OBGYN Flashcards
1
Q
Bartholins Abcess
- caused by
- sxs
- tx
- recurrent
A
- blockage of gland
- painful lump in vulva w/o fever
- incise and drain
- biopsy
2
Q
Vulva
- parts
- glands
- blood supply
- lymph
- innervation: ant vs post
- effects of pregnancy
A
- mons pubis, labias, clitoris, glands
- bartholin: secrete mucus, at 4 and 8 o clock and non palpable; skene: inside, glands are on either side of urethral opening
- external and internal pudendal
- medial superficial inguinal
- ant: ilioinguinal and genital; post: perineal
- increase thickness of mucosa, loosen CT, and increase muscle
3
Q
Vagina
- Blood supply: primary vs secondary
- Innervation: symp vs para
A
- internal illiac -> hypogastric -> uterine -> vaginal; hypogastric -> middle rectal and inf vaginal a, that anastamose with cervical
- s: hypogastric plexus; p: pelvic N
4
Q
Cervix
- blood supply
- innervation
- parts
- epi
- composed of
- effects of water pregnancy
A
- internal iliac -> uterine -> cervical and vaginal
- hypogastric plexus
- portio vaginalis (part that protrudes into vag), external os (lowest opening, squamous), endocervical canal (inside cervix before opening to uterus, columnar), internal os (opening of cervix into uterus)
- starts as squamous and transitions into columnar
- CT and and SM
- decreased collagen and increase in water causes it to soften and increase in glands to create mucus plug
5
Q
Uterus
- parts
- histo
- blood supply
- innervation
- anatomy to ureter
- why does it enlarge when pregnant
A
- fundus (upper part), corpus (body), cornu (part that connects to FT bilat, cervix (part of uterus that protrudes into vagina)
- mypmetrium and endometrium (columnar)
- int illiac -> hypogastric -> uterine and aorta -> ovarian
- superior and inferior hypogastric plexus
- urter travels under uterine a
- myometrial hypertrophy and hyperplasia, caused by estrogen at beginning or pregnancy and then mechanical distention as baby gets bigger
6
Q
Fallopian Tubes
- parts
- blood supply
- innervation
A
- infundibulum (closest to ovary, have fimbriae), ampulla (where fertilization occurs), isthmus (smallest portion), intramural (where it connects to uterus)
- uterine and ovarian A
- pelvic and ovarian plexus
7
Q
Ovaries
- blood supply
- innervation
A
- aorta -> ovarian artery
- aortic plexus
8
Q
Ligaments
- infundibulopelvic (suspensory)
- round
- cardinal
- uterosacral
A
- connects ovary to pelvic wall; contains ovarian vessels
- uterus through inguinal canal to labia majora; remains of gubnaculum
- from cervix and lateral vagina to pelvis; most important
- from cervix and inserts into fascia over sacrum, some support of uterus
9
Q
Pelvic Muscles
- pelvic diaphragm
- urogenital diaphragm
- perineal body
- blood supply
- nerve supply
A
- broad sling of pelvis that support internal organs; levator ani muscles
- external to pelvic diaphragm; deep transverse perineal, constrictor of urethra, internal and external fascial coverings; maintains urinary continence
- central tendon where muscles converge
- internal pudendal a -> inferior rectal and post labial
- pudendal
10
Q
Naegles Rule
- what is it
- assumptions
A
- LMP + 1 yr - 3 months + 7 days
- normal gestation is 280
- pts have 28 day menstrual cycle
11
Q
Sxs of pregnancy
- menses
- breast
- skin
- uterus
- cervix
- vagina
- GI
- heart
- GU
A
- stops
- tender, biger, larger nipples and areola
- striae gravidum (stretch marks), linea nigra, melasma, angioma (red elevation at central point with branching vasculature)
- soft and elastic
- softer, beaded mucus under microscope bc of progestone causing decrease in sodium chloride in mucus
- increased blood flow causing it to look blue or purple (chadwicks sign)
- n/v, at 2-12 wks gestation
- prolonged anagen
- increase frequency urine
12
Q
Fundal Height
- 12
- 15
- 20
- 28
- 32
- 36
- 40
A
- pubic symphysis
- midway between pubic symphysis and umbilicus
- umbilicus, then 1 cm higher for each week after
- 8 cm above umbilicus
- 6 cm below xiphoid
- 2 cm below xiphoud
- 4 cm below xiphoid -> bc baby descends
13
Q
beta- HCG
- function
- peaks
- 1500 or greater
- false positives
- urine vs serum
A
- sustain corpus luteum first 7 wks of pregnanacy to have increased progesterone and prevent shedding of uterus
- 10 wks
- should be able to see gestational sac; in not -> ectopic
- proteinuria or UTI
- qualitative (just tells you there is enough for positive) vs quantitative (gives you actual level)
14
Q
Fertilization
- timing
- location
A
- usually occurs 24 hrs after fertilization
- ampulla of FT
15
Q
Pre implantation
- morula
- blastomere
- blastocyst
A
- 16 mutlipotenet stem cells
- after morula before it leaves FT
- when it gets into the uterus
16
Q
Implantation
- day
- after
- placental disk
- decidua
A
- 5 or 6
- begins to make placenta by dividing into trophoblast and synctiotrophoblast
- trophoblasts closest to myometrium, others will form chorionic membranes
- name of the endometrium of uterus during pregnancy
17
Q
Embryology Important Milestones
- Week 3
- 5
- 7
- 10
- 11
- 12
- 16
- 24
- 32
A
- primitive streak and groove form
- hand and foot plates develop
- intestines grow outside abd cavity
- intestines back into abdomen
- kidneys begin to form and excrete urine and liver starts to function
- sex of baby can be seen, colon rotates, baby makes breathing motions
- myelination of nerves and ossification of bones
- develop alveoli and secrete surfactant
- fetal immune system functions
18
Q
Metabolic Changes of Pregnancy
- water metabolism: what happens, why 3
- carb metabolism: early vs late
- blood vol: what happens, why (3), made of
- iron: what happens
- immunology: what happens, T3
- coagulation: increased, decreased
A
- retention bc: increase in venous pressure bc compression of IVC; decreased insterstital pressure, increased hydration of CT allowing for laxity of joints but leading to pooling
- first 20 weeks will have increased sensitivity to insulin but after 20 weeks will have insulin resistance bc of increase in plasma insulin level
- Increase in blood vol by 50% to help meet demand of increased uterus, protect against impaired venous return and protect from blood loss at delivery; increase in erythrocytes and platelets but exponentially a lot more plasma
- increased need bc of hematopoesis; greatest need in T2
- throughout pregnancy there is decrease in immune system but in T# there is oncrease in granulocyte (PMN) and CD8
- increase concentration of all clotting factors, fibrinogen, and resistance to protein C
19
Q
Changes to Systems during Pregnancy
- CV: time frame; what happens; heart location; murmur; BP
- Resp: increase in, decrease in, unchanges, acid-base physio
- GU: increase, decrease, dysfunction of, ureters, bladder
- GI: location, lowers -> causes, liver, gall
- Endo: pituitary, thyroid, parathyroid
A
- starts at 8th week; increase in CO with decreased resistance and increased heart rate; heart displaced to left and up; norml systolic ejection murmur bc of increased amount of flow along pulmonic and aortic valves; BP will decrease mid preg and increase at end
- increase in tidal vol but decrease in functional residual capacity bc of elevated diaphragm but RR stays same; resp alkalosis bc more CO2 blown off
- increase in GFR, creatinine clearance and plasma flow; decreased BUN and creatinine in serum bc of increased flow; renal tubules use some ability to reabsorb and so there is some spilling of AA, glucose etc in urine; ureters dilate and bladder decreases tone
- everything is displaced upward, lower LES tone and decrease peristalsis causing constipation and GERD (progestone) , alk phos will double but albumin in serum will decrease but total will show increase, progesterone impairs gallbladder contraction by inhibiting CCK and estrogen inhibits intraductal transport of bile acids
- increase production of prolactin and oxytocin; T3 and TBG increase bc of estrogen but gland not increase so goiters must be evaluated; PTH decrease in T1 but then increase throughout rest of pregnancy bc estrogen blocks PTH effect on bone resorption and so serum levels rise so that Ca can be shed for baby
20
Q
Parity
- order
A
- term, pre-term, abortions, living
21
Q
Frequency of visits
- 1wk- 28
- 28-36
- 36 on
A
- every 4 weeks
- every 2 weeks
- every week
22
Q
Tests at Visits
- every visit
- 6-8
- 11-13
- 16-20
- 26-28
- 32
- 36
- 38- 40
A
- urine to look for protein/glucose spilling and fetal HR and fundal height
- Hct/Hb, Rh, blood type, pap, UA and culture, gonn/ chl/ RB/ Hep B/ HIV/ TB, CF
- US for DS or cfDNA
- fetal anatomy and quad
- diabetes, give Anti-D immunoglobulin
- just urine, HR, fundal height
- Strep B, cervix
- cervix
23
Q
Fetal Surveillance
- Fetal Movement Count
- Non Stress Test
- Biophysical Profile
A
- how much fetus moves in 1 hr, 3x a week
- looks at baseline HR, variability, and periodic changes like decelerations and accelerations
- Non stress test and ultrasound (breathing, movement, muscle tone and amniotic fluid)
24
Q
BPP
- Non stress test
- breathing
- movement
- muscle tone
- amniotic fluid
- modified
A
- reactive
- 1 episode of breathing movements for 30 sec in 30 min
- 3 body or limb movements within 30 min
- 1 or more episodes of extension with return to flexoin
- making sure there is enough fluid
- just NST and amniotic fluid level
25
Q
Cell-free fetal DNA
- what is it
- when
A
- screening test for trisomy 21, 18, 13 and sex aneuploidy
- after 10 wks
26
Q
First trimester screen
- when
- downs
- edwards
- NT defects
A
- between 11 and 13 wks
- beta HCG elevated, AFP and inhibin A low
- all are low
- AFP high, everything else normal
27
Q
Chorionic Villus sampling
- what is it
- used for
- when
- risks
- vs amniocentesis
A
- sample of chorionic villi taken through abdomen or cervix
- only evaluates chrom abnormalities not NTD
- 9-12 weeks
- high risk of loss (1%), and limb defects if done before 9 wks
- aspiration of amniotic fluid, done at 15-20 wks, lower risk
28
Q
Weight gain in pregnancy
- less than 18
- normal
- over 25
A
- 30-40 lb
- 25-35 lb
- 15-25 lb
29
Q
PICA
- what is it
A
- compulsive ingestion of non food substances with little or no nutritional value
30
Q
Common Questions
- caffeine
- exercise
- heartburn
- constipation
- varicose v
- sex
- air travel
A
- only 300 mg/day; can increase risk for spontaneous abortions
- fine
- caused by relaxing of LES bc of progesterone
- caused by progesterone -> decrease in GI motility
- LE -> thrombophlebitis
- no restrictions unless there is ruptured membranes or placenta previa
- not after 35 wks
31
Q
Stages of Labor
- latent: classified, prolonged
- active: classification, fetal descent
- fetal expulsion
- placental separation: time frame, signs
A
- onset of labor and end at 4 cm; G1 -> 20 hrs, G2 -> 14 hrs
- 4cm to 10 cm; 7-8 cm; G1 -> 1.2cm/ hr, G2 -> 1.5 cm/hr
- 10 cm until fetus is delivered; G1 -> less than 2 hr or 3 with epi, G2 -> less than 1 hr or 2 with epi
- usually less than 10 min, but abnormal if more than 30 min; gush of blood, lengthening of cord, firm fundus
32
Q
Rupture of Membranes
- what is it
- how to know
- confirmation
A
- water breaks
- pooling of fluid on speculum exam, fluid expeled with valsalva
- ferning and positive nitrazine (turns blue bc it is basic compared to vaginal fluid)
33
Q
Presentation of Fetus
- normal
- face
- sinciput
- brow
- breech
A
- vertex: baby is face down
- face up, so neck is extended
- head between vertex and face presentation causing ant fontanelle to present first
- eyebrows present first, must be converted to vertex in order for vaginal delivery
- presentation is butt
34
Q
Types of Breech
- Complete
- Incomplete
- Frank
A
- both legs flexed and down
- one led extended and up, other flexed and down
- both legs extended and up but babies butt still down and head still up
35
Q
Checking for Nuchal Cord
- what happened
- how to tx
- complications
A
- umbilical cord wrapped around neck
- slip finger under cord and slip over infants head
- unable to slip around head so have to cut
36
Q
Perineal Lacerations (72)
- first
- second
- third
- fourth
A
- fourchette, perineal skin, vaginal mucosa but NO fascia or muscle
- 1st + fascia and muscle or perineal body
- 2nd + involvement of anal sphincter
- extends through rectal mucoa and exposes lumen of rectum
37
Q
Movements of Labor
- engagement
- descent
- flexion
- internal rotation
- extension
- external rotation
- expulsion
A
- largest part of head through pelvic inlet
- fetal head passes down through pelvis
- chin to chest allowing for smallest diameter of head to pass through birth canal
- turning of head so that occiput is by pubic symphysis
- once fetal head is out, turn again so the baby is sideways and can deliver shoulders
- delivery of ant shoulder then post
38
Q
Measurement of uterine contractions
- external
- intrauterine pressure cath
A
- only frequency of contractions
- frequency, duration, and strength of contraction (montevideo units)
39
Q
Fetal Heart Rate Patterns
- baseline
- accelerations
- decelerations
- reassuring
A
- most common heart rate lasting for 10 or more min; usually 110-160
- periodic changes above or below baseline
- two accelerations at leat 15 BPM above baseline lasting for 15 sec in 20 min
40
Q
Decelerations
- early : cause
- late: cause, looks like, tx
- variable: cause, looks like, tx
- prolonged
- sinusoidal
A
- caused by head compression and regulated by vagal stimulation -> benign
- caused by uteroplacental insuff during contractions; gradula decrease below baseline that occur after contraction; O2, lateral decub position, pitocin off
- abrupt onset deceleration that normally looks like a V or W; fetal autonomic response to cord compression; amnioinfusion to alleviate cord compression
- isolated decelerations that are greater than 15 bpm that last for 2-10 min; caused by cervical exam, uterine hyperactivity, UC compression
- fluctutations in FHR baseline with reg amplitude and frequency; baby is in distress
41
Q
Beat to beat variability
- what is it
- less than 28 weeks
- decrease
- increase
A
- variation of succive beats controlled by ANS, increase caused by symp and decrease caused by parasymp, and these two sxs are usually pushing and pulling
- neuro immature, so decrease in varibaility is normal
- ## fetal acidemia, asphyxia, maternal acidemia
42
Q
Classification of Fetal Heart Rate
- category I
- category II
- category III
A
- normal FHR
- anything that is not I or III
- absent variability + recurrent late decelerations, recurrent variable decelerations, brady cardia; or sinusoidal pattern
43
Q
Abnormal Labor Patterns
- prolongation disorder (latent phase)
- protraction disorder: dilation, descent
- arrest disorder:
- causes
- tx
A
- null: >20 hr, para: >14 hr
- prolonged dilation (slow rate cervical dilation)- null: 1.2cm/hr, para: 1.5 cm/hr; prolonged descent (slow rate of fetal descent) - null: <1 cm/hr, para: <2 cm/hr
- complete cessation of dilation or descent
- abnormalities in contraction, presentation of baby, pelvis of mom, or birth canal
- induction
44
Q
Induction Methods
- oxytocin
- prostaglandins: 2 types, natural way
- mechanical
A
- pitocin; stimulates uterine contractions
- misoprostol (cytotec) - synthetic PGE1 analog used for cervical ripening intravaginally or orally OR cervidel - PGE2 analog in gel or vaginal insert for cervical ripening; sex, orgasm, breast stim increases prostaglandins
- foley balloon (cook cath): passed through internal cervical os and into extra amniotic space, inflated and rested on internal os to cause traction; laminaria- seaweed sticks put into cervix and when wet start to expand;
45
Q
Cesearean Delivery
- low
- classic
- indication
- trial of labor after cesarean
A
- horizontal incision made in lower uterine segement
- vertical incision made in contractile portion of uterus; premature, fetal transverse w/ back down or placenta previa
- mandatory if prior classical or elective if prior low, failure to progress, breech, concern for fetal well being
- risk of uterine rupture after c section, 10% with classical and 1% w/ low transverse
46
Q
Operative Vaginal Delivery
- forcep delivery: indications; must have
- vacuum delivery: indications; advantages and dis
A
- lack of progress in second stage of labor, fetal distress, maternal exhaustion; cervix must be fully dilated
- same indications as forcep; safer and easier to perform but only used during contractions and small increase in cepahlohematoma
47
Q
Cephalohematoma
- what is it
- vs caput succedaneum
A
- collection of blood under periosteum of skull caused by ruptured vessels and does NOT cross suture lines
- temporary swelling of fetal head from prolonged engagment, does cross suture lines
48
Q
Regional Anesthesia
- pudendal block
- paracervical
- spinal: where, when, first, contraindication
- epidural: where, spinal levels, effect on delivery, contraindication
A
- local infiltration of pudendal nerve w/ lidocaine, sometimes used with epidural
- injected at 3 and 9 o clock around cervix; helps with contractions during first stage of labor, but not anything after bc pudendal is not blocked
- anesthetic into subarachnoid space, given for uncomplicated cesearean and vaginal delivery; must give 1 L of IV to prevent hypotension; severe pre-clampsia
- injection in epidural space, lumbar IV space or sacral hiatus; abd (8th Thoracic to 1st Sacral) vs vaginl (10th thoracic to 5th sacral); longer second stage of labor; severe preeclampsia
49
Q
Puerperium
- what is it
- uterus
- endometrial changes
- placental
- vessels
- cervix
- vagina
- peritoneum
- urinary tract
- heme
A
- period of confinement between birth and 6 weeks after delivery
- fundus at umbilicus after delivery and should start shrinking within 2 days postpartum, causing after pains. Will be back in true pelvis by 2 weeks post partum.
- superficial part will become necrotic and slough off and basal layer becomes new endometrium
- vessels become thrombosed and site decreases in size
- large vessels are obliterated by hyaline changes and replaced by smaller vessels
- external os contracts and narrows by end of first week, after vaginal delivery the external os is a horiztonal slit instead of small oval opening
- broad and round ligaments relax and abdomen will be soft and flabby with stretch marks
- bladder has increased capacity and insensitive to intravesical pressure so over distenetion, incomplete bladder emptying and excessive residual urine lead to UTI; ureters and renal pelvsises return to normal size
- increased WBC during and after labor, hemoglobin and hematocrit should increase, blood vol returns to normal a week after delivery
50
Q
Post Partum infection
- positive cocci
- positive bacilli
- aerobic bacilli
- anaerobic bacilli
- dx
A
- group A and B strep
- clostridium and listeria
- e coli, klebsiella, proteus
- b. fragilis
- fever and fundal tenderness
51
Q
Types of Post Partum Infections
- Endometriosis: invovles, more common with, when does it develop, treat
- UTI: caused by
- Surgical Site Infection: sxs; dx; tx
- Episiotomy: sxs, r/o, tx
A
- infection involving decidua, C section, postpartum day 2-3, treat with IV antibiotics
- usually caused by cath, urinary stasis, and frequent pelvic examinations
- fever, wound erythema, tenderness, and purulent drainage; gram stain and should be drained, irrigated and debrided
- pain at site and disruption of wound, r/o rectal vaginal fistula, open clean and debride wound
52
Q
Post-partum contraception
- lactational amenorrhea
- OCP
- Depo
- IUD
- Implanon
A
- when you exclusively breast feed it prevents ovulation for up to 6 months
- combined or progestin only
- progesterone injection lasts for 3 months, does not effect breast milk production
- can be inserted immediately after giving birth or 6 weeks after
- progesterone releasing implant in arm tht lasts for 3 years
53
Q
How is milk made
- contains
- colustrum
- when
A
- after delivery of baby the decrease in progesterone and estrogen allow for milk production
- eveyrhting except vit K
- more protein and IgA, less sugar and fat
- colostrum turns into milk w/i 1 weeks of breast feeding and becomes fully mature milk by 4 weeks
54
Q
Breast Fever
- mastitis: bug, sxs, dx, tx, breast feeding
- breast abcess: sxs, dx, tx, breast feeding
A
- staph aureus from infant nasopharynx or strep viridans; 4 wks post-partum with fever and chills, focal erythema; culture milk; dicloxacillin and continue breast feeding
- suspected when fever does not improve with abx in 48-72 hrs; US to see collection of fluid; broad spectrum abx; continue breast feeding
55
Q
Contraindications to Breast Feeding
- infections
- meds
- radiotherapy
A
- HIV, active lesion on breast from herpes, TB
- bromocriptine, CA drugs
- none if used for CA, but if usde for dx like CT must pump and dump for while then resume
56
Q
Post Partum Thyroid Dysfunction
- what is it
- thyrotoxicosis: onset, mechanism, sxs, tx
- hypothyroidism: onset, mechanism, sxs, tx, sequelae
A
- transient lymphocytic thyroiditis in 5-10% of women after giving birth
- 1-4 months post-partum; destruction induced hormone release; small painless goiter; bb
- 4-8 months post-partum; thyroid insufficiency; goiter, fatigue, inability to concentrate; thyroxine for 6-12 months; 1/3 permanent hypothryoidism
57
Q
Pre-gestational Diabetes
- what is it
- maternal complications
- fetal complications
- echo: when. why
- when to deliver: well controlled vs uncontrolled, test before
A
- diabetes that existed before pregnancy
- HTN, preeclampsia, preterm delivery, c section, polyhydraminos, infections
- preterm birthm macrosomia, caudal regression (absence of sacrum), NTDs, neonatal hypoglycmia (bc hyperplasia of fetal beta cells from constantly elevated sugar)
- at 20 weeks, increases risk of fetal congenital heart disease
- 37 wks w/ poor glycemic control, need to do amniocentesis before to look for maturity by measuring level of lecithin;lor 38 wks with good glycemic control
58
Q
Hyperthyroidism and pregnancy
- what to look for
- PTU
- methimazole
- thyroidectomy
- complications
A
- low TSH and high T4; only T3 and TBG increases in pregnancy
- drug of choice for 1st trimester; inhibits conversion of T4 to T3
- used after T1 bc readily crosses placenta
- only used when medical management fails
- women who remain hyperthyroid despite treatment have higher risk of preeclampsia
59
Q
Chronic HTN and pregnancy
- diff from gestational
- before pregnancy
- second trimester
- complications
- management
- delivery
- meds
- avoid
A
- HTN before 20 wks of gestation
- look for renal and cardiac dysfunction (left ventricle hypertrophy)
- BP drops, so if seeing pt for first time could appear normotensive
- super-imposed preeclampsia (preeclampsia in setting of chronic HTN) and abruptio placenta
- fetus should be tested for adequate perfusion and receive US to monitor growth
- at term, vaginal> C section
- lebatalol and alpha methyldopa
- ACE and ARB -> teratogens
60
Q
Cardiovascular Dx and pregnancy
- monitor for
- risk of Congenital heart defect
- delivery
- stenosis: results in, CHF
- prolapse: sxs, dx, tx
A
- CHF
- 4%
- vaginal
- pulm HTN bc increase in preload causes overload in left atrium which back up into lungs; 25% will have CHF
- asymptomatic, click on physical exam, safe
61
Q
Pulm Dx and pregnancy
- asthma: rule of 1/3
- pneumonia: complications; DX, TX
A
- 1/3 improve, worsen, stay same; fetal growth restrictions
- PROM or acidemia (bc unable to blow off CO2); CXR w/ abd shield; can use normal abx
