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M3 - Clerkships > OBGYN Clerkship > Flashcards

OBGYN Clerkship Flashcards

1
Q

Still birth
1. fetal death > (BLANK) weeks, prior to delivery
2. two of the highest yield test for identifying the cause for still birth are (Blank) and (blank)

A
  1. 20
  2. placental evaluation
  3. fetal autopsy
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2
Q

Management of intrauterine fetal demise?
1. 20-23 weeks
2. >= 24 weeks

A
  1. dilation and evacuation OR vaginal delivery
  2. vaginal delivery
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3
Q

PCOS
1. androgen excess (e.g. acne, male pattern baldness, hirsutism)
2. oligoovulation or anovulation
3. polycystic ovaries on U/S

Labs
- Testosterone (A)?
- Estrogen (B)?
- LH/FSH (C)?

Treatment? (3 parts)

A

A. increase
B. increase (peripheral androgen conversion in adipose tissue and decreased level of sex-hormone binding globulin)

C. LH/FSH imbalance
Tx: - weight loss (first line)
- oral contraceptive pills for menstrual regulation
- Letrozole for ovulation induction

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4
Q

How does high levels of estrogen affect hormone axis in patients with PCOS?

(GnRH, LH, FSH, etc)

A
  1. Hypothalamus –> causes high frequency, short interval GnRH pulses
  2. This frequency leads to preferentially produce LH, resulting in imbalance of LH and FSH release from anterior pituitary
  3. This results in lack of LH surge –> failure of follicle maturation and oocyte release (anovulation)
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5
Q

What is the HPG axis
1. Hypothalamus
2. Anterior pituitary
3. Gonads

A
  1. Hypothalamus –> GnRH
  2. Anterior pituitary –> LH, FSH
  3. Gonads –> sex hormones (testes - testosterone and ovaries - estradiol and progesterone)

–Sex hormones have negative effect on anterior pituitary and hypothalamus

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6
Q

Prolactin Hormone Axis
1. Hypothalamus
2. Anterior pituitary
3. breasts

A
  1. Hypothalamus release dopamine which has negative feedback on prolactin release
  2. Ant. Pit. –> prolactin
  3. Galactorrhea from breasts

–> increased prolactin also has negative feedback on hypothalamus to release less GnRH

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7
Q

In adolescents, the immature hypothalamic-pituitary-ovarian axis causes anovulation and can result in heavy, irregular menstrual bleeding.

  1. In hemodynamically stable patients
  2. In hemodynamically unstable patients
  • what is the best treatment for this
A
  1. In hemodynamically stable patients, heavy vaginal bleeding is managed with high-dose oral contraceptive therapy to stabilize the endometrium and stop the acute bleeding.
  2. In hemodynamically unstable, anemic patients (eg, tachycardia, hypotension), a dilation and curettage and/or a packed red blood cell transfusion may be indicated. A dilation and curettage removes the endometrium to quickly stop bleeding in an acute situation.
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8
Q

-Vulvovaginal dryness, irritation, pruritus
-Dyspareunia
-Vaginal bleeding
-Urinary incontinence, recurrent urinary tract infection
-Pelvic pressure

On pelvic exam
–Narrowed introitus
-Pale mucosa, ↓elasticity, ↓rugae
-Petechiae, fissures
-Loss of labial volume

What is this?
How to treat?

A

This genitourinary syndrome of menopause
—> (or atrophic vaginitis), the result of a physiologic decline in estrogen production from depleted ovarian follicles. Low estrogen levels cause diminished blood flow and decreased collagen and glycogen production in the vulvovaginal tissues that result in the loss of epithelial elasticity and subsequent atrophy. The atrophic urogenital epithelium becomes thin, dry, and easily denuded, making it more susceptible to injury (eg, trauma, infection). Therefore, even minimal tissue manipulation (eg, wiping with toilet paper) can cause vestibular fissures and vaginal petechiae, leading to vulvar or vaginal bleeding.

Tx
1. Vaginal moisturizer and lubricant
2. Topical vaginal estrogen

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9
Q

—Thin, white, wrinkled skin over the labia majora/minora; atrophic
changes that may extend over the perineum & around the anus
—Excoriations, erosions, fissures from severe vulvar pruritus
—Dysuria, dyspareunia, painful defecation

  1. What is this
  2. In what patient population does it usually occur?
  3. Treatment?
A
  1. Vulvar lichen sclerosus - chronic inflammatory condition that causes thinning of the vulvar skin in hypoestrogenic populations. white, atrophic papules form and eventually merge into plaques, leading to thin, white vulvar lesions and changes in vulvar architecture (eg, adherence of the labia at the midline). These lesions are chronically inflamed and can result in perianal and vulvar pruritus, at times so severe that it awakens affected individuals from sleep. Excessive scratching can result in excoriations, lichenification (ie, thickened skin), and edema of the labia. Lichenification of the perianal region can result in anal fissures and constipation
  2. Prepubertal girls & perimenopausal or postmenopausal women
  3. Superpotent corticosteroid ointment
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10
Q
  1. What causes primary dysmenorrhea (physiologic painful menses)?
  2. What is treatment?
A
  1. excessive prostaglandin production
  2. NSAID drugs (stops prostaglandin production) and combo OCP
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11
Q

Why can epidural anesthesia cause hypotension?

A
  1. epidural has sympathetic blockade - this leads to venodilation and blood distribution to lower extremities because of venous pooling
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12
Q

What are risk factors for endometrial adenocarcinoma?

A
  1. Causes for excess estrogen
    -Obesity
    -Chronic anovulation/PCOS
    -Nulliparity
    -Early menarche or late menopause
    -Tamoxifen use
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13
Q

Endometrial hyperplasia/cancer
1. clinical features?
2. way to evaluate
3. treatment

A
  1. Heavy, prolonged, intermenstrual &/or postmenopausal bleeding
  2. Endometrial biopsy (gold standard)
    -Pelvic ultrasound (postmenopausal women)
  3. Tx–
    –> Hyperplasia: progestin therapy or hysterectomy
    —> Cancer: hysterectomy
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14
Q

Amniotic fluid <=5 cm or single deepest pocket of amniotic fluid <2 cm on U/S indicates what?

A

oligohydramnios - primary cause is decreased fetal urine output

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15
Q

Decreased fetal urine output (oligohydramnios)
1. early gestation may indicate…
2. 2nd and 3rd trimester may indicate…

A
  1. renal abnormalities causing urine outflow obstruction (pos. urethral valve for ex) or impaired urine production (renal agenesis for ex)
  2. Second- and third-trimester oligohydramnios is typically due to rupture of membranes or decreased renal perfusion as the consequence of chronic uteroplacental insufficiency. In chronic uteroplacental insufficiency, placental dysfunction causes decreased fetal perfusion, oxygenation, and nutrition. In response, the fetus has decreased fetal movement (as in this patient), slowed growth (with possible fetal growth restriction), and preferential shunting of blood from the kidneys to the brain, resulting in decreased urine production and eventual oligohydramnios.
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16
Q

Acute postpartum urinary retention (>= 6 hours after vaginal delivery or urinary catheter removal after C section) causes

  1. an inability to void
  2. overflow incontinence

—> due to (BLANK) nerve injury and (BLANK).

A
  1. pudendal
  2. bladder atony

Risk factors include prolonged labor, perineal trauma, and regional neuraxial anesthesia.

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17
Q

How is postpartum urinary retention managed?

A
  1. self limited condition
  2. intermittent catheterization
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18
Q
  1. Patients with fetal growth restriction/FGF have a high risk for intrauterine fetal demise and require what for assessment?
A
  1. umbilical artery doppler ultrasound to assess placental perfusion.
    –This test measures intravascular flow and resistance in the umbilical artery, with increasing resistance indicating decreasing placental perfusion and worsening fetal hypoxia. These measurements are used to identify patients who require urgent delivery to minimize the risk of fetal demise.
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19
Q
  • severe, constant, unilateral pelvic pain may indicate ovarian torsion
    1. How is this dx
    2. How is this managed?
A
  1. This is a clinical diagnosis
  2. managed with diagnostic laparoscopy for manual detorsion of the adnexa and removal of any contributory cysts or masses; oophorectomy may be required if the ovary is necrotic
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20
Q
  • Painless intermenstrual bleeding
  • Women in 30s and 40s
  • Most are benign and asymptomatic but can cause abnormal uterine bleeding
  • Pts typically have regular monthly menses

What is this most likely?

A
  1. endometrial polyp
  2. Treat by hysteroscopic polypectomy
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21
Q
  • Heavy, painful menses
  • women age >40 years old
  • Regular menses with no intermenstrual bleeding
  • Boggy, uniformly enlarged uterus
  1. What is this likely?
A
  1. adenomyosis
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22
Q
  • Regular but heavy, prolonged menses
  • Irregularly enlarged, bulky uterus
  1. What does this sound like?
A
  1. Uterine leiomyomas (fibroids)
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23
Q

Hypertensive disorders of pregnancy
1. Chronic hypertension
– systolic and diastolic parameters
– age of gestation?

A
  1. Systolic pressure ≥140 mm Hg &/or diastolic pressure ≥90 mm Hg prior to conception or at <20 weeks gestation
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24
Q

Hypertensive disorders of pregnancy
1. Gestational HTN
-parameters and age of gestation?

A
  1. New-onset elevated blood pressure at ≥20 weeks gestation
  2. No proteinuria or signs of end-organ damage
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25
Q

Hypertensive disorders of pregnancy
1. Preeclampsia
-parameters and age of gestation?

A
  1. New-onset elevated blood pressure at ≥20 weeks gestation

AND

Proteinuria OR signs of end-organ damage

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26
Q

Hypertensive disorders of pregnancy
1. Eclampsia
- parameters

A
  1. Preeclampsia
    AND
    New-onset tonic-clonic seizures
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27
Q

Prenatal diabetes screening
1. When for a high risk patient?
2. When for a non high risk?
3. what happens if high risk patient has normal screen?

A
  1. First trimester screen
  2. Third trimester screen (24-28 weeks)
  3. Still has to get trimester screen
    –when any of these screens are abnormal you get gestational diabetes mellitus

Other:
1. When someone has GDM, needs postpartum screen
–> normal: 1-3 year glucose screen + 1st trimester for next gestations
–> abnormal: T2DM

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28
Q

What is the screening for gestational diabetes mellitus?

A

1 hour glucose challenge test (GCT)

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29
Q

Postmenopausal bleeding
1. You get either a TVUS endometrium (usually less invasive first) or Endometrial biopsy
2. endometrium <= (BLANK) mm = observation
3. endometrium > (BLANK) mm = endometrial biopsy which will indicate pathology

A
  1. <= 4 mm
  2. > 4 mm

Endometrial biopsy may show atypia, neoplasia which would require further management

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30
Q

What are some complications of cervical excisional procedures? (cold knife conization, LEEP, etc)

A
  1. cervical stenosis (stricture of cervical canal due to scar tissue)
  2. preterm birth
  3. preterm prelabor rupture of membranes
  4. 2nd trimester pregnancy loss
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31
Q
  1. When are moms screened for GBS in their pregnancy?
  2. Indications for intrapartum prophylaxis?
A
  1. rectovaginal culture at 36-38 weeks gestation
  2. GBS bacteriuria or GBS UTI
    –GBS positive rectovaginal culture
    –Unknown GBS status PLUS any of the following: <37 weeks, intrapartum fever, rupture of membranes >= 18 hours
    –prior infant with early onset neonatal GBS infection
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32
Q

Clinical features
- complex ovarian mass
- Juvenile type: precocious puberty
- Adults type: breast tenderness, abnormal uterine bleeding, postmenopausal bleeding

Labs: Increased estradiol and inhibin

Histopathology: call-exner bodies (cells in rosette pattern)

  1. What is this? And what is the pathogenesis?
  2. Management?
A
  1. Granulosa cell tumor (tumors that come out of egg in ovary)
  2. endometrial biopsy (endometrial cancer) and surgery (for tumor staging)
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33
Q
  1. What are sex cords?
  2. What do granulosa cells make?
  3. What do theca cells make?
A
  1. embryonic structures which eventually will give rise to the adult gonads (testes, ovaries)
  2. estrogen (use androstenedione from theca cells to make estrogen)
  3. use cholesterol to make androstenedione
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34
Q
  1. Surface of ovary leads to what kind of tumors?
  2. Eggs in ovary can lead to what kind of tumors?
  3. Follicles and cortex/stroma (tissue surrounding egg in the ovary) can lead to what kind of tumors?
A
  1. epithelial tumors
  2. germ cell tumors
  3. sex cord stromal tumors
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35
Q
  1. Encephalopathy
  2. oculomotor dysfunction
  3. postural and gait ataxia
  4. what is this?
  5. pathophysiology?
A
  1. wernicke encephalopathy
  2. thiamine deficiency
    – can be caused by chronic alcohol use (most common), malnutrition, hyperemesis gravidarum
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36
Q

Hyperemesis gravidarum
1. Chloride levels
2. acid/base status
3. Potassium levels
4. Glucose levels
5. AST/ALT values

tx:?

A
  1. Hypochloremic
  2. metabolic alkalosis
  3. hypokalemia
  4. hypoglycemia
  5. elevated AST and ALT

Tx: antiemetics, fluids, and thiamine supplements.
if giving glucose given AFTER thiamine*

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37
Q
  1. What is placenta previa?
  2. What is vasa previa
  3. What is placenta accreta?
  4. What is abruptio placentae?
A
  1. Placenta covers the cervix. Pts are at risk for severe antepartum hemorrhage which presents as painless vaginal bleeding and occurs without contractions
  2. Unprotected umbilical vessels pass over the cervix + bleeding is PAINLESS
  3. Placenta grows too deeply into the uterine wall
  4. Premature placental separation from uterus
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38
Q

Abruptio placentae
1. clinical features?
-bleeding?
-pain?
-contractions?
-uterus on exam?

A
  1. sudden onset vaginal bleeding
  2. abdominal pain
  3. high frequency contractions
  4. tender, firm uterus after rupture of membranes (following an uncontrolled gush of amniotic fluid, esp in those with uterine overdistension like twins or polyhydramnios)

Risk factors: HTN, cocaine use, abdominal trauma, prior incident

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39
Q

Pregnant patients getting treated for GBS but with history of penicillin allergy should get treated with?

A
  1. Cefazolin
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40
Q

Secondary amenorrhea is defined as no period for (BLANK) months in women with previously regular menses

OR

(Blank) months in women with previously irregular menses

A
  1. > = 3 months
  2. > = 6 months
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41
Q

Initial evaluations in a person with 2ndary amenorrhea is what?

A
  1. pregnancy test
  2. Serum FSH, TSH, and prolactin levels
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42
Q

Interstitial cystitis (IC)
1. Definition
2. sx
3. typical patient
4. management

A
  1. painful bladder syndrome - chronic painful bladder condition of uncertain etiology.
  2. pain exacerbated by bladder filling and relieved by voiding. Urinary frequency, urgency, chronic pelvic pain, and dyspareunia.
  3. women >40, chronic pain pts, sexual dysfunction, and psych illnesses
  4. Management includes bladder training, fluid management, analgesics, and avoidance of any precipitating agents (eg, caffeine, alcohol, artificial sweeteners).

The diagnosis of IC is largely clinical; however, additional laboratory testing—including a urinalysis, postvoid residual, and sexually transmitted infection screening—is performed to exclude other conditions (eg, cystitis, urinary obstruction, malignancy).

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43
Q

What is cystocele?

A
  1. Bladder prolapse into the anterior vaginal wall
    -may cause dyspareunia and urinary symptoms (eg, frequency)
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44
Q

What is preterm prelabor rupture of membrane (PPROM)

A
  1. rupture of membranes at <37 weeks prior to onset of labor (irregular contractions and closed cervix)
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45
Q
  1. What is management of PPROM <34 weeks with no complications
  2. What about with infection, fetal/maternal compromise
  3. 34 to <37 weeks?
A
  1. prophylactic latency antibiotics (to prevent infection), corticosteroids (decrease RDS risk), fetal surveillance
  2. Delivery, intraamniotic infection tx, corticosteroids (betamethasone), magnesium if <32 weeks
  3. delivery, GBS prophylaxis, +/- corticosteroids
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46
Q

Why does pregnancy increase risk of aspiration?

A
  1. elevated progesterone delays gastric emptying and decreases esophageal sphincter tone
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47
Q
  • unifocal, friable plaque or ulcer
  • typically on the labia majora
  • persistent vulvar irritation (vulvar excoriations, erythema), and/or pain
  • intermittent bleeding and dyspareunia

what does this likely indicate?

A
  1. likely vulvar squamous cell carcinoma.
    –dx is with vulvar biopsy

risk factors:
- tobacco use
- vulvar lichen sclerosus
- immunodeficiency
- prior cervical cancer hx
- vulvar/cervical intraepithelial neoplasia

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48
Q

Patients <32 weeks gestation require
1. (BLANK) to inhibit contractions and delay delivery (ie tocolysis)
2. Betamethasone to (BLANK)
3. (BLANK) to decrease risk of cerebral palsy
4. Penicillin to decrease the risk of (BLANK)

A
  1. Indomethacin
  2. promote fetal lung maturity
  3. Mg Sulfate
  4. Group B Strep infection
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49
Q

What is tocolysis?

A

an obstetrical procedure carried out with the use of medications with the purpose of delaying the delivery of a fetus in women

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50
Q

Indomethacin adverse fetal effects
1. MOA:
2. vascular effects
3. Renal effect
4. Method to prevent this?

A
  1. cyclooxygenase inhibitor and leads to decreased prostaglandin (mediators of inflammation “vasodilation”, fever, and pain) production
  2. vasoconstriction (e.g. premature closure of ductus arteriosus)
  3. Decreased renal perfusion and fetal oliguria can result in oligohydramnios. This is usually transient and resolves with discont. of meds.
  4. Patients typically receive indomethacin for <=48 hours
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51
Q

Differentiate between
1. endometriosis
2. endometrial polyps
3. Uterine leiomyomata (fibroids)
4. adenomyosis

A
  1. Ectopic endometrial glands. Heavy, painful menses and IMMOBILE uterus.
  2. Localized hyperplastic growth of endometrial glands. Typically has intermenstrual bleeding.
  3. Proliferation of myometrial smooth muscle. Heavy, regular menses. Large, irregularly shaped uterus.
  4. endometrial glands and stroma accumulate abnormally within uterine myometrium causing a boggy, tender, symmetrically enlarged uterus
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52
Q

Peripartum Cardiomyopathy
1. what is this?
2. When does it present in pregnancy
3. Sx
4. Heart sounds
5. Management

A
  1. Dilated cardiomyopathy + secondary mitral regurgitation
  2. During last month of pregnancy or within 5 months following delivery
  3. Progressive dyspnea on exertion, lower extremity edema, S3 (decomp. heart failure)
    — EF <45%
  4. S3 (decomp heart failure), Holosystolic murmur at apex (secondary mitral regurgitation)
  5. Urgent delivery if hemodynamically unstable. St management of heart failure with reduced EF (e.g. beta blocker, diuretics)
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53
Q
  1. How do you take out a placenta that is placenta accreta?
A
  1. Surgical removal of the uterus (hysterectomy) with the placenta in situ - this minimizes further maternal bleeding
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54
Q

What transition between latent and active phase of labor occurs at (BLANK) cm dilation

A
  1. 6 cm dilation
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55
Q
  1. Active phase of labor has an expected, predictable rate of cervical dilation of (BLANK) cm every 2 hours
  2. Active phase arrest is defined as:
  3. Best next step to manage active phase arrest is (BLANK)
A
  1. > =1 cm every 2 hours
  2. No cervical change for >= 4 hours with adequate contractions OR no cervical change for >= 6 hours with inadequate contractions
  3. Cesarean delivery
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56
Q
  1. What is protraction in “disorders of active phase of labor”
  2. How do you treat
A
  1. Cervical change slower than expected
    +/- inadequate contractions
  2. Oxytocin
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57
Q
  1. What are montevideo units?
  2. What value is adequate labor
A
  1. Substracting uterine resting pressure (mmHg) from peak intensity of each contraction in a 10 minute period and adding these values together
  2. Adequate labor is 200-250 MVUs
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58
Q
  1. (BLANK) is administered to patients with preeclampsia with severe features to prevent and treat eclamptic seizures
  2. Adverse effects/sx of this medication in overuse and how to treat it?
A
  1. Magnesium sulfate
  2. With too much it can get toxic - nausea, flushing, headache, and hyporeflexia (if mild)
    –Moderate: areflexia, hypocalcemia, somnolence
    –respiratory paralysis, cardiac arrest
  3. To treat: stop magnesium therapy and give IV calcium gluconate bolus
  • Magnesium sulfate works to prevent seizures by increasing seizure threshold
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59
Q

soft, mobile, nontender masses at the base of the labia majora at the 4 and 8 o’clock positions

  • what are these?
A

Bartholin duct cysts

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60
Q

Gartner duct cyst
1. What do these originate from?
2. Where do they appear?
3. How to differentiate between this and bartholin duct cysts

A
  1. incomplete regression of Wolffian duct
  2. appear along the lateral aspects of the upper anterior vagina.
  3. These do not involve the vulva, they grow in the vagina
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61
Q

Where are skene glands found?

A
  1. Bilateral paraurethral glands in the anterior vaginal vestibule. Lateral to urethral meatus
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62
Q

Placenta previa
-what symptoms occur?
- management?

A
  1. painless vaginal bleeding >20 weeks gestation
  2. No intercourse, no digital cervical examination, inpatient admission for bleeding episodes
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63
Q
  • Vaginal bleeding
  • pelvic pain
  • dilated cervix
  • <20 weeks

what is this?

A

inevitable abortion

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64
Q
  • vaginal bleeding
  • high frequency uterine contractions
  • more common in smokers
  • constant abdominal pain/tender uterus (firm) and fetal decelerations

What is this?

A

Placental abruption, separation of placenta from the uterus prior to fetal delivery

–risk factors for this is HTN, preeclampsia, abdominal trauma, prior abruptio placentae, cocaine and tobacco use

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65
Q

What is needed to confirm dx of vulvar lichen sclerosus and rule out vulvar cancer

A
  1. vulvar punch biopsy
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66
Q

Clinical
1. Vascular thrombosis (arterial or venous)
2. Pregnancy morbidity
— >=3 consecutive, unexplained fetal losses before the 10th weeks
—- >= 1 unexplained fetal losses after 10th week
—- >= 1 premature births of normal neonates before 34th week due to preeclampsia, eclampsia, or placental insufficiency)

Lab findings
- Lupus anticoagulant
- anticardiolipin antibody
- Anti-beta2 glycoprotein antibody I

  1. what is this syndrome?
  2. What is the criteria from these clinical, lab findings that indicate this syndrome?
  3. What is treatment given?
A
  1. antiphospholipid-antibody syndrome - prothrombotic autoimmune disorder caused by antibodies.
  2. Needs 1 from clinical and 1 from lab criterion to meet syndrome dx
  3. Give low molecular weight heparin

**these antibodies cross react with a VDRL test to produce a false positive result
–they can also interfere with coagulation test reagents resulting in prolonged PTT
–mild thrombocytopenia that is immune mediated is typical

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67
Q

Differential diagnosis of vaginitis
1. Bacterial vaginosis (gardnerella vaginalis)
2. Trichomoniasis (Trichomonas vaginalis)
3. Candida vaginitis (candida albicans)

  • How does discharge/smell differ?
  • How does pH differ?
  • What type of histology will you see?
  • treatment?
A
  1. Bacterial vaginosis (gardnerella vaginalis)
    -Thin, off white discharge with fishy odor
    -pH >4.5
    - clue cells and positive whiff test
    - metronidazole or clindamycin
  2. Trichomoniasis (Trichomonas vaginalis)
    - thin, yellow-green malodorous, frothy discharge + vaginal inflammation
    - pH >4.5
    - motile trichomonads
    - metronidazole; treat sexual partner too
  3. Candida vaginitis (candida albicans)
    - thick, cottage cheese discharge with vaginal inflammation
    - normal vaginal pH (3.8-4.5)
    - pseudohyphae
    - Fluconazole
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68
Q

Intraamniotic infection (chorioamnionitis)
- risk factors: (BLANK)
- diagnosis: maternal fever PLUS >= 1 of the following (BLANK)
- management

A
  1. Risk factors: PROM (>18 hours), preterm prelabor ROM, prolonged labor, internal fetal/uterine monitoring devices, repetitive vaginal exams, presence of genital tract pathogens
  2. fetal tachy (>160), maternal leukocytosis, purulent amniotic fluid
  3. broad spectrum antibiotics and delivery
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69
Q

If fetal presentation (eg, cephalic, breech) is uncertain on digital cervical examination, (BLANK) should be performed to confirm fetal presentation and determine the safest route of delivery.

A

transabdominal ultrasonography

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70
Q
  1. What is asherman syndrome?
  2. What are risk factors for this?
  3. Clinical features
  4. evaluation and tx
A
  1. Formation of intrauterine adhesions
  2. infection or after intrauterine sx like suction and sharp curettage
  3. Abnormal uterine bleeding, 2ndary amenorrhea, light menses, infertility, cyclic pelvic pain, recurrent pregnancy loss
  4. Hysteroscopy to ID and lyse adhesions
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71
Q
  • Typically in multiparous women age >40
  • new onset dysmenorrhea
  • heavy menstrual bleeding
  • chronic pelvic pain
  • boggy, tender, symmetrically enlarged uterus

what is this likely?

A
  1. adenomyosis
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72
Q
  1. What are some causes of fetal tachycardia (>160/min)
  2. What are some causes of fetal bradycardia (<110/min)
A
  1. maternal fever, med adverse effect, fetal hyperthyroidism, fetal tachyarrhythmia
  2. maternal hypothermia, med adverse effect, fetal hypothyroidism, fetal heart block
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73
Q

what is considered uterine tachysystole?

A
  1. > 5 contractions in 10 minutes
    –associated with late fetal decelerations bc there is transient decrease in placental perfusion during contractions and inadequate recovery time between contractions.
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74
Q
  1. What is polymorphic eruption of pregnancy (PEP)
  2. How to tx
A
  1. pruritic, urticarial papules and plaques of pregnancy. Happens in 3rd trimester of pregnancy or immediately postpartum. Occurs with overstretching of the skin causing underlying connective tissue damage – chronic inflammation results in this rash/abdominal striae that spreads in centrifugal spread but spares umbilicus.
  2. Topical corticosteroids, antihistamines
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75
Q

One contraindication to IUD insertion (both copper-containing and progestin-releasing) —> BLANK

A

unexplained, abnormal vaginal bleeding

Abnormal bleeding is often a symptom of an underlying condition that requires further evaluation before IUD insertion

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76
Q

What is urethral hypermobility?

A

Substantial weakness of the pelvic floor muscles can result in urethral hypermobility, in which the urethra abnormally moves with increased intraabdominal pressure (eg, jogging, coughing) and is unable to fully close

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77
Q

What are risk factors for placenta previa?

A
  1. prior placenta previa
  2. increasing cesarean delivery rates — uterine scar and change in vascularity likely alter early pregnancy implantation
  3. multiple gestation (ie increased placental surface area)
  4. advanced maternal age

*most cases are found incidentally in 2nd trimester
*most resolve by the 3rd trimester but if persistent then undergo c section at 36-37 weeks gestation

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78
Q

Nonstress test
Reactive: pulse, variability, accelerations
Nonreactive: pulse, variability, accelerations

  • what does each mean
  • what is most often cause of nonreactive results
A
  1. Reactive: baseline 110-160/min, mod variability, and >= 2 accels in 20 min
  2. Nonreactive - does not meet above criteria
  3. Reactive means baby is not causing concern for hypoxemia and acidemia. Nonreactive is concerning for this.
  4. quiet fetal sleep cycle (lasts <= 40 min
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79
Q

postmenopausal bleeding require
1. BLANK for cervical cancer
2. and either blank or blank for endometrial cancer

A
  1. pap smear
  2. endometrial biopsy or TVUS
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80
Q

Fetal diagnosis of (BLANK) occurs with
-acardia
-anencephaly
-bilateral renal agenesis
-holoprosencephaly
-Intrauterine fetal demise
-pulmonary hypoplasia
-thanatophoric dwarfism

What is obstetric management?

A
  1. nonviable fetus
  2. vaginal delivery, no fetal monitoring
  3. if not still born then give palliative neonatal care
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81
Q

PPROM
1. Definition
2. symptoms
3. tests
4. management

A
  1. membrane rupture at <37 weeks prior to labor
  2. vaginal pooling or fluid from cervix
  3. nitrazinze-positive (blue) fluid, ferning on microscopy
  4. <34 weeks (reassuring): latency antibiotics, corticosteroids
    – <34 weeks (nonreassuring): delivery
    – >= 34 weeks: delivery

*complications include preterm labor, intraamniotic infection, placental abruption, umbilical cord prolapse

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82
Q

What are some risk factors for PPROM?

A
  1. prior PPROM
  2. GU infection (ASB, BV, etc)
  3. Antepartum bleeding
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83
Q

Retained placenta symptoms

A
  1. uterine atony (ie. enlarged, boggy uterus)
  2. heavy vaginal bleeding
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84
Q

What other structures develop from common embryologic source as uterus, cervix, and upper third of vagina

A
  1. urogenital structures like kidneys, ureters
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85
Q

Methods of birth for moms with HIV

  1. Patients with viral loads <- 50 copies/mL
  2. Patients with viral loads >50 copies/mL but ≤1,000 copies/mL
  3. patients with viral loads >1,000 copies/mL
A

Patients with viral loads ≤50 copies/mL deliver vaginally. These patients continue their daily antiretroviral regimens.

Patients with viral loads >50 copies/mL but ≤1,000 copies/mL are at a slightly increased risk of vertical transmission and often receive intrapartum IV zidovudine along with their daily ART. However, vaginal delivery is still acceptable

In contrast, patients with viral loads >1,000 copies/mL get c - section

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86
Q

What does mucoid vaginal bleeding (ie, bloody show), during active labor indicate?

A

Normal labor progression can cause mucoid vaginal bleeding (ie, bloody show), particularly during active labor, due to rapid cervical dilation. Expectant management can continue for patients with bloody show and reassuring maternal-fetal status (ie, stable vital signs, category I fetal heart rate tracing).

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87
Q
  1. What is complete hydatidiform mole pregnancy mean?
  2. How to treat?
A

Complete hydatidiform mole pregnancies result from an abnormal fertilization of an empty ovum either by 2 sperm or by 1 spermthat subsequently duplicates its genome. This abnormal fertilization leads to trophoblastic proliferation and hydropic villi with no associated fetal development. The uncontrolled molar tissue proliferation and endometrial blood collection can cause first-trimester vaginal bleeding, a uterine size–date discrepancy, and markedly elevated β-hCG levels (eg, >100,000 mIU/mL).

Treatment is with suction curettage; due to the risk of malignant transformation (eg, choriocarcinoma), patients are followed with serial monitoring until the hCG level is undetectable

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88
Q

What is the most accurate way to determine estimated gestational age (EGA)?

A

ultrasound dating with fetal crown-rump measurement in first trimester. EGA should not be changed based on measurement discrepancies in 2nd or 3rd trimester

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89
Q
  1. What is the most effect emergency contraception method available?
  2. Within how much time of intercourse?
  3. Other methods of EC?
A
  1. copper containing IUD (>99% efficacy)
  2. Wtihin 120 hours (5 days and >99% efficacy)
  3. Then its progestin releasing IUD (5 days)
    –ulipristal (5 days but 98-99% efficacy)
    –Oral levonorgestrel (3 days and 92-98% effective)
    –Oral contraceptives (3 days and 75-89% effective)
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90
Q
  1. What is twin twin transfusion syndrome?
  2. What complications can arise?
A
  1. Unbalanced arteriovenous anastomoses between the shared placental vessels that supply the twins. This leads to blood movement where one fetus is getting more blood than the other.
  2. heart failure, fetal/neonatal mortality, anema/polycythemia, renal failure, oligo/polyhydramnios, etc
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91
Q
  • dysuria
  • postvoid dribbling of urine
    -dyspareunia
  • tender anterior vaginal wall mass that expresses a purulent or bloody urethral discharge

what is this?

A
  1. urethral diverticulum - localized outpouching of the urethral mucosa that can collect urine resulting in inflammation of surrounding tissue
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92
Q

Clinical features
1. Derm
-ash leaf spots
-angiofibromas of the malar region
-shagreen patches
2. Neuro
- CNS lesions (subependymal tumors)
- epilepsy
- intellectual disability
- autism and behavioral disorders
3. Cardio: rhabdomyomas
4. Renal: angiomyolipomas

what is this and what is inheritance pattern

A
  1. Tuberous sclerosus complex
    -mutation in TSC1 or TSC2 gene
    - autosomal dominant
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93
Q

why do women with spontaneous abortion require anti-D immunoglobulin after abortion if they are Rh negative

A
  1. The placenta is a barrier between the pregnant woman and fetus, but fetal erythrocytes may enter the woman’s circulation during abortion (induced or spontaneous, as in this patient), procedures (eg, amniocentesis), or delivery. Anti-D immunoglobulin is administered at these critical times and binds the D antigens on the fetal erythrocytes in the pregnant woman’s circulation, thereby preventing the formation of anti-D antibodies.
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94
Q

Uterine fibroid degeneration
1. pathophysiology
2. symptoms
3. treatment

A
  1. more likely during pregnancy - myometrial blood flow shifts toward the developing fetus and placenta.
  2. Infarcted, degenerating fibroid can cause severe abdominal pain, uterine tenderness, palpable, firm, and tender mass + signs of inflammation
  3. Diagnosis is confirmed by ultrasound, and the condition is conservatively managed with acute pain control (eg, indomethacin for patients <32 weeks gestation).
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95
Q

Ultrasound finding: partially calcified mass with multiple thin, echogenic bands

  1. what is this?
  2. What complication can it cause
  3. symptoms of this complication
A
  1. mature cystic teratoma/dermoid cyst - common in premenopausal women
  2. ovarian torsion - twisting around the supporting ligaments
  3. acute onset, severe pelvic pain. Can be complicated by peritonitis (fever, nausea, vomiting) and acute abdomen (rebound, guarding)
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96
Q

Unilocular, hypoechoic ovarian mass - what is this likely

A

endometriomas - encapsulated collections of old blood from ectopic endometrial implants that appear as homogenous cystic masses

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97
Q

multilocular with a high proportion of solid tumor and frequently associated with ascites

A

primary invasive epithelial tumor

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98
Q

large bilateral cystic masses rather than a unilateral mass - what is this likely?

A
  1. theca lutein cysts - they arise from markedly elevated beta hcg levels
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99
Q

multiloculated, cystic masses with distortion of normal adnexal structures
+ fever, tender mass, cervical motion tenderness, abnormal discharge

what is this likely?

A

tubo-ovarian abscesses

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100
Q
  • HTN at >= 20 weeks
  • Hyperreflexia
  • elevated Beta hCG
  • Headache and RUQ pain (hepatic swelling and stretching of Glisson capsule) - signs of end organ damage

1.what is this likely?

A
  1. preeclampsia with severe features (the last point)

*if it presents early on at <20 weeks this is abnormal and hydatidiform mole pregnancy should be looked into

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101
Q

What is management of hydatidiform mole?

A
  1. dilation and suction curettage
  2. serial betal-hCG post evac
  3. contraception for 6 months
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102
Q

What are clinical signs that there is hydatidiform mole?

A
  1. Abnormal vaginal bleeding ± hydropic tissue
  2. Uterine enlargement > gestational age
    3.Abnormally elevated β-hCG levels
    4.Theca lutein ovarian cysts
  3. Hyperemesis gravidarum
  4. Preeclampsia with severe features
  5. Hyperthyroidism
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103
Q

When is syphilis screened for during pregnancy?

A
  1. at the 1st prenatal visit
  2. 3rd trimester
  3. delivery if high risk
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104
Q

What are routine prenatal lab tests done in first visit? (8)

A
  1. Rh(D) type & antibody screen
  2. Hemoglobin/hematocrit, MCV, ferritin
  3. HIV
  4. VDRL/RPR – syphillis
  5. Hept B and Hep C–> HBsAg and anti-HCV Ab
  6. Rubella & varicella immunity
  7. Urine culture
  8. Urine dipstick for protein
  9. Chlamydia PCR (if risk factors are present)
  10. Pap test (if screening indicated)
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105
Q

What are tests done for pregnancy at 24-28 weeks (6-7 months)

A
  1. Hemoglobin/hematocrit
  2. Antibody screen if Rh(D)-negative (Anti-D immunoglobulin is universally administered at 28 weeks following a repeat negative antibody screen/indirect coombs test)
  3. 1-hr 50-g GCT (glucose challenge)
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106
Q

What tests are done during 36-38 weeks of pregnancy (9-9.5 months)

A
  1. GBS rectovaginal culture
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107
Q

Epidural can cause (BLANK) block resulting in hypotension and decreased placental perfusion (late fetal heart rate decels) - management is with

  1. IV fluids
  2. BLANK
A
  • sympathetic block
    2. vasopressors (phenylephrine)
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108
Q

What is terbutaline used for in labor and delivery?

A
  1. to treat recurrent late decels due to uterine tachysystole (>5 contractions/10 min)

–this is a beta 2 agonist and can cause vasodilation and hypotension

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109
Q

When is amnioinfusion used to tx changes in accels/decels?

A
  1. used to reduce umbilical cord compression - which can occur after rupture of membranes and is evidence by variable decels
  • not for late decels
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110
Q

Congenital uterine anomalies (arcuate, septate, bicornuate, didelphys, unicornuate)

  • what adverse reproductive and obstetric outcomes arise?
A

Spontaneous abortion: Congenital uterine anomalies are commonly associated with absent or abnormal vasculature and diminished uterine blood flow. Therefore, pregnancies experience decreased placental perfusion and inadequate nutrition, which can cause fetal growth restriction or recurrent pregnancy loss.

Preterm labor: Because it has 2 separate, smaller uterine cavities, a bicornuate or septate uterus cannot expand fully in volume to accommodate a full-term pregnancy. When the fetus becomes larger than the cavity, uterine overdistension may trigger preterm labor. Uterine anomalies may also adversely affect the structural integrity of the cervix, increasing the risk for cervical insufficiency and second-trimester pregnancy loss.

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111
Q

When someone has a uterine leiomyoma (fibroid) what can lead to regression of this fibroid on its own?

A

If pt is nearing menopause, decline in estrogen leads to regression in fibroid

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112
Q
  1. sudden onset unilateral pelvic pain
  2. nausea and vomiting
  3. palpable adnexal mass (absent doppler flow to ovary)
  • what is this?
A

ovarian torsion
–laparoscopy with detorsion
–ovarian cystectomy
–oophorectomy if necrosis or malignancy

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113
Q

HSV infection before or during pregnancy - yes

  1. Antiviral suppression beginning at (BLANK) weeks
  2. Lesion/prodromal sx during labor
    –> yes indicates (BLANK)
    –> no indicates (BLANK)
A
  1. 36 weeks
  2. yes indicates c section
  3. no indicates vaginal delivery
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114
Q
  1. who is considered high risk patient for STI in pregnancy
  2. What is screened in first prenatal visit and 3rd trimester?
A
  1. age <25, prior STI, high risk sexual activity
  2. HIV, syphillis, Hep B and C virus, Gonorrhea, Chlamydia
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115
Q
  1. What is HELLP syndrome?
  2. sx?
  3. What organ is commonly affected?
A
  1. Hemolysis, elevated liver enzymes, low platelets –> a spectrum of disease causing maternal endothelial dysfunction (e.g. HTN, vasospasm, platelet overactivation, etc)
  2. N/V, RUQ pain, headache, visual changes, HTN
  3. liver - microthrombi deposit in hepatic portal system and results in decreased hepatic perfusion, liver ischemia, hepatocellular injury –gradual distension of hepatic (glisson) capsule causes presentation of RUQ pain. Can progress to liver necrosis and hemorrhage (subcapsular hematoma)
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116
Q
  • Microangiopathic hemolytic anemia
  • elevated liver enzymes
    -thrombocytopenia
  • +/- proteinuria

-what is this lively?

A
  1. HELLP syndrome
117
Q

How does pulmonary edema happen in preeclampsia/eclampsia?

A
  1. start with systemic hypertension (generalized arterial vasospasm)
  2. this leads to increased afterload against which heart is pumping
  3. This increases pulmonary capillary pressure because blood is backing up into lungs
  4. This leads to pulmonary edema
118
Q
  • placenta is pale and enlarged, areas of necrosis surround umbilical vessels
    –these findings suggest (blank - what cause?)
A
  1. infectious cause of still birth likely transplacental (vertical) - This is because, upon exposure to a pathogen crossing from maternal to fetal circulation, fetal inflammatory cells mobilize along the umbilical vein, causing cord inflammation and perivascular foci of necrosis.

Several pathogens can be transmitted transplacentally and lead to IUFD, including:

Viruses: parvovirus B19 and cytomegalovirus
Bacteria: Listeria monocytogenes (listeriosis) and Treponema pallidum (syphilis)
Protozoa: Toxoplasma gondii (toxoplasmosis)

119
Q

large follicle with multiple subcentimeter follicles on ultrasound is consistent with?

A

normal postovulatory ovarian changes

120
Q

Infectious genital ulcers

-Pustules, vesicles, or small ulcers on erythematous base
-Tender lymphadenopathy
-Systemic symptoms common
- painful

1.what is this?
2. likely result of this?

A
  1. HSV
  2. resolution in a week
121
Q

Infectious genital ulcers

-Larger, deep ulcers with gray/yellow exudate
-Well-demarcated borders & soft, friable base
-Severe lymphadenopathy that may suppurate
- painful

what is this?

A

Haemophilus ducreyi (chancroid)

122
Q

Infectious genital ulcers

-Usually single ulcer (chancre)
-Indurated borders & hard, nonpurulent base
- painless

A

Treponema pallidum (syphillis)

123
Q

Infectious genital ulcers

Initial painless, small, shallow ulcers (often missed)
Then painful & fluctuant adenitis (buboes)

A

Chlamydia trachomatis serovars L1-L3 (lymphogranuloma venereum)

124
Q

Etiology of absent or minimal fetal heart rate variability

A
  1. CNS depressants (narcotics, alcohol, recreational drugs)
  2. temp fetal sleep
  3. prematurity
  4. fetal hypoxia
125
Q

what is given as preventative medication for preeclampsia?

A
  1. low dose aspirin at 12 weeks gestation
126
Q

What is the function of misoprostol (prostaglandin E1)

A

Can be used for medical abortion or pregnancy termination by stimulating uterine contractions

127
Q

What is physiologic leukorrhea

A

white, odorless mucoid cervical discharge that typically occurs midcycle due to increasing estrogen levels prior to ovulation

(microscopic exam can show rare polymorphonuclear leukocytes)

128
Q

What three indications lead to surgery for management for someone who has ectopic pregnancy?

A
  1. not stable
  2. bHCG is NOT <5,000 and there is NO fetal cardiac activity
  3. NOT a methotrexate candidate
129
Q

breastfeeding contraindications for instances in mom
1. active untreated (BLANK)
2. (BLANK) infection
3. (BLANK) breast lesions
4. active varicella infection
5. chemo or radiation therapy
6. active substance use disorder

breastfeeding contraindications for instances in infant
1. galactosemia

A
  1. active untreated TB
  2. HIV infection
  3. Herpetic breast lesions
  4. active varicella infection
  5. chemo or radiation therapy
  6. active substance use disorder
130
Q

What does the staircase sign on tocodynamometry indicate?

A

Disordered contractions that may occur in uterine rupture (full thickness myometrial tear) because myometrial fibers cannot contract in unison
–evidenced by progressively decreasing contraction amplitude that look like staircase

131
Q
  • sudden onset abdominal pain and uterus with decreasing rigidity
  • intraabdominal hemorrhage (e.g. diffuse back pain), vaginal bleeding, and shock due to quick bleeding
  • fetal heart rate tracing abnormalities
  • progressively decreasing contraction amplitude
  • loss of fetal station
  • palpable fetal parts on abdominal exam
A
  1. this is likely uterine rupture
    - management is with emergency laparotomy and c section
132
Q

sheehan syndrome
1. Symptoms
2. Pathophysiology
3. Treatment

A
  1. Lactation failure (↓ prolactin)
    –Amenorrhea, hot flashes, vaginal atrophy (↓ FSH, LH)
    –Fatigue, bradycardia (↓ TSH)
    –Anorexia, weight loss, hypotension (↓ ACTH)
    –Decreased lean body mass (↓ growth hormone)
  2. post partum hypopituitarism caused by necrosis of the pituitary gland. Usually a result of severe hypotension or shock caused by massive hemorrhage during or after delivery.
  3. Evaluation of pituitary hormones and replacing as needed
133
Q
  1. protracted labor (abnormally slow cervical dilation or fetal descent during active labor)
  2. Turtle sign: retraction of fetal head into the perineum after delivery
  • what are these warning signs of?
A
  1. shoulder dystocia
    —greatest risk factor for this is fetal macrosomia (EFW >4.5 kg or 9lb 14 oz)
134
Q

Risk factors for uterine rupture?

A
  1. Prior uterine surgery (c section, myomectomy)
  2. induction of labor/prolonged labor
  3. Congenital uterine anomalies
  4. Fetal macrosomia
135
Q

Preeclampsia is new-onset hypertension at ≥20 weeks gestation plus proteinuria or signs of end-organ damage (eg, renal dysfunction).

Patients with serum creatinine (BLANK) mg/dL or transaminases (BLANK) have preeclampsia with severe features

A

Patients with serum creatinine >1.1 mg/dL or transaminases >2x normal have preeclampsia with severe features

136
Q

treatment of high blood pressure in someone with preeclampsia to decrease stroke risk include
1. Blank A
2. Blank B
3. Blank C

A
  1. Hydralazine IV
  2. Labetalol IV (make sure patient is not in bradycardia)
  3. Nifedipine PO
137
Q

Why is sickle cell acute pain episodes more common in pregnancy?

A

– usually at 12 weeks gestation
—Due to increased metabolic demands and hypercoagulable state

*pain occurs due to repetitive red blood cell sickling, which causes microvascular occlusion, decreased perfusion, and tissue ischemia (e.g. abdominal tenderness)
* managed with fluid resuscitation and opioid pain control

138
Q
  • myometrial thinning and numerous placental lacunae (vascular spaces filled with maternal blood) is likely to indicate
A

placenta accreta (morbidly adherent placental attachment to the myometrium)

139
Q

5 alpha reductase deficiency
1. pathophysiology
2. symptoms

A
  1. impaired conversion of testosterone to DHT. Impaired virilization during embryogenesis. Normal male testosterone and estrogen levels.
  2. Male internal genitalia but female external genitalia. Phenotypically female at birth but at puberty patient virilizes due to spike in testosterone and you start to see clitoromegaly, increased muscle mass, male pattern hair development, nodulocystic acne
140
Q

Phemphigoid gestationitis
1. pathophysiology
2. skin description + symptoms
3. treatment

A
  1. anti-basement membrane antibodies affect the placenta + basement membrane at the dermoepidermal junction
  2. Patients typically have pruritus, followed by a rash that consists of erythematous papules/plaques that involve the umbilicus and subsequently develop into vesicles and bullae. Rash can spread bast abdomen but usually not face or mucous membranes.
    —during 2nd/3rd trimester
  3. High potency topical steroids and antihistamines
141
Q

Fetal hydrops
1. pathogenesis
2. clinical features
3. causes of this?

A
  1. increased cardiac output demand causing heart failure. Increased fluid movement into interstitial spaces (third spacing)
  2. Pericardial effusion, pleural effusion, ascites, skin edema, placental edema, polyhydramnios
  3. Rh(D) alloimmunization, Parvo B19 infection, fetal aneuploidy, cardiovascular abnormalities, Thalassemia
142
Q
  1. What is uterine atony?
  2. What is this the most common cause of?
  3. Clinical presentation?
  4. Interventions
A
  1. soft and weak uterus after childbirth
  2. post partum hemorrhage
  3. Enlarged, soft, boggy, poorly contracted uterus
  4. Bimanual uterine massage, high dose oxytocin/misoprostol, tranexamic acid, etc
143
Q

cell free fetal DNA test
1. what kind of test is this?
2. What does this test for?
3. When can it happen?

A
  1. Testing mom’s blood
  2. Trisomy 21, 18, 13 and aneuploidies, fetal sex determination
  3. > = 10 weeks gestation. Typically offerred to women age >= 35 because they are at increased risk of fetal aneuploidy
144
Q
  • vaginal bleeding
  • malodorous vaginal discharge
  • irregular vaginal lesion

—> what is this concerning for?
–> what is next step?
–> risk factors for this?

A
  1. vaginal cancer
  2. vaginal biopsy
  3. age >60, HPV infection, tobacco use, in utero DES exposure
145
Q

Why does preeclampsia not usually cause brain injury/neonatal hypoxia brain injury?

A
  1. Preeclampsia causes chronically low uteroplacental perfusion, over time the fetus adapts by preferentially shunting oxygenated blood from the body to the brain, thereby sparing brain injury
146
Q

leakage of clear fluid when a woman goes from sitting to standing position indicates what kind of incontinence?

A

stress urinary incontinence (due to increased intraabdominal stress)

147
Q

condylomata acuminata vs condylomata lata
- what is the difference?

A
  1. condylomata acuminata - anogenital warts caused by HPV a common sexually transmitted infection. HPV strains 6 and 11. Skin colored fleshy lesions that are typically asymptomatic and nontender BUT pruritic, friable lesions may occur
  2. condylomata lata - caused by secondary syphillis
    – raised, gray-white lesions that develop on mucosal surfaces. Typically have broader base and a smooth surface
148
Q

Nonclassic congenital adrenal hyperplasia
1. pathophysiology
2. symptoms

A
  1. partial 21 hydroxylase deficiency which results in impairment in 17-OHP conversion into cortisol and progesterone converting into aldosterone. This leaves with increased production of testosterone
    2.Typically in reproductive aged women with signs of hyperandrogenism (e.g. hirsutism, acne) and abnormal uterine bleeding
149
Q

urethral hypermobility is found in what kind of GU issue?

A

stress urinary incontinence - intermittent urine loss with increased intraabdominal pressure

150
Q

Postpartum fecal or flatal incontinence can occur due to (BLANK) injury associated with a third- or fourth-degree obstetric perineal laceration.

Evaluation is with (BLANK)

A

Postpartum fecal or flatal incontinence can occur due to external anal sphincter injury associated with a third- or fourth-degree obstetric perineal laceration.

Patients typically have weakened anal sphincter tone, asymmetric sphincter contraction, or a palpable defect on examination.

Evaluation is with endoanal ultrasonography.

151
Q
  1. What changes to thyroid hormone occur during pregnancy?
  2. What causes this change? (2)
A
  1. pregnancy leads to increased Thyroid hormone to cope with metabolic demands.
  2. Estrogen causes increased thyroxine binding globulin, leading to increased total (but not free) thyroid hormone levels

–hCG directly stimulates TSH receptors, causing increased production of thyroid hormone

152
Q

What is intrauterine synchiae?

A

Same as asherman syndrome
–complication of intrauterine surgeries such as hysteroscopic myomectomy or curettage
–sx: amenorrhea, infertility, and negative progesterone withdrawal test

152
Q

What are risk factors for tubal occlusion?

A

adhesions from PID
- endometriosis
- prior pelvic surgery

152
Q

Physical examination
- fever (>100.9 F)
- cervical motion, uterine, or adnexal tenderness
- mucopurulent cervical discharge
- lower abdominal pain
- abnormal bleeding

  • what is this?
  • treatment?
A
  1. Pelvic inflammatory disease
  2. inpatient: IV broad spectrum antibiotics or outpatient PO antibiotics

-risk factors: multiple sexual partners, age 15-25, previous PID, inconsistent barrier contraception, partner with STI

153
Q

What hypertension medications are teratogens for babies?
—> what can it lead to?

A
  1. ACE inhibitors
  2. Angiotensin II receptor blockers (ARBs)
    —fetal renal hypoplasia (e.g. bilateral, underdeveloped fetal kidneys) and oligohydramnios
154
Q

How long is stress urinary incontinence after vaginal delivery just managed with observation and reassurance?

A

<6 weeks after delivery due to pelvic floor muscle weakness. Typically it is self limited

155
Q

Symptoms
- fever >24 hours postpartum
- purulent lochia
- uterine tenderness

  1. What is this?
  2. How is this treated?
A
  1. postpartum endometritis
  2. clindamycin + gentamicin due to broad spectrum coverage
156
Q

Clinical presentation
- asymptomatic: incidental adnexal mass
- subacute: pelvic/abdominal pain, bloating, early satiety
- acute: dyspnea, obstipation/constipation, abdominal distention
- increased CA-125 levels

Ultrasound findings
- solid, complex mass
- thick septations
- ascites

  1. what is this?
  2. Risk factors?
  3. management
A
  1. epithelial ovarian carcinoma
  2. Family history, genetic mutations (BRCA1, BRCA2), Age >= 50, endometriosis, infertility, early menarche/late menopause
  3. surgical exploration, +/- chemotherapy
157
Q

What is the etiology of HELLP disorder?

A

–abnormal platelet development during early pregnancy with the placental release of antiangiogenic factors

–systemic microangiopathy and excessive platelet consuption (likely due to severe endothelial injury) that leads to overactivation of the coagulation cascade and thrombi formation in the microvasculature, causing microangiopathic hemolytic anemia

158
Q

What are contraindications to endometrial ablation? (2)

A
  1. desire for future fertility because endometrial ablation destroys basal layer of endometrium which impairs formation of the decidua basalis in early pregnancy
  2. current or high risk for endometrial cancer/hyperplasia - since endometrial ablation causes intrauterine scarring it significantly limits future endometrial evaluation for malignancy such as (e.g. endometrial bx) and could mask sx of endometrial cancer by obstructing uterine outflow
159
Q

A biophysical profile (BPP) is performed in patients at risk for (BLANK)

A
  1. uteroplacental insufficiency (e.g. >41 weeks)
  • chronic hypoxemia causes an abnormal BPP score and suggests imminent risk of fetal demise; delivery is typically indicated
160
Q

Hyperandrogenism in pregnancy is commonly due to what?

A

Benign, bilateral ovarian masses such as luteomas and theca lutein cysts

-these patients are observed and managed expectantly, as the symptoms and masses spontaneously regress after delivery

161
Q

What medication is used in PCOS patients to induct ovulation?

A

Letrozole

162
Q

How does copper containing IUD affect menstrual cycles?

A

tends to worsen menstrual bleeding, anemia, and dysmenorrhea

163
Q

In the immediate postpartum period, physiologic changes include uterine contraction, lochia, breast milk excretion and milk letdown, and chills and shivering causing hyperthermia or low-grade fever.

  • what causes this?
A

These changes are hormone-mediated (eg, increased oxytocin/prolactin levels, decreased estrogen/progesterone levels).

Patients with these normal findings are managed with routine postpartum care.

164
Q

acute fatty liver of pregnancy
1. when does this happen?
2. what are the symptoms
3. lab findings?
4. management?

A
  1. third trimester
  2. N/V, RUQ/epigastric pain, fulminent liver failure. This is an intrahepatic process due to microvesicular fatty infiltration of hepatocytes secondary to abnormal maternal fetal fatty acid metabolism.
  3. Profound hypoglycemia
    - increased aminotransferases (2-3x normal)
    - increased bilirubin
    - thrombocytopenia
    - DIC
  4. immediate delivery
165
Q

When getting a diagnostic dilation and curettage to distinguish between a nonviable intrauterine pregnancy and an ectopic pregnancy what finding can help differentiate?

A
  1. ectopic pregnancy: intrauterine contents have no chorionic villi on examination

An abnormal intrauterine pregnancy (including a recent complete spontaneous abortion) will have chorionic villi, a finding consistent with intrauterine placental development

In contrast, the intrauterine contents associated with an ectopic pregnancy will have no chorionic villi due to extrauterine pregnancy implantation.

166
Q

Risk factors of vulvovaginal candidiasis?

A
  1. diabetes mellitus
  2. immunosuppresion
  3. antibiotic use

–recurrent candidiasis warrants evaluation for diabetes mellitus

167
Q

Why is GnRH agonist therapy to treat heavy, regular menses not recommended for long term use?

A

adverse effects
- decreased bone density so it is avoided in patients with high risk such as adolescents, patients in wheelchair, etc

168
Q

What is the antibiotic therapy for staphylococcal toxic shock syndrome? (3)

A

vancomycin
cefepime
clindamycin

169
Q
  • Fever >102 F
  • Hypotension
  • Diffuse macular rash involving palms and soles
  • desquamation 1-3 weeks after disease onset
  • vomiting, diarrhea
  • altered mentation without FND
  1. What is this?
  2. How is it treated?
A
  1. staphylococcal toxic shock syndrome
  2. supportive therapy, removal of foreign object, antibiotic therapy
170
Q

Preterm labor management algorithm
1. If mom has maternal instability, intrauterine infection, fetal distress/demise –> this leads to immediate delivery

  1. If mom does not have the above and is
    A) <32 weeks (very preterm) what needs to be done? (4)
A
  1. Antenatal corticosteroids
  2. Penicillin if GBS+ or unknown
  3. Tocolysis: indomethacin
  4. Magnesium sulfate - protection against cerebral palsy
171
Q

Preterm labor management algorithm
1. If mom has maternal instability, intrauterine infection, fetal distress/demise –> this leads to immediate delivery

  1. If mom does not have the above and is
    B) 32-34 weeks (moderate preterm) what needs to be done? (3)
A
  1. antenatal corticosteroids
  2. Penicillin if GBS+ or unknown
  3. Tocolysis: nifedipine
172
Q

Preterm labor management algorithm
1. If mom has maternal instability, intrauterine infection, fetal distress/demise –> this leads to immediate delivery

  1. If mom does not have the above and is
    C) 34-37 weeks (late preterm) what needs to be done? (2)
A
  1. +/- Antenatal corticosteroids
  2. Penicillin if GBS + or unknown
  • preterm labor at >= 34 weeks gestation who have no contraindications to vaginal delivery receive expectant labor management
173
Q

Does positive leukocyte esterase with negative ntirite result indicate UTI?

A

Yes, typically e coli causes positive nitrite result but less common pathogens (e.g. staph saprophyticus) and some home remedies can cause a negative nitrite result

174
Q

Differentiate between the types of abortions
1. vaginal bleeding, closed cervical os, products of conception completely expelled

  1. vaginal bleeding, closed cervical os, fetal cardiac activity
  2. vaginal bleeding, dilated cervical os, production of conception may be seen or felt at or above cervical os
  3. no vaginal bleeding, closed cervical os, no fetal cardiac activity or empty sac
  4. vaginal bleeding, dilated cervical os, some products of conception expelled and some remain
A
  1. complete abortion
  2. threatened abortion
  3. inevitable abortion
  4. missed abortion
  5. incomplete abortion
175
Q

what are some scenarios that put a woman in high risk for preeclampsia? (6)

A
  1. prior preeclampsia
  2. Chronic kidney disease
  3. Chronic hypertension
  4. Diabetes Mellitus
  5. Multiple Gestation
  6. Autoimmune disease
176
Q

What is the treatment of nonpurulent cellulitis?

A

First generation cephalosporins (cephalexin) because they cover common skin pathogens

177
Q
  1. What are absolute contraindications to exercise during pregnancy? (7)
A
  1. amniotic fluid leak
  2. cervical insufficiency
  3. multiple gestation
  4. placental abruption or previa
  5. premature labor
  6. preeclampsia/gestational hypertension
  7. severe heart or lung disease
178
Q

What is a common breast mass that are estrogen sensitive and their size and tenderness can change with menses?

A

Fibroadenomas - typically unilateral, firm, well circumscribed, mobile masses in the upper outer quadrant

179
Q

Patients with GDM who have suboptimal glycemic control or need pharmacotherapy may be at increased risk for stillbrith

–what should be done to monitor baby throughout 3rd trimester?

A

–Nonstress testing (NST) at regular intervals beginning in third trimester to assess for fetal hypoxemia. (A reactive NST >= 2 accelerations has a high negative predictive value for fetal hypoxemia and stillbirth occuring within 1 week. A nonreactive NST requires further evaluation like a biophysical profile)

180
Q

What is the pathophysiology of maternal insulin resistance and hyperglycemia leading to stillbirth?

A
  1. maternal hyperglycemia can cause placental vasculopathy and decreased placental perfusion
  2. Also, maternal hyperglycemia induces fetal hyperglycemia, hyperinsulinemia, organomegaly, and macrosomia all of which contribute to increased fetal oxygen demand in third trimester. If fetal oxygen demand cannot be met, fetal hypoxemia, acidosis, and stillbirth can occur
181
Q

Clinical features
1. woman age 50-60
2. vulvar pain or pruritus
3. dyspareunia (pain during sex)
4. Erosive variant shows erosive, glazed lesions with white border, vaginal involvement +/- stenosis, associated oral ulcers
5. papulosquamous variant: small pruritic papules with purple hue

  1. what is this?
  2. How is it diagnosed
  3. treatment?
A
  1. vulvar lichen planus
  2. vulvar biopsy
  3. High potency topical corticosteroids
182
Q

What are complications of PPROM (membrane rupture at <37 weeks prior to labor onset) (4)

A
  1. Preterm labor
  2. intraamniotic infection
  3. placental abruption
  4. umbilical cord prolapse
183
Q

Delaying delivery to 42 weeks gestation can increase risk of what in the neonate? (4)

A
  1. macrosomia
  2. Dysmaturity syndrome (a fetus whose weight gain in the uterus stops after the due date, usually due to a problem with adequate delivery of blood to the fetus through the placenta, leading to malnourishment)
  3. Oligohydramnios ( late/post term pregnancies are at risk of decreased placental function that cause increased placental vascular resistance and uteroplacental insufficiency. This leads to CNS suppression and intrauterine fetal demise. To prevent this, blood is preferentially distributed to the brain rather than peripheral tissue, this redistribution can be evidenced on U/S as oligohydramnios (single deepest pocket <2 cm or amniotic fluid index <5 cm) since amniotic fluid is dependent on renal perfusion and urine production.)
  4. Demise
184
Q

Uterine sarcoma can be suspected in postmenopausal patients that have had what type of treatment?

A

sx: uterine mass that causes bulk symptoms (pelvic pressure, constipation) and abnormal or postmenopausal bleeding

–tamoxifen
–pelvic radiation

185
Q

When trying to treat preeclampsia with severe features…and the patient has myasthenia gravis what medication can be given instead of the contraindicated magnesium sulfate?

A
  1. valproic acid for seizure prophylaxis
    –Mg sulfate is contraindicated because it may trigger myasthenic crisis
186
Q

What is the indication for external cephalic version and at what point in the pregnancy can this happen?

A
  1. For breech/transverse presentation
  2. > = 37 weeks gestation

–contraindications include
-prior classical c section delivery
-prior extensive uterine myomectomy
-placenta previa

187
Q

What is high spinal anesthesia?

A

A life threatening complication of epidural anesthesia. This accidental injection of local anesthetic into the subarachnoid space that causes motor, sensory, and sympathetic blockage.
Pts are at risk for respiratory paralysis (e.g. dyspnea, hypoxemia)

188
Q

What is ovarian hyperstimulation syndrome?
—How is it evaluated
—what is management?

A
  1. increased hCG enhances ovarian vascular permeability and leads to acute fluid shift to extravascular space. Can be complication of ovulation induction.
    –Will see ascites, respiratory distress, hemoconcentration, hypercoagulability, electrolyte imbalances, multiorgan failure, DIC
  2. Fluid balance monitoring, serial CBC and electrolytes, serum hCG, pelvic ultrasound, chest x-ray, echo
  3. correct electrolyte imbalances, paracentesis and/or thoracentesis, thromboembolism prophylaxis
189
Q

How to differentiate between primary ovarian insufficiency vs intrauterine adhesions if they both show no withdrawal bleeding after progesterone withdrawal test is performed?

A

Primary ovarian insufficiency
- FSH is elevated
Intrauterine adhesions
- FSH is normal

190
Q

What is management of ruptured vasa previa?

A

Emergency c section because of high risk of fetal exsanguination and demise

191
Q

-dyspareunia
- dysmenorrhea
- chronic pelvic pain
- infertility
- dyschezia
- cyclic dysuria, hematuria

Physical exam:
- immobile uterus
- cervical motion tenderness
- adnexal mass

  • what is this?
A

endometriosis
- dx by direct visualization and surgical biopsy

192
Q

How can markedly elevated hCG affect thyroid hormone levels?

A

hCG and TSH have similar structures so elevations in hCG can mimic TSH and cause an increase in T3 and T4 concentrations. Therefore this can lead to over hyperthyroidism but sx resolve after hCG levels decrease

193
Q

Why are recurrent UTIs more common in postmenopausal women?

A
  • This is due to estrogen deficiency which causes
    1. vulvovaginal atrophy (thin vulva tissue)
    2. decreased bulk and elasticity of the bladder trigone and urethra resulting in increased risk of ascending infection
    3. Decreased vaginal lactobacilli and an elevated vaginal pH, leading to increased rate of vaginal E. coli colonization
194
Q

What is significant proteinuria considered on labs?
1. (BLANK) mg/24 hr
2. (Blank) + protein

A
  1. > 300 mg/24 hour
  2. 2+ and more
195
Q

Development of significant proteinuria prior to 20 weeks gestation suggests what?

A

This suggests underlying kidney disease that was likely present before conception.

196
Q

Gestational thrombocytopenia - benign condition that causes an isolated, mild thrombocytopenia (platelets 100-150k)
– likely due to increase in plasma volume
–commonly diagnosed in (BLANK) trimester
–management?

A
  1. 3rd trimester, but can show up as early as first trimester
  2. reassurance and observation
197
Q

Vaginal SQUAMOUS CELL CARCINOMA
1. location in GU system
2. risk factors

A
  1. large, symptomatic lesions, vaginal bleeding, malodorous vaginal discharge
    —irregular plaque or ulcer in the upper third of the posterior vagina
  2. persistent HPV infection, chronic tobacco use
198
Q

1.What are risk factors for vaginal clear cell adenocarcinoma?

A
  1. DES exposure in utero
199
Q

Why does preeclampsia with severe features increase risk of acute stroke?

A
  1. Preeclampsia is most likely caused by abnormal placentation and narrowed spiral artery formation
  2. resulting hypoperfusion, hypoxia, and ischemia of placenta trigger release of antiangiogenic factors causing maternal endothelial cell damage. This damage can manifest in liver (referred epigastric pain from stretching the hepatic capsule), kidneys (proteinuria from acute kidney injury), acute stroke in brain
    —activation of coag system, platelet aggregation, and vascular microthrombi formation leading to cerebral stroke
    —dysregulated cerebral blood flow causes inappropriate cerebral vasospasm, severely elevated perfusion pressure, and hemorrhagic stroke
200
Q

What effects on fetus heart can moms with systemic lupus erythematosus

A
  1. Neonatal lupus can occur due to passive placental transfer of maternal anti-SSA (Ro) and anti-SSB (La) antibodies
    –neonates may develop fetal AV block (irreversible injury) which appears on fetal heart rate tracing as persistent bradycardia
201
Q

What testing should be done for moms who had gestational diabetes during pregnancy?

A
  1. These moms have increased risk of type 2 diabetes mellitus
  2. They require postpartum diabetes mellitus screening with a 2 hour 75 g glucose tolerance test
202
Q

Oxytocin has a similar structure to antidiuretic hormone so prolonged or excessive oxytocin administration can cause (BLANK)

A
  • Hyponatremia
  • Also cerebral edema and generalized tonic clonic seizures
203
Q

how can radioactive iodine uptake scan differentiate between hyperthyroidism disorders: graves disease and autoimmune thyroiditis?

A
  1. Graves disease - has increased uptake of radioactive iodine. Thyroid is stimulated by autoantibodies to increase tissue metabolic activity, causing increased thyroid hormone synthesis.
  2. Painless autoimmune thyroiditis - thyroid tissue is destroyed leading to increased release of preformed thyroid hormone and hyperthyroidism but since thyroid cells are destroyed then there is LOW radioactive iodine uptake
204
Q

Nausea and vomiting of pregnancy - patients typically can tolerate some foods and fluids. Have no signs of hypovolemia or dehydration and no lab abnormalities.

  • first line tx:
  • if symptoms do not improve:
A
  • Dietary modifications: small frequent meals, bland foods, avoid food triggers
  • Oral vitamin B6, doxylamine succinate (oral H1 antihistamine)

Other tx:
- oral dopamine and 5HT antagonists
- IV fluids and IV antiemetics
- corticosteroids
- TPN or tube feedings

205
Q

What are some treatments for uterine atony after bimanual uterine massage + high dose oxytocin has been done?

(3)

A
  1. Tranexamic acid - prevents blood clot breakdown and significantly decreases blood loss if admin. within 3 hours of delivery. USED WITH CAUTION IN PATIENTS WITH HYPERCOAGULABILITY d/t risk of thromboembolism
  2. Carboprost tromethamine - stimulates contractions to increase uterine tone and decrease bleeding. Synthetic prostaglandin F2alpha analog that can cause brocnhospasm so CONTRAINDICATED IN PATIENTS WITH ASTHMA
  3. Methylergonovine - second line uterotonic agent that stimulates contractions. Potent vasoconstrictor so CONTRAINDICATED WITH HYPERTENSIVE DISORDERS d/t to increase risk of stroke
206
Q
  1. When does screening for NTD happen?
  2. what is measured?
  3. what is required after abnormals levels are found?
A
  1. 15-20 weeks gestation
  2. MSAFP - maternal serum alpha fetoprotein
  3. fetal ultrasound
    –its possible that multiple gestation or incorrect gestational age dating can cause elevated level (benign causes) but U/S can also find CNS abnormalities
207
Q

Ectopic pregnancy can be diagnosed by a persistent rise in beta hCG level following diagnostic dilation and curettage

  • medical therapy is (BLANK)
A
  1. methotrexate - folate antagonist that inhibits DNA synthesis in rapidly dividing cells (e.g. trophoblasts)
208
Q

Over 99% of viable intrauterine pregnancies have (BLANK) % rise in beta hCG levels over 48 hours

  • less than this indicates ectopic or abnormal/nonviable intrauterine pregnancy
A

> = 35%

2.5%

209
Q
  1. Secondary (late) postpartum hemorrhage (PPH) is (BLANK) hours after delivery
  2. What are risk factors for this?
  3. common causes for this?
A
  1. > 24 hours after delivery
  2. prolonged labor, fetal macrosomia, and intraamniotic infection
  3. retained products of conception, postpartum endometritis, and inadequate placental site involution
210
Q

Differences in physical exam for
- retained placenta
- retained products of conception

A
  1. immediate PPH with uterine atony (e.g. boggy, enlarged uterus)
  2. late PPH with either a boggy or firm uterus
211
Q

Treatment of
1. retained products of conception
2. placental site subinvolution
3. postpartum endometritis

A
  1. dilation and curettage
  2. uterotonics (oxytocin, methylergonovine, carboprost)
  3. broad spectrum IV antibiotics
212
Q

What is lochia

A
  1. vaginal discharge after giving birth containing blood, mucus, and uterine tissue
213
Q

Normal postpartum lochia
1. lochia rubra - duration is from birth to 3-4 days postpartum
2. lochia serosa - duration is from 4th postpartum day to 10-14th postpartum day
3. lochia alba - duration is from 11th pospartum day to 6 weeks postpartum

what is the description of each

A
  1. dark or bright red blood, odor similar to that of menstrual blood, occasional small clots, qty decreases each day
  2. serosanguineous (pink), brownish (old blood), qty gradually decreasing in amount
  3. white/yellow; creamy; light quantity
214
Q

Changes in MSAFP, beta-hCG, estriol, inhibin A

  1. Trisomy 18
A
  1. decreased MSAFP
  2. decreased beta-hCG
  3. decreased estriol
  4. normal inhibin A
215
Q

Changes in MSAFP, beta-hCG, estriol, inhibin A

  1. Trisomy 21
A
  1. decreased MSAFP
  2. increased beta-hCG
  3. decreased estriol
  4. increased inhibin A
216
Q

Can IUD be used in women with disorted uterine anatomy?

A

No because of the risk of malposition of the IUD, perforation, and expulsion

217
Q

What negative outcomes can result from pregnant women with ulcerative colitis?

A
  1. preterm delivery
  2. small for gestational age
    -most medications used to control UC are considered safe for continuation throughout pregnancy

sx of UC: hematochezia, abdominal pain, tenesmus (fecal urgency followed by straining and inability to defecate)

218
Q

duodenal atresia in fetus is commonly associated with what two disorders?

A
  1. trisomy 21
  2. VACTERL (vertebral, anal atresia, cardiac, tracheoesophageal fistula, esophageal atresia, renal, limb)
219
Q
  1. What antibiotic is given to pregnant patients with acute pyelonephritis?
  2. Those with symptomatic improvement can be transitioned to what oral antibiotics (2) - chosen based on fetal safety profile and urine culture sensitivity testing
A
  1. ceftriaxone
  2. cephalosporins (cephalexin) and penicillins
220
Q

Nitrofurantoin and TMP-SMX are commonly used to treat what infection?

A

acute cystitis (bladder) during pregnancy

  • Nitrofurantoin achieves poor concentration in the kidneys so this is not used for complete treatment of pyelonephritis
  • TMP-SMX is avoided in 3rd trimester bc of the risk for neonatal kernicterus
221
Q

Preeclampsia can present up to 6 weeks postpartum with headache and hypertension

–Those with FND should get what?

A

CT scan of the head since there is increased risk of stroke

222
Q

Differentiate between decreased ovarian reserve vs primary ovarian insufficiency

A
  1. Decreased ovarian reserve: these women have regular menstrual cycles but are infertile due to diminished ovarian reserve.
  2. Primary ovarian insufficiency: menopause before age 40. These patients have amenorrhea, hot flashes, and vaginal atrophy.
223
Q

Differentiate between how these present
1. breast engorgement
2. lactational mastitis
3. Plugged duct
4. Galactocele

A
  1. bilateral, symmetric fullness, tenderness, warmth
  2. tenderness/erythema + fever
  3. focal tenderness, palpable mass, firmness and/or erythema but no fever
  4. subareolar, mobile, well circumscribed nontender mass + no fever
224
Q

How differently do first vs 2nd/3rd trimester fetal growth restriction present?

  • what are the different causes?
A
  1. First trimester results in SYMMETRIC FGR d/t congenital disorders or first trimester infections
  2. 2nd/3rd trimester results in ASYMMETRIC FGR d/t placental insufficiency (such as HTN)
225
Q

Type II osteogenesis imperfect
1. defect in what type of collage
2. U/S findings

A
  1. Type 1 collagen
  2. multiple fractures, short femur, hypoplastic thoracic cavity, FGR, intrauterine demise
226
Q

Polyuria and dilute urine in the setting of normal serum sodium and fluid intake (2L) suggest what disease?

A
  1. diabetes insipidus
    low specific gravity (<1.006)
    –
227
Q

vacuum assisted vaginal delivery is the management option for patients with
- (BLANK) FHR tracings
- (BLANK) dilation

A
  • category III
  • complete (10 cm) dilation
228
Q

For patients with no prior preterm delivery a transvaginal U/S length measurement is recommended at (Blank-Blank) weeks gestation to assess the risk of preterm delivery

  1. what is done if incidental short cervix is found?
A
  1. 16-24 weeks
  • pts with normal length are at lower risk for preterm delivery and require no additional intervention
    -those with short cervix (<=2.5 cm on U/S) are at high risk for preterm delivery and are offered vaginal progesterone to prevent uterine contractions and preterm labor
229
Q

Cancer antigen 125 (CA-125) is released by cells from what structures? (2)

A
  1. peritoneum
  2. mullerian structures (uterus, fallopian tubes)

–conditions that irritate or stimulate these cells (endomteriosis, malignancy) cause elevations in these levels so CA-125 is no used in premenopausal women bc it is often falsely elevated

230
Q

lesion that is a papule at first then develops into nonexudative ulcer in center with indurated borders

-what is this likely?

A

primary syphilis
- mild to moderate, painless, bilateral lymphadenopathy is often present too

231
Q
  • mild symptoms like increased vaginal discharge
  • light vaginal bleeding
  • pelvic pressure
  • visible cervical dilation and no uterine contractions

what is this likely?

A

This is likely cervical insufficiency
- managed with cerclage placement (not in patients who have bulging or prolapsing amniotic membranes)

–vaginal discharge is from loss of mucus plug
–light bleeding is from cervical stretching

232
Q

What blood disorder can cause hydrops fetalis?

A

alpha thalassemia major (hemoglobin barts disease) - has an extreme affinity for oxygen. This results in severe fetal hypoxemia, development of high-output cardiac failure, and subsequent hydrops fetalis and intrauterine fetal demise.

233
Q

What corticosteroid is used for patients at risk for preterm delivery at < 34 weeks gestation

A

Intramuscular betamethasone, a corticosteroid, is indicated for patients at risk for preterm delivery at <34 weeks gestation.

Betamethasone stimulates fetal lung maturity and decreases the risk of neonatal respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, and overall morbidity and mortality associated with prematurity.

234
Q

Due to risk of fetal complications, patients with late/post term pregnancies undergo fetal monitoring with (Blank A) and (Blank B) to evaluate for uteroplacental insufficiency

—> management is what two things?

A
  1. nonstress test and amniotic fluid volume
  2. frequent fetal monitoring (e.g. nonstress test) and delivery prior to 43 weeks gestation
235
Q

pregnant patients with acute cervicitis require empiric treatment with (blank) and (blank)

A

ceftriaxone and azithromycin

nonpregnant patients are typically treated with ceftriaxone and doxycycline but doxy is a potential teratogen so that is why it is changed to azithromycin

236
Q

urinary incontinence- what are etiologies of each
1. stres
2. urge
3. overflow

A
  1. decreased urethral sphincter tone, urethral hypermobility
  2. detrusor overactivity
  3. impaired detrusor contractility, bladder outlet obstruction (such as with enlarged uterus due to fibroids)
237
Q
  1. what causes theca lutein cysts?
  2. presentation/symptoms
A
  1. ovarian hyperstimulation (d/t gestational trophoblastic disease, multifetal gestation, infertility treatmetn) — in hydatidiform mole you have elevated beta-hCG levels that cause hyperstimulation of ovaries and hypertrophy and luteinization of the theca cells. Ovary forms theca lutein cysts that can then secrete androgens —> leading to acute hyperandrogenism
  2. multilocular, bilateral cysts on ovaries that are 10-15 cm + hyperandrogenism sx like acne and hirsutism
238
Q

When face presentation occurs - which position is able to continue with vaginal delivery and which needs c-section

A
  1. mentum anterior can do vaginal delivery. Occiput fills the spacious sacral hollow so contractions can induce neck flexion or further extension to facilitate delivery
  2. mentum posterior requires c section - neck is already maximally extended. Neck flexion cannot happen because chin is hitting sacrum.
239
Q

What are the 7 cardinal movements of labor

A
  1. engagement (floating head)
  2. Descent
  3. neck flexion
  4. Internal rotation
  5. Neck extension on way out of cervix
  6. Restitution (repositioning of fetal head to align with rest of the body)
  7. Expulsion (first right then left shoulder)
240
Q

second stage arrest of labor is defined as

  1. lack of fetal descent after (A) hours of pushing in a primigravida with an epidural and then without epidural (B)
  2. or (C) in multigravida with an epidural and then without epidural (D)
A
  1. lack of fetal descent after >= 4 hours of pushing in a primigravida with an epidural (>=3 hrs w/out)
  2. or >= 3 hours in multigravida with an epidural (>=2 hrs w/out)
241
Q

How is second stage arrest of labor managed?

A

managed with operative vaginal delivery like vacuum assist

  • other indications for operative vaginal delivery include maternal exhaustion, fetal distress, and maternal conditions in which the valsalva maneuver is not recommended

–> this is during delivery of the baby

242
Q

Management of CIN 3 (high grade cervical dysplasia)
1. After excisional procedure of CIN 3 with clear margins…what is the next steps in management (2 parts)

A
  1. HPV based testing at 6 months post op
  2. annual HPV based testing for 3 years
243
Q

What is normal prolactin levels?

A

<20 ng/mL

244
Q

What are frank virilization signs that can come with sertoli leydig cell tumor (androgen secreting tumor)

A
  1. voice deepening
  2. male pattern baldness
  3. increased muscle bulk
  4. clitoromegaly
245
Q

1.What is meralgia paresthetica
2. sx
3. associated with?

A
  • compression of the lateral femoral cutaneous nerve
    -pain and paresthesia over the upper outer thigh
    -associated with pregnancy, tight clothing, obesity
246
Q

What symptoms come with stretching of the round ligament

A
  • this is caused by enlarging gravid uterus that causes irritation of local nerve fibers
  • pain in lower abdomen and ipsilateral labia, no sensory changes
247
Q
  1. nonclassic (late onset) congenital adrenal hyperplasia (CAH) has an elevated (BLANK) level
    –due to deficiency in what (BLANK)
A
  1. elevated 17-hydroxyprogesterone (17-OHP)
  2. 21-hydroxylase which is the enzyme necessary for conversion of 17-OHP to 11-deoxycortisol.
    –buildup of 17-hydroxyprogesterone is then diverted toward adrenal androgen synthesis resulting in hyperandrogenism
  • enzyme deficiency in nonclassic CAH is relatively mild, sufficient glucocorticoids and mineralcorticoids are produced; therefore patients don’t have salt wasting seen in classic CAH
248
Q

what is idiopathic hirsutism?

A

Excessive conversion of testosterone to dihydrotestosterone in the hair follicles.

Usually a positive family history and normal 17-OHP and androgen levels.

249
Q
  1. What is pubic symphysis diastasis
  2. symptoms of symptomatic pubic symphysis diastasis
A
  1. during pregnancy increased levels of progesterone and relaxin increase pelvic mobility and promote physiologic widening (diastasis) of the pubic symphysis to facilitate vaginal delivery

–> traumatic delivery (like fetal macrosomia, forceps assisted vaginal delivery, and multiparity) patients can develop symptomatic pubic symphysis diastasis which includes

  1. (suprapubic pain that radiates to back, hips, thighs, or legs and is exacerbated by walking, weight bearing, or position changes)
250
Q

First line treatment for uterine atony includes bimanual uterine massage and high dose oxytocin

–if atony persists then the best next step is

A
  1. tranexamic acid - antifibrinolytic agent that prevents the breakdown of blood clots to achieve hemostasis, and its use reduces maternal mortality rates from hemorrhage
251
Q
  1. What is pelvic thrombophlebitis
  2. How is it treated?
A
  1. postoperative or postpartum infected thrombosis of the deep pelvic or ovarian veins. Pts have persistent fever unresponsive to antibiotics
  2. anticoagulation and broad spectrum antibiotics
252
Q

mullerian agenesis is the absence of (3 things)

A
  1. uterus
  2. cervix
  3. upper one third of the vagina
253
Q

klinefelter syndrome
1. sex chromosome
2. symptoms

A
  1. 47, XXY
  2. can have breast development, tall stature, and minimal body hair. Have a penis and small, descended testes (hypogonadism)
254
Q

XYY karyotype
1. symptoms

A
  1. appear phenotypically male
  2. develop nodulocystic acne at puberty.
  3. They require neurodevelopmental evaluation due to the increased incidence of learning disabilities, behavioral problems, and developmental delay
255
Q

Most common sites of metastasis for breast cancer are… (4)

A
  1. bone
  2. liver
  3. lungs
  4. brain
256
Q

Evaluation of hyperthyroidism in pregnancy should initially focus on measuring concentrations of…

A

Free thyroxine (T4)

257
Q

–fever, migratory polyarthralgia, tenosynovitis, and pustular lesions over the distal extremities

what is this likely?

A

Disseminated gonorrhea due to N. gonorrhoeae

258
Q

When CONE biopsy shows microinvasive squamous cell carcinoma in cervix …what is next step in management?

A
  1. hysterectomy to ensure complete removal of the cancer
259
Q

when does nausea and vomiting happen in pregnancy?

A

6-9 weeks

260
Q

what vitamin is teratogenic?

A

Excessive vitamin A administration during pregnancy is teratogenic, leading to microcephaly, cardiac defects, and spontaneous abortion

261
Q

corpus luteum cysts
1. symptoms
2. Pelvic U/S
3. managed

A
  1. unilateral pelvic or abdominal pain that is sudden in onset and severe, most commonly after sexual intercourse or other physical activity
  2. complex cystic mass or free fluid in the pelvis is ruptured
  3. observation and supportive therapy

–common in pregnancy as the corpus luteum must enlarge to support a growing pregnancy

262
Q
  1. what artery if ruptured will lead to vulvar hematoma
  2. what artery if ruptured will lead to vaginal hematoma
A
  1. pudendal
  2. vaginal
263
Q

Ages 21-24 - LSIL on pap test

  • next step
A

Do another pap test in one year

264
Q

Genital herpes should be confirmed by what tests (include which is more sensitive)

A
  1. NAAT
  2. PCR
  3. Culture

*NAAT or PCR is 4 times more sensitive than culture

265
Q

ASCUS pap in patients 21-24
- next step?

– Persistent (2 years or more) ASCUS pap test in 21-24 year olds indicate what next step?

A

HPV reflex testing is recommended
- next step is expectant management and repeat cytology in 12 months

–then colposcopy

266
Q

colonscopy screening starts at..

A
  1. 50 years old, every 10 years (up to 75 years)
267
Q

Who is at an increased risk of cystic fibrosis

A

Non-hispanic white individuals, including Ashkenazi Jews, are at increased risk for being carriers for cystic fibrosis

268
Q

valproic acid is associated with what defects in fetus

A

Valproic acid = associated with increased risk for neural tube defects, hydrocephalus, and craniofacial malformations

269
Q

Intrapartum treatment vs infant prophylaxis
1. >1000 copies/mL or unknown HIV in mom
2. 50-1000 copies/mL
3. <= 50 copies/mL

A

Intrapartum treatment vs infant prophylaxis
1. IV zidovudine 3 hours before c-section
—ART for 6 weeks

  1. IV zidovudine based on individual decision
    —ART for 6 weeks
  2. IV zidovudine is not recommended
    —zidovudine for 4 weeks
270
Q

most common cause of endometritis? - bacteria

A
  1. staph aureus and streptococcus
    –mix of aerobes and anaerobes in the genital tract
271
Q

what level of progesterone (ng/mL) suggests healthy pregnancy?

A
  • greater than 20 ng/mL
    –<5 means abnormal or extrauterine pregnancy
272
Q

cervical cerclage is placed at (Blank) weeks

A
  • 14 weeks
    –most delay until preliminary fetal anatomic survey and aneuploidy testing are complete
273
Q

what is given to treat intrahepatic cholestasis of pregnancy?

A
  • ursodeoxycholic acid
274
Q

Kleihauer-Betke test purpose

A

Kleihauer-Betke (acid elution) test is used to quantify the amount of fetal blood to which mom’s circulation has been exposed to in order to determine Rh immune globulin dosing that would be adequate for mom
Frequently used when Rh negative mother gives birth to an Rh-positive child

275
Q

Average length of twin gestation is

A

35 wks

276
Q

Fetal division by day 3 = (blank) twins
By day 4-8 = (blank) twins
By day 9 = (blank) twins

A

Fetal division by day 3 = dichorionic diamniotic twins
By day 4-8 = monochorionic-diamniotic twins
By day 9 = monochorionic-monoamniotic twins

277
Q

Prolonged latent phase is >(blank) hours for nulliparas and >(blank) hours for multiparas

A

Prolonged latent phase is >20 hours for nulliparas and >14 hours for multiparas

278
Q

McRoberts maneuver

A

Retraction of the fetal head is a classic presentation of shoulder dystocia → McRoberts maneuver involves hyperflexing the mother’s legs to her abdomen and putting suprapubic pressure

279
Q

When someone has hx of prior spontaneous preterm birth they should be offered progesterone supplementation starting at (blank) weeks of gestation

A

16-24 weeks

280
Q

Antibiotic therapy with (2 blanks) is given to pts with PPROM to prolong the latency period by 5-7 days, reduce the incidence of maternal chorioamnionitis and neonatal sepsis

A

Antibiotic therapy with AMPICILLIN + ERYTHROMYCIN is given to pts with PPROM to prolong the latency period by 5-7 days, reduce the incidence of maternal chorioamnionitis and neonatal sepsis

281
Q

Rotterdam criteria for PCOS

A

Rotterdam criteria for PCOS
Chronic anovulation
Hyperandrogenism (clinical/biologic)
PCOS on ultrasound
—> still needs a testosterone level to rule out an androgen secreting tumor (acanthosis nigricans is associated with elevated androgen level and hyperinsulinemia)

282
Q

Succenturiate placental lobes

A

Lobes of the placenta that develop separately from the main placenta
Associated with hemorrhage when discovered antepartum. If undiagnosed until delivery, the mother may require oxytocin and manual extraction

283
Q

Antibiotic used for mastitis is

A

Antibiotic used for mastitis is dicloxacillin

284
Q

Pregnant women have increased risk for pyelonephritis bc

A

stagnation of urine from progesterone induced decreased ureteral tone and mechanical compression of the ureters at the pelvic brim, bladder, and ureteral orifices by gravid uterus

285
Q

Tx of condyloma acuminata

A

Tx of condyloma acuminata (assoc. with HPV) → topical formulations of podophyllotoxin, trichloroacetic acid, fluorouracil, or liquid nitrogen
Interferon therapy is tx used for severe condyloma acuminata. Usually saved for refractory disease

286
Q

what is the best way to identify clue cells in BV

A

Wet mount prep is most appropriate for BV (gardnerella vaginalis)

287
Q

High risk HPV strains are

A

High risk HPV strains are 16, 18, 31, and 33

M3 - Clerkships (8 decks)

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