Ob/Gyn Flashcards
Which of the following drugs is contraindicated in the second and third trimester of pregnancy: amoxicillin, azithromycin, ceftriaxone, ciprofloxacin, or doxycycline?
Doxycycline due to the risk of permanent discoloration of tooth enamel
Compare and contrast myomectomy to fibroid embolization
Uterine fibroid embolization requires a shorterhospitalization and less time off work. General anesthesia is not required, and a blood transfusion is unlikely to be needed. Myomectomy is recommended over fibroid embolization for patients who wish to become pregnant in the future. Uterine fibroids can occur or develop after either Myomectomy or embolization.
SSRIs in pregnancy
Generally safe except for paroxetine, which may cause congenital cardiac malformations with first trimester use, and is pregnancy category D
Benzodiazepines in pregnancy
Controversial due to a possible association with cleft lip/palate
Bupropion in pregnancy
Not well studied, but may cause increased risk of SAB.
When is maternal sero-positivity to CMV virus a contraindication to breast-feeding?
When it is of recent onset, or in mothers of low birth weight infants.
What is appropriate follow-up for a patient whose Pap smear indicates the presence of atypical squamous cells of undetermined significance, (ASC – US).
There are three appropriate follow-up options. Best is reflex testing for HPV. Another option is to repeat ttwp cytological exams performed at six-month intervals. The final option is a single colposcopy exam.
If the HPV test is negative, the Pap smear should be repeated at one year.
What is the first step in the evaluation of a woman over 35 with abnormal vaginal bleeding?
Endometrial biopsy
At what estimated fetal weight does ACOG recommend consideration of cesarean delivery without a trial of labor?
When the estimated fetal weight is 4500 g in a mother with diabetes, or 5000 g in the absence of diabetes.
What laboratory test should be done in a pregnant woman who has symptoms of flu and has been exposed to H1N1?
Real-time reverse transcript days PCR. Pregnant women are at greater risk for severe disease and complications from H1N1. Real-time PCR is the most definitive method to identify H1N1. Routine testing for H1N1 using rapid test is not recommended by the CDC because the sensitivities of the currently available rapid tests are quite poor.
What is the most common cause of abnormal vaginal discharge in a sexually active woman?
Bacterial vaginosis. It accounts for up to 50% of cases in some populations it is more common than either Candida albicans or trichomonas vaginalis infections.
What measurements are used to estimate just stational age during the first second and third trimester is a pregnancy?
Crown to rump length is the most accurate measurement of gestational age and is done at 7 to 14 weeks. After that other measurements are more reliable. In the second trimester, biparietal diameter and femur length are used. During the third trimester, biparietal diameter, abdominal circumference, and femur length are best for estimating gestational age.
What are the various types of decelerations seen on fetal monitoring and what do they represent?
Early deceleration’s are thought to result from vagus nerve response to fetal head compression, and are not associated with increased fetal mortality or morbidity. Variable decelerations are thought to be due to acute intermittent compression of the umbilical cord between fetal parts and the contracting uterus. Late decelerations are thought to be associated with uteroplacental insufficiency and fetal hypoxia due to decreased blood flow in the placenta this pattern is a warning sign and is associated with increasing fetal compromise, worsening fetal acidosis, fetal central nervous system depression, and or direct myocardial hypoxia.
What are the signs of uterine rupture during labor?
The only reliable sign is fetal distress. That classic signs of uterine rupture such as sudden, tearing uterine pain, vaginal hemorrhage, and loss of uterine tone or cessation of uterine contractions are not reliable and are often absent. Pain and bleeding occur in as few as 10% of cases.
How can serum progesterone levels be used to evaluate viability or status of a pregnancy?
A single serum level of 25 ng/mL or higher indicates a healthy pregnancy and excludes ectopic pregnancy with a sensitivity of 98%. If the level is less than 5 ng per milliliter the pregnancy is nonviable. Assessment of fetal well-being is difficult if levels are in the intermediate range of 5 to 25 ng/mL.
What are the criteria for diagnosis of bacterial vaginosis?
Patients must have three of the four Amsel criteria to be diagnosed with bacterial vaginosis. These include a pH of greater than 4.5, which is the most sensitive; clue cells greater than 20%, which is the most specific; a homogeneous discharge, and a positive with test.
What are the chances of getting pregnant with intercourse in relationship to the days before or after ovulation?
There is a 30% probability of pregnancy resulting from unprotected intercourse 1 to 2 days before ovulation, 15% three days before, 12% the day of ovulation, and essentially 0% 1 to 2 days after ovulation.
What does the CDC recommend in terms of antenatal screening for group B streptococcal disease?
Cultures from the vaginal introitus and rectum are the most sensitive for detecting group B strep colonization. No speculum exam is necessary. The closest time to delivery that cultures can be performed and allow time for results to be available is 35 to 37 weeks gestation.
A strawberry cervix is a feature of what sexually-transmitted disease?
Trichomonal vaginitis
What is the definition of delayed or interrupted puberty in girls?
It is defined as failure to to develop any secondary sex characteristics by age 13, to have menarche by age 16, or to have menarche five or more years after the onset of pubertal development.
What is the most accurate test to determine whether a patient with contractions is at high risk for preterm labor?
Vaginal fetal fibronectin. In symptomatic women this is the most accurate test for predicting spontaneous preterm delivery within 7 to 10 days. It is less accurate in those who are asymptomatic. If the fetal fibronectin is negative it maybe possible to avoid interventions such as hospitalizations, tocolysis, and corticosteroid administration.
What is the best regimen for emergency contraception?
It is called plan B. It is a contraceptive package that contains 20.75 mg tablets of levonorgestrel to be taken 12 hours apart.
Which measurement by ultrasound determination during the second trimester provides the most accurate estimate of gestational age?
Biparietal diameter is the most accurate parameter during the second trimester it has a 95% confidence level of being within 5 to 10 days of the actual just additional age when used at the proper time.
What are the risk factors for endometrial cancer?
A history of anovulatory cycles, obesity, nulliparity, history of tamoxifen use, and diabetes mellitus.
What is the emergency management of dysfunctional uterine bleeding?
Intravenous conjugated estrogen – 25 mg Q4 hours until bleeding slows for 12 hours. This is believed to be a stimulus for clotting at the capillary level. It promotes rapid growth of endometrium to cover denuded endometrial surface and stop bleeding. 75% will be controlled in six hours. Another possibility is oral conjugated estrogen 10 mg per day in four divided doses.
Oral contraceptive pills or 10 days of progestin each month should be started after the bleeding stops to prevent recurrence.
What is the non-emergency management of dysfunctional uterine bleeding?
One combined hormonal oral contraceptive pill for seven days. If the flow stops within 12 to 24 hours, the diagnosis of dysfunctional uterine bleeding can be confidently made. The combined oral contraceptive should be stopped at seven days. Regular OCP’s should be given for the next 3 to 6 months.
An alternative would be cyclic administration of progesterone for three months.
What patients tend to have thin endometrium?
They have heavy continuous uterine bleeding. They are often using a progestin dominant contraceptive pill, IUD, Depo-Provera, or minipill. They are excessively thin or have low body fat and may be hypoestrogenic. These include women with eating disorders and elite athletes.
Define menorrhagia
Cyclic prolonged and/or excessive bleeding
Define metrorrhagia
Bleeding at irregular and frequent intervals. This typically involves ovulatory cycles.
Define polymenorrhea
Menstrual cycles of less than 21 days
Define oligomenorrhea
Menstrual cycles of over 35 days
Define hypomenorrhea
Cyclic light flow
Define amenorrhea
Absence of menses for greater than six months
What needs to be excluded before you treat metrorrhagia?
Fibroids, polyps and endometrial cancer.
What are the possible treatments of metrorrhagia?
NSAIDs, antiestrogen such as danazol, oral contraceptive pills, continuous oral contraceptive pills, oral continuous progestins, levonorgestrel IUD, or surgical.
What is the surgical treatment of menorrhagia?
Hysterectomy is not used frequently anymore. What common are oblation procedures. These include first-generation procedures such as laser or rollerball resection; or second generation procedures such as cryoablation, laser intrauterine thermotherapy, radiofrequency ablation, thermal balloon ablation and microwave ablation.
What are the medical therapies for metrorrhagia and how much do they decrease bleeding?
NSAIDs, which work by decreasing prostacyclin and cause platelets anti-aggregating vasodilation, decrease blood flow 25 to 50%. The commonly used NSAID is Ponstel or mefenamic acid, 500 mg PO TID.
Danazol which is an entry antiestrogen drug, should be given at 200 mg every day. It decreases bloodflow by 50%, but it but side effects limit its use.
GnRH agonist and antifibrinolytic agents may both be used. Both are limited by side effects.
Levonorgestrel intrauterine systems causes an 80% decrease in blood loss and are more and more commonly used.
What are the steps in evaluating amenorrhea?
- rule out pregnancy. 2. get a TSH to evaluate for hypo or hyperthyroidism, and a prolactin level to evaluate for pituitary tumor (fasting, no breast stimulation). 3. Determine the relative estrogen status. This means performing a progestin challenge test, which involves administering 5 to 10 milligrams of medroxyprogesterone acetate once a day for 10 days. ANY bleeding within 2 to 7 days is positive. A positive test means anovulation.
What are the risk factors of and the treatment for anovulatory amenorrhea?
These are frequently OBC women with or without PCO OS. Progesterone is not being adequately produced in the luteal phase, which gives them an apposed estrogen stimulation. This increases the risk for endometrial cancer. The treatment is progestin 10 mg every day for 7 to 10 days every month, or OCP’s.
How should the work up continue if a woman who has amenorrhea has a negative progestin challenge?
She should be given an estrogen and progestin challenge test, which may involve simply giving oral contraceptive pills,. If there is no withdrawal bleeding, she has outflow tract obstruction (Asherman’s syndrome,
mullerian agenesis).
If there was positive withdrawal bleeding following estrogen/progestin challenge then FSH and LH should be measured. If they are low an MRI should be done, which if normal makes the diagnosis hypothalamic amenorrhea. If FSH and LH are high, the diagnosis is ovarian failure.
How is hypothalamic amenorrhea it diagnosed? What sorts of patients have it? What are its risks? How is it treated?
It is diagnosed by low or normal FSH LA H levels within normal prolactin, low levels of endogenous estrogen, and a normal MRI of the sella. There will be positive withdrawal bleeding following estrogen progestin challenge test. It is usually diagnosed by the exclusion of pituitary lesions. Patients who have it frequently have anorexia or bulimia, bulimia Kallmann’s syndrome, stress, high intensity exercise, or chronic illness.
These patients have a risk of decreased bone density of 10 to 20%. It cannot be completely overcome with supplemental calcium or weight-bearing exercise. It is unclear if calcium and a Cercis decrease the rate of fractures in in these patients. OCP’s do improve lumbar and total bone mineral but again the effect on fractures is unknown. The patient should increase their BMI to greater than 20 to restore menses. They should also decrease intensive exercise.
What is the suggested evaluation for polycystic ovary syndrome?
- Document biochemical hyperandrogenism me with a total testosterone and sex hormone binding globulin or bioavailable and free testosterone
- Exclusion of other causes of hyperandrogegism. A TSH, prolactin and 17 hydroxyprogesterone should be checked. Consider screening for Cushing’s syndrome and other rare disorders such as acromegaly.
- A transvaginal pelvic ultrasound to look for polycystic ovaries.
- Evaluate for metabolic abnormalities including a two hour glucose tolerance test and fasting lipid and lipoprotein levels.
What are the expected hormone levels in polycystic ovary syndrome?
FSH is normal to mildly elevated. LH is generally moderately elevated but this is dependent on timing of the sampling relationship to the last menses. Prolactin is normal to mildly elevated. Test Doster room and is normal to moderately elevated. There’s a normal serum estradiol, and increased serum estrone concentrations.
How do you manage PCOS with oligomenorrhea or amenorrhea?
With a combination low-dose oral contraceptive pill or with monthly progesterone.
How is PCOS with hirsutism managed?
With combination low-dose OCP’s, spironolactone or finasteride.
How is PCOS with insulin resistance managed?
Metformin
How is PCOS with infertility managed?
With clomiphene metformin and possibly pioglitazone.
What are the benefits and risks of post menopausal hormone replacement therapy?
The benefits include reduced risk of osteoporosis and related fractures, decreased colon cancer risk, and improvement of vasomotor symptoms.
The risks include increased risk of breast cancer, CVA, myocardial infarction, and venous thromboembolic events.
What are the contraindications to hormone replacement therapy?
The only absolute contraindication is a previous thromboembolic event. Heart disease, breast cancer and endometrial cancer are relative contraindications.
What are the most effective therapies for hot flashes?
Gabapentin 100 mg per day, clonidine 0.1 mg per day and venlafaxine 37.5 to 75 mg per day. All of these provide a significant reduction in hot flashes. There is some reduction in hot flashes with methyldopa at the expense of frequent side effects.
