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Senoir 21-2 > OBGYN LAST TEST > Flashcards

OBGYN LAST TEST Flashcards

1
Q

Smallest Cranial Diameter for The head through the BC

A

Suboccipitobregmatic Diameter

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2
Q

When can LEOPOLDS Maneuvers be done

A

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)
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3
Q

What is “0 station”

A

Station (how far has infant descended into pelvis)

0 station is level of ischial spines

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4
Q

TRAINGLE=

Diamond+

A

Triangle: occiput
Diamond: face

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5
Q

Most common position for the occiput in the delivery

A

LOA

Left occiput anterior

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6
Q

What position should the mother be in to assess fetal head position

A

Lithotomy Position

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7
Q

What is the most favorable and most common fetal head position for delivery

A

Favorable: OA
MC: LOA (Diamond in the Left positior compartment)

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8
Q

What is the Adverse event associated with OP fetal head

A

Arrest of descent

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9
Q

What are the complications of breed presentation

A

↑ Maternal & perinatal morbidity

Many studies report improved perinatal outcomes w/ cesarean deliveries

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10
Q

What is the risk involved when doing an external cephalic version

A

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

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11
Q

What are the absolute C/I for external Cephalic Version

A

Anything that precludes vaginal delivery:

  • placenta previa
  • multifetal placenta
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12
Q

4 phases of labor

A

Quiescence
Activation
Stimulation (Stages)
Involution

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13
Q

When is the initial start for Phase 1 labor

A

36-38 weeks

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14
Q

What is cervical ripening

A

Collagen fibril diameter ↑ & spacing between fibrils ↑

Loss of tissue integrity & ↑ compliance

Inflammatory changes:

  • Inflammatory cells invade extracellular matrix/stroma
  • Prostaglandins → modify extracellular matrix
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15
Q

What are the 3 stages of active labor

A

Stage 1: Clinical onset of labor → cervical effacement & dilatation (w/ contractions)

Stage 2: Fetal descent

Stage 3: Delivery of placenta & membranes → placental separation & expulsion

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16
Q

When should the placenta be delivered

A

AKA Puerperium: ~1+ hrs after delivery

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17
Q

What defines TRUE labor

A

REGULAR uterine contractions w/ cervical change

Cervical dilation 3-4cm or greater in presence of uterine contractions (Active Labor)

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18
Q

1st stage (Latent) of phase 3

A

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

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19
Q

1st stage (active) of phase 3 labor

A

Active Phase

-Cervical dilation 3-5 cm or more until completely dilated (10 cm)

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20
Q

What is 2nd stage of phase 3 labor

A

2nd Stage: fetal descent

From time of complete dilatation until delivery of infant

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21
Q

What is stage 3 of phase 3 labor

A

3rd Stage: delivery of placenta & membranes

From infant delivery until placental delivery ~<30 min
-If >60 mins → possible problem

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22
Q

What stage has the highest Risk of post-partum hemorrhage

A

stage 3 phase 3

6 hrs after delivery, mother at highest risk for developing post-partum hemorrhage

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23
Q

What is the rate of cervical dilation in labor

A

Primips → 1.2 cm/hr

Multips → 1.5 cm/hr

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24
Q

Do you admit pts in stage 1 labor?

A

Typically will not admit patient during Latent Phase of Labor unless membranes are ruptured

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25
Q

When should we use med or high does oxytocin in active labor

A

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

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26
Q

How often are cervical checks in active labor

A

Q1 (1st 2-3 hours) then Q2

Check

  • dilation
  • effacement
  • station (crowning)
  • position
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27
Q

What is the threshold for precipitous labor

A

(pregnancies that deliver in <3 hrs)

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28
Q

Define dysfunctional labor

A

Rates of dilation & descent exceed recognized normal time limits (too slow)

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29
Q

What are the 4 Ps of Labor

A

Power, Psyche, Passage, Passenger

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30
Q

What is the most common cause of Dystocia and C-section

A

Cephalopelvic disproportion/ mal position

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31
Q

What defines adequate power for labor

A

Adequate labor: 200 Montevideo units per IUPC for >2 hrs

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32
Q

What are three factors that lead to prolongation of the latent phase of pregnancy

A

Excessive sedation

Unfavorable cervical condition

False Labor

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33
Q

Define arrest of labor

A

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

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34
Q

What is the next step in a pt in labor dystocia

A

amniotomy (AROM) Artifical Rupture of Membranes

Recheck cervix in 2 hrs? No or minimal cervical change: place intrauterine monitor

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35
Q

Management for prolonged active phase of labor

A

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

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36
Q

What is Labor induction

A

stimulation of contractions before spontaneous onset of labor ±ROM

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37
Q

What scoring system is used in Induction

A

Use Bishop scoring system:

“How ready is the cervix for induction of labor?

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38
Q

What is the bishop scores for induction

A

Bishop score ≤4 → unfavorable cervix (indication that cervix not “ripe”)

Bishop score 9 → high likelihood for a successful induction

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39
Q

What is the 1st step to labor induction

A

Ripen cervix first! This will often stimulate labor!

Cervix is the “door”

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40
Q

What should the mother do 30 minutes prior to amniotomy

A

No walking for 30 min to ensure head fully engages in pelvis/prevent cord prolapse

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41
Q

3 maternal indications for induction

A

Preeclampsia

DM

Heart Dz

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42
Q

What is the initial agent for a pt with an unfavorable Bishops score (unrippened cervix)

A

PGE1 (Cytotec) & PGE2

(Prepidil/Cervidil)

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43
Q

Is indomethacin safe in pregnancy

A

NO! Causes cervical ripening and onset of labor

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44
Q

What is the role of oxytocin

A

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

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45
Q

ADE of Oxytocin use

A

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)

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46
Q

Define Tachysystole

A

> 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

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47
Q

What is the MGMT for tachsystole

A

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)

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48
Q

NML FHR

A

Normal FHR baseline: 110-160 bpm

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49
Q

NML Baseline fetal Variability

A

Moderate (normal): amplitude range 6-25 bpm

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50
Q

What is 15x15 and 10x10 on FHR

A

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

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51
Q

Can External Fetal Monitors assess contraction strength

A

NO!

shows timing & duration of contraction

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52
Q

What is the most reliable predictor of fetal well being

A

Variability of hr

Normal: 6-25 bpm

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53
Q

What are early decels

A

A VAgal response 2/2 cephalic pressure from contractions

NML
No intervention

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54
Q

What are variable decels

A

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

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55
Q

What are late decels

A

Starts/Lasts beyond uterine contractions (nadir occurs/extends beyond peak of ctx)

Uteroplacental insufficiency (possible fetal hypoxia/acidosis)

Must Intervene

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56
Q

What is VEAL CHOP

A

Variable Decels -Cord Compression
Early Decels- Head Compression
Accelerations- OKAY
Late Decels- Placental insufficiency

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57
Q

What are the interventions to decelaerations

A

LLD decubitus positioning

Decrease Pitocin/oxytocin if infusing

Increase IV fluids

Consider amnioinfusion

Elevate presenting part or

Trendelenburg if pushing

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58
Q

Intervention for cord compressions

A

Amnioinfusion, also can monitor strength of ctx this way

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59
Q

What is a reassuring finding in checking fetal blood with a non reassuring fetal heart rate

A

Results are reassuring if pH >7.25

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60
Q

What mediations are helpful for pain in false contraction

A

Sedatives (helpful only in false labor)
Promethazine (Phenergan)
Hydroxyzine (Vistaril)
Zolpidem (Ambien)

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61
Q

Procedure of choice for regional analgesia

A

Lumbar epidural

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62
Q

What are the 6 cardinal movements of labor

A 
Descent
Flexion
Internal rotation
Extension
External rotation (restitution)
Expulsion
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63
Q

How do you support the head during delivery

A

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
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64
Q

Define Caput Succedaneum

A

(boggy, crosses sutures)

High pressure of vaginal walls on head during labor

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65
Q

Define Cephalohematoma

A

(does NOT cross sutures, may be associated w/ jaundice)

Impact of skull on pelvic bones

Below periosteum

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66
Q

Define Subgleal Hematoma

A

(crosses sutures, jaundice/blood loss/may require transfusion & compression)
-Rare

Can be massive, life-threatening

  • Between scalp and periosteam
  • D/t rupture of veins
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67
Q

Indications for operative vaginal delivery

A

Forceps/Vacuum:

  • Prolonged 2nd stage of labor
  • Suspicion of impending fetal compromise
  • Breech delivery (forceps only)
  • Intended to shorten 2nd stage for maternal benefit
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68
Q

Correct placement of the vacuum for delivery

A

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.

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69
Q

What marks the 3rd stage of labor and what Rx is given at this stage

A

As soon as neonate is delivered

Oxytocin administered at time of placental delivery (to prevent bleeding)

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70
Q

What is chorioamnionitis

A

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

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71
Q

How do you dx chorioamnionitis

A

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

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72
Q

What is the tx approach to chroamnionitis

A

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

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73
Q

Turtle sign of the fetal head indicates?

A

Shoulder dystocia

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74
Q

Onset of hypoxia with shoulder dystocia

A

Hypoxic injury: severe hypoxia starts w/in 5 mins of delivery of head to perineum

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75
Q

What is HELPERR in shoulder dystocia

A
  1. Help (call for)
  2. Evaluate for episiotomy
  3. Legs hyperflexed
    (McRoberts maneuver)
  4. Pressure: suprapubic (not fundal) -to push fetal shoulder down
    “Rubin I”
  5. 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)
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76
Q

What part of HELPERR has the highest individual success rate for shoulder dystocia

A

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

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77
Q

Degree 1-4 Lacerations/ episiotomy

A

1st skin

2nd skin, subcutaneous tissue, perineal muscle

3rd above, and anal sphincter complex

4th All above plus rectal mucosa

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78
Q

When would you do a symphysiotomy for shoulder dystocia

A

Typically used only when surgical capabilities are not available

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79
Q

What is the approach to a cord prolapse

A

Tocolytics -> C-section Stat

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80
Q

What must you r/o in minor trauma in pregnancy

A

Rule-out placental abruption (monitor for ~4 hrs)

Also assess maternal fetal Hemorrhage -> Rhogam

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81
Q

When can we D/c a preg pt post trauma

A

Contracting <1 every 10 mins

No vaginal bleeding

No abd pain or tenderness

FHR reassuring

No visible bruising

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82
Q

What is the most common cause of Abruptio Placentae

A

HTN

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83
Q

What are the 4 Ts of postpartum hem

A 
Tone = uterine atony (75-80%)
Tissue = retained placenta/accreta
Trauma = vaginal/cervical laceration
Thrombin = coagulopathy
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84
Q

How do we estimate blood loss in post partum hem

A

When estimating blood loss based upon H&H:

Estimate 500 mL loss for every 3 volume percent drop in HCT

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85
Q

What is a boggy, soft uterus on bimanual examination

A

Uterine atony

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86
Q

Post partum hem can occur up to week ____ post partum

A

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

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87
Q

What is the treatment for Post Partum Hem

A

Call for help! EXAMINE.

External uterine massage
+Medications

Bimanual uterine compression

IV fluids (may need volume 3x EBL)

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88
Q

What are the Uterotonic Agents

A

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

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89
Q

Once Oxytocin is started for post partum hem

What is the next step

A

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

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90
Q

C/I for Methergine

A

Preeclampsia

HTN

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91
Q

C/I for hemabate

A

Asthma
Cardiac/ renal/ Liver dz
SZR pts

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92
Q

If a pt has HTN or Asthma

What is the rx to use instead of methergine or hemabate

A

Misoprostol

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93
Q

What is the classic disaster from post partum hem

A

Uterine inversion

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94
Q

a pt presents after birth with Failure of lactation, amenorrhea, breast atrophy, loss of pubic & axillary hair, hypothyroidism, & adrenal cortical insufficiency

Think

A

Sheehan syndrome

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95
Q

If a male partner is over 40 top at age of sperm donation

What is the genetic risk

A

Autism: 6x more likely if father >40yo at conception

Schizophrenia: 2x more likely if father was >45yo at conception; 3x if > 50

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96
Q

What is the recommended follow up when putting someone on Contraceptives

A

IUD?
Check for IUD strings.

Combined hormonal?
Check BP.

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97
Q

Can pts with HTN take COC?

A

NO, if BP is above 160/100 no COC

Also avoid depoprovera (shot)

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98
Q

If a pt is over age 35 and smokes more than 15 cigs a day

What is the recommendation for COC

A

AVOID/Do NOT use COC

Use with caution if >35 and smoker

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99
Q

Can pts with aura+ migraine take COC?

A

NO

Depo-provera is usually ok

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100
Q

Can pts with DM and end organ dz take COC?

A

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
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101
Q

If a pt is breastfeeding and is less than 1 month post partum

Can they take COC

A

Not recommended

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102
Q

Can a pt with DVTs take COC

A

No!

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103
Q

What is the contraception of choice in Breast Cancer Pts

A

IUD (copper)

No hormonal!

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104
Q

Can RA pts take depo-provera

A

use with caution, at risk of osteoporosis

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105
Q

Indications for IUD placement

A

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

106
Q

What is the duration of action for Mirena and Kyleena IUDs

A

5 years

107
Q

What is the duration of action for Liletta and Skyla IUDs

A

3 yrs

108
Q

What is the duration of action of Paraguard IUD

A

12 years

109
Q

What are the two most effective emergency contraceptives

A

The copper IUD is the most effective form of EC. When taken as directed, ulipristal is the most effective type of EC pill

110
Q

After implanting an IUD a pt may have increased AUB

How is this treated

A

NSAIDs

111
Q

What is the MOA of Levonorgestrel IUD

A

Mechanism of action:
Long-term progestin release → endometrial atrophy: hinders implantation

Progestin: thickens cervical mucus → hinders sperm motility

112
Q

What are the indications for Levonorgestrel IUD

A

Improves dysmenorrhea

Indicated for contraception, HMB, endometrial hyperplasia

113
Q

What is the greatest risk when using levonorgestrel IUD

A

During 1st month: greatest risk for device-related genital infection

High risk for STDs: screen prior to insertion

114
Q

If an IUD is placed more than 7 days after menses

What is the recommendation

A

Back-up method or abstinence x 7 days

115
Q

What is the F/u time frame for an IUD placement

A

6 weeks check strings

116
Q

When is the most common time to have an IUD become displaced

A

In the 1st month after placement

117
Q

What is the duration of action of Nexplanon (implant)

A

Ovulation suppressed for 3 yrs

Inhibits ovulation, implantation, and decreases sperm motility

118
Q

What is the ADE of all progestin-only contraceptives

A

irregular or heavy uterine bleeding

119
Q

What are the absolute C/I for Implants/ IUD (hormonal)

A

Current Breast Cancer and pregnancy

120
Q

When is the Nexplanon implant inserted

A

Insertion in superficial subdermis (w/in 5d of menses onset)

Placement >5d after LMP? Back-up method or abstinence x 7 d

121
Q

When is the return of ovulation after implant removal (NExplanon)

A

Within 6 weeks to a year

122
Q

What are the C/I of Depo provera

A

Contraindications: recent breast cancer, progesterone-positive cancer, & pregnancy

Absolute contraindication: current breast cancer

123
Q

What should all pts on Depo-provera be given..

A

Vit D and calcium

For reversible bone loss
Screen of OA

124
Q

What are the MOA of POPs

A

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)

125
Q

What is the window of efficacy with POPs

A

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

126
Q

What are the C/I for POPs

A

Breast CA and preg

127
Q

What is the MOA of CHCs

A

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

128
Q

What is the most important effect of CHCs

A

Most important effect: suppress GnRH → inhibit LH/FSH release → inhibit ovulation

129
Q

If a pt wanted to avoid mood changes, what phase of COCs should she be given

A

Monophasic

130
Q

What is a 1st day start for COC

A

Begin on 1st day of menses

No back-up required

131
Q

What is a Sunday start for COC

A

(avoid withdrawal bleeding on weekends):

Begin on 1st Sunday after menses starts

Back-up required for 1st wk

132
Q

What is a quick start for COC

A

1st pill taken day rx filled

Back-up required for 1st wk

Minimal confusion about when to start!

133
Q

If a pts COC patch falls off what is the guidance

A

<24 hrs: replace same patch → no back-up

> 24 hrs: place new patch, new day → back-up X 1 wk

134
Q

What is the shelf life of a nuvaring

A

Must be refrigerated, therefore poor option for deployment

4 months shelf life (↓ w/ hot environment)

135
Q

IF a Nuvaring falls out for more than 3 hours

What is recomended

A

If out for >3 hrs: rinse, replace but use back-up for 1 wk

136
Q

Pt misses her COC pill less than 48 hours

Advise

A

Take the missed pill
And return to schedule

No back up needed

137
Q

Pt misses her COC pill greater than 48 hours

Advise

A

Take most recent missed dose

Use back up x 7 days

138
Q

Pt misses her pill during the 2nd or 3rd week of her current COC pack

Advise

A

Discard placebo week

Start new pack

Plus back up x 7 days

139
Q

What is the only requirement before starting a pt on CHC

A

Check the BP

140
Q

When should vaginal diaphragms be placed prior to sex

A

6 hours before

Do not remove for 6 hours after

141
Q

What is the increased risk when using spermicides

A

Increased HIV and STI transmission

142
Q

What is the standard days method for BC

A

Avoid unprotected intercourse days 8-19 of menstrual cycle

In order to be effective, menstrual cycles must be regular & monthly every 26-32 days

143
Q

What is the 2 day and Billings method for cervical mucus

A

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

144
Q

When can the Cu IUD and ulipritstal be given for emergency contraception

A

Within 120 hours (5 days)

145
Q

What is lactational amenorrhea

A

Must do exclusive breastfeeding & have no menses

Unlikely to ovulate during 1st 10 wks after delivery

Must use alternative contraception after 6 months

146
Q

What are the recommend COCs for past partum

A

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

147
Q

How long does it take for a vasectomy to be effective

A

Stored sperm in reproductive tract requires 3 mos or 20 ejaculations to empty stored sperm

148
Q

When is the return of ovulation after pregnancy termination

A

Ovulation can resume as early as 2 weeks after early pregnancy termination

149
Q

What is fecundity

A

probability of achieving a live birth from a single menstrual cycle

150
Q

What is fecundabilty

A

ability to conceive; probability of achieving a pregnancy per month of “exposure”

20% per cycle

50% in three months

85% in a year

151
Q

What is the general advise to a couple wanting to conceive

A

Have sex every day within 5 days of ovulation or every other day for 10 days around ovulation

Do not use oil based lubricants

152
Q

If a woman is over the age of 35 what is the threshold to work up for infertility

A

6 months

153
Q

What is the triad of a fertility W/u

A

Ovulation
Normal female reproductive tract
Normal semen characteristics

154
Q

What is the time frame for viable sperm

A

~73 d to generate + time in epididymis to gain mobility = 3m

Any detrimental event in prior 90d can affect semen characteristics

155
Q

What is the general collection for sperm

A

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

156
Q

What is mittelschmerz

A

Ovulation (pain during menses)

unilateral, midcycle pelvic pain w/ ovulation (+/- additional sx: breast tenderness, acne, food cravings, mood changes)

157
Q

An increase of 0.4-o.8 degrees F vaginally indicated

A

Looking for a 0.4-0.8F increase on 2 consecutive days
Due to postovulatory ↑progesterone

OVUALTION HAS OCCURED

158
Q

What is the best at home method to predict ovualtion at home BEFORE is occurs

A

Urinary ovulation detection kits: urinary LH (at home)

159
Q

What are the key labs to get in an anovulation pt

A 
TSH
Prolactin
FSH
Total testosterone
DHEA-S (dehydroepiandrosterone sulfate)
160
Q

What are the 3 main etiologies of infertility

A

Ovarian

Male Fx

Tubal

Uneplained/ other

161
Q

What are the set of women we should consider for infertility testing

A

≥ 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

162
Q

What is the approach to testing FSH and estrogen in infertility

A

Test on cycle day 3: “day 3 labs”

163
Q

What is the standard work/up for infertility

A

FSH/ E2 on day 3

Serum Anti Mullerian (anytime)

And Antrol follicule count on day 3
-<5-7 : predicts poor response to ovarian stimulation

164
Q

AMH levels should be above what for fertility

A

Above 2

165
Q

What should FSH and E2 levels be for fertility

A

Less than 10

Above 20= bad

166
Q

What is the ideal antral follicle count for fertility

A

About 20

Less than 5 is bad

167
Q

What is the initial Rx for inferlility

A

Clomiphene citrate

Start 3rd-5th day of menstrual cycle

If no ovulation/failure to conceive in 3-6 m of max dose, refer

168
Q

How does metformin effect women with PCOS

A

↓ Insulin resistance

↑ Frequency of spontaneous ovulation

169
Q

What are the S/s of ovarian hyper stimulation syndrome

A

Ovarian enlargement

Abdominal distention

Ascites

Electrolyte imbalance

GI issues

Hypercoagulability

Respiratory compromise

Oliguria

Hemoconcentration

Thromboembolism

Hypovolemia ->renal/hepatic/pulm end-organ failure

170
Q

If a pts infertility problem is 2/2 anovulation/ irregular menses

What are the test and tx

A

Test:
BBT, LH. And Progesteone level

Tx: Clomiphene

171
Q

If a pts infertility is 2/2 uterine fibroids

What are the tests and tx

A

Hysterosalpingogram and SRGRY

172
Q

If a pts infertility is 2/2 male fx
(Hernia, Varicocele, mumps)

What is the tests and tx

A

Semen analysis

Tx: SRGRY or IVF

173
Q

If a pts infertility is 2/2 tubal, G/C, or PID

What are the tests and tx

A

Hystersalpingiogram

Tx; laparoscopy or IVF

174
Q

What is the treatment for pubic lice

A

Permethrin!!

Pyrethrins

Lindane (not in pregnancy/infant)

Treat household contacts/linens

175
Q

What is the treatment for scabies

A

Permethrin

Lindane (not in pregnant patient/infant)

Ivermectin orally repeat at 2 wks

Treat household contacts/linens

176
Q

HPV strains

A

6, 11

177
Q

Risk of HPV to a neonate

A

Birth canal to larynx transmission

178
Q

What are the treatment options for genital warts

A

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

179
Q

What are the provider treatments for genital warts

A

Provider applied:

  • podophyllin
  • trichloroacetic acid (TCA), -bichloroacetic acid (BCA); -cryotherapy
180
Q

What are the outpt treatments for genital warts

A

podofilox
or imiquimod
(not during pregnancy)

181
Q

What are the Surgical tx for genital warts

A

tangential scissor excision
tangential shave excision
curettage, or electrosurgery

182
Q

What is the screening and confirmatory test for syphillis

A

Screening: RPR or VDRL
(0.5-14% false positive, esp. in autoimmune disease)

Confirmation: FTA-ABS

183
Q

What is the reaction from PCN for syphillis treatment

A

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

184
Q

What is the follow up post syphillis treatment

A

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

185
Q

A pt presents with a “groove sign” lymph node and a small vesical or papule in the inguinal area

Think

A

Lymphogranuloma venereum

Tx:
Doxycycline 100 mg 2x daily x21 ds
Eyrthromycin 500 mg 4x daily x21 ds

186
Q

What is the treatment for chlamydia

A

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

187
Q

Treatment for gonorrhea

A

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

188
Q

What is the sequellae of PID

A

infertility, ectopic pregnancy, chronic pelvic pain

189
Q

What should be considered in a patient w/ tubal-factor infertility who lacks upper tract infection

A

Silent PID

190
Q

Dx criteria for PID

A 
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)

191
Q

Inpt treatment for PID

A

IV cefotetan or cefoxitin plus

PO/IV doxy

192
Q

Out pt treatment for PID

A

Ceftriaxone + Doxy

If BV or Trichomoniasis add: metro

193
Q

A pt presents with PID symptoms + adnexal mass, lower abdominal pain, fever, leukocytosis

Think

A

Tuboovarian abscess

Dx with US

Tx: broad spectrum IV abx; surgical if no improvement

194
Q

What is the cause of toxic shock syndrome

A

Exotoxin from Staphylococcus aureus

195
Q

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

A

Toxic shock syndrome

Tx: Antibiotics while awaiting cultures
Systemic support (IVF & electrolytes)
196
Q

What are the major criteria for Toxic shock syndrome

A

HOTN

Ortho Syncope

SBP < 90

Diffuse macular rash

Fever> 38.8C

Skin desquatmation

197
Q

What are the minor criteria for Tosic shock syndrome

A

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

198
Q

MC benign breast tumor

A

Fibroadenoma

199
Q

What is the risk of complex Fibroadenomas

A

Benign, but if “complex,” pts have 1.5-2x risk of breast cancer

200
Q

What is the w/u for simple cysts on the breast

A

No special mgmt

If recurrent excise

201
Q

What is the w/u for complicated cysts of the breasts

A

Consider aspiration,
Culture,
Cytology,
Core needle

202
Q

What is the w/u for complex cyst of the breast

A

Core needle

EXcision

203
Q

What is the treatment to fibrocystic breast changes

A

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
204
Q

What is the treatment for mastitis

A

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

205
Q

If mastitis doesn’t improve with ABXs

What is the next step

A

If mastitis doesn’t improve rapidly w/ antibiotics → ultrasound to r/o abscess

Abscess may require surgical drainage

206
Q

If a pt presents with mastitis in a non irritated or non pregnant breast

Think

A

Requires imaging & biopsy to exclude inflammatory breast cancer

207
Q

What is the w/u for breast pain not related to menses

A

Frequently simple cyst, but could be cancer → evaluation (exam, imaging, biopsy)

208
Q

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?

A

Concern for inflammatory breast cancer

Order Bx

209
Q

What is the spiral of sexual response

A

intimacy -> sexual stimuli-> arousal -> sexual desire

-> enhanced intiman y

210
Q

What is the arousal period of the sexual spiral

A

↑ Nitric oxide (NO) due to sexual stimulation → clitoral cavernosal artery relaxation → clitoral engorgement → ↑ clitoris sensitivity

211
Q

What is vaginismus

A

(pelvic floor muscle spasms → painful, difficult, or impossible to have sexual intercourse, have a gynecological exam, or to insert a tampon)

212
Q

What is the hormone responsible for libido

A

Testosterone

Excited by dopamine
Suppressed by serotonin

213
Q

What is the innervation for arousal

A

Modulated by parasympathetics

Enhanced by estrogen
-Lack of estrogen is most common cause of dysfunction in this phase

214
Q

What is the innervation for orgasms

A

Modulated by sympathetics

Optimized by clitoral input
(afferent concentration)

-Most treatable sexual phase disorder

215
Q

What is the most treatable sexual phase disorder

A

Orgasmic phase

216
Q

What are the risk factors for Dysparunia

A

Age <50
Hx of sexual abuse
Hx of PID
Depression, anxiety

217
Q

What is the leading cause of death during pregnancy

A

Homicide is a leading cause of death during pregnancy

218
Q

What are the risk factors for sexual assault

A

Physically or mentally disabled

Experiencing homelessness

Gay, lesbian, bisexual, or transgender

Alcohol/drug users

College students

Age <24

219
Q

What is the most often injured area during sexual assault

A

Genital wounds
-> posterior fourchette
(most often injured genital area)

220
Q

When should SAMFE kits be done

A

Valid forensic evidence can be collected up to 5 ds after sexual assault, but immediate examination ↑ opportunity to collect valuable physical evidence

221
Q

What tests should be ordered for victims of sexual assault

A

Check for STDs:

  • GC/Chlamydia
  • BV, Trichomonas, Candidiasis
  • HIV, Hep B, Syphilis
  • Blood alcohol & tox screen
222
Q

What is the F/u post sexual assault

A

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

223
Q

What is sexual trauma syndrome

A

↑ Lifetime risk for PTSD, major depression, & suicide ideation or attempt

224
Q

What is chronic pelvic pain as defined by ACOG

A

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

225
Q

What is allodynia

A

painful response to normally innocuous stimulus (i.e., cotton swab)

226
Q

How do MSK changes effect chronic pelvic pain

A

Concurrent lordosis and kyphosis are common postural changes associated with chronic pelvic pain.

227
Q

Chronic pelvic pain after surgery

Think

A

Adhesions

228
Q

A pt presents with chronic pelvic ache, pressure, & heaviness due to tortuous, congested ovarian or pelvic veins

Think

A

Pelvic Congestion Syndrome

229
Q

A pt with chronic pelvic pain that also worsens pre menstrally

What is the tx

A

(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

230
Q

What is the 1st line Tx for Chronic pelvic pain

A

NSADs

And then Anti- depressants
SSRI, SNRI, Gabapentin

231
Q

What is vulvodynia

A

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)

232
Q

What is the tx for vuvlodynia

A

Can spont resolve

CBT-> lidocaine or Gabapentin,

TCAs are 1st LINE!
(Amitriptyline)

233
Q

Dysparunia in the DSM5

A

DSM-5 merged dyspareunia & vaginismus as genito-pelvic pain/penetration disorder

234
Q

How does hypoestrogenism effect the vagina

A

Hypoestrogenism ->vaginal atrophy -> dyspareunia

235
Q

What is myofascial pain syndrome

A

Hyperirritable area w/in a muscle promotes persistent fiber contraction → trigger point

236
Q

What is the difference between primary and secondary myofascial pain syndrome

A

Primary myofascial pain syndrome → musculoskeletal conditions

Secondary myofascial pain syndrome → chronic visceral inflammatory conditions

237
Q

What three muscles make up the Levator ani

A

Pubococcygeus, iliococcygeus, puborectalis

238
Q

A pt prestents with lower abdominal pain, low back pain, dyspareunia, & chronic constipation

Think what pain syndrome

A

Levator Ani syndrome

Tx with massage and nsaids/ muscle relaxants

Last line botulism inj

239
Q

What is the tx for peripartum pelvic pain syndrome

A

Physical therapy, ther ex, analgesics (NSAIDS)

240
Q

What is the pudendal nerve distribution

A

(3 branches: perineal nerve, inferior rectal nerve, & dorsal nerve of the clitoris)

Inervates the clitoris, vulva, and the rectum

241
Q

A pt older than age 32 present with pain in the clitoris, vulva, and rectum
(Combined or alone)

Think what Nerve/ pain distribution

A

Pudendal neuralgia

Pain aggravated by sitting, relieved by sitting on a toilet seat/standing, may progress during day

242
Q

What is Nantes Criteria

A

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
243
Q

What is procidentia

A

Uterus prolapse in to the vagina

244
Q

What is the risk of prolapse with each pregnancy

A

Vaginal childbirth, especially increased parity (1.2x with each delivery)

245
Q

What are the tx options for pelvic organ prolapse

A

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

246
Q

A pt presents with frequency of urination, urgency and pelvic pain

Without cystoscopic finding

Think

A

Interstitial cystitis/ painful bladder syndrome

247
Q

Should pts with painful bladder syndrome drink cranberry juice to relieve s/s

A

No, may exacebte pain

Many potential triggers: alcohol, caffeine, smoking, spicy foods, citrus fruits & juices, carbonated drinks, & potassium

248
Q

What should be ordered in painful bladder syndrome to r/o cancer

A

Basic labs: UA, urine culture

If hematuria, cytology
(esp., in smokers) to r/o bladder cancer

249
Q

What are hunners ulcers/ lesions

A

Hunner ulcers: reddish-brown mucosal lesions w/ small vessels radiating toward a central scar →

rare, but diagnostic for interstitial cystitis (stiffen the bladder)

250
Q

What is the tx for painful bladder syndrome

A

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

251
Q

What does DIAPPERS mean for Incontinence

A

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
252
Q

What are the 3 degrees of stress incontinence

A

I → Only w/ severe stress (cough, sneeze, jumping, etc.)

II → Moderate stress (rapid movement, stairs)

III → Mild stress (standing)

253
Q

What medications should be avoided in incomplete bladder emptying syndrome

A

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)

254
Q

What is the 1st step in evaluating incontinence

A

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

255
Q

What is the tx to incontinence

A

Conservation managed: kegels

More:

  • diet changes
  • calcium glyerosphate
  • schedule voiding-
  • pessary
  • SRGRY
256
Q

Where do Anticholinergics work in incontinence

A

Anticholinergics work at level of detrusor muscle (inhibits muscarinic receptors) to blunt detrusor contractions

257
Q

What is the medication of choice for mixed incontinence pts

A

Imipramine: TCA w/ a-adrenergic effects and Anticholinergic effects

258
Q

What is the Rx of choice for urge incontinence pts

A

Mirabegron (antispasmodic)
→ β3-adrenergic receptor agonist
→ relaxes detrusor smooth muscle & ↑ bladder capacity
→ for urge incontinence

259
Q

What mediations must be avoided in stress incontinence pts

A

α-antagonists
(leads to internal urethral sphincter [IUS])
relaxation → leak)

260
Q

What are the medications to avoid in overflow pts

A

α-agonists (leads to IUS contraction)

Anticholinergics (inhibit bladder contraction, sedation, fecal impaction)

CCBs (relaxes bladder, fluid retention)

Senoir 21-2 (77 decks)

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