OB/Gyn Flashcards
external cephalic version can be performed at __ weeks
> =37 weeks
to decrease risk of prematurity if complication occurs (eg contractions, fetal distress, premature rupture of membranes- all would require immediate delivery)
contraindications to external cephalic version
Contraindications to vaginal delivery
- previous classical cesarean delivery
- extensive myomectomy (fibroid removal)
- placenta previa
These patients will undergo Cesarean at 37 weeks
choriocarcinoma most commonly metastasizes to the __
lungs
presentation of choriocarcinoma
- amenorrhea or abnormal uterine bleeding
- pelvic pain/pressure
- sxs from mets (lung, vagina)
- uterine mass
diagnosis of choriocarcinoma is confirmed by __
elevated b-hCG level
treatment for postpartum endometritis
clindamycin + gentamicin
clinical features of acute fatty liver of pregnancy
n/v
RUQ/epigastric pain
fulminant liver failure
lab findings of acute fatty liver of pregnancy
- profound hypoglycemia (liver can’t convert glycogen to glucose)
- elevated aminotrnsferases (2-3x normal)
- elev bilirubin
- thrombocytopenia (dt fulminant liver failure)
- possible DIC
management of acute fatty liver of pregnancy
immediate delivery
when is it considered preterm prelabor rupture of membranes
<37 weeks
risk factors for preterm prelabor rupture of membranes
anything that distends or weakens the membranes
- polyhydramnions
- GU infection
- antepartum bleeding
management of uncomplicated preterm prelabor rupture of membranes <34 weeks
inpatient expectant management with:
-prophylactic latency antibiotics (to prevent intraamniotic infection thereby increasing time between rupture and delivery)
- corticosteroids eg betamethasone (decr risk of neonatal respiratory distress syndrome)
- fetal surveillance (nonstress tests, fetal growth ultrasounds)
- tocolysis contraindicated as contraction often indicate complication that requires delivery or intervention
magnesium sulfate needed for preterm deliveries __ weeks and why?
<32 weeks if imminent delivery
fetal neuroprotection - reduce risk of cerebral palsy
time of onset postpartum blues vs depression vs psychossi
blues- 2-3 days (resolves within 2 weeks)
depression- within 4-6 weeks (can be up to 1 year)
psychosis - days to weeks
risk factors amniotic fluid embolism
advanced maternal age gravida >=5 cesarean or instrumental delivery placenta previa or abruption preeclampsia
2 main causes of cutaneous SCC
HPV infection
frequent sun exposure
Mammary paget disease is associated w what condition
adenocarcinoma
appearance of mammary paget disease
persistent, eczematous and/or ulcerating rash at nipple and spreads to areola
pain, itching, burning, no relief with corticosteroids
why might pt with von willebrand disease have normal PTT?
- mild to moderate vwf deficiency, may have enough factor 8 to maintain PTT levels
- stress or inflammation; vWF and factor 8 are acute phase reactants
- (pregnancy, OCP), thyroid hormone replacement increase vWF synthesis
how is the first stage of labor divided?
latent (0-6cm)
active (>=6-10cm)
normal labor progression in active phase
cervix dilates at least 1cm per hour
when is cesearean delivery needed during labor?
active labor arrest- no cervical change for 4 or more hours with adequate contractions / 6 hours or more with inadequate contractions; or category III Fetal heart tracing
when is an intrauterine pressure catheter placed?
when labor hasn’t completely arrested but cervical change slows to <1cm/2 hr (labor protraction)
if inadequate contractions, labor is augmented with oxytocin to incr contraction frequency and force
definition uterine tachysystole
> 5 contractions every 10 minutes
criteria of gestational hypertension (as opposed to chronic htn)
systolic pressure >= 140 or diastolic >=90 prior to conception OR 20 weeks
no proteinuria or end organ damage (otherwise preeclampsia)
maternal complications/risks of HTN
- superimposed preeclampsia
- postpartum hemorrhage
- gest diabetes
- abruptio placentae
- cesarean delivery
fetal risks when mom has HTN
- fetal growth restriction
- perinatal mortality
- preterm delivery
- oligohydramnios
fetal bradycardia rate? tachycardia?
<110 brady
>160 tachy
causes of fetal tachycardia
(>160)
- maternal fever
- med side effect (eg beta agonists)
- fetal hyperthyroidism
- fetal tachyarrythmia
causes of fetal bradycardia
- maternal hypothermia
- med side effect (eg beta blockers)
- fetal hypothyroid
- fetal heart block (eg anti Ro/SSA, anti-La/SSB)
signs and symptoms of chorioamnionitis/intraamniotic infection
- maternal fever >= 39C without another clear cause
- leukocytosis >15
- and/or purulent amniotic fluid
risk of developing IAI increases as labor progresses and after membrane rupture
complex ovarian cyst with calcified and hyperechoic areas
mature cystic teratoma (dermoid cyst)
explain hydrops fetalis in alpha thalassemia major
fetus makes hemoglobin barts (4 gamma chains) which have extremely high O2 affinity, doesn’t release O2 to tissues –> severe fetal hypoxrmia –> high output heart failure –> hydrops fetalis (eg skin edema, ascities) and fetal demise
friable cervix, yellow discharge in young female
most likely microscopic finding?
n gonorrhea or
chlamydia
no organisms (both are intracellular)
initial workup of recurrent pregnancy loss
- pelvic u/s
- karyotype
- thrombophilia testing
what is placenta previa
placenta covers the cervix
risk factors placenta previa
- previous placenta previa
- prior c-section
- multi gestation
how does placenta previa present
painLESS vaginal bleeding >20 weeks gestation
(eg nontender uterus, painless ireggular contractions)
*note bleeding is mostly maternal origin so many pts have reassuring fetal monitoring initially
management placenta previa
- no sex
- no digital cervical exam
- inpatient admission for bleeding episodes
most previas resolved by 3rd trimester
if persistent previa, undergo c-section at 36-37 weeks (prior to onset of labor)
what is placental abruption, how does it present?
(separation of placenta from uterus prior to fetal delivery
- vaginal bleeding
- uterine contractions
- constain abdominal PAIN
- fetal decels
definition preterm labor
cervical dilation 3cm or more, or effacement (length <2cm) with regular painful contractions at <37 weeks
pathognomonic finding ovarian torsion
lack of doppler flow
indications for giving anti-D immunoglobulin for Rh(D) negative patients
- at 28-32 weeks gestation
- within 72h of delivering Rh+ baby
- within 72h after spontaneous abortion
- ectopic preg
- threattened abortion
- hydatidiform mole
- chorionic villous sampling, amniocentesis
- abdominal trauma
- 2nd and 3rd trimester bleeding
- external cephalic version
**not indicated if dad is Rh-
GBS rectovaginal screening should be performed at __ weeks
35-37 weeks
results valid for about 5 weeks
definition of short interpregnancy interval
<18 months from delivery to next pregnancy
complications of short interpregnancy interval
- maternal anemia
- PPROM
- preterm delivery
- LBW
what causes painful genital ulcers
HSV, h ducreyi
what causes painLESS genital ulcers?
treponema pallidum
chlamydia trachomatis
common side effect of tamoxifen
hot flashes
theorized due to antiestrogenic activity in CNS which causes thermoregulatory dysfunction in the anterior hypothalamus
how to estrogen agonists increase risk of venous thromboemoblism
they increase protein C resistance
why are pregnant women at higher risk of pyelonephritis
progesterone-related smooth muscle relaxation causes ureteral dilation
–> allows bacteria to ascend readily to upper urinary tract
*one third of pts with asx bacteriuria do no completely eradicate the bacteria so repeat ucx required
next step for 21yo woman who has atypical squamous cells of undetermined significant, reflex HPV positive for high risk HPV
-repeat cytology in 12 months
21-24 is special age grp bc HPV so prevalent
if ASC-US persists for 2 years in age 21-24, would then do colposcopy
(if ASC-US in age >24 would do colposcopy)
guidelines cervical ca screening women age 30-64
- cotesting with cytology and HPV every 5 years
- 0r cytology alone every 3 years
which patients with ASC-US should get reflex HPV testing
recommended in patients >30
when should elective C-section be scheduled
at least 39 weeks (dt risk prematurity)
ACOG mammogram guidelines
offer screening mammo to women 40 and up annually
explain causes of R hydronephrosis in pregnancy
- compression by uterus which is rotated right
- right ovarian vein lies over right ureter
next step if pt has gestational trophoblastic disease
CXR
mets most commonly to lung
pregnancy weight gain guidelines
- underweight- gain 28-40
- normal- gain 25-35
- overweight- 15-25
- obese - 11-20
do you expect IUGR in pre-existing DM or gestational DM?
pre-existing
mcc elevated maternal serum AFP
other causes
most common: underestimation of gestational age
- twin gestation
- NTD
- abdominal wall defects
- pilonidal cysts
- cystic hydroma
- sacrococcygeal teratoma
ibuprofen is safe to take until ___. why?
32 weeks
premature closure of ductus arteriosus
what blood thinner is contraindicated in pregnancy
warfarin
Quad screen
- components
- when done
- who offered to
normal risk women in 2nd trimester (16-20 weeks)
AFP
hCG
unconjug estriol
inhibin
Cell free DNA (or NIPT screening) offered to who
when can it be done
women at increased risk for fetal aneuploidy
as early as 9 weeks and onward
risks of gestational DM
macrosomia, shoulder dystocia
metabolic disturbances
preeclampsia
polyhydramnios
most likely cause of variable decels
cord compression
what is a cause of early decels
head compression
features of twin twin transfusion syndrome
recipient baby
- plethoric
- polycythemic
- may get HF and hydrops from volume overload and poly
donor baby
- small
- anemic
- IUGR and oligo
protocol for baby born to HIV+ mom who has been treated
start AZT (zidovudine) immediately
APGAR components
HR RR Reflex Activity Color
safest method to suppress lactation
-breast binding, ice packs, analgesia. avoid breast stim
breastfeeding is a/w decreased risk of __
ovarian cancer
what hormonal changes occur right after delivery to allow milk prod?
rapid huge decrease in estrogen and progesterone -> progesterone no longer inhibiting alpha-lactalbumin by RER
progesterone withdrawal allows PRL to act unopposed in stimulating alpha-lactalbumin production
incr alpha-lactalbumin stimulates lactose synthase
signs that baby is getting enough milk
3-4 stools in 24h
6 wet diapers in 24h
weight gain
sounds of swallowing
strategy to increase milk supply and how it works
increase suckling - increases supply of oxytocin, which is responsible for milk ejection
(prolactin increases production)
treatment of nipple candidiasis
- topical clotrimazole or miconazole
- topical abx for often concurrent nipple fissures- triple antibiotic or mupirocin
- can rx topical steroid to facilitate healing or cases where nipples are very red and inflamed
-treat baby with oral nystatin, followed by oral flucon
what can 10-day medroxyprogesterone test tell you
can confirm low estrogen levels
presence of estrogen causes endometrial proliferation, which should shed when progesterone is withdrawn
pts without adequate estrogen will have min to no bleeding bc no lining to shed
what type of contraception is contraindicated in pt with migraine with aura
estrogen containing
incr risk stroke
untreated asx bacteriuria in pregnancy increases risk of
acute pyelo
cause of chancroid and what does it look like
H ducreyi
multiple deep painful ulcers
base may have gray to yellow exudate
risk factors for uterine inversion
things that overdistend the uterus
- macrosomia
- grand multiparity
- mult gestation
- polyhydramnios
- fast delivery
- placenta accreta
-iatrogenic- too much traction on umbilical cord when delivering placenta
management of uterine inversion
- immediate manual replacement (delay-uterus can swell and cervix can contract around it)
- uterine relaxants (eg nitroglycerine, terbutaline) to assist replacement if unsuccessful. prefer not to use bc can worsen uterine atony after replacement
- uterotonics only after uterus replaced
expected fetal tracings in placenta previa vs vasa previa
- normal fetal tracings in placenta previa early on as it’s mostly maternal blood loss
- rapid deterioration of fetal tracing in vasa previa as bleeding is mostly fetal origin
presentation of placenta previa
-painless vaginal bleeding after 20 weeks
dx and management of placenta previa
- dx: transabdominal, then transvaginal u/s
- management: no intercourse, no digital cervical exam; admission for bleeding episodes
how to evaluate risk for preterm labor
transvaginal u/s of cervical length
short cervix is strong predictor of ptl
definition short cervix
2cm or less without history of ptl
2.5cm or less with history of ptl
prevention of preterm birth, no h/o preterm labor
get TVUS cervical length, if short, give vaginal progesterone
prevention of preterm birth, yes h/o preterm labor
give IM progesterone
get TVUS cervical length, if normal get serial CL until 24
if short, do cerclage and serial CL until 24w
how does progesterone help prevent preterm labor
it maintains uterine quiescence and protects amniotic membranes against premature rupture
hematometra- what is it and cause
collection or retention of blood in uterus
caused by imperforate hymen or vaginal septum
fragile X genetics
GCC trinucleotide repeat
purpose of fetal fibronectin
what is it?
negative predictor of preterm delivery
fibronectin is an extracellular matrix protein that acts as adhesive of fetal membranes to decidua; presence in cervical mucous indicates disruption or injury to mat-fetal interface
testing indicated for recurrent first trimester losses
- lupus anticoagulant
- anticardiolipin antibodies
- DM
- thyroid disease
- uterine imaging to exclude septum or anomaly (hysterscopy or hysterography)
options to decrease risk perinatal transmission HIV
- IV zidovudine at time of delivery
- zidovudine to neonate
C-section before labor for viral load >1000
treatment for symptomatic MVP
beta blockers
risk factors for preeclampsia
- advanced maternal age
- nulliparity
- multip gestation
- obesity
- preexisiting med conditions (lupus, chronic HTN, DM)
complications in obesity and pregnancy
- chronic htn
- gestational dm
- preeclampsia
- macrosomia
- higher rates c-section and postpartum complic
what antidepressant should NOT be used in pregnancy
parocetine- class D, fetal cardiac malf and persistent pulm htn
therapeutic magnesium level for preeclampsia
4-7
loss of DTRs occurs at Mg __
7-10
respiratory depression occurs at Mg __
12-15
cardiac arrest occurs at Mg __
15
contraindications to expectant management of severe preeclampsia remote from term
- thrombocytopenia
- can’t control BP with max doses of 2 antihypertensives
- nonreassuring fetal tracings
- LFTs elev more than 2x normal
- eclampsia
- persistent CNS sxs
- oliguria
how much fetal blood is neutralized by 300mcg of rhogam?
30cc
signs of fetal hydrops
develops in presence of decr hepatic protein production
defined as collection of fluid in body cavities
- pericardial or pleural effusion
- placentomegaly (edema)
- polyhydramnios
- hepatosplenomegaly if extramedullary hematopoeisis is extensive
definition prolonged latent phase of labor
how to treat
> 20h for nulliparas
14h for multiparas
rest or augment labor
when should PID be treated in patient
severe, n/v, or pregnant
inpatient regimen for PID
IV cefoxitin and doxy
alternative: clindamycin and gentamicin
outpatient regimen for PID and what do these meds cover
ceftriaxone (gonorrhea and some gm neg)
doxycycline (chlamydia)
metronidazole (anaerobes, mycoplasma)
retraction of fetal head is classic presentation of __
shoulder dystocia
do mcrobert’s maneuver
management of IUGR
twice weekly non-stress test
AFI at least once a week
fetal growth restriction baby will be at risk for
- chronic diseases such as cardiovascular disease, htn, stroke, copd, t2dm, obesity
- cognitive delay in childhood
non stress test is based on what principle
that when fetus moves heart acelerates
fetal growth restriction is fetal weight less than __ percentile
10th
causes of prolonged periods fetal tachycardia
- maternal fever
- chorioamnionitis
when might amnioinfusion be used
repeated variable decels
how does head compression cause early decels
vagal nerve stim -> hr slows
uterine hyperstimulation can cause what fetal change
prolonged bradycardia
initial measures to evaluate and treat fetal hypoperfusion/occasional late decels
- left lateral position (increases perfusion to uterus)
- maternal O2
- stop oxytocin
- intrauterine resuscitation with tocolytics and IVF
most important source of lubrication in arousal phase
vaginal transudate
treatment for vaginismus
therapy with vaginal dilators
cause of intrahepatic cholestasis of pregnancy? treatment?
retain bile salt, which is deposited in dermis causing itching
initially- emollients and antihistamines
ursodeoxycholic acid- relieves itching and lowers serum enzyme levels
risk congenital varicella lowest in __ trimester
1st
what contraceptive decreases risk ovarian cancer
oral contraceptives
what contraceptive decr risk endometrial cancer
progesterone IUDs
oral levornogestrol (plan B) should be taken within __ (time) of intercourse
how does it work
72h
progesterone incr delays LH surge (thus delays ovulation)
copper IUD can be placed up to __ (time) after sex for emergency contraception
5 days
most freq cause of preterm labor
idiopathic
dehydration, uterine distortion (eg from fibroids) can be associated with ptl
benefits of betamethasone treatment in premature
- incr pulm maturity, decr risk of severe resp distress syndrome
- decr risk intracerebral hemorrhage and necrotizing enterocolitis in newborn
magnesium sulfate MOA preterm labor
competes w/ calcium for entry into cells
indomethacin MOA preterm labor
nonspecific COX inhibitor which blocks prostaglandin production
ritodrine use and MOA
management of preterm labor
impairs intracellular cAMP concentration, facilitating myometrial relaxation
*contraindicated in DM
nifedipine MOA preterm labor
CCB, interferes with calcium ion transfer thru myometrial cell membrane -> decr intracell calcium -> myometrial relaxation
atosiban use and MOA
used in preterm labor
- oxytocin receptor antagonist
- blocks intracytoplasmic calcium release
- downregulates prostaglandin synthesis
tx stable uncomplicated pyelo
FQ like cipro
alternative sulfa/tmp
tx rly sick pyelo
inpt IV aminoglycoside
plus ampicillin, piperacillin, or first gen cephalosporins, aztreonam, thhird gen cephalosporin, pip-tazo or FQ
when fevers and systemic sxs resolve, dc with 14 day course
what is blood show
bleeding that may occur as cervix dilates
can be seen in normal labor
septic pelvic thrombophlebitis
- relapsing remitting fevers
- thrombosis of pelvis venous system
- diagnosis of exclusion. CT scan will show thrombosed veins
- tx: short term anti coagulation
5 causes of post-op fever
Wind (atelectasis, PNA) pod 1-3 Water (UTI) pod 3-5 Walking (DVT, PE) pod 4-8 Wound (SSI) pod 5-7 Wonder drugs (anytime, drug fever)
what abx are not appropriate for nursing mothers
doxycycline
ciprofloxacin
tx endometritis
clindamycin, gentamicin
complications of epidural
- spinal headache
- localized back pain
- meningitis! (get LP!)
how to stimulate mensturation in pt with hypothalamic amenorrhea (such as athletes, nutri deficiency)
combined OCP
they are hyperestrogenic dt prolonged suppression of ovarian function
need estrogen to cause enough proliferation of endometrial tissue
(progestins alone would maintain endometrial atrophy)
elevated DHEAS and male features- most likely diagnosis
adrenal tumor
to test ferning, where should sample come from
vagina
*cervix can have false positives!
to do nitrazine and testing for ferning, where should sample come from
vagina
*cervix can have false positives!
latency abx for preterm prelabor rupture of membranes
ampicillin + erythromycin
clindamycin+gentamicin if chorionamnionitis suspected
what intervention can reduce the risk of preterm prelabor ROM?
weekly administration of 17a-hydroxyprogesterone starting between 16-20 weeks until 36 weeks
delivery is recommended at __ weeks for women with PPROM
34
expectant management eg tocolytics is contraindicated at 36w due to risk of chorionamniotis
what can cause false positive nitrazine test
semen
blood
normal vag pH
normal amniotic fluid pH?
normal vag 4.5-6
amniotic fluid 7.1-7.3
normal AFI
8-18
AFI of __ considered oligohydramnios
<5
when is c-section indicated for abruptio placentae
only if there are maternal or fetal indications
lichen planus
6 P’s
- purple
- pruritic
- polygonal
- planar
- papules
- plaques
may have oral lesions, alopecia, and extragenital rash
ultrasound findings c/w uteroplacental insufficiency
- growth restriction
- oligohydramnios
- placental calcifications
- fetal demise
definition macrosomia
> 4000g
what uterotonic contraindicated in hypertension
methergine
what uterotonic contraindicated in hypotension
Dinoprost (E2)
what uterotonic contraindicated in asthmatic pts
Hemabate (F2)
mechanism of factor V leiden
mutant factor V
protein C normally binds and inhibits factor V. but now it can’t –> hypercoagulable state
how do mifepristone and misoprostol working in terminating pregnancy
mifepristone- progesterone blocker
misoprostol- causes uterine contractions to expel contents
Rotterdam criteria for PCOS
- oligomenorrhea/anovulation
- lab or clinical evidence hyperandrogenism
- polycystic ovaries on ultrasound
can’t conceive bc of high prolactin, what may be the issue?
meds! antidopaminergic
eg quetiapine
hormones in exercise induced hypothalamic amenorrhea
normal FSH
low estrogen
how can you determine ovarian reserve
anti-Mullerian hormone
lichen sclerosis appearance
smooth white plaques
porcelain or parchment like
lichen planus
6 P’s
- purple
- pruritic
- polygonal
- planar
- papules
- plaques
lichen simplex chronicus
caused by itch scratch itch cycle
damages skin –> thick labia
treatment uncomplicated cervicitis
Empiric: Azithro + Ceftriaxone
confirmed chlamydia-azithro
(confirmed gonorrhea-azithro+ceftriaxone)
what condition is tolteridine contraindicated
narrow angle glaucoma
mirebegron
beta-3 antagonist
causes relaxation of detrusor muscle
avoid in htn, esrd, or liver disease
cause urge incontinence
overactive detrusor
cause stress incontinence
increase in intra-abdominal pressure
colpocleisis
vagina surgically obliterated
HRT effect on lipid
incr HDL
lower LDL
location of leiomyomas most likely to cause infertility
submucosal
intracavitary
purpose of using GnRH analogs before surgery
inhibit estrogen
reduce myoma size
decreased blood loss
therapy if pt has failed NSAIDs and OCPs for leiomyoma
GnRH agonist
temporary only to bridge to surgery
sequence of sexual maturation
- thelarche (breast budding)
- adrenarche (hair growth)
- growth spurt
- menarche
risk of isoimmunization during pregnancy
2% antepartum
7% after full term delivery
7% with subsequent pregnancy
incidence and size of transplacental hemorrhage incr as pregnancy advances
McCune Albright syndrome
premature menses, before breast and pubic hair development ____
what measure in amniotic fluid is best indicator of Rh hemolytic disease
bilirubin
nerves at risk in low transverse incision
- iliohypogastric (sensory groin and pubis
- ilioinguinal (sensory groin, symphysis, labium, upper inner thigh)
obturator nerve damage sx
can’t adduct thigh
can occur during LN dissection
best predictor that hysterectomy will improve chronic pelvic pain
tenderness confined to the uterus
hysterectomy done for chronic pelvic pain only has 50 percent chance of improving sxs even in carefully selected pts
positive Carnet’s sign
tenderness on lfexion of abdominal muscles
tx of pain that is constant, refractory to hormones and reproducible with palpation of somatic structures
suggestive of neuromuscular pain or fibromyalgia
- physical therapy
- exercise
- GABAergic meds like gabapentin/pregabalin may be helpful adjuncts
PMS vs PMDD
PMS mostly somatic sx
PMDD mostly psych sxs that seriously impair usual functioning and personal relationships
PMDD confined to __ phase of menstrual cycle
luteal
how to predict whether BL oophorectomy (ie surgical menopause) will help severe PMDD
improvement with course of GnRH agonist
*risks of causing early menopause = CVD, early bone loss, hot flashes
what supplement can improve PMS
at least 1200 mg calcium
sequence of sexual maturation
- thelarche (breast budding)
- adrenarche (hair growth)
- growth spurt
- menarch
cause of Kallmann syndrome
arcuate nucleus does not secrete GnRH
*also olfactory tract hypoplasia
Chadwick’s sign
blueish cervix due to increased blood flow
indication of pregnancy
ASCUS with negative HPV management
resume pap screening q3 years
adnexal mass and endometrial hyperplasia = what cancer
granulosa cell tumor
^ secretes high levels of estrogen which stim endometrial hyperplasia
ovarian mass ____ size increases suspicion for cancer
> 10cm
most common type of ovarian neoplasm in women <30 years
germ cell tumor
most common type of ovarian neoplasm in women >30 years
epithelial cell tumor
how does really high beta hcg affect other hormone
beta hcg alpha subunit identical to that in LH and RSH
so ovaries stimulated -> make lutein cysts
thyroid gland -> stim to make thyroid hormone -> TSH suppressed
what is nonreactive fetal stress test
no accels
mcc nonreactive fetal stress testt
fetal sleep cycle (can last as long as 40 min)
antiphospholipid syndrome
body makes Ab that makes blood more likely to clot
absolute CI to hormonal contraception
- active breast cancer
- migraines w/ aura
- uncontrolled htn
- active hepatitis, severe cirrhosis, liver cancer
- age 35 and up and 15 more more cigarettes/day
- ischemic heart dz, stroke
- less than 3 weeks postpartium
- prolonged immobilization
- thrombophilia (eg factor V Leiden, antiphospholipid antibody syndrome)
- venous thromboemoblism
GBS ppx for patients who have penicillin allergy but low risk for anaphylaxis
cefazolin
best conditions to get accurate prolactin levels
- fasting
- no breast stimulation for 24h
bloody fluid aspirated from breast mass - next step?
excisional biopsy to check for breast cancer
*note if it was CLEAR fluid and mass resolves, can just reexamine in 2 months
high risk groups that should get breast mri in addition to mammo for screening
- BRCA carriers, first degree rel of BRCA carriers
- mutations like Li-Fraumeni
- h/o chest radiation between age 10-30
breast mass, normall mammo. next step?
any solid breast mass on exam should be evaluated with cytology (FNA) or histology (excisional biopsy)
normal mammo does not rule out presence of cancer
risk of chorioamnionitis outweight benefits of continuing tocolytics beyond __ (time)
48h
frequent cause of cord compression
decreased amniotic fluid
abruptio placentae with reassuring maternal and fetal status - management?
expectant
c/s only if maternal or fetal indications
twins w single placenta has higher risk of _
twin twin transfusion syndrome
twins w single amniotic sac have higher risk of _
cord entanglement and IUFD
prophylactic latency abx indicated for __ weeks
<34
risk factors vaginal cancer
- age>60
- HPV
- smoking
- in utero DES (clear cell only!)
clinical feat vaginal cancer
- vag bleeding
- malodorous vag dc
- irregular vaginal lesion
most likely cause intermenstrual bleeding in 30-40yo, normal exam
endometrial polyp
uterus small nontender bc endmetr polyps are typically intracavitary
Depot medroxyprogesterone is given how often
every 3 months
Depot medroxyprogesterone is given how often
every 3 months
first line antihypertensives during pregnancy
beta blockers
CCB
hydralazine
methlydopa
definition of active phase labor protraction
cervix change <1cm every 2 hours
neuraxial anesthesia can lengthen which phase of labor
second stage (max dilation to fetal delivery)
definition preeclampsia
new onset htn (>=140 or >=90) at >=20 weeks
PLUS
proteinuria and/or end organ damage
definition of preeclampsia severe features
- BP >=160 or >=110 (two times at least 4 hours apart)
- thrombocytopenia
- elev Cr
- elev transaminases
- pulm edema
- visual or cerebral sxs
first degree lac
vaginal mucosa and perineal skin
second degree
vaginal mucosa, perineal skin + perineal body
third degree lac
anal sphincter muscles
fourth degree
rectal mucosa
dilation and evacuation for IUFD of what gest age
<24w
induction for vaginal delivery for IUFD of what gest age
> = 24 weeks
risk factors for postpartum uterine atony
- uterine fatigue (prolonged or precipitous labor)
- chorioanmnionitis
- uterine over distension (multigest, maacrosomia, polyhydramnnios)
- operative vag delivery
- retained placenta
- grand multip (>=5 deliiveries previously)
interventions for pp uterine atony
- bimanual uterine massage
- correct bladder distension
- hi dose oxytocin, misoprostol
- tranexamic acid
- carboprost, methylergonovine
- balloon tamponade
- poss surgery if unresolved
moa tranexamic acid
antifibrinolytic agent - prevents break down of blood clots to provide hemostasis
what HIV viral load may deliver vaginally
<=1000 copies, otherwise c/s
mechanism androgen insens syndrome
46,XY pt has nonfunctioning androgen receptors
has functioning testes that make Anti-Mullerian hormone –> no internal female genitalia
meanwhile testost no effect = no male external genitalia; default female external
testost aromatized to estrogen = breasts, tall
mechanism androgen insens syndrome
46,XY pt has nonfunctioning androgen receptors
has functioning testes that make Anti-Mullerian hormone –> no internal female genitalia
meanwhile testost no effect = no male external genitalia; default female external
why are pregnant women at incr risk for cholesterol gallstone formation?
elev Estrogen and Progesterone promote gallbladder stasis and cholesterol supersaturation
clinical features of Asherman syndrome
(intrauterine adhesions)
- AUB
- no menses
- infert, recurr pregnancy loss
- cyclic pelvic pain
inadvertent spinal block - mechanism, presentation
epidural cath accidentally punctures dura
hypotension, respiratory depression due to diaphragmatic paralysis
local anesthetic toxicity- mechanism, presentation
epidural catheter inadvert inserted into epidural vasculature
CNS anesthetic systemic toxicity, first blocks inhibitory pathways –> CNS overactivity (perioral numbness, metallic taste, tinnitus; may cause gen tonic clonic sz)
cardiovasc symp activation (tachy, hypertension) -> risk fulminant cardiovascular collapse
management local anesthetic systemic tox
- STOP drug
- benzos for seizure control
- supportive care
30w pregnant with R upper and R flank pain, n/v
acute appendicitis
appendix gets displaced cephalad = atypical presentation in preg, thus often late diagnosed
labs indicating proteinuria
> =300mg/24h
UPC>=0.3
or dipstick>=1+
labial adhesions/fused labia minor cause and tx
mostly in prepubertal girls due to low estrogen
inflammation (eg from poor hygiene, infection, diaper rash, trauma) can also contribute to dev of adhesions
topical estrogen only if lesions are symptomatic
when would you give intrapartum penicillin ppx to someone with unknown GBS statsus
- ROM for >=18 hours (incr bacteria so incr risk transmission)
- intrapartum fever
- delivery at <37 w (immature immune sys more susceptible to infection)
alsoo anyone with
- prior infant with early onset neonatal GBS infection
- GBS bacteriuria or GBS UTI in current preg regardless of treatment
causes of fetal hydrops
immune - Rh(D) alloimmunization
nonimmune
- parvo B19
- thalassemia (eg Hgb barts)
- fetal aneuploidy
- cardiovasc abnormalities
what are intrauterine synechiae
intrauterine adhesions (eg after infection, intrauterine surgery ashermans)
marker for epithelial ovarian cancer
CA-125
useful mostly in suspicious u/s postmenopausal women, as levels premenopausal can have false elevations
marker for epithelial ovarian cancer
CA-125
what non cancer things can cause elevated CA-125
- fibroids
- endometriosis
what is septic pelvic thrombophlebitis
a thrombosis of the deep pelvic or ovarian veins that becomes infected
a/w pelvic surgery or postpartum period
how is septic pelvic thrombophlebitis diagnosed
diagnosis of exclusion
persistent fever unresponsive to broad spectrum abx, neg infectious workup
treatment of septic pelvic thrombophlebitis
- anticoagulation
- broad spectrum abx
what is placenta accreta
uterine villi attach directly to myometrium instead of decidua
risk factors placenta accreta
- prior c/s
- hist D and C
- age >35
antenatal diagnosis of placenta accreta
u/s irregularity or absence of placental-myometrial interface
intraplacental villous lakes
management of antenatally diagnosed placenta accreta
planned cesearean hysterectomy
outpt PID tx
ceftriaxone + doxy
inpt PID tx
cefoxitin + doxy
labetalol
- what receptors it acts on
- mechanism
- time of onset
selective alpha-1
nonselective beta blocker
peripheral smooth muscle
metabolized in liver
IV- 10min
oral- 2h
nifedipine
CCB inhibits calcium influx into vascular smooth muscle
met by liver
oral-10-15 minutes
hydralazine
- MOA
- time of onset
directly dilates peripheral vessels
alters intracellular calcium release
inhibits smooth muscle calcium influx -> inhibt phosphorylation of myosin protein -> incr HR, SV, CO
met in liver
IV onset- 10-20 minutes
methyldopa MOA
chronic HTN in pregnancy
alpha2 agonist
what type of contraception should be avoided postpartum and why
avoid estrogen containing contraceptives <1month pp as it increases risk of thromboembolism
how does breastfeeding cause hypoestrogenism
inc prolactin inhibits GnRH release
patients may thus experience dyspareunia -> tx = nonhormonal lubricants, moisturizers
when should benign appearing endometrial cells on pap be worked up with endometrial sampling?
premenopausal w/ AUB or risk for endometrial hyperplasia
(otherwise not reported under age <=45 bc so common esp in first 10 days of period)
postmenopausal
how can PCOS cause infertility?
high androgens -> lots of peripheral andorgen conversion to estrones
high estrone -> high freq, short interval GnRH pulses
such GnRH pulses favor LH secretion from ant pit = LH/FSH imbalance = lack of LH surge = follicle fails to mature and release oocyte
= anovulation
definition postpartum urinary retention
can’t void >=6h after vaginal delivery or >=6 after foley removal after c/s
cause of postpartum urinary retention (2)
- Perineal trauma (prolonged second stage labor and/or perineal lac) –> perineal nerve injury
damaged pudendal nerve > decr voiding sensation and cause external urethral sphincter dysfunction
- Bladder Atony. Epidural anesthesia = reduced sensory and motor spinal cord impulses –> suppress micturition reflex and decr detrusor tone
management postpartum urinary retention
intermittent urethral catheterization + reassurance (usu self limited and resolves <1 wk)
gestational DM target
- fasting
- 1 hour postprand
- 2 hours postprand
- fasting <=95
- 1h pp <=140
- 2h pp <=120
treatment gestation DM
firstline: dietary mod
2nd line: insulin, metformin
management of hypothyroidism in pregnancy
in normal pregnancy, estrogen increases thyroid binding globulin = need more thyroid hormone to saturate the binding sites
also get an increase in thyroxine production as hCG stim TSH receptors (have sim alpha subunit)
==> incr total T4 but same free T4
BUT in pts with pre-existing hypothyroidism, they can’t increase thyroxine prod appropriately, so must increase thyroxine dosage and adjust q4 weeks based on labs
how can oxytocin cause hyponatremia
oxytocin has similar structure as ADH
elevated oxytocin can stim renal collecting ducts to increase free water absorption
thyroid labs in normal first trimester pregnancy
incr total T4 incr or unchanged total T3 decr TSH (suppressed by bhCG and increased T4)
symptoms maternal toxo infection
can be asx
if sx:
- fever
- diffuse nonpruritic maculopapular rash that resolves spontaneously
fetal findings toxo
T gondii preferentially destroys fetal neural tissue
- -> BL ventriculomegaly, intracranial calcification
- ascities, hepatosplenomegaly, fetal growth restriction
causes symmetric vs asymmetric fetal growth restriction
Symmetric- chromosomal abnormality, congenital infection
asymmetric- tihngs that cause placental insuff; maternal malnutrition
causes symmetric vs asymmetric fetal growth restriction
Symmetric- chromosomal abnormality, infection
asymmetric- tihngs that cause placental insuff
how preeclampsia can cause pulm edema
general vasospasm (htn) = incr afterload
also, decr albumin, decr renal function, and incr vascular permeability
normal renal lab changes in pregnancy and why
decr serum Cr
Renal blood flow (perfusion) and GFR increase in pregnancy. same prod of BUN and Cr but serum levels are decreased due to increased GFR
why increased urinary protein excretion in pregnancy
greater renal basement membrane permeability
up to 300mg/day
so UA with trace protein is normal in pregnancy
pt with elevated BP on OCPs, what should you do
stop the OCPs; can cause elevated BP and sometimes overt HTN
?mechanism, possibly estrogen increases hepatic angiotensinogen synth and other effects on renin-angiotensin system
risk of htn increases with duration of OCP use
pt with elevated BP on OCPs, what should you do
stop the OCPs; can cause elevated BP and sometimes overt HTN
?mechanism, possibly estrogen increases hepatic angiotensinogen synth and other effects on renin-angiotensin system
risks of intrahepatic cholestasis of pregnancy
bile acids can cross placenta and cause fetal complifcations
IUFD!
preterm delivery
neonatal resp distress syndrome
management of intrahepatic cholestasis of pregnancy
- deliver at 37wks
- frequent antepartum nonstress tests
- uresodeoxycholic acid (decr bile acid levels)
- antihistamines
why does intrahepatic cholestasis usu occur in 3rd trimester
incr Estrogen and Progesterone –> hepatobiliary tract stasis and decreased bile excretion
characteristics of postpartum psychosis
- depressed and/or manic mood
- severe insomnia
- agitation
- disorganized behavior
- **delusions and/or hallucinations
med emergency as mother may harm child under influence of delusions + at high risk for suicide
betamethason can be given __ weeks to prevent neonatal resp distress syndrome
<37 weeks gestation
bethanechol
stimulates M receptors, increasing bladder contractility
treats urinary retention (can tx overflow incont due to urinary retention)
biophysical profile
- purpose
- components
- meaning if abnormal
assess fetal oxygenation thru ultrasound observation and the nonstress test
components: (max 10pts)
- nonstress test
- AF volume
- fetal movements
- fetal tone
- fetal breathing movements
abnormal score (0-4) = fetal hypoxia due to placental insufficiency
Magnesium is excreted by _
kidneys
how does pregnancy increase risk kidney stones
progesterone induces urinary stasis and incr urinary calcium excretion
risk factor yeast infection
- increased estrogen (OCPs, pregnancy)
- DM
- immunosuppresion
- abx use
Amsel criteria
what is it, what is it for
BV
- pH>4.5
- whiff test
- clue cells
treatment BV
metronidazole or clindamycin
how do uretheral diverticula likely arise?
recurrent periurethral gland infections –> abscess that breaches urethral mucosa
causes tender ant vaginal wall mass. the diverticulum may collect urine and debris, resulting in purulent discharge, dysuria, or postvoid dribbling
pH of vaginitis bugs
BV and Trich >4.5
yeast is normal pH <4.5 (specifically 3.8-4.5)
complications after cervical conization
- cervical stenosis
- preterm birth
- PPROM
- 2nd trimester pregnancy loss
management of pregnant woman with h/o HSV
antiviral suppression starting at 36 weeks
if have lesions/prodromal symptoms during labor –> c-section
Erb-Duchenne palsy
- presentation
- nerve problem
waiter’s tip
C5 and C6
decreased or absent moro
Grasp reflex intact
Klumpke Palsy
- presentation
- nerve problem
claw hand
C8 and T1 excessive traction
ipsilateral miosis and ptosis
clinical features vaginal hematoma
- vaginal mass
- rectal or vaginal pressure
- +/- hypovolemic shock
treatment endometritis
gent/clinda
manual vacuum aspiration can be done for abortion at what age
up to 8 weeks
second stage arrest of labor
no descent after 4 or more horus of pushing in a primip with epidural (3 without)
or 3 or more horus in a multigravida with epidural (2 wituhout)
cause and symptoms of ovarian hyperstimulation syndrome
bhCG (used to stim mult ovarian follicles) causes exaggerated ovarian response and overexpression of VEGF -> incr vasc permeability and capillary leakage -> third spacing and VEGF leakage into intraperitoneal cavity -> ascites and abdominal distension
1-2 wks after ovulatio induction
- n/v/abd pain
- pleural effusions
- intravasc vol depletion (tachy, hemoconc, leukocytosis) due to third spacing, cab -> thromboemoblism, renal failure
inevitable vs incomplete abortion
inevitable- dilated cervix, VB without expulsion.
can see or feel products of conception at or above cervical os
incomplete- some prod of conception expelled, some remain
complex multiloculated adnexal mass with thick walls and internal debris
TOA
also will have fever, abd pain
congenital adrenal hyperplasia characterized by elevated ___
17-hydroxyprogesterone
management of Mullerian agenesis
get renal ultrasound! urogenital dev is from a common source so often have renal abnormalities
otherwise can also get surgery to elevate vagina
what abx can you use to treat UTI in pregnancy?
Amoxicillin! or nitrofurantoin, or cephelexin
what abx can NOT be used in pregnancy?
do NOT use x bactrim (folate metabolism, kernicterus) x cipro (bone deformities, arthropathy) x doxycycline (bone, tooth dev)
definition arrest second stage of labor
no fetal descent after pushing 3h (N) or 2h (M)
how does abruption increase risk of DIC
tissue factor released by decidual bleeding
postmenopausal woman with endometrial cells on pap testing - next step
further evaluate with endometrial bx
cause HELLP syndrome
abnormal placentation triggers systemic inflamm and activation of coagulation sys and complement cascade
–> platelets consumed
microangiopathic hemolytic anemia, esp detrimental to liver. MAHA also causes incr bilirubin production and RBC fragments on smear
–> hepatocellular necrosis and thrombi in portal system –> elevated liver enzymes, liver swelling, distension of hepatic capsule
duodenal atresia a/w
Down syndrome
VACTERL (vertebral, anal atresia, cardiac, tracheoesoph fist, esophag atresia, renal, limb)
u/s findings a/w down syndrome
- duodenal atresia
- esophageal atresia
- VSD
- AV septal defect
- thickened nuchal fold
mnemonic for bugs that can be treated with metronidazole
GET GAP on the Metro
Giardia Entameoba Trich Gardnerella (BV) Anaerobes Protozoa
mnemonic for HTN drugs safe in pregnancy
Hypertensive Moms Love Nifedipine
hydralazine
methyldopa
labetalol
nifedipine
