OB/GYN QBank Flashcards
1
Q
What 5 things are women w/ GDM at increased risk of?
A
- Polyhydramnios
- Gestation HTN
- Preeclampsia
- Fetal macrosomia
- C-section
NOT IUGR (that’s for pre-gestational diabetic)
2
Q
When do you screen for GDM?
A
24-28 wk gestation
As soon as possible if risk factors (BMI > 30, previous GDM, fam hx of DM) and rescreen at 24-28 wk
3
Q
Tx of GDM?
A
1st-line: dietary modification
2nd-line: insulin, oral agents (metformin, glyburide) -> don’t use sulfonylureas (chlopropamide, tolbutamide) or thiazolidinedione (glitazones)
4
Q
Effects of maternal hyperglycemia in 1st trimester?
A
Teratogen -> congenital heart disease, neural tube defects, small left colon syndrome (transient inability to pass meconium, resolve spontaneously)
Spontaneous abortion
5
Q
Effects of maternal hyperglycemia in 2nd and 3rd trimester?
A
Fetal hyperglycemia -> fetal hyperinsulinemia -> polycythemia (from increased metab demand), organomegaly, macrosomia (and shoulder dystocia, so offer C-section if weight > 9.9 lbs), neonatal hypoglycemia
6
Q
What happens to calcium in infants w/ diabetic mothers?
A
Hypocalcemia (from PTH suppression) -> monitor for hypocalcemic seizures
7
Q
Liver problems in HELLP?
A
Centrilobular necrosis
Hepatoma formation
Thrombi in portal capillary system
All can cause distension of hepatic (Glisson’s) capsule -> RUQ pain
8
Q
Sx of AFLP (acute fatty liver of pregnancy)? What trimester?
A
Vague stuff: n/v, abd pain, elevation of liver markers -> persistent vomitting is a major sx
Compared to HELLP, AFLP more likely to have extrahepatic stuff (leukocytosis, hypoglycemia, acute kidney injury) and less likely to have severe HTN; also see prolonged clotting time, hypocholesterolemia, hypofibrinogenemia, hypoalbuminemia
3rd trimester
9
Q
How do you differentiate peptic ulcer perforation from HELLP?
A
PU perforation -> hypotensive rather than HTN
10
Q
Life-threatening complication of severe preeclampsia?
A
Pulm edema (generalized arterial vasospasm -> increased systemic vascular resistance -> high cardiac afterload)
11
Q
Management of HGSIL (high grade squamous intraepithelial lesion)?
A
HGSIL found on Pap
- If age = or > 25 -> either LEEP (if not postmenopausal or pregnant) or colposcopy (then manage per guidelines)
- If age 21-24 -> do colposcopy -> if CIN 2,3, manage per guidelines; if no CIN 2,3, repeat colposcopy & cytology at 6-mo intervals for up to 2 yrs
- If pregnant, err on conservative side -> do colposcopy -> if negative, repeat Pap and colposcopy 6 wks after delivery; if positive, bx (and if this turns out to be CIN 2,3, repeat cytology and bx but not more frequently than every 12 wk)
12
Q
Earliest sign of MgSO4 toxicity and how to fix it?
A
Depressed DTR -> fix w/ immediate discontinuation and administer calcium gluconate
13
Q
3 causes of hyperandrogenism in pregnancy?
A
Luteoma: solid on US, 50% b/l, regress spontaneously after delivery, high risk of female fetal virilization (but no maternal tx warranted)
Theca luteum cyst: b/l cystic on US, assc. w/ molar or multiple gestation (high hCG), if assc w/ molar pregnancy, do D/C (but the cysts themselves regress spontaneously), low risk of fetal virilization
Krukenberg tumor: b/l solid on US, mets from GI so look for signs of cancer, high risk of fetal virilization
14
Q
Most common cause of hyperandrogenism in nonpregnant women?
A
PCOS
15
Q
When do you perform ECV (external cephalic version)? What does it put you at an increased risk of?
A
Between 37 wk gestation and onset of labor
CI if ruptured MEM, hyperextended fetal head, fetal/uterine abnormalities, non-reassuring fetal monitoring
Increased risk of placental abruption
16
Q
When do you perform internal podalic version?
A
Twin delivery to convert 2nd twin from a transverse/oblique presentation to breech
17
Q
When do you perform quadruple test?
A
2nd trimester (15-20 weeks)
18
Q
Profile on quadruple screening for trisomy 21? Sensitivity and false positive rate?
A
High “H” -> inhibin A and b-hCG
Low other things -> AFP, estriol
Sensitivity = 80%
False positive rate = 5%
19
Q
What 2 things should be offer if quadruple screening comes up abnormal?
A
- Cell-free fetal DNA testing -> sensitivity and specificity of up to 99%
- US to confirm GA and assess AF before doing invasive things like amniocentesis
20
Q
Profile on quadruple screening for trisomy 18?
A
Low AFP, estriol, and b-hCG
Normal inhibin A
21
Q
Profile on quadruple screening for open neural tube defects & abdominal wall defects?
A
High AFP but everything else is normal (estriol, b-hCG, inhibin A)
22
Q
Age cutoff in dx of premature ovarian failure?
A
35 yo
23
Q
Obese women w/ amenorrhea and normal FSH and LH. What’s the cause?
A
Anovulation
24
Q
Prolactin production is inhibited by? Stimulated by?
A
Inhibited by dopamine
Stimulated by TRH (so hypothyroidism can cause hyperprolactinemia) and serotonin
25
4 things to do for septic abortion?
1. blood & endometrial cultures
2. IVF & broad-spectrum abx
3. Suction curettage
4. Hysterectomy if no response to abx, abscess, clostridial infection
26
When to use misoprostol?
W/ mifepristone to terminate pregnancies up to 49 days of gestation
27
3 liver disorders unique to pregnancy? How to distinguish them?
All have elevated liver enzymes
1. **ICP** (intrahepatic cholestasis of pregnancy): intense pruritus, elevated bile acids, develop in 2nd-3rd trimester, jaundice uncommon (so do careful workup if this is present) -\> pruritus gravidarum is the mild variant of ICP
2. **HELLP**
3. **AFLP**: pruritus not a common feature, might have kidney injury
28
What do you prescribe for ICP?
Ursodeoxycholic acid -\> to increase bile flow and relieve itching (even tho it typically resolves weeks following delivery)
Naltrexon (opioid agonist) relieves itching as well
29
Fetal complications of ICP?
IUD, NRDS
30
When does PUPPP (pruritic urticarial papules and plaques of pregnancy) happen? How do you distinguish it from ICP?
3rd trimester -\> see red papules w/ striae w/ sparing around umbilicus, can extend to extremities but usually spare palms, soles, face (unlike ICP), also no liver lab abnormalities
31
What abx to use for TOA, postpartum endometritis, or anything involving polymicrobial infection w/ anaerobic component?
Clindamycin and gentamicin
32
Tx for vaginismus? Primary anorgasmia?
Vaginismus: relaxation, Kegel, dilator insertion
Primary anorgasmia: self-stimuation
33
What happens to TSH, free T4 & T3, and total T4 & T3 during pregnancy? What to do with levothyroxine dose in pts who become pregnant?
TSH decreases, free T4 & T3 slightly increase (b/c hCG alpha subunit is similar to TSH), total T4 & T3 increase (increased TBG)
Increase levothyroxine -\> b/c there's increased requirement in the 1st trimester (even tho T3 and T4 are already elevated in pregnancy from increased TBG)
Check TSH every 2-3 mo during pregnancy (more often than usual)
34
Management of threatened abortion?
Generally expectant management until either sx resolution or progression to inevitable, incomplete, or missed abortion
- US to make sure that fetus is present and alive
- reassurance and ultrasonogram 1 wk later
35
What is false labor and when does it usually occur in pregnancy?
Cx in lower abdomen (as opposed to back and upper abd like true labor), irregular, interval doesn't shorten, not increasing in intensity, no accompanied cervical changes, relieved by sedation
Occurs in last 4-8 wks of pregnancy
36
How long do you put ppl on tocolysis in the setting of premature labor?
At least 48 hrs to allow corticosteroids to take full effects
37
How do you distinguish glomerulonephritis (from SLE) from preeclampsia? Why do you need to separate them?
Will see proteinuria in both, but in glomerulonephritis you'll also see RBC cases in UA, rapid aggravation of proteinuria, assc. clinical signs (malar rash, ANA +)
Do renal bx if proteinuria persists after delivery
Need to distinguish them because tx are different (corticosteroids can even make preeclampsia worse)
38
Algorithm for 2ndary amenorrhea?
Amenorrhea for = or \> 3 cycles OR = or \> 6 mo -\> Check hCG -\> if neg -\>
1. hx of uterine procedure/infection -\> do hysteroscopy (check for Asherman syndrome, etc)
2. check prolactin -\> if elevated do brain MRI; check TSH -\> if elevated dx hypothyroidism; check FSH -\> if elevated dx premature ovarian failure
39
8 indications for prophylactic anti-D IG for unsensitized Rh-neg preggo?
1. 28-32 wks GA
2. w/in 72 hrs of delivery of Rh+ infant or any form of abortion
3. ectopic pregnancy, abortions
4. hydatidiform molar pregnancy
5. Procedures that might introduce mixing: AVS, amniocentesis, external version, D&C, preE, C-section, manual placenta extraction,
6. abd trauma
7. 2nd&3rd trimester bleeding, incl abruptio placentae
8. ECV Pplx not needed if father known to be Rh-
40
How does placenta previa commonly present?
Painless 3rd-trimester VB or bleeding w/ uterine cx
41
How do you dx placenta previa?
DONT do digital exam
Do transabd followed by transvaginal sonography
42
7 risk factors for placenta previa?
1. Multiparity
2. advanced maternal age
3. prior C-section
4. smoking
5. previous intrauterine surg
6. prior placenta previa
7. multiple gestation
43
How does uterine rupture typically present?
Sudden onset intense abd pain & VB assc. w/ hyperventilation, agitation, tachycardia, hypotension, "palpable protuberance" = fetal parts in lower abdomen, change in fetal station
Commonly assc. w/ labor esp if prior C-section
44
What's vasa previa and how does it present?
Fetal blood vessels cross fetal membranes in lower segment of uterus bet. fetus and internal cervical os
Present as painless VB that occurs on ROM (form ruptured fetal blood vessels) + rapid deterioration of fetal heart tracing (tachycardia followed by bradycardia and eventually sinusoidal pattern)
No changes in maternal VS and abd exam b/c bleeding is from fetus
45
When should you start antenatal fetal surveillance?
Starting at 41 wks GA
46
Define oligohydramnios?
AFI = or \< 5
Single deepest pocket \< 2 cm
47
Define polyhydramnios?
AFI = or \> 24 cm
Deepest vertical pocket = or \> 8 cm on US
48
What 5 things does biophysical profile (BPP) assess?
Each w/ score 0 (abnormal) and 2 (normal) =\> total of 8-10 is normal, 4 or less is abnormal
1. nonstress test (should have reactive fetal HR)
2. AF volume (should have AFI \> 5 cm or deepest vertical pocket = or \> 2 cm)
3. fetal movements (should have 3 or more general body movements)
4. fetal tone (should have 1 or more episodes of flexion/extension of limbs or spine)
5. fetal breathing movements (should have 1 breathing episode lasting for 30 sec)
49
What's the sequence of abnormalities seen on BPP in metabolically compromised fetus?
HR decel -\> then absent fetal breathing movements -\> then decreased body movements and fetal tone
50
How long is BPP conducted?
Over 30 min, bc fetal sleep cycle lasts 20 min and is usually disrupted by vibroacoustic stimulation
NST is performed for up to 40 min (making sure to capture HR outside of sleep cycle)
51
How does chorioamnionitis (intraamniotic infection) typically present? How do you manage preterm labor w/ chorioamnionitis?
Fetal tachycardia (\> 160/min) + maternal fever + uterine tenderness
If fetal tracing is reassuring, induce labor. (don't use tocolysis)
52
Is diffuse placental calcification on US normal?
Yes for late-term pregnancies
53
Dx procedure of choice in pregnant pts w/ renal colic?
US b/c no risk of radiation like CT or IV pyelogram
Can consider CT only in 2nd or 3rd trimester and as a last resort
54
What do you do when pregnant pts w/ kidney stones fail to improve w/ conservative measures?
Ureteroscopy or nephrostomy
Don't do shockwave lithotripsy (CI)
55
How do you eval nipple discharge?
**If unilat, bloody/serous, or assc. w/ palpable lump or skin changes** -\> likely pathologic so do mammogram w/ or w/out breast US + surgical eval
**If bilat, milky and nonbloody** -\> likely physiologic -\> do pregnancy test, serum TSH, prolactin, pituitary MRI
56
What 3 things do pregnant women w/ chronic HCV at an increased risk of?
GDM, cholestasis, preterm delivery
57
What do you do w/ pregnant women w/ chronic HCV?
Immunize them against HBV and HAV (safe to administer during pregnancy), avoid scalp electrodes
DONT need to C-section, avoid breastfeeding (unless maternal blood present), or use barrier protection (if serodiscordant and monogamous)
DONT use ribavirin (teratogenic)
58
Manifestations of congenital syphilis?
Intermittent fever, osteitis and osteochondritis, mucocutaneous lesions, LAD, hepatomegaly, persistent rhinitis
59
Triad of congenital toxo?
Chorioretinitis + hydrocephalus + intracranial calcification
60
How do you prevent neonatal infection from HIV or HSV?
Antiviral meds + C-section
61
4 risk factors for polyhydramnios?
Fetal malformations/genetic disorders, maternal DM, multiple gestation, fetal anemia
62
Gold standard for eval of cervical incompetence?
TVU cervical length \< 25 mm (short cervix, w/in 10 percentile)
63
Algorithm for tx of suspected endometriosis?
NSAIDs w/ or w/out combined hormonal contraceptives
If doesn't work, do laparoscopy
64
What cancer is endometriosis linked to?
Ovarian cancer
NOT endometrial or breast cancer
65
What's the big problem w/ endometriosis?
Infertility (almost half of endometriosis pts have this problem)
66
What's the most accurate method of determining GA?
1st trimester US w/ crown-rump length
If there's discrepancy in 2nd and 3rd trimester -\> consider growth problems (NOT revise the original GA)
67
After the first trimester what can be used to estimate GA?
* Fetal abd circumference
* Biparietal diameter
* Femur length
* Head circumference
* After 20 wks -\> can do fundal height (from pubic symphysis to top of fundus) -\> but this can be confounded by leiomyomata or obesity
68
Management of incomplete, inevitable, or missed abortion?
* If hemodynamically unstable & heavy bleeding -\> D&SC (w/ pplx abx)
* If hemodynamically stable & mild bleeding -\> either expectant management, prostaglandins (misoprostol), or D&SC -\> up to pts to choose
69
What is methotrexate used for?
Ectopic pregnancy
NOT spontaneous abortion
70
When do you screen for GBS? How long is the result valid for?
35-37 wk GA
Results valid for 5 wks
71
When should pregnant women be screened for HIV?
First prenatal visit, and then again in 3rd trimester if high risk
72
When should you start Pap smear?
21 yo regardless of age of coitarche
73
What's the guideline for cervical cancer screening and HPV testing in women age 30-65 yo?
Cotesting (HPV + cytology) every 5 yrs (preferred) OR cytology alone every 3 yrs (acceptable)
74
Management of ASCUS (atypical squamous cells of undetermined significance)?
HPV typing or repeat cytology in 12 mo
* if HPV typing negative -\> resume routine Pap every 3 years)
* if HPV typing positive, or if repeat cytology in 12 mo reveals ASCUS or higher -\> colposcopy + bx
* if HPV typing positive, and 21-25 yo -\> repeat cytology in 12 mo, only do colposcopy if repeat cytology reveals ASC-H (atypical squamous cells, but can't rule out HSIL), AGC (atypical glandular cells), or HSIL
75
Gold standard of dx herpes?
Culture - the earlier lesion works better
Great specificity but have 10-20% false negative rate
76
What's the protocol for elective C-section?
Has to go thru proper counseling but can schedule it at 39 wk GA
77
When do you start doing yearly mammogram?
\> 40 yo
78
What are the best contraceptions in terms of preventing pregnancy?
Depo-provera, IUD, sterilization (male or female), implanon
79
Protocol for colon cancer screening?
For avg risk, colonoscopy every 10 yrs starting at age 50 For FIRST DEGREE relative hx of colon cancer, every 10 yrs starting at age 40 or 10 years before the youngest relative diagnosed
80
Protocol for DEXA scan?
Starts at age 65 yo unless have early menopause, glucocorticoid therapy, sedentary lifestyle, alcohol consumption, hyperthyroidism, hyperparathyroidism, anticonvulsant therapy, vitamin D deficiency, family history of early or severe osteoporosis, or chronic liver or renal disease
81
What is peripartum cardiomyopathy and how does it present?
Heart failure from left ventricular systolic dysfx
Present towards the end of pregnancy or several months following pregnancy
82
What happens to lung fx during pregnancy?
Increased TV, increased minute ventilation, increased IC -\> compensated resp alkalosis
Decreased FRC, ERC, RV
Both compensated resp alkalosis and decreased FRC -\> get subjective SOB during pregnancy
83
What happens to SVR during pregnancy?
Systemic vascular resistance goes down
84
4 common causes of acute pulmonary edema in pregnancy?
Use of tocolytics (so suspect this with ppl admitted for preterm labor who develop bibasilar crackles), cardiac disease, fluid overload, preeclampsia
85
What happens to cardiac fx during pregnancy? What are the signs?
Increased CO from increase in both SV and HR
Hear systolic murmur in most women (up to 95%)
Diastolic murmur is always abnormal
86
Explain cause of hydronephrosis in pregnancy?
Compression of ureter by uterus and ovarian vein (very dilated during pregnancy)
Usually more significant compression on the right because of dextrorotation of uterus and because sigmoid colon cushions the left side
87
What's the best next step in pt presenting w/ n/v, VB w/ dilated cervix fleshy thing coming out, racing heart, elevated hCG, and snowstorm pattern in uterus?
CXR -\> lung is the most common site of metastasis disease in pts w/ gestational trophoblastic disease
NOT repeat hCG b/c right now would be of little value, but do that weekly after
88
Recommendation for weight gain during pregnancy?
* If underweight -\> should gain 28 – 40 pounds
* If normal weight (BMI 18.5 – 24.9 kg/m2) -\> 25 – 35 pounds
* If overweight (BMI 25 – 29.9 kg/m2) -\> 15 - 25 pounds
* If obese (BMI \> 30 kg/m2) -\> 11 - 20 pounds
89
What blood test would you recommend to AA pts pre-conception?
Hb electrophoresis and CBC -\> definitive dx of sickle cell and will also pick up HbC and thalassemia minor
NOT sickle cell prep bc might not detect w/ mild disease
90
What to screen for in Ashkenazi Jewish ppl pre-conception?
ONLY if both parents are AJ -\> screen for AR stuff including fanconi anemia, CF, Niemann-Pick, Tay Sachs, Canavan disease, Bloom syndrome, Gaucher’s disease
NOT beta thalassemia (affects Mediterranean ppl mostly)
91
What is the fetus at the highest risk of in women w/ poorly controlled diabetes?
Structural anomalies (cardiac or neural)
GU and limb defects are minor
92
When do you do CVS and what can you test it for?
10-12 wk GA, transabdominal or transcervical approach
Can do fetal chromosomal abnormalities, biochemical, or DNA-based studies (incl CF testing, etc) -\> so doesn't include things like neural tube defects or omphalocele (dx by U/S)
93
What is a first trimester combined test?
* Nuchal translucency
* PAPP-A (pregnancy associated plasma protein A)
* Beta-hCG
Detection rate of trisomy 21 and 18 is 85%
94
What is a triple screen test?
Second trimester AFP, Beta-hCG, uE3 (unconjugated estriol)
Detection rate of trisomy 21 and 18 is 69%
95
What is a sequential screen?
First trimester NT and PAPP-A + second trimester quad screen
Detection rate of trisomy 21 and 18 is 93%
96
What is a serum integrated screen and when is it performed?
First trimester PAPP-A + second trimester quad screen
When unable to obtain nuchal translucency
Detection rate of trisomy 21 and 18 is 85-88%
97
What's the order of detection rate for tests for trisomy 21 and 18?
Sequential screen (93%) \> serum integrated screen (85-88%), first trimester combined test (85%) \> quad screen (81%) \> triple screen (69%)
98
What false positive screen rate are detection rate set at for the tests detecting trisomy 21 and 18?
5% false positive
99
Risk of fetal loss assc. w/ CVS?
1%, not related to hx of prior miscarriage
100
Most common form of inherited mental retardation?
Fragile X
101
When should U/S be performed to evaluate GA?
Between 14-20 wk GA if there is greater than a 10 day discrepancy from LMP
102
Dose of folic acid supplement?
* 0.4 mg/day for low risk pts
* 4 mg/day for high risk pts (those w/ previous child w/ neural tube defect)
103
What do you do if you have thickened nuchal translucency in the first trimester screen and pt wants non-invasive test to rule out other anomalies?
Detailed fetal ultrasound and echocardiogram at 18-20 weeks
104
When is ibuprofen safe until?
32 wk GA (after this, premature closure of ductus arteriosus is a risk)
105
What will you find on pregnant pt w/ dehydration?
Ketonuria + tachycardia
106
What's labor warning?
Come back to hospital w/
* Contraction every 5 min for 1 hr
* Fetal movements less than 10 per two hours
* ROM
* VB
107
What's modified BPP? When is it used?
AFI + NST
Used when woman comes in suspecting labor/having decreased fetal movement; also use this for postterm surveillance (twice weekly after 41 wk GA, or when thinking it's postterm but uncertain of dates)
108
What do you do if you can't monitor fetal HR externally?
Place fetal scalp electrode
Do this before giving epidural
109
Pregnant woman w/ LOA fetal scalp visible at introitus. Fetal monitor shows HR to be in 60s. What do you do?
Assisted vaginal delivery
NOT emergent C-section
110
What do you do when blood + amniotic fluid gushes out while you're trying to place IUPC?
Withdraw (consider possibility of uterine perforation or placental abruption) -\> monitor fetus -\> try to place IUPC again if reassuring
111
What's the sign in umbilical cord prolapse?
Sustained fetal bradycardia (NOT variable deceleration like umbilical cord compression)
112
Management of umbilical cord prolapse?
Use your hand to elevate fetal head in vagina and perform emergent C-section
113
Complication of infant born to mother on intrapartum magnesium sulfate?
Respiratory distress
114
Size of infant born to mother w/ type 1 DM?
Small (unlike in GDM)
115
Consequence in the twins from TTTS?
* Recipient twin: plethoric, polycythemia, polyhydramnios, volume overload state (HF, cardiomegaly, tricuspid regurg, ventricular hypertrophy, hydrops), macrosomic
* Donor twin: anemia, high-output HF, oligohydramnios, IUGR, hydrops can happen as well
Surviving twin has high rate of neurologic defects (high risk of cerebral palsy)
116
What are infants born to diabetic mother at risk for?
Hypoglycemia, polycythemia, hyperbilirubinemia, hypocalcemia and respiratory distress
Thrombocytopenia is NOT a risk
117
What do yo do with infant born to mother who's HIV+?
Give AZT (zidovudine) immediately after delivery, do HIV testing after 24 hr
Discourage breastfeeding
118
Position for PPV in infants?
Sniffing position (tilt head back and chin up)
In adults it would be modified flex position
119
Apgar score calculation?
Each w/ max of 2 points: HR, Respiratory rate, Reflex, Activity, Color (1 for acrocyanosis)
120
Definition of postpartum hemorrhage (PPH)?
\> 500 cc after SVD, \> 1000 cc after C-section
121
Factor most influential to puerperal infection?
Endometritis is most closely related to mode of delivery (if vaginal -\> prolonged labor, PROM, etc are factors)
122
Most common cause of postpartum fever?
Endometritis (choose this even w/ C-section, don't worry about 5 W's) usually from mixed aerobic&anaerobic bacteria in genital tract (most commonly Staph aureus and strep)
123
Sx that distinguishes postpartum depression from postpartum blues or normal changes after delivery?
Ambivalence toward newborn
124
Most significant risk factor for postpartum depression?
Personal hx of depression (choose this even if s/he is socially isolated, contemplated terminating pregnancy, etc)
125
Safest method for suppression of lactation?
Breast binding (tight fitting bra), ice packs and analgesics
Don't intervene w/ hormonal tx or bromocriptine, don't do manual milk expression (prolactin stimulated?)
126
3 benefits of breastfeeding?
Increased uterine contraction (from oxytocin during milk letdown), decreased risk of ovarian cancer, decreased newborn risk of GI infections
127
How long should you encourage breastfeeding after delivery?
6 mo
128
Do you stop breastfeeding because of mastitis?
No, just give mom abx
129
Intense pain in breast w/ breastfeeding. Nipples pink, shiny, and peel at periphery. What's the organism?
Candida -\> so check baby's oral cavity
Staph aureus and other orgs are assc. w/ mastitis but don't cause intense nipple pain
130
Signs that baby is getting sufficient milk?
3-4 stools + 6 wet diapers in 24 hours, weight gain and sounds of swallowing
131
7 things that help with breast engorgement?
1. Frequent nursing
2. Taking a warm shower
3. Warm compresses to enhance milk flow
4. Massaging the breast
5. Hand expressing some milk to soften the breast
6. Wearing a good support bra
7. Using an analgesic 20 minutes before breast feeding
132
Pt w/ hCG lower than 2000 w/ cramping + spotting and no IUP on transvag U/S. What's the management?
Repeat hCG in 48 hrs (not later cos ectopic pregnancy can rupture). Hemodynamically stable so don't need to admit for observation
133
Woman w/ LMP 7 wks ago present w/ vag spotting for 3 days. Abnormal serial hCG and low progesterone. Transvag U/S show sac but no fetal pole. What's the next step?
D&C
NOT mifepristone or methotrexate
134
Progesterone level that suggests abnormal/extrauterine pregnancy?
\<5 ng/mL is abnormal/extrauterine pregnancy
\> 25 ng/mL is healthy pregnancy
135
How do you dx ectopic pregnancy?
One of the following
* a fetal pole outside the uterus on U/S
* hCG level over 2000 mIU/ml and is no IUP seen on U/S
* inappropriately rising hCG level (less than 50% increase in 48 hours) and has levels which do not fall following diagnostic dilation and curettage
136
Criteria for using methotrexate for ectopic pregnancy?
* hemodynamic stability
* nonruptured
* size \<4 cm without a fetal heart rate or \<3.5 cm in the presence of a fetal heart rate
* normal liver enzymes and renal fx
* normal CBC
* ability to f/u rapidly
137
Signs of RUPTURED ectopic pregnancy?
* Hypovolemia: tachycardia, hypotension
* Peritoneal signs: rebound, guarding and severe abdominal tenderness
138
Definition of recurrent abortions?
\> 2 consecutive losses or \> 3 spontaneous losses
139
Most common abnormal karyotype in spontaneous abortuses?
Trisomy
140
3 systemic diseases that are assc. w/ early pregnancy loss?
DM, chronic renal disease, lupus
141
Which causes increased risk of spontaneous abortion between hx of preeclampsia and cig smoking?
Cig smoking (environmental factor)
Hx of preeclampsia confers no risk of SAB
142
Pregnant lady 8 wk GA came in w/ heavy bleeding + dilated cervical os + anemic. What's the next step?
D&C b/c actively bleeding and anemic
Expectant management is only used when pt is stable
143
How do you manage pregnant woman w/ incompetent cervix?
Cerclage at 14 wk
High pregnancy wastage in 1st trimester so don't do it immediately
144
Evaluation of recurrent abortions?
* Test for lupus anticoag, DM, thyroid disease
* Hysteroscopy/hysterography to eval anatomy
* Infection
* Maternal/paternal karyotype
145
What does a single 1st trimester surgical abortion do to risk of subsequent 1st trimester abortions?
Does not increase risk
146
Normal post-void residual volume (PRV)? Overflow PRV?
PRV: 50-60 cc
Overflow: \> 300 cc
147
Etiologies of overflow incontinence?
* Hypoactive detrusor muscle: MS, DM, neurogenic disorder
* Obstruction: post-op, severe prolapse
Incontinence doesn't change with position
148
How do you dx urge incontinence?
Contraction of bladder when filling
149
Etiologies of GSI (genuine stress incontinence)?
Majority: urethral hypermobility (straining Q-tip test angle \> 30 from horizon)
Others: intrinsic sphincter deficiency (ISD) of urethra
150
Finding on intrinsic sphincteric deficiency (ISD)? Tx?
Q-tip test revealing immobile urethra
Urethral bulking procedure
151
Tx of GSI?
Oxybutynin (anticholinergic)
152
Tx of cystocele?
fixing defects in the pubocervical fascia, or reattach it to side wall (if separated from the white lines)
153
Mechanism of urge incontinence?
Bladder pressure \> urethral pressure
154
Positional variables in different types of incontinence?
* Urge: sitting and standing
* Stress: standing
* Overflow: not assc. w/ any position
155
Tx of symptomatic pelvic prolapse?
Initially: pessary
If that fails: surgeries -\> can consider colpocleisis (vagina is surgically obliterated -\> don't even need GA for surgery)
156
What risks are reduced w/ use of combined OCP?
Endometrial & ovarian cancer, PID, ectopic, endometriosis, benign breast changes
157
What's the most appropriate permanent sterilization method for woman who is morbidly obese w/ lots of comorbidities?
Vasectomy for her husband -\> both tubal sterilization and vasectomy have the same success rate (99.8%), but there are more risks of complications for tubal sterilization b/c you need to be under regional or general anesthesia
158
What contraception do you give to woman w/ menorrhagia, Wilson's disease and poorly controlled HTN?
Levonorgestrel IUD -\> lower failure rate than progestin-only pills
159
What factor should make you consider something else over combination patch (besides CI to estrogen therapy)?
Obesity -\> patch (Ortho Evra) has high failure rate in woman \> 198 lbs
160
Contraception for 20-yo G2P2 w/ BMI 27 who delivered 6 weeks ago?
LARC (long acting reversible contraception) -\> so IUD
Depo shots are not good for high BMI
161
6 etiologies for recurrent SAB?
* Anatomic
* Hyper/hypothyroidism
* Luteal phase defects
* Parental chromosomal abnormalities
* Immune (lupus anticoag)
* Idiopathic
162
Workup for recurrent SAB?
Antiphospholipid Ab syndrome -\> so check anticardiolipin and beta-2 glycoprotein Ab, PTT, and Russell viper venom time
163
When is 17-hydroxyprogesterone tx indicated?
pt w/ hx of prior preterm birth -\> to prevent another preterm
164
When is cervical insufficiency typically dx?
2nd trimester
165
Tx for antiphospholipid Ab syndrome?
Heparin + aspirin
166
When can you offer both medical and surgical abortion? And what are you at an increased risk of w/ medical abortion?
\< 49 days GA
Bleeding
167
Time cutoff for manual vacuum aspiration?
\< 8 wk GA
168
Time cutoff for D&C? Dilation and evacuation?
D&C: 16 wk GA
D&E: \>16 wk GA but need trained professional
169
Time cutoff for legal abortion?
24 wks
170
Woman 20 wk GA w/ fetus w/ trisomy 18. She desires autopsy. What abortion method?
Induction w/ vaginal prostaglandin -\> choose medical abortion rather than surgical b/c she wants autopsy
Don't do induction w/ oxytocin b/c high failure rate this early on
171
Tx regimen for BV?
Metronidazole 500 mg BID orally 7 days OR vaginal 0.75% gel QHS (at bedtime daily) for 5 days
172
Modified Amsel criteria?
3 out of 4 of: positive whiff, clue cells, pH \> 4.5, thin grey homogeneous discharge
173
What is phimosis and in what condition do you see this in?
Resorption of clitoris
Seen in lichen sclerosus
174
Inflamed lesions on labia + oral lesion + alopecia?
Lichen planus
175
Sx of vulvar vestibulitis and tx?
Severe tenderness on vestibular touch, abrupt onset, dysparenuria, etc
Tx: TCA, pelvic floor rehabilitation, biofeedback, topical anesthetics
176
Dx of thick, lichenified, enlarged and rugose labia, with or without edema? Tx?
Lichen simplex chronicus from chronic scratching/irritation
Tx: corticosteroids + antihistamine
177
Ceftriaxone dose for uncomplicated cervicitis vs. PID?
125 mg for simple, 250 mg for higher infection
178
How do you distinguish primary or recurrent HSV?
Systemic sx present w/ primary infection
HSV-2 more likely to recur
179
See ovarian cysts on U/S in asymp premenopausal at the time where you're expecting them to have menses. What's the dx? What's the next step?
Hemorrhagic cysts
Repeat U/S in 2 months
180
Pt w/ known hx of endometriosis controlled w/ NSAIDS wants to do something w/ infertility. Negative workup for infertility. Next step?
clomiphene citrate to stimulate ovulation
181
Mechanism of action of GnRH agonist, danazol, and combination OCP in relieving sx of endometriosis?
* GnRH agonist: down regulation of hypothalamus-pituitary gland production
* Danazol: suppresses mid-cycle surge of LH and FSH
* Combination OCP: pseudopregnancy state
182
Most sensitive imaging modality for eval of uterus and adnexa?
Transvag U/S (not CT)
183
Pt w/ pelvic pain and vag U/S showing dilated vessels traversing broad lig. Dx?
Pelvic congestion syndrome (pelvic varicosities)
184
Nerves susceptible to injury w/ low transverse incision?
Iliohypogastric (T-12, L-1)
Ilioinguinal (T-12, L-1) -\> lower distribution, might have pain w/ adduction
185
When is ductogram indicated?
Breast discharge from a single duct
186
What increases pain form fibrocystic breast changes?
Caffeine (but not alcohol)
187
1st and 2nd line tx for mastitis?
Dicloxacillin
If allergic to penicillin, use erythromycin
188
Definitive tx of pelvic pain due to endometriosis?
Hysterectomy w/ BSO
189
Sequence of sexual maturation?
Thelarche -\> adrenarche (hair growth) -\> growth spurt -\> menarche
190
Similarities and differences bet. Noonan syndrome and Turner?
Similarities: short stature, webbed neck, heart defects, abnormal faces
Differences: Noonan syndrome has normal karyotype, puberty, and fertility
191
What hx components do you find w/ McCune Albright syndrome?
Premature menses before breast and pubic hair
192
How do you manage precocious puberty?
Continuous GnRH
Observation only acceptable if precede normal pubertal age by a few months
193
Normal age of menarche?
9-17 yo
194
What hormone level do you wanna get w/ hypothalamic-pituitary amenorrhea?
FSH and LH (will be low)
195
Hirsutism + acne w/ normal DHEAS, testosterone, prolactin, TSH. What else should you check?
17-hydroxyprogesterone to rule out late onset 21-hydroxylase deficiency
196
OCP effects on hirsutism?
Decreases it -\> b/c it decreases androgen production by ovaries and increases SHBG to bind testosterone and make it unavailable to hair follicles
197
Mechanism of postpartum telogen effluvium (hair loss)?
High estrogen during pregnancy -\> synchronizes hair growth and thus hair shedding later as well (typically 3 mo, but can range 1-5 mo postpartum)
198
Name 2 esterogen-secreting tumors?
* Thecomas
* Granolosa cell tumors
199
In what phase of the cycle does inhibin secretion increase?
Luteal phase
200
When is observation not recommended for endometrial polyp?
When it's \> 1.5 cm in size
201
What's the mechanism behind mid-cycle bleeding?
Drop in estrogen during ovulation
202
How does OCP help w/ dysmenorrhea?
Progestin induces endometrial atrophy -\> prostaglandins are produced in endometrium
203
Tx for PMS?
SSRI
204
Dx of "endometrial glands/stroma and hemosiderin-laden macrophages" in pelvis?
Endometriosis
205
Dx of dysmenorrhea + menorrhagia w/ soft boggy uterus?
Adenomyosis
NOT endometrial hyperplasia or carcinoma, bc those are less common w/ regular period and would have intermenstrual spotting
206
How much calcium do postmenopausal women need per day?
1200 mg
207
Interval that you do DEXA? When can you begin tx w/ bisphosphonate?
Every 2 year and before giving bisphosphonate tx
Bisphosphonate tx can be started based on hx of osteoporotic fracture alone
208
Postmenopausal woman who desires tx for vaginal dryness and vasomotor sx. What do you give?
Lowest effective dose of combo HRT w/ shortest duration possible
209
What's most effective for hot flashes?
Estrogen
NOT SERMS! (make it worse)
210
Effects of HRT on lipid profiles?
Beneficial -\> lower LDL and increase HDL
211
Why do you sometimes get post-menopausal sx again when an already post-menopausal woman undergoes hysterectomy + BSO?
B/c of decreased circulating androgen (usually made by ovaries) -\> so decreased conversion by peripheral fat to estrogen
212
What lab to order in suspected exercise induced amenorrhea?
Estrogen (will be low) -\> bc we're interested in hypothalamic amenorrhea
213
What is clomiphene challenge test and what is it helpful for?
Give clomiphene day 5-9 of menses and check FSH levels on day 3 and 10
Help to determine ovarian reserve
214
Replacement of what vitamins can help improve PMS?
A, E, and B6
215
Sx of what disorder can mimic PMS?
Hypothyroidism
216
Risk factors for PMS? PMDD?
PMS: positive fam hx, deficiency in B6, magnesium, calcium
PMDD: hx of depression, anxiety, mental disorder
217
Risk factors for molar pregnancy?
Asian, 2 or more miscarriages, inadequate consumption of beta carotine and folic acid
218
Recurrent risk after one molar pregnancy? Two?
After one: 1-2% (20 fold from gen pop)
After two: 10%
219
Classic presentation of molar pregnancy?
Uterus size greater than date, VB, sky high hCG
220
Nulliparous female w/ LMP 6 wks ago, uterus 10 wk size, hCG 80,000. Next step?
Pelvic U/S for molar pregnancy (indication is inconsistent GA and size)
221
Standard management of molar pregnancy?
Suction and curettage
222
How long do you have to wait to get pregnant after curettage of molar pregnancy?
6 mo (bc serial hCG needs to be followed to monitor progression)
223
What is necessary to establish the dx of choriocarcinoma?
Quantitative hCG + recent hx of pregnancy
DONT bx met lesions bc choriocarcinoma is very vascular
224
Cutoff for wide local excision (as opposed to radical vulvectomy with groin node resection) of SCC on vulva?
* Microinvasion (\< 1 mm)
* Size \< 2cm
* Well differentiated
225
Dx of "chronic, unrelenting skin infection causing deep, painful scars and foul discharge"?
Hidradenitis suppurativa
226
What do you do w/ a 70 yo woman w/ firm, non-tender mass at the level of bartholin gland?
Excision/bx -\> any new onset bartholin "cyst" is highly suspicious for bartholin gland malignancy if \> 40 yo
227
Tx for woman w/ known VIN II and multiple whitish papules throughout her external genitalia?
CO2 laser ablation
228
"Fiery red mottled background with whitish hyperkeratotic areas" on vulva in a breast cancer survivor?
Paget's disease of the vulva (significant assc. w/ breast cancer but not as much as Paget's disease of the nipple)
229
False negative rate of pap smear?
20-30%
230
What is an ectoprion?
Area of columnar epithelium that has not yet undergone squamous metaplasia (on cervix)
231
32-yo with Pap showing HSIL, colposcopy shows acetowhite lesion with punctations that extends into the endocervical canal, endocervical speculum can't visualize the entire lesion, but endocervical curettage is negative. Next step?
Conization -\> this colposcopy is unsatisfactory b/c can't visualize the entire lesion; and endocervical curettage has low sensitivity so can't rule out malignancy -\> so need better sample
232
5 indications for cervical conization?
* unsatisfactory colposcopy, incl can't visualize entire transformation zone
* discrepancy bet. pap and bx
* positive endocervical curettage
* pap smear indicating adenocarcinoma in situ
* cervical bx that can't rule out invasive cancer
233
What is classified as microinvasive cervical cancer?
Invade \< 3 mm
234
When can you use cryotherapy for cervical lesion?
When you have cervical dysplasia, don't need specimen, cancer has been ruled out, and entire lesion can be visualized
235
When should woman stop having pap smear?
Age \> 65, no hx of moderate dysplasia or cancer, and past 3 pap or past 2 co-testing have been negative in the past 10 years (last test performed w/in 5 yrs)
236
How do you manage fibroids during pregnancy?
No tx needed, don't even need to follow w/ U/S unless pain or worry about soft tissue dystocia (if fibroid is below the fetus; will need C-section)
237
Medical tx of fibroids?
GnRH agonist (but of course always start w/ NSAIDs) -\> but only for short term -\> so use this 3-6 mo before you plan to do hysterectomy to shrink fibroids, or if you think the pt is at the age that will go into menopause soon anyway
238
50-yo w/ menorrhagia and pelvic exam reveals 14-wk size irregularly shaped uterus. Hematocrit 35%. Next step?
Endometrial sampling -\> always worry about cancer in this age group
239
Side effects of GnRH agonist? What happened to fibroids and menses after you stop GnRH agonist?
Hot flashes 3-4 wks after starting tx
If stop -\> resume growth at previous rate -\> grow to the same size in 3-4 mo; menses come back after 4-10 weeks; hot flashes resolve in 1-2 mo
240
5 risk factors for endometrial cancer besides unopposed estrogen and obesity?
Nulliparity, HTN, late menopause, DM, obesity (greatest risk factor)
Fam hx doesn't really matter unless has Lynch II
241
Chance of complex atypical hyperplasia to progress to endometrial cancer if untreated?
28%
242
Are most ppl w/ endometrial cancer symptomatic?
Yes - usually w/ VB
Less than 5% are asymp
243
What do you do if endometrial bx shows rare atypical cells?
D&C to further investigate
244
Postmenopausal woman w/ endometrial sample confirming FIGO grade 1 endometrioid adenocarcinoma. What test do you order next?
CXR -\> to look for mets (endometrial mets like lungs -\> present as MULTIPLE lung nodules)
245
What do you do to survey woman on Tamoxifen?
Just annual exam (endometrial bx not needed)
246
Risk factors for ovarian cancer?
* More ovulation: so early menarche, late menopause
* Nulliparity, white, increasing age, residents of N America and N Europe
* FAM HX (not in endometrial cancer)
smoking is NOT a risk factor
247
Dx of multilocular large ovarian cyst?
Mucous cystadenoma
248
Dx of large ovarian cyst w/ increased abd girth?
Serous cystadenoma
249
What imaging modality should you use for initial evaluation of suspected ovarian cancer?
CT of abdomen and pelvis
PET is only useful in evaluating recurrence
250
What's the most important prognostic factor in ovarian cancer?
Stage
251
Standard of care for advanced ovarian cancer?
Surgical cytoreduction followed by post-op chemo (taxane + platinum adjunct)
252
Is Amitriptyline safe to use during pregnancy?
Yes
253
Tx for pregnant woman dx w/ HIV?
IV zidovudine during labor and zidovudine for neonate for 6 wks (+serial HIV PCR)
254
Most common cause of septic shock in pregnant woman?
Acute pyelonephritis
255
What to use in pregnant woman whose asthma has been worsening (using more albuterol)?
Start on inhaled corticosteroids or cromolyn sodium
Save theophyllin for refractory cases
256
Meds to use for pregnant woman w/ thyroid storm?
thioamides (PTU), propranolol, sodium iodide, dexamethasone
DONT use radioactive iodide b/c will concentrate in fetal thyroid
257
What maternal conditions pose high mortality rate during pregnancy?
Pulm HTN, coarctation of aorta w/ valve involvement, Marfan w/ aortic involvement
\> 25% mortality
258
Tx for pregnant woman w/ symptomatic MVP?
B-blocker
259
Pregnant woman w/ cough, fever, chest pain, and dyspnea. What's next?
CXR -\> essential for pneumonia dx
Don't need sputum culture, etc.
260
What do you need to do to confirm IUP, ectopic, missed abortion?
Serial hCG (one quant hCG can't confirm)
261
What are obese pregnant women at an increased risk of?
* HTN
* PreE
* GDM
* Higher rate of C section
* Fetal macrosomia
* Pospartum complications
262
Define puerperium?
period of about 6 wk after delivery when things are returning to nonpregnant state
263
3 drugs for lupus sx?
* NSAIDs for athralgia and serositis
* Corticosteroids for severe diseases
* Hydrochloroquine for skin manifestations (assc w/ flares if discontinued)
264
What tx of breast cancer can't you do during pregnancy?
Radiotherapy
Chemo might be ok
265
Tx of depression during pregnancy?
* SSRI: can do sertraline, fluoxitine, but NOT paroxitine (Paxil) bc assc. w/ cardiac malformation and persistent pulm HTN ("P" for can't use during Pregnancy)
* TCA: triptyline stuff
* Bupropion
266
Test to order during suspected appendicitis in pregnancy?
Graded compression U/S -\> very sensitive and specific esp up until 35 wk GA, and less radiation exposure than helical CT
267
Criteria for dx of preE?
* \> 20 wk GA
* BP \> 140/90 on 2 occassions at least 4 hr apart (unless \> 160/110 which is considered severe, then can do shortened interval)
* Either
* Protein \> 300 mg / 24hr
* Plt \< 100K, creatinine \> 1.1, liver transaminases twice normal, pulm edema, cerebral or visual sx
268
When do you give magnesium sulfate in preE?
BP \> 160/110 and maternal sx
269
When do you give BP med to pregnant women?
BP \> 160/110
270
When is delivery recommended for gestational HTN or preE? What about severe preE?
* Gestational HTN or preE: when there's no severe features at or beyond 37 wk GA
* Severe preE: when \> 34 wk GA
271
Therapeutic range of MgSO4? Ranges of diff side effects?
Therapeutic: 4-7 mEq/L
Loss DTR: 7-10
Resp depression: 11-15
Cardiac arrest: \> 15
Pulm edema is not assc. w/ any particular value
272
When should you deliver regardless of GA in woman w/ preE?
* Plt ct \< 100K
* Pulm edema
* Renal failure, oliguria
* Abruption placentae
* DIC
* Persistent cerebral sx, ecalmpsia
* Non-reassuring fetal testing or fetal demise
* Can't control BP after max dose of 2 anti-HTN meds
* LFT more than 2 times normal
273
Active labor w/ BP 170/105, 3+ proteinuria, fetal HR 170 w/ decreased variability and sinusoidal pattern. BRB per vagina. What's the cause of this blood?
Abruptio placenta (preE and E are risk factors)
Tachyasystole and fetal anemia (tachycardia + sinusoidal pattern) support this dx too
274
What's the goal of antiHTN in pregnant pts?
Diastolic BP of 90-100 mmHg to prevent stroke or abruption
Not to achieve normal BP
275
Protocol for the emergency use/dose of anti-HTN in pregnancy?
* Hydralazine first line: start w/ 5 mg IV -\> then 10-15 mg every 20 min (max dose 40 mg)
* Labetalol: start w/ 10-20 mg IV -\> then 20 mg dose 10 min later -\> then 40 mg dose 10 min later -\> then 80 mg dose 10 min later (max dose 220 mg)
276
Risk of isoimmunization antepartum? full-term delivery? subsequent pregnancy? Assuming RhoGAM is not administered.
* Antepartum: 2%
* Full-term: 7%
* Subsequent pregnancy: 7%
277
Noninvasive technique to evaluate fetal anemia? Invasive technique?
* Noninvasive: Doppler to assess MCA peak systolic velocity
* Invasive: amniocentesis and cordocentesis
278
Signs of fetal hydrops on U/S?
* Abnormal fluid collection in 2 or more cavities: so pleural, pericardial, ascites, scalp edema
* Hepatosplenomegaly (if extramedullary hematopoeisis is extensive)
* Placentomegaly (placental edema) and polyhydramnios
279
How much of fetal blood is neutralized by 300 microgram of RhoGAM (routine dose)?
30 cc (so 15 cc of fetal RBC)
280
Current recommendations for RhoGAM for Rh- women without evidence of Rh immunization?
PPlx after 28 wk GA after an indirect Coomb's test and w/in 72 hr after delivery Rh+ baby or following OB procedures that could mix blood
This doesn't apply if father is known to be Rh-
281
What is Kleihauer-Betke test used for?
For determining fetal transplacental hemorrhage so you can give a correct dose of RhoGAM
Acid-elution test -\> mom's blood is washed out while fetal RBCs remain stained
282
What measurement indicates severity of Rh hemolytic disease?
Measures optical density of amniotic fluid -\> this is to detect bilirubin at 420-260 nm (wavelength absorbed by bilirubin) -\> delta OD450 (deviation of linearity at 450 nm) is an indication of severe hemolysis (heme pigment present) and might need intravascular intrauterine transfusion (or delivery is fetus is at term)
283
Dx of elevated AFP + 22 cm fundal height on 16 wk GA?
Twin gestation (bc fundal height exceeding GA)
284
U/S markers of fraternal twins?
* Twin peak (lambda) sign
* 2 separate placentas, posterior and anterior
* dividing membrane thickness \> 2 mm
* diff genders
285
Timing of division and chorionic/amniotic presentation?
* Divide before morula stage or within 3 days post-fertilization -\> dicho, diam
* Day 4-8 -\> monocho, diam
* Day 8-12 -\> monocho, monoam
* Day 13 -\> conjoined twin
Chorion is # of placentas
286
What is twin pregnancy at an increased risk of?
* 5 times higher fetal death rates compared to singleton
* 5-6 times cerebral palsy
* 58% increased risk of preterm (avg GA of 35-37 wk) -\> early good weight gain (wk 20-24) helps with this
* higher risk of IUGR
* higher risk of congenital anomalies in general, and these are usually discordant in the pair
287
What cho/am is TTTS most likely to be found in?
Monochorionic, diamniotic (2 placentas)
288
What is superfedunculation?
Fertilization of 2 separate ova w/ 2 separate intercourses in the same cycle
289
% of preterm births in twin, triplets, quadruplets?
Twin: 50% preterm
Triplets: 90%
Quadruplets: almost all
290
Optimal mode of delivery when twin A (first twin) is breech and twin B is vertex?
C-section
291
What hormone is elevated w/ dizygous multiple births?
FSH
292
Most common cause of SAB (be specific)?
Autosomal trisomy -\> 40-50% of the time
Trisomy 16 most common
293
At what GA is the risk of microcephaly and severe intellectual disability?
8-15 wk GA -\> so most susceptible of X-ray here
294
What are women w/ factor V leiden mutation at an increased risk of?
* stillbirth
* preE
* IUGR
* placental abruption
so suspect this in young woman w/ hx of DVT on OCP and losing late pregnancy & other screens have been normal except for U/S identifying asymmetric IUGR
295
36 wk GA now presented w/ fetal demise. problems during pregnancy are open neural tube defects, polyhydramnio, fetal weight \> 90 percentile, nonreactive NST a week before. What's the etiology?
Uncontrolled maternal DM
Antiphospholipid Ab syndrome and maternal HTN would have presented with oligohydramnio and IUGR
296
GA to meet definition of preterm labor?
\> 24 wk GA
297
G1P0 w/ vaginal spotting the last 2 days. 11 wk GA by U/S, but no fetal cardiac activity. No abd cramping or pain. Single most important test to perform?
Maternal blood type so that you can administer RhoGAM to prevent sensitization
(we already know by U/S that this is a nonviable pregnancy so don't need to do other things at this time)
298
What 7 things are fetuses w/ DM1 mother at an increased risk for?
* fetal death
* IUGR
* macrosomia
* polyhydramnios
* congenital malformations
* HTN complications
* preterm birth
299
Sequence of stages of grief?
Denial -\> Anger -\> Bargainin -\> Depression -\> Acceptance
300
Criteria for missed abortion?
CRL \> 7 cm on U/S w/ no fetal cardiac activity
Use misoprostol for induction (the question has GA at 12 wk and still uses this)
301
Why has C-section rate increased?
Less women are willing to go thru SVD after C-section b/c of the published complication (uterine rupture)
OB less willing to do spontaneous breech delivery
302
G2P1 at 40 wk GA w/ closed cervix, 20% effaced, -2 station. Strongly desires induction due to back pain. What do you do?
Administer cytotec to ripen cervix then augment w/ pit
Can't do AROM or foley bulb b/c cervix is closed
303
Risk factors for breech presentation?
* Uterine fibroids, uterine anomalies
* Prematurity
* Multiple gestation
* Genetic disorders
* Polyhydramnios
* Hydrocephaly, anencephaly
* Placenta previa
304
Definition of prolonged latent phase?
\>20 hours for nulliparas and \>14 hours for multiparas
Tx w/ rest or labor augmentation
DON'T do AROM during this phase (increases risk of infection)
305
4 risk factors of shoulder dystocia besides GDM and macrosomia?
* Prior delivery w/ shoulder dystocia
* Prolonged 2nd stage of labor
* Postterm pregnancy
* Maternal obesity
306
Mom w/ 5 cm cervix, 100% effaced, -1 station, intact membrane. Progressed to 7/100/0 in 2hr and received epi. Then doesn't progress at all for 4 hrs. Fetal tracing category I. What do you do?
This is secondary arrest of labor -\> do amniotomy
After that if still not satisfied, augment w/ pit
307
36 wk gestation w/ known placenta previa and third episode of heavy VB. U/S confirmed what you already know. What do you do?
C-section -\> b/c it's the third episode and it's near term
Don't need steroids
308
Diff bet. FFP and cryoprecipitate?
FFP: VIII, fibrinogen, V
Cryoprecipitate: VIII, fibrinogen, vWF
309
How do you manage placental abruption?
* unstable maternal VS or nonreassuring FHT at any GA: emergency C-section
* stable maternal VS, reassuring FHT, no placenta previa, at or more than 34 wk GA: trial of VD
310
What does maternal smoking put you at risk of?
* Placenta abruption
* preE
* infection
* placenta previa
* IUGR
311
Tocolytic agent in 33 wk GA patient w/ DM and myasthenia gravis?
Nifedipine (CCB)
Can't use terbutaline and ritodine b/c they're CI in diabetics. Terbutaline is ineffective for longer than 48 hrs anyway.
Can't use MgSO4 b/c it's CI in myasthenia gravis.
Can't use indomethacin b/c of risk of premature closure of DA at this point (past 32 wks).
312
How does MgSO4 work as a tocolytic agent?
Compete w/ calcium for entry into cells
313
Mechanism of action of terbutaline, use, and side effects?
B2 agonist
Use: short term tocolytic (ie for transferring to another hospital)
Side effects: tachycardia, hypotension, chest pain, anxiety
314
Side effect of CCB (nifedipine) as tocolytic agent?
Fetal hypoxia
315
Side effect of indomethacin as tocolytic agent besides premature closure of DA?
Oligohydramnios
316
What does the use of betamethasone during 24-34 wk GA do to newborn besides stimulating lung maturity and decreasing incidence of RSD?
* decreased intracerebral hemorrhage
* decreased necrotizing enterocolitis
* NOT assc. w/ increased infection or enhanced growth
317
When can you use fetal fibronectin test and what is its strength?
* In symptomatic women, 24-35 wk GA
* In asymptomatic women (so during routine screening), 22-30 wk GA
* Strength is in NPV -\> if neg, 99% of symptomatic women won't deliver in 2 weeks, and 96.7% of asymptomatic ones won't deliver before 35 wk GA
318
Evaluation of PROM?
Don't do digital exam b/c can introduce bac and cause chorioamnionitis
1. AF sampling: ferning or nitrazine of fluid from VAGINA (not cervix)
2. U/S to detect anomalies and measure AF volume
3. Manage according to GA
319
31 wk GA woman w/ Pre PROM. What's the role of tocolysis in this setting?
Delay delivery in order to administer steroids
320
Risk factors for pre PROM?
* Genital tract infection - most important
* smoking
* hx of prior pre PROM
* shortened cervical length
321
Time from PROM to labor of term and 28-34 wk GA?
* Term (38-42 wk): 90% will go into labor w/in 24 hr
* 28-34 wk GA: 50% w/in 24 hr; 80% w/in 48 hr
322
Best med to delay onset of labor for pre PROM?
Antibiotics -\> can delay labor for 5-7 days (longer than tocolysis and steroids) and prevent amnionitis and sepsis
323
2 things that are considered achievment of fetal lung maturity?
* Positive phosphatidylglycerol
* 34 wk GA
324
Neonatal survival when pre PROM happens at 20-23 wk GA?
25%
325
Indication of chorioamnionitis on amniocentesis?
Glucose less than 20 mg/dL
Increased IL-6 will also be found
Presence of leukocytes has low predictive value
326
Risk of recurrence of pre PROM? What do you use to reduce risk?
32%
17 alpha-hydroxyprogesterone to reduce preterm labor (pre PROM is assc. w/ preterm deliveries 1/3 of the time)
327
How do you manage PPROM?
* If \< 34 wk: tocolysis (only if ctx present tho) + steroids
* If \> 34 wk: augment labor. Expectant management at this point poses risk of chorioamnionitis. Tocolytics are CI at 36 wk GA
34 wk is the same cutoff for tocolysis & steroids in the setting of preterm labor!
328
Role of IUPC during labor?
If active phase, good interval of contraction but no cervix change -\> so wanna see if strenght of contraction is adequate so you can determine if you need pit
329
CI for the use of vaginal prostaglandin E2 (cervidil) for cervical ripening?
Prior C-section
330
Define fetal heart acceleration?
\> 15 bpm lasting more than 15 sec
331
What fetal heart tracing is amnioinfusion used for?
Repetitive variable decelerations
332
Etiology of early decel? Late decel? Variable decel? Sinusoidal pattern?
* Early decel: head compression
* Late decel: uteroplacental insufficiency, fetal hypoxia
* Variable decel (rapid dip): cord compression (esp in oligohydramnios)
* Sinusoidal pattern: severe fetal anemia
333
What does uterine hyperstimulation do to fetal heart tracing?
Prolonged bradycardia
334
CI for the use of methylergonovine as a uterotonic agent?
Vasoconstrictive -\> so don't use in HTN, preE
335
What prostaglandin is misoprostol?
E1
336
What uterotonic can't be used in ppl w/ asthma?
Prostaglandin F2-alpha (Hemabate) b/c of bronchio-constrictive effects
337
4 factors assc. w/ retained placenta?
* prior C-section
* Fibroids
* Prior curettage
* Succenturiate lobe of placenta
NOT placenta abruption, augmentation, parity, circumvallate placenta, etc
338
Routes of administration of oxytocin, misoprostol, prostaglandin F2-alpha as uterotonics?
* Oxytocin: dilute (20-80 units in a liter) rapid short time infusion
* Misoprostol: orally or rectally
* Prostaglandin F2-alpha: IM into the uterine muscle (can't do IV b/c of risk of bronchoconstriction)
339
Abx for suspected endometritis?
IV ampicillin/clindamycin + Gentamicin (G- coverage)
340
PPD#2 woman w/ firm and tender breast, no erythema, and nipples intact. Temp 100.4 F. Dx?
Breast engorgement
341
PPD#5 noticed fever since PPD#2 that's unresolved w/ antibiotics. Firm nontender uterus, normal UA, normal breast exam. What's the cause?
Septic pelvic thrombophlebitis (dx after excluding endometritis, mastitis, and cystitis)
Need both board spectrum IV abx and anticoag (heparin) -\> fever resolves rapidly
342
Define drug pregnancy categories.
* Category A: studies in pregnant women showed it to be safe
* Category B: studies in animal showed it to be safe. No adequate study in pregnant women.
* Category C: studies in animal showed it to be unsafe. No adequate study in pregnant women.
* Category D: studies in pregnant women showed it to be unsafe
* Category X: positive evidence in both animal and pregnant women that it's unsafe so don't use
343
What does prior hx of depression put postpartum women at risk of: postpartum blue or depression?
Postpartum depression
344
2 most common side effects of SSRIs? Can you be on it during lactation?
Insomnia and decreased libido
Can be safely used during lactation
345
What consequence on the neonate is 3rd-trimester use of SSRI assc. w/?
Abnormal muscle movement (EPS) and withdrawal sx (agitation and poor feeding, difficulty breathing) -\> these sx subside w/in hrs or day in some newborns w/out any tx
346
Indication for NST? Define reactive NST?
Indication: decreased fetal movement, etc
2 fetal HR accelerations of 15 bpm lasting 15 sec in 20 min
347
What is oxytocin challenge test used for?
Contraction stress test -\> look for persistent late decelerations after contractions (3/10) min -\> assess uteroplacental insufficiency
348
What 10 things is postterm pregnancy assc. w/?
* placental sulfatase deficiency
* fetal adrenal hypoplasia
* anencephaly
* inaccurate or unknown dates
* extrauterine pregnancy
* meconium aspiration (meconium staining of AF is 3-4 more common in postterm pregnancy)
* macrosomia
* oligohydramnios
* uteroplacental insufficiency
* dysmaturity (withered, meconium stained, long-nailed, fragile)
349
ACOG recommendation for postterm surveillance?
* Pt records of fetal kick count and fetal surveillance (CST, NST, BPP) -\> delivery for nonreassuring testing
* Induction of labor at wk 42, use cervical ripening agent first (prosta E1) if cervix unfavorable
350
Risk of recurrence of postterm pregnancy?
50%
351
36 wk GA patient w/ chronic HTN, class F diabetes w/ baseline 1 g proteinuria, tobacco use. Most likely etiology of IUGR?
Uteroplacental insufficiency -\> b/c of obvious vascular disease (class F diabetes w/ proteinuria)
NOT tobacco use in this case
352
Finding on Doppler U/S w/ IUGR?
Increased systolic/diastolic ratio -\> indicates increased vascular resistance
353
33 wk GA w/ DM1 was dx w/ IUGR. Next step?
Antenatal testing of fetal well being -\> can do multiple things
* NST twice weekly w/ AFI at least weekly
* BPP weekly
* U/S is not useful if more often than once every 2 weeks
* amniocentesis to assess lung maturity at a more advanced GA
354
5 short-term complications of IUGR?
* Fetal demise
* Perinatal demise
* Meconium aspiration
* Oligohydramnios
* Polycythemia
355
4 long-term complications of IUGR?
* CVD
* chronic HTN
* chronic obstructive lung disease
* DM
356
35 wk GA pt came in w/ decreased FM. Serial U/S show decreased of EFW from 60th to 20th percentile. NST and AFI are normal. What's next?
Weekly nonstress test
357
Indications for delivery of IUGR?
* Delivery now if 36 wk GA, oligohydramnios, abnormal dopper S/D ratio
* Delivery at term if reassuring fetal testing incl normal AFI
358
Is GDM assc. w/ increased risk of congenital anomalies?
No, pre-existing DM is
359
Define macrosomia in diabetic and non-diabetic pts.
* Diabetic: EFW \> 4000 g
* Non-diabetic: EFW \> 4500 g
360
Cuttoff for the size of fetal head (BPD) that could benefit from C-section?
\> 12 cm
361
7 requirements of forceps-assisted vaginal delivery?
* complete cervical dilation
* head engagement
* vertex
* clinical assessment of fetal size and maternal pelvis
* known position of the fetal head
* adequate maternal pain control
* ROM
362
Compared to forceps-assited delivery, what is vacuum-assisted delivery more at risk of? less at risk of?
* More at risk of cephalohematoma and jaundice, transient lateral rectus paralysis
* Less at risk of maternal lacerations
363
Most likely risk assc. w/ postpartum tubal ligation?
Unplanned pregnancy -\> failure rate of 1%, 1/3 of those are ectopics
Not necessarily risk for aspiration under anesthesia b/c postpartum tubal ligation is usually done under epidural or spinal anesthesia, and normally these can be done under regional or general anesthesia anyway
364
Pros and cons of CVS compared to amniocentesis?
* Pros: can perform earlier at 10-12 wk (vs. 15 wk) -\> if earlier than 10 wk tho, assc. w/ rare limb abnormalities
* Cons: higher loss rate (1-3% vs. 0.5%), inadequate sample
365
Postmenopausal pt w/ atrophic vagina desires tx for dysparenuria. What do you use?
Estrogen cream on vagina
Long-term use might require adding progestin b/c of systemic absorption and effects on endometrium
366
Advice for lesbian w/ active HSV-1 flare w/ herpetic lesions on the mouth?
Dental dam or latex condom cut in the middle is effective
367
4 categories of female sexual dysfx?
* desire: androgen and estrogen
* arousal: external genitalia
* orgasm
* sexual pain: use water-based lubricans if hx of breast cancer (can't do estrogen cream)
Body image is not one of the categories
368
Rate of tubal infertility after 1, 2, 3 episodes of PID?
1 episode: 12%
2 episodes: 25%
3 episodes: 50%
369
How much protein does pregnant woman need a day?
70g
370
Criteria to confirm GA at term
One of the following needs to be met
* Fetal heart tones have been documented for 20 weeks by a non-electronic fetoscope or for 30 weeks by Doppler
* It has been 36 weeks since a positive serum or urine HCG pregnancy test was performed by a reliable laboratory
* U/S of the crown-rump length at 6-12 wks, supports GA of at least 39 weeks
* U/S at 13-20 weeks confirms GA of at least 39 weeks, determined by H&P
371
Management of = or \> 41 wk w/ favorable cervix (dilation)?
Admit for induction
372
Management of suspected endometritis post abortion?
* IV abx immediately
* U/S to look for RPOC
* Repeat D&C if RPOC found
373
Mucopurulent cervicitis with exacerbation in the symptoms during and after menstruation is classically?
Gonorrhea
374
Diff bet. features of primary dysmenorrhea vs. endometriosis vs. pelvic congestion?
* Primary dysmenorrhea: pain DURING menses -\> manage w/ NSAIDs and OCP (like endo)
* Endometriosis: pain peaks BEFORE menses
* Pelvic congestion: pain peaks BEFORE menses, worsens w/ standing, and relieved by menses
375
When do you do umbilical artery Doppler velocimetry?
When suspecting IUGR
376
Strength of NST & next step if abnormal? How often do you do NST?
High NPV -\> if normal, low risk of fetal death, so don't need to perform anything else
Low PPV -\> if abnormal, do BPP or contraction stress test (if no CI to labor) -\> if these come back normal (CST shows no late or recurrent decels), can let pt go and f/u as appropriate
NST done at least weekly in 3rd trimester pregnancies that require ongoing antenatal surveillance
377
Diff in management of palpable breast mass in \< 30 yo and \> 30 yo?
\< 30 yo -\> U/S
\> 30 -\> mammogram & U/S
378
Mechanism and devastating complication of HELLP syndrome?
Mechanism: systemic inflammation + platelet consumption
Complication: DIC in half
379
Management of HELLP?
Prompt vag delivery esp if at or more than 34 wk GA (or any GA w/ maternal deterioration)
380
Management of preterm labor at \< 34 wk (regular contractions x 4 in 20 min or 8 in 50 min + cervical dilation/effactement + no indication for delivery)? 34-37 wk?
\< 34 wk: tocolysis + steroids + MgSO4 for neuroprotection
UNLESS fetus is incompatible w/ life anyway -\> allow SVD
34-38 wk: let them deliver
381
Criteria to satisfactory CST?
\> 3 contractions lasting for 40 sec in 10 min -\> can interpret as normal (no decels), abnormal (late decels following more than half of contractions), equivocal
Otherwise, unsatisfactory
382
Complications of shoulder dystocia?
* fx clavicle
* fx humerus
* erb-duchenne: C5-C6 affected
* klumpke palsy: + horner syndrome -\> C8 and T1 affected
* perinatal asphyxia
383
4 options for emergency contraception?
* Copper IUD (99% efficacy, 0-120hr postcoital)
* Ulipristal pill (\> 85%, 0-120hr): emergency contraception only
* Levonorgestrel pill (85%, 0-72hr): emergency contraception only
* OCPs (75%, 0-72hr)
384
Main side effect of raloxifene?
Increased risk of venous thromboembolism
385
Mechanism and tx of neonatal thyrotoxicosis (low BW, tachycardia, warm skin, irritability)?
Transplacental passage of anti-TSH receptor Ab from mom during3rd trimester (mother w/ known Graves' disease, even if surgically treated)
Tx: methimazole + B blocker -\> condition generally self-resolves w/in 3 months (maternal Ab disappear from baby's circulation)
386
Management of suspected IUFD (fetal heart tones not heard by Doppler)?
* confirm dx w/ real-time U/S (absence of fetal movement and cardiac activity)
* do maternal coagulation profile (IUFD can cause maternal coagulopahty)
* if suspected to be abnormal, such as fibrinogen w/in low-normal range (bc should have been higher in pregnancy) -\> induction of labor
* if normal -\> up to pt -\> IOL or watchful expectancy (labor occurs spontaneously in 80% of cases w/in 2-3 wk of IUFD; but higher risk)
387
Inpatient and outpatient regimen for PID?
* Inpatient: IV cefoxitin or cefotetan + doxycycline + clindamycin + gentamicin
* Outpatient: IM cefoxitin + PO probenecide + PO doxycycline; OR IM ceftriaxone + PO doxycycline
388
young female w/ LLQ pain that started suddenly, doesn't radiate, no other sx, LMP 2 wks ago, VS stable. Dx?
Midcycle pain (mittelschmerz) -\> can be unilateral b/c it lateralizes to ovary that produced mature ovum
389
Cause and presentation of ovarian hyperstimulationsyndrome?
Cause: iatrogenic complication of ovulation-inducing drugs
Presentation: abd pain + ascites + resp difficulty + other systemic findings
390
Dx of breast bx showing fat globules and foamy macrophages?
Fat necrosis
391
Tx of fibrocystic disease?
Cyst aspiration (don't need to send fluid to cytology if it's clear and accompanied by mass disappearance -\> just observe for 4-6 wks)
392
Indications for EMB in AUB?
* at or \> 45 yo and ALL postmenopausal women (may elect to start w/ TVUS evaluating thickened endometrial stripe first)
* \< 45 yo w/ persistent sx or risk factors
* Unopposed estrogen exposure
* Prolonged amenorrhea w/ anovulation
393
Management of eclampsia?
* MgSO4 to prevent recurrent seizures
* Labetalol or hydralazine if severely HTN (\>160/110) to prevent stroke
* Evaluate for delivery (IOL if no CI, or C-sec)
394
Vaginal discharge that's white or yellow, no odor, absence of other sx?
Physiologic leukorrhea
Under microscope see squamous cells and rare PMN leukocytes
395
Glucose levels in 2-step approach of GDM?
* Step 1: 50g oral glucose load and check 1-hr later (\< 140 mg/DL)
* Step 2: 100g oral glucose load
* fasting: \< 105 mg/dL
* 1-hr: \< 190
* 2-hr: \< 165
* 3-hr: \< 145
396
Complications of seizures?
* Pos. shoulder dislocation: hold arm aDducted and internally rotated
* Ant. shoulder dislocation: hold arm aBducted and externally rotated
* Todd paralysis: transient unilat weakness that spontaneously resolves
397
Complication of epidural? Tx?
Hypotension from blocking sympa -\> venous pooling and decreased return -\> decreased CO -\> can lead to fetal acidosis
prevented by aggressive IVF prior to epidural placement
tx: left uterine displacement (position pt on left side) to improve venous return + IVF + vasopressor
398
What test to perform after confirming presence of breast cancer?
FISH oncogene amplification OR immunohistochemical staining to look for HER2 -\> b/c if present, can use trastuzumab and anthracycline chemo
399
1st line agents for HTN management during pregnancy (NOT emergency situation)?
Labetalol and methyl dopa
CCB and hydralazine are alternatives
400
Management of 3 types of UTI during pregnancy?
* Nitrofurantoin 5-7 d OR amoxicillin 3-7 d OR fosfomycin single dose -\> avoid fluoroquinolones in all trimesters and bactrim in 1st and 3rd trimester
* Asymptomatic bacteriurea (CFU \> 100K colonies/mL)
* Acute cystitis (considered complicated UTI)
* Hospitalization and IV beta-lactams, meropenem; then change to 10-14 d course of PO abx after afebrile for 24 hr
* Acute pyelonephritis (flank pain, n/v, fever, CVA tenderness)
* Cephalexin is another abx that can be used in UTI during pregnancy
401
Cervical cancer screening guidelines for immunocompromised?
At onset of sexual intercourse, and every 6 mo for 2 years then annually
402
Management of pt w/ hyperemesis gravidarum (severe n/v + weight loss)?
* Pelvic U/S (b/c hyperemesis gravidarum is more common in multifetal or molar pregnancy)
* Tx w/ diet, hydration, ginger, pyridoxine w/ or w/out doxylamine
403
FSH/LH ratio in premature ovarian failure?
\>1.0
404
When do you do amniocentesis?
15-20 wk (same window as 2nd trimester quad screen)
405
Threshold for visualizing gestational sac on TAUS?
6500 IU/L
406
Initial workup of adnexal mass in postmenopausal women?
TVUS + CA-125 level
If both have benign features -\> may be observed w/ periodic U/S
If both are suspicious (\>10 cm, complex cyst, etc) -\> exploration
407
Exzematous rash near nipple that doesn't improve w/ topical treatment + bx shows large cells surrounded by halo-like areas invading epidermis. Dx?
Paget's disease of the breast -\> so most likely also have underlying adenocarcinoma
408
Stillbirth delivery options in 2nd vs. 3rd trimester?
2nd: D&C up to 24 wk \> IOL, SVD
3rd: IOL \> SVD, repeated C-section
409
Most effective strategy in preventing HIV transmission to neonate?
HAART \> elective C-section (beneficial if viral load at delivery is \> 1000 copies/mL)
410
46, XX w/ normal internal genitalia but ambiguous external genitalia at birth now presents w/ high testosterone&androstenedione&FSH&LH and undetectable estrogen. Dx?
Aromatase deficiency
NOT CAH, b/c in CAH you still synthesize estrogen
411
How do you tell placental abruption and preterm labor apart if there's no VB?
Preterm labor: pain intermittent and uterus relaxes w/ no pain bet. ctx
Concealed abruption: constant pain, nonreassuring FHT, uterine tenderness
412
Management of young woman presenting w/ breast lump?
Ask to return after menstrual period for reexamination (might show mass regression -\> benign) if no obvious sign of malignancy are present
Otherwise, proceed w/ U/S, FNA and/or excisional bx -\> mammogram not useful in young women b/c of high density of breast tissue
413
Vulvar ulcer that's initially painless papule and later became ulcerated; non-exudative base, raised, indurated margin; painless bilat inguinal LAD. Dx?
Primary syphilis (dx by darkfield microscopy)
Granuloma inguinale (donovanosis) which also has painless ulcers doesn't have assc. LAD and ulcers are red w/ beefy base -\> need abx to resolve (chancre resolve spontaneously)
414
12-hr post SVD now having low-grade fever, leukocytosis, bloody vag discharge. uterus firm and nontender. Next step?
Reassurance -\> this is normal
Won't be normal if foul-smelling lochia or tender uterus
415
How do you treat infertility due to premature ovarian failure?
IVF w/ donor oocytes (can't do clomiphene citrate b/c don't have functional eggs!)
416
75-yo w/ suspected lichen sclerosus. Next step?
Punch bx (wanna rule out SCC)
417
4 indications for GBS prophylaxis when GBS status is unknown
* Delivery at \< 37 wk
* Duration of ROM at or more than 18 hrs
* GBS bacteriuria in any conc during current pregnancy
* Prior hx of delivery of infrant w/ GBS sepsis
418
Test to tell bet. ruptured ovarian cyst vs. ovarian torsion?
Doppler velocimetry normal in ruptured cyst, and pelvic U/S shows free fluid next to the mass
419
Preferred method of contraception in lactating mothers?
Progestin-only oral conraceptives
420
Cause of overflow incontinence postpartum?
Epidural anesthesia -\> fix w/ indwelling catheter for 24 hr to decompress bladder and regain detrusor muscle fx
421
Management of endometrial hyperplasia in AUB?
Do EMB
* if no atypia (complex or simple hyperplasia) -\> do progestin therapy
* If atypia but simple hyperplasia & want future pregnancy -\> do progestin therapy
* If atypia but don't want medical tx or no plans for pregnancy -\> hysterectomy
422
Cervical mucus stretched into long thread (6 cm) when lifted vertically, pH is 6.5 or greater, ferning when smeared on microscopic slide. What phase of cycle?
Ovulatory phase
423
Reason for higher incidence of UTI in females compared to males? Reason for higher incidence of RECURRENT UTIs w/in female population?
Incidence compared to males: Shorter urethral length
Recurrnet incidence: Closer proximity of urethral meatus to anus
424
How to tell when AFP is elevated if it's from multiple gestation or from wall defects?
Look at uterine size -\> consistent w/ dates if it's from wall defects
425
What sign distinguish placental abruption from uterine rupture?
No uterine ctx in uterine rupture, whereas in placental abruption you have hypertonic/tender uterus
426
How to dx vasa previa and management?
Dx w/ doppler U/S -\> offered C-section prior to labor obset
If already VB -\> Apt test or Kelihauer-Betke test will differentiate maternal from fetal blood -\> C-section immediately if vasa previa
427
Dx of vulvar genital lesions that show resolution (turn white) w/ application of trichloroacetic acid? Tx?
Genital warts
Tx: small lesions can do trichloroacetic acid or podophyllin. Large lesions ned excision or fulguration (electric current)
428
Management of carpal tunnel syndrome?
Wrist splinting and NSAIDs
If that doesn't work, do local steroid injection
If that doesn't work, do surgical decompression
429
Why is alloimmunization of little concern w/ ABO?
Ab to ABO antigens cause mild disease in most newborns
If seen, it's usually O mother w/ group A or B baby (IgG formed)
430
How to distinguish fibroids from adenomyosis in pt presenting w/ menorrhagia and enlarged uterus?
Fibroids: firm, irregularyl enlarged uterus, sx of mass effects (constipation, urinary frequency)
Adenomyosis: soft, boggy uterus \< 12 wk size
431
Cause of infertility in 37-yo woman who still has regular menstrual cycles, healthy, w/ healthy partner, and has conceived before?
Decreased ovarian reserve -\> eval using FSH, clomiphene challenge, inhibin-B
432
Test to order in woman age 35 or more w/ increased risk of fetal aneuploidy?
Cell-free fetal DNA testing (cffDNA) -\> non invasive, performed at 10 wk GA or more, high sensitivity and specificity for aneuplodies, but not dx (abnormal testing is followed by CVS or amniocentesis)
Cousin w/ Down counts as high risk
433
When do you not need concurrent tx for gonorrhea w/ positive chlamydia?
When nucleic acid amplification reveals gonorrhea to be negative -\> it has 98-100% sensitivity for gonorrhea (vs. 80-92% sensitivity for chlamydia)
434
435
Cutoff Hg for definition of anemia in pregnancy?
1st & 3rd trimester: \< 11 g/dL
2nd trimester: \< 10.5 g/dL
