Incorrect Questions Flashcards
what is increased in a granulosa-theca cell tumor
inhibin
what is inhibin
a peptide that is produced by the ovaries in response to follicle-stimulating hormone and luteinizing hormone
- most sensitive tumor marker for granulosa cell tumor
granulosa-theca cell tumors produce what
estrogen
sertoli-leydig cell tumors produce what
androgens (androstenedione and testosterone)
symptoms of hyperestrogenism
postmenopausal bleeding, menstrual abnormalities, and sexual precocity in children
how do granulosa cell tumors present
hyperestrogenism and abdominal or pelvic pain
granulosa-theca cell tumor in a postmenopausal patient
unopposed estrogen can lead to endometrial hyperplasia or carcinoma
postmenopausal woman with vaginal bleeding and a large ovarian mass
hyperplasia or carcinoma of endometrium, but think granulosa cell tumor
when is CA-125 elevated
epithelial ovarian tumors
when is lactate dehydrogenase elevated
dysgerminomas
patient with mosaic Turner’s syndrome cc of infertility, menses started at 15, ended at 19. what is the diagnosis?
ovarian failure
definition of preterm labor
uterine contractions that affect cervical change experienced prior to 37wks of gestation
how do you confirm diagnosis of preterm labor
rupture of membranes or vaginal bleeding
what is the initial management of preterm delivery prior to 34wks?
corticosteroid therapy to hasten lung maturity and reduce perinatal morbidity and mortality
- betamethasone or dexamethasone
when should corticosteroids be given for fetal lung maturity
any pregnant woman likely to deliver her baby within the next 2wks so long as she is between 24 and 34wks gestational age
signs of ovarian carcinoma
frequently asymptomatic
late stage with vague GI symptoms including dyspepsia, anorexia, and abdominal fullness and/or bloating
risk factors of ovarian carcinoma
family history of ovarian cancer, BRCA1 and 2 gene mutations and hereditary non-polyposis colorectal cancer (HNPCC) mutations
nulliparity, early menarche, late menopause (d/t increased risk of mutations with ovulation)
why do patients with ovarian carcinoma present in late stages?
lack of reliable routine screening test
what will rectovaginal exam show in ovarian carcinoma?
solid, irregular adnexal mass or fullness and/or nodularity in the posterior cul-de-sac
what is an ominous sign for ovarian carcinoma?
ascites
- sign of intra-abdominal spread of disease
what is a uterine leiomyoma
benign smooth muscle tumor of the uterus
how does a patient with uterine leiomyoma present
hemorrhagia, pelvic pain and pelvic pressure, and/or infertility
how is uterine leiomyoma diagnosed
transvaginal ultrasound
presentation of placental abruption
sudden onset vaginal bleeding associated with severe abdominal or back pain
how is placental abruption diagnosed
ultrasound reveals separation of the placenta from the uterine wall
what is a serious maternal complication of placental abruption?
DIC
what are the fetal complications of DIC
hypoxemia, asphyxia, preterm labor, and low birth weight
how is a severe placental abruption managed
prompt cesarean delivery
what is a severe placental abruption
maternal hypotension
severe coagulopathy
ongoing maternal blood loss
non-reassuring fetal status
what is DIC
disruption of the hemostatic process, during which a massive activation of the clotting cascade leads to widespread thrombosis causing depletion of platelets and fibrinogen
what are risk factors for DIC
severe preeclampsia, amniotic fluid embolism, sepsis, placental abruption, and prolonged retention of fetal tissue after fetal demise
what is the most common long term complications of hysterectomy
incontinence, pelvic organ prolapse, and pelvic organ fistula
treatment of iron deficiency anemia in 2nd and 3rd trimester
IV iron supplementation
treatment of iron deficiency anemia in 1st trimester
oral iron replacement
clinical signs and symptoms of anemia
fatigue, pallor, palpitations or throbbing pulse, headache, dizziness or lightheadedness, and pica
what maternal complication is a patient with multiple gestations at an increased risk?
anemia
- in twin pregnancies, cardiac output increases up to 20% higher than singleton pregnancies -> increased plasma volume -> physiologic anemia
what are risks of multiple gestations
gestational hypertension and preeclampsia, gestational diabetes and physiologic anemia
next step in management of LSIL on pap smear
perform a colposcopy
what is a colposcopy
applying acetic acid to the cervix, which will turn dysplastic areas ‘acetowhite’
- these lesions should be biopsied and sent for histologic diagnosis
what receives a prompt colposcopy as the next step in management?
pregnant women with an LSIL pap smear
any woman regardless of age or pregnancy with high-grade intraepithelial lesion (HSIL)
women who have an atypical squamous cells of undetermined significance (ASCUS) + positive HPV
any woman with ASCUS cannot exclude high grade lesion
appropriate management of an LSIL on pap smear (or ASCUS) in a woman under 21
repeat pap in 1 year
patient requests the most accurate test to diagnose fetal anomaly at 10wks. what do you perform?
chorionic villus sampling
what is CVS
placing a needle transcervically to obtain a sample of the placenta for fetal karyotyping
what is asherman syndrome
condition of intrauterine adhesions (synechiae)
etiology of asherman syndrome
direct endometrial trauma, which causes endometrial inflammation, scarring, and the formation of adhesions
who presents with asherman syndrome
woman who have had several D&Cs, but may occur as a result of chronic uterine inflammation due to infection
asherman syndeom presentation
irregular menstrual bleeding (either hypomenorrhea or secondary amenorrhea) and infertility
risk factors for endometrial cancer
late menopause, obesity, irregular ovulation, olgomenorrhea, and nulliparity
most common pathologic type of endometrial cancer
adenocarcinoma
signs of endometrial cancer/hyperplasia
any postmenopausal bleeding until proven otherwise
congenital varicella
limb hypoplasia, IUGR, cicatricial skin lesions, chorioretinitis
what to do if a patient has no immunity to varicella zoster and is exposed between 8 and 20wks?
varicella zoster immune globulin to prevent transmission of disease and/or to minimize the severity of the infection
elective termination of pregnancy before 7wks?
medically induced
methotrexate, mifepristone, +misoprostol
elective pregnancy termination after 7wks, but before 14wks
suction dilation and curettage
what is a contraindication to trial of breech vaginal delivery?
absence of immediately accessible to operating rooms and staff for cesarean delivery if necessary
what is the first line therapy for a woman with acute episode of prolonged or heavy menstrual bleeding who has normal vital signs?
high dose oral estrogen-progesterone
what is a nucleic acid amplification test?
a way gonorrhea and chlamydia are tested
what is annual protocol for women under 24 who are sexually active
tested annually for chlamydia, gonorrhea, and HIV
what is the only benefit of laser vaporization for cervical intraepithelial neoplasia?
preservation of the squamocolumnar junction
what are the benefits of cryoablation for CIN
less perioperative bleeding
less perioperative pain
less risk of disease recurrence
lower cost of procedure
how is grade 1 CIN handled
generally left untreated until it has persisted for greater than 2 years or progressed to a higher grade lesion
what is the management of CIN 1 if persisted for 2 years?
ablation
what is the best treatment of the management of hot flashes and emotional lability due to menopausal symptoms with a history of thromboembolism?
paroxetine
what is the first line treatment for hot flashes
hormone replacement therapy
- estrogen and progesterone
- progesterone is added in women who still have a uterus to protect the endometrium from constant stimulation that results in an increase in endometrial cancer
what is a contraindication for HRT
risk of coronary artery disease and thromboembolic events
what is the second line treatment for hot flashes
venlafaxine or an SSRI
what does HRT relieve
hot flashes and vaginal atrophic
helps prevent osteoporosis
what is the next appropriate step in management of a 28wk-er 3/90% with a bulging bag after betamethasone and indomethacin are administered?
administer magnesium sulfate
- provide fetal neuroprotection
management of preterm labor: 34w0d - 36w6d
+- betamethasone
PCN if GBS positive/unknown
management of preterm labor: 32w0d - 33w6d
betamethasone
tocolytics
PCN if GBS positive/unknown
management of preterm labor: <32wks
betamethasone
tocolytics
magnesium sulfate
PCN if GBS positive/unknown
risk factors for preterm labor
multiple gestation, history of preterm delivery, history of cervical surgery (conization)
what is a first-line tocolytic?
nifedipine
what is a positive fetal fibronectin test
a positive fetal fibronectin test and a shortened cervix are associated with increased risk of preterm delivery
potential complications of Hepatitis C in pregnancy
gestational diabetes
cholestasis of pregnancy
preterm delivery
maternal management of Hepatitis C in pregnancy
Ribavirin is teratogenic & should be avoided
no indication for barrier protection in serodiscordant, monogamous couples
Hep A & B vax
prevention of vertical transmision of hepatitis C in pregnancy
vertical transmission strongly associated with maternal viral load
cesarean delivery not protective
scalp electrodes should be avoided
breastfeeding should be encouraged unless maternal blood present (nipple injury)
risk factors for vaginal cancer
age >60
HPV
tobacco use
in utero DES exposure (clear cell adenocarcinoma only)
clinical features of vaginal cancer
vaginal bleeding
malodorous vaginal discharge
irregular vaginal lesion
diagnosis of vaginal cancer
vaginal biopsy
management of vaginal cancer
surgery +/- chemoradiation
what is the initial evaluation of mixed incontinence?
voiding diary
- tracks fluid intake, urine output, and leaking episodes
- classify predominant type of urinary incontinence and determine optimal treatment
treatment of mixed incontinence
all require bladder training with lifestyle changes (weight loss, smoking cessation, decreased alcohol and caffeine intake) and pelvic floor muscle exercises
clinical presentation of mittelschmerz
recurrent mild and unilateral mid-cycle pain prior to ovulation
pain lasts hours to days
ultrasound findings of mittelschmerz
not indicated
clinical presentation of ectopic pregnancy
amenorrhea, abdominal/pelvic pain & vaginal bleeding
positive ß-hCG
ultrasound findings of ectopic pregnancy
no intrauterine pregnancy
clinical presentation of ovarian torsion
sudden-onset, severe, unilateral lower abdominal pain; nausea and vomiting
unilateral, tender adnexal mass on examination
ultrasound findings of ovarian torsion
enlarged ovary with decreased or absent blood flow
clinical presentation of ruptured ovarian cyst
sudden-onset, severe, unilateral lower abdominal pain immediately following strenuous or sexual activity
ultrasound findings of ruptured ovarian cyst
pelvic free fluid
clinical presentation of pelvic inflammatory disease
fever/chills, vaginal discharge, lower abdominal pain & cervical motion tenderness
ultrasound findings of PID
+/- tubo-ovarian abscess
epidemiology of vulvar lichen sclerosus
prepubertal girls & perimenopausal or postmenopausal women
clinical features of vulvar lichen sclerosus
thin, white, wrinkled skin over the labia majora/minora; atrophic changes that may extend over the perineum & around the anus
excoriations, erosions, fissures from severe pruritus
dysuria, dyspareunia, painful defecation
workup of vulvar lichen sclerosus
punch biopsy of adult-onset lesions to exclude malignancy
treatment of vulvar lichen sclerosus
superpotent corticosteroid ointment
definition of preterm prelabor rupture of membranes (PPROM)
membrane rupture at <37wks prior to labor onset
risk factors for PPROM
prior PPROM
GU infection (ASB, BV)
antepartum bleeding
diagnosis of PPROM
vaginal pooling or fluid from cervix
nitrazine-positive fluid
ferning on microscopy
management of PPROM in <34wks, reassuring
latency abx, corticosteroids
management of PPROM in <34wks, non-reassuring
delivery
management of PPROM in >34wks
delivery
complications of PPROM
preterm labor
intraamniotic infection
placental abruption
umbilical cord prolapse
risk factors of postpartum urinary retention
primiparity
regional neuraxial anesthesia (suppress micturition reflex and decrease detrusor tone -> bladder atony)
operative vaginal delivery
perineal injury (damage to pudendal nerve -> decreased voiding sensation and EUS dysfunction)
cesarean delivery
clinical features of postpartum urinary retention
small-volume voids or inability to void
incomplete bladder emptying
dribbling of urine
management of postpartum urinary retention
self-limited condition
intermittent catheterization
etiology of condylomata acuminata
HPV 6 & 11
clinical features of condylomata acuminata
multiple pink or skin-colored lesions
lesions ranging from smooth, flattened papules to exophytic/cauliflower-like growths
treatment of condylomata acuminata
chemical: podophyllin resin, trichloracetic acid
immunologic: imiquimod
surgical: cryotherapy, laser therapy, excision
prevention of condylomata acuminata
vaccination
barrier protection
pathology of a mature cystic teratoma
benign ovarian germ cell tumor
endoderm, mesoderm, ectoderm tissue
clinical features of mature cystic teratoma
most asymptomatic
ovarian torsion
struma ovarii subtype: hyperthyroidism
unilateral adnexal mass
ultrasound: complex, cystic, calcifications
gross appearance: sebaceous fluid, hair, teeth
management of mature cystic teratoma
ovarian cystectomy or oopherectomy
risk factors of ABO hemolytic disease
infants with blood types A or B born to a mother with blood type O
clinical features of ABO hemolytic disease
jaundice within 24hrs of birth anemia increase reticulocyte count hyperbilirubinemia positive Coombs test
management of ABO hemolytic disease
serial bilirubin levels, oral hydration, & phytotherapy for most neonates
exchange transfusion for severe anemia/hyperbilirubinemia
contraindications to copper IUD & progestin IUD placement (shared c/i)
pregnancy endometrial or cervical cancer unexplained vaginal bleeding gestational trophoblastic disease distorted endometrial cavity acute pelvic infection
contraindications to progestin IUD
active liver disease
active breast cancer
contraindications to copper IUD
Wilson disease
risk factors for intraamniotic infection (chorioamnionitis)
prolonged rupture of membranes (>18hrs) PPROM prolonged labor internal fetal/uterine monitoring devices repetitive vaginal examinations presence of genital tract pathogens
diagnosis of chorioamnionitis
maternal fever PLUS >/= 1 of the following:
- fetal tachycardia (>160/min)
- maternal leukocytosis
- purulent amniotic fluid
management of chorioamnionitis
broad-spectrum abx
delivery
maternal complications of chorioamnionitis
postpartum hemorrhage, endometritis
neonatal complications of chorioamnionitis
preterm birth, pneumonia, encephalopathy
what is the postexposure prophylaxis for sexual assault?
chlamydia - azithromycin gonorrhea - ceftriaxone trich - metronidazole HIV - multidrug regimen (tenofovir-emtricitabine with raltegravir) hep B - hep B vax +/- hep B IG
indications for prophylactic administration of anti-D IG for Rh (D) - negative patients
- at 28-32wks gestation
- <72hrs after delivery of Rh(D)-positive infant
- <72hrs after spontaneous abortion
- ectopic pregnancy
- threatened abortion
- hydatidiform mole
- chorionic villus sampling, amniocentesis
- abdominal trauma
- 2nd- & 3rd- trimester bleeding
- external cephalic version
clinical features of PCOS
androgen excess : acne, male pattern baldness, hirsutism
oligoovulation or anovulation : menstrual irregularities
obesity
polycystic ovaries on ultrasound
pathophysiology of PCOS
increase testosterone
increase estrogen
LH/FSH imbalance
comorbidities of PCOS
metabolic syndrome
obstructive sleep apnea
nonalcoholic steatohepatitis
endometrial hyperplasia/cancer
treatment options of PCOS
weight loss (first line)
OCPs for menstrual regulation
letrozole for ovulation induction
evaluation of unilateral nipple discharge
pathologic discharge
- breast ultrasound
- mammography if >30yo
evaluation of bilateral nipple discharge that is bloody or serous
pathologic discharge
- breast ultrasound
- mammography if >30yrs old
evaluation of bilateral nipple discharge if milky, nonbloody with palpable lump or skin change
pathologic discharge
- breast ultrasound
- mammography if >30
evaluation of bilateral nipple discharge if milky, nonbloody and without palpable lump or skin change
likely physiologic
- pregnancy test
- guaiac test
- serum prolactin, TSH
- consider MRI of pituitary
risk factors for uterine sarcoma
pelvic radiation
tamoxifen use
potsmenopausal patients
presentation of uterine sarcoma
abnormal/postmenopausal bleeding
pelvic pain or pressure
uterine mass
diagnosis of uterine sarcoma
ultrasound +/- additional imaging
endometrial biopsy
histopathology of surgical specimen
treatment of uterine sarcoma
hysterectomy
+/- adjuvant chemotherapy, radiation therapy
risk factors of chlamydia & gonorrhea in women
age <25
high-risk sexual behavior
manifestations of chlamydia & gonorrhea in women
asymptomatic
cervicitis
urethritis
perihepatitis (Fitz-Hugh-Curtis syndrome)
diagnosis of gonorrhea and chlamydia in women
nucleic acid amplification testing
treatment of chlamydia and gonorrhea in women
empiric: azithromycin + ceftriaxone
confirmed chlamydia: azithromycin
confirmed gonorrhea: azithromycin + ceftriaxone
complications of gonorrhea and chlamydia in women
pelvic inflammatory disease
ectopic pregnancy
infertility
genotype of α-thalassemia minima
1 gene loss
aa/a-
genotype of α-thalassemia minor
2 gene loss
aa/– or a-/a-
genotype. of hemoglobin H disease
3 gene loss
a-/–
genotype of hydrops fetalis, hemoglobin Barts
4 gene loss
–/–
clinical features of α-thalassemia minima
asymptomatic, silent carrier
clinical features of α-thalassemia minor
mild microcytic anemia
clinical features of hemoglobin H disease
chronic hemolytic anemia
clinical features of hydrops fetalis, hemoglobin Barts
high-output cardiac failure, anasarca, death inutero
definition of nonalcoholic fatty liver disease
hepatic steatosis on imaging or biopsy
exclusion of significant alcohol use
exclusion of other causes of fatty liver
clinical features of non-alcoholic fatty liver disease
mostly asymptomatic
metabolic syndrome
+/- steatohepatitis (AST/ALT ratio <1)
hyperechoic texture on ultrasound
treatment of non-alcoholic fatty liver disease
diet & exercise
consider bariatric surgery if BMI >/= 35
Rome IV diagnostic criteria of irritable bowel syndrome
recurrent abdominal pain/discomfort >/= 1 day/week for past 3 months & >/= 2 of:
- related to defecation (improves or worsens)
- change in stool frequency
- change in stool form
alarm features of irritable bowel syndrome
older age of onset (>50) GI bleeding nocturnal diarrhea worsening pain unintended weight loss iron deficiency anemia elevated CRP positive fecal lactoferrin or calprotectin family history of early colon cancer or IBD
modifiable breast cancer risk factors
hormone replacement therapy
nulliparity
increased age at first live birth
alcohol consumption
non-modifiable breast cancer risk factors
genetic mutation or breast cancer in first-degree relatives
white race
increasing age
early menarche or later menopause
reactive nonstress test
baseline of 110-160/min
moderate variability (6-25/min)
>2 accelerations in 20mins, each peaking >15/min above baseline & lasting >15sec
nonreactive nonstress test
does not meet criteria for reactivity
recommended vaccines during pregnancy
Tdap
inactivated influenza
Rho(D) IG
vaccines indicated for high risk pregnant patients
Hep B Hep A pneumococcus Haemophilus influenzae Meningococcus Varicella-zoster IG
vaccines contraindicated in pregnancy
HPV
MMR
live attenuated influenza
varicella
risk factors for ectopic pregnancy
previous ectopic pregnancy
previous pelvic/tubal surgery
PID
clinical features of ectopic pregnancy
abdominal pain, amenorrhea, vaginal bleeding
hypovolemic shock in ruptured ectopic pregnancy
cervical motion, adnexal &/or abdominal tenderness
+/- palpable adnexal mass
diagnosis of ectopic pregnancy
positive hCG
TVUS revealing adnexal mass, empty uterus
management of ectopic pregnancy
stable: methotrexate
unstable: surgery
pregnancy management of patient with no prior HSV infection
routine prenatal care
pregnancy management of patient with prior HSV infection
antiviral suppression beginning at 36 wks
pregnancy management of patient with lesion/prodromal symptoms of HSV during labor
Cesarean delivery
pregnancy management of patient with history of HSV without lesion/prodromal symptoms of HSV during labor
vaginal delivery
risk factors of intrauterine adhesions
infection - septic abortion, endometritis
intrauterine surgery - curettage, myomectomy
clinical features of intrauterine adhesions
abnormal uterine bleeding amenorrhea infertility cyclic pelvic pain recurrent pregnancy loss
evaluation of intrauterine adhesions
hysteroscopy
etiology of condyloma acuminata in children
HPV
clinical features of condyloma acuminata in children
pink/flesh-colored, verrucous papules & plaques
asymptomatic (most common)
pruritic, friable lesions
management of condyloma acuminata in children
sexual abuse assessment, especially age >4
clinical features of intrahepatic cholestasis of pregnancy
develops in 3rd trimester generalized pruritus pruritus worse on hands and feet no associated rash RUQ pain
laboratory abnormalities of intrahepatic cholestasis of pregnancy
increase total bile acids (>10micromol/L)
increase transaminases (<2x normal)
+/- increase total & direct bilirubin
obstetric risks of intrahepatic cholestasis of pregnancy
intrauterine fetal demise
preterm delivery
meconium-stained amniotic fluid
neonatal respiratory distress syndrome
management of intrahepatic cholestasis of pregnancy
delivery at 37wks gestation
ursodeoxycholic acid
antihistamines
clinical features of chronic autoimmune thyroiditis (Hashimoto thyroiditis)
predominant hypothyroid features
diffuse goiter
diagnostic testing of chronic autoimmune thyroiditis (hashimoto thyroiditis)
positive TPO antibody
variable radioiodine uptake
clinical features of painless thyroiditis (silent thyroiditis)
variant of chronic autoimmune thyroiditis
mild, brief hyperthyroid phase
small, nontender goiter
spontaneous recovery
diagnostic testing of painless thyroiditis (silent thyroiditis)
positive TPO antibody
low radioiodine uptake
clinical features of subacute thyroiditis (deQuervain thyroiditis)
likely postviral inflammatory process
prominent fever & hyperthyroid symptoms
painful/tender goiter
diagnostic testing of subacute thyroiditis
elevated ESR & CRP
low radioiodine uptake
GU syndrome of menopause symptoms
vulvovaginal dryness, irritatoin, pruritus dyspareunia vaginal bleeding urinary incontinence, recurrent UTIs pelvic pressure
GU syndrome of menopause physical examination
narrowed introitus
pale mucosa, decreased elasticity, decreased rugae
petechiae, fissures
loss of labial volume
GU syndrome of menopause treatment
vaginal moisturizer & lubricant
topical vaginal estrogen
risk factors for cervical cancer
immunocompromise early onset of sexual activity multiple or high-risk sexual partners previous STI tobacco use
pathogenesis of cervical cancer
HPV infection (16 & 18)
clinical manifestations of cervical cancer
asymptomatic postcoital or intermenstrual bleeding increased vaginal discharge inguinal lymphadenopathy pelvic or low back pain
diagnosis of cervical cancer
cervical biopsy on colposcopy
clinical presentation of epithelial ovarian carcinoma
asymptomatic; incidental adnexal mass
subacute: pelvic/abdominal pain, bloating, early satiety
acute: dyspnea, obstipation/constipation, abdominal distension
risk factors of epithelial ovarian carcinoma
family history genetic mutations (BRCA1, BRCA2) age >50 HRT endometriosis infertility early menarche/late menopause
protective factors of epithelial ovarian carcinoma
OCPs
multiparity
breastfeeding
laboratory findings of epithelial ovarian carcinoma
increase CA-125
ultrasound findings of epithelial ovarian carcinoma
solid, complex mass
thick septations
ascites
management of epithelial ovarian carcinoma
surgical exploration
+/- chemotherapy
pathogenesis of sertoli-leydig cell tumor
sex cord-stromal tumor
increase testosterone
clinical features of sertoli-leydig cell tumor
rapid onset virilzation - voice deepening - male-pattern balding - increased muscle mass - clitoromegaly oligomenorrhea unilateral, solid adnexal mass
management of sertoli-leydig cell tumors
surgery (tumor staging)
clinical features of uterine leiomyomas (fibroids)
heavy, prolonged menses pressure symptoms - pelvic pain - constipation - urinary frequency obstetric complications - impaired fertility - pregnancy loss - preterm labor enlarged, irregular uterus
workup of uterine leiomyomas
ultrasound
treatment of uterine leiomyomas
asymptomatic: observation
symptomatic: CHC, surgery
clinical features of PMS/PMDD
physical: bloating, fatigue, headaches, hot flashes, breast tenderness
behavioral: anxiety, irritability, mood swings, decreased interest
evaluation of PMS/PMDD
symptom/menstrual diary
treatment of PMS/PMDD
SSRI
ultrasound findings of congenital CMV
periventricular calcifications ventriculomegaly microcephaly intrahepatic calcifications fetal growth restriction hydrops fetalis
neonatal features of congenital CMV
petechiae
hepatosplenomegaly
chorioretinitis
microcephaly
long-term sequelae of congenital CMV
sensorineural hearing loss
seizures
developmental delay
description of lochia rubra
dark or bright red (blood)
odor similar to that of menstrual blood
occasional small clots
quantity decreasing each day
expected duration of lochia rubra
birth to 3-4 days postpartum
description of lochia serosa
serosanguineous (pink)
brownish (old blood)
quantity gradually decreasing in amount
expected duration of lochia serosa
4th postpartum day to 10th or 14th postpartum day
description of lochia alba
white/yellow
creamy
light quantity
expected duration of lochia alba
11th postpartum day to 6wks postpartum
risk factors of pyelonephritis in pregnancy
asymptomatic bacteriuria
diabetes mellitus
age <20
common pathogens of pyelonephritis in pregnancy
Escherichia coli
Klebsiella
Enterobacter
Group B strep
complications of pyelonephritis in pregnancy
preterm labor
low birth weight
acute respiratory distress syndrome
treatment of pyelonephritis in pregnancy
IV abx
supportive therapy
contraindication to labetalol
asthma
treatment of pre-eclampsia acutely
IV hydralazine, IV labetalol, or nifedipine PO
- lower BP acutely to decrease stroke risk
prevention/treatment of eclamptic seizures
magnesium sulfate IV or IM
management of CIN 3 if not currently pregnant
LEEP
cold knife conization
cryoablation
follow-up testing for CIN 3
pap testing with HPV co-testing 1 and 2 years postprocedure
definition of postpartum hemorrhage
> 500mL after vaginal delivery
>1000mL after cesarean delivery
risk factors for postpartum hemorrhage
prolonged or induced labor chorioamnionitis multiple gestation polyhydraminos grand multiparity operative delivery
causes of postpartum hemorrhage
uterine atony (most common) retained placenta genital tract laceration uterine rupture coagulopathy
treatment of postpartum hemorrhage
bimanual uterine massage, oxytocin IV fluids, oxygen uterotonics - methylergonovine, carboprost, misoprostol intrauterine balloon tamponade uterine artery embolization hysterectomy
how does neonatal lupus occur
passive placental transfer of maternal anti-SSA (Ro) and anti-SSB (La) antibodies
fetal findings of neonatal lupus
cardiac and cutaneous
most serious fetal finding of neonatal lupus
fetal atrioventricular block -> fetal bradycardia
what can prolonged fetal heart block cause?
cardiomyopathy and hydrops fetalis
what is the treatment of retroperitoneal hematoma
emergency laparotomy
what is the cause of post-cesarean delivery patients with hemorrhagic shock?
if no signs of uterine atony, most likely have intraabdominal bleeding from uterine artery injury
- most likely retroperitoneum bleeding
- no incisional bleeding
- minimal abdominal or back pain
what are the signs of hypovolemic shock due to postpartum hemorrhage
hypotension, tachycardia, and signs of decreased end-organ perfusion (e.g. fatigue, lightheadedness, cold skin)
most common cause of postpartum hemorrhage
uterine atony
what can be diagnosed in the second-trimester quadruple screen?
trisomy 18
trisomy 21
neural tube or abdominal wall defect
what markers are tested in the second-trimester quadruple screen?
maternal serum α-fetoprotein
ß-hCG
estriol
inhibin A
what are the markers for trisomy 18?
decreased maternal serum α-fetoprotein, ß-hCG, and estriol
normal inhibin A
what are the markers for trisomy 21?
decreased maternal serum α-fetoprotein, estriol
increased ß-hCG, inhibin A
what are the markers for neural tube or abdominal wall defects?
increased maternal serum α-fetoprotein
normal ß-hCG, estriol, inhibin A
how do you evaluate suspected polyuria?
complete 24hr urine collection
what to do if complete 24hr urine output is <3L?
not true polyuria
work up causes of urinary frequency
what is the diagnosis of complete 24hr urine output >3L?
polyuria present
if urine output in 24hrs >3L AND dilute:
water diuresis
primary polydipsia, diabetes insipidus
if urine output in 24hrs >3L AND concentrated
osmotic diuresis
increased solute excretion (glucose, urea, saline)
benefits of estrogen-progestin contraceptives
pregnancy prevention endometrial & ovarian cancer risk reduction menstrual regulation (e.g. anovulation, dysmenorrhea, anemia) hyperandrogenism treatment (e.g. hirsutism, acne)
risks of estrogen-progestin contraceptives
venous thromboembolism hypertension hepatic adenoma stroke, myocardial infarction (both very rare) cervical cancer
who are high-risk patients for STI screening in pregnancy
age <25
prior STI
high-risk sexual activity (e.g. multiple partners, commercial sex work)
what is the required screening of high-risk STIs in pregnancy
performed at initial PNV & 3rd trimester
- HIV
- syphilis
- hepatitis B
- gonorrhea
- chlamydia
what is the pathogenesis of endometriosis
ectopic implantation of endometrial glands
clinical features of endometriosis
dyspareunia dysmenorrhea chronic pelvic pain infertility dyschezia
physical examination of endometriosis
immobile uterus
cervical motion tenderness
adnexal mass
rectovaginal septum, posterior cul-de-sac, uterosacral ligament nodules
diagnosis of endometriosis
direct visualization and surgical biopsy
treatment of endometriosis
medical (OCPs, NSAIDs)
surgical resection
etiology of vulvar cancer
persistent HPV infection
chronic inflammation
risk factors of vulvar cancer
tobacco use vulvar lichen sclerosus immunodeficiency prior cervical cancer vulvar/cervical intraepithelial neoplasia
clinical features of vulvar cancer
vulvar pruritus
vulvar plaque/ulcer
abnormal bleeding
diagnosis of vulvar cancer
biopsy
management of preterm prelabor ROM - first question
<34 wks or 34 to <37wks?
management of preterm prelabor ROM if 34 to <37wks
delivery GBS prophylaxis (e.g. PenG) \+/- corticosteroids
management of preterm prelabor ROM if <34wks and uncomplicated
expectant management
latency antibiotics (e.g. ampicillin & azithromycin)
corticosteroids
fetal surveillance
management of preterm prelabor ROM if <34 wks and complicated by infection, fetal/maternal compromise
delivery
intra-amniotic infection treatment (e.g. ampicillin & gentamicin)
corticosteroids
magnesium if <32wks
what is eclampsia
severe preeclampsia + seizures
clinical features of eclampsia
hypertension proteinuria severe headaches visual disturbances right upper quadrant or epigastric pain 3-4mins of tonic-clonic seizure, usually self-limited
management of eclampsia
administer magnesium sulfate
administer antihypertensive agent
deliver the fetus
etiology of esophageal perforation
instrumentation (e.g. endoscopy), trauma effort rupture (Boerhaave syndrome) esophagitis (infectious/pills/caustic)
clinical presentation of esophageal perforation
chest/back &/or epigastric pain, systemic signs (e.g. fever)
crepitus, Hamman sign (crunching sound on auscultation)
pleural effusion with atypical (e.g. green) fluid
diagnosis of esophageal perforation on chest x-ray or CT scan
widened mediastinum pneumomediastinum, pneumothorax, pleural effusion
diagnosis of esophageal perforation on CT scan
esophageal wall thickening, mediastinal fluid collection
diagnosis of esophageal perforation on esophagography with water-soluble contrast
leak from perforation
management. of esophageal perforation
NPO, IV antibiotics & proton pump inhibitors
emergency surgical consultation
what is the inheritance of hemophilia A
x-linked recessive
maternal contraindications to breastfeeding
active untreated tuberculosis HIV infection herpetic breast lesions active varicella infection chemotherapy or radiation therapy active substance abuse
infant contraindications to breastfeeding
galactosemia
clinical features of engorgement
bilateral, symmetric fullness, tenderness & warmth
clinical features of nipple injury
abrasion, bruising, cracking &/or blistering from poor latch
clinical features of plugged duct
focal tenderness & firmness &/or erythema
no fever
clinical features of galactocele
subareolar, mobile, well-circumscribed, nontender mass
no fever
clinical features of mastitis
tenderness/erythema + fever
clinical features of abscess
symptoms of mastitis + fluctuant mass
risk factors of hyperemesis gravidarum
hydatidiform mole
multifetal gestation
history of hyperemesis gravidarum
clinical features of hyperemesis gravidarum
severe, persistent vomiting
>5% loss of prepregnancy weight
dehydration
orthostatic hypotension
laboratory abnormalities of hyperemesis gravidarum
ketonuria
hypochloremic metabolic alkalosis
hypokalemia
hemoconcentration
treatment of hyperemesis gravidarum
admission to hospital
antiemetics & IV fluids
pathogenesis of granulosa cell tumor
sex cord- stromal tumor
increase estradiol
increase inhibin
clinical features of granulosa cell tumor
complex ovarian mass juvenile subtype - precocious puberty adult subtype - breast tenderness - abnormal uterine bleeding - postmenopausal bleeding
histopathology of granulosa cell tumor
Call-Exner bodies (cells in rosette pattern)
management of granulosa cell tumor
endometrial biopsy (endometrial cancer) surgery (tumor staging)
definition of fetal growth restriction
ultrasound estimated fetal weight <10th percentile for gestational age
onset of symmetric fetal growth restriction
1st trimester
onset of asymmetric fetal growth restriction
2nd/3rd trimester
etiology of symmetric fetal growth restriction
chromosomal abnormalities
congenital infection
etiology of asymmetric fetal growth restriction
utero-placental insufficiency
maternal malnutrition
clinical features of symmetric fetal growth restriction
global growth lag
clinical features of asymmetric fetal growth restriction
‘head-sparing’ growth lag
management of fetal growth restriction
weekly biophysical profiles
serial umbilical artery Doppler sonography
serial growth ultrasounds
primary syphilis manifestations
painless genital ulcer (chancre)
secondary syphilis manifestations
diffuse rash (palms & soles) lymphadenopathy (epitrochlear) condyloma latum oral lesions hepatitis
latent syphilis manifestations
asymptomatic
tertiary syphilis manifestations
CNS (tabes dorsalis, dementia)
cardiovascular (aortic aneurysm/insufficiency)
cutaneous (gummas)
first test in evaluation of secondary amenorrhea
ß-hCG
if ß-hCG negative in secondary amenorrhea, what is checked next?
prolactin
FSH
testosterone
TSH
in evaluation of secondary amenorrhea: ß-hCG negative, increase prolactin, normal TSH
pituitary adenoma
in evaluation of secondary amenorrhea: ß-hCG negative, increase FSH
primary ovarian insufficiency
in evaluation of secondary amenorrhea: ß-hCG negative, hormones normal
prior uterine procedure
Asherman syndrome
in evaluation of secondary amenorrhea, ß-hCG negative, increase testosterone
PCOS
in evaluation of secondary amenorrhea: ß-hCG negative, increase TSH
hypothyroidism
definition of intrauterine fetal demise
fetal death at >20wks
diagnosis of intrauterine fetal demise
absence of fetal cardiac activity on ultrasound
management of intrauterine fetal demise at 20-23wks
dilation & evacuation
OR
vaginal delivery
management of intrauterine fetal demise at >24wks
vaginal delivery
complication of intrauterine fetal demise
coagulopathy after several weeks of fetal retention
clinical features of primary ovarian insufficiency
amenorrhea at age <40
hypoestrogenic symptoms (e.g. hot flashes)
increase FSH
decrease estrogen
major causes of primary ovarian insufficiency
Turner syndrome (45, XO) fragile X syndrome (FMR1 premutation) autoimmune oophoritis anticancer drugs pelvic radiation galactosemia
management of primary ovarian insufficiency
estrogen therapy (with progestin if intact uterus)
management of endometriosis
suspected endometriosis
- chronic pelvic pain
- dysmenorrhea
- deep dyspareunia
- dyschezia
questions to ask in management of endometriosis
contraindications to medical therapy?
need for definitive diagnosis?
history of infertility?
concern for malignancy or adnexal mass?
if the answer is yes to questions re endometriosis:
laparoscopy
if the answer is no to questions re endometriosis
NSAIDs +/- oral contraceptives
-> laparoscopy
pathogenesis of endometriosis
ectopic implantation of endometrial glands
clinical features of endometriosis
dyspareunia dysmenorrhea chronic pelvic pain infertility dyschezia
physical examination of endometriosis
immobile uterus
cervical motion tenderness
adnexal mass
rectovaginal septum, posterior cul-de-sac, uterosacral ligament nodules
diagnosis of endometriosis
direct visualization & surgical biopsy
treatment of endometriosis
medical (OCPs, NSAIDs)
surgical resection
what is the management of shoulder dystocia?
BE CALM
B - breathe; do not push
E - elevate legs & flex hips, thighs against abdomen (McROberts)
C - call for help
A - apply suprapubic pressure
L - enLarge vaginal opening with episiotomy
M - Maneuvers
- deliver posterior arm
- rotate posterior shoulder (Woods screw): apply pressure to anterior aspect of the posterior shoulder
- adduct posterior fetal shoulder (Rubin): apply pressure to the posterior aspect of the posterior shoulder
- mother on hands & knees : ‘ all fours’ (Gaskin)
- replace fetal head into pelvis for cesarean delivery (Zavanelli)
severe side effect of oxytocin
severe hyponatremia
-> seizure
treatment of oxytocin-induced hyponatremia
cessation of oxytocin infusion
gradual administration of hypertonic saline in symptomatic patients (e.g. seizures) to raise serum osmolality and reverse cerebral edema
what risk factors make methotrexate more likely to fail for ectopic pregnancy
ß-hCG >5000
gestational sac >3-4cm
positive fetal heart tones
treatment of symptomatic condyloma acuminata in pregnancy
trichloroacetic acid
treatment of endometriosis
laparoscopy
screening tests in the first trimester (before 14wks)
nuchal translucency ultrasound with PAPP-A
hCG measurement
relative contraindication to IUD
history of STI within the past 3 months
what is the initial diagnostic testing for PCOS
serum testosterone
after stabilizing the patient’s airway what is the most appropriate management for hypovolemic shock?
massive transfusion of packed red blood cells
what is the most appropriate course of action for a patient with suspected domestic violence?
ask open-ended questions to learn about possible abuse
what can poorly controlled blood sugars in the second and third trimester cause?
diabetic fetopathy
- fetal hyperinsulinemia
- hyperglycemia
- macrosomia
what is the screening test for HIV
HIV-1/2 antibodies and p24 antigen assay
presentation of tubo-ovarian abscess
fever, abdominal pain, and a complex multiloculated adnexal mass with thick walls and internal debris
laboratory findings in tubo-ovarian abscess
nonspecific increases
- leukocytosis, CRP, CA-125
- paired with fever -> infection rather than malignancy
how to diagnose tubo-ovarian abscess
imaging (pelvic ultrasound/CT scan)
treatment of TOA
broad-spectrum parenteral antibiotics
risk factor for magnesium toxicity
renal insufficiency
- excreted by the kidneys
clinical features of magnesium toxicity
mild: nausea, flushing, HA, hyporeflexia
moderate: areflexia, hypocalcemia, somnolence
severe: respiratory paralysis, cardiac arrest
maternal cardiopulmonary adaptations in pregnancy
cardiac: - increase cardiac output - increase plasma volume - decrease SVR respiratory: - increase tidal volume - decrease functional residual capacity (elevation of diaphragm
clinical manifestations of maternal cardiopulmonary adaptations to pregnancy
peripheral edema decrease BP increase HR systolic ejection murmur dyspnea
pathogenesis of adenomyosis
abnormal endometrial tissue within the uterine myometrium
risk factors for adenomyosis
age >40
multiparity
prior uterine surgery (e.g. myomectomy)
clinical features of adenomyosis
dysmenorrhea heavy menstrual bleeding chronic pelvic pain diffuse uterine enlargement (e.g. globular uterus) \+/- uterine tenderness
diagnosis of adenomyosis
clinical presentation
MRI & ultrasound: thickened myometrium
confirmation via pathology
treatment of adenomyosis
hysterectomy
adenomyosis vs. fibroids
adenomyosis
- chronic pelvic pain
- boggy and tender symmetrically enlarged uterus
fibroids
- pelvic pressure
- firm, irregularly enlarged uterus
what are endometrial polyps
common, well-vascularized, hyperplastic endometrial gland growths that extend into the uterine cavity
signs of endometrial polyps
abnormal uterine bleeding due to their friability and vascularity
- do not affect ovulation, so typically have regular monthly menses with painless, light intermenstrual bleeding
treatment of endometrial polyps
hysteroscopic polypectomy
definition of urethral diverticulum
urethral mucosa herniated into surrounding tissue
clinical features of urethral diverticulum
dysuria
postvoid dribbling
dyspareunia
anterior vaginal wall mass - associated expressed purulent or bloody urethral discharge
treatment of urethral diverticulum
surgical excision of the diverticulum
symptoms of PID
lower abdominal pain
abnormal bleeding
physical exam of PID
cervical motion tenderness
fever >38.3 C (>100.9)
mucopurulent cervical discharge
treatment of PID
third-generation cephalosporin + azithormycin or doxycycline
complications of PID
tubo-ovarian abscess
infertility
ectopic pregnancy
perihepatitis
what is Fitz-Hugh-Curtis disease
infection extends from the upper genital tract to spread throughout the abdomen and cause liver capsule inflammation
- patients with hepatic involvement present with symptoms of acute PID (fever, lower abdominal pain) as well as pleuritic RUQ pain
clinical features of acute fatty liver of pregnancy
nausea, vomiting
RUQ pain/epigastric pain
fulminant liver failure
laboratory findings of acute fatty liver of pregnancy
profound hypoglycemia increase aminiotransferases (2-3x normal) increase bilirubin thrombocytopenia DIC
management of acute fatty liver of pregnancy
immediate delivery regardless of gestational age
clinical features of menopause
- vasomotor symptoms
- oligomenorrhea/amenorrhea
- sleep disturbances
- decreased libido
- depression
- cognitive decline
- vaginal atrophy
diagnosis of menopause
clinical manifestations
increase FSH
treatment of menopause
topical vaginal estrogen
systemic hormone replacement therapy
what is ovulation
transition from the follicular phase to the luteal phase
what occurs before ovulation
LH surge
what is cervical mucus
secreted close to ovulation (late follicular phase) increases in quantity and can be perceived by patients as vaginal discharge
- clear, elastic, thin in consistency, and described similar in appearance to an uncooked egg white
- thought to facilitate transport into the uterus for conception
clinical presentation of acute appendicitis
nausea, vomiting, anorexia
initially: diffuse abdominal pain (visceral pain)
later: localized RLQ pain (somatic pain)
mild leukocytosis
examination of acute appendicitis
McBurney point tenderness
psoas sign: pain with right hip extension
obturator sign: pain with right hip internal rotation
rovsing sign: RLQ pain with LLQ palpation
diagnosis of acute appendicits
clinical presentation
CT scan or ultrasound
treatment of acute appendicitis
surgical appendectomy
acute appendicitis vs. ectopic pregnancy vs. ovarian torsion
acute appendicits: intrauterine pregnancy with normal adnexa and normal Doppler
ectopic pregnancy: non-intrauterine pregnancy
ovarian torsion: intrauterine pregnancy with abnormal Doppler
what is tranexamic acid
antifibrinolytic agent that prevents the breakdown of blood clots to achieve hemostasis
neonatal abstinence syndrome
high-pitched cry and irritability, sleep/wake disturbances, hyperactive primitive reflexes, hypertonicity, difficulty feeding, GI disturbances, autonomic dysfunction, and failure to thrive
what is the first step in managing postmenopausal bleeding
endometrial biopsy to exclude endometrial hyperplasia or endometrial carcinoma
causes of chronic neuropathic pelvic pain
entrapment of the ilioinguinal and/or iliohypogastric nerves during closure of a low-transverse fascial incision
where does ilioinguinal nerve entrapment occur
commonly at the lateral edge of the fascial incision where the nerves are coursing between the transversalis and internal oblique muscles
hallmark of neuropathic pain by nerve entrapment
burning or searing pain that is reproducible with palpation
trigger point nodule palpated at the lateral incision of c/section
inject with local anesthetics for diagnostic & therapeutic relief
what is the most common neonatal complication associated with vacuum-assisted delivery
cephalohematoma
- can result in hyperbilirubinemia as the extra blood products in the hematoma break down and enter the bloodstream
- causes jaundice
what is Kleihauer-Betke testing
serum evaluation that detects and quantifies fetal blood cells within maternal circulation
what is massive fetomaternal hemorrhage
blood loss of greater than 20mL/kg fetal weight
can occur spontaneously and can lead to intrauterine fetal demise
how is a stillbirth defined
fetal demise after 20wks GA
maternal symtpoms of fetal demise
decreased fetal movement and decrease in pregnancy symtpoms (breast tenderness, nausea, fatigue)
how is an unexplained stillbirth evaluated
postmortem diagnostic testing
- complete blood count
- urine toxicology
- serology for syphilis (in absence of prior testing)
- blood antibody screen (r/o alloimmunization)
- fasting glucose or glycosylated glucose testing (in absence of prior gestational diabetes testing)
- Kleihauer-Betke testing or flow cytometry to detect presence of fetomaternal hemorrhage
how to evaluate fetal hypoxemia
fetal scalp stimulation to induce accelerations
what is acute salpingitis
synonymous with pelvic inflammatory disease
most common cause of acute salpingitis
chlamydia trachomatis
neisseria gonorrhea
sexually active woman without a more likely cause for abdominal pain
PID - minimal diagnostic criteria:
- adnexal, uterine, or cervical tenderness on exam
supportive findings for diagnosis of PID
vaginal discharge fever >101 elevated CRP or ESR positive chlamydia/gonorrhea testing pelvic ultrasound = dilated tortuous fallopian tube (hydrosalpinx)
what’s the first thing a patient should receive upon admission for delivery?
IV catheter
what to give a patient who is stable, likely to deliver immediately, <34wks GA?
tocolytics to allow administration of a full course of antenatal corticosteroids, which takes 48hrs
most commonly given tocolytics
indomethacin
CCBs
terbutaline (beta2-agonist)
magnesium sulfate
what causes functional hypogonadotropic hypogonadism
excessive weight loss
strenuous exercise
chronic illness
eating disorder
what does hypogonadotropic hypogonadism cause?
decreased adipose tissue/fat reserves -> decrease leptin production
- > decrease GnRH from hypothalamus
- > decrease LH, FSH from pituitary
- > decrease estrogen from ovaries
- > amenorrhea, bone loss
risk factors for cervical insufficiency
collagen defects
uterine abnormalities
cervical conization
obstetric injury
clinical features of cervical insufficiency
> /= 2 prior painless, 2nd-trimester losses
painless cervical dilation
management of cervical insufficiency
cerclage placement
how to diagnose cervical insufficiency
1 of:
- painless cervical dilation in the current pregnancy
OR
- second-trimester cervical length of = 2.5cm plus a prior preterm delivery (i.e. ultrasound-based)
OR
>/= prior consecutive, painless, second-trimester losses (i.e. history-based), which typically present with mild symptoms (e.g. vaginal discharge, light spotting) followed by precipitous delivery
risk factors for placenta previa
prior placenta previa
prior cesarean delivery
multiple gestation
clinical features of placenta previa
painless vaginal bleeding >20wks gestation
diagnosis of placenta previa
transabdominal followed by transvaginal sonogram
management of placenta previa
no intercourse
no digital cervical examination
inpatient admission for bleeding episodes
risk factors for septic abortion
retained POC from:
- elective abortion with nonsterile technique
- missed or incomplete abortion (rare)
clinical presentation for septic abortion
fever, chills, abdominal pain
sanguinopurulent vaginal discharge
boggy, tender uterus, dilated cervix
pelvic ultrasound: retained POC, thick endometrial stripe
management of septic abortion
IV fluids
broad-spectrum antibiotics
suction curettage
presentation of adenomyosis
heavy monthly menstrual bleeding with dysmenorrhea
what is the Jarisch-Herxheimer reaction
patients receiving antibiotics for syphilis
what is Jarisch-Herxheimer reaction characterized by
headache, fever, flushing, tachycardia, and hypotension
- begins within 1-2hrs after initiation
- self-limited to 24-48hrs
treatment of Jarisch-Herxheimer
supportie
- acetaminophen and IV fluids
cause of Jarisch-Herxheimer
occurs after abx treatment of spirochete disease
- caused by release of large amounts of treponemal lipopolysaccharides and cytokines
major risk factor for primary dysmenorrhea
nulliparity
what viral load is HIV at greatest risk of causing vertical transmission
> 1000 RNA copies/mL
how to handle HIV viral load >1000
final viral load evaluation at 34-36wks
- Cesarean delivery at 38wks prior to the onset of labor or the rupture of membranes
treatment of HIV in pregnancy
IV zidovudine to decrease vertical transmission
- all HIV-positive mothers should receive a minimum of 6wks of oral zidovudine therapy for prophylaxis
what is a rectocele
rectum bulges into the posterior vaginal wall
how is a rectocele identified
posterior vaginal wall prolapses while the vaginal apex and anterior vaginal wall are fixated with a bi-valved speculum
what is the next step in management of PROM after 34wks?
induction of labor
characteristics of klinefelter syndrome
tall slender male with lack of secondary sexual characteristics and infertility
history of learning disorder
shy and immature
cause of Klinefelter syndrome
non-disjunction of chromosomes during either meiosis I or meiosis II resulting in XXY karyotype
where does the corpus luteum come from
results from LH-induced ovulation
cause of postpartum hemorrhage in a patient with presence of firmly contracted uterus
cervical laceration
what are you thinking if child presents with age-innappropriate sexual behaviors that are disruptive or intrusive to others
child abuse
potential signs of child abuse
inappropriate genital touching and knowledge of sexually explicit anatomy or behavior
regression
red flags for child abuse
unexplained injuries changes in behavior regression to earlier behaviors signs of neglect inappropriate sexual behaviors
how to diagnose congenital CMV
PCR for CMV DNA in the amniotic fluid obtained via amniocentesis
what is hysteroscopy used for
evaluation of abnormal uterine bleeding when an endometrialc ause is suspected
classic bleeding pattern of an endometrial polyp
metrorrhagia or intermenstrual spotting
proper breast examination
sitting and supine
what is the first line treatment fo prevention of progression of stress/urge urinary incontinence and pelvic organ prolapse
pelvic floor muscle training
what is the most likely cause of irregular bleeding in an adolescent
anovulatory bleeding
- failure of the ovary to develop a corpus luteum
where does the corpus luteum come from
results from LH-induced ovulation
why is the corpus luteum important
produces progesterone during a normal menstrual cycle and during pregnancy until about 8-10wks when placenta takes over
what is used to avoid cervical lacerations during dilatin
cervical preparation with prostaglandins or osmotic dilators
what are important allergies to remember for surgical patients
latex
- may vary from mild to anaphylaxis
most common presentation of anaphylaxis
tachycardia
hypotension
bronchospasm
cutaneous signs - flushing, urticaria
what has a cross-allergy to shellfish?
iodine
fetal alcohol syndrome characterized by
facial dysmorphisms
- short palpebral fissure, thin upper lip, smooth philtrum
growth retardation
CNS abnormalities
what is the preferred med to assist with alcohol cessation during pregnancy
naltrexone
what is the most common cause of hypothyroidism
hashimoto thyroiditis
what are symptoms of hypothyroidism
weight gain fatigue dry skin low pulse menstrual dysfunction - secondary amenorrhea -> decreased fertility
what is decreased in normal pregnancy
SVR
- widespread vasodilation
what is the next step in managing a visible lesion on the cervix
biopsy
what does a person have with a visible lesion on cervical exam, postcoital bleeding, and dyspareunia
cervical cancer
risks of staphylococcal toxic shock syndrome
tampon use
nasal packing
surgical/postpartum wound infection
pathogenesis of staphylococcal toxic shock syndrome
staphylococcus aureus
exotoxin release acting as superantigens
clinical features of staph toxic shock syndrome
fever >38.9 (102)
hypotension
diffuse macular rash involving palms & soles
desquamation 1-3wks after disease onset
vomiting, diarrhea
altered mentation without focal neurological signs
treatment of toxic shock syndrome
supportive therapy (fluid replacement) removal of foreign body (tampon) antibiotic therapy (clindamycin + vancomycin)
toxic shock rash vs. secondary syphilis
patients with syphilis have an indolent course rather than acute-onset hypotension and tachycardia (shock)
disease associations with HPV
cervical cancer vulvar & vaginal cancers anal cancer oropharyngial cancer penile cancer anogenital warts recurrent respiratory papillomatosis
vaccine indications for HPV
all female and male patients age 11-26
NOT indicated in pregnant women
pathogenesis of fetal hydrops
increase cardiac output demand causing heart failure
increase fluid movement into interstitial spaces (third spacing)
clinical features of fetal hydrops
pericardial effusion pleural effusion ascites skin edema placental edema polyhdramnios
etiology of fetal hydrops
immune
- Rh(D) alloimmunization
Nonimmune
- parvovirus B19 infection
- fetal aneuploidy
- CV abnormalities
- thalassemia (hemoglobin Barts)
pathophysiology of androgen insensitivity syndrome
X-linked mutation in androgen receptor
clinical features of androgen insensitivity syndrome
genotypically male (46, XY)
phenotypically female
breast development
absent or minimal axillary & pubic hair
female external genitalia
absent uterus, cervix, & upper 1/3 of vagina
management of androgen insensitivity syndrome
gender identity/assignment counseling
gonadectomy (malignancy prevention)
5-α reductase deficiency
cannot convert testosterone to dihydrotestosterone
- appear phenotypically female at birth
- develop virilization at puberty
- no breast development
Müllerian agenesis (Mayer-Rokitansky-Küster-Hauser syndrome)
primary amenorrhea due to lack of female internal genitalia
- otherwise normal female development
- female-range testosterone levels
cause of postoperative, unilateral back pain, nausea with vomiting and CVA tenderness
hydronephrosis from ureteral injury
risk of ureteral injury increases with
obesity
distorted pelvic architecture from malignancy
prior pelvic surgery
renal function in ureteral obstruction
normal because only 1 ureter is affected
- normal creatinine and urinalysis
diagnosis of ureteral obstruction
renal ultrasound
treatment of ureteral obstruction
surgical correction
complications of shoulder dystocia
fractured clavicle fractured humerus Erb-Duchenne palsy Klumpke palsy Perinatal asphyxia
fractured clavicle
- clavicular crepitus/bony irregularity
- decrease Moro reflex due to pain on affected side
- intact biceps & grasp reflex
fractured humerus
- upper arm crepitus/bony irregularity
- decrease Moro reflex due to pain on affected side
- intact biceps & grasp reflex
Erb-Duchenne palsy
- decrease Moro & biceps reflexes on affected side
- “waiter’s tip” = extended elbow, pronated forearm, flexed wrist & fingers
- intact grasp reflex
- damage to 5th and 6th cervical nerves
Klumpke palsy
- “claw hand” = extended wrist, hyperextended metacarpophalangeal joints, flexed interphalangeal joints, absent grasp reflex
- Horner syndrome (ptosis, miosis)
- intact Moro & biceps reflexes
- injury to 8th cervical nerve and 1st thoracic nerve & sympathetic fibers that run along
Perinatal asphyxia
- variable presentation depending on duration of hypoxia
- altered mental status (irritability, lethargy), respiratory or feeding difficulties, poor tone, seizure
differential diagnosis for postpartum hemorrhage
uterine atony
retained products of conception
genital tract trauma
inherited coagulopathy
risk factors for uterine atony
prolonged labor chorioamnionitis uterine overdistension (multiples, fetal macrosomia, polyhydramnios)
examination of uterine atony
enlarged, boggy uterus
management of uterine atony
bimanual uterine massage
uterotonic medications
risk factors for retained products of conception
succenturiate placenta
manual extraction of placenta
history of previous uterine surgery
examination of retained products of conception
enlarged, boggy uterus
placenta missing cotyledons
retained placental fragments on ultrasound
management of retained products of conception
manual extraction
risk factors for genital tract trauma
operative vaginal delivery
examination of genital tract trauma
laceration of cervix or vagina
enlarging hematoma
management of genital tract trauma
laceration repair
risk factors for inherited coagulopathy
history of abnormal bleeding in patient or family members
examination of inherited coagulopathy
continued bleeding despite contracted uterus
management of inherited coagulopathy
correction of coagulopathy
first line treatment for severe hot flashes (vasomotor symptoms)
hormone replacement therapy
monochorionic diamniotic twins at risk for
twin-twin transfusion syndrome
monochorionic diamniotic twins on ultrasound
T-sign
- 2 embryos, a single placenta, and a thin intertwin membrane that meets the placenta at a 90degree angle
dichorionic diamniotic twins on ultrasound
λ sign
complication of monochorionic monoamniotic
cord entanglement
conjoined twins
complication of dichorionic diamniotic twins
vanishing twin syndrome
what causes a fever within first 48hrs after surgery?
cytokine-mediated reaction initiated by normal tissue trauma encountered during the procedure
management of fever prior to 48hrs postoperatively
expectant management
- very unlikely to imply true infection
what is primary infertility
inability to conceive a child, despite efforts of regular unprotected intercourse, for a period of greater than 1yr
what is an important cause of infertility
pelvic inflammatory disease
- occurs in patients with an incompletely treated/untreated STI
- results in inflammation and scarring of reproductive organs
most common causes of PID
chlamydia trachomatis
neisseria gonorrhoeae
classic symptoms of PID
abdominal pain, vaginal discharge, fever, cervical motion tenderness, dyspareunia, and irregularities in menstrual cycle
how to decrease risk of neonatal sepsis
intrapatum maternal antibiotic therapy
causes of early-onset neonatal sepsis
group B streptococcus or Escherichia coli
who should receive antibiotics during labor to decrease risk of neonatal sepsis?
all women who are GBS positive during the current pregnancy or had a previous child affected by GBS
women with unknown GBS status who are either preterm or who have ruptured membranes >18hrs or who have fever/chorioamnionitis
signs of sepsis in the infant
lethargy, hypoxia, temperature instability, respiratory distress, poor perfusion, and hypotension
risk factors for neonatal sepsis
preterm delivery, premature rupture of membranes, prolonged rupture of membranes during delivery, chorioamnionitis, known vaginal GBS colonization during pregnancy, and maternal fever during labor
routine postoperative care after cesarean delivery
pain management
maternal-infant bonding (breastfeeding)
prophylaxis for infection
thromboembolism and hemorrhage
what is the standard staging and treatment procedure for all endometrial carcinoma?
total extrafasical hysterectomy with bilateral salpingo-oopherectomy with pelvic and paraaortic lymph node dissection
what is stage Ia endometrial carcinoma
tumor invades less than half the myometrium or endometrium
stage Ib endometrial carcinoma
tumor invades more than half of the myometrium
stage II endometrial cancer
tumor invades stromal connective tissue but confined to uterus
stage III endometrial cancer
tumors involves vagina, adnexa, with positive regional lymph nodes
stage IV endometrial cancer
tumor involves bladder mucosa with distant metastasis
treatment of low risk endometrial cancer
stage I
surgical resection only
treatment of intermediate risk endometrial cancer
stage Ib or stromal invasion
radiation therapy, but no clear data
treatment of high risk endometrial cancer
stage III or IV
chemotherapy and radiation therapy
how to diagnose herpes simplex virus
Tzanck smear of vesicle fluid
what are typical findings on Tzanck smear
multinucleated giant cells and epithelial cells containing eosinophilic intranuclear inclusion bodies
bacterial vaginosis examination
thin, off-white discharge with fishy odor
no inflammation
trichomoniasis examination
thin, yellow-green, malodorous, frothy discharge
vaginal inflammation
candida vaginitis examination
thick ‘cottage cheese’ discharge
vaginal inflammation
BV lab findings
pH >4.5
clue cells
positive whiff test (amine odor with KOH)
trich lab findings
pH >4.5
motile trichomonads
candida lab findings
normal pH
pseudohyphae
BV treatment
metronidazole or clindamycin
trich treatment
metronidazole
treat sexual partner
candida treatment
fluconazole
how to diagnose vesicovaginal fistula
bladder dye test
cause of vesicovaginal fistula
excessive fetal head compression during obstructed labor causes injury & necrosis to the maternal vagina, rectum, and bladder -> erosion and fistula development
- occurs within the first weeks postpartum
signs of vesicovaginal fistula
continuous vaginal discharge with an abnormally elevated pH (due to urine) which may be malodorous (due to surrounding necrotic tissue)
pelvic exam of vesicovaginal fistula
vaginal pooling of urine, visible defect, or an area of raised, red granulation tissue on the anterior vaginal wall
what does total/free T4 do in pregnancy and why
increases
ß-hCG stimulates thyroid hormone production in first trimester
estrogen stimulates TBG; thyroid increases hormone production to maintain steady free T4 levels
how is TSH changed in pregnancy and why
decreased
increased ß-hCG & thyroid hormone suppress TSH secretion
what to do with levothyroxine dose during pregnancy?
increase levothyroxine when patient becomes pregnant
definition of recurrent cystitis in women
>/= 2 infectons in 6 months >/= 3 infections in a year
risk factors for recurrent cystitis in women
sexually active
postmenopausal
first UTI at age <15
spermicide use
prevention of recurrent cystitis in women
daily abx prophylaxis
postcoital prophylaxis
presentation of a theca lutein cyst
multilocular
bilateral
10-15cm ovaries
pathogenesis of theca lutein cyst
ovarian hyperstimulation due to:
- gestational trophoblastic disease
- multifetal gestation
- infertility treatment
clinical course of theca lutein cyst
resolve with decreasing ß-hCG levels
pathogenesis of sheehan syndrome
obstetric hemorrhage complicated by hypotension
postpartum pituitary infarction
clinical features of sheehan syndrome
lactation failure (decrease prolactin)
amenorrhea, hot flashes, vaginal atrohpy (decrease FSH, LH)
fatigue, bradycardia (decrease TSH)
anorexia, weight loss, hypotension (decrease ACTH)
decreased lean body mass (decrease growth hormone)
what is sheehan syndrome
postpartum hypopituitarism
manifestations of Sheehan syndrome
fatigue, weight loss, hypotension, inability to breastfeed
associated conditions of wernicke encephalopathy
chronic alcoholism (most common)
malnutrition (e.g. anorexia nervosa)
hyperemesis gravidarum
pathophysiology of wernicke encephalopathy
thiamine deficiency
clinical features of wernicke encephalopathy
encephalopathy
oculomotor dysfunction (e.g. horizontal nystagmus, bilateral abducens palsy)
postural & gait ataxia
treatment of wernicke encephalopathy
IV thiamine followed by glucose infusion
exocrine features of sjögren syndrome
keratoconjunctivitis sicca
dry mouth, salivary hypertrophy
xerosis
extraglandular features of sjögren syndrome
raynaud phenomenon cutaneous vasculitis arthralgia/arthritis interstitial lung disease non-hodgkin lymphoma
diagnostic findings of sjögren syndrome
objective signs of decreased lacrimation (Schirmer test)
positive anti-Ro (SSA) &/o anti-La (SSB)
salivary gland biopsy with focal lymphocytic sialoadenitis
classification: primary if no associated CTD, secondary if comorbid CTD (SLE, RA, scleroderma
what is late-term pregnancy
> /= 41wks gestation
what is post-term pregnancy
> /= 42wks gestation
risk factors for late & post term pregnancy
prior post term pregnancy nulliparity obesity age >/= 35 fetal anomalies (e.g. anencephaly)
complications of late & post term pregnancy
fetal/neonatal - macrosomia - dysmaturity syndrome - oligohydramnios - demise maternal - severe obstetric laceration - cesarean delivery - postpartum hemorrhage
management of late & post term pregnancy
frequent fetal monitoring (nonstress test)
delivery prior to 43wks gestation
onset of anaphylactic transfusion reaction
within seconds to minutes
cause of anaphylactic transfusion reaction
recipient anti-IgA antibodies directed against donor blood IgA
key features of anaphylactic transfusion reaction
angioedema, hypotension, respiratory distress/wheezing, shock
IgA deficient recipient
onset of acute hemolytic transfusion reaction
within 1hr
cause of acute hemolytic transfusion reaction
ABO incompatibility (often clerical error)
key features of acute hemolytic transfusion reaction
fever, flank pain, hemoglobinuria
disseminated intravascular coagulation
positive Coombs test
onset of febrile nonhemolytic transfusion reaction
within 1-6hrs
cause of febrile nonhemolytic transfusion reaction
cytokine accumulation during blood storage
key features of febrile nonhemolytic transfusion reaction
fever & chills
onset of urticarial transfusion reaction
within 2-3hrs
cause of urticarial transfusion reaction
recipient IgE against blood product component
key features of urticarial transfusion reaction
urticaria
onset of transfusion-related acute lung injury
within 6hrs
cause of transfusion-related acute lung injury
donor anti-leukocyte antibodies
key features of transfusion-related acute lung injury
respiratory distress
noncardiogenic pulmonary edema with bilateral pulmonary infiltrates
onset of delayed hemolytic transfusion reaction
within days to weeks
cause of delayed hemolytic transfusion reaction
anamnestic antibody response
key features of delayed hemolytic transfusion reaction
often asymptomatic
laboratory evidence of hemolytic anemia
positive Coombs test, positive new antibody screen
onset of graft vs. host
within weeks
cause of graft vs. host
donor T-lymphocytes
key features of graft vs. host
rash, fever, GI symptoms, pancytopenia
gestational thrombocytopenia in pregnancy
isolated, mild (100-150k)
asymptomatic
diagnosis of exclusion
preeclampsia with severe features/HELLP syndrome causing thrombocytopenia in pregnancy
moderate to severe (<100k)
hypertension +/- headache/scotomata
+/- increase creatinine, increase AST & ALT
immune-mediated thrombocytopenia in pregnancy
isolated, moderate to severe (<100k)
asymptomatic or mucosal bleeding/bruising
normal PT, aPTT
thrombotic thrombocytopenic purpura (TTP)
severe (<30k)
neurologic symptoms (e.g. confusion, seizure), fever, abdominal pain, petechiae
normal PT, aPTT
disseminated intravascular coagulopathy (DIC)
moderate to severe (<100k)
bleeding (e,g. oozing IV sites) +/- thrombosis
increase PT, increase aPTT, decrease fibrinogen
how does levonorgestrel-containing IUD work
thickens cervical mucus
impairs implantation through decidualization of the endometrium
common side effect of levonorgestrel IUD
amenorrhea - can be used to improve anemia and abnormal uterine bleeding
systemic - mood changes, breast tenderness, headaches
weight gain is not a side effect
definition of vasa previa
fetal vessels overlying the cervix
risk factors of vasa previa
placenta previa
multiple gestations
in vitro fertilization
succenturiate placental lobe
clinical presentation of vasa previa
painless vaginal bleeding with ROM or contractions
FHR abnormalities (bradycardia, sinusoidal pattern)
fetal exsanguination & demise
management of vasa previa
emergency cesarean delivery
vasa previa vs. placenta previa
painless vaginal bleeding
placenta previa is primarily maternal blood loss -> heavy, persistent, signs of maternal hemorrhagic shock (hypotension, tachycardia) are present prior to severe fetal compromise
what is a urethral diverticulum
abnormal localized outpouching of the urethral mucosa into surrounding tissues
cause of urethral diverticulum
recurrent periurethral gland infections, which can develop into an abscess
urethral diverticulum presentation
tender anterior vaginal wall mass
- dyspareunia or a palpable mass on pelvic examination
may collect urine and debris -> purulent discharge, dysuria, postvoid dribbling
how to confirm diagnosis of urethral diverticulum
MRI
how to treat urethral diverticulum
surgical excision
acute management of tachyarrhythmias in pregnant women
adenosine
second-line agents for symptomatic SVT in pregnancy
digoxin
calcium channel blockers (verapamil)
ß blockers (metoprolol)
what are common causes of hyperandrogenism in pregnancy?
placental aromatase deficiency
luteoma
theca lutein cyst
Sertoli-leydig tumor
clinical features of placenta aromatase deficiency in pregnancy
no ovarian mass
high maternal & fetal virilization risk
resolution of maternal symptoms after delivery
clinical features of luteoma in pregnancy
solid, unilateral/bilateral ovarian masses
moderate maternal virilization risk; high fetal virilization risk
spontaneous regression of masses after delivery
clinical features of theca lutein cyst in pregnancy
cystic, bilateral ovarian masses
moderate maternal virilization risk; low fetal virilization risk
spontaneous regression of masses after delivery
clinical features of sertoli-leydig tumor in pregnancy
solid unilateral ovarian mass high maternal & fetal virilization risk surgery required (2nd trimester or postpartum)
pathogenesis of müllerian agenesis
müllerian duct system defect
abnormal development of uterus, cervix, & upper third of vagina
clinical features of müllerian agenesis
primary amenorrhea normal female external genitalia blind vaginal pouch absent or rudimentary uterus bilateral functioning ovaries (normal FSH)
management of müllerian agenesis
evaluate for renal tract abnormalities (renal ultrasound) vaginal dilation (surgical or nonsurgical)
definition. ofvasa previa
fetal vessels overlying the cervix
risk factors for vasa previa
placenta previa
multiple gestations
in vitro fertilization
succenturiate placental lobe
clinical presentation of vasa previa
painless vaginal bleeding with ROM or contractions
FHR abnormalities (bradycardia, sinusoidal pattern)
fetal exsanguination & demise
management of vasa previa
emergency cesarean delivery
prenatal care for sickle cell disease in pregnancy
baseline 24hr urine for total protein baseline chemistry panel serial urine culture pneumococcal vaccination folic acid supplementation aspirin serial fetal growth ultrasound
obstetric complications of sickle cell disease
spontaneous abortion
preeclampsia, eclampsia
abruptio placentae
antepartum bleeding
fetal complications of sickle cell disease
fetal growth restriction
oligohydramnios
preterm birth
from uteroplacental insufficiency
causes of hirsutism in women
polycystic ovary syndrome idiopathic hirsutism nonclassic 21-hydroxylase deficiency androgen-secreting ovarian tumors, ovarian hyperthecosis cushing syndrome
clinical features of PCOS
oligomenorrhea, hyperandrogenism, obesity
associated with type 2 diabetes, dyslipidemia, hypertension
clinical features of idiopathic hirsutism
normal menstruation
normal serum androgens
clinical features of nonclassic 21-hydroxylase deficiency
similar to PCOS
elevated serum 17-hydroxyprogesterone
clinical features of androgen-secreting ovarian tumors, ovarian hyperthecosis
more common in postmenopausal women
rapidly progressive hirsutism with virilization
very high serum androgens
clinical features of Cushing syndrome
obesity (usually of the face, neck, trunk, abdomen)
increased libido, virilization, irregular menses
antepartum fetal surveillance
nonstress test
biophysical profile
contraction stress test
doppler sonography of umbilical artery
description of nonstress test
external fetal heart rate monitoring for 20-40mins
normal result of nonstress test
reactive: >/= 2 accelerations
abnormal resul of nonstress test
nonreactive: <2 accelerations
recurrent variable or late decelerations
description of biophysical profile
nonstress test plus ultrasound assessment of:
- amniotic fluid volume
- fetal breathing movement
- fetal movement
- fetal tone
2 points per category if normal & 0 points if abnormal
max of 10
normal result of biophysical profile
8 or 10 points
abnormal result of biophysical profile
equivocal: 6 points
abnormal: 0, 2, or 4 points
oligohydramnios
description of contraction stress test
external fetal heart rate monitoring during spontaneous or induced (e.g. oxytocin, nipple stimulation) uterine contractions
normal result of contraction stress test
no late or recurrent variable decelerations
abnormal result of contraction stress test
late decelerations with >50% of contractions
description of doppler sonography of the umbilical artery
evaluation of umbilical artery flow in fetal intrauterine growth restriction only
normal result of doppler sonography of umbilical artery
high-velocity diastolic flow in umbilical artery
abnormal result of doppler sonography of umbilical artery
decreased, absent, or reversed end-diastolic flow
components of biophysical profile (BPP)
nonstress test amniotic fluid volume fetal movements fetal tone fetal breathing movements
normal finding of nonstress test for BPP
reactive fetal heart rate monitoring
normal finding of amniotic fluid volume for BPP
single fluid pocket >/= 2cm x 1cm or amniotic fluid index >5
normal finding of fetal movements for BPP
> /= 3 general body movements
normal finding of fetal tone for BPP
> /= 1 episodes of flexion/extension of fetal limbs or spine
normal finding of fetal breathing movements for BPP
> /= 1 breathing episode for >/= 30 seconds
BPP score of 0-4 /10 indicates
fetal hypoxia due to placental dysfunction
risk factors for placental insufficiency
advanced maternal age
tobacco use
hypertension
diabetes
risk factors for pubic symphysis diastasis
fetal macrosomia
multiparity
precipitous labor
operative vaginal delivery
presentation of pubic symphysis diastasis
difficulty ambulating
radiating suprapubic pain
pubic symphysis tenderness
intact neurologic examination
management of pubic symphysis diastasis
conservative
NSAIDs
physical therapy
pelvic support
clinical presentation of epithelial ovarian carcinoma
acute: shortness of breath, obstipation/constipation with vomiting, abdominal distention
subacute: pelvic/abdominal pain, bloating, early satiety
asymptomatic adnexal mass
laboratory findings of epithelial ovarian carcinoma
increase CA-125
ultrasound findings of epithelial ovarian carcinoma
solid mass
thick septations
ascites
management of epithelial ovarian carcinoma
exploratory laparotomy
assessing arterial blood gas
1 - look at pH
- <7.35 acidemia
- >7.45 alkalemia
2 - determine primary process
- in alkalemia, if elevated bicarb & PaCO2 = primary metabolic alkalosis
3 - determine degree of compensation
- Winter’s formula: PaCO2 = (0.9 * bicarb) + 16 +/- 2
metabolic acidosis
low pH <7.35
low HCO3- < 22
compensation:
- respiratory alkalosis (decrease PaCO2)
respiratory acidosis
low pH < 7.35
high PaCO2 >45
delayed compensatory response:
- metabolic alkalosis (increase HCO3-)
respiratory alkalosis
high pH > 7.45
low PaCO2 < 35
delayed compensatory response:
- metabolic acidosis (decrease HCO3-)
metabolic alkalosis
high pH >7.45
high HCO3- >28
compensatory response:
- respiratory acidosis (increase PaCO2)
commonly causes metabolic alkalosis in pregnancy
hyperemesis gravidarum
pathogenesis of congenital zika syndrome
single-stranded RNA flavivirus
transplacental transmission ot fetus
targets neural progenitor cells
clinical features of congenital zika
microcephaly, craniofacial disproportion
neurologic abnormalities (spasticity, seizures)
ocular abnormalities
diagnosis of congenital zika
neuroimaging: calcifications, ventriculomegaly, cortical thinning
zika RNA detection
risk factor for listeria monocytogenes
consumption of unpasteurized dairy products
in utero L monocytogenes
fetal demise or neonatal disseminated granulomatous disease
modifiable breast cancer risk factors
hormone replacement therapy
nulliparity
increased age at first live birth
alcohol consumption
non-modifiable breast cancer risk factors
genetic mutation or breast cancer in first-degree relatives
white race
increasing age
early menarche or later menopause
common cause of acute cervicitis
Chlamydia trachomatis
Niesseria gonorrhea
classic findings of acute cervicitis
mucopurlent cervical discharge and edematous, friable cervix that bleeds with manipulation
what would be visualized on light microscopy for acute cervicitis
no organisms
clinical features of bacterial vaginosis
thin, off-white discharge with fishy odor
no vaginal inflammation
laboratory findings of BV
pH >4.5
clue cells
positive whiff test
treatment of BV
metronidazole or clindamycin
complications of BV
increase risk of preterm birth
increase risk for acquisition of HIV, HSV type 2, gonorrhea, chlamydia, & trichomonas infections
risks of metronidazole in first trimester?
no! treat BV!
approach to postmenopausal bleeding
endometrial biopsy or TVUS endometrium
in evaluation of postmenopausal bleeding, if TVUS endometrium reveals >4mm
endometrial biopsy
in evaluation of postmenopausal bleeding, if TVUS endometrium reveals = 4mm
observation
in evaluation of postmenopausal bleeding, if endometrial biopsy benign
observation
in evaluation of postmenopausal bleeding, if endometrial biopsy atypic neoplasia
progestins
surgery
clinical presentation of hydatidiform mole
abnormal vaginal bleeding +/- hydropic tissue uterine enlargement > gestational age abnormally elevated Bega-hCG levels theca lutein ovarian cysts hyperemesis gravidarum preeclampsia with severe features hyperthyroidism
risk factors for hydatidiform mole
extremes of maternal age
history of hydatidiform mole
diagnosis of hydatidiform mole
‘snowstorm’ appearance on ultrasound
quantitative serum ß-hCG
histologic evaluation of uterine contents
management of hydatidiform mole
dilation & suction curettage
serial serum ß-hCG post evacuation
contraception for 6 months
clinical features vulvar lichen planus
women age 50-60 vulvar pain or pruritus dyspareunia erosive variant (most common) - erosive, glazed lesions with white border - vaginal involvement +/- stenosis - associated oral ulcers papulosquamous variant - small pruritic papule with purple hue
diagnosis vulvar lichen planus
vulvar biopsy
treatment vulvar lichen planus
high-potency topical corticosteroids
lichen planus vs. lichen sclerosus
lichen sclerosis has no vaginal involvement
management of hydatidiform mole
suction curettage -> weekly ß-hCG levels until undetectable
for hydatidiform mole, if weekly ß-hCG are increasing/plateauing
diagnosis of gestational trophoblastic neoplasia
for hydatidiform mole, if weekly ß-hCG are decreasing
monthly ß-hCG levels x6 months
for hydatidiform mole, if monthly ß-hCG x 6 months undetectable
surveillance complete
can attempt pregnancy
for hydatidiform mole, if monthly ß-hCG x 6 months becomes detectable
diagnosis of gestational trophoblastic neoplasia
example of gestational trophoblastic neoplasia
choriocarcinoma
clinical features of intraductal papilloma
unilateral bloody nipple discharge
no associated mass or lymphadenopathy
management of intraductal papilloma
mammography & ultrasound
biopsy, +/- excision
side effects & risks of combination oral contraceptives
breakthrough bleeding breast tenderness, nausea, bloating amenorrhea hypertension venous thromboembolic disease decreased risk of ovarian & endometrial cancer increased risk of cervical cancer liver disorders (hepatic adenoma) increased triglycerides (due to estrogen component
examples of selective estrogen receptor modulators (SERMs)
tamoxifen
raloxifene
mechanism of SERMs
competitive inhibitor of estrogen binding
mixed agonist/antagonist action
indications for SERMs
prevention of breast cancer in high-risk patients
Tamoxifen: adjuvant treatment of breast cancer
Raloxifene: postmenopausal osteoporosis
adverse effects of SERMs
hot flashes
venous thromboembolism
endometrial hyperplasia & carcinoma (tamoxifen only)
missed abortion
no vaginal bleeding
closed cervical os
no fetal cardiac activity or empty sac
threatened abortion
vaginal bleeding
closed cervical os
fetal cardiac activity
inevitable abortion
vaginal bleeding
dilated cervical os
products of conception may be seen or felt at or above cervical os
incomplete abortion
vaginal bleeding
dilated cervical os
some products of conception expelled & some remain
complete abortion
vaginal bleeding
closed cervical os
products of conception completely expelled
bartholin duct cyst
occurs due to blockage of the bartholin gland duct
location of bartholin glands
bilaterally at the posterior vaginal Introits and have ducts that drain into the vulvar vestibule at 4 and 8 o’clock positions
signs of bartholin duct cyst
often asymptomatic
increased tissue tension & friction -> vaginal pressure & discomfort with sexual activity, walking, or sitting
pelvic exam of bartholin duct cyst
soft, mobile, nontender, cystic mass palpated behind the posterior labium magus with possible extension into the vagina
treatment of bartholin duct cyst
I&D with possible Word catheter placement
what is external cephalic version
manual rotation of fetus to cephalic presentation
decreases cesarean delivery rate
indications for external cephalic version
breech/transverse presentation
>/= 37wks gestation
absolute contraindications to external cephalic version
contraindication to vaginal delivery
- prior classical cesarean delivery
- prior extensive uterine myomectomy
- placenta previa
complications of external cephalic version
abruptio placentae
intrauterine fetal demise
presentation of inflammatory breast cancer
rapid-onset edematous cutaneous thickening with a ‘peau d’orange’ appearance
edematous, erythematous, and painful
axillary lymphadenopathy suggestive of metastatic disease
next step in evaluation of inflammatory breast cancer
mammography and ultrasound
tissue biopsy necessary to confirm diagnosis
what is duodenal atresia
complete bowel obstruction
- fluid filled stomach and proximal duodenum with no distal intestinal air or fluid
duodenal atresia on ultrasound
double bubble sign
- fluid-filled stomach ad duodenum
signs of duodenal atresia
impairs fetal swallowing of amniotic fluid -> polyhdramnios
definition of polyhydramnios
single deepest pocket of amniotic fluid >/= 8cm
what is VACTERL associated with
trisomy 21 (Down syndrome)
what is VACTERL
Vertebral = Anal atresia Cardiac = ventricular septal defct Tracheoesophageal fistula Esophageal atresia Renal Limb
what is the two step approach for screening and diagnosing gestational diabetes
at 24-28wks:
- step 1: administer 50g oral glucose load, check serum glucose 1hr later
- step 2: if blood glucose >/= 140, administer 100g oral glucose load, check fasting serum glucose each hour afterwards for 3hrs
how to diagnose gestational diabetes
> /= 2 abnormals:
- fasting >/= 105
- 1hr >/= 190
- 2hr >/= 165
- 3hr >/= 145
what are physiologic adaptations to pregnancy as it relates to diabetes
pancreatic ß cell hyperplasia
increased insulin secretion
increased peripheral insulin resistance
what is pseudothrombocytopenia
laboratory error caused by platelet aggregation in vitro
how is pseudothrombocytopenia identified?
mild thrombocytopenia has peripheral blood smear evidence of large clumps of platelets
idiopathic thrombocytopenic purpura
presents with mild thrombocytopenia
often asymptomatic and no history of bleeding disorder
peripheral blood smear shows a paucity of platelets without platelet clumping
definition of preeclampsia
new-onset hypertension at >/= 20 weeks
plus
proteinuria &/or end-organ damage
severe features of preeclampsia
SBP >/= 160/110 ( 2x >/= 4hrs apart) thrombocytopenia increase creatinine increase transaminases pulmonary edema visual or cerebral symptoms
management of preeclampsia
without severe features: delivery at >/= 37wks with severe features: delivery at >/= 34wks magnesium sulfate (seizure prophylaxis) antihypertensives
breech types
frank
complete
incomplete
frank breech
hips flexed & knees extended (buttock presenting)
complete breech
hips & knees flexed
incomplete breech
1 or both hips not flexed (feet presenting)
risk factors for breech presentation
advanced maternal age >/= 35 multiparty uterine didelphys, septet uterus uterine leiomyomas fetal anomalies (e.g. anencephaly) preterm (<37wks) oligohydramnios/polyhydramnios placenta previa
management of breech presentation
external cephalic version
cesarean delivery
risk factors for vulvovaginal candidiasis
diabetes mellitus immunosuppression pregnancy OCPs antibiotic use
when to stop Pap testing
age 65 or hysterectomy PLUS - no history of CIN 2 or higher AND - 3 consecutive negative Pap tests OR - 2 consecutive negative co-testing results
Graves disease
thyroid stimulated by autoantibodies to increase tissue metabolic activity causing increased thyroid hormone synthesis
Graves disease radioactive iodine uptake
increased reuptake
increased release of thyroid hormone
painless autoimmune thyroiditis
the thyroid tissue is destroyed, leading to increased release of preformed thyroid hormone and resulting hyperthyroidism
painless autoimmune thyroiditis radioactive iodine uptake
low radioactive iodine uptake due to destroyed thyroid cells being unable to synthesize thyroid hormone
when to order CA-125
in a postmenopausal patient, measured in conjunction with pelvic ultrasonography to categorize an ovarian mass as likely malignant or benign
risk factors for endometrial hyperplasia/cancer
excess estrogen
- obesity
- chronic anovulation/PCOS
- nulliparity
- early menarche or late menopause
- tamoxifen use
clinical features of endometrial hyperplasia/cancer
heavy, prolonged, intermenstrual &/or postmenopausal bleeding
evaluation of endometrial hyperplasia/cancer
endometrial biopsy (gold standard) pelvic ultrasound (postmenopausal women)
treatment endometrial hyperplasia/cancer
hyeprplasia: progestin therapy or hysterectomy
cancer: hysterectomy
definition of shoulder dystocia
failure of usual obstetric maneuvers to deliver fetal shoulders
risk factors for shoulder dystocia
fetal macrosomia maternal obesity excessive pregnancy weight gain gestational diabetes post-term pregnancy
warning signs for shoulder dystocia
protracted labor
retraction of fetal head into the perineum after delivery (turtle sign)
methods of emergency contraception
copper-containing IUD
ulipristal
levonorgestrel
oral contraceptives
timing after intercourse for copper IUD emergency contraception
0-120hrs
timing after intercourse for ulipristal emergency contraception
0-120hrs
timing after intercourse for levonorgestrel emergency contraception
0-72hrs
timing after intercourse for OCPs emergency contraception
0-72hrs
efficacy of copper IUD for emergency contraception
> /= 99%
efficacy of ulipristal for emergency contraception
98-99%
efficacy of levonorgestrel for emergency contraception
59-94%
efficacy of OCPs for emergency contraception
47-89%
contraindications for copper IUD for emergency contraception
acute pelvic infection
severe uterine cavity distortion
Wilson disease
complicated organ transplant failure
diagnostic findings of amenorrhea in ovarian failure
increase FSH, LH
normal prolactin, TSH
diagnostic findings of amenorrhea in functional hypothalamic amenorrhea
decrease FSH, LH
normal prolactin, TSH
diagnostic findings of amenorrhea in Asherman syndrome
normal FSH, LH, prolactin, TSH
diagnostic findings of amenorrhea in prolactinoma
decrease FSH, LH
increase prolactin
normal TSH
diagnostic findings of amenorrhea in hypothyroidism
decrease FSH, LH
increase prolactin, TSH
normal findings in the postpartum period
transient rigors/chills peripheral edema lochia rubra uterine contraction & involution breast engorgement
routine care in postpartum period
rooming-in/lactation support serial examination for uterine atony/bleeding perineal care voiding trial pain management
clinical features of obsessive compulsive disorder
obsessions
- recurrent, intrusive, anxiety-provoking thoughts, urges, or images
compulsions
- response to obsessions with repeated behaviors or mental acts
- behaviors not connected realistically with preventing feared event
time consuming (>1hr/day) or causing significant stress or impairment
treatment of OCD
SSRI
cognitive behavioral therapy (exposure & response prevention)
physiologic corpus luteum cyst
confirmed by ultrasound revealing a simple-appearing ovarian cyst with normal Doppler flow
clinical features concerning for malignancy of adnexal mass
postmenopausal age
chronic or worsening pelvic pain
mass symptoms (bloating, constipation)
ovarian cancer screening
no screening tests exist
routine prenatal laboratory tests at initial prenatal visit
Rh (D) type, antibody screen Hgb/Hct, MCV HIV, VDRL/RPR, HBsAg Rubella & varicella immunity Pap test Chlamydia PCR urine culture urine protein
routine prenatal laboratory tests at 24-28wks
Hgb/Hct
antibody screen if Rh (D) negative
50-g 1-hr GCT
routine prenatal laboratory tests at 35-37wks
Group B streptococcus culture
who requires endometrial sampling with benign-appearing endometrial cells on Pap?
pemenopausal women with:
- abnormal uterine bleeding OR
- risk for endometrial hyperplasia
postmenopausal women
who requires endometrial sampling with atypical glandular cells on Pap?
women >/= 35 OR at risk for endometrial hyperplasia
who requires endometrial sampling with atypical glandular cells, favor neoplastic on Pap?
all women
mature cystic teratoma on ultrasound
hyperechoic nodules and calcifications
evaluation of intimate partner violence
routine annual exam
suspicious signs/symptoms
prenatal visits
consequences of intimate partner violence
homicide mental health disorders unintended pregnancy pregnancy complications (abrupt placentae) sexually transmitted infections
management of intimate partner violence
safety planning (e.g. local shelter referral) psychosocial counseling
high risk preeclampsia
prior preeclampsia chronic kidney disease chronic hypertension diabetes mellitus multiple gestation autoimmune disease
moderate risk preeclampsia
obesity
advanced maternal age
nulliparity
prevention of preeclampsia
low-dose aspirin at 12wks gestation
pathophysiology of neonatal thyrotoxicosis
transplacental passage of maternal anti-TSH receptor antibodies
antibodies bind to infant’s TSH receptors and cause excessive thyroid hormone release
clinical features of neonatal thyrotoxicosis
warm, moist skin
tachycardia
poor feeding, irritability, poor weight gain
low birth weight or preterm birth
diagnosis of neonatal thyrotoxicosis
maternal anti-TSH receptor antibodies >/= 500% normal
treatment of neonatal thyrotoxicosis
self-resolves within 3 months (disappearance of maternal antibody)
methmiazole plus ß blocker
fetal diagnosis of nonviable fetus
acardia anencephaly bilateral renal genesis holoprosencephaly intrauterine fetal demise pulmonary hypoplasia thanatophoric dwarfism
obstetric management of nonviable fetus
vaginal delivery
no fetal monitoring
neonatal management of nonviable fetus
palliative care if not stillborn
management of Erb-Duchenne palsy
observation and physical therapy
up to 80% have spontaneous recovery within 3 months
risk factors of ovarian torsion
ovarian mass
women of reproductive age
infertility treatment with ovulation induction
treatment of ovarian torsion
laparoscopy with detorsion
ovarian cystectomy
oopherectomy if necrosis or malignancy
major causes DIC
sepsis
severe traumatic injury
malignancy
obstetric complications
pathophysiology of DIC
procoagulant excessively triggers coagulation cascade ->
formation of fibrin-/platelet-rich thrombi & fibrinolysis ->
bleeding & organ damage (e.g. kidneys, lungs)
laboratory findings of DIC
thrombocytopenia prolonged PT & PTT decrease fibrinogen increase D-dimer microangiopathic hemolytic anemia (schistocytes)
congenital parvovirus 19
anemia (aplastic)
high-output congestive heart failure
cardiomyopathy
mom presentation of parvovirus 19
febrile illness with myalgia, arthralgias, lymphadenopathy, and lacy, erythematous rash
mom presentation of varicella-zoster
febrile illness
pruritic vesicular lesions in all stages of healing
congenital toxoplasmosis
intracranial calcifications
disseminated purpuric rash
seizures
chorioretinitis, hydrocephaly
classic triad of congenital toxoplasmosis
chorioretinitis
intracranial calcifications
hydrocephaly
congenital cmv vs. toxoplasmosis
toxoplasmosis has more diffuse calcifications and hydrocephaly
CMV has periventricular calcifications and microcephaly
congenital CMV
low birth weight, ventriculomegaly, hearing impairment
periventricular calcifications
congenital rubella syndrome
patent ductus arteriosus
hearing impairment
petechial, puerperal rash (‘blueberry muffin’ rash)
supplement for history of PPROM
spontaneous preterm birth prior to 37 weeks gestational age is an indication for 17-hydroxyprogesterone in subsequent pregnancies
when is progesterone given in history of PPROM
16 and 36 weeks
false labor
uterine contractions that do not result in cervical change
most likely cause of irregular bleeding in an adolescent
anovulatory bleeding
- failure of the ovary to develop a corpus luteum
most sensitive indicator of IUGR
abdominal circumference
independent risk factor for preterm labor
African American race
contraindications to MTX in ectopic pregnancy
ß-hCG >5000 fetal cardiac activity on TVUS heterotopic pregnancy hypersensitivity breastfeeding immunodeficiency active pulmonary disease peptic ulcer disease inability/unwillingness to comply with close follow-up <4cm
treatment of ectopic pregnancy >5.5cm
laparoscopic surgery
- salpingectomy or salpingostomy
pathophysiology of tuberous sclerosis complex
mutation in TSC1 or TSC2 gene
Autosomal Dominant
clinical features of tuberous sclerosis complex - dermatologic
ash-leaf spots
angiofibromas of the malar region
shagreen patches
clinical features of tuberous sclerosis complex - neurologic
CNS lesions - subependymal tumors
epilepsy - infantile spasms
intellectual disability
autism & behavioral disorders - hyperactivity
clinical features of tuberous sclerosis complex - cardiovascular
rhabdomyomas
clinical features of tuberous sclerosis complex - renal
angiomyolipomas
surveillance for tuberous sclerosis complex
tumor screening - regular skin & eye examinations - serial MRI of the brain & kidney - baseline echocardiography & serial ECG baseline EEG neuropsychiatric screening
medications to avoid in myasthenia gravis
magnesium sulfate fluoroquinolones, aminoglycosides NMS blocking agents CNS depressants muscle relaxants CCBs ß blockers opioids statins
risk of triglyceride-induced pancreatitis
triglyceride levels
- <500 = minimal risk
- 500-99 = mild risk
- 1000-1999 = moderate risk
- > = 2000 = high risk
other: pregnancy, alcoholism, obesity, uncontrolled diabetes
clinical features of triglyceride-induced pancreatitis
acute epigastric pain radiating to the back
+/- fever, nausea, vomiting
elevated serum lipase (>3x ULN)
management of triglyceride-induced pancreatitis
IV fluid hydration, pain control
glucose >/= 500 mg/dL: consider insulin infusion
glucose <500 mg/dL or severe pancreatitis (e.g. lactic acidosis, hypocalcemia): consider aphaeresis (therapeutic plasma exchange
risk factors of rectovaginal fistula
pelvic radiation obstetric trauma pelvic surgery colon cancer diverticulitis Crohn disease
clinical features of rectovaginal fistula
uncontrollable passage of gas &/or feces from the vagina
diagnostic studies for rectovaginal fistula
physical examination
fistulography
MRI
endosonography
rectovaginal fistula
posterior vaginal wall
dark red, velvety lesion
malodorous, tan-brown discharge
