EOR Topics to Review Flashcards
Which STI is a/w gram negative diplococci?
N. gonorrhea
Description of clue cells on wet mount?
Epithelial cells with stippled borders
Pathogen a/w chancroid?
Haemophilus ducreyi (gram negative fastidious rod)
Chancroid treatment
Abx (azithro, ceftriaxone or erythromycin) and drainage of any fluctuant inguinal lymph nodes
HSV treatment dosing
Acyclovir 400 mg TID
Valcyclovir 1000 mg BID
Description of discharge for BV (gardnerella vaginalis) infection
Thin/watery, homogenous, milky white/gray, malodorous (fishy odor)
Complications of PID
- Infertility
- Chronic pelvic pain
- Fitz Hugh Curtis syndrome
- Tubo-ovarian abscess
- Ectopic pregnancy
Condyloma acuminata pathogenic cause
HPV 6 and 11 (leads to pruritic, painless genital warts)
Treatment of condyloma acuminata (genital warts)
Patient applied: imiquimod (immune response modulator)
5-FU (fluorouracil) and trichloroacetic acid – cytodestructive therapies
Clinician administered: cryotherapy, surgical excision, electrosurgery
1st line treatment for atrophic vaginitis
Vaginal moisturizers and lubricants –> vaginal estrogen if refractory
Best test to diagnose gonorrhea/chlamydia?
NAAT testing
Lymphogranuloma vereneum big 5
- Etiology: genital ulcer disease caused by chlamydia trachomatis; common in tropical climates and in MSM
- Presentation: incubation of 3-12 days and secondary stage 2-6 weeks later
(primary presentation = PAINLESS genital ulcer that resolves spontaneously) followed by secondary stage (inflammation spreads to surrounding lymphoid tissues – anorectal sx, inguinal syndrome) - Dx: primarily clinical, but can confirm with NAAT
- Mgmt: 21 d doxy 100 mg BID (or erythromycin 500 mg qid for 21 days if pregnant or lactating)
MC bacterial STI and cause of cervicitis
chlamydia
Gonorrhea treatment in pregnancy
Ceftriaxone and azithromycin – CTX covers gonorrhea but need azithro to co-treat chlamydia
Strains of HPV most a/w cervical cancer
16 > 18
Nontreponemal syphilis testing (screening methods)
VDRL, RPR
Secondary syphilis presentation
- Maculopapular rash on palms and soles of feet
- Condyloma latum (wart like lesions on genitals NOT 2/2 HPV)
Tubo-ovarian abscess management
- Abx (cefotetan + doxy OR cefoxitin + doxy OR clindamycin + gentamicin)
- Invasive surgery if pts cannot be treated with antimicrobials alone (postmenopausal, suspected/overt sepsis, abscesses > 7 cm, ruptured abscess, failed abx therapy)
Lactational mastitis treatment algorithm
1st: NSAIDs (i.e. ibuprofen 800 mg) if sx arise within the last 24 hours
If sx > 24 h or refractory to NSAIDs: abx
- No MRSA coverage: dicloxacillin 500 mg PO, cephalexin
- MRSA coverage: Bactrim, clindamycin
Fibrocystic changes treatment if refractory to NSAIDs and supportive care
Tamoxifen (1st line)
Danazol
Biggest RF for breast abscess?
Smoking
Fibroadenoma MC presentation
Usually painless (although can intermittently be painful before cycle)
More common in adolescents (age range 15-35 y/o)
well circumscribed, smooth, rubbery, mobile mass
Core needle biopsy (+) tissue nonproliferation with fibrotic changes corresponds to?
Fibrocystic disease
Complications of Rh incompatibility
Hydrops fetalis – fluid accumulation (ascites, LE edema, pericardial/pleural effusions) and severe anemia +/- thrombocytopenia and neutropenia
TO AVOID: rho gam administration at 28 weeks in Rh- moms with exposure to Rh+ baby previously or Rh+ heterozygous dad
Gestational diabetes screening
1st: 50 g 1 hr GTT –> (+) if glucose > 130 after 1 hr
If 50 g is (+), proceed with 100 g 2 hr GTT (fast 8 hours prior) –> fasting glucose >/= 95, 1 hour glucose >/= 180, 2 hour >/= 155, 3 hr >/= 140
***single 75 g oGTT not rec by ACOG b/c it over diagnoses people with GDM
HELLP versus pree-eclampsia with severe features
HELLP syndrome:
- Low platelets and hemolysis labs are KEY – cannot make diagnosis without these present
Preeclampsia w/ severe features:
- Can also see low platelets and elevated LFTs/RUQ pain, but will NOT have hemolysis on labs
Biggest RF for placental abruption?
Prior placental abruption
Medical management for ectopic pregnancy versus SAB?
Ectopic: methotrexate
SAB: mifepristone + misoprostol
Cervical insufficiency MC causes miscarriages in the ____ trimester
2nd – at least 2 consecutive second trimester losses is enough for diagnosis, and repeated miscarriages in 2nd trimester should prompt you to think of cervical insufficiency as the cause
Risk factors/causes of cervical insufficiency
- h/o cervical trauma
- Ehlers Danlos
- Mullerian duct defects
Cervical length < __ mm supports diagnosis of cervical insufficiency
25
Cervical insufficiency treatment
- Progesterone supplementation – helps prevent preterm birth starting at 16 weeks gestation
- Cervical cerclage (1st line) – stitch that supports the cervix to prevent preterm birth AND reinforces cervical strength > avoid intercourse s/p placement
Treatment for simply cystitis in pregnancy
Fosfomycin 1 time dose
***macrobid should be avoided in 1st tri (and all others if possible) as it might cause some fetal birth defects
When can you start to see hydatiform mole on US?
8 weeks
Complications of gestational diabetes
- Macrosomia (> 4000 mg)
- Polyhydramnios
- Preeclampsia
- gHTN
- Other neonatal complications: shoulder dystocia, HCOM, hypoglycemia, etc.
Clinical finding to ensure therapeutic magnesium sulfate levels for preeclampsia prophylaxis?
(+) patellar reflexes
Glucose targets for pregnancy?
In pts with pre-existing diabetes:
A1C < 6% Fasting/preprandial: 60-99
Postprandial: 100-129
In gestational diabetes:
Fasting/preprandial < 95
Postprandial < 120
At what point in gestation are steroids and tocolytics no longer indicated?
> /= 34 weeks gestation
Placental abruption definitive management
Delivery – vaginal if stable and at term or C section (steroids and tocolytics before if GA < 34 weeks)
MC time for ectopic pregnancy to present?
6-8 weeks
Treatment of choice for hypertension in pregnancy with pmh of asthma or cardiac dysfunction/bradycardia?
Nifedipine ER
Placenta previa delivery recommendation
Cesarean at 37 weeks
MC complication of placental abruption
DIC
Molar pregnancy post operative monitoring
Serial (weekly) hCGs until level < 5
At what BP is anti-hypertensive treatment required for preeclampsia?
SBP > 160 or DBP > 110
When do you deliver for pts with preeclampsia?
With mild features - aim for 37 weeks gestation
With severe features - aim for 34 weeks gestation however typically mgmt is to deliver immediately (vaginal delivery not contraindicated)
Umbilical cord prolapse RFs
- Frank breech presentation
- Transverse presentation
- Low birth weight
- Low maternal BMI
- Prematurity
- Multiparity
- Prolonged labor
What test can be used to predict the probability of preterm delivery?
Fetal fibronectin
– negative ( < 50) is a strong predictor that the pt will not enter labor in the next 7-14 days
***used to predict probability of preterm labor in patients with INTERMEDIATE cervical length (20 to < 30 mm ONLY)
T or F: Asthma is a risk factor for preterm labor
True
Shoulder dystocia management
1) Apply gentle downward pressure on head
2) McRoberts maneuver – flex maternal hips to abdomen
3) Place pt on all 4 hours (Gaskin maneuver), maneuver to deliver posterior shoulder (Woods screw and Rubin maneuver)
4) Place fetal head back into perineum (Zavanelli maneuver)
Zavanelli is a LAST RESORT if everything else fails – proceed with emergent C section after this maneuver is complete
Major criteria for intraamniotic infection (aka chorioamnioitis)
T >/= 102.2 without another clear source
OR
T 100.4 PLUS one of the following:
- maternal WBC > 15
- FHR > 160
- purulent or malodorous amniotic fluid
T or F: you can breastfeed if you have HIV
True – as long as most recent viral load is undetectable, if NOT, then breastfeeding is contraindicated
What form of birth control is CI in the postpartum period (6 weeks after delivery)?
OCPs d/t increased VTE risk
At what point can pts resume intercourse after an uncomplicated vaginal delivery?
6-8 weeks
4 Ts of postpartum hemorrhage
Tissue (retained fetal/placental parts)
Tone (uterine atony – manage with uterine massage and oxytocin)
Trauma to birth canal
Thrombin disorder or coagulopathy
Risks of episiotomy in comparison to spontaneous vaginal tear
- Increased likelihood of dyspareunia
- Increased likelihood of repeat tears with future delivers
- Increased likelihood of wound dehiscence
- Longer perineal lacerations
What is septic pelvic thrombophlebitis?
Rare complication of postpartum endometritis where thrombus develops in pelvic vein and becomes infected
Most important RF for postpartum endometritis?
C section
Vaccines contraindicated in pregnancy
MMR (live, attenuated)
Varicella (live, attenuated)
Oral polio vaccine
BCG (live, attenuated)
Rotavirus
Yellow fever (live, attenuated)
Smallpox
Zoster (live, attenuated)
Order of Leopold maneuvers
1) Superior surface of fundus – determine consistency, shape, and mobility
2) Both sides of the uterus – direction of fetal back
3) Part of the fetus at the inlet and mobility is determined
4) Fetal attitude and degree of fetal extension into the pelvis is determined
Prenatal counseling regarding:
- Traveling
- Caffeine
- Seatbelt use
- Sleeping position
- Exercise
- Intercourse
Travel:
- maintain hydration and move LE to avoid venous stasis/thromboembolism
Caffeine:
- avoid or limit to < 200 mg/day (~1 cup of coffee)
Seatbelt use:
- Safe and advised, lap belt should be placed under the uterus
Sleeping position:
- Limited/mixed data on sleeping supine leading to decreased CO and fetal blood supply, mixed reviews on sleeping on L side to help increase venous return
- Overall rec is to sleep on L side
Exercise:
- Moderate intensity exercise 5-7 days/week
Intercourse
- Safe as long as there is no vaginal bleeding or ruptured membranes, placenta previa
What does the quad screen consist of and when is it usually done?
- AFP, hCG, estriol and inhibin A –> screens for down syndrome (+ screen if inhibin A and hCG are elevated, decreased AFP and estriol)
- Usually done 2nd trimester between 15 and 18 weeks EGA
Monozygotic versus dizygotic twins
Mono: single ovum splits into two fetuses (can be mixture of mono/dichorionic and mono/diamniotic)
Dizygotic: two separate ova fertilized in the same ovulatory period – almost always dichorionic and diamniotic (two separate placentas and two separate amniotic sacs, respectively)
Presentation of recipient versus donor twin in twin-twin transfusion syndrome
Recipient: enlarged umbilical cord/abdominal circumference/kidneys and bladder, polyhydramnios, hypertension
Donor: oligohydramnios, at risk for anemia, hypovolemia, kidney insufficiency, and pulmonary hypoplasia, hypotension
T or F: multiple gestation births increase risk of breast cancer
False – increased estrogen is a protective factor
Tx of choice for prophylaxis of ophthalmia neonatorum (conjunctivitis) in neonates
Erythromycin ophthalmic ointment (given to both eyes within 2 hours of birth)
US findings for oligohydramnios
DVP < 2 cm
Amniotic fluid index (AFI) < 5 cm
Causes of oligohydramnios
- rupture of membranes (MC)
- any fetal urinary tract anomaly: PCKD, renal agenesis, obstructive lesions, urinary tract blockage
- placental insufficiency: preeclampsia, chronic HTN or post term pregnancy (beyond 42 weeks), abruption
MC side effect of pitocin administration
Tachysystole
other ADRs (not as common): hyponatremia, hypotension
Elevated AFP a/w _____
Neural tube defects, anencephaly, spina bifida, conjoined wins, etc.
Abomdinal wall defects
If no anatomical defects – can be a/w certain rare cancers
***elevated AFP can indicate leakage from open neural tube defect directly into amniotic fluid
When do you screen for neural tube defects?
Maternal serum AFP 15-20 weeks gestation
***amniotic fluid AFP levels more accurate but not the preferred screening test
What medications are a/w neural tube defects?
Antiepileptics (carbamazepine, valproic acid)
Methotrexate
Naegele’s rule
(LMP - 3 months) + 1 week = EDD for patients with regular menstrual cycles
0, +5 and -5 station
0 = baby’s head at the level of the ischial spine
-5 = baby’s head at the level of pubic symphysis (aka highest station)
+5 = baby’s head at vaginal opening (aka lowest station)
Relative contraindications to neuraxial analgesia?
- Coagulopathy
- Infection at site of puncture
- Increased ICP
***common side effect of neuraxial analgesia = pruritus –> tx with opioid antagonists (naltrexone, naloxone) and postdural puncture headache (HA 6-72h after puncture, worse with sitting or standing) –> tx with epidural blood patch
At what gestational age do pts start to feel fetal movement?
Multiparous: 14 weeks
Primiparous: 18-20 weeks
Pregnancy specific physical exam findings
Chadwick sign = bluish hue to cervix first noticeable around 8-12 weeks gestation
Goodell sign = cervical softening
Hegar sign = softening of uterus
Osiander sign = pulsations felt in lateral vaginal forices (indicate lateral implantation)
Piskacek sign = asymmetrical uterine enlargement (indicates lateral implantation)
What vitamin can be teratogenic if taken in excess?
Vitamin A – can result in SAB or fetal malformations if taken excessively in first trimester
ex of vitamin A: retinol; should not exceed more than 5000 IU daily
Recommended folic acid dosing
No previous history of neural tube defects in previous pregnancies: 0.4 mg daily
Previous history of neural tube defects in prior pregnancies: 4 mg daily
Postterm (> 42 weeks GA) infant physical characteristics
Decreased or absent lanugo
Decreased or absent vernix caseosa (white, cheesy substance that covers fetal skin)
Dry, thin, loose skin covering thighs and buttocks
Components of BPP?
Fetal tone
Fetal HR (done with NST)
Fetal movement
Amniotic fluid volume
Fetal breathing
At what GA do hCG levels begin to plateau?
~20 weeks (remain constant between 2-50,000)
Levels begin to decline at 9-10 weeks gestation (previously doubling everyday)
At what hCG level should you be able to see a gestational sac on VUS?
2,000
What is the timeline for test of cure in pregnant patients who were treated for chlamydia?
3-4 weeks after treatment
Treatment of N/V in pregnancy
First: LSM – small, frequent meals; cold, clear beverages, avoiding any triggers for nausea
If refractory to dietary changes: pyridoxine (vitamin B6) + doxylamine if pyridoxine alone is ineffective
If still refractory: stepwise addition of H1 antagonists (dimenhydrinate, diphenhydramine) –> dopamine antagonists (metoclopramide, prochloperazine) –> serotonin antagonists (ondansetron)
Recommended calcium intake levels daily in pregnancy
1000 mg
Apgar scoring criteria
Appearance:
0 - cyanotic or widespread pallor
1- normal except extremities
2 - normal over entire body
Pulse:
0 - absent
1 - < 100 BPM
2 - > 100 BPM
Grimace (reflex response):
0 - no response
1 - grimaces
2 - sneeze, cough, or vigorous cry
Activity (muscle tone):
0 - absent
1 - arms and legs flexed
2 - active
Respirations:
0 - absent
1 - gasping, irregular
2 - good, crying
Timeline of splitting for twins
After 0-3 days fertilization: di, di
After 4-8 days: monochorionic, diamniotic (majority of monozygotic twins)
After 8-12 days: monochorionic, monoamniotic (rare)
After 13 days: conjoined
Hyperemesis gravidarum lab findings
Hypochloremic metabolic alkalosis
Hypokalemia
Transient LFT elevation (usually < 300 U/L)
Starvation ketosis
Pap recommendations
Age 21-29: pap smear q3 years
Age 30-65: co-testing (pap + HPV screening) q5 years
Management of abnormal pap results
Atypical squamous cells of undetermined significance or LSIL –> reflex HPV testing
HPV testing (+) if high risk HPV types are present –> further workup with colposcopy
If colposcopy abnormal –> excision with LEEP or ablation
Management of LSIL in pts 30+ with abnormal pap and negative HPV testing
Repeat cotesting in 12 months
Presentation of choriocarcinoma versus invasive mole
Choriocarcinoma:
- usually presents after SAB, live birth, still birth, or ectopic
- can arise from hydatidiform mole
- frequently metastatic –> spreads to lungs
Invasive mole:
- molar tissue invading uterine myometrium
- can cause uterine rupture if left untreated
- MC type of gestational trophoblastic neoplasia
- biopsy (+) trophoblastic cells and hydropic villi
MC histologic type of vulvar cancer?
Squamous cell
THINK: it arises on the skin and that is where squamous epithelium predominates
MC histologic type of cervical cancer?
Squamous cell – originates from ectocervix/near the squamoucolumnar junction, which is primarily lined with squamous cell epithelium
Next MC type is adenocarcinoma, which originates from the endocervix
Next step in management for a patient with atypical squamous cells of undetermined significance (ASC-US) on pap and positive HPV testing?
Colposcopy + endocervical sampling if there are NO IDENTIFIABLE gross cervical lesions on pelvic exam
Only colposocopy is fine if identifiable lesions
Ovarian cancer tumor marker
CA 125
Stages of pelvic organ prolapse
Stage 0 = no evidence of prolapse
Stage 1 = distal prolapse is 1 cm or more from distal hymen
Stage 2 = distal prolapse </= 1 cm or >/= 1 cm above hymen (essentially located AT the level of the hymen)
Stage 3 = distal prolapse > 1 cm below hymen
Stage 4 = complete prolapse
Most practical versus most DEFINITIVE way to diagnose ovarian torsion
Most practical = US w/ doppler, usually going to be your first initial method of testing
Most definitive = direct visualization at time of surgical eval
Which of the following is a physical exam finding most a/w cystocele?
A) Chandelier sign
B) Joint hypermobility
C) Scar from a previous tube thoracostomy
D) Thin body habitus
B
A – a/w PID, which increases risk of infertility, tuboovarian abscess, chronic pelvic pain, Fitz Hugh Curtis, but NOT pelvic organ prolapse
C – no associated increased risk
D – obesity is a/w pelvic organ prolapse d/t increased intraabdominal pressure, NOT thin body habitus
BPP indications and scoring
Indication – nonreactive NST
Scoring (everything is either 0 or 2 points) –
Over a 30 minute period, 2 points given if the following criteria are met:
Tone - 1 or more episodes of extension of a fetal extremity with return to flexion or opening and closing of a hand
Movements - at least 3 discrete body or limb movements
Breathing - at least 1 episode of rhythmic fetal breathing movements (watch diaphragm) of 30 sec or more
Amniotic fluid index - > 2 cm
Tx of choice for infertility in PCOS
Ovulation inducing agents (letrozole or clomiphene)
***reason for infertility in PCOS is anovulation
1st line hyperandrogenism treatment in PCOS patients
COCs > spironolactone if refractory after a few months
Leiomyoma classifications
- Subserosal → originate from myometrium at the serosal surface, pedunculated stalk appearance
- Cervical
- Intramural → located within uterine wall and extend to the serosal or mucosal surface
(Can sometimes be transmural and extend to both surfaces) - Submucosal → arise from myometrium just below endometrial surface and can exist completely within the endometrial cavity or extend into the myometrium
US findings for follicular cyst versus endometriomas versus corpus luteal cyst
Follicular cyst = smooth, thin walled, completely fluid filled w/ absence of echoes
Endometrioma = smooth walled, homogenous, with ground glass appearance
Corpus luteal cyst = heterogenous with hypoechoic areas representing fluid, hyperechoic areas representing internal debris (i.e. hemorrhage)
1st line pharmacologic management for uterine leiomyoma?
COCs, progestin releasing intrauterine device (i.e. Mirena IUD)
2nd line: gonadotropin releasing hormone agonists
if pts desire definitive treatment > myomectomy for fertility preservation, hysterectomy if no fertility desired
PCOS increases risk of which cancer?
Endometrial – anovulation leads to increased unopposed estrogen exposure
Management of ruptured ovarian cyst
HDS and low c/f malignancy (i.e. not postmenopausal) - close observation out patient, d/c with pain mgmt
HDS but large hemorrhage on US – admit for observation (monitor H&H, repeat pelvic US)
Hemodynamically unstable (at ANY point) or admitted for obs w/ ongoing bleeding – emergent laparoscopy to stop bleeding
At what Mirena IUD dose do you typically see amenorrhea?
52 mg
19.5 and 13.5 can cause lighter flow but rarely lead to amenorrhea
What STIs must you r/o before diagnosing chancroid?
HIV - PCR, Tzanck
Syphilis - VDRL, RPR
Frank versus complete breech
Frank = both hips flexed, both knees extended
Complete = both hips and knees flexed
Laceration tears
First degree = only perineal skin involved
Second degree = perineal skin and mucosa
Third degree = perineal tissues to external anal sphincter
Fourth degree = perineal tissues, external anal fissure AND rectal mucosa involvement (requirs systemic abx, debridement and secondary repair if initial repair separates and becomes infected)
***suture repair typically indciated for second degree and beyond
Frequency of repeat cervical exams during labor
- Prior to administration of anesthesia
- 2-4 hours during stage 1 of labor
- Every 1-2 hours during stage 2 of labor
Placental abruption delivery guidelines
If term and stable > can deliver vaginally
If term and nonreassuring fetal status > C section
If preterm and stable > inpatient conservative mgmt
Treatment of choice for umbilical cord prolapse
Definitive mgmt = emergent C section (can give tocolytics such as terbutaline while waiting to decrease uterine contractions)
Manual elevation of fetal head w/ 2 fingers, Trendelburg and knees to chest are all maneuvers that can help alleviate pressure
Next step in management for high grade ASC lesions on pap
Colposcopy regardless of HPV status
Early vs variable decelerations on fetal heart tracing
Early - uniform shape, nadir always matches peak of uterine contraction
Variable - rapid onset of 15 x 15 deceleration that lasts at least 30 seconds, varies in shape and intensity
In patients < 25 y/o (21-24), next steps if pap reveals LSIL?
Repeat cervical cytology in1 year – low chance of progressing to cervical cancer even if HPV+ in younger women
At what gestational age is mag indicated for neural protection?
< 32 weeks GA
Which of the following best represents a positive prognostic variable for successful external cephalic version of a fetus?
A) Amniotic fluid index < 10
B) Anterior placental location
C) Non-longitudinal fetal position
D) Thinner myometrial thickness
C – fetus only has to rotate 90 degrees instead of 180
A – negative prognostic indicator b/c this is not sufficient amniotic fluid for the maneuver
B – posterior is positive prognosis, not anterior
D – also negative prognostic indicator
When do you proceed with hysterectomy b/l salpingectomy + lymph node excision and chemo versus without lymph node excision and chemo?
If biopsy confirms STAGE 2 endometrial cancer > stage 1 proceed with hysterectomy and b/l salpingectomy only
CTX weight based dosing for gonorrhea treatment
500 g IM once if < 300 lb
1000 mg/1g IM once if > 300 lbs
***also want to cotreat for chlamydia if it has not yet been excluded
Differentiating choriocarcinoma versus placental site trophoblastic tumor
Both can present with vaginal bleeding s/p delivery or SAB
Choriocarcinoma = extremely elevated hCG
Placental site tumor = only slightly elevated hCG
Management of severe or prolonged abnormal uterine bleeding
Hemodynamically unstable:
- Stabilize w/ fluids and intrauterine tamponade
- Therapuetic measures – uterine curettage, high dose IV estrogen, uterine artery embolization, hysterectomy
Hemodynamically stable:
- High dose oral estrogen
- High dose oral contraceptives
- High dose progestins
- Gondaotropin releasing hormone agonists
- TXA
- Selective progesterone receptor modulators
- Endometrial ablation
What hormone is responsible for shedding of uterine lining?
Progesterone
1st line treatment of PMS
If mild sx (no socioeconomic or behavior disruption): daily exercise and relaxation techniques
If sx inhibiting QOL in terms of SES: SSRIs (fluoxetine and sertraline)
Multigestation pregnancy recommendations
Total weight gain goal is 37-54 pounds if starting BMI wnl (little less if BMI 25-29.9)
Take one prenatal vitamin during first trimester and an additional in the 2nd and 3rd
Exercise as tolerated
Supplement diet with 1 mg folate, 1000 IU vitamin D
Sleep on L side during 2nd and 3rd trimesters
What does AUB mean
Irregular uterine bleeding patterns
- Heavy or light menses
- Frequent, prolonged, or sporadic
***normal pelvic exam
T or F: Breast MRI is more sensitive than US and mammogram
True – used to help evaluate breast masses in young women with dense breasts
MC risk factor for ovarian torsion
Ovarian mass
Tx of choice for AUB confirmed to be non-malignant on endometrial biopsy assuming future fertility is not desired?
Endometrial ablation – want to ry non-invasive techniques first
Can proceed with vaginal hysterectomy but this is more invasive and risky
Risk factors for IUD failure or expulsion?
- Less than 25 y/o
- Insertion following 2nd trimester abortion
What marker should be used for repeating a urine pregnancy test in patients with irregular cycles OR patients with an unknown LMP? If cycle is regular?
Irregular: The date of last unprotected intercourse > urine preg test 14 days after this minimizes the chance of a false negative result
Regular: repeat urine pregnancy test in 1 week
6 cardinal movements of labor
Engagement
Descent
Flexion
Internal rotation
Extension
External rotation
Difference between leiomyoma vs endometrial polyp?
Leiomyoma = muscle cell tumors
Polyps = overgrowth of endometrial glands and stroma
Which of the following is true regarding physiologic changes during pregnancy?
A) Decreased cerebral blood flow
B) Decreased clotting factor VII
C) Increased cardiac afterload
D) Increased red blood cell mass
D – increased RBC production d/t increased plasma volume (to a greater extent), pregnancy is a hypovolemic state
A – blood flow INCREASES due to decreased peripheral vascular resistance with increased estrogen
B – clotting factor production increases, which is why preg results in increased VTE risk
C – pregnancy results in an increase in preload d/t increased cardiac output
What is the most accurate way to estimate due date on an initial prenatal visit?
Crown rump length from US findings
***Naegele’s rule assumes normal cycles, gestational sacs can be present even in nonviable pregnancies, and uterine size can be affected by body habitus
Is observational/expectant management of rectocele acceptable in asymptomatic patients?
Yes > many asymptomatic patients experience no prolapse progression
Does palpable break in rectovaginal fascia indicate possible fistula?
No – can be expected physical exam finding even with asymptomatic rectocele
Who performs breast abscess drainage?
I&D requires surgical referral > drainage necessary for tx, abx alone not sufficient
Pathophys of primary dysmenorrhea
Prostaglandin release from cervix at the beginning of menses
First line tx for primary dysmenorrhea
NSAIDs such as ibuprofen (COX-2 inhibitors that decrease prostaglandin release/production)
***can also try COCs but d/t more extensive side effect profile, trial NSAIDs first
What is the recommended next step in the reverse-sequence algorithm for syphilis if the treponemal test is positive and the reflex nontreponemal test is negative?
Perform a different non-treponemal test (RPR, VDRL) to confirm the initial results
Risk factors for placenta previa
- Prior C section
- Increased maternal age
- Multiple gestation
- Previous uterine procedures
Preterm labor clinical qualifications
5-1-1 rule > OR 4 contractions must occur every 5 minutes
Cervical length < 20 if negative fetal fibronectin, lngth of 20 to < 30 mm if positive fetal fibronectin on TVUS
Cervical dilation at least 3 cm
Protective factors for endometriosis
- Less estrogen exposure: Multiple births, extended intervals of lactation, late menarche
- Increased omega 3 fatty acid consumption
- Regular exercise
Which of the following describes fibrocystic changes on US?
A) Hypoechoic irregular nodules with spiculated margins
B) Subtle echogenic masses with reticular patterns and a well defined thin capsule
C) Well circumscribed, uniform round mass with thin pseudocapsule
D) Prominent fibroglandular tissue with small cysts but no discernable mass
D
A – potential for breast malignancy, must biopsy
B – lipoma
C – fibroadenoma
When is a D+C indicated for evaluation of AUB?
If endometrial biopsy confirms atypia of any kind > want to get thorough endometrial sample to r/o coexisting carcinoma OR if biopsy sample inadequate
Best way to confirm menopause diagnosis in pts > 45 versus < 45?
> 45: Clinical dx – labs not required if sx align and at expected menopausal age (47-mid 50s)
< 45 w/ potential menopausal sx: FSH, tSH, serum hCG, serum prolactin (FSH is best test)
Cervical mucus appearance when progesterone is HIGH and estrogen is LOW (aka luteal phase)
Thin (“raw egg white”)
When must sx occur to diagnose PMDD?
Start in the late luteal phase
Diagnostic criteria for PMDD?
At least 5 or more affective/psychiatric sx that start during late luteal phase of menstruation and resolve after menses is finished; sx must have been present for at least 9 months of the last year
***1st line tx = SSRIs (fluoxetine, sertraline)
MC symptom of leiomyoma?
Heavy menstrual bleeding
Adenomyosis TVUS and physical exam findings?
Physical exam = enlarged, mobile, globular uterus w no adnexal tenderness
TVUS = enlarged uterus
Adenomyosis first line pharmacologic treatment
First line = levonorgesterl-releasing intrauterine device
**This is really the only cause of AUB that Mirena is first line versus COC in patients who still have a uterus
Long term hormonal therapy for menopause increases risk of what cancer?
Breast
Diagnostics of acute versus chronic endometritis
Acute = clinical (Tx: gentamicin + clindamycin +/- ampicillin if GBS compromised)
Chronic = may require endometrial biopsy, (+) plasma cells in endometrial stroma (Tx: doxy + CTX)
MCC of primary amenorrhea
Turner syndrome (45 XO)
Androgen insensitivity
Mullerian agenesis
Outflow tract abnormalities (esp want to consider this in pts with primary amenorrhea and normal dev of 2ndary sex characteristics)
- Imperforate hymen
- Transverse septum
AUB + ENLARGED uterus on pelvic exam versus AUB + BOGGY uterus on pelvic exam
Enlarged (aka firm and enlarged) = leiomyoma
Boggy (aka soft and enlarged) = adenomyosis (also typically bleeds less than leiomyoma b/c the endometrial deposits are contained within the myometrium)
Primary dysmenorrhea risk factors
- Menarche before age 12
- Low BMI
- Age < 30
- Tobacco use
- Longer or irregular menstrual cycles
How does CIN versus cervical cancer present on colposcopy?
CIN = no visualized abnormalities b/c they are endocervical
Cervical carcinoma = exophytic, friable, soft or filiform cervical growth
First line treatment of variable decels on NST?
Maternal repositioning (Trendelenburg, knees to chest, manual 2 finger elevation) BEFORE going straight to delivery, though this is the definitive management if refractory
***variable decels d/t umbilical cord compression/prolapse
Tx of choice for pyelo in pregnancy
IV pip-tazo > AVOID FQs and aminoglycosides
Advantages of norethindrone (progesterone only) pill as postpartum contraceptive?
no increased risk of VTE
MOA: progesterone increases cervical mucus thickening, alters ovum transport, and inhibits implantation
almost as effective as COCs but MUST be taken in the same window (i.e. within 3 hours of the same time everyday)
Hyperpigmentation of pregnancy is known as ______ and first line treatment is _______
Chollasma (melasma outside of pregnancy); photoprotection to prevent UV exposure from worsening sx
Cervical cerclage is contraindicated in ________ pregnancies
Multigestation
Day 21 progesterone < 3 indicates ______ as possible causes of infertility
PCOS, hypothyroidism
PROM brief pathophys
Premature activation of metalloprotease enzyme degrades collagen and subsequently decreases membrane strength
MC pathogen a/w isolated chorioamnionitis
Ureaplasma urealyticum
Description of uterus in gestational trophoblastic disease
Enlarged uterus (i.e. uterus at umbilicus)
***other s/sx –> exaggerated signs of pregnancy (N/V) d/t increased cytotrophoblast and syncytiotrophoblast activity in partial and complete molar pregnancies, respectively
Method to reduce risk of breast cancer in BRCA+ patients wishing to maintain fertility?
Mastectomy
Compound fetal presentation
Head at opening of pelvis + an additional fetal part (i.e. hand or arm)
BV treatment in patients with extensive alcohol use
Clinda 2% cream 7 days (want to prevent disulfram like rxn with metronidazole)
Expected weight gain for singleton pregnancy w/ starting BMI 18.5-24.9
25 to 35 pounds
What aspect of amniotic fluid is important to identify with PROM?
Color – looking for presence of meconium > indicates high risk for fetal aspiration, lung infection, neonatal death > warrants immediate delivery if present
PPH pharmacologic options
Oxytocin/pitocin
Misoprostol – works by increasing uterine contraction
Methylergonovine
Carboprost
TXA (inhibits fibrinolysis)
What is a choriocarcinoma made of?
Cytotrophoblasts and syncytiotrophoblasts
Breast cancer treatment in ER+ (HR, PR) versus HER+ tumors
ER+ first line = tamoxifen
HER2+ first line = trastuzamab
Acute endometritis treatment
Polymicrobial coverage > gentamicin + clindamycin
***THINK: ECG
Acute endometritis treatment
Clindamycin + gentamicin
Chronic endometritis treatment
Doxy + CTX
