OBG part 3 Flashcards
___ is used to treat osteoporosis in patients who also require breast cancer prophylaxis.
Raloxifene
selective estrogen receptor modulator (SERM)
Increases risk of DVT/PE/hyper-coagulation
Prolactin, which is high in breastfeeding individuals, inhibits the release of ___
GnRH & Gonadotropins
resulting in low estrogen levels (dyspareunia)
The __ nodes are the primary lymphatic draining site for the distal vagina, vulva, and penis.
superficial inguinal
→ deep inguinal → ext iliac → para-aortic nodes
The ___ lymph nodes are the primary draining site for the cervix.
internal iliac
The ___ lymph nodes are the primary draining site for the body of the uterus.
external iliac
cervix= interenal iliac
The ___ lymph nodes are the primary draining site for the ovaries & testes.
para-aortic
blood supply directly from aorta
Lower abdominal pain (typically bilateral), cervical motion tenderness, and purulent vaginal discharge
Diagnosis is ___
PID
*can also px/w: dyspareunia, dysuria, ↑ WBC/ESR
Common causes of infectious vulvovaginitis (3)
inflammation/infection of vagina
Bacterial vaginosis
Vaginal yeast infection
Trichomoniasis
*other STDs & atrophic vaginitis
Complications associated with PID include (4)
pelvic peritonitis/sepsis
infertility (tubal scarring)
TOA
ectopic pregnancy
Fitz-Hugh-Curtis syndrome
Placenta previa risk factors (4)
h/o placenta previa
h/o cesarean delivery
h/o curettage
> 35 years
multiparity
How to work up suspected placenta previa?
Transvaginal ultrasound
*Digital vaginal examinations are c/i in case of hemorrhage of unknown cause
Management of Placenta Previa: Asymptomatic patients (EGA: ≤20w) Asymptomatic patients (EGA< 37w) Symptomatic stable pt (EGA< 37w) Severe, active bleeding (EGA< 37w) Regardless of sxs if gestational age > 37w
Asymptomatic patients (EGA: 18–20w) → f/u TVUS at 32 w (to monitor placement)
Asymptomatic patients (EGA< 37w) → expectant management* + admit
Symptomatic stable pt (EGA< 37w) → expectant management* + admit for Observation
Severe, active bleeding (EGA< 37w) → emergent cesarean
Gestational age > 37 weeks →immediate cesarean
*Expectant management
< 36w: corticosteroids
If mild uterine contractions: tocolysis & magnesium if <32
Painless (3T) vaginal bleeding (fetal blood) that occurs suddenly after ROM with Fetal distress ( like bradycardia) on FHT.
Fetal death can occur quickly through exsanguination or asphyxiation
VASA PREVIA
How to work up suspected vasa previa? (1)
Treatment
Transabdominal or TVUS with color Doppler
Emergency cesarean delivery
A NEGATIVE fetal fibronectin from cervical secretions rules of
Premature Labor
When is a vaginal exam contraindicated?
3
Vasa Previa
Placenta Previa
Placental Abruption
Sudden-onset abdominal or back PAIN (+/- between contractions)
uterine tenderness
Continuous vaginal bleeding
Fetal distress: Decelerations (60% of cases)
Vaginal Bleeding
Placental Abruption
Cx: DIC 2/2 fetal thromboplastin release
Work up for suspected placental abruption (3)
Transabdominal Ultrasound* Coagulation factors (DIC r/o) CBC (H&H)
*possible retroplacental hematoma
Treatment for placental abruption
Hemodynamic control
RhD ppx in RhD negative mothers
≤33w (HDS mom & baby)
- corticosteroids (betamethasone)
- tocolysis PRN
- Aim for a normal delivery
≥34w
Bleeding + contractions→ vaginal delivery
No bleeding + No contractions + ok baby → expectant management (steroids, tocolysis)
≥37w
Deliver
Placental Abruption complications
IUFD
DIC (thromboplastin)
Retro-placental hemorrhage into peritoneum
Uterine rupture
Vaginal bleeding with regular uterine contractions and cervical changes in laboring woman.
Bloody show
vaginal bleeding typically after sex with some pelvic pain
+/- Bruised and tender cervix without evidence of active bleeding
Cervical trauma
reassurance
Sudden pause in contractions Fetal distress (deteriorating FHR) Vaginal bleeding Hemodynamic instability Suspected diagnosis:
Uterine rupture
Risk factors
h/o c-section, Transmyometrial surgery
____ is associated with FEVER, abdominal pain, recent h/o PID, and LEUKOCYTOSIS
tuboovarian abscess
___ is the recommended treatment for breast abscesses with INTACT overlying skin
Ultrasound-guided fine needle aspiration
___ is the treatment of choice for breast abscesses that are complicated by overlying skin necrosis (purple, thin skin) or those that fail to respond to less invasive treatment attempts.
After, pts are tx w/ cephalexin or dicloxacillin
Surgical incision and drainage
Nausea and vomiting treatment escalation in pregnancy
pyridoxine (B6) → doxylamine → (anti-emetics) diphenhydramine, or promethazine/odansetrone/metoclopromide
Estrogen found within OCPs decreases ___ levels.
protein S
Anovulatory cycles are the mcc of AUB in otherwise healthy adolescents & typically occur up to ___ after menarche due to an immature hypothalamic-pituitary-ovarian axis.
2 years
*Anovulation→ deficit in progesterone→ unopposed estrogen→ negative feedback in HPA→ long menses
A death of a fetus before 20 weeks’ gestation.
The cervical os is closed and U/S shows a gestational sac w/ POC and absent fetal cardiac activity.
Missed abortion
Gravid uterus with closed cervical os, and U/S evidence of intrauterine pregnancy (double decidual sac sign) w/ vaginal bleeding and/or abdominal cramping, preserved fetal cardiac activity and appropriate serum β-hCG
Threatened abortion
Fever, Leukocytosis, cervical motion tenderness, bloody cervical discharge, positive ESR, and multiloculated adnexal mass points to
TOA 2/2 pelvic inflammatory disease
The intrauterine fetal demise before it attains viability
(< 20 weeks)
U/S shows an empty gestational sac or a fetus without fetal heart activity within the first 12 weeks.
Spontaneous abortion
(Miscarriage)
Dilation and curettage (D&C) is the treatment of choice for spontaneous abortion complicated by heavy vaginal bleeding.
Vaginal bleeding and lower abdominal cramping in combination with an open cervical os, a solid mass in the cervical canal, and absent fetal heart tones suggest an ____.
incomplete abortion
Incomplete abortion with foul-smelling vaginal discharge, cervical tenderness, and fever raise concern for intrauterine infection, indicating ___.
Tx:
septic abortion
IV clindamycin & gentamicin w/ suction & curettage
Dyspareunia and pruritus in a postmenopausal woman with a white vulvar plaque (+/- malignancy on bx) on pelvic examination are consistent with __.
Lichen sclerosus
tx: superpotent topical glucocorticoids( betamethasone or CLObetasol)
How to tell apart systemic bacterial infection (sepsis) from AF embolism?
Both can have hypotension, DIC, AMS etc.
However:
Bacterial sepsis→ Fever + sxs develop progressively over hours/days
AFE → NO FEVER + sxs develop within an hour or so
Elevation of serum LH levels after stimulation with a GnRH agonist indicates ___
central precocious puberty (CPP)
Adverse effects include:
HYPOKALEMIA→ fatigue, proximal muscle weakness, and decreased deep tendon reflexes. Tremor headache anxiety tachycardia/palpitations
Terbutaline (Beta-2 receptor agonists)
___ is indicated in patients with HELLP syndrome at ≥ 34 weeks’ gestation or at any gestational age if the maternal or fetal status deteriorates.
Immediate delivery
Risk of infection is high following P-PROM thus antibiotic prophylaxis with __ & __ is administered
> 34 weeks of gestation give ____ is given to induce fetal lung maturation.
To ensure fetal lung maturity, delivery can be delayed for up to 48 hours through administration of ___
ampicillin & azithromycin
betamethasone
Tocolytics (NSAIDs/Indomethacin, beta2-adrenergic agonists/Terbutaline, calcium-channel blockers/Nifedipine)
*provided vital signs of both mother and child remain stable
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___ is the best management option for women with cervical insufficiency, who are < 24 weeks’ gestation of a singleton pregnancy with a cervical length of <25mm
Transvaginal cervical cerclage
__ is the antidote for heparin overdose which has a prolonged aPTT
Protamine sulfate
Increased or Decreased in Sheehan syndrome: ACTH Aldosterone Cortisol TSH
decreased
Increased
decreased
decreased
__ trauma is more common in forceps delivery.
__ and __ injuries are more common in vacuum delivery.
External ear
cephalo-hematomas
brachial plexus
A small, concentric, hypoechoic myometrial mass in a nulliparous woman of reproductive age is suggestive of ___ , for which a history of early menarche and obesity are risk factors.
uterine leiomyoma
A nonstress test (NST) is considered reactive if there are ≥ _ fetal heart rate accelerations that last for at least 15 seconds and are > 15 bpm above the baseline within a __-minute period.
2
20
Placental abruption, retained fetal products, amniotic fluid embolism, and preeclampsia are risk factors for the development of __ in pregnant women
DIC
DIC is due to systemic release of thromboplastin resulting in an over activation of the coagulation cascade which causes a systemic consumption/depletion of both procoagulant and anticoagulant clotting factors, usually resulting in abnormal bleeding.
Labs: thrombocytopenia, increased PT and PTT, increased bleeding time, increased D-dimer, and decreased FIBRINOGEN and factor V concentrations.
___ are the first-line hormone-therapy for estrogen-positive and progesterone-positive breast cancers in POST-menopausal women.
Aromatase inhibitors
(exemestane, anastrozole, letrozole)
Side effects: decreased estrogen & decreased bone density
__ is a humanized antibody that is used against HER2 receptor-positive breast cancer.
Trastuzumab
side effects: flu-like sxs & HF
___ can be used to treat estrogen-positive breast cancer.
Selective estrogen receptor modulators (SERM) like Tamoxifen/Raloxifene
Tamoxifen: decreases bone density in pre-monpausal women
__ is a mitotic inhibitor that is a first-line treatment for triple-negative breast cancer and ovarian cancer.
Paclitaxel
