Reproductive (7%)

Updated 2025 PANCE Blueprint (Effective January 2025)

Recent Blueprint Changes (2025):

• Sexually transmitted infections removed from Reproductive System blueprint (now in Infectious Diseases)
• PID moved out of STI grouping (remains in Reproductive System)
• Added: Bartholin gland cysts
• Added: Gender identity to human sexuality topic
• Pregnancy: Singular topic (no longer divided into complicated/uncomplicated)
• Trauma in pregnancy: Added psychological trauma category

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MENSTRUAL DISORDERS

Amenorrhea

• Primary: No menses by age 16
• Secondary: Absence of menses ≥6 months

Dysmenorrhea

• Primary dysmenorrhea: No identifiable pathology; treat with NSAIDs
• Secondary dysmenorrhea: Associated with pelvic pathology (endometriosis, fibroids, PID, etc.)

Premenstrual Syndrome (PMS)

• Symptoms in luteal phase of cycle
• Diagnosis: Prospective symptom tracking
• Treatment: NSAIDs, SSRIs (if severe), lifestyle modification, OCP

Premenstrual Dysphoric Disorder (PMDD)

• PMS with severe symptoms causing significant functional impairment
• Marked mood changes, irritability, depression, anxiety
• Treatment: SSRIs (especially fluoxetine, sertraline), drospirenone-containing OCPs

Abnormal Uterine Bleeding (AUB)

• Mnemonic: PALM COEIN
  • Structural (PALM): Polyp, Adenomyosis, Leiomyoma (fibroids), Malignancy
  • Non-structural (COEIN): Coagulopathy, Ovulatory dysfunction, Endometrial (primary disorder), Iatrogenic (medications, procedures), Not yet classified
• Evaluation: Exclude pregnancy, pelvic exam, ultrasound, consider CBC, coagulation studies, endometrial biopsy if indicated

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CONTRACEPTION

Oral Contraceptive Pills (OCPs)

• Efficacy: 91% (typical use); 99% (perfect use)
• Absolute Contraindications (WHO Category 4):
  • Migraine with aura (increased stroke risk)
  • Age ≥35 and active smoker (cardiovascular risk)
  • Current/history of DVT/PE, thrombophilia
  • Major surgery with prolonged immobilization
  • Uncontrolled hypertension (≥160/100)
  • Migraine without aura can use (lower risk)
• Relative Contraindications: Hypertension (140-159/90-99), diabetes with complications, smoking <15 cigs/day and age <35
• Benefits: Reduced menstrual cramps, regulated periods, reduced ovarian/endometrial cancer risk
• Side effects: Nausea, weight gain, breakthrough bleeding, headache
• Note: Must assess drug interactions (some antibiotics, anticonvulsants decrease efficacy)

Depot-Medroxyprogesterone Acetate (Depo-Provera)

• Efficacy: 99% (best use-dependent contraception)
• Administration: IM injection every 12 weeks (11-13 weeks for safety window)
• Advantages: Long-acting, no daily compliance, private
• Disadvantages:
  • Delayed return to fertility (up to 12 months after last injection)
  • Bone mineral density loss (especially concerning in adolescents/young adults)
• Side effects: Irregular bleeding (may progress to amenorrhea), weight gain, headache
• Monitoring: BMD assessment if concerns or prolonged use

Intrauterine Device (IUD)

• Efficacy: >99% (most effective reversible contraception)
• Types:
  • Copper IUD (Paragard): Non-hormonal, 10 years duration, heavier menses possible
  • Hormonal IUD (Mirena, Kyleena, Liletta, Skyla): Progestin-releasing, lighter/absent periods, 3-7 years duration
• Advantages: Long-term, reversible, low maintenance, safe in breastfeeding
• Insertion: Can be inserted up to 5 days after unprotected intercourse for emergency contraception
• Contraindications: Active infection, unexplained vaginal bleeding, pregnancy, anatomic abnormalities
• Side effects: Cramping, heavier periods (copper), spotting (hormonal IUDs)
• Monitoring: Check strings monthly after insertion

Other Methods

• Barrier methods (condoms, diaphragm): 80-90% efficacy with typical use; STI protection
• Permanent (tubal ligation, vasectomy): >99% efficacy

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REPRODUCTIVE PATHOLOGY

BREAST DISORDERS

Benign

• Fibroadenoma: Benign, painless, mobile lesion; ultrasound for diagnosis
• Fibrocystic Changes: Periodic pain in upper outer quadrant; treat with NSAIDs or OCPs
• Galactorrhea: Check prolactin level (screen for pituitary adenoma)
• Gynecomastia: Consider spironolactone as cause/treatment
• Mastitis: Associated with breastfeeding; usually MSSA; treat with dicloxacillin
• Breast Abscess: Incision & drainage + antibiotics

Malignant

• Inflammatory Breast Cancer (IBC)
  • Younger patients (typically <50); very aggressive
  • Presentation: Peau d’orange (orange-peel skin appearance), breast erythema, edema, dimpling
  • Rapid onset over weeks
  • Poor prognosis
• Paget’s Disease of the Nipple
  • Preinvasive malignancy of nipple
  • Presentation: Persistent nipple itching, burning, unilateral nipple eczema/erosion
  • Spontaneous nipple discharge (often bloody)
  • Underlying intraductal carcinoma in >95% of cases
• Other Breast Cancers:
  • Invasive ductal carcinoma (most common)
  • Invasive lobular carcinoma
  • Presentation: Palpable mass, dimpling, nipple retraction, spontaneous discharge (bloody), skin changes
  • Risk factors: Age, family history, nulliparity, HRT, alcohol, obesity

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CERVICAL DISORDERS

Cervicitis

• Infectious causes: Usually gonorrhea/chlamydia (most common STI pathogens)
• Diagnosis: NAAT (nucleic acid amplification test) - gold standard; PCR/TMA
  • Specimens: Endocervical swab, first-void urine
  • Note: Sexually transmitted infections moved off PANCE Reproductive blueprint (now in Infectious Diseases section)
• Noninfectious causes: Mechanical irritation, allergic reaction, chemical irritation
• Presentation: Mucopurulent cervical discharge, cervical erythema, cervical friability
• Treatment (if infectious): Ceftriaxone + doxycycline (or azithromycin)

Cervical Dysplasia

• See malignancy section; associated with HPV

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OVARIAN DISORDERS

Polycystic Ovary Syndrome (PCOS)

• Diagnosis: Rotterdam criteria (2003) - requires 2 of 3:
  • Oligo- or anovulation (>35-day cycles)
  • Hyperandrogenism (clinical or biochemical)
  • Polycystic ovary morphology on ultrasound: ≥12 follicles (2-9 mm) in one ovary OR ovarian volume >10 mL
• Ultrasound findings: “Pearls on a string” appearance (follicles arranged peripherally with echogenic stroma)
• Associated findings: Elevated LH/FSH ratio, insulin resistance
• Infertility treatment: Clomiphene citrate or letrozole for ovulation induction
• Note: Can be diagnosed without ultrasound findings if hyperandrogenism + anovulation present

Ovarian Cysts

• Follicular cysts: Physiologic, normal finding
• Corpus luteum cysts: Functional cyst
• Hemorrhagic/Large cysts: >5 cm; monitor with ultrasound
• Endometrioma (Chocolate cyst): Cyst containing endometrial tissue; associated with endometriosis
• Dermoid cyst (Teratoma): Benign, may contain various tissue types

Ovarian Torsion

• Presentation: Severe, sudden-onset unilateral pelvic pain
• Diagnosis: Doppler ultrasound
• Definitive treatment: Surgical intervention (emergent)

Ovarian Cancer

• Tumor marker: CA-125
• (Additional details per staging/treatment protocols)

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ENDOMETRIAL DISORDERS

Endometrial Cancer

• Red flag: Postmenopausal bleeding = endometrial cancer until proven otherwise
• Definition: Bleeding >12 months after final menstrual period (~90% of EC cases present with postmenopausal bleeding)
• Risk factors: Unopposed estrogen, obesity, Lynch syndrome/BRCA mutations, PCOS, diabetes, nulliparity, older age
• Most common type: Adenocarcinoma
• Updated Evaluation (ACOG 2025 Guidelines):
  • Most patients: Transvaginal ultrasound AND endometrial biopsy recommended
  • Rationale: Ultrasound alone has low sensitivity; misses 5-12% of cancers
  • Endometrial thickness thresholds: ≤4 mm may be considered low-risk in select patients (single episode, no risk factors, fully visualized), but biopsy still preferred for most
  • Endometrial biopsy (EMB): Gold standard for tissue diagnosis; office procedure
  • Doppler imaging: May add sensitivity for high-risk morphology
• Differential diagnosis: Atrophic endometrium (most common), endometrial polyps, hyperplasia

Endometriosis

• Definition: Endometrial growth outside the uterus
• Presentation: Severe menstrual pain, dyspareunia; normal pelvic exam
• Diagnosis: Surgical (laparoscopy)
• Associated finding: Endometriomas (chocolate cysts)

Uterine Leiomyoma (Fibroids)

• Population: Reproductive-age women (30s-40s)
• Presentation: Heavy/prolonged bleeding (especially submucosal); enlarged uterus
• Medical therapy: Hormone-based treatments
• Surgical therapy: Myomectomy or hysterectomy

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VAGINAL/VULVAR DISORDERS

Vaginitis

• Bacterial Vaginosis (BV)
  • Findings: Clue cells, positive KOH whiff test (fishy odor), pH >4.5
  • Discharge: Thin, watery, gray/white
  • Diagnosis: Amsel criteria (≥3 of: thin discharge, pH >4.5, clue cells, whiff test)
  • Treatment: Metronidazole (oral/vaginal) or clindamycin
• Candidiasis
  • Findings: Hyphae/pseudohyphae on KOH, pH ≤4.5
  • Discharge: Thick, white, cottage-cheese
  • Risk factors: Recent antibiotics, immunosuppression, diabetes
  • Treatment: Azole antifungals (fluconazole, miconazole, clotrimazole)
• Trichomoniasis
  • Findings: Motile trophozoites, pH >4.5, vaginal inflammation
  • Discharge: Frothy, yellow/green, malodorous
  • Associated: Strawberry cervix, dysuria, urinary frequency
  • Treatment: Metronidazole (oral); treat partner
• Atrophic Vaginitis (Genitourinary Syndrome of Menopause)
  • Findings: Loss of rugae, shiny pale epithelium
  • Population: Postmenopausal women (low estrogen)
  • pH: >4.5
  • Symptoms: Dryness, dyspareunia, itching
  • Treatment: Vaginal estrogen, moisturizers, lubricants

Bartholin Gland Cysts

• Management: Word catheter placement

Vaginal/Vulvar Cancer

• Presentation: Non-tender lesion
• (Additional details per staging/treatment protocols)

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PELVIC PROLAPSE

Uterine Prolapse

• Staging: Stages 1-5 based on relationship to introitus
• Conservative: Pelvic floor physical therapy, pessary
• Surgical: Reserved for advanced stages

Cystocele (Anterior Prolapse)

• Symptoms: Urinary symptoms, urinary incontinence
• Management: Pelvic floor PT, pessary, or surgery

Rectocele (Posterior Prolapse)

• Symptoms: Constipation, straining sensation
• Management: Pelvic floor PT, pessary, or surgery

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INFECTIONS & INFLAMMATORY DISORDERS

Pelvic Inflammatory Disease (PID)

• Etiology: Ascending STI (most common cause of pelvic infection)
• Clinical findings: Cervical motion tenderness
• Diagnosis: Clinical diagnosis; ultrasound to rule out tubo-ovarian abscess (TOA)
• Treatment: Ceftriaxone + doxycycline + metronidazole
• Important: Treat clinically to prevent complications (infertility, chronic pelvic pain)

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FERTILITY & INFERTILITY

Infertility Basics

• Definition: Failure to conceive after 12 months of unprotected intercourse
• Etiology breakdown:
  • Male factor: 40%
  • Female factor: 50%
  • Multifactorial: 10%

Polycystic Ovary Syndrome (PCOS)

• Ovulation induction: Clomiphene citrate or letrozole

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MENOPAUSE & HORMONE REPLACEMENT

Definition

• Menopause: 12 months without menses
• Average age: 51 years

Vasomotor Symptoms

• Hot flashes, night sweats, flushing

Hormone Replacement Therapy (HRT)

• Indications: Vasomotor symptoms (primary), genitourinary symptoms
• Formulations:
  • Systemic: Oral, transdermal, patches (for moderate-severe symptoms affecting quality of life)
  • Topical/Local: Vaginal estrogen creams, rings, tablets (for local symptoms)
• Components:
  • Estrogen + progestin (for women with uterus) - progestin protects against endometrial cancer
  • Estrogen alone (for hysterectomized women)
• Risks/Benefits:
  • Benefits: Symptom relief, improved quality of life, bone protection
  • Risks: Breast cancer risk slightly increased with combined therapy (especially after 5 years); DVT/PE (transdermal safer than oral); stroke; endometrial cancer if unopposed estrogen
• Duration: Individualize; use lowest effective dose for shortest duration
• Contraindications: Unexplained vaginal bleeding, history of breast cancer (relative), active thromboembolism

Genitourinary Syndrome of Menopause (GSM)

• Symptoms: Vaginal dryness, dyspareunia, urinary frequency/urgency, recurrent UTIs
• Treatment:
  • First-line: Vaginal moisturizers, lubricants
  • If inadequate: Vaginal estrogen (cream, ring, tablet) or vaginal DHEA (ospemifene)
  • Systemic HRT if vasomotor symptoms also present

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PREGNANCY

Preconception/Prenatal Care

Vaccinations

• No live vaccines
• Indicated: Tdap, influenza

Prenatal Testing

• Rubella serology
• RPR (syphilis screening)

Second Trimester Screening

• Quad Screen (15-20 weeks): AFP, unconjugated estriol, hCG, inhibin A

Early Pregnancy Signs

• Quickening: Fetal movement sensation (18-20 weeks)
• Chadwick Sign: Blue discoloration of cervix
• Hegar Sign: Softening between fundus and cervix
• Naegele’s Rule: Estimate EDC (add 9 months, 7 days to LMP)

Gestational Diabetes Mellitus (GDM)

• Screening: All pregnant patients 24-28 weeks gestation (ADA recommendation)
• Two-Step Approach:
  • Step 1: 1-hour glucose challenge test (GCT) with 50g glucose (non-fasting)
    • Threshold: ≥140 mg/dL → proceed to diagnostic test (identifies ~80% of GDM)
    • Alternative: ≥130 mg/dL (identifies ~90% but lower specificity)
  • Step 2 (if abnormal Step 1): Fasting 100g OGTT (0, 1, 2, 3 hours)
    • Carpenter-Coustan Criteria:
      • Fasting: >95 mg/dL
      • 1-hour: >180 mg/dL
      • 2-hour: >155 mg/dL
      • 3-hour: >140 mg/dL
    • Diagnosis: ≥2 abnormal values = GDM
• High 1-hour GCT (≥180 mg/dL): May be diagnostic if fasting ≥95 without 3-hour OGTT

Hypertensive Disorders of Pregnancy

Gestational Hypertension

• BP ≥140/90 mmHg occurring after 20 weeks
• Without proteinuria or end-organ dysfunction

Preeclampsia

• Hypertension (≥140/90) + proteinuria or end-organ dysfunction after 20 weeks
• Treatment: Antihypertensive (e.g., labetalol)

Eclampsia

• Preeclampsia + seizures
• Management: Emergent delivery

HELLP Syndrome

• Definition: Hemolysis, Elevated Liver enzymes, Low Platelets
• Management: Emergent delivery

Gestational Trophoblastic Disease

Molar Pregnancy

• hCG: Disproportionately high for gestational age
• Ultrasound findings: “Snowstorm” or “grape-like” appearance
• Risk of malignant transformation

Abnormalities of Placentation

Placenta Previa

• Presentation: Painless vaginal bleeding
• Management: Avoid vaginal delivery; cesarean section

Placental Abruption

• Presentation: Painful vaginal bleeding
• Management: Urgent/emergent delivery

Vasa Previa

• Fetal blood vessels crossing amniotic membranes; at risk for rupture

Umbilical Cord Prolapse

• Cord descends through cervix; obstetric emergency
• Management: Emergent cesarean section

Premature Rupture of Membranes (PROM)

• Spontaneous rupture of membranes (SROM) <37 weeks
• Diagnosis: Nitrazine test, fern test
• Management: Corticosteroids to assist fetal lung development

Fetal Assessment

Nonstress Test (NST)

• Purpose: Assess fetal heart rate reactivity and well-being
• Findings: Normal (reactive) = 2 accelerations of ≥15 bpm for ≥15 seconds in 20-minute window
• Non-reassuring: Lack of reactivity, variable or late decelerations

Biophysical Profile (BPP)

• Components (5 parameters, each 0-2 points):
  • Fetal breathing movements
  • Fetal movement
  • Fetal tone
  • Amniotic fluid volume
  • NST result
• Score: 8-10 = reassuring; 6 = intermediate (requires follow-up); ≤4 = non-reassuring (consider delivery)

Fetal Heart Rate Monitoring

• Early Decelerations: Benign, due to head compression
• Late Decelerations: Concerning for fetal hypoxia
• Variable Decelerations: Due to cord compression

Bishop Score

• Purpose: Assesses cervical readiness for labor; predicts vaginal delivery success with induction
• Scoring: 0-13 = unfavorable (unlikely to achieve vaginal delivery with induction); ≥8 = favorable
• Components: Cervical dilation, effacement, consistency, position, fetal station (each 0-3 points)

Rh Incompatibility

• At-risk scenario: Mother Rh-negative, father Rh-positive (or unknown)
• Hemolytic disease risk: If mother develops anti-D antibodies (sensitization)
• Prevention (RhoGAM - anti-D immunoglobulin):
  • 28 weeks gestation: Standard dose (300 mcg IM in US)
  • Delivery: If baby is Rh-positive or unknown, repeat dose within 72 hours
  • Antepartum hemorrhage, amniocentesis, external cephalic version: Give dose within 72 hours
• Kleihauer-Betke test: Quantifies fetal-maternal hemorrhage; determines if additional RhoGAM needed
• Coombs test: Direct (DAT) on baby at delivery; detects fetal RBC sensitization

Complications of Labor & Delivery

Breech Presentation

• Delivery: Cesarean section
• Fetal assessment: External cephalic version (ECV) if appropriate

Shoulder Dystocia

• Fetal shoulder impaction during delivery; obstetric emergency
• (Management per ACOG guidelines)

Multiple Gestation

• (Special considerations per number/type of gestation)

Arrest Disorders

• Failure to progress in labor; may indicate need for cesarean section

Abnormalities of Pregnancy Loss

Spontaneous Abortion/Miscarriage

• Definition: Pregnancy loss <20 weeks
• Diagnosis: Ultrasound, serial hCG

Classifications of Abortion

• Threatened: Vaginal bleeding before 20 weeks; viable pregnancy
• Inevitable: Bleeding with open cervix; loss will occur
• Complete: All products of conception expelled
• Incomplete: Partial expulsion of products
• Missed: Fetal demise without expulsion
• Anembryonic: Gestational sac without fetus
• Habitual: Three or more consecutive losses
• Chemical pregnancy: Positive hCG, no ultrasound findings

Therapeutic Abortion (TAB)

• Medical abortion: Medication-induced (mifepristone ± misoprostol)
• Surgical abortion: Dilation & evacuation (D&E)

Ectopic Pregnancy

• Implantation outside uterus; life-threatening
• Diagnosis: Ultrasound, serial hCG
• Management: Medical or surgical

Fetal Distress

• Abnormal fetal heart rate patterns or biophysical findings
• Management: Urgent/emergent delivery

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POSTPARTUM CARE

Postpartum Hemorrhage (PPH)

• Definition (ACOG):
  • Cumulative blood loss ≥1000 mL OR blood loss with signs/symptoms of hypovolemia within 24 hours after birth, regardless of delivery route
  • Alternatively: >500 mL blood loss with vaginal delivery OR >1000 mL with cesarean delivery is considered abnormal and should be investigated
• Most common cause: Uterine atony (~70% of PPH cases)
• Other causes (Four Ts mnemonic): Tone (atony), Trauma (lacerations, rupture, inversion), Tissue (retained products, placenta), Thrombin (coagulopathy)
• Risk factors: Multiparity, prolonged labor, oxytocin use, general anesthesia, pre-eclampsia
• Management:
  • First-line: Uterine massage, bimanual compression
  • Pharmacologic: Oxytocin (10 IU IV/IM) first-line; also methylergonovine, misoprostol, carboprost if needed
  • Fluid resuscitation, CBC monitoring, cross-match blood
  • Consider tranexamic acid (TXA) for persistent bleeding
  • Interventional: Uterine balloon, angiographic embolization, surgical (hysterectomy as last resort)
• Prevention: Active management of third stage of labor with prophylactic oxytocin

Postpartum Pituitary Disorders

Sheehan Syndrome

• Etiology: Severe postpartum hemorrhage
• Pathophysiology: Pituitary infarction
• Presentation: Panhypopituitarism

Lymphocytic Hypophysitis

• Etiology: Autoimmune
• Presentation: Varies with degree of pituitary involvement

Postpartum Psychiatric Disorders

Postpartum Depression

• Onset: 4-6 weeks after delivery
• Presentation: Depressed mood, anhedonia, functional impairment

Postpartum Psychosis

• Onset: Within 2 weeks of delivery
• Presentation: Hallucinations, delusions, acute agitation
• Urgency: High; risk of harm to self or infant

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CERVICAL & GENITAL INFECTIONS

HPV & Related Conditions

• HPV 6/11: Low-risk; associated with genital warts
• HPV 16/18: High-risk; associated with cervical and other genital cancers
• Cervical dysplasia: Screen per guidelines; associated with HPV infection

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NEOPLASMS (Summary)

Breast Cancer

• See breast disorders section

Ovarian Cancer

• Tumor marker: CA-125

Cervical Cancer

• Risk factor: HPV (especially 16/18)

Vaginal/Vulvar Cancer

• Presentation: Non-tender lesion

Endometrial Cancer

• Red flag: Postmenopausal bleeding
• See endometrial disorders section

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TRAUMA IN PREGNANCY

• Physical trauma
• Psychological trauma
• Sexual assault/abuse
• (Assessment and management per institutional protocols)

Breast disorders

• Abscess: I&D, abx
• Fibroadenoma: benign, painless, mobile, US
• Fibrocystic changes: periodic, upper outer quadrant, NSAID / OCP
• Galactorrhea: prolactin level (pituitary adenoma)
• Gynecomastia: spironolactone
• Mastitis: breastfeeding, usually MSSA (dicloxacillin)

Cervical disorders
Cervicitis

• usually G/C
• noninfectious:
• NAAT / urine / swab for G/C
  Dysplasia

Contraceptive methods

• OCP contraindications: migraine with aura, 35+ smoker
• Depo-provera: lowers bone density, delayed return to fertility
• IUD:

Infertility

• failure to concieve after 12 months
• male 40%, female 50%, multifactorial 10%
• PCOS: clomiphene / letrozole

Menopause

• 12mo w/o menses
• avg age: 51
• HRT: systemic, topical
  • indicated for vasomotor symptoms
  • bonus: osteoporosis, CVD?
• GSM: vaginl estrogen

Menstrual disorders

• amenorrhea: age 16 (primary) or >6 months (secondary)
• dysmenorrhea
• Pre-menstrual syndrome (NSAID)
  • luteal phase
• PMDD: PMS + interferes with life (SSRI)
• Abnormal Uterine Bleeding
  • PALM COEIN

Neoplasms of the breast and reproductive tract
Benign
Malignant Ovarian disorders

• CA-125
  Vaginal/Vulvar Cancer
• non-tender
  Breast Cancer
• inflammatory
  • younger, peau du orange, warm, edematous
• Paget’s disease
  • itching/burning of nipple
    Cysts
• follicular (physiologic): normal!
• corpus luteum:

• 5cm: monitor with US

• Chocolate cyst = endometrioma
• dermoid =

Polycystic ovary syndrome

• pearls on a string / chocolate chip cookie

Ovarian Torsion

• severe, sudden onset unilateral pelvic pain
• doppler
• definitive: surgery

Endometrial Cancer

• postmenopausal bleeding = EC until proven otherwise
• risk: unopposed estrogen, obesity, lynch syndrome/BRCA , PCOS,
• MC = adenocarcinoma
• postmenopausal women: endo stripe >4mm
• Diagnosis: EMB

Pelvic inflammatory disease

• ascending STI; most common
• clinical dx: ultrasound for TOA
• cervical motion tenderness
• treat clinically to prevent complications
• ceftriaxone + doxycycline + metronidazole

Pregnancy
Abruptio placentae

• painful vaginal bleeding
  Breech presentation
• c-section
• ECD
  Cervical insufficiency
• previous loss
• cerclage
• <25mm cervix
  Cesarean and operative delivery
• arrest, fetal position,
  Classifications of abortion
• spontaneous: miscarriage, under 20wks, US, hcg
• TAB: therapeutic abortion (medication vs D&E)
• Abortions:
  • threatened
  • inevitable
  • complete
  • missed
  • incomplete
  • anembryonic
  • habitual
  • chemical
    Ectopic pregnancy
    Fetal distress
    Gestational diabetes
• All patients 24-28wks
• 1hr OGTT >140
  Gestational trophoblastic disease
• molar pregnancy
• HCG high for LMP
• snowstorm or grape on US
  Hypertensive disorders of pregnancy

• 140/90 occuring after 20wks

• labetolol
  Preeclampsia

Eclampsia

• seizures
• emergent delivery
  HELLP
• emergent delivery

Quickening: feeling baby move (18-20 weeks)
Chadwick sign: blue discoloration of cervix
Hegar sign: softening between fundus and vervix
Naegele’s Rule

Quad Screen: AFP, estriol, bHCG, ihibin A
Vaccines: no live, TDAP and flu
Prenatal teting

• Rubella, RPR

Nonstress test
BPP

Fetal Heartrate Monitoring
Early Decels
Late decels

Bishop Score

Labor/delivery
Multiple gestation
Placenta previa

• painless vaginal bleeding
  Vasa Previa

Postnatal/postpartum care
Postpartum hemorrhage

• loss >500ml blood
• uterine atony: MC
• trauma/ lacs
• pitocin
  Postpartum pituitary disorders
• sheehan
  • severe postpartum hemorrhage
• lymphocytic hypophysitits
  • autoimmune
    Postpartum psychiatric disorders
• postpartum depression: 4-6 weeks after delivery
• postpartum psychosis: within 2 weeksw
  Preconception/prenatal care
  Prelabor rupture of membranes
• SROM <37weeks
• nitrazine test
• coticosteroids to assist lung devlopment
  Rh incompatibility
• mom -, dad +
• give rhogam at 28 weeks
  Shoulder dystocia

Umbilical cord prolapse

Trauma in pregnancy
Physical
Psychological
Sexual

Uterine disorders
Endometriosis

• endometrial growth outside uterus
• normal pelvic exam
• severe menstrual pain +/- dyspareunia
• diagnosis: surgical (laparoscopy)
  Leiomyoma (fibroids)
• benign pelvic tumor
• reproductive age women (30’s/40’s)
• heavy/prolonged bleeding (especially submucosal), enlarged uterus
• medical therapy
• surgical therapy (myomectomy/hysterectomy)

Prolapse Vaginal/vulvar disorders
Bartholin gland cysts

• word catheter

Prolapse
Uterine

• staged based on relation to introitus (1-5)
• pelvic floor PT, pessary, surgery
  Cystocele
• anterior
• urinary symptoms
• • pelvic floor PT, pessary, surgery
    Rectocele
• posterior
• constipation, straining
  Vaginitis
• BV: clue cells, KOH +whiff (fishy), watery gray discharge
• Candidal: hyphae, thick white discharche, recent abx use
• Trichomonas: motile protozoans, yellow/green frothy discharge, strawberry cervix
• Atrophy: loss of rugae, shiny, postmenopausal

HPV 6/11: genital warts
HPV 16/18: high risk