OBGYN: Reno questions/answers Flashcards
Differentiate b/w placenta previa and abrupto placentae
- Placenta Previa
* placenta covers part or all of cervical os
* PAINLESS bleeding
* during 3rd tri MC - Abrupto Placentae
* placenta detaches from uterus
* PAINFUL bleeding (seen or unseen)
* MC during 3rd tri
define pre term
delivery before 37 week
list two diagnostic criteria for per term labor
- regular uterine contraction <4-6/hour
2. cervical change: effacement of 80% or dilation of 3+CM
explain management of preterm labor after 34 weeks and before 34 weeks
-when can u discharge?
BEFORE 34 WEEKS
- admit
- fetal monitoring
- give betamethasone
- attempt to delay delivery for 48 hrs using MAG SULFATE
- ABX prophylaxis for GBS
AFTER 34 WEEKS
- admit
- monitor
- deliver
**if 4-6 hours pass with no progression of cervical effacement or dilation—- can discharge
4 RF for PROM
- vaginal/cervical infection
- smoking
- multiple gestations
- prior pre-term delivery
list two methods used to diagnose PROM
- check for FERNING under microscope
2. use nitrazine paper to check for alkalinity– turns blue if +amniotic fluid
what should we never put inside a vagina in a woman with PROM
anything that is NOT sterile—she is already at incr risk of infection
explain difference b/w PROM and PPROM
PROM=rupture of mem at 37+ weeks
PPROM= rupture of mem prior 37 weeks
management for PROM and PPROM
PROM
- admit
- fetal monitoring
- monitor mom for infection
- induce labor if no spontaneous labor after 18 hours
PPROM
- admit
- fetal monitor
- if 34 weeks or less–>bethamethasone
- ABX +/-
- induce labor–> if after 48 hours OR earlier if signs of distress
Describe dystocia, 3 reasons, and its tx
Dystocia=labor that does not progress normally
management based off which of the three problems are causing it
- POWERS (intensity of contractions)–>give IV Oxytocin
- PASSENGER (fetus too big)–>c section
- PASSAGE (maternal pelvis too small)–>c section
what constitues arrest of labor
no change in cervical dilation or effacement despite 4 hours of adequate contractions (>200 montevideo units)
describe shoulder dystocia and its management
shoulders wont come out—- managed by different maneuvers
*if they dont work— break fetus clavicles
describe breech presentation and its management
butt coming out first
-managed based on experience of the OB and if they feel confident to deliver a breech vaginally
describe umbilical cord prolapse and its management
umbilical cord extends beyond the presenting fetal part
-managed by trying to release pressure on cord from baby’s head
list four MC indications for c-section
- dystocia
- prior c section
- breech presentation
- fetal distress
list absolute indication for a c-section
prior non-transverse uterine incision
describe uterine rupture
- list signs/symps (4)
- RF (5)
*when all muscle layers of uterus tear apart
S/S
- extreme pain (worse than labor)
- absent contractions
- bleeding
- fetal bradycardia*****
RF=previous uterine rupture, prior c-section, induction of labor with oxytocin, trauma, previous myomectomy
define PP hemorrhage
loss of blood >500 mL vaginal delivery, >1,000 mL C-section
four main causes of PP hemorrahge
- tone (uterine atony)
- tissue (retained placental tissue)
- trauma/lacerations
- thrombin (coag disorder)
RF for uterine atony (6)
- multiple gestations
- fetal macrosomia
- prolonged labor
- IV oxytocin
- Mag Sulfate to manage preeclampsia
- uterine leiomyomas/fibroids
tx for uterine atony
- uterine massage
- oxytocin
- if oxytocin doesnt work–>Methylergonovine
tx for refractory PP hemorrahge
tamponade
surgical ligation or cauterization of arteries
hysterectomy
3 causes of PP pain and how to manage it
- afterpains
- episiotomy
- lacerations
- breast engorgement
- post-epidural HA
- *tx=
- acetaminophen–NOT NSAIDS
- ASA
- codeine
describe colostrum and its purpose
yellow thick substance–secreted thru breast in first weeks PP–carries extra minerals, AAs and immunoglobulins (IgA) to protect baby from GI infections
riskiest time for PP hemorrahge
first hour after delivery
list five contraindications to BF
- maternal illicit drug use
- Maternal HIV
- maternal ETOH
- maternal untx, actiev TB
- BCA tx
explain how and why to start contraception after delivery
should start immediately after birth as ovulation can occur as early first 4 weeks
contraindications for contraception after delivery
no estrogen for at least first 12 weeks bc it incrs risk of clots and decrs milk prod
describe four main differences b/w PP blues and PP depression and list management of both
PP BLUES
- dep mood 2-4 days PP (up to 10)
- no thoughts of harming baby
- management=anticipatory guideance, recognition and reassurance
PP DEP
- major depression
- thoughts of harming baby
- starts b/w 2-4 weeks and 2 MO after delivery
- tx=antideps and CBT
how is HCG used to help diagnose early pregnancy loss
confirm that a pregnancy is no longer viable—- when HCG is falling at the approrapite rate
explain discriminatory zone of HCG and how it is used
- occurs at HCG=2500—-at this time you sould see a uterine pregnancy on sonogram
- if you dont see a pregnancy in uterus and HCG is 2500+, then it is ectopic until proven otherwise
when is it acceptable and not acceptable to use expectant management of an early pregnancy loss?
can be utilized in a pregnancy that is 12 weeks or less—aka during first trimester
cannot utilizze if pregnancy is >12 weeks OR if there are s/s of infection
describe medical management of early preg loss and how it is done
patient is given one does of mifepristone and then 24 hrs later one dose of misoprostol
explain gestational trophoblastic dz and how it is diagnosed and tx
diagnosed via physical exam—
*mismatch b/w gestational age and uterine size/fundal height and HCG (is very very very high)
sonogram: “snowstorm” or “cluster of grapes”
tx: surgical D/C
weekly and monthly HCG monitoring
RF for ectopic preg (6)
- previous
- tubal ligation
- IUD
- hx of PID
- smoking
- use of reproductive technology
MC location for ectpic and why?
fallopian tubes
WHY?
*fertilized egg’s trajectory is tubes then the uterus— it is very very very rare to have eg implant outside these two areas
s/s of a probable ectopic pregnancy
missed period \+ vaginal bleeding \+ lower abd pain
s/s and tx for acute ruptured ectopic preg
severe abd pain, rebound tenderness, dizziness, refered shoudler pain, hypovolemci shock
tx=surgery
diff in s/s, diagnosis and tx of
1. possible
2. probably
ectopic pregnancy
POSSIBLE
- vague s/s, +/- mild abd pain
- exma=normal
PROBABLE
- missed period, abd pain, vaiginal bleeding
- exam may have abd tenderness or + CMT
cause and tx of incompetent cervix
MCC= previous LEEP procedures
TX=cerclage— suture the cervix
s/s of abrupto placentae
painful cramps abd pain vaginal bleeding (seen or unseen) back pain potential hemodynamic instability MC 3rd tri
tx for abrupto placentae
immediate delivery
iv fluids
blood transfussion for mom
control bleeding
use to tx women with HTN in pregnancy
methyldopa
list two diagnostic criteria for pre-eclampsia
new onset HTN and new onset proteinuria
list criteria for HELLP
- hemolysis
- elevated liver enzymes
- low platelets
s/s of eclampsia + tx
tonic-clonic seizures
TX= mag, HTN meds
DEFINITIVE TX=DELIVERY****
tx for GD and MC fetal consequence
insulin
macrosomia
how much folic acid should woman take and when to start and wht does it prevent
- 4mg/day for 1st tri
* prevents neural tube defects
list 5 common drugs contraindicated in pregnancy
- warfarin
- tetracycline
- valproic acid
- lithium
- benzos
5 physical exam findings that are common in pregnancy (but not cmmon otherwise)
Sytolic murmurs S3 spier angiomas striae linea nigra
chadwick’s sign, what does it indicate, and what does it look like
bluish color of cervix and vulva around 8-12 weeks gestation
how high is fundus at 20 weeks
umbilicus
list 8 labs you need to order on every preg woman at her first prenatal visit
UA Rh Rubella Syphilis Hep B HIV Gonorrhea Chlymida PPD
be able to calculate delivery date based on Naegele’s rule
a. EDD= 1st day of LMP + 7 days – 3 months + 1 year
deescribe genetic testing for the fetus in second trimester and how its done
triple screening w/ AFP, beta HCG and estradiol
describe genetic screening for fetus in the first trimester and how its done
SONO–>NT thickness
MOM–>free HCG (if its up=risk of downs)
PAPP-A (LOW=risk of downs)
3 lifestyle mods that can help morning sickness
eat small and frequent meals avoid spicy or greasy food protein snacks at night saltine crackers by the bed room temp sodas
about when should a first time mother feel the baby move
20 weeks
list the 5 things that should be checked at every prenatal visit
BP UA (protein + glucose) weight uterine size fetal HR
purpose of Maneuvers of leopold
determine fetal position and lie
describe differences b/w glucose screening test and glucose challenge test
screening test= 1 hour— if positive, then move to the diagnostic test= glucose challenge test–>3 hours
what other dz should we screen mother for b/w 35 and 37 weks
GBS
5 components of Biophysical profile
non-stress testing fetal breathing fetal tones/heart rate amniotic fluid levels gross fetal movements
describe a non stress test and what results are + and -
nonstres test is when we monitor the fetal HR and mom indicates when baby moves
- –>we check the fetal tracing to make sure the HR goes up (>5 bpm from baseline >15 seconds) with movement
- –>if this happens TWICE in 20 mins– REACTIVE (+)
- —>this this does not happen— NONREACTIVE (-)
define fetal monitor accelerations and variations and what causes them
ACCELERATIONS: incr in fetal HR in response to fetal movement or uterine contractions
–considered “good” bc they wil stop occuring if the fetus is hypoxic
Variations/variability:
- difference in HR from beat-beat
- normal range of variability is 5-25 BPM difference between beats
explain fetal monitor decelerations and what they means, including wht makes them + and -
- early decel?
- variable decel
- late decel
DECELERATIONS=deceleration in fetal HR to fetal movement or uterine contractions
- EARLY decelerations occur at the same time as contractions and are normal in final stages of labor
- VARIABLE decelerations that have no correlation to moms contractions are also normal
LATE decelerations occur within 30 seconds of contraction and indicate fetal hypoxia
—repetative late decels in precense of 3 contractions within 10 min period= POSITIVE test and we need to deliver the baby ASAP
what causes symptoms of lightening, braxton hicks, and bloody show
LIGHTENING
*descent of fetal head into the pelvis— pelvic bone is now supporting some of the weight of the baby means the mom feels like the baby “got lighter”– hence name to lighten
BRAXON
- “practice” contractions occur prior to labor
- diff from regular contractions in that they occur RANDOMLY and there is NO cervical dilation or effacement
BLOOD SHOW
*mucus plug is released because of cervical effacement and dilation—often causes a small amt of bleeding
MC type of female pelvis
Gynecoid
what is fetal lie? presentation?
LIE
- relation of fetus to the longitudinal axis (think of mom’s spine) of the mother
- has to be longitudinal (parallel to spine) in order to have successful vaginal delivery
PRESENTATION
*which fetal part is set to come out first
4 stages of labor and ID the star and end of each pint
STAGE 1= onset of true labor
- STARTS: cervical effacement and dilation
- ENDS: dilation of 10 cm
STAGE 2= delivery stage
STARTS: complete dilation
ENDS: delivery of fetus—-fetus does six cardinal movements
STAGE 3: placenta
STARTS: once fetus is delivered
ENDS: placenta delivered
STAGE 4: first hour after delivery of placenta
***MC time for PP hemmorrahge
how quickly should the cervix dilate
once cervix reached 3-4 cm, it should begin dilating at a rate of 1-1.2 cm/hr
best position for mother to lie in during stage 1 labor and why
LEFT side— reduces compression of liver, hepatic blood flow and VC
describe difference b/w cervical effacement and dilation
effacement=cervix thins
dilation= cervix opens
6 cardinal movements of labor
1=engagement 2=descent 3=flexion 4=internal rotation 5=extension 6=external rotation
episiotomy and what are inds?
cut in the perinium to aid in delivery
no strict indications—- but they are often performed when there is difficulty getting fetal head out
3 signs of placental separation
- gush of blood
- lengthening
- uterus (fundus) becomes firmer
if we need to induce labor in a mother of 30 weeks, four things we must do
- admit and start fetal monitoring
- give betamethasone
- delay labor by 48 hours if possible with tocolytics (MAG)
- give GBS prophylaxs ABX
APGAR
a. Appearance
i. 0= blue-gray and pale all over
ii. 1= acrocyanosis: body pink but blue extremities
iii. 2=pink baby with no cyanosis
b. Pulse
i. 0=0 bpm
ii. 1= <100 bpm
iii. 2= >100bpm
c. Grimace
i. 0=no response to stimulation
ii. 1= grimaces feebly
iii. 2=pulls away, sneezes or coughs
d. Activity
i. 0=none
ii. 1=some flexion
iii. 2=flexes arms and legs and resists extension
e. Respiration
i. 0=absent
ii. 1=weak, irregular
iii. 2=strong, crying (30-60/min is normal)
describe normal vaginal discarhge– where does it come from
whtie or transparents
odorless
vulvar secretions from sebacoues, sweat, bartholin and skene glands
normal vaginal PH
3.8-4.5
role of lactobacilli in vagina
keep ph acidic—produces lactic acid and hydrogen peroxide
–prev growth of pathogens
BV -cause s/s diagnose tx
a. Cause
i. Gardnerella anaerobic bacteria
ii. Recent ABX use
b. Signs/Symptoms
i. Vaginal itching, vaginal burning, +/- pain with sex
ii. Vaginal discharge looks like gray/white profuse with fishy odor
c. Diagnose
i. Saline and KOH wet mount will show +clue cells
ii. pH >4.5
iii. Positive whiff test due
d. Treatment
i. Metronidazole PO 500 mg BID x 7 days or Intravaginal metronidazole gel x 5 days
Candidiasis cause s/s diagnose tx
a. Cause
i. Candida albicans—fungal infection
ii. Recent ABX use
b. Signs/symptoms
i. Thick cottage cheese/cheesy vaginal discharge
ii. Pruritis
iii. Dysuria
iv. Burning
v. Dyspareunia
vi. Vaginal or vulvar edema
vii. Erythema and vaginal inflammation
c. Diagnose
i. KOH wet mount will show hyphae or budding of yeast
ii. pH between 4-4.5 range
d. Treatment
i. Clotrimazole or Nystatin intravaginally 3-7 days OR Fluconazole 150 mg PO once
Trich
- cause
- s/s
- diagnose
- tx
a. Cause
i. MC found in sexually active women—STD
ii. Comes from parasite: trichomonas vaginalis
b. Signs/symptoms
i. Purulent, thin, frothy, malodorous, yellow-green discharge
ii. Burning, pruritis, dysuria, frequency, lower abdominal pain, dyspareunia
iii. Cervical exam will show a “strawberry cervix” or petechiae on the cervix
c. Diagnose
i. Wet mount will show pear shaped mobile protozoa with flagella
ii. pH is > 4.5
d. Treatment
i. Patient AND partner need treatmentMetronidazole 2g one time
list cause and s/s of cervicitis and PID
Cervicitis–> STDs/STIs like GC/Chlymadia, irritants, bac vaginosis
S/S: red inflammed cervix with green/yellow discahrge coming out of the os—— if additional +CMT and or fever it becomes PID
Cervicitis only= NOT CMT, no fever
INCR WBC on went mount for both
long term risks of PID
scared tubes=ectopic pregs and infertility
tx for PID–outPT
OUTPT
*ceftriaxone 250mg IM x1 and Doxycycline 100mgPO bid x14 days—recheck in 24 hours
how and when do we screen women for cervical CA
pap smear and HPV testing starting at age 21
which 3 HPV types do we screenwomen for
6
18
45
colposcopy
microscopic look at cervix
which pap/HPV results warrant colposcopy
anything ASCUS or higher
or
HPV 16, 18
what are the tx for cervical CA
LEEP
Cold Knife Cone
Hysterectomy
Chemotherapy
what is a leiomyoma
fibroid–collection of uterine muscle
what are the s/s of leiomyomas
tx?
AUB dysmenorrhea pelvic pressure fullness constipation and frequent urination (if pressing on bladder)
cyclic pelvic pain
bad cramps
heavy bleeding during menses
can cause infertility
TX= hormonal contraceptives
myomectomy
what is endometriosis
endometrial glands and/or stroma OUTSIDE uterus
s/s endometriosis
pelvic pain
dysmenorrhea
dyspareunia
dyschezia–constipation
endometriosis often causes?
infertility
endometriosis tx
laparoscopy & ablation
oophorectomy (bc it relies on estrogen for growth)
alarming sign for endometrial CA
abbnormal bleeding/spotting AFTER menopause
3 protective factors against endometrial CA
decr exposure to estrogen (many pregs, late menarch)
combined contraceptives
MC type of ovarian cyst
functional
why do ovarian cysts occur
follicle that does not ovulate
list two ways to differentiate ovarian cyst from ovarian CA
sonogram
biopsy— CA125
s/s ovarian torsion
severe lower abd pain
nauea
pelvic tenderness
how and when do we screen women for ovarian CA
we dont
list 3 s/s ovarian CA
early satiety
bloating
pelvic or abdominal pain
describe normal hormonal abnormalities of PCOS (3)
- androgen excess (incr testosterone)
- increased LH
- insulin resistance
s/s and tx PCOS
S/S
- menstrual dysfunctions/irregularities: oligomenorrhea (<9 periods/yr) or secondary amenorrhea
- Hirsutism
- acne
- androgenic alopecia
- insulin resistance—DM 2
- obesity
tx=hormonal contraceptives——– if that doesnt work enough then spironolactone
MC benign breast condition
Fibrocystic breast dz
what are breast cysts
small collections of fluid or a mix of fluid/debris in breast
what are two common types of breast imaging
mammogran
sonogram
list 8 RF for BCA
- age
- caucasian
- obesity
- tall
- more exposure to estrogen
- family hx with 1st deg relatives
- BRCA mutation
- ionizing radiation to chest
how and when should avg risk women be screened for BCA
starting at 21, CBE q 1-3 years
Mammos starting at 40
what breast s/s indicate possibility of BCA
hard non-motile irreg boarders non-painful p'eau d'orange new onset nipple inversion unilateral nipple dsx
two main types of atypical hyperplasia
atypical ductal hyperplasia (ADH)
Atypical lobular hyerplasia (ALH)
if atypical hyperplasia is found on biopsy, what should happen next
excisional biopsy/lumpectomy
what is the MC type of BCA
invasive ductal carcinoma
what is the most aggressive BCA
-list s/s
inflammatory BCA
S/s
- erythema
- swelling
- itching
- tenderness
- lymphadenopathy
what prevents lactogenesis in preg woman
high progesterone—produced by placenta
what hormone is released during suckling
prolactin
what are s/s and tx for mastitis
Rubor, dolor, calor, tumor and FEVER
unilateral, single quadrant
TX
- warm compress
- dicloxacillin 500 MG PO qid x 10-14 days and KEEP BF
what hormone is resp for preventing ovulation white BF
sucking + prolactin release causes inhibition of GnRH–>LH and FSH suppression
what hormones decr in and after menopause
-effects of this decr?
FSH and estrogen
EFFECTS
- hot flashes
- skin dryness
- hair loss
- loss of libido
- vaginal dryness
- amenorrhea
what is the main way hormonal contraception prevents pregnancy
inhib development and release of egg
what 3 BC contain estrogen
COCs
Nuva ring
Patch–ortho evra
3 types of EC
paraguard IUD
Ella
PLAN B
six main contraindications for COC
- HTN
- migraines with aura
- previous blood clots/strokes
- smoking + >35
- known thrombogenic mutations
- lupus with phospholipid antibodies
what must you warn patients about when starting combined hormonal contraceptives
ACHES
Abdominal pain Chest pain Headaches with aura Eye problems Severe leg pain
