Duff Questions Flashcards
What is the normal sequence of pubertal development?
1) thelarche
2) adrenarche/pubarche
3) growth spurt
4) menarche
Regulation of menstruation:
Hypothalamus regulatory role?
Produce GnRH
Regulation of menstruation:
Pituitary Gland regulatory role?
ps. which lobe of the pituitary gland?
Produce LH FSH
Anterior lobe
Regulation of menstruation:
Ovary regulatory role?
Theca cells - stimulated by? produce?
Graunulosa cells - stimulated by? produce?
LH –> theca; androgen precursors for estrogens
FSH –> granulosa; androgen precursors for estradiol
When does ovulation usually occur in relation to the onset of the next menstrual period?
14 days prior to next menstrual period
What is the average interval from one cycle to the next? What is the range of normal?
Average cycle: 28 days
3-5 days of bleeding
21-35 day range
Bacterial Vaginosis:
Clinical manifestations
Thin gray discharge
Odor
Minimal inflamation
No puritis
Bacterial Vaginosis:
Diagnostic tests
pH >4.5
+ amine test
+ saline microscopy
Bacterial Vaginosis:
Treatment
Oral metronidazole (500 mg 2x daily for 7 days)
Candida:
Clinical manifestations
ps. which candida is most common
Albicans
Puritis, erythema, edema, satelite pustules, white curd-like discharge
Candida:
Diagnostic tests
Normal vaginal pH
KOH
+/- culture
Candida:
Treatment
Topical antifungals - Miconazole, clortimazole, terconazole
Oral antifungals - Fluconazole
Trich:
Clinical manifestation
Frequency, dysuria, dyspareunia, erythema, puritis, yellow-green frothy discharge, punctate cervical hemorrhages
Trich:
Diagnostic tests
pH >4.5
pap smear
saline prep - moving! (not sperm)
+/- culture
Trich:
Treatment
Single 2g dose of metronidazole
Tx sexual partner
What organisms are most likely to cause a Bartholin’s gland abscess?
Gonorrhea, Chlamydia, coliforms, anaerobes
What is the best initial course of management for a Bartholin’s gland abscess?
Drainage + abx + sitz baths
Abx: doxy (100mg BID) + metronidazole (500 mg BID)
OR
amoxicillin + clavulanic acid (875 mg)
*augmentin
What is the best initial course of management for a Batholin’s gland cyst?
Drainage + sitz baths
What are the management options for a recurrent Batholin’s gland cyst of abscess?
Marsupialization + abx
* dont excise
What is the purpose of a Pap smear?
To screen for cervical ca./abnormal cervical cytology
What is the optimal methodology for obtaining a Pap smear?
Spatula + cytobrush in a liquid medium
What is the appropriate screening interval for a Pap smear in a 21yo nulligravid, unmarried, sexually active woman?
Every 3rd year w/o HPV co-test
What is the appropriate screening interval in a 60yo married woman who has never had an abnormal pap smear?
One more or no more
What are the principal risk factors for cervical cancer?
Young at @ 1st intercourse Multiple sexual partners Smoking HPV infection with high-risk strains Other STDs
What are the best methods to prevent cervical cancer?
Safe sexual practices
Cervical cytology (routine Pap smears)
HPV vaccine
A 24yo married woman, G2P2002 with no prior hx of an abnl Pap smear, has the following cytology report: “atypical squamous cells of undertemined significance, ASC-US,” What should be the next step in her eval?
Recreen @ appropriate interval
Reflex HPV test (low = rescreen, high = refer to OBGYN)
A 28yo woman G3P2103 has a cytology report which states: “high grade squamous intraepithelial lesion; HSIL.” What should be the next step in management of this patient?
refer for colposcopy and bx
A 56yo multiparous, postmenopausal woman had the following Pap smear report: “Endometrial cells present. No squamous abnormalities notes.” What should be the next step in eval of this pt?
RED FLAG: endometrial bx needed immediately
What conditions should be considered in the ddx of acute lower abd pain in a young woman?
adnexal torsion Ectopic pregnancy Appendicitis Ruptured ovarian cyst TOA Rapidly growing neoplasm
What is the usual manifestations of endometriosis?
Tetrad: Dysmenorrhea Dyspareunia Chronic pelvic pain Infertility
What is the best test for the dx of endometriosis?
Direct visualization by laparotomy and/or bx
What are the usual txs for endometriosis
Medical: oral contraceptives, depo-provera, GnRH analogue
Surgical: laparoscopic surgery, open laparotomy
What are the principlal risk factors for endometrial cancer?
Advanced age Early menarche Late menopause \+ family hx Obesity Low parity Unopposed estrogen stimulation (polycystic ovarian dz or HRT) HTN Diabetes
What is the most common histologic type of endometrial ca.?
Adenocarcinoma
What is the best diagnostic test for endometrial ca?
endometrial bx
What is the usual tx for early stage endometrial ca?
surgery or radiation
What are the major organisms that cause PID?
Gonorrhea, Chlamydia
What are the major disorders that should be considered in the ddx of PID
Ectopic Pregnancy Appendicitis Rupture Ovarian Cyst Adnexal torsion Diverticulitis
What lab studies are appripriate in the eval in the of a pt with suspected PID?
CBC (low Hct, inc WBC) HCG (preg test) STD screen US Laparoscopy
What is the appropriate outpt tx for PID
Oflaxacin OR Levofloxacin PLUS Metronidazole
OR
Ceftriaxone PLUS doxy +/- Metronidazole
What is the appropriate inpt for PID
Cefotetan + Doxy
OR
Clindamycin + Gentamycin
What are the usual clinical manifestations of polycystic ovarian syndrome (PCOS)?
Irregular/absent menses
Obesity androgen excess (acne or hirsuitism)
Infertility
Carbohydrate intolerance
Enlarged polycystic ovaries with a thickened capsule
What are the potential long-term sequelae of PCOS?
Persistent infertility
Endometrial hyperplasia
Endometrial cancer
Which type of ovarian tumor is most likely in a teenager and young adult?
Germ cell - dermoid cyst/cystic teratoma
Which type of ovarian tumor is most likely in a post-menopausal pt?
Serous most common
Mucinous also
What is the most appropriate imaging study to assess and ovarian mass?
US
What are the definitions of primary and secondary amenorrhea?
Primary: normal secondary sexual characteristics and no period by age 16 OR no secondary sexual characteristics and no period by 14
Secondary: No period in 3 months
What are 2 of the unusual causes of primary, as opposed to secondary amenorrhea?
Genetic abnormalities: androgen insensitivity syndrome, turners
Anatomic abnormalities: agenesis, vaginal septum
What is the most common cause of secondary amenorrhea?
Pregnancy
What is the usual cause of primary dysmenorrhea?
Excessive release of prostaglandin from a secretory endometrium.
What is the most effective treatment for primary dysmenorrhea?
NSAIDs
What are the principal causes of abnormal uterine bleeding?
Anovulatory bleeding Endometrial hyperplasia or ca. Myoma Endometrial polyp Chronic endometritis Bleeding d/o - VWD or thrombocytopenia Thyroid dz
What are the 2 tests of greatest value in assessment of a pt with abnormal uterine bleeding?
pelvic US or endometrial bx
What is the preferred test for the dx of gonorrhea and chlamydia?
Nucleic acid probe: PCR or NAAT
What are the drugs of choice for treating an uncomplicated chlamydia infection?
Azithromycin 1000 mg po 1 dose
Also doxy or erythromycin
What are the drugs of choice for treating an uncomplicated gonococcal infection?
Ceftriaxone (250 mg I.M. x1) PLUS Azithromycin (1000 mg ps x1)
What are the major l/t sequelae of gonorrhea and chlamydial infection?
Infertility (d/t damaged fallopian tubes)
Ectopic pregnancy
Chronic pelvic pain
In a primary care practice, what is the most likely stage os syphilis at the time of initial dx?
Latent –> wont usually see lesion, by they will test positive
What are the most useful diagnostic tests for the diagnosis of syphilis?
Serology
UDRL/RPR to screen
MHA/FTA to confirm
What is the characteristic lesion of primary syphilis?
Painless chancre lasting <2weeks
What are the characteristic lesions of secondary syphilis?
Condyloma latum
Mucous patches
What are the usual clinical manifestations of tertiary syphilis?
Destructive gummas
Aortic valve injury
CNS manifestations: dementia, tabes dorsalis, pupillary abnormalities
What is the drug of choice for tx syphilis?
PCN
What are the most useful tests for the dx of HSV infection?
PCR
What are the drugs of choice for tx HSV?
Acyclovir
Valacyclovir
What percent of pregnancies in the US are unplanned?
50%
What is the difference btwn the “theoretical effectiveness” vs. the “user effectivness” of a contraceptive method?
Theoretical = if you use it perfectly User = true to life (MOST IMPORTANT)
What are the 3 major natural family planning methods?
1) Basal Body Temp
2) Calendar rhythm
3) Observation of cervical mucous
What are the advantages and disadvantages of the IUD as a method of contraception?
Ads:
Highly effective
Red’n in menstrual blood loss and cramping (progesterone IUD only)
Inexpensive in long run
Disads:
Pain w insertion
infection, perforation, dysmenorrhea, menorrhagia
High initial cost
What is the max duration of use of the cervical cap? do you need an Rx? is it reusable?
<48h, no Rx, not reusable
How long should the diaphragm be left in place after intercourse?
6 hr
If a contraceptive method is classified as Category 3 by the CDC Medical Eligibility Criteria, what is the clinical implication for the patient?
Theoretical/proven risk outweighs advantages.
What is the primary mechanism of action of combination oral contraceptives?
Blocking ovulation
What is the overall effectiveness of combination oral contraceptives?
99% when used correctly
What is the difference btwn “absolute risk” and “relative risk”?
Absolute: x/1000 women will see this (MORE IMPORTANT)
relative: 4x as likely to get this compared to woman not using xyz
What are the absolute contraindications to use of combination oral contraception?
LOTS! Estrogen dependent rumor Hx of DVT or PE Pregnancy Hx of undiagnosed genital tract bleeding Liver, heart dz Smoking and >35yo Diabetes w/ vascular dz HTN, SLE migrane w aura Stroke Solid organ transplant
What are the major non-contraceptive medical benefits of combination oral contraceptives?
Decrease in: menstrual blood loss severity of dysmenorrhea freq of functional ovarian cysts freq of ectopic pregnancy
Which pts are candidates for the contraceptive patch and contraceptive ring?
Forgetful pts
What is the most appropriate regimen for emergency post-coital contraception?
Plan B (levonorgestrel) - 75% effective Copper IUD - 99% effective
What are the advantages and disadvantages of progestin-only oral contraceptives?
Adv: Rx for lactating women
Disad: pregnancy and breakthrough bleeding
What are the advantages and disadvantages of Deop-Provera?
Ads: Highly effective Good for forgetful people Doesnt adversely affect fertility Doesnt cause congenital anomalies Doesnt increase risk of cancer Can breast feed immediately
Dis: Breakthrough bleeding Wt gain Depression Bone loss
What are the most common clinical manifestations of menopause?
Amenorrhea Hot flashes Vaginal dryness Sleep disturbances Mood changes
What is the best test to confirm the diagnosis of menopause?
FSH –> elevated
What are the specific objectives of hormone replacement therapy?
Decrease hot flashes
What are the potential harmful effects of HRT in pts who are >60yo and/or have pre-existing CAD?
Increase risk of CAD
In addition to HRT, what are other appropriate interventions for a pt in early menopause?
Nutritional and psychological counseling, antidepressants, lifestyle modifications (quit smoking, wt loss, exercise)
What are the principle complications associated with osteoporosis?
Bone fractures: vertebral column and hip
What is the best test to confirm the diagnosis of osteopenia and osteoporosis?
BMD –> Bone Mineral Density
In addition to estrogen replacement, what other medications are of value in preventing/treating osteoporosis?
Calcium supplements
Vit D
Selective Estrogen Receptor Modifiers (SERMs)
Anti-resporptive agents - Bisphosphonates
Specific drugs: alendronate, risedronate, ibandronate, zoledronic acid
What is the most common cause of most pelvic support defects?
Childbirth (vaginal)
What is the most appropriate tx for vaginal vault prolapse?
Pessary
Surgery –> resuspend vault
What are the most appropriate tests for the evaluation of a pt with urinary incontinence?
Urodynamic testing
What is the most effective medical tx for a pt with urge incontinence?
Muscarinic receptor blockers
What is the preferred surgical approach for a patient with stress incontinence?
Transvaginal slings (TVT, TOT)
What lifestyle changes are of value in the management of a pt with urge or stress incontinence?
Urge:
Reduce wt, Stop smoking
Decrease/eliminate caffine intake
Re-train bladder
Stress:
Lose weight, Avoid caffeine
Re-train bladder
Empty bladder immediately before exercise
What is the frequency of infertility in the United States?
15%
What are the most common causes of male infertility?
Low sperm count
Diminished sperm mobility
What are the most common causes of female infertility?
Anovulation
Tubal obstruction
Endometriosis
Unexplained
What diagnostic tests should be performed to eval an infertile couple?
Female:
Serum progesterone = assess ovulation
BBTS = assess ovulation
Clomid challenge test = assess ovarian reserve
TSH = r/o hypothyroidism
Prolactin = assess pituitary microadenoma
HSG = ID tubal obstruction
Laparoscopy = assess uterine anomaly or endometriosis
Male:
Sperm analysis = count sperm, assess motility and morphology
What is the most appropriate tx for the major causes of infertility?
Female: fertility drugs, surgery for anatomic concerns
Male: IUI, ICSI, repair varicocele
What are the most common causes of 1st trimester pregnancy loss?
Karyotype abnormalities
Serious sytstemic dz (like antiphospholipid syndrome)
What are the principal maternal and fetal indications for pregnancy termination?
Maternal: serious systemic dz (antiphospholipid syndrome, diabetes)
Fetal: fatal genetic abnormalities, life threatening structural abnormality
What are the two options for 1st trimester pregnancy termination?
1) Medical: mifepristone + misoprostol
2) Suction curretage
What are the two options for 2nd trimester pregnancy termination?
1) Misoprostol
2) Dilation and evacuation - rare
What are the most important predisposing factors for an ectopic pregnancy?
PID and tubal surgery
What is the most common site for an ectopic pregnancy?
Ampulla (d/t it being the location of fertilization)
What 2 tests are of greatest value in diagnosing an ectopic pregnancy?
1) Anbornal increase in quantitative HCG (failure to double in 72h)
2) U/S: absence of intrauterine pregnancy; adnexal mass; blood in sac of douglas
What is the most appropriate management for a small unruptured ectopic pregnancy?
Methotrexate
- effective in 90% of patients (the other 10% will require a 2nd dose)
What is the most appropriate management for a larger, ruptured ectopic pregnancy?
Surgery: removal of ectopic or removal of tube
What is a molar pregnancy?
Gestational Trophoblastic Dz (GTD)
Tumor of placental tissue
Genotype: 46XX
- Can develop de novo or after a spontaneous abortion/term pregnancy
What are the most common clinical manifestations of a molar pregnancy?
1) Persistent bleeding in early 1/2 of pregnancy
2) Uterus large for dates
What are the most valuable tests for diagnosing a molar pregnancy?
1) Quantative HCG = markedly elevated
2) U/S
How should a pt with a molar pregnancy be treated?
Suction evacuation
*also monitor serum HCG to check for persistence
What are the most common medical diseases that complicate pregnancy?
HTN Diabetes (increasing prevalence d/t obese mothers) Connective tissue dz (lupus) Acquired heart dz (Mitral valve dz) STDs
Which medications are clearly teratogenic?
Valproic acid (unless it is the only drug that works) Carbamazepine Chemo tx Warfarin (use lovanox or heparin) Lithium Tetracyclines - affects fetal heart Quinolones ACE inhs BBlockers Isotretinoin Topiramate NSAIDs Heat Radiation
What are the potentially harmful effects of smoking in pregnancy?
1) more preterm deliveries
2) more placental abruptions
3) smaller babies
What is the purpose of screening for hep B in pregnancy?
HepB can pass from mother to fetus during birth; can give mother HepB-IG to prevent transmission
(vaccine infant at 0 months and 6 months)
What is the purpose of the Quad Screen test?
ID Neural Tube Defect (NTD) and Trisomy 18 & 21
(75-80% sensitive)
2nd trimester test
A 28 year old woman G2P1001, at 6 weeks gestation has a BMI of 21. What is an appropriate weight gain during pregnancy for this patient?
25-30lbs
What is the best diagnostic test to resolve discrepancies between uterine size and dates?
U/S
What are the most likely MATERNAL complications associated with chronic HTN in pregnancy?
CVA Renal dz Retinopathy Abruption Super-imposed pre-eclampsia
What are the most likely FETAL complications associated with maternal HTN
Interuterine Growth Restriction (IUGR)
Fetal Death
What are the clinical criteria for the dx of pre-eclampsia?
Triad:
BP >140/90 after 20w gestation
Proteinuria >300mg/24h
Edema
What are the 2 likely criteria that determine the management of pre-eclampsia?
severity of disease, gestational age
What are the usual clinical manifestations of placental abruption?
Abdominal pain Tetanic uterine contraction Dark red vaginal bleeding Coagulopathy Abnormal fetal heart rate pattern
What are the usual clinical manifestations of placenta previa?
Painless
Bright red vaginal bleeding
NO CHANGE IN FETAL HR
NO COAGULOPATHY
What are the major factors that cause preterm delivery?
Preterm PROM Multiple gestation Polyhydramnios Uterine anomaly Abruption Previa
What are the four most serious complications of prematurity?
Hyalinemembrane dz
IVH
NEV
Infection
Why are corticosteroids administered to mothers at risk for perterm delivery
decreased frequency of RDS, IVH, NEC
What percent of twins are monozygotic?
1/3
What is the best test to ID twins and assess zygosity?
U/S
What factors are associated with an increased risk of dizygotic twins?
Advanced age of mother, increased use of ART, African americans, + fam hx
What are the most common antepartum complications associated with a twin gestation?
#1 = preterm labor and delivery Spontaneous abortion Anomalies Impaired growth Polyhydraminos Twin-twin transfusion syndrome Pre-eclampsia Placental abnormalities
What are the most common intrapartum and postpartum complications associated with a twin gestation
Dysfunctional labor Malpresentation Abruption Abnormal FHR tracing Cesarean delivery Postpartum hemorrhage
What tests are of greatest value in identifying complications related to twins?
Early prenatal care Early U/S to determine zygosity Second trimester scan for anomalies, cervical length Third trimester scan for fetal growth Frequent prenatal appointments Limited activity Antepartum monitoring
What factors should be considered in determining the mode of delivery for twins?
Positioning of fetus (cephalic-cephalic, cephalic breech, both breech)
What is the principal cause of higher order multiples?
Assisted reproductive technologies (ARTs)
What are the 3 stages of labor?
1) onset of contractions
* latent: 0-4hr
* active: 4+hrs - dilating more quickly
2) full dilation until delivery
3) delivery of baby until delivery of placenta
What are the 2 phases of the 1st stage of labor?
latent and active
What are the most likely causes of abnormal labor?
Poor uterine contractility Over-sedation Intrauterine infection Malpresentation Malposition Fetopelvic disproportion
Which type of anesthetic provides the most consistent and uniform effect during labor and delivery?
Epidural
What are the most common indications for cesarean delivery?
Dystocia Repeat Stress Bleeding Malpresentation
What is the most common intraoperative complication of cesarean delivery?
Hemorrhage
What is the most common postoperative complication of cesarean delivery?
Infection (endometritis)
What is the preferred type of uterine incision for cesarean delivery?
Low transverse (Kerr) - 98% of all deliveries
An 18 year old primigravid woman at 39w gestation has been in labor for 10 hours. Her cervix has been 5cm dilated for 2 hrs. Her membranes are intact. She is having contractions eery 5-6 minutes. She rates the strength of the contractions 5+ on a scale of 10. What are the most appropriate next steps in management of this patient?
“Arrest of dilation”
Give pitocin or break amniotic sac
A 28 year old woman, G2P1001 at 41 weeks gestation has been in the 2nd stage of labor for 2 hrs. The fetal head has remained at 0 station despite strong contractions and excellent voluntary pushing efforts. The pts previous baby was delivered spontaneously and weighed 3080g. The estimated weight of the present baby is 3480 grams. What is the most appropriate next step in management of this patient?
Arrest of descent d/t fetopelvic discrepancy (size mismatch with weight) –> c-section
can only deliver vaginally if +3 +4 or +5 station
What are the principal causes of postpartum hemorrhage?
Uterine atony (drugs, chorioamnionitis, uterine overdistention, uterine malformation)
Retained placenta (accreta, increta, percreta)
Lacerations (cervical, vaginal)
Coagulopathy (severe preeclampsia, abruptio placentae, sepsis, amniotic fluid embolism)
What are the principal risk factors for postpartum endometritis?
Labor Ruptured membranes Multiple vaginal exams Pre-existing vaginal infection Cesarean delivery
What are the most appropriate antibiotics for tx of postpartum endometritis?
Clindamycin + gentamicin
Metronidazole + PCN + gentamicin
Cefotetan or timentin
What is the most appropriate treatment for a wound infection following esarean delivery?
Surgical drainage
Modify abx to target staphylococci and streptococci (Nafcillin, vancomycin)
What is the best test for the diagnosis of a pulmonary embolism?
Spiral CT scan
Also ventilation-perfusion scan, pulmonary angiogram
What is the most appropriate treatment for a pulmonary embolism?
Anticoagulation - lovanox ideally
Thrombolytic therapy
