OBGYN Flashcards
What is chorioamnionitis, risk factors, and how does it present?
Intra-amniotic infection.
Often a cx in patients with premature rupture of the membranes & prolonged rupture (>18hrs).
Pts have N/V and uterine fundal tenderness. Also may have abnorm contraction pattern d/t effect of IAI on uterine mm. contractility.
How to diagnose chorioamnionitis:
Diagnosis is based on presence of Maternal fever and 1+ of the following: fetal tachy (>160 bpm for 10+ min), maternal leukocytosis, maternal tachy, or purulent amniotic fluid.
Pts may have abnormal contraction pattern d/t effect of IAI on uterine mm. contractility.
What is likely seen on FHR tracing in abruptio placentae?
Nonreassuring FHR w/minimal variability and decelerations.
What is the mgmt. of Itraamniotic infection/Chorioamnionitis?
Broad spectrum abx and Delivery (augmentation of labor) to remove source of infection.
What cxs are a/w chorioamnionitis?
Maternal – postpartum hemorrhage, endometritis
Neonatal – preterm birth, pneumonia, encephalopathy.
What abx are used to tx IAI?
Broad spectrum: ampicillin, gentamicin, clindamycin.
What is ancef?
Cefazolin
What Rxs are contraindicated in pts w/IAI?
Tocolytics – nifedipine, indomethacin
When is GBS screening done?
Universal screening = rectovaginal culture at 35-37 weeks gestation.
DoC for GBS pphx?
Penicillin
Who should be treated in labor for GBS pphx?
Those with +GBS screen
Women who missed GBS screening who are in labor and <37wks gestation, develop intrapartum fever, or have prolonged ROM (for 18+ hrs).
Risk factors of ovarian torsion:
Ovarian mass, women of reproductive age, infertility tx w/ovulation induction.
What acid-base disturbance is a normal phenomenon of pregnancy? When is this seen?
Primary respiratory alkalosis – occurs d/t hypocapnia in late pregnancy that is caused by direct stimulatory effect of progesterone on the central respiratory center.
HPV vaccine indications:
All females 11-26
Men 9-21 or 9-26 for MSM and HIV pts.
What causes the HoTN a/w epidurals?
The SNS nerve fibers responsible for vascular tone are blocked – vasodilation and venous pooling occur w/decreased return to the R heart and decreased CO.
What does a uterus w/irregular enlargement on exam suggest?
Uterine leiomyomata.
What is the most common cause of prolonged or arrested 2nd stage?
Fetal malposition.
What is considered arrest of the 2nd stage of labor?
When there is no fetal descent after pushing 3+ hrs in nulliparous or 2+ hrs in multiparous women.
Fetal malposition is the most common cause.
What is the optimal fetal position?
Occiput anterior.
Who should take a prenatal vitamin?
All women of childbearing age, especially those contemplating conception.
Recommendation is to start prenatal 3 months prior to conception.
How long should conception be delayed following rubella vaccination?
1 month
What disease should be tested for in every 1st-prenatal visit?
Syphilis by RPR or VDRL.
When should the US date be used to predict GA?
If less than 8+6 weeks and discrepancy is 5+ days
9+0 to 15+6 weeks w/discrepancy of 7+ days
16+0 to 21+6 weeks w/discrepancy of 10+ days
22+0 to 27+6 weeks w/discrepancy of 14+ days
What is the quadruple screen and when is it preformed?
Blood tests to measure: AFP, hCG, estriol and inhibin A.
Done during second trimester
What pattern on quadruple screen will suggest Trisomy 18?
Decreased AFP
Decreased BhCG
Decreased estriol
Normal or low inhibin A
What pattern on quadruple screen will suggest Trisomy 21?
Decreased AFP
Increased hCG
Decreased estriol
Increased inhibin A
What pattern on quadruple screen will suggest Trisomy 13?
Decreased hCG
very decreased PAPP-A (pregnancy-associated plasma protein A).
What is the best test to determine if a fetus has an aneuploidy?
10-13 weeks = Chorionic villus sampling.
15-20 weeks = Amniocentesis
What should be administered to pts <32 weeks of gestation for neuroprotection?
Magnesium sulfate – decreases the risk of cerebral palsy.
What should be given to patients with HELLP syndrome? When should this be given, and for how long?
Mag sulfate – given immediately on diagnosis and continued for 24hrs after delivery.
What is cervical insufficiency? How is it diagnosed?
Painless cervical dilation leading to recurrent pregnancy losses (norm in 2nd trimester)
Diagnosed based on hx of either 2+ consecutive prior 2nd trimester losses OR 3+ early (<34wks) preterm births.
Tx of cervical insufficiency:
Transvaginal cerclage at 12-14 weeks (early 2nd trimester) and weekly IM hydroxyprogesterone caproate injects from 16-36 weeks (2nd - 3rd trimester).
What should be done in patients who present w/only one prior 2nd trimester loss, or 1-2 preterm births?
This isn’t sufficient to diagnose cervical insufficiency, so serial measurements of cervical length should be performed from 14-24 weeks.
A cerclage should be placed if cervical length is <25mm before 24 weeks.
Most common form of abnormal placentation?
Placenta accreta – where the placenta attaches to the superficial myometrium (but does not penetrate it like increta) instead of the decidual layer of the endometrium.
What is placenta increta?
Invasion of the placenta through the endometrium into the myometrium.
This can progress to placenta percreta.
What is placenta accreta?
Where the placenta attaches to the myometrium but does NOT penetrate it (like w/increta).
What is placenta percreta?
Where placenta perforates the myometrium and invades the serosa, or adjacent structures (like the bladder).
Risk factors for abnormal placentation:
Abnormal placentation = placenta accreta/increta/percreta.
Risks: prior C-section, inflammation, and placenta previa.
Most feared complication of an ectopic pregnancy:
Intraperitoneal hemorrhage
Cxs of placental abruption:
DIC, maternal shock, fetal distress
What does an empty gestational sac suggest?
AKA a pseudogestational sac, suggests an early pregnancy or a failed pregnancy – an anembryonic gestation.
Most common site of ectopic pregnancy:
Ampulla of the fallopian tube.
What should be administered to patients w/dehydration 2/2 hyperemesis gravidarum?
IV fluids and B1 (thiamine). Also possible electrolyte replacement dependent on labs.
How is gestational HTN managed?
With dietary modification and normal activities w/avoidance of high-intensity exercise.
UA and BMP should be performed weekly to exclude organ damage and developing eclampsia.
If SBP is ever >160 or DBP > 110 then the patient should go straight to the ED for tx.
What should be given as HIV pphx during pregnancy and delivery?
Zidovudine aka AZT
How are Rh- and ABO-HDFN differentiated?
Aka hemolytic disease of the fetus and newborn.
Both will have a positive direct Coombs test and direct hyperbilirubinemia w/in the first 24hrs.
ABO-HDFN will typically have spherocytosis (Rh will not)
Rh-HDFN will likely have severe anemia (ABO will not)
Rh-HDFN is more severe than ABO and can be life threatening, whereas ABO-HDFN can be completely asx.
What vaccine should be given to all mothers 27-36 weeks?
Tdap
What is the timeline of different monozygotic twins?
0-4 days: dichorionic, diamniotic (25%)
4-8 days: monochorionic, diamniotic (most common – 75%)
8-12 days: monochorionic, monoamniotic (rare)
>13 days: conjoined monochorionic, monoamniotic (rare)
All types will have 2 cords
What are risks of all twin pregnancies?
IUGR
Increased risk of infant mortality
Preterm birth
Cerebral palsy
What is twin-twin transfusion syndrome a complication of?
Unique complication to monochorionic, diamniotic twins.
chorion = the cushion the fetus is attached to
What is PUPPP and its treatment?
Pruritic urticarial papules and plaques of pregnancy.
Self-limited derm condition commonly seen in primigravids during the peripartum period.
Initially present as pruritic, erythematous papules in the area of the abdominal striae – can spread to torso and extremities.
Typically spares face, palms and soles.
Tx: moisturizing creams and f/u. Typically resolves w/in 1-2 weeks post-partum
What are the clinical features of uterine leiomyomas?
Heavy, prolonged menses
Pressure sxs: Pelvic pain, constipation, urinary frequency
Obstetric cxs: impaired fertility, pregnancy loss, preterm labor
Enlarged, irregular uterus
What should be done to investigate fibroids?
Pelvic US
How does a uterus w/fibroids feel on PE?
Enlarged, firm and irregular. May feel a prominent mass.
What are the features and causative organism of granuloma inguinale ?
aka Donovanosis
Caused by Klebsiella granulomatis.
Features: extensive/progressive ulcerative lesions w/OUT lymphadenopathy; base may have granulation type tissue; deep staining G- intracytoplasmic cysts (Donovan bodies).
NON-painful lesion
Cause and presentation of lymphogranuloma venereum:
Caused by C. trachomatis
Features: small, and shallow, painLESS ulcers; large, painFUL coalesced inguinal LNs (buboes); intracytoplasmic chlamydial inclusion bodies in epithelial cells and leukocytes.
What has the greatest sensitivity to diagnose syphilis in early infection?
Treponemal tests: FTA-ABS, TP-EIA (Enzyme immunoassay)
Nontreponemal (RPR, VDRL) may have negative results in early infection
When is laparoscopy indicated in patients with endometriosis?
If the patient has failed empiric therapy
If there are contraindications to Rx therapy
Need for definitive dx
Hx of infertility
Concern for malignancy or adnexal mass
What is often the only presenting sx of endometriosis?
Infertility
What should be the first step in investigation of primary infertility?
Hysterosalpingogram – used to diagnose anatomic abnormalities
Primary infertility - refers to couples who have not become pregnant after at least 1 year having sex without using birth control methods.
Secondary infertility - refers to couples who have been able to get pregnant at least once, but now are unable.
What is the management of abruptio placentae?
First step – aggressive fluid resuscitation w/crystalloids
Next – place pt in L lateral decubitus position to displace the uterus off the aortocaval vessels and maximize CO.
Infections to be tested for at all first prenatal visits:
HIV, HBV, Chlamydia, and syphilis
What patients are at increased risk for IAI?
Those with premature rupture of membranes or prolonged rupture (>18hrs)
Clinical features of lichen sclerosus:
Thin, white, wrinkled skin over the labia
Atrophic changes extending over the perineum and around the anus
Excoriations, erosions, and fissures from severe pruritus
Dysuria, dyspareunia, painful defecation, constipation and anal fissures
May see changes in vulvar architecture – adherence of labia at the midline
Workup and treatment of lichen sclerosus:
Punch biopsy (for adult lesions) to exclude malignancy Tx: superpotent corticosteroid ointment
Who does lichen sclerosus affect?
People with decreased estrogen: Prepubertal girls and peri/postmenopausal women
Biochemical profile in a patient with PCOS:
Increased testosterone, Increased estrogen, LH/FSH imbalance.
What are common signs/sxs of androgen-secreting tumors?
New-onset voice deepening (androgens lengthen and thicken the vocal cords – changing their acoustic freq. and changing the voice)
Frank virilization: male-pattern baldness, increased muscle bulk, clitoromegaly
What are the features of Bartholin gland cysts on PE?
Soft, mobile, nontender, cystic mass palpated behind the posterior labium majus w/possible extension into the vagina.
Pts may have pressure and discomfort with walking, exercise or sex
How does uterine rupture present?
During labor of prior c-section pts. w/sudden onset of vaginal bleeding, intense abdominal pain, palpable fetal parts through the abdominal wall and FHR abnormalities.
What should be done in patients w/High-grade squamous itraepithelial lesions on pap?
Immediate colposcopy.
May be done even in pregnancy w/cervical bx for all pts.
What should be done in pts who have an “inadequate colposcopy”?
Endocervical curettage – invasive procedure and deferred during pregnancy d/t risk of miscarriage and preterm delivery
What screening tests can be done to asses for aneuploidy in the 1st trimester?
Cell-free fetal DNA – has high sensitivity and specificity.
If the results of this are abnormal then the more invasive chorionic villus sampling can be taken and confirm the diagnosis w/fetal karyotyping.
When can amniocentesis be performed?
Second trimester (15-20 weeks)
When can chorionic villus sampling be performed?
First trimester (10-13 weeks)
When can cell-free fetal DNA be performed?
First trimester (10+ weeks) in patients at risk for aneuploidies (>35)
Diagnosis of ectopic pregnancy:
positive urine B-hCG test combined w/transvaginal US
What is pseudocyesis and how is it managed?
The belief that one is pregnant with the misinterpretation of bodily sxs (breast fullness, morning sickness, abdominal distention). The belief may be strong enough to misinterpret negative home pregnancy tests as positive.
Tx: psychiatric evaluation and tx
How does undiagnosed placenta accreta often present?
Difficulty w/placental delivery – placenta does not detach from the uterus and is extracted in pieces. Often also has severe maternal hemorrhage unresponsive to uterine massage and uterotonic Rxs.
Why might pts undergoing chemo or radiation become infertile? What does it cause and treatment?
These txs target rapidly dividing cells – affect theca and granulosa cells in the ovary and cause primary ovarian failure.
Causes: Primary ovarian failure. Will decrease estrogen production and cause increased LH and FSH in return.
Tx:
- HRT for menopausal sx relief and bone loss protection
- Cryopreservation for fertility
What is thought to cause HELLP syndrome?
Abnormal placentation – triggers systemic inflammation and activation of the coag and complement cascades.
Have platelet consumption and microangiopathic hemolytic anemia which is v detrimental to the liver.
What causes the elevated liver enzymes in HELLP syndrome?
Microangiopathic hemolytic anemia causes hepatocellular necrosis and thrombi in the portal system.
Also causes liver swelling and distention of the hepatic (Glisson) capsule.
MAHA also increases BR production (indirect hyperBRemia), and blood cell fragments on PBS.
Tx of HELLP syndrome:
Delivery of fetus
Mag for seizure pphx
Anti-HTN Rxs
Clinical features of HELLP:
Preeclampsia (increased BP + urine proteins after 20 wks)
Nausea/vomiting
RUQ abdominal pain
What would HTN and hyperreflexia (clonus) in pregnancy be concerning for?
Preeclampsia w/severe features
What is the treatment of postpartum endometritis?
Clindamycin and Gentamicin
Definition of preeclampsia:
New-onset HTN (SBP 140+ and/or DBP 90+) at 20+ weeks gestation PLUS proteinuria &/or end-organ damage
Severe features of preeclampsia (6):
SBP >160 or DBP 110 (2x 4hrs apart) Thrombocytopenia Increased Creatinine Increased Transaminases Pulmonary edema Visual or cerebral sxs
Mgmt of preeclampsia:
W/out severe features – delivery at 37+ weeks
W/severe features – delivery at 34+ weeks
Mag sulfate for seizure pphx
Anti-HTNs
C-section is not indicated unless there is a contraindication to labor, or there’s a non-reassuring FHR
What is primary ovarian insufficiency?
A form of hypergonadotropic hypogonadism.
Causes cessation of ovarian fxn age <40yr.
Characterized by amenorrhea or oligomenorrhea and sxs of decreased estrogen (hot flashes, fatigue).
Initial presentation = irregular menses or infertility.
Pts. often have hx of AI disorder – hypothyroidism etc.
What will be seen in the serum of pts. w/Primary ovarian insufficiency?
Increased GnRH, and FSH.
Decreased Estrogen
What are indications for an endometrial bx for women >35yrs?
Atypical glandular cells on pap test
What are indications for endometrial bx in women <45?
AUB plus:
Unopposed estrogen (obesity, anovulation)
Failed medical mgmt.
Lynch syndrome (HNPCC)
What are indications for endometrial bx in women >45?
AUB or postmenopausal bleeding
What is LEEP biopsy?
Loop electrosurgical excision procedure
A type of cone bx that removes the cervical transformation zone.
Does not evaluate the endometrium – not used to dx AGC on pap
What should be done to investigate ACG on pap?
Aka atypical glandular cells.
May be d/t either cervical or endometrial adenocarcinoma.
Investigated w/colposcopy, endocervical curettage and endometrial bx – allows evaluation of ecto- and endo cervix and endometrium
What causes the AUB following initiation of menses?
Immaturity of the developing HPG axis – produces inadequate quantities and proportions of GnRH, and therefore FSH and LH, to induce ovulation.
What are the signs and sxs of peripartum cardiomyopathy (PPCM)?
Causes rapid-onset systolic HF – fatigue, dyspnea, cough, pedal edema.
Occurs >36 weeks or in early puerperium.
What type of fibroids are a/w RPL?
Intracavity, intramural, and submucosal.
Subserosal fibroids are located outside of the uterine cavity and do not cause RPL.
When is gHTN diagnosed?
After 20 weeks
If a patient presents w/HTN prior to 20 weeks then it is considered chronic HTN.
Maternal pregnancy-related risks d/t HTN (5):
Superimposed preeclampsia Postpartum hemorrhage gDM Abruptio placentae C-section
Fetal pregnancy-related risks d/t HTN (4):
IUGR
Perinatal mortality/Stillbirth
Preterm delivery
Oligohydramnios
What will be seen on FHR tracing in fetal anemia?
Sinusoidal fetal heart tracing – smooth, undulating waveform w/no variability
What will be seen on FHR tracing in placental insufficiency?
Late decelerations, smooth and subtle drops in the FHR occurring after contractions d/t transient fetal hypoxia caused by placental hypo-perfusion during contractions.
How does round ligament pain often present?
With sudden pain localized to the lower uterus and exacerbated by movement/improved with rest. Often lasts a few seconds with radiation to the groin.
Tx: reassurance, maternity support belt and acetaminophen
What are associated risk factors for uterine rupture (6)?
Previous scarring of the uterus – prior c-section or other surgery
Blunt abdominal trauma
Multiple gestation pregnancy
Grand multiparity
Inappropriate oxytocin admin
Excessive fundal pressure during delivery
What is the best method for determining neural tube defects?
Amniocentesis
What type of ovarian cysts are a/w hydatidiform moles?
Theca-lutein cysts – a/w choriocarcinoma and hydatidiform moles
What type of ovarian cysts are a/w teratomas?
Dermoid cysts – a/w cystic teratomas
What is the pathogenesis and clinical features of Granulosa cell tms?
Path: Sex cord-stromal tm. Have increased estradiol and inhibin
Complex ovarian mass
Juvenile features: Precocious puberty w/increased bone age
Adult features: breast tenderness, AUB, postmenopausal bleeding
Histo and mgmt. of Granulosa cell tms:
Histo: call-exner bodies (cells in rosette pattern)
Mgmt: Endometrial bx (for ca screening) and surgery for staging
What causes the sxs and lab values in Granulosa cell tms?
Granulosa cells convert testosterone to estradiol (via aromatase) and secrete inhibin which blocks FSH release.
Therefore, uncontrolled growth of these cells results in v. high estradiol and inhibin levels and low FSH
What is secreted by dysgerminomas?
These are tumors of syncytiotrophoblast cells of the placenta – secrete LDH or B-hCG
What type of ovarian tm may cause hyperthyroidism?
Struma ovarii – a type of mature teratoma/dermoid cyst.
These secrete TSH
What type of ovarian tms may cause virilization and what lab values will be seen?
Sertoli-Leydig cell tms – ovarian sex cord-stromal tms. that produce androgens.
Have increased testosterone and androstenedione; decreased estrogen; normal levels of DHEAS
Pts present w/amenorrhea, deepening voice, clitoromegaly
May also have signs of hypoestrogenism: vaginal dryness, breast atrophy, etc.
What ovarian tms produce high amounts of AFP?
Yolk sac tumors
What is the first step in evaluating risk of preterm labor?
Measurement of cervical length by transvaginal US (TVUS) in the second trimester
What is the mgmt. to reduce risk of preterm labor in pts w/short cervix?
Pts w/short cervices and no hx of preterm labor – vaginal progesterone
Pts w/hx of preterm labor – IM progesterone starting in 2nd tri and serial TVUS
Cerclage may be indicated then if TVUS shows short cervix
Risk factors of endometrial hyperplasia/ca (5):
Anything w/xs estrogen OBESITY Chronic anovulation/PCOS Nulliparity Early menarche/late menopause Tamoxifen use
What is in the BPP and what are abnormal results?
Biophysical profile = Nonstress test plus US to assess the following:
Amniotic fluid volume
Fetal breathing movement
Fetal movement
Fetal tone
Each category (including NST) gets 2 pts, normal is 8-10 points
6 points = equivocal
0-4 = abnormal – predictive of fetal acidemia
Oligohydramnios is also abnormal finding on US
What are normal and abnormal results of NST?
NST = external FHR monitoring for 20-40 min
Normal: Reactive – 2+ accelerations
Abnormal: Nonreactive – <2 accelerations; recurrent variable or late decelerations
Risk factors for shoulder dystocia (5):
Fetal macrosomia Maternal obesity Excessive pregnancy weight gain gDM Post-term pregnancy
What effect on fetal growth does a short interpregnancy interval have?
Intervals <18mo are risks for IUGR
What is seen on US in a septic abortion?
Retained POC and thick/echogenic endometrial stripe w/active blood flow.
At what B-hCG level will a pregnancy be detectable by US?
> 1500
What is the mgmt. of HSV infection in pregnancy?
All pts w/prior HSV infection should receive antivirals from 36 weeks until delivery.
If lesions or prodromal sxs are present during labor – c-section
What is loss of fetal station pathognomonic for?
Uterine rupture – the presenting fetal part retracts back into the uterus.
How to dx gDM:
First do glucose challenge test, if >140 then do 3-hr glucose tolerance test to confirm. Must have 2+ of the following to diagnose: Fasting >95 1hr >180 2hr >155 3hr >140
Absolute contraindications to ECV:
Contraindications to vaginal delivery:
Prior classical cesarean
Prior extensive uterine myomectomy
Placenta previa
Anti-HTN Rxs used in pregnancy:
First Line: BBs (labetalol) and methyldopa, then CCBs (nifedipine), and Hydralazine.
Second line: Clonidine, Thiazides
Anti-HTNs contraindicated in pregnancy (5):
ACEIs ARBs Direct renin inhibitors Nitroprusside Spironolactone (mineralocorticoid R antags) Furosemide (relative contraindication)
What is the recommended antepartum mgmt. of HIV?
Get viral load at initial visit, every 2-4wks after initiation/change of tx, and then monthly until undetectable and every 3mos.
CD4 count every 3-6mos
Resistance testing
ART initiation
Avoid amniocentesis unless viral load <1000
What is the recommended intrapartum mgmt. of HIV?
Avoid artificial ROM, scalp electrode or operative vaginal delivery
VL <1000 – ART + vaginal delivery
VL >1000 – ART + zidovudine + C-section
What is the postpartum mgmt. of HIV?
Cont. ART for mother
Zidovudine for infants of mothers w/VL <1000
Multi-drug ART for infants of mothers w/VL >1000
What are the fetal risk factors for macrosomia (3)?
AfAm or Hispanic ethnicity
Male sex
Post-term pregnancy
What is the mgmt. in a newborn w/shoulder dystocia?
Gentle massage and PT to prevent contractures – most spontaneously recover w/in 3 months
Surgery (nerve grafting) is considered when no improvement by 3-6mos
How does lactation suppress ovulation?
High prolactin levels inhibit GnRH and thus LH and FSH.
1st line tx to induce ovulation in PCOS pts:
WEIGHT LOSS
If this fails – Clomiphene citrate (a SERM; will restore pulsatile GnRH secretion).
Factors, features and tx of Genito-pelvic pain/Penetration disorder:
Risks: Sexual trauma, lack of sexual knowledge, Hx of abuse
Features: pain w/penetration, distress/anxiety about sxs, no other cause of sxs
Tx: Desensitization tx, Kegels
Risk factors for development of PPH (6):
Prolonged or Induced labor Chorioamnionitis Multiple gestation Polyhydramnios Grand Multiparity Operative delivery
Causes of PPH (5):
#1: Uterine atony Retained placenta Genital tract laceration Uterine rupture Coagulopathy
What are uterotonics and what are they used for?
Oxytocin (DoC), Methylergonovine, Carboprost, Misoprostol
Used in the tx of PPH; cause the uterus to contract
What is a contraindication to methylergonovine?
Hx of HTN
The rx causes sm. mm. constriction, uterine contraction and vasoconstriction which can cause/worsen HTN.
What is a contraindication to Carboprost?
Asthma – it causes bronchoconstriction.
One differentiating factor of Lichen sclerosis v. GU syndrome of menopause:
Lichen Sclerosis DOES NOT affect the vagina – only the vulva/perineum
Menopause will affect all of these – pale vagina w/dryness and petechiae, discharge and atrophy.
What is a Category I FHR tracing?
Requires all of the following: Baseline 110-160 Moderate variability (6-25/min) No late/variable decelerations \+/- Early decelerations (the ones that mirror contractions) \+/- Accelerations
What is a category III FHR tracing?
Requires 1+ of the following:
Absent variability + recurrent late decels
Absent variability + recurrent variable decels
Absent variability + bradycardia
Sinusoidal pattern
What does a category III FHR tracing likely indicate?
Increased risk of severe fetal hypoxia (likely from uteroplacental insufficiency) – can easily lead to fetal acidemia, hypoxic brain injury and demise.
What is the mgmt. of a category III FHR tracing?
Initial – maternal repositioning and intrauterine resuscitative interventions (O2, IVF, discont. Uterotonics).
Those who do not improve w/initial mgmt. and are <10cm dilated need immediate C-section
What is the timeline for developing Sheehan syndrome?
May occur immediately postpartum or up to several years later.
How is secondary amenorrhea defined and evaluated?
Amenorrhea for 3+ mos in women w/previously regular menses or 6+ in women w/irregular menses.
Evaluation is started w/B-hCG pregnancy test followed by serum FSH, TSH and prolactin levels.
What does a fetal fibronectin test indicate?
Risk of preterm labor.
Fibronectin is produced from fetal cells and is found b/w decidua and uterine wall – starts to leak when labor is impending.
What do decreasing B-hCG levels indicate?
Demise – automatically exclude normal pregnancy.
B-hCG should increase until end of 1st trimester
What are the US findings in a missed abortion?
Embryo w/out cardiac activity or an empty gestational sac w/out a fetal pole (aka no embryo).
This can be seen in some early pregnancies, but if there is no continuation of embryonic development – missed abortion
What are causes of increased AFP?
Open neural tube defects
Ventral wall defects
Multiple gestation
Drugs used in maternal HTN crises:
IV Hydralazine, IV Labetalol, Oral Nifedipine.
If the pt. has bradycardia then labetalol can worsen this and shouldn’t be used.
If the pt. can’t tolerate PO then nifedipine cant be used
IV hydralazine is best
What is the workup in suspected physiologic nipple discharge?
Pregnancy test
Guaiac test
Serum prolactin and TSH
Possible MRI of pituitary
What is the workup in suspected pathologic nipple discharge?
Breast US and Mammography (if age 30+)
What is Postpartum thyroiditis?
Occurs normally w/in the first 6mos postpartum but may be diagnosed up to a year.
Have brief hyperthyroid phase first (nonspecific sxs norm – anxiety, palpitations), then hypo phase which normally causes concern (fatigue, wt. gain, constipation, etc.)
Labs may show hyponatremia and hypercholesterolemia
Normally self-limited
What are the common sxs of Aromatase deficiency in adolescents?
Delayed puberty
Osteoporosis – fractures easily
Undetectable estrogen – no breast development
High concentrations of gonadotropins – pubic and axillary hair, polycystic ovaries
Most common cause of a nonreactive NST:
Quiet fetal sleep cycle – lasts <40min
What is the pathogenesis of fibroids?
Proliferation of smooth muscle cells within the myometrium
What is the cause and features of adenomyosis?
Proliferation of endometrial glands inside the uterine myometrium – causes bulky, tender uterus that is uniformly enlarged
What is likely to be seen on FHR tracing in uterine rupture?
Fetal hypoxia – fetal tachycardia, minimal variability, and late decels.
May look like large accels + decels, but the “accelerations” may just be a high baseline (fetal tachy)
What are cxs of cervical conization (4)?
Cervical stenosis
Preterm birth
Preterm PROM
2nd trimester pregnancy loss
How do Theca lutein cysts present?
As multilocular, bilateral cysts (10-15cm) in the ovaries.
D/t ovarian hyperstimulation
Will resolve w/decreasing B-hCG levels
How does a complete mole form?
Fertilization of an empty ovum by either 2 sperm or by 1 that duplicates its genome – all paternal parts.
What is required to diagnose PMS and what is the tx?
Sx severity to a point of socioeconomic impact (missed work).
Tx: SSRIs (1st line) or combined OCs (2nd line)to induce anovulation
If both those txs fail can try Leuprolide
When are women screened for gDM?
At 24-28 weeks
High risk pts can be screened earlier
How to differentiate inflammatory breast ca. from infectious processes:
All commonly have warmth, pain and erythema.
Mastitis and abscesses often have fever and improve w/abx
IBC often have peau d’orange, itching, nipple changes, a palpable mass and lymphadenopathy
What is the mgmt. of shoulder dystocia?
“BE CALM”
Breath, don’t push
Elevate legs & flex hips against the abdomen (McRoberts maneuver)
Call for help
Apply suprapubic pressure
enLarge vaginal opening w/episiotomy
Maneuvers – deliver post. arm, rotate shoulder, etc.
What is the tx of ovarian torsion?
It is a gyn emergency!
Laparoscopy w/detorsion
Ovarian cystectomy
Oophorectomy if necrosis or malignancy
What is the pathognomonic US finding in ovarian torsion?
Presence of an adnexal mass and lack of Doppler flow.
When do we stop Pap testing?
At age 65 or hysterectomy plus no hx of CIN2 or higher
AND
3 consecutive neg. Paps OR 2 consecutive neg. co-testings
When must pap testing continue past age 65?
If the pt. has a hx of CIN2 or more testing must continue for 20 years after that result (may extend past 65)
Or if a woman has risk factors for cervical ca (IMCP’d, high-risk activity, tobacco, DES exposure)
What are the common US findings of epithelial ovarian carcinoma?
Solid mass w/thick septations and ascites (mod amount of peritoneal fluid)
What type of ovarian tumor arises from ectodermal cells?
Dermoid cysts/Mature cystic teratomas – these will appear as hyperechoic nodules w/calcifications on US.
What structures may be involved in epithelial ovarian carcinoma?
Can be malignancy involving the ovary, fallopian tube and peritoneum.
Abnormal proliferation in any of these will cause the hallmark large ovarian mass.
What are the features of Asherman syndrome?
Aka intrauterine adhesions. Features: AUB Secondary Amenorrhea (unresponsive to Progesterone challenge) Infertility Cyclic pelvic pain Recurrent pregnancy loss Evaluated w/Hysteroscopy
What are the current guidelines for Pap and HPV testing?
For women 21-29: Pap cytology alone every 3 years
Women 30-64: Pap w/HPV co-testing every 5 years
What are the features of chancroid?
Caused by H. ducreyi – mostly found in tropical and subtropical regions.
Have erythematous papules that progress to pustules and then painful ulcers norm w/yellow or grey exudate covering the bases.
Also have buboes
What serum abnormalities may be seen in AIS?
Typically will have increased testosterone, estrogen, and LH levels.
What blood tests are recommended at time of dx of PCOS?
Fasting lipid panel
What is 1st line tx for PCOS?
Metformin or other anti-DMs as well as OCs
What tm marker is a/w endodermal sinus ovarian tms?
Aka Yolk sac tms.
AFP is typically elevated
What is the maternal mgmt. of HCV in pregnancy?
Get HAV and HBV vaccinations if not already immune.
Otherwise nothing really – barrier contraception isn’t needed, can’t take ribavirin bc its teratogenic, and C-section is not protective.
Can still breastfeed
What is 1st line mgmt. of recurrent variable decelerations?
Maternal repositioning.
If this fails can do an amnioinfusion to decrease cord compression.
What needs to be investigated in Mullerian agenesis?
Renal abnormalities – all pts should get renal US
Mullerian anomalies may also occur and be a/w renal abnormalities (only 1/2 of the uterus forms and only 1 kidney and ovary etc.)
Type II will have renal and vertebral defects +/- auditory and cardiac defects.
Risk factors of placenta previa:
1 is prior c-section
Prior previa
Multiple gestation
Advanced maternal age (>35)
Contraindications to copper IUD:
Acute cervicitis and PID
Where are the skene glands located?
Lateral to the urethral meatus
What is size-dates discrepancy?
A >2cm difference in fundal height measurement from the gestational age.
Once ROM has occurred there will be a larger discrepancy – normal
What are luteomas of pregnancy?
Solid uni- or bilateral ovarian masses
Cause increased release of androgens – maternal and possible fetal virilization.
May be asx or present w/sxs of virilization
Ovarian masses will spontaneously regress after delivery – no tx required
How to differentiate Theca-lutein cysts from luteomas of pregnancy:
Both will present w/virilization of both mother and fetus and ovarian masses that regress after delivery.
Theca-lutein will be cystic and bilateral
Luteomas will be solid and unilateral or bilateral
What type of cancer does DES exposure predispose to?
Clear cell adenocarcinoma of the vagina
aka not squamous cell
Risk factors for vaginal ca.:
Age >60
HPV infection
Tobacco use
DES exposure in utero (clear cell adeno only)
Causes of fetal tachycardia (4):
Maternal fever
Medication side effect (B-agonists)
Fetal hyperthyroidism
Fetal tachyarrhythmia
Causes of fetal bradycardia (4):
Maternal hypothermia
Medication side effect (BBs)
Fetal hypothyroidism
Fetal heart block (anti-Ro/SSA, anti-La/SSB)
Is MMR vax safe during breastfeeding?
Yes. All non-immune mothers should receive it immediately post-partum
When should anti-D immune globulin be given?
In uncomplicated pregnancies at 28-32 weeks gestation and then again w/in 72 hrs of delivery. Other indications: amniocentesis chorionic villus sampling ECV Ectopic pregnancy <72hrs after spontaneous abortion Threatened abortion Hydatidiform mole Abdominal trauma/placental abruption 2nd or 3rd trimester bleeding
Tx of condylomata acuminata:
Chemical – podophyllin resin, trichloroacetic acid
Immunologic – imiquimod
Surgical – cryotherapy, laser therapy, excision
How does vulvar lichen planus appear?
As pruritic, glassy, bright red-purple lesions w/overlying white reticular line (Wickham striae)
What are the clinical features of intraductal papilloma?
Unilateral bloody nipple discharge w/o an associated mass or lymphadenopathy.
Benign dilation of breast duct.
What is a boggy, tender uterus in a non-pregnant woman suggestive of?
Adenomyosis
What kind of twins are at risk of cord entanglement?
Monochorionic monoamniotic (bc they’re in the same sac)
What are the long-term consequences of exercise-induced hypothalamic amenorrhea?
Decreased bone mineral density
Increased total cholesterol and TGs
What lab abnormalities are seen in Hyperemesis Gravidarum?
Ketonuria Hypochloremic metabolic alkalosis Hypokalemia Hemoconcentration HG may also cause transient hyperthyroidism but levels are not typically measured unless there are overt signs of hyperthyroidism
What is Intertrigo, and how is it txd?
A dermatitis caused by Candida (often in IMCP’d)
Features: Erythematous “beefy red” plaques w/in the inguinal folds. Typically in a symmetric mirror image pattern across skinfold w/satellite regions near primary infection.
May affect inguinal, axillary, gluteal, and inframammary folds.
Tx: Topical azoles – clotrimazole, ketoconazole
What Rx can be used in the tx of Hidradenitis suppurativa?
Doxycycline
Tx options of Spontaneous abortion:
Expectant and medical induction (Misoprostol) in stable pts.
Suction curettage in pts w/infection or hemodynamic instability
Maternal cxs of Twin pregnancy:
Hyperemesis gravidarum
Preeclampsia
gDM
Fe-def anemia
Fetal cxs of twin pregnancy:
Congenital anomalies IUGR Preterm delivery Malpresentation (breech) Placenta previa Abruptio placenta Cerebral palsy RDS Transfusion syndrome (monochorionic) Cord entanglement and conjoined (monoamniotic)
What are the features, onset and etiology of Symmetric FGR?
Onset: 1st trimester
Etiology: Chromosomal abnormalities, congenital infections (less common)
Features: Global growth lag – all organs are uniformly affected
What are the features, onset and etiology of assymmetric FGR?
Onset: 2nd or 3rd trimester
Etiology: Utero-placental insufficiency, maternal malnutrition, maternal vasculopathy (HTN, pre-gestational DM)
Features: “Head-sparing” growth lag – redistribution of blood flow spares brain, heart and placenta at the expense of less vital organs (abdominal viscera)
Effect of maternal depression on fetus:
A/w increased risk for cognitive delay and psych illness – depression, ADHD.
SSRIs should be continued throughout pregnancy – not teratogenic
Current guidelines for tx of Gonococcal infections:
Both azithromycin and ceftriaxone – both are active against N. gonorrhea and there is increasing resistance to cephalosporins, so monotx is not recommended
What is the best initial step in evaluating an adnexal mass in a postmenopausal woman?
Measurement of CA-125 levels in conjunction w/pelvic US
What procedure is contraindicated in a postmenopausal woman w/an ovarian mass?
Needle aspiration – high risk of spreading potential malignant cells
What is the mgmt. and potential cx of Intrauterine fetal demise?
20-23 weeks: can have dilation & evacuation or vaginal delivery (induced by Oxytocin, Misoprostol or Prostoglandin E2)
24+ weeks: requires vaginal delivery – induced like above
Cx: Coagulopathy/DIC if fetus is retained for several weeks
What is Mittelschmerz?
Unilateral pelvic pain occurring mid-cycle d/t ovulation/follicular cyst rupture.
Physiologic process – will be a simple, small, thin-walled cyst +/- free fluid
Features and tx of Magnesium toxicity:
Features:
Mild – N/HA, flushing, diaphoresis, hyporeflexia
Moderate – areflexia, hypocalcemia, somnolence
Severe – resp. paralysis, cardiac arrest
Tx: Stop Mag therapy, give IV Ca-Gluconate bolus
Biggest risk factor for Magnesium toxicity:
Renal insufficiency – mag is solely excreted by the kidneys
Risk factors of placental abruption (4):
Maternal HTN or preeclampsia/eclampsia
Abdominal trauma
Prior abruption
Cocaine and tobacco use
Risks for cornual/interstitial ectopic pregnancies:
Uterine anomalies – bicornuate uterus
IVF
How often does the medroxyprogesterone acetate (DMPA) shot need to be admin’d?
Every 3 months to prevent pregnancy – inhibits GnRH and suppresses ovulation.
Adverse effects of SERMs:
Both tamoxifen and raloxifene can cause hot flashes, and venous thromboembolisms.
Only tamoxifen can cause endometrial hyperplasia and ca.
Both also reduce risk of osteoporosis
Tx of neonatal thyrotoxicosis:
Self-resolves w/in 3 mos (maternal Abs disappear)
Short-term tx w/Methimazole plus BB
When is myomectomy a contraindication to vaginal delivery?
If it was extensive/the uterine cavity was entered
When is amnioinfusion contraindicated?
In a pt. w/a hx of uterine surgery
Tx of Stress incontinence:
Trial of conservative mgmt. – kegel exercises
Those who fail or request surgery – midurethral sling
Tx of overflow incontinence in women:
Cholinergic agonists (Bethanecol) and intermittent self-catheterization. Men are tx’d w/a-blockers (Tamsulosin)
Tx of urge incontinence:
Oxybutynin (antimuscarinic)
What is the purpose of hCG in pregnancy?
Responsible for maintaining the corpus luteum and adequate progesterone secretion until the placenta is able to produce it.
hCG production begins ~8 days after fertilization and doubles every 48hrs until it peaks at 6-8 weeks gestation.
1st line tx for asx bacteriuria in pregnancy:
Cephalexin
Amoxicillin-clavulanate (Augmentin)
Nitrofurantoin
Fosfomycin
Is TMP-SMX (Bactrim) safe during pregnancy?
Only during 2nd trimester.
Contraindicated in 1st d/t interference of folic acid metabolism, and in 3rd d/t increased risk of kernicterus
What is pubic symphysis diastasis and how does it present?
Widening of the pubic symphysis during vaginal delivery.
Most pts don’t experience sxs of this physiologic phenomenon but some experience: suprapubic pain radiating to back, hips, thighs, exacerbated by walking, and position changes.
What renal & urinary changes are seen in pregnancy?
Physiologic: Increased RBF, GFR, and BM permeability
Labs: Decreased BUN and Creatinine, Increased renal protein excretion (up to 300mg protein/1+ on dipstick)
How should a simple breast cyst in a pt <30 be managed?
Repeat breast exam in 2-4mos.
If they are symptomatic can aspirate the fluid and if it is clear then f/u 2-4mos
Cxs of inappropriate wt. gain in pregnancy:
Excessive – gDM, fetal macrosomia, C-section
Inadequate – FGR, preterm delivery
How much should underweight pts gain for pregnancy?
Underweight (BMI <18.5) need to gain 28-40lbs during pregnancy.
What is fetal organomegaly a potential cx of?
gDM and fetal hyperinsulinemia
What causes of bacterial vaginitis will cause subsequent vaginal inflammation?
Thrichomonas and Candida
Gardenerella (bac vaginosis) will not cause inflammation
What Rx is contra’d in Hydatidiform mole?
Misoprostol – high risk of incomplete uterine evacuation.
Most accurate method of determining GA:
First-trimester US w/crown-rump length measurement.
If later in the pregnancy there are discrepancies b/w US dating the 1st trimester US should be used and growth problems should be considered
Hallmark of endometrial polyps:
Intermenstrual spotting w/out uterine enlargement.
The polyps are in the uterine cavity and will not be palpated on adominopelvic PE
What affect will uteroplacental insufficiency have on amniotic fluid levels?
It causes chronic fetal hypoxemia and redistribution of blood flow sparing the brain at expense of other organs.
Will have decreased renal perfusion in fetal kidney – oligohydramnios
What are nuchal cords a/w on FHR tracing?
Variable decelerations
What effect will tamoxifen have on risk of ovarian cancer?
May decrease the risk
Increases the risk of endometrial ca. only
What defines the arrest of active/1st stage labor and how is it managed?
No cervical change for 4+hrs w/adequate contractions
or 6+hrs w/inadequate contractions (adequate = contractions of 200+ MVUs in 10min)
Tx of any cause of arrest is C-section
What is protraction of labor and its tx?
Cervical change slower than expected +/- inadequate contractions.
Tx w/oxytocin infusion
Mgmt of Epithelia ovarian carcinoma:
Exploratory laparotomy, Bx of any sort is contra’d d/t high risk of spreading suspected malignant cells
Mgmt of placenta previa:
When found early – no intercourse, no digital cervical exams, bedrest, and inpatient admission for bleeding episodes.
If in labor – c-section at 36-37 weeks
What might be seen on US in congenital HSV infection?
Placental, umbilical cord, and temporal lobe calcifications
Features and mgmt. of vaginal cancer:
Vaginal bleeding, malodorous vaginal discharge, irregular vaginal lesion (often in upper 1/3 of posterior vagina).
Dx w/vaginal bx and Tx w/surgery and chemo
How is vaginal intraepithelial neoplasia tx’d?
It is non-invasive
Tx: topical therapy or wide local excision
Mgmt of uterine inversion:
Aggressive fluid replacement
Manual replacement of the uterus
Placental removal & uterotonic Rxs after uterine replacement
pH difference b/w causes of vaginitis:
Bacterial (gardnerella) and Trichomoniasis have increased pH >4.5
Candida has normal pH: 3.8-4.5
What effect can estrogen have on the vaginal flora?
It can cause an imbalance and allow for candida proliferation.
So people at risk = pregnant women, postmeno on HRT, and those on OCs w/estrogen
Mgmt. of preterm labor in women <32wks GA:
Betamethasone
Tocolytics (Indomethacin DoC)
Mag Sulfate (neuroprotection)
Penicillin if GBS + or unknown
Risk factors for amniotic fluid embolism:
Advanced maternal age Gravida >5 (live or stillbirths) C-section or instrumental delivery Placenta previa or abruption Preeclampsia
What is vasa previa and how does it present?
Fetal vessels traverse the internal cervical os and are vulnerable to injury during amniotomy.
Presents as painless vaginal bleeding and FHR abnormalities (bradycardia d/t fetal exsanguiation) after amniotomy. Often see bright-red fluid w/ROM.
Normally need c-section right away
What features would suggest secondary (pathologic) causes of dysmenorrhea?
Sx onset >25
Unilateral/non-midline pelvic pain
No systemic sxs during menses
AUB (intermenstrual or postcoital)
Risk factors for cervical cancer:
Infection w/high-risk HPV strains (16, 18) Hx of STDs Early onset sexual activity Multiple or high-risk partners IMCP’d OC use Low socioeconomic status Tobacco use
Features of Congenital Zika Syndrome:
Microcephaly and craniofacial disproportion
Neurologic abnormalities (spasticity, seizures, hypertonia)
Ocular abnormalities
Contractures, club foot and limb abnormalities
Closed anterior fontanelle (craniosynostosis) and collapsed skull
Thin cerebral cortices w/intracranial calcifications (d/t tissue necrosis)
Ventriculomegaly
Tx of labial adhesions:
Topical estrogen for those w/sxs
Asx pts don’t need tx
Breast cancer risk factors:
HRT Nulliparity Increased age at first live birth EtOH consumption Fhx or genetic mutation White race Increasing age (>50) Early menarche/late menopause
Risks of and mgmt. for Intrahepatic cholestasis of pregnancy:
Risks: Fetal demise Preterm delivery Meconium-stained amniotic fluid Neonatal RDS Mgmt: Delivery at 37wks Ursodeoxycholic acid Antihistamines
Features and mgmt. of oxytocin toxicity:
Oxytocin is similar to ADH and cause water retention often leading to Hyponatremia.
Can present with: HA/AbdP/N/V, lethargy, HoTN, tachysystole and tonic-clonic seizures
Mgmt: correct hyponatremia w/hypertonic saline (3% NS)
Appearance and evaluation of a neonate w/fetal growth restriction:
Appearance: wide/lg. anterior fontanelle, thin umbilical cord, loose/peeling skin, minimal subQ fat, and meconium-stained amniotic fluid.
Evaluate w/placental histopathology; may consider karyotype, urine tox, and serology
Neonatal cxs of IUGR:
Polycythemia
Hypoglycemia
Hypocalcemia
Poor thermoregulation
Lethal fetal anomalies that are non-viable:
Acardia Anencephaly b/l renal agenesis Holoprosencephaly Fetal demise Pulmonary hypoplasia Thanatophoric dwarfism These conditions require vaginal birth w/minimization of maternal cxs
Features of Klumpke palsy:
Injury to C8 and T1
Presents w/claw hand (extended wrist, hyperextended mcp joints, flexed IP joints, and absent grasp reflex), Horner syndrome, Intact moro and biceps reflexes
Often caused by shoulder dystocia
Features of Erb-duchenne palsy:
Injury to C5 and C6
Presents w/waiter’s tip (extended elbow, pronated forearm, flexed wrist and fingers), intact grasp reflex. May have absent or decreased Moro
Absolute contraindications to exercise in pregnancy:
Amniotic fluid leak Cervical incompetence Multiple gestation Placenta abruption or previa Premature labor Preeclampsia/gHTN Severe heart or lung disease
Unsafe activities during pregnancy:
Contact sports
High fall risks (skiing, gymnastics, horseback riding)
Scuba
Hot yoga
Major causes of Primary ovarian insufficiency:
Turners Fragile X (even carriers) Autoimmune oophoritis Anticancer Rxs Pelvic radiation Galactosemia
Risk factors for vulvar cancer:
Tobacco use Vulvar lichen sclerosis IMCP’d Prior cervical ca. Vulvar/cervical intraepithelial neoplasia
Clinical features of vulvar cancer:
Vulvar pruritus, plaque/ulcer, abnorm bleeding
Need bx to dx
How does hypothyroidism cause amenorrhea?
The low thyroid hormones cause increased TRH – increased TSH and prolactin from the anterior pituitary.
Increased prolactin inhibits FSH and LH production – anovulation and AUB.
Features of Paget disease:
Paget disease – intraepithelial adenocarcinoma w/underlying DCIS or invasive breast ca.
Clinical features: Eczematous and/or ulcerating rash localized to the nipple and spreads to the areola, may have vesicles, scales, bloody discharge, and nipple retraction. Affected nipple may also have pain, itching and burning.
How to differentiate 5-a Reductase deficiency from AIS:
Both will be phenotypically female at birth, and develop external female genitalia w/internal male (testes in labia).
AIS will develop breasts during puberty and continue to have feminine characteristics.
Will have increased testosterone, estrogen and LH.
5-aR deficiency will have no breast development and will have virilization at puberty: clitoromegaly, increased mm. mass, nodulocystic acne, etc.
Will have normal testosterone/estrogen and LH will be normal or increased.
Risk factors for adenomyosis:
Age >40
Multiparity
Prior uterine surgery (myomectomy etc)
How does septic pelvic thrombophlebitis present and how is it tx’d?
Presents w/fever unresponsive to abx, no localizing signs/sxs, negative infectious evaluation.
It’s a dx of exclusion.
Tx: anticoagulation and BSA
What are risk factors for septic pelvic thrombophlebitis (6)?
C-section Pelvic surgery Endometritis PID Pregnancy Malignancy
What causes septic pelvic thrombophlebitis?
Caused by thrombosis of deep pelvic or ovarian veins (get b/l LQ tenderness) that becomes infected.
Predisposing factors: hypercoagulability of pregnancy, pelvic venous stasis and dilation, endothelial damage from infection and/or trauma during surgery
What is considered excessive alcohol consumption?
> 2drinks/day
What will be elevated in CAH?
Both classic and non-classic types will have 21-hydroxylase deficiency causing elevated 17-hydroxyprogesterone levels, normal DHEA and elevated testosterone
How to differentiate ovarian from adrenal androgen-secreting tumors:
Ovarian androgen-secreting tumors will have very high testosterone levels with normal DHEAS.
Adrenal will have very high DHEAS as well as increased testosterone.
What are the maternal cxs of an operative vaginal delivery (vacuum/forceps)?
GU tract injury
Urinary retention
Hemorrhage
What are the fetal cxs of an operative vaginal delivery (5)?
Laceration Cephalohematoma Facial n. palsy Intracranial hemorrhage Shoulder dystocia
What is a common cause of infertility in women >35?
Diminished ovarian reserve – decreased oocyte number and quality.
Ovulation and regular menses occur but conception rates decrease d/t diminished oocyte quality.
How will patients with acute fatty liver of pregnancy present?
Often have sxs of fulminant hepatic failure – scleral icterus, encephalopathy, leukocytosis and thrombocytopenia.
May present w/RUQ pain, elevated transaminases and IUFD
How does onset of decelerations differ?
Early decels a/w head compression are slow and have >30sec from onset to nadir
Variable have quick onset and are <30sec from onset to nadir
Late are gradual and have >/= 30 sec from onset to nadir
What pharmacotherapy can be used to tx stress incontinence?
Trick question – NONE
What are risk factors a/w uterine inversion and how will it present?
Risks – nulliparity, fetal macrosomia, placenta accreta, and rapid L&D
May result from xs fundal pressure and traction on umbilical cord before placental separation.
Presents w/smooth, round mass protruding through cervix/vagina, lower abdominal pain, hemorrhagic shock, and a uterus no longer palpable transabdominally
What can exclude endometrial ca. in postmenopausal women w/AUB?
An endometrial stripe = 4 mm.
This cannot exclude endometrial ca. in premenopausal women
How should suspected ectopic pregnancy in hemodynamically stable patients be managed?
Do TVUS – if non-diagnostic then measure serum B-hCG.
If B-hCG >1500 – repeat hCG and TVUS in 2d
If B-hCG <1500 – repeat hCG in 2d, once >1500 TVUS should be repeated
What effect does hPL have in the third trimester?
Human placental lactogen (a placental somatomammotropin) increases in the 3rd trimester and causes pancreatic B-cell hyperplasia causing increased peripheral insulin resistance – gDM
Risk factors for HG:
Multiple gestation
Hydatidiform mole
Hx of GERD
What is the only indication for HRT?
Vasomotor sxs in women <60 who have undergone menopause w/in the last 10yrs
How is placenta accreta diagnosed antenatally?
With US – see irregularity/absence of the placental-myometrial interface and intra-placental villous lakes
What is a Gartner duct cyst?
Results from incomplete regression of the Wolffian duct during fetal development.
Appear along lateral aspects of upper anterior vagina.
DO NOT INVOLVE VULVA (in contrast to Bartholin)
Cxs of ECV:
Abruptio placentae
IUFD
Risk factors for developing 2nd stage arrest of labor and its mgmt.:
Risks: Maternal obesity, xs pregnancy wt. gain, DM
Mgmt: operative vaginal delivery, c-section
What is the definition of the 2nd stage of labor?
Begins when cervix is 10cm dilated – ends w/fetal delivery.
What is the pathogenesis of congenital Zika syndrome?
ssRNA flavivirus targets neural progenitor cells.
Transplacental transmission to the fetus
What lab values are likely seen in acute fatty liver of pregnancy?
Prolonged PT, aPTT, and hypoglycemia w/encephalopathy
d/t acute microvesicular fatty infiltration of hepatocytes
Causes of Hyperandrogenism in pregnancy:
Placental aromatase deficiency – no ovarian mass
Luteoma – solid uni or bilateral masses
Theca lutein cysts – cystic bilateral masses
Sertoli-leydig tumor – solid unilateral mass (only one that needs sx)
What is the definition of primary amenorrhea?
Absence of menses w/normal secondary sex characteristics at age 15
or absence of both at age 13
How is primary amenorrhea evaluated?
First step – B-hCG to exclude pregnancy
If hCG is negative get FSH levels and Pelvic US
High FSH – karyotype
Normal FSH – Pelvic US or MRI to look for presence of uterus/ovaries
Prolactin and TSH can be obtained after FSH
Most important step in evaluating amenorrhea?
B-HCG!!
Regardless if they deny sexual activity or if its primary or secondary
What is suggested by a lack of uterine bleeding w/an estrogen-progesterone challenge?
Asherman syndrome
What are the current criteria to suggest genetic testing to assess hereditary cancer risk (6)?
Female breast cancer dx’d age 50 or less
Triple-negative breast cancer dx’d age 60 or younger
2+ primary breast cancers
Invasive ovarian or fallopian tube ca. or primary peritoneal ca.
Male breast ca.
1st, 2nd, or 3rd degree relatives w/breast ca. dx’d age 50 or younger
What is Meig’s syndrome?
Triad of pleural effusion and ascites in combo w/a benign ovarian tm. (norm. a fibroma)
What is the most common epithelial ovarian cancer and what are its common histo features?
Serous cystadenocarcinoma – malignant
Commonly bilateral
Histo: Will be lined w/ciliated, cuboidal, fallopian-like cells w/Psammoma bodies
What are the features of Mucinous cystadenocarcinoma?
2nd most common epithelial ovarian tm. (after serous cystadenocarcinoma)
Causes pseudomyxoma peritonei – aka Jelly Belly; Intraperitoneal accumulation of mucinous material from ovarian or appendiceal tm.
Will be multi-loculated and can become very large (up to 50lbs)
Will resemble GI cells on histo
What are the features and origins of immature teratomas?
These are aggressive, containing fetal tissue, arising from the neuroectoderm.
Most common postmenopausally
Will have immature/embryonic-like neural tissue
How is leuprolide beneficial in the tx of Endometriosis?
It reduces sxs by inducing a state of pseudo-menopause – decreases FSH and LH, and therefore estrogen which is needed to promote growth of the foreign tissue.
This causes infertility while being taken.
What is required for the dx of PID?
Aka Salpingitis
Pelvic pain
Tenderness of the cervix, OR uterus, OR adnexa on PE
Absence of an alternative explanation
How are PID and cervicitis distinguished from each other?
Pelvic pain and cervical motion tenderness are more consistent w/PID
Cervicitis often has no pain, but a friable cervix, postcoital bleeding, and an abnormal discharge
What are the palpable nodules in fibrocystic breast disease?
Inflamed and swollen breast lobules – d/t spikes in estrogen levels during the menstrual cycle.
How is fibrocystic breast disease tx’d?
NSAIDs
Ice packs
OCs
Characterisitcs of FBD—Sclerosing Adenosis:
Increased acini and intralobular/stromal fibrosis
a/w calcifications
Slight increase risk for cancer
Characteristics of FBD—Fibrosis subtype:
Hyperplasia of the breast stroma
Characterisitcs of FBD—Cystic subtype:
Cysts filled w/fluid
“blue dome cysts”
Characterisitcs of FBD—Epithelial/Ductal hyperplasia subtype:
Increased number of cell layers in the terminal ductal or lobular epithelium.
Increased risk of cancer
How is the 1st stage of labor defined?
Begins w/the onset of regular contractions and ends when the patient is 10cm dilated.
Has 2 phases:
Latent – gradual cervical dilation
Active – rapid cervical dilation
Transition b/w latent and active norm. occurs around 6cm dilation.
What defines the 3rd stage of labor?
Time b/w delivery of infant to delivery of placenta – should be 30min or less
What is the tx of congenital toxoplasmosis?
Spiramycin
How is the dx of Preeclampsia confirmed?
With a urine protein:creatinine ratio >= 0.3 or a 24-hr urine collection (gold standard) showing total protein >300mg.
Anyone w/HTN dx’d >20wks and a urine dipstick 1+ or below needs one of these tests.
How often do HIV+ pts need pap smears?
Need pap smear at initial evaluation, then 6mos later, and then yearly after that.
If hx of HPV, CIN or symptomatic HIV dx then go back to every 6mos.
What type of incontinence can fibroids lead to?
Overflow from urinary tract outlet obstruction
How is fetal growth restriction defined?
As estimated fetal weight <10th percentile for GA
Features of inevitable abortion:
Dilated cervix, w/viable fetus.
Pain and vaginal bleeding.
No PoC have been expelled – in contrast to incomplete where there’s a non-viable fetus and some PoC have been passed.
What cancers are a/w Lynch syndrome?
Early-onset colorectal ca.
Female genital tract, skin, stomach, pancreas, brain, breast and biliary tract.
Pts. dx’d w/CRC and have a 1st degree relative w/a Lynch assoc. ca. at <50yrs, or 2+ relatives dx’d w/Lynch assoc. cas. at any age should be tested for Lynch syndrome
What does a positive nitrazine test indicate?
Vaginal pH of 4.5-7.5, aka high
Will be positive in Bacterial vaginosis and trichomoniasis
Mgmt of tubo-ovarian abscess:
Admit and give IV abx for 48-72hrs
If hemodynamically unstable/signs of sepsis then need surgery
What are the features of Lichen simplex chronicus?
Chronic skin condition – caused by trigger/irritant or infection which leads to pruritus and scratching.
Scratching leads to skin damage – further itching – ongoing cycle damages the skin and causes thickened/rough skin.
Commonly on the vulva
What is the target BP range in pregnant pts?
140-150/90-100
This is mild HTN and shouldn’t be treated w/Rxs
If it ever rises to 150+/95+ then anti-HTNs should be started to meet target above
What is the most effective form of contraception?
Etonogestrel implant – aka implanon (99.95% effective)
A progestin-only hormonal contraceptive
What is the recommended tx of TSS?
IV vancomycin (covers MRSA) + Clindamycin (suppresses protein/toxin synthesis)
What will be seen on CT in Pseudomyoxoma peritonei?
Mucin-containing cysts w/calcified rims (calcifications can spread throughout the peritoneum).
Copious amounts of mucin in the abdomen can lead to SBO
What defines oligohydramnios?
AFI less than or equal to 5cm, or DVP <2cm
How can ovulation be confirmed?
With serum progesterone levels >3 – should be measured 1wk prior to expected menses
How is assessment of ovarian reserve done?
With measurement of FSH on day 3 of menses – elevated FSH means decreased number of follicles and oocytes.
What maneuver is performed in conjunction w/c-section in the setting of shoulder dystocia?
Zavanelli maneuver – involves admin of Terbutaline or NO to relax the uterus, then the baby head is shoved back in and c-section is performed.
Only done after all other maneuvers have failed
How would increased activity of 5-aR present?
In females with increased hair/hirsutism with absence of lab abnormalities.
Idiopathic increase causes more conversion of testosterone to DHT
DHT is more potent than testosterone and will cause the increased hair growth
Difference in sxs depending on location of fibroid:
Submucosal – very heavy and prolonged bleeding and infertility. Least common.
Subserosal – pelvic pain and abdominal pressure
Intramural – most common type and can cause increased menstrual bleeding, pain and infertility depending on the size, but likely to be asx. Will make the uterus feel larger than normal
How will CAH present at birth?
21 & 11-hydroxylase deficiencies will cause virilization of XX females (may be told its a girl from karyotype and then pops out w/a penis) or have ambiguous genies
All types of CAH will have b/l enlarged adrenal glands from xs ACTH stimulation in response to decreased cortisol
11 will have decreased renin, 21 will have increased renin and 17-hydroxyprogesterone.
Phases of the menstrual cycle:
Day 1-5: Menstrual phase – both progesterone and estradiol are low. Get bleeding and shedding of the endometrium.
Day 6-13: Proliferative phase – large peak of estradiol from mid-to end of this phase
Day 14: Ovulation
Day 15- 26: Secretory phase – Large peak and then plateau of progesterone throughout this entire phase
Day 27-28+: Premenstrual phase – progesterone and estradiol both drop right at the beginning
What are the features and tx of Thyroid storm in pregnancy?
Autonomic instability is the hallmark – HTN, fever/increased T, nervousness, palpitations, AMS, V/D, arrhythmias.
Tx: BB (propranolol), corticosteroids, and an anti-thyroid.
PTU is typically DoC in thyrotoxicosis bc of its quicker onset of axn.
In very ill pts. potassium iodide oral drops may be used instead of PTU but this may affect the fetal thyroid gland.
Tx of Hyperthyroidism in pregnancy:
PTU is DoC in 1st trimester, bc MMI is a/w cutis aplasia (congenital skin and scalp defects)
MMI is preferred in the 2nd and 3rd trimesters bc of the hepatotoxicity a/w PTU
PTU is preferred in thyroid storm bc of the quicker onset
RAI is contraindicated
What is the fetal cx associated w/untreated Thyroid storm?
Nonimmune hydrops and IUFD.
What effects does pregnancy have on thyroid hormone levels?
Increased estrogen causes increased TIBG and total T4 (thyroxine), but the active/free T4 and TSH levels remain unchanged.
What is likely the cause of hyperthyroidism postpartum?
Destructive lymphocytic thyroiditis.
High corticosteroid levels in pregnancy suppress AI response and then lead to flare in post-partum
Often + for anti-microsomal and anti-peroxidase Abs
Most consistent lab findings of HoThyroidism in pregnancy:
Decreased free T4
Unchanged total T4
Increased TSH and TIBG
What are the upper limits of normal for latent phase of labor?
20 hrs for nulliparous
14 hrs for multiparous
What is considered xs contractions/tachysystole?
Uterine contractions >5/10min.
Need to relax uterus – stop oxytocin or uterotonics and give Terbutaline/Beta-mimetic
What should be done when a FHR tracing shows lack of accelerations and minimal variability?
This would be a cat-II FHR tracing.
Should do scalp stimulation and try to induce an acceleration
If no accelerations can be induced, likely there’s fetal hypoxia
When should the cord be clamped for preterm infants?
Should be delayed and clamped b/w 30-60 sec.
This increased total Fe stores, Hb levels and decreases the risk of intraventricular hemorrhage.
Delayed clamping also improves Fe stores in term infants but increases risk of hyperbilirubinemia so should be clamped right away.
Prenatal risk factors of shoulder dystocia in order of significance:
Prior dystocia
Fetal macrosomia
gDM
When should amniotomy be avoided?
If there is an unengaged fetal part – it is higher than 0 station.
This commonly predisposes to umbilical cord prolapse bc the head is not taking up the space and blocking the cord.
What is the most common cause of late postpartum hemorrhage?
Subinvolution of the uterus – the placental implantation site doesn’t decrease in size like it should, and when the eschar falls off (7-10d postpartum) there is more bleeding than expected.
Tx is w/uterotonics
What should be done to investigate a high msAFP and what values are considered normal?
Normal msAFP during pregnancy is defined as levels 2.0-2.5 multiples of the median, anything greater is concern for neural tube defect.
First step in investigation is US to assess for incorrect dates and multiples
If <20 weeks may repeat msAFP
If >20 weeks may refer for genetic counseling and amniocentesis
1st step in mgmt. of an abnormal triple screen:
Basic US to determine correct GA, identify multiples and exclude fetal demise
Most common cause of abnormal screen = wrong dating
What is the rationale for giving acyclovir in a primary HSV outbreak?
It reduces viral shedding and the duration of infection – does not have any effect on future occurrences
What are some cxs of pyelonephritis in pregnancy?
Preterm labor Preterm delivery ARDS Urinary tract obstruction (ureterolithiasis) Perinephric abscess
How should pyelonephritis in pregnancy be managed?
With IV abx: Cefotetan, ceftriaxone, or amp+gent combo
Recurrence rate is very high, so suppressive tx w/nitrofurantoin should be continued throughout the rest of the pregnancy.
Most common cause of septic shock in pregnancy:
Pyelonephritis
