OB/GYN Flashcards
Definition: amenorrhea
No menses in 3 months if regular at baseline
No menses in 6 months if irregular
Weeks 1-13
First trimester
Weeks 14-27
Second trimester
Weeks 28-40 and up
3rd trimester
Fetal movement is present when
16-20 wks GA
Born after or at 37 weeks GA
Term
Definition: preterm delivery
Born at 24 weeks to 36 weeks GA
Born at 42 weeks and above
Post term
Softening of cervix during 1st 4wks
Goodell sign
Softening of the midline of the cervical 6wks
Ladin sign
Blue discoloration of vagina and cervix 6-8wks
Chadwick sign
The mask of pregnancy hyperpigmentation of the face most commonly on the forehead, nose and cheeks; it can worsen with sun exposure second trimester 16wks
Chloasma
A line of hyperpigmentation that can extend from xiphoid process to pubic symphysis second trimester
Linea nigra
Which cells produce Beta hCG?
Cytotrophoblast or syncytiotrophoblast in placenta
What is the best diagnostic test to confirm intrauterine pregnancy?
Ultrasound
BHCG level of >1500 IU/L a gestational sac should be seen on U/S at what gestational age?
5 weeks
Ultrasound confirms gestational age and checks for nuchal translucency within what gestational age range?
Between 11 and 14 wks
Genetic testing, including the Harmony test, Triple and Quad screen are performed at what genstational age range?
15-20 wks gestation
What is the most important screening test performed at gestational age 24-28 weeks?
Glucose load
Chorionic villus sampling to obtain fetal karyotype is performed at what gestational age range?
10 to 13 wks
Amniocentesis to obtain fetal karyotype is performed at what gestational age range?
After 15-20 weeks
Most common site of ectopic pregnancy
Ampulla of Fallopian tube
Period of amenorrhea
Unilateral lower abdominal or pelvic pain
Vaginal bleeding
If ruptured, can be hypotensive with peritoneal irritation
Ectopic pregnancy
What would be the best next step in management of a suspected ruptured ectopic pregnancy?
Stable-laparoscopy
Unstable- supportive care (IVF, blood products, pressors if needed) followed by laparoscopy
What would be the next best step in management for ectopic pregnancy which is not suspected to have ruptured?
Choice of medical treatment (methotrexate) vs surgery (laparoscopy)
What are the exclusion criteria for methotrexate for treatment of ectopic pregnancy? [4]
Suspected rupture (absolute)
Size greater than 4.0cm or greater than 3.5cm with cardiac activity (relative)
B-hcg greater than 5000 (relative)
Severe comorbid conditions (hematologic abnormalities, renal/liver failure, active pulmonary disease, PUD, immunocompromise)
Ultrasound findings demonstrating NO products of conception in a patient with suspected spontaneous abortion have what significance?
Complete abortion
Ultrasound findings demonstrating some products of conception, but no intact fetus, in a patient with suspected spontaneous abortion have what significance?
Incomplete abortion
Ultrasound findings demonstrating intact products of conception in a pregnant patient with vaginal bleeding and cervical dilation have what significance?
Inevitable abortion
Ultrasound findings demonstrating intact products of conception in a pregnant patient with vaginal bleeding but no cervical dilation have what significance?
Threatened abortion
Ultrasound findings demonstrating intact products of conception with NO fetal heartbeat have what significance?
Missed abortion
Treatment: septic abortion
D&C
Antibiotics (levofloxacin, metronidazole)
At what gestational age is urine pregnancy test expected to become positive?
4 weeks
The B-hcg level is expected to follow what trend during pregnancy?
Doubling every 48hrs for the 1st 4wks
Peak level at 10 weeks gestation
level drops in 2nd trimester
GBS screening is indicated at what gestational age?
35-37 weeks
Glucose load testing is performed at what gestational age?
24-28 weeks
Definition: complete abortion
SAB with no products of conception on ultrasound
Definition: incomplete abortion
SAB with some passage of fetal tissue and some remaining on ultrasound
Definition: inevitable abortion
Vaginal bleeding and cervical dilation in early pregnancy with products of conception intact (< 20 weeks, greater than 20 would be PTL)
Definition: threatened abortion
Vaginal bleeding at less than 20 weeks with no cervical dilation and products of conception intact
Definition: missed abortion
SAB with products of conception intact but absence of fetal heartbeat
(may have no vaginal bleeding)
Preterm birth occurs at what gestational age?
<37 weeks
Definition: Preterm Labor
contractions + cervical change occurring b/w 20 and 37 wks gestation
Preterm Labor: best next step delivery if
EGA 34-37 weeks & EFW >2500g
Preterm Labor: stop delivery when
EGA 24-33 weeks, EFW 600-2500g
What is the first step in management for preterm labor in a pregnancy that does not meet criteria for viable delivery?
betamethasone & tocolytics (magnesium sulfate)
Magnesium toxicity during preterm labor leads to what findings (2) and what physical exam maneuver should be checked?
- respiratory depression
- cardiac arrest
check deep tendon reflexes often
How can magnesium toxicity during preterm labor be reversed?
Calcium gluconate
Signs of PROM after sterile speculum exam [3]
- fluid pools in posterior fornix 2. fluid turns nitrazine paper blue 3. when dry, fluid has ferning pattern
PROM treatment before 32 weeks gestation
corticosteroids and Abx
PROM txt >37 weeks gestation, unknown GBS, >18 hours rupture
Penicillin is administered for prophylaxis
34-37 weeks gestation PROM, unknown GBS
Initiate Penicillin
PROM known GBS negative
NO Antibiotics
PROM,<34 weeks gestation, unknown GBS
Erythromycin and Ampicillin initiated
Third trimester bleeding differential diagnosis for Uterine bleed (4)
Uterine rupture, placenta previa, vasa previa, placental abruption
Definition and presentation: placenta previa
abnormal implantation of placenta over internal cervical os. Presentation: PAINLESS vaginal bleed usually presents >28 weeks
Digital vaginal exam is contraindicated in what trimester/circumstance
3rd trimester vaginal bleeding
or known placenta previa
Definition: vasa previa
fetal vessel present over cervical os
Treatment of placenta previa
strict pelvic rest
may require C-section (labor, severe hemorrhage, fetal distress)
Definition: placental abruption
Abnormal, premature separation of placenta from uterus
Risk factors for placental abruption (4)
- maternal HTN 2. prior placental abruption 3. tobacco and/or cocaine use 4. trauma
Clinical presentation for placental abruption
PAINFUL vaginal bleeding, possible contractions and fetal distress
Best diagnostic test for placental abruption
Transabdominal ultrasound
Placental abruption treatment
C-section (uncontrolled hemorrhage, fetal distress), vaginal delivery (placental separation is limited, fetal heart rate is assuring, fetal death prior to presentation)
uterine rupture risk factors (5)
- previous c-section (classical incision higher risk) 2. trauma 3. uterine myomectomy 4. uterine overdistention 5. placenta percreta
clinical presentation of uterine rupture
extreme abdominal pain, abnormal bump in abdomen, lack of uterine contractions, regression of fetus
treatment of uterine rupture
emergent laparotomy and delivery, repair of uterus or hysterectomy
Rhogram indications for Rh “unsensitized patients”
28 weeks gestation, delivery, procedures (amniocentesis), bleeding (abortion, abruption)
Rh incompatibility: Antibody titer <1:16 fetus is Rh + what diagnostic test do you order?
MCA doppler if peak MCA velocity >1.5MOM cordocentesis with transfusion if fetal Hct is <30%
Complications of macrosomia
shoulder dystocia, birth injuries, low apgar scores, hypoglycemia
Macrosomia treatment
Induction of labor: lungs mature EFW<4500g, c-section EFW>5000g
hyperemesis gravidarum
severe nausea and vomiting in pregnancy, usually self-resolves
Best initial therapy for hyperemesis gravidarum
dietary modification, avoidance of triggers, acupuncture, ginger, vitamin B6
If pregnant patient with hyperemesis gravidarum does not improve what is the best next step in managment?
Dopamine antagonist (Metoclopramide)
hyperemesis gravidarum pt with severe symptoms best next step in management?
antihistamines such as diphenhydramine
Asymptomatic bacteriuria is typically screened for in pregnant patients at what gestational age?
12 to 16 weeks
Treatment for asymptomatic bacteriuria in a pregnant patient?
Nitrofurantoin, amoxicillin, cephalexin
Symptoms of acute cystitis in a pregnant pt and txt…
urinary frequency, dysuria, presence of WBCs on UA, begin empiric thpy with nitrofurantoin or penicillin until senisitivity returns
Antibiotics to avoid in pregnancy
Bactrim, aminoglycosides, doxycycline and fluoroquinolones
If a pregnant patient presents with acute pyelonephritis how do you treat?
hospital admission and IV ceftriaxone. Nitrofurantoin or cephalexin is then given for the remainder of pregnancy to prevent recurrence.
Best initial test for PE in pregnancy is
V/Q scan
If V/Q scan is indeterminate in pregnancy what is the next best step in management?
CT pulmonary angiogram
Treatment of PE/DVT in pregnancy
LMW heparin
These PE/DVT meds are contraindicated in pregnancy
warfarin, direct thrombin inhibitors and factor Xa inhibitors
When should LMW Heparin be stopped in pregnancy for PE/DVT?
24 hours before delivery, resume 12 hours after c-section, 6 hours after vaginal delivery, continue for 6 weeks post-partum
How does one screen for cervical cancer during pregnancy?
Pap is safe during pregnancy, colposcopy is safe too, endocervical curettage should NOT be performed
May cause during pregnancy fetal: microcephaly, facial disproportion, hypertonia, seizures, irritability, sensorineural hearing loss. Order IgM and PCR for…
congenital zika
chronic HTN
BP >140/90 before 20 weeks gestation
Gestational HTN
BP >140/90 after 20 weeks gestation
Treatment for gestational or chronic HTN during pregnancy
labetalol, nifedipine, or methyldopa
mild preeclampsia
HTN >140/90 dipstick 2+, 24 hr greater than 300mg, edema of hands, feet, face
severe preeclampsia
HTN>160/110, dipstick 3+, 24 hr greater than 5g, generalized edema, impaired liver function, vision changes and mental status changes
Mild preeclampsia at term what is the next best step in managment?
induce delivery
Mild preeclampsia preterm what is the next best step in management?
Betamethasone (mature fetal lungs), Magnesium sulfate (seizure prophylaxis)
severe preeclampsia preterm what is the next best step in management?
- prevent eclampsia (magnesium sulfate), 2. control bp (hydralazine) 3. delivery (betamethasone)
severe preeclampsia term what is the next best step in management?
- prevent eclampsia (magnesium sulfate) 2. control bp (hydralazine) 3. delivery
Eclampsia
Tonic-clonic seizures occurring in pts with preeclampsia
Treatment for eclampsia
stabilize mother (seizure control: magnesium, BP control: hydralazine and labetalol) deliver baby
HELLP syndrome
Hemolysis, Elevated Liver Enzymes, Low platelets Txt: stablize mother (hydralazine and labetalol for bp and deliver baby)
How do you screen for gestational DM?
one hour glucose challenge test (50g glucose) non-fasting ingestion and serum measurement one hour later. If greater than 140mg/dL + test
What if the glucose challenge test is positive what test is performed next in presumed gestational DM?
3 hour glucose tolerance test (100mg glucose) fasting ingestion followed by serum glucose measurements at 1,2,3 hours after ingestion
early decelerations in OB are a sign of
head compression-normal (mirror mom’s contractions)
variable decelerations in OB are a sign of
umbilical cord compression
late decelerations in OB are a sign of
fetal hypoxia- intervention is needed (no return to baseline until contraction ends)
Treatment for lactational mastitis
dicloxacillin or cephalexin
Breast cancer screening starts at what age?
50, pts with a family hx of breast cancer 40
primary amenorrhea
absence of menstruation by age 15 in a female who has normal secondary sexual characteristics
causes for primary amenorrhea (6)
Turner syndrome (gonadal dysgenesis), Mullerian agenesis, delay of puberty, PCOS, hypopituitarism
Initial testing for primary amenorrhea includes
beta-HCG, TSH, prolactin, FSH, pelvic ultrasound
secondary amenorrhea
absence of menses for more than 3 months in a female who menstruates regularly or absence of menses for 6 months in a female who menstruates irregularly
causes of secondary amenorrhea (6)
pregnancy, hypothalamic amenorrhea, hyperprolactinemia, primary ovarian insufficiency, PCOS, thyroid abnormalities
best initial test for secondary amenorrhea
beta-HCG
Lab exams ordered in secondary amenorrhea
TSH, FSH, Prolactin levels
Abnormal uterine bleeding: menorrhagia
Heavy, prolonged menstrual bleeding, gushing of blood, clots may be seen (Endometrial hyperplasia, uterine fibroids, intrauterine devices, dysfunctional uterine bleed)
Abnormal uterine bleeding: hypomenorrhea
light menstrual flow, may only have spotting (obstruction-hymen, cervical stenosis, OCPs)
Abnormal uterine bleeding: metrorrhagia
intermenstrual bleeding: endometrial polyps, endometriral/cervical cancer, exogenous estrogen administration
Abnormal uterine bleeding: menometrorrhagia
irregular bleeding (endometiral polyps, endometrial/cervical cancer, exogenous estrogen administration, malignant tumors)
Abnormal uterine bleeding: oligomenorrhea
menstrual cycles >35 days long (pregnancy, menopause, anorexia, tumor secreting estrogen)
Abnormal uterine bleeding: postcoital bleeding
bleeding after intercourse (cervical cancer, cervical polyps, atrophic vaginitis)
Diagnosis/evaluation of abnormal uterine bleeding what test do you order?
CBC, pregnancy test, PT/PTT, pelvic ultrasound, endometrial biopsy, pap smear, thyroid studies, prolactin levels
Treatment of dysfunctional uterine bleeding
OCPs, cyclic progesterone, acute hemorrhage (D&C, IV estrogen), Long-term (Endometrial ablation, hysterectomy)
Bacterial vaginosis
Gardnerella, vaginal discharge with fishy odor, gray white , saline prep- clue cells treat with metronidazole or clindamycin
Candidasis vagina
candida albicans, white, cheesy discharge KOHL psedohyphae treat with nystatin, miconazole or clotrimazole
Trichomonas STD
Trichomonas vaginalis- profuse, green, frothy vaginal discharge, saline prep- motile flagellates. Treat both patient and partner with metronidazole
Physical exam of adenomyosis in female & TXT
uterus is large, globular, boggy, TXT: hysterectomy
Diagnosis: uterine abnormality: cyclical pelvic pain, abnormal bleeding, infertility. On physical exam nodular uterus with adnexal mass present
Endometriosis
Treatment of Endometriosis mild and severe disease
Mild: NSAIDs, combined OCPs severe: Danazol, leuprolide acetate (leupron), surgery
Diagnosis: OB/GYN amenorrhea or irregular menses, hirstuism and obesity, acne, insulin resistance
PCOS
Diagnostic test for PCOS
Pelvic ultrasound, elevated free testosterone, LH to FSH ratio >3:1
Treatment for PCOS
weight loss, OCPs, spironolactone (hirsutism), metformin (insulin resistance), colmiphene (infertility)
post-partum hemorrhage: uterine atony
Boggy uterus massage and use meds (oxytocin)
Post-partum hemorrhage: uterine inversion
Absent uterus on speculum exam manually reduce use tocolytics followed by oxytocin as needed to bring uterus down
Post partum hemorrhage: retained placenta
Firm uterus, placental blood vessels go to the edge. Burrows deeply, accessory lobe, placental tear. Txt with D&C or TAH f/u BHCG
Post-partum hemorrhage vaginal lacerations
Normal uterus txt with pressure and suture
Fibroids
Heavy menses, enlarged uterus, constipation, urinary frequency, pelvic pain/heaviness
