suitable alternative antibiotics
antimicrobial agent that is safe for use in are available
pregnancy is recommended except for Co-Amoxiclav - avoid in women at risk of preterm
fosfomycin which is given as a single dose labor
- In the absence of a urine culture and TMP-SMX - may be given on the second and third
sensitivity, empiric therapy should be trimester of pregnancy
based on local susceptibility patterns of - use in first trimester pregnancy is
uropathogens appropriate when no other suitable
- In cases where the result of a urine culture alternative antibiotics are available
shows an organism resistant to the - use only for culture proven
empirically started antibiotic in a clinically susceptible uropathogens due to high
improving patient, no adjustment is level of resistance
necessary. Adjust antibiotic therapy based
on urine culture results ONLY when there
is no improvement in the clinical signs and ACUTE UNCOMPLICATED PYELONEPHRITIS
symptoms and laboratory results or there
is worsening of condition - fever (T> 38°C)
Symptoms - chills
- Post-treatment urine culture 1 – 2 - flank pain
weeks after completion of therapy should - costo-vertebral angle tenderness
be obtained to confirm eradication of - nausea and vomiting
Monitoring bacteriuria and resolution of infection - with or without signs and symptoms of
- Pregnant patients with pyelonephritis, lower urinary tract infection
recurrent UTIs, concurrent gestational DM, - Urinalysis: Pyuria (> 5 wbc/hpf of
concurrent nephrolithiasis or urolithiasis, centrifuged urine)
and pre-eclampsia, should be monitored at - Urine culture: bacteriuria with counts of
monthly intervals until delivery to ensure > 10,000 cfu of uropathogen per ml on
that urine remains sterile during Diagnosis urine culture
pregnancy - Urinalysis and Gram stain are
recommended
- Urine culture and sensitivity test should
ANTIBIOTI RECOMMENDED PREGN BIRTH also be performed routinely to facilitate
CS DOSE AND ANCY DEFECTS / cost-effective use of antimicrobial agents
DURATION CATEGO NEONATAL and because of the potential for serious
RY COMPLICATIO sequelae if inappropriate antimicrobial
NS agent is used.
Cefalexin 500 mg QID for 7 - Blood cultures are NOT routinely
days B NONE recommended except in patients with
signs of sepsis
- Routine renal ultrasound is of limited Hemangioma - Rare malformations of blood vessesls than
clinical benefit and should be reserved for true neoplasms. Usually discovered
women who fail to respond to initial intitially during childhood. It is usually
treatment. single, 1-2 cm in diameter, flat, soft and
Indications - inability to maintain oral hydration or take colors range from brown, red or purple.
for medications These tumors range in size and not
Admission - concern about compliance encapsulated
- presence of possible complicating (co- Fibroma - The most common benign solid tumors of
morbid) conditions the vulva. It occurs in all age groups and
- severe illness with high fever, severe pain, commonly found in the labia majora.
marked debility Majority are 1-10 cm in diameter.
- signs of preterm labor Lipoma - Benign, slow-growing, circumscribed
- signs of sepsis tumors or fat cells arising from the sub
- In the absence of a urine culture and cutaneous tissue of the vulva
sensitivity, empiric therapy should be
based on local susceptibility patterns of VAGINA
uropathogens. Since E. coli remains to be • Urethral diverticulum- permanent, epithelialized, sac-like
the most common organism isolated, projection that arises from the posterior urethra, present at
antibiotics to which this organism is most a mass of the anterior vaginal wall. It is a common problem
Treatment sensitive and which are safe to give during discovered in 1-3% of women
pregnancy should be used • Inclusion cysts- the most common cystic structures of the
- The recommended duration of treatment vagina
is 14 days
• Dysontogenic cysts- thin walled, soft cysts of embryonic
- Intravenous antimicrobial therapy is
origin
usually continued until the patient is
o Gartner’s duct cysts – from the mesonephros
afebrile for 48 hours and symptoms have
o Mullerian cysts – from the
improved; afterward, the patient is treated
paramesonephricum
with oral antibacterials. The course of oral
o Vestibular cysts – fromt he urogenital sinus
therapy lasts for 10–14 days. If the patient
fails to respond clinically by 72 hours,
further evaluation should ensue for CERVIX
bacterial resistance to the antibacterial • Endocervical and Cervical Polyps – Most common benign
used, urolithiasis, perinephric abscess neoplastic growth of the cervix. It is most common in
formation or urinary tract abnormalities, multiparous women in their 40s-50s. Majority are smooth,
and the antibacterial agent should be soft, reddish purple to cherry red. They are fragile and
changed to include an aminoglycoside readily bleed when touched. It may arise to endocervical
- Post-treatment urine culture should be canal or ectocervix
obtained after completion of antibiotic • Nabothian cysts- retention cysts that are very common that
treatment to confirm resolution of the they are considered a normal feature of the adult cervix.
infection (“test of cure”) Aymptomatic and no treatment is necessary
- Patient should be followed up for • Cervical myoma- usually a solitary growth, small and most
symptoms of recurrent infection and are asymptomatic
Monitoring monthly urine culture should be
performed until delivery ASCCP GUIDELINES FOR MANAGEMENT OF ABNORMAL
- Recurrence of symptoms requires CERVICAL CANCER SCREENING TESTS AND CANCER
antibiotic treatment based on urine PRECURSORS
culture and sensitivity test results, in
addition to assessing for underlying 1. Unsatisfactory cytology – take in account the age and
genitourologic abnormality HPV status
- 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
*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 - Small, single, sessile but may be

Caruncles 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
Cysts - The most common large cyst of the vulva is absent TZ (Transformation zone)
a cystic dilatation of an obstructed HPV testing is UNACCEPTABLE for women aged 21-29
Bartholin’s duct. The most common small years old
vulvar cysts are epidermal inclusion cysts
or sebacious cysts.
Nevus - Vulvar nevi are one of the most common
benign neoplasms in females; generally
asymptomatic
Reflex HPV testing: ASCUS in Pap smear warrants HPV DNA

3. Women more than 30 years old, cytology negative, HPV determination
positive
6. Management of Women with Low-grade Squamous
Co-testing: Cytology (Pap smear) and determination of
Intraepithelial Lesions (LSIL)* †
HPV DNA
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. Management of Women Ages 21-24 yrs with Atypical

Squamous Cells, Cannot Rule Out High Grade SIL (ASC-
H) and High-grade Squamous Intraepithelial Lesion
(HSIL)
4. ASCUS- repeat cytology at 1 year: acceptable; HPV

TESTING: PREFERRED
5. Management of Women Ages 21-24 years with either

Atypical Squamous Cells of Undetermined Significance
(ASC-US) or Low-grade Squamous Intraepithelial Lesion
(LSIL)
9. Management of Women with High-grade Squamous Signs and - Most myomas are asymptomatic and may not
Intraepithelial Lesions (HSIL) Symptoms require intervention
- Immediate loop resection OR Colposcopy with endocervical - Common presentations: AUB, pressure
assessment symptoms and pain
- AUB is usually characterized by heavy bleeding
10. Initial Workup of Women with Atypical Glandular Cells - Myomas rarely cause pelvic pain
(AGC) - 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
11. Subsequent Management of Women with Atypical require therapy.
Glandular Cells (AGC) Types - 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
UTERUS stalk (pedunculated myoma) or may be broad
• Endometrial polyps – localized overgrowths of endometrial based (sessile). They do not need treatment
glands and stroma beyond the surface of the endometrium. unless they grow large. However, those on a
Majority are asymptomatic, but those who are symptomatic stalk can twist and cause pain. Easiest to
are associated with a wide range of bleeding patterns remove by laparoscopy
• Hematometra – uterus distended with blood and secondary - Intramural myomas- within the uterine
to gynatresia. Common symptoms include amennorrhea and myometrium and can range in size from
cyclic lower abdominal pain microspic to larger ones. Most do not cause
problems unless they become quite large
Leiomyomas/Myomas/Uterine Fibroids (lifted from POGS CPG distorting the uterine cavity or cause irregular
on Myoma and adnexal masses, 2010) external uterine contour. A sufficiently
enlarged myoma can cause pressure
Definition - Benign monoclonal tumors arising from symptoms. They often do not need any
smooth muscle cells of the myometrium treatment unless infertility and AUB are
- Contain large amount of extracellular matrix concerns
surrounded by a thin pseudocapusule of - Submucous myomas: proximate to the
areolar tissue or compressed muscle fibers endometrium and grow toward and bulge into
Risk - Become more common as women age, the endometrial cavity. They may either be
Factors especially from 30s to 40s through menopause. pedunculated or sessile. They can cause heavy
After menopause, myomas usually shrink menstrual period, as well as intermenstrual
- Most common in women with a higher BMI bleeding. Distortion of the endometrial cavity
- There appears to be a familial tendency milieu by these myomas may diminish
- Pregnancy decreases the risk of myomas implantation and sperm transport thus
- OCP and smoking decreases the risk producing infertility or abortion. They may
- Early menarche, high dat and eating large transform intro intracavitary myomas, and
amounts of red meat has been associated with may prolapse through the cervix
increased risk
Etiologies - Steroid hormones: estrogen and progesterone Differential Diagnosis for Myoma
(Theories) were considered most important regulators of 1. Adenomyosis and Adenomyoma
myoma growth Definition Adenomysosis: presence of endometrial tissue
- High mobility group proteins HMGI (C) and within the myometrium, at least 1 hpf from the base
HMGI (Y) code for proteins that help control of the endometrium
cell growth by indirectly regulating DNA Adenomyoma: an adenomyosis tha appears as a
transcription. Mutations in these genes are focal mass
probably secondary changes in already Symptoms - Often asymptomatic
genetically susceptible cells. - Symptoms include: heavy menstrual bleeding,
dyspareunia, dychezia, dysmenorrhea Definition - Most common benign, solid neoplasm of the
- Symptoms begin a week before the onset of ovary
menstrual flow and may not resolve until after - Often present in postmenopausal women
the cessation od menses Symptoms - Smaller tumors are asymptomatic
Signs - Uterus is diffusely enlarged but usually never - Bogger tumors can cause abdominal
exceeds 14cm in size enlargement secondary to the size of the tumor
- soft and tender uterus particularly at the time and ascites
of menses - Does not change the pattern of menstrual flow
- Mobility of the uterus is not restricted Signs - May be pedunculated and therefore easily
Diagnosis - Adenomyosis is a clinical diagnosis and can palpated during one examination yet difficult
only be confirmed by pathologic review to palpate on subsequent examination
- Imaging studies, although helpful, are not - Size varies from 6-30cm
definitive - The amount of ascites is directly proportional
- Sonographic criteria for the diagnosis of to the size of the tumor
adenomyosis include: Diagnosis - Usually misdiagnosed as myoma prior ro
• Heterogenous myometrial areas that are operation based on physical examination alone
not encapsulated and containing anechoic - Ovarian fibromas can have signal intensities
lacunae measuring 1-3mm in diameter similar to that of a pedunculated myoma and
and an area characterized by irregular ultrasound may not be able to differentiate the
cystic spaces measuring 1-7mm in two
diameter (honeycomb pattern) and - MRI can demonstrate continuity of a presumed
disrupting the normal fine speckled adnexal mass with the adjacent myometrium
pattern of the uterus this establishing the diagnosis of myoma or
- Sonographic criteria for the diagnosis of adnexal mass surrounded by ovarian stroma
adenomyosma include: and follicles thus establishing the ovarian
• Nonhomogenous circumscribed area in origin of the mass
the myometrium with indistinct margin,
containing hypoechoic areas larger than Degenerative Changes
5mm - The eventual fate of myomas is determined by its blood
• Circumscribed nodular aggregate of supply
smooth muscle and endometrial glands
seen together with compensatory Type of
hypertrophy of the myometrium degeneration
surrounding the site of ectopic Hyaline - 65%
endometrium - Mildest form of degeneration characterized
- Hysterosalpingography in general gives poor by loss of smooth muscle cells that are
diagnostic sensitivity and specificity replaced by fibrous connective tissue
- Transabdominal ultrasound exhibits higher Carneous or - Occurs in 5-10% of pregnant women
degree of sensitivity but poor specificity red - Can cause severe pain and peritoneal
- Transvaginal ultrasound exhibits satisfactory irritation
predictive value in the diagnosis - Characterized by extensive coagulative
necrosis
2. Leiomyosarcoma Calcific - Due to the deposition of calcium phosphates
Definition - A rare gynecologic malignancy and carbonates brought about by the
- May arise in a previously existing benign continued diminished blood supply and
leiomyoma (sarcomatous transformation) or ischemic necrosis of tissue
independently from smooth muscle cell of the Cystic or - Characterized by accumulation of edema
mymetrium hydropic fluid and often associated with collagen
Clinical - Median Age: 44-57 years old deposition
History - May be associated with a history of prior pelvic Fatty - Result from adipose metaplasia in myomas.
radiation therapy It contains an admixture of smooth muscle
Symptoms - Non-specific and mature adipose tissue
- Abnormal vaginal bleeding Malignant - May be a misnomer. It is unknow whether
- Pelvic pain or pressure myomas degenerate into leiomyosarcomes
- Enlarging abdomen (pelvic mass is the or whether they arise spontaneously
principal finding)
- Abnormal vaginal discharge Diagnosis of Myoma
Signs - A uterine mass increasing in size in Pelvic Examination - Manual palpation and estimation
postmenopausal woman of the size of the uterus is an
- Single large uterine mass tends to be softer due important part of routine
to tissue necrosis, internal cystic degeneration gynecological examination, as it is
and hemorrhage necessary to exclude abnormal
- Mass is difficult to separate from the growth of this reproductive organ
surrounding myometrium at attempted due to beign or malignant tumors
myomectomy - Uterine size, as assessed by
Diagnosis - Preop diagnosis is difficult bimanual examination, correlates
- Endometrial sampling and ultrasound well with uterine size and weight
including color Doppler have not found to be at pathologi examination, even in
reliable most obest women
- There is insufficient evidence to support routin Ultrasound - Typically ised to confirm the
biopsy of uterine fibroids diagnosis of myomas
- MRI is promising in distinguishing between - A complementary transabdominal
benign and malignant smooth muscle tumors. ultrasound evaluation may be of
An ill-defined margin of uterine smooth muscle value in selected cases such as
tumor on MRI is more in keeping with a large volume uteri
malignant process - Sonohysterography or saline
infusion sonograhy (SIS) provides
3. Ovarian fibroma additional informaltion over TVS
alone and is an important adjunct management of symptomatic intracavitary
in women with known or myomas
suspected myomas, particularly - Selective Uterine artery occlusion
before surgical or medical therapy Medical - Selective Progesterone Receptor Modulators
- Office hysteroscopy and SIS are Management (Ulipristal)
equivalent diagnostic tools for the - GnRH-agonist ± add-back
detection of intrauterine myomas
and polups
- All patients with submucous ADNEXA
myoma who are candidates for (POGS CPG on adnexal Masses, November 2018)
hysteroscpic removal should
undergo SHG for accurate - Masses arise from the ovaries, fallopian tubes and
preoperative grading surrounding connective tissue
- Real time US and Doppler are used
complementary to each other to Fuctional cysts – All are benign and usually does not cause
enhance the differentiation symptoms or require surgical management
between benign and malignant o Follicular cysts- most frequent cystic structures in
endometrial lisons normal ovaries. Mostly asymptomatic
- Color doppler SHG may be usedul o Corpus luteum cysts- minimum of 3 cm in diameter,
in distinguishing polyp from associated with normal, delayed menses or
submucsal myomas based on the amenorrhea. It may cause intraperitoneal bleeding
vascularity of the lesions (polyps o Theca lutein cysts- least common of the 3 physiologic
typicall contained a single feeding ovarian cyts, almost always found bilaterally, and can
vessel, whereas myomas had produce enlargement of the ovaries. It is caused by
several vessels, which arose from prolonged or excessive stimulation of the ovaries to
the inner myometrium gonadotropins. USUALLY OCCUR WITH PREGNANCY,
Hysterosalpingography - HSG obtains limited accuracy but INCLUDING MOLAR PREGNANCY.
because of the valuable Benign neoplams
information it provides about the o Benign cystic teratoma (Dermoid cyst)- cystic
cavity and tubes, it remains structures that on histologic examination contain
mandatory in the evaluation of elemetns of the three germ cell layers. Benign teratomas
infertility are among the most common ovarian neoplasms, and
Hysteroscopy - Diagnostic hysteroscopy and SIS are the most common neoplasms in prepubertal females
are equivalent diagnostic too;s for and teenagers. When opened, sebacous fluid along with
the detection of intrauterine hair, cartilage and teeth can be found
myomas and polyps o Endometriomas (Chocolate cyst) – usually associated
CT scan - Not currently a primary imaging with endometriosis, and one of the most common
modality for uterine myoma causes of the enlargement of the ovary. It range to small
MRI - TVS is as efficient as MRI in (1-5 mm) to 5-10 cm in diameter hemorrhagic cysts.
detecting myoma presence. Symptoms include pelvic pain, dyspareunia and
However, MRI is more accurate infertility
for exact myoma mapping and o Fibromas- most common benign, solid neoplasms of the
should be preferred when such ovary. Associated with Meig’s syndome (Ovarian
mapping is important fibroma + ascites + hydrothrorax)
- Recommended for preop o Brenner tumors (Transitional cell tumor)- rare, small,
evaluation when advanced smooth, fibroepithelial ovarian tumors that are
surgery of myomas is planned generally asymptomatic. 1-2% undergo malignant
especially for patients who want changes. Histologically, it is composed of solid
to preserve fertility masses/nests of epithelial cells (similar to transition
- MRI is superior to TVS for the cells of the urinary bladder) and surrounding fibrous
diagnosis of adenomyosis stroma
o Adenofibroma and Cystadenofibroma – benign, firm
Treatment of Myomas tumors, consists of fibrous and epithelial components
Hysterectomy - In women who do not wish to preserve Differential Diagnosis for Pelvic masses
fertility and who have been counseled Gynecologic Non-Gynecologic
regarding the alternatives and risks, Benign Malignant Benign Malignant
hysterectomy may be offered as the Functional Cyst Epithelial Diverticular GI cancers
definitive treatment cell abscess
Conservative - Myomectomy: option for women who wish carcinoma
Surgical to preserve their uterus but women should Endometrioma Germ cell Appendiceal Metastatic
Therapies be counseled regarding the risk of tumors abscess cancer
requiring futher intervention (ie. There is Tubo-ovarian Sex cord/ Nerve sheath Retroperito
a 15% recurrence and 10% of women abscess stromal tumors neal
undergoing a myomectomy since it is tumors sarcomas
dependent on the intraoperative fidings Mature teraoma Metastatic Ureteral
and the course of surgery) carcinoma diverticulum
- Abdominal myomectomy: most suggest a Serous Bladder
laparotomy for myomas exceeding 5-8cm, cystadenoma diverticulum
multiple myomas or when deep intramural Hydrosalpinx Pelvic kidney
myomas are present
Paratubal cysts
- Laparoscopic myomectomy
Leiomyoma
- Laparoscopic myolysis: alternative to
Mullerian
myomectomy or hysterectomy for selected
anomalies
women who wish to preserve their uterus
but do not desire future fertility
- Hysteroscopic myomectomy: first line -
In newborns, small functional cysts measuring <1-2cm may
conservative surgical therapu for the be found secondary to the influence of maternal hormones.
These cysts usually regress after the first few months of life
- With increasing age, the incidence of malignancy rises Dysgerminoma + - + -
Endodermal - + - -
History and PE Sinus Tumor
- Patient should be questioned about pain, particularly its Choriocarcinoma + - - -
location, quality and time of onset Immature - + + +
- Pain in the presence of an adnexal mass is often secondary to Teratoma
the distention of the ovarian capsule or compression of Embryonal + + - -
adjacent structure Carcinoma
Time of Onset/Quality of Pain Probable cause - Children with simple ovarian cyst <10cm with no malignant
Midcycle pain Ovulation features should be manage expectantly. Otherwise, surgery
Post-coital pain Ruptured follicular or corpus is preferred.
luteum cyst - Laparoscopy is preferred over open surgery in benign
Dyspareunia Endometriosis ovarian tumors. For malignany diseases, surgical staging is
Sudden onset with postive Ectopic pregnancy recommended but with preservation of the uterus and
prenancy test contralateral ovary even in advance disease.
Sudden onset of severe or Ovarian torsion
intermittent severe pain Management of Adnexal Masses in Reproductive Aged Women
associated with nausea and
vomiting Asymptomatic - Expectant management
with simple - Timing of ultrasound during the first half
Menstrual Disturbance cysts <5cm of the follicular phase (days 4-6)
Severe dysmenorrhea and Endometriosis or leiomyomas Asymptomatic - Yearly ultrasound follow-up
menorrhagia with simple - Consider further imaging (MRI) or surgical
Prolonged amenorrhea followed Polycystic Ovarian Syndrome cysts 5-7cm intervention
by menorrhagia, - Persistent: repeat ultrasound at 6 months
hyperandrogenism and PCO on with CA-125 determination
UTS Persistent - Surgical management
Bleeding in premenarchal or Granulosa cell tumor asymptomatic
postmenopausal patient with ovarian cyst or
solid ovarian mass with suspicion
Vague GI symptoms (dyspepsia, Ovarian carcinoma of malignancy
early satiety, sensation of - Functional ovarian cyst should not be prescribed with OCP
abdominal bloeating or fullness, - Observation should be advised for the asymptomatic woman
constipation or a change in when the evaluation shows Ca-125 levels <200U/mL and no
quality of stool) TVS finding suspicious for cancer
- Observation may also be advised for women with ovarian
Laboratory Tests and Serum Biomarkers cysts who are at high risk for surgical morbidity and
Laboratory tests - Pregnancy Test mortality
to be requested - Serial quantitative B-HCG to evaluate - Surgical management
should be based suspected ectopic pregnancy • Benign masses may be removed laparoscopically or
on associated - CBC: elevated WBC may indicate PID or through laparotomy
symptoms TOA, or pelvic abscess from volonic or • Ovarian cystectomy if the preoperative suspicion for
appendiceal pathology malignancy is low, the mass appears beign
Serum cancer - Does not need to be measured on all intraoperatively, and there is no evidence of metastatic
antigen (CA)-125 premenopausal women with simple disease
ovarian cyst on ultrasound • Aspiration of ovarian cyst SHOULD NOT be done
- Not recommended for differentiating
between benign and malignant adnexal Management of Adnexal Masses in Postmenopausal women
mass - Postmenopausal women who have adnexal masses with low
LDH, AFP and - Should be measured in all women under risk of malignany (normal CA 125 <35IU/ml, asymptomatic,
hCG the age of 40 with complex ovarian mass simple, unilateral, unilocular simple cysts, less than of equal
because of the likelihood of germ cell to 7cm in diameter) may be offered surveillance every 3-6
tumors months
- An estimation of the risk of malignancy is essential in the - If there is no increase in size, and if the Ca-125 remains
assessment of an ovarian mass (RMI: Risk of malignancy normal, frequency of surveillance may be decreased or may
index) be done annually
- Surgery
Imaging • Symptomatic
- Primary imaging modality: Grey scale, high frequency, 2D • Suspicious or persistent complex adnexal mass
transvafinal ultrasound with color Doppler imaging regardless of size
- UTS should be used to identify specific diagnosis, • Asymptomatic with simple adnexal cyst >7cm in
differentiate from a non-gynecologic pathologies, diameter
differentiate benign from malignant masses, or to evaluate
extent of the disease Management of Fallopian Tube Masses
- CT scan and MRI should be used as an afjunct to ultrasound Hydrosalpinx
for uncertain or problematic cases and to determine the Desirous of - Salpingostomy may be done in younger
extent of the disease 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
desirous of monitoring Strawberry cervix may be Metronidazole, 2g
pregnancy observed oral single dose
- Antibiotics should be started in women with hydrosalpinx to
prevent progressive damage to the tubes Women with this infection
should also be tested for
Tuboovarian Abscess other STDs
- Broad spectrum antibiotics should be initiated in women Candidiasis 75% of women may Topical azoles
with TOA until clinical improvement is achieved for 24-48 experience this in their (Butoconazole,
hours. lifetime. Predisposing Clotrimazole,
- Antibiotics include IV Clindamycin, Metronidazole or factors: pregnancy, Miconazole,
Cefoxitin. Once clinical improvemt is noted and the fever has diabetes, antibiotic use. Tioconazole,
resolved, antibiotics should be changed to oral preparation Discharge may be varied Nystatin,
and continued for 14 days from watery to thick Fluconazole)
- Surgical intervention should be done in patients suspected Atrophic Common in menopausal Estrogen cream
of ruptured TOA, abscess size larger than 8cm, and no vaginitis women
clinical response after initiation of antibiotics within 48 Cervicitis Presents with purulent Gonorrhea-
hours cervical discharge Ceftriaxone 250
- Surgical drainage using laparoscopy within 24 hours after mg IM single dose
initiation of antibiotic therapy should be done in women or
desirous of pregnancy with a TOA to maximize fertility, Cefixime 400 mg
minimize complications, shorter hospitalizations and faster oral single dose
response rate Chlamydia-
Doxycycline 100
Management of Paraovarian/Paratubal Cysts mg BID x 7 days
- Asymptomatic paraovarian/paratubal simple cysts Or Azithromycin 1
measuring 10 cm or less can be managed expectantl g oral single dose
- Surgery, preferably laparoscopy, should be advised based on Pelvic Diagnosis implies that the Outpatient
the presence/severity of symptoms, size and radiologic Inflammatory patient has upper genital treatment:
characteristics of the mass and the risk of malignancy Disease tract infection and Cefoxitin or
- To prioritize fertility preservation, cystectomy (enucleation inflammation (ascended to Ceftriaxone PLUS
from the mesosalpix) of the cyst should be done the endometrium and Doxycycline or
- Aspiration of cyst fluid should be avoided fallopian tubes) Azithromycin
Adnexal Masses in Special Populations: Pregnancy Commonly caused by N. Inpatient

- The most frequent types of ovarian masses are corpus gonorrhoea and C. treatment:
luteum cysts, endometriomas, benign cystadenomas, and trachomatis Cefoxitin or
mature cystic teratomas (dermoids) Cefotan PLUS
Diagnosis - Ultrasound must be the primary Triad: pelvic pain, cervical Doxycline
diagnostic tool motion and adnexal
- MRI may be used in cases where there is tenderness and fever Or
difficulty in distinguishng the nature of
the mass Clindamycin PLUS
- The use of tumor markers as an adjunctin Cefrtriaxone or
evaluating the mass should be Gentamicin
individualized Tubo-ovarian End stage process of PID Medical treatment
Treatment - May be observed if there are no Abscess or Abscess
options complications during the course of Drainage
pregnancy Genital Those with genital ulcers Chancroid:
- Elective surgical intervention should be Ulcers may have HSV or syphilis Azithromycin,
done in the second trimester of or chancroid Ceftriaxone,
pregnancy (14-16 weeks) Ciprofloxacin,
- In cases of complications such as rupture Erythromycin
or torsion, or when malignancy is
suspected, surgical intervention must be HSV: Acyclovir,
performed regardless of age of gestation Famciclovir,
- For ovarian torsion in a patient still Valacyclovir
desirous of pregnancy, it should be
managed by reduction of the torsion with Syphilis: Pen G
concomittant ovarian cystectomy Genital warts Manifestation of HPV 51 Goal of treatment
(external) is to remove the
warts but it is not
GENITOURINARY INFECTIONS and STDs Non-oncogenic HPV 6 and possible to
11 also cause external eradicate the
Diagnosis Description Treatment genital warts infection
Bacterial Most common cause of Metronidazole
Vaginosis vaginitis in the US Clindamycin Highly contagious Cryotherapy,
Imiquimod cream,
Women with BV are at risk Podophyllin,
for PID, Pregnant women Podofilox,
are at risk for PROM, Trichloroacetic
preterm labor and delivery, acid, Cautery,
chorioamnionitis Laser, Interferon
UTI E.coli is the most common Acute Cystitis:
Diagnosis: fishy vaginal pathogen for acute cystitis TMP-SMX,
odor; clue cells in histology Nitrofurantoin
Trichomonas Profuse, purulent, Metronidazole,
malodorous vaginal 500mg/tab BID x Pyelonephritis:
discharge with pruritus; 7 days or TMP-SMX,
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-to-
moderate 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 - Metabolic Syndrome Diagnostic Criteria
o Female waist >35 inches
POLYCYSTIC OVARY SYNDROME o Triglycerides >150 mg/dL
o HDL <50 mg/dL
- Characterized by a combination of hyperandrogenism o Blood pressure >130/85 mmHg
(either clinical or biochemical), chronic anovulation, o Fasting glucose: 110–126 mg/dL
and polycystic ovaries. It is frequently associated with o Two-hour glucose (75 gm OGTT): 140–199
insulin resistance and obesity mg/dL
- It is the most common cause of hyperandrogenism, - Treatment
hirsutism, and anovulatory infertility in developed o Hormonal contraception or ovulation
countries induction
- Criteria: o Hirsutism: Weight loss, Oral contraceptives,
o Oligoovulation or anovulation medroxyprogesterone, GnRH analogues,
o Clinical and/or biochemical signs of glucorticoids, ketoconazole, finasteride,
hyperandrogenism spironolactone, flutamide, metformin
o Polycystic ovaries and exclusion of other
etiologies (congenital adrenal hyperplasia, AMBIGUOUS GENITALIA AND CONGENITAL ADRENAL
androgen-secreting tumors, Cushing’s HYPERPLASIA
syndrome) - 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
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 Proper Use

- Hymen should establish a connection between the FAB Method may be used by regularly menstruating women and
lumen of the vaginal canal and the vestibule highly motivated couples
- May result to primary amenorrhea
- May cause hydrocolpos or mucocolpos- caused by Calendar - Woman records the length of her cycles
collection of secretions behind the hymen, and in rare Rhythm Method for several months
cases may build up to form a mass that obstructs the - FERTILE PERIOD:
urinary tract Previous shortest cycle – 18=_____
- May develop hematocolpos and hematometrium Previous longest cycle- 11= ____
overtime - the couple abstains from coitus during
- Fallopian tubes can also be distended because the this calculated fertile period
menstrual flow may back up through the tubes Standard Days - The couple should abstain from vaginal
Method (SDM) intercourse from menstrual days 8-19
VAGINAL AGENESIS among women with cycles of 26-32
- Also called Mullerian agenesis or Mullerian aplasia days
- Usually associated with the Mayer-Rokitansky-Kuster- Basal Body - BBT is recommended for any
Hauser (MRKH) syndrome Temperature reproductive age woman who is willing
o congenital absence of the vagina and uterus (BBT) to take and chart her BBT daily and
(in 75% of patients), although small masses of practice abstinence during her fertile
smooth muscular material resembling a days
rudimentary bicornuate uterus are not - The couple should refrain from vaginal
uncommon intercourse from the first day of
o Some patients have rudimentary uterine horns menses until 3 days after the
o 50% have concurrent urinary tract anomalies temperature rise of 0.2 to 0.5 C
o Presents with primary amenorrhea Cervical Mucus - Recommended for any reproductive
o PE findings shows a short vaginal pouch and
Method or age woman without evidence of vaginal
inability to palpate a uterus Billings infections or abnormal vaginal
Ovulation discharge
GYNECOLOGIC PROBLEMS IN PRE-PUBERTAL CHILDREN Method - The couple should refrain from vaginal
intercourse once the presence of a Generation Amount of Estrogen
clear, wet and slippery mucus secretion First Contain up to 10 times the dose of
is observed until the 4th day after her progestins compared to later generations
peak day of wetness Include: norethindrone, norethindrone
Symptothermal - STM is recommended for any acetate and ethynodiol diacetate
Method (STM) reproductive age woman who is willing Second More potent and at lower doses produce
to take and chart her BBT daily, has the and Anovulatory effect
diligence to chart her daily Levonorgestrel (LNG) and norgestimate
observations of her cervical mucus, Third Contain gonane progestins, such as
make a daily record of all these, and desogestrel or gestodene, and have
willing to practice abstinence during reduced androgenic and metabolic side
the fertile period effects
- Couple should refrain from vaginal Fourth Drosperinone, dienogest or nomegestrol
intercourse when the woman senses acetate
cervical secretions and the 3rd full day Third and second generation COCs are better tolerated than first
after the rise in BBT generation
Two-Day Method - Woman should have no evidence of
vaginal infection or abnormal Phasic Pills
discharge - developed to reduce the total progestin per cycle without
- Once she notices any secretions of any compromising the contraceptive efficacy or cycle control
type, color or consistency, the couple Type
should refrain from vaginal intercourse Monophasic - same amount of Estrogen and
on that day and the day after progesterone in every hormonal pill
Saliva Ovulation - Monitoring of ovulation using the Biphasic - The first 10 pills with one dosage and
Monitor saliva should be started at the end of the next 11 pills having another level
the menses of estrogen and progestin
- Couple should refrain from vaginal Triphasic - The first 7 pills with one dosage and
intercourse on the days that a ferning the next 7 pills have another level of
pattern is observed. estrogen and progestin and the last 7
Lactation Criteria: pills with yet another dosage
Amenorrhea - presence of amenorrhea Quadriphasic pills - Contains a bioidentical synthetic
Method (LAM) - exclusive breast-feeding (no estrogen, estradiol valerate and
supplements) dienogest. The product offers 4
- performed up to 6 months after progestin/estrogen dosing
delivery combinations during each 28-day
Special consideration: cycle
1. Women who is positive for HIV Monophasic pills should be the first choice for women staring
should avoid breastfeeding oral contraceptive use
2. Women with active/untreated TB
should not breastfeed. She may Mechanism of action
resume breastfeeding if she is on Low dose COC’s prevent pregnancy by the following processes:
TB medications for at least 2 1. Estrogen prevents ovulation by suppressing FSH release
weeks and is verified non- 2. Progestins prevent ovulation by supressing LH release.
infectious Cervical mucus is thickened thereby preventing sperm
3. Women with active herpes lesions passage
on the breast should not
breastfeed. Proper Use
Monthly COCs
Discontinuation 1. 21 pills-21 active tablets taken every day followed by 7
Advise the client that the discontinuation rates with FAB pill-free days
methods are high. These are mainly due to trouble learning a 2. 22 pills- 22 active tablets taken every day followed by 6
particular method, difficulty of using it, challenge of sexual pill-free days
abstinence, lack of confidence, dissatisfaction and shifting to 3. 24 pills- 24 active tablets taken every day followed by 4
another family planning method pill-free days
4. 28 pills- 21 active pills taken every day followed by 7
HORMONAL CONTRACEPTION inactive or reminder pills of different color. The
Progesterone - inhibit ovulation reminder pills do not contain hormones. No pill-free or
- thickening of the cervical mucus rest days
Estrogen - maintains thin endometrium Continuous COCs
- prevent unscheduled bleeding - Active pills are taken for 365 days of each year
- inhibit follicular development Extended cycle preparations
- Active pills are taken for 12 weeks followed by a one-week
COMBINED HORMONAL CONTRACEPTIVES pill free period for withdrawal bleeding
- taken daily and on time to prevent conception
How to Take COCs
Formulation - Take one pill regularly, preferably at the same time every
- classified into generations depending upon their day
introduction in the United States market, amount of estrogen - Start within the first 5 days of the menstrual period.
and the type of progestin used However if the client is certain that she is not pregnant, it
can be started anytime but a backup method is required for
COC classification according to the amount of Estrogen (EE) used: 7 days if started after the 7th day of menses
Generation Amount of Estrogen - Start the COCs as prescribed (Quick Start). This method may
First 50 mcg or more improve the initiation of use but a backup method is
Second Less than 50 mcg required for 7 days if started after the 7th day of menses.
Third Doses are now even lower ranging from
20-35mcg Missed Pills
COC classification according to the type of progestin used:

She should take a missed hormonal pill as soon as possible then hypertension, nephropathy,
keep taking pills as usual, one each day (She may take 2 pills at retinopathy or other vascular disease
the same time or on the same day) Cancer - A personal history of benign disease
1 pill missed or new Take hormonal pill asap or a family history of breast cancer is
pack started 1 day late No back-up required NOT a contraindication to COCs
- COCs reduces the risk for both
2 pills missed or new 1 hormonal pill asap endometrial and ovarian cancer
pack started 2 days No back-up required Thromboembolism - Not recommended for women with
late documented history of VTE
Migraine - Can be considered for women with
3 pills missed in a row 1 hormonal pill asap headaches migraine headache without aura
in the first or second Use back up for the next 7 days provided they are healthy, non-
week or new pack (+) intercourse in the past 5 days→ smoking and younger than 35 years
started 3 days late emergency contraception
Follow-up
3 pills missed in the Discard current pack and start new
The client should be advised to return to the clinic 3 months after
3rd week pack right away
the initiation then annually thereafter. However, the client
Use back-up method for the next 7
should return to the clinic anytime for any problem or questions
days
that may arise
(+) intercourse in the past 5 days→
emergency contraception
LONG ACTING HORMONAL CONTRACEPTIVE
Contraceptive Three layers:
Safety Patch 1. an outer protective layer of polyester
- COCs do not disrupt an existing pregnancy 2. an adhesive middle layer containing
- COCs do not cause birth defects and will not harm the fetus 75 mcg ethinyl estradiol and 6.0 mg
even if the woman becomes pregnant while taking the pills norelgestromin
or accidentally starts the pill when she is already pregnant 3. a polyester release liner that is
Drug Interaction removed prior to placement on the
- Effectiveness of COCs are reduced with rifampicin, skin
phenytoin, phenobarbital, carbamazepine, primidone and - delivers 150 mcg norelgestromin and 20
ethosoximide mcg ethinyl estradiol into the circulation
Side effects each day at a fairly constant rate for at
- Spotting, amenorrhea, nausea, breast tenderness, headaches least 9 days
and depression Contraceptive - Flexible soft colorless ring-shaped device
Return to Fertility Vaginal Ring made of ethylene vinyl acetate copolymers
- There is no delay of return to fertility after COCs are - Each ring contains 2.7 mg of ethinyl
discontinued estradiol and 11.7 mg of etonogestrel
Injectables Depo-MedroxyProgesterone Acetate
Special Groups (DMPA)
Smokers Should not be used for women who are - Given every 3 months
older than 35 years old and who smoke 15 MPA: 17-acetoxy-6-methylprogestin that has
sticks or more per day progestogenic activity in the human
Women older than Healthy, non-smoking women doing well - inhibits ovulation
40 on COCs can continue their method until - keeps endometrium thin
menopause after weighing the risks and - keeps cervical mucus thin
benefits - Non-contraceptive benefits (DEFINITIVE:
Postpartum/ - Started any time after 3 weeks salpingitis, endom CA, Iron deficiency
Breastfeeding postpartum if the client is NOT anemia, Sickle cell anemia; PROBABLE:
women breastfeeding and do not have any Ovarian cysts, dysmenorrhea,
other risk for venous thrombosis endometriosis, epileptic seizure, vaginal
- COCs are not recommended as the candidiasis)
first choice for breastfeeding women - Resumption of ovulation after DMPA is
- For those who are fully or nearly fully varied and may last up until 1 year
breastfeeding for 6 months, COCs are - In cycling women: Days 0-5 of the cycle
started anytime if still amenorrheic - Nonlactating women: 5 days postpartum
but should be started within the first - Exclusive BF : should not be given until at
5 days of menses, if menstruation has least 6 weeks postpartum
resumed Norethindrone Enanthate (NET-EN)
- COCs can be started immediately after - Given every 60 days for at least the 1st 6
an abortion. No back up months then every 12 weeks
contraceptive is needed if begun
within the first 7 days following Progestin-Estrogen (once monthly
abortion injectable)
Obesity - Should be used with caution in obese - 25mg MPA, 5mg estradiol enanthate
women older than 35 years old
because of the increased risk of VTE Subdermal Norplant
Hypertension - May be prescribed for healthy non- Implant -made of polydimethylsiloxane (Silastic)
smoking clients who are 35 years old containing levonorgestrel
or younger with well-controlled and Norplant II
monitored hypertension with no signs Implanon
of end-organ vascular disease - Third generation
Dyslipidemia - May be appropriate for healthy non- - duration of action of 3 years
smoking women with known - Extremely effective, and is much easier to
dyslipidemia without other known insert and remove than the multiple
cardiovascular risk factors levonorgestrel-releasing implants.
Diabetes Mellitus - Should be limited to healthy, non- - Contains 68 mg of the progestin
smoking women who are younger Etonogestrel
than 35 years and with no evidence of Adverse Reactions:
1. Bleeding irregularities introitus and the base of the penis during
2. Acne intercourse
Advantages:
EMERGENCY CONTRACEPTION 1. female controlled
Steroids - most effective if treatment begins within 72 2. can be inserted prior to the onset of
hours after an isolated midcycle act of coitus sexual activity
- Eg. A regimen of four tablets of ethinyl estradiol, 3. can be left in place for a longer time
0.05 mg, and dl-norgestrel, 0.5 mg, combination after ejaculation
oral contraceptive (Ovral), given in doses of two 4. offer greater protection against the
tablets 12 hours apart transfer of certain sexually
Copper - effective for 7 days after coitus transmitted organisms (Herpes and
IUD HPV)
5. polyurethane is stronger and thicker
INTRAUTERINE DEVICE (IUD) making it less likely to rupture
Mechanism of Action: induce a local inflammatory reaction of Disadvantages:
the endometrium, and the cellular and humoral components 1. cost (about three times higher)
expressed in the tissue and the fluid fill the uterine cavity to 2. ease of use
create an environment that is toxic to sperm, so fertilization of
the ovum does not occur STERILIZATION
Benefits Male sterilization Vasectomy
- a high level of effectiveness, - 13 to 20 ejaculations are required
- a lack of associated systemic metabolic effects after the procedure
- the need for only a single act of motivation for long-term use Female sterilization - Bilateral tubal Ligation
Contraindications - *Fimbriectomy (supposed protection
1. Pregnancy or suspicion of pregnancy from ovarian Ca)
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
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 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 www.topnotchboardprep.co.nr or email us at topnotchboardprep@yahoo.com

OBSTETRICS SUPPLEMENT HANDOUT Labia Majora 7-8x2-3x1-1.5cm

EMBRYOLOGIC MALE FEMALE VESTIBULE

Posterior Anal triangle

Urogenital (Anterior) Triangle: SUPERFICIAL SPACE

closed bounded deeply by the perineal

ischiocavernosus clitoral erection

bulbocavernosus Bartholin gland secretion

superficial may be attenuated or even absent

Urogenital (Anterior) Triangle: DEEP SPACE

Continuous lies deep to the perineal membrane and

Ishorectal wedge-shaped spaces found on either side of

PUDENDAL NERVE AND VESSELS

Course between the piriformis and coccygeus

dorsal nerve of skin of the clitoris

Blood Supply internal pudendal artery

Cervix: SQUAMO-COLUMNAR JUNCTION

SIZE Nulliparous: 6 to 8 cm (fundus=cervix) , 50-70 g • Diverticula

False ANT: lower abdomen Forward

EMBRYOLOGIC STRUCTURES AND DERIVATIVES

EMBRYOLOGIC MALE FEMALE

MESONEPHRIC DUCT Appendix of Appendix of

PLACENTAL STEROID HORMONES

DETERMINING THE AGE OF THE FETUS

Fetal Begins from 8 weeks after fertilization or 10

Fetal Circulation: CHANGES AFTER BIRTH

FETAL PULMONARY SYSTEM

FIRST TRIMESTER SONOGRAPHY

METHODS USED IN BREECH DELIVERY: EXTERNAL CEPHALIC VERSION

Definition of obstetric hemorrhage combining clinical and Important Causes of PPH:

2. Abnormalities of the reproductive tract 5. Maternal medical conditions

Congenital Rubella Syndrome

Parvovirus B19 Associated with abortion, nonimmune

INFECTIOUS DISEASES IN PREGNANCY Late onset sequelae include hearing

GBS can also cause maternal bacteriuria,

MRSA Skin and soft tissue infections are the most

TRIAD: Chorioretinitis, intracranial

*Notes: Notice that as one goes from ASB to Pyelonephritis

IMPORTANT GYNECOLOGIC CONCEPTS

Urethral - Small, single, sessile but may be

Reflex HPV testing: ASCUS in Pap smear warrants HPV DNA

Management of Pregnant Women with Low-grade Squamous

7. Management of Women with Atypical Squamous Cells:

8. Management of Women Ages 21-24 yrs with Atypical

4. ASCUS- repeat cytology at 1 year: acceptable; HPV

5. Management of Women Ages 21-24 years with either

Adnexal Masses in Special Populations: Pregnancy Commonly caused by N. Inpatient

VULVAR PAIN SYNDROMES

CONGENITAL ADRENAL HYPERPLASIA (CAH)

Labial Adhesions (Adhesive Vulvitis)

POGS CPG ON FAMILY PLANNING, 2ND EDITION (NOVEMBER

Reversible- temporary prevention of fertility; “active” method

FERTILITY AWARENESS-BASED METHODS

IMPERFORATE HYMEN Proper Use

COC classification according to the type of progestin used:

COITUS RELATED METHODS

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