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OBGYN Rotation Flashcards

1
Q

What is the best treatment for Bartholin’s gland abscess?

A

Incision and drainage followed by marsupialization, packing, or placement of Word catheter

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2
Q

In older patients with recurrent Bartholin’s abscess or cysts what should you consider?

A

Adenocarcinoma - take biopsy

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3
Q

What is the most common location for ectopic pregnancy?

A

Ampulla of fallopian tube

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4
Q

What is the treatment for round ligament pain?

A

Acetaminophen and rest

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5
Q

How do you determine the EDD?

A

Use 1st day of bleeding of last menstrual period

EDD = (LMP +1 years +7 days) - 3 months

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6
Q

Changes in cervical mucus during pregnancy

A

NOT PREGNANT: Estrogen –> increased NaCl in mucus –> crystallization –> ferning pattern

PREGNANT: Progesterone –> decreased NaCL in mucus –> no crystallization –> beading

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7
Q

What is Chadwick’s sign?

A

Bluish discoloartion of the vagianl and cervical mucosa due to vascular congestion in pregnancy

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8
Q

What is the function of b-hCG?

A
  • sustain corupus luteum during the first 7 weeks. After the first 7 weeks, the placenta makes its own hormones to sustain the pregnancy
  • can be deteted in maternal serum or urine 6-12 days after fertilization
  • increases by 66-100% every 48 hours prior to 10 weeks, then peaks at 10 weeks and nadirs at 14-16 weeks.
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9
Q

Up to 12 weeks, what predicts gestation age within 4 days?

A

crown-rump length

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10
Q

US and EDD

A

T1: +/- 4 days
T2: +/- 14 days
T3: +/- 21 days

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11
Q

Where does fertilization occur?

A

ampulla of the fallopian tube

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12
Q

Zygote maturation

A

zygote –> morula –> blastomere –> blastocyst

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13
Q

On what day after ovulation does implantation occur?

A

day 5-6

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14
Q

When does the placenta start to form?

A

during week 2

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15
Q

Why do vaginal secretions during pregnancy become more acidic?

A

Increased Lacobacillus acidophilus (inhibits growth of most pathogens and favors growth of yeast)

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16
Q

Recommended pregnancy weight gain

A 
BMI --> weight gain
 28-40 lbs
18.5-24.9 --> 25-35 lbs
25-29.9 --> 15-25 lbs
> 30 --> 11-20 lbs
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17
Q

Pruritic urticarial papules and plaques of pregnancy (PUPPP)

A

Onset: T2-T3
severe pruritus
Lesions: erythematous, urticarial, papules and plaques
Distribution: abdomen, thighs, buttocks, occasionally arms nad legs
No increased risk of fetal morbidity/mortality
Tx = topical steroids, antipruritic drugs (hydroxyzine, diphenhyramine, calamine lotion)

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18
Q

Intrahepatic cholestasis of pregnancy (bile not properly excreted form the liver)

A

Onset: T3
severe pruritus
Lesions: excoriations
Distribution: generalized palms and soles
increased risk of stillbirth
Intervention = chekc serum bile acids, liver function tests, antipruritics, ursodeoxycholic acid, fetal testing

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19
Q

What causes gestational diabetes?

A

placental hormon human placental lactogen (causes insulin resistance as it increases in pregnancy)

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20
Q

When is the best time to screen for glucose intolerance in pregnancy?

A

26-28 weeks

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21
Q

Hemoglobin levels in pregnancy

A

Normal average = 12.5

Abnormal = below 11.0

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22
Q

What causes hypercoaguable state in pregnancy?

A
  • Estrogen causes increase in clotting factors, except factors XI and XIII
  • Increased fibrinogen
  • Increased resistance to activated protein C
  • Decreased protein S
  • Average platelet count decreases
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23
Q

Cardiovascular changes in pregnancy

A 
Increased cardiac output
Decreased systemic vascular resistance
Increased HR
Systolic ejection murmurs = normal 
Diastolic murmurs = abnormal
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24
Q

Respiratory changes in pregnancy

A

Increased tidal volume
Increased minute ventilatory volume
Increased minute oxygen uptake
Decreased FRC and RV due to elevated diaphragm
(normal acid base status in pregnancy = compensated respiratory alkalosis)

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25
Q

Urinary changes in pregnancy

A

Increased GFR, Cr clearance, renal plasma flow
Decreased serum Cr, blood urea nitrogen
(right hydronephrosis is a normal finding in pregnancy)

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26
Q

GI changes in pregnancy

A

Effects of progesterone:
decreased LES tone –> heartburn
decreased bowel peristalsis –> constipation

Alkaline phosphatase activity in serum almost doubles during pregnancy

Serum albumin decreases, but total albumin increases because of a greater volume of distribution

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27
Q

Gallbladder in pregnancy

A

Progesterone –> impairs gallbladder contraction by inhibiting cholecystokinin-mediated smooth muscle stimulation

Estrogen –> inhibits intraductal transport of bile acids leading to cholestasis

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28
Q

Prolactin vs Oxytocin

A

Prolactin - PRODUCES milk

Oxytocin - lactation (milk letdown) + uterine contractions

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29
Q

Thyroid gland in pregnancy

A

Elevated TBG
Elevated total thyroxine and T3
Normal free T4
Normal TSH

(TSH is marker of thyroid disease)

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30
Q

Frequency of OB visits

A 
< 28 weeks = every month
28-36 weeks = every 2-3 weeks
36-41 weeks = once per week
41-42 weeks = every 2-3 days for fetal testing
42 weeks or more = plan for delivery
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31
Q

When to screen for Down’s Syndrome

A

11-13 weeks

NT increased, PAPP-A decreased, free b-hCG increased

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32
Q

Quad screen

A

16-18 weeks
AFP, b-hCG, Unconjugated estradiol, Inhibin A

Assesses risk of Downs syndrome, Edwards syndrome, NTDs

High AFP = NTD
Low AFP = Down’s syndrome (21), Edwards syndrome (18)

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33
Q

Non-stress Test (NST)

A

Evaluated 4 components of FHR tracing:

  1. Baseline
  2. Variability
  3. Periodic changes (decels, accelerations of at least 15 beats/min above baseline for 15 sec in a 20 min period)
  4. Uterine contractions

(Reactive NST = 2 or more accelerations over 20 min)

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34
Q

Contraction Stress Test (CST)

A

Measures how the FHR reacts to uterine contractions (performed if NST is nonreactive)
- pt placed in lateral recumbent position and contractions are stimulated with oxytocin

Adequate contractions = 3 times in 10 min lasting 40 sec

Interpretation: (decles = hypoxia)
negative = no late or sig variable decels
positive = late decles following 50% of more of contractions
equivocal = intermittent late decels of sig variable decles
unsatisfactory - fewer than 3 contractions in 3 min

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35
Q

Contraindications CST

A
  1. preterm labor pts at high risk of delivery
  2. PROM
  3. Hx of extensive uterine surgery or previous c-section
  4. Known placenta previa
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36
Q

Biophysical Profile (BPP)

A

BPP = NST + US

  1. NST
  2. Breathing: >1 episode of rhythmic breathing movements of 30 sec or more within 30 min
  3. Movement: >3 discrete body or limb movements in 30 min
  4. Muscle tone: > 1 episode of extension with return to flexion or opening/closing of a hand
  5. Determination of AFI: single pocket of AF > 2cm
Scoring: each category given score of 0-2
0: abnormal, absent, or insufficient
2: normal and present 
Total possible score = 10 points
Normal score: 8-10
Equivocal: 6
Abnormal < 4
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37
Q

Modified BPP

A

mBPP = NST + amniotic fluid index

AFI > 5 cm = adequate
AFI < 5 cm = abnormal (oligohydramnios)
AFI > 25 cm = abnormal (polyhydramnios)

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38
Q

Most common cause of oligohydramnios

A

Rupture of membranes

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39
Q

Doppler Velocimetry

A

Fetuses with normal growth: high-velocity diastolic flow
Fetuses with restricted growth: decreased velocity diastolic flow, increased flow resistance in umbilical artery and decreased resistance in MCA

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40
Q

What is brain sparing in hypoxic fetuses?

A

Increased S/D in umbilical artery + decreased S/D in middle cerebral artery

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41
Q

Down’s syndrome (trisomy 21)

A

Decreased AFP, Increased B-hCG, Decreased estradiol, Increased Inhibin A

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42
Q

Edwards syndrome (trisomy 18)

A

Decreased AFP, B-hCG, Estradiol, Inhibin A

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43
Q

When is amniocentesis performed?

A

15-20 weeks

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44
Q

Folic acid recommendations

A

Amount taken to prevents NTDS = 0.4 mg/day

Women with a previous child with an NTD = 4 mg/day well before conception

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45
Q

Which vitamins need to be supplemented in vegetarian mothers?

A

zinc, vitamin B12, and iron

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46
Q

Hyperemesis gravidarum

A

Leads ot hypochloremic alkalosis
Tx = IVF 5% dextrose, antiemetics
(dextrose helps to decrease the ketosis, which can cause a vicious cycle of nausea)

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47
Q

Live vaccines (not safe for pregnancy)

A

Measles, Mumps, Rubella, Varicella, Oral polio, Oral typhoid, Intransal influenza, BCG, Shingles

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48
Q

Immune globulins in pregnancy

A

Are safe! Treatment for exposure to measles, hepatitis A and B, tetanus, varicella, and rabies during pregnancy

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49
Q

Safe vaccines during pregnancy

A

Inactivated polio, Inactivated typhoid, Inactivated influenza, Diphtheria, Tetanus, Rabies, Meningococcus, Hepatitis B

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50
Q

What tests help determine whether the patient has ruptured the her membranes?

A

Perform a sterile speculum exam:

  1. Testing for pooling (fluid collection in posterior fornix = +)
  2. Valsalva (fluid coming through cervical os with bearing down = +)
  3. Ferning (crystallized sodium chloride in amniotic fluid = +)
  4. Nitrazine (jf paper turns blue, indicates basic pH = +)
  • Amniotic fluid has basic pH
  • Vaginal secretions have acidic pH
51
Q

Labor-inducing agents

A

Vaginal prostagladins = cervical ripening

IV pitocin = increase strength and frequency of contractions

52
Q

Which aspects of the fetus are described from the Leopold maneuvers?

A
  1. Lie
  2. Presentation
  3. Position
  4. Attitude
53
Q

Pregnant women < 34 weeks presents with breech presentation. Whats the next step?

A

Recheck fetal presentation at 36 weeks and then attempt external cephalic version if persistent breech

54
Q

Apgar Scores

A

Score of 0-2 for the following:

  • color
  • pulse
  • respirations
  • grimace
  • tone
55
Q

Which blood is used to determine blood type of baby?

A

venous blood

56
Q

Perineal lacerations

A

1st degree = involve the fourchette, perineal skin, and vaginal mucosa, but not the underlying fascia and muscle

2nd degree = 1st degree + fascia and muscle of perineal body but NOT the anal sphincter

3rd degree = 2nd degree + involvement of anal sphincter

4th degree = extend thruogh the rectal mucosa to expose the lumen of the rectum

57
Q

What is the most common cause of postpartum bleeding?

A

Uterine atony

Treatment = uterotonics (pitocin, methergine, hemabate, misoprostol)

Other causes: 4 T's
Tissue: retained placenta
Trauma: instrumentation, lacerations, episiotomy
Tone: Uterine atony
Thrombin: coagulation defects, DIC
58
Q

What is arrest of labor?

A

Lack of cervical change in active first stage for >2 hours with >200 Montevideo units of uterine activity

59
Q

What is a reassuring fetal heart tracing?

A

Reactive = 2 accelerations of at least 15 beats/min above the baseline, lasting for at least 15 sec, in 20 min.

  • Indicates well oxygenated fetus with an intact neurological and cardiovascular system
  • Fetus < 28 weeks gestation age is neurologically immature and thus is not expected to have a “reactive” FHR
60
Q

What is an early deceleration?

A
  • Normal, due to head compression during contractions
  • Nadir of gradual decel = peak of contraction
  • Effect regulated by vagal nerve activation
  • No intervention necessary
61
Q

What are late decelerations?

A
  • Abnormal, due to uteroplacental insufficiency (blood without enough oxygen)
  • Onset, Nadir, and Recovery occurring after uterine contraction onset, peak, and recovery
  • Can follow epidural (hypotension) or uterine hyperstimulation
  • Management: change maternal position to left lateral recumbent poisiton, give oxygen mask, stop pitocin, consider immediate delivery
62
Q

What are variable decelerations?

A
  • Abnormal, due to cord compression
  • can be see nwith oligohydramnios or a nuchal cord
  • abrupt decel
  • management: amnioinfusion, trendelenburg position, possible delivery
63
Q

Classification of variable decelerations

A

Mild: lasts 70-80 beats/min
Moderate: 30-60 sec and depth 60 sec and depth = 70-80 beats/min
Severe: > 60 sec and depth < 70 beats/min

64
Q

What are prolonged declerations?

A

Isolated decels that last 2-10 min.

Causes:

  • cervical examinations
  • uterine hyperactivity
  • maternal hypotension leading to transient fetal hypoxia
  • umibilical cord compression

Management:

  • stop oxytocin and prostaglandins
  • change maternal position
  • IV fluids
  • vasopressors (if necessary)
  • maternal O2
  • sterile vaginal exam to exclude cord prolapse, sudden cervical dilation, or fetal descent
65
Q

What causes decreases in beat-to-beat variability?

A
  • fetal acidemia
  • fetal asphyxia
  • maternal acidemia
  • drugs (narcotics, mag, barbs)
  • acquired or congenital neurologic abnormality

Best way to determine BTBV = internal FHR monitoring
(No BTBV = fetal acidosis –> deliver immediately)

66
Q

Abnormal Nulliparas Labor Patterns

A

Prolonged latent phase > 20 hr
Protracted active phase dilation 2 hrs
2. Descent > 1 hr
3. Failure to descent (no descent in deceleration phase or second stage of labor) > 1 hr

67
Q

Abnormal Multiparas Labor Patterns

A

Prolonged latent phase > 14 hr
Protracted active phase dilation 2 hrs
2. Descent > 1 hr
3. Failure to descent (no descent in deceleration phase or second stage of labor) > 1 hr

68
Q

Oxytocin

A

Stimulated uterine contraction
Complications = hyponatremia because structurally and functionally related to vasopressin or antidiuretic hormone; hyperstimulation

69
Q

Prostaglandins

A

Misoprostol (PGE1 analog)
- used for cervical ripening or induction

PGE2 gel and vaginal inster:

  • both contain dinoprostone
  • used for cervical ripening in women at or near term
70
Q

Induction methods

A

Oxytocin
Misoprostol
Foley balloon
Laminaria

71
Q

When to use a vertical incision (classical) for c-section

A
  1. Lower uterine segment is not developed
  2. Fetus is transver lie with back down
  3. Placenta previs
72
Q

What is the most common reason for c-section?

A

Previous c-section

73
Q

What are the requirements for a clinical diagnosis of PID?

A
  1. Abdominal tenderness
  2. Adnexal tenderness
  3. Cervical motion tenderness

Laparoscopy = gold standard for diagnosis
PID may develop into Fiz-Hugh-Curtis syndrome (perihepatic inflammation)

“Violin string” adhesions can be seen at the liver capsule on laparoscopy

74
Q

What are the criteria for hospitalization for PID?

A 
"GU PAP"
GI symptoms
Uncertain diagnosis
Peritonitis
Abscess
Pregnancy
75
Q

What is the treatment for PID?

A

INPATIENT:

  1. Cefoxitin/cefotelan + doxycycline (preferred for chlamydia)
  2. Clindamycin + gentamycin (preferred for abscess)

OUTPATIENT:

  1. Levofloxacin/oflaxacin + metronidazole
  2. Ceftriaxone/cefoxitin + doxycycline +/- metronidazole
  3. Sexual partners should be treated
76
Q

In what media does Neisseria gonorrhea grow?

A

Thayer-Martin in CO2-enriched environment

77
Q

What is the treatment for a patient with gonorrhea who is allergic to penicillin?

A

Spectinomycin

78
Q

What is the presentation of gonorrhea?

A

Dysuria
Endocervicitis
Vaginal Discharge

(may be asymptomatic)

79
Q

What is the gold standard diagnosis of gonorrhea?

A

DNA PCR

80
Q

What is the treatment for gonorrhea?

A 
Ceftriaxone
Cefixime
Ciprofloxacin
Ofloxacin
Levofloxacin
  • If coinfection with chlamydia not ruled out: Azithromycin or Doxycline
81
Q

Presentation of serotypes A-K of chlamydia

A

Mucopurulent discharge
Cervicitis
Urethritis
(more localized GU manifestations)

82
Q

What is reiter syndrome?

A

“can’t see, can’t pee, can’t climb a tree”
Conjunctivitis, Urethritis, Reactive arthritis

(follows chlamydia infection)

83
Q

Presentation of serotypes L1-L3 of chlamydia

A

lymphogranuloma venereum
Primary lesion = painless papule on genitals
Secondary stage = inguinal lymphadenitis with fever, malaise, and loss of appetite
Tertiary stage = rectovaginal fistulas, rectal strictures

84
Q

How do you diagnose chlamydia?

A

Nucleated amplification testing of cervis (NAAT, PCR)

85
Q

What is the treamtent for chlamydia?

A

Doxycycline or Azithromycin
Lymphogranuloma venereum = doxycycline
Pregnant = Azithromycin (doxycycline causes fetal feeth discoloration)

86
Q

Stages of syphilis

A

Primary: painlesss hard chancre
Secondary: generalized rsh on palms and soles, conyloma lata (appears 1-6 months after primary chancre)
Tertiary: years later with granulomas of skin and bones (gummas), aortic aneurysms, tabes dorsalis

87
Q

How do you diagnose syphilis?

A

Screening: RPR or VDRL
Treponemal tests (confirmation tests): FTA-ABS and MHA-TP
Visualizations of spirochetes on darkfield microscopy

88
Q

What is the treatment of syphilis?

A

Benathine penicillin G

- if allergic, desensitize

89
Q

Presentation for genital herpes

A

Primary infection: malaise, myalgias, fever, multiple PAINFUL genital vesicles with an erythematous base that progress to painful ulcers

Recurrent infection: viral stores in sacral ganglia

Nonprimary 1st episode: milder presentation due to preexisting antibodies

90
Q

How do you diagnose herpes?

A

Cytologic smear - multinucleated giant cells (Tzank test)

91
Q

What is the treatment for HSV?

A

Primary outbreak = Acyclovir or valtrex
Recurrent infection = Acyclovir or valtrex
Pregnancy = acyclovir or valtrex begining at 36 weeks

Famciclovir can also be used in pregnancy

(c-section is indicated for active herpes infection)

92
Q

How do you diagnose HIV?

A

ELISA: detects Abs to HIV (sensitive, not specific)
Western Blot: confirmation of ELISA (very specific)
PCR: confirmatory

93
Q

What are the lesions of HPV called?

A

condylomata acuminata (subtypes 6 and 11)

94
Q

How does HPV present?

A

Warts of various sizes (cauliflower-like papules)

95
Q

What is the treatment of HPV?

A

cryosurgery, laser ablation, electrocauterym trichloroacetic acid, aldara cream

96
Q

How to differential ulcerating genital lesions with vesicles

A

Herpes: multiple PAINFUL ulcers, base red
Chancroid: 1-3 PAINFUL ulcers, base yellow-gray
Syphilis: 1 PAINLESS ulcer, indurated
Lymphogranuloma venereum: 1 painless ulcer, not indurated
Graunolma Inguinale: ulcer, rolled, elevated, rough

97
Q

What is the treatment of H. ducreyi?

A

Ceftriaxone, ciprofloxacin, or azithromycin

98
Q

Bacterial Vaginosis

A 
Clinical: Malodorous discharge
Discharge: gray or white
pH: >4.5
Clue cells (epithelial cells with bacteria attached to their surface)
Whiff test positive
Tx: Metronidazole or clindamycin
99
Q

Candidiasis

A

Clinical: pruritus, erythema, edema, odorless
Discharge: white, “cottage cheese-like,” adherent to vaginal walls
pH: 4-4.5
Budding yeast and pseudohyphae
Tx: Imidazole

100
Q

Trichomoniasis

A

Clinical: copious, frothy discharge, malodorous, pruritus, urethritis
Discharge: green to yellow sticky, “bubbly” or “frothy”
pH: >4.5
Motile flagellated protozoa
Tx: Metronidazole + treat sexual partners
(only vaginitis that is sexually transmitted)

101
Q

A women presents with a strawberry field appearance of the cervix. What is the most likely diagnosis?

A

Trichomonas vaginitis

102
Q

What is the most common infection with an IUD?

A

Actinomyces: sulfa granules, gram positive + rod (like fungi)

103
Q

What is the biggest risk factor for the development of breast cancer?

A

The patient’s age

104
Q

What is the blood supply to the breast?

A

Internal thoracic artery
Lateral thoracic artery
Posterior intercostal artery
Thoracoacromial artery

105
Q

Screening mammogram

A

Every 1-2 years from age 40-49; after 50, annually

106
Q

When should self breast exams start?

A

Age 18

1 week after period

107
Q

When should clinical breast exams begin?

A

Age 21

108
Q

Over the age of 40, what is the initial imaging modality of choice for a breast lump?

A

Diagnostic mammogram

109
Q

< 40 years old, what is the imaging modality of choice for evaluating a breast mass?

A

Ultrasound

110
Q

Follow up recommendations after aspiration of cystic mass in breast

A

If fluid is cloudy/bloody –> excisional biopsy and imaging
If fluid is clear and resolution of cyst –> monitor
If cyst remains after aspiration –> excisional biopsy

111
Q

Risk factors for breast cancer

A 
personal hx of breast cancer
early menarche
nulliparity
alcohol intake
obesity
decreased physical activity
use of prolonged HRT (>5 yrs) during menopausal yrs
112
Q

A rubbery, firm, freely mobile, solid, and well circumscribed breast lesion in women 20-40 years old?

A

Fibroadenoma

113
Q

Cyclic breast pain?

A

Fibrocystic change (no increased risk for breast cancer, but should be completely excised)

114
Q

When do you start scrrening for TSH?

A 
Age 50, then every 5 years
Perioidic screening (19-64) if strong family history of thyroid disease or autoimmune disease
115
Q

Options for emergency contraception

A
  1. Plan B: 0.75 mg levonorgestrel q12h x 2 doses
  2. Oral combined estrogen-progesterin pills: 2 tabs stat, then 2 tabs 12 hr later
  3. Mifepristone 600 mg x 1 dose
116
Q

Down Syndrome (Trisomy 21)

A

uE3 - decreased
AFP - decreased
b-hCG - increased
Inhibin - increased

117
Q

Edwards (Trisomy 18)

A

uE3 - decreased
AFP - decreased
b-hCG - decreased
Inhibin - decreased

118
Q

FSH in menopause

A

Increased FSH due to decreased inhibin (inhibin inhibits FSH secretion) and resistant oocytes requrie more FSH to successfully mature, triggering greater FSH release

FSH levels double to 20 mlU/mL in perimenopause and increase to 40 in menopause

119
Q

Why does ovulation become less frequent in menopause?

A

Shortened follicular phase (luteal phase does NOT change)

120
Q

What wet mount finding is consistent with atrophic vaginitis?

A

Very few epithelial cells

121
Q

Physiology during menopause

A
  • Decreased estradiol level
  • FSH and LH levels rise (secondary to absence of negative feedback)
  • Androsetenedione is aromatized peripherally to estrone (less potnent than estradiol)
    Androstenedione and testosterone levels fall (produced by ovary)
    ** decline in estradiol-17b (occurs with cessation of follicular maturation)
122
Q

Grading of plevic prolapse

A

Grade I: to level of ischial spines
Grade II: between ischial spines and introitus
Grade III: up to introitus
Grade IV: past introitus

123
Q

Stress incontinence

A

Loss of urine (small amount) only with incread intra-abdominal

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