OBGYN Flashcards
When does bhcg peak?
Peaks at 10 weeks at 100,000 mIU/ml. decreases during 2nd trimester and levels off in the 3rd trimester
BHCG will double during the first 48 hours of pregnancy!!
Describe the changes of GFR and Renal blood flow during pregnancy?
GFR will increase early and then plateau throughout pregnancy
RBF will increase (increased CO) at first and then decline at the end of pregnancy
How much weight to gain during pregnancy?
11-16 kg (approx 25lbs)
How much iron does a woman take during pregnancy if she has a hx of NT defects in her other kids?
4 mg/day (usually only take 0.4mg/day!)
What additional nutritional guidelines do vegitarian moms have to follow?
Vit D and Vit B12 supplementation
When does maternal BP start to rise back to normal?
34 weeks
What metabolic state do pregnant women sit at due to their lung changes?
They are in compensated respiratory alkalosis b/c minute ventilation increases and so does TV. Rate stays the same and expiratory reserve DECREASES (belly)
GI changes in pregnant women?
Sphincter tone decreases (pee themselves)
Gastric emptying time increases (slower emptying) and GI motility decreases - both lead to constipation
When do you do the quad screen?
When is the glucose tolerance test for GDM?
When do you screen for Rh- (RhoGam)?
weeks 15-22 of pregnancy
weeks 24-28 of pregnancy
Weeks 28-30 of pregnancy
What can lead to a false reading of msAFP?
What if it is high?
inaccurate gestational age
high = Check the gestational age first, then be concerned for NT defects, GI wall abnormalities, or MULTIPLE GESTATIONS
low = Trisomy 21 or 18, or death
What are some risks of CVS?
Risks of Amniocentesis?
CVS = fetal loss (1%), limb defects can be caused if done
Why would you do an amniocentesis?
If the mom will be >35yo at birth
if she had an abnormal quad screen
if it is an Rh sensitized pregnancy
if you want to evaluate fetal lung maturity. (L:S ratio should be at least 2-2.5)
Environmental factors associated with spontaneous abortion>
Smokin, Drinkin, excessive caffeine, radiation
Lead and methotrexate exposure during pregnancy can cause:
higher risk of spontaneous abortions
What birth defects can phenytoin cause?
Carbamazapine?
Bactrim/sulfas?
Paroxetine?
cleft lip, MR, microcephaly, cardiac defects, IUGR
carb - NT defects
bactrim - cleft lip/palate
paroxetine - cardiac defects & pulmonary hypertension
Fetus is born with blueberry muffin rash, cataracts, and a PDA, what did mom do?
She was exposed to rubella
Fetus is born with a petechial rash and periventricular calcifications. What did mom do?
Exposed to CMV during pregnancy
Intra-uterine syphilis exposure =
Fetus is born with a rash, saddle nose, peg shaped teeth, deafness, and keratitis
Most common cause of early miscarriages?
late miscarriages?
early - chromosomal abnormalities
late - hypercoagulable state
17yo girl with genital HSV presents in labor, what do you do?
If she has current lesions, do a C-section. If not current you can do vaginally
MOA of misoprostol and mifepristone
Miso = PGE (prostaglandin) mif = progesterone
What is the cutoff for medical vs surgical abortions?
Medical = up to 7 weeks (vaginal or sublingual misoprostol can be used up till 9 weeks)
D/E or induction till 24 weeks.
What does sinosoidal variability on FH monitor indicate?
This is an indication of fetal anemia OR maternal meperidine use
What do early and late decels mean? Variable?
Early = normal head compression from the contraction late = uteroplacental insufficiency! Fetal hypoxemia! variable = umbilical cord compression
What does a contraction stress test look for?
It looks for decelerations (so a negative test is a good thing.)
What is the cutoff for oligohydramnios?
AFI 20-24 (polyhydramnios.)
What type of pain are contractions? Descent?
Contractions/Dilation = visceral pain Descent = somatic pain
What labs will be elevated with hyperemesis gravidarum?
Tx?
hi BHCG and estradiol (rule out moral pregnancy w/ US is the first step b/c of the hi BHCG)
Tx = B6, Doxylamine (antihistamine)
What is the biggest complication with GDM infants?
Pregestational DM?
what about DM1 babies?
They are huge >90th % and a higher risk of congenital malformations —-NEED NST starting at 30-32 weeks!
Pregestational DM = can cause NT defects, hypocalcemia, hyperinsulinemia, hi biliruben, large kids
DM1 babies will be small and hypoglycemic
What med to treat gestational HTN?
methyldopa, labetalol, nifedipine
NO ACEI OR DIURETICS
What seperates eclampsia from HELLP?
seizures.
HELLP will have the RUQ pain from the enlarged liver but it is still important to tx w/ mag sulfate if the pt is far from due date to prevent seizures in the chance that the preeclampsia progresses to eclampsia
What are the signs of mag sulfate tox?
Tx?
loss of DTRs, respiratory paralysis, coma
Tx = IV calcium gluconate
Developmental age vs Gestational age?
Developmental = age from conception (usually unknown) Gestational = age from the first day of the last period (older) - best measurement of this during 1st trimester is via U/S
What will labs look like during the 1st 48h for an intrauterin pregnancy?
BHCG will double over 48h and progesterone is higher than 5ng/ml
What are the risk factors associated with placenta previa?
How to deliver?
Prior C sections (puts you at even more of a risk of placenta acreta)
Grand multiparity
Advanced maternal age
Deliver by c-section
If the baby is RH+, what do you do the mother postpartum?
Give RhoGAM. tell them to delay another pregnancy for 1 year.
Give her RhoGAM peripartum (28w) if she is Rh- and dad is Rh+
What are the complications of Rh sensitivity peripartum?
What will labs show of the baby fluid?
You can get hydrops fetalis (Hb
Complete vs Incomplete Mole:
Complete = sperm fertilizes empty ovum. 46XX, no fetal tissue, but a SLIGHT CA RISK
Incomplete = 2 sperm 1 ovum. 69XXY. contains fetal tissue
Diet def of folate or beta carotene who presents w/ 1st trimester bleeding and lots of vomiting?
What additional test?
Mole.
Do a CXR for lung metz or trophoblastic pumonary emboli
Dizygotic twin =
2 seperate placentas.
TWINS HAVE HIGHER RISK OF INFANT DEATH RATE, MORE IUGR, PREMATURITY, AND CONGENITAL ABNORMALITIES
TTTS!
Big twin = polycythemic and polyhydramnios (could cause HF or hydrops)
Small twin will be IUGR, oligohydramnos
Tx for PPROM?
Tx for latent failure to progress?
Tx for active failure to progress?
Tx for 2nd stage failure to progress?
17a-hydroxyprogesterone
latent = rest, oxytocin
active = amniotomy, oxytocin, c-section
2nd stage = decrease the epidural, keep on the oxytocin, c-section/vacuum
What is the side effect of using indomethacin before 33 weeks?
PDA
What medication do you give to moms before c-section?
Sodium Citrate (decrease gastric acidity to prevent aspirations.)
What IM drug can you inject into the uterus to help with bleeding?
Prostaglandin F2a
Fever within 36h of birth, w/ uterine tenderness and smelly lochia?
Endometritis.
Caused by aerobic and anaerobic bacteria (staph and strep are most common)
Tx: BS Abx = clindamycin and gentamicin
Soft, boggy, enlarged uterus with lots of post partum bleeding?
Dx?
Tx?
Uterine Atony
Tx = bimanual uterine massage –> then oxytocin –> Prostaglandin (IM) –> Stitch it closed
Pt had endometritis, but now presents with waxing/waning fevers, back pain. Dx?
Tx?
Dx = septic pelvic thrombophlebitis
Tx = anticoagulate w/ heparin (septic thrombi can embolize!) and BS Abx
Prolactin = milk/duct production
Oxytocin = milk let down
Prolactin is inhibited while pregnant by what hormone(s)?
Estrogen and Progesterone levels are high throughout pregnancy and cause breast hypertrophy but no milk
Pros of breast milk?
decrease allergies
decrease mom weight
decrease GI/URI’s in babies
bonding
Contraindications to breast feeding?
- HIV, TB, alcohol/drug abuse, Heptatis and cracked nips
- tetracycline, chloramphenicol
- babies with galactosemia
What is the order of menarche?
TAGM
Thelarche, Adenarche, Growth Spurt, Menarche
Woman who bleeds monthly but does not ovulate? What phase is she stuck in? What tx?
Proliferative phase (unopposed estrogen) Tx w/ Medroxyprogesterone (MPA) to stop the endogrowth and convert to SECRETORY phase.
How do OCPs control menstrual pain?
What do they protect you against?
They kill the endometrium (which secretes all the PGE, which cause all the pain)
Protect you against endometrial and ovarian cancer
What structure produces the estrogen and progesterone?
the corpus leuteum
What will labs in menopause look like?
Increased FSH and LH (no estrogen inhibition)
INcreased total cholesterol
Lower HDL
What are the dangers of HRT for menopause?
It is estrogen and progesterone, so it can cause breast cancer or thromboembolism or liver disease
What are some alternatives to HRT for menopause>
SSRI/SNRI’s, gabapentin can decrease the frequency of hot flashes
Differential for primary amenorrhea in a girl with NO 2ndary sex characteristics?
- Growth Delay
- Ovarian insufficiency (turners)
- Central hypogonadism (stress, exercise, prolactin, kallmann’s syndrome (w/ anosmia))
Differential for primary amenorrhea in a girl with 2ndary sex characteristics?
This indicates that estrogen is made, but anatomic/genetic problems are present.
- Mullerian agenesis (short vag, abnormal uterus)
- Imperforate Hymen (blood in vag w/ blue bulging hymen mass)
- Androgen Insensitivity (pt will have breasts but no pubes)
D&C or endometritis causing trauma to the basal layer of the endometrium can cause…
2* amonorrhea.
This is called Asherman’s Syndromd
What is a side effect of bromocriptine?
Nightmares
What do the labs of these look like? Growth Delay Hypogonadotropic Hypogonadism Hypergonadotropic Hypogonadism Anovulatory Problem Anatomical Problem
Growth Delay - low GnRH, LH/FSH, E
Hypogonadotropic Hypogonadism - low GnRH, LH/FSH, E
Hypergonadotropic Hypogonadism - hi GnRH, LH/FSH, low E
Anovulatory Problem (PCOS) - hi all 3
Anatomical Problem - normal all 3
What is your next step after a positive progestin challenge?
You get a withdrawal bleed w/ a positive test.
Hi LH will mean PCOS
Low LH will mean idiopathic anovulation
What is the dreaded outcome of adenomyosis?
has an increased risk for endometrial CA
What is the first line tx for abnormal uterine bleeding>?
NSAIDs (will decrease the blood loss.)
Newborn girl with ambiguous genitalia, life threatening salt wasting and low bp? Dx?
21-hydroxylase def
REMEMBER THE MC A / MC A CHART!!
What to expect if testosterone levels are high in woman?
High DHEAS levels?
testosterone = Ovarian tumor
DHEA = adrenal tumor, or cushings, or CAH
What are considered androgens?
Testosterone and DHEAS
Extreme PCOS to the point of cliteromegaly and deep voice with high testosterone levels?
Thecosis
What is the tx for a PCOS woman who wants to conceive?
Clomiphene +/- metformin (ovulatory stimulation.)
Tx for hirsutism?
Spironolactone or finasteride
Woman presents with asymptomatic adnexal mass in the middle of her cycle. Dx? Tx?
Hemorrhagic Cyst
No treatment, they are benign. Do an U/S now and again in a few months
Differentiate these diseases:
BV
Vulvovaginal Candida
Trichomoniasis
BV = white/gray fishy discharge w/ a vag pH of >4.5. +whiff KOH. CLUE CELLS ON WET MOUNT w/ increased cocci and decreased lactobacilli. not dangerous to pregnancy. Tx = PO/vag metro or vag clinda
Candida = erythematous excoriated vulva/vagina w/ curdy texture and no odor. Tx = vag azole or PO fluconazole
Trichomoniasis = A motile flagellular STD. dysuria. Strawberry petechiae in vag/cervix. Tx = PO metro or tinidazole. TX THE PARTNERS AND TEST FOR OTHER STDS
Female w/ abdominal pain, fever, chills, discharge. U/S shows thickening or dilation of fallopian tubes w/ fluid in the culdesac and a + chandelier sign
PID
EXAMINE AND TX ALL SEXUAL PARTNERS!
PT W/ hx of PID comes in with jaundice, RUQ pain, elevated liver enzymes and shoulder pain. Dx?
Fitz-Hugh-Curtis syndrome
Diffuse macular erythematous rash w/ nonpurulent conjunctivitis
She also has desquamation of PALMS AND SOLES as she recovers
TSS. the reaction is due to the toxin, not the staph itself!
Tx w/ rehydration and antistaph drugs (naf/oxa) or vanc if allergic
Steroids can reduce the time of illness
What gyn cancer has the highest mortalitiy?
Ovarian CA, it is the second most common
A woman with symptomatic fibroids has tried NSAIDs and OCPs but these do not work, what is the next treatment?
Medroxyprogesterone (MPA) for 10 days to clear up garbage or Danazol to slow bleeding (this has masculine side effects.)
follow this with
GnRH analogs (leuprolide or nafarelin) to Shrink the fibroids, stop further growth and decrease surrounding vascularity
Last resort - myomectomy (if still wants kids) or TAH (if all done having kids(
Compare and contrast the 2 types of endometrial CA
Protective factors?
Both will present with abnormal bleeding
Type 1: endometroid (adenoCA) - most common. related to Estrogen exposure, starts with a precursor lesion of hyperplasia. Good prognosis
Type 2: Serous (Clear cell CA) - not related to Estrogen, due to p53 mutation. No precursor, poor prognosis.
Estrogen is a protective factor. Progestin for women of childbearing age
What are the risk factors for ovarian cancer?
Protective factor?
Tumor marker?
risk - age, low parity, low fertility, delayed child baring (aka more estrogen exposure)
negative risk factor = smoking!
Tumor marker = CA-125
Tumor markers for: Epithelial CA (melinoma, ovarian, colon) choriocarcinoma dysgerminoma granulosa cell CA
Epithelial CA (melinoma, ovarian, colon) = CA-125 choriocarcinoma = BhCG dysgerminoma = LDH granulosa cell CA = Inhibin Yolk sac = AFP granuloma/leydig/sertoli = estrogen/testosterone
What is the most common bug in pediatric vuvovaginitis?
G.A.S.
R/o child abuse if infectious.
If not infectious, think FOB or a rhabdomyosarcoma (bunch of grapes in the vagina.)
Central vs peripheral precocious puberty?
Signs of estrogen excess vs androgen excess?
Precocious = before 8yo
Central = early activation of hypothalamic GnRH. Dx = +LH test. tx = leuprolide
Peripheral = GnRH independent mechanisms (can be due to estrogen or androgen excess) Dx = (-) LH test
estrogen excess = breasts and vag blood (INDICATES OVARIAN CYSTS OR TUMOR)
androgen excess - hair, clitoris, acne (INDICATES ADRENAL TUMOR OF C.A.H.)
Tx of the peripheral causes of precocious puberty:
Ovarian cyst
CAH
Adrenal or Ovarian Tumors
McCune Albright Syndrome
Ovarian cyst = no tx, will regress
CAH = tx w/ glucocorticoids
Adrenal or Ovarian Tumors = surgery
McCune Albright Syndrome = antiestrogens (tamoxifen) or E synthesis blockers (ketoconazole/testolactone.)
Fibrocystic change is associated with which environmental risk factors?
caffeine, trauma
How do you screen for breast cancer in premenopausal women vs postmenopausal?
Pre - ultrasound (tells if it is cystic or solid)
post - mammography
Tx for HER2/Neu + breast cancer?
Trastuzumab
Dx step in asymptomatic ovarian mass in a postmenopausal woman?
Test her CA-125 levels (ok sens/spec) to see if it is malignant.
If U/S suggests a simple cyst, and CA-125 is not elevated, masses
