OB/Gyn Flashcards
1
Q
Criteria for discharge post surgery
A
Alert Ambulatory (to BL level) Adequate po intake Stable vitals Satisfactory bowel/urinary fxn
2
Q
What is footling breach?
A
Post membrane rupture, one single foot extending through the vaginal canal
3
Q
What is lochia?
A
Normal shedding of endometrium after delivery of placenta
red (lochia rubra) -> pinkish/brown (lochia serosa) -> yellowish white (lochia alba)
Lasts 6-8 weeks post partum
4
Q
Risk of vertical HIV transmission in a HIV + mom who declines ART delivery and c-section
A
25%
HIV + moms should receive ART and c-section
* 8% if ART alone and 2% or less in ART and c-section
5
Q
Pt has bleeding, pain, and hCG in the 400’s. U/s negative. Now what?
A
Recheck BhCG in a couple of days. Pregnancy rarely visible on U/s when < 1500.
Visualize in a couple of days to identify if ectopic pregnancy
6
Q
Mom at 27weeks is + for Syphillis. What next?
A
Confirm with MHA-TP (treponemal-specfic confirmatory test, more specific than RPR)
If this is also positive - tx mom for syphilis
Tx with penicillin. If allergic undergo penicillin desensitization
7
Q
A pt presents with twins, one vertex one breech. What are the Method of delivery options?
A
Successful vaginal delivery is likely as long as the breeched twin is the same size or smaller than the vertex.
8
Q
RhoGAM is indicated anytime mom is ___ and baby is ______
A
Mom is Rh- and baby is Rh+ regardless of blood type
Administer at 28wks and at delivery.
Failure = fetal hydrops
9
Q
Pt has:
more than 5 contractions/10 min
Contraction lasting 2+ minutes
Contraction of normal duration within 1 minute of each other. dx?
A
Uterine hyperstimulation
d/c oxytocin (causes non reassuring fetal hr tracing)
half life = 3-5 min
10
Q
Two malignant tumors that occur after abortion, ectopic pregnancy, or preterm/term pregnancy
A
Choriocarcinoma
Placental site trophoblastic dz
11
Q
Management of hyperemesis gravidarum?
A
pyridoxine-doxylamine followed by promethazine and/or ondansetron
12
Q
Pregnant woman AMS, RUQ pain, elevated LFTS, ABN coags. Dx?
A
Acute fatty liver of pregnancy
Microvesicular fatty infiltration usually occurring in late pregnancy.
presents with n/v, abd pain, jaundice
13
Q
Why is vitamin A supplementation contraindicated in pregnancy?
A
Increased risk of cranial neural crest malformations.
Can be considered in strict vegans and immigrants
14
Q
Mom presents in 3rd trimester for first prenatal visit also has HTN. Most likely finding on U/S?
A
Normal head and small abd circumference
Occurs due to diminished uteroplacental blood flow
15
Q
Maternal hypothyroidism predisposes baby to?
A
pregnancy loss Pre-eclampsia Placental abruption Low birth weight perinatal mortality Neuropshyc impairment
16
Q
Preggo with C-section history presents with bright red painless bleeding. Dx and at risk of?
A
Placenta previa
Massive hemorrhage
Usually plan a C-section at 35-36 weeks after confirmation of fetal lung maturity
17
Q
Painless vaginal bleeding post sexual activity in a preggo. Dx and assessment?
A
Placenta previa
Do an abd U/S
Digital exam is contra -> worsens the bleeding
RF’s of previa are multiparity and C-sections
18
Q
Cause of fetal deceleration during delivery?
A
Cord compression
19
Q
What supplement should a woman take while she is trying to get pregnant?
A
Folic acid 0.4 mg QD
Prevents NTD
20
Q
Preggo presents with painful vaginal bleeding following a trauma. Fetal heart rate 160. Dx?
A
Moderate placental abruption
21
Q
What is an acceptable amount of radiation to expose a preggo to?
A
5 rad
22
Q
Why do most preggo’s have a low HCT?
A
Decreased Serum:RBC ratio
Volume expanded
23
Q
What should be measured following a spontaneous abortion that has been confirmed by U/S?
A
Serial BhCG to rule out ectopic preggo
24
Q
Postpartum mom has little interest in her baby. Dx and Tx?
A
Post partum depression
Antidepressants and psychotherapy
25
When should a prophylactic cerclage be removed?
36-38 weeks gestation
| This is when fetal lungs are considered mature
26
If a mother continues to bleed postpartum despite fundal massage, dx and tx?
uterine atony
Associated with late delivery, large baby, multiparity, long labor
Soft boggy bloody uterus
Tx - Oxytocine, IM methergine, carboprost, and misoprotol
27
Should you culture a pt that had a positive GBS urine in her first trimester and a previous baby that had GBS sepsis?
No. Just give intrapartum penicillin
28
When is the earliest you can karyotype a fetus?
10 weeks - chorionic villus sampling (CVS)
15 week - amniocentisis
Triple marker screening not considered definitive, just suggestive
29
Should a preggo be treated for aymptomatic UTI?
Yes. Nitrofurantonin. Do this to prevent pyelo
| Untreated UTI also predisposes to low birth weight and prematurity
30
What should you do after D&C of a complete molar preggo?
Follow BhCG until it falls to zero
| Then place pt on OCP and follow BhCG monthly to evaluate if there is a metastatic process
31
What do you do for a fetal demise?
Induce labor
| Fetal demise = death in a fetus > 20weeks gestation. Usually from chromosomal anomaly but there are many causes
32
32 wk gestation with PPROM and lecithin:sphingoid of 1.5:1. Now what?
IM Betamethasone
| PPROM with incomplete fetal maturity (ratio should be 2:1)
33
If a near term fetus does not have appropriate accelerations, what evaluation should you do?
Biophysical profile
Assess: fetal movement, fetal tone, fetal breathing, AF volume, and results of non-stress test
8-10 = baby is ok
34
Chorionic villous sampling increases risk of what?
Infant limb defects
35
Vaginal bleeding in the first trimester without fetal loss is?
Threatened abortion
Some bleeding, risk of miscarriage, but baby is still ok
About half will advance to complete abortion
36
Woman feels a gush of fluid. On PE no pooling of fluid in the vagina or ferning pattern. Dx?
Involuntary loss of urine
| PPROm would have pooled fluid in the vag and a ferning pattern on a dried slide
37
If a woman becomes preggo within a month of receiving the MMR vaccine, is this reason to terminate the pregnancy?
No. The risk is small and shouldn't warrant termination by itself.
38
During induced delivery baby has late decelerations. Why?
Fetal academia, late decelerations are not reassuring.
| Correct by d/cing uterotoning drugs (ie oxytocin), add IVF, add oxygen, or change mom's position
39
During delivery baby has moderate to severe decels. Now what?
C-section
| Baby appears to be in distress
40
Why is a classic C-section scar contra for trial of vaginal birth?
they have 10% risk of uterine rupture.
| Perform an amnio at 36-37 weeks to confirm lung maturity prior to scheduling section.
41
How is arrest of active labor defined?
>3cm dilation = active phase
no cervical change in >4 hours with adequate contractions or >6 hours with inadequate contractions = arrest of labor
Consider adding pitocin for augmentation
42
What should be monitored in a preggo for 24 hours post trauma (ie MVA)
Fetal heart tones
Vaginal bleeding
Uterine tenderness
43
RF's and management of IUGR
RF's - uncontrolled HTN, congenital kidney/lung dz, abn karyotype,
Management - Induce labor esp if mom has HTN
44
Preggo has anxiety, NL TSH but high total T4. What should you do?
Reassure her. She is euthyroid (NL TSH) and her T4 is elevated because of elevated estrogen of pregnancy.
45
A fetus over 4500 g is considered
Macrosomia
| offer a C-section to prevent clavical and brachial plexus injury
46
Tx for mastitis?
Dicloxacillin
47
Female has dyschezia (painful defecation), dyspareunia (painful sex), and dysmenorrhea. Dx?
Endometriosis
| Dx through direct obs during laparoscopy
48
Tx for dysfunctional uterine bleeding in a hemodynamically stable pt?
High dose estrogen and progesterone
| Give IV estrogen if unstable
49
Most common cause of a vaginitis in a young girl (ie less than 10)
Foreign body
50
Most common site of endometriosis?
Ovaries
| Can present with nodularity of the uterosacral ligaments
51
Management of high-grade squamous intraepithelial lesion (HGSIL) on Pap smear?
Colposcopy to get bx and stage the lesion.
52
Vaginal itching with thining and atrophy of the skin?
Lichen sclerosis
| Tx - topical clobetasol or halobetasol
53
At what point in pregnancy does cervical insufficiency become concerning?
2nd trimester (16 weeks)
54
What are good prognostic factors in a bx of a breast lump?
less than 2 cm
No lymph nodes
estrogen and progesterone receptors (responds to tamoxifen)
Carcinoma in situ
55
When should GBS screening be performed?
between 35 and 37 weeks
56
Leak of urine due to involuntary bladder contraction?
Urge incontinence
Feel like they need to pee all the time because of detrusor overactivity
1st line tx - frequent voiding and kegals
2nd line - anticholinergics (tolterodine)
57
How do you treat breast cancer in a preggo?
Same as a non preggo but:
NO chemo in 1st trimester
NO radiation therapy
58
Appropriate chlamydia tx in a preggo?
Azithromycin
Essential to treat to prevent neonatal conjunctivitis and PPROM
retest 4-6 weeks later to confirm cure
59
Large uterus with endometrial glands within the myometrium
Adenomyosis
60
Following an endometrial bx, pt has severe abdominal pain. Why?
Uterine perforation
U/s will reveal fluid collection posterior to the uterus
More common side effects - cramping, vaso-vagal rxn
61
When is LEEP indicated?
For therapeutic removal and bx of cervical lesions
Outpatient with local anesthesia
Complications - minor bleeding, infection.
Later complications - cervical stenosis, cervical incompetence
62
How do you manage ovarian torsion?
Laproscopy to prevent necrosis
| Pt presents with intermittent lower quadrent pain, large ovary on U/S
63
Two major RF's for UTI
Sex
| hypoestrogenism - give estrogen as a preventative
64
Abdominal pain/tenderness, Cervical motion tenderness, adnexal tenderness. Dx?
PID
| Can also have fever, elevated ESR, leukocytosis
65
Breast mass that gets very large but does not involve skin, nodes, or chest wall.
Cystosarcoma phyllodes
| Usually benign
66
Pt has amenorrhea and galactorrhea. What is this concerning for?
Pituitary adenoma
Order an MRI
Tx - DA agonist (bromocriptine, cabergoline)
67
How do you DVT prophylax a non preg pt that has cancer?
Cancer = Hypercoagulable
| Enoxaparin and warfarin with INR goal of 2-3
68
What is physiologic leukorrhea?
Thin white discharge in a otherwise healthy female
Seen in neonates shortly after birth
Also seen in young girls months prior to menarche
Caused by increasing estrogen levels
69
Management for a fibroid pt that may still want to have children?
Myoectomy
| Presents with pelvic pressure, menorrhagea, anemia
70
Pap smear reveals atypical squamous cells of undetermined significance (ASCUS). Now what?
2 options:
1. Repeat cytology in 1 year - use this when HPV testing has not been done
2. Do HPV-DNA testing - if + for 16, 18, 31, 33, 35 then colposcopy
71
What is premenstrual dysphoric disorder? (PMDD)
combo of physical and emotional syx within a week of starting menses
abd bloating, breast tenderness, HA, dizziness
Labile mood, food cravings, increased appetite
72
Fxn of tamoxifen
Estrogen receptor modulator (agonist in uterus, bones, and liver; antag in breast tissue)
If a pt develops atypical hyperplasia d/c tamoxifen
73
First sign of precocious puberty in a female?
Thelarche (boobs) -> adrenache (hair) -> growth spurt -> menarche
Occurs at < 8y/o in females
74
First sign of precocious puberty in a male?
Testicular growth -> penile growth -> adrenarche (hair) -> growth spurt
<9 y/o in males
75
What is the primary AE of tamoxifen?
Endometrial changes
| Increases bone density
76
Hirtuism + oligomenorrhea + Infertility + Obesity
PCOS
Also IR (acanthosis nigricans)
Tx - weight loss, DM screening, BP and lipid control, metformin, and thiazolidinodiones
77
Morphology of chlamydia
GN Intracellular bacteria
| Infect squamocolumnar epithelial cells
78
How do you tx a pt with gonorrhea?
Azithromycin + ceftriaxone
azithro for chlamydia
ceftriaxone for gonorrhea
79
Pt continues to bleed despite fundal massage. Now what?
Give oxytocin to stop uterine atony
| Significant postpartum hemorrhage >500mL
80
Best way to evaluate vaginal bleeding in a preggo
Abd U/s
81
During labor baby hr falls to the 70s and the umbilical cord has prolapsed. management?
Prolapsed umbilical cord is an obstetric emergency.
| STAT c-section
82
Mom has seizure at 32 weeks. Now what?
Infuse Mg sulfate 6g x 15min to stabilize mom
| Then deliver baby
83
If a preggo fails the 1hr glucose tolerance test, what do you do?
Schedule a 3 hour test
| Normal 1 hr test is <140
84
Some Asian moms get darkened skin after pregnancy. What is ti and management?
Melasma (chloasma)
Common in darker skinned individuals and worsens with subsequent pregnancies
Avoid sun and wear sun block
Tx- hydroquinone
85
Rh- mom received Rhogam at 28 weeks. Why would you give another dose during this pregnancy?
Exposure to fetal blood (perform E-rosette test)
86
Causes of DIC during pregnancy
abruptio placentae, saline-induced therapeutic abortion, retained fetus syndrome, and initial phase of amniotic emobolism
87
How does hypothyroidism affect menstration?
Anovulation and irregular bleeding
| Anovulation is due to unopposed estrogen and this leads to an unstable endometrium with irregular bleeding
88
Ovarian enlargement due to cysts and third spacing
Ovarian hyperstimulation syndrome (OHHS)
Often seen in women needing fertility treatment
Tx - supportive care and prevent thromboembolic dz
89
MOA of acyclovir
Nucleoside analogue that inhibits viral DNA polymerase
90
What do you do if a preggo has an abn pap smear?
Get a colposcopy
| Treat them the same as a non preggo
91
T2DM begins having involuntary loss of urine and incomplete emptying
```
Hypotonic bladder (overflow incontinence)
Neuropathy -> loss of innervation to the bladder
```
92
Recommended outpt tx for uncomplicated UTI?
po Bactrim x 3 days
93
How do you manage PID in pregnancy?
Admit to the hospital
| IV clindamycin and gentamicin
94
Pt has PID with severe leukocytosis and fever. Y/s reveals ovarian mass
Tubo-ovarian abscesses (TOA)
Caused by PID ascending to the ovary or after pelvic surgery
Tx - IV abx and possibly surgery
95
How do you rule out endometrial cancer in a post menopausal woman with vaginal bleeding?
Endometrial bx
96
Best tx for urge incontinence?
Urge incontinence = unexpected immediate need to void
| 1st line = pelvic flood exercises and bladder training (Kegel's and timed voids throughout the day
97
Painless genital lesion caused by GN encapsulated bacteria
```
Klebsiella granulomatis
Donovanosis
Usually found in the tropics
Painless papules that ulcerates over weeks
Tx - Bactrim, doxy x 3wks
```
98
Hormonal abnormalities in PCOS
Increased Test
Decreased Sex hormone binding globulin
Increased LH:FSH (>1)
99
1 yr after pregnancy a woman is yet to start her periods again. TSH and Prolactin WNL. Why?
Secondary amenorrhea
Can occur after pregnancy due to inadequate progesterone or estrogen
Challenge with IM progesterone, if no bleeding after a week give estrogen and progesterone
100
What causes dysfunctional uterine bleeding and how do you treat?
Cause - anovulation, unopposed estrogen -> endometrium becomes unstable and sloughes randomly
Tx - (if hemodynamically stable) po cyclic progestins on days 14-25 of cycle or OCPs
101
Struma ovarii are associated with what hormone change?
Decreased TSH
Ovarian teratoma
Unilateral
Predominantly thyroid tissue
102
What do you do if you dx bacterial vaginosis in a preggo?
Po metronidazol
| top metro and not treating are both associated with preterm labor
103
Post menopausal woman has vaginal bleeding and bx + for endometrial adenoma. What do you do?
Hysterectomy
B/l adnexectomy
Lymph node sampling
104
Tx for premenstrual dysmorphic disorder?
SSRI's (Fluoxetine)
| QD or only when symptomatic
105
17 y/o has primary amenorrhea. On PE, normal external genitalia with short vagina, no uterus
Mullerian agenesis (Mayer-
rokitansky Kuster Hauser syndrome)
Lack of Mullerian stuctures - uterus, fallopian tubes, cervix, upper vagina
106
Use of OCP's x 3 years reduces risk of?
Endometrial cancer
| Reduces risk by 50%
107
How frequently should women 50-70 undergo mammography?
Yearly
108
How should you workup a girl that has long periods and gets anemic?
Get a coag panel
109
PCOS pt is able to conceive on clomiphene but loses the babies at ~20 weeks. Now what?
Examine with saline-infused sonohysterogram (SIS) to see the contours of the uterus
110
Breast with redness, fullness, peau d'orange
Inflammatory cancer of the breast
111
Malodorous greenish-gray vaginal discharge
Trichomonas
Flagellated protozoan
Strawberry cervix
112
COD in ovarian teratomas?
Torsion,
113
A couple struggling with infertility have an abn sperm count. Now what?
Repeat sperm count in a few weeks.
114
Tall female without pubic hair or menstration
Androgen insensitivity
46 XY
Blind-end vaginal pouch and breast development
115
Androgen insensitivity is at great risk for which malignancy?
Testicular
Intra-abdominal
Need a bilateral gonadectomy at puberty
116
What should you do following a pap with low-grade or high-grade squamous intrepithelial lesion?
Colpoxcopy with endocervical curettage in non preggo's
117
Young sexually active woman with abdominal pain
Dds: appendicitis, pelvic inflammatory dz, ectopic pregnancy, ovarian torsion, corpus luteum cyst formation
118
How long is the copper IUD effective?
10 years
| Contra's: pelvic infection w/in last 3 months
119
Post surgery pt is febrile and unresponsive to multiple abx
Septic pelvic thrombophlebitis
Post op or post partum infected thrombosis of the deep pelvic or ovarian veins
Tx- anticoags and broad spectrum abx
120
Pre-eclampsia with migraine, visual changes, elevated LFTs, elevated Cr.
Pre-eclampsia with severe features (ie end organ damage)
121
What is the tx of choice in a preggo with BP>160
IV labetalol
| However, if pt is HTN and bradycardic, hydralazine is a better choice
122
How do you manage a pt with previous classic C-section or myomectomy that is laboring?
Laparotomy and delivery
| Risk of uterine rupture is too high for vaginal delivery
123
What prenatal labs should be ordered at the initial OB visit?
```
RhD screen
CBC
HIV, VDRL/RPR, HBsAg
Rubella and Varicella titer
Pap (if needed)
Chlamydia PCR
Urine culture and protein
```
124
What labs should be ordered at 24-28wks of pregnancy?
CBC
Ab screen if Rh-
1 hr OGT
125
What labs should be ordered at 35-37 weeks of pregnancy?
GBS
126
Why does gestational DM happen?
In 2nd and 3rd trimester the placenta secretes hormones to increase maternal IR to promote fetal growth/metabolism. If women have inadequate pancreatic function to overcome the IR, they develop GDM
127
Preggo presents with HTN and RUQ pain
HELLP syndrome
Manifestation of severe preeclampsia
Hemolytic anemia, elevated LFTS, Low Platelet
Abdominal pain due to liver swelling with distension of the hepatic (Glisson's) capsule
128
Preeclamptic pt with lung crackles
Pulmonary edema is a life threatening complication of severe preeclampsia
Caused by increased vascular resistance, capillary permeability, pulmonary capillary hydrostatic pressure, and decreased albumin
129
How do you manage preeclampsia?
Mg sulfate - seizure prevention
BP control
Expedient delivery
130
How do you manage a laboring mom that has a nonviable fetus?
Goal of delivery is to minimize maternal morbidity and mortality
Vaginal delivery is the lowest risk
131
Why does a mom become hypotensive and tachycardic after an epidural?
Vasodilation and venous pooling
| Occurs in 10% of mom's receiving epidurals
132
How do you manage a breech baby at >37 wks in a laboring mom with no contra to SVD?
External cephalic version
| Reduces rate of C-section
133
Maternal fever + uterine tenderness
Chorioamnioitis
Dx'd clinically by presence of maternal fever + at least one of: uterine tenderness, maternal or fetal tachy, malodorous amniotic fluid, purulent vaginal discharge
RF: prolonged ROM
134
How do you manage chorio?
Broad spec sbx
Oxytocin
Get that baby out
135
Recommendations for exercise during a healthy pregnancy?
20-30 min of moderate exercise on most days
| Avoid high contact sports
136
Most common cause of primary postpartum hemorrhage?
Uterine atony
Caused by failure of the uterus to contract and compress the vessels at the insertion of the placenta.
Profuse vaginal bleeding and a soft boggy uterus
RF's Prolonged labor, induction of labor, operative VD, and fetal weight over 4kg
137
How do you manage uterine atony?
Infusion of oxytocin + bimanual uterine massage
138
What is a fetus at risk of in the setting of preeclampsia
Oligohydramnios
Fetal growth restriction/ small for gestational age
Caused by chronic uteroplacental insufficiency
139
Signs and risk factors of shoulder dystocia?
Signs: prolonged first or second stage of labor and turtle sign
RF's: maternal obesity, fetal macrosomia, excessive weight gain in pregnancy, Gestational DM, post-term pregnancy
140
>24 hr Post partum, pt is febrile + purulent lochia + uterine tenderness
Postpartum endometritis
Polymicrobial
IV clindamycin + gentamicin for broad spectrum coverage
141
How do you manage a fetus in traverse lie?
Most will spontaneously convert to vertex prior to term
Fetus is essentially perpendicular to the vagina
Can perform external cephalic version of c-section
142
Contraindications to breast feeding?
Maternal: active TB, HIV, Herpetic breast lesions, Active varicella, chemo/radiation, active substance abuse (esp mj as it is lipophilic)
Infant: Galactosemia
143
After delivery of placenta a smooth round mass protrudes through the vagina. Dx and management?
Uterine infversion
Fundus inverst and prolapses, not palpable transabdominally, severe pain, hemorrhage
Tx - manually replace the uterus and use utertonic drugs after replacement
144
How do you manage fetal demise >24 weeks
Induce vaginal delivery
Can be delayed to allow time for the mom to accept the diagnosis however, if fetus is retained for several weeks it can lead to coagulopathy
Cause of demise is UNK in the majority of cases
145
What are normal changes during the puerperium?
```
Shivering
Uterine contaction and involution
Lochia
Peripheral edema
Breast engorgement
```
146
Medroxyprogesterone is?
Depo shot
AE's breast tenderness, weight gain fatigue
Get UPT in a pt with these syx and has been amenorrhic for >1 month
147
How does the DEPO shot work?
Inhibits release of gonadotropin releasing hormone (GnRH) from the hypothalmus -> suppresses ovulation
Bleeding irregularities normal in 1st year and 50% will be amenorrhic after 1 yr
148
Pt at >6cm dilation has no cervical change for >4hrs with adequate contractions. Now what?
C-section
| Oxytocin won't help because she already has sufficient contractions
149
How do you manage a spontaneous abortion (fetal demise < 20 weeks) in a mom that is hemodynamically unstable (hypotensive, dizzy)
Suction curettage
150
How do you manage a spontaneous abortion in a stable pt?
```
Expectant management
Medical induction (misoprostol)
```
151
Vaginal spotting + lower abdominal pain + adnexal tenderness
Ecotpic preggo
| Get UPT and a transvaginal U/s
152
28 wk gestation w/ no fetal movement and no heart tones on doppler. Now what?
Absence of fetal heart activity on Transabdominal U/S to confirm fetal demise
153
Late term (41 wk) and post term (42 wk) pregnancies are at risk for?
Uteroplacental insufficiency
Biophysical profiles starting at 41wks
If <4 -> induce delivery to prevent intrauterine fetal demise
154
Why do preggos hyperventilate?
Progesterone changes the homeostatic set points in the medullary respiratory centers (more sensitive to changes in PcO2)
On ABG -> Increased PaO2, (100-110), low PaCO2 (27-32) and alkalosis (7.4-7.45
Small decrease in serum bicarb to compensate
155
Treatment for lichen sclerosis?
Topical steroid
Want an ultrapotent steroid (clobetasol)
UNK if this will prevent scarring and/or squamous cell carcinoma (SCC)
156
When is bx indicated for abn uterine bleeding?
Pt is >45
Or Pt is < 45 + any one of:
1. unopposed estrogen (obesity, chronic anovulation)
2. Failed medical management
3. Lynch syndrome (hereditary nonpolyposis colorectal cancer)
157
Complication of preeclampsia with thrombocytopenia, microangiopathic hemolytic anemia, RUQ pain, and elevated LFTs
HELLP syndrome
Caused by hepatic and systemic inflammation, activation of the coagulation cascade, and platelet consumption
Deliver if >34 weeks or if abn fetal testing
158
Pharyngitis, fever, lower abdominal pain in sexually active female?
Gonococcal pharyngitis + PID
| From oral sex
159
Female teen presents with primary amenorrhea, breast development, minimal pubic hair, absent uterus & upper vagina. Dx?
Androgen insensitivity syndrome (46XY)
X-linked mutation of androgen receptor
Will have male levels or Serum testosterone and cryptorchid testes
160
Female teen presents with primary amenorrhea, Tanner 4 breast and pubic hair. Absent or rudimentary uterus & upper vagina, ormal ovaries
```
Mullerian agenesis (46 XX)
Hypoplastic or absent mullerian duct system
```
161
Female teen with Tanner 4 breasts and pubic hair, Normal uterus, abn vagina, normal ovaries
Transverse vaginal septum (46XX)
| malformation of urogenital sinus and Mullerian ducts
162
Female teen with normal uterus, vagina, but streak ovaries?
```
Turner syndrome (45X)
Absence of X chromosome
```
163
What are the causes of abn uterine bleeding?
Fibroids
Adenomyosis
Endometrial hyperplasia/cancer
164
Female with heavy menses, constipation, urinary frequincy, pelvic pain/heaviness, enlarged uterus
Fibroids
165
Female with dysmenorrhea, pelvic pain, heavy menses, bulky globular tender uterus
Adenomyosis
"Boggy" uterus
Endometrial glands within the uterine m.
166
Female with hx of obesity nulliparity or chronic anovulation w/ irregular intermenstrual or postmenopausal bleeding. Nontender uters
Endometrial hyperplasia or cancer
167
Following a normal pregnancy mom has SOB, enlarged uterus, irregular vaginal bleeding, and infiltrates on CXR. Now what?
Choriocarcinoma likely
Get a quantitative BhCG
Chorio is a form of gestation trophoblastic neoplasia that arises from placental trophoblastic tissue that secretes BhCG
Can occur after a molar, normal preg, or spont abortion
Lung most frequent site of metastasis
168
On Stress test, the most likely cause of lack of fetal acceleration with NL movements?
Fetal sleep cycle
Can lastup to 40 min
Confirm with biophysical profile or contraction stress test
169
Irregular contractions, no cervical change
False labor (Braxoton- Hecks)
170
How do you manage a preggo with a pap result of high-grade squamous intraepithelial lesion?
Immediate colposcopy
| Risk of progression to cervial cancer is high enough that all pts need tx regardless of pregnancy status
171
Cause of variable contractions?
Cord compression
Oligohydramnios
Cord prolapse
172
During labor there are variable decelerations occur with >50% of contractions
Reposition the mom
173
How do you manage a pt that just had a d&c for a hydatidiform mole
If b-hcg is increasing - dx of gestation trophoblastic neoplasia
If b-hcg is decreasing - check monthly until undetectable, Contraception x 6 months
Accidental pregnancy clouds GTN screening
174
Tamoxifen tx for breast cancer increases the risk for?
```
Hot Flashes (most common)
Endometrial cancer
Venous thromboembolism
```
175
What type of adnexal mass is seen in endometriosis?
Endometrioma
Homogenous cystic ovarian mass
Pt is often also infertile
176
dysmenorrhea + heavy menstrual bleeding progressing to chronic pelvic pain
```
adenomyosis
endometrial glands burry in the myometrium
PE - Boggy, tender, enlarged uerus
Dx - pelvic u/s, and/or MRI
Tx - IUD, hysterectomy
```
177
Postcoital bleeding + mucopurulent discharge in a preggo
Acute cervicitis
chlamydia, gonorrhea
Tx - azithro + ceftriaxone
178
Healthy female teen presents with hirsutism, acne, and elevated 17-hydroxyprogesterone
Congenital adrenal hyperplasia
Partial deficincy of 21-hydroxylase
Low cortisol and and aldosterone stimulates ACTH to oversecrete causing an overall increase in adrogens (due to diversion away from cortisol production))
179
Unilateral breast pain that is diffusely warm, erythematous and some dimpling
Inflammatory breast carcinoma
Aggressive form of cancer w/ rapid onset
Can have nipple retraction
Dx -mammo + u/s, confirm with bx
180
How do you tx a preggo that has made diet modifications but postprandial blood glucose is >140
Insulin, metformin, or glyburide
| Insulin does not cross the placenta
181
How do you manage a laboring mom with shoulder dystocia
```
Stop pushing
Elevate hips against abdomen
Apply suprapubic pressure
Episiotomy
Deliver posterior arm, rotate,
If it fails -place fetal head back into pelvis for delivery
```
182
Who receives zidovudine?
Mom's requiring c-section
| Baby for 6+weeks after birth
183
New born has loose skin, thin umbilical card, wide anterior fontanel
Fetal growth restriction (<10%th)
| Examine the placenta for infection and/or infarction
184
Preggo hasn't been gaining weight and presents with AMS, nystagmus, and gait ataxia
```
Thiamine deficiency (wernicke)
Associated with hyperemesis gravidarum
```
185
uterus and post/ant vaginal walls prolapse through the vagina
```
Uterine procidentia (pelvic organ prolapse)
Can tx with pessary or surgery
```
186
OCP pt has new onset HTN
D/c OCP as these can exacerbate HTN
187
Management of PPROM w/o contraction in a preggo <37 wks
abx (GBS status unk)
steroids
delivery
188
unilateral bloody nipple discharge
Intraductal papilloma (benign)
Get mammo + u/s
bx +/- excission
189
You id a adnexal mass in a post menopausal woman.. Now what?
serum CA-125 level and pelvic u/s
Biomarker for epithelial ovarain cancer (specific in post menopausal women, because it is also elevated by endometriosis)
190
Pt has n/v dizziness and a molar pregnancy
Theca lutein cst
b/l multiloculated ovarian cyst hyperstimulation from abn trophoblastic proliferation
Tx - monitoring, should resolve after D&C for the mole and as BhCG falls
191
On quad screen:
| Increased Bhcg and inhibin
Trisomy 21
192
On quad screen:
| everything is low but inhibin is NL
Trisomy 18
193
On quad screen:
| Alpha fetal protein is elevated but all else is NL
Neural tube
194
Lithium use during pregnancy causes?
Congenital heart disease (Ebstein's anomaly)
| Wean preggo's off
195
Retenoids during preggo cause?
Serious tetragen
Craniofacial dysmorphism, heart defects, deafness
Women receiving this should be on strict contraception and d/c immeadiately if the become preggo
196
Primary RF for breast cancer?
Age
197
What is the most important direct role of hCG in pregnancy?
Maintenance of the corpus luteum
| Maintains progesterone until the placenta is able to produce progesterone
198
In normal pregnancy, hCG doubles every
48 hours
Peaks at 6-8 weeks
The alpha subunit is found in TSH, LH,and FSH
Beta is unique to hcg
199
Unexplained painful vaginal penetration (no other medical issues)
Genito-pelvic pain/penetration disorder (vaginismus)
Usually have a hx of trauma
Tx- desensitization and Kegel's
200
Lower abdominal pain, on u/s adnexal mass w/o doppler flow
Ovarian torsion
| Tx - laparoscopy w/ cystectomy
201
Gold standard of evaluating a woman suspicious for pre-eclampsia
Urine protein:Cr for a 24 hour urine
| Dipsticks have a high false -ve rate
202
Healthy pre-menopausal women with hx of chemo presents w/ amenorrhea and vaginal dryness
Primary ovarian insufficiency (hypergonadotrophic hypogonadism)
TSH, Prolactin - WNL
FSH, LH - elevated (no negative feedback from estrogen)
Look for a hx of chemotherapy
Tx - HRT and freeze eggs
203
Tx of asymptomatic UTI in a 1st trimester preggo?
Amox-clavulanate (augmentin)
Nitrofurntoin (macrobid)
Cephalexin
NOTE bactrim is contra in 1st trimester due to blocking folic acid metabolism
204
Tx for vaginal cadida?
po -azole (fluconazole)
OR
Top nystatin (NOT po)
205
Adolescent w/ unilateral abdominal pain around the time of ovulation
Mittelschmerz
Occurs when the follicle ruptures to release the egg -> this also leaks blood causing some peritoneum irritation
Tx - reassurance, lasts approx 1 day
206
Primary RF's for Squamous cell carcinoma of the vagina?
Smoking
HPV
Presents with vaginal bleeding and malodorous discharge in post menopausal female
207
Gold standard of testing for acute cervicitis
Nucleic acid amplification
208
If you suspect fibroids you should order a?
Pelvic u/s
209
Healthy female presents with fever, hypotension, and diffuse red macular rash of the palms and soles
Toxic Shock syndrome
Staph aureus
IVF and bx neded
210
3rd trimerster vaginal bleeding but Fetal heart rate is stable
Placenta previa
| HR is stable, if it were abruption mom would report pain and the fetal heart tracing would be abn
211
Elevated CA-125, cRP and febrile pt has a pelvic u/s revealing a large thick walled multiloculated mass filled with debris
Tubo-ovarian abscess
| Found in reproducte aged women with a hx of infection in the upper genital tract
212
Morbidly obese pt with amenorrhea but NL TSH, prolactin, FSH and LH
Anovulation secondary to morbid obesity
| Ovaries are producing estrogen, but progesterone is not produced at the normal post ovulation levels
213
Preggo has a large uterus and reports a long hx of incomplete voiding.
Fibroids
| Bulk related symptoms
214
Still born has short, bent extremities and XRay reveals multiple limb fx and hypoplastic thoracic cavity
Type II Osteogenesis imperfecta
Type II = fatal perinatal
AD, type 1 collagen defect -> decreased bone density, increased skeletal fragility
215
If you suspect a ruptured ectopic, what do you do?
Surgical exploration
216
Pt presents with guarding + decreased bowel sounds
Acute abdome
| in a female with + UPT -> hemoperitoneum due to interstitial ectopic (implanted in uterine carnu)
217
Incidental surgery finding of powder-burn lesions, nodules
Endometriosis
| If asymptomatic, just observe
218
Following induction of a delivery, mom has a seizure due to hyponatremia. Why?
Oxytocin toxicity causes hyponatremia, hypotension, tachysystole
Structure is similar to ADH causing excessive retention of water -> hyponatremia
Tx - gradual hypertonic saline
219
Which vaccines are recommended in pregnancy?
Tdap
Flu
Rhogam
NO: HPV, MMR, nasal flu, Varicella
220
Irregular menses and infertility. Low LH, FSH and estradiol
Hypogonadotropic hypogonadism
Loss of pulsatile GnRH due to weight loss, stress, or chronic illness
Tx - remove underlying stressor
221
Pt presents for first prenatal (amenorrhea, breast enlargement, morning sickness). On u/s, thin endometrial stripe
pseudocyesis
RF - infertility and previous pregnancy loss
Occurs when stress afftects the HPO axis
222
Obese Pt with abn uterine bleeding has a bx showing complex endometrial hyperplasia
Endometrial hyperlasia due to uncontrolled proliferation of the endometrium due to unopposed estrogen from the peripheral adipose
223
Laboring pt has moderate vaginal bleeding and baby has receded away from the pelvis
Uterine rupture
RF - csection
Loss of fetal station is pathognomonic
Tx - emergency laprotomy
224
AA preggo with hirstuism and b/l ovarian masses
Luteoma
Hyperandrogenism
Caused by ovarain mass, benign, AA
225
What is a renal change that is normal in preggo?
Decreased serum Cr
| Increased renal blood flow -> increased GFR -> increased GBM permeability
226
Modifiable RF's for breast cancer
HRT
Nulliparity
Age at 1st live birth
Alcohol consumption
227
How do you assess risk for preterm delivery in a preggo with a hx of cold knife bx?
TVUS
| Measure the cervical length
228
If a preggo has a short cervix (<2cm) at <24 wks give?
progesterone to maintain uterine quiescence
229
Preggo <20 wks presents with preeclampsia with end organ damage
Hydatidiform mole
Pt presents with - HA, HTN, Hyperreflexia and + UPT
Caused by abn trophoblastic tissue proliferation
230
Hormone levels in primary ovarian insufficiency
```
Cessation of ovarian function at <40
High FnRH, FSH (hypothal and pit activity)
Low estrogen (ovary)
```
231
Pt with irregular menses has a w/d bleed after progesterone challenge. what causes the irregularity?
Insufficient GnRH from the hypothalamus
Bleeding after progesterone challenge suggests nl estrogen production and endometerial proliferation (so ovaries are working)
HPO axis takes a while to mature in adolescents
232
preggo presents with syx suspicious of hyperemis gravidarum. How do you confirm?
RF's: Mole, multifetal gestation, hx of hyperemesis gravidarum
Signs: n/v, weight loss, dehydration
U/A ketones
Tx - antiemetics of IVF
Normal pregnancy associated nausea does not have ketones
233
When is ROM PPROM?
<37 weeks
234
Ovarian mass with calcifications and hyperechoic nodules
Cystic teratoma (dermoid ovarian cyst)
Benign ovarian tumor in premenopausal women
Tx - surgery
At risk of torsion
235
Initial screening for a women with a palpable breast mass
>30 Mammo
| <30 U/s
236
Risk of leaving asymptomatic cystitis untreated in a preggo
Pyelo
237
Wat can cause magnessium toxicity in a preeclamptic?
Renal insufficiency
| Mag is renally excreted
238
Newborn has small body size, microcephaly, hypoplasia of distant phalanges and nails, excess hair, and cleft palate and rib anomalies.
Phenytoin exposure
239
Newborn has rhinitis, hepatosplenomegaly, skin changes
Syphilis exposure
240
Newborn has midfacial hypoplasia, microcephaly, stunted growth, hyperactivity, IDD
Fetal alcohol syndrom
241
at <20 wks pt has spotting, decreasing bhcg, but closed cervix. Yolk sac but no fetal pole
Missed abortion
242
<20wks vaginal bleeding, closed os, fetal cardiac activity present
Threated abortion
243
<20 weeks, vaginal bleeding, dilated os, POC is felt/seen in the uterus
Inevitable abortion
244
<20 wks, vaginal bleeding, closed os, PO outside of the uterus
Complete abortion
245
What is the 1st step in managing a mom suspicious for a traumatic placental abruption
Resuscitate with fluids and crystalloids
Position mom in Left later decubitus position
Need to optimize maternal circulation
246
Initial workup for a pt suspicious for meopause
hCG
TSH
FSH
247
All sexually active women <25 should be screened for?
G/c
248
Women with endometriosis are at greatest risk of developing?
Infertility
249
Female <30 presents with an aysmptomatic soft, mobile, wel-circumscribed mass aprox the size of an egg at the base of the labia majora
Bartholin cyst
Caused by duct obstruction (dried glandular secretions, local trauma, idiopathic)
Gland distends due to accumulated fluid
Typically at 4 or 8 oclock position on labia majora
250
How do you tx an asymptomatic Bartholin cyst?
Observation, generally drain on their own
251
How do you tx a symptomatic Bartholin cyst?
I&D
Same as a Bartholin abscess
Word catheter prevents reoccurence
252
Tx for stress incontinence that fails medical management?
Urinary sling
253
Immigrant develops dyspnea during pregnancy. EKG id's new a fib
Rhemuatic mitral stenosis
| Can present during pregnancy due to extra stress on the heart
254
Shortly after delivery pt develops hyperthyroid syx of anxiety
Postpartum thyroiditis
Occurs w/in 6 months of birth
Caused by release of T3/T4 that had been sequestered by TBH
Followed by a hypothyroid phase (fatigue, weight gain) until T3/T4 production catches up
255
In placenta accreta the vili attach to?
Myometrium
NL placenta attaches to the decidua
Presents with difficulty delivering placenta and hemorrhage
256
Tx for breast abscess?
Needle aspiration and abx (dicloxacillin, cephalexin)
| Occurs due to untreated mastitis (presents similar but has a fluctuant mass)
257
What is absolutely contra in all breast cancer pts?
Hormonal contraception (copper IUD is ok)
258
Infetility pt presents with clear vaginal discharge and clear mucus over the cervical os
Ovulation
This clear thin cervical mucus corresponds with the LH surge (transition from follicular into into luteal phase)
Ovulation kits detect LH
259
Most common cause of second stage arrest of labor (no fetal descent in >3 hrs in nulli's and >2hrs in multi)
```
Fetal malposition (ie anything not occiput anterior
Optimal: occiput anterior
```
260
Fetal presentation refers to?
Presenting fetal part into the maternal pelvis (ie vertx vs breech)
261
Amphetamine abuse during pregnancy is associated with?
```
Preterm delivery
Preeclampsia
Abuptio placentae
Fetal growth restriction
Intrauterine fetal demise
```
262
Sexually active female has grouped, tender, shallow labial ulcers w/ mildly enlarged tender lymph nodes
HSV
263
Large deep painful vulvar ulcers with gray/yellow exudate and severe lymphadenopathy
chancroid
| H. ducreyi
264
Causes of painless genital ulcers
Trepenoma (syphillis)
| Chlamydia trachomatis L1-L3 - shallow ulcers and
265
Post partum pt had 3rd degree lac now presents with smelly vag discharge. PE small, red, velvety area on posterior vaginal wall w/ foul smelling brown discharge
Rectovaginal fistula
Usually present about 2wks postpartum
RF's: 3rd, 4th degree lacs
Can present with flatus or fecal incontinance
266
Shoulder dystocia produces claw hand
Klumpke palsy
Extended wrist, Hyperextended MCP's, Flexed IPS, absent grasp reflex
Damage to c8 and T1
Can also have eye findings of Horner syndrome
Tx - PT to prevent contractures, usually improve by 9 months
267
Shoulder dystocia produces waiter's tip
```
Erb-Duchenne palsy
Decreased moro and bicep reflex
Extended elbox, pronatoed forearm, flexed wrist, fingers
Intact grasp reflex
Damage to C5/6
```
268
Most common cause of unilateral bloody nipple discharge
Intraductal papilloma
269
Female with unilateral pelvic pain and free fluid on pelvic u/s, - UPT
Ruptured ovarian cyst
270
Best test to dx HSV?
PCR
271
Postpartum pt that received epidural is having continuous leaking of urine
Bladder atony (Post partum urinary retention and overflow incontinence)
RF's: epidural and perineal swellin
Cath her for dx (urinary retention >150mL) and tx
Most pts regain fxn after a few hours off of anesthesia
272
Pt has a resolved breast cyst after a FNA. When do you see her again?
2 months for repeat CBE.
| If all good -> 1 yr
273
STI with vag pH >5
Trichomonis
274
How do you manage a HCV preggo that has not been vaccinated for any heps?
Order HAV and HBV now (acute hep is life threatening for these guys)
Ribavririn - teratogenic
Vertical transmission risk is low - c-section not protective, encourage BF
275
What are complications of inadequate weight gain in a preggo?
Fetal growth restriction
| Preterm delivery
276
Preggo post partum has tachy cardia, DIC and poor O2 sat. Management
PE of amniotic fluid
prepare to intubate her and give supportive care
RF's for amniotic emobolism: advanced maternal age, multigravada
Amniotic fluid enters vasculature through placental insertion site or other uterine trauma
277
Post term preg is at risk for
oligo hydramnios
278
Neonate born to mom w/ hx of Graves dz is tachycardic. Why?
Transplacental TSH receptor ab
Causes neonatal thyrotoxicosis
Self resolves in 3 months
In mena time - methimazole + BBlocker
279
Primary amenorrhea with virilization, ambig ext genitalia at birth, but female internal organs
Congenital aromatase deficiency
Loss of conversion of androgens to estrogens
Virilized female with undetectable serum estrogen
280
Genital warts w/ multiple pink or skin colored lesions that range from smooth flat papules to cauliflower like
Condylomata acuminata
HPV 6, 11
Tx - trichloroacetic acid
281
amenorrhic postpartum that is able to breast feed
Lactational amenorrhea
Breastfeeding -> elevated prolactin -> inhibits GnRH -> LH/FSH production decreased
Exclusive breastfeeding often leads to anovulation and amenorrhea
282
Painful, itchy, eczematous, ulcerating rash on the nipple and areola
Paget disease of the breast
type of adenocarcinoma
Can also present with bloody discharge and nipple retraction
283
Why is mag sulfate given in preterm labore <32 wks?
Fetal Neuroprotection
| Given regardless if mom is preeclamptic
284
Pt with dysmenorrhea has cervical dilation and small firm mass within the uterus
Submucosal fibroid
can cause dilation when it prolapses through the os
Can be described as a labor like pain
285
What do you recommend for a hypothyroidism pt that wants to get pregnant?
Increase levothyroxine when the pt becomes preg
| Approx 30%
286
What happens if a pt declines tx for HSV?
Flare will resolve, and then they'll have decreasingly frequent recurrences
287
Pt has stress incontinence and irregularly enlarged uterus
Fibroids
Get a u/s
irregularly enlarged uterus
288
Premenopausal woman has dyspareunia, dry eyes, and decreased vaginal moisture
Sjogren's
anti-Ro/La
Bx - salivary gland
289
Management of CIN3 confirmed on colposcopy
If > 25
| Cervical conization or LEEP
290
What do you do if you really suspect syphillis but RPR is negative?
Tx with penicillin now and get a FTAA
291
post seizure, prego has arm in adduction and loss of external rotation
Posterior shoulder dislocation
292
Risks of untreated PID?
tubo-ovarian abscess, sepsis
293
Pt presents somewhat toxic with a ovarian mass.
Exp lap
| Advanced ovarian cancer can present with pelvic mass and ascites
294
Why are women infertile in PCOS?
Failure of follicle maturation due to imbalance in LH/FSH
295
b/l brownish gray nipple discharge
Non bloody discharge should be worked up for: pregnancy, guaiac, prolactin, TSH
Most likley physiologic galactorrhea
296
Post delivering a large baby mom has radiating suprapubic pain exacerbated by weight bearing
Pubic symphisis
Occurs after traumatic deliveries
Tx - supportive
297
Following pelvic surgery pt has painless loss of urine into the vagina
Vesicovaginal fistulas
PE pooling of clear watery fluid in the vagina
Dx - cysturoethroscopy
298
What should be checked in an obese pt with candida?
A1C
299
Contraindication for raloxifene?
Hx of DVT
| Used for osteoperosis in post menopausal
300
Ovarian mass w/ thick septations and solid components
Ovarian epithelial carcinoma
| abn proliferation of tubal epithelium
301
Greatest risk of chronic HTN in preggo?
Preterm labor
