📚 Clinical Reference Guides

Pregnancy lasts, on average, 280 days (40 weeks) from the first day of the LMP — 9 calendar months or 10 lunar months. Always expressed in completed weeks.

Rules to estimate EDD: Wahl (LMP+10 days, -3 months) · Naegele (LMP+7 days, -3 months).

Ultrasound correction: if it differs beyond the accepted margin, GA by ultrasound takes priority — the earlier the scan, the more reliable (maximum precision in the 1st trimester).

Systematic evaluation by parameter (normal/mild/moderate/severe) to detect clinical deterioration in time:

Low risk: no identifiable factors, standard follow-up.

Moderate: maternal age 35-39, overweight/obesity, adverse history, mild anemia, treated STI.

High risk: <15 or >35-40 years, multiple gestation, prior fetal death, prior preeclampsia, chronic hypertension, diabetes, heart disease, chronic renal/pulmonary disease, autoimmune disease, moderate/severe anemia, STI/HIV/hepatitis, active TB, uterine malformation, placenta previa, abruption, FGR, oligo/polyhydramnios, sexual violence, substance use.

Reassess at every visit.

Tdap: international 27-36 wk, national (EPI) 16-20 wk. COVID-19: international any trimester, national from 20 wk. Maternal RSV: 28-36 wk (not part of the national schedule). Flu: any trimester.

Contraindicated (live attenuated): MMR, varicella, yellow fever (except high risk), zoster, BCG, oral rotavirus.

• Folic acid: 400-800µg/day standard, 4-5mg/day high risk
• Iron: 30-60mg/day prophylaxis, 60-120mg/day anemia treatment
• Calcium: 1200mg/day (vs. 800 outside pregnancy)
• Vitamin D: 1000-2000 IU/day insufficiency, 2000-4000 deficiency
• Omega-3 (DHA): 200-300mg/day from 2nd trimester
• Iodine: 150-250µg/day from preconception

1st trimester: CBC, blood group/Rh/indirect Coombs, VDRL/RPR+confirmatory, HIV, HBsAg, glucose, urea/creatinine/uric acid, liver panel, TSH per risk, urinalysis/urine culture.

2nd trimester (24-28 wk): CBC, 75g OGTT, HbA1c if at risk, repeat VDRL/HIV, toxoplasmosis, urinalysis.

3rd trimester (35-37 wk): CBC, coagulation panel, glucose, renal/liver function, GBS swab.

1st trimester (5-14 wk): early scan + dedicated 11-14 wk scan (NT, nasal bone, ductus venosus, uterine artery Doppler).

2nd trimester (18-24 wk): complete morphology scan, placenta, amniotic fluid, cervical length per risk.

3rd trimester (32 wk+): growth, amniotic fluid, presentation, Doppler/biophysical profile as indicated.

• Vital signs: every visit
• Fundal height: from month 4
• FHR: Doppler from month 4, Pinard from month 6
• Leopold maneuvers: from month 6-7
• Genital exam: 1st visit and at month 8

Detection of heartbeat: real-time ultrasound 6-8 wk, Doppler from 12 wk, stethoscope from 20 wk.

Fetal movements: perceived from 18-20 wk (nulliparous).

Self-monitoring: 4 movements in the 1st hour = normal, or up to 10 in 12h · or 30min post each meal, totaling 10+.

If 10 movements are not reached in 12h, or fluid loss/contractions occur: seek care.

Warning signs: bleeding, foul-smelling discharge, decreased movements, severe abdominal pain, contractions before term, fever, severe headache/blurred vision, sudden edema, difficulty breathing, fluid loss.

Restrictions: tobacco, alcohol, drugs, unnecessary radiation, medication without indication.

The theoretical risk of a method is always lower than that of an unwanted pregnancy. Right to choose freely, without coercion.

Options: condom, ring, injectable, pills, copper/hormonal IUD, implant, sterilization, patch.

Estrogen-containing methods are contraindicated in the first 6 months of breastfeeding.

Safe and recommended: ≥150 min/week moderate aerobic activity (walking, swimming, stationary bike, prenatal yoga/pilates).

Avoid: contact sports/fall-risk activities.

Contraindications: TPL, placenta previa after week 26, PROM, FGR, severe heart disease, severe anemia.

WHO: minimum 8 contacts (before 12, then 20/26/30/34/36/38/40 wk). National (MSPyBS): minimum 4 (before 12, 22-26, 27-32, 36-38 wk).

Low risk: monthly up to 28 wk, every 2-3 wk up to 35-36, weekly in the last month.

Total energy cost ~80,000 kcal, ~300 kcal/day extra.

Gain by BMI: underweight 12.5-18.0kg · normal 11.5-16.0kg · overweight 7.5-11.5kg · obesity 6.0kg.

Distribution: 500g/month (T1) · 1000g/month (T2) · 1500g/month (T3). Macros: 55% carbs, 15% protein, 30% fat.

MAP = (SBP + 2×DBP) / 3

• MAP ≥105: warning for gestational hypertension/preeclampsia, assess proteinuria/hepatorenal function
• MAP >90 in 1st trimester (≤14 wk): higher risk, consider prophylactic aspirin
• MAP >90 outside 1st trimester: routine surveillance

By percentile (EFW): severe SGA/FGR <P3 · FGR P3-P10+abnormal Doppler · SGA P3-P10+normal Doppler · AGA P10-P90 · borderline LGA P90-P97 · significant LGA ≥P97.

By birth weight (WHO): extremely low <1000g · very low 1000-1499g · low <2500g · normal 2500-3999g · macrosomia ≥4000g · severe ≥4500g.

Classification:

• Chronic: BP ≥140/90 before pregnancy or diagnosed before week 20
• Gestational: BP ≥140/90 after wk 20, without proteinuria or organ dysfunction
• Preeclampsia: BP ≥140/90 after wk 20 + proteinuria (≥0.3g/24h) or ≥1 severity criterion, even without proteinuria
• Chronic with superimposed preeclampsia: worsening + new proteinuria/organ dysfunction
• Eclampsia: tonic-clonic seizures in preeclampsia, with no other neurological cause

Severity criteria (≥1 confirms severe preeclampsia): BP ≥160/110 on 2 readings 15min apart, thrombocytopenia <100,000, doubled transaminases, creatinine >1.1 or doubled, pulmonary edema, new neuro-visual symptoms.

Prophylaxis (high risk): ASA 100-150mg/day PO at night, from wk 12-16 to wk 36. Elemental calcium 1.5-2.0g/day if low intake.

Chronic treatment (BP >140/90): Labetalol 100-400mg PO q8-12h (max 2,400mg/day) · Alpha-methyldopa 250-500mg PO q6-8h · Extended-release nifedipine 20-60mg PO q12-24h.

⚠️ Contraindicated: ACE inhibitors, ARBs, renin inhibitors.

Hypertensive crisis (≥160/110): IV labetalol bolus 20mg → 40mg → 80mg q10min (max 300mg) · IV hydralazine bolus 5-10mg q20min (max 20mg) · Oral nifedipine 10-20mg (not sublingual).

Indication: preeclampsia with severity criteria, and eclampsia.

Dose: 4-6g IV loading dose in 100mL 0.9% NS over 15-20 min → continuous maintenance 1-2g/hour IV for 24h postpartum or post-last seizure.

Monitoring: patellar reflex present, RR >12-14/min, urine output >30mL/h.

⚠️ Signs of toxicity: RR<12rpm, absent patellar reflex, oliguria <30mL/h, AV block.

⚠️ Antidote — 10% Calcium Gluconate, two current standards (equivalent in available elemental calcium, not contradictory):

• National standard (MSPyBS Paraguay, Code Red 2nd ed. 2021): 10% Calcium Gluconate — 1g (10mL) IV slow push over 3 min.
• Advanced international resuscitation standard (AHA · Universidad de Antioquia · PAHO): 10% Calcium Gluconate — 3g (30mL) IV, or alternatively 10% Calcium Chloride — 1g (10mL) IV.

This is not a dosing error: 1g of calcium gluconate provides ~93mg of elemental calcium, while 1g of calcium chloride provides ~272mg — which is why the international advanced-resuscitation regimen uses a larger volume of gluconate (3g/30mL) to match the elemental calcium delivered by 1g of chloride. Which to use? The national standard for an isolated toxicity sign (RR<12, areflexia, oliguria); the international regimen for frank cardiorespiratory arrest from hypermagnesemia.

CPR specifics in pregnancy: continuous manual left uterine displacement (or 15-30° left lateral tilt) from the start, to relieve aortocaval compression; chest compressions slightly higher on the sternum; defibrillation at the same energies as outside pregnancy (not contraindicated).

Fundal height threshold (fundus at or above the umbilicus, ≈20 weeks): from this point on, the gravid uterus causes enough aortocaval compression to invalidate the effectiveness of chest compressions — this is the action threshold, defined by maternal benefit, not fetal viability.

≥22-24 weeks is a separate, later threshold: fetal viability — a secondary consideration about the expected neonatal outcome, not about whether to perform the hysterotomy.

4-5 minute rule: if there is no return of spontaneous circulation (ROSC) by 4 minutes of high-quality CPR, begin the cesarean/perimortem hysterotomy incision in situ (do not transfer to the operating room) to achieve delivery by minute 5. The primary goal is maternal: evacuating the uterus improves venous return and compression effectiveness.

Lipid elevation is physiological in pregnancy — no routine screening. Targeted in: family history of early CVD, pre-pregnancy obesity, prior diabetes/preeclampsia, severe hypertriglyceridemia.

Treatment: 1st line diet/exercise. Statins: FDA (2021) withdrew the absolute contraindication, individualized use in very high risk. Bile acid sequestrants (the only ones approved in pregnancy): Cholestyramine, Colestipol, Colesevelam. Omega-3: reduces preterm birth risk (Cochrane 2018).

Diagnosis: nocturnal palmoplantar pruritus, without primary skin lesion. Labs: bilirubin, AST/ALT, ALP, GGT.

Pathway 1 (with total bile acids): Normal <10 μmol/L · Anicteric 10-39 → delivery at wk 38 · Icteric 40-99 (+bili >1.2) → wk 36 · Severe ≥100 → wk 34-36.

Pathway 2 (regional Paraguay criterion, without total bile acids): Anicteric (AST/ALT >40, normal bili) → wk 38 · Icteric (+bili >1.2) → wk 36.

Treatment: Ursodeoxycholic acid 10-15mg/kg/day PO + Vitamin K if prolonged.

⚠️ Deliver at any sign of fetal compromise, regardless of pathway or GA.

Diagnosis: regular uterine dynamics (≥4/20min) + cervical changes, 22-36+6 wk.

TVUS: CL >30mm rules out TPL · CL <25mm high risk · 20-30mm → biomarkers (fetal fibronectin/PAMG-1).

Tocolysis (22/24-33+6 wk): Nifedipine (1st line) loading dose 10-20mg q20min → maintenance q6-8h · Atosiban (NICE/RCOG) · Indomethacin (before wk 32, do not combine with MgSO4 or nifedipine).

Cutoffs by guideline: ACOG wk 24-33+6 (late 34-36+6) · FIGO/WHO 24-34+6 · NICE offer 24-33+6, consider 34-35+6.

Regimens: Betamethasone 12mg IM q24h (2 doses) · Dexamethasone 6mg IM q12h (4 doses).

Rescue course: if >14 days have passed, GA <34 wk, imminent risk within 7 days.

Cutoffs by guideline: ACOG before wk 32 · NICE before wk 30 (consider 30-33+6) · FIGO/WHO before wk 32 (some extend to <34 if imminent).

Regimen: 4g IV loading dose over 20-30 min → maintenance 1g/hour until delivery or 24h.

⚠️ Antidote (see full detail in "Magnesium sulfate — Seizure prevention and management"): national standard 10% Calcium Gluconate 1g (10mL) IV slow push over 3 min · advanced international resuscitation standard 3g (30mL), or 10% Calcium Chloride 1g (10mL) — same concentration, larger gluconate volume to match the elemental calcium delivered by the chloride.

Clinical: clear fluid leakage (>90% reliability if visualized through the cervical os).

Tests: Fern test, Nitrazine (pH>6.5), PAMG-1/IGFBP-1, vaginal urea/creatinine (>90-95% sensitivity).

Amniocentesis (doubtful cases): Indigo Carmine + tampon, check staining at 20-30min. ⚠️ Methylene Blue contraindicated.

• Previable (<22-24 wk): expectant, counseling. No routine antibiotics/corticosteroids.
• Far from term preterm (24-33+6): expectant, inpatient, complete lung maturation course, neuroprotective MgSO4 if <32 wk, mandatory latency antibiotics, tocolysis restricted to 48h.
• Late preterm (34-36+6): delivery/induction at diagnosis. Exception: expectant until wk 37 if no infection.
• Term (≥37): induction within 12-24h.

Standard (7 days, 24-34 wk): Days 1-2 IV: Ampicillin 2g q6h + Erythromycin 250mg q6h. Days 3-7 oral: Amoxicillin 500mg q8h + Erythromycin 333mg q8h.

Alternative: Ampicillin 2g IV q6h x48h → Amoxicillin 500mg PO q8h x5d + Azithromycin 1g PO single dose.

⚠️ Avoid Amoxicillin+Clavulanate (neonatal NEC).

Immediate delivery: chorioamnionitis, abruption, fetal distress, established labor, stillbirth.

NVP: physiological, up to 80%, wk 4-9 to 16-20. HG: severe, 0.3-2%. Triad: intractable vomiting + >5% weight loss + ketonuria/electrolyte disturbance.

PUQE score (24h, 3 questions, 1-5pts): ≤6 mild · 7-12 moderate · ≥13 severe HG (inpatient).

1st line: Pyridoxine B6 10-25mg q6-8h · Doxylamine+Pyridoxine 2 tabs/night.

2nd line: Dimenhydrinate, Metoclopramide (<5 days), Promethazine.

3rd line: Ondansetron (from wk 10) · Methylprednisolone (last resort, >10 wk).

⚠️ Golden rule: Thiamine B1 100mg IV before/with the first dextrose infusion — prevents Wernicke's encephalopathy.

Methods: SDP/DVP (preferred) · AFI (4 quadrants).

Classic: Oligohydramnios AFI<5/SDP<2 · Normal 5.1-24.9/2.1-7.9 · Polyhydramnios AFI≥25/SDP≥8.

ACOG/SMFM ranges: Anhydramnios=0 · Severe <1/<3 · Lower borderline 5.1-8.0 (follow-up) · Physiological normal 8.1-18.0 · Upper borderline 18.1-24.9.

• Mild: AFI 25.0-29.9 (80% of cases)
• Moderate: 30.0-34.9
• Severe: ≥35 (>50% association with malformations)

Oligohydramnios: maternal (placental insufficiency, hypertension, APS, dehydration, drugs) · fetal (urinary anomalies, FGR, post-term) · membrane-related (PROM, TTTS donor).

Polyhydramnios: maternal (diabetes) · fetal (GI, CNS, neuromuscular, cardiac, chromosomal) · membrane-related (TTTS recipient) · idiopathic 50-60%.

Constitutional SGA: EFW/AC P3-P10, strictly normal Doppler, low risk.

Early FGR (<32 wk): isolated EFW/AC<P3 or UA with absent/reversed flow · or combined (≥2 of: EFW/AC<P10, UA-PI>P95, UtA-PI>P95).

Late FGR (≥32 wk, 70-80% of cases): isolated EFW/AC<P3 · or combined (≥2 of: EFW/AC<P10, drop >2 quartiles, CPR<P5, MCA-PI<P5, UtA-PI>P95).

Stage I (mild): EFW<P3, or CPR<P5, or UtA-PI>P95, or UA-PI>P95 with present diastolic flow. Doppler every 7 days. Delivery at wk 37.

Stage II (severe): persistent absent end-diastolic flow in UA (AEDF) >50% of cycles. Inpatient monitoring, Doppler every 48-72h. Elective cesarean at wk 34 (after lung maturation course).

Stage III: persistent reversed flow in UA, or DV-PI>P95. Strict hospitalization, Doppler every 24-48h. Cesarean at wk 30 (lung maturation + MgSO4 neuroprotection).

Stage IV: reversed/absent A-wave in DV, umbilical vein pulsations, or STV<3ms. Continuous emergency. Immediate cesarean from wk 26 (or limit of viability).

Summary of cutoffs: wk 37-38 (SGA/Stage I) · wk 34 (Stage II) · wk 30-32 (Stage III) · wk 26-28 immediate (Stage IV).

Confirmed HIV: immediate ART regardless of GA/CD4/viral load. Regimen: TDF+FTC/3TC+Dolutegravir.

Mode of delivery: vaginal if viral load undetectable · elective cesarean if VL>1000 at wk 36.

Neonatal prophylaxis: zidovudine 4mg/kg q12h x4 weeks.

Treatment: Benzathine penicillin G IM (the only option valid in pregnancy). Primary/secondary/early latent: 2.4M IU single dose. Late latent: 2.4M IU weekly x3 weeks.

Allergy: desensitization mandatory. Jarisch-Herxheimer reaction: 24h fetal monitoring.

HBsAg+: neonatal immunoprophylaxis within 12h (vaccine+HBIG). If HBV-DNA>200,000 IU/mL or HBeAg+: Tenofovir 300mg/day from wk 28.

Confirm Anti-HCV+ with HCV-RNA. Vertical transmission ~5-7% (up to 11% with HIV). No neonatal prophylaxis or antiviral treatment during pregnancy (contraindicated).

Confirmed (2 reactive techniques): vertical transmission ~5-10%. Benznidazole/nifurtimox contraindicated in pregnancy. Newborn: cord blood PCR + at 30 days; if positive, Benznidazole 5-7mg/kg/day x60d.

High avidity: indicates infection >16 wk before the test, not before conception — calculate GA at testing − 16wk to determine if it could have been in the 1st trimester.

3 levels of prevention: 1️⃣ primary (hygiene) · 2️⃣ secondary (infected mother: Spiramycin 1g q8h, does not cross the placenta) · 3️⃣ tertiary (fetal infection confirmed by amniotic fluid PCR: switch to Pyrimethamine+Sulfadiazine+Folinic acid, which does cross the placenta).

⚠️ Pyrimethamine-Sulfadiazine contraindicated in T1 (teratogenic) and the last month (kernicterus).

Duration: no single consensus — most continue until delivery; variants use alternating 3-week cycles, or others stop 2 weeks before delivery.

IgG(-): MMR vaccine contraindicated in pregnancy, vaccinate postpartum. IgM(+): Congenital Rubella Syndrome, risk>85% in T1 (cataracts, heart disease, deafness). No specific treatment. Mandatory reporting.

IgM(+) low avidity: vertical transmission 30-40%. Amniocentesis PCR if GA>21wk. Consider maternal Valacyclovir 8g/day. Newborn: urine/saliva PCR at 3 weeks.

Rh(-): indirect Coombs at T1 and at wk 28. Negative: anti-D prophylaxis at wk 28 and postpartum. Positive (sensitized): active surveillance for fetal anemia, no prophylaxis.

MCA-PSV in MoM: <1.29 normal · 1.29-1.49 mild anemia (surveillance) · ≥1.50 moderate-severe (cordocentesis+urgent transfusion).

ΔOD450 spectrophotometry, valid from wk 27. Zone 1 mild · Zone 2 moderate · Zone 3 severe (transfusion/delivery). Before wk 27: Queenan chart or MCA Doppler.

MoM≥1.50 before wk 35: cordocentesis+intrauterine transfusion (repeat every 2-4 wk). After wk 35: consider delivery instead of transfusion. Procedure-related fetal loss risk ~1-3%.

TSH: T1 0.1-2.5 · T2 0.2-3.0 · T3 0.3-3.5 µIU/mL. Hypothyroidism (clinical or subclinical): levothyroxine, target TSH per trimester. Hyperthyroidism: PTU in T1, Methimazole T2-T3. Never radioactive iodine.

Anti-TPO+ (>34IU/mL) + elevated TSH: Hashimoto's, start levothyroxine. Anti-TPO+ with normal TSH: recheck every 4-6wk (2-5x risk of gestational hypothyroidism). Some guidelines suggest adjusting already from preconception. Confirmed pregnancy on prior treatment: +25-30% starting dose.

Cervical length <25mm: vaginal progesterone 200mg/night, follow-up every 2wk. <15mm: urgent cerclage if <23+6wk. History of cervical insufficiency: prophylactic cerclage wk 12-14 + progesterone from the start.

Preterm birth/short cervix: solid evidence (see cervical insufficiency guide).

Threatened miscarriage: generally controversial (ACOG). Clearer benefit only with ≥1 prior miscarriage+bleeding (RR 1.08). Regimen: 400mg q12h until wk 16.

Luteal support in IVF/ICSI: established standard, routine practice. 400mg q12h vaginal.

Advanced maternal age alone: no solid independent evidence.

Risk x10 in pregnancy, x5 postpartum (peak 1st week), x4 with cesarean. ↑fibrinogen/FVII-VIII-X/vWF/PAI. ↓Protein S. Left lower limb predilection (May-Thurner + uterine compression).

DVT: lower-limb venous Doppler ultrasound. PE: 3-item triage (signs of DVT, hemoptysis, PE most likely) → D-dimer and/or CT angiography per result.

Criteria: ≥1 thrombosis or ≥1 obstetric morbidity + confirmed labs on 2 occasions (12 wk apart). Treatment: ASA 100mg/night + prophylactic LMWH from FHR confirmation until 42 days postpartum.

Point scale (1-4 per factor). Score 0: none · 1-4: pneumatic compression · 5-6: LMWH · ≥7: LMWH+compression.

Weight-adjusted prophylactic enoxaparin (20-80mg/day by kg). Therapeutic: 1mg/kg q12h, minimum 3-6 months + 6 wk postpartum. DOACs contraindicated. Avoid warfarin in T1 and peripartum.

Hold prophylactic LMWH 12h before puncture/surgery, therapeutic 24h before. Resume 12h post-vaginal / 24h post-cesarean.

Active bleeding, platelets<50,000, CrCl<15, PT<40%, persistent severe hypertension ≥4h.

Latch: mouth >130°, everted lip, chin touching breast, rounded cheeks. On-demand 8-12 feeds/day. Crack prevention: correct latch, avoid soaps, own milk after feeding.

Clinical picture: localized pain/erythema/warmth + fever ± flu-like symptoms. S. aureus predominant. Do not stop breastfeeding — frequent emptying of the affected breast (hand/nursing/pump), continue nursing on that side.

Antibiotic therapy (if systemic/persistent >12-24h despite emptying):

• Cephalexin 500mg PO q6h for 7-10 days (first line)
• Amoxicillin/clavulanate 875/125mg PO q12h (or 500/125mg q8h) for 7-10 days
• Penicillin allergy or suspected MRSA: Clindamycin 300-450mg PO q8h for 7-10 days

T1 fasting: <92 normal · 92-125 GDM · ≥126 pregestational. Wk 24-28: 75g OGTT (92/180/153), 1 abnormal value confirms. Postpartum: reclassify with adult OGTT.

Targets: fasting 70-95, 1h<140, 2h<120. Split diet into 6 meals. Insulin if ≥20% of readings out of target after 1-2 wk of diet/exercise.

15-15 rule for hypoglycemia. Scheduled basal-bolus regimen preferred over reactive sliding scale. Ultra-rapid analogs preferred over Regular insulin.

TDD: 0.7-1.0 IU/kg/day by trimester. 50% basal + 50% bolus. ISF = 1800/TDD (ultra-rapid). Titrate per persistent fasting/postprandial values.

Viral etiology (70-80%): Norovirus and Rotavirus (community outbreaks), enteric Adenovirus, Astrovirus. Self-limiting (24-72h): profuse watery diarrhea, nausea, vomiting, low-grade fever.

Bacterial: Campylobacter jejuni (most common bacterial cause), non-typhoidal Salmonella enterica / S. typhi (risk of bacteremia/transplacental spread), Shigella spp. (dysentery, tenesmus, mucus/blood), E. coli (ETEC/EPEC/STEC-EHEC O157:H7), Clostridioides difficile (post-antimicrobial).

Listeria monocytogenes: flu-like illness with fever, myalgias and preceding watery diarrhea. ⚠️ Critical risk: maternal bacteremia with transplacental spread → chorioamnionitis, septic abortion, intrauterine fetal death or severe neonatal sepsis.

Parasitic: Giardia lamblia, Entamoeba histolytica, Cryptosporidium parvum.

General management: hydration and electrolyte rebalancing as the cornerstone. Mild-moderate: ORS in frequent sips. Severe/oral intolerance: admission + 0.9% NS or Lactated Ringer's 2,000-3,000mL/24h, adjusted by electrolyte panel (potassium monitoring).

Safe symptomatic treatment: antiemetics (Doxylamine+Pyridoxine, Metoclopramide 10mg PO/IV q8h, Dimenhydrinate 50mg PO/IV q6-8h) · Acetaminophen 500-1000mg PO q6-8h (max 4g/day). Loperamide restricted use (avoid in inflammatory/dysenteric diarrhea with fever or suspected invasive pathogen, due to risk of toxic megacolon); Racecadotril has limited data in pregnancy.

By trimester:

• 1st trimester: mandatory differential diagnosis with Hyperemesis Gravidarum (AGE presents with watery diarrhea and sudden onset, unlike HG). Avoid NSAIDs entirely. If antibiotics are required: beta-lactams (Amoxicillin, Ampicillin) or macrolides (Azithromycin), safe during organogenesis.
• 2nd trimester: dehydration and prostaglandins from the intestinal inflammatory process can irritate the myometrium and trigger uterine activity/threatened late miscarriage. Differential: acute appendicitis (the cecum and appendix rise with the gravid uterus). Monitor FHR and cervical length if regular contractions are present.
• 3rd trimester: severe bacterial diarrhea and hypovolemia are frequent triggers of preterm labor (PTL) and placental abruption. Electronic fetal monitoring/NST with maternal fever. In the peripartum period, if active bacterial AGE is present (Salmonella, Campylobacter, Listeria): maximize enteric isolation and precautions during delivery (vertical transmission).

Antibiotic therapy — indications: dysenteric diarrhea (blood/mucus + fever ≥38.5°C), suspected/confirmed gestational Listeriosis, suspected invasive Shigella/Campylobacter/Salmonella, immunocompromised pregnant patients, severe dehydration or bacteremia/sepsis.

ILI (Influenza-Like Illness): sudden-onset fever (≥37.8-38.0°C) + cough or sore throat, with no other diagnosis. Virologic diagnosis: nasopharyngeal swab for multiplex RT-PCR (Influenza A/B, SARS-CoV-2, RSV), or rapid antigen test (high specificity, lower sensitivity — confirm with PCR if clinical suspicion is high and the result is negative).

1st trimester: Acetaminophen 500-1000mg PO q6-8h (max 3-4g/day). Early temperature control is mandatory — sustained hyperthermia >38.5°C during organogenesis is associated with neural tube defects and congenital heart disease. Influenza: Oseltamivir 75mg PO q12h x5d, within the first 48h (safe in all trimesters). Mild COVID-19: hydration and rest, avoid NSAIDs; risk of progression: consider Nirmatrelvir/Ritonavir based on risk-benefit balance.

2nd trimester: continue Acetaminophen and Oseltamivir at standard dosing. Fetal monitoring: FHR and uterine activity (paroxysmal cough and fever can induce myometrial irritability). Moderate/severe COVID-19 requiring O2: Dexamethasone 6mg/day IV/PO x10 days (or until discharge). Hospitalize if SpO2 <94% or tachypnea.

3rd trimester: greater vulnerability — diaphragm elevation reduces functional residual capacity, with risk of rapid hypoxemia and ARDS. Continuous electronic fetal monitoring (NST/CTG). Thromboprophylaxis in hospitalized COVID-19: Enoxaparin 40mg SC/day during admission, extend based on postpartum risk factors. If pregnancy must be ended for maternal respiratory deterioration between wk 24-34: Dexamethasone 6mg q12h (4 doses) — dual purpose (maternal treatment + fetal lung maturation).

Preferred antiviral regimens:

• Influenza A and B: Oseltamivir 75mg PO q12h x5 days (double to 10 days in immunosuppressed patients or severe ICU cases).
• High-risk mild-moderate COVID-19: Nirmatrelvir + Ritonavir (Paxlovid) 300/100mg PO q12h x5 days (start within the first 5 days of symptoms).
• Severe/hospitalized COVID-19 with hypoxemia (SpO2 <94%): Dexamethasone 6mg IV/PO once daily for up to 10 days + Remdesivir 200mg IV day 1, then 100mg IV/day x4 additional days (safe in pregnancy under hepatic/renal monitoring) + weight-adjusted prophylactic Enoxaparin.

The physiologic hypervolemia and baseline tachycardia of pregnancy mask the early signs of shock. The period of greatest risk is the defervescence phase (fever drop, days 3-7), with massive plasma leakage and hemoconcentration.

Obstetric risk: threatened miscarriage, preterm birth, placental abruption, postpartum hemorrhage and vertical transmission (if the illness occurs in the immediate peripartum period).

Group A — no warning signs (supervised outpatient management): acute fever + ≥2 of: myalgias, arthralgias, headache, retro-orbital pain, rash, leukopenia; no decompensated comorbidities and adequate oral tolerance. Abundant oral hydration 2-3L/day. Acetaminophen 500-750mg PO q6h (max 3g/day). ⚠️ Absolute prohibition: NSAIDs, Dipyrone (hypotension/dyscrasias) and Aspirin (hemorrhage/Reye syndrome). Daily clinical review with CBC (Hct/platelets) until 48h post-defervescence.

Group B — every pregnant patient is classified here due to her physiologic vulnerability → requires hospital observation:

• B1 (no warning signs, with a risk condition): hospitalization for close monitoring and maintenance oral or IV fluid/electrolyte replacement.
• B2 (with warning signs — incipient leakage): intense/continuous abdominal pain, persistent vomiting (≥3/h or ≥4/6h), fluid accumulation (ascites, pleural effusion, thickened gallbladder wall), mucosal bleeding, lethargy/drowsiness, postural hypotension, hepatomegaly >2cm, rising Hct with rapidly falling platelets. 0.9% NS or Lactated Ringer's 10mL/kg/h x1-2h → if improving: stepwise taper (5-7 → 3-5 → 2-3mL/kg/h) to complete 24-48h; if not improving or Hct rises: manage as Group C.

Group C — severe dengue (hemorrhagic/shock/organ failure, ICU management): dengue shock (weak/undetectable pulse, cold extremities, capillary refill >2sec, pulse pressure ≤20mmHg) or respiratory distress from fluid accumulation; severe hemorrhage (hematemesis, melena, massive genital bleeding/PPH, intra-abdominal bleeding); severe organ involvement (AST/ALT ≥1,000 IU/L, altered consciousness, cardiomyopathy, renal failure).

Resuscitation: crystalloids (Lactated Ringer's or 0.9% NS) 20mL/kg IV bolus over 15-30min. If shock reverses: reduce to 10mL/kg/h x1-2h and taper gradually. If it does NOT reverse after 2-3 boluses: elevated Hct → colloids (Albumin 0.5-1g/kg or synthetic colloids 10-20mL/kg over 30-60min); sharply falling Hct → suspect occult/GI/uterine hemorrhage → immediate packed red blood cell transfusion (10mL/kg).

Platelet transfusion: not recommended prophylactically based on count alone (<20,000-50,000/µL). Indicated for active severe hemorrhage or need for emergency surgery/cesarean with platelets <50,000/µL.

4-5-3 mnemonic rule for the first hour of management of obstetric septic shock (postpartum/endometritis/septic abortion source):

Fluid resuscitation: crystalloids 20-30mL/kg IV bolus within the first hour for hypoperfusion or elevated lactate.

Vasopressor (if MAP<65 despite volume load): Norepinephrine 0.05-0.5mcg/kg/min IV, titrated to MAP≥65.

Empiric antibiotic therapy within the first hour (postpartum/endometritis/septic abortion source): Ampicillin/Sulbactam 3g IV q6h + Gentamicin 5mg/kg/day IV — alternative: Piperacillin/Tazobactam 4.5g IV q6-8h ± Clindamycin (anaerobic/pelvic source coverage).

Obtain blood cultures and achieve source control (uterine evacuation if septic abortion/retained products) without delaying antibiotic initiation.

Candidiasis: C. albicans (85-90%). Intense itching + clumpy white discharge. pH<4.5, hyphae. Tx: Fluconazole 150mg PO single dose. Recurrent: days 1-4-7 → weekly maintenance x6mo.

Bacterial vaginosis: dysbiosis. Fishy-smelling discharge. Amsel ≥3/4. Tx: Metronidazole 500mg q12h x7d.

Trichomoniasis: STI. Frothy yellow-green discharge. "Strawberry" cervix. Tx: Metronidazole 2g single dose + treat partner.

Polymicrobial ascending infection. Stages (Monif): I salpingitis without peritonitis · II with pelvic peritonitis · III TOA · IV rupture/septic shock.

Dx: pelvic pain + cervical/uterine/adnexal motion tenderness.

Outpatient Tx: Ceftriaxone 500mg IM + Doxycycline 100mg q12h x14d + Metronidazole 500mg q12h x14d.

Inpatient: Ceftriaxone 1g IV q24h + same regimen. Surgery: TOA ≥8-10cm or failure at 48-72h; rupture = emergency.

In May 2026, an international consensus of 56 organizations (The Lancet, endorsed by WHO) renamed the condition from "Polycystic Ovary Syndrome (PCOS)" to "Polyendocrine Metabolic Ovarian Syndrome (PMOS)" — it does not change the diagnostic criteria (Rotterdam/Monash), it better reflects the systemic, metabolic and multi-hormonal nature of the condition.

≥2 of 3: (1) oligo/anovulation · (2) clinical/biochemical hyperandrogenism · (3) PCOM (ultrasound ≥20 follicles or elevated AMH).

Phenotypes: A complete · B anovulatory (normal ultrasound) · C ovulatory (PCOM, regular cycles) · D non-androgenic.

Endometrial gland/stroma within the myometrium. Criteria: asymmetric uterus, myometrial cysts 1-5mm, echogenic islands, fan-shaped shadowing, transition zone ≥12mm, translesional vascularity on Doppler. Classification: Focal or Diffuse.

rASRM: I minimal 1-5pts · II mild 6-15 · III moderate 16-40 · IV severe >40.

Enzian (deep): A vagina/rectovaginal septum · B uterosacrals/parametria · C rectum/sigmoid · FA extraperitoneal. Severity 1(<1cm)/2(1-3cm)/3(>3cm).

Type 0 pedunculated intracavitary · 1 sessile <50% intramural · 2 sessile ≥50% · 3 100% intramural (contacts endometrium) · 4 100% intramural (no contact) · 5 subserosal ≥50% · 6 subserosal <50% · 7 subserosal pedunculated · 8 other locations.

Distance relative to the hymen (0cm). Stage 0 no prolapse (-3cm) · I >1cm above the hymen · II between -1 and +1cm · III >+1cm without exceeding TVL-2 · IV total eversion.

SUI: urethral hypermobility, triggered by effort, small volume, no urinary frequency. UUI: detrusor overactivity, sudden urge, large volume, with frequency/nocturia.

SUI Tx: Kegel → pessaries → sling (TVT/TOT). UUI Tx: bladder retraining → antimuscarinics/Mirabegron → botulinum toxin/neuromodulation.

MRS (11 items): somatic, psychological, urogenital. Total 0-4 mild · 5-8 moderate · ≥9 severe (consider HRT).

HRT by uterine status: no uterus → estrogen alone. Uterus present, perimenopause → sequential/cyclic. Postmenopause → continuous combined.

Transdermal HRT (preferred, especially with hypertension, obesity BMI>30, hypertriglyceridemia, VTE risk): 17β-Estradiol gel 0.75-1.25g/day, or patches 25-50mcg/day.

Endometrial protection (intact uterus): Micronized natural progesterone 200mg/day for 10-14 days/month (sequential regimen) or 100mg/day continuous · or Dydrogesterone 10-20mg/day.

Tibolone (STEAR): 2.5mg/day PO (or 1.25mg/day in lower body weight or advanced perimenopause) — covers vasomotor symptoms, urogenital atrophy and bone loss prevention; does not require an added progestogen.

Mechanism: selective neurokinin-3 receptor (NK3R) antagonist — acts on hypothalamic KNDy neurons involved in thermoregulation, with no hormonal action.

Dose: 45mg PO once daily, with or without food.

Indication: moderate-to-severe vasomotor symptoms of the climacteric, a first-line alternative when HRT is contraindicated or not the patient's preference (hormone-dependent cancer history, VTE, personal preference).

Requires baseline and periodic monitoring of transaminases (liver enzyme elevation was described in the trials).

T-Score: normal ≥-1.0 · osteopenia -1.0 to -2.5 · osteoporosis ≤-2.5 · severe +fracture. Z-Score (premenopausal): ≤-2.0 abnormal.

FRAX (osteopenia): treat if major fracture risk ≥20% or hip ≥3%.

Basic support (all patients): Elemental calcium 1,000-1,500mg/day + Vitamin D3 800-2,000 IU/day (target ≥30ng/mL).

Antiresorptives: Alendronate 70mg PO weekly · Zoledronic acid 5mg IV annually · Denosumab 60mg SC every 6 months (do not stop abruptly without transitioning to another antiresorptive, due to rebound vertebral fracture risk).

Anabolics (severe osteoporosis/high fracture risk): Teriparatide 20mcg/day SC, maximum 24 months of use.

Categories: 1 no restriction · 2 benefits>risks · 3 risks>benefits · 4 absolute contraindication.

Cat 4 (combined methods): severe hypertension, VTE/thrombosis, thrombophilias, active breast cancer, smoker ≥35yo+15cig/day, migraine with aura, severe liver disease.

LAM (>98%): amenorrhea + exclusive breastfeeding + <6 months postpartum, all three together.

Progestin-only: Cat 1-2 from the start. Combined: Cat 4 if <6 wk breastfeeding; improves over time. Copper IUD: Cat 1 immediate (<48h) or delayed (≥4wk); Cat 3 in between.

PALM (structural): Polyp · Adenomyosis · Leiomyoma · Malignancy/hyperplasia.

COEIN (non-structural): Coagulopathy · Ovulatory dysfunction · Endometrial · Iatrogenic · Not otherwise classified.

Primary/secondary by definition. Secondary algorithm: β-hCG+TSH+PRL → progesterone challenge test (bleeds=anovulation/PCOS) → combined E+P test (bleeds=estrogen deficiency, measure FSH/LH) → hyper/hypogonadotropic.

No menarche by 13 without secondary sexual characteristics, or by 15 with characteristics. Breasts absent→FSH/LH (Turner vs. Kallmann). Breasts present→anatomy (MRKH vs. AIS vs. obstruction).

PCOS: ovulation induction or OCPs. Asherman's: hysteroscopy + estrogen. POI: HRT until 50-51 years.

💡 For hyperprolactinemia (anovulation/infertility), see the full guide in the "Preconception and Fertility" chapter.

Reproductive age: Mediterranean diet, 500-750kcal deficit, aerobic 150-300min/week + strength training.

Climacteric: protein 1.2-1.6g/kg/day, Calcium+Vitamin D, strength training 3x/week, impact/balance exercises.

Semaglutide 0.25→2.4mg/wk. Tirzepatide 2.5→10-15mg/wk. Indication: BMI≥30, or ≥27+comorbidity.

⚠️ "Ozempic babies" (restores ovulation), reduces OCP efficacy, stop ≥2 months preconception, risk of sarcopenia.

Basson model. Pelvic floor/Kegel. Lubricants. Dual protection + post-coital voiding.

GSM: hyaluronic acid, local topical estrogen, Prasterone, Ospemifene. HSDD: off-label transdermal testosterone + CBT.

Definition: onset of secondary sexual characteristics before age 8 (thelarche or adrenarche) or menarche before age 9.

Central precocious puberty (CPP/true, GnRH-dependent): premature activation of the hypothalamic-pituitary-gonadal axis, with a complete and accelerated isosexual sequence (thelarche → pubarche → menarche). Idiopathic in >80-90% of girls; rule out CNS lesions (hamartomas, gliomas, hydrocephalus), especially if <6 years.

Peripheral precocious puberty (PPP/pseudopuberty, GnRH-independent): autonomous secretion of sex steroids, with basal or suppressed FSH/LH from negative feedback. May be isosexual or contrasexual (virilization).

Non-progressive variants: isolated premature thelarche (no bone-age advance or uterine estrogenization) and idiopathic premature adrenarche (pubic/axillary hair and apocrine odor, with DHEA-S consistent with Tanner II-III and normal basal 17-OHP).

Pelvic ultrasound (transabdominal, with bladder filling) — quantitative criteria:

A pubertal uterus (2:1 ratio, visible endometrium) reflects sustained estrogen exposure — central or ovarian in origin. Strictly prepubertal uterus and ovaries with isolated adrenarche rule out a gonadal origin and point to the adrenal gland.

Algorithm: bone age by left hand-wrist X-ray (Greulich & Pyle) — an advance >1.5-2 years confirms biological impact. Basal LH ≥0.3mIU/mL + elevated estradiol + pubertal uterus → CPP (confirm with GnRH test, LH peak >5mIU/mL, and mandatory brain MRI). Basal LH <0.3mIU/mL (quiescent axis) → evaluate peripheral causes: elevated 17-OHP and DHEA-S → adrenal origin; elevated estradiol with normal 17-OHP → ovarian origin (autonomous follicular cyst, granulosa cell tumor, McCune-Albright).

Basal 17-OHP (points to adrenal origin): <1.0ng/mL rules out a major 21-hydroxylase deficiency. 1.0-2.0ng/mL gray zone — stimulation test needed. >2.0ng/mL high suspicion of non-classic congenital adrenal hyperplasia (NC-CAH). >10-20ng/mL virtually unequivocal diagnosis of CAH, or suspicion of an adrenal neoplasm (add adrenal ultrasound/CT/MRI).

ACTH stimulation test (250µg IV/IM, 17-OHP at 60 min): post-stimulation >10ng/mL (>1000ng/dL) is the gold standard confirming NC-CAH from 21-hydroxylase deficiency.

CPP — axis suppression with depot GnRH agonists: Leuprolide 3.75-7.5mg IM/SC every 28 days (monthly) or 11.25mg every 84 days (quarterly). Triptorelin 3.75mg IM every 28 days or 11.25mg every 12 weeks. Goal: growth velocity <4-5cm/year, stabilizing Tanner stage and preserving adult height. Discontinuation: once bone age reaches 11.0-11.5 years.

NC-CAH — adrenal suppression: hydrocortisone 8-12mg/m²/day in 2-3 oral doses, with the larger dose at night (suppresses the morning ACTH peak). Indicated for symptomatic accelerated adrenarche, bone age advanced >1.5-2 years, virilization, or compromised predicted height. Follow-up: growth velocity, annual bone age, and periodic 17-OHP/androstenedione/DHEA-S — avoid iatrogenic hypercortisolism.

Primary medical emergency. Do not require a prior police report. Non-judgmental history: time elapsed, type of contact, LMP, subsequent hygiene.

Exam with consent explained step by step. Forensic and clinical samples if <72h (HIV, VDRL, HBsAg, NAAT).

Levonorgestrel 1.5mg single dose (ideally <72h). Ceftriaxone+Azithromycin+Metronidazole. Hep B + Tetanus vaccination.

HIV PEP: TDF/FTC + Dolutegravir, start <72h, 28 days. Mandatory reporting. Immediate mental health referral.

Breast development (girls): M1 prepubertal (nipple only) · M2 breast bud/thelarche · M3 further enlargement without contour separation · M4 areola forms a secondary mound · M5 mature.

Genital development (boys): G1 infantile (<4mL) · G2 volume 4-8mL, scrotal reddening · G3 penile lengthening, 10-12mL · G4 increased girth+glans, 15-20mL, darkened scrotum · G5 adult, >20mL.

Pubic hair (both sexes): I no hair · II sparse/fine · III darker/curlier · IV adult type, reduced area · V adult type, complete.

Thelarche precedes menarche by ~2.5 years (average 12.5 years). Assess breast/genital development and hair separately.

Technique: AP X-ray of the left hand and wrist.

Greulich and Pyle Atlas: visual comparison by age/sex. Key milestone: sesamoid bone of the adductor pollicis marks the onset of the growth spurt (≈11 girls, 13 boys).

TW3 Method: quantitative, 20 bones, greater precision for predicting adult height.

Interpretation: normal ±1-1.5 years · delayed >1.5-2 years (constitutional delay, hypothyroidism, GH deficiency, malnutrition) · advanced >1.5-2 years (precocious puberty, obesity, CAH).

Embryology: Müllerian ducts → tubes/uterus/cervix/upper 2-3 of vagina. Urogenital sinus → lower 1/3 of vagina/hymen/bladder/urethra.

⚠️ 30-50% of Müllerian anomalies are associated with renal malformations — renal ultrasound mandatory.

Class I (MRKH): absent uterus/vagina, functional ovaries, primary amenorrhea with developed breasts.

Class II (unicornuate): failure of one duct. Risk of ectopic pregnancy in the rudimentary horn + preterm birth.

Class III (didelphys): 2 uteri/cervices, vaginal septum. OHVIRA syndrome: +obstructive septum+ipsilateral renal agenesis → hematocolpos.

Class IV (bicornuate): 1 cervix, external fundal notch >1cm.

Class V (septate, most common): normal serosa, internal septum. Leading cause of recurrent miscarriage. Tx: hysteroscopic metroplasty.

Class VI (arcuate): normal variant. Class VII (DES): T-shaped uterus.

Imperforate hymen: cryptomenorrhea + violaceous bulging → hematocolpos.

Transverse vaginal septum: perforated or complete. Congenital cloaca: vagina-urethra-rectum confluence (common in CAH).

Algorithm: 3D ultrasound → pelvic MRI → mandatory renal ultrasound → HSG/hysteroscopy.

Bettocchi/"no-touch" technique: no speculum or tenaculum.

Media: saline/Ringer's (bipolar) · Glycine/Sorbitol (monopolar only).

Fluid deficit limits: saline stop at 2,500mL (1,500 in cardiac/renal disease) · Glycine stop at 1,000mL (risk of severe hyponatremia).

Type 1 physiological (straight, smooth entry) · Type 2 tortuous (S/Z-shaped, requires scope rotation) · Type 3 stenotic/atrophic (prepare with estrogen ± Misoprostol) · Type 4 obstructed (adhesions/polyps, millimetric dissection).

Indications: AUB (1st choice for focal PALM-COEIN), polyps, FIGO 0/1/2 submucosal fibroids, hyperplasia/carcinoma, infertility/recurrent miscarriage, retained IUD.

Techniques: polypectomy (bipolar loop) · myomectomy (FIGO 0/1 ≤3-4cm, slicing) · metroplasty (septum incision) · adhesiolysis (centrifugal).

False tract/perforation: blunt+stable instrument→observation+antibiotics. Activated electrode→mandatory exploratory laparoscopy.

Vasovagal reflex: Trendelenburg+fluids+Atropine 0.5-1.0mg IV if persistent.

Gas embolism: do not purge with air, intrauterine pressure 70-100mmHg.

Hammock theory (DeLancey): fibroconnective/muscular support that compresses the urethra.

Q-Tip test: hypermobility if deflection ≥30°.

VLPP: >90 pure hypermobility · 60-90 mixed · <60 intrinsic sphincter deficiency (ISD).

Blaivas-Olsson: 0 not demonstrated · I <1.5cm without cystocele · IIa >1.5cm with cystocele · IIb already descended at rest · III open at rest (=ISD).

1st line: PFMT/Kegel ≥3 sets/day x3 months + biofeedback. Pessaries.

2nd line (office-based): Luksenburg system (suburethral PDO/PCL thread mesh, outpatient) — most recent technique, less consolidated evidence than the rest of this guide. Vaginal laser/radiofrequency. Bulking agents (Bulkamid).

Luksenburg system (suburethral spider web): PDO/PCL thread mesh, outpatient under local anesthesia — hammock-type support + directed neocollagenesis (12-24 months). Note: most recent technique, less consolidated evidence than the rest of this guide.

Other options: vaginal laser/fractional radiofrequency (collagen remodeling) · urethral bulking agents (Bulkamid) in elderly/high surgical risk patients.

Hypermobility (VLPP>60-90): Retropubic TVT (>85-90% efficacy, mandatory cystoscopy) · Transobturator TOT (lower bladder risk) · Burch colposuspension (if mesh contraindicated).

ISD (Blaivas III, VLPP<60): Retropubic TVT (superior to TOT) · Autologous fascial sling (rescue) · Artificial urinary sphincter (refractory).

Monthly, day 5-10 of the cycle. Inspection (3 positions) + palpation (3 fingers, circular motions, clavicle-inframammary fold, sternum-axilla).

NAAT/PCR: Chlamydia, gonorrhea, Mycoplasma genitalium, Trichomonas, high-risk HPV. Serology: syphilis, HIV, Hep B/C. Wet mount: Candida, clue cells, trophozoites.

Ceftriaxone 500mg IM single dose (1g if ≥150kg). Disseminated: 1g IV/IM q24h x7d. Azithromycin monotherapy no longer prioritized due to resistance.

With Chlamydia not ruled out: +Doxycycline 100mg q12h x7d. With Trichomonas: Metronidazole 500mg q12h x7d. Empiric PID: Ceftriaxone+Doxycycline+Metronidazole x14d.

Chlamydia: Doxycycline 100mg q12h x7d. M. genitalium: sequential therapy Doxycycline→Azithromycin (or Moxifloxacin if resistant). Ureaplasma: usual commensal, treat only if symptomatic.

Non-hormonal: Tranexamic acid 1.3g PO 3x/day x5 days/cycle. NSAIDs.

Hormonal: combined OCPs, progestins, 52mg LNG-IUD, GnRH agonists/antagonists with add-back therapy.

Criteria: stability, severity, failed medical treatment, fertility desire. Fibroid: myomectomy/RFA/embolization/hysterectomy. Adenomyosis: hysterectomy if fertility not desired. Polyps: polypectomy. Severe acute: D&C. Endometrial ablation: alternative, ends fertility.

28 days: Early follicular (1-5, menstruation) · Late follicular (6-13, E2>200) · Ovulatory (14±2, LH peak) · Mid luteal (15-24, P4>10) · Late luteal (25-28, luteolysis).

LH peak 24-36h pre-ovulation. Implantation window days 20-24. Day 21 P4 >3-5 confirms ovulation.

Basal body temperature (BBT) patterns: monophasic (no clear rise — suggests an anovulatory cycle, no functional corpus luteum) · biphasic (typical ovulatory pattern — rises ~0.3-0.5°C after ovulation, sustained through the luteal phase) · triphasic (second rise 6-12 days post-ovulation — may be associated with implantation/early pregnancy in ~12% of confirmed cases, not diagnostic on its own, ~88% of pregnancies do not show this pattern).

Early follicular (2-4): FSH <8-10 optimal, >15 low reserve. LH/FSH>2-3 suggests PCOS. AMH: optimal 1.2-3.5.

Mid luteal (day 21): P4 ≥10 optimal. Thyroid: TSH target <2.5. Normal PRL <20-25.

3 pillars: (1) Ovarian — hormonal profile + AMH + AFC. (2) Tubal — HSG/HyFoSy. (3) Uterine — 3D ultrasound/sonohysterography.

WHO 6th ed. minimum values: volume≥1.4mL, concentration≥16M/mL, progressive motility≥30%, morphology≥4%.

TMSC: >3-5M → IUI · 1-3M → IVF · <1M → direct ICSI.

Basic labs + serologies + Pap/mammogram as appropriate.

Folic acid: standard 400mcg/day · high risk 4-5mg/day (prior NTD, diabetes, obesity, anticonvulsants).

MTHFR: replace with methylfolate (400-800mcg standard, up to 5000mcg high risk).

Careful history/exam to choose studies. Essential female evaluation in parallel. Counseling on tobacco+STIs. Document outcomes. Psychosocial support.

Drugs: Clomiphene, Letrozole (1st line in PCOS), Gonadotropins.

Monitoring: baseline ultrasound day 2-4, follow-up every 48h. hCG trigger, ovulation 36-40h later.

OHSS: risk with PCOS, AMH>3.5, AFC>20. Prevention: step-up protocol, strict cancellation criteria.

Calendar: ovulation≈N-14, window N-18 to N-11.

LH test: start 3-4 days before, ovulation 24-36h post-positive.

Billings method: elastic/clear mucus near ovulation, peak day ≈13-14.

Normal PRL <20-25. Micro <10mm (50-150) · Macro ≥10mm (>200-250).

Dx: morning serum level, rule out macroprolactin/hook effect, MRI if PRL>100.

Tx: Cabergoline (1st line) 0.25-1.0mg/week · Bromocriptine (if seeking pregnancy) 2.5-7.5mg/day.

Ravel classification: CST I (L. crispatus, optimal) · CST II (L. gasseri, protective) · CST III (L. iners, transitional/vulnerable) · CST IV (polymicrobial dysbiosis/vaginosis, pH>4.5) · CST V (L. jensenii, protective).

Mechanism: dysbiosis degrades mucin → TLR-4 inflammation (IL-1β/6/8, TNF-α) → MMP-2/9 → facilitates HPV entry and delays clearance → accelerates LSIL→HSIL→cancer.

Biomarkers: ↑Sneathia/Fusobacterium, ↓D-lactic/L-lactic acid ratio.

Dysbiosis alters cervical mucus and causes chronic endometritis (αvβ3 integrins). Implantation failure/recurrent miscarriage via Th1/Th17. Favorable marker: L. crispatus >90%.

Management: Metronidazole/Clindamycin (CST IV) · topical lactic acid · probiotics (L. crispatus/gasseri) · pre-fertility work-up with culture/hysteroscopy+CD138.

Gut bacteria with Beta-Glucuronidase/Glucosidase that deconjugate estrogens inactivated in the liver → reabsorption → circulation → ERα/ERβ receptors.

Hyperactivity (Bacteroides, Clostridium, E.coli) → hyperestrogenism → endometriosis, fibroids, endometrial hyperplasia/cancer, breast cancer risk, PCOS.

Hypoactivity (antibiotics, ultra-processed diet) → hypoestrogenism → worse climacteric symptoms, bone mineral density loss, infertility from implantation failure.

Nutrition: fiber 25-30g/day, cruciferous vegetables (DIM), ↓alcohol/saturated fat.

Supplementation: Calcium D-Glucarate 500-1,500mg/day (hyperestrogenism) · probiotics (L. acidophilus/rhamnosus, Bifidobacterium) · prebiotics (inulin, FOS, GOS).

Healthy woman, BMI 18.5-24.9, BP<120/80, normal history, normal labs/serologies/Pap, complete vaccination.

Folic acid 0.4-0.5mg/day from ≥3 months preconception. Education (diet, exercise, cessation of toxic exposures). Fit to attempt pregnancy.

Underweight/overweight/class I obesity, treatable infections, mild-moderate anemia, rubella/Hep B seronegativity, interpregnancy interval<18-24mo.

Temporary contraception + correction of the cause + immunization (⚠️ live vaccine → delay ≥4 weeks). Reassess in 3-6 months.

Pregestational DM with HbA1c>7%, severe chronic hypertension, heart disease, CKD, active SLE, uncontrolled epilepsy, HIV with detectable viral load, history of NTD/severe preeclampsia/recurrent loss, active teratogenic drugs.

Immediate LARC contraception + mandatory referral + replacement of teratogenic drugs. Clearance only after ≥6 months of stability.

Pap at 1st/2nd prenatal visit. <30: Pap only. ≥30: co-testing/primary HPV. Colposcopy only if high-risk HPV+ or abnormal Pap.

Not during pregnancy, yes during preconception. Average risk: from age 40. Family history: 30-35. BRCA+: 25-30.

Age: <21 no screening · 21-29 Pap/3years · 30-65 high-risk HPV/5years (preferred) · >65 stop if adequate prior screening.

Pap: ASC-US→HPV triage · LSIL→colposcopy · ASC-H→mandatory colposcopy · HSIL→colposcopy+biopsy · AGC→+endocervical curettage.

I confined to the cervix (IA<5mm, IB visible) · II upper vagina/parametria · III lower vagina/pelvic wall/nodes · IV bladder/rectal/metastasis.

IOTA: B rules (benign) vs. M rules (malignant) — only B=benign, only M=malignant, both/neither=indeterminate.

O-RADS: 1 physiological (0%) · 2 almost certainly benign (<1%) · 3 low risk (1-<10%) · 4 intermediate (10-<50%) · 5 high (≥50%, mandatory referral).

Markers: CA-125, HE4 (more specific), ROMA index.

Categories: NILM (negative) · Squamous: ASC-US, ASC-H, LSIL (CIN1), HSIL (CIN2/3), invasive carcinoma · Glandular: AGC, AGC favor neoplasia, AIS, invasive adenocarcinoma.

TZ: Type 1 fully visible ectocervical · Type 2 visible endocervical component · Type 3 not fully visible.

Abnormal: Grade 1 (thin acetowhite, fine mosaic/punctation) · Grade 2 (dense acetowhite, rag sign/inner border/ridge sign) · Suspect invasion (atypical vessels, mass, necrosis).

Triad: Pap (cytological) → Colposcopy (topographic) → Biopsy (histopathological).

HSIL/CIN3 risk: <0.55% routine · 0.55-4% co-test in 1 year · 4-24% colposcopy · 25-59% colposcopy or immediate treatment · ≥60% direct immediate treatment.

By result: NILM+HPV16/18→colposcopy · ASC-US+HPV(+)→colposcopy · LSIL≥25yo→colposcopy · ASC-H→colposcopy always · HSIL≥25yo→excision/biopsy · AGC→colposcopy+mandatory endocervical curettage.

CIN 1: observation, co-test at 12 months. No routine LEEP unless persistent >2 years.

CIN 2/3: excision (LEEP/conization) or destructive (TZ1 only). Conservative exception: selected young patients, p16-negative CIN2, follow-up every 6mo up to 24mo.

Test of cure (HPV/co-test) at 6 months. Negative → annual x3 years, then every 3 years, minimum age 25 (even >65 years). Positive → immediate colposcopic re-evaluation.

Complementary ultrasound: dense breasts (ACR c/d), <30-35 years with a palpable mass, differentiate cyst/solid.

Density (ACR): a (fatty) · b (scattered) · c (heterogeneously dense, consider ultrasound) · d (extremely dense, ultrasound indicated).

BI-RADS: 0 incomplete · 1 negative (0%, routine) · 2 benign (0%, routine) · 3 probably benign (>0-≤2%, 6/12/24mo follow-up).

BI-RADS 4 (>2-<95%, biopsy mandatory): 4a (>2-≤10%) · 4b (>10-≤50%) · 4c (>50-<95%).

BI-RADS 5 (≥95%): spiculated mass, branching pleomorphic microcalcifications → immediate biopsy + oncology.

BI-RADS 6: previously proven malignancy → definitive treatment.

Values by phase: proliferative 4-8mm, periovulatory 8-12mm, secretory up to 14-16mm. AUB ≥45yo: biopsy mandatory. <45yo without risk factors: progestins/OCPs. With risk factors or failure: biopsy.

With PMB: ≤4mm expectant · >4mm biopsy mandatory. Asymptomatic: ≤11mm no routine biopsy · >11mm individualize. Continuous HRT target ≤4-5mm.

Almost always functional (anovulation). Transabdominal ultrasound. Biopsy/curettage contraindicated as 1st line. Progestins in the 2nd half of the cycle. Rule out coagulopathies if bleeding since menarche.

Measurement: sagittal plane, double layer. Echogenicity: uniform (trilaminar/hyperechogenic) vs. non-uniform (suggestive of pathology). Endometrial-myometrial interface regular vs. irregular (suspicious for invasion).

Color Score 1-4. Single dominant vessel → polyp. Multiple disorganized vessels → malignancy. Scattered vessels without a dominant one → hyperplasia.