ObGyn Case Files
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Case 1: Genuine Stress Incontinence: incontinence through the urethra
due to sudden increase in intra-abdominal pressure, in the absence of
bladder muscle spasm
o Differential Diagnosis:
 Genuine stress incontinence:
 No delay in incontinence with valsalva
 Urge Urinary Incontinence: requires urge or delay from a
cough; due to uncontrollable detrusor muscle contraction
 Delay incontinence with valsalva
 Overflow incontinence: associated with diabetes or neuropathy
 Large post-void residual
o Physiology:
 Normal: The pressure of the urethra and support from the
pelvic diaphragm is greater than the bladder pressure
providing continence.
 Normal: valsava “cough” intra-abdominal pressure is exerted
on the bladder and the proximal urethra providing continence
 Adnormal: proximal urethra is outs the pelvic diaphragm.
Valsalva increases intra-abdominal pressure on the bladder,
but the proximal urethra causing incontinence
o Clinical Presentation:
 Multiparous woman
 Incontinence related to stress activities
 No urge component and no delay from valsalva to drip
o Workup:
 H and P, UA, and Post-void residual
 GSI: 1) timed void and keigel exercises 2)urethropexy
 UUI: anticholinergic to prevent detrusor muscle contraction
 OI: catheter
o Treatment:
 Urethropexy: movement of the proximal urethra back into the
pelvic diaphragm
 Midurethral slings: mesh that is attached to act as a hammoack
for the proximal urethra
 Transvaginal or transobturator
Case 2: Health Maintenance
o Health maintenance approach
 Cancer screening, immunizations, addressing common
diseases
o Primary Prevention: modifying risk factors
o Secondary Prevention: catches disease in the asymptomatic stage
o Table 2-1, page 34
o Clinical Pearls:
ObGyn Case Files 1
Most common COD in women <20 yo is MVA
Most common COD in women ≥ 49 CVD
Major conditions in the ≥ 65 age group
 Osteoporosis, CVD, breast cancer and depression
Case 3: Uterine Inversion
o Differential Diagnosis:
 Uterine inversion: ragged red mass
 Vaginal or cervical prolapse: smooth appearance
o Clinical Presentation:
 Third stage of labor:
 Placenta cord has lengthened,
 A small amount of blood from the vagina
 Placenta with a ragged reddish mass around it
 Due to traction of the umbilical cord without separation
o Treatment:
 Anesthesiologist:
 Possible emergency surgery
 Halothane: relaxes uterus
 Cupped glove technique to reposition the uterus
 Start two IV lines
 Relax uterus
 Halothane, terbutaline, magnesium sulfate
 After repositioning of the uterus give oxytocin
o Clinical Pearls:
 Four signs of placenta separation
 Gush of blood
 Umbilical cord lengthening
 Globular and firm shape of the uterus
 Uterus rises to the anterior abdominal wall
 Almost certain to have maternal hemorrhage
 The fundus is the most likely site for placenta implantation
leading to uterine inversion
 Abnormally retained uterus: labor stage 3 lasting greater than
30 minutes -> next step: manual extraction
 Placenta accreta: increase risk for intrauterine inversion
Case 4: Perimenopause (Climacteric)
o Clinical Presentation:
 Irregular menses (anovulatory cycles)
 Feelings of inadequacy (vasomotor symptom)
 Hot Flushes (hypoestrogenism)
 Pathologic fractures (hypoestrogenism osteoporosis) ->
thoracic spine is the most common area
 Vaginal atrophy (decrease epithelial thickness)
o Workup:
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ObGyn Case Files 2
FSH and LH levels: abnormally elevated because of no feedback
inhibition
 DEXA scan: BMD
 Hypothyroidism, diabetes mellitus, HTN, and breast cancer
o Treatment:
 Estrogen therapy:
 Advantages: decreases fracture incidence and lower
incidence of colon and ovarian cancer; decreases
incidence of hot flashses; with progestin lowers
incidence of endometrial cancer
 Disadvantages: continuous therapy ->increases
likelihood of CVS and breast cancer
 Short term, low dose
 NOTE: FSH feedback is regulated by inhibin not
estrogen… so FSH would still be elevated with estrogen
therapy
 Clonidine: antihypertensive that may be used to decrease hot
flashes
 Raloxifene:
 Selective estrogen receptor modulator
 Prevents bone loss, but does NOT treat hot flashes
 Weight bearing exercises, Ca2+, Vit. D supplements -> maintain
bone density
o Clinical Pearls:
 Prolactinoma: hypothalamic dysfunction
 Turner’s syndrome: ovarian failure
 Marathon runner amenorrhea: hypothalamic dysfunction ->
corrected with weight gain
 Sheehan syndrome:
 Post-partum woman
 Amenorrhea and unable to breast feed
 Pituitary dysfunction
Case 5: Necrotizing fasciitis
o Clinical Presentation:
 Present in septic shock: severe hypotension
 Pathognomonic: crepitance
 Hemoconcentration and renal insufficiency
 Post-op: C-section or episiotomy
o Workup:
 Diagnosis made on CP
o Treatment:
 IV fluids immediately
 May require pressors if IV fluids are not sufficient raise bp (i.e.
dobuatmine/dopamine)
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ObGyn Case Files 3
Broad spectrum antibiotic (penicillin, gentamicin, and
metronidazole)
 Monitor UO to determine renal perfusion
 Note: septic shock presents initially as decrease in UO
o Clinical Pearls:
 Septic shock: vasodilation is the cause of the decrease in bp
 MAP of 65 mm Hg is required to maintain perfusion to vital
organs
 MAP = [2(diastolic pressure) + (systolic pressure)]/3
 “Sun-burn like rash” (desquamation) pathognomonic for S.
aureus
Case 6: Labor
o Stages of Labor
 Stage 1: (Latent) begging of uterine contractions and cervical
ripening; cervical dilation < 4cm (upper limit for latent phase is
14 hours). (Active) Cervical dilation from 4-10 cm
 Stage 2: Delivery of the fetus
 Stage 3: Delivery of the placenta (should occur within 30
minutes of the fetal delivery)
 Stage 4: time after the delivery of the placenta
o Clinical Pearls:
 Labor: cervical change accompanied by uterine contractions
 Protraction of the active phase: dilation of the cervix that is
less than expected
 Nulliparous (normal) ≥ 1.2 cm
 Multiparous (normal) ≥ 1.5 cm
 Arrest of the active phase: no cervical dilation in 2 hours
 Fetal hear rate variability:
 Decelerations: three types: early, variable, and late
 Accelerations: 15 bpm lasting at least 15 seconds
 Earl Decelerations: occurs at the same time as the contraction
and is gradual. Benign caused by fetal head compression
 Variable Deceleration: abrupt change in deceleration and
return to baseline. (not a smooth change). Caused by cord
compression
 Late Deceleration: occurs after the contraction peak started
 Abnormal labor the three P’s should be observed. Fetal
hypoxia (uteroplacental insufficiency) and if persistent
fetal acidemia
 Power, passenger, and pelvis
 Power assessment of uterine contractions (2 ways)
o Clinical: occurring every two to three minutes,
firm on palapation, and last 40-60 seconds
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ObGyn Case Files 4
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o 10 minute window: measure of mm Hg of
contraction above baseline = Montevideo unit ≥
200 is sufficient
o If not sufficient give oxytocin
 Fetal heart rate baseline 110-160 bpm
 Fetal tachycardia: variety of reasons (i.e. maternal fever)
 Fetal bradycardia: cord compression (most common)
 Cesarean delivery
 Cephalopelvic disproportion
 Arrest of the active phase with adequate uterine
contractions
Case 7: Threatened abortion
o Clinical Presentation:
 First trimester
 Vaginal spotting
 Lower abdominal pain
 β-hCG < 1500 – 2000 mIU/mL (discriminatory threshold for
US)
o Workup:
 Page 74, Figure 7-1
 Check β-hCG
 ≥ 1500 – 2000 mIU/mL do US
o IUP observed -> monitor closely
o No IUP consider laproscope
 ≤ 1500 – 2000 mIU/mL repeat level in 48 hours
o Normal rise ≥ 66% proabable normal IUP
monitor closely
o Abnormal rise ≤ 66% non viable pregnancy
 D and C
 Positive chorionic villi -.>
misscariage
 Negate villi -> ectopic pregnancy
 Treatment:
 Ectopic pregnancy
o Medical: Intramuscular methotrexate (side
effects lower abdominal pain); asymptomatic
and < 3.5 cm
o Surgical: laproscope
 Non- viable pregnancy
o Surgical: D and C
o Medical: vaginal misoprostol
 If patient presents with vaginal spotting, severe adnexal
pain, and hypotenstion -> laproscope is warranted
Case 8: Placenta Accreta
o Clinical Presentation:
ObGyn Case Files 5
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 Abnormally retained uterus -> indicative of placenta accreta
 Previous history of c-section, or myomectomy
 No cleavage plane of the placenta
o Workup:
 Complication: uterine inversion
o Treatment:
 Abdominal hysterectomy because the risk of hemorrhage
o Clinical Pearls:
 Placenta accreta: placenta adheres to the endometrium and
lacks decidual layer
 Placenta increta: placenta adheres to the myometrium
 Placenta percreta: placenta adheres to through the
myometrium and penetrates to the serosa
 Increase risk of placenta accreta with concurrent placenta
previa
Case 9: Gonococcal Cervicitis
o Differential diagnosis:
 Ectopic pregnancy (ruled out with negative pregnancy test)
 Threatened abortion (ruled out with negative pregnancy test)
 Upper genital tract disease (no lower abdominal pain)
o Clinical Presentation:
 Vaginal discharge
 Post-coital bleeding from endocervix infection
o Workup:
 Rule out pregnancy
 Diagnosis by gram stain and PCR
 N. gonorrhea: one dose ceftriaxone
 C. trachomatis one dose azithromycin or 7 days doxycycline
 Council patient on STD transmission
o Clinical Pearls:
 Gonorrhea is the most common cause of septic arthritis in
young women
 Most common cause of cervicitis/salpingitis ->Chlamydia,
followed by gonorrhea
 Vaginitis with “fishy odor” discharge: bacterial vaginosis
 Sexually transmitted pharyngitis -> gonorrhea (Chlamydia
does not cause pharyngitis)
 N. gonnorhea infection: cervicitis, septic arthritis, skin pustular
eruptions
 Gram negative diplococci -> N. gonorrhea
 Chlamydia and gonorrhea frequently coinfect
 Infant blindness
 Few hours after birth: chemical
 2-3 days old: Gonorrhea infection
 4-7 days old: Chlamydia infection
ObGyn Case Files 6
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Case 10: Complete Abortion
o Clinical Presentation:
 Less than 20 weeks gestation
 Abdominal pain, vaginal spotting
 Passage of fetal tissue (looks like a liver)
 Closed cervix
o Workup:
 Monitor βhCG levels to see that they are halved every 48-72
hours
 If not D and C is recommended
o Clinical Pearls:
 Threatened abortion: before 20 weeks gestation, vaginal
spotting, and without cervical dilation
 Inevitable abortion: before 20 weeks gestation, vaginal
spotting, and cervical dilation, no passage of fetal tissue yet
 Incomplete abortion: before 20 weeks gestation, vaginal
spotting, abdominal pain, passage of some fetal tissue, and
the cervix remains open with uterine contractions
 Tx: D and C
 Completed abortion: before 20 weeks gestation, expulsion of
all of the fetal tissue, and the cervix is closed
 Miss abortion: before 20 weeks gestation fetal demise without
symptoms of bleeding or cramping
 Differentiation between inevitable abortion and incompetent
cervix is +/- uterine contractions respectively
 Page 98
 Molar pregnancy: vaginal spotting, absence of fetal heart
tones, Fundal size greater than gestational dates. Diagnosis is
made by sonography
Case 11: Shoulder dystocia
o Risk Factors:
 Fetal macrosomia, maternal obesity, prolonged second stage of
labor, and gestational diabetes
o Clinical Presentation:
 Delivery of the head with retraction against the itroitus “turtle
sign”
o Treatment:
 McRoberts maneuver: placing the mother’s legs against the
chest -> increases the anterior rotation of the pubic symphysis
 Suprapubic pressure: displaces the fetal shoulder axis from
anterior-posterior to oblique
 Wood’s corkscrew maneuver: progressively rotating the
posterior shoulder 180 degrees
 Delivery of the posterior arm: decreases the fetal bony
diameter from the shoulder to the axilla
ObGyn Case Files 7
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 Zavanelli maneuver: shove the head back in and deliver by CS
o Clinical Pearls:
 Shoulder dystocia: delivery of the head with an inability of the
fetal shoulders to deliver spontaneously
 ERB palsy: brachial plexus injury from shoulder dystocia ->
waiter’s tip position
 Maternal complication of postpartum hemorrhage
 Fundal pressure is CONTRAINDICATED!!!!
Case 12: Ureteral injury post hysterectomy
o Clinical Presentation:
 Post-op from TAH/BSO presenting with fever and flank pain
o Workup:
 Intravenous pyelogram
 CT scan with contrast of the abdomen
o Treatment:
 IV antibiotics and the placement of a ureter stent (via
cystoscopy or percutaneous nephrostomy: placement of the
stent through the skin guided by radiology)
o Clinical Pearls:
 Cardinal ligaments:
 Connect the cervix to the posterior abdominal wall
 Contain the uterine arteries -> which pass of the ureter
and is a possible site for ureter injury in TAH
 Infundibular pelvic ligament:
 Contains the ovarian artery -> injure the pelvic brim of
the renal collecting system
 Bladder lacerations
 Top: suture up and good to go
 Lower segment (trigone area): may require ureter stent
 Meticulous dissection of the uterine aretery can lad to uterter
ischemia
 Vesicovaginal fistula: leakage from the vagina
Case 13: Postmenopausal Bleeding
o Differential diagnosis:
 Endometrial cancer
 Atrophic endometrium/vagina
 Endometrial polyp
o Clinical Presentation:
 Post-menopausal bleeding
o Workup:
 Endometrial biopsy followed by…
 Hysteroscopy
 Transvaginal ultrasound
 Endometrial strip greater than 5 mm is abnormal in
postmenopausal bleeding
ObGyn Case Files 8
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o Treatment:
 Surgical therapy TAH
o Risk Factors:
 Obesity, diabetes, HTN, prior anovulation (irregular menses),
late menopause, and nulliparity, PCOS, unapposed estrogen
exposure with no progesterone
o Clinical Pearls:
 Endometrial polyps: growth of endometrial glands and stroma,
which projects into the uterine cavity
 Atrophic endometrium: most common cause of postmenopausal bleeding
 Postmenopausal bleeding is endometrial carcinoma until
proven otherwise
 Surgically staged
 Endometrial carcincoma are the most common gyn.
Malignancy
 Presentation in an atypical patient (without risk factors) tends
to be a more aggressive disease
Case 14: Placenta Previa
o Differential diagnosis:
 Placenta previa: placenta lies near or covers the internal os
 Complete: covers the entire internal os
 Incomplete: covers part of the internal as
 Marginal: covers up to the internal as border
 Low-lying: not near the internal os, but is located low in
the pelvis
 Placenta abruption
 Separation of the normally implanted placenta
 Vasa previa
 Umbilical cord vessels insert into the membranes with
the vessels overlying the internal cervical os -> being
vulnerable to fetal exsanguination
o Clinical Presentation:
 Painless third trimester bleeding (antepartum bleeding:
bleeding after 20 weeks gestation)
o Workup:
 Ultrasound -> speculum examination -> digital examination
o Treatment:
 ABC of Mom, if hemodynamically stable wait til further in
gestation to deliver
 CS delivery at 36-38 weeks
o Clinical Pearls:
 Placenta previa, unlike placenta abruption, rarely leads to
coagulopathy
 Risk Factors for placenta previa
ObGyn Case Files 9
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Grand multiparity, prior CS, prior uterine curretage,
previous placenta previa, multiple gestation
 A low lying/marginal placenta in the early second trimester
should be monitored, but is of no concern because it should
migrate superior as the uterus grows
 Placenta previa increases the risk of placenta acreta
Case 15: Placental Abruption
o Differential diagnosis:
 See Case 14 placenta previa
o Clinical Presentation:
 Painful antepartum bleeding
o Workup:
 Serial Hb levels, fundal height, assessment of FHR
 Kleihauer-Best Test: differentiates between maternal and fetal
blood by the addition of the acid. Is based of the solubility of
maternal and fetal Hb
o Treatment:
 ABC of Mom
 If stable: expectant management
 Unstable: delivery (CS preferred)
o Clinical Pearls:
 Risk Factors: HTN, cocaine, short umbilical cord, trauma,
uteroplacental insufficiency, submucous leiomyomata, sudden
uterine decompression, smoking, Preterm PROM
 Concealed abruption: when the bleeding occurs behind the
placenta
 Fetamaternal hemorrhage: fetal blood enters maternal
circulation -> isoimmunization
 Couvelaire uterus: bleeding into the myometrium of the uterus
giving s discolored appearance to the uterus
 US is not helpful in the diagnosis
 Comlications:
 Uterine atony -> postpartum hemorrhage
 Coagulopathy: hypofibrinogenemia (below 100-150
mg/dL)
 Post-partum: HTN and Preeclampsia
Case 16: Cervical Cancer
o Clinical Presentation:
 Abnormal vaginal bleeding, postcoital spotting, and
malodorous discharge (necrotic tumor)
 Pelvic examination -> observed lesion
 Advance disease: ureter obstruction and spread to the
uterosacral/cardinal ligaments
o Workup:
 Screening test: Pap smear
ObGyn Case Files 10
Abnormal Pap: colposcopy with biopsies
Cervical carcinoma: cervical biopsy of the lesion (not a Pap
smear)
o Treatment:
 Early cervical carcinoma: radical hysterectomy (hysterectomy,
removal of cardinal and uterosacral ligaments, and removal of
the vaginal cuff)
 Advanced cervical carcinoma: radiation (brachytherapy:
radioactive implants near the tumor bed; teletherapy: external
beam of radiation)
 Prevention: HPV vaccine -> serotypes 16, 18, 6, and 11
o Clinical Pearls:
 CIN: pre-invasive lesions the cervix with cellular atypia
 Cervical carcinoma risk factors: early age of coitus, STD, early
childbearing, HPV, smoking, multiple sexual partners
 Most common site for lesions to arise is the squamocolumnar
junction
 Cervical carcinoma spread: cervix -> cardinal ligaments and
pelvic walls
 Colposcopy guided biopsy stains:
 Acetic acid: ppt cellular proteins changing the atypical
cells white
 Lugol’s iodine: stains normal cells with high glycogen
o Pap Smear:
 Screening test started 3 years after onset of sexual activity or
by age 21 -> annular pap until age 30
 After 3 consecutive negatives at 30 may screen every 2-3 years
 Hysterectomy with no history of cervical dysplasia no longer
require Pap
 Hysterectomy with a history of cervical dysplasia requires Pap
of the vaginal cuff
 After 65 yo with NO history of cervical dysplasia no longer
require Pap smear
 Cytology
 ASCUS, LSIL, HSIL
 AGUS
Case 17: Sheehan Syndrome (post-partum amenorrhea)
o Differential diagnosis:
 Post-partum amenorrhea
 Pregnancy (negative pregnancy test)
 Sheehan syndrome (anterior hypopituitarism:
hypoprolactinemia, hypothyroidism,
 Asherman syndrome (intrauterine adhesions)
o Follows D and C -> scarred endometrium
 Amenorrhea
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ObGyn Case Files 11
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PCOS: estrogen excess without progesterone, obesity,
hirsutism, and glucose intolerance
 Hypoestrogen
o Hypothalamic/pituitary dysfunction (low FSH)
o Ovarian failure (elevated FSH)
o Clinical Presentation:
 Post-partum hemorrhage
 Post-partum amenorrhea with evidence of anterior
hypopituitarism (inability to breast feed)
o Workup:
 Pregnancy test… if negative
 Evaluate pituitary function
 Sheehan syndrome
o Anterior hypopituitarism
o Will respond to OCP
 Asherman syndrome
o Normally functioning ant. pituitary
o Will not respond to OCP
o Treatment:
 Sheehan syndrome: replacement of hormones (T4, cortisol,
mineralocorticoids) and OCP
 Asherman syndrome: hysteroscopic resection of scar tissue
Case 18: Fetal Bradycardia (cord prolapse)
o Differential diagnosis:
 Cord prolapse
 Uterine rupture with prior CS
o Clinical Presentation:
 Fetal bradycardia after artificial rupture of membranes
 PE of the vagina demonstrates cord
 Trendelenburg position
o Workup:
 PE of the vaginal vault
 Confirm fetal heart rate (fetal scalp electrode or US)
 Improve maternal oxygenation and CO
 Position changes
 Oxygen
 IV fluids/pressors: ephedrine (hypotension from
epidural)
 Discontinue oxytocin
o Treatment:
 Push the presenting part superior in the vagina to relieve
pressure on the cord
 CS
o Clinical Pearls:
 Risk factors for cord prolapse
ObGyn Case Files 12
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Artificial rupture of membrane with unengaged fetal
part
 Transverse fetal lie
 Footling breech
 Engagement: The fetal part has passed the bony pelvic inlet
 Variability
 Increase in FHR 6-25 bpm for15 seconds (moderate)
 Indicative of good fetal oxygenation
 Absence of can be due to sedatives or fetal acidosis
 Decelerations -> Case 6
Case 19: Galactorrhea Due to Hypothyroidism
o Differential diagnosis:
 Primary hypothryoidism (TRH may act as a prolactin releasing
hormone)
 Pituitary adenoma (bilateral hemianopsia and headaches)
 Pregnancy (positive pregnancy test)
 Chest wall trauma
 Hypothalamic dysfunction
o Clinical Presentation:
 Galactorrhea, oligo/amenorrhea
 Nipple discharge will be have fat droplets
o Workup:
 History and Physical for possible drug reactions
 Pregnancy test
 Serum levels of prolactin and TRH, TSH, thyroxine
o Treatment:
 Hypothyroidism- > thyroxine hormone supplementation
 Pituitary adenoma -> transphenoid microsurgery
 Medical
 Bromocriptine/cabergolamine: dopamine agonist
o Clinical Pearls:
 Hyperprolactinemia inhibits the pulsing of GnRH, which
inhibits the cyclic releaes of FSH and LH resulting in the
amenorrhea and galactorrhea. Lack of FSH and LH cycling
leads to hypoestrogen -> osteoporosis
 Galactorrhea with normal menses indicates that the
hypothalamus is function normally and can rule out
hypothalamic dysfunction
 MRI is the most sensitive imaging test for pituitary adenoma
Case 20: Pruiritus (Cholestasis) of Pregnancy
o Differential diagnosis:
 Cholestasis of pregnancy
 Systemic itching and lack of a rash
 Pruritic Urcticarial paupules of pregnancy:
ObGyn Case Files 13
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Erythematous papules with a white halo and hives that
start on the abdomen and spread to the buttocks
 Histology shows lymphocytic and histiocyte invasion,
but is ne
 Herpes gestationis
 NOT associated with HSV
 Intense itching and vesicles on the abdomen and
extremities
 Diagnosis confirmed by IF positive for IgG+C3 in the BM
o Clinical Presentation:
 Systemic itching +/- jaundice
 No elevation of liver enzymes (important to differentiate it
from hepatitis which will have elevated liver enzymes)
o Workup:
 Serum bile acid levels
 Liver enzymes
o Treatment:
 Cholestasis of pregnancy -> antihistamines, cornstarch bath,
ursodeoxycholic acid (increase secretion of bile acids)
 Pruritic Urcticarial paupules of pregnancy (PUPP) -> topical
steroids and antihistamines
 Herpes gestationis -> ORAL steroids
o Clinical Pearls:
 INTRAHEPATIC cholestasis of pregnancy
 If associated with jaundice has an increase incidence of
prematurity, fetal distress and fetal loss
 Herpes Gestationis
 NOT related to HSV
 Maternal development of anti-BM IgG which leads to
deposition of IgG + C3 in the BM causing vesicles
Case 21: Salpingitis, Acute
o Differential diagnosis:
 Pyelonephritis, appendicitis, cholecystitis, diverticulitis,
pancreatitis, ovarian torsion, and gastroenteritis
o Clinical Presentation:
 Cervical motion tenderness, abdominal tenderness, adnexal
tenderness
o Workup:
 Clinical diagnosis; see clinical presentation
 Pregnancy test
 Chlamydia and gonorrhea test
 US for TOA
 Laparoscope is the gold standard for diagnosing PID
o Treatment:
 Inpatient: cefotetan and doxycycline
ObGyn Case Files 14
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 If it does not resolve in 48-72 hours laparoscope
o Clinical Pearls:
 PID: synonymous with acute salpingitis
 Cervical motion tenderness: tell tale sign of salpingitis
 Tubo-ovarian abscess: collection of purulent material around
the distal tube and ovary; usually treated with by antibiotic
therapy before drainage
 Acute salpingitis with RUQ pain is indicative of Fitz-HughCurtis syndrome
 Etiology: Chlamydia, gonorrhea, and polymicrobial
 IUD increases risk of PID
 OCP decreases risk of PID
 Long term sequelae: chronic pelvic pain, ectopic pregnancy,
involuntary infertility
Case 22: Pulmonary Embolus of Pregnancy
o Differential diagnosis:
 Reactive airway disease, pneumonia, pulmonary embolis
o Clinical Presentation:
 Dyspnea, acute onset, pleuritic chest pain, lungs: CTAB,
hypoxemia, clear chest x-ray
o Workup:
 Page 192; Figure 22-1
 Pulse oximetry and arterial blood gas
 Diagnosis of PE is made by a spiral CT, MRI angiography,
o Treatment:
 IV heparin 5-7 days and then switched to subq heparin to
maintain an aPTT at 1.5-2.5x control for three months
o Clinical Pearls:
 Etiology: hypercoagulable state of pregnancy -> high estrogen
and mechanical effect of venous stasis
 Other etiologies: Protein C and S resistance,
antithrombin III activity, Factor V Lieden mutation,
hyperhomocysteinememia, antiphospholipid syndrome
 Dyspnea: most common symptom of PE, tachypnea: most
common sign of PE
 Asthma: initially hyperventilation and decrease in PCO2 as the
patient begins to weaken PCO2 increases
 Page 193; Table 22-1
Case 23: HSV infection in Labor
o Clinical Presentation:
 Prodrome: tingling, burning, or itching of the perineal region,
o Workup:
 Acyclovir
 Primary infection: reduces viral shedding, pain
symptoms, and faster healing
ObGyn Case Files 15


 Prophylaxis: decrease symptoms and the need for a CS
o Treatment:
 Absence of herpetic lesions or prodrome symptoms -> patient
opt for a vaginal delivery
 Presence of herpetic lesions of prodrome symptoms -> CS
o Clinical Pearls:
 Neonatal HSV:
 Majority occurs through exposure of fluids during birth
 It can be systemic or localized
 5-10% may become infected transplacentally, but this
usually occurs during the primary infection
 Syphilis: 1st stage small, round painless chancre
 Chancroid: H. ducreyi painful genitial lesions
 Bartholin glands: painless abscesses at the entrance of the
vagina
 Vulvar carcinoma: nontender, ulcerative, and more common in
post-menopausal women
Case 24: Uterine Leiomyomata
o Differential Diagnosis
 Ovarian mass: lateral position
 Endometrial hyperplasia, polyp or uterine cancer:
metrorrhagia
 Pelvic kidney, TOA, endometrioma
o Clinical Presentation:
 Menorrhagia, enlarged midline mass that is irregular, and
contiguous with the cervix
o Treatment:
 OCP and NSAIDS
 GnRH agonists (most effective in first three months for
shrinking the fibroid
 Uterine artery embolization or myomectomy -> attempt to
preserve fertility
 Definitive treatment is hysterectomy
o Clinical Pearls:
 Carneous (red) degeneration: changes of the leiomyomata due
to rapid growth; the center becomes red, causing pain
 Most common tumor of the female pelvis and is leading
indication for hysterectomy
 Submucosal fibroids and the most likely associated with
recurrent abortions -> difficulty with fertility and embryo
implantation
 Leiomyosarcoma is differentiated from lieomyoma based on
different growth rates
Case 25: Preeclampsia and Hepatic Rupture
o Clinical Presentation:
ObGyn Case Files 16
Preeclampsia with severe onset of epigastric pain, abdominal
distension, syncope, hypotension, and tachycardia
o Workup:
 Labs: CBC, urinalysis, 24 hours protein collection, CMP, LDH,
and uric acid test
 Fetal testing : BPP
o Treatment:
 Page 219; Figure 25-1
 Delivery of the fetus
 MgSO4: seizure prevention
 HTN: postpartum treated with hydralazine or labetalol
o Clinical Pearls:
 Chronic HTN: BP 140/90 before 20 wks gestation
 Gestational HTN: BP 140/90 after 20 wks gestation
 Preeclampsia: HTN, proteinuria > 300 mg in 24 hours, and
edema at a gestational age greater than 20 wks due to
vasospasm (mild BP 140-160/90-110)
 Eclampsia: preeclampsia + seizures
 Severe preeclampsia: BP >160/110 (can be systolic, diastolic
or both), proteinuria > 5g in 24 hours or urine dipstick with 3+
or 4+ proteinuria
 Superimposed preeclampsia: preeslampsia in a patient with
chronic HTN
 Complications of preeclampsia are: placental abruption,
eclampsia, coagulopathies, hepatic rupture, hepatic capsular
hematoma, and uteroplacental insufficiency
 MgSO4 toxicity:
Case 26: Fibroadenoma of the Breast
o Differential diagnosis:
 Fibroadenoma: benign, smooth muscle tumor of the breast;
most common breast mass; does NOT respond to hormones
 Fibrocystic changes: lumpy-bumpy breast; most common
benign breast condition; lobules become swollen and cystic
that become fibrotic
 CP: cyclic, painful, engorged breast right before
mestruation
 Tx: decrease caffeine, NSAIDS, proper bra, OCP and oral
progestin
o Clinical Presentation:
 Firm, nontender, rubbery mass
o Workup:
 Core needle biopsy: 14-16 gauge needle used to extract tissue
and preserves cellular architecture


ObGyn Case Files 17
Fine needle aspiration: small gauge needle with associated
vacuum to aspirate fluid and cells from a breast mass or cyst,
does not preserve cellular architecture
 Triple assessment: clinical examination, US/Mammogram, and
histology (less than 35 may use FNA b/c less likely to be
malignant cancer
o Treatment:
 Small mass and not growing may choose to leave alone, but
most women opt for lumpectomy
 Over the age of 35, + Family Hx, or discordinant triple
assessment warrants further investigation: (excisional biopsy
or core needle biopsy)
Case 27: Infertility, Peritoneal Factor
o Differential diagnosis:
 Five basic factors of infertility: ovulatory, uterine, tubal, male
factor, and peritoneal factor (endometriosi/cervical factor)
o Clinical Presentation:
 Infertility: inability to conceive after 1 year of unprotected
intercourse
 Primary never been able to get pregnancy
 Secondary has a past history of pregnancy
o Workup:
 Ovulatory:
 Basal body temperature looking for a biphasic profile ->
rise occurs after ovulation and is due to progesterone
 Urine LH kit
 Progesterone levels
 Uterine problem: hysterosalpingogram (more common with
recurrent pregnancy loss not infertility)
 Tubal problem: hysterosalpingogram; laparoscope which is the
gold standard for diagnosis
 Male factor problems: semen analysis
 Peritoneal factor: laparoscope gold standard for diagnosis
 Cervical factor: too thick cervical mucous for the sperm to get
to the egg, rare, treated with intrauterine insemination
o Treatment:
 Surgery is the main treatment for tubal abnormalities or
endometriosis
o Clinical Pearls:
 Endometriosis: three D’s: dysmenorrhea, dyspareunia, and
dyschezia
 Fecundability: probability of achieving a pregnancy within one
mestrual cycle
Case 28: Abdominal Pain in Pregnancy (Ovarian Torsion)
o Differential diagnosis:



ObGyn Case Files 18

 Page 238; Table 28-1
o Clinical Presentation:
 More common at 14 wks gestation (uterus clears pelvic brim)
or postpartum
 Acuter onset unilateral abdominal or pelvic pain
 Nausea and vomiting
 NO fever, NO leucocytosis
o Workup:
 Usually differentiated based on history and physical exam
o Treatment:
 Surgical intervention
 Necrotic: removal of the ovary
 Ischemia: release the torsion -> untwist the pedicle
o Clinical Pearls:
 Ovarian torsion: is the most frequent and serious complication
of a benign ovarian cyst;
Case 29: Ectopic Pregnancy
o Differential diagnosis:
 Page 248; Table 29-2
o Clinical Presentation:
 Amenorrhea, vaginal spotting, abdominal pain, no intrauterine
pregnancy (IUP) observed
o Workup:
 hCG levels:
 >66% rise in 48 hours is indicative of a viable (IUP)
 <66% rise in 48 hours is indicative of abnormal
pregnancy (i.e. ectopic)
 Progesterone
 >25 ng/mL indicative of IUP
 <5 ng/mL indicative of an abnormal pregnancy
 US
 Crown-rump length or yolk sac -> + IUP
 Gestational sac is not a definitive measure of the
presence of an IUP because an ectopic can produce a
pseudogestational sac
 If no IUP is detected laparoscope is indicated for definitive
diagnosis
o Treatment:
 Surgical
 Preserve fertility: salpingostomy
 Do not wish to preserve fertility: salpingectomy
 Medical
 Pregnancy less than 4 cm methotrexate
o Clinical Pearls:
ObGyn Case Files 19
Plateau in hCG levels after 8 wks is indicative of miscarriage or
ectopic
Case 30: Anemia of Pregnancy (thalassemia)
o Differential diagnosis:
 Iron deficiency anemia: increase in demand
 Beta thalassemia
o Clinical Presentation:
 Microcytic anemia with normal iron levels and ferritin
 Elevated Hb A2 on electrophoresis
 NOTE: Elevated HbF indicative of alpha thalassemia
o Workup:
 CBC, Iron, Ferritin levels, Hb electrophoresis
o Treatment:
 Fe deficiency anemia: treatment with Fe for 3 - 4 weeks
 Beta thalassemia minor: no treatment indicated, monitor
o Clinical Pearls:
 Most common cause of megaloblastic anemia in pregnancy is
folate deficiency
 G6PD: hemolytic anemia following reducing drugs
(sulfonamides, nitrofurantoin, and antimalarial)
 NOTE: nitrofurantoin is a common drug used to treat
UTI in pregnancy




Case 31: Preterm Labor
o Clinical Presentation:
 Contractions with cervical change between the weeks 20-37
o Workup:
 Page 266 Table 31-2
 Fetal fibronectin: + may or may not be preterm labor – preterm
labor
 If in preterm labor: begin tocolysis, steroids (weeks 24-34),
GBS prophylaxis (penicillin)
 Cervical length assessment: TVUS -> less than 25 mm increase
risk in preterm labor
 Weekly injections of 17-hydroxyprogesterone caproate from
weeks 20 – 36 to prevent preterm
o Clinical Pearls:
 Tocolytic agents: Page 267 Table 31-3
 Gonococcal cervicitis strongly associated with preterm labor
(Chlamydia is not)
 Dyspnea on tocolysis is usually due to pulmonary edema

Case 32: Bacterial Cystitis
o Differential diagnosis:
ObGyn Case Files 20
Bacterial cystitis (E. coli), cervicitis (gonorrhea, chlamydia; no
growth on the urine culture), candidal vaginitis, and urethral
syndrome (urgency and dysuria caused by inflammation; urine
cultures are negative)
o Clinical Presentation:
 Dysuria, frequency, urgency
o Workup:
 UA and Urine culture
 Acute pyelonephritis: in pregnancy after treatment standard of
care is antibiotic prophylaxis to term
o Clinical Pearls:
 Pyelonephritis: UTI symptoms + flank tenderness and fever
 Asymptomatic bacturia has a high incidence in women with
sickle cell trait
Case 33: Contraception
o Clinical Pearls:
 Emergency contraception:
 Yuzpe method: two high doses of the combination pill
within 72 hours
o High incidence of N/V
 Plan B: two high doses of progesterone within 72 hours
 Copper IUD within 5 days
 OCP: decrease risk of endometrial and ovarian cancer
 Contraceptive patch has an increase risk of DVT
 35 yo and smoker is a contraindication for OCP
 Pages 283-285 Table 33-2
Case 34: Pyelonephritis, Unresponsive
o Clinical Presentation:
 Acute pyelonephritis: UTI symptoms plus flank pain and fever
 48 to 72 hours after the administration of antibiotics
(cephalosporin or ampicillin and gentamicin) there is not
response -> high risk for progression to ARDS
 Consider ureterolithiasis or perinephric abscess
 ARDS alveolar and endothelial damage leading to leaky
pulmonary capillaries caused by endotoxins, clinically causing
hypoxemia, large alveolar-arterial gradient, and loss of lung
volume (dyspnea and tachypnea)
 Temporary increase in creatinine and liver enzymes
o Treatment:
 ARDS: oxygenation and fluid management in severe cases
mechanical ventilation
o Clinical Pearls:
 Most common cause of sepsis in pregnant women is
pyelonephritis



ObGyn Case Files 21
Pregnancy with a case of acute pyelonephritis post treatment
has to be treated with antibiotic prophylaxis for the rest of the
pregnancy
Case 35: DVT in Pregnancy
o Clinical Presentation:
 Calf pain (deep linear cords), leg edema, increase in leg size
o Workup:
 Doppler flow (pregnant) and venography (not pregnant)
o Treatment:
 Bed rest and extremity elevation
 Heparin
 IV for 5-7 days, followed by oral heparin to reach
therapeutic dosing for three months, and then heparin
prophylaxis until 6 wks post partum
 MOA: stabilizes antithrombin and prevents clot
propogation
 Complications: osteoporosis and thrombocytopenia
o Clinical Pearls:
 Risk of DVT increases in pregnancy because of
hypercoagulable state (increase in clotting factors particularly
fibrinogen) and mechanical stasis induced from the gravida
uterus
 DVT complication is pulmonary embolism
Case 36: Dominant Breast Mass
o Clinical Presentation:
 Mobile, non-tender mass
o Workup:
 Mammography, US, FNA (less than 35), excisional biopsy/core
needle biopsy (greater than 35)
o Treatment:
o Clinical Pearls:
 Age is the most important risk factor for breast cancer
 Invasion of lymph nodes is the most important factor for
prognosis
 BRCA1 chromosome 17 mutation; BRCA2 chromosome 13
mutation; autosomal dominant inheritance
 Genetic testing for BRCA1/2 is required for two first degree
relatives with breast cancer
 3D breast mass, must be biopsied irregardless of imaging
results
 When to get a mammogram
 20-39: every 3 years
 40-49: every 2 years and yearly breast exam
 50+: annual breast exam



ObGyn Case Files 22
Most common cause of serosenguinous nipple discharge from a
single duct is intraductal papilloma
 Infiltrating intraductal carcinoma is the most common
histological type
Case 37: Ovarian Tumor (Struma Ovarii)
o Differential diagnosis:
 Benign or Malignant; gonadal, stromal, or epithelial ovarian
tumors
o Clinical Presentation:
 Complex cystic tumor, unilateral (multilobulated with thick
setpae)
 Symptoms of hyperthyroidism, but a normal physical exam for
the thyroid
o Workup:
 TVUS of the cyst to evaluate the mass and laparotomy with
ovarian cystectomy
o Germ Cell Tumors:
 Most common is a benign cystic teratoma (dermoid cyst)
 The most common tissue type is squamos, but the
dermoid can contain all three germ layers
 Complications: torsion of the ovary or rupture (rare)
 Immature teratoma/malignant teratoma
 Contains all three germ layers and the amount
immature neural elements determines the grade
 Grade I: treat with salpingoophrectomy
 Grade II-III: salpingoophrectomy and chemotherapy
o Epithelial Tumors:
 Serous: psammoma bodies; most common; bilateral
 Mucinous: unilateral; large; may rupture and lead to
pseudomyxoma peritoneii
 Endometroid: presence of endometrial glands
 Elevated CA125, but is nonspecific in reproductive women
o Stromal tumor:
 Granulosa theca cell tumor: solid and secretes estrogen
 Sertoli-leydig cell tumor: solid and secretes androgens
o Functional Cysts:
 Follicular, corpus luteal, and thecal-lutein
o Clinical Pearls:
 The presence of ascites on US is indicative of a malignant
process
 Page 316 Table 37-3
 Ovarian cancer staging: TAHBSO, lymph nodes, ascites,
omentum
Case 38: Fascial Disruption
o Differential diagnosis:



ObGyn Case Files 23
Superficial wound infection, wound dehiscence, fascial
disruption, evisceration
o Clinical Presentation:
 Larger volume of a serosanguinous fluid from the abdomen,
 Risk factors: vertical incision, obesity, DM,corticosteroid,
infection, increasing intra-abdominal pressure
o Treatment:
 Superficial wound infection: surgical drainage of the wound
and broad spectrum antibiotics
 Wound Dehiscence: surgical closure and broad spectrum
antibiotics
 Fascial Disruption: surgical repair and broad spectrum
antibiotics
 Evisceration: covering the bowel with a moist towel and
immediate surgical repair
o Clinical Pearls:
 Wound dehiscence: separation of the surgical incision with
peritoneum remaining intact
 Fascial disruption: disruption of the peritoneum and pannus
 Evisceration: fascial disruption with protruding bowel
 Wound dehiscence risk factors same as fascial disruption
 Most common cause of fascial disruption is the suture tearing
through the fascia
 Differentiation of lymphatic drainage and urinary tract fistula
is evaluation of the creatine level in the draining fluid from the
incision (elevated creatinine in urine)
 Superficial wound infection usually occurs due to infection or
hematoma
Case 39: Abdominal Pain In Pregnancy (Ruptured Corpus Luteum)
o Differential diagnosis:
 Ectopic pregnancy (most common cause of hemoperitoneum),
ruptured endometrioma, adnexal torsion, appendicitis, splenic
injury/rupture
o Clinical Presentation:
 Symptoms of hemorrhagic shock (tachycardia, hypotension,
syncope) and hemoperitoneum (abdominal pain, abdominal
distension, rebound tenderness, positive fluid wave)
o Workup:
 US demonstrating free fluid in the peritoneum which is
confirmed by laparoscope
o Treatment:
o Clinical Pearls:
 Corpus luteal cyst: grow under the influence of hCG and up to
weeks 10-12 produce the majority of the progesterone
required for pregnancy.


ObGyn Case Files 24



The cyst can have intrafollicular bleeding which may
become excessive leading to rupture and bleeding into
the peritoneum
 Carneous degeneration of a leiomyoma typically presents with
localized tenderness over the fibroid
 The first sign of hypovolemia is decreased urine output
 If cystectomy is performed before weeks 10-12 supplemental
progesterone should be given to prevent abortion
 Vaginal tissue discharge can be tested for the presence of
chorionic villi by the addition of the tissue to normal saline… if
the tissue floats in a frond pattern it is indicative of chorionic
villi and supports the diagnosis of an intrauterine pregnancy
 Hemorrhagic corpus luteum usually occurs in women with
bleeding tendencies
Case 40: Secondary Amenorrhea (intrauterine adhesions)
o Differential diagnosis:
 Pregnancy, hypothalamic/pituitary dysfunction, ovarian
dysfunction
o Clinical Presentation:
 Secondary amenorrhea post endometrial trauma (D and C)
o Workup:
 Pregnancy test, FSH and LH levels, Estrogen levels, basal body
temperature plot, trial OCP/progesterone withdraw, TSH,
prolactin levels
 Hysterosalpingogram/hysteroscopy (diagnostic gold standard)
o Treatment:
 Surgical hysteroscopy, placement of IUD or pediatric foley
catheter to prevent further adhesions, OCP
o Clinical Pearls:
 Intrauterine adhesions (Asherman syndrome) sin qua non is
endometrial trauma, especially to the basalis layer
 Myometrial adhesions have a worst prognosis
 CP: positive ovulation, normal hypothalamic and pituitary fnx,
with cyclic abdominal cramping post D and C and cone biopsy
-> diagnosis: cervical stenosis preventing passage of products
of menstration -> increase incidence of retrograde mestruation
and endometriosis
Case 41: Breast, Abnormal Mammogram
o Case 36: Dominant Breast Mass
o Clinical Pearls:
 A history of breast trauma with calcifications in the same area
is indicative of fat necrosis. However, a confirmatory biopsy is
still required
 Modern mammogram has no increase risk of malignancy
ObGyn Case Files 25
All breast masses or positive mammograms have to be
confirmed by biopsy
Case 42: Primary Amenorrhea, Mullerian Agenesis
o Differential diagnosis:
 Pregnancy, Turner syndrome (lack breast development),
androgen insensitivity (lack pubic and axillary hair), mullerian
agenesis (+ breast development and pubic/axillary hair; may
be positive for renal abnormalities)
o Clinical Presentation:
 Mullerian agenesis: Tanner stage IV for both breast and
pubic/axillary hair development, with renal abnormalities
 Androgen insensitivity: Tanner state IV for the breast, but
underdeveloped pubic/axillary hair
o Workup:
 Serum testosterone levels and karyotype
o Treatment:
 Androgen insensitivity: gonadal dysgenesis -> high risk of
malignant transformation
o Clinical Pearls:
 Estrogen: promotes breast development
 Sources: ovaries, adrenals, and peripheral conversion
 Testosterone: promotes pubic and axillary hair development
 Turner syndrome: lack of breast development and gonadal
dysgenesis
 Kallman syndrome: hypogonadotropic hypogonadism ->
deficiency of GnRH and inability to smell
Case 43: Septic Abortion
o Clinical Presentation:
 Post D and C for abortion presenting with fever and
leucocytosis
 Indications of retained products of conception
 Open cervical os, lower abdominal cramping, vaginal
bleeding
 Cervical motion tenderness and foul smelling discharge
o Workup:
 CBC with differential, Urinalysis, and CMP
o Treatment:
 Maternal ABC, broad spectrum antibiotic therapy (gentamicin
and clindamycin or metronidazole, ampicillin, and an
aminoglycoside), repeat uterine curretage
o Clinical Pearls:
 Septic abortion is caused by an ascending infection
 CT scan positive for air pockets in the myometrium ->
clostridium infection -> treatment with hysterectomy to
prevent significant morbidity and mortality



ObGyn Case Files 26


 Bacteria polymicrobial: streptococci, bacteroides, GBS, staph
Case 44: Postpartum hemorrhage
o Differential diagnosis:
 Uterine atony (most common cause), genital tract lacerations,
uterine inversion, placenta accreta, retained placenta, or
coagualopathy
o Clinical Presentation:
 PPH (>500mL vaginal and >1000mL CS)
 Boggy uterus on palpation
o Treatment:
 Maternal ABC
 Medical therapy
 Begin oxytocin -> methylergevine (contraindicated with
HTN)-> PGF2α (contraindicated with asthma) -> rectal
misoprostol
 Surgical therapy
 Ligation of uterine or internal iliac artery
 B-lynch stitch
 All else fails hysterectomy
o Clinical Pearls:
 Treatment for preeclampsia with MgSO4 increases the risk of
uterine atony
 Late PPH: subinvolution of the placental site occurring 10-14
days postpartum (hematoma from the placenta falls off and
bleeds) -> oral ergot alkaloids is the standard of care
 Risk of uterine atony Page 361 Table 44-1
Case 45: Pubertal Delay, Gonadal dysgenesis
o Differential diagnosis:
 Hypogonadotropic
 Hypogonadism
o Clinical Presentation:
 Delay in puberty (i.e. thelarche -> adrenarche -> growth spurt
-> menarche
o Workup:
 Measurement of FSH levels
 Decreased FSH -> hypogonadotropic
o Eating disorder, XS exercise, cushing syndrome,
pituitary adenomas, and craniopharyngiomas
 Elevated FSH -> hypogonadism
 Decrease estrogen and FSH -> FSH, prolactin, TSH, free
T4, adrenal and ovarian steroids
o Treatment:
 Hormonal therapy (i.e. OCP), HGH, and the prevention of
osteoporosis
o Clinical Pearls:
ObGyn Case Files 27
Most common karyotype of gonadal dysgeneisi is 45XO
Delayed puberty is the lack of secondary sexual characteristics
by age 14
 Primary amenorrhea with normal breast development ->
pregnancy test
Case 46: Breast Abscess and Mastitis
o Differential diagnosis:
 Mastitis/breast abscess
 Galactocele: noninfectious collection of milk in the mammary
duct due to blockage -> nonerythematous fluctuant mass
o Clinical Presentation:
 Breast pain, fever, induration, redness
 If + for fluctuance -> breast abscess
o Workup:
 If physical exam is+ for fluctuance confirm diagnosis with US
o Treatment:
 Mastitis -> S. aureus is the most common etiology and should
be treated with dicloxacillin
 Breastfeeding should be encouraged to prevent breast
abscess
 Breast abscess -> surgical drainage and dicloxacillin
o Clinical Pearls:
 Breast milk lacks vitamin D and needs to be supplemented at 2
months
 Maternal HIV infection is a contraindication to breastfeeding
 Best treatment for cracked nipples is air-drying and the
avoidance of harsh soaps
 Breast engorgement is due to vascular congestion and milk
accumulation -> Tx: breast binder, ice packs, and analgesia
 Note fever will not persist pass 24 hours




Case 47: Thyroid Storm of Pregnancy
o Clinical Presentation:
 Symptoms of hyperthyroidism: tachycardia, nevoursness,
sweating, diarrhea
 Autonomic instability/change in mental status-> hallmark of
thyroid storm
o Treatment:
 Propylthiouracil: inhibits peripheral conversion of T4 to T3
 Side effects: bone marrow aplasia -> increase risk of
sepsis
 Methimazole: similar to PTU, but contraindicated in
pregnancy
 Beta-blocker: to protect the heart
ObGyn Case Files 28

 Acetominophen/cooling blankets: treat hyperthermia
 Corticosteroids: prevent peripheral conversion of T4 to T3
o Clinical Pearls:
 Grave’s disease is the most common cause of hyperthyroidism
in the US -> treated with PTU
 During pregnancy total thyroxine levels increase, but relative
levels of thyroxine are maintained by a corresponding increase
in thyroid binding globulin
 Postpartum thyroiditis
 Postpartum hyperthyroidism patient is more likely to
demonstrate hypothyroidism after the delivery of the
placenta (decrease in corticosteroids) and rise of antimicrosomal/antiperoxidase immunoglobulins
 Maternal hypothyroidism left untreated can lead to neonatal
and childhood neurodevelopmental delays
 Pregnancy thyroid changes
 Increase: total T4, TGB
 Unchanged: free T4, TSH
Case 48: Chlamydial Cervicitis and HIV in pregnancy
o Chlamydia:
 Vertical transmission occurring during L and D causing
neonatal conjunctivitis and pneumonia
 Hence, why it is imperative to have a negative
Chlamydia screen in the third trimester
 It is not prevented by eye drops of erythromycin
prophylaxis -> however, this does work to prevent
gonococcal conjunctivitis
 Has a propensity for transitional and columnar epithelium
 Diagnosed by IF or PCR
 Treatment: amoxicillin for 7 days or one dose azithromycin
 Most common cause of conjunctivitis in the first month of life
 Because of repeat infection repeat testing is prudent in the
third trimester
o HIV:
 Vertical transmission can occur via transplacental, during
delivery, or breastfeeding
 Primary goal of HART therapy with pregnancy is to decrease
the viral load -> decrease the risk of vertical transmission
 Management
 Place Mom on HARRT therapy
 Scheduled CS
 If a vaginal delivery is decided on then IV AZT should be
given during the delivery
 Neonate receives oral AZT for 6 months
ObGyn Case Files 29
Most common method of HIV transmission to women in the US
is via heterosexual intercourse
Case 49: Parvovirus Infection in Pregnancy
o Clinical Presentation:
 Myalgia, lacy red rash, and low grade fever + exposure to a
child with parvovirus (slapped cheek presentation)
o Workup:
 Maternal serology of IgM and IgG antibodies to parvovirus
 US for fetal hydroamnios
 PUBS to diagnose fetal anemia
o Treatment:
 Fetal transfusion
o Clinical Pearls:
 Parvovirus is a single stranded DNA virus. Also called “fifth
disease”
 Fetal infection leads to suppression of RBC production -> fetal
anemia -> hydroamnios -> hydrops fetalis (high output cardiac
failure and third spacing)
 Sinusoidal FHR: FHR pattern is a sine wave every 3-5 minutes
and is indicative of severe anemia/fetal asphyxia
 Maternal Serology: Page 395 Table 49-1
 Causes of hydroamnios: gestation diabetes, isoimmunization,
syphilis, fetal cardiac arrhythmias, and fetal intestinal atresias
Case 50: Postpartum Endomyometritis
o Differential diagnosis: Postpartum Fever
 Atelectasis, pyelonephritis, breast engorgement, wound
infection, endometritis
 Endometritis, wound infection, necrotizing fasciitis, and septic
pelvic thrombophlebitis
o Clinical Presentation:
 Postpartum fever, fundal tenderness, foul smelling lochia
 Usually presents with postpartum fever on day 2
o Treatment:
 Broad spectrum antibiotic therapy
 Gentamicin and clindamycin
 If fever persist past 48 hours of antibiotics add
ampicillin to cover E. coli
 If fever persists 48-72 hours post ampicillin CT exam is
warranted to reveal an abscess or infected hematoma
o Clinical Pearls:
 Endometritis is caused by the ascension of bacteria into the
uterus
 Endometritis is a polymicrobial infection with the predominant
bacteria being anaerobic (i.e. bacteroides)
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Fever PPD #1 -> necrotizing fasciitis -> debridement and
antibiotics to cover streptococcus
 Fever POD #4 -> wound infection -> debridement and
antibiotics
 Septic pelvic thrombophlebitis: bacterial infection of pelvic
venous thrombi, usually involving the ovarian veins -> bacteria
spread from the placental implantation site -> antibiotics +/heparin
 The most common cause of fever post-CS is endomyometritis
Case 51: Syphillis
o Differential diagnosis:
 Syphillis:
 Stage 1: painless chancre and adenopathy +/- pain
 Stage 2: macular/papular rash of palms and soles and
condyloma lata
 Stage 3: cardiovascular abnormalities, neurosyphillis
 HSV: painful vesicular lesions with a sequlae of
encephalitis/urinary retention
 Chancre: painful chancre with ragged edges and a necrotic base
+ painful lymphadenopathy
o Clinical Presentation:
 Painless chancre and usually painless adenopathy
o Workup:
 RPR or VRDL if negative confirm with dark field microscopy
 MHA-TP and FTA-ABS test are used to confirm RPR/VRDL
o Treatment:
 Penicillin… if allergic desesntize and treat with penicillin
 < 1 year treat with one dose IM penicillin
 > 1 year treat with three courses of penicillin at 1 week
intervals
o Clinical Pearls:
 Abrupt increase in RPR titers post treatment is indicative of
reinfection
 Lumbar puncture can be used to diagnosis neurosyphillis
Case 52: Intra-amniotic Infection
o Clinical Presentation:
 PROM, maternal fever, fetal tachycardia, fundal tenderness
 First sign of chorioamnionitis is fetal tachycardia
o Workup:
 Sterile speculum exam showing pooling of the amniotic fluid in
the posterior vaginal vault
 Alkaline changes of the fluid and ferning pattern
 US to reveal oligohydroamnios
o Treatment:
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ObGyn Case Files 31
Less than 32 weeks antenatal steroids and antibiotics (has
been shown to delay pregnancy up to one week)
 After 34-35 wks induction of labor with the addition of
antibiotics (ampicillin/gentamicin) if infection is apparent.
o Clinical Pearls:
 Premature rupture of membranes: rupture of membranes
before the labor
 Complications of PROM: labor, chorioamnionitis, RDS,
placental abruption, and necrotizing entercolitis
 Listeria may induce chorioamnionitis without rupture of
membranes
 GBS and E. coli are the most common organisms to affect
neonates
Case 53: Bacterial vaginosis
o Differential diagnosis:
 Bacterial vaginosis, Trichomonas, and Candida
o Clinical Pearls:
 Page 423 table 53-1
 Organism of wet mount prep T. vaginalis
 Predominance of anaerobes in bacterial vaginosis
 BV and trichomonas are associated with alkaline pH and
positive whiff test
 Candidal vulvovaginitis infections are common in pregnancy
women who are taking broad spectrum antibiotics, diabetic, or
immunosuppressed
 BV is associated with preterm labor, post-partum endometritis,
and PID
 T. vaginalis is associated with an intense inflammatory process
and may induce punctuations of the cervix known as
“strawberry cervix”
Case 54: Hirsutism, Sertoli-Leydig Cell Tumor
o Differential diagnosis:
 Cushing syndrome: buffalo hump, HTN, central obesity, straie,
diagnosed with dexamethasone test
 Adrenal tumor: abrupt increase in DHEA-S (abrupt
presentation of hirsutism); virilization
 Adrenal hyperplasia: hirsutism, virilization, and anovulation;
elevated morning fasting 17-hydroxyprogesterone
 PCOS: elevated testosterone, but is a slow increase in
testosterone so the process of hirsutism is over a period of
years, patient is also obese with anovulatory cycles
 Sertoli-Leydig cell tumor: abrupt onset of hirsutism and
virilization with an ovarian mass
 Page 432 Table 54-1
o Clinical Presentation:
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ObGyn Case Files 32
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 Abrupt onset of hirsutism and virilization with an ovarian mass
o Workup:
 Based of the H and P
 Labs: DHEA-S, testosterone, 17-hydroxyprogesterone,
prolactin, and TSH
o Treatment:
 Sertoi-Leydig cell tumor: surgical excision
o Clinical Pearls:
 Abrupt growth of hirstusim is indicative of a ovarian or adrenal
androgen secreting tumor and slow growth of hirsutism is
indicative of PCOS
 The most common cause of hirsutism and irregular menses is
PCOS
Case 55: Serum Screening in pregnancy
o Clinical Pearls:
 At 16 weeks the fundus of the uterus should be at the levele
between the pubic symphysis and the umbilicus
 At 20 weeks the fundus should be at the level of the umbilicus
 Triple screen weeks 15-21
 Elevated msAFP -> indicative of neural tube defect
 Low msAFP and estradiol with an elevated hCG ->
indicative of Down’s syndrome
 Low msAFP, estradiol, and hCG -> indicative of trisomy
18
 First trimester screen for Down’s syndrome
 Low PAPP-A and beta hCG with thickened nuchal
translucency -> Down’s syndrome
 The genetics for a cleft palate/lip only are multifactorial
 Unexplained elevation of msAFP has an increase risk for still
brith
 Most common cause of abnormal triple screen is wrong dates
 95% of neural tube defects are determined by targeted US
Case 56: PCOS
o Differential diagnosis:
 See Case 54
o Clinical Presentation
 Long-standing history of irregular cycles, obesity, hirsutism,
and acne
o Workup:
 DHEA-S, 17-hydroxyprogesterone, testosterone, prolactin, TSH
 Endometrial biopsy
 Glucose tolerance test
 PCOS diagnosis is one of exclusion
o Treatment:
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OCP: to regulate cycles and decrease unopposed estrogen
exposure
 Diet and Exercise: reduce hyperinsulinemia and
hyperandrogenism
 Clomiphene citrate: to induce ovulation if pregnancy desired
o Clinical Pearls:
 PCOS patients are at an increase risk of developing metabolic
syndrome: DM, cardiovascular disease, hyperlipidemia, HTN
 Stage I endometrial carcinoma and a desire to maintain fertility
treat with high dose progesterone
 Testosterone largely secreted by the ovary and DHEA-S is
largely secreted by the adrenal gland
Case 57: Pelvic Organ Prolapse
o Differential diagnosis:
 Cystocele: Defect in the pelvic muscular support of the bladder
-> anterior pelvic organ prolapse
 Enterocele: Defect in the pelvic muscular support of the uterus
and cervix or vaginal cuff -> central pelvic organ prolapse
 Rectocele: Defect in the pelvic muscular support of the rectum
allowing feces to impinge on the vagina -> difficulty having BM
-> posterior pelvic organ prolapse -> Tx posterior repair
(colporrhaphy)
 Paravaginal defect: defect in levator ani attachments to the
lateral pelvic walls -> vaginal prolapse
o Clinical Presentation:
 Feeling as if something is falling out of the vagina.
 Past medical Hx of multiparity, heavy lifting
o Workup:
 Cystocele: valsalva bladder moves down/positive Q-tip test (60
degreee angle excursion or greater indicates cystocele)
 Rectocele: diagnosed usually by history of difficulty with BM
and the need to apply pressure to the vagina to have a BM
o Treatment:
 Mild -> pelvic floor exercises
 Pessary device
 Sacrospinous ligament fixation
 Sacroplexy fixing the vaginal cuff with using mesh to the sacral
bone
o Clinical Pearls:
 Uterine prolapse:
 Mild above the hymen
 Moderate at the hymen
 Complete beyond the hymen
 Procedentia: entire uterus is prolapsed outside of the
uterus
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Case 58: Twin Gestation with Vasa Previa
o Clinical Pearls:
 Case 14
 Monozygotic twins are associated with a higher rate of fetal
anomalies and maternal complications
 Maternal effects of pregnancy are enhanced in twin gestation:
increase N/V, anemia, BP, etc.
 Twin transfusion syndrome should be considered with growth
discordance and discrepancies in amniotic fluid -> Tx: laser
ablation of arteriovenous malformations
 Twin gestations without a dividing membrane is associated
with a high stillbirth rate due to cord entanglement
 Velamentous cord insertion: umbilical vessels separate before
reaching the placenta -> susceptible to tearing after membrane
rupture
 Chorionicity: number of placentas
 Amnionicity: number of amniotic sacs
 Page 462 Table 58-1
Timing of Division
Resulting chorionicity and amnionicity
First 72 hours
Dichorion/diamnion
Day 4-8
Monochorion/diamnion
Day 8
Monochorion/monoamnion
After day 8
Conjoined twins
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Case 59: Prenatal Care
o Page 467-480 Tables 59-1 to 59-3
Case 60: Lichen Sclerosis and Vulvar Cancer
o Differential diagnosis:
 Lichen planus
 Psoriasis: will have the presence of other silver scaley lesions
 VIN: diagnosed on biopsy
 Vitiligo
 Candida infection: presents with uncontrolled diabetes and
immunosuppression
o Clinical Presentation:
 Pruritus of the anogenital region in a figure eight pattern
 Post-menopausal women
 Itching worsens at night
 Vulva is thinned with a cigarette paper appearance
o Workup:
 Biopsy to rule VIN or vulvar cancer
o Treatment:
 Steroid ointment -> clobetasol
o Clinical Pearls:
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ObGyn Case Files 35
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Lichen sclerosis histology: thinned epidermis, hyperkeratosis,
and loss of the rete pegs
Bartholin gland cyst: polymicrobial infection; treated with
surgical drainage either by a Word catheter or
marsupialization
Lichen sclerosis patients have an increased risk of squamos cell
carcinoma
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