OBGYN Flashcards
1
Q
Most common first pregnancy sx
A
amenorrhea (if they have regular menses)
breast tenderness
nausea
vomiting
pregnant women experience a surge in estrogen, progesterone, and beta-human chorionic gonadotropin that leads to these sx
2
Q
morning sickness
A
cuased by an increase in beta HCG produced by the placenta, occurs until the 12th -14th week of pregnancy
3
Q
Embryo
A
Fertilization to eight weeks
4
Q
Fetus
A
eight weeks to birth
5
Q
Infant
A
birth to one year old
6
Q
Developmental age (DA)
A
number of days since ferilization
7
Q
Gestational age (GA)
A
number of days/weeks since the last mentrual period (usually 2 weeks longer than DA)
8
Q
Nagele rule
A
estimation of the day of delivery by taking the last menstural period, subtracting 3 onths, and adding 7 days.
for example a woman with LMP of oct 1 2015 will have an estimated delivery date of july 8 2016
9
Q
nagele rule:
A
LMP - 3 months + 7 days = estimated day of delivery
10
Q
First Trimester:
A
fertilization until 12 weeks (DA) or 14 weeks (GA)
11
Q
Second Trimester:
A
12(DA)/14(GA) weeks until the 24 week (DA) or 26 week (GA)
12
Q
Third Trimester:
A
24 (DA)/26(GA) weeks until delivery
13
Q
First Trimester overview
A
fertilization to 12 weeks (DA)
fertilization to 14 weeks (GA)
FIRST Screening
fetal heart tones with doppler
14
Q
Second trimester overview
A
12 weeks DA to 24 weeks DA
14 weeks GA to 26 weeks GA
genetic triople or quad screen
fetal movement at 16-20 weeks GA
anatomic us at 18-20 weeks GA
15
Q
third trimester overview
A
24 weeks DA to delivery
26 weeks GA to delivery
frequent visits
monitoring for labor
16
Q
Pre-viable
A
fetus born before 24 weeks
17
Q
pre-term
A
fetus born between 25 and 37 weeks
18
Q
early term
A
fetus born between 37 weeks and 38 weeks, 6 days
19
Q
full term
A
fetus born between 39 weeks and 40 weeks, 6 days
20
Q
late term
A
fetus born between 41weesk and 41 weeks, 6 days
21
Q
postterm
A
fetus born after 42 weeks
22
Q
Gravidity
A
the number of times a pts has been pregnant.
23
Q
parity
A
what happens to the pregnancy
1 full-term births
2 preterm births
3 abortions (both spontaneous and induced)
4 living children (if a pt has a multiople gestation pregnancy, one birth results in 2 living children)
24
Q
a woman with 6th pregnancy, 2 abortions, 2 children born at term, a set of twins born preterm
A
g6p2124
25
gp tip
f-pal
fullterm
preterm
abortions
living children
26
Goodell Sign
Physical Finding -
Time from conception -
Physical Finding - softening of the cervix
Time from conception - 4 weeks (first trimester)
27
Ladin sign
Physical Finding -
Time from conception -
Physical Finding - softening of the midline of the uterus
Time from conception - 5 weeks (first trimester)
28
Chadwick sign
Physical Finding -
Time from conception -
Physical Finding - blue discoloration of vagina and cervix
Time from conception - 6-8 weeks (first trimester)
29
Telangiectasi/ palmar erythema
Physical Finding -
Time from conception -
Physical Finding - small blood vessels/reddening of the palms
Time from conception - first trimester
30
Chloasma
Physical Finding -
Time from conception -
Physical Finding - the mask of pregnancy is a hyperpigmentation of the face most commonly on forehead, nose, and cheeks; it can worsen in the sun
Time from conception - 16 weeks (2nd trimester)
31
Linea nigra
Physical Finding -
Time from conception -
Physical Finding - a line of hyperpigmentationthat can extend from xiphoid processs to pubic symphysis
Time from conception - second trimester
32
the best initial test when suspecting pregnanyc is a
beta-hcg
33
Pregnancy diagnostic evaluation
beta hcg
both urne and serum testing are based on this, which is produced by the placenta. betahcg is produced rapidly in the first trimester doubling every 48 hours for the first 4 weeks. at 10 weeks of gestation, the betahcg peaks and levels will typicly drop in the second trimester, in the third timester, the levels will increase slowly again to a level of 20000 to 3000 iu/ml. betah hcg tests are all highly sensitive. at 5 weeks it should be 1000 to 1500
34
Pregnancy diagnostic evaluation
us
used to confirm an intrauterine pregnancy. can see gestational sac
35
beta hcg >1500 or 5 weeks =
gestational sax on us
36
Physiologic changes in pregnancy
Cardiology
increase in cardiac output (results in increased heart rate)
slightly lower blood pressure (lowest point occurs at 24-28 weeks)
37
Physiologic changes in pregnancy
GI
morning sickness: nausea and vomiting occur anytime throughout the day and are caused by an increase in estrogen, progesterone, and hcg made by the placenta
reflus: lower esophageal sphincter has decreased tone
constipation: motility in the large intestine is decreased
38
Physiologic changes in pregnancy
renal
increase in the size of kidney and ureters incerases the risk of pyelonpehritis (from compression of the ureters by the uterus)
increase in GFR (secondary to a 50% increase in plasma volume), decrease in bun/creatinine
39
Physiologic changes in pregnancy
hematology
anemia from an increase in plasma volume by 50%
```
hypercoagulable state
no increase in pt ptt or inr
increase in fibrinogen
virchow triad elements occur
venous stasis
```
40
virchow triad
hypercoagulation
endothelial damage
stasis
41
Prenatal care
First Trimester
patients should be seen every 4 to 6 weeks
between 11 and 14 weeks a n us can be done to confrim gestational age and check for nucahl tanslucency.
fetal heart sounds can be heard at the end of the first trimester
blood tests, pap smear and gonorrhea/chlamydia tests
42
Prenatal care
first trimester screening
may be offered to the pt
nonvinasive evaluation to identify risks of chormosoam abnormalitit
a combo of blood tests and us that evaluates the fetus for possible down syndrome
43
most accurate way of establishing geatational age at 11 to 14 weeks
us
44
pts account of lmp
often unreliable bc histories are inaccuratly remembered
45
Prenatal care
Second trimester
visits in the second timerster are used to screen for genetic and congenital problems, at 15 - 20 weeks perfomr a triple or a quad
ausculatation of fetal heart rate
16-20 weeks: quickening (feeling movement for the first time)
18-20 weeks: outine us for fetal malfomration
46
triple screen
maternal serum alpha fetoprotein (masafp), betah cg and estriol
47
quad screen
maternal serum alpha fetoprotein (masafp), betah cg and estriol and inhibin a
48
increase in MASFP
may indicate a dating error, neural tube defect, or abdominal wall defect. the addtition of beta hcg, estriol and inhibin a helps increase the sensitivty of msaft test
49
multiparous women experience what soone than primparous women
quickening
50
when is triple or quad screen done
15 to 20 weeks
51
Prenatal care
third trimester
visits are every 2 to 3 weeks until 36 weeks, after 36 weeks there is a visit every week
52
Braxton hicks contractions
occur during the third trimester. they are spontaneous and do not cause cervical dilation. if they become regular, the cervis should be checked to rule out preterm labor before 37 weeks. preterm labor opens the cervix but braxton hicks do not. beginning at 37 weeks, the cervix should be examined at every visit
53
Continued braxton hicks means you
should check the cervix
54
Third trimester testing
27 weeks
cbc
if hemoglobin <11, replace iron daily
55
Third trimester testing
24-28 weeks
glucose load
if glucose is >140 at one hour, perform oral glucose tolerance test
56
Third trimester testing
36 weeks
cervical cultures for Chlamydia and gonorrhea
treatment if positive
rectovabinal culture for group b strep
prophylactic antibiotics during labor
57
dont forget to give what with iron supplements
stoll softeners bc iron causes constipation
58
glucose load test
fasting or nonfasting ingestion of 50 g of glucose and serum glucose check 1 hour later
59
glucose tolerance test
fasting serum glucose ingestion of 100 g of glucose, serum glucose checks at 1,2, and 3 hours. elevated glucose during any two of these test is gestational diabetes
60
Other screening tests
Chronic villous sampling
amniocentesis
fetal blood sampling
61
Chronic villous sampling
done at 10 to 13 weeks in advanced maternal age or known genetic disease in parent
obtains fetal karyotype
catheter into intrauterin cavity to aspirate chorionic villi from placenta (can be done transabdominally or transvaginally)
62
Amnioventesis
Done after 11 to 14 weeks for advanced maternal age or known genetic diseaes in parent
obtains feteal karyotype (advanced maternal age)
needle transabdominally into the amniotic sac and withdraw amniotic fluid
63
Fetal blood sampling
percutaneous umbilical blood sample
done in pts with rh isoimmunization and when a fetal cbc is needed
nedle transabdominally into the uterus to get blood from theumbilical cord
64
Ectopic Pregnancy
definition
a pregnancy that implantes in an area outside of the uterus. this most commonly occurs in the ampulla of the fallopian tube
65
anatomy picture
pg 503
66
Ectopic Pregnancy
risk factors
pid
iud
previous ectopic pregnancies (strongest risk factor)
67
Ectopic Pregnancy
presentation
unialteral lower abdominal or pelvic pain
vaginal bleeding
if ruptured, can be hypotensivewith peritoneal irritation
68
Ectopic Pregnancy
diagnostic tests
beta-hcg: done to confirm the presence of a pregnancy
us: to locate the site of implatnation
laparoscopy: invasive test and treatment to visulaize the extopic pregnancy
69
Ectopic Pregnancy
treatment
unstable pts (low BP, high HR) should be given fluids and sent to surgery immediatly
70
Ectopic Pregnancy
medical treatment
cbc to monitor for anemia
blood/type screen
tansaminases to detec changed indicating hepatoxocity from the medications (methotrexate)
beta hcg to asses for success of treatment via a decrease in beta hcg
after these are obtained methotrexate a folate antagonist may be given, the pts beta hcg is followed to see if there isa 15 % decrease in 4 to 7 days. if there is no decrease beta hcg a second dose of methotrexate may be given. i fthe pts beta hcg is still no decreasin gafter the sedon dose surgery hsould be done and beta hcg still needs to followed weekly until it reaches 0
71
Exclusion criteria for Methotrexate
immunodeficiency: avoid it bc it is a immunosuppressive
noncomplinat pts: who knows if they will f/u to return for evalutation to know if the treatment worked and if they need a second dose or surgery
liver disease: hepatotoxicity is a serious side effect of methotrexate. baseline liver disease increases the risk of subsequent toxicity
ectopic is greater than 3.5 cm or larger: the larger the extopic, the greater th erisk of treatemnt failure
Fetal hearbeate auscultated: a pregnancy developed enought o have a heartbeat detectabel by auscultation has in increased risk of failure with methotrexate
72
Ectopic Pregnancy
surgery
done to ry and preserve the fallopian tube by cutting a hole in it (salpingostomy). however, rmeoval of the whole fallopina tube (salpingectomy) may be necessary. mothers who are rh negative should receive antid rh ig so taht subsuquent pregnanies will not be affected by hemolytic disease
73
ostomy
cut
74
ectomy
remove
75
Abortion
Definiton
defines as a pregnancy that ends before 20 weeks gestation or a fetus less than 500 grams. almost 80% of spontaneous abortions occur prior to 12 weeks gestation
76
Abortion
etiology
chromosomal abnormalities in the fetus account for 60 to 80% of spontaneous abortions. however, maternal factors that increase risk of abortion include
anatomic abnormalities
infections (STDs)
immunological factos (antiphospholipid syndrome)
malnutrition
trauma
rh isoimmunization
77
Abortion
Presentation
cramping abdominal pain
vaginal bleeding
may be stable or unstable, depending on the amount of blood loss
78
you cannot answer the most likely diagnosis test about abortion w/o
us
79
Abortion
diagnostic tests
CBC to evaluate blood loss and need for transfusion
blood type and th screen: should blood need to be transfused, and evaluations of need for antid rh immunoglobulin
us to distingush between the types of abortions
80
Complete abortion
US finding /answer to "most likely diagnosis" question -
treatment -
US finding /answer to "most likely diagnosis" question - no products of concetiop found
treatment - f/u in office
81
incomplete abortion
US finding /answer to "most likely diagnosis" question -
treatment -
US finding /answer to "most likely diagnosis" question - some products of concetiop found
treatment - Dand C/medical
82
inevitable abortion
US finding /answer to "most likely diagnosis" question -
treatment -
US finding /answer to "most likely diagnosis" question - products of conception intact, intrauterine bleeding, no dilations of cervix
treatment - D&C/medical
83
threatened abortion
US finding /answer to "most likely diagnosis" question -
treatment -
US finding /answer to "most likely diagnosis" question - products of conception intact, intrauterin bleeding, no dilation of cervix
treatment - bed rest, pelvic rest
84
missed abortion
US finding /answer to "most likely diagnosis" question -
treatment -
US finding /answer to "most likely diagnosis" question - death of getus, but all products of conception present in the uterus
treatment - D&C/medical
85
Septic abortion
US finding /answer to "most likely diagnosis" question -
treatment -
US finding /answer to "most likely diagnosis" question - infection of the uterus and the surrounding areas
treatment - D&C and IV antibiotics, such as levofloxacin and metronidazole
86
Abortion
medical treatment
occurs bia giving medications that induce laber, like misoprostol (a prostaglandin E1 analog). these agents help opne the cervix and expulse the fetus.
87
Abortion
Rh neg
they need rhogam
88
fertility drugs increase
multiple gestations
89
Multiple gestations
presentation
exponential growth of uterus
rapid wiegh tgain by mother
elevated beta-hcg and msafp (levels higher than expected for estimated gestational age ist he first clue to multiple gestation
90
Multiple gestations
diagnostic tests
us is done to visulaize the fetuses
91
monozygotic
1 egg and 1 sperm that splits
identical twins, same gender, same physical characteristics, same blood type, fingerprints differ
92
dizygotic
2 eggs and 2 sperm
fraternal twins. diff or same sex, they resemble each other, as any siblings would
93
Multiple gestations
complications
spontaneous abortion of one fetus
premature labor and delivery
placenta previa
anemia
94
Late pregnancy complications
Preterm labor is diagnosed when
there is a combination of contractions with cervical dilation
95
Late pregnancy complications
premature rupture of membranes pt
has a gush of fluid
96
Late pregnancy complications
pts with cervical incompetence
do not have a hx of contractions but there is painless dilation of the cervix
97
Late pregnancy complications
preterm labor risk factors
premautre ruputre of membranes
multiples gestation
previous hx of preterm labor
placental abruption
```
maternal factors
uteirn anatomical abnormalitites
infections (chorioamnionitis)
preeclampsia
intraabdominal surgery
```
98
Late pregnancy complications
preterm labor presentation
contractions (abdominal pain, lower back pain, or pelvic pain)
dilation of the cervix
occurs between 20 and 37 weeks
99
Late pregnancy complications
preterm labor evaluation
the fetus should be evaluated for weight, gestational age, and the presenting part (cephalic vs breeck).
100
Late pregnancy complications
circumstances in which preterm labor should not be stopped with tocolytics and delivery should occur are:
maternal severe htn (preeclampsia/eclampsia)
maternal cardiac disease
maternal cervical dilations of more than 4 cm
maternal hemorrhage (abruptio placenta, DIC)
fetal death
chorioamnionitis
101
Pretemr labor is occurring, contractions and cervical dilation
deliver if
34-37 EGA > 2500 grams
102
Pretemr labor is occurring, contractions and cervical dilation
stop delivery if
24-33 ega
600-2500 grams
betamethason
tocolytics
103
Mature the fetus's lungs means
increase surfactant
104
Preterm labor
corticosteroids
pt should be given betamethasone, a corticosteroid used to mature the fetus's lungs. the effects begin within 24 hours, peak at 48 hours, and persist for 7 days. corticosteroids decrease the risk of respiratory distress ydnfrome and neonatal mortality
105
Preterm labor
Tocolytics
when steroids are admintisterd, a tocolytic hosuld follow to allow tiem for steroids to work. tocolytics lsow the progerssion of cervical dialtion by decreasing uterine contractions
mag sulfate
ccb
terbutaline
106
mag sulfate as tocolytic
most commonly used tocolyitic. it decreases the uterine tone and contractions. side effects include flushing, headaches, diplopia, and fatigue.
107
ccb as tocolytics
side effects inclue headache, flushing, and dizziness
108
Terbutaline as a tocolyitic
beta-adrenergic,gectpeor agonist, causes myometrial relaxation. maternal effects include increase in heart rate leading palpitations and hypotension
109
magnesium toxicity
can lead to respiratory depression and cardiac arrest, so check deep tendon reflexes often.
110
indomethacin as a tocolytic
can be used, but is always wrong answer, ust it to close a pda
111
Premature rupture of membranes
presentation
presents with a hx of gush of lguid from the vagina
112
Late pregnancy complications
preterm labor
Premature rupture of membranes
Third trimetester bleeding
placental abruption
uterine rupture
rh incompatibilit
hypertension
diabetes
113
Premature rupture of membranes
diagnostic test
sterile speculum exam should confirm the fluid as amniotic fluid
fluid is present in the psoterior fonix
fluid turns nitrazine paper blue
when placed on slide and allowed to air dry, fluid has ferning pattern
114
Premature rupture of membranes
leads to
preterm labor
cord prolapse
placental abruption
chorioamniotis
115
Premature rupture of membranes
timeframe
can happen at anytime throughout pregnancy, it becomes biggest prblem whent eh fetus si preterm or wiht prlonged rupture of membranes
116
prolonged rupture ofmembranes
means that labor starts more than 24 ours before deliver
117
prom=
do fewer exams=decrease chorioamnionitis
118
Premature rupture of membranes
treatment depends on
depends on fetus gestational age and the presenceof chorioamniotis
119
Premature rupture of membranes
chorioamniotis
deliver now
120
Premature rupture of membranes
term fetus
wait 6 - 12 hours for spontaneous delivery, if not spontaneous then induce labor
121
Premature rupture of membranes
preterm fetus
w/o chorioamnionitis should be treated with betamethasone (to mature the lungs), tocolytics (to decrease contractions), ampicillin, and 1 does of azithromycin (to decrease tisk of devleoping chorioamnionitis while waiting for steroids to begin working)
if pt is penicillin allergic but low risk for anaphylaxis, cefazolin and azithromycin, if high risk for anapyhylaxis, then clindamicin and azithromycin is used
122
Third-trimester bleeding
placenta previa
placenta invasion (accreta, increta, percreta)
123
Placenta previa
is an abnormal implantation of the placenta over the internal cervical os. is the cause of about 20% of all prenatal hemorrhages
124
Placenta previa
increased risk with
previous cesaeran deliveries
previous uterine surgery
multiple gestations
previous placenta previa
125
why is digital vaginal exam ci in third-triemster vaginal bleeding
it may lead to increased separation between placenta and uterus, resulting in a severe hemorrhage.
126
first step in all thrid trimester vaginal bleeding
abdominal us
127
Placenta previa
presentation
painless vaginal bleeding
may be detected on routine us before 28 weeks, but usually does not cause bleeding until after 28 weeks
128
Placenta previa
diagnostic tests
a tansabdominal us is done to see where the placenta is lying in the uterus. a transvaginal us is not done for the same reason that a digital vaginal exam is not done; it is dangerous and can separate the placenta fruther from the uterus
129
Placenta previa
complete
complete covering of the internal cervical os
full moon
130
Placenta previa
partial
parital covering of the intrenal cervical os
half moon
131
Placenta previa
marginal
placenta is adjacent to the internal os (often touching edge of the os)
cresecent moon
132
Placenta previa
vasa previa
fetal vessel is present over the cervical os
133
Placenta previa
low-lying placenta
placenta that is impalnted in the lowr segments of the uterus bu tnot covering the intrenal cervical os (more than 0 cm but less than 2 cm away)
134
Placenta previa
when do you treat
wehre there is large-volume bleeding or a drop in hematocrit
indications for immediate cesarian delivery:
unstoppable labor (cervix dilated more than 4 cm)
severe hemorrhage
fetal distress
135
Placenta previa
treatment
strict pelvic rest, with nothing put into the vagina (intercourse)
prepare for life-threatening bleeding by type and screen of blood, cbc, and prothrombin time
prepare fetus with betamethasone for lungs
if delivery must be c section
136
Placental Invasion (accreta, increta, percreta)
when the placenta abnormally adheres to different areas of the uterus (placenta accreta) which is associated with placenta previa. this becomes a problem when the placenta must detach from the uterus after the fetus is born. often placental invatsion cannot be seen on prenatal us but does result in a significant amoutn of postpartum hemorrhage. pts are usually asymptomatic unless invasion into the bladder or rectum results in hematuria or rectal bleeding.if placenta cannot attach from uterine wall after delivery the result is catastrophic hemorrhage and shock, often require hysterectomy
137
placenta accreta
abnormally adheres to the superficical uterine wall
138
placenta increta
attaches to the myometrium
139
placenta percreta
invades into the uterine serosa, bladder wall, or rectum wall
140
Placental Abruption
premature separationo f the placenta form the uterus. resulsts in tearing of the placental blood vessels and hemorrhaging into the separated space. can occur before, during, or after labor. if the separation is large enough and life-threatening bleeding occurs, premature delivery. uterine tetany, disseminated intravascular coagulations, and hypovolemic shock can occur. however, if the defee of separation is amall with minor hemorrhage, then there may b eno clinical signs or sx
141
Placental Abruption
etiology
primary etiology is unknown
```
Precipitating factors:
maternal htn (chronic, pre or eclampsia)
prior placental abruption
maternal cocaine use
maternal external trauma
maternal smoking during pregnancy
```
142
Placental Abruption
presentation
third trimester vaginal bleeding
severe abdominal pain
contractions
possible fetal distress
143
Placental Abruption
diagnostic test
can present in a similar fashion to placental previa. ino order to distinguish between the two. a tranabdominal us is done. however, placenal abruption sill may not be seen on us
144
painful vaginal bleeding
painless vaginal bleeding
abruption
previa
145
concealed abruption description
blood is within uterine cavity
146
concealed abrutption complications
```
serious (occur with larger abruptions):
disseminated intravascular coagulation
uterine tetany
fetal hypoxia
fetal death
sheehan syndrome (postpartum hypopituitarism)
```
147
external abruption
blood drains thorugh cervix
148
Placental Abruption
treatment
delivery
149
Placental Abruption
indications for cesarean delivery
uncontrollabe maternal hemorrhage
rapidly expanding concealed hemorrhage
fetal distress
rapid placental separation
150
Placental Abruption
vaginal deliveries are indicated if
palcental separation is limited
fetal heart tracing is assuring
separation is extensive and fetus is dead
151
life-threatening to mother or baby
immediate dleivery
152
uterine rupture
life-threatening to mother and the fetus and usually occurs during labor
153
uterine rupture
risk factor
```
increase risk with previous cesarean deliveries (both types)
classical (longitudinal along uterus): higher risk of rupture
low transverse (more recent use)
```
trauma (most commonly mva)
uterin myometomy
uterine overdistention
polyhydramnios
multiple gestations
placenta percreta
154
uterine rupture
presentation
sudden onset of extreme abdominal pain
abnomral bump in abdomen
no uterine contractions
regression of fetus: fetus was movign toward dleivery, but is no longe rin the cnaal bc it withdrew intot he abdomen
155
uterine rupture means
there is a hole in the uterus
156
uterine rupture
treatment
treatment is an immediate laparotimy with delivery of the ferus. a cesarean delivery is not done, bc they baby may not be ni the uterus, but floating in the abdomen. repair of the uterus of hysterctocym will follow. if the pt undergoes a repair of the uterus, all subsuquent pregnancies will be deliverd via cesarean birth at 36 weeks
157
uterin rupture requires
immediate laparotomy and delivery of the fetus
158
Rh Incompatibility
occurs when the mother is rh negative and the baby rh psoitive. this is generally no a problem inthe first pregnancy as the mother has not developed antiboides to the foreing rh positive blood yet, when the first baby is delivered or getal red blood cells cross the placenta into the mother's bloodstream, she makes anitbodies against the Rh positive blood. when the mother gets pregnant for the second time, her antibodies attaxk the second rh positive baby. this lead to hemolysis of teh ferus's red blood cells anor hemolyti disease of the newborn
159
Rh Incompatibility
antibody titer - sensitized
further monitoring
160
Rh Incompatibility
antibody titer unsensitized
repeate at 28 weeks ang give rhogam as indicated
161
Rh Incompatibility
hemolytic disease of newborn
results in fetal anemai and extramedullary production of RBCs bc the baby's bone marrow is not able to make enough RBCs, so the live rans spleen help. Hemolyissi results in increased heme and bilirubin levels in plasma. bilirubin can be neurotoxic. these effects can lead to erythroblastosis fetalis, characterized by high fetal cardiac output (CHF)
162
extramedullary means
outside the bone marrow
163
Rh Incompatibility
initial prenatal visit
during the initial prenatal visit, an Rh antibody screening test is done. patietns who are Rh negative will have an Rh antibody titer done. PAtietns who are Rh negative but have no antibodies to Rh are unsensitized. patients who are th negative but have anitbodies to Rh are sensitized.
164
Rh Incompatibility
antibody screen
done to see if mother is Rh- or Rh+
165
Rh Incompatibility
antibody titer
done to see how many antibodies to Rh+ blood the mother has.
166
Rh Incompatibility
unsensitized patients
do not yet have antibodies to Rh positive blood. the goal is to keep it that way, so any time that fetal blood cells may cross the placent, anti-d rh immunoglobulins (rhogam) are given.
167
The following are some scenarios where fetal blood cells may cross into the mother's blood
amniocentesis
abortion
vaginal bleeding
placental abruption
delivery
168
Rh Incompatibility
Prenatal antibody screening unsensitized
prenatal antibody screening is done at 28 weeks and 35 weeks. patietns who continue to be unsensitized at 28 weeks should receive anti-d immunoglobulin prophylaxis. At deliver, if the baby is Rh positive, the mother should be given antiD immunoglobulin again
169
unsensitized=
no anti-rh antibodies present
170
Rh Incompatibility
sensitized patients
patients who are sensitized already have antibodies to rh positive blood. on the intial visit, if the patient is Rh negative and has antibodies, an antibody titer needs to be done via the indirect antiglobulin test. the paitent is considered sensitized if she has a titer level mroe than 1:4. if the titer is less than 1:16, no further treatment is necessary. However, if it reaches 1:16 at any point during the prenancy, serial amniocentesis should be done. serial amniocentesis allows for evaluation of the fetal bilirubin level.
171
Antibody titer > 1:16
do first amniocentesis at
if fetal cells rh negative after amniocentesis
16-20 weeks
if fetal cells rh negative manage like normal pregnancy.
172
Antibody titer > 1:16
if fetal cells rh posisitve after amniocentesis
do amniocentesis at 16-20 weeks.
if fetal cells rh positive, amniocentesies for fetal cells to be evaluated under spectrophotometer to evaluate biliribun
173
f fetal cells rh positive, amniocentesies for fetal cells to be evaluated under spectrophotometer to evaluate biliribun
low bili level
repeat amniocentesis in 2-3 weeks
174
f fetal cells rh positive, amniocentesies for fetal cells to be evaluated under spectrophotometer to evaluate biliribun
medium bili level
repeat amniocnetesis in 1-2 weeks
175
f fetal cells rh positive, amniocentesies for fetal cells to be evaluated under spectrophotometer to evaluate biliribun
high bilirubin level
fetus probably is anemic
do a percutaneious umbilical blood sample (fetal hematocrit) if that is low perfrm an intrauterin transfusion
176
preeclampsia is characterized by
htn, edema, proteinuria
177
eclampsia is characterized by
preeclampsia with seizures
178
hellp
preeclampsia with elevated liver enzymes and low platelets
179
Pregnancy htn
chronic htn
gestational htn
preeglamspia
eclampsia
hellp syndrome
180
chronic htn
is htn defined as a BP above 140-90 before the pt became pregnant or before 20 weeks of gestation. it may lead to preeclampsia
181
chronic htn treatment
methyldopa, labetalol, or nifedipine
182
Gestation htn
defined as a bp above 140/90 mm hg that starts after 20 weeks gestation, no proteinuia or edema
183
Gestation htn
treatment
treated only during pregnancy with methyldopa, labetalol, nifedipine
184
acei and arbs in pregnancy
cause fetal malformation, do not give
185
Preeclampsia Risk Factors
chornic htn
renal disease
186
only definitive treatment in Preeclampsia is
delivery
187
Mild Preeclampsia
htn -
proetinuria -
edema -
mental status changes -
vision changes -
impaired liver function -
htn - >140/90
proetinuria - dipstick 1+ to 2+; 24 hour urin >300mg
edema - hands, feet, face
mental status changes - no
vision changes - no
impaired liver function - no
188
Severe Preeclampsia
htn -
proetinuria -
edema -
mental status changes -
vision changes -
impaired liver function -
htn - >160/110
proetinuria - dipstick 3+; 24 urine >5 grams
edema - generalized
mental status changes - yes
vision changes - yes
impaired liver function - yes
189
Mild Preeclampsia at term treatment
delivery
190
Mild Preeclampsia preterm treatment
1. betamethasone to mature feral lungs
| 2. mag sulfate for seizure prophylaxis
191
Severe Preeclampsia treatment
1. prevent eclampsia with mag sulfate
2 contol bp with hydralazine
3 deliver (refer to mild treatment if preterm or term)
192
Eclampsia
defined as a tonic-clinc seizure occurring in a pt with a hx of preeclampsia
193
Eclampsia treatment
first stabilize the mother, then deliver the baby. seizure control is done with mag sulfate and blood pressure control with hydralazine
194
HELLP syndrome
PTs have hemolysis, elevated liver enzymes, low plateletes
195
HELLP syndrome
treatment
first stabilize the mother, then deliver the baby. seizure control is done with mag sulfate and blood pressure control with hydralazine
196
Diabetes
Pregestational diabetes
Gestational diabets
197
Pregestational diabetes
means that a women had diabetes before she becamee pregnant
198
Pregestational diabetes
maternal complications
four times more likely to have preeclampsia
two times more likley to have a spontaneous abortion
increased rate of infection
increased ostaprtum hemorrhage
199
Pregestational diabetes
fetal comlications
increase in congenital anomalies (heart and neural tube defects)
```
macrosomia
shoulder dystocia (fetus's shoulder gets stuck under the symphsysis pubis during delivery is one complications asociate with macrosomia
```
preterm labor
200
Pregestational diabetes
evaluation
these tests shuld be done ina ddition to the usual prenatal tests:
EKG
24 hour urine for baseline renal function
creatinin clearance
protein
HbA1C
ophthalmological exam fro baseline eye fucntion and assessing the condition of the retina
201
Pregestational diabetes
fetal testing 32-34 weeks
weekly nonstress test (NST) and us
NST: fetal well-being
US: fetal size
202
Pregestational diabetes
fetal testing >36 weeks
twice-weekly testing; one nst and one biophysical profile (BPP)
nst: fetal well-being
bpp: amount of amniotic fluid and fetal well-being
203
Pregestational diabetes
fetal testing 37 weeks
lecithin/sphingomyelin ratio (L/S ratio)
asess fetal lung maturity test (if mature>deliver)
204
Pregestational diabetes
fetal testing 38-39 weeks (if patient refuses L/S ratio)
no test, just induction of labor
205
Gestational diabetes
complications
preterm birth
fetal macrosomia
birth injuries from fetal macrosomia
neonatal hypoglycemia
mothers with getational diabetes are 4 to 10 ties more likely to develop type 2 diabetes after the delivery
206
Gestational diabetes
evaluation
routinely screened for between 24 and 28 weeks of gestational age. a glucose load test is done first. it consists of nonfasting ingestion of 50 g glucose, with a measurement of serum glucose one hour later. if the serum glucose is above 140mg/dl, then a glucose toleracne test is done. the glucose tolerance test consists of the ingestion of 100 g og flucose after fasting, with 3 measurements of serum glucose at 1,2,3 hours. if any serum glucose measurements are elevated, gestational diabetes is confirmed
207
glucose load test
nonfasting ingestion of 50 g of glucose followed by serum meaasurement of glucose one hour later
<140 mg/dl
no gestational diabetes
208
glucose load test
nonfasting ingestion of 50 g of glucose followed by serum meaasurement of glucose one hour later
>140mg/dl
oral glucose tolerance test
fasting ingestion of 100 mg of glucsoe gollowed by serum glucose measurements at 1,2, and 3 hours after ingestion
if all normal no further tests
elevation of serum glucose at 1,2 and 3 hours= gestational diabetes
209
gestational diabetes
first -line treatment
diabetic diet and exercise (walking) are the first line treatments for gestational diabetes. however, if this failus to control blood sugars adequately (fasting greater than 95 mg/dl and one hour postprandial greater than 140mg/dl), medication is indicated.
210
Gestational Diabetes
insulin
NPH before bedtime and aspart before meals
211
Gestational Diabetes
refractory to diet or refuse insulin
both metformin and glyburide may be both safe and effective
if they have type 2 diabetes they may not achieve glycemic control with oral agents and insulin should be used
212
do not tell pregnant ptiants what
to lose wieght it is the most common wrong answer, once patients are put on insulin they should follow fetal testing schdudel starting at 32 weeks
213
Fetal growth abnormalities
intrauterine growth restriction
macrosomia
214
Intrauterine growth restriction
definition
fetuses with Intrauterine growth restriction wiegh int he bottom 10% for their gestational age
215
Intrauterine growth restriction
etiology
chromosal abrnormalities
neural tube defects
infections
multiple gestations
maternal htn or renal disease
materanal substance abuse (smoking is the number-one preventable cause in the US)
216
Intrauterine growth restriction
diagnostic tests
us is done to cofirm gestational age and fetal weight
217
Intrauterine growth restriction
complications
premature labor
stillbirth
fetal hypxoia
lower iq
seizures
mental retardation
218
Intrauterine growth restriction
treatment
there is no conclusive treatment for iugr other htan to try and prevent :
quit smoking
prevent maternal infection with immunization (but not live immnizations)
219
Macrosomia
definition
fetuses with estimated birth weight over 4500 g are considered macrosomic babies
220
Macrosomia
risk factors
maternal diabetes or obesity
advanced maternal age
postterm pregnancy
221
Macrosomia
diagnostic tests
on phsical exam, normally the funal height should equal the gestational age in weeks (ie the life of the patient is 28 weeks so the fundal height is 28 cm), in macrosomia the fundal height will be at least 3 cm greater thant he gestational age (ie the pt is 28 weeks and the fundal height is 31 cm)
222
if fundal height is more than 3 cm greater than the gestational age
us should be done
us confirms gestational age by
223
us confirms gestational age by
femur length
abdominal circumference
head diameter
224
Macrosomia
shoulder dystocia
birth injuries
low apgar scores
hypoglycemia
clavicle fracture
brachial plexus injuries
225
Macrosomia
treatment
induction of labor should be considered if th elungs are mature before the fetus is above 4500 g in weight
c section delivery is indicated if fetus is above 4500 g in weight
226
Fetal Testing
Nonstress Test
Biophysical profile
227
Nonstress test (NST)
the nst allows the physician to check for fetal well-being while still in the uterus. NST measures fetal movements and assesses the fetal heart rate
228
A reactic Nonstress test (NST) is defined as:
detection of two fetal movements
acceleration of fetal heart rate greater than 15 bpm lasting 15 - 20 seconds over a 20 minute period
229
a reactive Nonstress test (NST) shows:
the fetus is doing well, and no furthur testing is indicated. if the nonstress test is nonreassruing the fetus could be sleeping. vibro acoustic stimulation is done to wake up the baby
230
Biophysical Profile
consists of NST
fetal chest expansions (count episodes fo fetal chest expansions; normal is 1 or more episodes in 30 minutes)
fetal movement (count fetal movements; normal is more than 3 in 30 minutes)
fetal muscle tone (fetus flexes an extremity)
amnioic fluid index (volume of amniotic fluid based on sonogram)
231
Biophysical Profile
scoring
each category is owrth 2 points, a bpp of 8 to 10 is normal, to 8 is inconclusive, less tahn 4 is abnormal
232
Normal Labor
EFM
physiological chagnes before labor
induction of labor
233
Electornic Fetal monitoring
when a pt presents in labor, an external tocometer is placed on the gravid abdmoen to measurethe fetal heart rate and uterine contractions
234
Fetal heart rate
normal: 110-160
brady: <110
tachy: >160
235
Accelerations
Normal accelerations are an increase in heart rate of 15 or more beats per minutes above the heart rate baseline for longer than 15-20 seconds. if this happens twice in 20 minutes, it is reassuring or normal
236
Early decelerations
decrease in heart rate that occurs with contractions
head compression
237
variable decelerationss
decrease in heart rate and return to baseline with no relationship to contractions
umbilical cord compression
238
Late decelerations
most serious and dangerous
decreasej in heart rate after contraxtion started. no return to baseline until contraction ends
fetal hypoxia
239
Physiological Changes Before Labor
lightening: fetal descent into the pelvic brim
braxton-hicks contractions: begin contractions that do not result in cervical dilation: they routinely start to increase in frequency towards the end of pregnancy
bloody show: blood-tinged mucus from vagina that is released with cervical effacement
240
Stage 1
begining to end -
duration -
begining to end - onset of labor > full dilation of cervix
duration - primipara 6-18 hours, multipara 2-10 hours
241
latent phase
begining to end -
duration -
begining to end - onset of labor > 4 cm dilation
duration - primipara 6-7 hours, multipara 4-5 hours
242
active phase
begining to end -
duration -
begining to end - 4 cm dilation > full dilation
duration - primapara 1 cm per hour (minimum), multipara 1.2 cm per hour (minimum)
243
stage 2
begining to end -
duration -
begining to end - full dilation of cervix > delivery of neonate
duration - primipara 30 mintues to 3 hours, mutlipara 5 mintues to 30 minutes
244
stage 3
begining to end -
duration -
begining to end - delivery of neonate > delivery of placenta
duration - 30 minutes
245
Stage 1 monitor the following
maternal blood pressure and pulse
electronic fetal monitor: fetal herat rate and uterine contraction
examine cervix to montor the progression of labor for:
cervical dilation
cervical effaceemnt
station
246
Station
where the fetus's head is located in relationship to the pelvis
measured -3 thorugh +3 (bottom of the ischial tuberosity)
0 is middle of pubic ramus
3 is about where the superior head of femur is
247
effaced
cervix is thinned out
248
Stage 2 of labor
begins whent he cervix is fully dilated andthe mother wants to push. The rate of fetal head descent determines the progression of this stage. the fetus goes thorugh severeal steps in this stage
249
Stage 2 of labor
step 1
engagement:
fetal head enters the pelvis occiput first
250
Stage 2 of labor
step 2
descent:
progresses as uterine contractions and maternal pushing occur
descent continues until the gerus is delivered
251
Stage 2 of labor
step 3
flexion:
fetal head flexion
252
Stage 2 of labor
step 4
internal rotation:
when fetus's head reaches the ischial spines, the fetus starts to rotate
rotation moves the safittal sutures into the forward position
253
Stage 2 of labor
step 5
Extension:
occurs so taht the head can pass through vagina (oriented forward and upward)
254
Stage 2 of labor
step 6
External Rotation:
during fetal head delivery, external rotation occurs, giving the shoulders room to descend
255
Stage 2 of labor
step 7
delivery of anterior shoulder:
gently downward pressure on the fetal head will aid in delivery of antrior shoulder
256
Stage 2 of labor
step 8
Delivery of posterior shoulder:
gentle upward pressure on the fetal head will aid in delivery of posterior shoudler
the rest of the fetus will follow
257
Stage 3 of labor steps
immediately after delivery, inspect and repair lacerations of the vagina while waiting for placental separation.
258
signs of placental separation include
fresh bleeding from vagina
umbilical cor-lengtheneing
uterine fundus rising
uterus becoming firm
259
Induction of Labor
means to start labor via medical means
260
Induction of Labor
medications
prostaglandin E2 is used for cervical ripening
oxytocin
exaggerates
normally found in the posterior pituitary (drug is aversion of the naurally occurring substance)
Amniotomy
puncture of the amniotic sac via an amniohook
inspect for a prolapsed umbilical cord before puncturing the amniotic sac
261
do not give prostaglandins to who
asthmatic patients it may provoke bronchospasm
262
arrest of cervical dilation
when there is no dilations of the cervix for more than 2 hours
263
protracted cervical dilations occurs when the
primara's cervix does not dilate more than 1.2 cm in one hour. it is dilating slowly but still dilating
264
arrest of descent is when
the fetal head does not move down into the canal
265
Prolonged latent stage
definition
occurs when the latent phase lasts longer thatn 20 hours for primipara and longer than 14 hours for multipara
266
Prolonged latent stage
etiology
Sedation
unfavorable cervix
uterine dysfunction with irregular or weak contractions
267
Prolonged latent stage
treatment
rest and hydration. most will convert to spontaneous delivery in 6 to 12 hours
268
Protracted Cervical Dilation
definition
protraction occurs when there is slow dilation during the active phase of stage 1 labor, less than 1.2 cm per hour in primipara women, and less than 1.5 cm per hour in multipara
269
Protracted Cervical Dilation
etiology
the 3 p's are:
power: strength and frequency of uterine contractions
passenger: size and position of fetus
passage: if passenger is larger than pelvis= cephalopelvic disproportion
270
Protracted Cervical Dilation
treatment
treatemnt of cephalopelvic disportion is c section. if the uterine contractions are weak, oxyctocin may be given
271
Arrest Disorders
Types
cervical dilation: no cervical dilation for 2 hours
fetal descent: no fetal descent for 1 hour
272
Arrest Disorders
etiology cephalopelvic disproportion
accounts for half of all arrest disorders
| treat via c section
273
Arrest Disorders
etiology malpresentation
fetus is older than 36 weeks with the presenting part soemthing other than the head, meaning the head is not downward
274
Arrest Disorders
other etiology
excessive sedation/anethesia
275
Malpresentation
lower half of fetus (pelvis and legs) is presenting part
the presenting part is the part of the fetal body that is closes to the vaginal canal and will be engaged when labor starts. normally it is the head (cephalic presentation); however, in malpresentation it can be a foot or a buttock
276
Malpresentation
can be felt on physical exam
leopold manuevers are a set of 4 manuervers that estimate the fetal weight and the presenting part of the fetus
vaginal exam: with malpresentation, u feel a mass isntead of the normal hard surgace of skull.
277
Malpresentation
diagnostic evaluation
the fetus needs to be visualized with us to confirm the diagnosis
278
frank breech
fetus' hips are flexed with extended knees b/l
279
complete breech
fetus's hips and knees are flexed b/l
280
footling breech
fetus's feet are first: one leg (single footling) or both legs (double footling)
281
Malpresentation
treatment
with external cephalic version, the caregiver maneuvers the fetus into a cephalic presntation (head down) through the abdominal wall. you should not perform this aneuver until after 36 weeks gestation. the fetus can maneuver itself into a cephalic presentation (head first) before 36 weeks
282
Shoulder Dystocia
occurs whent he fetus's head has been delivered but the anterior shoulder is stuck behind the pubic symphysis
283
Shoulder Dystocia
risk factors
maternal diabetes and obesity causes fetal macrosomia
postterm pregnancy allows the baby more time to grow
hx of prior shoulder dystocia
284
Shoulder Dystocia
Mcroberts maneuver
first-line treatment
| maternal flexion of knees into abdomen with suprapubic pressure
285
Shoulder Dystocia
Rubin maneuver
rotation of the fetus's shoulders by pushing the posterior soulder towards the fetal head
286
Shoulder Dystocia
woods maneuver
rotation of the fetus's shoulder by pushing the posterior choulder towards the fetal head
287
Shoulder Dystocia
other treatment
delivery of posterior arm
deliberate fracture of fetal clavicle
288
Shoulder Dystocia
Zavanelli maneuver
push fetal head back into the uterus and perform cesarean delivery
high rate of both maternal and fetal mortality
last maneuver to try
289
Potparum hemorrhage
definition
postpartum hemorrhage is defined as bleeding more than 500 ml after delivery. early postpartum bleeding occurs within 24 hours of delivery, while late postpartum bleeding occurs 24 hout to 6 weeks later
290
Potparum hemorrhage
etiology
normally, postpartum, the uterine contractions compress the blood bessels to stop blood loss. in uterine atony, this does not occur. uteirne atony accounts for 80% of postpartum hemorrhage. other causes include laceration, retained parts, and coagulopathy.
291
any factor that indicates that a fetus is too big or the pelvis is too small
is a risk factor for shoulder dystocia
292
Risk factos for Atony
anesthesia
uterine overdistention (such as in twins and polyhydramnios)
prolonged labor
laceration
retained placenta (can occur with placenta accreta)
coagulopathy
293
Potparum hemorrhage
treatment
examine the uterus by bimanual examination. assure that there is no rupture of the uterus and that there is no retained placenta. if the examination is unremarkable, bimanual compression and massage should be done. this will control most cases of postpartum bleeding. if the bimanual massage does not control the postpartum bleeding, administer oxytocin to make the uterus contract, constricting the blood vessels and decresing the blood flow
294
atony=
wihtout contractions
295
sheehan syndrome
after postparutm hemorrhage presents as inability to breastfeed
296
Premenstrual syndrome and premenstrual dysphoric disorder
definition
begin when women are in their 20s to 30s. PMDD is more severe version of PMS that will disrupt the pts daily activities
297
Premenstrual syndrome and premenstrual dysphoric disorder
sx
headache
breast tenderness
pelvic pain and lboating
irritability and lack of energy
298
Premenstrual syndrome and premenstrual dysphoric disorder
diagnostic tests
there are no tests for the diagnosis of pms or pmdd; pmdd has dsmV diagnostic criteria. the patient should chart her sx. the following must be present to meet the diagnsotic criteria:
sx should be present for 2 consecutive cycles
sx free period of 1 week in the first part of the cycle (follicular phase)
sx must be present in the secondhalf of the cycle (luteal phase)
dysfunction in life
299
Premenstrual syndrome and premenstrual dysphoric disorder
treatment
pt should decrease consumption of caffeine, alcohol, cifarettes, and chocolate and should exercise. if sx are severe give SSRIs
300
Menopause
definition
the result of permanenent loss of estrogen, Menopause occurs in pts aged 48 to 52. it starts with irregular menstrual bleeding. the oocytes produce less estrogen and progesterone, and both the LH and FSH start to rise. women are symptomatic for an average of 12 months, but some women can experience sx for years
301
Menopause
sx
mentrual irregularity
sweats and hot flashes
mood changes
dyspareunia (pain during sexual intercourse)
302
Menopause
physical exam findings
atrophic vaginitis
decrease in breast size
vaginal and cervical atrophy
303
decrease estrogen =
osteoporosis
304
Menopause
diagnostic tests/treatment
if the diagnosis is unclear, an increased FSH level is diagnostic. Hormone replacement therapy is indicated for short-term symptomatic relief as well as the prevention of osteoporosis
305
HRt is associated with
endometrial hyperplasia and can lead to endometrial carcinoma
306
HRT CI
estrogen-dependent carcinoma (breast or endometrial cancer)
hx of pe or DVT
307
postcoital bleeding
cervical cancer until proven otherwise
308
Menorrhagia
Description
heavy and prolonged menstrual bleeding
gushing of blood
clots may be seen
309
Menorrhagia
Etiology
endometrial hyperplasia
uterine fibroids
dysfunctional uterine bleeding
iud
310
Hypomenorrhea
Description
light menstrual flow
may only have spotting
311
Hypomenorrhea
Etiology
obstruction (hymen, cervical stenosis)
oral contraceptive pills
312
Metrorrhagia
Description
intermentrual bleeding
313
Metrorrhagia
Etiology
endometrial polyps
endometrial/cervical cancer
exogenous estrogen adminstration
314
Menometrorrhagia
Description
irregular bleeding
time intervals
duration
amount of bleeding
315
Menometrorrhagia
Etiology
endometrial polyps
enomterial/cervical cancer
exogenous estogen administration
malignant tumors
316
Oligomenorrhea
Description
mentrual cycle > 35 days long
317
Oligomenorrhea
Etiology
pregnancy
menopause
significant weight loss (anorexia)
tumor secreting estrogen
318
Postcoital bleeding
Description
bleeding after intercourse
319
Postcoital bleeding
Etiology
cervical cancer
cerical polyps
atrophic vaginitis
320
abnormaluterine bleeding diagnostic tests
cbc to see if hb and hct have dropped
pt/ptt to evaluate for coagulation disorder
pelvic us to visulaize any aatomical abnormlaity
321
Dysfunnctional uterine bleeding
definition
unexplained abnormal bleeding. also occurs wehn pts are anuovulatory. the ovary produces estrogen, but no corpus luteum is fomred. without the corpus luteum, progesterone is no produced. this prevents the usual withdrawal bleeding. the continuously high estrogen continues to stimulate growth ofthe endometrium. bleeding occurs only once the endometrium outgorws the blood supply
322
Dysfunnctional uterine bleeding
diagnostic tests
rule out systemic reaaseons for anovulation, such as hypothyroid and hyperprolactinimia. endometrial biopsy for women over 35 to exclude carcinoma
323
there is no specific test for
DUB confirm by excluding other causes
324
any pt older than 35 with abnormal bleeding should undergo
endometrial biopsy to rule out endometrial carcinoma
325
Dysfunnctional uterine bleeding
ocp treatment
adolescents and young women who are anobulatory
women over 35 who have a normal endometrial biopsy
326
Dysfunnctional uterine bleeding
acute hemorrhage
d and c is done to stop the bleeding
327
severe Dysfunnctional uterine bleeding
if pts are anemic, are ot controlled by ocps, or report that their lifestyle is compomised, treat with endometrial ablation or hysterectomy
328
Contraception
female condoms
vaginal diaphragm
ocps
vaginal ring
transdermal patch
im injection
iud
sterilization
329
female condoms
the female condome has 2 rings and a thing material in between. one ring is placed deep into the vagina whilet the other ring is left at the introitus. female condoms offer some protection against HIV and STDs and are under female control. they are larger and bulkier than male condoms
330
Vaginal Diaphragm
a circular ring with cotraceptiv jelly that covers the cervical canal. the diaphragm without the jelly is ineffective. the jelly is also used as a lubricant while placing the diaphragm
331
Vaginal diaphragm timing
should bej plaed 6 hours before intercourse and left in for at least 6 hours after intercourse
332
Disadvantages of a diaphragm
need to be fitted properly (can change with weight gain of pregnancies)
proper use of diaphragm requires advance perparation
improper placement or dislodging of diaphragm reduces efficacy
333
OCPs
most commonly a combo pill of both estrogen and progesterone. the pill is taken for 21 days and a placebo is taken for 7 days. during the 7 days of placebo pills, the pt will experience menstruation. women should start using the ocp on the sunday after menstruation
334
ocps reduce the risk of
ovarian carcinoma, endometrial carcinoma, and extopic pregnancy.
335
ocps increase risk of
thromboembolism
336
Vaginal Ring
a flexible vaginal ring that releases both estrogen and progesterone is inserted into the vagina for 3 weeks. hormones are released ona constant basis. when the ring is removed, withdrawal bleeding will occur. the gainal ring has similar side effects and efficacy to OCs
337
Transdermal ptach
a transdermal patch with a combination of estrogen and progesterone is palced on the skin for 7 days. eah week the previous patch is removed and a new patch is placed. three weeksa of patches are folowed by a ptach free week, during whichthe pt will experience whtdrawal bleeding. pathces should not be placed on the breast. the side effects and efficacy are the same as ocps
338
Im injection bc
depot medroxyprogesterone acetate is an im injection that is effective contraception for 3 months
339
IUD
placed intot he uterus an dprovides contraception for 10 years. there are 2 types, a copper device and a lveonorgestrel device. these devices are associated with pelvic inflammatory disease when they are placed. genital cultures must be done before placement of these devices
340
Sterilization
surgical sterilization can be done on both men and women. sterilization via tubal ligation and vasectomy is permanent and irreversible
341
Sterilization
tubal ligation
surgical procedure that women may choose to undergo for permanent contraception. the risk of prenanyc is very low, but if it occurs,there is an increased incidence of ectopic pregnancy
342
Sterilization
vasectomy
surgical procedure in which ligation of the as deferens is performed
343
Labial Fusion
occurs wehn excess androgen are present this can occure with extaneous angdorgen administration or by increaed androgen prodution. the most common cuase is 21b hydroxylase deficiency. the treatement of labial fusion is reconsructiv surgery
344
Lichen Sclerosis
age group affected
any age can be affected; however, is postmenopausal there is an increased risk of cancer
345
Lichen Sclerosis
description
white, thin skin extending from labia to perianal area
346
Lichen Sclerosis
treatment
topical steroids
347
Squamos cell hyperplasia
age group affected
any age; pts who have had chronic vulvar pruritus
348
Squamos cell hyperplasia
description
pt with chronic irritation develop hyperkeatosis (raised white lesion)
349
Squamos cell hyperplasia
treatment
sitz baths or lubricants (relieve the pruritus)
350
Lichen planus
age group affected
30s-60s
351
Lichen planus
description
biolet, flat papules
352
Lichen planus
treatment
topical steroids
353
Bartholin gland cyst
bartholin glands are locatedon the lateral sides of the vulva. they secrete mucus and can become obstructed, leading to a cyst or abscess that causes pain, tenderness, and dyspareunia
354
Bartholin gland cyst
pe
edema and inflammationof th earea with a deep fluctuant mass
355
Bartholin gland cyst
treatment
similar to other cysts or abscesses. it needs to be drained. a simple incision and drainage (I&D) should be done. if htey continue to recur then marsupialization should be done. during i&d the fluid released should be cultured for std such as gonorrhead and chlamydia
356
Bartholin gland cyst
marsupialization
is a form of i&d in which the open space is kept open with sutures. this allows the space to remian open, and decreases the risk of a recurrent Bartholin gland cyst
357
Vaginitis
types
bacterial vaginosis
canidiasis
trichomonas (the most comomn nonnviral std)
358
Vaginitis
risk factors
any factor that will increase th eph of the vagina like:
antibiotic use (lactobacillus normally keeps the vaginal ph below 4.5)
diabetes
overgrowth of normal flora
359
Vaginitis
sx
patients present with itching, pain, abnomral odor, and dishcarge
360
Bacterial Vaginosis
Pathogen -
sx -
diagnostic test -
treatment -
Pathogen - gardnerella
sx - vaginal discharge with fishy odor, gray white
diagnostic test - saline wet mount shows clue cells
treatment - metro or clindamycin
361
Candidiasis
Pathogen -
sx -
diagnostic test -
treatment -
Pathogen - candida albicans
sx - white, cheesy vaginal discharge
diagnostic test - KOH shows pseudopyphae
treatment - miconazole, or clotrimazole, econazole, or nystatin
362
Trichomonas (the most common nonviral STD)
Pathogen -
sx -
diagnostic test -
treatment -
Pathogen - trichomonas vaginalis
sx - profuse, green, frothy vaginal discharge
diagnostic test - saline wet mount shows motile flagellates
treatment - treat both pt and partner with metro
363
Malignant disorders
paget disease
squamos cell carcinoma
364
paget disease
definition
an intraepithelial neoplasia tha tmost commonly occurs in postmenopausal caucasian women
365
paget disease
presents with
vulvar soreness and pruritus appearing as a red lesion with a superficial white coating
366
paget disease
diagnosis
biopsy for definitive dx
367
paget disease
treament
bilateral lesion is a radiacl vulvectomy if unilateral a modified vulvectomy can be done
368
Squamos cell carcinoma
definition
most common type of vulvar cancer
369
Squamos cell carcinoma
presents with
pruritus
blood y vaginal discharge
postmenopausal bleeding
pe can range froma small ulcerated lesion to a large cauliflowerlike lesion
370
Squamos cell carcinoma
diagnosis
biopsy, staging is done while the pt is in surgery
371
Squamos cell carcinoma
staging
0-4a
372
Squamos cell carcinoma
state 0
carcinoma in situ
373
Squamos cell carcinoma
stage 1
limited to vaingal wall <2cm
374
Squamos cell carcinoma
stage 2
limited to vulva or pernieum >2cm
375
Squamos cell carcinoma
stage 3
tumor spreading to lower urethra or anus, unilateral lymph nodes present
376
Squamos cell carcinoma
stage 4
tumor invasion into bladder, rectum, or b/l lymph nodes
377
Squamos cell carcinoma
treatment
unilateral lesions iwhtout lymph node involvmeent is a modified radical vulvectomy. treatment for bilateral involvement is radiacl vulvectomy. lymph nodes that are invovled must undergo lymphadenectomy
378
Uterine abnormalities
adenomyosis
Endometriosis
379
Adenomyosis
definition
the invasion of ednometrial glands into the myometrium. this usually occurs in women between the ages of 35 and 50.
380
Adenomyosis
risk factors
endometriosis and uterin fibroids
381
Adenomyosis
presents with
dysmenorrhea and menorrhagia
382
Adenomyosis
diagnosis
cilinical diagnosis
on pe the uterus is large, globular, and boggy
MRI is the most accurate test
383
Adenomyosis
treatment
hysterectomy is the only definitive treatment. it is the only way to diagnose adenomyosis definitively
384
Endometriosis
definition
implantation of endometrial tissue outside of the endometrial cavity. Although the endometrial tissue can imoplant anywhere, the most commonsites are theovary and pelvic peritoneum. occurs in women of reproductive age andis more common if a first-degree realtive (mother or sister) has endometriosis
385
Endometriosis
presents
cyclical pelvic pain that start 1 to 2 weeks before menstruation and peaks 1 to 2 days before mensruation. the pain ends with menstruation. abnormal bleeding is common. the pe reveals a nodular uterusand adnexal mass
386
Endometriosis
diagnostic tests
diagnosis can be made only by direct visualization via laparoscopy. direct visualization of the endometrial impalnts looks like rusty or dark borwn lesions. on the ovary, a cluster of lesions called an endometrioma looks like a chocolate cyst.
387
Endometriosis
treatment
analgesics can be done with nsaids, if mild ocps may work
modeate to severe sx are placed on danazole or leuprolide acetate, both are used to decrease FSH and LH
388
Danazol
is an androgen derivative that is associated with acne, oily skin, wieght gain, hirsutism
389
Leuprolide acetate (leurpron)
is a GnRH agonsit and when given continuously suppresses estrogen. associated with hot flashes and decreased bone density
390
Endometriosis
surgical treatment
considered for pts who have severe sx or are infertil. surgery attempts to remove all fo the endometrial implants and adhesions, and to restore pelvic anatomy. pts who have completed their childbearing may undergo total abdominal hysterectomyy and bilateral salpingo-oophorectomy.
391
PCOS
symptoms
occur in women of reproductive age
amenorrhea or irregular menses
hirsutism and obesity
acne
diabetes mellitus type2 (increased insulin resistance
392
PCOS
diagnostic tests
pelvic us will show b/l enlarged ovaries with multiople cysts present. free testosterone will be elevated secondary to the high androgens. the high androgen level and obesity lead to an increase in estrogen formation outside the ovary. this stimulates LH secretion while inhibiting fsh secretion, leading to an LH to FSH ration of more than 3:1.
393
PCOS
treatment
weight loss: pts who are obese hsould be conuseled to lose weight, which will decrease the insulin resistance
ocps control the amounts of estrogen and progestin that are in the body. this both controls the androgen levels and prevents endometrial hyperplasia. this should be used only if the pt does not wish to have children
clomiphene and metformin should be used in pts who with to conceive
