Clinical questions - OBGYN Flashcards
1
Q
What should be performed at every prenatal visit?
A
maternal weight BP - monitor for pregnancy induced htn assess gestational age fetal tones after 12-13 weeks Fetal movement After 3rd trimester - fetal presentation (cephalic or breech)
2
Q
Fetal age assessment at 6-8 weeks
A
bimanual exam - uterus size of lemon
3
Q
Fetal age assessment at 8-10 weeks
A
bimanual exam - uterus size of orange
4
Q
Fetal age assessment at 10-12 weeks
A
bimanual exam - uterus size of grapefruit
5
Q
Fetal age assessment at 12 weeks
A
pubic symphysis
6
Q
Fetal age assessment at 16 weeks
A
1/2 way between pubic symphysis and umbilicus
7
Q
Fetal age assessment at 20 weeks
A
at umbilicus
8
Q
Fetal age assessment at 20-34 weeks
A
measure from pubic symphysis to top of funds - cm approx equal to weeks gestation
9
Q
counseling of smoking in pregnancy
A
increase risk of placental abruption, preterm birth, low birth weight, SIDS
cessation encouraged - nicotine replacement, bupropion
10
Q
alcohol use in pregnancy
A
teratogen
fetal alcohol syndrome
abstain completely
11
Q
Exercise in pregnancy
A
30 min per day, avoid abdominal trauma or falls
12
Q
Travel in pregnancy
A
no airplane travel after 36 weeks, avoid prolonged immobilization due to increased risk of DVTs
13
Q
Sexual intercourse in pregnancy
A
avoid in placenta previa
14
Q
Fetal alcohol syndrome
A
CNS problems
Growth retardation
Facial abnormalities - short palpebral fissure, smooth philtrum, thin vermillion border
15
Q
Leiomyoata uteri
A
benign tumors of smooth muscle of uterus - leiomyomas, fibroids
most asx
Sx:
menorrhagia - risk low Hgb, iron supplementation
Pelvic pressure
Tx:
Hormonal contraceptive to reduce bleeding but causes increased fibroid size
Endometrial ablation
Myomectomy if desire fertility
If done having kids - uterine artery embolization, hysterectomy
16
Q
Hyperemesis gravidarum
A
Severe nausea/vomiting causing dehydration, abnormal labs, wt loss
Mgmt: admission, IVF, IV antiemetics
17
Q
Normal N/V of pregnancy
A
resolves as pregnancy advances
Lifestyle changes - bland foods, slow eating, small frequent meals, avoid triggers
1st med: pyridoxine (B6) + doxylamine (unasom)
Benadryl or meclizine, or zofran
18
Q
Management of ovarian cysts
A
5-10 cm can watch
>10 cm requires surgery with risk of ovarian torsion
19
Q
During pregnancy, when is screening performed for syphilis
A
RPR or VDRL at 1st prenatal visit, if high risk beginning of 3rd trimester as well
confirm with treponema Ab tests
- FTA-Abs
- MHA-TP
20
Q
During pregnancy, when is screening performed for HIV
A
1st visit, if high risk 3rd trimester
21
Q
During pregnancy, when is triple/quadruple screening?
A
15-20 weeks
22
Q
During pregnancy, when is screening performed for gestational diabetes
A
24-28 wks
1 hr 50 g GTT, if abnl then 3 hr 100 g GTT
23
Q
Administration of Rh immune globulin if Rh negative
A
28 weeks, after delivery, any time risk of fetomaternal hemorrhage (miscarriage)
24
Q
During pregnancy, when is screening performed for g/c chlamydia
A
1st visit, high risk also in 3rd trimester
25
During pregnancy, when is screening performed for GBS
35-37 weeks
| if positive IV PCN during labor
26
Asymptomatic bacturia in pregnancy
outside of pregnancy- not treated
Always treat if pregnant - high risk of pyelonephritis with dilated ureters d/t pregnancy
```
PO abx for 3-7 days
Nitrofurantoin
Amox
Augmentin
Cephalexin
fosfomycin - one dose
```
Repeat UCx 1 week after abx completed
Anyone with a UCx positive after 2 cycles of abx needs suppressive tx with macrobid for remainder of pregnancy
27
Management of suspected ectopic pregnancy
If unstable - immediate surgery
Stable:
TVUS
Quant bhCG
-if bhCG >1500 IUP should be seen on TVUS, absence suggests ectopic pregnancy
-if less than 1500, repeat in 48-72 hrs
> If bhCG lower - failed pregnancy, follow level to 0
> if higher but not appropriately so proceed to D&C, if chorionic villi then failed IUP, if absent chorionic villi ectopic pregnancy
> If increased 66% in 48 hrs, repeat TVUS when >1500
28
Nonstress test
normal 2 or more accelerations in 20 minutes
29
Contraction stress test
give mom oxytocin and monitor for decals with contractions, sign of utter-placental insufficiency
30
Biophysical profile
```
Nonstress test
fetal breathing
fetal movement
fetal tone
amniotic fluid volume
```
31
Congenital syphilis infection
```
Growth restriction
prematurity
still birth
snuffles
hutchinson teeth
saber shins
```
32
Management of post-menopausal bleeding
endometrial biopsy to r/o hyperplasia and cancer
MC cause - atrophy of endometrium
10% endometrial cancer
33
Nutritional recommendations in pregnancy
supplement with folate and iron
additional 300-500 kcal daily
fully cooked meats
avoid unpasteurized dairy, deli meats (risk listeriosis)
limit fish to 12 oz per week - avoid shark, swordfish, king mackerel, tile fish
34
Weight gain recommendation for pregnancy with BMI of less than 18.5
28-40 lbs
35
Weight gain recommendation for pregnancy with BMI of 18.5-24.9
25-35 lbs
36
Weight gain recommendation for pregnancy with BMI of 25-29.9
15-25 lbs
37
Weight gain recommendation for pregnancy with BMI of 30 or more
11-20 lbs
38
teratogenic agent associated with abstain cardiac anomaly
Lithium
39
teratogenic agent associated with clear cell adenocarcinoma of the vagina
diesthylstilbestrol (DES)
40
teratogenic agent associated with microcephaly, intellectual disability, smooth philtrum
alcohol
41
teratogenic agent associated with gray baby syndrome
chloramphenicol (tx of RMSF in pregnancy, meningitis tx )
42
teratogenic agent associated with phocomelia (malformation of limbs)
Thalidomide
43
teratogenic agent associated with craniofacial anomalies, fingernail hypoplasia, developmental delay
phenytoin
44
Treatment of PID
GC and chlamydia penetrate the protective mucus and normal flora follow - treat as a polymicrobial infection
Output:
-Ceftriaxone IM + doxy OR PO cefoxitine + probenecid + doxy
inpt:
-IV (cefoxitine or cefotetan) + PO or IV doxy
OR IV clinda + gent
45
Pregestational diabetes
DM before pregnancy - type 1 or 2
Risk malformations, still births
Tx:
Insulin
fetal surveillance - weekly non stress tests starting 32-34 weeks
Deliver at 38 weeks - risk of late term fetal demise
46
Gestational diabetes
develops during pregnancy, resolves postpartum
risk fetal macrosomia
Tx: diabetic diet +/- insulin
47
Condition suggested by the following screening: high AFP
neural tube or abdominal wall defect, multiple gestations, MC - incorrect dating - confirm dating with u/s
48
Condition suggested by the following screening: low AFP, high bhCG, low estriol, high inhibin
Downs Sn - down up down up if in alpha order
49
Condition suggested by the following screening: low AFP, low bhCG, low estriol
Trisomy 18 - Edwards - all low
50
Next steps in management with abnormal triple/quad sscreening
targeted ultrasound
| amniocentesis
51
Recommended screening for ovarian cancer
No screening recs
| CA125 is only used for monitoring disease
52
Which type of abortion involves bleeding before 20 weeks gestation + no passage of products of conception (POC) + closed cervice
threatened abortion
53
Which type of abortion involves bleeding before 20 weeks + cramping + no passage of POC + open cervice
inevitable abortion
54
Which type of abortion involves passage of some POC + open cervix
incomplete abortion
55
Which type of abortion involves passage of all POC + closed cervix
complete abortion
56
Which type of abortion involves fetal death before 20 weeks gestation + no passage of POC + closed cervix
missed abortion
57
Which type of abortion involves spontaneous abortion complicated by uterine infection
septic abortion
58
Cervical insufficiency
painless cervical dilation during 2nd trimester
associated with prior LEEP or other procedure
TVUS with shortened cervical length
Tx: placement of cerclage - suture
59
Treatment of Graves disease in pregnancy
Thionamides
- 1st trimester propyltiouracil (PTU)
- 2nd/3rd trimester switch to methimazole
PTU has risk of liver failure which is why you switch
Methimazole - risk birth defects if used in 1st trimester - aplasia cutis - scalp defect
Both meds have risk of agranulocytosis (rare)
If can't take thionamides -> thyroidectomy
B-blockers like atenolol or propranolol for short term sxs control - can cause fetal growth restriction
If non-pregnant radio iodine ablation - can't in pregnancy as will also ablate fetal thyroid
60
Group B Streptococcus risk and ppx
Risk neonatal meningitis, pneumonia, or sepsis
ppx IV PCN G intrapartum
- anyone GBS + at 35-37 week screening
- Tx of any GBS bacturia this pregnancy
- Previous infant with early onset GBS infection (1st week of life)
- Unknown screening result + 1 of the following: intrapartum fever, PROM > 18hr, or preterm labor (before 37 weeks)
61
Age to start cervical cancer screening
21 yo regardless of age of first intercourse
62
cervical cancer screening guidelines for 21-29 yo
q3yrs
63
cervical cancer screening guidelines for 30+ yo
pap q3y
| pap with HPV contesting q5y
64
When do you stop cervical cancer screening
stop at age 65 if adequate screening
| do not screen after TAH performed for benign reason
65
Early deceleration
mirrors contraction - nadir at peak of contraction
head compression
66
Variable deceleration
Abrupt, V shaped, not necessarily with contraction
umbilical cord compression
67
Late deceleration
after peak of contraction, gradually decelerations with gradual return to baseline - U shaped
Fetal hypoxia - utter-placental insufficiency
68
Sinusoidal fetal tracing
severe fetal anemia
69
Features of preeclampsia
new onset HTN during second half of pregnancy 140/90 or higher
proteinuria (300 mg/24h or more) or end organ dysfunction (thrombocytopenia, AKI, elevated LFTs, pulmonary edema, cerebral or visual sxs)
70
PCOS
```
oligo or amenorrhea
Hyperandrogenism -> hirsutism
polycystic ovaries on US
Infertility
obesity
insulin resistance
endometrial hyperplasia
```
```
Mgmt:
Diet and exercise - wt loss
OCPs 1st line
Metformin 2nd line
spironolactone for hirsuitism
Clomiphene to induce ovulation for infertility
```
71
management of shoulder dystocia
Emergency - umbilical cord compression
Call for help - anesthesia, help with maneuvers
Suprapubic pressure
McRoberts maneuver - legs flexed against abdomen
Deliver posterior shoulder
Last resort Zavanelli maneuver -> STAT C/S
72
Complications associated with pregestational (overt) DM
```
Polyhydraminos - excess amniotic fluid
Congenital malformations
- caudal regression sn - sacral agenesis
-Situs inversus
-Neural tube defects
-cardiac anomalies: transposition of the great vessels
-Preterm birth
-Macrosomia
-unexplained still birth
-after deliver - hypoglycemia, hypocalcemia
```
73
Menopause
amenorrhea for more than 12 months
If less than 45 yo:
check bhCG, prolactin, TSH, FSH to r/o other causes of amenorrhea
Tx:
HRT with estrogen and progesterone with intact uterus
Never estrogen alone in intact uterus -> increased risk of endometrial cancer
-lowest dose for shortest time for sxs control
74
Management of genital HSV during pregnancy
rare for transplacental infection
direct contact risk -> skin/eye infection, CNS infection, disseminated dz/sepsis
Tx:
Suppressive tx with acyclovir at 36 weeks
Active infection at time of labor - prodromal or lesions -> C/S
75
Complete hydratiform mole
```
46XX
no fetal tissue
Vaginal bleeding, N/V, hyperemesis gravidarum
Uterus size larger than dates
bhCG markedly elevated
"Snow storm" on u/s
Risk of malignancy and choriocarcinoma
```
Tx: evacuation with suction curettage
Serial bhCG until zero with risk of malignancy
76
Stress incontinence
weakening of pelvic floor especially after having kids
Symptoms with an increased pressure - cough, sneeze
Treatments:
Lifestyle modification: Weight loss, time avoiding, pelvic floor exercises, avoid alcohol and caffeine
Pessary
Surgery
77
Urge incontinence
Detrusor muscle overactivity
Symptoms preceded with sudden urge to void
Treatment:
Lifestyle modifications
antimuscarinics: oxybutynin, darifenacin, tolterodine
78
Overflow incontinence
Inability to avoid normally due to over distention of the bladder - obstruction, neuropathy
Continuous leakage of urine
Tx cause
intermittent catheterization
79
How is HIV infection managed throughout pregnancy?
Screen during the first visit, and in high-risk during third trimester
Continue current ART regimen with goal for viral load as low as possible
Monitor VL
> 1000 give intrapartum IV zidovudine (AZT) + C/S delivery
less than 1000 -> SVD, no fetal scalp electrode monitoring
Infant: ppx ART, NO breastfeeding
80
Palpable breast mass worked up
```
If one of the following is suspicious, need excisional biopsy:
Exam
Imaging
-diagnostic mammography
-ultrasound
Fine needle biopsy
```
If all of these are normal there is a 99% chance it is benign
81
Management of DVT in pregnancy
Anticoagulate with enoxaparin or unfractionated heparin sq - no warfarin - teratogenic
Stop a/c with labor onset or 24 h before planned delivery
-resume 12 hr postpartum - warfarin ok with bridge, continue for at least 6 weeks
Avoid estrogen contraception in future
82
Intrahepatic cholestasis of pregnancy
Pruritic, elevated bile acid levels
occurs later in pregnancy - 2nd or 3rd trimester
Tx:
ursodeoxycolic acid to increase bile flow
hydroxyzine for itching
Deliver at 37-38 weeks d/t risk of fetal demise
83
Type of amenorrhea: ballet dancer with eating disorder
functional hypothalamic amenorrhea
84
Type of amenorrhea: short stature, low-set ears, webbed neck
Turner syndrome - check karyotype
85
Type of amenorrhea: following D&C after spontaneous abortion
Asherman sn - uterine scaring and adhesions
86
Type of amenorrhea: cyclic pelvic pain + blue budge at introits on exam
imperforate hymen
87
Type of amenorrhea: elevated testosterone level and no axillary or pubic hair on exam
androgen insensitivity sn
88
Type of amenorrhea: overweight female with acne and hirsutism
PCOS
89
Type of amenorrhea: postpartum patient with inability to breastfeed
Sheehan Sn - pituitary necrosis 2/2 hemorrhage
90
Type of amenorrhea: patient with anosmia
Kallman Sn
91
Type of amenorrhea: patient with galactorrhea
prolactinoma
92
Type of amenorrhea: MC cause
pregnancy
93
Postpartum hemorrhage
>1000 mL with C/S
| >500 mL with vaginal delivery
94
Uterine atony and postpartum hemorrhage management
No contraction to stop spiral a. bleeding
Uterus big and boggy
Tx (in order)
-fundal or bimanual massage -> encourages contraction
-explore uterine cavity for retained tissue
-uterotonic agent - Oxytocin IV, methylergonovine (increase BP - avoid in HTN), Carbopost (PGF2a - contraindicated in asthma due to bronchospasm)
-IVF +/- transfusion
If bleeding continues -> surgery: uterine artery ligation vs hysterectomy
95
Induction of labor
reasons:
- severe pre-eclampsia
- Chorioaminitis
- Post term pregnancy
```
Agent:
Oxytocin IV -short 1/2life, can titrate dose
Prostaglandin if cervix unfavorable
-Misoprostol - PGE1, give PO or PV
-Dinoprostone PGE2 - PV or intracervical
```
96
Next steps in management for abnormal pap with ASCUS
21-24 yo repeat in 1 yr
| 25+ yo co-test HPV, if positive -> colpo
97
Next steps in management for abnormal pap with ASC-H
colposcopy
98
Next steps in management for abnormal pap with LSIL
21-24 yo repeat in 1 yr
25-29 -> colpo
30+ get HPV if positive go to colposcopies, if negative repeat in 1 yr with HPV co-testing
99
Next steps in management for abnormal pap with HSIL
21-24 -> colpo
| 25+ LEEP or colpo
100
Risk factors and treatment for chorioamnionitis
ascending infection of membranes, placenta, and amniotic fluid
```
Risk:
PROM
Prolonged labor
multiple cervical exams
meconium fluid
internal monitors - fetal scalp electrode, IU pressure cath
```
Tx:
Broad spectrum abx - amp + gent
101
Premature preterm rupture of membranes PPROM
No contractions, less than 37 wk gestation
Mgmt:
Admit to hospital
manage expectantly - most deliver within 1 week
fever, abnormal heart tracing, or other signs of infection -> deliver baby
Corticosteroids - IM betamethasone q24h x2 for fetal lung maturity
Tocolysis to allow steroids to work - indomethacin, nifedipine, magnesium
ppx abx: amp + azithro
Deliver at 34 weeks if can make it that long
102
Gardnerella vaginalis (BV)
thin, gray-white discharge with fishy odor - coats vaginal walls
pH > 4.5
Wet mount: clue cells, Whiff test (KOH) - fishy
Tx: metronidazole or clinda
103
Candida spp. vaginal discharge
thick, white, cottage cheese like discharge with itching
Vaginal pH 4-4.5
Wet mount: yeast forms - pseudohyphae or budding yeast
Tx: PO fluconazole or topical clotrimazole, miconazole, or nystatin
104
Trichomonas vaginalis
Frothy, yellow-green discharge with fishy odor
Vaginal pH > 4.5
Wet mount: motile, pear shaped trichomonad
Tx: metronidazole
105
Metronidazole counseling
avoid alcohol for at least 3 days after tx finished due to disulfiram like reaction - n/d, flushing, tachycardia, headache
106
Endometritis
uterine tenderness with foul-smelling loch
Tx: broad spectrum IV abx - usually polymicrobial
-Gent + clinda
107
Management of pre-eclampsia with severe features
BP 160/110 or more
End organ dysfunction: thrombocytopenia, AKI, elevated LFTs, pulmonary edema, cerebral or visual disturbances
```
mgmt:
BP control to prevent stroke
-IV hydralazine, IV labetalol, PO nifedipine
Seizure ppx - IV MgSO4
Delivery definitive tx
```
108
Primary dysmenorrhea
painful period w/o cause
-heat, NSAIDs, combined (E&P) hormonal contraceptive
More serious:
- GnRH agonist - leuprolide induces medical menopause
- Sx not responding -> lap vs hysterectomy
109
ddx for third trimester bleeding
```
bloody show - normal cervical change
placenta previa
vasa previa
placental abruption
uterine rupture
```
110
Hemolytic disease of newborn
Rh- mom with Ab to fetus Rh+ (anti-D Ab)
in future pregnancy Ab cross placenta and attack fetal RBCs -> severe anemia and even death
Prevent with Rh IG (Rhogam, Rhophylac) at 28 weeks, after delivery, and anytime risk of fetomaternal hemorrhage - miscarriage, ectopic pregnancy
111
Medications to terminate prolonged vaginal bleeding
High dose PO estrogen then progestin tx after bleeding stops
Combo OCP taper - high dose with 1 week taper
High dose progestin
Tranexamic acid - blocks fibrin degradation -not commonly used
112
Treatment for postpartum mastitis
MC S. aureus
Continue breastfeeding or pump
Anti-staph PCN
I&D if abscess on U/S
113
Endometriosis
ectopic endometrial tissue - pelvis, bladder, colon
Classic sxs: dysmenorrhea, urinary/bowel sxs
```
Tx:
NSAIDs
Combo OCPs
GnRH agonist - leuprolide
Progestin
Danazol
Surgery
```
