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Step 2 > Ob-Gyn 4 > Flashcards

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
Q

What are the clinical features of endometriosis?

A
  1. Dyspareunia
  2. Dysmenorrhea (and sometimes back pain)
  3. Chronic pelvic pain
  4. Infertility
  5. Dyschezia
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26
Q

What are the physical exam findings of endometriosis?

A
  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
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27
Q

How is endometriosis diagnosed?

A

Direct visualization and surgical biopsy

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28
Q

How is endometriosis treated?

A
  1. Medical (OCs, NSAIDs)

2. Surgical resection

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29
Q

True or false - unicornuate uterus does not affect conception.

A

True - it may cause miscarriage, preterm labor, or fetal growth restriction, but does not affect conception.

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30
Q

What are risk factors for pseudocyesis?

A

History of infertility and prior pregnancy loss

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31
Q

What is the pathogenesis of pseudocyesis?

A

Likely occurs when the somatization of stress affects the hypothalamic-pituitary-ovarian axis and causes early pregnancy symptoms, or when bodily changes are misinterpreted.

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32
Q

When and why do adolescents often have anovulatory cycles with heavy, irregular menstrual bleeding?

A

During the first year after menarche; due to an immature hypothalamic-pituitary axis

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33
Q

Why does progesterone treatment help with anovulatory cycles?

A

Progesterone treatment helps stabilize this uncontrolled proliferation due to estrogen by causing differentiation into secretory endometrium. Cyclic progesterone withdrawal then causes menstruation

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34
Q

List 3 fetal risk factors for fetal macroscomia.

A
  1. African-American or Hispanic ethnicity
  2. Male sex
  3. Post-term pregnancy
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35
Q

What is the most common type of brachial plexus injury due to application of excessive traction secondary to shoulder dystocia?

A

Erb-Duchenne palsy, which involves the 5th, 6th, and sometimes 7th cervical nerves

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36
Q

Discuss the appearance of Erb-Duchenne palsy and what nerves lead to what findings.

A

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

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37
Q

How is Erb-Duchenne palsy treated in an infant?

A

Gentle massage and PT to prevent contractures

38
Q

Up to ___% of patients with Erb-Duchenne palsy upon delivery have spontaneous recovery within 3 months.

A

80

39
Q

Cephalohematoma (subperiosteal scalp swelling) can occur in any delivery, but is more common in the setting of ___. It usually resolves spontaneously without sequelae.

A

Instrumental delivery

40
Q

Why is prophylactic cesarean delivery not routinely recommended for suspected fetal macrosomia?

A

Because the rate of shoulder dystocia and associated complications is not significantly different in cesarean versus vaginal deliveries

41
Q

How is preterm labor managed at <32 weeks gestation?

A
  1. Betamethasone
  2. Tocolytics
  3. Magnesium sulfate
  4. Penicillin if GBS+ or unknown
42
Q

How is preterm labor managed from 32 0/7 to 33 6/7 weeks?

A
  1. Betamethasone
  2. Tocolytics
  3. Penicillin if GBS+ or unknown
43
Q

How is preterm labor managed from 34 0/7 to 36 6/7 weeks?

A
  1. +/- Bethamethasone

2. Penicillin if GBS positive or unknown

44
Q

List 3 risk factors for preterm labor.

A
  1. Multiple gestation
  2. History of preterm delivery
  3. History of cervical surgery (eg, conization)
45
Q

What is the role of corticosteroids in preterm labor?

A

Decrease the risk of neonatal respiratory distress syndrome

46
Q

What is the role of magnesium sulfate in preterm labor?

A

Fetal neuroprotection

47
Q

What is the first-line tocolytic of choice?

A

Indomethacin (nifedipine is another first-line)

48
Q

What is a common presentation of a dermoid ovarian cyst (mature cystic teratoma)?

A

Adnexal fullness on routine physical examination in an otherwise asymptomatic patient; some patients may experience pelvic pain or pressure

49
Q

What are the U/S findings of a dermoid ovarian cyst?

A

Hyperechoic nodules and calcifications (typical and diagnostic)

50
Q

How is a dermoid ovarian cyst treated?

A

Surgical removal of the cyst

51
Q

Follicular cysts are small physiologic cysts that occur in the ___ half of the menstrual cycle and are typically asymptomatic.

A

First

52
Q

How do follicular ovarian cysts appear on U/S?

A

Simple small, thin-walled cyst

53
Q

What is an ovarian endometrioma?

A

An encapsulated collection of old blood from ectopic endometrial implants on the ovary

54
Q

How does an ovarian endometrioma appear on U/S?

A

Homogenous cystic mass

55
Q

How does PCOS appear on U/S?

A

Ovaries ringed with multiple simple cysts

56
Q

What causes the formation of theca lutein cysts?

A

Ovarian stimulation by high beta-hcg level (eg, molar pregnancy)

57
Q

How do theca lutein cysts appear on U/S?

A

Multiseptated bilateral cystic masses; no calcifications or hyperechoic nodules

58
Q

True or false - theca lutein cysts do not appear outside of pregnancy.

A

True

59
Q

How does a tubo-ovarian abscess appear on U/S?

A

Multiloculated cystic mass with distortion of normal adnexal structures

60
Q

Pelvic pain in a patient with a known ovarian mass should be suspected as ___ until proven otherwise.

A

Ovarian torsion

61
Q

What type of ovarian mass has a higher likelihood of torsion than other types of ovarian masses?

A

Dermoid cysts

62
Q

What causes the symptoms of ovarian torsion?

A

Ischemia and necrosis

63
Q

How is ovarian torsion treated?

A

Surgical detorsion, cystectomy, and possible removal of the adnexa if there is necrosis despite restoration of circulation

64
Q

List findings suggestive of a breast abscess.

A
  1. Signs of mastitis (localized erythema/pain, fever, malaise)
  2. Fluctuant, tender, palpable mass
65
Q

How is a breast abscess managed?

A

Needle aspiration (usually under U/S guidance) and antibiotics; continued breastfeeding is recommended for continued milk drainage

66
Q

When is incision and drainage with packing recommended for breast abscesses?

A

Abscesses not responsive to needle aspiration and antibiotics, suspected necrotic material, and large (5+ cm) pus collections

67
Q

List the 4 types of urinary incontinence.

A
  1. Stress
  2. Urgency
  3. Mixed
  4. Overflow
68
Q

Compare the symptoms of the 4 types of urinary incontinence.

A
  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
Q

How is stress incontinence treated?

A
  1. Lifestyle modifications
  2. Pelvic floor exercises
  3. Pessary
  4. Pelvic floor surgery
70
Q

How is urge incontinence treated?

A
  1. Lifestyle modifications
  2. Bladder training
  3. Antimuscarinic drugs
71
Q

How is overflow incontinence treated?

A
  1. Identify + correct underlying cause
  2. Cholinergic agonists
  3. Intermittent self-catheterization
72
Q

Stress urinary incontinence is associated with ___ with or without ___.

A

Urethral hypermobility; pelvic organ prolapse (cystocele)

73
Q

What are risk factors for weakening of the pelvic floor muscles that lead to loss of bladder neck and bladder support?

A

Pregnancy, childbirth, obesity, menopause

74
Q

What test can be done to diagnose urethral hypermobility?

A

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
Q

___ should be advised in all patients with stress incontinence to improve pelvic floor strength.

A

Kegel exercises

76
Q

What is the most beneficial long-term treatment for urinary stress incontinence?

A

Urethral sling surgery

77
Q

Another form of stress urinary incontinence results from internal urethral sphincter deficiency, which is treated with ___. How do these work?

A

Injectable bulking agents; increase pressure at the bladder neck and reduce urine loss in patients with ISD

78
Q

What is the first-line treatment for stress urinary incontinence due to urethral hypermobility? What provides the best long-term outcome?

A

First-line: pelvic muscle exercises

Best long-term outcome: urethral sling surgery

79
Q

How is secondary amenorrhea defined?

A

Absence of menses for 3+ cycles or 6+ months in women who menstruated previously.

80
Q

What is the first step in evaluation of secondary amenorrhea?

A

Beta-hcg

81
Q

If beta-hcg is negative, what is the next step in evaluating secondary amenorrhea?

A
  1. Check Prl, TSH, FSH

2. If prior uterine procedure or infection, do a hysteroscopy

82
Q

What are the 3 most common causes of secondary amenorrhea?

A

Hyperprolactinemia, thyroid dysfunction, premature ovarian failure

83
Q

List the 8 routine prenatal lab tests completed at the initial prenatal visit.

A
  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
Q

List the routine prenatal lab tests done at 24-28 weeks.

A
  1. Hg/Hct
  2. Ab screen if Rh (D) negative
  3. 50-g 1-hour GCT
85
Q

List the routine prenatal lab tests done at 35-37 weeks.

A

GBS culture

86
Q

Why is the oral glucose challenge test performed at 24-28 weeks?

A

During the second and third trimesters of pregnancy, the placenta secretes hormones that increase maternal insulin resistance to promote fetal growth and metabolism.

87
Q

Who should undergo screening for diabetes during their initial prenatal visit and how should this be done?

A

Women at risk for undiagnosed DM2 ; Hgb A1c or oral GCT)

88
Q

What is the gold standard for diagnosis of proteinuria associated with preeclampsia?

A

24-hour urine protein collection

89
Q

Women who are breastfeeding are at risk for ___ if there are missed nursing sessions leading to inadequate milk drainage.

A

Lactational mastitis

90
Q

What is the most accurate way to determine estimated gestational age?

A

U/S dating with fetal crown-rump measurement in the first trimester

91
Q

After 20 weeks, the fundal height measurement correlates with gestational age by +/- ____.

A

3 weeks

92
Q

What can confound fundal heigh measurement?

A

Leiomyomata and obesity

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