ob Flashcards
There is increased risk of MS when ??
Although pregnancy is protective for MS, there is an increased risk in the early postpartum period
PROM typically causes a large gush of fluid but may also cause vaginal wetness or intermittent leakage of small volumes. Confirmation is usually with visualization of amniotic fluid emerging from the cervix with ???, nitrazine-positive testing (ie, turns blue), and/or ferning on microscopy.
Valsalva (eg, cough)
Patients with breech presentation and no contraindications to vaginal delivery (eg, placenta previa, prior classical cesarean delivery) are offered ?? , a procedure in which the fetus is manually rotated to cephalic presentation
external cephalic version (ECV)
monochorionic diamniotic twins (1 placenta, 2 amniotic sacs) are at risk for ??? , a complication that can result in heart failure and fetal/neonatal mortality in both twins. unbalanced arteriovenous anastomoses are present between the shared placental vessels that supply the twins
twin-twin transfusion syndrome (TTTS)
Normal internal genitalia, external virilization (eg, clitoromegaly), and undetectable serum estrogen levels in a female patient are consistent with a diagnosis of ??
aromatase deficiency
Müllerian agenesis causes primary amenorrhea due to the failed development of the uterus, cervix, and upper 1/3 of the vagina. (Normal external vagina + ovaries) development from a common embryologic source causes abnormalities in which system?
renal malformations are common and patients require evaluation with a renal ultrasound
complete torsion, typically triggered by physical activity (eg, walking), presents with severe, constant, unilateral pelvic pain due to ongoing ovarian ischemia.
Management is ???
diagnostic laparoscopy for manual detorsion of the adnexa and removal of any contributory cysts or masses; oophorectomy may be required if the ovary is necrotic.
patient’s anterior vaginal wall mass is most likely a ????, an abnormal localized outpouching of the urethral mucosa into surrounding tissues
urethral diverticulum
Bartholin glands are located at the ??? vulvar vestibule (4 and 8 o’clock positions)
posterior
vaginal bleeding and a tender, firm uterus after rupture of membranes most likely has >>
abruptio placentae. Placental abruption is the premature placental separation from the uterine wall prior to fetal delivery.
Secondary amenorrhea is amenorrhea for ≥ ???? months in women with previously regular menses (or ≥6 months in women with previously irregular menses). Initial evaluation includes a pregnancy test, followed by serum prolactin, TSH, and FSH level testing.
3
multiple gestation pregnancy (eg, triplet), pregnancy reduction to a lesser order gestation (eg, singleton) decreases ??
maternal morbidity (eg, preeclampsia, postpartum hemorrhage).
causes a diffuse maculopapular rash due to the widespread circulation of the pathogen. The rash usually begins along the skin-cleavage lines of the trunk and extends to the extremities, including the palms and soles.
secondary syphilis
Postpartum thyroiditis is an autoimmune disorder characterized by lymphocytic inflammation of the thyroid and disruption of thyroid follicles occurring <12 months after parturition. It can cause a self-limited hyperthyroid phase due to release of preformed thyroid hormone. Management includes ??
a beta blocker to attenuate adrenergic symptoms, but specific antithyroid therapy is not usually needed
composition of ovarin mass seen on ultrasound as a partially calcified mass with multiple thin, echogenic bands
cystic teratoma
calcified mass (eg, teeth) with multiple thin, echogenic bands (eg, hair).
Intra-amniotic infections (IAIs) are usually polymicrobial and ascend from the vagina, spreading through the amniotic fluid, membranes, placenta, uterine decidua, and umbilical cord. Treatment is with broad-spectrum intravenous antibiotics (eg, ampicillin, gentamicin, clindamycin) and ??
immediate delivery via augmentation of labor (to remove the source of infection).
hypertension, hyperreflexia (eg, clonus), and positive pregnancy test are concerning for preeclampsia with severe features. In addition to new-onset hypertension, pre-eclamptic patients often have signs of end-organ damage such as right upper quadrant pain (due to hepatic swelling and stretching of the Glisson capsule) and headache. Although preeclampsia typically presents in the late third trimester, preeclampsia at <20 weeks gestation can be a complication of ???
hydatidiform mole (HM)
risk factors for breech position include:
Advanced maternal age (≥35), Multiparity, Uterine didelphys, septate uterus, Uterine leiomyomas, Fetal anomalies (eg, anencephaly), Preterm (<37 weeks gestation), Oligohydramnios/polyhydramnios. and ????
Placenta previa
cardiovascular contraindications to pregnancy include Pulmonary arterial hypertension, Bicuspid AV with ascending aorta enlargement >50 mmC, and Symptomatic (3)????
Symptomatic mitral stenosis
Symptomatic aortic stenosis
Symptomatic heart failure with LVEF ˂30%
development of significant proteinuria (>300 mg/24 hr, ≥1-2+ protein) prior to 20 weeks gestation suggests what etiology?
underlying kidney disease that was likely present before conception
likely DM or other nephropathy
work up of bilateral vs. unilateral nipple discharge
see image
Patients in preterm labor at <32 weeks gestation require corticosteroids, penicillin, tocolysis, and ???? to decrease neonatal morbidity and mortality associated with preterm delivery.
magnesium sulfate
(1) ??? is the first-line treatment at <32 weeks gestation because of its high efficacy and few maternal adverse effects; as gestational age increases, however, indomethacin poses greater fetal risks (eg, premature closure of the ductus arteriosus). Therefore, (2)???? is preferred between 32 and 34 weeks gestation
Indomethacin
nifedipine
Indications for intrapartum prophylaxis:
GBS bacteriuria or GBS urinary tract infection in current pregnancy (regardless of treatment)
GBS-positive rectovaginal culture in current pregnancy
Unknown GBS status PLUS any of the following: <37 weeks gestation, Intrapartum fever, Rupture of membranes for ≥18 hours
?????? (one more)
Prior infant with early-onset neonatal GBS infection
Advanced ovarian cancer may present in postmenopausal women with an immobile pelvic mass. Suspected ovarian cancer with no distant metastases is managed with ??
exploratory laparotomy, staging, and tumor debulking
The initial menstrual cycles in adolescents are irregular and anovulatory due to ???
hypothalamic-pituitary-gonadal axis immaturity and insufficient secretion of gonadotropin-releasing hormone.
Endometriosis can present with dysmenorrhea and deep dyspareunia. Symptomatic patients are offered empiric medical therapy with ?? (2)
nonsteroidal anti-inflammatory drugs and/or combination oral contraceptives, which treat inflammation and suppress ovarian stimulation of endometriosis.
Stress urinary incontinence typically presents with leakage of urine with increased intraabdominal pressure (eg, intercourse). Treatment includes pelvic floor muscle exercises or ???
surgical midurethral sling placement
most common cause of unilateral, bloody nipple discharge is a ??
benign intraductal papilloma
Management of preterm premature rupture of membranes diagnosed at <34 weeks gestation is typically expectant. However, in patients with maternal fever + (3 things ????) delivery is indicated to decrease maternal and neonatal morbidity.
Fetal tachycardia (>160/min)
Maternal leukocytosis
Purulent amniotic fluid
The active phase of labor (6-10 cm cervical dilation) has an expected, predictable rate of cervical dilation of ≥??? cm every ?? hours.
≥1 cm every 2 hours
Preeclampsia with severe features increases the risk of which neurological condition?
acute stroke due to endothelial cell damage, dysregulation of cerebral blood flow, cerebral vasospasm, and vascular microthrombi formation, particularly in patients with severe hypertension (ie, systolic ≥160 or diastolic ≥110 mm Hg)
? is often diagnosed incidentally on second-trimester ultrasound revealing a low-lying placenta, myometrial thinning, and numerous placental lacunae.
Placenta accreta is the abnormal attachment of placental villi directly onto the myometrium rather than the decidua basalis
patient has uterine leiomyomata (ie, fibroids), benign tumors of the uterine myometrium. Women with symptomatic fibroids have prolonged, heavy menstrual bleeding (eg, 7-8 days every month, anemia).
Treatment of heavy menstrual bleeding is ???
Tranexamic acid (TXA) is used in heavy menstrual bleeding because it can reduce blood loss during menses by up to 50%.
inevitable abortion presents with heavy vaginal bleeding, cramping, and a dilated cervix without passage of gestational tissue. what is the management??
Surgical management (eg, suction curettage) is indicated for patients whose condition is hemodynamically unstable.
?? is an aggressive breast cancer that can present with unilateral breast rash, erythema, and edema. Metastatic disease (eg, axillary lymphadenopathy) is common on initial presentation
Inflammatory breast carcinoma (IBC)
Postpartum hemorrhage is defined as an estimated blood loss ≥1,000 mL or bleeding with signs/symptoms of hypovolemia. The management of postpartum hemorrhage due to uterine atony occurs in a stepwise approach. Initial treatment includes administration of ???
high-dose oxytocin, the first-line uterotonic agent.
is a potentially life-threatening postpartum complication that presents with a vaginal mass and possible hypovolemic shock due to massive occult bleeding.
Vaginal hematoma
Prior cone biopsy (eg, cervical conization) is a risk factor for ???? because it shortens the cervix and may alter its structural integrity.
Cervical insufficiency
how does hypothyroidism effect prolactin, FSH, and LH
Hypothyroidism causes decreased responsiveness of the pituitary to GnRH, leading to decreased gonadotropin (ie, FSH, LH) secretion.
Thyrotropin-releasing hormone, which is upregulated in hypothyroidism, stimulates the pituitary secretion of prolactin.
Hyperprolactinemia, whether due to hypothyroidism or as an isolated disorder, further suppresses gonadotropin secretion.
Condylomata acuminata vs Condylomata lata
Condylomata acuminata (anogenital warts) caused by human papillomavirus (HPV); lesions are exophytic, dry-appearing, and verrucous (ie, cauliflower-like), pruritic, friable lesions (eg, those that bleed with manipulation) may occur.
Condylomata lata, caused by secondary syphilis, are raised, gray-white lesions that develop on mucosal surfaces (eg, mouth, perineum).
primary amenorrhea (absent menarche by age ≥15 with secondary sexual characteristics), female external genitalia (eg, shortened lower two-thirds of the vagina), and male-range testosterone levels most likely has ???
androgen insensitivity syndrome (AIS)
life-threatening complication of epidural anesthesia is ??? that causes ascending motor, sensory, and sympathetic blockade. Patients are at risk for respiratory paralysis (eg, dyspnea, hypoxemia).
high spinal anesthesia, or accidental injection of local anesthetic into the subarachnoid space
Indomethacin (used for tocolysis during early contractions), a nonspecific cyclooxygenase inhibitor, decreases prostaglandin production and leads to fetal vasoconstriction (eg, premature closure of the ductus arteriosus).
this increases risk of what?
The subsequent decreased renal perfusion and fetal oliguria can result in oligohydramnios (ie, amniotic fluid index ≤5 cm)
Nonreactive NSTs are concerning for fetal hypoxemia and acidemia; however, the most common cause of a nonreactive NST is a ??
quiet fetal sleep cycle (which lasts ≤40 min).
management of adolescent girls with a new breast mass with clinical features consistent with a fibroadenoma
unilateral, firm, well-circumscribed, mobile masses in the upper outer quadrant
observation and reexamination after completion of a full menstrual cycle (or 4-6 weeks)
Leiomyomata uteri (particularly submucosal fibroids) can cause heavy, prolonged menses. Patients with symptomatic submucosal fibroids who desire future fertility are treated with ???
hysteroscopic myomectomy, which improves heavy menstrual bleeding and restores normal uterine anatomy, thereby decreasing infertility and future pregnancy complications (eg, recurrent pregnancy loss)
High-grade squamous intraepithelial lesions (HSILs) on Pap testing are concerning for underlying severe neoplasia (eg, CIN2, CIN3) or invasive cervical cancer, and all patients require evaluation with ???
immediate colposcopy
??? is a major risk factor for placenta previa
Prior cesarean delivery
If fetal presentation (eg, cephalic, breech) is uncertain on digital cervical examination, a ??? should be performed to confirm fetal presentation and determine the safest route of delivery.
transabdominal ultrasound
HELLP (Hemolysis, Elevated Liver enzymes, Low Platelets) syndrome can present with right upper quadrant pain, microangiopathic hemolytic anemia, elevated transaminases, and thrombocytopenia. The pathogenesis involves ???
widespread endothelial dysfunction leading to microangiopathy, overactivation of the coagulation cascade, and excessive platelet consumption.
First-line management of recurrent variable decelerations is intrauterine resuscitation with ???
umbilical cord compression with ≥50% of contractions = recurrent variable decelerations)
maternal repositioning (eg, left lateral, all-fours), which may reduce cord compression and improve fetal-placental blood flow. If the variable decelerations do not improve, an amnioinfusion (instillation of saline into the intrauterine cavity) can be administered.
During pregnancy, patients with sickle cell disease have an increased incidence of ??? due to increased metabolic demands and a hypercoagulable state.
acute vasoocclusive pain episodes (eg, abdominal pain)
Ectopic pregnancy (ie, pregnancy implanted in an extrauterine location) can be diagnosed by a persistent rise in β-hCG level following diagnostic ??
vs nonviable intrauterine pregnancy
dilation and curettage.
anti-D immune globulin is routinely administered at ??? weeks gestation and again within 72 hours of delivery if the baby is found to be Rh (D) positive.
28-32
The initial timing of 28-32 weeks is selected because the half-life of anti-D immune globulin is about 6 weeks, which would cover any potential future exposure to fetal red blood cells through most of the third trimester.
Uncomplicated preterm prelabor rupture of membranes at <34 weeks gestation is managed how?
expectantly with prophylactic latency antibiotics, corticosteroids, and inpatient monitoring. Delivery is at 34 weeks gestation or earlier in the event of complications (eg, intraamniotic infection, placental abruption).
Because oxytocin has a similar structure to antidiuretic hormone, prolonged or excessive oxytocin administration can cause severe ??
hyponatremia leading to cerebral edema and generalized tonic-clonic seizures.
initial prenatal labs include:
Rh(D) type & antibody screen
Hemoglobin/hematocrit, MCV, ferritin
HIV, VDRL/RPR, HBsAg, anti-HCV Ab
Rubella & varicella immunity
????
Urine dipstick for protein
Chlamydia PCR (if risk factors are present)
Pap test (if screening indicated)
Urine culture
labs at 24-28 weeks???
Hemoglobin/hematocrit
Antibody screen if Rh(D)-negative
1-hr 50-g GCT
labs at 36-38??
Group B Streptococcus rectovaginal culture
epidural analgesia blocks sympathetic nerve fibers responsible for vascular tone in the lower extremities, resulting in ??
vasodilation (venous pooling), decreased venous return to the heart, and decreased cardiac output.
Therefore, many patients develop hypotension and compensatory tachycardia (because sympathetic innervation to the heart via T1-T4 is unaffected by the block).
First-line medications for acute antihypertensive therapy include (for preeclampsia): (3)
Intravenous labetalol: a beta blocker with alpha-blocking activity. Labetalol is fast-acting, effective, and safe for use during pregnancy; however, contraindicated in patients with bradycardia (ie, <60/min), beta blockade with labetalol can further decrease the heart rate, resulting in dizziness or lightheadedness
Intravenous hydralazine: a direct arterial vasodilator. Hydralazine can cause tachycardia due to sympathetic nervous system stimulation.
Oral nifedipine: a calcium channel blocker. Although oral nifedipine can rapidly lower blood pressure, this patient may not be able to tolerate oral medications due to nausea/vomiting.
?? presents in the third trimester with pruritus that is worse on the hands and feet with no associated rash.
Intrahepatic cholestasis of pregnancy
Diagnosis is confirmed by elevated total bile acids (≥10 µmol/L). Management includes ursodeoxycholic acid and delivery at 37 weeks gestation.
???, commonly used in obstetrics for seizure prophylaxis (eg, in preeclampsia with severe features), is contraindicated in patients with myasthenia gravis because it may trigger a myasthenic crisis due to the inhibition of acetylcholine release.
Magnesium sulfate
Postpartum fecal or flatal incontinence can occur due to external anal sphincter injury associated with a third- or fourth-degree obstetric perineal laceration. Patients typically have weakened anal sphincter tone, asymmetric sphincter contraction, or a palpable defect on examination. Evaluation is with ???
endoanal ultrasonography.
Neonatal lupus can occur due to passive placental transfer of maternal anti-SSA (Ro) and anti-SSB (La) antibodies. fetus may develop which cardiac condition?
fetal atrioventricular block, which appears on fetal heart rate tracing as persistent bradycardia.
Pregnant patients positive for group B Streptococcus (GBS) receive intrapartum antibiotic prophylaxis to prevent early-onset neonatal GBS disease. Patients with a penicillin allergy that is low risk for anaphylaxis receive .
cefazolin
first-generation cephalosporin
fetus has ascites (eg, echolucent abdominal fluid), skin edema, polyhydramnios (single deepest pocket ≥8 cm), and placental thickening (reflecting intravillous edema) consistent with ??
hydrops fetalis (fetal hydrops);
The principle behind labor management of patients with lethal fetal anomalies (eg, anencephaly, bilateral renal agenesis) is to minimize maternal morbidity and mortality. Therefore, obstetric care for these patients is typically?
Vaginal delivery bc has a lower risk for maternal complications compared to cesarean delivery (eg, hemorrhage, infection, pulmonary embolism)
Sinusoidal fetal heart rate tracings are typically associated with severe fetal ???? They are a category III tracing that reflects an increased risk of fetal compromise (eg, hypoxemia, acidemia) and requires urgent cesarean delivery.
anemia
A complete hydatidiform mole can present with pelvic pressure, uterine size larger than expected for gestational age, and an ultrasound showing bilateral theca lutein ovarian cysts and an enlarged uterus with a heterogeneous mass composed of cystic spaces. Management is???
uterine evacuation with suction curettage.
Progestin-containing IUDs have the added benefit of ?? and minimal systemic side effects.
amenorrhea
???? (low FSH and estradiol) causes irregular menses and infertility via loss of pulsatile GnRH secretion precipitated by weight loss, stress, or chronic illness.
Hypogonadotropic hypogonadism
Patients with PCOS are at increased risk for ??? due to unregulated endometrial proliferation from unopposed estrogen stimulation.
endometrial hyperplasia and cancer
???? typically presents with a uterine mass (as in this patient’s enlarged, irregularly shaped uterus) that causes bulk symptoms (eg, pelvic pressure, constipation) and abnormal or postmenopausal bleeding.
Uterine sarcoma
Tamoxifen use is a significant risk factor for ??? due to its estrogen agonist effects on the uterus.
uterine sarcoma
Postmenopausal symptoms treatment for patients with a uterus require estrogen-plus-progesterone therapy. In contrast, patients without a uterus require ??
estrogen-only therapy (eg, transdermal estrogen patch)
Ultrasound features suggesting ??? are a solid mass with thick septations and the presence of ascites
Epithelial ovarian carcinoma w/malignancy
??? may occur secondary to chemotherapy and presents with amenorrhea and signs of estrogen deficiency (eg, vaginal dryness). Ovarian failure is characterized by increased FSH and LH due to lack of feedback inhibition from estrogen.
Ovarian failure
Patients with cervical intraepithelial neoplasia 3 on biopsy (eg, endocervical curettage) require ???
cervical conization, a type of excisional biopsy, due to the high risk of concurrent invasive cervical cancer and/or progression to cancer
Vulvovaginal candidiasis is characterized by white vaginal discharge, pruritus, erythema, and excoriations. Risk factors include ??? , immunosuppression, and antibiotic use. Recurrent candidiasis warrants evaluation for diabetes mellitus.
diabetes mellitus
Elevated prolactin levels associated with breastfeeding suppress ???? release and induce a hypoestrogenic postpartum state. Patients may experience dyspareunia due to atrophic vaginal changes (eg, dryness, loss of rugation). Treatment is supportive with nonhormonal lubricants and moisturizers.
GnRH release
the most common risk factor for endometrial adenocarcinoma
obesity
Herpes simplex virus (HSV) infection typically resolves how??
spontaneously within a week of lesion development
Antivirals (eg, acyclovir, valacyclovir) are used to decrease symptom duration and the number of recurrences.
In women with ovulatory menstrual cycles, a dominant follicle (ie, a large cyst with multiple smaller cysts) is formed during the follicular phase (resulting in an enlarged adnexa); when the oocyte is released during ovulation, pain can develop due to rupture of the follicle and subsequent release of a small amount of blood and fluid that irritates the peritoneum
what is this called??
Mittelschmerz
is a metastatic form of gestational trophoblastic neoplasia that may occur after a hydatidiform mole, normal pregnancy, or spontaneous abortion. The lungs are the most frequent site of metastasis.
Choriocarcinoma
should be suspected in postpartum women with an enlarged uterus, irregular vaginal bleeding, pulmonary symptoms, and multiple infiltrates on chest x-ray. Diagnosis is confirmed by an elevated β-hCG level.
Choriocarcinoma
As the ???? infection spreads farther into the intraperitoneal cavity, it can cause inflammation of the liver capsule (ie, perihepatitis or Fitz-Hugh–Curtis syndrome in 6%-10% of patients), resulting in vomiting and right upper quadrant tenderness. The pain is often pleuritic (ie, worsened with inspiration) due to fibrinous adhesion formation on the anterior liver surface
pelvic inflammatory disease
Vulvar lichen sclerosus is a chronic inflammatory condition that can present with vulvar pruritus, white vulvar plaques, and loss of normal architecture (eg, loss of labia minora). A ??? is recommended to confirm the diagnosis and rule out vulvar cancer.
vulvar punch biopsy
First-line treatment of vulvar lichen sclerosus is with superpotent topical corticosteroids (eg, clobetasol)
A ?? abortion refers to the passage of the products of conception through the cervix at <20 weeks gestation. The cervix then closes, and the associated pain and bleeding subside. Ultrasonography reveals an empty uterus.
complete
Persistently absent or minimal variability on fetal heart rate monitoring typically indicates fetal metabolic acidosis. However, what kind of medications can also cause decreased variability
CNS depressants - alcohol, opioid, recreational drugs
??? is a chronic inflammatory condition typically found in intertriginous areas (eg, inguinal region). The lesions occur due to occluded follicles that cause painful nodules and abscesses that can develop into draining sinus tracts and result in significant scarring
Hidradenitis suppurativa
???, an acquired hyperpigmentation disorder that commonly occurs during pregnancy, typically presents with bilateral, symmetric macules on sun-exposed areas of the face. It is clinically diagnosed and typically resolves postpartum. It is managed with avoidance of sun exposure and use of broad-spectrum sunscreen.
Melasma
