High yield Clinical Flashcards
(327 cards)
1
Q
What strains of HPV cause the majority of cancers
A
- 16, 18, 31, 45
- 16 and 18 cause 70%
2
Q
parity and risk factor for cervical neoplasia
A
High parity
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
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
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
6
Q
management of women with HSIL
A
- TREATMENT
- immediate loop electrosurgical excision or colposcopy
7
Q
what is the gold standard for diagnosis and treatment planning of cervix
A
colposcopy
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
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
10
Q
what is ECC
A
endocervical curettage
11
Q
what age does insurance cover for HPV vaccine
A
9-26
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)
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
14
Q
what are the excisional procedures for cervix
A
- CKC: cold knife cone
- LEEP: loop electrode excisional procedure
15
Q
symptoms of cervical carcinoma
A
- watery vaginal bleeding
- postcoital bleeding
- intermittent spotting
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
17
Q
Which HCs have less androgenic agents
A
- desogestrel
- norgestimate
- drospirenone
18
Q
mechanism of actions of progestin only oral contraceptive
A
primarily making cervical mucous thick and impermeable
19
Q
when are progestin only OCs used
A
-breastfeeding and women who have a contraindication to estrogen
20
Q
What is the weight caution on a transdermal patch contraceptive
A
-caution with use in women greater than 198 pounds
21
Q
what is the major side effect of the transdermal patch contraceptive
A
-same as OCs except greater risk of thrombosis
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
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
24
Q
what is a key side effect of depo
A
exacerbation of depression
25
what are some unique indications for used of depo-provera
- decreased number of crisis in sickle cell anemia
| - decrease risk of endometrial hyperplasia
26
contraindications for depo-provera
- known or suspected pregnancy
- unevaluated vaginal bleeding
- known or suspected malignancy of the breast
- liver dysfunction/disease
27
how long is Nexplanon used? (implant)
3 years
28
what is the only absolute contraindication for Nexplanon use
-known or suspected breast cancer
29
name for copper IUD
paragard
30
what type of female sterilization may be good for obese patients that might not be good candidates for other methods
Hysteroscopy: transcervical approach to tubal ligation
| -also called Essure system
31
what is it called when the bladder intrudes on the anterior vaginal wall
Anterior vaginal prolapse or cystocele
32
what is it called when the rectum intrudes on the posterior vaginal wall
Lower posterior vaginal prolapse or rectocele
33
what is a sagging uterovaginal canal after a hysterectomy called
vaginal vault prolapse
34
symptoms for a cystocele
- pelvic pressure or bulging sensation
- not old
- NO bowel or urinary complaints
- vaginal deliveries . . maybe a big baby
- smoking
- overweight
35
what are the treatment options for anterior vaginal prolapse (cystocele)
- do nothing
- pelvic floor physical therapy
- pessary
- surgery: anterior colporrhaphy
36
symptoms for apical prolapse
- older
- "something falling out"
- doesn't empty bladder completely and voids small amounts frequently
37
Treatment options for apical prolapse
- pessary
- Hysterectomy
- Colpocleisis: put everything back up and sew vagina up . . not good option if sexually active
38
symptoms of stress incontinence
-incontinence with coughing, sneezing, laughing
39
what tests can help in diagnosis of stress incontinence?
- 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)
40
Treatment options for stress incontinence
- 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
41
symtpoms of rectocele
- no bladder complaints
- needing to splint to have bowel movement
- pressure sensation and fullness in vagina
- lots of kids
42
what is the best option for treatment of rectocele
SURGERY
43
symptoms for urge incontinence
- 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
44
treatment for urge incontinence
- behavioral modification: less caffeine, limit fluids after 7 pm, bladder training
- antispasmodics: oxybutynin and tolterodine
45
when is gestational diabetes screening done and why
between weeks 24 -28
| -this is when placenta is pumping out most hPL
46
Describe the screening for gestational diabetes
- 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
47
what indicates good glycemic control in gestational diabetes
- fasting glucose less than 90 mg/dL
- 2 hour postprandial less than 120
- control with diet, oral hypoglycemic medications (glyburide), or insulin
48
When doing an ultrasound in a gestational diabetes patient, what weight do you recommend a cesarean section
greater than 4500 grams
49
describe treatment of maternal hyperthyroidism
- Methimazole in 2nd and 3rd trimester (can cause aplasia cutis and choanal atresia in 1st trimester)
- Propylthiouracil only in 1st trimester
50
what is the most common lesion of rheumatic heart disease in pregnancy
mitral valve stenosis
51
what is the most frequent cardiac arrhythmia in pregnancy
supraventricular tachycardia
52
when does post partum cardiomyopathy occur?
who is at risk?
mortality rate?
- within last weeks of pregnancy or within 6 months postpartum
- women with preeclampsia, HTN, and poor nutrition
- 10%
53
Treatment of symptomatic nausea and vomiting in pregnancy
- vitamin B6
- Doxylamine
- Promethazine
54
what is Mendelson's syndrome
- acid aspiration syndrome
- delayed gastric emptying and increased intraabdominal pressure in pregnancy
- can result in adult respiratory syndrome
55
treatment of Mendelson's syndrome
- supplemental oxygen
- maintain airway
- treatment for acute respiratory failure
56
how do you prevent mendelson's syndrome
- decrease acid in stomach
| - don't feed in labor
57
anemia in pregnancy defined as what?
Hct less than 30% and HgB less than 10
58
symtpoms of superficial thrombophlebitis
- palpable cord in calf
- most common in pts with varicose veins, obesity, and little physical activity
- swelling and tenderness
- will NOT result in PE
59
treatment for thrombophlebitis
- bed rest
- pain meds
- local heat
- no need for anticoagulatns
- wear support hose
60
why should u avoid estrogens post partum for contraception
risk of DVT
61
what is used to diagnose DVT?
- compression US with DOPPLER FLOW
| - MRI if suspect pelvic thrombosis
62
treatment of DVT in pregnancy
- 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
63
pts with a DVT or PE require what workup
thrombophilia
64
what is the most common pulmonary disease in pregnancy
asthma
65
most common type of headache in pregnancy?
| treated how?
- tension
| - acetaminophen
66
what seizure med should NOT be used in pregnancy as it is more teratogenic than others?
Which ones are most commonly used
- Valproate
| - Dilantin and phenobarbital
67
women on antiepileptics should be on what supplement
-1 to 4 mg of folic acid
68
What is considered prolonged second stage of labor? (an indication for operative vaginal delivery)
- Nulliparous: >2 hours without regional anesthesia or >3 hours with
- Multiparous: >1 hour w/o or >2 hours with
69
what are the maternal prerequisites for operative vaginal delivery
- adequate analgesia
- lithotomy position
- bladder empty
- verbal or written consent
70
what are the fetal prerequisites for operative vaginal delivery
- 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
71
what are the uteroplacental prerequisites for operative vaginal delivery
- cervix fully dilated
- membranes ruptured
- no placenta previa
72
what forceps are used for breech presentation
piper
73
during operative vaginal delivery, rotation of head should not exceed how much
45 degrees
74
what are the best presentations for operative vaginal delivery?
which are ok?
which can you NOT do?
- Right, left, or straight occipito-anterior
- Right, left, or straight occipito-posterior
- tranverse CANNOT
75
what is the advantage of vacuum assisted vaginal delivery over forceps?
delivery can be achieved with little maternal analgesia
76
what are the contraindications to vacuum assisted vaginal delivery
- gestational age less than 34 weeks
- suspected fetal coagulation disorder
- suspected fetal macrosomia
- Breech presentation
77
what is correct placement for vacuum?
posterior fontanelle
78
clinical pearls for vacuum assisted vaginal delivery?
- 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
79
preterm birth is defines as what
after 20 weeks but before 37 weeks
80
what is the diagnostic criteria for Preterm Labor
uterine contractions accompanied with cervical change or cervical dilation of 2 cm and/or 80% effaced
81
What is the link b/t preterm labor risk and cervix length
- 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
82
in the management of pre term labor, what cultures are taken?
what antibiotics are given empirically?
- Group B strep, also gonorrhea and chlamydia
| - typically penicillin
83
What are the tocolytic agents to suppress pre term labor and what are the routes of administration
- Magnesium sulfate (IV)
- Nifedipine (oral)
- Indomethacin (oral or rectally) mostly for extreme prematurity
84
what week does an infant become viable?
24 weeks
85
what hormone is used and thought to prevent pre term labor
-progesterone: IM (Makena) or vaginal (used in women with a shortened cervix <2.5 cm) . .
86
What do you NOT want to check in a patient with presumed premature rupture of membranes?
so how is the rupture confirmed?
do NOT check cervix . . increased risk of infection especially with the prolonged latency before delivery
-sterile speculum
87
what are the 3 tests used for confirmation of a PROM (premature rupture of membranes)
- Pooling
- nitrazine paper (turns blue)
- ferning
88
what is the ACOG recommendation for management of PPROM
48 hour course of IV ampicillin and Erythromycin/Azithromycin followed by 5 days of Amoxil and Erythromycin
-steroids up to 34 weeks
89
what is the rapid test for fetal lung maturity
- Lamellar body number density assessment (LBND)
| - typically more than 46,000
90
when the birth weight of a newborn is below the 10% for a given gestational age
Intrauterine Growth Restriction (IUGR)
91
what is the primary screening tool for IUGR
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
92
Describe what a Doppler study of umbilical artery will show if there is IUGR?
-there is normally high velocity diastolic flow but with IUGR there is diminution of umbilical artery diastolic flow
93
Describe the management of suspected IUGR
- 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
94
a baby with IUGR is at greater risk for what adult onset conditions?
- DM
- HTN
- Atherosclerosis
95
a pregnancy that continues past 42 weeks?
post term pregnancy
96
Fetal death after 20 weeks gestation but before the onset of labor
Intrauterine Fetal Demise (IUFD)
97
what is the management for IUFD?
- 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
98
definition of hypertensive pregnancy
-sustained blood pressure higher than 140/90
99
what are the different classes of hypertension in pregnancy
- 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
100
When evaluating chronic HTN in pregnancy, you need to assess for maternal end organ damage by getting what tests
- CBC
- glucose
- CMP
- 24 hour urine collection for total protein
- EKG
101
when does gestational HTN resolve
by 12 weeks post partum
102
symptoms of preeclampsia
- scotoma
- blurred vision
- epigastric and/or right upper quadrant pain
- Headache
103
risk factors for preeclampsia
- age <20 or >35
- primigravid
- prior history
- lots of others
104
what is the proteinuria findings if preeclampsia is severe
at least 5 gm/24 hour or 3+ protein on two random urine dips at least 4 hours apart
105
what physical exam findings will you have with preeclampsia
- Brisk reflexes
| - clonus
106
what lab findings will you have with preeclampsia
- increased: Hct, lactate dehydrogenase, transaminases (AST, ALT), uric acid
- thrombocytopenia
107
how do you manage the blood pressure in severe preeclampsia pts?
- hydralazine
- Labetalol
- Nifedipine
108
when do you deliver the baby in severe preeclampsia
if greater than 34 weeks
109
what is used for seizure prophylaxis in preeclampsia patients?
Dose?
magnesium sulfate
- IV
- loading dose of 4 gm bolus
- maintenance dose of 2 gm/hour
110
what is a variant of preeclampsia that gives right upper quadrant pain
HELLP syndrome
111
what might you be able to give to prevent preeclampsia
maybe aspirin
112
how do you manage HELLP syndrome?
deliver baby immediately
113
when is mammography best
40 years and older
114
what is useful in evaluating invconclusive mammogram findings
ultrasonography
115
Ultrasonography is best in evaluating whose breasts?
- young women less than 40
| - others with dense breast tissue
116
ultrasonography differentiates what breast lesions
cystic vs. solid
117
when is MRI used in imaging of breast
- post cancer dx for further eval of staging
- used with implants
- women at high risk for breast cancer like BRCA carriers
118
what is the only FDA approved treatment for mastalgia (breast pain)?
danazol
119
what are some life style recommendations for a patient with mastalgia?
- properly fitting bra
- weight reduction
- exercise
- decrease caffeine intake
- vitamin E supplementation
120
bloody nipple discharge is considered what?
cancer until proven otherwise
121
what are the characteristics of a breast mass that make it a concern for malignancy?
- >2 cm in size
- immobility
- poorly defined margins
- firmness
- skin dimpling/retraction/color changes
- bloody nipple discharge
- ipsilateral lymphadenopathy
122
what is the most common benign tumor in female breast
fibroedenomas . . usually in late teens and early 20s
123
what gene mutation is also associated with ovarian
BRCA1 . . also early onset
BRCA2 much lower risk of ovarian cancer
124
what breast cancer genetic mutation has worse prognosis and is found in 20-30% of invasive cancers
Her2/neu
125
what arteries does the functionalis of the endometrium contain?
the basalis?
spiral
basal
126
median age of menarche?
12.43
127
what tanner stage does menarche occur
at tanner stage IV . . rare before III
128
definition of primary amenorrhea
no menstruation by 13 WITHOUT secondary sexual development or by the age of 15 WITH secondary sexual development
129
what is the mean blood loss per menstrual period
- 30cc
| - 3-6 pads/day
130
how much blood loss is associated with anemia
80cc
131
what weight is essential to start menarche
106 lbs
132
what is the first physical sign of puberty?
thelarche
133
order of puberty events
- thelarche
- adrenarche
- growth
- menses
-TAG Me
134
ethnicity and puberty?
AA first then Hispanics then whites
135
Tanner stage: Preadolescent elevation of papilla only
1
136
Tanner stage: Breast bud stage; elevation of breast and papilla as a small mound with enlargement of the areolar region
2
137
Tanner stage: further enlargement of breast and areola without separation of their contours
3
138
Tanner stage: Projection of areola and papilla to form a secondary mound about the level of the breast
4
139
Tanner stage: Mature stage; projection of papilla only; resulting from recession of the areola to the general contour of the breast
5
140
Tanner stage: Preadolescent; absence of pubic hair
1
141
Tanner stage Sparse hair along the labia; hair downy with slight pigment
2
142
Tanner stage: Hair spreads sparsely over the junction of the pubes; hair is darker and coarser
3
143
Tanner stage: Adult-type hair; there is no spread to the medial surface of the thighs
4
144
Tanner stage: Adult type hair with spread to the medial thighs assuming an inverted triangle pattern
5
145
How do you diagnose True isosexual precocious puberty
- 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
what is treatment for true isosexual precocious puberty
-GnRH agonst (Leuprolide acetate)
147
when is puberty considered delayed?
- 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
what is the FSH level for HYPERgonadotropic Hypogonadism?
>30
| -turner
149
what are the FSH and LH levels for Hypogonadotropic Hypogonadism
FSH + LH = <10
150
what is the definition of secondary amenorrhea
patient with prior menses has absent menses for 6 months or more
151
what is the most common cause of hypogonadotropic hypogonadism
Kallman syndrome
152
what is the most common for of female gonadal dysgenesis
Turner
153
what do you check in a women with secondary amenorrhea and a negative pregnancy test
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
what are anatomic causes of secondary amenorrhea?
Asherman syndrome and cervical stenosis
155
diagnosis of PCOS
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
PCOS is increased risk for what cancer
endometrial
157
definition of polymenorrhea
abnormally frequent menses at intervals < 21 days
158
excessive and/or prolonged bleeding (>80mL and >7days) occurring at normal intervals
Menorrhagia
159
irregular episodes of uterine bleeding
metrorrhagia
160
heavy and irregular uterine bleeding
menometrorrhagia
161
Scant bleeding at ovulation for 1 or 2 days
intermentrual bleeding
162
menstrual cycles occurring >35 days but less than 6 months
Oligomenorrhea
163
when do most dysfunctional uterine bleeding occur
menarche (11-14) or perimenopause (45-50)
164
Structural causes of AUB?
| Nonstructural causes?
- P: polyp
- A: adenomyosis
- L: leiomyoma
- M: malignancy and Hyperplasia
- C: coagulopathy
- O: ovulatory dysfunction
- E: endometrial
- I: Iatrogenic
- N: not yet classified
165
histological illustration of adenomyosis causes what
enlargement of the uterus
166
Coagulopathies causing AUB
- heavy flow
| - Von Willebrand disease
167
Ovulatory dysfunction causing AUB
- unpredictable menses with variable flow
| - PCOS
168
Endometrial causes of AUB
infection
169
iatrogenic causes of AUB
IUD, exogenous hormones
170
what are the available tissue sampling methods used to evaluate AUB
- office endometrial biopsy
| - Hysteroscopy directed endometrial sampling
171
AUB treatment for massive bleeding
- hospitalization and transfusions if hemodynamically unstable
- 25 mg IV conjugated estrogens then hormonal treatment (combination hormonal therapy, Mirena)
172
AUB treatment for moderate bleeding
combination OCPs, Mirena
173
AUB treatment unresponsive to conservative therapy
-D&C, polypectomy, myomectomy, endometrial ablation, hysterectomy
174
what is the most common type of genital cyst
epidermal inclusion cyst
175
these are on the vulva and can enlarge and become painful in pregnancy and have a characteristic blue color
vulvar varicosities
176
most common benign solid tumors of vulva
fibroma
177
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
Vulvar vestibulitis
178
what does physical exam of atrophic vaginitis reveal?
- atrophy of external genitalia
- minora regresses
- majora shrinks
- loss of vaginal rugae
- vaginal introitus constriction
179
treatment for atrophic vaginitis
- topical estrogen
| - may consider oral estrogen to prevent recurrence
180
what does a biopsy of lichen simplex chronicus (squamous cell hyperplasia) show?
- Elongated rete ridges
| - hyperkeratosis of the keratin layer
181
biopsy of lichen sclerosis
- thin epithelium
| - loss of rete ridges and inflammatory cells lining the basement membrane
182
Treatment of lichen sclerosis
Clobetasol (steroid)
183
if this is not detected until after menarche, then it appears as a thin dark bluish structure which entraps menstrual flow
imperforate hymen
184
what is the most common vulvovaginal tumor
Bartholin's cyst
185
what stage of vulvar carcinoma has bilateral regional node metastases
IV
186
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
Verrucous carcinoma
187
vagina is lined by what epithelium
nonkeratinized stratified squamous epithelium
188
what needs to be done in the investigation of vaginal discharge
- obtain history
- Nitrazine paper
- Microscope
189
when viewing vaginal discharge under a microscope, where do you get the sample discharge?
posterior fornix
190
treatment of BV
metronidazole
| -not an STI so don't need to treat partner
191
Treatment of vulvovaginal candidiasis
- Diflucan
| - vaginal application with synthetic imidazoles (miconazole, teraconazole,)
192
Treatment for trichomoniasis
- Metronidazole
| - treat partner also
193
when is hCG first detecting in SERUM
6-8 days after ovulation
194
a urine pregnancy test can detect what level of hCG
titer of 25 IU/L
195
Levels of hCG double every how often?
2 days
196
a gestational sac can be seen via transvaginal ultrasound at what level of hCG
1500-2000 . DISCRIMINATORY LEVEL
197
what rise in hCG in 48 hours confirms an abnormal IUP or ectopic pregnancy
less than 53%
198
what are the most common cause of first trimester SABs?
which one specifically?
Which trisomy?
- chromosomal abnormalities
- 45XO . .Turner
- trisomy 16
199
what is a threatened abortion
vaginal bleeding and closed cervix
200
what is an inevitable abortion
vaginal bleeding and cervix partially dilated
201
what is an incomplete abortion
- vaginal bleeding, cramping lower abd pain with dilated cervix
- passage of some but not all the products of conception
202
what is a complete abortion
- passage of all products of conception (fetus and placenta) with a closed cervix
- with resolution of pain, bleeding and pregnancy symtpoms
203
what is a missed abortion
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
recurrent abortions is defined as what ?
3 successive SABs
205
cervical incompetence is usually seen with loss at which trimester
second
206
painless dilation of cervix and delivery (SAB)
cervical incompetence
207
what is the most common immunologic factor that causes spontaneous abortions
antiphospholipid syndrome
208
what is the leading cause of maternal death in the first trimester
ectopic pregnancy
209
Classic triad for ectopic pregnancy
- prior missed menses
- vaginal bleeding
- lower abdominal pain
210
symptoms of acutely ruptured ectopic pregnancy
-severe abdominal pain and dizziness
211
physical exam for acutely ruptured ectopic preganancy
- distended and acutely tender abdomen
- usually has cervical motion tenderness
- signs of hemodynamic instability (diaphoresis, tachycardia, loss of consciousness)
212
what will an US reveal if there is an acutely ruptured ectopic pregnancy
empty uterus with significant amount of free fluid
213
Describe the methotrexate treatment of ectopic pregnancy
- 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
what do you instruct a patient to avoid while take methotrexate for an ectopic pregnancy
Folate containing vitamins
215
what is the preferred surgical approach for ectopic pregnancy if pt is hemodynamically unstable?
stable?
- Laparotomy
| - Laparoscopy
216
Who do you give anti-D immunoflobulin to and when?
- 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
what test can be done to identify fetal RBCs in maternal blood and determine if additional RhoGAM is necessary
Kleinhauer-Betke test
218
if Rh-antibody titers in mother are less than 1:8 then what?
if > 1:16?
- 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
what is the most valuable tool for detecting fetal anemia?
Doppler assessment of peak systolic velocity in fetal MCA
220
what is the management of severe fetal anemia due to isoimmunization
- intrauterine transfusions b/t 18-35 weeks
| - use fresh group O, Rh-neg packed RBCs every 1-3 weeks
221
most common location of fibroids
within myometrium . . intramural
222
if an US reveals endometrial lining greater than what size then you need to sample the endometrium
> or equal to 4 mm
223
how do you treat simple and complex endometrial hyperplasia WITHOUT atypia?
WITH?
- progestin and resample in 3 months
| - hysterectomy
224
single most common benign ovarian neoplasm in premenopausal female
Benign cystic teratoma (Dermoid)
225
what is meigs syndrome
- ascites
- right pleural effusion
- ovarian fibroma
226
what is the name of the solid prominence located at the junction b/t a teratoma and normal ovarian tissue
Rokintanksy's protuberance
227
what women can you use CA-125 as a serum marker for ovarian tumors?
POST MENOPAUSAL
228
normal physical exam findings with pregnancy
- systolic murmurs exaggerated splitting and S3
- palmar erythema
- spider angiomas
- Linea nigra
- Striae Gravidarum
- chadwicks sign
229
what prenatal labs are done at 1st visit
- 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
what are the most important lab values of pregnancy
- Hct decreases 4-7% by 30-34 weeks
- hemoglobin: decreased 1.5-2 by 30-34 weeks
- clotting factors increase 7-10x
231
of weeks that have elapsed b/t first day of LMP and the date of delivery
gestational age
232
level of hCG that is negative?
positive?
what should level be by time of expected menses?
- <5
- >25
- about 100
233
when can you see gestational sac?
when can a fetal pole be seen by US?
When can you see cardiac activity?
- 5 weeks (hCG of 1500-200)
- 6 weeks (5200(
- 7 weeks (17,500)
234
what trimester is most accurate for dating a pregnancy
1st
235
what is Naegels rule
take LMP, minus 3 months, add 7 days and that is expected due date . . doesn't work in pts with irregulat cycles
236
what is used on US b/t 6-11 weeks and can determine due date within 7 days
Crown rump length (CRL)
237
what is used on US b/t 12-20 weeks to determine due date within 10 days
-femur length, biparietal diameter, and abdominal circumference
238
how is fetal demise diagnosed on US?
CRL >5 mm w/ absence of fetal cardiac activity
239
who needs genetic counseling?
advanced maternal age . . over 35 years old
240
what is the most common form of inherited mental retardation
Fragile X syndrome
241
what does a first trimester screening include
- 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
Describe the Triple screen done in the second trimester
- b-hCG, estriol, maternal serum alpho fetoprotein (AFP) biochemical markers
- b/t 16-20 weeks
- 70% detection rate of Trisomy 21
243
Describe the Quadruple screen done in second trimester
- b-hCG, estriol, AFP, and inhibin A
| - 80% Detection rate of Trisomy 21
244
Describe the Noninvasive prenatal testing Cell-free fetal DNA
- 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
if you have a positive Cell free fetal DNA test then you move on to what to confirm
- Amniocentesis (16-20 weeks0
- Chorionic villi sampling (11 weeks)
- both small risk for miscarriage
246
what anomaly does Thalidomide cause
phocomelia
247
what time period is the most vulnerable teratogenic stage
day 17-56 . . organogenesis
248
what is the most common teratogen to which a fetus is exposed
alcohol
249
what anticoagulant crosses the placenta and is a teratogen?
| which doesn't cross?
Coumadin
Heparin
250
what anticonvulsant is a teratogen
Dilantin
251
what is the critical period for radiation exposure to be teratogenic
b/t 2 and 6 weeks . . if before 2 weeks then either lethal or no effect at all
252
what is the amount of radiation that is no risk for teratogenesis
less than 5 rads
253
describe the frequency of prenatal office visits?
- Every 4 weeks until 28 weeks
- Every 2 weeks from 28-36 weeks
- then weekly until delivery
254
what occurs at routine prenatal office visits
- BP
- Weight
- urine protein
- measure uterus size . . 20 weeks at umbilicus
- Fetal heart rate by Doppler at 12 weeks
255
what screening is done at 20 weeks?
fetal survey US
256
what screening is done at 28 weeks?
- gestational diabetes and repeat Hb and Hct
- Rhogam injection to Rh neg. patients
- Tdap
257
What screening is done at 35 weeks?
-screening for group B strep carrier with vaginal culture . . treat in labor if positive
258
what is done to assess fetal well being
- 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
Describe the scoring of Biophysical profile
- 8-10 reassuring
- 6: Equivocal. Deliver if patient is at term
- 4 or less. Nonreassuring. consider delivery
260
definition of labor
progressive cervical dilation resulting from regular uterine contraction that occur at least every 5 minutes and last 30-60 seconds
261
irregular contractions without cervical change?
False labor (Braxton-Hicks contractions)
262
what is the classic female type of pelvis
gynecoid
263
what pelvis shapes have poor prognosis for delivery?
Android and Platypelloid
264
what is the diagonal conjugate?
- measure from inferior portion of pubic symphysis to sacral promontory
- if >11.5 cm then AP of pelvic inlet is adequate
265
first stage of labor
-onset of true labor to complete cervical dilation
266
second stage of labor
complete cervical dilation to delivery
267
third stage of labor
Delivery of infant to delivery of placenta
268
Fourth stage of labor
Delivery of placenta to stabilization of pt
269
what position do we encourage mom to be in during first stage of labor
left lateral recumbent
270
duration of first stage of labor for primiparas?
| Multipara?
- 6-18 hours
| - 2-10 hours
271
Rate of cervical dilation for primiparas?
| multiparas?
- 1.2 cm/hour
| - 1.5 cm/hour
272
what are the cardinal movements of labor?
- Engagement: presenting part at "zero" station
- Descent:
- Flexion
- Internal rotation
- Extension
- External rotation
- expulsion: anterior shoulder then posterior
273
1st degree perineal laceration?
2nd?
3rd?
4th?
- 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
Classic sign of placental separation?
- 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
what bishop score is induction unfavorable?
| favorable?
<6
| >8
276
Uterine contraction and cervical dilation result in visceral pain at what levels
T10-L1
277
Descent of fetal head and pressure from pelvic floor, vagina and perineum generate somatic pain via pudendal nerve . . what levels?
S2-S4
278
Regional anesthesia blocks what levels
T10 and below
279
what is the normal pH of fetal scalp blood
7.25-7.3
280
what is normal uterine activity?
| tachysystole?
- 5 contractions or less in 10 minutes averaged over 30 min
| - >5
281
an IUPC measures strength of uterine contractions in what units?
MVUs . . Montevideo units
| -need >200 (sum of contractions in 10 minute period) for at least 2 hours
282
normal baseline fetal heart rate
110-160
283
what is normal variability of fetal heart rate
moderate (6-25 bpm)
284
are accelerations in FHR normal
yes . .after uterine contractions but < 2 min
| -if more than 10 min then change in baseline
285
what type of decels are due to intracranial pressure from contraction and are not associated with fetal distress?
early . . mirror image of uterine contraction
286
Variable decels are associated with what
umbilical cord compression
287
Late decels are associated with what?
- uterine placental insufficiency (UPI)
| - if repetitive usually indicate fetal metabolic acidosis and low arterial pH
288
sinusoidal pattern of fetal heart rate associated with what
fetal anemia
289
what can alleviate cord compression
amnioinfusion
290
describe the fetal scalp stimulation test
when scalp is stimulated, if an acceleration of 15 bpm lasting 15 seconds occurs then fetal pH almost always 7.22 or greater
291
describe the latent phase of the first stage of labor
cervical softening and effacement occurs with minimal dilation (less than 4 cm)
292
describe active phase of first stage of labor
- starts at 4 cm dilation
- increase rate of dilationg and descent of presenting fetal part
- acceleration phase and deceleration phase
293
Maximal dilation rate of 5th percentile in nulliparous?
Descent rate?
same questions for multiparous?
- 1.2 cm/hour
- 1 cm/hour
1.5 cm/hour
2 cm/hour
294
cervical dilation of less than the norms constitutes what
Protraction disorder of dilation of active phase
295
if 2 or more hours elapse with NO cervical dilation?
| if 1 hour without change in descent
arrest of dilation
| arrest of descent
296
what are the 3 P's that can cause dystocia or difficult labor
- Power
- Passenger
- Passage
297
when should you consider labor augmentation
when contractions are less than 3 in 10 minutes period and/or the intensity is less than 25 mm/Hg
298
what fetal position is associated with more back discomfort?
OP
299
what is the maneuver used for should dystocia
McRobert's maneuver-hyperflexion and abduction of maternal hips
300
what is the most dangerous type of twinning
monochorionic monoamnionic
301
which type of twinning is influenced by maternal age, family history, and ethnicity
Dizygotic
302
What is seen on US in dizygotic twins?
| monozygotic?
- diff. fetal gender (can be)
- thick amnion-chorion suptum
- peak or inverted V sign
Dividing membrane is fairly thin
303
describe different time frames for retained dead fetus syndrome?
- 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
Monoamniotic twins should be delivered when
at 32 weeks
305
what twin presentations have to be delivered by C section
breech-breech and breech-vertex
306
1 unit of PRBC will increase Hb and Hct how much
- Hct by 3%
| - Hgb by 1 g/dL
307
how does placentat previa typically present
painless vaginal bleeding
308
main risk factors for placenta previa?
- maternal age > 35
| - previous C sections
309
premature separation of the normally implanted placenta
placental abruption
310
what is the most common cause of third trimester bleeding
placental abruption
311
what does placental abrution present as
PAINFUL bleeding
312
what is the most common risk factor for placental abruption
maternal HTN
313
what is the most common cause of DIC in pregnancy
Abruption
314
what is couvelaire uterus
- seen with placental abruption
| - extravasation of blood into the uterus causing red and purple discoloration of the serosa
315
Postpartum hemorrhage is defined as what?
>500cc following vaginal birth
| >1000cc following C section
316
describe primary post partum hemorrhage
- within 24 hours
| - usually uterine atony
317
leading cause of maternal death worldwide
postpartum hemorrhage
318
uterine atony causing post partum hemorrhage feels like what
boggy uterus
319
in the management of uterine atony, What in contraindicated in HTN patient?
Asthmatics?
Hypotensive?
- Methylergonovine
- 15-methylprostaglandin F2a
- Dinoprostone
320
50cc of platelets will increase platelet count how much
5-10 thousand
321
a unit (250) of FFP increases fibrinogen by how much?
10 mg/dl
322
a unit (40cc) of Crypercipitate increases fibrinogen how much?
10 mg/dl
323
defined as temp > 100.4 or higher that occurs for mor than 2 consecutive days during first 10 postpartum days
febrile morbidity
324
describe puerperal sepsis
after delivery pH of vagina becomes more alkaline . . . prone to infection
325
management of puerperal sepsis
- ampicillin and Gentamycin
| - if Bacteroides Fragilis then clindamycin
326
describe ovarian vein thrombophlebitis
- 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
describe Deep septic pelvic vein thrombophlebitis
- 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
