Ob-Gyn 1 Flashcards
1
Q
List medical circumstances in which minors can provide their own consent.
A
- Emergency care (all states)
- STIs (all states)
- Mental health and substance abuse treatment
- Pregnancy care
- Contraception
2
Q
List legal circumstances in which minors can provide their own consent.
A
- Financial independence
- Parent
- Married
- Active military service
- High school graduate
3
Q
True or false - in situations in which minors may be treated without parental consent, the patient also has the right to confidential treatment.
A
True
4
Q
Atypical glandular cells (AGC) on Pap testing may be due to either ___ or ___.
A
Cervical or endometrial adenocarcinoma
5
Q
When is an endometrial biopsy indicated?
A
35+ y/o: atypical glandular cells on Pap test
45+ y/o: abnormal uterine bleeding, postmenopausal bleeding
<45 y/o: abnormal uterine bleeding PLUS unopposed estrogen (obesity, anovulation), failed medical management, Lynch syndrome (hereditary nonpolyposis colorectal cancer
6
Q
How is AGC on Pap testing investigated?
A
Colposcopy, endocervical curettage, and endometrial biopsy (evaluates ectocervix, endocervix, and endometrium)
7
Q
List 2 risk factors for chlamydia and gonorrhea in women.
A
- <25 y/o
2. High-risk sexual behavior
8
Q
List 4 manifestations of chlamydia and gonorrhea in women.
A
- Asymptomatic (most common)
- Cervicitis
- Urethritis
- Perihepatitis (Fitz-Hugh-Curtis syndrome)
9
Q
How is chlamydia and gonorrhea diagnosed in women?
A
NAAT
10
Q
How are chlamydia and gonorrhea treated empirically?
A
Azithromycin + ceftriaxone
11
Q
How is confirmed chlamydia treated? Confirmed gonorrhea?
A
Chlamydia - azithromycin
Gonorrhea - azithromycin + ceftriaxone
12
Q
List 3 complications of chlamydia and gonorrhea in women.
A
- PID
- Ectopic pregnancy
- Infertility
13
Q
Classic presentation of acute cervicitis?
A
Mucopurulent discharge, friable cervix
14
Q
___ is a broad-spectrum regimen that provides polymicrobial coverage for PID.
A
Cefoxitin + doxycycline
15
Q
___ is used in the treatment of bacterial vaginosis and trichomoniasis.
A
Metronidazole
16
Q
List 4 risk factors for vaginal cancer.
A
- Age >60
- HPV infection
- Tobacco use
- In utero DES exposure (clear cell adenocarcinoma only)
17
Q
List the clinical features of vaginal cancer.
A
Vaginal bleeding, malodorous vaginal discharge, irregular vaginal lesion
18
Q
How is vaginal cancer diagnosed?
A
Vaginal biopsy, which determines the depth of invasion of atypical cells
19
Q
How is vaginal cancer treated?
A
Surgery + chemoradiation
20
Q
Describe the classic presentation of lesions inv aginal cancer.
A
Irregular plaque or ulcer located in the upper third of the posterior vagina
21
Q
When is endometrial biopsy indicated to evaluate for endometrial cancer?
A
Postmenopausal bleeding + an endometrial lining >4mm on U/S
22
Q
List the 4 major types of antepartum fetal surveillance.
A
- Nonstress test
- Biophysical profile
- Contraction stress test
- Doppler sonography of the umbilical artery
23
Q
What does antepartum fetal surveillance evaluate for?
A
Fetal hypoxia
24
Q
When is antepartum fetal surveillance performed?
A
Pregnancies with a high risk for fetal demise due to maternal (eg, HTN, DM) or fetal (eg, post-term pregnancy, growth restriction) conditions.
25
What is the most common antepartum fetal surveillance modality?
Biophysical profile (BPP)
26
What is involved in a nonstress test?
External fetal heart rate monitoring for 20-40 minutes
27
What is a normal non-stress test result?
Reactive: 2+ accelerations that are 15+ bpm above baseline and 15+ seconds long within a 20-minute period (can test for 40-minutes to account for a 20-minute fetal sleep cycle)
28
What is an abnormal non-stress test result?
Non-reactive: <2 accelerations
| Recurrent variable or late decelerations
29
What is involved in a biophysical profile?
Non-stress test + ultrasound assessment of amniotic fluid volume, fetal breathing movement, fetal movement, fetal tone
30
How is a biophysical profile scored?
2 points/category (5 total), 0 points if abnormal; normal result = 8 or 10 points, equivocal = 6 points, abnormal = 0, 2, or 4 points or oligohydramnios
31
What is involved in a contraction stress test?
External fetal HR monitoring during spontaneous or induced uterine contractions
32
What is a normal result in a contraction stress test?
No late or recurrent variable decelerations
33
What is an abnormal result in a contraction stress test?
Late decelerations with >50% of contractions
34
When is Doppler sonography of the umbilical artery used for antepartum fetal surveillance?
Fetal intrauterine growth restriction only
35
What is a normal result of Doppler sonography of the umbilical artery?
High-velocity diastolic flow in the umbilical artery
36
What is an abnormal result of Doppler sonography of the umbilical artery?
Decreased, absent, or reversed end-diastolic flow
37
If a BPP is equivocal (6/10), what should be done?
Repeat in 24 hours
38
___ is administered for seizure prophylaxis in patients with preeclampsia with severe features.
Magnesium sulfate
39
What is vibroacoustic stimulation used for during NST?
Stimulate a fetus to determine if lack of fetal HR accelerations is from fetal sleep
40
List 4 causes of hyperandrogenism in pregnancy.
1. Placental aromatase deficiency
2. Luteoma
3. Theca lutein cyst
4. Sertoli-Leydig tumor
41
Compare the types of ovarian masses seen in the 4 causes of hyperandrogenism in pregnancy.
1. Placental aromatase deficiency - no ovarian mass
2. Luteoma - solid, unilateral/bilateral ovarian masses
3. Theca lutein cyst - cystic, bilateral ovarian masses
4. Sertoli-Leydig tumor - solid unilateral ovarian mass
42
Compare the maternal and fetal virilization risk of the 4 causes of hyperandrogenism in pregnancy.
1. Placental aromatase deficiency - high maternal and fetal virilization risk
2. Luteoma - moderate maternal virilization risk; high fetal virilization risk
3. Theca lutein cyst - moderate maternal virilization risk; low fetal virilization risk
4. Sertoli-Leydig tumor - high maternal and fetal verilization risk
43
Compare the outcome/management of the 4 causes of hyperandrogenism in pregnancy.
1. Placental aromatase deficiency - resolution of maternal symptoms after delivery
2. Luteoma - spontaneous regression of masses after delivery
3. Theca lutein cyst - spontaneous regression of masses after delivery
4. Sertoli-Leydig tumor - surgery required (2nd trimester or postpartum)
44
How are patients with virilization during pregnancy and bilateral ovarian masses managed?
Observe and manage expectantly; symptoms and masses spontaneously regress after delivery due to falling beta-hcg levels
45
How do luteomas of pregnancy cause virilization?
Elevated beta-hcg levels stimulate the luteoma to release androgens, which may cause maternal virilization
46
How do theca lutein cysts cause virilization in pregnancy?
Markedly elevated beta-hcg levels (eg, hydatidiform mole, multiple gestation) cause ovarian hyperstimulation
47
Compare the risk of virilization of the female fetus in luteomas vs. theca lutein cysts.
Luteomas - high risk
| Theca lutein cysts - low risk
48
___ causes hyperandrogenism, anovulation, and infertility in non-pregnant women.
PCOS
49
___ is defined as fetal death at 20+ weeks.
Intrauterine fetal demise (aka stillbirth)
50
How is intrauterine fetal demise diagnosed?
Absence of fetal cardiac activity on U/S
51
How is intrauterine fetal demise managed?
20-23 weeks - dilation and evacuation OR vaginal delivery
| 24+ weeks - vaginal delivery
52
Even after an optimal evaluation of the cause of stillbirth, up to ___ of cases have no identifiable etiology.
Half
53
Most common cause of genital herpes?
HSV-2
54
Clinical presentation of genital herpes?
Cluster of painful vesicles, pustules, and/or ulcers on the labia, penis, buttocks, or thighs +/- systemic symptoms in primary infection
55
Treatment of genital herpes?
Acyclovir, famciclovir, valacyclovir
56
The majority of patients with primary genital HSV infection will experience ___. When are they most common?
Recurrences; most common during the first year after infection and then become less frequent over time as cell-mediated immunity improves
57
True or false - treatment of primary genital HSV infection can speed resolution of outbreaks and further reduce, but not eliminate, the frequency of recurrences.
True
58
What are 5 risk factors for an amniotic fluid embolism?
1. Advanced maternal age
2. Gravida 5+ (live births or still births)
3. Cesarean or instrumental delivery
4. Placenta previa or abruption
5. Preeclampsia
59
How does amniotic fluid embolism present?
Cardiogenic shock, hypoxemia respiratory failure, DIC, coma or seizures
60
How is amniotic fluid embolism treated?
Respiratory and hemodynamic support +/- transfusion
61
Amniotic fluid embolism is diagnosed clinically after excluding other causes of sudden postpartum cardiorespiratory failure such as what?
Eclampsia, peripartum cardiomyopathy, PE
62
Early recognition of AFES with respiratory and hemodynamic support can reduce maternal and fetal mortality, but survivors have a high incidence of ___.
Neurological damage
63
Define fetal growth restriction.
U/S estimated fetal weigh <10th % for gestational age
64
Compare the onset of symmetric and asymmetric fetal growth restriction.
S - 1st trimester
| A - 2nd/3rd trimester
65
Compare the etiologies of symmetric and asymmetric fetal growth restriction.
S - chromosomal abnormalities, congenital infection
| A - utero-placental insufficiency, maternal malnutrition
66
Compare the clinical features of symmetric and asymmetric fetal growth restriction.
S - global growth lag
| A - "head-sparing" growth lag
67
How is fetal growth restriction managed?
Weekly biophysical profiles, serial umbilical artery Doppler sonography, and serial growth ultrasounds
68
What are the associated risks for fetuses with growth restriction?
Increased risk of intrauterine demise and neonatal morbidity/mortality
69
Describe the pathophysiology of the "head-sparing" asymmetric growth pattern.
In normal fetal development, the fetal abdomen grows exponentially during the second and third trimester. Insults at this stage of pregnancy cause fetal blood flow to be redistributed to the vital organs (eg, brain) and away from the abdomen, resulting in an asymmetric pattern.
70
How can maternal hypertension cause asymmetric FGR?
Even when well-controlled, hypertension can cause underdevelopment of the spiral arteries in the placenta, resulting in increased vascular resistance. These vascular alterations can cause placental insufficiency and asymmetric FGR
71
Advanced maternal age is associated with increased risk for what issues?
Fetal chromosomal abnormalities and maternal comorbidities (eg, diabetes, hypertension); it is not an independent risk factor for FGR.
72
What substances are associated with FGR?
Cocaine, tobacco, alcohol; not caffeine
73
First trimester congenital infections result in ___ FGR.
Symmetric
74
Describe the results of a second-trimester quad screen that suggest trisomy 18.
MSAFP - decreased
Beta-hcg - decreased
Estriol - decreased
Inhibin A - normal
75
Describe the results of a second-trimester quad screen that suggest trisomy 21.
MSAFP - decreased
Beta-hcg - increased
Estriol - decreased
Inhibin A - increased
76
Describe the results of a second-trimester quad screen that suggest neural tube or abdominal wall defect.
MSAFP - increased
| Beta-hcg, estriol, and inhibin A - normal
77
When is the maternal serum quad test performed?
Second trimester (15-20 weeks)
78
What are the 4 components of the MS quad screen?
MSAFP, beta-hcg, estriol, inhibin A
79
Who is at increased risk of fetal aneuploidy?
Women 35+ y/o
80
What are the two most common causes of Down syndrome?
Meiotic nondisjunction (trisomy) or Robertsonian translocation
81
The quad screen detects ~___% of babies with Down syndrome but has a false-positive rate of ~___%.
80; 5
82
Patients with abnormal quad screening results can be offered ___ testing. This has a sensitivity and specificity of up to 99%.
Cell-free fetal DNA (measures circulating, free maternal and fetal DNA in maternal plasma)
83
List 5 normal findings of the postpartum period.
1. Transient rigor/chills
2. Peripheral edema
3. Lochia rubra
4. Uterine contraction and involution
5. Breast engorgement
84
List 5 components of routine postpartum care.
1. Rooming-in/lactation support
2. Serial examination for uterine atony/bleeding
3. Perineal care
4. Voiding trial
5. Pain management
85
Postpartum fever is defined as a temperature of ___ after the first 24 hours post-delivery.
100.4+ F or 38+ C
86
Intra-amniotic infection, aka chorioamnionitis, is a complication common in patients with what issue?
Premature rupture of the membranes and prolonged membrane rupture (>18 hours)
87
Define premature rupture of the membranes.
Rupture before the onset of regular contractions
88
How does intra-amniotic infection present?
N/V, uterine fundal tenderness
89
How is intra-amniotic infection diagnosed?
Maternal fever + at least 1 of the following: fetal tachycardia >160/min for at least 10 minutes, maternal leukocytosis, maternal tachycardia, uterine fundal tenderness, or purulent amniotic fluid
90
How does acute appendicitis present in third trimester patients?
RUQ pain rather than RLQ pain
91
List 6 risk factors for intraamniotic infection (chorioamnioticis).
1. Prolonged rupture of membranes (>18 hours)
2. Preterm premature rupture of membranes
3. Prolonged labor
4. Internal fetal/uterine monitoring devices
5. Repetitive vaginal examinations
6. Presence of genital tract infections
92
How is chorioamnionitis managed?
Broad-spectrum IV antibiotics (ampicillin, gentamicin, clindamycin, etc.) and immediate delivery via augmentation of labor
Antipyretics and IV fluids reduce maternal fever, which improves fetal tachycardia
93
What are maternal complications of chorioamnionitis?
Postpartum hemorrhage, endometritis
94
What are neonatal complication of chorioamnionitis?
Preterm birth, pneumonia, encephalopathy
95
Intra-amniotic infections are usually ___ and ascend from the vagina.
Polymicrobial
96
___ are administered to patients at risk for preterm delivery to promote fetal lung maturity and reduce the incidence of neonatal respiratory distress syndrome.
Corticosteroids
97
List 6 indications for hospitalization for PID.
1. Pregnancy
2. Failed outpatient treatment
3. Inability to tolerate oral medications
4. Noncompliant with therapy
5. Severe presentation (eg, high fever, vomiting)
6. Complications (eg, tubo-ovarian abscess, perihepatitis)
98
Presentation of PID?
Fever, lower abdominal pain, purulent cervical discharge, cervical motion and adnexal tenderness
99
Complications of untreated PID?
Tubo-ovarian abscess, abscess rupture, perihepatitis, sepsis
100
Rx - PID in the hospital?
IV cefoxitin or cefotetan + oral doxycycline, or IV clindamycin + gentamicin
101
Although commonly preceded by cervicitis with N. gonorrheae and C. trachomatis, PID is ___.
Polymicrobial
102
Rx - PID outpatient?
IM ceftriaxone + oral doxycycline
103
Why is doxycycline used to treat PID along with ceftriaxone?
PID - anaerobic coverage
104
What is an alternate treatment for PID that covers anaerobes?
Clindamycin
105
When is metronidazole added to treat PID?
When PID is complicated by tubo-ovarian abscess
106
What vaccines are recommended during pregnancy?
TDap
Inactivated influenza
Rho(D) Ig
107
What vaccines are indicated for high-risk pregnant patients?
```
Hepatitis A
Hepatitis B
Pneumococcus
H. influenzae
Meningococcus
Varicella-zoster Ig
```
108
What vaccines are contraindicated in pregnant patients?
HPV, MMR, live attenuated influenza, varicella
109
Rubella infection during pregnancy can cause what three problems?
Spontaneous abortion, intrauterine fetal demise, congenital rubella syndrome
110
What are the symptoms of congenital rubella syndrome?
Deafness, cardiac defects, hepatosplenomegaly, microcephaly, cataracts
111
True or false - the MMR vaccine is safe for breastfeeding mothers.
True
112
True or false - all rubella-non-immune patients should be vaccinated during the immediate postpartum period.
True
113
Define early decelerations.
Symmetric to contraction, nadir of deceleration corresponds to peak of contraction, gradual (30+ seconds from onset to nadir)
114
What are causes of early decelerations?
Fetal head compression; can be a normal tracing
115
Define late decelerations.
Delayed compared to contraction, nadir of deceleration occurs after peak of contraction, gradual (30+ seconds from onset to nadir)
116
What can cause late decelerations?
Uteroplacental insufficiency
117
Define variable decelerations.
Can be but not necessarily associated with contractions; abrupt (<30 seconds from onset to nadir), decrease 15+/min; duration 15+ seconds but <2 minutes
118
What can cause variable decelerations?
Cord compression, oligohydramnios, cord prolapse
119
Early decelerations are caused by fetal head compression leading to a ___ response and do not indicate fetal distress. In contrast, variable and late decelerations indicate risk for fetal ___ and ___.
Vagal; hypoxemia; acidosis
120
How is abnormal uterine bleeding (AUB) defined?
Menstrual bleeding that is prolonged (>5 days) and heavy (>1 pad/2 hours) with an irregular frequency.
121
Chronic AUB can result in ___, which in turn can present as syncope, palpitations, and tachycardia.
Symptomatic iron deficiency anemia
122
List three causes of abnormal menstrual bleeding.
1. Fibroids
2. Adenomyosis
3. Endometrial cancer/hyperplasia
123
How do fibroids present?
Heavy menses, constipation, urinary frequency, pelvic pain/heaviness, enlarged uterus
124
How does adenomyosis present?
Dysmenorrhea, pelvic pain, heavy menses, bulky, globular, and tender uterus
125
How does endometrial cancer/hyperplasia present?
History of obesity, nulliparity, or chronic anovulation; irregular, intermenstrual, or postmenopausal bleeding; nontender, normal size uterus
126
Compare the uterus on PE in fibroids vs. adenomyosis vs. endometrial cancer/hyperplasia.
Fibroids - irregular enlargement
Adenomyosis - bulky, globular, tender, uniformly enlarged
Endometrial cancer/hyperplasia - non-tender
127
How does endometriosis present?
Pelvic pain, heavy bleeding, irregularly enlarged uterus
128
Pathogenesis of endometriosis?
Cyclic bleeding of ectopic endometrial glands
129
Pathogenesis of adenomyosis?
Proliferation of endometrial glands inside the uterine myometrium
130
Pathogenesis of leiomyomata uteri (fibroids)?
Proliferation of smooth muscle cells within the myometrium
131
How do prolapsing submucous fibroids present?
Labor-like pain due to cervical distention by the solid mass, heavy vaginal bleeding
132
How is a hydaditiform mole managed?
1. Suction curettage
2. Weekly beta-hcg levels until undetectable
3. If they are decreasing, monthly beta-hcg levels for 6 months; once undetectable, surveillance is complete and pregnancy can be attempted
4. If increasing/plateauing, either right away, or after 6 months, diagnose gestational trophoblastic neoplasia
133
What causes a complete hydatidiform mole?
Abnormal fertilization of an empty ovum by either 2 sperm or 1 whose genome then duplicates
134
Hydatidiform mole is a premalignant disease that can develop into gestational trophoblastic neoplasia, such as ___.
Choriocarcinoma
