OBGYN Flashcards
FSH stimulates _____ cells to make _____.
sertoli/granulosa, estrogen
LH stimulates _____ cells to make _____.
leydig/theca, testosterone & progesterone
highest mortality for GYN cancers…
Ovarian > Endometrial > cervical
highest incidence of cancer in women…
breast > lung > colon
highest mortality of cancer in women…
lung > breast > colon
pap smear screening
21q3
do a pap smear and it comes out showing ASCUS. what do you do?
ASCUS = atypical squamous cells of uncertin significance.1. repeat pap q3 months untill resolves or do an HPV DNA screen.ASCUS and HPV + = ColposcopyASCUS and HPV - = q3yASCUS and +repeat = ColposcopyASCUS and -repeat = q3y
Who gets vaccinated for HPV?
EVERYONE!Female: 13-26male: 12-21 or 26 still up for debate.
how do you dx endometrial cancer?
this will be seen in post meno women wiht abnormal bleeding = do endometrial sampling and a D&C, can also do pelvic ultrasound to see if thickness is <5mm.
do bx for endometrial sampling and you see hyperplasia tx? adenocarinoma tx?
hyperplasia = progesterone –| estrogen via blocking FSHAdenocarcinoma = TAH + BSO*if there is mets tx w/Carboplatin & Paclitaxel
Tx of most GYN cancers w/mets?
Carboplatin & Paclitaxel
which mole has 69 chromosomes? pathogenesis?
incomplete mole, x2 sperm + 1 egg
which mole has 46 chromosomes? pathogenesis?
complete mole, 1 sperm + empty egg that duplicates.
Sx of a complete/incomplete mole?
elevated B-HCG, rapid increasing size compared to date, Hyperthyroidism(bhcg looks like TSH), Hyperemesis Gravidarum(severe, dehydrating morning sickness w/electrolyte abnormalities), snowstorm on pelvic U/S, grapelike masstx: D&C and give OCP to prevent pregnancy
MCC of Vulvar cancer? MC type?
SCC caused by HPV
DES is associated wiht….
Adenocarcinoma of the vagina
46XX w/primary amenorrhea
Mullerian agenesis= no Müllerian ducts = no uterus or upper vag+ boobs, pubes, ovaries but -uterus = primary amenorrhea
46XY w/primary amenorrhea
Androgen insensitivity=no androgen receptor! Balls present and making testosterone but due to lack of receptor wolf degrades, MIF degrades mullerian.+testes +breast -pubes -uterus =primary amenorrhea
45X w/primary amenorrhea
Turners!No ovaries and no estrogen!Streak ovaries, short stature, webbed neck, infertility, amenorrhea, broad chest, urinary track abnormalities, bicuspid aortic, aortic core Tatian, dysgerminomas risk, normal intelligence- ovaries,breast,pubes but + uterus = primary amenorrhea
Amenorrhea and can’t smell
Kallman syndrome = no GnRH = no LH & FSH = no E&P-boobs +uterus
Causes of primary amenorrhea
Kallman syndromeMullerian agen(46XX)Androgen insensitivity(46XY)Turners (45X)Swyer Syndrome(46XY)
What is important to do for ppl with androgen insensitivity that you don’t do for mullerian agenesis?
Remove testes once developed to prevent cancer and then start hormone therapy.
Kallmann syndrome tx
Replace hormones appropriate for sex
all girls should develop menarche by —- and begin to develop secondary sex char by —-.
15, 13
testosterone in mullerian agen vs androgen insens?
normal in mullerian but elevated in androgen insen.
what does a negative progesterone challenge test tell you?
absence of withdrawal bleeding is caused by either inadequat estrogen priming of the endometrium or outflow tract obstruction(imperforate hymen).
what does a positive Progesterone challenge test tell you?
diagnostic of anovulation! = need to give cyclic progesterone to prevent endometrial hyperplasia. give Clomiphene if pregnancy is desired.
What does a negative estrogen-progest challenge test tell you?
diagnostic of outflow obstruction or endometrial scarring(Asherman Syndrome) = do hysterosalpingogram(HSG) to ID
What does a positive estrogen-progest challenge test tell you?
bleeding = there just wasnt enough estrogen in the first place. look at FSH to ID etiology.elevated FSH = ovarian failurelow FSH = need to r/o brain tumor.
what is asherman syndrome?
scarring of the uterus due to extensive uterine curettage and infection-producting adhesions.
define secondary amenorrhea
women of reproductive age who has stopped having periods for >6 months. ^nobody waits that long to investigate though lol
causes of secondary amenorrhea
- Pregnancy2. Hypothyroidism3. Prolactinoma4. Meds5. Menopause6. Savage Syndrome/Resistant ovarian Syndrome7. Asherman’s Syndrome8. Hypothalamus9. Primary Ovarian Insufficiency
how does hypothyroid cause secondary amenorrhea? how do you treat?
hypothyroid = increased TSH = increases prolactin production = inhibits GnRH causing amenorrhea.*will also see dec FSH & LH(duh) just like wiht a prolactinoma.tx: levothyroxine
work up and tx of prolacintoma
suspect if galactorrhea or amenorhea. get prolactin level then MRI.tx: Pramixpaxole < cabergoline
what drugs will cause secondary amenorrhea?
DA antagoinist like atypical antipsychotics.
hormone levels in menopause…
elevated FSH and LH
28 yo women who has 2nd amenorrhea. FSH and LH are elevated. U/S shows many follicles. dx? tx?
Savage Syndrome/Resistant ovary Syndrome = basically early menopause =(*no tx =(
causes of vaginal bleeding in premenstral girls. Whats the most common?
- Foreign Body (MC)2. sexual abuse3. precocious puberty4. Sarcoma Botyroidesdx: speculum Exam!
causes of vaginal bleeding in reproductive age women. Whats the most common?
- Pregnancy(MC)2. Anatomy(PALM COEIN)3. Dysfunctional/abnormal Uterine Bleeding
causes of vaginal bleeding in postmenopausal women. Whats the most common?
- Atrophy(MC)2. Endometrial Carcinoma3. Hormone Repacment Therapy(HRT)
What are the escalating steps for heavy, life threatening bleeding.
*always remember 2 large bore IVs + IVF1. IV estrogen to stop2. Balloon tamponade3. D&C4. Uterine A. Embolization5. Hysterectomy
PALM COINE
Polyps, Adenomyosis, Leiomyomas, Malignancy, Coagulopathies, Ovarian Dysfunction, Endometrial probs, Iatrogenic = IUD, Not Yet Classified^causes of anatomic causes of uterine bleeding
What are Fibroids?
Leiomyomas in the Uterus = benign. Asymmetric, hard nodules, painful, may have iron def due to bleeding, can cause problems wiht pregnancy or obstruction due to location(due to size). Will increase in size with estrogen. dx: U/S tx: w/OCP
Adenomyosis. tx?
endometrium grows into the myometrium. symmetrically enlarged, soft, tender uterus, menorrhagia and dysmenorrhea
when is abnormal uterine bleeding(AUB) normal?
near menarche or menopause
how do you dx AUB? Tx?
exclusion! tx: OCP & NSAIDs to reduce bleeding
What happens in Polycystic ovarian Syndrome?
ovary is replaced by thousands of follicles that produce large amounts of estrogen which then is converted to testosterone = fat, hairy, irregular menses, deep voice, trouble getting prego, DM, dyslipidemiadx: LH/FSH >3 makes dx. elevated testosterone but normal DHEAStx: OCP + Metformin(reduces androgens), clomiphene to help with getting prego
IUP w/bleeding, closed OS, U/S shows live baby….
threatened abortion, get bed rest and see if its okay.
IUP w/bleeding, open OS & U/S shows dead baby..
inevitable abortion
IUP w/bleeding, + passage of clots, open OS, retained parts…
Incomplete abortion
IUP w/bleeding, + passage of contents, closed OS, U/S shows nothing…
complete abortion
1st trimester to induce abortion
misoprostol
Rh - mothers need to be given….
Rogam! = mom doesnt Rh factor and will have Ab to this factor – baby will have this factor = give rogam toprevent abortion
UPT +, vaginal bleeding…next step?
do U/S to diff = baby, abortion, molar prego or ectopic pregnancy
How do you use B-quant in ectopic prego?
B-quant = bhcg.If >/=1500 and in fallopian tube = ectopic.if <1500 and in fallopian tube = wait! may still be traveling to uterus = wait 48hrs and try again.
When can you use methotrexate + leukovorin for ectopic pregnancy?
if bhcg <5000 or 8000, <3cm, no heart tones, moms not on folate
tx for non-ruptured ectopic prego…
salpingostomy = reach in and remove
Amenorrhea
No peroids for 3+ consecutive months
Swyer Syndrome
46XY congenital lack of testes. Resulting in no MIS causing female appearance
What are the 3 phases of the mentral cycle? Days?
- Menstrual phase (1-4) drop in E&P cause break down of functional layer2. Proliferate phase( 5-14): follicle grows producing increasing estrogen which promotes the growth of endometrium and inhibits LH(this theca and progest)3. Secretory phase(14-28) high estrogen causes + feedback on LH causing theca to increase progesterone = stabilizing endometrium.
@d28 what happens if prego?
bhCG produced by implanted egg supports CL allowing it to continue to produce progesterone until wk 10 when placenta takes over allowing CL to degrade, bhcg levels to fall but E&P levels maintained
HD estrogen will….
Stimulate LH(test+P)
Prolactin production is triggered by…
TSH, D will block prolactin
How long after ovulation can an egg be fertilized?
12-24 h
How long after ejaculation can sperm survive in the vagina?
24-48h
How does lactation prevent pregnancy?
Elevated prolactin blocks GnRH but only works for about 6months
can you give OCPs to reduce the size of ovarian cysts?
nope! they dont work dont do this
what do you give a young girl wiht irregular, heavy bleeding? why?
NSAIDs, young women who just started menarche will often have abnormal cycles likely do to anovulation and NSAIDs are kinda like pushing the reset button on it to regulate the cycle.
what do you do when you find a cysts between 3-10cm?
reimage within 12 weeks(U/S) to show any growth. if not just ignore it. if less than 3cm dont need to reimage.
tx for complex cysts?
laparoscopy to remove just the cysts.
tx teratoma? type of pt u see this in? what are they at risk for? why?
<20 yoa, weight gain or abdominal growth, large cysts, tx w/cystectomy to spare ovary.*at risk for ovarian torsion due to extra weight from teratoma!
what is a chocolate cysts? sx?
endometriosis! causing dysmenorrhea, dyspareunia and infertility.
tx of endometriosis
NSAIDS + OCP then for real fix = surgical ablation/resection
what is the best dx for chocolate cysts?
laproscopic visulization w/lazer ablation.
how do you usually dx endometriosis?
give OCP trial and if they get better = endometriosis; give NSAIDs for pain.
women presents with severe and sudden onset of abdominal pain that was not provoked by anything. dx? workup? tx?
U/S will likely show a cysts = weight causes twisting around suspensory ligament.*surgery to untwist and tack down ovary! if necrotic remove.
Pt w/history of multiple Gc/Chla infections now presents with fever, leukocytosis and adenexal mass. workup ? tx?
U/S will show ABSCESS = needs to be drained and started on abx(cefoxitin, doxy, metro, clinda, genta)
where do the ovarian A & V come from on the right?
IVC & Aorta
where do the ovarian A & V come from on the left?
Aorta & Renal Vein*just like in men
what vessels are in the suspensitory ligmanets?
ovarian A & V
Where does the uterus get its blood supply from?
Internal iliac A. gives off uterine A.
What is post partum hemorrhage?
vaginal delivery = 500 ccC-section = 1000 cc
What can you do to stop post partum hemorrage?
- Uterine Massage2. Meds(OXYTOSIN)3. Balloon Tamponade4. Surgery = ligate Uterine A then Internal Iliac and if that doesnt work do TAH.
What is the Uterosacral Ligament?
connects uterus to the sacrum. need to be removed with TAH. Be careful bc they might look like Ureters
What is the Cardinal Ligament?
connects the uterus to the side wall + covers front and back of the uterus & connects the uterus to the bladder & rectum
what ligament is weak in…rectocele, cystocele & uterine prolapse?
weak cardinal ligament + pelvic floor relaxation*increased risk with large multiple births
Grading of Uterine Prolapse. how do you dx? tx?
- lower2. almost to vaginal opening3. right at vaginal opening4. prolapsed out of vagina.dx w/PE. tx w/ hysterectomy or sling
How do you dx cystocele?
PE will show mass @ the roof of vagina; presents w/incontence
how do you dx rectocele?
PE will show mass at back of vagina; constipation relieved by inserting fingers into the vagina
Stress IncontinenceCause? tx?
weakened pelvic floor can cause bladder to fall into the vagina = cystocele. any increase in intraabdominal pressure can cause leakage of urine. dx via PE. Tx = pessaries to strengthen floor. if that doesnt work do surgery
urge to void the bladder is at —-cc.
250
when the bladder reaches —cc and above it becomes painful.
500
Motor/Hypertonic Incontinencehow do you dx? tx?
random detrusor muscle contractions that can occur at any time, randomly & @all volumes.*day & night urination w/insuppressible urges.dx: cytometry = shows contractions at all volumes.tx: antispasmodics(solifenacin) or antimuscarinics(oxybutynin)
Overflow or Hypotonic Incontinencehow do you dx? tx?
lesions of the pine or nerves of any kinda(trauma, diabetic neuropathy, multiple sclerosis) = loss of sensory feedback indicating fullness. involuntary loss of urine day and night WITHOUT THE URGE OR ABILITY TO VOID. Bladder never empties.dx: cystometry shows absence contractionstx: timed voids w/bithanechol or cathiterization
pt w/constant and continuous leak of urine day or night…dx?
fistuladx: inject dye into bladder or rectum and insert tampon in vagina if leak then the dye will leak onto tampon
Human Chorionic Gonadotropin(hCG) is made by —- and peaks at —.
placental syncytiotrophoblast, 10 weeks
Human Placental Lactogen(hPL) is simular to —– and causes—-.
GH & Prolactin, antagonizes the cellular actions of insulin = pregnancy glucose intolerance
Estradiol
dominant during reproductive years = from granulosa cells
Estriol
dominant during pregnancy = from placenta
Estrone
dominant during menopause = from adipose tissue
Why do you get these skin changes in prego: Striae gravidarum, spider angiomas & palmer erythema, Chadwich Sign, Linea Nigra, Chloasma.
Striae gravidarum = stretch makrs, spider angiomas & palmer erythema = increased skin vascularity, Chadwich Sign = bluish or purple discoloration of the vagina and cervix as a result of increased vascularity, Linea Nigra = midline pigmentation, Chloasma = blotchy pigmentation fo the nose and face
Changes in Prego w/CV
decrease BP in 1st trimester, lowest at 24wks(should never see elevated arterial bp in prego). increase in plasma volume, decrease in SVR, increase in CO(loest in supine, highest in left later pos). left sternal systolic ejection murmer
Changes in Prego w/Endocrine
increase in pituitary size and vasculitty, increase cortisol, increase in TBG due to estrogen = elevated T3/T4 total but normal free T3/T4
Changes in Prego w/Renal
increase in volume = increase in kidney size, increase GFR, dec BUN, dec Cr, glucosuria
Changes in Prego w/Pulmonary
tidal volume increases due to elevated diaphragm, residual volume decreases ==> RESPIRATORY ALKALOSIS from dec Pco2 & inc pH
Changes in Prego w/GI
decreased GI motility & gastric motility due to increased progesterone
Changes in Prego w/Heme
increase in RBC MASS; will see dillutional anemia, increased WBC count(max 16,000 @3rd trimester), normal platlets, increased coag factors from liver
3 in utero shunts within fetus
- Ductus Venosus: umbilical vein –> IVC2. Foramen Ovale: RA –> LA3. Ductus Arteriosus: Pulmonary A —> descending aorta
puberty takes — yrs to complete and is usually done by age —.
3-4, 16 yoa
dafuq do the following do for lactation: Progest, Estro, Prolac, oxytocin
Progest: increase lobules, alveoliEstrogen: increase ductsProlac: milk productionOxy: milk let down
Colostrum
first secretion of mammary ducts after deliver, high in protein low in fat. contains IgA for passive immunity.
how many days after delivery for milk production to reach appreciable levels
1-3d
estrogens effect on prolactin
estrogen helps ducts develop but also antagonizes positive effect of prolactin on milk production; once placenta is removed prolactin can go to work.
What happens wk 1 postconception?
implantation of the blastocysts on the endometrium
What happens wk 2 postconception?
bilaminar germ disk with epiblast and hypoblast layers; invasion of material sinusoids by syncytiotrophoblast = 1st time bhCG prego test can be positive
What happens wk 3 postconception?
trilaminar germ disk with ectoderm, mesoderm & endoderm is formed
What happens wk 4-8 postconception?
Major organs formed most important time
after 9 wks teratogens will mostly effect..
organ hypertrophy and hyperplasia
Ionizing Radiation in pregnancy
no single diagnostic procedure results in radiation exposure to a degree that woudl threaten the developing baby.
Chemotherapy in prego..
greatest risk in first trimester; 2-3 is most resitant
Tobaccos fx on prego
causes intrauterine growth restriction(IUGR)
Fetal Alcohol Syndrome
midfacial hypoplasia, microcephaly, mental retardation, IUGR, short palpebral fissures, long philtrum, cardiac defects
Cocaine use in prego
assoc w/placental abruption, preterm deliver, intraventricular hemorrhage, IUGR
Marijuana use in prego
preterm delivery
Diethylstilbestrol(DES) in pregnancy..
“estrogen” that caused T-shaped uterus, vaginal adenosis w/risk of clear cell carcinoma, cervical hood, incomplete cervix, preterm delivery
Dilantin in pregnancy
aka phenytoin. can cause: fetal hydantoin syndrome(IUGR, craniofacial dysmorphism(epicanthal folds, depressed nasal bridge, oral clefts), mental retardation, microcephaly, nail hypoplasia, heart defects)
Isotretinoin(accutane) in pregnancy
congenital deafness, microtia, CNS defects, congential heart defects
Lithium in prego
ebsteins anomaly =atrialization of the right ventrical due to tricuspid valve being displaced down into the ventrical
streptomycin in prego
inhibits 30s ribosome. Causes CN8 dmg(hearing) = hearing loss
tetracyclin in prego
blocks 30s ribosome. teeth discoloration/anomalies after the 4th month
thalidomide in prego…what does this treat?
tx multiple myeloma. causes: phocomelia(malformed limbs), limb retardation, ear/nasal anomalies, cardiac defects, pyloric or duodenal stenosis
Trimethadione in prego..
anticonvulsant. causes: facial dysmorphisms(short upturned nose, slanted eyebrows), cardiac defects, IUGF, mental retardation
Valproic acid(depakote) in prego
NTD(spina bifida), cleft lip, renal defects
Warfarin(Coumadin) in prego
Chondrdysplasia(strippled dpiphysis), microcephaly, mental retardatoin, optic atrophy
define: abortion
loss prior to 20 wks
MC trisomy causing 1st trimester lost
trisomy 16
MC trisomy @term
21
Klinefelter Syndrome
47XXY; dx usually made during puberty = tall, testicular atrophy, azopermia, gynecomastia, truncal obesity, learning disorder, AI dz, low IQ
Down Syndrome
trisomy 21: mental retardation short stature, muscular hypotonia, brachycephaly, short neck, oblique orbital fissure, flat nasal bridge, small ears, nystagmus, protruding tongue, congential heart disease, duodenal atresia
Edward Syndrome
trisomy 18: profound mental retardation, rocker bottom feet, clenched fist, F > M; mean survival = 14days
Patau Syndrome
trisomy 13: frofound mental retardation, IUGR, Cyclopia, Proboscis, holoprosencephaly, severe cleft lip w/palate. meav survual = 2days
AD dz’s
polydactyly, hunting chorea, achondroplasia, marfan, myotonic dystrophy, PCKD, NF, Osteogenesis imperfecta
AR dz’s
deafness, CF, thalassemia, albinism, SS anemia, Tay-Sachs dz, PKU, CAH, Wilson
XLR Dz’s
Hemophila A, Color blindness, complete androgen insensitivity, diabetes insipidus, hydrocephalus, G6PD deficiency, Duchenne muscular dystrophy
neural tube should close by —- postconception.
22-28 d
women at risk for NTD should consume —mg of folic acid. Those who are not shoudl take —mg.
risk = 4mg; no risk = 0.4 mg
complications of D&C
endometritis and retained products of conception(POC)
medical abortion drugs….when can you use these?
Mifepristone = progesterone antagonist + Misoprostol = PGE1*used within first 63days, works w/in 3 days
D&E use? complications?
2nd trimester abortion procedure; comp: uterine performation, retained tissue, hemorrhage, infection, DIC
What 4 things need to be ruled out immediately in early prego bleeding?
Lesions, RH -, Molar Pregnancy, Ectopic Prego
type of abortion: sonogram w/nonviable prego but NO bleed, dilation or anything else
missed abortion tx w/D&C
type of abortion: viable prego w/vaginal bleeding but no cervical dilation
threatened abortion! = observation
type of abortion: vaginal bleeding, cramping, cervical dilation but no POC passed yet..
inevitable abortoin = D&C if bleeding is heavy if not just wiat
type of abortion: vaginal bleeding, cramping, cervical dilation with some but not all POC passed
incomplete abortion! = emergency D&C if bleeding is heavy if not wait
type of abortion: vaginal bleeding and cramping w/no POC on sonogram
complete abortion; if previous IUP had been confirmed just tx sx. if not then monitor bHCG to r/o ectopic prego
what is the most serious complication of fetal demise? when is this seen? what do you do if this is present?
DIC! seen w/fetal death >2 wks ago = due to release of thromboplastic from decaying fetus. if present do emergent D&C(<23wks) or induction w/prostoglandins(>/= 23wks). if not DIC just wait for natural abortion/delivery
dx of ectopic prego can be made with….
> 1500 bhCG w/o IUP on vaginal sonogram
tx of ruptured ectopic prego
SURGERY NOW!
tx of unruptured ectopic prego
- Methotrexate(<3.5cm, no fetal heart beat found, bhCG <6000)2. Laproscopy w/Salpinostomy or Salpingectomy
Criteria for methotrexate use for ectopic prego
<3.5cm, no fetal heart beat found, bhCG <6000
Define Abortion, preterm birth and full term birth
Abortion = <20 wksPTB = 20-36 wksFTB = >36 wks
whats Chorionic Villus Sampling(CVS)? when is this done? why?
U/S giuded samping of chorinonic villi = done between 10-12 wks = done for karyotyping
Amniocentesis. Whens this done? why?
U/S guided amio sampling, done after 15 wks, takes living fetal cells = fetal karyotpying, NTD screening,
Whats a Percutaneous Umbilical Blood Sample? Whats this used for? when can it be done?
transabdominal procedure done under U/S guidanace to sample fetal blood from umbilical vein after 20 wks. Done for karyotyping, looking at IgG, can be used to give transfusions. prego loss risk 1-2%
Fetoscopy. When is this done? WHy?
done after 20 wks, bascially fetal surgery or skin biopsy. prego loss risk 2-5%
how do you date a pregnancy?
40 weeks after last menstrual period
how do u calculate prego due date?
LMP - 3 months + 7 days
sx of prego in 1st trimester. normal weight gain?
NV, fatigue, breast tenderness, frequent urination, SPOTTING AND BLEEDING(20%), weight gain 5-8 lbs
sx of prego in 2nd trimester. normal weight gain?
feeling better!(morning sickness i gone), Round Ligament pain w/movment due to stretching. Normal weight gain is 1 lb per week after 20 wks
sx of prego in the 3rd trimester. normal weight gain?
decreased libido, back/leg pain, urinary freq, braxton-hicks contractions, LIGHTENING(fetal head moves into pelvis resulting in cervical dilation and less pressure on diaphragm), easier breathing, BLOODY SHOW(vaginal passageof bloody endocerical mucus indicating cerivcal dilation befor labor). 1lb per week after 20wks
Vaccines safe in prego(6)
influenza(all), hep B(exposed), hep A(exposed), Penumococcus(high risk only), Meningococcus(outbreaks), Typhoid
Vaccines you cannot give in prego(6)
measles, mumps, polio, rubella, yellow fever, varicella
How much weight should you gain during prego if you are underweight?
28-40lbs
How much weight should you gain during prego if you are of normal weight?
25-35lbs
How much weight should you gain during prego if you are overweight?
15-25lbs
How much weight should you gain during prego if you are obese?
11-20lbs
prego women lacks rubella ab. what do you do?
advise to avoid travel to places w/rubella & vaccinate AFTER delivery as it is a live vaccine
Mothers blood type is A-. why is this important?
she lacks the Rh surface antigen so she has antibodies to the surface antigen and will need rogam @ delivery + follow up testing
mother is + for syphilis. what do you do?
treat her w/ penicillin
mother is + for PPD test. how do you work this up?
CXR! if + treat w/triple therapy(RIPE) if negative treat w/9 months of INH + B6
Quad screening shows: decreased MS-AFP & Estriol but elevated hCG & Inhibin-A this corresponds w/….
Trisomy 21! DS!
Quad screening shows: decreased MS-AFP, Estriol, hCG & Inhibin-A this corresponds w/….
Trisomy 18! Edwards Syndrome
3rd trimester screening tests
- Diabetes2. CBC3. Atypical Antibody Testing
define late pregnancy bleeding…
vaginal bleeding after 20 wks
management of late bleeding in pregnancy..
CBC, DIC workup, type + cross + match, Sonogram! (NEVER PERFORM A DIGITAL OR SPECULUM EXAM UNTILL U/S RULES OUT PLACENTA PREVIA), large bore IV w/NS, Urinary Catheter
Abruptio Placentadx? tx?
normally implanted placenta separates from the uterine wall before delivery of the fetus. dx w/U/S. tx: C-section, vaginal delivery >36 wks, conservative if stable
Placenta Previadx? tx?
placenta is implanted in the lower uterine segment. dx w/U/S. tx: tx: C-section, vaginal delivery if less than 2cm covering os, conservative if stable then planned C-section
Placenta Accreta vs Placenta Increta vs Placenta Percreta
Placenta Accreta = villi invader the deeper layers of the endometrial deciduus basalis but do not penitrate myometrium.Placenta Increta = villi invade myometriumPlacenta Percreta = villi invade all teh way to the uterine serosa or the bladder
Placenta Accreta
Placenta Accreta = villi invader the deeper layers of the endometrial deciduus basalis but do not penitrate myometrium.
Placenta Increta
Placenta Increta = villi invade myometrium
Placenta Percreta
Placenta Percreta = villi invade all teh way to the uterine serosa or the bladder
Vasa Previa
fetal vessels transcerse over Os.classic triad: rupture of membranes, painless vaginal bleeding, fetal bradycardia
Uterine Rupturedx? tx?
vaginal bleeding, loss of electronic fetal HR, ab pain, loss of station of fetal head. dx: surgical exploration, tx w/ immediate delivery
Criteria for preterm labor
- 20-37 week2. 3 contractions in 30 min3. Cervical dilation of at least 2 cm or effacement
Matemal IV —
MgSO4
Tocolgtic agents can be used to prolong pregnancy for no more than —
72 hrs ! Enough time to move mom to place with neonatal ICU and give IV bethamethasone
4 tocolytic agents and their major C/I
- MgSO4 IV - renal insufficiency and myasthenia gravies2. Terbutaline - cardiac dz, DM, uncontrolled hyperthyroidism3. CCB (nifedipine)- hypotension4. Indomethacin(PG blocker) - >32 weeks = will close PDA :(
Define Premature Rupture of Membranes
rupture of the fetal membranes before onset of labor
What is the typical presentation of PROM? what is the MCC?
sudden gush of copeous vaginal fluid that is usually clear. U/S would show Oligohydramnios. MCC is infection(Chorioamnionitis) but can be non infectious
How do you dx Chorioamnionitis? when do you commonly see this?
CLINICALLY DX! = maternal fever, uterine tenderness in the presence of confirmed PROM in absence of UTI or URI.
Mother w/PROM that has uterine contractions present…how do you manage?
deliver baby + cervical culture to chck for chorioamnionitis = IV abx
define Post Term Pregnancy. MCC?
pregnancy that is 40 weeks or over. MCC is idiopathic!
How do you manage post term pregnancy?
- check gestational age! make sure shes actually post term!2. assess for likelihood of sucessful induction of labor by assessing cervix + bishop score. If bishop 8 or above = induce labor.
define Gestational Hypertension. how do you tx?
sustained BP elevation of 140/90 or greater after 20 weeks WITHOUT PROTEINURIA. tx conservatively(rest, water, less salt) if really high can use labetalol or hydralazine
What is the typical presentation of PROM? what is the MCC?
sudden gush of copeous vaginal fluid that is usually clear. U/S would show Oligohydramnios. MCC is infection(Chorioamnionitis) but can be non infectious
How do you dx Chorioamnionitis? when do you commonly see this?
CLINICALLY DX! = maternal fever, uterine tenderness in the presence of confirmed PROM in absence of UTI or URI.
Mother w/PROM that has uterine contractions present…how do you manage?
deliver baby + cervical culture to chck for chorioamnionitis = IV abx
define Eclampsia. tx?
> 140/90, Proteinuria, SEIZURES. tx: protect mothers airway and tongue, MgSO4 5g to stop seizures w/maintence 2g/h, IV oxy for deliver, diastolic BP goal 100-90 w/IV hydralazine and/or Labetalol
How do you manage post term pregnancy?
- check gestational age! make sure shes actually post term!2. assess for likelihood of sucessful induction of labor by assessing cervix + bishop score. If bishop 8 or above = induce labor.
define Gestational Hypertension
sustained BP elevation of 140/90 or greater after 20 weeks WITHOUT PROTEINURIA
define Preeclampsia. tx?
Sustained bp of 140/90 or greater WITH Proteinuria(>300 mg or Pro/Cr >0.3) tx: <37 wks = rest, hydralazine, benzo in hospital. if >37 wks = IV oxytocin to induce labor, IV MgSO4 to prevent seizures
pathophys of preeclampsia
diffuse vasospasm caused by loss of prego refractivness to vasoactive substances such as angiotension & changes decreases in prostacyclin(vasodil), increases in Thromboxane(vasoconstrictor)
tx of preeclampsia w/severe features
=sustained BP >160/110, evidence of maternal jeopardy, edematx: DELIVER NOW! = IV oxytocin, IV MgSO4 to prevent seizures, IV Hydralazine and/or Labetalol
define Eclampsia. tx?
> 140/90, Proteinuria, SEIZURES. tx: protect mothers airway and tongue, MgSO4 5g to stop seizures w/maintence 2g/h, IV oxy for deliver, diastolic BP goal 100-90 w/IV hydralazine and/or Labetalol
target diastolic bp in HTN mother
90-100
define HELLP syndrome. tx?
Hemolysis(H)Elevated Liver enzymes(EL)Low Platelets(LP)tx: prompt deliver w/corticosteroids to enhance post partium normalization of liver enzymes and platelet count.
what diabetic drug doesnt really cross the placental membrane?
Glyburide
Prego lady who is itchy. Says her sister had the same thing when she was Prego. No rash seen and dark urine. Dx? Tx?
Intrahepatic cholestasis of prego! Usually worse at night and on feet and hands too. Increased risk of preterm birth. Tx: ursodeoxycholic acid
Hirsutism
mild masculinization = fat and hairy
Virilization
hirsutism +! = fat, hairy, enlarged clitoris, deep voice, amenorrhea + increase in muscle mass
where does DHEA come from?
Adrenals in response to ACTH
5 common causes of Hirsutism/virilization
- PCOS2. Sertoli-Leydig Tumor3. Adrenal Tumor4. CAH5. Familial hirsutism
tx of vaginal atrophy
estrogen cream
tx of hot flashes
SSRI = venlafaxine
osteoporosis prophylaxis @ 50
Vit D3 + Ca
when do you do Osteoporosis screening?
dexa @ 65 or 60 if smoker
Osteoporosis tx
bisphosphonates
define Infertility
inability to conceive after 1 year
Which do you work up 1st in infertility M or F?
Male!
male workup for infertility includes…
- ED - look @ nighttime tumescence test. If psyc = counciling; If not = Sildenafil2. Semen analysis = look @ number + Motility
when should you advise a couple who wants to get pregnant to have sex?
5 days prior to ovulation and throughout the day of ovulation
ICSI vs IVD vs IUI
Intracytoplasmic Sperm Injection(ICSI) = manual sperm + egg + implantIn Vitro Fert(IVD) = Egg + sperm in dish, let fertilize nat + implant*Intrauterine Injection(IUI) = sperm injected into uterus
Female causes of infertility workup
- hostile mucous 6cm this is good. tx Estrogen2. Anovulation
What is a smush test? what is this used for?
tests infertility due to hostile cervical mucus = <6 cm on smush test = too thick =( idealy want >6cm this is good. tx Estrogen to thin mucus if too thick
Define Menopause
1yr w/o period
Primary ovarian insufficiency definition
Menopause(1yr w/o period) before age 40
MCC of Vulvovaginitis + sx
Candida, Gardnerella(BV), TrichomonasSx: pruritis, odor, discharge
workup for vulvovaginitis What would you see for each to dx?
normal saline slide & KOH prep slide1. Candida = Hyphae on KOH tx antifungal topical or fluconazole2. Gardnerella(BV) = clue cells on saline + fishy on KOH, tx metro3. Trichomonas = motile flagellated on saline, tx both partners w/metro
2 MCC of cervicitis + sx
Cla + Gonsx: yellow-green discharge, cervical motion tenderness = do wet mount + KOH + PCR
Tx for Cla + Gon
Cla = doxy or azithGon = IM Ceftriaxone
PID sx + MCCwhen do you admit?
MCC: Gon, Cla + vaginal florasx: pelvic pain, sick patient!, cervical discharge, cervical motion tenderness, uterine tenderness, adnexal tenderness (like cervicitis + other sx)**if NV, Fever = admit
Inpatient tx for PID
- Cefoxitin + doxy2. Clinda + Genta
Outpatient tx for PID
- Ceftriaxone IM + Doxy + Metro2. Cefox + probenecid + doxy + metroproben = prevents drug from being pee’d outmetro treats for anaerobes!
Define Intrauterine Growth Restriction(IUGR)
Fetus with an estimated fetal weight(EFW) <5th-10th percentile for gestational age.can be: Symmetric IUGR or Asymmetric IUGR(usually normal head but tiny body)
define Macrosomia. Complications for mom & baby?
EFW >90-95th for gestational age.Mom: perineal lacerations, PPH, Emergency C-section, pelvic floor injury.Fetus: shoulder dystocia, birth injury, asphyxia
What is a Contraction Stress Test(CST)? What do you want to see here?
tests ability of fetus to tolerate transitory decreases in intervillous blood flow that occur with uterine contractions. Expensive and 50% false +.Negative CST = no peaks on test = good sign!
What is a Nonstress Test? What are nomal results? what do you want to see?
tests frequency of fetal movements using an external heart rate monitor.<32 wks >10 bpm lasting >10s>32 wks >15 bmp lasting >15syou want to see peaks on test
oligohydramnios = —cm
<5cm fluid
Borderline oligohydramnios = —cm
5-8cm fluid
normal amniotic fluid = —cm
9-25cm of fluid
polyhydramnios = –cm
25 cm fluid
What is an Umbilical Artery Doppler? Was are some nonreassuring findings that may indicate need for delivery?
measures ratio of systolic and diastolic blood flow in the umbilical artery = bottom of troft should be above baseline for normal.*Nonreassuring findings = absent diastolic flow & reversed diastolic flow
what is the most common fetal lie& presentation in utero?
longitudinal = mom and baby on same vertical axis & cephalic = head comes out first
What does it mean if a babys lie is longitudinal?
baby and mom are in same vertical axis
What does it mean if a babys lie is transverse?
baby is at a right angle to the mother
What does it mean if a babys lie is oblique?
baby is at 45 degree angle to mother
describe a baby in frank breech
baby in breech w/legs extended up to head
describe a baby in complete breech
baby in breech with knees pulled against tummy
describe a baby in footling breech
baby in breech w/one leg extended out vagina and one knee pulled up against chest.
when does the transition from latent to active labor occur?
when cervix is 6 cm dilated
Describe the 4 stages of labor
1: Latent = onset of regular uterine contractions; Active: acceleration of cervical dilation(6cm)2: Cervix 10 cm dilated and baby descends through the birth canal3: baby delivery begins & ends with placenta delivery4: 2hr period after the end of stage 3, to monitor mom`
when do you admit a mom to the maternity unit?
when cervical dilation is at least 3 cm or PROM
Management of Prolapsed Umbilical Cord?
place pt in knee-chest position, elevate presenting pts, avoid palpating the cord, give C-Section.
Shoulder DystociaManagement?
delivery of fetal shoulders is delayed after delivery of the head. Associated w/shoulders in teh AP plane.tx: suprapubic pressure, internal rotation of the fetal shoulders to the oblique plane
normal FHR
110-160bpm
bradycardia in FHR
<110 bpm
tachycardia in FHR
> 160 bpm
What is a Biophysical Profile?
BPP: NST, Fetal chest expansions, fetal movement, fetal muscle tone, amniotic fluid index.Scored 0-10, each cat worth 2 pts, normal 8-10
@5 week b-hCG should be around….
1500-2000
@ what week will you have fetal heart beat? what will b-hCG be?
week 6! b-hCG should be around 5-6000.
how many kcals per day do you need to add for prego? what baout for breastfeeding?
300 kcal per day for prego & 500 kcal per day if breastfeeding.
Prego women w/HSIL(High grade squamous intraepithelial lesion) how do you F/U?
since shes pregnant you must do a colposcopy first & if invasive do cervical excision
@ what weeks is tocolytics C/I?
34 wks or more
before — wks you can give corticosteroids
37 wks
C/I to breastfeeding
Galactosemia, Untreated TB, HIV infection, Herpetic breast lesions, Active Varicella Infection, Chemo or Radiation, Active Substance Abuse
describe the normal changes in thyroid function during pregnancy
decreased TSH, Increased total T4 and mild increase in free T4
Pt has Hydatidiform mole removed. What will you see in b-hCG? How do you follow up?
b-hCG will slowly fall and be gone in 6 months. During this time she MUST BE ON CONTRACEPTION FOR 6 MONTHS
what type of cancer is mammary pagents dz?
adenocarcinoma
prego women w/hyperemesis gravidarum; confusion, fallen 2x while standing, nystagmus. dx?
wernicke encephalopathy(encephalopathy, oculomotor dysfunction/nystagmus, ataxia)
Risk factors for cervical cancer
tobacco use, low SES, Immunosup, oral contraceptive use, high risk sex partners, STI, HPV
inpatient PID tx
IV cefoxitin or cefotetan + doxycyclin If PCN allergy: clindamycin + gentamycin
outpatient PID tx
IM ceftriazone + oral doxy
Lichen Plantus v Lichen Simplex Chronicus v Lichen Sclerosus
Lichen Sclerosus = thin, white, wrinkled skin over the labia majora/minora + atrophic changes.Lichen Simplex Chronicus = hyperplastic response to repetitive scratching and irritation = thick leathery textured skin.*Lichen Planus = glassy bright red erosiuns and ulcerations of vulvovaginal area(purp papules assoc w/HEP C), wickham striae
Pathogenesis of ovarian torsion
ovary mass causes twisting of ovary = ischemia & necrosis
Why do you do a Biophysical Profile on a baby?
to asses fetal oxygenation through ultrasound observation and the nonstress test.
pt w/endometriosis are at greatest risk for….
infertility
what is Pseudocyesis?
woman who wants to be prego but cant basically believes shes prego = somatization stress!= somatization stress fx hypo-pit-ovar axis causing weight gain, amenorrhea and causes her to imagine a + prego test when its actually neg.dx: neg U/S, neg Prego tests + clinical
Tx of HELLP & Eclampsia?
delivery!
women in 3rd trimester comes in complaining of bleeding, PE shows bright red blood from cervix. dx?
placenta previa*shoudl always do U/S before PE
Tx of Hyperemesis Gravidarum
dietary modification > Diphenhydramine(anti-his) > Metoclopramide(D-antag) > Ondansetron(5HT antag)
What will you see with intra-amniotic Infection/Chorioamnionitis? tx?
PROM >18h, Uterine tenderness, maternal fever, fetal tach >160bpm maternal leukocytosistx: abx(ampicillin +gentamycin for vag +clindamycin if C) + delivery
Which Ig crosses the placenta?
IgG
Why is Rh incompatibility so much worse than ABO incompatibility?
Rh exposure takes time to develop so by end of 1st prego mom has recently started making IgG to baby = will make immediate attack on 2nd Rh + baby.*ABO incompatibility causes an acute response and will lyse RBCs. type O moms have large Anti A&B IgG = big hemolysis vs Type A&B moms have small O IgG & mostly IgM which doesnt really cross the membrane.
When is Rh screening done?
28 weeks
What do you do if mom is Rh- and baby is Rh+?
give Rogam @28wks and within 72 hr of birth
Presentation of Placenta Previa VS Placenta Abruption
Previa = painless vaginal bleeding in 3rd trimester, blood from cervixAbruption = Painful uterus w/bleeding in thrid trimester!
41w gestation. NST w/FHR 140. FHR decreased to 120 after contraction peak. BBP score of 4. no accelerations for >40 min dispite vibroacostic stimulation. dx?
Uteroplacental insufficiency
Itrauterine Fetal Demise(IUFD)How do you dx this?
fetal death at >20 weeks**can only dx w/lack of fetal cardiac activity(no heart movement) on transabdominal U/S*absent fetal movement or absence of fetal heart sounds on doppler could be bc baby is sleeping or not in the right position this is why you must visualize absence of heart movement w/U/S
Abortion vs Intrauterine fetal demise
Abortion is death before 20 wksIUFD comes after 20 wks
women cant get prego. she have regular menstral cycles and you have already worked up the dude and hes fine. what do you do next?
- Smush test for inhospitable Mucous2. check for ovulation(ovulation kit checking LH, Progesterone levels, BBT, Endometrial biopsy)
Managment of PPROM <34 wks; PPROM >34 wks
Preterm premature rupture of membbranes = <37 wks.if PPROM > 34 wks = deliery +abx + steroidsIf PPROM < 34 wks = managed expectantly if not infection +abx +steroids*if PPROM < 34 wks w/infection = delivery +abx + sterids**either way always give ABx + STEROIDS!
Presenation and tx of uterine rupture
sudden extreme abdominal pain, abnormal bump in abdoment, no contractions, regression of fetus as it is now floating in abdomen.tx: Laparotomy ASAP to get baby out then repair or hysterectomy
Uterine Inversion presentation and tx
lower abdominal pain, round mass protruding through the cervix, fundus not palpable, hemorragic shock.tx: fluid replacement, push uterus back in then remove placenta and give uterotonic drugs(helps uterus contract and stops bleeding)
treatment for overflow incont.
Anti-Cholinergic(betha) > cath
What is Pubic Symphysis Diastasis? cause? rf? tx?
progesterone & relaxin cause increased pelvic motility and widening, after tramatic delivery(fetal macrosomia, multiparity, precipitous labor, operative vag delivery) can present w/difficulty ambulating, RADIATING SUPRAPUBIC PAIN w/an intact neuro exam.tx: NSAIDs, PE, resolves 4-6 wks
define an acceleration on a NST (assume >35wks). whats a + NST?
acceleration: >15 bpm for >15s returning to normal w/in 2 min.+NST: >2 accel in 20 min each above 15bpm and >15s.
women reports pain with penitration. dx? tx?
genito-pelvic disorder = due to trauma, abuse or lack of knowledge.tx: kegals + desensitization
Hydralazin vs labetalol for HTN prego
cant give labetalol w/bradycardia
women with recurrent canidida inf…what shoudl you check?
a1c
baby born w/warm, moist skin, tachy, poor feeding, irritabliity, poor weight gain…dx?
neonatal thyrotoxicosis! mom prob has anti-TSHr ab! which cross the placenta causeing release of excessive TH in baby.tx: methimazol + BB = will resolve in 3 months
Young women tx for some cancer w/chemo now presents with menopause sx…wtf happened?
1 ovarian insufficiency due to chemo attacking ovaries.
28yo Prego. NV, RUQ Pain, BP 160/94, 98.9 F, Hg 8.5, Platelets 96K, +3 protein, AST/ALT elevated. dx? tx?
HELLP Syndrome = systemic inflammation + platelet consumption.tx: DELIVERY, MgSO4, Hydralazine
Whats the major benifit with transdermal estrogen?
no increased risk of DVT!
FHR monitoring: Nadir + contraction mirroring each otherWhat could this mean?
normal or fetal head compression
FHR monitoring: Nadir occurs slowly after contraction. as contraction subsides nadir is being reached.(late deceleration)What could this mean?
uteroplacental insufficiency
FHR monitoring: Nadir is sharp and not related to contractionsWhat could this mean?
cord compression, oligohydraminose, cord prolapse
How do you manage cord compression? what would you see on FHR monitoring?
move mother onto left side to avoid compressing IVC, Amnioinfusion if ruptured membranes.On FHR monitoring would see sharp decelerations not related to contractions.
describe the histology seen on bx of fat necrosis of the breast?
foamy macrophages w/fat.*may see in women how had previous breast surgery
HTN meds safe in prego
methyldopa, labetalol, hydralazine, nifedipine2nd line: clonidine, Thz
HELLP or Eclampsia…which do you deliver?
both! tx is immediate delivery!
Tx of chorioamnionitis?
- Abx(amp + genta +/- clinda if c-section)2. delivery
Placenta previa vs Placeta abrution on presentation?
Previa = PAINLESSAbrution = PAINFUL
Gestational diabetes goals. Tx hierarchy?
Fasting <95, 1hr pp <140, 2h pp <120tx: diet > insulin > metformin > glyburide
What labs do you need @ initial vists for prego?
1.RhD type + ab2.Hg/Hct, MCV(CBC)3.HIV, VDRL/RPR, HBsAg4.Rubella + varcella immunity5.pap test6. chlamydia PCR7. urine cult + protein
What labs do you need for prego @ 24-28 wks?
1.Hg/Hct, MCV(CBC)2.RhD type + ab3. 1hr Glucose tests
What labs do you need from prego @35-37 wks?
GBS Culture!
Genitourinary Syndrome of Menopausesx? pe?
sx: dryness, itching, dysparuria, urinary incon,recurrent UTI, Pelvic pressure, VAGINAL BLEEDINGpe: narrow introitus, pale mucosa, dec elasticity, dec rugae, PETECHIA, FISSURES, loss of labial volume
Women w/painful ulcers on vaginal who also has feeling of not being able to empty her bladder completely. comes in to ER complaining of Fever + HA + dysuria.how do you dx?
THIS IS HSV! dx w/ viral PCR*lumbosacral neuropathy of HSV can cause urinary retention
24 F prego, LMP 9w ago, recently stopped OCP and now has heavier periods, feels “incomplete bladder emptying” which she has had for awhile. PE shows 15w uterus w/irregular contores. dx?
leiomyomata uteri = bitch got fibroids she aight
Women with skin colored papules on labias. dx?
Condylomata acuminata = HPV 6 & 11!*smooth, flat, papules, or califlower like
Placental abrution risks factors? what are you worried about when thsi happens?
RF: HTN, trauma, Cocaine + tobacco*DIC, hypovolemic shock, fetal hypoxia, preterm deliver
Weird shit tahts normally w/in first few hrs of delivery
Shivers, temp <100.4 is considered normal, bloody discharge up to 3 weeks afterward(will get lighter and ligher in color)
Modifiable Breast cancer risk factors
HRT, Null parity, increase in age of 1st brith, alcohol
nonmodifiable breast cancer risk factors
BRCA +, 1st degree relative, white, increase in age, early menarch/late meno
23 yo F w/FNV, LQ tenderness, RUQ pain w/inspiration, intermenstral spotting, pain that is worse w/menses. dx?
PID! *intermenstral spotting was prob cervicitis
cause of symmetrical IUGR(<10% for gestational age) in 1st trimester.
Chromosomal Abnormalities > infection
cause of asymmetrical IUGR(<10% for gestational age) in 2/3st trimester.
HTN, smoking,maternal malnurition, utero-placental insufficiency
T/F raloxifene has no risk of DVTs
FALSE! Raloxifene still has risks of DVTs + hot flashes+bone & -breasts
When do u treat osteopenia?
- When they bc osteoportic 2. When they have a fragility fracture 3. When the FRAX score tells u to
15 yo girl with heavy heavy menstral bleeding. How do you stop bleeding?
IV estrogen + anti emetic bc it’s gonna make her sick
How do you explain post partum urinary retention? when shoudl you be able to pee?
regional anethesia can cause bladder atony. should be able to void 6h s/p deliver/cath removal
Hyperemesis Gravidarm dx vs regular NV in 1st trimester
presence of ketones in urine = hyperemesis!
RF for Shoulder Dystocia
big baby, mom obesity, increase weight gain in prego, gestational diabetes, post term prego
Sx in inflammatory breast carcinoma vs IDC or LBC
Inflammatory = Peau d’orange, edema + erythema*erythema not seen in others.
What happens if you dont treat primary genital herpes?
resolves on its own and will decrease in freq over time. Meds will speed resolution.
Mittelschmerz syn?
pain on 1 side of lower abdomen around d10-14 of menstral cycle lasting 1 d = ovulation!
can you breastfeed w/hep C?
yup!
mom gets epidural then hypotension why? tx?
epidural causes vasodilation + venous poolingtx: fluids, move onto Lside and give vasopressors
cervical insufficiency =
<2.5cmprogesterone
girl on period presetns with fever (102), diffuse macular rash on palsm + soles, hypotension, NV, diarrhea + AMS…dx? tx?
Toxic Shock Syndrome = will see desquamation 1-3 wks latertx: remove foreign body, Clinda+VancUsually due to GAS or S.Aureus
What must you do for a mom with hypothyroid in prego?
increase her dose of durgs bc TBG increases in prego and will further take up T4 resulting in low lvls if not.
Endometrial Bx Criteria
A. >45: AUB or postmeno bleedingB. <45: AUB w/unopposed estrogen(obesity, anov), failed men management, lynch syndrome.C. >35: Atypical GLANDULAR cells on pap
young girl w/pharyngitis, fever, lower ab pain. dx?
Gonococcal pharyngitis, test for w/NAAT
Sx of Oxytocin tox? tx?
3: Hyponatremia, Hypotension & TACHYSYSTOLEtx: 3% hypertonic saline*Oxytocin is simular to ADH
Sx of Mg tox? tx?
NV, flushing, HA, hyporeflexia, hypocal, respiratory paralysis, cardiac arresttx: stop Mg, IV Ca-gluconate bolus*sx will be worse with RENAL INSUFF!
do OCP cause weight gain?
nope
in addition to paps what must you do for owmen <25
pap + gon/chal test
tx of postpartum endometritis
clindamycin + genta
tx of Bactauria in prego
Cephelaxin, amox-clau, nitrofurantoin, fosfomycin
how do you measure cervical length?
trans vag U/S
baby born w/thin, loose skin + small, thin umbilical cord + wide anterior fontanel. cause?
FGR! = do placental hystopath
elevated AFP indicates…
abdominal wall defect*low is trisomy 18 or 21
define inadequate contractions?
<3 in 10 min w/ab soft to palp
Protracted labor in the active stage of labor.
<1.2cm/h for nullipar<1.5cm/h for multipar*tx w/augmentation of labor
Arrested labor in the acitve stage of labor.
no change in 4h w/good contracor no change in 6h w/o good contrac*tx w/augmentation of labor
Protracted labor in the second stage of labor.
longer than 2h in nullipar (3w/epi)longer than 1h in multipar(2 w/epi)*tx w/operative vag del or c-section
Arrested labor in the second stage of labor.
no pro after 3h in nulli par(4 w/epi)no pro after 2h in nulli par(3 w/epi)*tx w/operative vag del or c-section
What is secondary arrest of labor? how do you tx it?
cessation of labor that was initially doing fine for 2h…tx w/membrane rupture manually or just watch
APGAR score…explain..
Activity, Pulse, Grimance(irritability), Appearance, Respiration(cry?)0-2 normal is 7-10
how long do postpartum blues lasts? when is it postpartum depression?
blues = less than 2wksdepression = with in 6months
what organism causes mastitis? tx?
streptococcus!Penicillin or cephalosporin
Description of Candidiasis of the nipple. tx?
sore nipple, painful nipple, peeling at periphery.tx: mom w/topical clotrimazole or miconazole; baby w/oral nystatin
Signs babies is getting enough breastmilk
-3-4 stools in 24hrs-6 wet diapers in 24hrs-Weight gain-Sounds of swallowing
women is breastfeeding but experienceing great pain. her breasts are full and tender. what can you recommend to help?
frequent nuring, warm shower + hot compress, massaging breast + expressing milk to soften, good support bra, analgesic 20 min beofre breastfeeding.
- 6 wk prego B-hCG initially 1500, 48hrs later its 3100. She has 3 days of spotting and uterine cramping. What would you see on U/S?
Viable IUP = spotting common in 1st trimester & since BhCG dbled its prob a viable prego
RF for spontaneous abortion
DM, chronic RF, SLE, smoking, alcohol, radiation, infections, advaced age, advanced parity*preeclampsia is not a RF! neither is previous abortion!
T1 DM risks to baby…
spontaneous abortion, congenital malformations, IUFGR, Fetal Macrosomia, polyhydramnios, preterm birth, HTN Complication
Tx of HA in prego
Amitriptyline
how do you manage asthma inprego?
Inhaled BB, then inhaled corticosteroids or cromolyn sodium then subQ terbutaline+steroids for acute cases
how do you treat MVP in prego?
BB
Obesity risks to baby…
chronic HTN, Gestational diabetes, preeclampsia, fetal macrosomia, higher C-section rates, postpartum complications
SSRI that is not sage in prego…
paroxetine! other SSRIs are safe
target HTN in prego…
diastolic 90-100
risk factors for preeclampsia
previous hx, chronic HTN, multifetal prego, molar prego, diabetes, chronic renal dz, APLS, vascular dz, tripolidy, extremes of age
moms bleeding, baby shows tachy w/decreased variability and sinusoidal pattern…
placenta abruptio! =sinusoidal pattern shows placental insufficiency
U/S finding of RH dz…
- increase systol flow on MCA doppler.2. Fetal Hydrops(ascites, pericardial effusions + other effusions, scalp edema)
dafuq are lewis antibodies?
- Lewis Antibodies are IgM and do not cross the placenta = not associated w/isosensitization or hemolytic disease of the fetus = no F/U needed.
best indicator of severity of Rh hemolytic dz
bilirubin from amniotic fluid
Stages of Loss:
o Denialo Angero Bargainingo Depressiono Acceptance
Cytotec(Misoprostol)
o Given prior to PitocinGiven for women with unfavorable cervix/closed increases cervical ripening!
MC breech presentations
- Incomplete Breech = 3-4% *one leg down- Complete Breech = 5-12% *baby curled into ball with legs crossed- Frank Breech = 48-73% *babys legs straight up into the air
RF for breech presentation
o Prematurityo Multiple gestationo Genetic disorderso Polyhydramnioso Hydrocephalyo Anencephalyo Placenta previao Uterine anomalieso Uterine fibroids
Risks for baby/mom associated w/tobacco/smoking
o Placental abruptiono Placental previao IUGRo Preeclampsiao Infection
how long should stage 2 of labor last?
3h null2h muli*anything -1 is protracted(2h null, 1h multi)
managment of ROM & PROM?
delivery! they are at term so induce PROM and deliver be sure ot test PROM for GBS and give Ampicillin if needed
Transverse vs longitudinal cephalic v breech
Transverse = perpendicular to momlongitudinal = parallel with moncephalic = head @ cervixbreech = ass @ cervix
what should you always do when you find a prego women with HTN?
urinalysis for protein + if actual HTN and not transient = do U/S for IUGR
Preeclampsia
> 140/90 + protinuria = >37 deliver if <37 rest!*eclampsia, severe preeclampsia, HELLP deliver all these!
what causes hypercoagulability in prego?
increase clotting factors, decrease PC/S and INCREASED FIBRINOGEN*if you ever see normal fibrinogen in prego especially close to term think DIC.
complete breech
baby cris-cross apple sauce folded in a ball!
Post date baby date?
> 42wks
what do you give for seizure in a prego women with epilepsy?
phenobarbitol
what happens to TV, FEV1, FRC in prego?
tidal volume increases, FEV1 doesnt change, Functional residual capacity decreases
define premature rupture of membranes
ROM w/o contraction between 37-42 wks
what is required for an adequate CST?
3 contractions every 10 min
Precutaneous Umbilical Blood Sampling(PUBS)/Cordocentesis. why do you do this? when?
anytime between 20-32 wks to confirm fetal anemia & treat w/transfusion.*if >32 wks = deliver baby!
when do you check for anemia during pregnancy? what is normal? how do you F/U & tx?
1st and 3rd!28-30 wks = nadir of Hg/Hct: 10/30*if less than this do iron studies and tx w/iron supplimentation!
define preterm premature rupture of membranesManagement?
ROM w/o contractions between 24-36 wks>34 wks deliver<24 wks deliver/abort*24-26wks = steroids + expected managment –>risk for prolonged rupture of membranes
CST late decelerations
utero-placental insufficiency
how long shoudl stage 3 of labor last?
30 min. no matter how long the other stages were its always 30 min!
What are the rules for a reactive NST?
> 32wks = 15x15; 2x20*increase via 15 bpm for 15 sec w/2 of these occuring within 20 min<32wks = 10x10; 2x20
what bonds are broken when cervix dilates?
DISULFIDE BONDS
tx of hyperthyroid in prego? what will you see for TSH & T4:?
dec TSH, inc T4tx: CANNOT DO RADIO I! tx w/PTU and if needed can do surgery in 2nd trimester
incomplete breech
aka footling = one leg curled up the other leg sticking out!
what defines arrested active labor?
stage 1 active labor….>4h w/good contractions>6h w/o contractions
what do you do to check for Mg tox?
check DTR! these will go before respiratory depression!
Tx of epilepsy in prego?
all epilepsy drugs are teratogens!tx: L drugs are safest!*Leviteracetan & Lemotriginednt forget to add FOLIC ACID
tx of GBS?
ampicillin or Clindamycin if pcn allergy
tx of diabetes in prego?
insulin > metformin > glyburide
How long till active labor? nulli v multi?
20h in null; 14 multi*active labor is 6cm
how long should it take to progress through active stage 1 labor?
1.2 cm/h null1.5 cm/h multi*if slower = protracted labor
Misoprostole vs Mifepristone?
Misoprostole(PGE1) = causes uterus to contract ad expel productsMifepristone(–|PG) = causes trophoblast to be removed from the decidua = terminates prego
what do you test for in the 3rd trimester?
as you begin 3rd u check for 3 big things!1. Gestational Diabetes2. Alloimmunizatoin3. Anemia
tx of hypothyroid in prego? what labs will you see for tsh and t4?
dec T4 & inc TSHtx: frequent TSH assesment and give levothyroxine**if already on levo you will need to increase the dose for prego
Whats Cell-Free DNA screen? when can this be done?
ID genetic shit from babys cells that are in moms blood as early as 10 wks!
CST early decelerations
normal or head compression
whats the target BP in prego women?
BP <140/80
what happens in prego with renal shit?
increase in GFR, decrease in Cr
How do you test for gestational DM? when?
third trimester.-1h glucose: +>140-3h glucose: + if fasting >95, 1h>180 2h>155 3h>140
Define Preterm deliverymanagement?
20-34 wks<20 = abort>34 deliver20-34 depends! as long as no C/I = steroids + Tocolytics to help lungs mature! *will only last a day or so
Preeclampsia with severe features
> 160/110 + Proteinuria + any 1 of: Cr>1.1, Plt<100, elevated liver enzymes, RUQ pain, Pulmonary edema, HA or visual disturbances*basically its gonna look like help but its missing all aspects of help**can sometimes induce for vag delivery with this but often do C-section
what is prolonged rupture of membranes? managment?
> 18 hr ROM *risk for GBS, Chorioamnitis(baby still in infect), endometritis(baby out inf)tx: Ampicillin + Erythromycin
Tx of chorioamnionitis and endomeritis
clindamycin +gentamicin + ampicillin
define rupture of membranes
ROM + contraction between 37-42 weeks
If you have arrest of labor in stage 2 and you ahve already given oxytocin what do you do?
operation vaginal delivery > c-section*vacuum assited or forcepts
If you have labor arrest in stage 1 active and they tell u contractions are adequate….what do you do?
C-section! if not adequate give oxytocin!
whats the thinking behind a NST?
baby moves = increase in baby hr! –> you want to see accelerations & variability
when can you do amniocentesis? why?
> 16 wks to look for genetic defects. low risk to baby but not really done anymore bc if defects you basically only get 2-3 weeks to decided if u wanna keep it or not =/ been replaced with CVS and quad
HTN in prego?
140/80
when measuring fetal station what is 0?
ischial spine
frank breech
legs up in air
Nuchal Translucency(NT) When is this done? whats normal?
1st trimester(10-13w) - should be <3mm if more could indicate trisomy defect
when do you do MCA doppler? what does this telll u about the baby?
> 20 wks. “water flows faster than ketchup”*high diastolic = anemia
Triple Screen Vs Quad screen when are they done? why?
both in 2nd trimester(15-22wks) to id genetic disorder esp trisomies. x3 = AFP, hcg, Estriolx4 =AFP, Estriol, INHIBIN, Bhcg**18 all down, 21 has h*I up!
What is an adequate contraction? how can you tell?
use IUPC –> 200 mV in 10 min or 3 in 10 min that feel strong!
tx of HTN in prego?
alpha methyl dopa, labetalol, hydralazine,
CVS. when do you do this? why?
10-13 wks(1st trimester), checks for genetic abnormalites! = good bc can be done early = make decision earlier. 0.22% loss
what causes effacemnt of the cervix?
prostaglandins E2 can use topically to ripen cervixthis is why indomethacin can be a tocolytic
CST variable decelerations
cord compression
Tx of UTI in prego
alwasy treat!!! even if asymtomatic!1st = amoxicillin or`nitrofurantoin2nd = IV ceftriaxone
2 painfull 3rd trimester bleeding sc?
Placenta abruption & uterine rupture!
2 painless 3rd trimester bleeding sc?
Placenta previa & Vasa Previa
What do you do if you dnt know the Rh type of the baby? i.e. dad is unknown!
amniotic fluid PCR
tx of anemia in baby
*determined via Precutaneous Ubilical Blood Sampling(PUBS) if…>32 wks = deliver<32 wks = transfuse!
when do you give RhoGam in Rh- mom?
@28 wks and 72 hrs before fetal maternal mixing(birth)
Mom is Hep B +. How do you tx baby?
C-section to reduce risk of transmission +IVIg Hep B + HBV on day of delivery
What are the TORCH Infections?
Toxo, Other(Syphilis), Rubella, Cytomegalo, Herpes(HSV)
Sx of Toxo in mom?
mono-like illness in prego = baby will have brain calcifications, ventriculomegaly & seizures
sx of congential syphilis
1 trimester = dead baby2-3 trimester:saddle nose, saber skins, hutchinsons teeth(teeth w/pacman bites out of them), nasal discharge, generalized lymphadenopathy, hepatosplenomegaly.
sx of congential rubella*when soudl mom get vac?
1 trimester = IUGR or Abortion3 trimester: “blue-berry muffin baby”, petechia & purpura + 3Cs(Cataracts, Congenital Heart, Cdeafness)*MMR vac 3 months prior to prego or after + avoid unvac babies
sx of CMV in mom + baby
mom: looks like the flubaby: jaundice, petechial, LP, IUGR, hearing loss, hepatosplenomeagly*prob be a distractor
sx of HSV in mom
PAINFUL BURING PRODROM then appearance of vesicles!
Dx of HSV? Tx in prego?
PCR, (Val)acyclovir from 36-delivery
sx of HSV in baby?
IUGR, preterm birth, Blindness
Criteria for VBAC?
< 2 C-sections; Low Transverse incision on previous C-section
