OBGYN COMAT Flashcards
Etiology, precancer, cancer, screening, and presentation of cervical/vaginal/vulvar cancer?
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
Etiology, precancer, cancer, screening, and presentation of endometrial cancer?
Etiology: estrogen Precancer: dysplasia/atypia Cancer: adenocarcinoma Screening: none Pt: post-menopausal bleeder
Etiology, precancer, cancer, screening, and presentation of epithelial ovarian cancer?
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
Etiology, precancer, cancer, screening, and presentation of choriocarcinoma?
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
Which types of HPV are associated with malignancy?
HPV 16, 18, 30s
Which types of HPV are associated with warts?
HPV 6, 11
describe stage 1 cervical caner including 1A and 1B
involves only the cervix
1A = microscopic (only seen on cytology)
1B = macroscopic (can see with naked eye)
Involvement of the upper 2/3 of the vagina with cervical cancer makes it stage what?
2A
Involvement of the lower 1/3 of the vagina with cervical cancer makes it stage what?
3A
any involvement of the cardinal ligament in cervical cancer makes it stage what?
2B
Involvement of the pelvic side wall in cervical cancer makes it stage what?
3B
Distant metastases in cervical cancer makes it stage what?
4
what is the difference between 4A and 4B staging for cervical cancer?
4A = involvement of adjacent organs 4B = distant metastasis
What is the screening recommendation for Pap smears?
screen regardless of sexual activity q3 years stating at age 21
How often do you screen with Pap smears if the woman is HPV positive?
q1 year
In what scenario can you do Pap smears q5 years?
over age 30 when combined with HPV testing (can stop at age 65)
What is the next step on a positive Pap smear?
colposcopy (ectocervical inspection and endocervical curettage)
If +endo on colposcopy, what is the next step?
cone biopsy
If +ecto, -endo on colposcopy, what is the next step?
local ablation - cryo or leep
If a patient has ASCUS with an uncertain Pap smear, what is the next step?
HPV DNA or q6 months pap
What stage of cervical cancer requires chemo and radiation?
> /= 2B
What is the treatment for endometrial cancer?
total hysterectomy + bilateral salpingo-oophorectomy (removes the source of estrogen)
What is the next step in workup of a patient with post-menopausal bleeding?
in office endometrial sampling or D+C
If in office endometrial sampling or D+C is positive for hyperplasia, what is the next step? Who is this usually found in?
usually found in reproductive age females; give high dose progesterone
What are 4 presentations of endometrial cancer? What is the Dx?
- old + obese
- old + HRT/SERM
- young + PCOS
- granulosa-theca tumor
All present with vaginal bleeding
Dx: endometrial sampling or D+C (not pelvic u/s)
What are the 4 germ cell tumors of the ovary, and what are their tracking substances?
- dysgerminomas: chemo, LDH
- Endometrial sinus: AFP
- Teratoma: none; can cause storm ovarii
- choriocarcinoma: beta-hCG
Path, pt, dx, and tx of germ call ovarian tumors
Path: nonmalignant
Pt: teenage girls, adnexal mass, weight gain, stage I
Dx: transvaginal ultrasound
Tx: unilateral salpingo-oophorectomy
What are the 4 types of epithelial cell ovarian tumors?
serous, mucinous, endometroid (all 3 cyst adenomas), Brenners
What is the Path, pt, dx, and tx of epithelial cell ovarian tumors?
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
What are the 2 stromal cell ovarian tumors? What do they produce?
granulosa theca - produce estrogen
Sertoli-Leydig - produce testosterone
What findings on transvaginal u/s would make you think of a simple cyst? What is the next step?
smooth, small, no septations; stop workup
What findings on transvaginal u/s would make you think of a complex cyst? What is the next step?
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
What is the path, pt, dx, tx, and f/u of a complete mole?
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
What is the path, pt, dx, tx, and f/u of an incomplete mole?
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
Choriocarcinoma path, pt, dx, and tx
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)
What is the presentation, dx, and tx of SCC and melanoma of the vulva?
Pt: black and itchy lesion
Dx: biopsy
Tx: vulvectomy + LN dissection
What is the Pt, Dx, and Tx of Paget’s disease of the vulva?
Pt: red and itchy lesion
Dx: biopsy
Tx: wide local resection
If you see a grape-like mass in the vagina (not coming out of the cervix), what should you think of?
adenocarcinoma of the vagina caused by DES exposure
What is the definition of postpartum hemorrhage? What are the steps to stopping hemorrhage?
500cc after a vaginal birth and 1000cc after a C-section
- uterine massage
- oxytocin (methergin/hemabate - not the correct answer)
- balloon tamponade
- surgery -> uterine artery ligation -> internal iliac artery ligation -> TAH
What is significant about the uterosacral ligaments?
they need to be cut during a hysterectomy, but they look a lot like the ureter
path, pt, dx, and tx of pelvic floor relaxation
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)
How do you grade uterine inversion?
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
What is significant about the suspensory ligament of the ovary?
ovarian blood supply runs through here; can twist upon itself -> ovarian torsion
What ovarian cancers are commonly found in premenarchal women? Which ones are commonly found in post menopausal women? Reproductive age?
premenarchal: germ cell
post-menopausal: epithelial
reproductive: all ovarian cysts are likely benign
What test helps to evaluate an ovarian cyst?
transvaginal ultrasound (MRI is very expensive)
ovarian cyst/mass <3 cm -> next step?
nothing
ovarian cyst/mass <10cm -> next step?
repeat imaging in a couple of months
ovarian cyst/mass >10cm -> next step?
needs to be removed (laparoscopy > laparotomy)
ovarian cyst/mass that grows or fails to resolve -> next step?
needs to be removed (laparoscopy > laparotomy)
What are 6 types of complex ovarian masses?
- teratoma
- endometrioma
- ectopic
- torsion
- tubo-ovarian abscess
- cancer
path, pt, dx, and tx of ovarian teratoma
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)
path, pt, dx, and tx of ovarian endometrioma/endometriosis
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
path, pt, dx, and tx of ectopic pregnancy
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
path, pt, dx, and tx of ovarian torsion
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
path, pt, dx, and tx of tube-ovarian abscess
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
path, pt, dx, and tx of stress incontinence
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)
Describe a positive q-tip test for stress incontinence
apply q-tip to urethra; if it rotates more than 30 degrees, you have urethral mobility -> stress incontinence
path, pt, dx, and tx of hypertonic/motor urge/overactive bladder
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)
path, pt, dx, and tx of hypotonic/overfill/neurogenic bladder
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
path, pt, dx, and tx of irritated bladder
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
path, pt, dx, and tx of fistulas
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
Describe the tampon test for diagnosis of fistulas
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
pt, wet mount, and tx of candida vaginal infections
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)
pt, wet mount, and tx of bacterial vaginosis
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)
pt, wet mount, and tx of trhichomonas
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)
Path, pt, dx, and tx of cervicitis
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)
Path, pt, dx, and tx of PID
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
What is the most common cause of vaginal bleeding in the premenopausal female? reproductive age female? Post-menopausal female?
pre-menopausal: foreign body
reproductive: pregnancy
post-menopausal: vaginal atrophy
What is the most concerning cause of vaginal bleeding in the premenopausal female? Reproductive age? Post-menopausal?
pre-menopausal: sexual abuse
reproductive: anatomy, dysfunctional uterine bleeding, and cervical cancer
post-menopausal: endometrial cancer
What are the steps in management of a life-threatening pelvic bleed?
- 2 large bore IVs
- IVF boluses
- type and cross, transfusion
- IV estrogen (to stop uterine bleeding)
- surgical intervention
What are 4 options for surgical intervention of uterine bleeding?
- intracavitary tamponade
- D+C (preferred)
- UAE (uterine artery embolization) - usually for AVMs or fibroids
- total abdominal hysterectomy
passage of contents, os status, and u/s of a threatened abortion
no passage of contents, os is closed, u/s shows live baby (there’s just some bleeding that tips you off)
passage of contents, os status, and u/s of an inevitable abortion
no passage of contents, os is open, u/s shows baby is dead
passage of contents, os status, and u/s of an incomplete abortion
passage of clots or fetal tissue, os is open, u/s might show retained parts
passage of contents, os status, and u/s of a complete abortion
there was passage of contents, os is closed, ultrasound does not show a baby
passage of contents, os status, and u/s of a missed abortion
no passage of contents, os is closed, u/s shows dead baby (abortion happened but mom does not know)
What is medical management of a missed abortion?
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
If trasnvaginal u/s reveals an ectopic pregnancy with rupture or hemodynamic instability, what is the next step in management?
salpingectomy
If transvaginal u/s reveals an ectopic pregnancy without rupture and the patient is hemodynamically stable, what is the next step in management?
salpingostomy (open up tube and suck out ectopic)
What is the criteria to be able to use methotrexate +/- leucovorin for treatment of an ectopic pregnancy?
- beta-HCG < 5,000
- gestational size < 3.5 cm
- no fetal heart sounds
- mom should not have been on folate
If transvaginal u/s is inconclusive and the beta-HCG is >/= 1500, what do you do?
treat it like an ectopic
If transvaginal u/s is inconclusive and the beta-HCG is <1500, what do you do? What are the next steps?
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
Path, Pt, Dx, and Tx of uterine fibroids
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
What are the diagnostic criteria for PCOS?
- history of anovulation
AND - biochemical evidence of hyperandrogenism (LH:FSH > 3:1)
OR - imaging evidence of multiple ovarian follicles
precocious puberty workup
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)
At what approximate age and in what order does puberty occur for a girl?
breasts (age 8), axillary (age 9), growth spurt (age 10), menarche (age 11)
What is the treatment for constitutional central precocious puberty?
continuous leuprolide (turn off GnRH axis to allow bone age to catch up)
If GnRH stimulation test fails to change LH, what are the next steps in workup?
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)
what is the diagnostic definition of delayed puberty? What are the next steps in workup?
no secondary sexual characteristics by 13; no menarche by 15
do bone age and biochemical profile (LH/FSH)
What is the diagnosis with delayed puberty and increased FSH and LH? What is the next step in workup?
hypergonadotropic hypogonadism -> karyotype
What is the diagnosis with delayed puberty and non elevated FSH and LH? What is the next step in work-up?
hypogonadotropic hypogonadism -> prolactin level, TSH/free T4, pregnancy test, CBC, LFT, ESR, MRI
What is the next step in workup with hypogonadotropic hypogonadism with all subsequent testing negative (cannot find a cause, ie constitutional)
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
What are the possible diagnoses of a female who is > 15 yo, has not had menses, has a normal HPA, and has normal anatomy?
anorexia/weight loss, pregnancy prior to first bleed, imperforate hymen
What are the possible diagnoses of a female who is > 15 yo, has not had menses, has a normal HPA, but has abnormal anatomy?
~Qw34Mullerian agenesis - (X, X) with normal testosterone
androgen insensitivity syndrome/testicular feminism - (X,Y) with elevated testosterone
What are the diagnoses of a female who is > 15 yo, has not had menses, has normal anatomy, but lacks a normal HPA?
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
Craniopharyngioma/Kallmann’s syndrome
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
What do the mullerian ducts normally develop into?
upper 1/3 of vagina, uterus, tubes
Mullerian agenesis
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
Androgen insensitivity syndrome
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
Mullerian agenesis path, Pt, Dx, and Tx
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
Androgen insensitivity syndrome path, pt, dx, and tx
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
Turner syndrome
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
What is the definition of secondary amenorrhea?
3 consecutive cycles with no menses (in a patient who previously did have menses)
What are the 5 main causes of secondary amenorrhea?
- pregnancy (urine pregnancy test)
- hypothyroid (TSH)
- prolactinemia or prolactinoma (prolactin)
- medications
- HPO axis
What is the first step in workup when evaluating the HPO axis for secondary amenorrhea? When does this usually happen?
progesterone challenge; this usually happens at 6 months of amenorrhea (after negative workup of the most common causes at 3 months)
In the work-up of secondary amenorrhea, a positive progesterone challenge test means what diagnosis?
positive progesterone challenge test means progesterone caused menses -> PCOS dx
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?
give estrogen and progesterone; if does not cause menses -> problem with the endometrium -> Ashermann’s or ablation
What is the next step in workup of secondary amenorrhea following a negative progesterone challenge test, and positive estrogen + progesterone test?
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)
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?
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)
What is the treatment for organic erectile dysfunction?
phosphodiesterase inhibitors - tadalafil, sildenafil
What is the first step in workup of female infertility?
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
What is the treatment for hostile mucous?
estrogen or artificial insemination
What is a normal result on a mucous workup for female infertility? What’s the next step in workup?
normal test if >/= 6 cm on smush test and + for sperm, + fern sign
Now need to assess ovulations
If a female is found to be anovulatory in infertility workup, what is the treatment?
clomiphene or pergonal (clomiphene preferred)
if both mucous and ovulation are found to be normal on female infertility workup, what is the next step?
hysterosalpingogram -> visualize uterus and tubes
if mucous, ovulation, and hysterosalpingogram are found to be normal, what is the last step in workup?
exploratory laparotomy to look for endometriosis
How do clomiphene and pergonal work?
clomiphene disinhibits GnRH so the axis can continue; pergonal becomes FSH/LH
PE, testosterone level, DHEA-S level, imaging, Dx, and Tx of PCOS
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
PE, testosterone level, DHEA-S level, imaging, Dx, and Tx of Sertoli-Leydig tumor of ovary
PE: virilization Testosterone: very elevated DHEA-S: normal Imaging: unilateral ovary involvement Dx: transvaginal u/s Tx: resection
PE, testosterone level, DHEA-S level, imaging, Dx, and Tx of adrenal tumor
PE: virilization Testosterone: normal DHEA-S: very elevated Imaging: unilateral adrenal gland involvement Dx: CT/MRI; adrenal vein sampling Tx: resection
PE, testosterone level, DHEA-S level, imaging, Dx, and Tx of congenital adrenal hyperplasia
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)
PE, testosterone level, DHEA-S level, imaging, Dx, and Tx of familial hirsutism
PE: hirsutism Testosterone: normal DHEA-S: normal Imaging: normal Dx: N/A Tx: cosmetic/symptomatic
Path, Pt, Dx, and Tx of menopause
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
At what age are women screened for osteoporosis? What is the treatment? What measures can prevent osteoporosis?
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
What changes in vitals are expected in a pregnant woman?
decreased MAP due to decreased SVR; increased HR, increased preload, increased RBC, decreased Hgb (increased RBC/very increased plasma)
What are the changes to the primary clotting cascade in pregnancy?
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
What are the changes to the secondary clotting cascade in pregnancy?
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)
What are the changes to the kidney function during pregnancy?
increased GFR thus decreased Cr (normal = 0.4-0.8); obstructive uropathy at the pelvic brim as the uterus grows
How much weight should a woman gain during pregnancy?
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)
What GI side effects can you expect during pregnancy, and what are their treatments?
GERD -> PPI
nausea -> ondansetron
constipation -> stool softeners or motility agents
iron deficiency anemia -> iron (which will worsen constipation)
Explain the gravid/para/abortions system
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
What labs should be collected at the 10 weeks pregnancy appt?
Blood: ABO, Rh-Ag, Hgb/Hct, HIV, HepB, RPR, Titers for varicella and rubella
Urine: U/A + culture, proteinuria, gc/chlamydia
Cytology: Pap smear
Aneuploidy path, pt, dx, and tx
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
What is involved in a first trimester screening for aneuploidy?
u/s for nuchal translucency (<3 mm), PAPP-A, hCG
What is involved in a second trimester screening for aneuploidy?
Triple screen: hCG, AFP, estriol
Quad screen: above + inhibin-A
What are the expected results for a quad screening for Downs syndrome?
hCG: up
AFP: down
Estriol: down
Inhibin-A: up
What are the expected results for a quad screening for Edwards syndrome?
hCG: down
AFP: down
Estriol: down (very low)
Inhibin-A: down
path, pt, dx, and tx gestational diabetes
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
Explain the methods and cut off points for the 1 hour and 3 hour glucose tolerance tests for pregnant women
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
What 3 things are screened for during week 20-28 weeks of pregnancy?
gestational diabetes, alloimmunization, and maternal anemia
Path, pt, dx, and tx of alloimmunization
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
path, pt, dx, and tx of maternal anemia
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
How accurate is u/s for determining gestational age?
1st trimester = gestational age +/- 1 week
2nd trimester = gestational age +/- 2 weeks
3rd trimester = gestational age +/- 3 weeks
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?
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
When do you use amniocentesis? What is the goal of the study? What is the risk to the baby?
When: > 16 weeks
Goal: genetic disorders (Down’s)
Risk: 1/300 death
(almost always the wrong answer on test)
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?
When: > 10 weeks
Goal: genetic disorder dx with karyotype and genes
Risk: 1/500 death
Benefit: early detection -> early termination
When do you use percutaneous umbilical blood sampling? What is the goal of the study? What is the benefit of this test?
When: >20 weeks but <34 weeks
Goal: fetal anemia
Benefit: allows access (can transfuse through), allows confirmation
What do you use to treat asymptomatic bacteruria in a pregnant female?
amoxicillin
nitrofurantoin as 2nd line
cannot use: TMP-SMX or cipro
**and rescreen after treatment
What is the treatment for pyelonephritis in a pregnant woman?
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
Path, pt, dx, and tx of thyroid disorders in pregnancy
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)
path, pt, dx, and tx of seizure drugs
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)
If a pregnant woman experiences a seizure (with a prior hx of epilepsy), what treatment can be given?
phenobarbital + folate (essential)
What is the goal and treatment of HTN in a pregnant woman? (someone who already has HTN)
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
What is the goal and treatment plan of a diabetic woman who would like to conceive? (before, during, and post pregnancy)
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
What is the effect on the fetus of having uncontrolled sugars early on in pregnancy?
cardiac defects, especially transposition of the great vessels
What is the effect on the fetus of having uncontrolled sugars during pregnancy?
macrosomia -> increased risk of shoulder dystocia and C-section requirement
What is the difference between frank breech, complete breech, and footling positions?
frank breech: hips flexed, knees extended
complete breech: hips flexed, knees flexed
footling: hip extended
What constitutes prolonged or arrested active phase of labor? What do you use to help his?
no change in 4 hours or > 5 hours total of inadequate contractions; give oxytocin
What constitutes adequate contractions? If you do not have these, what can you do to help?
200 mV in 10 minutes (measure via IUPC); can give oxytocin
What are the steps in management of prolonged stage III of labor?
- uterine massage
- oxytocin
- manual extraction
What is the definition of prolonged rupture of membranes?
> 18 hours from rupture of membranes to end of labor
path, pt, dx, and tx of ruptured membranes
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
path, pt, dx, and tx of premature ROM
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
path, pt, dx, and tx of pre-term premature rupture of membranes
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
path, pt, dx, and tx of prolonged ROM
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
path, pt, dx, and tx of endometritis/chorioamnionitis
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)
path, pt, dx, and tx of preterm labor
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
What risk factors increases mom’s chance of having preterm labor?
smoking, decreased maternal age, multiple gestations, preterm ROM, uterine anatomical defects
path, pt, dx, and tx of post-dates
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
transient HTN: BP, timing, U/S, Sxs, Tx, and f/u
BP: >/= 140/80 Timing: non sustained elevation U/A: nothing Sxs: nothing Tx: nothing F/u: keep log of BP
chronic HTN: BP, timing, U/S, Sxs, Tx, and f/u
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
gestational HTN: BP, timing, U/S, Sxs, Tx, and f/u
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
preeclempsia w/o severe features: BP, timing, U/S, Sxs, Tx, and f/u
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
preeclampsia with severe features: BP, timing, U/S, Sxs, and tx
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)
eclempsia: BP, timing, U/S, Sxs, and Tx
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)
HELLP syndrome acronym, tx
H - Hemolysis
EL - Elevated Liver enzymes
LP - low platelets
Tx - give Mg+ and deliver
What are severe features of HTN in pregnancy?
decreased platelets, increased liver enzymes, RUQ abdominal pain, elevated Cr (1.1, or doubling), pulmonary edema, HA, vision changes, BP > 160/110
What are mag checks? Why/when are they used? What should you give on a positive mag check?
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
If the genders of twins are different, how many amnions and chorions are there?
have to be di-zygotic, di-amniotic, di-chorionic
What risks are involved with multiple gestations?
preterm labor, malpresentation -> increased risk of c-section
post partum hemorrhage
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?
mono-zygotic, mono-chorionic, di-amnionic twins
What are mono-chorionic twins at risk for?
twin-twin transfusion because they share the same blood supply
If you see on u/s twins that have the same gender, 1 placenta, no septum, and 1 sac - what is this called?
mono-zygotic, mono-chorionic, mono-amniotic
What are the risks of mono-amniotic twins?
conjoined twins and cord entanglement
path of di-zygotic, di-amniotic, di-chorionic twins
path: 2 fertilizations; 2 placentas; 2 sacs; often have 2 genders
path of mono-zygotic, di-chorionic, di-amniotic twins
path: 1 fertilization that split early
split between days 0-3 (tubal phase) - 2 separate placenta, 2 separate sacs
path of mono-zygotic, mono-chorionic, di-amniotic twins
path: 1 fertilization that split a little later
split between days 4-8 (blastocyst phase) - 1 placenta, 2 separate sacs
path of mono-zygotic, mono-chorionic, mono-amniotic twins
path: 1 fertilization that split late
split between days 9-12 for non conjoined twins and after day 12 for conjoined twins
What is the definition of post partum hemorrhage?
> 500 cc of blood loss with vaginal birth
> 1000 cc of blood loss with c-section
What PE findings should make you think of uterine inversion? What are the steps for treatment?
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
What PE findings should make you think of uterine atony? What are the steps for treatment?
postpartum hemorrhage with boggy uterus on physical exam
tx: uterine massage, restart oxytocin, medications
What PE findings should make you think of retained placenta? What are the steps for treatment?
postpartum hemorrhage and firm uterus on physical exam
tx: D+C but can progress to TAH
What PE findings should make you think of vaginal laceration? What are the steps for treatment?
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
What are solutions to unexplained ongoing postpartum bleeding?
uterine artery ligation
uterine artery embolization
total abdominal hyesterecomty
path, pt, dx, and tx of uterine atony
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
path, pt, dx, and tx of uterine inversion
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
path, pt, dx, and tx of vaginal laceration
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)
path, pt, dx, tx, and f/u of retained placenta
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
What laboratory levels do you expect in a pregnant woman with DIC?
decreased Hgb, decreased platelet, schistocytes, decreased fibrinogen, elevated INR
What is the treatment for DIC?
replenish stuff; give platelets, packed RBCs, cryoprecipitate, & FFP
What is the next step in workup following a non reassuring non stress test?
repeat the non stress test after vibroacoustic stimulation
What is the next step in workup following a non reassuring non stress test with vibroacoustic stimulation?
biophysical profile
What is the next step in workup following a biophysical profile score of 0-2?
deliver probably via c-section; impending fetal demise (if not already occurred)
What is the next step in workup following a biophysical profile score of 3-7?
make decisions based on gestational age
> 37 weeks -> high risk pregnancy; deliver (likely induction with vaginal delivery)
< 32 weeks -> contractions stress test
What is the next step in workup if a contractions tress test shows the absence of late decelerations and the absence of bradycardia?
this is a reassuring contraction stress test; leave baby in and give more time
What results on a contraction stress test indicate that fetal demise is imminent?
late decelerations and bradycardia
non stress test path, pt, dx, and tx
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
What HR constitutes fetal bradycardia? Fetal tachycardia?
bradycardia < 110
tachycardia > 160
What does 15/15, 2 in 20 mean?
We want 2 increases in HR within 20 minutes; the increases should be at least 15 bpm and last for 15 seconds each time
Biophysical profile
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
How is the amniotic fluid index measured?
add up four quadrants of womb (?), sum up and average;
oligo = < 5
reassuring 6-25
poly = >25
Path, pt, dx, and tx of contraction stress test
path: + contractions (done while in labor); looking for decelerations and bradycardia
pt: monitored in labor or has failed biophysical profile
What 3 types of decelerations should you know about? What do you do about each?
- Early deceleration - peak of deceleration occurs at the same time as the peak of contraction; represents head compression; requires no action
- Variable deceleration - no association between contractions and decelerations; represents cord compression; requires no action
- Late decelerations - decelerations begin when the peak of contractions occurs; represents utero-placental insufficiency; emergency C-section
What is considered adequate contractions? s
3 contractions/10 mins and 200 units
What are 3 causes of normal 3rd trimester bleeding? What do you want to order for workup? How is the diagnosis made?
- cervical lesions
- 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
Where does painless bleeding come from during pregnancy? Whose blood is it?
placenta; baby’s blood (always named with previa)
Where does painful bleeding come from during pregnancy? Who’s blood is it?
uterus; mom’s blood
path, pt, dx, and tx of placenta previa
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
path, pt, dx, and tx of vasa previa
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
path, pt, dx, and tx of uterine rupture
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)
pain, pt, dx, and tx of placental abruption
(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
In a fetus with possible hemolytic anemia, what is the diagnostic test of choice? What do you do if it’s positive? negative?
trans-cranial doppler; if negative -> stop work-up if positive (increased flow): deliver if >/= 32 weeks; if < 32 weeks -> percutaneous umbilical blood sampling/transfusion
path, pt, dx, and tx of group B strep
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)
What risk factors would make you give a mother treatment for GBS regardless of testing?
- previous pregnancy that was positive for GBS
- prolonged ruptured membranes
- intrapartum fever
Path, pt, dx, and tx of Hep B in pregnancy
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
Path, pt, dx, and tx of HIV in pregnancy
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
What is the treatment at the time of delivery for an HIV positive or suspected mom?
At delivery, 3 options:
- viral load < 1000 and currently on HAART -> deliver vaginally
- viral load > 1000 or stops taking HAART -> C-section
- unsure HIV status -> give AZT
Path, pt, and prevention of toxoplasmosis in pregnancy
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)
Path, pt, dx, and tx of syphilis in pregnancy (separate based on primary, secondary, tertiary)
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
What are the effects of syphilis on baby based on gestational age at infection?
1st trimester: dead baby
2nd trimester/early 3rd: Sniffles (rhinorrhea), Saber shins, saddle nose, Hutchison teeth
Path, pt, Tx, and prevention of Rubella
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)
Path and pt of CMV in pregnancy
Path: double-stranded DNA virus
Pt: looks like toxo but isn’t toxo
(likely to be a distractor on test according to OME)
Path, pt, dx, and tx of HSV
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
In what cases can you attempt vaginal delivery after a previous c-section? (VABC)
= 2 prior c-sections with low transverse incisions
When can you consider using vacuum or forceps assisted delivery?
fetal distress/prolonged labor/arrest of labor with full effacement and 2+ station
How do you grade vaginal lacerations?
I: only involves vagina
II: involves perineal body
III: involves anal sphincter
IV: involves anal mucosa and can cause a fistula
path, pt, tx, and risk of incompetent cervix
path: STIs, PID, multiple D+Cs
pt: multiple 2nd trimester losses
Tx: week 14 - insert cerclage; week 36 - remove
risk: cervical rupture
When should opiates be avoided during labor?
latent phase 1 d/t risk of prolongation; also if you give them very late in the labor baby will come out needing naloxone
epidural considerations/risks
- requires trocometer and breathing coach bc mom won’t be able to feel contractions anymore
- put it in the subdural -> hypotension -> death
paracervical block w/ lidocaine benefit and risk
benefit: helps pain in stage 1 of labor due to cervical dilation
risk: putting very close to baby -> can cause fetal bradycardia
pudendal nerve block benefit and risk
benefit: helps pain in stage II of delivery
risk: miss, no bad effects
What markers are elevated with granulose cell tumors?
estradiol and inhibin
How does the treatment of preeclampsia change based on gestation? When are antihypertensives used?
- 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)
Klinefelter syndrome path, pt, and labs
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
What are the two progesterone-only birth control options? For whom are these the best option?
progestin-only pill and depot medroxyprogesterone acetate (DMPA)
Used in women who smoke and are more than 35 years old
What are the steps of postpartum hemorrhage?
In this order:
- uterine massage
- IV fluids
- supplemental O2
- begin or increase oxytocin infusion
- methylergonovine (uterotonic medication)
- balloon tamponade
- uterine artery embolization or laparotomy
At 15 weeks gestational age, what is the normal rate of weight gain for the fetus?
5 grams per day
At 20 weeks gestational age, what is the normal rate of weight gain for the fetus?
10 grams per day
duodenal atresia on u/s, cardiac anomalies, shortened limbs - disorder? What would be seen on quad screen?
Down syndrome (trisomy 21); elevated hCG and inhibin-A, low estriol and AFP
What are the common clinical manifestations of preeclampsia?
diffuse edema, severe headache, visual disturbances, and abdominal pain
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?
4000 microgram/day; 400 micrograms/day minimum
What is the Jarisch-Herxheimer reaction?
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
Extensively explain when you might see the different hepatitis serum markers? (HBsAg, anti-HBs, HBeAg, Anti-HBc IgM and IgG)
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
What are the five parameters included int he fetal biophysical profile?
- fetal breathing movements
- gross fetal movement
- fetal tone
- amniotic fluid volume
- results of the non-stress test
(each is assigned a score of 0-2. A total score of 8-10 is normal)
When is colposcopy indicated? (7)
- persistent atypical cells of undetermined significance (ASCUS) or ASCUS with positive thigh-risk HPV subtypes
- ASC suggestive of high-grade lesion (ASC-H)
- Atypical glandular cells (ACG)
- Low-grade squamous intraepithelial lesions (LSIL)
- High-grade squamous intraepithelial lesion (HSIL)
- Lesions suspicious for invasive cancer
- . Presence of malignant cells
Which procedure is preferred: cryotherapy or laser vaporization? Why?
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
What are the preferred medications for alcohol cessation in a pregnant woman? Which therapies are contraindicated?
naltrexone is preferred; can use benzos if needed (but not daily)
C/I - acamprosate, disulfiram, topiramate
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?
increased alpha-fetoprotein
What are the seven cardinal movements of labor? (in order)
- Engagement
- Descent
- Flexion
- Internal rotation
- Extension
- External rotation
- Expulsion
What are complications of amniocentesis? When can it be performed?
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
What are the risk factors for endometrial carcinoma?
tamoxifen use, unopposed estrogen therapy, obesity, increasing age, a family history of endometrial cancer or HNPCC/Lynch, early menarche, and late menopause
neonatal abstinence syndrome from opiates
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)
What does opiate use during pregnancy increase the risks of?
increased risk of fetal growth restriction, placental abruption, placental insufficiency, premature delivery, miscarriage, and fetal death
What does cocaine use during pregnancy increase the risks of?
IUGR, placental abruption, preterm birth, and spontaneous abortion
What initiates stage I lactogenesis? Stage II?
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
What is the most appropriate management for primary dysmenorrhea when NSAIDs fail to control pain?
trial of OCPs
What markers are elevated with granulose cell tumors?
estradiol and inhibin
What is involved in fetal biometry?
combo of measurement of the biparietal diameter measurement, the femur length, the humerus length, the head circumference, and the abdominal circumference
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?
biometric measurement of the fetus
What are the two progesterone-only birth control options? For whom are these the best option?
progestin-only pill and depot medroxyprogesterone acetate (DMPA)
Used in women who smoke and are more than 35 years old
systemic illness with maculopapular rash with nasal discharge, LAD, HSM, and hemolysis in a 3-8 week old newborn? Tx?
congenital syphilis; tx = penicillin
facial clefts, omphalocele, and cardiac anomalies; cystic hygroma, polydactyly, holoporsencephaly - disorder? What would be seen on quad screen?
Patau (trisomy 13); quad screen cannot be used for Patua syndrome
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?
Edward syndrome (trisomy 18); low hCG, AFP, and estriol
duodenal atresia on u/s, cardiac anomalies, shortened limbs - disorder? What would be seen on quad screen?
Down syndrome (trisomy 21); elevated hCG and inhibin-A, low estriol and AFP
What are the common clinical manifestations of preeclampsia?
diffuse edema, severe headache, visual disturbances, and abdominal pain
What is Ashermann syndrome? What is the gold standard for diagnosis?
amenorrhea due to intrauterine adhesions; the gold standard for diagnosis of intrauterine adhesions is hysteroscopy
What is the Jarisch-Herxheimer reaction?
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
Extensively explain when you might see the different hepatitis serum markers? (HBsAg, anti-HBs, HBeAg, Anti-HBc IgM and IgG)
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
What happens to the TSH level during the first trimester of pregnancy?
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)
When is colposcopy indicated? (7)
- persistent atypical cells of undetermined significance (ASCUS) or ASCUS with positive thigh-risk HPV subtypes
- ASC suggestive of high-grade lesion (ASC-H)
- Atypical glandular cells (ACG)
- Low-grade squamous intraepithelial lesions (LSIL)
- High-grade squamous intraepithelial lesion (HSIL)
- Lesions suspicious for invasive cancer
- . Presence of malignant cells
Which procedure is preferred: cryotherapy or laser vaporization? Why?
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
What are the preferred medications for alcohol cessation in a pregnant woman? Which therapies are contraindicated?
naltrexone is preferred; can use benzos if needed (but not daily)
C/I - acamprosate, disulfiram, topiramate
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?
increased alpha-fetoprotein
What are the seven cardinal movements of labor? (in order)
- Engagement
- Descent
- Flexion
- Internal rotation
- Extension
- External rotation
- Expulsion
What are complications of amniocentesis? When can it be performed?
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
What are the risk factors for endometrial carcinoma?
tamoxifen use, unopposed estrogen therapy, obesity, increasing age, a family history of endometrial cancer or HNPCC/Lynch, early menarche, and late menopause
What changes in the breast are expected during the first trimester?
increasing branching of the ductal tree and increasing secretory gland formation
What changes in the breast are expected during the second and third trimesters?
lobular formation and enlargement, eventually nearly eliminating the fat and connective tissue stroma (accompanied buy the enlargement of the breasts)
What changes in the breast are expected at the time of parturition?
glandular proliferation and mitosis with scant remaining stroma
What initiates stage I lactogenesis? Stage II?
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
What is the most appropriate management for primary dysmenorrhea when NSAIDs fail to control pain?
trial of OCPs
deafness, cataracts or retinopathy, cardiac malformations (PDA), encephalitis, HSM with jaundice, and a petechial and puerperal rash in a newborn?
congenital rubella
hearing loss, HSM with jaundice, thrombocytopenia, chorioretinitis, cerebral calcifications, seizures, and microcephaly in a newborn?
congenital CMV
rapidly progressing systemic septic encephalitis, irritability, lethargy, and unable to feed in a newborn?
neonatal HSV
HSM with jaundice, disseminated purpuric rash, hydrocephalus, chorioretinitis, seizures, intracranial calcification, and ring-enhancing lesions in the brain parenchyma in a newborn? Tx?
congenital toxoplasmosis; tx = pyrimethamine and sulfadiazine
systemic illness with maculopapular rash with nasal discharge, LAD, HSM, and hemolysis in a 3-8 week old newborn? Tx?
congenital syphilis; tx = penicillin
What is the purpose of prostaglandins and osmotic dilators during pregnancy termination with dilation and evacuation?
avoiding cervical lacerations
fever, uterine tenderness, and purulent loch in the first 10 days after parturition?
postpartum endometritis
What are risk factors for chroioamnionitis? How does it present? How does this differ from endometritis?
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.
What is the definition of false labor?
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)
What is the presentation of maternal rubella infection? What is the next step in management of a pregnant patient with rubella?
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
What is Mittelschmerz?
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
What are risk factors for preterm labor? (10)
- African American race
- inter-pregnancy interval of 6 or less months
- prior preterm delivery
- infection
- Stressful working or living conditions
- low BMI
- tobacco use
- sexual abuse
- multiple gestation pregnancy
- Age less than 18 or older than 35
heavy vaginal bleeding, pelvic pressure, N/V, and elevated beta-hCG?
hydatidiform mole
What are risk factors for umbilical cord prolapse? (5)
- non-vertex fetal presentation
- prematurity
- iatrogenic or spontaneous rupture of membranes
- polyhydramnios
- multiparity
What is the most common presentation of umbilical cord prolapse? What is the best management?
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
What antibiotic prophylaxis should be administered for cesarean delivery? In what time frame?
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
What are the two classic findings of hyperemesis gravidarum?
weight loss of more than 5% of pre-pregnancy weight and ketonuria
What are risk factors for uterine atony?
- macrocosmic fetus
- prolonged induction of labor
- administration of magnesium
- polyhydramnios
- chorioamniotinitis
What is the MOA of misoprostol? What is it used for? C/I?
MOA - prostaglandin E1 analogue that causes vascular constriction by the uterine smooth muscle
Used in cases of uterine atony.
No significant C/I.
What is the MOA of 15-methyl-PGF2-alpha? What is it used for? C/I?
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
What is the MOA of methylergonovine? What is it used for? C/I?
MOA - ergot alkaloid that directly constricts blood vessels
Used in cases of uterine atony.
C/I: hypertensive disease (chronic HTN, preeclampsia, gestational HTN)
Path, Pt, Dx, and Tx of endometrial polyps
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
When does the placenta take over the production of progesterone from the corpus luteum?
after the first 35-47 days post-ovulation
What are the risk factors for primary dysmenorrhea? (4)
- nulliparity
- heavy menstrual flow
- smoking
- depression
If the IgG anti-Rh(D) antibodies are present in a pregnant mother, what is the next step in management?
u/s of the fetus to assess for evidence of hydrops fetalis
How is hydrops fetalis diagnosed on u/s?
2 or more of the following: ascites, pleural effusion, pericardial effusion, skin edema, and polyhydramnios
What are the most common indications for cesarean delivery? (3)
- failure to progress (arrest of dilation or arrest of fetal descent) during labor
- non-reassuring fetal heart tones
- fetal malpresentation
When is there the greatest risk of maternal-fetal transmission of HIV? What is the management at that stage?
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)
When should testing for chlamydia, gonorrhea, and HIV start? How often?
women under 24 yo who have been sexually active should be tested q 1 year for chlamydia, gonorrhea, and HIV
unilateral micro calcifications found on mammography are what?
ductal carcinoma in situ until proven otherwise
unilateral serosanguinous breast discharge in a non lactating woman?
intraductal papilloma
> 20 weeks gestation with sudden-onset vaginal bleeding, abdominal pain, back pain, and uterine contractions?
placental abruption
What are the risk factors for placental abruption? (6)
- advanced maternal age
- HTN
- cigarette smoking
- cocaine use
- African American race
- external trauma
Which antiviral for tx of Hep B is safest to use in pregnancy?
tenofovir
What testing is used to screen for HIV? What is the confirmatory testing?
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
What is the treatment for postpartum endometritis?
clindamycin and gentamicin
How is arrest of labor during the first stage defined?
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
Which medications are known to cause hyperprolactinemia?
antipsychotics (especially haloperidol, chlorpromazine, risperidone), CCBs (verapamil), histamine receptor antagonists (cimetidine and ranitidine), estrogens, and metoclopramide
Pt of toxic shock syndrome caused by group A strep? What other organisms can cause toxic shock syndrome? How does their presentation differ?
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
What are the risk factors for a newborn to be born with brachial plexus injuries that occur during delivery? (8)
- forceps- or vacuum-assisted delivery
- multiparity
- large for gestational age (birth weight greater than the 90th percentile)
- maternal diabetes
- breech presentation
- previous child with birth-related brachial plexus injury
- shoulder dystocia
- prolonged second stage of labor (>120 min or 180 with epidural)
What is one important step in workup of a granulosa cell tumor?
endometrial sampling to rule out hyperplasia or carcinoma because granulose cell tumors produce estrogen
abdominal bloating, increased abdominal girth, early satiety, and vague pelvic pain, pressure, and/or nausea due to GI obstruction?
ovarian cancer
At what point should pregnant women with iron deficiency anemia receive treatment? What type of treatment?
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)
When is asymptomatic bacteriuria diagnosed? What is the treatment?
diagnosed when there is greater than 100,000 colony-forming units
Abx Tx: cephalexin, nitrofurantoin, amoxicillin, amoxicillin-clavulanate, or fosfomycin
