Final Flashcards
(881 cards)
1
Q
What are the thyroid agents used to treat hypothyroidism
A
Levothyroxine (T4), liothyronine (T3), liotrix (4:1 ratio of T4:T3), thyroid desiccated
2
Q
What are the anti thyroid agents used to treat hyperthyroidism
A
Radioactive iodine sodium, methimazole, potassium iodide, propylthiouracil
3
Q
What is organic inaction
A
Iodine iodinated tyrosine residues within thyroglobulin molecule to make MIT and DIT
4
Q
What is the oral bioavailability of T4 vs T3
A
T4: 80% - half life 7 days
T3: 95% - half life 1 day
5
Q
What agents inhibit conversion of T4 to T3
A
Radiocontrast agents: iopanoic acid and ipodate
Amiodarone, beta blockers, corticosteroids
*used for thyroid storm
6
Q
What drugs decrease T4 absorption
A
Antacids, ferrous sulfate, cholestyramine, colstipol, ciproloxacin, PPIs, coffee
7
Q
What increases the metabolism of T3 and T4
A
CYPinducers: rifampin, rifabutin, phenobarbital, carbamezepine, phenytoin, imatinib, PPIs
8
Q
What are the features of levothyroxine
A
Long half life, easy to measure serum level
9
Q
Why is T3 not used for hypothyroid treatment
A
Short half life
10
Q
What are thioamides
A
Methimazole and PTU
11
Q
What are the contraindications to PTU and methimazole
A
Pregnancy; but if used, PTU is choice for first trimester and methimazole in 2nd and 3rd
12
Q
What is the MOA of PTU and methimazole
A
Inhibits thyroidal peroxidase catalyze reactions and blocks iodide organification and coupling of MIT and DIT to form T3 and T4; PTU blocks peripheral conversion of T4 to T3
13
Q
What are the adverse effects of PTU and methimazole
A
Macupapular pruritic rash, lupus like reaction, hepatitis (more common with PTU), cholestatic jaundice (more with methimazole), *agranulocytosis - reverse with CSF
14
Q
What are the anion inhibitors used for hyperthyroidism
A
Perchlorate, pertechnetate, and thiocyanate
*block thyroid gland ups take of iodide by inhibition transport mechanism; can be overcome with large doses of iodides
15
Q
What is the MOA of iodides used for hyperthyroidism
A
Inhibit organification and hormone release; used for thyroid storm, preoperative reduction of hyperplastic thyroid, and block thyroid uptake in emergency exposure to radioactive iodine; adverse rxn: acneiform rash, swollen salivary gland, mucinous membrane ulceration, conjunctivitis, metallic taste *avoid during pregnancy
16
Q
What is the most common beta blocker used to treat hyperthyroid symptoms.
A
Propranolol
17
Q
Is methimazole or PTU preferred overall as a treatment for hyperthyroidism
A
Methimazole
18
Q
Who is radioactive iodine treatment the treatment of choice for hyperthyroidism
A
Patients over 21
19
Q
What is the protocol for treatment of thyroid storm
A
Beta blockers, potassium iodide to prevent release of thyroid hormones from gland, PTU or methimazole, IV hydrocortisone to protect against shock and block conversion of T4 to 3, if above inadequate, plasmapharesis of dialysis
20
Q
What is mecasermin
A
IGF-1 agonist
21
Q
What is pegvisomant
A
GH antagonist
22
Q
What are the FSH analogs
A
Follitropin alpha and beta, urofollitropin
23
Q
What is the LH analog
A
Lutropin alpha
24
Q
What are the gonadotropin releasing hormone antagonists
A
Ganirelix, cetrorelix, degarelix, abarelix
25
What is bromocriptine used for
Parkinson’s, acromegaly, infertility, and galactorrhea
26
What is cabergoline
Dopamine receptor agonist; use to treat prolactin excess
27
What are the vasopressin receptor antagonists
Conivaptan and tolvaptan
28
What hormones use Gs receptors
LH, FSH, TSH, glucagon, PTH, PTHrP, ACTH, GHRH, CRH
29
What hormones use Gi pathways
Somatostatin
30
What hormones use a Gq pathway
TRH GnRH
31
What hormones use a cytokine receptor linked kinase pathway
GH and prolactin (JAK, tyrosine kinases)
32
What is somatropin
Recombinant human form of GH; CYP450 inducer
33
What are the effects of GH vs IGF-1 on blood glucose
GH increases it (hyperisulinemia) and IGF-1 will decrease it
34
What are the adverse effects of GH supplementation
Intracranial HTN, otitis media in patients with Turner syndrome, hypothyroidism, pancreatitis, gynecomastia in kids; in adults: peripheral edema, arthralgia and carpal tunnel; contraindicated in malignancy
35
How is mecasermin administered
Subcutaneous; adverse effect: hypoglycemia
36
What are the features of ocreotide
Somatostatin analog; subcutaneous
37
What is lanreotide used to treat
Acromegaly
38
What are the adverse affects of the somatostatin analogs
Gallstone, sinus bradycardia, vitamin B2 deficiency
39
What is urofollitropoin
Purified human FSH extracted from urine of postmenopausal women
40
What are the uses of urofollitropin and follitropin alpha/beta
Ovulation induction, spermatogenesis induction (urofollitropin),
41
What is lutropin alpha used for
Only in combo with follitropin alpha for stimulation of follicular development in infertile women with LH deficiency
42
What is choriogonadotropin alpha used for
Induce ovulation and pregnancy in anovulatory infertile females (pre treated with follicle stimulating hormones), treatment of hypogonadotropic hypogonadism, spermatogenesis inductions
43
How are all gonadotropin preparations administered
Subcutaneous or IM injection
44
What are the adverse effects of gonadotropin preparations
Ovarian hyperstimulation syndrome (enlargement, ascites, hydrothorax), multiple pregnancies which increases risk for gestational diabetes, preterm labor and preeclampsia
45
What does continuous administration of leuporlide produce
During first 7-10 days: agonist
| After 7-10 days: antagonist *used more for suppression than agonist
46
When is leuprolide used for stimulation vs suppression of gonadotropin production
- stimulation: infertility, LH responsiveness
| - suppression: ovarian hyperstimulation, endometriosis, uterine leiomyomata, prostate cancer, central precocious puberty
47
What are the adverse effects of leuprolide
Hot flashes, sweats, HA, depression, diminished libido, vaginal dryness, breast atrophy, decreased bone density
48
What are GnRH antagonists used for
Abarelix and degarelix are used to treat Advanced prostate cancer; ganirelix and cetrorelix used for ovarian hyperstimulation
49
How is bromocriptine or cabergoline administere
Oral or vaginal suppository; cabergoline has longer half life
50
Can dopamine agonists bee used to suppress postpartum lactation
No b/c increases incidence of stroke or coronary thrombosis
51
What is oxytocin administered for
IV: initiation of labor
IM: control of postpartum bleeding
52
What is the difference between desmopressin and vasopressin
Desmopressin has minimal V1 activity
53
How are vasopressin and desmopressin administered
Vaso: IV or IM
Desmo: IV, SQ, intranasally, or PO; longer half life
54
Besides DI, what else is desmopressin used to treat
Coagulopathy in hemophilia A and von willebrand dz
55
What is the MOA of conivaptan and tolvaptan
Tolvaptan antagonizes V2; conivaptan antagonizes V1 and V2
56
How does nuclear binding o f thyroid hormone initiation gene transcription
Dissociates NCoR/SMRT and HDAC and recruits co-activators and HATS
57
What are the features of propranolol
Non selective beta blocker; also inhibits conversion of T4 to T3
58
When is methimazole given
Before thyroid surgery; inhibits thyroperoxidase
59
When is potassium iodide used
To treat hyperthyroidism and prepare thyroid gland for removal - blocks iodine uptake; also used to treat deficiency, protects thyroid from radiation exposure, doesn’t affect heart
60
What are the indications for use of PTU
Graves, toxic multinodular goiter if intolerant of methimazole or suregery isn’t good option, in prep for thyroidectomy, used in radioactive iodine therapy intolerant of methimazole
61
Does PTU interfere with thyroid hormones given orally or by injection
No
62
Who is radioactive iodine therapy or thyroid cancer contraindicated in
Pregnant wom
63
What is the MOA of perchlorate
Competitive inhibitor of iodide uptake; blocks sodium iodide symporter, controls amiodarone induced thyroid dysfunction*
64
How does methimazole decrease the serum concentration of T3
Prevents addition of iodine to tyrosine residues
65
What are the rapid acting insulin’s
Aspart, lispro, glulisine
66
What are the short acting insulin’s
Regular insulin
67
What is the intermediate acting insulin
NPH (neutral protamine hagerdorn)
68
What are the long acting insulin’s
Detemir, glargine
69
What is the amylin analog
Pramlintide
70
What are the GLP-1 agonists
Exenatide and lliraglutide
71
What are the dipeptidyl-peptidase 4 (DPP-4) inhibitors
Sitagliptin, linagliptin, saxagliptin, alogliptin
72
What are the potassium ATP channel blocker drugs used for diabetes
Sulfonylureas and meglitinides
73
What are the 2 generations of sulfonylureas
First gen: chlorpropamide, tolbutamide, tolazamide
| Second gen: glipizide, glyburide, glimepiride
74
What are the meglitinides
Nateglinide, repaglinide
75
What drug falls in the biguanide category
Metformin
76
What are the thiazolidinediones
Pioglitazone and rosiglitazone
77
What are the SGLT2 inhibitors
Canagliflozin, dapagliflozin, empagliflozin
78
What are the inhibitors of alpha-glycosidases
Acarbose and miglitol
79
What classes of drugs fall under the insulin secretagogues category
Sulfonylureas, meglitinides, GLP-1 agonist, DPP-4 antagonist
80
What is the clincial use of rapid acting insulin’s
Postprandial hyperglycemia (take before meal as SQ)
81
What is the clinical use of short acting insulin
Basal insulin maintenance, overnight coverage, postprandial (if inject 45 min before meal), IV in urgent situations
82
What are the clinical use of intermediate acting insulin
Basal insulin maintenance overnight coverage, use is declining
83
What are the features of detemir and glargine (long acting)
Detemir: Lys 29 in B chain is a lipid and rapidly absorbed but bound to albumin
Glargine: AA sub in A and B chains enhance crystal stability, change pKa of insulin - soluble at low pH (4) but precipitates at 7; peakless
Clinical use: basal mainteance (1-2 SQ injections daily)
84
Besides diabetes what is insulin used as a treatment for
Hyperkalemia (in combo with glucose and furosemide)
85
What are the adverse effects of insulin
Hypoglycemia, lipodistrophy (hypertrophy of SQ fat at injection site, prevent by changing injection site or IM injections), resistance, hypersensitivity, hypokalemia
86
What are some causes of hypoglycemia while on insulin
Missing a meal, exercise, overdose
87
How do you treat insulin induced hypoglycemia
Glucose, diazoxide (KATP opener), glucagon
88
What is the MOA of amylin
Inhibits glucagon secretion, enhances insulin sensitivity, decreases gastric emptying(slows rate of glucose absorption), causes satiety
89
What is the onset of amylin analog (pramlintide)
Rapid; peaks in 20 min, last 3 hrs, used for T1DM, T2DM who take mealtime insulin, inject SQ before meals in adjunct to insulin
90
What are the adverse effects of amylin
Hypoglycemia (reduce insulin dose), drug interactions with anticholingergics (enhances their effects)
91
What regulates insulin secretion
- GPCR Gs ligand: beta2 agonists and GLP-1 agonists
| - GPCR Gi ligands: somatostatin and alpha 2 agonists - decrease secretion
92
What are the features of GLP-1
Synthesized by L cells;; promotes beta cell proliferation, insulin gene expression, glucose dependent insulin secretion; inhibits glucagon secretion, cause satiety and inhibits gastric emptying; *very short half life so not used as a drug
93
Does exenatide or liraglutide have a longer half life
Liraglutide
94
When is GLP-1 receptor agonist treatment indicated
T2DM patients who are not controlled by metormin/sulfonylureas/thiazolidinediones; *adminitered parenterally
95
What are the adverse effects of GLP-1 agonists
Lower risk of hypoglycemia (stimulates insulin release only during hyperglycemia), linked to cases of acute pancreatitis and pancreatic cancer
96
What is DPP-4
Serine protease
97
What are the clinical uses of DPP-4 inhibitors
Adjunct therapy to diet and exercise in patients with T2DM, used as monotherapy and in combo with metforin/sulfonylureas and TZDs; taken orally
98
What are the adverse effects of DPP-4 inhibitors
Upper respiratory tract infections, acute pancreatitis, hypoglycemia if combined with other secretagogues)
99
What channel do sulfonylurea drugs block
SUR receptor on Kir6. Inwardly rectifying potassium channels
100
What are the adverse effects of sulfonylureas
Hypoglycemia, weight gain, secondary failure, hypersensitivity - cross reaction with other sulfamides - sulfonamide abx, carbonic anhydrase inhibitors, diuretics
101
What drug interactions do sulfonylureas have
- enhance hypoglycemia effect:: displace binding with albumin - sulfonamides, clofibrate, salicylates; enhancing effect on KATP: ethanol; inhibiting CYP enzymes: azole antifungal, gemfibrozil, cimetidine
- decreases glucose lowering effect:: inhibiting insulin secretion: Beta blockers, CCBs; KATP channel: diazoxide, inducing CYP: phenytoin, griseofulvin, rifampin
102
What is the clinical use of meglitinides
Control of postprandial hyperglycemia in patients with T2DM, taken orally, can be alone or in combo
103
What is the MOA of metformin
Activation of AMP-dependent protein kinase which decreases GNG in the liver, increases glucose uptake, glycogen formation, and FA oxidation, lowers glucose levels, increases insulin activity; inhibitors mitochondrial OxPhos
104
What is the first line treatment for T2DM
Metformin; does not cause hypoglycemia or weight gain, taken orally, decreases risk of macro and microvascular complications
105
What are the pharmacokinetics of metformin
Not bound to plasma proteins, not metabolized, excreted unchanged in kidneys
106
What are the adverse effects of metformin
Decreased absorption of B12, lactic acidosis (esp under conditions of hypoxia, renal and hepatic insufficiency ), contraindiated in CHF, COPD, renal failure, chronic alcoholism and cirrhosis
107
What is the MOA of thiazolidinediones
Ligands of peroxisome proliferator-activated receptor gamma (PPARy) - nuclear receptor expressed in fat, muscle, liver and endothelium; increases GLUT4 in skeletal muscle and adipocytes, increases IRS1/22 PI3K, decrease PEPCK and NFkB, AP-1
108
What are the pharmacokinetics of thiazolidinediones
Taken orally once daily; onset is delayed (because depends on gene expression) - full effect 3 months; effects persist for months after discontinuing; metabolized by liver; can administer to patient with renal failure
109
What are the uses of thiazolidinediones
T2DM; can slay progression from prediabtes to diabetes; no hypoglycemia when used alone
110
What are the adverse effects of thiazolidinedione
Weight gain (doubled if given with insulin), edema (also doubled if given with insulin) - increases vascular permeability and expression of ENaC which allows incrased sodium and water reabsorption in collecting duct; exacerbation of HF - contraindicated if class III or IV;; increased triglycerides and LDL(rosiglitazone); osteoporosis - suppresses differentiation of MSCs to osteoblasts by inhibiting Runx2
111
What are the effects of SGLT2 inhibitors
Osmotic diuresis, induced weight loss, reduced BP, reduced plasma levels of uric acid, does not cause hypoglycemia
112
What are the clincial uses of SGLT2 inhibitors
Orally before 1st meal once a day in conjunction with diet and exercise therapy
113
What are the adverse effects of SGLT inhibitors
Hypotension, UTI, renal function impairment, hyperkalemia (esp if taking ACEIs, ARBs and K sparing diuretics)
114
How do alpha glycosidase inhibitors work
Prevent absorption of starch from gut by inhibiting breakdown of disaccharides into absorbable monosaccharides; lowers post prandial hyperglycemia and creates insulin sparing effect
115
What are the adverse effects of alpha glycosidase inhibitors
Flatulance, malabsorption, diarrhea bloating; decreases absorption of digoxin (acarbose) and propranolol and ranitidine ( miglitol)
116
How do synthetic steroids travel in the blood vs natural
Synthetic bind weakly to albumin so circulate as free steroids; also have a longer half life
117
Does prednisone or cortisol have more salt wasting effects
Cortisol
118
What are glucocorticoids metabolized by
CYP3A4
119
What does prednisone have to be converted to to have any effect
Prednisolone
120
What are the potent synthetic glucocorticoids
Prednisone, methylprednisolone, triamcinolone, dexamethasone, bethamethasone
121
What is needed to convert inert steroids into active steroids
11 beta HSD1 (1 ketoreductase); converts cortisone -> cortisol, 11 dehydrocorticosterone -> corticosterone, prednisone -> prednisolone
122
What do steroids displace when they bind to their receptor
Hsp90
123
What are the corticosteroid agonists
- glucocorticoids: prednisone
| - mineralocorticoids: fludrocortisone
124
What are the corticosteroid antagonists
- receptor antagonists: glucocorticoid (mifepristone) and mineralocorticoids (spironolactone)
- synthesis inhibitor: ketoconazole
125
What are inhibitors of 11 bet HSD2
Glycyrrhizin (licorice) and carbenoxolone (used or esophageal ulcers); increases activity of cortisol receptor - increases salt and water retention and potassium loss
126
What are the metabolic effects of glucocorticoids
- carb: increase GNG, increase glycogen synthesis, decreased glucose uptake
- lipid: increased lipolysis, lipogenesis, increased fat deposition
- protein: decreased AA uptake, decreased protein synthesis, development of myopathy and m wasting
127
What are the effects of glucocorticoids on the immune system
Decreased production of prostaglandins and leukotrienes, increased apoptosis of immune cells, decreased production of cytokines, decreased migration of neutrophils and macrophages, decreased expression of cell adhesion molecules
128
What is used to treat addisons
Glucocorticoids (hydrocortisone) and mineralocorticoids (fludrocortisone); also used to treat congenital adrenal hyperplasia
129
What are the short acting glucocorticoids (<12 hrs)
Hydrocortisone, cortisone, prednisone, prednisolone, methylprednisolone
130
What are the intermediate acting corticoidsteroids
Triamcinolone
131
What are the long acting (>36 hrs) corticosteroids
Betamethasone and dexamethasone
132
What is prednisolone used to treat
Organ transplant, hematologic cancers, inflammatory conditions; toxicities: adrenal suppression, growth inhibition, muscle wasting, osteoporosis, salt rentation, glucose intolerance, behavior changes
133
What are the most potent anti inflammatory corticosteroids
Dexamethasone and betamethasone; fluprednisolone is most potent intermediate acting
134
Which corticosteroids are only oral
Cortisone, prednisone, fluprednisolone, fludrocortisone
135
What is the most potent mineralocorticoids
Fludrocortisone *also most potent salt retention agent
136
Which glucocorticoid is the most potent salt retaining agent
Cortisone; fluprednisolone is the least
137
What corticosteroids are available topically
Hydrocortisone, triamcinolone, beta and dexamethasone
138
What is important about adrenalcorticoid drug dosing
- use lowest dose for shortest duration; use intermediate or short acting vs long acting
- Reduce systemic distribution: ciclesonide is a prodrug activated by esterases in bronchial epithelium - systemically absorbed
- give single daily doses in AM
- alternate short course pulse therapy
- dose tapering
139
What patient populations is glucocorticoid administration problematic
Immunocompromised, diabetics, patients with infections, peptic ulcers, HTN, CHF, angina, psychiatric conditions, osteoporosis (post menopausal), children
140
What are the toxicities assoc with mifepristone
Vaginal bleeding, ab pain, GI upset, HA; antagonist of glucocorticoid and progesterone receptors
141
What is fludrocortisone
Strong agonist at mineralocorticoid receptors; used to treat addisons; long duration of action
142
What is spironolactone used to treat
Aldosteronism, hypokalemia from diuretics, post MI; slow onset and offset; toxicities: hyperkalemia, gynecomastia
143
What are the toxicities of ketaconazole
Hepatic dysfunction; CYP interactions
144
What are the GnRH agonists
Leuprolide, gonadorelin, goserelin, buserelin, histrelin, nafarelin, triptorelin
145
Which vasopressin receptor agonist has limited V1 activity
Desmopressin
146
What signaling pathways does insulin act through
MAPK, PI3K
147
What’s the difference between leuprolide and ganirelix
Ganirelix immediately reduces gonadotropin secretion - leuprolide does so after about a week
148
What is leuprolide used to teat
Prostate and breast cancer, endometriosis, uterine fibroids, early puberty
149
What is ganirelix used to treat
Prevent premature ovulation in those undergoing fertility treatment involving ovarian hyperstimulation - prevents ovulation until triggered by injected HCG
150
What drugs are used for the induction of labor/control postpartum bleeding
Misoprostol, dinoprostone, carboprost, oxytocin, ergot alkaloids
151
What drugs are used to delay labor (tocolytics)
Terbutaline, indomethacin, nifedipine, MgSO4, atosiban
152
What drug is used to maintain a patent ductus arteriosus
Alprostadil
153
What drug is used to close patent ductus arteriosus
Indomethacin and ibuprofen
154
What are the anti-HTN used in pregnancy
Alpha-methyldopa, labetalol, hydralazine, sodium nitroprusside
155
What are the FDA teratogenic risk categories
A: controlled studies fail to demonstrate risk to fetus
B: animal studies have no demonstrated fetal risk, but no control studies in humans
C: studies in animals revealed adverse effects; given only if potential benefit justifies risk to fetus
D:evidence of human fetal risk but benefits might be acceptable
X: contraindicated in pregnancy
156
Describe amnion prostaglandin production
Synthesized because increase in phospholipase A2 and prostaglandin H synthase; during pregnancy, effects on maternal tissue is limited by inactivating enzyme (PGDH) in the chorion; during labor, PGDH levels decease
157
What stimulates cortisol production in the fetus
Trophoblasts secrete CRH
158
What factors cause uterine myocyte relaxation vs contraction
Relaxation: CRH, beta2 agonists, prostaglandin E2
Contraction: oxytocin, thrombin, prostaglandin F2alpha
159
What happens during cervical ripening
Collagen and glycosaminoglycans are broken down by MMPs
160
What is misoprostol
Prostaglandin E analog; induces uterine contractions and maintains ductus arteriosus patency; used for termination of pregnancy in combo with mifepristone; off label: cervical ripening, labor induction, incomplete abortion, postpartum hemorrhage; contraindication: previous C section
161
What are the fetal side effects of misoprostol
Hypoxia due to tachysystole (contractions occurring too rapidly)
162
What is dinoprostone
Prostaglandin E2 analo; induces uterine contractions and promotes cervical ripening; has a gel form, vaginal (used for cervical ripening at term) and suppositories (terminates pregnancy from 12-10th week); more expensive than misoprostol
163
What are the side effects of dinoprostone
Fever unresponsive to NSAIDs; hypoxia of fetus
164
What is carboprost
Prostaglandin Falpha analog; induces uterine contractions - prolong duration of action; used to induce abortion btw 13-20 weeks if failure o another; used or postpartum bleeding; *must be given by IM injection
165
What are the conraindications of carboprost
Hypersensitivity, acute PID, active cardiac, pulmonary, renal or hepatic dysfunction
166
What are the maternal adverse effects of carboprost
HTN, pulmonary edema (b/c potent vasoconstrictor), reduces body temp
167
What are contrainditions to oxytocin
Don’t give if fetus’ lungs are immature or cervix is not ripe; maternal side effects: water intoxication
168
What are the ergot alkaloids
Ergonovine or ethylergonovine; stimulates adrenergic, dopaminergic and serotonergic receptors; causes prolonged tonic uterine contraction and constricts arterioles and veins; used for postpartum bleeding
169
How must oxytocin be given
IV
170
What are the contraindications of ergot alkaloids
HTN, hypersensitivity
171
What are the adverse effects of ergot alkaloids
St Anthony’s fire: mania, psychosis, vomiting; dr gangrene (fingers, nose, penis, toes)
172
What is the first choice for limiting post partum bleeding
Oxytocin
173
What is the management protocol for premature rupture of membranes
- >34weeks: plan delivery; group B step prophylaxis, single corticosteroid course up to 36 weeks
- 32-34 weeks: group B strep prophylaxis, single corticosteroid course, antimicrobials
- 24-32 weeks: group B strep prophylaxis, single corticosteroid use; no consensus on tocolytics; antimicrobials; magnesium sulfate for neuroprotection
- <24weeks: no group B strep prophylaxis, single corticosteroid course, no consenus on tocolytics
174
What are the indications for antenatal corticosteroids
Women btw 24 and. 36 weeks with threatened pre term labor, antepartum hemorrhage, preterm rupture of membranes, or conditions requiring C section
175
What can you give to the mother to cause fetal lung maturation
- betamethasone: 2 doses by IM injection in 24 hr intervals
- dexamethasone: 4 doses by IM injection in 12 hour intervals
* not cortisol b/c placenta metabolizes it to cortisone
176
What is ritodrine
Beta2 agonist used for tocolysis; maternal effects: severe hallucinations
177
What is magnesium sulfate used for
Prevent eclamptic seizures; decrease risk for cerebral palsy; used for tocolysis (inhibitors Ach release at uterine NMJ); adverse effects skin flushing, HA, resp depression, in the fetus: m relaxation and CNS depression
178
What is terbutaline
Beta2 agonist; increases cAMP leading to K+ channel mediated hyperpolarization and dephosphorylation of myosin light chain; contraindications: cardiac arrythmias, poorly controlled thyroid dz or DM; maternal effects: pulm edema, MI, hypotension, SOB, hyperisulinemia, hyperglycemia; fetal side effects: hyperisulinemia, hyperglycemia, neonatal hypoglycemia, hypocalemia, hypotension
179
What is nifedipine
MOA: blocks calcium influx through voltage gated channels; used as tocolytic; contraindications cardiac dz, maternal hypotension *dont use with magnesium sulfate; no fetal side effects
180
What is indomethacins use as a tocolytic
Inhibits production of prostaglandin F2alpha; side effects: in fetus: bleeding, necrotizing enterocolitis, decreases in renal function with oligohydramnios, pulm HTN; maternal: gastritis bleeding
181
What is atosiban
Oxytocin inhibitor; used for tocolysis but not available in US
182
What are the best choices for delaying labor in the US
Nifedipine or indomethacin
183
What is alprostadil
PGE1; maintains patent ductus arteriosus; parenteral administration; adverse effects: pyrexia (spike in temp), hypotension, tachycardia, apnea
184
What are the side effects to given NSAIDS for closure of ductus arteriosus
Oliguria, edema, mild HTN due to decreased kidney function
185
What are the first and second line drugs for HTN during pregnancy
- first line: used for moderate HTN - oral alpha methyldopa (alpha2 agonist) or oral labetaolol (alpha/beta blocker)
- second line: used for severe HTN - parenteral labetolol, hydralazine (arterial vasodilator) or sodium nitroprusside (arterial and venous vasodilator)
186
What lab values would you see in someone with 21 beta hydroxylase deficiency
Low sodium, high potassium, low chloride, low bicarbonate, high BUN, high-normal creatinine, low glucose
187
How do you treat CAH secondary to 21 hydroxylase deficiency
Hydrocortisone, fluids, glucose, get potassium level down
188
What can addisons occur in conjunction with
As part of poolylandular autoimmune syndrome (type 1 or Type 2 - Schmidt syndrome which is addisons + hypothyroid + T1DM)
- X linked recessive disorder of long chain FA metabolism (adrenoleukodystrophy and adrenomyeloneuropathy) - neuro deterioration which can mimic multiple sclerosis
- infection (TB)
189
What is familial glucocorticoid deficiency
An inherited adrenal unresponsiveness to ACTH; due to mutation in receptors; isolated cortisol deficiency; increased skin pigmentation; mineralcorticoid always normal; AR
190
What is triple A (allgrove) syndrome
AR; mutation in AAAS gene that codes for ALADIN; sx: alacrima (no tears), achalasia, adrenal insufficiency, neuro disorder
191
What are the cholesterol biosynthesis disorders
Smith-lemli-optiz, abetalipoproteinemia
192
What are the sx of adrenal insufficiency
Fatigue, reduced stamina, weakness, anorexia, weight loss, skin hyperpigmentation, pain, psych sx, HA, salt craving, BP usually low and orthostatic
193
What lab findings will you see with primary adrenal insufficiency
Moderate neutropenia, low serum Na, high serum K, fasting hypoglycemia, hypercalcemia, low 8am plasma cortisol with increased ACTH, confirmatory test* cosyntropin (synthetic ACTH) stimulation test given IM -> then measure serum cortisol (if doesn’t respond, confirms primary adrenal insufficiency); elevated renin, low serum epi
194
What confirms the disagnosis of autoimmune Addison dz
Serum abs for 21 hydroxylase
195
What is required for diagnosis of 21 hydroxylase deficiency
Elevated 17-OH progesterone
196
How do you treat primary adrenal insufficiency
Glucocorticoid replacement: hydrocortisone, prednisone, prednisolone
Mineralocorticoids: fludrocortisone acetate
197
What tests can you order to diagnose acute adrenal crisis
ACHT stimulation, cortisol level, blood sugar, serum K or Na, serum pH
198
What is the treatment for acute adrenal crisis
Hydrocortisone, fluids/glucose, treat hyperkalemia
199
What is alabaster skin
Decreased skin pigmentation due to secondary adrenal insufficiency
200
What is McCune-Albright syndrome
Polyostotic fibrous dysplasia, cafe au lait spots, endocrine hyperfunction from multiple organs - can cause ACTH independent cushing
201
What is the screening test of choice for Cushing
Dexamethasone suppression test; low dose given at night and serum cortisol drawn in morning; if serum cortisol below a certain level, cushing excluded; results used in combo with ACTH drawn before dexamethasone given to determine causes
202
What is the only time cushing will be suppressed by high doses of dexamethasone
Cushing disease (pituitary adenoma)
203
What are localizing teaching queens for diagnosis of cushing syndrome
CT of adrenals for ACTH independent Cushing, MRI of pituitary for ACTH dependent, CT of chest and abdomen then PET if nothing found or location off ectopic sources of ACTH
204
When should you resect adrenal incidentelomas
If >4cm, no hx of malignancy and not obviously a benign lesion, cyst, or hemorrhage
205
What do ALL patients with an adrenal incidentaloma require
Testing for pheochromocytoma with plasma fractionated free metanephrines
206
What are the lab findings in primary hyperaldosteronism
Metabolic alkalosis (proton loss = H+ with K+)
207
What imaging is required in patients with primary hyperaldosteronism
Thin-section CT scan of adrenals to screen for adrenal carcinoma; adrenal v sampling required beforehand
208
What is the treatment for primary hyperaldosteronism
Removal of adenoma in Conn; if adrenal hyperplasia use spironolactone
209
What does NE vs epi cause with pheochromocytomas/paragangliomas
NE: HTN, epi: tachyarrhythmias; paragangliomas are more likely to met and secrete NE
210
What is von hippel lindau dz type 22
AD; 20% develop pheochromocytomas that secrete only NE; hemangiomas of retina, cerebellum brainstem hyperthyroidism, pancreatic cysts, endolymphatic sac tumors, cystadenomas of Adnexa or epididymis, pancreatic neuroendocrine tumors, renal cysts, adenomas, carcinomas
211
What are the sx of pheochromocytomas
Paroxysmal, increase BP, pounding HA, perspiration, panic, palpitations, pallor after its over
212
What is the most sensitive test for pheochromocytomas
Fractionated free metaneprhines in plasma; urinary is confirmatory
213
When should you perform a CT or MRI for a pheochromocytoma
Only if suggestive lab findings
214
What is the treatment for pheochromocytomas
Resection but patient can develop severe hypotension afterward; abdomen can be seeded during surgery resulting in multifocal recurrent tumors known as pheochromocytomatosis *prior to resection, treat with alpha blockers (phenoxybenzamine), calcium channel blockers (nifedipine), beta blocker ONLY after given alpha blocker
215
Can histopathology determine if a pheochromocytoma is malignant
No; need lifelong follow up
216
What is length vs height
Length is supine; height is standing
217
How do you calculate BMI
Mass in kg/height^ in meters
| Mass in lbs x 703/height^2 in inches
218
For children (2-18) what are the BMI categories
Underweight if <5th percentile for age, normal weight if 5th-85th percentile, overweight if 85-95th percentile, obese if >95th percentile, severe obesity if >120 percent of 95th percentile or BMI>35 (class I) or BMI >140 percent of 95th percentile or BMI >40 (class II)
219
What is the typical growth for kids
- < 4 years old: >7 cm/year
- 4-6 years old: >6cm/year
- 6 years-puberty: >5 cm/year (2inches)
- peak is 13.5 years in boys and 11.5 years in girls
220
How do you estimate the adult height of a child
Double the height of child at age of 2
-using mid parental height: for boys - dad’s height + mom’s height + 5/2; for girls - dads height + mom’s height - 5/2; target height is =/- 2 inches of mid parental height
221
What should you think of if weight falls off first in a child
Nutrition: not enough food, emesis, malabsorption, higher than average caloric requirements
222
What should you think of if length falls off first in a child
Endocrine: GH deficiency, hypothyroidism, Cushing syndrome
223
What should you think of if head circumference falls off first
Primary failure of brain to grow or severe craniosynostosis
224
What is bone age
Provides estimate of child’s skeletal maturation by assessing ossification of epiphyseal centers; helps estimate child’s growth potential; X-ray of let hand and wrist *bone age that is 2 standard deviations below the chronological age is considered delayed
225
How do you evaluate growth based on age
If less than 36 months, measure length while child is supine; if older than 24 months can use 2-20 yo chart but must be measured standing up (stature)
226
What is catch up or catch down growth
Occurs in 1st 18 months o life; some kids make up to a 25% downward correction on growth curve - occurs as more table food is introduced; after 24 months of age, usually growth along same curve
227
What does height below 3% indicate
Can be normal if growth is parallel to curve; abnormal if curve is falling progressively below 3% or if height crosses 2 major percentile lines in a downward direction of 6-12 months
228
How do you adjust growth curves for premature infants
For first 2 years, plot gestational age rather than chronological
229
What is the definition of short stature
Height 2 standard deviations below the mean height for age and sex (<3 percentile), height more than 2 standard deviations below the mid-parental height
230
What are causes of short stature
Familial, constitutional growth delay, idiopathic, hypothyroid, precocious puberty, turner, growth hormone def, Cushing, genetic, nutritional, chronic illness
231
What do you do for initial work up for concerning short stature
CBC with diff, CMP, thyroid function, IGF and IGFBP-3 levels*, UA and urine pH, ESR, CRP, celiac panel, bone age
232
What does GH def cause in the neonate vs children
- neonate: midline defects, microphallus, hypoglycemia, GH not relevant for growth during first year of life
- children: decreasing growth velocity, low IGF-1 andIGFBP-3 levels, low GH levels during stimulation using insulin, arginine or clonidine
233
What findings will you see with Turner syndrome
Short stature, delayed puberty, webbed neck, shield shaped chest, low posterior hairline, *check for karyotype, echo, renal US (horseshoe)
234
What is the definition of precocious puberty
Before 8 yo in girls, before 9 in boys; full activation of HPG axis
235
When should you consider precocious puberty as a diagnosis
- in girls: if progressive breast development or crossing major percentile lines upward on the linear growth chart
- in boys: if testicular and penile enlargement, or crossing major percentile lines upward on linear growth chart
236
What causes premature adrenarche
Increase in DHEA; appearance of pubic hair, axillary hair, odor, mild acne; associated with NORMAL rate of linear growth, no clitoromegaly, penile growth, or testicular enlargement
237
What is the PE findings of severe hypothyroidism in kids
Increased BMI from growth arrest but increase in weight, delayed relaxation of DTRs
238
What can case tall stature
- Beckwith-wiedemann syndrome: big head, big when young, normal adult height; overexpresion of IGF-2, do renal US
- GH excess: IGF-1, IGFbp-3
- homocystinuria: error of methionine, similar clinically to marfans
- infant of diabetic mother
- klinefelter: test LH, FSH testosterone
- marfans: diagnosis using Ghent nosology; test: fibrillin-1 gene mutation
239
What abnormal growth findings suggest a need for referral
- height: growth less than the 3rd percentile or greater than 95th percentile
- growth velocity: decreased or accelerated for age
- genetic potential: projected heigh varies from mid-parental heigh by more than 5 cm
- multiple syndromic or dysmorphic features: abnormal facies, midline defeats, body disproportions
- bone age: advanced or delayed by more than 2 SD
240
What are some etiologies of DKA
Inadequate insulin, infection (pneumonia, UTI, gastroenenteritis, sepsis), infarction, surgery, drugs (cocaine)
241
What are the initial sx of DKA
Anorexia, n/v, polyuria, thirst
242
What are signs of DKA
Kussmaul respiration’s, dry mucous membranes, poor skin turgor, tachycardia, hypotension, fever, ab tenderness
243
What is the effect of acidosis on potassium
Will shift out of the cells resulting in hyperkalemia
244
What will the sodium lab value be in someone with DKA
Measured (not corrected) sodium will be low secondary to hyperglycemia; for every 100 mg/dL that glucose is over 100 mg/dL, there will be a 1.6 meq reduction in sodium
245
What will the potassium lab values be in someone with DKA
Serum may be normal or high but actually have total body deficit*
246
What other lab values will you see in someone with DKA
Hypertriglyceridemia, hyperlipoproteinemia, hyperamylasemia (salivary; can suggest acute pancreatitis), leukocytosis
247
What is the rule for fluid replacement in DKA
1-2-3 rule; 2-3 liters NS over 1-3 hrs, then .5 NS at 150 ml/hr, when glucose reaches 250 mg/dL switch to D51/2NS at 100-200 ml/hr
248
What is the initial insulin administration for DKA
Regular insulin - 10-20 units IV* or IM, then 5-10 units/hr continuous IV, increase if no response in 1-2 hrs
249
What evaluations would you do for underlying causes of DKA
Culture, EKG, CXR, drug screen, additional hx
250
What is the initial monitoring you should do for someone in DKA
BSG at least hourly, electrolytes q2-4 hrs +/- ABGs, vital signs q1h, mental status and I/O q1h
251
When should you consider potassium replacement for DKA
If serum <5.5; when supplementing, keep in mind, renal fxn, baseline EKG, urinary output (measure hourly)
252
What is the glucose goal when treating DKA
150-250
253
When should you start intermediate or long acting insulin in someone recovering from DKA
When patient is able to eat (mental status improved, no n/v, no ab pain), anion gap normalized, allow overlap timing of IV w/ SQ insulin (30-60 min)
254
What factors can precipitate non ketotic hyperosmolar syndrome
Sepsis, MI, glucocorticoids, phenytoin, thiazides, impaired access to water
255
What are the sx of NKHS
Polyuria, thirst, altered mental state, but NO N/V AB PAIN OR KUSSMAUL
256
What are the lab results of someone with NKHS
Lactic acidosis with mild anion gap, moderate ketonuria from starvation, corrected serum sodium usually increased
257
What is the fluid deficit in NKHS
8-10 L (more than DKA)
258
What are the fluid replacement guidelines for NKHS
2-3 liters NS over first 1-3 hours; then .5 NS over 24-48 hrs, when glucose reaches 250, switch to D51/2NS at 100-200 ml/hrs
259
What are the insulin administration guidelines for NKHS
Regular insulin 5-10 units IV bonus, 3-7 units continuous infusion, transition when eating as with DKA
260
What is a HbA1C of 7 indicative of in terms of glucose
140; 6 is 110, 8 is 180
261
What does diabetic gastropathy lead to
Delayed gastric emptying, insulin-glucose mismatch, hyperglycemia
262
What is the screening for proteinuria
Spot random urine sample; might need to test for microalbuminuria if <300; use microalbuminuria:Cr ratio
263
When is a 24 hr urine collection used
To quantify large amounts of protein; used to measure protein and Cr clearance; Need to obtain serum Cr at same time to determine clearance
264
How can diabetes lead to immune compromise
Glucose >150 interferes with neutrophil function, general debilitation, multiple comorbidities
265
What is neuropathic Arthropathy
Malformations of the foot caused by diabetes
266
What is important for diabetic foot care
Daily inspection, dont walk barefoot, moisturize but not between or under toes, prescription shoes, podiatry visits
267
What monitoring should be done on diabetes patients
- quarterly: Hgb A1C, review self glucose monitoring (SGM) log, foot inspection
- annual: dilated eye exam, urine protein screening, monofilament testing
268
If calcium and phosphorus move in the same direction, what issue do you have
Vit D
269
If you have high calcium but low PTH, what is your working diagnosis
Malignancy, granulomatous dz, drugs, mets, MM, lymphoma, vit D intoxication
270
What sx would you expect with acute vs chronic hypercalcmia
Acute: polyuria, dehydration, renal impairment
Chronic: stones, bone weakness, psychiatric issues
271
How do you treat chronic hypercalcemia
Loop diuretics
272
What are the risks of treating hypercalcemia with loop diuretics
Stones; fluid shifting and volume depletion
273
What is the corrected calcium equation
Measured Ca + .08(4-serum albumin)
274
How do you treat hypocalcemia
Calcium and vitamin D; how much depends on how low Ca and sx; mild hypo: 8-8.4, moderate 7.5-8, severe <7.5
275
What is the effect of immobilization on calcium levels
Increased osteoclasts activity which leads to bone resorption and PTH suppression b/c of high calcium; leads to calciuria
276
What DEXA is used for screening vs diagnosis
Screening: peripheral
Diagnosis: central - lower spine and hip
277
What are the classifications for DEXA scan
Normal T score >-1
Osteopenia -1 - -2.5
Osteoporosis: <2.5
278
What should you give to replace calcium in someone with osteoporosis
1000-3000 mg/day (calcium carbonate - but can get constipated so don’t talk regularly); calcium citrate if low acid in stomach (H2 blockers, PPI, gastric)
279
What sexual sx can hyperthyroidism have
Oligomenorrhea, loss of libido, gynecomastia
280
What is needed to diagnose Graves’ disease
ONLY clinical history and physical exam; other tests will confirm but that’s all you need to diagnose
281
What scan is used to visualize graves
Radioactive iodine;; can use technetium but only iodine determines if uptake is increased
282
What do you give to someone with hyperthyroidism who has asthma and cannot tolerate beta blockers
Calcium channel blockers
283
How long to methimazole and PTU take to start working
2-8 weeks *do not use methimazole during pregnancy
284
If you find a thyroid nodule what tests would you do next if the TSH was low vs normal
If low, do a thyroid scan
| If normal, do FNA
285
What characteristic makes a benign thyroid nodule a more likely diagnosis
Tenderness, family hx of benign nodules, hashimotos, mobile nodule, concomitant diagnosis of hyper or hypothyroidism
286
What characteristics are more likely to predict a malignant thyroid nodule
Very young, very old, men, history of neck irradiation, firm, fixed nodes, LAD
287
Most thyroid nodules are _____
Cold
288
What is the approach to patient with a thyroid nodule
- low TSH -> thyroid scan -> if hot, ablate, resent or rx medically; if cold -> FNA
- if normal TSH -> FNA -> cytopathology -> if benign, monitor by US; if suspicious or malignant, surgery
289
What is Queen Anne sign
Loss of lateral aspect of eyebrows - seen in hypothyroidism
290
What are some things you should keep in mind when starting thyroid replacement
Start low recheck very 6-12 weeks, dissipated thyroid or T3 not easy to control and better to avoid, T4 prep provides steady levels of T3 and 4
291
What is method failure rate vs typical failure rate of contraception
Method: inherent rate if method is used correctly
Typical: rate when method is actually used by patient
292
What is the most effective reversible contraception
Hormonal contraceptive
293
What are the different types of hormonal contraceptives
OCP
Injectable: depomedroxyprogesterone acetate
Implantable: etonogestrel rod
IUD: levonorgestrel (Mirena, skyla, liletta, Kyleena)
Patches: orthoevra
Rings: nuva ring
294
What do combination estrogen and progesterone pills do
Suppression of hypothalamic gonadotropin releasing factors; progesterone suppresses LH (prevents ovulation and thickens mucus); estrogen stabilizes endometrium and allows less breakthrough bleeding (improves cycle control)
295
What is the progestin only OCP
Mini pill; makes cervical mucus think; ovulation still occurs in 40% of users; used mainly in breastfeeding women and women who have contraindication to estrogen; must be taken at same time everyday starting on first day of menses (if >3 hrs late, use back up for 48 hrs)
296
What are the benefits of OCPs
Menstrual regularity, improves dysmenorrhea, decrease risk of iron deficiency anemia, lower incidence of endometrial and ovarian cancers, benign breast and ovarian dz (cyst)
297
What are the side effects of OCP
Breakthrough bleeding, amenorrhea, bloating, weight gain, breast tenderness, nausea, fatigue, HA
SERIOUS Side effects: DVT, PE, cholestasis and GB dz, stroke and MI, hepatic tumors
298
What is the transdermal patch
Estrogen and progesterone; apply one patch weekly for 3 weeks to buttocks, outer arm or lower ab; *caution with use in women > 198 lbs; same side effects as OCP BUT* greater risk of thrombosis
299
What is the vaginal ring
Estrogen and progesterone; assoc with greater compliance bc once a month use - insert into vagina for 3 weeks; can be removed up to 3 hrs without affecting efficacy; better tolerated bc does not get metabolized by liver (less breakthrough bleeding)
300
Who cannot use combination contraceptives
Women over 35 who smoke, personal hx of thrombosis (patients with family hx need to be tested for thrombophilia), hx of coronary a dz, cerebral vascular dz, CHF, migraine with aura, uncontrolled HTN, sever liver dz; diabeetes chronic HTN, and SLE - individualized prescriptions
301
What is depo
IM injection every 11-13 weeks; maintains contraceptive level of progestin from 14 weeks; give within first 5 days of menses and if not use back up method for 2 weeks; MOA: thickening of mucus, decidualization of endometrium, blocks LH surge and ovulation; efficacy equal to sterilization and is not altered by weight
302
What are the side effects of depo
- Alterations of bone metabolism assoc with decreased estrogen; reversible after discontinuation; *over 2 years should consider alternative
- irregular bleeding (can improve with estrogen add back but wait till after second dose)
- weight gain
- exacerbation of depression
303
What are the indications for use of depo
Desire fo contraception, better compliance, breastfeeding, when estrogen is contraindicated, women with seizure disorders, sickle cell anemia (decreased # of crisis), anemia secondary to menorrhagia, endometriosis, decrease risk of endometrial hyperplasia
304
What are the contraindictions to depo
Known or suspected pregnancy, unevaluated vaginal bleeding, known or suspected malignancy of the breast, active thrombophlebitis or current/past hx of thromboembolic events or cerebral vascular disease
305
What are LARCS
Long acting reversible contraceptives
306
How long does nexplanon last
3 years; insert first 5 days of menses (if not, use back up for 7 days); MOA: thickens cervical mucus and inhibits ovulation
307
What are the side effects of nexplanon
Irregularly irregular vaginal bleeding, HA, vaginitis, weight increase, acne, breast pain
308
What are the indications for nexplanon
Convenient effective method of contraception, may be used in breastfeeding patients
309
What are the contraindications of the nexplanon
Known or suspected pregnancy, current or past hx of thrombosis, liver tumors or active liver dz (poorly metabolized), undiagnosed abnormal uterine bleeding, known or suspected breast cancer (*only absolute contraindication)
310
What are the complications of insertion of nexplanon
Infection, bruising, deep insertion, migration, persistant pain or paresthesias at insertion site
311
What are the available IUDs
```
Copper T (paragard)
Levonorgestrel releasing (mirena, liletta, skyla, kyleena)
```
312
What are the risks with IUDs
Increased risk of infection w/in first 20 days post insertion, increased risk of ectopic pregnancy, if becomes pregnant, offer removal if strings are visible (decreases risk of spontaneous abortion), uterine perforation at time of insertion (requires laparoscopy for removal), risk of malposition necessitating hysteroscopy for removal
313
What are the contraindications to IUDs
Breast cancer (only the levonorgestrel containing ones), recent puerperal sepsis, recent septic abortion, active cervical infection, Wilson’s dz (only copper one) uterine malformations (uterine septums, fibroids, significantly enlarged)
314
How long are each of the levonorgsterel IUDs good for
Mirena/kylena: 5 years
Liletta:3 year’s
Skyla: 3 years; used originally for nulliparous women b/c smaller
315
What are the benefits of the hormonal IUDs
Decrease in menstral blood loss, less dysmenorrhea, protection of endometrial lining from unopposed estrogen, convenient and long term
316
How long does copper T IUD work
10 years; MOA: copper interferes with sperm transport or fertilization and prevention of implantation
317
What must you do with a vaginal condom after intercourse
Leave it in there for 6-8 hrs
318
What must you use in addition to a diaphragm
Spermicide; may be inserted up to 6 hrs before intercourse and left in for 6-8 hrs after (no more than 24 hrs); must be fitted by doctor (fit may change after birth, weight change or surgery); *more likely to get UTIs (puts pressure on urethra and causes urinary stasis and altered vaginal flora from spermicide)
319
What is the Caya
A one size fits all diaphragm
320
What is the cervical cap
Smaller version of diaphragm applied to cervix itself; high risk of displacement and TSS; left in place for 6 hrs after (no more than 48)
321
What is the sponge
Sponge containing spermicide with dimple that fits over cervix; only one size; more effective in nulliparous women; left in place for 6 hrs (no more than 30 hrs)
322
What is the basal body temp method
Take temp and when notice temp diff avoid sex for 3 days
323
What is the cervical mucus method
Assess cervical mucus and note changes around ovulation (spinnbarketi) and avoid sex for 4 days
324
What is the symptothermal method
Combines cervical mucus and basal body temp; awareness of other signs of ovulation (breast tenderness, cramping)
325
Is there any contraindication to emergency contraception
No
326
What is plan B
Progestin only (levonorgesterel); 2 pills taken 12 hrs apart; OTC for women >17; must be used within 120 hrs; failure rate worsens after 72 hrs
327
What is Ella
Ulipristal acetate; indicted for up to 5 days after unprotected intercourse; postpones follicular rupture/inhibit or delay ovulation
328
How should you counsel patients seeking permanent sterilization
Address all other options (LARCS), reasons for choosing sterilization, discuss risk/benefits, screen for indicator of regret, possibility of failure and increase risk of ectopic, need to use condoms to prevent against STIs
329
What are the complications of vasectomy
Bleeding, hematomas, acute/chronic pain, local skin infections
330
Are vasectomies immediately effective
No; complete azoospermia within 10 weeks
331
How is female sterilization done laparoscopically
Occlude Fallopian tubes by
- electrocautery: fast, increase risk of thermal injury to surrounding tissue, poor reversibility, greater risk of ectopic
- clips: hulka is most reversible but greatest failure rate, filshie has lower failure rate
- bands: falope rings - intermediate reversibility and failure rate, higher incidence of post op pain, increased risk of bleeding
- salpingectomy
332
What is the most common approach for female sterilization
Mini laparotomy; infra umbilical incision in postpartum period or suprapubic incision as interval
333
What makes up the pelvic diaphragm l
Levator ani and coccygeus
334
What is an anterior vaginal prolapse
Cystocele
335
What is a lower posterior vaginal prolapse
Rectocele
336
What is a vaginal vault prolapse
When uterovagial canal sags (usually b.c uterus was removed)
337
What is the treatment for a cystocele
Do nothing, pelvic floor PT, Pessary, surgical correction (anterior colporrhaphy - pubocervical fascia is sutured in the midline and laterally to the Arcus tendinous fascia)
338
What are the treatments for uterine prolapse
Pessary, hysterectomy, colpocleisis
339
What is the diff btw Pessary used for cystocele vs uterine prolapse
Cystocele: support - ring or gehrung
| Uterine prolapse: gelhorn, donut, cube
340
What is the Q tip test
Insert a Q tip into urethra and have them valsalva: if moves >30 degrees, stress urinary incontinence
341
What are the treatments for urethrocele
Topical estrogen, pelvic floor PT, Pessary, surgery (suburethral sling - transvaginal or transobturator tape for vaginal approach; ab approach with Marshall-marchetti-krantz or Burch procedure)
342
What is the best treatment option for rectocele
Surgery
343
How do you treat urge incontinence/overactive bladder
- behavior modification: decrease caffeine, limit fluids after 7 pm, bladder training
- antispasmodic: oxybutynin, tolterodine
344
What hormonal changes occur to the breast
- estrogen: growth of adipose tissue and lactiferous ducts
| - progesterone: lobular growth and alveolar budding
345
What are the risk factors for breast cancer
Hx of atypical hyperplasia, high breast tissue density, first degree relative with breast or ovarian cancer, early menarche <12, late menopause >55, no term pregnancies, never breastfed, recent and Long term use of OCP, postmenopausal obesity, personal hx of endometrial or ovarian cancer, alcohol consumption, height (tall), high SES, ashkenazi Jewish
346
When will you always bx in the breast
If palpable mass
347
Who gets a mammogram
>40 years
348
When is MRI used for breast imaging
Adjunct to diagnostic mammography, post cancer diagnosis for evaluation and staging, used with implants, women at higher risk for breast cancer (BRCA)
349
What do you do if bloody fluid shows up on FNA
Send to cytology and need mammogram or US
350
What happens if a cyst reappears or does not resolve with FNA
Need mammogram/US and bx
351
When does cyclic breast pain occur
Starts at luteal phase and ends after onset of menses
352
What meds can cause breast pain
Anti-HTN, anti-depressants
353
What is the only FDA approved treatment for breast pain
Danazol; *bad side effects: menstrual irregularities, benign intracranial HTN, alters blood sugar, deepens voice, unusual hair growth and weight gain
354
What other therapies can be used to treat breast pain
selective estrogen receptor modulators (SERUMS) but increase risk of endometrial hyperplasia and DVT; OCP or depo; properly fitting bra, weight reduction, decrease caffeine, exercise, vit E supplementation, primrose oil
355
What is non-spontaneous, non-bloody, b/l nipple discharge associated with
Fibrocystic changes or ductal ectasia
356
What could milky discharge indicate
Prolactinoma or hypothyroidism or medication related (OCP/psychotropics)
357
How do you further evaluate bloody nipple discharge
Breast ductography; requires ductal excision
358
What breast masses are of concern for malignancy
> 2cm, immobile, poorly defined margins, firm, skin dimpling/retraction/color changes, bloody discharge, ipsilateral LAD
359
How are galactoceles typically treated
Needle aspiration
360
What are the proliferative lesions without atypia
Epithelial hyperplasia, sclerosing adenosis, complex sclerosing lesions (enlarged lobules distorted by scar-like fibrous tissue), papillomas (can cause serous or serosanguinous discharge)
361
What is the Gail model breast cancer risk
Calculates your risk of getting breast cancer; usefulness decreases in 2nd degree relatives, falsely elevated in patients w/ multiple breast biopsies, women considered high risk (5 year risk of 1.7% or more) counseled on prophylactic mastectomy, chemopreention, oophrectomy
362
What treatment is just as effective as mastectomy
Lumpectomy with radiation
363
What medical therapy is given for breast cancer
Given in all stages; chemo, hormonal (tamoxifen - reduces risk of CA in contralateral breast as well), aromatase inhibitors, trastuzumab (side effects: heart failure, resp problems, serious allergic reactions)
364
What is the follow up procedure or post treatment of breast cancer
First 2 year after dx: every 3-6 months
Annually after first 2 years
*most reoccurrences will happen within first 5 years
365
What do LH and FSH do
LH stimulates theca cells to produce androgens (androstenedione and testosterone) and FSH stimulates granulosa cells to convert these androgens into estrogens
366
What occurs during luteal phas e
FSH and LH are decreased via negative feedback from elevated estradiol and progesterone; if pregnancy does not occur, progsterone and estradiol declines as a result of regression of corpus luteum
367
Where is GnRH synthesized
Arcuate nucleus
368
What induces the LH surge
Elevated estradiol enhances GnRH release
369
How do estrogen levels fluctuate throughout the cycle
Early follicular low, 1 week before ovulation start to rise; reach max 1 day before LH peak; after peak but before ovulation, there is a fall then rises 5-7 days after ovulation
370
What changes does the LH surge cause
Cells on th follicular wall surface degenerates and forms a stigma, the follicular BM bulges through the stigma; this ruptures and the oocyte is expelled
371
What forms the corpus luteum
Luteinized granulosa cells, theca cells, capillaries, and connective tissue; produces copious amounts of progesterone and some estradiol;; normal life span is 9-10 days
372
What is the corpus luteum replaced by
Avascular scar called corpus albicans
373
What are the zones of the endometrium
- functionalis: shed at menses; contains spiral aa
| - basalis: provides stem cells for new functionalis after menses; contains basal aa
374
What happens during the menstrual endometrial phase
Disruption of endometrial glands and stroma, leukocyte infiltration, RBC extravasation; sloughing of functionalis and compression of basalis
375
What is the proliferative endometrial phase
Response to estrogen; increase in length of spiral aa and numerous mitosis seen
376
What happens during the secretory phase of the endometrium
Progresterone stimulates glandular cells to secrete mucus and glycogen; glands becom tortuous and lumens dilated; stroma becomes edematous, mitosis RARE, spiral aa extend into superficial layer of endometrium; *max thickness
377
If conception does not occur by what day will the corpus luteum regress
23
378
What medications can cause heavy menstrual bleeding
Warfarin, aspirin, clopidrogel; need intact clotting pathway
379
What is the median age of menarche
12.43; occurs within 2-3 years after thelarche at tanner stage IV; rare before stage III
380
What is primary amenorrhea
No menstruation by 13 years without secondary sexual development OR by the age of 15 with secondary sexual characteristics
381
What is the typical length of a cycle for an adult female
21-35 days; during first gynecological year: 21-45 days
382
Blood loss greater than what has been associated with anemia
80 cc; changing a pad q 1-2 hrs is considered excessive
383
What is onset of puberty determined by
Race, geographic location (girls in metropolitan areas at altitudes near sa level begin early), nutritional status (obese have early onset * mean weight of 106 lbs essential to start menarche)
384
What are the initial endocrine changes assoc with puberty
Adrenal androgen production and differentiation by zone reticularis -> causes growth of axillary and pubic hair (adrenarche or pubarche)
385
Where does the growth spurt occur
2 years earlier in girls than boys; occurs 1 year before onset of menses
386
What are the tanner stages for breast
-I: elevation of papilla only
II: breast bud; election of breast and papilla as a small mound with enlargement of areaolar region
III: further enlargement of breast and Areola /o separation of contours
IV: projection of areola and papilla to rom secondary mound above the breast
V: projection of papilla only resulting from recession of areola to general contour of breast
387
What is the tanner staging for pubic hair
- I: absence of pubic hair
- II: sparse hair along labia; downy with slight pigment
- III: hair spreads sparsely over junction of pubes; hair is darker and coarser
- IV: adult type hair; no spread to medial thigh
- V: adult type hair with spread to medial thigh assuming inverted triangle pattern
388
What is precocious puberty
Development of any sign of secondary sex characteristics prior to an age 2.5 SD earlier than age of expected pubertal onset; in US: 8 for girls and 9 for boys
389
What are the kinds of precocious puberty
- heterosexual: development of secondary sex characteristics opposite those of anticipated phenotypic sex; virilizing neoplasms, congenital adrenal hyperplasia, xposure to exogenous androgens
- isosexual: premature sex maturation that is appropriate or phenotype of individual; constitutional and organic brain dz (tumors, trauma, infection)
390
How do you diagnose true isosexual precocious puberty
Administration of exogenous GnRH and see a rise in LH levels consistent with older girls who are undergoing normal puberty; confirm with MRI of head (10% caused by CNS disorder - tumor, hydrocephalus, sarcoidosis, TB, abscess, NF, head trauma)
391
How do you treat isosexual precocious puberty
Most are idiopathic; treat with GnRH agonist (leuprolide)
392
What is pseudoisosexual precocious puberty
Results in increase estrogen levels and cause sex maturation without activation of HPO
393
What are causes of pseudoisosexual precocious puberty
Ovarian tumor, exogenous compounds, McCune Albright syndrome (somatic mutation; cystic bone defects, cafe au lait spots, adrenal hypercorticolism) and peutz jeghers (sex cord tumor that secretes estrogen)
394
What is delayed puberty
Secondary sex characteristics have not appeared by 13, if thelarche has not occurred by 14, no menarche by 15-16, when menses has not begun 5 years after thelarche
395
What are causes of delayed puberty
- hypergonadotropic hypogonadism: FSH > 30; turner
- hypogonadotropic hypogonadism: FSH + LH <10; physiologic delay, Kallman, anorexia, pituitary tumor, hyperprolatinemia, drug use
- anatomic causes: mullerian agenesis, imperforate hymen, transverse vaginal septum
396
If a patient with primary amenorrhea with no sexual characteristics present comes in what do you do?
Test FSH and LH;; if FSH and LH < 5 -> hypogonadotropic hypogonadism; if FSH > 20 and LH > 40 -> hypergonadotropic hypogonadism (do karyotype analysis; if 46 XX premature ovarian failure; 45 xo turner)
397
If a patient with sexual characteristics presents with primary amenorrhea what do you do
US of uterus; if absent or abnormal do karyotype -> if 46 XY, androgen insensitivity syndrome, if 46 XX mullerian agenesis; if uterus present and Normal check for outflow obstruction
398
What is kallman syndrome
Mutation in KAL gene on X chromosome that prevents migration of GnRH neurons to hypothalamus
399
If a girl has delayed puberty and karyotype testing comes back with a Y chromosome, what is recommenced
Gonadectomy to prevent malignant neoplastic transformation
400
What is androgen insensitivity syndrome
46 XY, male levels of testosterone, defect in androgen receptor; testes in ab wall and secrete AMH (therefore no uterus), ext female genitalia; breasts with smaller nipples caused by estrogen secretion in testes and conversion of androgens to estrogen in liver
401
What is mullerian agenesis or dysgenesis
Primary amenorrhea, breast development, testosterone consistent with females, 46 XX; causes obstruction of vaginal canal; absence of normal uterus (agenesis)
*congenital abnormalities of uterus or vagina are assoc with renal abnormalities so IV pyelogram should be ordered
402
What is the difference in presentation btw imperforate hymen and transverse vaginal septum
Both present with dysmenorrhea w/o vag bleeding; imperforate hymen will have bulging mass, transverse vaginal septum will not; imperforate dx with US; transverse dx with MRI
403
What should you first check if a patient presents with secondary amenorrhea
HCG
404
If HCG is negative in someone with secondary amenorrhea what should you check next
TSH and prolactin levels; if both normal do progestogen challenge test; if normal prolactin but abnormal TSH -> thyroid dz; if normal TSH but abnormal prolactin -> MRI of head
405
What are the causes of hyperprolactinemia
- < 100 ng/ml: ectopic production (bronchogenic carcinoma, ovarian dermoid cyst, RCC, gonadoblastoma), breast feeding, excessive exercise, severe head trauma, hypothyroidism, liver/renal failure, meds (OCP, antipsychotics, antidepressants, antiHTN, histamine blockers, opiates, cocaine)
- >100 ng/ml: pituitary adenoma, empty sella syndrome
406
What is a positive vs negative progsterone challenge test
- positive: bleeding -> normogonadotropic hypogonasim (PCOS)
| - negative: no bleeding -> indicates inadequate estrogenization or outflow tract abnormality
407
If you have a negative progesterone challenge test, what would you do next
Estrogen/progesterone challenge test
Negative -> outflow obstruction
Positive -> abnormality with HPO or ovaries; if elevated FSH and LH (hypergonadotropic hypogonadism - ovarian abnormal); if normal or low FSH/LH (hypogonadotropic hypogonadism - pit or hypothalamic ab; order MRI - if no tumor then hypothalamus is the cause)
408
What is given for the progestin vs estrogen/progestin challlenge test
- progestin: medroxyprogesteron acetate or norethindrone for 7-11 days
- estrogen/progestin: conjugated equine estrogen or estradiol for 21 days
409
What are the anatomic causes of secondary amenorrhea
Asherman syndrome or cervical stenosis
410
What leads to increase in circulating testosterone in PCOS
Elevated insulin and androgen levels reduce production of sex hormone binding globulins from liver
411
What do you need for diagnosis of PCOS
2 of the following: oligo/amenorrhea, biochemical or clincial signs of hyperandrogenism (LH:FSH 2:1), US revealing multiple small cysts beneath cortex of ovary
412
What are the abnormal hormonal feedback mechanisms in PCOS
Increased LH and decreased FSH leads to stimulation of theca cells and production of testosterone -> aromatization -> increased estrogen which feedsback and inhibits FSH
413
What are the treatments for PCOS
Weight loss, OCP (suppresses FSH and LH to allow for regression of overproduction of testosterone and stimulates SHBG), clomiphene citrate (induce ovulation), ovarian diathermy/laser tx, spironolactone and/or electrolysis, insulin sensitizing agents (biguanides - metformin)
414
If your progesterone challenge test is negative, estrogen challenge is positive, what do you check next
FSH and LH: if FSH > 20 and LH >40: hypergonadotropic hypogonadism; postmenopausal overran failure or premature ovarian failure (caused by ovarian injury by surgery, pelvic radiation, chemo, carrier of fragile X, autoimmune, mumps)
415
What is secondary amenorrhea hypogonadotropic hypogonadodism
FSH and LH < 5; perform MRI, if negative = hypogonadotropic hypogonadism -> anorexia or bulimia, chronic illness (liver dz, renal dz, DM, IBD, depression), cranial radiation ,excessive exercise, malnutrition, sheehans
416
Is hirsutism always pathologic
No; can be familial
417
What tests you should order in patients with hyperandrogenism
17-OH progesterone, 24 hr fre urinary cortisol or overnight dexamethasone suppression test, prolactin and TSH, glucose and lipid, testosterone and DHEA-S levels ( if >7000 suspect adrenal androgen producing tumor; if total testosterone >200 suspect ovarian androgen producing tumor)
418
What is polymenorrhea
Normally frequent menses; < 21 days
419
What is menorrhagia
Excessive and/or prolonged bleeding (>80 ml and >7 days) occuring at normal intervals
420
What is metrorrhagia
Irregular episodes of uterine bleeding
421
What is menometrorrhagia
Heavy and irregular uterine bleeding
422
What is intermenstrual bleeding
Scant bleeding at ovulation for 1 or 2 days
423
What is oligomenorrhea
Menstrual cycles >35 days but less than 6 months
424
What is DUB
Abnormal uterine bleeding that cannot be attributed to meds, blood dyscrasias, systemic dz, trauma, organic conditions (pregnancy, fibroids, polyps, adenomyosis, cancer); usually caused by aberrations of HPO axis
425
What is PALM COEIN
Causes for bleeding in reproductive age women
- Structural causes (PALM): polyp, adenomyosis, leiomyoma, malignancy
- nonstructural causes (COEIN): coagulopathy, ovulation dysfunction, endometrial, iatrogenic (IUD), not yet classified.
426
What tests should you order for someone with DUB
Pregnancy, CBC, vWF, PT PTT, TSH, chlamydia
| If indicated transvaginal US, saline infusion sonohysterography, MRI, hysteroscopy
427
How do you treat DUB (AUB)
If massive bleeding: hospitalization and transfusion, 25 mg IV conjugated estrogen then hormonal tx (combo hormonal therapy mirena)
If moderate bleeding: combination OCP, mirena
If unresponsive to conservative therapy: D&C, polypectomy, myomectomy, endometrial ablation, hysterectomy
428
What are the congenital anomalies of the vulva
Clitoromegaly, clitoral agenesis (secondary to failure of genital tubercle to form), bifid clitoris, midline fusion of labiasacrotal folds, cloaca (no definite separation btw vagina and bladder)
429
What is female pseudohermaphroditism
Caused by masculinization in utero of female fetus; CAH, ingestion of exogenous hormones, androgen secreting tumors of mother’s adrenal or ovaries; clitoromegaly, hypospadiac urethra meatus, and malpositioned vaginal orifice; internal organs normal
430
What is male pseudohermaphroditism
Results from mosaicism and can occur with varying degrees of virilization and mullerian development; ex: androgen insensivitivy syndrome
431
What is androgen insensitivity
Caused by genetic deficiency in androgen receptors; 46 XY, results in external female development, X lined recessive, testes undescended; mullerian inhibition substance produced high results in lack of uterus or Fallopian tubes
432
What is true hermaphroditism
Male and female eternally and internally;
433
How do you treat labial agglutination
Estrogen cream and masssage to separate
434
What is fox-fordyce dz
Severe pruritic raised yellow retention cyst in axilla and labia majora & Minora resulting from keratin plugged inflammation of apocrine glands
435
What are inclusion cysts of the vulva
Located beneath epidermis and are mobile, nontender, spherical and slow growing; most require no tx; develop when hair follicles become obstruction and the deeper portion swells to accommodate the desquamated portion
436
What are lentigo and nevi
Lentigo are freckles and nevi are moles; Need to distinguish from melanoma
437
What are urethral caruncles
Small fleshy red outgrowth at distal edge of urethra; children caused by spontaneous prolapse of urethral epithelium, postmenopausal women is secondary to contraction of hypoestrogenic vaginal epithelium resulting in everting of urethral epithelium
438
What is vulvar vestibulitis (adenitis)
One or more of minor vestibular glands becomes infected; erythematous dots that are extremely tender; severe dyspareunia and vulvar pain; rx: topical estrogens/hydrocortisone or surgical therapy
439
What is a sebaceous cyst
Caused by inflammatory blockage of sebaceous gland ducts; small smooth nodular masses on inner surface of labia minora/majora; contains cheesy sebaceous material
440
What is a fibroma
Most common benign solid tumor of vulva; can become huge
441
What is a hidradenoma
Lesion arising from sweat gland of vulva
442
What is a syringoma
Eccrine gland tumor
443
What are the traumatic lesions of the vulva
- vulvar hematomas: close observation
- female genital circumcision
- obstetric related trauma
444
What is atrophic vaginitis
Minora regresses and majora shrinks; loss of vaginal rugae, vaginal introoitus constriction; rx: topical estrogen, oral estrogen
445
What is the dif btw bx of lichen simplex chronicus (SC hyperplasia) and lichen sclerosis
SC hyperplasia: elongated rete ridges and hyperkeratosis; acanthosistx with steroid ointment and antiprurtic agent
Lichen sclerosis:think epithelium, loss of rete ridges and inflammatory cells lining BM; hyaline zone in superficial dermis; tx with clobetasol
446
What is lichen planus
Purplish, polygonal papules that can appear in erosive form; vulvar-vaginal-gingival syndrome; vulvar burning, severe insertional dyspareunia; treat with topical and systemic steroids
447
How is psoriasis inherited
AD; on vulva appears velvety
448
What is pemphigus
Autoimmune blistering dz involving vulvovaginal and conjunctival areas
449
What is bechets syndrome
Involves ulceration in genital, oral ares with uveitis
450
What vulvar issue can you see with crohns
Vulvar ulceration due to fistulization
451
What are decubitus ulcers
Can develop when chronic pressure is applied or secondary to tissue being moist secondary to urinary incontinence
452
What are the congenital anomalies of the vagina
- imperforate hymen
- vaginal septum: transverse (found in upper and middle 3rds of vagina as small sinus tract or perforation) midline longitudinal (creates double vagina - can attach to lateral wall an create a blind vaginal pouch)
- vaginal agenesis
- adenosis
- Gardner’s duct cyst
453
What are urethral diverticula
Small sac like projections in anterior vagina along posterior urethra; can cause recurrent UTI, dysuria; treat with urethral dilation or excision
454
What are inclusion cysts of the vagina
Result from infolding of vaginal epithelium; located in posterior or lateral wall in lower 1/3 of vagina; assoc with gynecological surgery or lacerations from childbirth
455
What do you need to do in a bartholin’s cyst in women >40
Bx to rule out carcinoma
456
What is a bartholin’s gland abscess
Results from blockage and accumulation of purulent material; painful inflammatory mass arises; tx: word catheterization (leave in 4-6 weeks) or marsupiliaztion (creates new duct opening by everting cyst wall onto the epithelial surface when it is sutured with interrupted absorbable sutures)
457
What are the 2 diff types of VIN
Usual (HPV assoc, smoking Nd immunocompromised)
| Differentiated (not assoc with HPV or smoking)
458
What is the treatment for VIN III
Local excision, vulvecotmy, or laser therapy
459
How can vulvar SCC spread
Direct extension, lymphatic emoblization, hematogenous spread
460
How do you treat vulvar SCC
Radical vulvectomy and regional lymphadenectomy; wide local excision of primary tumor with inguinal node dissection +/- preoperative radiation, chemo or both; stage I rarely has positive contralateral nodes; if post op nodes identified, need radiation
461
What is the prognosis for SCC vulvar cancer
State I and II: 60-80%
III: 45%
IV: 15%
462
What is verrucous carcinoma
Variant of SCC; met is rare; lesions are cauliflower like *radiation is contraindicated b/c may induce anaplastic transformation
463
What is the treatment for bathrolins gland caricinoma
Radical vulvectomy and b/l lymphadenectomy w post op radiation; recurrence is common
464
What is basal cell carcinoma of the vulva
Rolled edge ulceration; do not met; wide local excision is adequate
465
What is VAIN
Vaginal intraepithlial neoplasia; related to HPV; asymptomatic, consider when abnormal pap but no cervical lesions; if lesion involves vault, surgical excision needed if multifocal, treat with laser or topical 5FU (if unsuccessful may require vaginectomy)
466
How do you treat carcinoma of the vagina
Radiation or chemoradiation; when lower 1/3 involved, groin nodes should be included in treatment field or be removed; when upper vagina involved, surgical approach is warranted (radical hysterectomy, upper vaginectomy and b/l lymphadenectomy
467
What are the other rare vaginal cancers
- adenocarcinoma: most are met; treat with radical hysterectomy and vaginectomy or radiation
- malignant melanoma; usually in distal anterior wall; poor prognosis
- sarcoma botryoides; surgical resection, chemo and radiation
468
What is the vagina lined by
Nonkeratinized strat squamous
469
What is the normal vaginal pH
3.8-4.2
470
Where should you get a vaginal discharge sample from
Posterior fornix
471
What is the most common type of vaginitis
```
Bacterial vaginosis (caused by gardnerella vaginalis)
*risk: new or mult sex partners, smoking, IUD, douching; sx is odor that gets worse after intercourse
```
472
How do you treat bacterial vaginosis caused by gardnerella
Metronidazole 500 mg BID x 7
473
What is the treatment for vaginal candidiasis
Diflucan;; vaginal application with synthetic imidazoles (miconazole, Texaco azole)
**vaginal pH < 4.5 for infection; estrogen is a risk factor
474
How do you treat vaginal trichomoniasis
Metronidazole; *test partner
Diagnosis: saline wet mount shows motile trichomonads; frothy yellow discharge
475
What does failure of the paramesonephric ducts to fuse lead to
Uterus didelphysis (2 sep uterine bodies with its own cervix, attached Fallopian tube and vagina), bicornuate uterus w rudimentary horn, bicornuate uterus with or without double cervices
476
What does incomplete dissolution of the midline fusion of the paramesonephric ducts lead to
Septate uterus
477
What does failure of formation of Müllerian ducts lead to
Unicornate uterues
478
What are the congenital anomalies of the cervix
Result from malfusion of paramesonephric ducts causing didelphys cervix and septate cervix
479
What is the most common indication for a hysterectomy
Fibroids
480
What are the risk factors for developing fibroids
Increasing age during reproductive years, AA, nulliparity, family hx
481
What can happen to fibroids in postmenopausal patients
Can calcify; during pregnancy can grow or bleed into them
482
What is the most common location of fibroids
Intramural; subserosal can rarely attach to blood supply of omentum and lose uterine connection (parasitic fibroid)
483
What palpatory finding is indicative of leiomyoma
If palpated mass moves with cervix; do US to distinguish btw lateral leiomyomas and adnexal mass
484
What are the medical treatments for leiomyomas
Combination OCP, rings: first line
- progesterone only: depo, mirena
- GnRH agonist: depo-Lupron - can decrease fibroid size in 3 months; usually us to alter route of surgery
485
What are the surgical treatments for leiomyomas
- Myomectomy (hysteroscopic myomectomy for submucosal; laparoscopic or robotic for pedunculated, subserosal, or intramural)
- endometrial ablation
- uterine a embolization: microspheres/polyvinyl alcohol particles introduced into uterine a and occlude the a feeding the fibroid
- hysterectomy: only definitive therapy
486
What is important about what must be considered post myomectomy
If endometrial cavity is entered, must do C section for future deliveries
487
How can you detect endometrial polyps
US, saline hysterosonography or hysteroscopy
488
What do you néed to do to endometrial polyps
Remove them since endometrial hyperplasia can present same way
489
What is a nabothian cyst
Normal variant on the cervix; appear opaque with yellow or blue tint; result from squamous metaplasia in which a layer of superficial squamous cells traps a layer of columnar cells beneath its surface which continue to secrete mucus
490
Are endo or ectocervical polyps more common
Endo (beefy red) ecto are pale
491
What are the classifications of endometrial hyperplasia
Simple w/o atypia (1% progress to CA)
Complex w/o atypia (3%)
Simple with atypia (9%)
Complex with atypia (27%)
492
When do you Need to sample the endometrium in a postmenopausal woman
If an US reveals endometrial lining >4mm
493
How do you treat endometrial hyperplasia
- simple and complex w/o atypia: progestin and resample in 3 months
- simple and complex with atypia: hysterectomy
494
What is the adnexa
Ovaries, Fallopian tubes, upper portion of broad ligament and mesosalpinx
495
What are the functional ovarian cysts
- follicular: lined by granulosa cells; develops when follicle fails to rupture
- corpus luteum cysts: if fails to regress
- hemorrhagic cysts: more likely to cause sx; hemorrhage in corpus luteum
- PCOS
496
What are the characteristics of a theca-lutein cyst
Usually b/l; can develop in patients with high serum hCG (pregnancy, choriocarcinoma, hydatiform mole, ovulation induction with gonadotropins or clomid); regress when gonadotropins fall
497
What is a luteoma of pregnancy
Functional cyst; caused by hyperplastic reaction to theca cells; appears as reddish-brown nodules; surgical resection not indicated; usually regress post partum
498
What are the cysts in PCOS arrested in
Mid antral stage
499
What is the most common benign neoplasm in premenopausal female
Benign cystic teratoma (dermoid)
500
What do each of the epithelial cell tumors resemble
Mucinous: endocervical epithelium
Endometriod endometrium
Serous: Fallopian tube
501
What is the most common epithelial ovarian tumor
Serous cystadenoma; treatment: surgical (cystectomy vs oophorectomy vs hyst w oophorectomy)
502
What is the most common benign solid ovarian tumor
Fibroma
503
What is the rokintanksy protruberance
Solid prominence located at junction btw teratoma and normal ovarian tissue
504
What can rupture of a dermoid cyst lead to
Chemical peritonitis
505
Will serous or mucinous rupture cause more pain
Mucinous
506
What is the management of ovarian neoplasms
No persistent neoplasm should be assumed to be benign without surgical exploration and path exam
-if surgery warranted, collect pelvic washings for cytology exam, obtain frozen section for histo dx
Treatment depends on patients age and desire for fertility
507
How do you mange epithelial benign tumors
Unilateral salpingo-oophorectomy;; if mucinous perform an appendectomy; in young nulliparous can perform cystectomy; in older women, total ab hysterectomy w b/l salpingo-oophorectomy is appropriate
508
How are sex cord stromal tumors treated
Unilateral salpingo-oophorectomy if future pregnancies wanted
509
How are fibromas treated
Remove ovary
510
How do you treat a dermoid cyst
Cystectomy; examine other ovary; copiously irrigate pelvis to avoid chemical peritonitis
511
What is the diff btw hydro and pyosalpinx
Pyo is active infection; hydro is previous infection
512
What is the primary risk factor for ovarian torsion
Ovarian mass >5cm
513
What is used to diagnose ovarian torsion
US; definitive with direct visualization
Treat with detorsion and ovarian conservation with an ovarian cystectomy; salpingitis-oophorectomy performed if ovary is necrotic or suspect malignancy
514
What does HC therapy provide
Hormone regulation and pregnancy protection
515
What are the estrogenic forms of MHT
- estradiol: tablet or ring (acetate) cypionate (injection)
- conjugated estrogens: derived from pregnant mares
- esterified estrogens: combination of Na estrone sulfate and sodium equilin sulfate
- estropipate: crystalline estrone solubilized with sulfate and stabilized with *piperazine
516
What are the available progestinic components of MHT
- medroxyprogesterone: alone or with conjugated estrogen
- methyltestosterone: alone or with EE
- progesterone: alone
517
What are the effects of estrogen only therapy
Deceased produciton of cholesterol, anti-thrombin III, osteoclast activity
Increased production of triglycerides, HDL, clotting factors, platelet aggregation, sodium/fluid retention, thyroid binding globulin
518
What were the objectives of hormone trials of WHI
Examine MHTs beneficial or preventative affects on heart dz, osteoporosis related fractures, and risk of various cancers
519
What are the harms and benefits of combined estrogen and progestin therapy
- harms: breast cancer, coronary a dz, dementia, GB dz, stroke, venous thromboembolism, urinary incontinence
- Benefits: diabetes, all fractures, colorectal cancer
520
What are the harms and benefits of estrogen only therapy
- harms: dementia, GB dz, stroke, venous thromboembolism, urinary incontinence
- benefits: breast cancer decrease, decrease in all fractures, decrease in diabetes
521
What was the summary message from the WHI study
MHT very effectively minimizes/treats vasomotor symptoms and vaginal changes and their assoc complications; MHT should NOT be used to prevent CVD or dementia
522
What women are at increased risks of dementia from MHT therapy
>65
523
What are the 5 major points of agreement on MHT
- for younger women: MHT is acceptable (up to age 59 or within 10 years of menopause)
- for women with vaginal sx only: low doses of vaginal estrogen preferred
- for women with a uterus: combined therapy
- for women at risk of blood clots/stroke:both estrogen alone and estrogen with progestin will increase risk (risk is less if 50-59)
- for women at risk of breast CA: seen within 3-5 years of continuous estrogen with progestin therapy
524
What are SERMs and TSECs
- SERMS: selective estrogen receptor modulators: beneficial pro estrogenic actions in some tissues with beneficial anti estrogenic affects in other tissues
- TSECs: tissue selective estrogen complexes: combines elements of SERM with an estrogen compound
525
What are the SERM drugs
ospemifene and clompiphene
526
What is the TSEC drug
bazedoxifene
527
What are the SERM indications
Ospemifene used to treat moderate to severe dyspareunia MOA: estrogen agonist in vagina but anti estrogenic on breast; no known risk of endometrial cancer but still used with caution
528
What are the side effects of ospemifene
Worsening of hot flashes, coagulation, endometrial thickening and hyperplasia
529
What are the contraindications to ospemifene
Unusual or abnormal vaginal bleeding, thromboembolic dz, estrogen related neoplasia
530
What are the indications for TSECs
Bazedozifene (with conjugated estrogen) for women with intact uterus; treatment of moderate to severe vasomotore sx assoc with menopause, prevention of post menopausal osteoporosis
531
What is the MOA of bazedoxifene
Antagonistic activity in endometrium and breast tissue but also estrogenic affects in bone; does not stimulate endometrial proliferation; destroys HER2 malignant cells, less vaginal bleeding than CE with progestin therapy
532
What are the side effects of bazedoxifene
Estrogen related effects; can worsen hot flashes; contraindicated in all situations that estrogen are
533
What is an anti estrogen
Clomiphene; indications: infertility in anovulatory women; MOA: blocks inhibitory actions of estrogen on hypothalamus GnRH and pituitary gonadotropin release; dosed orally btw cycle days 5-9
534
What are the side effects of clomiphene
Multiple births, ovarian cysts (ovarian cancer with prolonged use), hot flashes, luteal phase dysfunction
535
What are the trimesters of pregnancy
First: first day of last menstrual period (FDLMP) - 13 weeks + 6days
Second: 14 weeks-27 weeks + 6 days
Third: 28-42 weeks
536
What is the estimated date of confinement
40 weeks after FDLMP
537
What is preterm delivery
20-36 weeks + 6 days
538
What are postdates
>42 weeks
539
What should you test on every women who presents with vaginal bleeding
Pregnancy
540
At what level of HCG can you see a gestational sac with transvaginal US
1500-2000; fetal pole seen around 5 weeks at HCG levels of 5200; not always exact (ie: multiple gestation)
541
What does an abnormal rise in HCG of less than 53% in 48 hrs confirm
Abnormal IUP or ectopic
542
What is biochemical pregnancy
Presence of HCG 7-10 days after ovulation but in whom menstruation occurs when expected
543
What indicates a drop in risk of fetal loss
If US reveals live appropriately grown fetus at 8 weeks gestation with cardiac activity
544
What is a spontaneous abortion
Loss before 20 wks; less than 500 grams; most occur in first trimester; 45 XO most common cause; trisomy 16 is most common trisomy
545
What are the types of spontaneous abortions
- threatened: vaginal bleeding and closed cervix; treatment is expected management
- inevitable: vaginal bleeding and cervix partially dilated; loss is inevitable
- incomplete: vaginal bleeding, cramping, dilated cervix; passage of some but not all of products of conception; treatment is D&C
- complete: passage of all products (fetus and placenta) with a closed cervix; no treatment needed
- missed: fetus has expired and remains in uterus; no sx; coagulation problems may develop (check fibrinogen weekly until SAB occurs or proceed with D&C); expectant management or misoprostol or D&C
- septic: fever, uterine and cervical motion tenderness, purulent discharge, retained infected products; start IV abx (amp, gent, or clind), suction D&C
- blighted ovum: anembryonic gestation; sac too large to not have embryo
- induced or elective
546
What is anembronic gestation
Fertilized egg develops a placenta but no embryo; treatment: expectant and medical management (misoprostol), D&C
547
What is the definition of recurrent abortions
3 successive SAB (excluding ectopic and molar)
548
What are general maternal factors that can cause recurrent abortions
- Infection: mycoplasma, chlamydia, listeria, toxoplasma
- smoking and ETOH
- medical disorders: diabetes, hypothyroidism, SLE, antiphospholipid ab syndrome, hypercoagulability; factor V Leiden, antithrombin III, protein C and S; prothrombin G20210A, ANA, anticardiolipin ab, methylene tetrahydrofolate reuctase
- maternal age
549
What are the local maternal factors responsible for recurrent abortions
- uterine abnormalities
- cervical incompetence: usually seen with 2nd trimester loss; painless dilation and delivery; risk: uterine anomalies, previous trauma, hx of conization; treat with cervical cerclage
550
What should you test in for in the parents if there are recurrent abortions
Karyotype: may be Ariel’s of chromosomal translocation (robertsonian)
551
What are the immunologic factors that can cause recurrent abortion
-antiphospholipid syndrome: most common; test lupus anticoagulant, anticardiolipin abs, anti-B2 glycoproteins I; treat with prophylactic dose of heparin and low dose aspirin
552
What do you see on the US of a POSSIBLE ectopic pregnancy
Thickened endometrial stripe (arias Stella reaction), rarely see ectopic pregnancy
553
What findings on US would suggest a probable ectopic
Variable amounts of fluid in cul de sac; may see ectopic
554
What are the PE findings of ruptured ectopic
Distance and acutely tender ab; cervical motion tenderness, diaphroesis, tachycardia;; US reveals empty uterus with significant amount of free fluid
555
What is the protocol for transvaginal US for dx of ectopic pregnancy
If doesn’t detect anything, closely follow with serial HCG and repeat US when HCG is within discriminatory zone
556
How do you manage an unruptured ectopic pregnancy
Methotrexate (folic acid antagonist which inhibits DNA synthesis and replication); check HCG levels on day 4 and 7; if HCG levels decrease by 15% continue to follow weekly until negative; if plateau or fall slowly, give another dose; if patient becomes sx or HCG increase, surgical intervention; tell patients to avoid folate cotaining vitamins
557
What are the contraindications to methotrexate
- absolute: IUP, breastfeeding, overt immunodeficiency, alcoholism, chronic liver dz, blood dyscrasias (bone marrow hypoplasia, thrombocytopenia, anemia), acute pulm dz, PUD, hepatic/renal dysfunction, ruptured ectopic or hemodynamically unstable, non compliant patient
- relative: gestational sac >3.5 cm, embryonic cardiac motion, HCG levels > 6000
558
Can some ectopics resolve spontaneously
Yees
559
What is the surgical management of ectopic pregnancy
Laparotomy is preferred if hemodynamically unstable; laparoscopy for stable patients; salpingectomy recommended if significant damage to tube, salpingostomy (incision made parallel to axis of tube and incision left open to heal by secondary intention (better result in long term tube function), salpingotomy (incision is sutured closed)
560
After surgical intervention for ectopic, what should you do
Repeat HCG titer in 3-7 days
561
Abs to what antigen most commonly cause rhesus Isoimmunization
D *caucasians most at risk
562
What can rhesus Isoimmunization cause
Hydrosphere fetalis from CHF and intrauterine fetal death
563
What do you give to prevent RH Isoimmunization
Prophylactic Rh immuno globulin (RhoGAM)
564
What is fetomaternal hemorrhage leading to Isoimmunization
Most commonly from routine uncomplicated vaginal deliveries; increased risk with C section, placenta previa or abruption and manual extraction of placenta; some occur in antepartum period (threatened abortions, ab trauma, ectopic, ob procedures - CVS, amino, external cephalic version)
565
When do you give anti-D IG
At 28 weeks and within 72 hours after delivery of an Rh+ infant or with any other factor that could increase fetomaternal hemorrhage
566
What is the kleinhauer-Betke test
Identifies fetal RBCs in maternal blood; determines if additional RHoGAM needed
567
What is the protocol for Rh testing
Test all pregnant women; if Rh neg and positive for anti-D abs, test dad; if dad is negative then dont do anything; if dad is homozygous -> plan to administer treatment; if heterozygous -> must test via cell free fetal DNA in maternal plasma or invasively with fetal antigen testing (amnio)
568
What do maternal Rh ab titers measure
Estimates severity of fetal hemolysis; if less than 1:8 - fetus not in serious jeopardy and recheck every 4 weeks; if >1:16 requires further evaluation (US and Doppler of middle cerebral a - *peak systolic velocity in MCA is most valuable tool for detecting fetal anemia) perform every 1-2 weeks from 18-35 weeks if >1,5, need to do percutaneous umbilical blood sampling and give intrauterine transfusion if needed
569
What is amniotic fluid spectrophotometery in Isoimmunization
Amniotic bilirubin measured but can make fetomaternal transfusion worse
570
What is the management of Isoimmunization
Severe: Hct <30% or 2 SD below mean; intrauterine transfusion btw 18-35 weeks using group O Rh - cells; if <20 weeks, intraperitoneal transfusion; intravascular into umbilical v preferred; repeat 1-3 weeks
Also do serial growth scans q 3-4 weeks; after 35 weeks, risk of intrauterine transfusion is great so deliver
571
What are the highest risk HPVs
16 18 31 45
572
What are the risk factors for cervical neoplasia
Multiple sex partners, young age at first intercourse, smoking, HIV, organ transplant, STI, DES, infrequent pap, high parity, low SES
573
What are the Pap smear screening guidelines
21-29: cytology every 3 years
30-65: HPV and cytology every 5 years
65 and older: no screening if negative prior screening
574
What are the epithelial cell abnormalities
Squamous: Atypical squamous cells: of undetermined significance, cannot exclude high grade, LSIL, HSIL, SCC
Glandular: atypical (endocervical, endometrial, glandular), adenocarcinoma (endocervical, endometrial, extrauterine)
575
How do you manage women with atypical squamous cells of undetermined significance on cytology
HPV testing is preferred -> if neg repeat in 3 years; if positive manage same as LSIL -> colposcopy
OR repeat cytology at one year; if neg, routine screening; if >ASC, colposcopy
576
How do you manage women with LSIL
If LSIL with neg HPV -> preferred repeat contesting at 1 year; if cytology and HPV neg, repeat testing at 3 years; if ASC or HPV positive -> colposcopy
If LSIL with no HPV test or HPV positive -> colposcopy
577
How do you manage women with HSIL
Immediate loop electrosurgical excision or colposcopy
578
What should you look for on colposcopy
Acetowhite changes, punctuations, mosaicism, abnormal vessels, masses (in order of severity of dz)
579
What are the treatment options for cervical lesions
- ablative: destroys tissue; cryotherapy or laser
| - excisional: cold knife cone (CKC) or loop electrode excisional procedure (LEEP)
580
When do you use excisional techniques for cervical lesions
If endocervical curettage positive (needs cold knife cone), if unsatisfactory colp (no SCJ), if substantial discrepancy btw pap and bx (ie: high grade pap and neg colp)
581
What are the risks of excisional procedures
Increased risk of cervical incompetence and resultant second trimester pregnancy loss, increased risk of preterm premature rupture of membranes (PPROM), cervical stenosis, operative risk
582
What are the sx of cervical cancer
Watery vaginal bleeding, postcoital bleeding, intermittent spotting *staged clinically (PE, radiologic exams, IV pyelogram, cystoscope, sigmoidoscopy, liver fxn)
583
How is cervical cancer treated
- microinvasive: cold knife cone or hysterectomy
- invasive: radical hysterectomy with LN dissection
- bulky dz: radical hysterectomy with LN dissection or radiation therapy and cisplatin based chemo
- stage IIb and greater: external beam radiation and concurrent cisplatin based chemo
584
What is brachytherapy
Insertion of radioactive implant directly into tissue for treatment of cervical cancer
585
How is the HPV vaccine administered
First dose, second dose 2 months later, 3rd dose 6 months from first
586
What ages can receive the HPV vaccine
9-45; not if pregnant
587
What does the 9 strain vaccine cover
6,11,16,18,31,33,45,52,58
588
What are the side effects of HPV vaccine
Syncope, dizziness, nausea, HA, fever, injection site reactions
589
What are some preconception care examples
- start folic acid supplementation 1 month before conception; .4 mg normally, but if hx of previous child with defects, 4.0 mg
- adequate glucose control in diabetic patients
590
What is parity
Number of pregnancies that led to a birth at or beyond 20 weeks or an infant weighing more than 500 grams; broken down into FPAL: full term, preterm, abortions, living
591
What are normal PE findings in pregnancy
Systolic murmurs, exaggerated splitting and S3, palmar erythema, spider angiomas, linea nigra, striae gravidarum, Chadwick’s sign
592
When are prenatal labs done
At first visit; CBC, type and screen, rubella (vaccination postpartum if not immune), syphilis, hep B surface Ag, HIV, cervical cytology and gonorrhea/chlamydia, screen for DM based on risk factors (obesity, hx of gestational DM, or macrosoma), urine culture
593
What are common lab values in pregnancy
- albumin decreased by 20 weeks
- calcium gradual fall
- chloride: no change
- creatinine: decreased by 20 weeks
- fibrinogen: increased
- fasting glucose: gradual fall
- potassium: fall by 20 weeks
- protein:: fall by 20 weeks then stable
- sodium: decreased by 20 weeks then stable
- BUN: decreased in first trimester
- uric acid:: decreased in first trimester then rise at term
594
What changes will you see in urine chemistry during pregnancy
Creatinine - no change
Protein: increased to 250-350/day
Creatinine clearance: decreased
595
What serum enzyme differences will you see in pregnancy
```
Amylase: increased
Transaminases: no change
Hematocrit: decreased by 30-34 weeks
Hemoglobin: decreased by 30-34 weeks
Leukocyte count: increased
Platelets: slight decrease
Factors 7-10 increase
```
596
How do you confirm pregnancy
Serum HCG: <5 negative; >25 positive; >100 reached by time of expected menses
- most urine HCG can detect >25
- transvaginal US: gestation sac seen at 5 weeks; fetal pole at 6 weeks (5200 HCG), cardiac activity at 7 weeks (17500 HCG)
597
How do you estimate gestational age and due date
Subtract 3 months + 7 days = expected due date;; only useful if 28 day cycles; PE size of uterus; US: crown rump length btw 6-11 weeks can estimate w/in 7 days; at 12-20 weeks measure femur length, biparietal diameter, and ab circumference can estimate within 10 days
598
What can diagnose fetal demise
If CRL >5mm with no cardiac activity
599
Who needs genetic counseling
Advanced maternal age (35 and up), previous child/family hx of birth defects, previous child with undiagnosed mental retardation, previous baby who died in neonatal period , multiple fetal losses, abnormal serum marker screening, consanguinity, maternal conditions, exposure to teratogens, abnormal US findings, parent who is known carrier
600
What are examples of AD disorders
Tuberous sclerosis, NF, achondroplasia, Craniofacial synostosis, adult onset polycystic kidney dz, MD
601
Who is offered CF screening
All pregnant women, people with family hx, partners of known CF carriers, parents with US findings of echogenic bowel, sperm donors and any patient who request
602
What is the most common inherited form of mental retardation
Fragile X; X linked
603
What is the first trimester screening for aneuploidy
- fetal nuchal translucency thickness (echo free area at back of neck btw 10-14 wks) - increased thickness assoc with chrom and congenital anomalies
- maternal serum b-human chorionic gonadotropin
- pregnancy assoc plasma protein A
* elevated beta HCG and low PAPP-A assoc with downs
604
What is the second trimester screen for aneuploidy
Triple screen: beta HCG,estriol, and maternal serum alpha feta protein; btw 16-20 weeks
Quadruple screen: beta HCG, estriol, AFP, and inhibin A; higher rate of detection of downs
605
What can elevated HCG or AFP and low PAPP-A be linked to
Preterm birth, intrauterine growth restriction, preeclampsia
606
What is noninvasive prenatal testing
9-10 weeks; tests cell free fetal DNA; does not test for open neural defects (monitor with maternal AFP or US)
* order only in high risk patients (advanced maternal age, hx of prior pregnancy with trisomy, family hx of chrom ab, fetal US ab, positive serum screening) if positive, proved with invasive test (amnio)
607
When are amnio or chorionic villi sampling done
Second trimester amnio: 16-20 weeks; CVS: 11 weeks (higher rate of miscarriage risk)
608
What did thalidomide cause
Phocomelia
609
When is the fetus most suceptible to teratogens
Day 17-56 post conception; after 4th month, teratogens usually cause restricted growth (with exception of brain and gonads)
610
What are some teratogenic agents
- Anti anxiety: meprobamate or clordiazepoxide; use fluoxetine instead
- antineoplastic: aminopterin and methotrexate (folic acid antagonists): exposure before 40 days is lethal; later causes IUGR, Craniofacial ab, mental retardation, miscarriage, stillbrith and neonatal death; alkylating (busulfan, chlorambucil, cyclophosphamide) - intrauterine growth restriction, death, cleft palate, limb reduction and poorly developed external genitalia
611
What are the features of fetal alcohol syndrome
Growth restriction, facial abnormalities (low set ears, smooth philtrum, thin upper lip, shortened palpebral fissures, flat midface), CNS dysfunction (microcephaly, mental retardation, and behavior disorders)
612
What anticoagulants are teratogenic
Coumadin: crosses placenta - spontaneous abortion, intrauterine growth restriction, CNS defects, still birth, fetal warfarin syndrome
*heparin does not cross placenta
613
Which anticonvulsants are teratogenic
- Diphenylhydantoin (Dilantin): fetal hydantoin syndrome - Craniofacial ab, limb reduction, growth restriction, mental deficiency, CV anomalies
- valproic aid: spina bifida
- carbamazepine: spina bifida; fingernail hypoplasia
- phenobarbital neonatal withdrawal and hemorrhage
614
What malformations can accutane cause
CNS (hydrocephalus, facial n palsies, cortical blindness), CV, Craniofacial defects (microcephalic with severe ear ab, microtia and cleft palate)
615
What does smoking interfere with in utero
Growth
616
What can early exposure to CMV in utero cause
Proptosis, triangular shaped mouth, depressed nasal bridge
617
What is the critical period where radiation can be most teratogenic
2-6 weeks post conception; if before 2 weeks either lethal or no effect at all; less than 5 rads of exposure = no risk
618
How can you control N/V of pregnancy
Eat small but frequent meals, avoid greasy fried foods, room temp soda and saltine crackers, accupuncute, meds (antihistamines, vit B6, antiemetic)
619
What causes heartburn in pregnancy
Relaxation of esophageal sphincter by progesterone; treatment do not lie down immediately after meals, elevate head of bed, eat smaller more frequent meals, antacids, H2 blocker
620
How can you treat bachace in pregnancy
Avoid excess weight gain, exercise, comfy shoes, use of pillows while sleeping, heat, massage
621
How often do pregnant women see the doc
Every 4 weeks until 28 weeks, every 2 weeks from 28-36 weeks, weekly until delivery
622
What is done in routine office visits for pregnant women
BP, weight (BMI <19 recommended weight gain is 28-40 lbs, 19-25: 25-35, >25: 15-25), urine protein, measurement of uterine size (20 weeks at umbilicus), fetal heart rate (Doppler at 12 weeks; fetoscope 18-20 weeks), fetal movement (first sensation known as quickening and occurs at 20 weeks), educate on preterm labor, discuss lifestyle situations (encourage ambulation), near term evaluate fetal lie and position
623
What screenings do you do throughout pregnancy
- 20 weeks: fetal survey US
- 28 weeks: gestation DM, repeat hbg and hct; rhogam injection to Rh neg, Tdap btw 27-36wks
- 35 weeks: group B strep carrier with vag culture - treat in labor if positive
624
What is included in assessment of fetal well being
- kick counting: 10 moments in 2 hours
- nonstress test: reactive - 2 accelerations of at least 15 beats above baseline lasting at least 15 seconds during 20 min of monitoring (if not reactive, contraction stress test or biophysical profile)
- contraction stress test: give oxytocin to establish at least 3 contractions in 10 min period; i late decelerations, delivery is warranted
625
What are the scores of the biophysical profile
- 8-10 is reassuring
- 6 is equivocal; delivery if patient is at term
- 4 or less: non reassuring, consider delivery
626
What is labor
Progressive cervical dilation resulting from regular uterine contractions occuring at lest every 5 min and lasting 30-60 seconds
*false labor: irregular contractions without cervical change
627
What presentations occur along which axes
- suboccipitobregmatic: had well flexed
- occipitofrontal: head deflected, occiput posterior
- supraoccipitomental: brow presentation - longest anteriorposterior diameter of head
- submentobregmatic: face presentation
* avg circumference measured in occipitofrontal plane is 34.5 cm
628
What is a gynecoid pelvic shape
Classic (50%); round at inlet, wide transverse diameter; wide suprapubic arch (>90 degrees); head generally rotates into occiput anterior position; good prognosis for delivery
629
What is an android pelvic shape
Male type of pelvis; widest transverse diameter is closer to sacrum; prominent ischial spines, narrow pubic arch; fetal head is forced to be in occiput posterior; arrest of descent is common; poor prognosis for delivery
630
What is an anthropoid pelvic shape
Resembles ape pelvis; larger anteroposterior than transverse; long narrow oval shape; narrow pubic arch; fetal head engages only anterioposterior diameter; usually in OP position; prognosis for delivery is good
631
What is the platypelloid pelvic shape
Flattened gynecoid pelvis; short AP and wide transverse diameter, wide bispinous diameter, wide suprapubic arch; fetal head has to engage transverse diameter; poor prognosis for delivery
632
What is assessed in clinical pelvimetry
- diagonal conjugate: from inf pubic symphysis to sacral promontory; if >11.5 cm, AP diameter is adequate
- obstetric conjugate: subtract 2 cm from diagonal conjugate; narrowest fixed distance through which the fetal head must pass
- pelvic outlet: measure ischial tuberosties (8.5 is adequate) and pubic arch
- infrapubic angle: put thumbs on pubic ramus and estimate angle; >90 is good
633
What is fetal lie
Reference is maternal spine to fetus spine; determines if infant is longitudinal, transverse or oblique
634
What are Leopold maneuvers
- palpate fundus: fetal head vs butt vs transverse
- palpate for spine and fetal small parts
- palpate what is presenting in pelvis with suprapubic palpation
- palpate for cephalic prominence (can feel chin or occipital protruberane if head is not deep in pelvis)
635
What is done in the cervical exam during labor
- dilation: at internal os
- effacement: thinning of cervix - reported as % of change in length
- station: degree of descent of the presenting part of the fetus; measured in cm from presenting part to ischial spines; when bone portion of head reaches level of ischial spine station is 0
- consistency and position: calculate bishop score
636
What are the stages of labor
- first: onset of true labor to complete cervical dilation
- second: complete cervical dilation to delivery
- third: delivery of infant to delivery of placenta
- fourth: delivery of placenta to stabilization of patient
637
What are the latent and active phases of the first stage of labor
- latent: early; period btw onset of labor; slow cervical dilation
- active: faster rate of dilation and begins when cervix is dilated to 4cm; admit for labor at this stage in term gestation
* this stage lasts 6-18 hrs in primiparas (1.2 cm per hour dilation) and 2-10 hrs in multiparas (1.5 cm per hour dilation)
638
What is the management of the first stage of labor
- maternal position: may ambulated if head is engaged and reassuring monitoring; if lying in bed, encourage left lateral recumbent
- fluids: IV used to hydrate
- labs: CBC and T&S
- maternal monitoring: vitals q1-2 hrs
- analgesia: provided adequate analgesia
- fetal monitoring: external continuous, intermittent if uncomplicated (q 30 min in active, q 15 in second stage), if complicated ( q 15 during active and q 5 during second stage); internal most accurate
- uterine activity: external tocodynomameter; internal pressure cath (helpful w/ oxytocin augment)
- vag exam: q 2hrs during active; record dilation/effacement/station
639
What are the benefits and risks of an amniotomy
Benefits: augments labor, allows assessment of meconium status
Risks: cord prolapse, prolonged rupture assoc with chorioamnionitis
640
What is the duration of second stage of labor
- primipara w/o epidural: 2 hrs
- primipara w epi: 3 hrs
- multi w/o epi: 1 hr
- multi w epi: 2 hrs
641
What are the cardinal movements of labor
- engagement: presenting part at zero station
- descent: force of uterine contraction and maternal valsalva
- flexion: OA: baby’s chin to chest - changes presentation to suboccipitobregmatic
- internal rotation: ischial spines; fetal head enters pelvis in transverse diameter and rotates so occipit turns anteriorly or posteriorly toward pubic symphysis
- ext: crowning occurs when largest diameter of fetal head is encircled by vaginal introitus; station is +5
- ext rotation: delivered head returns to its original position to align with fetal back
- expulsion anterior should delivers under pubic symphysis
642
What is the management of second stage of labor
- maternal position: avoid supine, dorsal lithotomy position
- bearing down: with each contraction mother should hold breath and bear down
- fetal monitoring: continuous
- vag exam: assess descent and confirm position
- delivery of fetus: usually RN x2, physician, and med tech, drape under butt, antiseptic soap cleanse vulva, modified ritigen maneuver performed sometimes, once head is delivered bulb suction oral cavity then nares, assess for cord
643
What are the indications for episiotomy
Likelihood of spontaneous laceration high; expedite delivery
- midline: most common; greater risk of extension; less postpartum pain
- mediolateral: greater blood loss, more difficult to repair, more postpartum pain, increase risk of dyspareunia
644
What is a modified Ritgen maneuver
Fingers of right hand are used to extend the head while counterpressure is applied to occiput by left hand to allow for more controlled delivery; simple manual support to perineum can be equally efffective
645
What are the categories of perineal lacerations
- first degree: superficial involving vaginal mucosa or perineal skin
- second: extends into mm of perineal body but does not involve anal sphincter
- third: extends through anal sphincter but not into rectal mucosa
- fourth: involves rectal mucosa
646
What is retained placenta
If placenta has not delivered within 30 min
647
What are the signs of placenta separation
Gush of blood from vag, lengthening of umbilical cord, fundus of uterus rises up, change in shape of uterine fundus from discoid to globular
*DO NOT pull on cord until classic signs are noted - can cause uterine inversion
648
What is the management of third stage of labor
Look for lacerations of cervix, vagina and perineum; monitor uterine bleeding; repair episiotomy or spontaneous lacerations, inspect placenta for completeness
649
What do you do during the fourth stage of labor
Vitals (BP and pulse), uterine fundal checks and assess for vag bleeding, postpartum hemorrhage commonly occurs during this time (uterine atony, retained placenta, unprepared vaginal or cervical laceration)
650
What is labor augmentation
Artificial stimulation of labor that has already begun
651
What are indications for induction of labor
Abruptio placentae, chorioamnionitis, fetal demise, preeclampsia/eclampsia, gestational HTN, premature rupture of membranes, postterm pregnancy, maternal medical conditions, fetal compromise (isoimmunization, severe intrauterine growth restriction, oligohydromnios)
652
What are the contraindications to induction of labor
Unstable fetal presentation, acute fetal distress, placental previa, previous classical C section or transfundal uterine surgery (myomectomy), any contraindications to vaginal birth (HIV with high viral load, active HSV)
653
What is a Bishop score
Takes into account cervical dilation (closed (0), 1 (1-2cm), 2 (3-4), 3 (>5), effacement 0(0-30), 1(40-50, 2 (60-70), 3 >80), station 0(-3), 1(-2) 2 (-1-0) 3 (>1), cervical consistency 0 firm 1 med 2 soft and position (posterior (0) midline (1) anterior (2)
Score < 6 is unfavorable
> 8 probability of vaginal delivery after induction is similar to spontaneous labor
654
What is used for cervical ripening
- cervidil (dinoprostone): PGE2; vaginal insert; contraindicated in previous c section
- cytotec (PGE1): orally or vaginally; cannot be readily removed if concerns arise; contraindicated in previous c section
- mechanical dilators: foley bulb or laminara japonicum
655
What are the complications of pitocin
- uterine tachysystole: more than 5 contractions in 10 min
- andidiuretic effect: can lad to water intoxication and convulsions and coma
- uterine m fatigue: increased risk of post partum hemorrhage
656
What is a side effect of regional anesthesia during labor
Decreases blood flow to uterus; give adequate hydration 30-60 min before; if hypotension does occur give vasoppresor (ephedrine)
657
What pain pathways are involved in labor Nd delivery
Uterine contractions: T10-L1 - visceral pain
Descent of head: somatic pain S2-4
Regional anesthesia applied below T10
658
What parenteral anesthesia options are available during labor
Morphine, fentanyl, meperidine, nalbuphine; more effective in early first stage; opioids cross placenta (can lead to resp depression)
659
What are the regional anesthesia options
Bupivicin or lidocaine + narcotic (fentanyl)
-epidural: most effective; catheter placed in epidural space btw L2-3 3-4 or 4-5
Spinal: single shot analgesia which provides excellent pain relief for limited procedures 30-250 min
660
What are the side effects of regional anesthesia
Spinal HA, fever, spinal hematomas and abscesses
661
What are the contraindications to regional anesthesia
Maternal coagulopathy, heparin use w/in 12 hrs, untreated maternal bacteremia, increased ICP caused by mass lesion, skin infection over site of needle placement
662
What are the local anesthesia options
- local infiltration of perineum: lidocaine; 20-40 min; used before episiotomy or with laceration repairs; toxic effects (hypotension, seizures, cardiac arrhythmias - more common with intravascular lesions so aspirate for blood before injecting)
- pudendal block: aids operative vaginal delivery in women who do not have regional anesthesia; complications - intravascular injection, hematomas and infections
663
Can you use inhaled anesthetics for labor and delivery
No; assoc with neonatal resp distress
664
What is external fetal monitoring
- Doppler US transducer placed on abdomen overlying fetal heart
- pressure sensitive tocodynanmometer transducer: detects and records contractions; useful for measuring frequency but not strength
* may not accurately record information if mother is obese
665
What is internal electronic fetal monitoring
- Fetal scalp electrode: rate is computed from R wave peaks of fetal ekg; maternal and fetal movement doesn’t alter quality; avoid in HIV patients
- intrauterine pressure catheter: soft plastic catheter placed transcervically; gives precise measurement of intensity of uterine contractions in mm of mercury
* requires membranes to be ruptured
666
What pH is considered fetal acidosis
<7.2; fetal scalp blood usually btw 7.25-7.3
667
What is seen on the fetal monitoring strip
Upper tracing shows HR; lower tracing shows uterine contractions
668
What are Montevideo units
Strength of contractions; add them in 10 min period for at least 2 hours; >200 is adequate for labor to progress
669
What is a normal baseline FHR
110-160; tach > 160; Brady <110
| *assessed btw contractions
670
What are causes of Brady and tachycardia in a fetus
- Brady: fetal hypoxia (late sign), obstetric anesthesia, pitocin, maternal hypotension, prolapsed or prolonged compression of umbilical cord, heartblock
- tachy: fetal hypoxia (early), meds (oxytocin excessive), arrhythmias, prematurity, maternal fever, fetal infection *chorioamnionitis is most common cause
671
What is baseline variability
Fluctuations in baseline FHR that are irregular in amplitude and frequency; measure peak to trough in bpm; absent (amplitude range undetected), minimal (amplitude range <5 bpm), moderate (normal; 6-25), marked (>25)
672
What is decreased variability indicative of
Possible fetal stress; ominous if assoc with persistent late decelerations; assoc with hypoxia and acidemia
*caused by: prematurity, sleep cycle, maternal fever, fetal tach, congenital anomalies, maternal hyperthyroidism, maternal drugs or substances
673
What is no change fetal heart rate
FHR maintains the same characteristics during contraction as in preceding baseline FHR
674
What is acceleration FHR
Abrupt increase in FHR; normal reassuring response
- >32 weeks, HR of >15 bpm above baseline for 15 sc or more by < 2 min
- <32 weeks, HR >10 bpm above baseline for 10 sec or more but < 2 min
675
What is prolonged acceleration FHR
Lasts >2 min; if >10 min, considered change in baseline
676
What are causes of accelerations
Spontaneous fetal movement, scalp stimulation or vibroacoustic stimulation, vaginal exam
677
What are early decelerations
Secondary to head compression (increased ICP); not assoc with fetal distress; same time as peak of contraction
678
What are variable decelerations
Secondary to umbilical cord compression (compresses umbilical vessels which activates baro and chemo receptors); abrupt decrease in FHR; before, during or after contraction; decrease in FHR is >15 bpm lasting >15 sec <2 min; dept and duration can vary with successive contractions
679
What is a “shoulder”
If slight compression of the umbilical cord, obstruction of umbilical v will occur; this returns reoxygenated blood to fetal heart; initial response is increase in FHR, if this is followed by a major drop in FHR, it’s called a shoulder
680
What are late decelerations
Caused by uterine placental insufficiency (UPI); *most ominous deceleration; repetitive late decelerations indicate fetal metabolic acidosis and low arterial pH; occurs after peak of contraction
Causes: excessive uterine activity, maternal supine hypotension
681
What are prolonged decelerations
Decrease in FHR from baseline >15 bpm lasting >2 min but <10 min; disruption of oxygen transfer; commonly seen during maternal pushing; change in baseline if lasts more than 10 min
682
What is a sinusoidal pattern of FHR
Smooth, sine wave undulating pattern; seen with fetal anemia
683
What is category I of FHR classification
Baseline 110-160; moderate variability, no late or variable decelerations, accelerations and early decelerations can be present; normal tracing
684
What is category II of FHR
- Intermittent variable decelerations (<50% of contractions) - no intervention required
- Recurrent variable decelerations (>50%): could indicate umbilical cord compression; reposition, amnioinfusion (instillation of normal saline to alleviate cord compression), modification of pushing efforts (push with every other contraction)
- min or absent variability, recurrent late decelerations, prolonged decelerations, tach or Brady, variable, late or prolonged decelerations during pushing: goal is to promote fetal oxygenation (lateral position, IV fluid bonus, O2, modification of pushing efforts, decrease in oxytocin rate, discontinuation of oxytocin) *look in chart for causes
- tachysystole: lateral positioning, IV bonus, decreased oxytocin rate, if no response give uterine tocolytic (terbutaline)
685
What is category III
Absent baseline variability, recurrent late or variable decelerations, Brady:increased risk of fetal academia
Sinusoidal pattern: increased risk of hypoxemia and acidemia
*prepare for delivery: reposition mother, IV bolus, O2, scalp stimulation test, if no improvement and scalp stimulation test does not result in acceleration, delivery advisable
686
What is fetal scalp stimulation
When scalp is stimulated and acceleration of 15 bpm lasting 15 sec occurs,the pH is >7.22; *useful to determine fetal sleep from acidosis
687
What is the criteria for gestational DM screening
- 50 gm one hour oral glucose tolerance test (>130-140 abnormal)
- may perform earlier in people at risk
- if abnormal follow by a 3 hour 100 gm OGTT (fail 3 hour with 2 or more ab values)
688
What are the maternal complications of gestational DM
Increased risk of gestational HTN, preeclampsia, C section, diabetes later in life
689
What are the fetal complications of GDM
Macrosomia, neonatal hypoglycemia, hyperbilirubinemia, operative delivery, shoulder dystocia, birth trauma
690
What is the antepartum management of GDM
Diabetic teaching, blood glucose monitoring, fetal testing weekly, US for estimated fetal weight (if >4500 gm recommend C section), if everything is controlled, can wait for spontaneous labor
691
What is the intrapartum management of GDM
- if controlled with diet, frequent monitor of blood glucose
- if on meds: hourly glucose monitoring (keep btw 80-120); insulin drip
- continuous fetal monitoring in labor
692
What are the maternal and fetal complications of pre-gestational diabetes
Maternal: worsening nephropathy and retinopathy, increased risk of preeclampsia, greater risk of DKA
Fetal: increased risk of spontaneous abortions, anatomic birth defects (sacral agenesis and cardiac), fetal growth restriction and prematurity
693
What are the classes of diabetes of pregnancy
- A1 gestational diet controlled
- A2: gestational insulin or oral med controlled
- B: pre-gestational; onset age 0 or older or duration less than 10 yrs
- C: onset age 10-19 or duration of 10-19 years
- D: onset before age 10 or duration >20 years
- F: diabetic nephropathy
- R: proliferative retinopathy
- RF: retinopathy and nephropathy
- H: ischemic heart dz
- T: prior kidney transplant
694
What is the management of gestational diabetes
Consult maternal fetal medicine specialist and nutritionist; fasting glucose <95, 2 hr postprandial <120, insulin is first line; exercise for half hour after meals
695
What is the antepartum management of preexisting diabetes
- maternal evaluation: 24 hr urine collection every trimester, ekg, detailed eye exam in first trimester, daily finger stick blood glucose values and HgBA1C)
- fetal evaluation: early US, detailed fetal anatomy US including fetal echo, biochemical testing for congenital malformations in first trimester 11-13 weeks or quad screen at 16-21 weeks , fetal growth US q 2-4 wks, fetal testing every week starting 32 weeks
* delivery options depend on estimated fetal weight and glycemic control
696
What is the postpartum management of diabetes
Insulin requirements drop off after delivery of placenta; GDM usually no further treatment (need 2 hr OGTT 6-12 weeks postpartum)
697
What are the treatments for maternal hyperthyroidism
PTU (only in 1st trimester; can cause liver toxicity) and methimazole (in 2nd and 3rd trimester - cancause aplasia cutis and choanal atresia in 1st)
698
What are the fetal affects of maternal hyperthyroidism
Meds can cross placenta and cause fetal hypothyroidism and goiter; increased risk of prematurity, IUGR, preeclampsia and stillbirth
699
How do you treat thyroid storm in a pregnant woman
High mortality rate; beta blockers, block secretion of thyroid hormone with sodium iodide; stop synthesis of thyroid hormone with PTU, halt peripheral conversion of T4 with dexamethasone, replace fluid loss, bring temp down
700
What is neonatal thyrotoxicosis
Due to transplacental transfer of thyroid stimulating abs; transient; mortality rate is 16%
701
What is neonatal hypothyroidism
Caused by thyroid dysgenesis, inbobrn erros of thyroid function, drug induced
702
What cardiac diseases can affect pregnancy
- rheumatic heart dz: mitral stenosis; high risk of developing HF, subacute bacterial endocarditis, and thromboembolism
- primary pulmonary HTN: contraindicated in pregnancy; epidural anesthesia is preferred and vaginal delivery may be an option
- cardiac arrhythmias: most common SVT - usually benign; afib/flutter more worrisome
- postpartum cardiomyopathy:no underlying dz; develops within last week of pregnancy or within 6 months postpartum, women with preeclampsia, HTN and poor nutrition at risk *mortality rate 10%
703
What is the management of cardiac dz in a pregnant woman
* all pregnant patients with heart dz need a cardiologist
- ekg and echo
- avoid excess weight and edema: low sodium, rest in left lateral position, adequate sleep
- avoid strenuous activity
- prevent anemia
- avoid infection
- anticoagulation (mech valves/afib)
- fetus needs echo
704
What is the delivery management for patients with cardiac dz
Should be delivered vaginally unless obstetric indications, pushing may need to b e avoided in second stage operative vaginal delivery, strict fluid management, abx prophylaxis for endocarditis in high risk patients (prosthetic valves, unrepaired heart dz, previous hx of endocarditis)
705
What is immune idiopathic thrombocytopenia
Igs attach to maternal platelets; can be confused with gestational thrombocytopenia; treatment: begun after platelets drop to 50,000; prednisone; IV Ig if severe, platelet transfusion, splenectomy; neonatal thrombocytopenia can occur
706
What is the effect of SLE on pregnancy
Can either improve or worsen it; flares are treated with prednisone;
-fetal complications: preterm delivery, fetal growth restrictions, stillbirth, miscarriage; *10% risk for neonatal lupus passive transfer of anti-Ro/SSA or anti-la/SSB
707
How do you treat antiphospholipid ab syndrome during pregnancy
Heparin/low molecular weight heparin and low dose aspirin; if hx of thrombosis - full anticoagulation
708
What do you do to manage renal disorders during pregnancy
-urine output BUN:Cr, fractional excretion of sodium, urine osmolality
-CV studies: in labor, may need swan ganz cath
-urologic studies: foley cath, renal US to dx obstructive source
Treatment:
-prerenal: restore volume
-renal:diuretic therapy, fluid restriction, hemodialysis
-post-renal: left lateral position, urethral cath, surgical intervention
709
What should you do for chronic renal failure in a pregnant patient
- serum Cr >1.5-2 worsens prognosis
- monitor 24 hr urine collections for protein and creatinine clearance
- manage HTN
- fetal surveillance w/growth US and nonstress/biophysical profiles
710
Is pregnancy recommended post renal transplant
No; may lose graft function or experience rejection; best candidates are 1-2 years post transplant with stable Cr and proteinuria w/o severe HTN
-fetal complications: steroid induced adrenal and hepatic insufficiency, prematurity, IUGR
711
What are the complications of pyelonephritis in a pregnant women
Preterm labor and increased uterine activity, adult respiratory distress syndrome; treat with IV hydration (but not aggressive b/c increased risk of pulmonary edema), abx, antipyretic, tocolytics if needed, suppression for remainder of pregnancy
712
What is hyperemesis gravidarum
Persistent N/V assoc with >5% loss of pre-pregnancy weight, ketonuria, dehydration; cause unknown; more common in first pregnancy, multi pregnancies, and trophoblastic dz
Treatment: IV fluids, electrolytes, glucose, vitamins and antiemetic; if severe:NG tube or parental nutrition
713
What are the effects of pregnancy on PUD
May improve condition; dx based on sx (endoscopy reserved only if severe); treatment avoid caffeine, spicy foods; antacids, H2 blockers/PPI, abx for H pylori
714
What is mendelsons syndrome
Acid aspiration syndrome; preg women at greater risk b/c delayed gastric emptying and increased pressure; can result in adult resp distress syndrome
Treatment: O2, maintain airway; prevention: decrease acid in stomach, do not feed in labor
715
What is the effect of IBD on pregnancy
Usually fine; can increase risk of miscarriage if flare during conception; treatment is same as nonpregnant
716
What is intrahepatic cholestasis of pregnancy
-cholestasis and pruritic in 2nd half or pregnancy; can recur with each pregnancy; assoc with OCP and multi gestation; increased risk of meconium stained amniotic fluid and fetal demise
-labs: reveal elevated serum bile acids
Treatment: cold baths, bicarbonate washes, ursodeoxycholic acid, fetal surveillance and delivery at early term
717
What are the sx of acute fatty liver of pregnancy
Ab pain, N/V, jaundice, irritability, polydipsia/pseudodiabetes insipidus, HTN, proteinuria
Lab: increased PT and PTT, elevated bilirubin, ammonia and uric acid, elevation of transaminases
718
What is the treatment for acute fatty liver of pregnancy
Termination;; supportive care: IV fluids with 10% glucose, blood product replacement (FFP and cryoprecipitate); if survive, fully recover
719
What is anemia of pregnancy
Physiologic decrease in HbG/hct
-hct <30% or HgB <10; most common reason is iron deficiency; screen at initial prenatal visit and 26-28 weeks; treat with iron supplement oral or IV
720
When is the greatest risk for thrombosis
5 weeks postpartum
721
What is the treatment for superficial thrombophlebitis
Bed rest, pain meds, local heat, no anticoagulants, wear support hose
722
What is the treatment for DVT during pregnancy
Low molecular weight heparin or unfractionated heparin - follow aPTT values with heparin and factor Xa to assure therapeutic levels
-Coumadin used for 6 weeks postpartum but not during pregnancy
723
What do patients with venous thrombosis or PE require
Thrombophilia workup: lupus anticoagulant, anticardiolipin ab, factor V Leiden, protein C and S, antithrombin III, prothrombin G20210A
724
What is the most common pulm dz in pregnancy
Asthma; severe asthma assoc with miscarriage, preeclampsia, intrauterine fetal demise, IUGR, preterm delivery
Treatment: same as in non pregnant
Fetal monitoring: serial growth US, NSTs/biophysical profiles, deliver for fetal growth restriction or maternal deterioration
Labor and delivery: stress dose of IV steroids if using daily inhaled or high potency oral for more than 3 wks
725
What are the most common type of HA seen in pregnant women
Tension; treat with acetominophen
| Migraines usually improve during pregnancy
726
How does MS effect pregnancy
Usually improves, may exacerbate postpartum increased risk of low birth weight and C section
727
What are the seizure treatment guidelines for pregnant patients
If seizure free for at least 2 years, may be able to discontinue prior to conception
-monotherapy should be attempted at lowest dose
*need to be on folic acid
Complications: preeclampsia, placental abruption, hyperemesis, premature labor, intrauterine fetal demise, increased risk of congenital malformations (cleft palate, cardiac)
728
When should you avoid giving antidepressant during pregnancy
1st trimester; if used in 3rd, risk of fetal withdrawal
729
When should you be concerned for postpartum depression
If persists after first 2 weeks; younger women at greater risk; severest form: postpartum psychosis
730
What are the categories of operative delivery
Vaginal: forceps assisted, vacuum extracted
| C section
731
When should you perform an operative vaginal delivery
Only if there is immediate ability to do C section if procedure fails
732
What are the maternal indications for a operative vaginal delivery
Maternal exhaustion, inability to have exclusive effort (SC lesion, NMJ disorders), Need to avoid maternal expulsive effort (aortic stenosis, aneurysm, brain tumor)
733
What are the teal indications for operative vaginal delivery
Non-reassuring fetal status (Brady, repetitive heart rate decelerations)
Other: prolonged 2nd stage of labor: nulliparous - >2 hours without region or >3 hrs with; multiparous - >1hr w/o regional or 2 hr w
734
What is the maternal and fetal criteria for operative vaginal delivery
- maternal: adequate analgesia, lithotomy position, bladder empty, verbal or written consent
- fetal: vertex presentation, fetal head must be engaged (at 0 station), position of fetal head must be known with certainty, station of fetal head must be >+2
735
What is the uteroplacental criteria for operative vaginal delivery
Cervix fully dilated, membranes ruptured, no placenta previa
736
What are the piper forceps used for
Breech baby
737
What is an outlet operative vaginal delivery
Scalp visible at introitus w/o separating labia; fetal skull reaches pelvic floor; Sagittal suture is in AP diameter or right or let occiput anterior or posterior position; fetal head is at perineum; rotation ones not exceed 45 degrees
738
What is a low operative vaginal delivery
Leading point of fetal head is at +2 station or more and is not on pelvic floor
739
What is a midpelvis and high forceps operative vaginal delivery
Fetal skull is above +2 station, *not ever indicated today
740
What are the clin pearls for application of forceps
- If not positive of position, dont apply
- if dont articulate easy, reapply; if still dont, dont apply
- always check that no vag tissue or cervix is caught in forceps
- check placement before applying traction: blades should fit fetal head evenly, should lie against fetal head so that they cover space btw orbits and ears
- traction applied in plane of least resistance and follows pelvic curve
741
What are the complications of forceps delivery
- maternal: laceration of vagina/cervix, episiotomy extension, pelvic hematomas, urethral and bladder injuries, uterine rupture
- fetal: facial lacerations, forcep marks, facial and brachial plexus injuries, skull fractures, intracranial hemorrhage, seizures
742
What are the indications for vacuum assisted vaginal delivery
Same as forceps; *advantage: delivery can be archived with little maternal analgesia
743
What are the contraindications to vacuum assisted vaginal delivery
Gestational age <34 weeks, suspected fetal coagulation disorder, suspected fetal macrosomia, breech presentation
744
What is the correct placement of the vacuum
Posterior fontanelle; called flexing median
745
What should you be aware of when doing vacuum assisted delivery
- no maternal tissue trapped in cup, placed in midline of sagittal suture, vacuum port should point toward occiput
- release suction btw contractions
- no more than 2 pop offs
- should not be applied more than 20 min
- no torsion or twisting of device during use
746
What are the complications of vacuum delivery
More failed deliveries with vacuum than forceps; fewer perineal injuries, increased incidence of fetal cephalohematoma, more scalp lacerations and bruising
747
What are the indications for c section
- fetal: non reassuring FHR, breech/transverse presentation, very low birth weight <1500, active HSV, immune thrombocytopenia purpura, congenital anomalies (gastroschisis, spina bifida)
- maternal-fetal: cephalopelvic disproportion, failure to progress, placental abruption, placenta previa
- maternal: obstructive benign and malignant tumors, large vulvar condyloma, ab cervical ceerclage, prior vaginal colporrhaphy, conjoined twins, maternal request
748
What are the c-section intraoperative complications
Uterine a laceration, bladder injuries, ureteral injuries, GI injury, uterine atony, placenta accreta, cesarean hysterectomy
749
What are the post op complications of a c section
Endomyometritis (infection of uterus), wound infection separation or dehiscence, urinary complications (retention, infection), GI complications (ileus, diarrhea), thromboembolic disorders (PE, DVT), septic pelvic thrombophlebitis (infected blood clot of ovarian v usually)
750
What is preterm birth
After 20 weeks but before 37; uterine contractions accompanied by cervical change or dilation of 2 cm and/or 80% effaced
751
What are the risk factors for preterm labor
AA (decrease access, high stress, poor nutrition), previous PTL, hx of second trimester abortion, repeated spontaneous 1st trimester abortion, bleeding in 1st trimester, UTI/genital tract infection, multiple gestation, uterine anomalies, polyhydramnios, incompetent cervix
752
What are the 4 pathways targeted to prevent PTL
Infection, placental-vascular, psycho social stress and work strain, uterine stretch
753
What is the infection pathway
Bacterial vaginosis can cause preterm delivery; treat women in preterm labor with abx (group B strep), treat gonorhea or chlamydia
754
How does assessment of the cervix reduce PTL
US for routine screening of cervical length to assess risk (especially if had LEEP/CKC); also can use fetal fibronectin (released from BM of fetal membranes in response to disruption of membrane)
755
How does stress induce PTL
Cortisol stimulates early placental CRH which assists labor at term; catecholamines can cause uterine contractions by affecting blood flow
756
When is the uterine stretch pathway a risk factor for PTL
Polyhydramnios, multiple gestation
757
What is the management of PTL
Cervical exam, evaluate for underlying correctable problems such as infection, external monitoring for uterine activity and FHR, reevaluate cervix at an hr, oral or IV hydrate (can resolve contractions), culture for group B strep, start empiric penicillin, CBC, urinalysis and urine culture, US
758
When can you begin tocolysis
If diagnosed 2 cm and/or 80% effaced or made cervical change; if gestational age is less than 34 weeks and no contraindication;
- magnesium sulfate (drug of choice) IV; competes with calcium for entry; continue therapy (IV) until received both doses of steroids *neuroprotection; give if at risk of delivering within 7 days
- nifedipine
- prostaglandin synthetase inhibitors (indomethacin)
759
What are the side effects of magnesium sulfate
Feeling of warmth and flushing, NV, resp depression, cardiac conduction defects and arrest
Neonate: loss of m tone, drowsiness, low apgar scores
760
What is nifedipine
Oral agent; minimal side effects; inhibits slow inward current of calcium during 2nd phase of AP; may replace magnesium as drug of choice
761
What is prostaglandin synthetase inhibitor
Inhibits prostaglandins that induce contractions; used on short term basis - mostly for extreme prematurity; oral or rectal administration; can result in oligohyramnios (decreases renal function), premature closure of fetal ductus arteriorsus resulting in pulm HTN and heart failure; greater risk of necrotizing enterocolitis and intracranial hemorrhage
762
What are NSAIDs used for
Decrease uterine activity; not for primary treatment fo PTL; used when dont meet requirement of PTL or after discontinuining magnesium
763
When can you give glucocorticoids
24-34 weeks gestation; 2 doses of betamethasone 24 hrs apart or 4 doses of dexamethasone q 12 hrs; can give rescue dose if more than a week
*a single course of betamethasone is recomended for women btw 34 and 36 6/7 wks at risk of preterm birth within 7 days who have not received previous course of corticosteroids
764
What are the prevention interventions for PTL
IM progesterone weekly from 16-36 weeks in women with previous hx of PTL/PPROM
Vaginal progesterone: in women its shortened cervix <2. 5 cm
Pessary-Arabin Pessary: in women with short cervix
765
What are the risk factors for PRROM
Vaginal/cervical infections, abnormal membranes, incompetent cervix, nutritional deficiency
766
What should you NOT do in a patient with presumed PROM
Do not check cervix - increases risk of infection; rupture confirmed using sterile speculum
767
What is used to confirm PROM
Pooling, nitrazine paper (turns blue) ferning; can also use US
768
What are the causes of false positive and negative nitrazine results
Positive: urine, semen, cervical mucous, blood, vaginitis
Negative: remote PROM with no remaining fluid, minimal leakage
769
What does the management of PPROM depend on
- gestational age: if <24 wks may lead to pulm hypoplasia and structural abnormalities
- amniotic fluid index< 5 cm is oligohydramnios
- fetal status
- maternal status
770
What is the conservative management of PPROM
Do vaginal pool of amniotic fluid to assess maturity; most will deliver at 34 weeks regardless of maturity (earlier if chorioamnionitis), abx (48 hrs of IV amp and erythromycin/azithromycin followed by 5 days of amoxicill and erythromycin, can or cannot use tocolytics, can use steroids up to 34 wks
771
How is a dx of chorioamnionitis made
Maternal temp >100.4, fetal or maternal tachycardia, tender uterus, foul smelling amniotic fluid/purulent discharge
772
How do you test for fetal lung maturation
Phosphatidylcholine (lecithin), phosphatidylinositol (PI)
and phosphatidylglyerol (PG)-
-L/S ratio (lecithin to sphigomyelin): lecithin increase after 35 weeks but sphingo stays the same - is affected by blood or meconium
-if PG present considered mature - not affected by presence of blood or meconium
773
What is the rapid test for fetal lung maturity
Lamellar body number density assessment
774
What is the definition of IUGR
When birth weight of newborn is below 10% for a given gestational age
At risk for: meconium aspiration, asphyxia, polycythemia, hypoglycemia, mental retardation, adult onset HTN, diabetes, atherosclerosis
775
What are the maternal causes of IUGR
Poor nutrition, low maternal weight, smoking, drug use, alcoholism, cyanotic heart dz, pulm insufficiency, antiphospholipid, hereditary thrombophilia, collagen vascular dz
776
What are the placental causes of IUGR
Insufficient substrate transfer through placenta or defective trophoblast invasion, conditions that can result in placental insufficiency (HTN, renal dz, placental cord ab ie velamentous cord, diabetes)
777
What are fetal causes of IUGR
Inadequate or altered substrate, intrauterine infections, listeriosis, TORCH, congenital anomalies, multiple gestation, chrom ab
778
What is primary screening tool for IUGR
Serial fundal height measurement; if lags more than 3 cm behind gestational age then order US (used for HTN, renal dz, diabetes, drugs, antiphospholipid, lupus)
779
What is the management of IUGR
-pre-pregnancy: optimizing dz process
-antepartum: decrease modifying factors (improve nutrition, stop smoking, bed rest); deliver before fetal compromise but after lung maturity
Monitor: non-stress test twice weekly, biophysical profile, Doppler studies of umbilical a
780
What are the components of the biophysical profile
- nonstress test
- fetal breathing movements: one or more episodes of rhythmic movements of 30 sec or more within 30 min
- fetal movement: 3 or more discrete body or limb movements within 30 min
- fetal tone: one or more episodes of extension of fetal extremity with return to flexion or opening and closing of hand
- determination of amniotic fluid volume:single vertical pocket of amniotic fluid exceeding 2 cm is adequate *regardless of composite score, amniotic volume <2 need further evaluation
781
What is a Doppler study of the umbilical artery used for
Umbilical flow velocity waveform of a normally growing fetus shows high velocity diastolic flow whereas IUGR there is diminution of umbilical a diastolic flow
782
What is the management of IUGR
If suspect IUGR:
- US normal -> no intervention
- US shows IUGR and >38 wks: deliver
- US shows IUGR and <38 weeks begin antenatal testing; if normal continue pregnancy, if abnormal deliver
783
Do IUGR require C section
Not always; after birth, monitor glucose (have less hepatic glycogen stores), monitor resp status b/c ARDS more common
784
What is post term pregnancy
Past 42 weeks; higher perinatal mortality; postmaturity syndrome: related to infarction of placenta; loss of subcutaneous fat, long fingernails, dry and peeling skin and abundant hair; at risk for macrosomia (>4500 gm), abnormal labor, shoulder dystocia and c section
785
What are the cause of postterm pregnancy
Fetal adrenal hypoplasia, anencephalic fetus, placental sulfatase def (x linked), extra-uterine pregnancy
786
What is the management of post term pregnancy
- in 41st week, begin antenatal testing to include twice weekly NST and biophysical profile, if ab or oligohydramnios induce labor
- in 42 week: induce labor
* prefer to induce at 41 week
787
What is intrauterine fetal demise
Fetal death after 20 weeks but before onset of labor
788
What is the management of intrauterine fetal demise
- watchful xpectancy: only up till 28 weeks; spontaneous labor will occur within 2-3weks
- induction of labor: more require cervical ripening
- monitoring of coagulopathy:risk of DIC; follow CBC, fibrinogen, PT/PTT/INR
789
What is included in follow up for intrauterine fetal demise
Search for cause: TORCH, parvovirus, listeria, anticardiolipin, fetal chrom, fetal autopsy
790
What are the risk of hypertensive dz in pregnancy
- maternal risks: MI, cardiac failur, CVA, renal failure, hepatic failure
- Fetal complications: IUGR, preterm birth, placental abruption, stillbirth, neonatal death
791
What are the blood pressure guidelines in pregnancy
Normal <120/80; elevated systolic 120-129 and diastolic <80
-stage I: systolic 130-139 or diastolic 80-90
-stage II: systolic 140 or greater or diastolic 90 or greater
Hypertensive crisis: systolic >180 and/or diastolic >120
792
What are the classifications of HTN in pregnancy
- chronic: present before or recognized during first half of pregnancy
- gestational: recognized after 20 weeks
- preeclampsia: after 20 weeks with proteinuria
- eclampsia
- superimposed preeclampsia/eclampsia: transposed onto chronic HTN
793
What evaluations should you do for chronic HTN
CBC, glucose, CMP, 24 hr urine for total protein, EKG
| Growth US monthly after 28 weeks; antepartum fetal testing btw 32-34 weeks
794
What is the management of mild chronic HTN
<160/110; antiHTN if reach threshold value; prenatal visits every 2-4 weeks until 34-36 weeks and then weekly; antepartum fetal monitoring; delivery btw 39-40 wks
795
How do you manage severe chronic HTN
>160/110 antiHTN (methyldopa, labetalol, nifedipine) *NO ACE INHIBITORS; if assoc renal dz, 24 hr urine q trimester; growth US q3-4 weeks, NST; delivery after 38 wks
796
What are the features of gestational HTN
Occurs after 20 weeks or within 48-72 hrs after delivery; resolves by 12 weeks postpartum
797
What are the sx of preeclampsia
Scotoma, blurred vision, epigastric or RUQ pain, HA
798
What are the risk factors for preeclampsia
Age <20 or >35; primigravid, multi gestation, hydatiform mole, diabetes, thyroid dz, chronic HTN, renal dz, collagen vascular dz, antiphospholipid ab, prior hx of preeclampsia
799
What effects does preeclampsia have on different organs
- brain: edema; fibrinoid nencrosis, microinfarcts
- heart: third spacing reduction in circulating blood volume
- lungs: noncardiogeenic pulm edema; changes in colloid osmotic pressure
- liver: sinusoidal fibrin deposition; subcap hematoma -> liver rupture; stretching of glissons capsule -> RUQ pain
- kidneys: swelling of glomerular cap; narrowing of cap lumen
- eyes: retinal vasospasm, retinal edema
800
What is mild vs severe preeclampsia
- mild: BP >140/90 but <160/110; proteinuria >300/24hr but <5gms/24 hr or single specimen urine protein:Cr .03; asymptomatic
- severe: >160/110 on 2 occasions 4 hrs apart; proteinuria of at lest 5gm/24 hr or 3+ protein on 2 random urine dips at least 4 hrs apart; oliguria <500 ml in 24 hrs; renal insufficiency Cr>1.1; sx
801
What exam findings can you see with preeclampsia
Brisk reflexes, clonus, edema; increased hct, LDH, transaminases and uric acid; thrombocytopenia
802
How do you manage mild preeclampsia
- <37 weeks: bed rest; once BPP or twice NST weekly antepartum testin; fetal growth US q3-4 weeks
- >37 wks: if favorabl cevix - induction, if not, use cervical ripening agent
803
How do you manage severe preeclampsia
Immediate hospitalization; deliver if >34 weeks; give hydralazine, labetalol or nifedipine; if <37 weeks administer corticosteroids and work towards delivery
804
What is the intrapartum management of preeclampsia
Vaginal delivery preferred; magnesium sulfate administered for seizure prophylaxis (4 gm bolus, maintainance dose of 2 gm/hr, monitor urine output and reflexes; therapeutic level btw 5-9 *dont get above 7-8 or can have loss of patellar reflexes, resp paralysis or cardiac arrest) - give calcium gluconate to reverse if give too much, pain management unless thrombocytopenia, fluid restriction to prevent overload
805
How do you manage seizures during eclampsia
Protect airway; magnesium sulfate; lorazepam if persistent; not indication for c section but emus may need some in utero resuscitation time
806
What do you do if someone has HELPP
Immediate delivery
807
What is uterus contraction via relaxation controlled by
- relaxation factors that increased cAMP
| - contraction: increase intracellular calcium; promote interactio of actin and myosin; gap junctions
808
What changes occur to the uterus during labor
Two segments form
- upper: actively contracts and retracts to expel fetus
- lower: becomes thinner and passive
809
What changes occur to the cervix during labor
Changes from firm, intact sphincter to soft structure; result of collagenolysis, increase in hyaluronic acid, decrease in dermatan sulfate (favors increased water content)
810
What are the abnormalities of labor
Protraction: slower than normal rate
Arrest: complete cessation of progress
Dysfunctional: rates of dilation and descent exceed times of normal labor patter
811
What does an arrested latent phase imply
Labor has not begun
812
What are abnormalities of the latent phase
Normal limits: nulli (20hrs), multi (14 hrs); prolonged latent phase has little effect on mortality; causes: most are patients who have entered labor w/o substantial cervical change; excessive use of sedatives or analgesics, fetal malposition
813
How do you manage abnormalities of latent phase
Therapeutic rest (sleep), morphine - can help progression, or aid in diagnosis of false labor
814
What are the abnormalities of the active phase
Normal limits: nulli (cervical dilation of 1.2 cm); multi (1.5cm/hr); if less than norm, protraction disorder of dilation of active phase; if 2 or more hours elapse with no cervical dilation -> arrest of dilation
-normal limits of fetal descent; nulli(1cm/hr), multi (2cm/hr); if < protraction of descent; if no change within 1 hr, arrest
815
Can abnormalities of the active phase have increased risk of perinatal mortality
Yes; causes of abnormalities: inadequate uterine activity, cephalopelvic disproportion, fetal malposition, anesthesia
816
What is dystocia
Difficult labor; not progressing; results from abnormalities of: power (uterine contractions or maternal expulsion), passenger (position, size, or presentation of fetus), or passage (maternal pelvic bone contracture); dx not made before trial of labor has been tried
817
When should you consider argumentation
If contractions <3 in 10 mins or intensity is <25
| -oxytocin after assessing: maternal pelvis, fetal position, station, maternal and fetal status
818
What is transverse arrest of descent
Persistent OT position with arrest of decent for 1 hr - occipitofrontal diameter becomes presenting diameter
819
What is the management of persistent OT position
- if pelvis is adequate, infant is not macrosomic, and contractions are inadequate, start oxytocin, rotate either manually or keilland forceps
- if pelvis inadequate or infant deemed to be macrosomic -> c section
820
Women with OP usually have what
More back pain
821
What is large for gestational age
Birth weight >90% for given gestational Ge
822
What about the baby can cause dystocia
Hydrocephalus (can see by US), fetal ascites or enlargement of organs, conjoined or locked twins
823
What are risk factors for macrosoma
Maternal diabetes, maternal obesity, weight gain during pregnancy,multiparity, male fetus, ethnicity, maternal birth weight, maternal height, maternal age <17 years, +50 glucose screen with negative result on 3 hr
824
What are the risks associated with macrosomia
Maternal morbidity: C section postpartum hemorrhage and vaginal lacerations
-fetal morbidity and mortality: fracture of clavicle, shoulder dystocia, damage to ns of brachial plexus (C5-6 erbs) klumpke C8-T1 (lower arm palsy), paralysis of entire arm
825
When do you do a c section for macrosomia
If >5000 gm in nondiabetic patients or >4500 in diabetic patients
826
What is shoulder dystocia
Delivery that requires additional obstetric maneuvers following failure of gentle downward traction on fetal head to effect delivery of the shoulders; caused by impaction of ant fetal shoulder behind the pubic symphysis or impaction of post shoulder on sacral promontory
*turtle sign: retraction of delivered fetal head against maternal perineum
827
What are the risks for shoulder dystocia
- antepartum: macrosomia, maternal diabetes, obesity, post term gestionan, short stature, previous hx of macrosomic birth, previous hx of shoulder dystocia
- during labor: labor induction, epidural analgesia, prolonged labor, operative vaginal deliveries
828
What complications can occur with shoulder dystocia
Brachial plexus injuries, fractured Clavicle or humerus, HIE, death
829
What is the management of shoulder dystocia
- mcrobert’s maneuver: hyperflexion and abduction of maternal hips
- suprapubic pressure: may dislodge impacted anterior shoulder; do not apply fundal pressure
- rotational maneuvers, delivery of post fetal arm, fracturing fetal clavicle
- proctoepisotomy
- zavanelli maneuver: cephalic replacement, last resort; poor prognosis significant risk of fetal mortality
830
What are the diff maneuvers for shoulder dystocia
- Rubin: place pressure on accessible shoulder to push it toward ant chest wall of fetus to decrease bisacrominal diameter and free impacted shoulder
- Wood’s corkscrew: apply prsssure behind post to rotate infant and dislodge anterior shoulder
- zavanelli: last resort; fetal head manually returned to its prerestitution position, slowly replaced i vagina; delivery is by emergent c section
831
Is shoulder dystocia an emergency
Yes; get anesthesiology and NICU; cannot be predicted or prevented; intial maneuvers are mcroberts and suprapubic pressure
832
What are the different placentation of monozygotic twins
- if cleavage 0-3 days: dichorionic, diamniotic; can be 2 separate placentas or 1 fused
- if cleavage in 4-8 days: monochorionic, diamoniotic *most common
- if cleavage in 9-12 days: monochorionic, monoamniotic *most dangerous
- if cleavage >13 days: conjoined twins
833
What is the chance of dizygotic twins influenced by
- maternal age: 2x more common after 35 y/o
- family hx and ethnicity: more common in AA
- most spontaneous twins are dizygotic
834
How do you confirm multiple gestation
US
835
What do monozygotic twins have an increased risk of
Congenital anomalies, weight discordancy, twin-twin transfusion, neuro sequelae, premature delivery, fetal demise
836
How do you determine zygosity
US
- dizygotic: diff fetal gender, visualization of thick amnion-chorion septum, peak or inverted V sign at base of septum
- monozygotic: dividing membrane is thin
* if US is not definitive, inspect placenta after delivery or do DNA analysis
837
What is the most common interplacental vascular anastomoses
Arterial-arterial
838
When does twin twin transfusion syndrome occur
Monochorionic; donor twin: hypovolemic, hypotensive, anemic, oligohydramnios, growth restriction; recipient twin: hypervolemia, polyhydramnios, thrombosis, HTN, polycythemia, edema, cardiomegaly, CHF
839
How do you diagnose twin transfusion syndrome
US; donor twin will be smaller in size “stuck appearance”, oligohydramnios
840
What is the treatment for TTTS
Serial amniocentesis with amniotic fluid reduction
| Laser photocoagulation of anastomoses on the placenta
841
What can arterial to arterial anastomoses in monozygotic twins cause
Thrombosis; acardiac twin
842
What umbilical cord abnormalities can be seen in monozygotic twins
Primarily seen in monochorionic twins; absence of umbilical a
-velamentous umbilical cord insertion - causes growth abnormalities
843
What is retained dead fetus syndrome
- if gestation >20 weeks; can cause DIC in mom - check platelets and fibrinogen levels weekly
- if <12 weeks: reabsorbed “vanishing twin syndrome”
- if >12 weeks: fetus shrinks, dehydrates and flattens - called fetus papyraceus
844
What are the complications of multiple gestation
- maternal: polyhydramnios, anemia, gestational HTN, preeclampsia, diabetes, preterm labor, C section, postpartum hemorrhage, uterine atony
- fetal: malpresenation, placenta previa, placental abruption, PROM, umbilical cord prolapse, IUGR, necrotizing enterocolitis
845
What is the antepartum management of multiple gestation
- first and second trimesters: 2 week office visits; US cervical length assessments
- third trimester: cervical length of 25 mm at 24-28 weeks increases premature birth; serial US to check for intrauterine growth q4-6 weeks - look for discordant fetal growth, NSTs or weekly BPP
846
When should monoamniotic twins be delivered
32 wks; hospitalization at 26 wks, antenatal steroids, FHR several times daily
847
When is the recommendation for delivery of twins
38 weeks if no complications; most deliver at 35-36 wks
848
How are vertex-transverse or vertex-breech presentations delivered
Can be delivered vaginally bt often c section
849
How are breech-breech or breech-vertex twins delivered
Always c section
850
What is the most common fetal malpresesntion
Breech
851
What factors are assoc with breech presentation
Prematurity (*most common), fetal malformations (hydrocephalus and anencephaly), multiple pregnancies, uterine malformations (bicornuate uterus)
Diagnosed by Leopolds maneuver, US and pelvic exam
852
What are the diff breech presentations
- frank: most common; thighs are flexed and LE are extended at knee
- complete: thighs are flexed, LE flexed
- incomplete: 1 or both thighs extended, 1 or both feet below buttocks
853
What is external cephalic version
Applying pressure to mothers abdomen to turn fetus to achieve vertex position *performed in hospital equipped to perform immediate c section
- candidates: 36 wks gestation not in labor
- contraindications: placenta previa, nonreassuring fetal monitoring, oligohydramnios, previous uterine surgery that is contraindicated for vaginal delivery
854
What are the requirements for ECV
Patient NPO for 7hrs, IV access, continuous electronic monitoring, confirm breech presentation with US, consider tocolytics or anesthesia
855
What is the criteria for vaginal delivery of the breech presentation
Fetus must be in frank or complete breech, gestational age >37 weeks, fetal weight 2500-4000 grams, fetal head must be flexed, adequate maternal pelvis, no maternal or fetal contraindications for vaginal delivery, availability of anesthesia and neonatla support, assistant must be scrubbed
856
How do you deliver a breech baby vaginally
One limb at a time, then to delivery head, use force on maxilla to keep head flexed and steady traction
857
What is a brown presentation
When presenting part is btw orbits and anterior fontanelle; presenting diameter is supraoccipitomental; frontal bones point of designation; persistent brow presentation needs c section; but most will convert to vertex
858
What is face presentation
Full extension of fetal head and neck; seen with fetal malformations (anencephaly); fetal chin is point of designation *cannot deliver mental posterior; can deliver mentum anterior
859
What is a compound presentation
When extremity is prolapsed alongside presenting fetal part; premature;
860
What is the most common type of abnormal placentation
Previa; *painless vaginal bleeding
Risk factors: maternal age >35, multiparity, multiple gestation, cocaine use and smoking, prior previa; previous c section
861
Can placenta previa sponteneously resolve
Yes; complete are least likely to resolve
862
What is the management of placenta previa
- preterm pregnacy: if bleeding not profuse, hospital on bed rest;
- deliver via c section at 36-37 wks
- if Rh neg, kleihauer Bette test
- NPO status
863
What is placenta accreta, increta, and percreta
- accreta: firm attachment to superficial myometerium; most common
- increta; invades myometrium
- percreta:through myometrium to serosal surface
864
What is the most common cause of third trimester bleeding
Placental abruption *painful bleeding, uterine tenderness, uterine hyperactivity, fetal distress or death
865
What are the risk factors for placental abruption
Maternal HTN (most common), cocaine, external maternal blunt trauma, polyhydramnios and multiparity, previous abruption
866
What is the management of placental abruption
-if mom and baby stable, can proceed with vaginal delivery
If not, do c section
*most common cause of DIC
867
What is couvelaire uterus
Extravasation of blood into uterus; caused by placental abruption
868
What are the risk factors for uterine rupture
Prior uterine incision (most common), injudicious use of oxytocin, external cephalic version, multiparity
869
What is the management of uterine rupture
Immediate laparotomy and delivery of fetus; repair rupture or do hysterectomy; *future pregnancies must be delivered via c section; upper segment rupture has higher recurrence rate
870
What are the fetal causes of 3rd trimester bleeding
Velamentous insertion of umbilical cord; inserts distance away from placenta and its vessels must traverse btw chorion and amnion without protection of Wharton’s jelly - if unprotected vessels pass over cervical os, called vasa previa *need to diagnose rapidly and proceed to delivery if ruptured
871
What is the definition of postpartum hemorrhage
>500 cc following vaginal birth
>1000 cc following c section
-primary:: within first 24 hrs (uterine atony)
-secondary: 24hhrs-2 weeks (subinvolution of uterus, sloughing of Escher or retained products)
872
What are risk factors for uterine atony
Enlargement, abnormal labor (precipitous, prolonged, augmented), conditions that interfere with contraction (leiomyomas and magnesium sulfate)
873
What is the management of uterine atony
Bimanual massage of uterus (also confirms dx - will feel boggy), oxytocin, methylergonovine (contraindicated in HTN), 15-methyl prostaglandin Fa (contraindicated in asthmatics), dinoprostone, misoprostol, uterine packing or large volume balloon catheter, interventional radiology, surgical
874
What are the risk factors for retained placenta
Previous c section, leiomyomas, prior D&C, accessory placenta lobe
875
What is the treatment for inverted uterus
Anesthesiologist, manually replace uterus, start oxytocin; rarely need laparotomy
876
What is febrile morbidity
Temp >100.4 for more than 2 consecutive days during the first 10 postpartum days; most due to endometritis; after pregnancy, pH of vag becomes more alkaline -> can grow anaerobic organisms (peptostreptococcus, peptococcus, strep, bacterioides fragilis); aerobic (e coli)
877
What are risk factors for developing puerperal sepsis
Poor nutrition and hygiene, anemia, premature rupture, prolonged rupture, prolonged labor, frequent vag examinations during labor, c section, operative vaginal delivery, cervical or vaginal lacerations, manual extraction of placenta, retained products
878
What is the management of puerperal sepsis
Abx should cover anaerobic; continue until afebrile for 48 hrs; ampicillin q hrs + gentamicin q24 hrs *bacterioides is resistant so give clindamycin
879
What are causes of persistent postpartum fever
Infected hematoma, surgical site infection, septic pelvic thrombophlebitis, drug fever
880
What is septic pelvic thrombophlebitis
Endothelial damage, venous stasis, hypercoagulability
- ovarian vein: fever and ab pain within 1 week after delivery; appear clinically ill
- deep septic vein: unlocalized fever in first few days that is nonresponsive to abx; do not appear clinically ill; no radiographic evidence of thrombosis; diagnosis of exclusion
881
How do you treat septic pelvic thrombophlebitis
- anticoagulation with unfractionated heparin or LMW heparin
| - if ovarian v thrombosis seen radiographically anticoagulants for 6 weeks
