Gynecology

Hot flashes, night sweats, palpitations, and sleep disturbances.

Vaginal dryness, dyspareunia, urinary frequency, urgency, and recurrent urinary infections.

Irritability, mood swings, fatigue, decreased libido, and memory loss.

Causes osteoporosis, joint pain, thinning skin, loss of elasticity, brittle nails, and reduced breast size.

Relief of menopausal symptoms, prevention/treatment of osteoporosis, and management of premature ovarian insufficiency.

Undiagnosed vaginal bleeding, breast/endometrial cancer, history of DVT/PE, and active liver disease.

Breast tenderness, bloating, nausea, mood swings, abnormal uterine bleeding, increased risk of VTE and breast cancer.

Mammography, lipid profile, glucose tolerance tests, and endometrial evaluation in certain cases.

To prevent the development of endometrial hyperplasia or malignancy caused by unopposed estrogen.

Orally or via transdermal patch/gel; transdermal is preferred in cases of impaired liver function or hypertriglyceridemia.

Increased risk of endometrial hyperplasia and endometrial cancer.

Regular exercise, calcium and vitamin D supplementation, smoking cessation, and maintaining a healthy weight.

Absence of menarche at: 1. 15 years of age with normal secondary sexual characteristics. 2. 13 years of age without secondary sexual characteristics.

Absence of menses for: 1. >3 months in individuals with previously regular cycles. 2. >6 months in individuals with irregular cycles.

- Normal puberty, but adrenarche and gonadarche occur late. - Hormonal levels: ↓ GnRH, ↓ FSH, ↓ Estrogen (prepubertal levels).

- Deficient GnRH release due to: Kallmann syndrome (anosmia, hypogonadism), Prader-Willi syndrome, Eating disorders, stress, competitive sports, CNS tumors (e.g., craniopharyngioma). - Hormonal levels: ↓ GnRH, normal/↓ FSH, ↓ Estrogen.

- Ovarian failure despite GnRH release (e.g., Turner syndrome). - Hormonal levels: ↑ GnRH, ↑ FSH, ↓ Estrogen.

- Outflow tract obstruction with otherwise normal puberty: Müllerian agenesis, Imperforate hymen, Vaginal atresia, Transverse vaginal septum. - Hormonal levels: Normal GnRH, FSH, and Estrogen.

1. Pregnancy (most common). 2. Ovarian disorders (e.g., PCOS, premature ovarian failure). 3. Medications (antipsychotics, contraceptives). 4. Endocrine disorders (e.g., hypothyroidism, Cushing syndrome). 5. Functional hypothalamic amenorrhea (e.g., stress, exercise, eating disorders). 6. Anatomical causes (e.g., Asherman syndrome).

1. Pregnancy test. 2. Evaluate secondary sexual characteristics. 3. Assess for anatomical anomalies (e.g., pelvic ultrasound). 4. Hormonal levels: FSH, LH, Prolactin, TSH, Estradiol.

- Induces withdrawal bleeding if estrogen is present. - No bleeding: Suggests estrogen deficiency or an anatomical problem.

1. Measure prolactin and TSH levels. 2. Perform a brain MRI to rule out a pituitary adenoma.

1. Caused by stress, excessive exercise, or eating disorders. 2. ↓ GnRH pulsatility → ↓ FSH and LH → ↓ Estrogen → Anovulation. 3. Associated with the female athlete triad: calorie deficit, low bone density, amenorrhea.

Dopamine agonists (e.g., bromocriptine, cabergoline).

1. Lifestyle modifications: reduce stress, increase calorie intake, achieve BMI >19. 2. GnRH or gonadotropin therapy for ovulation induction.

1. ↑ FSH levels (>30–40 mIU/mL) on two separate occasions. 2. ↓ Estradiol levels (<50 pg/mL). 3. >3 months of menstrual irregularities in women under 40 years old.

1. Hormone replacement therapy to prevent osteoporosis. 2. Ovulation induction if pregnancy is desired. 3. Address underlying causes if identified.

PCOS is a common endocrine disorder in women characterized by hyperandrogenism (hirsutism, acne), ovulatory dysfunction (irregular menses), and polycystic ovaries.

Affects 6–12% of women of reproductive age in the US.

Insulin resistance leads to hyperinsulinemia, increasing androgen production. Excess androgens disrupt follicle maturation, causing anovulation. Increased LH/FSH ratio and unopposed estrogen contribute to hyperplasia and carcinoma risks.

Menstrual irregularities, hyperandrogenism (hirsutism, acne), metabolic syndrome, infertility, obesity, skin conditions (acanthosis nigricans), and psychiatric symptoms (depression, anxiety).

Using Rotterdam Criteria: 2 out of 3 - (1) Oligo-/anovulation, (2) Hyperandrogenism (clinical or biochemical), (3) Polycystic ovaries on ultrasound. Exclude other endocrinological conditions.

Increased testosterone, LH:FSH ratio > 2:1, decreased SHBG, elevated androstenedione, and exclusion of thyroid dysfunction or congenital adrenal hyperplasia.

Lifestyle modifications (weight loss, healthy diet), combined oral contraceptives (regulate cycles, treat hyperandrogenism), metformin (improves insulin sensitivity), and antiandrogens (for hirsutism, alopecia).

Letrozole (first-line for ovulation induction), clomiphene citrate, exogenous gonadotropins, laparoscopic ovarian drilling, and IVF if other treatments fail.

Metabolic syndrome, cardiovascular disease, endometrial cancer, and infertility.

Ovarian hypertrophy with thick capsule, stromal hyperplasia and fibrosis, multiple small cystic follicles, hyperluteinized theca cells, and decreased granulosa cells.

Non-classic congenital adrenal hyperplasia (↑ 17-hydroxyprogesterone), androgen-secreting tumors (↑ DHEA-S > 700 µg/dL), Cushing syndrome (↑ cortisol levels), hypothyroidism (↑ TSH), and hyperprolactinemia (↑ prolactin).

Irregular uterine bleeding in nonpregnant individuals of reproductive age, with abnormalities in frequency, duration, regularity, or volume.

Frequency: Infrequent (>38 days), Frequent (<24 days). Duration: Prolonged (>8 days). Volume: Heavy menstrual bleeding. Intermenstrual bleeding: Random or cyclic bleeding between cycles.

PALM: Polyp, Adenomyosis, Leiomyoma, Malignancy/Hyperplasia. COEIN: Coagulopathy, Ovulatory dysfunction, Endometrial dysfunction, Iatrogenic, Not otherwise classified.

PCOS, thyroid disorders, hyperprolactinemia, obesity, perimenopause, Cushing syndrome, eating disorders.

1. Rule out pregnancy with β-hCG test. 2. Perform clinical history and gynecological examination. 3. Obtain CBC, coagulation tests, and thyroid function tests.

Pelvic ultrasound (preferably transvaginal ultrasound) to assess endometrial thickness and structural abnormalities.

1. Women ≥45 years with AUB. 2. Women <45 years with persistent bleeding despite treatment, obesity, PCOS, or unopposed estrogen exposure.

β-hCG, CBC, ferritin, platelet count, PT/PTT, thyroid function tests, and prolactin levels.

1. High-dose IV conjugated estrogen. 2. Immediate hemodynamic stabilization. 3. Intrauterine tamponade or surgical intervention if refractory.

Hormonal Therapy: Combined oral contraceptives, progestin-only therapy, or levonorgestrel IUD. Nonhormonal Therapy: NSAIDs or tranexamic acid during bleeding episodes.

1. Hysteroscopy: Polypectomy or myomectomy (fertility-sparing). 2. Dilation and Curettage (D&C). 3. Endometrial Ablation: Non-fertility-preserving. 4. Hysterectomy: Definitive treatment for refractory AUB.

Obesity, unopposed estrogen, PCOS, tamoxifen therapy, Lynch syndrome, diabetes mellitus.

Structural causes are identifiable on imaging (e.g., polyps, leiomyomas), while nonstructural causes involve hormonal, coagulopathic, or iatrogenic issues.

It classifies AUB into structural (PALM) and nonstructural (COEIN) causes, guiding targeted evaluation and management.

PID is a bacterial infection of the female reproductive organs that spreads beyond the cervix to the uterus (endometritis), fallopian tubes (salpingitis), ovaries (oophoritis), and surrounding pelvic structures. It can also involve the pelvic peritoneum (peritonitis).

The most common pathogens are Chlamydia trachomatis and Neisseria gonorrhoeae. Less common pathogens include E. coli, Ureaplasma, Mycoplasma, and anaerobes.

- Multiple sexual partners \n- Unprotected sex \n- History of prior STIs or PID \n- Use of intrauterine devices (IUDs), especially within the first 3 weeks of placement \n- Vaginal dysbiosis.

- Bilateral lower abdominal pain \n- Abnormal vaginal discharge (yellow/green, mucopurulent) \n- Fever (>38.3°C/101°F) \n- Pain during sex (dyspareunia) \n- Irregular bleeding (e.g., menorrhagia or metrorrhagia) \n- Painful urination (dysuria) or urgency.

Cervical motion tenderness refers to severe pain elicited by manipulation or movement of the cervix during a bimanual pelvic examination. It is a key diagnostic criterion for PID.

Presence of any of the following in a sexually active female with pelvic/lower abdominal pain and no alternative explanation: \n- Cervical motion tenderness \n- Uterine tenderness \n- Adnexal tenderness.

- Oral temperature > 38.3°C (101°F) \n- Mucopurulent cervical discharge \n- Cervical friability \n- Abundant WBCs on vaginal secretion microscopy \n- Elevated ESR or CRP \n- Confirmed cervical infection with N. gonorrhoeae or C. trachomatis.

- Pregnancy test (to rule out ectopic pregnancy) \n- Cervical swabs for N. gonorrhoeae and C. trachomatis \n- Wet mount microscopy for WBCs, trichomoniasis, or bacterial vaginosis \n- Blood tests: CBC, CRP, ESR, HIV testing, RPR for syphilis.

Imaging is indicated if the diagnosis is unclear, symptoms persist after treatment, or there is concern for complications (e.g., tubo-ovarian abscess). Transvaginal ultrasound is typically used.

- Infertility: due to fallopian tube scarring. \n- Chronic pelvic pain: from adhesions. \n- Ectopic pregnancy: increased risk due to tubal damage. \n- Tubo-ovarian abscess: can rupture, causing sepsis.

- IM ceftriaxone (single dose) \n- Oral doxycycline (14 days) \n- Oral metronidazole (14 days).

Indications for admission: \n- Concern for a surgical emergency (e.g., differential diagnosis of acute abdomen) \n- Severe illness (e.g., fever >38.5°C, nausea, vomiting) \n- Tubo-ovarian abscess \n- Pregnancy \n- Inability to tolerate or adhere to oral therapy.

- IV cefotetan or cefoxitin + IV/oral doxycycline. \n- If penicillin-allergic: IV clindamycin + IV gentamicin.

- Test and presumptively treat partners for chlamydia and gonorrhea. \n- Instruct patients and partners to abstain from sex until treatment is completed for all. \n- Educate on STI prevention.

Surgery may be required for: \n- Drainage of a tubo-ovarian abscess if unresponsive to antibiotics. \n- Removal of an IUD if no improvement after 72 hours of treatment.

- Ectopic pregnancy: rule out with pregnancy test. \n- Appendicitis: localized RLQ pain, fever. \n- Ovarian torsion: sudden, severe pain, adnexal mass on imaging. \n- Ruptured ovarian cyst: acute onset pain without fever. \n- Urinary tract infection: dysuria without pelvic tenderness.

- Practice safe sex (use condoms). \n- Limit the number of sexual partners. \n- Regular STI screening. \n- Timely treatment of STIs in both patient and partners. \n- Careful monitoring during and after IUD placement (higher PID risk in the first 3 weeks post-insertion).

Pelvic floor dysfunction is the inability to relax and coordinate pelvic floor muscles correctly to urinate and/or have bowel movements.

Urinary incontinence, urgency, and/or dysuria

Fecal incontinence

Dyssynergic defecation

Dyspareunia

Lower back or pelvic pain

Feeling of pressure on the pelvic region or rectum

Pelvic muscle spasms

Clinical features and physical examination

Pelvic ultrasound

Urodynamic studies

Anorectal manometry

- Pelvic floor muscle training (e.g., Kegel exercises) and physical therapy \n- Biofeedback and electrical stimulation (probes or electrodes to stimulate pelvic floor muscles) \n- Stool softeners and muscle relaxants

Gardnerella vaginalis

Gray/milky with a fishy odor

> 4.5

Clue cells

Metronidazole

Trichomonas vaginalis

Frothy, yellow-green, foul-smelling

Flagellated protozoa

Metronidazole; treat sexual partner(s)

Candida albicans

White, crumbly, thick (cottage cheese-like), odorless

4–4.5

Pseudohyphae

Topical azoles or nystatin; oral fluconazole in nonpregnant adults

Neisseria gonorrhoeae

Purulent, creamy

Gram-negative, intracellular diplococci

Ceftriaxone (IV/IM); treat sexual partner(s)

Chlamydia trachomatis serotype D–K

Purulent, bloody

Intracellular organisms that Gram stain poorly

Azithromycin or Doxycycline in nonpregnant patients; treat sexual partner(s)

Ectopic pregnancy occurs when a fertilized egg implants outside the uterus, most commonly in the fallopian tubes (95%). Rare sites include the ovary, cervix, and abdomen.

- Anatomic alterations: PID, tubal surgeries, endometriosis, previous ectopic pregnancy, ruptured appendix. - Nonanatomic: Smoking, age > 35, IVF or assisted reproductive technologies, IUD use.

- Lower abdominal pain (unilateral or bilateral). - Vaginal bleeding or spotting. - Amenorrhea (missed period). - Symptoms of pregnancy (nausea, breast tenderness, frequent urination).

- Acute abdomen: sudden, severe abdominal or pelvic pain. - Shock signs: hypotension, tachycardia, fainting, pallor. - Peritoneal signs: guarding, rebound tenderness.

1. Pregnancy test: Serum β-hCG. 2. Transvaginal ultrasound: Identify pregnancy location. 3. Laparoscopy if unstable or diagnosis is unclear.

β-hCG > 1,500–3,000 IU/L: A gestational sac should be visible on ultrasound. - If not, suspect ectopic pregnancy. - Rising, plateauing, or declining β-hCG levels help differentiate ectopic from normal or failing pregnancies.

Empty uterine cavity with thickened endometrial lining. - Tubal ring sign (echogenic ring in the fallopian tube). - Free fluid in the pouch of Douglas (suggests bleeding).

- Medical management: Methotrexate for stable, unruptured cases (β-hCG ≤ 5,000 IU/L, mass < 3.5 cm). - Expectant management: In asymptomatic patients with declining β-hCG levels and no ectopic mass on ultrasound.

- Hemodynamic instability. - Signs of rupture (severe pelvic pain, peritonitis). - Failed medical therapy.

- Salpingostomy: Removal of ectopic pregnancy while preserving the tube (for unruptured cases).

- Salpingectomy: Removal of the entire fallopian tube (preferred for rupture or severe damage).

- Ruptured ectopic pregnancy. - Intrauterine pregnancy. - Breastfeeding. - Methotrexate allergy.

Pain management.

- Rh immunoglobulin for Rh-negative patients with bleeding.

- Prenatal and contraceptive counseling after treatment.

- Helps differentiate ectopic from normal pregnancies.

- Normal IUP: β-hCG increases by >33–49% in 48 hours.

- Ectopic or failing pregnancy: Plateauing or falling β-hCG levels.

- Tubal rupture leading to hemoperitoneum or shock.

- Infertility (due to tubal scarring).

- Increased risk of ectopic pregnancy recurrence.

1. Severe, sudden abdominal pain.

2. Signs of shock: hypotension, tachycardia, pallor, fainting.

3. Acute abdomen (rigidity, guarding, or rebound tenderness).

4. Peritoneal irritation or free fluid on ultrasound.

Recurrent lower abdominal pain shortly before or during menstruation in the absence of pathologic findings that could account for the symptoms.

During adolescence, typically within three years of menarche.

Increased endometrial prostaglandin (PGF2 alpha) production leads to vasoconstriction/ischemia and stronger, sustained uterine contractions to prevent blood loss.

Spasmodic, crampy pain in the lower abdominal/pelvic midline, radiating to the back or thighs.

- Typically occurs during the first 1–3 days of menstruation.

- Accompanying symptoms: headaches, diarrhea, fatigue, nausea, flushing.

- Normal pelvic examination.

It is a diagnosis of exclusion. Rule out conditions that cause secondary dysmenorrhea.

- Symptomatic treatment: NSAIDs, topical heat.

- Hormonal contraceptives: combined oral contraceptive pill, IUD with progestogen.

- Pelvic inflammatory disease (PID)

- Intrauterine device (IUD)

- Adenomyosis

- Fibroids (intracavitary or intramural)

- Cervical polyps

- Endometriosis

- Adhesions

- Functional ovarian cysts

- Inflammatory bowel disease

Preeclampsia is new-onset gestational hypertension (≥ 140/90 mmHg) after 20 weeks of gestation with either proteinuria or end-organ dysfunction.

A severe form of preeclampsia characterized by Hemolysis, Elevated Liver enzymes, and Low Platelets. It may occur without hypertension or proteinuria.

- Nulliparity \n- Advanced maternal age (> 35 years) \n- Obesity \n- Family history of preeclampsia \n- Chronic hypertension \n- Diabetes mellitus \n- Renal disease \n- Multiple gestation \n- History of preeclampsia.

Abnormal trophoblastic invasion leads to poor placental perfusion. Release of antiangiogenic factors causes widespread endothelial dysfunction, resulting in hypertension, proteinuria, and end-organ damage.

- BP ≥ 140/90 but < 160/110 mmHg \n- Proteinuria: ≥ 300 mg/24 hours or urine protein/creatinine ratio ≥ 0.3

- BP ≥ 160/110 mmHg \n- Severe proteinuria (> 5 g/24 hours, but not mandatory) \n- End-organ dysfunction (e.g., CNS changes, liver involvement, renal impairment, thrombocytopenia, pulmonary edema).

- Eclampsia (seizures) \n- Placental abruption \n- HELLP syndrome \n- Acute renal failure \n- Disseminated intravascular coagulation (DIC).

- Intrauterine growth restriction (IUGR) \n- Preterm birth \n- Stillbirth \n- Placental insufficiency.

- BP ≥ 140/90 mmHg on two occasions after 20 weeks of gestation \n- Proteinuria: ≥ 300 mg/24 hours or protein/creatinine ratio ≥ 0.3, or dipstick ≥ 1+.

- CBC (platelet count) \n- CMP (AST, ALT, creatinine) \n- LDH (hemolysis marker)

- Acute control: Labetalol, hydralazine, or nifedipine \n- Chronic management: Methyldopa, labetalol, or long-acting nifedipine.

Magnesium sulfate. Monitor for toxicity (loss of reflexes, respiratory depression); treat toxicity with calcium gluconate.

- Immediate delivery if ≥ 37 weeks \n- If < 37 weeks: Deliver if severe preeclampsia, complications (e.g., HELLP), or fetal compromise.

Preeclampsia occurring in a patient with preexisting chronic hypertension.

- Gestational hypertension \n- Chronic hypertension \n- Gestational trophoblastic disease (onset < 20 weeks)

Monitor BP and symptoms postpartum (preeclampsia may persist or worsen). Screen for long-term cardiovascular risks.

(Levonorgestrel): Progestin-based emergency pill.

Copper IUD:

1. History of thromboembolism

2. Migraines with aura

3. Uncontrolled hypertension

4. Smoking in women > 35 years

5. Breast cancer

Progesterone and relaxin decrease smooth muscle tone, causing constipation, GERD (relaxed esophageal sphincter), and varicose veins/hemorrhoids (relaxed blood vessels and uterine pressure reducing venous return).

Increased oxygen demand, tidal volume, and physiological dyspnea due to progesterone. Decreased total lung capacity, residual volume, and expiratory reserve volume; estrogen causes nasal congestion and nosebleeds.

Peripheral vasodilation decreases blood pressure mid-pregnancy; heart rate increases by 20 bpm, cardiac output increases by 40%, and mild cardiac hypertrophy occurs.

Plasma volume increases, causing dilutional anemia; RBC, WBC, and platelets increase; fibrinogen and coagulation factors increase, enhancing clotting and creating a hypercoagulable state.

Hyperpigmentation (e.g., linea nigra, melasma, darkened nipples/areola), stretch marks (striae gravidarum), palmar erythema, and spider naevi due to increased prolactin and skin stretching.

• creening depends on risk factors:

  • High-risk women (e.g., past GDM, obesity): Fasting glucose at booking. If normal, do OGTT at 16–18 weeks.

  • Normal-risk women: Perform a 75g Oral Glucose Tolerance Test (OGTT) between 24–28 weeks.

    • OGTT criteria for GDM diagnosis:

      • Fasting glucose: ≥5.1 mmol/L.

      • 1-hour post-load glucose: ≥10 mmol/L.

      • 2-hour post-load glucose: ≥8.5 mmol/L.

For the Mother:

• During Pregnancy:

  • Hypertension and preeclampsia.

  • Premature delivery.

• During Labor:

  • Induced labor or cesarean section.

  • Perineal trauma or assisted vaginal delivery.

• Postpartum:

  • Higher risk of type 2 diabetes (DM2) or cardiovascular disease.

  • Postpartum hemorrhage or infection.

For the Baby:

• Before birth:

  • Macrosomia (big baby) leading to delivery trauma (e.g., shoulder dystocia).

  • Increased risk of stillbirth or polyhydramnios.

• After birth:

  • Neonatal hypoglycemia and respiratory distress.

  • Hyperbilirubinemia and NICU admission.

  • Long-term risk of obesity, diabetes, and heart disease.

• PAPPA: Low in trisomies.

• β-hCG:

  • High in Down syndrome.

  • Low in trisomy 18 and 13.

• Nuchal Translucency (NT): Enlarged in Down syndrome and trisomy 18.

Second-Trimester Key Markers:

• AFP: Elevated in neural tube defects or abdominal wall defects.

• Quad screen abnormalities suggest chromosomal anomalies.

Diagnostic Tests to Confirm Abnormalities:

• Chorionic Villus Sampling (CVS): Done early (10–13 weeks).

• Amniocentesis: Done later (15–20 weeks).

• cffDNA (NIPT): Non-invasive, detects chromosomal and inherited conditions.

Definition: Onset of labor until complete cervical dilation (10 cm). Phases:

1. Latent Phase

   • Characteristics: Mild, irregular contractions; gradual cervical dilation (< 1 cm/hour).

   • Duration:

     • Primipara: < 20 hours

     • Multipara: < 14 hours

2. Active Phase

   • Characteristics: Regular, stronger contractions; rapid cervical dilation (1–4 cm/hour).

   • Duration:

     • Primipara: ≥ 1.2 cm/hour

     • Multipara: ≥ 1.5 cm/hour

Clinical Features:

• Cervical effacement and dilation.

• Bloody show: Blood-tinged mucous discharge.

• Spontaneous rupture of membranes (SROM): Watery discharge from amniotic sac rupture.

Management:

• Pain relief: Analgesia upon request.

• Fetal heart rate monitoring.

• Assess fetal position via Leopold's maneuvers or ultrasound.

• Regular cervical and fetal descent checks.

• Amniotomy during active phase (if safe).

Definition: From full cervical dilation (10 cm) to delivery of the baby. Duration:

• Primipara: < 3 hours

• Multipara: < 2 hours

Clinical Features:

• Strong, regular uterine contractions.

• Crowning: Appearance of fetal head at the vaginal opening.

Management:

• Warm compresses and perineal massage for comfort.

• Encourage safe, comfortable maternal positioning.

• Episiotomy only if indicated (e.g., shoulder dystocia, assisted delivery).

• Delay cord clamping (~1 minute) or milk the cord.

Definition: From delivery of the baby to placenta expulsion. Duration: ~30 minutes

Clinical Features:

• Uterine contractions expel the placenta.

• Signs of placental separation:

  • Cord lengthening

  • Gush of vaginal blood (~300 mL loss)

  • Uterine fundal rebound (uterus becomes spherical).

Management:

• Fundal massage: Stimulates uterine contraction to minimize bleeding.

• Active management:

  • Oxytocin: Administered after cord cutting to enhance uterine contraction.

  • Controlled cord traction: Assists placental separation (Brandt-Andrews maneuver).

• Examine placenta for completeness (cord, membranes, 3 vessels).

Definition: Immediate postpartum period (~2 hours post-delivery).

Key Steps:

• Examine placenta for completeness.

• Repair any obstetric lacerations.

• Monitor closely for:

  • Postpartum hemorrhage.

  • Preeclampsia symptoms (e.g., elevated BP, seizures).

The 6-8 week period after birth when the body recovers from pregnancy and childbirth.

Low-grade fever, shivering, and leukocytosis, which do not necessarily indicate an infection.

The process where the uterus contracts and returns to its pre-pregnancy size by the 6th–8th week postpartum.

Painful uterine cramps caused by postpartum uterine contractions, more common in multiparous women.

Postpartum vaginal discharge from uterine lesions, cervical mucus, and other components during healing.

- Immediately after delivery: ~6 kg (13 lbs) from baby, amniotic fluid, and placenta.

After 4 weeks, all methods can be used depending on personal preference and breastfeeding status.

- Progestin-only pills, implants, or injections.

Combined hormonal contraceptives (estrogen + progestin) in the first 6 weeks due to the risk of reduced milk supply.

Obstetric causes: ectopic pregnancy, miscarriage (threatened, inevitable, complete, incomplete), implantation bleeding, placenta previa, gestational trophoblastic disease. Non-obstetric causes: infections, trauma, malignancy, uterine abnormalities (polyps, fibroids).

Vaginal bleeding of varying severity, abdominal cramping/pain, general weakness, nausea. Severe cases: tachycardia, hypotension, anemia, tachypnea, dyspnea, and syncope.

- Anamnesis and physical/vaginal/speculum examination.

- Transvaginal ultrasound (TVUS).

- Beta-hCG levels to evaluate pregnancy status and rule out ectopic pregnancy or miscarriage.

- Stage I (Secretory Initiation): During pregnancy, glands differentiate but prolactin action is blocked by high estrogen/progesterone levels. Colostrum may be expressed.

- Stage II (Secretory Activation): After delivery, decrease in estrogen/progesterone allows prolactin to act, oxytocin causes milk ejection (galactokinesis).

- Bonding between mother and child.

- Decreases risk of infant allergies, respiratory and GI infections.

- Faster uterine involution.

- Early maternal weight loss.

- Prolongs postpartum anovulation.

TORCH: Toxoplasmosis, Others (syphilis, listeria, varicella, parvovirus B19), Rubella, Cytomegalovirus, Herpes.

Impact: congenital defects, growth restriction, preterm birth, spontaneous abortion, lifelong morbidity (e.g., hearing/vision loss).

- Low viral load (<1000 copies/ml): Any delivery mode is acceptable.

- High viral load (>1000 copies/ml): Planned c-section at 38 weeks, IV zidovudine during labor.

- Infant prophylaxis: Zidovudine for low risk, combination therapy for high risk.

Placenta previa, placental abruption, uterine rupture, vasa previa.

Non-obstetric: cervical/vaginal lesions, cervical trauma, "bloody show" before labor.

Risk Factors: Uterine atony, retained placenta, trauma, coagulation disorders.

Prevention: Antenatal risk assessment (e.g., anemia), active management of the third stage of labor (e.g., oxytocin administration), bimanual uterine massage, controlled cord traction, careful monitoring postpartum

- Gestational hypertension: BP >140/90 after 20 weeks without proteinuria.

- Chronic hypertension: Diagnosed before 20 weeks or pre-pregnancy.

- Preeclampsia: Gestational HTN + proteinuria or end-organ dysfunction.

- Eclampsia: Severe preeclampsia with seizures.

High-risk pregnancy; ensure adequate folic acid supplementation (1–4 mg/day).

- Safest AED: Lamotrigine.

- Adjust AED dose for increased renal clearance during pregnancy.

- Post-pregnancy: Taper pregnancy-level AED doses, discuss contraceptive options.

- A: Safe in pregnancy (e.g., folic acid).

- B: No harm in animals or limited human data (e.g., metformin).

- C: Harm in animals, unclear in humans; benefits may outweigh risks (e.g., gabapentin).

- D: Harmful, but benefits may outweigh risks (e.g., losartan).

- X: Contraindicated in pregnancy (e.g., statins).

Causes neural tube defects (e.g., spina bifida), intrauterine growth restriction, and increased autism risk. Should be avoided in women of childbearing age unless no alternatives are available.

Given for seizure prophylaxis in severe preeclampsia. Monitor for magnesium toxicity (e.g., muscle weakness, respiratory depression), and provide calcium gluconate for reversal if needed.

Previous DVT, thrombophilia, antiphospholipid syndrome, lupus, sickle cell disease, acute respiratory infections, maternal age >35, gestational diabetes, smoking, obesity, prior stroke, hypertension, and cancers.

Mechanical: Compression stockings.

Medical: LMWH (e.g., enoxaparin 40 mg SC daily) or UFH in renal impairment.

Antepartum prophylaxis: Start in high-risk patients preconception or by 28 weeks. Continue until delivery.

Postpartum prophylaxis: Continue for 6 weeks–3 months.

Genetic factors, infections, cervical surgery, uterine malformations, chronic medical disorders (DM, HT), assisted reproduction, short cervix, smoking, alcohol use, stress, poor prenatal care, history of preterm birth, spontaneous abortion, and short interpregnancy interval.

- High-risk patients may benefit from progesterone supplements or cervical cerclage.

- If labor starts: corticosteroids for lung maturation (betamethasone), tocolytics (e.g., magnesium sulfate) to delay labor for 48 hours, and antibiotics for GBS prophylaxis.

- Magnesium sulfate for neuroprotection if <32 weeks gestation.

Short-term: Fever (endometritis), wound infections, hemorrhage, surgical injury, ileus, psychiatric complications.

Long-term: Placenta previa/accreta, uterine rupture, scar pain, adhesions, bowel obstruction, infertility, unexplained stillbirths, preterm births, and fetal complications like allergies and infections.

Maternal indications: Placenta previa, uterine rupture, severe HT, maternal skeletal deformities.

Fetal indications: Fetal distress (e.g., pathological CTG, acidosis), malpresentation, macrosomia, and multiple pregnancy with significant weight difference.

Cesarean delivery, prolonged labor, multiple cervical exams, retained products of conception, meconium-stained amniotic fluid, and low socioeconomic status.

Empiric antibiotics (IV clindamycin + gentamicin), removal of retained products of conception by curettage.

Birth asphyxia caused by oxygen deprivation during labor, leading to hypoxemia, hypercapnia, and acidemia. Associated with low Apgar scores (<3 at 5 minutes) and umbilical cord arterial pH <7.2.

1. Warmth and drying to prevent hypothermia.

2. Clear airways if necessary (suction mouth before nose).

3. Provide positive pressure ventilation for apnea or HR <100 bpm.

4. If HR <60 bpm, initiate chest compressions (3:1 ratio with ventilation).

5. Administer epinephrine if HR remains <60 bpm.

6. Continue resuscitation for up to 15 minutes if there is no improvement.

- Initial evaluation: Warm the baby, dry with warm towels, assess breathing/HR.

- Airway clearance: Suction mouth and nose.

- Positive pressure ventilation: 40-60 breaths/min for apnea or HR <100 bpm.

- Chest compressions: If HR <60 bpm, 3 compressions to 1 ventilation.

- Medications: Epinephrine 0.01–0.03 mg/kg via IV or endotracheal route every 3–5 minutes if HR <60 bpm.

Placenta previa, placental abruption, uterine rupture, vasa previa. Non-obstetric causes: vaginal/cervical lesions, trauma.

Active management of the third stage of labor: administration of oxytocin, controlled cord traction, and uterine massage. Assess antenatal risk factors (e.g., anemia), avoid unnecessary episiotomies, and maintain proper monitoring postpartum.