OB-Gyn Flashcards
Flank pain that radiates to groin
Renal colic (kidney stones)
Dx: US of kidneys & pelvis in pregnant pt
Ferning (Fern Test)
+amniotic fluid → Rupture of membranes (detects onset of labor)
- Occurs due to the presence of sodium chloride in cervical mucus under estrogen effect when the mucus dries on a glass slide. When high levels of estrogen are present, just before ovulation, the cervical mucus forms fern-like patterns due to crystallization of sodium chloride on mucus fibers. Also known as “arborization”.
- Disappearance of ferning suggests ovulation (when progesterone is dominant hormone)
- Persistence of ferning throughout menstrual cycle suggests anovulation
Anterior vaginal wall tenderness
Bladder pain syndrome
(+urinary Sx)
Postcoital bleeding/spotting
Cervical carcinoma
Chronic pelvic pain + uniformly enlarged boggy uterus + HMB (heavy menstrual bleeding)
Adenomyosis
(trapped endometrial glands in myometrium)
Tenderness in posterior cul-de-sac
(Pouch of Douglas; between uterus & colon)
Endometriosis
Atypical glandular cells on Pap
Endometrial biopsy indication
- +colposcopy
- +endocervical curettage
- to r/o cervical or endometrial adenocarcinoma
PCOS ovulation induction if wt loss fails
Letrozole > Clomiphene citrate
- Letrozole = nonsteroidal aromatase inhibitor
- Better fertility outcomes & fewer heterotrophic pregnancies compared to clomiphene
PCOS first line Tx
Wt loss
PCOS menstrual regulation Tx
OCPs
Failure of follicle maturation
PCOS
MOA: High adipose tissue → High peripheral androgen conversion → Persistently elevated estrone → Inhibitory feedback to hypothalamus → FSH suppression (+lack of LH surge) →Failure of follicle maturation → Infertility
Word catheter placement
for Bartholin gland cysts
- following I&D to allow for continued drainage & reepithelialization of a tract for future drainage
Contraindicated in migraine w/ aura
OCPs
(Estrogen-containing medications)
FSH in menopause
Elevated
Dx of PMS
Symptom diary of luteal phase symptoms
(2 weeks before menses until menses)
PMS Tx
SSRIs
Eczematous/ulcerating, itchy rash localized to nipple
Paget disease of the breast → Underlying adenocarcinoma
(thought to be caused by migation of neoplastic cells through the mammary ducts to the nipple surface)
UL bloody nipple discharge w/o lesions (clear breast)
Breast papilloma
- When a single tumor grows in a large milk duct, it’s called a solitary intraductal papilloma
Breast binding/tight bras are NOT RECOMMENDED for lactation suppression due to
Risk of mastitis, plugged ducts, increased pain, & inadvertent nipple stimulation
Failed induced progesterone withdrawal bleed
Asherman syndrome
(intrauterine adhesions)
- Secondary amenorrhea from previous uterine instrumentation or infection
Mittelschmerz
UL abd pain w/ ovulation in young women
(Day 10-14)
Clear, elastic, thin (uncooked egg white in appearance) cervical mucus secretion at cervical os
Corresponds to LH surge, indicating ovulation
(occurs just prior to ovulation & used to time intercourse in couples trying to conceive)
Erythematous breast + dimpling or pitting
Inflammatory Breast Carcinoma
- Order mammography, US, & tissue biopsy
Chemotherapy + amenorrhea
Ovarian failure
- Decreased Estrogen (due to loss of estrogen production from follicular granulosa cells)
- Elevated FSH & LH
- Normal PRL & TSH
- Hypergonadotropic hypogonadism (primary ovarian insufficiency)
- Tx: Hormone replacement therapy (HRT)
Theca cells & granulosa cells produce:
- Theca: Androstenedione (estradiol precursor)
- Granulosa: Estradiol (conversion from aromatase)
- Estradiol is later converted to estrogen, which is released from follicle during follicular phase;
- Estrogen peaks at end of follicular phase causing LH surge
- Progesterone is released from corpus luteum
- Progesterone is elevated during luteal phase (following ovulation)
- Hypothalamus (GnRH) → Anterior Pituitary (LH/FSH) → Ovary (theca/granulosa cells) → androstenedione, estrogen, progesterone (LH)
- Males:
- LH → Leydig → T → inhibits hypothalamus & AP
- FSH → Sertoli → Inhibin → inhibits AP
PID can lead to this presentation w/ RUQ pain
Perihepatitis
(Fitz-Hugh-Curtis Syndrome)
Sharp or stabbing pain w/ intercourse
Ovarian cyst (ruptured)
Natural form of contraception for first 6 months postpartum
Elevated prolactin for lactation (production, not ejection)
- PRL inhibits GnRH → decreased LH/FSH → Anovulation
Heterosalpingogram
Visualization of uterus/fallopian tubes to investigate infertility
Endometriosis after failing NSAIDs & OCPs
Diagnostic laparoscopy
Most common reason for female infertility
Endometriosis (~25%)
Pts w/ endometriosis are at an increased risk for
Infertility
(most common reason for female infertility; ~25%)
Adnexal mass w/o doppler flow
Ovarian torsion
(Adnexal torsion)
- Dx: Ultrasound
- Tx: Laparoscopy (cystectomy & detorsion)
Cervical lesion
“the answer is always colposcopy”
Proliferation of SM cells within the myometrium, irregular uterine enlargement, & chronic anemia/AUB (abnormal uterine bleeding)
Leiomyomata uteri
(fibroids)
Uniformly enlarged uterus
Adenomyosis
(proliferation of endometrial glands inside the uterine myometrium)
Irregularly enlarged uterus
Fibroids
Simple, small, thin-walled cyst
Follicular ovarian cyst
Adnexal mass w/ hyperechoic nodules, calcifications
Cystic teratoma
(non-seminomatous dermoid ovarian cyst)
- Elevated B-hCG, Elevated AFP
Stress incontinence is associated with
Urethral hypermobility
Tx:
- Kegels
- Urethral sling surgery
- Pseudoephedrine (alpha-adrenergic)
- SUO POB
Urge incontinence Tx
- Oxybutynin (antimuscarinic) and/or
- Tamsulosin (alpha-blocker)
Overflow incontinence Tx
Bethanechol (cholinergic)
“Bethany call me to stimulate your bowels and bladder”
HTN + Proteinuria in pregnant pt
Preeclampsia
- +seizures = Eclampsia
- Tx:
- Delivery
- Magnesium for Sz PPX
- Antihypertensive management
Hemolysis, elevated LFTs, thrombocytopenia in pregnant pt
HELLP Syndrome
(severe pre-eclampsia)
- Tx:
- Delivery
- Magnesium for Sz PPX
- Antihypertensive management
UL bloody nipple discharge w/o mass
Intraductal Papilloma
Ovarian mass + thick septations + ascites
Epithelial ovarian cancer
(from abnormal proliferation of tubal epithelium or ovarian epithelium)
CA-125 is used to detect epithelial ovarian cancer, particularly in:
Postmenopausal women
Also elevated in:
- Leiomyomata
- Endometriosis
Diminished ovarian reserve in women begins at
>35yo
Uterine synechiae
Asherman syndrome
(synechiae = adhesions)
Urethral hypermobility
Stress Incontinence
- Kegels
- Urethral sling surgery (long-term)
- Pseudoephedrine (alpha-adrenergic)
High-risk HPV
16 & 18
(cervical cancer)
Non-high risk strains of HPV
6 & 11
(Condylomata acuminata–genital warts)
- Tx: Trichloroacetic acid or surgical removal
Tamoxifen (SERM) is contraindicated if
h/o VTE
Tamoxifen (SERM) can cause
Endometrial carcinoma
Antiestrogens/Estrogen antagonists (SERMs) are indicated in
(Tamoxifen, raloxifene, clomiphene citrate)
ER+ breast cancer
- ADE: Vaginal dryness, decreased libido
- Tamoxifen can lead to endometrial cancer
- Clomiphene is Tx for PCOS infertility
PPROM Tx
(preterm premature rupture of membranes; <37 wks)
Abx + Steroids + Delivery @ 34 weeks
Pregnant pt w/ short cervix on TVUS or h/o preterm birth
Vaginal progesterone
(to maintain uterine quiescence & protect amniotic membranes against premature rupture)
- If short cervix AND h/o preterm birth = Cerclage
Short cervix on TVUS and h/o preterm birth
Cerclage
(if only one, then vaginal progesterone)
PPH <24 hours
(postpartum hemorrhage)
Uterine atony
Tx:
- Uterine massage
- Oxytocin (uterotonic; induces uterine contraction in PPH)
- Methylergonovine
Carboprost (Hemabate), uterotonic in PPH, is contraindicated in
Asthma pts
- Oxytocin
- Methylergonovine (contra in HTN)
- Carboprost (contra in Asthma)
- Misoprostol
Uterotonics
(Tx for PPH to induce uterine contraction)
Breastfeeding contraindications
(TB/HHV/CSG)
- Active TB
- Maternal HIV
- Herpetic breast lesions
- Varicella (active)
- Chemotherapy/Radiation
- Active Substance abuse
- Infantile Galactosemia
Baseline OB intake labs (first visit)
CBC, A1C, Rubella, Depression screen
Ovarian neoplasm risk factors
- Nulliparity
- FHx
- BRCA1 or BRCA2
- Early menarche
- Late menopause
- White
- Increasing age
- Residence in North America or Northern Europe
Ovarian cancer protection w/ OCP use
Five years cumulative use decreases lifetime risk by 1/2
Vaccines contraindicated in pregnancy
MMR & Varicella
Thyroid levels in pregnancy
Total T3, T4, TBG all increase during pregnancy
(increase levothyroxine dose during pregnancy)
Appropriate gestational weight gain
25-35 lbs if normal weight
- If underweight: 28-40 lbs
- If overweight: 15-25 lbs
- If obese: 11-20 lbs
Valproic acid teratogenic effect
Neural tube defects
- Elevated AFP on 20-week quad screen (ABEI: AFP, Beta-hCG, Estriol, Inhibin A)
T1DM teratogenic effects
Structural anomalies
(CV, neural tube)
Amniocentesis
US-guided diagnostic test for karytotype & DNA microarray testing if any pregnancy screen is positive
(_>_15 weeks)
Low PAPP-A (pregnancy-associated plasma protein A) on first trimester screen
Aneuploidy
- +thicker NT
Risk of IUGR is elevated in
Pre-existing diabetes, but not GDM
Most common form of inherited mental retardation
Fragile X syndrome
(AD Macroorchidism)
Most likely cause of elevated MSAFP
Underestimation of GA
(5% are NTD)
Ibuprofen in pregnancy
Can only be taken until 32 weeks of gestation
(due to risk of PDA closure)
Irregular contractions
Braxton-Hicks contractions
(begin at ~20 weeks, but varies)
Indications for prophylactic GBS Tx in unknown GBS status
- Hx of GBS-infected delivery
- Pre-term labor
- PROM > 18 hours
- Intrapartum fever (_>_38.0)
- GBS+ during pregnancy (Intrapartum NAAT+)
If no indications for GBS PPX, recto-vaginal culture at 35-37 weeks
PROM risk factors
- H/o PROM
- Genital tract infection (e.g. BV)
- Shortened cervical length (<22mm)
- Smoking
First stage of labor (latent + active)
- Latent labor: 0-6cm
- Active labor: 6-10cm
Second stage of labor
Delivery
(from when cervix is completely open to full delivery of baby)
Third stage of labor
Placenta
Umbilical cord prolapse
Elevate fetal head + CSx
Meconium-stained fluid + depressed infant
Intubate trachea, then suction meconium & other aspirated material from beneath the glottis immediately after delivery
IUGR + hypoglycemia at birth
Maternal T1DM
Fetal tachycardia + minimal variability
Septic infant (chorioamnionitis)
(pale, lethargic, febrile)
HIV + Birth: Protocol?
Start AZT on infant immediately
Postpartum Blues
Up to 2 weeks
PP-depression
2 weeks to 6mo + ambivalence toward newborn
Severe nipple pain
Candida
Decreases ovarian cancer
- Breastfeeding
- OCPs
Milk production vs. Milk ejection
- Milk production = Prolactin
- Milk ejection = Oxytocin
Female breast duct apparatus development during puberty
Insulin & Cortisol (steroid)
Tx for early ectopic pregnancy
Methotrexate (<4 cm)
Hypovolemia + Peritoneal + Positive UPT
Ruptured ectopic pregnancy
(Laparoscopy)
B-hCG doubles every 48 hours until
48d gestation
Stimulated by suckling
Oxytocin
(milk ejection)
No IUP on US + B-hCG over discriminatory zone
Ectopic Diagnosis
- Discriminatory zone = 2000; the level at which an IUP should be seen on US
B-hCG levels not rising fast enough w/ pregnancy (doubles every 2d until 48d GA)
Ectopic pregnancy
B-hCG levels do not fall following diagnostic dilation & curettage (D&C)
Ectopic pregnancy
Most common aberration leading to SAB
Trisomy 16
(14% of chromosomally abnormal abortions)
Prolonged Russell viper venom time (dRVVT)
APLS
(Antiphospholipid Antibody Syndrome)
- +recurrent pregnancy loss
- +h/o VTE
- Tx: Aspirin + Heparin
Medical abortion (mifepristone) is associated with a ___ blood loss than surgical abortion
Higher blood loss
Mifepristone can be offered in up to __ weeks GA
49 days (7 weeks)
- Vacuum aspiration up to 8w GA
Thin, gray homogenous vaginal d/c
Bacterial Vaginosis
- +positive whiff test (w/ potassium hydroxide)
- +clue cells
- +pH >4.5
- Tx: MNZ
Itchy vag + thick, white d/c + pH <4
Candidiasis
Lacy, reticulated labial/perineal pattern + remissions/flares of inflammatory mucocutaneous eruptions of vulva, skin, scalp (alopecia), nails, & gums
Lichen planus
Itch-scratch-itch cycle w/ normal vaginal pH
Lichen simplex chronicus
“Cold” or malaise symptoms followed by pruritus/pain
Primary HSV-1 infection
Low pelvic pain, urinary urgency, hematuria, no d/c
UTI
HBV exposure treatment (HBsAg positive)
HBIG + HBV vaccine series
GC/CT Tx
CTX + [Azithromycin or Doxycyline]
No doxy if pregnant
Order of maturation
Thelarche > Adrenarche > Growth spurt > Menarche
- Thelarche = breast/areolar development (10yo)
- Adrenarche = onset of axillary/pubic hair growth (pubarche)
- Menarche = onset of menses (12.7yo; > 85 lbs)
- Coitarche = age of first intercourse
Q-tip test straining angle > 30 degrees
Urethral hypermobility
(Genuine Stress Incontinence)
- Surgical Tx:
- Retropubic Urethropexy (surgically attaching slings to Cooper’s ligament–retropubic to urethra) to provide tension on urethra)
- Urethral bulking procedure (collagen injections into external bladder to compress lumen) if 2/2 intrinsic sphincteric deficiency w/o urethral hypermobility
Cystometrogram
Bladder scan
Least invasive tx for pelvic prolapse
Pessary fitting
Nodularity along back of the uterus along the uterosacral ligaments
Endometriosis
Chocolate cyst
Endometrioma
(Complex ovarian cyst)
- Functional hemorrhagic cyst = shorter duration
Endometriosis first line Tx
NSAIDs + OCPs
- 2nd-line Tx: GnRH agonist (e.g. leuprolide)
- If still refractory: Diagnostic laparoscopy
- First-line surgical Tx: Laser ablation
- Definitive Tx: Hysterectomy w/ BSO
Sudden onset pain + nausea + cyst on abd/pelvic US
Ovarian torsion
(pain + nausea + cyst = torsion)
Tx of mastitis
Penicillins
(most commonly staph aureus)
CIN III
LEEP
- CIN I = LSIL (low-grade squamous intraepithelial lesion) = No Tx
(becuase not invasive cervical cancer)
Acetowhite
Staining done during colposcopy to detect areas of high-grade lesions
PCOS increases the risk of these cancers
Endometrial & ovarian
(due to chronic unopposed estrogen)
PP hair loss due to high levels of estrogen is highest at
3mo PP
AUB (Abnormal Uterine Bleeding) mnemonic
PALM-COEIN
(Structural-Nonstructural)
- Polyp
- Adenomyosis
- Leiomyoma
- Malignancy and hyperplasia
- Coagulopathy
- Ovulatory dysfunction
- Endometrial
- Iatrogenic
- Not yet classified
Normal endometrial stripe thickness
< 4mm
Thickened endometrial stripe
> 4mm
- Endometrial cancer
- Normal aging
- Tamoxifen
Age range of premature ovarian failure
<35yo
HRT for osteoporosis is contraindicated in
CVD
- Tx: Vit D, 1200mg Calcium, Bisphosphonates
- Bisphosphonates inhibit bone resorption, preserving bone integrity
Imipramine (TCA) can cause
Hyperprolactinemia
Tx for PMDD (severe PMS; PMS refractory to OCPs or SSRIs)
BL oophorectomy
Nosebleeds during pregnancy
Pyogenic granulomas
“Pregnancy tumors”
(vascular lesions on anterior nasal septum common in pregnant women; hormonal)
PPROM Tx
Ampicillin + Erythromycin to prolong labor
Normal FHT
110-170
Low amniotic fluid glucose
Intraamniotic infection
Positive phosphatidylglycerol in vaginal fluid
Indicator of lung maturity
(or: 34w GA)
HTN Tx in pregnancy
Hypertensive Moms Love Nifedipine
- Hydralazine
- Methyldopa
- Labetalol
- Nifedipine
Mammography Screening
Every 2 years for women age 50-74
