Last Minute Review Flashcards
Pudendal Nerve
S2, 3, 4
Erb’s Palsy
Waiter’s Tip, C5-C6
Klumpke’s Paralysis
hand/wrist paralysis, C8-T1
Diagonal Conjugate
Symphysis to sacral prominence
Obstetrical Conjugate
Diagonal conjugate minus 2cm
Ant-Post Diameter of Mid pelvis
Sacrum to symphysis (11.5cm or more)
Interspinous Diameter
10cm or more
Anthropoid Pelvis
Oval shape, narrow
OP presentation
Android Pelvis
Heart shape Masculine pelvis, Prominent notch, 1st stage arrest MC
Platypelloid Pelvis
Wide diameter, OT presentation
Leopold’s Maneuvers
Fetal part at the upper and lower poles of uterus, side of the back, head flexed or extended
Cardinal Movements of Labor
Engage
Descent
Flexion
Internal Rotation
Extension
External Rotation
Expulsion
APGAR
Activity, Pulse, Grimace, Appearance, Respiration
Favorable Bishop Score
8 or more
(6 or less unripe)
1-2/50/-2 mid, med (1 point each=5)
Arrest of Descent
Nullip 3 hrs (4 hrs with epidural)
Multip 2hrs (3 hrs with epidural)
Lidocaine Side Effects
Metallic taste, perioral numbness, slurred speech, tinnitus, blurry vision, seizure, cardiac arrhythmia/arrest
maximum dose for lidocaine is 3.0 mg/kg body weight
without epinephrine and 7 mg/kg with epinephrine
Sensitivity
True Pos/ (True Pos + False neg)
Chance that people with disease actually test positive
Specificity
True Neg/ (True neg + False Pos)
Chance that people without the disease test negative
PPV
True Pos/ (True and False Pos)
Chance that positive test is correct
NPV
True neg/ (True and False neg)
Chance that negative test is correct
Weight Based Insulin
0.7-1.0 units/KG = total daily dose of insulin
AM dose (2/3 total daily dose)
- NPH is 2/3 AM dose
- Regular is 1/3 AM dose
PM dose (1/3 total daily dose)
- NPH is 1/2 PM dose
- Regular is 1/2 PM dose
Rapid Acting Insulin (onset, peak, duration)
Onset < 15 min
Peak 1-2 hrs
Lasts 4-5 hrs
Regular Insulin (onset, peak, duration)
Onset 30-60min
Peak 2-4 hrs
Lasts 6-8 hours
NPH Insulin (onset, peak, duration)
Onset 1-3 hrs
Peak 5-7 hrs
Lasts 13-18 hrs
Thyroid Storm Tx
PTU , Lugol Iodide, Dexamethasone
B blockers
Folic acid dose for high risk pt in preg
4mg/day
Normal folic acid dose in preg
400mcg/day
APLS Criteria
1 or more fetal losses at 10w or more, 1 or more PTD <34w due to Pre E, FGR, or placental insuff, 3 or more losses less than 10 weeks (not including chromosomal or anatomic issues)
+
Lab evidence of a positive LAC, ACA, or B2G on 2 occasions at least 12 weeks apart
Timing of Twinning Chorionicity
Di- Di : 0-3 days
Mono Di: 4-8 days
Mono Mono: 9-12 days
Conjoined: > 13 days
Estimated EFW for 20, 30, 40 weeks
400g @ 20w
1200g @ 30w
3600g @ 40w
GBS Treatment
PCN G 5 mil units, then 2.5 q4h
Amp 2g, then 1g q4h
Cefazolin 2g, then 1g q8h
Clinda 900mg q8hrs
Vanc 20mg/kg q8hrs
Avidity IgG
Low ~2-4 mo (recent)
High >6 months (more distant)
Rhogam Coverage for Volume of Fetal RBCs vs Whole Blood
1 dose covers 15cc of fetal RBCs (30cc whole blood)
Caprini Score (VTE Risk)
1-2 = low risk
3-4 intermediate risk
5 or more = high risk
Modified Wells Score for DVT risk/PE
If low (<4), get D Dimer
If high (4 or more), then US
Apixaban or rivaroxaban
Mechanism of Action
Factor Xa inhibitor
Dabigatran
Mechanisim of Action
Direct Thrombin Inhibitor
Heparin Antidote
Protamine Sulfate
Magnesium Antidote
Calcium gluconate
LMWH
Mechanism of action
Inhibits factor Xa
Heparin
Mechanism of action
Binds Antithrombin to prevent thrombin binding
TXA
Mechanism of action
Anti fibrinolytic
LMWH wait time before regional anesthesia
If ppx then 12hr
If therapeutic then 24 hrs
Anterior Abd Wall Muscle Layers
Ext Oblique
Internal Oblique
Transversus Abdominus
Rectus Abdominus
Ovarian Vein Drainage
R ovarian vein drains into IVC
L ovarian vein drains into L renal vein
Posterior Division of Internal Iliac (Hypogastric) Artery
Ilio-lumbar
Lateral sacral
Superior Gluteal
“I Love Sex” mnemonic
Anterior Division of Internal Iliac (Hypogastric) Artery
Umbilical art remnant
Superior, middle, inferior vesical
Middle rectal
Obturator
Internal Pudendal
Sciatic
Uterine
Vaginal
Ureter Course and Length
15cm x2
1. From renal pelvis descends from lateral to medial over psoas muscle
2. Enters pelvic brim at bifurcation of the common iliac vessels
3. Descends along sidewall posterior and inferior to ovarian vessels
4. Crosses under cardinal
5. Crosses under uterine (water under bridge)
6. Moves anteromedially to insert into bladder
Ureteral Injury Points
- near IP ligament
- Under uterine artery
- Near uterosacrals
- Near corners of vaginal cuff
Closing Bowel Laceration
Perpendicular to the long axis of the bowel
Cherney Incision
Excise rectus tendon off of pubis
Maylard Incision
Cut rectus, but must ligate the inferior epigastrics
Postop Fevers Causes
Wind (1-2 days) SBO, Ileus, Pneumonia
Water (2-5 days) - UTI
Wound (3-5 days) - SSI
Walk (7-10 days) - DVT/PE
Wonder drugs - allergies/reaction
Baden Walker
Stage 0 - no prolapse
Stage 1- more than 1cm above hymen
Stage 2- less than 1cm above or below hymen
Stage 3- more than 1cm below hymen (no more than 2 cm)
Stage 4- complete procidentia
Urethral Mobility
greater than 30 degrees
Intrinsic Sphincter Deficiency for Urethra
less than 60mmHg (leak point pressure)
and/or less than 20mmHg urethral closing pressure
Rectovaginal Fistula
Methylene blue in rectum
Or
Air in vagina, fluid in rectum, look for bubbling
Vesicovaginal fistula
Methylene blue in bladder, tampon test
Decompress up to 12 weeks (need at least 6 weeks foley)
Ureterovaginal fistula
Pyridium oral , tampon test
CT urogram or Retrograde pyelography
Discriminatory Zone
HCG 3,500 mIU/ml
MTX absolute contraindications
Renal, liver, or pulm disease
Peptic ulcer disease
Blood dyscrasia
Breastfeeding
Immunosuppression
Sensitivity to MTX
Ruptured
Unstable
MTX Relative Contraindications
HCG >5,000
Size >4cm
+Fetal cardiac activity
MTX dose
50mg/m2 BSA
Heterophile Antibodies
Serum HCG +
Urine HCG neg
BRCA1 Ovarian Cancer risk
40%, rrBSO 35-40yrs
BRCA2 Ovarian Cancer risk
20%, rrBSO 40-45yrs
Cervical Cancer: Stage IA1 and IA2
IA1 - 3mm or less depth
- CKC or simple hyst
IA2 - 3-5mm depth
- modified rad hyst + nodes
Cervical Cancer: Stage IB1-3
Invasion more than 5mm
IB1- 2cm or less
IB2 - 2-4cm
IB3 - more than 4cm
Cervical Cancer: Stage 2A-B
Upper 2/3 vaginal w/ or without parametrial involvement
2A- no parametria
2B- parametria
Cervical Cancer: Stage 3 A-C
Lower 1/3 vagina, side wall, hydronephrosis
3B- lower vagina only
3B - side wall or hydroneph
3C Pelvic or Para-aortic LN
Cervical Cancer: Stage 4 A-B
4A: Bladder or rectum
4B: Distant mets
Tumor Marker: Mucinous Epithelial Tumor
CEA
Tumor Marker: Non-Mucinous Epithelial Tumor
CA 125 (neg for 50% early epithelial ovarian cancers)
Tumor Marker: endodermal sinus or Embryonal
AFP, hCG
Tumor Marker: Choriocarcinoma, Germ Cell Tumor
HCG, (possible AFP or LDH)
Tumor Marker: Granulosa Cell tumor
Estrogen, Inhibin
Tumor Marker: Dysgerminoma
LDH, hCG
Lynch Screening
Colonoscopy q1-2 yrs starting at 20-25 or 2-5yrs before earliest cancer
Annual EMB at age 30 (or 10 yrs earlier than youngest)
+/- Annual pelvic/TVUS, possibly CA 125 q6 months
Discuss option of ppx hyst bso after chilbearing (age 40-45)
EIN- Cancer risk
10-25%
Benign Hyperplasia- Cancer risk
<5%
Endometrial Cancer Stage 1A-B
IA - less than 50% myometrial invasion
IB - more than 50% myometrial invasion
Endometrial Cancer Stage 2
2: Cervical stroma
Endometrial Cancer Stage 3A-C
3A - uterine serosa +/- adnexa
3B- vaginal +/- parametria
3C- Pelvic or Paraaortic LN
Endometrial Cancer stage 4A-B
4A- bladder rectum
4B- distant mets
Endometrial Cancer Follow up
Every 3 months for 2 years, then 6 months for 3 years, then annually
Partial Mole
Triploid (69 XXX or XXY) (2 sperm, 1 egg)
Fetal parts
SGA
GTN risk 5%
Stop after neg HCG (can repeat at 1 month)
Complete Mole
Diploid (46 XX or XY) - sperm and empty ovum
Snowstorm
LGA
Theca Lutein
Thyroid abnormalities
GTN risk 20%
Stop after HCG neg for at least 3-6 months
GTN WHO FIGO staging
Score 0-6 - single agent chemo
7+ high risk - combo chemo
(age, duration from last preg, HCG, size, mets # and location, failed chemo)
Screening: GCCT
Annually between 13-24
Screening: Diabetes
Annual if high risk or every 3 years after age 45
A1C 6.5 or higher (5.7-6.4 pre)
Fasting 126 or higher (100-125 pre)
Random 200 w/ symptoms
2*GTT
Screening: Lipid Profile
Every 5 years starting age 21
formally at age 40 with calculate CV risk with ASCVD risk calculator
Total cholesterol < 200 mg/dL, LDL < 100 mg/dL, HDL >60 mg/dL, and Triglycerides of <150 are normal values
Screening: Hep C/HIV
Once in lifetime
Shingles Vaccine
Age 50 - 2 dose series
Pneumococcal Vaccine
Age 65 or younger if risk factors
T score
SD from mean peak bone density of normal young adult
Low bone mass between T -1.0 and -2.5
Z score
SD from reference population of same age, sex, ethnicity
(better for premenopausal women)
FRAX
women 40-65 with frax of >8.4% = bone age of 65yo
If osteopenia and FRAX >3% hip fx or >20% major bone fracture in next 10 years > treat
Calcium Daily Intake
1300 less than age 18
1000mg for 19-50
1200mg for over age 50
Vit D Daily Intake
600 IUD until age 70
800 IU after age 70
Osteoporosis Tx options
Bisphosphonates (empty stomach w/ water, sit upright 30 min , CI: GERD, esophagitis)
SERM (raloxifene)
Rank L inhibitor (prolia)
inhibit bone resorption/osteoclast activity
Tamoxifen vs Raloxifene
Tamoxifen - prevents breast cancer [ useful for bRCA 2] (but increased risk of endo cancer)
Raloxifene - osteoporosis prevention but also good for decreasing breast cancer risk (no increased risk of endo cancer)
Vitamins to Screen for in Bariatric Patients
Vit D, Ca, Folic Acid, iron, B12, CBC
Syphilis Treatment (Primary or early latent, <1 yr)
Benzathine PCN 2.4mu IM x1
(doxy 100 BID for 14 days)
Syphilis Treatment (late latent > 1 yr or unknown)
Benzathine PCN 2.4million u IM q weekly x3
(doxy 100 BID for 28 days)
Puberty
TPAM
Thelarche (breast)
Pubarche (pubic hair)
Adrenarche (axillary hair)
Growth spurt
Menarche
Expected HCG Rise
49% for less than 1500
40% for 1500 to 3000
35% for greater than 3000
Cat 1 Definition
Normal baseline with moderate variability, with or without accels, no late or variable decels
Cat 3 Definition
Any baseline with absent variability with late or variable decelerations or sinusoidal pattern
MAP Calculation
[(2* Diastolic) + Systolic] / 3
or
(Diastolic + Diastolic + Systolic)/3
Magnesium Units, therapeutic range, and Toxicity
5 to 9 mg/dL
Loss of reflexes >9
respiratory arrest >12
cardiac arrest 30
antidote calcium gluconate 1 g 10 cc over 3 min
Magnesium contraindications
Myasthenia gravis
instead use phenytoin or diazepam
Chronic hypertension causes
Essential hypertension, coarctation, Cushing’s, renal disease, renal art stenosis, OSA, drug use
Incidence of TTTS in Monochorionic
10-15%
Twin Delivery timings
Di-Di - 38-39
Mono-Di 34-38
Mono-Mono 32-34 (must be C/S)
Calculation for discordance
(Larger fetus - smaller fetus)/ larger fetus = 20% or more
Quintero staging of TTTS in twins
Stage one: Polyhydramnios oligohydramnios
Stage two: absent bladder of donor twin
stage three: abnormal Doppler’s
stage four: hydrops
stage five: death
Early term
37+0 through 38 +6w
Full term
39+0 - 40+6
Late term
41+0-41+6w
Post term
42+0w or more
Toxoplasmosis (Fetal effects)
All head issues
Intracranial calcification, hearing loss, Chorioretinitis, low IQ
CMV (fetal effects)
Chorioretinitis, hearing loss, Hepatosplenomegaly, brain, abdominal and liver calcifications, FGR, hydrops
Parvovirus ( Fetal effects)
Spontaneous abortion, Fetal anemia, heart failure, hydrops, IUFD
Varicella (fetal effects)
Spontaneous abortion, IUFD, varicella Embryopathy (between 13-20w) - limb hypoplasia/cutaneous scarring
High fetal mortality if maternal infection <5 days before delivery
Listeria treatment
IV Ampicillin (at least 6g daily) for 14 days
If allergies then Bactrim
Hep B transmission risk
If Envelope antigen positive 90%
If only surface antigen positive 20%
Baby should get vaccine at birth and HBIG within 12-24 hrs
Hep D co-infection possible
Hep C transmission risk
6% ( doubles if also HIV+)
Much lower than Hep B
No treatment available in pregnancy
HIV Transmission risk
Without zidovudine 24%
With zidovudine 8%
Viral load <1000 copies/ml = 1- 2% if on HAART
HIV in Labor
Antepartum should be on HAART (3 agents, 2 diff classes)
Intrapartum should get 3hrs ZDV prior to CD
Do not need ZDV if undetectable viral load or viral load <1000 while on HAART
HIV Delivery Route
If VL >1000 then CD prior to labor at 38w
If VL <1000 then CD not needed, can have SVD
If VL unknown then CD
HSV transmission risk in preg
Primary infection 50% risk (40-80%)
Recurrent infection 3% risk
HSV Primary Treatment
Acyclovir 400mg TID for 7-10 days
Valacyclovir 1000mg BID for 7-10 days
Recurrent HSV treatment
Acyclovir 400 TID for 5 days
Valacyclovir 500 BID for 3 days
Suppressive HSV treatment
Acyclovir 400 BID
Valacyclovir 1000mg daily or 500 daily
(Valacyclovir 500 BID if pregnant, starting at 36w)
PPROM Latency Abx
(total 7 days)
Ampicillin IV + Azithromycin IV for 48 hrs
Amoxicillin PO and Azithromycin PO for 5 days
Critical Antibody Titer
1:16 (cutoff lower for Kell, titers not helpful)
Will need MCA dopplers at this level
Antibodies HDFN risk
Kell (Kills}, Kidd, Duffy (Dies), RhD, Little c, Big E
(DEcKK)
No HDFN: Lewis Lives
Autosomal Dominant
BRCA1 and 2
Lynch Syndrome
Osteogenesis imperfecta
Achondroplasia
Marfan
VW Type 1
Autosomal Recessive
CF, SMA
Sickle Cell anemia
CAH
Thalassemias
Alpha thalassemia
1 gene absent - asymtopmatic
2 genes absent - carrier, a-thal minor
3 genes absent- Hb H disease
4 genes absent - Barts- hydrops, a-thal major
Beta thalassemia
Hgb electrophoresis A2 >2.5%
Heterozygous - minor , asymptomatic, just mild anemia
Homozygous - major,severe anemia, death
Antibody to minor antigen - Alloimmunization Management
Check indirect coombs titers and Paternal testing
- if father neg, no more testing
- if positive - find out zygosity
Homozygous - MCA dopplers
Heterozygous - fetal blood type to determine risk
*(titers not helpful for Kell)
X linked recessive
Fragile X
Red green color blindness
Hemophilias
Thrombophilias
Factor V Leiden, Prothrombin mutation, Protein C or S deficiency, antithrombin deficiency, APLs
Other causes of elevated CA 125
Pregnancy, endometriosis, non-gyn malignancy, TOA/PID, inflammatory conditions (SLE/IBD)
Benign hyperplasia Cancer Risk
1-3%
EIN cancer risk
10-25%
Call Exner Bodies
Granulosa cell tumor
Brenner tumor (also has coffee bean nuclei)
Fried egg cells
Dysgerminoma
Psammoma bodies
Papillary serous and clear cell adenocarcinoma
Signet ring cells
Krunkenberg tumor
Langhan’s giant cells
TB
Islands pale core with dark rim
Hydatidiform mole
Schiller Duval Bodies
Endodermal sinus tumor (Yolk sac)
Next step if AGC on pap
Colpo with ECC
EMB if 35 or older OR risk factors
Follow up for Atypical endometrial cells on pap
ECC and EMB
If both neg then add Colpo
When to treat Woman under 25 for abnormal colpo results
CIN 3 - treat
CIN 2 persistent for 2 Years (would have colpo with cytology every 6 months)
Screening S/P LEEP
If neg Margin- Pap/HPV in 6 month then annually x3 if neg then q3 years for 25 yrs
If pos margin- Colpo/ECC in 6 months or repeat excision ( hyst if re-excision unsafe)
Lung Cancer screening
Adults age 50 to 60 with 20 pack yr history in current smoker or quit in the last 15 years need low-dose CT chest annually
Can discontinue screening once more than 15 years since quitting
T Score vs Z score
T is SD from mean peak bone density of a normal young adult (-2.5 is osteoporosis)
Z is from population of the same age, sex, race (-2.0 is osteoporosis)
Sexual Assault PPX
500mg ceftriaxone IM
100mg doxy BID x7 days
500mg metronidazole BID x 7 days
Hep B and HPV vaccines
If HIV pos assailant or suspected - HAART within 72 hrs
PID treatment regimen
Ceftriaxone 1g IM and Doxy 100 BID PO x 14 days and Flagyl 500mg BID x 14 days
Outpatient can do PO
Inpatient do IV ceftriaxone, can do PO or IV doxy + PO or IV flagyl
Amsel’s criteria for BV
pH > 4.5
+KOH whiff test
>20% clue cells
White gray homogenous discharge
OR
NAAT test
CAH
XX with ambiguous genitalia
Usually 21 Hydroxylase deficiency (created high levels 17 OHP)
Sometimes shock from salt wasting due to lack of cortisol
No uterus
+ Breast present
RKHS - mullerian agenesis - has pubic hair
AIS XY - no hair- need to remove gonads after puberty
Uterus present
Absent breast
Turners
Hypo hypo gonadism (Kallman)
Constitutional delay
Hormone Units: Progesterones, androgens, Prolactin
Progesterone ng/ml
AMH ng/ml
Prolactin ng/ml
Testosterone ng/dL
17OHP ng/dL
DHEA mcg/dL
Hormone units: Estrogen
pg/ml
Hormone units: FSH, LH, HCG, TSH
mIU/ml
MTX MOA
Dihydrofolate reductase inhibitor
Tamoxifen MOA
SERM
Anti-estrogen at breast.
Estrogenic at bones and endometrium
Clomiphene Citrate MOA
SERM
Anti estrogenic (weakly estrogenic)
Clomiphene 50 to 150 mg (Days 5-9)
Letrozole MOA
Aromatase inhibitor
Blocks estrogen production
Letrozole 2.5-7.5mg (day 3-7)
Gonadotropin MOA
Exogenous FSH acts in FSH receptors
Leuprolide MOA
GNRH Agonist - continuous instead of pulsatile
Creates an initial symptom flare
Cabergoline MOA
Dopamine agonist promotes Prolactin inhibiting factor
Less side effects than bromocriptine (nausea, HA, hypotension)
Emergency Contraception within 72 hrs
COCP
Two doses of 100ug estrogen and 0.5mg levonorgestrel 12 hrs apart
Progestin only Plan B
One dose is 1.5mg levonorgestrel OR
Two dose is 0.75mg 12 hrs apart
Copper and 52mg Levonorgestrel IUD and Ulipristal
Emergency Contraception within 5 days
Copper IUD (99%) (FDA approved)
52 mg LNG IUD
Ulipristal 30mg single dose
HRT dosing - preferred regimen
PO progesterone or micronized progesterone 200mg qHS (can also be done cyclic 12 days a month)
Transdermal estrogen (eg 0.025mg/d patch) patched applied once or twice weekly
WHI - combination tx (E+P)
Reduction of bone FX and colon cancer
Increased heart disease, breast cancer, stroke
WHI - estrogen alone ET
Reduction in bone fx rates
Increased stroke
*Statistically insignificant decrease in heart disease and breast cancer
Genitourinary syndrome of menopause Tx options
Vaginal estrogen (cream, pills, ring)
Ospemifene (SERM)
Non hormonal vasomotor Sx Tx
SSRI, SNRI - paroxetine, fluoxetine, venlafaxine
Gabapentin
Clonidine
Von Willebrand disease
Type 1 autosomal dominant - VWF deficiency
Type 2 -defective VWF
Type 3 autosomal recessive - absent VWF
Check CBC, PTT, PT
vWD factor antigen, Ristocetin cofactor activity, Factor 8
FTS components
NT
HCG
PAPP-A
QUAD screen
AFP
Inhibin
Estriol
HCG
H and I are high for Downs. Everything else is Low
65-80% sensitive
Ashkenazi Jewish Screening
CF
Tay Sachs
Canavan
Familial Dysautonomia
Risk factors for ureteral injury
Prior surgery, malignancy, large uterus, endometriosis, prolapse, infection
Mechanisms of ureteral injury
Kinking, laceration, transection, ligation, thermal injury, devascularization, crush injury
Postop imaging evaluation for ureteral injury
CT urogram or retrograde pyelography
How to decrease tension with Ureteral repairs
Boari flap (mid or distal)
Psoas hitch (distal)
DNA Mismatch repair genes a/w Lynch Syndrome
MSH2, MSH6
MLH1
PMS2
EPCAM
Lynch Syndrome cancer risks
Endometrial 20-60%
Colon 20-60%
Ovarian 5-10%
Risk of SCC with Lichen Sclerosis
5%
How to confirm pregnancy dating
US dating <20w, +UPT >36w, +FHTs for >30w
Anti seizure medication safe in pregnancy
Lamotrigine and Levetiracetam
(Lamictal and Keppra)
Anti-seizure meds that cause NTD
Valproate and Carbemazepine
( resistant to folate supplementation)
First Trimester Screen
HCG (elevated in T21, low in T18)
PAPP A. (Low if abnormal)
NT
85% sensitive
3hr GTT normal value cutoffs
95/180/155/140
Stress dose steroids
Prednisone 20mg daily (or it’s equivalent) for 3 or more weeks in the last 6 months
Stress dosing- 100mg IV hydrocortisone pre anesthesia and then 50-100mg IV q8h for 24hrs
Magnesium Toxicity levels
Therapeutic level
5-9 mg/dL
Loss of deep tendon reflexes
9 to 10 mg/dL
Respiratory Paralysis
12 to 16 mg/dL
Cardiac arrest
>30mg/dL
Antidote: 1gram (10ml) calcium gluconate IV over 2 min
Nerve Injury from a Pfannenstiel
Iliohypogastric and ilioinguinal
Temporary triangle of numbness above incision
Femoral nerve injury - cause and effect
Deep pelvic surgery, lateral retractors, excessive abduction
Loss of sensation anteromedial thigh
Weak hip flexion and knee extension
Pudendal nerve injury- cause and effect
Entrapment during SSLF
Perineal/mons/vulvar pain
Sciatic Nerve injury- cause and effect
Candy cane stirrups/external rotation of hip
Weak knee flexion and dorsiflexion of foot
Peroneal nerve injury- cause and effect
Allen leg supports, pressure on upper lateral tibia
Foot drop
Parenthesis over dorsal foot and lateral shin
Obturator nerve injury - cause and Effect
Paravaginal repair, TOT sling, radical pelvic dissection
Inability to abduction thigh, inner thigh numbness
Lidocaine dosage
LEEP 5-10cc 1% lido with Epi (1:100,000)
CS under local
30cc 1% lido without epi
60cc 1% lido with epi. (.5%)
Lidocaine side effects
Metallic taste. Peri-oral numbness. Tinnitus
Slurred speech. Altered consciousness
Convulsions
Cardia arrhythmias or arrest
PCOS Labs
Total and free testosterone, SHBG
Rule out other causes, consider-
HCG
FSH/LH, TSH, prolactin
testosterone (r/o androgen, secreting, ovarian tumor), DHEA (r/o adrenal tumor), 17 OHP(non classical CAH, 24 hour urinary free cortisol (r/o Cushing’s),
2*GTT and lipid panel
Metabolic Syndrome Criteria
3 or more of the following:
Blood pressure 130/85
Waist circumference 35 inches
Elevated fasting glucose over 100
HDL Less than 50.
Elevated triglycerides over 150
MC cause of CAH
21 hydroxylase deficiency (90%)
Presents like PCOS
17OHP level will be >200ng/dL
Confirm with a ACTH stim test
IV estrogen dosing
IV 25mg q4 hours up to 6 doses
Hirsutism treatment
Laser, shaving, waxing, depilatory management
OCP
Spironolactone
Finasteride
Flutamide
Eflornithine cream (FDA approved)
Weight loss
Athlete Triad
Low energy availability
Menstrual dysfunction
Low bone density
Bladder volumes
First sensation of bladder filling : 100cc
First urge to void: 200cc
Full bladder, difficulty holding: 300cc
Average bladder capacity: 350cc
OAB/Urge incontinence treatment options
Anticholinergics (oxybutynin - CI closed angle glaucoma, tolterodine)
Beta 3 agonist (mirabegron - CI HTN)
Intravesicular Botox q6 months
Implantable nerve stimulators
SUI treatment options
Bladder training, weight loss, pelvic exercises, bladder diet, timed voiding, decreased fluid intake
Dish pessaries with knob
TVT, TOT slings
Urethral bulking (collagen) best for ISD
Burch procedure
BRCA Risk reduction with Mastectomy and BSO
90% decrease in breast cancer
80% decrease in ovarian cancer (not 100% because of peritoneal cancers)
Breast cancer screening for BRCA carriers
Clinical breast exam twice yearly
MRI annual from age 25
At age 30 add annual mammogram (stagger q6 months)
Contraindications to HRT
Pregnancy, breast cancer, estrogen sensitive tumor, undiagnosed vaginal bleeding, severe liver disease, history of DVT, or thrombophilia, coronary heart, disease, CVA
ASCVD risk > 10%
Delivery timing for abnormal Doppler
Elevated - 37w
Absent - 33-34w
Reversed - 30-32w
FGR delivery timings
Isolated FGR 3-10%ile - 38-39+6w
Severe FGR <3% - 37+0w
FGR with comorbidities 34-37+6w
(elevated UAD: 37, absent UAD:33-34, reversed UAD: 30-32)
Advantages of LMWH over UFH
Better bioavailability
Less frequent dosing
Lower risk HIT
Does not cross placenta
No lab testing
Genitofemoral Nerve Palsy - cause and effect
Pelvic Sidewall Dissection
Sensory loss only (no motor) of mons, vulva, ant thigh
Cephalosporin Generations
1st- cefazolin, cephalexin
2nd - cefaclor
3rd - ceftriaxone, cefixime
4th - cefepime
Major Depression: SIG E CAPS
Need 3 + anhedonia
sleep, interest, guilt
energy
concentration, appetite, psychomotor slowing, suicidal thoughts
Alcohol Screen
TACE
Tolerance - 2 or more drinks to feel it
Annoyed
Cut back
Eye opener
Smoking Assessment - 5A’s
Ask (ask smoking hx)
Advise (counsel on risks)
Assess (willingness to quit)
Assist (meds, support groups)
Arrange (follow up/quit date)
EPDS Score, PHQ9 score
EPDS: Score > 10
PHQ9 : 5 (mild), 10 (mod, fairly sensitive/specific), 15 (mod severe), 20 severe
Arousal/Interest Disorder Tx
Bupropion or SSRI
Postmenopause - testosterone
Premenopause Addyi
Genitopelvic Pain causes
Vulvodynia, Vaginismus
Endometriosis, PID/infection, interstitial cystitis, abuse Hx/psychological
Other: GI, MSK, or Urinary
Vaginismus treatment
Psychotherapy, Extensive Pelvic PT, serial vaginal dilators, genital digital assessment, relaxation techniques, biofeedback
Vulvodynia Treatment options
Dx of exclusion (r/o infection, atrophy, dermatoses)
Vulvar care measures
Topical lidocaine 5%, estrogen cream, compounded tricyclic antidepressants
Oral amitriptyline or gabapentin
Biofeedback, pelvic PT, vaginal dilation, CBT, sexual counseling
Vestibulectomy
GU Syndrome of Menopause Treatment
Vaginal Lubricants (water or silicone)
Vaginal Moisturizers (hyaluronic acid or polycarbophil)
Low dose vaginal estrogen (0.5-1g 2x weekly)
Intravaginal prasterone/DHEA (intrarosa) - daily vaginal suppository
Ospemifene - SERM 60mg daily
Empiric Treatments after Sexual Assault
Ceftriaxone 500 mg IM
Doxycycline 100mg PO BID for 7 days
Metronidazole 500mg PO BID for 7 days
Vaccine: Hepatitis B if nonimmune or Gardasil
PEP HIV prophylaxis (antiretroviral + protease inhibitors) for 28 days (must be within 72 hours of contact)
Emergency contraception
Repeat testing for HIV, RPR, Hepatitis B at 6 weeks, 3 months, 6 months
Contraception Failure Rates
Etonorgestrel implant (0.05%), Vasectomy (0.15%), LNG IUD (0.2%), Cu IUD (0.8%), Depo Provera (6%), COC (9%)
Sterilization similar to IUD’s <1%
OCP Side Effects
Progesterone - mood changes/ fatigue, decreased libido
Estrogen - HTN, headaches, nausea, breast tenderness
OCP Contraindications
Breast Cancer, MI, Migraine with Aura, VTE, Known thrombogenic mutations, HTN (≥140/90), Smoker > 35
Other: Active Gallbladder or Liver disease, SLE with APLs +, HIV (on Efavirenz)
When to start Statin
LDL > 190
Age 40+ with Diabetes
ASCVD Score > 20% + age 40-75
Known vascular disease
How is asthma categorized?
Intermittent < 2 /week, <2 nights/month
(FeV1 normal)
Mild Persistent > 2 /week , 3-4 nights/month
(FeV1 normal)
Moderate Persistent Daily, > 1 night per week
(FeV1 = 60-80 predicted FeV1 )
Severe Persistent -Throughout day and night (FeV1 < 60 predicted)
Asthma Management
Intermittent -Beta-agonist (SABA) prn
(FeV1 normal)
Mild Persistent - Low dose inhaled steroid + SABA prn
(FeV1 normal)
Moderate Persistent - Med inhaled steroid + LABA
(FeV1 = 60-80 predicted FeV1 )
Severe Persistent - High inhaled steroid + LABA, or
Oral Steroid, or Theophylline
(FeV1 < 60 predicted)
Budesonide (Pulmicort): preferred Low dose inhaled steroid
Emergent Acute Vaginal Bleeding Treatment options
Conjugate equine estrogen (CEE) 25 mg IV q4h X24 h
OCP (ethinyl estradiol 35 meg) PO tid X 7 days, then daily
Medroxyprogesterone 20mg PO tid x 7days/ then daily
Tranexamic acid 1.3 g PO tid x 5 days
Definition of Primary Amenorrhea
13 without secondary sexual characteristics
15 with or without secondary sexual characteristics
Constitutional delay, outflow tract anomalies,
Turner’s, AIS, Mullerian Agenesis, secondary amenorrhea causes, endocrinopathies (PCOS, thyroid/adrenal disease, Cushing syndrome, DM)
Swyer Syndrome
46XY Sry gene mutation
Mullerian structures + testes
Amenorrhea, no ovaries, underdeveloped testes
Secondary Amenorrhea Workup
HCG, TSH, prolactin
FSH, progestin withdrawal challenge
Grading Hirsutism
Ferriman Gailwey score
9 sites graded 0-4
Grade of 8 or more is positive findings (cut offs vary by ethnicity)
Add back therapy for Leuprolide
Start before 6 months therapy
Norethindrone acetate 5mg PO daily, 0.625mg conjugated ethinyl estradiol- bone protective and contraception
Lupron max 12 months
Borderline Tumor (Low malignant potential)
USO, Pelvic washings, biopsy of visible lesions
Risk of recurrence: 30% if cystectomy, 15% if oophorectomy
Frozen is LMP mass, Likelihood of malignancy on final path: 40- 45%
PMDD criteria
History of two consecutive menstrual cycles demonstrating luteal phase symptoms and the exclusion of other medical conditions
5 or more symptoms must have been present during the week prior to menses, resolving within a few
days after menses starts
HRT Risks
E only: increased for VTE, Hip Fractures, Lung CA
(Benefits: Decreased risk of CHD, Breast cancer, Stroke Colorectal cancer, All bone fractures, All-cause mortality, Diabetes)
E+P: increased CHD, Breast cancer, Stroke, VTE
(Benefits: Decreased risk of Colorectal and Lung cancer, All bone fractures, hip fractures, All- cause mortality, Diabetes)
Risk factors of osteoporosis
history of fragility fractures, weight < 127 pounds, medical causes of bone loss (meds or dz), parental hip fracture, current smoker, alcoholism, RA
Secondary causes of Osteoporosis
Malabsorption, gastric bypass, vitamin D deficiency, adrenal insufficiency, smoker, alcoholism, multiple myeloma, leukemia, anticonvulsants, anorexia, bulimia, sickle cell disease, hyperparathyroidism, thyrotoxicosis.
Medications: Heparin, Lithium, H+ pump blocker.
When to use Raloxifene for Osteoporosis
Younger postmenopausal women with osteoporosis who have a low risk of hip fracture and stroke but concerned about breast cancer risk.
SE: hot flashes
DEXA scan timing
If normal - > q 15 years
If (-1.5 to -1.99) -> q 5 years
If (-2 to-2.49) -> q 2-3 years
Gail Model Risk of Breast Cancer
Age, menarche, age of first birth, # of first-degree family members with breast cancer, # of biopsies, atypical hyperplasia
Chemoprevention with tamoxifen/raloxifene indicated when:
5 - year risk: 1.7% or higher
Lifetime risk: 20%
Vulvar Paget’s - Next step in management
Mammogram, Colonoscopy, Pap Smear
90% time peri-anal disease is present associated with colorectal carcinoma
25% time associated with cervical adenocarcinoma
Gyn Onc for WLE with 2cm margins
Genetics : Integrated vs Sequential vs Contingent
Integrated: results released after both 1st and 2nd tri screens complete (96% sensitive)
Sequential: 1st tri results released then final result after 2nd tri tests (95%)
Contingent: 1st tri test is low, med or high risk. If high risk then offered 2nd tri test (88-94%)
First trimester screen vs Quad screen
FTS: PAPP A, HCG, NT (81-87%)
Quad: HCG inhibin A estriol AFP (81%)
Contraindications to operative vaginal delivery
Gestation less than 34 weeks
Head not engaged
Unknown fetal position
Osteogenesis imperfecta
Fetal bleeding disorder
Risks of macrosomia
Prior macrosomic infant
GDM or preGDM
Obesity
Postdates
Recurrent BV and Yeast
BV 3x in a year, initial treatment (500mg flagyl BID 1 week) then 2x weekly metrogel for 4-6 months
Yeast 3x or more in a year, initial treatment (diflucan every other day x3) then weekly oral or intravaginal azole for 6 months
(Check A1C and HIV)
OASIS Risk Factors
Hx of OASIS
Operative delivery
Midline episiotomy
Primiparity
Asian ethnicity
Increased fetal birth weight
OP presentation
Polycystic Ovaries Definition
Volume of ovary 10cm^3 or >12 follicles measuring between 2-9mm
Risk factors for ectopic
Prior hx of ectopic
Damaged tubes
Hx of STI/PID
IVF
IUD
Smoking
Intra amniotic infection (IAI) criteria
Fever 38.0-38.9 lasting more than 30 min with 1 risk factor (fetal tachycardia, malodorous or purulent fluid, elevated WBC count)
Or
temp of 39.0 or higher
Diagnosis confirmed with amniotic fluid culture or gram stain
Carrier testing for Ashkenazi Jews
CF, Tay Sachs, Canavan, Familial dysautonomia
Carrier testing for all patients
CF, SMA, Fragile x, hemoglobinopathies
GYN MOC Articles
- updated Markov model argues for the consideration of concurrent salpingo-oophorectomy for patients who are undergoing hysterectomy at age 50 and older and suggests that initiating estrogen in those who need salpingo-oophorectomy before age 50 years mitigates increased mortality risk
-RFA procedures have comparable or favorable safety profiles, recovery timelines, and reintervention rates. Data on future fertility and pregnancy are limited, although early reports are promising - Daily fezolinetant [Veozah] (30 and 45 mg were nonhormonal, efficacious and well tolerated for treating moderate to severe VMS associated with menopause
- new, single-dose clindamycin vaginal gel was highly effective, with excellent safety, in women disproportionately affected by bacterial vaginosis, with Nugent scores of 7-10 at study entry.
- Over 24 weeks, relugolix-CT significantly reduced moderate-to-severe uterine leiomyoma-associated pain with a more pronounced effect on menstrual pain
- In participants with recurrent vulvovaginal candidiasis, oteseconazole was safe and efficacious in the treatment and prevention of recurrent acute vulvovaginal candidiasis episodes and was noninferior to vulvovaginal candidiasis standard-of-care fluconazole
- povidone-iodine is preferable to chlorhexidine for vaginal preparation before hysterectomy because of lower rates of infectious morbidity and fewer emergency department visits. However, the absolute differences in infectious morbidity rates were approximately 1%, and in the event of an iodine allergy, chlorhexidine appears to be a reasonable alternative
- In the presence of an intrauterine fluid collection, the rate of ectopic pregnancy is very low. The size of the intrauterine fluid collection in a woman with a pregnancy of unknown location cannot be used to distinguish between a gestational sac and a pseudogestational sac, In assessing pregnancies of unknown location, clinicians should incorporate the entire clinical picture, including other sonographic findings
- Patients undergoing ovarian cystectomy for endometriomas had higher rates of perioperative adverse events than patients un- dergoing ovarian cystectomy for other benign neoplasms. Laparotomies were performed more often during oophorectomies for endometriomas than for other benign indications.
OB MOC Articles
- Despite a significant increase in GDM diagnosis and treatment with one-step testing, there is no difference in rate of LGA neonates compared with two-step testing among RCTs
- No difference in maternal serum AFP values was identified between Black and non-Black pregnant individuals when adjusted by maternal weight and gestational age at blood draw. These findings suggest that routine race-based adjustment of maternal serum AFP screening should be discontinued
- Congenital syphilis rates in the United States increased 261% during 2013–2018 and continues to increase in 2021
- Among nulliparous patients in the second stage with neuraxial analgesia, immediate pushing, compared with delayed pushing, did not increase perineal lacerations, POP-Q measures, or patient-reported pelvic floor symptoms
- cohort study of patients with a current singleton pregnancy suggests that VP was not associated with a reduction in recurrent PTB
- Manual rotation increased the rate of spontaneous vaginal delivery
- Amniotomy within 1 hour of Foley catheter expulsion resulted in 2.3 times faster delivery than expectant management. Therefore, early artificial rupture of membranes should be considered in individuals undergoing mechanical cervical ripening at term.
Office MOC articles
- > 50% of women under 25 years with CIN2 will regress to CIN1 or normal within 24 months, Absence of HPV 16 is the most important predictor of regression
- Regression rate of CIN 2 is high. Patients aged 25 to 30 years WITHOUT HPV16 should generally be recommended active surveillance for 15 months, whereas immediate treatment should be considered in cases with HPV 16
- Estrogen therapy use in premenopausal women who underwent BSO for benign gynecologic diseases has declined substantially over the past decade esp with increasing age
- Compared with non-users, women on combined oral contraceptives (COCs) and oral progestogen-only products had lower or no increased risk of depression
- Studies demonstrate that self-administration of subcutaneous DMPA (DMPA-SC) outside clinical settings is safe, effective, feasible, acceptable, and can improve continuation.
-Recent use of DMPA was associated with reduced leiomyoma development and increased leiomyoma loss. Such changes in early leiomyoma development in young women could delay symptom onset and reduce the need for invasive treatment.
If immediate CIN3+ risk is > 4%
Colpo if risk 4-24%
Expedited Tx or Colpo if risk 25-59%
Expedited Tx if risk 60% or more
If immediate CIN3+ risk is <4%
Return in 5 years if risk is <0.15%
Return in 3 years if risk is 0.15-0.54%
Return in 1 year if risk is 0.55% or more
Singleton Pregnancy, No prior PTB
- how to screen cervix
Screen at time of anatomy
If less than 25mm, then offer vaginal progesterone
If less than 10, can consider cerclage
If dilated, exam indicated cerclage
Singleton Pregnancy, WITH prior PTB before 34w
- how to screen cervix
Offer serial CL q2weeks from 16-24w
If less than 25mm, then offer cerclage or vaginal progesterone
If dilated then cerclage
Hx indicated Cerclage
Prior cerclage or
Hx of 2nd trimester loss due to painless dilation
TSH Goals in Pregnancy
First trimester, 0.1–2.5 mIU/L
Second trimester, 0.2–3.0 mIU/L
Third trimester, 0.3–3.0 mIU/L
Neonatal Herpes
Disseminated disease (25%)
CNS disease (30%)
Skin, eyes, or mouth (45%)
high mortality risk
Cervical Ectopic Tx
Multidose MTX (could do intraamniotic KCL if +FHT)
D&C if unstable - high hemorrhage risk
(PreOp cervical artery ligation, cerclage, vasopressive, UAE)
( Postop balloon tamponade, implantation site sutures, UAE, Uterine artery ligation)
Interstitial/Cornual Ectopic Tx
Multidose MTX
or Cornual resection
Cesarean Scar Ectopic Tx
MTX (hcg <5000mUI/mL and myometrium thickness <2mm)
KCl
or
Laparoscopy/laparotomy/hysteroscopy/D&C/ Combined
Pemphigoid Gestationis
Autoimmune blistering, large tense bullae, periumbilical
Tx w/ oral steroids
Polymorphic Eruption of Pregnancy (PEP)
AKA PUPPS
spares umbilicus, pruritic urticarial rash, erythematous papules and plaques
Tx antihistamines, topical steroids
Atopic Eruption of Pregnancy (AEP)
Eczematous changes on trunk and limbs
Tx Topical steroids
Congenital Rubella
Hearing loss, cataracts, rash, heart defects
