Case Files Flashcards
What are 3 physical findings that may be present in a patient with stress incontinence?
1) hypermobile urethra
2) cystocele
3) loss of urethrovesicle angle
What is the first line treatment for stress incontinence (2)?
Kegel exercises and timed voiding
Provide the mechanism, history, diagnostic tests, and treatment for stress incontinence?
Mechanism - bladder neck no longer intra-abdominal
History - painless urine loss with increased abdominal pressure, no urge to void
Tests - physical exam, loss of bladder angle
Treatment - urethropexy or sling
Provide the mechanism, history, diagnostic tests, and treatment for urge incontinence?
Mechanism - over-active detrusor
History - urge component
Tests - cystometric exam
Treatment - anticholinergic meds to relax detrusor
Provide the mechanism, history, diagnostic tests, and treatment for overflow incontinence?
Mechanism - over-distended, hypotonic bladder
History - Loss of urine with valsalva. DM or neuro injury
Tests - Postvoid residual
Treatment - self-cath
Provide the mechanism, history, diagnostic tests, and treatment for fistula wrt incontinence?
Mechanism - bladder/ureter communication with vagina
History - constant leakage. recent surgery
Tests - retrograde dye injected into bladder
Treatment - surgical repair
Comment on the approach to a female patient age 13-18 in for a well woman exam. Touch on cancer screening, immunizations, common diseases, and most common cause of death.
1) Cancer screen: Pap smear 3 yrs after sexual activity
2) Immune: Tetanus booster, Hep B vaccine, HPV vaccine between 9-26
3) Diseases: Depression
4) Most common: MVA
Comment on the approach to a female patient age 19-39 in for a well woman exam. Touch on cancer screening, immunizations, common diseases, and most common cause of death.
1) Cancer screen: Annual pap after 21 or 3 yrs post coital. 2-3 yrs after 30 if 3 consecutive normal tests.
2) Immune: Tetanus q10y, HPV vaccine between 9-26
3) Diseases: CVD
4) Most common: Malignant neoplasms, accidents
Comment on the approach to a female patient age 40-64 in for a well woman exam. Touch on cancer screening, immunizations, common diseases, and most common cause of death.
1) Cancer screen: Pap. 50: FOBT, colonoscopy q10y, mammography q1y.
2) Immune: Tetanus q10y, 50: influenza q1y, 60: varicella
3) Diseases: 45: Cholesterol q5y, BG q3y, 50: TSH q5y
4) Most common: Cancer, CVD
Comment on the approach to a female patient age 65+ in for a well woman exam. Touch on cancer screening, immunizations, common diseases, and most common cause of death.
1) Cancer screen: No Pap. FOBT, colonoscopy q5y, mammography q1y.
2) Immune: Tetanus q10y, pneumococcal, influenza q1y
3) Diseases: cholesterol q5y, BG q3y, BMD at 65
4) Most common: CVD
What are the signs of placental separation in the 3rd stage of labour (4)?
1) gush of blood PV
2) lengthening of umbilical cord
3) uterus rises in abdomen
4) uterus is firm
How long should the 3rd stage of labour last? What should be attempted if the placenta is still retained thereafter?
1) 30 mins
2) manual removal
What implantation site of the placenta is most likely to result in uterine inversion? What is the risk of uterus inversion?
1) fundus
2) PPH and shock
How should uterine inversion be treated (4)?
1) Ensure patient stable - large bore IVs and fluids
2) Uterine relaxation agents - halothane, terbutaline, magnesium sulfate
3) Manual or surgical reduction
4) initiation of uterotonic agents (oxytocin) to prevent PPH
What are the symptoms of ovarian failure resulting in low estrogen that are experienced during perimenopause and menopause (4)?
1) irregular menses
2) vasomotor symptoms - hot flashes
3) vaginal atrophy
4) bone loss
What would a hormone level look like in a post-menopausal woman wrt FSH, LH, and estrogen
1) high FSH and LH
2) low estrogen
What are some risks associated with estrogen-progestin treatment (4)?
1) CVD
2) Breast cancer
3) PE
4) stroke
What is Sheehan Syndrome? What structure is affected?
PPH causes hemorrhagic necrosis within the anterior pituitary. Cannot breast feed and will not ovulate due to lack of gonadotropin stimulation.
With respect to the first stage of labour, define latent phase, active phase, protraction of active phase, and arrest of active phase
1) latent phase - cervical effacement occurs, cervical dilation up to 4cm
2) Active phase - cervical dilation from 4cm to full. 1.2cm/hr in nulli, 1.5cm/hr in multi
3) protraction of active phase - dilation occuring slower than expected
4) arrest of active phase - no dilation with 2hrs.
What are the three types of fetal heart rate decelerations. What does each indicate, when do they occur wrt uterine contractions.
1) Early - mirror image of uterine contractions, represent fetal head compression
2) Variable - sharp decline and rebound, represent cord compression. Occur during contraction.
3) Late - occur after contraction, concerning, indicate fetal hypoxia.
What is the typical latent phase in nulli and multi women?
Nulli - less than 18-20 hrs
Multi - less than 14 hrs
What is the typical rate of the active phase in nulli and multi women?
Nulli - >1.2cm.hr
Multi - >1.5cm/hr
What is the length of the second stage of labour in nulli and multi women?
Nulli - less than 2 hrs (or 3 hrs if epidural)
Multi - less than 1 hr (or 2 hrs if epidural)
What is the upper limit of the 3rd stage of labour in nulli and multi women?
30 mins for both.
What constitutes clinically adequate uterine contractions? How can the assessment change with the insertion of a intrauterine pressure sensor?
1) clinical: q2-3m, strong on palpation, 40-60sec duration
2) Pressure sensor: 200 montevideo units in 10 min span
What does the hCG threshold refer to? What is its significance?
1) hCG level at which gestational sac should be visible via U/S (1500-2000)
2) No gestation sac on U/S after threshold reached indicates highly probable ectopic
What is the lowest acceptable increase in hCG in 2 days during early pregnancy? How can a progesterone level be used to differentiate intrauterine pregnancy vs non-viable pregnancy?
1) Must increase by 60% in 2 days
2) Progesterone >25ng/ml -> normal intrauterine gestation
3) Progesterone less than 5ng/ml -> nonviable pregnancy (SA vs ectopic)
In cases where SA or ectopic is suspected, how can they be differentiated from each other?
Do curettage of uterus. If villi present, then SA. If no villi present, then ectopic.
What is the medical management for asymptomatic, small ectopic pregnancy?
IM methotrexate
Differentiate placenta accreta, increta, and percreta
1) Accreta - Abnormal adherence, defect in decidua basalis, villi attached to myometrium
2) Increta - abnormal penetration into myometrium
3) Percreta - abnormal penetration into serosa and possibly bladder.
What are the risk factors for placenta acreta (5)?
1) placenta previa
2) Implantation in lower uterine segment or anterior lie
3) Previous C/S
4) Uterine curettage
5) Down’s syndrome fetus
What is the best management for placenta acreta? What is a suboptimal option and why is it attempted?
1) Hysterectomy
2) Cord ligation and methotrexate. Preserves fertility.
What are the SSx of Gonorrhea and Chlamydia (3)?
1) Cervicitis (endocervical inflammation)
2) Post coital bleed
3) Mucopurulent discharge (more common with chlamydia)
What is the approriate treatment for gonorrhea and chlamydia. How are they diagnosed?
1) Perform gram stain on discharge. If gram negative diplococci, then gonorrhea. Otherwise it is chlamydia.
2) Gonorrhea treatment: Ceftriaxone 125-250mg IM and treat prophylactically for chlamydia with Azithromycin 1g orally or doxycycline 100mg orally BID for 7-10 days.
3) Chlamydia: Treat as above (don’t treat for gonorrhea)
What are some risk factors for salpingitis (pelvic inflammatory disease) (3)?
1) IUD
2) past chlamydia or gonorrhea infection
3) Instrumentation or surgery through cervix into the uterus
Which STI can cause a pharyngitis with oral sex?
Gonorrhea
Which STI can cause a disseminated presentation with painful pustules on the skin?
Gonorrhea
Which STIs can cause blindness in a newborn?
Gonorrhea and Chlamydia
Provide the history, viability, and treatment for a threatened abortion. Is the cervix open? Has tissue passed?
Hx - vaginal bleed Viability - 50% Tx - U/S and hCG monitoring Cervix - closed Tissue passed - none
Provide the history, viability, and treatment for an inevitable abortion . Is the cervix open? Has tissue passed?
Hx - vaginal bleeding, cramping Viability - None Tx - Observation or D&C Cervix - open Tissue passed - none
Provide the history, viability, and treatment for an incomplete abortion. Is the cervix open? Has tissue passed?
Hx - vaginal bleeding, cramping Viability - None Tx - D&C Cervix - open Tissue passed - yes
Provide the history, viability, and treatment for an complete abortion. Is the cervix open? Has tissue passed?
Hx - vaginal bleeding, cramping previously Viability - None Tx - Follow hCG to zero Cervix - closed Tissue passed - yes, all
Provide the history, viability, and treatment for a missed abortion. Is the cervix open? Has tissue passed?
Hx - None Viability - None Tx - Observation or D&C Cervix - closed Tissue passed - none
What is a molar pregnancy? What are the signs (5)? How is it treated (3)?
1) Molar - trophoblastic tissue with no embryo or fetus
2) SSx - vaginal spotting, no fetal heart tones, size greater than dates, elevated hCG, snow storm appearance on U/S
3) Curettage, monitor hCG following curettage, chemotherapy if persistent
How is an incompetent cervix differentiated from an inevitable abortion? How is it treated?
1) incompetent cervix open without cramping and pain
2) Cerclage
An abortion refers to loss of fetus below what gestational age? What are the 2 most common causes of antepartum hemorrhage after these dates?
1) 20 wks
2) Placenta previa and abruption
What are common movements used in shoulder dystocia (5)?
1) McRoberts Maneuver (flex maternal thighs against abdomen to rotate pubic symphysis anteriorly)
2) Suprapubic pressure (attempt to rotate fetal shoulder)
3) Wood’s corkscrew (rotate posterior shoulder 180)
4) delivery of posterior arm
5) Zavanelli maneuver (replace head, C/S)
What clinical sign is seen in shoulder dystocia?
Turtle sign
When should shoulder dystocia be suspected?
Fetal macrosomia, GDM.
What are risks associated with shoulder dystocia and the manipulative practices to correct it (3)?
1) Post partum hemorrhage
2) Brachial plexus injury (Erb’s palsy)
3) Fetal hypoxia
What are the three locations where ureteral injury occurs during TAH and why?
1) transection of cardinal ligament (ureter passes under uterine artery)
2) Ligation of ovarian vessels in the infundibular ligament
3) Ureteral entry to the bladder, occurs when the vaginal cuff is ligated at the end of the TAH.
What are the steps in treating a ureteral injury following damage during a TAH (3)?
1) IVP to assess obstruction
2) IV ABx
3) Cystoscope with stent passage
What clinical signs (2) post-op would increase suspicion of ureteral ligation? What is the main complication?
1) Fever and Flank pain
2) Pyelonephritis
How sensitive is an endometrial biopsy at detecting endometrial cancer?
90-95%
What is the most common cause of postmenopausal bleeding? What is the cause?
1) Atrophic endometrium
2) low estrogen
What is an endometrial stripe? What is its significance?
1) Transvaginal U/S of endometrial thickness
2) >5mm is abnormal in postmenopausal patients
What is the concern with postmenopausal bleeding? How often will a patient presenting with a bleed have this disease?
1) Endometrial cancer
2) 20%
What is the major risk factor for the development of endometrial cancer? What are the other risk factors (9)?
1) Unopposed estrogen
2) Early menarche, late menopause, obesity, chronic anovulation, estrogen-secreting tumors, estrogen only OCPs, HTN, DM, Fam Hx of breast or ovarian cancer
What is the most common female genital tract malignancy?
endometrial cancer
How is endometrial cancer staged
1) Surgically (TAH BSO, omentectomy, lymph node samples, peritoneal washing)
What is protective against endometrial cancer?
Smoking
What are the two main causes of antepartum (20+ wks GA) bleeding? How are they differentiated clinically?
1) Placenta previa and placenta abruption
2) Previa is painless, abruption is painful (contractions)
What is the first step in the work-up of a suspect placenta previa bleed? What exams should not be done initially?
1) Do U/S
2) Don’t do speculum or digital exam
How is placenta previa managed? What is the method of delivery?
1) Expectant management (allow fetal lung maturation)
2) C/S
What are the risk factors for placenta previa (4)?
1) Multiple gestation or grand multiparity
2) Prior C/S
3) Prior curettage
4) Previous placenta previa
What is the risk of a vaginal delivery in a patient with placenta previa? Why?
1) PPH
2) Lower uterine segment has poor contractility
What should be done when placenta previa is noted in the early second trimester?
1) Observation
2) May resolve via transmigration as gravid uterus grows
What are the complications that can occur in placenta abruption (4)?
1) Hemorrhage
2) Fetal to maternal bleeding
3) Coagulopathy
4) Preterm delivery
What is the effectiveness of U/S in Dx placenta abruption and placenta previa?
Good in placenta previa, Bad in placenta abruption
What are the risk factors predisposing a mother to placental abruption (9)?
1) HTN
2) Cocaine
3) Short umbilical cord
4) Trauma
5) Uteroplacental insufficiency
6) Submucous leiomyoma
7) Sudden uterine decompression (AROM)
8) Cigarette smoking
9) PPROM
What is a clinical sign of placenta abruption (2)? What are the post partum risks (3)?
1) Pain and PV bleed
2) Uterine atony, PPH, Coagulopathy
What is the managment for placenta abruption? What is the preferred method of delivery? What medical management should be used for HTN in the post partum period?
1) Delivery
2) C/S
3) MgS for seizure prophylaxis
What are risk factors for cervical cancer (8)?
1) Early age of coitus
2) STDs
3) early childbearing
4) Low SES
5) HPV
6) HIV
7) Cigarette smoking
8) Multiple partners
The HPV vaccine guard against which strains of HPV and what diseases are these strain associated with (4)?
HPV 16 and 18: 50-70% of cervical cancer cases
HPV 6 and 11: genital warts
What are two signs suggestive of cervical cancer?
1) Abnormal pap
2) Post coital spoting
What is the next step following an abnormal pap finding?
colposcopy with biopsy
How is cervical cancer treated? Differentiate earl from late treatment therapies
1) Early: Surgery (hysterectomy) vs radiation
2) Late: Radiation (brachytherapy and teletherapy and Chemo (platinum-based)
What is Sheehan’s syndrome?
Hemorrhagic necrosis of the anterior pituitary following a post partum hemorrhage
What is Asherman’s syndrome?
Damaged / scarred decidua basalis of the endometrium, thus rendering it unresponsive.
Define post partum hemorrhage wrt vaginal and c-sections.
Vag: 500 ml loss, C/S 1,000 ml loss.
What is the first test that should be performed in a patient with amenorrhea?
Pregnancy test
Provide a DDx for amenorrhea (4)
1) Sheehan
2) Asherman
3) Hypothalamic cause - hypothyroid, hyperprolactinemia
4) PCOS
What are some characteristics of PCOS (5)?
1) High estrogen state, unopposed
2) Amenorrhea
3) Obesity
4) Hirsutism
5) Glucose intolerance
In a hypoestrogenic woman, how can hypothalmaic/pituitary cause be differentiated from ovarian failure?
FSH high in ovarian failure, low otherwise.
What are the anterior pituitary hormone levels and the response to OCP (progesterone withdrawal) in Sheehan’s and Asherman’s?
Sheehan - low hormones, positive for bleed
Asherman’s - Normal hormones, negative for bleed
In the case of a multiparous woman with one past C/S, what are two events that can cause significant and concerning fetal bradycardia?
1) Cord prolapse
2) Uterine rupture
What are the causes of hyperprolactinemia (8)?
1) Drugs (TCAs)
2) Hypothyroidism
3) Pituitary cause (adenoma)
4) Hyperplasia of lactotrophs
5) Empty sell syndrome
6) Acromegaly
7) Renal disease
8) Chest surgery or trauma
Explain the mechanism by which primary hypothyroidism can lead to galactorrhea and amenorrhea.
1) TRH and TSH high as trying to stim thyroid
2) TRH acts to also release prolactin
3) Prolactin causes galactorrhea
4) Prolactin inhibits cyclical GnRH, thus decreasing estrogen and progesterone cycles.
How is hyperprolactinemia treated?
Bromocriptine (Dopamine agonist). Safe during pregnancy.
What is the DDx for pruritus in pregnancy (3)?
1) Cholestasis of pregnancy
2) PUPPP - pruritic urticarial papules and plaques of pregnancy
3) Herpes gestationis
What are the SSx (5) and Tx (3) for cholestasis of pregnancy? What is the mechanism?
1) mechanism: accumulation of bile salts that are deposited into the dermis
2) SSx: no rash, 3rd trimester start, extremities more affected, may have jaundice, prematurity or fetal loss
3) Tx: antihistamines, cornstarch bath, ursodeoxycholic acid
What are the SSx (3) and Tx (2) for PUPP of pregnancy? What is the mechanism?
1) Mechanism: unknown
2) SSx: begins on trunk, erythematous urticarial plaques and papules, no affect on fetus
3) Tx: topical steroids and antihistamines
What are the SSx (4) and Tx (1) for PUPP of pregnancy? What is the mechanism?
1) Mechanism: autoimmune
2) SSx: pruritic bullous disease, 2nd trimester, small vesicles and tense bullae, risk of IUGR and stillbirth
3) Tx: oral corticosteroids
What is on the DDx with pelvic inflammatory disease (7)?
1) pyelonephritis
2) appendicitis
3) cholecystitis
4) diverticulitis
5) pancreatitis
6) ovarian torsion
7) gastroenteritis
What are the common organisms causing PID (3)?
1) Chlamydia
2) Gonorrhea
3) Anaerobic bacteria
What are the 3 clinical signs of PID?
1) Abdominal tenderness
2) Cervical motion tenderness (dypareunia)
3) Adnexal tenderness
4) May have F/N/V
What is Fitz-Hugh Curtis syndrome as it relates to PID?
Perihepatic adhesions
What is the outpatient management for PID (2)? What are the criteria that must be met for outpatient management (4)?
1) IM Ceftriaxone or 10-14d oral doxycycline BID
2) low-grade fever, no peritoneal signs, tolerance of medication, patient compliance.
What are the criteria for inpatient management (5)? What is involved in inpatient management (2)?
1) Failure of outpatient mgmt, pregnant, extremes of age, intolerance to oral meds, high fever/peritonitis
2) IV Cefotetan and IV or oral doxycycline
- if failure, then laporoscopy to evaluate disease
What is the appropriate treatment of a tubo-ovarian abscess? What is a potential complication?
1) Anaerobic coverage - clindamycin or metronidazole
2) Rupture - a surgical emergency
What are the long-term complications of PID (3)? How does IUD and OCP affect risk?
1) chronic pelvic pain, infertility, ectopic pregnancy
2) IUD increases, OCP decreases
What are two factors that increase PE risk in pregnancy? What is the preferred diagnostic work-up?
1) High estrogen is procoagulable and venous stasis due to gravid uterus
2) CT or MR angiogram of lungs
What are the normal values of pH, PO2, PCO2, and HCO3 in pregnancy?
1) ph 7.45
2) PO2 95-105
3) PCO2 28
4) HCO3 19
What is a clinical signs of PE? What is seen on blood gas? What is seen on CXR?
1) Dyspnea and pleuritic chest pain
2) Hypoxemia
3) Clear CXR
What is the treatment for PE in pregnancy?
1) IV anticoagulation for 5-7 days
2) Subcut heparin for 3 months (aPTT 1.5-2.5)
3) LMWH for remainder of pregnancy and 6wks post-partum
What are the signs of a herpes simplex virus prodrome (3)?
Burning, tingling, itching in perineal area
What is the major complication of neonatal herpes infection? What are 2 methods of transmission?
1) Neonatal encephalitis
2) fluids or secretions in the genital tract with labour
3) Transplacentally in the antepartum period
When is a vaginal delivery acceptable? When is a C/S recommended?
1) Vaginal - no lesions, no prodromal symptoms
2) C/S - lesions or prodromal symptoms
What can a leiomyoma transform into? What are the signs indicating this transformation (2)?
1) Leiomyosarcoma - malignant, smooth muscle tumor
2) Rapid growth over 1 year, radiation exposure is a RF
What is red degeneration of a leiomyoma? What causes this?
1) Center of fibroid becomes red (blood)
2) Due to rapid growth
What is the most common clinical sign of leiomyoma?
Menorrhagia
What type of leiomyoma is most likely to affect fertility?
Submucosal
What are findings of a leiomyoma on physical exam (5)?
1) Irregular
2) Midline
3) Firm
4) Non-tender mass
5) Moves with cervix
What are the medical treatments for leiomyomas (3)?
1) NSAIDs
2) Progestin
3) GnRH agonist (short-term only, shrink pre-operatively)
What are the surgical options for leiomyoma treatment (3)?
1) Hysterectomy - future pregnancy not desired
2) Uterine Artery Embolization - hyalinization of fibroid, fertility sparring
3) Myomectomy - fertility sparring, C/S in future is endometrium disrupted during excision.
Define gestational hypertension, preeclampsia, eclampsia, and superimposed preeclampsia.
1) Gestational HTN - HTN after 20 weeks GA, no proteinuria
2) Preeclampsia - HTN after 20 weeks GA, proteinuria (>300mg in 24h)
3) Eclampsia - seizure disorder associated with preeclampsia
4) Superimposed preeclampsia - preeclampsia on top of pre-existing HTN.
What are two clinical findings needed for the Dx of preeclampsia, differentiate severe and mild presentations.
1) Mild - BP >140/90, two independent measurements. Proteinuria >300mg in 24h, or 1 or 2+ on dipstick
2) Severe - BP >160/110, two independent measurements. Proteinuria >5g in 24h, or 3 or 4+ on dipstick. Symptoms.
What are the symptoms of preeclampsia (9)?
Headache, Vision changes, Hyperreflexia, proteinuria, pulmonary edema, coagulopathy, IUGR, Oligohydramnios, Increased liver enzymes
What are the complications of preeclampsia (5)?
1) Placental abruption / insufficiency
2) Eclampsia
3) Coagulopathy
4) Renal failure
5) Hepatic hematoma/rupture
What are the risk factors for preeclampsia (8)?
1) Nulliparity
2) Extremes of age
3) Black
4) Hx of preeclampsia
5) HTN
6) Renal failure
7) DM
8) Multifetal gestation
The risk of eclampsia (seizures) is greatest in labour and 24 hrs following delivery, what is the best anticonvulsant used to minimize seizure risk?
Magnesium Sulfate
What is the management for preeclampsia? Contrast preterm and term treatment.
Term - MgS and delivery
Pre-term - expectant if mild disease, MgS and delivery if severe disease.
Vaginal delivery possible in each case.
Severe preeclampsia may also be treated with what medications (2)?
Anti-HTN: labetalol and hydralazine
What are the characteristics on palpation of fibrocystic breast changes (3)?
1) Multiple changes
2) irregular
3) Lumpy breast
What is the clinical presentation of fibrocystic breast changes (4)?
1) Population: premenopausal women
2) Painful, engorged breast
3) Cyclically, worse before menses
4) May have serous or green discharge
What is the treatment for fibrocystic breast changes (5)?
1) Decrease caffeine
2) NSAIDs
3) Tight-fitting bra
4) OCPs (mixed or progestin only)
5) If severe: antiestrogen therapy, mastectomy
What is the clinical presentation of a fibroadenoma (4)?
1) Population: 20s
2) Firm and rubbery
3) Mobile
4) Does not change with cycle
What is the appropriate work-up for a fibroadenoma?
Biopsy with FNA or core needle biopsy
What are the two most common causes of bloody nipple discharge? What is the appropriate work-up?
1) Intraductal papilloma (benign)
2) Malignancy
3) Ductal exploration
What are the 5 factors to consider when approaching infertility?
1) Ovulatory
2) Uterine
3) Tubal
4) Male factor
5) Peritoneal factor (endometriosis)
What is the Hx, Test, and Tx used when working-up ovulatory factor as a potential cause of infertility?
Hx - irregular menses, obesity
Test - Basal Body Temp
Tx - Clomiphene citrate
What is the Hx, Test, and Tx used when working-up Uterine disorder as a potential cause of infertility?
Hx - fibroids
Test - hysterosalpingogram
Tx - hysteroscopic procedure
What is the Hx, Test, and Tx used when working-up Male factor as a potential cause of infertility?
Hx - Hernia, varicocele, mumps
Test - Semen analysis
Tx - Repair defect, IVF
What is the Hx, Test, and Tx used when working-up Tubal disorder as a potential cause of infertility?
Hx - Chlamydia or Gonorrhea
Test - Hysterosalpingogram
Tx - Laparoscopy, IVF
What is the Hx, Test, and Tx used when working-up Peritoneal (endometriosis) factor as a potential cause of infertility?
Hx - dysmenorrhea, dyspareunia, dyschezia
Test - Laparoscopy
Tx - Ablation of ectopic tissue
What is the timing, location, associated symptoms, and treatment of appendicitis as a cause of abdominal pain during pregnancy?
Timing - Any trimester
Location - RLQ or Right flank
AS - N/V, anorexia, leukocytosis/fever
Tx - surgical
What is the timing, location, associated symptoms, and treatment of cholecystitis as a cause of abdominal pain during pregnancy?
Timing - After 1st trimester
Location - RUQ
AS - N/V, anorexia, leukocytosis/fever
Tx - surgical
What is the timing, location, associated symptoms, and treatment of ovarian torsion as a cause of abdominal pain during pregnancy?
Timing - After 14 wks GA
Location - Unilateral, abdominal/pelvic
AS - N/V
Tx - surgical
What is the timing, location, associated symptoms, and treatment of Placental abruption as a cause of abdominal pain during pregnancy?
Timing - 2nd and 3rd trimester
Location - Midline, persistent
AS - PVB, NRFHT
Tx - Delivery
What is the timing, location, associated symptoms, and treatment of Ectopic pregnancy as a cause of abdominal pain during pregnancy?
Timing - 1st trimester
Location - unilateral pelvic/abdominal pain
AS - N/V, syncope, spotting
Tx - surgical, methotrexate
What are the clinical signs associated with ectopic pregnancy (5)?
1) Abdominal or adnexal pain and tenderness
2) Amenorrhea of 4-6 weeks
3) Irregular vaginal spotting
4) Tachycardia, hypotension, orthostasis
5) If rupture - shoulder pain, syncope
What are risk factors predisposing a woman to an ectopic pregnancy (5)?
1) Salpingitis/tubal adhesion/tubal surgery/congenital tubal abnormality
2) Infertility
3) IUD
4) prior ectopic
5) Induction of ovulation
Provide 3 approaches to diagnosing an ectopic pregnancy.
1) hCG > 1500, no gestational sac on U/S
2) Serial hCG rise of less than 66% in 48 hours
3) Progesterone level
Provide 3 treatments for ectopic pregnancies along with their indications and impacts.
1) Salpingectomy - for large or ruptured ectopics, impacts fertility
2) Salpingostomy with serial hCG - large ectopic, no rupture, preserved fertility
3) Methotrexate wth serial hCG- IM injection, ectopic less than 4cm, preserves fertility
What HgB value is considered anemic in pregnancy? What is the most common type of anemia in pregnancy? What tests can confirm the type of anemia in pregnancy (3)?
1) Less than 105
2) Iron deficient
3) MCV, ferritin, electrophoresis
What is another type of microcytic anemia that may be discovered in pregnancy? What is the mechanism of this disease and the impact on the fetus? How should the fetus be treated?
1) Thalassemia (beta)
2) MOA: deficient peptide production for globin molecule
3) Fetus with b-thalassemia major will suffer failute to thrive as fetal HgB decreases after birth. Transussion is treatment.
What is the mechanism of sickle cell disease? Is it AD or AR? What a SSx (4)?
1) MOA: point mutation of b-globin chain
2) AR
3) SSx: SOB, fatigue, pain (vaso-occlusive disease), IUGR and perinatal mortality
What are two types of macrocytic anemia, which is more common in pregnancy?
1) B12 deficiency
2) Folate deficiency (more common)
What population is more affected by G6PD deficiency? What drugs cause a hemolytic event in pregnanct when affected by this disease?
1) Blacks
2) Nitrofurantoin (also sulfonamides and antimalarial agents)
What are the SSx of HELLP syndrome (3)? What are the lab findings? What is the Tx?
1) Anemia, jaundice, thrombocytopenia
2) Hemolysis, elevated liver enzymes, low platelets
3) Delivery
What drugs are given to advance fetal lung maturity in cases of preterm labour?
Antenatal steroids - betamethasone or dexamethasone
What is preterm labour? How can it be defined in a nulliparous woman?
1) Labour between 20 and 37 weeks GA
2) Nulli in preterm labour if uterine contractions with 2cm cervical dilation and 80% effacement before 37 weeks.
What are the risk factors for preterm labour (8)?
1) PPROM
2) mulitple gestations
3) previous preterm labour
4) Hydramnios
5) Uterine anomalie/cervical cone biopsy/abdo trauma
6) Cocaine use
7) Black
8) Pyelonephritis
What is given to reduce the risk of preterm delivery when preterm labour is suspected?
Provide tocolytics and work-up causative agent for preterm labour
Provide the mechanism of action, side effects, and contraindications for the use of MgS as a tocolytic
1) MOA: competitive inhibition of calcium
2) SE: pulmonary edema
3) CI: MI, heart block, diabetic coma
Provide the mechanism of action, side effects, and contraindications for the use of terbutaline as a tocolytic
1) MOA: B-agonist, relaxes uterus
2) SE: pulmonary edema, high pulse pressure, tachycardia
3) CI: Arrythmia, HTN
Provide the mechanism of action, side effects, and contraindications for the use of Nifedipine as a tocolytic
1) MOA: inhibits Ca influx into sm muscle
2) SE: CHF, MI, pulmonary edema
3) CI: Hyptonesion
Provide the mechanism of action, side effects, and contraindications for the use of indomethacin as a tocolytic
1) MOA: Decreases PG synthesis
2) SE: closure of fetal ductus arteriosus. oligohydramnios 3) CI: 3rd trimester
Provide the mechanism of action, side effects, and contraindications for the use of 17-a-hydroxyprogesterone caproate as a tocolytic
1) MOA: progesterone replacement
2) SE: Breast pain and tenderness
3) CI: undiagnosed vaginal bleeding
What STI is associated with preterm delivery?
Gonorrhea
What are the 3 most common organisms that cause cystitis? What are the symptoms of cystitis (4)?
1) E. Coli, enterobacter, klebsiella
2) dysuria, urgency, frequency, possible hematuria
What Abx’s can be used to treat UTIs in pregnancy (4)? What should be avoided?
1) TMP/SMX, Nitrofurantoin, Ciprofloxacin, Cephalosporins
2) Doxycycline
What 3 organisms cause urethritis? When should you suspect urethritis instead of cystitis?
1) Chlamydia, Gonorrhea, Trichomonas
2) SSx of UTI, sterile culture or no response to Abx
What is the Yuzpe regimen? How is Plan B different?
Yuzpe - 2 OCP pills at 0hr, and 2 pills at 12hr
Plan B - Progestin only, two pills, one at 0hr, one at 12hr. Less N/V
What are the failure rates in 1yr for the following methods of contraceptives: nothing, rhythm, diaphragm, condom, pill/path/ring, Depo, IUD, femal and male sterilization
1) None - 85%
2) Rhythm - 25%
3) Diaphragm - 16%
4) Condom - 15%
5) Pill etc - 8%
6) Depo - 3%
7) IUD - 0.1-0.8%
8) Sterilization - 0.15-0.5%
Provide the mechanism, best use, and contraindications for OCPs
1) Mechanism - inhibits ovulation, thickens cervical mucous, thins endometrium
2) Use - dysmenorrhea, endometriosis
3) CI - thrombotic risk, migraine with aura, old smoker, liver disease
Provide the mechanism, best use, and contraindications for Progestin only pills
1) Mechanism - thickens cervical mucous, thins endometrium
2) Use - breast feeding
3) CI - patient compliance
Provide the mechanism, best use, and contraindications for Depo
1) Mechanism - inhibits ovulation, thickens cervical mucous, thins endometrium
2) Use - Sickle cell, epilepsy, long-term effect
3) CI - Osteoporosis, wt gain
Provide the mechanism, best use, and contraindications for IUDs
1) Mechanism - thickens cervical mucous, thins endometrium(progesterone). Inhibits sperm, damages ovum (copper)
2) Use - dymenorhea, endometriosis, long-term reversible
3) CI - Current STI or PID, Wilsons disease, unexplained vaginal bleed
What is the clinical presentation of pyelonephritis in pregnant women (6)? What are the lab results (2)? What is the most common causative agent?
1) Dysuria, frequency, urgency, CVA tenderness, F/C, N/V
2) Labs - pyuria and bacteriuria
3) E Coli
What is the appropriate treatment for pyeolonephritis in pregnancy (2)?
1) Cephalosporins or Ampicillin and Gentamicin - IV
2) Suppressive therapy for remainder of pregnancy on oral Abx
What should be suspected if pyelo not improving in 48-72 hrs (2)?
1) ureterolithiasis
2) Abscess
What is a serious sequelae of pyelonephritis in pregnancy? What are the clinical signs (4)? What is the causative agent? What is the treatment?
1) Acute respiratory distress syndrome (ARDS)
2) hypoxemia, large A-a gradient, lung infiltrates, threat of preterm labour
3) Endotoxin of gram-negative cell wall
4) Supportive - O2 and careful fluid mgmt
What factors increase the DVT risk in pregnancy (3)?
1) Stasis - caused by gravid uterus
2) Hypercoagulable - more clotting factors, estrogen
What are the signs of a DVT (3)? What is the first step in work-up
1) Muscle pain, deep linear cords in the calf, swelling of lower extremity
2) Doppler
How is a confirmed DVT managed in pregancy (3)?
1) IV heparin first 5-7 days
2) Subcut heparin for 3 months, aPTT of 1.5-2.5
3) Prophylactic heparinization for remainder of pregnancy and 6 wks postpartum
What are 2 side effects of long-term heparin use?
1) Osteoporosis (Vit K involved in bone metabolism)
2) thrombocytopenia
What is the most important risk factor in considering malignancy of a breast mass?
Age
Explain breast screening for women 20-39, 40-49, and 50+
20-39 - monthly self-exam, breast exam every 3 yrs
40-49 - monthly self-exam, breast exam yearly, mammogram every 2 yrs
50+ - annual mammography
What types of biopsies exist for breast masses, when is each indicated?
1) FNA, core needle biopsy (stereotactic), Excisional biopsy
2) Test depends on risk of BCa, and presence of palpable mass
The presence of BRCA increases the risk of which cancers? When should genetic screening be offered?
1) Breast and ovarian
2) If 2 first degree relatives affectede (autosomal dominant!)
What is seen of imaging of a dermoid cyst? What is used to view this lesion? What is the main complication? What is the appropriate treatment?
1) Cystic-solid
2) U/S
3) Ovarian torsion
4) ovarian cystectomy
What determines the malignancy of a teratoma? What is the treatment?
1) Immature neural elements
2) USO is early. USO and chemo if advanced or peritoneal seeding.
What is a stuma ovarii? What can they cause? What is the appropriate treatment?
1) teratoma with thyroid thissue
2) hyperthyroidism, 10% are malignant
3) Cystectomy, USO
What is the most common ovarian epithelial tumor? What is the largest? What is a common clinical sign? What is an appropriate tumor marker? What is the appropriate treatment?
1) Serous
2) Mucinous
3) Ascites
4) Ca 125
5) Chemo and surgical staging
What is the approach to ovarian masses inn the reproductive years? How does the approach change based on size?
1) Less than 5cm - likely functional cyst (follicular, corpus luteal, theca lutein). Observe
2) 5-8cm - U/S. If simple, observe. If complex, resect
3) >8cm - operate, likely tumor
What differentiate wound evisceration from fascial disruption?
Protrussion of omentum or bowel
What is the appropriate treatment for wound separation?
Open wound and drain. Broad sepctrum Abx. Secondary closure or primary closure days later.
What is the appropriate treatment for fascial disruption?
Repair and broad-spectrum Abx
What are risk factors for fascial disruption (8)?
1) DM
2) Vertical incision
3) Obesity
4) Infection
5) Cough
6) mal-nutrition
7) Abdominal distention
8) Steroid use
What is the treatment for evisceration?
Closure and broad spectrum Abx
When is fascial disruption or evisceration likely to occur in the PO period?
5-14 days
What are two causes of hemoperitoneum in a woman?
1) Ruptured ectopic
2) Ruptured corpus luteal cyst
What are the SSx of a ruptured corpus luteal cyst (3)?
1) Shock
2) Lower abdominal pain
3) Hemoperitoneum
How is rupture luteal cyst diagnosed? How is it treated? What treatment must be provided if removed within the first 12 weeks of pregnancy?
1) Laporoscopy
2) Removal
3) Exogenous progesterone
What is the first sign of shock?
Decreased urine output
What is the cause of asherman syndrome?
1) Damage to endometrium. Most often after D&C. Postpartum period and following a missed abortion are highest risk periods.
What are the methods for investigating Asherman Syndrome? What is the treatment (3)?
1) Hysteroscopy (gold standard), hysterosalpingogram
2) Operative hysteroscopy, insertion of IUD or Foley post-op, OCPs to preserve endometrium.
What are the mammographic findings suggestive of breast cancer (4)? What is warranted?
1) mass
2) speculated and invasive borders
3) distorted architecture
4) Asymmetric tissue density
5) Biopsy the mass
What can mimic the findings of breast cancer on mammography and is caused by trauma to the breast?
Fat necrosis
What are the two most common causes of primary amenorrhea in an individual with appropriate breast development?
1) Mullerian agenesis
2) Androgen insensitivity (testicular feminization)
Comment on breast tissue, pubic hair, uterus and vagina, testosterone level, karyotype, and complications in mullerian agenesis?
1) Breast - normal
2) Pubic hair - present
3) No uterus, short vagina
4) Testosterone - normal
5) Karyotype - 46xx
6) Complications - renal anomalies in 1 out of 3
Comment on breast tissue, pubic hair, uterus and vagina, testosterone level, karyotype, and complications in androgen insensitivity?
1) Breast - normal
2) Pubic hair - absent
3) No uterus, short vagina
4) Testosterone - high
5) Karyotype - 46xy
6) Complications - need gonadectomy after puberty
What is the most common cause of delayed puberty?
Gonadal dysgenesis (i.e. Turner syndrome)
What are two features of Kallman syndrome
1) GnRH deficiency (hypogonadotropic hypogonadism)
2) Anosmia
What are the symptoms of a septic abortion (4)? What is a lab finding?
1) uterine bleeding/spotting
2) abdominal tenderness
3) cervical motion tenderness
4) foul-smelling discharge
5) high WBC (fever)
What is the appropriate treatment for a septic abortion (3)?
1) ABCs
2) IV ABx (Gentamycin and Ampicillin)
3) D and C
What is the most common cause of post partum hemorrhage? What are the treatments in order offered (3)?
1) Uterine Atony
2) Uterine massage and IV oxytocin
3) IM postaglangin F2-a or Methergine or rectal misoprostol
4) Surgery, hysterectomy if severe
What are the contraindications for prostaglandin F2-a and Methergine?
1) PG - asthma
2) Methergine - HTN
What is the cause of late (>24hr) post partum hemorrhage (2)? And what are the appropriate treatments?
1) Subinvolvution of placental site - Methergine or Oxytocin or PG and follow-up
2) retained POC - IV Abx and D&C
What are the risk factors for uterine atony (7)?
1) MgS
2) Oxytocin during labour
3) Rapid labour and delivery
4) Overdistension of uterus
5) Chorioamnionitis
6) Prolonged labour
7) High parity
Describe FSH and sex hormones in hypertrophic hypogonadism as a cause of delayed puberty? What is the most common etiology? How is the diagnosis confirmed?
1) FSH high, estrogen low
2) Turner syndrome XO. Can also be 46XY (testicular feminization), or 46XX (ovarian failure)
3) FSH level and karyotype
Describe FSH and sex hormones in hypogonadotropic hypogonadism? What are the causes (3)?
1) FSH and estrogen are low
2) Poor eating (anorexia), exercise, chronic illness or stress
What is the appropriate treatment for delayed puberty?
Hormone replacement via OCP
What are the SSx of Turner Syndrome (6)?
1) XO phynotype
2) Lack true ovaries - fibrous streaks
3) Short stature
4) Infantile genitalia
5) Web neck
6) Shield chest, wide carrying angle
What is the best treatment for painful breast engorgement post partum?
Round the clock feeding. Also: binders, ice, and analgesia
What are the SSx of mastitis following pregnancy (3)? What does a fluctuant mass indicate?
1) Fever, chills, malaise
2) Red, swollen, tender breast
3) Tachycardia
4) fluctuant = abscess
What is the treatment for a simple mastitis? What if it is complicated by abscess?
1) Dicloxacillin
2) I&D and dicloxacillin
What is the presentation of a galactocele? How may it be treated (2)?
1) Non-erythematous fluctuant mass
2) Conservative or I&D
What vitamin should be supplemented when breast feeding?
Vit D
What is the TSH and free thyroxine level in Graves disease in pregnancy? What are two medical therapies that can be used?
1) TSH low, Thyroxine high
2) PTU or methimazole
What are the SSx of thyroid storm (4)? What is the appropriate treatment, explain the reason for providing each of the drugs (4)?
1) altered mental state, hyperthermia, hypertension, diarrhea
2) Labetalol - tachycardia
3) PTU - lower thyroxine level
4) Corticosteroids - prevent peripheral conversion of T4 to T3
5) Acetamenophen (or cold blankets) - hyperthermia
What are the normal changes to thyroid-binding globulin, total T4, free T4, and TSH in pregnancy?
1) TBG - elevated
2) Total T4 - elevated
3) Free T4 - normal
4) TSH - normal
What is the most common cause of hyperthryoidism in pregnancy? In the post-partum period?
1) Graves
2) Thyroiditis
What can chlamydia cause in the neonate (2)?
1) Conjunctivitis
2) Pneumonia
What complication can chlamydia cause in post-partum period? What are the appropriate therapies during pregnancy? What is contraindicated?
1) Late PP endometritis
2) Erythromycin, Amoxicillin, azithromycin
3) Doxycycline (and other tetracyclines)
What are the risks associated with gonorrhea during pregnancy (6)? What is the treatment?
1) abortion, preterm labour, PPROM, chorioamnionitis, neonatal sepsis, postpartum infection
2) Ceftiaxone IM. And Erythromycin (for pressumed chlamydia infection).
What are 4 steps to preventing HIV transmission in pregancy?
1) IV zidovudine (AZT) for mother
2) Oral syrup AZT for neonate
3) Schedule C/S
4) Don’t breast feed
What is the importance of IgM and IgG titers in the work-up for parvovirus (3)?
1) no IgM, positive IgG - past infection, immune
2) no IgM, IgG - inconclusive, retest in 2 weeks
3) IgM, no IgG - likely acute infection, confirm with retest in 2 weeks.
What impact can parvovirus have on pregnancy (4)? What is the typical presentation in the mother?
1) severe anemia, fetal abortion, stillbirth, hydrops
2) Myalgias, malaise, reticular rash
What is the treatment for a confirmed parvovirus in pregnancy? What is a concerning heart tracing finding?
1) Observation, intrauterine transfussion if anemia is severe
2) Sinusoidal pattern indications severe fetal anemia or asphyxia
When does endomyometritis present in the post-op period following C/S. What is the appropriate treatment? What is added to the treatment if not resolving? What if still not resolving?
1) Day 2
2) Gentamicin and clindamycin (anaerobic coverage)
3) Add Ampicillin
4) CT ?abscess?infected hematoma
How does the abx therapy change in endometritis of vaginal origin (vs. C/S)?
Dont need anaerobic coverage, Gentamicin and Ampicillin sufficient
What are the SSx of endomyometritis following C/S (3)?
1) Uterine tenderness
2) Foul smelling lochia
3) Fever
What is the presentation of a herpes ulcer (3)? What is the appropriate treatment?
1) Small, superficial, painful
2) Acyclovir
What is the presentation of syphillis (3)? How is it tested for (3)? What is the treatment?
1) indurated, nontender chancre, presenting 3 weeks after exposure
2) VDRL, RPR, darkfield microscopy
3) Penicillin 2.4 million units IM. If late latent period - x3 doses
How is syphillis treated if the patient is allergic to penicillin? How does this change in pregnancy?
1) erythromicin, doxycycline
2) Sensitize in pregnancy and give penicillin
What is the presentation of chancroid (3)? What is the treatment (2)?
1) soft and tender ulcer
2) Necrotic base, ragged edges
3) Tender lymphadenopathy
4) Azithromycin or Ceftriaxone
What are the risk factors for PPROM (8)?
1) Low SES
2) STD
3) Smoking
4) Cervical conization
5) Emergency circlage
6) Multiple gestations
7) Hydramnios
8) Placental abruption
What are the signs of chorioamnionitis (4)? What is the earliest sign?
1) Maternal fever, tachycardia, uterine tenderness, malodorous discharge
2) Fetal tachy
What is the approach to PPROM in a less than 32wk GA? Greater than 34wk GA? What if infection is present?
1) less than 32 weeks - antenatal steroids, broad spectrum ABx
2) >34 wks - deliver
3) Infection - Abx, induce labour
What can be assayed in amniotic fluid to confirm fetal lung maturity?
Phosphatidyl glycerol (PG)
Describe the appearance, vaginal pH, whiff test result, microscopic findings, and treatment for bacterial vaginosis?
1) Appearance - milky white discharge
2) pH - alkaline (>4.5)
3) Whiff test - positive
4) Microscope - clue cells
5) Tx - Metronidazole
Describe the appearance, vaginal pH, whiff test result, microscopic findings, and treatment for trichomonal vaginitis?
1) Appearance - frothy, yellow or green
2) pH - alkaline (>4.5)
3) Whiff test - positive
4) Microscope - protozoa (also, strawberry cervix)
5) Tx - Metronidazole
Describe the appearance, vaginal pH, whiff test result, microscopic findings, and treatment for candidal vaginitis?
1) Appearance - Curdy, lumpy
2) pH - acidic (less than 4.5)
3) Whiff test - neg
4) Microscope - pseudohyphae
5) Tx - Fluconazole or imidazole
What is suggested by hyperandrogenism associated with an adnexal mass?
Sertoli-Leydig tumor
What are the two most common origins for androgens in the female? How can they be differentiated?
1) Ovary - testosterone
2) Adrenal - DHEA-S
What is the most common cause of hirsutism with irregular menses?
PCOS
What is the treatment for hirsutism (4)?
1) wt loss
2) OCPs
3) Spironolactone
4) hair removal
