CNM Varney's Review Book Part A Flashcards
Cycle history last 12 months: shortest 26 days, longest 30 days. According to calendar method, what is the fertile period for this person?
Days 6-20 of her cycle.
Subtract 20 days from the shortest cycle,
subtract 10 days from longest cycle.
Who CANNOT use rhythm/calendar method?
menstrual cycle <25 days irregular cycles cycles that vary in length by 8 days or more postpartum women lactating women perimenopausal women
In order to avoid pregnancy, the woman using the cervical mucus method of family planning should avoid intercourse for a minimum of how many days following the peak day of her cyce?
3 days
What is nonoxynol-9 and how is it beneficial?
Is the active ingredient in most spermicidal preparations and is available without rx.
In the laboratory, is lethal to agents that cause GC, CT. trich, syphilis, and AIDS
Lowers the chance of becoming infected with a bacterial STI/STD
Timing of spermicide use
If you do not have sex within 1 hour of inserting the spermicide, need to reapply it
What lubricants are safe to use with polyurethane condoms?
Safe to use with any lubricant, including oil-based
What is the minimum amount of time after the last act of intercourse that a woman must leave a diaphragm in position in order to maximize contraceptive effectiveness?
6 hours
If a diaphragm is properly fit and cared for, how long is it good for?
2 years
Diaphragm facts
With typical use, failure rate ~18%
Frequency of intercourse significantly affects effectiveness among women who are consistent diaphragm users.
Use of spermicide significantly increases effectiveness of diaphragm.
32 yr old G2P1 successfully used a coil-spring diaphragm prior to birth of her child. Wishes to resume use. PE: uterus retroverted, arch behind symphysis pubis average, first-degree cystocele. Which method birth control to use?
A method other than a diaphragm
C/I in severe cystocele
severe uterine prolapse
severe anteversion or retroversion of uters
fistulas
known allergy to the rubber of the diaphragm or to the accompanying spermicidal preparation
Cervical cap/spermicide in relation to inertcourse
with the cervical cap, additional spermicide is not needed for repeated acts of intercourse
Absolute contraindications for insertion of IUD
recurrent PID pregnancy cervical or uterine carcinoma unexplained or abnormal uterine bleeding hx or presence of valvular heart disease Wilson's dz or allergy to copper uterine sound measurement outside 6-9 cm genital actinomycosis cervical mycosis ...
prerequisites to insertion of IUD
informed consent form
pregnancy test
GC/CT cultures
woman with IUD and +Uhcg is at increased risk for
sepsis
placenta previa
ectopic pregnancy
Which progestin is used as the index progestin in order to compare the biological potency of the various progestins used in oral conntraceptives?
Norethindrone
Why should you delay the initiation of COCP in pp woman who is not breastfeeding?
because earlier initiation of COCP can increase risk of thromboembolism
How soon after a first-term abortion can a woman safely start taking COCP?
immediately
what is the main mechanism of action of COCP to prevent pregnancy?
suppression of ovulation by suppression of FSH and LH
which sx should be reported immediately by a woman who is taking OCP?
hemoptysis (expectoration of blood-tinged mucous)
To ensure maximal contraceptive effectiveness and minimize chances of breakthrough bleeding, when in cycle should OCP be started?
within the first five days of the cycle
for at least how long shoudl a woman use back-up contraception if she has issed two of her COCPs?
7 days
Woman started COCP 2 months ago, is having breakthrough bleeding with each cycle. What do you do?
recommend that she use a back-up method until the bleeding has stopped, and reassure her that in most cases btb will remit by her fourth pill cycle
spotting and btb in early half of cycle (days 1-9), it is most likely due to …
estrogen deficiency
what contraceptives can be used as emergency contraception?
COCP, progestin-only pills, IUDs
what is the maximum amount of time after an unprotected act of intercourse that the Yupze regimen of oral contraceptive pills is considred to be effecdtive as a method of EC?
72 hours
maximum amount of time after unprotected intercourse that a copper IUD is considreed to be effective as method of EC?
5-7 days
What is Depo-Provera’s main mechanism of action?
suppression of ovulation by suppression of FSH and LH
most common side effect of Depo-Provera
menstrual changes
is depo protective against PID?
yes
how soon after birth can a woman who is breastfeeding initiate Depo?
6 weeks pp
When does Depo become effective if received within 5 days of beginning of her menstruation?
immediately
How soon after insertion does Norplant become effective in preventing pregnancy?
24-48 hours
Most commonly cited reason for discontinuing IUD
menstrual changes
Most popular method of birth control in US
sterilization
35 yr with G4P3013, smokes 1/2 pack/day, desires highly effective birth control for 3 months until husband our of military. does not desire any more children
depo
25 yr old G2P2 pp visit, plans to bf 6+ months. Has used COCs and condoms plus spermicide but found it irritating and caused yeast infections. Best bc method?
IUD
27 yr old G3P1111 has 11 mo child, wishes another in 1-2 yrs, hx of DVT during first pregnancy. Best bc method?
Diaphragm
amenorrhea workup results: UHCG: neg TSH: wnl Prolactin: wnl progestational challenge test: positive withdrawal bleed followin g10 days of 10 mg of provera What is the dx?
chronic anovulation
You would expect levels of all the following to be elevated during the ovulatory phase of the menstrual cycle EXCEPT:
FSH, LH, estrogen, progesterone
progesterone
What is the predominant hormone of the luteal phase of the menstrual cycle?
progesterone
relationship of HPV and cervical cancer
it is believed that HPV alone does not result in neoplastic changes and that cofactors to HPV infection are necessary for the development of cervical cancer.
What is the rx of choice for tx of BV in pregnancy?
metronidazole PO
adverse pregnancy outcomes associated with trich
PROM, PTB, LBW
chlamydia infection increases preg risk for
PROM, infertility, ectopic pregnancy
approx what % of women with untreated syphilis infxn experirence fetal or neonatal loss?
40%
what test is dx for syphilis?
postiive darkfield microscopic examinatino of exudate from chancre
appropriate agents in emergency tx of anaphylactic shock
corticosteroids
epinephrine
oxygen
lower abdominal pain, positive abdominal guarding, +CMT, +bilateral adnexal tenderness, +mucopurulent d/c, increased leukocytes on wet mount
PID
average age of menopause in women in US
51
what is the characteristic hormonal change of perimneopause (6-7 years before menopause)?
increased FSH levels
physiological changes seen in menopausal women r/t decreased estrogen
thinning of vaginal epithelium
atrophic endometrium
loss of bone density
benign skin changes
seborrheic keratosis
cherry angioma
fibroepithelioma
the most common symptom associated with menopause
hot flashes
connection between EPT and breast cancer
Women who take EPT daily have increased risk of breast cancer due to the progestin
Risk decreases to normal level after being off HRT for 3 years
Lean women or those with dense breasts may be at increased risk
EPT/HRT is prescribed for which women?
women who still have a uterus;
the progesterone protects the lining of the uterus
estrogen is prescribed alone for which women
those who have had a hysterectomy
relation of EPT/HRT and endometrial cancer
it is not increased in women with a uterus bc it is EPT, not ET
connection bt ET and BRCA
women without a uterus who were taking ET have slightly decreased risk for breast cancer, according to WHI study. British Million women study found 1-3% increase in risk
HRT and ovarian cancer
EPT not a link for sure
ET - risk associated with duration of use; with 5+ years of use, increased risk up to 50%
Estrogen/Progesterone Therapy/HRT and colorectal cancer
during tx, EPT seemed to show 40% decrease in risk, which was back to normal when checked 2 yrs after tx stopped
ET seemed to show no difference in risk
leading cause of death in postmenopausal women in US
cardiovascular dz
estrogen therapy decreases the risk of fractures by how much?
50% (but this is not a first-line tx for osteoporosis)
what therapeutic measure has not been demonstrated to decrease the risk of bone fracture in postmenopausal women?
addition of vitamin D to the diet
(ok, this is tricksy. USPS says don’t supplement with calcium/D with the intent to prevent fractures. National Osteoporosis Foundation says aim to get the recommended amounts through food, and supplement the rest.)
what therapeutic measures have been demonstrated to decrease the risk of bone fracture in postmenopausal women?
addition of calcium to the diet
weight-bearing exercises
estrogen replacement therapy (although again, this is not a first-line tx anymore with the intent of bone density improvement)
(ok, this is tricksy. USPS says don’t supplement with calcium/D with the intent to prevent fractures. National Osteoporosis Foundation says aim to get the recommended amounts through food, and supplement the rest.)
What is the minimum daily dose of conjugated estrogen that is effective in maintaining bone mass?
0.625 mg
what procedure would be indicated:
60 yo woman who has been on continuous HRT Prempro for 2 years and is experiencing uterine bleeding
endometrial biopsy
what is the standard dose for continuous HRT?
- 625 mg conjugated estrogens (Premarin) daily
2. 5 mg medroxyprogesterone (Provera) daily
menorrhagia
abnormally heavy and prolonged menstrual period at regular intervals (>80 ml/>7 days)
also called hypermenorrhea
causes of menorrhagia
abnormal clotting
disruption of normal hormonal regulation of periods
disorders of endometrial lining of the uterus
dysmenorrhea
abnormally painful periods
length of normal menstrual cycle
25-35 days
average blood flow in normal cycle
25-80 ml
menometrorrhagia
heavy bleeding which occurs frequently at irregular intervals
a regular tampon fully soaked will hold about how much blood?
about 5 ml
endometriosis r/t pain & blood loss
is a cause of pain (dysmenorrhea) but not usually alteration in menstrual blood loss
polymenorrhea
epimenorrhea
short cycles <21 days with normal menses
always anovulatory due to hormonal disorders
epimenorrhagia
short cycle with excessive bleeding
due to ovarian dysfunction
excessive menses and long intervals
anovular ovarian disorder d/t prolonged estrogen production
May occur after extended COC use
metrorrhagia
irregular or frequent flow, non-cyclic
dysfunctional uterine bleeding
abnormal endometrial bleeding of hormonal cause and related to anovulation
Which is a CNS depressant:
marijuana, alcohol, cocaine, amphetamines
alcohol
what is the approximate risk of perinatal HIV transmission without antiretroviral tx?
25%
During initial PE on woman who has just tested positive for HIV, a Mantoux test was performed. 48 hours later, woman returns to have Mantous test read. There is not an induration. What is the best interpretation of this?
the negative test could be due to anergy, therefore an anergy panel is indicated to verify the negative result.
Anergy is the absence of PPD reactivity in persons infected with TB. It can occur in immunocompromised persons, newly infected, or with miliary TB.
reactions over what size are considered positive for PPD testing in non-immunocompromised patients?
10 mm
which disease needs to be managed and tx differently in a woman with HIV infection?
candidiasis, UTI, GC/CT, syphilis
syphilis
what is the prophylactic tx of choice against pneumocystitis carinii pneumonia (PCP)?
Bactrim (TMP-SMX)
How soon after birth should an infant born to an HIV-infected woman start receiving zidovudine (ZDV)?
within 12 hours
what test should be administered to a newborn of an HIV+ mother to determine the baby’s HIV status?
viral culture and polymerase chain reaction teachnique
If PCR and viral culture are positive for newborn, what is the best interpretation and mgmt of these results?
the positive test results indicate a high chance that the infant is infected, but to confirm the dx, repeat testing using the same test is indicated.
What is the length, from the day of fertilization, of human gestation?
266 days
280 from LMP
what hormone is responsible for maintaining the corpus luteum of pregnancy?
hCG
if conception is normal, hCG should be produced how many days after conception (by blastocyst) to allow detection on very sensitive tests?
by 6 days after conception
By day 9 the syncytiotrophoblast is the primary source of what?
hCG
From what point on do hCG levels double?
from day 9
when do maternal serum levels of hCG peak?
around the 10th week
when does hCG reach its low in pregnancy?
around 18 weeks
then stays there through rest of pregnancy
What does hCG do for the corpus lutem?
signals the CL to continue progesterone production, keeping the endometrium thick and full of blood vessels for zygote
what anatomical/physiological change of pregnancy is thought to be caused by estrogen?
hypertrophy of the uterine wall
in terms of the maternal psychological processes of pregnancy, the first trimester is often described as…
period of adjustment
the fusion of the pronuclei of the sperm and ovum that happens with fertilization produces the…
zygote
when do each of these apply?
zygote, morula, blastocyst, embryo, fetus
zygote forms at fertilization, then becomes
morula as cell division takes place. Becomes a
blastocyst on day 5.
Embryo is until about 10 wks after LMP
Fetus from 10 wks gestation until birth
implantation begins approximately how soon after fertilization?
about 6 days
embryonic period in days is…
from the end of implantation until day 48 of fetal development (~7 weeks, so 8 weeks since conception, 10 wks since LMP)
eyelids of a fetus remain fused through what gestational age by LMP?
25th week
circulation in the first two weeks of gestation
primitive placental circulation is established
what is the decidua
uterine endometrium during pregnancy
teratogenic effects of tetracycline
discoloration of infant’s baby teeth
presumptive signs of pregnancy
maternal physiological changes that the woman experiences and that in most cases indicate to her that she is pregnant:
abrupt cessation of menstruation
n/v
tingling, tenseness, nodularity, enlargement of breasts, enlargement of the nipples
increased frequency of urination
fatigue
color changes of breasts
appearance of Montgomery’s tubercles or follicles
continued elevation of basal body temp without infection
expression of colostrum from nipples
excessive salivation
Chadwick’s sign
quickening
skin pigmentation/conditions: chloasma, striae, linea nigra, vascular spiders, palmar erythema
probably signs of pregnancy
maternal phyiological and anatomical changes other than presumptive sins that are detected upon examination and documented by examiner:
enlargement of abdomen
palpation of fetal outline
ballottement
fetal movement (may be positive)
enlargement of uterus
+Hegar’s sign
+Goodell’s sign (signif softening of vaginal portion of uterus)
Piskacek’s sign (palpable lateral bulge where tube meets uterus: 7-8 wks gest)
palpation of BH contractions
positive pregnancy test
positive signs of pregnancy
directly attributable to the fetus:
fetal movement
fetal heart tones
u/s evidence of pregnancy
what is Chadwick’s sign due to?
increased hemoglobin in maternal circulation
Woman is currently pregnant with four previous pregnancies: one 1st trimester EAB, 1 SAB, 1 premature live birth, 1 full-term delivery of twins. Twins alive, preemie died. G?P?
G5P2122
woman at 13 wks GA coming in for first appointment, which labs to order?
blood type, Hep B surface antigen test, serology test for syphilis
CAuses of nonpathological urinary frequency during pregnancy
decreased room for distention of the bladder
anteflexion of the enlarging uterus
pressure of fetal presenting part
There is positive evidence of human fetal risk but benefits from use in pregnant women may be acceptable despite the risk.
Category D
What is acceptable tx for women exposed to varicella in pregnancy
vaceination with varicella immune globulin can be considered
beta hCG detection in normal pregnancy
can be detected within 9-11 days following conception
