Hinjke Flashcards
What is a tier 1 contraceptives?
Progestin implants and IUD
Implanon
Copper IUD
Mirena
What are tier 2 contraceptives?
DMPA, rings, patches, OCP
What is a tier 3?
Condoms, diaphragms, caps, shield, spermicides, withdrawal, fertility awareness, natural family planning
What is the mechanism of action of implanon?
Negative feedback on hypothalamus decreasing GnRH
Thickens cervical mucus
Thins endometrium
What is a contraindication to using implanon?
Breast cancer
What drugs may decrease the efficacy of implanon?
Phenobarbital
Dilantin
St. John’s Wort
What are the emergency contraceptions?
Combo OCPs with 100 mcg of ethinyl estradiol and .5 mcg levonorgestrel twice 12 hours apart
Copper IUD
Plan B
How does a copper IUD work?
Immobilizes and kills sperm
Prevents implantation if fertilization
How long does a copper IUD last?
10-20 years
What is a contraindication in copper IUD?
Wilson’s disease and PID
How is a copper IUD used for contraception?
Can use for up to 5 days after
What do you worry about when your perforate laterally?
Bleeding through uterine artery
If patient feels pain immediately afterward - think perforation
How does levonorgestrel work?
Thickens cervical mucous
Thins endometrium
Does NOT prevent ovulation
How long does levonorgestrel work?
5 years
What are the contraindications to levonorgestrel?
Breast cancer
PID
How do tier 2 contraceptives work?
Thicken cervical mucous
Preventing ovulation by suppressing LH surge
What is a contraindication to OCPs?
Aura or hx of migraines Hx of uncontrolled HTN Hx of TE, stroke, MI, breast cancer Advanced DM Unexplained dysfunctional uterine bleeding - could have cancer
If someone on OCPs comes in with RUQ pain, what should you be thinking?
Cholelithiasis or benign hepatic tumor
What is the downside to ortho evra patch?
Skin irritation
Must be under 198 pounds
Higher risk of DVT!
What do you give to milking mothers for contraception?
The progesterone only pill - micronor
How does progestin only work as a contraceptive?
Thickens cervical mucous
Inhibits ovulation
Who cannot use progestin only?
Women who have had breast cancer in the last 5 years
What do progesterone and estrogen do to triglycerides?
They make them go up so don’t use for someone with hyperlipidemia
What is DMPA?
An IM injection every 3 months
What is the biggest problem with the DMPA?
Weight gain
Return to fertility may be prolonged
What is a contraindication for using DMPA?
If the patient has asthma
What is the Yuzpe method?
Using OCPs for emergency contraception
What is plan B?
Progestin only
.75 mg of levonorgestrel
Can take up to 5 days after
89% effective
What female sterilization method is good for patients who aren’t good with anesthesia?
Hysteroscopic - can be done in office.
Put little stainless steel coils in the Fallopian tubes — inflammatory reaction causes closure of the tubes.
Do a hysterosalpingogram afterward to make sure the tubes closed
What is the Texas law in abortion?
Legal up to 20 weeks
After 16 - must happen in a hospital
Under 18 must have parental consent
Info on alternatives must be provided 24 hours before
Descriptions of US findings must be given
Must offer to view US
What can be used for abortions before 7 weeks?
Mifepristone - anti progesterone
Misopristol - prostaglandin that causes uterine contractions
What is placental abruption?
Premature separation of normally implanted placenta
What are the risk factors for placental abruption?
HTN, hx of abruption, trauma, short umbilical cord (less than 30 cm), tobacco use, PROM
What is a succenturiate placenta?
An accessory placenta
Associated with postpartum hemorrhage or infection
What is velamentous cord insertion?
Vessels only surrounded by fetal membranes, no Wharton’s jelly
What is vasa previa?
When vessels course over the cervical os.
Associated with perinatal mortality
What is a complication of velamentous cord insertion?
Fetal exsanguination
What is the Apt test?
When you are trying to figure out who is bleeding - mom or baby.
Take blood from vag, put in water and add KOH. RBCS will lyse. Mom’s Hb will be brown and baby’s will be red
What is the greatest risk factor for velamentous cord insertion?
Multiples
What is the management for velamentous cord insertion?
Immediat abdominal delivery
Woman comes in at 30 weeks with painless vaginal bleeding and no contractions. Her vital signs are stable and is afebrile. What is the dx?
Placenta previa
A girl comes in with light vaginal bleeding after intercourse. Everything else is good. Cervix is friable. What is the dx?
Ectropion of pregnancy
What is cervical ectropion?
When the endocervical columnar epithelium is exposed to the vaginal milieu by eversion.
Preggers Patient comes in with heavy bleeding, ab pain, firm uterus. What is the dx?
Placental abruption
What does a normal placenta look like?
Diameter = 22 cm
Thickness = 2-2.5 cm
Cord length = 55-60 cm
Gray wrinkled shiny and translucent
Pregger patient comes in with bright vag bleeding and no pain or contractions. How do you dx placenta previa?
Pelvic US
What is placenta accreta?
Deep attachment of the placenta through the endometrium and myometrium of the uterus due to defective desidual formation.
Lots of hemorrhage and often leads to a hysterectomy
Accreta - superior
Increta - invades partially into the myometrium
Percreta - extends to the serosa of uterus
What are the risk factors for placenta accreta?
Prior c-section!!!!!
Scar tissue - asherman’s
What is a good method for determining the cause of third semester bleeding?
Pelvic US
What is a low lying placenta?
When the placenta is with 2 cm of the cervical os
What are the signs for placental abruption?
Painful vaginal bleeding
Increased uterine tone and activity
Uterine tenderness
If fibrinogen is down
What are the risk factors for a ruptured placenta?
Maternal HTN Trauma Prior abruption PROM Short umbilical cord Tobacco use Folate deficiency
What is the most common cause of DIC in pregnancy?
Placental abruption
What is the best way to manage a placental abruption?
A vaginal delivery
What are the consequences of placental abruption?
Fetal demise
Hypovolemic shock
Acute renal failure
Sheehan’s syndrome
What are the signs of uterine rupture?
Sudden onset of intense abdominal pain and some vaginal bleeding
No longer feel fetal parts
Mother has hx of C-section
What is the most consistent clinical finding with a uterine rupture?
Abnormal fetal heart rate
What is the treatment for uterine rupture?
If you can’t fix it - hysterectomy
What does uterine inversion cause?
HTN and postpartum hemorrhage
What is postpartum hemorrhage?
Blood loss of over 500 ml in vag delivery
Over 1000 ml in c-section
Patient with multiple different delivery attempts with fever and ok bp - had a c-section. what is dx?
Endometritis
What is uterine atony?
Loss of uterine muscle tone
What are the risk factors for uterine atony?
Multiples
Macrosomia
Prolonged labor
Over distention
How does trichomonas present?
Itchy Odor White, greenish discharge that pools in the fornix and has bubbles in it. Strawberry cervix Will see WBCs
How do BV present?
Odorous discharge Milky white Fishy Usually just see in the walls Presence of clue cells = Gardernella No WBCs
How does Candida present?
Itching
No odor
Clumpy white
Will see WBCs
What is the treatment for trich?
Metronidazole - 2 g
What is the treatment for candida?
Oral fluconazole
Vaginal miconazole
Boric acid suppositories
How do you diagnose a tuboovarian abscess?
US or CT
When do you hospitalize a patient when they have PID?
Pregnant
Unsure about the dx
Tuboovarian abscess
Sepsis
What is the protocol for PID?
Test for all STDs
Broad spectrum antibiotics because PID is a polymicrobial infection
What is Fitzhugh-Curtis syndrome?
Perihepatic adhesions presenting with RUQ pain
What are the clinical pearls for herpes?
Do not biopsy - too painful
Start tx immediately
Start suppressive tx at 36 weeks and consider c-section
What do you do for condyloma acuminatum?
Tx with TCA - chemical burn Surgical removal Antiviral - cidofovir Anti proliferation - podophyllotoxin Immunomodulatory - imiquimod
Is condyloma an indication for a c-section?
No, infection rate is low
What happens in lichen sclerosis?
You lose anatomical distinction between the labia minora and majora. Introitus is small
How does lichen sclerosis present?
Usually older woman with severe itching, especially at night who is not sexually active with husband because it is too painful
What is the tx for lichen sclerosis?
High dose steroids
When do you biopsy condyloma acuminatum?
If the lesions haven’t gotten better
What do you do to confirm diagnosis of lichen sclerosis?
Office punch biopsy
How does lichen planus present?
Older woman with vulvar itching, not having sex, burning
What is lichen sclerosis a risk factor for?
Vulvar SCC
What is the most common form of mental retardation?
Down’s syndrome
What are the sex-linked disorders mentioned?
Fragile X - triple repeat expansion on long arm of X
Duchenne’s muscular dystrophy
What are some multifactorial disorders?
Cleft palate
Spina bifida
Anencephaly
Pyloric stenosis
What is the recommendation is the patient has a history of babies with NT defects?
4mg of frolic acid daily
What is a triple marker screen?
Offered at 16-18 weeks
Tracks alpha fetoprotein, hCG, unconjugated estriol
What does an elevated MSAFP mean?
You need to do a sonogram because there are higher rates of NT defects associated with this
Can also do amniocentesis
What problem is associated with low MSAFP, UE3, and hCG?
Trisomy 18
What problem is associated with low MSAFP, UE3, and high hCG?
Down’s
When do you do a cordocentesis?
When there is rh factor problems to see how anemic the baby is and figure out when it’s time to get the baby out
What are the screening tests in the first trimester?
Serum hCG
Sono + Pregnancy associated plasma protein a
Thickened nuchal translucency
Chorionic villus sampling
What is the screening in the second trimester?
Quad screen: AFP, HCG UE3, inhibit a
When is the fetus most susceptible to teratogens?
3-8weeks
What does an FAH baby look like?
Low nasal bridge Thin upper lip Small chin Flat midface Short nose
What are the anxiolytics that can be teratogens?
Meprobamate and chlordiazepoxide
What are the anti neoplasticism agents?
MTX, amionopterin
Busulfan, chlorambucil, cyclophosphamide, nitrogen mustard
What is warfarin syndrome?
Stipples epiphysis
Nasal hypoplasia
Use heparin instead because it doesn’t cross the placenta as readily
What are the anticonvulsants?
Dilantin
Trimethadione
Valproic acid - NT defects
Carbamazepine - spina bifida
What is the problem with phenobarbital in pregnancy?
Low teratogenicity but baby goes through withdrawal
What do retinoids cause?
Ear defects, blindness,
What is preterm labor?
Contractions with cervical change prior to 37 weeks
What are the risk factors for preterm labor?
Infection Vascular problems (SLE) Placental problems Stress/strain Uterine stretch Hx of preterm Multiples
What are the two leading factors for preterm?
Multiples and hx
What is the most concerning diagnostic finding for preterm labor?
Cervical length less than 2.5 cm
What does the fetal fibronectin tell you?
If positive - you have a 50% chance of going into labor within the next 2 weeks
How do you treat preterm labor?
Give antibiotics
Give steroids prior to 34 weeks
Recommend hydration, bed rest
When do we use magnesium sulfate?
When they are having contractions - tocolytic
How does magnesium sulfate work?
It competes with calcium so it decreases contractions.
Makes you feel crummy
What else is mgso4 used for?
Neuroprotection
What is nifedipine?
It is a calcium channel blocker
Tocolytic and anti hypertensive
What is indomethacin?
Prostaglandin synthetics inhibitor - tocolytic
What is atosiban?
Oxytocin receptor antagonist
Tocolytic
What is PROM?
Rupture of membranes without other signs of labor.
Don’t induce until after 34 weeks
How do you diagnose PROM?
Pooling - fluid in the vault
Ferning - take liquid and dry it - if amniotic fluid, will see crystals
Nitrazine - paper that turns blue
Amnisure- detects alpha microtglobulin
What are the markers for fetal lung maturity?
Lecithin/sphingomyelin ratio is 2/1
Presence of phosphatidylglycerol with the ratio = great sign
Lamellar body density count
What is IUGR?
When fetus is below 10th percentile
What is symmetrical IUGR?
When head to abdominal ratio is normal. The whole fetus is small
What is symmetrical IUGR due to?
Infection
What is asymmetrical IUGR?
When the head is larger than the rest of the body
What is asymmetrical IUGR due to?
Vascular problems - HTN, SLE, DM
What is the screening test for gestational growth?
Fundal height
What is used to diagnose fetal IUGR?
US
What is fetal post aridity syndrome?
When the placenta functions poorly, SC fat loss, long fingernails and dry peeling skin on baby
What do you worry about in a mother who has been carrying a dead fetus for several weeks?
DIC - check fibrinogen
What is IUFD?
Death of the fetus past 20 weeks and before th onset of labor
