OBGYN LAST TEST Flashcards
Smallest Cranial Diameter for The head through the BC
Suboccipitobregmatic Diameter
When can LEOPOLDS Maneuvers be done
THIS DOES NOT REPOSTIONT THE BABY
~28 wks; typically ~35-36 wks
↓ fetal space to change position as delivery approaches
Confirms fetal:
- Lie
- Presentation (vertex, breech, shoulder)
- Estimated fetal weight (EFW)
What is “0 station”
Station (how far has infant descended into pelvis)
0 station is level of ischial spines
TRAINGLE=
Diamond+
Triangle: occiput
Diamond: face
Most common position for the occiput in the delivery
LOA
Left occiput anterior
What position should the mother be in to assess fetal head position
Lithotomy Position
What is the most favorable and most common fetal head position for delivery
Favorable: OA
MC: LOA (Diamond in the Left positior compartment)
What is the Adverse event associated with OP fetal head
Arrest of descent
What are the complications of breed presentation
↑ Maternal & perinatal morbidity
Many studies report improved perinatal outcomes w/ cesarean deliveries
What is the risk involved when doing an external cephalic version
Typically not performed before 36-37 wk
Risk of placental abruption, ROM, delivery
Can retry w/ epidural @39 wks, but if still not successful → C-section
What are the absolute C/I for external Cephalic Version
Anything that precludes vaginal delivery:
- placenta previa
- multifetal placenta
4 phases of labor
Quiescence
Activation
Stimulation (Stages)
Involution
When is the initial start for Phase 1 labor
36-38 weeks
What is cervical ripening
Collagen fibril diameter ↑ & spacing between fibrils ↑
Loss of tissue integrity & ↑ compliance
Inflammatory changes:
- Inflammatory cells invade extracellular matrix/stroma
- Prostaglandins → modify extracellular matrix
What are the 3 stages of active labor
Stage 1: Clinical onset of labor → cervical effacement & dilatation (w/ contractions)
Stage 2: Fetal descent
Stage 3: Delivery of placenta & membranes → placental separation & expulsion
When should the placenta be delivered
AKA Puerperium: ~1+ hrs after delivery
What defines TRUE labor
REGULAR uterine contractions w/ cervical change
Cervical dilation 3-4cm or greater in presence of uterine contractions (Active Labor)
1st stage (Latent) of phase 3
Latent Phase
Cervical dilation 0 to 3-5 cm
Typically will not admit to L&D in latent phase of labor until dilated at least ~3-4 cm
Exception: spontaneous rupture of membranes
1st stage (active) of phase 3 labor
Active Phase
-Cervical dilation 3-5 cm or more until completely dilated (10 cm)
What is 2nd stage of phase 3 labor
2nd Stage: fetal descent
From time of complete dilatation until delivery of infant
What is stage 3 of phase 3 labor
3rd Stage: delivery of placenta & membranes
From infant delivery until placental delivery ~<30 min
-If >60 mins → possible problem
What stage has the highest Risk of post-partum hemorrhage
stage 3 phase 3
6 hrs after delivery, mother at highest risk for developing post-partum hemorrhage
What is the rate of cervical dilation in labor
Primips → 1.2 cm/hr
Multips → 1.5 cm/hr
Do you admit pts in stage 1 labor?
Typically will not admit patient during Latent Phase of Labor unless membranes are ruptured
When should we use med or high does oxytocin in active labor
if no cervical dilation at rate of 1 cm/hr or more in 1st stage of labor OR no descent of fetal head for 1 hr in 2nd stage
How often are cervical checks in active labor
Q1 (1st 2-3 hours) then Q2
Check
- dilation
- effacement
- station (crowning)
- position
What is the threshold for precipitous labor
(pregnancies that deliver in <3 hrs)
Define dysfunctional labor
Rates of dilation & descent exceed recognized normal time limits (too slow)
What are the 4 Ps of Labor
Power, Psyche, Passage, Passenger
What is the most common cause of Dystocia and C-section
Cephalopelvic disproportion/ mal position
What defines adequate power for labor
Adequate labor: 200 Montevideo units per IUPC for >2 hrs
What are three factors that lead to prolongation of the latent phase of pregnancy
Excessive sedation
Unfavorable cervical condition
False Labor
Define arrest of labor
Dilatation: 2 hrs w/ NO cervical change
Descent: 1 hr w/ NO fetal descent
If inadequate or absent cervical change w/in 2 hrs of admission? Suspect dystocia
What is the next step in a pt in labor dystocia
amniotomy (AROM) Artifical Rupture of Membranes
Recheck cervix in 2 hrs? No or minimal cervical change: place intrauterine monitor
Management for prolonged active phase of labor
Confirm Dilatation: at least 6 cm
AROM (amniotomy) if membranes intact
- Sometimes cushion of fluid prevents head from full engagement w/ cervix
- Allows placement of internal monitor to confirm contraction strength (Montevideo units)
Augment: w/ oxytocin if <200 Montevideo units
Maternal/fetal monitoring for 2-4 hrs w/ adequate ctx (at least 200-250 Montevideo units)
Consider extending observation period to 6 hrs if patient is nulliparous/singleton
C-section should be considered if above guidelines exceeded or fetal distress
What is Labor induction
stimulation of contractions before spontaneous onset of labor ±ROM
What scoring system is used in Induction
Use Bishop scoring system:
“How ready is the cervix for induction of labor?
What is the bishop scores for induction
Bishop score ≤4 → unfavorable cervix (indication that cervix not “ripe”)
Bishop score 9 → high likelihood for a successful induction
What is the 1st step to labor induction
Ripen cervix first! This will often stimulate labor!
Cervix is the “door”
What should the mother do 30 minutes prior to amniotomy
No walking for 30 min to ensure head fully engages in pelvis/prevent cord prolapse
3 maternal indications for induction
Preeclampsia
DM
Heart Dz
What is the initial agent for a pt with an unfavorable Bishops score (unrippened cervix)
PGE1 (Cytotec) & PGE2
(Prepidil/Cervidil)
Is indomethacin safe in pregnancy
NO! Causes cervical ripening and onset of labor
What is the role of oxytocin
Synthetic version (Pitocin):
Causes uterine contractions:
(not intended to ripen the cervix)
Used to induce labor at term
1st line drug for post-partum hemorrhage
ADE of Oxytocin use
Hyperstimulation
(w/ resultant fetal distress)
Uterine rupture
Fluid overload (used ~72H; otherwise, water intox risk: “ADH”)
Uterine fatigue non-responsiveness
Uterine atony (postpartum & risk of PPH)
Define Tachysystole
> 5 ctx in 10-min period
(avg over 30 min)
Ctx occurring w/in 1 min of one another
Any ctx lasting 2 mins or more
What is the MGMT for tachsystole
Discontinue augmentation med (if in use)
Position mother onto her left side
Cervical exam to r/o cord entrapment
Oxygen
ß-agonist (250 µg SC terbutaline;
FDA approved as tocolytic)
NML FHR
Normal FHR baseline: 110-160 bpm
NML Baseline fetal Variability
Moderate (normal): amplitude range 6-25 bpm
What is 15x15 and 10x10 on FHR
NML accelerations
FHR increase above the baseline
@32 or more wks: 15 bpm for 15 sec
<32 wks: 10 bpm for 10 sec
If an acceleration lasts 10 mins or longer, it is a baseline change
Can External Fetal Monitors assess contraction strength
NO!
shows timing & duration of contraction
What is the most reliable predictor of fetal well being
Variability of hr
Normal: 6-25 bpm
What are early decels
A VAgal response 2/2 cephalic pressure from contractions
NML
No intervention
What are variable decels
Cord compression
(reduced fluid vs nuchal cord)
Mild: <30 sec
Moderate: 30-60 sec
(both not <70 bpm)
Severe: >60 sec & <60 bpm (60x60)
Must Intervene
What are late decels
Starts/Lasts beyond uterine contractions (nadir occurs/extends beyond peak of ctx)
Uteroplacental insufficiency (possible fetal hypoxia/acidosis)
Must Intervene
What is VEAL CHOP
Variable Decels -Cord Compression
Early Decels- Head Compression
Accelerations- OKAY
Late Decels- Placental insufficiency
What are the interventions to decelaerations
LLD decubitus positioning
Decrease Pitocin/oxytocin if infusing
Increase IV fluids
Consider amnioinfusion
Elevate presenting part or
Trendelenburg if pushing
Intervention for cord compressions
Amnioinfusion, also can monitor strength of ctx this way
What is a reassuring finding in checking fetal blood with a non reassuring fetal heart rate
Results are reassuring if pH >7.25
What mediations are helpful for pain in false contraction
Sedatives (helpful only in false labor)
Promethazine (Phenergan)
Hydroxyzine (Vistaril)
Zolpidem (Ambien)
Procedure of choice for regional analgesia
Lumbar epidural
What are the 6 cardinal movements of labor
Descent Flexion Internal rotation Extension External rotation (restitution) Expulsion
How do you support the head during delivery
Provide gentle resistance for controlled delivery
-In & slightly downward gentle pressure
Support perineum to prevent tearing
- Apply direct pressure
- Squeeze/pressure of perineum
Controlled pushes
- Short pushes helps control force of head delivery
- Body delivery strong long push
Define Caput Succedaneum
(boggy, crosses sutures)
High pressure of vaginal walls on head during labor
Define Cephalohematoma
(does NOT cross sutures, may be associated w/ jaundice)
Impact of skull on pelvic bones
Below periosteum
Define Subgleal Hematoma
(crosses sutures, jaundice/blood loss/may require transfusion & compression)
-Rare
Can be massive, life-threatening
- Between scalp and periosteam
- D/t rupture of veins
Indications for operative vaginal delivery
Forceps/Vacuum:
- Prolonged 2nd stage of labor
- Suspicion of impending fetal compromise
- Breech delivery (forceps only)
- Intended to shorten 2nd stage for maternal benefit
Correct placement of the vacuum for delivery
Correct cup placement at the flexion point. Along the sagittal suture, this spot lies 3 cm from the posterior fontanel and 6 cm from the anterior fontanel.
What marks the 3rd stage of labor and what Rx is given at this stage
As soon as neonate is delivered
Oxytocin administered at time of placental delivery (to prevent bleeding)
What is chorioamnionitis
Infection of membranes & amniotic fluid surrounding fetus
Risk factors:
Prolonged rupture of membranes/PROM (>18 hr)
Multiple digital examinations
Instrumentation (FSE/IUPC) internal fetal/uterine monitoring
How do you dx chorioamnionitis
Maternal fever (>100.4) AND at least 2 of following:
Tachycardia:
- Maternal >100 bpm
- Fetal >160 bpm
Abdominal/fundal tenderness
Leukocytosis
Foul or culture-positive amniotic fluid
What is the tx approach to chroamnionitis
NOT an indication for emergent C-section
Empiric broad-spectrum antibiotics continued for 24-48 hrs after delivery
Monitor postpartum: risk of uterine atony & postpartum hemorrhage
Turtle sign of the fetal head indicates?
Shoulder dystocia
Onset of hypoxia with shoulder dystocia
Hypoxic injury: severe hypoxia starts w/in 5 mins of delivery of head to perineum
What is HELPERR in shoulder dystocia
- Help (call for)
- Evaluate for episiotomy
- Legs hyperflexed
(McRoberts maneuver) - Pressure: suprapubic (not fundal) -to push fetal shoulder down
“Rubin I” - Enter vagina (these maneuvers done in any sequence according to need):
-Rotational maneuvers: Rubin, Wood’s screw, Reverse Wood’s Screw
6) Remove posterior arm
7) Roll patient to all-fours position → hands & knees (Gaskin maneuver)
What part of HELPERR has the highest individual success rate for shoulder dystocia
removal of the Posterior Arm (Step 5) has high individual success rate; however:
-Not done 1st as a minor dystocia often resolves w/ McRoberts (leg hyperflexion) or suprapubic pressure (Rubin I)
-More potential for maternal perineal trauma when entering vagina & removing arm
Degree 1-4 Lacerations/ episiotomy
1st skin
2nd skin, subcutaneous tissue, perineal muscle
3rd above, and anal sphincter complex
4th All above plus rectal mucosa
When would you do a symphysiotomy for shoulder dystocia
Typically used only when surgical capabilities are not available
What is the approach to a cord prolapse
Tocolytics -> C-section Stat
What must you r/o in minor trauma in pregnancy
Rule-out placental abruption (monitor for ~4 hrs)
Also assess maternal fetal Hemorrhage -> Rhogam
When can we D/c a preg pt post trauma
Contracting <1 every 10 mins
No vaginal bleeding
No abd pain or tenderness
FHR reassuring
No visible bruising
What is the most common cause of Abruptio Placentae
HTN
What are the 4 Ts of postpartum hem
Tone = uterine atony (75-80%) Tissue = retained placenta/accreta Trauma = vaginal/cervical laceration Thrombin = coagulopathy
How do we estimate blood loss in post partum hem
When estimating blood loss based upon H&H:
Estimate 500 mL loss for every 3 volume percent drop in HCT
What is a boggy, soft uterus on bimanual examination
Uterine atony
Post partum hem can occur up to week ____ post partum
Can occur up to 12 wks after delivery
Clinically worst if occurs w/in 1-2 weeks postpartum
Evaluate: TVUS → retained products
Treatment: uterine cavity empty → medications used 1st
What is the treatment for Post Partum Hem
Call for help! EXAMINE.
External uterine massage
+Medications
Bimanual uterine compression
IV fluids (may need volume 3x EBL)
What are the Uterotonic Agents
Oxytocin/Pitocin (1st line)
10 units IM or 10–20 units/L @100 cc/hr
Methergine (methylergonovine) (1st line)
0.2 mg IM
NOT for pre-eclampsia/HTN!
Hemabate (carboprost tromethamine) – prostaglandin F-2α
250 mcg IM
-NOT for asthma, cardiac, renal, liver dz, seizure patients
Once Oxytocin is started for post partum hem
What is the next step
After Oxytocin/Pitocin, typically also start methergine, then give hemabate next
If that doesn’t work or there are contraindications to both, give misoprostol trial
C/I for Methergine
Preeclampsia
HTN
C/I for hemabate
Asthma
Cardiac/ renal/ Liver dz
SZR pts
If a pt has HTN or Asthma
What is the rx to use instead of methergine or hemabate
Misoprostol
What is the classic disaster from post partum hem
Uterine inversion
a pt presents after birth with Failure of lactation, amenorrhea, breast atrophy, loss of pubic & axillary hair, hypothyroidism, & adrenal cortical insufficiency
Think
Sheehan syndrome
If a male partner is over 40 top at age of sperm donation
What is the genetic risk
Autism: 6x more likely if father >40yo at conception
Schizophrenia: 2x more likely if father was >45yo at conception; 3x if > 50
What is the recommended follow up when putting someone on Contraceptives
IUD?
Check for IUD strings.
Combined hormonal?
Check BP.
Can pts with HTN take COC?
NO, if BP is above 160/100 no COC
Also avoid depoprovera (shot)
If a pt is over age 35 and smokes more than 15 cigs a day
What is the recommendation for COC
AVOID/Do NOT use COC
Use with caution if >35 and smoker
Can pts with aura+ migraine take COC?
NO
Depo-provera is usually ok
Can pts with DM and end organ dz take COC?
End organ disease (retinopathy/nephropathy/neuropathy)
OR
+Vascular dz or >20 yrs w/DM
- COC generally not recommended depending on severity
- Depo-Provera generally not recommended
If a pt is breastfeeding and is less than 1 month post partum
Can they take COC
Not recommended
Can a pt with DVTs take COC
No!
What is the contraception of choice in Breast Cancer Pts
IUD (copper)
No hormonal!
Can RA pts take depo-provera
use with caution, at risk of osteoporosis
Indications for IUD placement
Women in stable, monogamous relationships (low risk for STI)
Women who need or desire to avoid hormones (copper version only)
Can be used in nulliparous women & adolescents
Levonorgestrel-containing IUD often considered for AUB
What is the duration of action for Mirena and Kyleena IUDs
5 years
What is the duration of action for Liletta and Skyla IUDs
3 yrs
What is the duration of action of Paraguard IUD
12 years
What are the two most effective emergency contraceptives
The copper IUD is the most effective form of EC. When taken as directed, ulipristal is the most effective type of EC pill
After implanting an IUD a pt may have increased AUB
How is this treated
NSAIDs
What is the MOA of Levonorgestrel IUD
Mechanism of action:
Long-term progestin release → endometrial atrophy: hinders implantation
Progestin: thickens cervical mucus → hinders sperm motility
What are the indications for Levonorgestrel IUD
Improves dysmenorrhea
Indicated for contraception, HMB, endometrial hyperplasia
What is the greatest risk when using levonorgestrel IUD
During 1st month: greatest risk for device-related genital infection
High risk for STDs: screen prior to insertion
If an IUD is placed more than 7 days after menses
What is the recommendation
Back-up method or abstinence x 7 days
What is the F/u time frame for an IUD placement
6 weeks check strings
When is the most common time to have an IUD become displaced
In the 1st month after placement
What is the duration of action of Nexplanon (implant)
Ovulation suppressed for 3 yrs
Inhibits ovulation, implantation, and decreases sperm motility
What is the ADE of all progestin-only contraceptives
irregular or heavy uterine bleeding
What are the absolute C/I for Implants/ IUD (hormonal)
Current Breast Cancer and pregnancy
When is the Nexplanon implant inserted
Insertion in superficial subdermis (w/in 5d of menses onset)
Placement >5d after LMP? Back-up method or abstinence x 7 d
When is the return of ovulation after implant removal (NExplanon)
Within 6 weeks to a year
What are the C/I of Depo provera
Contraindications: recent breast cancer, progesterone-positive cancer, & pregnancy
Absolute contraindication: current breast cancer
What should all pts on Depo-provera be given..
Vit D and calcium
For reversible bone loss
Screen of OA
What are the MOA of POPs
Progestin Only Pills (POPs aka “mini-pills”)
Only 1 formulation in US (norethindrone 0.35mg)
Progestin → thickens cervical mucus → impairs sperm motility
Progestin → thins endometrium → inhibits implantation
Unreliable ovulation inhibition (not primary MoA)
What is the window of efficacy with POPs
All pills active & taken daily at same time → narrow window for loss of efficacy (3-4 hours) → if late/missed, back-up contraception for 48 hrs
What are the C/I for POPs
Breast CA and preg
What is the MOA of CHCs
Combined Hormonal Contraceptives (CHCs) - contains both estrogen & progestin
Inhibits pituitary gonadotropin (i.e., LH) release → suppresses ovulation
Thickens cervical mucus → impairs sperm motility
Thins endometrium → inhibits implantation
Estrogen:
Negative feedback to pituitary → suppresses ovulation
Stabilizes endometrium → prevents intermenstrual bleeding = cycle control
What is the most important effect of CHCs
Most important effect: suppress GnRH → inhibit LH/FSH release → inhibit ovulation
If a pt wanted to avoid mood changes, what phase of COCs should she be given
Monophasic
What is a 1st day start for COC
Begin on 1st day of menses
No back-up required
What is a Sunday start for COC
(avoid withdrawal bleeding on weekends):
Begin on 1st Sunday after menses starts
Back-up required for 1st wk
What is a quick start for COC
1st pill taken day rx filled
Back-up required for 1st wk
Minimal confusion about when to start!
If a pts COC patch falls off what is the guidance
<24 hrs: replace same patch → no back-up
> 24 hrs: place new patch, new day → back-up X 1 wk
What is the shelf life of a nuvaring
Must be refrigerated, therefore poor option for deployment
4 months shelf life (↓ w/ hot environment)
IF a Nuvaring falls out for more than 3 hours
What is recomended
If out for >3 hrs: rinse, replace but use back-up for 1 wk
Pt misses her COC pill less than 48 hours
Advise
Take the missed pill
And return to schedule
No back up needed
Pt misses her COC pill greater than 48 hours
Advise
Take most recent missed dose
Use back up x 7 days
Pt misses her pill during the 2nd or 3rd week of her current COC pack
Advise
Discard placebo week
Start new pack
Plus back up x 7 days
What is the only requirement before starting a pt on CHC
Check the BP
When should vaginal diaphragms be placed prior to sex
6 hours before
Do not remove for 6 hours after
What is the increased risk when using spermicides
Increased HIV and STI transmission
What is the standard days method for BC
Avoid unprotected intercourse days 8-19 of menstrual cycle
In order to be effective, menstrual cycles must be regular & monthly every 26-32 days
What is the 2 day and Billings method for cervical mucus
Billings Method: abstain from intercourse from start of menses until 4 days after watery/slippery mucus is identified
Two-day Method: intercourse is considered safe if woman did not note presence of mucus on day of or day prior to planned intercourse
When can the Cu IUD and ulipritstal be given for emergency contraception
Within 120 hours (5 days)
What is lactational amenorrhea
Must do exclusive breastfeeding & have no menses
Unlikely to ovulate during 1st 10 wks after delivery
Must use alternative contraception after 6 months
What are the recommend COCs for past partum
For nursing mothers: progestin-only is preferred method (reduce risk of ↓ lactation)
Progestin-only pill runs high risk of failure (3-4 hour window)
Estrogen-progestin contraceptives
↓ Rate & duration of milk production (limited data)
Do not prescribe prior to 4 weeks due to ↑ clotting (venous thrombotic event) risks
How long does it take for a vasectomy to be effective
Stored sperm in reproductive tract requires 3 mos or 20 ejaculations to empty stored sperm
When is the return of ovulation after pregnancy termination
Ovulation can resume as early as 2 weeks after early pregnancy termination
What is fecundity
probability of achieving a live birth from a single menstrual cycle
What is fecundabilty
ability to conceive; probability of achieving a pregnancy per month of “exposure”
20% per cycle
50% in three months
85% in a year
What is the general advise to a couple wanting to conceive
Have sex every day within 5 days of ovulation or every other day for 10 days around ovulation
Do not use oil based lubricants
If a woman is over the age of 35 what is the threshold to work up for infertility
6 months
What is the triad of a fertility W/u
Ovulation
Normal female reproductive tract
Normal semen characteristics
What is the time frame for viable sperm
~73 d to generate + time in epididymis to gain mobility = 3m
Any detrimental event in prior 90d can affect semen characteristics
What is the general collection for sperm
Abstain for at least 2 days prior to sampling
Amount: >1.5 mL
Count: >15M /mL
Normal: at least 2 specimens a few weeks apart
Abnormal: at least 3 specimens a few weeks apart
What is mittelschmerz
Ovulation (pain during menses)
unilateral, midcycle pelvic pain w/ ovulation (+/- additional sx: breast tenderness, acne, food cravings, mood changes)
An increase of 0.4-o.8 degrees F vaginally indicated
Looking for a 0.4-0.8F increase on 2 consecutive days
Due to postovulatory ↑progesterone
OVUALTION HAS OCCURED
What is the best at home method to predict ovualtion at home BEFORE is occurs
Urinary ovulation detection kits: urinary LH (at home)
What are the key labs to get in an anovulation pt
TSH Prolactin FSH Total testosterone DHEA-S (dehydroepiandrosterone sulfate)
What are the 3 main etiologies of infertility
Ovarian
Male Fx
Tubal
Uneplained/ other
What are the set of women we should consider for infertility testing
≥ 35 years old after 6 months of trying
< 35 years old after 1 year of trying
Risk for decreased ovarian reserve
Women considering egg freezing
What is the approach to testing FSH and estrogen in infertility
Test on cycle day 3: “day 3 labs”
What is the standard work/up for infertility
FSH/ E2 on day 3
Serum Anti Mullerian (anytime)
And Antrol follicule count on day 3
-<5-7 : predicts poor response to ovarian stimulation
AMH levels should be above what for fertility
Above 2
What should FSH and E2 levels be for fertility
Less than 10
Above 20= bad
What is the ideal antral follicle count for fertility
About 20
Less than 5 is bad
What is the initial Rx for inferlility
Clomiphene citrate
Start 3rd-5th day of menstrual cycle
If no ovulation/failure to conceive in 3-6 m of max dose, refer
How does metformin effect women with PCOS
↓ Insulin resistance
↑ Frequency of spontaneous ovulation
What are the S/s of ovarian hyper stimulation syndrome
Ovarian enlargement
Abdominal distention
Ascites
Electrolyte imbalance
GI issues
Hypercoagulability
Respiratory compromise
Oliguria
Hemoconcentration
Thromboembolism
Hypovolemia ->renal/hepatic/pulm end-organ failure
If a pts infertility problem is 2/2 anovulation/ irregular menses
What are the test and tx
Test:
BBT, LH. And Progesteone level
Tx: Clomiphene
If a pts infertility is 2/2 uterine fibroids
What are the tests and tx
Hysterosalpingogram and SRGRY
If a pts infertility is 2/2 male fx
(Hernia, Varicocele, mumps)
What is the tests and tx
Semen analysis
Tx: SRGRY or IVF
If a pts infertility is 2/2 tubal, G/C, or PID
What are the tests and tx
Hystersalpingiogram
Tx; laparoscopy or IVF
What is the treatment for pubic lice
Permethrin!!
Pyrethrins
Lindane (not in pregnancy/infant)
Treat household contacts/linens
What is the treatment for scabies
Permethrin
Lindane (not in pregnant patient/infant)
Ivermectin orally repeat at 2 wks
Treat household contacts/linens
HPV strains
6, 11
Risk of HPV to a neonate
Birth canal to larynx transmission
What are the treatment options for genital warts
Provider applied: podophyllin, trichloroacetic acid (TCA), bichloroacetic acid (BCA); cryotherapy
Patient applied: podofilox or imiquimod (not during pregnancy)
Surgical: tangential scissor excision, tangential shave excision, curettage, or electrosurgery
What are the provider treatments for genital warts
Provider applied:
- podophyllin
- trichloroacetic acid (TCA), -bichloroacetic acid (BCA); -cryotherapy
What are the outpt treatments for genital warts
podofilox
or imiquimod
(not during pregnancy)
What are the Surgical tx for genital warts
tangential scissor excision
tangential shave excision
curettage, or electrosurgery
What is the screening and confirmatory test for syphillis
Screening: RPR or VDRL
(0.5-14% false positive, esp. in autoimmune disease)
Confirmation: FTA-ABS
What is the reaction from PCN for syphillis treatment
Jarisch-Herxheimer reaction
50% of 1° syphilis & 90% 2° syphilis w/in 8 hrs of PCN treatment
Caused by release of endotoxin when large #s of organisms are killed by antibiotics
Presentation: fever, malaise, & HA
What is the follow up post syphillis treatment
After initial tx → re-evaluate @ 6 mos intervals for serologic testing & clinical re-evaluation
Use same test to follow titers
If have to re-treat → weekly PCN injections for 3 wks
A pt presents with a “groove sign” lymph node and a small vesical or papule in the inguinal area
Think
Lymphogranuloma venereum
Tx:
Doxycycline 100 mg 2x daily x21 ds
Eyrthromycin 500 mg 4x daily x21 ds
What is the treatment for chlamydia
Azithromycin 1 g po x1
OR
Doxycycline 100 mg BID x7 ds
-Treat all sexual contacts
(“EPT” as permitted by law)
-Test for other STI’s (gonorrhea)
Abstinence for 7 ds on antibiotic
No test of cure needed except in pregnancy
Rescreen in 3-4 mos
Treatment for gonorrhea
Primary: ceftriaxone 250 mg IM + azithromycin 1 g oral
Secondary: other cephalosporin orally or IM + azithromycin 1 g oral
Tertiary: cephalosporin orally or IM + doxycycline 100 mg bid x1 wk
Fluoroquinolones no longer recommended
Treat all sexual contacts
Test for other STI’s (chlaymdia)
Abstinence for 7 ds on antibiotic
Rescreen in 3-4 mos
What is the sequellae of PID
infertility, ectopic pregnancy, chronic pelvic pain
What should be considered in a patient w/ tubal-factor infertility who lacks upper tract infection
Silent PID
Dx criteria for PID
Uterine tenderness OR Adnexal tenderness OR Cervical motion tenderness
+1 or more of the following:
- Oral temp >101.6ºF (38.3˚C)
- Mucopurulent cervical discharge or cervical friability
- Abundant WBCs on saline microscopy of cervical secretions
- ↑ ESR or CRP
- Presence of C. trachomatis or N. gonorrhea
Studies: sonography (primary imaging tool)
Inpt treatment for PID
IV cefotetan or cefoxitin plus
PO/IV doxy
Out pt treatment for PID
Ceftriaxone + Doxy
If BV or Trichomoniasis add: metro
A pt presents with PID symptoms + adnexal mass, lower abdominal pain, fever, leukocytosis
Think
Tuboovarian abscess
Dx with US
Tx: broad spectrum IV abx; surgical if no improvement
What is the cause of toxic shock syndrome
Exotoxin from Staphylococcus aureus
A pt presents with a diffuse macular rash that is not painful or itchy
Plus fever, malaise, and diarhhea
2 days after surgery or menstration
Think
Toxic shock syndrome
Tx: Antibiotics while awaiting cultures Systemic support (IVF & electrolytes)
What are the major criteria for Toxic shock syndrome
HOTN
Ortho Syncope
SBP < 90
Diffuse macular rash
Fever> 38.8C
Skin desquatmation
What are the minor criteria for Tosic shock syndrome
At least 3 minor criteria must be met
Diarrhea or vomiting
Involves the mucous membranes
Myalgias or elevated Cr level 2xNML
Elevated BUN
Thrombocytopenia
Elevated bilirubin
AMS
MC benign breast tumor
Fibroadenoma
What is the risk of complex Fibroadenomas
Benign, but if “complex,” pts have 1.5-2x risk of breast cancer
What is the w/u for simple cysts on the breast
No special mgmt
If recurrent excise
What is the w/u for complicated cysts of the breasts
Consider aspiration,
Culture,
Cytology,
Core needle
What is the w/u for complex cyst of the breast
Core needle
EXcision
What is the treatment to fibrocystic breast changes
If bothersome, aspirate cysts to relieve pain
If clear fluid, and cyst remits, ok; if bloody or residual mass = biopsy
Baseline mammogram in pts > 25 yo
Ultrasound if not relieved with:
- Symptom reduction
- ↓ Chocolate intake
- ± Caffeine
- Wear supportive bra
- Avoid breast trauma
What is the treatment for mastitis
Continue to breast feed/pump to prevent milk stasis
Treatment: dicloxacillin, cephalexin, amoxicillin-clavulanate
If PCN allergic: erythromycin
If MRSA risk/hx: trimethoprim-sulfamethoxazole, clindamycin, or vancomycin
If mastitis doesn’t improve with ABXs
What is the next step
If mastitis doesn’t improve rapidly w/ antibiotics → ultrasound to r/o abscess
Abscess may require surgical drainage
If a pt presents with mastitis in a non irritated or non pregnant breast
Think
Requires imaging & biopsy to exclude inflammatory breast cancer
What is the w/u for breast pain not related to menses
Frequently simple cyst, but could be cancer → evaluation (exam, imaging, biopsy)
A 22 yo nulliparous woman is noted to have a tender, hot, red, right breast and lymphadenopathy of the R axilla despite antibiotics prescribed for mastitis x 2 weeks. She is not lactating. What do you do next?
Concern for inflammatory breast cancer
Order Bx
What is the spiral of sexual response
intimacy -> sexual stimuli-> arousal -> sexual desire
-> enhanced intiman y
What is the arousal period of the sexual spiral
↑ Nitric oxide (NO) due to sexual stimulation → clitoral cavernosal artery relaxation → clitoral engorgement → ↑ clitoris sensitivity
What is vaginismus
(pelvic floor muscle spasms → painful, difficult, or impossible to have sexual intercourse, have a gynecological exam, or to insert a tampon)
What is the hormone responsible for libido
Testosterone
Excited by dopamine
Suppressed by serotonin
What is the innervation for arousal
Modulated by parasympathetics
Enhanced by estrogen
-Lack of estrogen is most common cause of dysfunction in this phase
What is the innervation for orgasms
Modulated by sympathetics
Optimized by clitoral input
(afferent concentration)
-Most treatable sexual phase disorder
What is the most treatable sexual phase disorder
Orgasmic phase
What are the risk factors for Dysparunia
Age <50
Hx of sexual abuse
Hx of PID
Depression, anxiety
What is the leading cause of death during pregnancy
Homicide is a leading cause of death during pregnancy
What are the risk factors for sexual assault
Physically or mentally disabled
Experiencing homelessness
Gay, lesbian, bisexual, or transgender
Alcohol/drug users
College students
Age <24
What is the most often injured area during sexual assault
Genital wounds
-> posterior fourchette
(most often injured genital area)
When should SAMFE kits be done
Valid forensic evidence can be collected up to 5 ds after sexual assault, but immediate examination ↑ opportunity to collect valuable physical evidence
What tests should be ordered for victims of sexual assault
Check for STDs:
- GC/Chlamydia
- BV, Trichomonas, Candidiasis
- HIV, Hep B, Syphilis
- Blood alcohol & tox screen
What is the F/u post sexual assault
1-2 wks & 2-4 mos
- Review labs, examine for STIs, repeat STI testing as applicable
- Vaccinations as needed
At ED or clinic discharge → ensure safe place to go, transportation, resource information, support in place
What is sexual trauma syndrome
↑ Lifetime risk for PTSD, major depression, & suicide ideation or attempt
What is chronic pelvic pain as defined by ACOG
Noncyclic pain that persists for 6+
Months
Pain that localizes to anatomic pelvis, to anterior abdominal wall at or below umbilicus, or to lumbosacral back or buttocks
Pain sufficiently severe to cause functional disability or lead to medical intervention
What is allodynia
painful response to normally innocuous stimulus (i.e., cotton swab)
How do MSK changes effect chronic pelvic pain
Concurrent lordosis and kyphosis are common postural changes associated with chronic pelvic pain.
Chronic pelvic pain after surgery
Think
Adhesions
A pt presents with chronic pelvic ache, pressure, & heaviness due to tortuous, congested ovarian or pelvic veins
Think
Pelvic Congestion Syndrome
A pt with chronic pelvic pain that also worsens pre menstrally
What is the tx
(2/2 estrogen causing venous dilation)
Higher rates in parous women; resolve after menopause
May see varicosities
Treatments: hormonal suppression, ovarian vein embolization, or hysterectomy w/ BSO
What is the 1st line Tx for Chronic pelvic pain
NSADs
And then Anti- depressants
SSRI, SNRI, Gabapentin
What is vulvodynia
Vulvar discomfort (at least 3-6 m) in absence of relevant visible findings or a specific, clinically identifiable neurologic disorder (i.e., no identifiable cause)
What is the tx for vuvlodynia
Can spont resolve
CBT-> lidocaine or Gabapentin,
TCAs are 1st LINE!
(Amitriptyline)
Dysparunia in the DSM5
DSM-5 merged dyspareunia & vaginismus as genito-pelvic pain/penetration disorder
How does hypoestrogenism effect the vagina
Hypoestrogenism ->vaginal atrophy -> dyspareunia
What is myofascial pain syndrome
Hyperirritable area w/in a muscle promotes persistent fiber contraction → trigger point
What is the difference between primary and secondary myofascial pain syndrome
Primary myofascial pain syndrome → musculoskeletal conditions
Secondary myofascial pain syndrome → chronic visceral inflammatory conditions
What three muscles make up the Levator ani
Pubococcygeus, iliococcygeus, puborectalis
A pt prestents with lower abdominal pain, low back pain, dyspareunia, & chronic constipation
Think what pain syndrome
Levator Ani syndrome
Tx with massage and nsaids/ muscle relaxants
Last line botulism inj
What is the tx for peripartum pelvic pain syndrome
Physical therapy, ther ex, analgesics (NSAIDS)
What is the pudendal nerve distribution
(3 branches: perineal nerve, inferior rectal nerve, & dorsal nerve of the clitoris)
Inervates the clitoris, vulva, and the rectum
A pt older than age 32 present with pain in the clitoris, vulva, and rectum
(Combined or alone)
Think what Nerve/ pain distribution
Pudendal neuralgia
Pain aggravated by sitting, relieved by sitting on a toilet seat/standing, may progress during day
What is Nantes Criteria
Dx for Pudenal Neuralgia
Diagnosed via Nantes criteria:
- Pain follows pudendal innervation path
- Worse w/ sitting
- No associated sensory loss
- Does not awaken patient from sleep
- Relieved by nerve blockade
What is procidentia
Uterus prolapse in to the vagina
What is the risk of prolapse with each pregnancy
Vaginal childbirth, especially increased parity (1.2x with each delivery)
What are the tx options for pelvic organ prolapse
Correct underlying issues:
If postmenopausal & signs of atrophy: topical estrogen
If asymptomatic/mild symptoms: pelvic floor muscle exercises (Kegel’s)
If woman unfit/unwilling for surgery OR has prolapse with urinary incontinence: pessary
Surgery
A pt presents with frequency of urination, urgency and pelvic pain
Without cystoscopic finding
Think
Interstitial cystitis/ painful bladder syndrome
Should pts with painful bladder syndrome drink cranberry juice to relieve s/s
No, may exacebte pain
Many potential triggers: alcohol, caffeine, smoking, spicy foods, citrus fruits & juices, carbonated drinks, & potassium
What should be ordered in painful bladder syndrome to r/o cancer
Basic labs: UA, urine culture
If hematuria, cytology
(esp., in smokers) to r/o bladder cancer
What are hunners ulcers/ lesions
Hunner ulcers: reddish-brown mucosal lesions w/ small vessels radiating toward a central scar →
rare, but diagnostic for interstitial cystitis (stiffen the bladder)
What is the tx for painful bladder syndrome
avoid bladder irritants/triggers
PT
Rx:
Amitriptyline
Cimetidine
Hydroxyzine
Only FDA approved med: Elmiron
No response? =
Short-duration, low-pressure bladder distention & fulguration of Hunner ulcers
What does DIAPPERS mean for Incontinence
Delirium:
- ACUTE confusion: clouded sensorium impedes recognition & ability to void
- Most common cause in hospitalized patients
Infection
(symptomatic UTIs NOT asymptomatic bacteriuria)
Atrophic vaginitis/urethritis
Pharmaceuticals:
-diuretics, anticholinergics, psychotropics, opioids, alpha-blockers (in women), alpha-agonists (in men), & calcium channel blockers
Psychological factors
(severe depression w/ psychomotor retardation)
Excess urinary output/Endocrine disease
Restricted mobility
Stool impaction
- Common cause in hospitalized/immobilized patients
- Disimpaction restores continence
What are the 3 degrees of stress incontinence
I → Only w/ severe stress (cough, sneeze, jumping, etc.)
II → Moderate stress (rapid movement, stairs)
III → Mild stress (standing)
What medications should be avoided in incomplete bladder emptying syndrome
Medications to avoid:
(these can cause urinary retention -> eventual overflow)
Calcium channel blockers
(decrease smooth muscle contractility in bladder)
Alpha-adrenergic agonists
(contract the bladder neck)
What is the 1st step in evaluating incontinence
Rx review
Then eval for prolapse and pelvic strength
And then Q-tip test
(Q-tip test: change in angle by >30 degrees to horizontal suggests hypermobility (possible stress incontinence))
Then bimanual and rectovaginal exam
What is the tx to incontinence
Conservation managed: kegels
More:
- diet changes
- calcium glyerosphate
- schedule voiding-
- pessary
- SRGRY
Where do Anticholinergics work in incontinence
Anticholinergics work at level of detrusor muscle (inhibits muscarinic receptors) to blunt detrusor contractions
What is the medication of choice for mixed incontinence pts
Imipramine: TCA w/ a-adrenergic effects and Anticholinergic effects
What is the Rx of choice for urge incontinence pts
Mirabegron (antispasmodic)
→ β3-adrenergic receptor agonist
→ relaxes detrusor smooth muscle & ↑ bladder capacity
→ for urge incontinence
What mediations must be avoided in stress incontinence pts
α-antagonists
(leads to internal urethral sphincter [IUS])
relaxation → leak)
What are the medications to avoid in overflow pts
α-agonists (leads to IUS contraction)
Anticholinergics (inhibit bladder contraction, sedation, fecal impaction)
CCBs (relaxes bladder, fluid retention)
