Ob-Gyn 2 Flashcards
1
Q
Define missed abortion.
A
Intrauterine pregnancy demise at <20 weeks prior to expulsion of products of conception
2
Q
Presentation of a missed abortion?
A
May be asymptomatic or have decreased pregnancy symptoms (nausea, breast tenderness); closed cervix
3
Q
Ultrasound findings of a missed abortion?
A
Embryo without cardiac activity or an empty gestation sac without a fetal pole
4
Q
Some early pregnancies can present without a fetal pole; how is viability determined?
A
Repeat ultrasounds and serial beta-hcg; repeat ultrasounds of a viable pregnancy reveal continued embryonic development. Serial beta-hcg levels normally increase until the end of the first trimester; decreasing beta-hcg levels indicate a demise and exclude a normal pregnancy
5
Q
Presentation of a threatened abortion?
A
Vaginal bleeding; closed cervical os
6
Q
Ultrasound findings of a threatened abortion?
A
Fetal cardiac activity
7
Q
Presentation of an inevitable abortion?
A
Vaginal bleeding; dilated cervical os; products of conception may be seen or felt at or above the cervical os
8
Q
Presentation of an incomplete abortion?
A
Vaginal bleeding; dilated cervical os; some products of conception expelled, some remain
9
Q
Presentation of a complete abortion?
A
Vaginal bleeding; closed cervical os; products of conception completely expelled
10
Q
Most common pelvic tumor in women?
A
Leiomyomata uteri (fibroids)
11
Q
Fibroids are benign smooth muscle tumors that arise from the ___ and are most common in women of ___ age, especially those of ___ ethnicity.
A
Myometrium; reproductive; African American
12
Q
Clinical presentation of fibroids is variable depending o the size, location, and number of fibroids. Extremely large fibroids can cause ___ and other mass symptoms (eg, urinary frequency, constipation). The uterus may also be so enlarged that it is palpable as a ___ abdominal mass. An irregular uterine ___ is also consistent with fibroids.
A
Pelvic pressure; globular; contour/protuberance
13
Q
Fibroids involving the ___ may resulting heavier and longer menses with dysmenorrhea.
A
Submuocsa
14
Q
Recurrent pregnancy loss can be associated with ___, ___, and ___ fibroid types that distort the uterine cavity.
A
Intracavitary, submucosal, intramural fibroid
15
Q
___ occurs when endometrial tissue grows into the myometrium.
A
Adenomyosis
16
Q
Presentation of adenomyosis?
A
Dysmenorrhea, menorrhagia, soft, boggy, uniformly enlarged uterus
17
Q
A bicornuate uterus is most often ___ and noted incidentally during surgery.
A
Asymptomatic
18
Q
What is the hallmark of endometrial polyps?
A
Intermenstrual spotting without uterine enlargement
19
Q
___ occurs when endometrial glands implant outside the uterus.
A
Endometriosis
20
Q
Classic symptoms of endometriosis?
A
Infertility, dyspareunia, dysmenorrhea
21
Q
Presentation of ovarian cancer?
A
Adnexal mass and non-specific GI symptoms, such as early satiety, constipation/diarrhea, anorexia, bloating, and increased abdominal girth
22
Q
When is syphilis screening indicated in pregnancy?
A
Universal at first prenatal visit
Third trimester and delivery if high risk
23
Q
How is syphilis screened for in pregnancy?
A
Nontreponemal (RPR, VDRL)
Treponemal (FTA-ABS)
24
Q
What is the treatment for syphilis in pregnancy?
A
IM benzathine penicillin G (usually 1 dose weekly for 3 weeks); if allergic to PCN, must be desentizied
25
What are the effects of syphilis on pregnancy?
Intrauterine fetal demise, preterm labor
26
What are the fetal effects of syphilis in pregnancy?
1. Hepatic - hepatomegaly, jaundice
2. Hematologic - hemolytic anemia, decreased platelets
3. MSK - long bone abnormalities
4. FTT
27
Which STIs should all pregnant women receive screening for?
HIV, HBV, CT, syphilis
28
If a pregnant patient tests positive for syphilis with either screening test, what must be done next?
Confirmation with the other test (false positives are common)
29
Untreated syphilis is marked by a high risk greater than ___% of fetal complications.
80
30
What are the two disorders of the active phase of labor?
1. Protraction
| 2. Arrest
31
What are the clinical features of protracted labor?
Cervical change slower than expected +/- inadequate contractions
32
How is protracted labor treated?
Oxytocin
33
What are the clinical features of active phase labor arrest?
No cervical change for 4+ hours with adequate contractions OR no cervical change for 6+ hours with inadequate contractions
34
How is arrested labor treated?
Cesarean delivery
35
What are the possible etiologies of active-phase labor anormalities?
1. Uterine (eg, inadequate contractions)
2. Fetal (eg, malpresentation, non-OA position, macrosomia)
3. Pelvic (deformity or fracture)
36
What determines the number of Montevideo units (MVUs) with an intra uterine pressure catheter in place?
Peak contraction pressure - baseline intrauterine pressure = MVUs
37
Define adequate contractions in MVUs.
200+ MVUs in a 10-minute interval
38
Non-classic congenital adrenal hyperplasia is ___ (inheritance pattern).
Autosomal recessive
39
Discuss the pathophysiology of non-classic congenital adrenal hyperplasia.
The majority of cases are due to partial deficiency in 21-hydroxylase, which results in impaired conversion of 17-OHP to 11-deoxycortisol. Buildup of 17-OHP is diverted toward adrenal androgen synthesis, resulting in hyperandrogenism. Gluco and mineralocorticoids are normal.
40
Clinical features of non-classic congenital adrenal hyperplasia?
```
Presents in adolescence or early adulthood (non-classic = late)
Early pubic/axillary hair growth
Severe acne
Hirsutism and oligomenorrhea in girls
Increased growth velocity and bone age
Increased 17-hydroxyprogesterone level
VIRILIZATION IS RARE
```
41
How is non-classic congenital adrenal hyperplasia treated?
Hydrocortisone
42
Why are glucocorticoids and mineralocorticoids normal in non-classic CAH?
The enzyme deficiency is relatively mild; production is sufficient. Patients do not have the salt-wasting seen in classic CAH. Electrolytes and blood pressure remain normal.
43
How is diagnosis of CAH confirmed?
Exaggerated 17-OHP response on ACTH stimulation test
44
___ typically present in adulthood with rapidly progressive hirsutism and virilization. What lab result is notable in this condition?
Androgen-producing adrenal tumors; serum DHEAS >700 microg/dL
45
How do ovarian germ cell tumors (eg, embryonal carcinoma, choriocarcinoma) typically present?
Abdominal ascites, pelvic mass, pregnancy symptoms (eg, breast tenderness)
46
What lab result is seen with ovarian germ cell tumors and why?
False-positive pregnancy test; tumors secrete beta-hcg
47
What causes idiopathic hirsutism?
Excessive conversion of testosterone to dihydrotestosterone in the hair follicles; there is usually a positive family history and normal 17-OHP and androgen levels
48
Patients with PCOS have menstrual irregularities and hyperandrogenism as in non-classic CAH. What is different?
17-OHP is not elevated in PCOS
49
When are vaccinations indicated DURING pregnancy?
If the vaccine has minimal risk, if significant risk exists for infection exposure, and if increased morbidity and mortality are associated with infection
50
What types of vaccines are safe in pregnancy?
Immunoglobulins, toxoids, inactivated vaccines
51
True or false - the inactivated influenza vaccine is safe during every trimester of pregnancy and while breastfeeding.
True
52
What should be done if a patient with no evidence of varicella immunity is exposed to varicella?
Post-exposure prophylaxis (in pregnancy, this includes VZ Ig)
53
How are patients with a breech presentation typically managed? Why?
Cesarean delivery at term; because breech vaginal deliveries have a higher rate of complications compared with cephalic vaginal deliveries
54
Patients with breech presentation who do not want to undergo scheduled cesarean delivery can be offered an ___.
External cephalic version (procedure that manually rotates the fetus to cephalic presentation)
55
Indications for the ECV procedure?
Breech/transverse presentation, 37+ weeks gestation
56
What are absolute contraindications to ECV?
Contraindications to vaginal delivery -
Prior classical (vertical uterine incision) cesarean delivery
Prior extensive uterine myomectomy
Placenta previa
57
What are complications of the ECV procedure?
Abruptio placentae, intrauterine fetal demise
58
Define stress urinary incontinence.
Involuntary loss of urine due to increased abdominal pressure (eg, coughing, sneezing)
59
What is the best test to confirm a diagnosis of fibroids?
Ultrasonography of the pelvis
60
___ is performed to visualize the bladder cavity to evaluate for cancer.
Cystoscopy
61
What is the gold standard test for UTI?
Urine culture
62
___ can be a presenting symptom of fibroids due to direct pressure on the bladder from an irregularly enlarged uterus.
Urinary stress incontinence
63
Presentation of tubo-ovarian abscess?
Fever, abdominal pain, and a complex multiloculated adnexal mass with thick walls and internal debris
64
Discuss the pathophysiology of tubo-ovarian abscess.
Polymicrobial infection of the upper genital tract extends to the fallopian tubes and creates an inflammatory exudate, purulent fluid, and wall thickening, which conglomerate into a complex mass to create pyosalpinx and TOA.
65
What are some lab findings of TOA?
Increases in non-specific indices (eg, leukocytosis, CRP, CA-125), fever
66
How is TOA diagnosed and treated?
Dx - imaging (pelvic U/S, CT scan, etc.)
| Rx - broad-specrum parenteral antibiotics
67
How does an endometrioma of the ovary typically appear on ultrasound?
"Ground glass" appearance
68
How is asymptomatic bacteriuria defined?
The growth of 100,000+ CFU/mL of a single bacteria from a clean catch urine specimen from a patient who has no UTI symptoms.
69
List 3 risk factors of asymptomatic bacteriuria.
1. Pre-gestational DM
2. History of UTI
3. Multiparity
70
List 4 common pathogens causing asymptomatic bacteriuria, including the most common.
1. E. coli (most common)
2. Klebsiella
3. Enterobacter
4. GBS
71
List 4 first-line treatment options for asymptomatic bacteriuria.
1. Cephalexin
2. Amoxicillin-clavulanate
3. Nitrofurantoin
4. Fosfomycin
72
Why does pregnancy increase risk for asymptomatic bacteriuria?
Increased progesterone levels cause smooth muscle relaxation and ureteral dilation; because of these physiologic changes, patients with untreated ASB during pregnancy are at increased risk for ascending infection; it is also associated with increased risk of preterm labor and low birth weight
73
Because of the risk of pyelonephritis and other complications, all women are screened for ___ with a urine culture at the initial prenatal visit.
ASB
74
What is done after antibiotic treatment of ASB is finished?
Test of cure - repeat urine culture
75
What is cervical insufficiency?
Painless cervical dilation that causes second trimester pregnancy loss (risk factors include a history of cervical trauma and cervical surgery)
76
What causes chorioamnionitis?
Ascent of normal vaginal flora into the uterus
77
Risk factors for chorioamnionitis?
Prolonged membrane rupture, operative vaginal delivery, GBS colonization
78
A protracted first stage of labor is most commonly due to fetal ___, which is commonly associated with ___.
Macrosomia; GDM
79
What happens to thyroid hormones during pregnancy?
Estrogen induces an increase in serum thyroxine-binding globulin levels, requiring an increase in the amount of thyroid hormone to saturate the binding sites. It is also increased due to the stimulatory effects of hCG on TSH receptors. This leads to an increase in total thyroid hormone levels, with a minimal increase in free hormone levels and a decrease in TSH.
80
What happens to thyroid hormones during pregnancy in women who have hypothyroidism?
They are unable to increase thyroxine production appropriately and are at risk for a worsening hypothyroid state and adverse maternal and fetal effects.
81
How should women being treated for hypothyroidism be managed in pregnancy?
Patients on a stable dose of thyroid replacement should have their dose increased by ~30% at the time the pregnancy is detected. It should be adjusted subsequently (typically in 4-week increments) based on TSH using pregnancy-specific norms.
82
How do total T4, free T4, and TSH change in pregnancy in the first trimester?
Total T4 - increased
Free T4 - unchanged or mildly increased
TSH - decreased
83
List 4 risk factors for placental abruption.
1. Maternal HTN or preeclampsia/eclampsia
2. Abdominal trauma
3. Prior placental abruption
4. Cocaine and tobacco use
84
Presentation of placental abruption?
Sudden-onset vaginal bleeding (seen in 80%), abdominal or back pain, high-frequency, low-intensity contractions, hypertonic, tender uterus
85
What is abruptio placentae?
Retroplacental bleeding between the placenta and uterine decidua that can cause placental detachment and vaginal bleeding.
86
The larger the area of placental detachment, the greater the risk for maternal complications such as ___ and ___.
DIC (due to tissue factor released by decidual bleeding); hypovolemic shock.
87
What are potential fetal complications of abruptio placentae?
Hypoxia and preterm delivery
88
Compare the contraction pattern in uterine rupture vs. abruptio placentae.
Uterine rupture - loss of contraction pattern and loss of fetal station
Abruptio - high-frequency, low-intensity contractions
89
Define umbilical cord prolapse.
Umbilical cord delivers through the cervix ahead of the presenting fetal part
90
DDx - vaginitis
1. Bacterial vaginosis (Gardnerella)
2. Trichomoniasis
3. Candida vaginitis
91
Compare the physical findings of vaginitis.
1. Bacterial vaginosis - thin, off-white discharge with a fishy odor, no inflammation
2. Trichomoniasis - thin, yellow-green, malodorous, frothy discharge, vaginal inflammation
3. Candida vaginitis - thick, cottage cheese discharge, vaginal inflammation
92
Compare the laboratory findings of vaginitis.
1. Bacterial vaginosis - pH >4.5, clue cells, positie whiff test (amine odor with KOH)
2. Trichomoniasis - pH >4.5, motile trichomonads
3. Candida vaginitis - normal pH (3.8-4.5), pseudohyphae
93
Compare the treatments of vaginitis.
1. Bacterial vaginosis - metronidazole or clindamycin
2. Trichomoniasis - metronidazole (tinidazole is also an option); treat sexual partner
3. Candida vaginitis - fluconazole
94
When treated with metronidazole, patients should refrain from alcohol consumption - why?
Risk for a disulfiram-like reaction
95
How is trichomoniasis transmitted?
Sexually
96
What information should be given to patients being treated for trichomoniasis?
1. Avoid alcohol while taking metronidazole
2. Treat the partner empirically (testing is unnecessary due to the high rate of concurrent carriage, difficulty of diagnosis in men, decreased compliance when delaying partner treatment, and low cost)
3. Avoid sexual activity until both partners have completed treatment
97
First line treatment for chlamydia?
Azithromycin
98
What causes candida vaginitis and bacterial vaginosis?
Imbalance of vaginal flora (not sexual transmission)
99
Presentation of trichomonas infection?
Vaginal discharge, pruritis, dysuria, dyspareunia, sometimes asymptomatic
100
___ is a chronic inflammatory condition of the anogenital region that can affect women at any age.
Lichen sclerosis
101
Discuss the pathogenesis of lichen sclerosis.
Can have an autoimmune pathogenesis, may coexist with other AI conditions
102
True or false - extragenital involvement of lichen sclerosis is possible.
True
103
Presentation of lichen sclerosus?
Intense pruritus and white atrophic plaques involving the vulva and sometimes perianal skin but not the vagina
104
How is lichen sclerosus diagnosed and what is ruled out this way?
Punch biopsy; rules out vulvar SqCC
105
Physical findings of lichen sclerosus?
Porcelain-white polygonal patches with atrophy of normal genital structures; sclerosus and scarring lead to obliteration of the labia minora and clitoris and a decrease in the diameter of the introitus
106
True or false - lichen sclerosus is a vulvar premalignant lesion.
True (vulvar SqCC occurs with greater frequency)
107
What causes menopause-related atrophic vaginitis?
Hypoestrogenemia
108
Compare the clinical features of atrophic vaginitis vs. lichen sclerosus.
Atrophic - vulvovaginal dryness, loss of vaginal elasticity and rugae, thinning vulvar skin/loss of minora, decreased vaginal diameter
Lichen sclerosus - white vulvar plaques/loss of minora, vulvar dryness, intense pruritus, perianal "figure of 8" involvement, spares vagina
109
Compare the treatment of atrophic vaginitis vs. lichen sclerosus.
Atrophic - low-dose topical estrogen
LS - high-potency topical steroids
110
What information should patients be given regarding high-potency topical corticosteroid treatment of LS?
1. It is not known whether corticosteroids can prevent scarring and ScQQ.
2. More than once-daily application increases AE such as skin atrophy, discoloration, and striae
111
___ is commonly used to treat genital warts.
Cryotherapy
112
____ is reserved for the treatment of vulvar cancer.
Radical vulvectomy
113
___ are an estradiol-secreting ovarian sex-cord stromal tumor which can cause a concomitant endometrial hyperplasia/cancer.
Granulosa cell tumors
114
Clinical features of granulosa cell tumors?
1. Complex ovarian mass
2. Juvenile subtype- precocious puberty
3. Adult subtype - breast tenderness, abnormal uterine bleeding, post-menopausal bleeding
115
Histopathology of granulosa cell tumors?
Call-Exner bodies (cells in a rosette patter)
116
Management of granulosa cell tumors?
1. Endometrial biopsy (endometrial cancer)
2. Surgery (tumor staging) - premenopausal women desiring future fertility who have a granulosa cell tumor and no endometrial cancer can undergo a uterus-sparing procedure; those with both require a hysterectomy and bilateral salpingo-oophorectomy + chemo/radiation depending on the stage
117
Discuss the pathogenesis of granulosa cell tumors.
Sex cord-stromal tumor secretes estradiol. This causes uncontrolled endometrial proliferation.
118
What is a hysterosalpingogram used for?
To evaluate the uterine cavity and fallopian tubes in patients with infertility or uterine anomalies
119
List three risks for Staph toxic shock syndrome
1. Tampon use
2. Nasal packing
3. Surgical/postpartum wound infection
120
What are the clinical features of Staph TSS?
Fever >38.9 C (102 F), hypotension, diffuse macular rash involving palms and soles, desquamation 1-3 weeks after disease onset, vomiting, diarrhea, altered mentation without focal neurologic signs
121
How is Staph TSS treated?
1. Supportive therapy (fluid replacement)
2. Removal of foreign body
3. Antibiotic therapy (eg, clindamycin + vancomyin)
122
Disseminated gonococcal infection, caused by N. gonorrhoeae, can present with a ___, rather than a macular, dermatitis. What other symptoms are seen?
Pustular; associated tenosynovitis and a migratory asymmetric polyarthralgia
123
What are risk factors for ovarian cancer?
Age, use of fertility drugs, uninterrupted ovulation (eg, nulligravidity), and BRCA mutation
124
___ is a biomarker for epithelial ovarian cancer.
Cancer antigen 125 (CA-125)
125
What are some other causes of elevated CA-125?
Common gynecologic conditions (eg, leiomyomata, endometriosis) that are more common in premenopausal patients; the specificity of CA-125 levels is much greater in postmenopausal women
126
Why is needle aspiration contraindicated in postmenopausal women with an adnexal mass?
Risk of spreading potentially malignant cells should the mass prove cancerous
127
List the 2 SERMs.
Tamoxifen and Raloxifene
128
MOA - SERMs?
Competitive inhibitor of estrogen binding; mixed agonist/antanosti action
129
What are the indications of SERMs?
Prevention of breast cancer in high-risk patients;
Tamoxifen - adjuvant treatment of breast cancer
Raloxifene - postmenopausal osteoporosis
130
AE of SERMs?
Hot flashes; venous thromobemoblism; Tamoxifen only - endometrial hyperplasia and carcinoma
131
What are the tissue-specific effects of raloxifene?
Estrogen agonist activity on the bone, estrogen antagonist activity in the breast and uterus
132
All medicines with estrogen agonist activity, including OCs, HRT, and all SERMS increase the risk for ___.
VTE
133
Discuss and compare the risks associated with raloxifene and tamoxifen.
Tamoxifen - increased risk of uterine cancer, increased risk of breast cancer, increased risk of CAD
Both - NO increased risk of ovarian cancer, increased risk of VTE
134
Presentation fo SLE nephritis in pregnancy?
Edema, malar rash, arthritis, hematuria, hypertension
135
Lab findings of SLE nephritis in pregnancy?
Nephritic range proteinuria
Urinalysis with RBC and WBC casts
Decreased complement levels
Increased ANA titers
136
How is SLE nephritis diagnosed in pregnancy?
Renal biopsy
137
List 5 obstetric complications to SLE nephritis in pregnancy.
1. Preterm birth
2. Cesarean delivery
3. Preeclampsia
4. Fetal growth restriction
5. Fetal demise
138
List risk factors for SLE flares.
Pregnancy, postpartum period, discontinuation of hydroxychloroquine, active disease prior to conception
139
In patients known to have SLE prior to conception, the appearance of proteinuria during pregnancy may represent an SLE flare complicated by ___, ___, or both.
Nephritis; preeclampsia
140
How can lupus nephritis be distinguished from preeclampsia?
Both present with edema, HTN, and proteinuria. However, lupus nephritis presents with the associated signs and symptoms of SLE (eg, joint pain, malar rash), and the presence of RBC casts on urinalysis. It can be further distinguished by decreased complement levels and increasing ANA titers.
