OBGYN Flashcards
Intrahepatic Cholestasis of Pregnancy
Elevated total bile acids, intrauterine demise.
Most common in 3rd trimester
Increased estrogens cause cholestasis
Bile acids cause itching in hands and feet, not harmful to mother but can cross placenta, deadly to fetus.
Bile acid levels about 40 are concerning
Tx: Ursodeoxycholic acid and delivery at 37 weeks. Consistent monitoring of the fetus until delivery.
ABO Hemolytic Disease
Infants with type A/B born to mothers with type O.
Usually not severe, jaundice, anemia, increased reticulocytes, positive coombs
Tx: phototherapy, supportive, if severe exchange transfusion.
Fibrocystic changes of the breast
Often occur premenstrually, diffuse and symmetric changes of breast tissue in women of child bearing age. NSAIDS or OCPs to treat.
Vulvar Cancer (Squamous Cell)
Unifocal Erythematous friable plaque or ulcer, Risks HPV, tobacco use, immunodeficiency.
Dx: Biopsy
Vulvar Lichen Planus
Puritic purple plaques (P x4) sometimes with white striae (Whickhams)
Vulvar Lichen Sclerosis
multiple white papules that converge into one plaque, single lesions are uncommon. Lesions can become excoriated. The disease can extend into the perianal area.
Uterine Inversion
Can cause fatal post partum bleeding, usually happens after traction of umbilical cord. Fundus will be lost to US and palpation.
Aggressive rehydration and blood products, 1st manually attempt replacement, then try uterine relaxants.
Management of Preterm labor
Considerations: Steroids, Tocolytics, Abx, and MgSulfate
Gestational Age:
<32 weeks: Steroids (Betamethasone), tocolytics (Indomethacin), MgSO4, abx if necessary
32-33.6 weeks: Steroids, Toco, Abx if necessary
34-36.6 weeks: Steroids and Abx if necessary
Premature Ovarian Failure
GnRH, FSH, and LH increase, prolactin and TSH should be normal. Estrogen should be low.
Endometrial cells on pap smear
<45 years old: Normal, no evaluation
>45 years old: Requires endometrial biopsy
Active Phase Arrest
No cervical progression in 4 hours with adequate contractions (200 MVUs within 10minutes) or No cervical changes within 6 hours with inadequate contractions.
Usually happens in post term labor, should proceed to C section.
HepC in Pregnancy
Potential complications: Diabetes, Cholestasis of pregnancy, preterm delivery
Maternal Management: Hep A & Hep B vaccinations
Prevention of Transmission: Transmission is associated with maternal viral load, C section not protective, Avoid scalp electrodes, breast feeding okay as long as there is no nipple injury.
PCOS
Hirsutism, Oligomenorrhea, Obesity, Multiple follicles on Ultrasound.
Increased testosterone, estrogen
FSH/LH imbalance
Weight loss: tx
OCPs for symptom management
Clomiphene for pregnancy.
Risk Factors for Placenta Previa
Prior C section, previous placenta previa, multiple gestation, maternal age >35
Normal labor progression
0-6 cm:latent
6-10cm: active, should progress at 1cm/2hrs, if it falls below that, place intrauterine pressure measuring device.
Amniotic fluid embolization syndrome presentation and risk factors
Amniotic fluid enters maternal circulation causing inflammations and vasoconstriction. Presents with seizures, cadiogenic shock, and DIC.
Risks: Grand multiparity, placental trauma (previa, abruption, mechanical), preeclampsia
3 Ds of Endometriosis
Dysmenorrhea, dysparenunia, dyschezia
Physiologic leukorrhea
White, odorless, vaginal discharge with predominately epithelial cells and occasional PMNs. No other symptoms other than the discharge. Occurs midcycle.
Genetic Testing in pregnancy
Low genetic risk pregnancy (<35 yo): Can do Protein A, BHCG, and transnuchal rigidity in first trimester. Can do quadruple screen (alpha feto, BHCG, estradiol, inhibin A) in 2nd trimester. Chorionic vilus sampling to confirm in weeks 10-12 or amniocentesis in 13+ weeks.
High Genetic Risk Pregnancy (>35yo): cell free DNA testing can be done at 10 weeks. Use CVS or Amnio to confirm.
Vaccines in pregnancy
NO: MMR, Varicella, live influenza, HPV
YES: Tdap, RhoD, inactivated influenza,
High-Risk Pts: HepA/B, pneumococcus, Hflu, meningococcus, Varicella IgG.
Atypical glandular cells on Pap Testing
If over 35, indication for endometrial biopsy
Anovulaiton in the setting of obesity
Insulin resistance increases the levels of circulating androgens. High adipose tissues increases levels of aromatase, an enzyme that converts androgens into estrone. Estrone suppresses GnRH and thereby causing an imbalance in FSH/LH (Although this may not be reflected in lab work) that leads to anovulation.
Management of Hydatidiform Mole
D&C (Can do a hysterectomy if done with childbearing)
Serial B-HCG
Contraception for 6 months
Management of Endometriosis
OCPs & NSAIDs
If they fail medical therapy, you are concerned for malignancy, there is a history of infertility, or there are contraindications for medical therapy then you need to do a laparoscopy.
Chronic Hypertension in Pregnancy
HTN prior to pregnancy or confirmed before 20 weeks
Any HTN in pregnancy is associated with preterm labor.
Gestational HTN
HTN starting at 20 weeks with no proteinuria or end organ damage.
Intraductal Papilloma
Bloody nipple discharge with no palpable mass or radiologic findings.
Ductal Carcinoma in situ
Microcalcifications on mammogram
Fat Necrosis of the breast
irregular masses with oily cysts on imaging.
Inflammatory Breast Cancer
Diffuse erythema, edema, peau d’orange
Lobular breast carcinoma
Fixed palpable breast mass with irregular borders. Sometimes bilateral.
Paget Disease of the Breast
Form of ductal carcinoma that presents with ezcematous nipple discharge extending to the areola. +/- blood nipple discharge.
Choriocarcinoma
Risks: Advanced maternal age, prior complete mole
Amenorrhea/Abnormal uterine bleeding, metastasis to lungs or vagina, enlarged uterus, elevated BHCG.
Usually follows complete mole, but can also occur after delivery of a healthy infant or spontaneous abortion.
Postpartum hemorrhage uterotonics
Oxytocin first line
Methylergonovine: dont use w HTN
Carboprost: don’t use with Asthma or COPD.
Acute Cervicitis
Mucopurulent discharge with a friable cervix that may bleed. Swabbing shows no organisms but this is caused by chlamydia or gonorrhea.
Exercise induced hypothalamic amenorrhea
Excessive exercise causing amenorrhea.
Decreased FSH/LH. Estrogen, and and GnRH
Asherman Syndrome
Intrauterine adhesions from infection or repeat D&Cs. Patient will present with amenorrhea, abnormal uterine bleeding, and infertility due to loss of endometrium.
Hydatidiform Mole
Risk: VItamin A def
BHCG mimics TSH and causes a rise in T3/T4
Most effective emergency contraceptive
copper IUD (99% effective up to 120 hours)
Physiologic Hydronephrosis of pregnancy
Hydronephrosis and hydroureter due to compression by the uterus. If no signs of stones or infection no further management is needed.
Cephalohematoma
Does not cross suture lines
Caput Succedaneum
Crosses suture lines
Subgaleal hemorrhage
blood loss between periosteum and aponeurosis, shearing of emissary veins, scalp welling that can move, cross suture lines, and may continue to expand for days after delivery. The patient may have significant blood loss.
Evaluation of IUFD
Fetal: Autopsy, examination of placenta and cord, karyotyping and genetic testing.
Maternal: Kleihauer-Betker test for fetomaternal hemorrhage, antiphospholipid, coag studies.
Late Decels
If occuring with more than 50% of contractions, stop uterotonics.
2nd Stage Arrest
3 or more hours of pushing in a primigravida without an epidural (Some allow for 4 hours with an epidural)
OR
2 or more hours of pushing in multigravida without an epidural (3 with an epidural)
Vaginal Cancer
Age >60, HPV, Tobacco, DES exposure in utero
Vaginal bleeding, discharge, vaginal lesion
biopsy –> surg/chemo
Pregnancy w/ history of cervical conization
transvaginal ultrasound to evaluate for cervical stenosis.
Progesterone prevents the risk of preterm labor.
Imaging of choice for gynecologic masses
Pelvic US
Chorionic villus sampling timeframe
10-13weeks
Amniocentesis timeframe
15-20 weeks
Rapid onset virilization <1 year
Increased DHEA = Adrenal tumor
Normal DHEA = Ovarian tumor
Epithelial ovarian carcinoma
Septations, solid mass, peritoneal fluid. Increased CA125
If ascites present must perform a laparotomy.
Theca lutein cysts
10-15cm ovaries bilaterally caused by hyperstimulation by B-HCG. Seen in trophoblastic disease, multifetal gestation, or fertility treatments. Resolves with decreasing levels of BHCG.
Bacterial vaginosis
thin, off white discharge. pH above 4.5, clue cells. Positive whiff test. Metronidazole or clindamycin
Trichomoniasis
thin, green yellow discharge, inflammation, pH above 4.5, motile organisms seen. Metronidazole for both partners.
Chorioamnionitis
Definition
Management
Maternal fever + 1 of the following:
Fetal Tachycardia (above 160)
Maternal leukocytosis
Purulent amniotic fluid
Tx: Abx and immediate delivery
Increased serum AFP in pregnancy
neural tube defects, gastroschisis, omphalocele, or multiple gestations.
Septic thrombophlebitis
Thrombus formation in pelvic or ovarian veins after delivery. Presents as fever unresponsive to abx.
Tx: abx and anticoagulation
Placentia previa
Pelvic rest (no intercourse or cervical checks), routine obstetric care, recheck with ultrasound at 28 weeks. Deliver at 36-37 weeks with C section if still present.
Pelvic pain exacerbated by exercise
Endometriosis
Endometriosis
Dyspareunia, dyschezia, dysmenorrhea, chronic pelvic pain, infertility.
Physical Exam: immobile uterus, cervical motion tenderness, adnexal mass, nodules found along various ligaments.
If the ovary is involved, a homogenous cystic mast is common.
Hypothyroidism causing secondary amenorrhea
Signs and symptoms of hypothyroidism Decreased T3/4 causes increased TRH. Increased TRH causes increased TSH and Prolactin Increased Prolactin decreases GNRH Decreased GnRH causes decreased FSH/LH
Risks of short interval pregnancies
Maternal anemia
PPROM
Preterm delivery
Low birth weight
How to differentiate hyperemesis gravidarum from normal N/V during pregnancy
wt loss from prepregnancy and +Ketones in urine
Routine ID screening in pregnant patients
HepB, HIV, Chlamydia, and syphilis
Proteinuria and HTN before 20weeks pregnant
Not preeclampsia, look for other causes.
HSV Management in pregnancy
Prophylaxis starting at 36wks if HSV+
C section if lesions present during labor
Incidental ovarian mass in a postmenopausal woman
Pelvic US and CA125
Never needle biopsy
HRT
Women under 60 who have undergone menopause within the last 10 years and are experiencing vasomotor symptoms.
Recurrent Variable Decels
Variable decels present with >50% of contractions
Tx: maternal repositioning —> amnioinfusion
Active phase arrest vs protraction
Protraction: slow cervical changes +/- inadequate contractions = Oxytocin
Arrest: No cervical changes over 4 hours with adequate contractions = C section
Soft, mobile, nontender mass shortly after stopping breast feeding
Galacocele
Preeclampsia at 37 weeks
Induce delivery, only do a c section if otherwise indicated.
Contraindications to levonorgestrel IUD
Breast cancer, active liver dz, active pelvic infection
Contraindications to copper IUD
Wilson Dz, Copper allergy, heavy menstrual bleeding, and acute pelvic infection.
Management of hyperemesis gravidarum
Supportive. must get a pelvic ultrasound to rule out a mole or identify multigestation.
