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Ob-Gyn 4 Flashcards

1
Q

Define shoulder dystocia.

A

Failure of usual obstetric maneuvers to deliver fetal shoulders

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2
Q

List 5 risk factors for shoulder dystocia.

A
  1. Fetal macrosomia
  2. Maternal obesity
  3. Excessive pregnancy weight gain
  4. Gestational diabetes
  5. Post-term pregnancy
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3
Q

List 2 warning signs for shoulder dystocia.

A
  1. Protracted labor

2. Retraction of fetal head into the perineum after delivery (turtle sign)

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4
Q

Why is shoulder dystocia an obstetric emergency?

A

Risk for neonatal brachial plexus injury, clavicular and humeral fracture, and, if prolonged, hypoxic brain injury and death

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5
Q

What is the major risk factor for shoulder dystocia?

A

Fetal macrosomia (estimated fetal weight >4.5 kg (9.9 lb))

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6
Q

True or false - shoulder dystocia also frequently occurs in patients with no risk factors and can be difficult to predict.

A

True

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7
Q

Hypertension and a short interpregnancy interval (eg, <18 months) are risk factors for ___.

A

Fetal growth restriction

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8
Q

What is the main risk factor for septic abortion?

A

Retained products of conception from:

  • Elective abortion with nonsterile technique
  • Missed or incomplete abortion (rare)
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9
Q

What are the signs and symptoms of septic abortion?

A

Fever, chills, abdominal pain; sanguinopurulent vaginal discharge, boggy and tender uterus, dilated cervix

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10
Q

How does septic abortion present on pelvic US?

A

Retained POC, thick endometrial stripe

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11
Q

How is septic abortion managed?

A
  1. IV fluids
  2. Broad-spectrum antibiotics
  3. Suction curettage
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12
Q

When is a hysterectomy indicated in the setting of septic abortion?

A

Pelvic abscess or if the patient does not improve after suction curettage and 48 hours of broad-spectrum antibiotics

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13
Q

List 4 risk factors for IUFD.

A

Nulliparity, obesity, HTN, DM

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14
Q

What confirms diagnosis of IUFD?

A

Absence of fetal cardiac activity on U/S

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15
Q

A Kleihauer-Betke test can confirm or exclude ___.

A

Fetomaternal hemorrhage

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16
Q

How is IUFD evaluated (fetal)?

A
  1. Autopsy
  2. Gross and microscopic examination of placenta, membranes, and cord
  3. Karyotype/genetic studies
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17
Q

How is IUFD evaluated (maternal)?

A
  1. Kleihauer-Betke test for fetomaternal hemorrhage
  2. Antiphospholipid antibodies
  3. Coagulation studies (for history of recurrent pregnancy loss, family or personal history of venous thrombosis, fetal growth restriction
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18
Q

For patients with unexplained IUFD, what is the recurrence risk?

A

<1%

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19
Q

How does physiologic galactorrhea present?

A

Bilateral, gray (or milky, clear, yellow, brown, or green), nonbloody nipple discharge without signs of malignancy (breast mass, lymphadenopathy, nipple changes, unilateral discharge)

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20
Q

What is the most common cause of galactorrhea?

A

Hyperprolactinemia

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21
Q

What can cause hyperprolactinemia?

A

Pituitary prolactinoma, medications, hypothyroidism, pregnancy, or chest wall/nipple stimulation (eg surgery, trauma, shingles)

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22
Q

What medications can cause galactorrhea?

A

Antipsychotics, antidepressants, opioids (dopamine inhibitors)

Estrogen-containing contraceptives (stimulating pituitary lactotrophs)

Chronic use of histamine receptor blockers (eg, cimetidine) can inhibit estradiol metabolism and increase Prl levels

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23
Q

How should galactorrhea be evaluated?

A

Pregnancy test, serum Prl, TSH, possible MRI of the brain

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24
Q

What is the pathogenesis of endometriosis? What causes the pain in endometriosis? What is theorized to cause infertility?

A

Ectopic implantation of endometrial glands; pain is caused by the accumulation of cyclically shed blood from ectopic endometrial tissue; pelvic adhesions interfere with oocyte release and/or block sperm entry

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25
What are the clinical features of endometriosis?
1. Dyspareunia 2. Dysmenorrhea (and sometimes back pain) 3. Chronic pelvic pain 4. Infertility 5. Dyschezia
26
What are the physical exam findings of endometriosis?
1. Fixed, immobile uterus that can be tilted laterally due to adhesion formation 2. Cervical motion tenderness 3. Adnexal mass 4. Recto-vaginal septum, posterior cul-de-sac, uterosacral ligament nodules
27
How is endometriosis diagnosed?
Direct visualization and surgical biopsy
28
How is endometriosis treated?
1. Medical (OCs, NSAIDs) | 2. Surgical resection
29
True or false - unicornuate uterus does not affect conception.
True - it may cause miscarriage, preterm labor, or fetal growth restriction, but does not affect conception.
30
What are risk factors for pseudocyesis?
History of infertility and prior pregnancy loss
31
What is the pathogenesis of pseudocyesis?
Likely occurs when the somatization of stress affects the hypothalamic-pituitary-ovarian axis and causes early pregnancy symptoms, or when bodily changes are misinterpreted.
32
When and why do adolescents often have anovulatory cycles with heavy, irregular menstrual bleeding?
During the first year after menarche; due to an immature hypothalamic-pituitary axis
33
Why does progesterone treatment help with anovulatory cycles?
Progesterone treatment helps stabilize this uncontrolled proliferation due to estrogen by causing differentiation into secretory endometrium. Cyclic progesterone withdrawal then causes menstruation
34
List 3 fetal risk factors for fetal macroscomia.
1. African-American or Hispanic ethnicity 2. Male sex 3. Post-term pregnancy
35
What is the most common type of brachial plexus injury due to application of excessive traction secondary to shoulder dystocia?
Erb-Duchenne palsy, which involves the 5th, 6th, and sometimes 7th cervical nerves
36
Discuss the appearance of Erb-Duchenne palsy and what nerves lead to what findings.
Weakness of the deltoid and infraspinatus (C5), biceps (C6), and wrist/finger extensors (C7) leads to predominance of the opposing muscles and the characteristic "waiter's tip" posture
37
How is Erb-Duchenne palsy treated in an infant?
Gentle massage and PT to prevent contractures
38
Up to ___% of patients with Erb-Duchenne palsy upon delivery have spontaneous recovery within 3 months.
80
39
Cephalohematoma (subperiosteal scalp swelling) can occur in any delivery, but is more common in the setting of ___. It usually resolves spontaneously without sequelae.
Instrumental delivery
40
Why is prophylactic cesarean delivery not routinely recommended for suspected fetal macrosomia?
Because the rate of shoulder dystocia and associated complications is not significantly different in cesarean versus vaginal deliveries
41
How is preterm labor managed at <32 weeks gestation?
1. Betamethasone 2. Tocolytics 3. Magnesium sulfate 4. Penicillin if GBS+ or unknown
42
How is preterm labor managed from 32 0/7 to 33 6/7 weeks?
1. Betamethasone 2. Tocolytics 3. Penicillin if GBS+ or unknown
43
How is preterm labor managed from 34 0/7 to 36 6/7 weeks?
1. +/- Bethamethasone | 2. Penicillin if GBS positive or unknown
44
List 3 risk factors for preterm labor.
1. Multiple gestation 2. History of preterm delivery 3. History of cervical surgery (eg, conization)
45
What is the role of corticosteroids in preterm labor?
Decrease the risk of neonatal respiratory distress syndrome
46
What is the role of magnesium sulfate in preterm labor?
Fetal neuroprotection
47
What is the first-line tocolytic of choice?
Indomethacin (nifedipine is another first-line)
48
What is a common presentation of a dermoid ovarian cyst (mature cystic teratoma)?
Adnexal fullness on routine physical examination in an otherwise asymptomatic patient; some patients may experience pelvic pain or pressure
49
What are the U/S findings of a dermoid ovarian cyst?
Hyperechoic nodules and calcifications (typical and diagnostic)
50
How is a dermoid ovarian cyst treated?
Surgical removal of the cyst
51
Follicular cysts are small physiologic cysts that occur in the ___ half of the menstrual cycle and are typically asymptomatic.
First
52
How do follicular ovarian cysts appear on U/S?
Simple small, thin-walled cyst
53
What is an ovarian endometrioma?
An encapsulated collection of old blood from ectopic endometrial implants on the ovary
54
How does an ovarian endometrioma appear on U/S?
Homogenous cystic mass
55
How does PCOS appear on U/S?
Ovaries ringed with multiple simple cysts
56
What causes the formation of theca lutein cysts?
Ovarian stimulation by high beta-hcg level (eg, molar pregnancy)
57
How do theca lutein cysts appear on U/S?
Multiseptated bilateral cystic masses; no calcifications or hyperechoic nodules
58
True or false - theca lutein cysts do not appear outside of pregnancy.
True
59
How does a tubo-ovarian abscess appear on U/S?
Multiloculated cystic mass with distortion of normal adnexal structures
60
Pelvic pain in a patient with a known ovarian mass should be suspected as ___ until proven otherwise.
Ovarian torsion
61
What type of ovarian mass has a higher likelihood of torsion than other types of ovarian masses?
Dermoid cysts
62
What causes the symptoms of ovarian torsion?
Ischemia and necrosis
63
How is ovarian torsion treated?
Surgical detorsion, cystectomy, and possible removal of the adnexa if there is necrosis despite restoration of circulation
64
List findings suggestive of a breast abscess.
1. Signs of mastitis (localized erythema/pain, fever, malaise) 2. Fluctuant, tender, palpable mass
65
How is a breast abscess managed?
Needle aspiration (usually under U/S guidance) and antibiotics; continued breastfeeding is recommended for continued milk drainage
66
When is incision and drainage with packing recommended for breast abscesses?
Abscesses not responsive to needle aspiration and antibiotics, suspected necrotic material, and large (5+ cm) pus collections
67
List the 4 types of urinary incontinence.
1. Stress 2. Urgency 3. Mixed 4. Overflow
68
Compare the symptoms of the 4 types of urinary incontinence.
1. Stress - leakage with Valsalva/increased intra-abdominal pressure (coughing, sneezing, laughing) 2. Urgency - sudden, overwhelming, or frequent need to void 3. Mixed - features of stress and urgency incontinence 4. Overflow - constant dribbling and incomplete emptying
69
How is stress incontinence treated?
1. Lifestyle modifications 2. Pelvic floor exercises 3. Pessary 4. Pelvic floor surgery
70
How is urge incontinence treated?
1. Lifestyle modifications 2. Bladder training 3. Antimuscarinic drugs
71
How is overflow incontinence treated?
1. Identify + correct underlying cause 2. Cholinergic agonists 3. Intermittent self-catheterization
72
Stress urinary incontinence is associated with ___ with or without ___.
Urethral hypermobility; pelvic organ prolapse (cystocele)
73
What are risk factors for weakening of the pelvic floor muscles that lead to loss of bladder neck and bladder support?
Pregnancy, childbirth, obesity, menopause
74
What test can be done to diagnose urethral hypermobility?
Dorsal lithotomy position, insert cotton swab into the urethral orifice, an angle of 30+ degrees from the horizontal on increase in intra-abdominal pressure
75
___ should be advised in all patients with stress incontinence to improve pelvic floor strength.
Kegel exercises
76
What is the most beneficial long-term treatment for urinary stress incontinence?
Urethral sling surgery
77
Another form of stress urinary incontinence results from internal urethral sphincter deficiency, which is treated with ___. How do these work?
Injectable bulking agents; increase pressure at the bladder neck and reduce urine loss in patients with ISD
78
What is the first-line treatment for stress urinary incontinence due to urethral hypermobility? What provides the best long-term outcome?
First-line: pelvic muscle exercises Best long-term outcome: urethral sling surgery
79
How is secondary amenorrhea defined?
Absence of menses for 3+ cycles or 6+ months in women who menstruated previously.
80
What is the first step in evaluation of secondary amenorrhea?
Beta-hcg
81
If beta-hcg is negative, what is the next step in evaluating secondary amenorrhea?
1. Check Prl, TSH, FSH | 2. If prior uterine procedure or infection, do a hysteroscopy
82
What are the 3 most common causes of secondary amenorrhea?
Hyperprolactinemia, thyroid dysfunction, premature ovarian failure
83
List the 8 routine prenatal lab tests completed at the initial prenatal visit.
1. Rh (D) type, Ab screen 2. Hg/Hct, MCV 3. HIV, VDRL/RPR, HBsAg 4. Rubella and varicella immunity 5. Pap test (if screening indicated) 6. Chlamydia PCR 7. Urine culture 8. Urine protein
84
List the routine prenatal lab tests done at 24-28 weeks.
1. Hg/Hct 2. Ab screen if Rh (D) negative 3. 50-g 1-hour GCT
85
List the routine prenatal lab tests done at 35-37 weeks.
GBS culture
86
Why is the oral glucose challenge test performed at 24-28 weeks?
During the second and third trimesters of pregnancy, the placenta secretes hormones that increase maternal insulin resistance to promote fetal growth and metabolism.
87
Who should undergo screening for diabetes during their initial prenatal visit and how should this be done?
Women at risk for undiagnosed DM2 ; Hgb A1c or oral GCT)
88
What is the gold standard for diagnosis of proteinuria associated with preeclampsia?
24-hour urine protein collection
89
Women who are breastfeeding are at risk for ___ if there are missed nursing sessions leading to inadequate milk drainage.
Lactational mastitis
90
What is the most accurate way to determine estimated gestational age?
U/S dating with fetal crown-rump measurement in the first trimester
91
After 20 weeks, the fundal height measurement correlates with gestational age by +/- ____.
3 weeks
92
What can confound fundal heigh measurement?
Leiomyomata and obesity

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