OBGYN Main Handout - October 2023 PLE 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 will be rendered obsolete for the next batch since...

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. IMPORTANT LEGAL INFORMATION The handouts, videos and other review materials, provided by Topnotch Medical Board Preparation Incorporated are duly protected by RA 8293 otherwise known as the Intellectual Property Code of the Philippines, and shall only be for the sole use of the 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. 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Topnotch review materials are updated every six (6) months based on the current trends and feedback. Please buy all recommended review books and other materials listed below. THIS HANDOUT IS NOT FOR SALE! INSTRUCTIONS To scan QR codes on iPhone and iPad 1. Launch the Camera app on your IOS device 2. Point it at the QR code you want to scan 3. Look for the notification banner at the top of the screen and tap To scan QR codes on Android 1. Install QR code reader from Play Store 2. Launch QR code app on your device 3. Point it at the QR code you want to scan 4. Tap browse website This handout is only valid for the October 2023 batch. This will be rendered obsolete for the next batch since we update our handouts regularly. OBSTETRICS AND GYNECOLOGY – MAIN HANDOUT Obstetrics Gynecology By Shayne C. Fajutagana, MD, DPOGS By Nina Katrina C. Banzuela, MD, FPOGS Contributors: Manuel S. Vidal, Jr, RCh, MD, Jian Kenzo O. Leal, MD, Anna Rominia d.P. Cruz, MD Contributors: Shayne C. Fajutagana, MD, DPOGS Jian Kenzo O. Leal, MD Anna Rominia d.P. Cruz, MD TOPIC PAGE Obstetrics Review Pregnancy Maternal Adaptations in Pregnancy Preconceptional and Prenatal Care Early Pregnancy Complications Ectopic Pregnancy Abortion Recurrent Pregnancy Loss Gestational Trophoblastic Diseases Labor Dysfunctional Labor Induction and Augmentation of Labor Delivery Complications of Labor and Delivery Fetal Complications of Pregnancy Multifetal Gestation Obstetric Hemorrhage Hypertensive Diseases in Pregnancy Gestational Diabetes Mellitus Selected Medical Complications in Pregnancy Gynecology Review Developmental Biology of Sex Errors in Sexual Determination and Differentiation Reproductive Anatomy Reproductive Endocrinology Abnormalities of the Menstrual Cycle Amenorrhea Pediatric Gynecology Precocious Puberty Hyperandrogenism Infertility Menopause Osteoporosis Urinary Incontinence 1 2 3 6 6 7 7 8 9 14 15 17 18 20 22 23 27 28 29 40 42 43 47 51 55 57 59 61 63 66 68 68 Pelvic Organ Prolapse Endometriosis Gynecologic Infections Benign Gynecologic Lesions Neoplastic Disease of the Upper and Lower Genital Tract Family Planning 69 70 71 76 82 89 PREGNANCY GUIDE QUESTION: Pregnancy and Pregnancy Test https://qrs.ly/rnex3zk • Pregnancy – product of conception implanted typically in uterus or atypically in other locations DEFINITIONS • Embryo – from time of fertilization until 8 weeks pregnancy (10 weeks’ gestational age [GA]) • Fetus – after 8 weeks until time of birth • 1st trimester –from 12 weeks up to 14 weeks’ GA • 2nd trimester –from 12–14 until 24–28 weeks’ GA • 3rd trimester –from 24–28 weeks until delivery • Infant – between delivery and 1 year of age o previable – delivered prior to 23–24 weeks o preterm – between 24–37 weeks o term – between 37–42 weeks o postterm – beyond 42 weeks • Nulligravida – a woman who currently is not pregnant and has never been pregnant • Gravida – a woman who is currently pregnant or has been in the past, irrespective of pregnancy outcome • Nullipara – a woman who has never completed a pregnancy beyond 20 weeks’ gestation; may not have been or pregnant or may have had an abortion or an ectopic pregnancy • Primipara – a woman who has been delivered only once of a fetus or fetuses born alive or dead with an estimated AOG of at least 20 weeks • Multipara – a woman who has completed 2 or more pregnancies to 20 weeks’ gestation or more • Grand multipara – a woman who has had at least 5 births (live or stillborn) that are at least 20 weeks age of gestation • GP-TPAL designation o Gravidity, Parity, Term, Preterm, Abortus, Living children § Gravidity – number of times a woman has been pregnant § Parity – number of pregnancies that led to birth > 20 weeks AOG or infant > 500 g § Preterm – born between 24–37 weeks § Abortus – pregnancy losses before 20 weeks § Multifetal pregnancy – counts as 1 for TPA, but number of children alive counts separately for L § Grand multipara – a woman whose parity is ≥ 5 DATING THE PREGNANCY • Developmental age (DA) – number of weeks and days since fertilization (conceptional/embryonic age) • Gestational age (GA) – age in weeks and days from last menstrual period (LMP); + 2 weeks from DA • Estimated date of confinement (EDC) / estimated date of delivery (EDD) – computed via Naegele’s rule o EDC/EDD = LMP – 3 months, + 7 days o 280 days after LMP; 266 days after LMP if via assisted reproductive technology • Ultrasound - rarely off by 7–8% from GA; Should not differ from LMP dating by o >1 week in the first trimester o >2 weeks in the second trimester o >3 weeks in the third trimester • Auscultation of fetal heart tones by 20 weeks via stethoscope, or 10 weeks via Doppler ultrasound • Quickening usually between 16-20 weeks DIAGNOSIS Ultrasound • Gestational sac seen at 5 weeks on transvaginal ultrasound or at a beta-hCG of 1,500-2,000 mIU/mL • FH motion seen at 6 weeks or at beta-hCG of 5,000-6,000 mIU/mL TOPNOTCH OBSTETRICS AND GYNECOLOGY MAIN HANDOUT BY DR. FAJUTAGANA AND DR. BANZUELA 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. Page 1 of 91 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. • systolic pressure decreases 5–10 mm Hg and diastolic pressure decreases 10–15 mm Hg o reaches nadir at week 24 (24 – 26 weeks in Williams) o between 24 weeks and term, blood pressure returns to prepregnancy levels • (Williams) larger cardiac silhouette d/t 1) left and upward displacement, 2) benign pericardial effusion Beta-hCG (urine or serum) • hormone produced by the placenta • will rise to a peak of 100,000 mIU/mL by 10 weeks of gestation, decrease throughout the second trimester, and then level off at approximately 20,000 to 30,000 mIU/mL in the third trimester. • Will turn POSITIVE on urine pregnancy test around the time of missed menses • • • • • • • • Signs Bluish discoloration of vagina and cervix (Chadwick sign) Softening and cyanosis of the cervix at or after 4 wk (Goodell sign) Softening of the uterus after 6 wk (Ladin sign) Softening of the uterine isthmus after 6 weeks (Hegar sign) Breast swelling and tenderness Development of the linea nigra from umbilicus to pubis Telangiectasias Palmar erythema • • • • RESPIRATORY SYSTEM • Total lung capacity (TLC) decreases 5% because of elevation of diaphragm (~4 cm) • Tidal volume (TV) increases 30–40% à inspiratory capacity (IC) increases o increased TV lowers blood PCO2 slightly and paradoxically causes physiological dyspnea • expiratory reserve volume (ERV) decreases ~20% (15-20% in Williams) à functional residual capacity (FRC) decreases (↓20-30% in Williams) • constant respiratory rate with increased TV à minute ventilation increases 30–40% à increases alveolar (PAO2) and arterial (PaO2) oxygen levels, decreases PACO2 and PaCO2 levels Symptoms Amenorrhea Nausea and vomiting Breast pain Quickening— fetal movement MATERNAL ADAPTATIONS IN PREGNANCY GUIDE QUESTION: Maternal Physiology https://qrs.ly/geex3zn REPRODUCTIVE SYSTEM Uterus • Myometrial hypertrophy > hyperplasia • Uterine blood flow increases to 500–750 mL/min o d/t systemic vascular resistance decrease via progesterone, relaxin, and increased refractoriness to angiotensin II, norepinephrine • Contractions may occur weeks prior to delivery Braxton Hicks True Labor Painless Painful Irregular rhythm, infrequent Rhythmic, frequent Cervix does not progress Cervix thins, dilates Ovaries • Corpus luteum of pregnancy – max function between 6–7 wks o initially produces progesterone à placenta assumes production of progesterone à corpus luteum degrades into corpus albicans • Cervix • Arias-Stella reaction – loss of polarity, pleiomorphism, intraluminal budding • Eversion marked proliferation of cervical glands • Ferning –arborization of amniotic fluid due to high amounts of salt and estrogen • Goodell’s sign – cervical softening CARDIOVASCULAR SYSTEM • cardiac output increases by 30–50% o maximum output at 20–24 weeks and maintained until delivery o initially from increased stroke volume à maintained by increased heart rate à stroke volume returns to near prepregnancy levels by end of third trimester • Systemic vascular resistance decreases à fall in arterial blood pressure o due to elevated progesterone, leading to smooth muscle relaxation (and refractoriness to angiotensin II – Williams) Pulmonary changes in pregnancy. From Williams’ Obstetrics, 25th edition. Green = increased volumes; Red = decreased volumes • • • • • Increased Inspiratory • capacity (IC) Tidal volume (TV) Resting minute ventilation Peak expiratory flow rates Airway • conductance • Decreased Functional residual • capacity (FRC) • = ERV + RV o Expiratory • reserve volume (ERV)• o Residual volume (RV) • Total lung capacity* Pulmonary resistance Unchanged Respiratory rate Total lung capacity (FRC + IC)* Lung compliance Maximum breathing capacity Forced or timed vital capacity *unchanged or decreases by < 5% at term GASTROINTESTINAL SYSTEM • Morning sickness – nausea and vomiting in 70% of pregnancies, d/t o elevations in estrogen, progesterone, and hCG. o may also be due to hypoglycemia à treated with frequent snacking o typically resolve by 14–16 weeks o Hyperemesis gravidarum – pathologic morning sickness associated with weight loss (≥5% of pre-pregnancy weight), ketosis, and loss of electrolytes • gastric emptying time increases (unchanged in Williams) and lower esophageal tone decreases à reflux o anesthesia may further increase GET (risk factor for regurgitation and aspiration of gastric contents) • decreased esophageal tone may cause ptyalism, or spitting • large bowel motility decreases à increased water absorption and constipation • pelvic vessels congest d/t gravid uterus à increases abdominal pressure, and with constipation à hemorrhoids RENAL SYSTEM • kidneys increase in size, and ureters dilate (R > L) during pregnancy à hydronephrosis of pregnancy: risk factor for pyelonephritis • relaxin mediates vasodilation à glomerular filtration rate (GFR) increases by 50% early in pregnancy (25-50% starting 2nd trimester in Williams) and maintained until delivery à blood urea nitrogen and creatinine decrease by ~25% • RAAS activation à aldosterone increases à sodium resorption increases o Normonatremia is maintained d/t GFR increase o AVP threshold decreases à serum osmolality decreases by 10 mOsm/kg TOPNOTCH OBSTETRICS AND GYNECOLOGY MAIN HANDOUT BY DR. FAJUTAGANA AND DR. BANZUELA 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. Page 2 of 91 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 • plasma volume increases 50% (40-45% in Williams), while RBC volume increases 20-30% à physiological anemia of pregnancy à hematocrit and hemoglobin decreases o hypervolemia probably for increased metabolic demand, protection from impaired venous return, and protection against blood loss in delivery • WBC count increases to ~10.5 million/mL (6-16 million) à further increases to >20 million/mL in stressful conditions • Platelets slightly decrease d/t increased plasma volume and increased peripheral destruction • Pregnancy is considered hypercoagulable state with increase in thromboembolic events o Levels of fibrinogen and factors VII–X increase o However, clotting and bleeding times do not change o Increased rate of thromboembolic events (may also be due to other elements of Virchow’s triad: increased venous stasis & endothelial damage) ENDOCRINE SYSTEM • Pregnancy is a hyperestrogenic state, mainly d/t o Placenta production, from plasma-borne precursors produced by maternal adrenal glands o Ovaries contributing to lesser degree, from estrogen precursors produced in ovarian theca cells o Fetal well-being was correlated with maternal serum estrogen levels (e.g. low estrogen levels in fetal death and anencephaly) • In addition to estrogen, placenta produces o hCG § α subunit of hCG is identical to α subunits of luteinizing hormone (LH), follicle-stimulating hormone (FSH), and thyroidstimulating hormone (TSH), whereas tβ subunits differ § hCG levels double every ~48 hours during early pregnancy à peaks at ~10–12 weeks à declines to steady state after week 15 o relaxin § remodels reproductive tract to accommodate labor o Human placental lactogen (hPL) § ensures constant nutrient supply to fetus. hPL is also known as human chorionic somatomammotropin (hCS) § cause lipolysis with increase in circulating free fatty acids § acts as insulin antagonist (diabetogenic effect) à insulin and protein synthesis • Prolactin levels increased during pregnancy à decreased after delivery à increased in response to suckling • Pregnancy is considered a euthyroid state, despite subtle changes in thyroid hormone production o Estrogen stimulates thyroid binding globulin à elevation in total T3 and T4, but free T3 and T4 remain constant (Free T4 slightly increases in 1st trimester, then decreases – Williams) o hCG weakly stimulates thyroid à slight increase in T3 and T4 and slight decrease in TSH early in pregnancy MUSCULOSKELETAL AND DERMATOLOGICAL SYSTEM • Change in center of gravity during pregnancy à posture shift and lower back strain, which worsens during third trimester • Pregnancy is associated with carpal tunnel syndrome; results from compression of the median nerve; incidence varies, and symptoms are usually self-limited • Spider angiomata and palmar erythema occur due to increased estrogen in skin • hyperpigmentation of nipples, umbilicus, abdominal midline (the linea nigra), perineum, and face (melasma or chloasma) occur due to increased melanocyte-stimulating hormones and steroid hormones • Breast enlargement typically occurs, pathological enlargement is termed gigantomastia • Colostrum may be produced as early as few months into pregnancy (but only expressed 2nd day postpartum – Williams) METABOLISM AND NUTRITION Caloric equivalent of eating for ~1.15 persons • An additional 80,000 kcal is needed during pregnancy specially in the last 20 weeks of gestation • Average woman requires 2,000 to 2,500 kcal/day; caloric requirement increased by 300 kcal/day during pregnancy and by 500 kcal/day when breastfeeding o 100-300kcal/d caloric increase is recommended (Williams 26th) o Most gain 20–30 lbs during pregnancy (mean: 28.6 lbs in Williams) Category (BMI) Underweight (<18.5) Normal weight (18.5-24.9) Overweight (25.0-29.9) Obese (>=30) Total Weight Gain Range (lb) 28-40 Weight Gain in 2nd and 3rd trimester Mean in lb/wk (range) 1 (1-1.3) 25-35 1 (0.8-1) 15-25 0.6 (0.5-0.7) 11-20 0.5 (0.4-0.6) Williams Obstetrics Table 10-4: Recommendations for Total and Rate of Weight Gain in Pregnancy • Nutritional requirements o Protein: increases from 60 to 70 or 75 g/day o Calcium: 1.5 g/day o The recommended daily diet allowance (RDA) for Calcium is 1200mg/day in Blueprints and 1000mg/day in Williams o 1500mg/day in patients taking heparin o Iron: +18mg daily o Folate (helps prevent NTDs): increases from 0.4 to 0.8 mg/day § 400 mcg/day supplementation for all until first trimester § 4mg/day for patients with a history of child with NTDs Since mahilig sila magtanong ng difference in dosages minsan, to add: 4mg/day supplementation with folic acid is also advised for patients with Type 2 Diabetes Mellitus (Blueprints and Williams 25th ed) and in patients with seizure disorders (Williams 26th ed). Increased folic acid supplementation of around 2-4mg/day is also recommended for patients with ulcerative colitis to counteract the antifolate actions of sulfasalazine. Dr. Anna Rominia Cruz PRECONCEPTIONAL AND PRENATAL CARE PRECONCEPTIONAL COUNSELING • Folic acid: Begin 0.4 mg/day one month prior to conception for all patients; then increase to 4mg/day for patients high risk for NTDs • A pre-conceptional hemoglobin A1c level goal below 7% is recommend for patients with diabetes mellitus • For a woman recently vaccinated with live vaccines (i.e. varicella-zoster, measles, mumps, rubella, polio, chickenpox, and yellow fever), it is recommended to get pregnant at least a month after administration PRENATAL CARE Initial Visit and First Trimester CBC Pap smear Blood type and antibody screen RPR/VDRL Rubella antibody screen Hepatitis B antibody screen Urinalysis and urine culture VZV titer PPD HIV screening Gonorrhea culture Chlamydia culture Early screening for aneuploidy Second Trimester MSAFP/triple or quad screen Obstetric ultrasound Amniocentesis REMARKS Primarily for hematocrit Screening for cervical CA Rh (-) mothers: should be given RhoGAM at 28 wks Screening for syphilis If nonreactive, give vaccine postpartum -Screen for asymptomatic bacteriuria In patients with no history of chickenpox During the 1st or 2nd trimester to screen for PTB in high risk patients Offered routinely Repeated in the 3rd trimester in high-risk populations Nuchal translucency + serum markers (hCG, PAPP-A) at 11-14wks MSAFP, beta-hCG, estriol +/- inhibin A at 15-20 weeks 18-20 wks: screening utz for fetal malformation In NTDs: Banana sign – cerebellum is pulled caudally and flattened Lemon sign –concave frontal bones For women interested in prenatal diagnosis TOPNOTCH OBSTETRICS AND GYNECOLOGY MAIN HANDOUT BY DR. FAJUTAGANA AND DR. BANZUELA 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. Page 3 of 91 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 Hematocrit Glucose loading test High-Risk Group Hct becomes close to its nadir GDM screening; 75g OGTT based on local CPG BLUEPRINTS: 50g GLT: check after 1hr à if ≥ 140 mg/dL*, proceed to do glucose tolerance test (GTT) *other institutions use a lower threshold of 130 or 135 mg/dL RPR/VDRL GBS culture Ultrasound + other tests for fetal wellbeing 2 or more to diagnose as GDM on 100g OGTT: FBS 95 mg/dL; 1hr 180; 2hr 155; 3hr 140 --at 36-37 6/7 weeks (previously 3537 weeks); if (+) à IV penicillin once in labor to prevent neonatal GBS infection BPP – score of 8 to 10 is reassuring Doppler – abnormal findings: decrease, absence, or reversal of diastolic flow in the umbilical artery NST At 35-36 weeks: confirm fetal presentation; if breech, offer external cephalic version at 37 to 38 weeks African American, Southeast Asian Family history of genetic disorder (e.g., Prenatal genetics referral hemophilia, sickle cell disease, fragile X syndrome), maternal age 35 or older at time of EDC Prior gestational diabetes, family history Early GLT of diabetes, Hispanic, Native American, Southeast Asian, obese Pregestational diabetes, unsure dates, Dating sonogram at first visit recurrent miscarriage HPN, renal disease, preGDM, prior preeclampsia, renal transplant, SLE PreGDM, prior cardiac disease, HPN PreGDM Graves disease All thyroid disease PPD+ Blueprints 7th edition, Table 1-3: Routine Tests in Prenatal Care with edits and comments Note that based on the POGS CPG on Diabetes in Pregnancy, 75g OGTT is done at 24-28 weeks AOG and repeated at 32 weeks for patients high risk for developing GDM or those who developed new symptoms. Blueprints lang ang third trimester ang OGTT! Dr. Anna Rominia Cruz Williams Obstetrics 26th edition Table 10-1. Typical Components of Routine Prenatal Care 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 SLE Specific Test Sickle cell prep for African Americans; Hgb electrophoresis for both Prenatal genetics referral Early GLT Dating sonogram at first visit BUN, Crea, uric acid, 24h urine collection ECG HbA1c, ophthalmology for eye exam TSI TSH +/- FT4 CXR after 16 wks AOG Anti Rho, anti-La antibodies (can cause fetal complete heart block Blueprints 7th edition, Table 1-4: Initial Screens fin Specific High-Risk Groups ROUTINE PRENATAL VISITS • The following must be performed and assessed on each followup 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 o Beyond 32-34 weeks, Leopold maneuvers are performed to determine presentation Dr. Anna Rominia Cruz PRENATAL CARE https://qrs.ly/erex3zs GUIDE QUESTION: Prenatal Screening https://qrs.ly/ayex402 TOPNOTCH OBSTETRICS AND GYNECOLOGY MAIN HANDOUT BY DR. FAJUTAGANA AND DR. BANZUELA 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. Page 4 of 91 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 TRISOMY 21 TRISOMY 18 MSAFP Decreased Decreased BetahCG Increased Decreased Estriol Decreased Decreased Inhibin Increased Decreased Other remarks Down Syndrome Edward Syndrome (eighteen) -choroid plexus (CP) cysts -up to 2 yrs of life TRISOMY 13 Depends on defect Depends on defect Depends on defect Depends on defect Patau Syndrome -up to 1 yr of life IMMUNIZATION IN PREGNANCY • Routinely recommended: o Influenza one dose IM yearly o Tetanus-diphtheria-acellular pertussis (Tdap) § Preferably between 27-36 weeks AOG § Primary: two doses IM at 1-2 month interval with 3rd dose 612 months after the 2nd dose § Booster: single dose IM once per pregnancy (every 10 years as part of wound care if 5 years since last dose) • May be given as postexposure prophylaxis: hepatitis B, rabies, tetanus, hepatitis A, rabies, meningococcus • Yellow fever: if for travel to high-risk areas • Contraindicated: measles, mumps, rubella, varicella, zoster, smallpox • Not recommended unless high-risk exposure: typhoid, polio • Not recommended: human papillomavirus (HPV) COMMON CONCERNS IN PREGNANCY • Back pain – usually in the 3rd trimester when the patient’s center of gravity has shifted o Management: mild exercise (like stretching), gentle massage, heating pads, Tylenol for mild pain, narcotics or muscle relaxants for severe pain, physical therapy • Constipation - ↓ bowel motility due to ↑ progesterone à ↑ water absorption from the GI tract o Management: increase oral fluid intake, stool softener/bulking agents, laxatives (avoided during 3rd trimester due to risk of preterm labor) • Contractions – patients are advised regarding Braxton Hicks contractions; dehydration may increase contractions • Dehydration – due to expanded intravascular space and ↑ third spacing à intravascular volume status is difficult to maintain o May cause contractions secondary to cross-reaction of vasopressin with oxytocin receptors • Edema – compression of IVC and pelvic veins by the uterus à increased hydrostatic pressure in the lower extremities o Management: elevation of lower extremities above the heart, sleeping in a lateral decubitus position o Edema of face and hands may indicate preeclampsia • GERD – relaxation of the LES, increased transit time in the stomach o Management: may be started on antacids; multiple small meals per day; avoid lying down within 1 hr of eating; H2 blockers or PPI may be given • Hemorrhoids - ↑ venous stasis & IVC compression; o Management: topical anesthetic and steroids, prevention of constipation with ↑ fluids, ↑ dietary fiber, use of stool softeners • Pica – cravings for inedible items such as dirt/clay; patient is advised to maintain adequate nutrition • Round ligament pain – usually late in 2nd trimester or early in 3rd trimester; pain in the adnexa, lower abdomen, or groin; due to rapid expansion of the uterus & stretching of ligamentous attachments; usually self-limited o Management: warm compress or acetaminophen • Urinary frequency – due to ↑ compression of the bladder by the growing uterus; ↑ intravascular volume & GFR leading to ↑ urine production • Varicose veins – may be due to relaxation of the venous smooth muscle and ↑ intravascular pressure o Management: elevation of the lower extremities, use of pressure stockings, referred for surgical therapy if persistent beyond 6 months postpartum ANTEPARTUM FETAL ASSESSMENT • Oxytocin challenge test or contraction stress test (CST): achieve at least 3 contractions in 10 min; test of uteroplacental function • Satisfactory test: 3 or more contractions lasting 40 seconds or more in a 10-minute period • Positive CST (abnormal): late fetal heart deceleration (due to uteroplacental insufficiency) following ≥50% of contractions even if the contraction frequency is < 3 in 10 minutes • Negative CST (normal): no late or significant variable decelerations • Equivocal-suspicious: intermittent late decelerations or significant variable decelerations • Equivocal-hyperstimulatory: FHR decelerations that occur in the presence of contractions more frequent than every 2 minutes or lasting > 90 seconds • Unsatisfactory: fewer than 3 contractions in 10 minutes or an uninterpretable trace • Methods: o Oxytocin infusion o Nipple stimulation • Nonstress test (NST): test of fetal condition; most antenatal testing units use the NST, beginning at 32 to 34 weeks of gestation in high-risk pregnancies and at 40 to 41 weeks for undelivered patients • Fetal heart rate acceleration in response to fetal movement as sign of fetal health o ≥32 weeks: acceleration ≥15 bpm from baseline, lasts for ≥15 secs, but <2 mins from onset to return o <32 weeks: acceleration ≥10 bpm from baseline, lasts for ≥ 10 secs, but <2 mins from onset to return • Considered REACTIVE (reassuring) if there are ≥ 2 accelerations in 20 mins; otherwise: NONREACTIVE NST • Biophysical profile (BPP) • Components (BATMaN): 1. Fetal Breathing 2. Amnionic fluid volume 3. Fetal Tone 4. Fetal Movement 5. Nonstress test (NST) – may be omitted if all 4 sonographic components are normal COMPONENT Nonstress testa Fetal breathing Fetal movement Fetal tone Amniotic fluid volumeb SCORE 2 ≥ 2 accelerations of ≥ 15 beats/min for ≥ 15 sec within 20-40 min ≥ 1 episode of rhythmic breathing lasting ≥ 30 sec within 30 min ≥ 3 discrete body or limb movements within 40 min ≥ 1 episode of extremity extension and subsequent return to flexion A pocket of amniotic fluid that measures at least 2 cm in two planes perpendicular to each other (2 x 2 cm pocket) SCORE 0 0 or 1 acceleration within 20-40 min < 30 sec of breathing within 30 min < 3 discrete movements 0 extension/flexion events Largest single vertical pocket ≤ 2 cm aMay be omitted if all four sonographic components are normal. evaluation warranted, regardless of biophysical composite score, if largest vertical amniotic fluid pocket ≤ 2 cm. bFurther GUIDE QUESTION: Antenatal Fetal Testing https://qrs.ly/vfex40h BPP SCORE INTERPRETATION 10 Normal, nonasphyxiated fetus 8/10 (Normal AFV) 8/8 (NST not done) Normal, nonasphyxiated fetus RECOMMENDED MANAGEMENT No intervention Repeat test weekly twice weekly No intervention Repeat testing per protocol TOPNOTCH OBSTETRICS AND GYNECOLOGY MAIN HANDOUT BY DR. FAJUTAGANA AND DR. BANZUELA 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. or Page 5 of 91 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. BPP SCORE INTERPRETATION RECOMMENDED MANAGEMENT 8/10 (Decreased AFV) Chronic fetal asphyxia suspected DELIVER 6 Possible fetal asphyxia 4 Probable fetal asphyxia 0-2 Almost certain fetal asphyxia DELIVER if: • AFV abnormal • Normal AFV >36 weeks with favorable cervix • Repeat test ≤6 o If Repeat test > 6: observe and repeat per protocol • Repeat testing on the same day • If BPP score ≤6: DELIVER DELIVER NEURAL CONTROL OF BPS ACTIVITY BPS PARAMETER Fetal Tone CNS CENTER • Fetal • Movement Fetal • Breathing • Fetal Heart Reactivity AOG Cortex• 7.5 – 8.5 Subcortical Area wks Cortex-Nuclei • 9 weeks HYPOXIA CASCADE • Last affected • 3rd Ventral surface • 20-21 wks • 2nd of 4th ventricle Medulla & Posterior • 24-26 wks • 1st affected Hypothalamus FETAL BLOOD SAMPLING • Percutaneous umbilical blood sampling – needle is placed transabdominally into the uterus and phlebotomizing the umbilical cord o used to asses for fetal anemia (e.g. in Rh isoimmunization), for fetal transfusion, karyotyping, and for assessment of fetal platelet count FETAL LUNG MATURITY • Lecithin to sphingomyelin ratio (L/S): type II pneumocytes secrete a surfactant that uses phospholipids o Lecithin increases as the lungs mature o Sphingomyelin decreases beyond 32 weeks o L/S ratio > 2 is associated with only rare cases of RDS • Levels of phosphatidylglycerol • Saturated phosphatidyl choline • Presence of lamellar body count • Surfactant to albumin ratio EARLY PREGNANCY COMPLICATIONS ECTOPIC PREGNANCY DIAGNOSIS OF ECTOPIC PREGNANCY • History: unilateral pelvic or lower abdominal pain, vaginal bleeding, and amenorrhea • Physical examination: tender adnexal mass, small uterus for gestational age, bleeding from cervix • Ruptured ectopic pregnancies: hypotensive, tachycardic, unresponsive o show signs of peritoneal irritation secondary to hemoperitoneum • Laboratory findings: low β-hCG level for gestational age o Normal bHCG doubling time: 1.4-2.0 days o In ectopic pregnancy, poorly implanted placenta receive low blood supply à β- hCG levels do not double every 48 hours o Hematocrit: decreased in ruptured ectopic pregnancies • Imaging findings o Gestational sac with yolk sac on UTZ indicates IUP o In IUP, β-hCG levels should be 1,500–2,000 mIU/mL. o Fetal heartbeat: β-hCG level > 5,000 mIU/mL o Hemorrhaging, ruptured ectopic pregnancy may reveal intraabdominal fluid throughout pelvis and abdomen MANAGEMENT OF ECTOPIC PREGNANCY • Surgical procedure o Exploratory laparotomy – if patient is unstable o Exploratory laparoscopy – procedure of choice o Salpingostomy – resection of ectopic pregnancy, leaving fallopian tubes as is o Salpingectomy – resection of ectopic pregnancy with removal of fallopian tubes o Cornual resection – for interstitial pregnancies • Medical management o Methotrexate § Factors for success: small ectopic § < 3.5 cm (Williams and POGS CPG on Ectopic Pregnancy. but <5cm in Blueprints) § Serum β-hCG level < 5,000 § No fetal heartbeat § Reliable follow-up § Single dose regimen (50 mg/m2) IM methotrexate vs multidose regimen (88% vs 93% effectiveness) § β-hCG levels rise after methotrexate therapy, then fall 10– 15% after 4–7 days § Contraindications: § Sensitivity to MTX § Evidence of tubal rupture § Breast feeding § Intrauterine pregnancy § Hepatic, renal, or hematological dysfunction § Peptic ulcer disease § Active pulmonary disease § Immunodeficiency • When fertilized egg implants outside uterine cavity SINGLE DOSE MULTIDOSE • Fallopian tube in 95%–99% of ectopic pregnancy Up to four doses of One dose; repeat if o Implantation in ampulla is 70%, followed by isthmus (12%) Dosing both drugs until serum necessary and fimbriae (11%) 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 Dosage mg/m2 BSA (D1) Leucovorin 0.1 mg/kg, • > 1:100 of pregnancies are ectopic D2, 4, 6, 8 o secondary to increase in assisted fertility, sexually transmitted Serum B-hCG Days 1 (baseline), 4 Days 1, 3, 5, and 7 infections, and pelvic inflammatory disease level and 7 • Cardinal signs: vaginal bleeding and/or abdominal pain • If serum B-hCG with missed menses • If serum B-hCG declines < 15%, give Risk Factors for Ectopic Pregnancy 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 maximum of four surveillance doses • Current use of exogenous hormones including progesterone Posttherapy or estrogen Weekly until serum B-hCG undetectable surveillance • IVF and other assisted reproduction • DES-exposed patients with congenital abnormalities • Use of an IUD for birth control ECTOPIC PREGNANCY • Smoking https://qrs.ly/gfegwyc *risk of a subsequent ectopic pregnancy is 10% after one prior 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 • • • • • 15–25% pregnancies undergo spontaneous abortion (SAB) Abortus – fetus lost before 20 weeks’ gestation or < 500 g Complete abortion – expulsion of POC before 20 weeks Incomplete abortion – partial expulsion before 20 weeks Inevitable abortion – no expulsion of POC, but vaginal bleeding and dilation of cervix will unlikely result in pregnancy • Threatened abortion – any vaginal bleeding before 20 weeks, without dilation of cervix or expulsion of any POC • Missed abortion – death of embryo or fetus before 20 weeks with complete retention of POC • Septic abortion – any abortion complicated with infection FIRST TRIMESTER ABORTIONS • 60–80% SABs in first trimester are associated with abnormal chromosomes, 95% are due to maternal gametogenesis errors • 95% usually due to autosomal trisomy (50-60% in Williams) MANAGEMENT OF FIRST-TRIMESTER ABORTIONS • Stabilize if hypotensive • Incomplete abortion, inevitable abortions, missed abortions – allow to finish course, or may be completed via surgical or medical means o Surgical: dilatation and curettage (D&C) o Medical: prostaglandins ± mifepristone • Threatened abortion – followed up for possibility of bleeding o Bed rest and analgesia with acetaminophen o Rh-negative – RhoGAM to prevent isoimmunization o Contraceptives if desired o Offer elective cerclage in subsequent pregnancies only if with history of recurrent midtrimester losses or prior preterm birth with short cervix (Williams) o If without preterm birth but with short cervix, offer progesterone up to 36 6/7 weeks o Prophylactic elective cerclage: 12–14 weeks’ gestation, maintained until 37 weeks o If cervical cerclage fails à abdominal cerclage is offered at 12–14 weeks à mode of delivery is by CS o If with previous preterm birth, IM 17-hydroxyprogesterone offered until 36 weeks AOG o Emergent cerclage: done when cervix is already dilated or effaced RECURRENT PREGNANCY LOSSES (RPL) • Classical definition: three or more consecutive pregnancy losses at <20 weeks’ gestation or with a fetal weight <500 g. • New definition from American Society for Reproductive Medicine (2020): 2 or more failed pregnancies confirmed by sonographic or histopathological examination • < 1% of population diagnosed with recurrent pregnancy loss • Risk of SAB: o after one prior SAB, 20–25% o after two consecutive SABs, 25–30% o after three consecutive SABs, 30–35% ESHRE 2017 Pregnancy Ectopic and molar pregnancies not included AOG Up to 24 wks Recurrence 2 May be nonconsecutive SECOND-TRIMESTER ABORTIONS • Between 12 to 20 weeks • Abnormal chromosomes do NOT often cause late abortions • Infection, maternal uterine or cervical anatomic defects, maternal systemic disease, exposure to fetotoxic agents, and trauma are associated with late abortions MANAGEMENT OF SECOND-TRIMESTER ABORTIONS • At 16–24 weeks, dilatation and evacuation may be done or labor induced with oxytocin or prostaglandins • Aggressive dilatation must be done prior to D&E • Rule out preterm labor and cervical insufficiency o Preterm labor – tocolysis o Cervical insufficiency – cerclage GUIDE QUESTION: Second-trimester abortion and Cervical insufficiency https://qrs.ly/wnex418 CERVICAL INSUFFICIENCY • Painless cervical dilation and effacement, often in second trimester à increased exposure of fetal membranes to vaginal flora and risk of trauma as cervix dilates. • Possible short-term cramping or contracting à cervical dilation or vaginal pressure à chorionic and amniotic sacs bulge through cervix • Cervical insufficiency cause ~15% second-trimester losses DIAGNOSIS OF CERVICAL INSUFFICIENCY • Dilated cervix on routine examination, ultrasound, or during bleeding, vaginal discharge, or membrane rupture • mild cramping or pressure in lower abdomen or vagina • More cervical dilation than expected with level of contractions • differentiation between cervical insufficiency and PTL o Cervical insufficiency – mild cramping and advancing cervical dilation and/or amniotic sac bulging through cervix, due to dilated cervix and exposed membranes o PTL – contractions/cramping leading to cervical change Timing ASRM 2013 Clinical pregnancy documented by UTZ or histopath Only mentions that majority is lost prior to 10 weeks 2 Consecutive RCOG 2011 All pregnancy losses not further defined Up to 24 wks 3 Consecutive ETIOLOGIES OF RPL • Similar to spontaneous abortions • 15% RPL due to antiphospholipid antibody (APA) syndrome • Possible luteal phase defect and insufficient progesterone DIAGNOSIS OF RPL • Obtain parents’ karyotype and POC karyotypes from each SAB • Examine maternal anatomy – saline infusion sonography (SIS) and hysteroscopy • Screening for metabolic, immunologic, and hematologic disorders + APAS panel o APAS panel: lupus anticoagulant, anticardiolipin antibody IgG and IgM, beta glycoprotein IgG and IgM o Factor V Leiden deficiency o Prothrombin G20210A mutation o ANA o Russell viper venom o Antithrombin III, protein S, and protein C o Hba1c • Obtain serum progesterone in luteal phase of menstrual cycle • Cultures from cervix, vagina, endometrium to r/o infection MANAGEMENT OF RPL • Patients with chromosomal abnormalities: IVF or preimplantation diagnosis • Anatomic abnormalities may not be correctable (for Asherman syndrome à hysteroscopic adhesiolysis; for uterine leiomyomas à excision; for congenital genital tract anomalies, disease-specific treatment – Williams) • Cerclage: for cervical insufficiency • Progesterone: for luteal phase defects • Low-dose aspirin: for APA syndrome • SQ heparin (low molecular weight or unfractionated): for thrombophilia • Appropriate therapy for maternal systemic diseases MANAGEMENT OF CERVICAL INSUFFICIENCY • Previable fetus – expectant management or elective termination • Viable fetus – tocolysis and corticosteroids • Cerclage – suture at cervical–vaginal junction (McDonald) (at the internal os level) or at internal os (Shirodkar) (transverse incision of the anterior cervical mucosa at level of internal os ) TOPNOTCH OBSTETRICS AND GYNECOLOGY MAIN HANDOUT BY DR. FAJUTAGANA AND DR. BANZUELA 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. Page 7 of 91 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. GESTATIONAL TROPHOBLASTIC DISEASE (GTD) • Abnormal proliferation of trophoblastic (placental) tissue • Four major classifications o molar pregnancies (80%) o persistent GTD and invasive moles (10% to 15%) o gestational choriocarcinoma (2% to 5%) o very rare placental site trophoblastic tumors (PSTTs) • hCG: tumor marker for diagnosing the disease and as a tool for measuring the effects of treatment • Most curable gynecologic malignancy d/t sensitivity to chemotx EPIDEMIOLOGY • decreased rate of GTD in African American women • Low and intermediate rates: North America and Europe • Moderate to high rates: Latin America and Asia • Highest: among South East Asian women and women in Japan (1 in 500 pregnancies) RISK FACTORS • Most common risk factors: extremes in age and prior history of GTD • Age: Adolescents and 36-40 year-olds: 2x risk, women >40 y/o: 10x risk • Nulliparity > multiparity • history of GTD o No previous history: 0.1% o 1 previous molar pregnancy: 1-2% (0.9% for complete moles and 0.3% for partial moles - Williams) o 2 previous molar pregnancies: 16-28% (20% - Williams) • Diet: low in β-carotene, folic acid, and animal fat • Ethnicity: Asians, Hispanics, and American Indians • Other possible associated factors: smoking, infertility, spontaneous abortion, blood group A, and a history of OCP use COMPLETE MOLAR PREGNANCY PATHOGENESIS • result from the fertilization of an enucleate ovum/empty egg, one whose nucleus is missing or nonfunctional, by one normal sperm that then replicates itself • all chromosomes are paternally derived • most common karyotype: diploid 46,XX • placental abnormality: noninvasive trophoblastic proliferation à grape-like vesicles Features Most common karyotype Chromosomal origin Complete mole (90%) Genetics 46,XX All paternally derived Pathology Incomplete mole (10%) 69,XXY/XXX (or XYY – rare) Extra paternal set Coexistent fetus Absent Present Fetal RBCs Absent Present Chorionic villi Hydropic Few hydropic Trophoblasts Severe hyperplasia Minimal/ no hyperplasia Associated embryo Symptoms/signs symptomsa Classic Uterine size Theca lutein cysts hCG levels Nonmetastatic malignant GTD Metastatic malignant GTD Rate of subsequent GTN (Williams) Clinical presentation None Abnormal vaginal bleeding Common 50% larger for dates 15-25% (25-30% - Williams) High Malignant potential Present Missed abortion Rare Size = dates Rare Slightly elevated 15-25% 2-4% 4% - 15-20% 1-5% Follow-up Weeks to normal 14 weeks 8 weeks hCG (9 weeks – Williams) (7 weeks – Williams) aHyperemesis gravidarum, early preeclampsia, hyperthyroidism, anemia, excessive uterine size CLINICAL PRESENTATION History • irregular, heavy vaginal bleeding in the setting of a positive pregnancy test (97%): most common presenting symptom o caused by separation of the tumor from the underlying decidua, resulting in disruption of the maternal vessels. • All other symptoms mainly d/t hCG production Symptom Percentage Vaginal bleeding 90-97 Passage of molar vesicles 80 Anemia 50 Uterine size larger than dates 30-50 Bilateral theca lutein cysts 15-25 Hyperemesis gravidarum 10-25 Preeclampsia 10-15 Hyperthyroidism 10 Trophoblastic pulmonary emboli 2 Common symptoms of molar pregnancy, in descending frequency. From Blueprints Obstetrics and Gynecology, 7th edition. Physical examination • absence of fetal heart sounds • expulsion of grape-like molar clusters from the vaginal canal • palpable large bilateral theca lutein cysts (less frequent) • initially presumed to be a threatened abortion. Labs and imaging • hCG levels > >100,000 mIU/mL • UTZ: snowstorm pattern due to chorionic villi swelling • theca lutein cysts >6 cm • definitive diagnosis: histopathological exam of the uterine tissue TREATMENT OF COMPLETE MOLAR PREGNANCY • suction D&C: definitive treatment o hysterectomy if non-desirous of future pregnancies • uterotonics to minimize blood loos • RhoGAM for Rh-negative women • adjunctive anti-hypertensives and beta blockers PROGNOSIS • prognosis is excellent: persistent postmolar GTD: 6-32% in complete moles, <5% in partial moles • serial hCG surveillance o 48 hours after evacuation then o every 1 to 2 weeks until negative for 3 consecutive weeks o then followed monthly for an additional 6 months o plateau/rise in hCG is indicative of malignant postmolar GTD o phantom hCG: (+) hCG but negative urine PT – no tx needed • contraception: to avoid pregnancy interfering with surveillance • Risk factors for persistent trophoblastic disease o β-hCG levels >100,000 mIU/mL o ovaries >6 cm (theca lutein cysts > 6 cm – Williams) o large uterine sizes (14 to 16 weeks) o may give chemoprophylaxis: methotrexate + folinic acid/dactinomycin) PARTIAL MOLAR PREGNANCY PATHOGENESIS • normal ovum is fertilized by two sperm simultaneously • triploid karyotype with 69 chromosomes, two sets are paternally derived • most common karyotype is 69,XXY (80%) • placenta: focal hydropic villi and trophoblastic hyperplasia primarily of the cytotrophoblast • notable due to presence of embryo • often misdiagnosed as spontaneous or missed abortions • much lower malignant potential than complete moles CLINICAL PRESENTATION • delayed menses and (+) urine PT • vaginal bleeding from miscarriage or incomplete abortion in late first trimester or early second trimester (90%) • physical examination typically normal d/t slightly elevated hCG, (+) fetal heart sounds, uterine size small for gestational age • UTZ: fetus with cardiac activity, congenital malformations, and/or IUGR • “Swiss-cheese” appearance • definitive diagnosis: histopathological exam of the uterine tissue 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 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. Page 8 of 91 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 • suction D&C PERSISTENT POSTMOLAR GTD AND INVASIVE MOLES PROGNOSIS • <5% will develop persistent malignant disease • Similar surveillance strategy with complete moles • average time to normalization of levels: 8 weeks (partial mole) (7 weeks – Williams) vs 14 weeks (complete mole) (9 weeks – Williams), 2-4 weeks following a normal pregnancy, miscarriage, or termination • contraception is warranted to avoid pregnancy interference DIAGNOSIS • Plateau/rise in hCG levels, excessive uterine size, large theca lutein cysts • UTZ: invasion of an intrauterine mass into the myometrium • Doppler: high vascular flow MOLAR PREGNANCY https://qrs.ly/47ex41h GESTATIONAL TROPHOBLASTIC NEOPLASIA (GTN) • 20% of patients with GTD o persistent postmolar pregnancies or invasive molar pregnancies (75%) o gestational choriocarcinomas (25%) o placental site trophoblastic tumors (rare) • Diagnosis: plateauing/rising hCG levels after molar evacuation. • Most common presentation: abnormal uterine bleeding >6 weeks following pregnancy • Staging system: Revised FIGO Staging System • Extreme sensitivity to chemotherapy o low-risk disease: single- agent chemotherapy o high-risk disease: combination chemotherapy. o surgical intervention: for high-risk patients or for PSTT FIGO STAGING OF MALIGNANT GTD Stage I Stage II Stage III Stage IV Confined to the uterus Metastases to the pelvis Metastases to the lung (with or without pelvic metastases) Distant metastases (with or without lung metastases) REVISED FIGO SCORING SYSTEM FOR GTDA RISK FACTORS 0 1 2 Age (yrs) Antecedent pregnancy Pregnancy event to tx interval (mos.) Pretx hCG levels (mIU/mL) No. of metastases Sites of metastases Largest tumor size, including uterine tumor (cm) Prior number of failed chemotx drugs ≤39 ≥40 Mole Abortus Term <4 4-6 7-12 0 Lung, vagina 1,00010,000 1-4 Spleen, kidney 10,000100,000 5-8 3-4 5 <1,000 • 1 in 15,000 pregnancies • hydropic chorionic villi and trophoblast proliferation into the myometrium • rarely metastasize and are capable of spontaneous regression • Risk factors o hCG > 100,000 mIU/mL o Uterine size >14–16 wk o Theca lutein cysts >6cm o Coexistent fetus MANAGEMENT • Avoid repeat D&C • Single-agent chemotherapy (MTX or dactinomycin) • If with metastases: single agent for low risk, multiagent for high risk • Similar follow up and surveillance with GTD GESTATIONAL CHORIOCARCINOMA • 1 in 20,000 to 40,000; common in Asian or African descent • malignant necrotizing tumor: invasion of uterine wall and vasculature à necrosis and potentially severe hemorrhage • “the great imitator” • pure epithelial tumor: sheets of anaplastic cytotrophoblasts and syncytiotrophoblasts in the absence of chorionic villi • hematogenous spread • rate of development: o 50% after a complete molar pregnancy o 25% after a normal-term pregnancy o 25% after miscarriage, abortion, or ectopic pregnancy DIAGNOSIS • late postpartum bleeding, or abnormal uterine bleeding years after an antecedent pregnancy • symptoms of metastatic disease • Labs: elevated hCG levels • Imaging: look for metastases (lung CXR, brain/chest/abdominal CT/MRI) 4 MANAGEMENT • Similar treatment for low-risk and high-risk patients • cure rate: 95% to 100% if low-risk, 50-70% if high-risk • Similar follow-up and surveillance >12 >100,000 GI tract Single agent PLACENTAL SITE TROPHOBLASTIC TUMORS (PSTT) >8 Brain, liver • extremely rare tumors from invasion of the myometrium and vasculature from intermediate cytotrophoblasts of the placental implantation site • absence of villi, intermediate trophoblasts, and (+) hPL (vs syncytiotrophoblasts, cytotrophoblasts, (+) hCG from other types of malignant GTD) • rarely metastasize Multiagent DIAGNOSIS • most common symptom of PSTT: persistent irregular vaginal bleeding • Labs: (+) hPL • UTZ: uterine mass, less hemorrhage than seen in gestational choriocarcinomas The total score is obtained by adding the individual scores for each prognostic factor. 0-6 = low risk, ≥7 = high risk a Revised FIGO Staging of GTD. From Blueprints Obstetrics and Gynecology, 7th edition TREATMENT • generally not sensitive to chemotherapy • hysterectomy is the treatment of choice for PSTT • multiagent chemotherapy to prevent recurrence LABOR OBSTETRIC EXAMINATION o 3rd – Pawlick grip • Leopold maneuvers § Engaged? o 1st – Fundal grip § Engaged – not movable § What occupies fundus? § Not engaged – movable § Breech (rump) – large nodular mass o 4th – Pelvic grip § Cephalic (head) – hard round ballotable § What is the prominence? o 2nd – umbilical grip § Brow – resistance to descent of fingers § Where is the back? § Flexed – opposite from back § Back – hard and resistant § Extended – occiput same side with back § Fetal extremities – small and irregular mobile parts TOPNOTCH OBSTETRICS AND GYNECOLOGY MAIN HANDOUT BY DR. FAJUTAGANA AND DR. BANZUELA 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. Page 9 of 91 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 True conjugate: anteroposterior diameter from uppermost margin of symphysis pubis to sacral promontory o Obstetrical conjugate: shortest distance between sacral promontory and symphysis pubis (typically ≥10 cm, but cannot be measured directly) o The obstetrical conjugate is estimated indirectly by subtracting 1.5–2 cm from diagonal conjugate, feeling for sacral promontory using tips of fingers, and noting position of lower border of pubic symphysis CERVICAL EXAMINATION GUIDE QUESTION: Bishop Score https://qrs.ly/laex42t • Bishop score o Bishop score >8 – cervix favorable for spontaneous and induced labor Score 0 1 2 3 Dilation (cm) Closed 1–2 3–4 ≥5 Effacement (%) 0–30 40–50 60–70 ≥80 Station –3 –2 –1, 0 ≥+1 Consistency Firm Medium Soft Position Posterior Mid Anterior o Cervical dilation – assessed using one or two fingers to determine how open cervix is at level of internal os o Effacement – subjective determination of how much length is left of cervix and how effaced o Station – relation of fetal head to ischial spines o Consistency – firm, soft, or somewhere in between o Position – from posterior to mid to anterior FETAL PRESENTATION • Vertex – fetal occiput as reference • Breech – fetal sacrum as reference o Frank breech: § flexed hips § extended knees § feet near fetal head o Complete breech: § flexed hips § one or both knees flexed § at least one foot near the breech o Incomplete or footling breech: § one or both hips not flexed § foot or knee lies below breech in birth • Face presentation – mentum is reference point • Shoulder presentation – acromion is reference point The Bishop score. . From