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Obstetrics and Gynecology > OBSGYN OSCE review > Flashcards

OBSGYN OSCE review Flashcards

1
Q

what is included in a general gynecological history

A
  1. ID–> age, occupation, relationship status
  2. CC
  3. HPI–> onset, course, duration, OPQRST
  4. Menses
  5. Sexual history
  6. contraception
  7. PAP and mammography
  8. general gyne history
  9. PMH/past surgical history, meds, allergies
  10. social history
  11. family history
  12. obstetrical history
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2
Q

what questions do you ask on a menses history

A

LMP

menarche

regularity

frequency

interval

flow

spotting

PMS/dysmenorrhea

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3
Q

what should you ask on a sexual history

A

active?

age of coitarche

number of partners and gender

STI/blood born disease work up before?

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4
Q

what should you ask on history about contraception

A

method

duration

side effects

plans for future

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5
Q

what should you ask on a general gyne history

A

discharge

itching

dyspareunia

post coital bleeding

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6
Q

what is an outline for an obstetric history

A
  1. ID
  2. EDD my US/LMP, GA
  3. US dates
  4. LMP dates
  5. CC
  6. HPI–> 4 cardinal questions
  7. current OB history –> complications (diabetes, HTN), GBS status, blood type
  8. Past OB history –> SVD or C/S, reasons for C/S, miscarriages and abortions and their management and complications, PPH, transfusion required?
  9. past gyne history–> STI, paps etc
  10. PMHx, meds, allergies
  11. social history, family history
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7
Q

describe an approach to a focused gynecological physical exam

A
  1. inspection, vitals, stigmata of disease
  2. quick screen of HEENT, CV, Resp
  3. abdo exam–> IAPP, special maneuvers
  4. pelvic exam–> inspection, speculum exam, special swabs/pap, bimanual exam, rectovaginal exam
  5. testing for cervical/vaginal infections
    - -GC/chlamydia culture testing (endocervical)
    - -general swab for all other infections (posterior fornix) for gram stain (intracellular diplococci are gonorrhea and large gram positive rods are lactobacilli)
    - -pH paper test (lateral vaginal walls)
    - -whiff test with KOH
    - -vaginal saline wet prep (trich vs BV)
    - -vaginal saline wet prep plus KOH
  6. bimanual exam–> vaginal walls, cervix, CMT, uterus (size, mobility), adnexa, uterosacral nodularity
  7. rectovaginal exam
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8
Q

what does large gram positive rods on endocervical swab indicate

A

lactobacilli

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9
Q

what does intracellular diplococci indicate on endocervical swab indicate

A

gonorrhea

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10
Q

what does a vaginal saline wet prep test for

A

trich vs BV

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11
Q

what does a vaginal saline wet prep plus KOH test for

A

yeast

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12
Q

describe an approach to the pelvic exam

A
  1. introduction and detailed explanation–> empty bladder–> abdo exam
  2. wash hands, sterile gloves, get all equipment ready
  3. give notice
  4. inspection–> vesicles, lacerations, rash etc
  5. speculum exam–> use hot water as lubricant instead of lube, comment on anatomy
  6. pap–> SHORT end of spatula and cytobrush (NEVER in pregnant women) –> wipe on slide and then fix
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13
Q

describe an approach to a focused obstetrical exam

A
  1. inspection, vitals, stigmata of disease
  2. quick screen of HEENT, CV, resp
  3. abdo exam–> IAPP
    - -intro and explanation, empty bladder
    - -examine on right side of patient
    - -palpate the fundus for contractions
    - -SFH
    - -leopolds maneuvers
  4. FHR–> baseline, variability, accels, decels
  5. sterile speculum exam
  6. vaginal exam (confirm no previa beforehand)
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14
Q

what are leopolds maneuvers

A

presentation–>

  1. fundus for whether head or bum
  2. lie–> longitudinal, oblique or transverse
  3. engagement
  4. attitude–> flexion/extension–cant assess unless head is engaged in pelvis
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15
Q

what are the cardinal movements of labour

A
  1. engagement and descent
  2. flexion
  3. internal rotation
  4. extension
  5. restitution/external rotation
  6. expulsion
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16
Q

describe the cardinal movement of labour:

engagement and descent

A

biparietal diameter (largest transverse diameter) of the fetal head passes through the pelvic inlet–> most commonly assumes OT position

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17
Q

describe the cardinal movement of labour:

flexion

A

descending fetal head meets resistance of pelvic floor and passively flexes to allow smallest diameter to present to the pelvis–> posterior fontanel in the center of the birth canal

remains OT

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18
Q

describe the cardinal movement of labour:

internal rotation

A

occiput rotates anteriorly to come under the symphysis–> OT into oblique position, OA or OP (OA most common)

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19
Q

describe the cardinal movement of labour:

extension

A

occiput comes into direct contact with inferior part of maternal symphysis and swivels under the bone, extending the head as it comes clear… chin delivers last

check nuchal cord after this

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20
Q

describe the cardinal movement of labour:

restitution

A

head restitutes to the original position before internal rotation–> transverse position to bring fetal shoulder in line with AP diameter of pelvic outlet

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21
Q

describe the cardinal movement of labour:

expulsion

A

anterior shoulder comes under symphysis, folloed by posterior shoulder, distends peritoneum

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22
Q

what is the shortest diameter of the pelvis

A

interspinous diameter

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23
Q

how do you manage the placenta after expulsion of the neonate

A

signs: sudden gush of blood, lengthening of the cord, uterus is globular and firm

check for 3 vessels, attachment point of cord, succenturiate lobe, is it complete

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24
Q

describe an approach to a vaginal exam in labour

A

general inspection

assess cervix

  • -location
  • -consistency
  • -effacement
  • -dilation
  • -membranes

assess fetus

  • -presenting part (cephalic/breech)
  • -position (triangle is OA)
  • -station (NOT assessable in blue box)
  • -caput (NOT assessable in blue box)
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25
Q

what are the causes and risk factors for PPH

A

PREVIOUS history of PPH

tone

tissue

trauma/tears

thrombosis

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26
Q

what kinds of things can cause uterine atony leading to PPH

A

inversion

overdistended uterus–> macrosomia, multiples, poly, multiparity

exhausted uterus from prolonged labour, rapid labour, augmentation, chorioamnionitis

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27
Q

what kinds of tissue problems can cause PPH

A

retained POC

incomplete placenta

invasive placenta–accreta

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28
Q

what kinds of trauma and tears can cause PPH

A

hematoma

uterine rupture

lacerations (cervix, vagina, episiotomy)

assisted delivery

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29
Q

what kinds of thrombotic events can cause PPH

A

coagulopathy

anticoagulant tx

intravascular hemolysis and DIC

severe preeclampsia/eclampsia

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30
Q

how would you manage a PPH

A
  1. call for help
  2. ABCs, vitals
  3. two large bore IVs, start NS
  4. lab–> group and screen, crossmatch and coag profile
  5. foley catheter to monitor urine volume
  6. assess and manage TONE
    - -bimanual massage
    - -oxytocin 40 U IV in 1 L NS–> fast infusion
    - -misoprostol suppository/hemabate/ prostin/ methergine/ ergotamine
  7. assess and manage TISSUE
    - -check placenta–manual removal of retained
    - -express uterus for clots
  8. assess and manage trauma/tears
    - -repair
  9. assess and manage thrombosis
    - -replace missing factors according to coag results
    - -packed RBCs, platelets
  10. surgical management
    - -Bakri balloon insertion
    - -D and C
    - -ligation of uterine/ovarian artery (main branches of internal iliac)
    - -embolization
    - -hysterectomy
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31
Q

how much/how would you administer oxytocin in the context of a PPH

A

40 U IV in 1 L NS fast infusion

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32
Q

what are some ways to prevent PPH

A

10 U of oxytocin IM after anterior shoulder delivery

breast feeding ASAP to cause uterine contraction

if has risk factors, be ready with IV etc

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33
Q

what are complications from PPH

A

anemia

Sheehans–> unable to breastfeed due to low PRL–> check other hormones

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34
Q

what is the ddx for AUB/menorrhagia that presents as a heavier than normal period

A

fibroid

adenomyosis

endometrial polyp

coagulopathy

could also be…
endometrial hyperplasia or cancer
cervical polyps or cancer

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35
Q

what is the ddx for AUB/menorrhagia that presents as intermenstrual bleeding

A

breakthrough bleeds from OCP/IUD

cervical polyp/ectropion

infection (endometrial, cervical or vaginal)

endometrial hypertrophy or cancer

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36
Q

what is the ddx for AUB/menorrhagia that presents as post coital bleeding

A

cervical polyp

cervical friable lesion

cervical cancer

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37
Q

what are some “other” causes for AUB/menorrhagia

A

trauma

lacerations

instrumentation

thyroid problem/prolactin problem

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38
Q

what history should you ask, beyond normal gyne history, in the setting of AUB/menorrhagia

A

intermenstrual, menstrual or post coital?

associated symptoms–fever, pain, discharge?

pregnancy?

family history of coagulopathy or cancers?

constitutional sx?

menopausal sx?

risk factors for endometrial cancer

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39
Q

what are the risk factors for endometrial cancer

A

early onset of menarche

late menopause

nulliparity

diabetes

obesity

exogenous estrogen use

chronic anovulation (irregular periods)

personal history

family history

lack of OCP use

HTN

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40
Q

what physical exam should you do for AUB/menorrhagia

A

inspection/vitals
height and weight
signs of anemia?
stable?

quick HEENT/CV/RESP/GI screen (rule out other sources of bleeding

abdo exam–> IAPP and special maneuvers

pelvic exam–> inspection, speculum, bimanual

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41
Q

what labs should you do for AUB/menorrhagia

A

pregnancy test

CBC

TSH, PRL, FSH

coagulation workup–> INR, PTT, fibrinogen

androgen workup if hirsutism suspected

pap smear

cultures for STI

endometrial biopsy

hysteroscopy if you have one

pelvic U/S or transvaginal U/S for endometrial thickness

HSG (MRI)

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42
Q

treatment for uterine bleeding due to fibroids

A

NSAIDS

provera

danazol

GnRH agonists for 3-6 mo to shrink fibroids

uterine artery embolization

hysteroscopic/lap/abdo myomectomy

hysterectomy

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43
Q

treatment for uterine bleeding due to adenomyosis

A

hormonal regulation

endometrial ablation

hysterectomy

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44
Q

treatment for uterine bleeding due to endometrial hyperplasia

A

progestin therapy

D and C

hysterectomy

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45
Q

treatment for uterine bleeding due to endometrial cancer

A

TAHBSO

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46
Q

how do you manage mild to moderate uterine bleeding

A

OCP

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47
Q

how do you manage severe uterine bleeding

A

admit

stabilize

premarin IV then to oral estrogen when bleeding stops

NSAIDS, OCPs, progestin, danazol, IUD, D and C, endometrial ablation, hysterectomy

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48
Q

ddx for oligomenorrhea

A

PCOS

pregnancy

anovulation

hypothyroid/
hyperprolactinemia

hypo hypo–> stress, anorexia, exercise

anovulatory

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49
Q

ddx of PCOS/hirsutism

A

PCOS

metabolic syndrome

cushings

androgen secreting tumour

CAH

androgen drug exposure

theca lutein cysts

stromal hyperplasia/
hyperthecosis

idiopathic hirsutism due to high 5 alpha reductase activity

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50
Q

history to ask for PCOS/hirsutism

A

onset and signs of hyperandrogenism –> if rapid with virilization–> consider androgen secreting tumour

signs of virilization

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51
Q

physical exam for PCOS and hirsutism

A

focus on clinical signs of virilism/hirsutism –>

male pattern balding

acne

oily skin

truncal obesity

acanthosis nigricans

pubic hair distribution

deepening of voice

increased muscle mass

clitoromegaly

breast atrophy

male body habitus

cushinoid features

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52
Q

labs to order for PCOS/hirsutism

A

CBC

serum testosterone

DHEA-S

serum 17-OHP

dexamethasone suppression test and 24 hour urine cortisol

FSH, LH, PRL, TSH, beta hCG

cholesterol panel

DM screen

pelvic U/S or transvaginal U/S

endometrial biopsy

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53
Q

treatment for PCOS

A

lifestyle mods

screening/monitoring for endometrial cancer, HTN, dyslipidemia, DM, sleep apnea

if trying to conceive–> weight loss, clomiphene citrate, metformin, FSH injection, ovarian drilling or IVF

if not trying to conceive–> weight loss, OCP/progestin and anti-androgens

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54
Q

how do you diagnose gestational DM

A

SCREEN with 50 mg glucose load at 24-28 weeks–> measure 1 hour later

  • -if above 7.9 mmol/L, confirm with 75 g OGTT test
  • -if above 10.3 mmol/L, diagnosis is made

DIAGNOSE with 2 hr 75mg OGTT after overnight fast–2 or more abnormal values is diagnostic

  • -fasting above 5.1 mmol/L
  • -1 hour above 10 mmol/L
  • -2 hour above 8.5 mmol/L

if GDM is diagnosed, then have to do a 75g OGTT at 6-12 weeks post partum

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55
Q

what complications are associated with GDM

A

fetal macrosomia

birth injury

neonatal hypoglycemia

hypocalcemia

hyperbilirubinemia

polycythemia

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56
Q

how do you manage GDM

A
  1. nutritional counseling
    - -BG self monitoring
    - -count carbs (200-220 g carbs per day)
    - -aim for fasting BG less than 5.3, post prandial less than 7/8
  2. start insulin therapy if targets not reached within a matter of 1-2 weeks
  3. serial assessment of fetal wellbeing especially if insulin treatment
    - -fetal movement counting daily
    - -U/S for growth, fluid, dopplers, NST, BPP
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57
Q

what is the starting dose of insulin for GDM

A

4U short acting/rapid acting insulin before meals

4U intermediate acting at bedtime (NPH)

total daily doses–> 0.6U/kg before 6 weeks, 0.7U/kg 6-18 weeks, 0.8U/kg from 18-26 weeks, 0.9U/kg from 26-30 weeks, 1U/kg from 36-40 weeks

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58
Q

how do you manage delivery in GDM

A

check level q1-2 hours and give IV insulin infusion/dextrose infusions if glucose levels exceed 6.5mmol/L

early induction of labour at 38-40 weeks

avoid forceps/vacuum due to increased risk of shoulder dystocia

prophylactic C/S for macrosomia (i.e above 4500-5000 g)

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59
Q

how do you manage GDM post partum

A

6-12 weeks post partum, do 75g 2 hour OGTT

annual fasting glucose to screen for T2DM

lifestyle mods

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60
Q

what is the workup for HELLP

A

CBC–platelets, HgB– plus diff

lytes

AST, ALT

albumin

bilirubin

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61
Q

workup for DIC/hemolysis

A

INR

PTT

fibrinogen

LDH

peripheral smear

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62
Q

renal workup

A

Cr

Uric acid

BUN

UA

24 hour protein urine

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63
Q

how do you manage an acutely elevated BP in a pregnant woman (including dosages)

A

treat immediately if sBP above 160 or dBP above 110 –> try and get it below this

  1. nifedipine (10 mg q45 min)
  2. labetalol (20 mg IV q 30 min)–contraindicated in asthma or heart failure
  3. hydralazine (5 mg IV q 30 min)

4 for seizure prophylaxis–> MgSO4 4g STAT over 20 min then 1g/hr–> antidote is calcium gluconate

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64
Q

how do you manage chronically elevated BP in a pregnant woman

A

goal is sBP 130-135 and dBP 80-105

  1. methyldopa
  2. labetolol/nifedipine XL 30 mg daily at 18:00
  3. diuretics if have special indications

avoid ACEi, angtiotensin II receptor antagonists, atenolol

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65
Q

how do you manage HELLP acutely

A
  1. order blood products, including platelets
  2. platelet transfusion prior to vaginal delivery/C section if count is below 20
  3. consider corticosteroids if count is below 50
  4. Mg prophylaxis (4 g stat over 20 min then 1g/hr)
  5. stabilize and deliver at all GA
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66
Q

how do you manage eclampsia acutely

A

call for help

ABC

stabilize

deliver

MgSO4 2g IV STAT to control seizures then 1.5g/hr plus valium

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67
Q

what BP meds are safe for breastfeeding (to control HTN post partum)

A

nifedipine

labetalol

methyldopa

captopril

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68
Q

non gyne ddx for PID

A

appendicitis

diverticulitis

bowel perf

inflammatory bowel disease

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69
Q

gyne ddx for PID

A

ectopic

ovarian torsion

tubo-ovarian abscess

hemorrhagic cyst rupture

TB salpingitis

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70
Q

what should you ask on history for PID

A
  1. how old are you (15-25 yo is highest risk)
  2. age at first coitus
  3. form of contraception
  4. sexual history–how many sexual partners recently?
  5. new partner?
  6. prior history of PID/pelvic infections or STDs? worked up for STDs in the past?
  7. smoker?
  8. recent instrumentation like IUD insertion, D and C etc
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71
Q

what elements to look for on physical exam for PID

A

unstable vitals, may have high fever

abdo tenderness with or without rebound tenderness and peritonitis

Fitzhugh curtis syndrome

increased vaginal discharge with abnormal odour, abnormal bleeding

adnexal tenderness, uterine tenderness

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72
Q

what is Fitzhugh curtis syndrome

A

inflammation of the liver capsule due to PID leading to adhesions

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73
Q

what tests should you order for PID

A

CBC

ESR

chlamydia and gonorrhea cervical gram stain

beta hcg

LFTs

kidney function

lactate

blood culture

pelvic U/S

do a diagnostic lap if appy cant be ruled out

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74
Q

how do you manage PID

A

if stable–outpatient with follow up in 48-72 hours

hospitalize if indicated

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75
Q

when should you hospitalize with IV abx for PID

A
  1. unstable vitals, severe V and V, high fever, septic
  2. if surgical emergency i.e appy cant be excluded
  3. pregnant
  4. likely to be non compliant at outpatient
  5. unresponsive to oral therapy
  6. known tubo-ovarian abscess
  7. presence of IUD
  8. immunodeficient or HIV positive
  9. peritonitis present in upper quadrants
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76
Q

what is the oral abx tx for PID

A

ceftriaxone 250 mg IM plus doxycycline 100 mg PO BID for 14 days with or without metronidazole 500 mg PO BID for 14 days

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77
Q

what is the IV tx for PID

A

cefoxitin 2g IV q6h plus doxycycline 100 mg IV/PO q 12h

continue IV tx until clinical improvement for 24 hours–> then step down to oral doxycycline

if allergic to cephalosporins, use IV clinda and genta

78
Q

how do you treat tubo-ovarian abscess

A

ampicillin to cover gram positive plus gentamicin to cover gram neg plus metronidazole to cover anaerobes

79
Q

what does ampicillin cover

A

gram positive

80
Q

what does gentamycin cover

A

gram negative

81
Q

what does metronidazole cover

A

anaerobes

82
Q

what are the most common organisms causing PID

A

chlamydia is more common that gonorrhea

83
Q

what are the possible sequelae of PID

A

infertility

ectopic pregnancy

chronic pelvic pain

dyspareunia

pelvic adhesions

84
Q

what are the things to think about for post partum care with regard to:
brain

A

baby blues

PP depression

PP headache

contraception

85
Q

what are the things to think about for post partum care with regard to:
breasts

A

skin to skin

breastfeeding

engorgement

mastitis

86
Q

what are the things to think about for post partum care with regard to:
bowel

A

constipation

87
Q

what are the things to think about for post partum care with regard to:

bladder

A

diuresis

incontinence

UTI

88
Q

what are the things to think about for post partum care with regard to:

belly

A

uterine involution

endometritis

incision site

after pain

skin

89
Q

what are the things to think about for post partum care with regard to:

bleeding

A

PPH

lochia

90
Q

what are the things to think about for post partum care with regard to:

bottom

A

hemorrhoids

perineum

91
Q

what is a way to remember all the things to cover in post partum care

A

7 Bs

brain, breasts, bowel, bladder, belly, bleeding, bottom

92
Q

non obsgyn ddx for ectopic

A

appendicitis

diverticulitis

cystitis/stone

93
Q

obstetric ddx for ectopic

A

ovarian torsion

hemorrhagic cyst rupture

PID

94
Q

gyne ddx for ectopic

A

threatened abortion

95
Q

what should you ask on history for ectopic

A

previous hx of ectopic

hx of PID/pelvic infection or STI/pelvic surgeries or endometriosis

IVF

means of birth control–IUD?

congenital abnormalities of the tube?

96
Q

what should you look for in physical for ectopic

A

general well being and vitals

peritoneal signs–rupture?

tender adnexa, uterus small for GA

97
Q

what labs should you get for ectopic?

A

CBC

type and screen

crossmatch

quantitative b hCG

transvaginal U/S

LFTs and renal function

98
Q

what should you do in the case of a suspected ectopic, hCG less than 2000, cant see IUP

A

monitor 48 hours (must increase by 66%)

99
Q

what should you do in the case of a suspected ectopic, nCG above 2000 and cant see IUP

A

likely ectopic

100
Q

what three signs suggest a ruptured ectopic

A

positive pregnancy test

hemodynamic instability

peritoneal signs

101
Q

how do you manage a ruptured, unstable ectopic

A

ABCs

large bore IVs with NS/blood product and pressors ready

exploratory laparotomy to stop bleeding and remove ectopic

*if ruptured but stable, can do exploratory laparoscopy to evacuate hemoperitoneum, coagulate bleeding and salpingotomy/ salpingectomy

102
Q

what are the options for an unruptured, stable ectopic

A

surgery or methotrexate

103
Q

what are the criteria for using methotrexate for an ectopic

A

less than 3.5 cm

no FH motion seen

hCG below 5000

hemodynamically stable and no signs of rupture

104
Q

what is the dosing of methotrexate for ectopic

A

50 mg/m2 IM

track serial HCG

105
Q

contraindications to methotrexate therapy for ectopic

A

hemodynamically unstable

impending/ongoing ectopic mass rupture

immunodeficient, active pulm disease, peptic ulcer disease

coexistent viable intrauterine pregnancy

breastfeeding

non compliant with follow up

baseline hematologic/RENAL/ hepatic lab values that are abnormal

106
Q

what are the surgical options for treatment of ectopic

A

laparoscopy for salpingotomy or salpingectomy
–> follow HCG weekly until less than 5

laparotomy if unstable

107
Q

ovulatory ddx for infertility

A

advanced maternal age

hypo hypo

PRL

hypothyroid

POF

ovarian tumour

PCOS

obesity

androgen excess (i.e CAH)

cushings

108
Q

structural ddx for female infertility

A

blocked tubes–> PID, tubal ligation, endometriosis, previous ectopic, pelvic adhesions

uterine fibroids

congenital malformation of the uterus

uterine septum

uterine polyps

asherman’s syndrome

cervical stenosis from procedures or infection

cervicitis

109
Q

ddx of male causes of infertility

A

abnormal sperm

testicular failure from mumps/trauma

varicocele

chromosome abnormalities (Klinefelter)

impotence

hypo hypo

110
Q

labs to order to work up infertility

A

semen analysis

confirmation of ovulation

TSH

PRL

day 21 progesterone

FSH

LH

pap smear

STD cultures

111
Q

how to work up possible ovulatory causes of infertility

A

menstrual history

mid luteal progesterone

LH urinary kit

basal body temp

FSH, LH, PRL, TSH

testosterone, DHEAS, 17-OHP, 24 hour cortisol

overnight dex suppression test

day 3 FSH

clomiphene challenge test

antral follicle count

AMH

112
Q

work up of structural causes of female inferility

A

HSG

hysteroscopy

pelvic U/S

laparoscopy

113
Q

workup of male infertility

A

semen analysis

TSH, FSH, PRL, testosterone

karyotype

testicular U/S

114
Q

management of ovulatory causes of infertility

A

correct endocrine problems

clomiphene

gonadotropin injection

115
Q

management of structural causes of female infertility

A

surgical correction if possible

endometriosis corrected by lap/IVF

tubal disease–> lap or IVF

surrogate

116
Q

management of male infertility

A

improvement in coital practices

varicocele repair

low semen volume or poor semen managed by washing sperm for ICSI and IUI

117
Q

what do you do if infertility remains unexplained

A

IVF and ICSI or donor sperm and egg

118
Q

menopause symptoms related to menstruation

A

change in flow

irregular

119
Q

menopause symptoms related to urogenital

A

incontinence, UTIs

vaginal atrophy, dyspareunia

vaginal dryness/itching

shrinking length and diameter

reduced sensitivity and libido

increased trauma

pelvic prolapse

120
Q

menopause symptoms related to vasomotor

A

hot flashes

night sweats

insomnia

121
Q

menopause symptoms related to psych

A

worsening PMS

depression

irritability

mood swings

loss of concentration

poor memory

anxiety

122
Q

menopause symptoms related to other

A

weight gain

skin changes

dental changes

123
Q

what physical exams should be done when a woman is presenting in menopause

A

full physical from head to toe

include breast, pelvic (sensitive because atrophy) and pap smear

124
Q

what labs should be ordered in menopause

A

FSH to confirm

cholesterol level, DM screening, mammography if warranted, pap, UA, DEXA if high risk for OP, TSH

125
Q

lifestyle mods for menopause

A

weight bearing exercise and eat healthy

stop smoking

reduce caffeine and alcohol

126
Q

what meds can be used to manage menopause

A

HRT for 6-12 mo if still has uterus

vitamin D and calcium/ bisphosphonate for OP

vaginal estrogen cream or lubricant for vaginal atrophy

SSRI/SNRI/Clonidine for vasomotor symptoms

127
Q

contraindications to HRT for menopause

A

chronic liver impairment

pregnancy

known estrogen dependent neoplasm (breast, ovary, uterus)

hx of clots

undiagnosed vag bleeding

128
Q

benefits of HRT for menopause

A

improves sx

decreases bone loss

decreases colon ca

reduces CV risk if begun early in menopause

129
Q

risks of HRT for menopause

A

increased risk of breast ca

cholecystitis

CV risk if started after menopause

130
Q

ddx for vaginal discharge

A

BV

trichomonas

yeast infection

chlamydia and gonorrhea

normal discharge of ovulation

bartholin’s duct abscess

non gyne discharge

rule out: PID, TSS, endometritis

131
Q

what should you rule out with pelvic disharge

A

PID

TSS

endometritis

132
Q

what are the 4 cardinal questions of obstetrics

A
  1. are you bleeding
  2. has your water broken
  3. are you having contractions
  4. is the baby moving

1-3–> is she in labour?

4–> baby’s health

133
Q

GO OVER ANTEPARTUM HEMORRHAGE CARDS

A

DO IT–for bleeding in third trimester

134
Q

what is the mechanism of the combined OCP

A

suppresses ovulation

thickens cervical mucus

prevents tube peristalsis

decidualizes endometrium

97% effective in typical use

135
Q

pros of the combined OCP

A

improved cycle regulation

less dysmenorrhea, menorrhagia, PMS sx

increased bone mineral density

decreases PID, endometriosis, ectopic pregnancy

decreased endometrial and ovarian ca

decreased fibroid risk, functional cysts, benign breast disease

less colon ca

decreased perimenopausal sx

less acne or hirsutism

136
Q

cons of the combined OCP

A

spotting/breakthrough bleeding

breast tenderenss

nausea, vomiting

mood changes

fluid retention and weight gain

headache

mild increase in clotting

post pill amenorrhea up to6 mo

gall bladder disease–cholelithiasis, cholecystitis

benign liver adenoma (rare)

cervical adenoca (rare)

retinal thrombosis (rare)

137
Q

absolute contraindications to the combined OCP

A

pregnancy

less than 6 weeks post partum and lactating

history of DVT, PE, VTE

hereditary thrombophilia

smoker over age 35 with more than 15 cigs per day

ischemic heart disease

CVA

uncontrolled HTN (sBP above 160 or dBP above 100)

complicated valvular disease (pulm HTN, a fib, subacute bacterial endocarditis)

migraine headache with aura or focal neuro sx

DM with neuropathy/retinopathy/ nephropathy

severely high cholesterol

BREAST/ENDOMETRIAL CA

LIVER DISEASE

UNEXPLAINED VAG BLEEDING

138
Q

relative contraindications to combined OCP

A

controlled HTN

fibroids

lactating

migraines in women over 35

high cholesterols

mild liver disease

symptomatic gall bladder disease

history of cholelithiasis on OCP

lupus

seizure disorder

use of meds that interfere with OCP metabolism

139
Q

drugs that reduce the efficacy of the OCP

A

barbituates

carbamazepine

phenytoin (dilantin)

rifampin

st johns wort

topiramate

140
Q

medications whose efficacies are changed by the OCP

A

diazepam (valium)

hypoglycemics

methyldopa

phenothiazines

theophylline

TCA

141
Q

what advice should be given to a woman just starting the OCP

A

start immediately

take pill for 21/28 days then for the 7 days take placebo or no pill

may get withdrawal bleeding within 3-5 days of completion of 21 days or hormones

for first week–> USE BACK UP CONDOM

take at same time every day

142
Q

what do you do if you miss a dose of the OCP in the first week

A

missed 1 pill–> take the 1 missed pill and continue rest of packet at normal

if missed more than 1 pill–> take 1 pill, then take 1 pill a day until the end of the packet; use barrier method for 7 days, and use emergency contraception if had unprotected sex within last 5 days

143
Q

what do you do if you miss a dose of the OCP in the 2nd or 3rd week

A

missed less than 3 pills–> take 1 pill and 1 pill a day until end of packet–> skip hormone free interval cycle

missed 3 or more pills–> take 1 pill and 1 pill a day until end of packer; use barrier method for 7 days and use emergency contraception if you had unprotected intercourse within the last 5 days; skip hormone free interval period

144
Q

how does the level of estrogen in the combined hormonal patch compare to the OCP

A

higher in patch

145
Q

how do you use the combined hormonal patch for contraception

A

change patch weekly for 3 weeks–no patch for 1 week, get withdrawal bleeding

146
Q

what do you do if you miss a combined hormonal patch in the first week

A

if delayed patch change for less than 1 day–> change patch ASAP and reapply new patch at same time next week

if delayed patch change for more than or equal to 1 day–> change patch ASAP and reapply new patch at same time next week… barrier method for 7 days and emerg contraception of unprotected sex for last 5 days

147
Q

what do you do if you miss a combined hormonal patch in the 2nd or 3rd week

A

if delayed patch change for less than 3 days–> change patch ASAP, reapply new patch at same time next week…finish current cycle and start new cycle without hormone free interval

if delayed patch change for more than or equal to 3 days–> change patch ASAP, reapply new patch at same time next week… finish current cycle and start new cycle right away without hormone free interval–> barrier method for 7 days and emerg contraception if unprotected sex within last 5 days

148
Q

how does the nuva ring work

A

continuous low steady hormones

total hormone exposure is lower

left in place for 3 weeks then removed for 7 days with withdrawal bleeding

149
Q

what do you do if you miss a nuva ring in the first week

A

ring absent for less than or equal to 3 hours–> insert ring ASAP and keep scheduled ring cycle

ring absent for more than 3 hours–> insert ring ASAP and keep scheduled ring cycle with addition of barrier for 7 days and emerg contraception if unprotected in last 5 days

150
Q

what do you do if you miss a nuva ring in the second or third week

A

ring absent for less than 3 days–> insert ring ASAP and keep scheduled ring cycle… no hormone free interval before next cycle

ring absent for more than or equal to 3 days–> insert ring ASAP and keep scheduled ring cycle… no hormone free interval before next cycle… ass barrier for 7 days, emerg contraception if unprotected in last 5 days

151
Q

absolute contraindications to DMPA

A

pregnancy

breast ca

unexplained vag bleeding

152
Q

what happens if you are taking the progestin only pill, and you delay your pill by more than 3 hours or miss more than or equal to 1 pill

A

if you had unprotected intercourse in last 5 days–> emerg contraception–> continue taking one pill daily at same hour–> back up contraception for 48 hours

if no recent unprotected sex–> take 1 pill asap, continue daily at same hour… back up contraception for 48 hours

153
Q

what meds have drug interections with Yuzpe or Plan B

A

anticonvulsants

rifampin

st johns wort

154
Q

contraindications to emerg contraception

A

pregnancy

no contraindications for hormonal meds

155
Q

contraindications for copper IUD

A

uterine anomaly

undiagnosed vag bleeding

stenosed cervix

wilsons disease

copper allergy

PID/STI

cervical or endometrial ca

inability to place/retain device

156
Q

what should you counsel the patient on when they take emerg contraception

A

need to take as soon as possible

side effects

some spotting/period like bleeding can happen after taking pills

next period will be off by 2-3 days

followup with GP–> if no period within 3 weeks–> take pregnancy test

get a regular form of birth control and use condoms to prevent STIs

157
Q

what are common side effect of emerg contraception

A

nausea

vomiting

fatigue

dizziness

if you vomit within 1 hour of taking pill, may need another dose

158
Q

definition of primary amenorrhea

A

no menses by age 14 with no secondary sex characteristics OR no menses by 16 with secondary sex characteristics

159
Q

definition of secondary amenorrhea

A

no menses for 3 mo if normal cycle, and 9 mo if previous oligomenorrhea

160
Q

what is the ddx for primary amenorrhea regarding the hypo/pituitary axis

A

stress

diet

exercise

congenital GnRH deficiency or tumour suppression

constitutional delay

hyperprolactinemia

hypothyroid

infiltrative disease

161
Q

what is the ddx for primary amenorrhea regarding the ovary

A

congenital dysgenesis (i.e turners, XY, XX)

gonadal dysgenesis –> XY–sawyers syndrome

PCOS

162
Q

what is the ddx for primary amenorrhea regarding the congenital outflow tract

A

imperforate hymen

transverse vaginal septum

mullerian agenesis

163
Q

what is the ddx for primary amenorrhea regarding receptor/enzyme problems

A

complete androgen insensitivity (46 XY)

5 alpha reductase deficiency

17 alpha reductase deficiency

164
Q

what should you rule out first in the setting of secondary amenorrhea

A

PREGNANCY

165
Q

what can cause hypo hypo secondary amenorrhea

A

stress
diet
exercise

PRL

hypothyroid

infiltrative disease

inflammatory/iatrogenic causes

meds

ANYthing that damages the hypothalamus or pituitary

sheehans

166
Q

what can cause hyper hypo secondary amenorrhea

A

premature ovarian failure

perimenopausal

turners

167
Q

what can cause eugonadotropic hypogonadism leading to secondary amenorrhea

A

PCOS

outflow tract abnormality (ashermans, cervical stenosis)

168
Q

what can cause secondary amenorrhea that has not yet been covered

A

non classical CAH

steroid secreting tumours of the ovary

adrenal tumour

chronic disease

169
Q

what should you ask on history for amenorrhea

A

endocrine sx–> galactorrhea, weight loss, diet, thyroid sx, hirsutism, virilization

170
Q

what should you focus on on physical for amenorrhea

A

syndromal features?

neuro exam

signs of androgen excess or insulin resistance

galactorrhea, breast devel

signs of cushings

estrogenization in pelvic exam

171
Q

what tests should you order to work up amenorrhea

A

beta HCG

TSH

PRL

FSH

progestin challenge– > if bleeding, either PCOS or outflow tract abnormality//if not bleeding, do estrogen plus progestin challenge–> if bleeding, indicates low endogenous estrogen so measure FSH, LH–> if high FSH/LH–> karyotype (POF vs chromosome problem)//if low FSH/LH, do MRI (look for brain mass, infiltrations vs functional disease)

172
Q

when is SIPS offered

A

before 13+6 weeks

173
Q

when is QUAD offered

A

after 13+6 weeks

174
Q

what are the 5 parts of SIPS

A

at 10-13+6 weeks–> PAPP-A

at 15-20+6–> AFP, hCG, inhibin A, uE3

85% detection rate (vs 77% for QUAD)

4% false detection rate

175
Q

what trisomy is characterized by low MSAFP, low estriol, high beta hCG and low PAPP-A

A

trisomy 21

176
Q

what trisomy is characterized by low MSAFP, low estriol, low beta hcg and low PAPP-A

A

trisomy 18

177
Q

what trisomy is characterized by variable MSAFP, estriol, beta hcg

A

trisomy 13

178
Q

what is IPS

A

SIPS plus NT

179
Q

when is IPS offered

A

if mom is 35 or older at EDD

twins

IVF and ICSI

hx of child/pregnancy with trisomies

HIV positive

180
Q

what do you do if the nuchal translucency is above 3.5mm

A

NT above 3.5mm–> increased risk of fetal heart defect–> offer echo at 18-20

181
Q

what are the diagnostic prenatal tests

A

CVS and amnio

182
Q

when do you do a CVS or amnio

A

positive screening tests

mom above 40 at EDD

greater risk for chromosomal abnormality

multiple gestation AND above 35 at EDD

183
Q

when do you do CVS

A

between 10-12+6 weeks

184
Q

what is the CVS loss rate

A

1-2%

185
Q

what are the side effects of CVS

A

cramping, bleeding, infection

186
Q

what are the risks of CVS

A

fetal limb deformation if done early

187
Q

when is amnio done

A

after 15 weeks

188
Q

what is the amnio loss rate

A

0.5%

189
Q

what are the risks of amnio

A

bleeding

fluid leakage

infection

cramping

190
Q

what are the maternal risks of multiple gestation

A

preterm labour and PPROM

placenta previa

cord prolapse

PPH

cervical incompetence

GDM

preeclampsia

Obstetrics and Gynecology (21 decks)

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