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
2
Q
In older patients with recurrent Bartholin’s abscess or cysts what should you consider?
A
Adenocarcinoma - take biopsy
3
Q
What is the most common location for ectopic pregnancy?
A
Ampulla of fallopian tube
4
Q
What is the treatment for round ligament pain?
A
Acetaminophen and rest
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
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
7
Q
What is Chadwick’s sign?
A
Bluish discoloartion of the vagianl and cervical mucosa due to vascular congestion in pregnancy
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.
9
Q
Up to 12 weeks, what predicts gestation age within 4 days?
A
crown-rump length
10
Q
US and EDD
A
T1: +/- 4 days
T2: +/- 14 days
T3: +/- 21 days
11
Q
Where does fertilization occur?
A
ampulla of the fallopian tube
12
Q
Zygote maturation
A
zygote –> morula –> blastomere –> blastocyst
13
Q
On what day after ovulation does implantation occur?
A
day 5-6
14
Q
When does the placenta start to form?
A
during week 2
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)
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
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)
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
19
Q
What causes gestational diabetes?
A
placental hormon human placental lactogen (causes insulin resistance as it increases in pregnancy)
20
Q
When is the best time to screen for glucose intolerance in pregnancy?
A
26-28 weeks
21
Q
Hemoglobin levels in pregnancy
A
Normal average = 12.5
Abnormal = below 11.0
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
23
Q
Cardiovascular changes in pregnancy
A
Increased cardiac output Decreased systemic vascular resistance Increased HR Systolic ejection murmurs = normal Diastolic murmurs = abnormal
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)
25
Urinary changes in pregnancy
Increased GFR, Cr clearance, renal plasma flow
Decreased serum Cr, blood urea nitrogen
(right hydronephrosis is a normal finding in pregnancy)
26
GI changes in pregnancy
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
27
Gallbladder in pregnancy
Progesterone --> impairs gallbladder contraction by inhibiting cholecystokinin-mediated smooth muscle stimulation
Estrogen --> inhibits intraductal transport of bile acids leading to cholestasis
28
Prolactin vs Oxytocin
Prolactin - PRODUCES milk
| Oxytocin - lactation (milk letdown) + uterine contractions
29
Thyroid gland in pregnancy
Elevated TBG
Elevated total thyroxine and T3
Normal free T4
Normal TSH
(TSH is marker of thyroid disease)
30
Frequency of OB visits
```
< 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
```
31
When to screen for Down's Syndrome
11-13 weeks
| NT increased, PAPP-A decreased, free b-hCG increased
32
Quad screen
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)
33
Non-stress Test (NST)
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)
34
Contraction Stress Test (CST)
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
35
Contraindications CST
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
36
Biophysical Profile (BPP)
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
```
37
Modified BPP
mBPP = NST + amniotic fluid index
AFI > 5 cm = adequate
AFI < 5 cm = abnormal (oligohydramnios)
AFI > 25 cm = abnormal (polyhydramnios)
38
Most common cause of oligohydramnios
Rupture of membranes
39
Doppler Velocimetry
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
40
What is brain sparing in hypoxic fetuses?
Increased S/D in umbilical artery + decreased S/D in middle cerebral artery
41
Down's syndrome (trisomy 21)
Decreased AFP, Increased B-hCG, Decreased estradiol, Increased Inhibin A
42
Edwards syndrome (trisomy 18)
Decreased AFP, B-hCG, Estradiol, Inhibin A
43
When is amniocentesis performed?
15-20 weeks
44
Folic acid recommendations
Amount taken to prevents NTDS = 0.4 mg/day
| Women with a previous child with an NTD = 4 mg/day well before conception
45
Which vitamins need to be supplemented in vegetarian mothers?
zinc, vitamin B12, and iron
46
Hyperemesis gravidarum
Leads ot hypochloremic alkalosis
Tx = IVF 5% dextrose, antiemetics
(dextrose helps to decrease the ketosis, which can cause a vicious cycle of nausea)
47
Live vaccines (not safe for pregnancy)
Measles, Mumps, Rubella, Varicella, Oral polio, Oral typhoid, Intransal influenza, BCG, Shingles
48
Immune globulins in pregnancy
Are safe! Treatment for exposure to measles, hepatitis A and B, tetanus, varicella, and rabies during pregnancy
49
Safe vaccines during pregnancy
Inactivated polio, Inactivated typhoid, Inactivated influenza, Diphtheria, Tetanus, Rabies, Meningococcus, Hepatitis B
50
What tests help determine whether the patient has ruptured the her membranes?
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
Labor-inducing agents
Vaginal prostagladins = cervical ripening
| IV pitocin = increase strength and frequency of contractions
52
Which aspects of the fetus are described from the Leopold maneuvers?
1. Lie
2. Presentation
3. Position
4. Attitude
53
Pregnant women < 34 weeks presents with breech presentation. Whats the next step?
Recheck fetal presentation at 36 weeks and then attempt external cephalic version if persistent breech
54
Apgar Scores
Score of 0-2 for the following:
- color
- pulse
- respirations
- grimace
- tone
55
Which blood is used to determine blood type of baby?
venous blood
56
Perineal lacerations
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
What is the most common cause of postpartum bleeding?
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
What is arrest of labor?
Lack of cervical change in active first stage for >2 hours with >200 Montevideo units of uterine activity
59
What is a reassuring fetal heart tracing?
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
What is an early deceleration?
- Normal, due to head compression during contractions
- Nadir of gradual decel = peak of contraction
- Effect regulated by vagal nerve activation
- No intervention necessary
61
What are late decelerations?
- 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
What are variable decelerations?
- Abnormal, due to cord compression
- can be see nwith oligohydramnios or a nuchal cord
- abrupt decel
- management: amnioinfusion, trendelenburg position, possible delivery
63
Classification of variable decelerations
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
What are prolonged declerations?
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
What causes decreases in beat-to-beat variability?
- 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
Abnormal Nulliparas Labor Patterns
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
Abnormal Multiparas Labor Patterns
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
Oxytocin
Stimulated uterine contraction
Complications = hyponatremia because structurally and functionally related to vasopressin or antidiuretic hormone; hyperstimulation
69
Prostaglandins
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
Induction methods
Oxytocin
Misoprostol
Foley balloon
Laminaria
71
When to use a vertical incision (classical) for c-section
1. Lower uterine segment is not developed
2. Fetus is transver lie with back down
3. Placenta previs
72
What is the most common reason for c-section?
Previous c-section
73
What are the requirements for a clinical diagnosis of PID?
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
What are the criteria for hospitalization for PID?
```
"GU PAP"
GI symptoms
Uncertain diagnosis
Peritonitis
Abscess
Pregnancy
```
75
What is the treatment for PID?
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
In what media does Neisseria gonorrhea grow?
Thayer-Martin in CO2-enriched environment
77
What is the treatment for a patient with gonorrhea who is allergic to penicillin?
Spectinomycin
78
What is the presentation of gonorrhea?
Dysuria
Endocervicitis
Vaginal Discharge
(may be asymptomatic)
79
What is the gold standard diagnosis of gonorrhea?
DNA PCR
80
What is the treatment for gonorrhea?
```
Ceftriaxone
Cefixime
Ciprofloxacin
Ofloxacin
Levofloxacin
```
* If coinfection with chlamydia not ruled out: Azithromycin or Doxycline
81
Presentation of serotypes A-K of chlamydia
Mucopurulent discharge
Cervicitis
Urethritis
(more localized GU manifestations)
82
What is reiter syndrome?
"can't see, can't pee, can't climb a tree"
Conjunctivitis, Urethritis, Reactive arthritis
(follows chlamydia infection)
83
Presentation of serotypes L1-L3 of chlamydia
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
How do you diagnose chlamydia?
Nucleated amplification testing of cervis (NAAT, PCR)
85
What is the treamtent for chlamydia?
Doxycycline or Azithromycin
Lymphogranuloma venereum = doxycycline
Pregnant = Azithromycin (doxycycline causes fetal feeth discoloration)
86
Stages of syphilis
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
How do you diagnose syphilis?
Screening: RPR or VDRL
Treponemal tests (confirmation tests): FTA-ABS and MHA-TP
Visualizations of spirochetes on darkfield microscopy
88
What is the treatment of syphilis?
Benathine penicillin G
| - if allergic, desensitize
89
Presentation for genital herpes
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
How do you diagnose herpes?
Cytologic smear - multinucleated giant cells (Tzank test)
91
What is the treatment for HSV?
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
How do you diagnose HIV?
ELISA: detects Abs to HIV (sensitive, not specific)
Western Blot: confirmation of ELISA (very specific)
PCR: confirmatory
93
What are the lesions of HPV called?
condylomata acuminata (subtypes 6 and 11)
94
How does HPV present?
Warts of various sizes (cauliflower-like papules)
95
What is the treatment of HPV?
cryosurgery, laser ablation, electrocauterym trichloroacetic acid, aldara cream
96
How to differential ulcerating genital lesions with vesicles
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
What is the treatment of H. ducreyi?
Ceftriaxone, ciprofloxacin, or azithromycin
98
Bacterial Vaginosis
```
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
Candidiasis
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
Trichomoniasis
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
A women presents with a strawberry field appearance of the cervix. What is the most likely diagnosis?
Trichomonas vaginitis
102
What is the most common infection with an IUD?
Actinomyces: sulfa granules, gram positive + rod (like fungi)
103
What is the biggest risk factor for the development of breast cancer?
The patient's age
104
What is the blood supply to the breast?
Internal thoracic artery
Lateral thoracic artery
Posterior intercostal artery
Thoracoacromial artery
105
Screening mammogram
Every 1-2 years from age 40-49; after 50, annually
106
When should self breast exams start?
Age 18
| 1 week after period
107
When should clinical breast exams begin?
Age 21
108
Over the age of 40, what is the initial imaging modality of choice for a breast lump?
Diagnostic mammogram
109
< 40 years old, what is the imaging modality of choice for evaluating a breast mass?
Ultrasound
110
Follow up recommendations after aspiration of cystic mass in breast
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
Risk factors for breast cancer
```
personal hx of breast cancer
early menarche
nulliparity
alcohol intake
obesity
decreased physical activity
use of prolonged HRT (>5 yrs) during menopausal yrs
```
112
A rubbery, firm, freely mobile, solid, and well circumscribed breast lesion in women 20-40 years old?
Fibroadenoma
113
Cyclic breast pain?
Fibrocystic change (no increased risk for breast cancer, but should be completely excised)
114
When do you start scrrening for TSH?
```
Age 50, then every 5 years
Perioidic screening (19-64) if strong family history of thyroid disease or autoimmune disease
```
115
Options for emergency contraception
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
Down Syndrome (Trisomy 21)
uE3 - decreased
AFP - decreased
b-hCG - increased
Inhibin - increased
117
Edwards (Trisomy 18)
uE3 - decreased
AFP - decreased
b-hCG - decreased
Inhibin - decreased
118
FSH in menopause
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
Why does ovulation become less frequent in menopause?
Shortened follicular phase (luteal phase does NOT change)
120
What wet mount finding is consistent with atrophic vaginitis?
Very few epithelial cells
121
Physiology during menopause
- 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
Grading of plevic prolapse
Grade I: to level of ischial spines
Grade II: between ischial spines and introitus
Grade III: up to introitus
Grade IV: past introitus
123
Stress incontinence
Loss of urine (small amount) only with incread intra-abdominal
