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COMLEX 2 > OBGYN COMAT > Flashcards

OBGYN COMAT Flashcards

1
Q

Etiology, precancer, cancer, screening, and presentation of cervical/vaginal/vulvar cancer?

A

Etiology: HPV
Precancer: CIS
Cancer: SCC
Screening: screen for cervical cancer with a Pap smear
Pt: post-coital bleeding with cervical cancer; black, itchy lesions with vulvar and vaginal cancer

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2
Q

Etiology, precancer, cancer, screening, and presentation of endometrial cancer?

A 
Etiology: estrogen
Precancer: dysplasia/atypia
Cancer: adenocarcinoma
Screening: none
Pt: post-menopausal bleeder
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3
Q

Etiology, precancer, cancer, screening, and presentation of epithelial ovarian cancer?

A

Etiology: ovulation
Precancer: low malignant potential (will not see/discover this)
Cancer: epithelial ovarian cancer
Screening: none
Pt: renal failure from obstructed ureter, SBO, ascites

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4
Q

Etiology, precancer, cancer, screening, and presentation of choriocarcinoma?

A

Etiology: gestational trophoblastic disease (mole, incomplete mole, normal pregnancy)
Precancer: same as etiology
Cancer: choriocarcinoma
Screening: follow beta HCG while on OCPs
Pt: hyperemesis gravidarum, hyperthyroid, size-date discrepancy

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5
Q

Which types of HPV are associated with malignancy?

A

HPV 16, 18, 30s

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6
Q

Which types of HPV are associated with warts?

A

HPV 6, 11

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7
Q

describe stage 1 cervical caner including 1A and 1B

A

involves only the cervix
1A = microscopic (only seen on cytology)
1B = macroscopic (can see with naked eye)

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8
Q

Involvement of the upper 2/3 of the vagina with cervical cancer makes it stage what?

A

2A

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9
Q

Involvement of the lower 1/3 of the vagina with cervical cancer makes it stage what?

A

3A

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10
Q

any involvement of the cardinal ligament in cervical cancer makes it stage what?

A

2B

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11
Q

Involvement of the pelvic side wall in cervical cancer makes it stage what?

A

3B

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12
Q

Distant metastases in cervical cancer makes it stage what?

A

4

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13
Q

what is the difference between 4A and 4B staging for cervical cancer?

A 
4A = involvement of adjacent organs
4B = distant metastasis
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14
Q

What is the screening recommendation for Pap smears?

A

screen regardless of sexual activity q3 years stating at age 21

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15
Q

How often do you screen with Pap smears if the woman is HPV positive?

A

q1 year

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16
Q

In what scenario can you do Pap smears q5 years?

A

over age 30 when combined with HPV testing (can stop at age 65)

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17
Q

What is the next step on a positive Pap smear?

A

colposcopy (ectocervical inspection and endocervical curettage)

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18
Q

If +endo on colposcopy, what is the next step?

A

cone biopsy

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19
Q

If +ecto, -endo on colposcopy, what is the next step?

A

local ablation - cryo or leep

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20
Q

If a patient has ASCUS with an uncertain Pap smear, what is the next step?

A

HPV DNA or q6 months pap

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21
Q

What stage of cervical cancer requires chemo and radiation?

A

> /= 2B

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22
Q

What is the treatment for endometrial cancer?

A

total hysterectomy + bilateral salpingo-oophorectomy (removes the source of estrogen)

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23
Q

What is the next step in workup of a patient with post-menopausal bleeding?

A

in office endometrial sampling or D+C

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24
Q

If in office endometrial sampling or D+C is positive for hyperplasia, what is the next step? Who is this usually found in?

A

usually found in reproductive age females; give high dose progesterone

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25
Q

What are 4 presentations of endometrial cancer? What is the Dx?

A
  1. old + obese
  2. old + HRT/SERM
  3. young + PCOS
  4. granulosa-theca tumor

All present with vaginal bleeding
Dx: endometrial sampling or D+C (not pelvic u/s)

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26
Q

What are the 4 germ cell tumors of the ovary, and what are their tracking substances?

A
  1. dysgerminomas: chemo, LDH
  2. Endometrial sinus: AFP
  3. Teratoma: none; can cause storm ovarii
  4. choriocarcinoma: beta-hCG
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27
Q

Path, pt, dx, and tx of germ call ovarian tumors

A

Path: nonmalignant
Pt: teenage girls, adnexal mass, weight gain, stage I
Dx: transvaginal ultrasound
Tx: unilateral salpingo-oophorectomy

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28
Q

What are the 4 types of epithelial cell ovarian tumors?

A

serous, mucinous, endometroid (all 3 cyst adenomas), Brenners

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29
Q

What is the Path, pt, dx, and tx of epithelial cell ovarian tumors?

A

Path: trauma = ovulation; very malignant; BRCA1/2 and HNPCC at increased risk
Pt: age -> post menopausal, null/low parity (the more ovulations you have, the more likely to get it); usually present as stage 3B or worse; generally asymptomatic; peritoneal seeding; advanced stages = renal failure, SBO, ascites
Dx: no screening; do trasnvaginal u/s; CT scan to stage; track with CA-125
Tx: TAH + BSO, chemo with paclitaxel

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30
Q

What are the 2 stromal cell ovarian tumors? What do they produce?

A

granulosa theca - produce estrogen

Sertoli-Leydig - produce testosterone

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31
Q

What findings on transvaginal u/s would make you think of a simple cyst? What is the next step?

A

smooth, small, no septations; stop workup

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32
Q

What findings on transvaginal u/s would make you think of a complex cyst? What is the next step?

A

large, septations, loculated; evaluate age and symptoms

young girl with asymptomatic mass - germ cell tumor; USO

older and asymptomatic or patient has RF, SBO, or ascites - epithelial tumor -> TAH + BSO + paclitaxel

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33
Q

What is the path, pt, dx, tx, and f/u of a complete mole?

A

Path: completely molar, complete chromosomes (46), completely spermal; good fertilization but bad egg
Pt: size-date discrepancy; very elevated beta HCG (>100,000); can have hyperthyroidism, hyperemesis gravid arum; grape-like mass in vagina; adnexal mass
Dx: transvaginal u/s -> snow storm pattern
Tx: suction curettage
F/u: follow beta HCG q 1 week x 12 months while on OCP

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34
Q

What is the path, pt, dx, tx, and f/u of an incomplete mole?

A

path: incomplete molar, incompletely chromosomal (69), incompletely spermal (2 sperms, 1 egg); good egg, bad fertilization
Pt, dx, tx, and f/u are the same as a complete mole

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35
Q

Choriocarcinoma path, pt, dx, and tx

A

path: malignant; product of gestational contents
pt: increased beta-HCG; can occur after miscarriage, molar pregnancy, or normal pregnancy (worst prognosis)
dx: transvaginal u/s; best test is biopsy via D+C; stage with CT scan (mets to lungs + brain MC)
tx: surgery (TAH or debulking for advanced) + chemo (MAC - methotrexate, actinomycin D, +/- cyclophosphamide)

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36
Q

What is the presentation, dx, and tx of SCC and melanoma of the vulva?

A

Pt: black and itchy lesion
Dx: biopsy
Tx: vulvectomy + LN dissection

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37
Q

What is the Pt, Dx, and Tx of Paget’s disease of the vulva?

A

Pt: red and itchy lesion
Dx: biopsy
Tx: wide local resection

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38
Q

If you see a grape-like mass in the vagina (not coming out of the cervix), what should you think of?

A

adenocarcinoma of the vagina caused by DES exposure

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39
Q

What is the definition of postpartum hemorrhage? What are the steps to stopping hemorrhage?

A

500cc after a vaginal birth and 1000cc after a C-section

  1. uterine massage
  2. oxytocin (methergin/hemabate - not the correct answer)
  3. balloon tamponade
  4. surgery -> uterine artery ligation -> internal iliac artery ligation -> TAH
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40
Q

What is significant about the uterosacral ligaments?

A

they need to be cut during a hysterectomy, but they look a lot like the ureter

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41
Q

path, pt, dx, and tx of pelvic floor relaxation

A

path: large or multiple births -> stretched cardinal ligament
pt: vaginal fullness, chronic back pain
dx: clinical based on speculum exam (if something is falling down from the top, that’s a cystocele; if you see something falling down from the bottom, that’s a rectocele; if you see the cervix much closer to you than it should be, that’s a uterine inversion)
tx: pelvic floor strengthening, hysterectomy (used for uterine inversion), colporrhaphy (used for cystocele or rectocele)
f/u: disease specific (cystocele might present with incontinence; rectocele might present with constipation)

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42
Q

How do you grade uterine inversion?

A

1 - uterus down at the level of the vagina but not to the opening
2 - uterus at vaginal opening but not outside vagina
3 - uterus progressed outside the vagina
4 - full inversion, outside of the body

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43
Q

What is significant about the suspensory ligament of the ovary?

A

ovarian blood supply runs through here; can twist upon itself -> ovarian torsion

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44
Q

What ovarian cancers are commonly found in premenarchal women? Which ones are commonly found in post menopausal women? Reproductive age?

A

premenarchal: germ cell
post-menopausal: epithelial
reproductive: all ovarian cysts are likely benign

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45
Q

What test helps to evaluate an ovarian cyst?

A

transvaginal ultrasound (MRI is very expensive)

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46
Q

ovarian cyst/mass <3 cm -> next step?

A

nothing

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47
Q

ovarian cyst/mass <10cm -> next step?

A

repeat imaging in a couple of months

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48
Q

ovarian cyst/mass >10cm -> next step?

A

needs to be removed (laparoscopy > laparotomy)

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49
Q

ovarian cyst/mass that grows or fails to resolve -> next step?

A

needs to be removed (laparoscopy > laparotomy)

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50
Q

What are 6 types of complex ovarian masses?

A
  1. teratoma
  2. endometrioma
  3. ectopic
  4. torsion
  5. tubo-ovarian abscess
  6. cancer
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51
Q

path, pt, dx, and tx of ovarian teratoma

A

path: benign
pt: young women (teens), usually asymptomatic; might notice weight gain or abdominal fullness
dx: u/s -> enormous cyst
tx: conservative -> remove cyst only (can remove whole ovary if older and done having kids)

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52
Q

path, pt, dx, and tx of ovarian endometrioma/endometriosis

A

path: retrograde menses; estrogen responsive
pt: dysmenorrhea, dyspareunia, infertility
dx: U/S will show cyst; best test = diagnostic laparoscopy with laser ablation (seeing a chocolate cyst is diagnostic for endometrioma/endometriosis)
for endometriosis w/o endometrioma: requires histology, do OCP trial first
tx: pain control (NSAIDs), OCPs or GnRH analogs, diagnostic laparoscopy with laser ablation for endometrioma

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53
Q

path, pt, dx, and tx of ectopic pregnancy

A

path: early implantation from stricture or pelvic inflammatory disease; happens most commonly at the ampulla
pt: amenorrhea/spotting, abdomdinal pain, LPT+
dx: urine pregnancy test -> qualitative positive; if beta HCG > discriminatory zone -> U/S should show pregnancy; if U/S shows empty uterus -> ectopic
* discriminatory zone = level beta HCG should be at for a viable pregnancy (between 1500-2000)
tx: salpingostomy (use without rupture), salpingectomy (use if rupture present), methotrexate +/- leucovorin (used in early pregnancy -> beta HCG <5000, gestational size < 3cm, and no fetal heart tones)
* can also use MTX with beta HCG <8,000 and gestational size <3.5 cm but test should be clear

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54
Q

path, pt, dx, and tx of ovarian torsion

A

path: pedicle, suspensory ligament
pt: spontaneous abdominal pain, ovary could be toxic
dx: U/S with doppler to see decreased BF to ovary
tx: surgical emergency to untwist ovary

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55
Q

path, pt, dx, and tx of tube-ovarian abscess

A

path: PID, gonorrhea/chlamydia or vaginal flora
pt: abdominal/pelvic pain with no other cause of symptoms and 1 of 3:
1. cervical motion tenderness
2. adnexal tenderness
3. uterine tenderness
(patient will probably also be toxic so look for fever and leukocytosis; presence of WBC on wet prep increases chances of having PID)
dx: U/S to see abscess/cyst
tx: inpatient therapy -> IV:
1. cefoxitin + doxy + metro (preferred)
2. clindamycin + gentamicin

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56
Q

path, pt, dx, and tx of stress incontinence

A

path: big, multiple births; stretching of cardinal ligament -> cystocele -> pushes urine out with abdominal pressure
pt: squeeze and pee; no urge associated; no nocturnal symptoms
dx: physical exam will reveal a cystocele and you will have a positive q-tip test
tx: pelvic floor strengthening (kegals) -> pessaries -> surgeries (MMK and burch procedures)

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57
Q

Describe a positive q-tip test for stress incontinence

A

apply q-tip to urethra; if it rotates more than 30 degrees, you have urethral mobility -> stress incontinence

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58
Q

path, pt, dx, and tx of hypertonic/motor urge/overactive bladder

A

path: random spasms of detrusor muscle
pt: + urge, + nocturnal symptoms; leak with contraction
dx: PE = normal, U/A = normal, cystometry shows spasms
tx: antispasmodics (oxybutynin)

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59
Q

path, pt, dx, and tx of hypotonic/overfill/neurogenic bladder

A

path: absent detrusor contractions; look for MS, trauma, or anti-spasmodic medications
pt: leaks before bladder explodes; no urge; + nocturnal symptoms; leak regularly throughout the day
dx: distended bladder on PE, +/- focal neurologic deficit responsible; U/A - normal; cystometry = decreased contractions
tx: bethanechol; intermittent vs chronic indwelling catheters

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60
Q

path, pt, dx, and tx of irritated bladder

A

path; inflammation due to stones, cancer, or UTI

pt: frequency, urgency, dysuria; + urge, no nocturnal incontinence
dx: PE normal, U/A positive for WBC if infection and RBC for cancer or stones; cystometry normal/not needed
tx: UTI = Abx (amoxicillin, nitrofurantoin, TMP-SMX); stones ID via imaging, cancer will need imaging and surgery

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61
Q

path, pt, dx, and tx of fistulas

A

path: continuous leak; epitheliazed tract between two organs (occur with inflammation and radiation, such as surgery, cancer, or IBD)
Pt: continuous leak with normal function
Dx: PE = fistula; U/A and cystometry not useful; tampon test
tx: surgery

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62
Q

Describe the tampon test for diagnosis of fistulas

A

put tampon where you think the exit of the fistula is; inject the urethra/bladder with blue dye; wait for blue dye to show up on the tampon

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63
Q

pt, wet mount, and tx of candida vaginal infections

A

pt: diabetes, steroid use, Abx as risk factors; thick, white, sticky discharge with no odor
wet mount: hyphae (KOH)
tx: anti-fungals (OTC topicals first, Rx fluconazole x1 next)

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64
Q

pt, wet mount, and tx of bacterial vaginosis

A

pt: thin, grey-white, copious discharge with fishy odor, +whiff test (KOH prep)
wet mount: clue cells (saline prep)
tx: metronidazole (topical first, then oral)

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65
Q

pt, wet mount, and tx of trhichomonas

A

pt: ping-pong effect between partners; yellow-green frothy discharge, cervical erythema (strawberry cervix)
wet mount: flagellated, motile organisms (saline prep)
tx: metronidazole (PO and must treat both partners at the same time)

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66
Q

Path, pt, dx, and tx of cervicitis

A

Path: infection of cervix; caused by GC/chlamydia, or organisms that cause vulvovaginitis
Pt: cervical motion tenderness + mucopurulent discharge but without other signs of PID
Dx: physical exam, GC/chlamydia NAAT+PCR, wet prep (do not do gram stain + culture)
Tx: GC: ceftriaxone x 1 IM
chlamydia: doxy or azithro (treat both)

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67
Q

Path, pt, dx, and tx of PID

A

Path: ascending infection caused by GC 1/3 of time, chlamydia 1/3 of time, and vaginal flora 1/3 of time
Pt: sick/toxic; dx criteria:
1. pelvic/abdominal pain
2. no other cause of symptoms
3. any one of the following be positive: cervical motion tenderness, adnexal tenderness, uterine tenderness
look for: fever, leukocytosis, d/c
Dx: clinical; can do transvaginal u/s to help identify tuba-ovarian abscess of free fluid
Tx: in patient = severely ill, N/V (cannot tolerate PO), or pregnant = cefoxitin and doxy IV; back-up (allergy/pregnancy) = clindamycin + gentamicin
outpatient regimen = ceftriaxone IM x1 + doxy + metronidazole

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68
Q

What is the most common cause of vaginal bleeding in the premenopausal female? reproductive age female? Post-menopausal female?

A

pre-menopausal: foreign body
reproductive: pregnancy
post-menopausal: vaginal atrophy

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69
Q

What is the most concerning cause of vaginal bleeding in the premenopausal female? Reproductive age? Post-menopausal?

A

pre-menopausal: sexual abuse
reproductive: anatomy, dysfunctional uterine bleeding, and cervical cancer
post-menopausal: endometrial cancer

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70
Q

What are the steps in management of a life-threatening pelvic bleed?

A
  1. 2 large bore IVs
  2. IVF boluses
  3. type and cross, transfusion
  4. IV estrogen (to stop uterine bleeding)
  5. surgical intervention
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71
Q

What are 4 options for surgical intervention of uterine bleeding?

A
  1. intracavitary tamponade
  2. D+C (preferred)
  3. UAE (uterine artery embolization) - usually for AVMs or fibroids
  4. total abdominal hysterectomy
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72
Q

passage of contents, os status, and u/s of a threatened abortion

A

no passage of contents, os is closed, u/s shows live baby (there’s just some bleeding that tips you off)

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73
Q

passage of contents, os status, and u/s of an inevitable abortion

A

no passage of contents, os is open, u/s shows baby is dead

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74
Q

passage of contents, os status, and u/s of an incomplete abortion

A

passage of clots or fetal tissue, os is open, u/s might show retained parts

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75
Q

passage of contents, os status, and u/s of a complete abortion

A

there was passage of contents, os is closed, ultrasound does not show a baby

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76
Q

passage of contents, os status, and u/s of a missed abortion

A

no passage of contents, os is closed, u/s shows dead baby (abortion happened but mom does not know)

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77
Q

What is medical management of a missed abortion?

A

misoprostol (in first trimester) -> oxytocin -> or D+C if she wants to to be faster
**Remember that all Rh- mothers need to be given Rhogam

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78
Q

If trasnvaginal u/s reveals an ectopic pregnancy with rupture or hemodynamic instability, what is the next step in management?

A

salpingectomy

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79
Q

If transvaginal u/s reveals an ectopic pregnancy without rupture and the patient is hemodynamically stable, what is the next step in management?

A

salpingostomy (open up tube and suck out ectopic)

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80
Q

What is the criteria to be able to use methotrexate +/- leucovorin for treatment of an ectopic pregnancy?

A
  1. beta-HCG < 5,000
  2. gestational size < 3.5 cm
  3. no fetal heart sounds
  4. mom should not have been on folate
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81
Q

If transvaginal u/s is inconclusive and the beta-HCG is >/= 1500, what do you do?

A

treat it like an ectopic

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82
Q

If transvaginal u/s is inconclusive and the beta-HCG is <1500, what do you do? What are the next steps?

A

too soon to tell -> have mom come back in 48 hours to repeat beta-HCG

If the beta-HCG doubles -> intrauterine pregnancy
If the beta-HCG fails to double -> ectopic pregnancy

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83
Q

Path, Pt, Dx, and Tx of uterine fibroids

A

Path: benign growths of the myometrium (not cancerous); estrogen responsive
Pt: asymptomatic, anemia/bleeding, painful, can lead to infertility
Dx: transvaginal u/s (best imaging test is an MRI)
Tx: meds: OCPs 1st line, NSAIDs for pain
surgery: myomectomy if want kids later; TAH if does not want kids later
leuprolide shrinks fibroids before surgery

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84
Q

What are the diagnostic criteria for PCOS?

A
  1. history of anovulation
    AND
  2. biochemical evidence of hyperandrogenism (LH:FSH > 3:1)
    OR
  3. imaging evidence of multiple ovarian follicles
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85
Q

precocious puberty workup

A

secondary sex characteristic at age = 8yo -> bone age with wrist x-ray -> + when bone age is 2+ years greater than chronological age -> GnRH stim test -> increased LH -> central (do MRI to look for tumor or constitutional)

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86
Q

At what approximate age and in what order does puberty occur for a girl?

A

breasts (age 8), axillary (age 9), growth spurt (age 10), menarche (age 11)

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87
Q

What is the treatment for constitutional central precocious puberty?

A

continuous leuprolide (turn off GnRH axis to allow bone age to catch up)

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88
Q

If GnRH stimulation test fails to change LH, what are the next steps in workup?

A

U/S of abdomen, U/S of adrenals, transvaginal U/S, DHEAS, testosterone, 17-OH-progesterone -> will result in CAH (steroid tx) or tumor (resection tx) or cyst (reassurance)

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89
Q

what is the diagnostic definition of delayed puberty? What are the next steps in workup?

A

no secondary sexual characteristics by 13; no menarche by 15

do bone age and biochemical profile (LH/FSH)

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90
Q

What is the diagnosis with delayed puberty and increased FSH and LH? What is the next step in workup?

A

hypergonadotropic hypogonadism -> karyotype

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91
Q

What is the diagnosis with delayed puberty and non elevated FSH and LH? What is the next step in work-up?

A

hypogonadotropic hypogonadism -> prolactin level, TSH/free T4, pregnancy test, CBC, LFT, ESR, MRI

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92
Q

What is the next step in workup with hypogonadotropic hypogonadism with all subsequent testing negative (cannot find a cause, ie constitutional)

A

wait (there is not obvious pathology causing it so wait for them to catch up); do not give growth hormone; can skip all the lab tests if mom has a positive family history of delayed puberty also

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93
Q

What are the possible diagnoses of a female who is > 15 yo, has not had menses, has a normal HPA, and has normal anatomy?

A

anorexia/weight loss, pregnancy prior to first bleed, imperforate hymen

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94
Q

What are the possible diagnoses of a female who is > 15 yo, has not had menses, has a normal HPA, but has abnormal anatomy?

A

~Qw34Mullerian agenesis - (X, X) with normal testosterone

androgen insensitivity syndrome/testicular feminism - (X,Y) with elevated testosterone

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95
Q

What are the diagnoses of a female who is > 15 yo, has not had menses, has normal anatomy, but lacks a normal HPA?

A

Kallmann syndrome (no FSH, no LH, no mass on MRI)
craniopharyngioma (no FSH, no LH, MRI + for mass)
Turner’s syndrome (X,O), increased FSH, increased LH, + transvaginal u/s

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96
Q

Craniopharyngioma/Kallmann’s syndrome

A

Path: craniopharyngioma: anterior pituitary
Kallmann’s: hypothalamus
Pt: + uterues/tubes, no secondary sex characteristics
**Kallmann’s: anosmia
Dx: decreased FSH, decreased LH, MRI
Tx: estrogen + progesterone, resect if tumor

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97
Q

What do the mullerian ducts normally develop into?

A

upper 1/3 of vagina, uterus, tubes

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98
Q

Mullerian agenesis

A

genetically female, has secondary sex characteristics bc she has ovaries; has vulva/vagina/clitoris; only doesn’t have the mullerian ducts so lacks upper 1/3 of vagina, uterus, and tubes

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99
Q

Androgen insensitivity syndrome

A

genetically male; develops testes, which produce mullerian-inhibiting factor -> no upper 1/3 of vagina, uterus, or tubes; testosterone can’t do anything on body, so testosterone -> estrogen and progesterone -> external female genitalia

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100
Q

Mullerian agenesis path, Pt, Dx, and Tx

A

Path: idiopathic loss of mullerian ducts (X,X)
Pt: + secondary sex characteristics, + external female parts; no uterus
Dx: (X,X), normal testosterone, normal FSH, LH
Tx: elevate vagina, cannot have kids

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101
Q

Androgen insensitivity syndrome path, pt, dx, and tx

A

path: (X,Y) with resistance to testosterone, + secondary sexual characteristics, + external female genitalia, no uterus or tubes (MIF)
Dx: (X,Y), elevated testosterone, FSH and LH normal, u/s shows testes
Tx: elevate vagina, after puberty (age 21) do orchiectomy

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102
Q

Turner syndrome

A

path: streak ovaries (X,O)
pt: webbed neck, broad spaced nipples, shield like chest, cardiac problems (coarctation, bicuspid aortic valve), - secondary sexual characteristics, + external female genitalia, + uterus
Dx: (X,O) (can be X,X theoretically), elevated LH, FSH, u/s shows streak ovaries
Tx: give estrogen and progesterone; f/u echo

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103
Q

What is the definition of secondary amenorrhea?

A

3 consecutive cycles with no menses (in a patient who previously did have menses)

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104
Q

What are the 5 main causes of secondary amenorrhea?

A
  1. pregnancy (urine pregnancy test)
  2. hypothyroid (TSH)
  3. prolactinemia or prolactinoma (prolactin)
  4. medications
  5. HPO axis
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105
Q

What is the first step in workup when evaluating the HPO axis for secondary amenorrhea? When does this usually happen?

A

progesterone challenge; this usually happens at 6 months of amenorrhea (after negative workup of the most common causes at 3 months)

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106
Q

In the work-up of secondary amenorrhea, a positive progesterone challenge test means what diagnosis?

A

positive progesterone challenge test means progesterone caused menses -> PCOS dx

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107
Q

What is the next step of work-up of secondary amenorrhea following a negative progesterone challenge test? What diagnosis is indicated by a negative test?

A

give estrogen and progesterone; if does not cause menses -> problem with the endometrium -> Ashermann’s or ablation

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108
Q

What is the next step in workup of secondary amenorrhea following a negative progesterone challenge test, and positive estrogen + progesterone test?

A

means there is a problem with the signal -> get FSH, LH, and FSH:LH (if elevated/elevated ration -> ovarian problem); (if normal/low -> brain problem)

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109
Q

What are the possible ovarian problems causing secondary amenorrhea (negative progesterone challenge test, positive estrogen + prog test, elevated LH, FSH, FSH:LH)? How are they differentiated?

A

differentiated by u/s

follicles -> resistant ovarian syndrome/savage syndrome (treated like menopause, gives high dose hormone replacement if desires fertility)

no follicles -> menopause (< 40 = premature ovarian failure)

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110
Q

What is the treatment for organic erectile dysfunction?

A

phosphodiesterase inhibitors - tadalafil, sildenafil

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111
Q

What is the first step in workup of female infertility?

A

mucous workup (couple has sex in the middle of the woman’s cycle right before coming into the clinic) -> smush test -> abnormal if < 6cm on smush test or no sperm when you look under microscope -> hostile mucous

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112
Q

What is the treatment for hostile mucous?

A

estrogen or artificial insemination

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113
Q

What is a normal result on a mucous workup for female infertility? What’s the next step in workup?

A

normal test if >/= 6 cm on smush test and + for sperm, + fern sign

Now need to assess ovulations

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114
Q

If a female is found to be anovulatory in infertility workup, what is the treatment?

A

clomiphene or pergonal (clomiphene preferred)

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115
Q

if both mucous and ovulation are found to be normal on female infertility workup, what is the next step?

A

hysterosalpingogram -> visualize uterus and tubes

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116
Q

if mucous, ovulation, and hysterosalpingogram are found to be normal, what is the last step in workup?

A

exploratory laparotomy to look for endometriosis

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117
Q

How do clomiphene and pergonal work?

A

clomiphene disinhibits GnRH so the axis can continue; pergonal becomes FSH/LH

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118
Q

PE, testosterone level, DHEA-S level, imaging, Dx, and Tx of PCOS

A 
PE: hirsutism
Testosterone: increased
DHEA-S: normal
Imaging: bilateral ovary involvement
Dx: LH:FSH >3:1; u/s showing follicles
Tx: exercise + weight loss; metformin, OCPs if not desiring pregnancy; clomiphene if wanting to be on pregnancy; spironolactone
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119
Q

PE, testosterone level, DHEA-S level, imaging, Dx, and Tx of Sertoli-Leydig tumor of ovary

A 
PE: virilization
Testosterone: very elevated
DHEA-S: normal
Imaging: unilateral ovary involvement
Dx: transvaginal u/s
Tx: resection
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120
Q

PE, testosterone level, DHEA-S level, imaging, Dx, and Tx of adrenal tumor

A 
PE: virilization
Testosterone: normal
DHEA-S: very elevated
Imaging: unilateral adrenal gland involvement
Dx: CT/MRI; adrenal vein sampling 
Tx: resection
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121
Q

PE, testosterone level, DHEA-S level, imaging, Dx, and Tx of congenital adrenal hyperplasia

A

PE: hirsutism
Testosterone: normal
DHEA-S: elevated
imaging: bilateral adrenal gland invovlement
Dx: CT/MRI: 17-OH-progesterone level in urine
Tx: give cortisol and aldosterone (via fludrocortisone)

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122
Q

PE, testosterone level, DHEA-S level, imaging, Dx, and Tx of familial hirsutism

A 
PE: hirsutism
Testosterone: normal
DHEA-S: normal
Imaging: normal
Dx: N/A
Tx: cosmetic/symptomatic
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123
Q

Path, Pt, Dx, and Tx of menopause

A

Path: ovarian failure -> decreased estrogen, infertility
Pt: hot flashes, vaginal atrophy, frequent UTI, decreased libido, irritability and mood swings, cessation of menstrual periods for 12 consecutive cycles
Dx: clinical; decreased estrogen, increased FSH, no ovarian follicles on u/s (but you should not choose to order these tests)
Tx: do NOT pick phytoestrogens or HRT; SSRI/SNRI esp venlafaxine (NOT sertraline or fluoxetine), estrogen creams, Vit D + Ca for prophylaxis against osteoporosis

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124
Q

At what age are women screened for osteoporosis? What is the treatment? What measures can prevent osteoporosis?

A

dexa scan at 65 yo; bisphosphonates for tx

prophylaxis: prevent with Vit D and Ca (if Vit D deficiency, replace with 50,000 units weekly), exercise

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125
Q

What changes in vitals are expected in a pregnant woman?

A

decreased MAP due to decreased SVR; increased HR, increased preload, increased RBC, decreased Hgb (increased RBC/very increased plasma)

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126
Q

What are the changes to the primary clotting cascade in pregnancy?

A

primary cutting cascade involves platelets doing the 3 A’s: adhesion, activation, aggregation to form a platelet plug surrounded by a fibrinogen mesh

Pregnancy:
increased vWF = increased adhesion (1st A) -> increases amount of fibrinogen mesh

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127
Q

What are the changes to the secondary clotting cascade in pregnancy?

A

Fibrinogen -> fibrin (clot) usually broken down via tPA to split products

Pregnancy:
increased factors 7, 8, 10. increased inhibitor to tPA, reduced protein C + S

(protein C + S are anticoagulant, so less of them = hypercoagulable; factors 7, 8, and 10 are pro-coagulants, so more of them = hypercoagulable)

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128
Q

What are the changes to the kidney function during pregnancy?

A

increased GFR thus decreased Cr (normal = 0.4-0.8); obstructive uropathy at the pelvic brim as the uterus grows

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129
Q

How much weight should a woman gain during pregnancy?

A

BMI and how much weight woman should gain each week of pregnancy (roughly):
<18.5 -> 1.0 lb/week (total of 28-40 lb)
18.5-25 -> 0.75 lb/week (total of 25-35 lb)
25-30 -> 0.50 lb/week (total of 15-25 lb)
>30 -> 0.25lb/week (total of 10-20 lb)

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130
Q

What GI side effects can you expect during pregnancy, and what are their treatments?

A

GERD -> PPI
nausea -> ondansetron
constipation -> stool softeners or motility agents
iron deficiency anemia -> iron (which will worsen constipation)

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131
Q

Explain the gravid/para/abortions system

A 
gravid = counts once for each event of pregnancy (twins = 1)
para = counts once for each event of delivery (twins = 1)
abortions = loss of any reason
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132
Q

What labs should be collected at the 10 weeks pregnancy appt?

A

Blood: ABO, Rh-Ag, Hgb/Hct, HIV, HepB, RPR, Titers for varicella and rubella

Urine: U/A + culture, proteinuria, gc/chlamydia

Cytology: Pap smear

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133
Q

Aneuploidy path, pt, dx, and tx

A

Path: Down syndrome c21 (drinking age), Edward syndrome c18 (voting age), Patau’s syndrome c13 (PG-13); risk significantly increases with increased maternal age (but increased prevalence in younger women due to increased number of pregnancies)
Pt: asymptomatic screen (increased maternal age or previous pregnancy with aneuploidy)
Dx: screening tool (noninvasive); confirm with confirmatory test (invasive)
Tx: termination

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134
Q

What is involved in a first trimester screening for aneuploidy?

A

u/s for nuchal translucency (<3 mm), PAPP-A, hCG

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135
Q

What is involved in a second trimester screening for aneuploidy?

A

Triple screen: hCG, AFP, estriol

Quad screen: above + inhibin-A

136
Q

What are the expected results for a quad screening for Downs syndrome?

A

hCG: up
AFP: down
Estriol: down
Inhibin-A: up

137
Q

What are the expected results for a quad screening for Edwards syndrome?

A

hCG: down
AFP: down
Estriol: down (very low)
Inhibin-A: down

138
Q

path, pt, dx, and tx gestational diabetes

A

path: diabetes that develops after 20 weeks gestation
pt: BMI > 30, history of gestational DM, pre-diabetic at increased risk
dx: 1 hour glucose tolerance test + 3 hour glucose tolerance test (100g load)
tx: insulin: post-prandial sugars < 180

139
Q

Explain the methods and cut off points for the 1 hour and 3 hour glucose tolerance tests for pregnant women

A

1 hour test - 50g glucose load; if >/= 140 have to do 3 hour test

3 hour test - 100g glucose load; measure:
fasting: >/= 90
1 hour: >/= 180
2 hour: >/= 155
3 hour: >/= 140
Any 2 of the above values need to be positive to make dx of gestational diabetes

140
Q

What 3 things are screened for during week 20-28 weeks of pregnancy?

A

gestational diabetes, alloimmunization, and maternal anemia

141
Q

Path, pt, dx, and tx of alloimmunization

A

Path: mom is Rh-Ag negative and has had a baby that is Rh-Ag positive; if she has another baby that is Rh-Ag positive, can develop fetal anemia
Pt: Rh-Ag negative mom during first trimester labs
Dx: screening to see if Abs are already developed
If Rh-Ab negative and baby could be Rh-Ab positive, give Rh(D)immunoglobulin (Rhogan) at 28 weeks and within 72 hours of delivery

142
Q

path, pt, dx, and tx of maternal anemia

A

Path: Hgb (RBC/plasma) where RBC is increased, but plasma is greatly increased, so Hgb is low; a normal Hgb at week 28 is 10:30
Pt: asymptomatic screen at week 28 with Hgb test
Dx: Hgb < 10 or Hct < 30 -> iron studies
Tx: iron

143
Q

How accurate is u/s for determining gestational age?

A

1st trimester = gestational age +/- 1 week
2nd trimester = gestational age +/- 2 weeks
3rd trimester = gestational age +/- 3 weeks

144
Q

When do you use a transcranial doppler? What is the goal of the study? What is the risk to the baby? What are the pros and cons of this test?

A

When: >20 weeks
Goal: assess for fetal anemia/alloimmunization
Risk: none
*highly sensitive (if normal, do not have to worry about dz); cannot diagnose, cannot provide access

145
Q

When do you use amniocentesis? What is the goal of the study? What is the risk to the baby?

A

When: > 16 weeks
Goal: genetic disorders (Down’s)
Risk: 1/300 death
(almost always the wrong answer on test)

146
Q

When do you use chorionic venous sampling? What is the goal of the study? What is the risk to the baby? What is the benefit of this test?

A

When: > 10 weeks
Goal: genetic disorder dx with karyotype and genes
Risk: 1/500 death
Benefit: early detection -> early termination

147
Q

When do you use percutaneous umbilical blood sampling? What is the goal of the study? What is the benefit of this test?

A

When: >20 weeks but <34 weeks
Goal: fetal anemia
Benefit: allows access (can transfuse through), allows confirmation

148
Q

What do you use to treat asymptomatic bacteruria in a pregnant female?

A

amoxicillin
nitrofurantoin as 2nd line
cannot use: TMP-SMX or cipro
**and rescreen after treatment

149
Q

What is the treatment for pyelonephritis in a pregnant woman?

A

admit for ceftriaxone IV -> reassess and if improved -> 10 days Abx

if does not improve -> worried about a perinephric abscess -> treat for 14 day Abx; visualize with u/s

Pick Abx based on culture and sensitivity

150
Q

Path, pt, dx, and tx of thyroid disorders in pregnancy

A

Path: hyper: fetal demise; hypo: cretinism
Pt: Hyper: everything increased
Hypo: everything decreased
Dx: TSH
Tx: hyper: PTU, or resection of thyroid in 2nd trimester
hypo: levothyroxine with TSH f/u q4 weeks
**increased thyroid binding globulin will increase the dose of levothyroxine needed (often 25% increase needed)

151
Q

path, pt, dx, and tx of seizure drugs

A

Path: all antiepileptic drugs are teratogens
Pt: has epilepsy prior to pregnancy
Dx: clinical
Tx: L drugs are safe:
Leviteracetam + Lamotrigine (do NOT give valproate, phenytoin, or carbamazepine)

152
Q

If a pregnant woman experiences a seizure (with a prior hx of epilepsy), what treatment can be given?

A

phenobarbital + folate (essential)

153
Q

What is the goal and treatment of HTN in a pregnant woman? (someone who already has HTN)

A

Goal: <140/80
Tx: same meds: alpha-methyl-dopa, labetalol, hydralazine (if you have to pick, choose alpha-methyl-dopa); can NOT use diuretics, ACEi, ARBs, or CCBs
*tighter screening for eclampsia

154
Q

What is the goal and treatment plan of a diabetic woman who would like to conceive? (before, during, and post pregnancy)

A

Before pregnancy: goal A1C of < 7%; do it with diet and exercise; change oral meds -> insulin

During pregnancy: increased insulin requirement; use basal-bolus insulin targeting post-prandial sugars

Post-pregnancy:
massive reduction in insulin requirement

155
Q

What is the effect on the fetus of having uncontrolled sugars early on in pregnancy?

A

cardiac defects, especially transposition of the great vessels

156
Q

What is the effect on the fetus of having uncontrolled sugars during pregnancy?

A

macrosomia -> increased risk of shoulder dystocia and C-section requirement

157
Q

What is the difference between frank breech, complete breech, and footling positions?

A

frank breech: hips flexed, knees extended
complete breech: hips flexed, knees flexed
footling: hip extended

158
Q

What constitutes prolonged or arrested active phase of labor? What do you use to help his?

A

no change in 4 hours or > 5 hours total of inadequate contractions; give oxytocin

159
Q

What constitutes adequate contractions? If you do not have these, what can you do to help?

A

200 mV in 10 minutes (measure via IUPC); can give oxytocin

160
Q

What are the steps in management of prolonged stage III of labor?

A
  1. uterine massage
  2. oxytocin
  3. manual extraction
161
Q

What is the definition of prolonged rupture of membranes?

A

> 18 hours from rupture of membranes to end of labor

162
Q

path, pt, dx, and tx of ruptured membranes

A

path: spontaneously, artificially, or pathologic
pt: rush of fluids; can be stained with meconium, bloody, or clear
dx: speculum exam -> will see pooling
nitralazine test -> turns blue;
under slide -> see ferning;
u/s -> oligohydramnios
Tx: term: delivery
in between: risk vs benefit (infection vs lung maturity)
abortion: deliver

163
Q

path, pt, dx, and tx of premature ROM

A

path: infection, usually GBS
pt: +ROM, +term, no contractions
dx: clinical; look at GBS status
tx: deliver (method depends on how sick mom/baby are)
GBS+ or unsure -> give ampicillin
GBS - -> watch and wait

164
Q

path, pt, dx, and tx of pre-term premature rupture of membranes

A

path: infection, GBS
pt: +ROM, not at term, no contractions
Dx: clinical = ROM
Tx: gestational age >34 weeks -> deliver
gestational age between 24-34 weeks -> steroids for lung maturity
gestational age < 24 -> abortion

165
Q

path, pt, dx, and tx of prolonged ROM

A

path: entrance of vaginal flora into mom; also still worried about GBS
pt: + ROM with no delivery within 18 hours
dx: clinical; confirm ROM
tx: delivery
GBS+ or unknown -> ampicillin
GBS- -> wait
*risk of waiting + endometritis/chorioamnionitis

166
Q

path, pt, dx, and tx of endometritis/chorioamnionitis

A

path: vaginal flora ascends into mom’s sterile uterus
pt: prolonged ROM fever/toxic
dx: (vaginal culture always the wrong answer) rule out other infection with U/A, CXR, blood cultures
tx: ampicillin, gentamicin, +/- clindamycin (treat gram negatives and anaerobes)

167
Q

path, pt, dx, and tx of preterm labor

A

path: idiopathic
pt: + contractions AND cervical change, not at term
dx: clinical
tx: based on gestational age:
> 34 weeks -> deliver
between 20-34 weeks -> steroids + tocolytics
< 20 weeks -> abortion

168
Q

What risk factors increases mom’s chance of having preterm labor?

A

smoking, decreased maternal age, multiple gestations, preterm ROM, uterine anatomical defects

169
Q

path, pt, dx, and tx of post-dates

A

path: macrosomic, shoulder dystocia, dysmaturity
pt: > 40 weeks by conception or > 42 weeks by date
dx: clinical
tx: sure of your dates + cervix is favorable -> induce labor
sure of your dates + cervix is not favorable -> c-section
not sure of your dates, regardless of cervix -> non stress test + u/s for biophysical profile

170
Q

transient HTN: BP, timing, U/S, Sxs, Tx, and f/u

A 
BP: >/= 140/80
Timing: non sustained elevation
U/A: nothing
Sxs: nothing
Tx: nothing 
F/u: keep log of BP
171
Q

chronic HTN: BP, timing, U/S, Sxs, Tx, and f/u

A

BP: >/= 140/80
Timing: sustained; onset before 20 weeks gestation
U/A: nothing
Sxs: nothing
Tx: alpha-methyl-dopa (can also use labetalol or hydralazine)
F/u: close monitoring with frequent U/A and u/s

172
Q

gestational HTN: BP, timing, U/S, Sxs, Tx, and f/u

A

BP: >/= 140/80
Timing: sustained; onset after 20 weeks gestation
U/A: nothing
Sxs: nothing
Tx: alpha-methyl-dopa (can also use labetalol or hydralazine)
F/u: can progress to preeclampsia

173
Q

preeclempsia w/o severe features: BP, timing, U/S, Sxs, Tx, and f/u

A

BP: >/= 140/80
Timing: sustained; onset after 20 weeks gestation
U/A: > 300 mg/dL protein
Sxs: nothing
Tx: > 37 weeks -> deliver; < 37 weeks -> wait
f/u: weekly follow-up

174
Q

preeclampsia with severe features: BP, timing, U/S, Sxs, and tx

A

BP: >/= 160/110
Timing: sustained; onset after 20 weeks gestation
U/A: > 5g/dL protein
Sxs: positive alarm symptoms
Tx: give Mg+ and deliver (usually vaginal via induction)

175
Q

eclempsia: BP, timing, U/S, Sxs, and Tx

A

BP: doesn’t matter
Timing: sustained; onset after 20 weeks gestation
U/A: doesn’t matter
Sxs: seizures
Tx: give Mg+ and deliver (usually by c-section)

176
Q

HELLP syndrome acronym, tx

A

H - Hemolysis
EL - Elevated Liver enzymes
LP - low platelets
Tx - give Mg+ and deliver

177
Q

What are severe features of HTN in pregnancy?

A

decreased platelets, increased liver enzymes, RUQ abdominal pain, elevated Cr (1.1, or doubling), pulmonary edema, HA, vision changes, BP > 160/110

178
Q

What are mag checks? Why/when are they used? What should you give on a positive mag check?

A

Magnesium is used to prevent seizures in pregnancy; mag checks involving checking DTRs while on mag; if DTRs decrease, it is a sign of an impending decrease in the respiratory drive -> could kill patient; give calcium

179
Q

If the genders of twins are different, how many amnions and chorions are there?

A

have to be di-zygotic, di-amniotic, di-chorionic

180
Q

What risks are involved with multiple gestations?

A

preterm labor, malpresentation -> increased risk of c-section
post partum hemorrhage

181
Q

If you see on u/s twins that have the same gender, 1 placenta, have a septum, and have 2 sacs - what is this called?

A

mono-zygotic, mono-chorionic, di-amnionic twins

182
Q

What are mono-chorionic twins at risk for?

A

twin-twin transfusion because they share the same blood supply

183
Q

If you see on u/s twins that have the same gender, 1 placenta, no septum, and 1 sac - what is this called?

A

mono-zygotic, mono-chorionic, mono-amniotic

184
Q

What are the risks of mono-amniotic twins?

A

conjoined twins and cord entanglement

185
Q

path of di-zygotic, di-amniotic, di-chorionic twins

A

path: 2 fertilizations; 2 placentas; 2 sacs; often have 2 genders

186
Q

path of mono-zygotic, di-chorionic, di-amniotic twins

A

path: 1 fertilization that split early

split between days 0-3 (tubal phase) - 2 separate placenta, 2 separate sacs

187
Q

path of mono-zygotic, mono-chorionic, di-amniotic twins

A

path: 1 fertilization that split a little later

split between days 4-8 (blastocyst phase) - 1 placenta, 2 separate sacs

188
Q

path of mono-zygotic, mono-chorionic, mono-amniotic twins

A

path: 1 fertilization that split late

split between days 9-12 for non conjoined twins and after day 12 for conjoined twins

189
Q

What is the definition of post partum hemorrhage?

A

> 500 cc of blood loss with vaginal birth

> 1000 cc of blood loss with c-section

190
Q

What PE findings should make you think of uterine inversion? What are the steps for treatment?

A

postpartum hemorrhage with absent uterus on physical exam
tx: manual manipulation, tocolytics to put it back in place, and uterine tonics to help it contract back down where it needs to be

191
Q

What PE findings should make you think of uterine atony? What are the steps for treatment?

A

postpartum hemorrhage with boggy uterus on physical exam

tx: uterine massage, restart oxytocin, medications

192
Q

What PE findings should make you think of retained placenta? What are the steps for treatment?

A

postpartum hemorrhage and firm uterus on physical exam

tx: D+C but can progress to TAH

193
Q

What PE findings should make you think of vaginal laceration? What are the steps for treatment?

A

postpartum hemorrhage with a normal uterus on physical exam

tx: sutures
* *If you have this on PE but cannot find the vaginal laceration, you need to consider DIC

194
Q

What are solutions to unexplained ongoing postpartum bleeding?

A

uterine artery ligation
uterine artery embolization
total abdominal hyesterecomty

195
Q

path, pt, dx, and tx of uterine atony

A

Path: a-tonic uterus; can be in the setting of prolonged labor, oxytocin or tocolytics use
Pt: postpartum hemorrhage + boggy uterus
dx: clinical
tx: uterine massage
give oxytocin if withdrawal of oxytocin caused this
methergin/hemabate can help (probably not answer)
surgery last resort

196
Q

path, pt, dx, and tx of uterine inversion

A

path: uterus pushes so hard that it births itself; can occur with oxytocin or traction
pt: postpartum hemorrhage with an absent uterus
dx: speculum exam
tx: manually replace
might need to use tocolytics to calm it down then use oxytocin to get it to contract to where it belongs
surgery last resort

197
Q

path, pt, dx, and tx of vaginal laceration

A

path: both cervix and vagina affected; precipitous delivery, macrocosmic baby, episiotomy
pt: postpartum hemorrhage + normal uterus on physical exam
dx: clinical; speculum exam
tx: pressure, sutures (anesthetics first)

198
Q

path, pt, dx, tx, and f/u of retained placenta

A

path: placenta burrows deeply; accessory load during delivery; placental tear; depth of invasion determines name
pt: postpartum hemorrhage and a firm uterus on physical exam
dx: placental dx; blood vessels go to the edge
tx: obtain remaining part of placenta -> D+C -> TAH
f/u with beta HCG levels

199
Q

What laboratory levels do you expect in a pregnant woman with DIC?

A

decreased Hgb, decreased platelet, schistocytes, decreased fibrinogen, elevated INR

200
Q

What is the treatment for DIC?

A

replenish stuff; give platelets, packed RBCs, cryoprecipitate, & FFP

201
Q

What is the next step in workup following a non reassuring non stress test?

A

repeat the non stress test after vibroacoustic stimulation

202
Q

What is the next step in workup following a non reassuring non stress test with vibroacoustic stimulation?

A

biophysical profile

203
Q

What is the next step in workup following a biophysical profile score of 0-2?

A

deliver probably via c-section; impending fetal demise (if not already occurred)

204
Q

What is the next step in workup following a biophysical profile score of 3-7?

A

make decisions based on gestational age
> 37 weeks -> high risk pregnancy; deliver (likely induction with vaginal delivery)
< 32 weeks -> contractions stress test

205
Q

What is the next step in workup if a contractions tress test shows the absence of late decelerations and the absence of bradycardia?

A

this is a reassuring contraction stress test; leave baby in and give more time

206
Q

What results on a contraction stress test indicate that fetal demise is imminent?

A

late decelerations and bradycardia

207
Q

non stress test path, pt, dx, and tx

A

Path: no contractions; looking at fetal HR with variability and accelerations
Pt: high risk patients or decreased fetal movement
Dx: variability and accelerations - > 32 weeks 15/15 and 2 in 20; < 32 weeks 10/10 and 2 in 20
Tx: reassuring - stop
non-reassuring - repeat with virboacoustic stimulation

208
Q

What HR constitutes fetal bradycardia? Fetal tachycardia?

A

bradycardia < 110

tachycardia > 160

209
Q

What does 15/15, 2 in 20 mean?

A

We want 2 increases in HR within 20 minutes; the increases should be at least 15 bpm and last for 15 seconds each time

210
Q

Biophysical profile

A

Path: does not use contractions; evaluates APGAR
Pt: failed non stress test/vibroacoustic stimulation
Dx: use NST, amniotic fluid index, look at baby’s breathing, movement, and tone (0-2 points for each above)
Tx: 8-10 = reassurance

0-2 = fetal demise -> c-section

211
Q

How is the amniotic fluid index measured?

A

add up four quadrants of womb (?), sum up and average;
oligo = < 5
reassuring 6-25
poly = >25

212
Q

Path, pt, dx, and tx of contraction stress test

A

path: + contractions (done while in labor); looking for decelerations and bradycardia
pt: monitored in labor or has failed biophysical profile

213
Q

What 3 types of decelerations should you know about? What do you do about each?

A
  1. Early deceleration - peak of deceleration occurs at the same time as the peak of contraction; represents head compression; requires no action
  2. Variable deceleration - no association between contractions and decelerations; represents cord compression; requires no action
  3. Late decelerations - decelerations begin when the peak of contractions occurs; represents utero-placental insufficiency; emergency C-section
214
Q

What is considered adequate contractions? s

A

3 contractions/10 mins and 200 units

215
Q

What are 3 causes of normal 3rd trimester bleeding? What do you want to order for workup? How is the diagnosis made?

A
  1. cervical lesions
  2. cervical dilation
    3.. bloody ROM
    Order:
    Mom: vitals + Hgb + physical exam (speculum, bimanual, etc), (get platelets and coags if you have ongoing bleeding and suspect DIC)
    Baby: non stress test or contraction stress test for baby to assess HR
    Dx - will be made by u/s and decision to do surgery will be made based on fetal HR
    Tx - reassurance, induce, c-section, crash section
216
Q

Where does painless bleeding come from during pregnancy? Whose blood is it?

A

placenta; baby’s blood (always named with previa)

217
Q

Where does painful bleeding come from during pregnancy? Who’s blood is it?

A

uterus; mom’s blood

218
Q

path, pt, dx, and tx of placenta previa

A

path: placenta implants at the cervical os, cervix dilates and tears placenta; bleeding baby’s blood
Pt: painless bleeding
Dx: u/s -> will show transverse lie of baby
non stress test or contraction stress test will show fetal distress
TX: urgent C-section

219
Q

path, pt, dx, and tx of vasa previa

A

path: accessory lobe implants at the cervical os; blood vessels tear when cervix dilates
pt: painless bleeding; baby’s blood
dx: U/S -> will not show anything
NST/CST -> fetal distress
Tx: urgent C-section

220
Q

path, pt, dx, and tx of uterine rupture

A

path: attempting VBAC (vaginal birth after cesarian), c-section scar + oxytocin -> uterus tears and baby is delivered into the peritoneum
Pt: + contractions; VERY painful; loss of fetal station
Dx: no dx -> go straight to treatment
Tx: crash section (have seconds to get baby out)

221
Q

pain, pt, dx, and tx of placental abruption

A

(remember this does not contain the word previa so the bleeding is not from the placenta/baby)
path: HTN/cocaine use, MVA -> rips placenta off
Pt: PAINFUL bleeding (mom’s blood)
Dx: U/S, NST/CST, Mom’s vitals, Hgb and AMS
Tx: c-section

222
Q

In a fetus with possible hemolytic anemia, what is the diagnostic test of choice? What do you do if it’s positive? negative?

A 
trans-cranial doppler; if negative -> stop work-up
if positive (increased flow): deliver if >/= 32 weeks; if < 32 weeks -> percutaneous umbilical blood sampling/transfusion
223
Q

path, pt, dx, and tx of group B strep

A

Path: mom: benign normal flora
baby: can lead to PROM, pre-term delivery, chorioamnionitis, pneumonia, sepsis
Pt: 1: +prenatal care, asymptomatic screen (week 10 + week 35)
2: no prenatal care -> normal delivery -> next day, toxic baby
Dx: 1. U/A + urine culture
2. clinical w/ baby crashing
3. risk factor positive
Tx: ampicillin, cefazolin, clindamycin, vancomycin (depending on amount of penicillin allergy)

224
Q

What risk factors would make you give a mother treatment for GBS regardless of testing?

A
  1. previous pregnancy that was positive for GBS
  2. prolonged ruptured membranes
  3. intrapartum fever
225
Q

Path, pt, dx, and tx of Hep B in pregnancy

A 
Path: vertical transmission
Mom: asymptomatic carrier
Pt: asymptomatic screen week 10
Dx: HBV Ag = infected
(HBVeAg = currently infectious)
HBV Ab = presume they are immune (HBVsAb = immune due to vaccine OR exposure; HBVcAb = immune due to exposure)
Tx: perform C-section to avoid mixing of blood; give baby Hep B IVIg and Hep B vaccine
F/u: vaccinate mom before pregnancy
226
Q

Path, pt, dx, and tx of HIV in pregnancy

A

Path: CD4 count as marker of risk for opportunistic infection; increased in viral load = increased infectious risk
Pt: 1. asymptomatic screen with prenatal care
2. no prenatal care
Dx: 1st: ELISA
confirm: western blot
Tx: 2+1 (2 nucleoside reverse transcriptase inhibitors + 1 non nucleoside reverse transcriptase inhibitor) OR 1 protease inhibitor (boosted with retonavir)
2NRTIs = tenofovir + emtricitabine or lamivudine, zidovudine, abacavir (less studied than first two)
NRTI = nevirapine, efavirenz (teratogen, do not pick)
PI = atezanavir

227
Q

What is the treatment at the time of delivery for an HIV positive or suspected mom?

A

At delivery, 3 options:

  1. viral load < 1000 and currently on HAART -> deliver vaginally
  2. viral load > 1000 or stops taking HAART -> C-section
  3. unsure HIV status -> give AZT
228
Q

Path, pt, and prevention of toxoplasmosis in pregnancy

A

Path: T. gondii found in cat feces, undercooked meat, and cysts in soil
Pt: mom: mono-like illness (fever, malaise, HSM, anterior cervical LAD)
baby: brain calcifications, ventriculomegaly, seizures
prevent: check mom’s toxo Ab status (positive -> no problem, negative = counsel on avoiding exposure)

229
Q

Path, pt, dx, and tx of syphilis in pregnancy (separate based on primary, secondary, tertiary)

A

Path: T. plaidum, spirochete, STI
Pt: 1. primary disease: painless chancre on genitals
2. secondary disease: targeted lesions on palms and soles (contagious)
3. latent disease: positive test but no symptoms
4. tertiary disease: neuro symptoms
Dx: primary: dark field microscopy
secondary: RPR -> confirm with FT-Abs
tertiary: CSF (VDRL or RPR)
Tx: primary: penicillin IM x 1
secondary: penicillin IM x 1
early latent: penicillin IM x 1
late latent: penicillin IM q week for 3 weeks
tertiary: penicillin IV q4 hours for 7-10 days

230
Q

What are the effects of syphilis on baby based on gestational age at infection?

A

1st trimester: dead baby

2nd trimester/early 3rd: Sniffles (rhinorrhea), Saber shins, saddle nose, Hutchison teeth

231
Q

Path, pt, Tx, and prevention of Rubella

A

Path: primary viremia is the problem (mom was never exposed or never vaccinated)
Pt: 1. prenatal care + unvaccinated -> needs to avoid
2. no prenatal care
baby: blueberry muffin baby (petechia and purpura) + 3 C’s: cataracts, congenital heart defects, deafness
1st trimester: IUGR/abortion
Tx: avoidance (avoid sick people, unvaccinated people, and young babies that can’t have MMR)
Prevention: MMRV before pregnancy (it’s live attenuated so it cannot be given once pregnant)

232
Q

Path and pt of CMV in pregnancy

A

Path: double-stranded DNA virus
Pt: looks like toxo but isn’t toxo
(likely to be a distractor on test according to OME)

233
Q

Path, pt, dx, and tx of HSV

A

Path: STI, primary viremia = congenital defects; secondary reactivation = puts baby at worse of getting infected
Pt: mom: painful burning prodrome with eruptions on a painful erythematous base
Dx: can be clinical; PCR from scraping
Tx: (val)acyclovir; consider C-section
*congenital herpes: IUGR, pre-term delivery, blindness

234
Q

In what cases can you attempt vaginal delivery after a previous c-section? (VABC)

A

= 2 prior c-sections with low transverse incisions

235
Q

When can you consider using vacuum or forceps assisted delivery?

A

fetal distress/prolonged labor/arrest of labor with full effacement and 2+ station

236
Q

How do you grade vaginal lacerations?

A

I: only involves vagina
II: involves perineal body
III: involves anal sphincter
IV: involves anal mucosa and can cause a fistula

237
Q

path, pt, tx, and risk of incompetent cervix

A

path: STIs, PID, multiple D+Cs
pt: multiple 2nd trimester losses
Tx: week 14 - insert cerclage; week 36 - remove
risk: cervical rupture

238
Q

When should opiates be avoided during labor?

A

latent phase 1 d/t risk of prolongation; also if you give them very late in the labor baby will come out needing naloxone

239
Q

epidural considerations/risks

A
  1. requires trocometer and breathing coach bc mom won’t be able to feel contractions anymore
  2. put it in the subdural -> hypotension -> death
240
Q

paracervical block w/ lidocaine benefit and risk

A

benefit: helps pain in stage 1 of labor due to cervical dilation
risk: putting very close to baby -> can cause fetal bradycardia

241
Q

pudendal nerve block benefit and risk

A

benefit: helps pain in stage II of delivery
risk: miss, no bad effects

242
Q

What markers are elevated with granulose cell tumors?

A

estradiol and inhibin

243
Q

How does the treatment of preeclampsia change based on gestation? When are antihypertensives used?

A
  • Patients presenting w/o severe features prior to 37 weeks of gestation can be managed expectantly with bed rest, seizure prophylaxis with magnesium sulfate, and close monitoring
  • Patients after 37 weeks or in the presence of severe features, treatment is prompt delivery
  • Antihypertensive therapy is used for acute control of BPs that are in the severe range ( >160/110)
244
Q

Klinefelter syndrome path, pt, and labs

A

Path: due to non-disjunction of chromosomes during either meiosis I or II resulting in an XXY karyotype; Sx become evident during early childhood or puberty
Pt: hx of a learning disorder and are shy/immature compared to others that age; gynecomastia, small penis and testicles, and lack of secondary sexual characteristics
Labs: low testosterone, high FSH and LH, increased estradiol

245
Q

What are the two progesterone-only birth control options? For whom are these the best option?

A

progestin-only pill and depot medroxyprogesterone acetate (DMPA)

Used in women who smoke and are more than 35 years old

246
Q

What are the steps of postpartum hemorrhage?

A

In this order:

  1. uterine massage
  2. IV fluids
  3. supplemental O2
  4. begin or increase oxytocin infusion
  5. methylergonovine (uterotonic medication)
  6. balloon tamponade
  7. uterine artery embolization or laparotomy
247
Q

At 15 weeks gestational age, what is the normal rate of weight gain for the fetus?

A

5 grams per day

248
Q

At 20 weeks gestational age, what is the normal rate of weight gain for the fetus?

A

10 grams per day

249
Q

duodenal atresia on u/s, cardiac anomalies, shortened limbs - disorder? What would be seen on quad screen?

A

Down syndrome (trisomy 21); elevated hCG and inhibin-A, low estriol and AFP

250
Q

What are the common clinical manifestations of preeclampsia?

A

diffuse edema, severe headache, visual disturbances, and abdominal pain

251
Q

For patients with twin gestation or a history of prior neural tube defect, how much folic acid should be supplemented? How much for a normal pregnancy?

A

4000 microgram/day; 400 micrograms/day minimum

252
Q

What is the Jarisch-Herxheimer reaction?

A

HA, fever, flushing, tachycardia, hypotension that begins 1-2 hours after the initiation of antibiotic therapy for syphilis; self-limited to 24-48 hours; Tx with acetaminophen and IV fluids as needed

253
Q

Extensively explain when you might see the different hepatitis serum markers? (HBsAg, anti-HBs, HBeAg, Anti-HBc IgM and IgG)

A

HBsAg - present through the incubation period and infectious state
Anti-HBs - if a patient gains immunity to this virus, either due to infection of immunization, HBsAg changes to this
(neither will be present in the window phase)
HBeAg - Hep B early antigen; indicates active viral replication in the liver; always present in the acute phase and may or may not be present in the chronic stage
Anti-HBc - present during the acute, chronic, or previous hep B infections (including window phase)_
Anti-HBc IgM changes to IgG during the chronic infection

254
Q

What are the five parameters included int he fetal biophysical profile?

A
  1. fetal breathing movements
  2. gross fetal movement
  3. fetal tone
  4. amniotic fluid volume
  5. results of the non-stress test
    (each is assigned a score of 0-2. A total score of 8-10 is normal)
255
Q

When is colposcopy indicated? (7)

A
  1. persistent atypical cells of undetermined significance (ASCUS) or ASCUS with positive thigh-risk HPV subtypes
  2. ASC suggestive of high-grade lesion (ASC-H)
  3. Atypical glandular cells (ACG)
  4. Low-grade squamous intraepithelial lesions (LSIL)
  5. High-grade squamous intraepithelial lesion (HSIL)
  6. Lesions suspicious for invasive cancer
  7. . Presence of malignant cells
256
Q

Which procedure is preferred: cryotherapy or laser vaporization? Why?

A

Cryotherapy is generally preferred over laser vaporization.
Advantages of cryotherapy: in-office, minimally invasive, less perioperative pain, cheaper cost, less bleeding risk, less risk of disease recurrence
The only advantage laser vaporization offers is preservation of the squamocolumnar junction, which allows subsequent colposcopic examinations to remain adequate

257
Q

What are the preferred medications for alcohol cessation in a pregnant woman? Which therapies are contraindicated?

A

naltrexone is preferred; can use benzos if needed (but not daily)

C/I - acamprosate, disulfiram, topiramate

258
Q

What quad screen results are expected when an u/s of a fetus shows apparent disruption of the fetal skin contour overlying the lumbar region?

A

increased alpha-fetoprotein

259
Q

What are the seven cardinal movements of labor? (in order)

A
  1. Engagement
  2. Descent
  3. Flexion
  4. Internal rotation
  5. Extension
  6. External rotation
  7. Expulsion
260
Q

What are complications of amniocentesis? When can it be performed?

A

Amniocentesis is performed after 15 weeks gestation.
Complications: leakage of amniotic fluid (most common), frank rupture of membranes prematurely, direct and indirect fetal injury, infection, and fetal loss

261
Q

What are the risk factors for endometrial carcinoma?

A

tamoxifen use, unopposed estrogen therapy, obesity, increasing age, a family history of endometrial cancer or HNPCC/Lynch, early menarche, and late menopause

262
Q

neonatal abstinence syndrome from opiates

A

high-pitched cry, irritability, sleep/wake disturbances, hyperactive primitive reflexes, hypertonicity, difficulty feeding, GI disturbances, autonomic dysfunction, and failure to thrive (Sx begin within the first 24 hours)

263
Q

What does opiate use during pregnancy increase the risks of?

A

increased risk of fetal growth restriction, placental abruption, placental insufficiency, premature delivery, miscarriage, and fetal death

264
Q

What does cocaine use during pregnancy increase the risks of?

A

IUGR, placental abruption, preterm birth, and spontaneous abortion

265
Q

What initiates stage I lactogenesis? Stage II?

A

Stage I - initiation of secretion - begins as a response to the high levels of circulating progesterone
Stage II - activation of secretion of large amounts of breastmilk - response to the rapid decline in progesterone after delivery of the placenta and supported by the presence of prolactin and cortisol

266
Q

What is the most appropriate management for primary dysmenorrhea when NSAIDs fail to control pain?

A

trial of OCPs

267
Q

What markers are elevated with granulose cell tumors?

A

estradiol and inhibin

268
Q

What is involved in fetal biometry?

A

combo of measurement of the biparietal diameter measurement, the femur length, the humerus length, the head circumference, and the abdominal circumference

269
Q

What is the next step in management of a patient with premature rupture of membranes following PE, neuro exam, pelvic exam, and a non stress test?

A

biometric measurement of the fetus

270
Q

What are the two progesterone-only birth control options? For whom are these the best option?

A

progestin-only pill and depot medroxyprogesterone acetate (DMPA)

Used in women who smoke and are more than 35 years old

271
Q

systemic illness with maculopapular rash with nasal discharge, LAD, HSM, and hemolysis in a 3-8 week old newborn? Tx?

A

congenital syphilis; tx = penicillin

272
Q

facial clefts, omphalocele, and cardiac anomalies; cystic hygroma, polydactyly, holoporsencephaly - disorder? What would be seen on quad screen?

A

Patau (trisomy 13); quad screen cannot be used for Patua syndrome

273
Q

clenched fists, overlapping digits, cardiac anomalies, neural tube defects, and congenital diaphragmatic hernia; rocker bottom feet, choroid plexus cysts - disorder? What would be seen on quad screen?

A

Edward syndrome (trisomy 18); low hCG, AFP, and estriol

274
Q

duodenal atresia on u/s, cardiac anomalies, shortened limbs - disorder? What would be seen on quad screen?

A

Down syndrome (trisomy 21); elevated hCG and inhibin-A, low estriol and AFP

275
Q

What are the common clinical manifestations of preeclampsia?

A

diffuse edema, severe headache, visual disturbances, and abdominal pain

276
Q

What is Ashermann syndrome? What is the gold standard for diagnosis?

A

amenorrhea due to intrauterine adhesions; the gold standard for diagnosis of intrauterine adhesions is hysteroscopy

277
Q

What is the Jarisch-Herxheimer reaction?

A

HA, fever, flushing, tachycardia, hypotension that begins 1-2 hours after the initiation of antibiotic therapy for syphilis; self-limited to 24-48 hours; Tx with acetaminophen and IV fluids as needed

278
Q

Extensively explain when you might see the different hepatitis serum markers? (HBsAg, anti-HBs, HBeAg, Anti-HBc IgM and IgG)

A

HBsAg - present through the incubation period and infectious state
Anti-HBs - if a patient gains immunity to this virus, either due to infection of immunization, HBsAg changes to this
(neither will be present in the window phase)
HBeAg - Hep B early antigen; indicates active viral replication in the liver; always present in the acute phase and may or may not be present in the chronic stage
Anti-HBc - present during the acute, chronic, or previous hep B infections (including window phase)_
Anti-HBc IgM changes to IgG during the chronic infection

279
Q

What happens to the TSH level during the first trimester of pregnancy?

A

elevated levels of hCG act like TSH an stimulate the thyroid gland leading to an increase in total thyroxine and triiodothyronine levels (feedbacks to decrease TSH)

280
Q

When is colposcopy indicated? (7)

A
  1. persistent atypical cells of undetermined significance (ASCUS) or ASCUS with positive thigh-risk HPV subtypes
  2. ASC suggestive of high-grade lesion (ASC-H)
  3. Atypical glandular cells (ACG)
  4. Low-grade squamous intraepithelial lesions (LSIL)
  5. High-grade squamous intraepithelial lesion (HSIL)
  6. Lesions suspicious for invasive cancer
  7. . Presence of malignant cells
281
Q

Which procedure is preferred: cryotherapy or laser vaporization? Why?

A

Cryotherapy is generally preferred over laser vaporization.
Advantages of cryotherapy: in-office, minimally invasive, less perioperative pain, cheaper cost, less bleeding risk, less risk of disease recurrence
The only advantage laser vaporization offers is preservation of the squamocolumnar junction, which allows subsequent colposcopic examinations to remain adequate

282
Q

What are the preferred medications for alcohol cessation in a pregnant woman? Which therapies are contraindicated?

A

naltrexone is preferred; can use benzos if needed (but not daily)

C/I - acamprosate, disulfiram, topiramate

283
Q

What quad screen results are expected when an u/s of a fetus shows apparent disruption of the fetal skin contour overlying the lumbar region?

A

increased alpha-fetoprotein

284
Q

What are the seven cardinal movements of labor? (in order)

A
  1. Engagement
  2. Descent
  3. Flexion
  4. Internal rotation
  5. Extension
  6. External rotation
  7. Expulsion
285
Q

What are complications of amniocentesis? When can it be performed?

A

Amniocentesis is performed after 15 weeks gestation.
Complications: leakage of amniotic fluid (most common), frank rupture of membranes prematurely, direct and indirect fetal injury, infection, and fetal loss

286
Q

What are the risk factors for endometrial carcinoma?

A

tamoxifen use, unopposed estrogen therapy, obesity, increasing age, a family history of endometrial cancer or HNPCC/Lynch, early menarche, and late menopause

287
Q

What changes in the breast are expected during the first trimester?

A

increasing branching of the ductal tree and increasing secretory gland formation

288
Q

What changes in the breast are expected during the second and third trimesters?

A

lobular formation and enlargement, eventually nearly eliminating the fat and connective tissue stroma (accompanied buy the enlargement of the breasts)

289
Q

What changes in the breast are expected at the time of parturition?

A

glandular proliferation and mitosis with scant remaining stroma

290
Q

What initiates stage I lactogenesis? Stage II?

A

Stage I - initiation of secretion - begins as a response to the high levels of circulating progesterone
Stage II - activation of secretion of large amounts of breastmilk - response to the rapid decline in progesterone after delivery of the placenta and supported by the presence of prolactin and cortisol

291
Q

What is the most appropriate management for primary dysmenorrhea when NSAIDs fail to control pain?

A

trial of OCPs

292
Q

deafness, cataracts or retinopathy, cardiac malformations (PDA), encephalitis, HSM with jaundice, and a petechial and puerperal rash in a newborn?

A

congenital rubella

293
Q

hearing loss, HSM with jaundice, thrombocytopenia, chorioretinitis, cerebral calcifications, seizures, and microcephaly in a newborn?

A

congenital CMV

294
Q

rapidly progressing systemic septic encephalitis, irritability, lethargy, and unable to feed in a newborn?

A

neonatal HSV

295
Q

HSM with jaundice, disseminated purpuric rash, hydrocephalus, chorioretinitis, seizures, intracranial calcification, and ring-enhancing lesions in the brain parenchyma in a newborn? Tx?

A

congenital toxoplasmosis; tx = pyrimethamine and sulfadiazine

296
Q

systemic illness with maculopapular rash with nasal discharge, LAD, HSM, and hemolysis in a 3-8 week old newborn? Tx?

A

congenital syphilis; tx = penicillin

297
Q

What is the purpose of prostaglandins and osmotic dilators during pregnancy termination with dilation and evacuation?

A

avoiding cervical lacerations

298
Q

fever, uterine tenderness, and purulent loch in the first 10 days after parturition?

A

postpartum endometritis

299
Q

What are risk factors for chroioamnionitis? How does it present? How does this differ from endometritis?

A

Risk factors: prolonged labor, prolonged rupture of membranes, internal fetal or uterine monitoring, tobacco use
Pt: fever, fetal tachycardia, maternal tachycardia, uterine tenderness, and foul vaginal odor
Endometritis is a postpartum infection of the decidua whereas chorioamnionitis is an infection fo the amniotic fluid, fetal tissue, placenta, and/or decidua.

300
Q

What is the definition of false labor?

A

unchanging cervical examination despite continued uterine contractions (cervical effacement of at least 80% and cervical dilation of more than 2 cm is the onset of labor)

301
Q

What is the presentation of maternal rubella infection? What is the next step in management of a pregnant patient with rubella?

A

Pt - maculopapular, slightly pruritic rash that begins on the face and travels to the trunk and extremities; tender LAD, arthralgias, mild fever, and fatigue

The most appropriate next step in managing a patient who acquires rubella prior to 18 weeks gestational age is to counsel her regarding pregnancy termination

302
Q

What is Mittelschmerz?

A

lower abdominal or pelvic paint hat occurs midway during the menstrual cycle at the time of ovulation; typically the pain is sudden in nature and may last anywhere from a few hours to several days

303
Q

What are risk factors for preterm labor? (10)

A
  1. African American race
  2. inter-pregnancy interval of 6 or less months
  3. prior preterm delivery
  4. infection
  5. Stressful working or living conditions
  6. low BMI
  7. tobacco use
  8. sexual abuse
  9. multiple gestation pregnancy
  10. Age less than 18 or older than 35
304
Q

heavy vaginal bleeding, pelvic pressure, N/V, and elevated beta-hCG?

A

hydatidiform mole

305
Q

What are risk factors for umbilical cord prolapse? (5)

A
  1. non-vertex fetal presentation
  2. prematurity
  3. iatrogenic or spontaneous rupture of membranes
  4. polyhydramnios
  5. multiparity
306
Q

What is the most common presentation of umbilical cord prolapse? What is the best management?

A

The most commons sign of umbilical cord prolapse is prolonged fetal bradycardia.

Emergent cesarean delivery; while awaiting delivery, a few things can help: manually elevating the presenting fetal part, bladder filling, placing the patient in steep Trendelenburg or knee-chest position, and administering tocolytics

307
Q

What antibiotic prophylaxis should be administered for cesarean delivery? In what time frame?

A

cefazolin within 60 minutes of the start of the procedure; clindamycin is used in combo with an aminoglycoside (gentamicin or tobramycin) for patients with severe penicillin allergy

308
Q

What are the two classic findings of hyperemesis gravidarum?

A

weight loss of more than 5% of pre-pregnancy weight and ketonuria

309
Q

What are risk factors for uterine atony?

A
  1. macrocosmic fetus
  2. prolonged induction of labor
  3. administration of magnesium
  4. polyhydramnios
  5. chorioamniotinitis
310
Q

What is the MOA of misoprostol? What is it used for? C/I?

A

MOA - prostaglandin E1 analogue that causes vascular constriction by the uterine smooth muscle

Used in cases of uterine atony.

No significant C/I.

311
Q

What is the MOA of 15-methyl-PGF2-alpha? What is it used for? C/I?

A

MOA - prostaglandin F2-alpha analogue that constricts the smooth muscle of the uterus to close the bleeding uterine vasculature bed

Used in cases of uterine atony.

C/I: asthma

312
Q

What is the MOA of methylergonovine? What is it used for? C/I?

A

MOA - ergot alkaloid that directly constricts blood vessels

Used in cases of uterine atony.

C/I: hypertensive disease (chronic HTN, preeclampsia, gestational HTN)

313
Q

Path, Pt, Dx, and Tx of endometrial polyps

A

Path: benign overgrowths of endometrial tissue that occur most commonly in women 40-50yo
Pt: bleeding between periods (metrorrhagia) but can also present with heavy/prolonged bleeding (menorrhagia) or heavy/prolonged bleeding AND bleeding between periods (menometorrhagia)
Dx: pelvic u/s or sonohysterogram
Tx: hysteroscopic polypectomy

314
Q

When does the placenta take over the production of progesterone from the corpus luteum?

A

after the first 35-47 days post-ovulation

315
Q

What are the risk factors for primary dysmenorrhea? (4)

A
  1. nulliparity
  2. heavy menstrual flow
  3. smoking
  4. depression
316
Q

If the IgG anti-Rh(D) antibodies are present in a pregnant mother, what is the next step in management?

A

u/s of the fetus to assess for evidence of hydrops fetalis

317
Q

How is hydrops fetalis diagnosed on u/s?

A

2 or more of the following: ascites, pleural effusion, pericardial effusion, skin edema, and polyhydramnios

318
Q

What are the most common indications for cesarean delivery? (3)

A
  1. failure to progress (arrest of dilation or arrest of fetal descent) during labor
  2. non-reassuring fetal heart tones
  3. fetal malpresentation
319
Q

When is there the greatest risk of maternal-fetal transmission of HIV? What is the management at that stage?

A

Risk of maternal-fetal transmission is greatest when the viral load is greater than 1000 copies per mL.

For these women, cesarean delivery is recommended prior to the beginning of labor or rupture of membranes (usually 38 weeks)

320
Q

When should testing for chlamydia, gonorrhea, and HIV start? How often?

A

women under 24 yo who have been sexually active should be tested q 1 year for chlamydia, gonorrhea, and HIV

321
Q

unilateral micro calcifications found on mammography are what?

A

ductal carcinoma in situ until proven otherwise

322
Q

unilateral serosanguinous breast discharge in a non lactating woman?

A

intraductal papilloma

323
Q

> 20 weeks gestation with sudden-onset vaginal bleeding, abdominal pain, back pain, and uterine contractions?

A

placental abruption

324
Q

What are the risk factors for placental abruption? (6)

A
  1. advanced maternal age
  2. HTN
  3. cigarette smoking
  4. cocaine use
  5. African American race
  6. external trauma
325
Q

Which antiviral for tx of Hep B is safest to use in pregnancy?

A

tenofovir

326
Q

What testing is used to screen for HIV? What is the confirmatory testing?

A

Screening - fourth generation assays that detect the HIV p24 antigen and HIV antibodies

If positive, should be followed by a confirmatory HIV-1/HIV-2 antibody differentiation immunoassay

327
Q

What is the treatment for postpartum endometritis?

A

clindamycin and gentamicin

328
Q

How is arrest of labor during the first stage defined?

A

Arrest of the first stage of labor is diagnosed only after 6 cm of dilation.

The diagnosis is made when a woman has had 4 or more hours of adequate uterine contractions with no cervical change or when a woman has received oxytocin for 6 or more hours with no cervical change

329
Q

Which medications are known to cause hyperprolactinemia?

A

antipsychotics (especially haloperidol, chlorpromazine, risperidone), CCBs (verapamil), histamine receptor antagonists (cimetidine and ranitidine), estrogens, and metoclopramide

330
Q

Pt of toxic shock syndrome caused by group A strep? What other organisms can cause toxic shock syndrome? How does their presentation differ?

A

Pt - early, high fever and hypotension with a diffuse erythematous, desquamating rash and evidence of involvement of at least two organ systems (renal, liver, or pulmonary insufficiency, coagulopathy, soft tissue necrosis)

Organisms that can cause toxic shock syndrome: group A streptococcus, Staphylococcal aureus, or Clostridium sordellii

Clostridium sordellii will have absence of rash or fever and absence of rash or muscle necrosis

331
Q

What are the risk factors for a newborn to be born with brachial plexus injuries that occur during delivery? (8)

A
  1. forceps- or vacuum-assisted delivery
  2. multiparity
  3. large for gestational age (birth weight greater than the 90th percentile)
  4. maternal diabetes
  5. breech presentation
  6. previous child with birth-related brachial plexus injury
  7. shoulder dystocia
  8. prolonged second stage of labor (>120 min or 180 with epidural)
332
Q

What is one important step in workup of a granulosa cell tumor?

A

endometrial sampling to rule out hyperplasia or carcinoma because granulose cell tumors produce estrogen

333
Q

abdominal bloating, increased abdominal girth, early satiety, and vague pelvic pain, pressure, and/or nausea due to GI obstruction?

A

ovarian cancer

334
Q

At what point should pregnant women with iron deficiency anemia receive treatment? What type of treatment?

A

Pregnant women with IDA (ferritin less than 30) should receive iron supplementation.

During the 1st trimester, only oral iron supplementation is recommended.

During the 2nd and 3rd trimesters, oral or IV iron can be used. IV iron should be used when the patient does not tolerate oral iron, when the Hgb does not increase as expected with oral iron, and when IDA is severe (HgB 8-10)

335
Q

When is asymptomatic bacteriuria diagnosed? What is the treatment?

A

diagnosed when there is greater than 100,000 colony-forming units

Abx Tx: cephalexin, nitrofurantoin, amoxicillin, amoxicillin-clavulanate, or fosfomycin

COMLEX 2 (11 decks)

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