CF Flashcards
1
Q
Nulliparous women dilate at what rate during active phase
A
1.2cm/hr
2
Q
What features would suggest retained products of conception (i.e. after abortion)?
A
Open cervical os, lower abdominal cramping, vaginal bleeding, signs of infection
3
Q
Why are we concerned about hemorrhage when performing curettage in an infected uterus?
A
Higher risk of perforation when infected
4
Q
2 most common complications ass. with spontaneous abortion
A
Infection and Hemorrhage
5
Q
Signs/sxs of septic abortion
A
Uterine bleeding and/or spotting in 1st Trimester + signs of infection. May see abdominal tenderness, cervical motion tenderness, foul-smelling vag discharge
6
Q
In septic abortion, where does the infection come from/travel to?
A
Ascends from Vagina or Cervix. Goes to Endometrium –> Myometrium –> Perimetrium –> Peritoneum
7
Q
Which organism causes septic abortion?
A
Polymicrobial –> Anaerobic strep, bacteroides, E coli, GBS are common
8
Q
Bloody Show
A
A sign of impending labor that is often accompanied by the loss of the mucus plug. May present as bloody mucus in the vaginal vault.
9
Q
What is the cutoff for ‘anemia in pregnancy’
A
10.5
10
Q
Accelerations
A
> 15bpm above baseline for at least 15 seconds
11
Q
Adequate Contractions
A
> 200 Montevideo Units in a 10min. window
12
Q
Protracted Labor
A
Some progression but taking longer than normal (i.e. 0.5cm/hr)
13
Q
Bloody Show
A
A sign of impending labor that is often accompanied by the loss of the mucus plug. May present as bloody mucus in the vaginal vault.
14
Q
Combination of which 2 antibiotics works well for septic abortion tx 95% of the time
A
Gentamicin + Clindamycin (want broad spectrum with good anaerobic cover)
15
Q
When do you begin uterine curettage for removal of retained products of conception/septic abortion?
A
4 hours after starting IV antibiotics
16
Q
Why is urine output carefully observed in the setting of septic abortion?
A
because Oliguria = early sign of septic shock
17
Q
Pelvic exam finding for Mullerian agenesis pt
A
blind vaginal pouch/vaginal dimple
18
Q
Why does uterine inversion lead to PPH
A
Prevents adequate myometrial contraction
19
Q
Absence of breast development points towards what hormonal state and condition?
A
Hypoestrogenic state –> Gonadal dysgenesis aka Turner syndrome
20
Q
Next step in management after a shoulder dystocia has occurred
A
McRobert’s Maneuver - hyperflexion of maternal hips onto maternal abdomen and/or suprapubic pressure
21
Q
Primary Amenorrhea = no menarche by age ____
A
16
22
Q
Primary amenorrhea, normal breast, pubic, and axillary hair. Absent uterus
A
Mullerian agenesis
23
Q
First dx test for any woman with primary or secondary amenorrhea?
A
Pregnancy test
24
Q
T/F Fundal Pressure should be applied immediately following Dx of shoulder dystocia
A
False, it should be avoided due to increased risk of neonatal injury. McRoberts uses suprapubic pressure
25
+ whiff test
BV or Trich
26
Why do menses and intercourse exacerbate the fishy odor of BV?
Both introduce an alkaline substance
27
what are Amsel's criteria?
3/4 indicate BV
1. Homogenous, gray-white discharge
2. vaginal pH>4.5
3. Postive whiff test
4. Clue cells on wet mount
(Gram stain is gold standard but rarely used clinically)
28
Strawberry cervix
Trichomonas
"Strawberries are trich-y to Cerve"
29
why does antibiotic use dispose to Candida vaginitis?
normal lactobacilli in vagina inhibit fungal growth (these are reduced by antibiotic)
30
which of the 3 vaginitis microscopic dx is assisted by KOH?
Candida: KOH lyses leukocytes and erythrocytes, can identify hypahae/pseudohyphae easier
31
Classic mammogram finding of breast cancer
A. Small cluster of calcifications around a small mass
or B. masses with ill-defined borders (spiculated/invasive)
or C. asymmetric increased tissue density
32
Next dx step if mammogram is suspicious for cancer
Stereotactic core biopsy
33
role of MRI in identifying breast cancer?
Can detect early breast cancers missed by mammography, especially in younger pts or BRCA pts
34
Name this method of breast cancer workup: Computerized,digital 3-D view of breast allows us to direct the needle to the biopsy site
Stereotactic Core Biopsy (needle localization is also acceptable)
35
Name this method of breast cancer workp: Multiple mammographic views of the breast allow us to localize the lesion with assistance of a sterile wire
Needle Localization
36
Digital mammogram has better sensitivity than film in which conditions:
Age<50, premenopausal, dense breasts
37
Define radical hysterectomy
removal of the Uterus, Cervix, and supportive ligaments (cardinal, uterosacral, and proximal vagina)
38
Who gets HPV vaccine?
M/F aged 9-26. Quadrivalent = 6, 11, 16, 18
39
What's acetowhite change refer to?
(colposcopy) Addition of acetic acid to the cervix will turn cervical intraepithelial lesions white. Dysplastic lesions will often have vascular changes (punctuations, atypical, etc)
40
Next step to evaluate an abnormal Pap smear?
Colposcopic examinations with directed biopsies
41
T/F: When a woman presents with a cervical mass, Pap smear is appropriate
FALSE. Pap smear is a screening test, best used for asymptomatic women. BIOPSY OF MASS = best test for visible lesion
42
How is advanced cervical cancer (>4cm) best tx?
Radiotherapy: Brachytherapy (implants) with teletherapy (whole pelvis radiation) + chemo (cis-platinum) to sensitize the tissue to radiotherapy
43
Staging procedure for Cervical cancer (5)
1. Exam under anesthesia
2. IV Pyelogram
3. Chest Xray
4. Barium enema or proctoscopy
5. Cystocopy
44
most common cause of death due to cervical cancer?
Bilateral ureteral obstruction leading to uremia
45
how can hydronephrosis be caused by cervical cancer?
Cancer often spreads to pelvic sidewalls (via cardinal) and obstruct one or both ureters
46
T/F: Pap smear is no longer needed after hysterectomy
False. In the case that hysterectomy was performed for cervical dysplasia, Pap smear of vaginal cuff is still needed
47
Whats the protocol if ASCUS (Atypical Squamous Cells of Uncertain Significance) is found?
May be observed instead of immediate colp/HPV testing
| vs HSIL/LSIL req colp
48
Women younger than age 25 with biopsy proven CIN 1 or 2
may be observed with serial Pap since resolution rate is high
49
Atypical glandular cells (AGCs) on pap. Next steps?
Colp, endocervical curettage, and endometrial biopsy
50
What is radical trachelectomy?
Removal of cervix and upper vagina (leaves uterus). Newer option for cervical cancer tx in younger women who desire children
51
2 clinical signs that can indicate advanced cervical cancer
Flank tenderness
| Leg swelling
52
T/F: Eye prophylaxis is effective for preventing gonoccoal and chlamydial conjunctivitis
False, its actually only effective against GC (even though chlamydia more common)
53
Which infection is late postpartum endometritis (2-3 weeks post) ass. with?
Chlamydia
54
Tx for chlamydia
Erythromycin, amoxicillin, or azithro
| Tetra/doxy CI in preg
55
T/F: GC and Chlamydia are ass. with abortion, preterm labor, PPROM, chorio, neonatal sepsis, postpartum infection
False: Gonococcal cervicitis IS ASSOCIATED WITH ALL OF THESE. Links between these and chlamydia are unclear
56
T/F: Heterosexual spread of HIV is the most common mode of transmission
True
57
The goal in pregnancy is to maintain an HIV viral load under:
1000 RNA copies/mL (higher than this prior to labor/ROM, c-section reduces risk of vertical transmission)
58
What to give HIV infecte owmen who delivers vaginally?
IV Zidovudine during labor
59
Which HIV drug is associated with congenital anomalies?
Efavirenz (NNRTI) --> Neural tube defects
60
Tx for co-infection for HIV and HBV?
Tenofovir and lamivudine. Infants should get Hep B IG at birth and start vacc. within 12 hours.
61
Can women with Hep B or Hep C breastfeed?
Only if they don't have co-infection with HIV
62
T/F: C/s does not affect the perinatal transmission of hep c
true
63
How is cervical cancer staged?
Clinically
64
2 key tests in assessment of extrauterine pregnancy
hCG (look for #s above 1500-2000 threshold-->should see pregnancy on US by this threshold, if not its likely ectopic)
Transvaginal US (look for IUP)
65
Most common reason for maternal mortality in the first 20 weeks gestation
Hemorrhage from ectopic gestation
66
If you suspect extrauterine pregnancy in a women, should you give methotrexate?
No, b/c you are not 100% sure and could destroy any intrauterine gestation. Do Laparoscopy instead
67
What is the most sensitivite way to detect IUP, as early as 5.5 weeks?
Transvaginal sonography>transabdominal
68
What finding demonstrates definite IUP?
Crown-rump length or yolk sac
| ID of a gestational sac is sometimes misleading
69
How does a normal gestational sac appear?
Eccentrically located with a decidual sign (echogenic rim around sac)
70
A rise in hCG of at least ____% in ____hours is indicative of a normal pregnancy
53% in 48 hours
71
Progesterone level of > than _____ng/mL = always normal IUP
level < than ____ng/mL = always abnormal
25
5
72
Procedure used in a woman with ectopic pregnancy that can not be treated medically (ruptured/too large) but wants to preserve fertility
Salpingostomy
| vs salpingectomy normally performed if not wanting to preserve fertility
73
Prinicipal form of medical therapy for ectopic
Methotrexate (one time, low dose, intramuscular injection)
74
What are the conditions in which methotrexate can be used to tx ectopic?
1. less than 3.5cm diameter
2. no fetal cardiac activity
3. hCG<5000
75
Levels of hCG that plateau in the first 8 weeks of preg indicate:
Abnormal pregnancy (miscarriage or ectopic)
76
Classic triad of sxs of ectopic
Amenorrhea
Vaginal Spotting
Abdominal Pain
77
Tx of choice for all ovarian malignancies?
Surgical staging
78
Name for an androgen effect other than hair pattern (clitromegaly, male balding, deepening of voice, ACNE)
Virilism
79
Hirsutism is most commonly associated with:
Anovulation (PCOS)
80
Causes of Virilization
1. Adrenal Hyperplasia or androgen-secreting tumor(high DHEA-S)
2. Androgen-secreting tumors of the ovary (high Testosterone)
(note: not really ass. with PCOS)
81
The rapid onset of hirsutism or virilization usually indicates:
Androgen-secreting tumor (NOT PCOS if its rapid, esp if not really related to menarche)
82
Hyperandrogenism + adnexal mass most commonly =
Sertoli-Leydig cell tumor of the ovary
83
5 basic factors to consider for infertility
1. Ovulatory
2. Uterine
3. Tubal
4. Male factor
5. Peritoneal factor (endometriosis)
84
3 D's of Endometriosis
1. Dysmenorrhea
2. Dyspareunia
3. Dyschezia
85
Infertility = Inability to conceive after ___ of unprotected sex
1 year
86
Define fecundability and its estimated % for a normal couple
Probability of achieving a pregnancy within one menstrual cycle
20-25%
87
Easiest/cheapest method of detecting ovulation
Basal body temperature (rises 0.5F for 10-12 days after ovulation)
88
Ovulation occurs ___hours after onset of the LH surge
36 hours (measured by urine LH kit)
89
Do the majority of women with tubal factor infertility have hx of chlamydia or GC?
No, majority don't have hx of STI (because asymptomatic)
90
Prevalence of endometrioitis in infertile women:
25-40%
91
Gold standard for dx tubal issues or endometriosis as causes infertility
Laparoscopy
92
Lesion of various appearances, from clear to red to the classic "powder burn" color are associated with:
Endometriosis
93
What is the choice tx for endometriosis
Laparoscopy or Laparotomy (so not DnC)
94
Technique used if male factor infertility
Intracytoplasmic spermatic injection (think of it like the sperm can't make it on its own)
95
Pt has to use one's fingers to apply pressure on vagina to achieve BM
One sign of Pelvic Organ Prolapse
96
Tx options for hot flushes
1. Estrogen replacement therapy w/Progestin (most effective. If uterus gone, don't need progestin)
2. Clonidine
3. Gabapentin
4. SSRI
note: SERM does NOT work
97
Which hormones fall earliest in menopause?
Anti-Mullerian hormone is the earliest marker; Inhibin B is next; finally, E2 falls.
98
Inhibin and FSH levels during menopause
FSH is elevated, Inhibin is low (as is E2)
99
Is hormone replacement therapy to tx vasomotor sxs in menopausal woman continued forever?
No, it should be used in the lowest dose for the shortest duration feasible
100
What complications is a PCOS pt at risk for?
1. DM
2. Endometrial cancer
3. Hyperlipidemia
4. Metabolic syndrome
5. CV disease
101
Dx for PCOS
Req 2/3:
1. Oligo/amenorrhea
2. Hyperandrogenism
3. US evidence of small, multiple ovarian cysts
(LH:FSH ratio is unreliable)
102
Exclusion of these secondary causes of hyperandrogenism before labeling PCOS
1. Congenital adrenal hyperplasia.
2. Hyperprolactinemia, 3. Adrenal/ovarian tumor
4. Cushing syndrome
5. Thyroid disorders
103
PCOS tx
BMI<30: Clomiphene citrate (SERM)
| BMI>30: Letrozole (aromatase inhibitor)
104
In female, testosterone is largely secreted by the ____ and DHEA-S by the _________
Ovary (T)
Adrenal Gland (DHEA)
105
Pts with PCOS should be screened for: (2)
Glucose intolerance
| Lipid abnormalities
106
cHTN vs gHTN
Chronic: BP 140/90 before pregnancy or before 20 weeks, or persisting more than 12 weeks postpartum
Gest: HTN w/o proteinuria at >20weeks for at least 4 hours
107
Preeclampsia definition
140 or 90 measured 2x, 6 hours apart + new onset proteinuria (>300mg in 24hrs, or UP:C >0.3)
108
If there is HTN but no proteinuria, how else can you make dx of preeclampsia
HTN + one of the following "severe features":
1. Thrombocytopenia
2. Impaired LFTs
3. Renal insuff (Cr>1.1)
4. Pulm Edema
5. Cerebral disturb
6. Visual impairment
109
What is cHTN pt at risk for?
1. IUGR
2. Fetal Demise
3. Placental abruption
4. Superimposed preeclampsia
5. Eclampsia
110
Underlying pathophys of pre-E
tissue hypoxemia = heVasospasm and "leaky vessels" = serum leakage and molysis/necrosis/end-organ damage
111
What is the cure for Pre-E?
TERMINATION OF PREGNANCY = delivery
112
What is the effect of pre-E vasospasm on BP, Intravascular volume, and oncotic pressure?
Increased BP (increased systemic vascular resistance)
Decreased Intravascular Volume and Oncotic Pressure (leakage)
113
Complications of preeclampsia
1. Placental abruption
2. Eclampsia
3. Coagulopathies
4. Renal Failure
5. Hepatic subcapsular hematoma
6. Hepatic rupture
7. Uteroplacental insufficiency
Fetal growth restriction, poor Apgar, and fetal acidosis also seen
114
Risk factors for Pre-E
1. Nulliparity
2. African american
3. Extremes of age
4. Previous pre-E
5. cHTN
6. chronic renal dx
7. obesity
8. antiphospholipid syndrome
9. diabetes
10. multifetal gest.
115
Lab tests for preE
CBC, UA and 24 hr urine protein, LFT, LDH (hemolysis), and Cr
Fetal testing (BPP) to check uteroplacental insuff
116
management of acutely elevated BP (160/110 for >15 min = HTN emergency)
Use IV labetolol or IV hydralazine or oral nifedipine immediately to avoid stroke. Recheck 20 minutes later
117
mgmt for preE with severe features
Over 34 weeks: give MgS04 and deliver
Less 34: corticosteriods, mag, and asses M/F stability. If stable, wait 48 hrs for steroids to work and deliver.
118
When is the greatest risk of Eclampsia occurrence?
1. Just prior to delivery
2. During labor (intrapartum) -->give preE pt mag
3. w/in 1st 24 hours postpartum
119
1st sign of mag toxicity:
Hyporeflexia (loss of deep tendon reflexes).
Side effect of mag = pulmonary edema
120
Cystometric exam can differentiate between:
Urge and stress incontinence
121
No delay from cough to incontinence:
Genuine Stress Incontinence
122
From stress incontinence, where is the proximal urethra relative to the pelvic diaphragm
Falls below it.
Thus, when the patient coughs, intra-abdominal P is exerted to the bladder but not to the proximal urethra, and bladder pressure exceeds urethral = urinary flow
123
Delay between cough and void
Urge incontinence
124
Best tx's for stress and urge incontinence
Stress: Surgical (sling)
Urge: Medical (kegel, lifestyle, antimuscarinics, Mirabegron)
125
Best tx for uncomplicated cystitis
3 day course of Bactrim
126
What are the classic sxs of cystitis?
Dysuria, urgency, frequency.
Note: Fever is NOT usually seen. Typically seen when upper tract involvement i.e. pyelo
127
Do we tx asymptomatic bacteriuria?
We always tx this in pregnant women (1/4 would go on to develop infection)
128
agens for urethritis
Chlamydia, Gonococcus, Trichomonas
129
Typical sxs of UTI but no growth in culture (so sterile pyuria) and no response to antibiotics
Suspect urethritis (chlamydia, gonorrhea, trichomonas)
130
Tx for urethritis
Typically do Doxy + ceftriaxone for the C/NG infection. In pregnant, substitute Azithromycin for doxy
131
between which weeks is considered 'term'?
37-42
132
If a pt is rubella nonimmune, when do you immunize?
POSTPARTUM!
| Rubella vaccine = live attenuated = do NOT give during pregnancy
133
Define Labor
Cervical change accompanied by regular uterine contractions
134
After how many cm dilation do we say active labor has begun?
6cm (not 4)
135
How do we define "arrest of active phase"?
No progress in the active phase of labor (>6cm) for:
-4 hours if adequate ctxs
-6 hours if inadequate ctxs
(assuming ROM)
136
Define adequate ctxs
every 2-3 minutes, firm on palpation, lasting at least 40-60 seconds (clinical) or at least 200 Montevideo units
137
how are Montevideo units calculated?
exaine a 10-min window; add each ctx's rise above baseline (each mmHg is a Montevideo unit) --> 200 = normal ctxs
138
Late decels suggest fetal ____, and if recurrent or together with decreased variability, suggest fetal ____
hypoxemia; acidemia
139
reasons for C-section
(in order of freq)
1. LABOR DYSTOCIA (does not include prolonged latent)
2. ABNORMAL FHT
3. fetal malpresentation
4. multiple gestation
5. macrosomia
140
How can we try to intervene after seeing many variable decels?
Amnioinfusion
141
What is a good way to asses fetal acid-base status when abnormal FHR patterns are present?
Scalp stimulation....if it induces an acceleration, highly correlates to a normal umbilical cord pH (>7.2)
142
when should external cephalic version be offered?
To women after 36 weeks with malpresentation
143
Intervention for pt that becomes hypotensive following epidural/spinal
IV fluid bolus OR admin Ephedrine (vasopressor)
144
Vaginal exam reveals cord through cervix
Umbilical cord prolapse --> Elevate presenting part and EMERGENCY C/S
145
Uterine tenderness + Vaginal bleeding
Placental abruption --> support BP and stabilize pt, consider c/s
146
what type of defect are the thalassemias?
Quantitative (vs sickle cell is qualitative)
147
Woman develops dark-colored urine after taking Nitrofurantoin for UTI. What does she likely have?
G6PD-Deficiency...hemolysis. Also consider HELLP if there is also thrombocytopenia
148
Elevated _____ = Beta-thal
| Elevated _____ = Alpha-thal
```
A2 hemoglobin (B)
HbF (A)
```
149
4 signs of placental separation
1. Gush of blood
2. Lengthening of cord
3. Globular/firm shape of uterus
4. uterus rises up to anterior ab. wall
150
Common complication of uterine inversion
Hemorrhage (due to atony)
151
Nerve injury related to shoulder dystocia
Erb Palsy = brachial plexus C5-C6. Arm hands limply by the side and is internally rotated.
152
Signs that a baby is getting sufficient milk
1. 3-4 stools in 24 hrs
2. 6 wet diapers in 24 hrs
3. wt gain
4. sounds of sucking
153
If you suspect ruptured ectopic, whats next step in mgmt?
EXPLORATORY SURGERY (lap). Not methotrexate or DnC.
154
Pt has inappropriate hcg levels (dont rise 50% in 48 hours) and levels that do not fall after dx'ic D and C
Ectopic
155
Mag toxicity and solution
Muscle weakness, loss of DTReflexes, Respiratory Depression!, nausea
--> Administer calcium gluconate if need to restore respiratory function
156
How to diff. preeclampsia with or without severe features based on protein level?
24-hr Protein>300 = mild preE (no severe features)
| 24-hr Protein>5000 = PreE with severe features
157
Initial steps after fetal bradycardia
Improve maternal oxygen and CO to uterus:
1. Put pt on her side (move uterus away from vessels)
2. IV fluid bolus if V depleted
3. 100% O2 by face mask
4. Stop Pit
Also MUST do vaginal exam to assess for cord prolapse
158
If fetal bradycardia is due to hyper stimulation with Pit, what can be done?
Give beta-agonist such as terbutaline to relax uterine musculature
159
Lack of myometrial ctxs, resulting in a boggy uterus
Uterine atony
160
An ergot that induces myometrial ctxs to tx Uterine atony
Methergine (CI in HTN pt)
161
3 agents that can be used for Atony
1. Methergine (ergot. CI in HTN)
2. PGF2-alpha (CI in asthma pt)
3. Misoprostol (rectal. often preferred method)
162
Surgical therapy for atony if medical mgmt fails
1. Exploratory lap + uterine artery or internal iliac artery ligation
2. b lynch stitch
3. hysterectomy
163
If uterus is firm contracted while bleeding persists, what is the likely etiology of PPH?
Genital tract laceration. Also, uterine inversion, placenta accreta, retained placenta, and coagulopathy (if no laceration).
164
PPH that doesnt start until 2 weeks postpartum (secondary PPH)
usually due to Subinvolution of the Placental Site...eschar of placenta falls off. Tx with oral ergot (methergine)
165
what are the steps involved in "active mgmt of 3rd stage of labor" and why perform it
1. Pit immediately upon delivery
2. Late cord clamping
3. Gentle cord traction
Decreases risk/severity of PPH
166
Define chorionicity
The # of placentas. In monozygotic, can be MC or DC. In dizygotic, always DC (same rule applies for amnion)
167
Complications ass. with twins
1. Preterm delivery
2. Congenital malformations
3. Pre-E
4. PPH
5. Twin-Twin Transfusion
168
Link btwn OCPs and twins?
OCP slows tubal motility, which is a possible cause of twins (so increases incidence)
169
best imaging to detect vasa previa?
color Doppler ultrasound
170
mgmt if vasa previa is identified?
Planned c/s before ROM, around 35-36 wks gestation (note: digital vaginal exam is CI in vasa previa)
171
If fetal bleeding is uncertain, which two tests can differentiate btwn maternal and fetal bleeding?
Apt test and Kleihauer-Betke test
172
What to do if presence of prodromal sxs or genital lesions suspicious for HSV?
C/s to prevent neonatal infection
173
highest risk factor for neonatal HSV infection
acquisition of new maternal HSV infection near time of delivery
174
Painless antepartum (after 20 weeks) vaginal bleeding
```
Placenta previa (vs abruption usually painful)
-->may have postcoital bleeding earlier in preg
```
175
Next steps after patient complains of antepartum (after 20 weeks) vaginal bleeding
Ultrasound to rule out placenta previa BEFORE doing a speculum or digital exam (because these can induce bleeding)
176
Placenta accreta is more common with placenta _____
previa
| esp in presence of uterine scar i.e. prior c/s
177
Risk factors for Placental Abruption
1. HTN! (chronic and preE)
2. Cocaine use and Smoking
3. Trauma (MVA)
4. Uteroplacental insuff
5. PPROM
PREVIOUS HX OF ABRUPT. = #1 though
"Abruptly had High Blood Pressure after getting into an MVA while Smoking Cocaine"]
178
Bleeding into the myometrium of the uterus, giving a discolored appearance to the uterine surface
Couvelaire Uterus
179
Why can placental abruption lead to coagulopathy (esp in cases severe enough to cause fetal death)?
Hypofibrinogenemia
180
Painful antepartum vaginal bleeding
abnormal adherence of placenta to uterine wall (abnormal decidua basalis layer of the uterus)
181
Accreta vs Increta vs Percreta
Accreta: placenta attaches to the myometrium
Increta: Penetrates into myometrium
Percreta: All the way through myometrium, possibly adjacent organs
182
Risk factors for accreta
Low lying placenta, previa, prior C/s or uterine curettage, or prior myomectomy
183
Usual mgmt. of placenta accrete/previa
Prelabor c/s + hysterectomy at 34-35 weeks + beta-methasone
184
Where is appendicitis located in a pregnant patient?
Superior and lateral to McBurney point (because enlarged uterus pushes on appendix)
185
Tx for appendicitis in pregnancy?
Surgical, regardless of gestational age. + IV antibiotic
186
Why is there a risk of gallstones in pregnant patient?
Increase in gallbladder volume and biliary sludge = common physiologic effect of preg.
187
Most frequent and serious complication of a benign ovarian cyst
Ovarian torsion
188
most common cause of septic shock in pregnancy
Pyelo
189
how can we detect fetal anemia in utero?
Fetal Doppler. Middle cerebral artery peak systolic velocity
190
How do corpus luteum cysts develop?
From mature Graafian follicles; ass. with normal endocrine f(x) or prolonged progesterone
191
If corpus luteum cyst is excised, does anything need to be supplemented?
If pregnancy is less than 10-12 weeks, supplement with progesterone (placenta takes over for the corpus luteum in making progesterone after this)
192
Mother and father of fetus are both Rh-. When do you admin Rhogham?
You don't need to
193
Rh antibody screen comes back positive for Lewis antibodies. What are these and when do you give Rhogam?
They are IgM and thus don't cross placenta, so no need to admin Rhogham
194
Which type of twins are most likely to undergo Twin-Twin transfusion?
Diamniotic, monochorionic
195
Most common trisomy in abortuses?
Trisomy 16
196
between which weeks is fetus most susceptible to developing intellectual disability and microcephaly i.e. after radiation exposure
8-15
197
What should be documented before initating HRT for menopause sxs?
tissue dx consistent with normal endometrium, or a pelvic ultrasound with an endometrial stripe of <4mm ought to be documented
198
Which hormone replacement should not be used in woman with intact uterus?
Do not use estrogen-only b/c increased risk of endometrial cancer
199
Which of the following levels do we assess for dx of menopause: FSH, LH, Estrogen?
FSH only
200
Which is more effective for treating hot flashes, Estrogen or SERM (i.e. raloxifene, clomiphene)?
ESTROGEN
We do NOT use SERMS...these may actually cause hot flashes
201
HRT effect on lipids (note: not rec for primary prevention CVD)
Increase HDL
Decreased LDL
(estrogen increases TG and LDL catabolism and #LDL-R = lower LDL)
(HRT blocks hepatic lipase = less conversion of HDL = more HDL)
202
Menopausal patient has DEXA of -1.7. What's next step in mgmt. of pt?
Assess her risk factors for fracture
(prior fracture, FHx osteoporosis, race, dementia, hx of falls, nutrition, smoking, low BMI, E2 def, alcohol, physical activity)
203
Why does BSO in postmenopausal woman cause resurgence of menopausal sxs?
Abrupt drop in circulating androgens (which are peripherally converted to estrogen)
Note: Ovaries stop producing estrogen at menopause, but continue to produce androgen
204
Labs for Exercise-induced hypothalamic amenorrhea
Normal FSH
| Low Estrogen
205
Tx for exercise-induced hypothalamic amenorrhea
Gain wt by less exercise and more calories
| If menses fail to resume, can use exogenous gonadotropins (LH and FSH); clomiphene does NOT work
206
What is a clomphene challenge test and what does it tell us?
Give clomid on days 5-9 of menstrual cycle; check FSH on day 3 and day 10
Determines Ovarian reserve
207
What is better for maximizing chances of pregnancy, Ovulation predictor kits or basal body temperatures?
Ovulation predictor kits, because it tells you before you ovulate, versus BBT tells you after
208
Premenstrual dysphoric disorder (PMDD) occurs during which phase of menstrual cycle?
functional impairment present during last week of luteal phase and begin to resolve with beginning of follicular phase
209
Which vitamin deficiencies are associated with increased PMS?
Vitamin A, E, and B6
210
T/F: SSRIs can be used to tx PMS
True
211
Why does Exercise improve PMS sxs?
Release of endorphins (and NOT related to estrogen)
212
Risk factors for developing PMS
Family Hx
| Def of B6, Calcium, or Magnesium
213
Describe the basic mechanism/defect causing cholestasis in pregnant patient
Intrahepatic Cholestasis of Pregnancy (ICP) --> bile salts are incompletely cleared by the liver, accumulate in the body, and deposit in the dermis
214
Which trimester does cholestasis in a pregnant patient typically occur?
3rd
215
Treatment of choice for ICP (cholestasis)
UDCA (Ursodeoxycholic acid)
| Also, BPP or NST, and plan to deliver @37-38 weeks (increase risk of stillbirth)
216
What's the consideration for contraception in women with prior ICP?
Cholestasis and pruritis may recur with the use of OCP/estrogen containing meds, so alternative contraception should be recommended
217
What's the etiology of Herpes gestationis?
Autoimmune (No relation to HSV)
218
What are the 5 components of BPP?
1. NST
2. Fetal breathing
3. Fetal tone
4. Fetal movement
5. Amniotic fluid volume
Each scored 0 or 2. Scores 8/10 with normal amniotic fluid, or 10/10 are reassuring.
219
Pulse ox of less than 90% corresponds to an O2 of ____
less than 60 mmHg
220
A clear chest radiograph in the face of hypoxemia
PE
221
If fetus is breech, which body part is most likely palpable?
Buttocks.
| So frank breech is most common. Incomplete (footling) is less so.
222
Threatened abortion occurs during which trimester?
First (so before week 12ish)
223
Cervicitis is caused by:
Chlamydia, Gonorrhea, Trichomonas, or other infections -->presents as vaginal bleeding
224
What is the role of Nifedipine, Ampicillin, and Prostaglandin's i.e. in preterm labor
Nifedipine: Tocolytic
Ampicillin: GBS prophylaxis for status unknown
Don't use PG's -->utertonic agents increase ctx rate
225
What should be done prior to digital examination if you are suspecting preterm labor?
Fetal Fibronectin assay -->swab the posterior vaginal fornix for fetal fibronectin
226
What do + and - results indicate on Fetal fibronectin assay
+: Risk of preterm birth
| -: Strongly ass. with no delivery within 1 week
227
A basement mem protein that helps bind placental membranes to the decidua of the uterus
Fetal Fibronectin Assay
228
What is sufficient to make the dx of Preterm Labor?
Contractions + 2cm dilation and 80% effacement (btwn 20-37 weeks)
229
4 commonly used Tocolytic agents
1. Nifedipine
2. Indomethacin
3. Terbutaline
4. Ritodrine
230
If delivery is before ____ weeks, Mag should be given for neuroprotection (cerebral palsy)
32
231
Cervical length of
25
232
What is funneling (of cervix)?
Impinging of the amniotic cavity into the cervix --> Increases the risk of preterm delivery
233
Biggest risk factor for preterm delivery?
Prior spontaneous preterm birth
234
Side effect of Nifedipine
Pulmonary edema and respiratory depression
235
What is the goal of Antenatal steroids (given btwn 23-37 weeks)?
<28 weeks: Lower risk fo Intraventricular hemorrhage
| >28 weeks: Prevent respiratory distress syndrome
236
What can you do between weeks 16-36 to prevent a high risk (prior hx) patient from preterm birth?
Weekly injection of 17 alpha-hydroxyprogesteronecaproate (blocks AP gonadotropin release; maintains pregnancy)
237
Which infection is ass. with increased risk of Preterm labor?
Gonorrhea (more so than Chlamydia)
238
What are the sequelae from Indomethacin closure of PDA?
Pulmonary hypertension and Oligohydramnios. May see variable decels (from cord compression from oligo)
239
If a patient presents at 28weeks with preterm contractions and dilation to 1cm and 50% effaced, has a fever, tender fundus and elevated wbc count but category 1, what do you do?
She has intra-amniotic infection: Thi sis an indication for delivery. You INDUCE LABOR, instead of giving tocolytics.
240
Side effects and CI of terbutaline and ritodrine (beta agonists)
Cause Pulm Edema, increase Pulse Pressure, Hyperglycemia, Hypokalemia, and Tachycardia.
CI in Diabetic pts, HTN, seizure, and arrhythmia
241
1. Drugs that prevent calcium entry into muscle cells by inhibiting calcium transport
2. Drugs that compete with calcium entry into cells
3. Drugs that increase cAMP in the cell = decrease free calcium
1. CCB's i.e. Nifedipine
2. Mag sulfate
3. Beta agonists (terbutaline/ritodrine)..also relax smooth muscle
242
Side effects of mag sulfate (competitively inhibits calcium entry)
Areflexia first, then Pulmonary Edema, Respiratory Depression and Cardiac Depression
243
When a patient is admitted with PPROM, what are indications for delivery ?
Infection
Abruption
Nonreassuring fetal status
-->Deliver these at 34 weeks.
PPROM>34 weeks, can also deliver
244
How is dx of PPROM confirmed after a patient complains of a "gush of fluid"?
1. Speculum exam showing pooling of amniotic fluid in the posterior vaginal vault
2. + Nitrazine test (shows ALKALINE changes of vag fluid)
and
3. Ferning patern of fluid on microscopy
-->speculum is neg but suspicion high, and US shoulding oligo is consistent with PPROM
4. AmniSure immunoassay
245
What is the AmniSure immunoassay?
- Test for PPROM
| - checks for Alpha Macroglobulin-1 = protein with 10,000x more conc. in amniotic fluid
246
Common complications of preterm delivery
Respiratory distress syndrome
Chorio
Abruption
Necrotizing enterocolitis
247
What type of decal would you expect after PPROM?
Variables due to cord compression due to Oligo
248
What does presence of Phosphatidyl Glycerol (PG) in vaginal fluid?
Fetal Lung Maturity!! You may now deliver, and should not give steroids .
249
Which organism can cause Chorio without rupture of membranes?
Listeria
250
Which antibiotics do you give to PPROM patient?
Ampicillin and Erythromycin...prolongs latency period by 5-7 days (more so than tocolytics)
251
Ruptured membranes and a tender fundus indicate:
Chorio
| -->Proceed to delivery
252
What are prostaglandins used for and when are they CI?
Used for cervical ripening (CERVIDIL)
CI if previous C/s
253
what does fetal tachycardia typically indicate?
maternal fever/chorio
254
T/F: BPP has no value during labor
True
255
Initial measures to treat fetal hypo perfusion (late decals)
- change mom to left lateral position
- O2 supp
- tx mom hypotension
- DC Pit
- maybe tocolytics/fluids
-->all are measures to improve uteroplacental blood flow (before jumping to c/s)
256
Risk factors for Uterine Atony
- Precipitous labor (<3hrs)
- Multiparity
- General anesth.
- Pit
- Prolonged Labor
- Macrosomia
- Hydramnios
- Twins
- Chorio
257
Cytotec =
Cytotec = Misoprostol = Prostaglandin E1 (analog)
258
Methergine =
Methylergonovine = Ergot
259
Hemabate =
Prostaglandin F2-alpha = Carboprost
260
3 drugs used as uterotonic agents to stop PPH
1. Oxytocin (Pit)
2. Prostaglandins (Hemabate = PG F2alpha; Cytotec - PGE aka misoprostol)
3. Ergot(Methergine =Methylergonovine)
261
Which uterotonic agent should not be used in Asthmatic?
PGF2 = Hemabate = potent smooth m constrictor and bronchio constrictor
262
Who should methergine not be given to?
Its a vasoconstriction agent --> avoid in HTN and preE pts
263
Factors ass. with retained placenta:
1. Prior C/s
2. Fibroids
3. Prior curettage
4. Succenturiate lobe of placenta
264
Lack of gonadal f(x) is indicated by high ____ levels
FSH
265
Lack of gonadal f(x) phenotype in XY vs XX
XY: Female genitalia, b/c MIF and testosterone not produced
XX: Ovarian failure -> Primary amenorrhea and incomplete breast dev.
266
How to diff. btwn Mullerian agenesis and AIS?
AIS has high testosterone
267
Patients with ovarian failure should be given:
Estrogen and progestin treatment (promote secondary sex characteristics, reduce risk osteoporosis)
268
Prolactin concentrations are ____ in women with amenorrhea
Higher
269
Thrombosis of the venous system and pelvis, leading to postpartum infection
Septic thrombophlebitis...treat with heparin anticoagulation + antibiotics (be careful, q stem may say theyre already on broad spectrum antibiotics)
270
Patient has fever 20 hours after C-section...what's most likely cause and what is your next step in mgmt.?
ATELECTASIS
| Get a CXR!
271
What is one of the earliest signs of fetal hydrous?
Hydramnios/excess amniotic fluid (uterine size greater than that predicted by dates + fetal parts difficult to palpate)
272
"No evidence of harm to fetus in animal studies; however, therea are no adequate and well-controlled studies in pregnant woman or animal studies that have shown adverse effect"
Category B Drugs
273
"Adverse effects have been shown in animal studies and there are no good studies in humans, but potential benefits may warrant use of drug"
Category C Drugs
274
"Good studies in pregnant women have shown known risks to fetus"
Category D Drugs
275
"Drugs that should not be used in pregnancy, because studies have shown positive evidence of fetal abnormalities"
Category X Drugs
276
3rd trimester SSRI use side effects:
- Agitation
- Increased/decreased muscle tone
- Tremor
- Sleepiness
- Severe difficulty breathing
- Difficulty In feeding
(note: Safe to use during breastfeeding though)
277
this test assesses uteroplacental insufficiency and looks for persistent late decels after contractions
Contraction stress test (can usually just do NST though)
278
Post term pregnancies can be caused by:
1. Placental sulfatase deficiency
2. Fetal adrenal hypoplasia
3. Anencephaly
4. Inaccurate dates
5. Extrauterine pregnancy
(so NOT AFP def, adrenal hyperplasia, or renal/chromosomal abnormalities)
279
Post term pregnancies can result in:
1. Macrosomia
2. Oligohydramnios
3. Meconium aspiration
4. Uteroplacental insuff
5. Dysmaturity
280
Infant that looks withered, meconium stained, long-nailed, fragile, and associated small placenta
Fetal Dysmaturity --> high risk when gest. age exceeds 43 weeks...great risk for stillbirth
281
Ultrasound of ________ = best way to date a pregnancy in first trimester
Crown-rump length (as opposed to gestational sac)
282
When thinking about PPROM, after which gestational age would treatment be to go ahead and deliver?
After 34-35 weeks
283
Parvo infections in pregnancy may cause fetal infection, that can lead to suppression of :
erythrocyte precursors of bone marrow...severe aplastic anemia can result, leading to fetal hydrops
284
What is one of the earliest signs of fetal hydrous?
Hydramnios/excess amniotic fluid (uterine size greater than that predicted by dates + fetal parts difficult to palpate)
285
Classic triad of rubella sxs
1. Cataracts
2. Sensorineural deafness
3. Cardiac defects (pulm artery stenosis + PDA)
-may also see microcephaly, IUGR, thrombocytopenia purpura
286
Erythema infectiosum is caused by:
Parvo b19 (ss-DNA virus)
287
Excess fluid in body cavities, such as ascites, skin edema, pericardial effusion, pleural effusion
Fetal hydrops
288
What does a sinusoidal heart rate on FHT indicate?
Severe fetal anemia or asphyxia (can evaluate using Middle cerebral artery Doppler)
289
Most common congenital infection in the US
CMV (DNA virus)
290
CMV complications in infants
- Microcephaly
- Periventricular calcifications
- Deafness
- Chorioretinitis (blindness)
- Seizures
- Interstitial Pneumonia
291
Transmission of CMV is highest in the ____ trimester; neonatal effects are worst in the ____ trimester
3rd
| 1st
292
What's the tx for CMV?
There is NONE
| PREVENTION: Careful hand washing, avoid sharing utensils esp. with children
293
Best method to dx Toxo?
PCR
294
Classic triad of Toxoplasmosis sx's
1. Chorioretinitis (blindness)
2. Hydrocephalus
3. Intracranial calcifications
295
Tx for Toxo
- Pregnant women are tx with SPIRAMYCIN to reduce transplacental transfer
- Fetal infection is tx w/pyrimethamine and sulfadiazine
296
RNA Togavirus
Rubella
297
Maternal infection with ____ in the 1st 8 weeks confers an 80% risk of major congenital defects; 50% btwn 9-12 weeks; no risk at 20+ weeks
Rubella
298
Classic triad of rubella sxs
1. Cataracts
2. Sensorineural deafness
3. Cardiac defects (pulm artery stenosis + PDA)
-may also see microcephaly, IUGR, thrombocytopenia purpura
299
What is the tx for rubella?
None...prevention is by immunization of susceptible patients
300
Most common cause of hyperthyroidism in pregnancy
Graves -->Tx = PTU
301
Since Methimazole (MMI) and PTU both tx Graves and both can cross the placenta, which drug do you use?
1st Trimester: Use PTU...MMI has been linked to aplasia cutis (congenital skin or scalp defects)
2-3rd Trimester: Use MMI...PTU linked to hepatic toxicity
(radioactive iodine is always CI in preg)
302
How is the fetus protected if maternal hypothyroidism is identified?
Maternal PTU or injection of intra-amniotic thyroxine (fetal hypothyroidism)
303
What is the cause of Postpartum thyroiditis (Hyper->Hypo->Eu) (~5%)
Similar to Hashimotos...Anti-microsomal and Anti-Peroxidase antibodies
304
Mgmt for thyroid storm in preg
Beta blocker (Propranolol), corticosteroids, and PTU/MMI
305
What is the implication of maternal Graves on the fetus?
Can cause fetal hyperthyroidism due to IgG antibodies crossing the placenta
306
Effect of pregnancy on thyroid proteins?
Total thyroxine: Increased
Free T4: no change
TSH: no change
Thyroid-binding globulin: Increased
307
Kidney stones, lethargy, and pain that presents in pregnancy:
Hyperparathyroidism -->2nd trimester surgery = tx
308
Factors affecting head growth (IUGR)
Chromosomal abnormalities
| Severe and early intrauterine infections (TORCH)
309
List TORCH infections
Toxoplasmosis
Rubella
CMV
Herpes
310
Factors of IUGR that will preserve head size but affect rest of body (asymmetric)
Situations of relative hypoxia or decrease in nutrients provided to the fetus
311
Most common cause of asymmetric IUGR
maternal vascular disorder: HTN, smoking, illicit drug use
312
most common cause of symmetric IUGR
Simply a constitutionally small baby with no adverse problems.
313
Maternal risk factors contributing to IUGR
1. HTN disease (cHTN or preE)
2. Renal disease
3. Cardiac/respiratory distress
4. Underweight/poor pregnancy wt gain
5. Significant anemia
6. Cocaine/Tobacco
314
Uterine placental factors contributing to IUGR
1. Placenta abruption
2. Placenta previa
3. Infection (toxo, HSV, Parvo)
(placenta is important for nutrients and transportation btwn mother and fetus)
315
What's the difference btwn Small for gestational age and IUGR?
Both are <10th percentile weight
SGA is for infant, IUGR is for fetus
316
Why do we repeat US for fetal growth in 3 weeks after suspecting IUGR?
to evaluate severity: No growth after 3 weeks = profound IUGR; normal interval growth = constitutionally small baby or dating error
317
Asymmetric vs Symmetric IUGR
Asy: Preserved Head Circumference, but Abdominal Circumference and Femur Length lag behind
Symm: HC, AC, and FL are all small
318
Combo of US criteria + NST to assess fetal well-being over 30 minutes; fetal breathing, movement, tone and amniotic fluid are assessed
BPP
319
With IUGR, Doppler flow in the ____ is helpful
Umbilical artery
320
When assessing flow through umbilical artery via Doppler US, what is the significant of "reverse end-diastolic flow"
Associated with a high stillbirth rate within 48 hours
| "Absent end diastolic flow" has moderate high stillbirth risk"
321
The pathophysiology of ______ = "leaky capillaries"
ARDS...fluid from intravascular space permeates into the alveolar areas
322
Pyelonephritis can lead to: (3)
1. Preterm labor
2. Preterm delivery
3. ARDS
323
Which antibiotics can be used for pyelo?
Cephalosporins OR Amp-Gent
| Give suppressive therapy for remainder of pregnancy after acute incident resolved (w/Nitrofurantoin 100mg daily)
324
What should you suspect if peel is not improving clinically after antibiotics 48-72 hours later?
Urinary tract obstruction (ureterolithiasis) or perinephric abscess
325
Why do patients with identified Pyelo sometimes develop ARDS?
Antibiotic therapy causes release of endotoxins from cell wall to enter blood stream -->Endotoxinemia (also causes uterine contractions and preterm L and D)
326
Risk factors for developing endomyometritis
Long labor, IUPC, numerous vag exams, low socioeconomic status, multiple gestations, young maternal age, GBS, chamydia, manual extraction of placenta
327
When physical exam does not reveal a focus, including no dyspnea, what is most like cause of fever after c/s?
Endomyometritis -->usually polymicrobial and due to ascending vagina l organisms. May have foul-smelling lochia
328
Tx for endomyometritis
IV Gentamicin + Clindamycin = good anaerobic coverage post c/s
if post vaginal, can just do Ampicillin + Gentamicin
"For c/s, us G&C; For V, remember that V stands for vAG"
329
You tx endomyometritis with Gent/Clind but no improvement in 48 hours. What are you concerned about and how do you manage?
Concerned about enterococcal infection --> Add Ampicillin
Other possibility is wound infection (fever post op day 4)--> surgical debridement + antimicrobials
330
Tx for mastitis
Dicloxacillin (anti-staph)
| -->if fever still persists 48 hours later, suspect abscess
331
Tx for breast engorgement
Breast binder, ice packs, and analgesics
332
Fluctuance of the breast indicates:
Abscess
333
Best tx of cracked nipples:
Air drying and avoidance of harsh soap
334
How is DKA dx once suspected?
STAT arterial blood gas, blood sugar, electrolytes with anion gap, and serum ketones
335
Most important initial tx if mother goes into DKA?
IV fluid infusion with 2 large bore IV's using isotonic solution (normal saline)
336
Fetus is showing late decels and mother is showing very high glucose and signs of DKA...why the late decels and how soon do you go to c/s?
Maternal acidosis translates to fetal acidosis. Acidosis causes late decels. Don't need c/s because correction of maternal acidosis should correct fetal acidosis.
337
Dx criteria for DKA in pregnancy
1. pH<7.35
2. glucose >200
3. Ketones >5
4. can also see bicarb <18 + ketonuria
338
T/F: Pregestational diabetes and Gestational diabetes put fetus at risk of miscarriage and congenital anomalies, as well as ocular and renal disease
False...these risks are associated with Pre-gestational diabetes (due to exposure during conception and embryogenesis)
339
Leading cause of blindness in reproductive age women
Diabetic retinopathy
340
Fasting and 1 hour postprandial glucose targets in pregnancy
<105
| <140 1 hour post prandial
341
When do you want to deliver in diabetic patients?
If well controlled: 39 weeks
| Poorly controlled: Before 39 weeks (after fetal lung maturity is confirmed)
342
Elective c/s should be considered in diabetics with EFW of > ______g due to potential for _______
4500g
| Shoulder dystocia
343
Maternal hyperglycemia during L&D leads to neonatal ______
hypoglycemia --> increased risk of neurodevelopment delay
344
DKA occurs more commonly in _____ trimester due to increased ___ levels and should be suspected with an arterial pH of < _____
2nd-3rd trimester b/c increased hPL
| pH<7.35
345
When is routine screening for gestational diabetes performed?
26-28 weeks. Can do early screen @16 for high risk pt
346
Postpartum mgmt for GDM pts?
Screen for overt DM using 75g oral GTT @6 weeks postpartum
347
Should GDM pts breastfeed?
Yes, because it can decrease maternal weight, as well as childhood obesity
348
Fundal height at umbilicus corresponds to :
20 weeks
349
Pt has prenatal Pap smear showing ASCUS, what's next step in mgmt? What about LGSIL/HSIL?
ASCUS: Observe and repeat Pap postpartum
| LGSIL/HSIL: Colposcopy
350
Fundal ht in CM corresponds to gestational age from ___-____ weeks. If there is a discrepancy of more than ___cm, an US is needed
20-34
| 3cm
351
T/F: Some abnormal findings will be normal in pregnancy, such as glycosuria (due to increase GFR); other seemingly normal findings are worrisome, i.e. PC02 level of 40 (indicates severe CO2 retention)
True
352
When do you give rubella vaccine to a pregnant pt who is non-immunized?
Postpartum since its a Live attenuated; stay away from sick individuals.
353
If pregnant pt has +RPR or VDRL, what is the mgmt?
if <1 year: Penicillin x1
| >1 year: Penicillin IM each week x3
354
Tx for chlamydia in pregnant
Azithromycin or Amoxicillin (no Doxy in preg)
355
Preg pt has +HBsAG, how do you manage?
Check serology to see if chronic vs active; Baby needs HBIG + HBV vaccine
356
T/F: Nuchal Translucency done @ 11-13 weeks;
Trisomy screen @16-18 weeks;
GBS culture @35-37 weeks
True
357
T/F: Starting at age 45, screening includes Lipid profile q5 and Fasting blood glucose q3; @50, start TSH q5 years
True
358
Screening in HIV-positive women
1. Pap smears twice in first year after dx/entry of care, and then annually
2. Usual immunizations EXCEPT varicella zoster (withheld)
3. Pneumococcal 13 valent
359
T/F: Most common cause of mortality in women <20 years = MVA; in woman >39 = Cardiovascular Disease
True
360
Most common infections ID'd after sexual assault (4)
Trich, Gonno/Chlam, Hep B
| -->common regimen = Ceftriaxone, Metronidazole, Azithromycin and HBIG + HBV vaccine if not immunized
361
most effective form of emergency contraception
Copper IUD inserted within 120 hours postcoital
362
If a patient has signs and sxs of pyelo after a laparoscopic procedure/hysterectomy, what should you be suspicious about?
Ureteral obstruction/injury --> do IV Pyelogram or CT abdomen w/contrast
363
Procedure in which placement of a stent into the renal pelvis though the skin under a radiologic guidance to relieve a urinary obstruction
Percutaneous Nephrostomy
364
Most common location for ureteral injury?
@the Cardinal Ligament (through which uterine arteries traverse...water under the bridge)
365
Cervical motion tenderness suggests:
PID
366
causes of Cervicitis (mucopurulent discharge)
GC, Chlamydia, OR TRICH (can cause both vaginitis and cervicitis)
367
Most common cause of septic arthritis in females
GC
368
T/F: IUD increases risk for PID, OCP decreases risk for PID
True
369
Patient has PID and nan adnexal mass. Dx?
Tubo-ovarian abscess -->can be medically tx with IV antibiotics (include clinda or metro for anaerobic coverage
370
pelvic pain + tender nodules of the uterosacral ligament or retroverted uterus
Endometriosis
371
Woman has a vulvar ulcer, you do PCR for HSV, its negative. You do Darkfield microscopy for syphilis, its negative. What do you assess for next?
Candida, HIV, EBV
372
most common sx of fibroids
Menorrhagia (excessive bleeding)
373
few things to consider when intermenstrual bleeding
endometrial hyperplasia, endometrial polyp, cancer, fibroids
374
what is the leading indication for hysterectomy in the US?
Fibroids
375
Irregular, firm, midline nontender mass that moves contiguously with the cervix
Fibroid
376
What is the medical tx for fibroids?
- Start with NSAIDS or progestin
- GnRH agonists lead to decrease in size within 3 months (only used prior to operation)
- levongesterol IUD (for pts w/o distortion of uterine cavity)
377
Most common cause of spontaneous abortion?
chromosomal abnormality of the embryo (karyotypic abnormality)
378
Pregnancy w/vaginal spotting during 1st half of pregnancy; does not delineate viability of preg
Threatened abortion
379
A pregnancy <20 weeks w/cramping, bleeding, and cervical dilation; no passage of tissue
Inevitable abortion
380
A pregnancy <20 weeks w/cramping, bleeding, and open cervical os + some passage of tissue through vagina/some retained in utero
Incomplete abortion
381
What is the state of cervix and uterine ctxs in an incomplete abortion?
Cervix remains open due to continued uterine ctxs -->ctxs b/c trying to expel the retained tissue
382
A pregnancy <20 weeks in which all products of conception passed, cervix is closed
Completed abortion
383
What is the state of cervix and uterine ctxs in a complete abortion?
Cervix closed, ctxs have stopped
384
A pregnancy <20 weeks w/embryonic or fetal demise but no sxs such as bleeding or cramping
Missed abortion
385
how is a noviable IUP managed?
1. Expectantly
2. D and C (surgical)
3. Misoprostol (medical)
386
T/F: Rh negative women with threatened abortion, spontaneous abortion, or ectopic pregnancy should receive RhoGAM to prevent isoimmunization
True
387
Painless cervical dilation in 2nd trimester
Insufficient cervix (there will be no ctxs; vs in inevitable abortion, ctxs are what leads to cervical dilation)
388
Vaginal spotting, absence of fetal heart tones, size greater than dates, and markedly elevated hCG levels
Molar pregnancy (trophoblastic tissue without a fetus) -->Snowstorm appearance on US --> do suction curettage
389
What are the types of spontaneous abortion?
Threatened, Inevitable, Incomplete, Complete, and Missed
390
Which types of abortion present with open cervical Os
Inevitable and Incomplete
| so os is closed in Threatened, Complete, and Missed
391
Which types of abortion present with passage of tissue
Incomplete (some), and Complete
| so not seen in Threatened, Inevitable, or Missed
392
Whats the DDx for patient with threatened abortion?
Viable IUP, Spontaneous abortion, or Ectopic pregnancy
393
Hx of DVT makes which type of contraception CI?
Estrogen-containing (OCP, Patch, or Ring)
394
In a pt with heavy menses and hx of DVT, which contraception would you recommend?
Mirena (levonorgesterol IUD), Nexplanon (progestin implant), or Depo (Depot medroxyprogesterone acetate) --> the progestin helps thin the endometrial lining and reduce bleeding; anything w/E2 is CI b/c DVT
395
T/F: IUD protects against STI
False
396
How is diaphragm used?
Must be fitted by a physician. Placed 1-2 hours before sex, use with spermicide, leave inside for at least 8 hours after
397
How is a cervical cap used?
Fitted by a physician. Can be left in place for up to 48 hours and is more comfortable. Only for use in women with normal cervical cytology
398
Most common side effects of OCPs
Nausea, breast tenderness, fluid retention
399
main risks of OCPs
Venous Thromboembolism, Stroke (in pt w/migraine and aura), MI (women who are smokers)
400
non-contraceptive benefits of OCPs
1. increase risk of ovarian, colon, or endometrial cancer
2. Shorter duration of periods
3. Less blood loss during periods
4. Improving pain from dysmenorrhea/endometriosis
5. Less AUB
6. Improves acne
401
CI's to estrogen
- hx of thromboembolic disease
- age>35 that smoke
- women who develop N/V on OCPs
- women who are lactating
402
T/F: OCPs decrease risk for ovarian and endometrial cancer
TRUE
403
T/F: Hysterectomy is the choice procedure for permanent sterilization
False...not done for this. Do Essure coils
404
T/F: Obesity and having chronic problems increase risks during general anesthesia and surgery
True. Therefore, this patient would benefit more from partner vasectomy than personal tubal ligation
405
Who should not use the patch for contraception?
Pts who weigh >200 lbs
406
T/F: In a septic abortion, the cervix is closed
FALSE: CERVIX IS DILATED
407
Tx with 17-hydroxyprogesterone (17-OH progesterone) is indicated in a patient with:
Prior hx of preterm birth
408
Antiphospholipid antibodies are associated with:
recurrent pregnancy loss
409
Hx of dvt or recurrent pregnancy loss, +anti-cardiolipin, prolonged dilute Russel Viper = _______, tx with _____
antiphospholipid syndrome; tx with HEPARIN + aspirin (NOT corticosteroids)
410
Medical abortion is ass. with higher _____ than surgical
higher blood loss
411
Pt has a missed abortion @ 10 weeks gestation; whats best medical mgmt?
Misoprostol (PG) --> will induce uterine cramping with expulsion.
(vs Mifepristone is for termination; Oxytocin is not effective @ this gestational age)
412
CI to IUD placement
1. Current pregnancy
2. Current STI
3. PID: Current or w/in 3 months
4. Unexplained vaginal bleeding
5. Malignant gest. trophoblastic disease
6. Untreated Cervical or Endometrial cancer
7. Fibroids distorting endometrial cavity
8. Curent breast cancer (no Mirena)
9. Pelvic TB
413
main side effect of emergency contraception pills:
nausea and vomiting (GI)
414
Firm, contender, rubbery breast mass, typically mobile and occurring in young women
Fibroadenoma --> confirm dx w/biopsy
415
Best breast imaging for younger patients
Ultrasound > mammography due to dense breast tissue
416
Cyclic, painful, engorged breasts, more pronounced just before menstruation, occasionally w/serious or green breast discharge
Fibrocystic changes
417
Breast changes described as multiple, regular, with lumpiness of the breast
Fibrocystic changes (benign)
418
Tx for fibrocystic breast changes
Decrease caffeine ingestion, add SNAID, a tight-fitting bra, OCP, or oral progesterone
419
A mass that feels separate from the remainder of the breast tissue
Dominant breast mass
420
BRCA1 is located on chromosome ___, BRCA2 on ___
BRCA1 on 17
| BRCA2 on 13
421
Most important risk factor for developing breast cancer
AGE
422
Clinical breast exam should be preferred every ____ years in women aged _____
every 3 years in women 20-39
| every year if over 40 + mammogram
423
Mammogram guidelines
ACOG says year CBE and mammo after 40; USPSTF says biennial mammo in ages 50-74
424
Pt has dominant breast mass and negative mammogram. Next steps?
Can't fully trust the mammogram (10% FN's) --> proceed w/histologic diagnosis
425
What's the recommended imaging for screening women with 20% or higher lifetime breast cancer risk (i.e. BRCA)
its actually MRI...
426
Why does hypothyroidism cause galactorrhea?
Hypothyroid = elevated TRH --> acts like a prolactin-releasing hormone
427
causes of galactorrhea
1. Pregnancy
2. Pituitary adenoma
3. Breast stimulation
4. hypothyroidism
5. chest wall trauma
6. meds (TCA, anti-HTN, OCP, narcotics)
428
physiology of irregular menses due to hypothyroidism
Elevated TRH and TSH; hyperprolactinemia (from TRH) = increase dopamine...this produces GnRH = disrupt pulsatile GnRH release = follicle development disrupted = E2 decreases and menstrual cycles become irregular/cease
429
When patient has irregular menses due to hypothyroidism, what will be the response to a progestin challenge?
There will be no bleeding in response, since there will be insufficient endometrium
430
What should you keep in mind when measuring Prolactin levels?
Prolactin should be measured in the morning (b/c it is @ lowest physiologic level)
431
What's the risk of a patient with galactorrhea and regular menses for having prolactinemia?
relatively low, because hyperprolactinemia = common cause of menstrual disturbances
432
What causes sheehan syndrome?
Hypotension in the setting of PPH --> hypertrophy of prolactin-secreting cells -->hemorrhagic necrosis of the AP gland
433
Asherman syndrome (intrauterine adhesions) due to:
curettage that damages decidua basalts layer *so endometrium is unresponsive)
434
When a women is hypoestrogenic, what are the 2 main general causes and how can you diff. them?
```
Hypothalamic/Pituitary diseases
Ovarian failure (Elevated FSH Level)
```
435
2 most common causes of secondary amenorrhea after PPH: Sheehan syndrome vs Asherman (intrauterine Adhesions: LH surge, cortisol/ prolactin (ability to breastfeed), bleeding when given E2/P
Sheehan: No LH surge, low cortisol and prolactin, Yes bleed
Asherman: Normal LH surge, cortisol, and prolactin; no bleed
436
Define delayed puberty
Lack of secondary sex characteristics by age 14
437
Most common cause of precocious puberty in women?
Idiopathic --> tx w/GnRH agonist
438
What's the first sign of puberty?
Breast budding (thelarche), avg age = 10.8 (next is pubic/axillary hair @ 11).
439
When does growth spurt and menarche occur (relatively)?
Growth spurt 1 year after thelarche, around 12 years.
| Menarche = 2.3 years post thelarce = 12.9
440
What is hypergonadotropic hypogonadism?
High FSH, Low Estrogen --> due to gonadal def. Most common cause of this type of delayed puberty = TURNER'S
441
mgmt goals for patient with delayed puberty
1. Initiate and sustain sexual maturation
2. Prevent osteoporosis from hypoestrogenemia
3. Promote full height potential
442
Tx for Hypergonadotropic Hypogonadism (i.e. turners)
Since its a High FSH, Low E2 state...give unopposed E2 for 2-3 years before progestin is added -->E2 will promote growth of bones and breasts. Can then give OCP (E protects against osteo; p against endometrial cancer)
443
How is precocious puberty defined clinically
breast development before 7 (whites) or 6 (blacks)
444
Dx of precocious puberty (LH and FSH levels)
LH and FSH barely detectable: Peripheral cause= Granulosa cell tumor, McCune Albright, Adrenal tumor
LH and FSH in reproductive range: Central cause = brain tumor, meningitis, hydrocephalus, head trauma
445
Height of child with untreated precocious puberty
Initial taller than peers, but early long bone epiphyseal closure = eventual height shorter
446
Acceptable initial testing for endometrial cancer
1. Endometrial biopsy
| 2. Transvaginal ultrasound
447
T/F: A blind sampling of the endometrium, with biopsy device, is not very good for detecting cancer
False, it has a 90-95% sensitivity so its a good test. If negative, can do hysteroscopy for direct visualization
448
Most common cause of postmenopausal bleeding
Atrophic endometrium --> friable tissue of endometrium/vagina due to low estrogen levels
449
What's the usefulness of identifying endometrial stripe
Tells us thickness on transvag ultrasound.
| Thickness >4mm = abnormal in postmenopausal woman
450
Endometrioid, estrogen-dependent cancer in perimenopausal/early menopause pt with classic risk factors of unopposed estrogen. Low grade
Type 1 Endometrial Cancer (ESTROGEN DEPENDENT)
451
Aggressive disease w/cell types of papillary serous or clear cell, estrogen independent. Late menopausal women, thin patients, or having regular menses.
Type 2 Endometrial Cancer (ER NEGATIVE)
| -->more likely to have thin endometrial stripe
452
Endometrial hyperplasia + atypia strongly associated with:
Endometrial Cancer
453
Presence of ascites + weight loss
ovarian cancer
454
Gyn cancer presentation in order of prevalence:
1. Postmenopausal vag bleeding
2. Abnormal vag bleeding/friability/mass
3. leading cause of gynecologic cancer death
4. itching/ulcer/mass
1. Endometrial
2. Cervical
3. Ovarian
4. Vulvar
455
benign cystic teratoma containing thyroid tissue = hyperthyroid sxs
Struma ovarii
456
Germ cell tumors
Ovarian tumors presenting in younger women (20-30s)
- Dysgerminoma
- Endodermal sinus tumor
- Embryonal carcinoma
- Choriocarcinoma
- Teratoma (mainly mature/benign cystic teratoma)
- Polyembryoma
457
Hypo echoic area, or echoic band-like strand in a hypo echoic medium, or appearance of a cystic structure with a fat fluid level
Ultrasound appearance of Demoid cysts aka mature benign cystic teratomas
458
MRI of ovary shows complex multilobulated massed with thick septa
Struma ovarii (thyroid tissue)
459
secondary amenorrhea, Progestin challenge tests results in bleeding:
Probably PCOS
460
Secondary amenorrhea, no bleeding in response to Progestin challenge and no abnormality in prolactin or tsh
1. Outflow tract problem (normal E2)
2. Premature Ovarian failure (low E2, high FSH/LH)
3. Hypothalamic/Pituitary prob (Low E2, low FSH/LH)
461
Tx of choice for Asherman (intrauterine adhesions)
Operative hysteroscopy --> allows direct transection of adhesions
462
What is the post-op mgmt after operative hysteroscopy for Ashermans?
IUD or a pediatric Foley catheter for 7 days to prevent the recently lysed adhesions from reforming
--> also, consider Depo/E+P admin
463
When is 1st trimester screen performed?
10-13 weeks
| -->PAPP-A and b-hCG or transvag US for nuchal translucency = risk of Downs and Trisomy 18
464
When is trisomy (triple) screen done?
| look for Downs, tri 18, or neural tube defects
15-21 weeks (second trimester)
-->Maternal AFP, hCG, inhibin-A, and unconjugated E2
(remember, 21 and 18 also looked at during 1st tri screen)
465
Where is AFP made?
Alpha-fetoprotein first made by fetal yolk sac, and later by fetal GI tract and Liver
-->Increases if there is a neural tube opening
466
What levels of maternal AFP are suspicious for neural tube defects?
>2.0-2.5 MOM
467
causes of elevated maternal serum AFP?
1. Neural tube defects
2. underestimation of GA
3. Oligo
4. Decreased maternal weight
5. Multiple Gestations
6. Cystic hygroma/fetal skin defects
468
causes of decreased maternal serum AFP ?
1. Overestimation of GA
2. Increased maternal weight
3. Chromosomal trisomies
4. Fetal death
5. Molar pregnancy
469
Levels of AFP, estriol, and and hcg in downs
AFP: low
Estriol: low
hcg: high
(in trisomy 18, all markers are low)
470
When are teratogens most dangerous?
Day 15-60 (organogenesis)
| -->1st 2 weeks = all or none effect...either fetus dies or recovers
471
Drug used to tx endometriosis that inhibit mid-cycle FSH and LH surge
Danazol (17 alpha etinyl testosterone deriv)
472
What are some risk factors for molar pregnancy?
- ASIAN RACE
- Age below 20 or above 35 (though incidence is higher in btwn b/c thats who gets pregnant)
- low carotene and vitA deficiency
473
T/F: Complete and partial moles are ass. with a hx of infertility and SAB
False...PARTIAL moles are ass. with hx of infertility and SAB
474
A hytadiform mole (complete and partial) has replacement of normal placental trophoblastic tissue by:
hydropic placental villi
| especially found diffusely in complete
475
Which has identifiable fetal or embryonic structures: partial or complete mole?
Partial only
476
The karyotype of a complete mole is ____, and partial mole is ____
Complete: Diploid (46XX)
Partial: Triploid
477
What kind of mole is more common and also more likely to undergo malignant transformation?
Complete>partial
478
How can you recognize molar pregnancy clinically?
- findings consistent w/confirmed pregnancy
- uterine size>date discrepancy
- exaggerated subjective sxs of pregnancy
- painless 2nd trimester bleeding
- hCG levels excessively elevated
479
What should you suspect in any woman who presents with findings suggestive of severe HTN prior to 20 weeks in pregnancy?
MOLAR PREGNANCY
| -->the high hCG can cause marked gHTN, proteinuria, hyperthyroidism, tachycardia, SOB, and hyperreflexia
480
How does partial mole typically present?
As a missed abortion (vaginal bleeding is less common in partial than in complete)
481
Why are theca lutein cysts ass. with moles?
Because they are multi cystic ovaries resulting from follicular stimulation by high hCG...are not malignant...will regress spontaneously within few months of mole evacuation (don't need surgical removal)
482
Tumor with a red, granular appearance; is intermingled syncytiotrophoblastic and cytotrophoblastic elements w/abnormal cellular forms
Choriocarcinoma
483
Rapid myometrial and uterine vessel invasion and systemic metastases from hematogenous embolization to lung, vaagina, CNS, kidney, and liver
Choriocarcinoma
484
Choriocarcinoma may occur after:
1. molar pregnancy
2. normal pregnancy
3. abortion
4. ectopic pregnancy
485
Is chemotherapy effect for gestational trophoblastic neoplasia, including malignant forms?
Yes, highly; and allows for future reproduction
486
How is nonmetastatic persistent GTN tx?
Single-agent chemotherapy: Methotrexate or Actinomycin D
487
Whats the combination tx regimen for high risk metastatic GTN?
```
Etoposide
Methotrexate
Actinomycin D
Cyclophosphamide
(O)Vincristine
```
EMACO
488
What two types of epithelium meet at the SCJ junction in cervix?
Squamo-Columnar J(X)
- ->columnar cells
- ->stratified, nonkeratinizing squamous
489
How do you define the transformation zone in the cervix?
Area between the original SCJ (childhood, inside external os) and active SCJ (rolls out to cervical surface)
490
Where are Nabothian cysts (they are non-pathological)?
Glands w/in the columnar epithelium on the cervical surface become trapped by squamous epithelium metaplastic activity
491
Why does acetic acid help visualize abnormal cervical cells on colposcopy?
Dehydrates cells, causing those with large nuclei to appear white
492
Next steps for pt with ASCUS (on pap)?
1. Reflex HPV DNA testing
or
2. Repeat cytology @ 6 and 12 months
493
Next steps for pt with +ASCUS and +HPV DNA?
Manage same way as LSIL woman: COLPOSCOPY
494
What is a common outpatient procedure used to tx CIN 1?
Cryotherapy
495
T/F: Cold knife cone and LEEP are ass. with increased risk of 2nd tri pregnancy loss secondary to cervical incompetence, PTL, PPROM, and cervical stenosis
True
496
How many doses is the HPV vaccine and when do you give them?
1st: @ elected date (9-26 recommended time)
2nd: 1 month later
3rd: 6 months later
Safe when breastfeeding, not given during pregnancy
497
most common indication for hysterectomy
Fibroids
498
What is tranexamic acid?
An Anti-fibrinolytic agent used to tx menorrhagia
499
What are the common sxs of a corpus luteum cysts (corpus luteum thats greater than 3cm)?
1. Pain: dull, ipsilateral, lower quadrant
| 2. Missed periods
500
Why do patients with corpus luteum cysts miss periods
Produces progesterone for longer than usual 14 days; menstruation typically delayed a few days to several weeks, usually occurs w/in few weeks
501
Patient not using OCPS, has regular periods, presents with acute pain late in the luteal phase
Hemorrhagic/ruptured luteal phase cyst
| -->if no hemoperitoneum or hypoveolemia (surgical intervention), can give analgesics and reassure
502
What is "quickening" and when is it reported?
Patients initial perception of fetal movement
| -->16-20 weeks
503
When should urine pregnancy tests be performed (in the day)?
Early-morning, because highest concentration of hCG
504
Are urine or serum pregnancy tests more specific and sensitive?
Serum --> test for the unique beta subunit of hCG, can even detect before the patient has missed a period (versus urine typically 4 weeks after LMP)
505
Gestational age = number of weeks that have elapsed between:
First day of LMP (not the presumed time of conception)....and date of delivery
506
Fetal Bradycardia vs prolonged decel
Prolonged decel: under 100-110bpm for >2min
Brady: "">10 min
507
Fetal bradycardia etiology: +maternal respiratory compromise/mental status change
1. Seizures
2. PE
3. Amniotic Fluid Embolism
508
Fetal bradycardia etiology: +hypotension
Commonly after Epidural placement
509
Fetal bradycardia etiology: +increased vaginal bleding
1. Uterine rupture (fetal station will be higher than expected)
2. Placental Abruption
510
Fetal bradycardia etiology: manual vaginal inspection
Check for cervical dilation, fetal station, prolapsed umbilical cord, uterine hyperstimulation, fetal parts outside the uterus. If station very low, decels could be from rapid descent (vagal response)
511
Tx of Fetal bradycarida: initial mgmt
1. Patient moved to left/right lateral decubitus position(resolve IVC compression, decreased preload, or uncompress umbilical cord by fetus)
2. Oxygen - face mask
512
post mortem finding of fetal cells in the maternal pulmonary vasculature
Amniotic Fluid Embolism
