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ChicKen Review > 4. OB/GYN & female reproductive system > Flashcards

4. OB/GYN & female reproductive system Flashcards

1
Q

Pruritus and elevated total bile acids and/or aminotransferases in pregnancy is suggestive of what?

A

Intrahepatic cholestasis of pregnancy (ICP).

Note: jaundice is uncommon in patients with ICP.

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2
Q

Fetal heart rate monitoring: VEAL CHOP

A

Variable decel: Cord compression. (V and C)
Early decel: head compression. Generally a benign event. (E and H)
Accelerations: Oxygenation (good prognostic factor. (A and O))
Late accel: placental insufficiency. (L and P)

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3
Q

What contraceptive is contraindicated in patients with breast cancer?

A

All hormone-containing contraception
Copper IUDs can be used.
Note: other contraindications to combined hormonal contraceptives are migraines, smoking, hx of VTE, stroke, ischemic heart disease, liver cancer, cirrhosis, <3wk postpartum

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4
Q

Cause of postpartum persistent fever unresponsive to antibiotics 5 days after a c-section?

A

Septic pelvic thrombophlebitis - Diagnosis of exclusion
Infected thrombosis of the deep pelvic or ovarian veins.
Tx - anticoag and broad-spectrum abxs

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5
Q

Pregnant patients without immunity to rubella should get vaccinated when?

A

Immediately postpartum with the live-attenuated MMR vaccine - prevents future infection but avoids theoretical risk of congenital rubella

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6
Q

When is Rho(D) immunoglobulin indicated?

A 
In Rh(D)-negative patients with their second child if child is Rh(D) positive. 
Give at 28 weeks gestation for prophylaxis and after delivery if child is Rh(D) positive. Only give first trimester if there is uterine bleeding
Ectopic pregnancy, hydatidiform molar preg, amniocentesis, abd trauma, 2nd and 3rd trimester bleed
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7
Q

Best approach for management of a painful, simple breast cyst that is relieved by aspiration?

A

Close interval follow-up (repeat breast exam in 2 mo)

Note: breast US is first-line imaging study

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8
Q

What are modifiable risk factors that can be reduced to dec risk of breast cancer?

A

Alcohol consumption
nulliparity
hormone replacement therapy
Inc age at first live birth

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9
Q

What are normal physiologic adaptations to pregnancy?

A

Inc in GFR, RBF, renal BM permeability (decreases BUN and Cr and inc urinary protein excretion)
Hypercoagulable - minimizes bleeding during delivery
Inc plasma vol –> mild dilutional anemia

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10
Q

Pelvic cramping in first few days of menses with normal physical exam is due to what?

A

Primary dysmenorrhea - caused by inc prostaglandin release from endometrial sloughing

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11
Q

Mood swings, irritability, fatigue, bloating, hot flashes, and breast tenderness in 40 yo F is due to what?

A

commonly due to premenstrual syndrome PMS
Occur in 1-2 weeks bf menses - confirm with symptom diary
Tx w SSRIs

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12
Q

Patient at 8 wk gestation with US showing intrauterine gestational sac with yolk sac but no fetal pole.B-hCG levels decreasing. Closed cervix and scant vaginal discharge on pelvic exam. Dx?

A

Missed abortion

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13
Q

What is Mittelschmerz?

A

Physiologic cause of unilateral abdominal pain in young women. Pain occurs in the middle of the menstrual cycle (day 10-14) - time of ovulation. Exclude acute pathology

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14
Q

Advanced ovarian cancer may present with pelvic mass and ascites. After US is performed, next step?

A

ex lap with cancer resection and staging with inspection of the entire abdominal cavity.
Note: image-guided bx is contraindicated if there are malignant features bc can spread cancer.

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15
Q

what is the best way to prevent congenital rubella?

A

Live attenuated vaccine prior to conception - first trimester maternal fetal transmission of rubella is teratogenic.

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16
Q

When can pap testing be discontinued?

A

Patients >65yo who has no hx of CIN2+ And 3 neg pap tests or 2 consecutive negative co-tests

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17
Q

Management of preterm labor at:

  1. 34-36 6/7 wk
  2. 32-33 6/7 wk
  3. <34 wk
A
  1. Betamethasone, Penicillin if GBS positive, C-section if contraindications to vaginal delivery (eg breech)
  2. Betamethasone, tocolytics, penicillin if GBS pos
  3. Betamethasone, tocolytics, magnesium sulfate, penicillin if GBS pos
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18
Q

What is the preferred initial imaging modality for suspected gynecological tumors?

A

Pelvic ultrasound - has high sensitivity for diagnosing uterine fibroids and ovarian pathology

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19
Q

Reproductive age female with LLQ pain, hx of DVT on anticoag, dec Hct, and hemoperitoneum. Dx?

A

Ruptured ovarian cyst - patients on anticoag can bleed intra-abdominal from this rupture and become hemodynamically unstable

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20
Q

What is the most significant risk factor for spontaneous preterm delivery?

A

History of spontaneous preterm delivery in a prior pregnancy. Can manage with progesterone supplementation and serial cervical length measurements.
Other RF: multiple gestation, short cervical length, cervical surgery, cigarette use

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21
Q

All meds with estrogen AGONIST activity (eg OCPs, hormone replacement, SERMS) inc risk for what?

A

venous thromboembolism; hot flashes.
Therefore, current or prior VTE (eg PE, DVT< retinal vein thrombosis) are contraindications to raloxifene and tamoxifen
note: tamoxifen inc risk of endometrial hyperplasia and carcinoma

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22
Q

How does morbid obesity cause amenorrhea?

A

Due to anovulation. Ovaries produce estrogen, but progesterone not made at normal post ovulation levels, so progesterone withdrawal menses at the end of the cycle doesnt occur.
Note: FSH and LH levels are normal.

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23
Q

Kids with vaginal foreign bodies present with foul-smelling vaginal discharge and spotting (toilet paper most common). How do you remove it?

A

Calcium alginate swab or irrigation with warm fluid after topical anesthetic applied. Exam under anesthesia done only if this doesnt work.

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24
Q

Physiologic galactorrhea is usually bilateral and can be milky, yellow, brown, gray, or green. What is the MCC? What tests should be done to evaluate it?

A

Hyperprolactinemia
Tests: pregnancy test, serum prolactin, TSH, possible MRI of brain
Note: unilateral bloody nipple discharge is always pathologic and most likely intraductal papilloma

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25
Q

Vaginal dryness, pruritus, dysuria, pale vainal mucosa, diminished labial fat pad, and scarce pubic hair in older woman is a sign of what? Tx?

A

Atrophic vaginitis

Tx - vaginal estrogen therapy if moderate or severe

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26
Q

Define arrest of active labor? What do you do if this happens?

A

Arrest of active labor = cervical dilation of >=6 cm when there is no cervical change for >=4 hours with adequate contractions or for >=6 hours with inadequate contractions
C-section is indicated

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27
Q

Evaluation of abnormal uterine bleeding with ____ is necessary in patients >=45. Patients <45 with obesity and abnormal uterine bleeding due to chronic anovluation also need this eval bc inc risk of endometrial hyperplasia

A

Endometrial biopsy

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28
Q

In pregnancy, what can cause primary metabolic alkalosis?

A

Hyperemesis gravidarum - significant vol depletion and loss of gastric acid.
Note: hypocapnia is a normal phenomenon of late pregnancy –> primary resp alkalosis

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29
Q

Prego patient with discrepancy in uterine size and calculated gestational age, hx of heavier, longer menses with pelvic pressure bf the pregnancy, and enlarged uterus with irregular contour is most consistent with what?

A

Leiomyomata uteri

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30
Q

An Anti-D antibody titer of 1:32 reflects a pregnant woman is what? How do ou prevent this?

A

Alloimmunized - sensitized (occurs when mom is Rh neg and fetus Rh pos)
Prevent by admin anti-D immune globulin at 29 weeks gestation and repeat within 72 h of delivery

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31
Q

Patient with CIN3 on cervical bx and >25yo should be managed how?

A

Cervical conization (type of excisional bx) bc it is a high-grade premalignant lesion that can progress to invasive squamous cell cervical carcinoma

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32
Q

How do you manage endometriosis?

A

NSAIDs and OCPS can be initiated empirically. Laparoscopy is indicated after failure of empiric therapy.
Note: endometriosis is an estrogen-dependent condition

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33
Q

1/4 of patents with endometriosis present with what complication?

A

infertility. Ectopic foci of hemorrhage and adhesions can distort pelvic anatomy –> obstruct oocyte release or sperm entry –> infertility

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34
Q

When is surgical management (suction curettage) indicated for an inevitable abortion?

A

A hemodynamically unstable patient

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35
Q

Loss of fetal station is pathognomonic for what complication? Sx include sudden onset abd pain, recession of presenting part during active labor, and fetal HR abnormalities.

A

Uterine rupture. Typically occurs in patients with prior uterine surgery.

36
Q

Acute postpartum urinary retention and overflow incontinence may be caused how?

A

Bladder atony - regional anesthesia reduces sensory and motor impulses of the sacral spinal cord, which suppresses the micturition reflex and decreases detrusor tone. Can also result from pudendal nerve palsy from pelvic floor injury or tissue trauma.

37
Q

How can hyperemesis gravidarum result in encephalopathy, oculomotor dysfunction, and gait ataxia?

A

Thiamine def –» wernicke encephalopathy

Tx: antiemetics, fluids, and thiamine supplementation.

38
Q

What is the best way to evaluate proteinuria in a patient with preeclampsia?

A

Urine protein-to-creatinine ratio or a 24-h urine collection for total protein (gold standard)

39
Q

What causes increased risk for preterm delivery?

A

history of cervical surgery (eg cold knife conization); short cervix at <24 weeks gestation (admin progesterone to maintain uterine quiescence and dec risk of preterm delivery).
Transvaginal US measurement of cervical length is the gold standard for further eval
Note: fetal fibronectin levels are useful to eval for preterm delivery after 20 weeks.

40
Q

What are indications for hospitalization for PID?

A

Pregnancy, failed outpatient tx, cant tolerate oral meds, noncompliant, severe presentation (high fever, vomiting), complications (eg tubo-ovarian abscess)

41
Q 
Postpartum endometritis (polymicrobial infx):
RF? Sx? tx?
A

RF: c section, chorioamnionitis, GBS colonization, prolonged rupture of memb, operative vaginal delivery
Sx: Fever >24h postpartum, purulent lochia, uterine fundal tenderness
Tx: Clinda + gentamicin

42
Q

What abx treat the following:

  1. Pyelonephritis in pregnancy
  2. N gonorrhoeae/chlamydia
  3. Lactational mastitis
  4. Syphilis, group b strep prophylaxis
  5. Breast abscess
A
  1. Ceftriaxone
  2. Ceftriaxone + azithromycin
  3. Dicloxacillin
  4. Penicillin
  5. Vancomycin
43
Q

What should be performed to any woman of childbearing age with acute-onset abdominal age before any diagnostic tests?

A

Pregnancy test

  • if positive –> pelvic ultrasound
  • if negative –> abdominal CT
44
Q

Patients with negative serology and strong clinical evidence of primary syphilis (eg chacre) should be managed how?

A

Tx empirically with IM benzathine penicillin G (reduces risk of transmission). Nontreponeal tests (eg RPR, VDRL) have high false-neg rates.
Note: treponema pallidum cannot b cultured, so bx unhelpful

45
Q

If fetal movement decreases or becomes imperceptible by the mother, what should be done?

A

Perform a nonstress test to document fetal well being.
Normal if in 20min there are at least 2 accelerations of the fetal heart rate of at least 15 beats/min above the baseline and lasting at least 15 sec each.
If <2 acc noted in 20 min, test is abnormal
Note: MCC of a nonreactive (abnormal) NST is a fetal sleep cycle; vibroacoustic stim is used to awaken the fetus

46
Q

OCP benefits and risks?

A

Benefits: prevent preg, dec endometrial and ovarian Ca, reduce Fe def anemia by regulating menstrual cycle, dec risk of benign breast disease (eg fibroadenoma)
Risks: VTE, HTN, hepatic adenoma, stroke and MI (rare)

47
Q

An ovarian mass in a postmenopausal women is highly concerning for malignancy. How do you investigate further?

A

Pelvic US and CA-125 –> further imaging

48
Q

How can you differentiate primary dysmenorrhea from endometriosis?

A

Dysmenorrhea (cramps) involves crampy lower-abd pain during menses and normal exam WITHOUT dyspareunia or GI sx. Tx: OCP and NSAIDs
Endometriosis: occurs 102wk PRIOR to menses and peaks bf menstruation. Assoc with infertility.

49
Q

Screening for osteoporosis with what is recommended in all women >=65 and for younger women with equivalent risk of osteoporotic fx?

A

DEXA

Note: serum ca and phosphorus are normal in majority of patients with osteoporosis

50
Q

Advanced cervical cancer may present as vaginal bleeding with a cervical lesion. What are major RF for squamous cell cervical cancer?

A

HPV virus 16 and 18
SMOKING
other RF: early onset sexual activity, multiple sex partners, immunosuppresion.
Bx –> excise, radiate, or chemo.

51
Q

How does estrogen deficiency in postmenopausal women result in GU sx such as UTIs and incontinence?

A

Hypoestrogen –> atrophy of vaginal layers and urethral mucosal epithelium –> dec urethral closure pressure and loss of urethral compliance.

52
Q

The majority of patients with mammary Paget disease have what type of underlying breast cancer?

A

Breast adenocarcinoma (starts in glandular tissue)

53
Q

Women on HRT with estrogen alone can cause what condition that can present with postmenopausal bleeding? How do you evaluate this?

A

Endometrial hyperplasia or adenocarcinoma
Pelvic US or endoemtrial bx
If >4mm on US, bx must be performed to exclude malignancy

54
Q

What are 3 causes of hyperandrogenism in pregnancy. Dx? management?

A
  1. Luteoma (solid, benign, regress spontaneously after delivery) - observe
    2 theca luteum cyst (cysts, assoc w/molar preg and multiple gestation, regress spont after delivery) - suction and curettage if mole seen
  2. Krukenberg tumor (solid mass, mets from primary GI tract) - bx, surgery

Dx - pelvic US

55
Q

What can occur after a traumatic delivery and present with radiating suprapubic pain that is worse with amublation or weight-bearing? management?

A

Pubic symphysis diastasis - conservative and supportive care

56
Q

What are contraindications to breastfeeding?

A 
Active, untreated Tb
Varicella infx`
herpetic breast lesions
Current chemo
illicit drug use (marijuana, cocaine, opioids)
57
Q

How do you manage a patient with placenta previa at 36-37 weeks?

A

C section. Labor is contraindicated bc placenta would detach first and this would deprive the fetus of oxygen. Placental disruption could also cause hemorrhage.

58
Q

How do you treat patients with Candida vaginitis? What is seen on wet mount?

A

Wet mount: Pseudohyphae
Tx - azole (fluconazole)
Note: intravaginal nystatin can be used, but oral wont work (only for thrush)

59
Q

Infertility, irregular menses, and free testosterone levels elevated in a female of repro age is concerning for what?

A

PCOS
Note: high estrone –> inhib GnRH from hypothal –> LH//FSH imbalance –> no LH surge –> no follicle maturation and oocyte release

60
Q

Androgen insensitivity syndrome is characterized by a phenotypic F with 46, XY karyotype. When is bilateral gonadectomy recommended to dec risk of gonadal malignancy?

A

After completion of puberty (eg attainment of adult height)

61
Q

How do you treat gestational diabetes?

A

First-line: diet and exercise

If this fails, insulin or oral anti-diabetic meds are indicated

62
Q

How do you manage shoulder dystocia (aka what does BE CALM stand for?)

A
  1. Breathe, dont push, lower head of bed
  2. Elevate legs into McRoberts position
  3. Call for help
  4. Apply suprapubic pressure
  5. Enlarge vaginal opening with episiotomy
    6 .Maneuvers (delivery posterior arm, all fours, replace head to vagina –> Csection)
63
Q

What is PPROM? RF?

How do you manage it if <34 wks or 34-37 weeks?

A

preterm premature rupture of membranes (<37wks)
RF: hx of prior preterm, multiple gestation, prior PPROM, genital tract infx, smoking
<34 wk: Abx, corticosteroids (betamethasone - dec risk of Resp distress in neonate), fetal surveilance (hospitalize for observation); magnesium if <32 wk
34-37wk: abx, +/- corticosteroids, delivery

64
Q

Why is external cephalic version (correct fetal malpresentation - aka breech) contraindicated in a patient with PPROM?

A

Decreased amniotic fluid is a contraindication

65
Q

T/F: weight gain is related to combined OCPs?

A

False

66
Q

Epidural anesthesia and perineal edema are RF for postpartum urinary retention and overflow incontinence. How do you manage it if it develops?

A

Urethral catheterization is indicated for dx and treatment

67
Q

If there is dec fetal mvt and a nonstress test is nonreactive, further evaluation should be done with what? What does it measure?

A

Biophysical profile or contraction stress test
Biophysical: amniotic fluid vol, fetal breathing mvt, fetal mvt, fetal tone.
Contraction stress: oxytocin or nipple stim is done until 3 contractions occurs every 10 min. Note: placenta previa, prior myomectomy are contraindications (CI to labor).

68
Q

An abnormal biophysical profile score (eg 4/10) is consistent with what? What are RF for an abnormal score? How does scoring work?

A

Fetal hypoxia due to placental dysfunction/insufficiency
RF: adv maternal age, smoking, HTN, DM
2 points per category for total of 10pts: NST, amniotic fluid >=2x1cm, fetal mvt >=3, fetal tone >=1 flexion/extension of limb or spine; fetal breathing mvt >=1 breathing episode for >=30sec

69
Q

Complications of excess weight gain vs inadequate weight gain in pregnancy?

A

Excess: gestational DM, fetal macrosomia, C-section
Low: fetal growth restriction, preterm
Note: underweight pts are advised to gain 12-18kg (28-40lbs) during preg

70
Q

What is the B-hCG level expected for an intrauterine pregnancy? If it below this threshold, what should be done if pregnancy is suspected?

A

1500-2000IU/L

Remeasure in 2 days if <1500. If >1500, TVUS should be repeated.

71
Q

Hypogonadotropic hypogonadism is characterized by ___FSH and ___ estrogen levels? What conditions is it assoc with?

A

low FSH and estrogen –> irreg menses and infertility

Assoc with excess wt loss, strenuous exercise, chronic illness, eating d.o

72
Q

What maternal infection should be screened for at the first prenatal visit?

A

Syphilis and other STIs (HIV, HBV, Chlamydia, syphilis.

Note: GBS screening isnt done until 35-37wk.

73
Q

Uterine inversion is an uncommon but potentially fatal cause of postpartum hemorrhage. Management?

A

Aggressive fluid replacement
Manual replacement of the uterus - laparotomy if attempts at manual replacement fail
Placental removal and uterotonic drugs after uterine repalcement

74
Q

What is the MCC of vaginal bleeding in the neonatal period?

A

Maternal withdrawal of estrogen - similar to the follicular phase of menstruation (causes growth of endometrial lining)
- bleeding is self-limited and no tx required

75
Q

What are some fetal and maternal complications of preeclampsia?

A

Fetal: Oligohydramnios, fetal growth restriction, small for gestational age (d/t chronic uteroplacental insufficiency)
Maternal: abruptio placentae, DIC, eclampsia

76
Q

Differentiate between symmetric (global growth lag) and asymmetric (head-sparing) fetal growth restriction

A

Symmetric: onset 1st trimester. D/t chrom abnormalities/congenital infx.
Asymmetric: onset 2nd/3rd trimester. D/t utero-placental insuff or maternal malnutrition

77
Q

What do you do if you suspect a patient has lichen sclerosis (cigarette paper skin, intense pruritus)?

A

Punch biopsy to confirm and rule out vulvar SCC
tx: high potency topical steroids
Note: no pruritus is seen with atrophic vaginitis

78
Q

How can you differentiate hyperemesis gravidarum (see wt loss of >5% of prepreg wt)from typical nausea and vomiting of pregnancy

A

HG will have the presence of ketones on UA, electrolyte abnormalities. Occurs due to prolonged hypoglycemia
Severe HG is an indication for hospital admission for IV antiemetics, rehydration, and electrolyte repletion

79
Q

Pregnant women with chronic hep C should be given what?

A

Hep A and B vaccines now
Consequences of chronic hep C: gestational DM, cholestasis of pregnancy, preterm delivery.
Dont use ribavirin bc teratogenic.
Breastfeeding is encouraged unless maternal blood present.

80
Q

Presence of maternal fever and >=1 of the following: uterine tenderness, maternal or fetal tachy, malodorous amniotic fluid, or purulent vaginal discharge is diagnostic for what? What is an important RF? Tx

A

Chorioamnionitis
Prolonged rupture of membranes is an important RF.
Tx: broad-spectrum abx, delivery (with oxytocin to accelerate labor)

81
Q

Endometriosis (dysmenorrhea, deep dyspareunia, and dyschezia) should be treated how?

A

NSAIDs and/or OCPs

Laparoscopy if there is tx failure, adnexal mass or acute sx

82
Q

Primary amenorrhea evaluation order if there is no breast development ?

A
  1. Pelvic exam for presence of uterus
    2a. Uterus present: serum FSH
    3a. Inc FSH –> karyotype; dec FSH –> cranial MRI
    2b. uterus absent: karyotype serum testosterone
    3b: normal F testosterone levels –> abnormal mullerian dev; normal M testosterone levels –> androgen insensitivity syndrome
    Note: breast dev is a sign of estrogen presence
83
Q

What should be considered in a patient with a known ovarian mass and is presenting with abdominal pain?

A

Ovarian torsion - dangerous complication that can lead to ischemic necrosis of the ovary

84
Q

What is Mittelschmerz?

A

Refers to unilateral pelvic pain in the middle of a physiologic menstrual cycle d/t ovulation (day 14).

85
Q

If fetal heart tones are not heard by doppler, what should be done next? How do you address the mother in addition to comforting her when she wants to know how to prevent this from happening in future pregnancies?

A

Transabdominal ultrasound is done to confirm the diagnosis of intrauterine fetal demise
Discuss doing fetal autopsy, fetal karyotype, placental exam and maternal lab testing to determine etiology

86
Q

In Mullerian agenesis, patients have normal phenotype and genotype, but what female repro organs are absent?

A

Uterus, cervix, and upper vagina (failure of mullerian ductal system to differentiate) –> dont menstruate
Note: ovaries and external genitalia develop normally

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