OBGYN Clerkship

Question 1

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)

Answer 1

1. 20
2. placental evaluation
3. fetal autopsy

Question 2

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

Answer 2

1. dilation and evacuation OR vaginal delivery
2. vaginal delivery

Question 3

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)

Answer 3

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

Question 4

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

(GnRH, LH, FSH, etc)

Answer 4

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)

Question 5

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

Answer 5

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

Question 6

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

Answer 6

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

Question 7

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

Answer 7

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.

Question 8

-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?

Answer 8

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

Question 9

—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?

Answer 9

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

Question 10

1. What causes primary dysmenorrhea (physiologic painful menses)?
2. What is treatment?

Answer 10

1. excessive prostaglandin production
2. NSAID drugs (stops prostaglandin production) and combo OCP

Question 11

Why can epidural anesthesia cause hypotension?

Answer 11

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

Question 12

What are risk factors for endometrial adenocarcinoma?

Answer 12

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

Question 13

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

Answer 13

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

Question 14

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

Answer 14

oligohydramnios - primary cause is decreased fetal urine output

Question 15

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

Answer 15

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.

Question 16

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).

Answer 16

1. pudendal
2. bladder atony

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

Question 17

How is postpartum urinary retention managed?

Answer 17

1. self limited condition
2. intermittent catheterization

Question 18

1. Patients with fetal growth restriction/FGF have a high risk for intrauterine fetal demise and require what for assessment?

Answer 18

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.

Question 19

• severe, constant, unilateral pelvic pain may indicate ovarian torsion
  1. How is this dx
  2. How is this managed?

Answer 19

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

Question 20

• 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?

Answer 20

1. endometrial polyp
2. Treat by hysteroscopic polypectomy

Question 21

• Heavy, painful menses
• women age >40 years old
• Regular menses with no intermenstrual bleeding
• Boggy, uniformly enlarged uterus

1. What is this likely?

Answer 21

1. adenomyosis

Question 22

• Regular but heavy, prolonged menses
• Irregularly enlarged, bulky uterus

1. What does this sound like?

Answer 22

1. Uterine leiomyomas (fibroids)

Question 23

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

Answer 23

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

Question 24

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

Answer 24

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

Question 25

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

Answer 25

1. New-onset elevated blood pressure at ≥20 weeks gestation AND Proteinuria OR signs of end-organ damage

Question 26

Hypertensive disorders of pregnancy 1. Eclampsia - parameters

Answer 26

1. Preeclampsia   AND New-onset tonic-clonic seizures

Question 27

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?

Answer 27

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

Question 28

What is the screening for gestational diabetes mellitus?

Answer 28

1 hour glucose challenge test (GCT)

Question 29

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

Answer 29

1. <= 4 mm 2. > 4 mm Endometrial biopsy may show atypia, neoplasia which would require further management

Question 30

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

Answer 30

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

Question 31

1. When are moms screened for GBS in their pregnancy? 2. Indications for intrapartum prophylaxis?

Answer 31

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

Question 32

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?

Answer 32

1. Granulosa cell tumor (tumors that come out of egg in ovary) 2. endometrial biopsy (endometrial cancer) and surgery (for tumor staging)

Question 33

1. What are sex cords? 2. What do granulosa cells make? 3. What do theca cells make?

Answer 33

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

Question 34

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?

Answer 34

1. epithelial tumors 2. germ cell tumors 3. sex cord stromal tumors

Question 35

1. Encephalopathy 2. oculomotor dysfunction 3. postural and gait ataxia 1. what is this? 2. pathophysiology?

Answer 35

1. wernicke encephalopathy 2. thiamine deficiency -- can be caused by chronic alcohol use (most common), malnutrition, hyperemesis gravidarum

Question 36

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

Answer 36

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***

Question 37

1. What is placenta previa? 2. What is vasa previa 3. What is placenta accreta? 4. What is abruptio placentae?

Answer 37

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

Question 38

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

Answer 38

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

Question 39

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

Answer 39

1. Cefazolin

Question 40

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

Answer 40

1. >= 3 months 2. >= 6 months

Question 41

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

Answer 41

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

Question 42

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

Answer 42

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). 

Question 43

What is cystocele?

Answer 43

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

Question 44

What is preterm prelabor rupture of membrane (PPROM)

Answer 44

1. rupture of membranes at <37 weeks prior to onset of labor (irregular contractions and closed cervix)

Question 45

1. What is management of PPROM <34 weeks with no complications 2. What about with infection, fetal/maternal compromise 3. 34 to <37 weeks?

Answer 45

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

Question 46

Why does pregnancy increase risk of aspiration?

Answer 46

1. elevated progesterone delays gastric emptying and decreases esophageal sphincter tone

Question 47

- 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?

Answer 47

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

Question 48

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)

Answer 48

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

Question 49

What is tocolysis?

Answer 49

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

Question 50

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

Answer 50

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

Question 51

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

Answer 51

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

Question 52

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

Answer 52

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)

Question 53

1. How do you take out a placenta that is placenta accreta?

Answer 53

1. Surgical removal of the uterus (hysterectomy) with the placenta in situ - this minimizes further maternal bleeding

Question 54

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

Answer 54

1. 6 cm dilation

Question 55

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)

Answer 55

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

Question 56

1. What is protraction in "disorders of active phase of labor" 2. How do you treat

Answer 56

1. Cervical change slower than expected +/- inadequate contractions 2. Oxytocin

Question 57

1. What are montevideo units? 2. What value is adequate labor

Answer 57

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

Question 58

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?

Answer 58

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

Question 59

soft, mobile, nontender masses at the base of the labia majora at the 4 and 8 o'clock positions - what are these?

Answer 59

Bartholin duct cysts

Question 60

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

Answer 60

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

Question 61

Where are skene glands found?

Answer 61

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

Question 62

Placenta previa -what symptoms occur? - management?

Answer 62

1. painless vaginal bleeding >20 weeks gestation 2. No intercourse, no digital cervical examination, inpatient admission for bleeding episodes

Question 63

- Vaginal bleeding - pelvic pain - dilated cervix - <20 weeks what is this?

Answer 63

inevitable abortion

Question 64

- vaginal bleeding - high frequency uterine contractions - more common in smokers - constant abdominal pain/tender uterus (firm) and fetal decelerations What is this?

Answer 64

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

Question 65

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

Answer 65

1. vulvar punch biopsy

Question 66

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?

Answer 66

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

Question 67

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?

Answer 67

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

Question 68

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

Answer 68

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

Question 69

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.

Answer 69

transabdominal ultrasonography

Question 70

1. What is asherman syndrome? 2. What are risk factors for this? 3. Clinical features 4. evaluation and tx

Answer 70

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

Question 71

- Typically in multiparous women age >40 - new onset dysmenorrhea - heavy menstrual bleeding - chronic pelvic pain - boggy, tender, symmetrically enlarged uterus what is this likely?

Answer 71

1. adenomyosis

Question 72

1. What are some causes of fetal tachycardia (>160/min) 2. What are some causes of fetal bradycardia (<110/min)

Answer 72

1. maternal fever, med adverse effect, fetal hyperthyroidism, fetal tachyarrhythmia 2. maternal hypothermia, med adverse effect, fetal hypothyroidism, fetal heart block

Question 73

what is considered uterine tachysystole?

Answer 73

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.

Question 74

1. What is polymorphic eruption of pregnancy (PEP) 2. How to tx

Answer 74

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

Question 75

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

Answer 75

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

Question 76

What is urethral hypermobility?

Answer 76

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

Question 77

What are risk factors for placenta previa?

Answer 77

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

Question 78

Nonstress test Reactive: pulse, variability, accelerations Nonreactive: pulse, variability, accelerations - what does each mean - what is most often cause of nonreactive results

Answer 78

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

Question 79

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

Answer 79

1. pap smear 2. endometrial biopsy or TVUS

Question 80

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

Answer 80

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

Question 81

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

Answer 81

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

Question 82

What are some risk factors for PPROM?

Answer 82

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

Question 83

Retained placenta symptoms

Answer 83

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

Question 84

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

Answer 84

1. urogenital structures like kidneys, ureters

Question 85

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

Answer 85

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

Question 86

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

Answer 86

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).

Question 87

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

Answer 87

Complete hydatidiform mole pregnancies result from an abnormal fertilization of an empty ovum either by 2 sperm or by 1 sperm that 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

Question 88

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

Answer 88

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

Question 89

1. What is the most effect emergency contraception method available? 2. Within how much time of intercourse? 3. Other methods of EC?

Answer 89

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)

Question 90

1. What is twin twin transfusion syndrome? 2. What complications can arise?

Answer 90

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

Question 91

- dysuria - postvoid dribbling of urine -dyspareunia - tender anterior vaginal wall mass that expresses a purulent or bloody urethral discharge what is this?

Answer 91

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

Question 92

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

Answer 92

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

Question 93

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

Answer 93

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.

Question 94

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

Answer 94

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).

Question 95

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

Answer 95

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)

Question 96

Unilocular, hypoechoic ovarian mass - what is this likely

Answer 96

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

Question 97

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

Answer 97

primary invasive epithelial tumor

Question 98

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

Answer 98

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

Question 99

multiloculated, cystic masses with distortion of normal adnexal structures + fever, tender mass, cervical motion tenderness, abnormal discharge what is this likely?

Answer 99

tubo-ovarian abscesses

Question 100

- 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?

Answer 100

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

Question 101

What is management of hydatidiform mole?

Answer 101

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

Question 102

What are clinical signs that there is hydatidiform mole?

Answer 102

1. Abnormal vaginal bleeding ± hydropic tissue 2. Uterine enlargement > gestational age 3.Abnormally elevated β-hCG levels 4.Theca lutein ovarian cysts 5. Hyperemesis gravidarum 6. Preeclampsia with severe features  7. Hyperthyroidism

Question 103

When is syphilis screened for during pregnancy?

Answer 103

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

Question 104

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

Answer 104

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)

Question 105

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

Answer 105

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)

Question 106

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

Answer 106

1. GBS rectovaginal culture

Question 107

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

Answer 107

- sympathetic block 2. vasopressors (phenylephrine)

Question 108

What is terbutaline used for in labor and delivery?

Answer 108

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

Question 109

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

Answer 109

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

Question 110

Congenital uterine anomalies (arcuate, septate, bicornuate, didelphys, unicornuate) - what adverse reproductive and obstetric outcomes arise?

Answer 110

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.

Question 111

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

Answer 111

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

Question 112

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

Answer 112

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

Question 113

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)

Answer 113

1. 36 weeks 2. yes indicates c section 3. no indicates vaginal delivery

Question 114

1. who is considered high risk patient for STI in pregnancy 2. What is screened in first prenatal visit and 3rd trimester?

Answer 114

1. age <25, prior STI, high risk sexual activity 2. HIV, syphillis, Hep B and C virus, Gonorrhea, Chlamydia

Question 115

1. What is HELLP syndrome? 2. sx? 3. What organ is commonly affected?

Answer 115

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)

Question 116

- Microangiopathic hemolytic anemia - elevated liver enzymes -thrombocytopenia - +/- proteinuria -what is this lively?

Answer 116

1. HELLP syndrome

Question 117

How does pulmonary edema happen in preeclampsia/eclampsia?

Answer 117

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

Question 118

- placenta is pale and enlarged, areas of necrosis surround umbilical vessels --these findings suggest (blank - what cause?)

Answer 118

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)

Question 119

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

Answer 119

normal postovulatory ovarian changes

Question 120

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?

Answer 120

1. HSV 2. resolution in a week

Question 121

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?

Answer 121

Haemophilus ducreyi (chancroid)

Question 122

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

Answer 122

Treponema pallidum (syphillis)

Question 123

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

Answer 123

Chlamydia trachomatis serovars L1-L3 (lymphogranuloma venereum)

Question 124

Etiology of absent or minimal fetal heart rate variability

Answer 124

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

Question 125

what is given as preventative medication for preeclampsia?

Answer 125

1. low dose aspirin at 12 weeks gestation

Question 126

What is the function of misoprostol (prostaglandin E1)

Answer 126

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

Question 127

What is physiologic leukorrhea

Answer 127

white, odorless mucoid cervical discharge that typically occurs midcycle due to increasing estrogen levels prior to ovulation (microscopic exam can show rare polymorphonuclear leukocytes)

Question 128

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

Answer 128

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

Question 129

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

Answer 129

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

Question 130

What does the staircase sign on tocodynamometry indicate?

Answer 130

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

Question 131

- 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

Answer 131

1. this is likely uterine rupture - management is with emergency laparotomy and c section

Question 132

sheehan syndrome 1. Symptoms 2. Pathophysiology 3. Treatment

Answer 132

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

Question 133

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?

Answer 133

1. shoulder dystocia ---greatest risk factor for this is fetal macrosomia (EFW >4.5 kg or 9lb 14 oz)

Question 134

Risk factors for uterine rupture?

Answer 134

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

Question 135

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

Answer 135

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

Question 136

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

Answer 136

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

Question 137

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

Answer 137

-- 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

Question 138

- myometrial thinning and numerous placental lacunae (vascular spaces filled with maternal blood) is likely to indicate

Answer 138

placenta accreta (morbidly adherent placental attachment to the myometrium)

Question 139

5 alpha reductase deficiency 1. pathophysiology 2. symptoms

Answer 139

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

Question 140

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

Answer 140

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

Question 141

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

Answer 141

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

Question 142

1. What is uterine atony? 2. What is this the most common cause of? 3. Clinical presentation? 4. Interventions

Answer 142

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

Question 143

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

Answer 143

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

Question 144

- vaginal bleeding - malodorous vaginal discharge - irregular vaginal lesion ---> what is this concerning for? --> what is next step? --> risk factors for this?

Answer 144

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

Question 145

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

Answer 145

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

Question 146

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

Answer 146

stress urinary incontinence (due to increased intraabdominal stress)

Question 147

condylomata acuminata vs condylomata lata - what is the difference?

Answer 147

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

Question 148

Nonclassic congenital adrenal hyperplasia 1. pathophysiology 2. symptoms

Answer 148

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

Question 149

urethral hypermobility is found in what kind of GU issue?

Answer 149

stress urinary incontinence - intermittent urine loss with increased intraabdominal pressure

Question 150

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)

Answer 150

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.

Question 151

1. What changes to thyroid hormone occur during pregnancy? 2. What causes this change? (2)

Answer 151

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

Question 152

What is intrauterine synchiae?

Answer 152

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

Question 152

What are risk factors for tubal occlusion?

Answer 152

adhesions from PID - endometriosis - prior pelvic surgery

Question 152

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

Answer 152

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

Question 153

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

Answer 153

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

Question 154

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

Answer 154

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

Question 155

Symptoms - fever >24 hours postpartum - purulent lochia - uterine tenderness 1. What is this? 2. How is this treated?

Answer 155

1. postpartum endometritis 2. clindamycin + gentamicin due to broad spectrum coverage

Question 156

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

Answer 156

1. epithelial ovarian carcinoma 2. Family history, genetic mutations (BRCA1, BRCA2), Age >= 50, endometriosis, infertility, early menarche/late menopause 3. surgical exploration, +/- chemotherapy

Question 157

What is the etiology of HELLP disorder?

Answer 157

--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

Question 158

What are contraindications to endometrial ablation? (2)

Answer 158

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

Question 159

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

Answer 159

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

Question 160

Hyperandrogenism in pregnancy is commonly due to what?

Answer 160

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

Question 161

What medication is used in PCOS patients to induct ovulation?

Answer 161

Letrozole

Question 162

How does copper containing IUD affect menstrual cycles?

Answer 162

tends to worsen menstrual bleeding, anemia, and dysmenorrhea

Question 163

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?

Answer 163

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.

Question 164

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

Answer 164

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

Question 165

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

Answer 165

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.

Question 166

Risk factors of vulvovaginal candidiasis?

Answer 166

1. diabetes mellitus 2. immunosuppresion 3. antibiotic use --recurrent candidiasis warrants evaluation for diabetes mellitus

Question 167

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

Answer 167

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

Question 168

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

Answer 168

vancomycin cefepime clindamycin

Question 169

- 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?

Answer 169

1. staphylococcal toxic shock syndrome 2. supportive therapy, removal of foreign object, antibiotic therapy

Question 170

Preterm labor management algorithm 1. If mom has maternal instability, intrauterine infection, fetal distress/demise --> this leads to immediate delivery 2. If mom does not have the above and is A) <32 weeks (very preterm) what needs to be done? (4)

Answer 170

1. Antenatal corticosteroids 2. Penicillin if GBS+ or unknown 3. Tocolysis: indomethacin 4. Magnesium sulfate - protection against cerebral palsy

Question 171

Preterm labor management algorithm 1. If mom has maternal instability, intrauterine infection, fetal distress/demise --> this leads to immediate delivery 2. If mom does not have the above and is B) 32-34 weeks (moderate preterm) what needs to be done? (3)

Answer 171

1. antenatal corticosteroids 2. Penicillin if GBS+ or unknown 3. Tocolysis: nifedipine

Question 172

Preterm labor management algorithm 1. If mom has maternal instability, intrauterine infection, fetal distress/demise --> this leads to immediate delivery 2. If mom does not have the above and is C) 34-37 weeks (late preterm) what needs to be done? (2)

Answer 172

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

Question 173

Does positive leukocyte esterase with negative ntirite result indicate UTI?

Answer 173

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

Question 174

Differentiate between the types of abortions 1. vaginal bleeding, closed cervical os, products of conception completely expelled 2. vaginal bleeding, closed cervical os, fetal cardiac activity 3. vaginal bleeding, dilated cervical os, production of conception may be seen or felt at or above cervical os 4. no vaginal bleeding, closed cervical os, no fetal cardiac activity or empty sac 5. vaginal bleeding, dilated cervical os, some products of conception expelled and some remain

Answer 174

1. complete abortion 2. threatened abortion 3. inevitable abortion 4. missed abortion 5. incomplete abortion

Question 175

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

Answer 175

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

Question 176

What is the treatment of nonpurulent cellulitis?

Answer 176

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

Question 177

1. What are absolute contraindications to exercise during pregnancy? (7)

Answer 177

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

Question 178

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

Answer 178

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

Question 179

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?

Answer 179

--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)

Question 180

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

Answer 180

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

Question 181

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?

Answer 181

1. vulvar lichen planus 2. vulvar biopsy 3. High potency topical corticosteroids

Question 182

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

Answer 182

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

Question 183

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

Answer 183

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

Question 184

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

Answer 184

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

Question 185

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?

Answer 185

1. valproic acid for seizure prophylaxis --Mg sulfate is contraindicated because it may trigger myasthenic crisis

Question 186

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

Answer 186

1. For breech/transverse presentation 2. >= 37 weeks gestation --contraindications include -prior classical c section delivery -prior extensive uterine myomectomy -placenta previa

Question 187

What is high spinal anesthesia?

Answer 187

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)

Question 188

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

Answer 188

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

Question 189

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

Answer 189

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

Question 190

What is management of ruptured vasa previa?

Answer 190

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

Question 191

-dyspareunia - dysmenorrhea - chronic pelvic pain - infertility - dyschezia - cyclic dysuria, hematuria Physical exam: - immobile uterus - cervical motion tenderness - adnexal mass - what is this?

Answer 191

endometriosis - dx by direct visualization and surgical biopsy

Question 192

How can markedly elevated hCG affect thyroid hormone levels?

Answer 192

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

Question 193

Why are recurrent UTIs more common in postmenopausal women?

Answer 193

- 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

Question 194

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

Answer 194

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

Question 195

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

Answer 195

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

Question 196

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?

Answer 196

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

Question 197

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

Answer 197

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

Question 198

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

Answer 198

1. DES exposure in utero

Question 199

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

Answer 199

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

Question 200

What effects on fetus heart can moms with systemic lupus erythematosus

Answer 200

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

Question 201

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

Answer 201

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

Question 202

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

Answer 202

- Hyponatremia - Also cerebral edema and generalized tonic clonic seizures

Question 203

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

Answer 203

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

Question 204

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:

Answer 204

- 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

Question 205

What are some treatments for uterine atony after bimanual uterine massage + high dose oxytocin has been done? (3)

Answer 205

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

Question 206

1. When does screening for NTD happen? 2. what is measured? 3. what is required after abnormals levels are found?

Answer 206

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

Question 207

Ectopic pregnancy can be diagnosed by a persistent rise in beta hCG level following diagnostic dilation and curettage - medical therapy is (BLANK)

Answer 207

1. methotrexate - folate antagonist that inhibits DNA synthesis in rapidly dividing cells (e.g. trophoblasts)

Question 208

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

Answer 208

>= 35% 2.5%

Question 209

1. Secondary (late) postpartum hemorrhage (PPH) is (BLANK) hours after delivery 2. What are risk factors for this? 3. common causes for this?

Answer 209

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

Question 210

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

Answer 210

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

Question 211

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

Answer 211

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

Question 212

What is lochia

Answer 212

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

Question 213

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

Answer 213

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

Question 214

Changes in MSAFP, beta-hCG, estriol, inhibin A 1. Trisomy 18

Answer 214

1. decreased MSAFP 2. decreased beta-hCG 3. decreased estriol 4. normal inhibin A

Question 215

Changes in MSAFP, beta-hCG, estriol, inhibin A 1. Trisomy 21

Answer 215

1. decreased MSAFP 2. increased beta-hCG 3. decreased estriol 4. increased inhibin A

Question 216

Can IUD be used in women with disorted uterine anatomy?

Answer 216

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

Question 217

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

Answer 217

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)

Question 218

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

Answer 218

1. trisomy 21 2. VACTERL (vertebral, anal atresia, cardiac, tracheoesophageal fistula, esophageal atresia, renal, limb)

Question 219

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

Answer 219

1. ceftriaxone 2. cephalosporins (cephalexin) and penicillins

Question 220

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

Answer 220

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

Question 221

Preeclampsia can present up to 6 weeks postpartum with headache and hypertension --Those with FND should get what?

Answer 221

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

Question 222

Differentiate between decreased ovarian reserve vs primary ovarian insufficiency

Answer 222

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.

Question 223

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

Answer 223

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

Question 224

How differently do first vs 2nd/3rd trimester fetal growth restriction present? - what are the different causes?

Answer 224

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)

Question 225

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

Answer 225

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

Question 226

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

Answer 226

1. diabetes insipidus low specific gravity (<1.006) --

Question 227

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

Answer 227

- category III - complete (10 cm) dilation

Question 228

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?

Answer 228

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

Question 229

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

Answer 229

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

Question 230

lesion that is a papule at first then develops into nonexudative ulcer in center with indurated borders -what is this likely?

Answer 230

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

Question 231

- mild symptoms like increased vaginal discharge - light vaginal bleeding - pelvic pressure - visible cervical dilation and no uterine contractions what is this likely?

Answer 231

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

Question 232

What blood disorder can cause hydrops fetalis?

Answer 232

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.

Question 233

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

Answer 233

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.

Question 234

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?

Answer 234

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

Question 235

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

Answer 235

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

Question 236

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

Answer 236

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)

Question 237

1. what causes theca lutein cysts? 2. presentation/symptoms

Answer 237

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

Question 238

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

Answer 238

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.

Question 239

What are the 7 cardinal movements of labor

Answer 239

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)

Question 240

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)

Answer 240

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)

Question 241

How is second stage arrest of labor managed?

Answer 241

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

Question 242

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)

Answer 242

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

Question 243

What is normal prolactin levels?

Answer 243

<20 ng/mL

Question 244

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

Answer 244

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

Question 245

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

Answer 245

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

Question 246

What symptoms come with stretching of the round ligament

Answer 246

- this is caused by enlarging gravid uterus that causes irritation of local nerve fibers - pain in lower abdomen and ipsilateral labia, no sensory changes

Question 247

1. nonclassic (late onset) congenital adrenal hyperplasia (CAH) has an elevated (BLANK) level --due to deficiency in what (BLANK)

Answer 247

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

Question 248

what is idiopathic hirsutism?

Answer 248

Excessive conversion of testosterone to dihydrotestosterone in the hair follicles. Usually a positive family history and normal 17-OHP and androgen levels.

Question 249

1. What is pubic symphysis diastasis 2. symptoms of symptomatic pubic symphysis diastasis

Answer 249

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

Question 250

First line treatment for uterine atony includes bimanual uterine massage and high dose oxytocin --if atony persists then the best next step is

Answer 250

1. tranexamic acid - antifibrinolytic agent that prevents the breakdown of blood clots to achieve hemostasis, and its use reduces maternal mortality rates from hemorrhage

Question 251

1. What is pelvic thrombophlebitis 2. How is it treated?

Answer 251

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

Question 252

mullerian agenesis is the absence of (3 things)

Answer 252

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

Question 253

klinefelter syndrome 1. sex chromosome 2. symptoms

Answer 253

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

Question 254

XYY karyotype 1. symptoms

Answer 254

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

Question 255

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

Answer 255

1. bone 2. liver 3. lungs 4. brain

Question 256

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

Answer 256

Free thyroxine (T4)

Question 257

--fever, migratory polyarthralgia, tenosynovitis, and pustular lesions over the distal extremities what is this likely?

Answer 257

Disseminated gonorrhea due to N. gonorrhoeae

Question 258

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

Answer 258

1. hysterectomy to ensure complete removal of the cancer

Question 259

when does nausea and vomiting happen in pregnancy?

Answer 259

6-9 weeks

Question 260

what vitamin is teratogenic?

Answer 260

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

Question 261

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

Answer 261

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

Question 262

1. what artery if ruptured will lead to vulvar hematoma 2. what artery if ruptured will lead to vaginal hematoma

Answer 262

1. pudendal 2. vaginal

Question 263

Ages 21-24 - LSIL on pap test - next step

Answer 263

Do another pap test in one year

Question 264

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

Answer 264

1. NAAT 2. PCR 3. Culture *NAAT or PCR is 4 times more sensitive than culture

Question 265

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?

Answer 265

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

Question 266

colonscopy screening starts at..

Answer 266

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

Question 267

Who is at an increased risk of cystic fibrosis

Answer 267

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

Question 268

valproic acid is associated with what defects in fetus

Answer 268

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

Question 269

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

Answer 269

Intrapartum treatment vs infant prophylaxis 1. IV zidovudine 3 hours before c-section ---ART for 6 weeks 2. IV zidovudine based on individual decision ---ART for 6 weeks 3. IV zidovudine is not recommended ---zidovudine for 4 weeks

Question 270

most common cause of endometritis? - bacteria

Answer 270

1. staph aureus and streptococcus --mix of aerobes and anaerobes in the genital tract

Question 271

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

Answer 271

- greater than 20 ng/mL --<5 means abnormal or extrauterine pregnancy

Question 272

cervical cerclage is placed at (Blank) weeks

Answer 272

- 14 weeks --most delay until preliminary fetal anatomic survey and aneuploidy testing are complete

Question 273

what is given to treat intrahepatic cholestasis of pregnancy?

Answer 273

- ursodeoxycholic acid

Question 274

Kleihauer-Betke test purpose

Answer 274

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

Question 275

Average length of twin gestation is

Answer 275

35 wks

Question 276

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

Answer 276

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

Question 277

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

Answer 277

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

Question 278

McRoberts maneuver

Answer 278

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

Question 279

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

Answer 279

16-24 weeks

Question 280

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

Answer 280

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

Question 281

Rotterdam criteria for PCOS

Answer 281

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)

Question 282

Succenturiate placental lobes

Answer 282

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

Question 283

Antibiotic used for mastitis is

Answer 283

Antibiotic used for mastitis is dicloxacillin

Question 284

Pregnant women have increased risk for pyelonephritis bc

Answer 284

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

Question 285

Tx of condyloma acuminata

Answer 285

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

Question 286

what is the best way to identify clue cells in BV

Answer 286

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

Question 287

High risk HPV strains are

Answer 287

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