OBGYN Main Handout March 2023 PDF

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

TOPNOTCH OBSTETRICS AND GYNECOLOGY MAIN HANDOUT BY DR. FAJUTAGANA AND DR. BANZUELA-CRUZ For inquiries visit www.topnotchboardprep.com.ph or https://www.facebook.com/topnotchmedicalboardprep/ This handout is only valid for the March 2023 PLE batch. This will be rendered obsolete for the next batch since we update our handouts regularly. Gynecologic Infections 71 Benign Gynecologic Lesions 76 IMPORTANT LEGAL INFORMATION Neoplastic Disease of the Upper and Lower Genital Tract 82 Family Planning 89 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: PREGNANCY 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 reproduced, GUIDE QUESTION: 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 Pregnancy and Pregnancy Test Topnotch Medical Board Preparation Incorporated. Any violation and or infringement, https://qrs.ly/taegwwt whether intended or otherwise shall be subject to legal action and prosecution to the full extent guaranteed by law. Pregnancy – product of conception implanted typically in DISCLOSURE uterus or atypically in other locations The handouts/review materials must be treated with utmost confidentiality. It shall be the DEFINITIONS 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 Embryo – from time of fertilization until 8 weeks pregnancy (10 disposed in any manner. Any handout/review material found in the possession of another weeks’ gestational age [GA]) 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 current Fetus – after 8 weeks until time of birth trends and feedback. Please buy all recommended review books and other materials listed 1st trimester –from 12 weeks up to 14 weeks’ GA below. THIS HANDOUT IS NOT FOR SALE! 2nd trimester –from 12–14 until 24–28 weeks’ GA 3rd trimester –from 24–28 weeks until delivery INSTRUCTIONS Infant – between delivery and 1 year of age To scan QR codes on iPhone and iPad o previable – delivered prior to 23–24 weeks 1. Launch the Camera app on your IOS device o preterm – between 24–37 weeks 2. Point it at the QR code you want to scan 3. Look for the notification banner at the top o term – between 37–42 weeks of the screen and tap o postterm – beyond 42 weeks To scan QR codes on Android Nulligravida – a woman who currently is not pregnant and has 1. Install QR code reader from Play Store 2. Launch QR code app on your device never been pregnant 3. Point it at the QR code you want to scan Gravida – a woman who is currently pregnant or has been in the 4. Tap browse website past, irrespective of pregnancy outcome This handout is only valid for the March 2023 batch. Nullipara – a woman who has never completed a pregnancy This will be rendered obsolete for the next batch beyond 20 weeks’ gestation; may not have been or pregnant or since we update our handouts regularly. may have had an abortion or an ectopic pregnancy Primipara – a woman who has been delivered only once of a fetus or OBSTETRICS AND GYNECOLOGY fetuses born alive or dead with an estimated AOG of at least 20 weeks Multipara – a woman who has completed 2 or more pregnancies – MAIN HANDOUT to 20 weeks’ gestation or more Grand multipara – a woman who has had at least 5 births (live Obstetrics Gynecology or stillborn) that are at least 20 weeks age of gestation By Shayne C. By Nina Katrina C. GP-TPAL designation Fajutagana, MD, DPOGS Banzuela-Cruz, MD, FPOGS o Gravidity, Parity, Term, Preterm, Abortus, Living children Contributors: Contributors: § Gravidity – number of times a woman has been pregnant Manuel S. Vidal, Jr, RCh, MD, Shayne C. Fajutagana, MD, DPOGS § Parity – number of pregnancies that led to birth Jian Kenzo O. Leal, MD, Jian Kenzo O. Leal, MD > 20 wks AOG or infant > 500 g Anna Rominia d.P. Cruz, MD Anna Rominia d.P. Cruz, MD § Preterm – born between 24–37 weeks TOPIC PAGE § Abortus – pregnancy losses before 20 weeks Obstetrics Review § Multifetal pregnancy – counts as 1 for TPA, but number Pregnancy 1 of children alive counts separately for L Maternal Adaptations in Pregnancy 2 § Grand multipara – a woman whose parity is ≥ 5 Preconceptional and Prenatal Care 3 Early Pregnancy Complications 5 DATING THE PREGNANCY Ectopic Pregnancy 5 Developmental age (DA) – number of weeks and days since Abortion 6 fertilization (conceptional/embryonic age) Recurrent Pregnancy Loss 7 Gestational age (GA) – age in weeks and days from last Gestational Trophoblastic Diseases 7 menstrual period (LMP); + 2 weeks from DA Labor 9 Estimated date of confinement (EDC) / estimated date of Induction and Augmentation of Labor 14 Dysfunctional Labor 14 delivery (EDD) – computed via Naegele’s rule Delivery 16 o EDC/EDD = LMP – 3 months, + 7 days Obstetric Hemorrhage 18 o 280 days after LMP; 266 days after LMP if via assisted Hypertensive Diseases in Pregnancy 22 reproductive technology Diabetes Mellitus in Pregnancy 23 Ultrasound - rarely off by 7–8% from GA; Should not differ Medical Complications in Pregnancy 24 from LMP dating by Puerperium 34 o >1 week in the first trimester Gynecology Review o >2 weeks in the second trimester Developmental Biology of Sex 35 o >3 weeks in the third trimester Errors in Sexual Determination and Differentiation 37 Auscultation of fetal heart tones by 20 weeks via stethoscope, Reproductive Anatomy 38 or 10 weeks via Doppler ultrasound Reproductive Endocrinology 42 Quickening usually between 16-20 weeks Abnormalities of the Menstrual Cycle 48 Amenorrhea 52 DIAGNOSIS Precocious Puberty 55 Ultrasound Pediatric Gynecology 56 Gestational sac seen at 5 weeks on transvaginal ultrasound or at Hyperandrogenism 56 a beta-hCG of 1,500-2,000 mIU/mL Infertility 59 FH motion seen at 6 weeks or at beta-hCG of 5,000-6,000 Menopause 62 mIU/mL Osteoporosis 64 Urinary Incontinence 65 Pelvic Organ Prolapse 65 Endometriosis 66 TOPNOTCH OBSTETRICS AND GYNECOLOGY MAIN HANDOUT BY DR. FAJUTAGANA AND DR. BANZUELA-CRUZ Page 1 of 92 For inquiries visit www.topnotchboardprep.com.ph or email us at [email protected] This handout is only valid for the March 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-CRUZ For inquiries visit www.topnotchboardprep.com.ph or https://www.facebook.com/topnotchmedicalboardprep/ This handout is only valid for the March 2023 PLE batch. This will be rendered obsolete for the next batch since we update our handouts regularly. Beta-hCG (urine or serum) o reaches nadir at week 24 (24 – 26 weeks in Williams) hormone produced by the placenta o between 24 weeks and term, blood pressure returns to pre- will rise to a peak of 100,000 mIU/mL by 10 weeks of gestation, pregnancy levels decrease throughout the second trimester, and then level off at (Williams) larger cardiac silhouette d/t 1) left and upward approximately 20,000 to 30,000 mIU/mL in the third trimester. displacement, 2) benign pericardial effusion Will turn POSITIVE on urine pregnancy test around the time of RESPIRATORY SYSTEM missed menses Total lung capacity (TLC) decreases 5% because of elevation of diaphragm (~4 cm) Signs Symptoms Tidal volume (TV) increases 30–40% à inspiratory capacity Bluish discoloration of vagina and cervix Amenorrhea (IC) increases (Chadwick sign) Nausea and o increased TV lowers blood PCO2 slightly and paradoxically Softening and cyanosis of the cervix at or vomiting causes physiological dyspnea after 4 wk (Goodell sign) Breast pain expiratory reserve volume (ERV) decreases ~20% Softening of the uterus after 6 wk (Ladin Quickening— (15-20% in Williams) sign) fetal à functional residual capacity (FRC) decreases Softening of the uterine isthmus after 6 movement (↓20-30% in Williams) weeks (Hegar sign) constant respiratory rate with increased TV à minute Breast swelling and tenderness ventilation increases 30–40% à increases alveolar (PAO2) and Development of the linea nigra from arterial (PaO2) oxygen levels, decreases PACO2 and PaCO2 levels umbilicus to pubis Telangiectasias Palmar erythema MATERNAL ADAPTATIONS IN PREGNANCY GUIDE QUESTION: Maternal Physiology https://qrs.ly/rtegwwy Pulmonary changes in pregnancy. From Williams’ Obstetrics, 25th edition. REPRODUCTIVE SYSTEM Green = increased volumes; Red = decreased volumes Uterus Increased Decreased Unchanged Myometrial hypertrophy > hyperplasia Inspiratory Functional Respiratory rate Uterine blood flow increases to 500–750 mL/min capacity (IC) residual capacity Total lung o d/t systemic vascular resistance decrease via progesterone, Tidal volume (FRC) = ERV + RV capacity (FRC + relaxin, and increased refractoriness to AT II, norepinephrine (VT) o Expiratory IC)* Contractions may occur weeks prior to delivery Resting reserve Lung Braxton Hicks True Labor minute volume (ERV) compliance ventilation o Residual Maximum Painless Painful Peak volume (RV) breathing Irregular rhythm, infrequent Rhythmic, frequent expiratory Total lung capacity Cervix does not progress Cervix thins, dilates flow rates Forced or timed capacity* Airway Pulmonary vital capacity Ovaries conductance resistance Corpus luteum of pregnancy – max function between 6–7 wks *unchanged or decreases by < 5% at term o initially produces progesterone à placenta assumes production of progesterone à corpus luteum degrades into GASTROINTESTINAL SYSTEM corpus albicans Morning sickness – nausea and vomiting in 70% of Cervix pregnancies, d/t o elevations in estrogen, progesterone, and hCG. Arias-Stella reaction – loss o may also be due to hypoglycemia à treated with frequent of polarity, pleiomorphism, snacking intraluminal budding 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 Eversion - gastric emptying time increases (unchanged in Williams) and marked proliferation of lower esophageal tone decreases à reflux cervical glands o anesthesia may further increase GET (risk factor for regurgitation and aspiration of gastric contents) decreased esophageal tone may cause ptyalism, or spitting Ferning –arborization of large bowel motility decreases à increased water absorption amniotic fluid due to high and constipation amounts of salt and estrogen pelvic vessels congest d/t gravid uterus à increases abdominal pressure, and with constipation à hemorrhoids Goodell’s sign – cervical softening RENAL SYSTEM CARDIOVASCULAR SYSTEM kidneys increase in size, and ureters dilate (R > L) during cardiac output increases by 30–50% pregnancy à hydronephrosis of pregnancy: risk factor for o maximum output at 20–24 weeks and maintained until delivery pyelonephritis o initially from increased stroke volume à maintained by relaxin mediates vasodilation à glomerular filtration rate increased heart rate à stroke volume returns to near pre- (GFR) increases by 50% early in pregnancy (25-50% starting 2nd pregnancy levels by end of third trimester trimester in Williams) and maintained until delivery à blood urea Systemic vascular resistance decreases à fall in arterial nitrogen and creatinine decrease by ~25% blood pressure RAAS activation à aldosterone increases à sodium resorption o due to elevated progesterone, leading to smooth muscle increases relaxation (and refractoriness to angiotensin II – Williams) o Normonatremia is maintained d/t GFR increase systolic pressure decreases 5–10 mm Hg and diastolic pressure o AVP threshold decreases à serum osmolality decreases by decreases 10–15 mm Hg 10 mOsm/kg TOPNOTCH OBSTETRICS AND GYNECOLOGY MAIN HANDOUT BY DR. FAJUTAGANA AND DR. BANZUELA-CRUZ Page 2 of 92 For inquiries visit www.topnotchboardprep.com.ph or email us at [email protected] This handout is only valid for the March 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-CRUZ For inquiries visit www.topnotchboardprep.com.ph or https://www.facebook.com/topnotchmedicalboardprep/ This handout is only valid for the March 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 1200mg/day in Blueprints and 1000mg/day in Williams to 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 ENDOCRINE SYSTEM mg/day Pregnancy is a hyperestrogenic state, mainly d/t o 400 mcg/day supplementation for all until first trimester o Placenta production, from plasma-borne precursors o 4mg/day for patients with a history of child with NTDs, produced by maternal adrenal glands Since mahilig sila magtanong ng difference in dosages minsan, to add: 4mg/day o Ovaries contributing to lesser degree, from estrogen supplementation with folic acid is also advised for patients with Type 2 Diabetes precursors produced in ovarian theca cells Mellitus (Blueprints and Williams 25th ed) and in patients with seizure disorders o Fetal well-being was correlated with maternal serum estrogen (Williams 26th ed). Increased folic acid supplementation of around 2-4mg/day is levels (e.g. low estrogen levels in fetal death and anencephaly) also recommended for patients with ulcerative colitis to counteract the In addition to estrogen, placenta produces antifolate actions of sulfasalazine. Dr. Anna Rominia Cruz o hCG § α subunit of hCG is identical to α subunits of luteinizing hormone (LH), follicle-stimulating hormone (FSH), and PRECONCEPTIONAL AND PRENATAL CARE thyroid-stimulating hormone (TSH), whereas tβ subunits differ PRECONCEPTIONAL COUNSELING § hCG levels double every ~48 hours during early Folic acid: Begin 0.4 mg/day one month prior to conception for pregnancy à peaks at ~10–12 weeks à declines to all patients; then increase to 4mg/day for patients high risk for 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 varicella-zoster, measles, mumps, rubella, polio, chickenpox, and known 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 in1st trimester, then decreases – Williams) antibody screen RhoGAM at 28 wks o hCG weakly stimulates thyroid à slight increase in T3 and RPR/VDRL Screening for syphilis T4 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 Amniocentesis o Most gain 20–30 lbs during pregnancy (mean: 28.6 lbs in Williams) diagnosis TOPNOTCH OBSTETRICS AND GYNECOLOGY MAIN HANDOUT BY DR. FAJUTAGANA AND DR. BANZUELA-CRUZ Page 3 of 92 For inquiries visit www.topnotchboardprep.com.ph or email us at [email protected] This handout is only valid for the March 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-CRUZ For inquiries visit www.topnotchboardprep.com.ph or https://www.facebook.com/topnotchmedicalboardprep/ This handout is only valid for the March 2023 PLE batch. This will be rendered obsolete for the next batch since we update our handouts regularly. Third Trimester o UTZ for NT + serum PAPP-A and free beta-hCG, or Hematocrit Hct becomes close to its nadir o Blood test to assess relative quantity of fetal cfDNA for GDM screening; 75g OGTT based on chromosomes 13, 18, and 21à cfDNA is detected as early as 5 local CPG weeks; offers ↑ detection rate and ↓ false (+) rate Second trimester BLUEPRINTS: o Screening for MSAFP between 15-18 weeks: ↑MSAFP = ↑risk 50g GLT: check after 1hr for NTD, ↓ in some aneuploidies like Down Syndrome à if ≥ 140 mg/dL*, proceed to do o Between 18-20 weeks: most patients are offered a screening Glucose loading test glucose tolerance test (GTT) UTZ to screen for common fetal abnormalities (Congenital *other institutions use a lower threshold of 130 or Anomaly Scan) 135 mg/dL § Spina bifida: “lemon” sign (concave frontal bones), 2 or more to diagnose as GDM on “banana” sign (a cerebellum that is pulled caudally and 100g OGTT: flattened) FBS 95 mg/dL; 1hr 180; 2hr 155; o Also noted are AFV, placental location, and gestational age 3hr 140 RPR/VDRL --- Third trimester at 36 wks (Williams: 35-37 wks); if o RhoGAM is given at 28 weeks to Rh negative patients GBS culture (+) à IV penicillin once in labor to o Beyond 32-34 weeks, Leopold maneuvers are performed to prevent neonatal GBS infection determine presentation BPP – score of 8 to 10 is reassuring o In breech presentation: external cephalic version (ECV) is Doppler – abnormal findings: offered at 37-38 weeks decrease, absence, or reversal of Ultrasound + other diastolic flow in the umbilical artery tests for fetal well- NST PRENATAL CARE being https://qrs.ly/zsegwx6 At 35-36 wks: confirm fetal presentation; if breech, offer ECV at 37 to 38 weeks ROUTINE PROBLEMS OF PREGNANCY Blueprints 7th edition, Table 1-3: Routine Tests in Prenatal Care Back pain – usually in the 3rd trimester when the patient’s center of gravity has shifted High-Risk Group Specific Test o Management: mild exercise (like stretching), gentle massage, Sickle cell prep for heating pads, Tylenol for mild pain, narcotics or muscle African Americans; Hgb relaxants for severe pain, physical therapy African American, Southeast Asian electrophoresis for Constipation - ↓ bowel motility due to ↑ progesterone à ↑ both water absorption from the GI tract Family history of genetic disorder o Management: increase oral fluid intake, stool (e.g., Prenatal genetics referral Prenatal genetics softener/bulking agents, laxatives (avoided during 3rd hemophilia, sickle cell disease, referral trimester due to risk of preterm labor) fragile X syndrome), maternal age Contractions – patients are advised regarding Braxton Hicks 35 or older at time of EDC contractions; dehydration may increase contractions Prior gestational diabetes, family Dehydration – due to expanded intravascular space and ↑ third history Early GLT of diabetes, Early GLT spacing à intravascular volume status is difficult to maintain Hispanic, Native American, o May cause contractions secondary to cross-reaction of Southeast Asian, obese vasopressin with oxytocin receptors Pregestational diabetes, unsure Edema – compression of IVC and pelvic veins by the uterus à Dating sonogram at dates, Dating sonogram at first visit increased hydrostatic pressure in the lower extremities first visit recurrent miscarriage o Management: elevation of lower extremities above the heart, HPN, renal disease, preGDM, prior BUN, Crea, uric acid, sleeping in a lateral decubitus position preeclampsia, renal transplant, SLE 24h urine collection o Edema of face and hands may indicate preeclampsia PreGDM, prior cardiac disease, HPN ECG GERD – relaxation of the LES, increased transit time in the HbA1c, ophthalmology stomach PreGDM for eye exam o Management: may be started on antacids; multiple small Graves disease TSI meals per day; avoid lying down within 1 hr of eating; H2 All thyroid disease TSH +/- FT4 blockers or PPI may be given PPD+ CXR after 16 wks AOG Hemorrhoids - ↑ venous stasis & IVC compression; Anti Rho, anti-La o Management: topical anesthetic and steroids, prevention of antibodies (can cause constipation with ↑ fluids, ↑ dietary fiber, use of stool SLE fetal complete heart softeners block Pica – cravings for inedible items such as dirt/clay; patient is Blueprints 7th edition, Table 1-4: Initial Screens fin Specific High-Risk Groups advised to maintain adequate nutrition ROUTINE PRENATAL VISITS Round ligament pain – usually late in 2nd trimester or early in The following must be performed and assessed on each follow- 3rd trimester; pain in the adnexa, lower abdomen, or groin; due up prenatal care visit to rapid expansion of the uterus & stretching of ligamentous o Blood pressure: ↓ during 1st & 2nd trimesters, slowly returns attachments; usually self-limited to baseline during the 3rd trimester; ↑BP may be a sign of o Management: warm compress or acetaminophen preeclampsia Urinary frequency – due to ↑ compression of the bladder by o Weight: large weight gain towards the end of pregnancy can the growing uterus; ↑ intravascular volume & GFR leading to ↑ be a sign of fluid retention and preeclampsia urine production o Urine dipstick: presence of protein may be indicative of Varicose veins – may be due to relaxation of the venous smooth preeclampsia, glucose of DM, and leukocyte esterase of UTI muscle and ↑ intravascular pressure § Pregnant women are at an ↑risk for complicated UTI (e.g. o Management: elevation of the lower extremities, use of pyelonephritis) due to ↑urinary stasis from mechanical pressure stockings, referred for surgical therapy if persistent compression of ureters and progesterone-mediated beyond 6 months postpartum smooth muscle relaxation o Measurement of the uterus: between 20 and 34 weeks, fundic height in cm correlates closely with AOG in weeks GUIDE QUESTION: o Auscultation of FHT: after 10-14 weeks, Doppler UTZ is used Prenatal Screening First trimester: early screening for aneuploidy is offered https://qrs.ly/9negwxd between 11-13 weeks either with: TOPNOTCH OBSTETRICS AND GYNECOLOGY MAIN HANDOUT BY DR. FAJUTAGANA AND DR. BANZUELA-CRUZ Page 4 of 92 For inquiries visit www.topnotchboardprep.com.ph or email us at [email protected] This handout is only valid for the March 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-CRUZ For inquiries visit www.topnotchboardprep.com.ph or https://www.facebook.com/topnotchmedicalboardprep/ This handout is only valid for the March 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 TRISOMY 13 GUIDE QUESTION: Depends on Antenatal Fetal Testing MSAFP Decreased Decreased defect https://qrs.ly/aeegwy7 Depends on Beta-hCG Increased Decreased defect Depends on RECOMMENDED Estriol Decreased Decreased BPP SCORE INTERPRETATION defect MANAGEMENT Depends on No intervention Inhibin Increased Decreased Normal, non- defect 10 Repeat test weekly or Edward asphyxiated fetus twice weekly Syndrome Patau 8/10 Other Down (eighteen) Syndrome (Normal AFV) No intervention remarks Syndrome -choroid plexus (CP) -up to 1 yr of Normal, non- 8/8 Repeat testing per cysts life asphyxiated fetus (NST not protocol -up to 2 yrs of life done) 8/10 Chronic fetal ANTEPARTUM FETAL ASSESSMENT (Decreased asphyxia suspected DELIVER AFV) Oxytocin challenge test or contraction stress test (CST): achieve DELIVER if: at least 3 contractions in 10 min; test of uteroplacental function AFV abnormal Satisfactory test: 3 or more contractions lasting 40 seconds or Normal AFV >36 weeks more in a 10-minute period with favorable cervix Possible fetal Positive CST (abnormal): late fetal heart deceleration (due to 6 asphyxia Repeat test ≤6 uteroplacental insufficiency) following ≥50% of contractions o If Repeat test > 6: even if the contraction frequency is < 3 in 10 minutes observe and repeat Negative CST (normal): no late or significant variable per protocol decelerations Repeat testing on the Equivocal-suspicious: intermittent late decelerations or Probable fetal 4 same day significant variable decelerations asphyxia If BPP score ≤6: DELIVER Equivocal-hyperstimulatory: FHR decelerations that occur in Almost certain fetal the presence of contractions more frequent than every 2 0-2 DELIVER asphyxia minutes or lasting > 90 seconds Unsatisfactory: fewer than 3 contractions in 10 minutes or an NEURAL CONTROL OF BPS ACTIVITY uninterpretable trace BPS HYPOXIA Methods: CNS CENTER AOG PARAMETER CASCADE o Oxytocin infusion Cortex- 7.5 – 8.5 Last o Nipple stimulation Fetal Tone Subcortical Area wks affected Nonstress test (NST): test of fetal condition; most antenatal Fetal Cortex-Nuclei 9 weeks 3rd testing units use the NST, beginning at 32 to 34 weeks of Movement gestation in high-risk pregnancies and at 40 to 41 weeks for Fetal Ventral surface 20-21 2nd undelivered patients Breathing of 4th ventricle wks Fetal heart rate acceleration in response to fetal movement as Medulla & Fetal Heart 24-26 sign of fetal health Posterior 1st affected Reactivity weeks o ≥32 weeks: acceleration ≥15 bpm from baseline, lasts for Hypothalamus ≥15 secs, but 5,000 mIU/mL medical means o hemorrhaging, ruptured ectopic pregnancy may reveal o Surgical: dilatation and curettage (D&C) intraabdominal fluid throughout pelvis and abdomen o Medical: prostaglandins ± mifepristone Threatened abortion – followed up for possibility of bleeding MANAGEMENT OF ECTOPIC PREGNANCY o Bed rest and analgesia with acetaminophen Surgical procedure o Rh-negative – RhoGAM to prevent isoimmunization o Exploratory laparotomy – if patient is unstable o Contraceptives if desired o Exploratory laparoscopy – procedure of choice o Salpingostomy – resection of ectopic pregnancy, leaving SECOND-TRIMESTER ABORTIONS fallopian tubes as is Between 12 to 20 weeks o Salpingectomy – resection of ectopic pregnancy with Abnormal chromosomes do NOT often cause late abortions removal of fallopian tubes Infection, maternal uterine or cervical anatomic defects, o Cornual resection – for interstitial pregnancies maternal systemic disease, exposure to fetotoxic agents, and Medical management trauma are associated with late abortions o Methotrexate § Factors for success: small ectopic (< 5 cm, serum β-hCG MANAGEMENT OF SECOND-TRIMESTER ABORTIONS level < 5,000, and w/o fetal heartbeat), reliable ffup At 16–24 weeks, dilatation and evacuation may be done or labor (40 y/o: 10x risk – Williams) McDonald or Shirodkar method), usually at 12–14 weeks’ Nulliparity > multiparity gestation, maintained until 36-38 weeks (37 weeks – history of GTD Williams) o no previous hx: 0.1% o if cervical cerclage fails à abdominal cerclage is offered at o 1 previous molar pregnancy: 1-2% (0.9% - Williams) 12–14 weeks à mode of delivery is by CS o 2 previous molar pregnancies: 16-28% (20% - Williams) o If with previous preterm birth, Diet: low in β-carotene, folic acid, and animal fat IM 17-hydroxyprogesterone offered until 36 weeks AOG other possible associated factors: smoking, infertility, (if without preterm birth but with short cervix, offer spontaneous abortion, blood group A, and a history of OCP use progesterone – Williams) COMPLETE MOLAR PREGNANCY RECURRENT PREGNANCY LOSSES (RPL) PATHOGENESIS recurrent or habitual aborter – three or more consecutive SABs result from the fertilization of an enucleate ovum/empty egg, < 1% of population diagnosed with recurrent pregnancy loss one whose nucleus is missing or nonfunctional, by one normal Risk of SAB: sperm that then replicates itself o after one prior SAB, 20–25% all chromosomes are paternally derived o after two consecutive SABs, 25–30% most common karyotype: diploid 46,XX o after three consecutive SABs, 30–35% placental abnormality: noninvasive trophoblastic proliferation ETIOLOGIES OF RPL à grape-like vesicles Similar to spontaneous abortions 15% RPL due to antiphospholipid antibody (APA) syndrome Complete mole Incomplete mole Features Possible luteal phase defect and insufficient progesterone (90%) (10%) Genetics DIAGNOSIS OF RPL Most common 69,XXY/XXX 46,XX obtain parents’ karyotype and POC karyotypes from each SAB karyotype (or XYY – rare) Chromosomal All paternally examine maternal anatomy Extra paternal set origin derived Screening for metabolic/hematologic disorders + APAS panel Pathology o lupus anticoagulant o factor V Leiden deficiency Coexistent fetus Absent Present o prothrombin G20210A mutation Fetal RBCs Absent Present o ANA o anticardiolipin antibody Chorionic villi Hydropic Few hydropic o Russell viper venom o antithrombin III, protein S, and protein C Minimal/ Trophoblasts Severe hyperplasia obtain serum progesterone in luteal phase of menstrual cycle no hyperplasia cultures from cervix, vagina, endometrium to r/o infection Clinical presentation Associated None Present MANAGEMENT OF RPL embryo Abnormal vaginal patients with chromosomal abnormalities: IVF or Symptoms/signs bleeding Missed abortion preimplantation diagnosis Classic symptomsa Common Rare anatomic abnormalities may not be correctable (for Asherman 50% larger for syndrome à hysteroscopic adhesiolysis; for uterine Uterine size Size = dates dates leiomyomas à excision; for congenital genital tract anomalies, 15-25% disease-specific treatment – Williams) Theca lutein cysts (25-30% - Rare cerclage: for cervical insufficiency Williams) progesterone: for luteal phase defects hCG levels High Slightly elevated low-dose aspirin: for APA syndrome Malignant potential SQ heparin (low molecular weight or unfractionated): for Nonmetastatic 15-25% 2-4% thrombophilia malignant GTD appropriate therapy: for maternal systemic diseases Metastatic 4% - malignant GTD Follow-up GESTATIONAL TROPHOBLASTIC DISEASE 14 weeks 8 weeks Weeks to normal (GTD) hCG (9 weeks – (7 weeks – abnormal proliferation of trophoblastic (placental) tissue Williams) Williams) aHyperemesis gravidarum, early preeclampsia, hyperthyroidism, four major classifications o molar pregnancies (80%) anemia, excessive uterine size Comparison of complete mole vs partial mole. From Blueprints Obstetrics and Gynecology, 7th edition o persistent GTD and invasive moles (10% to 15%) o gestational choriocarcinoma (2% to 5%) o very rare placental site trophoblastic tumors (PSTTs) TOPNOTCH OBSTETRICS AND GYNECOLOGY MAIN HANDOUT BY DR. FAJUTAGANA AND DR. BANZUELA-CRUZ Page 7 of 92 For inquiries visit www.topnotchboardprep.com.ph or email us at [email protected] This handout is only valid for the March 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-CRUZ For inquiries visit www.topnotchboardprep.com.ph or https://www.facebook.com/topnotchmedicalboardprep/ This handout is only valid for the March 2023 PLE batch. This will be rendered obsolete for the next batch since we update our handouts regularly. CLINICAL PRESENTATION TREATMENT OF PARTIAL MOLAR PREGNANCY History suction D&C irregular, heavy vaginal bleeding in the setting of a positive PROGNOSIS pregnancy test (97%): most common presenting symptom o caused by separation of the tumor from the underlying 6 Labs and imaging weeks following pregnancy hCG levels > >100,000 mIU/mL staging system: Revised FIGO Staging System UTZ: snowstorm pattern d/t chorionic villi swelling extreme sensitivity to chemotherapy theca lutein cysts >6 cm o low-risk disease: single- agent chemotherapy definitive diagnosis: histopathological exam of the uterine tissue o high-risk disease: combination chemotherapy. o surgical intervention: for high-risk patients or for PSTT TREATMENT OF COMPLETE MOLAR PREGNANCY FIGO staging of malignant GTD suction D&C: definitive treatment Stage I Confined to the uterus o hysterectomy if non-desirous of future pregnancies Stage II Metastases to the pelvis uterotonics to minimize blood loos Stage III Metastases to the lung (with or without pelvic RhoGAM for Rh-negative women metastases) adjunctive anti-hypertensives and beta blockers Stage IV Distant metastases (with or without lung PROGNOSIS metastases) prognosis is excellent: persistent postmolar GTD: 6-32% in Revised FIGO scoring system for GTDa complete moles, 100,000 mIU/mL 0 o ovaries >6 cm (theca lutein cysts > 6 cm – Williams) No. of metastases 0 1-4 5-8 >8 o large uterine sizes (14 to 16 weeks) Splee Lung, o may give chemoprophylaxis: methotrexate + folinic n, Brain, Sites of metastases vagin GI tract acid/dactinomycin) kidne liver a y Largest tumor size, PARTIAL MOLAR PREGNANCY including uterine 3-4 5 PATHOGENESIS tumor (cm) normal ovum is fertilized by two sperm simultaneously Prior number of Single Multi- triploid karyotype with 69 chromosomes, two sets are failed chemotx drugs agent agent paternally derived a The total score is obtained by adding the individual scores for most common karyotype is 69,XXY (80%) each prognostic factor. 0-6 = low risk, ≥7 = high risk placenta: focal hydropic villi and trophoblastic hyperplasia Revised FIGO Staging of GTD. From Blueprints Obstetrics and Gynecology, 7th edition primarily of the cytotrophoblast PERSISTENT POSTMOLAR GTD AND INVASIVE MOLES notable d/t presence of embryo 1 in 15,000 pregnancies often misdiagnosed as spontaneous or missed abortions hydropic chorionic villi and trophoblast proliferation into much lower malignant potential than complete moles the myometrium CLINICAL PRESENTATION rarely metastasize and are capable of spontaneous regression delayed menses and (+) urine PT Risk factors vaginal bleeding from miscarriage or incomplete abortion in late o hCG > 100,000 mIU/mL first trimester or early second trimester (90%) o Uterine size >14–16 wk physical examination typically normal d/t slightly elevated hCG, o Theca lutein cysts >6cm (+) fetal heart sounds, uterine size small for gestational age o Coexistent fetus UTZ: fetus with cardiac activity, congenital malformations, DIAGNOSIS and/or IUGR Plateau/rise in hCG levels, excessive uterine size, large theca “Swiss-cheese” appearance lutein cysts definitive diagnosis: histopathological exam of the uterine tissue UTZ: invasion of an intrauterine mass into the myometrium Doppler: high vascular flow TOPNOTCH OBSTETRICS AND GYNECOLOGY MAIN HANDOUT BY DR. FAJUTAGANA AND DR. BANZUELA-CRUZ Page 8 of 92 For inquiries visit www.topnotchboardprep.com.ph or email us at [email protected] This handout is only valid for the March 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-CRUZ For inquiries visit www.topnotchboardprep.com.ph or https://www.facebook.com/topnotchmedicalboardprep/ This handout is only valid for the March 2023 PLE batch. This will be rendered obsolete for the next batch since we update our handouts regularly. MANAGEMENT MANAGEMENT Avoid repeat D&C Similar treatment for low-risk and high-risk patients Single-agent chemotherapy (MTX or dactinomycin) cure rate: 95% to 100% if low-risk, 50-70% if high-risk If with metastases: single agent for low risk, multiagent for high risk Similar follow-up and surveillance Similar follow up and surveillance with GTD PLACENTAL SITE TROPHOBLASTIC TUMORS (PSTT) GESTATIONAL CHORIOCARCINOMA extremely rare tumors from invasion of the myometrium 1 in 20,000 to 40,000; common in Asian or African descent and vasculature from intermediate cytotrophoblasts of the malignant necrotizing tumor: invasion of uterine wall and placental implantation site vasculature à necrosis and potentially severe hemorrhage absence of villi, intermediate trophoblasts, and (+) hPL (vs “the great imitator” syncytiotrophoblasts, cytotrophoblasts, (+) hCG from other pure epithelial tumor: sheets of anaplastic cytotrophoblasts and types of malignant GTD) syncytiotrophoblasts in the absence of chorionic villi rarely metastasize hematogenous spread DIAGNOSIS rate of development: most common symptom of PSTT: persistent irregular vaginal o 50% after a complete molar pregnancy bleeding o 25% after a normal-term pregnancy o 25% after miscarriage, abortion, or ectopic pregnancy Labs: (+) hPL UTZ: uterine mass, less hemorrhage than seen in gestational DIAGNOSIS choriocarcinomas late postpartum bleeding, or abnormal uterine bleeding years TREATMENT after an antecedent pregnancy symptoms of metastatic disease generally not sensitive to chemotherapy Labs: elevated hCG levels hysterectomy is the treatment of choice for PSTT Imaging: look for metastases (lung CXR, brain/chest/abdominal multiagent chemotherapy to prevent recurrence CT/MRI) 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 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. TOPNOTCH OBSTETRICS AND GYNECOLOGY MAIN HANDOUT BY DR. FAJUTAGANA AND DR. BANZUELA-CRUZ Page 9 of 92 For inquiries visit www.topnotchboardprep.com.ph or email us at [email protected] This handout is only valid for the March 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-CRUZ For inquiries visit www.topnotchboardprep.com.ph or https://www.facebook.com/topnotchmedicalboardprep/ This handout is only valid for the March 2023 PLE batch. This will be rendered obsolete for the next batch since we update our handouts regularly. Performing the pelvimetry. From TeachMeAnatomy and Williams’ Obstetrics. Diagonals of the pelvic exam o True conjugate: anteroposterior diameter from uppermost GUIDE QUESTION: margin of symphysis pubis to sacral promontory Diagnosis of o Obstetrical conjugate: shortest distance between sacral Ruptured Membranes promontory and symphysis pubis (typically ≥10 cm, but