Obstetrics and Gynecology Main Handout (October 2023) PDF

TOPNOTCH OBSTETRICS AND GYNECOLOGY MAIN HANDOUT BY DR. FAJUTAGANA AND DR. BANZUELA For inquiries visit www.topnotchboardprep.com.ph or https://www.facebook.com/topnotchmedicalboardprep/ This handout is only valid for the October 2023 PLE batch. This...

TOPNOTCH OBSTETRICS AND GYNECOLOGY MAIN HANDOUT BY DR. FAJUTAGANA AND DR. BANZUELA For inquiries visit www.topnotchboardprep.com.ph or https://www.facebook.com/topnotchmedicalboardprep/ This handout is only valid for the October 2023 PLE batch. This will be rendered obsolete for the next batch since we update our handouts regularly. Pelvic Organ Prolapse 69 Endometriosis 70 IMPORTANT LEGAL INFORMATION Gynecologic Infections 71 Benign Gynecologic Lesions 76 The handouts, videos and other review materials, provided by Topnotch Medical Board Preparation Incorporated are duly protected by RA 8293 otherwise known as the Neoplastic Disease of the Upper and Lower Genital Tract 82 Intellectual Property Code of the Philippines, and shall only be for the sole use of the Family Planning 89 person: a) whose name appear on the handout or review material, b) person subscribed to Topnotch Medical Board Preparation Incorporated Program or c) is the recipient of this electronic communication. No part of the handout, video or other review material may be PREGNANCY reproduced, shared, sold and distributed through any printed form, audio or video recording, electronic medium or machine-readable form, in whole or in part without the written consent of Topnotch Medical Board Preparation Incorporated. Any violation and or GUIDE QUESTION: infringement, whether intended or otherwise shall be subject to legal action and prosecution to the full extent guaranteed by law. Pregnancy and Pregnancy Test https://qrs.ly/rnex3zk DISCLOSURE The handouts/review materials must be treated with utmost confidentiality. It shall be the Pregnancy – product of conception implanted typically in responsibility of the person, whose name appears therein, that the handouts/review materials are not photocopied or in any way reproduced, shared or lent to any person or uterus or atypically in other locations disposed in any manner. Any handout/review material found in the possession of another DEFINITIONS person whose name does not appear therein shall be prima facie evidence of violation of RA 8293. Topnotch review materials are updated every six (6) months based on the Embryo – from time of fertilization until 8 weeks pregnancy (10 current trends and feedback. Please buy all recommended review books and other weeks’ gestational age [GA]) materials listed below. THIS HANDOUT IS NOT FOR SALE! Fetus – after 8 weeks until time of birth 1st trimester –from 12 weeks up to 14 weeks’ GA INSTRUCTIONS 2nd trimester –from 12–14 until 24–28 weeks’ GA To scan QR codes on iPhone and iPad 3rd trimester –from 24–28 weeks until delivery 1. Launch the Camera app on your IOS device 2. Point it at the QR code you want to scan Infant – between delivery and 1 year of age 3. Look for the notification banner at the top o previable – delivered prior to 23–24 weeks of the screen and tap o preterm – between 24–37 weeks To scan QR codes on Android o term – between 37–42 weeks 1. Install QR code reader from Play Store 2. Launch QR code app on your device o postterm – beyond 42 weeks 3. Point it at the QR code you want to scan Nulligravida – a woman who currently is not pregnant and has 4. Tap browse website never been pregnant This handout is only valid for the October 2023 batch. Gravida – a woman who is currently pregnant or has been in the This will be rendered obsolete for the next batch past, irrespective of pregnancy outcome since we update our handouts regularly. Nullipara – a woman who has never completed a pregnancy beyond 20 weeks’ gestation; may not have been or pregnant or OBSTETRICS AND GYNECOLOGY may have had an abortion or an ectopic pregnancy Primipara – a woman who has been delivered only once of a fetus or – MAIN HANDOUT fetuses born alive or dead with an estimated AOG of at least 20 weeks Multipara – a woman who has completed 2 or more pregnancies Obstetrics Gynecology to 20 weeks’ gestation or more By Shayne C. By Nina Katrina C. Grand multipara – a woman who has had at least 5 births (live Fajutagana, MD, DPOGS Banzuela, MD, FPOGS or stillborn) that are at least 20 weeks age of gestation Contributors: Contributors: GP-TPAL designation Manuel S. Vidal, Jr, RCh, MD, Shayne C. Fajutagana, MD, DPOGS o Gravidity, Parity, Term, Preterm, Abortus, Living children Jian Kenzo O. Leal, MD, Jian Kenzo O. Leal, MD § Gravidity – number of times a woman has been pregnant Anna Rominia d.P. Cruz, MD Anna Rominia d.P. Cruz, MD § Parity – number of pregnancies that led to birth TOPIC PAGE > 20 weeks AOG or infant > 500 g Obstetrics Review § Preterm – born between 24–37 weeks Pregnancy 1 § Abortus – pregnancy losses before 20 weeks Maternal Adaptations in Pregnancy 2 § Multifetal pregnancy – counts as 1 for TPA, but number of Preconceptional and Prenatal Care 3 children alive counts separately for L Early Pregnancy Complications 6 § Grand multipara – a woman whose parity is ≥ 5 Ectopic Pregnancy 6 Abortion 7 DATING THE PREGNANCY Recurrent Pregnancy Loss 7 Developmental age (DA) – number of weeks and days since Gestational Trophoblastic Diseases 8 fertilization (conceptional/embryonic age) Labor 9 Gestational age (GA) – age in weeks and days from last Dysfunctional Labor 14 menstrual period (LMP); + 2 weeks from DA Induction and Augmentation of Labor 15 Estimated date of confinement (EDC) / estimated date of Delivery 17 Complications of Labor and Delivery 18 delivery (EDD) – computed via Naegele’s rule Fetal Complications of Pregnancy 20 o EDC/EDD = LMP – 3 months, + 7 days Multifetal Gestation 22 o 280 days after LMP; 266 days after LMP if via assisted Obstetric Hemorrhage 23 reproductive technology Hypertensive Diseases in Pregnancy 27 Ultrasound - rarely off by 7–8% from GA; Should not differ Gestational Diabetes Mellitus 28 from LMP dating by Selected Medical Complications in Pregnancy 29 o >1 week in the first trimester Gynecology Review o >2 weeks in the second trimester Developmental Biology of Sex 40 o >3 weeks in the third trimester Errors in Sexual Determination and Differentiation 42 Auscultation of fetal heart tones by 20 weeks via stethoscope, Reproductive Anatomy 43 or 10 weeks via Doppler ultrasound Reproductive Endocrinology 47 Quickening usually between 16-20 weeks Abnormalities of the Menstrual Cycle 51 Amenorrhea 55 DIAGNOSIS Pediatric Gynecology 57 Ultrasound Precocious Puberty 59 Gestational sac seen at 5 weeks on transvaginal ultrasound or at Hyperandrogenism 61 Infertility 63 a beta-hCG of 1,500-2,000 mIU/mL Menopause 66 FH motion seen at 6 weeks or at beta-hCG of 5,000-6,000 Osteoporosis 68 mIU/mL Urinary Incontinence 68 TOPNOTCH OBSTETRICS AND GYNECOLOGY MAIN HANDOUT BY DR. FAJUTAGANA AND DR. BANZUELA Page 1 of 91 For inquiries visit www.topnotchboardprep.com.ph or email us at [email protected] This handout is only valid for the October 2023 PLE batch. This will be rendered obsolete for the next batch since we update our handouts regularly.  TOPNOTCH OBSTETRICS AND GYNECOLOGY MAIN HANDOUT BY DR. FAJUTAGANA AND DR. BANZUELA For inquiries visit www.topnotchboardprep.com.ph or https://www.facebook.com/topnotchmedicalboardprep/ This handout is only valid for the October 2023 PLE batch. This will be rendered obsolete for the next batch since we update our handouts regularly. Beta-hCG (urine or serum) systolic pressure decreases 5–10 mm Hg and diastolic pressure hormone produced by the placenta decreases 10–15 mm Hg will rise to a peak of 100,000 mIU/mL by 10 weeks of gestation, o reaches nadir at week 24 (24 – 26 weeks in Williams) decrease throughout the second trimester, and then level off at o between 24 weeks and term, blood pressure returns to pre- approximately 20,000 to 30,000 mIU/mL in the third trimester. pregnancy levels Will turn POSITIVE on urine pregnancy test around the time of (Williams) larger cardiac silhouette d/t 1) left and upward missed menses displacement, 2) benign pericardial effusion RESPIRATORY SYSTEM Signs Symptoms Total lung capacity (TLC) decreases 5% because of elevation Bluish discoloration of vagina and cervix Amenorrhea of diaphragm (~4 cm) (Chadwick sign) Nausea and Tidal volume (TV) increases 30–40% à inspiratory capacity Softening and cyanosis of the cervix at or vomiting (IC) increases after 4 wk (Goodell sign) Breast pain o increased TV lowers blood PCO2 slightly and paradoxically Softening of the uterus after 6 wk (Ladin Quickening— causes physiological dyspnea sign) fetal expiratory reserve volume (ERV) decreases ~20% Softening of the uterine isthmus after 6 movement (15-20% in Williams) à functional residual capacity (FRC) weeks (Hegar sign) decreases (↓20-30% in Williams) Breast swelling and tenderness constant respiratory rate with increased TV à minute Development of the linea nigra from ventilation increases 30–40% à increases alveolar (PAO2) and umbilicus to pubis arterial (PaO2) oxygen levels, decreases PACO2 and PaCO2 levels Telangiectasias Palmar erythema MATERNAL ADAPTATIONS IN PREGNANCY GUIDE QUESTION: Maternal Physiology https://qrs.ly/geex3zn REPRODUCTIVE SYSTEM Pulmonary changes in pregnancy. From Williams’ Obstetrics, 25th edition. Uterus Green = increased volumes; Red = decreased volumes Increased Decreased Unchanged Myometrial hypertrophy > hyperplasia Inspiratory Functional residual Respiratory rate Uterine blood flow increases to 500–750 mL/min capacity (IC) capacity (FRC) Total lung o d/t systemic vascular resistance decrease via progesterone, Tidal volume = ERV + RV capacity (FRC + relaxin, and increased refractoriness to angiotensin II, (TV) o Expiratory IC)* norepinephrine Resting minute reserve Lung compliance Contractions may occur weeks prior to delivery ventilation volume (ERV) Maximum Braxton Hicks True Labor Peak expiratory o Residual breathing capacity Painless Painful flow rates volume (RV) Forced or timed Irregular rhythm, infrequent Rhythmic, frequent Airway Total lung capacity* vital capacity Cervix does not progress Cervix thins, dilates conductance Pulmonary resistance Ovaries *unchanged or decreases by < 5% at term Corpus luteum of pregnancy – max function between 6–7 wks GASTROINTESTINAL SYSTEM o initially produces progesterone à placenta assumes Morning sickness – nausea and vomiting in 70% of production of progesterone à corpus luteum degrades into pregnancies, d/t corpus albicans o elevations in estrogen, progesterone, and hCG. Cervix o may also be due to hypoglycemia à treated with frequent snacking Arias-Stella reaction – loss o typically resolve by 14–16 weeks of polarity, pleiomorphism, o Hyperemesis gravidarum – pathologic morning sickness intraluminal budding associated with weight loss (≥5% of pre-pregnancy weight), ketosis, and loss of electrolytes gastric emptying time increases (unchanged in Williams) and Eversion - lower esophageal tone decreases à reflux marked proliferation of o anesthesia may further increase GET (risk factor for regurgitation and aspiration of gastric contents) cervical glands decreased esophageal tone may cause ptyalism, or spitting large bowel motility decreases à increased water absorption and constipation Ferning –arborization of pelvic vessels congest d/t gravid uterus à increases abdominal amniotic fluid due to high pressure, and with constipation à hemorrhoids amounts of salt and estrogen RENAL SYSTEM Goodell’s sign – cervical softening kidneys increase in size, and ureters dilate (R > L) during pregnancy à hydronephrosis of pregnancy: risk factor for CARDIOVASCULAR SYSTEM pyelonephritis cardiac output increases by 30–50% relaxin mediates vasodilation à glomerular filtration rate o maximum output at 20–24 weeks and maintained until delivery (GFR) increases by 50% early in pregnancy (25-50% starting 2nd o initially from increased stroke volume à maintained by trimester in Williams) and maintained until delivery à blood urea increased heart rate à stroke volume returns to near pre- nitrogen and creatinine decrease by ~25% pregnancy levels by end of third trimester RAAS activation à aldosterone increases à sodium resorption Systemic vascular resistance decreases à fall in arterial increases blood pressure o Normonatremia is maintained d/t GFR increase o due to elevated progesterone, leading to smooth muscle o AVP threshold decreases à serum osmolality decreases by 10 relaxation (and refractoriness to angiotensin II – Williams) mOsm/kg TOPNOTCH OBSTETRICS AND GYNECOLOGY MAIN HANDOUT BY DR. FAJUTAGANA AND DR. BANZUELA Page 2 of 91 For inquiries visit www.topnotchboardprep.com.ph or email us at [email protected] This handout is only valid for the October 2023 PLE batch. This will be rendered obsolete for the next batch since we update our handouts regularly.  TOPNOTCH OBSTETRICS AND GYNECOLOGY MAIN HANDOUT BY DR. FAJUTAGANA AND DR. BANZUELA For inquiries visit www.topnotchboardprep.com.ph or https://www.facebook.com/topnotchmedicalboardprep/ This handout is only valid for the October 2023 PLE batch. This will be rendered obsolete for the next batch since we update our handouts regularly. HEMATOLOGICAL SYSTEM Total Weight Weight Gain in 2nd and plasma volume increases 50% (40-45% in Williams), while RBC Category (BMI) Gain Range 3rd trimester volume increases 20-30% à physiological anemia of (lb) Mean in lb/wk (range) pregnancy à hematocrit and hemoglobin decreases Underweight 28-40 1 (1-1.3) o hypervolemia probably for increased metabolic demand, (20 million/mL in stressful conditions (25.0-29.9) Platelets slightly decrease d/t increased plasma volume and Obese (>=30) 11-20 0.5 (0.4-0.6) increased peripheral destruction Williams Obstetrics Table 10-4: Recommendations for Total and Rate of Weight Gain in Pregnancy Pregnancy is considered hypercoagulable state with Nutritional requirements increase in thromboembolic events o Protein: increases from 60 to 70 or 75 g/day o Levels of fibrinogen and factors VII–X increase o Calcium: 1.5 g/day o However, clotting and bleeding times do not change o The recommended daily diet allowance (RDA) for Calcium is o Increased rate of thromboembolic events (may also be due to 1200mg/day in Blueprints and 1000mg/day in Williams other elements of Virchow’s triad: increased venous stasis & o 1500mg/day in patients taking heparin endothelial damage) o Iron: +18mg daily o Folate (helps prevent NTDs): increases from 0.4 to 0.8 mg/day ENDOCRINE SYSTEM § 400 mcg/day supplementation for all until first trimester Pregnancy is a hyperestrogenic state, mainly d/t § 4mg/day for patients with a history of child with NTDs o Placenta production, from plasma-borne precursors produced Since mahilig sila magtanong ng difference in dosages minsan, to add: 4mg/day by maternal adrenal glands supplementation with folic acid is also advised for patients with Type 2 Diabetes o Ovaries contributing to lesser degree, from estrogen Mellitus (Blueprints and Williams 25th ed) and in patients with seizure disorders precursors produced in ovarian theca cells (Williams 26th ed). Increased folic acid supplementation of around 2-4mg/day is o Fetal well-being was correlated with maternal serum estrogen also recommended for patients with ulcerative colitis to counteract the levels (e.g. low estrogen levels in fetal death and anencephaly) antifolate actions of sulfasalazine. Dr. Anna Rominia Cruz In addition to estrogen, placenta produces o hCG § α subunit of hCG is identical to α subunits of luteinizing hormone PRECONCEPTIONAL AND PRENATAL CARE (LH), follicle-stimulating hormone (FSH), and thyroid- PRECONCEPTIONAL COUNSELING stimulating hormone (TSH), whereas tβ subunits differ Folic acid: Begin 0.4 mg/day one month prior to conception for § hCG levels double every ~48 hours during early pregnancy à all patients; then increase to 4mg/day for patients high risk for peaks at ~10–12 weeks à declines to steady state after week 15 NTDs o relaxin A pre-conceptional hemoglobin A1c level goal below 7% is § remodels reproductive tract to accommodate labor recommend for patients with diabetes mellitus o Human placental lactogen (hPL) For a woman recently vaccinated with live vaccines (i.e. § ensures constant nutrient supply to fetus. hPL is also known varicella-zoster, measles, mumps, rubella, polio, chickenpox, and as human chorionic somatomammotropin (hCS) yellow fever), it is recommended to get pregnant at least a month § cause lipolysis with increase in circulating free fatty acids after administration § acts as insulin antagonist (diabetogenic effect) à insulin and protein synthesis Prolactin levels increased during pregnancy à decreased PRENATAL CARE after delivery à increased in response to suckling Initial Visit and First REMARKS Pregnancy is considered a euthyroid state, despite subtle Trimester changes in thyroid hormone production CBC Primarily for hematocrit o Estrogen stimulates thyroid binding globulin à elevation in Pap smear Screening for cervical CA total T3 and T4, but free T3 and T4 remain constant (Free T4 Blood type and Rh (-) mothers: should be given slightly increases in 1st trimester, then decreases – Williams) antibody screen RhoGAM at 28 wks o hCG weakly stimulates thyroid à slight increase in T3 and T4 RPR/VDRL Screening for syphilis and slight decrease in TSH early in pregnancy Rubella antibody If nonreactive, give vaccine MUSCULOSKELETAL AND DERMATOLOGICAL SYSTEM screen postpartum Change in center of gravity during pregnancy à posture shift Hepatitis B antibody -- and lower back strain, which worsens during third trimester screen Pregnancy is associated with carpal tunnel syndrome; results Urinalysis and urine Screen for asymptomatic bacteriuria from compression of the median nerve; incidence varies, and culture symptoms are usually self-limited In patients with no history of VZV titer Spider angiomata and palmar erythema occur due to chickenpox increased estrogen in skin During the 1st or 2nd trimester to PPD hyperpigmentation of nipples, umbilicus, abdominal midline screen for PTB in high risk patients (the linea nigra), perineum, and face (melasma or chloasma) HIV screening Offered routinely occur due to increased melanocyte-stimulating hormones and Gonorrhea culture Repeated in the 3rd trimester in steroid hormones Chlamydia culture high-risk populations Breast enlargement typically occurs, pathological enlargement Early screening for Nuchal translucency + serum markers is termed gigantomastia aneuploidy (hCG, PAPP-A) at 11-14wks Colostrum may be produced as early as few months into Second Trimester pregnancy (but only expressed 2nd day postpartum – Williams) MSAFP/triple or quad MSAFP, beta-hCG, estriol +/- inhibin screen A at 15-20 weeks METABOLISM AND NUTRITION 18-20 wks: screening utz for fetal Caloric equivalent of eating for ~1.15 persons malformation An additional 80,000 kcal is needed during pregnancy specially in the last 20 weeks of gestation Obstetric ultrasound In NTDs: Average woman requires 2,000 to 2,500 kcal/day; caloric Banana sign – cerebellum is pulled requirement increased by 300 kcal/day during pregnancy caudally and flattened and by 500 kcal/day when breastfeeding Lemon sign –concave frontal bones o 100-300kcal/d caloric increase is recommended (Williams 26th) For women interested in prenatal o Most gain 20–30 lbs during pregnancy (mean: 28.6 lbs in Williams) Amniocentesis diagnosis TOPNOTCH OBSTETRICS AND GYNECOLOGY MAIN HANDOUT BY DR. FAJUTAGANA AND DR. BANZUELA Page 3 of 91 For inquiries visit www.topnotchboardprep.com.ph or email us at [email protected] This handout is only valid for the October 2023 PLE batch. This will be rendered obsolete for the next batch since we update our handouts regularly.  TOPNOTCH OBSTETRICS AND GYNECOLOGY MAIN HANDOUT BY DR. FAJUTAGANA AND DR. BANZUELA For inquiries visit www.topnotchboardprep.com.ph or https://www.facebook.com/topnotchmedicalboardprep/ This handout is only valid for the October 2023 PLE batch. This will be rendered obsolete for the next batch since we update our handouts regularly. Third Trimester High-Risk Group Specific Test Hematocrit Hct becomes close to its nadir Sickle cell prep for African African American, Southeast GDM screening; 75g OGTT based on Americans; Hgb Asian local CPG electrophoresis for both Family history of genetic BLUEPRINTS: disorder (e.g., Prenatal 50g GLT: check after 1hr genetics referral hemophilia, Prenatal genetics referral à if ≥ 140 mg/dL*, proceed to do sickle cell disease, fragile X Glucose loading test glucose tolerance test (GTT) syndrome), maternal age 35 *other institutions use a lower threshold of 130 or or older at time of EDC 135 mg/dL 2 or more to diagnose as GDM on Prior gestational diabetes, 100g OGTT: family history Early GLT of Early GLT FBS 95 mg/dL; 1hr 180; 2hr 155; diabetes, Hispanic, Native 3hr 140 American, Southeast Asian, obese RPR/VDRL --- Pregestational diabetes, at 36-37 6/7 weeks (previously 35- unsure dates, Dating 37 weeks); if (+) à IV penicillin Dating sonogram at first visit GBS culture sonogram at first visit once in labor to prevent neonatal recurrent miscarriage GBS infection HPN, renal disease, preGDM, BPP – score of 8 to 10 is reassuring BUN, Crea, uric acid, 24h prior preeclampsia, renal Doppler – abnormal findings: urine collection transplant, SLE decrease, absence, or reversal of diastolic flow in the umbilical artery PreGDM, prior cardiac Ultrasound + other ECG NST disease, HPN tests for fetal well- HbA1c, ophthalmology for being PreGDM At 35-36 weeks: confirm fetal eye exam presentation; if breech, offer Graves disease TSI external cephalic version at 37 to 38 All thyroid disease TSH +/- FT4 weeks PPD+ CXR after 16 wks AOG Blueprints 7th edition, Table 1-3: Routine Tests in Prenatal Care with edits and comments Anti Rho, anti-La antibodies Note that based on the POGS CPG on Diabetes in Pregnancy, 75g OGTT is done at SLE (can cause fetal complete 24-28 weeks AOG and repeated at 32 weeks for patients high risk for developing heart block GDM or those who developed new symptoms. Blueprints lang ang third trimester Blueprints 7th edition, Table 1-4: Initial Screens fin Specific High-Risk Groups ang OGTT! ROUTINE PRENATAL VISITS Dr. Anna Rominia Cruz The following must be performed and assessed on each follow- up prenatal care visit o Blood pressure: ↓ during 1st & 2nd trimesters, slowly returns to baseline during the 3rd trimester; ↑BP may be a sign of preeclampsia o Weight: large weight gain towards the end of pregnancy can be a sign of fluid retention and preeclampsia o Urine dipstick: presence of protein may be indicative of preeclampsia, glucose of DM, and leukocyte esterase of UTI § Pregnant women are at an ↑risk for complicated UTI (e.g. pyelonephritis) due to ↑ urinary stasis from mechanical compression of ureters and progesterone-mediated smooth muscle relaxation o Measurement of the uterus: between 20 and 34 weeks, fundic height in cm correlates closely with AOG in weeks o Auscultation of FHT: after 10-14 weeks, Doppler UTZ is used First trimester: early screening for aneuploidy is offered between 11-13 weeks either with: o UTZ for NT + serum PAPP-A and free beta-hCG, or o Blood test to assess relative quantity of fetal cfDNA for chromosomes 13, 18, and 21à cfDNA is detected as early as 5 weeks; offers ↑ detection rate and ↓ false (+) rate Second trimester o Screening for MSAFP between 15-18 weeks: ↑MSAFP = ↑risk for NTD, ↓ in some aneuploidies like Down Syndrome o Between 18-20 weeks: most patients are offered a screening UTZ to screen for common fetal abnormalities (Congenital Anomaly Scan) § Spina bifida: “lemon” sign (concave frontal bones), “banana” sign (a cerebellum that is pulled caudally and flattened) o Also noted are AFV, placental location, and gestational age Third trimester o RhoGAM is given at 28 weeks to Rh negative patients Williams Obstetrics 26th edition Table 10-1. Typical Components of Routine Prenatal Care o Beyond 32-34 weeks, Leopold maneuvers are performed to 36-37 6/7 weeks na rin ang GBS screening sa main text ng Williams 26th ed. Nakalimutan lang ata nila ito iedit LOL haha determine presentation Dr. Anna Rominia Cruz PRENATAL CARE GUIDE QUESTION: https://qrs.ly/erex3zs Prenatal Screening https://qrs.ly/ayex402 TOPNOTCH OBSTETRICS AND GYNECOLOGY MAIN HANDOUT BY DR. FAJUTAGANA AND DR. BANZUELA Page 4 of 91 For inquiries visit www.topnotchboardprep.com.ph or email us at [email protected] This handout is only valid for the October 2023 PLE batch. This will be rendered obsolete for the next batch since we update our handouts regularly.  TOPNOTCH OBSTETRICS AND GYNECOLOGY MAIN HANDOUT BY DR. FAJUTAGANA AND DR. BANZUELA For inquiries visit www.topnotchboardprep.com.ph or https://www.facebook.com/topnotchmedicalboardprep/ This handout is only valid for the October 2023 PLE batch. This will be rendered obsolete for the next batch since we update our handouts regularly. QUAD SCREENING TABLE ANTEPARTUM FETAL ASSESSMENT TRISOMY 21 TRISOMY 18 TRISOMY 13 Oxytocin challenge test or contraction stress test (CST): achieve Depends on MSAFP Decreased Decreased at least 3 contractions in 10 min; test of uteroplacental function defect Beta- Depends on Satisfactory test: 3 or more contractions lasting 40 seconds or Increased Decreased more in a 10-minute period hCG defect Depends on Positive CST (abnormal): late fetal heart deceleration (due to Estriol Decreased Decreased uteroplacental insufficiency) following ≥50% of contractions defect Depends on even if the contraction frequency is < 3 in 10 minutes Inhibin Increased Decreased defect Negative CST (normal): no late or significant variable Edward Syndrome Patau decelerations Other Down (eighteen) Syndrome Equivocal-suspicious: intermittent late decelerations or remarks Syndrome -choroid plexus (CP) cysts -up to 1 yr of significant variable decelerations -up to 2 yrs of life life Equivocal-hyperstimulatory: FHR decelerations that occur in the presence of contractions more frequent than every 2 IMMUNIZATION IN PREGNANCY minutes or lasting > 90 seconds Routinely recommended: Unsatisfactory: fewer than 3 contractions in 10 minutes or an o Influenza one dose IM yearly uninterpretable trace o Tetanus-diphtheria-acellular pertussis (Tdap) Methods: § Preferably between 27-36 weeks AOG o Oxytocin infusion § Primary: two doses IM at 1-2 month interval with 3rd dose 6- o Nipple stimulation 12 months after the 2nd dose Nonstress test (NST): test of fetal condition; most antenatal § Booster: single dose IM once per pregnancy (every 10 testing units use the NST, beginning at 32 to 34 weeks of years as part of wound care if 5 years since last dose) gestation in high-risk pregnancies and at 40 to 41 weeks for May be given as postexposure prophylaxis: hepatitis B, rabies, undelivered patients tetanus, hepatitis A, rabies, meningococcus Fetal heart rate acceleration in response to fetal movement as Yellow fever: if for travel to high-risk areas sign of fetal health Contraindicated: measles, mumps, rubella, varicella, zoster, o ≥32 weeks: acceleration ≥15 bpm from baseline, lasts for smallpox ≥15 secs, but 5,000 mIU/mL NEURAL CONTROL OF BPS ACTIVITY o Hemorrhaging, ruptured ectopic pregnancy may reveal BPS HYPOXIA intraabdominal fluid throughout pelvis and abdomen CNS CENTER AOG PARAMETER CASCADE Cortex- 7.5 – 8.5 MANAGEMENT OF ECTOPIC PREGNANCY Fetal Tone Last affected Subcortical Area wks Surgical procedure Fetal o Exploratory laparotomy – if patient is unstable Cortex-Nuclei 9 weeks 3rd Movement o Exploratory laparoscopy – procedure of choice Fetal Ventral surface o Salpingostomy – resection of ectopic pregnancy, leaving 20-21 wks 2nd Breathing of 4th ventricle fallopian tubes as is Medulla & o Salpingectomy – resection of ectopic pregnancy with removal Fetal Heart Posterior 24-26 wks 1st affected of fallopian tubes Reactivity Hypothalamus o Cornual resection – for interstitial pregnancies FETAL BLOOD SAMPLING Medical management Percutaneous umbilical blood sampling – needle is placed o Methotrexate transabdominally into the uterus and phlebotomizing the § Factors for success: small ectopic umbilical cord § < 3.5 cm (Williams and POGS CPG on Ectopic Pregnancy. but o used to asses for fetal anemia (e.g. in Rh isoimmunization), for 2 is associated with only rare cases of RDS § Sensitivity to MTX Levels of phosphatidylglycerol § Evidence of tubal rupture Saturated phosphatidyl choline § Breast feeding Presence of lamellar body count § Intrauterine pregnancy Surfactant to albumin ratio § Hepatic, renal, or hematological dysfunction § Peptic ulcer disease EARLY PREGNANCY COMPLICATIONS § Active pulmonary disease § Immunodeficiency ECTOPIC PREGNANCY When fertilized egg implants outside uterine cavity SINGLE DOSE MULTIDOSE Fallopian tube in 95%–99% of ectopic pregnancy Up to four doses of o Implantation in ampulla is 70%, followed by isthmus (12%) One dose; repeat if Dosing both drugs until serum and fimbriae (11%) necessary B-hCG declines by 15% May occur on ovary, cervix, outside of fallopian tube, abdominal Methotrexate 1 mg/kg, wall, or bowel Medication Methotrexate 50 D1, 3, 5, 7 PLUS > 1:100 of pregnancies are ectopic Dosage mg/m2 BSA (D1) Leucovorin 0.1 mg/kg, o secondary to increase in assisted fertility, sexually transmitted D2, 4, 6, 8 infections, and pelvic inflammatory disease Serum B-hCG Days 1 (baseline), 4 Days 1, 3, 5, and 7 Cardinal signs: vaginal bleeding and/or abdominal pain level and 7 with missed menses If serum B-hCG Risk Factors for Ectopic Pregnancy If serum B-hCG declines < 15%, give level does not additional dose; History of STIs or PID Indication for decline by 15% repeat serum B-hCg Prior ectopic pregnancy* (STRONGEST RISK FACTOR) additional from day 4 to day 7 in 48 hrs and Previous tubal surgery (highest risk – Williams) dose < 15% decline compare with Prior pelvic or abdominal surgery resulting in adhesions during weekly previous value; Endometriosis surveillance maximum of four Current use of exogenous hormones including progesterone doses or estrogen Posttherapy Weekly until serum B-hCG undetectable IVF and other assisted reproduction surveillance DES-exposed patients with congenital abnormalities Use of an IUD for birth control Smoking ECTOPIC PREGNANCY *risk of a subsequent ectopic pregnancy is 10% after one prior https://qrs.ly/gfegwyc ectopic pregnancy and increases to 25% after more than one prior ectopic pregnancy TOPNOTCH OBSTETRICS AND GYNECOLOGY MAIN HANDOUT BY DR. FAJUTAGANA AND DR. BANZUELA Page 6 of 91 For inquiries visit www.topnotchboardprep.com.ph or email us at [email protected] This handout is only valid for the October 2023 PLE batch. This will be rendered obsolete for the next batch since we update our handouts regularly.  TOPNOTCH OBSTETRICS AND GYNECOLOGY MAIN HANDOUT BY DR. FAJUTAGANA AND DR. BANZUELA For inquiries visit www.topnotchboardprep.com.ph or https://www.facebook.com/topnotchmedicalboardprep/ This handout is only valid for the October 2023 PLE batch. This will be rendered obsolete for the next batch since we update our handouts regularly. ABORTION o Offer elective cerclage in subsequent pregnancies only if with history of recurrent midtrimester losses or prior preterm birth 15–25% pregnancies undergo spontaneous abortion (SAB) with short cervix (Williams) Abortus – fetus lost before 20 weeks’ gestation or < 500 g o If without preterm birth but with short cervix, offer Complete abortion – expulsion of POC before 20 weeks progesterone up to 36 6/7 weeks Incomplete abortion – partial expulsion before 20 weeks o Prophylactic elective cerclage: 12–14 weeks’ gestation, Inevitable abortion – no expulsion of POC, but vaginal bleeding maintained until 37 weeks and dilation of cervix will unlikely result in pregnancy o If cervical cerclage fails à abdominal cerclage is offered at Threatened abortion – any vaginal bleeding before 20 weeks, 12–14 weeks à mode of delivery is by CS without dilation of cervix or expulsion of any POC o If with previous preterm birth, Missed abortion – death of embryo or fetus before 20 weeks IM 17-hydroxyprogesterone offered until 36 weeks AOG with complete retention of POC o Emergent cerclage: done when cervix is already dilated or Septic abortion – any abortion complicated with infection effaced FIRST TRIMESTER ABORTIONS RECURRENT PREGNANCY LOSSES (RPL) 60–80% SABs in first trimester are associated with abnormal chromosomes, 95% are due to maternal gametogenesis errors Classical definition: three or more consecutive pregnancy losses at multiparity Labs and imaging history of GTD hCG levels > >100,000 mIU/mL o No previous history: 0.1% UTZ: snowstorm pattern due to chorionic villi swelling o 1 previous molar pregnancy: 1-2% (0.9% for complete moles theca lutein cysts >6 cm and 0.3% for partial moles - Williams) definitive diagnosis: histopathological exam of the uterine tissue o 2 previous molar pregnancies: 16-28% (20% - Williams) Diet: low in β-carotene, folic acid, and animal fat TREATMENT OF COMPLETE MOLAR PREGNANCY Ethnicity: Asians, Hispanics, and American Indians suction D&C: definitive treatment Other possible associated factors: smoking, infertility, o hysterectomy if non-desirous of future pregnancies spontaneous abortion, blood group A, and a history of OCP use uterotonics to minimize blood loos RhoGAM for Rh-negative women COMPLETE MOLAR PREGNANCY adjunctive anti-hypertensives and beta blockers PATHOGENESIS PROGNOSIS result from the fertilization of an enucleate ovum/empty egg, prognosis is excellent: persistent postmolar GTD: 6-32% in one whose nucleus is missing or nonfunctional, by one normal complete moles, 100,000 mIU/mL karyotype (or XYY – rare) Chromosomal origin All paternally derived Extra paternal set o ovaries >6 cm (theca lutein cysts > 6 cm – Williams) Pathology o large uterine sizes (14 to 16 weeks) Coexistent fetus Absent Present o may give chemoprophylaxis: methotrexate + folinic acid/dactinomycin) Fetal RBCs Absent Present Chorionic villi Hydropic Few hydropic PARTIAL MOLAR PREGNANCY PATHOGENESIS Minimal/ normal ovum is fertilized by two sperm simultaneously Trophoblasts Severe hyperplasia no hyperplasia triploid karyotype with 69 chromosomes, two sets are Clinical presentation paternally derived Associated embryo None Present most common karyotype is 69,XXY (80%) Abnormal vaginal placenta: focal hydropic villi and trophoblastic hyperplasia Symptoms/signs Missed abortion bleeding primarily of the cytotrophoblast Classic symptomsa Common Rare notable due to presence of embryo Uterine size 50% larger for dates Size = dates 15-25% often misdiagnosed as spontaneous or missed abortions Theca lutein cysts Rare much lower malignant potential than complete moles (25-30% - Williams) hCG levels High Slightly elevated Malignant potential CLINICAL PRESENTATION Nonmetastatic delayed menses and (+) urine PT 15-25% 2-4% malignant GTD vaginal bleeding from miscarriage or incomplete abortion in late Metastatic 4% - first trimester or early second trimester (90%) malignant GTD Rate of subsequent physical examination typically normal d/t slightly elevated hCG, 15-20% 1-5% (+) fetal heart sounds, uterine size small for gestational age GTN (Williams) Follow-up UTZ: fetus with cardiac activity, congenital malformations, Weeks to normal 14 weeks 8 weeks and/or IUGR hCG (9 weeks – Williams) (7 weeks – Williams) “Swiss-cheese” appearance aHyperemesis gravidarum, early preeclampsia, hyperthyroidism, definitive diagnosis: histopathological exam of the uterine tissue anemia, excessive uterine size Comparison of complete mole vs partial mole. From Blueprints Obstetrics and Gynecology, 7th edition TOPNOTCH OBSTETRICS AND GYNECOLOGY MAIN HANDOUT BY DR. FAJUTAGANA AND DR. BANZUELA Page 8 of 91 For inquiries visit www.topnotchboardprep.com.ph or email us at [email protected] This handout is only valid for the October 2023 PLE batch. This will be rendered obsolete for the next batch since we update our handouts regularly.  TOPNOTCH OBSTETRICS AND GYNECOLOGY MAIN HANDOUT BY DR. FAJUTAGANA AND DR. BANZUELA For inquiries visit www.topnotchboardprep.com.ph or https://www.facebook.com/topnotchmedicalboardprep/ This handout is only valid for the October 2023 PLE batch. This will be rendered obsolete for the next batch since we update our handouts regularly. TREATMENT OF PARTIAL MOLAR PREGNANCY PERSISTENT POSTMOLAR GTD AND INVASIVE MOLES suction D&C 1 in 15,000 pregnancies PROGNOSIS hydropic chorionic villi and trophoblast proliferation into 100,000 mIU/mL 2-4 weeks following a normal pregnancy, miscarriage, or termination o Uterine size >14–16 wk contraception is warranted to avoid pregnancy interference o Theca lutein cysts >6cm o Coexistent fetus DIAGNOSIS MOLAR PREGNANCY Plateau/rise in hCG levels, excessive uterine size, large theca https://qrs.ly/47ex41h lutein cysts UTZ: invasion of an intrauterine mass into the myometrium Doppler: high vascular flow GESTATIONAL TROPHOBLASTIC NEOPLASIA (GTN) MANAGEMENT 20% of patients with GTD Avoid repeat D&C o persistent postmolar pregnancies or invasive molar Single-agent chemotherapy (MTX or dactinomycin) pregnancies (75%) If with metastases: single agent for low risk, multiagent for high risk o gestational choriocarcinomas (25%) Similar follow up and surveillance with GTD o placental site trophoblastic tumors (rare) Diagnosis: plateauing/rising hCG levels after molar evacuation. GESTATIONAL CHORIOCARCINOMA Most common presentation: abnormal uterine bleeding >6 1 in 20,000 to 40,000; common in Asian or African descent weeks following pregnancy malignant necrotizing tumor: invasion of uterine wall and Staging system: Revised FIGO Staging System vasculature à necrosis and potentially severe hemorrhage Extreme sensitivity to chemotherapy “the great imitator” o low-risk disease: single- agent chemotherapy pure epithelial tumor: sheets of anaplastic cytotrophoblasts and o high-risk disease: combination chemotherapy. syncytiotrophoblasts in the absence of chorionic villi o surgical intervention: for high-risk patients or for PSTT hematogenous spread FIGO STAGING OF MALIGNANT GTD rate of development: Stage I Confined to the uterus o 50% after a complete molar pregnancy Stage II Metastases to the pelvis o 25% after a normal-term pregnancy Metastases to the lung (with or without pelvic o 25% after miscarriage, abortion, or ectopic pregnancy Stage III metastases) DIAGNOSIS Distant metastases (with or without lung late postpartum bleeding, or abnormal uterine bleeding years Stage IV metastases) after an antecedent pregnancy REVISED FIGO SCORING SYSTEM FOR GTDA symptoms of metastatic disease RISK FACTORS 0 1 2 4 Labs: elevated hCG levels Age (yrs) ≤39 ≥40 Imaging: look for metastases (lung CXR, brain/chest/abdominal Antecedent CT/MRI) Mole Abortus Term pregnancy MANAGEMENT Pregnancy event Similar treatment for low-risk and high-risk patients to tx interval 12 cure rate: 95% to 100% if low-risk, 50-70% if high-risk (mos.) Similar follow-up and surveillance Pretx hCG levels 1,000- 10,000- 100,000 (mIU/mL) 10,000 100,000 PLACENTAL SITE TROPHOBLASTIC TUMORS (PSTT) No. of metastases 0 1-4 5-8 >8 extremely rare tumors from invasion of the myometrium Sites of Lung, Spleen, Brain, and vasculature from intermediate cytotrophoblasts of the GI tract metastases vagina kidney liver placental implantation site Largest tumor absence of villi, intermediate trophoblasts, and (+) hPL (vs size, including syncytiotrophoblasts, cytotrophoblasts, (+) hCG from other 3-4 5 uterine tumor types of malignant GTD) (cm) rarely metastasize Prior number of Single Multi- DIAGNOSIS failed chemotx agent agent most common symptom of PSTT: persistent irregular vaginal bleeding drugs aThe total score is obtained by adding the individual scores for each Labs: (+) hPL prognostic factor. 0-6 = low risk, ≥7 = high risk UTZ: uterine mass, less hemorrhage than seen in gestational Revised FIGO Staging of GTD. From Blueprints Obstetrics and Gynecology, 7th edition choriocarcinomas TREATMENT generally not sensitive to chemotherapy hysterectomy is the treatment of choice for PSTT multiagent chemotherapy to prevent recurrence LABOR OBSTETRIC EXAMINATION Leopold maneuvers o 3rd – Pawlick grip o 1st – Fundal grip § Engaged? § What occupies fundus? § Engaged – not movable § Breech (rump) – large nodular mass § Not engaged – movable § Cephalic (head) – hard round ballotable o 4th – Pelvic grip o 2nd – umbilical grip § What is the prominence? § Where is the back? § Brow – resistance to descent of fingers § Back – hard and resistant § Flexed – opposite from back § Fetal extremities – small and irregular mobile parts § Extended – occiput same side with back TOPNOTCH OBSTETRICS AND GYNECOLOGY MAIN HANDOUT BY DR. FAJUTAGANA AND DR. BANZUELA Page 9 of 91 For inquiries visit www.topnotchboardprep.com.ph or email us at [email protected] This handout is only valid for the October 2023 PLE batch. This will be rendered obsolete for the next batch since we update our handouts regularly.  TOPNOTCH OBSTETRICS AND GYNECOLOGY MAIN HANDOUT BY DR. FAJUTAGANA AND DR. BANZUELA For inquiries visit www.topnotchboardprep.com.ph or https://www.facebook.com/topnotchmedicalboardprep/ This handout is only valid for the October 2023 PLE batch. This will be rendered obsolete for the next batch since we update our handouts regularly. Leopold’s maneuvers. A) Fundal grip. B) Umbilical grip. C) Pawlick grip. D) Pelvic grip. From Blueprints Obstetrics and Gynecology 7th edition PELVIMETRY Characteristics of different pelvises. From Blueprints Obstetrics and Gynecology, 6th edition. Performing the pelvimetry. From TeachMeAnatomy and Williams’ Obstetrics. Diagonals of the pelvic exam o Cervical dilation – assessed using one or two fingers to o True conjugate: anteroposterior diameter from uppermost determine how open cervix is at level of internal os margin of symphysis pubis to sacral promontory o Effacement – subjective determination of how much length is o Obstetrical conjugate: shortest distance between sacral left of cervix and how effaced promontory and symphysis pubis (typically ≥10 cm, but o Station – relation of fetal head to ischial spines cannot be measured directly) o Consistency – firm, soft, or somewhere in between o The obstetrical conjugate is estimated indirectly by o Position – from posterior to mid to anterior subtracting 1.5–2 cm from diagonal conjugate, feeling for sacral promontory using tips of fingers, and noting position of FETAL PRESENTATION lower border of pubic symphysis Vertex – fetal occiput as reference Breech – fetal sacrum as reference CERVICAL EXAMINATION o Frank breech: § flexed hips GUIDE QUESTION: § extended knees Bishop Score § feet near fetal head https://qrs.ly/laex42t o Complete breech: § flexed hips § one or both knees flexed Bishop score § at least one foot near the breech o Bishop score >8 – cervix favorable for spontaneous and o Incomplete or footling breech: induced labor § one or both hips not flexed Score 0 1 2 3 § foot or knee lies below breech in birth Dilation (cm) Closed 1–2 3–4 ≥5 Face presentation – mentum is reference point Effacement (%) 0–30 40–50 60–70 ≥80 Shoulder presentation – acromion is reference point Station –3 –2 –1, 0 ≥+1 Consistency Firm Medium Soft Position Posterior Mid Anterior The Bishop score.. From Blueprints Obstetrics and Gynecology 7th edition. TOPNOTCH OBSTETRICS AND GYNECOLOGY MAIN HANDOUT BY DR. FAJUTAGANA AND DR. BANZUELA