OB/GYN: Shelf Review Notes
Table of Contents
Obstetrics.......................................................................................................................................................................................................2
Normal pregnancy / Prenatal care............................................................................................................................................................2
Early Pregnancy Complications..................................................................................................................................................................4
Prenatal Screening...........................................................................................................................................................................................5
Normal L&D........................................................................................................................................................................................................7
Antepartum Hemorrhage..............................................................................................................................................................................9
L&D Complications........................................................................................................................................................................................10
Fetal complications of pregnancy...........................................................................................................................................................11
Hypertension & Pregnancy........................................................................................................................................................................13
Diabetes in pregnancy.................................................................................................................................................................................14
Infectious Diseases in Pregnancy............................................................................................................................................................15
Infections that can affect the fetus (TORCH, etc)........................................................................................................................16
Other Medical Complications of Pregnancy........................................................................................................................................17
Postpartum care / complications............................................................................................................................................................19
Gynecology................................................................................................................................................................................................21
Benign Lower Genital Tract Disorders..................................................................................................................................................21
Benign Upper Genital Tract Disorders..................................................................................................................................................23
Endometriosis / Adenomyosis.................................................................................................................................................................24
Lower reproductive tract infections......................................................................................................................................................25
Upper reproductive tract infections.......................................................................................................................................................27
Pelvic organ prolapse...................................................................................................................................................................................28
Urinary Incontinence...................................................................................................................................................................................29
Puberty...............................................................................................................................................................................................................30
Menopause.......................................................................................................................................................................................................30
Amenorrhea.....................................................................................................................................................................................................31
Menstrual cycle abnormalities.................................................................................................................................................................32
Hirsutism & Virilization..............................................................................................................................................................................33
Contraception / Sterilization....................................................................................................................................................................34
Elective Termination of Pregnancy........................................................................................................................................................35
Infertility and Assisted Reproductive Technologies........................................................................................................................36
Vulvar / Vaginal Neoplasia........................................................................................................................................................................38
Cervical Neoplasia / Cancer.......................................................................................................................................................................39
Endometrial Cancer......................................................................................................................................................................................40
Ovarian Tumors..............................................................................................................................................................................................41
Gestational Trophoblastic Disease..........................................................................................................................................................43
Breast Disease & Breast Cancer...............................................................................................................................................................45
Benign breast disease............................................................................................................................................................................45
Malignant breast disease:.....................................................................................................................................................................46
Other random stuff........................................................................................................................................................................................47
, Obstetrics
Normal pregnancy / Prenatal care
● Urine preg test: positive around time of missed cycle.
○ Gestational sac on transvag U/S @ b-hCG of 1500-2000 (5wks)
○ Fetal heart @ b-hCG of 5-6000 (6wks)
● TPAL: remember abortus = < 20 wk losses (TAB/SAB/ectopic)
Dates & stuff
● 0-8wks = embryo, 8wks-birth = fetus.
● 0 to 12-14 wks = 1st tri, 12-14 to 24-28 = 2nd tri, > 24-28 wks = 3rd tri.
● Viability @ 24 wks or greater, Term @ 37 to 42 wks, Postterm @ > 42 wks
● Date with U/S; take LMP if within 1 wk in 1st tri, 2 wks in 2nd, 3 wks in 3rd. Early = more accurate
● Do fundal ht > 20 wks, Doppler for fetal heart beat after 10-14 wks
● Should feel quickening ~ 16-20 wks
Physiology of pregnancy:
● CV:
○ CO increases 30-50%, most in 1st trimester, SV first, then HR.
○ SVR decreases (BP falls) 2/2 progesterone, nadir @ wk 24 (then volume increases catch up)
● Pulm: Tidal volume increases (bigger breaths, horizontal expansion), TLC decreases (diaphragm
elevated), respiratory rate stays the same, but minute ventilation increases (2/2 tidal volume increase),
○ so PaO2 increases, PaCO2 decreases (30 mm @ 20 wks), helping baby get oxygen
● GI:
○ N/V in first trimester, should resolve by 14-16 wks, otherwise consider hyperemesis gravidarum
(lose > 5% wt, go into ketosis), encourage frequent snacking.
○ Prolonged gastric emptying / GES tone lowered 2/2 progseterone = reflux
○ Decreased motility in large bowel = more water absorbed = constipation
● Renal:
○ kidneys bigger, ureters dilate → pyelonephritis
○ GFR increases (50%) early, 2/2 increased plasma volume, so BUN and Cr drop
● Heme:
○ Plasma volume increases 50% , RBC mass increases 20-30%, dilutional anemia
○ WBC increases to ~10.5, plts only drop a little (should be > 100)
○ Hypercoagulable state (more factors VII-X, fibrinogen) although INR/PTT stay the same
● Decreased oncotic pressure! Tocolysis with terbutaline can cause pulmonary edema (already
prediposed from decreased oncotic pressure)
● Endocrine: lots of estrogen from adrenal precursors converted in placenta.
○ hCG, LH, FSH, TSH all have same alpha subunit. hCG maintaisn corpus luteum in early pregnancy.
○ hPL ensures nutrient supply, diabetogenic
○ PRL increased during pregnancy
○ TBG increased by estrogen, so total T3/T4 increase but fT4 stays the same
, ○ Glucosuria is common in pregnancy!
Nutritional stuff
● Folate stuff:
○ 4mg/day folate if previous hx NTD, on carbamazepine or valproate, or pregestational DM
○ Otherwise 0.4-0.8 mg/day for all other women of “reproductive potential”
● Weight gain in pregnancy: don’t ever want to lose weight, just gain less if overwt.
○ Underweight (BMI < 18.5) → 28-40 lbs.
○ Normal wt (BMI 18.5-24.9) → 25-35 lbs.
○ Overweight (BMI 25-30) → 15-20 lbs
○ Obese (BMI > 30) → 11-20 lbs
○ Add 300kcal/day in pregnancy, 500kcal/day in breastfeeding.
Antenatal screening:
● First trimester (NT/ nasal bone on U/S and PAPP-A/free b-hCG bloodwork) @ 11-13 wks
○ Can do CVS around 9-12 wks if concerns, > 1:200 risk miscarriage
● Quad screen (MSAFP, b-hCG, estriol, inhibin A) @ 18-20 wks
○ Can do amnio after ~ 15wks if concerns, 1:200ish risk miscarriage
● Anatomy screening U/S @ 18-20 wks also.
● Glucose loading test @ 27-29 wks (earlier if multiples / hx).
○ GLT: 50g challenge, check in 1 hr, if 140 or more, go to OGTT
○ OGTT: 100g challenge, measure fasting and at 1,2,3h. Should be less than 95/180/155/140.
○ 6wk PP: 75g challenge, measure in 2 hrs.
BPP: 0 or 2 scoring for AFI, fetal tone, fetal activity, breathing movements, NST
● U/S with cord doppler if worried for placental insufficiency (decrease / reversal of flow)
NST: in 20 min, need 2 accels that are 15 bpm above baseline x 15 seconds
● U/S if worrisome.
Contraction stress test: get 3 ctx in 10m, analyse FHR
Fetal lung maturity:
● L/S ratio > 2 = RDS is rare
● also use phosphatidylglycerol, saturated phosphatydal choline, surfactant / albumin ratio, lamellar body ct
Routine pregnancy problems
● Lower back pain → stretching, gentle excercise, Tylenol, massage, heating pads
● Constipation → drink water, colace. Avoid laxatives in 3rd tri (increased PTL?)
● Contractions → if braxton-hicks, drink lots of water (vasopression → oxytocin receptors), reassure.
○ If q10m or less, think PTL & bring in to check cervix. If no change, reassuring.
● Edema (compressed IVC) → elevate legs, sleep on side if helps, worry for PEC if hands/face
● GERD → many small meals, start antacids, don’t lay down right after eating. H2 blockers / PPI if persists.
● Hemorrhoids: 2/2 IVC compression → topical anesthetics, steroids, prevent constipation
● Pica → tell pt to stop, get good nutrition instead. If toxic substance, call poison control or toxicology
consult
● Round ligament pain: late in 2nd tri / early in 3rd, adnexa / lower abdomen / shoots to labia. Warm
compresses or acetaminophen.
, ● Urinary frequency: check urine, keep up PO hydration
● Varicose veins (LE or vulva) → elevate, use compression stockings.
Early Pregnancy Complications
Ectopic:
● Unilateral pelvic / lower abd pain, vaginal bleeding, SGA uterus. If ruptured, can see peritoneal signs
● Get transvag U/S & bHCG: IUP can be seen on transvag u/s with bHCG of 2000 or so
○ if less and no IUP seen and patient stable, repeat bHCG in 48 hrs (should double, but won’t if
ectopic 2/2 poorly implanted placenta)
○ If not stable / peritoneal signs of rupture, stabilize (ABC / fluids / blood products / pressors if
needed), then do laparoscopy if stabilized, laparotomy if crashing.
● Methotrexate criteria:
○ hemodynamic stability, nonruptured ectopic pregnancy,
○ size of ectopic mass <4 cm without a fetal heart rate or <3.5 cm in the presence of a fetal heart rate,
○ normal liver enzymes and renal function, normal white cell count, and
○ the ability of the patient to follow up rapidly (reliable transportation, etc.,) if her condition changes
○ F/u with bHCG (should be 10-15% drop after 4-7d after treatment), if not, 2nd dose MTX
SAB: before 20 wks (later = stillbirth)
● Complete if all POC out before 20wks, Incomplete if some but not all POC out by 20 wks, Inevitable if no
POC but VB/ cervical dilation, Threatened if any VB before 20 wks w/o POC expulsion or cervical diation,
Missed if embryo/fetus dies < 20 wks with retention of all POC.
● 1st trimester: think chromosomes.
○ Stabilize pt if hypotensive, then check cervix / get bHCG quant, CBC, type & screen, U/S, r/o ectopic
○ If complete, can follow (if no signs of infection), send tissue to path
○ If incomplete, inevitable, or missed can finish on own, or do D&C, or give misoprostol
(prostaglandin) to induce cervical dilation / ctx.
○ If threatened, follow up as o/p, pelvic rest.
○ If Rh negative, get RhoGAM
● 2nd trimester: think infection, maternal dz, trauma, cervical defects like insufficiency (late 2nd tri)
○ If incomplete / missed, can finish on own, induce with high dose oxytocin / prostaglandins, or
go to D&E (need to use laminaria first)
○ Need to r/o PTL (painful ctx → cervical change) / incompetent cervix (painless cervical change)
■ incompetent cervix: 2/2 surgery, trauma, ?DES, or idiopathic. Can do cerclage, both if hx
in previous pregnancy or in emergency. If elective, place at 14 wks (2/2 chance of 1st
trimester sab). Consider betamethasone / tocolysis if close to 24 wks.
● Habitual aborters (3+ consecutive SABs)
○ W/U:
■ HSG for maternal anatomy,
■ karyotypes for translocations (parents / POC),
■ screen for hypothyroidism / DM / hypercoagulability (Factor V Leiden / prothrombin
G20210A, antiphospholipid ab, Protein C/S),
■ r/o infection (cx cervix, vagina, endometrium)
○ Antiphospholipid antibodies
■ Consider if hx DVT, prolonged DRVVT, anticardiolipin abs, recurrent first trimester losses.
Table of Contents
Obstetrics.......................................................................................................................................................................................................2
Normal pregnancy / Prenatal care............................................................................................................................................................2
Early Pregnancy Complications..................................................................................................................................................................4
Prenatal Screening...........................................................................................................................................................................................5
Normal L&D........................................................................................................................................................................................................7
Antepartum Hemorrhage..............................................................................................................................................................................9
L&D Complications........................................................................................................................................................................................10
Fetal complications of pregnancy...........................................................................................................................................................11
Hypertension & Pregnancy........................................................................................................................................................................13
Diabetes in pregnancy.................................................................................................................................................................................14
Infectious Diseases in Pregnancy............................................................................................................................................................15
Infections that can affect the fetus (TORCH, etc)........................................................................................................................16
Other Medical Complications of Pregnancy........................................................................................................................................17
Postpartum care / complications............................................................................................................................................................19
Gynecology................................................................................................................................................................................................21
Benign Lower Genital Tract Disorders..................................................................................................................................................21
Benign Upper Genital Tract Disorders..................................................................................................................................................23
Endometriosis / Adenomyosis.................................................................................................................................................................24
Lower reproductive tract infections......................................................................................................................................................25
Upper reproductive tract infections.......................................................................................................................................................27
Pelvic organ prolapse...................................................................................................................................................................................28
Urinary Incontinence...................................................................................................................................................................................29
Puberty...............................................................................................................................................................................................................30
Menopause.......................................................................................................................................................................................................30
Amenorrhea.....................................................................................................................................................................................................31
Menstrual cycle abnormalities.................................................................................................................................................................32
Hirsutism & Virilization..............................................................................................................................................................................33
Contraception / Sterilization....................................................................................................................................................................34
Elective Termination of Pregnancy........................................................................................................................................................35
Infertility and Assisted Reproductive Technologies........................................................................................................................36
Vulvar / Vaginal Neoplasia........................................................................................................................................................................38
Cervical Neoplasia / Cancer.......................................................................................................................................................................39
Endometrial Cancer......................................................................................................................................................................................40
Ovarian Tumors..............................................................................................................................................................................................41
Gestational Trophoblastic Disease..........................................................................................................................................................43
Breast Disease & Breast Cancer...............................................................................................................................................................45
Benign breast disease............................................................................................................................................................................45
Malignant breast disease:.....................................................................................................................................................................46
Other random stuff........................................................................................................................................................................................47
, Obstetrics
Normal pregnancy / Prenatal care
● Urine preg test: positive around time of missed cycle.
○ Gestational sac on transvag U/S @ b-hCG of 1500-2000 (5wks)
○ Fetal heart @ b-hCG of 5-6000 (6wks)
● TPAL: remember abortus = < 20 wk losses (TAB/SAB/ectopic)
Dates & stuff
● 0-8wks = embryo, 8wks-birth = fetus.
● 0 to 12-14 wks = 1st tri, 12-14 to 24-28 = 2nd tri, > 24-28 wks = 3rd tri.
● Viability @ 24 wks or greater, Term @ 37 to 42 wks, Postterm @ > 42 wks
● Date with U/S; take LMP if within 1 wk in 1st tri, 2 wks in 2nd, 3 wks in 3rd. Early = more accurate
● Do fundal ht > 20 wks, Doppler for fetal heart beat after 10-14 wks
● Should feel quickening ~ 16-20 wks
Physiology of pregnancy:
● CV:
○ CO increases 30-50%, most in 1st trimester, SV first, then HR.
○ SVR decreases (BP falls) 2/2 progesterone, nadir @ wk 24 (then volume increases catch up)
● Pulm: Tidal volume increases (bigger breaths, horizontal expansion), TLC decreases (diaphragm
elevated), respiratory rate stays the same, but minute ventilation increases (2/2 tidal volume increase),
○ so PaO2 increases, PaCO2 decreases (30 mm @ 20 wks), helping baby get oxygen
● GI:
○ N/V in first trimester, should resolve by 14-16 wks, otherwise consider hyperemesis gravidarum
(lose > 5% wt, go into ketosis), encourage frequent snacking.
○ Prolonged gastric emptying / GES tone lowered 2/2 progseterone = reflux
○ Decreased motility in large bowel = more water absorbed = constipation
● Renal:
○ kidneys bigger, ureters dilate → pyelonephritis
○ GFR increases (50%) early, 2/2 increased plasma volume, so BUN and Cr drop
● Heme:
○ Plasma volume increases 50% , RBC mass increases 20-30%, dilutional anemia
○ WBC increases to ~10.5, plts only drop a little (should be > 100)
○ Hypercoagulable state (more factors VII-X, fibrinogen) although INR/PTT stay the same
● Decreased oncotic pressure! Tocolysis with terbutaline can cause pulmonary edema (already
prediposed from decreased oncotic pressure)
● Endocrine: lots of estrogen from adrenal precursors converted in placenta.
○ hCG, LH, FSH, TSH all have same alpha subunit. hCG maintaisn corpus luteum in early pregnancy.
○ hPL ensures nutrient supply, diabetogenic
○ PRL increased during pregnancy
○ TBG increased by estrogen, so total T3/T4 increase but fT4 stays the same
, ○ Glucosuria is common in pregnancy!
Nutritional stuff
● Folate stuff:
○ 4mg/day folate if previous hx NTD, on carbamazepine or valproate, or pregestational DM
○ Otherwise 0.4-0.8 mg/day for all other women of “reproductive potential”
● Weight gain in pregnancy: don’t ever want to lose weight, just gain less if overwt.
○ Underweight (BMI < 18.5) → 28-40 lbs.
○ Normal wt (BMI 18.5-24.9) → 25-35 lbs.
○ Overweight (BMI 25-30) → 15-20 lbs
○ Obese (BMI > 30) → 11-20 lbs
○ Add 300kcal/day in pregnancy, 500kcal/day in breastfeeding.
Antenatal screening:
● First trimester (NT/ nasal bone on U/S and PAPP-A/free b-hCG bloodwork) @ 11-13 wks
○ Can do CVS around 9-12 wks if concerns, > 1:200 risk miscarriage
● Quad screen (MSAFP, b-hCG, estriol, inhibin A) @ 18-20 wks
○ Can do amnio after ~ 15wks if concerns, 1:200ish risk miscarriage
● Anatomy screening U/S @ 18-20 wks also.
● Glucose loading test @ 27-29 wks (earlier if multiples / hx).
○ GLT: 50g challenge, check in 1 hr, if 140 or more, go to OGTT
○ OGTT: 100g challenge, measure fasting and at 1,2,3h. Should be less than 95/180/155/140.
○ 6wk PP: 75g challenge, measure in 2 hrs.
BPP: 0 or 2 scoring for AFI, fetal tone, fetal activity, breathing movements, NST
● U/S with cord doppler if worried for placental insufficiency (decrease / reversal of flow)
NST: in 20 min, need 2 accels that are 15 bpm above baseline x 15 seconds
● U/S if worrisome.
Contraction stress test: get 3 ctx in 10m, analyse FHR
Fetal lung maturity:
● L/S ratio > 2 = RDS is rare
● also use phosphatidylglycerol, saturated phosphatydal choline, surfactant / albumin ratio, lamellar body ct
Routine pregnancy problems
● Lower back pain → stretching, gentle excercise, Tylenol, massage, heating pads
● Constipation → drink water, colace. Avoid laxatives in 3rd tri (increased PTL?)
● Contractions → if braxton-hicks, drink lots of water (vasopression → oxytocin receptors), reassure.
○ If q10m or less, think PTL & bring in to check cervix. If no change, reassuring.
● Edema (compressed IVC) → elevate legs, sleep on side if helps, worry for PEC if hands/face
● GERD → many small meals, start antacids, don’t lay down right after eating. H2 blockers / PPI if persists.
● Hemorrhoids: 2/2 IVC compression → topical anesthetics, steroids, prevent constipation
● Pica → tell pt to stop, get good nutrition instead. If toxic substance, call poison control or toxicology
consult
● Round ligament pain: late in 2nd tri / early in 3rd, adnexa / lower abdomen / shoots to labia. Warm
compresses or acetaminophen.
, ● Urinary frequency: check urine, keep up PO hydration
● Varicose veins (LE or vulva) → elevate, use compression stockings.
Early Pregnancy Complications
Ectopic:
● Unilateral pelvic / lower abd pain, vaginal bleeding, SGA uterus. If ruptured, can see peritoneal signs
● Get transvag U/S & bHCG: IUP can be seen on transvag u/s with bHCG of 2000 or so
○ if less and no IUP seen and patient stable, repeat bHCG in 48 hrs (should double, but won’t if
ectopic 2/2 poorly implanted placenta)
○ If not stable / peritoneal signs of rupture, stabilize (ABC / fluids / blood products / pressors if
needed), then do laparoscopy if stabilized, laparotomy if crashing.
● Methotrexate criteria:
○ hemodynamic stability, nonruptured ectopic pregnancy,
○ size of ectopic mass <4 cm without a fetal heart rate or <3.5 cm in the presence of a fetal heart rate,
○ normal liver enzymes and renal function, normal white cell count, and
○ the ability of the patient to follow up rapidly (reliable transportation, etc.,) if her condition changes
○ F/u with bHCG (should be 10-15% drop after 4-7d after treatment), if not, 2nd dose MTX
SAB: before 20 wks (later = stillbirth)
● Complete if all POC out before 20wks, Incomplete if some but not all POC out by 20 wks, Inevitable if no
POC but VB/ cervical dilation, Threatened if any VB before 20 wks w/o POC expulsion or cervical diation,
Missed if embryo/fetus dies < 20 wks with retention of all POC.
● 1st trimester: think chromosomes.
○ Stabilize pt if hypotensive, then check cervix / get bHCG quant, CBC, type & screen, U/S, r/o ectopic
○ If complete, can follow (if no signs of infection), send tissue to path
○ If incomplete, inevitable, or missed can finish on own, or do D&C, or give misoprostol
(prostaglandin) to induce cervical dilation / ctx.
○ If threatened, follow up as o/p, pelvic rest.
○ If Rh negative, get RhoGAM
● 2nd trimester: think infection, maternal dz, trauma, cervical defects like insufficiency (late 2nd tri)
○ If incomplete / missed, can finish on own, induce with high dose oxytocin / prostaglandins, or
go to D&E (need to use laminaria first)
○ Need to r/o PTL (painful ctx → cervical change) / incompetent cervix (painless cervical change)
■ incompetent cervix: 2/2 surgery, trauma, ?DES, or idiopathic. Can do cerclage, both if hx
in previous pregnancy or in emergency. If elective, place at 14 wks (2/2 chance of 1st
trimester sab). Consider betamethasone / tocolysis if close to 24 wks.
● Habitual aborters (3+ consecutive SABs)
○ W/U:
■ HSG for maternal anatomy,
■ karyotypes for translocations (parents / POC),
■ screen for hypothyroidism / DM / hypercoagulability (Factor V Leiden / prothrombin
G20210A, antiphospholipid ab, Protein C/S),
■ r/o infection (cx cervix, vagina, endometrium)
○ Antiphospholipid antibodies
■ Consider if hx DVT, prolonged DRVVT, anticardiolipin abs, recurrent first trimester losses.
