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Step 2 UWORLD > OB > Flashcards

OB Flashcards

1
Q

A patient is 28 weeks pregnant and is rubella non-immune. How is this handled?

A

Wait til post-partum period for immunization since MMR is a Live vaccine!

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2
Q

When is Anti-D immunoglobulin given?

A

Indications for Rh(D)neg patients:

  • between 28-32 weeks
  • <72 hours after delivery Rh+ infant
  • <72 hrs after SAB
  • ectopic pregnancy
  • threatened abortion
  • hydatidiform mole
  • CVS/Amniocentesis
  • abdominal trauma
  • 2nd/3rd trimester bleeding
  • external cephalic version
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3
Q

what is done in the type and antibody screen?

A 
Check blood type: A, B, AB, O
Rh(D) status: + or -
RBC antibodies (alloimminuzed or not)
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4
Q

When do you test for GBS?

A

rectovaginal swab at 35-37 weeks b/c results valid for 5 weeks. Can become colonized at any time, so earlier results would not be valid

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5
Q

T/F: Pregnant women should undergo screening with urine culture and tx of symptomatic bacteriuria only in the first trimester

A

F: Should undergo screening and tx of even asymptomatic bacteruria in 1st trimester b/c risk of pyelo

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6
Q

what are the components of a BPP (biophysical profile)?

A
  1. NONSTRESS TEST (reactive hr)

US:

  1. amniotic fluid volume
  2. fetal movements ( >3 gen body movements)
  3. fetal tone ( >1 ep flexion/extension)
  4. fetal breathing movements (>1 breathing ep >30 sec)

total scored 0-10; 2 = normal for each, minimum 30 minutes test

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7
Q

scoring indications for BPP

A

8-10: Normal
6: equivocal
<4: INDICATION FOR DELIVERY to prevent intrauterine demise

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8
Q

Late term (41 weeks) and post-term (42) pregnancies are at risk of _________ _________

A

Uteroplacental insufficiency

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9
Q

What risks come with uteroplacental insufficiency?

A
  • Compression of uterine vessels during contractions cause hypoxia = reflex fetal bradycardia = late decels
  • poor fetal perfusion = poor urine production = oligohydramnios
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10
Q

Fetal tachycardia, maternal fever and uterine tenderness

A

intra-amniotic infection (chorioamnionitis)

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11
Q

T/F: Nuchal cords are rare and cause for immediate delivery

A

False. Common finding on US and delivery, and can resolve before delivery. Associated with variable decels but not with adverse fetal outcomes.
(cord becomes wrapped around fetal neck)

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12
Q

When is betamethasone used?

A

Decrease respiratory distress syndrome in preterm infants. Admin @ <37 weeks for high risk patients

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13
Q

T/F: Intrapartum penicillin is most effective for GBS prophylaxis if admin prior to labor

A

False. Bacteria regrows rapidly during labor

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14
Q

What is indomethacin used for in pregnant patients?

A

Tocolysis. Indomethacin is contraindicated after 32 weeks due to risks of PDA closure. Tocolysis is not done after 34 weeks.

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15
Q

Mag sulfate is admin for ____ _____ at <32 weeks

A

fetal neuroprotection

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16
Q

How can you monitor for adequacy of contractions during labor?

A

Intrauterine tocometer (after membranes ruptured). 200 Montevideo units in a 10 minute period.

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17
Q

Why is shoulder dystocia an emergency?

A

risk for neonatal brachial plexus injury, clavicular and humeral fracture, and possibly hypoxic brain injury and death

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18
Q

Biggest risk factor for shoulder dystocia

A

fetal macrosomia –> maternal obesity, GDM, post-term pregnancy, excessive wt gain during preg

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19
Q

warning signs of an impending shoulder dystocia

A

prolonged first and second stage of labor, and retraction of the head into perineum after delivery (turtle sign)

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20
Q

What is stage 1 of labor?

A

0cm - 10cm.
Latent: 0-6cm. <20 hours (np), <14 hours (mp)
Active: 6-10cm

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21
Q

What is stage 2 of labor?

A

10cm - fetus delivery. <3 hours (np), <2 hours (mp)

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22
Q

What is stage 3 of labor?

A

fetus delivery - delivery of placenta. <30 minutes

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23
Q

What allows cervical dilation?

A

Breakage of disulfide bonds. Stimulated by fetal head engagement

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24
Q

Shortening/thinning/ripening of the cervical canal

A

effacement

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25
Q

How is PPROM managed at 34-37 weeks?

A

Preterm Premature ROM

  1. Antibiotics
  2. +/- Corticosteroids
  3. Delivery
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26
Q

What is PPROM?

A

Preterm Premature ROM, so <37 weeks

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27
Q

How is PPROM managed <34 weeks

A
  1. Antibiotics (Intrapartum Penicillin for GBS status unknown)
  2. Corticosteroids

If signs of infection: Delivery + Mag if <32 weeks
No infection: Fetal surveillance

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28
Q

When is amnioinfusion appropriate?

A

Refers to saline instillation into uterine cavity. Done for tx of recurrent variable decels due to umbilical cord compression during labor

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29
Q

most common cause of postpartum hemorrhage <24 hours after delivery

A 
Uterine atony 
(myometrial contractions important for compression of placental vessels aka hemostasis)
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30
Q

risk factors for uterine atony (which leads to PPH)

A
  • prolonged labor
  • over distention (fetal wt >4000g, multiple gest), polyhydramnios
  • chorioamnionitis
  • unresponsive to pit
  • forcep/vacuum delivery
  • htn disorders
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31
Q

clinical indications of uterine atony

A

soft (Boggy) and enlarged (above the umbilicus)

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32
Q

Post partum ultrasound shows a thin endometrial stripe. What does this mean?

A

Suggests and empty and normal uterine cavity, making retained placenta etc unlikely

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33
Q

Definition of PPH

A

Post partum hemorrhage:
>500mL after vaginal delivery
>1000mL after c/s

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34
Q

Uterotonic agents that can be used to tx PPH/uterine atony

A
  • Oxytocin is 1st line
  • Methylergonivine: smooth m contraction, vasoconstrict
  • Carboprost: synthetic PG, c/i in asthma b/c bronchoconstrictor

Uterine massage –> Methylergonivine –> Oxytocin

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35
Q

T/F: Placenta previa is a c/i to vaginal delivery

A

True (only if covering/<2cm from cervical os)

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36
Q

How can you use fetal fibronectin levels to predict preterm delivery?

A

Levels are high til 20 weeks and low in 2nd/3rd tri and increase at term. Elevated levels just prior to term = increased risk.

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37
Q

T/F: Patients with prior cervical surgery at increased risk of preterm delivery

A

True, i.e conization.

  • ->Gold Standard test: TransVAGINAL US to measure cervical length
  • ->Progesterone therapy maintains uterine quiesence w
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38
Q

pregnant patient comes in with hypertension. Whats the cutoff for primary vs gestational? (week)

A

20 weeks. Prior to this its primary htn.

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39
Q

Fetal risks due to maternal htn

A

Preterm delivery, oligo, growth restriction

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40
Q

maternal risks due to maternal htn

A

PreE, PPH, GDM, Placental abruption, C/s

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41
Q

how does placental abruption present?

A

sudden onset vaginal bleeding + tender uterus. also, high frequency, low intensity contractions. It is due to premature placental detachment.

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42
Q

who gets placental abruption?

A

smoker/cocaine use, maternal PreE/htn, abdominal trauma

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43
Q

maternal complications of placental abruption

A

hypovolemic shock and DIC.

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44
Q

Tx of PreE

A

Mag Sulfate

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45
Q

Tx of PreE

A

Mag Sulfate + delivery

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46
Q

Chronic pelvic pain, urinary urgency, painful sex in a female

A

Interstitial cystitis

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47
Q

Sxs and risk factors for vesicovaginal fistula

A

occurs after pelvic surgery, get painless continous urine leakage from vagina (clear fluid). dont be thrown, the UA may show + cystitis
Dx: dye test and cystourethroscopy

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48
Q

1st line anti-htn meds in pregnancy

A

-Methyldopa!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

  • Beta blockers (labetolol)
  • Hydralazine
  • CCB (nifedipine)
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49
Q

anti-htn meds CI in pregnancy

A

ACE-I
ARB
Furosemide
Spironolactone

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50
Q

T/F: Trisomy 18 and 21 both have increased hCG and decreased AFP

A

False. 21 has increased hCG, 18 has decreased. in addition, 21 has increased Inhibin A

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51
Q

T/F: Needle aspiration of an adnexal mass in postmenopausal women is CI

A

True, risk of seeding malignant cells. Do CA-125 levels

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52
Q

Pruritis, elevated bile acids and ALT/AST in pregnancy

A

Intrahepatic cholestasis of pregnancy (ICP)

–>Ursodeoxycholic acid helps increase bile flow, early delivery once term is recommended

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53
Q

Ischemic pituitary necrosis after pregnancy

A

Sheehans: fatigue, wt loss, hypotension, poor breast feeding

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54
Q

clinical features of HELLP

A

PreE, N/V, RUQ pain

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55
Q

Tx of HELLP

A

Delivery, Mag Sulfate for seizure prophy, anti-htn

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56
Q

Dx workup for endometriosis

A

Laparoscopy

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57
Q

Pelvic pain + thickened uterosacral ligament

A

Endometriosis

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58
Q

T/F: Big future risk with endometriosis is osteoporosis

A

False, Infertility

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59
Q

Dx of chorioamnionitis

A

Clinical. Fever + 1 of the following:

  • uterine tenderness
  • maternal, fetal tachycardia
  • purulent vaginal discharge
  • malodorous amniotic fluid
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60
Q

What is a reactive nonstress test?

A

at least 2 accelerations in 20 minutes lasting 15 seconds (HR is increasing with movement)

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61
Q

What is a non-reactive nonstress test?

A

No accelerations, typically indicating fetal hypoxia from 1. placental insufficiency or 2. fetal anomaly (cardiac/neuro).

–>but, most common cause is fetal sleep cycle. So NST should be >40 minutes if nonreactive.

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62
Q

Endometrial glands in the myometrium, causing dysmenorrhea and heavy menses

A

Adenomyosis

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63
Q

Symmetrically enlarged uterus that feels boggy, tender, globular + dysmenorrhea

A

Adenomyosis

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64
Q

most effective emergency contraception

A

Copper IUD, can be inserted up to 5 days later. CI = acute cervicitis and PID

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65
Q

risk factors for placental insufficency ( 0-4/10 on BPP)

A

tobacco, htn, diabetes, AMA

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66
Q

Toxicity of oxytocin

A

(its similar to ADH) water retention, hyponatremia and thus seizures

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67
Q

Fetal hydantoin syndrome (phenytoin)

A

small body size, microcephaly, digital hypoplasia, cleft palate (this feature is not part of FAS)

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68
Q

T/F: All pregnant women are screened for GDM

A

True, this happens at 24-28 weeks

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69
Q

Target blood glucose levels for GDM patients

A

<95, 1 hour post prandial <140

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70
Q

How do you manage a delivery with shoulder dystocia? The head is out but shoulders not passing

A

Flex moms hips against the abdomen (McRoberts manuever) .

Breathe, dont push
Elevate hips (mcroberts)
Call for help
Apply suprapubic pressure
Largen opening with episiotomy 
Manuevers
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71
Q

obesity causes amennorhea due to:

A

anovulation

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72
Q

What are the LH and FSH levels in anovulation?

A

Normal, as is estrogen. Have low progesterone, so no progesterone withdrawal menses

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73
Q

What lab values would be abnormal in premature ovarian failure?

A

Elevated LH and FSH

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74
Q

what is lochia

A

vaginal bloody/mucus discharge up to 6-8 weeks post partum

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75
Q

Next step if suspecting lichen sclerosis (atrophy, pruritis, white patches)

A

vulvar punch biopsy

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76
Q

Tx for atrophic vaginitis (dryness, thinning) and lichen sclerosis (same + pruritis, white patches)

A

AV: Low dose topical estrogen
LS: High dose corticosteroids (clobetasol)

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77
Q

which vaccines do you give in pregnancy?

A

Tdap
Inactivated Influenza
Rho Immunoglobulin

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78
Q

some contraindications to external cephalic version

A 
uterine/fetal anomaly 
multiple gestation
oligo
ruptured mem
extended fetal head
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79
Q

complications of cervical conization (for CIN 2, 3)

A

Cervical stenosis
Preterm birth, PPROM
2nd tri preg loss

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80
Q

gold standard for dx CIN

A

Colposcopy

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81
Q

how is dx of ectopic preg made?

A

Pregnancy test + transvaginal US

transabdominal will show no uterine preg

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82
Q

Patient presents with inevitable abortion at 10 weeks. Tx?

A

Hemo stable: Misoprostol
Hemo unstable: Suction curettage

Needs Rhogam also

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83
Q

Patient presents with ruptured ectopic. Tx?

A

Hemo stable: Methotrexate
Hemo unstable: Surgery (laparosopy)
(note: NOT a D/C…this is for spontaneous/inevitable abortion)

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84
Q

vaccines contraindicated in pregnancy

A

MMR
Varicella
HPV
Live attenuated influenza

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85
Q

vaccines safe in pregnancy

A

Tdap
Inactivated influenza
Rhogam

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86
Q

what labs are ordered during 2nd trimester visit (24-28weeks)?

A
  • Oral glucose challenge test for GDM screen (50g 1 hr)
  • Antibody screen if Rh-
  • Hgb/HCT
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87
Q

what labs are ordered during 3rd trimester visit (35-37 weeks)?

A

GBS culture

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88
Q

what labs are ordered during initial prenatal visit?

A
  • Rh type, antibody screen
  • Hgb/HCT/MCV
  • HIV, VDLR/RPR, HbsAG
  • Rubella and varicella titers
  • Pap test (if screening indicated)
  • Chlamydia PCR (note: GC only in high risk)
  • Urine culture
  • Urine protein (note: not a 24-hour protein)
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89
Q

When is exercise contraindicated for a pregnant patient?

A
  • multiple gestation
  • cervical incompetence
  • premature labor
  • placenta previa/abruption
  • PreE/gHTN
  • amniotic fluid leak

otherwise, ok to exercise

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90
Q

sinusoidal fetal heart rate tracing (smooth undulating sign wave)

A

Fetal anemia

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91
Q

Hypoglycemia and fetal sleep give what type of FHR?

A

Nonreactive NST (no accelerations)

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92
Q

Types of abortions in which the cervical os is closed

A

Missed (no bleeding or cardiac), Threatened (bleeding and cardiac activity), Complete (bleeding or none)

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93
Q

Types of abortions in which there is no bleeding

A

Missed, possibly Complete

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94
Q

Types of abortions with dilated cervical os

A

Inevitable, Incomplete

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95
Q

serial beta-hcg levels increase until:

A

end of first trimester

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96
Q

US findings in a missed abortion (<20 weeks)

A
  • embryo without cardiac activity

- or empty gestational sac without a fetal pole (would first repeat in a week to see if any change)

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97
Q

T/F: AMA is a risk factor for spontaneous abortion

A

true

98
Q

how can you determine if patient has a hydatiform mole?

A

heavy bleeding/abnormal gestation, snowstorm appearance on US, markedly elevated hCGH (>100,000)

99
Q

signs of a missed abortion

A
  • may be asx, have decreased pregnancy sxs (nausea, breast tenderness), and light vaginal bleeding
  • PE reveals closed cervix
  • US shows no caridac activity/no fetal pole
  • hCG levels decrease
100
Q

the major risk factor for preterm delivery

A

PRIOR PRETERM DELIVERY (i.e due to preterm labor or PPROM)

  • ->IM progesterone in 2nd/3rd tri minimizes risk
  • ->serial cervical measurements, Cerclage if short
101
Q

Normal changes in pueriperium period (after delivery)

A

firm/contracted uterus; shivering; breast enlargement; peripheral edema; LOCHIA: Red discharge for first few days, until white discharge 2-3 weeks later

102
Q

Protracted or arrested first stage of labor (i.e. active phase)

A

If adequate ctxs: C-section

Otherwise: Oxytocin

103
Q

Why do patients with HELLP/PreE with impending E syndrome develop abdominal/RUQ pain?

A

Liver swelling with DISTENTION of the hepatic capsule

104
Q

Tx of HELLP syndrome

A

Mg, Deliver, anti-htn drugs

105
Q

T/F: Pulmonary edema is a life-threatening complication of severe PreE

A

True: arterial vasospasm = increased afterload/systemic htn = increase pulm cap P = Pulm Edema. Also have dec albumin and renal f(x). Give O2, fluid restriction and diuresis.

106
Q

Major indication of Mag Sulfate toxicity (preg)

A

Absent deep tendon reflexes

107
Q

Adhesions, powder burns lesions, nodules, chocolate cysts, endometrial glands and stroma outside the endometrium

A

endometriosis

108
Q

tx for asx endometriosis

A

observation

109
Q

tx for sx endometriosis

A

OCP OCP OCP!!! Nsaids for pain relief. if necessary: Progesterone IUD (or GnRH analog: Leoprolide, danazol)

110
Q

adverse effects of oxytocin

A

Hyponatremia, Hypotension, Uterine Tachysystole (abnormally frequent ctxs)

111
Q

fetal malposition vs malpresentation

A

Malposition: rel of fetal presenting part (i.e. occiput anterior/posterior/transverse) to maternal pelvis. This is cause for arrested 2nd stage of labor

Presentation: Vertex (head first) vs breech. can cause labor protraction

112
Q

Management of intrauterine fetal demise (aka greater than 20 weeks) –> i.e. MISSED ABORTION

A

<24 weeks: Dilation and evacuation (suction curettage)
>24 weeks: Oxytocin to induce Vaginal delivery
(when patient is ready, can wait a few days. Don’t wait too long because risk of coagulopathy)

113
Q

Meds given during preterm labor

A

<32 weeks: Betamethasone, Tocolytic (Indomethacin/Nifedipine), Mag Sulfate, Penicillin if GBS unknown

32-34: Betamethasone, Tocolytic, Pen if GBS?

> 34: Betamethasone, Pen if GBS?

114
Q

Indomethacin and Nifedipine, when used during labor, are:

A

Tocolytics

115
Q

Mag sulfate is given during preterm labor

A

32; neuroprotection

116
Q

Progesterone is given to patients with a prior hx of ______ ______ to prevent _____ ______

A

Preterm labor x2

117
Q

+ Fetal fibronectin and shortened cervix on US indicate:

A

increased risk preterm delivery

118
Q

When does fetal growth restriction occur? Symmetric vs asymmetric

A

Symmetric: First trimester (chrom abnormalities, infection)
Asymmetric: 2nd/3rd (placental insuff aka HTN or DM, malnutrition)

119
Q

Difference btwn symmetric and asymmetric growth restrction

A

Sym: 1st tri. Global delay
Asymm: 2nd/3rd. Head-sparing delay

120
Q

features of wernicke encephalopathy (secondary to hyperemesis gravidarum, malnutrtion, alcohol)

A
  • Encephalopathy
  • Oculomotor dysf(x) aka nystagmus
  • ataxia (postural/gait)
  • labs: elevated LFTs, hypochloremic metab acid, hypoglycemia
121
Q

Premature detachment of the placenta due to rupture of maternal decidual vessels

A

Placental abruption

122
Q

T/F: Hydatiform mole can cause preeclampsia

A

True, typically <20 weeks gestation

123
Q

After suction curettage of molar pregancy, why do you give OCP for 1 year?

A

So you can track b-hCG levels and monitor for development of choriocarcinoma (bad shit). check it every week

124
Q

whats the difference between a threatened and inevitable abortion?

A

Threatened: no passage of contents; cervix closed; LIVE BABY STILL…can be rescue w/strict bed rest

Inevitable: no passage contents; CERVIX OPEN; DEAD BABY

125
Q

tx for AUB

A

1st line: OCP. Also, NSAIDs (effects PG)

126
Q

most common cause of AUB

A

Anovulation

progesterone isnt produced and proliferative endometrium due to E2 continues to grow until outgrows blood supply

127
Q

Tx for PCOS

A

METFORMIN 1st.
OCP (no preg desired) or Clomiphene (des preg)
Spironolactone for hirsutism

128
Q

LH:FSH ratio to keep in mind of rdx of PCOS

A

LH:FSH>3:1. so lots of LH. Also look for elevated DHEAS and Testosterone

129
Q

Etiology of AUB

A

Structural: PALM
(polyp, adenomyosis, leiomyoma, malignancy)

Nonstructural: COEIN
(Coag, ovulatory dysfx, endometrial, IUD, nothing)

130
Q

T/F: Fibroids can turn into uterine cancer

A

False. Leiomyoma aka fibroids are benign

131
Q

T/F: Fibroids are progesterone responsive

A

False, they are Estrogen responsive. Tx with OCP

132
Q

Medical tx for Fibroids

A

OCP OCP OCP (levonorgestrel IUD is equiv to ocp also)

-for a big ass fibroid that needs to be shrunk, give Leoprolide (GnRH agonist)

133
Q

tx for structural causes of AUB

A

Fibroids and Adenomyosis: OCP!

Polyp: Surgical excision (hysteroscopic polypectomy)

134
Q

T/F: Copper IUD is good for a patient who typically has heavy periods

A

False, Copper IUD can cause heavy bleeding

–>use levonogestrel IUD

135
Q

T/F: Levonogestrel IUD creates barrier by thickening cervical mucus and impairing implantation. Common side effect = amenorrhea = good for anemic/AUB patients

A

True

136
Q

T/F: Lactation is considered an acceptable form of contraception

A

False. Gives some degree of contraception b/c causes anovulation, but ovulation can resume while mother is breast feeding

137
Q

Dx workup for _____ ______ includes Q-tip test which looks for abnormal urethrovesicle angle

A

Urethral hypermobility aka Stress Incontinence (can also be caused by dec urethral sphincter tone)

138
Q

T/F: Menopausal patients with atrophic vaginitis may have dysuria/frequency in the absence of UTI

A

True, due to embryological origin of both tracts it can happen together

139
Q

Proliferation of smooth muscle within myometrium

A

Fibroids

140
Q

Menstrual bleeding >5 days and heavy

A

AUB

141
Q

Presentation of endometrial cancer

A

Post-menopausal bleeding with normal sized uterus

142
Q

Bulky, tender uterus that is uniformly enlarged

A

Adenomyosis

143
Q

Risks of OCPs

A
  • DVT
  • Hypertension
  • Hepatic Adenoma
  • rare: stroke/MI
144
Q

Benefits of OCPs

A
  • contraception
  • Endometrial/Ovarian CA risk reduction
  • menstrual regulation, reduced IDA
  • reduced risk benign breast dz (fibroadenoma)
145
Q

when is an IUP seen on US?

A

hcg>1500-2000

146
Q

Antimuscarinic and Cholinergic agonist: Assign to type of incontinence

A

Anti-muscarinic (oxybutynin): Urge incontinence

Cholinergic (bethanechol): Overflow

147
Q

Female with hx of miscarriages and heavy bleeding, abnormal PE

A

Fibroids bruh bruh. “globular mass”

148
Q

T/F: Intraductal papilloma presents with unilateral bloody discharge and no other sxs

A

true

149
Q

When would you expect a patient to have breast fat necrosis?

A

after trauma or surgery. ill-defined breast mass with irregular borders

150
Q

Diffusely warm and erythematous breast with some dimpling after mastitis

A

PEASANT: PEAU d Orange = Inflammatory breast CA.
May also have itching, lymphadenopathy(mets), nipple retraction/flattening.

(not abscess…which would present with high fever and responsive to antibiotics).

151
Q

tender, shallow labial ulcers with mildly enlarged and tender inguinal lymph nodes

A

PEASANT: HSV, not Chlamydia!! If painful vesicles, its either HSV (small/shallow) or H Ducreyi (large/deep)

152
Q

painless small labial ulcers with large and painful inguinal lymphadenopathy

A

LGV from CT

153
Q

T/F: Lymphogranuloma venerum is different from granuloma inguinale

A

True

154
Q

Small painless vulvar papule that becomes ulcerated, along with mild non tender inguinal lymphadenopathy

A

Peasant: Syphilis! Not LGV (which has large and painful inguinal lymphadenopathy)

155
Q

tx for patient with suspected syphilis but negative RPR/VDLR

A

Penicillin…RPR/VDRL are non-treponemal tests and have high FN rate

156
Q

What is the clue that women >35 is having infertility due to decreased ovarian reserve?

A

Regular menstrual cycles. Having decreased number and quality of oocytes (so lower conception rate)

157
Q

What is a clue that patient is having infertility due to hypothalamic dysf(x)?

A

Lots of exercise/stress AND anovulation ( so normal periods makes this less likely and probs decreased ovarian reserve)

158
Q

whats the worst type of ovarian cancer? Presents with ascites/obstructive sxs (i.e. renal/uro)

A

Epithelial ovarian ca. Will see inc CA-125.

–>Tx: ex lap

159
Q

Condylomata lata vs condylomata accuminata

A

CL: secondary syphillis. flat velvety lesions, broad base, lobulated/plaque-like

Condylomata accuminta = GENITAL WARTS (HPV 6/11). soft, pink, or skin colored, cauliflower/papular growths. can bleed or itch sometimes.
–>Tx: Podophyllin resin/trichloroacetic acid, Imiquiod, cryo/laser therapy

160
Q

Lichen planus vs lichen sclerosis

A

LP; pruritic, glassy bright RED erosions and ulceration

LS: pruritic WHITE thin wrinkled (prepubertal or postmenopausal)

161
Q

Adverse effects of SERMS (tamoxifen/raloxifen)

A
  • Hot flashes
  • DVT
  • Endometrial hyperplasia/cancer (Tamox only)

Note: NOT osteoporosis…it can actually increase bone density (raloxifene is used for osteo)

162
Q

Post-menopausal bleeding in the setting of HRT

A

Endometrial cancer worry…get pelvic ultrasound…worried if endometrial stripe >4mm

163
Q

most common use and side effect of Tamoxifen

A

Use: Adjuvant to tx ER+ breast cancer

Side effect: Hot flashes

164
Q

presentation of ovarian follicular cyst

A

Small, occur in first half of menstrual cycle . simple/thin-walled

165
Q

presentation of cystic teratoma

A

aka dermoid ovarian cyst. premenopausal chick. adnexal fullness. US = hyperechoic with calcifications

166
Q

presentation of theca-lutein cysts

A

Occur only during pregnancy!!
from ovarian stim by high hcg (i.e. molar pregnancy, pregnancy) and resolve after these levels decline. US: multiseptated bilateral cystic masses without hyperechoic nodules or calcifications

167
Q

Pelvic pain in a patient with ovarian mass (i.e. benign cyst, tumor, etc)

A

OVARIAN TORSION UNTIL PROVEN OTHERWISE PEASANT. AKA ISCHEMIC NECROSIS

168
Q

sudden onset lower abdominal pain in female following strenuous/sexual activity. US: pelvic free fluid

A

ruptured ovarian cyst

169
Q

fevers/chills, cervical motion tenderness, lower abdominal pain and vaginal discharge

A

PID. May have TOA associated

170
Q

bilateral gray mammary discharge that is guaic negative in non-breast feeding woman

A

galactorrhea. can be clear/milky. check prolactin and tsh levels. MRI for prolactinoma.

171
Q

Atypical glandular cells on Pap. next step?

A

if >35 or <35 w/risk factors (obesity/anovulation): look for both endometrial and cervical ca: Endometrial bx, endocervical curettage and colposcopy

172
Q

causes of variable decels

A

Umbilical Cord compression
Oligo
Cord prolapse

173
Q

when should you be weary of calling it an early decel on FHR?

A

If it is abrupt onset, sharp peaks, drop far. Can be recurrent variables (occur with >50% ctxs) in this case (cord compression) –> would need maternal repositioning or amnioinfusion

174
Q

difference between intermittent and recurrent variable decels on FHR?

A

Both umbilical cord compression. Occur with:
<50% ctxs: Intermittent –>well-tolerated
>50: Recurrent –>alleviated by maternal repositioning or amnioinfusion

175
Q

If you suspect renal colic in pregnancy, how would you dx?

A

UA and US.

CT and IV Pyelogram are contraindicated, as is shockwave lithiotripsy

176
Q

Postpartum women with enlarged uterus, irregular vaginal bleeding, pulmonary sxs and multiple infiltrates on CXR. Dx and dz?

A

Get a b-HCG…suspect Choriocarcinoma (lung mets most common)

177
Q

Elevation of bHCG after a miscarriage, normal delivery or molar pregnancy

A

Choriocarcinoma

178
Q

Dx, mgmt, and staging of choriocarcioma

A

elevated bHCG in postpartum female. Transvaginal US; cut it out with curettage (bx) and stage it with CT

179
Q

Tx of choriocarcinoma

A

Total abdominal hysterectomy/debulking + chemo (Methotrexate, Actinomycin D, Cyclophosphamide) if refractory

180
Q

Complete mole makeup

A

“Completely male”….normal number of chromosomes but its all sperm (good fertilization but bad egg so sperm doubles)

181
Q

@ sperm fertilizing one egg…abnormal # chromosomes (69)

A

Incomplete mole

182
Q

Management of molar pregnancy

A
  1. Suction curettage (grape-like mass)
  2. track HCG weekly (assure its gone)
  3. OCPs prevent pregnancy (choriocarcinoma monitoring…looking for increasing hcg)
183
Q

most accurate way to determine gestational age

A

First trimester US (with crown-rump length): bitch do NOT change based on discrepencies with 2nd/3rd term measurements. I.e. fundal height is not more accurate

184
Q

T/F: Lichen sclerosis/planus do not affect the vagina, whereas atrophic vaginitis does

A

False. Lichen sclerosis does NOT affect vagina, so if they say vaginal mucosa appears thin and pale it cant be LS.

Lichen planus can involve vagina but will be erythematous/erosive lesions

185
Q

which is the only cancer staged clinically (not surgically)?

A

Cervical: Colposcopy, rectal and vaginal exams. Further down the vagina, higher the grade. can also use CT

Ia/b: Cervic
IIa: upper 2/3 vagina
-can use local tx up to here, after its chemo/rads
IIIa: lower 1/3 vagina
IV: Adj organs and distant mets
186
Q

patient starts having sex at 13. When should she receive Pap?

A

annually at 21 regardless of when she lost viriginity

187
Q

Abnormal pap (AGUS, not ASCUS), next step?

A

(reflexive) colposcopy…samples ectocervix (bx) and endocervix (curettage).

+Ecto only: LEEP, Cryo or laser (local)
+Endo: Cone biopsy required.

If pregnant, defer colpo/cone bx until after (takes 3-7 years to develop cancer from precancer so 9 months is fine)

188
Q

Pap shows ASCUS. Next step?

A

Either get a HPV DNA to see if its high risk HPV (then you would get colposcopy), or repeat the pap q3-6 months.

So NOT reflexive colp like with AGUS

189
Q

Risk factors for cervical cancer

A 
HPV
SMOKING SMOKING SMOKING SMOKING SMOKING
hx STDs
# of sexual partners and age at onset 
immunosuppression (HIV)

Note: NOT obesity/fhx

190
Q

T/F: Endometrial cancer is ruled out when US shows thin endometrial stripe (<4mm)

A

True nigglet

191
Q

T/F: Progesterone-only contrapcetion, i.e. IUD or pill, and OCPs increases risk of endometrial cancer

A

FALSE AF. prevents endometrial cancer (by stimulating differentiation of endometrial cells). Progesterone = Protective

192
Q

T/F: Endometriosis is a risk factor for ovarian cancer, which can prevent as ascites

A

True AF. FHx is also risk factor.

193
Q

T/F: Endometriosis presents with big risk of endometrial cancer

A

False, Infertility. can lead to ovarian cancer.

194
Q

dyspareunia, dysmenorrhea, chronic pelvic pain, infertility, dyschezia

A

endometriosis

195
Q

systemic inflammation and platelet consumption in pregnancy complicated by htn

A

HELLP –> inflammatory

196
Q

mgmt of HELLP

A

stabilize mom, delivery baby! life-threatening.

197
Q

tx for intrahepatic cholestasis of pregnancy (intense nocturnal pruritis on hands and feet, dark urine)

A

ursodeoxycholic acid (also used for PBC and PSC)

198
Q

Intermenstrual spotting without uterine enlargement

A

Endometrial polyps

199
Q

Adnexal mass + GI sxs (constipation/diarrhea/bloating/ascites)

A

Ovarian cancer

200
Q

exercise-induced amennorhea is due to

A

hypothalamus (low GnRH, low LH/FSH, low E2)

–>tx: increase calories, estrogen, calcium and vit D

201
Q

T/F: Lung cancer is the most common in men and women

A

False. Sex (breast/prostate) are most common. Lung is most fatal.

202
Q

how often should women get mammograms?

A

Start at 50 and then q2 years

203
Q

when is hyperemesis gravidarum and theca-lutein cysts (and hyperthyroidism) seen?

A

MOLAR PREGNANCIES (ANY GTBD).

204
Q

bilateral cystic enlargements of the ovary, size greater than dates, absence of fetal heart tones, severe n/v

A

Molar pregnancy (any GTBD). bilat = theca lutein cysts

205
Q

first thing to do in any postmenopausal woman with bleeding

A

look for endometrial cancer: Either Dilation with curettage (DandC) or endometrial bx (sampling).

  • Negative: probs vaginal atrophy (E2 creams help)
  • Hyperplasia: give progesterone
  • Adenocarcinoma: TAH and BSO
206
Q

T/F: Tamoxifen and OCPs are protective against endometrial cancer

A

False. OCPs are protective. Tamoxifen = estrogen agonist in the uterus = increased risk.

207
Q

why are germ cell tumors in female treated conservatively and what does this mean?

A

Usually benign tumors in teenage girls. They tend to get big before they get bad, so can remove them in Stage 1 (non malignant).
Tx: Unilateral oopherectomy so they can have kids.

-Teratoma, Choriocarcinoma, Endodermal Sinus (AFP), Dysgerminoma (LDH, responds to chemo)

208
Q

What are the epithelial ovarian cancers and how do they present?

A

These are horrible, present very late and malignant. Post menopausal female, ascites/SBO/renal failure.
Serous/Mucinous/Endometroid CystAdenoCarcinoma, as well as Brenner Tumor

209
Q

why do molar pregnancies cause hyperthyroidism and hypeemesis gravidarum?

A

way increased b-hCG

210
Q

grape-like mass in vagina vs cervix

A

Vagina: Clear cell adenocarcinoma (DES)
Cervix: Molar pregnancy

211
Q

Squamous cell carcinoma of vagina and vulva are caused by _____. The other 2 types of cancer in the vulva are:

A
  • SCC = HPV.
  • Vulvar: also from melanoma (black lesion; SCC is also black), Pagets (red lesion).
  • vulvar cancer = pruritic.
  • Paget = local resection
  • 2 black ones need vulvectomy and LN dissection (mets potential)
212
Q

US of female with adnexal mass shows complex cyst. Next step?

A

DONT do OCP or Aspiration (doesnt decrease size; can seed)

Do Laparoscopic removal.

213
Q

Young girl with lots of weight gain, abdominal girth, US showing complex cyst that is enormous. Dx and risk of:

A

Teratoma (DERMOID CYST). Any female with adnexal mass at risk for Ovarian torsion. Do cytectomy without oophorectomy (teratoma is benign)

214
Q

what will US of endometriosis show

A

complex cyst

215
Q

how do you manage ectopic pregnancy?

A

If ruptured: Salpingectomy (get the tube out)
Not ruptured: try for salpinostomy (preserves fertility)
Methotrexate is most fertility sparing: can be used if no heart tones, zygote <3.5cm, HCG <5000 (up to 8000), No hx folate supplementation

216
Q

T/F: Threatened abortion is treated/saved by bedrest only

A

TRUE AF

217
Q

Pregnant patient comes in due to bleeding. No passage of contents, cervix is closed, US shows live baby. Tx?

A

Bedrest –> Threatened abortion

218
Q

What do you need to give mom after an abortion?

A

IVIg (Rhogham) to prevent isoimmunization (if she is Rh-)

219
Q

female comes in with some form of life-threatening uterine bleeding, what are you giving her?

A

IV Estrogen! (will ultimately taper to OCPs and NSAIDS, the mainstay of AUB tx

220
Q

T/F: Prolactinoma causing secondary amenorrhea is best treated by surgical resection

A

False. BEST TREATMENT/1ST LINE = PRAMIPREXOLE/ROPINOROLE (dopamine agonists…dopamine inhibits prolactin. bromocriptine is the other option, meded says no MTB yes). only do surgery if medical doesn’t work.

221
Q

mom is GBS+, but penicillin-allergic. What do you give at 35-37 weeks?

A

Erythromycin or clindamycin.

Say PCE to GBS @35-37 weeks

222
Q

How do you tx neonatal sepsis (i.e. GBS)

A
  • AMPICILLIN!! (you gave mom intrapartum penicillin, give baby amp).
  • Empiric tx = ampicillin and gentamicin, with cefotaxime if possible meningitis.
223
Q

HIV drugs and pregnancy

A
  • get HIV+ mom on HAART asap (Tenofiver + Emtricatabine and Nevirapine)
  • do a c/s to decrease bloody contact
  • if all else fails, give ZIDOVUDINE @ delivery; contraindicated in pregnancy = Efavirenz and delavirdine (NNRTI). Screen baby at 6mo.
224
Q

How do we screen for fetal anemia?

A

Transcranial doppler: INCREASED flow = fetal anemia

  • If + and <34 weeks: PUBS (percutaneous umbilical cord sampling to get a fetal Hgb) to confirm
  • If + and >34 weeks: deliver
225
Q

Tx of fetal anemia

A

-if you’ve gotten a PUBS (+transcranial doppler and <34 weeks), transfuse through the PUBS

226
Q

when is Rhogham given to Rh- mom?

A

Rh+ baby (dad is positive or unknown)..give at 28 weeks and w/in 72 hours of delivery

Also, with PPH, abortion, previa/abruption and D/C

227
Q

With isoimmunization (Rh stuff), Rh- mom is exposed on first baby. Would her antibodies attack this baby?

A

Nope because 1st exposure creates IgM (unless prior blood transfusion).
2nd exposure causes IgG, which crosses placenta and leads to fetal anemia.

228
Q

whats the main cause of PROM (premature rom)

A

Ascending infection: usually E coli or GBS

  • ->give Amp and Gent
  • ->since they are term (not pPROM), deliver
229
Q

PPH: Boggy vs absent vs firm uterus

A

Boggy: Atony (most common). Massage, methergine, pit

Absent: Inversion. Tack fornices/traction and pit

Firm: Retained placenta (accreta/increta/percreta), do D&C, possible hysterectomy. f/u US/bhCG

230
Q

which of the causes of PPH may present as continued bleeding weeks after delivery and vessels that run to the edge?

A

Retained placenta –> increased risk with multiparity (gets old/used up…placenta would either go wide (previa) or deep (retained))

231
Q

“uterus may sometimes go wide or deep, looking for its oil” what does this mean bruh

A

in a multip, vascular supply of uterus not as rich. placenta wants blood. so may have to go wide (results in previa) or deep (results in retained placenta –>PPH with firm uterus)

232
Q

difference btwn placenta previa and vasa previa

A

both are baby’s blood.

  • Placenta previa: placenta covering Os and cervical dilation tears it. Get c/s
  • Vasa previa (rare): vessels across Os (connected to Accessory lobe). Presents with fetal Bradycardia. Get c/s
233
Q

Loss of fetal station (3rd trimester bleeding)

A

Uterine rupture (prior c/s scar so VBAC)

  • ->no dx steps
  • ->need CRASH C/S…minutes to get baby out before suffocates (no air in peritoneum)
234
Q

the 3 causes of placental abruption

A

HTN
Cocaine
MVC
get a c/s (or US and NST, moms vitals)

235
Q

HTN in pregnancy i.e. chronic (before 20 weeks). whats the med quick quick

A

alpha-methyldopa
alpha-methyldopa
alpha-methyldopa

(labetolol/hydralazine as backups)

236
Q

why are seizures seen in eclampsia?

A

Fetal proteins cause diffuse vasospasm (start seeing this in PreE)…seizures occur due to cerebral vasospasm

237
Q

tx for retained placenta (firm uterus)

A

manual removal or D and C. May need hysterectomy.

238
Q

decreased fetal movement. whats next?

A

First NST: look for 15, 15, 2 in 20 (15bpm increase in HR sustained for at least 15 seconds occurring 2x in 20 min)
Non-reassuring? Vibroacoustic stim (baby might be sleeping). 15, 15, 2 in 20
Non reassuring? BPP (NST + US)….0-4: deliver (c/s); 8-10: reassure, repeat qweek.
–>if 4-8: >36 week you deliver (vag). i f<36, do a contraction stress test (only if in labor tho)…admit them and watch. would only need to deliver (c/s) if late decels

239
Q

when do you do a contraction stress test?

A

DURING LABOR (you don’t induce ctxs for a failed BPP)

  • ->look for 3 ctxs every 10 min first
  • ->early and variable decels are fine
  • ->late decels = deliver now (c/s)
240
Q

pregnant lady with htn and abdominal pain. What is the first thing you want to think?

A

SIGN OF IMPENDING ELAMPSIA. caused by capsular stretch. Need to give magnesium, control BP with metoprolol/hydralazine, and get baby out (induce or c/s). get CBC, DIC and LFTs also to r/o full eclampsia (c/s).

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