O&G incorrects Flashcards
First step in management of woman of reproductive age with abdominal pain? BP = 110/80
Hemodynamically stable thus = BHCG !!
If deemed pregnant then TVUSS
If not then other imaging to rule out other causes. Also need to know if pregnant to use other imaging modalities
Unstable = straight to resus, laparoscopy if ectopic suspected f
Why is decreased uterine mobility and uterosacral ligament thickening seen in endometriosis?
Inflammation of excess tissue and fibrosis and adhesions
Adhesions are extrauterine!
Intrauterine = pelvic inflammatory disease
Raloxifene is used in post menopausal osteoporosis especially in patients at risk of? However this drug increase the risk of?
Breast cancer
VTE risk due to estrogen agonist activity. Avoid in history of
38 year old. Amenorrhea 3 months. Bitemporal hair thickening, coarse hair on upper lip. Abdominal bloating and cramping. Large pelvic mass extending through left lower quadrant. No tenderness or ascites. Urine pregnancy test negative. Diagnosis?
Serotoli leydig cell tumour (deepening of voice, male pattern baldness, increased muscle bulk and clitoromegaly may be present and help distinguish from PCOS)
Not PCOS as you would have bilateral ovarian symptoms and symptoms happen over a longer period
Not struma ovarii as you have hyperthyroidism not virilisation
Choriocarcinoma = positive pregnancy test
Pregnant woman, shortness of breath doing household chores or walking 2/6 systolic murmur. 2+ pitting Edema. Bloods show respiratory alkalosis? Next step in management?
Provide reassurance only
Chronic hyperventilation occurs in pregnancy due to elevated progesterone and gives the sensation of dyspnea
Murmur = physiological, edema is normal due to urterine compression of vena cava
Patient did not have pulmonary embolism as PaO2 was high !! And you would expect a low one/hypoxia Pe
Patient did not have heart failure as auscultation of the lungs was clear with no crackles
Urethral diverticulum symptoms?
Dysuria
Post voidal dribbling
Dyspareunia
Anterior vaginal wall mass
Purulent/bloody urethral discharge
Stress inncontinence in contrast = +ve valsalva
Vesicovaginal fistula = continuous urine flow, no vaginal mass
managment of pregnant patient with no increase in dilation from 8cm in 4 hours?
- Proceed to ceasarean delivery!! -> patient is in active phase arrest (active phase is 6cm - 10cm)
- oxytocin is used to enhance contractions if less than 200 montevideo units, it is used in protracted labour eg rate of <1cm every 2 hours, but NOT arrested
prostaglandin is just used for cervical ripening in early labour induction
- operative vaginal delivery only an option at 10cm dilation eg expedite delivery in cat 3 tracings, maternal exhaustion etc
insert notes on google drive for incorrects
patients are at risk of lead exposure need lead levels monitored if they live in house built before?
1978!!
past question put date 1983 of a house as trick option
at first prenatal visit, how is syphilis screened for?
rapid plasma reagin test
30 weeks pregnant, twin pregnancy
RUQ pain, severe nausea and vomiting
- elevated liver enzymes - scleral icterus
- Thrombocytopenia!!! (due to dic)
- profound hypoglycemia!!! - helps distinguish
- leukocytosis!!! - helps distinguish
- anemia (hemolytic anemia due to dic)
- raised creatinine (AKI)
next step in management?
immediate delivery!!
patient has acute fatty liver of pregnancy
pregnant patient with new onset htn >20 weeks with no signs of end organ damage, minimal proteinuria +1
next step in management?
24 hour urine protein collection!!!
clinical signs of end organ damage = headache, visual changes, RUQ
lab signs of end organ damage = raised creatinine or transaminases, elevated platelet count
protein of at least +2 is diagnostic!!
10 weeks pregnant, thrombocytopenia, no other symptoms. blood smear shows clumping of platelets
most likely diagnosis?
pseudothrombocytopenia
intrauterine demise management?
IOL for vaginal delivery, ideally within a week
when a pregnant mother tests positive for carrying an autosomal recessive gene for a condition eg tay sachs, next step in management?
test father
if positive, then CVS or amnio
tuboovarian abscess symptoms
cystic masses with distortion of adnexal structures , fever, abnormal discharge, cervical motion tenderness
management of adnexal mass on ultrasound for mass with benign features vs malignant features
malignant -> (solid components, thick septations, increased vascularity) = immediate laparoscopy
benign = reassurance and observation if premenopausal, ca-125 if post menopausal
irregular menses with spotting
sexually active with a partner
lower abdominal pain 5 days ago -> now RUQ pain
fevers, chills, vomiting
diagnosis?
Pelvic inflammatory disease!
sti can present with irregular menstrual bleeding -> subtle sign
ascending infection to uterus -> fever and lower abdominal pain
further ascension -> perihepatitis/fitz hugh curtis syndrome = nausea, vomiting RUQ
other than pregnancy, what other obstetric condition may present with preeclampsia with severe features?
management?
hydatidiform mole
suction currettage
name some beniign physiological conditions that develop in pregnancy
increased upper lip hair, PUPP (itchy abdomen in straie), spider angioma, melasma
what is pathological nipple discharge?
how is it investigated?
how is physiological nipple discharge investigated?
unilateral, bloody discharge, spontaneous OR associated with breast abnormalities (palpable mass, skin changes)
<30 = ultrasound
>30 = mammogram
>/= 40 =. ultrasound and mammogram
if normal ultrasound/mammogram -> MRI of breast!!!
physiological = measure serum prolactin and TSH!, do a pregnancy test
describe breast cyst management pathway
breast ultrasound is 1st line imaging if <30 years
helps determine if complex cyst (thick walled, septated, solid and cystic components) or simple cyst (thin walled, anechoic/fluid filled, no echogenic debris or solid components)
- complex = biopsy
- simple:
- asymptomatic simple cyst = observe
- Tender simple cyst = FNA for pain relief. if non bloody aspirate and the cyst resolves no additional management. if it doesnt resolve = biopsy and additional imaging!!!. If Bloody aspirate = biopsy and additional imaging.
management of non cyclic unilateral focal breast bain?
mass -> biopsy
no mass -> imaging
cyclical lower abdominal pain and pain with defecation 13 year old, no menarche yet, firm mass protruding between labia majora which swells with valsalva maneuevre
most likely diagnosis/
imperforate hymen
- collecting blood -> pain on defecation, back pain, pelvic pressure due to pressure on surrounding organs
forceps delivery with 3rd degree laceration which was sutured
presents 4 weeks later with malodorous vaginal discharge
dark red area on pasterior vaginal wall associated with malodorous tan brown discharge
most likely diagnosis?
rectovaginal fistula
discharge = feces passing through vagina
dark red velvety lesion = rectal mucosa that is visible
vesicovaginal fistulas in contrast = clear watery liquid (urine) and located on anterior vaginal wall
what are the indications for GBS prophylaxis in pregnancy?
name all 5
1.GBS bacteriuria or GBS urinary tract infection in current pregnancy regardless of treatment
+ve GBS rectovaginal culture in current pregnancy
2.prior infant that had GBS-infection eg neonatal sepsis
unknown GBS Status plus any of:
3.- <37 weeks gestation
4.- intrapartum fever
5. - rupture of membranes for 18 hours or more
60 year old woman, large ovarian mass and post menopausal bleeding. endometrial hyperplasia with no atypia on biopsy. most likely diagnosis?
granulosa cell tumour (seen in a granny!) -> endometrial hyperplasia and cancer risk due to unopposed estrogen secretion by tumour!! histology = call exner bodies/cells in rosette pattern
emryonal carcinoma and yolk sac tumour = young people!! different symptoms
note!! when granulosa cell tumour occurs in young child = precocious puberty = make them a granny/adult
management of pregnant patient, history of hypertriglyceridemia. now presenting with pancreatitis like symptoms. RUQ ultrasound normal. next step in management?
Lipid panel!!
pregnant women, particularly those with history of high triglycerides are at increased risk of triglyceride induced pancreatitis
not ERCP as this is used to for gallstones and in case of gallstones, ultrasound will likely not be normal -> it may show biliary tree dilatation, biliary sludge, some gallstones etc
management of patient with hypothyroidism wishing to become pregnant?
increase levothyroxine dose when patient becomes pregnant
treatment for gonorrhea and chlamydia?
ceftriaxone and doxycycline which covers both pathogens
pregnant woman, asymptomatic. booking bloods were normal. now has AST of 300, ALT OF 254. Alk phos is normal.
next step in management of patient?
viral hepatitis serology!!
due to hepatocellular pattern of injury!! (normal alk phos)
infection could have been contracted after initial tests
LFTs are not severely raised suggesting move from active to chronic phase of the disease
woman pregnant
in first pregnancy had placental abruption and was given anti d immunoglobulin
now she has anti D antibodies. what does this mean?
inadequate dose of anti d immunoglobulin given after first pregnancy
woman that has been trying to concive for years
reports morning sickness, abdominal distension and positive pregnancy test
however hosptial pregnancy tests are negative and ultrasound shows thin endometrial stripe
most likely diagnosis?
pseudocyesis
NOT a missed abortion as ultrasound will show an unviable fetus. morning sickness would have resolved and pregnancy test will be positive
treatment for asymptomatic bacteuria in pregnancy?
nitrofurantoin, fosfomycin!! or trimethroprim sulfomexazole - drug depends on gestation!!!. eg at 10 weeks can use fosfomycin
trimethorprim sulfomexaxzole avoided in first semester as it interferes with folic acid metabolism
ABO hemolytc disease occurs in a woman with blood group X and a fetus with blood group __ ?
describe symptoms
O -> wOman
A or B -> fetus
asymptomatic, mild anemia, jaundice = mild disease typically
neonatal graves disease symptoms?
risk factors?
course of disease
low birth weight
tachycardia
high bp or goitre may be seen
mother who has or had graves disease
self resolves within months!!. treat in intermim with methimazole, beta blockers etc
1st line preventative therapy for migraines in pregnancy?
beta blockers -> propranolol, metoprolol
Pyelonephritis management during pregnancy?
if clinical improvement shown (no fever for 48 hours), what is further management?
broad spectrum IV antibiotics -> Ceftriaxone!!!
further management = oral beta lactam!! eg cephalosporins eg cephalexin!! or penicillins!! (as they are safe during all trimesters)
then cephalexin prophylaxis for rest of pregnancy
a pregnant patient with fever, nausea, vomiting and RUQ pain most likely has?
management?
acute appendicitis!!
urgent surgery!! -> risk of fetal demise
differentiate from Preeclampsia as in appendicitiis peritoneal signs (rebound, guarding) may be present and fever is present
if it was placental abruption -> uterine tenderness and uterine tachysystole (decelerations with uterine contractions) would occur
ureteral obstruction -> colicky symptoms, abnormal urinalysis
trichomonas treatment?
meTRonidazole!! - also for BV
not doxycycline!!!
a post partum patient with fever, leukocytosis and right sided pain most likely has?
acute appendicitis!!
amennorrhea of at least 3 months (secondary amenorrhea), after a negative pregnancy test, what is the next step in management?
FSH, TSH, and PROLACTIN!
to rule out HPO disfunction
if patient described has a bit of acne that could be normal AND acne worsens after stopping OCP
irregular menses, hirsutism, acne AND elevated 17-hydroxyprogesterone is seen in?
non classic congenital adrenal hyperplasia!!! (partial deficiency of 21 hydroxylase activity)
mild so electrolytes and bp normal
post hysterectomy
right sided back pain
costovertebral angle tenderness
urinalysis is normal
most likely diagnosis?
other way it may present?
hydronephrosis -> due to ureteral injury during surgery!!!! and resulting outflow obstruction
also seen post c section
can have abdominal distension(pain and bloating), large volume of intraabdominal fluid on ultrasound, eatery vaginal discharge due to overflow, and fever and nausea due to peritoneal irritation
normal urinalysis as only one ureter affected
conduct renal ultrasound
management for a woman in labour with an active genital herpes lesion?
c section!!
post partum 10 days, severe headache + seizure + papilledema + history of DVT in mother. normal BP
normal CT scan
next step in management?
do MRI of brain with MR VENOGRAPHY (concerned for Cerebral venous thrombosis!)
CT normal in 30% of cases
may also present with stroke
AVOID thrombolytics! Risk of intracerbral hemorrhage due to thin walled venous structures
treatment = heparin
Vaginal spotting and mild cramping common in first trimester. benign in patient with closes cervix and intrauterine normal gestation
post partum woman with irregular vaginal bleeding, enlarged uterus, pulmonary symptoms and multiple infliltrates on CXR. next step in diagnosis?
BHCG -> most likely choriocarcinoma
can occur after normal pregnancy and spontaneous abortion!! as well as molar pregnancy
pulmonary symptoms = metastasis!! -> lungs is most common site
p.e would not explain bleeding or pulmonary symptoms
in choriamonionaitis after broad spectrum antibiotics, what is the next step in management?
labour augumentation
NOT c section -> this is reserved for obstetric indications eg non reassuring fetal ctg, breech presentation, prior uterine surgeries etc. fetal tachycardia alone is not sufficient to warrant this
pre eclampsia can present with severe features (low plateletets, low hemoglobin or elevated wbcc due to inflammation)
when eclampsia occurs with this (new onset siezures)
how do you manage?
magnesium sulfate AND prompt delivery
what is the criteria for second stage arrest of labour?
causes?
3 or more hours of pushing in primagravida
2 or more hours of pushing in multip
- cephalopelvic disproportion -> suggested by moulding and caput
- fetal malposition
- inadequate contractions = <200 montevideo units over 10 minutes
- maternal exhaustion
amniotic fluid embolism presents with resp failure (profound hypoxia may cause siezure), shock/hypotension and dic in labour or postpartum period
1st step in management?
intubation! with mechanical ventilation!! -> correct hypoxemia
after that: vasopressors for BP, transfusion to correct DIC
effect of pregnancy on blood pressure?
diagnosis of pregnant woman at 14 weeks with BP reading of 138/92?
decreases!
Chronic hypertension as diastolic blood pressure is >/= 90!
most common risk factors for pprom?
genital tract infection - asymptomatic bacturia, BV
history of pprom
(also antepartum bleeding)
next step in a patient with history of lichen sclerosis and a new vulval lesion (white firm plaque) - > next step in management?
vulval biopsy!!! to evaluate for vulval cancer. as lichen sclerosis is a risk factor
if benign lichen sclerosis found -> continue high dose corticosteroids!
malignant but non invasive -> imiquimod or laser ablative therapy
malignant and invasive -> excision
vulval cancer symptoms -> pruritus, plaque/ulcer, bleeding
repeat screening for stis in 3rd trimeter eg 28 weeks is done for which pregnant woman?
age <25
prior sti
high risk sexual activity
distinguish between mullerian agenesis
5 alpha reductase deficiency
mullerian agenesis -> female ranging testosterone levels!! normal pubic hair!!. 46 XX. breasts present. absent uterus cervix and upper vagina BUT ovaries present!!
5 alpha reductase -> virilazation at puberty (clitoremegaly, acne, male pattern hair development) will be present!! absent development of breasts!! due to testosterone receptors. 46 XY. normal pubic hair!!. male ranging testosterone levels
(5 alpha reductase cant convert testosterone to DHT so undescended testes and phenotypically female but male internal genitalia)
Androgen insensitivtiy syndrome -> breast development due to aromoatization of testosterone to estrogen!!.(think of this one as insensitive so you do the things you wouldnt normally do like grow breasts - the androgen receptor in the breast is not working so it doesnt inhbit breast growth) minimal pubic hair!! due to insensitivity to androgen. 46 XY. male ranging testosterone levels.
No clitoromegaly here/virilization as the testosterone receptor is non functional!! No female internal organs so no uterus or ovaries
intrauterine fetal demise with fetus showing multiple limb fractures and a hypoplastic thoracic cavity is most likely?
type 2 osteogenesis imperfecta
contraindications to COCP?
increased VTE risk including smoking
increased cardiovascular risk including uncontrolled hypertension, stroke, ischemic heart disease, migraine with aura. (cocp can worsen htn and thus increase risk of MI and stroke).
medical conditions negatively affected by increased estrogen - active breast cancer, active liver disease (acute hepatitis, liver cancer)
post partum
initial couple of months anxiety and excessive worry about child
followed by fatigue, weight gain despite normal exercise, constipation
exam -> bradycardia, lower extremetiy edema
most liklely diagnosis?
next step in management?
postpartum thyroiditis -> brief hyperthyroid then hypo then euthyroid. condition associated with anti-tpo antibodies. goitre may be present
thyroid function studies!
postpartum thyroiditis and postpartum depression may have overlapping symptoms. PT should be excluded first
also note: painless/ silent thyroiditis is similar to postpartum thyroiditis however no association to pregnancy so is not diagnosed within 1 year of pregnancy
7 year old precocious puberty and ovarian mass. diagnosis?
granulosa cell tumour
a dysgerminoma doesnt cause this and they differentiate into scincitiotrophoblasts so secrete lactate dehydrogenase and b-hcg
emergency c section, 2 days later fever of 38.3
uterine is soft and fundus is tender. headeache and fatigue
what intervention would have been most effective at preventing this presentation?
preoperative antibiotics
patient has postpartum endometritis = fever >24 hours postpartum + uterine tenderness
offensive lochia may also occur and headahce/malaise
pregnant woman with 24 hour urinary output of 5.5 after an intake of 3. specific gravity 1.001
all other labs normal
what is the diagnosis?
Diabetes insipidus
polyuria/urinary output> 3. AND specific gravity aka urine density <1.006 indicating dilute urine
37 weeks pregnant
no prenatal care
rupture of membranes 2 days ago which is now meconium stained
in active labour 6 cm
next step in management?
administer penicillin!!!
prophylaxis as GBS status uknown and she has rupture of membreanes for >18 hours
How to interpret the quadruple screen test for
- downs syndrome
- Trisomy 18/Edwards
- neural tube/abdominal wall defect
- the child with down syndrome says HI! = ELEVATED HCG and inhibin A . (others low). thick of it as excited to say hi
- Edward is a low HEAp = low hcg, low estradiol, low afp
- neural tube defect = elevated AFP only
multiple pregnancy increases afp due to more fetal tissue present.
why does providing obstetricians with clinical performance data compared to national benchmarks help improve quallity of care?
data driven feedback is very effective!!
describe treatment of moderate or severe menopause
contraindications to estrogen eg breast cancer, VTE = Paroxetine (an ssri)
no contraindications = estrogen only HRT if no uterus, estrogen + progesterone if uterus
mangnesium sulfate may cause hypermagnesmia due to?
renal insuffficiency
oxytocin toxicity causes?
SIADH
a low lying placenta with myometrial thinning and numerous lacunae indictes what condition?
name a serious potential complication
placenta accreta
postpartum hemorrhage
ace/arb use in pregnancy fetal complication vs presentation of ARPKD
ACE/or ARB -> bilateral UNDERDEVELOPED kidneys and oligohydramnios
ARPKD -> bilaterally ENLARGED polycystic kidneys and oligohydramnios
describe options for contraception after a baby and the side effects/ positive effects
medroxyprogesterone injection - induces anovulation (decreased menstural bleeding) by high levels of progesterone which is appetite stimulant -> weight gain, mood changes!!
copper IUD -> increased menstrual bleeding and dysmennorrhea
progestin-releasing IUD -> locally acting not systemic so decreased risk of weight gain, mood changes. decreases heavy menstrual bleeding! by inducing ammenorrhea. but the bleeding may be irregular
COCP - 1st line for premenstrual syndrome
progestin only methods can be initiated at any time after delivery whilst COCP only after 6 weeks due to VTE risk
when would you screen a pregnant patient for diabetes at 1st prenatal visit (eg at 10 weeks)?
What test is used to screen?
obesity (BMI>/=30)!!!!! + at least one of:
- prior macrosomic infant = birth weight >/= 4kg!!
- PCOS -> suggested by irregular menstrual cycles
- age >/= 40
- prior GDM
- family history of type 2 diabetes
1-hr 50g GCT NOT fasting blood glucose level
gct >/= 200 is diagnostic
what is the amniotic fluid index for oligo and polyhdramnios?
oligo = </= 5 cm
poly = >/= 24 cm
what is the pathology behind PCOS?
failure of follicle maturation and oocyte release
Tamoxifen is used as an adjuvant treatment for breast cancer and prevention of breast cancer in high risks patients. what are the side effects?
(T amoxifen T reats breast cancer)
Hot flashes! = most common!! “Hot tamale”
VTE! - “hot tamale -> think red hot sauce”
Endometrial cancer NOT ovarian. (a serm)
uterine sarcoma
Raloxifene is used for postmenopausal osteoporosis. and prevention of breast cancer in what are the side effects?
hot flushes
and VTE
postpartum endometritis antibiotic regimen?
Ceftriaxone + clindamycin
hypothalamic dysfunction eg due to intense exercise is unlikely to be the cause of infertility in a woman with regular menses.
POI = amennorrhea
hyopthyroidism also = irregular menses
what is uterine synechia?
causes?
presentation
aka ashermans syndrome -> endometrial scarring and intrauterine adhesions -> light menses/ammenorrhea
d&c risk factor
what are the contraindications to these drugs used for PPH
- methylergonovine
- Carboprost
- tranexamic acid
- hypertensive patients
- asthma
- caution in hypercoagulable conditions
(note oxytocin first line and misoprostol second line. both have note contraindications)
an older woman with vulvar pain and pruritus
erythematus vulvar lesions with white border
erythematus vagina that is stenotic
oral ulcers
what is the diagnosis?
lichen planus!
a different variant presents as just small puritic papules with purple hue
patient with rupture of membranes resulting in bright red amniotic fluid. sinusoidal pattern on ctg? what is the most likely cause of this pattern?
management?
fetal blood loss. sinusoidal pattern = fetal anemia
blood loss in this case = ruptured vasa praevia
urgent c section -> risk of fetal hypoxemia
it is a cat 3 tracing!!!
36 year old, worsening pelvic pressure and dyspareunia
pelvic mass that extends to umbilicus, it is mobile with several palpable protuberances
what is the diagnosis?
why is it not ovarian cancer?
palpable protuberances = irregular uterine contour
extending to umbilicus = severe uterine enlargement
mass effect may cause pelvic pressure, pain with intercourse, urinary frequency, constipation
ovarian cancer = FIXED mass due to invasive spread into nearby structures. AND fluid wave on examination! (ascites)
sudden severe unilateral lower abdominal pain. ultasound shows thin walled ovarian cyst. free fluid in the pelvis
what is the most likely diagnosis?
management?
ruptured ovarian cyst! -> due to free fluid
hemodynamically stable with no signs of infection -> observation and reassurance!!
hemodynamically unstable eg continued bleeding from ruptured cyst -> cystectomy
post partum endometritis symptoms?
fever
uterine tenderness
offensive lochia
name the causes of secondary post partum hemorrhage
(PPH >24 hours!!! after delivery)
- RPC - heavy bleeding +/- uterine atony. intraamniotic infection is a risk factor!!! as causes adherence of placental membrane. differentiate from retained placenta with causes primary PPH
- placental site subinvolution -heavy bleeding, uterine atony
- postpartum endometritis - intramniotic infection is risk factor!!. but expect fever, uterine tenderness etc
fetal ultrasound shows?
edematous scalp
single deepest pocket of amniotic fluid is 12 cm
echolucent abdominal fluid (ascites)
no other dismorphic features
most likely diagnosis?
hydrops fetalis due to alpha thalessemia major!!!
achondroplasia would present with hydrops fetalis + macrocephaly + shortened long bones
turners syndrome could present with hydrops fetalis but also cystic hygroma + nuchal thickening
effect of pregnancy on serum blood urea, creatinine and nitrogen?
explain it
decreases these.
in pregnancy you increase cardiac output to prepare for blood loss in delivery. so increased blood flow to kidneys and increased GFR and urine protein excretion
note! pregnancy is associated with leukocytosis possibly due to inflammation
risk factors for cervical stenosis?
symptoms?
LEEP/conization
dsymennorrhea/amennorrhea -> impedement of menstruation blood flow
infertility -> sperm cant travel up
dyspareunia
painful periods
cervical motion tenderness
laterally displaced cervix
what is the most likely diagnosis?
endometriosis!! -> fibrosis and adhesions causes pelvic anatomy distortion -> lateral displacement of cervix
PID -> can cause dyspareunia and cervical motion tenderness BUT cervix will appear inflamed (cervicitis) and fever would likely be present!!
periventricular intracranial calcifications
intrahepatic calcifications
fetal growth restriction
maternal flu like symptoms from first son who got it in nursery
most likely diagnosis?
CMV
what is the criteria fro choriamnionitis!!!
note the presence of this criteria would indicate urgent c section delivery!!
maternal fever + at least one of:
- fetal tachycardia!! >160 per min - may just be this present!!
- maternal leukocytosis!!
- purulent amniotic fluid
management of asymptomatic patient with placenta preavia at early gestation?
routine obstetric care! -> 90% cases resolve spontaneously
repeat ultrasound done in 3rd trimester ie >28 weeks gestation to check for resolution
when is a doppler ultrasound used in pregnancy screening?
for surveillance of fetal growth restriction = estimated fetal weight <10th percentile
it is an ultrasound of the umbilical artery
prolapsed fibroid symptoms?
labor like pain due to cervical dilatation
menopausal woman with dysuria, urgency incontinence, nocturia and recurrent utis
reduced vulvar elasticity, labia retraction
patchy erythema of vagina
not sexually active
most likely diagnosis?
pathology?
genitourinary syndrome of menopause!!! OR atrophic vaginitis
other possible symptoms: vaginal dryness, dyspareunia, vaginal bleeding, pelvic pressure
pathology = estrogen deficiency!!
management of patients with asymptomatic endometriosis?
reassurance and observation
placental abruption in previous pregnancy. had a c section
now presents at 38 weeks gestation with severe abdominal pain, vaginal bleeding and abdomen has an irregular mass
history of smoking and cocaine use
what risk factor likely contributed to presentation?
PRIOR UTERINE SURGERY!!!
IRREGULAR MASS -> UTERINE RUPTURE = protruding fetal mass
not seen in placental abruption
complications of hyperemesis gravidarum and inappropriate weight gain or underweight
fetal growth restriction
preterm delivery
8 months pregnant painless vaginal bleeding
normal ctg
smokes
irregular contractions
most likely diagnosis?
placenta praevia
placental abruption = painful AND ctg will show decelerations
decelerations also seen in uterine rupture
management of patient requesting a c section in absence of maternal or fetal indications?
refer patient to another O&G specialist
irregular menstrual bleeding every 60 days
heavy
weight = 120kg -> pay attention to kg weight!
everything else normal
most likely cause?
anovulation due to obesity
and abnormal uterine bleeding due to obesity
42 year old
fatigue and hot flushes!
cranky and intermittent bloating
menses regular every 30 days
LMP 3 weeks ago
smoker
most likely condition?
next best step in management?
premenstrual syndrome!
A symptom diary = 1st step!!!
then = SSRI
COCP can be used but avoid with contraindications!! -> >/= 35 years, smoking
define preeclampsia
what is the criteria for preeclampsia with severe features?
new HTN >/= 20 weeks + proteinuria OR signs of renal dysfunction. you don’t need symptoms eg headache to have preeclampsia!
severe = creatinine >1.1 OR Transaminases >2x normal !
patient with preeclampsia
pulse is 53/min
an episode of emesis
what is best next step in management?
IV Hydralazine!!! -> avoid labetalol due to presence of bradycardia (HR<60)
Avoid nifedipine (oral drug) due to emesis
not patient also requires MGS
41 year old
heavy vaginal bleeding
LMP 4 months ago
hot flushes, night sweats, smooth warm skin, palpitations
TSH is 0.1
blood in vaginal vault with closed cervix
positive hcg
no fetal heartbeat
uterus enlarged at the level of the umbilicus
roux en y gastric bypass 7 years ago
most likely diagnosis?
symptoms point to Hyperthyroidism. HM can present with hyperthyroidism + vaginal bleeding. (can also present with theca lutein cysts, preeclampsia with severe features)
roux en y surgery -> vitamin A deficiency = risk factor
NOT an inevitable abortion as cervix will be dilated and these typically occur in the first trimester
In addition to colposcopy and endocervical curretage,
when would you perform an endometrial biopsy
if ATYPICAL GLANDULAR CELLS (AGCS) are seen on a pap test?
> /= 35!!!!
OR
<35 AND risk factors for endometrial cancer
- obesity
- anovulation
the AGCs could be caused by cervical or endometrial cancer
but if you see ENDOMETRIAL CELLS and the patient is post menopausal -> you MUST do an endometrial biopsy
uncomplicated delivery 2 months ago
hyperthyroid symptoms
enlarged and non tender thyroid
URTI 2 weeks ago
low uptake on radioactive iodine scan
most likely diagnosis
postpartum thyroiditis!! - can present as hypertyroid, hyper then hypo, or just hypo!! thyroid peroxidase antibody test = diagnostic
note: de quervains presents after URTI but thyroid will be tender!!
pregnancy causes an increase in T3 and T4 and decreased TSH (hyperthyroid like state) but you are asymptomatic!! also free T4 is unchanged
describe features suggesting a secondary cause of dysmennorrhea eg endometriosis, rather than primary
how does primary dysmennorhea present?
age >25 at onset
unilateral pelvic pain
abnormal uterine bleeding -> intermenstrual, post coital
no systemic symptoms -> eg nausea fatigue
primary:
- after menstrual cycles have established
- pain radiating to bilateral legs
- fatigue, nausea, vomiting, diarrhea
what are the contraindications to breastfeeding?
Active substance abuse
active untreated TB
HIV infection
active varicella infection
herpetic breast lesion
chemo or radiotherapy
28
bilalteral yellow nipple discharge
no axillary or clavicular lymphadenopathy
pregnancy test is negative
galactorea evaluation (TSH and prolactin are normal)
on sertraline for anxiety and depression
next step in management?
no further management required -> transient idiopathic galactorrhea
note antispychotics are associated with nipple discharge not SSRIs
infertility, irregular menses
low FSH, LH and estradiol
no other symptoms, normal physical exam
what is the most likely diagnosis?
hypogonadotrophic hypogonadism!!
NOT POI as FSH levels will be raised and menopausal symptoms present!
what is the pathophysiology behind hypotension (an adverse reaction) after epidural administration?
vasodilation and venous pooling in lower extremeties!!!
due to sympathetic blockade
pregnant women with history of herpes but no active infection. management?
Aciclovir suppressive therapy from 36 weeks until delivery
dyspareunia and dryness during sex after delivering a baby is due to?
hypoestrogenism!! (secondary to lactation)
in breastfeeding patients, elevated prolactin levels suppress GnRH causing low FSH, LH and estrogen
low gnrh = lactational amenorrhea
hypoestrogenism = menopausal like symptoms + vulvovaginal atrophy
preeclampsia can present up to 6 weeks postpartum as htn and a headache. patients at increased risk of stroke
in what scenario would screening be carried out for ovarian cancer?
family history suggestive of a hereditary cancer syndrome, so at least 1 of:
- male breast cancer
- bilateral breast cancer
- breast cancer diagnosed aged <50
- multiple members on 1 side of family with breast or ovarian cancer
- azkenazi jewish ancestry
- at least 3 relatives with a lynch syndrome associated cancer
first step in management of uterine inversion?
manual reduction!!!
if fails -> laparotomy
fever
abdominal pain
high wcc
tender uterus
tender right adnexal mass
ultrasound = large, thick walled multiloculated mass filled with debris obliterating the right adnexa
sexually active
most likely diagnosis?
tuboovarian abscess! -> ultrasound findings key
a complication of PID
PID symptoms:
- fever
- cervical, uterine or adnexal tenderness
- purulent dischage
no vomiting and nausea = rules out appendiceal abscess
proper response to mother asking for reason for childs sti clinic visit
i need permission from daughter to discuss this with you - confidentiality is key
DONT say i recommend you discuss this with daughter as you are avoiding a proper response to mother
when fetal hydrops is present,
what test can be done to rule out Rh maternal antibodies as the cause?
indirect coombs test !
what are the 2 causes of symmetric growth restriction?
how do you differentiate the 2 in a question?
chromosomal abnormalities - more common
congenital infection - less common due to spontaneous abortion, ultrasound will have findings eg ventriculomegaly, intracranial calcifications
too much or prolonged oxytocin exposure can cause cerebral edema, tonic clonic siezures and severe hyponatremia!
sudden onset unilateral pelvic pain + vomiting + adnexal tenderness. most likely diagnosis?
ovarian torsion!
- you dont need a palpable mass!
what contraception is contraindicated in women with active breast cancer?
avoid hormonal contraceptives -> estrogen or progesterone or cocp
copper iud recommended
if a uterine massage and high dose oxytocin fail to resolve uterine atony, what is the next best step in management?
tranexamic acid!! -> antifibrinolytic
if this fails then give a second line uterotonic like carboprost but remember to avoid this in asthma
BPP is preformed in patients at risk of uteroplacental insufficiency eg >/= 41 weeks pregnant.
abnormal BPP scores, particularly </=4 suggest severe hypoxemia with imminent risk of stillbirth. in these cases delivery is indicated.
also note in uteroplacental insufficienty -> blood flow in fetus is diverted away from kidneys and to brain, thus oligohydramnios is common
BPP has 5 criteria each scored 0 for abnormal or 2 for normal. max score is 10.
describe some absolute contraindications to pregnancy
pulmonary arterial hypertension
peripartum cardiomyopathy
HF with LVEF <30%
severe coarctation
severe mitral stenosis
severe symptomatic aortic stenosis
severe aortic dilation (Marfans syndrome)
if pregnant already, discuss abortion
how do you determine menopause in a woman without previous menses eg due to hysterectomy?
measure serum FSH - elevated
sheehans syndrome typicall presentation?
lactation failure
hypotension and anorexia -> secondary adrenal insufficiency
state fetal and maternal complications of placental abruption
fetal -> hypoxia, preterm birth, fetal demise
maternal -> DIC!! maternal hemorrhage,
Pregnant
right sided abdominal pain
fever
nausea
tenderness over right flank
but no abdominal pain or guarding
most likely diagnosis?
acute pyelonephritis!!
not appendicitis as NO rebound or guarding (peritoneal signs)
management of recurrent urinary tract infection in a post menopausal woman?
vaginal estrogen -> improves genitourinary atrophy
when patients request a nonindicated test or imaging, you should ask them if theyve had any concerns about their health!! -> dont respond saying sometimes patients are anxious because that is presumptious
a failed 10 day medroxyprogesterone challenge indicates a deficiency of what?
estrogen deficiency put the patient at risk of what?
deficiency of estrogen!!
(in an athlete with secondary amennorrhea, this points to FHA as the cause).
estrogen deficieny -> decreased bone mineral density
thin fused labia minora in a 2 year old is what conditions?
what causes it?
risk factors?
labial adhesions
low estrogen production
poor hygeine, diaper rasher, infection/vaginitis, stradle injury
risk of utis
symptomatic -> topical estrogen
how does the complication of epidural analegesi (local anesthetic systemic toxicity) present?
CNS overactivity -> perioral numbness, metallic taste, tinnitus
tonic clonic siezures!!!
risk of cardiovascular collapse
in a PUL where imagining has been non diagnostic, what is the next best step in management?
repeat b hcg in 48 hours
intertrigo common cause?
risk factors
treatment?
candida albicans
systemic cortocsteroids, DM = immunosuppressed
topical azoles
doxycycline = hidradenitis supporative treatment
estrogen = vulvovaginal atrophy/ genitourinary syndrome of menopause
trichloraceatic acid = condyloma acuminata
trimethorprim-sulfomexazole = used in cellulitis -> typicall unilateral not bilateral lesion
how to reduce the complication rates for shoulder dystocia?
simulation drills with entire clinical team -> teach them to respond quickly safely and effectively
a patient had myomectomy for fibroids 8 months ago, now has amennorrhea/ light spotting infertility and a negative progesterone withdrawal test. cyclic pelvic pain without bleeding
what is the most likely diagnosis?
management?
ashermans syndrome - complication of uterine surgery eg curretage, myomectomy
other risk factors -> infection (septic abortion, endometritis)
(negative progesterone test occurs despite normal estrogen and progesterone)
hysteroscopy and lysis of adhesions
note: condition may also cause recurrent pregnancy loss
why are progestin subdermal implant and estrogen transdermal patch not used for emergency contraception?
slow release of hormones
copper IUD, progestin IUD and __ are the medications for emergency contraception that have the longest efficacy window at up to 120 hours.
ulipristal
estrogen containing contraceptives eg estrogen containing ring is contraindicated in patient with htn
watery discharge throughout the day and night following a hysterectomy.
most likely diagnosis?
vesicovaginal fistula
contrast to vaginal cuff dehiscence which also occurs after hysterectomy and causes vaginal fluid BUT the vaginal apex would appear inflamed, indurated or open!
pregnant woman with a postive interferon gamma release assay
next best step in management?
Obtain CXR!!! -> differentiate active or latent TB!
(If active, then you need to get sputum cultures)
NOTE: Tuberculin skin testing and IGRA are both diagnostic. once one of them is positive, go straight to CXR
patient in labour on epidural analgesia
- fetal tracing showing late decelerations
- maternal hypotension
next best step in management?
Phenylephrine!!! (vasopressor)
(+ iv fluids and left lateral positioning)
symptoms due to sympathetic block from epidural
(maternal hypotension causes decreased placental perfusion -> late decelerations = sign of uteroplacental insufficiency!!)
at what endometrial thickness would you be concerned for endometrial cancer?
> 4 cm
in sexually active patients with primary dysmennorhea first line treatment?
COCP!
not nsaids due to need for contraception
note: COCP does NOT cause weight gain
next step in management for a fetus with anencephaly in breech position? mother is in labour
vaginal delivery!!! & no fetal monitoring
- fetus is not viable so preserve maternal mortality
- if fetus is born alive = palliative care
other lethal fetal conditions which require this management:
- acardia
- bilateral renal agenesis
- holoprosencephaly
- intrauterine fetal demise
- pulmonary hypoplasia
- thantophoric dwarfism
how does acute cervicitis present?
spotting
bloody yellow/discharge from cervical os
c section earlier today
now lightheaded and need to immediately lie down
low blood pressure
pulse 124
pale cold skin
minimal lochia and no clots
uterine fundus is firm
no bleeding from incisional site
next best step in management?
emergency laparotomy!!!
retroperitoneal hematoma! -> uterine artery injury
(rare cause of PPH)
PPH supported by hypovolemic shock findings
most common risk factor for endometrial cancer?
obesity! (estrogen exposure)
(and then chronic annovulation/PCOS)
chronic pelvic pain and pressure for 8 months
stopped OCP 2 years ago but hasnt been able to have kids -> hinting at infertility!!
ultrasound = unilocular hypoechoic mass
most likley diagnosis?
endometriosis!! (endometrioma seen)
NOT epithelial ovarian carcinoma -> would have septate mass on ultrasound with solid and cystic components.
NOT mature teratoma -> would not cause infertility. would have calcifications and hyperechoic nodules on ultrasound
unexplained vaginal bleeding eg irregular pattern, imb, is a contraindication to IUD insertion
management of maternal concern of decreased fetal movement?
non stress test
decreased movement may be due to hypoxemia/acidemia -> conserving energy for brain -> increased risk of fetal demise
during pregnancy, which conditions require low dose aspirin from 12 weeks gestation until delivery?
(preeclampsia prophylaxis!)
in this high risk group, what screening is also done at first prenatal visit?
prior preeclampsia
CKD1
chronic HTN!
Diabetes mellitus - type 1 and 2!!
multiple gestation!!!
autoimmune disease!!
24 hour urine protein collection
post operative incisional pain in the absence of signs of infection is managed with observation and reassurance
how to differentiate between ovarian torsion and ruptured ovarian cyst?
ruptured cyst = free fluid on ultrasound!!!!
bleeding may be seen. observation and reassurance if no sign of infection. surgery if infection or hemodynamically unstable
ovarian torsion = enlarged ovary with decreased or absent blood flow on ultrasound
- may also have tender mass on exam
primary dysmenorrhea pathophysiology?
increased endometrial prostaglandin production
gastroenteritis following food consumption + intrauterine fetal demise is most likely caused by infection by which organism?
Listeria
if pregnant mother is exposed to varicella but has positive IgG then no further treatment required. Varicella vaccine is contraindicated in pregnancy
what vaccines do you administer during pregnancy?
influenza -> asap
Tdap and antiD -> 3rd trimester
don’t administer MMR as live attenuated
vaginal cancer risk factors?
age >60
smoking
in utera DES exposure -> clear cell carcinoma only!! not squamous cell
risk associated monochorionic monoamniotic twins?
management?
twin to twin transfusion - monochorionic
cord entanglement and fetal demise - monoamniotic
in patient monitoring (from 28 weeks)
c section at 32–34 weeks
management of adolescents eg age 15 concerned by irregular heavy menstrual bleeding due to immature hpo axis?
oral progesterone therapy
management of recurrent cystitis with negative cultures after course of antibiotics (resolving cystitis)
daily antibiotic prophylaxis
post coital antibiotics
management of asymptomatci pelvic organ prolapse?
observation and reassurance only
urinary frequency, back pain and groin pain (round ligament pain) can be physiological in pregnancy.
if ultrasound showing bilateral hydronephrosis with right kidney larger than left what is next step in management?
nothing -> physiological
differentiate
epidural associated hypotension
local anaesthetic toxicity
and high spinal anaesthesia
local anesthetic toxicity = cns symptoms eg perioral numbness, tinnitus + siezure + cardiovascular collapse
high spinal anesthesia - UPPER extremity weakness (ascending paralysis) + respiratory paralysis
*lower extremity weakness is EXPECTED with epidural
what happens to fibroids as you near menopause?
spontaneous regression
(due to decreased estrogen levels)
complications of shoulder dystocia?
- fractured clavicle - crepitus, decreased moro reflex due to pain
- fractured humerus -> crepitus, decreased moro reflex due to pain
- erb palsy -> decreased moro and biceps reflex. waiters tip sign! intact grasp reflex. injury to 5th and 6th cervical nerves!
- Klumpke palsy -> claw hand + horners syndrome!!!. injury to C8 and T1!!. note damage to sympathetic fibres runing along these causes horners
- perinatal asphyxia -> AMS, poor tone, seizures
management of recurrent variable decelerations?
- maternal repositioning -> first line-> to resolves the umbilical cord compression!
- if insufficient -> amnioinfusion
note: c section is not indicated/not cat 3 unless variability is absent as well!
treatment of syphilis if penicillin allergic?
skin testing and peniciliin desensitization
80 years old
friable perineal laceration
vulva edema and tenderness
post menopausal bleeding
refusing to bathe etc
most likely diagnosis?
management?
elder abuse
sexual abuse screening
note: vulvar cancer/ lichen sclerosis -> typically preceeded by months to years of vulvar pruritis and plaque like lesions
congenital uterine abnormalities increases risk of what pregnancy complication?
- preterm labour!!! - small cavity
- fetal growth restriction and recurrent pregnancy loss -> poorly vascularized uterues
patients with bipolar disorder during pregnancy should be switched from valproate to which medication?
lamotrigine!
11 year old
thin white skin with excoriations -> adherence of labia at midline
small anal fissure noted
most likely diagnosis?
lichen sclerosis!
(seen in hypoestrogenic populations = prepubertal and post menopausal)
can also cause dyuria, dyspareunia, painful defecation
treat with corticosteroids
biopsy only needed in adults as they are the ones at risk of vulvar cancer
NOT! Labial adhesions -> these are seen in girls peak incidence age 2-3 are not associated with lichenification and have no anal involvement. treated with topical estrogen
persistent fever in the post partum period unresponsive to broad spectrum antibiotics with a negative infectious screen suggests what condition?
risk factors?
differentiation from surgical site infection?
septic pelvic thrombosis (diagnosis of exclusion)
thrombosis of deep pelvic or ovarian veins which becomes infected
rfs: c section, chorioamnionitis/endometritis
SSI will have fever but also incisional site erythema or induration
PPROM is indicated when rupture of membranes and contractions could be present but they are IRREGULAR and the cervix is closed.
management from 34 weeks?
management before 34 weeks if uncomplicated?
34 weeks = delivery! GBS prophylaxis with penicillin G!! (+/- corticosteroids)
before 34 weeks = expectant!, latency antibiotics!! with azithromycin and ampicillin!! (+ corticosteroids) (+inpatient monitoring)
*mgs only given for preterm DELIVERIES <32 weeks
Hyperemesis gravidarum can cause hypoglycemia and elevated serum transaminases, also a complication of HG is wernickes encephalopathy
at what point is preterm labour treated with expectant managment rather than tocolysis?
> /= 34 weeks -> expectant management
management of women under/ <45 with menopausal symptoms and abnormal uterine bleeding?
must exclude endocrine disorder -> measure FSH, TSH and Prolactin
> /= 45 -> clinical diagnosis, give HRT/patient education
treatment for chlamydia only infection?
treatment for gonorrhea only infection?
- doxyclyline, (azythromycine in pregnancy). use the acronym CAD.
- ceftriaxone
all women regardless of psychiatric history require screening for post partum depression
what are the indications to offer cell free fetal DNA testing at the first prenatal visit?
it is offered from gestation >/= 10 weeks
age >/= 35
abnormal serum screening test (quadruple test)
ultrasound findings associated with fetal aneuploidy
prior pregnancy with fetal aneuploidy
parental-balanced robertsonian translocation
- if cffdna is +ve -> CVS or amniocentesis
patient diagnosed with mullerian agenesis, next best step in management?
renal ultrasound
urogenital structures develop from the same embryological origin!
what are the indications for cervical cerclage placement?
> /= 2 prior painless second trimester losses
OR
Painless cervical dilation
OR
second trimester ultrasound </= 2.5 + a prior preterm delivery
unilateral bloody discharge without coexisting mass or lymphadenopathy is most likely what diagnosis?
how would you differentiate this from
1. invasive ductal carcinoma?
2. mammary ductal ectasia?
benign intraductal papilloma! (discharge can also be non bloody)
(line and project into duct and when the duct stalk twist, they bleed)
not palpable due to intraductal location and small size!, also NOT visualised on mammography!!!
- ultrasound and mri important for evaluation of duct pathology!!!!
- invasive ductal carcinoma -> same symptoms BUT also irregular breast mass and lymphadenopathy
- mammary duct ectasia -> blue or blue green discharge!! + sub-areola lump
abnormal uterine bleeding eg irregular, spotting OR postmenopausal bleeding + ovarian mass
diagnosis?
granulosa cell tumour
abdominal pain, vaginal bleeding and contractions after abdominal trauma is most likely what condition?
patient has gone into hemorrhagic shock.
after IV fluids, what is next step in management?
placental abruption
transfuse blood products!!
vasopressor is contraindicated in isolated hemorrhagic shock!! this is because peripheral vascular tone is already increased.
can also decrease uterine blood flow and impair fetal oxygenation (it is, however used in epidural reaction causing maternal hypotension!)
pregnant woman
type 2 diabetes
BMI 36
Enlarged liver
ultrasound = hyperechoic appearing liver
AST = 115
ALT = 125
all else normal
most likely diagnosis?
why not gallstones?
why not Alcoholic hepatitis?
NAFLD - rfs, ultrasound findings, AST/ALT <1
if it were gallstones -> most likely have bladder wall thickening and if ascending cholangitis fever, leukocytosis
alcoholic hepatitis characterised by AST predominance and moderate alcohol intake wont cause it
What is the medical term for genital warts?
condylomata accuminata (think of accumulating!)
condylomata lata = secondary syphilis
in an abnormal lie, at what time will most babies spontaneously turn into normal lie on their own?
at term!!!
= >/= 37 weeks!!!!
abdominal pain in a woman that is relieved with urination and is associated with dyspareunia is most likely what condition?
normal urinalysis
interstitial cystitis (idiopathic chronic bladder pain). may also be associated with urinary frequency and urgency
not a cystocele -> as positive valsalva would be expected = prolapse sign
44
premenopausal
dyspareunia
dry vagina
saline eye drops for chronic dry eyes
dental caries
most likely diagnosis?
inadequate vaginal secretions!!!
(sjogrens)
fetal ultrasound showing dilated fluid fild segment and dilate proximal intestinal segment + polyhydramnios
37 year old woman
what additional ultrasound finding may be observed?
Ventricular septal defect!!!
this is a description of duodenal atresia!! (double bubble sign) -> associated with down syndrome which is associated with heart defects
what are some absolute contraindications to exercise in pregnancy?
- risk of preterm birth
- cervical insufficiency or cerclage
- preterm labour during current pregnancy
- PPROM - risk of antepartum bleeding
- placenta praevia
- persistent second or 3rd trimester bleeding - underlying condition that could be exacerbated by exercise
- severe anemia
- preeclampsia
- lung disease, heart disease
a diagnostic dilation and curettage is done for a pregnancy of unknown location.
if after this procedure, b hcg level continues to rise, what is the managment?
methotrexate! -> indicates ectopic pregnancy
if it were to fall instead, it would indicate a non viable intrauterine pregnancy. this group require reassurance and observation as non viable tissue has been removed by d&c.
if intrauterine tissue analysis shows no chorionic villi = ectopic pregnancy
if chorionic villi = non viable intrauterine pregnancy
treatment of asymptomatic BV?
no additional management
management of suspicious cervical lesion?
cervical biopsy
chronic pelvic/lower abdominal pain and abnormal vaginal bleeding (with wiping, post coital) is most likely what diagnosis?
what are the other signs seen on examination?
PID!!!! (2 key symptoms. due to cervicitis)
- cervical, uterine or adnexal tenderness
- mucopurulent discharge
- fever
Toxic shock syndrome like syphilis, will cause a widespread maculopapular rash that covers palms and soles. However,
in a complete abortion, why might a small cyst be seen in the adnexa and fluid in the pelvis?
cyst = corpus luteum
free fluid -> retrogade bleeding from spontaneous abortion
last week cephalic presentation
now in labour with cervical dilation but only a taught bulging amniotic sac is felt. next step in management?
transvaginal ultrasound -> to be sure about the presenting part as things can always change
must be done before amniotomy to prevent umbilical cord prolapse
recurrent candidiasis, next step in investigation?
hemoglobin A1C
management of patients who have their corpus luteum removed before at least 10 weeks gestation during their pregnancy?
progesterone supplementation
indications for hospitalisation for PID?
Pregnancy
failed outpatient treatment
risk of non adherence to outpatient therapy
severe presentation -> high fever!!, vomiting!!(inability tolerate oral antibiotics), dehydration (dry mucous membranes, long cap refill)
complications -> tuboovarian abscess, perihepatitis
