OB + Gynecology Flashcards

Question

Plan B ELLA

Answer 1

Levongestril Take w/in 72 hrs of unprotected sex OTC or take 1 Lo-Ovral mono phasic STAT then another in 24 hrs ELLA is prescription and you can take it up to 120 hours post coitus (5 days)

Answer 2

Spring implanted into fallopian Tube to irritate it into scarring shut Recheck in 3 mo with post-procedure Salpingogram. Can be undone but thereafter a high ectopic risk

Answer 3

Methotrexate - 90% effective (2 doses) also used for ectopic pregnancy termination. Must have surgical abortion if fails d/t teratogenic effect of methotrexate. Mifepristone (RU 486) + Prostaglandin E1 (Misoprostol) A partial progesterone receptor agonist and glucocorticoid antagonist also used experimentally to treat cushigs dz. -MOST EFFECTIVE Abortion method less than 7 weeks, use up to 9 weeks in US Better than aspiration under 7 weeks. - 600 mg dose in office followed by a 400 mg dose of Misoprostol at home to encourage contractions. Can't give these in primary care, refer to Planned Parenthood or Gyne

Answer 4

Primary starts soon after Menarche. It's caused mainly by E2 cutting off the blood supply to the endometrium which causes CRAMPING, necessary to dislodge the sloughing tissue and propel it out through the cervix. NSAIDS (with proper education as to use) and caffeine are Rx mainstays. Midol contains Tylenol, which doesn't have any effect on E2 but it does relieve pain - Deb says its not her favorite but I'm not sure we want to interfere with E2's job, just make it so the resultant pain is more manageable. Secondary usually affects women over age 25 and is usually caused by Endometriosis.

Answer 5

E2 is released in response to the breakdown of endometrial tissue at the end of the Luteal phase, when the corpus runs of of progesterone to support it and a placenta has not formed to take over progesterone production. E2 constricts the blood supply to the endometrium, worsening the situation there and killing off more cells. As they die of hypoxia, they are sloughed from the mesometrium and the irritable, hypoxic uterus cramps, propelling the slough out the cervix. Ischemia Hurts. It hurts in the heart, it hurts in the muscles after a work out and it hurts in the uterus. We call it Cramps.

Answer 6

Fibroids Noncancerous MYOMETRIAL (muscle) growths that often appear during middle to late child bearing years causing either no symptoms or painful protracted menses and low back ache. Fibroids are a main reason for hysterectomy in this age group. They "retreat" after Menopause. They are round and can grow as large as a grapefruit - these can be felt through the abdominal wall, of course. Unfortunately, they do not stay IN the uterus and can grow outside it (subserosal), into its muscular walls (submucosal + intramural) and even in the broad ligament between the uterus and ovaries. It can also pedunculate from the cervix into the vagina (in statu nascendi) They do not become malignant. There ARE malignant fibroid like tumors of the uterus but they do not develop FROM the benign fibroids and having benign fibroids is not a risk for malignancy. Malignant tumors are present AFTER menopause. They do, however become life threats when they grow elsewhere in the gut, strangling the intestines. This used to be rare but is seen with increasing frequency and is thought to arise from a laparoscopic hysterectomy technique employing a MORCELLATOR which chops the uterus up into bits inside the abdominal cavity then extracts the bits (obviously not ALL of them) out through the small incision. It may not be a good idea to liberate this uterine tissue into the abdominal cavity like that when it clearly has the ability to colonize other tissues. African American decent is the biggest fibroid risk in the US with an estimated 80% of women developing fibroids by their 40s - not all are problematic. OBESITY, its related comorbidities and diet high in red meat (hormones or fat?)

Answer 7

Growth of endometrial tissue outside the uterus, usually on the outside of the uterus, the ovaries or tubes but it can migrate far. It is thought to escape the uterus during menstruation via the fallopian tubes (retrograde menstruation). There are more developmental theories though. The immune system ought to snap these bits up and dispose of them but if it is compromised, it may not. Also, there has been a huge reduction in "menstrual rest" since women no longer spend decades pregnant and that is thought to have increased the incidence of escaped endometrial tissue. The problem is that, wherever it is, endometrial tissue behaves as if its in the uterus and it BLEEDS/sloughs in response to the monthly cycle. Blood is an irritant whenever its is outside its vessels and this causes inflammation, E2 is released to deal with it all and severe cramping results Cramping can involve the low back and often radiates to the legs. Endometriosis is associated with Ovarian Cancer, Brain Cancer and Non-Hodgkins Lymphoma. Interestingly, it is NOT associated with endometrial cancer. Family Hx is the main risk but Dioxin exposure has also been implicated YOU CANNOT SEE ENDOMETRIOSIS ON SONOGRAM. YOU MUST DO A LAPAROSCOPIC INVESTIGATION AND BIOPSY THE TISSUE. PROGESTERONE inhibits endometrial growth and so progestagin therapy is an option for management. Other Estrogen Blockers are employed. This is an old disorder, not new. Hippocrates was prescribing early marriage and child bearing to women ages ago so as to resolve maladies of the uterus. Indeed VAGINAL (not c-section) Childbirth reduces recurrence (perhaps by widening the cervical opening and making it the easier way out?) Unfortunately, infertility does result from endometriosis.

Answer 8

Endometrial growth INTO the Myometrium

Answer 9

Sonogram Sonos for all dysmenorrhea in sexually active females. You can ID: ``` Pregnancy Ectopic Ovarian Cyst Torsion Fibroids ``` You CANNOT see ENDOMETRIOSIS on Sono

Answer 10

Pelvic Exam Tender? RX for PID Didn't resolve pain? Sono Find something on Sono? Laparoscopy + Biopsy to ID tissue

Answer 11

Cover all the likely stds: 250mg of Cephtriaxone IM 1mg of Axithromycin PO in office Send her out the door with a 10 day supply of Doxy 100mg BID for syphillis and whatever else might be in there.

Answer 12

Fluoxitine days 16/18- Menstruation Now FDA approved (SaraFem) B6, 100 mg daily Mg, 200-360 mg daily You may be able to back off the SaraFem once the vitamin regimen is well underway. If this doesn't work, work up for major depressive disorder, might need SSRIs all month? OR.... check their hormone levels and consider bioid progesterone therapy...

Answer 13

Premenstrual Dysphoric Disorder PMS on steroids... Especially last two days before menstruation. Monophasic BC (Yaz or Effexor) Check hormone levels and consider progesterone Consider Fluoxitine daily? This is in the DSMIV Major risk of bipolar disorder

Answer 14

Adhesions + Endometriosis

Answer 15

Shoulder Pain from Blood, Gas or other irritant in the Peritoneal Cavity. Worse when lying down with legs raised and that spreads the blood/irritant around and manages to really irritate the phrenic nerve, hence the shoulder pain. With ectopic, the irritant is blood, possibly lots, that's why they pass out.. Left Shoulder Kehr is classic for ruptured spleen

Answer 16

Pregnancy Test (dip stick in office) and clean catch for Qualitative b-HCG serum test Anything over 1500 should show up on a pelvic Ultra Sound. If it doesn't show, and there's pain/spottig its ectopic untilproven to have implanted appropriately Transvaginal or Pelvic Ultrasound looking for mass in the tubes and uterus and elsewhere (could be outside in the peritoneal cavity!)

Answer 17

Ectopic pregnancy where b-HCG less than 5000 Over 5000 the fetus is too big and could cause a rupture before methotrexate works. Ectopic Mass on sono is less than 3.5 cm - anything larger is an imminent rupture risk. No Kidney or Liver Dz - these contraindicate Methotr. Pt is Hemodynamically Stable - If Bp + HR are at all unstable, surgically remove the ectopic Methotrexate takes a while to work but serial b-HCGs should drop by 25% within 7 days of administration IF its working. If it isn't, give it again, check b-HCG and re-administer up to 3X. If b-HCG doesn't fall after the third time, surgery is indicated. Even if it works, Methotrexate takes months to complete and you have to keep having the patient come back for b-HCGs until she's back to baseline (5 Units/mL). Still, Methotrexate carries no risk of causing adhesions and is thus preferable to surgery if the patient is suitable.

Answer 18

Blighted Ovum 50% of all miscarriages that are not d/t chromosomal anomaly are blighted ova. The mother may not even be aware of these miscarriages as they would be flushed with the normal period or perhaps just a little late.

Answer 19

15-20% !!! Miscarriage is common, very. 50% are d/t chromosomal anomaly. Half the remainder are Blighted Ova and the remaining 25% have mixed etiologies but Progesterone deficiency is a big one. If progesterone does not rise with HCG the pregnancy cannot be sustained even if there is no chromosomal anomaly so, if you patient wants to be pregnant and is spotting in the 1st trimester, along with her quantitative HCG, get her Progesterone levels. If its low for the gestational age, supplement with transvaginal Progesterone suppositories. Of course supporting a genetically doomed pregnancy with progesterone may be a bad idea but that is a call for the specialists in OB, not you in PC. Put her on the progesterone (DMII may be a contraindication) and refer her. They will test the chromosomes and decide whether or not to continue to support the pregnancy.

Answer 20

If the cervix is closed and there is spotting, the pregnancy may be saved by bed rest and progesterone suppositories. If the cervix is open, the pregnancy is doomed If its open and the "Products of Conception" are visible, the miscarriage is either complete or partial (underway). Send the "product" to the lab and schedule a Sono to ensure no "bits" remain to cause infection. Follow your pt's b-HCG until its back to normal (5 U/mL) If its only partially complete, the pt needs a D+C to clear the product from the womb.

Answer 21

Give her Rho-Gam at 28 weeks and whenever you do an invasive intervention like amniocentesis that might mix fetal blood cells with maternal cells and then dose her again within 3 days of birth. This will protect the next Rh(+) baby from being attacked by mom's antibodies.

Answer 22

Bluish Vulva/Cervix of Pregnancy Also a BOGGY UTERUS is a physical sign on exam of early pregnancy.

Answer 23

An abnormal situation in which an unfertilized egg implants in the endometrium and grows. Complete Mole: An egg with no maternal DNA is fertilized by 1-2 sperm and implants into the uterine lining and begins to grow. It can't become a fetus but it knows enough to divide and grows into a mass. 20% of Complete Mole Pregnancies just keep growing, becoming aggressively malignant. These look like clusters of grapes or a Snow Storm Pattern on Sonogram Partial Moles: These usually have 3 complete sets of DNA. The mothers and two sets of the father's DNA, either from two sperm or d/t the father's DNA spontaneously duplicating on entering into the egg. Partial Moles may in fact result in a fetus growing in the uterus with the tumor. There is the potential for malignancy. It could also just be a missed miscarriage where the pregnancy became non-viable but just wasn't expelled. these don't continue to grow. You can spot this because the b-HCG on these goes wild, much higher than it is supposed to be. Also the Malignant Completes metastasize If not metastatic, D+C is the Rx. If b-HCG doesn't plummet after D+C, STAT Hysterectomy is in order to prevent metastasis

Answer 24

Molar Pregnancy Look for uterus bigger than expected for gestational age and b-HCG higher than expected for gestational age

Answer 25

Fasting BG of over 126 Random BG of over 200 A1C of over 7 Glucose Tolerance of over 140 Gestational Diabetes predisposes the mother to DMT2 later in life but for the fetus, the risks are the same as for being born to a woman who had diabetes before becoming pregnant

Answer 26

Hypoglycemia @ birth - Fetuses of diabetic mothers are constantly exposed to high sugars. This causes them to up regulate Insulin production and down regulate Glucagon. This results in baby being able to process all that sugar while in utero but leads to underdevelopment of the response to low blood sugar (because the fetus never encounters this phenomenon) so its alpha cells and liver do not produce and store Glucagon for a crisis and, a sugar crisis (in the form of birth) is coming. When normal babies are born and cut off from Mom's blood sugar supply, their own glucagon levels skyrocket and stay high until colostrum or formula is taken in. When babies of diabetic women are born, not only is there is no glucagon peak but they have learned to maintain an abnormally high insulin level in utero - No sugar source, no glucagon and extra insulin add up to hypoglycemia pretty fast - its a 911 if not planned for in advance and addressed immediately at birth. Diabetes makes a pregnancy high risk for mom (pre-eclampsia and later DMT2) and for baby... Mom's RBCs are all hyperglycosylated (bound to sugar) and sugared up Hb doesn't carry O2 very well, risking hypoxia (and brain damage) in baby. Baby adapts by making more RBCs so each scrap of O2 can be snagged. All well and good but extra RBCs clog up the works and bump into each other and become raggy. They get broken down in the brand new spleen and suddenly the little hepatic system os overwhelmed with breakdown products of RBCs and the baby is jaundiced even before birth just for having too much bilirubin for his liver to process, even if his liver is mature it just can't handle that much.

Answer 27

Baby over 8lbs 12 ounces

Answer 28

Fetal Insulin blocks the production of surfactant in fetal lung tissue. In a normal baby late in development the adrenals come online and secrete enough cortisol to oppose insulin's suppression of surfactant synthesis in the lung. Surfactant is made and the baby is born ready to breathe. In the fetus of a diabetic woman, there is so so much insulin in play in order to manage the mother's high BG that the baby's adrenals cannot produce ENOUGH cortisol to overcome insulin's effect in the lung and surfactant continues to be suppressed even to full term. Thus is a full term macrocosmic baby of a diabetic woman similar to a preterm baby - no surfactant, not ready to breathe at birth, high risk of Acute Respiratory Syndrome. For this reason, the surfactant level of a diabetic woman's fetus needs to be followed in late pregnancy and she must be treated with betamethasone if surfactant isn't online by 38 weeks. The stress of compression through the birth canal typically causes a burst of cortisol from a normal baby's adrenals which in turn produces a surge in surfactant just as baby is being born and getting ready to scream. A C-Section baby, diabetes or not, doesn't get that surge of surfactant and is less ready to breathe than a vaginally delivered baby. A diabetic C-Section baby has two strikes against him in the respiration department at birth in that hyperinsulemia reduced his surfactant production before birth and C-Section delivery side-stepped his cortisol/surfactant surge from delivery compression.

Answer 29

No surfactant at birth, risk of ARDS Treat with betamethasone

Answer 30

Bigger babies have bigger shoulders If they get stuck in a vaginal birth, the OB may have to break the clavicle(s) to get those shoulder(s) through. If they opt for C-Section to avoid that, there is still the problem of not being squeezed in the birth canal and missing out on the cortisol/surfactant surge that creates. Don't be hyperglycemic during pregnancy

Answer 31

They have a surprisingly high risk of cardiomegaly and heart failure as well as The most frequent cardiac anomalies in IDMs include ventricular septal defect, transposition of great arteries and aortic stenosis. Defects involving the great arteries, including truncus arteriosus and double outlet right ventricle, are also more prevalent in IDMs Neonatal Echocardiography and septal thickness measurement is in order for fetuses of Diabetic Women

Answer 32

Before 36/37 weeks actual cut off is disputed Labor before 36 weeks WITH: - Dilation and/or - Effacement If there is bloody/watery discharge test it to confirm it's Amniotic Fluid and, if it is, watch maternal temp for infection

Answer 33

50% of babies born with CP are premature So many things increase risk of even a normal infant sustaining brain damage before or during birth that could result in cerebral palsy but premature birth is a solid risk. Asphyxia during after or prior to birth is the other big risk -Maternal Shock + Hemorrhage - Placental Complications (Abruptio, Previa, Prolapse) Infection/Inflammation - may increase oxygen demands that, if unmet, lead to brain damage. Specific bugs: -rubella – German measles -toxoplasmosis – infection caused by parasite -herpes – sexually transmitted disease -chorioamnionitis – inflammation of fetal membranes due to bacterial infection

Answer 34

Less than 5 lbs 8 ounces or 2500 grams

Answer 35

Fetal Fibronectin This is a sticky protein that is normally present in amniotic fluid early and in the last two weeks of pregnancy. It should not be there between. Its presence is 95% accurate for delivery within 2 weeks If you find it before 36 weeks, give the woman MgSO4 and/or Terbutaline (B2 Antagonist) to slow onset of labor and begin treating with IV Betamethasone to ripen the lung tissue into producing surfactant in anticipation of an early delivery.

Answer 36

Bacterial Vaginosis d/t Gardnerella Give Metronidazole, 500 mg BID 7-10 days if drinkers, give Clindamycin Cream or MetroGel

Answer 37

Triple Screen for: Yeast BV Trich

Answer 38

Tests for Genetic Anomalies in pregnancy | mainly Trisomy anomalies

Answer 39

MgSO4 (Ca channel blockade somehow) Terbutaline (Beta 2 Antagonist) Nifedapine (CCB)

Answer 40

Premature Rupture of Membranes Main cause of premature birth If over 36 weeks, induce labor within 24 hrs If under 36 weeks: Stave off labor and ripen lungs Keep mom in bed, Trendelenberg if necessary while you give IV steroids and monitor maternal temp for fever, giving IV ABX if it appears. Give MgSO4/Terbutaline/Nifedapine to stave off active labor while the steroids work on the lungs.

Answer 41

The appearance of dried amniotic fluid on a glass slide under the microscope

Answer 42

For Amniotic Fluid in Vaginal Secretions: If Yellow, no Amniotic Fluid present If Blue, Amniotic Fluid is present

Answer 43

Preeclampsia Rx is Methyl Dopa for HTN 250-500mg BID PO Trial of labor may cause Bp to skyrocket so these women get sectioned in a facility with a NICU Test the proteinuria with micro albumin test, much more sensitive Most common in nulliparous women under 17 and over 35

Answer 44

``` H-Hemolysis E-Elevated L-Liver Enzymes L-Low P-Platelets ``` HELLP is a complication of Preeclampsia. ``` Suspect it if: Epigastric or RUQ pain N/V Signs of Preeclampsia (HTN, Edema, Proteiuria) Pulmonary Edema ``` This is serious business so if that baby is over 34 weeks, get ready to deliver it C-Section. See if you can control symptoms with MgSO4/Nifedapine/Terbutaline long enough to get enough steroids in to ripen those lungs but get ready for an emergency C-Section

Answer 45

16, 18 (guardisil) 31,33,45 6 + 11 (guardisil)

Answer 46

Polymerase chain Rxn Chlamydia GC Better than bacterial culture

Answer 47

BLOOD MARKER FOR OVARIAN CANCER mildly elevated in all gyne inflammation

Answer 48

Non-Treponal Antibody Test - Initial Syphilis Screen - Highly Sensitive but Non-Specific for syphilis, have to do RPR if +. This tests for Antibodies that will disappear 3 or so years after syphilis is successfully treated, so it can be used to dx a second case of syphilis Treponal Antibody Test is highly specific for syphilis but tests for IgG Antibodies, which will remain for life after someone is cured of syphilis, this test cannot be used to dx a second case of syphilis after the first is cured. It CAN dx the first case. RPR - Rapid Plasma Reagent for confirmation when Non-Treponal Antibody Screen is (+) and to monitor the effectiveness of syphilis treatment by serial AB measurements. VDRL on CSF for NeuroSyphilis

Answer 49

The SYPHILIS spirochete, ugly cousin of the Borrelia Burgdorfi spirochete of Lymes disease. Both can get into the CSF

Answer 50

Inability to contract. The main cause of postpartum bleeding ``` Oxy during labor can cause it MgSO4 can do it Retained Placenta HUGE baby FULL bladder MANY pregnancies (full term - stretching) Lots more... ``` Rx for Post Partum Bleeding is UTERINE MASSAGE and PITOCIN IM/IV. If that doesn't work, give a prostaglandin (METHYLPROSTAGLANDIN) but not to Asthmatics as it will cause smooth muscle contraction in the bronchioles as well.

Answer 51

Retained Placenta: Normally the placenta adheres to the base membrane of the uterine lining, the ENDOmetrium Accreta: Placenta is firmly attached to the MYOmetrium but has not grown INTO the muscular layer. Often d/t uterine scar: prior C-Section or prior D+C 75% of retained placentae are Accreta. If diagnosed before birth, C-Section with D+C or hysterectomy are the Rx Increta: The placenta grows INTO the Myometrium 20% Again, C-Section but need for hysterectomy increases Percreta: The placenta grows THROUGH the MYOmetrium and through the SEROSA, the Uterine Covering. This requires hysterectomy Ultrasound in the 2nd/3rd trimesters makes the DX and differentiates between severities. MRI can help if Ultrasound is vague.

Answer 52

Means likely PID AKA: Chandelier Sign MucoPurulent Discharge also Likely Test for Gonorrhea, Chlamydia Rx: 250mg Cephtriaxone IM in the office and 10-14 days of Doxy 100mg BID. We were trained 1mg Azithromycin (4 250mg tabs in the office at that visit) but that's more for males. In contrast to Chlamydia Urethritis in males, PID in women is a DEEP infection and we really need good penetration. Plus Doxy will also cover Syphilis, which she could have an not yet know.

Answer 53

STDs, most particularly CHLAMYDIA

Answer 54

What happens?? Chlamydia and/or Gonorrhea inflame the liver capsule and adhesions form between it and the parietal peritoneum. We call it FITZ-HUGH-CURTIS Syndrome It presents rather like cholecystitis in that it is RUQ pain that may radiate to the left shoulder but timing is wrong in that it has no relation to eating. Deep breaths, coughing and laughing aggravate. It presents essentially as RUQ pleuritic pain. Ultrasound is usually inconclusive, unless there are incident gallstones, which may misdirect the DDX and result in surgery. At least if this does happen, the liver/peritoneal adhesions may be seen. Cervical testing for Chlamydia (5X more likely) and Gonorrhea confirm the Dx and the usual treatment is administered for PID. If the Dx was made without actually trying to take out the GB and antibiotics don't fix the pain, endoscopic surgery can release the adhesions.

Answer 55

VOLUME: Plasma and RBCs increase but plasma increases more. Overall volume increase is 30-40% or around a 2L increase (normal being 4.5 - 5.5 L). It is diluted though so Hb usually drops to around 10.5 from normal of around 14. HCT/Hb drops from 42/14 to 34/10.4 WBC increases from 4-10.5 to 5-20 as there's lots more to be tickling the immune system RBCs stay the same, that's why the volume increase is dilution. Its also why some pregnant women become less exercise intolerant (that and a huge belly and back strain...) COAGULATION FACTORS increase with the increased plasma including Fibrinogen.

Answer 56

Mullerian Dysgenesis or Agenesis 46,XX (normal chromosome number) but there is a genetic substitution that causes the uterus cervix and vagina to be affected - the patient is otherwise normal and has ovaries so they do enter into puberty but no menstruation. It is the cause of 15% of primary amenorrhea cases. Rx is surgical vagina. Procreation possible via removal of eggs surgically and surrogacy.

Answer 57

Turner Syndrome Webbed Neck Small Stature Low estrogen due to genetically depleted primordial follicles

Answer 58

Asherman's syndrome

Answer 59

Low estradiol Increased FSH Increased LH The message is being sent but Ovaries are Not responding. Interestingly, this is the same in MENOPAUSE

Answer 60

PROM - Premature Rupture of Membranes 34 is the Magic Week... Before 34 weeks: Save the pregnancy if you can. Admin Corticosteriods to mature the alveoli and IV Amox or Ampicillin to forestall infection. After 34 weeks, proceed to delivery either by induction or C-Section Tocolysis (pharmaceutical suppression of labor) is not recommended. Terbutaline (B2 agonism), Nifedipine (peripheral Ca++ blocker relaxes smooth muscle) and/or MgSO4 are not recommended for PROM

Answer 61

pH: Use Nitrazine Paper!!! Amniotic Fl is usually a bit basic pH7-7.5 whereas Vaginal Secretions should be acidic 4.5 - 5.5. Pee is usually 5 but should not be in the Vagina from which you will retrieve your sample. NITRAZINE paper is YELLOW at pH 5 (normal vaginal secretions) and turns OLIVE as pH moves on toward 6. Beyond pH 6 it becomes increasingly GREEN-BLUE, turning BLUE-Grey at pH7. By pH 7.5, which would be taken as pure amniotic fluid, the paper would be DEEP BLUE. FERNING: amniotic fluid ferns on a slide when dry, lots of protein.

Answer 62

Think PITUITARY ADENOMA Test SERUM PROLACTIN - You'll need support to MRI If Prolactin is Elevated, you can MRI the Pituitary. If there is an ademona (more specifically a PROLACTINOMA), BROMOCRIPTINE is the drug of choice Dopamine normally inhibits Prolactin and Bromocriptine is a Dopamine Agonist Prolactin reigns in normal lactation when the body is invested in not getting pregnant. Prolactin suppresses estrogen so follicles do not develop. It also suppresses Testosterone. Sex drive may decrease, vaginal dryness may cause painful intercourse and osteoporosis is a risk.