OB/GYN Flashcards

Question

Ovarian Cysts: follicular, corpus luteal, theca lutein defintion

Answer 1

Fluid-filled sac within the ovaries MC related to ovulation (usually unilateral) Common in reproductive years – most spontaneously resolve within a few weeks Follicular Cysts: MC – occur when follicles fail to rupture & continue to grow *Lengthening of follicular phase - transient secondary amenorrhea *Does not become clinically significant until it is large enough to cause pain or persists beyond one menstrual cycle Corpus Luteal Cysts: fail to degenerate after ovulation *composed of granulosa cells Theca Lutein: excess beta-hCG causes hyperplasia of theca interna cells (rare) *seen in hydatidiform mole, hCG & clomid use

Answer 2

Most are asymptomatic – may be associated w/ abnormal uterine bleeding or dyspareunia PE: unilateral pelvic pain or tenderness, mobile palpable cystic adnexal mass Follicular: mild to moderate lower abdominal pain & alteration in menstrual intervals Corpus Luteal: asymptomatic, pain & local tenderness, ovarian torsion or rupture & bleeding Theca Lutein: usually bilateral, pelvic heaviness dx Transvaginal U/S *Follicular: smooth, thin-walled uniocular *Corpus Luteal: complex, thicker-walled w/ peripheral vascularity Malignancy: *Low risk: anechoic, uniocular fluid-filled cysts *High risk: solid, nodular, thick septations If suspicious 🡪 tumor markers (CA-125, alpha-fetoprotein, beta-hCG) Beta-hCG to r/o pregnancy tx If <8cm: supportive – rest, NSAIDs, repeat U/S after 1-2 cycles *most cysts <8cm are functional & usually spontaneously resolve *OCPs may prevent recurrence but don’t treat existing ones If >8cm or persistent: laparoscopy or laparotomy Postmenopausal: laparoscopy or laparotomy if large or CA-125 is elevated *cysts in postmenopausal women are considered to be malignant until proven otherwise

Answer 3

Asymptomatic or sudden onset of unilateral lower abdominal pain often sharp & focal, often occurring during sexual activity or strenuous physical activity sx Abnormal uterine bleeding PE: *unilateral pelvic pain or tenderness *+/- mobile palpable cystic adnexal mass *may have signs of hemodynamic compromise if massive bleeding (uncommon) dx Transvaginal U/S – initial TOC *adnexal mass + pelvic fluid Beta-hCG CBC tx Uncomplicated: expectant management for most – observation, analgesics, rest *uncomplicated means absence of hemodynamic instability, large volume or ongoing blood loss, fever, leukocytosis, or suspicion of malignancy Stable + significant hemoperitoneum: hospitalization, close observation, fluid replacement Hemodynamically unstable or ongoing hemorrhage: laparoscopy usually preferred over laparotomy; cystectomy preferred over oophorectomy

Answer 4

Ascending infection of the upper reproductive tract Pelvic or lower abdominal pain, dysuria, dyspareunia, vaginal discharge or bleeding, N/V PE: *lower abdominal tenderness *fever *purulent cervical discharge *cervical motion tenderness (Chandelier sign) Tubo-Ovarian Abscess: acute lower abdominal pain, vaginal discharge, systemic sxs (fever, chills) *PE: unilateral adnexal tenderness *Ruptured: acute abdomen (guarding, rebound) + sepsis Fitz Hugh-Curtis Syndrome: inflammation of the liver capsule w/ adhesion formation resulting in RUQ pain (perihepatitis) *seen in 10% of women w/ PID S/SXS: RUQ pain due to perihepatitis (liver capsule involvement); may radiate to right shoulder DX: laparoscopy: “violin-string” adhesions on anterior liver surface; often have normal LFTs or slight elevations DX: presumptive diagnosis made in any sexually active woman presenting w/ pelvic or lower abdominal pain + have evidence of cervical motion, uterine, or adnexal tenderness on exam *this is sufficient for tx d/t serious sequelae if tx delayed/not given Other supportive findings: *temp >101oF (>38.3oC) *abnormal cervical or vaginal mucopurulent discharge or cervical friability *presence of abundant numbers of WBCs on saline microscopy of vaginal secretions (>15-20 WBCs/high power field or more WBCs than epithelial cells) *documentation of cervical infection w/ N. gonorrhea, C. trachomatis, or M. genitalium Workup: UPT (r/o ectopic pregnancy), NAAT (for G/C & M. genitalium), microscopy of vaginal discharge, HIV screening, RPR/VDRL Imaging (if needed): U/S preferred tx Inpatient: INITIAL: *ceftriaxone 1g IV q24h PLUS *doxycycline 100mg PO q12h PLUS *metronidazole 500mg PO or IV q12h PO after 24-48h of sustained clinical improvement: *doxycycline 100mg BID PLUS *metronidazole 500mg BID x14d total Outpatient: *ceftriaxone IM x1 PLUS <150mg: 500mg ≥150mg: 1g *doxycycline 100mg BID PLUS *metronidazole 500mg BID x14d total Pregnant: inpatient tx indicated *substitute doxycycline w/ azithromycin

Answer 5

Inflammatory mass involving the fallopian tubes, ovaries, & occasionally other pelvic organs *Most occur as a complication of PID MC in ages 15-25 sx *Pt will have hx of PID Classic presentation: acute lower abdominal pain, vaginal discharge, & systemic sxs (fever, chills) PE: unilateral adnexal tenderness Ruptured: leaking contents into the abdominal cavity – pts present w/ an acute abdomen (guarding & rebound tenderness) & sepsis *requires immediate surgical exploration dx Transvaginal U/S – inflammatory adnexal mass tx ADMIT for IV abx *(cefoxitin or cefotetan) + doxycycline *abx alone are sufficient for pts that are hemodynamically stable, lack signs of an acute abdomen, & are premenopausal

Answer 6

Painful menstruation Primary: ↑ prostaglandins RF: menarche before 12yo, nulliparity, smoking, family hx, obesity Secondary: pelvis/uterus pathology (endometriosis, PID, adenomyosis, leiomyomas) *pain severity will progressively worsen sx Recurrent, crampy midline lower abdominal pain or pelvic pain 1-2 days before or at the onset of menses gradually diminishing over 12-72hrs *may be associated w/ HA, N/V/D PE: will be normal if primary dx H&P, UPT, pelvic U/S *Laparoscopy if secondary causes are suspected tx Supportive therapy: heat, vitamin B & E, exercise NSAIDs or estrogen-progestin OCPs are first line *Laparoscopy indicated if unresponsive to 3 cycles of initial therapy to r/o secondary causes Secondary: treat underlying cause

Answer 7

Partial or complete premature separation of the placenta from the uterine wall (prior to delivery of the fetus) The blood may be concealed (within the uterine cavity) or external (blood drains through the cervix) Patho: *rupture of maternal blood vessels in the decidua basalis, leading to bleeding into the separated space *the subsequent release of tissue factor, thrombin generation lead to the other findings Risk Factors: prior abruption most significant RF *maternal HTN MC (e.g., chronic, preeclampsia, eclampsia) *smoking, alcohol use, cocaine, folate deficiency, advanced maternal age, abdominal trauma, multiple gestation, PPROM, chorioamnionitis *trauma – all pts involved in MVA, fall, or traumatic event should be evaluated *more common in AA

Answer 8

Sudden onset of PAINFUL 3rd TM vaginal bleeding (often dark red), severe abdominal pain (uterine contractions) *may have black pain or signs of shock from blood loss *premature delivery may occur PE: *tender rigid (hypertonic) uterus *fetal distress may occur (e.g., fetal bradycardia) DO NOT PERFORM A PELVIC EXAM!! dx Primarily a clinical dx Transabdominal U/S – may show a retroplacental clot (but not reliable); may be helpful to distinguish between abruptio & previa Workup: CBC, blood type & cross, fibrinogen level tx Delivery – often by c-section but vaginal delivery possible & may often follow rapid labor Complications: abruption is the MCC of coagulopathy in pregnancy – DIC, fetal death Couvelaire uterus: blood penetrates the uterus to such an extent that the serosa becomes blue/purple *Kleihauer-Betke test is essential to determine the amount of fetal-maternal hemorrhage; Rh D immunoglobulin given to Rh (-) mother

Answer 9

Abnormal placenta placement over or close to the internal cervical os Types: *complete: complete coverage of the cervical os *partial: partial coverage of the cervical os *marginal: adjacent to the internal os (leading edge of the placenta is <2cm from the internal os) Risk Factors: *major: previous placenta previa, previous c-section, multiple gestations *increasing age & previous uterine surgery *smoking sx Sudden onset of PAINLESS vaginal bleeding in the 3rd TM (may be bright red) usually after 28wks *absence of abdominal pain or uterine tenderness PE: *soft, nontender uterus DO NOT PERFORM DIGITAL VAGINAL/SPECULUM EXAM – may cause increased separation, resulting in severe hemorrhage dx Transabdominal U/S initially followed by transvaginal U/S for confirmation tx Stabilization w/ premature fetus: watchful waiting if the pt is stable; pelvic rest (no vaginal intercourse) Delivery when stable: if L:S ratio > 2:1, >36wks, blood loss >500mL, coagulation defects, or persistent labor *c-section usually preferred in complete, major degrees, & w/ fetal distress

Answer 10

Placenta Accreta: invasion of placental tissue into the uterus prevents placenta from separating from uterine wall leading to hemorrhage – tx is hysterectomy

Answer 11

Fetal vessels are present over the cervical os—fetal mortality approached 60% if not discovered before delivery due to fetal exsanguination S/SXS: ROM followed by PAINLESS vaginal bleeding + fetal distress (bradycardia) DX: may be seen prior to delivery as the vessels crossing the os TX: immediate c-section

Answer 12

Rupture of the amniotic membranes before the onset of labor If it occurs prior to 37wks 🡪 preterm premature rupture of membranes (PPROM) sx Gush of fluid or persistent leakage of fluid from the vagina or vaginal discharge dx Sterile speculum exam: pooling of secretions in posterior fornix w/ inspection Nitrazine paper test: turns blue if pH >6.5 (amniotic fluid pH is ~7 whereas vaginal pH usually ~4) Fern test: amniotic fluid dries in a fern pattern (crystallization of estrogen & amniotic fluid) U/S to check amniotic fluid index *avoid digital vaginal examination unless delivery is imminent (to avoid introduction of infection)

Answer 13

Complications: may lead to chorioamnionitis or endometritis if prolonged (>24h) *cord prolapse, placental abruption PROM: *Expectant: admit w/ fetal monitoring & wait for spontaneous labor (90% will go into labor within 24hrs after PROM) – monitor for infection (chorioamnionitis or endometritis) *Labor induction: if chorioamnionitis or labor does not occur within 18hrs of rupture -prostaglandin cervical gel or oxytocin PPROM: ≥34wks, no sign of maternal or fetal infection or distress: admit w/ fetal monitoring & wait for labor <34wks: administer steroids (betamethasone) to enhance fetal lung maturity *if 24-32wks 🡪 admin magnesium sulfate (neuroprotection) *tocolytics may be given to delay delivery 48hrs to allow steroids to work if not in advanced labor (>4cm), no signs of chorioamnionitis, & no signs of non-reassuring fetal testing *abx (ampicillin + erythromycin) often given to prevent infection *Prompt delivery if signs of maternal or fetal infection or distress

Answer 14

A pregnancy that ends before 20wks gestation – almost 80% occur before 12wks sx Crampy abdominal pain & vaginal bleeding Recurrent SAB: ≥3 consecutive losses <20wks GA (15% risk in 1st pregnancy) *↑ risk w/ each pregnancy loss dx *U/S *CBC *blood type & Rh screen *serial beta-hCG titers *progesterone levels

Answer 15

Threatened dx: *products of conception (POC) intact *cervical os CLOSED tx: *supportive observation at home, bed rest, & close follow up to see if sxs either resolve or progress to abortion *serial beta-hCG to see if doubling to see if viable Inevitable dx: *POC intact *cervical os OPEN tx: *surgical evacuation: D&C if <16wks; dilation & evacuation if ≥16wks *medical: misoprostol *expectant management Incomplete dx: *some POC expelled from uterus *cervical os OPEN tx: Options include: *expectant: allow POC to fully pass w/ serial beta-hCG & transvaginal U/S to determine when complete *surgical evacuation: D&C <16wks; D&E ≥16wks *medical: misoprostol Complete dx: *all POC expelled from uterus *cervical os usually closed tx: *RhoGAM if indicated, follow up beta-hCG Missed dx: *POC intact *cervical os CLOSED *no bleeding or cramping tx: *surgical evacuation: D&C <16wks; D&E ≥16wks *medical: misoprostol Septic dx: *some POC retained *cervical os CLOSED – cervical motion tenderness *foul brown discharge, fever, chills tx: *D&E to remove POC + broad spectrum abx (levofloxacin + metronidazole)

Answer 16

Neisseria gonorrhea *most women are asymptomatic S/SXS: mucopurulent discharge, vulvar itching/burning *be sure to think of gonococcal pharyngitis in anyone w/ persistent pharyngitis, dx w/ culture dx Nucleic acid amplification test Gram stain: gram (-) diplococci tx <150kg: ceftriaxone 500mg IM x1 ≥150kg: ceftriaxone 1g IM x1 Alt: cefixime (400mg PO) *MC complication is salpingitis

Answer 17

*MC reported STI in US S/SXS: mucopurulent discharge, hypertrophic cervical inflammation dx Nucleic acid amplification test Culture UA – will reveal pyuria w/ no organisms on gram stain tx Doxycycline 100mg BID x7d Alt: Azithromycin 1g PO x1 (preferred in pregnancy)

Answer 18

Trichomonas vaginalis: flagellated protozoan sx *Purulent, malodorous, thin vaginal discharge – green/yellow, frothy <10% *Burning, pruritus, dysuria, frequency and dyspareunia *Postcoital bleeding *30% of women can be asymptomatic PE: erythematous vulva and vaginal walls (mucosa), thin (snot like) discharge *Strawberry (punctuated) cervix (<2%) dx Wet prep – mobile flagellated organism (trichomonads) & many leukocytes tx Metronidazole (2g once or 500mg BID x7d) OR Tinidazole (2g once) *Avoid ETOH on metronidazole – disulfiram rxn

Answer 19

An overgrowth of anaerobic bacteria, which replaces the normal lactobacilli of the vagina, increased pH allows for growth of Gardnerella vaginalis sx *Vaginal discharge – white homogenous consistency *Fishy odor – exacerbated by menses, intercourse, or douching (introduction of alkaline substances) PE: *Vaginal discharge – “spilled milk over the tissue”, homogenous thin white discharge that coats the vaginal walls *No erythema or inflammation of vaginal mucosa dx Wet mount – CLUE CELLS (bacterial coated epithelial cells); NO LEUKOCYTES Vaginal fluid pH >4.5 (elevated) Whiff test: addition of KOH leads to release of a fishy odor Gram stain – gold standard tx Metronidazole PO or topical *500mg BID x7d *250mg TID x7d Clindamycin topical

Answer 20

Atrophy of the vaginal epithelium due to diminished estrogen levels sx *vaginal dryness, dyspareunia *vaginal inflammation *infection & recurrent UTIs w/ increased pH (loss of lactobacilli which normally converts glucose to lactic acid) dx: clinical tx Vaginal moisturizers – improves sxs of dyspareunia & dryness but no effect on atrophy Topical vaginal estrogens – safest, most effective medical therapy – cream, vaginal ring, vaginal troches ADRs: vaginal bleeding, breast pain, nausea, thromboembolism (DVT, CVA, PE), endometrial cancer (less risk compared to oral estrogen) Ospemifene – SERM; estrogen agonist in vagina/bone, estrogen antagonist in breast/uterus

Answer 21

90% from Candida albicans sx *Vulvar itching, burning, dysuria, dyspareunia *Vaginal discharge PE: *Erythematous vulvar and vaginal tissue *Thick, adherent “cottage cheese” discharge, no odor dx KOH prep on microscopy: PSEUDOHYPHAE tx Topical or intravaginal miconazole (monistat), clotrimazole, terconazole Fluconazole 150mg PO *Recurrences are common; if frequent, work up diabetes/autoimmune disease

Answer 22

Neoplasm due to abnormal placental development w/ trophoblastic tissue proliferation arising from gestational tissue (not maternal in origin) – 80% benign Abnormal proliferation of the syncytiotrophoblast and replacement of normal placental trophoblastic tissue by hydropic placental villi sx Painless vaginal bleeding, preeclampsia (HTN) BEFORE 20wks, hyperemesis gravidarum (due to elevated beta-hCG levels) *tachycardia, weight loss (d/t hyperthyroidism) PE: uterine size & date discrepancies (larger or smaller than expected) dx Beta-hCG: markedly elevated w/ complete (e.g., >100,000mIU/mL) Pelvic U/S *complete: central heterogenous mass w/ multiple discrete anechoic spaces “snowstorm” or “cluster of grapes” appearance, absence of fetal pole & heart tones *partial: gestational sac & fetal heart tones may be present plus abnormal tissue tx Surgical uterine evacuation mainstay of tx ASAP to avoid risk of choriocarcinoma development *Pts are followed weekly until beta-hCG levels fall to an undetectable level

Answer 23

*Malignant transformation of trophoblastic tissue *Tumor has a red, granular appearance on cut section and consists of intermingled syncytiotrophoblastic and cytotrophoblastic elements with many abnormal cellular forms *Characterized by rapid myometrial and uterine vessel invasion and systemic metastases resulting from hematogenous embolization – lung, vagina, CNS, kidney, liver *May follow molar pregnancy, normal term pregnancy, abortion or ectopic *Abnormal bleeding for 6wks after any pregnancy should be evaluated w/ hCG to exclude new pregnancy or GTN -Failure to regress after treatment of molar pregnancy suggests further treatment is needed Treatment: *Usually highly sensitive to chemotherapy, allowing a cure/future fertility *Nonmetastatic persistent GTN - single dose MTX *Use FIGO score for staging

Answer 24

New onset of HTN (>140/90mmHg) occurring after 20wks gestation + proteinuria or end-organ dysfunction in a previously normotensive female *BP measurements done on at least 2 occasions at least 4hrs apart Risk Factors: preexisting HTN, nulliparity, maternal age <20yrs or >35yrs, diabetes, chronic renal disease, autoimmune disorders patho *As the placenta integrates into the endometrial layer, there is defective remodeling of the spiral arteries *Pt develops placental hypo-perfusion; that releases proinflammatory proteins into maternal circulation, which cause vasoconstriction of maternal vascular system and end-organ damage *Damage of endothelial cells potentiates the release of inflammatory cytokines

Answer 25

Pre-Eclampsia w/o Severe Features BP ≥140/90 *≥2 occasions ≥4h apart PLUS Proteinuria: ≥300mg 24h OR protein:Cr >0.3 Pre-Eclampsia w/ Severe Features *any ONE of the following BP ≥160/110 Platelets <100,000 SCr >1.1mg/dL or 2x baseline ALT/AST 2x normal or persistent epigastric/RUQ pain Pulmonary edema Cerebral/visual changes (HA, blurred vision, flashing lights)

Answer 26

MILD: anti-HTN meds NOT recommended ≥37wks: delivery <37wks: expectant management w/ delivery @37wks *daily weights, weekly BP & dipstick, bed rest * antenatal corticosteroids to mature lungs if <34wks SEVERE: delivery is only cure!!!! ≥34wks: delivery *magnesium sulfate (D/C ≥24hrs after delivery) *BP control (labetalol, hydralazine, nifedipine) <34wks: steroids for fetal lung maturity *delivery at 34wks if well-controlled w/ anti-HTN *sxs/not controlled w/ anti-HTN meds 🡪 delivery

Answer 27

MATERNAL INDICATIONS: *Recurrent severe HTN *Recurrent severe symptoms of pre-E *Progressive renal insufficiency *Persistent thrombocytopenia *Pulmonary edema *Suspected placental abruption *Progressive labor or ROM FETAL INDICATIONS: *Gestational age >34wks *Severe fetal growth restriction (<5%) *Persistent oligohydramnios *BPP of 4/10 or less on two occasions 6 hours apart *Reversed end-diastolic flow on umbilical artery Doppler *Recurrent variable or late decelerations during NST *Fetal demise

Answer 28

WARNING: In patients with pre-E WITHOUT severe features, anti-HTN therapy may ↓ risk to pre-E w/ severe features, however it can also impair fetal growth by ↓ blood flow to the fetoplacental unit *For women w/ chronic HTN, it is recommended to initiate anti-HTN therapy when BP reaches >160/105 *Do not withhold therapy in women w/ severe features that do not meet “number criteria” if there are signs of end-organ damage ACUTE IV/IM AGENTS Labetalol: FIRST LINE; contraindicated in pts that cannot tolerate non-selective BBs (asthma) Hydralazine: higher or frequent dosage is associated w/ maternal hypotension, HA, & fetal distress (may be MC than w/ other agents) Nifedipine: may observe reflex tachycardia & HA CHRONIC PO AGENTS Labetalol: well-tolerated, potential bronchoconstriction Nifedipine: do NOT use sublingual forms Methyldopa: may not be as effective in control of severe HTN but multiple safety studies Thiazide diuretics: second line agent ACEI/ARB: CONTRAINDICATED (associated w/ fetal anomalies)

Answer 29

*Severe preeclampsia can also present w/ HELLP syndrome H: hemolysis EL: elevated liver enzymes LP: low platelet count tx Delivery: ≥37wks: delivery after maternal stabilization <37wks: delivery after stabilization if mother has any of the following: *DIC *Liver infarct or hemorrhage *Renal failure *Pulmonary edema *Placental abruption *Non-reassuring fetal status

Answer 30

Preeclampsia + seizures or coma sx Signs of Impending Eclampsia: *HA +/- blurred vision *photophobia *epigastric/RUQ pain *altered mental status Abrupt onset of tonic-clonic seizures tx MEDICAL EMERGENCY!!!! ABCD – airway, breathing, circulation, delivery (c-section MC) IV magnesium sulfate for seizures & BP stabilization (IV labetalol or hydralazine) followed by delivery of the fetus (once the mother is stabilized) *lorazepam only used if seizures are refractory to magnesium sulfate IV magnesium sulfate *loading dose of 4-6g followed by maintenance of 1-2g/hr for ≥24h Magnesium sulfate – therapeutic levels: 4.8-8.4mg/dL *can monitor for toxicity w/ patellar reflexes

Answer 31

Infection of the decidua (pregnancy endometrium) *MC postpartum infection Usually polymicrobial (often vaginal flora, aerobic, & anaerobic bacteria) *group A & B streptococci, staph, klebsiella, proteus, Enterobacter, enterococcus, E. coli Risk Factors: *C-SECTION BIGGEST RISK FACTOR sx Fever, uterine tenderness, tachycardia that parallels rise in temp, midline lower abdominal pain May have vaginal bleeding or discharge (foul-smelling lochia) *diminished or absent bowel sounds is a sign of a more serious infection ALARM FINDINGS: Fever ≥103F OR Fever ≥102F plus *HR ≥110 for at least 30min *RR ≥20 for at least 30min *manual WBC w/ 10% bands *BP ≤90/60 dx Mainly a clinical dx – fever (≥100.4F), tachycardia, abdominal pain, uterine tenderness 2-3d after c-section, postpartum, or postabortal WBC 15,000-30,000 w/ left shift (leukocytosis) Elevated LDH tx Clindamycin + gentamicin If GBS: ADD ampicillin or Augmentin