APGO

Question 1

a 52 year old perimenopausal patient who is a smoker presents with irregular bleeding after intercourse. she has not had mensesfor 3 years and she has not seen a gynecologist for 10 years. a lesion is seen on the cervix. what do you do?

Question 2

PID is also known as […]

symptoms include:

Question 3

what is a common situation for which consent need not be obtained?

Question 4

Informed consent is unnecessary in an emergency situation if a delay in treatment would risk the patient’s health/life

Question 5

what vaccines cant you give to pregnant ladies?

Answer 5

what vaccines cant you give to pregnant ladies?

Question 6

depo-provera

Question 7

what is the number one killer in women? in a healthy woman with no symptoms and no risk factors, what is one thing they can do to help prevent this?

Question 8

what are the recommendations for starting pap smears?

Answer 8

begin pap smears at 21 regardless of sexual history.

Question 9

how does hpv cause cancer?

Question 10

risk factors for osteoporsis

Answer 10

1) early menopause
2) glucocorticoid therapy
3) sedentary lifestyle
4) alcohol consumption
5) hyperthyroidism (or overtreatment of hypothyroidism)
6) hyperparathyroidism
7) anticonvulsant therapy
8) vitamin D deficiency
9) family history of early or severe osteoporosis
10) chronic liver or renal disease.

Question 11

changes in thyroid hormone in pregnancy

Answer 11

thryoid binding globulin increases during pregnancy due to increased circulating estrogens. this causes an increase in total thyroxine. however, free thyroixine remains constant. T3 levels also increase however free T3 stays constant.

Question 12

how much weight should a pregnant lady gain?

Answer 12

underweight (BMI < 18.5 kg/m2) total weight gain 28 – 40 pounds

normal weight (BMI 18.5 – 24.9 kg/m2) total weight gain 25 – 35 pounds

overweight (BMI 25 – 29.9 kg/m2) total weight gain 15 - 25 pounds

obese (BMI > 30 kg/m2) total weight gain 11 - 20 pounds.

Question 13

what happens to the hematocrit during pregnancy?

Answer 13

both the plasma volume and the RBC mass increase. but the plasma volume increases more so the hematocrit goes down overall.

There is normally a 36% increase in maternal blood volume; the maximum is reached around 34 weeks. The plasma volume increases 47% and the RBC mass increases only 17%. This relative dilutional effect lowers the hemoglobin, but causes no change in the MCV.

Question 14

plasma osmolality is […] during pregnancy.

Answer 14

plasma osmolality is decreased during pregnancy.

The release of human chorionic gonadotropin during pregnancy may be responsible for a mild resetting of the osmostat downward that is responsible for a fall in the serum sodium concentration of about 5 meq/L

Question 15

what defects are caused by uncontrolled diabetes before pregnancy

Answer 15

neural tube defects
cardiovascular defects
genitourinary and limb defects have also been reported.

Question 16

lysosomal storage disease associated with azkenazi jews

Answer 16

tay sachs (gene frequency= 1/30 compared to 1/300 usually)

the most commonly inherited disease in general in this population is CF

Question 17

autosomal recessive diseases that are associated with azkenazi jews

Answer 17

Fanconi anemia, Tay-Sachs disease, Cystic Fibrosis, and Niemann-Pick disease are all autosomal recessive conditions that occur at an increased incidence in Jews of Ashkenazi descent.

Question 18

the most common genetic cause of retardation

Answer 18

fragile x syndrome

(down syndrome is often not inherited)

Question 19

non invasive screening for chromosomal abnormalities

Answer 19

Patients who desire non-invasive assessment of their risk for aneuploidy can have first trimester screen (a fetal nuchal translucency (NT) measurement and a maternal serum PAPP-A) and a second trimester quadruple screen. The sequential screen yields a 95% detection rate for Down syndrome at a 5% false-positive rate. The first trimester screen alone yields an 85% detection rate. The NT is the measurement of the fluid collection at the back of the fetal neck in the first trimester. A thickened NT may be associated with fetal chromosomal and structural abnormalities as well as a number of genetic syndromes. Since the fetus in this case had a thickened NT, this patient should be scheduled to have a detailed fetal ultrasound and echocardiogram at 18-20 weeks to rule out anomalies. A thickened NT is not associated with preeclampsia and growth restriction.

Question 20

screening recommendations for chromosomal abnormalities

Answer 20

American Congress of Obstetrics and Gynecology (ACOG) recommends that all patients be offered aneuploidy screening and invasive prenatal diagnosis as indicated.

Question 21

complications of gestational diabetes on the fetus

Answer 21

Shoulder dystocia
metabolic disturbances
preeclampsia
polyhydramnios
macrosomia
neonatal hypoglycema
polycythemia
hyperbilirubinemia
hyocalcemia
respiratory distress

Question 22

birth defect associated with valproate

Answer 22

Valproic acid use during pregnancy is associated with a 1 to 2% incidence of neural tube defects, specifically lumbar meningomyelocele. Fetal ultrasound examination at approximately 16 to 18 weeks gestation is recommended to detect neural tube defects. Other malformations have been reported in the offspring of women being treated with valproic acid and a fetal valproate syndrome has been described which includes spina bifida, cardiac defects, facial clefts, hypospadius, craniosynostosis, and limb defects, particularly radial aplasia. Case reports have associated prenatal exposure to valproic acid with omphalocele and lung hypoplasia.

Question 23

umbilical prolapse causes what kind of fetal heart rate patterns?

Answer 23

sustained decelerations.

Question 24

the stages of labor

Answer 24

First stage — The first stage refers to the interval between the onset of labor and full cervical dilatation. It has been subdivided into three phases according to the rate of cervical dilatation

Latent phase — The period between the onset of labor and the point at which a change in the slope of the rate of cervical dilatation is noted. It is characterized by slow cervical dilatation, and is of variable duration.

Active phase — This phase is associated with a faster rate of cervical dilatation and usually begins by 2 to 4 cm of cervical dilatation [8-10]. The active phase is broken down further into an acceleration phase, a phase of maximum slope, and a deceleration phase, but these subdivisions are rarely employed today.

Descent phase — Descent of the fetus usually coincides with the second stage of labor. Not all investigators accept the existence of a separate descent phase.

Second stage — The second stage of labor refers to the interval between full cervical dilatation (10 cm) and delivery of the infant.

Third stage — The third stage of labor refers to the time from delivery of the baby to separation and expulsion of the placenta.

Question 25

when mom is on magnesium for preeclampsia baby is at risk for […]

Answer 25

when mom is on magnesium for preeclampsia baby is at risk for respiratory distress because it interferes with muscle function and respiratory effort.

Question 26

a foul smell at delivery means what?

Answer 26

the infant may be septic- expect a lethargic, pale, febrile baby

Question 27

APGAR score

Answer 27

Appearance, Pulse, Grimace, Activity, Respiration

Question 28

other than timeframe, how can you differentiate postpartum depression from postpartum blues

Answer 28

ambivalence towards the newborn is more a symptom of depression

Question 29

risk factors for endometritis

Answer 29

prolonged labor
prolonged rupture of membranes
multiple vaginal examinations
internal fetal monitoring
removal of the placenta manually
low socioeconomic status
c section

Question 30

risk factors for postpartum depression

Answer 30

past history of depression
marital conflict
lack of perceived social support from family and friends
having contemplated terminating the current pregnancy
stressful life events in the previous twelve months
sick leave in the past twelve months related to hyperemesis, uterine irritability or psychiatric disorder.

Question 31

signs that baby is eating enough

Answer 31

3-4 stools in 24 hours
6 wet diapers in 24 hours
weight gain
sounds of swallowing.

Question 32

beta hcg in a normal pregnancy

Answer 32

should rise 50% every 48 hours until the pregnancy is 42 days old

Question 33

progesterone in an abnormal pregnancy

Answer 33

progesterone less than 5ng/ml suggests an abnormal or extrauterine pregnancy

Question 34

treatment for a suspected abnormal pregnancy

Answer 34

dilatation and curretage can be both diagnostic and theraputic. monitor the hcg for a week after and if it continues to rise, suspect ectopic pregnancy and treat accordingly.

Question 35

criteria for medical treatment of ectopic pregnancy

Answer 35

hemodynamic stability

non-ruptured ectopic pregnancy

size of ectopic mass <4 cm without a fetal heart rate or <3.5 cm in the presence of a fetal heart rate

normal liver enzymes and renal function

normal white cell count

the ability of the patient to follow up rapidly if her condition changes (reliable transportation, etc.)

Question 36

when can you treat an ectopic pregnancy medically (methotrexate)

Answer 36

when the patient satisfies the following:

hemodynamic stability
nonruptured ectopic pregnancy
size of ectopic mass <4 cm without a fetal heart rate or <3.5 cm in the presence of a fetal heart rate
normal liver enzymes and renal function
normal white cell count
the ability of the patient to follow up rapidly (reliable transportation, etc.)

Question 37

do abortions increase the risk of future miscarriages?

Answer 37

no.

Question 38

missed abortion

Answer 38

fetal demise without cervical dilatation or passage of products of conception

Question 39

patients with pulmonary hypertension are at […]% risk for death during pregnancy/labor.

Answer 39

patients with pulmonary hypertension are at 25-50% risk for death during pregnancy/labor.

similar stats are for aortic coarctation or aortic root problems in marfan’s

Question 40

should you treat bacterial vaginosis during pregnancy?

Answer 40

yes it increases the risk of preterm deliveries.

Question 41

screening for diabetes during pregnancy

Answer 41

This evaluation can be done in two steps, a 50-g oral glucose challenge test is followed by a diagnostic 100-g oral glucose tolerance test (OGTT) if initial results exceed a predetermined plasma glucose concentration.

low risk: are not routinely screened.

average risk: screening is performed at 24 – 28 weeks while t

high risk: (severe obesity and strong family history) screening should be done as soon as feasible.

Question 42

diagnosing appendicitis during pregancy

Answer 42

difficult to make in pregnancy because anorexia, nausea, and vomiting that accompany normal pregnancy are also common symptoms of appendicitis.

the enlarged uterus shifts the appendix upward and outward toward the flank, so that pain and tenderness may not be located in the right lower quadrant.

ddx includes- preterm labor, pyelonephritis, renal colic, placetal abruption, or degeneration of a uterine myoma.

diagnose with a graded compression ultrasound.

Question 43

complications of obesity in pregnancy

Answer 43

chronic hypertension, gestational diabetes, preeclampsia, fetal macrosomia, as well as higher rates of Cesarean delivery and postpartum complications

Question 44

two most common causes of anemia in pregancy and postpartum?

Answer 44

iron deficiency and acute blood loss.

Question 45

how do you detect fetal anemia?

Answer 45

middle cerebral artery peak systolic velocity. this is invasive

can also use doppler ultrasonography which is not invasive.

Question 46

fetal hydrops on ultrasound

Answer 46

Fetal hydrops is easily diagnosed on ultrasound. It develops in the presence of decreased hepatic protein production. It is defined as a collection of fluid in two or more body cavities, such as ascites, pericardial and/or pleural fluid and scalp edema. On occasion, when extramedullary hematopoiesis is extensive, there will be evidence of hepatosplenomegaly. Placentomegaly (placental edema) and polyhydramnios are also seen on ultrasound.

Question 47

when is rhogam usually given?

Answer 47

28 weeks gestation

Question 48

potential consequences of multiple gestation

Answer 48

prematurity has the most significant consequences as it is associated with an increased risk of respiratory distress syndrome (RDS), intracranial hemorrhage, cerebral palsy, blindness, and low birth weight. Intrauterine growth restriction, intrauterine death of one or more fetuses, miscarriage and congenital anomalies are all more common with multiple gestations, as are the complications of preeclampsia, diabetes and placental abnormalities.

Question 49

if a dead fetus remains in utero for 3-4 weeks it can cause a […]

Answer 49

if a dead fetus remains in utero for 3-4 weeks it can cause a coagulopathy from decresed fibrinogen levels

in this case maternal fibrinogen levels should be monitored to track the coagulopathy

Question 50

the definition of a prolonged latent phase of labor

Answer 50

>20 hours for nulliparas and >14 hours for multiparas, and may be treated with rest or augmentation of labor

Question 51

cytotec

Answer 51

misoprostol (PGE1)- helps to ripen the cervix and causes uterine contractions.

Question 52

fetal fibronectin test

Answer 52

this is a test to determine the likelihood of delivery within the next 2 weeks. it has a high negative predictive value and a low positive predictive value.

Fibronectin is an extracellular matrix protein that is thought to act as an adhesive between the fetal membranes and underlying deciduus. It is normally found in cervical secretions in the first half of pregnancy. Its presence in the cervical mucus between 22 and 34 weeks is thought to indicate a disruption or injury to the maternal-fetal interface. Fetal fibronectin is FDA approved for use in women with symptoms of preterm labor from 24 to 35 weeks and during routine screening of asymptomatic patients from 22 to 30-weeks gestation.

Question 53

side effects of calcium channel blockers

Answer 53

decreased uteroplacental blood flow

Question 54

the definition of labor

Answer 54

contractions that cause cervical change

Question 55

early decelerations are caused by […]

Answer 55

early decelerations are caused by head compression which causes vagal stimulation in the baby. This type of deceleration has a uniform shape, with a slow onset that coincides with the start of the contraction and a slow return to the baseline that coincides with the end of the contraction. Thus, it has the characteristic mirror image of the contraction

Question 56

when is the vibroacoustic stimulation test used?

Answer 56

Vibroacoustic stimulation is not indicated unless the NST is non-reactive.

Question 57

treatment for fetal hypoperfusion (as an aside how do you know the fetus is hypoperfused?)

Answer 57

a change in maternal position to left lateral position which increases perfusion to the uterus, maternal supplemental oxygenation, treatment of maternal hypotension, discontinue oxytocin, consider intrauterine resuscitation with tocolytics and intravenous fluids, fetal acid-base assessment with fetal scalp capillary blood gas or pH measurement.