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OBGYN Clerkship > Gynecology > Flashcards

Gynecology Flashcards

1
Q

Is cervical cancer biopsy safe during pregnancy?

A

YES

And it should be done if there is irregular post-coital bleeding

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2
Q

Kleihauer Betke test

A
  • Utilized to determine if there is fetal blood in maternal circulation, with a threshold of 5 mL
  • Required in Rh negative patients with heavy menstrual bleeding to determine if there is fetomaternal hemorrhage that may lead to Rh-alloimunization
  • Prevent w/ anti-D immunoglobulin
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3
Q

Intermittent adnexal torsion

A
  • Causes severe lower quadrant abdominal pain and nausea episodically.
  • Dopplar ultrasound may not catch it if the ovarian blood supply is not acutely contorted.
  • May progress to persistent torsion at any point
  • Diagnose and treat w/ laporoscopy
    • Oophorectomy may be required if ovary is necrotic
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4
Q

Anovulatory cycles

A

Common in the first years after menarche and the last few years before menopause

It manifests with menstrual cycle variability, menorrhagia, and intermittent “spotting” in lieu of a period. Patients will describe that their period sometimes “skips” months.

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5
Q

Ddx for vaginal bleeding within the first trimester of pregnancy

A
  1. Spontaneous abortion
  2. Viable, intrauterine pregnancy
  3. Ectopic pregnancy
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6
Q

Workup for vaginal bleeding within the first trimester of pregnancy

A
  • Serial beta hCG levels
    • beta hCG should raise by 50% over a 48 hour period
    • If it decreases over this period instead, the pregnancy is not viable (could mean spotaneous abortion or still an ectopic pregnancy)
  • Transvaginal ultrasound
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7
Q

Beta hCG rule of 10’s

A
  • beta hCG peaks at 10 weeks estimated gestational age
  • This peak is approximately 100,000
  • From here, it decreases, and at term it is approximately 10,000
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8
Q

What do we expect to see on transvaginal ultrasound for a woman who has an estimated gestational age of 4.5-5 weeks?

A

A gestational sac

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9
Q

What do we expect to see on transvaginal ultrasound for a woman who has an estimated gestational age of 5-6 weeks?

A

A yolk sac and amnionic sac

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10
Q

What do we expect to see on transvaginal ultrasound for a woman who has an estimated gestational age of 5.5-6 weeks?

A

A yolk sac, amnionic sac, and the beginnings of the fetal pole

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11
Q

Types of spontaneous abortion

A
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12
Q

What is the most common cause of spontaneous abortion within the first trimester?

A

Aneuploidy of the fetus

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13
Q

What is the most common cause of spontaneous abortion within the second trimester?

A
  • Maternal systemic disease (like antiphospholipid syndrome)
  • Abnormal placentation
  • Other anatomic considerations
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14
Q

Risk factors for spontaneous abortion

A
  • History of spontaneous abortion
  • Smoking
  • Having an IUD in place
  • Uncontrolled diabetes
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15
Q

What things do patients often think may have contributed to a spontaneous abortion that really are not risk factors?

A
  • Drinking lots of coffee while pregnant
  • Having sex while pregnant
  • Exercising while pregnant
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16
Q

Treatment options for spontaneous abortion

A
  1. Expectant management (waiting to see if the body will clear the abortion without the need for intervention)
  2. Surgical evacuation (dilation and curettage OR manual vacuum aspiration)
  3. If in first trimester, vaginal misoprostol
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17
Q

When a patient undergoes spontaneous abortion, as part of future obstetric management, you must check her ___ to see if she needs ___.

A

When a patient miscarries, as part of future obstetric management, you must check her blood type to see if she needs Rhogam.

Spontaneous abortion can be a sensitizing event that induces anti-RhD or anti-RhCE. Administering Rhogam for a woman before she completes abortion may prevent a episode of fetal hemolytic anemia and another lost pregnancy.

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18
Q

Endometritis following spontaneous evacuation of pregnancy

A
  • Treat w/ broad spectrum Abx with anaerobe coverage
    • Oral cefotetanplusdoxycycline is often used
      • Cefotetan is a second generation cephalosporine
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19
Q

Signs and symptoms of septic abortion

A
  • Fevers
  • Chills
  • Lower abdominal pain
  • Foul-smelling vaginal discharge
    • Home abortion is a major risk factor
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20
Q

Causes of third trimester vaginal bleeding

A

Placenta previa and placental abruption are the most common concerning causes

Vaginal or cervical tear, cervical polyps, or severe cervicitis are benign causes.

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21
Q

When a patient presents with second or third trimester bleeding, you CAN NOT perform a cervical exam until . . .

A

. . . the location of the placenta has been confirmed

You do NOT want to do a cervical exam on someone with placenta previa

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22
Q

If there is significant blood loss from third trimester bleeding, the first things you should do are. . .

A

. . . give fluid and (if there may be need for emergent delivery) betamethasone.

Betamethasone here is to ensure sufficient surfactant production in the event that we may need to perform caesarean section.

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23
Q

Placenta previa management should balance the risks of ___ with the risks of ___.

A

Placenta previa management should balance the risks of prematurity with the risks of heavy bleeding.

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24
Q

If a patient in their third trimester presents with vaginal bleeding and is found to have placenta accreta, increta, or percreta, the likely management is. . .

A

. . . casearean hysterectomy

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25
Q

Placental abruption

A
  • Premature separation of a normally implanted placenta.
  • Usually occurs around 20 weeks gestation
  • Symptoms include profuse vaginal bleeding, uterine pain and tenderness, sometimes with hemorrhagic shock and DIC
    • Note that placental abruption is the most common cause of coagulopathy in pregnancy
    • ​There may be bleeding into the uterus rather than outside of the body. This causes the uterus to become enlarged and bluish in color, termed Couvelaire uterus.
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26
Q

Risk factors for placental abruption

A
  • Trauma
  • Cocaine use
  • Hypertension
  • Multiple gestations
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27
Q

Management of placental abruption

A
  • Mild symptoms:
    • Modified activity (bed rest for much of the day)
  • Moderate to severe symptoms:
    • Monitoring vital signs, fluids, monitoring of fetal HR pattern
    • Delivery in the case of severe hemorrhage
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28
Q

Most common cause of coagulopathy in pregnancy

A

Placental abruption

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29
Q

1:1:1 rule for treatment of massive hemorrhage

A

If you were to give only RBCs and fluids for hemorrhage, you would end up with diluted clotting factors!

The 1:1:1 rule states that you should give 1 unit RBCs to 1 unit platelets to 1 unit FFP in order to preserve coagulation and clotting along with treating shock.

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30
Q

General rules regarding when to transfuse

A
  • Hb 6-7: Transfusion recommended
  • Hb 7-8: Transfusion should be considered
  • Hb 8-10: Transfuse only if symptomatic anemia or angina
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31
Q

Whenever a pregnant patient presents with vaginal bleeding, you should ask yourself, “Are they ___?”

A

Whenever a pregnant patient presents with vaginal bleeding, you should ask yourself, “Are they Rh negative?”

Do they need Rhogam?

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32
Q

SLE and pregnancy

A

Ideally, an SLE patient looking to become pregnant should have a period of at least 6 months of quisecence of SLE prior to conception

Active SLE at time of conception is a strong risk factor for poor outcomes.

Many medications will also need to be adjusted prior to conception (ex, antifolates, hydroxychloroquine)

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33
Q

Commonly used antihypertensives which are save to use during pregnancy

A

Methyldopa

Labetalol

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34
Q

Since ___ cannot be administered during pregnancy, a preconception visit is the perfect time to offer ___.

A

Since live vaccines cannot be administered during pregnancy, a preconception visit is the perfect time to offer varicella and rubella vaccines to someone who is not immune.

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35
Q

All women who are pregnant or planning to become pregnant should be screened for ___.

A

All women who are pregnant or planning to become pregnant should be screened for HIV and other STIs.

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36
Q

Women should avoid ___ during pregnnacy

A

Women should avoid cat faeces during pregnnacy

Toxoplasmosis

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37
Q

Standard panel of preconception genetic tests

A
  • Hemoglobinopathies (sickle cell, alpha and beta thalassemia)
  • Tay Sachs
  • Canavan disease and familial dysautonomia
  • Cystic fibrosis
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38
Q

Preimplantation genetic diagnosis

A

IVF where fertilized eggs are screened for genetic diseases prior to being implanted

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39
Q

Ways to sample genetic material of a fetus for genetic diagnosis

A
  • Chorionic villus sampling
  • Amniocentesis
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40
Q

All pregnant women and women trying to conceive should take . . .

A

. . . 0.4 mg of folic acid supplementation daily.

OR, 4 grams daily if they have a family history of neural tube defect

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41
Q

Home pregnancy tests will become positive with a beta hCG level of approximately. . .

A

. . . 25

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42
Q

Intake visit

A

First obstetrical visit, at 6-8 weeks EGA

43
Q

First prenatal visit

A

Before 12 weeks EGA

44
Q

Risks of smoking during pregnancy

A
  • Miscarriage
  • Placental abruption
  • Fetal growth restriction
  • Preterm delivery
  • Birth defects
  • Sudden infant death syndrome (SIDS)
45
Q

Estimate date of delivery

A

Calculated as 40 weeks past LMP

46
Q

Prenatal visit schedule

A
  • Intake: 5-8 wks
  • Prenatal visits start: Just before wk 12
  • Wks 12-28: Every 4 wks
  • Wks 28-36: Every 2 wks
  • Wks 36-delivery: Every week
47
Q

Content of a prenatal visit

A
  • Weight
  • Blood pressure
  • Fetal assessment
48
Q

Screening tests during prenatal course

A
  • 1 Hour glucose tolerance test: 24-28 wks, or at initial prenatal visit for obese patient
  • First trimester trisomy 18/21 screen: 10-13 wks
  • Maternal serum aneuploidy screening: 15-20 wks
  • Fetal survey ultrasound: 18-20 wks
    *
49
Q

Fetal heart rate may first be monitored at ___

A

Fetal heart rate may first be monitored at 12 wks

50
Q

First trimester trisomy 18 and 21 screen

A
  • Performed at wks 10-13
  • By ultrasound
    • Assessment of nuchal translucency
  • Blood test
    • PAPPA and free beta hCG
51
Q

Maternal serum test for detection of aneuploidys

A
  • At weeks 15-20
  • Triple test:
    • alpha fetoprotein
    • estriol
    • hCG
  • Quad test:
    • triple test plus inhibin
52
Q

Non-stress test

A
  • Test we employ if we have reason to be concerned about a pregnancy
    • ex, risk factors like GDM, smoking, pre-eclampsia, etc
  • Measures fetal heart rate, patterns, and accelerations for at least 20 minutes with external transducer
  • It is considered “reactive” if there are at least 2 accelerations over the 20 minute period
53
Q

Maternal kick counts

A

A way for women to assess fetal movement at home

Starting at 32 wks, the test may be performed by:

Lying on side and counting kicks. Normal counts are >5 movements in 1 hour, or >10 movements in 2 hours.

54
Q

Fundal height measurement

A

Measurement of fetal size

Calculated as the distance from pubic symphysis to top of fundus

Reference is approximately equal to # of weeks gestation

55
Q

Amnionic fluid index

A
  • 4 quadrant assessment of amnionic fluid pockets
  • Decreased urine output is the result of the fetus shunting fluid to the brain and away from the kidneys, decreasing fluid output
56
Q

Assessment of fetal lung maturity

A

May be necessary in cases of suspected pre-term delivery

Performed by sampling amnionic fluid and checking for markers of lung maturity (lecithin-to-sphingomyelin (L/S) ratio and the presence or absence of phosphatidylglycerol.)

57
Q

Pregnancy weight gain recommendations stratified by prepregnancy BMI

A
58
Q

Too much vs too little weight gain in pregnancy

A
  • Too much:
    • Fetal macrosomia
    • Post-partum obesity
  • Too little:
    • Preterm delivery
    • Intrauterine growth restriction
    • Low birth weight
59
Q

Foods with specific risks in pregnancy

A
  • Unpasteurized milk/dairy products, cold cuts: Listeria monocytogenes
  • Large fish (tuna, shark, king mackerel): Mercury toxicity
  • “Herbal remedies”: Unregulated and often contain teratogenic substances
60
Q

What types of exercise should be avoided during pregnancy?

A
  • Those w/ risks of falling or abdominal trauma
  • No new strenuous exercises that she did not partake in pre-pregnancy
61
Q

Contraindications to sex during pregnancy?

A
  • Placenta previa
  • Premature rupture of membranes
62
Q

Most airlines allow travel for pregnant individuals up to ___ wks gestation.

A

Most airlines allow travel for pregnant individuals up to 36 wks gestation.

63
Q

How should a pregnant patient who wishes to travel by air be counseled?

A
  • She should not if she is >36 wks gestation
  • She should get up and walk every 1-2 hours while in flight (avoid prolonged sitting)
  • Remind of importance of seatbelts worn LOW on hipbones
64
Q

Recommendations regarding radiation in pregnancy

A
65
Q

Contraction of uterus post-partum

A
  • Uterus retracts to the pelvic cavity by 2 weeks post-partum
  • It is back to its normal size by 6 weeks post-partum
66
Q

Phases of lochia

A
  • Lochia: Post-partum vaginal discharge
    • Lochia rubra: First few days. Menses-like blood.
    • Lochia serosa: First few weeks. Lighter, more watery.
    • Lochia alba: White-yellow discharge that may persist for 6-8 weeks.
67
Q

Post-partum pain

A

Vaginal and vulvar pain persists for several weeks post-delivery

Most women will require some sort of analgesia, but usually OTC medications are sufficient.

68
Q

Kegel exercises

A
  • Help reduce the risk of post-partum pelvic floor insufficiency and prolapse
69
Q

Return to normal cardiovascular function in the post-pregnancy period

A

Takes about 2-3 weeks

Significant diuresis

70
Q

Return to normal coagulation status in postpartum period

A

Takes about 6-8 weeks

71
Q

7B’s of post-partum care

A
  1. Breast feeding (exclusive for at least 6 months over bottle)
  2. Bladder (ask about urinary symptoms, retention, incontinence)
  3. Bowel (women taking opioids or with 3rd or 4th degree lacerations should be offered a stool softener)
  4. Bleeding
  5. Bottom (perineal pain or irritation)
  6. Blues (post-partum depression)
  7. Birth control (fertility returns fairly rapidly, before ~6 weeks postpartum, ensure that the patient has a plan)
72
Q

All post-partum women should urinate within ___ hours of delivery or catheter removal

A

All post-partum women should urinate within 6 hours of delivery or catheter removal

73
Q

Breastfeeding-induced protection against pregnancy

A
  • Breastfeeding induces hormonal changes that delay the return of the menstrual cycle
  • In order for this to work, it must be exclusive, every 3 hours, and the patient must be amenorrheic
  • OCP should be avoided in the immediate postpartum period as it may hamper breast milk production
74
Q

Why is OCP contraindicated immediately post-partum?

A
  • Two reasons:
    1. Risk of thromboembolism in the postpartum state
    2. It hampers initial breast milk production (but is safe again once breast milk has been established)
75
Q

Immediate post-partum contraception

A
  • Avoid OCP to ensure proper breast milk production and risk of thromboembolism (2-3 weeks at least for the latter even if the patient is not breastfeeding)
  • Instead, we tend to use:
    • Progesterone contraception
    • Progesterone IUD
    • Mini-pill / Micronor
    • Nexplanon
76
Q

“ovulation predictor kit”

A

Urine test that measure LH to detect the LH surge 24-36 hours prior to ovulation

77
Q

Why are older women more likely to have twins?

A

FSH creeps up with age due to dropping estrogen levels

Higher FSH, more follicle stimulation, more likely to stimulate two at once, more twins

78
Q

Basal rate of twins for physiologically normal women of child-bearing age

A

2-3% of pregnancies

79
Q

Assessing ovarian reserve

A

AMH is made by granulosa cells, more AMH = more eggs

FSH/E2 is self explanatory

Should be drawn on cycle day 3

80
Q

Single most important marker of egg quality

A

Age of the patient

81
Q

What is the optimal time to draw blood to assess hormones for female infertility and baseline hormone levels?

A

Day 3 of the menstrual cycle

82
Q

FSH should always be measured with ___ to properly assess its value

A

FSH should always be measured with estradiol to properly assess its value

83
Q

If someone is on the pill, you cannot assess their. . .

A

. . . FSH, LH, AMH, or baseline gonadal function

A 4-8 week washout period is necessary prior to testing for accurate results

84
Q

Hysterosalpingogram

A
  • X-ray of the female pelvic organs with dye flushed into uterus
  • Catheter placed into uterus and 5-10 mL of water-based contrast is flushed into the uterus
  • X-ray here shows “normal fill and spill”, where the uterus is highlighted, the tubes are highlighted, and there is spillage into the pelvis at the fimbriae
85
Q

Hydrosalpinx

A
  • Visualized on hysterosalpingogram
  • Due to obstruction in fallopian tube, often with inflammatory fluid in the tube
  • Indication for tube removal (hydrosalpingectomy)
86
Q

Why can you take mifepristone up to 5 days after sex and have it still be effective?

A

Because it is preventing implantation, which happens ~1 week after fertilization

87
Q

Baskets for categorizing infertility

A
88
Q

___ has the oldest average maternal age in the country

A

BOSTON has the oldest average maternal age in the country

89
Q

Approach to first trimester bleeding and abdominal pain

A
  • Non-viable intrauterine pregnancy
    • Spontaneous abortion
    • Molar pregnancy
  • Viable intrauterine pregnancy
    • Physiologic implantation bleeding
    • Sub-chorionic hemorrhage
  • Non-viable extrauterine pregnancy
    • Ectopic pregnancy
90
Q

Risk factors for ectopic pregnacy

A
  • History of prior ectopic pregnancy
  • Scarring of the fallopian tube
    • Tubal surgeries (including tubal ligation)
    • Chlamydial infection
    • History of pelvic inflammatory disease
  • Smoking (secondary ciliary dyskinesia)
91
Q

Triad of ectopic pregnancy

A
  • Amenorrhea
  • Vaginal bleeding
  • Abdominal pain
92
Q

Treatment of ectopic pregnancy

A
  • Medical
    • Methotrexate (if not contraindicated)
  • Surgical
    • Salpingostomy (removal of just the ectopic pregnancy, requires beta hCG followup)
    • Salpingectomy (removal of fallopian tube, no beta hCG followup)
93
Q

When is methotrexate contraindicated for ectopic pregnancy?

A
  • Absolute:
    1. Hemodynamic instability
    2. Liver or kidney abnormalities
    3. Active lung disease
    4. Breastfeeding
    5. Inability to comply with followup beta hCG testing
  • Relative (all essentially fetus too advanced for methotrexate to work):
    1. Fetal cardiac activity
    2. High beta hCG (>5000)
    3. Size > 3.5 cm
94
Q

Layers of the fallopian tube

A

Mucosa

Muscularis

Serosa

95
Q

Peg cells

A
  • Noncilliated, secretory cells of the fallopian tube
  • Produce substances which provide protection and nutrition for the egg and sperm
96
Q

Salpingitis isthmica nodosa

A
  • Aka diverticulosis of the fallopian tube
  • Nodular thickening of the proximal fallopian tube
  • Associated with reactive hypertrophy and sometimes inflammation
  • Etiology unknown, but occurs when the tubular mucosa penetrates into the muscular layer of the fallopian tube and resultant hypertrophy of surrounding muscle
97
Q

Risk factors for ectopic pregnancy

A
  • Previous ectopic pregnancy
  • Smoking (cilia function impaired)
  • In-vitro fertilization
98
Q

Ultrasound findings consistent with ectopic pregnancy

A
  • No pregnancy present in the uterus
  • Presence of an adenxal mass
99
Q

Echogenic or complex fluid in the pelvis on ultrasound is consistent with ___.

A

Echogenic or complex fluid in the pelvis on ultrasound is consistent with hemoperitoneum.

This is often seen in ectopic pregnancy.

100
Q

Beta hCG in ectopic pregnancy

A

In ectopic pregnancy, beta hCG is usually substantially lower secondary to poor trophoblast function due to lack of blastocyst implantation. It is important to note that not all ectopic pregnancies will have low rise in beta hCG – some will be within reference range.

Thus, if ultrasound findings are ambivalent, a repeat beta hCG in 48 hours with little to no increase in beta hCG levels is still suggestive of the diagnosis of ectopic pregnancy

101
Q

Ectopic pregnancy should ALWAYS remain on the differential for elevated beta hCG until. . .

A

. . . intrauterine pregnancy is diagnosed

102
Q

Treatments for ectopic pregnancy

A
  • Medical:
    • For patients who are asymptomatic, hemodynamically stable, compliant w/ care
    • Methotrexate (dihydrofolate reductase inhibitor)
  • Surgical:
    • Salpingectomy ipsilateral to ectopic pregnancy
    • Salpingostomy (removes just the ectopic, more conservative)
  • All therapies must be followed with serial beta hCG to ensure complete resolution of the ectopic pregnancy
103
Q

Ddx for colicky RLQ abdominal pain in an anatomically female patient

A
  • Appendicitis
  • Ovarian torsion
  • Ectopic pregnancy
104
Q

Why is it believed that women of African descent are more prone to fibroids?

A

When thoroughly controlling for other variables, women of African descent tend to have significantly levels of estradiol in the luteal phase despite similar gonadotropin levels.

OBGYN Clerkship (30 decks)

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