GYN-Contraceptives/Pregnancy Flashcards
1
Q
How does Hormonal Contraception function?
A
Inhibits ovulation by inhibiting mid-cycle luteinizing hormone (LH) surge
2
Q
Does hormonal contraception protects against STI?
A
No
3
Q
Oral Contraceptive pills schedule or how to use?
A
Start on 1st day of menses
§ Take daily on schedule, 21-day pill pack + 7-day sugar
4
Q
Types of OCP?
A
Estrogen + progestin or progestin alone (very compliant-becasue has to be taken at same time daily as ovulation can occur)
• Progestin alone safe in breastfeeding, ↓ side effects because
no estrogen
5
Q
Pro’s of OCP’s
A
dysmenorrhea & menorrhagia • improves acne • ↓ PID, ectopic pregnancy • protection against ovarian cancer, endometrial cancer & osteoporosis
6
Q
Cons of OCPs:
A
↑ risk of thromboembolism
• weight gain, nausea, headaches
• ↑ risk of gallstones, hypertension (HTN
7
Q
Implants
A
Etonogestrel (Nexplanon)
• Lasts 3 years
Failure rate 0.05%
8
Q
Injectable
A
Medroxyprogesterone (Depo Provera)
• Q3mo IM injection
• Failure rate 5%
9
Q
Transdermal
A
Norelgestromin (Ortho Evra)
• On 3 weeks, off 1 week
• Failure rate 10%
10
Q
Intravaginal
A
Etonogestrel/Ethinyl estradiol (Nuvaring)
• In 3 weeks, out 1 week
• Failure rate 7%
• Must be removed during intercourse & replaced within 3 hrs
• Must be a very compliant & comfortable with body
11
Q
What is Intrauterine device (IUD)?
A
Mechanism not completely understood; spermicidal, elicits sterile
inflammatory response
o Does not affect ovulation
o Most effective method after sterilization & abstinence
12
Q
What is the increase risk of an IUD?
A
↑ risk insertion-related PID (uterus is sterile but vagina is not sterile?)
13
Q
Does IUD protects against sTI?
A
NO
14
Q
Most effective method after sterilization & abstinence
A
Intrauterine device (IUD)
15
Q
Types of IUD
A
Hormonal and Copper
16
Q
Hormonal IUD?
A
Mirena, Kyleena, Liletta, Skyla)
• 3-6 years of protection depending on type
17
Q
Copper IUD?
A
Paraguard-not hormonal
• 10 years of protection
18
Q
Barrier methods?
A
Male & female condoms; Intravaginal device (diaphragm, sponge)
19
Q
Male & female condoms
A
Female not very widely used
§ STI protection
§ Failure rate average 20%
§ Must know how to properly use
20
Q
Intravaginal device (diaphragm, sponge)?
A
Must be left in place 6-24 hrs post-intercourse § ± STI protection § Failure rate 15% § Used with spermicide nonoxynol-9 § ↑ risk of toxic shock syndrome
21
Q
Emergency Contraception?
A
Progestin-only
Ulipristol acetate
Copper IUD
22
Q
When is progestin hormonal contraception prefer?
A
After pregnancy, estrogen may affect breast milk production and increases risk of thromboemolism (remember pregnancy alone is a risk)
23
Q
Copper IUD
A
Most effective within 5 days of unprotected intercourse
24
Q
Ulipristol acetate
A
30 mg dose
o Prescription only
o Most effective within 5 days of unprotected intercourse
25
Progestin-only
```
1.5 mg dose
o Available over-the-counter (OTC)
o No age restriction
o Most effective within 72 hrs of unprotected intercourse
o Side effect: nausea & vomiting
```
26
Definition of Infertility
failure to conceive after 1 year of regular unprotected intercourse
27
Female causes of Infertility
Anovulatory cycles
● Ovarian dysfunction
● Structural issues
28
Male causes of Infertility
40%
| ● Abnormal spermatogenesis/motility issues
29
Work-up & management of Infertility?
```
Semen analysis
● Endocrine evaluation (thyroid stimulating hormone [TSH], follicle stimulating
hormone [FSH], prolactin)
● Anatomical evaluation (hysterosalpingogram)
● Reproductive assistance
o Clomiphene to induce ovulation
o Intrauterine insemination (IUI)
o In-vitro fertilization (IVF)
```
30
Diagnosis of pregnancy
Serum human chorionic gonadotropin (hCG) can detect pregnancy as early as 5
days post-conception
● Serum levels double every 48 hours in normal pregnancy
● Urine hCG can detect as early as 14 days post-conception
● Naegele rule
o Expected date of delivery (EDD) = 1st day of last menstrual period (LMP) +
1 year - 3 months + 7 days
31
Serum levels hCG doubles every?
48 hrs
32
Maternal physiologic changes
Cardiovascular: ↑ heart rate (HR), ↑ cardiac output (CO), ↑ stroke volume (SV), ↓
blood pressure (BP), ↓ peripheral vascular resistance (PVR)
● Pulmonary: ↑ tidal volume, ↓ expiratory reserve
● Hematologic: ↑ blood volume, ↑ fibrinogen, ↓ hematocrit
● GI: ↑ gastric emptying time, ↓ sphincter tone
33
```
When is (Prenatal care)
First appointment schedule during pregnancy?
```
6-8 weeks, then Q monthly
34
Initial labs of pregnancy for mom? Baby?
Mom: CBC, Rh factor, U/A, STI swab, HIV, Rubella & Hep B titers
Baby; Fetal heart tones by doppler: 10-12 weeks
35
Naegele rule
Expected date of delivery (EDD) = 1st day of last menstrual period (LMP) +
1 year - 3 months + 7 days
36
Pregnancy nutrition?
Prenatal vitamin with folic acid + iron, dietary
calcium, smoking
& alcohol cessation; avoid mercury-containing fish, uncooked food
(goodbye sushi🍣) & unpasteurized cheese (goodbye fancy cheeses
37
When is genetic testing recommended?
Recommended at 9-14 weeks
38
What is tested in genetic testing?
Pregnancy-associated plasma protein A (PAPP-A); Along with nuchal scan & b-hCG levels, can detect genetic disorders
39
Every visit of pregnancy what will be done?
weight, fetal heart tones, fundal height, urine dip for
| glucose and protein
40
When is quad screen done? What is check during quad screen?
15-20 weeks: 𝛂-fetoprotein, 𝛃HCG, estriol, inhibin A
41
Trisomy 21
“2 up, 2 down”: ↑𝛃HCG, ↑ inhibin A ↓ 𝛂FP, ↓estriol
42
Trisomy 18
Trisomy 18 “still underage”: All four low
43
Open neural tube defect:
↑ 𝛂FP
44
Prenatal care at 10 weeks?
Fetal Heart Tones by doppler
45
Prenatal care at 18 weeks?
Quickening
46
Prenatal care at 18-20 weeks?
Ultrasound for full anatomic screen
47
Prenatal care at 20 weeks?
Fundal height at umbilicus
48
Prenatal care at 24-28 weeks?
Glucose Tolerance Test
49
Prenatal care at 18 weeks?
RhoGAM if mom (-) and dad (+/unknown)
50
Prenatal care at 36-37 weeks?
Group B strep screen
51
Rh incompatibility (Level 1)?
Rh (-) mom carrying Rh (+) baby may develop anti-Rh antibodies with any
fetal blood leak into maternal circulation.
● Ab then can attack fetal RBC of subsequent Rh(+) pregnancies causing
hemolysis
52
Prevention of RH incompatibility?
Prevention: Give RhoGAM at 28 weeks with Rh(-) mom, Rh(+)/unknown dad
● Give second RhoGAM at birth if baby is indeed Rh(+)
● Give RhoGAM after abortion, ectopic pregnancy, vaginal bleeding,
amniocentesis or any suspicion of blood mixing in Rh(-) moms
53
Sexual/physical abuse in pregnancy (Level 1)
Psychosocial discussions of support, safety at all prenatal appointments
● Women at higher risk for physical abuse during pregnancy
54
Abruptio Placentae (Level 1)?
Definition: Premature separation of a normally implanted placenta
55
S/S of Abruptio Placentae (Level 1)
S/S: Painful, dark red vaginal bleeding, abd pain, fetal distress
○ Remember symptoms from the name→ an “abrupt” ripping of the
placenta would be painful
56
DX of Abruptio Placentae (Level 1)
U/s, no pelvic exam
57
Tx of Abruptio Placentae (Level 1)
Mild: Inpatient monitoring
| ○ Moderate to severe: Deliver that baby
58
Breast Cancer (Level 1)?
```
#1 non-skin cancer in women, #2 most common cause of cancer deaths in
women. Two main variants: Ductal and lobular
```
59
Risks of Breast Cancer (Level 1)?
↑ exposure to estrogen (early menarche, late menopause,
| nulliparity), BRCA 1&2, 1º FH, age >65yr
60
S/s of Breast Cancer (Level 1)?
Painless, hard, non-mobile lump, most in upper outer quadrant
61
Late findings of reast Cancer (Level 1)?
Nipple retraction, nipple discharge, peau d’orange skin
| thickening, axillary lymphadenopathy
62
DX of Breast Cancer (Level 1)?
Mammogram, U/S, biopsy
63
What % is breast Ca found by patient
90%
64
What age to a female pt being for the following : Screening: Mammogram, self breast exam, yearly clinical exam
> or - to 40
65
Screening: Mammogram guidelines, self breast exam, yearly clinical exam
ACS: Annual mammogram ≥ 40yo
● USPSTF: Mammograms q2y 50-74yo; q2y at 40yo if ↑risk; 10y prior to age
of 1º relative’s diagnosis
66
What is Ectopic pregnancy (Level 2)
Definition: Implantation of fertilized ovum outside uterus
● Areas of implant -- Fallopian tube > abdomen > ovary, cervix; Top of “Do not miss” list of every woman of reproductive age presenting
with abdominal pain
67
Risks of Ectopic pregnancy (Level 2)
PID, IUD use, endometriosis
68
S/S Ectopic pregnancy (Level 2)
Classic triad of unilateral abdominal pain + vaginal bleeding +
amenorrhea (d/t pregnancy)
● If ruptured: syncope, signs of hemorrhagic shock
69
DX of Ectopic pregnancy (Level 2)
(+) pregnancy test, transvaginal U/S showing empty uterus
| ● Confirm with serial HCGs not doubling as expected
70
TX Ectopic pregnancy (Level 2)
Small, non-ruptured: Methotrexate (disrupts cell multiplication)
○ Ruptured, complicated: Surgery
○ Don’t forget RhoGAM for Rh negative mothers
○ Follow up 𝛃HCG is key!
71
Risks of Gestational diabetes (Level 1)
Prior h/o GD, multiple gestations, obesity, non-white ethnicity, prior
delivery of baby >9lb
72
DX of Gestational diabetes (Level 1)
Dx: 1h Glucose Challenge Test at 24-28wk
| ○ If BS ≥140mg/dL, confirm with 3h 100g Glucose Tolerance Test
73
TX of Gestational diabetes (Level 1)
Tx: Diet, exercise, meds to keep FBS <95 mg/dL (metformin, insulin)
74
If HTN < 20 weeks
→considered Chronic Hypertension
o Treat BP; monitor BP, urine for protein, and other symptoms as
pregnancy progresses
75
If HTN > 20 weeks + other symptoms
→considered Preeclampsia/Eclampsia
76
If HTN >20 weeks + no other symptoms
considered pregnancy induced
77
Preeclampsia
Occurs >20 weeks to 6 weeks postpartum
● Triad: HTN + proteinuria +/- edema
○ BP ≥ 140/90 on 2 occasions >4 hours apart AND
○ Proteinuria >300 mg/24hr or >1+ on dipstick
● Or in the absence of proteinuria, new-onset hypertension + new onset of:
○ Thrombocytopenia (platelets <100,000/microL)
○ Renal insufficiency (serum creatinine >1.1mg/dL)
○ Impaired liver function (elevated LFTs)
○ Pulmonary edema
○ Cerebral or visual changes
78
Severe Preeclampsia
```
Two severe BP values SBP ≥ 160 or DBP ≥ 110 obtained 15-60 minutes
apart
● End-organs affected
○ Persistent oliguria <500mL/24hr
○ Progressive renal insufficiency
○ Unremitting headache/visual disturbances
○ Pulmonary edema
○ Epigastric /RUQ pain
○ LFTs 2x normal
```
79
Management Severe Preeclampsia
If GA ≥ 37 weeks → Deliver that baby
○ If GA < 37 weeks → Bedrest, daily weights, BP and proteinuria
monitoring
○ If <34 week, steroids for lungs
○ Magnesium to prevent seizures
○ Labetalol and/or hydralazine to lower BP (goal <160/110)
80
HELLP syndrome:
Severe pre-eclampsia + Hemolysis, Elevated LFTS, Low
| Platelets
81
Eclampsia ?
Preeclampsia criteria + abrupt onset tonic-clonic seizures
Seizure timing: 25% antepartum, 50% intrapartum, 25% postpartum (most
within 48 hours but can be up to weeks postpartum)
82
S/S Eclampsia
Headache, visual changes, RUQ pain
83
Eclampsia TX?
```
Definitive treatment is delivery
○ ABCDs
○ Magnesium for seizures
○ Fetal monitoring while stabilizing mom
○ BP control with labetalol and/or hydralazine
○ Deliver that baby when mom is stable
```
84
What is Placenta previa (Level 1)
Placental implantation on or close to cervical os
| ● May be complete, partial or marginal
85
S/S Placenta previa (Level 1)
Painless bright red 3rd trimester bleeding, no fetal distress
o Remember 3 Ps - 3 rd trimester P ainless P lacenta P revia
86
DX of Placenta previa (Level 1)
U/S, no pelvic exam
87
Tx Placenta previa (Level 1)
Bed rest, stabilize baby (tocolytics, steroids), delivery
88
What is Postpartum hemorrhage (Level 1)
Bleeding >500 cc after vaginal delivery or >1000 cc after
| c-section; Common reason for maternal death in first 24 hours after delivery
89
Causes of Postpartum hemorrhage (Level 1)
Uterine atony, uterine rupture, genital tract trauma, retained
placental tissues, infection
90
S/S Postpartum hemorrhage (Level 1)
Hypovolemic shock, soft boggy uterus with dilated cervix
91
tx Postpartum hemorrhage (Level 1)
```
Uterotonic agents (Oxytocin, Misoprostol), bimanual massage, artery
embolization
```
92
Common reason for maternal death in first 24 hours after delivery
Postpartum hemorrhage
93
What is Premature rupture of membranes (PROM) (Level 1)
Premature (PROM): >1 hour before onset of labor
| ● Preterm Premature (PPROM): <37 weeks gestation
94
Risks of Premature rupture of membranes (PROM) (Level 1)
Smoking, STIs, multiple gestations
95
s/s of Premature rupture of membranes (PROM) (Level 1)
Gush or leak of fluid, vaginal discharge
96
DX of Premature rupture of membranes (PROM) (Level 1)
Sterile speculum exam for visual inspection
■ NO digital exam
○ Nitrazine paper test (turns blue if pH >6.5)
○ Fern test
97
TX of Premature rupture of membranes (PROM) (Level 1)
Depends on GA and fetal lung maturity
○ Steroids for lung maturity <34 weeks
○ If infection present or fetal distress: Abx and deliver that baby
98
Def of Cord Prolapse
Abnormal positioning of umbilical cord during labor → cord compression & fetal
hypoxemia (obstetrical emergency!)
99
Overt Cord Prolapse
Cord moves in front (ahead) of fetal presenting part & protrudes thru
cervical canal, into or out of, vagina
100
Occult Cord Prolapse
Cord is positioned alongside the presenting part
101
Presentation: Cord Prolapse
Abrupt severe, prolonged fetal bradycardia or new onset severe
variable decelerations in a labor that was previously progressing with normal
tracings
102
DX: Cord Prolapse
clinical; visualization or palpation of cord
103
Tx: Cord Prolapse
Prompt cesarean section delivery
o Temporizing measures: manually elevating the presenting part off the cord,
placing pt in Trendelenburg or knee-chest position, retrofilling bladder with
500-700 mL saline, administering tocolytic agent (eg. terbutaline
