GYNECOLOGY

 The menstrual cycle is notoriously variable, but lasts an average of 28 days. It is divided into
2 phases
I. Follicular phase, occurs before ovulation. 
II. Secretory (luteal) phase, which occurs after ovulation. 
The follicular phase begins with menstruation (day 1). The duration of menses is also
variable, but lasts on the average between 3 - 5 days. At the same time, under the influence
of FSH, primordial follicles in the ovarian capsule begin to grow, with one follicle
outgrowing the rest to form the dominant follicle. This mature ovarian follicle (graafian
follicle) then begins to produce higher and higher levels of estrogen. Luteinizing hormone
(LH) which is initially suppressed by low levels of estrogen then becomes stimulated once
estrogen levels surpass a certain threshold (36 - 48 hours before ovulation). This causes an
LH burst and results in follicular rupture and ovulation, which occurs about 9 hours after
the LH peak. 
The ruptured follicle then develops into a corpus luteum. The corpus luteum then goes on
to secrete progesterone which thickens and vascularizes the endometrium during the
secretory phase. If pregnancy occur, the corpus luteum is maintained and continues
secreting progesterone, suppressing menstruation. However, the absence of pregnancy
causes regression of the corpus luteum. Reduced progesterone thins the endometrium,
eventually culminating in menses. 
The secretory (luteal) phase is constant across all women, lasting approximately 14 days.
Therefore, a shorter menstrual cycle is governed by the duration of the follicular phase.
This means that higher initial levels of FSH would result in earlier ovulation, and an overall
shorter menstrual cycle.
 Selective serotonin receptor inhibitors (SSRIs) such as paroxetine and fluoxetine have been
associated with increased breast cancer recurrence and/or death among women using
tamoxifen, and it should be stopped.
 Epithelium that stains white after the application of acetic acid during colposcopy indicates
cervical dysplasia.
 Cervical Neoplasia: Premalignant lesions of the cervix, most (65%) of the lesions will
spontaneously regress, others (20%) remain static, only minority (15%) progress to cervical
cancer. The most common cause of cervical cancer is HPV 16 and 18
Pap smear (cytology): the best screening test
ASC-US => Repeat in 12m.
LSIL (21-24) => Repeat in 12m.
LSIL (>25) => Colposcopy
ASC-H/HSIL => Colposcopy
Squamos cell carcinoma => invasive cancer
Frequency of Pap smear screenings:
Age 21-29 => every 3 years
Age 30–65 => every 3 years or every 5 years with HPV testing (recommended)
 HIV positive women => every 6 months after diagnosis for the first year, and then annually.
 When the biopsy (histology) is complete it is compared with the level of Pap smear
Pap ---- Histology
LSIL => CIN1
HSIL => CIN2 or CIN3
If the pap smear is worse the histology, then CONE BIOPSY is performed.
Other indications for CONE BIOPSY are:
I. Abnormal histology
II. Lesion entering the endocervical canal
III. microinvasive carcinoma
IV. unsatisfactory on colposcopy
Colposcopy (histology): CIN (Cervical Intraepithelial Neoplasia)
CIN1 => follow up Pap smear in 6 months and 12 months/ colposcopy and Pap in 12
months OR HPV DNA test in 12 months.
CIN1,2,3 => Cryotherapy/ Laser vaporization/ LEEP/ Conization
CIN 2,3 => Hysterectomy is acceptable with recurrent CIN 2,3 only
CERVICAL CANCER => treat as follows
 Cervical Cancer: POSTCOITAL VAGINAL BLEEDING clinical staging
Tx.
Ia1/Ia2 => Total (simple) hysterectomy
IB-IIA => radical hysterectomy+ pelvic paraaortic lymphadenectomy + peritoneal washing
(premenopausal)/ Pelvic radiation (postmenopausal)
IIB/III/IV => radiation+ chemotherapy
 Endometrial Hyperplasia: POSTMENOPAUSAL VAGINAL BLEEDING
The most common gynecologic malignancy
Dx. Endometrial biopsy
Type I: are more common (85%) IN YOUNG WOMEN PREMENOPAUSAL are associated with
either endogenous or exogenous unopposed estrogen exposure and usually consist of a
low-grade or well-differentiated tumor with a favorable prognosis. Tx. PROGESTERONE and
follow up endometrial biopsy
Type II: IN POSTMENOPAUSAL WOMEN independent of estrogen
Tx.
Simple/ complex hyperplasia without atypia => progesterone
Simple/ complex hyperplasia with atypia => Desire kids =>progesterone
=> No kids desired => TAH+BSO
Endometria carcinoma => TAH+ BSO+ pelvic and paraaortic lymphadenectomy
 Ovarian Cancer: ADNEXAL MASS + ASCITES

 Granulosa-Theca Cell: is a sex cord-stromal ovarian cancer that is associated with find
endometrial hyperplasia and vaginal bleeding concomitantly in up to 50% of these patients.
Microscopically:
Grooved (“coffee bean”) nuclei
Call-Exner bodies
Theca cells
 Endometriosis: DYSPARENUNIA DYSMENORREA INFERTILITY
is a disorder where abnormal growth of endometrium-like tissue are present in locations
outside the uterus. The most common site of disease is the ovary, cul-de-sac, anterior and,
broad ligament, uterosacral ligaments, uterus, fallopian tubes, sigmoid colon, appendix,
and round ligaments. The bowel, bladder, ureters, lung, brain and kidney may also harbour
endometrial deposits. 
Sx. infertility, dysmenorrhea and dyspareunia. pelvic or low back pain beginning
premenstrually and subsides after menses begins, tender nodules in the posterior vaginal
fornix, pain on uterine motion.
Dx. Laparoscopy is the gold standard.
Tx.
I. Medically: Danazol (side effects: acne, oily skin, deep voice, weight gain, hirsutism,
masculinization), (MOA: Inhibit gonadotropin release which leads to inhibition of
luteinizing hormone (LH) and follicle-stimulating hormone (FSH) => low estrogen)
NSAIDS, OCPs, GnRH analogs, Aromatase inhibitors.
II. Surgically: If fertility desired => lysis of adhesions
If fertility is not desired => TAH+BSO
 Endometriosis decreases success of IVF in terms of lower pregnancy rates (regardless of the
male factor), fertilization rates, implantation rates, mean number of oocytes retrieved, and
peak estradiol concentrations.
 The main contraindications to hysterosalpingography (HSG):
I. presence of an adnexal mass
II. allergy to iodine or radiocontrast dye
III. Pregnancy
IV. suspicion of active pelvic infection
 The main contraindications to estrogen therapy are as follow:
I. undiagnosed abnormal vaginal bleeding
II. known, suspected, or history of cancer of the breast
III. known estrogen-dependent neoplasia (endometrial cancer)
IV. active DVT,PE , or a history of these conditions
V. arterial thromboembolic disease
VI. liver dysfunction or disease
 Hematometra: A late complication of the cervical conization is cervical stenosis, which can
lead to a collection of blood in the uterus (hematometra) during the menstrual period
 Pelvic organ prolapse (POP):
POP are more common in women with advanced age.
Treatment begins with a non-surgical approach (pessaries, pelvic exercises, or direct
management of symptoms). The surgical approach depends on whether the uterus is still
present. IF THE UTERUS IS PRESENT, options include hysterectomy and uterine suspension.
IF THE UTERUS HAS BEEN REMOVED, the main options are sacrocolpopexy (attachment of
the vaginal cuff to the sacral promontory), and fixation to the uterosacral/ sacrospinous
ligament
The 5 main surgical techniques for apical vaginal repair are:
Sacrospinous ligament fixation: Absent uterus (done after hysterectomy)
A popular method of vaginal vault suspension.
carries a risk of injuring the pudendal nerve or pudendal vessels and the sacral plexus
which causes gluteal and posterior leg pain.
Iliococcygeal vaginal suspension: Absent uterus (done after hysterectomy)
Bilateral uterosacral ligament suspension: Absent uterus (done after hysterectomy). This
technique, can be done at the time of vaginal hysterectomy or to correct posthysterectomy
apical cuff prolapse. A risk of this procedure is medial displacement and twist of the
ureters. The ureter injury should be suspected in cases of flank pain, Hydronephrosis.
Abdominal sacrocolpopexy: Absent uterus (done after hysterectomy)
It is an excellent primary procedure for apical vaginal prolapse and enterocele and is the
procedure of choice for those who are already having an abdominal approach.
carries a risk of intraoperative hemorrhage of sacral veins
 Obliterative vaginal operations (colpocleisis and Le Fort’s operation): Highly effective in
elderly chronically ill who do not desire coital function and prolapse is refractory to
pessary.
 Menopause: During menopause, we observe regression of the breast size, cyst formation
and breast pain. The estrogen deficiency leads to atrophic changes in the urinary and
vaginal tract, causing symptoms such as vaginal dryness, urinary urgency, incontinence,
dyspareunia, and vaginal atrophy. Low estradiol levels and high FSH are observed on these
women.
 Ovarian Hyperstimulation Syndrome (OHSS): is a complication present in up to 5% of the
patients going through IVF.
Sx. ascites, and hemoconcentration, abdominal distention, abdominal discomfort, and
nausea, dyspnea.
These women are at risk of electrolyte abnormalities, abnormal liver function tests,
respiratory distress, and hyponatremia (fluid shift from the intravascular to the
extravascular spaces)
Risk factors: polycystic ovary syndrome, multiple follicles, and high estradiol levels. 
Tx. Expectant management (usually resolves spontaneously in 1-2 weeks)
 Swyer’s syndrome (pure gonadal dysgenesis):  the SRY gene is not functioning. These
patients possess the 46,XY genotype but do not secrete testosterone or AMH, resulting in
feminization of internal and external genitalia.
should have the gonads removed regardless of age to prevent the possible development of
gonadoblastoma.
 IVF: characteristics that influence the success rate of IVF……

 Gestational complications of an IVF:

I. multiple gestations
II. ectopic pregnancy
III. preterm birth
IV. low-birth-weight infants
V. congenital abnormalities / epigenetic disorders
first-trimester miscarriages in IVF have the same risk as in spontaneous pregnancies.

  Copper T 380A IUD  Levonorgestrel secreting IUD (Mirena)

Efficiency 0.8% 0.7%
Lifespan 10 years 5 years
Bleeding abnormal bleeding during Abnormal bleeding during first semester
pattern all the period of use -  of use, trending to significant decrease
increases menstrual flow in menstrual flow after few months of
use
Risk of PID increased same as women that dont use IUD
 In normal situations, Hysterectomy, C-Section And Surgical Abortion, the prophylactic
antibiotic is required only before incision, but when blood loss>1500ml or surgery is longer
than 3 hours an additional intraoperative dose is needed.
 Injections of exogenous gonadotropins is usually the first line therapy to induce ovulation
in patients with hypoestrogenic HYPOTHALAMIC amenorrhea.
Sheehan’s syndrome: necrosis of the anterior pituitary gland, caused by severe blood loss
and hypotension during delivery leading to HYPOPITUITARISM (decreased TSH, prolactin,
FSH, LH, and estradiol) 
All deficient hormones must be replaced in cases of pituitary insufficiency.
The patient has a HYPOESTROGENIC HYPOTHALAMIC amenorrhea.
Tx. exogenous gonadotropins: human recombinant FSH combined with human
recombinant LH or human menopausal gonadotropin (hMG).
 Intracytoplasmic sperm injection (ICSI): is an in vitro fertilization (IVF) technique indicated
in the following situations:
I. < 5 million total normal motile sperm/mL
II. retrieved sperm
III. borderline-quality semen. 
IV. cryopreserved oocytes (defrosted ovum)

 Semen Analysis: A normal semen analysis rules out any important male factor of infertility,
yet an abnormal test needs to be repeated in 4 weeks for confirmation.
A semen specimen should be obtained after avoiding intercourse for 2-3 days, and analysis
should be performed within 1 hour of ejaculation.
The entire ejaculate should be collected since the first part contains the highest sperm
density.
 Gamete intra fallopian transfer (GIFT) and Zygote intra fallopian transfer (ZIFT) are
treatments for infertility that are rarely performed. Both require laparoscopy. GIFT is used
in women with normal tubal function yet ZIFT is used for fallopian tube blockage. In GIFT
fertilization takes place in a catheter, and in ZIFT fertilization is in-vitro.
 Hirsutism: is defined as the development of androgen-dependent terminal body hair in a
woman in places in which terminal hair is normally not found. The most common
underlying cause of hirsutism is polycystic ovary syndrome (PCOS). The treatment is based
on androgen suppression.
Flutamide (androgen receptor antagonist) is the most efficient one (monitoring of patients
because of serious risk of hepatotoxicity)

Pathology Bacterial vaginosis/ Trichomonas Candida

Gardnerella vaginitis vulvovaginitis
Smell Fishy odor Purulent foul smell Odorless

Discharge Grey-white Yellow-green White “cottage cheese”

PH >4.5 >4.5 4-4.5
Others Clue cells Strawberry cervix Fungal infection
Bacteria infection Flagella (parasite)
Itching/Burning No Yes Yes
Tx. Metronidazole Metronidazole Fluconazole
Clindamycin Tx. sexual partner Clotrimazole (-azole)
Bacterial vaginitis increases the risk of Preterm labor, PROM, and endometritis.

 Lichen sclerosus: is a diffuse atrophy of the vulva, causing pruritus and a charecteristic
whitish thin and wrinkled skin areas (“onion skin”/ “cigarette paper skin”), fusion of labial
and periclitoral folds.
most commonly in the labia majora and minora, clitoris and periclitoris, perineal body.
Tx. Colbetasol (steroid) and biopsy (associated with vulvar SCC)
 Behcet’s disease: classically characterized by recurrent ORAL and GENITAL ULCERS and
UVEITIS.
The genital ulcers are usually painful.
Ocular lesions may result in iridocyclitis or blindness. Therefore, an ophthalmic examination
should be performed in suspected.
 Unexplained infertility: is diagnosed in 15-20% of infertile couples when the results of a
standard infertility workup are normal. The diagnosis, similar to our case, generally implies
a normal uterine cavity, bilateral patent tubes, normal semen analysis, and evidence of
ovulation (normal menstruation). Management consists of an empiric stepwise approach,
including Sperm DNA fragmentation to quantify DNA damage. DNA damage may lead to
poor fertility outcomes, even in the case of a normal initial sperm test. Surgery to rule out
endometriosis should also be discussed.
Tx. expectant observation with timed intercourse, ovarian stimulation with or without IUI,
and IVF.
 The Luteinizing hormone (LH) levels throughout the menstrual cycle are highest while using
sequential oral contraception.
 Urinary Incontinence: There are two types:
I. Stress incontinence: loss of urine with physical exertion (coughing, sneezing,
laughing)
Tx.
Nonsurgical: pelvic physiotherapy, behavioral therapy, and pessaries.
Surgical (is Sx. fails to improve): The midurethral sling is the gold standard, Marshall-
Marchetti-Krantz (MMK) procedure, Burch’s colposuspension and transurethral
bulking.
II. Urge incontinence: involuntary leakage of urine, associated with a sudden compelling
desire to void
Tx. Anticholinergic drug, alpha blockers
 Urinary retention=> neostigmine
 Fitz-Hugh Curtis syndrome (Perihepatitis): caused by inflammation of the liver capsule,
usually caused by Chlamydia Trachomatis or Neisseria Gonorrhoeae in patients with pelvic
inflammatory disease (PID). It causes adhesion between liver and peritoneum, resembling
“violin strings” in laparoscopy.  
Sx. lower genital tract infection associated with right upper quadrant pain or pleuritic pain.
Tx. supportive with nonsteroidal anti-inflammatory drugs (NSAIDs)
 The mons pubis is the most innervated area of the female reproductive system. It is
followed by the labia majora, clitoris, labia minora, hymenal ring, and vagina.
 Localized vulvodynia: is an inflammation of the vestibular glands (most commonly the
posterolateral vestibular glands) from an unknown etiology. Patients present with
insertional pain including intercourse, sitting. Pain during physical exam with a cotton
applicator.
Tx.
Temporary sexual abstinence
Topical cortisone ointments
Topical lidocaine cream and Physical therapy
Surgical excision of the glands
 OBSTETRICS
 Infertility: is defined as failure to conceive after 12 months of frequent unprotected
intercourse.
Fecundability: is the probability of achieving pregnancy in one menstrual cycle.
Fecundity: is the probability of ACHIEVING LIVE-BIRTH in one menstrual cycle.
 The complete molar: is diploid because it arises when an empty ovum is fertilized by a
haploid sperm that duplicates its chromosomes or by 2 haploid sperm.
The partial (incomplete) mole: arises when an ovum is fertilized by a 2 sperms, that is why
the partial mole is always triploid.

Tx. Terminate the molar pregnancy via suction curettage and institute serial beta hCG
monitoring for surveillance
 Breech presentation (including frank, complete and footling): is associated with higher
morbidity and mortality to the mother and the fetus, due to associated factors such as fetal
anomalies, prematurity, birth trauma, and umbilical cord prolapse. When cord prolapse
occurs with a compound presentation, a cesarean delivery is required (Umbilical cord
prolapse is an emergency, more commonly seen in non-vertex presentations)
 Trial Of Labor After Cesarean Section (TOLAC):  
Suitable candidates for TOLAC:
I. with 1 prior low-transverse cesarean section
II. who present in labor
III. with nonrecurring conditions (eg, breech, abnormal fetal heart rate patterns,
placenta previa in prior pregnancy)
IV. with a prior vaginal delivery
Not suitable candidates for TOLAC:
Prior classical (vertical) uterine incision or prior myomectomy
 Increase in cardiac output 1 week postpartum is considered to be pathologic. During labor
cardiac output may increase or demonstrate minimal changes largely depending on the
conduct of labor and delivery, however cardiac output declines 28% within 2 weeks
postpartum from peak values observed at 38 weeks’ gestation.
 Achondroplasia is an autosomal dominant disease in which the primary feature is dwarfism.
 Infants to Diabetic Mother (IDM) have a 2-8 fold increased risk for structural malformation
compared to infants born to nondiabetic mothers. The most common malformations in
IDMs are:
I. CNS anomalies (Neural tube defects, anencephaly, holoprosencephaly)
II. Heart defects (ASD, VSD, TGA, Aortic Coarctation, TOF, Truncus arteriosus,
dextrocardia, cardiomegaly)
III. Renal and urinary anomalies (hydronephrosis, renal agenesis, ureteral duplication)
IV. GIT anomalies (duodenal atresia, anorectal atresia, omphalocele)
V. Spinal anomalies (caudal regression syndrome, sacral agenesis)
VI. Respiratory distress syndrome
VII. Polycythemia
VIII. Hypoglycemia, hypocalcemia, hyperbilirubinemia
 Gestational DM (GDM):
all patients with GDM should have a 2-hour, 75-g OGTT approximately 6 weeks postpartum.
Normal OGTT => check every 3 years
Abnormal OGTT => check annually
 Gestational HTN:
> 20 weeks pregnant
BP > 140/90 (taken 2 times, 4 hours apart)
No proteinuria
Tx. conservative
 Preeclampsia:
> 20 weeks pregnant
BP > 140/90
Proteinuria (>300 mg/24h. in urine)
Tx.
< 37 => conservative (if both baby and mom are OK), delivery at 37
> 37 => MgSO4 (prevent seizures) + Oxytocin (induce labor)
 Preeclampsia with severe fewature:
> 20 weeks pregnant
BP > 140/90
Headache/Visual changes/Epigastric pain/HELLP syn./DIC/ Pulmonary edema
OR
BP > 160/110
Proteinuria
Tx. MgSO4, Labetalol/hydralazine (decrease BP), Oxytocin,
 betamethasone (in pregnancy <34 week)
PROMPT DELIVERY AT ANY GESTATIONAL AGE
 Superimposed preeclampsia:
Preexisting HTN < 20 week + Preeclampsia
 MgSO4 administered IV loading dose of 6 g in 20-30 minutes, followed by a maintenance of
2 g/hour for 12 hours.

 A normal nonstress test (NST) is defined as ≥ 2 fetal heart rate (FHR) accelerations, at least
15 beats/min above the baseline and lasting at least 15 seconds, within a 20-minute period.
 CT angiography is the most reliable test when pulmonary embolism (PE) is suspected, it has
a sensitivity and specificity of 94% in the nonpregnant patient for detecting PE and it is
done during pregnancy despite the consequences of radiation.
 Women with a history of a prior spontaneous preterm birth have higher risk of new
preterm labor than those who have no past preterm birth.
 The white blood cell count increases during normal pregnancy and can physiologically
REACH UP TO 25,000/MM3 DURING LABOR.
 the gestational age is calculated from the first day of the last menstrual period.
 Skin changes during pregnancy:
Chloasma (melasma): the mask of pregnancy is skin darkening of the forehead, bridge of
nose, or cheek bones. Exacerbated by sunlight.
Linea nigra: causing darkening of the lower midline from the umbilicus to pubis.
 Pelvic organ changes during pregnancy:
Chadwick sign: bluish discoloration of the vagina and the cervix.
Hegar sign: widening and softening of the body or isthmus of the uterus. Occurs at 6-8
weeks menstrual age or gestational age.
Leukorrhea: increase in vaginal discharge, secondary to hormonal changes.
Uterine contractions: painless (Braxton Hicks contraction), usually begin at 28 weeks of
gestation and increase in regularity with advanced gestational age . Usually disappear with
walking or exercise.
 Placenta previa: typically presents with painless vaginal bleeding, usually in the third
trimester
Placenta accreta: to the superficial myometrium
Placenta increta: further into the myometrium
Placenta percreta: completely through the myometrium into the serosa and even to
adherent organs
This condition is associated with previous cesarean or uterine surgery.
The recommended management of placenta accreta is a planned preterm cesarean
hysterectomy.
 Contraindications for vacuum delivery are as follows:
I. Face or breech presentation
II. True cephalopelvic disproportion
 III. Congenital anomalies of the fetal head (hydrocephalus)
IV. Gestational age < 34 weeks
V. Unengaged fetal head
VI. Fetal demineralization disorder (osteogenesis imperfecta)
VII. Known or suspected fetal bleeding diathesis (hemophilia)
 Cause of postpartum hemorrhage 4 T’s:
I. Tone (uterine atony is the most common)
II. Trauma (laceration, uterine rupture)
III. Tissue (retained placental tissue)
IV. Thrombin (coagulopathy)
 Pregnant women with complicated varicella-zoster virus (VZV) infection should be treated
with intravenous acyclovir for 10 days. Complicated VZV infection includes pneumonia,
encephalitis and disseminated infection.


 Pregnant patients with severe pneumonia should be managed as an inpatient with

intravenous beta-lactam antibiotic (ceftriaxone or cefotaxime) +
azithromycin. Fluoroquinolones such as ciprofloxacin, levofloxacin or moxifloxacin which
are commonly used in nonpregnant patients should be avoided in pregnant patients due to
their risk of fetal arthropathy and malformations.
Other treatment options are as follows based on type of organism: 
I. Influenza: oseltamivir, zanamivir, amantadine, rimantadine
II. Pseudomonas:  piperacillin-tazobactam, cefepime, meropenem, or imipenem +
azithromycin
III. Mycoplasma or Chlamydophila: azithromycin (doxycycline is contraindicated in
pregnancy due to fetal teeth staining and deformities and skeletal malformations) 
IV. Varicella: acyclovir 
 V. Pneumocystis pneumonia in HIV-positive patients: trimethoprim-sulfamethoxazole
(potentially teratogenic in first trimester) 
VI. Disseminated fungal infection: intravenous amphotericin B + post-delivery oral
fluconazole
 Rh-negative women who carry Rh-positive fetuses are at risk of Rh alloimmunization and
subsequent hemolytic disease of the newborn. If fetal red blood cells pass into the
mother’s circulation in sufficient quantities (occurring mainly after fetomaternal
hemorrhage during pregnancy or at delivery), maternal IgG antibodies to the D antigen
develop, cross the placenta and risk the fetus.
WHEN THERE IS NO HISTORY OF PREVIOUS FETUS AFFECTED BY RH ALLOIMMUNIZATION:
the patient should be followed up with antibody titers at intake, 20 weeks’ EGA, and then
every 2-4 weeks.
· If antibody titers are <1:32, there is no indication for further intervention.
· If antibody titers are >1:32, then ultrasound assessment of blood flow in the fetal
middle cerebral artery (MCA) every 2 weeks is carried.
WHEN THERE IS HISTORY OF A PRIOR FETUS AFFECTED BY RH ALLOIMMUNIZATION:
amniocentesis is indicated to determine the fetal genotype if the father of the fetus is
heterozygous for D antigen. If the fetus has the D antigen, that fetus is considered to be at
risk of hemolytic disease and severe anemia and for this reason, MCA Doppler surveillance
is initiated at 18 weeks and repeated every 1–2 weeks.
 Patients presenting with mild Hyperemesis Gravidarum (HEG) are given supportive
measures including hydration and vitamin supplementation, such as vitamin B6
(pyridoxine), 10-30 mg for up to 4 times daily.
 Hyperemesis Gravidarum (HEG): is defined as intractable nausea, vomiting beginning in the
first trimester of pregnancy, resulting in dehydration, ketonuria, and weight loss (>5% of
prepregnancy weight).
pathogenesis is unknown, it is thought that increased levels of human chorionic
gonadotropin (hCG), estradiol, and possible progesterone are potential contributing
factors. associated with oral contraceptives and multiple gestations.
Symptoms typically begin between 3 and 5 weeks of pregnancy and 80% resolve by 20
weeks gestation.
Maternal complications:
I. Wernicke’s Encephalopathy
II. Acute Tubular Necrosis
III. Central Pontine Myelinolysis
IV. Mallory-Weiss Tear
V. Pneumomediastinum
VI. Splenic Rupture
VII. metabolic alkalosis (due to loss of acidic gastric contents), however, ketosis may
develop as well if oral intake is poor, leading to metabolic acidosis (Drmada says
M.Acidosis in not a complication, medexam says it is)
Tx.
 Mild (nausea and vomiting): supportive, hydration and vitamin such as vitamin B6
(Pyridoxine)
Continued Sx. after 48 hours add Doxylamine, Promethazine, or Dimenhydrinate
For persistent symptoms: Prochlorperazine, Metoclopramide, or Trimethobenzamide.
Dehydration or weight loss: Thiamine (B1), and Ondansetron or Methylprednisolone.
Unable to maintain weight: total enteral or parenteral nutrition.
 Non Sress Test (NST): Normal baseline is between 110 and 160 beats/min. Accelerations
are defined as elevations above the baseline of 15 bpm lasting 15 seconds or longer. Two or
more accelerations in a 20-minute interval are reassurin
 Acute fatty liver of pregnancy (AFLP): is a rare complication usually occurring in the third
trimester.
Sx. malaise, fatigue, anorexia, nausea, vomiting, headaches, epigastric/RUQ pain, jaundice,
THROMBOCYTOPENIA, HYPOGLYCEMIA, SIGNIFICANTLY ELEVATED LIVER FUNCTION TESTS,
HYPERAMMONEMIA and coagulopathy.
Tx. immediate (vaginal/c-section) delivery+ platelets administration prior to delivery
 Both progesterone and estrogen are linked to the pathogenesis of cholecystitis during
pregnancy (decreases gallbladder contractility leading to stasis thus facilitating stone
formation) and increase bile lithogenicity.
 Intrahepatic cholestasis ICP: is characterized by accumulation of bile acids in the liver with
subsequent accumulation in the plasma
Sx. pruritus, jaundice, increased levels of alkaline phosphatase, bilirubin, and serum bile
acids. AST and ALT mildly elevated.
Tx. Ursodeoxycholic acid (UDCA). It is recommended to perform fetal surveillance twice per
week and deliver the fetus at 37-38 weeks or even at 36 weeks after obtaining confirmation
of fetal lung maturity
 The Bishop score: is a method of pelvic scoring for elective labor induction, and a score of 9
or more is considered as safe.
Labor induction may be performed due to maternal or fetal indications (preeclampsia, DM,
heart disease, prolonged pregnancy, Rh incompatibility, PPROM, placental insufficiency,
chorioamnionitis, suspected IUGR or fetal abnormality).

 Hypothyroidism in pregnancy:
The most common cause is Hashimoto’s thyroiditis
During pregnancy, the demand for thyroid hormone increases, therefore TSH should be
followed EVERY TRIMESTER or EVERY 4 WEEKS in case a change in dosing is required.
The incidence of overt hypothyroidism is about 1:1000-2000 deliveries, and subclinical
hypothyroidism is more common 23:1000 (2.3%)
Other causes include transient painless/ subacute thyroiditis, drugs, radiation, congenital,
hypothalamic/ pituitary disease, inherited metabolic disorders, and thyroid hormone
resistance syndromes.
Complications spontaneous abortions, preeclampsia, placental abruption, IUGR,
prematurity, and intrauterine fetal demise; IN THE FETUS, it may cause neonatal
hypothyroidism which may lead to cognitive deficiencies
 Cytomegalovirus (CMV): is transmitted in saliva, semen, cervical secretions, breast milk,
blood, or urine. The risk of neonatal vertical transmission is higher with primary maternal
infection (30-40%) than recurrent infection (<2%).
Sx./Complications: of infant => petechiae, hepatosplenomegaly (HSM), jaundice,
thrombocytopenia, MICROCEPHALY, chorioretinitis, or nonimmune hydrops fetalis,
neurologic defects and hearing loss, abdominal/ intracranial calcifications,
ventriculomegaly, ascites, echogenic bowel, and IUGR.
Dx. PCR.
Combined Oral Contraceptives (OCP): Treatment with OCP has several benefits, that take
place after 1 year of use and remain even after a significant period from discontinuation of
the drug:
I. Reduces risk of ovarian cancer (by 40-80%)
II. Reduces risk of endometrial cancer (by 50%)
III. Reduces risk of ectopic pregnancy (by 90%)
IV. Reduces risk of PID
V. Reduces menstrual disorders
VI. Reduces risk of benign breast disease
VII. Reduces acne
VIII. Protects against bone mineral density loss
IX. Reduces development of colorectal cancer
X. Reduces progression of rheumatoid arthritis
 Patients with postpartum fever should undergo investigations including history, a physical
exam and cultures to determine the source of fever, before starting treatment. Other labs
include CBC, blood and lochia cultures, and a urinalysis, should be sent. Therefore, the
most important first step is an investigation for the source of fever, afterwards a decision
on empiric treatment could be made.
 The first menstrual cycles (at puberty) are anovulatory and therefore may be frequent and
with heavy bleeding. This condition requires no invasive diagnostic procedures, and is
treated with oral estrogen.
 EndometRITIS: is an infection of the uterine endometrium. This may be seen early (first 24
hours) in the postpartum period with fever, tachycardia and sepsis.
Endometritis is associated with:
PROM
Infection with (GBS, Chlamydia Trachomatis, Trichomonas Vaginalis)
In women with PROM, oxytocin decreases the risk of chorioamnionitis and endometritis.
 Labor induction: may be performed in several methods:
I. Intravenous oxytocin transfusion: stimulates uterine contractions
II. Cervical ripening: used for an unfavorable cervix
o Prostaglandins (Misoprostol Vaginally or Intracervically not IV)
o Laminaria (hygroscopic rods which absorb moisture and expand) into the internal os
o Foley catheter into the cervical canal
 III. Membrane manipulation: artificial rupture of the membranes is used when the
cervix is favorable
 Appendicitis: in pregnancy presents similarly to the classic symptoms in the general
population. However 2 main differences are present:
I. Displacement of the appendix UPWARD as pregnancy advances, still the most
common location for pain is in the right lower quadrant
II. Masking of leukocytosis due to the normal leukocytosis of pregnancy
Tx. early surgical treatment- open or laparoscopic appendectomy.

RISK FACTORS/COMPLICATIONS
 Smoking is a risk factor for premature menopause (primary ovarian insufficiency)
 Preeclampsia risk factors:
Preexisting diabetes mellitus
Chronic HTN, CKD, or both
History Preeclampsia
Multifetal pregnancy
Primiparity
History of thrombophilia
Pregnancy conceived via in vitro fertilization
Obesity
SLE
Advanced maternal age > 40 years
 Maternal complications of hyperthyroidism:
I. Preeclampsia (most common)
II. Pregnancy-induced hypertension
III. Placental abruption
IV. Preterm delivery
V. Spontaneous abortion
VI. Thyroid storm
VII. Anemia
VIII. Higher susceptibility to infections
IX. Cardiac arrhythmias
X. Congestive heart failure
Fetal complications of hyperthyroidism:
I. Fetal and neonatal hyperthyroidism
II. Intrauterine growth restriction (IUGR)
III. Stillbirth
IV. Prematurity
V. Morbidity related to antithyroid medications
 PROM risk factors:
 I. Maternal infection (UTI, lower genital tract infection, STI)
II. Intrauterine infection
III. Cervical insufficiency
IV. Polyhydramnios
V. History of PROM/ preterm birth
VI. Multiple previous pregnancy
VII. Nutritional deficit
VIII. Decreased tensile strength of membranes.