OB/GYN Flashcards
What signs and tests could confirm the presence of rupture of membranes?
- Visualization of amniotic fluid leaking from the cervix
- Presence of pooling of amniotic fluid in the posterior vaginal fornix
- Demonstration of a pH above 6.5 in fluid collected from the vagina using Nitrazine paper
- Visualization of “ferning” on a sample fluid on an air-dried microscopic slide
What is the recommended treatment for Group B strep infection during pregnancy?
- IV penicillin (or ampicillin, cephalothin, erythromycin, clindamycin, vancomycin)
What are the 3 stages of labor?
1) Onset of labor until the cervix in completely dilated
2) From cervical dilation (10cm) to the delivery of the fetus
3) Delivery of the baby to the delivery of the placenta and membranes
What is the range for a baseline fetal heart rate?
- 110-160bpm
What agent is given when contractions are inadequate in frequency or power?
- Oxytocin
What is shoulder dystocia?
- Shoulder dystocia => anterior shoulder does not readily pass below the pubic symphysis and requires re-orienting the baby, the mother, or episiotomy
What are the maternal benefits of breastfeeding?
- more rapid return of uterine tone with reduced bleeding and quicker return to non-pregnant size
- more rapid return to prepregnancy body weight
- reduced incidence of ovarian and breast cancer
- lower cost ( no need to purchase formula)
What hormonal contraceptives can be used in breastfeeding women?
- Progestin only “minipill” is recommended as combined hormonal contraceptives can interfere with milk supply
What is endometritis?
- polymicrobial infection of the endometrium of the uterus, usually caused by ascending infection from the vagina
What is lochia?
- yellow-white discharge consisting of blood cells, decidual cells, and fibrinous products that occurs following delivery
When does menstruation return for NON breastfeeding women?
- menstruation usually restarts by the third post partum month
What are th 4 Ts of postpartum hemorrhage?
- Tone: uterine atony (most common)
- Trauma: cervical, vaginal, or perineal lacerations; uterine inversion
- Tissue: retained placenta or membranes
- Thrombin: coagulopathies
What is the initial management of uterine atony?
- IV administration of oxytocin and initiation of bimanual uterine massage
- Methylergonovine if above fails to control bleeding (contraindicated in HTN; can increase BP)
- If above fails/is contraindicated prostaglandin F2a (hemabate) IM or intramyometrially (do not give in asthma)
- If above fails/is contraindicated Misoprostol can be given rectally or orally
What is a sign of postpartum endometriosis?
- postpartum fever
- uterine tenderness
- foul smelling lochia
- more common in Cesarean deliveries
Apart from endometriosis what are the other causes of postpartum fever?
- atelectasis
- wound infection
- venous thromboembolic disease
What percentage of women experience maternity blues and postpartum depression?
- Maternity blues: 30-70% and up to 10 days
- Postpartum depression: 10-20% and within 4 weeks but up to 1 year.
What group of women will be unable to breastfeed?
- ACTIVE (not chronic) Hep B, C, HIV, and breast reduction with nipple transplantation
When can a breastfeeding woman begin oral contraceptives?
- 6 weeks post partum
- IM depo-provera/medroxyprogseterone, IUDs, and refitted diaphragms can also be started 6 weeks postpartum
When can non-breastfeeding women begin oral contraceptives?
- 3 weeks as the risk of thromboembolic disease is higher in those who start at earlier times
What is the contraception rate of women who breastfeed exclusively?
- 98% for 6 months as lactation induces amenorrhea
What type of contraception is contraindicated in women >35 who smoke?
- oral contraception
What are the various types f hormonal contraceptives?
- combination pill
- progestin pill
- norplant
- depo-provera
- transdermal
- intravaginal ring
What are various types of barrier contraceptives?
- spermicides
- condoms
- sponge
- diaphragm
- cervical cap
What are the various types if IUDs?
- Progesterone
- Copper T
What are various types of post-coital contraception?
- Plan B: Levonorgestrel
- Mifepristine: RU 486
What is the mechanism of action of the combination (progestin and estrogen) oral contraceptive?
- suppresses ovulation through inhibition of the hypothalamic-pituitary-ovarian axis
- thickens cervical mucous to inhibit sperm penetration
- discourages implantation into an unfavorable, thin endometrium
- alters motility of uterus and fallopian tubes
What conditions do oral contraceptives protect against?
- Ovarian cancer
- endometrial cancer
- iron deficiency anemia
- pelvic inflammatory disease
- fibrocystic breast disease
Who are barrier agents best suited for?
- individuals not desiring hormones
- Decrease STI
What are the disadvantages and contraindications for barrier contraceptive agents?
- pelvic organ prolapse
- patient discomfort with placing devices on genitals
- lack of spontaneity
- allergies to material
- diaphragm may be associated with more UTIs
What are the disadvantages and contraindications of combined hormonal contraceptives?
- thrombogenic mutations, prior thromboembolic event
- cerebrovascular or coronary artery disease
- contraindicated in smokers over 35
- uncontrolled hypertention
- diabetic retinopathy, nephropathy, peripheral vascular disease
- known/suspected breast or endometrial cancer
- undiagnosed vaginal bleeding
- migraines with aura
- liver tumors, disease, or failure
- known or suspected pregnancy
Who is the progestin only oral pill best suited for?
- mechanism similar to combined hormonal contraceptives
- best for breast feeding women
What is the mechanism of action of injectable contraception?
- inhibits ovulation
- thins endometrium
- alters cervical mucus to inhibit sperm penetration
Who is the injection contraception best suited for?
- Breast feeding women
- Desire for long term contraception
- Iron deficiency anemia
- Sickle cell disease
- Epilepsy
- Dysmenorrhea
- Ovarian cysts
- Endometriosis
What disadvantages/contraindications are associated with injectable contraception?
- depression
- osteopenia/osteoporosis
- weight gain
What is the mechanism of action of sub dermal arm implants for contraception?
- inhibits ovulation
- thins endometrium
- thickens cervical mucous to inhibit sperm penetration
Who is the sub dermal arm implant best suited for?
- Breast feeding
- Desire for long term contraception (last for 3 years)
- Iron deficiency anemia
- Dysmenorrhea
- Ovarian cysts
- Endometriosis
What are the disadvantages/contraindications of the sub dermal arm implants?
- current or past history of thrombosis/thromboembolic disorders
- hepatic tumors, active liver disease
- undiagnosed abnormal vaginal bleeding
- known or suspected carcinoma of the breast or personal history of breast cancer
- hypersensitivity to any of the components of Implanon
- MAY LEAD TO IRREGULAR BLEEDING
What is the mechanism of action of the levonorgestrel IUD (mirena)?
- thickens cervical mucous
- thins endometrium
What is the levonorgestrel IUD best suited for?
- long term, reversible contraception
- stable, monogamous relationships
- menorrhagia
- dysmenorrhea
What are the contraindications/disadvantages of the levonorgestrel IUD?
- current STI or recent PID
- unexplained vaginal bleeding
- malignant gestational trophoblastic disease
- cervical, endometrial, or breast cancer
- abnormalities distorting the uterine cavity
- uterine fibroids distorting endometrial cavity
What is the mechanism of action of the Copper T?
- inhibits sperm migration and viability
- changes transport of the ovum
- damages ovum
What is the Copper T best suited for?
- long term, reversible contraception
- stable, monogamous relationships
- contraindication to contraceptive steroids
What are the contraindications/disadvantages of the Copper T?
- WILSON DISEASE
- MAY CAUSE MORE BLEEDING/DYSMENORRHEA
- current STI or recent PID
- unexplained vaginal bleeding
- malignant gestational trophoblastic disease
- cervical, endometrial, or breast cancer
- abnormalities distorting the uterine cavity
- uterine fibroids distorting endometrial cavity
What is the failure rate of the progestin and combined pill?
- Minipill: 1-3%
- Combination pill 1-2%
When can OCPs be started for menstruating women, postpartum women, and post abortion?
- Menstruating women: first day after the start of menses
- Postpartum & nonbreastfeeding: 4th week after delivery
- Post abortion: day after abortion
What are the recommendations of a missed OCP dose?
- If a pill is missed, it should be taken as soon as possible and the next dose should be taken as usual
What should be done if two pills are missed?
- If two pills are missed, take two pills together on 2 consecutive days to catch up and alternative contraception should be used for 7 days
What is depo-provera/medroxyprogesterone?
- Depo-provera is an injectable form of a progestin with a failure rate of only 1%
- It is injected every 3 months IM
What are the side effects of depo-provera?
- irregular menses
- weight gain
- facial/body hair growth
- amenorrhea after 1 year
What is the transdermal contraceptive patch?
- combined hormone patch with 3 weeks on and 1 week off
What is the efficacy and risk of the patch?
- Patch has efficacy and side effect profile similar to the OCPs
- Perhaps increased risk of vascular thrombosis
The intravaginal ring contraceptive is similar to what other method?
- Transdermal patch: ring is inserted by the user, 3 weeks in, 1 week out
- Similar side effect profile of OCP
What is the rate of failure of spermicides alone?
- 20-30%
Spermicides, when combined with WHAT other form of contraception, has efficacy rates comparable to OCPs (1-3%)?
Condoms
What type of condom is highly effective against preventing STIs?
- LATEX condoms
What is the birth control failure rate of condoms?
- 15%
Can female condoms be used with male latest condoms?
Yes
What ist he failure rate of the female condom?
- 21-26%
What is the failure rate of the sponge?
18-28%
*rare side effect of toxic shock syndrome
What other contraception does the diaphragm need to be effective?
- NEEDS spermicide to be placed in the diaphragm
- Diaphragm is placed by a doctor
What is the failure rate of the diaphragm with spermicide?
- 6-18%
What are the failure rates of the Copper T (paraguard) and the Mirena?
- Copper T: 4-5%
- Mirena: less than 1%
Does knowledge/access to emergency (post coital) contraception increase high risk behavior?
NO
What is the yuzpe method?
Yuzpe method: taking combined OCPs for emergency contraception within 72 hours of unprotected sex
- can decrease the risk of pregnancy by 74%
What is the most effective emergency contraceptive?
- Mifepristone (RU486) 600mg
What is the next step in evaluation of a breast cyst?
- Needle aspiration of the cyst
What types of breast lesions are more indicative of malignancy?
- hard, fixed in place
- nontender
- indistinct borders
- overlying skin dimpling/retraction
The identification of a new solid breast mass in a woman >35 warrants what type of assessment?
- triple assessment: clinical breast examination, imaging (mammography), pathology assessment either by core biopsy or surgical excision
What is the place for ultrasound in breast imaging?
- Used in women younger than 35 with suspected fibroadenoma or fibrocystic changes
- can be used in adjunct to mammography
- Can be used in women with denser breasts or persistent breast pain
What type of fine needle breast aspiration would be considered unlikely to be benign?
- Mass does not resolve
- Fluid is bloody or no fluid is aspirated
- If lesion recurs
Spontaneous, persistent, bloody, discharge from a single duct associated with a mass is most likely representative of what process?
- Pathologic process: intraductal papillomas, duct ectasia, cancers, infections
- Tx is surgical excision of the terminal duct
What is the initial diagnostic test for a complaint of menstrual cycle irregularity?
- Pregnancy test
What is the treatment to regulate menstrual cycles in women with PCOS?
- Oral contraceptive pills
Detail the hormones involved in the menstrual cycle.
- GnRH is secreted by the hypothalamus, which stimulates the anterior pituitary to secrete FSH and LH
- As the FSH level rises, it causes an ovarian follicle to mature and it to release estrogen which induces endometrial proliferation
- A mid cycle LH surge causes ovulation and the follicle is transformed into the corpus luteum that secretes progesterone, which compacts and matures the endometrium
- If pregnancy does not occur, the production of progesterone abruptly decreases, resulting in sloughing of the endometrium and a menstrual bleed.
What is used to treat PCOS induced insulin resistance?
- Metformin
- Thiazolidinediones ( -glitazone)
What is used to treat PCOS induced infertility?
- Weight loss
- clomiphene citrate
- aromatase inhibitors, gonadotropins
What is a common causes of menorrhagia with regular intervals between bleeding?
Anatomic abnormalities:
- Leiomyomata (fibroids) => create an increased endometrial surface area with a resultant increase in menstrual bleeding
- Endometrial polyps => same mechanism as leiomyomata
- Coagulopathy (von Willebrand)
- Medication (warfarin)
- Liver disease
- Thrombocytopenia
What is asherman syndrome?
- Asherman syndrome: scarring within the uterine cavity caused by trauma from uterine curettage. Can result in reduction in the size of the uterus as the walls become scarred to each other. Can lead to reduce menstrual bleeding
How is chronic anovulation evaluated?
- Prolactin and LH serum levels
What are risk factors for endometrial carcinoma?
- History of anovulatory menstrual cycles
- obesity
- nulliparity
- older than 35yo
- use of tamoxifen
- unopposed exogenous estrogen
Who should get a workup for endometrial carcinoma?
- women with risk factors for endometrial cancer
- women
What is the workup for endometrial carcinoma?
- imaging of the pelvic organs with an ultrasound and an endometrial biopsy
What is the definitive treatment for refractory irregular menstrual bleeding and malignancy?
- Hysterectomy
