ObGyn Part 2 (233- 267) Headache (306-308) Flashcards
1
Q
Process of progressive effacement and dilation of the uterine cervix resulting from contractions of uterus
A
Labor
2
Q
Uterine contractions without effacement or dilation of cervix
A
False labor - Braxton Hicks contractions
3
Q
Under what criteria are patients told to come to the hospital?
A
Regular contractions q5minutes for atleast 1 hour, ROM, significant bleeding or decreased fetal movement.
4
Q
What does Leopold maneuver help with?
A
Helps figure out fetal lie
5
Q
What should you check for on vaginal exam when pt comes in L&D?
A
ROM
Cervical effacement
cervical dilation
6
Q
What is fetal station
A
Level of fetal presenting part relative to the ischeal spines measured -3 to +3
7
Q
Where is fetal station 0? Why is it significant?
A
Presenting part is at ischeal spines
Means that biparietal diameter of the head negotiated the pelvic inlet (smallest part of pelvis)
8
Q
How many stages are in labor?
A
4
9
Q
What defines stage 1 of labor?
A
onset of labor and full cervical dilation (10cm)
10
Q
What stage of labor do latent and active phases occur? Definition?
A
Latent = cervical effacement and early dilation Active = more rapid cervical dilation usually at 3-4 cm
11
Q
What 2 devices do you use to monitor the uterine activity?
A
External tocodynameter measures frequency and duration of contractions
IUPC - intrauterine pressure catheter measures intensity by measuring intrauterine pressure
12
Q
What is the prefered analgesic during labor and when is it given?
A
Meperidene and/or epidural block w/ continuous infusion not given until active stage of labor
13
Q
What is stage 2 of labor?
A
interval between complete cervical dilation and delivery of infant
14
Q
How are episiotomies done?
A
Usually midline, but not preferred.
Better if delivery happens in a slow controlled fashion with natural tears
15
Q
What is checked in the fetus after the head is delivered?
A
bulb suction of nose and mouth and neck evaluated for nuchal cord
16
Q
How are shoulders delivered?
A
gentle downward pressure on head to deliver anterior shoulder followed by easy upward to deliver posterior shoulder
17
Q
What should cord blood be sent for?
A
ABO and Rh testing
18
Q
What is stage 3 of labor?
A
infant between delivery of infant and delivery of placenta
19
Q
What are 3 signs of placental separation?
A
- Uterus rises in abdomen
- Gush of blood
- Lengthening of the umbilical cord
20
Q
Excessive pulling on the placenta could cause what complication?
A
risk of uterine inversion
profound hemorrhage
retained placenta
21
Q
How long could it take for placenta to be expulsed?
A
Up to 30 mins
22
Q
What is stage 4 of labor?
A
immediate post partum period lasting 2 hours, during which pt undergoes significant physiologic attention.
23
Q
What should be done by physician after pt delivers baby and placenta?
A
systematically evaluate cervix, vagina, vulva, perineum and periurethral area for lacerations
24
Q
Serious post partum complications occur in what time frame?
A
1-2 hours post partum
25
Define dystocia
Difficult labor
26
How do you evaluate dystocia?
3 P's
Power
Passenger
Pasasge
27
Define Power
refers to strength, duration and frequency of contractions
28
At what rate must contractions occur for cervical dilation to occur?
>3 contractions per 10 minutes
29
Define Passenger
Refers to fetal weight, fetal lie, presentation and postion
30
What 3 presentations of the fetus can cause dystocia?
Occiput posterior, face presentation, hydrocephalus
31
Define Passage
Difficult to measure pelvic diameters.
32
What passage issues might contribute to dystocia?
distended bladder, uterine fibroids, adnexel or colon masses
33
What 2 prolongation disorders is dystocia divided into?
Prolonged latent phase
| Prolonged Active phase
34
What is prolonged latent phase defined as in a multigravida vs primagravida woman?
>20 hours in a primigravid
| >14 hrs in a multigravida
35
What is prolonged active phase defined as in a multigravid vs primigravid woman?
>12 hours of active phase
36
A prolonged active phase puts mom at risk for what 2 things?
Intrauterine infection
| C-section
37
What is it called when cervical dilation during active phase stops for more than 2 hours? Why would this happen?
Secondary arrest
| Could happen bc ccephalopelvic disproportion or ineffective uterine contractions
38
What cervical condition must be present to induce labor?
if cervix is "ripe"
39
What score can quatify cervical readiness and what 4 factors are used?
Bishop score
| Dilation, effacement, station and postion
40
What Bishop score is associated with successful induction?
9-13
41
What bishop score is associated with high liklihood of failed induction?
0-4
42
What are some contraindications for induction?
placenta previa
active genital herpes
abnormal fetal lie
cord presentation
43
What agent can be used to attempt to ripen cervix?
Prostaglandin E2 gel
44
How do laminarias or rods work to dilate the cervix?
Absorb moisture and slowly expand dilating the cervix
45
If fetus has descended far enough, but is not delivering, what could be done?
Vaccum or forceps
OR
C-section
46
What is post partum hemorrhage defined as?
blood loss >500 ml associated with delivery
47
Whats the most common cause of post partum hemorrhage?
Uterine atony
Others: lacerations, retained placenta
48
What is uterus normally supposed to do after delivery?
quickly contracts, compressing spinal arteries and this prevents excessive bleeding
49
What are some risk factors for uterine atony?
```
mutiple gestations
hydramnios
multipariety
macrosomia
previous hx of post partum hemorrhage
fibroids
magnesium sulfate
general anesthesia
prolonged labor
amnionitis
```
50
How to dx uterine atony?
clinically - boggy uterus
51
How to treat uterine atony?
Uterine massage
IVF and transfusions as needed
Medically - oxytocin, methykergonovine
If unsuccessful, surgery intervention needed
52
placental villi abnormally adhere to superficial lining of the uterine wall
placenta accreta
53
placental villi penetrate into uterine muscle layer
placenta increta
54
placental villi completely invade uterine muscle layer
placenta percreta
55
How many days post partum does engorgement occur?
3 days
56
What are 3 causes of tender, enlarged breasts post partum?
engorgement
mastitis
plugged duct
57
What vitamins does breast milk provide?
All vitamins except vitamin K
58
Are OCPs contraindicated in breast feeding women?
no
59
What are 2 post-partum immunizations to be considered?
Rubella if nonimmune
| Rhogam is mother is Rh negative
60
What time frame does post partum blues occur?
2-3 days pp, resolves within 1-2 weeks
61
What symptom is especially worrisome?
Mother who has estranged herself from her newborn or become indifferent
62
What is the most common infection post c-section? Tx?
metritis (uterine infection)
| Tx: first generation cephalosporin
63
At what week limit is it considered abortion?
64
Does a single pregnancy loss significantly increase risk of future pregnancy loss?
No
65
What is the cause of upto 50% of early spontaneous abortions
chromosomal abnormalities
66
Vaginal bleeding in first half of any pregnancy is presumed to be _____ unless another dx can be made
spontaneous abortion
67
Vaginal bleeding in the first 20 weeks of pregnancy without passage of tissue or ROM with cervix closed
Threatened Ab
68
Threatened abortion with dilated cervical os and or ROM accompanied by cramping with expulsion of POC
Inevitable Ab
69
Documented pregnancy that spontaneously aborts all POCs -- suspect if bHCG fails to decline
Completed Ab
70
Cramping, bleeding passage of tissue with dilated cervix and visible tissue in vagina or endocervical canal
Incomplete Ab
71
Lack of uterine growth, lack of fetal heart tones and cessation of pregnancy sx, failure of expelling POC
Missed Ab
72
>2 consecutive or total of 3 spontaneous abortions. Dx? Tx?
Recurrent abortions
| Tx: surgical cerclage -- sutures cervix closed
73
Implantation outside the uterine cavity is called
Ectopic pregnancy
74
Where can ectopic pregnancies refer pain to?
shoulder pain from hemiperitoneal irritation of diaphragm
75
What lab finding may suggest non viable pregnancy?
very low progesterone
76
What drug can be used early on to abort pregnancy especially if size is
Methotrexate
77
Sudden painless bleeding during pregnancy weeks 20-30. Dx? Tx?
Placenta previa
| Ts with hemodynamic support, expectant management and deliver by C-Seciton when fetus is mature enough
78
Painful bleeding and frequent uterine contractions any time after 20 weeks. Dx? Tx?
Placental abruption
| Tx: hemodynamic support, urgent c-section or vaginal induction if pt is stable and fetus is not in distress
79
Define pre-term labor
between 20-36 weeks gestation
| contractions occuring at 30 seconds
80
What drugs can be given for tocolysis to prolong delivery?
MgSO4
B2 agonists such as Terbutaline or Ritodrine
Ca blockers like nifedipine
Indomethacin
81
What are contraindications to tocolysis?
```
Cervical dilation >3 cm
mature fetus
chorioamnionitis
significant vaginal bleeding
anomolous fetus
```
82
During what weeks is betamethasone instituted to enhance pulmonary maturity?
24-34 weeks
83
What 3 tests are done to see if pt had PROM
nitrazine test uses pH to distinguish alkaline amniotic vs acidic vaginal
Fern test - amniotic fluid dried on slide = fern pattern
Pool - US confirms dx by noting oligohydramnios
84
2 sperate ova fertilized by 2 sperate sperm... incidence increaases with age and pariety... what kind of twins?
dizygotic twins
85
Blood flow is inturrupted by a vascular anastomoses such that one twin becomes the donor twin and one twin is the recipient twin
twin-twin transfusion syndrome
86
Under what conditions is vaginal birth tried in multiple gestation pregnancy?
if first baby is vertex then attempt to deliver vaginally
87
What complication is it important to watch for after vaginal delivery of twins?
uterine atony and post partum hemorrhage because the overdistended uterus may not clamp down
88
What stage of cell division are follicles arrested in?
prophase of meiosis
89
When does ovulation begin?
puberty
90
Once the dominant follicle ruptures, what happens to the corpus luteum?
Corpus luteum secretes progesterone to "prepare" the endometrium for implantation
91
What are the 3 phases of the menstrual cycle?
Follicular (proliferative)
Ovulatory
Luteal (secretory)
92
How long does the follicular phase of the menstrual cycle last?
days 1-13
93
Why does LH surge happen on days 11-13?
Estadiol induced negative feedback on FSH and positive feedback on LH in anterior pituitary
94
What days does the ovulatory phase occur?
Days 13-17
95
How long after the LH surge does ovulation occur?
30-36 hours
96
Day 15 to menses is what phase?
luteal (secretory phase)
97
What hormone is predominant in the luteal phase?
progesterone
98
What does progestin in an OCP do?
supresses LH and thus ovulation
| Also, thickenes cervical mucus so it's less favorable to semen
99
What is Estrogen's role in an OCP?
supresses FSH so it prevents seclection and maturation of a dominant follicle
100
What effect do estrogen and progesterone together have on the endometrial lining?
Thin the endometrial lining and cause a light/missed menses
101
What is the difference between monophasic and phasic OCPs?
monophasic deliver constant dose of estrogen and progestin
| Phasic alter ratio slightly ususally by varying dose of progestin
102
What are some absolute contraindications to using OCPs
pregnancy, DVT, thromboembolic dz, endometrial CA, smoking, >35, hyperlipiemia, cerebrovascular dz
103
How often should women 21-30 get a PAP smear?
Every 2 years
104
What are the PAP guidelines for women >30 with 3 negative paps?
screen once every 3 years
105
What are some risk factors for CIN?
HIV
Immunosuppressed
exposure to DES
previous CIN
106
If pap shows mild-low atypia, what should be done?
repeat pap - atypia may regress
107
If pap shows mild-high grade atypia, what should be done?
Intense evaluation
| Colposcopy
108
How are colposcopies done?
cervix is washed with acetic acid solution and the white areas and abnormally vascularized areas are chosen for punctate biopsy
Endocervical curettage (ECC) is also done so disease further up in the canal may also be detected.
109
What is the next step if the colposcopy is positive or unsatisfactory or +ECC comes back?
Cone biopsy
| Then if + excision of lesion
110
Review Alternative OCPs chart
p. 251
111
HPV vaccine protects against which strains?
16, 18 (cervical CA), 6 and 11 (genital warts)
112
For what age range is HPV vaccination recommentded
11-26 (can be given as young as 9)
113
What organism is likely to cause vaginitis in women who are diabetics, pregnant or have HIV?
Candida
114
Endometrial tissue in extrauterine locations, most commonly ovaries. Dx?
Endometriosis
115
Candida vs. Trichomonas vs. Gardnerella chart
p. 253
116
Endometrial implants within the uterine wall, dx?
adenomyosis
117
Endometriosis involving an ovary with implants large enough to be considered a tumor, filled with chocolate appearing fluid "chocolate cysts" Dx?
Endometrioma
118
What are the 3D's of Endometritis?
dysmenorrhea, dyspareunia, dyschezia
119
How to you dx endometritis?
laparoscopy or laparotomy with histologic confirmation
120
What is the pharmacologic treatment? Surgical treatment for endometritis?
NSAIDS + OCPs (other options p.255)
| Defnitive treatment is hysterectormy + oophorectomy
121
absence of menstruation
amenorrhea
122
woman who has never mesntruated
primary amenhorrhea
123
menstrual age woman who has not menstruated in 6 months
secondary amenhorrhea
124
Whats the most common cause of amenhorrhea?
pregnancy
125
What is the most common anatomic cause to secondary amenhorreha?
Asherman's syndrome - scarring of uterine cavity after D&C
126
How can you symptomatically distinguish estrogen deficiency from hypothalamic-pituitary failure vs. ovarian failure
Hypothalamic- pituitary failure does not cause hot flashes
127
Irregular menstruation without anatomic lesions of the uterus. Dx? Cause? Tx?
Dysfunctional uterine bleeding - dx w/ transvag US
Usually due to chronic estrogen stimulation
Convert proliferative endometrium to secretory one by giving progestational agent for 10 days
128
What are the 2 most common reasons for hirsuitism?
PCOS and/or adrenal hyperplasia
129
What is the average age of menopause in US?
Age 51
130
What is the first line treatment for menopause?
estrogen hormone replacement therapy (HRT)
| - HRT increases the risk of stroke, MI and possibly breast CA
131
Which SERM is known to decrease the risk of breast ca?
Raloxifene
132
What is the number one cause of androgen excess and hirsuitism? Labs? Tx?
PCOS
Increased LH/FSH and testosterone
OCPs to decreased LH
133
Pt with rapid onset of hirsuitism acne amenorrhea, virilization. Usuaully occuring in 20-40 years. Dx? Labs?
Sertoli-Leydig cell tumor
Decreased LH/FSH,
VER VERY high testosterone
134
What does 21 alpha hydroxylase defect cause? Labs?
Congenital adrenal hyperplasia
| Labs: increased LH/FSH and DHEA
135
What is the most common cause of infertility?
Male partner is the MCC but also because workup is simpler
136
Normal semen excludes male cause in ____% of couples
90%
137
What should the female workup of infertility include?
Temperature (drops during menses and rises 2 days after LH surge at time of progesterone rise)
138
What does temperature elevation >16 days suggest?
Pregnancy
139
What is the best predictor of fertility potential in women?
| What number is a poor prognosis?
FSH
| >25 correlates with poor prognosis
140
What is the most common reason for anatomic disorders (ie. scarring, adhesions, endometriosis, trauma)
Acquired bc of salpingitis secondary to nisseria gonorrhoeae and Chlamydia
141
What is the first line drug for anovulation?
Clomiphene - an estrogen antagonist that relieves negative feedback on FSH allowing follicle development
142
Prolapse of urethra
urethrocele
143
prolapse of bladder
cystocele
144
prolapse of rectum
rectocele
145
Bladder pressure exceeds urethral pressure briefly at times of strain or stress such as coughing or laughing
Stress incontinence
146
Neuropathic bladder resulting in loss of control of bladder function resulting in involuntary bladder contraction? Dx
Or bladder atony? Dx?
Urge incontinence
overflow incontinence
147
What is the most common type of endometrial cancer?
adenocarcinoma
148
What are some risk factors to endometrial ca?
unopposed post menopausal estrogen replacement therapy
menopause after age 52
Obesity, nulliparity, feminizing ovarian tumors, PCOS
149
Abnormal proliferation of glandular and stromal elements .. ddx?
endometrial hyperplasia
150
Pap smear is not reliable in diagnosing endometrial ca, but what finding would mandate an endometrial evaluation?
Atypical glandular cells of undetermined significance? (AGCUS)
151
How can you treat simple/ complex hyperplasia?
progesterone to reverse hyperplastic process promoted by estrogen
152
What is the most important prognostic factor of endometrial ca?
histologic grade
153
What is the 2nd most important prognostic factor of endometrial ca?
depth of myometrial invasion
154
Whats another name for fibroids?
leiomyomas
155
What is the most common indication for a hysterectomy?
Fibroids
156
Whats the medical tx for fibroids?
estrogen inhibitors such as GnRH agonists to shrink uterus
157
What is the surgical option for pts who have fibroids but still want to preserve fertility?
Myomectomy
158
Rare malignancy of uterine corpus accounts for 3% of ca
leiomyosarcoma
159
What are some risk factors for cervical ca?
```
esrly sexual intercourse
multiple sexual partners
HPV esp 16, 18
Cigarette smoking
Early childbearing
immunocompromised
```
160
Whats the average age of cervical ca dx?
50
161
What type of cells are most cervical cancers?
squamous
162
Review ovarian neoplasms
p.265
163
What is the most common epithelial cell ovarian neoplasm?benign or malignant?
Serous cystadenoma, bengin unless bilateral
164
What is the most common germ cell ovarian neoplasm?
teratoma aka dermoid cyst
165
What are functional tumors that secrete hormones?
stromal cell
Glanulosa tumor makes estrogens
Sertoli Leydig makes androgens
166
Tx for all ovarian benign tumors
excision
167
What is the most lethal gynecologic ca?
Ovarian because of lack of early detection and increased rate of metastasis
168
What is chromosomal makeup if a complete mole?
no fetus 46 XX
169
What is the chromosomal make up of an incomplete mole
has a fetus and molar degneration 69 XXY
170
How to diagnose molar pregnancy?
Ultrasound and EXTREMELY high bHCG levels
171
What is the tx for molar pregnancy?
removal by D&C
Nonmetastatic perisistant = methotrexate
f/u with HCG levels
172
Pt with band like bilateral HA dull in quality, Dx? Tx?
Tension HA
| Nsaids, acetaminophen
173
Male with unilateral HA associated with ipsilateral lacrimation, ptosis, nasal congestion and rhinorrhea. Dx? Tx?
Cluster HA
| 100% O2 or a triptan, 2nd line is dihydroergotamine
174
Female with unilateral, HA with aura. Associated with scotoma, teichopsia, photopsias, rhodopsias, nausea and photophobia. Dx? Tx?
Migrane
Tx acutely with triptan
Prophylax with B blocker or ca channel blocker
175
Female with unilateral temporal HA a/w jaw claudication, temporal artery tenderness with palpation ESR>50. Dx? Tx? Complication?
Termporal Arteritis (Giant cell) - screen with ESR, dx with Bx
Tx with corticosteroids
Complication of optic neuritis and blindness
176
Episodic severe pain shooting from mouth to ipsilateral ear/eye/nose, peaks at age 60. Dx? Tx?
Trigeminal neuralgia - Dx with CT/ MRI
| Tx: Carbamazepine (1st line) or phenytoin
177
Worst HA of life bc of ruptured berry aneurysm. Dx? Tx?
Subarachnoid hemorrhage - Dx with CT
| Tx with immediate neuro surg evaluation and nimodipine
178
Medical and dental conditions affecting the TMJ and/or the muscles of mastication. Dx? Tx?
TMJ
| Tx: nsaids, muscle relaxants, mouth gaurd
179
What should you suspect in pts who wake up in the middle of the night by a headache who have projectile vomiting or who have had focal neuro deficits? What to order?
Increased ICP
| Get a head CT
