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Repro 2 > High yield Clinical > Flashcards

High yield Clinical Flashcards

1
Q

What strains of HPV cause the majority of cancers

A
  • 16, 18, 31, 45

- 16 and 18 cause 70%

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2
Q

parity and risk factor for cervical neoplasia

A

High parity

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3
Q

General Cervical screening guidelines

A
  • under 21: no screening
  • 21-29: cytology alone every 3 years
  • 30-65: HPV and cytology every 5 years
  • 65 and over: no screening following adequate negative prior screening
  • After hysterectomy: no screening
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4
Q

Management of a women with atypical squamous cells of undetermined significance (ASC-US) on cytology

A
  • Repeat cytology at 1 year
  • if negative then back to routine
  • if positive then colposcopy
  • also do HPV testing
  • if negative then repeat contesting @ 3 years
  • if positive then colposcopy
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5
Q

management of a woman with LSIL

A
  • if with negative HPV test then repeat cotesting @ 1 year is preferred but colposcopy acceptable
  • then if repeated is negative for cytology and HPV then repeat cotesting @ 3 years
  • if original LSIL has no HPV test or the HPV is positive then do colposcopy
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6
Q

management of women with HSIL

A
  • TREATMENT

- immediate loop electrosurgical excision or colposcopy

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7
Q

what is the gold standard for diagnosis and treatment planning of cervix

A

colposcopy

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8
Q

Acetowhite changes

A

for a colposcopy the cervix is washed with 3% acetic acid which dehydrates cells and large nuclei of abnormal cells turn white

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9
Q

what are the things you look for in a colposcopy in order of severity of disease

A
  • Acetowhite changes
  • punctations
  • abnormal vessels
  • masses
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10
Q

what is ECC

A

endocervical curettage

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11
Q

what age does insurance cover for HPV vaccine

A

9-26

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12
Q

When are excisional treatment options of the cervix done

A
  • endocervical curettage positive
  • unsatisfactory colposcopy (No SCJ)
  • substantial discrepancy b/t pap and biopsy (high grade pap and negative colposcopy)
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13
Q

what are the risks of excisional cervical procedures

A
  • increased risk of cervical incompetence and resultant 2nd trimester pregnancy loss
  • increased risk of preterm premature rupture of membranes (PPROM)
  • cervical stenosis
  • operative risks: bleeding, infections
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14
Q

what are the excisional procedures for cervix

A
  • CKC: cold knife cone

- LEEP: loop electrode excisional procedure

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15
Q

symptoms of cervical carcinoma

A
  • watery vaginal bleeding
  • postcoital bleeding
  • intermittent spotting
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16
Q

describe the injection series for HPV vaccine

A
  • first dose
  • second dose 2 months later
  • third dose 6 months from the first

-if less than 15 then 2 doses separated by 6-12 months

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17
Q

Which HCs have less androgenic agents

A
  • desogestrel
  • norgestimate
  • drospirenone
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18
Q

mechanism of actions of progestin only oral contraceptive

A

primarily making cervical mucous thick and impermeable

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19
Q

when are progestin only OCs used

A

-breastfeeding and women who have a contraindication to estrogen

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20
Q

What is the weight caution on a transdermal patch contraceptive

A

-caution with use in women greater than 198 pounds

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21
Q

what is the major side effect of the transdermal patch contraceptive

A

-same as OCs except greater risk of thrombosis

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22
Q

who can’t be on combo contraceptives

A
  • women over 35 who smoke
  • women with history of thromboembolic event
  • moderate to sever liver disease or liver tumors
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23
Q

what is the FDA black box warning for Depo-Provera shot

A
  • if used for more than 2 years should consider alternative method
  • concern for bone disease
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24
Q

what is a key side effect of depo

A

exacerbation of depression

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25
Q

what are some unique indications for used of depo-provera

A
  • decreased number of crisis in sickle cell anemia

- decrease risk of endometrial hyperplasia

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26
Q

contraindications for depo-provera

A
  • known or suspected pregnancy
  • unevaluated vaginal bleeding
  • known or suspected malignancy of the breast
  • liver dysfunction/disease
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27
Q

how long is Nexplanon used? (implant)

A

3 years

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28
Q

what is the only absolute contraindication for Nexplanon use

A

-known or suspected breast cancer

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29
Q

name for copper IUD

A

paragard

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30
Q

what type of female sterilization may be good for obese patients that might not be good candidates for other methods

A

Hysteroscopy: transcervical approach to tubal ligation

-also called Essure system

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31
Q

what is it called when the bladder intrudes on the anterior vaginal wall

A

Anterior vaginal prolapse or cystocele

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32
Q

what is it called when the rectum intrudes on the posterior vaginal wall

A

Lower posterior vaginal prolapse or rectocele

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33
Q

what is a sagging uterovaginal canal after a hysterectomy called

A

vaginal vault prolapse

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34
Q

symptoms for a cystocele

A
  • pelvic pressure or bulging sensation
  • not old
  • NO bowel or urinary complaints
  • vaginal deliveries . . maybe a big baby
  • smoking
  • overweight
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35
Q

what are the treatment options for anterior vaginal prolapse (cystocele)

A
  • do nothing
  • pelvic floor physical therapy
  • pessary
  • surgery: anterior colporrhaphy
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36
Q

symptoms for apical prolapse

A
  • older
  • “something falling out”
  • doesn’t empty bladder completely and voids small amounts frequently
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37
Q

Treatment options for apical prolapse

A
  • pessary
  • Hysterectomy
  • Colpocleisis: put everything back up and sew vagina up . . not good option if sexually active
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38
Q

symptoms of stress incontinence

A

-incontinence with coughing, sneezing, laughing

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39
Q

what tests can help in diagnosis of stress incontinence?

A
  • physical exam
  • Q tip test: put Q tip in urethra and have them do Valsalva and if it moves more than 30 degrees then confirms stress incontinence
  • urodynamics
  • postvoid residual (less than 50 mL is normal)
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40
Q

Treatment options for stress incontinence

A
  • topical estrogen
  • pelvic floor physical therapy/kegels
  • pessary
  • surgery - suburethral sling (transvaginal tape or transobturator tape for vaginal approach. . . abdominal approach with Marshall-Marchetti-Kranz or Burch procedure
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41
Q

symtpoms of rectocele

A
  • no bladder complaints
  • needing to splint to have bowel movement
  • pressure sensation and fullness in vagina
  • lots of kids
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42
Q

what is the best option for treatment of rectocele

A

SURGERY

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43
Q

symptoms for urge incontinence

A
  • maybe no kids
  • urinary urgency and frequency
  • no bowel complaints
  • 3-4 times a night but only small amounts
  • drinks 5-6 diet sodas a day and has a bottle of water with her at all time
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44
Q

treatment for urge incontinence

A
  • behavioral modification: less caffeine, limit fluids after 7 pm, bladder training
  • antispasmodics: oxybutynin and tolterodine
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45
Q

when is gestational diabetes screening done and why

A

between weeks 24 -28

-this is when placenta is pumping out most hPL

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46
Q

Describe the screening for gestational diabetes

A
  • 50 gram 1 hour oral load glucose challenge (>130-140 is abnormal)
  • if abnormal then followed by a 3 hours 100 gm oral load glucose tolerance test
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47
Q

what indicates good glycemic control in gestational diabetes

A
  • fasting glucose less than 90 mg/dL
  • 2 hour postprandial less than 120
  • control with diet, oral hypoglycemic medications (glyburide), or insulin
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48
Q

When doing an ultrasound in a gestational diabetes patient, what weight do you recommend a cesarean section

A

greater than 4500 grams

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49
Q

describe treatment of maternal hyperthyroidism

A
  • Methimazole in 2nd and 3rd trimester (can cause aplasia cutis and choanal atresia in 1st trimester)
  • Propylthiouracil only in 1st trimester
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50
Q

what is the most common lesion of rheumatic heart disease in pregnancy

A

mitral valve stenosis

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51
Q

what is the most frequent cardiac arrhythmia in pregnancy

A

supraventricular tachycardia

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52
Q

when does post partum cardiomyopathy occur?
who is at risk?
mortality rate?

A
  • within last weeks of pregnancy or within 6 months postpartum
  • women with preeclampsia, HTN, and poor nutrition
  • 10%
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53
Q

Treatment of symptomatic nausea and vomiting in pregnancy

A
  • vitamin B6
  • Doxylamine
  • Promethazine
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54
Q

what is Mendelson’s syndrome

A
  • acid aspiration syndrome
  • delayed gastric emptying and increased intraabdominal pressure in pregnancy
  • can result in adult respiratory syndrome
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55
Q

treatment of Mendelson’s syndrome

A
  • supplemental oxygen
  • maintain airway
  • treatment for acute respiratory failure
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56
Q

how do you prevent mendelson’s syndrome

A
  • decrease acid in stomach

- don’t feed in labor

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57
Q

anemia in pregnancy defined as what?

A

Hct less than 30% and HgB less than 10

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58
Q

symtpoms of superficial thrombophlebitis

A
  • palpable cord in calf
  • most common in pts with varicose veins, obesity, and little physical activity
  • swelling and tenderness
  • will NOT result in PE
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59
Q

treatment for thrombophlebitis

A
  • bed rest
  • pain meds
  • local heat
  • no need for anticoagulatns
  • wear support hose
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60
Q

why should u avoid estrogens post partum for contraception

A

risk of DVT

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61
Q

what is used to diagnose DVT?

A
  • compression US with DOPPLER FLOW

- MRI if suspect pelvic thrombosis

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62
Q

treatment of DVT in pregnancy

A
  • lovenox
  • switch to heparin at 36 weeks
  • Coumadin is used for 6 weeks postpartum but not during pregnancy due to risk of fetal hemorrhage or teratogenesis
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63
Q

pts with a DVT or PE require what workup

A

thrombophilia

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64
Q

what is the most common pulmonary disease in pregnancy

A

asthma

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65
Q

most common type of headache in pregnancy?

treated how?

A
  • tension

- acetaminophen

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66
Q

what seizure med should NOT be used in pregnancy as it is more teratogenic than others?
Which ones are most commonly used

A
  • Valproate

- Dilantin and phenobarbital

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67
Q

women on antiepileptics should be on what supplement

A

-1 to 4 mg of folic acid

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68
Q

What is considered prolonged second stage of labor? (an indication for operative vaginal delivery)

A
  • Nulliparous: >2 hours without regional anesthesia or >3 hours with
  • Multiparous: >1 hour w/o or >2 hours with
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69
Q

what are the maternal prerequisites for operative vaginal delivery

A
  • adequate analgesia
  • lithotomy position
  • bladder empty
  • verbal or written consent
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70
Q

what are the fetal prerequisites for operative vaginal delivery

A
  • vertex presentation (head down)
  • Fetal head must be engaged (biparietal diameter at 0 station)
  • position of fetal head must be known with certainty
  • station of fetal head must be >+2
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71
Q

what are the uteroplacental prerequisites for operative vaginal delivery

A
  • cervix fully dilated
  • membranes ruptured
  • no placenta previa
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72
Q

what forceps are used for breech presentation

A

piper

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73
Q

during operative vaginal delivery, rotation of head should not exceed how much

A

45 degrees

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74
Q

what are the best presentations for operative vaginal delivery?
which are ok?
which can you NOT do?

A
  • Right, left, or straight occipito-anterior
  • Right, left, or straight occipito-posterior
  • tranverse CANNOT
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75
Q

what is the advantage of vacuum assisted vaginal delivery over forceps?

A

delivery can be achieved with little maternal analgesia

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76
Q

what are the contraindications to vacuum assisted vaginal delivery

A
  • gestational age less than 34 weeks
  • suspected fetal coagulation disorder
  • suspected fetal macrosomia
  • Breech presentation
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77
Q

what is correct placement for vacuum?

A

posterior fontanelle

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78
Q

clinical pearls for vacuum assisted vaginal delivery?

A
  • release suction b/t contractions
  • no more than 2 “pop offs”
  • should not be applied more than 20 minutes
  • No torsion or twisting of device during use
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79
Q

preterm birth is defines as what

A

after 20 weeks but before 37 weeks

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80
Q

what is the diagnostic criteria for Preterm Labor

A

uterine contractions accompanied with cervical change or cervical dilation of 2 cm and/or 80% effaced

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81
Q

What is the link b/t preterm labor risk and cervix length

A
  • relative risk of 2.4 for length of 3.5 cm
  • RR of 6.2 for length of 2.5

basically shorter cervix = greater risk

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82
Q

in the management of pre term labor, what cultures are taken?
what antibiotics are given empirically?

A
  • Group B strep, also gonorrhea and chlamydia

- typically penicillin

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83
Q

What are the tocolytic agents to suppress pre term labor and what are the routes of administration

A
  • Magnesium sulfate (IV)
  • Nifedipine (oral)
  • Indomethacin (oral or rectally) mostly for extreme prematurity
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84
Q

what week does an infant become viable?

A

24 weeks

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85
Q

what hormone is used and thought to prevent pre term labor

A

-progesterone: IM (Makena) or vaginal (used in women with a shortened cervix <2.5 cm) . .

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86
Q

What do you NOT want to check in a patient with presumed premature rupture of membranes?

so how is the rupture confirmed?

A

do NOT check cervix . . increased risk of infection especially with the prolonged latency before delivery

-sterile speculum

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87
Q

what are the 3 tests used for confirmation of a PROM (premature rupture of membranes)

A
  • Pooling
  • nitrazine paper (turns blue)
  • ferning
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88
Q

what is the ACOG recommendation for management of PPROM

A

48 hour course of IV ampicillin and Erythromycin/Azithromycin followed by 5 days of Amoxil and Erythromycin
-steroids up to 34 weeks

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89
Q

what is the rapid test for fetal lung maturity

A
  • Lamellar body number density assessment (LBND)

- typically more than 46,000

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90
Q

when the birth weight of a newborn is below the 10% for a given gestational age

A

Intrauterine Growth Restriction (IUGR)

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91
Q

what is the primary screening tool for IUGR

A

serial fundal height

  • if fundal height lags more than 3 cm behind the gestational age then order an ultrasound
  • ultrasound will do measurements of the fetus
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92
Q

Describe what a Doppler study of umbilical artery will show if there is IUGR?

A

-there is normally high velocity diastolic flow but with IUGR there is diminution of umbilical artery diastolic flow

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93
Q

Describe the management of suspected IUGR

A
  • if US normal then no intervention
  • if US shows IUGR and greater than 38-39 weeks then deliver
  • if US shows IUGR and <38-39 weeks then do antenatal testing
  • if antenatal testing normal then continue pregnancy
  • if antenatal testing abnormal then deliver
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94
Q

a baby with IUGR is at greater risk for what adult onset conditions?

A
  • DM
  • HTN
  • Atherosclerosis
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95
Q

a pregnancy that continues past 42 weeks?

A

post term pregnancy

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96
Q

Fetal death after 20 weeks gestation but before the onset of labor

A

Intrauterine Fetal Demise (IUFD)

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97
Q

what is the management for IUFD?

A
  • Watchful expectancy: only up til 28 weeks . . most will have labor within 2-3 weeks of fetal demise
  • Induction of labor: most require cervical ripening
  • Monitoring of coagulopathy: risk of DIC, follow CBC, fibrinogen level, PT/PTT/INR
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98
Q

definition of hypertensive pregnancy

A

-sustained blood pressure higher than 140/90

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99
Q

what are the different classes of hypertension in pregnancy

A
  • Chronic: present before of recognized during first half of pregnancy
  • Gestational: recognized after 20 weeks gestation
  • preeclampsia: occurs after 20 weeks gestation and coexists with proteinuria
  • eclampsia: new onset seizure activity associated with preeclampsia
  • superimposed preeclampsia/exlampsia: transposed onto chronic HTN
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100
Q

When evaluating chronic HTN in pregnancy, you need to assess for maternal end organ damage by getting what tests

A
  • CBC
  • glucose
  • CMP
  • 24 hour urine collection for total protein
  • EKG
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101
Q

when does gestational HTN resolve

A

by 12 weeks post partum

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102
Q

symptoms of preeclampsia

A
  • scotoma
  • blurred vision
  • epigastric and/or right upper quadrant pain
  • Headache
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103
Q

risk factors for preeclampsia

A
  • age <20 or >35
  • primigravid
  • prior history
  • lots of others
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104
Q

what is the proteinuria findings if preeclampsia is severe

A

at least 5 gm/24 hour or 3+ protein on two random urine dips at least 4 hours apart

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105
Q

what physical exam findings will you have with preeclampsia

A
  • Brisk reflexes

- clonus

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106
Q

what lab findings will you have with preeclampsia

A
  • increased: Hct, lactate dehydrogenase, transaminases (AST, ALT), uric acid
  • thrombocytopenia
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107
Q

how do you manage the blood pressure in severe preeclampsia pts?

A
  • hydralazine
  • Labetalol
  • Nifedipine
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108
Q

when do you deliver the baby in severe preeclampsia

A

if greater than 34 weeks

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109
Q

what is used for seizure prophylaxis in preeclampsia patients?
Dose?

A

magnesium sulfate

  • IV
  • loading dose of 4 gm bolus
  • maintenance dose of 2 gm/hour
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110
Q

what is a variant of preeclampsia that gives right upper quadrant pain

A

HELLP syndrome

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111
Q

what might you be able to give to prevent preeclampsia

A

maybe aspirin

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112
Q

how do you manage HELLP syndrome?

A

deliver baby immediately

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113
Q

when is mammography best

A

40 years and older

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114
Q

what is useful in evaluating invconclusive mammogram findings

A

ultrasonography

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115
Q

Ultrasonography is best in evaluating whose breasts?

A
  • young women less than 40

- others with dense breast tissue

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116
Q

ultrasonography differentiates what breast lesions

A

cystic vs. solid

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117
Q

when is MRI used in imaging of breast

A
  • post cancer dx for further eval of staging
  • used with implants
  • women at high risk for breast cancer like BRCA carriers
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118
Q

what is the only FDA approved treatment for mastalgia (breast pain)?

A

danazol

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119
Q

what are some life style recommendations for a patient with mastalgia?

A
  • properly fitting bra
  • weight reduction
  • exercise
  • decrease caffeine intake
  • vitamin E supplementation
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120
Q

bloody nipple discharge is considered what?

A

cancer until proven otherwise

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121
Q

what are the characteristics of a breast mass that make it a concern for malignancy?

A
  • > 2 cm in size
  • immobility
  • poorly defined margins
  • firmness
  • skin dimpling/retraction/color changes
  • bloody nipple discharge
  • ipsilateral lymphadenopathy
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122
Q

what is the most common benign tumor in female breast

A

fibroedenomas . . usually in late teens and early 20s

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123
Q

what gene mutation is also associated with ovarian

A

BRCA1 . . also early onset

BRCA2 much lower risk of ovarian cancer

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124
Q

what breast cancer genetic mutation has worse prognosis and is found in 20-30% of invasive cancers

A

Her2/neu

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125
Q

what arteries does the functionalis of the endometrium contain?
the basalis?

A

spiral

basal

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126
Q

median age of menarche?

A

12.43

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127
Q

what tanner stage does menarche occur

A

at tanner stage IV . . rare before III

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128
Q

definition of primary amenorrhea

A

no menstruation by 13 WITHOUT secondary sexual development or by the age of 15 WITH secondary sexual development

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129
Q

what is the mean blood loss per menstrual period

A
  • 30cc

- 3-6 pads/day

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130
Q

how much blood loss is associated with anemia

A

80cc

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131
Q

what weight is essential to start menarche

132
Q

what is the first physical sign of puberty?

133
Q

order of puberty events

A
  • thelarche
  • adrenarche
  • growth
  • menses

-TAG Me

134
Q

ethnicity and puberty?

A

AA first then Hispanics then whites

135
Q

Tanner stage: Preadolescent elevation of papilla only

136
Q

Tanner stage: Breast bud stage; elevation of breast and papilla as a small mound with enlargement of the areolar region

137
Q

Tanner stage: further enlargement of breast and areola without separation of their contours

138
Q

Tanner stage: Projection of areola and papilla to form a secondary mound about the level of the breast

139
Q

Tanner stage: Mature stage; projection of papilla only; resulting from recession of the areola to the general contour of the breast

140
Q

Tanner stage: Preadolescent; absence of pubic hair

141
Q

Tanner stage Sparse hair along the labia; hair downy with slight pigment

142
Q

Tanner stage: Hair spreads sparsely over the junction of the pubes; hair is darker and coarser

143
Q

Tanner stage: Adult-type hair; there is no spread to the medial surface of the thighs

144
Q

Tanner stage: Adult type hair with spread to the medial thighs assuming an inverted triangle pattern

145
Q

How do you diagnose True isosexual precocious puberty

A
  • administer exogenous GnRH and see a resultant rise in LH levels consistent with older girls who are undergoing normal puberty
  • also MRI of the head
146
Q

what is treatment for true isosexual precocious puberty

A

-GnRH agonst (Leuprolide acetate)

147
Q

when is puberty considered delayed?

A
  • when secondary sexual characteristics have not appeared by the age of 13
  • if thelarche has not occurred by 14
  • no menarche by 15-16
  • when menses has not begun 5 years after onset of thelarche
148
Q

what is the FSH level for HYPERgonadotropic Hypogonadism?

A

> 30

-turner

149
Q

what are the FSH and LH levels for Hypogonadotropic Hypogonadism

A

FSH + LH = <10

150
Q

what is the definition of secondary amenorrhea

A

patient with prior menses has absent menses for 6 months or more

151
Q

what is the most common cause of hypogonadotropic hypogonadism

A

Kallman syndrome

152
Q

what is the most common for of female gonadal dysgenesis

153
Q

what do you check in a women with secondary amenorrhea and a negative pregnancy test

A

TSH and prolactin levels

  • if both normal then progesterone challenge test
  • if positive then normogonadotropic hypogonadism . . most common is PCOS
  • if negative then do estrogen/progesterone challenge test
154
Q

what are anatomic causes of secondary amenorrhea?

A

Asherman syndrome and cervical stenosis

155
Q

diagnosis of PCOS

A

need 2 of the following

  • Oligomenorrhea or amenorrhea
  • Biochemical or clinical signs of hyperandrogenism (LH to FSH 2:1)
  • U/S revealing multiple small cysts beneath cortex of ovary
156
Q

PCOS is increased risk for what cancer

A

endometrial

157
Q

definition of polymenorrhea

A

abnormally frequent menses at intervals < 21 days

158
Q

excessive and/or prolonged bleeding (>80mL and >7days) occurring at normal intervals

A

Menorrhagia

159
Q

irregular episodes of uterine bleeding

A

metrorrhagia

160
Q

heavy and irregular uterine bleeding

A

menometrorrhagia

161
Q

Scant bleeding at ovulation for 1 or 2 days

A

intermentrual bleeding

162
Q

menstrual cycles occurring >35 days but less than 6 months

A

Oligomenorrhea

163
Q

when do most dysfunctional uterine bleeding occur

A

menarche (11-14) or perimenopause (45-50)

164
Q

Structural causes of AUB?

Nonstructural causes?

A
  • P: polyp
  • A: adenomyosis
  • L: leiomyoma
  • M: malignancy and Hyperplasia
  • C: coagulopathy
  • O: ovulatory dysfunction
  • E: endometrial
  • I: Iatrogenic
  • N: not yet classified
165
Q

histological illustration of adenomyosis causes what

A

enlargement of the uterus

166
Q

Coagulopathies causing AUB

A
  • heavy flow

- Von Willebrand disease

167
Q

Ovulatory dysfunction causing AUB

A
  • unpredictable menses with variable flow

- PCOS

168
Q

Endometrial causes of AUB

169
Q

iatrogenic causes of AUB

A

IUD, exogenous hormones

170
Q

what are the available tissue sampling methods used to evaluate AUB

A
  • office endometrial biopsy

- Hysteroscopy directed endometrial sampling

171
Q

AUB treatment for massive bleeding

A
  • hospitalization and transfusions if hemodynamically unstable
  • 25 mg IV conjugated estrogens then hormonal treatment (combination hormonal therapy, Mirena)
172
Q

AUB treatment for moderate bleeding

A

combination OCPs, Mirena

173
Q

AUB treatment unresponsive to conservative therapy

A

-D&C, polypectomy, myomectomy, endometrial ablation, hysterectomy

174
Q

what is the most common type of genital cyst

A

epidermal inclusion cyst

175
Q

these are on the vulva and can enlarge and become painful in pregnancy and have a characteristic blue color

A

vulvar varicosities

176
Q

most common benign solid tumors of vulva

177
Q

this is a syndrome of intense sensitivity of skin of posterior vaginal introitus and vulvar vestibule resulting in dyspareunia and pain on attempted use of tampons

A

Vulvar vestibulitis

178
Q

what does physical exam of atrophic vaginitis reveal?

A
  • atrophy of external genitalia
  • minora regresses
  • majora shrinks
  • loss of vaginal rugae
  • vaginal introitus constriction
179
Q

treatment for atrophic vaginitis

A
  • topical estrogen

- may consider oral estrogen to prevent recurrence

180
Q

what does a biopsy of lichen simplex chronicus (squamous cell hyperplasia) show?

A
  • Elongated rete ridges

- hyperkeratosis of the keratin layer

181
Q

biopsy of lichen sclerosis

A
  • thin epithelium

- loss of rete ridges and inflammatory cells lining the basement membrane

182
Q

Treatment of lichen sclerosis

A

Clobetasol (steroid)

183
Q

if this is not detected until after menarche, then it appears as a thin dark bluish structure which entraps menstrual flow

A

imperforate hymen

184
Q

what is the most common vulvovaginal tumor

A

Bartholin’s cyst

185
Q

what stage of vulvar carcinoma has bilateral regional node metastases

186
Q

This type of carcinoma is a variant of squamous cell carcinoma of the vulva and lesions are cauliflower like and may be confused with condyloma. . . radiation is contraindicated because it may induce anaplastic transformation

A

Verrucous carcinoma

187
Q

vagina is lined by what epithelium

A

nonkeratinized stratified squamous epithelium

188
Q

what needs to be done in the investigation of vaginal discharge

A
  • obtain history
  • Nitrazine paper
  • Microscope
189
Q

when viewing vaginal discharge under a microscope, where do you get the sample discharge?

A

posterior fornix

190
Q

treatment of BV

A

metronidazole

-not an STI so don’t need to treat partner

191
Q

Treatment of vulvovaginal candidiasis

A
  • Diflucan

- vaginal application with synthetic imidazoles (miconazole, teraconazole,)

192
Q

Treatment for trichomoniasis

A
  • Metronidazole

- treat partner also

193
Q

when is hCG first detecting in SERUM

A

6-8 days after ovulation

194
Q

a urine pregnancy test can detect what level of hCG

A

titer of 25 IU/L

195
Q

Levels of hCG double every how often?

196
Q

a gestational sac can be seen via transvaginal ultrasound at what level of hCG

A

1500-2000 . DISCRIMINATORY LEVEL

197
Q

what rise in hCG in 48 hours confirms an abnormal IUP or ectopic pregnancy

A

less than 53%

198
Q

what are the most common cause of first trimester SABs?
which one specifically?
Which trisomy?

A
  • chromosomal abnormalities
  • 45XO . .Turner
  • trisomy 16
199
Q

what is a threatened abortion

A

vaginal bleeding and closed cervix

200
Q

what is an inevitable abortion

A

vaginal bleeding and cervix partially dilated

201
Q

what is an incomplete abortion

A
  • vaginal bleeding, cramping lower abd pain with dilated cervix
  • passage of some but not all the products of conception
202
Q

what is a complete abortion

A
  • passage of all products of conception (fetus and placenta) with a closed cervix
  • with resolution of pain, bleeding and pregnancy symtpoms
203
Q

what is a missed abortion

A

fetus has expired and remains in uterus . . no symptoms

-coagulation problems may develops, check fibrinogen levels weekly until SAB occurs or proceed with suction D&C

204
Q

recurrent abortions is defined as what ?

A

3 successive SABs

205
Q

cervical incompetence is usually seen with loss at which trimester

206
Q

painless dilation of cervix and delivery (SAB)

A

cervical incompetence

207
Q

what is the most common immunologic factor that causes spontaneous abortions

A

antiphospholipid syndrome

208
Q

what is the leading cause of maternal death in the first trimester

A

ectopic pregnancy

209
Q

Classic triad for ectopic pregnancy

A
  • prior missed menses
  • vaginal bleeding
  • lower abdominal pain
210
Q

symptoms of acutely ruptured ectopic pregnancy

A

-severe abdominal pain and dizziness

211
Q

physical exam for acutely ruptured ectopic preganancy

A
  • distended and acutely tender abdomen
  • usually has cervical motion tenderness
  • signs of hemodynamic instability (diaphoresis, tachycardia, loss of consciousness)
212
Q

what will an US reveal if there is an acutely ruptured ectopic pregnancy

A

empty uterus with significant amount of free fluid

213
Q

Describe the methotrexate treatment of ectopic pregnancy

A
  • give 50 mg IM x 1
  • check hCG levls on day 4 and 7
  • if decrease by 15%, continue to follow weekly until negative
  • if they plateau or fall slowly then give another dose
  • if pt becomes symptomatic or if hCG titers increase then proceed with surgical intervention
214
Q

what do you instruct a patient to avoid while take methotrexate for an ectopic pregnancy

A

Folate containing vitamins

215
Q

what is the preferred surgical approach for ectopic pregnancy if pt is hemodynamically unstable?
stable?

A
  • Laparotomy

- Laparoscopy

216
Q

Who do you give anti-D immunoflobulin to and when?

A
  • at 28 weeks and within 72 hours after delivery of a Rh D + infant
  • give to a Rh-negative women who is not RhD alloimmunized
217
Q

what test can be done to identify fetal RBCs in maternal blood and determine if additional RhoGAM is necessary

A

Kleinhauer-Betke test

218
Q

if Rh-antibody titers in mother are less than 1:8 then what?
if > 1:16?

A
  • usually indicate fetus is NOT in serious jeopardy and recheck q 4 weeks
  • requires further eval . . detailed US to detect hydrops and Doppler studies of Middle cerebral artery (MCA)
219
Q

what is the most valuable tool for detecting fetal anemia?

A

Doppler assessment of peak systolic velocity in fetal MCA

220
Q

what is the management of severe fetal anemia due to isoimmunization

A
  • intrauterine transfusions b/t 18-35 weeks

- use fresh group O, Rh-neg packed RBCs every 1-3 weeks

221
Q

most common location of fibroids

A

within myometrium . . intramural

222
Q

if an US reveals endometrial lining greater than what size then you need to sample the endometrium

A

> or equal to 4 mm

223
Q

how do you treat simple and complex endometrial hyperplasia WITHOUT atypia?

WITH?

A
  • progestin and resample in 3 months

- hysterectomy

224
Q

single most common benign ovarian neoplasm in premenopausal female

A

Benign cystic teratoma (Dermoid)

225
Q

what is meigs syndrome

A
  • ascites
  • right pleural effusion
  • ovarian fibroma
226
Q

what is the name of the solid prominence located at the junction b/t a teratoma and normal ovarian tissue

A

Rokintanksy’s protuberance

227
Q

what women can you use CA-125 as a serum marker for ovarian tumors?

A

POST MENOPAUSAL

228
Q

normal physical exam findings with pregnancy

A
  • systolic murmurs exaggerated splitting and S3
  • palmar erythema
  • spider angiomas
  • Linea nigra
  • Striae Gravidarum
  • chadwicks sign
229
Q

what prenatal labs are done at 1st visit

A
  • CBC
  • type and screen for Rh
  • Rubella: vaccinate postpartum if not immune
  • Syphilis (RPR)
  • HIV
  • cervical cytology and gonorrhea and chlamydia
  • screen for diabetes based on risk factors
  • urine culture
230
Q

what are the most important lab values of pregnancy

A
  • Hct decreases 4-7% by 30-34 weeks
  • hemoglobin: decreased 1.5-2 by 30-34 weeks
  • clotting factors increase 7-10x
231
Q

of weeks that have elapsed b/t first day of LMP and the date of delivery

A

gestational age

232
Q

level of hCG that is negative?
positive?
what should level be by time of expected menses?

A
  • <5
  • > 25
  • about 100
233
Q

when can you see gestational sac?
when can a fetal pole be seen by US?
When can you see cardiac activity?

A
  • 5 weeks (hCG of 1500-200)
  • 6 weeks (5200(
  • 7 weeks (17,500)
234
Q

what trimester is most accurate for dating a pregnancy

235
Q

what is Naegels rule

A

take LMP, minus 3 months, add 7 days and that is expected due date . . doesn’t work in pts with irregulat cycles

236
Q

what is used on US b/t 6-11 weeks and can determine due date within 7 days

A

Crown rump length (CRL)

237
Q

what is used on US b/t 12-20 weeks to determine due date within 10 days

A

-femur length, biparietal diameter, and abdominal circumference

238
Q

how is fetal demise diagnosed on US?

A

CRL >5 mm w/ absence of fetal cardiac activity

239
Q

who needs genetic counseling?

A

advanced maternal age . . over 35 years old

240
Q

what is the most common form of inherited mental retardation

A

Fragile X syndrome

241
Q

what does a first trimester screening include

A
  • maternal age
  • Fetal nuchal translucency thickness (NT): increased thickness associated with both chromosomal and congenital anomalies
  • maternal serum b-hCG
  • pregnancy associated plasma protein A (PAAP-A)
242
Q

Describe the Triple screen done in the second trimester

A
  • b-hCG, estriol, maternal serum alpho fetoprotein (AFP) biochemical markers
  • b/t 16-20 weeks
  • 70% detection rate of Trisomy 21
243
Q

Describe the Quadruple screen done in second trimester

A
  • b-hCG, estriol, AFP, and inhibin A

- 80% Detection rate of Trisomy 21

244
Q

Describe the Noninvasive prenatal testing Cell-free fetal DNA

A
  • 9-10 weeks
  • tests cell free fetal DNA, thought to be derived apoptosis of trophoblastic cells that have entered the maternal circulation
  • higher detection rate for trisomies
  • does NOT test for open neural fetal defects: continue to evaluate for NTD with maternal serum alphafetoprotein or US
245
Q

if you have a positive Cell free fetal DNA test then you move on to what to confirm

A
  • Amniocentesis (16-20 weeks0
  • Chorionic villi sampling (11 weeks)
  • both small risk for miscarriage
246
Q

what anomaly does Thalidomide cause

A

phocomelia

247
Q

what time period is the most vulnerable teratogenic stage

A

day 17-56 . . organogenesis

248
Q

what is the most common teratogen to which a fetus is exposed

249
Q

what anticoagulant crosses the placenta and is a teratogen?

which doesn’t cross?

A

Coumadin

Heparin

250
Q

what anticonvulsant is a teratogen

251
Q

what is the critical period for radiation exposure to be teratogenic

A

b/t 2 and 6 weeks . . if before 2 weeks then either lethal or no effect at all

252
Q

what is the amount of radiation that is no risk for teratogenesis

A

less than 5 rads

253
Q

describe the frequency of prenatal office visits?

A
  • Every 4 weeks until 28 weeks
  • Every 2 weeks from 28-36 weeks
  • then weekly until delivery
254
Q

what occurs at routine prenatal office visits

A
  • BP
  • Weight
  • urine protein
  • measure uterus size . . 20 weeks at umbilicus
  • Fetal heart rate by Doppler at 12 weeks
255
Q

what screening is done at 20 weeks?

A

fetal survey US

256
Q

what screening is done at 28 weeks?

A
  • gestational diabetes and repeat Hb and Hct
  • Rhogam injection to Rh neg. patients
  • Tdap
257
Q

What screening is done at 35 weeks?

A

-screening for group B strep carrier with vaginal culture . . treat in labor if positive

258
Q

what is done to assess fetal well being

A
  • Kick counting: 10 movement in 2 hours
  • NST: non stress test; Reactive- 2 accelerations of at leaste 15 beats above baseline lasting at least 15 sec during 20 minutes of monitors
  • If the test is nonreactive then need contraction stress test or biophysical profile
  • Contraction Stress Test: CST– give oxytocin to establish at least 3 contraction in a 10 min period. if late decels are noted with majority of contractions the test is positive and delivery is warranted
259
Q

Describe the scoring of Biophysical profile

A
  • 8-10 reassuring
  • 6: Equivocal. Deliver if patient is at term
  • 4 or less. Nonreassuring. consider delivery
260
Q

definition of labor

A

progressive cervical dilation resulting from regular uterine contraction that occur at least every 5 minutes and last 30-60 seconds

261
Q

irregular contractions without cervical change?

A

False labor (Braxton-Hicks contractions)

262
Q

what is the classic female type of pelvis

263
Q

what pelvis shapes have poor prognosis for delivery?

A

Android and Platypelloid

264
Q

what is the diagonal conjugate?

A
  • measure from inferior portion of pubic symphysis to sacral promontory
  • if >11.5 cm then AP of pelvic inlet is adequate
265
Q

first stage of labor

A

-onset of true labor to complete cervical dilation

266
Q

second stage of labor

A

complete cervical dilation to delivery

267
Q

third stage of labor

A

Delivery of infant to delivery of placenta

268
Q

Fourth stage of labor

A

Delivery of placenta to stabilization of pt

269
Q

what position do we encourage mom to be in during first stage of labor

A

left lateral recumbent

270
Q

duration of first stage of labor for primiparas?

Multipara?

A
  • 6-18 hours

- 2-10 hours

271
Q

Rate of cervical dilation for primiparas?

multiparas?

A
  • 1.2 cm/hour

- 1.5 cm/hour

272
Q

what are the cardinal movements of labor?

A
  • Engagement: presenting part at “zero” station
  • Descent:
  • Flexion
  • Internal rotation
  • Extension
  • External rotation
  • expulsion: anterior shoulder then posterior
273
Q

1st degree perineal laceration?
2nd?
3rd?
4th?

A
  • vaginal mucosa and/or perineal skin
  • extends to muscles of perineal body but no anal sphincter
  • completely through anal sphincter but not into rectal mucosa
  • rectal mucosa
274
Q

Classic sign of placental separation?

A
  • Gush of blood from vagina
  • lengthening of umbilical cord
  • Fundus of uterus rises up
  • change in shape of uterine fundus from discoid to globular
275
Q

what bishop score is induction unfavorable?

favorable?

276
Q

Uterine contraction and cervical dilation result in visceral pain at what levels

277
Q

Descent of fetal head and pressure from pelvic floor, vagina and perineum generate somatic pain via pudendal nerve . . what levels?

278
Q

Regional anesthesia blocks what levels

A

T10 and below

279
Q

what is the normal pH of fetal scalp blood

280
Q

what is normal uterine activity?

tachysystole?

A
  • 5 contractions or less in 10 minutes averaged over 30 min

- >5

281
Q

an IUPC measures strength of uterine contractions in what units?

A

MVUs . . Montevideo units

-need >200 (sum of contractions in 10 minute period) for at least 2 hours

282
Q

normal baseline fetal heart rate

283
Q

what is normal variability of fetal heart rate

A

moderate (6-25 bpm)

284
Q

are accelerations in FHR normal

A

yes . .after uterine contractions but < 2 min

-if more than 10 min then change in baseline

285
Q

what type of decels are due to intracranial pressure from contraction and are not associated with fetal distress?

A

early . . mirror image of uterine contraction

286
Q

Variable decels are associated with what

A

umbilical cord compression

287
Q

Late decels are associated with what?

A
  • uterine placental insufficiency (UPI)

- if repetitive usually indicate fetal metabolic acidosis and low arterial pH

288
Q

sinusoidal pattern of fetal heart rate associated with what

A

fetal anemia

289
Q

what can alleviate cord compression

A

amnioinfusion

290
Q

describe the fetal scalp stimulation test

A

when scalp is stimulated, if an acceleration of 15 bpm lasting 15 seconds occurs then fetal pH almost always 7.22 or greater

291
Q

describe the latent phase of the first stage of labor

A

cervical softening and effacement occurs with minimal dilation (less than 4 cm)

292
Q

describe active phase of first stage of labor

A
  • starts at 4 cm dilation
  • increase rate of dilationg and descent of presenting fetal part
  • acceleration phase and deceleration phase
293
Q

Maximal dilation rate of 5th percentile in nulliparous?
Descent rate?

same questions for multiparous?

A
  • 1.2 cm/hour
  • 1 cm/hour

1.5 cm/hour
2 cm/hour

294
Q

cervical dilation of less than the norms constitutes what

A

Protraction disorder of dilation of active phase

295
Q

if 2 or more hours elapse with NO cervical dilation?

if 1 hour without change in descent

A

arrest of dilation

arrest of descent

296
Q

what are the 3 P’s that can cause dystocia or difficult labor

A
  • Power
  • Passenger
  • Passage
297
Q

when should you consider labor augmentation

A

when contractions are less than 3 in 10 minutes period and/or the intensity is less than 25 mm/Hg

298
Q

what fetal position is associated with more back discomfort?

299
Q

what is the maneuver used for should dystocia

A

McRobert’s maneuver-hyperflexion and abduction of maternal hips

300
Q

what is the most dangerous type of twinning

A

monochorionic monoamnionic

301
Q

which type of twinning is influenced by maternal age, family history, and ethnicity

302
Q

What is seen on US in dizygotic twins?

monozygotic?

A
  • diff. fetal gender (can be)
  • thick amnion-chorion suptum
  • peak or inverted V sign

Dividing membrane is fairly thin

303
Q

describe different time frames for retained dead fetus syndrome?

A
  • 20 weeks: risk for DIC
  • less than 12 weeks: reabsorbed . . vanishing twin syndrome
  • greater than 12 weeks: shrinks, dehydrates and flattens called fetus papyraceus
304
Q

Monoamniotic twins should be delivered when

A

at 32 weeks

305
Q

what twin presentations have to be delivered by C section

A

breech-breech and breech-vertex

306
Q

1 unit of PRBC will increase Hb and Hct how much

A
  • Hct by 3%

- Hgb by 1 g/dL

307
Q

how does placentat previa typically present

A

painless vaginal bleeding

308
Q

main risk factors for placenta previa?

A
  • maternal age > 35

- previous C sections

309
Q

premature separation of the normally implanted placenta

A

placental abruption

310
Q

what is the most common cause of third trimester bleeding

A

placental abruption

311
Q

what does placental abrution present as

A

PAINFUL bleeding

312
Q

what is the most common risk factor for placental abruption

A

maternal HTN

313
Q

what is the most common cause of DIC in pregnancy

314
Q

what is couvelaire uterus

A
  • seen with placental abruption

- extravasation of blood into the uterus causing red and purple discoloration of the serosa

315
Q

Postpartum hemorrhage is defined as what?

A

> 500cc following vaginal birth

>1000cc following C section

316
Q

describe primary post partum hemorrhage

A
  • within 24 hours

- usually uterine atony

317
Q

leading cause of maternal death worldwide

A

postpartum hemorrhage

318
Q

uterine atony causing post partum hemorrhage feels like what

A

boggy uterus

319
Q

in the management of uterine atony, What in contraindicated in HTN patient?
Asthmatics?
Hypotensive?

A
  • Methylergonovine
  • 15-methylprostaglandin F2a
  • Dinoprostone
320
Q

50cc of platelets will increase platelet count how much

A

5-10 thousand

321
Q

a unit (250) of FFP increases fibrinogen by how much?

322
Q

a unit (40cc) of Crypercipitate increases fibrinogen how much?

323
Q

defined as temp > 100.4 or higher that occurs for mor than 2 consecutive days during first 10 postpartum days

A

febrile morbidity

324
Q

describe puerperal sepsis

A

after delivery pH of vagina becomes more alkaline . . . prone to infection

325
Q

management of puerperal sepsis

A
  • ampicillin and Gentamycin

- if Bacteroides Fragilis then clindamycin

326
Q

describe ovarian vein thrombophlebitis

A
  • fever and abdominal pain within 1 week after delivery or surgery
  • appear clinically ill: fever, abdominal pain localized to the side of affected vein
  • 20% seen radiographically
327
Q

describe Deep septic pelvic vein thrombophlebitis

A
  • usually have unlocalized fever in first few days that is non responsive to antibiotics
  • do NOT appear clinically ill
  • no radiographic evidence of thrombosis
  • Diagnosis of exclusion

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