Ob Gyn Flashcards
when do you get a Quantitative Beta hCG?
- diagnose and follow ectopic pregnancy
- to monitor trophoblastic disease
- to screen for fetal aneuploidy
When is the gestational sack visible by ultrasound?
Five weeks gestational age
What defines an embryo?
0 to 8 weeks
What defines a fetus?
8 weeks to delivery
What as an infant?
Delivery to one year
What is the term pregnancy?
37 weeks or later
What is a preterm pregnancy
20 to 36 weeks
What renal change occurs during pregnancy
Increased GFR ~50%, increased renal flow
How does blood pressure change during pregnancy
Decreases 10% by 34 weeks then normalizes
How does heart rate change during pregnancy
Gradually increases twenty percent
How does cardiac output change during pregnancy
Increases
How’s peripheral vascular resistance changing pregnancy
Decreases
How does peripheral venous distention change during pregnancy?
Progressively increasing
What is the effect of an increase title volume during pregnancy?
Create an increased CO2 gradient for the fetus for gas exchange
How does fibrinogen change during pregnancy?
Increases
What is the recommended folic acid supplementation during pregnancy
0.4 mg a day 4 mg a day if h/o neural tube defects in prior pregnancies
Rh negative when do you give Rhogam?
Week 28 and postpartum if the fetus is Rh positive
What drug: fetal renal tubular dysplasia and neonatal renal failure, oligohydramnios, IU GR, lack of cranial ossification
ACEis
What drugs: growth restriction before and after birth, mental retardation, mid facial hypoplasia, renal and cardiac defects
alcohol
What drug: virilization of female, advanced genital development in males
Androgens
What drugs: note to defects, fingernail hypoplasia, microcephaly, developmental delay, IUGR
Carbamazepine
What drugs: bowel atresia, congenital malformations of the heart, face and GU tract, microcephaly, IUGR, cerebral instructions
Cocaine
What drugs: clear cell adenocarcinoma of the vagina or cervix, vaginal adenosis, Amber melodies of the cervix and uterus or testes possible infertility
DES
What drug: increase spontaneous abortion rate, stillbirths
Lead
What drug: congenital heart disease
Lithium
What drugs: increased spontaneous abortion rate
Methotrexate
What drugs: cerebral atrophy, microcephaly, mental retardation, spasticity, Seizures, or blindness
Organic Mercury
What drugs: IUGR, mental retardation, microcephaly, dysmorphic craniofacial features, cardiac defects, fingernail hyperplasia
Phenytoin
What drugs: microcephaly, mental retardation
Radiation
What drug: hearing loss cranial nerve eight damage
streptomycin and kanamycin
What drug: permanent teeth discoloration, hypoplasia of tooth enamel
Tetracycline
What drug: neural tube defects, minor craniofacial defects
valproic acid
What drugs: increased SAB rate, thymic agenesis, cardiovascular defects, craniofacial dysmorphism, micropthalmia, cleft lip or palate, mental retardation
Vitamin A
Nasal hypoplasia and stippled bone epiphyses, developmental delay, IUGR, ophthalmologic abnormalities
Warfarin
Mgmt of fetus with anomaly incompatible with life
allow labor to procede
First stage arrest definition
no cervical change for >4 hours with adequate contractions or no cervical change for >6 hours with INadequate contractions
When screen for GDM?
first visit in pts with a history of diabetes, otherwise 24-28 weeks with OGTT
when check AFP?
15-20 weeks
when check for GBS?
35-37 weeks
when hear fetal heart tones
10 to 12 wks on US
when order US to evaluate fetus?
- size date discrepancy >2-3cm
- suspect fetal death or demise
- RF for pregnancy related problems ex. SLE, DM, HTN, renal disease
should ASA be avoided in pregnancy?
yes, unless pts have Anti phospholipid syndrome
what are rare disorders associated with prolonged gestation?
anencephaly and placental sulfatase deficiency
what can a low AFP indicate?
Down syndrome, fetal demise, inaccurate dates
what can a high AFP represent?
neural tube defects, ventral wall defects, multiple gestation or inaccurate dates
what do if AFP elevated?
repeat it if remains elevated–> US to look for anatomical abnormality
US uncertain–> amnio
rec for Downs syndrome screening
offer to all women prior to 20 weeks
best test when suspect intrauterine fetal demise
real-time ultrasound
what is the best diagnostic test for endometriosis?
laparoscopy
how confirm a true PCN allergy
skin testing
MCC elevated AFP
neural tube defects and abdominal wall defects , also multiple gestations
first line testing for thalassemia
CBC
pt with positive pregnancy test, but no evidence of ectopic pregnancy on imaging, next step?
repeat B hCG in 48 hours
what meds can be used as emergency contraception ootions
ulipristal pill (antiprogestin) delays ovulation
levonorgenstrel pill (progestin, delays ovulation)
OCPs “”
**not mifepristone and misoprostol
MCC of a nonreactive non stress test?
fetal sleep cycleuse vibroacoustic stimluation to awaken fetus
patient with dyspareunia, dysmenorrhea and dyschezia: dx and tx
EndometriosisOCPs + NSAIDS
if no improvement the laparoscopy
tx for chlamydia if asymptomatic
single dose azithro or 7 day course of doxy
what is the association between hypothyroidism and hyperprolactinemia?
TRH stimulates prolactin production
34 yo trying to get pregnant, 3 months of amenorrhea, next step?
IVF!
mgmt of threatened abortion
- ascertain fetus is present and alive
2. reassurance and performance of US one week later-bed rest
Downs Syndrome testing for woman at 10 wks gestation?
cell free fetal DNA
mgmt of a pregnant woman with severe nausea and vomiting
US to rule out trophoblastic dz or multifetal gestation
Tamoxifen increases risk of what?
endometrial cancer
tx preeclampsia
hydral or labetalol to decrease BP
mag sulfate to prevent or tx eclamptic seizures
suppression of lactation
tight fitting bra and ice packs and analgesics
depressed DTRs indicate what? mgmt?
Mag sulfate toxstop mag sulfate and start Ca gluconate
1 RF for clear cell adenocarcinoma?
in utero exposure to DES
sudden vaginal bleeding an a hypertonic, tender uterus: dx? mgmt?
placental abruptionemergency C section
Dx: painless hemorrhage coinciding with rapid fetal deterioration and preceded by ROM
torn fetal vessel
vasa previa
see tachycardia followed by bradycardia and a sinusoidal pattern
dx: antenatal and trasvag doppler US
MCC heavy or prolonged menses in a young woman who recently started menstruating
anovulation
decreased aFP, bHCG, estriol and normal inhibin A
trisomy 18
increased AFP, nml bHCG, estriol adn inhibin A
neural tube or abdominal wall defect
mgmt of septic abortion
suction curreage
most accurate way to determine estimated gestational age?
US dating in the FIRST TRIMESTER
patients with complete androgen insensitivity with cryptorchid gonads: when intervene?
gonadectomy after puberty
mucopurulent discharge and erythematous, friable cervix: ddx
Cervicitis, either chlamydia or gonorrhea
cause of schistocytes and platelet consumption seen in HELLP
MAHA
overall cause of HELLP is abnormal placentation, but the specific cause of plt/RBC damage is due to systemic inflammation and platelet consumption
Does a woman with HELLP have to have a C section?
NO!She needs to DELIVER
vaginal delivery is preferred in women in labor or with ROM and a vertex presentation, can induce!
which pregnant women should be vaccinated against the flu?
ALL of them
what is alloimmunity?
immune response to antigens from members of the same species
patient with orthostatic changes and cervical motion tenderness, dx?
ectopic pregnancy
what are common tocolytic drugs?
beta agonists
CCBs
NSAIDs
Bilateral breast discharge, brown, serous or milky or unilateral: next step in mgmt?
mammo +/- US surgical eval
bilateral breast discharge that is not milky, serous or bloody: next step in mgmt
likely physiologic
- pregnancy test
- serum TSH and prolactin
- consider pituitary MRI
fetal heart rate monitoring mneumonic?
VEAL CHOP
Variables: cord compression. (V and C)
Early decelerations: head compression. This is generally a benign event. (E and H)
Accelerations : oxygenation – which explains why they’re generally a good prognostic factor. (A and O)
Late accelerations : placental insufficiency. (L and P)
hemodynamically stable pt with an incomplete abortion: mgmt?
expectant, prostaglandins or surgical eval
what abx for mastitis
diclox or cephalexin
risk factors for vaginal squamous cell cancer
smoking
HPV
MC symptoms of vaginal cancer?
vaginal bleeding
malodorous vaginal discharge
what 3 criteria do you need for PID?
One: abdominal pain
two: adnexal tenderness three: cervical motion tenderness
tx chlamydia pt for gonorrhea?
No…
tx gonorrhea pt for chlamydia
yes! unless testing is negative
tx for chlamydia in pregnant pt
erythromycin
What is the first test to order any women of reproductive age without uterine bleeding?
Pregnancy test
Why is dilation and curettage done in women older than age 35 with dysfunctional uterine bleeding?
To rule out endometrial cancer also get H&H
Fertility evaluation after semen evaluation
Documentation of ovulation: basal bike temperature, luteal phase progesterone, and or a endometrial biopsy
What is the medical therapy to restore female fertility?
Clomiphene citrate to induce ovulation if the woman is hypo estrogenic, use human menopausal gonadotropin which is a combination LH and FSH
At what age can primary amenorrhea be diagnosed? What is the first step in diagnosis?
The diagnosis of primary amenorrhea is made when a girl has not menstruated by the age 16 years. patient should also be evaluated in the absence of secondary sexual characteristics by age 14 years, or in the absence menstruation within two years of developing secondary sex characteristics such as breast development, axillary and pubic hair. The first step is to rule out pregnancy
What is the average age of menopause
51
Bilateral, multiple, cystic breast lesion are tender to the touch especially around ovulation
fibrocystic disease
step 2 mgmt of woman >35 with a breast mass
Bx and mammo
what are the major problems with IUDs?
increase risk of PID esp with actinomyces and ectopic pregnancies
classic cause of ambiguous genitalia?
adrenogenital syndrome aka CAH
tx: steroids and IV fluids immediately
do you know the gender of a child with ambiguous genitalia?
NO, need to karyotype
bunch of grapes protruding from pediatric vagina?
sarcoma botryoides, malignant tumor, type of embryonal rhabdomyosarcoma
benefits of estrogen tx?
decreased osteoporosis and fractures
reduced hot flashes
decreased risk of colorectal cancer
risks of estrogen tx
Endometrial cancer Coronary heart dz VTE breast cancer if estrogen and progesterone stroke gallbaldder dz
absolute contraindications to estrogen therapy
unexplained vaginal bleeding active liver dzhistory of thromboembolism CAD history of endometrial or breast cancer pregnancy
what do before starting estrogen therapy
endometrial bx
US or D+C to rule out endometrial hyperplasia or cancer
when stop OCPs in relation to surgery
1 month prior
start 1 month after
what drugs can interfere with OCP metabolism and make them less effective
rifampin and antiepileptics
OCPs relation to ovarian and endometrial cancer?
decrease incidence of ovarian cancer by 50%, reduce endometrial cancer
when give RhoGAM for Rh - women
28-30 weeks after antibody screen
why do D+E for intrauterine fetal demise
to prevent DIC at gestational age > 16 weeks
normal non-stress test
external HR monitoring for 20-40 minutes
15 x 15 (bpm x seconds) is normal
treatment for incompetent cervix prior to 24 weeks
betamethasone and strict bed rest
stage 1 of labor
onset to complete cervical dilation (10cm)
stage 2 of labor
dilation to delivery
Amniotic fluid index #s for oligo and poly hydramnios
oligo 20
MCC oligohydramnios
ROM
oligohydramnios and meconium in amniotic fluid
amnioinfusion
mgmt intrauterine fetal demis
delivery within 3 weeks and f/u autopsy to search for a cause
GDM pathophys
increased human placental lactogen, estrogen, progesterone that causes insulin antagonism
what if GBS is seen on urine cx on woman dx with UTI during pregnancy?
give PCN during labor
tx for CMV during pregnancy
postpartum GCV
how ddx lupus flare vs. pre-E
complement decreased in lupus
what counts as the postpartum period
6 weeks after delivery
contraindications to breast feeding
HIV and active HBV infection
OCPs during breastfeeding?
progestin only
risk of tamoxifen
endometrial cancer
definition of first stage arrest
no cervical change in 4 hrs despite adequate contractions or 6 hours with inadequate contractions
definition of first stage arrest
no cervical change in 4 hrs despite adequate contractions or 6 hours with inadequate contractions
cause of uterine abnormalities
problems in fusion of paramesonephric ducts
tx chancroid
azithro or ctx
painful chancre + inguinal LAD
chancroid
tx toxic shock
nafcillin IV
tx toxic shock
nafcillin IV
FSH over what level indicates ovarian failure
40
when can you do a medical abortion?
1 risk factor for vaginal squamous neoplasia
multiple sexual partners
persistent abnormal pap but normal cervical bx, dx?
vulvar intra epithelial neoplasia
colpo directed bx–> local excision, laser ablation or topical 5-FU
pap results, what is mgmt if anything other than ASC-US?
colpo + cervical bx
pap results: ASC-US, mgmt?
HPV DNA testing
if HPV negative, repeat pap in 1 year
if HPV positive, colpo + cervical bx
when do a cone bx
Microinvasion
CIN stages relate to what?
how far into epithelium
mgmt CIN I
repeat pap Q 6 months x 2 or HPV testing in 12 months
- 65% regress
- LEEP if persistent for 2 years
mgmt CIN II or III
LEEP
what is the #1 cancer killer of women in 3rd world countries
cervical SCC
tx cervical SCC
hysterectomy (stage 0, in situ)
up to chemo (cisplatin, internal and external radiation for stage IV)
how dx endometrial CA in a premenopausal woman?
endometrial bx
how dx endometrial CA in a postmenopausal woman?
U/S, endometrial stripe > 5mm –> bx
Tx for endometrial CA
TAHBSO
+/-
pelvic/paraaortic LN-ectomy
radiation (if high risk)
1 prognostic factor for endometrial cancer?
grade
type 2 endometrial cancer, what etiology?
clear cell
pap serous
1 RF for ovarian cancer
family history
protective factors for ovarian cancer
OCPs
multip
breastfeeding
chronic anovulation
**all decrease ovulation
mgmt of ovarian CA?
Dx pelvic U/S –> stage –> tx
tx for epithelial ovarian CA
surgery (TAHBSO, omentectomy, pelvic/paraaortic lymph node ectomy) +carboplatin/paclitaxel
tx for germ cell ovarian CA?
USO + BEP (bleomycin, etoposide, cisplatin)
tx for sex-cord stromal CA?
USO
what is Meigs syndrome?
2/2 ovarian cancer: fibroma, ascites and right sided hydrothroax
MC ovarian epithelial tumor
serous cystadenocarcinoma
psammoma bodies indicate what kind of cancer?
papillary
what kind of ovarian cancer: pt with appendiceal carcinoma “jelly belly”
mucinous cystadenocarcinoma
tumor with elevated LDH associated with Turner syndrome
dysgerminoma
elevated AFP and schiller-duval bodies, dx?
yolk sac tumor
schiller duval bodies look like glomeruli
choriocarcinoma has elevated what lab?
b-hcg
elevated AFP and bHCG: dx?
teratoma
Call-Exner bodies = what kind of tumor?
granulosa cell
how dx complete mole?
very elevated bhcg >100k
pelvic US showing snowstorm appearance
Tx: D+C and oxytocin
follow bHCG for a few months
1 RF for breast cancer
Family history
rapidly growing breast mass in a teenager: dx and tx
Dx: giant juvenile fibroadenoma
tx: removal to avoid breast deformity (not CA)
Phyllodes mgmt
core or incisional bx since FNA is insufficienct, tx: excision with negative margins
papilloma mgmt
galactogram/ductogram guided excision due to small risk of carcinoma
how dx. fibroadenoma
US or FNA
breast mass in 20yo that becomes very large
Phyllodes tumor
does have malignant potential to become a SARCOMA: cannot do FNA, need to do are core bx
does a history of trauma rule out breast cancer?
NO
how does breast cancer tx change during pregnancy?
no chemo during first trimester
no radioTHERAPY during pregnancy
treatment of a resectable breast tumor?
lumpectomy + axillary sampling + post-op radiation (only if small, in a large breast and away from nipple and areola)
OR
modified radical mastectomy with axillary sampling
inflammatory cancer mgmt?
needs pre-op chemotherapy
DCIS mgmt
doesn’t metastasize but has high incidence of local recurrance so need total simple mastectomy if lesions are scattered + SLNB or if clumped together lumpectomy + radiation
what meds do women get for ER/PR positive tumors if pre or post menopausal
pre: Tamoxifen
Post: anastrozole
how follow up abnormal cell free fetal DNA testing
fetal karyotyping via CVS in first trimester or
amnio in second trimester
initial workup of an adnexal mass in a POSTmenopausal woman
TVUS
CA-125 level (if high, suspicious for malignancy in a post menopausal woman)
what are US features suspicious for an adnexal malignancy on US
size > 10cm
nodular or fixed
ascites
evidence of metastasis
–> Gyn Onc
when recommend starting pap smears
age 21 REGARDLESS of sexual activity
how does amenorrhea occur in female athletes
caloric deficiency that leads to decreased LH and GnRH which causes an estrogen deficiency
tx of acute AUB
high dose estrogen, high dose OCPs, high dose progestin, tanexamic acid if prog/est both contraindicated
mgmt of 15 yo with primary amenorrhea who has no breast develop and a uterus?
serum FSH
if low –> MRI
if elevated –> karyotyping
tx of recurrent variable decels after oxygen, repositioning?
amnioinfusion: artificial ROM and infusion of saline into the amniotic cavity
pt with IUFD with any changes in coagulation
immediate delivery
hyperemesis gravidarum: what other test?
US to look for multigestation or molar pregnancy
what is the most reliable way to date fetus
crown rump length on first trimester US
best way to delay labor in PPROM?
antibiotics
PCN or amp
how does GDM effect fetus calcium
HYPOcalcemia due to increased insulin!
woman with h/o PID, next best test in workup of infertility?
hysterosalpingogram
what is normally seen in woman with pre-existing DM but not women with GDM
IUGR
best test to detect severe fetal anemia?
MCA peak systolic velocity
what does a negative fetal fibronectin test indicate?
if negative, mom is unlikely to deliver in the next 14 days
signs newborn is well hydrated
Signs that a baby is getting sufficient milk include 3-4 stools in 24 hours, six wet diapers in 24 hours, weight gain and sounds of swallowing.
what is the most effective birth control method after abstinence?
depo provera
prolonged rupture of membranes
> 18hrs before onset of labor
ddx IUGR vs. decreased growth potential
decreased growth potential: stays small
IUGR: falls off growth curve
weight cut off where C section is indicated?
4500 g
what should you consider if a woman has pre-eclampsia before the 3rd trimester?
trophoblastic dz
mgmt and treatment of Chorioamnionitis
- Mgmt: Dx amnioscentesis and cx amniotic fluid
* Tx: broad spectrum Abx (amp, gent, clinda) and delivery (can be vaginal!)
are pre-E and eclampsia RFs for future HTN?
no
major causes of pregnancy associated mortality associated with childbirth?
PE
pregnancy induced HTN
hemorrhage
causes of oligohydramnios
IUGR, PROM, postmaturity, renal agenesis
causes of polyhydramnios
maternal diabetes, multiple gestation, neural tube defects, GI anomalies, hydrops fetalis
foul smelling lochia indicates what? tx?
endometritis
clinda and gent since polymicrobial
who gets progesterone supplementation during pregnancy?
women 16-36 weeks with a singleton pregnancy and a history of preterm birth
progesterone can reduce the risk of preterm birth in patients with a short cervical length on vaginal US at
what do you give to patients in preterm labor?
tocolytics
corticosteroids for fetal lung maturity
MgSO4 for neuro protection
abnormal non stress text, next step?
BPP
GDM target insulin levels
fasting
DX premature ovarian failure
FSH in menopausal range for 3 months–> IVF
also have decreased estrogen
how dx incompetent cervix?
TVUS
mgmt of patient with prolonged PROM?
broad spectrum Abx (Amp, Gent, Clinda) and delivery: oxytocin if in labor, C section only if there is an obstetric indication
can also give mom anitpyretics which can help fetal tachycardia
mom with quad screen showing increased risk of Downs Syndrome, next step?
US during 18-20 weeks
placenta previa mgmt:
fluid resuscitate if bleeding
> 37 weeks –> scheduled C section
close monitoring of hct, expectant mgmt, amnio at 36 weeks to eval fetal lung maturity
how do GFR and BUN change during pregnancy
decrease! 2/2 increase in renal plasma flow and GFR
treatment for a threatened abortion
reassurance and outpatient follow up
