OBGYN Reverse Flashcards
Sexual expression is determined by ? five factors
Masters and Johnson describe ? four stage sexual response cycle in 1966
Basson proposed ? revised sexual response cycle in 2001
Psychological Learned Environment Spiritual Social
Excitement Plateau Orgasm Resolution
Intimacy Stimuli Arousal Desire Enhanced intimacy
? is the biological component of the Sexual Response Cycle and what control this component
? carries that most weight of the cycle
Desire Phase is driven by ? hormone while Arousal Phase is driven by ? hormone
Sexual Drive- influenced by neuroendocrine
Motivation
Emotional willingness
D: testosterone, excited- T, suppressed- Serotonin
A: E2 from parasympathetic
Menopause sexual dysfunction is d/t ?
What are the three phases of sexual response
? underlying Dxs are comorbid w/ sexual d/os
Hypo-estrogen
Inc FSH= hot flashes
Desire (Libido)
Excitement (Arousal)
Orgasm (Climax)
Anxiety/Depression
Excitement/arousal is a reflex controlled by ? nerves and controlled by ? system
The excitement/arousal phase is enhanced by ? hormone and the lack of this is the MC ?
Orgasmic phase reflex is controlled by ? nerves and modulated by ?
T11-L2, S2-4; Parasympathetic
Estrogen; MCC of dysfunction of excitement phase
T11-L2, S3-4; Sympathetic
What are the four RFs for developing dyspareunia
Difference between fe/male sexual assault in military
? are the RFs for violence against women and when are the RFs lowest
Hx of abuse/PID
Age <50
Depression/Anxiety
Unwanted touch: MC to men
More likely reported/investigated- MC to women
Age 16-24y/o
Witnessing violence as child
Lowest: 65/> y/o
What are the support structures of the pelvis
What are the pelvic organs
Define Chronic Pelvic Pain
Perineum
Urogenital diaphragm
Levator ani
Vagina
Rectum Uterus Bladder Vagina
Non-cyclic pain lasting 6mon+ severe enough for functional disability/medical intervention
What is used for first line Tx of Chronic Pelvic Pain
How are neuropathic Sxs Tx
How are dysmenorrhea/dyspareunia Sxs Tx
What surgical options are available
Acetaminophen and NSAIDs
SS/NRI TCA Gabapentin
CoCs Progestin GnRH agonist
Hysterectomy Neurolysis
Define Vulvodynia
What is used for Tx
When does Localized Provoked Vulvodynia become a DDx
Vulvar discomfort x3mon w/out identifiable cause
Topical Lidocain/Gabapentin
Antidepressant- TCA (max 200mg Amitriptyline)
New onset insertion pain x 3mon
What are the two sub-classifications of Dyspareunia and the causes
Exam for dyspareunia mirrors the exam for ?
How is this condition Tx
Insertion: d/t vulv-odynia/itis, poor lube
Deep: pain d/t endometriosis, adhesions or bulky leiomyomas
Chronic Pelvic Pain
Vaginismus- desensitization, counseling
Atrophy- estrogen cream
Poor lube- lube and arousal
Structural- surgery
Pudendal Neuralgia is Dx w/ ? criteria
Define Cystocele, Rectocele, Enterocele, Procidentia
? is the 3rd MC indication for hysterectomy
Nantes: Pain along pudendal nerve path Worse w/ sitting No sensory loss Does not awaken Relieved w/ nerve block
C: bladder prolapse
R: rectum prolapse
E: bowel prolapse
P: uterus prolapse
Pelvic organ prolapse
Define Splinting/Digitation associated w/ pelvic organ prolapses
Which type of prolapse presents w/ urinary retention
What are the RFs for prolapse
Splint: manual bolstering improves Sxs
Digit: manual pressure aids w/ BMs
Cystocele
Inc abdominal pressure CT d/o Age- risk double each decade Vaginal delivery- 1.2x per delivery Elective forcep delivery Race: hispanic/white
Although unknown, Interstitial Cystitis and/or Painful Bladder Syndrome is potentially d/t ? two etiologies
These two Dxs are considered when
Pts w/ this condition but Dx w/ UTIs will present w/ ? c/c
Mast cell activation; Defected mucin layer
Unexplained chronic pelvic pain w/ voiding Sxs
Cranberry juice exacerbates pain
Define Hunner Ulcer
Define Glomerulations
What is first and second line Txs for Interstitial Cystitis/Painful Bladder Syndrome
What is the only FDA approved medication for Tx Interstitial Cystitis/Painful Bladder Syndrome
Red/brown lesion w/ radiating vessel to central scar causing bladder stiffening- Dx for interstitial cystitis
More common; petechia/sub-mucosal hemorrhage (not unique to interstitial cystitis)
1st: Education, Behavior mod
2nd: PT Elmiron Amitriptyline Cimetidine Hydroxyzine
Elmiron- repairs bladder defects
What can be injected into bladder for Interstitial Cystitis/Painful Bladder Syndrome Txs
? MedHx makes females 2.5x more likely to be admitted to nursing homes than peers
What are the transient causes of incontinence
Lidocaine Heparin Dimethyl Sulfoxide
Incontinence
Delirium- MC in hospitalized Pts Infections Atrophic vaginitis/urethritis Pharm: A-blockers (women) A-agonists (men) Psych Excess output/Endocrine dz Restricted mobility Stool impaction
What are the three degrees of Stress Incontinence Severity
How is the bladder controlled by the nervous system
? type of receptors are more predominant in the bladder dome and ? type of receptors are more predominant in the bladder neck
1: only w/ severe stress (cough, sneeze, jump)
2: moderate stress (movement, stairs)
3: mild stress (standing)
Peripheral, Autonomic:
Sympathetic: A/B receptors
Parasympathetic: Muscarinic/Nicotinic receptors
Dome: muscarinic, b-adrenergic receptors
Neck: a-adrenergic receptors
What meds do Pts w/ incomplete/overflow bladder emptying and stress incontinence need to avoid
? is the MC type of incontinence seen in women
How is urethral hypermobility assessed for during stress incontinence exams
Overflow: A-agonsits, CCBs
Stress: A-antagonists
Mixed
Q-tip test, angle changes >30* to horizontal= hypermobility and possible stress incontinence
Most cases of incontinence can be Tx conservatively w/ ?
What medication can be added to incontinence Tx to dec urgency/frequency
? medications can be used to work at detrusor muscle level
Kegels: 50-60 contractions/day
Calcium glycerosphate
Anticholinergics- inhibit muscarinic receptors to blunt contractions
? is a combo drug used for mixed incontinence Tx
? is a combo anti-spasmodic drug used for urge incontinence Tx
Botulinum injections can be used for Tx ? types of incontinence
Imipramine: TCA w/ a-adrenergic and anticholinergic effects
Mirabegron: relaxes detrusor, increases bladder capacity
Idiopathic detrusor overactivity
Urge
Urge Incontinence Tx methods
Stress Incontinence Tx methods
Overflow Incontinence Tx methods
Schedule
Anticholinergic: Detrol, Ditropan
Kegels
Pessary/kegel Imipramine Topical estrogen Surgery Duloxetine
Intermittent catheterizations
Surgery
Most breast dzs arise from ? structures
Because of their location these growths are very sensitive to ? hormones
When does breast epithelial cells proliferate and why
Terminal duct-acinar (lobules)
Est/Progest/Prolactin
Luteal- fullness week prior to menses d/t water content
? is the MC benign breast tumor and MC breast d/o
How does this MC appear on PE and what type of f/u is needed
? Pt populations are these more common in and what happens w/ age/menopause
Tumor: fibroadenoma
D/o: fibrocystic changes
Well circumscribed, rubbery and mobile;
No FamHx of breast Ca; f/u 3-6mon
Adolescent/pre-menopause;
Calcify and spontaneously involute
Simple Cysts appear as ? on US and need ? management for Tx
Complicated Cysts appear as ? on US
Complex Cysts appear as ? on US
Sololucent, smooth margins
No special management unless
Recurrent- consider excise
Internal echoes, proteinaceous debris
Consider aspiration, culture, cytology
Abnormality doesn’t resolve w/ aspiration- core needle
Septa/intracystic mass usually papillaoma
Core needle biopsy and/or excise
Define Fibrocystic Breast Changes
What causes these changes
These changes are characterized by ? that is d/t ?
Ropy, nodular tissue d/t dilated ducts and dense collagen
Collagen stromal response to hormones/GF
Hyperplasia- low progesterone compared to estrogen
How will Fibrocystic Breast Changes present to clinic
How are these Tx
What baseline order needs to be started if Pt is >25y/o
Bilateral cysts w/ pain worse pre-cycle (late luteal phase)
Aspiration for pain, Danazol but high androgen s/e
Bloody/residual= biopsy
Baseline mammogram (cut off age for US/Mamm- 30)
What is the preferred eval technique for the following exam/imaging findings:
Palpable cystic lesion
Recurrent cyst w/ bloody fluid
Non-Dx FNA
Solid palpable mass
Non-Dx core needle biopsy
PCL: needle drainage
Recurrent: excision
ND-FNA: core/excision biopsy
Solid: core needle biopsy
NDx CNBx: excision biopsy
What are the indications for breast biopsy
Mammography BIRADS Categories
Breast mass
Benign mass w/ personal/FamHx Ca
Equivocal mammograpy/cytology results
0- Incomplete: more/prior imaging needed for comparison
1- Negative: routine mammogram
2- Benign: routine mammogram
3- Probably benign: short interval f/u
4- Suspicious: biopsy
5- Highly suggestive of malignancy: biopsy
6- Biopsy proven malignancy: surgery
Pthirus Pubis
Sarcoptes Scabei
Crabs w/ contact transmission
Present: Adenopathy Itch Excoriation
Dx: exam/microscopy
Tx: Permethrin Pyrethrins Lindane- c/i in pregnancy/infancy
Scabies w/ contact transmission
Present: Dermatitis Itch
Dx: oil scrape and exam
Tx: Lindane Ivermectin- repeat at 2wks Permethrin
HSV is the most prevalent STI w/ more frequent recurrences of ? strain
What does the initial outbreak of the infection present as ? and holds the greatest risk to whom
How is it Dx
HSV-2 from saliva/contact transmission
HA Malaise Adenopathy Fever;
Neonate/fetus
Culture Abs PCR
Genital warts is d/t ? infection
What does this cause to develop
How is this Dx
How is it Tx by provider and Pt
HPV-6, 11
Condylomata acuminatum
Acetic acid
Biopsy if treatment failure
Provider: Podophyllin Chloroacetic acid Cryo
Pt: Podofilox Imiquimod
What microbe causes Syphilis and how is infection spread
How is this seen in clinic
How is this screened for and how is a Dx confirmed
Treponema pallidum- contact, transplacental
Painless chancre w/ hard, raised borders shedding spirochetes
Screen: RPR or VDRL
Confirm: FTA-Abs
How does Secondary Syphilis present
Time frame for Early or Late Latent Syphilis
What systems can Tertiary Syphilis infect differently between men and women
Bacteremia Condylomata lata- pink plaques in warm/moist areas Adenopathy Maculopapular rash on palm/sole Exanthem- actively sheds spriochetes
Early: 1yr after secondary syphilis w/out Tx
Late: >1yr after initial infection
CV CNS MSK:
CV/Neuro less common in females
What is the reaction seen in Pts in response to Syphilis Tx and what causes this reaction to develop
How is Primary, Secondary and Early Late (<1yr) Syphilis Tx
How is Late Latent, Tertiary, or CV Syphilis Tx
When are Pts f/u with after Tx
Jarish Herxheimer- Fever Malaise HA d/t endotoxin release
Benzathine PCN G 2.4M units IM
PCN allergic and non-pregnant: Doxy x 14d
PCN allergy: Erythromycin
Benzathing PCN G 2.4M units IM weekly x 3wks
PCN allergic and non-pregnant: Doxy x 28d
Re-eval at 6mon;
Re-Tx w/ weekly PCN x 3wks
How does Chlamydia survive in the body
How is it Dx
How is it Tx
Intracellular bacteria
Culture Ag PCR*
Azith, Doxy w/ abstinence x 7d
Re-screen in 3mon
How is Gonorrhea Dx
What is used Primary, Secondary and Tertiary for Gonorrhea Tx
What class is no longer recommended for Tx
Gram stain
Culture- Thayer martin media
PCR- DNA/nucleic acid
Primary: IM 250mg Ceftriax+PO 1g Azith
Secondary: PO/IM Cephalosporin+PO 1g Azith
Tertiary: PO/IM Cephalosporin+Doxy 100mg x 7d
Abstinence x 7d
Re-screen at 3mon
Fluoroquinolones
PID is MCC by ?
What are the three possible sequelae
How is the ultimate Dx of Silent PID given
Ascending lower tract infection;
BV (anaerobes) Chlamydia Gonorrhea
Mycoplasmas: Hominis Urealyticum Genitalium
Infertility CPP Ectopic
Tubal-factor infertility w/ Hx compatible for UTIs
When do Sxs of Acute PID tend to present
What are the criteria for Dx
What is the primary imaging tool for Pts w/ PID
During/After menses
Uterine/Adnexal/Cervical tenderness w/ 1 or more: Fever > 101.6 WBCs on microscopy Inc ESR/CRP Chlamydia/Gonorrhea Cervical d/c or friability
US
How is PID Tx outpatient
If one of the meds needs to be replaced, what is used instead
How is PID Tx inpatient
Ceftriaxone 250mg IM
Doxy 100mg PO x 14d
Metronidazole (if +Trich/BV) 500mg PO BID x 14d
If Ceftriax can’t be used: Cefoxitin w/ Probenecid or
3rd Gen Cephalosporins
Cefotetan or Cefoxitin w/ Doxy or,
Clinda w/ Gentamcin or
Amp/Sulbactam w/ Doxy
How does Tuboovarian Abscess present on PE
How is this Dx
What happens if rupture occurs
PID Sxs w/ adnexal mass Fever Leukocytosis
US or CT/MRI
Peritonitis
What causes Toxic Shock Syndrome
When/how does this appear on PE
What causes this to develop
Exotoxin from Staph A
Diffuse itching macular rash
OHOTN
Fever Malaise Diarrhea- 2d after surgery/mense onset
Absorbent tampon/contraceptive sponge
All major criteria must be met for a Dx of Toxic Shock Syndrome which include ?
Define Fecundity and Fecundability
Chances of fertility drops by half after ? age
Temp >38.8*C HOTN- SBP <90 Orthostatic syncope Late desquamation Diffuse macular erythema
Dity: probability of live birthper menstrual cycle
Ability: ability to conceive; pregnancy probability per month of exposure
37-45y/o
What is the conception window and how often should sex take place to maximize fertilization
What needs to be avoided during fertilization window
When is a fertility work up warranted
5 days prior through day of ovulation;
qDay or QoD x 10days
Oil based lubricants
Failure after 12mon w/out contraception
>35y/o after 6mon w/out contraception
What are the 5 etiologies of infertility in sequence
Ovulatory Male factor Tubal/uterine Unexplained Other
What type of menstrual Hx suggests ovulation is occurring
Define Mittelschmerz
What four other Sxs may present with this sign
Menses q25-35d lasting 3-7d
Unilateral mid-cycle pelvic pain w/ ovulation
Luteal phase Sxs:
Tenderness Acne Craving Moods
How does body temperature reflect ovulation
At home ovulation kits are testing for ?
? is a more direct/earlier predictor of ovulation than basal body temps
04-0.8* increase x 2 consecutive days d/t post-ovulatory progesterone
LH surge
Mid-Luteal serum progesterone- correlates to ovulation and corpus luteum
What labs are drawn for anovulation work up in Pts w/ Hx of irregular cycles
What is the miscarriage risk in women >40y/o
What 4 populations should fertility testing be conducted
Prolactin Testosterone DHEA-S TSH FSH
50-75%
35/> after 6mon of trying/just starting
<35y/o after 12mon of trying
Dec ovarian reserve risk
Considering egg freezing
? is used as initial Tx for anovulatory, infertile women
What is the MOA
When is this considered a failure
Clomiphene citrate- SERM and day 3-5 of cycle
Inc FSH levels to inc ovarian follicle activity
Max dose 100mg x 6mon- refer
Other then Clomid, what three classes of drugs are used for infertility Tx
Top three most effective contraceptions
What are the 3 leading causes of infant death
Metformin- dec insulin resistance, inc ovulation
Aromatase inhibitors
Gonadotropins
Implant, IUD, Sterilization
Congenital malformation
Low weight
SIDS
All women of reproductive age should be taking ? nutritional supplement and when should amount be increased
All women above and below ? BMI level should be counseled about risks of infertility/pregnancy
? Dx is 6x more likely for offspring if father is >40y/o at contraception
Folic acid- dec neural tube defects BMI >35 DMT1 Med/FamHx NTD Valproate/Carbamazepine
30kg or higher, <18.5kg
Autism
What are the failure rates of Tier 1-4 contraception
What are the criteria to be reasonably certain a woman is not pregnant
When are CoCs and Depo avoided as contraception
1: <1%
2: <10%
3: >10%
4: spermicide, sponge
7d or less after start of menses/abortion
No intercourse since start of last menses
Consistent, correct contraception use
<28d post-partum
Breast feeding 85% or more of the time
Uncontrolled HTN >160/100
What contraception considerations are taken for Pts w/ MedHx of migraines w/ or w/out aura
What contraception considerations are taken for Pts w/ diabetes
What contraception considerations are taken for Pts w/ SLE
No aura: CoCs w/ caution
W/ aura, any age: no CoCs, Depo ok
End organ dz/Vascular dz/>20yrs w/ DM: no CoC/Depo
Neg Ab syndrome: CoC use safe
Pos/Unknown Ab syndrome- avoid hormones
Depo needs to be use w/ caution or avoided in Pts w/ ? Dx
? contraception consideration is taken for Pts w/ breast Ca of Hx of DVT/embolisms
Pts breast feeding or Hx of DVT/emboli need to avoid ? methods
Osteoporosis, RA
Avoid hormones
CoCs
Copper IUDs are good for ? long
Mirenea/Kyleena are good for ? long
Liletta/Skyla are good for ? long
Generally, their MOA is ?
10yrs
5yrs
3yrs
Prevent fertilization
MOA of Copper IUD
Copper IUDs have no effect on ?
What are adverse effects of using this method
Local inflammatory response
Dec sperm/egg viability
Blastycyst inflammation reaction
Inhibit ovulation
Menstrual changes for first 3mon, Tx w/ NSAIDs
Immediate fertility return w/ d/c
MOA of Levonorgestrel IUDs
What will Pts commonly report as adverse effects of this method
What benefit can this offer to a certain population
Progestin atrophies endometrium, prevents implantation
Dec sperm mobility
Inconsistent ovulation suppression
Irregular bleeding x 6mon
Amenorrhea x after 2yrs
Improves dysmehorrhea
IUDs lost is most common during ? and is higher if ?
? is the next step if provider can’t see strings
What are the risks if pregnancy/miscarriage does occur
MC in first month;
Post partum or <25y/o
R/o pregnancy, cytology brush twirl, then US
More likely ectopic;
2nd trimester miscarriage- higher infection risk
Nexplanon may be the preferred contraceptive option for ? two populations
How much/often are Depo injections
What are the two benefits does Depo offer
Post-partum/abortion
Lactating mothers
Medroxyprogesterone- 150mg IM (shoulder/glut) q3mon
Improves menorrhagia, dysmenorrhea, endometrial pain
Dec risk for endometrial hyperplasia/Ca
What are the 4 relative c/i for Depo use
What is the only absolute c/i for Depo use
What are the adverse effects of Depo use especially in ? population
Recent breast Ca
Progestin pos Ca
Prior ectopic
Pregnant
Current breast Ca
Bleeding Bone loss HTN Anovulation Weight Functional cyst
Severe HTN- risk of stroke
What are the two absolute c/is for mini-pill use
Combined Hormone Contraceptives include ? forms
What is their MOA
Breast Ca, Pregnant
CoC- pills
Patches
Transvaginal rings
Suppress hypothalmic gonadotropic release to block LH/FSH from pituitary and inhibit ovulation
P: dec motility/implantation
E: cycle control, dec break through bleeds
Why do CHCs have <35mcg of estrogen and modified progestin
What are the pros/cons of 3rd Generation Progestins
What are the pros/cons of 4th Generation Progestins
E: Less risk for thromboembolism
P: Dec androgenic effects
Dec androgen/lipid profile effect
Inc risk of venous thrombosis
PMS Sxs- breast tenderness/bloat
HyperKa risk
? is the most popular reversible contraception method in US
What benefits do these most popular have
What risk do they carry
Oral CHC pills
Dec Ca risk w/out inc risk for breast Ca
Improve cycle irregularities
Dec PMDD Sxs
Blood clots
What are the 3 methods of initiating oral CHC pills
When are the embolism risks of CHCs the highest
What are the top 3 s/e reported when d/c oral contraceptives
First day: start on cycle day one w/out back up
Sunday: begin first Sunday after menses starts, no weekend withdrawal bleeding; back up x7d
Quick: start on day Rx is filled, back up x 7d
Inc 5x during pregnancy/post partum
Weight gain Irregular bleeding Nausea
Directions for use of Transdermal CHC
What risk do Transdermal CHCs have
What can cause this form to fail
Weekly application to arm, abdomen, torso (not breast)
1 patch x 3wks, one wk patch free w/ bleeding
Higher VTE risk than COCs
90kg or bigger
How is back up protection used when using transdermal CHCs
Directions for Transvaginal Rings
When is back up needed
Delayed in first week- reapply, back up x7d
Delayed in 2/3 week- <2d, no back up; >2d, back up x 7d
Detached <24hrs: replace same patch, no back up
Detached >24hrs: new patch on new day, back up x 7days
3wks in, 1wk out w/ refrigeration required
Day 1 start- no back up
Day 2-5 start- back up x7days
Falls out and replaced <3hrs- no back up
Falls out and replaced >3hrs- back up x 7d
? is the only requirement prior to starting CHCs
How are diaphragms used for contraception
? form of contraception has a higher failure rate than diaphragms
What risk do spermicides carry
Document BP
Insert 6hrs prior, left in place x 6hrs
Cervical caps
Inc risk for HIV/STI transmission
What are the three fertility awareness methods
Standard Day: avoid sex on day 8-19 of cycle; only effective if cycles q26-32 days
Cervical mucus:
Billings Method: no intercourse from menses-4d after slippery mucus identified
Two day Method: sex is safe if no mucus is noted on day of/prior to intercourse
Symptothermal: mucus and body temp measured; requires 12-17d of abstinence/month
Plan B emergency contraception needs to be taken within ? hrs
How long after vasectomy until father is “safe”
How long after miscarriage/abortion for ovulation to return
Medical options for early termination of pregnancy in non-surgical Pts
Progestin only/COC: <72hrs
Progestin receptor modulator/antagonist: <120hrs (most efficient oral regimen)
Copper IUD inserted <120hrs (most effective)
3 months/20 orgasms
2wks
Mifepristone, Methotrexate- day one
Misoprostol- day three
When are Leopolds maneuvers started
What are the four parts of the assessment
When is the fetus considered to be ‘engaged’ in labor
Can begin at 28wks,
Typically at 35-36wks
1st: What part occupies the fundus
2nd: What side is the back on
3rd: What is the presenting part
4th: Is it brow or occiput
Biparietal diameter (greatest transverse diameter in occiput presentation) passes through pelvic inlet
What are the 3 types of breech presentation
What pelvic diameters are suggested prior to attempting vaginal delivery
If fetus is found to be breech, ? maneuver can be attempted and w/ ? potential adverse outcomes
Frank: hip flexion, knee extension
Complete: hip flexion, knee flexed
Incomplete breech: one of both hips unflexed
AP 10.5cm or >
Inlet transverse 12cm or >
Midpelvic interspinous 10cm or >
External cephalic version, 36-37wks;
39wks w/ epidural; failure= C-section
ROM Abruption Delivery
What are the 4 phases of labor
What happens during each phase
The Three Stages of Labor occur during ? phase of labor
1: Quiescence, preludes parturition
2: Activation, preparation for labor
3: Stimulation, process of labor
4: Involution, parturient recovery
1: cervical softening
2: cervical ripening, uterus prepares for labor
3: contraction, dilation, expulsion
4: involution, repair, breast feeding
Phase 3- stimulation
Phase 1 of Labor
Phase 2 of Labor
Phase 3 of Labor
Phase 4 of Labor
Prelude to Parturition:
Changes at 36-38wks:
Myometrial relaxation, cervical softening
Preparation for Parturition:
Uterus activation/Cervical ripening/Isthmus formation
Head descends to pelvic inlet (baby dropped)
Parturition; Active Labor:
Stage 1: Effacement, Dilation
Stage 2: Descent
Stage 3: Placenta delivery
Recovery from Parturition/Puerperium:
Uterine involution/contractions
Lactogenesis
What is the sequence of labor onset
How does the timing between contractions help identify the stage of labor
Contractions normally last ? long and are every ? time
What are the hypotheses of why there pain associated w/ labor contractions
Prodromal/False to Latent to Active
Latent- 10min apart
Active: 3-5min apart
Avg: 60 sec long, 5/< in 10min averaged over 30min
Myometrium hypoxia
Nerve ganglia contractions
Cervical/peritoneum stretching
Stage 1 of Labor
Stage 2 of Labor
Stage 3 of Labor
Clinical onset:
Latent- dilation, not admitted unless 3-4cm dilated/ROM
Active- >5cm dilated, 4-6hrs until delivery
Fetal Descent: complete dilation until delivery
Placental delivery, usually <30min
>60min= problem
When are mothers at highest risk for developing post-partum hemorrhage
What are the names of the two labor curves
How much cervical dilation is expected for Pimips/Multips
What are the indications for administering oxytocin during labor
Most: first hour
Risk remains for 6hrs after delivery
Friedman and Zhang
Prim: 1.2cm/hr
Multi: 1.5cm/hr
No dilation at 1cm/hr in first stage or,
No descent for 1hr in second stage
What is assessed during a cervical check
Define Precipitous Labor and Delivery
What underlying Hx is seen w/ these types of deliveries
Dilation Effacement Station Position
Deliveries <3hrs
Cocaine abuse
Define Labor Dystocia
What are 4 potential components causing this issue
? is the MC cause of dystocia and subsequent c-section
Dysfunctional labor; too slow
Fetal abnormalities
Abnormal forces
Bony abnormalities
Soft tissue abnormalities
Cephalopelvic disproportion from malposition
What are the 4 P’s of Labor Dystocia causes
Average Latent Phase is ?hrs but factors affecting this time include ?
When is latent phase of labor considered to be prolonged
Power: 200 Montevideo units per IUPC x2hrs
Passage
Passenger
Pysche- only applies to 2nd stage
6-8hrs
Nulli/Primipara: >20hrs
Multipara: >14hrs
What is protraction dystocia defined as
What is arrest defined as
What is the next step after inadequate cervical changes have occured x 2hrs and dystocia is suspected
Null: <1.2cm dilation, <1cm descent/hr
Multi: <1.5cm dilation, <2cm descent/hr
Dilatation: 2hrs w/out cervical changes
Descent: 1hr w/out fetal descent
AROM: amniotomy
Oxytocin augmentation if <200 MV units x10min
No/little change- place intrauterine monitor
What is the best method to document fetal maturity
Define Montevideo unit
Cervical ripening uses ? scoring system
First trimester US
Sum of contraction amplitudes in 10min period; 200 is enough for labor
Bishop;
4 or less: unfavorable, indication for ripening
9- high likelihood for successful induction
Define Labor Induction
Define Labor Augmentation
When can weekly membrane stripping be started for induction
Stimulation of contraction before spontaneous onset; includes ripening
Enhanced spontaneous contractions that are inadequate d/t failed dilation/descent
37wks
What prostaglandins can be used for cervical ripening
Ripening agents are only useful if ?
? is the only FDA approved drug for induction/augmentation
E1: Misoprostol
E2: Cervidil and Prepidil
Active labor is NOT underway
Oxytocin- normally released from posterior pituitary d/t response of canal distention/mammary stimulation
Two precautions taken when performing amniotomy
Three indications for maternal induction
Two indications for maternal augmentation
Keep hand placed to r/o umbilical prolapse
No walking x 30min after to ensure head engagement
Pre-eclampsia DM Heart dz
Abnormal labor
Prolonged latent/active phase
? medication is the initial med used for un/favorable Bishop scores
NSAID MOA
ASA MOA
Un: Prostaglandins- initiate labor, maintain ductus
Fav: oxytocin
Inhibit phospholipase A2 converting ethanolamine into arachidonic acid
Inhibit arachidonic acid conversion to prostaglandins via cycloxygenase
Oxytocin can hyperstimulate the uterus which is defined as ?
This is also the first line drug for ?
When using Oxytocin and inc D-cels are noted, what are the next steps
Tachysystole: >5 contractions per 10min
Contractions w/in 1min of each other
Contraction lasting >2min
Post-partum hemorrhage
D/c med Put mother on left side Cervical exam r/o cord entrapment O2 Terbutaline- B-agonist tocolytic
Fetal HR is considered brady/tachy when
Define Minimal, Moderate and Marked variability
Definitions of Accelerations for <32 and >32wks EGA
Brady: <110, Tachy: >160
Min: 5 or less
Mod: 6-25bpm
Mark: >26 or more bpm
32wks: 15/15, <32wks: 10/10
>2min but <10min
10min or longer= baseline reset
Why are Fetal Scalp Electrodes and Intrauterine Pressure Catheters used and what requirement is needed prior to sue
What is the Tocodynamometer used for
? external fetal monitoring value is most reliable indicator of fetal well being
Must have ROM for use:
FSE: fetal HR based on R-R interval
IUPC: timing, duration and strength of contraction
Timing/duration of contraction via external monitors (no contraction strength measurement)
Variability, norm: 6-25bpm
Define VEAL CHOP
Which ones require intervention
? is the most frequent abnormal pattern seen w/ fetal monitoring and what is a severe classification of this MC
Variable decel: cord compression
Early decel: head compression
Accel: okay
Late decel: placental insufficiency
Variable, Late
Variable decels;
60 FHR decel x 60 sec
Absent/Minimal fetal variability can indicate ? issues are present
? lab result is reassuring after a fetal scalp blood sample is taken for HR tracing
How are non-reassuring FHR patterns managed
Acidosis, Hypoxemia
pH >7.25
D/c augmentation meds Put mother on L-side/all fours Cervical exam r/o cord entrapment O2, Fluids Elevate presenting part/Trendelenburg if pushing
Non-pharm pain management is most effective if used when
How long does Fentanyl, Morphine or Demerol last
What three sedatives can be used but only for ?
First stage
F: 20-60min
M: 1-2hrs
D: 4-6hrs
False labor;
Promethazine Hydroxyzine Zolpidem
Uterus is innervated by ? nerves
? is the procedure of choice for regional analgesia but w/ ? adverse reactions
What are two other forms of regional analgesia used
What is the risk of general anesthesia
T10-L1: body
S2-4: canal/cervix
Lumbar epidural: Bupivicaine w/ Fentanyl adjacent to canal; Prolonged 2nd stage, fever HA
Spinal: anesthesia into canal, causes HAs
Pudendal: only relieves perineal pain for 2nd stage
Uterine atony
What are the seven cardinal movements of labor
Every Darn Fool In Egypt EatsRaw Eggs
Engagement
Descent
Flexion- descending head meets resistance
Internal rotation- occiput moves to pubic symphisis
Extension- therwise posterior perineum would be impinged; uterine contraction exerts Posterior then Anterior force
External rotation (restitution)- occiput rotates to left ischial tuberosity (right to right)
Expulsion
Define Caput Succedaneum
Define Cephalohematoma
Define Subgaleal hemorrhage
Boggy head that crosses sutures
Boggy head that doesn’t cross sutures, associated w/ jaundice
Crosses sutures w/ jaundice/blood loss possibly requiring compression
Four indications for vaginal operative delivery w/ forcep/vacuum and w/ ? end benefit
Vacuum delivery systems attach to ? part of head
Normally how long for placental separation to occur
Prolonged 2nd stage
Breech- forcep only
Suspicion for fetal demise
Shortens 2nd stage for maternal benefit
Flexion point- 3cm anteriorly from posterior fontanelle, 6cm posterior from anterior fontanel
4-12min, longer in pre-terms
How is Chorioamnionitis Dx
How is this managed
? is a potential warning sign of fetal asphyxia
Fever >100.4 and two of: Foul/culture pos amniotic fluid Leukocytosis >15K Abdomen/fundal tenderness Tachycardia (maternal >100, fetal >160)
Induction (not C-section)
Broad spectrum ABX
Monitor postpartum for atony/hemorrhage
Meconium- vasovagal process secondary to contraction
4 RFs for shoulder dystocia
Should Dystocia management in order mnemonic
Which step has the highest individual success rate
5- remove posterior shoulder
Macrosomia Obesity DM Prior dystocia
HELPERR Help Evaluate for episiotomy Legs hyperflexed (McRoberts maneuver) Pressure, suprapubic Enter vagina for rotation (Rubin Reverse/Wood's Screw) Remove posterior arm Roll Pt onto all 4s (Gaskin maneuver)
Define Zavanelli Maneuver during shoulder dystocia
? is used only when surgical capabilities are not available
Two steps for managing cord prolapses
Replacing birthed head back into canal in anticipation for c-section
Symphysiotomy
Tocolytics, Stat C-section
What is the MCC of non-OB fetal demise
Mothers are observed for ? long after minor trauma to r/o abruptions and can only be d/c if ? criteria are met
? is the MCC of Abruptio Placentae and what is a common complication after this occurs
MVAs
4hrs; Contracting less than once q10min No vaginal bleeds No abdominal pain/tenderness Fetal HR reassuring No visible bruising
HTN; DIC
How does Abruptio Placentae present
What happens if blastocytes implant too low in uterine wall and how would it present if not caught on US
Intact coag system is not necessary to post-partum hemostasis unless ?
Vaginal bleeding w/ contractions
Uterine tenderness
Non-reassuring fetal HRs
Placenta previa- avoid vaginal deliveries:
Painless vaginal bleeding
Laceration of Perineum Uterus Birth canal
Criteria for post-partum hemorrhage
What are the 4 etiologies
How is blood loss estimated
Vaginal: >500mL C-section: >1L or S/Sxs of hypovolemia <24hrs of delivery
Atony Tissue Trauma Thrombin
500mL loss for every 3% HCT drop
Post-partum hemorrhage is clinically worse if occurring at ? time frame and d/t ?
What uterotonic agents can be used
How long are these used for before moving to surgical interventions
1-2wks post-partum d/t abnormal involution of placental site
Oxytocin- first line
Methergine- first line/IM only; not for HTN/Pre-Ecl
Carboprost- not for asthma, Card/Renal/Liver dz, seizure
Misoprostol- used for asthmatics, HTN
30min
Name of balloon used for tampony and ? type of fluid is used during resuscitation
Rapid blood infusion is done if Hct drops below ?
How is maternal shock monitored for
Bakri; Crystalloids
<25%
Urine output >30mL/hr
Preferred >50mL/hr
? is the “classic” hemorrhage disaster
Define Sheehan Syndrome
How does this syndrome present
Uterine inversion
Pituitary failure after hemorrhage induced ischemia/necrosis
Failed lactation Amenorrhea Breast atrophy Loss of secondary hair Adrenal cortex insufficiency
Start episiotomy in ? location using ? tool
What are the 4 degrees of tears that occur during birth
What gestation factors/risks increases w/ age and what three factors place Pts more susceptible for this risk
Midline w/ scissors
1st: skin
2nd: skin, SQ
3rd: skin, SQ, sphincter
4th: skin SQ sphincter and rectal mucosa
Twins, parity;
Mother’s FamHx, Nutrition, FSH
Define Superfetation
Define Superfecundation
What happens during TTT
Second conception in already pregnant woman;
Two embryos of different ages in same uterus
Fertilization of two ova in same menstrual cycle but not same coitus/male
Donor twin- anemic, growth restriction, oligohydramnios
Recipient twin- polycythemic, overloaded, hydrops, polyhydramnios
Define Threatened Abortion
Define Incomplete Abortion
Define Complete Abortion
Define Missed Abortion
Define Inevitable Abortion
Define Recurrent Abortion
Bleeding w/ closed os during first 20wks
Tissue remains in uterus
All products have been expelled
Non-viable products retained in uterus
PROM w/ open cervix and bleeding
Three or more losses <20wks or fetus <500g
80% or more of early pregnancy losses occur prior to ? mile marker
How are Spontaneous Abortions managed if TV-US is unclear
Majority of ectopic pregnancies occur in what two locations
12wks
Serial hCG-
Inc w/out intrauterine pregnancy= ectopic
Dec w/out intrauterine pregnancy= complete abortion
Ampulla then Isthmic
What are the Triad Sxs of Ectopic pregnancy
What will be seen on PE
What time frame is an intrauterine sac, yolk sac and fetal pole detectable on US
Spotting/bleeding Amenorrhea Pain
PooP
Blood in Pouch of Douglas= posterior fornix bulge
Tender mass palpated next to uterus
Gestational sac: 4-5wks (1500hCG)
Yolk sac: 5-6wks (5200 hCG)
Fetal pole: 5.5-6wks (17500 hCG)
After Dx of unruptured extra-uterine pregnancy is made, what is the next step
Define Heterotopic Pregnancy
How are ectopic pregnancies medically managed and in ? populations
Laparotomy
IUP and ectopic pregnancy at same time
Methotrexate- targets rapidly proliferating tissue;
ASx Motivated Compliant
What are the three predictors of a good outcome of medical Tx of ectopic pregnancy w/ Methotrexate
What are 3 adverse effects of use
What is the difference between a Salpingostomy and Salpingectomy
Low hCG
Small pregnancy
No fetal cardiac activity
Marrow Mucosa Respiratory affected
Excreted in breast milk
Hepatotoxic
- ostomy: removal of unruptured pregnancy
- ectomy: removal of tube and pregnancy
Define Gestational Trophoblastic Dz and the two groups
? three populations are these higher in
What are the two RFs for development
Tumors of abnormal trophoblast proliferation;
Hydatidiform: +villi
Non-molar trophoblastic malignant neoplasm: -villi
Asian Hispanic American indian
Extreme age (>40= 10x risk) Prior hydatidiform mole
Define Complete Molar Pregnancy
What will hCG levels be at and w/ association to ?
What will Pt present w/ as c/c
Empty ovum w/ no maternal chromosomes, 46XX
> 100K, Theca Lutein cysts
1st trimester bleeding
Hyperemesis gravidum
Pre-Eclampsia
Define Partial Molar Pregnancy
What Pt education goes w/ Dx
Gestational Trophoblastic Neoplasias almost always develop after ?
Fertilized ovum by two sperm= 69XXX/XXY
Nonviable embryo present
Lower risk for subsequent trophoblastic neoplasias
Pregnancy: Hydatidiform > miscarriage
What are the four groups of Gestational Trophoblastic Neoplasias
Placental site trophoblastic tumor: chemo resistant
Invasive: MC after hydatidiform mole, less metastatic
Epitheloid: low hCG, chemo resistant and commonly mets
Choriocarcinoma: MC after SAB/term pregnancy; can mets and associated w/ ovarian theca lutein cysts
What is the MC presentation of Gestational Trophoblastic Neoplasia
? Dx/finding is pathognomonic for a molar pregnancy
How are Hydatidiform Moles Tx
How are Gestational Trophoblastic Neoplasia Tx
Irregular bleeding w/ uterine subinvolution
Pre-E/E developing <20wks w/out MedHx chronic HTN
Dnc
Serial hCG q1-2wks until undetectable
Then monthly surveillance x 6mon
Chemo alone, pregnancy avoidance x 12mon
Hysterectomy if chemo resistant
What f/u step is taken for pregnancies that follow Hydatidiform/GTN Tx
? affect do hydatidiform moles have on fertility
? is the MC fetal hematologic abnormality and three other causes
Serum hCG checked at 6wk PP f/u
None
MC: RBC alloimmunization
Parvovirus B19
Fetomaternal hemorrhage
a-Thalassemia
How fetal anemia abnormalities be detected on US
How does Rh-D alloimmunization occur
? fetal heart rate pattern suggest possible fetomaternal hemorrhage and needs ? further eval
Middle cerebral artery peak systolic velocity
Rh-D neg mother develops anti-D Abs from Rh-D pos fetus
Sinusoidal pattern;
Kleihauer Betke test: quant test for fetal RBCs in maternal circulation
Fetal transfusion is needed at ? Hct %
Hydrops has developed if Hct is under ? %
? is the target Hct for nonhydropic fetus
<30%
<15%
40-50%
? is the MCC of severe thrombocytopenia among term newborns
How will this MCC present in neonates
How is it Tx
Alloimmune thrombocytopenia: maternal alloimmunization to fetal platelet Ags, Abs cross placenta
Unexpected thrombocytopenia, petechiae or intracranial hemorrhage
IVIG steroids and C-section at/near term
What happens in RBC alloimmunization
What happens in Fetal Thrombocytopenia
Define Immune Thrombocytopenia and when is Tx indicated
Maternal ABs cross placenta to destroy fetal RBCs
Maternal antiplatelet Abs cross placenta into fetus
Maternal autoimmune d/o causing fetal thrombocytopenia but w/out hemorrhage risk at delivery
Maternal platelets <30K w/ CCS or IVIG
No response= splenectomy
What else will be present in cases of Hydrops Fetalis
What are the etiologies of this condition
How are Hydrops Fetalis evaluated
Placenta megaly, Polyhydramnios
RBC alloimmunization- immune
Aneuploidy (MC),
Infection (MC w/ P-B19),
Abnormalities >90% of cases: non-immune
Sonograph
Amniocentesis
Kleihauer Betke test if anemia suspected
Indirect Coombs for alloimmunization
Tachy is considered any rate higher than ? and brady is anything below ?
MC Arrhythmia seen in fetus’
What is the risk in sustained tachy dysrhythmias
What can be administerred for convert fetal rhythms
> 180bpm, <110bpm
Premature Atrial Contractions; benign and resolve w/ time
Hydrops d/t impaired ventricular filling
Digoxin Sotalol Flecainide Procainamide
? is the MCC of fetal bradycardia
Maternal use of ? med can be used to Tx fetal bradycardia
What are the three levels of severity of Polyhydramnios
Congenital heart block
Terbutaline if fetal HR <55bpm
Mild: 25-29.9
Mod: 30-34.9
Severe: >35cm
What four infections can lead to Polyhydramnios
How is Oligohydramnios Dx
Maternal use of ? drugs can cause Oligohydramnios
? is the only factor that causes IUGR to Woman, Fetus and Placenta
Toxoplasmosis Parvovirus CMV Syphilis
AFI <5cm or, Deepest pocket <2cm
ACEI ARB NSAID
Infection
What are the three phases of fetal growth
What is the difference between A/Symmetric Growth Restriction and what measurement is used to differ
What other fetal abnormality may be seen w/ placental abnormalities
Phase 1, 1-16: hyperplasia at 5g/day
Phase 2, 17-32: hyperplasia/trophy at 15-20g/day
Phase 3, 33+, hypertrophy w/ the most fetal fat/glycogen accumulation
Head/Abdomen circumference:
Symmetric: dec cell size and number
Asymmetric: maternal HTN causing ‘brain-sparing’ development
Accelerated lung maturation- inc stress causes inc adrenal glucocorticoid secretions
IUGR can be suspected after ? PE finding
Define Macrosomia and what are the RFs for macrosomia
More than half of deliveries will occur as c-sections if baby weighs more than ?
Fundal growth lagging >3cm
> 90th percentile, >4500g or more at birth
DOPPLAR-M: DM Obesity Post-term gestation Previous macrosomic infant Large parents Adv age Racial factors Multi-parity
> 4000g
How are macrosomia Pts managed
Why does pregnancy induce mild hyperthyroidism
MC form of Hyper/Hypo-thyroidism
Non-DM: prophylactic labor induction
DM: C-section
Placental production of hCG and hCT;
hCG resembles TSH
Hyper: Graves; dec TSH, inc free T4 (thyroxine)
Tx: PTU 1st T; inhibits T4 to T3 w/ less placental crossing
Methimazole 2nd T
Hypo: Hashimotos; inc TSH, dec free T4 (thyroxine)
Tx: Levothyroxine
Both Hypo/Hyper-thyroidism have ? risks during pregnancy
What teratogenicitic risks do anti-epileptic meds have for pregnancy/lactation
How are these Pts managed
Both: pre-eclampsia, prematurity
Pregnant: neural tube defects
Lactation safe
Lowest dose of Rx monotherapy w/ folic acid and Vit K
Seizing Pt w/ no MedHx of seizures needs ? Dx considered and Tx w/ ?
? liver enzyme increases w/ pregnancy
Define HELLP Syndrome
Eclampsia; Mg sulfate
Alkaline phosphate
Severe Pre-E w/ hepatocellular damage:
Hemolysis Elevated Liver enzyme, Low Platelets
Intrahepatic Cholestasis in pregnancy can have ? onset and w/ ? risks to fetus
What will Pts present with and what will be seen on lab results
How is it Tx
Late/multi-fetal pregnancy;
Demise Preterm Resp-distress
Pruritus, Jaundice
Inc bile acids, bili, AlkPhos
Antihistamine and topical emolients
Ursodeoxycholic acid- dec pruritus and bile acid
Acute Fatty Liver of Pregnancy is associated w/ ? conditions
What will be seen on lab results
What is Tx
Late pregnancy w/ pre-e or twin gestation
Inc- Ammonia Bili Uric acid Transaminase
Dec- Coags Glucose
Delivery, maternal support
Half of pregnancy associated suicides are related to ? and w/ ? RF
Define PUPPP
How does this present
How is it Tx
Partner violence; previous psych admissions
Pruritic Urticarial Papule Plaque of Pregnancy;
AKA Polymorphic Eruption of Pregnancy
Urticarial plaques w/in striae on abdomen/upper thighs, sparing peri-umbilicus
PO Antihistamines Emollients Topical CCS
Define Pemphigoid Gestationis
What complications can arise from this condition
What CV complications indicate need for C-section delivery
Papule, Plaques and Vesicles on abdomen/extremities w/ umbilical involvement
Pre-term birth, Growth restrictions, Transient natal lesions
Dilated aortic root >4cm/aneurysm Recent MI Acute CHF Warfarin in past 14d Emergency valve replacement after surgery Severe aortic stenosis w/ Sxs
When does ACOG recommend HTN medication use
What is a worse form of HTN
HELLP Syndrome is a more severe form of ? Dx and how is it monitored for
How is it Tx
Nothing for BP <160/105
Chronic HTN w/ superimposed proteinuria (>300mg/day) prior to 20wks
Pre-eclampsia;
LDH and maternal platelet count
Mg Sulfate, Antihypertensives
Criteria for Gestational HTN
Criteria for Pre-Eclampsia
What four etiologies can cause this
New onset HTN >140/90 after 20wks EGA w/out proteinuria and resolves <12wks PP
HTN w/ proteinuria (or protein/Cr ratio >0.3) or end organ damage after 20wks; MC seen after 34weeks
Trophoblastic invasion into uterine vessels
Immune/Maternal intolerance
Genetics
How is severe pre-eclampsia managed in order
What is definitive Tx
Pre-term labor/birth is anything in ? range
1st: seizure prophylaxis w/ Mg Sulfate/Diazepam
BP: hydralazine, labetalol
CCS for pulm maturity if <34wks
Deliver regardless of EGA, vaginal preferred
20-37wks
How/why do infections induce preterm labor/birth
A decreased level in ? hormone can increase preterm labor risk
What PE finding is reassuring for determining true/false labor
Inc phospholipase A activity
Dec cervical length/changes
Progesterone
No cervical changes x2hrs
What test has a high negative predictive value for preterm labor Dx
How does the cervical length correlate to risk for pre-term labor
Why is hydration so important during pregnancy
Fetal Fibronectin (Trophoblast glue)- basement membrane protein produced by fetal membranes
> 30mm: very low risk
20-30mm: check FFN
<20mm: significant risk
ADH looks like oxytocin to uterus
Steroids can be used in pre-term labor for lung immaturity between ? weeks and what is used
What tocolytics can be used depending on the gestational age
Why is Mg Sulfate also used between 24-32wks
23-34wks, repeat at 34wks if first dose 7d or > ago
Betamethasone 12mg IM x 2
Dexamethasone 6mg IM x 4
48hr delay:
23-32wks: Indomethacin
32-34wks: Nifedipine (1st) Terbutaline (2nd)
Prevent cerebral palsy
When using Mg Sulfate for preterm labor management, serum levels must be kept below ? to prevent ?
What is the antidote if too much is given
Mg Sulfate needs to be totally avoided in ? population
Dont use for longer than ? days to prevent ?
<10mg, dec DTRs signal early sign of resp distress
Ca gluconate, 10mL
Myasthenia gravis
<7days; dec fetal Ca levels
What s/e can indomethacin use as preterm labor tocolytic cause
Fetal s/e of CCB usage
In most mammals, ? triggers onset of labor
Oligohydraminos
Dec uterine/umbilical blood flow
Progesterone withdrawal
? is the only FDA approved drug for preventing recurrent pre-term births
What two populations is this med used in
How does Cervical Insufficiency present
When is a cerclage considered
17 OHP-C (17-a hydroxyprogesterone caproate; synthetic progesterone
Prior preterm birth
No prior preterm but US proven short cervix
Painless 2nd trimester dilation
Single pregnancy
Prior pre-term birth <34wks
Cervical length <25mm and
Gestational age <24wks
How often is cervical insufficiency assessed w/ US and what are indications for cerclage placement
Define PROM
Define PPROM
Membrane rupture before 24wks carries ? risk to fetus
q2wks; <15mm or <25mm at 24wks
Rupture before onset of labor; single most identifiable factor of preterm delivery
Preterm Premature Rupture of Membranes- rupture <37wks
Lung hypoplasia
BV infections are linked w/ ? adverse outcomes
? is the most reliable indicator for membrane rupture
How is this Dx confirmed
Preterm labor
PPROM
Chorioamnionitis
Spontaneous abortion
Pooling/Expulsion
Pt valsalvas w/ sterile speculum exam; +fluid= Dx
Define Ferning Test w/ labor
Define Nitrazine test
Define Post-Term Pregnancy and what genetic issue can cause this
Vaginal fluid placed on slide and air dries; amniotic fluid crystalizes
Paper turns blue w/ alkaline fluid (pH >6.5)
Gestation of 42wks or more;
X-linked placental sulfatase deficiency
What skin changes are seen w/ Post-Term Pregnancies
How are these Pts managed at 41wks
How are these Pts managed at 42wks
Loss of protective vernix caseosa
Prostaglandin E w/ membrane stripping
Labor induction
Defect of ? nutrient causes neural tube defects and when should it be consumed
Hyperthermia can cause ? defect
Hyperglycemia can cause ? defect
Valproic acid can cause ? defect
Folic Acid;
Pre-conception through first trimester
Anencephaly- frog eye sign
Cranial, Cervical, Thoracic defects
Lumbosacral
Neural tube defects are screened for in first and second trimesters by looking for ?
The marker screened for in 2nd Trimester is made ?
What will be seen if defected levels are present
1st: nuchal translucency on US
2nd: Maternal Serum Alpha Feto-Protein at 16-18wks
Yolk sack,
GI tract/liver
Defected integument system= inc AFP in amniotic fluid;
Eval w/ sonography/US (DxTOC for NTDs)
? abnormality accounts for half of all fetal chromosomal anomalies
When is this screened for
How is CF inherited
Trisomy 21
All women presenting for prenatal care <20wks
1st trimester- nuchal skin US
2nd trimester- Triple/Quad screen
Autosomal recessive on CFTR number 7, encodes Cl channel protein
Define Tay Sachs
How are high/low risk populations tested for this
How does this present to clinic and how is it Dx
Autosomal recessive mutation causing progessive neurodegeneration/early death
High: DNA base mutation analysis
Low: hexosaminidase A serum level
Galactosemic infant’s unmetabolized milk builds and damages liver, eye, kidney, brain
Chorionic villus sample/Amniocentesis
Four indications to perform amniocentesis
What is used to separate samples if multiple gestational sacs
What two populations have increased risk of fetal loss d/t amniocentesis procedures
Congenital Fetal lung maturity Alloimmunization Genetics
Indigo carmine dye
Class 3 obesity, Twin pregnancies
Two indications to perform Chorionic Villus Sampling
What is the benefit of doing this tests
What are the adverse risks
Fetal karyotype
Genetic analysis
Earlier results than amniocentesis (done at 10-13wks vx 15-20wks)
Higher loss rate, especially fetus w/ inc nuchal translucency
Define Cordocentesis
MC indication to perform this test
What other benefit does this test have
How can the complications of this procedure be grouped together
Percutaneous Umbilical Blood Sample (PUBS):
Fetal blood sample taken via US guidance from vein
Fetal anemia assessment
Fetal karyotype 48hrs sooner than amniocentesis/CVS
More transitory
Using amenorrhea to Dx pregnancy is not reliable until ? long
Why is there bleeding associated w/ first month of pregnancy
? is the common early sign
x 10days or more after expected menses
Implantation
Fatigue
What is the role of hCG in early pregnancy
How quickly does it increase
What is the difference between the Qualitative and Quantitative tests
Prevents corpus luteum involution
Doubles q2.2 days
Peaks levels at day 60-70
Qual: urine test, detects + 8-9 days after ovulation
Quant: blood draw to follow doubling time
What are the three possible causes of False Positive pregnancy tests
TVUS can Dx pregnancy by identifying ? structures at ? weeks
End of pregnancy uterus is ? many times bigger than normal and holds average ? much fluid
Exogenous hCG/tumor
Renal failure
Sac: 4.5-5wks Pole: 6wks Heart: 6-7wks
500-1000x bigger w/ avg 5L
Uterus is too big to fit in pelvis by ? week and as it ascends it rotates ? direction
Placental perfusion requires uterine blood to perfuse ? area
Braxton hicks intensity measures ? much and these early contractions are d/t ? stimulation
13wks or >; Right
Placental intervillous space
5-25mmHg; Estradiol
What does the mucus plug contain to prevent infection and why is this mucus usually thick
How long does corpus luteum maintain progesterone levels
Define Theca Lutein Cysts
Immunoglobulins, Cytokines;
Progesterone
At least week 7
Exaggerated physiological follicle stimulation
Where is relaxin secreted from
What does it do
What does it NOT do
Corpus luteum Decidua Placenta
Remodels CT
Initiates renal vasculature augmentation
Dec serum osmolality
Inc arterial compliance
Peripheral joint laxity
Define Glands of Montgomery
Estrogen/Progesterone effect on breasts
Why is there an increase in striae
Hypertrophic sebaceous glands appearing as scattered elevations on areolae
E: adipose deposition, ductal growth, proliferation
P: alveola/ampulla hypertrophy, secretory
Inc cortisol d/t estrogen causing insulin resistance/striae
? female gland enlarges by 135% during pregnancy
When is the peak size seen
When does it return to normal size
Pituitary d/t prolactin levels
First few days
6mon post-partum
? naturally produced tocolytic is produced during pregnancy to relax uterus
How do ventral hernias form
What two skin changes can be seen other than striae
These skin changes can be causes by ? non-pregnancy factor
Progesterone
Diastasis recti d/t expansion
Linea nigra- dark pigments
Chloasma/Melasma- irregular patches on neck/face
OCPs
Why do pregnant Pts have increased incidences of angioma/telangiectasias and palmar erythema
What is considered average weight gain during pregnancy
Why do Pts retain water easier/more
Inc estrogen increases cutaneous blood flow
27.5lbs (12.5kgs)
Dec osmolality/colloid pressure
Inc venous pressure d/t partial vena cava occlusion
Protein metabolism increases by ? x during pregnancy
What is considered normal carbohydrate metabolism during pregnancy
When does maternal fat accumulation stop or decrease
1000g
Mild fasting hypo
Post prandial hyperglycemia and hyperinsulinemia
3rd trimester
When do leptin levels peak along w/ ? other food hormone
What inflammatory marker can be used as marker for bacterial inflammation after delivery
What type of EKG change will be seen during pregnancy and what sound will be heard
2nd trimester w/ ghrelin
Inc procalcitonin
LAD;
Exaggerated splitting of S1 w/ loud S1 and S2, possibly S3 w/ 90% of Pts having systolic murmurs;
10% will have continuous murmur d/t breast vasculature
What CV system constrictor helps regulate vasoconstriction and is seen at pathological levels in pre-eclampsia
? urine/blood ratio is a suspected pathogenesis behind pre-eclampsia
How is Morning Sickness Tx
Endothelin
PGI2 : thromboxane
Pyridoxine B6 w/ Doxylamine (unisom), Phenothiazine
What are the risks of using serotonin antagonists for Tx of N/V in pregnancy
Define Epulis Gravidarum
What is the MC form of Pica seen in pregnancy and what can cuase this to set in
Long Qtc >440
Pyogenic granuloma of gums, resolve w/ delivery
Amylophagia, starch;
Fe deficiency
What is first line medication Tx for GERD
What is safe for use in pregnancy for constipation and what needs to be avoided for Tx
When does round ligament pain set in
TUMS then endoscopy if no relief
Colace, Fiber, Bulk formers;
Stimulants- risk for megacolon
2nd trimester w/ R > L
Define Intrauterine Demise
Define Preterm labor
Define Macrosomia
Define Low birth weight
Define Extremely Low birth weight
Death >20wks
Labor prior to 37wks
Weight >4kg
- 5-2.5kg
- 5-0.99kg
Define IUGR
Define advance maternal age
Define Adolescent Pregnancy
Weight <10th percentile
35y/o or > at delivery
<20y/o at delivery
? obesity factor help contribute and lead to insulin resistance
What is the recommended weight gain for Pts depending on starting BMI
How is asthma managed during pregnancy
Adipokines
BMI 25-29.9: 15-25lbs
BMI 30/>: 11-20lbs
SABA and inhaled CCS
Steroid use >3wks, consider stress dose during L/D to prevent adrenal crisis
? is the leading cause of pregnancy related deaths and when is this risk the highest
What sign would be seen on PE and what two stratifies are not valid
How are PEs during pregnancy manged
PE; 1-3wks post-partum
+homans;
D-dimer and Wells criteria
LMWH- Lovenox
Avoid Coumadin
? is the leading cause of septic shock in pregnancy
When is DM screened for in pregnancy and how is this done
What is used medicinally for first line management and when is insulin indicated
Pyelonephritis
24-28wks w/ US at 20wks if +DM Dx
Step 1: 50g glucose challenge; 140/>, order Step 2
Step 2: 100g after over night fast;
Fasting: 95mg 1hr: 180mg 2hr: 155mg 3hr: 140mg
PO Sulfonylureas: Glyburide, Metformin;
Fasting glucose persistently >95
Definition of embryo timeline
Definition of Fetus time line
Fetal viability is defined as ?
Define Previable
Define Periviable Birth
Fertilization to 8wks; 10 wks gestational age
> 8wks until birth (>10wks gestational age)
20-24wks
Infant delivered <24wks
Delivery occurring between 20 +0 through 25 +6
Define Preterm
Define Term
Define Post-Term
Define Abortus
Delivery 24-37wks, <259 days
Delivery between 37-41 +6
Delivery at/> 42wks; 294 days or more
Fetus weighs <500g or <20 wks EGA
Define Placenta Previa
How does this present if unknown
What are the three types
Placenta develops in lower segment/zone of dilation
Painless 3rd trimester bleeding/8th month
Marginalis- placenta touches margin of os
Partialis- placenta covers part of os
Centralis- placenta covers entire os
Define Placenta Accreta
Define Placenta Increta
Define Placenta Percreta
Abnormal adherence of placenta to uterine wall w/ defected decidua basalis
Accreta w/ penetration into myometrium
Myometrium invasion and into surrounding structures
Define Velamentous Placenta
Define Vasa Previa
Define G_P_TPAL
Umbilical cord attached to adjoining membranes w/ vessels entering separately
Umbilical vessels between head and os; C-section 35-37wks
Gravids- number of pregnancies, twins/+ count as 1
Parity- number of births after 20wks w/ twins/+ count as 1
Term Preterm Abortus Live
Define Primigravida
Define Nullipara
Define Primipara
Define Grand Multipara
Currently in first pregnancy
No prior births prior to 20wks
One prior birth >20wks EGA
Five or more births after 20wks
Normal duration of pregnancy is called ? and is calculated as ?
How long is a pregnancy and starting from ? day
New OB appointments start at ? and then f/u how often as long as they’re uncomplicated
Gestational age; Menstrual age
1st day of LMP;
280 days/40wks divided into epochs
10-12wks;
1st/2nd Trimester: q4wks
28-36wks: q2wks
36wks+: q7d
? pelvic angle can be measured directly
Most favorable pelvic shape for delivery
Female mid-pelvis is measured at ? land mark and how do these land marks help w/ labor
OB conjugate: diagonal - 1.5-2cm= XX, Should be 10cm/>
Gynecoid > Anthropoid
Ischial spine;
Stations, ischial spine= 0 station
How is EDD determined by Naegele’s Rule
? is the most accurate method to predict gestational age
When do EDD need to be adjusted to US dates
1st day LMP
Subtract 3mon
Add 7 days
Adjust year forward
Crown Rump length during first trimester
<9wks EGA w/ >5d difference in days
>9wk - <14wks w/ >7d difference in days
What perinatal infections are mothers screened for
What type of virus is HIV and when are screenings done for this
How are HIV+ mothers managed
TORCH+:
Toxoplasmosis Other Rubella CMV HSV
RNA retrovirus
New OB, Repeat 3rd trimester for high risk
Antiretroviral therapy; viral load <1000 can do vaginal delivery; >1000= C-section w/ no breast feeding
Risk of Toxoplasmosis in pregnancy
How is this Tx depending on who is infected
What are late signs of congenital syphilis
1st trimester: low infective, severe sequelae
3rd trimester: high infective, less sequelae
Spiramycin- maternal infection only
Pyrimethamine-Sulfadizine w/ folinic acid for maternal and fetal infection
Hutchinson teeth
Saber shins
Saddle nose deformity
FTT/Deaf
How is syphillis Tx in pregnancy
What is the risk
? IgG titer is conducted on all pregnant Pts
Benzathine PCN G 2.4M units w/ 2nd dose 7d later
Jarisch- Herxheimer: Tx w/ antipyretic, O2, hydrate
Contraction Fever Dec movement/FHR decels
Rubella- RNA virus
Live virus= not during pregnancy, ok for breastfeeding
? is the MC congenital viral infection
How does it present in clinic
When is HSV prophylaxis started
CMV- DNA herpes virus
Mental retardation, delayed development, vision/hearing issues
Acyclovir at 36wks
How is varicella Tx after pregnancy w/ exposure
Why is there this risk
How is Hep B screened for and what maternal carrier has a higher transmission risk
Baby: VZIG w/in 96hrs and contact isolation
Mother: VZIG if w/in 6d of exposure
No vaccination during pregnancy
HBsAg;
+HbAg w/ risk for fetus to be chronic carrier
How is a new born of HBsAG mother w/ Hep B Tx
What risks do chlamydia and gonorrhea have for infants
How are these Tx during pregnancy
HBIG w/ vaccine <12hrs of birth w/ +breast feeding
C: conjunctivitis, pneumonia
G: conjunctivitis
C: Amox TID x 7d or Azith x 1dose
G: Ceftriax or Cefixime
Define Strep Agalactiee and this is the MCC of ?
How is this Tx during labor
How is Bacteriuria Tx
GBS- number one cause of neonatal sepsis
Recommended: PCN G
Alternate: Ampicillin
Allergy: Clinda, Vanc
Empirically w/ test of cure: Nitrofurantoin, Amox, Ampicillin
How is TB tested for if Pt received Bacille Calmette Guerin vaccine
How is TB Tx
How is Zika prevented during pregnancy
Interferon gamma release assay- TB Gold/Spot
Latent: INH w/ Pyridoxine x 9mon
Active: RIPE x 2mon, RI x 4mon
No travel, Condoms
? vaccine is recommended at any gestational age
When is MMR administered
How long into pregnancy can air travel be done and how much exercise is recommended
Influenza
Post-partum w/out breast feeding c/i
36wks; 150min/wk
Low mercury containing seafood/shellfish should be limited to ? amount
? sweetener needs to be avoided
Keep ASA ingestion below ? amount
Caffeine intake limit
Smoking causes dec birth weight by an average of ?
? is the leading cause of preventable developmental disabilities world wide
8-12oz/wk
6oz/wk of white tuna/albacore
Saccharin
<100mg
<200mg= no risk
200g less than non-smokers
Alcohol
? does Fetal Alcohol Syndrome appear
Limit x-ray exposure to ? amount
When are domestic violence screenings conducted
Micrognathia Flat midface Indistinct philtrum Thin upper lip Short palpebral fissure/nose
<5 rads
First prenatal
Once per trimester
Post-partum visit
Recommended time to screen for depression/behavioral health
4 known c/i for breast feeding
Criteria for elective delivery
Once during perinatal period
Lithium
Active TB
Chemical dependency
HIV
Initial hCG 36wks prior
FHTs documented x30wks
Dating US prior to 20wks GA
What is done at 10wks
What is done at 18wks
What is done at 18-20wks
What is done at 20wks
What is done at 24-28wks
What is done at 28wks
What is done at 36wks
FHT w/ doppler
Quickening (Primi- 18-20wks; Multi- 16-18wks)
Anatomy scan
Fundal height at umbilicus
GTT
Rhogam
GBS screening
Fetus is at risk from maternal stress until ?
How much weight gain is expected per trimester
How much of a calorie increase is needed
22wks
1st: 3-6lbs
After 20wks: 1 lb/wk
25-35lbs overall if normal BMI 18.5-24.9
300-400/day; 500/day during breast feeding
When is the lowest maternal BP expected at ? week and beware of BPs over ? level
How is edema defined in pregnancy
How long is a fetal sleep cycle
26wks; >140/90
> 1+ after 12hrs bed rest or
Gain of 5lbs in 1wk
20-75min, avg 23min
What is the Qualitative/Screening test of fetal-maternal hemorrhage
What is the quant test done
How much is a standard dose of Rhogam and how much coverage is given
Erythrocyte rosette screen- maternal serum mixed w/ IgM
Kleihauer Betke test- citric acid ghosts mom’s cells
300mcg- covers 30cc
Fetal Aneuploidy tests for ? MC
What is included in a Triple Screen during second trimester
What is included in a Quad Screening and better at IDing the MC w/ less false-pos rates
Downs Syndrome
13-16wks:
MSAFP Unconjugated estriol Total hCG
15-20wks: Inhibin A
US view of ? structure correlates to dec risk for Downs
What are the Quad Screening results seen in Trisomy 21
What are the Quad Screening results seen in Trisomy 18
Nasal bone
Dec MSAF/Estriol
Inc b-hCG/Inhibin
All four decreased
When are Amniocentesis/CVS offered to Pts
When is antenatal testing started
Amniotic fluid is similar to ?
> 35y/o at delivery
32y/o at delivery w/ twins
Pos previous pregnancy/serum markers
Known translocation abnormalities
Uncomp: 32-34wks
High risk: 26-28wks
Extracellular fluid
Fetal urine production begins at ? and is the main contributor by ?
Define Biophysical Profile and the BPP scoring system
Begins 8-11; Primary: 18wks
Done if demise is suspected/delivery would benefit:
Fetal breathing, movement, tone
NST accelerations
AFI
Modified: AFI w/ vibroacoustic NST x10min
10: Norm- rpt q7d unless DM/post-term then twice/wk 8: Normal AFI- repeat per protocol Dec AFI- asphyxia risk= delivery 6: Dec AFI- deliver Normal AFI and >36wks w/ favorable cervix- deliver Repeat test 6 or less: deliver 4: Repeat same day, 6/< is delivery 0-2: Almost certain asphyxia, deliver
When are BPPs done for diabetic mothers
Doppler of umbillical artery is especially useful in cases of ?
What are the four types of uterine growths and what three are estrogen dependent
Class A: 37-40wks: qWk 40+wks: 2x/wk Class B/worse: Twice weekly starting at 34wks Post-term: Start at 42wks and twice weekly
IUGR- quantified w/ Sys/Dias ratio
LAE: Leiomyomata Endometrial hyperplasia Aenomyosis Polyps
Structural causes of uterine bleeding
Non-structural causes of uterine bleeding
Polyp
Adenomyosis
Leiomyoma
Malignancy
Coagulopathy Ovulatory Endometrial Iatrogenic Not classified
? is the MC pelvic tumor in women
How is this MC distinctly ID’d in surgery
This MC often leads to ? sequelae
Leiomyomas- benign, smooth muscle tumor
Distinct autonomy from surrounding myometrium d/t CT layer
Hysterectomy
? type of Leiomyomas are associated w/ infertility
How are these viewed w/ imaging
How are they managed
Submucosal
US, not CT
MRI differentiates fibroid vs adenomyosis
COCs/Mirena- dec bleeding
Uterine artery ablation
Hysterectomy
Define Adenomyosis
How does it present to clinic
How are Adenomyosis Dx
How is it Tx
Endometrial glands and stroma in uterine muscle wall; Endometriosis in myometrium
Heavy, abnormal bleeding/dysmenorrhea in parous women 40-50y/o
US- hetergeonous w/ echotexture then MRI
Manage: Progestin IUD, GnRH agonists, COC, Danazol
Tx: Hysterectomy
Define Endometrial Polyp
Incidence peaks at ? age w/ ? MC Sx
How are they Tx
Hyperplastic over growth of endometrium on stalks
50y/o w/ metrorrhagia
Sx/Large= hysterscopic polypectomy
Define Endometrial Hyperplasia and what is the MC presentation
Why does this occur
How is this Dx
This condition is the only known direct precursor to ?
Endometrial overgrowth during proliferative phase;
AUB in post-menopausal women
Recurrent/Chronic annovulation (unopposed estrogen)
Endometrial biopsy (gold standard) then DnC
Post-Menopause: TVUS equivalent to first Dx step
Invasive Dz
What type of endometrial hyperplasia has the most/least malignancy potential
How is endometrial hyperplasia w/ atypia managed depending on Pts pregnancy wishes
How is endometrial hyperplasia w/out atypica Tx regardless of menopause status
Most: complex w/ nuclear atypia
Least: simple w/out nuclear atypia
Postmenopause: hysterectomy w/ BSO
Premenopause, done: hysterectomy w/ salpingectomy
Pre-menopause, wants: Progestins w/ endometrial biopsy q3mon
Low progestin/COC x 3-6mon w/ endometrial biopsy
What is the MC Gyn cancer in the USA and what is the MC presentation
What is the primary Tx for this MC
? syndrome has an increased risk for endometrial cancer
Endometrial; vaginal bleeding
Hysterectomy w/ BSO and node staging
Lynch Syndrome- hereditary non-polyposis colorectal cancer
Endometrial cancer presents as sentinel cancer, prophylactic hysterectomy at 40y/o
Post-menopausal women w/ TVUS endometrial stripe larger than ? need biopsy to eval for hyperplasia Ca
Elevation in ? tumor marker indicates a more advanced endometrial cancer process and need ? f/u radiological images ordered
Endometrial cancer will respond to ? hormone
5mm/>
Ca-125:
CXR, CT scan
Progestin- Tamoxifen upregulates progesterone receptor expression
What are the two types of functional ovarian masses
What are the two types of inflammatory ovarian masses
When is a follicle considered to be a functional cyst
Follicular, Lutein cysts
Neisserian salp/oo-itis
Pyogenic oophoritis
> 3cm in reproductive age woman, Dx on US
? type of functional cyst is more symptomatic
What is the MC benign ovarian neoplasm
What is the largest, benign ovarian neoplasm
Hemorrhagic
Serous cystadenoma (epithelial)
Mucinous cystadenoma (epithelial)
Stromal ovarian neoplasms are d/t ? and include ? three types
? is the MC ovarian neoplasm and what do they contain
What risk do these MC types carry
Estrogen/Androgen excess:
Granulosa Thecal: estrogen (resemble ovaries)
Sertoli Leydig- testosterone (resemble testis)
Fibroma- non-functional, non-hormonal
Germ cell- benign cystic teratoma w/ rapid growth;
Mature forms of all three germ cells: exto/meso/endo-derm
Ovarian torsion
? US finding is reassuring for ovarian masses
Ovarian tumor marker is only beneficial in ? population though
What causes the highest rates of ovarian torsions to occur
Unilocular
Post-menopausal only
Right sided adnexa (ovary and tube) 6-10cm
? are the four steroid hormones that can cause “maleness” and ? tissue do they affect
Define Hypertrichosis and the three types of hairs seen w/ this condition
Define Hirsutism caused by androgens
DHEA- adrenal
Androstenedione- adrenal, ovary
Testosterone- adrenal, ovary, adipose
Dihydrotestosterone- most potent; follicles, genital skin
Non-sexual hairs NOT d/t androgens:
Vellus Lanugo Variants
Terminal, thick hair in male patterns d/t androgens
Define Virilization caused by androgens
What three deficiencies are androgen related and can cause hyperandrogenemia
Define PCOS and what is required for a Dx
Male pattern baldness Acne Inc labido Deep voice Clitomegaly
21 hydroxylase- MC
11b hydroxylase
3b hydroxysteroid dehydrogenase
Inc androgen/estrogen levels;
Hyperandrogenism
Oligo/annovulation
Polycystic ovaries
What are the five MC clinical presentations of PCOS in order
Androgens circulate through body attached to ?
What causes the major transporter to increase
Hirsutism AUB Polycystic ovaries Infertility Obesity
Sex Hormone Binding Globulin > Albumin, only the 1-2% that are free are bioactive
SHBG-
Inc by estrogen
Dec by androgen/insulin
Define Ovarian Hyperthecosis
What three forms of virilization will be seen
What two PE/lab results will be seen
Nests of luteinized theca cells in ovarian stroma
Temporal balding
Clitomegaly
Deep voice
Greater insulin resistance, Acanthosis nigrans
Define HAIRAN Syndrome
What three criteria are needed to Dx Idiopathic Hirsutism
What is the believed pathogenesis behind this condition
Hyper Androgenic Insulin Resistant Acanthosis Nigricans
Normal serum androgen level
No menstrual irregulars
No identifiable cause
Milder form of PCOS w/ inc 5-a reductase activity
How is PCOS Anovulation Tx
How is PCOS Hirsutism Tx
When do Pts need to be f/u w/ and what can be added but w/ ? s/e
What medication can be used to slow hair growth but no permanently remove it
COCs or Progestin only
Clomiphene/Metformin if attempting pregnancy
COCs- inhibit LH secretion
6mon, add anti-adrogenic agent
Spironolactone: inc K levels, especially if w/ NSAID/ACEI
Flutamide: hepatotoxicity
Finasteride: male fetal teratogenicity
Eflornithine- inhibits enzyme needed for hair follicle growth
Difference between Depilation and Epilation
Average age of Dx for ovarian cancer is ? and claims ? dangerous fact
What is the MC type of ovarian cancer and when are these seen in ages
De: hair removal above skin
Epi: shaft and root removed from below skin
Early 60s, more deaths than any other Gyn malignancy
Epithelial- >50y/o
Germ cell- 15-29y/o
Stromal- any age
What are ovarian cancer protective factors
What genetic markers make Pts predisposed to ovarian cancer
These carriers have ? option to prevent cancer formation
Hysterectomy Diet w/ high fiber, low fat Breast feeding*** Long term OCP use w/ anovulation Tubal ligation
BRCA 1 and 2: tumor suppressor gene repair protein to preserve chromosomal structure
Prophylactic ovary removal at end of child bearing or 40y/o= 90% ovarian prevention, dec breast Ca risk
What are four common lab results seen in ovarian cancer screenings
? is the most useful initial and follow up test for imaging ovarian cancer
What imaging results suggest malignancy
Thrombocytosis
HypoNa
CA-125
Human epididymal protein 4 tumor marker
TVUS then CT
Muliloculated, solid, echo Papillary projection Neovascularization Thick septa Size >5cm
What makes ovarian cancer Pts have a better prognosis
What are the four types of benign cervical dz
Cervical os must be ? size for sufficient flow
BRCA mutations- more susceptible to chemo
Nabothian Polyp Cervicitis Stenosis
5mm, <2mm= retrograde flow
How is cervical stenosis caused and what are the Tx for pre/post-menopause PTs
Define Nabothian Cyst
Cervical polyps usually arise during ? time and are usually ? size
LEEP/Cold Knife
Hypoestrogen
Pre: dilators, Post: estrogen x 4wks
Trapped columnar cells continue secreting mucus
Endocervical canal during reproductive years;
<3cm
How ae Cervical Polyps Tx based on size
Endocervix contains ? cells while ectocervix contains ? cells
What causes the SC junction to move location
Small, pedunculated: grasp and twist w/ forceps
Sessile: forcep removal w/ cauterize
Endo: glandular columnar
Ecto: squamous
Extend/evert: young and hormones
Regress: low estrogen, long lactation, long term progestin
What three RFs place Pts at increased risk for cervical Ca
HPV virus causes nearly all cervical neoplasms, ? is a ‘surrogate’ for cervical cancer
Fetal exposure to ? chemical increases risk for adenocarcinoma
Early age first intercourse/pregnancy
Inc parity
Cervical Intraepithelial Neoplasia 3- squamous epithelial lesions
Diethylstilbestrol- used to prevent miscarriages 1938-71
? is the MC STI in the US
? type of microbe is this STI
What are the four categories of CIN
HPV, > 150 types hides in basal cell/basement membrane
Double stranded DNA virus
Mild Mod Sev Adenocarcinoma in Situ- full thickness
What are the high and low risk forms of HPV
How are these prevented
Define Pap Testing
Low: 6, 11
High: 16*, 18
16- most oncogenic world wide
Gardasil between 9-45y/o:
6 11 16 18 31 33 45 42 58
Cervical cytology test q3yrs
Define Primary HPV testing
Define Co-Testing
Define Reflex HPV Testing
HPV DNA test q5yrs
Pap and HPV test q5yrs
+ ASCUS cytology reflexes for HPV test
Define HPV-Based testing
How often are Paps conducted based on age
Primary HPV test alone or co-test
<21y/o: none
21-29: Pap q3yrs
30-54:
Primary HPV or Co-testing q5yrs
Pap q3yrs
When can Pap tests be d/c after 65y/o
No Hx of CIN2 or higher in past 20 yrs and:
Two consecutive negative Primary HPVs w/in 10yrs, most recent in 5yrs or
Two consecutive negative Co-tests w/ past 10yrs, most recent in 5yrs or
Three consecutive negative Pap tests in past 10yrs, most recent 5yrs
If inadequate/unknown screening has been done for Pts >65, how often are they scheduled for cervical pap/screening
Cervical dysplasia screenings posthysterectomy
Annual Co-test x 3yrs then q5yrs
No CIN2 or higher x 20yrs:
+cervix: age appropriate screening
- cervix: no screening
Pos CIN2 or higher x 20yrs:
Vaginal cuff cytology even after total hysterectomy
Continue for 20yrs past CIN2 Dx/Tx date, even if extends beyond 65y/o
What is the non-standard strategy for HPV screening
Pap results use ? system and what are the 5 sections of the result report
HPV HR DNA screen is pos and cytology is negative and Pt is 30/> y/o
Bethesda:
Specimen type Adequacy Interpretation Description Notes/recs
? are the 5 cervical dysplastic types
ASCUS- atypical SC of undertermined significance (MC abnormal cytology, preceded CIN2,3)
LSIL- low grade squamoud intraepithelial lesion
ASC-H- atypical squamous, cannot exclude HSIL
HSIL- high grade squamous intraepithelial lesion
AGC- atypical glandular cells
ASCUS results management
> 30y/o:
+HPV: colpo
-HPV: HPV based testing in 3yrs
25-29y/o:
+HPV: colpo
-HPV: HPV based testing in 3yrs
No HPV test: Pap in 12mon, then colpo if abnormal
<25y/o:
Repeat pap in 12mon
If reflex HPV is Pos, repeat pap in 12mon
If reflex HPV is neg, routine screen
What is the down side to +LSIL cervical dysplasia results
How are these results managed by age
No HPV reflex tests
> 25y/o:
+HPV: colpo
-HPV: repeat HPV 12mon
Unknown HPV: colpo
<25y/o:
Repeat pap in 12mon
If reflex HPV is Pos, repeat pap in 12mon
If reflex HPV is neg, routine screen
How are ASC-H results managed
How are HSIL results managed
How are +AGC results managed
Doesn’t matter, Colpo
> 25y/o:
Colpo or LEEp
<25y/o:
Colpo
Atypical endometrial: endo-metrial/cervical sample and colpo
Other: Colpo w/ endocervical sample unless pregnant
>35y/o:colpo and endocervical/metrial samples
Define Colposcopy and what is needed prior to all procedures
What are the steps of this procedure
Screening for cervical cancer to assist w/ Dx visualization/biopsy
Qualitative pregnancy test
Cleansed w/ acetic acid- neoplasm of cervical dysplasia turns white (sample and curettage)
Green filter accentuates CIN lesions
Schiller test w/ Lugol iodine- failure to fully stain= dys/neo-plasia
What is the next step for Coplos where the entire T-zone can’t be visualized on exam
? population is less likely to have successful pre-cervical cancer treatments
MC Gyn Ca in world is
LEEP, Cold Knife Cone
HIV Pts
Cervical Ca
? is a poor prognosis finding in Pts w/ cervical Ca
? form of cervical Ca has a worse prognosis than squamous cell and why is this prognosis worse
? is the MC type of cervical cancer and it’s location
Lymphovascular spread
Mucinous adenocarcinoma;
Occult d/t location allows for later detection
SCC from ectocervix
How can cervical cancer bleeding be managed
How can cervical cancer be Tx during pregnancy
How often d/ Pts need f/u
What medical hormone therapy is not c/i for cervical Ca Tx
Monsel paste- ferric subsulfate w/ packing
Cisplatin w/ vincristine/paclitaxel after first trimester
q3mon x 2yrs then,
q6mon x 5yrs post-tx then
Annual w/ full body lymph node check
Estrogen
What microbe causes erythrasma and how is it Dx on PE
How is it Tx
Normal vaginal flora is ? pH and responds to ?
Corynebacterium, Red on Woods lamp
Wide: erythromycin
Local: topical clinda
4-4.5, estrogen
? is the predominant microbe found within the vagina and how does this microbe help protect the vagina
Of the two categories of vaginitis, what are the two non-inlfammatory causes
Which one appears in both non/inflammatory categories
Lactobacilli;
Lactic acid, H2O2
BV, Candidiasis
Candidiasis
? is the MCC of vaginal d/c and vaginitis
Dx criteria for BV
What result would be seen w/ nitrazine paper
BV- grey d/c w/ fishy odor e/t overgrowth of anaerobes/ loss of lactobacilli
Amsels:
Clue cells Odor whiff test pH >4.5 D/c
Blue= pos if pH >4.5
How is recurrent BV w/ no prior extended treatment managed
How is BV w/ prior extended Tx managed
What is two differences done w/ recurrent BV Tx
Vaginal Metrogel/Clindamycin x 2wks
PO Metronidazole/Tinidazole x 2wks
Same as acute but acutely x 2wks then,
Suppression w/ weekly Metronidazole gel/twice weekly PO metronidazole/Tinidazole x 6mon
Tx of male partner offers no benefit
Probiotics help recurrent/chronic
2nd MCC of vaginitis
What are the two MC forms of this MC microbe
How is this Dx
Candidiasis- itch, burn, irritation, nonodorous cottage cheese
Albicans > Glabrata (resistant to -azoles)
Glabrata > in DMT2 population
pH <4.5
Erythema
KOH w/ budding yeast, pseudohyphae
What factors contribute to chronic candidiasis
How are recurrent cases Tx acutely and for suppression
What is used to Tx non-albicans induced recurrent VVC
Dec mannose binding lectin
Inc IL-4
Acute: PO Fluconazole on day 1,4,7 Suppression: PO Fluconazole wkly x6mon External Sxs: mid-potency steroid
Boric acid > Fluconazole
? is the 3rd MCC of vaginal d/c and ? is the gold standard for Dx
How is the MC Tx
If another Dz is present, which needs to be Tx more aggressively
Trichomoniasis- frothy yellow d/c w/ musty odor and strawberry cervix;
NAAT
Metronidazole, Tinidazole w/ test of cure at 1 and 6mon
BV > Trich
How does Lichen Sclerosis present on PE
How are Lichen Sclerosis cases managed
What medical Txs are available
Cellophane/cigarette paper w/ pruritus, irritation
Inc risk of vulvar malignancy, biopsy and f/u q12mon
Topical Clobetasol
Retinoids if severe/unremitting
Phototherapy and 5-Amino Avid if severe
Lichen sclerosis MC affects ? site while Lichen Simple Chronicus MC affects ? site
How are cases of LSC managed
How would Atopic Dermatitis be managed
LS: perenium
LSC: majora
Sitz bath w/ PO antihistamine
Cotton glove wear at night w/ topical steroids
Unresolved in 3wks- biopsy
Tacrolimus w/ topical steroid/dry skin Tx
What causes Inverse Psoriasis
What causes Inverse Psoriasis in vulva area
How are these cases managed and what is used once control is obtained
T-cell mediated autoimmune response
Trauma, koebnerization
Emollient, Steroids
Calcipotriene once controlled
What 5 drugs can induce Lichen Planus
What does Lichen Planus look like on PE
Of the 3 variants, which one is MC and most difficult to Tx
? syndrome can develop that is also Tx resistant but ? can be used
NSAID BB Methyldopa PCN Quinine
Red erosion w/ white border
Erosive > Papulosquamous, Hypertrophic
Vulvovaginal- vagina and gingiva
Clobetasol, vaginal hydrocortisone
What causes Intertrigo
? is the MCC of vaginal irritation after menopause
When do bartholin cysts become concerning for cancer but if they occur in ? location have no pain
Friction in warm, moist skin folds
Atrophic vaginitis
> 40y/o= biopsy; In ducts= painless
How are Bartholin Cysts managed
? is a sequelae of the cyst that can develop w/ ? correlation
What are the indications to use ABX after cath placement
ASx- none, unless >40y/o
Word catheter
Cath failure/after two caths= marsupilization
Abscess, G/C
Pregnancy, Cellulitis, Systemic, ImmComp;
Fqnln Augmentin TMP-SMX Second gen Cephalospor.
MC type of vulvar cancer is ? type and develop on ? landmark
? is the 2nd MC etiology of vulvar cancer
What are the 5 other types of vulvar cancers seen
SCC on Hart line
Malignant melanoma- poor prognosis
Verrucous: cauliflower w/ pruritus; radiation resistant
BCC: older Pt’s majora w/ poor pigmentation and pruritus
Vulvar Sarcoma: rare, affects broader age range
Barthlin Gland: peak occurrence mid 60s
Vulvar Paget: eczematous, red neoplasia
What are the RF for vulvar cancer in Pts <55y/o
How do these RFs change for Pts >55y/o
What is the f/u schedule post-vulvar Ca Tx
HPV, smoking
Non-smokers w/out STD Hx but long history lichen sclerosis
q3mon x 3yrs
q6mon x 5yrs
Annually
Vulvar Ca w/ ? recurrence is almost always fatal
Most cancers found in vagina are ?
What is the MC vaginal Ca, c/c and location
Inguinal node
Mets to vagina
SCC d/t HPV, presents MC as bleeding in MC site of upper third wall
What causes Clear Cell vaginal Ca
What are the two types of mesenchyma tumors
Why are there increased incidence of vulvovaginal candidiasis during pregnancy
Diethystillbestrol exposure
Rhabdo: MC vaginal malignancy <5y/o
Leiomyosarcoma: 140 cases ever
Inc lactic acid production- more acidic
Inc vaginal glycogen stores
Wash fruits/veggies d/t ? risk
Avoid raw eggs d/t ? risk
? herbal teas can induce labor
Avoid raw/undercooked seafood d/t ? risk
Toxo/Listeria
Salmonella
Raspberry leaf tear
Norovirus
What single gene d/os are screened for during pregnancy
Trisomy 18 and 13 are called ?
CVS testing offers no info about ? but carries ? risk if done too early
CF Sickle Tay-Sachs Hgbnopathies
18: Edwards
13: Patau
NTDs; jaw/limb abnormalities
Kick counts start on ? week
First line tool for fetal surveillance
? BPP score is associated w/ normal fetal pH, poor predictor
Done w/
28wks
NST
8-10: normal
6: retest in 12-24hrs
Deck 4
Leiomyomas are AKA ?
Ovarian androgen production in ? cells occurs d/t ?
Peripheral conversion of these products occurs ?
Fibroids
Theca, d/t LH- cholesterol+cAMP= androstedione/testosterone
Granulosa, d/t FSH- androstedione/testosterone+cAMP (aromatization)= estrone/estradiol
Adipocyte: androstenedion into estrone/testosterone/estradiol
Hair follicle/genital skin: testoterone via 5-a reductase into dihydrotestosterone/estradiol-17
Pap Co-Testing and Reflex testing determine ?
Vulvar cancer Tx w/ wide, local excision is only appropriate for ? stage Ca
Define Puberty
HPV presence, not genotype
Microinvasive, IA
Development of secondary characteristics w/ reproductive capabilities
Why does puberty not start during toddler years
What is the sequence of changes seen in order
What is the proposed puberty initiator hormone
HPO axis suppressed by estradiol
CNS inhibition of GnRH
TAPuP Me
Thelarche Adrenarche Pubarche Peak growth Menarche
Pubarche can be normal variant
Leptin produced in adipocytes
What marks the onset of puberty
Tanner Staging
Pulsatile GnRH release from anterior pituitary triggering FSH/LH
No Budy Elevates 2 Mountains in Adulthood:
1: no glandular tissue
2: buds form
3: breast elevated
4: secondary mounds
5: adult size
No Small Cat Sparing Thighs
1: no hair
2: small amount of hair
3: coarse hair
4: adult like sparing thighs
5: adult like encompassing thighs
Define Precocious Puberty
What are the two types and Txs
Secondary characteristics <8y/o or <2.5SD
Central: gonadotropin dependent;
Isosexual: same characteristics as phenotype
Tx: GnRH agonist- inhibits LH/FSH
Peripheral: gonadotropin independent;
Hetersexual or Isosexual
Define Delayed Puberty
What is the MCC
Menstrual cycles usually occur ? often, last ? long and have ? much blood loss
Lack of thelarche by 13y/o
No menses by 16y/o
Constitutional/physiologic delay
q28d +/-7d
x3-7d
20-60ml
When are menses most erratic
Why is the follicular phase the one most focused on
How much estrogen is required for ovulation to occur
2yrs after menarche
3yrs before menopause
Variable- dependent on estradiol reaching threshold level
200pg x 50hrs for LH surge to occur
Events of Follicular phase
Events of Luteal Phase
First day of menses to ovulation
Inc FSH develops primary follicle
Follicle increases estrogen to proliferate endometrium
Day 14- LH surge after estrogen surge, stimulates ovulation 36-40hrs later
Begins 1-2d after LH surge, ends w/ first day of menses
Define duration
Corpus luteum produces E/P to make endometrium ready for implantation
Corpus luteum dissolves after 14 days w/out fertilization
Progesterone withdrawl= menses
? hormone is similar to LH
Follicular Phase is AKA
What occurs during an Anovulatory Menstrual Cycle
hCG
Proliferative phase
Ovary fails to produce mature follicle
Proliferative phase occurs in endometrium, does not progress into luteal phase
Break through bleeds occur
Define Primary Amenorrhea
Define Secondary Amenorrhea
MCC of Secondary Amenorrhea
No menses by 16y/o w/ normal 2* characteristics
No menses or 2* characteristics by 14y/o
No menses w/in 3yrs of thelarche
No menses x3mon after previous menses
Pregnancy
Secondary Amenorrhea evaluation flow chart
Pregnancy test, TSH, Prolactin
Progesterone challenge test:
+ bleed: anovulatory, PCOS
- bleed- conduct E/P challenge test
+ bleed: check FSH
>40: menopause/premature ovary failure
<5: stress, CNS tumor, Sheehans
- bleed: outflow obstruction, Ashermans
DDxs for AUB
How is acute menorrhagia managed
How is chronic/recurrent menorrhagia managed
PALM-25% COEIN-75%:
Poly Adenomyosis Leiomyoma Malignancy/Hyperplasia
Coagulopathy Ovulatory Endometrial Iatrogenic Not class.
Stable:
COC/Medroxypred
Unstable or no response x24hrs:
Dnc, Tamponade, Artery embolization, Hysterecomy
Normalize prostaglandins- NSAIDs
Coordinate sloughing x 1 cycle: MedroxyPred, COCs
Endometrial suppression: Progestin only, Levo IUD
Anti-fibrinolytic therapy- TXA
More severe dysmenorrhea Pts will have higher levels of ? in menstrual fluid
Initial dysmenorrhea Tx is ?
MC site for endometriosis glands to be found
Prostaglandins- highest in first 2 days of menstruation
NSAIDs COCs Progestin only
Estrogen dependent in right sided peritoneum
What are the four pathogenesis of endometriosis
What are the 3-Ds of this condition
Preferred imaging for work up and only method to definitively Dx
Retrograde menstruation
Mullerian dysplasia
Lympatic spread
Stem cell
Dysmenorrhea Dyspareunia Dyschezia
CT, laparoscopy
What type of cysts are seen on adnexal masses of endometriosis
How is this Tx
Define PMS/PMDD
Chocolate cysts
Barbed uterosacral ligament
NSAID, OCPs- if ineffective, refer to OBGYN for definitive Dx
Danaols- androgen analog that inhibits FSH/LH
Leuprolide- GnRH agonist induces pseudomenopause
PMS: Sxs w/out impairement
PMDD: five Sxs w/ impairement
Sxs of PMS/PMDD occur during ? part of cycle
Why does bloat/weight gain occur
How are these conditions Tx
Luteal d/t dec serotonin activity
Progesterone w/ anti-mineralcorticoid properties
Estrogen w/ RAAS activatio
Altered E+/fluid balance
Exercise/Stress/Diet
SSRI
COC, GnRH agonist, Danazol
NSAIDs, Diuretics
? dietary adjunct can help w/ PMS/PMDD Sxs
Define Menopause
Define Premature Ovarian Failure
Pyridoxine B6- serotonin production cofactor
12mon since last menses
Menses stop <40y/o d/t high FSH
What hormone changes are seen in menopause
What are the Sxs of Menopause
High FSH/LH
Low E/P
FSHIUL Flash flush forgetful Sad skin sweat HA Heart dz Insomnia Urinary Sxs Libido decrease
? is the leading cause of death in women >50y/o
Why is this
When is the risk between wo/men the same
CVDz
Estrogen is cardio-protective
70y/o
Why do we never give unopposed estrogen to woman w/ uterus
? med is used prophylactically to lower risk of Pre-E
What is a key part of Dx PMS and ? lab is recommended to be ordered
Inc risk of endometrial hyperplasia/Ca/neoplasia
ASA
No Sxs during follicular phase; TSH
ABX for non-surgical Tx of tubo-ovarian abscesses
How are abscesses associated w/ mastitis Tx
? type of breast Ca presents as eczematous lesion on nipple
Cephalosporin w/ Doxy or,
PCN Allergy: Clindamycin w/ Gentamycin
ABX w/ drainage- Diclox Cephalex Clinda TMP Vanc
Continue feeding/emptying affected side
Paget’s Dz
? microbe causes BV
Why do Pts need to avoid alcohol during Tx w/ Metronidazole
RF for Vulvar Ca
Gardnerella vaginalis d/t inc coccobacilli numbers
Disulfiram reaction
Vulvar LS ImmDef syndrome Smoking Hx of cervical Ca Intraepithelial neoplasia
MC microbe causing Barthlin cysts
How is pregnancy Dx w/ TVUS
Post-coital bleeding can suggest ? issue
E Coli
Gestational sac w/ yolk sac
Cervical Ca
Define Oligomenorrhea
Define Polymenorrhea
Define Hypomenorrhea
Define Amenorrhea
Define Menorrhagia
Define Metrorrhagia
Oligo: cycle >35d long
Poly: cycle <21d long
Hypo: scant menstruation
Amen: absent x 6mon
Men: regular cycle w/ excessive flow/duration
Metro: irregular cycle
First and Second line medical therapy for Primary Dysmenorrhea Tx
How is AUB managed
MCC of uterine bleeding in post-menopause women
1st: NSAID
2nd: estrogen-progestin
Hormones DnC/Ablation Hysterectomy
Atrophy of mucosa/endothelium
MC non-viral STD in the world
? microbe can hematogenous spread and cause Chorioamnionitis
Gestational diabetes Dx w/ ? fasting level or ? A1c
Trichomonas vaginalis
Listeria
> 95, 6.5%
What time during menstrual cycle offers most reliable exam for fibrocystic breast dz
How is trichomoniasis Tx
What medication can be used for endometrial hyperplasia Tx in women attempting to preserve fertility
Directly after menstruation
Metronidazole 500mg BID x 7d
Tinidazole
Megestrol acetate w/ biopsy q3mon
? is the MCC of AUB in pre-menopause women that are obese
What tocolytics are used in pre-term labor
? hormones are high in the follicular phase and ? hormones are high in the luteal phase
Endometrial hyperplasia
It's Not My Time: Indomethacin Nifedipine Mg sulfate Terbutaline
Follicular: LH, Estradiol
Luteal: FSH, Progesterone
Hormone shift seen in menopause
? RF puts women at high risk for developing pre-eclampsia and how can this be avoided
MCC of PID
Inc FSH, dec E/P
Autoimmune d/o; ASA
Chlamydia trachomatis
MCC of menorrhagia
? is the preferred initial Dx test of choice for painless, vaginal bleeding in post-menopausal woman
? is the MC type of endometrial carcinoma
Fibroids- leiomyoma
TVUS
Adenocarcinoma
? medication is used for hot flash/menopause Sxs if estrogen is c/i
? causes anovulatory bleeding
First, Second and Third line Tx for PMS/PMDD
Gabapentin
Failed corpus luteum development= no progesterone
Unopposed estrogen stimulation
Exercise/stress reduction
SSRI
GNR agonist
Most concerning outcome to newborn born to diabetic mother
Estrogen receptor positive breast cancer can be Tx w/ ? medication
MC type of GYN cancer
Hypoglycemia
Tamoxifen
Uterine
? is the longest phase of labor and what marks the start/end
Stages of labor
MC vulvar cancer and the MCC
First stage- true contractions, ending w/ fully dilated cervix
First-
Early: 0-3cm, 8-12hrs
Active: 3-7cm, 3-5hrs
Transition: 7-10cm, 30-120min
Second: end of dilation to delivery
Third: fetal delivery to placental delivery
SCC d/t HPV
Why do ovarian torsions rarely have complete blood supply cut off on US images
Leading cause of GYN death
Dual supply from uterine and ovarian artery
Ovarian Ca
