OBGYN Flashcards
1st trimester testing options
To determine chromosomal abnormalities with advanced maternal age: chorionic villus sampling (10-13weeks) or amniocentesis (11-14weeks). AFP, estriol, HCG, and inhibin A serve similar purpose to screen for certain aneuploidy
To determine Rh isoimmunization: percutaneous umbilical blood sample
Tocolytic agents
used to slow cervical dilation in premature labor and allow betamethasone to take effect for fetal lung development
Magnesium sulfate
CCBs
terbutaline
Magnesium toxicity: clinical presentation and TX
respiratory depression and cardiac arrest
NOTE: check DTRs often
Tx with Ca
Magnesium sulfate: side effects
flushing
HA
diplopia
fatigue
CCBs: side effects
HA, flushing, dizziness
Terbutaline: side effects
palpitations
hypotension
PPROM: TX
with chorioamnionitis: delivery (can be vaginal)
without chorioamnionitis: betamethasona, tocolytics, ampicillin, and azithro + do fewer exams
Painless vaginal bleeding in 3rd trimester
placental previa
placenta previa: risk factors
previous C-section
previous uterine surgery
multiple gestations
previous placenta previa
5 types of placenta previa
complete partial marginal vasa previa (fetal vessel present over cervix) low-lying placenta
placenta previa =
abnl implantation of the placenta over the internal cervical os
Placental abruption =
premature separation of the placenta from the uterus, resulting in hemorrhaging into the sparated space
Placental abruption vs previa vs uterine rupture
both 3rd trimester vaginal bleeding
abruption: severe abdominal pain and contractions
placenta previa: painless
uterine rupture: sudden onset severe abdominal pain, abnl bump in abdomen, no contxs, regression of fetus
NOTE: placental abruption and previa are distinguished via transabdominal US
Placental abruption: risk factors
maternal HTN prior placental abruption cocain use external trauma smoking
Complications of a concealed placental abruption
DIC uterine tetany fetal hypoxia fetal death sheehan syndrome (postpartum hypopituitarism)
Scenarios when fetal RBCs may enter moms circulation
amnocentesis abortion vaginal bleeding placental abruption delivery
Timeline for prenatal antibody screening
at 28 and 35 weeks
if unsensitized at 28wks, give rhogham (anti-D Rh immunoglobulin)
if baby found to be rh positive at delivery, give rhogham again
If mom sensitized, obtain antibody titer via indirect antiglobulin test and, if positive, do amnio to see if fetal RBCs Rh positive. If so, plan serial amniocenteses to assess fetal bili levels throughout pregnancy
Chronic vs gestational HTN
chronic: bp >140/90 before 20 weeks gestation or before pregnancy altogether
gestational: high bp after 20weeks gestation
both tx with methyldopa, labetalol, or nifedipine
Mild vs severe preeclampsia
Mild: >140/90, dipstick 1+ to 2+ protein, edema isolated to hands feet, and face, no AMS, no vision #, no impaired liver; TX without bp meds or mag sulf
severe: >160/110, dipstick 3+ to 4+ protein, generalized edma, AMS, vision changem impaired liver function; TX with mag sulfate, hydralazine, and delivery
HELLP: features
Hemolysis
elevated liver enzymes
low platelets
3 diseases of aneuploidy
Downs (21)
Edwards (18)
Pataws (13)
1st trimester screening measures
U/s looking at nuchal translucency
papp-A
HCG
2nd trimester screening measures
triple: HCG, AFP, estriol
quad: +inhibin A
2nd trimester screening measures: Downs vs Edwards
Downs: HCG up, AFP and estriol down, inhibin A up
Edwards: all down
“Downs is up”
Labs to get btw 20-28weeks
blood sugar
RH status
Hgb
Diagnosing gestational DM
1-hr gtt (asymptomatic screen): if greater than 140 --> 3 hr gtt: fasting >90 1hr >180 2hr >155 3hr >140 NOTE: any 2 = gDM
Accuracy of US in determing GA
1st trimester: GA +/- 1week
2nd trimester: GA +/- 2weeks
3rd trimester: GA +/- 3weeks
Percutaneous umbilical blood sampling: Use
done after postive trasncranial doppler
Allows for access for transfusion in preterm baby in iso-immunized mom
asymptomatic UTI in pregnant woman: TX
amoxicillin
nitrofurantoin if penicillin allergic
Cystitis in a pregnant woman: TX
amoxicillin
nitrofurantoin if penicillin allergic
Pyelonephritis in pregnancy: TX
ceftriaxone inpatient then 10 day course of antibx if initial improvement
if no initial improvement, get US to look for abscess
seizure ppx in pregnancy: ideal drugs
leveteracitam or lamotrigine
NOTE: valproate and phenytoin more teratogenic
If pregnant woman seizes, give ___
phenobarbital
Adequate contractions during labor
3 contractions every 10 minutes or 200mV in 10 minutes
Preterm GA
weeks 24-37
Infectious premature rupture of membrane: most common cause and tx
GBS
PROM (occurs during term but no contxs yet)
TX with ampicillin if GBS positive or unknown
endometritis/chorioamnionitis: definition and TX
infection of endometrium vs chorion (sac)
ampicillin + gentamycin +/- clindamycin
Worry about fetal lung maturity before____
34weeks
Severe features of pre-eclampsia
BP >160/110 thrombocytopenia elevated LFTs RUQ pain HA vision change Nl or elevated creatinine Generalized edema
Fraternal twins =
Di-zygotic (2 fertilizations), di-chorionic, di-amniotic gestation
Different types of mono-zygotic gestations (3)
(1) Mono-zygotic, di-chorionic, di-amniotic (early split of single fertilization)
(2) Mono-zygotic, mono-chorionic, di-amniotic (split during blastocyst phase with 2 organisms sharing a placenta and at risk for twin-twin transfusion syndrome)
(3) Mono-zygotic, mon-chorionic, mono-amniotic (split after day 12–> conjoined twins at risk for cord entanglement)
Post-partum hemorrhage: vaginal vs c-section
vaginal: 500cc
C-section: 1000cc
post-partum hemorrhage with firm uterus =
retained placenta (accreta, increta, percreta)
NOTE: Follow Beta-HCG after getting the retained part out
Ways to stop uterine bleeding (3)
Uterine artery ligation (OB)
Uterine artery embolization (IR)
Hysterectomy (OB)
Post-partum hemorrhage and boggy uterus following prolonged labor =
uterine atony
TX: oxytocin, methergine, hemabate
US-based biophysical profile: scores and components
8-10 (good)
0-2 (fetal demise imminent–> c-section)
Occurs if there is a failed NST+vibro-acoustic stimulation
Components: NST (0-1) amniotic-fluid index (0-2) NL is btw 8 and 25 breathing (0-2) movement (0-2) tone (0-2)
Heart rate rises: NL
Hr rise of 15bpm in 15 minutes
2 rises in 20 minutes
VEAL CHOP
Variable decels
early decels
accels
late decels
Cord compression (maybe OK)
head compression (OK)
OK
utero-placental insufficiency (bad)
Delivery of fetus with anemia due to moms attack
greater than 32 weeks
Risk factors for GBS infection
previous GBS infection
prolonged ROM
intrapartum fever
All of these neeed intrapartum antibx (ampicillin, cefazolin, clinda, or vanc)
What to give with mom who is Hep B positive
Hep B IVIG AND vaccine at delivery
What antiretroviral therapy to give in pregnancy
tenofavir + emtricibane + Nevirprine
OR
zidovidine + larunidine + atazanavir
Intranatal toxo infection
Mom with risk factors for exposure and mono-like illness during pregnancy (didnt have previous exposure to toxo and antibodies to protect herself)
Baby: brain calcifications, ventriculomegaly, seizures
TX of late latent vs tertiary syphillis
late latent: IM qwk x3
tertiary: IV q4hr x 7-10d
Intranatal rubella exposure: effects on baby
Primary viremia most dangerous
blueberry muffin rash (petechia and purpura)
Cataracts
Congenital heart defects
Deafness
IUGR (if contracted in first trimester)
Congenital herpes infection: clinical features
IUGR
preterm
blindness
Lacerations during episistomies
Grade I: only involves vagina
II: extends into perineum
III: invades anal sphincter
IV: involves anal mucosa
Post-coital bleeding
cervical cancer (SCC)
black and itchy vulvar lesions
vulvar cancer (SCC)
Symptoms of ovarian cancer
these are symptoms of invasion
renal failure, SBO, ascites
Hyperemesis gravidarum, hyperthyroidism, and size-dates discrepancies =
choriocarcinoma
If pap smear shows ASCUS
get either HPV DNA testing (if positive, do colpo) or another pap in 6months (if again ASCUS, do colpo)
Features of colposcopy
brushing to sample endocervix
depresser-stick for ectocervix
Endometrial carcinoma: TX
total abdominal hysterectomy and BSO +/- chemo and radiation if their are mets
Risk factors of placenta accreta
prior c-section
h/o dilation and curettage
advanced maternal age
Baby with small body size, microcephaly, digital hypoplasia, nail hypoplasia, midfacial hypoplasia, hirsutism, cleft palate, and rib anomalies
fetal hydentoin syndrome
Follow-up of abnormal prenatal screen at 15wks
amnio
Follow-up of abnormal prenatal screen at 10-13 weeks
chorionic villus sampling
N/V, elevated serum aminotransferases, and hypoglycemia in 3rd trimester
acute fatty liver of pregancy
Encephalopathy, oculomotor dysfunction (horizontal nystagmus), and postural and gait ataxia in setting of hyperemesis gravidarum
thiamine deficiency –> Wernicke encephalopathy
TX with IV thiamine followed by glucose infusion
AA pregnant female with new facial hair and bilateral ovarian masses is most likely
luteoma
will spontaneously regress after pregnancy
Intrahepatic cholestasis of pregnancy: TX
ursodeoxycholic acid
Condylomata lata vs acuminata
lata: from secondary syphilis, flat velvety lesions
acuminata: from HPV(6 and 11), cauliflower-like and skin-colored
Unilateral bloody discharge without a coexisting breat mass and with a normal mammogram
intraductal papilloma
Prevention of preterm labor in female with past preterm delivery
serial cervical length measuremments
progesterone administration
cerclage placement
Secondary amenorrhea due to intrauterine adhesions from endometrial infection or instrumentation
asherman syndrome
Meds to give in preterm labor <32 weeks vs btw 32 and 34
<32: betamethasone, tocolytics, mag sulf, penicillin if GBSpositive or unknown
32-34: betamethasone, tocolytics, penicillin if GBSpositive or unknown
Normal physiologic thyroid related changes in pregnancy: Total T4 vs free T4 vs TSH
Estrogen increases TBG
Total T4: increases
Free T4: unchaged or mildly increased
TSH: decreased (beta-HCG suppresses)
Extraglandular features of Sjogren syndrome
arthritis raynauds dyspareunia cutaneous vasculitis ILD non-Hodgkin lymphoma
Complications of cervical conization
cervical stenosis
cervical incompetence
preterm delivery
Ovarian germ cell tumors
Dysgerminoma: chemo, LDH
Endometrial sinus: AFP
Teratoma: can cause stroma ovarii
Choriocarcinoma: beta-HCG
NOTE: these are nonmalignant and present as adenexal masses at stage I
Ovarian epithelial cell tumors
seroud
mucinous
endometroid
brenners
NOTE: all considered cystoadenocarcinomas, extremely malignant, risk increases with age (more ovulations), present as stage IIIb, seed peritoneally producing ascites
Genes that predispose risk for ovarian epithelial cell tumors
BRCA 1/2
HNPCC
Marker to track ovarian epithelial cell tumors
Ca-125
Ovarian stromal cell tumors
granulosa-theca–>estrogen
sertoli-leydig–>testosterone
size-date discrepancy, hyperemesis gravidarum, markedly elevated beta-HCG , hyperthyoroidism
complete or incomplete molar pregnancy
molar pregnancy: management
suction curretage
follow beta-HCG for year while on OCPs (so that you know rise in beta-HCG is from invasive disease)
choriocarcinoma: TX
surgical + medical (with mtx, actinomycin D, and cyclophophamide if refractory)
Vulvar cancers (3)
SCC: black and itchy
melanoma: black and itchy
NOTE: both the above involve vulvectomy and LN dissection
pagets: red and itchy (good prognosis)
Grape like mass in vagina =
adenocarcinoma
think DES exposure in utero
PCOS: Meds and MOAs
OCPs: regulate menses
clomiphene: ovulation induction
spironolactone: for hirsutism
NOTE: 1st line tx is weight loss
PID: Empiric tx
Inpatient: for those who are severely ill, N/V, or pregnant–> cefoxitin + doxy or clind + gent
Go to surgery if no improvement
Outpatient: Ceftriaxone, Doxy, and metro
Discriminatory beta-HCG
1,500 is threshold
Causes of vaginal bleeding in a non-pregnant woman
Polyps
Adenomyosis
Leiomyoma
Malignancy
Coagulopathy Ovarian dysfxn Endometrium Iatrogenic (IUDs) Non-specified
Symptomatic leiomyoma: TX
first line: OCPs
for pain: NSAIDs
Surgery: if need to first shrink, use leuprolide then myomectomy; if doesnt want kids TAH
LH:FSH ratio in PCOS
3:1
Congenital adrenal hyperplasia
Hirutism
Mildly elevated DHEAS from adrenals bilaterally
Dx with CT/MRI and elevated 17-OH-progesterone in urine
Tx with cortisol and/or fludrocortisone
Signs of placental separation during stage 3 labor
fresh bleeding from vagina
umbilical cord lengthening
uterine fundus rising
uterus becomes firm
Contraindications to hormone replacement therapy in menopause
estrogen-dependent carcinoma (breat or endometrial)
H/o PE/DVT
Indications for endometrial biopsy
any patient older than 35 with AUB
TX vaginal candidiasis
miconazole or clotrimazole, econazole, or nystatin
Large, globular, and boggy uterus in woman btw 35 and 50 =
adenomysis
Adenomyosis: risk factors
endometriosis
uterine fibroids
Cyclic pelivc pain that starts 1-2 weeks before menses and peaks 1-2 days after menstruation begins
endometriosis
Nodular uterus with adenexal mass =
endometriosis
Leuprolide: MOA
GnRH agonist that when given continuously will turn off hypothalamic-pituitary-ovary axis (suppresses estrogen)
Leuprolide: side effects
hot flashes
decreased bone density
Diffuse breat erythema, warmth, pain, and edema with a peau dorange appearance and axillary LDN=
inflammatory breast carcinoma
Amenorrhea/oligomenorrhea, sxs decreased estrogen (hot flashes) in woman < 40yo
Primary ovarian insufficiency
hypergonadotropic hypogonadism
Causes of hypothalamic hypogonadism
relative caloric insufficiency
strenuous exercise
NOTE: will not see menopausal sxs as in POF
Dysmenorrhea with heavy menstrual bleeding that starts later in the reproductive years with progression to chronic pelivc pain
adenomyosis
Uterus in adenomyosis
boggy, tender, uniformaly enlarged
pelvic US in adolescent showing adenexal mass with hyperechoic nodules and calcifications
dermoid ovarian cyst (aka mature cystic teratoma)
Complication of ovarian dermoid cysts
ovarian torsion (presents as acute-onset unilateral lower abdominal pain that occus d/t necrosis of the ovarian from ischemia with lack of circulation)
Holding position of arm with anterior shoulder dislocation vs posterior dislocation
anterior: arm held abducted and externally rotated
posterior: arm held adducted and internally rotated
Oxytocin toxicity
seizures from free water reabsorption and hyponatremia
Tx of pulmonary edema in preeclampsia
loop diuretic (furosemid)
Beta-HCG levels in hydatidiform mole
> 100,000!
Lichen sclerosis: TX
high-potency topical steroids
NOTE: vulvectomy is for SCC (transformed lichen sclerosis)
Lichen sclerosis: clinical features
itchiness
dyspareunia
Loss of anatomical strcutures of the vulva (loss of clitoral hood)
