OBGYN Shelf Flashcards
Clinical features of vaginal cancer (3)
Vaginal bleeding
Malodorous vaginal discharge
Irregular vaginal lesion
Risk factors for vaginal cancer (4)
Age > 60
HPV infection
Tobacco use
In utero DES exposure
Indication for endometrial bx
Postmenopausal bleeding and endometrial stripe >4mm on US
Theca lutein cyst presentation (3)
Multilocular
Bilateral
10-15 cm ovaries
Theca lutein cyst pathogenesis (3)
Ovarian hyperstimulation due to:
Gestational trophoblastic dz
Multifetal gestation
Infertility tx
Complete hydatidiform mole
A gestational trophoblastic dz resulting from the abnormal fertilization of an empty ovum by either 2 sperm or single sperm that duplicates its genome upon fertilization
The resultant gestation is composed of abnormal, proliferative trophoblastic tissue that secretes markedly elevated b-hCG.
b-hCG causes hyperstimulation of the ovaries and hypertrophy and luteinization of the theca cells. The thecal cells secrete androgens, leading to acute hyperandrogenism
Absolute contraindications for combined hormonal contraceptives (9)
Migraines with aura
Severe HTN
Ischemic heart disease, stroke
Age >35 and smoking >15 cigarettes/day
<3 weeks postpartum
Hx of VTE
Thrombophilia (factor V Leiden, antiphospholipid syndrome)
Active breast cancer
Active or severe liver dz
Vesicovaginal fistula
Aberrant connection between the bladder and vagina allowing urine to constantly drain into the vaginal, creating continuous, painless urinary leakage.
Dx visualization of pooling of clear fluid in vaginal on pelvic exam vs bladder dye testing
Causes and timing of vesicovaginal fistulas
Immediately following intraoperative bladder injury (c-section, hysterectomy)
Stress urinary incontinence (SUI)
Intermittent, involuntary loss of urine with increased intraabdominal pressure (coughing, laughing, sneezing).
D/t either decreased urethral sphincter muscle tone or urethral hypermobility from weakened pelvic floor muscles
Overflow incontinence
Continuous, painless loss of urine due to chronic urinary retention.
D/t diminished contractility of bladder detrusor (neurogenic bladder from DM), external compression of urethral outlet (fibroids, prolapse) that impede bladder emptying
Peripartum cardiomyopathy (PPCM)
Dilated cardiomyopathy that develops during the last month of pregnancy or within 5 months following delivery. Present with progressive dyspnea on exertion, lower extremity edema, and an S3 suggestive of decompensated heart failure. PPCM often causes secondary mitral regurgitation, which causes a holosystolic murmur best heard at the apex.
Overactive bladder (OAB)
Excessive involuntary detrusor muscle spasms creating a sudden urge to urinate, typically followed by an immediate loss of urine
3 type of urinary incontinence
Stress urinary incontinence
Overflow incontinence
Urge incontinence/ overactive bladder
3 risk factors for peripartum cardiomyopathy
Maternal age >30
Multiple gestation
Eclampsia or preeclampsia
Peripartum cardiomyopathy management
Urgent delivery if hemodynamically unstable vs standard management of HFrEF (beta blockers, diuretics)
Ectopic pregnancy dx
positive hCG
Transvaginal US showing adnexal mass and empty uterus
Ectopic pregnancy clinical features
Abdominal pain, amenorrhea, vaginal bleeding
Hypovolemic shock in ruptured ectopic pregnancy
Cervical motion, adnexal and/or abd tenderness
+/- palpable adnexal mass
Ectopic pregnancy management
MTX if stable vs surgery if unstable
Preterm prelabor rupture of membranes (PPROM)
ROM <37 w gestation prior to the onset of labor (closed cervix and irregular cxns)
PPROM management
<34 w w/o complications require inpatient expectant management with prophylactic latency abx (ampicillin and azithromycin), corticosteroids (betamethasone) to decrease risk of NRDS, and fetal surveillance (nonstress test, fetal growth US)
Stress urinary incontinence management
Conservatives: pelvic floor muscle exercises to strengthen and stabilize pelvic musculature
Pts who fail conservative tx or desire surgical management can undergo midurethral sling procedure which prevents urethral hypermobility and allows urethral compression
Ddx for postpartum hemorrhage
Uterine atony
Retained products of conception
Genital tract trauma
Inherited coagulopathy
Abnormally elevated maternal serum AFP (MSAFP) work up
MSAFP >2.5 MoM is suggestive of fetal NTD but can also be due to benign causes such as multiple gestations and incorrect gestational age dating (most common cause)
Abnormal MSAFP level require US to evaluate for NTDs, multiple gestations, and determine accurate gestational age
Rubella infection during pregnancy
Can cause spontaneous, abortion, intrauterine fetal demise, or congenital rubella syndrome (deafness, cardiac defects, hepatosplenomegaly, cataracts, microcephaly)
All women are tested for rubella immunity at 1st prenatal visit by anti rubella IgG. Vaccination is contraindicated during pregnancy but all nonimmune pts should be vaccinated during the immediate postpartum period
Anemia in pregnancy
Hemoglobin <11 g/dL and MCV <80 fL
Rho(D) immunoglobulin administration
Rho(D) immunoglobulin administration given to Rh(D)-negative patients at 28 w and after delivery if the infant is Rh(D) positive. 1st trimester immunization is only indicated in the setting of uterine bleeding
Spinal epidural abscess presentation
Classic triad: fever, focal/severe back pain, and neurologic findings (motor/sensory changes, bowel/bladder dysfunction, paralysis)
Elevated ESR
Spinal epidural abscess management
Broad spectrum abx (ceftriaxone and vancomycin)
Urgent aspiration/surgical decompression
Classic exam findings of endometriosis
Posterior fornix tenderness,
Decreased uterine mobility
Uterosacral ligament thickening
Cervical motion tenderness
Adnexal mass
Rectovaginal septum, posterior cul-de-sac, and uterosacral ligament nodules
Endometriosis management
Initial tx: NSAIDs and combined OCP
Pts who fail medical management, diagnostic laparoscopy recommended because it allows for definitive dx and is therapeutic via removal of endometriotic lesions
Common symptoms of endometriosis
Chronic pelvic pain
Dysmenorrhea
Deep dyspareunia
Dyschezia
Infertility
Cyclic dysuria, hematuria
Clinical features of breast fibroadenoma
Solitary, firm, well circumscribed mobile mass
Cyclic premenstrual tenderness
Clinical features of a breast cyst
Solitary, well circumscribed mobile mass
+/- tenderness
Clinical features of fibrocystic changes
Multiple, diffuse nodulocystic masses
Cyclic premenstrual tenderness
Management of solitary palpable breast mass
Pts < 30: US +/- mamo
Pts >40: mamo +/- US
Pts 30-40: can do either
Preeclampsia definition
New-onset HTN (>140/90) at >20 w AND proteinuria OR signs/symptoms of other end-organ damage
Preeclampsia severe features
BP >160/110
Platelets <100,000
Creatinine >1.1 mg/dL or 2X normal
Elevated transaminases >2x ULN
Pulmonary edema
Vision or cerebral symptoms (HA)
Preeclampsia management
<37 w w/o sever features: expectant
>37 w or >34 w w/ severe features: delivery
Severe range BPs: IV labetalol, IV hydralazine, PO nifedipine
Magnesium sulfate seizure prophylaxis
HELLP syndrome
Hemolysis Elevated Liver enzymes and Low Platelets
Life-threatening disorder related to preeclampsia with severe features. Likely related to abnormal placental development early in pregnancy with the placental release of antiangiogenic factors which cause widespread maternal endothelial dysfunction and dysregulation of vascular tone
Clinical findings of HELLP syndrome
N/V
RUQ pain
HA
Visual changes
HTN
HELLP syndrome lab abnormalities (4)
Microangiopathic hemolytic anemia
Elevated liver enzymes
Thrombocytopenia
+/- proteinuria
HELLP syndrome treatment (3)
Delivery
Magnesium sulfate for seizure prophylaxis
Antihypertensives (hydralazine)
HELLP syndrome complications (5)
Abruptio placentae
Subcapsular hematoma
Acute renal failure
Pulmonary edema
DIC
Clinical features of uterine leiomyomas (fibroids) (3)
Heavy, prolonged periods
Pressure symptoms (pelvic pain, constipation, urinary frequency)
Obstetric complications (impaired fertility, pregnancy loss, preterm labor)
Enlarged, irregular uterus
Uterine leiomyoma work-up
US
Uterine leiomyoma treatment
Observation if asymptomatic vs hormonal contraception or hysteroscopic myomectomy
Cervical conization
A cone-shaped bx performed to remove the entirety of the transformation zone while allowing adequate depth to access the endocervical canal dysplasia. It is both diagnostic (evaluation for concurrent invasive cancer) and therapeutic (Removal of dysplasia
Adenocarcinoma in situ of the cervix
A premalignant lesion of cervical adenocarcinoma that has a 30-70% chance of progression to invasive cancer, along with a 15% chance of cobcurrent invasive cervical cancer.
Tx requires excision (cervical conization) of the lesion
Evaluation of atypical glandular cells on Pap in pts ≥35
Colposcopy
Endocervical curettage*
Endometrial bx*
*Nonpregnant
Evaluation of atypical glandular cells on Pap in pts ≤35 with risk factors
Colposcopy
Endocervical curettage*
Endometrial bx*
*Nonpregnant
Evaluation of atypical glandular cells on Pap in pts ≤35 without risk factors
Colposcopy
Endocervical curettage*
*Nonpregnant
GBS antenatal screening
Rectovaginal cx at 36-38 w gestation. Good for 5 weeks
Indications for intrapartum GBS prophylaxis
GBS bacteriuria or UTI in current pregnancy
GBS positive rectovaginal cx in current pregnancy
Unknown GBS status PLUS any of the following : <37 w, intrapartum fever, ROM >18 hrs
Prior infant with early-onset neonatal GBS infection
Intrapartum GBS prophylaxis
IV penicillin
If pt has a pcn allergy then cefazolin if mild vs clindamycin or erythromycin depending on sensitivity if severe pcn allergy
Active phase of labor
6-10 cm dilation
Has an expected, predictable rate of cervical dilation of ≥ 1 cm every 2 hours
Active phase arrest
No cervical change in 4 hours despite adequate cxns (≥200 Montevideo units averaged over 10 minutes)
OR
No cervical change in ≥6 hours with inadequate cxns
Management is c-section
Prostaglandin use in labor
Used for cervical ripening (softening the cervix) in early labor induction
Oxytocin
A uterotonic used to augment labor by increased the frequency and force of cxns if cxns are inadequate (<200 Montevideo units and can be used in protracted labor (cervical dilation rate <1 cm/2 hours but not arrested)
Protracted labor
Cervical dilation rate <1 cm/2 hours but not arrested
Initial evaluation of anovulatory infertility
TSH and PRL levels
Epithelial ovarian carcinoma presentation
Asymptomatic: incidental adnexal mass
Subacute: pelvic/ abdominal pain, bloating, early satiety
Acute: dyspnea, obstipation/constipation, abdominal distention
Epithelial ovarian carcinoma risk factors
Family hx
BRCA1, BRCA2
Age ≥50
Endometriosis
Infertility
Early menarchy/late menopause
Lab and US findings of epithelial ovarian carcinoma
Elevated CA-125
On US: solid, complex mass; thick septations; ascites
CA-125
a protein released by cells from the peritoneum, uterus, and fallopian tubes; which are in close proximity to the rapidly growing ovary (malignancy)
In postmenopausal women with malignant appearing mass, CA-125 aids in dz monitoring and response to tx
In postmenopausal women with benign-appearing mass, CA-125 stratifies the risk for cnacer
Cervical insufficiency
A structural weakness of the cervix causing spontaneous, painless cervical dilation and potential second-trimester pregnancy loss
Patient present with mild symptoms (increased vaginal discharge, light vaginal bleeding, pelvic pressure) on exam, bulging amniotic membranes may be seen
Rescue cerclage
A suture used to reinforce and add tensile strength to the cervix to prevent further dilation in the setting of cervical insufficiency
