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USMLE Step 2 > ob/gyn > Flashcards

ob/gyn Flashcards

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USMLE® Step 1 flashcards
0
Q

tx for hyperemesis gravidarum

A
  • hydration
  • ginger
  • pyridoxine (vitamin B6) and/or doxylamine
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1
Q

Hyperemesis gravidarum

A
  • characterized by severe, persistent nausea and vomiting and >5% loss of pre-pregnancy weight
  • diagnosis is made in pregnant patients who are dehydrated and malnourished w/o another explanation for their symptoms
  • pts w/ multifetal gestation or molar pregnancy are at increased risk of HG; therefore, an ultrasound should be performed in pregnant pts w/ severe vomiting and weight loss
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2
Q

Pelvic inflammatory disease

A

-may manifest on US as thickened, fluid-filled oviducts, abscesses in the uterus and adnexa, and free fluid in the pelvis

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3
Q

Endometrial adenocarcinoma (malignant transformation of the endometrium)

A
  • can metastasize to both ovaries

- more common in postmenopausal women and is not associated with pregnancy

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4
Q

Gestational trophoblastic disease

A
  • caused by abnormal trophoblastic proliferation, resulting in an abnormal placenta that can be seen on US
  • associated w/ bilateral ovarian enlargement secondary to hyperstimulation from high b-hcg levels and ovarian cyst formation (theca lutein cycts)
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5
Q

molar pregnancy

A
  • partial (69 XXY, XXX, XYY) or complete (lacking genetic material resulting in no fetal tissue)
  • complete moles are caused by 2 sperm fertalizing an empty ovum, and are usually symptomatic due to markedly elevated serum b-hcg levels; may manifest w/ hyperemesis gravidarum, enlarged uterus, theca lutein ovarian cysts.
  • partial moles are less symptomatic due to lower b-hcg levels compared to complete moles
  • tx is uterine evacuation w/ suction curettage
  • may become gestational trophoblastic neoplasis so you MUST follow w/ serial serum b-hcg levels after evacuation
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6
Q

Acute fatty liver of pregnancy (AFLP)

A
  • characterized by nausea, vomiting, abdominal pain, and significant elevations of liver markers in the third trimester
  • many features overlap with HELLP syndrome, but pts w/ AFLP are more likely to have additional extrahepatic complications such as leukocytosis, hypoglycemia, and acute kidney injury
  • severe hypertension is less likely in AFLP than in HELLP syndrome
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7
Q

Peptic ulcer perforation

A
  • presents w/ sudden, severe epigastric pain that may become generalized
  • pts will have peritonitis w/ abdominal rigidity on exam and may be hypotensive
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8
Q

rupture of hepatic adenoma

A
  • results in intraabdominal bleeding w/ peritonitis (tenderness and rebound) and hypotension from acute blood loss
  • requires immediate surgical intervention
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9
Q

HELLP syndrome

A
  • potential manifestation of severe preeclampsia
  • RUQ pain, Hemolytic anemia, Elevated Liver enzymes, and Low Platelet count in a pregnant patient raise suspicion for the syndrome
  • the abdominal pain is due to liver swelling w/ distention of the hepatic (Glisson’s) capsule
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10
Q

Remember that alkaline phosphatase is normally elevated in pregnancy

A

.

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11
Q

amniotic fluid embolism

A
  • can cause sudden hypoxemic respiratory failure and hypotensive shock
  • pathogenesis involves amniotic fluid entering into the maternal circulation during labor or delivery
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12
Q

Excessive magnesium sulfate

A
  • can cause neuromuscular depression
  • toxicity is characterized by decreased respiratory effort/apnea, muscle paralysis, somnolence, visual disturbances, and decreased or absent deep-tendon reflexes
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13
Q

Pregnant women are at increased risk for both community-acquired pneumonia from decreased cell-mediated immunity and aspriation pneumonia from increased intraabdominal pressure and a relaxed lower esophageal sphincter

A

.

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14
Q

Risk for pulmonary embolus is increased in pregnancy due to increased thrombotic effects of estrogen

A

.

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15
Q

Pulmonary edema

A
  • life threatening complication of severe preeclampsia
  • caused by increased systemic vascular resistance, capillary permeability, pulmonary capillary hydrostatic pressure, and decreased albumin
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16
Q

PCOS

A
  • characterized by an unbalanced estrogen secretion that may result in endometrial hyperplasia and carcinoma
  • should be suspected in any patient who has menstrual irregularities and evidence of hyperandrogenism; this includes clinical (hirsutism, acne, male pattern baldness) and/or biochemical (high serum androgens) hyperandrogenism; no need to visualize the cysts w/ US to establish diagnosis
  • women have adequate estrogen due to peripheral conversion of androgens, but are oligo- or anovulatory and are deficient in PROGESTERONE secretion leading to endometrial hyperplasia, intermittent breakthrough bleeding, and dysfunctional uterine bleeding
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17
Q

25% of pregnancies have some extent of vaginal bleeding in the first trimester. In half of these cases a spontaneous abortion will actually occur.

A

.

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18
Q

incomplete abortion

A
  • evacuation of some fetal tissue while a remainder is retained in the uterine cavity
  • symptoms include: vaginal discharge of blood and tissue-like material, abdominal cramps, and cervical dilation
  • retained products of conception can be visualized w/ transvaginal US
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19
Q

Complete abortion

A
  • the whole conceptus passes through the cervix
  • after this passage, the cervix closes and uterine contractions subside
  • US shows an empty uterus
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20
Q

Inevitable abortion

A
  • vaginal bleeding, lower abdominal cramps that may radiate to the back and perineum and a dilated cervix
  • US demonstrates a ruptured or collapsed gestational sac w/ absence of fetal cardiac motion
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21
Q

Ectopic pregnancy

A
  • typically presents w/ acute onset abdominal pain and dark red vaginal bleeding in the first trimester
  • physical exam reveals an adnexal mass, and US shows no gestational sac in the uterus
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22
Q

threatened abortion

A

-characterized by any hemorrhage occurring before the 20th week of gestation w/ a live fetus and a closed cervix

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23
Q

tx for missed abortion

A
  • dilation and curettage

- cervix is closed and expulsion of the expired fetus does not always occur spontaneously

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24
Q

standard of care for threatened abortion

A
  • reassurance and outpatient follow-up

- can advise bed rest and avoidance of sexual intercourse, but there is no evidence that this is effective

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25
Q

Risk factors for osteoporosis

A
  • modifiable: low estrogen levels, malnutrition, decreased caclium, decreased vitamin D, use of certain meds like glucocorticoids or anticonvulsants, immobility, cigarette smoking, excessive alcohol consumption
  • non-modifiable: female gender, advanced age, small body size, late menarche/early menopause, caucasian and asian ethnicity, and family hx of osteoporosis
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26
Q

lifestyle modifications for pts at risk for osteoporosis

A

-weight bearing exercises, smoking cessation, and decreased alcohol consumption

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27
Q

intrinsic renal disease

A

BUN/Cr ratio of about 10:1

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28
Q

values representing prerenal azotemia

A

BUN/Cr ratio of greater than 20:1

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29
Q

How does kidney function change in pregnant patients?

A

Serum BUN and Cr are usually decreased in pregnant pts due to an increase in renal plasma flow and GFR
-this increase in renal function begins early in the fist trimester, progresses gradually until reaching 40-50% above the non-pregnant state by mid-pregnancy, and remains unchanged until term

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30
Q

clomiphene citrate

A

-estrogen analog that can be used to induce ovulation in anovulatory women who have some ovulatory reserve, such as pts w/ PCOS

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31
Q

Metformin may be used to promote ovulation in pts w/ PCOS as the insulin resistance seen in this condition may contribute to the inability to ovulate normally

A

.

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32
Q

GnRH agonists

A

-used in a pulsatile fashion to induce ovulation and as a chronic therapy to suppress ovulation

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33
Q

Progesterone in infertility

A

-used to correct luteal phase defect, which is characterized by failure of the corpus luteum to produce sufficient progesterone to maintain the endometrium and allow implantation of an embryo

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34
Q

Premature ovarian failure

A
  • characterized by amenorrhea, hypoestrogenism, and elevated serum gonadotropin levels in women age < 40 years
  • the amenorrhea only needs to be of 3 months duration w/ FSH in menopausal range to meet diagnostic criteria
  • may be secondary to accelerated follicle atresia or a low initial number of primordial follicles
  • most commonly idiopathic, but may also be due to mumps, oophoritis, irradiation, or chemotherapy
  • can be associated w/ autoimmune disorders such as Hashimoto’s thyroiditis, Addison’s disease, type 1 diabetes mellitus, and pernicious anemia
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35
Q

tx of infertility for premature ovarain failure

A

in vitro fertilization w/ donor oocytes

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36
Q

overflow incontinence

A
  • can be caused by diabetic neuropathy
  • characterized by loss of small amounts of urine from an over distended bladder, and a markedly increased residual volume
  • patients usually have a long hx of diabetes that is not well controlled
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37
Q

stress incontinence

A
  • common cause of incontinence in older women
  • high number of vaginal deliveries may lead to pelvic floor muscle weakness
  • proximal urethra prolapses outside pelvis due to pelvic relaxation, so rise in intraabdominal pressure (coughing, sneezing, laughing) causes rise in bladder pressure and urine is lost in small amounts
  • aggravating factors: morbid obesity, pregnancy, COPD, smoking
  • physical exam may show pelvic floor weakness such as uterine prolapse and/or cystocele
  • tx: Kegel exercises, pessaries, estrogen replacement if postmenopausal, Burch procedure, or sling procedures
  • urinalysis, cystometry, and postvoid residual volume are normal
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38
Q

Chorionic villous sampling

A

-involves inserting a needle through the abdomen or cervix to extract fetal tissue for genetic analysis and assessing karyotype

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39
Q

missed abortion

A
  • form of spontaneous abortion defined as intrauterine fetal death before 20 weeks gestational age w/ complete products of conception and a closed cervix
  • pts often develop loss of pregnancy symptoms and scant to light vaginal discharge
  • pelvic US is necessary for diagnosis
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40
Q

management of incomplete, inevitable, or missed abortion

A
  • hemodynamically UNSTABLE, heavy bleeding: surgical evacuation
  • hemodynamically STABLE, mild bleeding: expectant management, prostaglandins, or surgical evacuation
  • surgery achieves more complete evacuation than medical or expectant management
  • in the case of medical or expectant management, US is generally performed to confirm that there are no retained products of conception
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41
Q

management of septic abortion

A
  • blood and endometrial cultures
  • broad spectrum antibiotics
  • surgical evacuation of uterine contents
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42
Q

Methotrexate

A
  • folic acid antagonist that disrupts rapidly dividing cells

- used to treat some cases of ectopic pregnancy but is not effective for spontaneous abortion

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43
Q

Oxytocin infustion

A
  • can stimulate uterine contractions to expel retained fetus and POC
  • must be given IV in the hospital
  • often used to augment labor, treat postpartum hemorrhage, and expel a retained fetus following fetal demise in the late second or third trimester. However, it is not usually used in the first trimester
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44
Q

HPV vaccine indications

A
  • all girls and women age 9-26 (including those w/ hx of genital warts, abnormal cytology, or positive HPV DNA test
  • boys and men age 9-21 (up to age 26 for men who have sex with men)
  • immunocompromised individuals (including HIV pts) age 9-26
  • NOT indicated in pregnant women
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45
Q

Cervical cancer screening

A
  • should start at age 21 in most women (except those w/ HIV or SLE, and organ transplant or immunocompromised individuals) regardless of the age of onset of sexual activity
  • Routine testing for HPV is not indicated for women age < 30
  • HPV vaccine is recommended for all girls and women (except those who are pregnant) age 9-26 regardless of HPV status or sexual activity
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46
Q

Trisomy 18 (Edwards) on quadruple screen

A
  • MSAFP: decreased
  • b-HCG: decreased
  • Estriol: decreased
  • Inhibin A: normal
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47
Q

Trisomy 21 (Down syndrome) on quadruple screen

A
  • MSAFP: decreased
  • b-HCG: increased
  • Estriol: decreased
  • Inhibin A: increased
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48
Q

Neural tube or abdominal wall defects on quadruple screen

A
  • MSAFP: increased
  • b-HCG: normal
  • Estriol: normal
  • Inhibin A: normal
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49
Q

Maternal serum quadruple test

A
  • performed in the second trimester (15-20 weeks) and consists of maternal serum a-fetal protein (MSAFP), b-HCG, estriol, and inhibin A.
  • looks for trisomy 18, trisomy 21, and neural tube or abdominal wall defect
  • pts w/ abnormal quadruple screen results can be offered CELL-FREE FETAL DNA testing, which measures circulating, free maternal and fetal DNA in maternal plasma and has a sensitivity and specificity of up to 99%
  • an US should be performed to evaluate for fetal anomalies
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50
Q

maternal quadruple screen in Down syndrome

A
  • decreased MSAFP and estriol

- increased b-HCG and inhibin A

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51
Q

maternal quadruple screen in Trisomy 18

A

-normal inhibin A level and low MSAFP, estriol, and b-HCG

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52
Q

maternal quadruple screen in open neural tube defects and abdominal wall defects (gastroschisis, omphalocele, etc.)

A

-elevated MSAFP; the rest of the markers are normal

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53
Q

Endometrial ablation

A
  • destroys the endometrium, including the basalis layer, to prevent endometrial regeneration
  • CONTRAINDICATED in pts w/ endometrial hyperplasia because it prevents future evaluation of the endometrium by biopsy
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54
Q

when is hysterectomy indicated in abnormal uterine bleeding?

A
  • if after endometrial biopsy (must always be done!) there is hyperplasia W/ ATYPIA, and the patient has completed childbearing or failed medical management
  • the risk of progression to endometrial adenocarcinoma is as high as 30%, and up to 50% of women with endometrial atypia have concomitant endometrial adenocarcinoma!
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55
Q

Women w/ abnormal uterine bleeding

A
  • should undergo endometrial biopsy to evaluate for hyperplasia versus cancer
  • progestin therapy is the tx of choice for those w/ NO ATYPIA
  • hysterectomy is the tx of choice for hyperplasia with atypia
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56
Q

HELLP syndrome

A
  • Hemolysis (microangiopathic hemolytic anemia): Schistocytes on peripheral smear, elevated bilirubin, and low serum haptoglobin
  • Elevated Liver enzymes: Aspartate aminotransferase or alanine aminotransferase twice the upper limit of normal
  • Low Platelet count: Platelets < 100,000
  • Right upper quadrant or epigastric pain and nausea or vomiting (30-90% of pts)
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57
Q

HELLP syndrome

A
  • life-threatening complication that may occur in women w/ preeclampsia
  • thought to result from abnormal placentation, triggering systemic inflammation and activation of the coagulation system and complement cascade
  • circulating platelets are rapidly consumed, and microangiopathic hemolytic anemia is particularly detrimental to the liver
  • the resulting hepatocellular necrosis and thrombi in the portal system cause elevated liver enzymes, liver swelling, and distension of the hepatic (Glisson’s) capsule
  • half of women w/ HELLP syndrome progress to DIC, which can lead to life-threatening multiorgan failure
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58
Q

Acute fatty liver of pregnancy (AFLP)

A
  • can cause acute hepatic failure in the third trimester or early postpartum period
  • most pts will have a prolonged PT and PTT, hypoglycemia, and encephalopathy
  • may see acute microvesicular fatty infiltration of hepatocytes
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59
Q

Idiopathic thrombocytopenic purpura (ITP)

A
  • characterized by autoimmune platelet destruction
  • pts may have ecchymosis/petechiae and mucosal bleeding
  • peripheral smear would show megakaryocytes
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60
Q

Intrahepatic cholestasis of pregnancy

A

-manifests as generalized pruritis, hyperbilirubinemia, and transaminitis due to elevation of serum bile acid concentration from impaired bile acid flow

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61
Q

Preeclampsia is a risk factor for placental abruption (separation), which classically presents w/ vaginal bleeding, excruciating abdominal pain, and uterine tenderness/rigidity

A

.

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62
Q

Hemolytic uremic syndrome (HUS)

A
  • most commonly presents after infection w/ Shiga-toxin producing bacteria H5717 E. coli and causes thrombocytopenia and hemolytic anemia
  • typically have bloody diarrhea and renal failure
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63
Q

normal fetal heart tracing

A

-110-160/min heart rate, long term variability >2 cycles/min, beat to beat variability 6-25/min

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64
Q

fetuses at <34 weeks gestation

A
  • at risk for lung immaturity and neonatal respiratory distress syndrome
  • if maternal and fetal status are both reassuring, pts <34 weeks can receive course of corticosteroids (eg, betamethasone) prior to delivery
  • however, delivery should not be delayed beyond 48 hours due to risk for rapid deterioration
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65
Q

tx of intrahepatic cholestasis of pregnancy?

A

ursodeoxycholic acid

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66
Q

tx of thrombotic thrombocytopenic purpura

A

plasmapheresis to remove pathogenic autoantibodies

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67
Q

when to consider prophylactic transfusion of platelets?

A
  • to prevent spontaneous bleeding in pts w/ platelets < 10,000
  • exception to this rule is in asymptomatic children w/ idiopathic thrombocytopenic purpura, in which the condition usually recovers spontaneously
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68
Q

HELLP syndrome is life-threatening, and delivery is the cornerstone of treatment. Immediate delivery is warranted at > 34 weeks gestation or with deteriorating maternal or fetal status. Vaginal delivery is preffered if the cervix is favorable or if the woman is in labor, the fetus is vertex, and the overall clinical status is otherwise stable.

A

.

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69
Q

Pregnancy effects on thyroid hormones?

A
  • associated w/ an increase in TBG, resulting in increased total T4 and T3, a normal free T4 and T3, and a normal TSH
  • increased estrogen leads to increase in circulating TBG and hCG mildly stimulates TSH receptor, however these values usually still remain within the normal range
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70
Q

Dopamine antagonists can cause secondary or tertiary hypothyroidism

A

.

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71
Q

First trimester triple test

A
  • done at 9-13 weeks

- pregnancy associated plasma protein, b-HCG, nuchal translucency

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72
Q

US finding expected in Down syndrome fetus at 18-20 week anatomy scan?

A

-endocardial cushion defect, duodenal atresia, cystic hygroma

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73
Q

cell-free fetal DNA testing

A
  • indications: maternal age > 35, abnormal maternal serum screening test, sonographic findings associated with fetal aneuploidy, previous pregnancy w/ fetal aneuploidy, parental-balanced Robertsonian translocation
  • application: screening for trisomy 21, 18, 13 and sex-chromosome aneuploidies; fetal sex determination
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74
Q

amniocentesis

A
  • recommended for confirmation of abnormal quadruple screen results
  • Its invasive and should be guided by US to determine the best site for needle insertion. The needle must be positioned to draw adequate amniotic fluid without injuring the fetus, placenta, and maternal bowel and bladder
  • best performed at 16-20 weeks gestation, but US should be performed first to confirm gestational age and assess amniotic fluid
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75
Q

Chorionic villus sampling (CVS)

A

-indicated for early screening in women who desire fetal karyotyping at 10-13 weeks gestation

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76
Q

Cordocentesis (percutaneous umbilical blood sampling)

A
  • can be used for fetal blood gas analysis, karyotyping, and blood culture
  • highly invasive and carries a risk of umbilical cord bleeding/hematoma, placenta injury, and fetal loss
  • reserved for cases when maternal blood testing, amniocentesis, and CVS fail to provide adequate or timely diagnostic information
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77
Q

Pregnancy-associated plasma protein A (PAPP-A)

A
  • glycoprotein produced by the trophoblast
  • during the first trimester, PAPP-A can be measured w/ b-hCG and US nuchal translucency w/ a detection rate of about 85% for Down syndrome
  • fetuses w/ Down syndrome produce less PAPP-A
  • the marker is less accurate w/ increasing gestational age and is therefore not used in the second trimester
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78
Q

quadruple screen

A
  • genetic screening performed in the second trimester
  • low maternal serum a-fetoprotein, low estriol, increased b-hCG, and increased inhibin A are associated w/ trisomy 21
  • a thorough transabdominal US should be performed to evaluate fetal anatomy and measure growth
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79
Q

Serum progesterone measurement to detect ovulation is performed in mid-luteal phase.

A

.

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80
Q

Semen analysis

A
  • simple test that helps to identify male factor as the cause of infertility. Male factors are said to account for 20-30% of the infertility causes
  • Semen analysis should be performed early in the evaluation of the infertile couple, usually as the initial screening test
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81
Q

UTIs

A
  • the increased incidence of UTIs in women is due to the shorter length of the female urethra compared to males
  • other predisposing factors include: sexual intercourse, recent antibiotic use, the use of spermicidal contraceptives, and a close proximity of the urethra to the anus
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82
Q

unlike tamoxifen, raloxifene does NOT increase the risk for endometrial cancer

A

.

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83
Q

Raloxifene

A
  • selective estrogen receptor modulator (SERM) that increases bone mineral density and is used to prevent osteoporosis, although it is somewhat less effective than bisphosphonates and estrogen for this purpose
  • important side effect is increased risk for venous thromboembolism!
  • may also cause hot flashes and leg cramps
  • unlike tamoxifen, raloxifene does NOT increase the risk for endometrial cancer
  • raloxifene decreases the risk for breast cancer
  • mixed agonist/antagonist of estrogen receptors
  • in breast and vaginal tissue, it is an antagonist, whereas in bone tissue, it is an agonist
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84
Q

preterm labor

A

-labor before 37 weeks gestation

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85
Q

Corticosteroid treatment during pregnancy

A
  • not proven to have a benefit after 34 weeks gestation; its use is limited to the period between 24 and 34 weeks
  • steroids require 24-48 hours to have a maximum benefit on fetal lung maturity
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86
Q

Fetal distress (repetitive late decelerations) is an indication for emergent cesarean section

A

.

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87
Q

In the immediate postpartum period, a low-grade fever, leukocytosis and vaginal discharge are normal findings. The vaginal discharge (lochia) is initially bloody (lochia rubra), then serous (lochia serosa), and finally white to yellow (lochia alba) days following delivery.

A

.

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88
Q

Note that low grade fever and leukocytosis are common during the first 24 hours of the postpartum period. Intrapartum and postpartum chills are also common. Lochia (vaginal discharge) is also normal the first few days following delivery. After 3 to 4 days, the color becomes pale and the discharge is then called lochia serososa, then it become yellow-white and is called lochia alba. If a foul smelling lochia is noted, endometritis should be suspected.

A

.

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89
Q

what are the 2 most common causes of hypopituitarism in the postpartum period? Explain.

A
  • Sheehan’s syndrome and lymphocytic hypophysitis
  • Sheehan’s syndrome develops due to ischemic necrosis of the pituitary gland (sometimes even the hypothalamic nuclei) because of peri-partum bleeding.
  • Lymphocytic hypophysitis is less common and is not related to peri-partum hemorrhage. Pts typically have headaches, visual disturbances, and pituitary failure
  • note that overt diabetes insipidus is uncommon in Sheehan’s syndrome
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90
Q

Valproic acid

A
  • increases availability of GABA

- side effects include blood dyscrasias and liver toxicity

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91
Q

Aripiprazole

A

-partial agonist of dopamine D2 receptors; does NOT cause galactorrhea

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92
Q

Carbamazepine

A

-side effects: aplastic anemia and SIADH

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93
Q

Lamotrigine side effects

A

-rash, Stevens-Johnson syndrome, toxic epidermal necrolysis

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94
Q

Risperidone

A
  • atypical antipsychotic that is a dopamine and serotonin antagonist
  • inhibiting dopamine leads to elevated serum prolactin levels, which causes oligomenorrhea, amenorrhea, and galactorrhea; as well as weight gain
  • been found to increase prolactin levels to a greater extent than do many of the other antipsychotics
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95
Q

how does pregnancy increase risk of UTIs?

A

-stasis of urine from compression by the enlarging uterus, as well as smooth muscle relaxation caused by progesterone

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96
Q

Chorioamnionitis

A

-result of PROM, intrauterine instrumentation, STIs, and prolonged labor

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97
Q

Endometritis

A

-commonly seen as a result of PID due to STIs, infections such as TB, instrumentation of the genital tract, and after caesarean delivery

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98
Q

what is a normal glucose tolerance test for a pregnant woman?

A

-1 hour glucose of less than 140 mg/dL

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99
Q

Asymptomatic bacteriuria

A
  • occurs when the urine culture grows > 100,000 CFU per ml of a single organism in an asymptomatic patient
  • its important to promptly treat the infection to prevent progression to pyelonephritis in the pregnant patient, which can result in septicemia, preterm labor and low birth weight babies
  • amoxicillin, ampicillin, nitrofurantoin, and cephalexin are commonly used to treat the patients
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100
Q

5-a-reductase deficiency

A
  • cannot convert testosterone to the more potent DHT
  • they have a 46 XY genotype, male internal genitalia, and female or undermasculinized external genitalia at birth
  • at puberty, they experience masculinization due to testosterone (ie. increase in phallus size, muscle growth, voice deepening) but lack breast development
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101
Q

Androgen insensitivity syndrome

A
  • 46 XY karyotype and a defective androgen receptor that results in end-organ resistance to androgens
  • testicular secretion of anti-Mullerian hormone, which results in male internal genitalia. However, the testicular testosterone is converted to estrogen, resulting in breast development
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102
Q

Imperforate hymen

A
  • can result in an apparent amenorrhea due to vaginal obstruction
  • can be distinguished from Mullerian agenesis by cyclic abdominal pain, the presence of a uterus, and the visualization of an imperforate hymen and hematocolpos
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103
Q

Turner syndrome

A
  • 45 XO genotype, short stature, small nonfunctional ovaries

- they do not typically develop secondary sexual characteristics

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104
Q

Mullerian agenesis (Mayer-Rokitansky-Kuster-Hauser syndrome)

A
  • phenotypically and genotypically female
  • experience breast development and body hair growth at puberty but do not menstruate due to a congenitally absent or underdeveloped uterus, cervix, and upper vagina
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105
Q

complete androgen insensitivity syndrome

A
  • X-linked mutation of androgen receptor
  • breast development is present
  • absent uterus and upper vagina; cryptorchid testes
  • minimal to absent axillary and pubic hair
  • 46 XY
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106
Q

Mullerian agenesis

A
  • Hypoplastic or absent mullerian ductal system
  • breast development is present
  • absent or rudimentary uterus and upper vagina; normal ovaries
  • normal axillary and pubic hair
  • 46 XX
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107
Q

Transverse vaginal septum

A
  • malformation of urogenital sinus and Mullerian ducts
  • breast development is present
  • normal uterus, abnormal vagina; normal ovaries
  • normal axillary and pubic hair
  • 46 XX
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108
Q

Turner syndrome

A
  • Complete/partial absence of 1 X chromosome
  • Variable breast development depending on ovarian function
  • normal uterus and vagina; streak ovaries
  • normal axillary and pubic hair
  • 45 XO
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109
Q

Complete XY gonadal agenesis (Swyer syndrome)

A
  • SRY gene mutation on Y chromosone
  • No breast development
  • normal uterus and vagina; streak gonads
  • minimal to absent axillary and pubic hair
  • 46 XY
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110
Q

Copper IUD emergency contraception

A
  • most effective emergency and long-term contraception
  • causes inflammatory reaction that is toxic to sperm and ova and impairs implantation
  • can be used up to 120 hours after intercourse
  • 99% efficacy
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111
Q

Ulipristal pill emergency contraception

A
  • antiprogestin that delays ovulation
  • can be used up to 120 hours after intercourse
  • > 85% effective
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112
Q

Levonorgestrel pill emergency contraceptive

A
  • aka “Plan B”
  • most readily available emergency contraception; it works by delaying ovulation but is ineffective post-fertilization
  • efficacy decreases with time over the course of 72 hours in which its indicated
  • 85% effective
  • progestin that delays ovulation
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113
Q

OCPs as emergency contraception

A
  • progestin that delays ovulation like Plan B
  • 0-72 hours after intercourse
  • 75% effective
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114
Q

Mifepristone and Misoprostol

A

-abortive medications

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115
Q

In most states, adolescents seeking pregnancy options may receive confidential medical care without parental consent. Levonorgestrel and ulipristal are widely available oral emergency contraceptive options. The copper IUD is the most effective emergency and long-term contraception option and requires a provider who is trained to insert the device.

A

.

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116
Q

Hypertrophic cardiomyopathy

A
  • common cause of sudden death in young people, particularly African Americans
  • a hypertrophic intraventricular septum obstructs the left ventricular outflow tract
  • hypovolemia and other conditions that decrease venous return worsen symptoms
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117
Q

Aortic insufficiency

A

-may result from rheumatic heart disease and can present with heart failure and atrial fibrillation, but it is less common than mitral stenosis in women of childbearing age

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118
Q

Mitral stenosis

A
  • classically presents during pregnancy due to physiologically increased total blood volume
  • its most often due to rheumatic fever and occurs much more often in countries with limited access to antibiotics
  • may present w/ atrial fibrillation and pulmonary edema
  • physical exam may reveal a diastolic rumble at the apex and/or an opening snap
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119
Q

Primary syphilis

A
  • 2 to 3 weeks after infection w/ Treponema pallidum, pts develop a PAINLESS papule at the site of inoculation
  • this papule ulcerates, forming a chancre w/ puched-out base and raised, indurated margins
  • most lesions occur on the genitalia, and are accompanied by painless inguinal adenopathy
  • if left untreated, the chancre of primary syphilis heals spontaneously within one to three months
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120
Q

Chancroid

A

-PAINFUL ulcers with a deep, purulent base and painful lymphadenopathy

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121
Q

Granuloma inguinale (Donovanosis)

A
  • PAINLESS genital ulcers that have a red, beefy base and there is NO associated adenopathy
  • the ulcer does NOT resolve without antibiotic treatment
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122
Q

Basal cell carcinoma

A
  • greatest risk factor is sun exposure
  • most common sites are face and trunk
  • lesions appear as pearly-colored papules covered with telangiectasias
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123
Q

The genital ulcers seen in chancroid and genital herpes differ from the ulcer of primary syphilis in that both are PAINFUL.

A

.

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124
Q

how do you best diagnose PRIMARY syphilis?

A
  • by dark field microscopy (identification of spirochete)
  • serologic testing like serum RPR is a nontreponemal test that should be avoided in suspected cases of PRIMARY syphilis due to the high rate of false negative results. This is because many patients with primary syphilis have yet to form antibodies against the organism
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125
Q

Tzanck smear

A
  • used in diagnosis of Herpes simplex, Varicella, and Cytomegalovirus
  • Multinucleated giant cells on Tzank smear are characteristic of Herpes and Varicella
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126
Q

Nontreponemal serologic tests (VDRL, RPR)

A
  • used as a SCREENING test for syphilis, and treponemal serologic tests (FTA-ABS) are used for confirmation
  • note that darkfield microscopy is also an effective method of diagnosing syphilis, but requires proper equipment and clinical expertise.
  • in primary syphilis, there is a high rate of false-negative results to serologic testing, and therefore darkfield microscopy is necessary
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127
Q

An intrauterine pregnancy should be seen with transvaginal US at b-hCG levels of 1,500-2,000 mIU/mL. If the level is

A

.

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128
Q

Dilatation and curettage is performed when the pregnancy has been confirmed to be nonviable via serial b-hCG measurements and the location of the pregnancy cannot be determined by US. Decision must be made with caution so as not to interrupt a viable intrauterine pregnancy. It is essential to confirm the presence of trophoblastic tissue in the specimen!!!

A

.

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129
Q

Lithium in pregnancy

A

-associated w/ congenital heart disease, classically Ebstein’s anomaly, and should be weaned in pregnant women w/ stable bipolar disorder

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130
Q

Isotretinoin in pregnancy

A
  • woman who is treated with isotretinoin should receive strict contraception
  • associated w/ craniofacial dysmorphism, heart defects, and deafness
  • women should have 2 effective forms of contraception in use for at least 1 month prior to initiating treatment. contraception must be continued during treatment, and for 1 month after isotretinoin is discontinued. In addition, patients must have a pregnancy test the week before beginning treatment, and should have periodic pregnancy tests during therapy
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131
Q

Kallmann syndrome

A
  • presents w/ delayed/absent puberty and anosmia
  • the karyotype will be consistent with their male or female phenotype
  • FSH and LH levels are low, consistent w/ gonadotropin-releasing hormone deficiency
  • X-linked recessive disorder of migration of fetal gonadotropin-releasing hormone and olfactory neurons, resulting in hypogonadotropic hypogonadism and rhinencephalon hypoplasia
  • short stature, primary amenorrhea, absent breast development, eunuchoid appearance with small external genitalia and absent secondary sexual characteristics (pubic/axillary hair, voice deepening, libido)
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132
Q

Turner syndrome

A
  • short stature
  • narrow, high arched palate
  • low hairline
  • webbed neck
  • broad chest w/ widely spaced nipples
  • cubitus valgus
  • horse shoe kidney
  • low set ears
  • coarctation of aorta
  • bicuspid aortic valve
  • streak ovaries, amenorrhea, and infertility
  • FSH levels are generally elevated due to primary ovarian failure
  • 45 XO
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133
Q

Klinefelter syndrome

A
  • 47 XXY
  • male phenotype
  • intellectual disability
  • sparse facial/body hair
  • gynecomastia
  • cryptorchidism
  • infertility
  • long legs
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134
Q

acute appendicitis of pregnancy

A
  • may result in a ruptured appendix if the diagnosis is delayed beyond 24-36 hours
  • many of the symptoms including nausea and vomiting, mimic symptoms of pregnancy; most common symptom is right lower-quadrant pain
  • depending on the gestational age of the pregnancy, the location of pain and tenderness may be higher than expected due to displacement of the appendix upward by gravid uterus
  • pts may or may not have a fever; an elevated leukocyte count may be present in appendicitis as well as in normal pregnancy
  • US w/ a graded compression technique should be first test!!! Noncompression and dilation of the appendix are diagnostic of appendicitis.
  • nonvisualization of appendix on US does NOT exclude the diagnosis of acute appendicitis; if US is nondiagnositc, MRI can be performed
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135
Q

Gonococcal cervicitis

A
  • mucopurulent discharge; friable cervix with easy bleeding
  • nucleic acid amplification testing for diagnosis
  • 3rd generation cephalosporin PLUS azithromycin or doxycycline for chlamydia coverage
  • second most common cause of cervicitis in US after Chlamydia trachomatis; also a major cause of urethritis and PID
  • more than 50% of women are ASYMPTOMATIC
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136
Q

Treatment of bacterial vaginosis and Trichomonas infection?

A

metronidazole

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137
Q

antibiotic tx for tubo-ovarian abscess or postpartum endometritis

A

-Clindamycin and gentamicin (used for polymicrobial infection w/ an anaerobic component)

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138
Q

EARLY fetal heart tracing

A
  • symmetric to contraction
  • nadir of deceleration corresponds to peak of contraction
  • gradual (>30s from onset to nadir)
  • can be due to fetal head compression
  • can be normal fetal tracing; if there is otherwise normal baseline rate, normal variability, and no late or variable decelerations, this pattern does not indicate fetal distress and no change in management is required
  • does NOT indicate fetal distress
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139
Q

LATE fetal heart tracing

A
  • delayed compared to contraction
  • nadir of deceleration occurs after peak of contraction
  • gradual (> 30s from onset to nadir)
  • can be due to Uteroplacental insufficiency, fetal hypoxia, or fetal acidosis
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140
Q

VARIABLE fetal heart tracing

A
  • can be but not necessarily associated w/ contractions
  • abrupt onset (< 30s from onset to nadir)
  • decrease >15bpm; duration >15s but < 2 min
  • due to CORD COMPRESSION, OLIGOHYDRAMNIOS, CORD PROLAPSE
  • like late decelerations, recurrent variable decelerations also indicate fetal distress with risk of hypoxemia and acidosis
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141
Q

Spontaneous fetal activity on fetal heart tracing

A
  • often associated w/ ACCELERATIONS

- accelerations generally indicate normal fetal oxygenation

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142
Q

Early deceleration on fetal heart tracing are caused by fetal head compression leading to vagal response and do NOT indicate fetal distress. In contrast, variable and late decelerations indicate risk for fetal hypoxemia and acidosis.

A

.

143
Q

what STIs should ALL pregnant women be screened for, regardless of risk factors?

A
  • Syphilis, HIV, and hepatitis B
  • note that screening for other infections in pregnancy (ie chlamydia, gonorrhea, hepatitis C) is based on the patient’s risk factors
  • note that screening for syphilis is usually with the RPR or VDRL test; if test is positive, then diagnosis is confirmed w/ treponemal test such as FTA; treatment is with penicillin.
144
Q

what is the most accurate method of determining gestational age?

A
  • First trimester US w/ crown-rump length measurement
  • estimated gestational age should not be changed based on measurement discrepancies on a second or third trimester US
  • the accuracy varies from +/- 3 to 5 days between 7-14 weeks gestation
  • after the first trimester, fetal abdominal circumference, biparietal diameter, femur length, and head circumference are used to estimate gestational age; these are less accurate
145
Q

maternal smoking

A
  • associated with an increased risk of ASYMMETRIC fetal growth restriction
  • pregnant women who stop smoking by the third trimester have similar fetal birth weights compared to pregnant women who do not smoke
146
Q

Fetal growth restriction

A
  • fetal weight < 10th percentile
  • can be SYMMETRIC or ASYMMETRIC
  • Symmetric: due to FETAL FACTORS; both the head and body are affected; includes: congenital anomalies, chromosomal abnormalities, and congenital infections (ie toxoplasmosis, CMV, rubella, malaria)
  • Asymmetric: due to MATERNAL FACTORS; the body is affected but the head is spared; any maternal disorder associated w/ vascular disease (HTN, DM, preeclampsia, and cigarette smoking) can lead to asymmetric growth restriction
147
Q

symmetric fetal growth restriction

A
  • affects head and body

- caused by fetal anomalies, abnormal fetal karyotype, and early maternal viral infection

148
Q

Asymmetric fetal growth restriction

A
  • affects body only
  • generally appears later in pregnancy and is caused by maternal vascular disease, including hypertension, diabetes, and smoking
149
Q

Stillbirth delivery options

A
  • stillbirth is defined as fetal death at > 20 weeks gestation
  • risk factors: HTN, DM, smoking > 10 cigarettes per day, and advanced maternal age
  • most common presenting symptom is ABSENT FETAL MOVEMENT
  • 2nd trimester: D&C (up to 24 weeks), Induction of labor, spontaneous vaginal delivery
  • 3rd trimester: Induction of labor +/- cervical ripening agents, spontaneous vaginal delivery, repeat C-section upon maternal request if patient has a hx of prior cesarean delivery
150
Q

In the third trimester, labor induction w/ oxytocin for stillbirth is apporpriate, even in a patient w/ a prior cesarean delivery. Vaginal delivery is preferable as potential maternal morbidity exists w/ cesarean delivery, without any fetal benefit. The patient should be counseled about the risks and benefits of both delivery routes.

A

.

151
Q

Secondary amenorrhea

A
  • absence of menses for > 3 cycles or > 6 months in women who previously had menses
  • initial evaluation includes b-hCG to exclude pregnancy, followed by serum prolactin to exclude prolactinoma and TSH to rule out hypothyroidism; pts w/ normal TSH and prolactin require serum FSH and LH to evaluate for ovarian failure and hypothalamic pituitary disorders
  • can be due to pregnancy, hypothalamic (GnRH deficiency), functional (eating disorders, stress), uterine (Asherman’s syndrome), pituitary (prolactinoma), and endocrine (hypothyroidism); and PCOS
152
Q

Hysterosalpingogram

A

-indicated for pts w/ amenorrhea and hx of uterine procedures, normal lab studies (TSH, prolactin, FSH), and no withdrawal bleeding on estrogen/progestin stimulation test

153
Q

Functional amenorrhea

A
  • can be due to significant stress, systemic illness w/ weight loss, eating disorders (ie anorexia nervosa), or strenuous daily exercise.
  • more common in women w/ BMI < 18.5
154
Q

Pts w/ findings of hyperandrogenism (ie hirsutism, severe acne) also need serum testosterone to exclude PCOS, DHEA to rule out an adrenal source of androgens, and early morning 17-hydroxyprogesterone to evaluate for nonclassic 21-hydroxylase deficiency

A

.

155
Q

Mifepristone

A
  • progestin receptor antagonist
  • can be used as emergency contraception to prevent ovulation and blocks the action of progesterone which is needed to maintain pregnancy
156
Q

Diagnosis of ectopic pregnancy

A

made when:

  • a fetal pole is visualized outside the uterus on US
  • the patient has a b-hCG level over the discriminitory zone (1200-2000) and there is no intrauterine pregnancy seen on US
  • the patient has inappropriately rising b-hCG level (less than 50% increase in 48 hours) and has levels which do not fall following diagnositc D&C
157
Q

Conditions needing to be met prior to initiating methotrexate for ectopic pregnancy

A

these include:

  • hemodynamic stability
  • nonruptured ectopic pregnancy
  • size of ectopic mass < 3.5cm in the presence of a fetal heart rate
  • normal liver enzymes and renal function
  • normal WBC count
  • ability of the patient to follow up rapidly if her condition changes
158
Q

sequence of sexual maturation

A

-Thelarche, Adrenarche, Growth spurt, Menarche

159
Q

3 known critical elements of secondary sexual characteristics

A
  • adequate body weight
  • sleep
  • optic exposure and sunlight
160
Q

psychosocial causes of delayed puberty

A
  • eating disorders
  • excessive exercise
  • stress/depression
161
Q

Partial deletions of the long arm of the X chromosome

A

-can cause premature ovarian failure

162
Q

Noonan’s syndrome

A
  • short stature
  • webbed neck
  • heart defects
  • abnormal faces
  • delayed puberty
  • normal karyotype
163
Q

Kallmann syndrome

A
  • olfactory tract hypoplasia and the arcuate nucleus does not secrete GnRH
  • females have no sense of smell and do not develop secondary sexual characteristics
  • diagnosis of exclusion in most cases during the workup of delayed puberty
  • anosmia w/ delayed puberty
  • Tx is pulsatile GnRH therapy
164
Q

True precocious puberty

A

manifested by premature secretion of GnRH hormone in a pulsatile manner

  • generally a diagnosis of exclusion
  • tx is GnRH agonist to suppress pituitary production of FSH and LH
  • the process should be treated if the bone age or puberty is advanced by several years
165
Q

normal age for menarche

A

-between nine and 17

166
Q

Remember that renal anomalies occur in 25-35% of females w/ Mullerian agenesis!!! Do a renal US!

A

.

167
Q

Premenstrual dysphoric disorder

A
  • describes a severe form of PMS in which the diagnostic criteria include 5 out of 11 clearly defined symptoms, FUNCTIONAL IMPAIRMENT, and prospective charting of symptoms
  • all 3 areas need to be present for the diagnosis
168
Q

what vitamin deficiencies have been associated w/ an increase in PMS?

A
  • Vitamin A, E, and B6

- replacement might improve symptoms

169
Q

Diagnostic tool for determining if PMS is present?

A

-Prospective symptom calendar

170
Q

PMS and PMDD occur during which phase of the menstrual cycle?

A

-Luteal phase

171
Q

PMS vs PMDD?

A

-PMS is characterized by mild to moderate symptoms, while PMDD is associated with severe symptoms that seriously impair usual daily functioning and personal relationships

172
Q

Risk factors for PMS

A
  • family history of PMS, vitamin B6, calcium, or magnesium deficiency
  • Note that previous anxiety, depression, or other mental health problems are significant risk factors for developing PMDD
173
Q

Function of b-hCG?

A

Helps sustain the corpus Luteum during the first 7 weeks of pregnancy. After that the placenta takes over for the corpus Luteum in making progesterone to sustain pregnancy

174
Q

How much should hCG increase during the first 10 weeks of pregnancy?

A

66-100% every 48 hours

175
Q

At what gestational age can fetal heart tones be heard on Doppler?

A

10 weeks

176
Q

Most reliable way of dating gestational age?

A

US before 12 weeks measuring the crown-rump length

177
Q

Complete androgen insensitivity syndrome

A
  • X linked mutation of androgen receptor
  • breast development present
  • absent uterus and upper vagina; cryptorchid testes
  • minimal to absent axillary and pubic hair
  • 46 XY
178
Q

Mullerian agenesis

A
  • Hypoplastic or absent mullerian ductal system
  • breast development present
  • absent or rudimentary uterus and upper vagina; normal ovaries
  • normal axillary and pubic hair
  • 46 XX
179
Q

Transverse vaginal septum

A
  • malformation of urogenital sinus and mullerian ducts
  • breast development present
  • normal uterus, abnormal vagina; normal ovaries
  • normal axillary and pubic hair
  • 46 XX
180
Q

Turner syndrome

A
  • complete/partial absence of 1 X chromosome
  • breast development variable depending on ovarian function
  • normal uterus and vagina; streak ovaries
  • normal axillary and pubic hair
  • 45 X
181
Q

primary amenorrhea

A

-absence of menses by age 15 in someone who has normal growth and secondary sexual characteristics

182
Q

5a-reductase deficiency

A
  • 46 XY
  • cannot convert testosterone to dihydrotestosterone
  • manifests as ambiguous genitalia at birth (undervirilization) and a male internal urogenital tract (due to AMH)
183
Q

Chorioamnionitis

A
  • diagnosed clinically be the presence of maternal fever and 1 or more of the following: uterine tenderness, maternal or fetal tachycardia, malodorous amniotic fluid, or purulent vaginal discharge
  • prolonged rupture of the membranes is an important risk factor
  • note that it can also occur in pts w/ intact membranes
  • usually a POLYMICROBIAL infection
184
Q

Prolonged rupture of membranes

A

-occurs before the onset of labor and is defined as prolonged when rupture lasts > 18 hours between the time of rupture and birth

185
Q

abruptio placenta

A
  • women w/ premature ROM are at increased risk
  • presents w/ PAINFUL vaginal bleeding
  • uterine tenderness, abnormal uterine contractions, and fetal distress due to poor placental perfusion may be evident
186
Q

Acute cervicitis

A

-manifests as purulent cervical discharge due to Trichomonas, Chlamydia, or Gonorrhea in the ABSENCE of uterine tenderness

187
Q

Pelvic inflammatory disease

A

-extremely rare after the first trimester

188
Q

common risk factor for chorioamnionitis

A

-prolonged ROM

189
Q

Chorioamnionitis (intra-amniotic infection)

A
  • risk factors: prolonged rupture of membranes, prolonged labor, internal fetal or uterine monitoring devices, presence of genital tract pathogens
  • diagnosis: maternal fever > 100.4 PLUS 1 or more of the following: maternal tachycardia, uterine tenderness, malodorous/purulent amniotic fluid or vaginal discharge, WBC >15,000, fetal tachycardia
  • tx: broad spectrum antibiotics (ie ampicillin, gentamicin, clindamycin), delivery
  • complications: maternal uterine atony, postpartum hemorrhage, endometritis, premature birth, infection, encephalopathy, cerebral palsy, death of infant
190
Q

Tocolysis to prevent labor is contraindicated in a patient w/ an intraamniotic infection, regardless of gestational age

A

.

191
Q

Tx for chorioamnionitis

A
  • prompt administration of broad spectrum antibiotics followed by delivery to reduce the risk of life-threatening neonatal infection and maternal complications
  • chorioamnionitis is not an indication for cesarean delivery
192
Q

PID

A
  • may lead to tubo-ovarian abscess, abscess rupture, pelvic peritonitis, and sepsis if left untreated
  • inability to take oral meds due to nausea and vomiting is an indication for inpatient tx of PID
  • diagnosis: fever > 38C, leukocytosis, elevated ESR, purulent cervical discharge, adnexal tenderness, cervical motion tenderness, lower abdominal tenderness
  • most common cause of infertility in women age < 30 w/ normal menstruation
  • regimes for inpatients: cefoxitin or cefotetan/doxycycline, and clindamycin/gentamicin (all IV)
  • regimens for outpatients: IM cefoxitin w/ oral probenecid and oral doxycycline, or IM ceftriaxone and oral doxycycline
193
Q

Differential diagnosis of menorrhagia

A
  • endometriosis
  • fibroids
  • adenomyosis
  • endometrial cancer/hyperplasia
  • endometritis
194
Q

endometriosis

A
  • pain w/ menses
  • dyspareunia
  • infertility
195
Q

fibroids

A
  • heavy menses w/ clots
  • constipation, urinary frequency, pelvic pain/heaviness
  • enlarged uterus
  • frequently coexist w/ adenomyosis
196
Q

adenomyosis

A
  • dysmenorrhea, pelvic pain
  • menorrhagia
  • bulky, globular and tender uterus
  • occurs most frequently in parous women age > 40 and typically presents w/ dysmenorrhea, menorrhagia, and pelvic pain. Uterus is symmetrically enlarged but < 12 weeks size
  • confirmation of the diagnosis requires surgical pathology after hysterectomy
  • other associations: early menarche, short menstrual cycles, prior uterine surgery, and preterm birth. More than 50 % of women w/ adenomyosis have concurrent fibroids or an adenomyoma (adenomyosis limited to one portion of the uterus)
197
Q

endometrial cancer/hyperplasia

A
  • hx of obesity, nulliparity, or chronic anovulation
  • irregular, intermenstrual, or postmenopausal bleeding
  • small, nontender uterus
  • women age > 45 w/ irregular bleeding require an ENDOMETRIAL BIOPSY to exclude malignancy
198
Q

endometritis

A
  • recent instrumentation of the uterus (ie abortion, uterine surgery, intrauterine device placement)
  • foul smelling discharge
  • fever
  • usually causes pelvic pain
  • presentation is typically acute (within 10 days of the procedure)
199
Q

von Willebrand disease (vWD)

A

-inherited bleeding disorder that causes easy bruising, bleeding, heavy menses, nosebleeds, and excessive bleeding after surgery or delivery

200
Q

Excess LH secretion occurs in PCOS

A

.

201
Q

cause of irregular menstrual cycles in women shortly following menarche

A
  • usually anovulatory due to immaturity of the developing hypothalamic-pituitary-gonadal axis that does not produce adequate quantities and proportions of the hormones (LH, FSH) required to induce ovulation
  • estrogen is present, but not progesterone
202
Q

Ovarian and adnexal torsion

A
  • occurs most commonly in women of reproductive age
  • primary risk factor is ovarian enlargement (ie pregnancy, tumors)
  • pts develop sudden onset of unilateral lower abdominal pain (usually right-sided), nausea, and vomiting
  • diagnosis is confirmed w/ US using color doppler
  • management includes laparoscopic surgery
203
Q

Differentiate between appendicitis and ovarian torsion

A
  • both often present similarly w/ sudden onset of lower abdominal pain, nausea, and vomiting
  • however, appendicitis usually begins as periumbilical pain that migrates to the right lower quadrant. Pts may also have anorexia and bowel complaints.
204
Q

Ovarian hyperstimulation syndrome

A
  • serious complication of gonadotropin therapy for infertility
  • characterized by ovarian enlargement from multiple cysts w/ fluid shifts out of the intravascular space that results in ascites and hypovolemia
205
Q

Ruptured ovarian cyst

A
  • presents w/ sudden onset of lower abdominal pain (at midcycle), often following strenuous physical activity or sexual intercourse
  • may be accompanied by light vaginal bleeding
  • in rare cases, significant hemorrhage from cyst rupture can lead to shock and hemoperitoneum
206
Q

Pregnant women w/ high-grade squamous intraepithelial lesion on Pap testing should be evaluated w/ colposcopy. If the initial colposcopy is negative, repeat cytology and colposcopy are recommended after delivery. Cervical biopsy and LEEP are NOT performed during pregnancy unless there is a lesion suggestive of invasive cancer.

A

.

207
Q

formula for determining amount of respiratory compensation during a metabolic ALKALOSIS?

A

expected PaCO2 = (0.9 x bicarb) + 16 +/- 2

208
Q

formula used to assess respiratory compensation in primary metabolic ACIDOSIS?

A

Winter’s formula

PaCO2 = (1.5 x bicarb) + 8 +/- 2

209
Q

Hypocapnia in pregnancy

A
  • normal phenomenon of late pregnancy caused by a direct stimulatory effect of progesterone on the central respiratory center
  • this leads to increased respiratory drive, relative hyperventilation, and primary respiratory alkalosis
210
Q

Obesity can cause hypoventilation (Pickwickian syndrome), leading to chronic respiratory acidosis

A

.

211
Q

Intrapartum fetal heart rate monitoring- VEAL CHOP

A
  • Variable decelerations –> Cord compression/prolapse; oligohydramnios
  • Early decelerations –> Head compression
  • Accelerations –> Ok (normal fetal oxygenation)
  • Late decelerations –> Placental insufficiency
212
Q

Umbilical cord prolapse

A
  • surgical emergency that happens when the cord is the presenting part
  • can occur w/ rupture of the membranes
  • cord becomes compressed, compromising blood flow and oxygenation of the fetus
  • it is PAINLESS and may be diagnosed on fetal heart monitoring, w/ sudden changes frequently characterized by deep, recurring variable decelerations
213
Q

Preterm labor

A
  • contractions and cervical change prior to 37 weeks gestation
  • pain associated w/ preterm labor is INTERMITTENT and the uterus relaxes w/ no pain between contractions
214
Q

Manifestations of placental abruption

A
  • include vaginal bleeding (80% of cases), abdominal pain, uterine tenderness, and uterine contractions w/ increased uterine tone
  • the absence of blood on pelvic exam does NOT rule out this condition
215
Q

Needle aspiration is CONTRAINDICATED in postmenopausal women w/ an adnexal mass due to its poor sensitivity and possibility of seeding cancer cells into the peritoneal cavity.

A

.

216
Q

Asymptomatic women w/ pelvic masses

A
  • should be evaluated initially by transvaginal US and then a cancer antigen (CA)-125 level
  • any elevation of CA-125 in a postmenopausal woman raises suspicion for ovarian cancer
  • If the US suggests a simple cyst and the CA-125 level is not elevated, masses < 10 cm can be followed conservatively
217
Q

ABO incompatibility

A
  • generally occurs in a group O mother with a group A or B baby, but ABO incompatibility causes less severe hemolytic disease of the newborn than does Rh(D) incompatibility.
  • Affected infants are usually asymptomatic at birth w/ absent or mild anemia and develop neonatal jaundice, which is usually successfully treated w/ phototherapy
218
Q

Endometriosis

A
  • typically presents w/ chronic pelvic pain (may be worse during menses), dyspareunia, infertility, and sometimes w/ bowel/bladder problems
  • pts w/ pelvic pain and no complications can be treated empirically w/ NSAIDs, COC’s, progestins, or GnRH agonists
  • Laparoscopy is useful for diagnosis and tx of complicated endometriosis (ie bowel/bladder obstruction, rupture of endometrioma) and for pts refractory to medical therapy
219
Q

Apgar score

A

10 points total; assign 0-2 for each of the following:

  • Color
  • Pulse
  • Respirations
  • Grimmace
  • Tone
220
Q

4 causes of postpartum hemorrhage

A

The 4 T’s:

  • retained Tissue
  • Trauma
  • uterine Tone
  • Thrombin (coagulation defects)
221
Q

Mittelschmerz

A
  • recurrent mild and unilateral midcycle pain due to normal follicular enlargement prior to ovulation
  • pain lasts a few hours to couple of days
  • US is frequently normal and not needed
222
Q

Ectopic pregnancy

A
  • amenorrhea, crampy abdominal pain and vaginal bleeding
  • no intrauterine pregnancy on transvaginal US
  • positive serum hCG
223
Q

Ovarian torsion

A
  • acute onset of severe unilateral lower abdominal pain, nausea and vomiting
  • unilateral, tender adnexal mass on exam
  • pelvic US w/ Doppler shows enlarged ovary w/ decreased blood flow
224
Q

Ruptured ovarian cyst

A
  • sudden onset severe unilateral lower abdominal pain immediately following strenuous or sexual activity
  • pelvic US shows free fluid near ovarian cyst
225
Q

Pelvic inflammatory disease

A
  • fever/chills, new vaginal discharge, lower abdominal pain, dysuria, painful defecation and cervical motion tenderness
  • transvaginal US to rule out tubo-ovarian abscess
226
Q

Ruptured ovarian cyst

A
  • presents w/ acute onset of unilateral pelvic pain immediately after strenuous activity or sexual intercourse
  • pelvic US can confirm the diagnosis by showing free fluid in the pelvis
  • supportive care (eg analgesics) is recommended for uncomplicated cyst rupture; complicated cyst rupture may require surgical intervention
227
Q

Asymptomatic bacteriuria during pregnancy

A
  • increases the risk of cystitis, pyelonephritis, preterm birth, low birth weight, and perinatal mortality
  • E. coli accounts for > 70% of cases
  • Accepted regimens include nitrofurantoin for 5-7 days, amoxicillin or amoxicillin-clavulanate for 3-7 days, or fosfomycin as a single dose
  • Fluroquinolones should be avoided during pregnancy, and TMP/Sulfa should be avoided in the 1st and 3rd trimesters
228
Q

Increased serum androgen levels can suppress ovulation by suppressing GnRH as well as FSH release by feedback inhibition (think PCOS)

A

.

229
Q

serum Inhibin B level

A
  • used to determine ovulatory reserve

- will decrease in older women who have a decreased capacity to ovulate

230
Q

Misoprostol is a synthetic prostaglandin approved for use with mifepristone to terminate pregnancies of < 49days gestation.

A

.

231
Q

Septic abortion

A
  • medical emergency that should be treated promptly w/ broad-spectrum antibiotics and surgical evacuation of the uterus
  • after the initial tx, the patient should be monitored closely for signs of systemic sepsis
232
Q

Elevated maternal serum a-fetoprotein

A
  • seen in fetal abnormalities such as open neural tube defects, gastroschisis, and omphalocele
  • also elevated in a multiple gestation pregnancy
  • an US should be performed to evaluate the fetal anatomy
233
Q

Dysgerminomas

A
  • arise in younger women or in children, with an average incidence at the age of 20
  • they are usually unilateral and occasionally undergo torsion
  • the tumor is neutral and does not secrete either male or female sex hormones
234
Q

Sertoli-Leydig cell tumors

A
  • produce androgens and cause defeminization followed by masculinization
  • women in the childbearing age may complain of an altered body contour, flattening of the breasts, and scanty, irregular menstruation, ultimately ending in amenorrhea
  • pts may develop hirsutism, coarsening of features, and enlargement of the clitoris
235
Q

mature teratomas

A
  • aka dermoid cysts

- often benign and do not produce either estrogens or androgens

236
Q

serous cystadenoma

A
  • most common cystic ovarian neoplasms, accounting for about 30% of all ovarian tumors
  • and 25% of all these are malignant, and about half of the cases are bilateral
  • they usually do not produce estrogen or androgen
  • ovarian mass and abdominal pain are the presenting features
237
Q

Granulosa cell tumors

A
  • produce excessive amounts of estrogen, and can present w/ precocious puberty in younger children and postmenopausal bleeding in elderly pts
  • this has to be differentiated from heterosexual precocious puberty or virilizing symptoms which are usually produced by excessive androgens
238
Q

human placental lactogen (hPL)

A
  • produced by the placenta, and serum levels quickly decrease after delivery of the placenta
  • insulin antagonist effect and plays an important role in nutrition of the fetus by causing maternal lipolysis and insulin resistance thus increasing delivery of fatty acids and glucose to the fetus
239
Q

Elevated prolactin levels suppress GnRH release thereby suppressing LH and FSH production and ovulation. This is the reason for anovulation and amenorrhea in lactating mothers.

A

.

240
Q

preferred form of hormonal contraception for lactating mothers?

A
  • Progestin-only oral contraceptives
  • note that sterilization, barrier methods, IUDs and progestin-only oral contraceptives can all be used in the postpartum period
241
Q

Intrauterine fetal demise (IUFD)

A
  • death of a fetus in utero that occurs after 20 weeks gestation and before the onset of labor
  • a coagulation profile should be drawn after diagnosis to detect incipient DIC
  • Fibrinogen levels in the low normal range may be an early sign of consumptive coagulopathy, esp. if there is an associated decrease in platelet count, increase in PT and PTT or the presence of fibrin split products
  • labor should be induced w/o delay in pts w/ intrauterine fetal demise who develop coagulation abnormalities
242
Q

Physicians can refuse to perform elective abortions for personal or professional reasons. If you refuse to perform any procedure then you should attempt to refer the patient to another physician who can and will.

A

.

243
Q

Uterine leiomyoma (fibroids)

A
  • risk factors: family history, early menarche
  • clinical features: urinary frequency, constipation (secondary to compression), heavy prolonged menses w/ clots, pelvic pressure or pain, pregnancy difficulties (impaired fertility, pregnancy loss, preterm labor)
  • workup: Ultrasound
  • Tx: observation if no significant symptoms, hormonal contraception, embolization, or surgery if symptomatic
244
Q

Pelvic US is the preferred initial imaging modality for suspected gynecological tumors. It has high sensitivity for diagnosing uterine fibroids and ovarian pathology.

A

.

245
Q

Bilateral edema of the lower extremities in pregnancy

A
  • most commonly a benign problem
  • Preeclampsia and DVT should also be considered, but are unlikely in the absence of other classic symptoms of these conditions
246
Q

Androgen insensitivity syndrome

A
  • characterized by a phenotypic female w/ a 46 XY karyotype
  • BILATERAL GONADECTOMY is recommended after completion of puberty (ie attainment of adult height) to decrease risk of gonadal malignancy
247
Q

Cholelithiasis

A
  • classic risk factors: female, fat, forty
  • gallstones may occur w/ rapid weight loss due to a very low calorie diet or bariatric surgery
  • unopposed estrogen use (hormonal therapy) and oral contraceptives also increase the risk of cholelithiasis
248
Q

Endometrial hyperplasia occurs in pts w/ unopposed estrogen levels, such as those with PCOS

A

.

249
Q

major risk factors for gout

A
  • male, diuretic use, alcohol consumption, obesity, and a diet rich in purines (organ meats, game, seafood)
  • starvation w/ rapid weight loss can precipitate an acute gout attack
250
Q

Pts w/ functional hypothalamic amenorrhea and weight loss, particularly those w/ anorexia nervosa, may have thyroid function tests resembling euthyroid sick syndrome, as seen in pts w/ severe illness. These pts may have a low T3, low/low-normal thyroxine, low/low-normal thyroid-stimulating hormone, and elevated reverse T3

A

.

251
Q

Functional hypothalamic amenorrhea

A
  • due to suppression of the hypothalamic pituitary ovarian axis by strenuous exercise, anorexia nervose, marijuana use, starvation, stress, depression, or chronic illness
  • pts are at risk for bone loss due to estrogen deficiency
252
Q

Physiologic galactorrhea

A
  • usually bilateral and can be milky (most common), yellow, brown, gray, or green.
  • hyperprolactinemia is the most common cause of physiologic galactorrhea
  • galactorrhea should be evaluated w/ serum prolactin, TSH, and possible brain MRI
  • Pts w/ unilateral or bloody (gross or occult) nipple discharge, palpable abnormalities, or skin changes should be evaluated for possible malignant causes
253
Q

Hyperprolactinemia

A

-most common cause of physiologic galactorrhea
-can be due to pituitary prolactinoma, meds (antipsychotics, opioids), hypothyroidism, pregnancy, oral contraceptives, or chest wall/nipple stimulation (surgery, trauma, shingles).
pts w/ prolactinoma often develop symptoms of hypogonadism (hot flashes, oligo/amenorrhea)

254
Q

Findings suggesting malignancy include UNILATERAL discharge, SEROUS or BLOODY (gross or occult) rather than milky discharge, palpable breast abnormalities, and associated skin changes (Paget disease of the breast). These pts require mammography and possible US.

A

.

255
Q

False labor

A
  • usually occurs in the last 4-8 weeks of pregnancy
  • contractions are felt in the lower abdomen, are irregular, occur at an interval that does not shorten and do not increase in intensity
  • the the last month of pregnancy, pts may experience contractions that become rhythmic, occurring every 10-20 minutes, and contractions of greater intensity, mimicking more closely the contractions of actual labor
  • in all cases of false labor, however, contractions are NOT accompanied by progressive cervical changes and are usually RELIEVED BY SEDATION
  • all such patients need reassurance and discharge home
256
Q

True labor

A
  • contractions that occur at regular intervals w/ a progressively shortening interval and increasing intensity
  • the pain in true labor occurs in the back and upper abdomen and is NOT relieved by sedation
  • cervical changes are typically observed
257
Q

Luteal phase defect

A
  • indicates poor preparation of the endometrium for implantation due to a progesterone deficiency
  • following ovulation, progesterone is produced in increased amounts by the corpus luteum
258
Q

Impaired oocyte transport

A
  • in the fallopian tube is commonly the result of previous PID or endometriosis
  • other uncommon causes of ciliary dysmotility may also play a role
259
Q

PCOS

A
  • characterized by anovulation or oligo-ovulation, signs of androgen excess, such as male-pattern hair growth and acne, and ovarian cysts
  • results from abnormal GnRH secretion that stimulates the pituitary to secrete excessive LH and insufficient FSH
  • excess LH stimulates excess androgen production by ovarian theca cells resulting in hirsutism, male escutcheon, acne and androgenic alopecia
  • anovulation is caused in part by imbalances in LH and FSH production and in part by insulin resistance in these pts
260
Q

Laparoscopy with visualization and biopsy of implants is the only definitive way to diagnose endometriosis. It is indicated when NSAIDs and hormonal contraceptive therapy has failed.

A

.

261
Q

Endometriosis most commonly affects which age group?

A

Nulliparous women 25-35

262
Q

Endometriosis

A
  • risk factors: nulliparity, early menarche, shorter menstrual cycles, menstrual outflow obstruction
  • pathogenesis: ectopic endometrial tissue forms on or just beneath pelvic mucosa/serosal surfaces. Cyclic hyperplasia and degeneration occur in response to female sex hormones. Chronic hemorrhaging leads to formation of FIBROTIC PELVIC ADHESIONS.
  • clinical presentation: dyspareunia, dysmenorrhea, pelvic pain, infertility
  • diagnosis: direct visualization on laparoscopy +/- biopsy
263
Q

Abruptio placenta occurs more commonly in which patients?

A

-advancing age, hypertension, preeclampsia, renal disease, and cocaine or tobacco use

264
Q

Risk factors for breast cancer

A

-positive family hx, genetic mutations (BRCA1, BRCA2, or p53), early menarche, late menopause, prolonged hormone replacement therapy, and nulliparity

265
Q

Risk factors for endometrial carcinoma

A

-advancing age, unopposed estrogen or prolonged tamoxifen use, obesity, nulliparity, and anovulatory conditions

266
Q

Pts w/ endometriosis are at an increased risk of impaired fertility or infertility due to chronic inflammation and adhesion formation. Endometriosis is diagnosed in 25-50% of women being evaluated for infertility, and almost half of women w/ endometriosis have impaired fertility.

A

.

267
Q

Common symptoms of PMS

A
  • mood swings, irritability, fatigue, bloating, and breast tenderness
  • symptoms occur in the 1-2 weeks prior to menses and resolve w/ onset of menstrual flow
  • the diagnosis is often readily apparent and can be confirmed w/ a menstrual diary
  • PMS can be differentiated from normal menstruation by the degree of distress and impaired functioning
268
Q

what is the earliest sign of magnesium sulfate toxicity?

A
  • Depression of the deep tendon reflexes

- Tx requires stopping the magnesium sulfate infusion and administration of calcium gluconate

269
Q

Contraindications to external cephalic version

A
  • indications for cesarean delivery regardless of fetal lie (ie failure to progress during labor, non-reassuring fetal status)
  • placental abnormalities (ie placenta previa or abruption)
  • oligohydramnios
  • ruptured membranes
  • hyperextended fetal head
  • fetal or uterine anomaly
  • multiple gestation
270
Q

Internal podalic version

A

-performed in twin delivery to convert the second twin from a transverse/oblique presentation to a breech presentation for subsequent delivery

271
Q

External cephalic version

A

-can be attempted in women w/ breech pregnancies at >37 weeks gestational age if there are no contraindications to vaginal delivery, and fetal well-being has been established. These maneuvers can reduce the rate of cesarean section.

272
Q

Prophylactic cesarean section and induction of labor have NOT been consistently shown to prevent complications related to shoulder dystocia.

A

.

273
Q

US of the kidneys and pelvis is recommended to evaluate renal colic in pregnant patients. Low-dose CT urography may be considered only in the second and third trimesters.

A

.

274
Q

Maternal combination antiretroviral therapy during pregnancy and neonatal zidovudine therapy can reduce perinatal HIV transmission to

A

.

275
Q

what is the most important intervention for preventing the spread of HIV from mother to child during pregnancy?

A
  • administration of COMBINATION ANTIRETROVIRAL THERAPY to the mother throughout pregnancy. It should be administered as soon as possible during pregnancy, regardless of maternal CD4 count or viral load.
  • a 3 drug regimen of 2 nucleoside reverse transcriptase inhibitors (NRTIs) plus a non-nucleoside reverse transcriptase inhibitor or a protease inhibitor.
  • Zidovudine should be administered to the neonate for > 6 weeks
276
Q

what is the first line therapy for PMS/PMDD?

A

-SSRIs

277
Q

causes of fetal growth restriction (weight < 10th percentile)

A
  • Asymmetric (maternal factors): vascular disease, antiphospholipid antibody syndrome, autoimmune disease, cyanotic cardiac disease, substance abuse (tobacco, alcohol, cocaine)
  • Symmetric (fetal factors): genetic disorders, congenital heart disease, intrauterine infection (malaria, CMV, rubella, toxoplasmosis, varicella)
278
Q

Etiologies of fetal growth restriction

A
  • maternal vascular disease, fetal anomalies, aneuploidy, intrauterine infection, and substance abuse
  • HTN is a risk factor for asymmetric fetal growth restriction secondary to uteroplacental insufficiency
279
Q

Advanced maternal age is a significant risk factor for spontaneous abortion. Incomplete abortion is characterized by bleeding, cramping, and partial passage of fetal tissue. Depending on patient preference, hemodynamically stable patients w/ incomplete abortion can undergo expectant management, misoprostol, or dilation and evacuation.

A

.

280
Q

Benefits and risks of combined estrogen-progestin contraceptives

A
  • benefits: pregnancy prevention, endometrial and ovarian cancer risk reduction, menstrual regulation w/ reduction in iron deficiency anemia, reduction in risk of benign breast disease
  • risks: venous thromboembolism, HTN, hepatic adenoma, very rarely stroke and MI
281
Q

which drug is used to treat gonorrhea?

A

ceftriaxone

282
Q

which drug is used to treat BV and trichomoniasis?

A

Metronidazole

283
Q

which drug is used to treat Chlamydia?

A

doxycycline

284
Q

Adenomyosis

A
  • may cause dysmenorrhea, typically in women age > 35

- bulky, globular, and tender uterus

285
Q

Endometriosis

A
  • tenderness along the uterosacral ligaments, nodularity in the cul-de-sac, and adnexal enlargement due to an endometrioma
  • pain from endometriosis usually precedes menses by a few days
286
Q

Primary dysmenorrhea

A
  • pelvic cramping during the first few days of menses in the context of a normal physical exam
  • caused by increased prostaglandin release from endometrial sloughing during menses
287
Q

Medical treatment options for acute abnormal uterine bleeding

A
  • high dose IV or oral estrogen
  • high dose combined oral contraceptive pills
  • high dose progestin pills
  • tranexamic acid
288
Q

Acute abnormal uterine bleeding in adolescents

A
  • usually a result of anovulatory cycles from an immature hypothalamic-pituitary-ovarian axis
  • evaluation for pregnancy and bleeding disorders is generally advised
  • high dose estrogen is the first line tx for pts w/ moderate to severe bleeding
289
Q

symptoms of molar pregnancy

A
  • first trimester vaginal bleeding associated w/ expulsion of vesicles, excessive nausea and vomiting, and uterine size larger than dates
  • US shows a “snow storm” appearance, and b-hCG serum levels are increased beyond what would be expected in a normal pregnancy
290
Q

most significant risk factors for spontaneous abortion

A
  • maternal smoking
  • advanced maternal age
  • previous spontaneous abortion
291
Q

most common causes of antepartum hemorrhage?

A

-placenta previa and abruptio placenta

292
Q

Vaginal exam is contraindicated in the case of antepartum hemorrhage because it can aggravate the bleeding from placenta previa

A

.

293
Q

relationship between prolactin, TRH, and dopamine?

A
  • Prolactin production is STIMULATED by serotonin and TRH, and INHIBITED by dopamine (think about dopamine agonists such as bromocriptine)
  • Hypothyroidism may result in amenorrhea and galactorrhea!
294
Q

Intrahepatic cholestasis of pregnancy

A
  • intense pruritis
  • elevated bile acids and levels of liver aminotransferases
  • diagnosis of exclusion
  • jaundice is uncommon in pts w/ ICP and warrant further workup
295
Q

HELLP

A
  • preeclampsia, RUQ pain, Nausea/Vomiting

- Hemolysis, moderately elevated liver aminotransferases, thrombocytopenia

296
Q

Acute fatty liver of pregnancy

A
  • malaise
  • RUQ pain
  • N/V
  • sequelae of liver failure
  • hypoglycemia, mildly elevated liver aminotransferases, elevated bilirubin, possible DIC
297
Q

Preeclampsia-eclampsia syndrome

A
  • diagnosed based on elevated blood pressure (>140 systolic or 90 diastolic), w/ new-onset proteinuria or end organ damage (thrombocytopenia, impaired liver function, pulmonary edema, and cerebral or visual symptoms)
  • lab abnormalities in a pre-eclamptic patient may raise suspicion for HELLP
298
Q

Pruritic urticarial papules and plaques of pregnancy (PUPPP)

A
  • skin condition that develops in the third trimester
  • abdominal exam shows red papules within striae w/ sparing around the umbilicus, sometimes extending to the extremities
  • the palms, soles, and face are rarely involved, helping to distinguish it from Intrahepatic cholestasis of pregnancy (ICP)
  • there are no lab or liver abnormalities associated w/ PUPPP
299
Q

Group B strep screening

A
  • Screening by vaginal and rectal culture and PENICILLIN prophylaxis have drastically reduced the incidence of neonatal GBS infection
  • universal screening occurs at 35-37 weeks gestation as the result is most accurate within 5 weeks of the anticipated delivery date
  • Exceptions include a hx of GBS bacteriuria, UTI, or an infant w/ early onset GBS disease; these pts should receive antibiotic prophylaxis w/o testing
300
Q

what do you do if a patient presents in labor w/ an unknown GBS status?

A

-initiate prophylaxis w/ penicillin if:

18 hours

301
Q

Epidural anesthesia in labor impairs bladder function, and an overdistended bladder may lose its ability to contract and result in urinary retention and overflow incontinence. Urinary retention is treated w/ short term indwelling catheterization.

A

.

302
Q

normal bladder capacity and postvoid residual volume?

A
  • normal bladder capacity: 400-600 mL

- PRV: < 50 mL

303
Q

mucopurulent discharge, erythematous/friable cervix, no organisms on gram stain

A
  • Chlamydial cervicitis

- Tx is azithromycin

304
Q

mucopurulent discharge, erythematous/friable cervix, gram negative diplococci

A
  • Gonorrheal cervicitis

- Tx is Ceftriaxone

305
Q

Thin, green-yellow, or grayish frothy, malodorous discharge; “strawberry cervix”

A
  • Trichomonas vaginitis

- Tx is Metronidazole

306
Q

The most common cause of mucopurulent cervicitis is Chlamydia trachomatis, followed by Neisseria gonorrhoeae. The 2 organisms cannot reliably be distinguished by examination, and nucleic acid amplification testing is recommended to differentiate between them. If test results are not available, empiric therapy for both chlamydial and gonococcal infection should be prescribed.

A

.

307
Q

Do not confuse condyloma acuminata and condyloma lata. Condyloma lata is caused by secondary syphilis and is characterized by flat, velvety lesions. They respond to penicillin.

A

.

308
Q

Lichen sclerosus

A
  • presents as white, thin, and wrinkled skin over the labia

- typically affects postmenopausal females and causes pruritus

309
Q

Lichen planus

A
  • typically affects middle-aged women
  • lesions may be hyperkeratotic, erosive or papulosquamous in appearance
  • pruritis, soreness, and vaginal discharge are common
310
Q

Genital warts

A
  • caused by HPV and present as clusters of pink lesions on the genitalia.
  • small lesions can be treated in the office w/ trichloroacetic acid or podophyllin
311
Q

Montevideo unit

A
  • # of uterine contractions in 10 minutes x contraction strength
  • contraction strength = peak mmHg - baseline mmHg using internal pressure catheter
  • adequate labor = 200 montevideo unites
312
Q

Arrest of labor in the first stage

A
  • diagnosed when dilation is 6 cm or more with ruptured membranes in the setting of no cervical change for 4 or more hours despite ADEQUATE contractions (> 200 montevideo units for >2 hours) OR when there is no cervical change for >6 hours w/ INADEQUATE contractions.
  • Pts who do not meet criteria should be observed if there is no fetal distress
313
Q

Menopause

A
  • average age 51
  • can be diagnosed clinically in women over the age of 45 w/ a 12 month hx of amenorrhea without other physiologic causes
314
Q

Symptoms of menopause include irregular or absent menses, heat intolerance, flushing, insomnia, and night sweats. Hyperthyroidism and menopause can have similar presentations, and serum TSH and FSH levels should be checked in pts w/ these symptoms.

A

.

315
Q

Endometrial biopsy is indicated for evaluating abnormal uterine bleeding in: ?

A
  • women 45 or older and all postmenopausal women
  • women less than 45 w/ persistent symptoms or risk factor for endometrial cancer (obesity, diabetes, unopposed estrogen exposure, PCOS, early menarche, etc.)
  • unopposed estrogen exposure (eg obesity, PCOS)
  • prolonged amenorrhea w/ anovulation
316
Q

Sheehan syndrome (pituitary infarction)

A
  • risk factors: heavy blood loss during or after delivery with hypotension &/or need for large volume blood transfusion
  • can occasionally occur after normal delivery
  • loss of anterior pituitary hormones (GH, prolactin, FSH, LH, TSH, ACTH)
  • inability to lactate, amenorrhea
  • loss of sexual hair, anorexia, weight loss, lethargy
  • hyponatremia
317
Q

Inhibin

A

-made by the granulosa cells of ovarian follicles and causes feedback inhibition of pituitary FSH release

318
Q

Amniotic fluid embolism syndrome

A
  • typically presents w/ rapid onset of respiratory failure, severe hypotension, and DIC during labor or the immediate postpartum period
  • the diagnosis is made clinically, and management is supportive
  • it is rare, unpredictable, and associated w/ poor maternal and fetal outcomes
  • risk factors: advanced maternal age, gravida >5 (live births or stillbirths), cesarean or instrumental delivery, placenta previa or abruption, preeclampsia
  • presentation: cardiogenic shock, hypoxemic respiratry failure, DIC, coma or seizures
319
Q

Variable decelerations

A
  • usually suggest umbilical cord compression
  • intermittent or recurrent
  • intermittent: require no specific interventions
  • recurrent: require maternal intrauterine resuscitative measures
  • most cases can be managed w/ oxygen administration and change in maternal position
320
Q

evaluation of a patient w/ primary amenorrhea

A
  • FSH measurement should be ordered if there is no breast development
  • pituitary MRI is the next step if FSH is decreased
  • Karyotyping is the next step if FSH is increased
321
Q

contraction stress test (oxytocin challenge test)

A
  • mother is given IV oxytocin sufficient to result in 3 contractions every 10 minutes, and the effect these contractions have on fetal heart activity is recorded
  • if a late deceleration is noted at each contraction, the test is positive and delivery is usually recommended
322
Q

If fetal movement decreases or becomes imperceptible by the mother, a nonstress test (NST) should be carried out to document fetal well being.

A

.

323
Q

Nonstress test

A
  • reactive (normal) if in 20 minutes there are at least 2 accelerations of the fetal heart rate of at least 15 beats/min above the baseline and lasting at least 15 seconds each
  • if < 2 accelerations are noted in 20 minutes, the test is considered nonreactive (abnormal) and further assessment is required
324
Q

late-term and postterm pregnancy complications

A
  • FETAL: oligohydramnios, meconium aspiration, stillbirth, macrosomia, convulsions
  • MATERNAL: cesarean delivery, infection, postpartum hemorrhage, perineal trauma
325
Q

Oligohydramnios

A
  • single deepest vertical pocket of amniotic fluid < 5 cm on transabdominal US
  • common complication of prolonged pregnancies
326
Q

normal birth weight

A

-between 5.5-9.9 lbs

327
Q

Polyhydramnios

A
  • deepest vertical pocket > 8 cm or an amniotic fluid index of > 24 cm
  • associated w/ congenital fetal malformations or maternal diabetes
328
Q

Risk factors for preeclampsia

A

-extremes of maternal age ( 40), nulliparity, chronic hypertension, hx of preeclampsia, diabetes mellitus, and renal disease

329
Q

Oligohydramnios is a common complication of late term and postterm pregnancies. Pts w/ prolonged pregnancies should be evaluated for oligohydramnios and undergo delivery if the amniotic fluid is low on US.

A

.

330
Q

Anemia in pregnancy

A

-Hgb < 11 g/dL in the 1st and 3rd trimesters and < 10.5 g/dL in the second

331
Q

Hyperemesis gravidarum

A

-usually occurs EARLY in pregnancy (not in the 3rd trimester) and presents w/ significant vomiting leading to volume depletion and a hypochloremic metabolic alkalosis

332
Q

Preeclampsia

A
  • commonly presents after 20 weeks gestation w/ proteinuria or evidence of end organ damage
  • pts typically develop severe hypertension, headaches, nausea/vomiting, and vision problems (ie blurry vision)
  • lab studies usually show thrombocytopenia, elevated liver enzymes, microangiopathic hemolytic anemia, and elevated creatinine > 1.1 mg/dL
333
Q

The elevated progesterone during pregnancy stimulates the respiratory centers in the brain to cause increased tidal volume, increased minute ventilation, increased PaO2, and a physiological chronic compensated respiratory alkalosis.

A

.

334
Q

Labor should be allowed to proceed in patients where the fetus has been diagnosed w/ a severe congenital anomaly incompatible w/ life

A

.

335
Q

The early follicular phase immediately follows menstruation. The cervical mucus in this phase is thick, scant and acidic. It does not allow penetration by spermatozoa.

A

.

336
Q

In the mid and late luteal phase, ovulation has already occurred. In these phases, the cervical mucus becomes progressively thicker and exhibits less stretching ability. This mucus is inhospitable to sperm.

A

.

337
Q

In the ovulatory phase of the menstrual cycle, cervical mucus is profuse, clear and thin. It will stretch to approximately 6 cm and exhibit ferning on a microscope slide smear prep

A

.

338
Q

The first-line agents for management of essential hypertension in pregnancy

A
  • LABETALOL and METHYLDOPA
  • calcium channel blockers and hydralazine are acceptable alternate therapies
  • ACE-inhibitors and angiotensin receptor blockers are contraindicated in pregnancy!
339
Q

Treatment for lactational mastitis

A
  • breastfeeding women are at risk if missed nursing sessions leading to inadequate milk drainage
  • tx consists of analgesics, frequent BREASTFEEDING (not pumping), and antibiotics directed at Staphylococcal aureus
340
Q

Primary vaginal cancer

A
  • bloody, malodorous discharge, and an irregular vaginal lesion
  • risk factors for squamous cell carcinoma of the vagina are similar to cervical cancer (ie smoking, HPV infection)
  • diagnosis is by biopsy and tx is determined after staging
341
Q

Primary ovarian failure

A
  • defined as primary hypogonadism in a woman under age 40
  • causes: chemotherapy, radiation, autoimmune ovarian failure, Turner’s syndrome, and fragile X syndrome
  • decreased estrogen levels, and increased FSH and LH levels. Developing follicles are the main source of estrogen, and since impaired follicular development is the cause, there is depressed estrogen levels. This results in loss of feedback inhibition of estrogen on FSH and LH, causing both to become elevated. The elevated of FSH is generally greater than that of LH due to slower clearance of FSH from the circulation
  • FSH elevation in the setting of > 3 months of amenorrhea in a woman under age 40 confirms the diagnosis
  • all pts w/ secondary amenorrhea should receive a pregnancy test, prolactin level, and FSH level
342
Q

Obesity is a common cause of amenorrhea. The amenorrhea is the result of anovulation. The FSH and LH levels are usually normal! The ovaries are still producing estrogen, but progesterone is not being produced at the normal post ovulation levels.

A

.

343
Q

What is umbilical artery flow velocimetry used for?

A
  • only beneficial in monitoring growth-restricted fetuses (< 10th percentile)
  • normal test would show high velocity diastolic flow in umbilical artery
344
Q

Clomiphene citrate

A

-estrogen analog that can be used to induce ovulation in anovulatory women who have some ovulatory reserve, such as pts w/ PCOS

345
Q

Findings suggesting malignancy of breast

A
  • UNILATERAL discharge
  • SEROUS or BLOODY (gross or occult) rather than milky discharge
  • Palpable breast abnormalities
  • skin changes (eg Paget disease of the breast)
  • These pts require mammography and possible US
346
Q

Leiomyomas are estrogen dependent!! This is why the grow during pregnancy and regress after menopause.

A

.

347
Q

Dysfunctional uterine bleeding is any abnormal bleeding not associated with tumor, inflammation, or pregnancy.

A

.

348
Q

Transvaginal US is the gold standard for evaluating the cervix for cervical incompetence in pregnancy. A cervical length below the 10th percentile for gestational age is considered a short cervix. This includes cervices less than 25mm at gestational age 23-28 weeks.

A

.

349
Q

Adenomyosis

A
  • occurs most frequently in parous women age > 40 and typically presents w/ dysmenorrhea, menorrhagia, and pelvic pain.
  • on physical exam, the uterus is symmetrically enlarged, globular, and boggy but is usually < 12 weeks size
  • confirmation of the diagnosis requires surgical pathology
350
Q

Chancroid (ulcers w/ a deep, purulent base and PAINFUL lymphadenopathy) and genital herpes are PAINFUL.
Syphilis and Granuloma inguinale (Donovanosis; red, beefy base with NO associated lymphadenopathy) are PAINLESS ulcers. Unlike primary syphilis, the ulcer of granuloma inguinale does NOT resolve w/o antibiotic treatment.

A

.

351
Q

Dysgerminomas

A
  • arise in younger women or in children, w/ an average incidence at the age of 20.
  • they are usually UNILATERAL and occasionally undergo TORSION
  • the tumor is NEUTRAL and does not secrete either male or female sex hormones
352
Q

Sertoli-Leydig cell tumors

A
  • produce ANDROGENS and cause defeminization followed by masculinization
  • women in the childbearing age may complain of an altered body contour, flattening of the breasts, and scanty, irregular menstruation, ultimately ending in amenorrhea
  • pts may develop hirsutism, coarsening of features, and enlargement of the clitoris
353
Q

Mature teratomas

A
  • aka dermoid cysts

- often benign and do not produce either estrogens or androgens

354
Q

Serous cystadenomas

A
  • most common cystic ovarian neoplasm, accounting for about 30% of all ovarian tumors
  • about 25% of these are malignant, and about half of cases are BILATERAL
  • they usually do NOT produce estrogen or androgen
  • ovarian mass and abdominal pain are the presenting features
355
Q

Granulosa cell tumors

A
  • produce excessive amounts of estrogen, and can present with precocious puberty in younger children and postmenopausal bleeding in elderly patients
  • this has to be differentiated from heterosexual precocious puberty or virilizing symptoms which are usually produced by excessive androgens
356
Q

What are the indications to giving antibiotics for group B strep during labor if it is unknown what the mother’s group B status is?

A

antibiotics should be given if:

  • labor starting at less than 37 weeks (preterm labor)
  • prolonged membrane rupture (water breaking 18 or more hours before delivery)
  • fever during labor

USMLE Step 2 (7 decks)

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