OBGYN Precision & Pearls #2 Flashcards
What is trophoblastic disease (molar pregnancy)?
Also, explain what complete vs partial means
Pregnancy due to nonviable fertilized egg implanting, leading to abnormal placental development
-Complete (Diploid 46XX): all paternal chromosomes and no fetal tissue
Partial (Triploid 69XXX or XXY): egg fertilized by 2 sperm. Fetal tissue present but not viable
A molar pregnancy has a higher risk of developing into _______ and some risk factors for a molar pregnancy include…..
Choriocarcinoma
Prior molar pregnancy and extremes of age (<20 and > 35)
What are some symptoms of a molar pregnancy?
-Painless vaginal bleeding
-Uterine size/date discrepancies (larger than expected)
-Preeclampsia before 20 weeks
-Hyperemesis gravidarum earlier than usual
-Choriocarcinoma (METS MC to lungs)
What labs are done for a molar pregnancy and what do they normally show?
-Beta HCG very high (>100,000)
-Alpha fetoprotein very low
-Pelvic US: snowstorm or cluster of grapes (no fetal parts or heart tones)
Treatment for a molar pregnancy
Surgical uterine evacuation (suction curettage). Followed weekly until Beta HCG levels fall to undetectable level.
Chest XR to check for METS for choriocarcinoma. If present, chemo/radiation.
Risks for developing gestational diabetes, fetal risks of diabetes, and maternal complications of gestational diabetes.
Risks for developing: Obesity, > 25 years old, African American race, Family history, birthing baby > 4000g, multiple gestations
Fetal complications: Macrosomia (MC), preterm labor, neonatal hypoglycemia, neonatal hypocalcemia
Maternal complications: 50% chance of developing DMII after pregnancy
How long postpartum should the mother be screened for diabetes?
Screen mom 6 weeks postpartum for DM and then yearly afterwards
Screening for gestational diabetes (2 step)
What is the GOLD STANDARD diagnostic?
Step 1: 50g 1 hr glucose challenge test: If 130-140g, do 3 hour test
Step 2: 100g 3 hr glucose challenge test: Positive if 2 or more of the following: (>95 after fasting, >180 at 1 hour, >155 at 2 hours, >140 at 3 hours)
Testing is done at 24-28 weeks
3 hour glucose challenge is the GOLD STANDARD
What is the treatment for gestational diabetes
1) Lifestyle modifications: diet and exercise/walking
2) Insulin (1st DOC)
3) Glyburide and Metformin also safe in pregnancy
What is another recommendation for gestational diabetes and delivery times?
Daily fingersticks overnight and after each meal
Labor induction at 38 weeks if uncontrolled/macrosomia.
Labor induction at 40 weeks if controlled/no macrosomia
Recommend C-section if diabetic
What is normal morning sickness considered?
Nausea and vomiting up until 16 weeks
What is hyperemesis gravidarum?
Severe, excessive morning sickness associated with weight loss and electrolyte imbalance. Persists > 16 weeks
Treatment for Hyperemesis gravidarum
-PO or IV Fluids
-Bland diet: BRAT (Bananas, Rice, Applesauce, Toast)
-Pyridoxine (B6) + Doxylamine
What is chronic preexisting hypertension and what is the treatment?
Hypertension before 20 weeks gestation
Treatment: Labetolol, Nifedipine, Methyldopa are first line agents
What two anti-hypertensive classes should NOT be used in treatment of gestational hypertension?
ACE and ARB
On the other hand, what is transitional hypertension? What is the treatment for this?
New onset hypertension after 20 weeks gestation with NO proteinuria or end organ dysfunction
Nifedipine, Labetolol, Methyldopa
When does transitional hypertension normally resolve?
12 weeks postpartum
For pregnancy HTN, what should you do to monitor the patient?
Check BP
Ask about symptoms of HTN such as headache, visual symptoms.
Check for fetal growth restriction.
Look for edema.
Increased DTR’s.
What is preeclampsia? What does it mean to have MILD vs SEVERE?
New onset hypertension after 20 weeks gestation with proteinuria and end organ dysfunction.
MILD: >140/90, proteinuria > 300mg/24 hours (or dipstick 1+ or 2+)
SEVERE: >160/110, proteinuria >5g (or dipstick 3+)
What are some end-organ symptoms of preeclampsia?
Headache, flashes, blurry vision, RUQ pain, peripheral edema
-Progressive renal insufficiency: oliguria
-Thrombocytopenia
-HELLP Syndrome: Hemolytic anemia, elevated liver enzymes, low platelets
Treatment for preeclampsia (if >37 weeks vs < 37 weeks)
-If 37 or more weeks: prompt delivery
-If < 37 weeks, expectant management (daily weights, BP monitoring, dipsticks, bed rest, steroids for lung maturity)
-Give IV Mag Sulfate to prevent seizures
What is eclampsia? What is the treatment?
Preeclampsia + onset of tonic-clonic seizures, or coma
-Also can have hyperreflexia
Treatment: ABCD’s first, IV Mag Sulfate for seizures, Lorazepam is 2nd line for refractory.
Delivery of fetus once patient stabilized.
BP meds: Hydralazine or Labetolol IV
How long postpartum can preeclampsia continue?
6 weeks postpartum
Postpartum depression can occur in what time frame? What is the treatment?
2 weeks - 12 months postpartum
SSRI + CBT
MC type of vaginal cancer. What is the MC site of this cancer?
Squamous cell carcinoma
Posterior wall of the upper 1/3 of the vagina
Symptoms of vaginal cancer? What is the definitive diagnostic and treatment?
Abnormal vaginal bleeding (postcoital)
Biopsy is definitive
Surgical excision or radiation therapy is treatment
MC type of vulvar cancer? MC risk factor for this cancer? Symptoms? MC location?
Squamous cell carcinoma
HPV 16 and 18, DES exposure, 50 years old
Vulvar pruritis, bleeding, pain
Labia Majoris
What is seen on exam in a patient with vulvar cancer?
Red or white ulcerative or crusted lesion
Definitive diagnostic for vulva cancer
Biopsy with acetic acid
Explain the two types of multiple gestations and what diagnostics show if the patient does have multiple babies.
Dizygotic (Fraternal): 2 ova by 2 sperm
Monozygotic (Identical): 1 ovum that splits
Elevated B-HCG and maternal serum alphafetoprotein higher than normal
What diagnostic is done to confirm multiple gestation?
US
Explain what happens in Rh Alloimmunization
When an RH- mom carries an RH+ fetus, she develops anti-RH antibodies with any fetal blood that leaks into maternal circulation.
The antibodies attack fetal RBC of subsequent RH+ pregnancies, causing hemolysis.
Symptoms of RH hemolysis attack
Jaundice, kernicterus, hydrops fetalis, anemia
What are the 3 situations in which RhoGAM is given to an Rh-negative mom?
-at 28 weeks gestation
-within 72 hours of delivery of an RH+ baby
-after any potential mixing of blood (spontaneous abortion, vaginal bleeding, etc.)
Explain vaginal bleeding in a neonate
This is normal and called false menses. It is cause by the sudden drop in mother’s estrogen after birth. The pink discharge should not last more than 3-4 days.
What is placenta previa? What are the MC symptoms of this condition?
Abnormal placement of placenta over or close to the os
-Sudden onset of bright red painless bleeding in the 3rd trimester. No abdominal tenderness or uterine tenderness. Soft, nontender uterus
What diagnostic can be done to confirm placenta previa? What should NOT be done?
Pelvic US (Transvaginal US)
Do NOT perform pelvic exam
What is abruptio placentae and what is the pathophysiology of this condition?
Premature separation of a normally implanted placenta
Rupture of maternal blood vessels in the decidua basalis
Risks for abruptio placentae as well as symptoms of this condition?
Maternal HTN (MC)
History of trauma (car crash, being hit in the stomach, etc.)
Sudden onset of dark red vaginal bleeding in 3rd trimester. Abdominal pain. Tender, rigid uterus. Fetal Distress!
What is one maintenance/education thing that patients should be aware to control HSV-1 or HSV-2?
Educate patients about safe sex, condom use, etc.
What are three indications to perform a C-section on a pregnant patient?
-Failure to progress during labor (MC)
-Nonreassuring fetal status
-Fetal malpresentation
-Multiple gestations
What are two things that should be done to the patient if undergoing a C-section?
IV Cefazolin 60 minutes before incision
Mechanical thromboprophylaxis (get up and move around to avoid clots)
Is vaginal birth after previous C-section safe? What are some cases in which it is NOT safe?
Yes, considered safe.
-Placenta previa, heart disease, SOB.
-The baby is less likely to have respiratory problems after birth, less pain/quicker recovery, less risk to future pregnancies, less risk of bleeding/infection/blood clots
What are the periooperative ABX prophylaxis recommendations for a pregnant patient
C-section: IV Cefazolin +/- Azithromycin if performed after rupture of membranes.
If ROM or in labor, vaginal cleansing with povidone-iodine vaginal scrub for 30 seconds to reduce risk of endometritis.
Risk factors for breast cancer
-BRCA1 and BRCA2 gene
-Age > 60 years old
-Increased # of menstrual cycles
-Increased exposure to estrogen: Obesity, ETOH, OCPs, endometrial cancer
What is seen on exam in a patient with breast cancer? (Describe the mass)
-Painless, hard fixed mass MC in upper outer quadrant
-Skin changes: erythema, skin retraction, nipple inversion
-Axillary LAD
Explain inflammatory breast cancer
Red, swollen, warm, itchy breast
Peau d’ Orange: lymphatic obstruction (poor prognosis)
Where does breast cancer MC MET to (4 options)
-Bone, Brain, liver, lung
2B2L
What diagnostics should be done if a patient has a breast mass (if patient > 40 and if patient < 40)
< 40: Initial is US
> 40: Initial is Mammogram
If positive, then biopsy. FNA or large needle/core biopsy.
Explain the positives and negatives of FNA vs large needle/core biopsy
FNA: removes least tissue but no receptor testing
Core biopsy: greater deformity but allows for receptor testing
Most accurate test for breast cancer
Open biopsy
What are the three recommendations for breast cancer screening (mammogram, clinical breast exam, and self breast exam)
-Mammogram: annually for > 40 years old or 10 years prior to age of 1st degree relative diagnosed
-Clinical Breast Exam: age 20-39 at least every 3 hours, and > 40 annually
-Self Breast Exam: monthly > 20 years old (immediately after menstruation or on days 5-7 of menses in shower leaning forward)
For breast cancer prevention, what can be given and to who? How long is the treatment usually given?
Tamoxifen or Raloxifene in postmenopausal women or >35 years old at high risk
-Treatment usually for 5 years
-Remember that Tamoxifen is preferred, but has an increased risk of DVT
Treatment for breast cancer depends on staging. What does this mean?
Lumpectomy with sentinel node biopsy and follow up radiation if small and early
Mastectomy if large tumor
Most useful drugs if breast cancer is ER positive and pre-menopausal women: ______
ER+ and postmenopausal women: _______
HER2 positivity: _______
Anti-Estrogen (Tamoxifen)
Aromatase inhibitors (Letrozole, Anastrozole)
Trastuzumab (Monoclonal Ab treatment)
Ovarian cancer has the highest mortality of all gynecological cancers. What are some risk factors for this condition?
Increased number of ovulatory cycles (nulliparity, early menarche, late menopause, > 50 years old)
-BRCA1 and BRCA2
-Family history
-Lynch Syndrome
-Smoking
-Sedentary Lifestyle
True or False: OCP use reduces risk of ovarian cancer?
True
Symptoms of ovarian cancer
Asymptomatic until late in disease
-Ascites, solid/fixed/irregular ovarian mass
-Sister Mary Joseph nodule (METS to umbilical lymph nodes)
-Change in bowel habits
-Early satiety
Diagnostics done for ovarian cancer
Pelvic US (initially)
Ca-125 levels
CT of abdomen and pelvis to stage
Treatment for ovarian cancer
-Early stage: TAH-BSO + selective lymphadenectomy
-Surgery: tumor debulking, CA-125 used to monitor treatment progress
-Chemotherapy (Cisplatin or Carboplatin)
MC type of ovarian cyst
Symptoms of an ovarian cyst
Diagnostics done for this condition
Follicular cyst
Unilateral pelvic pain, mobile adnexal mass
Transvaginal US
Treatment for an ovarian cyst if < 8 cm:
If > 8 cm:
If post-menopausal:
<8 cm: Supportive. Most resolve. NSAIDs, rest.
> 8 cm: Laparoscopy or Laparotomy
Post-Menopausal: Laparoscopy or Laparotomy if large or CA-125 levels elevated. Malignant in this population until proven otherwise.
For mucopurulent cervicitis, what should you do first?
Obtain culture for gonorrhea and chlamydia
See strawberry cervix on exam
Treatment for cervicitis
Empirically while you wait for culture
Ceftriaxone + Azithromycin + Metronidazole +/- Doxy
-Week of abstinence
When is induction of labor done and why?
What are some absolute contraindications to this?
What is used to induce labor (based on Bishop Score).
if >40-42 weeks or any gestational age where complications may occur
-Placenta Previa, Active Genital Herpes, Breech Presentation, Uterine Scar from C-Section
Bishop Score < 6: cervical ripening with Prostaglandin gel (Misoprostol)
Bishop Score > 6: IV Oxytocin (Pitocin)
Health Maintenance, Patient Education, and Preventative Measures for puberty
-Recommend HPV vaccine for boys and girls
-Recommend HepB and TDaP boosters
-Protected sex and condom use discussed
-Gynecomastia in males can be normal and will usually resolve spontaneously
What are the cardinal movements of labor in order
-Engagement
-Descent
-Flexion
-Internal Rotation
-Extension
-External Rotation
-Expulsion
Normal pregnancy is the MCC of _______. What is the nausea and vomiting due to?
Secondary amenorrhea
Rise in beta-HcG
On a patient who is pregnant, uterus and cervix changes occur. Explain these and what they are.
Ladin’s Sign:
Hegar’s Sign:
Goodell’s Sign:
Chadwick’s Sign:
-Ladin: uterus softening after 6 weeks
-Hegar: uterine isthmus softening after 6-8 weeks
-Goodell: cervical softening with increased vascularization at 4-5 weeks
-Chadwick: bluish discoloration of cervix and vulva at 8-12 weeks
Explain fetal distress (why it occurs and what you seen on diagnostics)
Occurs when a fetus does not receive adequate amount of oxygen
Abnormal fetal HR, repetitive variable decelerations, low biophysical profile, and late decelerations
What is menorrhagia?
What treatment options can be given for this?
heavy bleeding at normal intervals
OCPs: regulates the cycles, thins endometrial lining. Progesterone, Mirena, Leuprolide + Progesterone
What diagnostics should be done if a patient has Fragile X Syndrome?
XR of spine: check for scoliosis
Echo to exclude MVP
Molecular testing (DNA - FMR1 gene, PCR)
Ophthalmology exam
Audiology exam
Explain the karyotype of the following genetic conditions:
Turner Syndrome:
Klinefelter’s Syndrome:
Fragile X:
Down Syndrome:
Prader-Willi Syndrome:
Tay-Sach’s Disease:
-Turner: 45, XO (female)
-Klinefelter: 47,XXY (male)
-Fragile X: MC gene related cause of Autism, FMR1 gene (male)
-Down Syndrome: 3 copies of chromosome 21
-Prader Willi: deletion of genes on chromosome 15
-Tay Sachs: Autosomal recessive mutation of HEXA gene on chromosome 15
