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Clerkship > OBGYN > Flashcards

OBGYN Flashcards

1
Q

GBS screening

A

Every woman should have vaginorectal GBS swab done at 35-37wks GA

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2
Q

GBS prophylactic treatment indications

A

If no swab was done, tx based on following risk factors:

  • Preterm labour <37wks
  • Maternal temp >38C (suggests chorioamnionitis)
  • Prolonged rupture of membranes >18h if symptomatic
  • GBS bacteriuria in pregnancy
  • Prev GBS w/ documented early onset GBS sepsis
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3
Q

GBS antibiotic treatment

A

Penicillin G 5 million units IV x1 then Penicillin G 2.5million U IV q4h until delivery
If Pen allergic, but no risk of anaphylaxis –> Ancef 2g IV x1, then Ancef 1g IV q8h
If pen allergic and risk of anaphylaxis, clindamycin 900mg IV q8h
If resistant to clindamycin, use vancomycin

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4
Q

Maternal fever intrapartum

A

> 38C
Suggests chorioamnionitis
Initial management: Rehydration, frequent temp checks, continuous fetal monitoring

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5
Q

Gestational diabetes screen

A

Record date, gestational weeks, +ve or -ve result of screening test btwn 24-28wks gestation

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6
Q

Stage 1 of labour

A

Onset of contractions - 10cm dilation
Latent: 0-4cm
Active: 4-10cm

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7
Q

Stage 2 of labour

A

10cm dilation –> baby comes out
latent: 10cm dilation
Active: pushing

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8
Q

Stage 3 of labour

A

Baby comes out –> placenta delivered

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9
Q

Stage 4 of labour

A

Placenta delivered –> 1h post partum

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10
Q

Cord blood samples taken at

A

2-3min post-birth, up to 20min max

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11
Q

Normal values of fetal venous blood gas

A

Arterial pH: 7.21-7.35

Venous pH: 7.3-7.4

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12
Q

When to get intrapartum fetal scalp blood sampling

A

Atypical/abnormal FH tracings
>34 wks GA when delivery not imminent
Cervix dilated at least 3cm, cephalic presentation, ruptured membranes

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13
Q

Results of fetal scalp blood sampling

A

pH >/= 7.25 –> repeat if FHR abnormality persists
pH 7.21-7.24 –> repeat within 30mins or consider delivery if rapid fall since last sample
pH = 7.20 –> DELIVER

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14
Q

Results of lactate scalp testing

A 
<4.2 = normal 
4.2-4.8 = Repeat within 30min 
>4.8 = DELIVER
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15
Q

APGAR Scores

A 
Appearance - colour 
Pulse 
Grimace 
Activity 
Respiration 
Max out of 10 (0, 1, 2 for each category)
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16
Q

Normal IA

A

110-160bpm
Regular rhythm
Absence of decelerations
Presence of accelerations

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17
Q

Abnormal IA

A

HR <110 or >160
Irregular rhythm
Presence of decelerations
Absence of accelerations over prolonged period

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18
Q

Frequency of IA

A

Low risk pregnancy
Latent phase of stage 1: q1h
Active phase of stage 1: q15-30min
Stage 2: q5-15min

High risk pregnancy
Stage 1: q15min
Stage 2: q5min

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19
Q

Grades of variability

A

Absent
Minimal (undetectable to = 5bpm)
Moderate/normal (6-25bpm)
Marked (>25bpm)

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20
Q

Reasons for decreased variability

A

Benign: Fetal sleep, very premature (<28wks)
Concerning: Hypoxic acidosis, anemia (<70g/L), congenital anomalies

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21
Q

Reasons for marked variability

A

Maternal stimulant ingestion, hypoxia

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22
Q

Normal accelerations on EFM

A

Term: >/= 15bpm above baseline for >/= 15s

<32wks: >/=10bpm for = 10s

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23
Q

Prolonged accelerations/decelerations

A

> /=2 min

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24
Q

Late decelerations

A

Gradual, shallow decrease (onset to nadir is >/=30s) a/w contraction

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25
Q

Sinusoidal pattern on EFM

A

Smooth, rhythmic undulating wave-like pattern for >20min
May be a/w severe fetal anemia
If less smooth and accelerations present, more likely to be benign (narcotic admin, fetal thumb sucking)

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26
Q

Normal variation of contractions

A

no more than q2min (5 in 10min)

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27
Q

Fetal movements

A

Count up to 6 or at 2h
Call if <6 in 2h
Recommended to be aware of movement counting if healthy/no risk factors at 26-32wks
Daily counting recommended for women with risk factors at 26-32 wks
Daily counting for identified complication once fetus viable

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28
Q

Perform NST 2x weekly for

A

Post-date pregnancy

Insulin-treated GDM

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29
Q

Contraction stress test

A

3 contractions of 60s each in 10min period to assess fetal heart rate
Via nipple stimulation or oxytocin IV
+ve result if late decelerations occur with >50% contractions –> proceed with delivery

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30
Q

Conditions a/w risk for placental insufficiency

A

HTN
Diabetes or other conditions predisposing to HTN
IUGR
Oligohydramnios

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31
Q

Kleihauer-Betke Test

A

Extent of fetomaternal hemorrhage by estimating volume of fetal blood that entered maternal circulation

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32
Q

Rhogam

A

Rh IgG
Give to Rh- mom at 28wks and within 72h of delivering Rh+ baby/+ve Kleihauer test/invasive procedure/ectopic preg/miscarriage/APH

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33
Q

Consequences of Rh antibody in fetus

A

Fetal hemolytic anemia -> heart failure –> fetal hydrous or erythroblastosis fetalis (immune-mediated hemolytic anemia)

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34
Q

IUPC readings

A

Contractions adequate if at 50-60mmHg above baseline

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35
Q

Tachysystole

A

> 5 contractions over 10minutes

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36
Q

Keep infusing epidural until

A

End of 3rd stage

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37
Q

Bishop Score

A

Rates readiness of cervix for induction of labour (success of vaginal delivery)
1. Effacement (%)
2. Station (scale 1/5)
3. Consistency (soft, medium, firm)
4. Dilation
5. Position
= 5 –> labour unlikely to start without induction
>/= 9 –> labour likely to start spontaneously

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38
Q

Delayed cord clamping

A

30-60s recommended for term infants
Pro: Increases Fe stores in 6mo of age
Con: Increased risk of hyperbili, polycythemia in IUGR

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39
Q

Placental separation signs

A
  1. Elongation of umbilical cord
  2. Uterus contracts and rises
  3. Gush of blood
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40
Q

Average blood loss at vaginal delivery

A

< 500mL

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41
Q

Cardinal movements of labour

A 
Extension
Descent 
Flexion
Internal rotation 
Extension
Restitution and external rotation
Expulsion
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42
Q

Dystocia definition

A

Active first stage = >4h of <0.5cm/h dilation or no dilation over 2h
Active second stage: >1h of active using without descent of presenting part or no cervical dilation over 2h

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43
Q

Etiology of first stage dystocia

A 
4 Ps: 
Power
Passage 
Passenger
Psyche
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44
Q

Etiology of second stage dystocia

A

Uterine inertia
Fetal malposition
Cephalopelvic disproportion

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45
Q

Maneuver used in shoulder dystocia

A

McRoberts maneuver - flex mom’s thighs back against abdomen

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46
Q

GBS bacteriuria treatment

A

Bacteriuria >/= 10^4 CFU/mL –> amoxicillin, penicillin or cephalexin 3-7d (at time of dx PLUS abx during delivery)
Bacteriuria < 10^4 CFU/mL –> No tx required, abx during delivery

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47
Q

Maternal intrapartum fever tx

A

Ancef 2g IV q6h + Flagyl 500mg IV q8h until 24h afebrile

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48
Q

Major complication of PPROM at <18-20 weeks

A

Pulmonary hypoplasia secondary to severe oligohydramnios (disrupts canalicular phase of respiratory development)

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49
Q

Pre-term labour dx

A

> 20wks but <37wks
Dx needs regular contractions (>/= 4/20min or 8/60min) PLUS at least 1 of:
Cervix >/= 2-3cm
80% effacement
Progressive cervical change (cervical length <20mm on transvag US OR cervical length <30mm w/ +ve fetal fibronectin)

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50
Q

Fetal fibronectin

A

FIRST TEST to do on sterile speculum exam for premature labour work-up (can’t have anything in vagina for prev 24h)
Protein used to help “glue” amniotic sac to lining of uterus
Detected in vaginal d/c toward end of pregnancy
If +ve btwn 22-34wks –> increased risk of preterm labour
If -ve –> not likely to deliver in next 2wks

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51
Q

Steroid use for lung maturity

A

Give if 24-34 wks GA
Starts working at 18h, full benefit at 48h, lasts 7d
Betamethasone 12mg IM q24h x 2 doses (preferred)
Or Dexamethasone 6mg IM q12h x 4 doses

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52
Q

Tocolytic

A

Prolongs delivery for ~48h to achieve full benefit of steroids in maturing lung, enable transfer, etc.
Indocid 100mg supp PR PR x 1 dose then 25mg PO q6h x 48h if <32wks
Adalat PA 10mg q20min max 4 doses then 4h later Adalat XL 30mg BID x 48h

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53
Q

Antibiotics given for PPROM

A

Increase latency and decrease risk of chorioamnionitis
Ampicillin 2g IV q6h x 48h AND erythromycin 250mg IV q6h x 48h THEN amoxicillin 500mg PO q8h x 5d AND erythromycin 333mg PO q8h x 5d
OR mono therapy Erythromycin 250mg PO q6h x 10d
If pt goes into labour and don’t know GBS status –> switch to Pen G intralabour

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54
Q

Overall tx for preterm labour

A 
Bed rest
Hydration - 500mL NS bolus, 125cc/h if dehydrated 
Steroids 
Tocolytics
MgSO4 
GBS prophylaxis
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55
Q

Overall tx for PROM

A

Steroids if appropriate

Abx to increase latency

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56
Q

Components of biophysical profile

A 
BATMAN: 
Breathing 
Amniotic fluid volume 
Tone 
Movements
alright alright alright 
NST

Score out of 10 based on 30min U/S

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57
Q

C/I to MTX tx for ectopic pregnancy

A 
IUP 
Ruptured 
Renal/hepatic dysfunction
Immunodeficiency 
Breastfeeding
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58
Q

MTX selection criteria for use in treating ectopic pregnancy

A

Hemodynamically stable
No C/I
hCG = 5000mIU/mL
No fetal cardiac activity detected on TVUS, size <3-4cm

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59
Q

Medical abortion up to 10wks GA

A

Mifepristone + Misoprostol

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60
Q

Medical abortion up to 7wks GA

A

Methotrexate + Misopristol

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61
Q

Medical abortion in 2nd trimester

A

Mifepristone + Misoprostol

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62
Q

Induction abortion

A

> 16wks (usually >18wks)
Fetal demise induced by KCl or Digoxin
Misoprostol +/- Mifepristone for expulsion

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63
Q

Pre-existing HTN

A

BP > 140/90 BEFORE 20wks GA and persisting >7wks postpartum

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64
Q

Gestational HTN

A

Systolic >/= 140 OR diastolic >/= 90 in prev normotensive pt found >/= 20wks GA

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65
Q

Antihypertensives to avoid in pregnancy

A

ACEi, ARBs, Prazosin, Diuretics, Atenolol

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66
Q

Antenatal steroids for lung maturity considered in < ___ wks

A

34

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67
Q

Postpartum blood pressure

A

Increases by 3-4d PP, settles on its own

if not back to normal by 12wks PP = chronic HTN

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68
Q

Goals for diabetes in pregnancy

A

Fasting glucose =5.3
Random glucose =7.8
2h post-prandial =6.7

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69
Q

Induce labour by… in pregnant diabetes patients

A

38 wks

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70
Q

Screening options for GDM

A

1 step Fasting 75gOGTT

2 step: Non-fasting 50g OGTT –> Fasting 75g OGTT

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71
Q

1 step 75g OGTT results

A

GDM if >/=1 of:
Fasting: 5.1
1h PG: 10.1
2h PG: 8.5

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72
Q

2 step 50g/75g OGTT results

A 
Non-fasting 50g
1h PG: >/= 11.1 --> GDM
if 7.8-11 --> proceed to step 2 
Fasting 75g: GDM if >/= 1 of
FPG >/= 5.3 
1h PG >/= 10.6
2h PG >/= 9
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73
Q

Kleihauer Betke Test

A

Tests amount of maternal-fetal hemorrhage

Used to help dose rhogam

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74
Q

L/S Ratio

A

Lecithin-Sphingomyelin ratio
Passes freely into amniotic fluid in last 3mo of pregnancy
Lecithin rises in amniotic fluid but sphingomyelin stays same –> L/S ratio increases = babies lungs are ready

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75
Q

Apt test

A

NaOH mixes with blood
Pink = fetal blood
Yellow = Maternal blood
To test for vasa previa

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76
Q

PPH

A

> 500cc in vaginal delivery
1000cc in CS
Within 24h after delivery
If >24h-12wks - delayed/late/secondary PPH

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77
Q

4Ts of postpartum hemorrhage

A

Tone
Tissue
Thrombin
Trauma

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78
Q

Drugs of choice for PPH management

A

Oxytocin 20-40U in 1L, wide open
Ergot 250mg mcg IM or IV q2-4h
hemabate 250mcgIM q15min to max of 8 doses

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79
Q

Ergot C/I

A

HIV meds or HTN hx

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80
Q

Hemabate C/I

A

Asthma

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81
Q

Uterus vascular supply

A

Uterine artery

Utero-ovarian artery (from ovarian artery)

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82
Q

Factor V Leiden

A

Factor V mutation that affects its interaction with Protein C (natural anticoagulant)

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83
Q

Prothrombin gene mutation

A

Prothrombin = thrombin precursor – cleaves fibrinogen to fibrin

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84
Q

Hemoglobin level that you start to worry about pathologic anemia

A

<105g/L

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85
Q

TSH targets

A

1st trimester: <2.5

2nd/3rd trimester: <3.0

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86
Q

Most common cause of hypothyroidism

A

Chronic AI thyroiditis

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87
Q

Most common cause of hyperthyroidism

A

Graves’ dz

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88
Q

Gestational hyperthyroidism

A

Physiologic thyroid stimulation from hCG levels in early pregnancy
Generally no tx required
Possible tx: Propranolol - antithyroid activity

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89
Q

Graves’ tx

A

Propylthiouracil during preconception and 1st trimester

Methimazole after 1st trimester

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90
Q

Imaging test to tell you fallopian tubes open

A

Hysterosalpingogram

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91
Q

Endometriosis staging

A 
I = minimal
II = mild 
III = moderate 
IV = severe
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92
Q

Most common type of cyst found in women age 20-40yo

A

Dermoid cyst/teratoma

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93
Q

Outpatient empiric abx tx for PID

A

Cefoxitin or Ceftriaxone IM x 1 + 14d doxy + metronidazole
3rd gen cephalosporin –> Gonorrhea
Doxy –> chlamydia
Metronidazole –> anaerobes

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94
Q

Inpatient abx tx for PID

A

Cefoxitin 2g IV q6h x 24h
Doxycycline 100mg PO q12h
Metronidazole 500mg IV q12h

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95
Q

Perimenopause

A

Period prior to menopause and first year after

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96
Q

Menopause

A

12 consecutive months of amenorrhea with no other pathologic or physiologic cause
<1000 oocytes
High FSH due to low Estrogen

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97
Q

Premature ovarian insufficiency

A

Menopause occurring 2SDs below mean (typically <40s)
Amenorrhea for >4mo preceded by duration of disordered menses
FSH >30mIU/mL x2 at least 1 mo apart

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98
Q

Infertility

A
  • Inability to conceive within 20mo of
    • Unprotected regular coitus
    • Lack of contraception with risk for pregnancy
  • OR 12mo of donor inseminations
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99
Q

Principle steroid of post-menopausal ovary

A

Androstenedione

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100
Q

Potency of estrogens

A

17-B estradiol > estrone > estriol

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101
Q

3 symptoms that vaginal estrogens are used for

A

Recurrent UTIs
Vaginal atrophy
Urge symptoms

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102
Q

C/I to estrogens

A 
Unexplained vaginal bleeding 
Active VTE
Stroke hx 
E-dependent cancer
Coronary heart disease 
Acute liver dysfunction
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103
Q

Normal vaginal discharge findings

A

Aymptomatic
pH 4-4.5
Wet mount - epithelial cell, lactobacilli
Amine/KOH test - negative

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104
Q

Candidiasis

A

Pruritus, tenderness, dyspareunia
Erythema, thick “cottage cheese-like” discharge
pH 4-4.5
Wet mount - pseudohyphae
Amine/KOH test - negative/pseudohyphae
Tx - fluconazole, boric acid (only if symptomatic)
If complicated/recurrent:
- Fluconazole 3 doses then weekly for 6 months
- Topical azoles for 14d
- Boric acid 300mg for 14d then 5d per month

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105
Q

Bacterial vaginosis

A 
Malodourous thin grey discharge 
Adherent discharge
pH > 4.5 
Wet mount - clue cells, PMN 
Amine/KOH - Positive 
Tx: 
Asymptomatic - treat only if pregnant, prior to IUD insertion or gene procedure 
Symptomatic - flagyl PO, flagyl gel, clindamycin cream
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106
Q

Trichomoniasis vaginalis

A

Malodourous, white/yellow discharge
Strawberry cervix
pH > 5-6
Wet mount - Motile, flagellated protozoan
Amine/KOH test - negative
Tx - Metronidazole 500mg PO BID x 7d or Metronidazole 2g PO x 1

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107
Q

Cytolytic vaginosis

A 
pH 3.5-4.5 (acidic) 
Wet mount- no WBCs, false clue cells 
Amine/KOH - negative 
Tx - Sodium bicarb douching or sitz baths (1 tbsp in 2 cups warm water, 3x/wk) 
Improves within 3 wks
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108
Q

Desquamative inflammatory vaginitis

A 
Pain and diffuse discharge
Vaginal inflammation
pH > 4.5 
Profuse WBCs 
Tx: 2% clindamycin cream qhs for 14d or 25mg HC suppository ohs for 14d (may require tx for 4-6wks)
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109
Q

Lichen sclerosis

A

Childhood to elderly affected
Hypopigmentation, ivory white papules/plaques, thin skin, hour-glass figure affected (excludes vagina), can cause anatomical change (ie. loss of labia/clitoral anatomy)
Tx - bx to R/O cancer, barrier cream, clobetasol propionate 0.05% ointment

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110
Q

Lichen simplex chronics

A

Primary - chronic scratching
Secondary - incomplete tx of eczema, dermatitis, atopic dermatitis
Thickened, leathery and increased skin markings
Tx - remove irritants (most common = overwashing/medicating), restore barrier, topical steroids ointment (triamcinolone, clobetasol)

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111
Q

Lichen planus

A

Can cause loss of labia/normal clitoral anatomy
Very painful/burning/sig dyspareunia
Tx - high potency topical corticosteroid (ie. clobetasol), tacrolimus as 2nd line

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112
Q

Provoked vestibulodynia (PVD)

A

Allodynia of introitus and modest amount of pelvic muscle hypertonicity
Burning, ripping, tearing pain
Type of chronic pain syndrome (often comorbid with other pains ie. TMJ, IBS)

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113
Q

Vaginismus

A

Extreme form of pelvic muscle hypertonicity plus further reflexive peri-vaginal muscle tightening
NOT burning ripping, tearing pain

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114
Q

Rotterdam Criteria

A 
Androgen excess (hirsutism and/or high serum free T levels)
Ovulatory dysfunction (mid-luteal phase serum progesterone) 
PCOS
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115
Q

Oligomenorrhea

A

Infrequent menstrual cycles (>/=35d cycles)

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116
Q

Clomiphene citrate

A

SERM
Blocks E receptors at pituitary and hypothalamus –> blocks negative feedback –> increased FSH and LH secretion –> multiple follicular growth –> multiple ovulation
Take days 3-7 of cycle

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117
Q

Letrozole

A

Aromatase inhibitor
Take days 3-7 of cycle
Suppresses ovarian estradiol secretion –> reduces E negative feedback at pituitary and hypothalamus –> increased FSH –> multiple ovarian follicle stimulation

118
Q

Primary amenorrhea

A

No menses by 14yo and absence of sex characteristics OR no menses by 16yo with presence of sex characteristics

119
Q

Secondary amenorrhea

A

Previous hx of menstruation AND no menses for 3 cycles or 6months

120
Q

Polyp treatment

A 
Premenopausal and symptomatic --> remove
Premenopausal and asymptomative, remove if have risk factors for endometrial hyperplasia/CA OR IF : 
- polyp >1.5cm in diameter
- multiple polyps 
- infertility 
- prolapsed through cervix 
Postmenopausal --> remove ALL polyps
121
Q

Types of uterine fibroids

A

Submucosal
Intramural
Subserosal

122
Q

Conservative approach for uterine fibroids appropriate if:

A

Symptoms absent/minimal
Fibroids <6-8cm in size
Not submucosal (more likely to be symptomatic)
Pregnant

123
Q

GnRH agonists

A

Leuprolide
Danazol
Used short term (6mo) pre-hysterectomy/myomectomy to reduce fibroid size and reduce bleeding

124
Q

Ulipristal acetate

A

Partial progesterone receptor agonist

125
Q

Tranexamic acid

A

Anti-fibrinolytic which helps with heavy menstrual bleeding

126
Q

Ovarian tumour marker

A

CA 125
Protein expressed on membrane of normal ovarian tissue and ovarian carcinomas
<35 U/mL is normal

127
Q

U/S criteria for spontaneous miscarriage/nonviable pregnancy

A

Intrauterine pregnancy
Mean sac diameter >25mm with no yolk sac or embryo
CRL >/= 7mm with no cardiac activity
Absence of embryo with heartbeat >/=2wks after scan that showed gestational sac w/o yolk sac
Absence of embryo with heartbeat >/= 11d after scan that showed gestational sac w/ yolk sac
Typically repeat U/S in 1-2 wks for F/U and official dx

128
Q

Ovarian torsion treatment

A

Repro aged women: Lap ovarian detorsion +/- ovarian cystectomy (preferred 6-8wks later) +/- oophoropexy (teens with long suspensory ligaments)
Older women: Salpingo-oophorectomy

129
Q

Endometriosis treatment

A

1st line - OCP & NSAID
2nd line - Progestin
3rd line - GnRH agonist (Lupron)
3rd line - Aromatase inhibitor (Letrazole)

130
Q

Best imaging for PID

A

TVUS

Abdo CT not helpful

131
Q

Potential complications of PID

A 
Recurrence
Ectopic pregnancy 
Fitz-Hugh Curtis Syndrome 
Infertility 
CPP
Reiter's Syndrome 
TOA 
Hydrosalpinx (fallopian tube filled/blocked with sterile fluid) 
Chronic salpingitis
132
Q

Tubo-ovarian abscess tx

A

If hemo unstable –> surgical intervention

If hemorrhage stable, <9cm abscess, adequate response, pre-menopause –> abx (cefoxitin and doxy)

133
Q

Partner traceback for STI goes back…

A

60d

134
Q

Chlamydia follow-up

A

Test of cure not needed, but can be done in 4wks

Rescreen should be done in 6mo

135
Q

Monozygotic twins that divide at day 3

A

Dichorionic diamniotic

136
Q

Monozygotic twins that divide at days 4-7

A

Monochorionic diamniotic

137
Q

Monozygotic twins that divide at days 8-13

A

Monochorionic monoamniotic

138
Q

Hormone involved in gestational diabetes

A

Human placental lactogen (HPL)

139
Q

Pulmonary TB xray finding

A

Hilar adenopathy

140
Q

I:E ratio

A

Normally 1:1 or 1:2

In obstructive disorders, expiration is PROLONGED and ratio is decreased

141
Q

Levonorgestral IUD MOA

A

Thickens cervical mucous (primary)

Endometrial thinning

142
Q

Copper IUD MOA

A

Biochemical and morphological changes to endometrium
Affect sperm motility
Affects tubal transit
Toxic to sperm

143
Q

Depo Provera (Progestin) MOA

A

Inhibits secretion of FSH and LH from pituitary
Increases thickness of cervical mucus
Thins endometrium

144
Q

Combined OCPs MOA

A

Suppression of pituitary release of LH and FSH (inhibits ovulation)
Increased cervical mucous

145
Q

1st trimester screening tests

A

Dating ultrasound
Chorionic villus sampling
1st trimester combined screen (NT U/S and hCG/PAPP-A blood test)
NIPT (starts at 10 wks)

146
Q

Chorionic villus sampling

A

Chromosomal abnormalities

No NTD data

147
Q

2nd trimester screening tests

A

Detailed U/S
Amniocentesis
Quad

148
Q

Quad screening tests

A

hCG, Inhibin A, AFP, Estriol

Do if mom comes for screening for first time in 2nd trimester

149
Q

Amniocentesis

A 
Chromosomal abnormalities (more accurate than CVS)
AND NTD data
150
Q

NIPT

A

Tests for cell-free fetal DNA circulating in maternal serum
Less invasive
Not covered by MSP yet
If positive, F/U with CVS or amniocentesis

151
Q

SIPS

A 
Blood tests taken at 10-13wks and 15-20 wks 
Tests for chromosomal anomaly and NTD 
1st blood test hCG, PAPP-A 
2nd blood test is quad 
Offered to all pregnant women
152
Q

IPS

A

SIPS + Nuchal Translucency

153
Q

Contraindications for labour induction

A 
Prior CS 
Uterine rupture 
Any incision into uterus 
Placenta or vasa previa 
Active genital herpes 
Cord prolapse 
Invasive cervical CA 
Already having regular uterine activity (>/= 2 contractions/10min)
154
Q

Contraindications for mechanical/foley induction

A

Low lying placenta (relative C/I)

GBS is NOT a C/I

155
Q

Opioid use in labour

A

Latent stages –> IM morphine

Active labour –> IV Fentanyl

156
Q

Assessment for PPROM

A
  • Sterile speculum exam - nitrizine, ferning, cervical/vaginal swabs for C&S, GS, chlamydia, vaginal/rectal swab for GBS (if not already done)
    DO NOT DO VE b/c of increased risk of infection
    Urinalysis
    CBC
    U/S
157
Q

Assessment for preterm labour

A 
Sterile speculum exam - fetal fibronectin, vag/cervical swab for C+S, GS, chlaydia, vaginal-rectal swab for GBS, nitrazine and ferning if suspect PPROM 
If no PPROM --> do VE 
CBC
Urinalysis 
U/S
158
Q

Functional cyst

A

Failure of follicle to rupture during ovulation

159
Q

Corpus luteal cyst

A

Failure of corpus luteum involution

160
Q

Theca lutein cyst

A

Hyperstimulation of luteinized follicles from high hCG

161
Q

Types of ovarian cyst histology

A

Serous
Mucinous
Endometroid
Clear cell

162
Q

Ovarian neoplasm that classically produces severe irritation from chemical peritonitis

A

Mature cystic teratoma

163
Q

Contraindications to progesterone contraception

A 
Pregnancy
Current PID 
Progesterone receptor +ve breast CA (current or hx) 
Uterine abnornality
AUB not yet investigated 
Known endometrial CA
Pelvic TB 
Severe liver dz 
Postpartum >48h and <4wks
164
Q

Depo Provera S/Es

A 
Weight gain 
Amenorrhea, irregular bleeding 
Acne 
Delayed return to fertility 
Decreased BMD
165
Q

Combined OCP C/I

A 
<4wks postpartum if breastfeeding
<21d postpartum if not breastfeeding 
Smoker >35 
Vascular dz 
HTN 
Migraine with aura 
Hx of stroke 
Known thrombophilia
Current breast CA 
Acute DVT 
Liver dz, SLE with APLAs
166
Q

Combined OCP reduces risk of certain types of cancer

A

Endometrial, ovarian and colorectal cancer

167
Q

Plan B

A

Levonorgestrel high dose
Up to 5d after unprotected intercourse
Not for women BMI >25
Only works if taken before LH surge

168
Q

Ulipristal Acetate

A 
Selective progesterone receptor modulator 
Up to 5d after unprotected intercourse
Works better for women BMI >25
Can interrupt ovulation 
Rx only
169
Q

Most effective emergency contraception

A

Copper IUD - within 7d

Best if BMI > 30

170
Q

4 signs associated with likely miscarriage

A
  • Embryonic bradycardia (FH <100bpm after 6wks)
  • Small gestational sac size
  • Enlarged or abnormal yolk sac (>5mm)
  • Subchorionic hemorrhage
171
Q

Uterine findings for ectopics

A
  • Thickened endometrial interface
  • Fluid or blood in endometrial cavity
  • Pseudosac
  • Decidual cysts
  • Peritoneal findings  40-80% of ectopic pregnancies will have free fluid in pelvis
172
Q

Typical protocol for miscarriage management

A

 Pre-medicate: Tylenol, NSAIDs, gravol
 Misoprostol 800mcg PV, one repeat dose if no effect at 24h
 F/U at 48h
 Home pregnancy test at 3 wks, call if +ve
 2% have excessive bleeding and need emerg D&C

173
Q

Urge incontinence

A

1 or more of
Freq >8 voids/24h
Nocturia >1x/night

174
Q

DIAPPERS mnemonic

A 
Delirium 
Infection or inflammation
Atrophy 
Pharmaceuticals (ie. diuretic)
Psychological
Excessive UO 
Restricted mobility 
Stool impaction
175
Q

Medication commonly used for urinary incontinence

A

Anticholinergics (mirabegron, oxybutynin, tolterodine)

176
Q

3 ligaments that attach sacrum to rest of pelvis

A

Sacroiliac
Sacrospinous
Sacrotuberous

177
Q

4 muscles that border pelvic cavity

A

Levator ani
Obturator internus
Coccygeus
Piriformis

178
Q

3 muscles that make up urogenital triangle

A

Bulbocavernosus
Ischiocavernosus
Superficial transverse perineal

179
Q

3 components of levator ani

A

Pubococcygeus
Ileococcygeus
Puborectalis

180
Q

Ovarian CA type more common in <20yo

A

Germ cell

181
Q

Ovarian CA type more common in >20yo

A

Epithelial tumours

182
Q

3 clinical features of molar pregnancy

A

hCG >100 000
Symptoms suggestive of molar – hyperemesis, hyperthyroid, abnormal bleeding, pelvic pressure/pain, uterine size greater than GA
TVUS features of complete/partial mole

183
Q

TVUS features of complete mole

A

Absence of embyro/fetus, amniotic fluid
Central heterogenous mass with many anechoic spaces (snowstorm pattern)
Ovarian theca lutein cysts

184
Q

TVUS features of partial mole

A

Fetus may be identified, viable but growth restricted
Amniotic fluid present but volume low
Placental abnormal
THeca lutein cysts absent

185
Q

___% of molar pregnancies will become GTN

A

10-15

At lifelong risk

186
Q

Molar pregnancy management

A

Uterine evacuation
Weekly bhcg until negative x 2
Partial mole can then stop monitoring
Complete mole continue monthly x 6mo

187
Q

Risk factors for developing GTN after molar pregnancy

A

Complete mole with signs of trophoblastic proliferation (uterine size > GA, serum hCG levels > 100 000)
Ovarian theca lutein cysts >6cm in diameter
Age >35-40yo

188
Q

GTN includes

A

Choriocarcinoma
Placental site trophoblastic tumour
Epithelioid trophoblastic tumour
Invasive mole

189
Q

GTN diagnosis

A

hCG level plateaus across 4 measurements over 3 wks
hCG level increases >10% across 3 readings over 2 wk duration
Persistence of detectable serum hCG for >6mo after molar evaucuation

190
Q

Low risk GTN management

A

Low risk –> MTX;
If resistant to MTX –> actinomycin D mono agent chemotherapy
If resistant to both –> hysterectomy

191
Q

High risk GTN management

A

Etoposide, MTX and actinomycin D multi agent chemo

May require surgery

192
Q

GTN remission status

A

hCG undetectable for 3 consecutive weeks

193
Q

Misoprostol

A

Prostaglandin E1 analog

194
Q

Mifepristone

A

Antiprogesterone agent

195
Q

First visible sign on U/S of pregnancy

A

Gestational sac

Visible at 4 wks GA via TVUS

196
Q

Structure that confirms pregnancy is intrauterine

A

Yolk sac
Distinguishes from pseudo gestational sac or anembryonic pregame
Seen at 5 wks
# yolk sacs = # pregnancies

197
Q

Rhombencephalon

A

Anatomic landmark that helps distinguish head from tail in embryo at 7-8 wks

198
Q

4-5wk GA on U/S

A

Gestational sac visible

FHR or embryo occasionally visible

199
Q

7-8 wks GA on U/S

A 
Embryo and cardiac activity always visible 
Head, body and extremities identifiable 
Midgut herniation at wk 7 
Rhombencephalon visible 
CRL measurable
200
Q

9-12 wk GA on U/S

A

Human features more distinct
Nuchal translucency after 11 wks
Babe completely formed by 12 wks

201
Q

Protective factors against ovarian CA

A

OCP
Pregnancy breast feeding
Prophylactic salpingectomy
Hysterectomy (without removal of ovaries)

202
Q

Most common form of ovarian cancer

A

High grade serous epithelial cancer

203
Q

3 sets of cells that give rise to ovarian CA

A

Ovarian epithelium
Germ cells
Ovarian stroma

204
Q

CA-125

A

Ovarian CA tumour marker

205
Q

CA 19-9

A

Upper GI
Pancreas
Mucinous ovarian CA

206
Q

CA 15-3

A

Breast CA

207
Q

CEA

A

Colon CA

208
Q

Bloodwork to order for germ cell tumour workup

A

AFP, LDH bHCG

209
Q

Risk of Malignancy Score

A

U/S features:

  • Multilocular cyst
  • Presence of solid areas
  • Bilaterality of lesions
  • Presence of ascites
  • Presence of intra-abdominal metastasis

1 = no or one abnormality
4 = 2 or more abnormalities
Premenopausal: +1
Postmenopausal +4

Abnormality score x pre or post-menopausal score x CA125 level

210
Q

Ovarian CA Staging

A 
I = Limited to ovaries 
Ia = 1 ovary
Ib = 2 ovaries 
Ic = Rupture 
II = Ovaries and pelvic extension 
III = Mets to peritoneum/retroperitoneum/superficial liver mets 
IV = distant mets beyond peritoneal cavity
211
Q

Early decels associated with

A

Head squeeze

Benign

212
Q

Variable decels associated with

A

Cord compression

213
Q

Late decels associated with

A

Uteroplacental insufficiency

214
Q

Normal variations in contractions

A

No more than q2min (max 5/10min)
<90s duration
Coupling or tripling
Moderate-strong intensity on palpation (>25mHg but <75-80mmHg above baseline per contraction via IUPC)
Soft resting tone btwn contractions for at least 30s

215
Q

Intrauterine resuscitation

A 
Change maternal position
D/C oxytocin
O2 by mask 
Hydrate 
Vaginal exam to confirm dilatation and descent 
Keep mom calm
216
Q

Workup for abnormalities in fetal movement counts

A

U/S
NST
If NST normal –> resume daily fetal movement counts. If risk factor add AFI and umbilical artery doppler study as part of ongoing fetal surveillance.
If NST atypical –> Repeat NST later or next day, CST, AFI and umbilical artery doppler
If NST abnormal: Sonographic assessment (growth, AFI, UA doppler), BPP, CST, consider delivery

217
Q

Normal NST

A

Strong negative predictive value of stillborn in 7d after

218
Q

Umbilical artery doppler done at

A

3rd trimester

219
Q

Absent end diastolic flow management

A

<32wks: Increase FHS. Consider steroids.

>/=32 wks: Delivery may be indicated. Consider steroids first.

220
Q

Reverse end diastolic flow management

A

Delivery indicated, regardless of GA

If steroids required, increase FHS until delivery

221
Q

Symphysis fundal height

A

12 weeks = symphysis
16 weeks = mid way to umbilicus
20 weeks = umbilicus
SFH +/- 3cm from GA

222
Q

Folic acid for low risk woman

A

0.4-1mg daily from 8-12wks pre-conception until 10-12wks post-conception

223
Q

Folic acid for high risk woman

A

5mg daily from 8-12wks pre-conception until 10-12wks post-conception
Then multivitamin with 0.4-1mg of folic acid until 4-6wks after birth

224
Q

Ideal fetal positioning

A

Occiput anterior

225
Q

Pre-eclampsia prophylaxis

A

Daily ASA 81mg

226
Q

Primary issue associated with hypertension in pregnancy

A

Poor placentation

227
Q

1st line meds for hypertension in pregnancy

A 
Labetalol 
Nifedipine (long-acting CCB) 
Methyldopa
228
Q

Induce delivery at ___ wks for uncomplicated pregnancies with only occasional BP elevations

A

38-39wks

229
Q

Induce delivery ___ wks for pregnancies with frequent high BPs

A

37 wks

230
Q

Postpartum BP

A

Peaks 3-5d postpartum
Almost always back to normal by 12 weeks
If >/=12wks PP –> chronic HTN

231
Q

Pre-eclampsia

A

GTN HTN plus one or more of:

1) New proteinuria (>30mg/mmol or >/=0.3g/d
(2) one or more adverse conditions/severe complications

232
Q

HELLP Syndrome

A

Hemolysis
Elevated liver enzymes
Low platelets

233
Q

MgSO4 for HELLP syndrome

A

Usually started at labour onset and continued 12-24h post-delivery

234
Q

Eclampsia

A

Gestational HTN with seizures

>/=1 generalized convulsion and/or coma in setting of pre-eclampsia

235
Q

Eclampsia management

A

Aggressive management once diastolic pressure >/= 106 or systolic >/= 160
Hydralazine or Labetalol IV
MgSO4 to prevent recurrence
Deliver (irrespective of GA)

236
Q

Fetal monitoring in eclampsia

A

NST, AFI or BPP weekly starting at 32wks GA

237
Q

Velamentous cord insertion

A

Umbilical cord inserts into fetal membranes then travels within membranes to placenta –> exposed vessels vulnerable to rupture in early labour
If vessels near cervix = vasa previa

238
Q

HPV strains associated with genital warts

A

6 and 11

239
Q

HPV strains associated with cervical CA

A

16 and 18

240
Q

Pap smear results that you can follow with cytology in 6mo

A

LSIL

ASCUS (If <30 or no HPV DNA testing available)

241
Q

HELLP Syndrome management

A

Deliver baby! Regardless of GA week. May be able to prolong slightly for steroids if <34wks and otherwise stable, do not prolong for >48h

242
Q

MgSO4 antidote

A

Calcium glutinate

243
Q

Risk of seizure from pre-eclampsia highest during…

A

24h postpartum

Continue MgSO4 for 12-24h after delivery

244
Q

Pre-eclampsia management

A 
If stable, may admit and follow +/- decide to deliver if 34-36wks 
If severe, stabilize and deliver
Manage BP (Labetalol, Nifedipine)
MgSO4
245
Q

Insulin resistance in pregnancy

A

Increased

246
Q

Frequency of HbA1c testing in pregnancy

A

Monthly

247
Q

GDM F/U

A

2g OGTT at 6wk PP

248
Q

Extra antepartum surveillance in GDM

A

2nd trimester onwards: Fetal echo, repeat urinalysis each semester, NST weekly, U/S biweekly (then weekly after 32wks)

249
Q

Placenta previa C/S vs SVD

A

> 2cm from os –> SVD
1-2cm –> gray zone
<1cm –> C/S
Any degree of overlap after 35 wks –> C/S

250
Q

Placenta previa clinical presentation

A

Painless bleeding at 30wk GA
Uterus soft and non-tender
FHR usually normal

251
Q

Placenta previa management

A

<37 wks and hemo stable –> expectant management

>37wks and/or hemo unstable –> C/S

252
Q

Most common cause of DIC in pregnancy

A

Placental abruption

253
Q

Placental abruption clinical presentation

A

Acute painful vaginal bleeding usually at ~20wks GA
Shock out of proportion to apparent blood loss
+/- fetal distress

254
Q

Dx of placental abruption

A

Clinical
U/S not sensitive
Kleihauer

255
Q

Vasa previa definition, dx and tx

A

Fetal vessels pass over cervical os (a/w cord insertion, accessory lobes)
Painless vaginal bleeding and fetal distress
Dx:
- Apt test
- Wright stain - nucleated RBCs (fetal)
Tx: emergency C/S

256
Q

Water under the bridge

A

Ureter travels UNDER uterine artery

257
Q

Twin to twin transfusion syndrome

A

Arterial blood from donor twins passes through placenta into vein of recipient twin

258
Q

Monochorionic monoamniotic management

A

NSTs twice a day, starting at 26 wks
Weekly U/S
C-section at 32weeks if stable

259
Q

Dichorionic sonographic findings

A

2 separate placental sites
Inter-twin membrane is thick (4 layers)
Lambda or twin peak sign – chorionic villic visible going up in between amnions

260
Q

Dichorionic diamniotic management

A

Lowest risk
Recommend routine scans q4wks
Usually deliver by 38wks

261
Q

Monochorionic diamniotic management

A

Risk of TTTS, TAPS, TRAP, sIUGR
Recommend routine scans q2wks starting at 16wks
Deliver by 36-37wks

262
Q

Twin monitoring

A

Up to 28 wks –> q2wks

28-36wks –> weekly

263
Q

Normal prenatal screening visits

A

Up to 28wks –> q4wks
28-36wks –> q2wks
>36wks –> weekly

264
Q

hCG secreted by…

A

syncytiotrophoblasts

265
Q

Progesterone produced by…

A

Corpus luteum until 10wks

Then placenta

266
Q

Respiratory changes in pregnancy

A

Increase TV, minute ventilation, inspiratory capacity
Decreased residual volume, expiratory reserve volume, functional residual capacity
No change in in vital capacity, RR, FEV1

267
Q

Hypothyroid meds changes in pregnancy

A

Increase meds due to increased TBG and decreased GI absorption (double dose on Sat and Sun)

268
Q

When to refer women for infertility

A

<35yo: 12mo of trying
35-39: 6-12mo of trying
>40: Within 3mo of trying
Unless irregular menses, hx of PID, endometriosis, poor semen analysis, abnormal fertility test = refer right away

269
Q

Most common causes of infertility in couples

A

Tubal and pelvic pathology

Male problems

270
Q

Infertility female work-up

A 
Ovulatory function: 
Mid-luteal phase progesterone 
Ovulation kits detecting LH surge 
If abnormal, test ovulatory reserve: 
Day 3 FSH (normal if <10) PRL, TSH, PCOS work-up
AMH (higher the better)
Antral follicle count
271
Q

Trichomonas Vaginalis management

A

Metronidazole 2g, even if asymptomatic
No sexual intercourse 7d after treatment
Re-screen 2wks-3mo after finishing tx
All sexual partners should be treated as well, don’t need to be screened as well

272
Q

Factors that affect menopause age

A

Smoking –> hastens by 2 years
BMI –> delays menopause
Ethnicity
Parity (lower parity goes into menopause earlier)

273
Q

Chemo agent used in breast CA that ages ovaries by 10y

A

Cyclophosphamide

274
Q

4 categories of patients who should receive transdermal E

A

At risk for VTE
Poor absorption
Spontaneous or estrogen-induced hypertriglyceridemia
Obese with metabolic syndrome
Consider also in: smokers, HTN, sexual dysfunction

275
Q

Risks associated with hormone therapy from WHI trial

A

More strokes, VTE, less hip fracutre
More breast CA after >/=5yrs of use, risk back to baseline after stopping
E-only: More breast CA, less CRC

276
Q

Amsel’s criteria for BV

A 
Need 3/4 of: 
Characteristic of d/c (thick, white, malodours) 
pH >4.5 
Wet mount - Clue cells, PMN
Amine whiff test (+)
277
Q

Pigmented lesion biopsy

A

Punch biopsy, completely excise

278
Q

Blistering lesion biopsy

A

Suture, lift and cut technique

279
Q

Ulcerated lesion biopsy

A

Incisional if large, excision if <1cm

280
Q

Lichen sclerosus or lichen simplex chronicus or lichen planus that causes distortion of normal anatomy

A

Lichen sclerosus and lichen planus

Lichen planus can extend into the vagina, possibly even causing it to close up

281
Q

Lichen simplex chronicus AKA

A

Squamous cell hyperplasia

282
Q

Medications a/w loss of vaginal lubrication

A

Antihistamine

Anticholinergic

283
Q

Polycystic ovaries

A

> 12 astral follicles 2-9mm in one ovary

284
Q

Test to R/O congenital adrenal hyperplasia

A

17-OHP

Often ordered to test metabolic dysfunction as source of ovulatory dysfunction

285
Q

Most common cause of primary amenorrhea

A

Hypergonadotropic Hypogonadism

286
Q

AI diseases associate with hypergonadotropic hypogonadism

A 
SLE 
T1DM 
Addison's
Thyroid 
Myasthenia graves
287
Q

5 alpha reductase deficiency

A

Can’t convert T –> DHT

Androgen synthesis disorder

288
Q

Hypogonadotropic hypogonadism

A 
Structural CNS (adenoma, prolactinoma, sheehan's) 
Endo (hypothyroid, hyperprolactinemia)
Non-CNS (constitutional delay of puberty, functional hypothalamic amenorrhea, isolated GnRH deficiency)
289
Q

If both thyroid and prolactin are off, which do you fix first?

A

Thyroid –> prolactin will flollow

Hypothyroid – TRH activates lactotrophs to secrete prolactin –> hyperprolactinemia

290
Q

Velamentous cord insertion

A

Umbilical cord inserts into choriamniotic membranes then travels within membranes to placenta (btwn amnion and chorion)
Exposed vessels are not protected by Wharton’s jelly

Clerkship (7 decks)

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