OB\GYNE Review

HazimRaffaa R4 (4-2021 )
 Bacterial vaginosis (BV)
• Patient will be complaining of malodorous vaginal discharge
• PE will show thin, gray/white discharge
• Labs will show pH > 4.5, clue cells
• Diagnosis is made by KOH to smear → fishy odor, "whiff
test", Amsel Criteria
• Most commonly caused by Gardnerella vaginalis
• Treatment is metronidazole
• Alternative Tx :
1) inidazole 2 g PO daily for 2 days
2) tinidazole 1 g PO daily for 5 days
3) clindamycin ovules 100 mg intravaginally daily for 3 days
 Trichomoniasis
• Patient will be a woman complaining of malodorous vaginal discharge
• PE will show frothy, green/yellow discharge, "Strawberry cervix"
• Labs will show pH > 5, flagellated, motile, pear shaped
• Diagnosis is made by wet mount
• Most commonly caused by Trichomonas vaginalis
• Treatment is metronidazole
 Candida Vaginitis
• Risk factors: antibiotic use, diabetes
• White cottage cheese discharge
• Pseudohyphae
• Fluconazole
Question: For how long after treatment of chlamydial cervicitis should patients be
counseled to avoid sexual intercourse?
Answer: 7 days.
 Genital Herpes Simplex
• Patient will be complaining of a painful genital rash
• PE will show grouped erythematous, shallow, cluster of vesicles and
lymphadenopathy
• Labs will show multinucleated giant cells on Tzanck smear
• Diagnosis is made clinically. Gold standard is tissue culture with
polymerase chain reaction (PCR)
• Most commonly caused by herpes simplex virus (HSV) type 2
• Treatment is acyclovir
 Condyloma Acuminata
• Human papillomavirus (HPV) infections are very common and are
the cause of a variety of cutaneous and mucous membrane lesions,
including anogenital or venereal warts called condyloma
acuminata. Genital warts are most commonly caused by HPV types
6 and 11 and the lesions can undergo malignant transformation.

• Patient will be complaining of genital lesions

• PE will show cauliflower-like lesion
• Most commonly caused by HPV 6 & 11
• Comments: most common STD
Pelvic Inflammatory Disease (PID)
 Patient with a history of multiple sexual partners or
unprotected sex
 Complaining of lower abdominal pain, cervical motion
tenderness ("Chandelier sign"), painful sexual intercourse
 PE will show mucopurulent cervical discharge
 Most commonly caused by Chlamydia trachomatis
 Out-pt treatment is ceftriaxone + doxycycline
 Fitz-Hugh-Curtis syndrome
 Fitz-Hugh- Curtis syndrome causes right upper quadrant pain, which is
commonly pleuritic in nature. In most cases, the patient will have either a
preceding episode of pelvic inflammatory disease (PID) or have
concomitant PID symptoms.

Comments: Fitz-Hugh-Curtis syndrome:

perihepatitis + PID
 Tubo-ovarian Abscess
 Patient will be a woman with a history of pelvic inflammatory disease
(PID)
 Complaining of lower abdominal pain, fever, vaginal discharge
 PE will show unilateral adnexal tenderness
 Diagnosis is made by ultrasound
 Most commonly caused by a complication of pelvic inflammatory disease
 Treatment is intravenous antibiotics and/or surgical drainage
 Endometriosis
• Patient will be complaining of pre or mid-cycle
Dysmenorrhea, Dyspareunia, Dyschezia (painful bowel
movement)
• PE will show uterosacral nodularity or a fixed or retroverted
uterus
• Diagnosis is made by laparoscopy
• Most common site is ovaries
 Endometritis
• Patient will be a woman 2 - 3 days post c-section
• Complaining of fever, abdominal pain,foul smelling lochia
• PE will show purulent vaginal discharge, cervical motion tenderness,
uterine tenderness
• Labs will show leukocytosis
• Most common postpartum infection
• Treatment is :

Post cesarean section post vaginal delivery

Clindamycin + gentamicin Ampicillin + gentamicin
 Behçet’s syndrome
 The original description of Behçet’s syndrome included
recurring genital and oral ulcerations and relapsing uveitis

 Patient will be complaining of recurring genital and oral

ulcerations, and relapsing uveitis
 PE will show painful genital and oral ulcers with a necrotic
center and surrounding red rim
Q : At what gestational age should pregnant women with Herpes simplex virus
begin suppressive therapy to reduce the likelihood of lesions during labor ?

- Answer: Suppressive therapy should be initiated at 34-36 weeks of gestation.

 Chancroid
• Patient will be sexually active
• Complaining of painful genital ulcers
• PE will show pustules which ulcerate, ulcers on an erythematous base
covered by a gray or yellow purulent exudate and painful
lymphadenopathy (bubo)
• Most commonly caused by Haemophilus ducreyi

• Treatment is ceftriaxone 250 mg or one gram of oral

azithromycin
 Normal Pregnancy
• Increased blood volume, cardiac output, tidal volume
• Decreased functional residual capacity, systemic vascular
resistance
• Respiratory alkalosis: 3rd trimester
• Doppler heart tone at 10 weeks
• HR increased 10-15 bpm
• BP decreased in 2nd trimester, normalizes in 3rd .
• Serum beta-hCG: doubles every 2 days in early pregnancy
 Normal Pregnancy
• Fundal height:
 o 12 weeks: pubic symphysis
 o 20 weeks: umbilicus
 o 20 - 32 weeks: height (cm) above symphysis = gestational age (weeks)

• Transvaginal ultrasound: IUP visualized when beta-hCG > 1500

• Transabdominal ultrasound: IUP visualized when beta-hCG > 4000
 Fetal Heart Rate

Early decelerations Head Compression

Late decelerations Placental Insufficiency

Variable decelerations Cord Compression

 Normal Labor and Delivery
• Labor stages:
• 1st stage: slow cervical dilation to full dilation (10 cm)
• 2nd stage: 10 cm dilation to delivery of baby
• 3rd stage: delivery of placenta
• 4th stage: postpartum

• Delivery stages: engagement, descent, flexion, internal rotation,

extension, external rotation, expulsion
 Hyperemesis Gravidarum
 Peak incidence: weeks 8-12
 Weight loss
 Hypokalemia
 Ketonemia
 Rx: IVF with 5% dextrose, antiemetics
 Pyridoxine ( B6 ) considered first-line treatment for nausea in
pregnancy

Question: What electrolyte abnormalities can be seen in patients with hyperemesis

gravidarum?
Answer: Hypokalemia with a hypochloremic metabolic alkalosis.
 Preeclampsia
• Patient will be pregnant > 20 weeks gestation
• Complaining of visual disturbances, severe headaches, or asymptomatic
• PE will show new-onset hypertension (>140/90 mm Hg) with proteinuria
(> 300 mg/24 hr)
• Treatment is the prevention of seizures with magnesium sulfate and
prevention of permanent maternal organ damage
• Comments: New onset hypertension < 20 weeks gestation suspect molar
pregnancy.
 Eclampsia
• Patient with a history of pre-eclampsia (new onset of hypertension and
proteinuria or end-organ dysfunction, after 20 weeks of gestation)
• Complaining of seizures
• Treatment is magnesium sulfate (unresponsive seizures:
benzodiazepines/phenytoin) and delivery
• Comments: can occur up to 6 weeks postpartum .
• Comments: New onset hypertension < 20 weeks gestation suspect molar
pregnancy
 HELLP Syndrome
 HELLP Syndrome (Hemolysis, Elevated Liver function tests,
and Low Platelets)
 Patient will be a pregnant
 Labs will show microangiopathic hemolytic anemia (low
hemoglobin and schistocytes on blood smear),
thrombocytopenia, and elevated liver function tests
 Management is blood pressure management, magnesium
sulfate for prevention of eclamptic seizures and delivery of
the fetus
 Bleeding in Pregnancy
Early Preg Late Preg Post Partum

1. Abrtions 1. Placental PPH

2. Ectopic Preg Abruption
3. Molar Preg 2. Placenta Previa
 Abortion History Examination Treatment
Types :
little bleeding + no cervix is closed + Rest, sedation and
Threatened abdominal pain. normal fetus in US synthetic progesterone
and HCG injections

massive bleeding + abd. cervix is open + D&C “abortion” to save

Inevitable pain. bleeding clot + (+ve) mother's live"
fetal heart rate in US.

abd. pain + bleeding + cervix is open + (+ve) evacuate & curettage

Incomplete some products of bleeding + no F.H + ( D&C )
gestation some products of baby
Vagainal bleeding ē cervix is close and the No active intervention
Complete passage of all products of uters is empty .
gestation
(pain & bleeding have
subsided)
disappear of preg. (-ve ) F.H= dead fetus D&C
Missed symptoms early. ( between
4 -6 weeks )
 Ectopic Pregnancy
• Patient with a history of prior ectopic, PID, tubal surgery, IUD
• Complaining of vaginal bleeding, abdominal pain,amenorrhea
• PE will show adnexal tenderness or unexplained hypotension
• Labs will show positive pregnancy test and lower than expected serum
beta-hCG levels
• Diagnosis is made by ultrasound
• Most commonly located in a fallopian tube
• Treatment is methotrexate or surgery

The discriminatory zone refers to the hCG range at which a viable intrauterine pregnancy
should be seen. For transvaginal ultrasound, the discriminatory zone is 1000–2000 mIU/mL
hCG.
Ectopic pregnancy, spontaneous abortion, and gestational trophoblastic disease are
associated with unpredictable hCG levels and may be diagnosed by ultrasound at hCG levels
that are below 1000 mIU/mL.
 Ectopic
Pregnancy
 Molar Pregnancy
• Patient will be complaining of nausea, vomiting, abdominal pain, and vaginal
bleeding
• PE will show uterine size that is larger than expected for dates
• Labs will show beta-hCG that is higher than expected for dates
• Diagnosis is made by ultrasound showing “snowstorm” or "bag of grapes"
appearance
• Treatment is dilation and curettage
• Comments: new onset hypertension < 20 weeks gestation suspect molar
pregnancy

Question: What is the treatment of choice of low-risk gestational trophoblastic

neoplasia?
Answer: Chemotherapy using either methotrexate or actinomycin D.
 Placental Abruption
 Patient will be in her third trimester
 With a history of hypertension, trauma, or cocaine use
 Complaining of painful vaginal bleeding
 Labs will show hypofibrinogenemia
 Placenta Previa
• Patient will be a pregnant woman in her third trimester

• Complaining of painless vaginal bleeding

• Diagnosis is made by ultrasound (transvaginal >
transabdominal) – gold standard
• Comments: Do not do a digital vaginal exam
 Postpartum Haemorrhage ( PPH )
• Patient will have a cumulative blood loss of ≥1000 ml or
bleeding associated with signs and symptoms of hypovolemia
within 24 hours of birth regardless of route of delivery
• PE will show an enlarged “boggy” uterus
• Most commonly caused by uterine atony
• Treatment is uterine massage, oxytocin, prostaglandins, or
surgery
 Premature Rupture of Membranes
(PROM)
• PROM: membrane rupture prior to labor
• Preterm PROM (PPROM): PROM occurring < 37
weeks
• Fluid ferning + blue nitrazine paper = amniotic fluid
• Admission, OB consultation

Question: Why is amoxicillin/clavulanic acid avoided in the treatment of Preterm PROM?

Answer: Amoxicillin/clavulinic acid has been associated with an increased risk of necrotizing
enterocolitis.
 Umbilical Cord Prolapse
 Patient with a history of malpresentation, PROM
 Cord precedes presenting part increasing cord pressure
leading to fetal anoxia
 Treatment is emergent c-section
 - If delay in c-section : Trendelenburg position, knee-chest
position, bladder filling, elevation of presenting fetal part
 Nuchal Cord
• Umbilical cord becomes wrapped around the fetal neck
• Type A: Encircles the neck in an unlocked pattern
• Type B: Encircles the neck in a locked pattern
• Risk factor: long cord
• Management:
 Attempt to bring loop over baby's neck, somersault maneuver
 If not possible, clamp and cut, delivery quickly
 Resuscitate baby as necessary
 Shoulder Dystocia
• Large fetal size
• Turtle sign: fetal head pulled tight against perineum
• Management:
 o Episiotomy
 o Empty bladder
 o McRoberts maneuver: flexing hips/legs
 o Wood screw maneuver: anterior shoulder is pushed towards the baby's chest,
posterior shoulder is pushed towards the baby's back
 o Clavicle fracture
 o Last resort: Zavenelli maneuver (reinsert fetal head followed by C-section)
 Uterine Rupture
• RFs: multiple C-sections, uterine scar, cocaine, prostaglandin
use
• Sudden severe uterine pain + vaginal bleeding
• FHR abnormalities
• Rx: emergent c-section
 Chorioamnionitis
• Intra-amniotic infection
• Risk factors: preterm labor, premature rupture of
membranes, prolonged rupture of membranes
• GBSinfection at 18 hrs
• Rx:ampicillin+gentamicin
 Mastitis
• Patient will be a breastfeeding mother
• Complaining of breast erythema, tenderness, fever
• Most commonly caused by Staph. aureus
• Management includes cool compresses and analgesics in between
feedings
• Antibiotics: Dicloxacillin, cephalexin, TMP-SMX (MRSA), clindamycin (PCN
allergic)
• Comments: continue breast feeding to avoid progression to
abscess
 Bartholin Abscess
• Pain with sitting/walking
• Other signs and symptoms include :
 a lump under the skin on the affected side of the vagina
 fever
 pain during walking, sitting, or sex
 swelling, and a hot sensation around the abscess

• diagnosis based on symptoms and a physical examination.

• Locations: 4 o’clock, 8 o’clock

• Rx: Marsupialization ( I&D on mucosal surface, word catheter )

 Uterine Prolapse
• Risk factors: multiparity, age, decreasing estrogen levels,
trauma
• Rx: Kegel exercises, pessary, surgery
Abnormal Uterine Bleeding (formerly
Dysfunctional Uterine Bleeding)
• MCC of abnormal vaginal bleeding in reproductive women
• Menarche, perimenopause
• Anovulatory:
 o Estrogen, progesterone endometrial hyperplasia/bleeding
 o Unpredictable bleeding

• Ovulatory: Predictable bleeding

• Dx of exclusion
• Rx: combination OCPs
• Unstable bleeding: IV estrogen
 AUB
• The treatment for dysfunctional uterine bleeding, now termed abnormal uterine
bleeding, in nonpregnant patients involves treatment with high-dose intravenous
conjugated estrogen
• Stable patients can be treated with oral contraception and NSAIDs. NSAIDs reduce
endometrial prostaglandin levels and promote vasoconstriction, despite having
anti-platelet activity. In an unstable patient, tranexamic acid and high-dose
intravenous conjugated estrogen can be used during initial resuscitation.
‫التعاريف مهمة جدا‬
 Premenstrual Syndrome ( PMS )
• Patient will be a woman, 1 - 2 weeks prior to cycle
• Complaining of sleep disturbances, decreased focus, emotional
lability, breast tenderness, or HA, that resolves after menstruation
begins
• Treatment is dec caffeine intake, exercise, stress reduction, NSAIDs,
SSRIs, OCPs
• Comments: Symptoms do not hinder personal/professional life
(unlike premenstrual dysphoric disorder)
 Uterine Fibroids (Leiomyoma)
• Patient will be an African-American woman, 20 - 40-years-old
• Complaining of menorrhagia and dysmenorrhea
• PE will show a palpable, asymmetric, and non-tender uterus
• Diagnosis is made by pelvic ultrasound
• Majority do not require surgical or medical treatment
• Severe cases: Myomectomy (fertility can be preserved) or hysterectomy
 Menopause
 Patient will be a woman over 45-years-old
 With a history of amenorrhea for 12 months
 Complaining of hot flashes, sleep disturbances, depression,
or vaginal dryness
 Labs will show decreased estrogen and elevated follicle-
stimulating hormone ( FSH ) levels
 Atrophic Vaginitis
• Patient will be a postmenopausal woman
• Complaining of dyspareunia, dryness, bleeding, itching
• PE will show a pale, dry, shiny epithelium
• Most commonly caused by a decrease in estrogen
• Treatment is lubricants, moisturizers, topical estrogen (2nd
line)
Thank You
HazimRaffaa
ROSH – AAFP
2021