High Yield Repro Flashcards
What does progestin do in COC pills?
Prevents LH surge/ovulation, thickens cervical mucus, reduces tubal motility/peristalsis, decidualizes endometrium
(Progesterone only pill can suppress ovulation but not consistently)
What does estrogen do in COC pills?
Reduces FSH/follicular development, increases endometrial proliferation
Ideally start hormonal contraceptive within __ days of LMP
5
`What type of birth control pill must be taken at the SAME TIME every day with no pill-free interval
Progestin-only pill
What is the depo-provera shot? Pros/cons?
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
Name 5 types of hormonal contraceptives (non-IUD)
1) COC pills
2) Transdermal (Ortho Evra)
3) Nuva ring
4) Progestin-only pill
5) Depo-provera
How do COCs modify the risks of ovarian/endometrial cancer and STIs?
Reduce them
STIs because of more cervical mucus
Absolute contraindicates to COCs (9)
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
Do ABs reduce COC effectiveness?
ONLY RIFAMPIN
anti-mycobacterial; treats TB and Neisseria meningitidis which can cause meningitis
Irregular breakthough bleeding when starting OCP usually resolves after…
3 cycles
Can COCs be used immediately after delivery?
No evidence harmful to baby but may decrease milk prod. Not recommended 6-wk postpartum, ideally >3mo if BF
Progestin-only contraceptive methods would be recommended for whom?
Postpartum
Contraindications to E (thromboembolic or myocardial disease)
Side-effects from E
Why must STIs be considered when choosing an IUD?
Risks of PID
high STI risk = contraindication
How does the copper IUD (Nova-T) work?
Foreign body reaction in endometrium
Toxic to sperm, alters sperm motility
What test should you run before IUD insertion?
Cervical swabs for gonorrhea/chlamydia
Describe 4 methods of emergency postcoital contraception
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
At what gestational age is abortion legal in Canada?
Any! Most <12 weeks though, very rare >24 unless danger of some sort
Pro and con of medical abortion (vs aspiration)
More “control”/privacy
Cons: longer, more awareness of blood loss and tissue passage
3 risks of teenage pregnancy to mother + baby
Mother: eclampsia, puerperal endometritis, systemic infections
Baby: Low birth weight, preterm delivery, other severe neonatal conditions
Medical abortion timing, options, mechanisms
<9 weeks
Mifegymiso = mifepristone (blocks progesterone receptors) + misoprostol (uterine contractions)
Methotrexate+ miso (toxic to trophoblasts) or miso alone (least effective)
Are U/S required before Mifegymiso
Nope! Unless ectopic suspected or unsure about gestatinoal age
Prep for abortion surgery (3)
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)
Osmotic dilator example for cervical prep for abortion
Laminaria tents
What type of bleeding is expected in a medical abortion? How much is too much?
Heavy bleeding <24 hours, light until next period is ok
4 soaked pads in 2 hours –> ED
What is the followup to medical abortion?
B/W 7 days later to make sure it worked
What is the difference between spontaneous abortion and stillbirth?
Spontaneous abortion <20 wks
Stillbirth >20 weeks
Name 5 types of spontaneous abortions
1) Threatened
2) Inevitable
3) Incomplete
4) Complete
5) Missed
What type of spontaneous abortion is potentially reversible? What can you do?
Threatened - avoid strenuous PA - weekly pelvic U/S - R/O treatable causes of bleeding - RhD immune globin prophylaxis (<5% actually abort)
Why might suction D & C used after birth or abortion?
Remnants of fetus/tissues after abortion, pieces of placenta after childbirth:
Bleeding risk (can lead to DIC)
Infection –> sepsis
Diagnosis of spontaneous abortion
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
Define subchorionic hematoma
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.
Threatened abortion: definition
Vaginal bleeding + cramps
Cervix closed/soft
Inevitable abortion: definition + management
Increased bleeding/cramps, +/- ROM
Cervix closed, then os opens and products start to expel
Approach: Watch and wait, Mif + Misoprostol, D&C, (+/- Rhogam)
Are Mifepristone and misoprostol administered at the same time?
No, Mifepristone given first
Incomplete abortion: definition + management
Extremely heavy bleeding/cramps, tissue passed
Cervix open
Treatment options: Watch/wait, Mif&Miso, D&C, (+/- Rhogam)
Complete abortion: definition + management
Bleeding and complete passage of sac & placenta
Cervix closed, bleeding stopped
Expectant management, no D&C
Missed abortion: definition & management
No bleeding (fetal death in utero), cervix closed Options: watch & wait, Mif/Miso, D&C (+/- Rhogam)
Any woman presenting with abdominal pain, vaginal bleeding, and amenorrhea is ____ until proven otherwise
Ectopic pregnancy
Most common location of ectopic pregnancy
Ampulla (between isthmus & infundibulum) - 70%!
50% of ectopic pregnancies are due to…
Damage to fallopian tubes after PID
can also be egg abnormalities or transmigration to contralateral tube
Risk factors for ectopic pregnancies (>50% have no RFs!)
Previous ectopic pregnancy IUD PID in past, salpingitis Infertility/induced ovulation Pelvic/abdo surgieries Smoking Uterine leiomyomas/adhesions/abnormal anatomy
Norm serum hCG trajectory. If ectopic?
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
3 components of suspected ectopic pregnancy
1) Positive urine B-hCG
2) Acute abdomen (may be distended)
3) Vaginal bleeding (+/-shock)
If hemodynamically stable and suspected ectopic pregnancy, what do you do?
If hemodynamically unstable or impending/current ruptured ectopic pregnancy?
1) Transvaginal U/S & Serum b-hCG to determine treatment
2) Immediate surgery
When is expectant management ok in initially suspected ectopic pregnancy?
B-hCG low/declining
No fetal heartbeat or extrauterine sac suspicious for ectopic pregnancy
Patient reliable for follow-up
What med can be used for an ectopic pregnancy and what are the indications? (not including Rhogam)
Methotrexate:
- small (<3.5 cm), unruptured
- Low b-HCG
Compliance & follow-up assured
What surgeries can be done for ectopic pregnancy?
Salpingostomy (if tube salvageable & patient can follow up w/ weekly b-hCG)
Salpingectomy (tube damaged or ipsilateral recurrence)
At what point is an intrauterine pregnancy visible on transabdominal US? Transvaginal
TA: 6-8 weeks
TV: 5 wks = gestational sac, 7-8 wks = heart activity
Due date calculation (conditions?)
1st day of LMP + 9 mo + 7 days
Cycle must be regular (if regular >28 days, add that # of days)
Recommended supplements in early pregnancy
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
If a minor is being sexually abused, do you contact the police?
No, contact CAS
Age of consent to sex
Non-exploitive: 16yo Exploitive: 18yo Exceptions: 14-15 yo --> 5 year max 12-13 --> 2 year max
hCG is structurally similar to…
LH
Human placental lactogen (hPL) has structure/function similar to what 2 hormones?
GH (–> fetal bone growth, diabetogenic in mother)
Prolactin (–> breast development)
What estrogen is mostly specific to pregnancy?
Estriol
Progesterone has a ____ effect on SM (examples?)
Relaxing
uterus, BVs, ureters, GE sphincter, intestines
Goodell’s sign =
Chadwick’s sign =
Hegar’s sign =
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)
2 skin changes caused by increased estrogen (e.g. during pregnancy)
Spider angiomas, palmar erythema
Blood pressure during pregnancy
Nadir @ 24 weeks due to BV relaxation then back to normal levels because…
Hyper-dynamic circulation (CO, HR, BV all increase; myocardial hypertrophy)
Hematologic changes during pregnancy
Physiologic anemia due to DILUTION
Plasma increases more than RBCs, so lowers hematocrit
Hypercoagulable state
Why do some autoimmune diseases improve during pregnancy?
Higher leukocyte count but impaired function
How do TLC, FRC, and RV change during prevnancy?
How do VC and FEV1 change?
TLC/FRC/RV decrease
VC/FEV1 stay the same
What is the purpose of the mild resp alkalosis resulting from increased minute ventilation in pregnancy?
Helps CO2 diffuse across placenta from fetus –> mamma
3 GI impacts of pregnancy (other than nausea)
1) GERD (increase intra-abdo pressure + progest relaxes GE sphincter)
2) Constipation (decreased GI motility)
3) Gallstones (stasis)
Risk factors for UT during pregnancy?
Urinary stasis
Glycosuria
Ureter/renal pelvis dilation
What happens to GFR during pregnancy? Impact?
Increases due to high CO
–> lower creatinine, uric acid, BUN
First trimester until week ___, 2nd until week ___
13, 26
The embryo is extremely susceptible to teratogens from week __ to week __, when the process of ___ occurs
3-8, organogenesis
Fetal cardiac activity is visible by TV ultrasound when a woman is ___ weeks pregnant ( ___ fetal age)
6 weeks pregnants
4 weeks fetal ago
4 heart chambers present and begins to beat!
Neural plate begins to form at ___ weeks DEVELOPMENT, neural tube closes by week __
3, 4
Fetopathies are most likely to lead to what kinds of abnormalities?
Functional issues (e.g. behavioural/learning) Minor structural things
Gastrulation
formation of the trilaminar embryonic disc (endoderm, mesoderm, ectoderm) through migration of epiblasts (all embryonic tissues originate from epiblasts); week 3!
Weeks 2-4 mnemonic:
Week 2 - 2 layers (bilaminar disc)
Week 3 - 3 layers (trilaminar disc)
Week 4 - 4 limb buds + 4 heart chambers
Define neurulation
Formation of neural tube + neural crests
Neural tube –> CNS + retina
Neural crest –> PSNS, adrenal medula, etc.
2 examples of neural tube defects
Spina bifida
Anencephaly
Weeks of: germinal period, embryonic period, fetal period
1-2
3-8
9+
What is antiphospholipid syndrome?
Autoimmune disease
Anti-PL Abs activate platelets/vascular endothelium –> hypercoag state
Antiphospholipid syndrome & pregnancy effects
Miscarriages (usually >10 weeks, placental insufficiency, preeclampsia
Placental insufficiency is characterized by
Inadequate blood flow to placenta + impairment of substance exchange b/w fetus + mamma
Antisphospholipid syndrome 2o prophylaxis in someone who wants to have kids
LMWH + aspirin
When is the highest risk for DVT & PE in pregnant woman?
Most DVTs T3/post-partum
Most PEs post-partum
Link Virchow’s triad to increased VTE risk in pregnancy
Hypercoagulability: increased clotting factors, decreased proteins C/S
Stasis: decreased venous tone/flow, uterus impacts venous return
Endothelial: vascular damage @ delivery
Treatment for VTE during pregnancy
LMWH (d/c >24 hrs before delivery); or UFH
WARFARIN CONTRAINDICATED
Affect of teratogens pre-implanatation phase (1-2 weeks)
All-or-nothing effect (spontaneous abortion, never even know you’re pregnant)
Impacts of maternal pregestational/gestational DM on embryo?
Birth defects, spontaneous abortion
Transposition of great vessels, VSD, truncus arteriosus
Neural tube defects
Caudal regression syndrome (usually die as infant)
Impacts of maternal pregestational/gestational DM on FETUS?
Chronic fetal hyperglycemia –> fetal hyperinsulinemia, islet cell hyperplasia, more IGF/GH/metabolism –> fetal hypoxia
Macrosomia, polycythemia, neonatal hypoglycemia, resp dirtress, hypertrophic cardiomyopathy
Graves disease in mother causes what in baby?
Neonatal thyrotoxicosis (TSH receptor Abs move through placenta)
Heart defects associated with FAS
VSD!
Also PDA, ASD, ToF
Heat-lung fistulas
Facial features of FAS
Smooth philtrum
Thin upper lip
Downslanting/short palpebral fissures
Epicanthal folds
THrough what mechanism does cigarette smoking cause birth defects
Nicotine –> catecholamines –> vasoconstriction of uteroplacental BVs –> detal oxygen deprivation
(–> LBW, IUR, preterm labor/miscarriage due to placental abnormalities)
What is placental abruption?
Premature separation of placenta –> antenatal hemorrhage
Name the TORCH infections
Toxoplasmosis Others (Syphilis, Varicella, Parvovirus B19, Listeriosis) Rubella Cytomegaly (CMV) Herpes Simplex Virus
Transplacental transmission occurs following __ infection of a ___ mother. Why?
Transplacental
Seronegative
IgM is formed first, only IgG can cross placenta
Which vaccines can you not get DURING pregnancy?
Live attenuated: MMR, Varicella
what type of immunization for varicella can you give during pregnancy?
Passive VZIG (not active VZV vaccine)
Antibiotics that are SAFE during pregnancy
Penicillins (amoxicillin, ampicillin)
Cephalosphorins
Macrolides (erythromycin, azithromycin)
Nitrofurantoin (UTIs)
Antihypertensives that are ok during pregnancy
"Moms Love Healthy Newborns" Methyldopa (crises) Labetalol (or metoprolol) during T1-T2 Dihydralazine (arterial dilator) Nifedipine (dihydro CCB) [AVOID diuretics, ACEi, ARB, atenolol]
Good/bad anticoags during pregnancy?
BAD: Warfarin (teratogenic), other oral anticoags (apixaban, rivaroxaban, dabigatran - data gaps, safe side)
GOOD: Heparin; low-dose aspirin ok for high-risk preeclampsia
Analgesics during pregnancy?
NSAIDS: ok in T1 but not T2-T3
Acetaminophen good in T3
Opioids for severe pain
Thyroid drugs during pregnancy?
NO RADIOACTIVE IODINE
T1 –> PTU; T2 –> methimazole
L-thyroxine for hypothyroid
Diabetes treatment during pregnancy?
INSULIN even for GD/Type 2
Oral antidiabetics lead to pre-eclampsia, neonatal jaundice, macrosomia, neonatal hypoglycemia
Best anti-allergens during pregnancy?
First-gen antihistamines (e.g. chlorpheniramine)
What used to be used as a basis for invasive prenatal screening for aneuploidy but is NOT anymore?
Maternal age
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 =
Prenatal screening
If patient doesn’t present early enough for FTS, they could do
MSS (maternal serum screening) during second trimester
Most common aneuploidies screened for?
Trisomies 21, 13, 18
What is nuchal translucency and what might it signify
Sonolucent area behind neck in T1
Bigger –> more risk of chromosome aneuploidy
Very big –> risk for other congenital anomalies/malformation syndromes
Down syndrome associated with ___ beta hCG
High
Down syndrome associated with ___ AFP in maternal serum
Low
eFTS Detection rate for T21?
85-90%
FP = 3-5%
eFTS takes into consideration maternal serum markers (AFP, PIGF, PAPP-A, hCG) + ___ and ___ to calculate risk. When is this done?
Maternal age
Nuchal translucency
Week 11-14
Main diff between MSS and eFTS?
MSS is later (week 15-20) and biochemical only + maternal age (no NT)
81% detection rate for T21
NIPS uses what DNA?
circulating free PLACENTAL DNA
Baseline NIPS uses proportions to look for what?
Trisomies 21/18/13, sex chromosome aneuploidies
Detection rate of NIPS?
99-100%, FP<1%. But still not perfect and very $$!!!
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?
Keeping pregnancy –> no
Terminating –> yes
Indications for amniocentesis or CVS
Screened positive for trisomy
Abnormal US
Risk of single gene disorder
Previous chromosomal abnormality or carrier
When would CVS be more or less desirable than amnio?
Can be done EARLIER (11-14 weeks)
but higher miscarriage risk (1-2%) so not more desirable later
Accuracy is same b/w tests
When is amniocentesis done? Risk of miscarriage?
> 15 weeks
1/200-1/400
Post CVS or amnio DNA tests?
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)
Does patient need anesthetic for amniocentesis?
Nah, not too painful. Do under U/S
2 types of CVS and how do you choose?
Transabdominal or Transcervical
Depends on position of placenta/baby, choose on day of procedure based on what is safest
Why is it important to do a karyotype after positive QFPCR after amnio/CVS?
Because you need to know if it’s a translocation to predict risk in future pregnancies
Name a cardiac “soft sign’ associated with aneuploidy on ultra sound. LR?
Echogenic intracardiac focus (LR for DS = 2)
In screening for DS, you look for increased nuchal ___ in T1 and nuchal ___ in T2
Translucency
Fold
What ultrasounds are typically performed?
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?]
What is the “normal” frequency, regularity, & duration of menses?
24-38 days
Variation up to 9 days
Duration up to 8 days
Name the structural causes of abnormal uterine bleeding
Polyps Adenomyosis Leiomyomas (submucosal + other) Malignancy & hyperplasia (PALM)
Non-structural causes of abnormal uterine bleeding
Coagulopathy Ovulatory dysfunction Endometrial (disorders of mechanisms for local hemostasis) Iatrogenic Not yet specified (COEIN)
What is an endometrial polyp? Role in AUB?
Localized endometrial tumor
May be asymptomatic or contribute to AUB. If found, may be incidental, NOT necessarily the cause
What is Adenomyosis?
Benign disease of unknown etiology characterized by endometrial tissue in the uterine wall
Condition that is often associated with endometriosis or uterine fibroids and presents with dysmenorrhea, menorrhagia, chronic pelvic pain, and uniform enlargement of the uterus
Adenomyosis
No line separating endo/myometrium on US/MRI may indicate what?
Adenomyosis
Adenomyosis in AUB is often a ___ finding in AUB?
Incidental (not the source of symptoms)
Define Leiomyoma
AKA?
AKA Uterine fibroids or myoma
Benign tumor of SM of uterus (common!)
Uterine malignancy is diagnosed how? Needs to be investigated in what populations?
Endometrial biopsy
Any woman >45 who presents with AUB, any post-menopausal bleeding
Most common coagulopathy causing AUB?
von Willebrand disease
Diagnosing AUB-E (endometrial) is done how?
Diagnosis of exclusion
e.g. if predictable menses with heavy bleeding, it’s probably not an ovulation issue
The PALM-COIEN classification of AUB is for what population?
Reproductive age
AUB: PALM may be ___ but not ___; COIEN may be __ but not ____
PALM may be seen but not a cause
COIEN may be a cause but not be seen
AUB-O pathophys?
No ovulation –> E unopposed by B –> persistent proliferation, unstable –> irregular/heavy shedding (common near menarche & menopause)
Key components of general physical exam for AUB?
1) Vital signs, including weight/BMI
2) Thyroid
3) Skin exam
4) Abdo exam
What is some key bloodwork to initially order when working up AUB?
CBC/Ferritin
B-hCG
TSH
What is tranexamic acid
Antifibrinolytic that can be prescribed for AUB
What analgesic can reduce uterine bleeding?
NSAIDs (though not generally used as primary treatment for bleeding, mainly pain)
2 primary hormonal treatment options for AUB?
COC or progestins (IUD, depo-provera, oral)
Next step if endometrial biopsy insufficient for diagnosis?
Dilation & curettage (curette = “spoon” that scrapes out some endometrium)
What is the most common manifestation of uterine fibroids?
Asymptomatic
What is sonohysterography?
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
What is the most important question when seeing if someone is a candidate for endometrial ablation to treat AUB?
Desire for future pregnancy (contraindication)
What are the 2 most common causes of postmenopausal uterine bleeding? What is the main point of diagnosis?
Endometrial atrophy & endometrial polyps
Need to rule out malignancy(10%)
Examples of “climacteric” symptoms
Vaginal dryness
Night sweats, hot flashes/heat intolerance
Dyspareunia
Irritability
Atrophic features of menopause (atrophic vaginitis, osteoporosis) are due to what?
Reduced estrogen
Difference in menopausal HRT with and without hysterectomy
Hysterectomy –> E-only
Uterus present –> E & P (prevent endometrial hyperplasia/cancer)
3 primary features of PCOS?
Hyperandrogenism
Oligo/anovulation
Polycystic ovaries (not required)
PCOS strongly associated with?
Metabolic syndrome
Insulin resistance
Female athlete triad syndrome is a form of what? What are the 3 components?
Functional hypothalamic amenorrhea:
Menstrual dysfunction
Calorie deficit (eating disorders)
Decreased bone density/osteoporosis
3 significant causes of acquired hypogonadotropic hypogonadism
Eating disorders
Stress
Intense exercise
(alter pulsatile GnRH secretion via leptin/insulin/glucacon/catecholatmines, cortisol, opioids)
4 differentials of eugonadotropic amenorrhea
PCOS
Non-classic (late-onset) CAH
Ovarian tumors
Hyperprolactinemia & thyroid disorders
Define secondary amenorrhea
No meanses >3 mo in patients w/ previously regular cycles, >6 months if previous irregular cycles
What is Sheehan syndrome?
Ischemia/necrosis of pituitary due to severe PPH
GTPAL: What are the weeks limits on TPA?
Alternative?
<20 wks = abortion
<37 = Preterm
37+ weeks = term
Gravida/Para = pregnancy/delivery
In GTPAL, twins count as how many deliveries?
1 (but 2 living children!)
In patients with hypogonadism/POF need to give ___
Estrogen therapy! (COCs or HRT) to prevent osteoporosis
Initial diagnostic workup for secondary amenorrhea
Pregnancy test FSH (if high --> POF) TSH (if high --> hypothyroidism) Prolactin (high --> iatrogenic, tumors) Progestin challenge
Describe the progestin challenge in secondary amenorrhea
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)
Amenorrhea + virilizatino
What diagnostics?
DDx?
Testosterone, DHEA-S, 17-hydroxyprogesterone
PCOS, CAH, Cushing syndrome, androgen-producing tumor
Define menometrorrhagia
Irregular/excessive flow
Uterine contractility is mediated by ___?
Hormonal interaction?
Prostaglandins
Progesterone PREVENTS prostaglandin production, stabilize uterus and allowing it to relax/stretch
Expected weight gain during pregnancy
25-35 lbs if normal BMI
30-40 is underweight
15-25 if overweight
10-20 if obese
Recommended screening time for GDM
Risk for type 2 –> A1C first antenatal visit (in case undetected diasese)
Otherwise all women 24-28 gestational age
“Preferred” approach to GDM screening at 24-28 weeks. Step 1?
50g Glucose challenge test (nongasting, measure PG @ 1 hr)
- 8 + –> move on to 75g OGTT
- 1 –> diagnostic, no further testing necessary
“Preferred” approach to GDM screening at 24-28 weeks. Step 2?
75 g OFTT
Fasting >5.3
1 hr >10.6
2 hr >9.0 = positive!
What is the “alternative” approach to GDM screening at 24-28 weeks gestational age?
1-step 75 g OGTT but cutoffs are lower (2 hr >8.5)
Target FPG in GDM?
<5.3
Women with GDM should be trialed on ___ for __ weeks, if that doesn’t work then initiate ____
Nutritional therapy/physical activity
1-2 weeks
Pharmacologic therapy
Pharmacologic therapy for GDM
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
Define hysterosalpingogram
Catheter inserted through cervix via speculum
Fluoroscopic images obtained while instilling iodinated contrast to opacify uterine cavity/FTs
Define sonohysterogram
Catheter used to inject saline into uterine cavity
Transvaginal ultrasound
Define hystero-salpingo-contrast sonography
Echogenic contrast injectected
Transvaginal U/S before + after
(assesses tubal patency & uterine cavity)
Tests for ovulatory function
Regularity of cycle + molimina symptoms
Mid-luteal serum progest = most accurate lab (too low –> anovulation)
OTC LH ovulation prediction kits
Antral follicle count is used to assess ___ and is performed how?
Ovarian reserve Transvaginal US (<4-10 in days 2-4 of cycle = poor ovarian reserve)
What is Clomiphene?
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
High FSH in Day 3 FSH or Clomiphene Citrate Challenge Test indicates…
Low ovarian reserve (lack of feedback inhibition)
2 indirect markers of diminished ovarian reserve? Recommended fertility treatment for DOR?
Low AMH (anti-mullerian hormone) High FSH Donor eggs (low chance of conception with own eggs even via IVF)
Infertility treatment for ovulatory disorders (6)
Weight modulation Ovulation induction agents (clomiphene citrate, aromatase inhibitors, gonadotropin therapy) Metformin Laparoscopic surgery Dopamine agonists (hyperprolactinemia) ARTs
Fertility treatment for tubal factor infertility & adhesions
Surgical reconstruction or IVF (latter if severe disease)
Unexplained infertility empiric treatment?
1) Clomiphene w/ IUI
2) Gonadotropins w/ IUI or ARTs
Common fertility treatment for endo
Ovulatio induction + IUI
What is IUI?
Washed sperm placed directly in uterus during natural or induced-ovulation
5 steps of IVF
1) Controlled ovarian stimulation (e.g. GnRH agonists)
2) Ocyte retrieval
3) IVF
4) Embryo transferred ot uterus
5) Luteal phase support (progesterone)
What is intracytopasmic sperm injection and when is it useful?
When sperm aren’t motile, can’t be ejaculated etc.
Inject 1 sperm rather than throwing them in dish togetehr
When working up male fertility need to review exposures/health issues from last _____. Why?
3 months (spermatogenesis takes 75 days)
Questions to ask in male infertility history (6)
- 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
If <10 million/Ml sperm, what tests?
Testosterone & FSH
LH & prolactin may follow if indicated
May do genetic testing after counselling (Y deletions, Klinefelter, CF)
Oligozoospermia
<15 million/mL
Azoospermia
No sperm :(
Asthenozoospermia
Abnormal motility ( varicocele, infection, abnormalities of flagella, ejaculatory duct obstruction)
Teratospermia
Many abnormal sperms (<4% normal mophology)
hCG simulation test looks for ___ function in men. Normal has rise in ____
Leydig cell
Plasma testosterone
How does a varicocele lead to infertility?
Retrograde/abnormal blood flow impairs spermatogenesis
Male infertility diagnosis
Oligospermia, low testosterone, high LH/FSH
Primary gonadal failure –> androgen therapy
Male infertility diagnosis
Oligospermia, normal testosterone and LH, high FSH
Seminiferous tubule failure –> ART
Male infertility diagnosis
Oligospermia, normal testosterone and LH/FSH
Seminal fluid fructose
Absent –> congenital absence of vas deferens/seminal vesicles
Present –> testicular biopsy –> ductal obstruction or spermatogenic failure
Male infertility diagnosis
Oligospermia, low testosterone and LH/FSH
Hypothalamic-pituitary disease
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____
1.5-3 hours (8-12 per day)
Sleep long periods
Baby should produce ___ wet diapers per day by end of first week + __ stools per day for babies 1-4 wks old
6 wet diapers
4 stools
How much weight might baby lose in first week? Regain by?
7%
Regain by end of 2nd week
What pathogen causes mastitis? Treatment?
Staphylococcus aureus (from infant of mother's skin) ABs + continue breastfeeeding (alt breast every 2-3 hours)
2 types of infant jaundice associated with breastfeeding. Describe + treatment
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
Absolute contraindication to breastfeeding in infant
Galactosemia
Exclusively breastfeed until ___
Formula-fed babies need to stay on commercial formula until?
6 months
9-12 months for formula
When can cow’s milk be introduced to baby?
After 1 year
Most recommended type of formula if no contraindications?
Cow’s milk (but don’t give plain cow’s milk!!)
What types of formulas are good vs bad for babies with weak immune system/preemies?
Good: ready-to-feed & liquid concentrate (sterile)
Bad: powder (not sterile)
Prenatal visit frequency
0-30 wks: q4 wks
32-36 wks: q2 wks
37+ wks: q1 wk
What are the 4 golden questions to ask EVERY pregnant patient regardless of reason for appointment?
- Leaking of fluids
- Vaginal bleeding
- Fetal movement
- Contractions
Prenatal HR/RR?
Can be slightly higher normally
HR up to 110 normal
RR up to 24 normal
Start doing Leopold’s maneuver at __ weeks
At ___ weeks baby “commits” to position, send for U/S if may be breech after this pt
30 wks
36 wks
When does the symphysis-fundal height NOT match the number of weeks?
After 38 weeks height often decreases because baby’s head is engaged
Begin checking FHR at ___ wks because?
12 wks because before then uterus hasn’t risen out of pelvis
FHR is normally ___bpm and best heard most often in the _____ area
110-160 (if you hear <100 probably a maternal vessel)
RLQ
Fetal movement begins to be felt around…
16-20 weeks
Normal U/S schedule in low-risk pregnancy?
3 total:
1 - Dating U/S (~8 weeks)
2 - Nuchal translucency scan (~12 weeks)
3 - Anatomy scan (~20 wks)
How much bleeding is typically TOO much?
Soaking 1 pad per hour for 2+ hrs
