This document provides an overview of several topics in OB Gyn including abortions, ectopic pregnancy, endometriosis, pelvic inflammatory disease, surgical issues in pregnancy, placental concerns, vulvar/vaginal cancer, ovarian tumors and cancer, Krukenberg tumor, endometrial cancer, and cervical cancer. Key points covered include risk factors, presentations, diagnostic approaches, and treatment options for various conditions.

1. OB Gyn
ABSITE STUDY

2. Anatomy

3. Abortions
 Missed – 1st trimester bleeding, closed os, positive sac
on US, no heartbeat
 Threatened - 1st trimester bleeding, positive heartbeat
 Incomplete – tissue protruding through os

4. Ectopic Pregnancy
 Pregnancy anywhere other than uterus
 Risk factors – PID, prior ectopic, IUD,
diethylstilbestrol exposure
 MC site – ampulla of fallopian tube
 Ruptured – shoulder pain, abd distention,
shock
 PE – palp adenexal mass, positive B-hCG
 Tx –
 Methotrexate – if stable, B-hCG <15,000, no
liver/renal Dx, <3.5cm
 Otherwise surgery –
salpingostomy/salpingectomy

5. Endometriosis
 Cyclical or constant pain, dysmenorrhea, dyspareunia
 Adhesions/infertility
 Can cause rectal bleeding
 “Chocolate cysts”
 MC site - ovaries
 Path – Endometrial glands, stroma
 Tx – NSAIDS, OCP, Lupron, Laser ablation, Lysis of adhesions for infertility, hysterectomy

6. Pelvic inflammatory disease
 Multibacterial – N. Gonorrhoeae, Chlamydia
trachomatis, vaginosis, E. Coli
 Dx – vaginal discharge, fever, n/v, bilateral adnexal
pain, cervical motion tenderness,
 Elevated WBC, ESR,
 US – TOA, hydrosalpinx
 Tx - Cefoxitin with doxycycline
 Sequelae – TOA, infertility due to adhesions, ectopic
pregnancy, Fitz-Hugh-Curtis

7. Surgical Issues in Pregnancy
 Appendicitis – Preterm labor, spontaneous abortion,
maternal mortality
 Classis signs – RLQ pain, Rovsing sign, etc – Absent
 US, may diagnose, MRI, CT, Laparoscopy if uncertain
 Acute Cholecystitis
 Predisposed due to increased cholelithiasis
 Similar presentation

8. Surgical Issues in Pregnancy
 Trauma
 Treat mother, left lateral decubitus position, increased
blood volume shock may be delayed
 Labs – get Rh status
 Ovarian torsion
 R/o ectopic
 Tx is surgical detorsion

9. Placental Concerns
 Vasa Previa – Unprotected fetal vessels
traverse fetal membranes over internal
cervical os – associated with fetal
hemorrhage
 Placenta Previa – Placenta partially or
completely covers cervical os – painless
bright red vaginal bleeding
 Abruption – Deceleration injury, placenta
separates from the uterus, presents as
vaginal bleeding, contractions, fetal distress
 High fetal mortality
 Fetal blood in maternal circulation –
Kleihauer-Betke test

10. Vulvar/Vaginal CA
 Vulvar
 Older women, nulliparous, obese
 <2cm (Stage 1) - WLE and ipsilateral inguinal LND
 >2cm (Stage 2 or more) - Radical vulvectomy with
bilateral inguinal LND, postop XRT in margins <1cm
 Vaginal
 SCC >50, Adenocarcinoma <30
 RF – diethylstilbesterol (clear cell CA of vagina)
 Tx – resection for early stage, XRT as primary or adjuvant
tx
 MC vaginal tumor – invasion

11. Ovarian Tumors
 Follicular Cyst – resolves in 3 months, pre-menopausal
 Granulosa thea cell tumor – 25% malignant, 5-15%
associated with endometrial cancer
 Mucinous cystadenoma – 30% malignant, grow very large
 Serous cystadenoma – 10% malignant
 Cystic Teratomas – most common ovarian tumor in
pregnancy, 15% bilateral, 5% malignant
 Choriocarcinoma – from hydatidform molar pregnancy,
secretes hCG
 Germ cell - 5% of all ovarian cancer, 1/3 malignant

12. Ovarian Cancer
 #1 cause gynecologic death (35% 5yr survival)
 Nullparity, late menopause, early menarche increase risk
 Stage I – limited to ovaries, II – pelvic extension, III –
abdominal cavity or nodes, IV – distant mets
 Staging includes Peritoneal washing, TAH with BSO,
Omentectomy, Diaphragmatic/peritoneal biopsies, Pelvic
and para-aortic lymph node dissection
 May consider unilateral SO if low grade/low risk stage I
 Chemo – cisplatin and paclitaxel for residual disease
 Debulking may improve survival benefit (<1cm)

13. Ovarian Cancer
 Meigs Syndrome
 Pelvic ovarian fibroma
 Hydrothorax and Ascites
 Tx remove tumor
 Pseudomyxoma peritonei
 Mucin tumors to peritoneal surfaces
 Abd fills with mucin
 Yields small bowel obstructions

14. Krukenberg Tumor
 Malignant Met to Ovary from GI, Breast, or
Uterus
 Usually bilateral, freely mobile
 Retains ovarian shape but can be large
 Mucin Secreting signet ring cells
 Makes up 1-2% of ovarian CA
 If suspected, attempt to find primary

15. Endometrial Cancer
 80% postmenopausal
 Risk factors – late menopause, nulliparity, unopposed
estrogen, obesity, tamoxifen, HTN, DMII
 Sx – Abnormal vaginal bleeding
 Dx – Office endometrial Bx with Pipelle or D&C
 Tx – stages 1 or 2 (endometrium/cervix) total
hysterectomy/BSO or XRT, stages 3 or 4 total
hysterectomy/BSO/XRT

16. Cervical Cancer
 HPV 16/18
 Sx – vaginal bleeding/discharge, dyspareuia
 Stage 1 cervix only, stage 2 upper 2/3 of vagina, stage
3 pelvic sidewall, lower vagina, posterior nodes, stage
4 bladder/rectal invasion or mets
 Microscopic disease w/o basement membrane
invasion – cone bx
 Treat stage 1 or 2a TAH and pelvic LND w/ chemo/rads
for high grade, stage 2b to 4 chemo/rads only w/
salvage surgery