21.1 Gynecology and Obstetrics

Gynecology and Obstetrics

Quick Answer: Associated Clinical Sciences is 13% of NBCE Part II, and OB/GYN items reward pattern recognition across the pelvic exam, breast screening, normal pregnancy physiology, and obstetric emergencies. Know the difference between painless bleeding (placenta previa) and painful bleeding (abruptio placentae), recognize preeclampsia triad components, and understand when pregnancy-related back pain is appropriate for supportive chiropractic care versus when it signals a referral-level complication.

Gynecologic Examination

The standard gynecologic examination proceeds in a fixed sequence: external inspection, speculum examination, bimanual palpation, and rectovaginal examination when indicated (suspected posterior uterine or adnexal pathology, or when bimanual findings are limited by body habitus).

Inspection evaluates the vulva for lesions, atrophy, condyloma, and Bartholin cysts. Speculum examination visualizes the vagina and cervix for discharge, ectropion, polyps, and cervical lesions. The Papanicolaou (Pap) smear screens for cervical dysplasia and carcinoma; current guidelines recommend cytology alone every three years in women 21–29, and HPV co-testing every five years in women 30–65. A positive HPV high-risk test with normal cytology requires follow-up per ASCCP guidelines — not reassurance alone.

Bimanual examination assesses uterine size, position (anteverted vs. retroverted), mobility, and tenderness; adnexal masses; and cervical motion tenderness. Cervical motion tenderness with purulent discharge and fever supports pelvic inflammatory disease (PID) — a referral and antibiotic emergency that can cause tubo-ovarian abscess and infertility.

High-Yield Gynecologic Conditions

Breast Examination and Disease

Clinical breast examination supplements mammography, the primary screening tool for average-risk women. The exam evaluates symmetry, skin changes, nipple discharge, and palpable masses using a systematic pattern (vertical strips or clock-face method).

Benign findings include fibrocystic change (bilateral, cyclical, mobile lumps), fibroadenoma (young women, rubbery, mobile, well-circumscribed), and galactocele. Malignancy red flags include a fixed, hard, irregular mass; skin dimpling or peau d'orange (lymphatic obstruction); nipple retraction or bloody discharge; and axillary lymphadenopathy.

Inflammatory breast cancer presents with diffuse erythema, warmth, and peau d'orange mimicking mastitis but without fever or purulent discharge — biopsy, not antibiotics alone. Any suspicious mass requires imaging (diagnostic mammography ± ultrasound) and tissue diagnosis when indicated.

Normal Pregnancy Physiology

Pregnancy produces predictable systemic changes that Part II tests as "normal vs. pathologic":

• Cardiovascular: Blood volume increases 40–50%; cardiac output rises; systolic BP typically decreases in the second trimester (10–15 mmHg) then returns toward baseline — this is physiologic, not hypotensive shock
• Hematologic: Plasma volume expands more than red cell mass → physiologic anemia (hemoglobin may fall to ~11 g/dL); iron and folate supplementation are standard
• Respiratory: Tidal volume increases; PaCO2 falls to ~30 mmHg (compensated respiratory alkalosis); dyspnea of pregnancy is common and benign when no hypoxia or crackles
• GI: Decreased lower esophageal sphincter tone → GERD; decreased GI motility → constipation
• MSK: Ligamentous laxity from relaxin; increased lumbar lordosis and posterior pelvic pain — the chiropractic-relevant presentation
• Renal: GFR increases ~50%; physiologic glycosuria and proteinuria up to trace may occur

Fundal height approximates gestational age in centimeters from 20–36 weeks (e.g., 24 cm ≈ 24 weeks). Discrepancies suggest multiple gestation, polyhydramnios, oligohydramnios, or intrauterine growth restriction.

Labor, Delivery, and Postpartum

Labor is defined by regular uterine contractions producing cervical change. The three stages:

1. First stage (onset of labor to full cervical dilation): latent phase (0–6 cm, slower) and active phase (≥6 cm, faster dilation)
2. Second stage (full dilation to delivery of infant): pushing and descent
3. Third stage (delivery of infant to delivery of placenta): watch for postpartum hemorrhage if the placenta does not deliver within 30 minutes or bleeding exceeds 500 mL

Fetal heart rate monitoring basics: normal baseline 110–160 bpm. Late decelerations (gradual fall after contraction peak) suggest uteroplacental insufficiency. Variable decelerations (abrupt dips) suggest cord compression. Early decelerations (mirror contractions) are benign (head compression).

Postpartum Complications

"Baby blues" — tearfulness and mood lability days 1–10 postpartum — resolves spontaneously. Postpartum depression persists beyond two weeks and impairs function; postpartum psychosis (hallucinations, delusions, risk of infanticide) is a psychiatric emergency.

Obstetric Emergencies and Disorders

These distinctions are among the highest-yield OB items on Part II:

Third-Trimester Bleeding

• Placenta previa: placenta implants over or near the internal cervical os → painless bright red bleeding in the third trimester; diagnosis by ultrasound; no digital cervical exam (can provoke hemorrhage); delivery by cesarean
• Placental abruption: premature separation of normally implanted placenta → painful vaginal bleeding, rigid tender uterus, fetal distress; associated with trauma, cocaine use, hypertension; emergency cesarean if non-reassuring fetal status

Hypertensive Disorders of Pregnancy

Preeclampsia severe features include BP ≥160/110, thrombocytopenia, impaired liver function, renal insufficiency, pulmonary edema, or new-onset cerebral/visual symptoms. Definitive treatment is delivery.

Other High-Yield Obstetric Topics

• Ectopic pregnancy: positive β-hCG with empty uterus on ultrasound, adnexal mass, pain, bleeding; ruptured ectopic is a surgical emergency
• Hyperemesis gravidarum: persistent vomiting with weight loss, ketonuria, electrolyte disturbance — beyond normal morning sickness
• Gestational diabetes: screen at 24–28 weeks (glucose challenge test); macrosomia and shoulder dystocia risks
• Rh incompatibility: Rh-negative mother sensitized by Rh-positive fetus → hemolytic disease of the newborn; prevented by Rho(D) immune globulin at 28 weeks and postpartum

Chiropractic Relevance in Pregnancy

Pregnant patients commonly seek chiropractic care for mechanical low back pain, sacroiliac dysfunction, and postural headache. Supportive care — including gentle mobilization, soft-tissue therapy, exercise prescription, and pelvic support belts — is appropriate when no obstetric contraindication exists.

Contraindications to spinal manipulation in pregnancy include:

• Vaginal bleeding of unknown etiology, placenta previa, or suspected abruption
• Preeclampsia, eclampsia, or HELLP syndrome
• Premature labor or ruptured membranes
• Placenta accreta spectrum or known placenta previa on imaging
• Moderate-to-severe vaginal bleeding, uncontrolled hypertension, or non-reassuring fetal status

Use modified tables or side-lying positions after the first trimester; avoid prone positioning with an abdominal cutout when uncomfortable. Document gestational age, obstetrician clearance when applicable, and any red-flag symptoms at each visit.

Takeaways: Pap/HPV screening intervals matter; breast cancer red flags are fixed, irregular, and associated with skin or nodal changes; placenta previa bleeds painlessly while abruption is painful; preeclampsia after 20 weeks combines hypertension with proteinuria or end-organ signs; and pregnancy back pain is treatable conservatively only when obstetric complications are excluded.