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Women's Health > hello > Flashcards

hello Flashcards

1
Q

What is Mastodynia/mastalgia?

A

breast tenderness or pain

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2
Q

What does cyclic Mastodynia suggest?

A

luteal phase tenderness

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3
Q

Is Mastodynia increased or decreased in OCP and HRT users?

A

increased

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4
Q

What is the MOA of bromocriptine?

A

dopaminergic agonist that inhibits the release of prolactin from the anterior pituitary

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5
Q

What is the MOA of danazol?

A

synthetic testosterone that binds to progesterone and androgen receptor sites

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6
Q

What is the most common benign breast condition?

A

fibrocystic breast disease

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7
Q

What ages is fibrocystic breast disease common in?

A

30 to 50 yo

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8
Q

What is the etiology behind fibrocystic breast disease?

A

due to an exaggerated stromal response to hormones - assoc with a long follicular or luteal phase

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9
Q

What all does fibrocystic breast disease include?

A

cysts, papillomatosis, fibrosis, adenosis, and ductal epithelial hyperplasia

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10
Q

What are the most common pathologic causes of nipple d/c?

A

Intraductal papillomas, carcinoma and fibrocystic chgs with ectasia of the ducts (less frequently)

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11
Q

What are common causes of nipple d/c?

A

CNS lesions, hypothalamic pituitary d/o, systemic dz, medications and herbs, chest wall lesions

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12
Q

What is the mean age of breast cancer diagnosis?

A

60-61 yo

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13
Q

What is Rubin Maneuver?

A

insert index and middle fingers into vagina against the fetal posterior and anterior shoulder and push/rotate towards the fetal chest –> this helps rotate the shoulders into the oblique position

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14
Q

What is Woods (Screw) maneuver?

A

fingers are used to apply pressure posterior shoulder and push/rotate towards the fetal back –> this will rotate the fetal trunk inward about 180 degrees in a winding motion

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15
Q

What is Barnum (or Jacquemier) maneuver?

A

delivery of the posterior arm - hand is placed into the maternal sacral hollow - the fetal posterior arm is identified and pressure is placed on the antecubital fossa - this should cause forearm flexion across the chest where the forearm can be gripped extending the arm above the head and delivering the fetus arm first

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16
Q

What is the Zavanelli maneuver?

A

the infants head is replaced into the vaginal canal and uterus if possible and there is a subsequent C section –> however high infant mortality if possible

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17
Q

What is the treatment for Mastodynia?

A

acetaminophen/NSAIDs, Vit B6, Danazol, Bromocriptine Danazol is preferred over bromocriptine

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18
Q

What is the work up for fibrocystic breast disease?

A

biopsy to r/out carcinoma –> FNA is both diagnostic and therapeutic

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19
Q

What is the tx for fibrocystic breast disease?

A

may only need supportive bra, dec intake of nicotine and caffeine, there is a possible response to low salt diet and vit E supplements, HCTZ can be given premenstrually, if symptoms are severe enough Danazol can be used

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20
Q

What are the clinical characteristics of fibrocystic breast disease?

A

round, soft to firm or tense, mobile, usually TENDER, multiple and well demarcated

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21
Q

What is the most common causative organism of mastitis?

A

staph aureus

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22
Q

What are the clinical manifestations of mastitis?

A

flu like symptoms with unilateral breast tenderness that is red and warm to the touch –> diagnosis is mostly made by PE findings

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23
Q

What is the treatment for mastitis?

A

penicillinase-resistant antibiotic such as dicloxacillin or Nafcillin OR a cephalosporin

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24
Q

Should a lactating women continue to breastfeed after being diagnosed with mastitis?

A

YES, prevents the accumulation of infected material in the breast

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25
Q

What are two different types of abscesses?

A

lactational and subareolar

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26
Q

What is the causative organism of a lactational abscess?

A

staph aureus

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27
Q

What is the causative organism of a subareolar abscess?

A

mixed infection w/ anaerobes, staphylococci and streptococci

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28
Q

How can you treat a lactational abscess?

A

w/ Nafcillin, cefazolin, or vancomycin

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29
Q

How do you treat a subareolar abscess?

A

broad spectrum ABX

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30
Q

How can the involved duct in galactorrhea be identified?

A

by pressure at different sites around the nipple at the margin of the areola

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31
Q

What are the clinical manifestations of pathologic galactorrhea?

A

unilateral discharge coming from a single duct that can be serous, bloody or serosanguineous… +/- mass

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32
Q

What tests should be ordered in a women presenting with multiductal non-bloody discharge from the breast with a normal physical exam and negative imaging?

A

pregnancy tests, prolactin levels, renal and thyroid function tests, w/ endocrinology follow up

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33
Q

What tests should be ordered when a women presents with discharge from the breast that is suggestive of a pathologic cause (unilateral, single duct, bloody or serous)?

A

mammogram and US - can reveal underlying abnormalities of the duct ductography - can delineate an Intraductal filling defect

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34
Q

When may purulent discharge from the breast be present?

A

when there is a subareolar abscess –> tx may require excision of the abscess and related lactiferous sinus

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35
Q

What is a Fibroadenoma?

A

a benign tumor composed of stromal and epithelial elements that represent a hyperplastic or proliferative process in a single terminal ductal unit

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36
Q

What is the age range from Fibroadenoma?

A

15 to 55… however most common in those younger than 40

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37
Q

What are the clinical characteristics of a fibroadenoma?

A

round or discoid, smooth, firm, rubbery, well circumscribed, mobile, and NON TENDER

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38
Q

What is the most common size of a fibroadenoma?

A

1 to 5 cm

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39
Q

How do you diagnosis a fibroadenoma?

A

physical exam and biopsy results

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40
Q

What is the treatment for a fibroadenoma?

A

if no family hx of breast cancer and the pt is stable she can be followed up clinically… if the fibroadenoma is large it can be removed by excisional biopsy

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41
Q

When should a fibroadenoma be biopsied?

A

in women younger than 25 years of age, and if the mass is suspicious for cancer

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42
Q

What cancer does breast cancer increase the risk of developing?

A

endometrial cancer

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43
Q

What are some preventative measures for breast cancer?

A

early pregnancy, prolonged lactation, chemical or surgical sterilization, exercise, and low fat diet

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44
Q

What are the risk factors of breast cancer?

A

increasing age, known BRCA 1 or 2 gene, fam hx of gynecologic malignancy, first degree relative with BC, personal hx of BC, exposure to ionizing radiation especially if prior to the age of 30

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45
Q

What amount of invasive breast cancers are estrogen receptor positive?

A

all invasive lobular cancers and 2/3 of invasive ductal cancers

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46
Q

What are the clinical characteristics of inflammatory breast carcinoma?

A

diffuse, brawny edema with an erysipeloid border –> usually w/out an underlying palpable mass

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47
Q

What type of carcinoma does Paget’s disease typically lead to?

A

ductal carcinoma

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48
Q

What are the clinical manifestations of Paget’s disease?

A

eczematous lesion - red, scaling, and crusty patch on the nipple, areola, or surrounding skin

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49
Q

What is the significance of finding a palpable mass in a woman with paget’s disease?

A

95% of masses are found to be invasive… mostly infiltrating ductal carcinoma

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50
Q

What is the definition of pregnancy associated breast cancer?

A

breast cancer that is diagnosed during pregnancy, in the first post partum year, or anytime during lactation

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51
Q

What is the minimal tx of choice for breast cancer during pregnancy?

A

modified radical mastectomy

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52
Q

What are the mammogram results for ductal carcinoma in situ?

A

clustered microcalcification –> diagnosed then by needle or excision bx and treatment is surgical excision

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53
Q

What are the mammogram results for lobular carcinoma in situ?

A

nothing is seen on mammogram –> dx incidentally when a bx is done for another condition –> tx is a local excision

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54
Q

Where are ER positive tumors most likely to metastasize?

A

the bone, soft tissue, and genital organs

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55
Q

Where are ER negative tumors mostly likely to metastasize to?

A

liver, lung, and brain

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56
Q

Where are most breast cancers found?

A

45% are found in the upper outer quadrant and 25% are under the nipple and areolar area

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57
Q

Is breast pain a typical symptom of breast cancer?

A

NO, breast cancer rarely presents with breast pain

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58
Q

What are the later symptoms of breast cancer?

A

skin or nipple retraction, axillary lymphadenopathy, breast enlargement, redness, edema, brawny induration, peau d’orange, pain, fixation of mass to chin or chest wall

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59
Q

What are the late symptoms of breast cancer?

A

ulceration, supraclavicular lymphadenopathy, edema of arm, distant mets

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60
Q

When are monthly self breast exams recommended?

A

5 days after menses for pts older than age 20

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61
Q

What is the only screening method that has been consistently found to decrease the mortality of breast cancer?

A

mammogram

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62
Q

What are the screening recommendations for clinical breast exams for a pt younger than 40 yo?

A

every 3 yrs if greater than 40 exams should be done annually

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63
Q

When is an MRI indicated for screening for BC?

A

should be given in addition to a mammogram every year for women at high risk: known BRCA gene or first degree relative with BRCA gene, greater than 20% lifetime risk based primarily on family history, and prior mantle radiation

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64
Q

What are biopsy findings suggestive of carcinoma?

A

spiculated mass, asymmetric local fibrosis, and microcalcifications with a linear branched pattern

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65
Q

Oncotype dx is used for?

A

used to help determine the need for chemo for women with stage I or hormone receptor positive cancer –> looks at 21 genes and determines the likelihood of the cancer recurring or spreading

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66
Q

What stages of BC are curative treatments most commonly used for?

A

stage I, IIA, IIB, or locally advanced IIIB

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67
Q

At what stage of BC is palliative treatment considered?

A

stage IV disease, and for previously tx pts who develop distant mets or unresectable local recurrence

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68
Q

When is adjuvant therapy such as medical tx options considered?

A

based on lymph node status, age of patient, size of primary tumor, and ER/PR status

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69
Q

When is chemotherapy indicated in BC?

A

lymph node positive pts or high risk lymph node negative pts… those with adverse prognostic factors such as tumor size > 1 cm, positive lymph nodes, and high grade disease

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70
Q

What is the duration for chemotherapy during BC?

A

duration for 3-6 mo or 4-6 cycles offer the optimal benefit

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71
Q

What is the difference in aromatase inhibitors and tamoxifen in developing adverse complications?

A

AIs have less risk of endometrial cancer, venous thromboembolic events and hot flashes than tamoxifen however AIs have a higher risk of musculoskeletal d/o, osteoporosis, and cardiac events

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72
Q

Can aromatase inhibitors be used in premenopausal women?

A

NO, b/c of the paradoxical estrogen feedback on the hypothalamus

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73
Q

How often is a physical exam recommended for follow up post breast cancer treatment?

A

every 4 mo for the first 2 years then every 6 mo until year 5 (so for the next 2 years) then annually after that

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74
Q

When is a mammogram recommended for follow up post breast cancer treatment?

A

annually for all patients and no less than 6 mo after the completion of RDX

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75
Q

When is a CXR recommended for follow up post BC tx?

A

annually for those that received irradiation

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76
Q

True or False: pts with ER/PR positive tumors have a more favorable prognosis

A

TRUE

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77
Q

True or False: modified and simple or partial mastectomies have equivalent survival rates when followed by XRT

A

TRUE

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78
Q

When is surgery indicated for palliative treatment?

A

pts with good performance status, minimal organ involvement, prolonged disease free interval, or slow disease growth –> if complete resection of the tumor or metastasis is reasonable

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79
Q

What is considered local palliative therapy?

A

radiation or surgery –> these are reserved for pts in order to control their symptoms and minimize the risk for complications

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80
Q

When is palliative radiation treatment indicated?

A

good for certain bone or soft tissue mets to control pain or avoid fracture - can be especially useful in the tx of the isolated bony mets and chest wall recurrences

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81
Q

True or False: hormone manipulation for BC tx is less successful in postmenopausal women

A

false! it is usually more successful

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82
Q

When should cytotoxic drugs be considered in the treatment of metastatic breast cancer?

A

if visceral mets are present (especially brain or pulm lymph node spread), if hormonal tx is unsuccessful and the dz has progressed after an initial response to hormone manipulation, and if the tumor is ER and PR negative

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83
Q

What are the most common cytotoxic drugs being used for hormone refractory metastatic breast cancer?

A

taxanes

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84
Q

What is the most common site of breast cancer metastasis?

A

the BONE

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85
Q

How is bisphosphonate therapy dosed in palliative tx for breast cancer?

A

typically given IV every 3-4 wks and continued indefinitely

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86
Q

What labs and exams are recommended with the use of bisphosphonate therapy?

A

dental exams, creatinine and renal fxn, calcium and vit D levels are recommended b/c of the risk of osteonecrosis of the jaw, renal insufficiency, and hypocalcemia with prolonged therapy

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87
Q

Mauriceau maneuver

A

used during the 3rd step of partial extraction/assisted delivery of breech presentation – used to deliver the head of the fetus

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88
Q

When is a total breech extraction used in a vaginal delivery?

A

when there is fetal distress or when the 2nd twin is in non-vertex position after the 1st is successfully delivered

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89
Q

What are complications of vaginal delivery of a fetus that is in breech presentation?

A

umbilical cord prolapse, spinal injury to infant, and head entrapment at the cervix

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90
Q

When is a transverse incision used in a caesarean section for a breeched presentation baby?

A

term labor w/ a well developed lower uterine segment

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91
Q

When is a low vertical incision used in a C-section for the delivery of a fetus with a breech presentation?

A

premature gestation, unlabored uterus, malpresentations

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92
Q

What are specific indications for a C-section for a breech presentation fetus?

A

EFW greater than or equal to 3500 gms or less than 1500 gms contracted or borderline maternal pelvic measurements nonflexed or hyperextended head footling presentation variable fetal HR decelerations unengaged presenting fetal part dysfunctional or prolonged labor prolonged ROM premature fetus (25-35 wks) mother that: elderly primigravida, infertility problems, or poor obstetric hx

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93
Q

What is the definition of premature rupture of membranes?

A

rupture of the amniotic membranes occurring at least 1 hour before the onset of active labor at or after 37 wks gestation

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94
Q

What is the definition or preterm premature rupture of membranes?

A

rupture of the amniotic membranes that occurs before 37 wks gestation

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95
Q

What is the definition of prolonged premature rupture of membranes?

A

rupture that occurs more than 18 hours before the onset of labor

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96
Q

What are some potential causes of PROM?

A

apoptosis and catabolic enzyme activity, inflammatory process or maternal uterine infection, multiple prior pregnancies, hx of PROM, nutritional deficits, dec tensile strength of membranes

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97
Q

What should you do if there is no obvious leakage but PROM is suspected?

A

place pad under the perineum and monitor for leakage, cough of Valsalva can detect loss of fluid through the cervix on exam

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98
Q

What will be seen on an US in PROM?

A

low placental fluid index, oligohydraminos

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99
Q

When do most patient go into spontaneous labor when PROM is at or near term?

A

within 24 hours

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100
Q

What is the most common causative organism of Chorioamnionitis?

A

B streptococcus

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101
Q

What is the management when Chorioamnionitis is present?

A

IMMEDIATE deliver regardless of gestational age… induce labor PRN

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102
Q

When is external cephalic version best indicated?

A

with a single pregnancy greater than or equal to 36 weeks or a non vertex 2nd twin

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103
Q

How is external cephalic version performed?

A

for breech delivery –> move fetus into cephalic position with external pressure and manipulation of the maternal abdomen

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104
Q

If external cephalic version is unsuccessful what should you do?

A

wait for spontaneous labor and monitor for spontaneous conversion to cephalic position –> can induce labor or C-section as indicated

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105
Q

When is external cephalic version contraindicated?

A

multiple pregnancies, placental abnormalities, fetal distress, and abnormal uterine structure

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106
Q

What are complications of a breech vaginal delivery?

A

umbilical cord prolapse, spinal injury to the infant, head entrapment at the cervix

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107
Q

What are favorable indicators when considering a vaginal delivery of a breech fetus?

A

frank breech, gestation >/= 34 weeks, EFW 2000-3500 gms, flexed head, adequate maternal pelvis of approx 10 x 11.5 cm)

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108
Q

When do Braxton hicks contractions occur?

A

final 1-2 wks of pregnancy

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109
Q

What are examples of fetal lie?

A

transverse of longitudinal

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110
Q

What are examples of fetal presentation?

A

breech or vertex

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111
Q

What is the definition of dilation?

A

determines how open the cervix is at the internal os

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112
Q

What is the rate of dilation for a nulliparous women?

A

1-1.2 cm/hr

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113
Q

What is the rate of dilation for a multiparous women?

A

1.5 cm/hr (dilate faster than nulliparous women)

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114
Q

True or false: in a nulliparous woman effacement usually precedes dilation where as in a multiparous woman dilation precedes effacement

A

TRUE

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115
Q

What is 100% effacement?

A

when the mother is ready to deliver and the cervix is paper thin or ripened

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116
Q

What is the bloody show?

A

loss of the mucous plug and often proceeds true labor

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117
Q

What is station?

A

the relationship of the fetal head to the ischial spines

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118
Q

What is a bishop score that indicates a cervix that is favorable for spontaneous deliver?

A

a score of greater than 8

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119
Q

What is induction?

A

the attempt to begin labor in a non laboring patient

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120
Q

What is augmentation?

A

the process of increasing already present labor

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121
Q

What is related to the success of induction?

A

the bishop score

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122
Q

What bishop score leads to an increased number of failed inductions?

A

a score of less than 5

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123
Q

What medication can you use to prepare a woman for induction?

A

prostaglandins to ripen the cervix

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124
Q

When are prostaglandins contraindicated?

A

maternal asthma, glaucoma, more than one prior C-section, or an unstable fetus

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125
Q

What is stage 1 of labor?

A

begins with onset of true labor to complete cervical dilation and effacement

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126
Q

What is the avg duration of stage 1 of labor in a nulliparous vs multiparous woman?

A

nulli - 6 to 18 hrs multi - 2 to 10 hours

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127
Q

What is the latent phase of stage 1 of labor?

A

onset of labor until 3-4 cm of dilation

128
Q

What is the active phase of stage 1 of labor?

A

ranges until greater than 9 cm dilation

129
Q

What is the transmit time during stage 1 on labor affected by?

A

power - the strength and frequency of contractions passenger - size and position of the fetus pelvis - size and shape of pelvis

130
Q

What is stage 2 of labor?

A

expulsion - from the time of full dilation to the delivery of the infant

131
Q

What is the average time for stage 2 of labor?

A

usually 30 min; may be up to 3 hrs in a nulliparous woman

132
Q

How often should you assess the apgar score after delivery?

A

at 1 and 5 min post delivery

133
Q

What are the degrees of lacerations during labor?

A

First degree - through the skin and mucous Second degree- extends into the perineal body Third Degree- extends into our through the anal sphincter Fourth degree - into the mucous of the anus

134
Q

What is stage 3 of labor?

A

from delivery to the separation and expulsion of the placenta

135
Q

What are the 4 signs of placental separation?

A

cord lengthening outside the vagina, a fresh rush of blood, uterine fundus rising up, uterus becoming more firm and globular

136
Q

When is a retained placenta diagnosed?

A

when it has not been delivered after 30 minutes

137
Q

What is considered the 4th stage of labor?

A

the hour after delivery when tears, lacerations, and hemorrhage are evaluated and treated

138
Q

In a pt in labor how often should you check the status of membranes and perform cervical exams?

A

usually every 2 hrs; can be more frequent as labor progresses

139
Q

During stage 1 of labor how is the patient positioned?

A

she can sit in a chair or ambulate

140
Q

What is the diet of a woman in stage 1 of labor?

A

clear liquids and ice chips - avoid food

141
Q

How often is intermittent fetal monitoring performed?

A

every 15 minutes

142
Q

When is continuous monitoring of fetal heart done?

A

after determining baseline to monitor for fetal distress

143
Q

What is the typical baseline fetal HR?

A

between 120-160 bpm

144
Q

What are normal accelerations in fetal HR?

A

an increase of 15 bpm for 15 sec above the normal baseline HR are reassuring and actually are a sign of fetal well being

145
Q

What can a fetal HR of above 160 indicate?

A

infection, hypoxia, or anemia

146
Q

What can cause early decelerations?

A

increased vagal tone due to compression of the fetal head during contractions… these occur when approaching the 2nd stage of labor and are usually benign

147
Q

How are early decelerations related to contractions?

A

they begin and end at the same time

148
Q

What are variable declarations?

A

occur at any time and drop more than early or late decels; rapid drops in fetal HR with a return to baseline with variable shape and no pattern; usually a result of umbilical cord compression but if mild and infrequent then they are benign

149
Q

What are late decelerations?

A

fetal HR drops during the 2nd half of the contraction - begins at the peak of contraction and then returns to baseline after the contraction is complete; associated with uteroplacental compromise and always are worrisome

150
Q

What test gives the most accurate fetal HR pattern?

A

an electrode attached to the fetus head

151
Q

When is an electrode attached to the fetal head used?

A

when there are repetitive decelerations and it is difficult to monitor externally

152
Q

What are contraindication to electrode monitoring the fetus?

A

fetal thrombocytopenia, maternal hepatitis or HIV

153
Q

What is the management when a non-reassuring fetal HR is present?

A

stop oxytocin if able change maternal position administer O2 per mask measure fetal scalp pH - can eval for hypoxia and acidosis pH > 7.25 is normal pH

154
Q

How soon can US confirm or detect pregnancy?

A

as early as 5 wks by detecting the gestation sac or the fetal heart at 6 wks

155
Q

What is Nagel’s rule?

A

EDC is first day of LMP minus 3 mo plus 7 days

156
Q

What is EDC?

A

estimated date of confinement

157
Q

Is EDC measured from menstrual weeks or conception weeks?

A

menstrual weeks 40 wks = really 38 wks + 2 weeks of ovulation

158
Q

What does US use to determine gestational age?

A

uses the fetal crown to rump length at 5-12 wks can also use femur length

159
Q

TRUE or FALSE: the further along a pregnancy the more reliable an US is in determining age

A

FALSE: it is less reliable

160
Q

When does fetal quickening occur?

A

18-20 wks primigravida 14-18 wks multigravida

161
Q

When can a fetal US detect fetal heart tones?

A

by 5-6 weeks

162
Q

When can a handheld doppler US detect fetal heart tones?

A

9-10 weeks

163
Q

When can a non-electrical fetoscope detect fetal heart tones?

A

18-20 weeks

164
Q

What is gravida?

A

every pregnancy is a gravid event

165
Q

What is considered term?

A

37-42 weeks

166
Q

What is considered preterm?

A

20-36 weeks

167
Q

What is Chadwick’s sign?

A

bluish discoloration of the vagina and cervix

168
Q

What is Goodell’s sign?

A

softening and cyanosis of the cervix after 4 weeks

169
Q

What is Hegar sign?

A

softening between the fundus and the cervix

170
Q

What is the time frame for the first trimester?

A

lasts until 14 wks gestation

171
Q

What is the time frame for the second trimester?

A

14 weeks - 28 weeks

172
Q

What is the time frame for the third trimester?

A

lasts from 28 weeks gestation to delivery

173
Q

What are the most common causes of direct obstetrical deaths?

A

hypertensive diseases of pregnancy hemorrhage infection/sepsis thromboembolism in developing countries obstructed labor and complications from illegal abortion, ectopic pregnancy, complications from anesthesia, and amniotic fluid embolism

174
Q

What are the most common causes of indirect obstetrical deaths?

A

asthma heart disease Type 1 Diabetes SLE and other conditions that are aggravated by pregnancy to the point of death

175
Q

What is the estimated % of preventable pregnancy related deaths?

A

80%

176
Q

What is the definition of pregnancy related mortality?

A

direct or indirect causes of maternal death counted from conception to 1 year postpartum

177
Q

What immunizations should you educate a pt on before conception that are not recommended during pregnancy?

A

MMR, varicella, polio, and yellow fever

178
Q

Ideally when should the first visit occur after the LMP?

A

6-8 weeks

179
Q

At what week is a brush no longer allowed to be used during a pap smear exam?

A

no brush after 10 weeks, spatula only

180
Q

What cultures are required at the initial visit?

A

cultures for G/C

181
Q

What are the labs included during the initial visit?

A

CBC, blood type and Rh antibody screen, RPR/syphilis, rubella titer, varicella, Hep B surface antigen, herpes simplex virus, urinalysis, random glucose, HIV testing, screening for CF, SC, and thalassemia, and Coombs test ir irregular antibody screen

182
Q

What medical history is required to obtain on an initial visit?

A

GYN hx: pap smears, ovarian cysts, fibroids, and STIs cardiovascular asthma, autoimmune d/o, bleeding d/o, and seizure d/o

183
Q

After the initial visit how often are follow up visits recommended?

A

every 4 weeks until the 32nd week every 2 weeks up until the 36th week then weekly thereafter

184
Q

When can fetal movement typically be detected?

A

approx 20 weeks

185
Q

When is a vaginal exam to check to cervix usually added into the visits?

A

added after 36 weeks

186
Q

What should be included in each return visit after the initial visit?

A

focused history and physical, maternal vitals, BP, and weight checked, measurement of fundal height, evaluation of heart sounds starting at 10 weeks, and labs such as urinalysis which may show glucosuria, ketonuria, and proteinuria

187
Q

When is the fundal height just above the pubic symphysis?

A

12 weeks

188
Q

When is the fundal height between the pubic symphysis and the umbilicus?

A

14-16 weeks

189
Q

When is the fundal height at the level of the umbilicus?

A

20-22 weeks

190
Q

When does the fundal height start correlating to the gestational age?

A

22-38 weeks

191
Q

At 22-38 weeks how much should the fundal height be growing?

A

1 cm every week

192
Q

When is the fundal height found 2-3 cm below the xiphoid process?

A

38-40 weeks

193
Q

When does genetic and congenital screening typically occur?

A

during the second trimester

194
Q

What is included in the Ultrascreen?

A

US to look at nuchal translucency, PAPP-a and hCG, screening for trisomy 21 and 18

195
Q

When is can the Ultrascreen be performed?

A

during the 1st trimester however better when combined with the 2nd trimester testing for combined risk

196
Q

During the second trimester special testing when is it appropriate to only get an AFP?

A

if the first trimester Ultrascreen was performed

197
Q

What is the Quadruple Screen?

A

hCG, estriol, inhibin-A, and AFP

198
Q

When is the Quadruple screen typically performed?

A

during the 2nd trimester 15-19 6/7 weeks - longer if specialty labs

199
Q

What does an elevated AFP correlate with an increased risk of?

A

risk of neural tube defects

200
Q

What does a decreased AFP correlate with?

A

down syndrome

201
Q

What does a decreased estriol indicate?

A

increased risk of trisomy 21 and 18

202
Q

What is an increased hCG correlated with?

A

trisomy 21

203
Q

What is a decreased hCG correlated with?

A

trisomy 18

204
Q

When is an anatomy US usually performed?

A

usually around 20 weeks; there is a lower sensitivity when performed prior to 18 weeks

205
Q

What can be seen on the anatomy US?

A

head, heart, abdomen, long bones, genitalia, fluid, uterine architecture

206
Q

What is included in the 24-28 week prenatal care visit?

A

a GDM screen 1 hour after non-fasting 50g load standard to screen everyone

207
Q

What is a normal blood sugar level when screening for GDM?

A

less than 130-140

208
Q

What happens if you fail the initial GDM screening?

A

you will fast over night and then drink a glucose solution and blood levels will be measured every hour for 3 hours… if two are higher than normal then GDM is diagnosed

209
Q

What is included in the 27-36 prenatal care visits?

A

TDAP new recommendations violence screening plans for feeding, circumcision, and pain control (no need to educate patients of breast feeding yet)

210
Q

What is included in the 36 wks prenatal care visits?

A

group B hemolytic strep testing - GBS results expire after 5 wks G/C testing –> chlamydia can lead to blindness Leopold maneuvers to estimate fetal size begin more routine checking of cervix

211
Q

What should you begin checking at prenatal visits at >37 weeks?

A

cervical checks dilation effacement station

212
Q

What is the increase in body water during pregnancy?

A

6.5 to 8.5 L

213
Q

How many liters is the amniotic fluid?

A

3.5 L

214
Q

How soon can cardiovascular changes be seen in a pregnant woman?

A

as early as 5 weeks gestation

215
Q

When taking an EKG on a pregnant pt how should the leads be adjusted?

A

move the leads out to the left

216
Q

How much does the HR increase in a pregnant woman?

A

15-20 above nongravid

217
Q

When does the CO increase peak?

A

30-50% increase peaks at 30 wks

218
Q

What is increased cardiac output dependent upon?

A

maternal position supine is lower than lateral recumbent or knee-chest

219
Q

How can supine hypotension manifest?

A

N/V, dizziness, and syncope

220
Q

Is vascular resistance decreased or increased during pregnancy?

A

decreased

221
Q

What murmur can be heard in a pregnant patient?

A

splitting 1st heart sound - systolic murmur diastolic murmurs can be heard and should still be worked up

222
Q

When can BP changes start being seen?

A

as early as 8 weeks typically nadir midpregnancy and then return to normal at term - although sometimes they can be higher

223
Q

What are normal pregnancy complaints?

A

dyspnea, decreased exercise tolerance, fatigue, orthopnea, and chest discomfort

224
Q

What pregnancy complaints should you not ignore?

A

hemoptysis, worsening dyspnea, syncope or CP with exertion

225
Q

When a pregnant pt has cold symptoms what should you tell them to avoid?

A

nasal decongestants –> can lead to HTN and rebound congestion

226
Q

What acid/base disturbance occurs during pregnancy?

A

chronic respiratory alkalosis - decreased PaCO2, and increased PaO2

227
Q

What makes a pregnant patient more susceptible to apnea?

A

decreased O2 reserves

228
Q

Is total lung capacity decreased of increased during pregnancy?

A

dec 5% secondary to elevation of the diaphragm

229
Q

Is the tidal volume decreased or increased during pregnancy?

A

increased 30-40% the tidal volume is the amount of air that is displaced when normal inhalation and exhalation occurs

230
Q

How many calories should a pregnant woman be consuming in a day?

A

300kCal/day

231
Q

What is the pathology behind GERD in a pregnancy woman?

A

progesterone relaxes the sphincter

232
Q

What are GI labs that may present during pregnancy?

A

decreased albumin increased alk phos other liver enzymes should not be changed - changes can indicate a pregnancy complication such as pre-eclampsia or cholestasis or pregnancy

233
Q

What is the treatment for N/V during pregnancy?

A

supportive care B6 and Unisom are 1st line treatment

234
Q

What is Zofran associated with when used early in pregnancy?

A

heart defects and cleft palate

235
Q

When can Zofran be used to tx N/V during pregnancy?

A

used as a last resort when everything else has been tried and they still cannot keep anything down and they are losing weight and have electrolyte imbalances

236
Q

Is hydronephrosis uncommon during pregnancy?

A

No, this may be visualized on US because of position of the uterus pressing more on the right the ureter are dilated and can make radiographs more difficult to interpret - Right > left

237
Q

Should hematuria in a pregnant pt be worked up?

A

it is common but still should be worked up

238
Q

What kidney laboratory test results may be seen during pregnancy?

A

BUN/Cr decrease (b/c of hyperfiltration) proteinuria 300 mg glycosuria (1-10mg of glucose per day)

239
Q

Is A1c useful for diagnosing GDM during pregnancy?

A

NO, look at the postprandial glucose levels

240
Q

When should proteinuria during pregnancy be cause for concern?

A

when there is associated HTN

241
Q

What cholesterol levels can be seen during pregnancy?

A

increased triglycerides (200-300 is normal) increased total cholesterol and increased LDL

242
Q

When does total triglycerides return to normal?

A

around 8 weeks postpartum

243
Q

Does cholesterol return to normal faster or slower than triglycerides?

A

cholesterol takes longer to return to normal; especially is the mother is nursing

244
Q

Does TSH increase or decreased during first trimester?

A

slightly decreases then it returns to normal pre-pregnant levels

245
Q

For how long is the fetus dependent on maternal thyroid hormone?

A

until 12 weeks

246
Q

What adrenal levels can be seen during pregnancy?

A

increased aldosterone, cortisol, and ACTH

247
Q

What pituitary hormones increase during pregnancy?

A

the pituitary increases in size making it susceptible to bleeding prolactin from anterior and oxytocin from posterior increase

248
Q

What can rash of hands and feet of a pregnant women indicate?

A

cholestasis disease and in these cases early delivery is needed

249
Q

What musculoskeletal chgs are seen during pregnancy?

A

inc maternal calcium absorption reversible trabecular bone loss lumbar lordosis widening of the pubic symphysis loosening of the sacroiliac and pubic joints relaxin

250
Q

What is severe gum disease linked to during pregnancy?

A

poor outcomes such as preterm labor and low birthweight unfortunately treatment does not decrease the risk

251
Q

What are the 5 components of electronic fetal monitoring?

A

baseline heartrate beat to beat variability accelerations decelerations maternal contractions

252
Q

What is the teratogenic period?

A

day 31 to day 71

253
Q

When have all major organ systems of the fetus been established?

A

by 10 weeks

254
Q

What is drug category A?

A

tested safe on a human fetus?

255
Q

What is drug category B?

A

tested safe on animals or tested safe on pregnancy despite abnormal animal

256
Q

What is drug category C?

A

some risks noted in animals; Phenergan

257
Q

What is drug category D?

A

risks likely outweigh the benefits ACEIs, Warfarin, NSAIDs

258
Q

What is drug category X?

A

no; incompatible with life, requires surgery producing major dysfunction

259
Q

What are examples of category B drugs?

A

Tylenol (acetaminophen), Benadryl (diphenhydramine), Pepcid (famotidine), Claritin (loratadine)

260
Q

What pregnancy complications can occur from smoking?

A

abruption, placenta previa, growth restriction, prematurity, prolonged rupture of membranes, SAB, SIDs, cleft palate

261
Q

What pregnancy complications can occur from alcohol?

A

growth retardation, facial anomalies, CNS defects

262
Q

What pregnancy complications can occur from cocaine use?

A

cardiac, CNS, and abruption

263
Q

What are medications to avoid during pregnancy?

A

decongestants, HMG CoA reductase inhibitors, ACEIs and ARBs, Warfarin, Retinoic Acid, NSAIDs, Methotrexate, Cytotec (misoprostol), sulfonamide antibiotics, valproic acid and carbamazepine, lithium, tetracyclines, aminoglycosides

264
Q

What are the side effects of aminoglycosides?

A

ototoxicity and nephrotoxicity

265
Q

What are some side effects of tetracyclines?

A

cartilage and bone; bone earlier in pregnancy and cartilage later in pregnancy

266
Q

What are some effects of valproic acid and carbamazepine?

A

neural tube defects and cleft lip

267
Q

What are the effects of NSAIDs during pregnancy?

A

increase PG and premature closure of PDA

268
Q

What effect do statins have during pregnancy?

A

fetal skeleton

269
Q

What effect do ACEIs and ARBs have during pregnancy?

A

fetal kidneys

270
Q

What effects does Warfarin have during pregnancy?

A

skeletal defects

271
Q

When is the initial postpartum visit usually scheduled?

A

4-6 wks after delivery C-section mothers may be seen sooner

272
Q

What labs are usually ran during the postpartum visit?

A

2h 75g glucose challenge for GDM CBC, TSH

273
Q

What are the B’s of postpartum visits?

A

bleeding/lochia - gone by 6 wks postpartum breastfeeding bowels - constipation can continue bladder - dysuria normal for a few weeks, not after 6 wks Blues - postpartum depression Birth control - wait until postpartum visit for intercourse; try to wait 6 wks to heal

274
Q

What do abnormally low PAPP-A and abnormally high beta-hCG levels indicate an increased risk for?

A

trisomy 21 … and other genetic d/os

275
Q

What is the nuchal translucency screening test?

A

US measurement of the nuchal space - screens for trisomy’s 13, 18, and 21 as well as for turner syndrome

276
Q

When is the nuchal translucency screening test performed?

A

10-13 weeks

277
Q

What happens if an abnormally wide measurement for gestation age is detected on the nuchal fold scan?

A

chorionic villus sampling or amniocentesis is offered

278
Q

How is CVS performed?

A

a catheter or needle is used to biopsy placental cells

279
Q

What is a disadvantage of CVS?

A

CVS specimens cannot be used in AFP testing for neural tube defects amniocentesis specimens however can

280
Q

Is the risk of spontaneous abortion after CVS and amniocentesis the same?

A

yes, once adjusted for the fact that CVS is performed at an earlier gestational age

281
Q

What levels are screened for during second trimester screening?

A

unconjugated estriol, AFP, and inhibin A

282
Q

What levels of estriol, AFP, and inhibin A indicate an increased risk for trisomy 21?

A

low estriol low AFP high inhibin A

283
Q

Abnormally high levels of what are associated with an increased risk for neural tube defects?

A

abnormally high AFP AFP can detect 75-85% of defects such as spina bifida and anencephaly

284
Q

What strategy gives the best chance of detecting trisomy 21 disorders?

A

combining first trimester screening and second trimester screening can detect 94% to 96% of trisomy 21 d/o

285
Q

In second trimester screening what are you checking by US?

A

fetal viability, growth in relation to gestational age, placental status and location, amniotic fluid levels, looking for lethal malformations

286
Q

What is amniocentesis?

A

involves the withdrawal of amniotic fluid via needle under US guidance for prenatal diagnosis

287
Q

When is amniocentesis usually performed?

A

during 15-18 weeks

288
Q

What are the indications for amniocentesis and CVS?

A

maternal age of 35 yrs or older previous child with chromosomal abnormality patient or father of baby with chromosomal anomaly neural tube defect risk (amniocentesis only) abnormal first-trimester or second-trimester maternal serum screening tests two previous pregnancy losses abnormal ultrasound

289
Q

When are results for amniocentesis available?

A

they are not available for a minimum of 7 days

290
Q

When are CVS results available?

A

preliminary test results are available 48 hours after the procedure

291
Q

What is the goal of third trimester screening?

A

screening for fetal well being

292
Q

What is used to monitor fetal well being during the 3rd trimester?

A

external doppler monitor along with an external stress test gauge for uterine contraction (together these are called the non-stress test (NST)) –> these tests can also assess risks for those with preexisting maternal complications and pregnancies with complications US can also be used late in pregnancy

293
Q

What does a normal (reactive) NST require?

A

two accelerations of fetal HR in 20 minutes of up to 15 bpm from the baseline HR for a duration of 15 seconds… and the absence of deceleration

294
Q

What are a negative side effect of contractions?

A

they decrease the flow of blood to the placenta –> this is poorly tolerated by a stressed fetus and can lead to hypoxia and concomitant relative bradycardia

295
Q

What are decelerations defined as?

A

a decline in fetal HR of 15 bpm or lasting more than 15 sec or a slow return to baseline… persistent late decelerations which begin after the peak of the contraction warrant intervention

296
Q

What is the biophysical profile (BPP)?

A

the BPP examines five parameters, including NST, amniotic fluid level, gross fetal movements, fetal tone, and fetal breathing. each parameter has a maximum of 2 points; a total of 10 points is possible

297
Q

How is the BPP evaluated?

A

with ultrasound later in pregnancy to monitor fetal well being

298
Q

What are maternal complications associated with GDM?

A

infection, miscarriage, neuropathy, postpartum hemorrhage, pre-eclampsia, vascular or end organ involvement (kidneys)

299
Q

What are fetal complications of GDM?

A

should dystocia, traumatic delivery, prematurity, IUGR, delayed lung maturity, macrosomia, congenital abnormalities

300
Q

When is the first glucose tested recommended for pregnant women?

A

a random glucose should be obtained at the first prenatal visit to check for pre-existing DM –> then follow up with repeat screening around 24-28 wks

301
Q

What are the high risk factors that mandate early GDM screening?

A

age greater than 35-40 yo obesity (non pregnant BMI > 30) prior hx of GDM heavy glucosuria (> +2 on dipstick) hx or unexplained stillbirth PCOS strong family history of DM

302
Q

What is the normal fasting glucose?

A

less than 105

303
Q

In the 1 hr glucose test after a glucose load of 50 gm what is the normal glucose level?

A
304
Q

What is done if the glucose test 1hr after a 50 gm glucose load is abnormal (positive) what should be done?

A

an OGTT

305
Q

What is an OGTT?

A

the pt fasts overnight then receives 100 gm of glucose in the am - the glucose is then checked at hour 1,2, and 3 post glucose load

306
Q

In the OGTT what is the normal 1 hr glucose level?

A

less than 180

307
Q

In the OGTT what is the normal 2 hr glucose level?

A

less than 155

308
Q

In the OGTT what is the normal 3 hr glucose level?

A

less than 140

309
Q

When is GDM diagnosed?

A

when 2 or more of the levels in the OGTT are elevated

310
Q

Are oral hypoglycemic agents such as metformin indicated in GDM?

A

not as of now because they can cross the placenta - they are used in other countries and the US is debating them

311
Q

When does more aggressive non-stress test monitoring begin for a pt with GDM?

A

at 24 weeks

312
Q

What should be given to a GDM pt in labor?

A

IB glucose as 5% dextrose in LR –> want to avoid hyperglycemia in the mother in order to minimize the risk of neonatal hypoglycemia after delivery if the mother is on insulin during the pregnancy it is reasonable to have continuous infusion during labor

313
Q

How often are you monitoring BG during labor in a pt with GDM?

A

every 2-4 hours in early labor and every 1-2 hours in active labor

314
Q

What is the at home management for a pt with GDM?

A

a glucometer should be used at home in order to check their blood glucose levels fasting, 1-2 hr postprandial at each meal, and again at bedtime

315
Q

When does induction occur in a pt with GDM?

A

when the glucose is poorly controlled or there are signs of macrosomia induction occurs at 38 weeks

316
Q

When should pts who had GDM receive screening postpartum?

A

screened again at 6 weeks and then yearly

Women's Health (8 decks)

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