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OBGYN > Case Files Clinical Pearls > Flashcards

Case Files Clinical Pearls Flashcards

1
Q

How do we determine normalcy of labor?

A

cervical change versus time

during active labor, a nulliparous woman’s cervix should change over 1.2 cm/hr. A multip should change over 1.5 cm per hour

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2
Q

What is the term used when cervical change is progressing, but at a slower rate than expected?

A

protraction of active phase

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3
Q

What is the definition of arrest of active phase?

A

when there is no progress in the active phase of labor for 2 hours

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4
Q

CS for labor abnormalities in the absence of clear cephalopelvic disproportion is generally reserved for what?

A

arrest of active phase with adequate uterine contractions

note - if she’s not having adequate contractions, you can give pitocin

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5
Q

How do we typically define adequate uterine contractions?

A
  1. greater than 200 montevideo units with an IUPC

2. uterine contractions every 2-3 minutes, firm on palpation, and lasting at least 40-60 sec

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6
Q

In general, latent labor occurs when the cervix is less than __ cm dilated.

A

4

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7
Q

What are early decels typically caused by?

A

they are mirror images of uterine contractions and are caused by fetal head compressions

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8
Q

What are variable decels usually caused by?

A

they are abrupt in decline (less than 15 sec to nadir) and adrupt in resolution, usually caused by cord compression

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9
Q

What are late decels usually caused by?

A

they are gradual in shape and are offset form the uterine contractions

usually caused by uteroplacental insufficiency (and resultant hypoxia)

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10
Q

What is the normal fetal heart rate baseline?

A

110-160

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11
Q

What is the most common cause of anemia in pregnancy?

A

iron def

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12
Q

Iron deficiency causes a microcytic anemia. What is the other possible cause of a mcirocytic anemia in this context?

A

thalassemia

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13
Q

How can you diagnose a thalassemia?

A

Hgb electrophoresis

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14
Q

An elevated A2 hemoglobin level is suggestive of what thalassemia? How about an elevated hemoglobin F?

A

elevated A2 = beta thal

elevated F = alpha thal

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15
Q

For mild anemias in a woman without risk factors for thalassemia, what is the most appropriate first step?

A

trial of iron and recheck in 3-4 weeks

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16
Q

In pregnancy, anemia is diagnosed at a Hgb less than?

A

10.5

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17
Q

What is the most common cause of megaloblastic anemia in pregnancy?

A

folate deficiency

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18
Q

Although it can occur spontaneously, what is the most common cause of an inverted uterus?

A

undue traction on the cord when the placenta has not yet separated

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19
Q

What are the 4 signs of placental separation?

A

gush of blood
lengthening of the cord
globular-shaped uterus
uterus rising up to the anterior abdominal wall

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20
Q

What is the most common complication of an inverted uterus and why does it happen?

A

hemorrhage

because an inverted uterus can’t contract down

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21
Q

What is the length of time you expect a placenta to be delivered?

A

30 mintues

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22
Q

If a placenta is not delivered after 30 minutes, what do you do?

A

manual extraction

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23
Q

What are some relaxing agents that can be used to help reposition an inverted uterus?

A

halothane
terbutaline
magnesium sulfate

(note - after you reposition, you turn these off and start pitocin)

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24
Q

What is the biggest risk factor for should dystocia?

A

feta lmacrosomia, especially in gestational diabetes because they tend to pack the weight on in their shoudlers and abdomen

(but also maternal obesity and prolonged second stage of labor)

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25
Q

What is the most common injury to the neonate in a shoulder dystocia

A

brachial plexus injury

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26
Q

What is the first action to take in a shoulder dystocia?

A

Mcroberts maneuver and suprapubic pressure

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27
Q

Where should you NOT put pressure after a shoulder dystocia is diagnosed?

A

fundal - increases injury to baby

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28
Q

What are some subsequent maneuvers if McRoberts doesn’t work?

A
  1. Wood’s corkscrew (progressively rotating the posterior shoulder 180 in a corkscrew fashion)
  2. delivery of the posterior arm
  3. zavanelli maneuver
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29
Q

What is the definition of fetal bradycardia?

A

fetal heart rate less than 110 for at least 10 minutes

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30
Q

What are the steps to take with fetal bradycardia?

A

confirm fetal HR vs mom’s HR
vaginal exam to assess for cord prolapse
positional changes (on side to improve blood return)
oxygen via face mask (100%)
IV fluid bolus and pressors of hypotension
DIscontinue oxytocin (baby may not be able to recoop if contractions are coming too quickly)

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31
Q

What is the best therapy for a cord prolapse?

A

elevation of the presenting part and emergency CS

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32
Q

What fetal presentations will increase the risk for prolapse?

A
  1. cephalic is the head isn’t engaged into the pelvis yet
  2. footling breach
  3. transverse lie
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33
Q

What is the most common finding with uterine rupture?

A

fetal heart rate abnormality such as deep variable decels or bradycardia

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34
Q

What is the best treatment for a suspected uterine rupture?

A

emergent CS

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35
Q

What are the risk factors for uterine atony (and hence, PPH)?

A 
magnesium sulfate (so pre-ecclpampsia)
oxytocin use during labor
rapid labor and/or delivery
overdistention of the uterus from macrosomia, multifetal pregnancy or hydramnios
chorioamnionitis
prolonged labor
high parity
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36
Q

A PPH with a firm uterus on exam is most likely due to what?

A

a genital tract laceration

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37
Q

What is the most common cause of a LATE PPH?

A

subinvolution of the uterus

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38
Q

Hypertensive disease is a contraindication for what medictation used in PPH?

A

Methergine

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39
Q

Asthma is a contraindication for what medication used in PPH?

A

Prostaglandin F2-alpha

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40
Q

What are some potential causes of elevated msAFP?

A 
underesetimation of gestational age
multiple gestations
neural tuve defects
abdominal wall defects
cystic hygroma
fetal skin defectsa
sacrococcygeal teratoma
decreased maternal weight
oligohydramnios
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41
Q

What are some potential causes of low msAFP?

A 
overestimated gestational age
chromosmal trisomies
molar pregnancy
fetal death
increased maternal weight
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42
Q

What is the next step in the evaluation of an abnormal triple screen?

A

a targeted ultrasound

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43
Q

Which are associated with higher rates of complications - monozygotic or dizygotic?

A

monozygotic

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44
Q

How do the maternal physiologic changes differ in a twin pregnancy compared to a singleton pregnancy?

A
  1. increased nausea and vomiting (from the increased bhcg)
  2. greater physiologic anemia (because plasma increases more, but RBC mass increases less)
  3. greater increase in blood pressure after 20 weeks
  4. greater increase in size and weight of the uterus
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45
Q

What should be suspected when there is a substantial discordance of the twins and discrepancy of the distribution of the amniotic fluid volume?

A

twin-twin-transfusion syndrome

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46
Q

What is a serious condition that can cause rapid fetal demise after ruptur eof membranes?

A

vasa previa

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47
Q

How can we go about diagnosing vasa previa prenatally?

A

it’s hard, but US with color doppler can sometimes pick it up

and if it does - C-section

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48
Q

What are the indications for c-section in a woman with HSV?

A

if she has prodromal symptoms or suscpicious lesions of the genital tract at the time of labor

note that even if she doesn’t have this, there is a small chance that she could pass HSV to her infant during a vaginal delivery

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49
Q

Most neonatal herpes infections occur from HSV from genital tract secretions, but what percent of neonatal infections are acquired in utero?

A

5% - usually due to primary infections during pregnancy

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50
Q

What drug is given in pregnancy during primary HSV infections to decrease the duration of viral shedding and duration of the lesions?

A

acyclovir

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51
Q

Acyclovir suppression can decrease the likelihood of recurrence and need for cesarean. When do we start it?

A

36w GA

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52
Q

What are the 5 main risk factors for placenta previa?

A 
grand multiparity
prior cs
prior uterine curettage
previous placental previa
multiple gestation
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53
Q

If a woman comes to triage with spotting, why should you get an US (or at least look at the most recent one) before attempting a speculum or digital exam?

A

because she may have a previa, and a vaginal exam could promote more bleeding

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54
Q

What route of delivery do you opt for with placenta previa? And when?

A

CS at 34 weeks

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55
Q

Why don’t we get super worried yet about a placenta previa diagnosed in early gestation?

A

most of the time the placenta will move away from the cervix as the lower uterine segment undergoes further development.

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56
Q

What are the risk factors for placenta abruption?

A 
hypertension!!!!
cocaine use
short umbilical cord
trauma
uteroplacental insufficiency
submucosal leiomyomata
sudden uterine decompression (hydramnios)
cigarette smoking
pPROM
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57
Q

True or false: US can establish the diagnosis of abruption with a high degree of certainty.

A

false - it’s not helpful in a majority of cases. you have to go based on the clinical picture

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58
Q

During an abruption, bleeding can seep into the uterine muscle and cause what?

A

a reddish discoloration known as the Couvelaire uterus

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59
Q

When the abruption is of sufficient severity to cause fetal death, 1/3 of cases will also be complicated by what?

A

coagulopathy - secondary to hypofibrinogenemia (below 100-150 mg/dL)

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60
Q

What are the risk factors for placenta accreta?

A 
placenta previa (especially if hx of cs)
implantaiton over the lower uterine segment
prior CS scar or other uterine scar
uterine curettage
fetal down syndrome
age over 35 yo
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61
Q

In placenta percreta, which organ will the placenta often adhere to?

A

the bladder

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62
Q

What is the usual management for placenta accreta?

A

hysterectomy

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63
Q

Placenta accreta is associated with a defect in what layer?

A

the decidua basalis

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64
Q

What should be included in a differential diagnosis of abdominal pain in pregnancy?

A 
appendicitis
cholecystitis
ovarian torsion
placental abruption
ectopic pregnancy
ruptured corpus luteum
red degeneration of a uterine fibroid
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65
Q

What is the most common time for ovarian torsion to occur during pregnancy?

A

14 weeks GA - when the uterus rises above the pelvic brim

or

immediately postpartum when the uterus rapidly involutes

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66
Q

Why does appendicitis present differently in a pregnant woman?

A

pain will be more superior and lateral, as the appendix is pushed over by the uterus

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67
Q

What is the management for ovarian torsion?

A

surgical untwisting of the pedicle to observe for viability. If blood perfusion cannot be reestablished, the ovary needs to be removed

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68
Q

The most common cause of hemoperitoneum in pregnancy is an ectopic, but what can mimic this?

A

a ruptured corpus luteum

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69
Q

If the corpus luteum is excised in a pregnancy of less than 10 to 12 weeks GA, what hormone will need to be supplemented?

A

progesterone

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70
Q

What are the three main specific causes of pruritis in pregnancy?

A

intrhepatic cholestasis of pregnancy
pruritic urticarial papules and plaques of pregnancy
herpes gestationis

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71
Q

What differentiates these three causes of pruritis?

A

cholestasis: prutritis without visible skin rash
PUPPP: intense pruritis with erythematous papules on abdomen and extremities
HG: Intense itching and vesicles

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72
Q

How does one make the diagnosis of cholestasis?

A

it’s actually a clinical diagnosis - increased bile acids or elevated LFTs are not necessary to diagnose

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73
Q

What are the fetal complications of cholestasis? So when do you typically deliver?

A

prematurity
fetal distress
fetal loss

so deliver at 37w

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74
Q

WHa this the management for cholestasis?

A

antihistamines, cholesteryamine (but associated with vitamin K def), ursodeoxycholic acid is better tolerated

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75
Q

Are there adverse fetal effects for PUPPP or herpes gestationalis?

A

not really

HG can cause transient lesions on the baby’s skin, but they self-resolve

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76
Q

What is the management for acute fatty liver of pregnancy?

A

delivery

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77
Q

How do we confirm a diagnosis of PE in a pregnant patient?

A

spiral CT scan (less radiation than a ventilation-perfusion scan)

D-dimer will generally be positive in pregnancy regardless of clot or not

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78
Q

What is the most common presenting symptom of PE? Sign?

A 
symptoms = dyspnea
sign = tachycardia
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79
Q

PE during pregnancy wins the prize for what?

A

the most common cause of maternal mortality

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80
Q

A PO2 less than ___ in a pregnant woman is abnormal

A

80 mm Hg

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81
Q

What is the most accurate method to diagnose a DVT?

A

venous duplex doppler sonography (physical exam is not very useful)

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82
Q

In general, treatment of preeclampsia at term is…

A

magensium sulfate and delivery

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83
Q

What is the first sign of mag toxicity?

A

loss of DTRs

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84
Q

What are the risk factors for preterm labor?

A 
pPROM
multiple gestations
previous preterm labor or birth
hydramnios
uterine anomaly
hx of cervical cone biopsy
cocaine abuse
african american race
abdominal trauma
pyelonephritis
abdominal surgery in pregnancy
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85
Q

In preterm labor, tocolysis is considered if the GA is less than?

A

34-35 weeks

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86
Q

In preterm labor, intramuscular steroids are administered if the GA is less than ___. For what purpose?

A

34 week to encourage fetal lung development

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87
Q

What medications do we use for tocolysis?

A

terbualine
ritodrine
nifedipine
indomethacine

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88
Q

Dyspnea occurring in a woman with preterm labor and tocolysis is usually due to what?

A

pulmonary edema as a side effect of the tocolytic

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89
Q

What is the most common cause of neonatal morbidity in a preterm infant?

A

respiratory distress syndrome

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90
Q

What are the side effects of beta-agonist tocolytics (terbutaline, ritodrine)?

A

pulmonary edema, tachycardia, widened pulse pressure, hyperglycemia, and hypokalemia

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91
Q

A negative cervical fetal fibronectin assay suggests what?

A

99% predictive that the patient will not deliver in the next week

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92
Q

Infection of what given weekly from 16 wk to 36 w in women with hx of prior spontaneous preterm births decreases the risk of preterm birth by one-third?

A

progesterone

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93
Q

What is the earliest sign fo chorioamnionitis?

A

fetal tachycardia

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94
Q

Pregnancies complicated by PPROM and chorio should be treated how?

A

broad spec antibiotics like amp and gent followed by delivery

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95
Q

With PPROM before 32 weeks, we typically utilized corticosteroids for fetal lung development unless…

A

there are signs of infections

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96
Q

What are some potential causes of hydramnios?

A 
fetal CNS anomalies (can't swallow)
fetal GI tract malformations (can't swallow)
fetal choromsomal anomalies
fetal nonimmune hydrops (parvo)
maternal diabetes
isoimmunization
multiple gestations
syphilis
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97
Q

What is the most common infectious cause of non-immune hydrops? How about the most common non-infectious cause?

A

parvovirus B19

fetal cardiac arrhythmias

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98
Q

What is one of the earliest manifestations of fetal hydrops?

A

hydramnios

and then excess fluid located in 2 or more fetal body cavities

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99
Q

What are the best treatments for chlamydial cervicitis in pregnancy?

A

erythromycin or amoxicillin for 7 days or a one-time dose of azithromycin

doxycyclines are contraindicated in pregnancy because they can cause fetal tooth discolortaion

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100
Q

What is the main concern with chlamydia - issues for mom or issues for baby?

A

issues for baby - can cause pneumonia and conjuncitivitis

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101
Q

True or false: opthalmic antibiotics administered to the noonate will help prevent chlamydial conjuncitivits, but not gonococcal conjuncitivitis.

A

false - they work against gonococcal, but not chlamydial

you need to use oral erythromycin for that

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102
Q

What is the most common mode of HIV transmission in women?

A

heterosexual contact

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103
Q

What is the most common cause of hyperthyroidism in pregnancy?

A

graves disease

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104
Q

What is the most common cause of hyperthyroidism in the postpartum period? When? With what kind of antibodies?

A

destructive lymphocytic thyroiditis
associated with antimicrosomal antibodies
1-4 months post-partum

can lead to hypothyroid eventually

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105
Q

What is the treatment for thyroid storm in pregnancy?

A

MMI or PTU (more likely PTU)
steroids
beta-blockers

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106
Q

True or false? Maternal graves disease doesn’t lead to fetal hyperthyroidism because the antibodies are IgM.

A

false - they’re IgG, so they can cross the placenta and cause fetal hyperthyroidism

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107
Q

What is pregnancy’s effect on total thyroxine levels? Why?

A

Increases thyroid-binding globulin
total thyroxine increases
free T4 stays the same
TSH is unchanged

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108
Q

Maternal hypothyroidism that is untreated can lead to what?

A

neonatal and childhood developmental delays

109
Q

What are some maternal factors that can cause itnrauterine growth restriction?

A 
hypertensive disease
renal disease
cardiac/resp disease
underweight and/or poor pregnancy weight gain
significant anemia
substance abuse with cocaine or tobacco
110
Q

What are some uterine or placental factors that can contribute to IUGR?

A

abruption
placenta previa
infection

111
Q

What are some fetal factors that can contribute to IUGR?

A 
multiple gestation
aneuploidy
congneital syndromes
structural fetal malformations
infection
112
Q

What is IUGR defined as?

A

birthweight less than the 10th percentil for GA

but that means 10% of all babies will meet this defintion, so also consider morbidity and/or mortality associated with the failure to reach growth potential

113
Q

What is the difference between symmetric and asymmetric IUGR?

A

assymetric - preservation fo the head circumference while the abdominal circumference and femur length lag behind

symmetric - all parameters including the head circumference are small

114
Q

WIth IUGR, doppler imaging of what is helpful? What finding is associated with a high stillbirth rate within 48 hours?

A

the umbilical artery

reverse or absent end-diastolic flow

115
Q

What are some causes of symmetric IUGR?

A

fetal chromosomal abnormalities, congenital syndromes, or severe fetal infections

116
Q

What are some causes of asymmetric IUGR?

A

maternal vascular disorders like hypertensive disease

117
Q

If the IUGR is coupled with olighydramnios, what is the management?

A

delivery is typical because there is a greatly increased risk of fetal death

118
Q

What is the most common cause of sepsis in pregnancy?

A

pyelo

119
Q

What is the treatment for pyelo in pregnancy?

A

IV antibiotics - cefotetan or ceftriaxone or the combo or amp and gent; continued until the fever has been gone for 24 hr

then switch to oral antimicrobials

then leave them on suppression therapy for the rest of the pregnancy

120
Q

If clinical improvement hasn’t occurred after 48-72 hours of appropriate abx therapy, what additional complications need to be considered?

A

urinary tract obstruction or perinephric abscess

evaluate using ultrasound or CT

121
Q

2-5% of pregnant women with pyelo will develop what severe complication? Why?

A

ARDS

as the abx lyse the bacteria, endotoxin is released into the blood and can damage the lung parenchyma

122
Q

A woman with a fever after a c-section without any obvious cause for the fever likely has what?

A

endomyometritis

123
Q

What is the pathogenesis of endometritis? What bugs?

A

ascending infection from the normal vaginal flora (so mostly polymicrobial ,but especially anerobes like bacteroides)

124
Q

What are some common signs/symptoms other than fever for endometritis?

A

uterine tenderness

foul-smelling lochia

125
Q

What is the typical drug regimen for endometritis?

A

post CS: gentamicin and clindamycin

post vaginal: gentamicin and ampicillin

126
Q

If there is no response to antibiotics in 48 hours, what is the likely cultprit?

A

enterococcus (treat with amp)

127
Q

What is the best treatment for a wound infection?

A

open up the sound, change the dressings, and start antimicrobials

inspect the fascia for integrity

128
Q

What is the management for septic pelvic thrombophlebitis?

A

antibiotics and heparin

129
Q

When do women typically present with mastitis?

A

2-4 weeks post partum

130
Q

What is the best treatement for postpartum mastitis?

A

oral antistaphylococcal antibiotics like dicloxacillin

131
Q

The presence of fluctuance in a red, tender, indurated breast suggests what?

A

an abscess which will need surgical drainage

132
Q

What is the best treatment for cracked nipples?

A

air drying and avoiding harsh soaps

133
Q

True or false: breast engorgement rarely cuases a high fever persisting more than 24 hours.

A

true

134
Q

HbA1c levels less than __% prior to conception are associated with neonatal morbidity and congenital anomaly rates comparable to the general population.

A

7%

135
Q

HbA1c levels greater than 11% prior to conception are associated with neonatal morbidity rates as high as __%?

A

25%

136
Q

What are the two most common congenital anomalies asociated with pregestational diabetes?

A

cardiac and neural tube defects (so get them on extra folate!)

137
Q

True or false: DKA typically occurs at higher serum glucose levels during pregnancy compared to outside of pregnancy.

A

false - occurs at lower serum glucose levels (even as low at 200)

138
Q

Why is tight control of maternal glucose during labor crucial?

A

because neonatal hypoglycemia can occur with maternal hyperglycemia during labor and delivery

139
Q

What are the risk factors for gestational diabetes?

A

maternal obesity, family history, PCOS, previous GDM, fetal macrosoma in prior birth, or unexplained fetal or neonatal demise

140
Q

When should women with GDM be screened for overt diabetes (meaning checking to see if they actually had diabetes prior to pregnancy that went undiagnosed)?

A

at the 6 weeks post partum visit (with a 20hr 75g oral glucose challenge)

141
Q

WHat oral medication is considered a safe alternative to insulin for treatment of GDM?

A

glyburide

142
Q

What causes the hot flushes of menopause?

A

hypoestrogenemia

143
Q

SIgnificant vasomotor symptoms is the current indication for what treatment?

A

hormone replacement with both estrogen and progestin (unless no uterus, then just estrogen)

144
Q

What are the important cornerstones in the prevention of osteoporosis?

A

weight bearing exercise
calcium and vit D
estrogen replacement

145
Q

Continuous estrogen-progestin therapy may be associated with increased risk for what? Decreased risk for what?

A

increased risk for cardiovascular disease and breast cancer

decreased risk for fracture and colon cancer

146
Q

What is the sequence of biochemical markers in the life of tthe ovary as it fails?

A

Anti-mullerian hormone falls first
then inhibin B (thus increasing FSH and LH)
then finally estradiol

147
Q

What should be at the top of your differential if a woman develops a fever after a hysterectomy or oophorectomy?

A

ureteral injury

148
Q

Meticulous ureteral dissection can lead to what type of injury?

A

devascularization and ischemic injury since the vascular channels run along the adventitia of the ureter

149
Q

What diagnosis should be considered when there is constant leakage or drainage form the vagina after surgery or radiation therapy?

A

a vesicovaginal fisculta

150
Q

What is the imaging test of choice to assess a postoperative patient with a susepcted ureteral injury?

A

intravenous pyelogram

151
Q

WHat are the typical management options for pelvic organ prolapse?

A

pessary devices or surgery

152
Q

anterior defects lead to ____. Treatment is ____

A

cystocele, treated with anterior colporrhaphy and mid urethral sling

153
Q

Central defects lead to ___. Treated with ____.

A

enteroceles and vaginal vault prolapse or uterine prolapse

treated with resection of the enterocele hernia sac and fixation of the vagina to secure ligamentous tissue or the sacrum

154
Q

Posterior defects lead to ___. Treated with ____.

A

Rectoceles

treated with posterior colporrhaphy

155
Q

Lateral defects are caused by what? How are they managed?

A

levator ani weakness

repair is a paravaginal repair - reattachment of the levator ani to the pelvic side wall

156
Q

How would fascial disruption present after abdominal surgery?

A

copiou amounts of serosanguineous fluid draining from the incision (usually 5-14 days post op)

157
Q

What is the diagnosis if there is bowel or omentum coming through the incision?

A

an eviseration

158
Q

What is the management for a superficial wound separation or infection?

A

opening the wound to drain
antibiotics
wet-to-dry dressing changes

159
Q

What are some risk factors for fascial disruption?

A 
obesity
malnutrition
chronic cough
cancer and/or radiation
vertical incisions
infection
intra-abdominal distension
diabetes
corticosteroid use
160
Q

What should be ruled out first in a woman who presents with urinary incontinence?

A

UTI

161
Q

Which incontinence is treated surgically and which is treated medically

A

stress - surgical

urge - medical

162
Q

What is the most common surgery used to treat stress incontinence?

A

midurethral slings (vs. Burch urethropexy)

163
Q

Why might someone opt for the urethropexy?

A

concerns over the mesh eroding through the tissue

164
Q

What type of study do we use to differentiate between genuine stress incont and urge incontinence?

A

cystoemtric or urodynamic evaluation

165
Q

A postvoid catheterization showing a large residual volume suggests what type of incontinence?

A

overflow

166
Q

Which is more common - gonorrhea or chlamydia?

A

chlamydia

167
Q

what is the treatment for gonorrhea?

A

125-250 mg ceftriazone IM

168
Q

What is the treatment for chlamydia?

A

azithromycin 1 g orally or doxycycline 200 mg orally bid for 7-10 days

169
Q

What tests are avaiable to look for gonorrhea and chlamydia in someone who refuses pelvic exam?

A

urine NAATs

170
Q

What are some signs and symptoms of acute salpingitis?

A 
abdominal tenderness
cervical motion tenderness
adnexal tenderness
vaginal discharge
fever
pelvic mass on physical exam or US
171
Q

What are the criteria for hospitalization with PID?

A
  1. if surgical emergencies can’t be ruled out (appy)
  2. pregnancy
  3. unresponsive to outpatient oral therapy after 48 hrs
  4. unable to tolerate oral therapy (nausea, vomiting)
  5. severe illness with upper peritoneal signs or fever over 102F
  6. Tubo-obarian abscess
172
Q

What is the outpatient treatment regimen for PID?

A

IM ceftriaxone 250 mg as single injection and oral doxycycline 100 mg bid for 14 days with or without metronidazole twice a day for 14 days

173
Q

What is the inpatient treatment regimen for PID?

A

IV cefotetan 2 gm IV every 12 hours and oral or IV doxycycline bid to continue 24 hours after clinical improvement

then discharge on oral doxycycline 100 mg bid for 14 days

174
Q

What would be a reason to add metronidazole?

A

TOA (because usually anerobes cause TOAs)

175
Q

True or false: Like most abcesses, TOAs should be surgically drained?

A

false - they can usually be managed by antibiotics alone

maybe sometimes you can have IR drain it if it’s really big to hasten recovery

176
Q

What is the gold standard for diagnosis of PID?

A

laparoscopy is the only definitive diagnosis

177
Q

Describe what bacterial vaginosis will look like on pelvic exam?

A

discharge is a white homogenous coating describe like “spilled milk over the tissue”

pH will be alkaline

The vaginal epithelium will not be erythematous or inflamed (because BV is not inflammatory, unlike candida or trich)

Adding KOH leads to release of amines causing a fishy odor (whiff test)

178
Q

Why is the pH alkaline in BV?

A

because BV is an overgrowth of anerobic bacteria in the vagina, replacing lactobacilli

179
Q

What is the treatment for BV?

A

metronidazole (orally or vaginally)

180
Q

What does the discharge look like with trichomonas?

A

frothy yellow-green to gray

181
Q

What does the cervix look like with trichomonas?

A

intensely inflamed with classic punctate lesions (strawberry cervix)

182
Q

What is the treatment for trichomonas?

A

usually 2g metronidazole orally (for patient and partner)

can use tinidazole if resistant

treatment usually not vaginally because it won’t reach the urethra or skene’s glands very well

183
Q

What will the pH be for a vaginal yeast infection?

A

will be normal (less than 4.5) - unlike BV and trich

184
Q

What are the treatments for vaginal candida?

A

oral diflucan or topic imidazoles like terconazole or miconazole (monistat)

185
Q

What are some risk factors for a vaginal candida infection?

A

pregnancy
antibiotic use
diabetes
immunosuppression

186
Q

Describe the classic presentation of primary syphillis?

A

a nontender ulcer with clean-appearing edges, often accompanied by painless inguinal adenopathy

187
Q

What are the main differences between the nontreponemal testa nd teh specific serologid tests?

A

nontreponemal (VDRL or RPR) are nonspecific antitreponemal antibody tests. these titers will fall with effective treatment

specific serologic tests like TP-PA, MHC-TP or FTA-ABS are antibody tests directed against the treponemal organism itself. They will remain positive for life after infection

188
Q

True or false: nontreponemal tests sometimes are negative in the first stage of syphillis.

A

true

189
Q

If you really suspect syphillis and the nontreponemal test are negative, what is the next step?

A

culture with darkfield microscopy for the spirochetes

190
Q

In the second stage of syphillis, what is necessary to make the diagnosis?

A

a positive treponemal test (because the nontreponemal can be falsely positive here)

191
Q

What does secondary syphillis look like?

A

macular papular rash anywhere on the body but usually on the palms and soles of feet

condylomata lata on the vulva

192
Q

What is the treatment of choice for all stages of syphillis?

A

penicillin G

primary, secondary, and early latent: one injection of long-acting benzathine penicillin G 2.4 million units intramuscularly

late-latent syphilis: 7.2 million units IM divided as 2.4 million units every week for a total of three courses

193
Q

When do you do a test of cure for syphillis?

A

6 and 12 months after treatment for early syphillis and additionally at 24 months after treating late latent

194
Q

What is the treatment of choice in an uncomplicated cystitis (non-pregnant woman)?

A

3-day course of trimethorpim/sulfa

195
Q

True or false: asymptomatic bacteriuria in pregnancy does not warrant antibiotic treatment until symptoms arise.

A

false - you always treat bacteriuria in pregnancy because 25% of the time it will progress to pyelo if left untreated

196
Q

What should you suspect in a woman who has UTI symptoms but negative urine cultures?

A

urethritis, typically caused by chlamydia or gonorrhea

197
Q

What is the most common symptom of uterine leiomyomata?

A

menorrhagia

198
Q

Very rarely, uterine fibroids will progress to leiomyosarcoma. What is a sign that this has occurred?

A

rapid growth - an increase in more than 6 wks gestational size in 1 year

also suspect if the woman has a history of radiation to the pelvis

199
Q

What is the initial management for fibroids?

A

medical - NSAIDs or progestin therapy

gonadotropin-releasing hormone agonists lead to a decrease in uterine fibroid size, reaching max effect in 3 mos. but will regrow after med stopped.

200
Q

If a patient fails medical management, what’s the main option? How about if fertility is desired?

A

hysterectomy or uterine artery embolization

can try myomectomy if desire pregnancy

201
Q

Myomectomy increases the risk for what in pregnancy?

A

uterine rupture

so if the endometrial cavity is entered during the myomectomy, they probably need to have a c-section

202
Q

When a pregnancy woman less than 20 weeks gestation has vaginal bleeding, it is described as a what?

A

a threatened abortion

203
Q

What is the discriminatory zone for beta-Hcg?

A

the level at which an intrauterine pregnancy should be seen on US

1500-2000 mIU/mL

204
Q

Typically, if the beta hcg is below the discriminatory zone, you repeat in 48 hours to see if it doubles. But what is another option?

A

check a single prosterone level - levels greater than 25 ng/ml almost always indicate a normal IUP whereas values less than 5 ng/mL usually correlate with a nonviable gestation

205
Q

What type of ectopic patient is the ideal candidate for methotrexate therapy?

A

someone who is asymptomatic with a small (less than 3.5 cm) ectopic pregnancy

and who is able to follow-up

206
Q

What are the two strategies for managing a non-viable intrauterine pregnancy in this situation?

A

either medically with misoprostol or surgically with a D&C

207
Q

What are some findings that would urge you have order immediate surgery in a patient suspected of having an ectopic pregnancy?

A

severe abdominal pain with peritoneal signs

hypotension, tachycardia

208
Q

What is the difference between a threatened abortion and an inevitable abortion?

A

threatened - vaginal bleding prior to 20 weeks with a closed cervical os

Inevitable abortion - vaignal bleeding (with or without cramping) with an open cervical os

209
Q

What is the difference between an inevitable abortion and an incomplete abortion?

A

inevitable - os is open, but no tissue has passed

incomplete - os is open and tissue visible

210
Q

How can you differentiate between a complete and incomplete abortion on exam?

A

incomplete - os will still be open with tissue

complete - os will be closed

211
Q

How can you differentiate between an inevitable abortion and an incompetent cervix?

A

an inevitable abortion has an open os that opened because of abdominal contractions

an incompetent cervix will have an open os without contractions

212
Q

What do we follow after a complete abortion?

A

hcg levels.

they should halve every 48-72 hours. If they plateau, there is retained product of conception

213
Q

What is the general cause of a septic abortion?

A

the retained POC acts as a nidus for infection by ascending, polymicrobial (particularly anaerobes) from the lower genital tract`

214
Q

What is a common complication of curettage for septic abortions?

A

hemorrhage

215
Q

A firm, nontender, smoothly mobile breast mass in a young woman is most likely what?

A

a fibroadenoma

216
Q

What is the best initial imaging modality of a breast mass in a younger patient?

A

ultrasound - their breast tissue is too dense for mammography

217
Q

True or false: a breast mass must be biopsied regardless of mammogram results.

A

true

218
Q

In general, what is the biggest risk factor for the development of breast CA?

A

age

219
Q

A woman with two first-degree family members with breast cancer should have what workup?

A

BRCA1 or 2 screening

220
Q

Women with a family histroy of breast cancer should have annual mammography starting at what age?

A

35

221
Q

What is the most common cause of unilateral serosanguineous nipple discharge froma single duct?

A

intraductal papilloma

222
Q

What is the most common histological type of breast cancer?

A

infiltrating ductal carcinoma

223
Q

What is the management for a breast cyst in which the fluid is straw-colored or clear and the breast mass disappears upon aspiration?

A

no further workup is necessary

224
Q

What are some mammographic findings suggestive of cancer?

A

small cluster of calcifications or a mass with irregular borders

225
Q

What are two accepted methods of assessing suspicious mammographic nonpalpable masses?

A

stetrotactic core biopsy or needle-localizaiton excisional biopsy

226
Q

What is a breast pathology that can mimic breast cancer on mammography, but is totally benign?

A

fat necrosis from previous trauma to the breast

note - you should still excise these lesions to confirm the diagnosis

227
Q

After pregnancy is ruled out, what is the most common cause of secondary amenorrhea after uterine curettage?

A

intrauterine adhesions (Ashermann’s syndrome)

228
Q

Secondary amenorrhea can be caused by abnormalities in what four compartments?

A

hypothalamus
pituitary
ovary
uterus (outflow tract)

229
Q

What is the best way to diagnose Ashermann’s syndrome?

A

hysterosalpingogram or saline infusion sonohysterography

can conform with hysteroscopy

230
Q

What is the best treatment for Ashermann’s syndrome?

A

hysteroscopic resection

231
Q

The evaluation of secondary amenorrhea should include what lab tests?

A

pregnancy test
prolactin level
TSH level
FSH/LV/estradiol levels

232
Q

What is the management for galactorrhea in the face of normal menses and a normal prolactin level?

A

it can be observed - the normal menses indicates normal hypothalamic funciton

233
Q

What should be the first step in evaluation of a woman with oligomnorrhea and galactorrhea?

A

pregnancy test

234
Q

Women with hyperprolactinemia have an increased risk for what disease process?

A

hypoestrogenemia leading to osteopororosis

235
Q

Which can lead to hyper[rolactinemia - hypothyroidism or hperthyroidism?

A

hypothyroidism (TRH increases prolactin release)

236
Q

Why does hyperprolactinemia (and thus hypothyroidism) cause amenorrhea?

A

the high prolactin suppresses pulsative GnRH release, so you get decreased LH and FSH leading to hypothalamic amenorrhea (hypogonadotropic hypogonadism)

237
Q

What is the most sensitive imaging test to assess pituitary adenomas?

A

MRI

238
Q

What are the two most common causes of secondary amenorrhea after postpartum hemorrhage?

A

Sheehan syndrome

Ashermann’s syndrome

239
Q

What is the primary medical manatement for PCOS ?

A

OCPs

240
Q

Rapid onset hursutism and/or virilization usually indicates what?

A

an androgen-secreting tumor

241
Q

What are the two most common locations of androgen production and secretion in a woman?

A

ovary and adrenal gland

242
Q

What is the most common cause of hirsutism and irregular menses?

A

PCOS

243
Q

What is the most common cause of ambiguous genitalia in the newborn?

A

congenital adrenal hyperplasia, usually due to 21-hydroxylase enzyme deficiency

244
Q

Hyperandrogenism in the face of an adnexal mass usually indicates what kind of tumor?

A

sertoli-leydig

245
Q

What is the most common cause of sexually infantile primary amenorrhea?

A

gonadal dysgensis (Turner Syndrome)

246
Q

What is the most common karyotype associated with gonadal dysgenesis? What are some other options?

A

45XO
46,XX
46,XY

247
Q

What defines “delayed puberty”?

A

no development of secondary sexual characteristics by age 14

248
Q

What lab test will distinguish ovarian failure from CNS dysfunction as a cause of delayed puberty?

A

FSH - will be high in ovarian failure (with low estradiol)

if both are low, then it’s a CNS issue

249
Q

What defines precocious puberty?

A

development of secondary sexual characteristics before age 7, and before age 6 in african americans

250
Q

What is the most common cause of precocious puberty?

A

idiopathic (a diagnosis of exclusion)

251
Q

What is the treatment for idiopathic precocious puberty?

A

GNRH-agonist therapy

252
Q

What are the two most o=common cause of primary amenorrhea in a woman with normal breast development/

A

androgen insensitivity and mullerian agenesis

253
Q

What physical exam finding will differentiate between androgen insensitivity and mullerian agenesis?

A

androgen insensitivity will have scan pubic and axillary hair whereas mullerian agenesis will have normal hair

254
Q

What lab finding will differentiate between androgen insensitivity and mullaerian agenesis?

A

androgen insensitivity will have elevated testosterone (into the normal range for a male)

255
Q

Mullerian agenesis is commonly associated with congenital anomalies in what other organ system?

A

renal

256
Q

WHat are the five basic factors that can cause infertility?

A

ovulatory, uterine, tubal, male, and peritoneal

257
Q

Ovulatory disorders are usually amenable to medical treatment. What about tubal, uterine or peritoneal factors?

A

nope - usually need surgery

258
Q

What is the biggest risk factor for endometrial carcinoma?

A

unopposed estrogen (early menarche, late menopause, estrogen therapy, nulliparity, obesity, etc)

259
Q

Why is endometrial cancer usually discovered at an early stage?

A

Because it usually presents early with abnormal uterine bleeding

260
Q

What are the two main high-risk HPV strains for cervical cancer?

A

16 and 18

261
Q

What symptoms would suggest that cervical cancer has advanced?

A

flank tenderness or leg swelling

262
Q

Advanced cervical cancer is best treated how?

A

with radiation brachytherapy

263
Q

True or false: a visible cervical lesions should be evaluated by a pap smear and colposcopy

A

false - a pap smear is not useful if you can already see a lesion - just go right to biopsy

264
Q

What is the most common ovarian tumor in a woman younger than 30?

A

a benign cystic teratoma (dermoid cyst)

265
Q

What is the most common ovarian tumor in a woman older than 30?

A

a serous cystadenoma

266
Q

An ovarian mass larger than ___ cm in a postenopausal woman mos tlikely represents an ovarian tumor and should generally be removed

A

5 cm

267
Q

An ovarian mass larger than __ cm in a premenopausal woman is likely a tumor and should be removed. Anything smaller is probably a what?

A

10 cm

smaller than that is probalby just a functional simple cyst

268
Q

Mucinous tumors of the ovary can grow to be very large. If they rupture intra-abdominally, they can cause what?

A

pseudomyxoma peritonei (often leading to bowel obstruction)

269
Q

Lichen sclerosis can ultimately contribute to what kind of cancer?

A

squamous cell

OBGYN (1 decks)

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