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step 2 ck - IM mix > OBGYN mix UWQ : june 28th 2021 > Flashcards

OBGYN mix UWQ : june 28th 2021 Flashcards

1
Q

McCune -Albright syn

sym?

A

triad:
- > cafe au lait spots
- > polyostotic fibrous dysplasia
- > autonomous endocrine hyperfunction

—> GnRH -ind precocious puberty

—-> early puberty

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2
Q

Routine prenatal lab screening ?

A

initial prenatal visit:

  1. RH (D) type, AB screen
  2. Hbg / Hct, MCV
  3. HIV, VDRL/RPR ( SYPHILIS) HBsAg
  4. Rubella + varicella immunity
  5. Pap test (if needed)
  6. Chlamydia PCR + neisseria gonorrhea
  7. Urine Pn + culture

—-> inactivated influenza vaccination : safe every trimester + breastfeeding !!

wk: 15-20
- > trisomy testing: MS-AFP, b-HCG, Estriol, Inhibit-A :
- > cell -free fetal DNA testing : circulating, free maternal , fetal DNA in mat plasma
- > trisomy 13, 18, 21
- > SMA !!!!

24-28 wks: Beginning 3rd trimester

  1. Hbg/ Hct
  2. AB Rh(D) -
  3. 50g 1 hr Oral glc challenge test
  4. REPEAT: HIV, Syphilis, Gonorrhea, Chlamydia , HBV

35-37 wks:

  • -> GBS culture
  • -> rx: Intrapartum penicillin !!

** LEAD exposure: house < 1978!!!

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3
Q

missed abortion

sym?
lab?
rx?

A

<20 wks gestation

  • > expulsion products
  • > ASX / dec pregnancy sym
  • > CLOSED CERVIX
  • > NO BLEEDING!!
  • > NO fetal cardiac

risk factor: spontaneous abortion
-> adv maternal age : inc chrm abnormalities

dx:
-> u/s : EMBRYO w/o cardiac activity / empty gestational sac w/o fetal pole (NO embyro)

  • –> normal inc b-HCG till end of 1st trimester
  • -> dec b-HCG : demise !!!

rx: MISOPROSTOL : dilation + myometrial contraction to expel IU content : labor induction

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4
Q

hydatidiform mole

lab?

A
  • > snowstorm appearance
  • -> heavy vag bleeding
  • > enlarge uterus + HETERGENOUS cystic mass
  • > b-HCG >100,000 IU/L !!!
  • > elev T3, T4 : hyperthyroidism !!!

rx:

  • -> SUCTION CURETTAGE !!!
  • > hysterectomy

f/u: b-HCG level

risk :

  • > Vit A def ( Roux-en-Y sx)
  • > adv age >40
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5
Q

incomplete abortion?

A

< 20 wk GA !!!

  • > PAINful!!!!
  • > BLEEDING
  • > DILATED cervix , -> SOME passage of products
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6
Q

threatened abortion ?

A
  • > vaginal BLEEDING
  • > CLOSED CERVIX
  • > fetal cardiac activity: + NORMAL IU Gestation !!

—> asso with subchorionic hematoma : abnormal collection blood btwn placenta + uterus

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7
Q

vulvar lichen sclerosus

sym?
dx?
rx?

A
  • > PREpuberty girls + peri-menopauseal / post-menopause
  • –> asso : alopecia areata

sym:

  • > THIN WHITE wrinkled skin LABIA PLAQUES , atrophic extend over perineum + anus ( clitoral HOOD retraction)
  • -> adherence at labia at midline
  • > EXCORIATION , erosion , fissure from severe pruritus
  • > dysuria , dysparenunia, painful defecation
  • ** NOT affect VAGINA***

dx:
- > punch biopsy r/o Ca ( elderly)

rx: steroids ointment
- –> CLOBETASOL

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8
Q

ectopic pregnancy

sym?

A
  • -> cornual ectopic
  • > hemodyn unstable : ruptured ectopic pregnancy

—> unilateral pain + light vag bleeding

dx: U/S COMPLEX adnexal mass !!!

–> D&C : sample w/in endometrial cavity
postprocedure b-hcg level
——> neg / dec b-HCG : confirms abnormal IUP : observe + reassurance
—-> persistent rise b-HCG s/p D&C: ectopic preg

rx:
stable: MTX!!!
- -> continue monitoring b-HCG level till become undet

unstable: ER sx exploration!!!

  • —> if pt has IUD : CONFIRM with TVUS to locate intra/ extrauterine pregnancy?
  • > if intrauterine : REMOVE IUD !!
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9
Q

breech presentation

rx?

A
  • -> > 36 wk
  • -> Ext cephalic version !!!

–> vaginal delivery if successful : FRANK/ COMPLETE BREECH

!!! CONTRA vag delivery:

  • > INCOMPLETE BREECH/
  • –> FOOTLING

!! —-> PRIOR C/S delivery !!

  • -> placnta previa
  • > prior ext uterine myomectomy

inc risk:

  • > PROM
  • > abruptio placentae
  • > preterm labor

RF:

  • > adv age > 35 yr
  • > fibroids
  • > uterine didephys, septate uterus
  • > fatal anomalies
  • > preterm < 37 GA
  • > oligo/ poly- hydramnios
  • > placenta previa
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10
Q

internal PODALIC version

useage?

A

TWIN delivery

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11
Q

menopause

rx?

A

HRT: prevent
—> VASOMOTOR symptoms !! Hot flashes, night sweat, sleep disturbance

** not recommend: osteoporosis / CVD prevention! inc risk of thromboemboli

-> vag atrophy : pruritus, dryness, irriation
-> dysparenunia
!!!! -> Urinary incontinence , recurrent UTI
-> pelvic pain
-> hyperestrogenism

hx: Low estrogen: loss epi elasticity!!
- > vag PETECHIAE, vest FISSURES !!!
* * NOT cause white PLAQUES!! / NOT inv perianal region !!!

dx:
- > clx
- > elev vaginal PH > 5 !! –> inc risk of UTI !!!

rx: mod - severe vasomotor syn:

INTACT UTERUS: Menopausal hormone therapy : E + P : inc risk breast Ca long term use

NO uterus : ESTROGEN only MHT ( transdermal estrogen patch)

–> contra to E patch : breast Ca, venous throboembolism , CVD, endometrial ca

—> switch rx: SSRI, gabapentin ( dizziness/ HA), clonidine ( hypotension)

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12
Q

physio pregnancy hydronephrosis ?

physio?
rx?

A

-> bil kidney enlargement
-> bil dilation renal pelvises + Proximal ureters
MC @ right ureter

  • > inc maternal BV
  • > req inc renal filtration : greater renal vasculature + int tix

-> begins 1st trimester
: high P level –> Ureteral DILATION + dec peristalsis

rx: NO additional rx

*** uretheral stents + nephrostomy tube: ureteral blockage ( nephrolithiasis) !!–> microscopic hematuria + unilateral image (stones)

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13
Q

endometriosis

sym?
rx?

A
  • –> ectopic implant endometrial glands ( UNILOCULAR adrexal gland!!!)
  • —> lat displacement of cervical
  • > dysmenorrhea
  • > DEEP DYSPAREUNIA
  • > chronic pelvic pain: throughout the MENSES !!!
  • —–> infertility
  • > dyschezia
  • > cyclic dysuria !!!!
  • > hematuria

PE:

  • > post cul-de -sac !!!! , retrovag septum
  • > immobile uterus
  • > cervical motion tenderness !!!!

–> bladder : bladder pain, supra-pubic tenderness , bladder inflammation

hx: HOMOGENOUS . low level echos ( blood)

dx:
TV u/s
-> direct visualization : LP !!!!! surgical biopsy

rx:
AXS: reassure + observe only

Med: Sym pt
OCP, NSAIDS
–> GnRH + ( leuprolide/ lupron ) : E suppression / Testo derivative ( Danzol)

-> surgery resection: LP fulguration of lesions

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14
Q

vaginismus

sym?
rx?

A

-> Genitopelvic pain / penetration dx

  • > dyspareunia
  • > pain with ANY vag penetration ( sex, speculum exam!!)

rx: desensitization therapy
kegal exercise
CBT

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15
Q

placenta previa

sym?
rx?

A

–> placenta covers CERVIX!!!

inc risk:

  • > multiparity
  • > adv age > 35
  • > prior C/S!!! Major risk
  • > prior placenta previa
  • > multiple gestation

comp:
antepartum hemorrhage
—–> PAINLESS !!!! HEAVY Vag bleeding !!!! w/ or w/o contraction

dx:
-> repeat u.s performed 3rd trimester

rx:
-> pelvic REST !!
routine OB care
C/S > 36-37 wks

contra:

  • > Digital cervical exam
  • > DRE
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16
Q

Anti-D Ig

given?

A

postpartum up to 72 hrs

lab:
KLEIHAUER _BETKE TESTING

Coombs test +
—-> hemolytic fetalis

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17
Q

postpartum hemorrhage
> 1000 ml

MCC

rx?

A
  • –> uterine ATONY !!!
  • —-> SOFT , boggy, enlarged uterus !!!
  • -> fundus ABOVE the umbilicus : DEC uterine tone !!!!

RF:

  • –> insufficient uterine contractility
  • > uterine fatigue
  • > operative vag delivery forceps assisted
  1. bimanual uterine massage + high dose OXYTOCIN : inc Ca in muscle cell –> inc uterus contraction!
  2. tranexamic acid : antifibrinolytic : prevent breakdown blood clots to achieve hemostasis : reduce mat mortality hemorrhage
  3. 2nd line Uterotonic agents:
    - > methylergonovine ( se: HTN + inc risk of STROKE !!! potent vasoconstrictor )
  • > carboprost ( prostaglandin F2a analog) tromethamine ( se: asthma: bronchospasm !! )
  • > misoprostol

—> FFP blood infusion

  1. IU balloon tamponade
  2. LP: D&C
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18
Q

gestational HTN –> Preeclampsia with severe syndrome!!!!

dx?
lab?

A 
new onset HTN > 20 wks 
!!!! SBP > 140 / DBP > 90
-------> inc comp: preterm!!! 
--> FGR!!! 
-> fetal OLIGOHYDRAMIOSIS

inc risk:

  • –> TWIN preg !!!
  • -> type 1 DM

lab:
1. BP measure
2. clx EOF : WORSENING HA!!!! visual change , RUQ pain
3. EO dmage : UA, CR, AST, ALT, PC
4. fetal nonstress test
- —-> UA : high false Neg !!

!!!! GS: 24 hr urine collection total pn!!!

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19
Q

preeclampsia

up to 6 wk postpartum !!

risk?
patho?
rx?

A

-> abnormal narrowed spiral artery formation : placental hypoperfusion , hypoxia, ischemia —-> endothelial cell damage !!!

!!!! with severe features:
risk: HELLP syn :

-> Liver : stretch hepatic capsule
-> kidney: Pnuria : AKI
-> brain : ACUTE STROKE !!!!
!!! —-> Pt < 100,000
HTN SBP >140/ DBP >90

–> pul edema

——> + coagulation sys + Pt : vascular microthrombi formation –> ischemia STROKE !!

——> dysreg CBF : cerebral vasospasm : inc perfusion pressure : rupture IC vessels : HEMORRHAGIC STROKE !!! HA, visual change

dx:
- -> 24 hr urine total pn collection
- -> CT scan head!!

rx:
- > IV labetalol : fast acting, effective
- -> se/ BRADYCARDIA !!

  • > IV hydralazine : direct arterial vasodilator !!
  • > oral Nifedipine: CCB

> 37 wks / >34 wk with severe sym: delivery !

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20
Q

SAH

risk?

A
  • > SMOKING

- > chronic HTN

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21
Q

sinusoid fetal HR tracing

?

A

Category 1: reassuring : low risk fetal hypoxemia + acidemia

Category 3:
> 1 sym:
–> inc risk fetal compromise + req urgent rx

!!!! —> severe fetal anemia : rupture vasa previa !!!!

  • –> fetal exsanguination + deterioration
    rx: ER c/s
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22
Q

fetal tachycardia > 160/ min !!!

etio?

—-> intraamniotic inf : chorioamnionitis !!!!!

sym?
dx?
rx?

A
  • > FEVER , inc SNS
  • > asso prolonged preterm prelabor rupture of membrane (PPROM)!!!
    dx: nitrazine + fluid !!!

FEVER + any one:

  • > tachycardis,
  • > inf
  • > purulent AF

rx:
!!! IMMEDIATELY DELIVERY!! + AB ( ampicillin + gentamicin) !!!
–> reduce mat endometritis, neonatal early onset SEPSIS, cerebral palsy

—> if < 34 GA: steroids!!!

—-> if < 32 GA: MgSO4 if preeclampisa

** no need C/S

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23
Q

-> VARIABLE deceleration

etio?

A

—> UC compression !!!!
—> oligohydramnios
AFI <5 cm
—> cord prolapse

rx:
- -> Maternal repositioning!!
- -> AMINOINFUSION saline: reduce UC compression

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24
Q

mature cystic teratoma ( dermoid cyst)

hx?
sym?
rx?

A

-> germ cell tumor benign : somatic diff of primordial germ cell

  • -> sebaceous fluid, teeth, hair
    hx: HYPERECHOIC nodules + Calcification
  • -> heterogeneous solid + fluid !!!!!

sym: intermittent, colicky pain
- > trigger by phy activity

risk:

  • > torsion
  • > ischemia / necrosis

rx: LP ovarian cystectomy / oophorectomy

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25
Q

uterine leiomyomas ( fibroids)

sym?
dx?
rx?

A

-> age < 35 yr
-> IRREGULAR , firm infertility
UTERUS !!!
—-> proliferation SMOOTH MUSCLE w/in myometrium

loc:
1. SUBmocosal : dec fertility + protuding into uterine cavity
—-> se/ compress embryo implantation / growth !
Dec endometrial thickness + reduce vascularity fibroids!
!!!! —> DEGENERATING fibroids : uterine contraction : PROSTAGLANDIN release + fundal tenderness

rx: hysteroscopic MYOMECTOMY ( maintain fertility!! )
2. SUBserosal : enlarge + BULK -> constipation

–> asso w/ : dysmenorrhea

dx: pelvic U/S !!!
rx:
ASX: observe!!!!

sym: HT ( hormonal contraception) : with SYMPTOMS patient
- > Sx

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26
Q

polyhydramnios

etio?
sym?

A

-> uterine size larger than dates discrepancy !!!!!
AFI > 24

etio:
-> fetal urination + removal imbalance

-> DM !!: fetal macrosomia : inc risk of PROTRACTED LABOR

  • > TE fistula
  • > IDIOPATIC
  • -> cong infection
  • -> DM
  • > Anencephaly

risk: dyspnea ( mat lung compression) : < 37 wks : rx/ Betamethasone !!!

  • > abd pain ( inc uterine size)
  • > preterm contraction ( inc IU pressure)
  • > PROM
  • > UC prolapse
  • > preterm labor
  • > malposition fetus

rx: mild / ASX
- –> amniocentesis
- –> expectant management

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27
Q

amenorrhea , insomnia, WG

dx?

A

–> HCG level!!!!

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28
Q

dec ovarian reserve?

A
  • -> age 35 !!!
  • > dec Oocyte # + quality
  • > reg MC

lab:

  • > dec estradiol, inhibin production
  • -> normal neg feedback: suppression –> INC FSH !!!!
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29
Q

primary ovarian insufficiency

sym?

A

2ndry amenorrhea ( lack MC > 6 mo with previous irregular cycles)

menopause before <40 yr !!

  • > HOT flashes
  • > Amenorrhea
  • > Vag atrophy
  • > Osteoporosis
  • > CAD

lab:
- > Inc FSH, LH !!
- > dec ESTROGEN
- -> LACK progesterone progesterone challenge test : NO slough off

inc risk:
-> FMR1 premature carriers
( mRNA over-expression: cytotoxic effect on ovarian primordial follicles -> accelerate follicle depletion
-> TS
—> CMT + radiation rx: target dividing cancer cells

rx: Estrogen containing rx to red ostoporosis , CVD

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30
Q

fetal hydrops

sym?

A

patho:

  • > inc cardiac Output demand –> HF ( bradycardia)
  • > inc fluid movement –> interstitial space ( 3rd spacing)

sym:

  • > pericardial effusion
  • > pleural effusion!!!
  • > ascites
  • > skin edema
  • > placental edema
  • > POLYHYRDAMNIOS
  • —> SLAPPED CHEEK RASH !!!!!

etio:
immune: RhD alloimmune

nonimmune:

  • > parvovirus B19 !!!!
  • —–> transmit: resp droplets
  • > fetal aneuploidy
  • > CV abnormalities
  • > thalassemia ( Hbg barts) !!!!
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31
Q

recurrent cystitis

rx?

A
  • > > 2 inf / 6 mo
  • > > 3 inf / year

risk: sexual active
- > postmeno
- > 1st UTI < 15 yr
- > spermicide use

ppx:
daily AB PPX
-> POSTCOITAL PPX!!!

  • *** renal U/S : + urine culture with recurrent cystitis
    eg. proteus
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32
Q

bladder Ca

dx?

A

dx:

cystoscopy

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33
Q

adenomyosis

sym?
etio?
dx?

A
  • > multiparous > 40 yr
  • —–> ENDOMETRIAL GLANDS + STROMA win myometrium

sym:

  • > HEAVY MC bleeding MC
  • —> new onset dysmenorrhea : cyclic shedding
  • –> BOGGY, tender UTERUS
  • > SYMMETRICALLY enlarged

dx/

  • > pelvic u.s
  • > MRI
  • > hysterectomy

rx: OCP, P-releasing IUD
- > tranexamic acid ( antifibrinolytic agent) !!!!

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34
Q

2ndry amenorrhea >

A
  • > amenorrhea > 3 mo with previous reg MC
  • > > 6 mo irregular mc

-> most women return spontaneous MC w/in 1-3 mo cessation OCP

—> HPO axis dysfunction + endo abnormal

dx:
HOP axis: FSH, TSH, prolactin level !!!
—> elev prolactin: f/u MRI

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35
Q

preg Diabetic insipidus ( DI)

sym?
lab?

A
  • > low sp gravity < 1.006
  • > polyuria > 3 L UO
  • > diluted urine ( water diuresis)
  • -> POOR ADH production: unable to inc renal water reabsorption in CT !!!

Pregnancy: placental production enz : vasopressinase : inc ADH breakdown
—> unmasking DI

dx: challenge with desmopressin ( ADH analogue)

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36
Q

gestational DM

sym?

A 
-> polyuria
osm diuresis ( excess glc : hyperglycemia / urea : AKI)

–> high sp gravity : conc urine

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37
Q

hyerandrogenism in pregnancy

sym?
etio?

A

-> acne, male pattern terminal hair

  • > maternal: ovarian masses
  • > fetal: placental aromatase def

sym:
BIL ovarian masses u/s

etio:

  1. Luteoma preg:
    - -> SOLID, bil mass
    - > inc b-HCG: + leuteoma Lutein cells —> inc ANDROGENS release : mat + fetal VIRILIZATION !!!
  2. Theca lutein cysts:
    - > CYSTIC , BIL mass
    - > elev b-HCG
    - > low risk fetal virilization
    - —-> Ovarian hyper-stimulation from abnormal trophoblastic proliferation

rx: observe + exp management
resolve after delivery !!!!

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38
Q

Sertoli - leydig tumor

sex cord stromal tumor

sym?
lab?
rx?

A

RAPID onset !!! <1 yr

+ elev testosterone
—> suppress FSH, LH

*** (congenital adrenal tumor: DHEA > 700 ug/dL )

  • > virilization : voice deepening, male pattern BALDING, inc muscle mass, CLITOROMEGALY
  • > ESTROGEN DEFICIENCY: oligomenorrhea/ amneorrhea, abnormal uterine bleeding, vulvovaginal ATROPHY!
  • > unilateral, solid, COMPLEX MASS
    rx: sx
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39
Q

cholelithiasis in preg

patho?
sym?
dx?
rx?

A
  • > inc Biliary chol excretion ( estrogen)
  • > dec GB motility ( progesterone)

sym:
- > recurrent, postprandial epigastric / RUQ pain

dx: abd U/S
- > RUQ u/s with echo foci ( stones/ sludge)

rx:
pain control
-> cholecystectomy ( recurrent / complicated)

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40
Q

Gestiatonal thrombocytopenia

sym?

A
  • > ASX
  • > MILD red PC 100,000- 150,000

rx: reassurance and observe

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41
Q

epi ovarian Ca

sym?
RF?
protective factor?
lab?
dx?
rx?
A

sym:

  • > AXS
  • > subacute:pelvic/ abd pain . bloating , early satiety
  • > acute: dyspnea, obstipation / constipation, abd distension

RF: LONG Estrogen exposure

  • > FX
  • > BRAC1,2
  • > Age> 50
  • > HRT
  • > endometriosis
  • > infertility
  • > early menarche/ late menopause

protective:
OCP
multiparity
breastfeeding

dx:

  • —> inc CA-125 !
  • > u/s : solid , complex mass , THICK SEPTATION, ASCITES

rx: LP + sx staging +/- CMT

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42
Q

obesity + anovulation

sym?

A

chronic >.6 mo abnormal uterine bleeding –> 2ndry excess adipose tix : OBESITY!!!

+ HPO axis :

  1. inc insulin resistance + hyperglycemia
    - —> dec production SHBG —> elev free androgen level
    - —> inc aromatized adipose tix –> ESTRONE (estrogen elev) !!!

high estrone : high freq short interval GnRH pulses : inc LH /FSH ratio imbalance –> ANOVULATION !!!

inc risk: ENDOMETRIAL HYPERPLASIA/ CA !!!!

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43
Q

fetal macrosomia

etio?

A
  • > maternal obesity
  • > excessive preg WG
  • > GDM
  • > post term preg

sign: PROLONGED 1st / 2nd stage labor
- > TURTLE SIGN

  • ** uterine fibroids: NOT affect fetal growth
  • -> inc risk : miscarriage,, malpresentation , c/s
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44
Q

eclampsia

sym?

A

HTN + SEIZURE
(GTC)
-> postictal state
: HA, n/v, hyperreflexia, elev CR

** NOT CAUSE FEVER / TACHYPNEA !!

dx: CT scan : bil frontal / occipital lobe EDEMA !!!
- –> inc risk: stroke,

rx: MgSO4 birth < 32 GA !!!
- —> delivery !!

  • *** triptan abortive rx: NOT USED during pregnancy!! risk FGR + preterm labor
  • -> unilateral throbbing pain
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45
Q

osteoporosis risk factors?

A

NONmodifiable:

  • > adv age
  • > postmeno
  • > low BW: low bone mass : inc risk fragility fracture !!!

MODIFIABLE:

  • > smoking
  • > ETHO
  • > lifestyle
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46
Q

OCP se?

A

-> primary dysmenorrhea

—-> rx: OCP : Estrogen- Progestin oral / vaginal ring
se/ n, bloating, breast tenderness
-> breakthru bleeding

  • > !!!!! severe HTN : : ABSOLUTE contra in MIGRAINE pt
  • > estrogen med inc Hepatic angiotensinogen synthesis + RAS
  • > inc risk CERVICAL CA!!!!
  • —–> DEC risk: ovarian + endometrial ca!!!!
  • > venous Thromboembolism !!!: MI + STROKE !!!!
  • > hepatic adenoma !!!
  • > inc TG

—> AVOIDED in breast feeding / postpartum < 1 month !!! DVT risk
hypercoagulability

*** WG not asso with OCP!!!!

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47
Q

Medroxyprogesterone ( progesterone) acetate
IM injection

se?

A
  • > inc body fat, dec lean muscle mass
  • > WG!!!!

–> DEC bleeding by 50% + amenorrhea in 20%

NOT rx for young aldolescent : sig risk bone mineral density loss!!!

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48
Q

Latent phase : cervical 0- 6 cm

!!! active phase labor 6-10 cm dilation : normally progression > 1 cm / 2 hr !!!!

stages?
etio?

A

Protraction: cervical change slower than expected +/- inadeq contraction
—–> rx: OXYTOCIN

Arrest:
—> No cervical change > 4 hrs ( < 1 cm/ 2 hr) w/ adequate contraction ( > 200 MV unit in 10 mins)

OR

—> No cervical change > 6 hrs ( < 1 cm / 2 hr) w/ INadequate contraction ( <200 MV units)

rx: C/S!!!!!

etio:

  • > uterine : inadeq contraction
  • > fetal : malposition, macrosomia, CEPHALOPELVIC DISPORPORTION!!!!!
  • -> >41 wks GA
  • > pelvis: deformity / fracture
  • > maternal obesity , WG, adv age
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49
Q

twin preg

risk?

A
  • > spontaneous PRETERM labor !!!
  • -> preeclampsia
  • > GFR
  • > uterine crowding + uterine over-distension ( uterine size-date discrepancy)
  • —> over stretch myometrium: inc prostaglandin +
  • –> inc # oxytocin receptor + contractility w/in uterus
  • –> abd vasoconstriction + inc pt aggregation

rx: ASA @ 12 wks gestation

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50
Q

fetal dysmaturity syn?

A

post term > 42 wks gestation

  • > age related : infarction , Calcification !!!
  • > uteroplacental insufficiency

risk of fetal demise!!!!

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51
Q

cervical insufficiency

RF?
sym?
rx?

A

RF:

  • > Collagen defects
  • > Uterine abnormalities
  • > Cervical conization!!
  • > Ob injury
sym:
≥2 prior painless, 2nd-trimester losses
-> PAINLESS cervical dilation
-> mild sym with inc Vag discharge , light bleeding, pelvic pressure 
-> NO uterine CONTRACTION!!

rx:
CERCLAGE:
ind for:
–> cervix < 2.5 cm < 24 GA

or

-> hx of 2nd trimester deliveries !!!

!!!!! PROGESTERONE SUPP:
-> @ term del prior + cervix < 2.5 cm

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52
Q

screening chylamdia + gonorrhea?

A

MC STD in:

  • > age < 25
  • > high risk sexual beh !!!!

high prevalence
–> inc risk PID , infertility, ectopic preg , tubal scarring !!!

rcx:
-sexual active women
-> ANNUAL SCREENING!!!
NAAT (GS)

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53
Q

stress urinary incontience ( SUI)

sym?
rx?

A

-> intermittent involuntary loss urine

-> inc intra-abdominal pressure ( coughing, laughing)
——> dec urethral SPHINCTER muscle tone !!!
+ INSUFFICIENT URETHRAL SUPPORT : urethral HYPER-MOBILITY !!!!! weaken pelvic floor muscle

risk:
obesity, pregnancy, chronic high impact exercise

rx: kegal exercise, pessary , midurethral sling

—> postpartum SUI: self limit < 6 wks

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54
Q

overflow incontience

sym?
rx?

A

-> CONTINOUS, PAINLESS LOSS URINE

–> diminish / IMPAIR contractility bladder detrusor : neurogenic bladder : DM ( osmotic diuresis)

  • > demyelination sacral SC ( cauda equina) : impairment lower motor neuron input to bladder -> detrusor underactivity !
  • > chronic urinary retention : elev postvoid residual > 150 mL !!!!
  • > ext compression of urethral outlet ( fibroids, prolapse) : BLADDER OUTLET OBSTRUCTION!!!!!

rx:
Cholinergic (bethanechol) : + M receptors to cause bladder contractility

  • > Alpha-blocker ( tamsulosin) : BPH for men : relax bladder neck + prostate neck SM
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55
Q

overactive bladder

(URGE) ?

A

excessive (Overactivity) involuntary detrusor muscle SPASM (

  • > sudden urge to urinate
  • > immediate loss urine

etio:
- > MS

rx:

  • > Anti-Muscarinics: inhibit blasser spasm ( oxybutynin)
  • -> promote bladder relaxation

–> Mirabegron : beta -3 -adrenergic agents : + beta receptor in detrusor muscle : SM relaxation

-> time voiding technique

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56
Q

antiphospholipid ab syndrome (APS)

syn?
lab?
rx?

A

** TRANSIENT ischemic attack: MC APS etio

1 clinical + 1 lab MUST:

clx:
-> vascular thrombosis : Arterial/ venous

  • > preg morbidity:
    1. > 3 consecutive , un-explain fetal loss < 10 wk
    2. > 1 un-explain fetal loss > 10 wk
    3. > 1 premature birth before 34 wks due to preeclampsia , eclampsia , placental insuff

lab:
- > lupus anticoag
- > anticardiolipin ab
- > anti-beta -2 glycopn ab
- –> AB cross-reaact with VDRL : false +

rx: LMWH !!!

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57
Q

anovulatory cycles

rx?

A

unopposed estrogen + : proliferation endometrium

rx: PROGESTERONE help control + stabilize

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58
Q

postpartum lochia?

stages?
dx?
rx?

A
  1. lochia rubea: birth - 3/4 days
    - –> dark / bright red ; odor similar to menses ; SMALL clots
  2. lochia serosa : s/p 4th - 14 days
    - –> Serosanguineous pink; brownish old blood
  3. lochi alba : 11- 6 wks s/p
    - -> white / yellow; creamy ; light quality

–> postpartum , endometrial shedding + regeneration : lochia

dx: OBSERVE + reassurance
6-8 wks s/p !!!!

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59
Q

nephrolithiasis

sym?

A
  • > hematuria + WBC on UA
  • > colicky pain radiated from flank to pelvis

dx:
renal u/s

rx: pain control
iv hydration
-> complicated : cystoscopy, stent

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60
Q

urethral diverticulum ?

A

-> herniation urethral mucosa into surrounding tix

  • > dysuria
  • > postvoid dribbling
  • > urethral discharge
  • > ant vaginal mass

dx: MRI
rx: surgery excision

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61
Q

vesicovaginal fistula

sym?
dx?
rx?

A
  • -> urinary CONSTANT leaking ANTerior
  • > abnormal bladder + vaginal fistulization !!!

etio:
1. intra-operative bladder injury : c/s , hysterectomy

  1. wk- mo s/p Sx / child birth : ob labor : tix necrosis / sloughing
  2. pelvic radiotherapy: !!!!! microvascular injury ( endarteritis) , progressive tix ischemia ( raised , RED GRANULATION TIX) + breakdown
    dx: bladder dye testing

rx:
sx repair + bladder decompression ( catherterization)

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62
Q

trichomoniasis

Trichomonas vaginalis

sym?

A

-> thin, yellow-GREEN , Malodorous FROTHY discharge

–> MOTILE , flagellated ovoid protozoa
trichomonads !!! wet mount microscopy

  • > vag inflammatory
  • > Ph > 4.5

rx: metronidazole
- > rx partner also!! -> etho cessation : disulfiram like rxn

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63
Q

pseudothrombocytopenia

sym?
lab?
dx?
rx?

A

lab error: pt aggregation in vitro : peripheral BS –> LARGE CLUMPS pt !!!

–> incompletely mixed blood sample / presence Ab EDTA

dx: confirm with : non-EDTA anticoag mising normalizes the automated PC
rx: monitor

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64
Q

primary syphilis

sym?
dx?
rx?

A 
Single, PAINLESS CHANCRE 
---> papule , non-exudative ulcer 
with INDURATED BORDERS !!!!!!!!!!!
-> PAINLESS LAD!!!!!! 
-----> NOT asso with POSTCOITAL BLEEDING / CERVICAL LESIONS!!

—> 2ndry syphilis: condylomata lata

dx:

  1. NON trep: VDRL + RPR
  2. Specific trep: FTP-ABS

rx: PNC-G
- —-> pen allergy : desensitized : IM PNC-G benzathine !!

** nonpregnant: DOXYCYCLIN!!! contra : fetal bone growth !!

** azithromycin/ doxycyclin: rx: chlamydia

** neisseria: ceftriaxone

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65
Q

chancroid

sym?

A

haemophilus ducreyi

  • > multiple + DEEP ulcers
  • > base gray - yellow exudate
  • > organism clump in long parallel strands
  • > PAINFUL !!!!
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66
Q

chylamydia trachomatis

sym?

A

Lymphogranuloma venereum

  • > small, shallow ulcers,
  • > large, PAINFUL INGUINAL LN ( BUBOES)
  • > intracytoplasmic chlamydial Inclusion bodies epi cells + leukocytes
  • > not painful lesion !!

rx” azithromycin

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67
Q

breast Ca
BRCA

hypercoagulable dx

contraceptive rx?

A

–> COPPER IUD
( hormone free)
10 yr duration

** all other hormone -containing contraceptives CONTRA !!!!
estrogen / progesterone

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68
Q

shigellosis

sym?

A

fever, abd pain, tenesmus

bloody diarrhea up to 7 days

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69
Q

rectus abdominis diastasis ?

A

stretching abd :

  • > wken linea alba , fascia
  • > nontender midline mass
  • > NO asso fascia defect
  • > NO asso pain, acute GI sym / risk strangulation / incarceration

rx: observe + reassure
- > resolve postpartum

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70
Q

postpartum thyroidism

sym?

A 
-> brief hyperthyroid phase 
release TH 
-> subseq HYPOthyroidism phase
-> hypercholesterolemia 
-> hypoNa

lab:

  • > TSH elev
  • > free T4 low
  • > anti-thyroid peroxidase autoab

*** adrenal insuff: dec BP

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71
Q

ovarian torsion

sym?

A
  • > adnomyosis inc risk
  • > age > 40
  • > heavy MC bleeding
  • > tender, globular uterus
  • –> hix of OVARIAN CYST / mass

sym:
sudden onset , UNILATERAL pelvic pain!!! NON-radiating pain

  • > n/v
  • > PARTIAL: intermittent adnexal rotation: self resolves + spontaneous adnexal untwisting allows BF to return
  • > doppler: normal BF
-> COMPLETE rotation around IP ligament 
( ovarian vessels) 
-> adnexal tenderness / fullness 
-> peritonitis 
--> dopples u/s : DEC / absent ovarian BF

rx:
ER LP !!!!

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72
Q

unilat ureter laceration

etio?

A

-> large intraabd fluid -> watery vaginal discharge

uroperitoneum
-> gyn Sx ( hysterectomy)

——> Ureteral OB + HYDRONEPHROSIS ( nonradiating focal back pain , unilateral CVA tenderness)

URETER vulnerable to injury !!
proximal to ovarian vessels ( Infudibulopelvic / suspensory lig) + UTERINE VESSELS ( near cervix)

lab: normal Cr + UA ( contra kidney normal )

dx:
u/s renal
Ct urograpy

rx: SX repair

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73
Q

intraabd abscess

sym?

A

high FEVER
leukocytosis
abd tenderness

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74
Q

intraductal papilloma

sym?
rx?

A

-> benign PAPILLARY tumor arising from breast duct lining

sym:

  • > unilateral bloody niple discharge ( nonbloody)
  • > no asso with breast mass/ LAD

rx: MAMMOGRAPHY + u/s
_> biopsy + excision !

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75
Q

ductal ectasia

sym?

A

-> benign brerast duct thickening + dilation –> CLOGs the duct!!!!

  • -> bloody nipple discharge, duct widens
  • -> buildup fluid
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76
Q

biophysical profile

?

Stress test (heart), lungs, movement, AF voln

A

Max score = 10
<4 abnormal
—-> fetal HYPOXIA: placenta dysfunction

2 = normal each component
+ OLIGOHYDRAMNIOS ( deepest pocket < 2cm / AFI < 5)

  1. NONstress test:
    - –> reactive fetal HR monitoring : > 2 acceleration , baseline 110-160/ min, moderate variablility , normal fetal acid-base status

–> NONreactive NST:
< 2 acceleration : fetal hypoxemia + acidemia

  1. AF Voln: single fluid pocket > 2 * 1 cm / AFI > 5
  2. fetal movement: >3 general body movement
  3. fetal breathing movement: >1 breathing ep > 30 sec
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77
Q

Late deceleration

etio?

A

late term preg > 41 wks

–> chronic fetal hypoxemia : !!!!
interrupt intervillous BF —-> UTEROPLACENTAL INSUFFICENCY!!

—> CNS suppression + fetal demise

—-> peripheral tix blood supp, redistribute to BRAIN

  • -> dec movement, RR, muscle tone !!!
  • -> oligohydramnios
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78
Q

placenta abruption ?

A
  • —> PLACENTA vasoconstriction + ISCHEMIA !!!
  • -> endothelial dysfunction

—> Premature placenta separation from uterus!!

  • -> 3rd trimester !!
  • -> PAINFUL abd pain , BACK pain , uterine TENDERNESS

-> fetal FR deceleration !!!!! fetal hypoxia

  • -> VAGINAL BLEEDING!!!! ( mini bleeding if w/in intrauterine cavity)
  • –> DISTENDED uterus

—> HIGH frequency CONTRACTIONS !!

RF: HTN, cocaine, smoking

  • > prior abruptio placentae
  • > preeclampsia
  • > abd trauma

dx: clx
- > U/S +/- retroplacental hematoma

comp:

  • > fetal hypoxia, preterm birth , mortality
  • > mat hemorrhage, DIC !!!!
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79
Q

uterine rupture

?

A

-> during LABOR !!

RF:
-> PRIOR c/s delivery

  • > SUDDEN vaginal bleeding !!!!
  • —>SEPARATION of INELASTIC UTERINE SCAR TIX!!!
  • > intense abd PAIN !!!!
  • —-> palpable fetal parts thru abdominal wall ( IRREGULAR MASS)

-> FHR abnormal : deceleration , bradycardia!!!!

———-> IRREGULAR contraction + DECREASE in intensity !!

  • -> LOSS fetal STATION!!!
    eg. +1 –> -3

CONTRA: OXYTOCIN: induce labor augmentation + induction !

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80
Q

Oligohydramnios
AFI < 5 cm

early gestation?

late ?

A
  1. early: fetal etio
    FGR : 1st trimester SYMMETRIC
  • -> aneuploidy (DS trisomy 21)
  • > renal agenesis : ACEI / ARB , POTTER syn, pul hypoplasia

-> Post urethral valves : bil HYDRONEPHROSIS

–> AF DEP on normal fetal urine production

  1. 2nd/ 3rd trimester:

Fetal growth restriction !!!
ASYMMETRIC :
—»» “ HEAD -sparing “ growth lag

!!!!!! –> uteroplacental insuff ( FGR) : HTN / preGDM / cocaine / drugs use
dx: MAT VASCULAR DX —> UMBILICAL ARTERY DOPPLER U/S !!!

  • -> maternal : dehydration
  • > SPONTANEOUS ROM ( normal fetal growth) @ TERM!!!!

sym: inc CLEAR vaginal discharge
- -> sudden/ slow leakage

rx; URGENT delivery

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81
Q

hyperemesis gravidarum

lab?

A

also occur with:
wernicke encephalopathy!

-> vomiting: loss HCl
–> met alkalosis
inc PH , inc HCO3
–> compensate PaCO2 inc
-> hypoglycemia
-> elev AST, ALT

** normal preg: hypocapnia : direct + of progesterone on CNS : inc Resp drive –> hyperventilation + chronic resp alkalosis ( PCO2 dec )

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82
Q

esophageal perforation

sym?
dx?
rx?

A
  • > boerhaave syn
  • > esophagitis
  • > endoscopy , trauma

sym:

  • > Chest / back , epi pain
  • > Crepitus , HAMMAN sign ( crunching sound )
  • > Pleural effusion with atypical fluid

dx:

  • > CXR/ CT : widened mediastinus , pnmediastinus, pnthroax, pleural effusion
  • > Ct : esophageal wall thickening, mediastinal fluid collection
  • > esophagography with water soluble contrast : leak from perforation

rx: NPO, IV ab, PPI
- > ER sx repair !

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83
Q

cervical conization
COLPOSCOPY
(GS) dx CIN !!!!

ind?
comp?

A

PAP smear –> high risk COLPOSCOPY
—-> ENDOCERVICAL CURETTAGE

  • > CIN 2 + 3 ( high risk progress into SCC)
  • –> MARGIN free: repeat PAP + HPV co-testing Q1y , Q2y

tech: COLD knife CERVICAL CONIZATION / electrocautery ( LEEP)

comp:
-> cervical stenosis : 
scar tix !!! 
-> preterm birth 
-> preterm PROM
-> 2nd trimester preg loss

*** DOES NOT WEAKEN the PELVIC FLOOR MUSCLE !!!

** not limit mobility : not related to thromboembolism

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84
Q

asherman syn?

A

endometrial affected: intrauterine adhesion from inf / sx:

  • > D&C
  • > endometrial ablation
  • > endometrial resection

lab: NO progesterone on w/drawal challenge
- > NORMAL ESTROGEN, FSH !!!

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85
Q

placenta accreta

risk?
sym?
rc?

A

-> morbidly adherent placental attachment to MYOMETRIUM!!

RF:
Placenta previa + prior uterine surgery
–> C/S , D&C , myomectomy
—> MANUAL PLACENTAL EXTRACTION!!

sym:
- > prenatal: U/S : low lying placental inc # lacunae , myometrial thinning
- —> Uterine enlargement + atony !!

-> postpartum: adherent placenta, postpartum hemorrhage !!!!

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86
Q

primary vs 2ndry dysmenorrhea?

A
  1. primary:
    physio + pain with MC ( asso sym)

—> excessive Prostaglandin production !!!!
uterine contraction + promotes endometrial sloughing

  • -> usually painful MC in aldoscents after ovulatory , regular MC established already
  • -> midline pain radiate to BILATERAL legs / BACK !!!!
  • –> clx dx
  • -> not req PE
    rx: NSAIDS : inhibits prostaglandin synthesis
  1. Secondary: PATHOLOGIC
    - -> UNILATERAL nonmidline pelvic pain !!! ( LOC of PAIN)
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87
Q

perineal laceration s/p vag delivery

rx?

A

1st degree:
-> vaginal mucosa + perineal skin

2nd : bulbovavernosus muscle + perineal body
–> high vascularity
vag tix

3rd: ext anal sphincter + int anal sphincter
- –> pudendal nerve injury

4th: rectal mucosa
- –> ANAL / fecal incontinence !!!

Uncomplicated: no fever / purulence
–> conserve rx: NSAIDS , sitz baths

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88
Q

ASX bacteriuria

sym?
etio?
rx?

A

> 100,000 CFU/ ml Bacteria

  • –> Leuukocyte esterase + !!!!
  • > nitrates Variable

–> NO sym: dysuria, urinary freq

  • –> Progesterone: SM relaxation + uretheral dilation: inc risk acute pyelonephritis !!!
  • > FLANK pain, FEVER, tachycardia maternal + fetus !
    risk: Sepsis, ARDS, preterm labor

dx: u/c screening initial visit
- -> repeat U/C ( test of cure ) performed few wks after completion of Ab therapy

RF:

  • > preGDM
  • > hx UTI
  • > multiparity

etio:

  • > e.coli (MC)
  • > klebsiella
  • > enterobacter
  • > GBS : intraamniotic inf

rx: 5-14 days to complete el bact!!

u/c sensitivity testing:

  • > cephalexin !!
  • > amx- clauvlanate
  • > nitrofurantoin
  • > fosfomycin
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89
Q

ruptured ovarian cyst

sym?
dx?
rx?

A

acute pelvic pain at repro age

  • > peritoneal irritation leaking cyst content
  • > unilateral lower abd pain after strenuous activity / sex

dx; CBC
u/s : pelvic FREE FLUID from cyst !!!!

rx:
- > stable : NSAIDS
- > unsable: SX

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90
Q

weight gain in preg?

A

kcal 350-450 / day

12-11-7-5 ( +5/6kg)

BMI < 18.5 : ideal gain 12-18 kg

18.5- 24.9 : gain 11-16 kg

25-30 : gain 7-11 kg

> 30 : 5-9kg

comp underweight:

  • -> LBW
  • > preterm delivery
  • > Fetal GROWTH RESTRICTION!!
  • —> inc risk Neonatal POLYCYTHEMIA/ HYPERVISCOSITY!!!

excess WG:

  • > GDM
  • > fetal macrosomia
  • > C/S
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91
Q

sickle cell dx in preg

sym?
rx?
risk?

A

-> inc met demand
-> hypercoag state !!
-> vaso-occlusive pain crisis
-> acute pain episodes hrs- days
@ chest, abdomen, long bones

MICROVASCULAR OCCLUSION , dec perfusion , tix ischemia ( abdominal tenderness)

rx: flid + opioid

risk:

  • > inc risk preeclampsia
  • > placental abruption
  • > fgr
  • > preterm delivery
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92
Q

uterine inversion

sym?
comp?
rx?

A
  • > postpartum hemorrhage
  • > excessive TRACTION UC + abnormal adherent placenta !!!!

-> severe abd pain + “SMOOTH” MASS PROTRUDING from cervix / vag

comp

  • -> hemorrhagic shock , hypotension, neurogenic shock
  • -> paradoxical bradycardia

rx: manual replacement of uterus !!!!
- -> req uterus to relax!!
* ** uterine relaxant: terbutaline, NG :reserved for unsuccessful pt
- -> se/ uterine atony

*** oxytoxin ( uterotonics) are DISCONTINUED!!!!

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93
Q

spontaneous abortion

rx?

A
  • > heavy vag bleeding, cramping , DILATED CERVIX
  • > NO POC yet!

u/s: intrauterine gestional lower uterine segment : inevitable abortion!!!

rx: SUCTION CURETTAGE : UNstable pt
-> tachycardia, hypotensive , anemia
Roh(D) IG

  • -> stable pt: expectant / MIFEPRISTONE ( synthetic prostaglandin antagonist) / MISOPROSTOL ( PGE-1 agonist) : uterine contraction + expulsion retained POC
  • –> SLOW ONSET!
94
Q

HIV rx?

A

Antepartum:

  • > HIV RNA viral load at initial visit, q2-4 wks after initial / change rx, monthly until undetectable , q3m
  • > start RX asap -> avoid amniocentesis unless viral load <1000

intrapartum: avoid ROM, fetal scalp electrode, operative vag delivery

  • > viral load <1000 : ART + vag delivery
  • > viral load > 1000 : ART + ZVD + C/S

Postpartum:

  • > mother: continue rx
  • > infant ( mother viral load < 1000) : ZVD
  • > infant (mat viral >1000) : multirx ART!!
95
Q

idopathic ICH

sym?
dx?
rx?

A

RF: obese women
-> rx

sym:

  • > HA
  • > vision loass, enlarged blind spot
  • > pulsatile tinnitus
  • > diplopia , palsy N6
  • > papilledem

dx: neuroimaging: MRI brain !!! BEFORE LP exclude other causes cerebral herniation !!!

MR venography r/o Cerebral vein thrombosis !!!!
—> Rx: heparin

-> LP : elev opening pressure

rx: WL
- > acetazolamide

96
Q

Mg toxicity

?

A

HyperMg:
due to—> renal excretion: risk for RENAL FAILURE !!! inc Cr

mild:
- > n, flushing, HA, hyporeflexia

moderate:
-> areflexia, hypocalcemia!!!
somnolence

severe:
- > Resp failure, !!!! paralysis, cardiac arrest
- -> CONTRA in MG pt. !!

rx: stop MG
give : IV ca gluconate bolus!!

97
Q

DRE

prior exam?

A

-> transabdominal U/S prior to confirm –> det route of delivery !

98
Q

vulvodynia ?

A

-> vestibular hypersensitivity : persistent localized vulvar pain with light tough!!!

99
Q

NONalcoholic fatty liver dx?

A

type 2 DM, obesity
-> eleve AST/ALT < 1 : steatohepatitis
—> insulin resistance
unregulated hepatic TG synthesis , peripheral lipolysis + free fatty acid uptake into liver

dx:
u/s
-> hyperechoic texture : hepatic steatosis !!!!

ASX
-> met syn

100
Q

acute fatty liver pregnancy

sym?
rx?

A
  • > 3rd trimester !!!
  • > Mitochondira (LCHAD) enz deficiency: microvesicular fatty enz not functioning !!

!!!! -> fulminant liver failure : scleral icterus, profound HYPOGLYCEMIA ( cannot break down glc), inc bilirubin

  • -> RUQ pain !
  • -> AMMONIA

lab:

  • > LFT: elev ast, alt (2-3x normal) !!!!
  • > elev PT
  • > elev TOTAL bilirubin
  • > RUQ pain
  • > thrombocytopenia PT < 100,000/mm !!!!
  • -> inc risk MOF, DIC !!!!!
  • -> pul edema ( inc hydrostatic pressure)

dx: liver biopsy

rx: IMMEDIATELY DELIVERY!!!
high mortility rate regardless gestation AGE

101
Q

GBS

screening?
ppx?
ind?
rx?

A

antenatal sx: Rectovag culture 36-38wk

ind for intrapartum PPX:

  • –> GBS bacteriuria / GBS UTI in current preg
  • –> GBS + rectovaginal culture current preg
  • –> unknown GBS + any one:
    1. < 37 wk gest
    2. intrapartum fever
    3. ROM > 18 hrs
  • -> prior infant with early onset neonatal GBS inf

intapartum PPX: IV PCN

102
Q

invasive cervical ca

sym?

A

sym:

  • > irregular Vag bleeding + cervical mass !!!!
  • > POSTCOITAL!!
  • > no routine PAP test screening

*** HIV pt: Q6-12 mo screening !!

risk:
- > IMP
- > smoking!!!!!!!!!!
- > multiple sex partners
- > HPV 16. 18, 31, 33

PE:

  • > cervical FRIABILITY ( bleeding with manipulation)
  • > raised , EXOPHYTIC MASS!!!!
  • > tix necrosis , watery , mucoid vag discharge

dx:
Cervical BIOPSY!!!!
safe during preg

rx: oncology + sx

103
Q

Staphylococcal toxic shock syndrome

risk?
patho?
sym?
rx?

A

Risks:

  • > Tampon use
  • > Nasal packing
  • > Sx /postpartum wound inf

Patho:
1. S. aureus
Exotoxin —> superantigens TSS-1

Sym:
-> Fever >38.9 C 
-> Hypotension
-> Diffuse macular rash involving palms & soles
 Desquamation 1-3 wk after disease onet
-> v/ d
AMS w/o focal neuro signs

rx:
fluid replacement
-> Removal of foreign body (eg, tampon)
-> !!!!! Antibiotic therapy (eg, clindamycin plus vancomycin)

104
Q

ceftriaxone?
rx

Macrolides
rx?

A

Ceftriaxone, a third-generation cephalosporin
—> rx: gram-negative infections (eg, Neisseria meningitidis)

macrolide : rx: chlamydia trachomatis

105
Q

Granulosa cell tumor

A

patho:
Sex cord–stromal tumor
↑ Estradiol !!!!!
↑ Inhibin

sym:
Complex ovarian mass : elev estradiol !!! uncontrolled endometrial proliferation !!!
—> inc risk endometrial hyperplasia/ ca

-> Juvenile subtype
Precocious puberty

-> Adult subtype
Breast tenderness
Abnormal uterine bleeding

-> Postmenopausal bleeding

hx:
Call-Exner bodies (cells in rosette pattern)

rx:
Endometrial biopsy (endometrial cancer)
Surgery (tumor staging)
-> cmt/ radiation

106
Q

Granulosa cell tumor

A

patho:
Sex cord–stromal tumor
↑ Estradiol !!!!!
↑ Inhibin ( suppress pituitary FSH release via negative feedback)

sym:
Complex ovarian mass : elev estradiol !!!

uncontrolled endometrial proliferation !!! THicken > 4 mm endometrial stripe on u/s
—> inc risk endometrial hyperplasia/ ca

-> Juvenile subtype
Precocious puberty

-> Adult subtype
Breast tenderness!!! : fibrocystic change

!!!-> Abnormal uterine bleeding

!!!-> Postmenopausal bleeding

hx:
Call-Exner bodies (cells in rosette pattern)

rx:
Endometrial biopsy (endometrial cancer)
Surgery (tumor staging)
-> cmt/ radiation

107
Q

preterm labor
unstable?

vs

stable

GA < 32
GA 32-34
GA > 34

rx?
dx?

A

Maternal instability , IU inf, fetal distress/ demise : IMMEDIATELY delivery!!!

Stable:
!!!! 1. < 32 wks : very preterm
-> antenatal steroids
-> IM PENICILLIN if GBS +/ unknown

-> tocolysis: INDOMETHACIN (NSAIDS: CO1 +2 inhibitor) : dec PROSTAGLANDIN production : fetal vasoconstriction –> dec renal perfusion
+ fetal oliguria

-> MgSO4: neuro protection !!

  1. 32-34 wks (moderate preterm)
    - > antenatal steroids

-> PNC if GBS/ unknown

-> tocolysis :
indomethacin (se/ oligohydramnios, closure PDA)

NIFIDIPINE ( se/ mat hypotension / tachycardia)

  1. 34-37 wks: late
    - > antenatal steroids
    - > if GBS/ unknown

dx: FETAL FIBRONECTIN TESTING : GA 22-35 -> det preterm labor

*** IM 17- hydroxyprogesterone : PRIOR preterm delivery !!! to prevent recurrence

108
Q

secondary late postpartum hemorrhage

etio?
inc risk: 
-> prolonged labor
-> macrosomia
-> intraamniotic inf
A
  1. retained Product of conception ( POC)
    - -> LATE HEAVY bleeding : sat > 1 pad/ hr , passage LARGE CLOTS!!!! +/- uterine ATONY!! / FIRM UTERUS!!
    rx: D& C
  2. Placenta site subincolution :
    - > heavy bleeding
    - > uterine atony
    rx: uterotonics ( oxytocin, methlergnovine, carboprost)
  3. postpartum endometritis
    - > fever
    - > uterine tenderness
    - > purulent lochia
    rx: IV ab ( clindamycin + gentamicin)
109
Q

Epidural analgesia toxicity ?

A
  • > Bupivacaine : local anesthetic slow release
    sym: initially blocks inhibitory Na+ neural pathways : cause CNS OVERACTIVITY: peri-oral numbness, metallic taste, tinnitus, GTC seizure, CV collapse
    rx: cessation rx, BZD
110
Q

Uterine procidentia ( full uterine prolapse)

pelvic organ prolapse

definition?
sym?
rx?

A

RF:

  • > obesity
  • > multiparity!!!!!!
  • > hysterectomy
  • > postmenopausal age

sym:
-> pelvic pressure: bulging mass INC with VALSALVA maneuver !!!!! : splinting : apply pressure to help imp bowel movement

—-> multiparity: inc intraabdominal pressure + pelvic floor wkening + laxity! STRESS UI

———-> levator ani muscle complex injury !!!! ( ext anal sphincter)

  • > ob voiding
  • > urinary retention
  • > urinary incontinence

-> incomplete defecation + constipation: posterior prolapse!!!

  • > fecal urgency, incontinence
  • > sexual dysfunction
rx: 
ASX: OBSERVE
-> WL
-> kegal exercise 
-> vaginal pessary !!!!
-> surgical repair : poor candidate : eldery , obese, class III HF , poor control DM
111
Q

Mullerian agenesis ( mayer- Rokitansky -Kuster- Jauser syn)

sym?

A
  • > ABSENT Uterus + Cervix + upper 1/3 VAGINA !!!
  • > NORMAL 2ndry sexual char ( breast, ext genitalia) + OVARIES!!!

lab:

  • > normal FSH ( normal ovarian function) !!!!
  • > normal ext genitalia + lower 2/3 vagina ( BLIND vaginal pouch) !!!

rx: renal u/s
- -> screen for duplicated ureters

112
Q

menarche age?
thelarche age?
pubarche?

A

menarche 12.5 yr

Primary amenorrhea:
–> if >13 yr no menarche + NO 2ndry sex char

or

–> > 13 yr no menorche WITH 2nd sex char

113
Q

IUD

contra ind?

A

-> explained , abnormal vaginal BLEEDING!!!!

etio:

  • > inf ( PID, cervicitis): actinomyces isrealii ( anaerobic bat)
  • -> filamentous, G+ bacilli , branching pattern
    rx: PNC
  • > polys
  • > endometrial Ca/ hyperplasia : obesity

dx: NEED further dx !!!!

contra:
- > ACTIVE breast Ca ( not contra with FX)
- > active liver dx
- > pregnancy

114
Q

T sign?

Lambda sign?

A

T sign:

  • -> MONOchorionic diamniotic twin
  • –> inc risk : TTTS
  • > unbalance AV anastomoses : shared placenta vessels
  • –> donar twin: low resistance/pressure : anemia, RF, oligohydramnios , HF , FGR
  • –> recipient twin: polycythemia, polyhydramnios, cardiomegaly, high output HF, hydrops fetalis

lambda sign:
–> Dichorionic Diamniotic twin

115
Q

Septic pelvic thrombophlebitis

sym?

A

DAY 5-6 s/p postpartum: postpartum fever due to injury

  • > hypercoagulable state thrombus, and hematogenous spread of infection to the pelvic veins (eg, ovarian veins)
    rx: heparin IV
116
Q

surgical site infection
-> cellulitis

sym?
rx?

A

incisional bact contamination

  • > wound induration + erythema
  • > spread to surrounding subcutaneous tix
  • > edema, subcutaneous fluid accumulation , inc peri-incisional pain

rx:
cephalexin

117
Q

dysgerminoma

lab?

A

inc LACTATE DEHYDROGENASE

  • > malignant GERM cell tumor
  • > rapid enlarging , painful masses
118
Q

CRL ?

A

best assessment GA : first trimester

–> gestational sac diameter: 4.5-6 Gestational wk +/- 5-7 days

CRL
–> btwn wk 7-14 !!!
+/- 3-5 days

biparietal D, HC, femur length:
14-20 wk
21-30 wk
>30 wk

119
Q

Urethral injury?

vagina

A
  • > urinary retention , dribbling
  • > urinary freq, dysuria

-> slow / interrupted stream from foreign body

120
Q

postpartum Urinary retention

RF?
sym?
rx?

A

-> inability to void > 6 hrs s/p vag delivery !!!

  • > acute urinary retention : overflow incontinence
  • > over distended bladder

etio:
- > perineal trauma : prolong 2nd stage labor / perineal laceration : PUDENDAL N injury

  • > reduce sensory / motor sacral SC impulses from regional neuraxial anesthesia ( epidural anesthesia) : BLADDER ATONY!!!
  • > operative forceps assist vag delivery
    rx: !!!! int urethral catheterization + reassurance , self limiting resolves < 1 wk
121
Q

Euthyroid sick syndrome?

A

alternation biochem thyroid function test: NONTHYROID ILLNESS !!!!

  • > LOW total T3 + free T3
  • > NORMAL T4 + TSH
122
Q

thyroid function in pregnancy

lab?

A

Estrogen + syn TBG —-> dec TBG clearance
—> inc TH production to maintain free hormones level

-> hcg directly + TSH receptors : inc TOTAL T4 + T3—> inc/ normal free T4

  • –> feedback shutdown TSH!!!
  • –> TSH DECREASE!!!
123
Q

brenner tumor

sym?

A

benign subtype epithelial ovarian tumor

—> like bladder
-> pale, yellow tan , encapsulated
“coffee bean nuclei”

-> ASX

124
Q

embryonal ca?

A
  • > ovarian germ cell tumor
  • > YOUNG Women

–> abd ascites, pelvic mass, preg sym ( breast tenderness)

  • > aFP + HCG elev!!!
  • > false + pregnancy test
125
Q

late + post -term pregnancy

def?
RF?
comp?
rx?

A

late term: > 41 wk GA
Post -term : > 42 wk GA

RF: prior post term preg

  • > nulliparity
  • > obesity
  • > fetal anomalies ( anencephaly)

comp:
fetal:
- > macrosomia
- > dysmaturity syn
- > oligohydramnios <2 cm deepest pocket !!!!
- > demise

Maternal:

  • > severe ob laceration
  • > c/s delivery
  • > postpartum hemorrhage

rx: freq fetal monitoring ( nonstress test)
- > DELIVERY prior to 43 wk

126
Q

Rheumatic heart dx?

A

MC: MS > AR

-> new atrial fibrillation can further increase transmitral gradient and left atrial pressure,

with dramatic worsening of pulmonary congestion and pulmonary edema.

127
Q

migraines during pregnancy.

rx?

A

1st line: APAP + Beta blockers / CCB

2nd /3rd:
opioids (eg, acetaminophen-codeine), antiemetics, and NSAIDS (in the 2nd trimester only)

*** ergotamine/ Triptans : contra in preg: risk HYPERTONIC uterine contraction + vasoconstriction : preterm labor, FGR ( triptans)

** TOPIRAMATE : contra in pregnancy: fetal cleft lips/ LBW

** NSAIDS: avoided in 1st + 3rd trimester: spontaneous abortion, premature PAD closure, oligohydramnios, renal dysfunction

128
Q

Ovarian hyperstimulation syndrome
OHSS

sym?

A

patho:
inc HCG enhances ovarian vascular permeability
—> 1-2 wks

–> exaggerate ovarian response: BIL enlarge, cystic ovaries , multiple follicles

dx: US : inc doppler flow
- > over-expression VEGF!!!

  • > acute fluid shift to EVS : vascular permeability + capillary leakage
  • > 3rd spacing , ascites, abd distension
  • -> pleural effusion , IV dep
  • > severe thromboembolism , RF, death
129
Q

TOA?

A

–> HIGH FEVER , cervicitis

comp PID –> UNILATERAL lower abd pelvic pain, ovarian mass
–> FItz- Hugh Curtis syn: vomiting + RUQ pain !!!

  • > u/s : MULTICYSTIC complex adrenal mass with enhancing rims
    rx: IN- patient rx: IV cefoxitin ( G - bact )+ oral doxycycline ( G+ bact) !!!
130
Q

postmeno bleeding

dx?

A

—> > 45 women with ENDOMETRIAL CELL in PAP test: need to perform : ENDOmetrial Biopsy!!!

TV U/S endometrium

or

> 4 mm: endometrial biposy

—> atypia neoplasia : Progestin, SUGERY!!

endometrium < 4 mm : no additional dx
–> rx / progestin IUD

131
Q

Intrahepatic cholestasis of pregnancy

sym?
lab?
risk?

A

dev @ 3rd trimester: inc ESTROGEN induced

sym:
-> Generalized pruritus
worse on hands & feet @ night !!!!!!!!
-> No associated rash
-> RUQ pain

lab:
!!!! ↑ Total bile acids (≥10 µmol/L) —> cross placenta !!!

↑ Liver transaminases (typically <2x normal, rarely >1000 U/L)
± ↑ Total & direct bilirubin

comp:
- —> IU fetal demise: BILE ACIDS > 100 umol/L

  • > preterm delivery
  • > meconium stain AF ( Bile acid elev)
  • > neonatal RDS

rx: ursodeoxycholic acid ( dec BA level)
- > anti-histamines
- > delivery @ 37 wks GA

132
Q

Routine Postpartum screening ?

A

intimate partner violence

s/p 3-6 wks delivery

133
Q

SERM
tamoxifen
Raloxifene ?

A

competitive inhibitor estrogen receptor binding
—> ANTAGONIST effect breast!!

se:

  • > hot flashes
  • > venous thromboembolism : DVT, Pul emboli, retinal vein thrombosis !!!!!

!!!!!! -> endometrial hyperplasia + Ca ( tamoxifen only)

-> uterine sarcoma ( tamoxifen only) !!!!!! —> estrogen agonist on UTERUS

protective:

  • > CVD
  • > inc bone density ( Roloxifene)
134
Q

pubic symphysis diastasis ( physio widening ) ?

A

—> inc progesterone + relaxin : inc PELVIC mobility + promote physio widening ( diastasis ) of the pubic symphysis to faciliate vag delivery !!!!

etio: traumatic delivery
-> fetal macrosomia
-> forceps assised vag delivery
multiparity

sym:
- > suprapubic pain radiates to back, hip, thigh, leg
- > exacerbated by walking !!!
- > pt tenderness to palpation over pubic symphysis + waddling gait

rx:
-> PT
-> pelvic support
recovery in 4 wks

135
Q

femoral nerve damage ?

A
  • > McRobert maneuver
  • > numbness over ANT + medial thigh
  • > inability to extend leg, flex hip, diminished patellar reflexes
136
Q

GDM

screening?
target?
rx?

A

-> screening 24-28 wks GA!!!

inc risk of:

  • > HTN, preeclampsia
  • > fetal macrosomia
  • > C/s

lab:
fasting glc < 95mg/dl
OGTT 1hr< 140 mg/dl
2 hr < 120mg/dl

any ONE above need RX + dx with GDM!!

—> INSULIN: does NOT cross placenta

!!! F/U post partum : fasting glc 24-72 hr
-> 2 hr 75g GTT at 6-12 week visit !!

  • ** gliflozin : SGLT-2 inhibitor : dec blood glc , inc glc excretion in urine
  • > se/ UTI, WL
  • ** TZD ( pioglitazone) : : imp insulin sensitivity + PPAR receptor
  • -> se/ edema, fluid retention, HF
137
Q

shoulder dystonia

rx?

A

BE CALM
Breath , do not push
Elev leg, flex thigh, hip –> McRoberts

Call for help
Apply suprapubic pressure
enLarge vag opening with episiotomy
Maneuvers

138
Q

septic abortion

RF?
sym?
rx?

A

RF: retained POC from

  • > elective abortion with nonsterile technique
  • > missed / incomplete abortion

sym:

  • > fever, chills, abd pain
  • > sanguinopurulent, MALODOROUS vag discharge
  • > boddy, tender uterus , dilated cervix

dx: pelvic u/s : RETAINED POC , thick endo stripe

rx: IV fluid , AB
- > ER: SUCTION CURETTAAGE !!!

139
Q

complete abortion?

A
  • > VAG bleeding
  • > cervix OPEN
  • > ALL POC

PE:
-> empty uterus
normal adenxa
-> closed cervix

140
Q

Grave’s dx in pregnancy?

A

–> neonatal thyrotoxicosis

  • > Transplacental passage mat Anti-TSH receptor ab
  • > ab bind to infant TSH receptor + excessive TH release

sym: warm, moist, tachycardia
- > poor feeding, irritability, poor WG
- > LBG / PRETERM birth

dx: mat anti-TSH receptor AB > 500 % normal !!!!!

rx: self resolve w/in 3 mo !!
- > methimazoe + beta blocker

141
Q

Nonviable fetus :
Anencephaly

rx?

A

Fetal dx:
Acardia
Anencephaly : NTD defect @ wk 5-6 GA

Bil renal agenesis

Holoprosencephaly: absent cerebrum , calcarial defect, abnormal cerebellum / BS

Intrauterine fetal demise
Pul hypoplasia
Thanatophoric dwarfism

Rx:
spontaneous Vaginal delivery
No fetal monitoring

Neonatal rx:
Palliative care if not stillborn

NTD PPX: 0.4 mg folic acid daily
-> high risk : 4mg/ daily

142
Q

CTS in pregnancy

rx?

A

rx:
- > WRIST SPLINTING
- > steroids injection
- > sx severe / refractory sym

–> resoloves spontaneously after childbirth

143
Q

Achondroplasia

A

non-lethal AD:

  • > bone dysplasia -> macrocephaly, frontal bossing,
  • > midface hypoplasia,
  • > genu varum, and limb shortening.
144
Q

type 2 OI

u/s dx?

A

Patho:
AD
Type 1 collagen defect

u/s:
Multiple fractures
Short femur
Hypoplastic thoracic cavity: pulmonary hypoplasia

Fetal growth restriction
Intrauterine demise

Prognosis:
Lethal

145
Q

PCOS

sym?
comorb?
lab?
rx?

A

sym: SLOW progressive onset!!
- > Androgen excess (eg, acne, male pattern baldness, hirsutism)

  • > Oligoovulation or anovulation (eg, menstrual irregularities)
  • > Obesity
  • > Bil enlarged Polycystic ovaries on u/s
patho:
↑ Testosterone levels
↑ Estrogen levels
LH/FSH imbalance
--> will have w/drawal bleeding!! 
Comorbidities
-> Metabolic syndrome:
eg, diabetes: NIGRICANS: insulin resistance, HTN 
-> OSA
-> Nonalcoholic steatohepatitis
-> Endometrial hyperplasia/cancer
Rx:
Weight loss (first-line)
OCP : mc regularity
!!! Letrozole: aromatase inhibitor 
--> inhibit neg feedback : normalize LH, FSH 
 for ovulation induction
146
Q

candida intertrigo?

A

topical nystatin : clotrimazole

sym: vulvar pruritis
- -> erythematous plaques with SATELLITE lesions inc inguinal folds

-> poor control DM

147
Q

rx to AVOID in MG?

A
  • -> NMJ : autoab against ach receptor skeletal muscle
  • –> avoid resp muscle wkness!!!

Magnesium sulfate: inhibit ach release at NMJ : trigger myasthenic crisis!!! )

Fluoroquinolones, aminoglycosides
Neuromuscular blocking agents
CNS depressants
Muscle relaxants
Calcium channel blockers
Beta blockers
Opioids
Statins
148
Q

TG ind pancreatitis

lab?
rx?

A

dx: LIPID panal !!!
TG level > 1000 !!!
—> inc AMYLASE + LIPASE

rx: IV fluid, pain control
- > glc> 500mg/dL : insulin infusion

-> glc < 500 mg/dL / severe pancreatitis : Lactic Acidosis, hypoCa, : apheresis : therapeutic plasma exchange

149
Q

Premenstrual syndrome and
premenstrual dysphoric disorder

sym?
dx?
rx?

A

sym:
- > occur during luteal phase 1-2 wk prior to MC!!!!

sym: bloating, fatigue, headaches, hot flashes, breast tenderness

Affective sym: anxiety, irritability, mood swings, decreased interest; more severe in premenstrual dysphoric disorder

dx:
Symptom/menstrual diary

rx:
SSRI

150
Q

HSV prior

rx?

A

hx genital HSV : receive prophylactic antiviral therapy from wk 36 GA till delivery

—> reduce active lesions at delivery + C/S if currently @ active stage !!

151
Q

Mix Urinary incontience

dx?
rx?

A

dx:
VOIDING diary!!
–> to det optimal rx

rx: bladder training + lifestyle changes
- > WL, smoking cessation , dec Etho,
- > kegals

  • *** urodynamic tesing: measure bladder filling + empty ( cystometry) , urine flow, pressure ( urethral , leak point)
  • —> reserve for complicated UI ( no response to rx) / considering sx intervention
152
Q

Klumpke palsy?

A

C8-T1: ipsilateral miosis + ptosis ( Horner syn)

-> "Claw hand"
Extended wrist
-> Hyperextended MCP joints
-> Flexed IP joints
-> Absent grasp reflex!!! 
!!! -> Horner syndrome (ptosis, miosis)

-> Intact Moro & biceps reflexes

rx: gental massage + PT
-> recovery in few months
if 3-6 mon ths not improve: SX

153
Q

Erb- Duchenne palsy:

A

MC brachial plexus injury: C5-6th

–> ↓ Moro & biceps reflexes on affected side

—> “Waiter’s tip”

->Extended elbow
-> Pronated forearm
Flexed wrist & fingers
—> Intact grasp reflex!!!

154
Q

Breast abscess

RF?
sym?
dx?
rx?

A

Lactational mastitis :

RF:
maternal age> 30
-> nulliparity
-> smoking

sym:

  • > fever , malaise
  • > focal inflammation: UNILATERAL breast erythema + pain
  • > fluctuant , tender mass

dx:
If NO improvement after AB with systemic sym: breast u/s

rx: Ab: dicloxacillin / cephalexin ( bother effective against MSSA)
- > drainage with u/s guide / sx incision

155
Q

oxytocin toxicity?

A

excess / proling oxytocin:

  • —> effect as ADH ( vasopressin)
  • -> elev level renal CT : inc water reabsoption!!

se/ acute hypoNa

  • > dec serum OSM
  • > inc free water movement into brain cell : cerebral EDEMA + seizure!!

-> postpartum seizure in eclampsia

lab: LOW Na !!!
- > severe hypoNa

rx: cessation rx
- > HYPERTONIC saline ( 3% saline) raise serum osm + reverse cerebral edema!!

** ICH : BP > 160/ 110

156
Q

pseudocyesis ?

A

-> sym early prenanacy + believe she is pregnant!

somatization of stress : affects HPO axis

  • -> early preg sym
  • > weight gain , amenorrhea

rx: psy rx

157
Q 
interstitial cystitis 
( bladder pain syn)

sym?
dx?
tx?

A

-> asso with psy + pain dx ( fibromyalgia)

sym:
- > bladder pain with filling , RELIEF with voiding
- > inc URINARY freq , urgency
- > dyspareunia

dx: bladder pain with NO other cause for > 6 wks
- > normal U/A

rx: not curative
- > beh mod: bladder training , IV fluid
- > amitriptyline, pentosan polysulfate Na
- > analgesics acute exacerbation

158
Q

urethral diverticulum?

A

abnormal outpouching of the urethra, can cause urethral tenderness, urinary frequency, and dyspareunia.

!!!! –> tender anterior vaginal mass

  • > purulent urethral discharge
  • > inc pain with voiding
159
Q

Beckwith-Wiedemann syndrome

A
  • > polyhydramnios;
  • > macrosomia
  • > omphalocele
160
Q

Cystic fibrosis

A

-> hyperechogenic bowel or absent gallbladder on prenatal ultrasound

161
Q

latent TB

rx?

A

+ IFN-g
TST : false + : pt with BCG vaccine

if positive: CXR f/u

SAFE with shielding

162
Q

acute viral hepatitis ?

A
  • fever, vomiting, and RUQ pain
  • > travel to endemic regions.
  • > jaundice and changes in stool color
163
Q

ER OCP?

A

Ulipristal pill: progestin receptor blocker : delay ovulation + impairing implantation

can take up to 120 hrs s/p sex

-> alternate: copper IUD, oral levoorgesteral ( plan B)

*** progestin releasing subdermal implant : LONG acting , reversible !!!!

transdermal E -P patch: slow release!!!!

164
Q

hidradenitis suppurativa?

A

chronic inflammatory
-> recurrent occlusion of hair follicles in intertriginous regions (eg, groin, axilla).

–> solitary, painful nodule surrounding a follicle up to month –> draining abscess sinus tract + scar formation!!

-> chronic, prog course + recurrences affect same region

-> 20-40 yr
RF -> Obesity, tobacco use, and family history.

165
Q

Genital tract trauma (eg, vaginal laceration)?

A
  • -> Operative vaginal delivery
  • > infant > 4000g
  • > nulliparity
  • > prolong 2nd stage labor

—-> profuse postpartum hemorrhage
–> VAGINAL SIDEWALL DEFECT!!!
mini bleeding from cervical Os

  • > Laceration of cervix or vagina
  • -> supply from UTERINE artery!!

rx:
Laceration repair

166
Q

VAGINAL hematoma

A

-> Enlarging vaginal hematoma

  • —> MASSIVE OCCULT bleeding + hypovolemia SHOCK !!! Vag MASS protruding
  • > mini vag bleeding

rx:
- > Nonexpanding: observation!!!

-> Expanding: embolization, surgery

167
Q

bartholin duct cyst?

A

-> blockage bartholin gland duct

–> loc @ bil posterior vag INTROITUS : ducts that drain into vulvar vestibule 4 / 8 o’clock position

–> NOT palpable unless ductal blockage occurs : mucoid fluid buildup + cyst formation

sym:
ASX
-> blockage: vag pressure + discomfort with sex, walking, sitting
-> soft , mobile, nontender CYCTIC MASS behind POSTERIOR labium MAJUS!

rx: ASX: expectantly: observe !!
sym: incision _ drainage : word catheter placement

168
Q

Epidermal inclusion cysts?

A

raised, mobile, flesh-colored nodules

-> associated with a central punctum.

169
Q

Peripartum cardiomyopathy

?

A

—> LAST month of pregnancy / w/in 5 mo post-delivery!!

  • > dyspnea and peripheral edema
  • > acute pulmonary edema ( diffuse infiltrates )
  • > hyperventilation and respiratory alkalosis.

–> inc JVP

170
Q

Pul embolism ?

A

acute hyperventiliation + resp alkalosis

-> hypoxemia

171
Q

vag sq cell ca?

A

–> vaginal bleeding, malodorous discharge, and an irregular ULCERATIVE lesion.

RF:

  • > age >60,
  • > chronic tobacco use
  • > human papillomavirus infection.

dx:

  • > biopsy
  • —> determines the depth of invasion of atypical cells.
172
Q

Normal labor progression?

A

contractions + cervical dilation
—> spontaneous ROM;

—> NOT cause acute onset of pain + minimal variability.

173
Q

mittelschmer?

A

occur day 10-14!!
counting from first day of MC

–> rupture of follicule releases the egg.

  • > physio corpus luteum cyst
  • > lower pelvis pain at site of ovulation, ulilateral, last few days
  • > resolve without rx
174
Q

Copper IUD

A

—-> NOT rx for dysmenorrhea : inflammatory rxn in uterus + inc BLEEDING !!!!

Benefits:

  • –> NO effect on HTN!!
  • > high efficacy > 99%
  • > no future on fertility
175
Q

skene gland cyst?

A

bilateral PARAURETHRAL GLANDS - ant vag vestibular

–> urethral meatus

176
Q

Gartner duct cyst?

A

incomplete regression of the Wolffian duct during fetal development.

–> lateral aspects of the upper anterior vagina.

177
Q

bipolar dx in preg

rx?

A

LAMOTRIGINE

—> 2nd gen antipsy:
Quetiapine, risperidone can be considered

AVOID:
–> lithium : EBSTEIN anomaly!!! avoid in preg! lichen

–> valproate / carbamazepine : NTD , anencephaly , myelomeningocele

178
Q

conflict of interest ?

A

inform consent influenced / biased by providers self INTEREST!!!

179
Q

veracity ?

A

being truthful

eg. not informing alternative options if available

180
Q

Pelvic congestion syndrome?

A

–> dull, ill-defined pelvic ache that worsens with intercourse or during long periods of standing.

181
Q

renal venous thrombosis ?

A

subsequent unilat renal infarction
–> hypercoagulable state (eg, malignancy).

—> HEMATURIA!!

182
Q

complete molar pregnancy (hydatidiform mole)

sym?

A
  • -> abnormal proliferation of hyperplastic chorionic villi
  • -> 46 XX, no fetus parts

–> abnormally enlarged uterus (ie, uterine size > gestational age)

183
Q

Androgen insensitivity syndrome

sym?

A
  • -> X-linked mutation in androgen receptor
  • -> non functioning androgen receptors : peripheral androgen resistance !!
  • —-> produce TESTOSTERONE!!!!

sym:
–> (46,XY karyotype)

  1. Non-functioning androgen receptor: prevent male reproductive st ( Wolffian duct, urogenital sinus ) : male external genitalia ( penis, prostate)
    - –> female ext genitalia : shortened lower 2/3 vagina

Puberty: Testo –> aromatized into estrogen :
–> Breast dev + tall

—> PRIMARY AMENORRHEA : absent menarche by >15 yr with 2ndy sex char)

-> Peripheral androgen resistance: ABSENT or minimal axillary & pubic hair

  • > Regression of MULLERIAN st ( internal st) : Absent uterus, cervix, & upper one-third of vagina
  • —–>!!!!! Cryptorchid testes ( NO OVARIES)!!!

rx:
Gender identity/assignment counseling
-> Gonadectomy (malignancy prevention)

184
Q

blunt abdominal trauma
induce abruptio placenta

rx?

A
  • > hypovolemic shock from hemorrhage (ie, hemorrhagic shock)
  • > hypotension, tachycardia, and cool extremities.

Rx:

  • > rapid resuscitation with replacement of IV voln, transitioning from crystalloid to blood products
  • > left lateral decubitus positon

MASSIVE transfusion protocol ( MTP): packed RBC : PT: FFP = 1: 1: 1 ratio to avoid coagulopathy from dilution of pt and clotting factors

** ER c/s : category 3 tracing : variability + late deceleration

*** CONTRA :: NE :
isolated hemo shock: perip vascular tone already INC ==> dec BV
–> dec Uterine BF : impair fetal O2

185
Q

Acute cervicitis

sym?
rx?

A

FIRST trimester bleeding
-> closed cervix

  • > ASX
  • -> Mucopurulent discharge : yellow mucus, bloody at ext os
  • -> NO vulvovaginal erythema
  • > Postcoital/intermenstrual bleeding
  • > Friable cervix !!!

dx: NAAT: chlamydia , neisseria
_. wet mount microscopy
-: > test of cure after RX

rx: emp rx: ceftriaxone + doxycycline

inc risk:

  • > spontaneous abortion: rx/ mifefristone, misoprostol / surgical curettage
  • > PPROM
  • > neonate :conjunctivitis
186
Q

retroperitoneal hematoma

A

Hemo shock !!!
no sign of uterine atony

  • —> uterine artery injury
  • -> rapid + massive blood loss acc in retroperitoneum

—> no incisional bleeding + mini abd / back pain

RX: HEMO UNSTABLE PT: ER LP!!

  • ** CT scan abd + pelvis: STABLE pt
  • -> arterial embolization control bleeding
187
Q

Functional hypothalamic amenorrhea

sym?

A
  • > relative caloric deficiency (eg, athletes, eating disorders)
  • –> LOW BMI

lab:
- > decreased GnRH secretion in hypothalamus
- > NO withdrawal bleeding after a progesterone challenge due to low estrogen levels;
- > LH + FSH levels are LOW
- > low estrogen production

188
Q

acute hemolytic transfusion reaction due to ABO incompatibility ?

lab?
comp?
rx?

A
  • > Intravascular hemolysis
  • > ABO incompatibility
  • > within mins - hours of transfusion
  • > fever !!!!
  • > hemoglobinuria, acute RF: oliuria, anuria
  • > hypotension + hemolysis !!!

lab:
- > Positive direct Coombs test!!!!!
- > Hemolysis (eg, ↑LDH, ↑indirect bilirubin)

Complications

  • > Acute renal failure
  • > DIC

rx:
- > IV normal saline + O2, vasopressors

189
Q

transfusion rxn timeline ?

A

0-sec/ming: Anaphylactic : anti-IgA ab deirect against donar blood IgA

  • –> angioedema , hypotension , resp distress/ wheezing, shock
    rx: EPi

min - 1 hr: Acute hemolytic : ABO incompatibility ( often clerical error)
—> fever, flank pain, DIC, + Coombs test

1 hr - 6 hrs: febrile nonhemolytic (MCC) , TACO , TRALI, TTBI , urticarial
—-> cytokine acc during blood storage: fever + chills !!

> 2 days: delayed hemolytic
—> anamnestic ab response: Asx , hemolytic anemia , + coombs test , + new ab screen

190
Q

Galactorrhea

sym?
lab?

A
  • > PHYSIOLOGICAL galactorrhea is usually bilateral and guaiac (blood) negative
  • –> milky, pale gray discharge

–> BENIGN

etio:
- > hyperprolactinemia, : pituitary prolactinoma,!!
- > Rx
- > hypothyroidism,
- > pregnancy,
- > Chest wall/nipple stimulation (eg, surgery, trauma).

lab:
-> serum prolactin and TSH levels

dx: MRI
rx: reassurance + f/u

191
Q

Second stage arrest of labor?

A

—> NO fetal descent after pushing for:
≥3 hours if nulliparous
≥2 hours if multiparous

RF:
Maternal obesity
Excessive pregnancy WG
DM

Etio:

  • > Cephalopelvic disproportion
  • > Fetal Malposition !!! MCC
  • —-> Ideal head position is: occiput Anterior
  • > Inadequate contractions
  • > Maternal exhaustion

Rx:
Operative vaginal delivery
C/s

192
Q

Cell-free fetal DNA testing

noninvasive @ GA > 10

?

A

Maternal age ≥35 :

testing ind for?

  • > fetal aneuploidy
  • > Prior pregnancy with fetal aneuploidy
  • > Parental-balanced robertsonian translocation

Applications

  • > Screening for trisomy 21, 18, 13 & sex chromosome aneuploidies
  • > Fetal sex determination

dx:
abnormal results : fetal karyotyping 1st trimester : Chorionic villus sampling / 2nd trimester amniocentesis

193
Q

candida vulvovaginitis

sym?

A

normal vag flora

-> OCP : alternate vag flora balance

Vulvovaginal erythema and vaginal discharge : vulvar priritus , dysparenunia , dysuria

  • > ph < 4. 5 !!
    rx: oral azole
194
Q

malignant hyperthermia?

A

genetic mut alters control IC Ca
-> trigger by volatile anesthetics , succinylcholine, excessive heat

sym:
- > Masseter muscle/generalized RIGIDITY!!
- > Sinus tachycardia
- > Hypercarbia resistant to increased minute ventilation
- > Rhabdomyolysis
- > Hyperkalemia
- > Hyperthermia (late manifestation)

rx:
- > Respiratory/ventilatory support
- > Immediate cessation of causative anesthetic
- > Dantrolene

195
Q

inflammatory breast carcinoma

A

pain, erythema, and warmth.

  • -> cutaneous edema + thickening Peau d’ orange
  • > sup skin dimplinig , fine pitting
  • > LAD

-> limit imp s/p AB // worsening infection ( breast abscess)

dx: mammography
u/s breast + axillary LN
-> tix biopsy : confirm dx

196
Q

Infiltrating ductal carcinoma

or

lobular breast carcinoma

sym?

A
  • > Skin dimpling or breast contour changes.

- > do NOT cause diffuse breast erythema, edema, and a peau d’orange appearance

197
Q

IU fetal demise

rx?

A

< 24 GA : D& Evacuation / vaginal delivery

> 24 : vaginal abortion
–> can be delayed till pt is ready

198
Q

congenital TOXOPLASMOSIS

sym?
rx?

A

Classic triad:

  • > Chorioretinitis
  • > Diffuse INTRAcranial calcifications @ BG !!!
  • > Hydrocephalus!!!
  • > Microcephaly (brain atrophy) or macrocephaly (severe hydrocephalus)
  • > Seizures
  • > jaundice, -> HSM, rash, FGR

dx: Toxoplama serology / PCR
rx: Pyrimethamine, sulfadiazine , folinic acid

199
Q

VZV ?

A

FGR

-> limb abnormalities ( bone/ muscle hypoplasia )

200
Q

Vulvar SCC ?

A

2ndry to persistent HPV

RF:

  • > chronic tobacco
  • > vulvar lichen sclerosus: malignant transformation !!!
  • > ICP
  • > prior cervical ca
  • > vulvar / cervical intraepi ca

sym:
-> vulvar irritation, intermittent bleeding, and a UNIFOCAL, FRIABLE mass , white plaque @ labia majora

dx: vulvar
BIOPSY

201
Q

Choriocarcinoma

RF?
sym?
rx?

A

—> gest trophoblastic Ca ( malignancy) : placental trophoblastic tix + secretes b-HCG

RF:

  • > adv maternal age
  • > Prior complete hydatidiform mole

sym:

  • > Amenorrhea or abnormal vag bleeding
  • > Pelvic pain/pressure
  • > sym from MTS: (lung, vagina) —>pul MTS, dyspnea, chest pain , hemoptysis, dyspnea
  • > enlarge uterine mass

lab:
elev β-hCG
-> CXR

rx: 
AGGRESSIVE ca !!!
suction D& C !!!!
Chemotherapy
OCP s/p 1 yr

f/u serial serum b-HCG post evacuation !!

202
Q

PID ind primary infertility

dx?

A

–> tubal scarring + ob

dx:
HYSTEROSALPINGOGRAM
-. mini invasive
identify uterine cavity anomalies ( bicornuate uterus)

203
Q

CMV

sym?

A

–> vertical transmission

u/s:

  • > PERIventricular Ca+
  • > Intrahepatic Ca+
  • > FGR
  • > Hydrops fetalis
  • > Ventriculomegaly
  • > Microcephaly

dx:
–> amniocentesis

Neonatal sym:

  • > Petechiae
  • > HSM
  • > Chorioretinitis
  • > Microcephaly

Long-term seq:

  • > Sensorineural hearing loss
  • > Seizures
  • > dev delay
204
Q

congenital rubella ?

A
  • > cong deafness
  • > cong cataracts
  • > cong Heart dx

–> large ant fontanelle !

205
Q

GARDENERELLA vaginalis

bacterial vaginosis?

A

CLUE CELL
-> thin, gray white
FISH ODOR

Ph > 4.5

NO inflammation , vulvovaginal erythema

inc risk:

  • -> PPROM / ROM < 37 GA
  • > placental abruption
  • > intraamniotic infection
206
Q

epidural analgesia

se?

A

loc @ L2-L5 level, blocking nerves

se/
-> Hypotension (sym nerve fiber blocked

–> vasodilation (venous pooling), dec VR to the right side of the heart, and Dec CO

–> dec placental perfusion + fetal acidosis

rx:
- > IV hydration + vasopressor
- > left uterine displacement to imp VR

207
Q

“high spinal” or “total spinal” injury?

A
  • DANGEROUS
  • > epidural ascends to SC depresses BS activity !!! T1-T4

Intrathecal injection / overdose anesthesia

sym:
hypotension, bradycardia , resp failure

  • > diaphragmatic paralysis
  • > cardiac arrest

C3-C5: dysphagia, resp paralysis

C6-8 : Upper ext wkness

208
Q

“wet tap”

injury?

A
  • > leakage CSF if dura is inadvertently punctured

- > postural HA , worsen with sitting up + imp with lying down after delivery

209
Q

NTD

etio?
FR?
screening?

A

Types:

  • > Anencephaly
  • > Encephalocele
  • > Spina bifida, myelomeningocele

RF:

  • > Low folic acid intake
  • > Methotrexate,
  • > antiepileptics
  • > Diabetes mellitus
  • > Prior pregnancy with NTD

screening:
- > 2nd-trimester U/S: wk 15-20 GA!!!

-> Maternal serum AFP: > 2.5 MoM abnormal !!

Prevention

  • > Average risk: 0.4 mg folic acid daily
  • > High risk: 4 mg folic acid daily

elev etio:

    • GA dating error (MCC)
    • multiple gestation
210
Q

Ovarian thecomas

?

A
  • > benign sex cord–stromal tumors
  • > MC in postmenopausal women.
  • > secrete ESTROGEN!!
  • > abnormal uterine/postmenopausal bleeding
  • > NOT cause virilization.
211
Q

Nonclassic congenital adrenal hyperplasia

patho?
sym?
rx?

A

AR: slow progression over yrs

lab:

  • > ↓ 21-Hydroxylase activity
  • > Normal glucocorticoids & mineralocorticoids
  • > ↑ Androgens + elev DHEA !!!!
sym:
Early pubic/axillary hair growth
Severe acne
Hirsutism & oligomenorrhea in girls
↑ Growth velocity & bone age
------> ↑ 17-Hydroxyprogesterone level
*** NO bil labial masses !

dx:
- > 17-OHP response : ACTH stimulation test

Rx:
Hydrocortisone

212
Q

labial adhesion ?

A
  • > age < 2 yr @@
  • > not asso with lichenification
  • > NO perianal inv
213
Q

streptococcal dermatitis ?

A
  • > superinfection in patients with a constant irritant (eg, bathing suit)
  • > perianal pruritis and anal fissures.
  • > bright, erythematous perianal rash with sharply demarcated borders

*** NOT thin, white skin.

214
Q

Zika virus ?

A

SS RNA Flavivirus

  • > Transplacental transmission to fetus
  • > Targets neural progenitor cells

sym:

  • > SEVERE Microcephaly !!!
  • > craniofacial disproportion
  • > neuro abnormal (eg, spasticity, seizures)
  • > Ocular abnormalities

dx:
- > intracrainial Calcifications ( tix necrosis)
- > ventriculomegaly, cortical thinning

Zika RNA detection

215
Q

5-alpha-reductase deficiency

sym?

A

–> 46,XY genotype

  • > Impaired testo –> DHT conversion
  • > Impaired virilization during embryogenesis

lab:
NORMAL male testosterone & estrogen levels

sym:
- > Male internal genitalia (eg, testes, vas deferens)

——> NO BREAST !!!!!! testo bind to breast androgen receptor : inhibits breast tix proliferation

-> Female external genitalia (eg, blind-ending vagina)

-> Phenotypically female at birth
Virilization at puberty (↑ testosterone): deep voice

Clitoromegaly: undescended testes ( bil labial masses, clitoris protruding from clitoral hood)

Increased muscle mass
Male-pattern hair development
Nodulocystic acne

216
Q

normal preg changes physio?

A 
Physio: 
↑ Renal blood flow
↑ GFR
↑ Renal basement membrane permeability
-> inc CO + BP inc 
lab:
↓ Serum BUN
↓ Serum creatinine
----> inc GFR excretion ! 
↑ Renal protein excretion
-> pt dec / normal
217
Q

asthma in preg?

A

resp changes in preg:

  • > inc TV, inc Min vent
  • > dec RV

–> resp alkalosis comp met acidosis ( inc HCO3 loss)

rx:
- > acute: beta agonist short acting
- > sys steroids for acute exacerbation

218
Q

vasa previa

RF?
sym?
rx?

A

—-> Fetal vessels overlying the cervix: prone to tear + rupture of mem/ contractions

RF:
Placenta previa
Multiple gestations
IVF
Succenturiate placental lobe

sym:
-> PAINLESS vag bleeding with ROM or contractions

  • > FHR: bradycardia, sinusoidal pattern
  • > Fetal exsanguination & demise

Rx:
ER C/S

219
Q

chronic HTN pregnancy

rx?

A
  • > extended release Nifedipine : ccb
  • > labetalol
  • > hydralazine
  • > methyldopa

*** atenolol: asso LBW

220
Q

Short interpregnancy interval

comp?

A

-> <6-18 months from delivery to next pregnancy

comp:
- > Maternal anemia
- > PPROM
- > Preterm delivery
- > Low birth weight

221
Q

postpartum period

normal ?

A

NORMAL finding:
-> Transient rigors/chills: dec Estrogen + progesterone

  • > Peripheral edema
  • > Lochia rubra: shedding uterine decidua + blood
  • > Uterine contraction & involution: inc OXYTOXIN
  • > Breast engorgement : inc Prolactin
Routine
care:
-> Rooming-in/lactation support
-> Serial exam for uterine atony/bleeding
-> Perineal care
-> Voiding trial
-> Pain management
222
Q

diabetic nephropathy in preg?

A
  • -> inc Pnuria
  • > elev cr
  • > htn

< 20 GA

223
Q

Pituitary apoplexy

sym?

A
  • > spontaneous hemorrhage into the pituitary gland
  • > common in :pituitary adenoma.

sym:
-> acute headache, visual field defects, and decreased visual acuity.

224
Q

HBV vaccine

mother + neonate ?

A

vaccine during preg is OK : KILLED vaccine

Infants of mothers with hepatitis B

  • –> can safely breastfeed
  • —> if administration of the HB Ig + HB vaccination series
  • > rxm: breast feeding ok!!

infant: passive HBIg + active immunication HB vaccine

225
Q

Breastfeeding contraindications

A

Maternal:

  • > Active untreated TB
  • > HIV infection*
  • > Herpetic breast lesions
  • > Active varicella infection
  • > CMT or radiation therapy
  • > Active substance use disorder

Infant:
Galactosemia

226
Q

plugged duct breast?

A

-> focal tenderness + firmness +/- erythema

NO fever

227
Q

Down syn:

A

Down syndrome + VACTERL :

Vertebral,
Anal atresia
Cardiac, Tracheoesophageal fistula
Esophageal atresia
Renal
Limb association
  • -> duodenal atresia requires evaluation for other fetal malformations (eg, VSD)
  • > thickened nuchal folds
228
Q

turner syn 45 xo?

A

horseshoe kidneys-> ob causing oligohydramnios (not polyhydramnios).

-> cardiac defects (eg, coarctation of the aorta)

  • > cystic hygromas
  • > hydrops fetalis.
229
Q

edward syn trisomy 18 ?

A

diaphragmatic hernia

  • > rocker-bottom feet
  • > clenched hands with overlapping finger
230
Q

trisomy 13 patau syn?

A

midline defects (eg, microcephaly, cleft lip/palate, omphalocele).

step 2 ck - IM mix (5 decks)

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