ObGyn Part 2 (233- 267) Headache (306-308) Flashcards
Process of progressive effacement and dilation of the uterine cervix resulting from contractions of uterus
Labor
Uterine contractions without effacement or dilation of cervix
False labor - Braxton Hicks contractions
Under what criteria are patients told to come to the hospital?
Regular contractions q5minutes for atleast 1 hour, ROM, significant bleeding or decreased fetal movement.
What does Leopold maneuver help with?
Helps figure out fetal lie
What should you check for on vaginal exam when pt comes in L&D?
ROM
Cervical effacement
cervical dilation
What is fetal station
Level of fetal presenting part relative to the ischeal spines measured -3 to +3
Where is fetal station 0? Why is it significant?
Presenting part is at ischeal spines
Means that biparietal diameter of the head negotiated the pelvic inlet (smallest part of pelvis)
How many stages are in labor?
4
What defines stage 1 of labor?
onset of labor and full cervical dilation (10cm)
What stage of labor do latent and active phases occur? Definition?
Latent = cervical effacement and early dilation Active = more rapid cervical dilation usually at 3-4 cm
What 2 devices do you use to monitor the uterine activity?
External tocodynameter measures frequency and duration of contractions
IUPC - intrauterine pressure catheter measures intensity by measuring intrauterine pressure
What is the prefered analgesic during labor and when is it given?
Meperidene and/or epidural block w/ continuous infusion not given until active stage of labor
What is stage 2 of labor?
interval between complete cervical dilation and delivery of infant
How are episiotomies done?
Usually midline, but not preferred.
Better if delivery happens in a slow controlled fashion with natural tears
What is checked in the fetus after the head is delivered?
bulb suction of nose and mouth and neck evaluated for nuchal cord
How are shoulders delivered?
gentle downward pressure on head to deliver anterior shoulder followed by easy upward to deliver posterior shoulder
What should cord blood be sent for?
ABO and Rh testing
What is stage 3 of labor?
infant between delivery of infant and delivery of placenta
What are 3 signs of placental separation?
- Uterus rises in abdomen
- Gush of blood
- Lengthening of the umbilical cord
Excessive pulling on the placenta could cause what complication?
risk of uterine inversion
profound hemorrhage
retained placenta
How long could it take for placenta to be expulsed?
Up to 30 mins
What is stage 4 of labor?
immediate post partum period lasting 2 hours, during which pt undergoes significant physiologic attention.
What should be done by physician after pt delivers baby and placenta?
systematically evaluate cervix, vagina, vulva, perineum and periurethral area for lacerations
Serious post partum complications occur in what time frame?
1-2 hours post partum
Define dystocia
Difficult labor
How do you evaluate dystocia?
3 P’s
Power
Passenger
Pasasge
Define Power
refers to strength, duration and frequency of contractions
At what rate must contractions occur for cervical dilation to occur?
> 3 contractions per 10 minutes
Define Passenger
Refers to fetal weight, fetal lie, presentation and postion
What 3 presentations of the fetus can cause dystocia?
Occiput posterior, face presentation, hydrocephalus
Define Passage
Difficult to measure pelvic diameters.
What passage issues might contribute to dystocia?
distended bladder, uterine fibroids, adnexel or colon masses
What 2 prolongation disorders is dystocia divided into?
Prolonged latent phase
Prolonged Active phase
What is prolonged latent phase defined as in a multigravida vs primagravida woman?
> 20 hours in a primigravid
>14 hrs in a multigravida
What is prolonged active phase defined as in a multigravid vs primigravid woman?
> 12 hours of active phase
A prolonged active phase puts mom at risk for what 2 things?
Intrauterine infection
C-section
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
What cervical condition must be present to induce labor?
if cervix is “ripe”
What score can quatify cervical readiness and what 4 factors are used?
Bishop score
Dilation, effacement, station and postion
What Bishop score is associated with successful induction?
9-13
What bishop score is associated with high liklihood of failed induction?
0-4
What are some contraindications for induction?
placenta previa
active genital herpes
abnormal fetal lie
cord presentation
What agent can be used to attempt to ripen cervix?
Prostaglandin E2 gel
How do laminarias or rods work to dilate the cervix?
Absorb moisture and slowly expand dilating the cervix
If fetus has descended far enough, but is not delivering, what could be done?
Vaccum or forceps
OR
C-section
What is post partum hemorrhage defined as?
blood loss >500 ml associated with delivery
Whats the most common cause of post partum hemorrhage?
Uterine atony
Others: lacerations, retained placenta
What is uterus normally supposed to do after delivery?
quickly contracts, compressing spinal arteries and this prevents excessive bleeding
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
How to dx uterine atony?
clinically - boggy uterus
How to treat uterine atony?
Uterine massage
IVF and transfusions as needed
Medically - oxytocin, methykergonovine
If unsuccessful, surgery intervention needed
placental villi abnormally adhere to superficial lining of the uterine wall
placenta accreta
placental villi penetrate into uterine muscle layer
placenta increta
placental villi completely invade uterine muscle layer
placenta percreta
How many days post partum does engorgement occur?
3 days
What are 3 causes of tender, enlarged breasts post partum?
engorgement
mastitis
plugged duct
What vitamins does breast milk provide?
All vitamins except vitamin K
Are OCPs contraindicated in breast feeding women?
no
What are 2 post-partum immunizations to be considered?
Rubella if nonimmune
Rhogam is mother is Rh negative
What time frame does post partum blues occur?
2-3 days pp, resolves within 1-2 weeks
What symptom is especially worrisome?
Mother who has estranged herself from her newborn or become indifferent
What is the most common infection post c-section? Tx?
metritis (uterine infection)
Tx: first generation cephalosporin
At what week limit is it considered abortion?
Does a single pregnancy loss significantly increase risk of future pregnancy loss?
No
What is the cause of upto 50% of early spontaneous abortions
chromosomal abnormalities
Vaginal bleeding in first half of any pregnancy is presumed to be _____ unless another dx can be made
spontaneous abortion
Vaginal bleeding in the first 20 weeks of pregnancy without passage of tissue or ROM with cervix closed
Threatened Ab
Threatened abortion with dilated cervical os and or ROM accompanied by cramping with expulsion of POC
Inevitable Ab
Documented pregnancy that spontaneously aborts all POCs – suspect if bHCG fails to decline
Completed Ab
Cramping, bleeding passage of tissue with dilated cervix and visible tissue in vagina or endocervical canal
Incomplete Ab
Lack of uterine growth, lack of fetal heart tones and cessation of pregnancy sx, failure of expelling POC
Missed Ab
> 2 consecutive or total of 3 spontaneous abortions. Dx? Tx?
Recurrent abortions
Tx: surgical cerclage – sutures cervix closed
Implantation outside the uterine cavity is called
Ectopic pregnancy
Where can ectopic pregnancies refer pain to?
shoulder pain from hemiperitoneal irritation of diaphragm
What lab finding may suggest non viable pregnancy?
very low progesterone
What drug can be used early on to abort pregnancy especially if size is
Methotrexate
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
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
Define pre-term labor
between 20-36 weeks gestation
contractions occuring at 30 seconds
What drugs can be given for tocolysis to prolong delivery?
MgSO4
B2 agonists such as Terbutaline or Ritodrine
Ca blockers like nifedipine
Indomethacin
What are contraindications to tocolysis?
Cervical dilation >3 cm mature fetus chorioamnionitis significant vaginal bleeding anomolous fetus
During what weeks is betamethasone instituted to enhance pulmonary maturity?
24-34 weeks
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
2 sperate ova fertilized by 2 sperate sperm… incidence increaases with age and pariety… what kind of twins?
dizygotic twins
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
Under what conditions is vaginal birth tried in multiple gestation pregnancy?
if first baby is vertex then attempt to deliver vaginally
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
What stage of cell division are follicles arrested in?
prophase of meiosis
When does ovulation begin?
puberty
Once the dominant follicle ruptures, what happens to the corpus luteum?
Corpus luteum secretes progesterone to “prepare” the endometrium for implantation
What are the 3 phases of the menstrual cycle?
Follicular (proliferative)
Ovulatory
Luteal (secretory)
How long does the follicular phase of the menstrual cycle last?
days 1-13
Why does LH surge happen on days 11-13?
Estadiol induced negative feedback on FSH and positive feedback on LH in anterior pituitary
What days does the ovulatory phase occur?
Days 13-17
How long after the LH surge does ovulation occur?
30-36 hours
Day 15 to menses is what phase?
luteal (secretory phase)
What hormone is predominant in the luteal phase?
progesterone
What does progestin in an OCP do?
supresses LH and thus ovulation
Also, thickenes cervical mucus so it’s less favorable to semen
What is Estrogen’s role in an OCP?
supresses FSH so it prevents seclection and maturation of a dominant follicle
What effect do estrogen and progesterone together have on the endometrial lining?
Thin the endometrial lining and cause a light/missed menses
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
What are some absolute contraindications to using OCPs
pregnancy, DVT, thromboembolic dz, endometrial CA, smoking, >35, hyperlipiemia, cerebrovascular dz
How often should women 21-30 get a PAP smear?
Every 2 years
What are the PAP guidelines for women >30 with 3 negative paps?
screen once every 3 years
What are some risk factors for CIN?
HIV
Immunosuppressed
exposure to DES
previous CIN
If pap shows mild-low atypia, what should be done?
repeat pap - atypia may regress
If pap shows mild-high grade atypia, what should be done?
Intense evaluation
Colposcopy
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.
What is the next step if the colposcopy is positive or unsatisfactory or +ECC comes back?
Cone biopsy
Then if + excision of lesion
Review Alternative OCPs chart
p. 251
HPV vaccine protects against which strains?
16, 18 (cervical CA), 6 and 11 (genital warts)
For what age range is HPV vaccination recommentded
11-26 (can be given as young as 9)
What organism is likely to cause vaginitis in women who are diabetics, pregnant or have HIV?
Candida
Endometrial tissue in extrauterine locations, most commonly ovaries. Dx?
Endometriosis
Candida vs. Trichomonas vs. Gardnerella chart
p. 253
Endometrial implants within the uterine wall, dx?
adenomyosis
Endometriosis involving an ovary with implants large enough to be considered a tumor, filled with chocolate appearing fluid “chocolate cysts” Dx?
Endometrioma
What are the 3D’s of Endometritis?
dysmenorrhea, dyspareunia, dyschezia
How to you dx endometritis?
laparoscopy or laparotomy with histologic confirmation
What is the pharmacologic treatment? Surgical treatment for endometritis?
NSAIDS + OCPs (other options p.255)
Defnitive treatment is hysterectormy + oophorectomy
absence of menstruation
amenorrhea
woman who has never mesntruated
primary amenhorrhea
menstrual age woman who has not menstruated in 6 months
secondary amenhorrhea
Whats the most common cause of amenhorrhea?
pregnancy
What is the most common anatomic cause to secondary amenhorreha?
Asherman’s syndrome - scarring of uterine cavity after D&C
How can you symptomatically distinguish estrogen deficiency from hypothalamic-pituitary failure vs. ovarian failure
Hypothalamic- pituitary failure does not cause hot flashes
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
What are the 2 most common reasons for hirsuitism?
PCOS and/or adrenal hyperplasia
What is the average age of menopause in US?
Age 51
What is the first line treatment for menopause?
estrogen hormone replacement therapy (HRT)
- HRT increases the risk of stroke, MI and possibly breast CA
Which SERM is known to decrease the risk of breast ca?
Raloxifene
What is the number one cause of androgen excess and hirsuitism? Labs? Tx?
PCOS
Increased LH/FSH and testosterone
OCPs to decreased LH
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
What does 21 alpha hydroxylase defect cause? Labs?
Congenital adrenal hyperplasia
Labs: increased LH/FSH and DHEA
What is the most common cause of infertility?
Male partner is the MCC but also because workup is simpler
Normal semen excludes male cause in ____% of couples
90%
What should the female workup of infertility include?
Temperature (drops during menses and rises 2 days after LH surge at time of progesterone rise)
What does temperature elevation >16 days suggest?
Pregnancy
What is the best predictor of fertility potential in women?
What number is a poor prognosis?
FSH
>25 correlates with poor prognosis
What is the most common reason for anatomic disorders (ie. scarring, adhesions, endometriosis, trauma)
Acquired bc of salpingitis secondary to nisseria gonorrhoeae and Chlamydia
What is the first line drug for anovulation?
Clomiphene - an estrogen antagonist that relieves negative feedback on FSH allowing follicle development
Prolapse of urethra
urethrocele
prolapse of bladder
cystocele
prolapse of rectum
rectocele
Bladder pressure exceeds urethral pressure briefly at times of strain or stress such as coughing or laughing
Stress incontinence
Neuropathic bladder resulting in loss of control of bladder function resulting in involuntary bladder contraction? Dx
Or bladder atony? Dx?
Urge incontinence
overflow incontinence
What is the most common type of endometrial cancer?
adenocarcinoma
What are some risk factors to endometrial ca?
unopposed post menopausal estrogen replacement therapy
menopause after age 52
Obesity, nulliparity, feminizing ovarian tumors, PCOS
Abnormal proliferation of glandular and stromal elements .. ddx?
endometrial hyperplasia
Pap smear is not reliable in diagnosing endometrial ca, but what finding would mandate an endometrial evaluation?
Atypical glandular cells of undetermined significance? (AGCUS)
How can you treat simple/ complex hyperplasia?
progesterone to reverse hyperplastic process promoted by estrogen
What is the most important prognostic factor of endometrial ca?
histologic grade
What is the 2nd most important prognostic factor of endometrial ca?
depth of myometrial invasion
Whats another name for fibroids?
leiomyomas
What is the most common indication for a hysterectomy?
Fibroids
Whats the medical tx for fibroids?
estrogen inhibitors such as GnRH agonists to shrink uterus
What is the surgical option for pts who have fibroids but still want to preserve fertility?
Myomectomy
Rare malignancy of uterine corpus accounts for 3% of ca
leiomyosarcoma
What are some risk factors for cervical ca?
esrly sexual intercourse multiple sexual partners HPV esp 16, 18 Cigarette smoking Early childbearing immunocompromised
Whats the average age of cervical ca dx?
50
What type of cells are most cervical cancers?
squamous
Review ovarian neoplasms
p.265
What is the most common epithelial cell ovarian neoplasm?benign or malignant?
Serous cystadenoma, bengin unless bilateral
What is the most common germ cell ovarian neoplasm?
teratoma aka dermoid cyst
What are functional tumors that secrete hormones?
stromal cell
Glanulosa tumor makes estrogens
Sertoli Leydig makes androgens
Tx for all ovarian benign tumors
excision
What is the most lethal gynecologic ca?
Ovarian because of lack of early detection and increased rate of metastasis
What is chromosomal makeup if a complete mole?
no fetus 46 XX
What is the chromosomal make up of an incomplete mole
has a fetus and molar degneration 69 XXY
How to diagnose molar pregnancy?
Ultrasound and EXTREMELY high bHCG levels
What is the tx for molar pregnancy?
removal by D&C
Nonmetastatic perisistant = methotrexate
f/u with HCG levels
Pt with band like bilateral HA dull in quality, Dx? Tx?
Tension HA
Nsaids, acetaminophen
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
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
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
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
Worst HA of life bc of ruptured berry aneurysm. Dx? Tx?
Subarachnoid hemorrhage - Dx with CT
Tx with immediate neuro surg evaluation and nimodipine
Medical and dental conditions affecting the TMJ and/or the muscles of mastication. Dx? Tx?
TMJ
Tx: nsaids, muscle relaxants, mouth gaurd
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
