COMBANK OBGYN COMAT Flashcards
tx of uterine atony
- bimanual uterine massage asap
- if not resolved by 1, IV oxytocin infusion
- if still not resolved, admin another uterotonic agent (IM methylergonovine or rectal misoprostol)
pt with noncyclical pain, menorrhagia, and globular uterus … suspect _____
adenomyosis
difference between adenomyosis and endometriosis
Endometrial tissue - A = in myometrium - E = outside repro tract Pain - A = non- cyclical - E = cyclical Age - A = 40s and up - E = under 35 Fertility - A = parity and uterine surgeries (ex/ C/S) - E = difficulty conceiving
oxytocin effect on electrolytes
high dose has antiduretic and natriuretic effects
— can cause hyponatremia
oxytocin structurally similar to ______
vasopressin
beware high dose vasopressin admin can cause uterine contractions
most common vaginal cancers by age
- premenopausal women = adenocarcinoma, endodermal sinus tumor, rhabdomyosarcoma
- postmenopausal women = squamous cell carcinoma
vaginal cancer associated with DES exposure in utero
clear cell adenocarcinoma
most common cause of immediate pospartum fever (2-3days)
endometritis
Esp after C/S
most common abx regimen for PID
ceftriaxone (IM) + doxycycline (PO)
initial dx modality for postmenopausal bleeding
endometrial biopsy or Transvaginal US (not abd US)
– due to high suspicion for endometrial hyperplasia or carcinoma
rheumatologic disorder associated with hx of miscarriage
antiphospholipid antibody syndrome (in associateion with SLE)
how to dx SLE
need 4 out of 11 criteria, including: mucocutaneous manifestations evidence of serositis and arthritis renal failure neuro manifestations hematological and/or immunological markers
classic SLE sx
fever, malaise, joint pain, rash,
+/- glomerulonephritis, pericarditis, endocarditis
classic Sjogren’s syndrome sx
- dry eyes, dry mouth, bilateral parotid gland enlargement
- can also have fever, malaise, fatigue, arthritis
what type of heme dz in lupus
hemolytic anemia with reticulocytosis, leukopenia, lyphopenia, thrombocytopenia
what type of mucocutaneous manifestations in SLE
oral ulcers, discoid lesions, malar rash, photosensitivity
what type of kidney dz in SLE
glomerulonephritis: subendothelial immune complex deposits with marked thickening of capillary walls
what is included in fetal biophysical profile
sonographic assessment of 4 discrete biophysical variables: fetal movement, tone, breathing, amniotic fluid volume,
and nonstress testing.
- each assigned 2 (normal) or 0 (abnormal)
what is included in modified fetal biophysical profile
NST as a measure of acute oxygenation and assessment of AFV as a measure of longer-term oxygenation
dx of IUGR
ultrasound screening + *umbilical artery Doppler velocimetry
— IUGR is associated with diminished blood flow to maternal and fetal vessels
most common causes for a delay in the latent phase of labor
unripe cervix and false labor
common causes of galactorrhea
pituitary adenoma/prolactinoma, pituitary stalk compression, side effect of medications, and physiologic conditions (e.g., pregnancy, breast stimulation)
medications that cause galactorrhea
antipsychotics (Ex/ chlorpromazine), opiates, methyldopa, and serotonin reuptake inhibitors
— dopamine inhibits prolactin secretion. So dopamine antagonists prevent inhibition of prolactin
What does the bishop score mean?
- used to determine likelihood of vaginal delivery
- determines if cervix is “favorable” and thus mode of induction
how to interpret bishop score
- score >8 indicates that there is a high likelihood of a spontaneous vaginal delivery.
- A score of ≤ 6 indicates that the cervix is unfavorable and will need a cervical ripening agent
how to calculate bishop score
using the fetal station, plus four characteristics of the cervix: dilation, effacement, consistency, position
Fetal heart rate tracing category I
only reassuring components (baseline heart rate 110-160/min, moderate variability, no late or variable decelerations, early decelerations may be present or absent, accelerations may be present or absent)
Fetal heart rate tracing category II
those that cannot be classified as category I or category III
Fetal heart rate tracing category III
have concerning findings (absent variability and any of the following: , recurrent variable or late decelerations, bradycardia OR sinusoidal pattern).
how to detect fetal anuploidies as early as 9 weeks
serum PAP-A and B-HCG in combo with ultrasound (nuchal translucency)
when can you do amniocentesis
15-20w
when can you do chorionic villus sampling
10-12w
— more invasive, need US first
recc for IUD in place in pregnant woman
- remove in first trimester (decreases miscarriage rate)
- if string not visible, do US guided. Or can do hysteroscopy
What does elevated DHEA-S mean?
dehydroepiandrosterone sulfate
- produced by adrenal gland
- = hyperandrogenism from adrenal source (rather than PCOS)
Skene’s glands are located on
anterior surface of the vagina, directly below the urethra
Nabothian cysts
mucus-filled cysts located on the surface of the cervix.
Gartner’s duct
embryological remnant of the mesonephric duct.
Hyperemesis gravidarum vs physiologic nausea and vomiting of pregnancy (morning sickness)
hyper:
intractable vomiting with dehydration, metabolic alkalosis, hypokalemia, hyponatremia, hypochloremia, elevated hematocrit, and weight loss.
Phyllodes tumors
rare breast masses characterized by their large, multilobular shape (rapidly expanding)
use of Vitamin B6 (pyridoxine) supplementation in preg
tx of nausea
What are Amsel’s criteria used for?
clinical criteria used for diagnosing BV
How to use Amsel’s criteria
3/4 to make dx of BV:
- Homogenous vaginal discharge
- Discharge has a pH greater than or equal to 4.5
- Positive whiff test: an amine like odor when discharge mixed with 10% KOH
- A wet mount demonstrating 20% more clue cells than vaginal epithelial cells
cause of GERD in pregnancy
increased progesterone causes smooth muscle relaxation, decreases LES tone and gastric motility -> increases the risk for GERD
chancroid characteristics
sx:
- painful ulcer (papule -> pustule -> ulcer, gray base)
- painful inguinal lymphadenopathy
notes:
- common in sex workers in underdeveloped areas
- age 15-19
- G stain shows G neg rods.
- Tx: azithromycin, ceftriaxone, ciprofloxacin, or erythromycin
common causes of cervicitis
chlamydia, gonorrhea
– chlamydia often otherwise asymptomatic
description of anogenital warts
- cauliflower-like lesion on vagina, vulva, and labia
- typically itchy
- also: discrete papillary, exophytic lesion on thigh
risk factors for ectopic implantation
- conditions that can damage and alter the structure of Fallopian tubes.
- – ex/ chlamydia, trich
- smoking
pilonidal cyst sx
Acute exacerbations cause sudden onset of pain with stretching of the skin in the intergluteal area. Intermittent swelling with purulent or bloody drainage can occur.
Chronic disease can result in recurrent drainage and pain.
Bartholin duct cyst sx
- unilateral, soft and painless mass medial to the labia minora.
- patients are typically asymptomatic but may sense the presence of the cyst when ambulating or bending. Larger cysts may cause discomfort during sexual intercourse, sitting or ambulating.
Gartner’s duct cysts
- Wolffian (Müllerian) remnants
- usually found on the lateral or posterior vaginal walls
- may present in adolescence with difficulty inserting a tampon or dyspareunia
trichilemmal or pilar cyst
- mobile mass that contains fibrous tissue and fluid
- scalp, face, upper arms and back are usually affected.
- hairy areas are susceptible b/c cysts form at root sheath of follicle
antidote for Mg Sulfate
calcium gluconate
sx of magnesium sulfate toxicity
bradycardia, hypotension, decreased patellar reflexes and flaccid paralysis
Definitive management for an ectopic pregnancy
removal of the Fallopian tube.
when can use Methotrexate as alternative to surgical treatment of an ectopic pregnancy.
- pt not bleeding, hemodynamically stable
- β-HCG level < 5000 miU/mL.
- gestational size less than 4 cm,
Colpocleisis
surgical closing of the vaginal canal designed to treat vaginal prolapse in elderly females who are no longer sexually active.
- – thought to prevent uterine prolapse too
- – not used much anymore
Primary dysmenorrhea
pain associated with menses
- no actual pelvic pathology.
- starts shortly after menarche
Secondary dysmenorrhea
- pain associated with menses:
- – pain associated with endometriosis, pelvic inflammatory disease, uterine fibroids, etc.
- see in the 20s and 30s after previous normal menstruation
Risk factors for primary dysmenorrhea
menarche before the age of 12, nulliparity, smoking, family history, and obesity.
Risk factors for pre-eclampsia and eclampsia
multiple gestations, age at either extreme of reproduction, African-American or Hispanic race, hydatidiform mole, and extrauterine pregnancy
(NOT hx Sz or hx HTN)
Risk factors associated with an increased risk for maternal mortality include
advanced maternal age,
African-American or Hispanic race,
obesity, and
multifetal gestation.
Incomplete spontaneous abortions are managed with
- tissue extraction by forceps if POCs can be visualized at the cervical os.
- – Dilation and curettage may be performed if bleeding continues
- Misoprostol may be used instead of dilation and curettage for patients at less than 12 weeks gestation who are hemodynamically stable and do not desire surgical management.
Osteoporosis T score
bone density that falls 2.5 standard deviations (SD) below the mean for a young normal individual (a T-score of less than -2.5).
Osteopenia T score
between -1 and -2.5
dx severe osteoporosis
T-score less than -2.5
+ history of one or more fragility fractures
cervical insufficiency is defined as
recurrent painless cervical dilation in the absence of uterine contractions, infection, placental abruption or uterine anomaly.
(dx of exclusion)
Risk factors for cervical insufficiency
prior cervical laceration,
history of cervical conization (or CIN b/c they prbly had procedure),
multiple terminations with mechanical cervical dilation,
congenital cervical anomaly, and
collagen abnormalities.
contraindication to carboprost as uterotonic agent
hx asthma
— b/c prostaglandin analog. side effects include nausea, vomiting, and bronchoconstriction.
contraindication to methylergonovine as uterotonic agent
HTN or preeclampsia
– b/c ergot derivative that causes vascular smooth muscle contraction (also why IM only, not IV)
thresholds to treat asymptomatic bacteriuria in pregnancy
- clean-catch urine culture with >100,000 colonies/mL
or - catheterized urine culture with >100 colonies/mL
difference between chronic HTN and gestational HTN
chronic is before 20w
gestational is at or after 20w
s/sx of uterine rupture
fetal bradycardia, abdominal pain, loss of fetal station, maternal hypotension, uterine tenderness
risk factors for uterine rupture
previous C-section, myomectomy, ectopic pregnancy
how to dx chorioamnionitis
clinical and requires maternal fever of 38.0° C (100.4° F) that is not attributable to any other cause plus any one of the following:
- maternal or fetal tachycardia,
- uterine tenderness,
- foul-smelling amniotic fluid,
- purulent discharge, and
- leukocytosis
fetal “Engagement”
descent of the biparietal diameter of the fetal head below the plane of the pelvic inlet
— has occurred if at station 0
fetal “external rotation”
the fetus resumes its face-forward position, with the occiput and spine lying in the same plane.
fetal “internal rotation”
fetal occiput rotates from its original position (usually transverse) toward the symphysis pubis (occiput anterior) or, less commonly, toward the hollow of the sacrum (occiput posterior)
Menorrhagia
irregularly prolonged or heavy menstrual period that maintains a normal menstrual cycle (between 21-35 days)
— causes include coagulopathy (ITP, hemophilia, von Willebrand’s), Endometriosis, Leiomyoma, or Neoplasms
Metrorrhagia
uterine bleeding at irregular intervals, typically occurring between menstrual periods
— causes: contraceptive medications, called “breakthrough bleeding”, or underlying disorders such as leiomyomas, endometriosis, or genitourinary neoplasms
Menometrorrhagia
- menstruation cycle is heavy or prolonged AND occurs at irregularly intervals
- – combination of metrorrhagia and menorrhagia
Intermenstrual bleeding vs Metrorrhagia
- both involve bleeding in between cycles
- Metrorrhagia is separated by re-occurring at irregular intervals
Polymenorrhea
regular menstruation cycles occurring at irregularly shortened intermenstruation intervals, defined as 21 days or fewer
GBS Tx if penicillin allergy
- if NO hx anaphylaxis, urticaria, angioedema, or respiratory distress: Cefazolin
- if any of the above: vancomycin or clindamycin
Full anatomic screen should take place when?
between weeks 18-20
One-hour glucose challenge test is used to screen for gestational diabetes mellitus when?
between weeks 24-28.
when to do Testing for HIV in pregnancy?
initial prenatal appointment
Group B streptococcus culture is typically collected when? (preg)
between weeks 32-36.
when to do Cystic fibrosis (CF) screening in preg?
- indicated if there was a family history of CF on either side of the family.
- Discussion of genetic screening should take place at initial prenatal appointments.
Maternal benefits of breast feeding
early maternal/infant bonding, more rapid rate of uterine involution, decreased postpartum blood loss, lower cost compared to formula and decreased risk of ovarian cancer and premenopausal breast cancer
breastfeeding and cancer risk
breastfeeding for greater than 12 months decreases the risk of epithelial ovarian cancer.
— This is thought to be secondary to decreased ovulation during breastfeeding.
- also decreased risk of premenopausal breast cancer
side effect of ritodrine and terbutaline
both are B-2 agonists
- can cause hyperglycemia in diabetic mothers
first-line for treatment of cessation of premature labor
- Indomethacin if less than 32w
- – can’t use if hx PUD or renal/hepatic disease/bleeding disorder
Why can’t use ACE inhibitors in preg?
1st tri: increased risk fetal cardiac and CNS malformation
2nd-3rd tri: renal hemodynamics -> decreased GFR
when to start MMG screening
begin at age 40 or 10 years before the earliest diagnosed breast cancer in a relative.
meds for uterine relaxation
– ex/ to aide with retained placenta or uterine inversion or during EXIT procedure
volatile anesthesia (invasive, risky)
or
IV or sublingual nitroglycerin (first line)
1h GTT values
50g oral glucose given
Done at 24-28w
positive if > 130 at 1hr
first line tx for preeclampsia
- Labetalol
- delivery = only cure
contraindication to Labetalol
asthma pt
Viscero-somatic reflex for bladder and lower ureters
Sympathetic: T12-L2
Kallmann syndrome
- failure of olfactory and GnRH neuronal migration from the olfactory placode.
- causes primary amenorrhea, absent breast development, anosmia and color blindness
Klinefelter syndrome
- primary hypogonadism in males
- extra X chromosome
- small testes, low sperm count and infertility, decreased virilization, increased length of the long bones of the legs, and mild developmental abnormalities.
Swyer syndrome
- male karyotype, female phenotpye
- normal appearig woman who presents with delayed puberty
Turner’s syndrome info
- missing an X chromosome (all or part)
- premature ovarian failure, primary amenorrhea, and infertility
- – primordial follicles undergo accelerated atresia -> oocyte depletion before puberty
- lack of gonadal estrogen production
- – failure of breast development
Turner’s syndrome classic findings
webbed neck
shield chest
short stature
sexual infantilism
adenomyosis vs leiomyomas
Size
- Unlike leiomyomas, adenomyosis causes homogenous enlargement of the uterus that may be detectable on ultrasound
Pain
- adenomyosis pain non-cylical
- leiomyomas cyclical (hormonally responsive)
What to do next if you have abnormal AFP on second tri screen
first step = fetal ultrasound to rule out inaccurate gestational age or multiple gestations
medications that cause galactorrhea
those that cause lactotroph stimulation or inhibit dopamine: antipsychotics, TCAs, SSRIs, some antiemetics (metoclopramide, prochlorperazine), and some antihypertensives (verapamil, methyldopa).
when to suspect physiologic nipple discharge
in women who are not pregnant, have normal serum prolactin levels, and are not on psychiatric medications.
most reliable sign for dx of uterine rupturre
non-reassuring FHR patterns
sx of placental abruption
vaginal bleeding with acute, severe, and constant abdominal pain late in pregnancy
— emergency!
Risk factors for placental abruption
maternal hypertension, advanced maternal age, multiparity, cocaine use, tobacco use, chorioamnionitis and trauma
viscerosomatic reflex for the uterus
T9-L2 bilaterally
viscerosomatic reflex for the Fallopian tubes
T10-L2 ipsilaterally
Progestin only pills main mechanism of action
thickening of cervical mucus to inhibit sperm penetration
acceptable abx for asymptomatic bacteriuria in pregnancy
amoxicillin, ampicillin, nitrofurantoin, and first gen cephalosporins
Features of severe preeclampsia
BP ≥ 160/110 mmHg on two occasions at least four hours apart,
thrombocytopenia,
impaired liver function,
progressive renal insufficiency,
pulmonary edema,
new-onset cerebral or visual disturbances
NOTE: Massive proteinuria (>5g) was an old feature. Doesn’t count anymore
Ovarian resistance syndrome
- rare cause of hypergonadotropic hypogonadism
- dx: characterized by increased GnRH and LH/FSH levels accompanied by decreased estrogen and progesterone levels
- sx: women present early in life with amenorrhea, delayed breast development, elevated gonadotropins, low estrogen, and normal karyotype
first-line medication for acute management of tachyarrhythmias
adenosine
- this is in everyone, including pregnant women
- — second line agents include digoxin, CCBs, B-blockers
