Central precocious puberty
Continuous GnRH
Pseudoprecocious puberty
Remove tumor, cortisol replacement for CAH
Pros of HRT for menopause
Control symptoms
Reduced risk of osteoporosis
Reduced risk of colorectal cancer
May decrease coronary calcification if taken age 50-59 (unknown correlation w/ cardiac disease)
Cons of HRT for menopause
Increases risk of invasive breast cancer, endometrial cancer (NO estrogen w/o progesterone if woman still has uterus)
Increases risk of stroke, heart disease, hypercoagulability, biliary disease
Non-HRT options for hot flashes
Desvenlafaxine, venlafaxine
Clonidine
Gabapentin
Time
Menopause treatment
Vaginal lubricants (dyspareunia)
Calcium, vitamin D, bisphosphonates, weight bearing exercise (osteoporosis risk)
SERMs (tamoxifen, raloxifene) (osteoporosis risk)
Emergency contraception
High dose OCPs (lots of AE) Levonorgestrel (Plan B, just progesterone) Copper IUD (insertion w/i 4-5 days of intercourse) Mifepristone (RU 486) (low dose, high dose for abortion)
Pros of OCPs
Reliable
Reduce risk of endometrial and ovarian cancer
Decreased incidence of ectopic pregnancy
Menses lighter, more regular, less painful
C/I for OCPs
Pregnancy
History of DVT/PE/hypercoagulability disorder
History of estrogen-dependent tumor
History of stroke or CAD
Poorly controlled HTN
Smokers >35 yo
Hepatic disease or neoplasm
Abnormal vaginal bleeding of unknown etiology
Migraine w/ aura, neuro sx or vascular involvement
Amenorrhea, behavioral
Behavior modification (eating, exercise)
Amenorrhea, anatomic
Surgical correction
Amenorrhea, HPO dysfunction
Leuprolide (GnRH agonist), pulsatile
Amenorrhea, prolactinoma
Dopamine agonists (bromocriptine, cabergoline)
Dysmenorrhea
NSAIDs, OCPs
PMS, PMDD
NSAIDs, OCPs
Vitamin B6, SSRI +/- alprazolam, exercise, progestins
Endometriosis
OCPs, progestins, GnRH, NSAIDs, (danazol)
Laparoscopy
Definitive = hysterectomy + b/l salpingo-oopherectomy
Abnormal uterine bleeding
Treat cause
NSAIDs, OCPs
Endometrial ablation / hysterectomy
When to get endometrial biopsy w/ abnormal uterine bleeding
Patient >45
Patient w/ multiple risk factors for endometrial cancer
Patient w/ persistent AUB >6 months
PCOS
Exercise, weight loss OCPs (or at least progesterone by itself) Spironolactone Metformin Consider statin, acne meds as needed
PCOS if patient wants to get pregnant
Clomiphene (antiestrogen, acts at hippocampus)
Pelvic prolapse
Mild - pelvic floor exercises
Moderate - pessary
Severe - surgery
Uterine fibroids (leiomyomas)
Asymptomatic - observation
GnRH agonists (temporary), OCP/IUD (for bleeding)
Myomectomy, hysterectomy, UAE
Endometrial cancer
TAH w/ bilateral salpingo-oopherectomy and LN sampling
Progestins to maintain fertility then surgery after finished
Add chemo/radiation for mets
Cervical cancer
Microscopic (<5 mm): TAH or conization
Visibly invasive: radical hysterectomy + lymphadenectomy
Major invasion/mets: radiation + chemo
SCC of the vagina
Radiation
Lichen sclerosis
Punch biopsy to r/o SCC
Steroids (clobetasol)
Benign ovarian tumors
Observation for functional cysts
Cysectomy or oopherectomy if malignant potential
TAH-BSO for postmenopausal
Ovarian cancer
Epithelial - TAH-BSO w/ pelvic wall sampling, abdominal omentum resection, LN resection w/ adjuvant chemo
Germ cell - oopherectomy +/- debulking w/ chemo
Fibrocystic changes
Observation
Caffeine and dietary fat reduction, OCPs
Breast abscess
I&D, antibiotics (dicloxacillin, cephalexin, amoxicillin-clavulanate, TMP-SMX for MRSA, metronidazole for anaerobes), continue breastfeeding
Phyllodes tumor
Excision (some malignant potential)
Fibroadenoma
May observe if asymptomatic
Surgical excision or US-guided cryotherapy
Intraductal papilloma
Surgical excision (rare malignant potential)
Physiologic anemia of pregnancy
Iron supplementation if Hct <10.5 (second trimester)
Increased nutritional demands of pregnancy
Folic acid, calcium, iron
Protein, fluids
Vitamin D, B12 for strict vegetarians
Vaccines indicated during pregnancy
Tetanus q10 years (esp P of TdaP) in 2nd/3rd trimester
Influenza (shot) annually
Only if indicated: pneumococcal, meningococcal, Hep A/B
Vaccines C/I during pregnancy
Live
MMR, varicella
Oral polio, intranasal influenaza
Postpartum or post-abortion vaccines
Rubella before discharge if non-immune
TDaP if none in last 10 years
Varicella before discharge if non-immune (2nd dose 4-8 weeks later)
Gestational or pregestational diabetes
Diet and exercise
Insulin = DOC
Preeclampsia
Delivery is only definitive cure
Monitor patient closely (out or inpatient)
Blood pressure control
MgSO4 until 24 hrs post delivery
Eclampsia
Delivery is only definitive cure
Stabilize w/ O2 and blood pressure control
MgSO4 until 48 hrs post delivery
Try diazepam to control acute seizure
BP medications in pregnancy
HTN moms love nifedipine Hydralazine Methyldopa Labetalol (BB) Nifedipine
Epilepsy in pregnancy
Keep on anticonvulsants w/ folate supplementation
Diazepam to break active seizures (Mg is useless)
Asthma in pregnancy
Same as non-pregnant
Mild intermittent: short-acting B agonists (albuterol) PRN
Mild persistent: add low dose inhaled steroid
Moderate persistent: medium dose steroid or low dose steroid + long-acting B agonist (salmeterol)
Severe persistent: high dose inhaled steroid + long-acting B agonist
Hyperemesis gravidarum
Hydration, avoid large meals
Vitamin B6 + ginger
OTC doxylamine
Prescription ondansetron or promethazine
DVT in pregnancy
Heparin / LMWH until 6 weeks postpartum (stop during L&D)
Can switch to warfarin PP (safe during breastfeeding)
UTI in pregnancy
Amoxicillin, nitrofurantoin, cephalexin x7 days
NO fluoros
Toxoplasmosis in pregnancy
Pyrimethamine, sulfadiazine, folinic acid
avoid cat litter boxes, raw meat, unpasteurized milk, gardening
Rubella in pregnancy
No treatment while pregnant
Rubeola in pregnancy
Immune serum globulin during pregnancy
Syphilis in pregnancy
Maternal or neonatal penicillin
CMV in pregnancy
No treatment while pregnant
Ganciclovir may decrease effects in newborns
HSV in pregnancy
Acyclovir starting wk 34-36
Deliver by c-section if active lesions
Acyclovir may be beneficial in newborns
Hep B in pregnancy
Maternal vaccination (can be during pregnancy) Vaccination and Ig for neonate
HIV in pregnancy
HAART during pregnancy (avoid certain drugs)
AZT during labor
Usually c-section
No breastfeeding
Gonorrhea/chlamydia in pregnancy
Erythromycin for mom or baby (can be eye drops for neonate)
VZV in pregnancy
Varicela Ig to nonimmune mother and neonate born during active infection
GBS in pregnancy
IV B-lactams (penicillin/ampicillin) or clindamycin if:
+GBS screening at week 36
+GBS bacteruria during pregnancy
Previous infant with GBS infection
If no screening, intrapartum fever, preterm labor or prolonged rupture of membranes
Parvovirus B19 in pregnancy
Monitor fetal hemoglobin
Possible transfusion by PUBS
Ectopic pregnancy
MTX (<5,000 B-hCG, etc) or surgical excision
Threatened abortion
Bed rest, limited activity
Missed abortion
Expectant management (most pass w/i 2 weeks)
Misoprostol (PGE1)
D&C
Inevitable abortion
Expectant management
Misoprostol (PGE1)
D&C
Incomplete abortion
Misoprostol (PGE1)
D&C
Complete abortion
None
Intrauterine fetal demise
<24 weeks can undergo D&E
Induce labor and delivery (oxytocin, PGE1, 2)
IUGR
Monitor
Nutrition/O2/bed rest for mom
Delivery if fetal growth slows further or maternal or fetal distress
Oligohydramnios
Expectant management if no fetal distress
Delivery if fetal distress
Hydration +/- bed rest
Polyhydramnios
Percutaneous drainage if mom very uncomfortable or threat of pre-term labor
32 weeks: amnioreduction alone
PROM / PPROM
34 weeks: abx + delivery
Preterm labor, tocolysis
MgSO4, terbutaline, indomethacin or nifedipine (48 hrs)
Preterm labor, overall
Tocolysis + glucocorticoids <34 weeks
Ampicillin if delivery imminent
Placenta previa
Bed rest, RhoGam, tocolysis + steroids
C-section usually (can try vaginal in low-lying)
Placenta abruptio
Bed rest inpatient
Usu have quick delivery, if not perform c-section for hemodynamic instability
Molar pregnancy
D&C
Follow B-hCG to zero and then 1 year after
Choriocarcinoma
Hysterectomy
Chemo (MTX, etc) if metastatic
Follow B-hCG to zero and then 1 year after
Early decels during labor
None (head compression)
Variable decels during labor
Change mother position
Late decels during labor
Possibly need prompt delivery
Labor dystocia - assessment
3Ps
Power - contraction strength (>200 MVU/10 min), duration and frequency (every 2-3 min)
Passenger - baby size, lie (anterior occiput/looking down > posterior occiput/looking up)
Pelvis - shape and diameter
Non-reassuring fetal heart tones during labor
Maternal O2, movement to LLD
Turn off oxytocin/cervidil (maybe terbutaline to stop)
Manage maternal hypotension
Vaginal exam for cord prolapse
Breech presentation
Offer ECV at 37 weeks
C-section if unchanged
Indications for c-section
Maternal: eclampsia, prior uterine surgery (inc c-section), cardiac disease, birth canal obstruction, maternal death, cervical cancer, active genital herpes
Fetal: acute fetal distress, malpresentation, cord prolapse, macrosomia
Both: failure to progress in labor, placenta previa or abruptio, cephalopelvic disproportion
Postpartum bleeding
Uterine massage + oxytocin/pitocin
Mastitis
Continue nursing
Rest, ibuprofen, antibiotics (dicloxacillin cephalexin, TMP-SMX for MRSA, metronidazole for anaerobes)
I&D for abscess
Oral contraceptives for lactating women
Progesterone only
Postpartum bleeding w/ HTN
Hemabate (if no asthma)
Postpartum bleeding w/ asthma
Methergine (methylergonovine) (if no HTN)
Postpartum bleeding, non medical options
Uterine or iliac artery ligation, arterial embolization, hysterectomy
D&C for retained placenta
Tamponade
Postpartum endometritis
Gentamicin + clindamycin +/- ampicillin
Infantile thrush
Nystatin oral suspension
SIDS prevention
Sleep on back Sleep on firm surface Avoid soft objects in bed Avoid overheating Use pacifier while sleeping No smoking
Work-up on newborn w/ single umbilical artery
Renal sonogram for abnormalities
Car seat guidelines
<13 in back seat
