OB Flashcards
A patient is 28 weeks pregnant and is rubella non-immune. How is this handled?
Wait til post-partum period for immunization since MMR is a Live vaccine!
When is Anti-D immunoglobulin given?
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
what is done in the type and antibody screen?
Check blood type: A, B, AB, O Rh(D) status: + or - RBC antibodies (alloimminuzed or not)
When do you test for GBS?
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
T/F: Pregnant women should undergo screening with urine culture and tx of symptomatic bacteriuria only in the first trimester
F: Should undergo screening and tx of even asymptomatic bacteruria in 1st trimester b/c risk of pyelo
what are the components of a BPP (biophysical profile)?
- NONSTRESS TEST (reactive hr)
US:
- amniotic fluid volume
- fetal movements ( >3 gen body movements)
- fetal tone ( >1 ep flexion/extension)
- fetal breathing movements (>1 breathing ep >30 sec)
total scored 0-10; 2 = normal for each, minimum 30 minutes test
scoring indications for BPP
8-10: Normal
6: equivocal
<4: INDICATION FOR DELIVERY to prevent intrauterine demise
Late term (41 weeks) and post-term (42) pregnancies are at risk of _________ _________
Uteroplacental insufficiency
What risks come with uteroplacental insufficiency?
- Compression of uterine vessels during contractions cause hypoxia = reflex fetal bradycardia = late decels
- poor fetal perfusion = poor urine production = oligohydramnios
Fetal tachycardia, maternal fever and uterine tenderness
intra-amniotic infection (chorioamnionitis)
T/F: Nuchal cords are rare and cause for immediate delivery
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)
When is betamethasone used?
Decrease respiratory distress syndrome in preterm infants. Admin @ <37 weeks for high risk patients
T/F: Intrapartum penicillin is most effective for GBS prophylaxis if admin prior to labor
False. Bacteria regrows rapidly during labor
What is indomethacin used for in pregnant patients?
Tocolysis. Indomethacin is contraindicated after 32 weeks due to risks of PDA closure. Tocolysis is not done after 34 weeks.
Mag sulfate is admin for ____ _____ at <32 weeks
fetal neuroprotection
How can you monitor for adequacy of contractions during labor?
Intrauterine tocometer (after membranes ruptured). 200 Montevideo units in a 10 minute period.
Why is shoulder dystocia an emergency?
risk for neonatal brachial plexus injury, clavicular and humeral fracture, and possibly hypoxic brain injury and death
Biggest risk factor for shoulder dystocia
fetal macrosomia –> maternal obesity, GDM, post-term pregnancy, excessive wt gain during preg
warning signs of an impending shoulder dystocia
prolonged first and second stage of labor, and retraction of the head into perineum after delivery (turtle sign)
What is stage 1 of labor?
0cm - 10cm.
Latent: 0-6cm. <20 hours (np), <14 hours (mp)
Active: 6-10cm
What is stage 2 of labor?
10cm - fetus delivery. <3 hours (np), <2 hours (mp)
What is stage 3 of labor?
fetus delivery - delivery of placenta. <30 minutes
What allows cervical dilation?
Breakage of disulfide bonds. Stimulated by fetal head engagement
Shortening/thinning/ripening of the cervical canal
effacement
How is PPROM managed at 34-37 weeks?
Preterm Premature ROM
- Antibiotics
- +/- Corticosteroids
- Delivery
What is PPROM?
Preterm Premature ROM, so <37 weeks
How is PPROM managed <34 weeks
- Antibiotics (Intrapartum Penicillin for GBS status unknown)
- Corticosteroids
If signs of infection: Delivery + Mag if <32 weeks
No infection: Fetal surveillance
When is amnioinfusion appropriate?
Refers to saline instillation into uterine cavity. Done for tx of recurrent variable decels due to umbilical cord compression during labor
most common cause of postpartum hemorrhage <24 hours after delivery
Uterine atony (myometrial contractions important for compression of placental vessels aka hemostasis)
risk factors for uterine atony (which leads to PPH)
- prolonged labor
- over distention (fetal wt >4000g, multiple gest), polyhydramnios
- chorioamnionitis
- unresponsive to pit
- forcep/vacuum delivery
- htn disorders
clinical indications of uterine atony
soft (Boggy) and enlarged (above the umbilicus)
Post partum ultrasound shows a thin endometrial stripe. What does this mean?
Suggests and empty and normal uterine cavity, making retained placenta etc unlikely
Definition of PPH
Post partum hemorrhage:
>500mL after vaginal delivery
>1000mL after c/s
Uterotonic agents that can be used to tx PPH/uterine atony
- Oxytocin is 1st line
- Methylergonivine: smooth m contraction, vasoconstrict
- Carboprost: synthetic PG, c/i in asthma b/c bronchoconstrictor
Uterine massage –> Methylergonivine –> Oxytocin
T/F: Placenta previa is a c/i to vaginal delivery
True (only if covering/<2cm from cervical os)
How can you use fetal fibronectin levels to predict preterm delivery?
Levels are high til 20 weeks and low in 2nd/3rd tri and increase at term. Elevated levels just prior to term = increased risk.
T/F: Patients with prior cervical surgery at increased risk of preterm delivery
True, i.e conization.
- ->Gold Standard test: TransVAGINAL US to measure cervical length
- ->Progesterone therapy maintains uterine quiesence w
pregnant patient comes in with hypertension. Whats the cutoff for primary vs gestational? (week)
20 weeks. Prior to this its primary htn.
Fetal risks due to maternal htn
Preterm delivery, oligo, growth restriction
maternal risks due to maternal htn
PreE, PPH, GDM, Placental abruption, C/s
how does placental abruption present?
sudden onset vaginal bleeding + tender uterus. also, high frequency, low intensity contractions. It is due to premature placental detachment.
who gets placental abruption?
smoker/cocaine use, maternal PreE/htn, abdominal trauma
maternal complications of placental abruption
hypovolemic shock and DIC.
Tx of PreE
Mag Sulfate
Tx of PreE
Mag Sulfate + delivery
Chronic pelvic pain, urinary urgency, painful sex in a female
Interstitial cystitis
Sxs and risk factors for vesicovaginal fistula
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
1st line anti-htn meds in pregnancy
-Methyldopa!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
- Beta blockers (labetolol)
- Hydralazine
- CCB (nifedipine)
anti-htn meds CI in pregnancy
ACE-I
ARB
Furosemide
Spironolactone
T/F: Trisomy 18 and 21 both have increased hCG and decreased AFP
False. 21 has increased hCG, 18 has decreased. in addition, 21 has increased Inhibin A
T/F: Needle aspiration of an adnexal mass in postmenopausal women is CI
True, risk of seeding malignant cells. Do CA-125 levels
Pruritis, elevated bile acids and ALT/AST in pregnancy
Intrahepatic cholestasis of pregnancy (ICP)
–>Ursodeoxycholic acid helps increase bile flow, early delivery once term is recommended
Ischemic pituitary necrosis after pregnancy
Sheehans: fatigue, wt loss, hypotension, poor breast feeding
clinical features of HELLP
PreE, N/V, RUQ pain
Tx of HELLP
Delivery, Mag Sulfate for seizure prophy, anti-htn
Dx workup for endometriosis
Laparoscopy
Pelvic pain + thickened uterosacral ligament
Endometriosis
T/F: Big future risk with endometriosis is osteoporosis
False, Infertility
Dx of chorioamnionitis
Clinical. Fever + 1 of the following:
- uterine tenderness
- maternal, fetal tachycardia
- purulent vaginal discharge
- malodorous amniotic fluid
What is a reactive nonstress test?
at least 2 accelerations in 20 minutes lasting 15 seconds (HR is increasing with movement)
What is a non-reactive nonstress test?
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.
Endometrial glands in the myometrium, causing dysmenorrhea and heavy menses
Adenomyosis
Symmetrically enlarged uterus that feels boggy, tender, globular + dysmenorrhea
Adenomyosis
most effective emergency contraception
Copper IUD, can be inserted up to 5 days later. CI = acute cervicitis and PID
risk factors for placental insufficency ( 0-4/10 on BPP)
tobacco, htn, diabetes, AMA
Toxicity of oxytocin
(its similar to ADH) water retention, hyponatremia and thus seizures
Fetal hydantoin syndrome (phenytoin)
small body size, microcephaly, digital hypoplasia, cleft palate (this feature is not part of FAS)
T/F: All pregnant women are screened for GDM
True, this happens at 24-28 weeks
Target blood glucose levels for GDM patients
<95, 1 hour post prandial <140
How do you manage a delivery with shoulder dystocia? The head is out but shoulders not passing
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
obesity causes amennorhea due to:
anovulation
What are the LH and FSH levels in anovulation?
Normal, as is estrogen. Have low progesterone, so no progesterone withdrawal menses
What lab values would be abnormal in premature ovarian failure?
Elevated LH and FSH
what is lochia
vaginal bloody/mucus discharge up to 6-8 weeks post partum
Next step if suspecting lichen sclerosis (atrophy, pruritis, white patches)
vulvar punch biopsy
Tx for atrophic vaginitis (dryness, thinning) and lichen sclerosis (same + pruritis, white patches)
AV: Low dose topical estrogen
LS: High dose corticosteroids (clobetasol)
which vaccines do you give in pregnancy?
Tdap
Inactivated Influenza
Rho Immunoglobulin
some contraindications to external cephalic version
uterine/fetal anomaly multiple gestation oligo ruptured mem extended fetal head
complications of cervical conization (for CIN 2, 3)
Cervical stenosis
Preterm birth, PPROM
2nd tri preg loss
gold standard for dx CIN
Colposcopy
how is dx of ectopic preg made?
Pregnancy test + transvaginal US
transabdominal will show no uterine preg
Patient presents with inevitable abortion at 10 weeks. Tx?
Hemo stable: Misoprostol
Hemo unstable: Suction curettage
Needs Rhogam also
Patient presents with ruptured ectopic. Tx?
Hemo stable: Methotrexate
Hemo unstable: Surgery (laparosopy)
(note: NOT a D/C…this is for spontaneous/inevitable abortion)
vaccines contraindicated in pregnancy
MMR
Varicella
HPV
Live attenuated influenza
vaccines safe in pregnancy
Tdap
Inactivated influenza
Rhogam
what labs are ordered during 2nd trimester visit (24-28weeks)?
- Oral glucose challenge test for GDM screen (50g 1 hr)
- Antibody screen if Rh-
- Hgb/HCT
what labs are ordered during 3rd trimester visit (35-37 weeks)?
GBS culture
what labs are ordered during initial prenatal visit?
- 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)
When is exercise contraindicated for a pregnant patient?
- multiple gestation
- cervical incompetence
- premature labor
- placenta previa/abruption
- PreE/gHTN
- amniotic fluid leak
otherwise, ok to exercise
sinusoidal fetal heart rate tracing (smooth undulating sign wave)
Fetal anemia
Hypoglycemia and fetal sleep give what type of FHR?
Nonreactive NST (no accelerations)
Types of abortions in which the cervical os is closed
Missed (no bleeding or cardiac), Threatened (bleeding and cardiac activity), Complete (bleeding or none)
Types of abortions in which there is no bleeding
Missed, possibly Complete
Types of abortions with dilated cervical os
Inevitable, Incomplete
serial beta-hcg levels increase until:
end of first trimester
US findings in a missed abortion (<20 weeks)
- embryo without cardiac activity
- or empty gestational sac without a fetal pole (would first repeat in a week to see if any change)
T/F: AMA is a risk factor for spontaneous abortion
true
how can you determine if patient has a hydatiform mole?
heavy bleeding/abnormal gestation, snowstorm appearance on US, markedly elevated hCGH (>100,000)
signs of a missed abortion
- 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
the major risk factor for preterm delivery
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
Normal changes in pueriperium period (after delivery)
firm/contracted uterus; shivering; breast enlargement; peripheral edema; LOCHIA: Red discharge for first few days, until white discharge 2-3 weeks later
Protracted or arrested first stage of labor (i.e. active phase)
If adequate ctxs: C-section
Otherwise: Oxytocin
Why do patients with HELLP/PreE with impending E syndrome develop abdominal/RUQ pain?
Liver swelling with DISTENTION of the hepatic capsule
Tx of HELLP syndrome
Mg, Deliver, anti-htn drugs
T/F: Pulmonary edema is a life-threatening complication of severe PreE
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.
Major indication of Mag Sulfate toxicity (preg)
Absent deep tendon reflexes
Adhesions, powder burns lesions, nodules, chocolate cysts, endometrial glands and stroma outside the endometrium
endometriosis
tx for asx endometriosis
observation
tx for sx endometriosis
OCP OCP OCP!!! Nsaids for pain relief. if necessary: Progesterone IUD (or GnRH analog: Leoprolide, danazol)
adverse effects of oxytocin
Hyponatremia, Hypotension, Uterine Tachysystole (abnormally frequent ctxs)
fetal malposition vs malpresentation
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
Management of intrauterine fetal demise (aka greater than 20 weeks) –> i.e. MISSED ABORTION
<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)
Meds given during preterm labor
<32 weeks: Betamethasone, Tocolytic (Indomethacin/Nifedipine), Mag Sulfate, Penicillin if GBS unknown
32-34: Betamethasone, Tocolytic, Pen if GBS?
> 34: Betamethasone, Pen if GBS?
Indomethacin and Nifedipine, when used during labor, are:
Tocolytics
Mag sulfate is given during preterm labor
32; neuroprotection
Progesterone is given to patients with a prior hx of ______ ______ to prevent _____ ______
Preterm labor x2
+ Fetal fibronectin and shortened cervix on US indicate:
increased risk preterm delivery
When does fetal growth restriction occur? Symmetric vs asymmetric
Symmetric: First trimester (chrom abnormalities, infection)
Asymmetric: 2nd/3rd (placental insuff aka HTN or DM, malnutrition)
Difference btwn symmetric and asymmetric growth restrction
Sym: 1st tri. Global delay
Asymm: 2nd/3rd. Head-sparing delay
features of wernicke encephalopathy (secondary to hyperemesis gravidarum, malnutrtion, alcohol)
- Encephalopathy
- Oculomotor dysf(x) aka nystagmus
- ataxia (postural/gait)
- labs: elevated LFTs, hypochloremic metab acid, hypoglycemia
Premature detachment of the placenta due to rupture of maternal decidual vessels
Placental abruption
T/F: Hydatiform mole can cause preeclampsia
True, typically <20 weeks gestation
After suction curettage of molar pregancy, why do you give OCP for 1 year?
So you can track b-hCG levels and monitor for development of choriocarcinoma (bad shit). check it every week
whats the difference between a threatened and inevitable abortion?
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
tx for AUB
1st line: OCP. Also, NSAIDs (effects PG)
most common cause of AUB
Anovulation
progesterone isnt produced and proliferative endometrium due to E2 continues to grow until outgrows blood supply
Tx for PCOS
METFORMIN 1st.
OCP (no preg desired) or Clomiphene (des preg)
Spironolactone for hirsutism
LH:FSH ratio to keep in mind of rdx of PCOS
LH:FSH>3:1. so lots of LH. Also look for elevated DHEAS and Testosterone
Etiology of AUB
Structural: PALM
(polyp, adenomyosis, leiomyoma, malignancy)
Nonstructural: COEIN
(Coag, ovulatory dysfx, endometrial, IUD, nothing)
T/F: Fibroids can turn into uterine cancer
False. Leiomyoma aka fibroids are benign
T/F: Fibroids are progesterone responsive
False, they are Estrogen responsive. Tx with OCP
Medical tx for Fibroids
OCP OCP OCP (levonorgestrel IUD is equiv to ocp also)
-for a big ass fibroid that needs to be shrunk, give Leoprolide (GnRH agonist)
tx for structural causes of AUB
Fibroids and Adenomyosis: OCP!
Polyp: Surgical excision (hysteroscopic polypectomy)
T/F: Copper IUD is good for a patient who typically has heavy periods
False, Copper IUD can cause heavy bleeding
–>use levonogestrel IUD
T/F: Levonogestrel IUD creates barrier by thickening cervical mucus and impairing implantation. Common side effect = amenorrhea = good for anemic/AUB patients
True
T/F: Lactation is considered an acceptable form of contraception
False. Gives some degree of contraception b/c causes anovulation, but ovulation can resume while mother is breast feeding
Dx workup for _____ ______ includes Q-tip test which looks for abnormal urethrovesicle angle
Urethral hypermobility aka Stress Incontinence (can also be caused by dec urethral sphincter tone)
T/F: Menopausal patients with atrophic vaginitis may have dysuria/frequency in the absence of UTI
True, due to embryological origin of both tracts it can happen together
Proliferation of smooth muscle within myometrium
Fibroids
Menstrual bleeding >5 days and heavy
AUB
Presentation of endometrial cancer
Post-menopausal bleeding with normal sized uterus
Bulky, tender uterus that is uniformly enlarged
Adenomyosis
Risks of OCPs
- DVT
- Hypertension
- Hepatic Adenoma
- rare: stroke/MI
Benefits of OCPs
- contraception
- Endometrial/Ovarian CA risk reduction
- menstrual regulation, reduced IDA
- reduced risk benign breast dz (fibroadenoma)
when is an IUP seen on US?
hcg>1500-2000
Antimuscarinic and Cholinergic agonist: Assign to type of incontinence
Anti-muscarinic (oxybutynin): Urge incontinence
Cholinergic (bethanechol): Overflow
Female with hx of miscarriages and heavy bleeding, abnormal PE
Fibroids bruh bruh. “globular mass”
T/F: Intraductal papilloma presents with unilateral bloody discharge and no other sxs
true
When would you expect a patient to have breast fat necrosis?
after trauma or surgery. ill-defined breast mass with irregular borders
Diffusely warm and erythematous breast with some dimpling after mastitis
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).
tender, shallow labial ulcers with mildly enlarged and tender inguinal lymph nodes
PEASANT: HSV, not Chlamydia!! If painful vesicles, its either HSV (small/shallow) or H Ducreyi (large/deep)
painless small labial ulcers with large and painful inguinal lymphadenopathy
LGV from CT
T/F: Lymphogranuloma venerum is different from granuloma inguinale
True
Small painless vulvar papule that becomes ulcerated, along with mild non tender inguinal lymphadenopathy
Peasant: Syphilis! Not LGV (which has large and painful inguinal lymphadenopathy)
tx for patient with suspected syphilis but negative RPR/VDLR
Penicillin…RPR/VDRL are non-treponemal tests and have high FN rate
What is the clue that women >35 is having infertility due to decreased ovarian reserve?
Regular menstrual cycles. Having decreased number and quality of oocytes (so lower conception rate)
What is a clue that patient is having infertility due to hypothalamic dysf(x)?
Lots of exercise/stress AND anovulation ( so normal periods makes this less likely and probs decreased ovarian reserve)
whats the worst type of ovarian cancer? Presents with ascites/obstructive sxs (i.e. renal/uro)
Epithelial ovarian ca. Will see inc CA-125.
–>Tx: ex lap
Condylomata lata vs condylomata accuminata
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
Lichen planus vs lichen sclerosis
LP; pruritic, glassy bright RED erosions and ulceration
LS: pruritic WHITE thin wrinkled (prepubertal or postmenopausal)
Adverse effects of SERMS (tamoxifen/raloxifen)
- Hot flashes
- DVT
- Endometrial hyperplasia/cancer (Tamox only)
Note: NOT osteoporosis…it can actually increase bone density (raloxifene is used for osteo)
Post-menopausal bleeding in the setting of HRT
Endometrial cancer worry…get pelvic ultrasound…worried if endometrial stripe >4mm
most common use and side effect of Tamoxifen
Use: Adjuvant to tx ER+ breast cancer
Side effect: Hot flashes
presentation of ovarian follicular cyst
Small, occur in first half of menstrual cycle . simple/thin-walled
presentation of cystic teratoma
aka dermoid ovarian cyst. premenopausal chick. adnexal fullness. US = hyperechoic with calcifications
presentation of theca-lutein cysts
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
Pelvic pain in a patient with ovarian mass (i.e. benign cyst, tumor, etc)
OVARIAN TORSION UNTIL PROVEN OTHERWISE PEASANT. AKA ISCHEMIC NECROSIS
sudden onset lower abdominal pain in female following strenuous/sexual activity. US: pelvic free fluid
ruptured ovarian cyst
fevers/chills, cervical motion tenderness, lower abdominal pain and vaginal discharge
PID. May have TOA associated
bilateral gray mammary discharge that is guaic negative in non-breast feeding woman
galactorrhea. can be clear/milky. check prolactin and tsh levels. MRI for prolactinoma.
Atypical glandular cells on Pap. next step?
if >35 or <35 w/risk factors (obesity/anovulation): look for both endometrial and cervical ca: Endometrial bx, endocervical curettage and colposcopy
causes of variable decels
Umbilical Cord compression
Oligo
Cord prolapse
when should you be weary of calling it an early decel on FHR?
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
difference between intermittent and recurrent variable decels on FHR?
Both umbilical cord compression. Occur with:
<50% ctxs: Intermittent –>well-tolerated
>50: Recurrent –>alleviated by maternal repositioning or amnioinfusion
If you suspect renal colic in pregnancy, how would you dx?
UA and US.
CT and IV Pyelogram are contraindicated, as is shockwave lithiotripsy
Postpartum women with enlarged uterus, irregular vaginal bleeding, pulmonary sxs and multiple infiltrates on CXR. Dx and dz?
Get a b-HCG…suspect Choriocarcinoma (lung mets most common)
Elevation of bHCG after a miscarriage, normal delivery or molar pregnancy
Choriocarcinoma
Dx, mgmt, and staging of choriocarcioma
elevated bHCG in postpartum female. Transvaginal US; cut it out with curettage (bx) and stage it with CT
Tx of choriocarcinoma
Total abdominal hysterectomy/debulking + chemo (Methotrexate, Actinomycin D, Cyclophosphamide) if refractory
Complete mole makeup
“Completely male”….normal number of chromosomes but its all sperm (good fertilization but bad egg so sperm doubles)
@ sperm fertilizing one egg…abnormal # chromosomes (69)
Incomplete mole
Management of molar pregnancy
- Suction curettage (grape-like mass)
- track HCG weekly (assure its gone)
- OCPs prevent pregnancy (choriocarcinoma monitoring…looking for increasing hcg)
most accurate way to determine gestational age
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
T/F: Lichen sclerosis/planus do not affect the vagina, whereas atrophic vaginitis does
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
which is the only cancer staged clinically (not surgically)?
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
patient starts having sex at 13. When should she receive Pap?
annually at 21 regardless of when she lost viriginity
Abnormal pap (AGUS, not ASCUS), next step?
(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)
Pap shows ASCUS. Next step?
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
Risk factors for cervical cancer
HPV SMOKING SMOKING SMOKING SMOKING SMOKING hx STDs # of sexual partners and age at onset immunosuppression (HIV)
Note: NOT obesity/fhx
T/F: Endometrial cancer is ruled out when US shows thin endometrial stripe (<4mm)
True nigglet
T/F: Progesterone-only contrapcetion, i.e. IUD or pill, and OCPs increases risk of endometrial cancer
FALSE AF. prevents endometrial cancer (by stimulating differentiation of endometrial cells). Progesterone = Protective
T/F: Endometriosis is a risk factor for ovarian cancer, which can prevent as ascites
True AF. FHx is also risk factor.
T/F: Endometriosis presents with big risk of endometrial cancer
False, Infertility. can lead to ovarian cancer.
dyspareunia, dysmenorrhea, chronic pelvic pain, infertility, dyschezia
endometriosis
systemic inflammation and platelet consumption in pregnancy complicated by htn
HELLP –> inflammatory
mgmt of HELLP
stabilize mom, delivery baby! life-threatening.
tx for intrahepatic cholestasis of pregnancy (intense nocturnal pruritis on hands and feet, dark urine)
ursodeoxycholic acid (also used for PBC and PSC)
Intermenstrual spotting without uterine enlargement
Endometrial polyps
Adnexal mass + GI sxs (constipation/diarrhea/bloating/ascites)
Ovarian cancer
exercise-induced amennorhea is due to
hypothalamus (low GnRH, low LH/FSH, low E2)
–>tx: increase calories, estrogen, calcium and vit D
T/F: Lung cancer is the most common in men and women
False. Sex (breast/prostate) are most common. Lung is most fatal.
how often should women get mammograms?
Start at 50 and then q2 years
when is hyperemesis gravidarum and theca-lutein cysts (and hyperthyroidism) seen?
MOLAR PREGNANCIES (ANY GTBD).
bilateral cystic enlargements of the ovary, size greater than dates, absence of fetal heart tones, severe n/v
Molar pregnancy (any GTBD). bilat = theca lutein cysts
first thing to do in any postmenopausal woman with bleeding
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
T/F: Tamoxifen and OCPs are protective against endometrial cancer
False. OCPs are protective. Tamoxifen = estrogen agonist in the uterus = increased risk.
why are germ cell tumors in female treated conservatively and what does this mean?
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)
What are the epithelial ovarian cancers and how do they present?
These are horrible, present very late and malignant. Post menopausal female, ascites/SBO/renal failure.
Serous/Mucinous/Endometroid CystAdenoCarcinoma, as well as Brenner Tumor
why do molar pregnancies cause hyperthyroidism and hypeemesis gravidarum?
way increased b-hCG
grape-like mass in vagina vs cervix
Vagina: Clear cell adenocarcinoma (DES)
Cervix: Molar pregnancy
Squamous cell carcinoma of vagina and vulva are caused by _____. The other 2 types of cancer in the vulva are:
- 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)
US of female with adnexal mass shows complex cyst. Next step?
DONT do OCP or Aspiration (doesnt decrease size; can seed)
Do Laparoscopic removal.
Young girl with lots of weight gain, abdominal girth, US showing complex cyst that is enormous. Dx and risk of:
Teratoma (DERMOID CYST). Any female with adnexal mass at risk for Ovarian torsion. Do cytectomy without oophorectomy (teratoma is benign)
what will US of endometriosis show
complex cyst
how do you manage ectopic pregnancy?
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
T/F: Threatened abortion is treated/saved by bedrest only
TRUE AF
Pregnant patient comes in due to bleeding. No passage of contents, cervix is closed, US shows live baby. Tx?
Bedrest –> Threatened abortion
What do you need to give mom after an abortion?
IVIg (Rhogham) to prevent isoimmunization (if she is Rh-)
female comes in with some form of life-threatening uterine bleeding, what are you giving her?
IV Estrogen! (will ultimately taper to OCPs and NSAIDS, the mainstay of AUB tx
T/F: Prolactinoma causing secondary amenorrhea is best treated by surgical resection
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.
mom is GBS+, but penicillin-allergic. What do you give at 35-37 weeks?
Erythromycin or clindamycin.
Say PCE to GBS @35-37 weeks
How do you tx neonatal sepsis (i.e. GBS)
- AMPICILLIN!! (you gave mom intrapartum penicillin, give baby amp).
- Empiric tx = ampicillin and gentamicin, with cefotaxime if possible meningitis.
HIV drugs and pregnancy
- 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.
How do we screen for fetal anemia?
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
Tx of fetal anemia
-if you’ve gotten a PUBS (+transcranial doppler and <34 weeks), transfuse through the PUBS
when is Rhogham given to Rh- mom?
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
With isoimmunization (Rh stuff), Rh- mom is exposed on first baby. Would her antibodies attack this baby?
Nope because 1st exposure creates IgM (unless prior blood transfusion).
2nd exposure causes IgG, which crosses placenta and leads to fetal anemia.
whats the main cause of PROM (premature rom)
Ascending infection: usually E coli or GBS
- ->give Amp and Gent
- ->since they are term (not pPROM), deliver
PPH: Boggy vs absent vs firm uterus
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
which of the causes of PPH may present as continued bleeding weeks after delivery and vessels that run to the edge?
Retained placenta –> increased risk with multiparity (gets old/used up…placenta would either go wide (previa) or deep (retained))
“uterus may sometimes go wide or deep, looking for its oil” what does this mean bruh
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)
difference btwn placenta previa and vasa previa
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
Loss of fetal station (3rd trimester bleeding)
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)
the 3 causes of placental abruption
HTN
Cocaine
MVC
get a c/s (or US and NST, moms vitals)
HTN in pregnancy i.e. chronic (before 20 weeks). whats the med quick quick
alpha-methyldopa
alpha-methyldopa
alpha-methyldopa
(labetolol/hydralazine as backups)
why are seizures seen in eclampsia?
Fetal proteins cause diffuse vasospasm (start seeing this in PreE)…seizures occur due to cerebral vasospasm
tx for retained placenta (firm uterus)
manual removal or D and C. May need hysterectomy.
decreased fetal movement. whats next?
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
when do you do a contraction stress test?
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)
pregnant lady with htn and abdominal pain. What is the first thing you want to think?
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).
