Hemolytic uremic syndrome :

• Triad of :

  1. Renal failure.

  2. Microangiopathic hemolytic anemia.

  3. Thrombocytopenia.

• Treatment: Plasmapheresis

Acute fatty liver of pregnancy (AFLP) :

Causes : Acute hepatic failure, in the third trimester or early post-partum period.

(Prolonged PT , PTT + moderate elevation transaminases level.)

Acute viral hepatitis :

• Lab : elevation of transaminases level into thousands.

• Clincally: constitutional symptoms  nausea , vomiting , clay-colored stools , dark-urine , clinical jaundice.

Idiopathic (immune) thrombocytopenic purpera :

- Characterized by autoimmune destruction of platelets - Patient manifest with :

1. Bleeding from skin & gums.

2. Hypersplinism.

Time

100-g Glucose (Used in USA)

Fasting

95 mg/dL

5.3 mmol/L

1-h

180 mg/dL

10.0 mmol/L

2-h

155 mg/dL

8.6 mmol/L

3-h

140 mg/dL

mmol/L

Autopsy of the fetus & placenta



Diethylstillbestrol (DES):

• Synthetic preparation possessing estrogen proprieties, which was widely used between 1947 & 1971 for treatment of threatened abortion.

• Female offspring of women who ingested DES during their pregnancy are at increased risk of developing : 1- clear cell adenocarcinoma of the vagina & cervix .

  2. Carvical anomalies.

  3. Vaginal malformations.

 The most important risk factor for squamous cell carcinoma of cervix & vagina : HPV.

Uterine rupture

(Clinical presentation is highly variable and need

high index of suspicion)

TTT: delivery by emergency C.S

• Can be difficult to distinguish from placental abruption (especially when there is history of C.S).

• Symptoms of uterine ruptured are preceded with: agitation/tachycardia/hyperventilation.

-- Intense abdominal pain + mild or massive vaginal bleeding

-- after rupture occurs , slight relieve followed by return of pain may occur -- Vitally : patient usually present with signs of hypovolmic shock !

-- Presenting part may retract (Loss of fetus station!!) and no longer palpated on pelvix exam / where fetal limbs may easily palpated by abdominal examination. - It's : 1- mostly problem during active labor NOT during antepartum.

• Risk with low transverse C.S is 1% / with classic vertical C.S 9% 2- If antepartum: usually with history of abdominal trauma.

Placenta previa

Abnormal insertion of the placenta on the lower uterine segment near or over cervical os.

• Presents with: bright red, Painless vaginal bleeding in 3^rd trimester (maternal in origin).

Typically NO uterine tenderness.

• Treatment if complete: (depends on severity of bleeding & age of pregnancy) :

  1. If stable mother at term  Scheduled C.S

  2. If stable mother not at term  expectant management & may corticosteroids with amniocentesis at 36 weeks  deliver if lung is mature.

3) In unstable mother + continued bleeding + late deceleration 

emergency C.S

Vasa previa

Rare condition in which the fetal blood vessels traverse the fetal membranes across the lower segment of the uterus between the baby and internal cervical os (velamentous cord insertion).

Presents with :

- Painless anterpartum (3^rd trimester) /intrapartum hemorrhage (after natural or artificial rupture of membranes "amniotomy" + associated with rapid deterioration of FHR from tachycardia to bradychardia to a sinusoidal pattern (maternal vital signs are normal) : immediately after rupture of membranes, the baseline FHR increases to 160 beats/min.

and then drop to 70 beats/min. with repeatitve late deceleration.

The most likely cause of the current condition is : ruptured fetal umbilical vessels.

• If fetal bleeding is suspected: an Apt test – which differentiate maternal from fetal blood – can be performed to confirm diagnosis.

• The condition is associated with a high fetal mortality rate "75%" due to fetal exsanguination.

• Treatment: immediate C.S delivery ("crash-C.S").

1 - Postpartum hemorrhage :

 Pos-partum hemorrhage at 1^st 24 h is : The most common cause 80% is , It's important to make quick diagnosis by palpation of :

1. Firmness of uterus  Soft "boogy" sensation

2. Location of uterus  Poorly contracted uterus ( will read that uterine funds is at the umbilicus ).

• If bleeding is persistent after ttt : other causes should be excluded :

• The most appropriate next step in management of this patient : lifetime membership.

1. First step is General supportive measures :

Fundal or bimanual message / IV / Crystalloid infusion / notification of blood bank

2. N ext most appropriate step in this is  Uterotonic agents : / Carboprost / methylergonovine.

C.S Hystrectomy	1- Abnormal adherent placenta 2- Rupture uterus 3- All attempts failed !.
D & C	If there is retained placenta : - U/S : echogenic mass / Absence of normal endometrial step (less common) - Non-intact placenta on examination.
Uterine artey embolization Or Uterine or IIA ligation	- Vitally stable patient (no excessive bleeding)  failed all attempts , and want to preserve fertility ****alternative to hystrectomy
Uterine packing	- Uterine atony is the cause AND Oxytocin is not controlling it

2- Puerperal infection :

• Puerperal infection : Woman with a fever greater than 38 C (100.4 F) outside of the first 24 hours postpartum.

• Post-Partum UTI : (after 1^st 24 – 48 hour postpartum) : ask for

• Postpartum endometritis: ( 2^nd – 3^rd postpartum day ) with : .

• Risk factors :

  1. Prolong rupture of membranes (>24 hour),

  2. Prolonged labor ( >12 hours),

  3. C-section

  4. Intrauterine pressure catheters or fetal scalp electrodes.

• The most common cause of this condition is : (gram –ve/+ve, aerobic , anaerobic).

• The most appropriate therapy is :

1) Clindamycin (IV) combined with
2) Gentamicin (IV)

Chlamydia Trachomatis	Most common cause of mucopurulent cervicitis - A common cause of PID Uncommon cause of endometrititis  if it's would be many days after labor not in first 48 – 72 h.
Group B streptococcal infection	Common cause of : endometritis + neonatal sepsis Women screened & ttt before labor for it it's part of the polymicrobial infection
N.gonorrhea	Can be a gram –ve of polymicrobial infection in < 10% of cases
S.aures	Not commonly isolated
S.epidermidis	Can be part of polymicrobial infection

• Low grade fever + Leukocytosis + Chills + bloody vaginal discharge ( lochia rubra) " after 2 -3 days discharge become pale and called lochia serosa , then yellow or white and called lochia alba //// IF THERE IS FOUL-SMELL LOCHIA  suspect ENDOMETRITITS" are common during first 24 hour of the post-partum period  most appropriate next step is : .

3- Postpartum DVT :

• Complaint: A woman , one week postpartum presents with: dull pain in her Lt. or Rt.leg for about 3 days - Physical examination: Swollen , tender , mildly erythematous leg.

• Doppler: reveals a thrombus in the superficial part of the femoral vein of the left leg (It's called "Superficial femoral vein" BUT it's deep vein)

  Anticoagulation with heparin.

• The most appropriate next step in management is :

• Pregnancy female G2+P1  with obestatric history of intrapartum placental abruption in previous pregnancy  she received Anti-D immunoglobulin at 28 weeks and immediate post-partum 

• In her current pregnancy , you decide to determine her antibody titres and it was lifetime membership. 1:34 (>1:16)  the most likely

explanation of the positive antibody screen (anti-D immunization in this patient) is :

Low dose of anti-D immunoglobulin postpartum

• T he qualitative test used to determine presence of feto-maternal hemorrhage is: rosette test.

  • If negative  standard dose of anti-D immunoglobulin should be given

  • If positive the amount of hemorrhage can be evaluated using : - Kleihauer-Betke stain or

    • Fetal red cell stain using flow cytometry

And the Anti-D imm unoglobulin dose should be corrected accordingly.

No Prophylaxis early in this pregnancy	No need for early prophylaxis , because risk of alloimmunization before 28 weeks is low
Too early administration of Anti-D postpartum	Too late (after 72 Hour) administration of Anti-D post partum , may result in failure of anti-D immunoglobulin prophylaxis.
Low dose of Anti-D at 28 weeks of pregnancy	Standard dose of Anti-D immunoglobulin should be administrated at 28 weeks of uncomplicated pregnany

• Educational objective :

• After events associated with excessive feto-maternal hemorrhage (as placental abruption) , the failure to correct the dose of anti-D immunoglobulin may result in maternal alloimmunization.

O ccur in 1^st pregnancy (Primigravida) in contrast to Rh in 2^nd pregnancy Patient is missing a blood type , have antibodies to the missing antigens.

Blood type	Antibodies against
A	B
B	A
O	A & B
AB	----

Mother with blood group O AND Father with blood group AB  will develop baby with blood group either A or B (both differ from mother group )  so resulting in formation of IgG antibodies in the mother wich cross the placenta resulting in "Hemolytic Disease of the Newborn (HDN)" which is :

( than Rh factor does)

Affected infants are asymptomatic in at birth or with absent or mild anemia and develop neonatal jaundice , which is usually successfully treated with phototherapy.

• Most common reason for higher incidence of UTI in female than males are: .

• Asymptomatic bacteruria :

  • Pregnancy prenatal visit  Asymptomatic & showed in urine culture : clean-catch urine culture >100.000 colony- forming units.(mostly E.Coli)

  • Pregnancy is at risk of developing UTI because enlarged uterus compression resulting in stasis of urine AND Smooth muscle relaxation & ureteral dilatation caused by progesterone.

    Acute Pyelonephritis

  • If It's not treated  The patient is at risk of developing: (in 30 – 40% of cases) , which may cause : 1) Septicemia 2) preterm labor 3) low birth weight babies

  • Treatment : The most appropriate initial pharmacotherapy for this patient is :

(3 days are nor sufficient).

To download the full file and the other USMLE  Short courses ( 3 days ) of TMP-SMX, can be used to treat non-complicated cystitis in non-pregnant woman.

files, please click here to SUBSCRIBE and get a lifetime membership.

• Presenting with nausea , vomiting , AND MOST COMMONLY: Rt. lower-quadrant pain  change according GA due to upward displacement of appendix.

• Leukocytosis can be elevated in BOTH : appendicitis & normal pregnancy

• The most appropriate next step for diagnosis is : with a graded compression technique  Noncompression & dilatation of appendix are diagnostic.

• If U/S is not diagnostic: MRI

• If U/S is not diagnostic & MRI is not available : CT (there is risk on fetus)

• A diagnostic laparoscopy with laparoscopic appendectomy maybe option BUT

• Lower, midline vertical laparotomy is a more common procedure, especially when diagnosis is uncertain.

Patient with findings suggestive of SLE ( Bilateral malar rash , photosensitivity , hematuria ) + past history of abortions  are at increased risk of subsequent abortions  the main pathophysiological feature for this are:

SLE autoantibodies ( Lupus anticoagulant + Anti cardiolipin antibodies )

• Which result in venous thromboembolic events in placenta.

• Pregnant female undergone amniocentesis  immediate after procedure she developed :

1. Loss of conciseness

2. B reathlessness / Cyanosis + O2 saturation is 75% (Respiratory failure) on 100% O2 flow.

3. Generalized tonic-clonic seizures.

4. Hypotension & tachycardia ( cardiogenic shock )

5. Generalized purpuric rash ( DIC )

• The first step in management of AFE is respiratory support  If mask ventilation didn't correct hypoxia , the most appropriate next step is :

Intravenous fluid	Once airway is secured & breathing is adequate  IV fluid to correct hypotension.
LWMH	Would be an appropriate choice if the patient had pulmonary thromboembolism / BUT this is a scenario of AFE.
IV Diazepam	Securing airway & airway should be done first before controlling seizure.

• ICP is a functional disorder of bile formation that develops in the second and third trimesters of pregnancy.

• The condition is characterized by intense pruritus and increased serum bile acid concentrations.

• Etiology:

unclear, but it is thought that genetic & hormonal factors (eg, higher levels of estrogen or progesterone) influence that.

• Clinical manifestations:

  • intense, intolerable generalized pruritus that is especially significant on palms & soles and worsens at night.

  • Evidence of skin excorations may be present.

  • Jaundice exists in 3^rd trimester of pregnancy (in 10-20% of patients).

• Laboratory evaluation:

  • Serum total bile acids are typically increased and may be the only finding.

  • Liver function studies are suggestive of cholestasis :

To download the full file and the other USMLE - Alkaline phosphatase 

-Total & direct bilirubin

• GGTP is usually either normal or only mildly elevated.

files, please - _{Aminotransferases}click her _{may be quite high (s}e ometimes > 1000U/L)to SUBSCRIBE, which requires the ruling out of viral hepatitis. and get a

• Diagnosis of ICP by exclusion :

  • It is founded on the presence of pruritus and elevated levels of serum bile acids and/or aminotransferases in the absence of other diseases that could cause such findings. lifetime membership.

• Treatment : is based on Symptom relief & preventing complications in the mother and fetus : is most promising, (as it increases bile flow and can relieve pruritus).

• Prognosis :

A) Mother :

• Good, as the condition resolves shortly after delivery WITH NO hepatic sequelae.

• It may recur in subsequent pregnancies, and affected women are also at increased risk of developing gallstones.

B) Fetus :

• ICP pregnancy poses more danger to the fetus than to the mother, as :

  1. fetal prematurity.

  2. meconium-stained amniotic fluid.

  3. intrauterine demise.

 Therefore, the preferred approach in managing the pregnancies of women with ICP includes an : early delivery once fetal lung maturity is established.

• If non-African descent, with presence of thalasemia anemia in her family is suspected (at risk of hemoglobinopathies that may affect their offspring during pregnancy or after birth) , came for preconception counseling  the most appropriate initial screening test is :

• If no abnormality is found  No further testing.

• If there is anemia & reduced MCV  Further testing is required.

Hb electrophoresis in this patient	It would be obtained in this patient if the CBC is : Anemic + MCV+ Proof of normal iron intake.
Hb electrophoresis in this patient & her husband	If offered if an abnormal Hb level is diagnosed in the patient.
Iron level , TIBC , ferritin level	If CBC is abnormal , and MCV is decreased  additional testing is required : They are normal in Thalasemia They are abnormal in iron deficiency anemia

• Pregnant female in 3^rd trimester of pregnancy + complaining of dull, low back pain : the pain in minimal in the morning, but increases at the end of the day  the most likely cause of this patient complaint is :

Increased lumber lordosis

- The main cause of this pain is : 1- Increased lumber lordosis

2- Relaxation of the ligaments supporting the sacroiliac and other joints of the pelvic girdle  due to hormonal factors

• Mitral stenosis is classically presents during pregnancy due to increase blood volume most commonly due to Rheumatic Heart disease.

• Risk factors :

  1. LEEP

  2. Multiple gestation

  3. DES exposure

  4. Previous history of pre-term birth.

5. Previous history of 2^nd trimester pregnancy loss

• False labor contractions :

• Start in last 4 – 8 weeks of pregnancy

• Occurs in lower abdomen + irregular + No shortening interval + No increase in intensity ( may regular and increase in intensity in last month) + MOST IMPORTANT IN FALSE LABR : closed cervix (NO progressive cervical changes) + relieve by sedation.

  Reassurance and discharge the patient home.

• Most important next step:

• Peripheral edema in pregnancy :

• Bilateral edema of the lower extremities in pregnancy is most commonly a benign problem.

  Abnormal labor :

• Preeclampsia & DVT should also be considered (BUT unlikely in absence of other classic symptoms of these conditions). To download the full file and the other USMLE

• Breech presentation (25% before 28weeks): e.g. G2+P1 at 37 weeks (30 weeks was breech and still), intact

membranes , closed cervix , good fetal well-being.

files, please click here to SUBSCRIBE and get a

• I n presence if decreased fetal movement  suspect fetal compromise Non-stress test : reactive  most appropriate next step is :

  • NST is usually performed in :

3) High risk pregnancies starting at 32 – 34 weeks. 4) Decrease fetal movement in any pregnancy.

• The most common cause of non-reactive is sleeping baby ( do Vibroacoustic stimulation) NOT a diseased baby - Biophysical profile is done when : non-reactive + no response to vibroacoustic stimulation.

• Pregnant with numbness & burning sensation in her Rt.Hand making sleeping is difficult  Carpal Tunnel Syndrome (CTN)

  • Due to estrogen-mediated depolymerization of ground substance , which cause intetstitial edema of hands & face.

-

• All healthy pregnancy woman with uncomplicated pregnancies are . daily at a

moderate intensity that allows the mother to carry on conversation while exercising ( If she can't  means intensity of exercise is too great ).

• Renal calculi in pregnancy require special consideration to avoid radiation exposure in most modilities  the best next step for management this patient is:

• Sexually active female , with scant vaginal discharge ( Yellow mucopurulent discharge is seen at cervical Os )  is

suggestive of mucopurulent cervicitis , the most common cause is : :

• Asymptomatic in 50%

• The prevalence of this condition is 10%

• Risk factor is : OCP  cervical ectopy created by OCP predispose to colonization of C.Trachomatis.

•  late ulcerated (chancre): punched-out base , raised , indurated margins + files, please painless bilateral inguinal lymphadenopathy / (If left unclick here to treated SUBSCRIBE heal within 1 – 3 months ).and get a

-

• Non-treponemal Serological testing (VDRL & RPR) lifetime membership.  used in screening of syphilis ( because antibodies may not yet formed in 1ry syphilis  false negative results " avoided in 1ry syphilis".

  Penicillin desensitization.
  Chancroid	Painful	Ulcers with deep purulent base + painful lymphadenopathy
  Herpes genitalis
  		Prodrome of burning & pruritis  multiple vesicles  ulcers.
  Granuloma inguinale (Donovanosis)	Painless	Red beefy base + NO adenopathy Doesn't resolve without antibiotic TTT.

• T reponemal test ( FTA-ABS )  used for confirmation. - Can't be cultured .

• Pregnancy female with +ve screening & confirmatory tests and allergic to Penicillin  most appropriate next step is :

• p sychological cause

  • Teenager is Complaining of : intense pain during vaginal intercourse.

  • Speculum examination is not allowed due to tense perineal masculture.( due to involuntary contractions of muscles)

    Kegel exercises and gradual dilatation

  • Most appropriate next step : by vaginal dilator ( insertion of objects of gradual increasing in size for desensitization).

Primary anorgasmia	Advise self stimulation techniques
Post-menopausal Vaginal dryness	Prescribe vaginal lubricant
Hypoactive sexual desire	Refer to a sex therapist

• Triad of :

  1. Urgency

  2. Frequency & Nocturia

  3. Chronic Pelvic Pain ( lower abdominal pain ) in absence of other disease could explain symptom.

- Pelvic pain is classically exacerbated by  1- Sexual intercourse (dyspareunia).

2- Filling the bladder  So, typically relieved by voiding.

• Examination :

 Palpation of ant. Vaginal wall cause severe pain  NO cervical motion tenderness

• Investigations : Urine analysis is normal !!  Exclude UTI.

Cystocele	Herniation of the bladder with associated descent of the ant. Vaginal wall. Similar symptoms of : urgency + Frequency & incontinency BUT asymptomatic.
Pelvic inflammatory disease Antibiotics inpatient (IV): 1) Cefoxitin or Cefotetan & Doxycyclin 2) Clindamycin & Gentamycin Antibiotics outpatient (IV): Cefoxitin IM + Probenecid PO + Doxycycline PO Ceftriaxone IM+Doxycycline PO PID is mostly caused by : 1- N.gonorrhea files, please 2- C.trachomatis 3- Genital Mycoplasma	- Criteria for diagnosis : 1- Fever >38 2- leukocytosis 3- Elevated ESR Purulent cervical discharge 3 tendernesses : - Lower abdominal tenderness Adenxal tenderness Cervical motion tenderness - Most common cause of infertility in women < 30 years old with normal menses. If left untreated  tuboovarian abscess/abscess rupture/pelvic peritonitis/sepsis. Should be managed before cultures are obtained : (never delayed until culture obtained) To download the full file and the other USMLE are recommended for: High Fever. Failure to respond to oral antibiotics. click her3) Inability to take e oral medications to SUBSCRIBE( will mention patient is vomiting in and get a the question). Pregnancy. For patient at risk of noncompliance ( teenagers / low socioeconomic states)



• Passing small amount of urine , occurring with activities that  Intra-abdominal pressure (coughing/sneezing) in

  pelvic floor muscle weakness

• Old female + high parity +obesity  which predispose to:  leading to urethral

hypermobility, which may diagnosed by : inserting a cotton-swab into the urethral orifice and demonstrating an angle of >30 degree upon increase in intra-abdominal pressure.

• Investigations are normal:

1- Urine analysis / 2 - Cystometry / 3- Post-void residual volume - Treatment:

• Kegel exercises (pelvic muscle exercises)  advised in all patients with to restore pelvic floor strength.

  Urethropexy

• BUT the most beneficial long-term management of this patient is : (restoration of the urethrovesical angle).

Urge inconti Caused by  Treatment :				nence	1) Detrusor instability	All results in : Sudden & frequent loss of moderate to large amount of urine 3- Accompanied with nocturia & frequency
					2) Bladder irritation from neoplasm
					3) Interstilial cystitis		There is dysuria , urgency , frequency with abnormal urine analysis.
	Oxybutinin therapy
Overflo incontine Treatment :				w nce	1) Diabetic Neuropathy (Patient usually have a long history of diabetes that are not well controlled.	Loss of small amount of urine from an over distended bladder. Markedly increased residual volume.
	1- Bethanechol
	2- Alpha blockers

1. Severe Valvular pruritis ( for many moths ) , dysuria , dyspareunia , defecation is painful.

2. The valvular skin is :

   • White ( porcelain-white polygonal macules&patches)

   • Thin (cigarette paper) - excoriation

3. Libia minor are difficult to visualize : Oblitration to labia minor & clitoris &  diameter of introitus.

• Vulvar SCC is at risk  so suspicious lesions should choose :

  Hight potency Class I Topical Corticosteroids

• Most appropriate next step in management : (ointment) for 4 weeks,with maintenance therapy: less potent topical steroid or topical calcineurin inhibitor.

Radical Vulvectomy	In higher risk of malignancy : 1- invasive SCC 2- melanoma
Less disfiguring procedures	In : 1- basal cell carcinoma 2- smaller SCC
Vaginal Estrogen Replacement	In : Menopausal-related atrophic vaginitis
Cryotherapy	In: genital warts

• Heavy vaginal bleeding(may with intermenstrual bleeding) + Normal physical examination & U/S + negative pregnancy test = No organic cause ( DUB is disease of exclusion , most often due to anovulation).

• In adolescent female , treatment depends on amount of bleeding : (AFTER EXCLUDING HYPERPLASIA & CARCINOMA IF HAIGH RISK)

1. If mild  iron supplementation

   High dose estrogen therapy.

2. If moderate + NO active bleeding  Cyclic progestin , should be added. 3) If moderate with active bleeding / or severe 

 If hormonal therapy failed only  Endometrial ablation OR Hystrectomy.

• Endometrial biopsy is indicated is selective patient to rule out endometrial hyperplasia & carcinoma :

  Endometrial biopsy

  1. Women > 35 year old with DUB . ( The most appropriate next step is : ).

  2. Obese (described by BMI)

     Gynecological neoplasia :

  3. Hypertensive. To download the full file and the other USMLE 4_{- Diabetic.}

files, please click here to SUBSCRIBE and get a

Endometrial Hyperplasia

Premenopausal women with simple or complex endometrial hyperplasia WITHOUT atypialifetime membership.  risk of cancer progression :

• S imple(risk 8%) or complex(29%) endometrial hyperplasia WITH atypia  TTT is Hystrectomy if no desired future fertility/ BUT if desired fertility  cyclic progestin with 3-6 month biopsy.

Low dose OCP  appropriate for prevention of hyperplasia in anovulatory conditions (PCO) "not sufficient if occurred"

Tamoxifen	Raloxifene
Tamoxifen  Exaggerate menopausal symptoms EXCEPT: it  osteoporosis risk +  cardiovascular risk.	It's first line agent for prevention of osteoporosis (even more effective than biphosphonates)
- Increase risk of Endometrial cancer (agonist effect) - Increase risk of thromboembolism.	DON'T increase risk of Endometrial cancer. Increase risk of thromboembolism So,
		Contraindicated If there is a history of DVT.

Cervical cancer screening :  Women age 21-24 years with : ASC-US OR LSIL .

In those young age :

• HPV infection is transient &

• Malignant transformation is rare.

 Thus colposcopy is not performed unless the patient : demonstrates ASC on 3 consecutive Pap smears.

- This help triage high-risk HPV-positive patients and leads to fewer colposcopies :

• If HPV is positive : colposcopy will be required.

• If HPV is negative : repeat both Pap cytology & HPV test in 3 years.

T o download the full file and the other USMLE files, please click here to SUBSCRIBE and get a

- HPV vaccine : is recommended for : lifetime membership.

1. All girls & women (except those who are pregnant) age 9 -26 regardless of HPV status pr sexual activity.

2. All boys & men age 9-21 .

 HSIL diagnosed during pregnancy :

High grade Squamous Intraepithelial Lesions (HSIL) diagnosed by Pap smear during pregnancy

• The management of any women with "HSIL" is Colposcopy & directed biopsy ( The aim of colposcopy during pregnancy is to exclude Invasive cervical cancer) :

• If directed biopsy is negative the best next step is :

LEEP (excisional procedur		e)			Recommended for all patients except: Adolescents Pregnant women with HSIL on Pap BUT without CIN II or greater on biopsy since the abnormal area may have been missed by biopsy.
	Only indicated in pregnancy	if
	lesion suggestive of invasive
	cancer detected at colposco	py.
Termination of pregnan		cy			There is no indication for termination of pregnancy in presence of abnormal Pap.
Endocervical curettage					Contraindicated in pregnant female.
Repeat Pap smear					Repeating pap smear will not change management of the patient  a repeat colposcopy is still required after delivery.

V aginal cancer :

• Squamous cell carcinoma  is the most common form of vaginal cancer.

• Risk increase with age (mostly >60 years).

• Most common symptoms : vaginal bleeding & malodorous vaginal discharge.

• Definitive diagnosis is made by: biopsy.

• Treatment (depends on staging) :

  • Stage I & II ( no extension to the pelvic wall and no metastases ) :

    • if tumor less than 2 cm in size  may removed surgically

      radiotherapy

    • if tumor more than 2 cm in size  treated by .

The point in some questions is that patient may present with very old age & co-morbid conditions (poor surgical candidate) even if < 2 cm Radiation alone is sufficient.

• Stage III & IV & tumors > 4 cm :

  • Combination chemotherapy.

  • If poor surgical candidate  radiation alone is sufficient.

Childbearing adenxal mass

Physiological cysts (Luteal or Follicular)

• Most common cyst during reproductive years.

• Asymptomatic  unless torsion has occurred with large cysts.

• U/S : fluid-filled simple cystic mass.

Sertoli-Leydig tumor

(Androgen )

- defeminization followed by musculinization :

• Women in childbearing age with : altered body contour / flattening of breast

scanty irregular menstruation  followed by amenorrhea .

• There is hirsuitism / coursing of features / enlargement of the clitoris.

Post-menopausal adenxal mass

To downlo The initial workup of an ad

• If CA-125 is low AND ma

• If CA-125 is elevated O

files, pleasthe patient should b

therapy as : 1- Com

OTHER CHOICES:

• Needle aspirati poor sensitivity if mass is malig

• Repeated vagi

enxal mass should include : ad the full file and the other USMLE Transvaginal U/S + S_{erum CA-125}

ss has benign features on U/S  patient is observed with periodic U/S.

e ee v_{aluated by an experience}click hered gynecologic oncologist for exploration and possible additional to SUBSCRIBE and get a R suspicious features on U/S ( size >10cm, nodular or fixed pelvic mass, ascitis , metastasis )  bination chemo. 2- Needle aspiration for cytology ( They will be other choices in the question) lifetime membership.

on for cytology : is contraindicated in postmenopausal woman with an adenxal mass  it has

(25% - 82%) / procedure is not curable and will be recurrence in 1 year (in 25% of cases)/ and nant there might b spillage into peritoneal cavity changing staging & prognosis of cancer) nal U/S : is appropriate once the clinical findings , U/S , CA-125 suggest simple benign cyst.

Serous cystadenoma

• M

• 2

• H

• C

• T

ost common cystic ovarian neoplasm (30% of all ovarian tumors).

5% of these are malignant:

• Epithelial tumor is most common malignant in post-meno.

• Most common epithelial tumor is Serous. alf of these are bilateral. omplaint: Ovarian mass + abdominal pain. umor markers : (high CA-125 level in postmenopausal woman is suspicious of malignancy).

Theca Cell Tumor

(Estrogen )

- B - P

enign ovarian tumors.

ost-menopusal age:

- Tumor  estrogen level  Post-menopausal bleeding

Endometrial hyperplasia

Estrogenic feature (Hypertrophy of breasts)

Absence of menopausal signs (e.g.vaginal atrophy)

Granulosa cell tumor

(Estrogen )

• 10

• Bi

% of solid malignant tumors.

modal age distribution :

1) Pre-pubertal age :

• Tumor  estrogen level  precocious puberty ( development of 2ry sexual charac.) 2) Post-menopusal age:

• Tumor  estrogen level  Post-menopausal bleeding

Endometrial hyperplasia

Estrogenic feature (Hypertrophy of breasts)

Absence of menopausal signs (e.g.vaginal atrophy)

Pre-pubertal adenxal mass

Granulosa cell tumor

1) Pre-pubertal age :

- Tumor  estrogen level  precocious puberty ( development of 2ry sexual charac.)

(Estrogen )

Dysgerminoma

• Most common malignant germ cell tumor.

• They arise in children (prepubertal) or young women (20year)

• Tumor markers :

Mature teratoma

(Dermoid cyst)

• Peak: 20 to 40 years. ( can also be seen in infancy + menopause) - Benign

• B-HCG is negative.

• U/S : complex cyst  NEVER do Fine Needle Aspiration of complex ovarian cyst.

serous adenocarcinoma :

CA-125 , CEA

LDH , B-hCG , a-FP.

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• Solid ovarian tumors (viewed by US) are almost always malignant and demand immediate and aggressive evaluation

files, please and TT in all age groups, except in pregnancclick hery. e to SUBSCRIBE and get a

• If a pt has sudden onset hirsutism or virilization during pregnancy, do physical exam and pelvic US:

If US shows no ovarian mass:  do an abdominal CT to rule out adrenal mass.

If US shows lifetimbilateral cystic:e membership.  theca lutein cysts (rule out high b-hcg states: Molar pregnancy & Twins)

If US shows bilateral solid:  pregnancy luteoma.

 Bilateral solid ovarian masses discovered incidentally in a multiparius African-American pregnant woman most likely signify a pregnancy luteoma. This is a benign self-limited condition and requires no treatment.

If US shows unilateral solid: do a laparotomy or laparoscopic biopsy to rule out malignancy.

• Typically multiparous woman < 40 year old.

• Complaint : dysmenorrheal + Menorrhagia

  Adenomyosis

• Bimanual examinations shows : Symmetrically enlarged + tender uterus + soft consistency  Most probable diagnosis is: .

Fibroids	- Asymmetrical enlarged uterus + non tender + firm consistency.
Endometriosis	Presents with dysmenorrhea + infertility Uterus is not diffusely enlarged

• Benign condition in which foci of endometrial glandular & stromal tissue are found in location outside uterus.

• 20 – 30 year old female is Complaining: 3 hallmark features "3Ps" : 1- Dysmenorrhea  It's worse pre-menstrually 2- Dyspareunia. 3- Dyschezia

+ Chronic (>6 months) pelvic pain & low sacral back pain + Infertility.

Other symptoms: hematochezia / hematuria / premenstrual or postmenstrual spotting.

• Examination: * Tender posterior vaginal fornex (rectovaginal tenderness)

• Tenderness on motion of uterus ( due to presence of ectopic endometrial tissue ).

• Tender adenxal mass /or firm nodularity in broad ligaments / uterosacral ligament in cul-de-sac.

• Ultrasound: may demonstrate homogenous endomterioma on ovary (DON'T confuse if there is fertility + ovarian mass)

• The most appropriate diagnostic test is : (gold standard).

  Infertility

• The patient is at risk of developing of: ( 30% of female evaluated for infertility are having endometriosis)

  Combined estrogen progesterone pills(OCPs)

• Treatment: are first line agents in the treatment of endometriosis in young women desiring future fertility.

• When a woman presents with dyspareunia , the following must be ruled out :

• Presence of : Dysmenorrhea + Heavy menses + Enlarged uterus  is classic for uterine fibroids.

 The enlarged uterus in fibroid : aymmterical +Firm + Non-tender

(enlarged uterus in adenomyosis: symmetrical + soft + tender)

• T he most common benign uterine tumor in women.

• The most common indication of hysterectomy.

• They are estrogen dependant tumors :

• Increase in size with use of : OCPs / Pregnancy.

• Decreases in size with : menopause

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• The differential diagnosis of a breast mass includes :

1. Fibrocystic disease,

2. Fibroadenoma,

3. Mastitis/abscess, 4- Fat necrosis

5- Breast cancer.

• A young woman who presents with a breast lump can be : asked to return after her menstrual period for (which may reveal regression of the mass) if no obvious signs of malignancy are present.

• is common in the first 24 to 72 hours after childbirth secondary to milk accumulation / peaks 3-5 days postpartum and improves spontaneously in most patients.

• Complaints: feel breast fullness, tenderness and warmth.

• Treatment (symptom control): you can do cool compresses, acetaminophen, NSAIDS.

• Initial menstrual cycles in pubertal females (first 1 – 2 years) are anovulatory :

They are irregular and may with menorrhagia ( prolonged or heavy menstruation, typically lasting longer than 7 days or exceeding 80 mL ).

This is due to immaturity of the developing hypothalamic-pituitary-gonadal axis, that does not produce adequate quantities and proportions of the hormones (i.e. FSH and LH) required to induce ovulation.

Bleeding disorders (coagluopathies)

Result in: unusually heavy menses (not irregular) that may frequently require blood transfusion.

• Midcylce pain (mittleschmerz) :

• Abdominal pain in a young female with regular menstrual periods (not taking OCPs = ovulating), in the

middle of her cycle (LMP was2 weeks ago ) with a benign history and clinical examination is most likely :

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• Early follicular phase immediately follows menstruation :

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• In the ovulatory phase :

  • Cervical mucus is lifetime membership.profuse, clear and thin.

  • It will stretch to approximately 6 cm, its pH is ≥ 6.5 (more basic than other phases and allow penetration by spermatozoa)  Exhibit “ferning” on microscopic slide smear preparation.

 The mucus of the post and pre-ovulatory phases, which is scant, opaque and thick.  Evaluation of the cervical mucus is part of infertility workup.

• Primary dysmenorrhea (usually appears 6 to 12-months after menarche) :

  • Lower abdominal pain radiating to the thighs & back, begins hours before menstruation = 1ry dysmenorrhea.

  • It is caused by increased levels of prostaglandins

  • Treatment :

1. NSAIDs are the most effective for treatment;

2. Oral contraceptive pills inhibit ovulation and are also effective.

• Luteal phase defect

  • Luteal phase defect is confirmed by endometrial biopsy.

• Luteal phase defect is first attempted with progesterone supplements.

• Clomiphene citrate or hMG can be tried if progesterone gives no results.

 Clomiphene citrate (estrogen analogue) acts by binding to hypothalamic estrogen receptors and suppressing the inhibitory effect estrogen has on GnRH production.

• Major complication of ovulation induction are:

1. Multiple gestation

2. OHSS (ovarian hyperstimulation syndrome):

• is a complication that occurs in 1-3% of patients under ovulation induction.

• OHSS may be complicated with ovarian torsion, ovarian rupture, thrombophlebitis and renal insufficiency.

• 2 Causes

1-

• History of previous complicated pregnancy with post-partum bleeding.

• Features of hypoprolactinemia: formula feeding (Failure to lactate after birth).

• Features of hypothyroidism: leathargy + weight gain + fatigue /sparse pubic hair + dry skin + delayed tendon reflexes.

• Features of hypogonadism : she hasn't had any menstrual period following delivery.

2- Lymphocytic hypophysitis (Autoimmune destruction) :

• Not related to peri-partum period.

• Presents with : Hypopituitrism + Headache + Blurred vision .

Other cause : Infiltrative disorders  sarcoidosis : Not post-partum /diabetes insipidus is more common to occur

( uncommon in Sheehan)

is defined as development of 2ry sexual characters <8 years in girls / <9 years in boys.

1. Central (): have pubertal levels of basal FSH, LH + that  with GnRH stimulation.

*All central , should have brain image  to exclude CNS lesions.

• If patient is at advanced Tanner stage  should be to prevent premature

epiphyseal plate fusion with short stature.

• Cyproterone acetate  steroidal component used in Europe as 2^nd line treatment of hirsutism.

2. Peripheral ): have low level of FSH, LH + NO response to GnRH.

   • Example: 1- Congenital Adrenal Hyperplasia / 2- Estrogen producing Ovarian Cyst.

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Blacken sentences = Aromatase Deficiency.

 begin 1-2 weeks before menses  regress around time of menstrual flow…

• Physically: typically abdominal bloating/headache/fatigue/breast tenderness

• Psychologically : typically anxiety / mood swings / difficult concentration / decrease lipido

Pre-menstrual dysphoric disorder (PMDD): is severe variant with severe irritability & anger.

FIRST STEP is confirming diagnosis :

If patient mentioned the symptoms  the most appropriate next step in management is for 2-3 months and note any associated symptoms :

 When symptoms repeatedly in the days prior to menstruation & resolve with onset of menses : PMS is confirmed  If symptoms occur irregularly or throughout the menstrual cycle : primary mood disorder is more likely.

Alprazolam	Effective BUT not 1st like of TTT due to sedation and dependence
Cognitive Behavioral Therapy (CBT)	CBH in PMS is effective in those who prefer avoiding the medications BUT DIAGNOSIS MUST BE CONFIRMED FIRST
SSRIs (fluoxetine)		1st line treatment	BUT DIAGNOSIS MUST BE CONFIRMED FIRST
Life style modification	1) Diet  decrease : caffeine / Na diet 2) Stress reduction techniques.

• Menopausal female  has aromatase enzyme only in peripheral fat tissue ( Not in granulosa cell of ovaries ) that To download the full file and the other USMLE converts androgen to estrogen resuting in (especially in obese women) :

 Decrease in some menopausal symptoms as vagianl dryness & dyspareunia

files, please  BUT may result inclick her HOT FLASHES. e to SUBSCRIBE and get a

• Night sweats + insomnia + irregular menses  Differential Diagnosis in middle-aged female are :

1. Thyrotoxicosis.

   obtain FSH , LH

2. Menopause. lifetime membership.

- Most appropriate next step in management is: ( to differentiate)

( Don't choose : Reassurance It's menopause ! / or Hormonal Replacmemnt Therpay  because this patient is not presenting with classic clinical symptoms of menopause , you should choose checking FSH,LH first to exclude thyrotoxicosis ).

• Atrophic Vaginitis : - Clinical Diagnosis , typically : Vaginal Dryness , Dyspareunia , Dysuria , Pruritis, Urinary frequeucny.

• Examination: pale , dry , smooth vaginal epithelium , scarce pubic hair , loss of labial fat bad.

• Differential Diagnosis: many symptoms can also be seen in UTI IF Urine dipstick is normal rules out UTI.

• Treatments:

1. First step in management in mild atrophic vaginitis vaginal lubricants.

   Vaginal Estrogen Replacement.

   	Contraceptive pills :

2. First step in management in Severe atrophic vaginitis 

• Even though OCPs may worsen diabetes they do not precipitate diabetes in a non-diabetic patient.

• OCPs are steroid compounds  therefore cause Na & water retention; 

• Weight gain is not a side effect of combined OCP  .

BUT  weight gain have been reported with use of medroxyprogesterone use ( so, don't switch OCPs to it)

• As for breast cancer, the risk does not seem to change with their use.

• Postpartum contraceptions :

  • Contraceptive methods than can be used in postpartum period include :

    1. Progetin-only contraceptives : preferred in lactating women ( + no DVT complications of combined pills)

    2. Sterlization (tubal ligation) : Not preferred if mentioned she only need contraception for short time NOT perminant !

    3. Barrier methods.

    4. IUD.

• Emergency contraceptive :

  Levonorgestrel

  •  is the recommended method up to 120 hour after intercourse.

 Prostaglandin E2 suppository  is used as 2^nd trimester abortifacient

• Infertile young female with :

• History of stressful life , excessive exercise , eating disorders.

• Failure to conceive.

• Irregular menses or 2ry amenorrhea.

• FSH & LH are both decreased

• This suggest diagnosis of hypogondaotropic Hypogonadism : hypothalamic dysfunction with insufficient

Pulsatile GnRH release   FSH , LH

• The patient is at great risk for : (osteoporosis)

  Pulsatile GnRH release.

• Treatment : 1) First line is to cut down the stress 2) If this failed , the next management step is :

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• Infertile female with signs suggestive of normal ovulation :

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2. Mid-cycle pelvic pain (mittleschmerz)

3. Egg white vaginal discharge. lifetime membership.

4. Rise body temperature during luteal phase.

 So, testing of ovulation by : mid-luteal phase progesterone / serum prolactin level / Serum testosterone / serum inhibin B Is not likely to identify the cause of infertility ,,, so the most appropriate next step is : .

 Serum inhibin B : is used to determine ovulatory reserve. It will be decreased in older women who have a decreased capacity to ovulate.

• I nability to conceive after > 1 year of frequent intercourse. (for those >35)  definition of infertility is shortened to >6 months).

• The best initial next step in management of a couples with infertility is : as initial screening test.

• After excluding male factors of infertility (20-30%)  then go ahead for female evaluation !

• Female , infertile , with a strong desire to get pregnant  may result in some hormonal changes mimicking those of pregnancy : Amenorrhea / enlargement of breasts & abdomen / morning sickness / weight gain / sensation of fetal movement / reported +ve pregnancy test ( but at office will be –ve)

  pseudocyesis

  • The most likely diagnosis is :  a form of conversion disorder & need psychiatric evaluation.

• Presence of any 2 of the following 3 signs & symptoms :

1. Clinical ( i.e hirsuitism , acne , male pattern baldness "androgenic alopecia") AND/Or Biochemical ( i.e. hight serum androgen , increase LH/FSH ratio)

2. Amnorrhea or oligomenorrhea

3. Pelvic U/S with cystic ovaries (small cysts are noted around the ovaries in a classic " string of pearls" appearance.

• All patients with clinical symptoms suggestive of PCOS, is recommended to have :

 2 hour glucose > 140  presumptive of Impaired glucose tolerance (insulin resistence)  2 hour glucose > 200  consistent with diabetes mellitus type II.

• Any women with PCOS & impaired glucose tolerance  The following is indicated: Which has following benefits :

1. Helps preventing DM type II

2. Helps losing weight (most PCOS are obese)

3. In conjugation with clomiphene citrate, it helps to induce ovulation ( however not FDA approved just for this purpose.

4. It has modest effect on suppression androgen production thus help correcting hirsuitism. - PCOs at increased risk of:

1. 50% are obese.

2. Insulin resistence & DM type II 3- Cardiovascular disease.

4- Endometrial cancer ( monitoring of CA-125 used to monitor therapy for ovarian cancer NOT endometrial) - Treatment of :

• Evaluation of Primary amenorrhea :

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lifetime membership.

• Turner syndrome :

  1. 14 year old female with primary amenorrhea.

  2. Short stature

  3. Hypertension in upper extremities + Low BP in low extramities (Coarcatation of aorta)

      FSH , LH

  4. Ovarian dysgenesis :

-  Inhibin : marker of ovarian function -  Estrogen : Estrogen replacement therapy - Normal GH : despite short stature.

 Testosterone	In : 1- klinefelter syndrome 2- cryptorchidism
 Testosterone	In Androgen resistance syndrome: Female phenotype with a XY genotype.
 LH	In hypothalamic hypogonadism ( 2ry hypogonadism)

• Irregular menstrual cycles in women shortly after menarch :

• Young female with her menses has just started BUT it's irregular (anovulatory) + administration of progesterone results in withdrawal bleeding in 3 days (menses after progesterone chalange)  the most likely explination for her irregular menses is :

• This is due to immaturity of the developing H-P-G axis that doesn't produce adequate quantities of the hormones FSH & LH required to induce ovulation.

• In absence of ovulation ( which results in Corpus Luteum formation progesterone production which maintain endometrium ) , the endometrium builds up under influence of estrogen , but without influence of progesterone , the cue to slough endomterium is lacking and menstrual-like bleeding occurs due to estrogen breakthrough bleeding.

Marked estrogen deficiency	Menses due to progesterone challenge wouldn't occur in the setting of estrogen deficiency as estrogen is required to build up endometrium.
Excess LH secretion	To download the full file and the other USMLE Occurs in PCOS
Marked andogen excess	Occurs in PCOS + would have symptoms of virilization.

• fiPremature Ovarian Fales, please iclilure ck her: e to SUBSCRIBE and get a

• Irregular menses with menopausal level of FSH,LH (absence of menses for 3 months is enough) +  estrogen in women < 40 years : Premature ovarian lifetime membership.failure.

• Mostly is idiopathic OR 2ry to : radiation, chemo, mumps , oophoritis.

• Associated with autoimmune disease : Hashimoto , Addison , Diabetes type 1 , pernicious anemia - Question presents as women with menopausal symptoms.

   FSH , LH ( FSH/LH ratio > 1.0 ) >= 3 months

• Diagnosis conformed by :  estrogen +

• P atient has lack viable oocytes  so only way to allow pregnancy in this patient is :

		In Vitro Fertilization using donor oocytes.
Clomiphene citrate	Induce ovulation with those with ovulatory reserve as PCOS
Metformin	Promote ovulation in PCOS , as insulin resistance affect normal ovulation.
GnRH agonist	Pulsatile form  induce ovulation ( need ovulatory reserve ) Chronic therapy  suppress ovulation
Progesterone	Correct : Luteal phase defect .

• Anovulation secondary to Morbid Obesity :

  • Female , with morbid obesity , is complaining of irregular menses followed by amnorrhea (e.g for 9 month) with :

• Serum TSH , prolactin normal

• FSH , LH  normal

The ovaries are still producing estrogen , BUT progesterone is not being produced at normal post ovulation levels  therefore, progesterone withdrawal menses at the end of the cycle doesn't occur.

Menopause	Defined as 1 year of no menses (not 9 month). FSH , LH are 
Pituitary dysfunction	- FSH , LH are  (< 5mIU/mL)
Premature Ovarian Failure	FSH<40 , LH <25 are  Occur in women < 40 year old.
Post-tubal ligation syndrome	Dysmenorrhea / heavy bleeding or spotting / changes in length or regularity of menstrual cycle. Long periods of amenorrhea is not usually reported !

• Secondary amenorrhea in athlete female :

  • A marathon runner female presents with 2ry amenorrhea  most likely etiology is :

• In female athletes, there is a relative caloric deficiency secondary to in adequate nutritional intake as compared to the amount of energy expended.

• Women with this condition is have shown to have  level of LH , GnRH  resulting in estrogen deficiency

 So, these women at increased risk of all conditions associated with estrogen deficiency, including:

infertility , vaginal atrophy , breast atrophy , osteopenia.

• Hyperprolactinemia :

Prolactin production is :

• Stimulated by : serotonin & TRH(TRH is increased in 1ry hypothyroidism Prolactin  amenorrhea & galactorrhea) .

• Inhibited by : dopamine.

Riseperidone side effects :

• It's dopamine & serotonin antagonist that can cause: weight gain / hyperprolactinemia  which leads to

amenorrhea & galactorrhea.

Galactorrhea :

1- Bilateral nipple discharge that is : Clear / Milky / yellow/brown/green discharge.

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3- Negative guaiac.

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 Another most common cause of bilateral nipple discharge is pregnancy  FIRST , you exclude it if mentioned in the question that LMP was about one week ago lifetime membership. then look for the cause :

- Causes :

a- Prolactinoma, b- Hypothyroidism c- Overstimulation of the nipple d- OCPs e- medications which lower dopamine levels are common causes of galactorrhea.

Mammography	Used for both : Screening breast cancer Evaluation certain cases of breast lump & discharge  it would be indicated if : Breast lump positive guaiac or grossly bloody nipple discharge.
U/S	Is one test can be used to evaluate a breast mass , useful at : discerning fluid-filled masses from solid masses. Evaluating the dense breast tissue of the younger women. In guided biopsies. It's not a part of the work-up for galactorrhea.
Cytological examination	Indicated in : Uniductal & guaiac positive nipple discharge Not indicated in guaiac negative discharge.
Surgical Evaluation	Would be indicated in this patient if she had : Breast lump positive guaiac or grossly bloody nipple discharge.

• Lactation suppression :

  Tight fitting bra & ice packs & avoid stimulation of

  nipples & analgesics to control pain.

  • Female just delivered  with death of her fetus  breast engorgement (warm , firm , tender to palpation)  the following is the most appropriate next step in management:

NO ROLE OF MEDICATIONS IN SUPRESSION OF BREAT MILD PRODUCTION

• Age-related decrease ovarian reserve :

  decreased ovarian reserve.

  • The most common cause of decreased fertility in women in their 4^th decade who are still experiencing menstrual cycles (to exclude premature ovarian failure which is 2ry amenorrhea before 40 years) is 