Ob/Gyn APGO Flashcards
abnormal pap test results… whats the best next step in management?
colposcopy
- also do reflex HPV testing for high-risk HPV types
- if negative then do repeat testing in one year
whens the earliest indication to give a pt a pap smear?
21 years old regardless of coitarche
cervical cancer screening for women ages 30-65
-whats special about pts ages 21-24
cytology and HPV cotesting every 5 years (preferred)
or
cytology alone every 3 years (acceptable)
-no need to HPV test alone
- pts 21-24 –> considered a special population are ususally positive for HPV and end up clearing it anyways so its not worth it to test them for HPV
- do expectant management and repeat cytology alone in 12 months if a pt does test positive for HPV
pt with lower abdominal pain, adenexal pain/tenderness, fever, cervical motion tenderness, and vaginal discharge
pelvic inflammatory disease (usually caused by chlamydia and gonorrhea)
gold standard to diagnose herpes
culture: highly specific not super sensitive (false negative 10-20% of the time)
best to culture very early in course
how often do you screen for colon cancer in a pt with average risk
start screening at age 45-50
- yearly hemoccult testing
- flexible sigmoidoscopy every 5 years
- colonoscopy every 10 years
if pt has a first degree relative with colon cancer before age 60 then screen at age 40 or 10 years before dx of their relative and repeat every 5 years
DEXA test
used to test for bone mineral density… specifically in women who show signs of osteoporosis prior to age 65
what age should annual mammograms start for women?
40
how much folate should you give a woman of reproductive age
daily 400 microgram supplement
note: non-high risk pts get at least 0.4mg/day
high risk pts (pts with neural tube defect in previous pregnancy) get 4mg/day
what are the normal physiologic changes to lung capacities during pregnancy
increases: inspiratory capacity (due to increases in tidal volume and inspiratory reserve volume)… minute ventilation also increases –> responsible for respiratory alkalosis in pregnancy
respiratory rate does not change
decreases: functional residual capacity
why are pregnant pts more likely to get pulmonary edema
decreased plasma osmolality
sickle cell anemia prevalence in black pts and how to test for it in a pregnant pt
1/500 (autosomal recessive)
carrier state is found in 1/10 blacks
*test for this and all other hemoglobinopathies via electrophoresis
mediterranean populations are most at risk for what
beta-thalassemia
ashkenazi jews are at risk for what
fanconi anemia, tay-sachs, neimen pick, cystic fibrosis (all are autosomal recessive)
what is the best test for trisomy 21 and 18
cell free DNA screening with a detection rate of over 99% at 0.2% false-positive rate
most common form of inherited mental retardation
fragile x
most reliable method for confirming gestational age
dating ultrasound (specifically during the first trimester)
what do you expect to see in a pt with pre-existing diabetes vs gestational diabetes
pre-existing –> intrauterine growth restriction
gestational diabetes –> shoulder dystocia, metabolic disturbances, preeclampsia, polyhydramnios, and fetal macrosomia
short in duration and less intense contractions associated with pain in the lower abdomen/groin
braxton-hicks contractions
how will a pregnant pt with dehydration present
maternal tachycardia and ketonuria
why would you do a nitrazine test
confirm rupture of membranes of if a pt is unsure about leakage of fluid
what do you do if the pt has an umbilical cord prolapse?
immediate c-section (even if the mom and baby both seem totally fine)
what is the single greatest risk factor for 3rd and 4th degree lacerations
median episiotomy
insufficient power of contractions
< 240 Montevideo units
give ptosin if this occurs
type 1 diabetic… what do you expect to see with the baby
small and hypoglycemic baby
fetal tachycardia and minimal variability
septic infant
treatment for sheehan syndrome?
estrogen and progesterone replacement and supplementation with thyroid and adrenal hormones
what is the best positioning for breast feeding
mom and baby being belly to belly
how does candida of the nipple present
- sore nipples and burning thats worse with breastfeeding
- tips of nipples are pink and shiny with peeling at the periphery
- make sure to check the babies mouth for candida and treat both mom and baby
what are the signs that the baby is getting enough breast milk
3-4 stools in 24hrs
6 wet diapers in 24hrs
weight gain
sounds of swallowing
what are the three ways an ectopic pregnancy can be diagnosed
- fetal pole is visualized outside the uterus on ultrasound
- the patient has a b-hCG level over the discriminatory zone (2,000 to be seen on ultrasound) and no intrauterine pregnancy is seen on ultrasound
- the patient has inappropriately rising b-hCG level (less than 50% increase in 48hrs) and has levels that do not fall following diagnostic dilation and currettage
signs of a ruptured ectopic pregnancy
- hypovolemia (tachycardia and hypotension)
- peritoneal signs (rebound, guarding, and severe abdominal tenderness)
- positive pregnancy test
*if you see a pt with this then perform a laparoscopy
most common abnormal karyotype that causes a spontaneous abortion
autosomal trisomy
most common cause of sepsis in pregnancy
acute pyelonephritis
how to treat a pregnant lady with thyroid storm
thioamides (PTU), propranolol, sodium iodide, and dexamethasone
*do not give radioactive iodine cause it may concentrate in the fetal thyroid and cause congenital hypothyroidism
gestational diabetes screenings
universal screening done for everyone between 24 and 28 weeks
-but for high risk pts you can screen them at their first visit
- 50g 1hr oral glucose challenge test
- diagnostic 100g 1hr oral glucose tolerance test if initial results exceed a predetermined plasma glucose concentration
OR
- just do a 75g 2hr oral glucose tolerance test
obese pregnant pts have a higher risk of what
increased maternal morbidity due to
- chronic hypertension***
- gestational diabetes
- preeclampsia***
- fetal macrosomia
- higher rate of c-section
- higher rate of postpartum complications
which depression med is contraindicated in pregnant pts
paroxetine (SSRI) –> other SSRIs are ok
-increased risk of fetal cardiac malformations and persistent pulmonary hypertension
whats the next step in a pregnant pt with suspected appendicitis
graded compression ultrasound
when is the “best” time to get varicella infection during a pregnancy
first trimester –> lowest risk of congenital anomalies
*give them oral acyclovir 5x/day for 7days
classic signs of magnesium toxicity
muscle weakness
loss of deep tendon reflexes
nausea
respiratory depression (11mEq/L)
*if mag is given in very high doses (15mEq/L) cardiac arrest is also possible
definitive treatment for preeclampsia
delivery of baby and placenta
what is a major indicator for delivery in a pt with preeclampsia/HELLP syndrome
thrombocytopenia (< 100,000)
define HELLP syndrome
hemolysis
elevated liver enzymes
low platelets
third trimester bleeding and fetus in tachysystole with evidence of fetal anemia
abruptio placentae
-hypertension and preeclampsia are risk factors
what is the goal for a pregnant pt with hypertension
not a normal blood pressure but into a safer range of diastolic 90-100 mmHg
*to prevent maternal stroke or abruption
risk factors for developing preeclampsia
parity family history obesity chronic hypertension chronic renal disease*** strongest factor
what non-invasive test can detect severe anemia
middle cerebral artery peak systolic velocity via doppler ultrasonography
lewis antibodies
IgM (does not cross the placenta)
-not associated with isosensitization or hemolytic disease of the fetus
memory device for certain antibodies: lewis lives, duffy dies, kell kills
ultrasound markers for twins
- dividing membrane thickness more than 2mm
- twin peak (lambda) sign
- different fetal genders
- two separate placentas (anterior and posterior)
twin infant death rate is how many times higher than singletons
5x higher in twins
-incidence of congenital anomalies is also increased
how can you try to avoid premature twin births
adequate weight gain in the first 20 to 24 weeks can reduce the risk of premature, preterm, low-weight babies
most accurate way to date a fetus that may already be dead
femur length cause long bone measurements are most reliable
uncontrolled diabetes during organogenesis
associated with high rate of birth defects (usually spine and heart affected)
what does a cone biopsy increase the risk of in a pregnant patient
cervical incompetence/insufficiency
all women with vaginal bleeding during pregnancy need to get what tested?
maternal blood type to check for their Rh-factor
what is associated with a breech presentation
prematurity multiple gestations genetic disorders polyhydramnios hydrocephaly anencephaly placenta previa uterine anomalies uterine fibroids
amniotomoy
artificial rupture of membranes
what position is most associated with umbilical cord prolapse
back up, transverse lie
first movement used in management of shoulder dystocia
McRoberts maneuver –> hyperflexing mothers legs to abdomen to widen pelvis and flatten lumbar spine
biggest risk factor for placenta abruption
polyhydramnios with rapid decompression of intrauterine cavity
pt in third trimester with abdominal pain, bleeding, uterine hypertonus, and fetal distress
risk factors: smoking, cocaine, chronic hypertension, trauma, prolonged premature rupture of membranes
placental abruption
what is smoking a risk factor for
- placental abruption
- placental previa
- fetal growth restriction
- preeclampsia
- infection
what is nifedipine used for in ob
its a calcium channel blocker and can be used as a tocolytic (helps to slow down/stop preterm labor)
which tocolytics are contraindicated in pts with diabetes
terbutaline (also has bad side effects and doesn’t work that well) and ritodrine
what does betamethasone from 24 to 34 weeks gestation do
its a steroid
- increases pulmonary maturity and reduces the incidence/severity of RDS
- decreased intracerebral hemorrhage and necrotizing enterocolitis in the newborn
fibronectin
extracellular matrix protein that acts like an adhesive b/w fetal membranes and underlying decidua
- if its in the cervical mucous b/w 22 and 34 weeks its thought to indicate a disruption or injury to the maternal-fetal interface
- testing for this has a very strong negative predictive value (if its not there then you likely wont deliver in 14 days)
magnesium sulfate mechanism of action
competes with calcium for entry into cells
atosiban mechanism of action
oxytocin receptor antagonist that blocks the intracytoplasmic calcium release associated with contractions and downregulates prostaglandin synthesis
if a woman has a tender fundus and ruptured membranes what should you think of
chorioamnionitis
how to reduce the risk of PPROM in a woman who has already had it in a previous pregnancy
17 alpha-hydroxyprogesterone
when a woman has PPROM when is the best time for delivery
34 weeks
repetitive frequent painful contractions with vaginal bleeding is indicative of what
abruptio placetae
prolonged periods of fetal tachycardia + maternal fever
chorioamnionitis
how to evaluate and treat fetal hypoperfusion
change in maternal position to left lateral position (which increases perfusion to the uterus), maternal supplemental oxygen, treatment of maternal hypotension, discontinuation of oxytocin, intrauterine resuscitation with tocolytics and IV fluids
most common cause of postpartum hemorrhage
uterine atony
risk factors: precipitous labor, multiparity, general anesthesia, oxytocin use in labor, macrosomia, hydramnios, twins, chorioamnionitis
B-lynch suture
uterine compression suture
-helpful during unresponsive uterine atony
most common source of fever on a 1 day postpartum woman
lungs (especially think of this if the woman was under general anesthesia)
most common side effect of fluoxetine
insomnia (you can breastfeed while taking this med)
-third trimester use of SSRIs have been associated with poor neonatal adaptation (agitation, poor feeding, and insomnia)
what is associated/at risk with late term and postterm pregnancies
macrosomia oligohydramnios meconium aspiration uteroplacental insufficiency dysmaturity
pt with intrauterine growth restriction at 36 weeks, oligohydramnios, and abnormal umbilical artery doppler studies…. best next step?
delivery
compare fetal heart tracings for fetal anemia vs hypoxia
fetal anemia: sinusoidal pattern with regular smooth sine waves with regular amplitude and frequency
fetal hypoxia: absent variability, bradycardia, and/or recurrent late decelerations
what type of birth control decreases the risk of endometrial and ovarian cancer
OCPs
manual vacuum aspiration
can be used to terminate a pregnancy less than 8 weeks GA
-complications of ashermans syndrome increases with every termination
what to do if a pt wants a surgical abortion
D&C + doxycycline
pink-red appearance with overlying white keratin
squamous cell hyperplasia
different treatments for vestibulodynia
- tricyclic antidepressants to block to block sympathetic afferent pain loops
- pelvic floor rehabilitation
- biofeedback and topical anesthetics
- surgery as last resort
compare lichen sclerosis to lichen simplex chronicus
lichen sclerosis –> thin skin (epidermis), fibrosis of dermis, postmenopausal women, benign but slight increased riks for squamous cell carcinoma
lichen simplex chronicus –> thick skin (hyperplasia of vulvar squamous epithelium), leathery skin, chronic irritation and scratching (ITCHY), benign with no increased risk of squamous cell carcinoma
*NOTE –> both of them + vulvar carcinoma all present with leukoplakia
dental dam
latex product used to prevent STI transmission
if a pt has sex with someone who is hepB positive what should you do
post-exposure prophylaxis (within 7 days with blood contact and 14 days with sexual exposure)
if pt is unvaccinated and exposed –> 1 dose HBIG + HB vaccine series
if source status is unknown –> HB vaccine series only
pt had vaccine and responded –> do nothing
pt is had vaccine and did not respond –> HBIG + HBV vaccine series OR 2 doses of HBIG
if a pt was treated for PID in the past what should you keep an eye out for in pts
tubal infertility
1x PID 12%
2x PID 25%
3x PID 50%
first line treatment for pt with intrinsic sphincteric deficiency
urethral bulking procedure
- minimally invasive
- 80% success rate
mirabegron
beta 3 adrenergic agonist
- can give to pts with detrusor overactivity (urge incontinence)
- relaxes the detrusor muscle
-not for pts with hypertension, ESRD, or liver disease
tolterodine
acceptable treatment for urge incontinence
-not for pts with narrow-angle glaucoma
urge incontinence
overactivity of the detrusor muscle causing uninhibited contractions
-you can do a mid-urethral sling for this
colpocleisis
vagina is surgically obliterated and can be performed quickly without general anesthesia
-used for vaginal prolapse
adenomyosis
endometrial lining in the myometrium
danazol
synthetic androgen used to treat endometriosis but OCPs are still first line cause danazol has more androgenic side effects
definitive diagnosis in a pt for endometriosis who has failed the two most common treatments (OCPs and NSAIDs)
exploratory surgery and biopsies
interstitial cystitis
chronic inflammatory condition of the bladder
- recurrent irritative voiding symptoms of urgency and frequency
- kinda looks like a pt with a UTI but negative cultures and possible pelvic pain/pain with sex
- possibly more common in women with endometriosis
whats one of the biggest factors associated with chronic pelvic pain
physical and/or sexual abuse
pt has a low transverse incision and subsequent nerve problems
nerve entrapment syndrome (you should be most worried about the following 2 nerves)
- iliohypogastric nerve (T12, L1)
- ilioinguinal nerve (T12, L1)
what can increase pain levels in a pt with fibrocystic breast changes
caffeine intake
criteria for MRI breast cancer screening
- BRACA carriers or 1st degree family of BRACA carriers
- Li-Fraumeni pts or other genetic cancer disorders
- 20-25% risk of breast cancer
- women with history of chest radiation b/w 10 and 30 years old
complications from a LEEP procedure
infection, bleeding, cervical stenosis, persistent disease, and possibly risk for preterm delivery
best way to workup incidental finding of adnexal mass in an otherwise healthy pt
pelvic ultrasound
breast budding
thelarche (usually the first step in puberty)
chadwicks sign
blue-ish cervix that indicates extra blood flow to the cervix usually due to pregnancy
why would you test for 17-hydroxyprogesterone
to test for late onset 21-hydroxylase deficiency
high levels of what hormone can cause an increase of the synchrony of hair growth
high estrogen levels in pregnancy cause this
then….
postpartum telogen effluvium (hair loss) affects 40-50% of women
hyperthecosis
more severe form of PCOS
-associated with much higher levels of androstenedione and testosterone
why does dysmenorrhea improve with OCPs
progestin in them causes endometrial atrophy (endometrium is where the prostaglandins are formed so less are formed if its atrophic)
most helpful treatment for a pt with hot flashes
estrogen therapy at the smallest dose possible for the shortest amount of time
for a woman in menopause and otherwise good health… what are the benefits and risks of using combined hormone replacement therpy
increase in breast cancer risk
decrease in colon cancer risk
T-scores
osteopenia = -1 to -2.5 osteoporosis = less than -2.5
what should you look out for in a bipolar pt trying to get pregnant
if they are on quetiapine then look out for hyperprolactinemia as this can cause difficulty in getting pregnant
exercise induced hypothalamic amenorrhea is characterized by what lab values
normal FSH and low estrogen
how to determine ovarian reserve in a pt struggling to conceive at an older age
anti-mullerian hormone
what medication helps with PMS
OCPs
what vitamins and minerals have been shown to help with the symptoms of PMS
calcium
vitamins B6 and E
what race is more likely to get a molar pregnancy
asians (and more in women younger than 20 and older than 40)
treatment for a molar pregnancy
suction curettage
what type of mole is more likely to cause GTD
complete mole
how is choriocarcinoma diagnosed
presence of beta-hCG around 3 months post partum
histopathology of atypical immature parabasal cells with high nucleus to cytoplasm ratio and numerous mitotic figures with enlarged hyperchromatic nuclei
-full thickness involvement without invasion into the basement membrane
this is a lesion on the vulva
VIN III (do a wide local incision)
when is cryotherapy used
cervical dysplasia treatment (cancer must be completely ruled out)
whats the next step in a pt who has had an endocervical curettage that came back positive
cervical conization
what medication can make vaginal atrophy worse
tamoxifen because it can antagonize the estrogen receptors in the vagina
what is deep dyspareunia associated with
conditions that cause pelvic inflammation
- endometriosis
- prior pelvic surgery
lubrication during the arousal phase of intercourse is most dependent on what
transudate of fluid across the vaginal mucosa as genitalia become increasingly engorged with blood
note: vulvar glands play a small role in keeping the introitus moisturized
flibanserin
indicated for premenopausal hypoactive sexual desire disorder but is not appropriate if it might get better on its own
how to decrease a womans risk of ovarian cancer
OCPs help do this (long-term suppression of ovulation)
adnexal mass + endometrial hyperplasia
granulosa cell tumor
whats a common etiology of ovarian torsion
enlarged ovary with a dermoid cyst (contain oily contents that are less dense than surrounding tissue) this causes it to raise and has the infundibulopelvic ligament become unstable more likely to have an ovarian torsion
sonographic characteristics that make cancer more likely
- complexity with solid components
- size greater than 10cm
- mural nodules or excrescences
- presence of ascites and bilaterally
most common ovarian neoplasm in women less than 30
germ cell tumor
what medications do you give to a pregnant pt with mitral valve prolapse (palpitations, intermittent chest pain, systolic ejection murmur with a click)
beta-blocker
if a pt has a positive nitrazine test and negative ferning/normal AFI… what should you look out for in the question
if she just had sex semen (blood can too) can cause a false positive for the nitrazine test
