OB, UST Revalida Review Flashcards
OB History
G P (TPAL)
Rule for EDD
Naegele’s Rule +7 -3
Fundic height measurement starts at
16-18 weeks AOG
Leopold’s manoeuvre starts at
28-30 weeks
LM 1
Fundal grip
LM 2
Umbilical grip
LM 3
Pawlik grip
LM 4
Pelvic grip
Leopold’s maneuvers
Level of uterus-AOG: Symphysis pubis
12 weeks
Level of uterus-AOG: Midway between symphysis pubis and umbilicus
16 weeks
Level of uterus-AOG: Umbilicus
20 weeks
Adnexa cannot be evaluated if the uterus is ___ months size
3 months
Consistency of cervix if pregnant
Soft
Probable signs of pregnancy
1) Abdominal enlargement 2) Ballotement (20th week) 3) Braxton-Hicks contractions (28th week) 4) Outlining of fetus 5) (+) pregnancy test 6) Hegar sign 7) Goodell sign 8) Softening of cervix 9) Beaded pattern of cervical mucus
Softening of uterine isthmus
Hegar sign
Cyanosis of cervix
Goodell sign
When Goodell sign is appreciated
4 weeks
When softening of cervix is appreciated
6-8 weeks
Beaded cervical mucus is an effect of what hormone
Progesterone
Onset of elevated β HCG in pregnancy
8-9 days after ovulation
Peak of elevated β HCG in pregnancy
60-70 days
Nadir of β HCG in pregnancy
14-16 weeks
Positive signs of pregnancy
1) FHT 2) Perception of active fetal movement by the examiner 3) Recognition of embryo or fetus by ultrasound
FHT-weeks: TVS
6-8 weeks
FHT-weeks: Doppler
10-12 weeks
FHT-weeks: Stethoscope
18 weeks
When active fetal movement is perceived by examiner
20 weeks
UTZ-weeks: Gestational sac
4-5 weeks
UTZ-weeks: Fetal heart beat
6-8 weeks
CRL is predictive of gestational age up to ___ weeks
12
Most accurate determinant of gestational age
1st trimester ultrasound
LMP may be used in determining gestational age if difference from early ultrasound is
Less than 2 weeks
Danger signs of pregnancy
1) Persistent headache 2) Blurring of vision 3) Persistent nausea and vomiting 4) Fever and chills 5) Hypogastric pain 6) Decreased fetal movement 7) Dysuria 8) Bloody vaginal discharge 9) Watery vaginal discharge 10) Edema of hands and feet
When to request: TVS for fetal viability and aging
Less than 12 weeks
When to request: Fetal biometry
> 13 weeks
When to request: BPS
28 weeks
Physiologic anemia, 1st, 2nd, and 3rd trimester respectively
Less than 11 g/dL; less than 10.5 g/dL; less than 11 g/dL
WBC level in pregnancy
Leukocytosis
When to request HBsAg
Near term
What tests to request on the first visit
1) UTZ 2) CBC 3) Blood typing 4) UA 5) HBsAg if near term 6) Pap smear 7) GDM screening
Caloric requirements in pregnancy
1st trim: 2000 kcal/day 2nd trim: 2300 kcal/day 3rd trim: 2300 kcal/day
Normal weight gain pregnancy
25-35 pounds or 1 pound per week; 2 pounds in 1st trimester, 11 lbs each in the 2nd and 3rd trimester
Iron requirement for the entire pregnancy
1g
Breakdown of 1g iron need for pregnancy
300 mg: fetus and placenta 500 mg: expanding maternal hgb mass 200 mg: excreted
Amount of daily elemental iron required in pregnancy
30 mg
Required daily calcium supplementation in pregnancy
400-900 mg
Daily zinc requirement in pregnancy
12 mg
Impairs phosphorus absorption
Antacid
Daily folate requirement in pregnancy
350 mcg/day
Frequency of prenatal check up
1) Monthly until 28 weeks 2) Every 2 weeks until 36 weeks 3) Weekly 37 weeks onwards
Criteria for preterm labor
1) After 20 weeks, before 37 weeks 2) Regular contractions (4 in 20 minutes) 3) At least 1 of the following: Progressive cervical changes, cervical dilatation of 2 cm or more, effacement of 80% or more
Preterm labor: Etiology
1) Infection 2) Low socio-economic and nutritional status 3) Maternal factors: Uterine anomalies 4) Fetal factors: Multiple pregnancies, PROM, congenital malformations
Preterm labor: Predictors
1) Biochemical: Fibronectin and estriol 2) Sonographic: Cervical funnelling (YVU on sonography) and cervical length
Cornerstone in management of preterm labor
Forestall preterm delivery
Management of preterm labor
1) Tocolysis 2) Bedrest 3) Treat underlying infection
Preterm delivery should be delayed for only how long
At least 48 hours to allow steroids to work
Tocolytics
1) Beta agonist (ritodrine, terbutaline, isoxuprine) 2) MgSO4 3) CCB (nifedipine, nicardipine) 4) PG inhibitors (indomethacin, naproxen)
MOA in tocolysis: Beta agonist
Reduction of intracellular Ca
MOA in tocolysis: MgSO4
Calcium antagonist
Steroid therapy is indicated at what AOG
24-34 weeks
Betamethasone dose
12 mg/IM Q24h x 2 doses
Dexamethasone dose
6 mg/IM Q12h x 4 doses
Steroid that can cause periventricular leukomalacia
Dexamethasone
When to screen for GDM: Average risk
24-28 weeks
GDM: Screening modality
Average risk - FBS, RBS, HbA1c; High risk - 75g OGTT
High risk for GDM
1) Strong family history of DM 2) Obese, BMI >30, or excessive gestational weight gain 3) Previous history of GDM, htn, metabolic syndrome, PCOS, and macrosomic infant 4) Glucosuria 5) Age >25 6) Poor OB history: Fetal demise, fetal malformation 7) Current use of steroids 8) Member of ethnic groups with high GDM prevalence (includes Filipinos)
Macrosomia, weight
> 9 lbs
Protocol for evaluation of diabetes in pregnant Filipino women
Protocol for evaluation of diabetes in High Risk pregnant Filipino women
Diabetogenic hormones secreted by placenta
1) GH 2) CRH 3) Placental lactogen 4) Progesterone
Fetal complications of GDM
o Abortion o Congenital anomalies o IUGR o Macrosomia o Hydramnios o Birth injury o Preterm delivery o Unexplained fetal death
Maternal complications of GDM
o Preeclampsia o Infections o Dystocia o Higher incidence of operative delivery o Diabetic Nephropathy, Retinopathy, Diabetic Neuropathy o Ketoacidosis
GDM management
1) Diabetic diet 2) 7-point CBG monitoring 3) Refer to endo if uncontrolled 4) Fetal surveillance
Diabetic diet: kcal/kg/day for normal body weight
30-35
Diabetic diet: kcal/kg/day for obese
24
Diabetic diet: Caloric composition
Complex carbs 40-50% Proteins 20% Unsaturated fats 30-40% Given as 3 meals and 3 snacks daily
7-point CBG monitoring
Pre-meals (3), 1 hours post meals (3), and at bedtime
Normal pre-meal CBG
70-100 mg/dL
Normal 1hr pp CBG
Less than 140 mg/dL
Normal 2hr pp CBG
Less than 120 mg/dL
When to do congenital anomaly scan
18-20 weeks
Conditions in GDM wherein early delivery is indicated
1) Vasculopathy 2) Nephropathy 3) Prior stillbirth 4) Poor glucose control
Htn in pregnancy is defined with a BP of
140/90 or higher on more than 1 occasion
Systolic BP of 140 mmHg or higher or a diastolic BP of 90 or higher on more than 1 occasion, > 20 weeks AOG, no proteinuria
Gestational Htn
Systolic BP of 140 mmHg or higher or a diastolic BP of 90 or higher on more than 1 occasion, before 20 weeks AOG and persists beyond 12 weeks postpartum; no proteinuria
Chronic Htn
Systolic BP of 140 mmHg or higher or a diastolic BP of 90 or higher on more than 1 occasion, after 20 weeks AOG; (+) proteinuria
Preeclampsia
Proteinuria level to diagnose preeclampsia
300 mg or more in a 24 hour urine specimen
Maternal risk factors for preeclampsia
1) First pregnancy 2) Age under 20 or over 35 3) High bp before pregnancy 4) Previously preeclamptic 5) Short inter pregnancy interval 6) Family history of preeclampsia 7) Obesity 8) DM 9) Kidney disease 10) RA 11) Poor protein or low calcium status
Paternal risk factors for preeclampsia
1) First time father 2) Previously fathered a preeclamptic pregnancy
Fetal risk factors for preeclampsia
1) Multifetal pregnancy 2) Hydrops/triploidy 3) Hydatidiform mole
BP in mild preeclamspia
More than 140/80
BP in severe preeclampsia
More than 160-110
Proteinuria in mild preeclampsia
>300 mg/d or > +1 dipstick
Proteinuria in severe preeclampsia
>2g/d or > +2 dipstick
Cardinal principles in the treatment of preeclampsia
1) Prevent convulsions 2) Control htn 3) Deliver at optimum time and mode
Anticonvulsant of choice in pregnancy
MgSO4
MOA of MgSO4 in preventing convulsion
Reduces cerebral vasoconstriction and ischemia
MgSO4: Loading dose
4g SIVP over 20 mins 5g deep IM on each buttocks
MgSO4: Maintenance dose
5g deep IM on each buttocks q6
MgSO4: Serum therapeutic level
4-7 mEq/L
MgSO4: Parameters to monitor
1) DTR ++ 2) RR more than 12/min 3) UO at least 25-30 cc/hour
MgSO4 toxic level: Loss of patellar reflex
10 mEq/L
MgSO4 toxic level: Respiratory depression
12 mEq/L
MgSO4 toxic level: Altered atrioventricular conduction and complete heart block
15 mEq/L
MgSO4 toxic level: Cardiac arrest
>25 mEq/L
Management for MgSO4 toxicity
Calcium gluconate 1g IV
Antihypertensives of choice to control bp in preeclampsia
1) Nicardipine 10 mg in 90cc D5W to run at 10 ugtts/min, titrate at increments/decrements of 5 ugtts/min to maintain BP of MAP 20% 2) Hydralazine 5 mg IV bolus followed by 5 mg incremental increases half hourly if DBP does not improve up to a total of 20 mg
Normal pH of the vaginal environment
3.8-4.2
Characterized by depletion of the normal lactobacillus population and an overgrowth of vaginal anaerobes accompanied by loss of usual vaginal acidity
Bacterial vaginosis
Bacterial vaginosis: Microorganism associated
Gardnerella vaginalis
Criteria for bacterial vaginosis
Amsel criteria
Components of Amsel criteria
1) Thin green or gray-white homogenous discharge 2) Clue cells 3) pH >4.5 4) Amine door with 10% KOH (Whiff test)
Amsel criteria: # of criteria to be satisfied for appropriate diagnosis
3 out of 4
Bacterial vaginosis: Treatment of choice
Metronidazole 500mg BID x 7 days
Bacterial vaginosis: Alternative regimens
1) Metronidazole 2g single dose 2) Clindamycin 300 mg BID x 7 days
Condition: Copious yellow-green frothy discharge with pruritus and dysuria
Trichomonas
Condition: (+) hyphae or spores
Candidiasis
Condition: Severe vulvar pruritus with curd-like, whitish discharge to vaginal walls
Candidiasis
Condition: Fishy odor
Bacterial vaginosis
Vaginal pH in candidiasis
Less than 4.5
Vaginal pH in trichomoniasis
>4.5
Treatment of choice for trichomoniasis
Metronidazole 500 mg BID x 7 days
T/F In trichomoniasis infection, treat sexual partner
T
Treatment for Candidiasis
1) Fluconazole 150 mg OD 2) Miconazole 100 mg vaginal suppository x 7 days 3) Clotrimazole vaginal tablet
Treatment for mixed vaginal infection
1) Miconazole + Metronidazole (Neopenotran) vaginal suppository ODHS x 7 days 2) Nystatin + Metronidazole (Flagystatin) vaginal suppository ODHS x 7 days
HPV type: Benign warts
HPV 6 & 11
HPV type: Premalignant and malignant lesions
HPV 16 & 18
Conditions that predispose to HPV infection
1) Immunosuppression 2) DM 3) Pregnancy 4) Local trauma
Treatment for condyloma acuminata
1) Podofilox 0.5% solution or gel 2) Imiquimod 5% cream 3) Cryotherapy 4) TCA 5) Electrocautery 6) Surgical excision
Podofilox: MOA
Antimitotic
Podofilox: T/F May be given in pregnant women
F
Imiquimod: MOA
Immune enhancer
Imiquimod: May be given in pregnant women
F
Cryotherapy: MOA
Thermal-induced cytolysis
Cryotherapy: Dose
Once a week for 1-2 weeks
Condyloma acuminata treatment that may be given to women
Cryotherapy
TCA: MOA
Chemical coagulation of proteins
TCA: T/F May be given to pregnant women
F
HPV serotypes covered by Cervarix
HPV 16 & 18
HPV serotypes covered by Gardasil
HPV 6, 11, 16, and 18
Cervical CA vaccination: Age group
13-26 y/o
T/F Males can be given cervical Ca vaccination
T
Genital ulcers, syphilis: Incubation period
2-4 weeks
Genital ulcers, syphilis: Primary lesion
Papule
Genital ulcers, syphilis: # of lesions
Usually solitary
Genital ulcers, syphilis: Edges
Sharply demarcated, round or oval
Genital ulcers, syphilis: Depth
Superficial or deep
Genital ulcers, syphilis: Base
Smooth, non purulent
Genital ulcers, syphilis: Induration
Firm
Genital ulcers, syphilis: Pain
Unusual
Genital ulcers, syphilis: Lymphadenopathy
Firm, nontender, bilateral
Genital ulcers, syphilis: Causative organism
T. pallidum
Genital ulcers, syphilis: Screening
RPR, VDRL
Genital ulcers, syphilis: Confirmation
FTA-ABS, MHA-TP
Genital ulcers, syphilis: Lesion of primary syphilis
Chancre
Genital ulcers, syphilis: Treatment for primary lesion
PEN G 2.4M units/IM single dose
Genital ulcers, herpes: Incubation
2-7 days
Genital ulcers, herpes: Primary lesion
Vesicle
Genital ulcers, herpes: # of lesions
Multiple
Genital ulcers, herpes: Edges
Erythematous
Genital ulcers, herpes: Depth
Superficial
Genital ulcers, herpes: Base
Serous, erythematous
Genital ulcers, herpes: Induration
None
Genital ulcers, herpes: Pain
Common
Genital ulcers, herpes: Lymphadenopathy
Firm, tender, bilateral
Genital ulcers, herpes: Causative agent
HSV 1 and 2
Genital ulcers, herpes: Diagnosis
1) Tzanck smear 2) Viral culture 3) Serology
Genital ulcers, herpes: Treatment
Acyclovir 200 mg, 5x/day for 7-10 days
Genital ulcers, chancroid: Incubation
1-14 days
Genital ulcers, chancroid: Primary lesion
Papule or pustule
Genital ulcers, chancroid: # of lesions
Multiple
Genital ulcers, chancroid: Edges
Undermined, ragged, irregular
Genital ulcers, chancroid: Depth
Excavated
Genital ulcers, chancroid: Base
Purulent
Genital ulcers, chancroid: Induration
Soft
Genital ulcers, chancroid: Pain
Very tender
Genital ulcers, chancroid: Lymphadenopathy
Tender, may suppurate, unilateral
Genital ulcers, chancroid: Causative agent
Haemophilus ducreyi
Genital ulcers, chancroid: Diagnosis
GSCS
Genital ulcers, chancroid: Treatment
Azithromycin single dose
Genital ulcers, lymphogranuloma vereneum: Incubation
3 days-6 weeks
Genital ulcers, lymphogranuloma vereneum: Primary lesion
Papule, pustule, or vesicle
Genital ulcers, lymphogranuloma vereneum: Edges
Elevated, round, or oval, irregular
Genital ulcers, lymphogranuloma vereneum: Lymphadenopathy
Tender, may suppurate, unilateral
Genital ulcers, donovanosis: Incubation
1-4 weeks
Genital ulcers, donovanosis: Primary lesion
Papule
Genital ulcers, donovanosis: Depth
Elevated
Genital ulcers, donovanosis: Base
Red and rough “beefy”
Genital ulcers, donovanosis: Lymphadenopathy
Pseudoadenopathy
Bleeding occurs at intervals of > 35 days and usually is caused by a prolonged follicular phase
Oligomenorrhea
Bleeding occurs at intervals of less than 21 days and may be caused by a luteal- phase defect.
Polymenorrhea
Bleeding occurs at normal intervals (21 to 35 days) but with heavy flow (>=80 mL) or duration (>=7 days)
Menorrhagia
Bleeding occurs at irregular, noncyclic intervals and with heavy flow (>=80 mL) or duration (>=7 days)
Menometrorrhagia
Bleeding is absent for 6 months or more in a nonmenopausal woman
Amenorrhea
Irregular bleeding occurs between ovulatory cycles
Metrorrhagia
Spotting occurs just before ovulation, usually because of a decline in the estrogen level
Midcycle spotting
Bleeding recurs in a menopausal woman at least 1 year after cessation of cycles
Postmenopausal bleeding
Bleeding is characterized by significant blood loss that results in hypovolemia (hypotension or tachycardia) or shock
Acute emergent AUB
ovulatory or anovulatory bleeding is diagnosed after the exclusion of pregnancy or pregnancy-related disorders, medications, iatrogenic causes, obvious genital tract pathology, and systemic conditions
DUB
First thing to consider in patients with AUB
Rule out pregnancy
Ovulatory vs anovulatory: Usually secondary to a systemic or organic pelvic pathology
Ovulatory
Causes of AUB in anovulatory cycles
1) DUB 2) Endocrine disorders
Causes of AUB in ovulatory cycles
1) Systemic 2) Reproductive tract
Most common reproductive tract cause of AUB
Accidents of pregnancy
Structural causes of AUB
PALM 1) Polyp 2) Adenomyosis 3) Leiomyoma 4) Malignancy and hyperplasia
Non-structural causes of AUB
COEIN 1) Coagulopathy 2) Ovulatory dysfunction 3) Endometrial 4) Iatrogenic 5) Not classified
Criteria for diagnosis of PCO
1) 12 or more follicles measuring less than 10mm in diameter located subcapsularly 2) Increased ovarian volume more than 10 cm3
T/F Both ovaries must fit definition for diagnosis of PCO
F, only one
PCO management
1) Lifestyle modification w/ a target weight loss of 5-10% of initial weight, and target BMI 20-25 2) Metformin 500 mg BID or TID 3) Progesterone challenge (thick endometrium) or OCP (thin endometrium)
Medroxyprogesterone challenge
o Medroxyprogesteroneacetate(MPA) 10mg/tab 1 tab OD x 5 days o Comebackon Day 1 or Day 2 of menses o MPA 10mg/tab 1tab OD on Days16-25 of menses x 6 cycles o Repeat TVS after treatment
PCOS treatment that improves menstrual regularity among women with PCOS, regardless of body mass index
OCP
First choice in the treatment of hirsutism in PCOS
OCP
Component of OCP that suppresses LH hence decreases ovarian androgen production
Estrogenic component
Pinkish to reddish smooth polypoid mass protruding out of the cervical os
Endometrial polyp
Reddish, meaty tissue protruding out of the cervical os; with minimal vaginal bleeding
Submucous myoma
Heavy menstrual bleeding, and progressive dysmenorrhea
Adenomyosis
Uterus symmetrically enlarged, doughy, tender
Adenomyosis
Treatment of heavy menstrual bleeding: Non-hormonal
1) NSAIDs 2) Tranexamic acid
Treatment of heavy menstrual bleeding: Hormonal
1) COCs 2) Estrogens 3) Oral progestins 4) Depot progestins 5) Danazol 6) GnRH agonists 7) LNG-IUS
Fixed retroverted uterus; nodularities in cul de sac
Endometriosis
PID, etiologic agent: Rapid onset, and the pelvic pain usually begins a few days after the onset of a menstrual period
N. gonorrhea
PID, etiologic agent: Indolent course with slow onset, less pain, and less fever
C. trachomatis
PID in IUD, timing
At the time of insertion and 3 weeks after placement
PID: Minimum criteria for initiating therapy
1) Cervical motion tenderness 2) Uterine tenderness 3) Adnexal tenderness
Criteria for hospitalisation of PID
1) Surgical emergency 2) Pregnancy 3) Non-response to oral therapy 4) Inability to tolerate outpatient regiman 5) Severe illness, nausea and vomiting, high fever, tubo-ovarian abscess 6) HIV infection with low CD4+ count
Presumptive symptoms of pregnancy
1) Skin pigmentation (chloasma, linea nigra, striae gravidarum) 2) Nausea and vomiting 3) Thermal signs 4) Fatigue 5) Breast symptoms 6) Anatomical breast changes 7) Perception of feral movement (quickening) 8) Disturbance in urination 9) Cessation of menstruation 10) Changes in vaginal mucosa (Chadwick sign)
Condition: Strawberry cervix
Trichomonas vaginalis
Most commonly used method to rate the readiness of the cervix for induction of labor.
Bishop score
Bishop score
Bluish discoloration of the vagina
Chadwick sign
What happens to the cardiovascular output of the mother in pregnancy?
It increases with peak at the 2nd trimester (40%)
Mechanism of HPL as a diabetogenic hormone
Anti-insulin
A in FPAL includes
1) Abortion (spontaneous or induced) 2) H. mole, 3) Ectopic pregnancy
“Term” is defined as
37-42 weeks
Preterm is defined as
Asynclitism in which the sagittal suture is closer to the sacrum
Anterior asynclitism
Abortion is defined as
Conceptus is defined as fetus if AOG is
Less than 8 weeks AOG
Conceptus is called embryo if AOG is
Less than 8 weeks
Relation of the long axis of fetus to that of the mother
Pole that refers to the fetal head
Pole that refers to the fetus’ breech and flexed extremities
Podalic pole
Refers to the relationship of an arbitrarily chosen portion of the fetal presenting part to the right or left side of the birth canal
Fetal position
Cardinal movements of labor
EDFIEEE: Engagement, Descent, Flexion, Internal rotation, Extension, External rotation, Expulsion
First requisite for birth of the newborn
Descent
Cardinal movement that is essential for the completion o the newborn except when the fetus is small
Internal rotation
Asynclitism in which the sagittal suture is closer to the symphysis pubis
