ob gyn shelf Flashcards
what bp meds in preg
hydralazine labetolol nifedipine methyldopa
which pregnant patients should get aspirin and when
pts at high risk of of pre-e: history of PreE, preterm delivery, multiple pregnancies, DM of any type, pre existing HTN, autoimmune disorders start 81mg aspirin 12-16 weeks ideally
magnesium sulfate adverse effects
flushing toxicity shows up first as decreased or absent DTRs, can lead to respiratory depression and cardiac arrest
tx for cholestasis of pregnancy
ursodeoxycholic acid cholestasis of pregnancy usually resolves a couple days after delivery
HELLP can lead to stretching of Glisson’s capsule and even subcapsular hematoma which can rupture and lead to exsanguination. What should you do for a HELLP patient with severe abdominal pain?
get Ultrasound
RUQ pain in gravida woman with pyuria, fever
appendicitis
acute fatty liver of pregnancy –> starts with vague symptoms like malaise, nausea, abdominal pain then leads to –>
hypoglycemia liver failure renal failure can also cause thrombocytop
most accurate test for age in early pregnancy
crown to rump length
most common cause of PROM
ascending infection
if AFI <5, then
oligohydramnios
potter sequence
oligohydramnios –> uterine compression –> funny faces, PULMONARY HYPOPLASIA, bowed legs, club feet
uti tx for preggars
amoxicillin (nitrofurantoin if penicillin allergic) remember repeat u/a after tx
pyelo in pregnant woman
admit to give ceftriaxone. if she improves, she gets 10 days abx. If she doesnt improve, worry about perinephric absecess: get US
hyperthyroidism in preg leads to ________ hypothyroidism in preg leads to________
hyperthyroid–> fetal demise hypothyroid–> cretinism
hypothyroid tx in preg
levothyroxine, test TSH every 4 weeks, will need higher levothyroxine dose!
hyperthyroid tx in preg
PTU, if sx only 2nd trimester
epilepsy tx in preg
L drugs! lamotrigene or leviteracetem Folic acid! if seizing, phenobarbital
consequences of poorly controlled blood sugars in preg
transposition of great vessles, macrosomia increasing risk for shoulder dystocia
tx for diabetes in pregnancy
insulin- basal bolus strategy. Increased insulin demand in pregnancy. Be sure to reduce after delivery so you dont crash her. Target *post* prandial sugars in preg.
“third trimester” labs
weeks 20-28 test for gestational dm (1 hr gtt , +/- 3 hr gtt) anemia Hgb<10 alloimmunization -Rh-ag - mom; screen for Rh-ab’s, have to be right type and titer to cause fetal anemia
risk factors for gestational diabetes
obesity (BMI>30), hx of gdm, pre-diabetic prior to pregnancy
how does glucose tolerance testing work in 20-28wk?
Give 1 hour GTT, should be less than 140. If positive, give 3 hour gtt (100g sugar): Fasting <95 1 hour<180 2 hour <155 3hr <140 (failing 2 of the above is positive test)
Antibodies in Rh- mom with first Rh+ baby are Ig__ and with second baby are Ig__.
IgM with first baby - cant cross placenta IgG with second baby - can most def cross placent
what titer levels with Rh- mom with rh+ baby make you worry?
greater than or equal to 1:8. Get transcranial doppler next
If Rh- mom has anti Rh antibodies >1:8, what do you do next?
get transcranial doppler to see if baby is compensating for anemia with increased cardiac output. If no increased flow – no worries! If flow is increased: delivery if 32w+, if younger than 32w do PUBS (test hemoglobin and transfuse)
what do you do with mom who is Rh ag and antibody negative with Rh+ baby…
delivery, hemorrhage, procedure, csection – any blood mixing…give Rh(D)Ig at 28 weeks and within 72hrs of mixing event
describe cardiovascular changes in pregnancy
bp drops because systemic vascular resistance goes way down.
there is compensatory increased cardiac output because HR goes up a bit and preload goes way up because RBC increase a ton
dont forget that even though there are more RBCs, HgB actually drops because there is also a bigger rise in plasma volume
anemia in preggars is <10
if mom with gestational DM refuses insulin, what can you use?
metformin
glyburide
signs of hyperemesis gravidum
weight loss
ketonuria
IVF, thiamine, electrolytes
antiemetic step ladder for pregnancy
pyridoxine, doxylamine
diphenhydramine
methylprednisolone (not first trimester)
people also use metoclopramide (reglan) and ondansetron (not first trimester), scopolamine (not first trimester)
criteria for diagnosis of cervical insufficiency
cervix <25mm before 24 weeks
AND
>2 mid trimester preg loss, >3 unexplained preterm deliveries , clinical diagnosis (a short cervix alone is not enough)
what’s the first thing you should do when mom has low BP
lay on left side. she might have her uterus compressing the IVC
fetal hydrops
generalized edema of the fetus, can be cause by fetal anemia, infections like parvovirus B19, chromosomal abnormalities, congenital heart defects
threatened abortion
vaginal bleeding, fetal activity, cervical os is closed. this is reversible
avoid strenuous activity, weekly pelvic ultrasound until it goes one way or the other, rule out treatable causes of vaginal bleed, give Rhogam if Rh- mom
inevitable abortion
cervical os is open. can’t do anything.
Option 1: expectant management if <14wks, Surgical evacuation is usually recommended if evacuation does not occur after 4 weeks
Option 2: medical management. Pretreat with mifepristone first (if available) and then 24 hrs later, misoprostal
Option 3: Dilation and curettage
missed abortion
baby is aborted but cervical os is closed –> no bleeding, no fetal activity, no expulsion of conception products.
incomplete abortion
usually >12wks, stuff in uterus and cervical canal, cervical os open
Option 1: expectant management if <14wks, Surgical evacuation is usually recommended if evacuation does not occur after 4 weeks
Option 2: medical management. Pretreat with mifepristone first (if available) and then 24 hrs later, misoprostal
Option 3: Dilation and curettage. Preferred if hemorrhage or septic abortion
spontaneous abortion
<20wks
downtrending bHCG, no fetal cardiac motion
do a pelvic exam to make sure bleeding is coming from uterus/cervix. If no fetal heart beat or the bleed is definitely uterine, do transvaginal ultrasound
stillbirth
>20 wks
Spontaneous labor usually begins within 2 weeks of intrauterine fetal death. However, labor may be induced with oxytocin if maternal disease develops (e.g., coagulation abnormalities) or if the patient prefers induction.
Vaginal delivery is safer than cesarean section
Patients should be offered a fetal autopsy to determine the cause of death.
major complications of retained products of conception
- septic abortion
- release of thromboplastin into circulation leading to DIC
- endometritis
normal level of fibrinogen in preggars can be a sign of…..
DIC
fibrinogen should be elevated in moms, also other clotting factors like vWF, factors 7, 8, 10
(moms are procoagulable because of this and also have less protein C, S)
which of the following hurt? placenta previa, placental abruption, vasa previa
placental abruption –> abdominal pain
placenta previa, vasa previa…painless vaginal bleed
how to tx GBS if penicillin allergy?
ampicillin if no allergy
cefazolin if mod allergy
clindamycin
vanc is last resort
risk factors for placental abruption
HTN! cocaine, smoking, previous abruption, trauma, PPROM
remember placental abruption causes pain, rigid uterus from hypertonic contractions. Some cases wont cause vaginal bleed because it retroplacental hemorrhage. +fetal distress
**vaginal exam contraindicated**
risk factors for placenta previa
hx C-section, previous previa, multiparity, multiple gestation, advanced maternal age, smoking
vasa previa
what is it?
risk factors?
fetal vessles are right over the cervical os with baby presenting above those. bleed after membranes rupture
risk factors: vilamentous cord insertion, placenta previa, IVF, multiple gestation
signs of uterine rupture
sudden severe pain, contractions stop, fetal distress, vaginal bleeding, hemodynamic instability
treatment of placental abruption
-get hemodynamically stable, give rhogam if mom is Rh-
if <34 weeks, try to give tocolytics. Give ANCS
34-36 weeks: if +ctx, do vaginal delivery. If you can hold off on labor, just manage expectantly
>36 weeks + acute abruption–> deliver
most common pathogens causing omphalitis
Staph, group A strep.
give ampicillin, gentamicin
most common pathogens of chorioamnionitis
E coli, ureaplasma, mycoplasma, GBS
IAI tx
ampicillin + gentimicin (add metronidazole or clinda if getting c-section)
rubella signs
rash that starts at head and moves down the body, sparing palms and soles
post auricular lymphadenopathy
flu like symptoms
polyartheritis
what do you do for mom with rubella?
if >20 weeks, congenital effects unlikely
congenital defect from lithium
epsteins anomaly
congenital effects of B19
hydrops, fetal death, fetal anemia
after exposure, test mom for infection/immunity
IgM+, IgG -/+ acute infection
IgM- IgG- susceptible
IgM- IgG+ immune
causes of fulminant liver failure in pregnancy
hep E v
fatty liver of pregnancy
HELLP
preeclampsia –> hepatic rupture
very toxic neonate with meningitis and visceral granulomas
listeria (unpasturized dairy products)
granulomas like swiss cheese
date range of pre term labor
20-37 wks
complications of pre term birth for neonate
intraventricular hemorrhage
necrotizing enterocolitis
respirtory distress syndrome
when and what do you do for fetal neuroprotection?
<32 weeks
mag sulfate
clinical signs of amniotic embolism
acute respiratory collapse, cardiovascular collapse, DIC, AMS, prolonged PT, respiratory acidosis
stages of labor
first: (latent) <6 cm
(active) 6-10cm
second: from when cervix is completely dilated until birth of infant
third: birth of infant until placenta expulsion
fourth: 2 hr postpartum period , monitor for hemorrhage, preeclampsia
early deceleration
gradual (>30s) onset to nadir
head compression causes vagal response
most often during active phase of labor
variable deceleration
abrupt to nadir (<30s), lasts at least 15seconds
cord compression, if >=50% of contractions then you need to start worrying–> intrauterine resuscitation
if that doesn’t work, then emergency c-section
late deceleration
placental insufficiency
gradual to nadir (>=30s)
–> fetal hypoxia, acidosis
give intrauterine resuscitations
intrauterine resuscitation measures
left lateral decubitus
amniotic infusion
maternal oxygen
maternal IVF
first maneuver for shoulder dystocia
McRoberts
foot drop after prolonged delivery
peroneal nerve compression
HIV treatment in pregnancy
2+1
Tenofovir, Emtricitabine (or zidovidene, lanividine)
+
Neviraprine or atazanivir/ritonavir
dont use combo pill of tenofovir, emtricitabine and efavirenz bc efavirenz is teratogen
when c-section for HIV+
viral load >1000 or no HART
if HIV status unknown in woman who presents for delivery, what do you do?
give her AZT
toxo
mono like illness in mom
baby: brain calcifications, ventriculomegaly, seizure
risk factors for meconium aspiration
obesity, older maternal age, postterm
look for yellow/green amniotic fluid
loss of fetal station is specific for
uterine rupture
what should you do first when there is variable decels in more than 50% of contractions
this is sign of umbilical cord compression. First reposition mom, give her oxygen and IVF.
if that doesnt work, give amnioinfusion
if uterus is contracting >5x/10min…you can give ternutaline
tocolytics
MINT
magnesium sulfate
indomethacin
nifedipine
terbutaline
No cervical change at >6cm dilation for 4 hours with adequate contractions (>200 Montevideo units)
arrested active phase –> c section
steroids for fetal lung maturity below ____ weeks
34
how long is a prolonged second stage of labor?
3 hours in prima
2 hours in multiparous
add 1 hr for epidural
beta 2 receptor agonists like terbutaline can cause what electrolyte derangement?
hypokalemia (beta 2 agonists can cause intracellular potassium shift)
–> fatigue, proximal muscle weakness, decreased DTRs
tx for pregnant woman with pyelonephritis
in patient iv cefotaxime
get cx, can switch to oral when afebrile for 24-48hrs according to cx sensitie
what UTI-causing bacterium causes alkaline urine and is associated with catheters
Proteus mirabilis
(can lead to struvite, magnesium ammonium phosphate, stones)
chronic suprapubic pain, urgency and frequency. Often with dyspareunia. urinalysis, postvoid residual bladder scan are normal
interstitial cystitis
a diagnosis of exclusion
asymptomatic bacturia treatment in pregnancy
amoxicillin/calvulanate
recurrent uncomplicated UTI treatment
daily or postcoidal sulfamethoxazole-trimethoprim for 3 months
alternatives: ciprofloxicin
self-tx at first onset of symptoms
what are findings on colposcopy that are suspicious of neoplasia?
Typical findings that are suspicious of neoplasia are uptake of acetic acid (white discoloration), coarse or atypical vessels, and yellow discoloration after iodine staining.
what kind of epithelium on the endocervix? ectocervix?
endocervix: columnar epithelium
ectocervix: nonkeratinizing squamous epithelium
On colposcopy, you find white lesions under acetic acid application. What it is?
condylomata acuminata (HPV)
On colposcopy you find White membrane that cannot be scraped off
cervical leukoplakia
on colposcopy you find Punctate lesions or coarse mosaic pattern
cervical intraepithelial neoplasia
(precancerous)
if you find atypical vessels on colposcopy, you should think…
cervical cancer
vaginal pH greater than 4.5 should make you think…
bacterial vaginosis
Postmenopausal women with an endometrial thickness greater than ____ mm should undergo hysteroscopy and endometrial curettage to rule out endometrial carcinoma
10mm
human chorionic gonadotropin (hCG) is secreted by ___________ and does what action in first 6 or so weeks of pregnancy
human chorionic gonadotropin (hCG) is secreted by syncytiotrophoblasts (the cells that invade the endometrium)
maintains corpus luteum until placenta starts to make its own progesterone
describe hormone axis that is responsible for puberty in females
you have a girl with precocious puberty and her bone scan shows bone age >2 yrs above chronological age. What is your next step?
GnRH (leuprolide) stim test.
If LH is stimulated by leuprolide, then you know her hypothal–> pituitary axis is active and it’s a central condition. You need to look at brain with MRI. If tumor–> resect. If no tumor–> it’s constitutional; treat with continuous leuprolide which turns off the axis!
if stim test did not raise LH, it’s a peripheral lesion. Get US of adrenal glands, transvag US for ovaries, test DHEAS, testosterone levels, 17-hydroxyprogesterone in urine if considering congenital adrenal hyperplasia.
if cyst: reassure
congenital adrenal hyperplasia
can’t make glucocorticoids and mineralcorticoids, so everything gets shunted to androgens. Percocious puberty. Give exogenous glucocorticoids and mineral corticoids and the body will chill out.
what tests do you do first for delayed puberty?
bone age scan, FSH, LH levels
if FSH/LH elevated: hypergonadotropic gonadotropism
if FSH/LH low, axis is still turned off. Look for pregnancy, prolactin, thyroid, CBC, LFT, ESR, MRI of brain
testosterone is made in the ….
ovaries
DHEA-S is made in the…
adrenal glands
PCOS is a problem of anovulation, leaving atretic follicles that cause…
excess in androgens.
modestly elevated testosterone –> hirsuitism
DHEAS is normal bc adrenal glands aren’t affected.
Dx: US shows bilateral cysts on ovaries or LH:FSH>3:1
PCOS treatment
diet, exercise
metformin
OCPs
clomiphine if she wants pregnancy
spironolactone for hirsuitism
sertoli leydig tumor
sex cord stromal tumor of ovaries
high testosterone, normal DHEAS
+hirsuitism
dx: transvaginal ultrasound.
resect (not malignant)
adrenal tumor
DHEA will be very high–> virilization
testosterone is normal (ovaries are fine)
get CT or MRI to look at adrenal glands.
**Do adrenal vein sampling to figue out which adrenal gland is hyperfunctioning because it can be the one without the mass
congenital adrenal hyperplasia
moderately elevated DHEAS, normal testosterone, hirsuitism
Get CT/MRI
Dx: 17-OH-Progesterone in urine
(high 17-OH-progesterone is a result of absent 21-beta-hydroxylase. All the cholesterol goes to DHEAS bc cant make aldosterone and cortisol. Body freaks out and sends even more cholesterol …even more DHEAS)
can be severe enough to cause virilization
tx: Give Cortisol +/- Fludrocortisone
Tx for CAH
cortisol +/- fludrocortisone
menopause avg age
51
premenarchal cancer risk factors
toxins
3 categories of ovarian cancer
germ cell, stromal or epithelia
cervical, vaginal, and vulvar cancer are most commonly _______________ carcinoma
squamous cell
all due to HPV exposure
precancer== carcinoma in situ
**black itchy lesions on vulva, post-coital bleeding from cervical cancer
endometrial cancer is caused by exposure to….
type of cancer….
common first symptom…
estrogen
adenocarcinoma
precursor = dysplasia, atypia
post-menopausal bleeding
ovarian epithelial cancer is caused by…..
ovulation
present with late stage symptoms: small bowel obstruction, ureter obstruction, ascites
choriocarcinoma:
etiology?
symptoms?
comes from gestational trophoblastic disease (mole, incomplete mole, or even normal pregnancy)
follow beta HCG while pt on contraceptive
hyperemesis gravidarum, hyperthyroidism, size-date discrepancy
OCPs do not cause breast cancer
radiation for _________ can lead to breast cancer
chest radiation for example lymphoma
USPSTF recommendations for mammogram
mammogram every 2 years starting at 50
what do you do if mammogram +?
core biopsy to diagnose
someone under 30 comes in with breast lump. What do you do?
wait for a couple of menstral cycles and see if it goes away. If it doesnt, get ultrasound which will show mass or cyst. you need to find out if its a problem so get fine needle aspiration.
bloody = cancer
fluid = cyst :)
pus = abcess
what do you always do before axillary lymph node resection in breast cancer?
senteniel lymph node biopsy to see if you can spare axillary LN and avoid lymphedema
chemo for breast cancer
doxarubacin
cyclophosphamide
paclotaxil
side effect of doxarubacin, danorubacin?
CHF …dose dependent and irreversible. make sure you get ECHOs
what’s difference between tamoxifen and raloxifen?
both are estrogen receptor modulators for breast cancer. Tamoxifen works better for breast cancer but risks DVT and endometrial carcinoma. Raloxifen doesnt work as well but also doesnt have these risks.
Tamoxifen causes endometrial cancer because it is a estrogen receptor antagonist in breast and a estrogen receptor agonist in the endometrium. go figure.
What are targeted breast cancer therapies?
If Her2Neu positive, traztuzumab or bevacizumab. Her2neu has worse prognosis. Know that traztuzumab can cause CHF that is NOT does dependent but is Reversible.
If Her2neu negative, give tamoxifen or raloxifen if PREmenopausal. Give aromatase inhibitor if POST menopausal (anastrozole, letrozole)
post partum hemorrhage = 500cc after vaginal birth or 1000cc (L) after C-section. What things can you do?
uterine massage
pitocin
methergen
if these fail, exploratory laparotomy. start by ligating uterine artery, then internal iliac, then total abdominal hysterectomy
round ligament is made of….
broad ligament is made of…
round ligament = smooth muscle
broad ligament = loose aerolar tissue
don’t provide structural support
uterosacral and cardinal ligaments are responsible for support. prolapse happens when cardinal ligament gets floppy
pubococcygeus, puborectalis, and iliococcygeus mm make up the…
levator ani
in constant contraction
what artery are you trying to avoid for port placement in laparoscopy?
inferior epigastric arteries
you can find pudendal nerve for nerve block at…
level of ischeal spine. palpate ischeal spine and inject 1 cm inferior and medial. be sure to aspirate so you avoid pudendal artery and inferior gluteal artery
remember that anterior to urethra, the innervation is not pudendal n but rather ileoinguinal nerve
HPV strains that cause warts
6, 11
hpv strains that cause cancer
16, 18, 30s
procedure for endocervical cancer
cone biopsy
ecto: LEEP, cryo
cervical cancer in upper 2/3 of vagina is stage____
cervical cancer in lower 1/3 of vagina is stage____
cervical cancer in upper 2/3 vagina is stage IIa, if it’s gone into cardinal ligament it’s IIb
lower i/3 vag = IIIa, if also abdominal wall IIIb. chemo is usually platinum based
IIa or better: local excision
IIb or worse, chemo and radiation
ages for guardasil
girls 11-26
boys 11-21
risk factors for endometrial cancer
obesity (peripheral conversion)
anovulation (think PCOS)
nulliparity
age
hormone replacement therapy
SERM like tamoxifen
how do you assess for endometrial cancer
biopsy or D&C
if hyperplasia: treat with progesterone
if cancer: total abdominal hysterectomy and bilateral salpingooverectomy
Germ cell ovarian tumor
nonmalignant, always stage 1 bc dont invade BM
teen girls
present as: weight gain, adnexal mass
dx: transvaginal ultrasound
tx: unilateral salpingooverectomy
types: dysgerminoma (track with LDH), endodermal sinus (track with AFP), teratoma (malignant in boys), choriocarcinoma (track with bHCG)
types of epithelial
types of epithelial cell ovarian tumors
**poor prognosis**usually present IIIb or worse**seed peritoneally
they are cystadenocarcinoma and arise from epithelial trauma (ovulation) (OCPs, preg will decrease risk)
serous
mucinous
endometroid
Brenners
presenting symptoms of epithelial ovarian cancer
ascites, small bowel obstruction, renal failure
get transvag US, then CT to stage. Track with Ca-125
total abdominal hysterectomy and bilateral salpingooverectomy
chemo with Paclitaxel
screening for BRACA+ patients
yearly transvaginal US + Ca125
TAH+BSO at 35
types of ovarian stromal cell tumors
granulosa-theca (produce estrogen)
sertoli-leydi (produce testosterone)
workup for adnexal mass
Transvaginal US
(smooth small cyst WITHOUT septations, fluid is not loculated = simple cyst, normal)
otherwise: complex cyst. biopsy, think about what kind of tumor it is based on symptoms, history
complete mole genetics
all sperm, 46 chromosomes
(empty egg, sperm haploid dublicates)
vaginal bleeding, very elevated bHCG (talking >100K) which can cross react and cause hyperthyroidism, hyperemesis gravidarum, size-date discrepancy
grape like mass that protrudes through cervix
dx: snowstorm on transvag us
complete mole symptoms, dx, tx
vaginal bleeding, very elevated bHCG (talking >100K) which can cross react and cause hyperthyroidism, hyperemesis gravidarum, size-date discrepancy
grape like mass that protrudes through cervix
dx: snowstorm on transvag us
tx: suction curretage. only D&C if in 2nd trimester
contraception! Serial bHCG for a year to look for invasive disease
Incomplete mole genetics
egg is fertilized by two sperms–> 69 chromosomes
there are fetal parts
symptoms: vaginal bleeding, very elevated bHCG (talking >100K) which can cross react and cause hyperthyroidism, hyperemesis gravidarum, size-date discrepancy
grape like mass that protrudes through cervix
dx: snowstorm on transvag us
tx: suction curretage, contraception and serial bHCG for a year to look for choriocarcinoma
choriocarcinoma
malignant
“gestational trophoblastic neoplasia”
elevated bHCG
transvag US –> curettage. Stage with CT.
surgical tx: TAH, debulking for more advanced disease
medical: MAC: methotrexate & actinomycin D +/- cyclophosphamide . advanced disease gets more chemo
red pruritic lesion on vagina/vulva
Paget’s
good prognosis
black itchy lesion on vulva
melanoma or SCC
grape like mass in the vagina
look for DES exposure in mom that leads to adenocarcinoma
menopause treatments
estrogen creme for vagina, dyspareunia
venlafaxine is bestlafaxine for hot flushes (fluoxetine and sertraline do not work)
symptoms of menopause
hot flashes
vaginal atrophy/thinning mucosa
more UTIs
decreased libido
mood swings from estrogen withdrawal
cessation of menses for 12 consecutive cycles
what screening should be done for menopausal/perimenopausal women
DEXA
LDL
don’t do FSH, follicle US unless it’s premature ovarian failure
what is adnexal mass in premenarchal girl most likely to be
Germ cell tumor (sertoli leydig or granulosa theca)
in postmenopausal woman, what is adnexal mass most likely to be
epithelial cancer
in women, teratomas tend to be benign or malignant?
benign
asymptomatic but she’ll feel weight gain
usually teens/twenties. tx is conservative: remove cyst only and leave ovary if young.
they are likely to recur
symptoms of endometriosis
dysmenorrhea
dyspareunia
dyschezia
infertility
symptoms/signs of ectopic pregnancy
positive pregnancy test, bHCG>2000, empty uterus on US
amenorrhea, abdominal pain
treatment for ectopic pregnancy
salpinostomy (remove ectopic preg only; if no rupture)
salpinjectomy (remove tube if rupture)
methotrexate + leucovorin rescue (most fertility preserving)
what causes tubulovarian abscess
gonorrhea/chlamydia or vaginal flora
treatment for tubulovarian abcess
there’s a good chance she’ll be toxic and need inpatient treatment: IV cefotoxine + doxycycline + metronidazole
second line: clinda + gentamycin
only need to drain abcess if not cleared with abx; ovary is so vascular that there is a good chance that abx will resolve the abcess!
signs/symptoms of tubuloovarian abcess
abdominal pain, fever, +/- leukocytosis,
WBC on wet prep
FSH stimulates conversion of …..by….
FSH stimulates conversion of androgens to estrogen by aromatase
tissues that have aromatase: adrenal glands, adipose, placenta, testicles, ovaries
______ cells in ovaries make estrogen
granulosa cells
________ cells in ovaries make androgens, stimulated by __________
LH stimulates theca cells to make androgens
what is estrogen’s effect on blood vessles?
estrogen is protective against athersclerosis but increases clotting
signs of low estrogen (can be due to menopause, ovarian failure, anatomic or genetic stuff like Turner’s or aromatase insufficiency (<–high androgens), hyperprolactinemia, GnRH agonists like leuprolide
Hot flashes
Headaches
Reduced libido
Breast atrophy
Decreased bone density and secondary osteoporosis
Urogenital atrophy
Dyspareunia
menopause is confirmed by….
elevated FSH levels, 12 months without period
pathophys of menopause
Numerical depletion of ovarian follicles with age → ↓ ovarian function → ↓ estrogen and progesterone levels → loss of negative feedback to the gonadotropic hormones → ↑ GnRH levels → ↑ levels of FSH and LH in blood (hypergonadotropic hypogonadism) → ↑ frequency of anovulatory cycles
premature ovarian failure is before age….
40
symptoms of endometriosis
dysmenorrhea, chronic pelvic pain, dyschezia, dyspareunia, abnormal uterine bleeding
do exam for rectovaginal tenderness, adnexal masses
*TVUS
laparoscopy is confirmative
medical treatment options for endometriosis
NSAIDs
OCPs
danazol (steroid)
GnRH agonist (buserelin, goserelin)
goserelin, buserelin
A gonadotropin-releasing hormone receptor agonist that can either be used to stimulate (via pulsatile administration) or suppress (via continuous administration, which downregulates GnRH receptors) LH and FSH secretion. Commonly used continuously to treat hormone-sensitive prostate cancer, precocious puberty, menorrhagia, and endometriosis. Used in pulsatile fashion to increase fertility
symptoms of PCOS
acne
hirsuitism
obesity, insulin insensitivity
infertility
maybe virilization
testing for PCOS
measure testosterone
LH:FSH ratio >2
can measure 17-hydroxyprogesterone to rule out non classical congenital hyperplasia
check for metabolic syndrome (HgA1c, BG, lipid panel )
+clinical diagnosis overrules blood tests+
differential diagnosis for PCOS
pregnancy
cushings (too much cortisol)
androgen-secreting tumor
exogenous androgens
congenital adrenal hyperplasia
exogenous steroids
treatment for PCOS
weight loss
OCPs
for fertility: clomiphene, letrozole
Free fluid in the pouch of Douglas in a pregnant patient should raise concern for —–
ruptured ectopic pregnancy
how does prolactinemia affect FSH, LH?
prolactin –> negative feedback on GnRH –> low FSH, low LH, low testosterone, low estrogen
why can hypothyroidism lead to galactorrhea?
low thyroid hormones will lead to upregulation of TRH and thus TSH. TRH will cross react in anterior pituitary and lead to more prolactin release along with more TSH
tx for bacterial vaginitis
metronidazole (topical, then oral)
tx for trich
treatment for chlamydia in pregnancy
NO DOXY
azithromycin
PID tx for really toxic ppl
inpatient
cefoxitin + doxy
(clindamycin and gentamycin is alternative)
outpt PID tx
metronidazole+IM ceftriaxone + doxy
(notice that those cover the most common bugs that cause PID - GC, CT, vaginal flora)
true or false: hormone levels are the same between women with and without PMS or PMDD
true, the amount of estrogen, progesterone are not different between women who have PMS, PMDD and those that don’t. It seems that hormones play a role in PMS/PMDD but aren’t sufficient to explain it
women with PMS/PMDD experience symptoms during the ______phase
luteal phase (second half, high progesterone)
treatment options for PMDD, PMS
aerobic exercise
magnesium, calcium supplements
fresh, not processed food
NSAIDS
OCPs
SSRIs
last resorts: trial with leuprolide to see if “medical ovarectomy” helps; if so you can consider ovarectomy but remember this forced menopause can cause other probs like cardiovascular disease, hot flashes, osteoporeosis
PMS criteria
PMDD critieria
CORE SYMPTOMS:
irritability
Depressed mood
Anhedonia
Anxiety/tension
risks and benefits of systemic hormone therapy for menopause sx
if they have uterus, they must get estrogen AND progesterone bc unoppossed estrogen –> endometrial cancer
taking E&P leads to increased breast cancer, coronary heart disease, stroke, VTE. decreased colon cancer and fractures
for women only taking estrogen, there was increased VTE but not cardiovascular disease
contraindications for HRT for menopause
cardiovascular disease, stroke, breast cancer, DVT hx, liver disease
combined estorgen-progesterone HRT –> increased coronary heart disease, stroke, VTE. decreased colon cancer and fractures, decreased LDL and increased HDL
estrogen only HRT can only be given to ppl without uterurs. Only increased VTE
nulliparous in active labor expected to dilate at —- per hour
1.2cm per hour
multiparous woman in active labor expected to dilate at — per hour
1.5cm/hr
how to measure montevideo and the normal labor montevideo units
with intrauterine tocometer, measure amplitude of ctx over ten minutes and add together. Normal is >200
what parts of the baby head can you palpate on digital exam during labor?
what’s ideal baby head position for deliver
occiput anterior
(occiput posterior (sunny side up) and occiput transverse mean a bigger diameter has to go through pelvis)
what’s it called when baby head wont fit through pelvis
cephalopelvic disproportion
can be due to baby size, pelvic size/shape, adipose tissue
two ways to augment labor
AROM, oxytocin
(with pitocin you want to avoid uterine tachysystole or 5 ctx/10 minutes over 30 min period
what’s it called when mom is having 5 ctx per 10 minutes over 30 minute period
uterine tachysystole
shoulder dystocia interventions
You have 5 minutes
- McRoberts manuever
- Suprapubic pressure
- Try to deliver posterior shoulder. you may need to do episiotomy
Other options:
- woodscrew/rubin
- get patient on hands and knees
- clavicular fracture
- zavenilli procedure
risk factors of cord prolapse
fetus is not vertex
SROM or AROM before head engaged in pelvis
intervention: zavenelli + emergency c section
breech delivery
Ideally do c-section
if not, don’t put traction on baby because you’ll extend the head and make it harder to deliver; put suprapubic pressure when mom’s pushing has delivered to umbilicus
definition of labor
painful uterine ctx
&
cervical dilation
when should a preggo go to hospital
woman presents at weu and might be in labor. what will you do?
- Fetal heart tones
- Presentation (US or exam)
- Sterile vaginal exam: dilation/effacement/station
- dilation of internal os
- normally cervix is 4cm thick, 2cm thick is 50%, not thick is 100%
- station: # cm above or below ischeal spine
4 stages of labor
- latent phase - up to 4cm dilation; active phase - after 4 cm to 10cm and more brisk; visceral pain T10-L1
- complete dilation to delivery of infant; somatic pain S2-S4
- delivery of placenta
- 2hours postpartum
interventions in stage 3 of labor to diminish risk of hemorrhage
(stage three is from delivery of infant to delivery of placenta)
- Fundal massage
- gentle cord traction
- IV/IM pitocin
definition of pre-eclampsia
HTN after 20weeks with proteinuria or end organ dysfunction
chronic hyptension in pregnancy vs. gestational hypertension
chronic hypertension is diagnosed before <20 weeks
gestational hypertension is diagnosed after >20 weeks without organ damage signs (which would be preeclampsia)
anti hypertensives are for severe range bp in pregnancy which are…
160 systolic or 110 diastolic
when should you ideally deliver preE babes
37 weeks
if severe features: 34 weeks
don’t forget betamenthasone for under 34 weeks
may have to deliver earlier if things go downhill
ssris for pms pdd
sertraline,
citalopram, escitalopram (new)
nonhormonal treatment for hot flashes
venlafaxine (SNRI)
clonidine
ssris
gabapentin (esp. for sleeping prob)
black coash and soy
menopause –> vaginal atrophy and dryness
–> higher pH and more bacterial vaginosis
–>dysparenuia bc vagina can’t expand without rugae
–> more UTIs because distance between vagina and urethra shortens
you can do vaginal estrogen cream, rings, tablets
what do you do for chorioamnioitis
- tylenol
- IVF
- abx
- delivery
abx choices for GBS
- ampicillin
- if penicillin allergy, cefazolin
- if life-threatening penicillin allergy, there’s enough cross reaction between penicillin and cephalosporin, so give Clindamycin
- vancomycin
when to give GBS abx
- history of GBS
- positive 36wk screen
- intrapartum fever
- prolonged rupture of membranes
(don’t have to if planned c-section and membranes are intact)
what to do if preggo is HepB positive
c-section
1st day of life: HepB vaccine and IgG
*ideally mom is vaccinated before pregnancy*
how to make HIV dx
- ELISA
- confirm with Western Blot
treating HIV in pregnancy
goal: is to bring viral load down
tx: 2+1
2 nucleotide reverse transcriptase inhibitor +( 1 non nrti or 1 protease inhibitor&ritonovir)
2NRTI: [tenofovir +emtracitabine ($$)][B] + neviraprine (C) or atazanovir/ritonovir
can you give Atripla ( Efavirenz/emtricitabine/tenofovir combo pill) in pregg
this HIV HARRT combo pill can NOT be given in pregnancy because efavirenz is teratogen
how do you deliver HIV+ mom
low viral load, <1000: vag
high viral load, >1000: c-section
if you don’t know her status, give AZT
what are the TORCH infections
T oxo
Other (Syphilis)
Rubella
Cytomegalovirus
HSV
where do you get T. gondii
cysts in soil, cat feces, undercooked meat
what are Toxo symptoms for mom?
mono like illness
infant with brain calcifications
ventriculomegaly
seizure
toxo
what are signs/symptoms of congenital toxo?
- ventriculomegaly
- brain calcifications
- seizure
symptoms of primary syphilis
painless chancre
symptoms of secondary lesions
targetoid lesions that include palms, soles
snail track oral lesions
cranial nerve defects, condyloma lata
RPR and confirm with FTP-Abs
signs of latent syphilis
+RPR, VRDL but no symptoms
signs of tertiary syphilis
neuro symptoms, like not being able to feel feet
tabes dorsalis, gumma (ulcerating granulomas), coronary arterities, aortic aneurysm
**Diagnose with CSF via RDR
neurosyphilis–> IV penacillin
congenital syphillis
Snuffles
Saber shins
Saddle nose
HutchinsonS teeth
blueberry muffin
cataract
congenital cardiac defect
deafness
if first trimester, IUGR
congenital rubella
dsDNA virus that causes mono like disease
cmv
painful burning on vulva
hsv prodrome
confirmatory test for HSV
not necessary
PCR
IUGR
preterm delivery
blindness
congenital HSV
bilateral cataracts, sensorineural hearing loss (secondary to a cochlear dysfunction), and a heart defect – typically patent ductus arteriosus or pulmonary artery stenosis
congenital rubella
in setting of post partum hemorrhage from uterine atony, a mom has been given bimanual uterine massage and oxytocin. she’s still bleeding. what do you do next?
tranexamic acid
methylergonovine
carboprost tromethamine
misoprostol
carboprost can’t be given to patients with what underlying condition?
asthma
methylergonovine can’t be given to patients with underlying….
cardiovascular problems
side effects of misoprostol, carbopost
hypertension
bronchospasm
fever
most common pathogen that causes bacterial vaginosis
Gardnerella vaginalis
painless genital nodules that eventually ulcerate to form large, beefy-red lesions that bleed easily
Granuloma inguinale
caused by Klebsiella granulomatis
mom presents with virilization and baby is at high risk of virilization; there are no ovarian masses. what is it?
probably placental aromatase deficiency
mom’s symptoms resolve after delivery
in setting of post partum hemorrhage, you’ve tried bimanual massage and oxytocin without success. What’s your next step?
tranexamic acid
In setting of postpartum hemorrhage, you’ve tried massage, oxytocin and tranexamic acid and she’s still bleeding. You can try second line utertonic agents now like carboprost tromethamine. What’s a contraindication of carboprost tromethamine?
don’t use carboprost tromethamine in pts with asthma as it can cause bronchospasm
In setting of postpartum hemorrhage, you’ve tried massage, oxytocin and tranexamic acid and she’s still bleeding. You can try second line utertonic agents now like methylergonovine, carboprost tromethamine or misoprostal. What’s a contraindication of methylergonovine?.
Dont use methylergonovine in pts with hypertension (regardless of current BP) bc it can cause stroke.
If these dont work, the next step is balloon tamponade then laparotomy
how do you manage preggos with HSV?
start suppression at 36weeks with acyclovir
if they have lesions or prodome during labor, they must have c-section. otherwise, vaginal delivery if possible
solid unilateral or bilateral ovarian masses, lead to moderate virilization of mom and high risk of virilization of baby; resolve after delivery
luteoma
cystic bilateral ovarian masses; mom might get virilization; low fetal virilization risk; spontaneously resolve after delivery
theca lutein cyst
solid unilateral ovarian mass with high risk of both maternal and fetal virilization; requires surgery in either second trimester or postpartum
sertoli leydig tumor
Retention of a dead fetus for > 2 weeks increases the risk of systemic absorption of _____________produced by the placenta and dead fetus. This activates the coagulation cascade and causes disseminated intravascular coagulation (DIC).
thromboplastin
sudden painless vaginal bleeding after rupture of membranes and fetal distress
ruptured vasa previa. **occurs with ROM because the vasa previa are located in the membranes
if a breast mass is highly suspicious for cancer, what kind of biopsy?
core needle biopsy (cancer will shake you to your core)
use fine needle aspiration for less suspicious masses
Irregularly defined and dense periareolar breast mass with erythyma, ecchymosis, and skin retraction after a trauma to the breast. US/Mammography shows fluid filled cyst with course rim calcification
fat necrosis of breast
Solitary, well-defined, non-tender, rubbery and mobile mass with popcorn calcifications
fibroadenoma
Painless, smooth, multinodular lump in the breast in women 40-50 years old. On core needle biopsy, Leaf-like architecture with papillary projection of epithelium-lined stroma
phylloides tumor (benign)
benign tumor behind the nipple that is most common cause of bloody nipple discharge
intraductal papilloma
what do you do for a pt less than 30 with a palpable breast mass? what about a patient over 30yo?
For patient less than 30, if you think probability of malignancy is low you recheck 3-10 days after menses. If you think probability of malignancy is high in pt over 30, then you do US and/or fine need aspiration.
For patient over thirty, always get a mammogram. a suspicious mass gets a core needle biopsy.
hormone therapy for post menopausal women with ER or PR+ breast cancer
aromatase inhibitor (anastrozole, letrozole, exemestane) plus tamoxifen (or raloxifen)
aromatase inhibitors increase risk of osteoporesis
what is letrozole and what are its side effects?
letrozole is aromatase inhibitor. Used for postmenopausal ER+ breast cancer.
raises risk of OSTEOPOREOSIS! side effects are basically menopause symptoms
what is anastrozole and what are major side effects?
anastrozole is aromatase inhibitor. Used for postmenopausal ER+ breast cancer.
raises risk of OSTEOPOREOSIS! side effects are basically menopause symptoms
drug for HER2+ breast cancer
trastuzamab
**cardiotoxic** get ECHO
Trastuzamab is used to target HER2+ breast cancer. What’s its major risk?
cardiotoxicity. Get ECHOs.
Most vulvar cancers are sqaumous cell carcinoma. Paget disease of the vulva is ….
Adenocarcinoma
Low risk of underlying invasive Paget disease/invasive adenocarcinoma (unlike Paget disease of the breast which is always associated with underlying carcinoma)
lichen sclerosis
get punch biopsy
treatment = topical steroids (clobetasol or betamethasone) or tacrolismus (calcineurin inhibitor)
can also do oral steroids, oral retinoids, phototherapy (these are all second line)
In-utero exposure to diethylstilbestrol (DES) is associated with…
cervical cancer
symptoms of uterine leiomyoma
- abnormal menstration (dysmenorrhea, menorrhagia, metorrhagia (bleeding between periods)
- mass effect (e.g. back, pelvic pain, pressing on bladder)
- infertility , dyspareunia
what pretreatment do you give before surgical removal of uterine fibroids?
leuprolide or goserelin (GnRH analogues) to shrink the tumors and reduce tumor vascularization
cancers associated with Lynch syndrome (hereditary nonpolyposis colorectal cancer)
- colorectal cancer
- gastric cancer
- endometrial cancer
(also increased risk of ovarian cancer)
struma ovarii (mature teratoma) is an ovarian germ cell tumor that contains what type of tissue?
thyroid
can cause hyperthyroidism
a rapidly growing ovarian mass in teen girl that has fried egg cells on histology
dysgerminoma . malignant.
malignant and aggressive ovarian tumor in child or teen that has schillar duval bodies
yolk sac tumor (endodermal sinus tumor)
dont use trimethoprim sulfate in pregnancy because it can cause
cardiac defects, neonatal jaundice/kernicterus
birth defect caused by aminoglycosides
ototoxicity/deafness
A Mean Guy stepped on a babys ear
congenital effects of intrapartum tetracycline use
discoloration of teeth, bone growth restriction
teethracycline discolors teeth
risks of intrapartum NSAID use
pulmonary hypertension in fetus and premature closure of ductus arteriosus; also inhibits uterine contractility
what medications for hyperthyroidism in pregnancy? First trimester? Second and third trimester?
First trimester: propylthiouracil
2nd&3rd: methimazole
why don’t we use methimazole in first trimester for hyperthyroidism?
methimazole in first trimester can cause aplasia cutis (missing portion of skin), craniofacial and GI malformations in fetus
what medication do we use for hyperthyroidism in first trimester?
propylthiouracil
what congenital defects are caused by phenytoin and carbamazepine?
Fetal hydantoin syndrome
Characterized by cleft palate, phalanx/fingernail hypoplasia, excessive hair growth, and intrauterine growth restriction
Due to impaired absorption of folate
Neural tube defects (carbamazepine only)
what congenital defects are caused by valproate?
neural tube defects
congenital defects caused by intrapartum steroids?
Reduced birth weight
Increased risk of preeclampsia
Increased risk of oral and lip clefts
risks of isotretinoin or excessive vitamin A
High risk of miscarriage
Multiple congenital malformations, including cardiac anomalies, facial cleft, and skeletal abnormalities
Meigs syndrome
Benign ovarian fibroma + ascites + right pleural effusion
what sort of tests might you run for bleeding in early pregnancy
bHCG - confirm pregnancy, look for elevations consistent with molar preg, doubling q48hrs consistent with viable pregnancy
US - look for intrauterine preg, fetal heart tones
CBC to look at blood loss
Blood typing to see if mom is Rh- and needs rhogam
group, save, cross match if worried will need transfusion
histology: look at expelled products; might not be anything trophoblast indicating ectopic preg
medical management of incomplete abortion
mifepristone + misoprostol
previous surgery like appendectomy, PID, and conception after infertility/assisted conception, IUDs are risk factors for…
ectopic pregnancy
always suspect ectopic preg for early preg bleeding
medical management of ectopic preg
methotrexate and serial bHCG levels
only if hemodynamically stable
surgical management of ectopic pregnancy
laparoscopy with serial bHCGs
medical treatment for hyperemesis gravidarum
admit
IVF
IM metoclopramide, IV ondansetron, prochlorperazine (compezine), B6, steroids in severe cases
3 miscarriages = recurrent miscarriage. What tests would you do?
- karyotype of parents
- chromosomal analysis of products of conception
- check mom for lupus anticoagulent, anticardiolipin antibodies (both antiphospholipid)
