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Preclerkship > High Yield Repro > Flashcards

High Yield Repro Flashcards

1
Q

What does progestin do in COC pills?

A

Prevents LH surge/ovulation, thickens cervical mucus, reduces tubal motility/peristalsis, decidualizes endometrium

(Progesterone only pill can suppress ovulation but not consistently)

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2
Q

What does estrogen do in COC pills?

A

Reduces FSH/follicular development, increases endometrial proliferation

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3
Q

Ideally start hormonal contraceptive within __ days of LMP

A

5

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4
Q

`What type of birth control pill must be taken at the SAME TIME every day with no pill-free interval

A

Progestin-only pill

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5
Q

What is the depo-provera shot? Pros/cons?

A

IM injection of depot medroxyprogesterone acetate (DMPA)
Pros: very effective, suppresses ovulation, amenorrhea in 1-2 years in most women
Cons: bone density, weight gain, 9 months till fertility restored

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6
Q

Name 5 types of hormonal contraceptives (non-IUD)

A

1) COC pills
2) Transdermal (Ortho Evra)
3) Nuva ring
4) Progestin-only pill
5) Depo-provera

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7
Q

How do COCs modify the risks of ovarian/endometrial cancer and STIs?

A

Reduce them

STIs because of more cervical mucus

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8
Q

Absolute contraindicates to COCs (9)

A 
Pregnancy
Undiagnosed abnormal bleeding
Smoker >35 yr
Congenital hyper-TAGs
Migraines w/ focal neurological symptoms
Uncontrolled HTN
Estrogen-dependent tumors
Thromboembolic events/disorders
CVD/CAD
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9
Q

Do ABs reduce COC effectiveness?

A

ONLY RIFAMPIN

anti-mycobacterial; treats TB and Neisseria meningitidis which can cause meningitis

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10
Q

Irregular breakthough bleeding when starting OCP usually resolves after…

A

3 cycles

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11
Q

Can COCs be used immediately after delivery?

A

No evidence harmful to baby but may decrease milk prod. Not recommended 6-wk postpartum, ideally >3mo if BF

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12
Q

Progestin-only contraceptive methods would be recommended for whom?

A

Postpartum
Contraindications to E (thromboembolic or myocardial disease)
Side-effects from E

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13
Q

Why must STIs be considered when choosing an IUD?

A

Risks of PID

high STI risk = contraindication

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14
Q

How does the copper IUD (Nova-T) work?

A

Foreign body reaction in endometrium

Toxic to sperm, alters sperm motility

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15
Q

What test should you run before IUD insertion?

A

Cervical swabs for gonorrhea/chlamydia

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16
Q

Describe 4 methods of emergency postcoital contraception

A

1) Yuzpe method (within 72 hours, take OCPs equating to 100ug ethinyl estradiol + 55 mcg levonorgestrel X 2 12 hrs apart), not as effective as others
2) Plan B = levonorgestrel 750 ug X 2 2 hours apart within 72 hours
3) Ulipristal (SPERM = selective progesterone receptor modulator); antiprogesteron, delays ovulation (within 5 days)
4) Postcoital IUD: Copper or levonorgestrel 52 (Liletta); up to 7 days, prevents implantation

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17
Q

At what gestational age is abortion legal in Canada?

A

Any! Most <12 weeks though, very rare >24 unless danger of some sort

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18
Q

Pro and con of medical abortion (vs aspiration)

A

More “control”/privacy

Cons: longer, more awareness of blood loss and tissue passage

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19
Q

3 risks of teenage pregnancy to mother + baby

A

Mother: eclampsia, puerperal endometritis, systemic infections
Baby: Low birth weight, preterm delivery, other severe neonatal conditions

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20
Q

Medical abortion timing, options, mechanisms

A

<9 weeks
Mifegymiso = mifepristone (blocks progesterone receptors) + misoprostol (uterine contractions)
Methotrexate+ miso (toxic to trophoblasts) or miso alone (least effective)

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21
Q

Are U/S required before Mifegymiso

A

Nope! Unless ectopic suspected or unsure about gestatinoal age

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22
Q

Prep for abortion surgery (3)

A

1) Alloimmunization prevention (RhD immune globulin)
2) Confirm GA: Menstrual dating + bimanual exams and/or pelvic US
3) Cervical dilation (>12 wks –> osmotic dilators, prostaglandins)

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23
Q

Osmotic dilator example for cervical prep for abortion

A

Laminaria tents

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24
Q

What type of bleeding is expected in a medical abortion? How much is too much?

A

Heavy bleeding <24 hours, light until next period is ok

4 soaked pads in 2 hours –> ED

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25
Q

What is the followup to medical abortion?

A

B/W 7 days later to make sure it worked

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26
Q

What is the difference between spontaneous abortion and stillbirth?

A

Spontaneous abortion <20 wks

Stillbirth >20 weeks

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27
Q

Name 5 types of spontaneous abortions

A

1) Threatened
2) Inevitable
3) Incomplete
4) Complete
5) Missed

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28
Q

What type of spontaneous abortion is potentially reversible? What can you do?

A 
Threatened
- avoid strenuous PA
- weekly pelvic U/S
- R/O treatable causes of bleeding
- RhD immune globin prophylaxis
(<5% actually abort)
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29
Q

Why might suction D & C used after birth or abortion?

A

Remnants of fetus/tissues after abortion, pieces of placenta after childbirth:
Bleeding risk (can lead to DIC)
Infection –> sepsis

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30
Q

Diagnosis of spontaneous abortion

A

No fetal cardiac activity on pelvic Doppler U/S
Pelvic exam shows blood from cervix
Transvaginal U/S –> no fetal cardiac motion
B-hCG declining

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31
Q

Define subchorionic hematoma

A

Hematoma formation between the chorion and uterine wall caused by separation of the endometrium from the chorion.

Smaller hematomas may cause slight vaginal bleeding but usually do not endanger the fetus. Larger hematomas can cause extensive separation of chorion and endometrium, compress the fetus and lead to Premature rupture of membranes (PROM) and abortion.

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32
Q

Threatened abortion: definition

A

Vaginal bleeding + cramps

Cervix closed/soft

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33
Q

Inevitable abortion: definition + management

A

Increased bleeding/cramps, +/- ROM
Cervix closed, then os opens and products start to expel
Approach: Watch and wait, Mif + Misoprostol, D&C, (+/- Rhogam)

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34
Q

Are Mifepristone and misoprostol administered at the same time?

A

No, Mifepristone given first

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35
Q

Incomplete abortion: definition + management

A

Extremely heavy bleeding/cramps, tissue passed
Cervix open
Treatment options: Watch/wait, Mif&Miso, D&C, (+/- Rhogam)

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36
Q

Complete abortion: definition + management

A

Bleeding and complete passage of sac & placenta
Cervix closed, bleeding stopped
Expectant management, no D&C

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37
Q

Missed abortion: definition & management

A 
No bleeding (fetal death in utero), cervix closed
Options: watch & wait, Mif/Miso, D&C (+/- Rhogam)
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38
Q

Any woman presenting with abdominal pain, vaginal bleeding, and amenorrhea is ____ until proven otherwise

A

Ectopic pregnancy

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39
Q

Most common location of ectopic pregnancy

A

Ampulla (between isthmus & infundibulum) - 70%!

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40
Q

50% of ectopic pregnancies are due to…

A

Damage to fallopian tubes after PID

can also be egg abnormalities or transmigration to contralateral tube

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41
Q

Risk factors for ectopic pregnancies (>50% have no RFs!)

A 
Previous ectopic pregnancy
IUD
PID in past, salpingitis
Infertility/induced ovulation
Pelvic/abdo surgieries
Smoking
Uterine leiomyomas/adhesions/abnormal anatomy
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42
Q

Norm serum hCG trajectory. If ectopic?

A

Positive in serum after 9 days (urine 28 days after LMP). Doubles every 1.5-2 days, peaks ~10 weeks
(10 IU at missed menses, 100,000 UI at 10 wks, 10,000IU at birth = “rule of 10s”)
Reduced in most ectopic pregnancies

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43
Q

3 components of suspected ectopic pregnancy

A

1) Positive urine B-hCG
2) Acute abdomen (may be distended)
3) Vaginal bleeding (+/-shock)

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44
Q

If hemodynamically stable and suspected ectopic pregnancy, what do you do?
If hemodynamically unstable or impending/current ruptured ectopic pregnancy?

A

1) Transvaginal U/S & Serum b-hCG to determine treatment

2) Immediate surgery

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45
Q

When is expectant management ok in initially suspected ectopic pregnancy?

A

B-hCG low/declining
No fetal heartbeat or extrauterine sac suspicious for ectopic pregnancy
Patient reliable for follow-up

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46
Q

What med can be used for an ectopic pregnancy and what are the indications? (not including Rhogam)

A

Methotrexate:
- small (<3.5 cm), unruptured
- Low b-HCG
Compliance & follow-up assured

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47
Q

What surgeries can be done for ectopic pregnancy?

A

Salpingostomy (if tube salvageable & patient can follow up w/ weekly b-hCG)
Salpingectomy (tube damaged or ipsilateral recurrence)

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48
Q

At what point is an intrauterine pregnancy visible on transabdominal US? Transvaginal

A

TA: 6-8 weeks
TV: 5 wks = gestational sac, 7-8 wks = heart activity

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49
Q

Due date calculation (conditions?)

A

1st day of LMP + 9 mo + 7 days

Cycle must be regular (if regular >28 days, add that # of days)

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50
Q

Recommended supplements in early pregnancy

A

Folic acid from 8-12 weeks preconception to end of T1 (0.4-1 mg daily, 5 mg if risk factors)
Iron supplements if deficient + prenatal vitamins

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51
Q

If a minor is being sexually abused, do you contact the police?

A

No, contact CAS

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52
Q

Age of consent to sex

A 
Non-exploitive: 16yo
Exploitive: 18yo
Exceptions:
14-15 yo --> 5 year max 
12-13 --> 2 year max
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53
Q

hCG is structurally similar to…

A

LH

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54
Q

Human placental lactogen (hPL) has structure/function similar to what 2 hormones?

A

GH (–> fetal bone growth, diabetogenic in mother)

Prolactin (–> breast development)

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55
Q

What estrogen is mostly specific to pregnancy?

A

Estriol

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56
Q

Progesterone has a ____ effect on SM (examples?)

A

Relaxing

uterus, BVs, ureters, GE sphincter, intestines

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57
Q

Goodell’s sign =
Chadwick’s sign =
Hegar’s sign =

A

Goodell’s sign = softening of cervix (4-6 wk)
Chadwick’s sign = bluish discolouration of vergix & vagina (vascular engorgement)
Hegar’s sign = softening of cervical isthmus (uterus )(6-8 wks)

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58
Q

2 skin changes caused by increased estrogen (e.g. during pregnancy)

A

Spider angiomas, palmar erythema

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59
Q

Blood pressure during pregnancy

A

Nadir @ 24 weeks due to BV relaxation then back to normal levels because…
Hyper-dynamic circulation (CO, HR, BV all increase; myocardial hypertrophy)

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60
Q

Hematologic changes during pregnancy

A

Physiologic anemia due to DILUTION
Plasma increases more than RBCs, so lowers hematocrit
Hypercoagulable state

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61
Q

Why do some autoimmune diseases improve during pregnancy?

A

Higher leukocyte count but impaired function

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62
Q

How do TLC, FRC, and RV change during prevnancy?

How do VC and FEV1 change?

A

TLC/FRC/RV decrease

VC/FEV1 stay the same

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63
Q

What is the purpose of the mild resp alkalosis resulting from increased minute ventilation in pregnancy?

A

Helps CO2 diffuse across placenta from fetus –> mamma

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64
Q

3 GI impacts of pregnancy (other than nausea)

A

1) GERD (increase intra-abdo pressure + progest relaxes GE sphincter)
2) Constipation (decreased GI motility)
3) Gallstones (stasis)

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65
Q

Risk factors for UT during pregnancy?

A

Urinary stasis
Glycosuria
Ureter/renal pelvis dilation

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66
Q

What happens to GFR during pregnancy? Impact?

A

Increases due to high CO

–> lower creatinine, uric acid, BUN

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67
Q

First trimester until week ___, 2nd until week ___

A

13, 26

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68
Q

The embryo is extremely susceptible to teratogens from week __ to week __, when the process of ___ occurs

A

3-8, organogenesis

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69
Q

Fetal cardiac activity is visible by TV ultrasound when a woman is ___ weeks pregnant ( ___ fetal age)

A

6 weeks pregnants
4 weeks fetal ago
4 heart chambers present and begins to beat!

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70
Q

Neural plate begins to form at ___ weeks DEVELOPMENT, neural tube closes by week __

A

3, 4

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71
Q

Fetopathies are most likely to lead to what kinds of abnormalities?

A 
Functional issues (e.g. behavioural/learning)
Minor structural things
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72
Q

Gastrulation

A

formation of the trilaminar embryonic disc (endoderm, mesoderm, ectoderm) through migration of epiblasts (all embryonic tissues originate from epiblasts); week 3!

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73
Q

Weeks 2-4 mnemonic:

A

Week 2 - 2 layers (bilaminar disc)
Week 3 - 3 layers (trilaminar disc)
Week 4 - 4 limb buds + 4 heart chambers

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74
Q

Define neurulation

A

Formation of neural tube + neural crests
Neural tube –> CNS + retina
Neural crest –> PSNS, adrenal medula, etc.

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75
Q

2 examples of neural tube defects

A

Spina bifida

Anencephaly

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76
Q

Weeks of: germinal period, embryonic period, fetal period

A

1-2
3-8
9+

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77
Q

What is antiphospholipid syndrome?

A

Autoimmune disease

Anti-PL Abs activate platelets/vascular endothelium –> hypercoag state

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78
Q

Antiphospholipid syndrome & pregnancy effects

A

Miscarriages (usually >10 weeks, placental insufficiency, preeclampsia

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79
Q

Placental insufficiency is characterized by

A

Inadequate blood flow to placenta + impairment of substance exchange b/w fetus + mamma

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80
Q

Antisphospholipid syndrome 2o prophylaxis in someone who wants to have kids

A

LMWH + aspirin

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81
Q

When is the highest risk for DVT & PE in pregnant woman?

A

Most DVTs T3/post-partum

Most PEs post-partum

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82
Q

Link Virchow’s triad to increased VTE risk in pregnancy

A

Hypercoagulability: increased clotting factors, decreased proteins C/S
Stasis: decreased venous tone/flow, uterus impacts venous return
Endothelial: vascular damage @ delivery

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83
Q

Treatment for VTE during pregnancy

A

LMWH (d/c >24 hrs before delivery); or UFH

WARFARIN CONTRAINDICATED

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84
Q

Affect of teratogens pre-implanatation phase (1-2 weeks)

A

All-or-nothing effect (spontaneous abortion, never even know you’re pregnant)

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85
Q

Impacts of maternal pregestational/gestational DM on embryo?

A

Birth defects, spontaneous abortion
Transposition of great vessels, VSD, truncus arteriosus
Neural tube defects
Caudal regression syndrome (usually die as infant)

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86
Q

Impacts of maternal pregestational/gestational DM on FETUS?

A

Chronic fetal hyperglycemia –> fetal hyperinsulinemia, islet cell hyperplasia, more IGF/GH/metabolism –> fetal hypoxia
Macrosomia, polycythemia, neonatal hypoglycemia, resp dirtress, hypertrophic cardiomyopathy

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87
Q

Graves disease in mother causes what in baby?

A

Neonatal thyrotoxicosis (TSH receptor Abs move through placenta)

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88
Q

Heart defects associated with FAS

A

VSD!
Also PDA, ASD, ToF
Heat-lung fistulas

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89
Q

Facial features of FAS

A

Smooth philtrum
Thin upper lip
Downslanting/short palpebral fissures
Epicanthal folds

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90
Q

THrough what mechanism does cigarette smoking cause birth defects

A

Nicotine –> catecholamines –> vasoconstriction of uteroplacental BVs –> detal oxygen deprivation
(–> LBW, IUR, preterm labor/miscarriage due to placental abnormalities)

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91
Q

What is placental abruption?

A

Premature separation of placenta –> antenatal hemorrhage

92
Q

Name the TORCH infections

A 
Toxoplasmosis
Others (Syphilis, Varicella, Parvovirus B19, Listeriosis)
Rubella
Cytomegaly (CMV)
Herpes Simplex Virus
93
Q

Transplacental transmission occurs following __ infection of a ___ mother. Why?

A

Transplacental
Seronegative
IgM is formed first, only IgG can cross placenta

94
Q

Which vaccines can you not get DURING pregnancy?

A

Live attenuated: MMR, Varicella

95
Q

what type of immunization for varicella can you give during pregnancy?

A

Passive VZIG (not active VZV vaccine)

96
Q

Antibiotics that are SAFE during pregnancy

A

Penicillins (amoxicillin, ampicillin)
Cephalosphorins
Macrolides (erythromycin, azithromycin)
Nitrofurantoin (UTIs)

97
Q

Antihypertensives that are ok during pregnancy

A 
"Moms Love Healthy Newborns"
Methyldopa (crises)
Labetalol (or metoprolol) during T1-T2
Dihydralazine (arterial dilator)
Nifedipine (dihydro CCB)
[AVOID diuretics, ACEi, ARB, atenolol]
98
Q

Good/bad anticoags during pregnancy?

A

BAD: Warfarin (teratogenic), other oral anticoags (apixaban, rivaroxaban, dabigatran - data gaps, safe side)
GOOD: Heparin; low-dose aspirin ok for high-risk preeclampsia

99
Q

Analgesics during pregnancy?

A

NSAIDS: ok in T1 but not T2-T3
Acetaminophen good in T3
Opioids for severe pain

100
Q

Thyroid drugs during pregnancy?

A

NO RADIOACTIVE IODINE
T1 –> PTU; T2 –> methimazole
L-thyroxine for hypothyroid

101
Q

Diabetes treatment during pregnancy?

A

INSULIN even for GD/Type 2

Oral antidiabetics lead to pre-eclampsia, neonatal jaundice, macrosomia, neonatal hypoglycemia

102
Q

Best anti-allergens during pregnancy?

A

First-gen antihistamines (e.g. chlorpheniramine)

103
Q

What used to be used as a basis for invasive prenatal screening for aneuploidy but is NOT anymore?

A

Maternal age

104
Q

The identification, among apparently normal pregnancies, of those at sufficient risk of a specific fetal disorder to justify SUBSEQUENT invasive and/or costly prenatal diagnostic tests or procedures =

A

Prenatal screening

105
Q

If patient doesn’t present early enough for FTS, they could do

A

MSS (maternal serum screening) during second trimester

106
Q

Most common aneuploidies screened for?

A

Trisomies 21, 13, 18

107
Q

What is nuchal translucency and what might it signify

A

Sonolucent area behind neck in T1
Bigger –> more risk of chromosome aneuploidy
Very big –> risk for other congenital anomalies/malformation syndromes

108
Q

Down syndrome associated with ___ beta hCG

A

High

109
Q

Down syndrome associated with ___ AFP in maternal serum

A

Low

110
Q

eFTS Detection rate for T21?

A

85-90%

FP = 3-5%

111
Q

eFTS takes into consideration maternal serum markers (AFP, PIGF, PAPP-A, hCG) + ___ and ___ to calculate risk. When is this done?

A

Maternal age
Nuchal translucency
Week 11-14

112
Q

Main diff between MSS and eFTS?

A

MSS is later (week 15-20) and biochemical only + maternal age (no NT)
81% detection rate for T21

113
Q

NIPS uses what DNA?

A

circulating free PLACENTAL DNA

114
Q

Baseline NIPS uses proportions to look for what?

A

Trisomies 21/18/13, sex chromosome aneuploidies

115
Q

Detection rate of NIPS?

A

99-100%, FP<1%. But still not perfect and very $$!!!

116
Q

If patient screens positive with FTS (week 11-14) then with NIPS (~2+ weeks later get results) shows high-risk for T21 again, do they need further testing?

A

Keeping pregnancy –> no

Terminating –> yes

117
Q

Indications for amniocentesis or CVS

A

Screened positive for trisomy
Abnormal US
Risk of single gene disorder
Previous chromosomal abnormality or carrier

118
Q

When would CVS be more or less desirable than amnio?

A

Can be done EARLIER (11-14 weeks)
but higher miscarriage risk (1-2%) so not more desirable later
Accuracy is same b/w tests

119
Q

When is amniocentesis done? Risk of miscarriage?

A

> 15 weeks

1/200-1/400

120
Q

Post CVS or amnio DNA tests?

A

QFPCR (quantitative fluorescent) for ALL cases (shows aneuploidies)
Karyotype for large chromosome imbalances or balanced rearrangements, if QFPCR abnormal
Microarray for smaller imbalances, if PCR normal
Targeted testing required for single gene disorders (none of above work)

121
Q

Does patient need anesthetic for amniocentesis?

A

Nah, not too painful. Do under U/S

122
Q

2 types of CVS and how do you choose?

A

Transabdominal or Transcervical

Depends on position of placenta/baby, choose on day of procedure based on what is safest

123
Q

Why is it important to do a karyotype after positive QFPCR after amnio/CVS?

A

Because you need to know if it’s a translocation to predict risk in future pregnancies

124
Q

Name a cardiac “soft sign’ associated with aneuploidy on ultra sound. LR?

A

Echogenic intracardiac focus (LR for DS = 2)

125
Q

In screening for DS, you look for increased nuchal ___ in T1 and nuchal ___ in T2

A

Translucency

Fold

126
Q

What ultrasounds are typically performed?

A

1) Dating US from 7-12 weeks (CRL)
- Nuchal translucency between 11-14 weeks, often combined
2) Detailed anatomy US done between 18-22 weeks
[3)U/S to check if baby’s head is down (34-35 wks) sometimes?]

127
Q

What is the “normal” frequency, regularity, & duration of menses?

A

24-38 days
Variation up to 9 days
Duration up to 8 days

128
Q

Name the structural causes of abnormal uterine bleeding

A 
Polyps
Adenomyosis
Leiomyomas (submucosal + other)
Malignancy & hyperplasia
(PALM)
129
Q

Non-structural causes of abnormal uterine bleeding

A 
Coagulopathy
Ovulatory dysfunction
Endometrial (disorders of mechanisms for local hemostasis)
Iatrogenic
Not yet specified 
(COEIN)
130
Q

What is an endometrial polyp? Role in AUB?

A

Localized endometrial tumor

May be asymptomatic or contribute to AUB. If found, may be incidental, NOT necessarily the cause

131
Q

What is Adenomyosis?

A

Benign disease of unknown etiology characterized by endometrial tissue in the uterine wall

132
Q

Condition that is often associated with endometriosis or uterine fibroids and presents with dysmenorrhea, menorrhagia, chronic pelvic pain, and uniform enlargement of the uterus

A

Adenomyosis

133
Q

No line separating endo/myometrium on US/MRI may indicate what?

A

Adenomyosis

134
Q

Adenomyosis in AUB is often a ___ finding in AUB?

A

Incidental (not the source of symptoms)

135
Q

Define Leiomyoma

AKA?

A

AKA Uterine fibroids or myoma

Benign tumor of SM of uterus (common!)

136
Q

Uterine malignancy is diagnosed how? Needs to be investigated in what populations?

A

Endometrial biopsy

Any woman >45 who presents with AUB, any post-menopausal bleeding

137
Q

Most common coagulopathy causing AUB?

A

von Willebrand disease

138
Q

Diagnosing AUB-E (endometrial) is done how?

A

Diagnosis of exclusion

e.g. if predictable menses with heavy bleeding, it’s probably not an ovulation issue

139
Q

The PALM-COIEN classification of AUB is for what population?

A

Reproductive age

140
Q

AUB: PALM may be ___ but not ___; COIEN may be __ but not ____

A

PALM may be seen but not a cause

COIEN may be a cause but not be seen

141
Q

AUB-O pathophys?

A

No ovulation –> E unopposed by B –> persistent proliferation, unstable –> irregular/heavy shedding (common near menarche & menopause)

142
Q

Key components of general physical exam for AUB?

A

1) Vital signs, including weight/BMI
2) Thyroid
3) Skin exam
4) Abdo exam

143
Q

What is some key bloodwork to initially order when working up AUB?

A

CBC/Ferritin
B-hCG
TSH

144
Q

What is tranexamic acid

A

Antifibrinolytic that can be prescribed for AUB

145
Q

What analgesic can reduce uterine bleeding?

A

NSAIDs (though not generally used as primary treatment for bleeding, mainly pain)

146
Q

2 primary hormonal treatment options for AUB?

A

COC or progestins (IUD, depo-provera, oral)

147
Q

Next step if endometrial biopsy insufficient for diagnosis?

A

Dilation & curettage (curette = “spoon” that scrapes out some endometrium)

148
Q

What is the most common manifestation of uterine fibroids?

A

Asymptomatic

149
Q

What is sonohysterography?

A

an imaging technique in which sterile saline is instilled into the endometrial cavity and TVUS is performed. This procedure allows for careful architectural evaluation of the uterine cavity to detect small lesions (eg, polyps or small submucous fibroids) that may be missed on TVUS

150
Q

What is the most important question when seeing if someone is a candidate for endometrial ablation to treat AUB?

A

Desire for future pregnancy (contraindication)

151
Q

What are the 2 most common causes of postmenopausal uterine bleeding? What is the main point of diagnosis?

A

Endometrial atrophy & endometrial polyps

Need to rule out malignancy(10%)

152
Q

Examples of “climacteric” symptoms

A

Vaginal dryness
Night sweats, hot flashes/heat intolerance
Dyspareunia
Irritability

153
Q

Atrophic features of menopause (atrophic vaginitis, osteoporosis) are due to what?

A

Reduced estrogen

154
Q

Difference in menopausal HRT with and without hysterectomy

A

Hysterectomy –> E-only

Uterus present –> E & P (prevent endometrial hyperplasia/cancer)

155
Q

3 primary features of PCOS?

A

Hyperandrogenism
Oligo/anovulation
Polycystic ovaries (not required)

156
Q

PCOS strongly associated with?

A

Metabolic syndrome

Insulin resistance

157
Q

Female athlete triad syndrome is a form of what? What are the 3 components?

A

Functional hypothalamic amenorrhea:
Menstrual dysfunction
Calorie deficit (eating disorders)
Decreased bone density/osteoporosis

158
Q

3 significant causes of acquired hypogonadotropic hypogonadism

A

Eating disorders
Stress
Intense exercise
(alter pulsatile GnRH secretion via leptin/insulin/glucacon/catecholatmines, cortisol, opioids)

159
Q

4 differentials of eugonadotropic amenorrhea

A

PCOS
Non-classic (late-onset) CAH
Ovarian tumors
Hyperprolactinemia & thyroid disorders

160
Q

Define secondary amenorrhea

A

No meanses >3 mo in patients w/ previously regular cycles, >6 months if previous irregular cycles

161
Q

What is Sheehan syndrome?

A

Ischemia/necrosis of pituitary due to severe PPH

162
Q

GTPAL: What are the weeks limits on TPA?

Alternative?

A

<20 wks = abortion
<37 = Preterm
37+ weeks = term
Gravida/Para = pregnancy/delivery

163
Q

In GTPAL, twins count as how many deliveries?

A

1 (but 2 living children!)

164
Q

In patients with hypogonadism/POF need to give ___

A

Estrogen therapy! (COCs or HRT) to prevent osteoporosis

165
Q

Initial diagnostic workup for secondary amenorrhea

A 
Pregnancy test
FSH (if high --> POF)
TSH (if high --> hypothyroidism)
Prolactin (high --> iatrogenic, tumors)
Progestin challenge
166
Q

Describe the progestin challenge in secondary amenorrhea

A

1) 10 days progestin. Withdrawal bleeding indicates anovulation w/ E present (P deficient, e.g. PCOS, POF)
2) No bleeding and low FSH –> E + P challenge; Bleeding –> hypogonadotropic hypogonadism; No bleeding –> endometrial or anatomical problem
(if high FSH, probably means you have hypergonadotropic hypogonadism or POF)

167
Q

Amenorrhea + virilizatino
What diagnostics?
DDx?

A

Testosterone, DHEA-S, 17-hydroxyprogesterone

PCOS, CAH, Cushing syndrome, androgen-producing tumor

168
Q

Define menometrorrhagia

A

Irregular/excessive flow

169
Q

Uterine contractility is mediated by ___?

Hormonal interaction?

A

Prostaglandins

Progesterone PREVENTS prostaglandin production, stabilize uterus and allowing it to relax/stretch

170
Q

Expected weight gain during pregnancy

A

25-35 lbs if normal BMI
30-40 is underweight
15-25 if overweight
10-20 if obese

171
Q

Recommended screening time for GDM

A

Risk for type 2 –> A1C first antenatal visit (in case undetected diasese)
Otherwise all women 24-28 gestational age

172
Q

“Preferred” approach to GDM screening at 24-28 weeks. Step 1?

A

50g Glucose challenge test (nongasting, measure PG @ 1 hr)

  1. 8 + –> move on to 75g OGTT
  2. 1 –> diagnostic, no further testing necessary
173
Q

“Preferred” approach to GDM screening at 24-28 weeks. Step 2?

A

75 g OFTT
Fasting >5.3
1 hr >10.6
2 hr >9.0 = positive!

174
Q

What is the “alternative” approach to GDM screening at 24-28 weeks gestational age?

A

1-step 75 g OGTT but cutoffs are lower (2 hr >8.5)

175
Q

Target FPG in GDM?

A

<5.3

176
Q

Women with GDM should be trialed on ___ for __ weeks, if that doesn’t work then initiate ____

A

Nutritional therapy/physical activity
1-2 weeks
Pharmacologic therapy

177
Q

Pharmacologic therapy for GDM

A

1) Basal-bolus injection therapy INSULIN
2) Metformin is alternative but crosses placenta and long-term data not available (inform patient)
3) Glyburide (sulfonylurea secretagogue) is last-line

178
Q

Define hysterosalpingogram

A

Catheter inserted through cervix via speculum

Fluoroscopic images obtained while instilling iodinated contrast to opacify uterine cavity/FTs

179
Q

Define sonohysterogram

A

Catheter used to inject saline into uterine cavity

Transvaginal ultrasound

180
Q

Define hystero-salpingo-contrast sonography

A

Echogenic contrast injectected
Transvaginal U/S before + after
(assesses tubal patency & uterine cavity)

181
Q

Tests for ovulatory function

A

Regularity of cycle + molimina symptoms
Mid-luteal serum progest = most accurate lab (too low –> anovulation)
OTC LH ovulation prediction kits

182
Q

Antral follicle count is used to assess ___ and is performed how?

A 
Ovarian reserve
Transvaginal US
(<4-10 in days 2-4 of cycle = poor ovarian reserve)
183
Q

What is Clomiphene?

A

SERM (selective estrogen receptor modulator)
Used to induce ovulation
also acts as a partial estrogen agonist in the hypothalamus resulting in an estrogenic negative feedback inhibition, thus increasing gonadotropins

184
Q

High FSH in Day 3 FSH or Clomiphene Citrate Challenge Test indicates…

A

Low ovarian reserve (lack of feedback inhibition)

185
Q

2 indirect markers of diminished ovarian reserve? Recommended fertility treatment for DOR?

A 
Low AMH (anti-mullerian hormone)
High FSH
Donor eggs (low chance of conception with own eggs even via IVF)
186
Q

Infertility treatment for ovulatory disorders (6)

A 
Weight modulation
Ovulation induction agents (clomiphene citrate, aromatase inhibitors, gonadotropin therapy)
Metformin
Laparoscopic surgery
Dopamine agonists (hyperprolactinemia)
ARTs
187
Q

Fertility treatment for tubal factor infertility & adhesions

A

Surgical reconstruction or IVF (latter if severe disease)

188
Q

Unexplained infertility empiric treatment?

A

1) Clomiphene w/ IUI

2) Gonadotropins w/ IUI or ARTs

189
Q

Common fertility treatment for endo

A

Ovulatio induction + IUI

190
Q

What is IUI?

A

Washed sperm placed directly in uterus during natural or induced-ovulation

191
Q

5 steps of IVF

A

1) Controlled ovarian stimulation (e.g. GnRH agonists)
2) Ocyte retrieval
3) IVF
4) Embryo transferred ot uterus
5) Luteal phase support (progesterone)

192
Q

What is intracytopasmic sperm injection and when is it useful?

A

When sperm aren’t motile, can’t be ejaculated etc.

Inject 1 sperm rather than throwing them in dish togetehr

193
Q

When working up male fertility need to review exposures/health issues from last _____. Why?

A

3 months (spermatogenesis takes 75 days)

194
Q

Questions to ask in male infertility history (6)

A
  • Prior testicular insults (torsion, cryptorchidism, trauma)
  • Infections (mumps orchitis, epididymitis, STIs)
  • Environmental factors (excessive heat, radiation, chemo, pesticide exposures)
  • Meds (testosterone, cimetidine (H2 blocker), SSRIs, spirolactone affect spermatogenesis; others as well)
  • Recreational drugs (alcohol, tobacco, marijuana)
  • Sexual function, freq, timing; use of lubes; previous fertility of both partners
195
Q

If <10 million/Ml sperm, what tests?

A

Testosterone & FSH
LH & prolactin may follow if indicated
May do genetic testing after counselling (Y deletions, Klinefelter, CF)

196
Q

Oligozoospermia

A

<15 million/mL

197
Q

Azoospermia

A

No sperm :(

198
Q

Asthenozoospermia

A

Abnormal motility ( varicocele, infection, abnormalities of flagella, ejaculatory duct obstruction)

199
Q

Teratospermia

A

Many abnormal sperms (<4% normal mophology)

200
Q

hCG simulation test looks for ___ function in men. Normal has rise in ____

A

Leydig cell

Plasma testosterone

201
Q

How does a varicocele lead to infertility?

A

Retrograde/abnormal blood flow impairs spermatogenesis

202
Q

Male infertility diagnosis

Oligospermia, low testosterone, high LH/FSH

A

Primary gonadal failure –> androgen therapy

203
Q

Male infertility diagnosis

Oligospermia, normal testosterone and LH, high FSH

A

Seminiferous tubule failure –> ART

204
Q

Male infertility diagnosis

Oligospermia, normal testosterone and LH/FSH

A

Seminal fluid fructose
Absent –> congenital absence of vas deferens/seminal vesicles
Present –> testicular biopsy –> ductal obstruction or spermatogenic failure

205
Q

Male infertility diagnosis

Oligospermia, low testosterone and LH/FSH

A

Hypothalamic-pituitary disease

206
Q

Mothers should be encouraged to feed on demand or about every ___ hours (___ feedings/day), a frequency that gradually decreases over time
small infants and late preterm infants should not be allowed to____

A

1.5-3 hours (8-12 per day)

Sleep long periods

207
Q

Baby should produce ___ wet diapers per day by end of first week + __ stools per day for babies 1-4 wks old

A

6 wet diapers

4 stools

208
Q

How much weight might baby lose in first week? Regain by?

A

7%

Regain by end of 2nd week

209
Q

What pathogen causes mastitis? Treatment?

A 
Staphylococcus aureus (from infant of mother's skin)
ABs + continue breastfeeeding (alt breast every 2-3 hours)
210
Q

2 types of infant jaundice associated with breastfeeding. Describe + treatment

A

Breastfeeding jaundice: insufficient breastfeeding –> too few calories, less bowel motion, less bilirubin excretion. More feeds!
Breastmilk jaundice: too much beta-glucuronidase in milk –> more decong/reabsorption of bilirubin; keep breastfeeding

211
Q

Absolute contraindication to breastfeeding in infant

A

Galactosemia

212
Q

Exclusively breastfeed until ___

Formula-fed babies need to stay on commercial formula until?

A

6 months

9-12 months for formula

213
Q

When can cow’s milk be introduced to baby?

A

After 1 year

214
Q

Most recommended type of formula if no contraindications?

A

Cow’s milk (but don’t give plain cow’s milk!!)

215
Q

What types of formulas are good vs bad for babies with weak immune system/preemies?

A

Good: ready-to-feed & liquid concentrate (sterile)
Bad: powder (not sterile)

216
Q

Prenatal visit frequency

A

0-30 wks: q4 wks
32-36 wks: q2 wks
37+ wks: q1 wk

217
Q

What are the 4 golden questions to ask EVERY pregnant patient regardless of reason for appointment?

A
  1. Leaking of fluids
  2. Vaginal bleeding
  3. Fetal movement
  4. Contractions
218
Q

Prenatal HR/RR?

A

Can be slightly higher normally
HR up to 110 normal
RR up to 24 normal

219
Q

Start doing Leopold’s maneuver at __ weeks

At ___ weeks baby “commits” to position, send for U/S if may be breech after this pt

A

30 wks

36 wks

220
Q

When does the symphysis-fundal height NOT match the number of weeks?

A

After 38 weeks height often decreases because baby’s head is engaged

221
Q

Begin checking FHR at ___ wks because?

A

12 wks because before then uterus hasn’t risen out of pelvis

222
Q

FHR is normally ___bpm and best heard most often in the _____ area

A

110-160 (if you hear <100 probably a maternal vessel)

RLQ

223
Q

Fetal movement begins to be felt around…

A

16-20 weeks

224
Q

Normal U/S schedule in low-risk pregnancy?

A

3 total:
1 - Dating U/S (~8 weeks)
2 - Nuchal translucency scan (~12 weeks)
3 - Anatomy scan (~20 wks)

225
Q

How much bleeding is typically TOO much?

A

Soaking 1 pad per hour for 2+ hrs

Preclerkship (25 decks)

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