5 ⼀PREGNANCY I (BREAST/REPRO) Flashcards
Full term infant = 37- 42WG
etx for Gestational Transient Thyrotoxicosis (4)
- βhCG shares α subunit with TSH.
- during pregnancy, ⇪ [fetal βhCG] stimulates [Maternal Thyroid gland TSH receptors] ➜ [⇪ TOTAL Maternal T4 and T3] secretion
- In [Gestational Transient Thyrotoxicosis], [Multiple gestation or hyperemesis gravidarum] ➜ VERY high [fetal βhCG] ➜ [⇪ ⇪ ⇪ TOTAL Maternal T4 and T3]
- that resolves by 16WG
What is Asherman syndrome?
[Intrauterine adhesions and endometritis] from uterine instrumentation (D&C) ➜ [cyclic abd pain and secondary amenorrhea] immediately following instrumentation
Full term infant = 37- 42WG
Choriocarcinoma (the most aggressive kind of ⬜ ) can follow any type of ⬜ and presents with ⬜-4
________________
What 2 locations does Choriocarcinoma occur?
[gestational trophoblastic neoplasia] ; pregnancy ;
[AFTER PREGNANCY ➜ irregular vaginal bleeding + enlarged uterus + positive pregnancy test]
________________
Vagina | Lung
Full term infant = 37- 42WG
Major causes of Antepartum Hemorrhage - 3
Antepartum = right before childbirth
- [Placental abruptioPAINFUL]
- [Placental previanonpainful]
- Vasa Previa
Full term infant = 37- 42WG
CP for Placental Abruptio - 4
Risk factors = HTN, cocaine, smoking, prior abruptio, abd trauma
- sudden PAINNNFFULLL antepartum vaginal bleeding (which can –> hypovolemic shock, [DIC-from decidual bleeding releasing tissue factor 7] and fetal demise) - (UNLESS CONCEALED = then no vag bleeding)
- Distended firm uterus
- abd AND/OR back pain
- [low intensity contractions]
etx: HTN of maternal decidual vessels –> rupture –> premature detachment of placenta from endometrium
pregnant patient 35 WG p/w Nonpainful vaginal bleeding
Next step is (⬜ Digital Cervical Exam | TVUS) and why?
TVUS
s/f Placenta PREVIA, in which digital Cervical Exam is contraindicated since it enters endocervical canal. TVUS and speculum do NOT enter endocervical canal
_________________
Placenta Previa
Full term infant = 37- 42WG
Of the 3 placental demise, which is a/w Nonpainful antepartum vaginal bleeding?
Placenta Previa
Recurrent UTI refers to (⬜2)
________________
Tx?
[≥2UTI in 6 mo]
or
[≥3UTI in 12 mo]
________________
Postcoital abx prophylaxis
(Bactrim, nitrofurantoin, cephalexin, cipro)
Full term infant = 37- 42WG
Amniotic Fluid Embolism tx
supportive
__________________________________
release of fetal amniotic fluid into maternal circulation (during labor or immediately postpartum) ➜ maternal massive inflammatory response that causes acute hypoxemia, hypotension, DIC
Full term infant = 37- 42WG
Amniotic Fluid Embolism etx
_________________
What are the 2 major risk factors for this?
release of fetal amniotic fluid into maternal circulation (during labor or immediately postpartum) ➜ maternal massive inflammatory response that causes acute
hypOxemia
[hypOtension 2/2 obstructive shock]
DIC
_________________
Placenta Previa and Placenta Abruptio
After the Rupture of Membranes, when is it safe for labor to begin?
[1 - 18 hours after ROM] (no sooner⼀no later)
________________
labor starting ≥18H after ROM ➜ chorioamnionitis ➜ neonatal sepsis
________________
Do not confuse this with PPROM (Preterm Premature Rupture Of Membrane)
Chorioamnionitis Tx = Abx –> Delivery
PPROM is defined as ⬜
How do you manage PPROM when it occurs ≥ 34WG? -3
= [Preterm Premature Rupture Of Membranes before 37 WG]
_________________
[(PCN with azithromycin) + Betamethasone] + DELIVERY
Complications = Chorioamnionitis/Endometritis/Cord Prolapse/Placenta Abruptio
Preterm Labor is defined as ⬜
How do you manage Preterm Labor when it occurs 34 to 36+6 WG ? -3
= [regular uterine ctx → cervical diLation before 37 WG]
_________________
[(PCN with azithromycin) + Betamethasone] + DELIVERY
- Complications = Chorioamnionitis/Endometritis/Cord Prolapse/Placenta Abruptio*
PPROM = Preterm Premature Rupture Of Membranes before 37 WG
Define Preterm Labor -2
{[regular uterine ctx that ➜ cervical diLation] < 37 WG}
Full term infant = 37- 42WG
PPROM = [Preterm Premature Rupture Of Membranes before 37 WG]
[Betamethasone antenatal CTS] is given to pregnant patients with [Preterm labor/PPROM/Severe Preeclampsia] before 37 WG]
_________________
What are the 4 major benefits of using [Betamethasone antenatal CTS]?
[Betamethasone antenatal CTS] ⬇︎
- [NRDS via STIMULATING LUNG MATURATION]
- IVH
- Necrotizing enterocolitis
- Neonatal mortality from prematurity
Complications = Chorioamnionitis/Endometritis/Cord Prolapse/Placenta Abruptio
Full term infant = 37- 42WG
How do you manage PPROM when it occurs < 34WG? -4
{(PCN with azithromycin) + Betamethasone + Tocolytics] + WW until 34WG*}
*if baby not compromised, fetal surveillance until 34 WG and then deliver!
Complications = Chorioamnionitis/Endometritis/Cord Prolapse/Placenta Abruptio
Full term infant = 37- 42WG
When are pts screened for Group B Strep via vaginal and rectal swab?
36-38 WG
results are valid for 5 weeks
When does a breech pregnant patient become eligible to receive [External Cephalic Version]?
≥37 WG
Pregnant patients with Sickle Cell Anemia have ⇪ risk for developing ⬜ , which presents with what 4 s/s ?
_________________
how is this different from [Acute fatty liver of pregnancy]? (2)
[Acute Sickle Liver Crises 2/2 vasooclusive crisis]
- [hemolysis (anemia/jaundice/icterus)]
- [RUQ pain with mild transaminitis]
- NV
- fever
_________________
SAME AS AFLP except…
AFLP = 3rd trimester and AFLP = [RUQ pain with SEVERE TRANSAMINITIS> 300]
[Recurrent pregnancy lost] is defined as ⬜ . What heme/onc abnormality is a/w [Recurrent pregnancy lost]?
how is it managed?
[≥3 consecutive < 20WG spontaneous abortions]
_________________
Antiphospholipid syndrome (ASA for thrombosis px)
[Recurrent pregnancy lost] is defined as ⬜ . What anatomical abnormality is a/w [Recurrent pregnancy lost]?
how is it managed?
[≥3 consecutive < 20WG spontaneous abortions]
_________________
Uterine septum (tx = hysteroscopic surgical resection)
What is shoulder dystocia? how does it present?
_________________
management? (6)
▶initial failure to deliver fetal ANT shoulder = OBSTETRIC EMERGENCY!
▶ fetal head retraction into perineum after head delivers
_________________
B.E. C.A.L.M.
Full term infant = 37 - 42 WG
shoulder dystocia is managed with the mnemonic [⬜ C.A.L.M.]
Describe the 5 Maneuvers used to manage shoulder dystocia
B.E. C.A.L.M.
_________________
◮Deliver [POST ARM]
◮[Woods Screw: rotate POST shoulder by applying pressure to [anterior POST shoulder]
◮[Rubin: ADDuct POST shoulder by applying pressure to [posterior POST shoulder]
◮[Gaskin: “all fours”]
◮[Zavanelli: convert to Cesarean]
Screening for gestational DM is done ⬜ WG
_________________
how is gestational DM screening done?
24-28WG
_________________
inadequate control of gestational DM ➜ ⬜ and ⬜
_________________
Tx for gestational DM? (4)
fetal macrosomia / shoulder dystocia
_________________
1st: diet
2nd: INSULIN
–(alternative)–> [glyburide vs metformin]
describe [menopause transition] (4)
_________________
What sx during menopause transition are c/f malignancy? (2)
- occurring over years before [true menopause (51 yo)],
- [DECREASING menstrual bleeding (amount and # of days)]
- [Longer Intermenstrual intervals]
- vasomotor sx
_________________
[INCREASED menstrual bleeding] or [shorter intermenstrual intervals] = [endometrial hyperplasia/CA] possible
Diagnostic criteria for this condition? (4)
Bacterial Vaginosis
- gray vaginal discharge
- amine odor after KOH application
- clue cells on wet mount
- vaginal pH >4.5
tx for this condition? (2)
Bacterial Vaginosis
- [metronidazole (PO or PV)]
- [Clindamycin (PO or PV)]
pregnant patient p/w symptomatic Bacterial Vaginosis
Do we treat her? why or why not?
YES - ONLY IF SYMPTOMATIC ; symptom relief
_________________
unclear if tx ⬇︎ obstetric complications (spontaneous abortion/preterm labor) from BV
In addition to ⬜ and ⬜, TDaP is 1 of the 3 vaccines safe during pregnancy
[influenza dead vaccine]IM
[anti-RhoD IG]
During pregnancy, when is TDaP given?
why is it given at this time during pregnancy?-2
[3T≥28]
TDaP given [3rd trimester ≥28WG] enables [maternal TDaP Ab] transferance thru placenta to baby
What are the absolute contraindications to combined OCP (7)
- [Migraine with aura (due to ⇪ stroke risk)]
- [SEVERE HTN ≥160/100]
- [SMOKING ≥15 cig/day]
- [Female age ≥35]
- Hypercoagulability (factor 5 leiden/antiphospholipid)
- [ACTIVE BREAST CA]
- [ACTIVE LIVER disease]
pregnant pt p/w asymptomatic bacteriuria
[Pregnant Asymptomatic bacteriuria requires abx treatment.]
Does [NONPregnant Asymptomatic bacteriuria] also require tx?
_________________
What are the 3 abx choices for Pregnant UTI?
NO TX<–(-PRG)–[Female Asx bacteriuria]–(+PRG)–> [CAF abx]
- [cephalexin x 5d]
- fosfomycin x 1
- [amox/clav x 7d]
* repeat urine culture 1 week after abx completion to test for cure*
* tx should be guided by culture susceptibility*
Why is Iron Deficiency anemia common during pregnancy? -2
_________________
What would you expect on Peripheral Blood Smear?
[⇪ iron demand] paired with inadvertent [inadequate maternal iron intake] —> [Pregnancy_IDA]
_________________
microcytic hypOchromic RBC
describe [early pregnancy of undetermined location]
_________________
management?
★ [early pregnancy of undetermined location] occurs when βhCG is 0-3500 = [βhCG discriminatory zone ≤3500]
★ ★ pregnancy cannot be located/visualized while in [βhCG discriminatory zone ≤3500]..
_________________
★ ★ ★ ➜{[repeat βhCG q48h] to determine if [INC of βhCG] is c/w normal pregnancy (normal = ≥35% βhCG INC every 48h)}
DDx for [Urge Urinary Incontinence] - 4
“Sudden urge to urinate all the time”
Detrusor hyperactivity 2/2
- UTI
- Estrogen deficiency (urethral closure –> ⬆︎intrabladder pressure –> urge)
- Multiple Sclerosis
- DM
“Sudden urge to urinate all the time”
What is the DDx for [Overflow Urinary Incontinence]-2
_________________
etx?-3
“Overflow of urine e/b involuntary dribbling”
- DM neuropathy
- mechanical obstruction
“Overflow of urine e/b involuntary dribbling”
a.“Overflow of urine evidenced by involuntary dribbling” ⼀comes from Overdistended bladder
b.{Overdistended bladder ⼀comes from [incomplete emptying (⇪PVR)]}
c.
-{[incomplete emptying ( ⇪ PVR)] comes from
1.⭐[DM ⬇︎Detrusor activity] vs
2.⭐[mechanical obstruction]}
What is [Genitourinary syndrome of menopause]?
Menopause ➜ VulvoVaginal atrophy ➜ pelvic organ prolapse / dyspareunia / [Urge Urinary Incontinence]
“Sudden urge to urinate all the time”
Tx for [Urge urinary incontinence] (3)
“Sudden urge to urinate all the time”
1st: [Timed Voiding bladder training] + [⬇︎ wt / smoking / etoh / caffeine]
2nd: [Oxybutynin vs Tolterodine (Anticholinergic)]
3rd: [BoTox vs perQ tibial nerve stimulation]
________________
detrusor HYPERactivity ➜ “Sudden urge to urinate all the time”
Women with Urinary Incontinence are recommended to restrict daily fluid intake to what amount?
[≤1.9L (or ≤64oz) /day]
[Intrinsic Sphincter deficiency] and [Urethral hypermobility] are a/w
[⬜ urinary incontinence]
Stress
“Stress transabdominal causes urine leakage!”
🧠“Stress transabdomnal(cough, laugh, lift, sneeze) causes urine leakage!” = [⊕Bladder Stress Test]
Indications for Pessary - 2
- [Pelvic Organ Prolapse(c/s surgery if good candidate)]
- [Stress urinary incontinence“Stress transabdominal causes urine leakage!”]
Tx for Stress Urinary Incontienence - 4
“Stress transabdominal causes urinary leakage!”
- URETHRAL SLING
- Kegel exercise physical therapy
- Vaginal pessary
- Bladder neck Injectable bulking if etx is related to sphincter deficiency
“Stress transabdominal causes urinary leakage!”
Adenomyosis CP - 3
- symmetrically enlarged TENDER uterus (> 12 weeks in size)
- [menstrual and INTERmenstrualMenorrhagia]
- Dysmenorrhea eventually –> Chronic Pelvic Pain
etx: glands invade uterine myometrium –> blood deposition inside myometrium during cycle –> dysmenorrhea from irregular contractions and menorrhagia from extra deposited blood
What are the risk factors for stress urinary incontinence secondary to pelvic floor weakening - 3
“Stress transabdominal causes urinary leakage!”
- Pregnancy/Childbirth
- Obesity
- Menopause
“Stress transabdominal causes urinary leakage!”
Diagnosed with Q-tip urethral hypermobility test
etx for Stress urinary incontinence - 3
“Stress transabdomnal(cough, laugh, lift, sneeze) causes Urine leakage!” = [⊕Bladder Stress Test]
due to:
- [⇪ Urethral mobility] (injury that weakens pelvic floor muscles | urethral prolapse → [⇪ Urethral hypermobility]
- or [bladder cystocele] can –> bladder prolapse –> vaginal bulge and incontinence)
- [⬇︎Urethral tone(menopause)]
Tx = Kegel excercises vs urethral sling
Most common causes of Intermenstrual bleeding - 5
“I’m seeing some spotting in between my periods”
- Adenomyosis
- Endometrial Polyps(nonpainful & light)
- Endometrial CA(Hyperplasia vs ADC, Older Female)
- Cervical PID
- Cervical CA
describe Fibroadenoma cp
In teen females,
[Upper/Outer SINGLE rubbery mobile breast mass]
that becomes PAINFUL PREMENSTRUATION
but
RELIEVED POSTMENSTRUATION
What are the sx of Breast Engorgement-4 ; When does this usually occur?
- b/l Breast Fullness
- b/l Breast Tenderness
- b/l Breast warmth
- No Fever
Usually occurs 3 days postpartum when colostrum is replaced with milk, but can occur anytime during breastfeeding
Tx = BREASTFEED, Cool compress, APAP, NSAIDS
How can you differentiate Breast Engorgement from Mastitis? ; How can you differentiate Breast Engorgement from Plugged Ducts?
- Breast Engorgement is BL without fever and Mastitis is uL WITH FEVER (Breast abscess is Mastitis with fluctuance)
- Breast Engorgement is BL and Plugged Ducts is uL
A Woman comes in with c/o breast engorgement (BL tender, swollen, firm) after she elected to not breast feed
How do you induce Lactation suppresion? - 3
- NSAIDs for pain/inflammation
- COMFORTABLE Bra that avoids nipple stimulation
- Cool Compress to breast
Engorgement in and of itself eventually –> Lactation suppresion on its own due to negative feedback! do NOT breast bind as this causes mastitis. Don’t use drugs to treat this.
What are the major risk factors for Breast CA - 8
- 1st degree relative with breast CA
- Prolonged estrogen exposure (menstruating outside of 12-52 y/o range vs utero DES vs HRT)
- Genetics (BRCA 1/2 mutation)
- Alcoholic
- Obesity
- Radiation
- Age 40-70 yo
- White
Average Menopause onset = 51
DDx for palpable breast mass - 5
[CCAFF]
- CA
-
Cyst
_________________ -
Abscess
_________________ - Fat necrosis of breast
- Fibroadenoma
What are the common side effects of OCPs - 6
- HTN
- Breast Tenderness
- ⬆︎TriAcylGlycerides
- Bloating with Nausea
- Breakthrough bleeding = most common (usually with lower estrogen doses)
- Venous thromboembolism (Migraine w/aura is a ctd for Combined OCPs)
Wt Gain is NOT a side effect of combined OCPs and OCPS actually ⬇︎risk of Endometrial and Ovarian CA
Why do women who’ve recently delivered and are breastfeeding have no menstrual cycles?
Elevated Prolactin (responsible for mammogenesis and galactogenesis) inhibits GnRH release –> anovulation and amenorrhea for ≤ 6 months
after 6 months, even with breastfeeding women will start to ovulate again and even before then, this is not a reliable form of contraception
patient p/w [Bilateral breast discharge with no lumps, LAD or nipple changes]
likely diagnosis?
_________________
List initial labs to order? -4
Explain rationale for each lab
Hyperprolactinemia is most common cause of galactorrhea
- PROLACTIN levels - Prolactinoma could –> Hyperprolactinemia
- TSH levels - hypOthyroidism could –> ⬆︎TRH & TSH –> Hyperprolactinemia since TRH stimuales prolactin release
- PREGNANCY test - Pregnancy could –> Hyperprolactinemia since TSH shares same α-subunit as bHCG
- MED REVIEW - D2 blockers/Antidepressants/Opioids all –> Hyperprolactinemia
Selective Estrogen Receptor Modulators (SERMs) are used for _______(indications)-3 ;
What are the main side effects of SERMs? - 3
- ⬇︎Breast CA risk
- adjuvant tx for Breast CA (Tamoxifen)
- Postmenopausal Osteoporosis (Raloxifene)
SIDE EFFECTS
A: Hot Flashes
B: Venous Thromboembolism (all estrogen agonist ⬆︎resistance to protein C)
C: Endometrial Hyperplasia/ADC
note: SERMs not only modulate estrogen receptors but they actually block estrogen binding competitively
Which substance actually exacerbates the cyclical bilateral pain associated with Fibrocystic changes of breast?
Caffeine
What’s the most common cause of unilateral breast discharge (serous or bloody)?
Intraductal Papilloma
CP of [Fat necrosis of Breast] - 4
- Firm mass after trauma
- IRREGULAR SHAPED mass
- overlying erythema
Mammogram: Oil cyst +/- calcifications that appear malignant but has fat globules and foamy macrophages on bx
Tx for lactational mastitis?-4
Tx =[KEEP BREASTFEEDING] + Dicloxacillin + Ibuprofen
drain via needle aspiration if abscess is present
tx for acute bacterial prostatitis -3
TMP-SMX
Cipro
[bladder decompression (via suprapubic catheterization)]
Pt p/w [>3 month dysuria + pelvic pain +/- ejaculatory pain]
how do you workup Chronic Prostatitis? (3)
________________
how do you interpret this workup? (2)
[UA/UCx before prostate massage] → prostate massage → [UA/UCx after prostate massage]
_________________
UA = [pyuria > 20]
+
{[ (cp/cpps) ⬅︎ ⊝} (UCx?) {⊕(bacteriuria ≥10 fold INC after prostate massage) ➜ CBP ]
✏️Urine Culture: [neg = cp/cpps] vs [bacteriuria > 10 fold increase = CBP]
[cp/cpps = Chronic prostatitis chronic pelvic pain syndrome]
[CBP = Chronic BACTERIAL Prostatitis]
how do you differentiate [Chronic prostatitis chronic pelvic pain syndrome] from [Chronic bacterial prostatitis]?
[Chronic Prostatitis chronic pelvic pain syndrome] will have NEGATIVE CULTURE
________________
> 3 month dysuria + pelvic/perineal pain
What is the cause of [Chronic prostatits chronic pelvic pain syndrome]?
________________
Tx?
UNKNOWN
________________
Prostate Enlargement Meds (alpha blockers)
pt p/w severe back pain 2/2 metastatic lesions from hormone-refractory prostate CA
Tx?
EBRT
________________
External Beam Radiation Therapy
Pregnant patients require 3 Prenatal Lab visits: [Initial] [24-8WG] [36-8WG]
_________________
Name the [36-8WG Prenatal lab]
Pregnant patients require 3 Prenatal Lab visits: [Initial] [24-8WG] [36-8WG]
_________________
List the 4 [24-8WG Prenatal labs]
24-8WG testing is performed due to [expanding RBC mass] and [insulin resistance from hPL secretion]
Pregnant patients require 3 Prenatal Lab visits: [Initial] [24-8WG] [36-8WG]
_________________
List all [15 INITIAL Prenatal labs]
“Mom needs to [BiPU⑥-⑤- 4③-②-1] before she can (Burp U)”
{BLOOD⑥ [Hgb|Hct|MCV|ferriTin|(RhoD type / Ab screen)]}
{ID⑤ [HIV|HBV|HCV|Syphilis|[chlamydia PCR (if risk factors)]}
(4 Prenatal LAB GROUPS)
{PX③ [Rubella immunity|Varicella immunity|Pap (if indicated)]}
{URINE② [Cx | dipstick protein]}
(1st Prenatal Labs)
___________________________x____________________________________
[HBV=HepB Surface Antigen] | [HCV=anti-HCV Ab] | [Syphilis=VDRL/RPR]
describe Gestational Thrombocytopenia
[2nd/3rd trimester] pregnancy, benign asymptomatic [thrombocytopenia< 70K] that spontaneously resolves after delivery
For laboring patients, what are the contraindications to [SENA (Spinal Epidural Neuraxial analgesia)] ?
platelet❌ (thrombocytopenia | rapid ⬇︎ platelet) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
this is because [SENA] in the setting of platelet dysfxn → ⇪ risk for [Spinal Epidural Hematoma]
When is it appropriate to diagnose a teenage boy with [“Delayed” boy puberty]?
lack of [testicle enlargement to GOE 4cc] BY 14 Y/O
_________________
obtain bone radiograph / FSH, LH, testosterone
PPROM = Preterm Premature Rupture Of Membranes before 37 WG
________________
What are 2 px therapies for PPROM?
- Progesterone{ PV ≤ [1st trimester] < IM }
- Cerclage
PPROM Complications = Chorioamnionitis/Endometritis/CORD PROLAPSE/Placenta Abruptio
What factors indicate ⬆︎ risk for possible Preterm labor? - 4
Full Term delivery = 37 - 42WG
1st best indicator: PRIOR PRETERM DELIVERY = STRONGEST INDICATOR
2nd best: [Short cervical insufficiency ≤ 2cm] per transVaginal US (or 2.5 if preterm hx present) - hx of cold knife conization?
3rd best: + Fetal Fibronectin BUT ONLY BETWEEN 20-37WG
4th best: Circumstantial (Smoking, multiple gestation, IVF, obesity)
Full term infant = 37- 42WG
How do you manage Preterm Labor 34 to 36+6 WG - 3
“Pregnant Bitches”
+
{(WW until 34WG delivery)unless [fetal compromise | infxn] → DELIVER STAT}
Full term infant = 37 -42WG
How do you manage Preterm Labor 32 to 33+6WG - 4
“Pregnant Bitches Take”
+
{(WW until 34WG delivery)unless [fetal compromise | infxn] → DELIVER STAT}
Full term infant = 37 - 42WG
How do you manage Preterm Labor < 32WG - 5
“Pregnant Bitches Take Money”
+
{(WW until 34WG delivery)unless [fetal compromise | infxn] → DELIVER STAT}
tx for Endometriosis - 5
- observation if asx
- NSAIDs 1st
- Contraceptive (OCP/IUD progesterone)
- Leuprolide (GnRH agonist that ⬇︎Endometrial gland estrogen stimulation)
- Hysterectomy with oophorectomy
Findings: Gun Powder Burn lesions, Adhesions, Chocolate fluid
Dx = Laparoscopy to biopsy endometriotic lesions
PPROM = Preterm Premature Rupture Of Membranes before 37 WG
________________
Name the 4 possible complications of PPROM?
Which is an Obstetric Emergency and how is it maanged?
PPROM patients are at ⇪ risk for
1. ⚠️[UMBILICAL CORD PROLAPSE = OBSTETRIC 911] : [tx = relieve cord compression ➜ Cesarean STAT]
________________
2.Chorioamnionitis
3.Endometritis
4.Placenta Abruptio
Describe the [Hypothalamic-Pituitary-Testicle] axis starting with [GnRH from hypothalamus]
________________
How does a Prolactinoma affect this axis?
Prolactin inhibits GnRH secretion from hypothalamus ➜ [⬇︎FSH/LH] ➜ [⬇︎ secondary sex characteristics (testicle size/facial hair/libido)]
How does Cervical Cancer present? -4
________________
What does Cervical Cancer in HIV+ patients indicate?
- [friable exophytic cervical mass]
- [irregular vaginal bleeding +/- mucoid vaginal dischage]
- postcoital bleeding
- ulcerative cervical lesions
________________
AIDS DEFINING ILLNESS
How do you work up new [Palpable Breast Mass]?
VesicoVaginal Fistula is a complication of ⬜ that presents how? _________________
name a subtle physical exam finding for small vesicovaginal fistulas
▶pelvic surgery ;
▶small vesicovaginal fistula from bladder to vagina ➜
{continuous nonpainful malodorous urine leak from Bladder To vagina
▶ [+/- red granulation (if small vv fistula)]}
_________________
When is a [repeat βhCG] indicated in pregnancy? (2)
1.pregnancy of undetermined location
2.{in pts with βhCG < 1500}
(→ warrants [repeat βhCG in 48 hours])
Whats the most frequent complication of TURP?
________________
TransUrethral Resection of Prostate
Retrograde Ejaculation
patient p/w balanitis (glans penis inflammation)
What else should they be worked up for? why?
DM ; Balanitis is a/w high blood glucose
[NSLP hCAT] is AKA Postpartum thyroiditis
[NSLP hCAT] etx (4)
[Nonpainful Subacute Lymphocytic Postpartum - hCAT]
🔲 autoimmune disorder (involves anti-Thyroid PerOxidase Ab = variation of hCAT) that
🔲 within a year of childbirth –> [brief nonpainful HYPERthyroid goiter] –>
🔲 [brief nonpainful hypOthyroid goiter (may require thyroid replacement if severe)]
🔲 –> Euthyroid back to normal
[Nonpainful Subacute Lymphocytic Postpartum - hCAT]
Tx for Hyperthyroidism during pregnancy? -3
________________
MAINTAIN MILD HYPERTHYROIDISM DURING PREGNANCY
by trimesters
1st = PropylThioUracil
2ND = METHIMAZOLE
3RD = METHIMAZOLE
________________
[PTU = Hepatotoxic] // [Methimazole = teratogenic during 1st trimester]
how is newborn heart disease related to gestational DM?
_________________
What is the prognosis for this? (2)
🍼newborns born from [gestational DM/maternal DM] have ⇪ risk for excess glycogen deposition in [fetal myocardium]
🍼→ thickened [fetal interventricular septum] = transient HOCM
🍼➜ [Tachypnea + Respiratory distress]
_________________
(once natural insulin levels start to normalize ➜ ⬇︎myocardial glycogen deposition)
even if newborn has transient HOCM sx… MOST SPONTANEOUSLY RECOVER BY 3 WEEKS
What are the recommendations regarding Exclusive Breastfeeding?
_________________
How does this change if newborn baby is losing weight ?
[Exclusive breastfeeding] SHOULD BE ENCOURAGED TO ALL.
_________________
Within 1st week of life there is [EXPECTED WEIGHT LOSS (≤ 10% from birth)] – so this should not stop [Exclusve breastfeeding]!
Primary amenorrhea is defined as ⬜ -2
[1° amenorrhea] =
[(13+ yof) with still No❌menstruation]
________or_________
[(15+ yofwith secondary sex ∆) with still No❌menstruation]
How do you workup Primary amenorrhea?
A postpartum pregnant patient p/w R facial droop
What should you tell her? (3)
PBP = Pregnant Bells Palsy
- Pregnant/Postpartum Patients have INC risk for PF7BP
- PBP tx = [CTS +/- acyclovir]
- PBP pgn = [full recovery ≤3 mo]
_________________
[PF7BP = Peripheral Facial CN7 Bells Palsy]
What is Priapism?
_________________
What are the common risk factors? (4)
[painful erection > 4h] 2/2 impaired penile blood outflow (out of corpora cavernosa) ➜ irreversible ischemic injury = MEDICAL 911
_________________
- PDE5 inhibitors
- [intracavernosal alprostadil injection]
- Trazodone
- Sickle Cell Disease
Priapism
treatment? (3)
[non-Rx ( urination, cold compress)] < sx 4h < [{Corpora Cavernosa aspiration} –(if sx persist)-→ {intracavernosal phenylephrine}]
Name the major risk factors for Recurrent UTI -4
- cystitis ≤ 15 yo
- Spermicide use
- New sexual partner
- Postmenopause
cp of Uterine Sarcoma -4
postmenopausal woman with new pelvic pain
uterine mass
ascites
metastatsis (pleural effusion)
________________
tx = hysterectomy
Lichen Sclerosus MOD
autoimmune chronic inflammation of [vulva, perineum and anal region] that affects [hypOestrogenic women (prepubertal and peri/postmenopausal)] and–> Vulva SQC
________________
THIS DOES NOT AFFECT THE VAGINA!
dx = vulvar punch biopsy
s/s Lichen Sclerosus - 5
- Pruritus SEVERE
- Dyspareunia
- White Grayish pale vulva (distinguishes from postmenopausal vaginal atrophitis)
- Cigarette paper texture vulva (thin, crinkled)
- loss of vulvar anatomy (introitus, labia minora, clitoral hood)
dx = vulvar punch biopsy
What are the main causes of Premature primary Ovarian Insufficiency? - 4
- natural Menopause
- Chemotherapy - targets rapidly dividing granulosa/theca cells
- Radiation - targets rapidly dividing granulosa/theca cells
- oophorectomy
Turner syndrome is the sex chromosomal disorder most likely associated with physical findings at birth
_________________
How does Turner Syndrome affect intelligence?
may cause [mild learning disability] BUT DOES NOT AFFECT OVERALL INTELLIGENCE
________________
Most turner syndrome fetuses miscarry within 1st trimester
Turner syndrome is the sex chromosomal disorder most likely associated with physical findings at birth
_________________
Describe the 5 [Comorbidity Screenings] for patients with Turner syndrome (5)
- [EENT ⼀(Strabismus, OME, hearing loss] =renal US
- [CV ⼀Aorta(Coarctation/Dissection (WORST WITH PREGNANCY)/Dilatation), CHD(bicuspid aortic valve), Metabolic Syndrome XDIVe] = 4EBP, EKG, echo, GET AORTIC IMAGING
- [Renal ⼀Horseshoe Kidney] =renal US
- [Bone ⼀Osteoporosis] =DEXA, 25OHvitD
- [autoimmune ⼀Celiac, hypOthyroid] =antI-TED, TSH⼀free T4
________________
- Most turner syndrome fetuses miscarry within 1st trimester*
- 4EBP: 4-Extremity BP*
Turner syndrome is the sex chromosomal disorder most likely associated with physical findings at birth
________________
Name all the sx of Turner Syndrome (20)
________________
[Learning disability WITH NORMAL INTELLIGENCE]
[Lymphedema congenitally of hands/feet from abnormal lymphatic system development]
Most turner syndrome fetuses miscarry within 1st trimester
[Turner syndrome] is the most SexCD a/w physical findings at birth
a.The most fatal comorbidity for Turner syndrome is ⬜.
b. Why does pregnancy INC risk of developing this comorbidity?
🔎SexCD = Sex Chromosomal Disorder
a. [Aortic DISSECTIONor rupture];
b. [pregnancy hormones weaken aortic wall + hyperdynamic state of pregnancy can → Aortic DISSECTION]
etx of PCOS
________________
What are the primary effects of this etx?-4
DM/Obesity–> Hyperinsulinemia which –> ⬆︎⬆︎⬆︎LH secretion –> [⬆︎⬆︎⬆︎ovarian theca Androgen secretion] = HAG ➜ PCOSAPES 🔎
1.[Androgen characteristics(acne, balding, hirsutism)]
2.[Polycystic Ovarieson US]
3.[Endometrial ADC]
4.[Sterile (infertiity)]
🔎
[ HAG (HYPERandrogenemia)] →
_________________
1.[Androgen characteristcs(acne, hirsutism, balding)]
2.{[Polycystic Ovarieson US] 2/2 [⬆︎Estrone (from ⇪ conversion of Androgen)] →(estrone neg feedback on hypOthalamus)–> ⬇︎GnRH → ⬇︎FSH → ⬇︎follicle maturation → (FOLLICLE ATRESIA) → Polycystic Ovaries and Ovarian enlargement}
3.[Endometrial ADC(FOLLICLE ATRESIA) also → ⬇︎progesterone → (io\unopposed Estrone) → endometrial ADC)]
4.[Sterile (infertility)(FOLLICLE ATRESIA → Anovulation = Amenorrhea = Sterile_Infertile)]
___________________________x____________________________________
tx = Wt loss ➜ SOCK
_________________
Note: if pt has high levels of sex hormone binding globulin, total testosterone may be low. so clinical dx may be necessary
Tx for PCOS - 5
[Wt loss–> SOCK]
SOCK:Spironolactone,OCP (1st line after wt loss),Clomiphene for infertility,Ketoconazole
________________
*etx: DM/Obesity–>Hyperinsulinemia which –> ⬆︎⬆︎⬆︎LH secretion –> ⬆︎ovarian theca Androgen secretion –> APES
Pathological gynecomastia comes from {[⇪estrogen] | [⬇︎Androgen] | [Rx]}
List the conditions that cause gynecomastia by [INC estrogen✳] (5)
✳*(either via ⇪ estrogen production or ⇪peripheral conversion of androgen to estrogen)**
✳*(either via ⇪ estrogen production or ⇪peripheral conversion of androgen to estrogen)**
Pathological gynecomastia comes from {[⇪estrogen] | [⬇︎Androgen] | [Rx]}
List the conditions that cause gynecomastia by [DEC androgen] (3)
Pathological gynecomastia comes from {[⇪estrogen] | [⬇︎Androgen] | [Rx]}
List the common Rxmedications (and explain how) they cause pathologic gynecomastia (5)
1.GnRH🟢(⬇︎androgen production )
2. Ketoconazole( ⬇︎androgen production )
- [5α reductase-inhibitor( ⬇︎peripheral conversion to DHT)]
- Spironolactone( androgen 🟥)
- Bialutamide( androgen🟥)
Rx = medication effect
Pathological gynecomastia comes from {[⇪estrogen] | [⬇︎Androgen] | [Rx]}
① the most common cause of pathologic gynecomastia in older men is ⬜.
_________________
② What is the MOA for this? (2)?
① Rx⼀Spironolactone
_________________
② Spironolactone has 2 MOA
- [aldosterone R blocker] for HFrEF
- [androgen R blocker] also, which ➜ [⬇︎androgen effect] ➜ pathologic gynecomastia in men
[spironolactone-induced pathologic gynecomastia] tx = switch to Eplerenone (has less androgen R blockade)
Rx = med effect
Pathological gynecomastia comes from {[⇪estrogen] | [⬇︎Androgen] | [Rx]}
① the most common cause of pathologic gynecomastia in older men is ⬜.
_________________
② what’s the treatment for the pathologic gynecomastia caused by this factor?
① Rx⼀Spironolactone
_________________
② tx = switch to Eplerenone (has less androgen R blockade)
Rx = Med effect
In terms of presentation, describe the 3 possible types of Male Breast Enlargement
Describe Physiologic Gynecomastia -4
-P hG is a benign glandular proliferation of male breast tissue occurring 2/2 [2 ⼀component hormone imbalance]
-especially in overweight/obese,
-1st component = [DEC testicular testosterone (with normal aging)]
and
-2nd component = [INC adipocyte (androgen → estrogen) (with Obesity)]
[T or F] History alone (i.e. phone consultation) is sufficient to diagnose acute uncomplicated cystitis, and can be treated empirically without urine culture
TRUE
_________________
physical exam is only required for complicated cystitis (fever, chills, flank pain, CVA TTP = pyelonephritis) and urine cx if initial tx fails
{[CAN Fosfomycin Control] Basic Uncomplicated Cystitis ??}
Turner = what 3 main clinical features?
Why does Turner syndrome cause Amenorrhea ?
SHORT
[AMENORRHEA1º > 2º] =Turner syndrome causes [streak ovaries gonadal dysgenesis] = 1º ovarian insufficiency
→ [DEC PiE and T (which DEC feed back on hypothalamus/ANT PIT)] → Elevated FSH & LH
_________________
PiE_T: Progesterone/inhibin/Estrogen _ Testosterone
[hyPOPUBERTAL (pubertal arrest I.e. Tanner3 instead of Tanner5 at 18yo)]
a. Explain why [Prolactinoma > 200 prolactin level] is a common cause of amenorrhea and infertility in Women
* * *
b. name the other manifestations of Prolactinoma (7)
a. ⇪ Prolactin suppresses GnRH → ⬇︎LH → ⬇︎E2 .
- No LH surge = no ovulation = amenorrhea and infertility
* * *
b. 📸
Prolonged Prolactinoma can → female osteoporosis
Tx for Prolactinoma (3)
{[Cabergoline v Bromocriptine(dopamine R agonist)] = inhibits prolactin secretion → ⬇︎Prolactinoma size}
–(if fails)–>
Surgery
How do you manage HIV in a newly pregnant patient?
________________
How is the newborn managed once it’s born?
MOM = [TRIPLE ANTIRETROVIRAL THERAPY] THROUGHOUT PREGNANCY
________________
newborn = Zidovudine ≥ 6 wks
________________
viral load/CD4 count labs q 3 months
At what HIV viral load count is Vaginal Delivery safe?
Vaginal Delivery ≤ 1000 HIV copies
________________
> 1000 copies = C Section
Full term infant = 37 - 42WG
How do you manage Preterm Labor < 32WG - 5
[(Pregnant(+azithromycin)) Bitches Take Money]
+
[Watchful Wait until 34WG Delivery *]
**Watchful Waitfetal surveillance until 34WG Delivery*(unless fetal compromise|infxn → STAT DELIVERY)
Full term infant = 37 - 42WG
Tocolytics are NOT used in managing Preterm Labor [(34 to 36+6) WG]
Why specifically is [IndomethicinTocolytic] not used? -2
[(Pregnant(+azithromycin)) Bitches]
- Premature closure of ductus arteriosus
- Oligohydramnios
Full term infant = 37 - 42WG
Tocolytics are NOT used in managing Preterm Labor [(34 to 36+6) WG]
Why specifically is [NifedipineTocolytic] not used?
[(Pregnant(+azithromycin)) Bitches]
Maternal hypOtension with reflex tachycardia
Full term infant = 37 - 42WG
Tocolytics are NOT used in managing Preterm Labor [(34 to 36+6) WG]
Why specifically is [Magnesium(as a Tocolytic)] not used?
[(Pregnant(+azithromycin)) Bitches]
Magnesium is a weak tocolytic so it doesn’t actually help with slowing contractions down in preterm delivery
When indicated, [neonatal (Group B Strep) prophylaxis] has 2 parts: PREpartum and POSTpartum
PREpartum: [neonatal GBS prophylaxis] abx (which consist of ⬜3 ) must be given ⬜ hours before delivery to be adequate!
[p|a|c] ; ≥4
________________
[p|a|c]= [pCN *or *ampicillin or ceFAZolin]
When indicated, [neonatal (Group B Strep) prophylaxis] has 2 parts: PREpartum and POSTpartum
POSTpartum: How do you complete [neonatal GBS prophylaxis] (3) ?
_________________
PRE**partum**:** must give [p|a|c**] abx [intrapartum ≥4h before delivery]
________________
[p|a|c]= [pCN orampicillin or ceFAZolin]
[Cell-free fetal DNA test] is routinely offered at prenatal screens [⬜ weeks gestation] to [⬜ patients] due to ⬜
________________
What does [Cell-free fetal DNA test] screen for? -4
≥10WG ;
[Advanced Maternal age > 35 yof] ;
[higher risk of chromosomal abnormalities in this group]
________________
PEDS
- [Pateau trisomy 13]
- [Edwards trisomy 18]
- [Down syndrome trisomy 21]
- [Sex Chromosome aneuploidies(Klinefelter, XXX)]
Select mode of Delivery (Vaginal | Cesarean) for [Dichorionic Diamniotic twins] positioned:
Vertex/Vertex
Vaginal
Select mode of Delivery (Vaginal | Cesarean) for [Dichorionic Diamniotic twins] positioned:
Vertex/BREECH (3)
[Cesarean (1a.if NPT too small ( < 1500 g ) or 1b.NPT too big ( wt ≥ 20% PT wt ) → Csxn)]
vs
2.{[Vaginal]- if (⊝CSxn criteria) and (⊕MDexperience)}
NPT:NonPresentingTwin |
PT: PresentingTwin
Select mode of Delivery (Vaginal | Cesarean) for [Dichorionic Diamniotic twins] positioned:
BREECH/Vertex
Cesarean
Select mode of Delivery (Vaginal | Cesarean) for [Dichorionic Diamniotic twins] positioned:
BREECH/BREECH
Cesarean
How does [GnRH agonist] help treat Leiomyoma?
GnRH agonist ➜ temporary amenorrhea ➜ ⬇︎Leiomyoma size and ⬇︎vaginal bleeding
how do you treat acute asthma exacerbation in pregnant patients?
same as non-pregnant asthma exacerbation except:
Oyxgen to SaO2 ≥95% (nonpregnant ≥90%)
short term CTS benefit > minor risk in pregnant patients
[Nausea/Vomiting in Pregnancy] ranges from mild to severe. Severe NVP is AKA ⬜
What’s sx discern [mild NVP] from [SEVERE NVP] -3
________________
How do you manage mild NVP? -3
SEVERE NVP = HYPEREMESIS GRAVIDARUM
________________
[Nausea/Vomiting in Pregnancy] ranges from mild to severe. Severe NVP is AKA ⬜
What’s sx discern [mild NVP] from [SEVERE NVP] -3
________________
How do you manage [SEVERE NVP]? -3
- SEVERE NVP = HYPEREMESIS GRAVIDARUM*
- ________________*
Pt (without previous DM) now with gestational DM delivers baby w/o complication
How do you manage her postpartum course? -2
d/c antiHyperglycemic therapy after delivery
➜ At [6-12 wk postpartum] = [2H oral glucose tolerance test] (due to ⇪ DM2 risk)
💡 2H(instead of 1H) is used during [gestational DM] POSTpartum course — to ensure resolution of gestational DM
Endometrial Polyps cause what type of vaginal bleeding?
intermenstrual vaginal bleeding
🧠other causes of intermenstrual bleeding= Adenomyosis, Endometrial CA, Cervical PID, Cervical CA
pt with Eisenmenger syndrome wants to get pregnant
What should you tell her? (2)
❌ [Eisenmenger syndrome] is a contraindication for Pregnancy since VSD/HF→ high maternal mortality rate and poor fetal pgn
❌[Eisenmenger syndrome] pregnancy should be avoided/terminated
What are the causes of Acute Cervicitis? -5
5 major signs of Acute Cervicitis?
- Asx
- Mucopurulent discharge
- Postcoital bleeding
- intermenstrual bleeding
- Friable cervix
Pregnancy requires 50% greater thyroid hormone requirements
________________
How does the body achieve this? -2
- 1st trimester, fetal βhCG stimulate maternal TSH receptors ➜ [⇪ maternal T3/T4 production] (but remember, this INC T3/T4 feed back on ANT Pit ➜ low TSH 1st trimester)
and
- elevated maternal estrogen ➜ [⇪ thyroxine binding globulin] ➜ [⇪ binding sites for T4 to travel on] ➜ [⇪ TOTAL (not free) maternal T4 available]
________________
(hypOthyroid patients wont be able to INC maternal T3/T4 production ➜ requires INC exogenous dose/Levothyroxine )
Describe [Simple breast cyst]
________________
benign fluid filled mass 2/2 breast duct obstruction
________________
patient is diagnosed with
“palpable breast mass”
Describe your workup -5
Describe the following contraception:
[LevonorgestrelProgestin IUD] (4)
1.[long & reversible]
2.Thickens cervical mucus( → blocks sperm entry)
3.[⬇︎menstrual bleeding(nml and anticoagulated pts) by thinning uterine lining]
4.used in pts with contraindication to estrogen OCP
Describe the following contraception:
Copper-containing IUD (5)
✔︎ [long & reversible]
✔︎ [toxic to sperm and ova(endometrial inflammation)]
✔︎ [Most effective Emergency Contraception(administer ≤5d from sexual intercourse)]
❗️⇪ menstrual bleeding
❗️ ⇪ dysmenorrhea
Describe the following contraception:
BL tubal Ligation (2)
▶NOT reversible (only indicated in pts finished with childbearing)
▶does NOT help menorrhagia
Ovarian torsion occurs in ⬜ women and presents with (⬜2 sx)
_________________
how do you diagnose this?
reproductive ; [uL pelvic pain + tender adnexal mass]
_________________
[Pelvic Ultrasound with color Doppler]
(will show enlarged edematous ovary with ⬇︎blood flow)
What are the sx of [Leiomyoma Fibroids] -4
enlarged irregularly shaped uterus
menorrhagia
dysmenorrhea
mass effect (constipation/pelvic pressure/urinary sx)
For Women who wish to preserve fertility:
What is the MOA for the 1st line tx of [Leiomyoma Fibroids]
_________________
Whats another tx for this?
[LevonorgestrelProgestin IUD] Reversibly induces endometrial atrophy ➜ thins uterine lining = [⬇︎ (leiomyoma fibroid) size] and [⬇︎ uterine bleeding]
_________________
[Combined OCP]
What are the recommendations regarding Bariatric Surgery and Pregnancy?
After Bariatric Surgery, Delay Pregnancy x 1 year to optimize wt loss and nutrition
patients with fetal growth restriction (defined as ⬜ ) are at ⇪ risk for ⬜
_________________
How is this managed?
[estimated fetal wt < 10th%tile for gestational age]; STILLBIRTH
_________________
[Serial Antenatal testing]
Describe purpose of [Percutaneous Umbilical Sampling]
high risk procedure that samples fetal blood to confirm severe fatal anemia (hydrops fetalis)
AFP is a protein found in the [⬜ fetal | Maternal] serum and made by the (⬜3).
It is obtained during pregnancy at ⬜ weeks gestation via ⬜
_________________
What constitutes as an elevated AFP?
Maternal;
[Fetal Yolk Sac] / GI /Liver
________________
15-20
________________
Quad BUAD screen
if AFP > 2.5 ➜ get anatomical US!
Name the causes of nonpregnant [Abnormal Uterine Bleeding]? -9
_________________
How do you treat ACUTE heavy nonpregnant[Abnormal Uterine Bleeding]?-3
in nonpregnant women
(PALM COINE)(see image)
__________________
- HDS*: [HIGH DOSE ESTROGEN combined OCP]
- NPO|Refractory*: [Estrogen IV]
- HDUS*: [D&C (surgical endometrial removal)]
🄴strogen [“_e_nlarges” (builds/fixes)] EMT ➜ hemostasis
Why is it common for adolescents to have [anovulation f/b irregular heavy menstruation], especially around menarche? (4)
▩a1. Menses normally occurs when corpus lutem(a byproduct after ovulation) produces 🄿rogesterone and when this 🄿 drops –> [Menses shedding].
▩a2. immaturity of [hypothalamic-pituitary-gonadal axis(common around menarche)] –> inadequate GnRH –> low FSH (although enough to stimulate 🅴strogen secretion) and low LH⭐( →anovulation)⭐
▩a3. NO ovulation –> No [corpus luteum🄿rogesterone] to (rise and fall) → [NO menses shedding]
▩a4. [NO menses shedding] io\ unopposed [EMT 🅴 “enlargement”] .. ➜ accumulated EMT (eventually) ➜ breakthrough bleeding = ⭐irregular heavy menstruation⭐
🔎EMT = Endometrum
“🄴strogen (_e_nlarges) EMT”(= proliferates and repairs EMT ➜ EMT growth & hemostasis)
_________________
“🄿rogesterone (_p_repares, _p_rotects, _p_eels) EMT” =
🄿Rise ➜ prepares EMT⼀for fertilized egg implantation via decidualization
🄿Level ➜ protects EMT ⼀from error during [estrogen-based enlargement]
🄿Fall ➜ peels EMT⼀ via sloughing ➜ [menses shedding]</sup>
_________________
Tx =
1. [Progestin-only|Combined OCPs]to supplement deficient 🄿
2. self-limited to 1-4y post menarche ___________________________x____________________________________
immaturity of hypothalamic-pituitary-gonadal axis –> inadequate amounts of GnRH –> low FSH and LH –> lack of ovulation –>No [corpus luteumprogesterone] for shedding = [No Menses = Anovulation] → eventually (because estrogen still proliferates/repairs Endometrium) [accumulated cycle-anovulation] eventually → estrogen breakthrough bleeding = irregular heavy
Which hormone induces prolactin production during pregnancy?
🅴strogen
🔎EMT = endometrium
“🅴strogen (_e_nlarges) EMT”(= proliferates but repairs EMT ➜ EMT growth & hemostasis)
What is Pubic Symphysis Diastasis?
What is the clinical presentation of this after a traumatic delivery? (4)
Physiological widening of pelvis by [🄿rogesterone and relaxin](to facilitate vaginal delivery)
✔︎ [POSTPartum suprapubic TTP] that
a.radiates to Back and/or Hips
b.worst with weight bearing, walking or position change
c.self-limited to 4 weeks POSTPartum
CP for Endometriosis - 6
“The 3Ds Isn’t All endometriosis”
- TTP along UteroSacral ligament
- Dysmenorrhea💊
- [Dyspareunia deep pelvisposterior cul-de-sac implants]💊
- [Dyschezia (painful defecation)posterior cul-de-sac implants]💊
OR
5.Infertility of unknown origin
OR
6.ASX🚫💊
“The 3Ds Isn All endometriosis”
Findings: [Gun Powder Burn* lesions], ADHESIONS–>immobile uterus, Chocolate fluid*
Dx = Laparoscopy to biopsy & remove endometriotic lesions
___________________________x____________________________________
▶{[🚫💊tx🚫] = no tx indicated}
▶{💊tx = [NSAIDs –> (combined OCP|IUD progesterone)]}
Tenderness along the uterosacral ligament should make you suspicious for what disorder?
Endometriosis
TTP along UteroSacral ligament
“The 3Ds Isn’t All Endometriosis”
Tx for Lichen Sclerosis
Clobetasol ointment (high potency topical CTS)
dx = vulvar punch biopsy
Ectopic pregnancy can be managed medically with methotrexate (⬜MOA) unless its contraindicated which ➜ Surgery instead
________________
What are the contraindications for MTX in ectopic pregnancy? -5
folic acid blocker
________________
- liver disease (DEC MTX clearance)
- renal disease (DEC MTX clearance)
- ruptured ectopic (free fluid in posterior-cul-de-sac)
- immunodeficiency
- high failure probability (fetal cardiac activity, βhCG>5000 )
the 2 diagnostic criteria for [ruptured ectopic pregnancy] are ⬜ and ⬜
_________________
How do you manage suspected ectopic pregnancy?
positive UPT
+
HDuS hemoperitoneum
_________________
What’s the most common side effect of combined OCP?
Irregular breakthrough bleeding
_________________
2/2 thin atrophic endometrium that sheds UNEVENLY
Oligohydramnios –> ⬜ sequence.
Name the 3 most common causes of Oligohydramnios
Oligohydramnios –> POTTER Sequence
- ARPKD
- BL Renal agenesis
- Obstructive Uropathy POSTERIOR URETHRAL VALVES are the most common cause of obstructive uropathy in newborn BOYS (which causes renal damage –> oligohydramnios during utero)
Oligohydramnios –> ⬜ sequence.
Describe this clinical presentation for this Sequence
Oligohydraminos –> POTTER Sequence
Pulmonary hypOplasia
[Oligohydraminos 2/2 RENAL FAILURE 2/2 RENAL AGENESIS/ARPKD/Obstructive Uropathy]ultimately → POTTER
[Twisted Face & Extremities]
Twisted Skin
Ears set low
RENAL FAILURE2/2 Renal AGENESIS/ARPKD/Obstructive Uropathy
What is often the cause of Early Decelerations on Fetal Heart Tracing
Head Compression of Fetus
these occur WITH contractions and no tx is required
what is subchorionic hematoma ?
_________________
management?
abnml blood collection between [Uterus chorion] and gestational sac that presents as 1st trimester bleeding or incidental US finding
_________________
Expectant (serial US for reassurance)
📝can result in placental dysfunction ➜ sPontaneous abortion/placenta abruptio/PPROM/preeclampsia/preterm labor/IUGR/IUFD
What are the potential complications of Subchorionic Hematoma? (6)
sPontaneous abortion/
placenta abruptio/
PPROM/
preeclampsia/
preterm labor/
IUGR/
IUFD
_________________
subchorionic hematoma can result in placental dysfunction and ➜ (above)
Emergency contraception should be offered within ⬜ days of unprotected intercourse.
⬜ is the most effective therapy and ⬜ is the most effective ORAL therapy.
_________________
Name all 5 options
5 ; [COPPER IUD] ; [UlipristalAntiProgestin]
In general, what’s the most effective Nonemergentcontraception overall?
_________________
MOA? (2)
[PSI(Progestin Subdermal Implant)r3 year]
_________________
progesterone
- thickens cervical mucus and ⬇︎tubal motility ➜ inhibits sperm migration
- ⬇︎ [FSH and LH secretion] ➜ stops ovulation
[PSI-Progestin Subdermal Implant (long-acting + reversible)]
Preeclampsia is typically diagnosed ____ weeks gestation. What is the exception to the rule?
GOE 20WG! ;
_________________
Since Preeclampsia is a possible complication of Hydatidiform mole ⼀and Hydatidiform mole may occur < 20WG ➲ Preeclampsia can be diagnosed < 20WG only when that Preeclampsia is a complication of Hydatidiform mole
“Hydatidiform Mole is HEAVY!”
PreEclampsia dx = [Gestational HTN + Proteinuria]
How do you clinically diagnose SEVERE PreEclampsia? - 9
PreEclampsia plusANY ONE OF THE FOLLOWING:
- Systolic > 160
- Diastolic > 110
- [refractory HA]+/- HYPERreflexia
- [scotoma vision ∆]
- [Pulmonary Edema (from ⬇︎albumin)]
- [RUQ OR Epigastric pain]
- [Doubling of LFTs]
- [Platelets < 100K]
- [Cr > 1.1 or doubled from baseline]
although not criteria, [SEVERE PreE] may also p/w HYPERreflexia
PreEclampsia –> SEVERE PreEclampsia –> HELLP and at anytime, Eclampsia is possible
What are the potential CP for Hydatidiform Mole? - 5
“Hydatidiform Mole is HEAVY!”
5.HEAVYPreeclampsia(Severe Preeclampsia)
4.HEAVYThyroid(HYPERthyrodism)
3.HEAVYVomiting(Hyperemesis Gravidarum)
2.HEAVYUterus (Uterus larger than expected gestational age but with regular countour)
⭐1. [HEAVYVAGINAL BLEEDING. ]⭐
HHIIGH LEVELS OF bHCG (> 100,000)
Most of the time this is caused by sperm implanting an EMPTY ovum
