CREOGS Flashcards
Which CMV antibody findings are most consistent with a diagnosis of primary infection?
IgM positive
IgG positive, low avidity (immature antibodies, in last 2-4mo)
Fetal sequelae of CMV, when is it worst?
growth restriction, hydrops fetalis, and myocarditis. Worst 1st trimester.
Most common time for transplacental exposure to CMV
Can occur anytime but 3rd trimester most commong
1st tri screening includes
bHCG, PAPP-A, NT
1st tri screen bHCG high
Tri 18 or 21
1st tri screen PAPP-A low
Tri 18 or 21
In the US what % of women experience stalking?
16% or 1 in 6
Medications that cause galactorrhea
Metoclopramide, first generation psychotics, and risperidone (Da blockade)
Cardinal movements of labor
Engagement, descent, flexion, internal rotation, ext, external rotation, explusion
What to avoid after MTX?
Sun (Dermatitis), pregnancy (3 months), folic acid, intercourse until bHCG neg
What med has been shown to reduce transplacental toxo transmission to fetus in women who are acutely infected with toxo?
spiramycin to reduce transplacental parasitic transfer. Spiramycin is a macrolide antibiotic that concentrates in the placenta but does not readily cross it.
Treatment of fetus or neonate if suspected to have toxo?
If the fetus is infected with toxoplasmosis, it should be treated with a combination of pyrimethamine, sulfadiazine, and folinic acid
Treatment PMS, PMDD
Despite SSRIs and SNRIs being the recommended first-line treatments, some women may prefer to start with OCs, especially if contraception is important.(drospirenone)
AMH made by what cells? How do levels vary with age?
Serum AMH is made by the granulosa cells of pre-antral and small antral follicles, and levels vary indirectly with female age.
Test for those with GDM, when pp, what is positive, and what do do with + result?
75g 2 hour test. 4-12 weeks pp, >200 diagnostic for DM2, 140-199 concerning for impaired glucose tolerance. If positive refer to diabetes management.
Most life threatening complication of UAE
Septic shock from a necrotic fibroid
bowel injuries usually present on what days
4-7, usually due to thermal injury due to tissue necrosis
rare disorder of pregnancy, presents with N/V, jaundice, impaired renal function, low serum glucose, elevated LFTS, elevated bili, 50% of time with HTN, sometimes high ammonia, sometimes DIC
acute fatty liver of pregnancy
what is the mirena IUD failure rate
0.2%
in patients with endometriosis and desire for future fertility and endometrioma, how would you manage endometrioma
surgical intervention ie cystectomy
Initial step in management of pregnancy involving alloimmunized patient
Determine the paternal erythrocyte antigen status (if homozygous then all children RhD positive, if Htz then 50% likelihood and then do amniocentesis)
When does RhD appear on fetal RBC?
After 7 weeks GA, therefore SAB before 7 weeks GA has low risk Alloimmunization
When is colon cancer screening recommended to start for all women? What about AA women?
All - 50
AA - 45
Age group most affected by IPV?
16-24yo
what is the risk of vertical transmission to neonate during a vagina delivery in a woman with HIV on HAART and VL <1000 copies/mL
1-2%
what is risk of vertical transmission of woman with HIV and no intervention?
25%
Ilioinguinal nerve injury
inner thigh, labia majora, groin, all sensory, T12-L1
iliohypogastric nerve injury
gluteal skin and superficial tissues and skin in the region above the pubic symphysis, all sensory, T12-L1
genitofemoral nerve injury
pain or paresthesia in the labia or within the femoral triage, all sensory, L1-L2
lateral cutaneous femoral nerve injury
lateral thigh, sensory only, L2-3
femoral nerve injury
Both sensory and motor, weakness of hip flexion, leg adduction, and knee extension, paresthesia over anterior and medial thigh, loss of patellar reflex, L2-4
most common type of fibroid degeneration that causes pain
Carenous, red, causes pain and localized peritoneal irritation
what are the hemostatic agents that do not contain human or animal products?
microporous polysacchardie spheres (arista) and oxidized generated cellulose (surgicel)
Max dose of lidocaine
4mg/kg
max dose of lido with epi
7 mg/kg
treatment of post c-section pelvic abscesses? most common organisms?
Broad abx and surgical intervention for drainage (gent,amp,clinda).
Organisms: coliforms and gram negative, Bacteriodes and prevotella
treatment of endometritis, type of bacteria
gent, clinda
polymicrobial, gram positive cocci, s aureus and Gbs, gram neg ecoli, k pneumoniae, proteus
what to add to Gent clinda in endometritis if still febrile?
add coverage for enteroccocs with ampicillin
Vaccines to give for aslpenia
Haemophilus influenza type b, neisseria meningitidis, and streptococcus penumoniae 9Hib, meningococcal and pneomococcus vaccines both the 23 valent polysaccharide and pneumococcal conjucate 13 valent) - to be given 14 days prior to procedure or 14 days after
Respiratory changes in pregnancy:
1) vital lung capacity
2) minute ventilation
3) tidal volume
4) inspiratory capacity
5) functional residual capacity
1) VLC - unchanged (FRC+inspiratory capacity)
2) , 3), 4) - increased
5) FRC decreased
most important prognostic indicators in vulvar melanoma
Depth of invasion and presence of surface ulceration are the MOST important prognostic indicators.
beta thal major, what is most increased? What is lost? Caused by absent what?
Hgb F is most increased (two alpha and two gama chains). Caused by absent beta globin gene, deficient or absent beta-chain production, leading to absence of hgbA (two alpha two beta chains)(homozygous, cooley anemia)
In non obese patients, at what angle should you insert the primary umbilical trochar? why?
45 degrees, to avoid injury to any major vessels
DM complicates what percent of pregnancies? What percent of those are GDM? What percent of those women with GDM develop T2DM?
7% pregnancies
90% GDM
70% Lifetime
alpha thal common among? who is more likely to have cis deletions? hgb bart leads to what?
- SE asian, african, west indian, mediterranean
- Cis: SE asian (Hgb bart 4 or Hb H 3 disease)
- hgb bart is del of all 4 alpha globin genes and presents as severe microcytic anemia, hydrops fetalis, and is usually fatal in utero
HPV gene wth highest oncogenic potential
HPV 16 - 60% cervical cancer
Hpv 18 - 15% of cases
hpv vaccine dosing
<15
>15
Ninevalent 16,18,6,11
- <15 2 doses, 0 and 6-12mo
- > 15 3 doses, 0, 1-2, 6 months
What contraceptive has the best efficacy for preventing pregnancy?
contraceptive implant, 1 year failure 0.05%
what are the characteristic features of postterm pregnancies?
Postmaturity syndrome: decreased subQ pat, decreased vernix, decreased lanugo, mec, oligo
most common time for injury in laparscopy?
when accessing the abdomen
max dose of lidocaine?
4mg/kg plain
signs of lidocaine toxicity
metallic taste, tinnitus, tingling lips, agitation, seizures
Difference between 5alpha reductase and androgen insensitivity
Both phenotypic female (amenorrhea) with a 45, xy karyotype.
- AIS breast dev as high levels of T -> E
- 5Alpha will develop male secondary characteristics at puberty
Risk of rhD alloimmunization with CVS?
14% of fetal-maternal hemorrhage of 0.6ml or more
Risk of rhD alloimmunization with SAB? With D&c?
1-5-2% with SAB, 4-5% if D&C
Risk of rhD alloimmunization with amnio?
2-6%
ECV
2-6%
Physiologic changes after epidural placement
- Increase mat Temp
- Decrease pvr
- iNcrease mat hr
- RR unchanged
- 2nd stage longer
what kind of mass? “Homogenous cyst with low level internal echos”
- Endometrioma
what kind of mass? “Anechoic cyst with thin, well defined wall”
- Simple cyst
what kind of mass? “Cystic mass with irregular walls, thick, irregular septations, and solid echogenic elements”
- Malignancy
what kind of mass? “Heterogenous ovarian mass with an echogenic mural nodule?”
- Mature teratoma
what kind of mass? “Hyperechoic “lace like” cystic mass with posterior acoustic enhancement”
- Hemorrhagic cyst
What type of face presentation can be delivered vaginally?
Mentum anterior
When to give TDAP in pregnancy
27-36 weeks, or for wound care at any time ( dont give again)
What labs and how often do we check for HIV+ women who are pregnant
CD4 and Viral load qtrimester and at 34-36 weeks
Viral load >1000 copies/ml what type of delivery
C-section at 38 weeks to decrease risk of transmission to fetus, if <1000 copies/ml then TOL and c-section
us criteria for placenta accreta
1) thinning or absence of the hypoechoic myometrial zone in the anterior LUS
2) thinning irregularity or focal disruption of the linear hypoechoic uterine serosa/bladder wall complex
3) presence of focal mass-like elevations or extentions of tissue with the same echogenicity of placenta beyond uterine serosa
4) Luncar vascular spaces in the placenta
risk of placenta accreta with previous c-sections
0 - 3% 1 - 11% 2 - 40% 3 - 61% 4 - 67%
Risk of uterine sarocoma with myomectomy or hyst for presumed fibroid?
1:500 (range 1:342 to 1:1000)
DHEAS >700 suspicious for
adrenal tumor, get adrenal CT next
management of pelvic congestion syndrome
- selective venous embolization
Uncomplicated injuries of the upper third of the ureter are repaired with …
- uretero-uretero-stomy with stent
Injuries to lower 1/3 or ureter require
- uretero-neo-cystostomy with psoas hitch
Best option for prenatal diagnostic tool for fetal congenital CMV infection
Amnio, performed at >21 weeks Ga and >6 weeks form maternal infection
Rescue therapy for pregnant women with asthma
B2 agonist short acting
The risk of what fetal conditions is most increased by obestiy?
neural tube defects
decreased risk - gastroschisis
highest prevalence of DV in which population?
pregnant 3rd trimester
contraindications to breast feeding
- T-cell lymphotrophic virus type I or II
- Active herpes simplex virus (HSV) lesion on maternal breast
- Infant with galactosemia
- Active recreational drug use or excessive alcohol use
- Active, untreated tuberculosis
- Untreated brucellosis
- Recent radioactivity exposure
- Treatment with certain chemotherapy cytotoxic drugs such as methotrexate, cyclophosphamide, cyclosporine, doxorubicin, and mycophenolate
- HIV positive status (in industrialized countries)
Definition of precocious puberty
Development of secondary sexual characteristics before age 8 years in girls is defined as precocious puberty.
Trimester in pregnancy most associated with DV?
3rd
monochorionic twins have what chance of neurologic damage and death after demise of other twin?
neurological injury, 18%, death, 15%
dichorionic twins have what chance of neurologic damage and death after demise of other twin?
neurological injury, 1%, death, 3%
MRI findings in women with eclampsia
MRI findings of posterior reversible encephalopathy syndrome (PRES) show hyperintense T2 lesions, which indicate edema in the subcortical and cortical (that is, the white and gray matter junction) regions of the parietal and occipital lobes.
If you remove a corpus luteum before 10 weeks, what do you have to supplement with?
Progesterone through 10 weeks. Options:
1) Weekly 17ohp
2) Daily micronized progesterone 200-300mg
3) The last option is 8% progesterone vaginal gel PLUS 100-200 mg of micronized progesterone orally
Risk of CO2 with hysteroscopy?
AFE, put patient in left lateral decubitus position and reverse Tberg.
At how many weeks after conception is the developing fetus MOST sensitive to the lethal effects from ionizing radiation
0-2 weeks after conception (GA 4-8 weeks), all of none phenomenon
Radiation effects 2-8 weeks after conception, then 6-27 weeks and beyond
- 2-8 weeks teratogenicity
- after intellectual disability
when to do amniocentesis? risk?
after 15 weeks, risk 0.1-0.3% pregnancy loss
most reliable sign of placental separation
cord lengthening
Gastroschisis:
- no sac
- location of defect, right paraumbilical
- concurrent aneuploidy - rare 1%
- associated anomalies - GI, atresia, malrotation
- sex prevalence - none
- maternal age - young average age 20
- 1/2000 births
- 90-95% survival rate depending on degree of bowel injury
Omphalocele:
- sac covering (peritoneum)
- Location, central
- concurrent aneuploidy - common 50%, T13, 18, 21
- associated anomalies - Cardiac defects (20%), Beckwith-Weidemann syndrome, Bladder extrophy, Pentalogy of Cantrell
- sex prevalence - males
- maternal prevalence - More common in extremes of reproductive age (< 20 or >40 years)
- 1/3000-1/5000 births
- prognosis: Depends on severity of herniation and associated anomalies
blood vessels in the subq tissue that originate from the femoral artery
- The superficial circumflex iliac artery is a small branch that runs up to the region of the anterior superior iliac spine.
- The superficial epigastric artery is a small branch that crosses the inguinal ligament and runs to the region of the umbilicus.
1st line treatment chronic vaginitis
- hygiene counseling
Tumor marker: Inhibin
Granulosa cell
Tumor marker: LDH
Dysgerminoma
Tumor Marker: AFP
Yolk sac (endodermal sinus), and embryonal carinoma
Tumor Marker: Ca-125
epithelial
Tumor Marker: CEA
mucinous
Tumor Marker: HCG
choriocarcinoma, embryonal
Most common cause of infertility
Male factor (40-50%)
Abx for PPROM
IV amp 2g q6, erythromycin 250 q6 (48hr) followed by PO amox 250mg q8 and erythomycin (5d)
Why no amoxicillin-clavulanic acid?
associated with increased risk necrotizing enterocolitis
Cutoff for endometrial stripe with PMB
If >4mm -> sample (so 5mm)
Functional residual capacity in pregnancy, increase or decrease
Decrease due to upward shift of diaphragm
How many calories burned in a week for weight loss?
2000 calories, or 3.5-5hr exercise in a week
What to start pregnant woman with mild persistent asthma in pregnancy?
low dose inhaled corticosteroid
Post term pregnancy outcomes for fetus
- Convulsions 2. Mec 3. NICU admission 4. Macrosomia 5. low 5 min apgar 6. post-maturity syndrome
Contraceptive efficacy greatest to lowest
- Nexplanon 2. Vasectomy 3. Salpingectomy 4. Mirena
Possible lethal side effect of hyperthyroidism if left untreated
hydrops
Thin endometrial lining with clomiphene -> what next
switch to letrozole
How to diagnose POI?
Two FSH >40 in 2 separate months
How to repair bladder dome by size in gyn procedures, <2mm, <1cm, <2cm, >2cm
<2mm expectant management
<1cm leave catheter in place for 5-7d then cystogram
<2cm repair in 1 layered running closure with absorbable suture
>2cm repair in 2 layers running closure with absorbable suture
preterm birth rate with twin gestations
59%
partially embedded IUD managment
office hysteroscopy
deeply embedded iud management
laparoscopy
ppx antibiotic choice for D&C (pregnancy related)
doxycycline before
Which are more common indirect or direct inguinal hernias?
indirect (2/3)
direct (1/3)
Which type of inguinal hernia passes through hesselbach triangle?
Direct
What is hesselbach triangle?
Inferior border is inguinal ligament, superolateral border and inferior epigastrics, medial border is rectus
Most common type of hernia in women
inguinal
Which has higher rate of strangulation, femoral or inguinal hernias?
femoral (15-20%)
Most sensitive in detecting a concealed abruption?
contractions
rate of multi-fetal pregnancy with 2 embryo transfer?
30%
pregnancy rates with 4,2,1 embryo transferred?
40,30,20%
when is the ideal time to determine chorionicity for twins?
Late first to early 2nd trimester <14 weeks
Time of cleavage after fertilization for di/di twins? US findings?
3 days
Lambda sign
Time of cleavage after fertilization for mo/di twins? US findings?
4-8 days, t sign
Time of cleavage after fertilization for mo/mo twins? US findings?
9-12 days
Time of cleavage after fertilization for conjoined twins? US findings?
> 13 days
<21 ASCUS pap, next step?
cytology in 1 year
What structures should be in view for a 2nd tri AC?
vertebrae, portal sinus, stomach, and umbilical vein in view.
treatment for high risk GTN per WHO criteria?
EMACO - etoposide, MTX, actinomycin D, cyclophosphamid, vincristine
Low risk GTN treatment?
<7, Methotrexate, if sensitivity to MTX then actinomycin D
class II muellerian anomalies
- Unicornaute uterus
- 40% association with renal and urological anomalies, and imaging of the GU tract should occur when these anomalies are seen.
- Rupture of accessory horn usually happens at <20 weeks
1. unicornuate uterus without accessory structures.
2. unicornuate uterus with communicating accessory horn, and
3. unicornuate uterus with nonfunctioning, noncommunicating accessory horn
Partial mole karyotype
69 XXX or 69 XXY
Biopsy containing atypical ductal hyperplasia chance of cancer
approximate 30% risk of either carcinoma in situ or invasive carcinoma in the tissues surrounding a
Treatment of small bowel needle stick injury? >5mm injury?
- needlestick: inspection, irrigation, abx if hemostatic
- <5mm: 2 layer closure
Definition of fetal engagement in pelvis?
Passage of the widest presenting part in vertex position; this is when the biparietal diameter passes through the pelvic inlet
risk of cancer with endometrial polyp?
<1%
when does fever occur with alcohol withdrawl?
48-96 hours
What are the predictors of meconium aspiration syndrome in babies with med (highest OR to lowest)
1) NRFHT 2) need for endotracheal suctioning 3) 1 minute apgar score <4
What therapy has been shown to lower fetal loss in women with APLS?
LMWH and ASA 81mg
What is epulis gravidarum?
Vascular swelling of the gums in pregnancy
After hysteroscopic sterilization, what % of patients still have tubal patency at 3 months?
3.5%
ART pregnancies have a higher risk of what perinatal risks?
- multifetal gestation
- placenta previa (abnormal placentation)
- abruption
- cesarean delivery
- prematurity
- low birth weight
- small for gestational age
- preeclampsia
- birth defects.
What % of patients with PTL deliver at term?
50%
What 5 of PTL resolves spontaneously?
30%
What is the % chance of placenta accreta with a placenta previa and 1st c-section (primary) 2nd 3rd 4th 5th
1st - 3% 2nd - 10% 3rd - 40% 4th - 61% 5th - 67%
What percent of pregnancies that occur after tubal sterilization result in ectopic pregnancy?
1/3
What type of laparoscopic sterilization has the highest rate of failure?
with bipolar electocautery
What mullerian anomaly is caused by partial lack of resorption of the midline septum.
- how common?
Uterine septum, 80-90% of major malformations, also the anomaly associated with the highest risk of adverse pregnancy outcomes - miscarriage rate 65%
What mullerian anomaly is caused by partially incomplete fusion of the two Mullerian ducts?
bicornuate uterus
What mullerian anomaly is caused by lack of fusion of the two Mullerian ductss?
Uterine didelphus
What mullerian anomaly is caused by failure of one Mullerian duct to develop?
Unicornuate uterus
What causes a T shaped uterus?
diethylstilbestrol (DES) exposure in women who took this drug between 1938 and 1975. Anomalies range from hypoplastic T-shaped cavities to irregular cavities with adhesions
The risk of having a cesarean section for delivery is reduced by what % in those who undergo an ECV at 36 weeks’ gestation.
50%
Which of the following is the BEST step in the management of a patient with a prolactinoma and symptoms of headaches and vision changes?
dopamine receptor agonist
What is the preferred regimen for postpartum endometritis?
IV clindamycin plus gentamicin for patients with normal renal function, with the recommended dosage of clindamycin 900 mg every 8 hours and gentamicin every 8 hours.
Organism most associated with asymptomatic chronic IUD users?
Actinomyces Israelii
What clotting factors are increased in pregnancy? Decreased?
Increased - Factor 7, 8, 10, 12, fibrinogen, PAI1, PAI2, von willebrand factor. Decreased protein s.
Most accurate assessment of cephalopelvic disproportion?
bispinous diameter
Muscles of superficial perineal space?
corpora cavernosa of clitoris, corpus spongiosum of vestibular tissue, ischiocarvernosus, bulbospongiosus, superficial transverse pernei, brances of pudenadal vesseld and nerves and urethra and vagina
Origin of fetal umbilical arteries?
internal iliac arteries -> become medial umbilical fold distally and proximally become the superior vesical arteries
median umbilical ligament is a remnant of what fetal structure?
fetal allantoic stalk or urachus
lateral umbilical folds
inferior epigastric vessels
recommendation for pneumococcal vaccine in adults?
> 65yo should receive PPSV23 (penumovax), PCV12 is shared decision making and should be given at least 1 year before PPSV23
what % of women with elevated maternal serum AFP have child with neural tube defect?
2%
How many trinucleotide repeats to be a fragile X premutation carrier? What disease are the at risk for?
55 to 200, POI
Most common aneuploidy associated with cystic hygroma in second trimester? First trimester?
Turner syndrome, monosomy 45X 2nd, downs 1st
At what GA does neural plate begin to form?
3 weeks GA
1st line uterotonic for D&C?
methergine
Most common site of injury of the ureter in a hysterectomy?
level of uterine arteries 80% (cervix)
average blood flow to uterus at term?
500mL/min, 10-15% of maternal cardiac output
lynch syndrome related genes
MLH1, MSH2, MSH6, PMS2, EPCAM
Arterial vessels off abdominal aorta in order?
Celiac trunk, SMA, renal, ovarian, IMA
Ovarian venous return l vs r
Right - Ivc
Left - left renal vein
Mirabegron MOA
beta 3 adrenergic receptor agonist
Benefit of delayed cord clamping in preterm infant?
Lower rate of necrotizing enterocolitis (and IVH)
What perfect increase hypothyroid medication in pregnancy?
25%
WHAT IS GOLD STANDARD FOR SCREENING FOR CUSHINGS SYNDROME?
24 hour free cortisol
first line treatment for vaginal agenesis?
vaginal dilators
IN a 28 day cycle when is the corpus luteum usually seen?
Day 14-16
Most common congenital infection?
CMV
What is dinoprost?
Prostaglandin E2
What is cytotec?
Prostaglandin E1
What is hemabate?
Prostaglandin 15 methyl PGF2 alpha
How much body weight needs to be lost in a patient with PCOS to resume ovulation?
5% initial body weight
Most common infectious pathogen assocaited with vulvovaginitis in peds?
Group A strep?
Indications for APLS?
- 1 or more unexplained deaths or normal appearing fetus >10 weeks GA
- 1 or more premature deliveries due to severe preE, eclampsia, of placental insufficiency
- 3 or more unexplained losses <10 weeks GA
- Personal history of vascular thrombosis
Diagnose APLS
at least 1 clinical criteria and at least 1 APS antibody persistently elevated 12 weeks apart
APS testing
Anti B2 glycoprotein, lupus anticoagulant, anticardiolipin antiodies
new name for vaginismus and dyspareunia?
Genito-pelvic pain and penetration disorder
CPSP fire risk stratification
1 point each for surgical site above ziphoid, open oxygen source, ignition source (electrocautery)
Women with HIV with viral load >1000 copies/mL at time of delivery? What med to give? how soon before delivery?
- Give zidovudine
- 3 hours beforec-section
Risk of mesh erosion after transvaginal mesh for POP?
11%
What hgb is deficient in those with beta thal?
Hgb A(2 alpha, two beta chains)
Triad for urethral diverticulum?
incontinence (dribbling post void0, dysuria, dyspareunia
