OB/GYN Flashcards
1
Q
What conditions are suggested by an excessive amount of beta HCG? (3)
A
- twin pregnancy
- hydatiform mole
- cancer (choriocarcinoma, embryonal carcinoma)
2
Q
What conditions are suggested by an inadequate amount of beta HCG? (3)
A
- ectopic pregnancy
- threatened abortion
- missed abortion
3
Q
What substance during pregnancy is responsible for the predisposition of pregnancy to glucose intolerance and diabetes?
A
human placental lactogen
level parallels placental growth
4
Q
What is Chadwick sign?
A
bluish/purplish discoloration of the vagina and cervix as a result of increased vascularity during pregnancy (occurs at 6-8 weeks gestation)
5
Q
what is linea nigra?
A
increased pigmentation of the lower abdominal midine from pubis to the umbilicus during pregnancy (occurs during 2nd trimester)
6
Q
What is chloasma?
A
blotchy pigmentation of the nose and face (worse with sun; occurs at 16 weeks)
7
Q
What are the cardiovascular changes that occur during pregnancy? (6)
A
- initial lowering of blood pressure (then rises to normal)
- femoral venous pressure doubles/ triples
- plasma volume increases
- systemic vascular resistance declines
- cardiac output increases (greatest in lateral decubitus)
- systolic ejection murmur at left sternal border (due to increased CO passing through aortic valve)
8
Q
What are the hematologic changes that occur during pregnancy? (5)
A
- RBC mass increases (need additional iron)
- Hg and Hct decreases (due to dilutional effect of increased plasma volume)
- leukocytosis
- elevated ESR
- hypercoaguable state (due to increase in factors 5, 7, 8, 9, 12 and vWf and decrease of protein C and S)
9
Q
What are the gastrointestinal changes that occur during pregnancy? (3)
A
- GERD/ reflux (due to decrease gastric motilty, increased emptying time of stomach, decreased lower esophageal sphincter tone)
- constipation (due to decreased colonic motility and increased transit time of colon)
- morning sickness (4-8 weeks to 14-16 weeks gestation from estrogen, progesterone, HCG)
(due to effects of progesterone and intraabdominal content displacement)
10
Q
What are the pulmonary changes that occur during pregnancy? (4)
A
- tidal volume increases (airflow in and out)
- minute ventilation increases (b/c increase of tidal volume)
- residual volume decreases (b/c upward displaced abdominal content)
- respiratory alkalosis (due to increased ventilation leading to decreased CO2)
11
Q
What are the renal changes that occur during pregnancy? (4)
A
- increased kidney size (increases risk of pyelonephritis and stress urinary incontinence)
- ureteral diameter increases (due to progesterone)
- GFR, renal plasma flow and creatinine clearance increases (decrease in BUN and creatinine)
- urine glucose increases (due to decreased tubal reabsorption of glucose)
12
Q
What are the endocrine changes that occur during pregnancy? (4)
A
- increased pituitary size (due to increased vascularity that makes susceptible to ischemia)
- increased cortisol production
- increased thyroid size (due to increased vascularity)
- increased thyroid binding globulin (leading to increased total T3 and T4 while free T3 and free T4 unchanged)
13
Q
What is the function of the ductus venous in fetal circulation?
A
carries blood from umbilical vein to inferior vena cava
14
Q
What is the function of the foramen ovale in fetal circulation?
A
carries blood from right atrium to left atrium
15
Q
What is the function of the ductus arteriosus in the fetal circulation?
A
shunts blood from pulmonary artery to descending aorta
16
Q
What structure in the breast tissue is responsible for keeping the breast in their characteristic shape and position and support breast tissue?
A
Cooper’s ligament
loosened in elderly and pregnancy
17
Q
What hormone is responsible for stimulation of milk production?
A
Prolactin
antagonized by estrogen and dopamine
18
Q
What hormone is responsible for milk ejection from lactating breast?
A
oxytocin (released in response to suckling)
19
Q
At what point during the pregnancy does the syncytiotrophoblast invade the maternal sinusoids and allow for detection of beta HCG?
A
week 2
20
Q
At what point during the pregnancy does the forming embryo form the trilaminar germ disk with an ectoderm, mesoderm, and endoderm?
A
week 3
21
Q
What period during pregnancy is the fetus at highest risk of teratogenic risk?
A
weeks 4-8 (when major organs and organ systems forming)
22
Q
What primordial strucutre forms the fallopian tubes, corpurs of the uterus, cervix and distal vagina?
A
Mullerian (paramesonephric) ducts
do not require hormonal stimulation to form
23
Q
What primordial structure forms the vas deferens, seminal vesicles, epididymis, and efferent ducts?
A
Wollfian (mesonephric) duct
requires stimulation with testosterone to form
24
Q
What hormone is required for differentiation of the male external genitalia into penis and scrotum?
A
DHT (dihydrotestosterone)
25
What cells are responsible for producing mullerian inhibitory factor in males to prevent female internal reproductive system formation?
Sertoli cells
26
What cells are responsible for producing testosterone in males to promote male internal reproductive system formation?
Leydig cells
27
What complications are associated with smoking during pregnancy?
1. intrauterine growth restriction
| 2. preterm delivery
28
A female pt presents with amenorrhea, breast tenderness, nausea, vomiting and fatigue and is in reproductive age most likely suffers from ...
pregnancy (initial test is beta HCG)
29
What is a common complication of valproic acid use during pregnancy?
neural tube defects
30
What is a common complication of warfarin use during pregnancy?
Chondrodysplasia (stippled epiphysis)
31
What is the developmental age?
days since fertilization
32
what is the gestational age?
days since the last menstrual period (2 weeks longer than developmental age)
33
What is Nagele's rule?
take the first day of last menstrual period, subtract 3 months and then add 7 days
(gives you estimated date of delivery)
34
What is the most accurate way to determine gestational age, especially in pregnancy in which last mesntrual cycle is unknown?
ultrasound in 1st trimester
35
What is considered first trimester?
fertilization to 12 weeks developmental age
| fertilization to 14 weeks gestational age
36
What is considered second trimester?
12 weeks to 24 weeks developmental age
| 14 weeks to 26 weeks gestational age
37
What is considered third trimester?
24 weeks developmental age to birth
| 26 weeks gestational age to birth
38
What diagnostic test are done during first trimester to assess for chromosomal abnormalities?
FIRST screen (combination of nuchal transluceny and serum markers)
39
What diagnostic tests are done during second trimester to assess for chromosomal abnormalities?
1. triple screen (MS-AFP, beta HCG, estriol)
| 2. quad screen (inhibin A, MS-AFP, beta HCG and estriol)
40
When does quickening (mother feeling fetal movements) initially occur?
between 16-20 weeks gestational age
41
When is the anatomic ultrasound performed to look for possible defects?
between 18-20 weeks gestational age
42
What does bleeding in the first trimester suggest? (2)
1. abortions
| 2. ectopic pregnancy
43
What does bleeding in the third trimester suggest? (4)
1. placental aburption
2. placental previa
3. vaso previa
4. labor
44
What is considered a preterm delivery?
birth of fetus between 24 weeks and 37 weeks gestational age
45
What is considered a term delivery?
birth of fetus between 37 weeks and 42 weeks gestational age
46
What is considered a post-term delivery?
birth of fetus after 42 weeks gestational age
47
What is gravidity?
total number of times that a woman has been pregnant
48
What is parity?
result of the pregnancies
| full term, preterm, abortions, living children
49
What does F-PAL stand for in terms of parity?
F: full term birth
P: preterm births
A: abortions
L: living children
50
What is Goodell sign and when does is occur?
softening of cervix that occurs at 4 weeks gestational age
51
what is ladin sign and when does is occur?
softening of uterine midline; occurs at 6 weeks gestational age
52
When do telangiectasias (small blood vessels) and palmar erythema (reddening of palm) occur during pregnancy?
during 1st trimester
| associated with increased estrogen
53
What is the typical rise in beta HCG during a normal pregnancy?
doubles every 48 hours for first 4 weeks (peaks at 10 weeks gestation; drop of 2nd trimester)
54
What diagnostic test is used to confirm intrauterine pregnancy?
ultrasound (gestational sac within uterus at 5 weeks gestation/ beta HCG of 1500)
55
How often are office visits during the first trimester?
every 4-6 weeks
| maternal bp, weight and fetal well being
56
what tests are done at the initial pre-natal visit? (10)
1. type and antibody screen
2. hct, Hg, MCV
3. cervical cytology
4. rubella titers
5. urine culture
6. rpr/ VDRL
7. HIV
8. Hep B antigen
9. Gonorrhea
10. chlamydia
57
When can fetal heartbeats first be heard with doppler?
end of 1st trimester
58
What are the findings on quad screen that suggest Down syndrome (trisomy 21)?
elevated beta-HCG and inhibin A
| decreased MS-AFP and estriol
59
What are the findings on quad screen that suggest trisomy 18?
low beta- HCG, estriol, and MS-AFP
60
A pt presenting with elevated maternal serum alfa fetal protein (MS-AFP) and an ultrasound showing banana sign (compression of cerebellum in posterior fossa) suggests....
neural tube defect
61
What is normal heart rate of fetus during pregnancy?
110-160 beats per minute
62
What are braxton hicks contractions?
sporadic contractions that do not cause cervical dialation
63
What is the function of the CBC obtained at 27 weeks?
detect iron deficiency anemia (tx: iron and stool softner)
64
When is the glucose tolerance test performed (50 gram glucose ingestion) and what is considered abnormal?
24-28 weeks gestation; >140 at 1 hour (then perform oral glucose challenge test with 100 grams of glucose)
65
When is rectovaginal culture for group B strep testing performed during pregnancy?
36 weeks (if positive, treat with ampicillin at time of delivery)
66
When is chorionic villus sampling performed during pregnancy?
10-13 weeks gestation
| used to detect chromosomal abnormalities
67
When is amniocentesis normally done during pregnancy?
15-20 weeks gestation
| used to detect chromosomal abnormalities
68
When is percutaneous umbilical blood sample performed?
presence of Rh isoimmunization and when fetal CBC is needed
69
What is the most common site of ectopic pregnancy?
fallopian tube (usually ampulla)
70
What are the risk factors for ectopic pregnancy? (5)
1. previous ectopic pregnancy
2. PID (pelvic inflammatory disease)
3. intrauterine devices (IUD)
4. endometriosis
5. prior tubal surgery
71
A pt presents with amenorrhea, unilateral lower abdominal/ pelvic pain and vaginal bleeding most likely suffers from....
Ectopic pregnancy
| usually 6-8 weeks after last menstrual period
72
A female pt presenting with amenorrhea, unilateral lower abdominal/ pelvic pain, vaginal bleeding, hypotension and peritoneal irritation most likely suffers from ...
ruptured ectopic pregnancy
73
What is the best initial test in a premenopausal women presenting with abdominal pain or vaginal bleeding?
pregnancy test (beta HCG)
74
What is the diagnostic test for ectopic pregnancy?
beta- HCG with ultrasound (locates implantation site)
75
What is discriminatory zone for beta HCG level?
1500-2000 (at this level, should be able to detect embryo sac via ultrasound)
76
What is the diagnostic test of choice for a pt with suspected ruptured ectopic pregnancy?
laparoscopy (allows for test and treatment of ectopic pregnancy)
77
What is the best initial treatment for a pt presenting with ruptured ectopic pregnancy (peritoneal signs) and unstable (low BP, etc)?
IV fluids, blood products and dopamine (followed by surgery)
78
What are medical treatment for non-ruptured ectopic pregnancy?
methotrexate
| pt must be medically stable, comply w/ post treatment followup, no fetal cardiac activity, beta- HCG less than 5000
79
What is involved in post-treatment followup for methotrexate treatment of ectopic pregnancy?
beta HCG level checked at days 4 and 7 post treatment
| > 15% drop suggest sucessful; if not then second dose possible
80
What are contra-indications for methotrexate therapy for ectopic pregnancy? (11)
1. hemodynamically unstable pt
2. ectopic mass rupture
3. abnormalities in CBC, LFTs or renal fucntion test
4. hx of immunodificency, active pulmonary disease, peptic ulcer disease
5. allergic to MTX
6. co-existing viable intra-uterine pregnancy
7. breastfeeding pt
8. non-compliant pt
9. no access to medical institution
10. positive fetal heart activity
11. fetal sac greater than 3.5 cm
81
What is an important treatment for all Rh negative mothers?
RhoGAM (anti-D Rh immunoglobulin to prevent hemolytic anemia in subsequent births)
(w/in 72 hours of onset of bleeding)
82
What is a complete abortion?
no products of conception left behind (just followup)
83
What is incomplete abortion?
some products of conception left behind (perform D&C or medical tx)
84
What are maternal risk factors for abortions? (8)
1. advancing maternal age (>35 y/o)
2. anatomic abnormalities (uterine, adhesions-Asherman syndrome)
3. exposure to DES
(T-shaped uterus)
4. infections (HIV, syphilis, listeria, chlamydia)
5. immunologic (lupus, antiphospholipid syndrome)
6. endocrinologic (thyroid, diabetes)
7. malnutrition
8. trauma
85
A pregnant pt presents with cramping abdominal pain, vaginal bleeding, hypotension, tachycardia most likely suffers from ...
abortion
86
What is an inevitable abortion?
products of conception intact but intrauterine bleeding present and cervix dilated (D&C or medical tx)
87
What is a threatened abortion?
products of conception intact, intrauterine bleeding, no dilation of cervix (tx via bed rest and pelvic rest)
88
What is a missed abortion?
death of fetus, all products of conception present in uterus (tx via D&C or medical)
89
What is a septic abortion?
infection of uterus and surrounding areas (tx: D&C and IV antibiotics)
90
What are monozygotic twins?
identical twins (same gender, physcial characteristics, blood type but different fingerprints)
due to fertilization of egg w/ 1 sperm and then splitting
91
What are dizygotic twins?
fraternal twins
| due to 2 different eggs being fertilized by different sperm
92
What is lamda sign and what does it suggest?
triangular peak of chorion extending from placenta to inter-twin membrane; dichorionic and diamniotic pregnancy
93
When does cleavage occur in monozygotic twins to result in dichorionic-diamniotic gestation?
days 1-3
| each baby has own placenta and own sac
94
When does cleavage occur in monozygotic twins to result in monochorionic- diamniotic gestation?
days 4-8 (each baby has own sac but share placenta)
95
When does cleavage occur in monozygotic twins to result in monochorionic- monoamniotic gestation?
days 8-13 (share placenta and sac)
96
When does cleavage occur in monozygotic twins to result in conjoined twins?
days 13-15
97
What is a complication of monochorionic twins (share placenta)?
Twin-twin transfusion syndrome (vascular anastomosis leading to difference in perfusion leading to 1 twin being anemic and the other volume overload)
98
What is the best initial step in management of a pregnant pt in pre-term labor between 24-33 weeks (fetal weight of 600-2500g)?
Stop delivery via tocolytics (so can give betamethasone to mature fetal lungs)
99
What are risk factors for preterm labor? (6)
1. premature rupture of membranes
2. multiple gestations
3. hx of preterm labor
4. placental abruption
5. maternal infection
6. uterine abnormalities (bicornate uterus)
100
A pt presenting with contractions and cervical dilation during pregnancy between 20-37 weeks of gestation most likely suffers from ....
preterm labor
101
What factors indicate immediate delivery of a pregnant women in pre-term labor? (9)
1. severe maternal hypertension (pre-eclampsia)
2. maternal cardiac disease
3. cervical dilation > 4 cm
4. maternal hemorrhage (placental abruption, DIC)
5. fetal death
6. chorioamnionitis
7. preterm rupture of membranes (> 34 weeks)
8. fetal distress
9. intrauterine growth restriction with reverse diastolic flow
102
What is the best initial step in management of a pregnant pt in preterm labor between 34-37 weeks (fetal weight > 2500 grams)?
let preterm labor evolve to delivery
103
What is the role of corticosteroid administration during preterm labor?
increases pulmonary surfactant to mature lungs (decrease risk of respiratory distress syndrome)
104
What are common tocolytics used to halt pre-term labor?
1. magnesium sulfate (headaches, flushing, diplopia)
2. calcium channel blockers (headache, flushing, dizziness)
3. beta agonist (hypotension, tachycardia, chest tightness)
4. prostaglandin inhibitors (premature closure of PDA if used after 34 weeks)
105
What is the antidote for magnesium toxicity (decreased deep tendon reflexes, respiratory distress, cardiac arrest)?
Calcium gluconate
106
A pt presents with gush of fluid from vagina before contractions begin most likely suffers from ....
premature rupture of membranes
107
What is the major complication of premature rupture of membranes?
infection (reduce number of pelvic exams)
108
What is prolonged premature rupture of membranes?
rupture of membranes occurred more than 24 hours before onset of labor
109
What are the signs of ruptured membranes? (3)
1. pooling of fluid in posterior fornix
2. nitrazine paper turns blue
3. ferning of fluid
110
What is treatment for premature rupture of membranes if before 32 weeks?
corticosteroids and antibiotics
111
What is differential diagnosis for uterine causes of third trimester bleeding?
1. uterine rupture
2. placenta previa
3. vasa previa
4. placental abruption
112
A pt presents in 3rd trimester with painless vaginal most likely suffers from ....
placenta previa (placenta over cervical os)
113
What are risk factors for placenta previa?
1. previous scar (C-section)
2. multiple gestations
3. hx of placenta previa
114
What is the initial step in management for a third trimester bleed?
```
transabdominal ultrasound (to assess placenta)
(digital vaginal exam is contraindicated)
```
115
What is vasa previa?
fetal vessels that present over cervical os
116
What is the treatment for placenta previa?
1. strict pelvic rest
2. type and screen, CBC test
3. deliver by C-section (if labor, severe hemorrhage or fetal distress)
117
What is placenta accreta?
placenta villi invade deeper layers of endometrial deciduus basalis (no invasion of myometrium)
118
What is placenta increta?
placental villi invade into myometrium
119
What is placenta percreta
placenta villi penetrate through serosa and may invade surrounding organs (bladder or bowel)
120
What is treatment for placenta accreta/ increta/ percreta?
cesarian hysterectomy (C-section to remove baby then remove uterus)
121
A pregnant pt presents with painful bleeding associated with severe abdominal pain during third trimester most likely suffers from ...
placental abruption (abnormal, premature separation of placental from uterus)
122
What are risk factors for placental abruption?
1. maternal hypertension
2. hx of placental abruption
3. smoking or cocaine use
4. trauma (motor vehicle accident)
123
What is the delivery plan for a pt presenting with placental abruption?
1. C-section: uncontrollable hemorrhage, fetal distress
| 2. vaginal: placental separation limited, reassuring fetal monitor, fetal death prior to presentation
124
A pregnant pt presents during third trimester with sudden abominal pain, abnormal abdominal bump, lack of contractions, regression of fetal parts, profuse vaginal bleeding and history of uterine incision most likely suffers from ...
Uterine rupture
125
What is treatment for uterine rupture?
immediate laparotomy and repair of uterus in young (hysterectomy in old)
126
What are risk factors for uterine rupture? (5)
1. previous C-section (classical)
2. trauma
3. uterine myomectomy (removed fibroid)
4. uterine overdistention (polyhydramnios, multiple gestations)
5. placenta percreta
127
What is Rh incompatibility?
mother is RhD negative and baby is RhD positive, so mom makes antibodies against fetal blood cells that cross placenta during delivery/ abortion/ trauma
(problematic for subsequent pregnancies with RhD positive babies)
128
What is the clinical significance of Rh incompatibilty?
1st baby: mild anemia, mild hyperbilirubinemia
| 2nd baby: hemolytic disease of newborn (due to IgG formation that crosses placenta)
129
A newborn with fetal anemia, extramedullary production or RBCs (hepatosplenomegaly), elevated bilirubin (neurotoxic) and heme levels, and high output cardiac failure (Hydrops fetalis) most likely suffers from ...
Hemolytic disease of newborn (secondary to Rh incompatability)
130
When should pt receive Rhogam if unsensitized (negative antibody titer) Rh negative pregnant mom with Rh positive baby?
1. 28 weeks
2. at time of birth 3. at time of bleeding
4. procedures (amniocentesis)
131
what should be done if Rh antibody titers is greater than 1/16 in Rh negative mother?
1. type father's Rh (to determine if baby positive)
2a. middle cerebral dopplers (peak flow > 1.5 multiples of median)
2b. amniocentesis
132
When do you perform an intrauterine transfusion?
if fetal hct < 30% via percutaneous umbilical blood sampling
133
A pregnant pt presents with sustained hypertension with proteinuria and is more than 20 weeks gestation most likely suffers from ...
Pre-eclampsia
mild: > 140/90, protein > 300 mg
severe: > 160/110, protein > 5 grams, altered mental status, vision changes, abnormal LFTs
134
A pregnant pt greater than 20 weeks gestation presenting with sustained hypertension without proteinuria most likely suffers from ...
Gestational Hypertension
135
A pregnant pt less than 20 weeks gestation persenting with sustained hypertension with out proteinuria most likely suffers from ...
Chronic hypertension
136
What is the treatment for chronic hypertension or gestational hypertension in a pregnant pt?
1. labetalol
2. nifedipine
3. methyldopa
(avoid ACEi and ARBs)
137
A pregnant pt presents with hypertension, seizures and proteinuria most likely suffers from ...
Eclampsia
138
What is treatment for mild pre-eclampsia if at term?
induce labor
139
What is treatment for mild pre-eclampsia if preterm?
give betamethasone (mature lungs)& magnesium sulfate (prevent seizures)
140
What is the treatment for severe pre-eclampsia?
1. magnesium sulfate (seizure prophylaxis)
2. hydralazine (control bp)
3. delivery based on preterm or term
141
What is the only definitive treatment for pre-eclampsia?
delivery
142
What is treatment for eclampsia?
1. magnesium (5 g IV bolus) or diazepam
2. IV hydralazine/ labetalol
3. delivery
143
A pregnant pt presents with elevated LFTs, hemolysis, thrombocytopenia, hypertension and proteinuria most likely suffers from ...
HELLP syndrome (hemolysis, elevated liver, low platelet syndrome)
144
What is the treatment for HELLP syndrome?
1. control BP (hydralazine/ labetalol)
| 2. delivery
145
What is the next best step for a pregnant pt with an elevated 1 hour glucose tolerance test (glucose > 140 after 1 hour)?
3 hour glucose tolerance test
146
What are maternal complications of diabetes during pregnancy?
1. pre-eclampsia
2. abortion
3. increased infection
4. increased post partum hemorrhage
147
What are fetal complications of diabetes during pregnancy?
1. heart defects, neural tube defects
2. macrosomia (increase risk of shoulder dystocia)
3. preterm labor
4. neonatal hypoglycemia
148
What are tests that one would obtain if a pregnant pt has pregestetional diabetes?
1. ELG
2. 24 hour urine as baseline renal function
3. HgA1C
4. Eye exam
149
What is the treatment for pregestational diabetes?
type 1: insulin
| type 2: metformin/ glyburide or insulin
150
At what point during the pregnancy should a diabetic pregnant pt receive weekly non-stress test and ultrasound?
32-36 weeks gestation
| NST to assess fetal well being, U/S to assess fetal size
151
At what point during the pregnancy should a diabetic pregnant pt receive twice weekly non-stress test and 1 biophysical profile?
36 weeks gestation
152
What test is performed at 37 weeks in a diabetic pregnant patient?
Lecithin/ sphingomyelin ratio (assess for fetal lung maturity; if mature then deliver)
153
What is gestational diabetes?
glucose intolerance diagnosed during pregnancy
154
What is nerves are damaged in Erb's Palsy?
C5 and C6 nerve root (weakness of deltoid, biceps and infraspinatus)
155
What nerves are damaged in Waiter's Tip Palsy?
C5-C7 nerve root
156
What nerves are damaged in Klumpke's Palsy?
C8-T1 nerve roots (Horner's syndrome, hand paralysis)
157
When is glucose challenge test (50 grams with glucose after 1 hour) performed to assess for gestational diabetes?
between 24-28 weeks of gestation
158
What is the initial step in management of pregnant pt diagnosed with gestational diabetes?
1. diet and exercise (walking)
| 2. check blood sugar (if fasting > 90, post-prandial > 140 then treat with meds)
159
What should you do in a pregnant pt post partum if she was diagnosed with gestational diabets during pregnancy?
2 hour glucose tolerance test (to assess for type 2 diabetes)
160
What is symmetric intrauterine growth restriction?
brain in proportion with rest of body
| due to problem occuring before 20 weeks
161
What is asymmetric intrauterine growth restriction?
brain weight is not decreased; abdomen is smaller than head
| occurs > 20 weeks due to uteroplacental insufficiency
162
When should a fundal height equal gestational age in weeks?
20-36 weeks gestation
| if discrepancy of 3 cm or more, obtain ultrasound
163
What is the definition of intrauterine growth restriction?
< 2500 grams
164
What measurements are performed during ultrasound to determine estimated fetal weight? (3)
1. head circumference (occiptal frontal diameter, bitemporal diameter)
2. femur length
3. abdomenal circumference
165
What is the definition of macrosomia?
birth weight > 4000 grams
166
What are risk factors associated with macrosomia?
1. maternal diabetes
2. post-term pregnancy
3. fetal genetic syndrome
4. advanced maternal age
167
What are common complications of macrosomia?
1. shoulder dystocia
2. birth injuries (cervical fractures, brachial plexus injury)
3. asphyxia (low apgar scores)
4. hypoglycemia
168
When should a C-section be performed in a pregnancy with a macrosomic fetus?
1. diabetic: EFW > 4500 grams
| 2. nondiabetic: EFW > 5000 grams
169
What does VEAL CHOPS stand for when assessing a non-stress test?
Variable: cord compression
early decls: head compression (w/ onset of contraction) from contraction
accelerations: okay!
late decls: placental insufficiency (after contractions)
170
What is considered a reactive non-stress test?
2 accelerations lasting less than 2 minutes in a 20 minute window
(> 10 beats/min lasting 15 secs if < 32 weeks; > 15 beats/min lasting 15 secs if > 32 weeks)
171
what is the next best step in management of a nonreactive non-stress test result?
fetal vibroacoustic stimulation
172
What are the 5 componenets of a biophysical profile?
1. non-stress test
2. fetal breathing
3. amniotic fluid volume
4. fetal movement
5. fetal tone
(score > 8 is reassuring)
173
What is lightening?
fetal head decent into pelvic brim
174
What is blood show?
blood tinge mucous that is present as cervix effaces
175
What is considered stage 1 of labor?
onset of labor to full dilation
| latent: 0-4 cm; active: 4- 10 cm
(1. 2 cm/hour or 1.5 cm/hour)
176
What is considered stage 2 of labor?
full dilation to delivery of neonate
| 1-2 hours
177
What is stage 3 of labor
delivery of neonate to delivery of placenta
| 30 mins; if longer, then placental retention
178
What is assessed with a cervical exam during labor?
1. fetal station (head location w/in pelvis)
2. dilation
3. effacement (thinning of cervix)
179
What are the cardinal movements of labor? (7)
1. engagement
2. descent
3. flexion (smallest diameter of head pass thru pelvic brim)
4. internal rotation
5. extension
6. external rotation (shoulders descend)
7. expulsion
180
What are the signs of placental separation?
1. bloody show
2. umbilical cord lengthening
3. firming of uterus/ uterus fundus rising in abdomen
181
What are indications for operative vaginal delivery? (3)
1. maternal exhaustion
2. fetal distress with adequate distension
3. fetal head fail to rotate
182
What are ways that can induce labor? (5)
1. PGE2 (cervical ripening)
2. PGE1 (misoprostol for cervical ripening)
3. oxytocin (increases uterine contraction)
4. amniotomy (stimulates release local prostaglandins)
5. foley ballon
183
What pregnant patients should not receive prostaglandin analogues for induction of labor?
asthmatic pt (can induce bronchospasm)
184
What is the next best step in management after using amniotomy to induce labor?
assess for prolapsed umbilical cord
185
What is considered arrest in cervical dilation?
no cervical dilation for 2 hours once in active stage 1
186
What is prolonged latent stage?
> 20 hours in primipara
> 14 hours in multipara
187
What is treatment for prolonged latent stage?
1. rest
| 2. hydration
188
What is protracted cervical dilation?
occurs in stage 1 of labor and:
1. < 1.2 cm/hr in primipara
2. < 1.5 cm/hr in multipara
189
What are causes of protracted cervical dilation? (3 P's)
1. power (strength of contraction)
2. passenger (macrosomia & position of fetus)
3. passage (size of pelvis)
190
What is treatment of protracted cervical dilation?
1. pitocin (power)
2. amniotomy (power)
3. C-section (passenger, passage)
191
What is considered arrest of fetal descent?
no fetal descent for 1 hour (after cervix completely dilated and pt pushing for 1 hour)
192
What is the definitive diagnostic tool used to assess for malposition of fetus?
ultrasound
| can tell from Leopold maneuvers and vaginal exam
193
What is frank breech position?
fetus hips are flexed with extended knees bilaterally
194
What is complete breech?
hips and knees are flexed
195
What are treatments are available for malpositioned pregnancies?
1. external cephalic version (after 36 weeks gestation)
| 2. C-section
196
What is the next best step in management if there is entrapment of the anterior shoulder behind the pubic symphissi after delivery of fetal head (shoulder dystocia)? (5)
1. McRobert's manuever (hyperflexion at hips) w/ suprapubic pressure
2. Rubin maneuver
3. Woods maneuver
4. delivery of posterior arm
5. fracture fetal clavicle
6. Zavanelli maneuver (push head back in for C-section)
197
A post partum pt is not able to breastfeed after delivery associated with post-partum hemorrhage most likely suffers from ....
Sheehan Syndrome (pituitary ischemia secondary to hypovolemia)
198
What is the definition of postpartum hemorrhage?
> 500 ml blood loss after delivery
199
What is the most common cause of post-partum hemorrhage?
Uterine atony (no uterine contraction)
200
A pregnant pt who develops post-partum hemorrhage after prolonged/ rapid with a soft uterus that feels like dough palpable above the umbilicus most likely suffers from ...
uterine atony
201
What are the steps in management of a post-partum hemorrhage? (8)
1. examine perineum, vagina, cervix for laceration
2. bimanual exam of uterus (rutured uterus or retained products)
3. give uterotonics (oxytocin, methylergonovine, misoprostol)
4. uterine artery embolization (if stable)
5. D&C if products retained
6. B- lynch stitch
7. uterine artery ligation
8. hysterectomy
202
A pre-menopausal women presents with headache, breast tenderness, pelvic pain, bloating, irritability, anhedonia associated with her menstrual cycle (post-ovulatory weeks) resulting in dysfunction and resolves with onset of menses most likely suffers from ...
Premenstrual syndrome
203
What are pharmacologic treatments for premenstrual syndrome?
1. SSRIs (fluoxetine)
2. GnRH agonist
3. NSAIDs
204
What are the changes associated with menopause? (7)
1. decreased estrogen & progresterone
2. amenorrhea
3. hot flashes/ sweats
4. dyspareunia (pain w/ sex)
5. mood changes
6. vaginal/ cervical atrophy
7. osteoporesis
205
What is the treatment for symptoms associated with menopause?
hormone replacement therapy (estrogen w/ or w/out progesterone)
206
What are contraindications to hormone replacement therapy for menopause?
1. breast or endometrial cancer
2. hx of PE or DVT
3. abnormal uterine bleeding
4. stroke
5. liver disease
207
What are causes of menorrhagia (heavy, prolonged menstrual bleeding)?
1. endometrial hyperplasia
2. uterine fibroids
3. dysfunctional uterine bleeding
4. IUD
208
What are causes of hypomenorrhea (light menstrual flow, spotting)?
1. obstruction (imperfoate hymen, cervical stenosis)
| 2. OCPs
209
What are causes of metrorrhagia (intermenstrual bleeding)?
1. polyps
2. endometrial/ cervical cancer
3. exogenous estrogen
210
What are causes of oligomenorrhea (menstrual cycle > 35 days apart)?
1. pregnancy
2. menopause
3. anorexia (weight loss)
4. tumor secreting estrogen
211
What are causes of postcoital bleeding (bleeding after sex)?
1. cervical cancer
2. polyps
3. atrophic vaginitis
212
What is dysfunctional uterine bleeding?
unexplained abnormal bleeding (negative CBC, pregnancy test, PT/PTT, thyroid, pelvic U/S, endometrial biopsy, prolactin, Pap smear)
213
What is the treatment for dysfunctional uterine bleeding?
1. OCPs
2. cyclic progestins
3. D&C if hypertrophic lining
4. IV estrogen (if atrophic lining)
5. long term tx (endometrial ablation, hysterectomy)
214
How does progesterone in oral contraceptive pills prevent pregnancy?
1. thickens cervical mucus
| 2. suppresses LH (preventing ovulation0
215
What is the role of estrogen in OCPs in preventing pregnancy?
suppresses FSH to prevent maturation of follicles
216
What are contraindications for use of OCPs?
1. active thromboembolic disease
2. undiagnosed vaginal bleeding
3. pregnancy
4. smoking if older than 35 y/o
5. corneal occlusion
6. impaired liver function
7. migraine w/ aura
217
What is the most effective form of birth control?
1. sterilization (tubal ligation, vasectomy)
| 2. reversible long acting contraception (IUD, implanon)
218
What is the cause of labial fusion?
excess androgens (ie 21 beta hydroxylase deficiency)
219
A postmenopausal women presents with white, thin skin from labia to perianal area (described as cigarette paper or parchment paper skin) most likely suffers from ...
Lichen Sclerosus
220
What is treatment for Lichen Sclerosus?
topical Steroids
221
A female presenting with chronic vulvar pruritis leading to irritaion causing hyperkeratosis and raised white lesions most likely suffers from ...
Squamous Cell hyperplasia (lichen simplex chronicus)
222
What is the treatment for squamous cell hyperplasia?
sitz bath and lubricant to relieve pruritis
223
A female aged 30's-60's presents with pruritic, polygonal, papular and purple rash of the vulva most likely suffers from ...
Lichen Planus
224
What is the treatment for Lichen Planus?
topical steroids
225
A female presents with pain, tenderness and dyspareunia with associated edema and inflammation of the vulva and deep fluctuant mass most likely suffers from ...
Bartholin Glands cyst
226
what is the treatment for bartholin glands cyst?
1. I&D
2. word catheter placement after I&D
3. excision or marsupialization (if recurrent)
227
A pt presents with vaginal itching, profuse green and frothy vaginal discharge and motile flagellates on wet mount most likely suffers from ...
Trichomonas vaginalis
228
A pt presenting with fishy odor gray white discharge and the presences of clue cells on saline prep most likely suffers from ...
Bacterial Vaginosis (due to Gardnerella)
229
What is the treatment for Bacterial vaginosis?
Metronidazole (or clindamycin)
230
A pt presents with thick, white cottage cheese like vaginal discharge and has pseudohyphae on KOH prep most likely suffers from ...
Candidiasis (due to Candida albicans)
231
What is the treatment for vaginal candidiasis?
Miconazole (clotrimazole, econazole, nystatin)
232
What is the treatment for Trichomonas vaginalis?
metronidazole
| treat both pt and partner
233
A postmenopausal white women presents with vulvar soreness, itching, has red lesion with superficial white coating on vulva most likely suffers from ...
Paget's disease of vulva
234
A female pt presents with pruritis, bloody vaginal discharge, postmenopausal bleeding and the presence of lesions (small ulcerated to large cauliflower) on vulva most likely suffers from ...
Squamous Cell Carcinoma of vulva
235
A female pt with hx of endometriosis/ urterine fibroids presents with dysmenorrhea and menorrhagia and large, globular, boggy uterus most likely suffers from ...
Adenomyosis (invasion of endometrial glands into myometrium)
236
What is the treatment for adenomyosis?
hysterectomy
237
A reproductive aged female pt presents with cyclic pelvic pain (pain peaks with menses), abnormal bleeding, dyspareunia, and infertility most likely suffers from ...
(can have nodular uterus or adnexal mass if endometroma present)
Endometriosis (endometrial tissues outside endometrial cavity)
238
What is the treatment for endometriosis?
mild: NSAIDs & OCPs
severe: danazole, leuprolide or surgery
239
A female presents with amenorrhea or irregular menses, hirsutism, obesity, acne, and insulin resistance most likely suffers from ...
Polycystic Ovarian Syndrome
| most common cause of androgen excess in reproductive aged women
240
what are diagnostic tests for polycystic ovarian syndrome?
1. pelvic ultrasound (string of pearl appearance & multiple follicles)
2. elevated free testosterone
3. LH/FSH ratio of 3:1
241
What is treatment for polycystic ovarian syndrome?
1. weight loss
2. OCPs (if dont want pregnancy)
3. clomiphene (if want to be fertile)
(use spironolactone for hirsuitim, metformin for insulin resistance)
242
What is the first sign of pregnancy found on physical exam?
Goodell sign (softening of the cervix that is felt at 4 weeks)
243
At what point during a pregnancy can a pregnancy be visualized via ultrasound as detection of a gestational sac?
5 weeks gestation (when Beta HCG > 1500)
