ACOG Qs Flashcards
describe screening for gestational diabetes
- done at 24-28 wks in women w/o risk factors
- done at 1st prenatal appt for women w/risk factors (previous hx gestational DM, obese bmi>30, glucose metabolism issues
- screen with 50g oral glucose, diagnostic test w/ 75 g 2 hr oral glucose
OR
-75g 2 hour oral glucose challenge
def of labor
onset of contractions+cervical effacement and dilation
Latent phase Active phase
latent phase: 0 cm to 6 cm dilated active phase: 6 cm to 10 cm dilated
define the diagnosis of preeclampsia
-htn after 20 wks gestation -BP>140/90 2 times >4 hours apart -proteinuria: >300 mg/24 hour urine, protein/Cr>0.3, urine dipstick +1 OR -systemic signs: platelets <100K, Cr>1.1, LFTS 2x normal, pulmonary edema, visual or cerebral signs
pregnancy risk factors for developing preeclampsia
1-preeclampsia in prior pregnancy first pregnancy multiple gestation preeclampsia in 1st degree relative
what maternal past medical history increases the risk for preeclampsia?
renal disease chronic htn hypercoagulability diabetes mellitus obesity >40 years old lupus
complications of preeclampsia
-eclampsia-development of seizures -HELLP syndrome: hemolysis, elevate liver enzymes, low platelets (epigastric pain, malaise, nausea, headache in 3rd trimester) -placental abruption -stroke -renal damage -liver damage -ARDS
normal fetal heart rate
110-160 bpm
preeclamptic woman with 3rd trimester vaginal bleeding is likely due to?
placental abruption -signs on fetal heart tracing:tachycardia, sinusoidal heart rate pattern)
what occurs at these different MgSO4 levels in mEq/L 4-7 7-10 10-15 >15
4-7: therapeutic level 7-10: loss of DTRs (deep tendon reflexes) 10-15: respiratory depression (<12 breathes/min) >15: cardiac arrest
1st trimester vaginal bleeding differentials
what are the 3 cardinal signs of an ectopic pregnancy
amenorrhea
vaginal bleeding (1st trimester)
abdominal pain
gardnerella
- signs
- RX
gray white discharge
foul odor
ph>4.5
RX: metronidazole or clindamycin
what maternal medical condition is assoc with the highest rate of mortality
pulmonary htn, eisenmengers (R–>L shunt)
what is the management for pregnant women with cardiac diseases
- discuss terminating the pregnancy
- labor and delivery management
–early epidural to minimize cardiac stress
–forceps or vacuum assisted vaginal delivery to prevent valsalva while pushing
–fluid management: bc postpartum there’s massive venous return as vena cava is no longer impinged
management for renal disease in pregnant women
1st line-recommend termination of pregnancy
-inc risk of preeclampsia, gestational diabetes, htn
- evaluate for preeclampsia via
- baseline level of proteinuria (bc renal disease can cause proteinuria) vs new onset proteinuria
- uric acid levels: dec renal clearance–>buildup
- BP inc of > 30/15
pregnant woman experiences tachycardia, bulging eyes, diaphoresis…diagosis..RX
thyroid storm
- RX
- PTU/Methimazole-block production of T4, PTU also (-) peripheral conversion of T4–>T3
- B blockers-to slow HR
- dexamethasone (-) thryoid hormone production and periheral T4–>T3 conversion
- antipyretics
*
Pregnany woman with asthma, what should be given for
- mild asthma
- moderate asthma
- acute setting
mild asthma-SABA as needed
moderate-if SABA use is >2x per week give SABA+inhaled corticosteroids, cromolyn (mast cell stabilizer) if refractory
acute setting-systemic steroids (oral), terbutaline (B2 agonist)
can radioactive I131 be given to a pregnant woman in thyroid storm
No-bc it can cross the placenta causing neonatal hypothyroidism
pregnant woman with lupus. what are the complications
placental thrombosis->2nd trimester fetal loss
neonatal lupus-malar rash, heart block
***lupus can resemble preeclampsia
***perform serial fetal echos to determine risk of fetal heart block
what meds should be given to pregnant women with lupus
lovenox or heparin-to prevent placental thrombosis
aspirin-to prevent thrombosis
steroids-bc lupus is an autoimmune disease
for refractory lupus-cyclophosphamide
you suspect postpartum depression in a woman. what is your next step.
-
- evaluate for harm to self or baby
- prescribe an SSRI
SSRIs during pregnancy
- never give an SSRI to a person with a fam hx or diagnosis of Bipolar disorder bc it could provoke mania
- paroxetine contraindicated-causes pulmonary htn and cardiac malformations
name the different types of herpes infections
initial primary infection
-1st infection, symptoms severe, antibody (-)
initial non-primary infection
-1st infection, moderate severity, antibody (+)
recurrent infection
-recurrent symptoms, mild symptoms, antibody (+)
asymptomatic infection
at what wk do we induce women for elective c-sections and why
after 39 wks-to prevent prematurity
is vaginal bleeding in a perimenopausal woman with menopause symptoms a contraindication for hormone replacement therapy?
yes
-abnormal vaginal bleeding can be a sign of endometrial cancer, and HRT (estrogen) can worsen it. Must either perform a biopsy or US with endometrial stripe <4 mm to ok giving HRT
what amt of Ca is appropriate to give a postmenopausal woman
1200 mg Ca total
-With inc age there’s a decrease in bioavailable vit D, which dec Ca absorption
-
risks assoc with taking HRT (estrogen +progestin)
protective effects of HRT
- inc risk of breast cancer
- CV event: thromboembolism, DVT, PE, stroke
protective effects: dec risk of colon cancer and fractures
risks assoc with taking estrogen only for menopause symptoms
-estrogen alone causes inc risk of cv events (stroke, thromboembolism)
give estrogen to post menopausal women w/o a uterus
give estrogen+progestin to women with a uterus-to prevent endometrial hyperplasia
contraindications to taking hormone replacement therapy
Contraindications
Undiagnosed vaginal bleeding-could be endometrial cancer
Pregnancy
Breast cancer/endometrial cancer
Chronic liver disease
Hyperlipidemia
Recent DVT/stroke
Coronary artery disease
Recommendations of hormone replacement therapy
- <60 yrs, within 10 yrs of menopause
- only treat HRT with the smallest effect dose that affects daily life
- only treat if the pt has symptoms affect daily living, if they don’t then do expectant management (watch & wait)
for hormone replacement therapy
- estrogen only inc risk of
- estrogen+progestin inc risk of
estrogen only-no inc risk of breast cancer, inc risk of CV events
estrogen+progestin: breast cancer (so progestins are the culprits)
describe the source of estrogen pre and post menopausal
premenopause-ovaries
postmenopause-ovarian androgens converted in the periphery (fat tissue)
- after menopause ovaries stop making estrogen, but estrogen continues to be high bc ovaries make androgens that are converted into estrone by fat tissue
- body weight is directly proportional to estrogen levels
most common symptom of gestational trophoblastic diseases?
Vaginal bleeding
a woman has a molar pregnancy removed, her b-hcg after 2 months falls then rises again. Next step
-redo b-hcg 48 hrs later to determine the rate of rise. you don’t know if this is persistent trohoblastic disease or normal
a woman w likely molar pregnancy, if you suspect metastatic choriocarcinoma what is the next step
- do not biopsy bc choriocarcinoma is too vascular
- instead, do a chest xray (lung mets), liver labs (liver mets), brain mri (brain mets) before surgical D&C in case you need to
on pelvic exam you find a fleshy mass w/a stalk off the cervix. next step
polypectomy-you can confirm on pelvic exam a polyp. colposcopy is not done for polyps, it’s done for suspicion of cervical dysplasia and cancer
fibroids and pregnancy
- should fibroids be followed during pregnancy
- should fibroids be removed during pregnancy
- complications of fibroids during pregnancy
- no need to follow them during pregnancy bc most are asymptomatic
- fibroid removal (myomectomy) is contraindicated in pregnancy and during c-sections
- soft tissue dystocia and red (carneous) degeneration
a pregnant woman with fibroids becomes symptomatic. what is the process causing this.
Red (carneous) degeneration/necrobiasis
- venous thrombosis and
- symptoms: pelvic/abdom pain, fever, inc wbc count
-
which type of leiomyomas can affect implantation leading to pregnancy loss
submucosal and intracavitary fibroids
- disturb endometrial vasculature
- cause local inflammation
- secrete vasoactive sources
- Removal by hysteroscopic myomectomy can help improve pregnancy, but fibroids are an uncommon reason for miscarriage
in perimenopausal and menopausal women with vaginal bleeding what is the next step in management
endometrial sampling to rule out endometrial hyperplasia
mech of GnRH agonists play in treating fibroids
chronic GnRH use–>desensitize the pituitary via overstimulation–>dec estrogen and progesterone–>
- dec fibroid size
- amenorrhea->dec blood loss, improvement of anemia
GnRH agonists for fibroid RX. characteristics
- should only be used for a few months to dec fibroid size before surgery to improve anemia, and dec blood loss during surgery
- if you stop the drug the fibroid will start growing again at its original rate
- SE: hot flashes, last 1-2 months will on the drug
- who should use it: women close to menopause bc at menopause dec estrogen will cause the fibroid to shrink, women who will be undergoing surgical removal
surgical treatment options for fibroids
- myomectomy: for women who want to still have kids
- hysterectomy: for women done having kids
- uterine artery embolization: contraindicated in women who want kids
- endometrial ablation-contraindicated in women who want kids
what diagnostic test would help determine kallman syndrome
-olfactory challenge: bc mech of disease is failure of migration of GnRH releasing hormones from the olfactory bulb—.>dec CnRH–>dec estrogen and progesterone–> lack of primary and secondary sexual characteristics+anosmia
*diagnosis of exclusion
what other anomaly is associated with mullerian agenesis
renal anomalies
-should perform a renal ultrasound
what organs does a pt with mullerian agenesis have
have ovaries–>secondary sex characteristics present
no uterus, no cervix, no upper vagina->ends in a blind pouch
bluish color of the cervix…
Chadwicks sign-inc blood flow to the cervix=sign of pregnancy
critical elements of sexual characteristics development
weight: min of 85-106 pounds is need to start menses
optic exposure to sunlight
sleep
how does signif weight loss, excercise and anorexia lead to amenorrhea
anorexia causes HPO axis dysfunction by causing dec GnRH pulsatile secretion–>dec FSH, LH–>dec estrogen, progesterone->amenorrhea
**excercise induced ->normal FSH, low estrogen
-RX: gonadotropins: give FSH, LH. This is more effective than giving clomiphene
Infertility: pt with hx of PID. What diagnostic would be used to evaluate her
Hysterosalpingogram-xray that visualizes the uterus and fallopian tubes. PID can cause both uterine adhesions and blockage of the fallopian tubes
-if adhesions are found the perform hysteroscopy or laproscopy to remove adhesions
Infertility: pt with obesity, hirsutism can’t get pregnant after a year of trying. Which hormone will help aid in the dx?
Testosterone-high, due to inc lh>fsh ratio. Most other causes of infertility cause dec testosterone
Progesterone levels-imp after dx PCOS as low progesterone indicates anovulation.
infertiity: woman can’t conceive after 1 yr. She is bipolar and takes antipsychotics.
- what hormone is high?
- next step
Prolactin is high: antipsychotics=Dopamine antagonists which inc prolactin->(-) GnRH->(-) FSH, LH,–>dec estrogen, progesterone
- next step: change to a new drug
- if after changing to a new drug prolactin levels are still high then –>MRI to determine if
Infertility: Woman professional runner has hypothalamic amenorrhea and hasn’t been able to get pregnant for over 1 yr.
-RX
Gondadotropins (LH, FSH)
2nd line-Clomiphene:
can basal body temp be used to time intercourse to conceive?
NO!
- basal body temp rises 1 degree at ovulation, so it tells you you have already ovulated and the egg is viable for only 24 hours
- instead use an ovulation predictor kit
A G0P0 woman can’t get pregnant for >1 yr. She and her husband are both early with no prior STIs. next step?
-check male factor
–sperm
what 2 drugs can be used to induce ovulation for women with pcos
metformin-drug for DM, but also inc fertility
Clomiphene-SERM
colnonoscopy criteria
start at 50 yrs old
do either a colonoscopy every 10 yrs or guided sigmoidoscopy every 5 yrs
if they have risk factors: 1st degree relative with colon cancer before 60 yrs old then either start colonoscopy at 40 yrs old or 10 yrs before colon cancer diagnosis
When should a dexa scan be performed
dexa scan at age 65 or if risk factors then before
mom w/ hx of opioid abuse (merperidine) delivers a limp baby. next step in RX?
- give the baby PEEP and prepare to intubate
- wrong ans: suction and give naloxone-if mom used opiates this can cause lifethreatening neonatal withdrawal
APGAR SCORE
- Appearance
- pink (acyanotic)=2 - Pulse
>100=2
- Grimace
- cough, sneeze, pull away from suction=2
- grimace in response to nasal suction=1
- no response to nasal suction=0 - Activity
- move all 4 limbs=2
- weak tone=1
- flaccid=1 - R-respirations
- good breathing/crying=2
- slow, irreg breathing=1
- absent breathing
a baby is born vaginally. What are the immediate things to do in order
- place skin to skin contact with mom for thermoregulation, then light suction if needed
- do not oversuction (Delee) bc (+) the posterior pharyx (+) vagus–>bradycardia - 30-60 sec after birth clamp and cut umbilical cord
- dry off with a towel
Naegels rule for estimated due date
know your LMP, have regular periods
EDD=LMP-3 months+7days
For 1st trimester pregnancy wht is the best dating option
Ultrasound to measure crown rump length
hcg
- purpose
- describe its rate of rise
-purpose: maintains the corpus luteum until the placenta takes over at 8 wks
r-ate of rise: doubles every 48 hrs. if it plateaus or doesnt rise–>ectopic, miscarriage
-
urine hcg test
serum hcg test
- urine hcg test-qualitative, only tells you if you’re pregnant or not, hcg is present in urine by day 14
- serum hcg-quantitative, tells if you’re pregnant and hcg value, present in serum by day 6-9
-hcg peaks at 10 wks (100,000) then falls
what week can you prove that a pregnancy is not ectopic
week 6-yolk sac seen on TVUS
A D+C is being performed and fatty tissue is coming through the currette. Whats going on
omental fat w/possible accidental removal of bowel
-stop the D+C and perform laparoscopy to access the abdomen and look at the bowel for any signs of damage
Complications of vacuum vs forceps delivery
vacuum delivery
- cephalohematoma–>jaundice due to hemorrhage
- lateral rectus paralysis (temporary)
- neonatal scalp lacerations
forceps delivery
- maternal lacerations
- cn palsies
-
breech presentation
-types of breech
breech presentation
-management
before 37 wks–>nothing, bc baby is likely to move spontaneously into the vertex position
after 37 wks–>attempt external cephalic inversion (press on abdomen to get baby to move. better than internal cephalic version
-cant do this in active labor or if there are any anomalies/issues with the baby
if a woman is in active labor and the baby is breech what is the recommendation
recommend a c-section to dec risk of fetal complications
how do question stems discuss breech presentaton
ex: the sacrum is anterior
what is the #1 complication of tubal ligation
unplanned pregnancy–>1/3 of post-tubal pregnancies end in ectopics
cervical insufficiency
-RX
-painless cervical dilation causing loss of nonviable fetuses
RX: cerclage (McDonald procedure)-make a pursestring suture and the cervicovaginal junction to close the cervix.
cerclage must be removed at 37 wks or prior to labor
biggest risk factor for ectopic pregnancy
previous ectopic pregnancy>inflammation (PID), tubal surgery (tubual ligation), smoking (dec fallopian tube cilia
1st trimester bleeding differential and how to evaluate them
spontaneous abortion
normal intrauterine pregnancy w/implantation bleeding
ectopic pregnancy
-evaluate via b-hcg, transvaginal US
cardinal features of ectopic pregnancy
1st trimester vaginal bleeding
amenorrhea+other pregnancy signs
abdominal pain
ectopic pregnancy, what to do
- stable unruptured ectopic pregnancy confirmed
- ruptured ectopic pregnancy, unstable
-
- stable unruptured ectopic pregnancy confirmed–>salpingectomy/salpingostomy/methotrexate
- ruptured ectopic pregnancy, unstable-exploratory laparotomy first to identify and stop abdom bleeding
risk factors for ectopic pregnancy
- # 1 previous hx of ectopic pregnancy
- age btwn 35-44 yrs
- tubal surgery
- abdominal/pelvic surgery
- congenital uterine malformations
- inflammation (PID, endometritis)
consequence of septic abortions
- hemorrhage
- infections
RX for septic abortions
1-maintain bp–>give IV isotonic NS, maybe vasopressors
-MAP<65 means tissues are not being perfused
woman has a septic abortion and receives 48 hrs of antibiotics.
what is hematometra
blood collecting in the uterus
- cause : imperferate hymen, transverse vaginal septum, congenital cervical stenosis, can develop after an abortion
- symptoms: cyclical abdominal pain with a pelvic mass (blood)
when should a cerclage placed and when should it be taken out
placed at wk 14-to allow time to perform fetal assessments to check for chrom abnormalities etc.
removed-prior to labor at 37 wks
Lupus
- what does it often mimic in presentation
- rx for myalgias/serositis, rx for severe flare ups
- mimics HELLP syndrome
- rx for myalgia, serositis: nsaids
- rx for more severe flare ups: corticosteroids
Pregnant woman with n/v, abdominal pain
- diagnosis
- Which imaging to choose
Appendicitis
- Dx
1. Compression US-show a “non-compressible tubular blind ended structure”
2. MRI-if findings are inconclusive on US.
-
- congenital varicella-is less likely to occur if mom is infected in the 1st>3rd trimester. sx: limb hypoplasia, cns defects, cutaneous scar in dermatome pattern
- neonatal varicella-greatest risk of developing this right before delivery, baby can then dev varicella zoster
- contracting varicella during preg doesn’t change the mode of delivery (vaginal or c section)
RX: acyclovir 5x/day for 7 days
pelvic pain, urinary frequency, urgency, dysparunia
interstitial cystitis-chronic bladder inflammation, assoc with autoimmune diseases, endometritis…
in evaluating treatmnet options for pelvic pain, what is the biggeest predictor of treatment response
depression
2 most common non-gyn reasons for chronic pelvic pain
irritable bowel syndrome
interstitial cystitis
pelvic fullness, heaviness that extends to the vagina, vulva
pelvic congestion syndromes-dilation, stasis, and congestion of pelvic veins
- unknown cause
- standing for long periods, coitus, fatigue
