OBGYN quiz 2 Flashcards
What is the main cause for late bleeding in pregnancy?
Placenta previa
pregnant patient presents in the 2nd trimester with painless vaginal bleeding, specifically bright red blood in large volumes. What is on the top of your differential?
placenta previa
what is the greatest morbidity related to prematurity?
placenta previa
when is placenta previa most common?
2nd trimester
what is the term used to describe placental migration away from a C-section scar and invades deeper into maternal tissue?
Accreta
What is the term used to describe placental invasion into myometrium of the uterus; reaching to the outer serosa but not penetrating it?
Increta
Term for invasion of placenta transmurally through uterus and into bowel, causing perforation?
percreta
what is the diagnostic test of placenta previa?
Transvaginal US - to localize and assess the placenta
Management for a placenta previa with NO BLEEDING?
expectant management (no intercourse and no digital exams)
management for palcenta previa with BLEEDING
get blood type (Rh), may need tocolysis/steroids/amniocentesis/transfer
How long is a patient with placenta previa monitored before discharge?
72 hours of inpatient observation
what is the condition called where the placenta has separated or abruptly pulled away/
placental abruption
what would a MILD placental abruption look like?
unnoticed during pregnancy, seen when placenta is delivered (clot behind the placenta)
what would a MODERATE placental abruption look like?
SYMPTOMATIC (acute PAIN!), tender abdomen
what would a SEVERE placental abruption look like?
fetal demise w/ or without coagulopathy
what would the symptoms be for placental abruption?
ACUTE PAIN due to uterine distention from bleeding
pain varies from mild cramping to SEVERE cramping and back pain
True or false: in placental abruption, the pain is proportionate to the amount of blood lost
FALSE
pain is NOT proportionate to amount of blood loss
which imaging test could you do to assess placental abruption, and what would you see?
Transvaginal ultrasound -
retroplacental echolucency,
abnormal thickening of placenta
torn placental edge
Treatment placental abruption?
operative or vaginal delivery (if fetal demise, deliver vaginally)
Uterine rupture is MOST COMMONLY associated with a history of _____
previous c-section
other than hx previous c-section, what are the risk factors for uterine rupture?
inappropriate oxytocin use
trophoblastic neoplasia
uterine anatomical anomaly
What happens to the fetal heart rate in a patient with uterine rupture?
Sudden PLUMMET of fetal HR
What is “stair step”, and where is it seen?
decrease or cessation of contractions, seen in uterine rupture
What is the treatment for asymptomatic uterine rupture?
expectant management
what is the treatment for SYMPTOMATIC uterine rupture?
emergent C-section in UNDER 15 minutes
what is the timeframe that a c-section in a uterine rupture needs to be done under?
15 minutes!!!
Can someone with a uterine rupture have another successful pregnancy later on?
No - uterus won’t handle it. HYSTERECTOMY is usually performed
What is the condition called when fetal vessels run in separate membranes of the placenta, and lobes alternate between alive and dead?
Vasa previa
what is the treatment for vasa previa?
Immediate C-section
how much cardiac output does the uterus receive?
20-30% CO
True or false: aortocaval compression causes 30% of cardiac output to be sequestered, causing signs of hypovolemia to be masked.
TRUE
What do the letters in CABD for basic life support in pregnant women stand for?
C - circulation
A- airway
B-breathing
D - defibrillator
what side do you roll a mother onto while performing CPR?
LEFT - if can’t roll the patient, try and manually pull the uterus to the left to get pressure off the IVC in abdomen
mother is deceased after how many minutes of CPR?
4 minutes
–> you now have 2 minutes to get baby out
what are some signs that a patient may be experiencing an amniotic fluid embolism?
restlessness, n/v, respiratory distress, seizures, pallor, diaphoresis, sense of impending doom
while monitoring a pregnant patient post-car accident, how long to monitor if they experience <6 contractions/hr
monitor 4-6 hours then D/C if stable
while monitoring a patient post-car accident, how long to keep them if they have >6 contractions/hr
monitor overnight, then D/C
postpartum hemorrhage is defined as how much blood loss?
> 500 mL
also look for signs of hypovolemia
what do you give a patient who is experiencing post-partum hemorrhage?
oxytocin!
what nonpharmacological things can you do for a patient who is having post-partum hemorrhage?
continuous cord traction
uterine massage
What are the 4 T’s of postpartum hemorrhage?
Tone
Trauma
Tissue
Thrombin
If the T(one) regarding assessment of postpartum hemorrhage is a soft, boggy uterus, what actions do you take next?
give oxytocin, then carboprost, then misoprostol, then methylergonovine
What might the “TISSUE” (4 T’s) mean regarding post-partum hemorrhage
retained placenta - inspect, explore uterus and remove the placenta. Then curretage
What are the 4 medications used in post-partum hemorrhage, in order!
Oxytocin
Carboprost
Misoprostol
Methylergonovine
What are the 3 categories of hypertensive disorders in pregnancy?
Chronic HTN
Gestational HTN
Preeclampsia-eclampsia
what is chronic hypertension in pregnancy, and how do you manage it?
hypertension present BEFORE pregnant; continue to treat it throughout
Is there proteinuria in chronic or gestational hypertension?
NO
What 3 classes of pre-eclampsia?
Preeclampsia
Eclampsia
HELLP syndrome
is there proteinuria in preeclampsia?
YES
True or false: preeclampsia is a multi-system disorder including the eyes, lungs, liver, blood, CNS, pancreas, kidneys
TRUE
What is diagnostic of preeclampsia?
NEW onset high BP + Proteinuria
2 readings >140/90 or 1 reading >160/110
What level of proteinuria must be present to diagnose preeclampsia/eclampsia
dip stick of >1+
300 mg/24 hours
diagnosing preeclampsia WITHOUT proteinuria includes a platelet count of ______, and transaminases _____ normal level
platelets <100,000
AST/ALT 2x normal limit
Treatment of preeclampsia WITHOUT severe features
expectant management if <37 weeks
treatment of preeclampsia WITH severe features
admit, prevent seizures, lower BP to prevent cerebral hemorrhage, expedite delivery
what do you give mother as the preferred anticonvulsant to protect her from seizures
Mg sulfate
Is it possible to give too much Mg to a mother?
yes - leads to paralysis and cardiac arrest
Which type of preeclampsia pictures gets Mg?
Preeclampsia w/ severe features
eclampsia
What is the antidote for Mg?
calcium gluconate 1 g over 3 minutes
What are the 3 meds used in lowering severe high BP during pregnancy
Lebatolol
Nifedipine
Hydralazine
Eclampsia is defined as a patient who has preeclampsia and develop ____
seizures
is it possible to have eclampsia AFTER baby delivers
YES - greatest risk continues 24 hours after delivery!
What 3 factors define HELLP syndrome?
H - hemolysis
EL - elevated liver enzymes
LP - low platelets
True or false: eclampsia usually happens during labor
FALSE - commonly happens postpartum
Treatment of HELLP
monitor BP, continue Mg for 24 hours until stable
This disorder looks very similar to preeclampsia (hypoglycemia, elevated liver enzymes, prolonged PTT), but there is NO high blood pressure. What is the disorder?
Acute fatty liver
This disorder presents with the usual late pregnancy symptoms (edema, dyspnea, fatigue), but can actually be a cause of Heart failure
peripartum cardiomyopathy
diagnosis of peripartum cardiomyopathy?
ECHO
symptoms of peripartum cardiomyopathy
edema, fatigue, dyspnea
Patient presents with unilateral calf pain, which measures 2 cm greater than the other side. What is your concern?
DVT
which leg is most likely to develop a DVT?
LEFT (88% more likely)
treatment of DVT in pregnancy
LMWH
after delivery, can go back to warfarin/etc.
Steroids during preterm labor only work during which weeks of pregnancy?
26-34 weeks, otherwise using them has no benefit
what is the BISHOP score used for?
labor management: assess cervix for ability/risks of vaginal delivery.
What infection is present if pH < 4.5, no odor, cheesy discharge
Yeast vaginitis
Treatment yeast vaginitis
Topical “azole”
Fluconazole ORAL
What do you use to diagnose bacterial vaginitis
AMSEL criteria
What are the 4 characteristics of the amsel criteria (bacterial vaginitis)
- thin homogenous discharge
- positive sniff test (strong fishy smell)
- clue cells (adherent to cervical squamous cell)
- pH > 4.5
Is pH > 4.5 in yeast or bacterial vaginitis?
Bacterial
Treatment BV
Metronidazole PO
PROFUSE thin discharge, no smell, no symptoms
Trichomonas
What is a hallmark symptom of trichomonas?
Strawberry cervix
Cervicitis, but categorized as vaginitis
Treatment Trich
Metronidazole P.O.
Do you report trich to MDH?
Yes
Treatment for herpes
Acyclovir
It’s a chronic condition
What do the ulcers of HSV look like?
White center red ring
Primary stage of syphilis ulcer characteristics
Red center white ring
Secondary stage is sores on hands
Difference between herpes and syphilis ulcers
Herpes has many ulcers while syphilis usually has one or 2 chancroid ulcers
Treponema pallium causes what STI
Syphilis
Chronic and systemic
Syphilis treatment
Penicillin or doxycycline
Papulosquamous eruption is found when and where?
Secondary stage of syphilis- it is the extragenital sores
What is the most common cause of mucopurulent cervicitis?
Chlamydia
Who are we required to screen for chlamydiea?
All sexually active females under 24 years
What might a patient with chlamydia present with?
Commonly asymptomatic; mucopurulent cervical discharge and cervical motion tenderness
Treatment chlamydia
Azithromycin ONE SINGLE DOSE
What infection is the number 1 cause of septic arthritis in young adults
Gonorrhea!
Sexually actively patient presents with painful red swollen knee- what do you think?
Gonorrhea (assume coinfection wh chlamydia)
True or false: if patient has gonorrhea, ALWAYS treat both gonorrhea and chlamydia.
True
Treatment gonorrhea
Cefixime or ceftriaxone
What is the disorder called when pathogens ascend the upper genital tract, and when is the most common time this happens?
Pelvic inflammatory disease: happens during menses when cervix is open
Most common pathogen that causes PID?
CHLAMYDIA
Gonorrhea
E.coli
How does PID presentation differ from other infections?
Bilateral pelvic pain that radiates, mucopurulent cervical discharge, as exam tenderness, fever, REBOUND TENDERNESS
What might you see on transvaginal US for PID
Thick, fluid filled tubes
Also elevated WBC, ESR on labs
Patient presents 2 days postpartum, with fever and uterine tenderness- what are you concerned about
Endometritis (commonly presents after delivery or procedure)
What will WBC and bacterial cultures look like for endometritis
WBC >20,000
Bacteria: mixed- anaerobic streptococci, gram negative Coliforms
Treatment endometritis
Clindamycin + gentamicin (inpatient)
OUTPATIENT: metronidazole + doxy
Rare, dangerous condition cause by staph aureus and it’s exotoxins
Toxic shock syndrome
Patient presents with fever 102, diffuse macular rash. What are you thinking and what might happen 1-2 weeks later
Toxic shock syndrome; followed by desquamination
Treatment TSS
Clindamycin + vanco
Treatment of mastitis
Staph aureus - dicloxacillin
Staph aureus can cause which 2 disorders we learned about
Mastitis and TSS
Management of brewer abscess as it progresses from mastitis
Incision and drainage
Then CEFAZOLIN + METRONIDAZOLE
Is breastfeeding allowed with mastitis and breast abscess?
Mastitis- yes! Allows the infection to leave without harming baby
Breast abscess NO!
Condition of leaking blood into peritoneal cavity causing extreme pain at time of ovulation
Mittelschmertz
In which disorder would you see a “chocolate cyst”
Endometriosis
What is the gold standard for diagnosing endometriosis
Laparoscopy
Treatment plan for endometriosis
NSAIDs —> OCs is dysmenorrhea does not respond
Do OCs continuously for 1-2 months before moving into further work up
treatment for Mittelschmertz
none for pain; if severe enough, can administer OCs to prevent ovulation (which is causing the pain)
what is the disorder involving menstrual pain w ovulatory cycles and NO STRUCTURAL ABNORMALITIES
primary dysmenorrhea
Treatment for primary dysmenorrhea
NSAIDs
can do OCs if contraception is desired
secondary dysmenorrhea is menstrual pain associated with STRUCTURAL PATHOLOGY: what 2 disorders are included in this category?
endometriosis
adenymyosis
IUD in uterus
symptoms or endometriosis
progressively worsening menstrual pain, improves after period, dyspareunia
if you see blue/black “powder burned” implants within the tissue of an organ outside of the uterus, what is this a hallmark of?
Endometriosis
treatment endometriosis?
continuous oral contraceptives: progestins
surgical ablation of endometrial implants or total hysterectomy (for severe)
what is the disorder characterized by ingrowth of endometrial tissue into the MYOMETRIUM?
adenomyosis
diagnostic for adenomyosis
US: heterogeneous myometrium (not a smooth muscle layer)
treatment adenomyosis
OCs, NSAIDs, hysterectomy if meds are not working
chronic pelvic pain is described as _____ of continuous noncyclic pain
> 6 months
which type of pain is most likely to be Gynecologic
recurrent
estrogen dips below _____ when hot flashes develop
<20
FSH and LH rise in response to low estrogen. what level is diagnostic of menopause?
FSH/LH >35 + absence of menses for 1 year
BEST treatment for menopause
oral estrogen!
if uterus still present, ADD progestin to estrogen
what does GUSM stand for?
Genitourinary syndrome of menopause
what is the presentation of GUSM?
shortening/narrowing of vagina
- thinning of vaginal lining, reducing lubrication
- chronic vaginal discharge
Treatment GUSM
topical estrogens
what is normal vaginal flora?
Lactobacillus
3 treatment options for menopause
estrogen, progesterone, Duavee
