SMLE Obstetrics and Gynecology Syllabus

What are the two most common causes of primary postpartum hemorrhage, and what is the '4 Ts' mnemonic?

Uterine atony is the most common cause. The 4 Ts: Tone (atony), Trauma (lacerations), Tissue (retained products), and Thrombin (coagulopathy).

Define primary versus secondary postpartum hemorrhage by timing and blood loss.

Primary: $>500$ mL (vaginal) or $>1000$ mL (cesarean) within $24$ hours of delivery. Secondary: excessive bleeding from $24$ hours up to $12$ weeks postpartum.

What is the first-line uterotonic drug for postpartum hemorrhage due to uterine atony?

Oxytocin (IV or IM). Second-line agents include ergometrine, carboprost (contraindicated in asthma), and misoprostol.

What is the normal duration and progression of lochia after delivery?

Lochia rubra (red, days $1$–$3$), lochia serosa (pink-brown, days $4$–$10$), then lochia alba (yellow-white, up to $6$ weeks).

What distinguishes postpartum blues, postpartum depression, and postpartum psychosis?

Blues: mild, self-limited, peaks day $3$–$5$, resolves within $2$ weeks. Depression: persistent low mood $>2$ weeks, onset within first year. Psychosis: delusions/hallucinations, days–weeks postpartum, a psychiatric emergency.

When does ovulation typically resume postpartum in non-lactating versus fully lactating women?

Non-lactating women may ovulate as early as $\sim 4$–$6$ weeks postpartum. Full (exclusive) lactation delays ovulation via prolactin-induced suppression (basis of the lactational amenorrhea method).

What are the classic clinical features of postpartum (puerperal) endometritis?

Fever, uterine (fundal) tenderness, foul-smelling lochia, and tachycardia, typically 2–3 days postpartum. Cesarean delivery is the biggest risk factor.

What is Sheehan syndrome?

Postpartum hypopituitarism caused by ischemic necrosis of the pituitary gland following severe postpartum hemorrhage/hypotension. Presents with failure to lactate, amenorrhea, and hypothyroidism/adrenal insufficiency.

Define the normal parameters of the menstrual cycle: cycle length, duration of flow, and blood loss.

Cycle length $24$–$38$ days, duration of flow $\leq 8$ days, and normal blood loss $5$–$80$ mL per cycle.

Define primary versus secondary amenorrhea.

Primary amenorrhea: no menses by age $15$ with secondary sexual characteristics, or by age $13$ without them. Secondary amenorrhea: absence of menses for $\geq 3$ months in a previously menstruating woman (or $\geq 6$ months if oligomenorrheic).

What are the diagnostic (Rotterdam) criteria for polycystic ovary syndrome (PCOS)?

At least $2$ of $3$: (1) oligo/anovulation, (2) clinical or biochemical hyperandrogenism, (3) polycystic ovaries on ultrasound ($\geq 12$ follicles or ovarian volume $>10$ mL), after excluding other causes.

What is the definition and typical management of primary dysmenorrhea?

Painful menstruation without underlying pelvic pathology, caused by excess prostaglandins ($PGF_{2\alpha}$). First-line treatment is NSAIDs and/or combined oral contraceptives.

What is the PALM-COEIN classification of abnormal uterine bleeding?

Structural causes (PALM): Polyp, Adenomyosis, Leiomyoma, Malignancy/hyperplasia. Non-structural (COEIN): Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not otherwise classified.

How does endometriosis classically present and what is the gold-standard diagnosis?

Cyclical pelvic pain, dysmenorrhea, deep dyspareunia, and infertility. Gold-standard diagnosis is laparoscopic visualization (with histology) of ectopic endometrial tissue.

What hormonal changes define menopause and what confirms it biochemically?

Permanent cessation of menses ($12$ months of amenorrhea), average age $\sim 51$. Biochemically: elevated FSH ($>25$–$40$ IU/L) and low estradiol due to ovarian follicular depletion.

Distinguish menorrhagia, metrorrhagia, and menometrorrhagia.

Menorrhagia: heavy or prolonged bleeding at regular intervals. Metrorrhagia: bleeding at irregular/intermenstrual intervals. Menometrorrhagia: heavy and irregular bleeding combined.

What is the most common cause of pelvic inflammatory disease (PID)?

Sexually transmitted organisms, most commonly Chlamydia trachomatis and Neisseria gonorrhoeae, ascending from the lower genital tract.

What are the minimum clinical criteria for diagnosing PID (CDC)?

Sexually active woman with pelvic/lower abdominal pain and at least one of: cervical motion tenderness, uterine tenderness, or adnexal tenderness on exam.

What is the Fitz-Hugh–Curtis syndrome?

Perihepatitis (inflammation of the liver capsule) complicating PID, causing right-upper-quadrant pain with characteristic 'violin-string' adhesions between the liver and diaphragm.

What is the recommended outpatient antibiotic regimen for mild-to-moderate PID?

Ceftriaxone $500$ mg IM single dose PLUS doxycycline $100$ mg twice daily for $14$ days PLUS metronidazole $500$ mg twice daily for $14$ days (to cover anaerobes).

What are the major long-term complications of PID?

Tubo-ovarian abscess, chronic pelvic pain, infertility (from tubal scarring), and increased risk of ectopic pregnancy.

How does a tubo-ovarian abscess (TOA) present and how is it managed?

Fever, adnexal mass, and pelvic pain in a patient with PID; confirmed on ultrasound/CT. Management: broad-spectrum IV antibiotics; surgical/percutaneous drainage if large ($>7$ cm), ruptured, or unresponsive.

What organism-specific factor increases PID risk with intrauterine device (IUD) use?

Risk of PID is slightly increased only within the first $3$ weeks after IUD insertion, primarily related to pre-existing lower-genital-tract infection at the time of insertion.

What HPV subtypes are most associated with cervical cancer, and what is the primary prevention?

High-risk HPV types $16$ and $18$ cause $\sim 70\%$ of cervical cancers. Primary prevention is HPV vaccination (e.g., 9-valent) plus regular cervical screening.

What is the current cervical cancer screening strategy by age?

Ages $21$–$29$: cytology (Pap) every $3$ years. Ages $30$–$65$: HPV testing alone every $5$ years, co-testing every $5$ years, or cytology every $3$ years.

What is the most common gynecologic malignancy in developed countries and its cardinal symptom?

Endometrial (uterine) carcinoma. Cardinal symptom is postmenopausal bleeding, which warrants endometrial biopsy.

List the major risk factors for endometrial carcinoma.

Unopposed estrogen exposure: obesity, nulliparity, early menarche/late menopause, PCOS, tamoxifen, chronic anovulation, and Lynch syndrome (HNPCC).

Which gynecologic cancer has the highest mortality, and what tumor marker is used to monitor it?

Ovarian cancer (often diagnosed late). Serum CA-125 is used for monitoring epithelial ovarian cancer (not for screening in low-risk women).

What genetic mutations markedly increase the risk of ovarian and breast cancer?

BRCA1 and BRCA2 mutations. BRCA1 confers up to $\sim 40$–$46\%$ lifetime ovarian cancer risk; BRCA2 up to $\sim 10$–$20\%$.

What is the most common histologic type of ovarian cancer and of cervical cancer?

Ovarian: epithelial (serous) carcinoma is most common. Cervical: squamous cell carcinoma is most common.

How does vulvar carcinoma most commonly present and what is its predominant histology?

Presents as a chronic vulvar lump, pruritus, or non-healing ulcer/plaque, typically in postmenopausal women. Predominant histology is squamous cell carcinoma.