OBGYN Reverse Flashcards

1
Q

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

A

Psychological Learned Environment Spiritual Social

Excitement Plateau Orgasm Resolution

Intimacy Stimuli Arousal Desire Enhanced intimacy

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2
Q

? 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

A

Sexual Drive- influenced by neuroendocrine

Motivation
Emotional willingness

D: testosterone, excited- T, suppressed- Serotonin
A: E2 from parasympathetic

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3
Q

Menopause sexual dysfunction is d/t ?

What are the three phases of sexual response

? underlying Dxs are comorbid w/ sexual d/os

A

Hypo-estrogen
Inc FSH= hot flashes

Desire (Libido)
Excitement (Arousal)
Orgasm (Climax)

Anxiety/Depression

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4
Q

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 ?

A

T11-L2, S2-4; Parasympathetic

Estrogen; MCC of dysfunction of excitement phase

T11-L2, S3-4; Sympathetic

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5
Q

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

A

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

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6
Q

What are the support structures of the pelvis

What are the pelvic organs

Define Chronic Pelvic Pain

A

Perineum
Urogenital diaphragm
Levator ani
Vagina

Rectum Uterus Bladder Vagina

Non-cyclic pain lasting 6mon+ severe enough for functional disability/medical intervention

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7
Q

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

A

Acetaminophen and NSAIDs

SS/NRI TCA Gabapentin

CoCs Progestin GnRH agonist

Hysterectomy Neurolysis

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8
Q

Define Vulvodynia

What is used for Tx

When does Localized Provoked Vulvodynia become a DDx

A

Vulvar discomfort x3mon w/out identifiable cause

Topical Lidocain/Gabapentin
Antidepressant- TCA (max 200mg Amitriptyline)

New onset insertion pain x 3mon

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9
Q

What are the two sub-classifications of Dyspareunia and the causes

Exam for dyspareunia mirrors the exam for ?

How is this condition Tx

A

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

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10
Q

Pudendal Neuralgia is Dx w/ ? criteria

Define Cystocele, Rectocele, Enterocele, Procidentia

? is the 3rd MC indication for hysterectomy

A
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

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11
Q

Define Splinting/Digitation associated w/ pelvic organ prolapses

Which type of prolapse presents w/ urinary retention

What are the RFs for prolapse

A

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
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12
Q

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

A

Mast cell activation; Defected mucin layer

Unexplained chronic pelvic pain w/ voiding Sxs

Cranberry juice exacerbates pain

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13
Q

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

A

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

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14
Q

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

A

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
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15
Q

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

A

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

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16
Q

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

A

Overflow: A-agonsits, CCBs
Stress: A-antagonists

Mixed

Q-tip test, angle changes >30* to horizontal= hypermobility and possible stress incontinence

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17
Q

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

A

Kegels: 50-60 contractions/day

Calcium glycerosphate

Anticholinergics- inhibit muscarinic receptors to blunt contractions

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18
Q

? 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

A

Imipramine: TCA w/ a-adrenergic and anticholinergic effects

Mirabegron: relaxes detrusor, increases bladder capacity

Idiopathic detrusor overactivity
Urge

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19
Q

Urge Incontinence Tx methods

Stress Incontinence Tx methods

Overflow Incontinence Tx methods

A

Schedule
Anticholinergic: Detrol, Ditropan
Kegels

Pessary/kegel
Imipramine
Topical estrogen
Surgery
Duloxetine

Intermittent catheterizations
Surgery

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20
Q

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

A

Terminal duct-acinar (lobules)

Est/Progest/Prolactin

Luteal- fullness week prior to menses d/t water content

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21
Q

? 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

A

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

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22
Q

Simple Cysts appear as ? on US and need ? management for Tx

Complicated Cysts appear as ? on US

Complex Cysts appear as ? on US

A

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

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23
Q

Define Fibrocystic Breast Changes

What causes these changes

These changes are characterized by ? that is d/t ?

A

Ropy, nodular tissue d/t dilated ducts and dense collagen

Collagen stromal response to hormones/GF

Hyperplasia- low progesterone compared to estrogen

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24
Q

How will Fibrocystic Breast Changes present to clinic

How are these Tx

What baseline order needs to be started if Pt is >25y/o

A

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)

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25
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
26
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
27
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
28
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
29
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
30
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
31
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
32
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
33
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
34
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
35
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
36
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
37
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
38
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
39
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
40
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
41
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
42
What are the 5 etiologies of infertility in sequence
``` Ovulatory Male factor Tubal/uterine Unexplained Other ```
43
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
44
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
45
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
46
? 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
47
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
48
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
49
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
50
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
51
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
52
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
53
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
54
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
55
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
56
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
57
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
58
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
59
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
60
? 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
61
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
62
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
63
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
64
? 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
65
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
66
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
67
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
68
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
69
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
70
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
71
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
72
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
73
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
74
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
75
# 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
76
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
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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
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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
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# 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
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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
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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
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? 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
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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 ```
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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
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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
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# 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
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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 ```
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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
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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
90
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
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# 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
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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
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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
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4 RFs for shoulder dystocia Should Dystocia management in order mnemonic Which step has the highest individual success rate
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) ``` #5- remove posterior shoulder
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# 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
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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
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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
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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
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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
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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
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? 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 ```
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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
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# 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
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# 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
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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
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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)
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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
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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
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# 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 ```
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# 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
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# 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
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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
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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
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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
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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
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Fetal transfusion is needed at ? Hct % Hydrops has developed if Hct is under ? % ? is the target Hct for nonhydropic fetus
<30% <15% 40-50%
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? 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
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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
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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
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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
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? 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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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# 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 ```
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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
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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
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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
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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
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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
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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
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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
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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
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? 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
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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
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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
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# 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
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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
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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
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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)
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? 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
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# 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
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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
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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
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# 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
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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
153
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
154
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
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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
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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
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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
158
# 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
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? 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
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? 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
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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
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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
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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
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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
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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
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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
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# 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 1. 5-2.5kg 0. 5-0.99kg
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# Define IUGR Define advance maternal age Define Adolescent Pregnancy
Weight <10th percentile 35y/o or > at delivery <20y/o at delivery
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? 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
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? 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
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? 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
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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
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# 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
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# 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
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# 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
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# 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
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# 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
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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
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? 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
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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
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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
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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
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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
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? 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
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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
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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
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# 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
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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
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? 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
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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
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? 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
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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
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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
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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
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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
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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
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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
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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
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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
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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 ```
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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 ```
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Structural causes of uterine bleeding Non-structural causes of uterine bleeding
Polyp Adenomyosis Leiomyoma Malignancy ``` Coagulopathy Ovulatory Endometrial Iatrogenic Not classified ```
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? 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
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? 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
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# 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
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# 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
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# 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
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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
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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
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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
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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
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? 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)
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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
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? 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
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? 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
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# 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
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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
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# 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
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# 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
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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
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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
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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
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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 ```
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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
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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
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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
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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
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? 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
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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
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# 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
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# 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
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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
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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
234
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 ```
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? 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
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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
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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
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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
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# 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
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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
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? 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
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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
243
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
244
? 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
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? 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
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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
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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
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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
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? 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
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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
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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
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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
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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
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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
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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.
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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# 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
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# 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
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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
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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
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? 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
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# 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
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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
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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
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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
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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
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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
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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
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? 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
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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 ```
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? 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
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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
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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
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? 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 ```
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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
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# 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
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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
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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%
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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
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? 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
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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
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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
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? 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
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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
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? 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
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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