OB/GYN UWorld Flashcards
1
Q
which contraceptive devices are contraindications in pts with breast cancer
A
hormone-containing methods of contraception should be avoided in pts with breast cancer,
as estrogen and progesterone may have a proliferative effect on breast tissue
esp concern hormone receptor-postivie breast cancer
2
Q
what is the most effective non-hormonal contraceptive
A
copper IUD
3
Q
what are absolute contraindications for combined hormonal contraceptives
A
migraine with aura >=15 cigarettes/day PLUS age >35 HTN >160/100 heart disease DM with end-organ damage h/o thromboembolic disease antiphospholipid-antibody syndrome h/o stroke breast cancer cirrhosis and liver cancer major surgery with prolonged immobilization use <3 weeks postpartum
4
Q
what are you required to do if a pt is HIV positive
A
report positive HIV tests to the local health department
the local health department usually contacts the pt’s contacts (anonymously)
5
Q
what is dx in pt with “3 D’s”:
dysmenorrhea, dyspareunia, and dyschezia
A
endometriosis
6
Q
what is empiric tx for endometriosis
A
NSAIDs and/or combined oral contraceptives
OCPs are thought to reduce pain by ovulation suppression, which may result in atrophy of endometrial tissue
laparoscopy if treatment fails, adnexal mass, or acute symptoms
7
Q
what is dx in female >20 weeks gestation with new-onset BP >140/90 + proteinuria and/or end-organ damage
A
preeclampsia
8
Q
what are the 6 severe features of preeclampsia
A
systolic BP >160 or diastolic BP >110
(2x at least 4hrs apart)
thrombocytopenia
high Creatinine
high transaminases
pulmonary edema
visual or cerebral symptoms
9
Q
how do you manage preeclampsia, depending on whether severe features are present
A
Magnesium sulfate (seizure prophylaxis) Antihypertensives
w/o severe features: delivery at >=37 weeks
w/ severe features: delivery at >= 34 weeks
10
Q
what are 6 risk factors for preeclampsia
A
multiple gestation nulliparity preexisting DM advanced maternal age CKD prior preeclampsia
11
Q
what are 3 treatment options for preeclampsia in a hypertensive crisis
A
IV labetalol (beta blocker w/ alpha-blocking activity) --avoid in bradycardia
IV hydralazine (vasodilator)
oral Nifedipine (CCB) --avoid with emesis
12
Q
which drug prevents/treats eclamptic seizures
A
IV or IM Magnesium sulfate
13
Q
what are 2 indications for oxytocin use
A
induction or augmentation of labor
prevention and management of postpartum hemorrhage
14
Q
what are 3 adverse effects in excessive oxytocin administration
A
hyponatremia (water intoxication)
–can cause generalized tonic-clonic seizure
hypotension
tachysystole
15
Q
what has a similar structure to oxytocin that explains some of its action
A
ADH
prolonged doses of oxytocin can cause water retention and hyponatremia
16
Q
how do you treat acute hyponatremia / water intoxication
A
hypertonic saline (3% saline) to normalize the Na levels
17
Q
what are nl Mg levels, how does magnesium toxicity present and what serum level does it become toxic
A
normal serum levels: 1.5-2
therapeutic levels for pregnancy seizure prevention: 5-8
toxic Mg: >8
toxicity presents: hyporeflexia lethargy headache respiratory failure ultimately cardiac arrest (no seizures)
18
Q
run through the 5 portions of the biophysical profile during pregnancy; and their normal findings
A
- Nonstress test:
- -reactive fetal heart rate monitoring - Amniotic fluid volume
- -single fluid pocket >2x1 cm or amniotic fluid index >5 - Fetal movements
- - >= 3 general body movements - Fetal Tone
- - >= 1 episode of flexion/extension of fetal limbs or spine - Fetal breathing movements
- - >= 1 breathing episode for >= 30 seconds
0 - 2 for each; max score of 10
8-10 is normal
6 is equivocal
<= 4 is an indication for delivery to prevent intrauterine fetal demise (fetal hypoxia 2/2 placental insufficiency)
19
Q
what are late and post-term pregnancies at risk for
A
41-42 weeks’ gestation are at risk for
uteroplacental insufficiency
20
Q
how long is the fetal sleep cycle, and how is it disrupted
A
fetal sleep cycle lasts for 20 minutes
usually disrupted by vibroacoustic stimulation
21
Q
what is dx in pregnant F who presents with fetal tachycardia (>160), maternal fever, and uterine tenderness
A
intraamniotic infection (chorioamnionitis)
22
Q
what is dx in female with unilateral bloody nipple discharge w/o associated mass or Lymphadenopathy
A
intraductal papilloma
23
Q
what is dx in female with well demarcated, round, firm, and mobile breast mass
A
fibroadenoma
24
Q
what is dx in female with nipple discharge and mass / Lymphadenopathy
A
infiltrating ductal carcinoma
25
what does imaging show for infiltrating ductal carcinoa
a lesion with micro calcifications
26
what marks the second stage of labor
start:
when the cervix is dilated to 10cm
progression:
evaluated via fetal station, which measures the descent of the presenting part through the pelvis
ends:
fetal delivery
27
how is progression during the second stage of labor evalutated
by determining fetal station
28
what does fetal station measure
descent of the presenting part through the pelvis during the second stage of labor
29
what defines an arrested second stage
when there's no fetal descent after pushing:
> 3 hrs if nulliparous
> 2 hrs if multiparous
30
what is optimal fetal position during second stage labor
occiput anterior ("occipital" part of head is anterior)
it facilitates the cardinal movements of labor
31
what are breech presentation types x 5
frank:
butt going through pelvis; both feet up by head
incomplete:
butt going through pelvis; 1 foot up by head
complete:
butt going through pelvis; no feet up by head
single footing:
1 leg through pelvis
double footing:
both legs through pelvis
32
what is the most common cause of second-stage arrest
fetal malposition
33
what is dx in pt with thin, off-white discharge with fishy odor; no inflammation
bacterial vaginosis
| Gardnerella vaginalis
34
what are lab findings in gardnerella vaginalis
pH >4.5
clue cells
positive whiff test
35
what is tx for bacterial vaginosis
metronidazole or clindamycin
36
what is dx in pt with thin, yellow-green, malodorous, frothy discharge with vaginal inflammation
trichomoniasis
37
what are lab findings in trichomoniasis
```
pH >4.5
motile trichomonads (pear-shaped)
```
38
what is tx for trichomoniasis
metronidazole for pt and sexual partner
39
what is dx in pt with thick, cottage-cheese discharge and vaginal inflammation
candida vaginitis
40
what are lab findings in vaginal candidiasis
```
normal pH (3.8 - 4.5)
pseudohyphae
```
41
what is tx for candida vaginitis
fluconazole
42
what is dx in pt with low FSH and estradiol
hypogonadotropic hypogonadism
43
what causes hypogonadotropic hypogonadism
excessive weight loss
strenuous exercise
chronic illness
eating disorder
44
what sequence of labs occurs in hypogonadotropic hypogonadism
decrease in amplitude and frequency of GnRH pulses secreted by the hypothalamus,
decreasing LH and FSH production,
which also reduces ovarian estrogen production
45
what are lab values in PCOS
FSH and estradiol levels are normal to increased
high LH/FSH ratio
insulin resistance
elevated testosterone
46
what are possible fetal complications of late-term and post-term pregnancy
```
oligohydramnios** (common)
meconium aspiration
stillbirth
macrosomia
convulsions
```
47
what are possible maternal complications of late-term and post-term pregnancy
Cesarean delivery
infection
postpartum hemorrhage
perineal trauma
48
why does oligohydramnios happen in late and post-term pregnancies
an aging placenta may have decreased fetal perfusion,
resulting in decreased renal perfusion,
and decreased urinary output from fetus
49
which trimester is the inactivated influenza vaccine safe during pregnancy
inactivated influenza vaccine is safe during every trimester,
and during breastfeeding
it should be given during the initial prenatal visit
50
which 3 routine prenatal lab tests should be done at the 24-28 week visit
Hemoglobin/Hct
Antibody screen if Rh(D) negative
50-g 1 hour Glucose challenge test (GCT)
51
which 1 routine prenatal lab test should be done at 35-37week visit
group B streptococcus culture
52
contrast symmetric vs asymmetric fetal growth restriction:
onset
etiology
clinical features
symmetric:
1st trimester onset
chromosome abnormality or congenital infection etiology
global growth lag
asymmetric:
2nd/3rd trimester onset
utero-placental insufficiency or maternal malnutrition etiology
"head sparing" growth lag
53
what is the definition of fetal growth restriction
ultrasound estimated fetal weight <10th percentile for gestational age
54
how do you manage fetal growth delay
weekly biophysical profiles
serial umbilical artery doppler sonography
serial growth ultrasounds
55
how can you treat atrophic vaginitis
topical vaginal estrogen therapy for moderate-severe cases
moisturizers and lubricants for mild cases
56
what signs and symptoms are indicative of menopause
```
symptoms:
vulvovaginal dryness, irritation, pruritus
dyspareunia
vaginal bleeding
urinary incontinence, recent UTI
pelvic pressure
```
```
PE:
narrowed introitus
pale mucosa, decreased elasticity and rugae
petechiae, fissures
loss of labial volume
```
57
what is dx in pt with vulvar white plaque formation, "cigarette paper" skin changes, and loss of normal anatomical markers (obliteration of clitoris or labia minora, figure of 8 appearance)
lichen sclerosis
58
how do you treat lichen sclerosis
high-potency corticosteroid ointment
| --clobetasol
59
what is the recommended initial treatment for dyspareunia
vaginal oil-based lubricants
60
what is dx in pt with fever, lower abdominal pain, purulent cervical discharge, cervical motion and adnexal tenderness
PID
61
what are possibilities if PID is left untreated
infection can progress to tube-ovarian abscess
abscess rupture
perihepatitis
sepsis
62
what two organisms usually precede PID
Neisseria gonorrhoeae and Chlamydia trachomatis
63
what is management for PID, depending on severity
indications for hospitalization:
pregnancy
failed outpatient tx
inability to tolerate oral medications
noncompliant with therapy
severe presentation (high fever, vomiting)
complications (tube-ovarian abscess, perihepatitis)
(also adolescents w/ risk of non-compliance)
inpatient:
these pts will receive IV cefoxitin or cefotetan plus oral doxycycline
outpatient:
intramuscular ceftriaxone plus oral doxycycline
64
what is dx in pt with chronic pelvic pain > 6 months, dysmenorrhea, non cyclical pain that can be exacerbated by exercise, and adnexal mass
endometriosis
65
what is the finding of a homogenous cystic ovarian mass highly suggestive of
endometrioma in endometriosis
66
what is dx in pt with endometrial glands in the myometrium;
| typically F >40 w/ secondary dysmenorrhea and menorrhagia; symmetrically enlarged uterine size
adenomyosis
67
what does epithelial ovarian carcinoma look like
septated mass with solid components
68
what would give an ultrasound appearance of calcifications and hyper echoic nodules
mature teratoma (dermoid cyst)
69
what appears on ultrasound as a complex, thick-walled mass with air-fluid levels
tubo-ovarin abscess
70
what refers to rupture of membranes at <37 weeks gestation prior to onset of labor
preterm premature rupture of membranes PPROM
71
what is dx in pregnant pt with increased leakage frequency, nitrazine-positive vaginal fluid, and decreased amniotic fluid index
preterm premature rupture of membranes PPROM
72
how do you manage PPROM 34-37 weeks
Antibiotics
+/- corticosteroids
delivery (and intrapartum Penicillin for Strep B coverage)
73
how do you manage PPROM <34 weeks
```
signs of infection or fetal compromise:
antibiotics
corticosteroids
Magnesium if <32 weeks
delivery
```
no signs:
antibiotics
corticosteroids
fetal surveillance
74
how do you treat recurrent variable decelerations due to umbilical compression during labor
amniotransfusion
75
which exercises are unsafe in pregnancy
contact sports (basketball, hockey, soccer)
high fall risk (skiing, gymnastics, horseback riding)
scuba diving
hot yoga
76
what exercise regimen is recommended in pregancy
20-30min of moderate-intensity exercise on most/all days is recommended
77
how do thyroid values change in the first trimester of pregnancy
total T4 increases
free T4 unchanged or mild increase
TSH decreased
78
what is the mechanism of changing thyroid values in first trimester pregnancy
beta-hCG stimulates thyroid hormone production in first trimester
estrogen stimulates TBG
thyroid increases hormone production to maintain steady free T4 levels
increased beta-hCG and thyroid hormone suppress TSH secretion
(hCG has structural similarity to TSH and can directly stimulate TSH receptors)
79
what is dx in pt with low total and free T3 with a normal T4 and TSH
euthyroid sick syndrome
alteration in biochemical thyroid function tests in the setting of severe non thyroid illness
80
```
what is dx in pt with increased total and free thyroid hormone levels
proptosis
diffuse goiter
HTN
tachycardia
```
graves disease
81
what is dx in pt with hyperthyroidism with suppressed TSH
following an acute viral illness
painful, tender goiter
subacute thyroiditis (granulomatous or De Quervain)
82
what is definition of spontaneous abortion
pregnancy loss <20 weeks
83
how do you manage a spontaneous abortion
```
expectant
medical induction (misoprostol)
```
suction curettage if infection or hemodynamic instability
84
what signs/symptoms should raise suspicion for spontaneous abortion
<20 weeks gestation
heavy vaginal bleeding
cramping
dilated cervix
ultrasound that shows nonviable fetus (no heartbeat)
intrauterine gestation in the lower uterine segment
85
why is oxytocin not effective in stimulating uterine contractions or expelling retained products of conception during first or second trimesters
there are few oxytocin receptors in the uterus during early pregnancy
86
what is next step once Lichen Sclerosis is identified
vulvar punch biopsy
LS is pre-malignant lesion for squamous cell carcinoma
87
what commonly treats genital warts
cryotherapy
88
what treats genital herpes
acyclovir
89
what is dx in pt with an enlarged, irregular, firm uterus
pregnancy difficulties
heavy, prolonged menses with clots
urinary frequency, constipation, pelvic pressure/pain (compressive symptoms)
uterine leiomyomas (fibroids)
90
what is the workup when a uterine fibroid is suspected on H&E
pelvic ultrasound
higher sensitivity than CT for both uterine and ovarian pathology
91
what is treatment for uterine fibroids
observation if no significant symptoms
hormonal contraception, embolization, or surgery if symptomatic (usually the large fibroids causing compressive symptoms)
92
what is the most common pelvic tumor in reproductive-age women
uterine leiomyoma / fibroid
93
what is the next step when there's clinical suspicion of endometrial hyperplasia or carcinoma
endometrial biopsy
94
what is dx in pt with cyclic lower abdominal pain in absence of menarche, with PE showing a blue bulging vaginal mass that swells with increased intraabdominal pressure (valsalva), and increasing pressure on surrounding pelvic organs (lower back pain, pelvic pressure, defecatory rectal pain)
imperforate hymen
95
what is treatment for imperforate hymen
incision of the hymen and drainage of the hematocolpos
96
what is dx in pt with amenorrhea and blind vaginal pouch
complete mullerian agenesis
97
what organs are missing in mullerian agenesis
uterus and cervix
98
what is dx in pt with pelvic pressure and vaginal bulge that increases with Valsalva, typically in postmenopausal Females
pelvic organ prolapse
99
what is dx in infant pt with polypoid or "grape like" mass protruding from the vagina with associated vaginal discharge and bleeding
sarcoma botryoides
100
when is a core biopsy indicated in a female pt <30yo
evidence of a complex cyst or complicated cyst (echogenic debris, thick septa, solid components)
or if mass recurs / does not disappear after aspiration
101
what are GnRH, FSH, and estrogen levels in:
hypothalamic hypogonadism:
low GnRH
low FSH
low estrogen
Primary ovarian insufficiency:
high GnRH
high FSH
low estrogen
PCOS:
high GnRH
normal FSH (LH/FSH ratio imbalance)
high estrogen
normal ovulation:
normal GnRH
normal FSH
normal estrogen
exogenous estrogen use:
102
what is the definition of primary ovarian insufficiency
cessation of ovarian function <40 yo
it's a form of hypergonadotropic hypogonadism
103
what is pathogenesis of Sheehan syndrome
heavy permpartum blood loss complicated by hypotension and/or blood transfusion
postpartum pituitary infarction
104
what is dx in pt recently postpartum with lactation failure, hypotension, weight loss, fatigue, and postpartum hemorrhage
Sheehan syndrome-
| ischemic necrosis of pituitary
105
what is dx in pregnant pt with HTN, thrombocytopenia, and proteinuria
HELLP syndrome
hemolysis
elevated liver enzymes
low plt count
106
what is dx in pt with acute renal injury, thrombocytopenia, and microangiopathic hemolytic anemia frequently 2/2 Gastroenteritis
HUS
107
how does SLE with nephritis present in pregnancy
pre-eclampsia + SLE signs (malar rash, etc)
108
what are appropriate maternal cardiopulmonary adaptations to pregnancy and their clinical manifestations
cardiac:
- -increase cardiac output (inc SV early; inc HR late)
- -increase plasma vol
- -decrease SVR
respiratory:
- -increase TV
- -decrease FRC (elevation of diaphragm)
clinical manifestations:
- -peripheral edema (plasma vol expansion)
- -low BP
- -high HR
- -systolic ejection murmur (inc CO)
- -dyspnea
--nocturnal leg pain (lactic and pyruvic acid)
109
what is RhoGAM
anti-D immune globulin
110
when is anti-D immune globulin (RhoGAM) indicated
unsensitized, Rh- females at 28 weeks gestation
or within 72 hours of any procedure/incident in which there is any possibility of feto-maternal blood mixing (incl delivery, abortion, ectopic, mole, villus sampling, trauma)
111
```
what is dx in pregnant pt with:
low alpha-fetoprotein
low beta-hCG
low estriol
normal Inhibin A
```
Trisomy 18
112
```
what is dx in pregnant pt with:
low alpha-fetoprotein
high beta-hCG
low estriol
high Inhibin A
```
Trisomy 21
113
```
what is dx in pregnant pt with:
high alpha-fetoprotein
normal beta-hCG
normal estriol
normal Inhibin A
```
neural tube or abdominal wall defect
114
what are the 4 values included in quadruple screening
alpha-fetoprotein
beta-hCG
estriol
inhibin A
115
when is the quadruple screening test performed
second trimester 15-20 weeks
116
what is the next step after an abnormal quadruple screening
pts are offered cell-free fetal DNA testing
ultrasound
117
what is term for failure of primary neurulation
myelomeningocele
118
what is a paraumbilical bowel evisceration with no covering membrane
gastroischisis
119
what is a peritoneum-covered sac at the umbilicus
omphalocele
120
what is the most important direct role of hCG in pregnancy
maintenance of the corpus luteum
| maintain progesterone secretion until the placenta is able to produce progesterone on its own
121
what is the timing of hCG levels during pregnancy
hCG production/secretion by the syncytiotrophoblast begins ~8 days after fertilization
hCG levels double every 48 hours until they peak at 6-8 weeks gestation
122
what is the structure of hCG
alpha subunit: common to hCG, TSH, LH, and FSH
beta subunit: unique to hCG, and is used as the basis of virtually pregnancy tests
123
what hormone inhibits uterine contractions
progesterone
124
which hormone is responsible for induction of prolactin production during pregnancy
estrogen
125
which hormone is responsible for preparing the endometrium for implantation of a fertilized ovum
progesterone
126
what is definition of preterm labor
regular contractions at <37 weeks gestation that cause cervical dilation and/or effaceent
127
which drugs postpone delivery
tocolytics:
```
indomethacin
nifedipine (CCB)
```
128
what drugs decrease risk of neonatal RDS in preterm delivery
corticosteroids (betamethasone)
129
which drug is administered <32 weeks gestation to lower the risk of neonatal neurological morbidities like cerebral palsy in pts who are expected to deliver within the next 24 horus
Magnesium sulfate
130
what does a positive fetal fibronectin test or a shortened cervix mean for pt
increased risk of preterm delivery
131
what is administered to pts with a h/o prior preterm delivery or a shortened cervix to prevent preterm delivery
progesterone
132
what is the medical management for preterm labor, depending on gestational age
```
<32 weeks:
betamethasone
tocolytics
magnesium sulfate
Penicillin if GBS positive or unknown
```
32 - 33 weeks:
betamethasone
tocolytics
Penicillin if GBS positive or unknown
34 - 36 weeks:
+/- betamethasone
Penicillin if GBS positive or unknown
133
what is dx in female pt with normal internal genitalia, external virilization, and undetectable serum estrogen levels
aromatase deficiency
unable to convert androgens to estrogens
134
what may happen to mother if fetus has aromatase deficiency
transient masculinization of the mother that resolves after delivery
(inability of placental to convert androgens to estrogens)
135
what happens to patients with aromatase deficiency in adolesence
delayed puberty
osteoporosis
undetectable estrogen levels (no breast development)
high concentrations of gonadotropins, resulting in polycystic ovaries
136
what is generic dx in female pt with ambiguous external genitalia, normal uterus and ovaries, and electrolyte abnormalities
congenital adrenal hyperplasia
137
what is dx in pt with hypogonadotropic hypogonadism with anosmia, delayed puberty, and low/absent LH/FSH
Kallman syndrome
X-linked
138
what is dx in pt with triad of:
cafe au lait spots
polycystic fibrous dysplasia
autonomous endocrine hyperfunction
McCune-Albright syndrome
139
what is the most common endocrine feature of McCune-Albright syndrome
precocious puberty
140
```
what is dx in pts with:
virilization
insulin resistance
low/normal LH and FSH
post-menopausal
ultrasound with solid-spearing, enlarged ovaries
```
ovarian hyperthecosis
141
what is the first-line management step in assessing a palpable breast mass in females >30yo
mammography
142
what is the "scenario" that puts one at risk for ABO incompatibility
infants with blood types A or B born to a mother with blood type O
143
what is the response when a type O mother is worried about ABO incompatibility
signs of hemolytic disease are typically mild and apparent only in ~1/3 infants
possible mild anemia at birth, may have jaundice
144
why can ABO incompatibility affect a first pregnancy
by the time a type O female becomes pregnant, she likely already has anti-A and anti-B IgG antibodies that can cross the placenta
--early A and B antigen exposure early in life from things like food, bacteria, and viruses
145
what is the next step if fetal movement decreases or becomes imperceptible by the mother
non-stress test NST
146
how is an NST test performed and what are possible results
record fetal HR while monitoring for spontaneous perceived fetal movements
reactive/normal if there are at least 2 accelerations of the fetal HR of at least 15 beats/min above baseline lasting at least 15 seconds each in 20 minutes
nonreactive/abnormal if <2 accelerations are noted in 20 min
147
what is the most common cause of a nonreactive NST and how is it managed
fetal sleep schedule
use vibroacoustic stimulation to awaken the fetus and allow a timely test
148
what is inheritance pattern for Hemophilia A
X linked recessive
149
what are the 2 etiologies of early decelerations of fetal HR
fetal head compression (stimulating vagal response which slows HR)
or can be normal fetal tracing
150
what are early deceleration findings
Nadir of deceleration corresponds to peak of contraction
gradual (>30 sec from onset to Nadir)
symmetric to contraction
151
what are late deceleration findings
Nadir of deceleration occurs after peak of contraction
gradual (>30 sec from onset to nadir)
delayed compared to contraction
152
what is the etiology of a late deceleration
uteroplacental insufficiency
153
what are variable deceleration findings
can be but not necessarily associated with contractions
abrupt (<30sec from onset to nadir)
decrease >15/min; duration >15 sec but <2 min
154
what are 3 etiologies of variable decelerations
cord compression
oligohydramnios
cord prolapse
155
which types o fetal HR decelerations are normal and which ones indicate fetal hypoxemia and acidosis
early decelerations do not indicate fetal distress
late and variable decelerations indicate risk for fetal hypoxemia and acidosis
156
at what beta-hCG level can a Transvaginal ultrasound be able to visualize an intrauterine pregnancy
hCG >1500
if hCG is lower than this, wait ~2 days, remeasure, and repeat TVUS
--hCG levels increase quickly
157
what is dx in pt with fever, firm, red, tender, swollen quadrant of 1 breast; +/- myalgia, chills, and malaise
mastitis
158
what is the most common cause of mastitis
staph aureus
159
how do you manage mastitis
continue breastfeeding
analgesics
Abx targeting staph aureus
160
what causes menopausal genitourinary syndrome
hypoestrogenism
- -the bladder trigone, urethra, pelvic floor muscles, and endopelvic fascia possess estrogen receptors and are maintained by adequate estrogen levels
- -hypoestrogenism results in atrophy of superficial and intermediate layers of the vagina and urethral mucosal epithelium
- -diminished urethral closure pressure and loss of urethral compliance contribute to urgency, frequency, UTIs, and incontinence
161
what are 4 first-line treatment options in asymptomatic bacteriuria
cephalexin
amoxicillin-clavulanate
nitrofurantoin
fosfomycin
162
what is dx in pt with soft, mobile, well-circumscribed mass at base of labia majora; usually asymptomatic; <30 yo
bartholin duct cyst
163
what skin involvement results from infection by HPV 6 and 11
condylomata acuminata
exophytic or sessile growths that may be solitary or multiple but do not form cystic masses
164
what cyst results from incomplete regression of the Wolffian duct during fetal development
Gartner duct cyst
165
what cyst is described as single or multiple and are submucosal along the lateral (parallel) aspects of the upper anterior vagina; do not involve vulva
Gartner duct cyst
166
what presents as small, firm, painless bumps with central pits; usually asymptomatic or local itching
molluscum contagiosum
167
what presents with a chancre (round, painless ulcer)
primary syphillis
168
what is dx in pt with a raised and fleshy, often ulcerated, vulvar lump or mass; with long-standing vulvar pruritis
vulvar cancer
| most are squamous cell carcinomas
169
how do you tx asymptomatic vs symptomatic Bartholin duct cyst
asymptomatic: observation
symptomatic: I&D, followed by placement of a Word catheter
170
what is dx in pt with prolonged menstruation, dysmenorrhea, miscarriages, and PE showing irregular uterine contour that may be palpable in the abdomen as a globular mass
```
uterine leiomyomata (fibroids)
--most common pelvic tumor in females
```
171
what is dx when pt presents with dysmenorrhea, menorrhagia, and soft, boggy, uniformly enlarged uterus
adenomyosis
172
what is inter menstrual spotting without uterine enlargement hallmark for
endometrial polyps
173
what is dx in pt with adnexal mass and nonspecific GI symptoms (early satiety, constipation/diarrhea, anorexia, bloating, increased abdominal girth)
ovarian cancer
174
what is hallmark dx in painful, itchy, eczematous, and/or ulcerating rash on nipple that spreads to areola
Paget disease of the breast
175
what do 85% of pts with mammary Paget disease have
underlying breast adenocarcinoma
176
what is dx in reproductive-age pt with acute lower abdominal pain, N/V, usually in setting of known adnexal mass
ovarian torison
177
what is gold standard for dx of ovarian torsion
pelvic ultrasound showing an ovarian mass with absent Doppler flow
178
what is the management of ovarian torsion
emergency laparoscopic detorsion and surgical restoration of anatomy with cystectomy
179
what is the most common etiology of intrauterine fetal demise
can be maternal, placental, or fetal, but etiology is most often unknown
180
what is most common cause of congenital adrenal hyperplasia
21-hydroxylase deficiency
181
what is dx in female pt with hyperandrogenism (hirsutism, acne), elevated 17-hydroxyprogesterone, +/- hyponatremia, menstrual irregularities in adolescence/adulthood
non classic congenital adrenal hyperplasia
182
what are normal renal changes during pregnancy and the mechanisms
increase GFR and renal size, decrease BUN and serum Cr
--increase cardiac output and RBF 2/2 progesterone, with increase in renal excretion
urinary frequency, nocturia
--high urine output and Na excretion
mild hyponatremia
--hormones reset threshold to increase ADH release from pituitary
183
what are normal heme changes during pregnancy and the mechanisms
dilutional anemia
--increased plasma volume and RBC mass
prothrombotic state
--hormone-mediated decrease in total protein S antigen activity; increase in fibrinogen and coagulation factors
184
what are normal CVS changes during pregnancy and the mechanisms
increase cardiac output and HR
| --increase blood volume, decrease SVR
185
what are normal pulmonary changes during pregnancy and the mechanisms
chronic respiratory alkalosis with metabolic compensation
high PaO2 and low PaCO2
--progesterone directly stimulates central respiratory centers to increase Tidal Volume and minute ventilation
186
what's the strongest risk factor for a fragility fracture
prior history of a fragility fracture
187
```
what is dx in pt with presence of maternal fever and >= 1 of the following:
uterine tenderness
maternal or fetal tachy
malodorous amniotic fluid
purulent vaginal discharge
```
chorioamnionitis (intra-amniotic infection)
188
what is an important risk factor for chorioamnionitis
prolonged rupture of the membranes PROM
189
what is the most appropriate treatment of chorioamnionitis
prompt administration of broad-spectrum Abx followed by delivery to reduce the risk of life-threatening neonatal infection and maternal complications
--oxytocin accelerates labor
190
what is dx in pregnant pt with sudden onset abdominal pain, recession of the presenting part during active labor, and fetal heart rate abnormalities
uterine rupture
191
what is a major risk factor for uterine rupture
prior uterine surgery, such as a scar of prior cesarean delivery
192
what is loss of fetal station pathognomonic for
rupture
193
what is dx in pt with fever, abdominal pain, and complex multiloculated adnexal mass with thick walls and internal debris on ultrasound with h/o PID
tubo-ovarian abscess (TOA)
194
what is the abdominal pain in HELLP syndrome due to
liver swelling with distension of the hepatic (Glisson's) capsule
195
what is dx in pt with secondary amenorrhea, negative pregnancy test, normal prolactin and normal TSH
functional hypothalamic amenorrhea (hypoestrogenemia)
196
what does a challenge with medroxyprogesterone acetate do
it's a progestin challenge test that can confirm low estrogen levels
the presence of estrogen causes proliferation the endometrium, with
sloughing after the progesterone is withdrawn
--pts with low estrogen will have little/no bleeding after progesterone withdrawal as there is no endometrial lining to shed
197
what is a significant concern in pts with functional hypothalamic amenorrhea
decreased bone mineral density 2/2 estrogen deficiency
198
what is the immediate management of uterine inversion
replacement of uterus
if placenta is still attached, wait to remove it until the uterus is replaced to reduce risk of massive hemorrhage
199
what is first line imaging to assess fallopian tube patency
hysterosalpingogram
200
what is gold standard for evaluating risk of preterm delivery
transvaginal ultrasound measurement of cervical length
201
what hormone maintains uterine quiescence and protects amniotic membranes against premature rupture
progesterone
202
what is the only way to definitively diagnose endometriosis
laparoscopy with visualization and biopsy of endometrial implants
indicated after NSAIDs and hormonal contraceptives have failed
203
what is a major risk of endometriosis
infertility
cyclic accumulation of ectopic foci of hemorrhage and adhesions can distort pelvic anatomy and impair fertility by obstructing oocyte release or sperm entry
204
what are first 2 steps when ovarian malignancy is suspected
pelvic ultrasound and CA-125
205
what is dx in pt when uterine villi attach to the myometrium presenting w/ placental adherence and hemorrhage at time of attempted placental delivery
placenta accreta
206
what is dx in pt with ultrasound showing irregularity or absence of the placental-myometrial interface and intraplacental villous lakes
placenta accreta
207
what is dx in pt with premature detachment of placenta from uterus; presents w/ vaginal bleeding, sudden abdominal or back pain, tense distended uterus, and fetal HR abnormalities
placental abruption
208
what is dx in pt whose placenta implants over the internal cervical os
placenta previa
209
what is dx when uterus fails to contract after placental delivery
uterine atony
210
what is dx when fetal vessels traverse the amniotic membranes over the internal cervical os; presents w/ painless antepartum bleeding and fetal HR abnormalities just after the rupture of membranes
vasa previa
211
how do levothyroxine requirements change during pregnancy
increase
pts with hypothyroidism should increase their thyroid meds
212
why are thyroid hormone requirements increased during pregnancy
estrogen induces an increase in serum TBG levels, requiring an increase in the amount of thyroid hormone needed to saturate the binding sites
213
what are the vaccine indications for HPV
all females 11-26yo
males 9-21 yo (9-26 for those who have sex w/ men or have HIV)
214
when does pap testing begin
pap testing begins at age 21 in immunocompetent pts regardless of age of onset of sexual activity or number of sexual partners
215
what is dx in pt with proliferation of SM cells within the myometrium and irregular uterine enlargement
leiomyomata uteri (fibroids)
216
what is dx in pt with cyclic bleeding of ectopic endometrial glands; presents as pelvic pain, heavy bleeding (no anemia), or an irregularly enlarged uterus
endometriosis
217
what is dx in proliferation of endometrial glands inside the uterine myometrium; presents w/ bulky/boggy, tender uterus that is uniformly enlarged
adenomyosis
218
what is concern in postmenopausal females with bleeding and normal-sized uterus
endometrial hyperplasia w/ atypia, progressing to endometrial carcinoma
219
what is dx in pt with fever >24 hrs postpartum, uterine fundal tenderness, and purulent lochia
postpartum endometritis
220
what is treatment for postpartum endometritis
clindamycin and gentamycin
polymicrobial infection requiring broad-spectrum Abx
221
what are 3 liver disorders unique to pregnancy
intrahepatic cholestasis of pregnancy
HELLP
acute fatty liver of pregnancy
222
what is dx in pregnant pt with intense pruritus;
diagnosis of exclusion w/ labs:
high bile acids
high aminotransferases
intrahepatic cholestasis of pregnancy
223
```
what is dx in pregnant pt with malaise, RUQ pain, N/V, sequelae of liver failure; labs:
hypoglycemia
mildly elevated liver aminotransferases
elevated bilirubin
possible DIC
```
acute fatty liver of pregnancy
224
what is commonly prescribed in intrahepatic cholestasis of pregnancy for treatment, and its MOA
Ursodeoxycholic acid
increase bile acid flow and relieve itching
225
what are maternal and fetal risk factors for fetal macrosomia
```
maternal:
advanced age
DM
excessive weight gain during pregnancy, or pre-existing obesity
multiparity
```
fetal:
african american or Hispanic ethnicity
male
post-term pregnancy
226
what is the most common type of brachial plexus injury during delivery, and what does it involve
Erg-Duchenne palsy
involves 5th, 6th, and sometimes 7th cervical nerves
227
what is dx in pt with weakness of deltoid and infraspinatus muscles (C5), biceps (C6), and wrist/finger extensors (C7), leading to predominance of the opposing muscles
Erb-Duchenne palsy
"waiter's tip" posture
228
what is treatment for Erb Duchenne palsy
gentle massage and PT to prevent contractures
up to 80% pts have spontaneous recovery within 3 months; otherwise, surgical intervention is considered
229
what is next step when evaluating renal colic in pregnant pts
ultrasound of kidneys and pelvis
low-dose CT urography may be considered only in 2nd and 3rd trimesters
230
what is the HIV management protocol during pregnancy
antepartum:
- -testing of HIV-1 viral load months until undetectable; then every 3 months
- -CD4 cell count every 3 months
- -Resistance testing if not previously performed
- -Initiation or continuation of HAART
- -Avoidance of amniocentesis if viral load is detectable
Intrapartum:
- -avoidance of artificial ROM, fetal scalp electrode and operative delivery
- -Viral load <1000 copies: continuation of HAART and vaginal delivery
- -Viral load >1000 copies: Zidovudine and cesarean delivery
Postpartum:
- -Mother: continuation of HAART
- -Infant: Zidovudine for >6 weeks plus serial HIV testing
231
what is recommended in pts at >37 weeks gestation with breech presentation
offer external cephalic version
Cesarean delivery is necessary if ECV fails
vaginal delivery of a singleton breech fetus is generally contraindicated due to increased his for birth asphyxia and trauma
232
what is dx when fetal Doppler sonography fails to detect a fetal heart rate in pts with decreased or absent fetal movement >20 weeks
Intrauterine fetal demise
233
what is management when intrauterine fetal demise is suspected
absence of fetal cardiac activity on ultrasound is necessary to confirm diagnosis
234
what is gold standard method of diagnosing Cervical Intraepithelial Neoplasia (CIN)
colposcopy
235
what is the recommendation for CIN 3
cervical conization (excision of the intact transformation zone)
CIN 3 is premalignant with high risk of progressing to SCC
236
what are 3 potential complications of a cervical conization
```
cervical stenosis (scar tissue)
cervical impotence
preterm delivery
```
237
what is dx in pt with formation of intrauterine adhesions from infection or intrauterine surgical interventions (involving endometrium)
Asherman syndrome
238
what are the 2 methods of cervical conization
cold knife conization
loop electrosurgical excision procedure (LEEP)
239
what test is highly sensitive and specific screening for fetal aneuploidy, can be ordered at >=10 weeks gestation
plasma cell-free fetal DNA testing
240
how can you confirm abnormal cell-free fetal DNA testing
confirmed by chorionic villus sampling at 10-12 weeks or amniocentesis at 15-20 weeks
241
what is dx in pt with bilateral, symmetric fullness, tenderness and warmth of breasts 3-5 days after delivery
breast engorgement
242
what causes breast engorgement
colostrum is replaced by milk
243
what is dx in newborn with small body size, microcephaly, digital hypoplasia, nail hypoplasia, mid facial hypoplasia, hirsutism, cleft palate, and rib anomalies
fetal hydantoin syndrome
| exposure to anticonvulsant meds during fetal development
244
what 2 medications commonly cause fetal hydantoin syndrome
anticonvulsants, most notably phenytoin and carbamazepine
245
what is dx in newborn with rhinitis, HSM, and skin lesions; later findings of interstitial keratitis, Hutchinson teeth, saddle nose, saber shins, deafness, and CNS involvement
congenital syphilis
246
what is dx in newborn with mid facial hypoplasia, microcephaly, and stunted growth; also CNS damage (hyperactivity, intellectual disability, learning disability) is typical
fetal alcohol syndrome
247
what are your 4 emergency contraception options, MOA, time after intercourse to use, and efficacy
copper IUD:
- -copper causes inflammatory reaction that is toxic to sperm and ova; impairs implantation
- -0-5 days
- -99% efficacy
Ulipristal pill:
- -antiprogestin; delays ovulation
- -0-5 days
- ->85% efficacy
Levonorgestrel pill:
- -progestin; delays ovulation
- -0-3 days
- -85% efficacy
OCPs:
- -Progestin; delays ovulation
- -0-3 days
- -75% efficacy
248
what is dx in non psychotic F who present with signs and symptoms of early pregnancy (amenorrhea, morning sickness, abdominal distension, breast enlargement) and belief that she is pregnant, but evaluation excludes pregnancy (neg pregnancy test and ultrasound)
Pseudocyesis
249
what is the management for pseudocyesis
pseudocyesis is a form of somatization, so management requires psych evaluation and tx
250
what is dx in pt with androgen excess, oligo- or an-ovulation, obesity, and polycystic ovaries
PCOS
251
what malignancy is associated with PCOS
endometrial hyperplasia/cancer
due to unregulated endometrial proliferation from unopposed estrogen stimulation
252
what is the treatment option for PCOS pt who wants to conceive
clomiphene citrate for ovulation induction
253
how do you treat treponema pallidum
penicillin
254
how do you screen and confirm syphilis
screen with either a nontreponemal test (VDRL) or a treponemal-specific test (fluorescent treponemal antibody absorption)
confirm with the other test type, as there's a high false positive rate
255
when should you screen for syphilis in a pregnant pt
first prenatal visit
256
how do you treat syphilis in pregnant pt w/ penicillin allergy
penicillin skin test to evaluate for the presence of an IgE-mediated response
positive test = pts are desensitized to penicillin prior to receiving treatment with intramuscular penicillin G benzathine
257
how do you manage chronic Hepatitis C in pregnancy
Hepatitis A and B vaccination with inactivated/killed vaccines
- -Ribavirin is teratogenic and should be avoided
- -no indication for barrier protection in serodiscordinant, monogamous couples
258
how do you prevent vertical transmission of Hepatitis C in pregnancy
vertical transmission strongly associated with maternal viral load
Cesarean delivery is not protective
scalp electrodes should be avoided
breastfeeding should be encouraged unless maternal blood is present (nipple injury)
259
how do you manage chronic hepatitis C in non-pregnant pts
combination of Interferon-alpha and Ribivirin
260
what does primary HTN increase the risk of in pregnancy for mom and fetus?
maternal:
- -superimposed preeclampsia
- -postpartum hemorrhage
- -gestational diabetes
- -abruptio placentae
- -Cesarean delivery
fetal:
- -fetal growth restriction/small for gestational age
- -perinatal mortality
- -preterm delivery (not PPROM)
- -oligohydramnios
261
what is the initial management of blunt abdominal trauma (MVC) in pregnant pt (30 weeks)
aggressive fluid resuscitation and uterine displacement to optimize maternal circulation
--leave pt in LL decubitus position to displace uterus off aortocaval vessels to maximize CO
--BAT/MVC is a significant risk factor for severe hemorrhage from abrupt placenta
262
what is the first-line treatment and second best long-term outcome treatment for stress urinary incontinence
pelvic floor exercises are first-line
urethral sling surgery provides the best long-term outcome
263
what is stress incontinence due to
urethral hypermobility
264
how do you diagnose urethral hypermobility
place pt in dorsal lithotomy position
insert cotton swab into urethral orifice
>=30 degree angle from horizontal to increase intraabdominal pressure (coughing) signifies urethral hypermobility
265
what is treatment for urinary retention due to neurogenic bladder
intermittent self-catheterization
266
what are alpha-blockers and cholinergics helpful in treating for urinary symptoms
help with bladder contraction
alpha blockers: urgency incontinence associated w/ BPH
bethanechol: tx overflow incontinence due to diabetic neuropathy
267
what are antimuscarinics used for in urinary symptoms
treat urge incontinence
| --sudden urge to urinate at any time
268
what is dx in pt with crampy lower abdomen and/or back during menses; normal examination
primary dysmenorrhea
269
how do you manage primary dysmenorrhea
NSAIDs and hormonal contraceptions for pain relief
270
which dx has pain that peaks before menses
endometriosis
271
what is the most accurate way to determine estimated gestational age (EGA)
ultrasound dating with fetal crown-rump measurement in the first trimester is most accurate
- -accuracy varies from +/- 3 to 5 days between 7 - 14 weeks gestation
- -EGA should not be changed based on measurement discrepancies on a 2nd/3rd trimester ultrasound; growth problems should be considered in this case
272
what are daughters of mothers who took Diethylstilbestrol (DES) at risk for
40-fold increase clear cell adenocarcinoma of vagina and cervix
structural anomalies of the reproductive tract (hooded cervix, T-shaped cervix, small uterine cavity, vaginal septae, vaginal adenosis)
pregnancy problems (ectopic pregnancy, pre-term delivery)
infertility
273
what is Diethylstilbestrol (DES)
synthetic estrogen used widely 1938-1971 for prevention of spontaneous abortion, premature delivery, and postpartum lactation suppression
banned in US due to adverse effects
274
what is the major risk factor for CCA vs SCC in the vagina and cervix
CCA: daughter of DES mother
SCC: HPV and tobacco
275
when are rectovaginal cultures obtained for GBS screening
35-37 weeks gestation
276
who should receive GBS prophylaxis without testing
pregnant pts with a history of
GBS bacteriuria
UTI
infant w/ early-onset GBS disease
277
how do you manage GBS prophylaxis
give Penicillin 4 hours before delivery
278
what is dx in pt with diffuse breast erythema, warmth, pain, and edema w/ peau d'orange appearance
inflammatory breast carcinoma
279
what does condylomata acuminata come from
HPV 6, 11
| genital warts
280
what is dx in pt with single or multiple pink or skin-colored lesions; lesions range from smooth, flattened papule to exophytic/cauliflower-like growth
genital warts
condylomata acuminata
HPV 6, 11
281
how do you treat condyloma acuminata
small lesions may be treated with applications of trichloroacetic acid
or podophyllin resin
excisional therapy may be considered for larger lesions
recurrence rate is high, regardless of tx modality
282
what is dx in pt with flat, velvety lesions; broad base and flat surface; lobulated and plaque-like
condyloma lata
| secondary syphilis
283
what is dx in pt with single/clustered blisters or superficial, tender ulcers
HSV
284
what is dx in pt with pruritic, glassy, bright red erosions and ulceration involving the vulva and vagina
genital lichen planus
285
what is dx in pt with poxvirus and single or multiple "pearly" (smooth, firm) painless nodules with central dimples/pits; no bleeding on contact
molluscum contagiosum
286
what is the only current indication for hormone replacement therapy
vasomotor symptoms (severe hot flashes) in women <60 yo who have undergone menopause within the last 10 yrs
287
what are contraindications to hormone replacement therapy
```
history of:
CAD
thromboembolism
TIA/stroke
breast cancer
endometrial cancer
```
288
how do you manage pts with severe vasomotor symptoms (hot flashes) with a contraindication to systemic HRT
SSRIs
289
what is the concern with HRT in treating menopause symptoms
the estrogen component treats menopausal symptoms
but if unopposed (no progesterone),
can cause endometrial proliferation and hyperplasia
therefore, in pts with a uterus- HRT must contain a progestin component for endometrial protection
290
what is dx in pt with h/o pelvic surgery and painless continuous loss of clear, watery fluid from the vagina
vesicovaginal fistula (urine leak)
291
how can you diagnose a vesicovaginal fistula
PE
dye test
cystourethroscopy
292
how can you prevent vesicovaginal fistula
bladder catheterization in the immediate postoperative period allows a small fistula to heal
otherwise, surgical correction is indicated
293
what is the first sing of puberty in girls
breast development (thelarche)
age 8-12
in response to rising estrogen levels
294
when is menarche expected during puberty
~Tanner stage 4
approximately 2-2.5 yrs after initial breast bud development
avg age 12.5
295
what are contraindications to external cephalic version
indications for Cesarean delivery regardless of fetal lie (failure to progress during labor, non-reassuring fetal status)
placental abnormalities (placenta previa or abruption)
oligohydramnios
ruptured membranes
hyperextended fetal head
fetal or uterine anomaly
multiple gestation
296
what is the most common cause of postpartum hemorrhage
uterine atony (failure to contract)
297
what is initial management of postpartum hemorrhage 2/2 uterine atony
bimanual uterine massage and uterotonic agents
- -oxytocin (first line)
- -methylergonovine (risk of vasoconstriction/HTN)
- -Carboprost (risk of bronchoconstriction/asthma)
298
what is dx in pt with skin/nipple retraction, calcifications on mammography, and biopsy showing fat globules and foamy histiocytes
fat necrosis of the breast
| --can mimic breast cancer; associated with breast surgery and trauma
299
what ultrasound finding often correlates with benign breast etiology
hyperechoic mass
300
how do pts with androgen insensitivity present
male karyotype
male testosterone levels
breast development (testosterone is aromatized into estrogen)
primary amenorrhea (absent ovaries, uterus, and cervix)
minimal pubic and axillary hair
301
what is pathogenesis s of androgen insensitivity syndrome
end-organ resistance to androgens 2/2 mutated androgen receptor
pts have functioning testes and secrete AMH and testosterone
--AMH stimulates regression of Mullerian ducts (no uterus, cervix, or upper vagina)
no masculization 2/2 androgen resistance
- -Wolffian duct degeneration
- -fetal urogenital sinus does not differentiate into a penis and scrotum
- -male 2ndary sex characteristics are minimal/absent (hair, voice)
302
what is best next step in management with a high-grade squamous intraepithelial lesion Pap test result vs low-grade
high grade:
immediate colposcopic examination and biopsy of cervical abnormalities due to high risk of progression to cervical cancer
low grade or undetermined significance:
HPV co-testing
303
what dx in pathogenesis that involves systemic inflammation, activation of the coagulation cascade, and platelet consumption
HELLP syndrome
304
what are 2 maternal complications from abruptio placentae
hypovolemic shock
DIC
305
what is the pathophysiology of neonatal thyrotoxicosis
transplacental passage of maternal anti-TSH receptor antibodies
antibodies bind to infant's TSH receptors and cause excessive thyroid hormone release
306
what is dx in newborn with warm, moist skin, tachy, poor feeding, irritability, poor weight gain, and low birth weight/preterm birth
neonatal thyrotoxicosis
307
how do you dx neonatal thyrotoxicosis
maternal anti-TSH receptor antibodies >= 500% normal
308
how do you treat neonatal thyrotoxicosis
self-resolves within 3 months (disappearance of maternal antibody)
methimazole PLUS beta-blocker
309
when do you want to use Tamoxifen vs Raloxifene
Tamoxifen: adjuvant treatment of breast cancer
--endometrial hyperplasia and endometrial carcinoma
Raloxifene: postmenopausal osteoporosis
310
what is management for placenta previa
Cesarean delivery
NO intercourse or digital vaginal examination
vaginal delivery is contraindicated
311
who should be screened for chlamydia and gonorrhea
all sexually active women <25 yo should undergo annual screening for Chlamydia and gonorrhea due to high rates of asymptomatic infection that can lead to infertility
312
what is the gold standard for screening/diagnosis of chlamydia and gonorrhea
nucleic acid amplification testing
313
what is dx in pt with pain with vaginal penetration, distress/anxiety over symptoms, and no other medical cause
genitor-pelvic pain/penetration disorder
previously vaginismus
314
what is dx in pt with insomnia, fatigue, weight gain, amenorrhea, and an enlarged uterus
pregnancy
315
what are concerns for lithium exposure in pregnant women for fetuses?
first trimester: cardiac malformations
--septal defects; and possibly Epstein's anomaly
2nd and 3rd:
goiter, transient neonatal neuromuscular dysfunction
316
what is dx in pt in active phase of labor with cervical change slower than expected; +/- inadequate contractions
protraction to help with contraction strength
317
how do you treat protraction during active phase of labor
oxytocin
318
what is dx in pt in active phase of labor with no cervical change for >4hrs with adequate contractions
OR
no cervical change for >6hrs with inadequate contractions
arrest
319
how do you treat arrest of the active phase of labor
cesarean delivery
320
what is dx in post-op pelvic pt with persistent fever unresponsive to Abx and bilateral lower abdominal pain; no localizing signs/symptoms
septic pelvic thrombophlebitis
post-op/postpartum infected thrombosis of the deep pelvic or ovarian veins
321
what is medroxyprogesterone's MOA
Depot medroxyprogesterone acetate (DMPA) is administered intramuscularly every 3 months to prevent pregnancy by inhibiting the release of GnRH form the hypothalamus and suppressing ovulation
322
what is dx in pt with postmenopausal bleeding, thickened endometrium, breast tenderness, and large pelvic/adnexal mass
granulosa cell tumor
| --secretes estrogen and causes hormonal effects
323
what is the major risk factor for shoulder dystocia
fetal macrosomia
post-term pregnancy
maternal obesity
gestational DM
excessive maternal weight gain during pregnancy
324
when do you stop pap testing
```
Age 65 or hysterectomy
PLUS
no h/o CIN 2 or higher
AND
3 consecutive negative Pap tests
OR
2 consecutive negative co-testing results
```
325
what is dx in pt with recurrent sudden mild and unilateral mid-cycle pain prior to ovulation lasting hours-days; may mimic appendicitis
Mittelscherz
326
what is dx in pt with sudden-onset, severe, unilateral lower abdominal pain immediately following strenuous or sexual activity; ultrasound shows pelvic free fluid
ruptured ovarian cyst
327
what is dx in pt with sudden-onset, severe, unilateral lower abdominal pain; N/V; unilateral, tender adnexal mass on examination; ultrasound shows enlarged ovary with decreased or absent flow
ovarian torsion
328
what is the most significant risk factor for spontaneous preterm delivery
h/o spontaneous preterm delivery in a prior pregnancy
329
what is dx in pt with Keratoconjunctivitis sicca, dry mouth, salivary hypertrophy, xerosis of skin, Raynaud phenomenon, cutaneous vasculitis, arthralgias/arthritis, interstitial lung disease
Sjogren syndrome
330
what are diagnostic findings of Sjogren syndrome
objective signs of decreased lacrimation (Schirmer test)
postive anti-Ro (SSA) and/or anti-La (SSB)
salivary gland biopsy with focal lymphocytic sialoadenitis
331
what is dx in pt with pain to superficial touch of the vaginal vestibule rather than dryness
vulvodynia
| formerly vestibulodynia
332
what is dx in pt with amenorrhea, lactational failure, and persistent hypotension
Sheehan syndrome,
| a complication of massive obstetrical hemorrhage
333
what is used for dx and treatment of postpartum urinary retention
urethral catheterization
334
which 3 vaccines are recommended during pregnancy
Trap
Inactivated influenza
Rho(D) immunoglobulin
335
which 6 vaccines are indicated for high-risk pts
```
Hepatitis B
Hepatitis A
Pneumococcus
Haemophilus influenzae
Meningococcus
Varicella-zoster immunoglobulin
```
336
which 4 vaccines are contraindicated in pregnancy
HPV
MMR
live attenuated influenza
Varicella
337
what 4 labs/tests should you get to evaluate galactorrhea
serum pregnancy test
serum prolactin
TSH
possible MRI of brain
338
what is dx in pt with PID complicated by perihepatitis
Fitz-Hugh-Curtis disease
339
what is dx in pt with fever, lower abdominal tenderness, mucopurulent cervical discharge, and cervical motion and uterine tenderness; possible inter menstrual spotting,
PID
340
what are the 2 painful types of infectious genital ulcers
HSV (small vesicles or ulcers)
Haemophilus ducreyi (chancroid; larger, deep ulcers w/ gray/yellow exudate)
341
what is the most sensitive test for HSV
PCR
| viral culture can be used, but less sensitive
342
what is the recurrence pattern of genital herpes if left untreated
it will resolve, with decreasingly frequent recurrences
343
what is the management of shoulder dystocia
BE CALM
Breathe; do not push
Elevate hips against abdomen (McRoberts position)
Call for help
Apply suprapubic pressure
enLarge vaginal opening w/ episiotomy
Maneuvers:
--deliver posterior arm
--rotate 180 degrees (Woods corkscrew)
--collapse anterior shoulder (Rubin maneuver)
--replace fetal head into pelvis for cesarean delivery (Zavanelli maneuver)
344
what causes the genitourinary syndrome of menopause (atrophic vaginitis)
due to loss of vaginal wall elasticity from lack of estrogen
345
what is the best option for managing intrauterine fetal demise depending on weeks gestation?
20-23 weeks:
Dilation and evacuation
OR
vaginal delivery
>= 24 weeks:
induction of labor for vaginal delivery
--it can be delayed to allow time for parental acceptance of dx
--retention of fetus for several weeks can lead to coagulopathy
346
what is dx in an immigrant pt with h/o recurrent sore throats and new onset AF w/ RVR
rheumatic mitral stenosis
may be brought on by pregnancy 2/2 physiologic increases in HR and blood volume that raise the transmittal gradient and LA pressure
347
what causes infertility in PCOS pts
anovulation from failed follicular maturation and oocyte release
persistently elevate estrone levels due to peripheral androgen conversion in adipose tissue and decreased levels of SHBG.
- -high estrone levels provide negative feedback to hypothalamus, which inhibits GnRH secretion
- -imbalance in LH and FSH release from anterior pituitary
- -LH/FSH imbalance results in a lack of LH surge
- -failure of follicle maturation
348
what are 4 benefits and 4 risks of Combined estrogen-progestin contraceptives
Benefits:
- -pregnancy prevention
- -endometrial and ovarian cancer risk reduction
- -menstrual regulation with reduction in iron deficiency anemia
- -reduction in risk of benign disease
Risks:
- -Venous thromboembolism
- -HTN
- -Hepatic adenoma
- -Very rarely, stroke and MI
349
what test is used to determine appropriate dose of anti-D immune globulin
Kleihauer-Betke (KB) test
```
maternal RBCs fixed on a slide
slide is exposed to acidic soln
adult Hb lyses
leaves "ghost" cells
dose of anti-D immune globulin is calculated from the % of remaining fetal hemoglobin
```
350
what is the standard dose of anti-D immune globulin given, and when?
300 micrograms at 28 weeks gestation usually prevents alloimmunization
- -~50% of Rh- women will need higher dose after delivery, placental abruption, or procedures
- -do KB test to determine dosage
351
what is helpful to dx PMS
symptom diary
352
what is an effective tx option for PMS
SSRIs
353
when do PMS symptoms typically occur
1-2 weeks prior to menses during the luteal phase
| --resolve with menses
354
what is management for pts with active genital herpes lesions at the time of delivery
Cesarean delivery to reduce risk for neonatal HSV
355
what should management be for pregnant women w/ h/o genital HSV infection
prophylactic acyclovir or valacyclovir beginning at 36 weeks gestation
356
distinguish between placenta previa and placental abruption
placenta previa:
- -placenta implants over internal cervical os
- -painless antepartum vaginal bleeding
- -normal fetal HR tracings
placental abruption:
- -premature separation of placenta from uterus
- -vaginal bleeding
- -distended and very tender uterus
- -fetal HR tracing abnormalities
357
what is the work-up process of secondary amenorrhea
amenorrhea for >=3 cycles or >=6 months:
beta-hCG
--positive = pregnancy
prior uterine procedure/infection?
--hysteroscopy
check prolactin, TSH, FSH
- -high prolactin = brain MRI
- -high TSH = hypothyroidism
- -high FSH = premature ovarian failure
358
how should you manage pts with uncomplicated preterm premature rupture of membranes (PROM) at <34 weeks gestation?
manage conservatively with antenatal corticosteroids and antibiotics (betamethasone) to decrease risk of neonatal RDS
delivery should occur at 34 weeks or in the setting of intrauterine infection or deteriorating fetal/maternal status
359
what is the next step in pregnancy management if first-trimester screen is abnormal
diagnostic testing with either:
amniocentesis
- -15-20 weeks
- -definitive karyotype dx
- -invasive; risk of membrane rupture, fetal injury, and pregnancy loss
chorionic villus sampling
- -10-13 weeks
- -definitive karyotype dx
- -invasive; risk of spontaneous abortion
(quadruple test is not indicated if the first-trimester screen is already abnormal, as they have similar sensitivity/specificity)
360
what are indications for endometrial biopsy, depending on age of pt
>=35
<45
>= 45
>= 35:
atypical glandular cells on Pap test
```
<45:
abnormal uterine bleeding PLUS:
--unopposed estrogen (obesity, anovulation)
--failed medical management
--lynch syndrome (HNPCC)
```
>=45:
abnormal uterine bleeding
postmenopausal bleeding
361
how do you manage persistent variable decelerations (occurring with >50% of contractions)
may be alleviated by maternal repositioning
362
how do you manage intermittent variable decelerations (occurring with <50% of contractions)
well-tolerated by fetus
363
what is fetal scalp stimulation used for
an attempt to induce accelerations when they are absent
--does not treat variable decelerations and could exacerbate decelerations if parasympathetic tone increases in response to the stimulus
364
what are the 2 indications for oxytocin and 3 adverse effects
indications:
- -induction or augmentation of labor
- -prevention and management of postpartum hemorrhage
adverse effects:
- -hyponatremia
- -hypotension
- -tachysystole
365
what is the most significant risk factor for precipitous labor
multiparity
366
what is likely dx in pt with preeclampsia at <20 weeks gestation, and what causes the preeclampsia
hydatidiform mole
preeclampsia is likely due to abnormal placental spiral artery development,
which causes placental hypo perfusion, placental ischemia, and maternal hypertension
367
what are 5 modifications that can be done ro reduce risk of ovarian cancer in a pt with BRCA mutation
bilateral salpingo-oophrectomy
(recommended as soon as child-bearing is complete)
oral contraceptive use
age <30 at first live birth
breastfeeding
tubal ligation
368
what does the workup for a pt with decreased fetal movement
pt should undergo antenatal fetal testing with a non stress test (NST)
followed by a biophysical profile or contraction stress test if the NST is nonreactive
369
which lab value is helpful for monitoring growth-restricted fetuses (estimated fetal weight <10th percentile)
umbilical artery flow velocimetry
370
what is the screening test for ovarian cancer in an asymptomatic, average-risk pt without an adnexal mass?
no screening test for these pts
ovarian cancer is most commonly dx in advanced stages and therefore has high mortality rates
371
what is the cause of initial irregular and anovulatory cycles in adolescents, aka "abnormal uterine bleeding" following menarche
hypothalamic-pituitary-gonadal axis immaturity and insufficient secretion of GnRH
372
what is dx in pt with painless lesion that begins as a papule and converts to a nonexudative ulcer with indurated borders; may have mild-moderate bilateral lymphadenopathy
primary syphilis
373
what is dx in intrauterine fetal demise associated with growth restriction, multiple limb fractures, and a hypo plastic thoracic cavity
type 2 osteogenesis imperfecta
- -auto dominant
- -defective type 1 collagen synthesis
- -decreased bone density and increased fragility
374
what is dx in intrauterine fatality that presents with pulmonary hypoplasia, limb deformities (clubfoot, hip dislocation, but not limb fractures) and oligohydramnios
potter sequence
375
what is the most common cause of Potter sequence
urinary tract abnormalities (bilateral urinary agenesis, PKD)
376
what causes amenorrhea in a breastfeeding female
elevated prolactin levels inhibit GnRH release, thereby suppressing LH and FSH production
--anovulation and amenorrhea
377
what is hypotension 2/2 epidural anesthesia caused by
blood redistribution to the LE and venous pooling from sympathetic blockade of nerves responsible for vascular tone
- -decreased venous return to the R heart
- -decreasded cardiac output
378
how can you prevent hypotension 2/2 epidural anesthesia? treat it?
prevent:
aggressive IV volume expansion prior to epidural placenta
treat:
- -left uterine displacement (pt positioning) to improve venous return from the IVC
- -additional IV fluid bolus
- -vasopressor administration
379
what is dx in post-abortion pt with fever, chills, abdominal pain, sanguinopurulent vaginal discharge, boggy, tender uterus w/ dilated cervix, and pelvic ultrasound showing retained parts of conception, thick endometrial stripe
septic abortion
380
what are the 3 things to manage septic abortion
IV fluids
broad-spectrum Abx
suction curettage
381
what should you do after dx and removal (suction curettage) of hydatidiform mole
serial beta-hCG monitoring to ensure it's decreasing/undetectable for at least 6 months
--this also means contraception for 6 months so a pregnancy does not interfere with beta-hCG levels
you need to monitor the pt because they're at risk for gestational trophoblastic neoplasia
382
what is the term for the longitudinal axis of the fetus is perpendicular to the longitudinal axis of the uterus
transverse lie
| --can be either back up (with the spine toward the maternal head) or back down (with the spine toward the cervix)
383
what is the management of a transverse lie
it's typically transient prior to term
- -most fetuses spontaneously convert to breech or vertex presentation
- -ultrasound at 37 weeks to determine delivery management
384
how close does the placenta have to be to the cervical os to be considered placenta previa
<2 cm from the cervical os
>2cm from the cervical os is not considered placenta previa and does not require Cesarean delivery
385
what is dx in postpartum pt with difficulty ambulating, radiating suprapubic pain, pubic symphysis tenderness, and intact neuro exam with a traumatic delivery
pubic symphysis diastasis
386
what is management for pubic symphysis diastasis
conservative:
NSAIDs
physical therapy
pelvic support
--most pts recover within 4 weeks postpartum
387
what is dx in pt with adhesions and powder-burn lesions/nodules
endometriosis (AKA "chocolate cysts")
388
what is management of asymptomatic vs symptomatic endometriosis (incidental finding)
asymptomatic:
observation
symptomatic:
- -conservative management includes NSADs, OCPs, a progesterone IUD
- -definitive tx includes surgical resection and hysterectomy with oophorectomy
389
what is MOA of leuprolide
GnRH agonist
- -suppresses estrogen stimulation of endometrial tissue
- -poorly tolerated due to menopausal symptoms
390
what is dx in pt with amenorrhea, diffuse abdominal pain, and hemodynamic instability, possible bleeding
ruptured ectopic pregnancy
391
what symptoms accompany blood in abdomen and pelvis (ex ruptured ectopic pregnancy)
syncope, hypotension, tatty
irritation of nearby structures:
- -diffuse abdominal pain
- -cervical motion tenderness
- -shoulder pain (referred from diaphragm)
- -urge to defecate (blood in posterior cul-de-sac)
392
what 5 conditions can minors (<18yo) be medically emancipated for
emergency care
STD
substance abuse (most states)
pregnancy care (most states)
contraception
393
what are 4 first-line, 2 second-line, and 5 contraindicated antihypertensives in pregnancy
First line (safe):
- -methyldopa (alpha-2 agonist)
- -beta blocker (labetalol)
- -Hydralazine (arterial vasodilator)
- -CCB (nifedipine)
Second line:
- -Thiazide diuretics
- -Clonidine
Contraindicated:
- -ACE inhibitors
- -ARBs
- -Aldosterone blockers
- -Direct renin inhibitors
- -Furosemide
394
describe the contractions in a false labor vs latent labor in terms of timing, strength, pain, and cervical change
false labor:
- -irregular, infrequent timing
- -weak strength
- -no/mild pain
- -no cervical change
latent labor:
- -regular, increasing frequency timing
- -increasing intensity strength
- -painful
- -cervical change
395
what is dx in pt postpartum (mole, normal pregnancy, or spontaneous abortion) with enlarged uterus, irregular vaginal bleeding, pulmonary symptoms, and multiple pulmonary infiltrates on CXR
choriocarcinoma
- -metastatic form of gestational trophoblastic neoplasia
- -dx confirmed w/ elevated beta-hCG
396
what is dx in pt with rapid cessation of breastfeeding, bilateral fullness and tenderness, no erythema, and afebrile
engorgement
| --milk production exceeds release
397
how do you manage a pt's desire for lactation suppression 2/2 engorgement
NSAIDs, supportive bra, avoid nipple stimulation/manipulation, and ice packs
--Dopamine agonists (bromocriptine) inhibits prolactin secretion from anterior pituitary to suppress lactation, but is no longer approved by the USFDA for lactation suppression due to side effects
398
what is dx in pt with recurrent pregnancy loss, prior TIA
thrombophilia/hypercoagulability
--Antiphospholipid syndrome is an autoimmune disorder that presents w/ pregnancy complications or VTE/arterial thrombosis due to membrane antiphospholipid antibodies
399
what is the next step in management after pt presents with signs/symptoms of ectopic pregnancy
dx is made by a positive pregnancy test and transvaginal ultrasound showing the gestational sac at an ectopic site
400
when do you use laparoscopy vs laparotomy
laparoscopy:
gold standard tx for ruptured ectopic pregnancy which presents with diffuse abdominal pain and eventually hemodynamic instability
laparotomy:
may be considered in pts with acute bleeding
401
what is the first-line treatment for Candida vaginitis
```
oral azole (fluconazole)
--intravaginal agents are equally efficacious, but pts prefer oral over intravaginal
```
(oral nystatin is only used for oral candidiasis; intravaginal nystatin would treat Candida vaginitis though)
402
what is the best way to diagnose uterine fibroids
ultrasound of pelvis
403
what is best management for uterine procidentia (a form of pelvic organ prolapse) in a poor surgical candidate
pessary
404
what are 3 causes of hyperandrogegism in pregnancy
luteoma
theca luteum cyst
Krukenberg tumro
405
what is dx in pregnant pt wth hyerandrogenism, bilateral solid ovarian masses on ultrasound, and metastasis from primary GI tract cancer; fetal virilization risk?
Krukenberg tumor
| --high fetal virilization risk
406
what is dx in pregnant pt with hyperandrogegism, bilateral solid ovarian cysts on ultrasound; associated with molar pregnancy and multiple gestation; and regress spontaneously after delivery; fetal virilization risk?
Theca luteum cyst
| --low fetal virilization risk
407
what is dx in pregnant pt with hyperandrogegism, yellow-yellow/brown masses (often w/ areas of hemorrhage) of large lutein cells; solid ovarian masses on ultrasound (50% bilateral); and regress spontaneously after delivery; fetal virilization risk?
Luteoma
| --high fetal virilization risk
408
what is proper tx for asymptomatic pt who tests positive for chlamydia but negative for gonorrhea using nucleic acid amplification testing?
gonorrhea only?
Chlamydia only:
Azithromycin only
Gonorrhea only:
Azithromycin + ceftriaxone
409
how should a pt deliver if they have a history of a classical Cesarean delivery or extensive myomectomy for leiomyoma removal
delivery requires laparotomy and delivery
--labor and vaginal delivery are contraindicated due to significant risk of uterine rupture
410
what is dx in pt with decreased urethral sphincter tone; urethral hypermobility
stress incontinence
411
what is dx in pt with detrusor hyperactivity
urge incontinence
412
what is dx in pt with impaired detrusor contractility (bladder atony); bladder outlet obstruction
overflow incontinence
413
```
distinguish between vaginal squamous cell carcinoma vs clear cell adenocarcinoma with:
epidemiology
risk factors
location
clinical features
dx
```
Squamous cell:
- ->60yo
- -Risk factors: HPV 16 or 18; h/o cervical dysplasia or cancer; smoking
- -Located: upper 1/3 of posterior vaginal wall
Clear cell adenocarcinoma:
- -<20yo
- -Risk factors: in utero exposure to diethylstilbestrol
- -LocateD: upper 1/3 of anterior vaginal wall
clinical features are the same:
- -malodorous vaginal discharge
- -postmenopausal or postcoital vaginal bleeding
- -irregular mass, plaque, or ulcer in vagina
Dx:
--biopsy
414
what is the rule for pregnant women making decisions for their unborn children
a woman who has mental capacity has the right to refuse treatment, even if it places her unborn child at risk
--maternal autonomy supersedes the rights of the unborn child while it is still physically attached to her
415
what is the best way to evaluate proteinuria when testing for preeclampsia
urine protein-to-creatinine ratio or a 24-hour urine collection for total protein (gold standard)
416
what is dx in pt with ultrasound findings of a solid mass with thick sepations, ascites/peritoneal fluid
epithelial ovarian carcinoma
| --presents with bloating and pelvic pain
417
what is dx in pt with confusion/encephalopathy, ataxia, and horizontal nystagmus and bilateral abducens palsy
Wernicke Encephalopathy
418
what is the etiology and 3 associated conditions of wernicke encephalopathy
Thiamine deficiency
chronic alcoholism (most common)
malnutrition (anorexia nervosa)
Hyperemesis gravidarum
419
what is dx in pt with hyperemesis gravidarum, enlarged uterus, and bilaterally enlarged ovaries
complete hydatidiform mole, a type of gestational trophoblastic disease
420
what causes the enlarged ovaries in a hydatidiform mole
the gestation is composed of proliferative trophoblastic tissue that secretes high levels of beta-hCG
the markedly elevated beta-hCG levels cause hyper stimulation of the ovaries and formation of theca lutein cysts, which are large, bilateral, multilocular ovarian cysts
421
what is dx in pt with pharyngitis with fever and lower abdominal pain in a young, sexually active female
gonococcal pharyngitis with PID
--Neisseria gonorrhea is common STD that can cause cervicitis leading to PID; and pharyngitis occurs during urogenital contact
422
what is dx in newborn with large anterior fontanel, thin umbilical cord, loose skin, and minimal subcutaneous fat
fetal growth restriction
423
what evaluation step is included when a growth-restricted fetus is born
evaluation includes histopathologic examination of the placenta to asses for infection and/or infarction
424
what dx should you consider/suspect in a pt with recurrent candidiasis in an otherwise "normal" pt
diabetes mellitus
--candidiasis risk factors are DM, immunosuppression, and Abx
425
what is dx in pt with a pregnancy loss at <20 weeks gestation prior to expulsion of products of conception; typically asymptomatic, or light vaginal bleeding; findings of closed cervix, decreasing beta-hCG; no fetal cardiac activity or empty sac
missed abortion
426
what is dx in pregnant pt with pain, bleeding, dilated cervix, and passage of some products of conception and some remain
incomplete abortion
427
what is dx in pregnant pt with vaginal bleeding, closed cervical os, and fetal cardiac activity
threatened abortion
428
what is dx in pregnant pt with vaginal bleeding, dilated cervical os, products of conception may be seen or felt at/above cervical os
inevitable abortion
429
what is surgical removal of uterine fibroids called
myomectomy
430
how do you manage epithelial ovarian carcinoma
exploratory laparotomy and resection of cancer with inspection of entire abdominal cavity
--a biopsy of the pelvic mass is contraindicated due to risk of spreading cancerous cells throughout the abdomen
431
what is smoking a cancer risk factor for
cervical cancer
432
what is dx in shoulder dystocia pt with:
clavicular crepitus/bony irregularity
decreased Moro reflex due to pain on affected side
intact biceps and grasp reflexes
Fractured clavicle
433
upper-arm crepitus/bony irregularity
decreased Moro reflex due to pain on affected side
intact biceps and grasp reflexes
Fractured humerus
434
decreased Moro and biceps reflexes on affected side
"waiter's tip" w/ extended elbow, pronated forearm, and fleeced wrist and fingers
intact grasp reflex
Erg-Duchenne palsy
damage to nerves C5-C6
435
"claw hand" with extended wrist, hyperextended metacarpophalangeal joints, flexed interphalangeal joints, and absent grasp reflex
Ipsilateral Horner syndrome (ptosis, miosis)
intact Moro and biceps reflexes
Klumpke palsy
damage to nerves C8 and T1 (hand paralysis and IL Horner syndrome)
436
variable presentation depending on duration of hypoxia
altered mental status (irritability, lethargy)
respiratory or feeding difficulties
poor tone
seizure
perinatal asphyxia
