Obstetric/Gynecologic Disorders Flashcards
hypertension in pregnancy prior to 20 weeks gestation
essential hypertension or molar pregnancy
conditions associated with increased nuchal translucency
down’s syndrome, turner syndrome, neural tube defects, congenital heart defects
decreased AFP, decreased unconjugated estriol, elevated inhibin A, elevated beta-hCG
down’s syndrome or turner’s syndrome
at what hemoglobin level should physiologic anemia of pregnancy be treated as iron deficiency anemia
first trimester: hemoglobin < 11
second trimester: hemoglobin < 10.5
what supplements should be given to women on anticonvulsants during pregnancy
folate and vitamin K (last month)
what supplements should be given to complete vegetarians during pregnancy
vitamin B12, iron, vitamin D
lab findings characteristic of HELLP syndrome
hemolysis, elevated liver enzymes, and low platelets
difference between preeclampsia and gestational hypertension
proteinuria, gestational hypertension is usually third trimester only
how long is magnesium sulfate continued after delivery in preeclampsia
24 hours
how long is magnesium sulfate continued after delivery in eclampsia
48 hours
what gestational age is maternal triple or quad screen offered to women?
16-18 weeks
when is 1 hour OGTT performed?
24-28 weeks
how does TSH change during pregnancy?
TSH stays the same, free T3/T4 stay the same
total T3/T4 increase because of increased thyroxine binding globulin
how much folate is needed in pregnancy
400 micrograms/day
how much iron is needed in pregnancy
30 mg/day
how much calcium is needed in pregnancy
1200 mg/day
when can amniocentesis be performed
after 16 weeks gestation
when can chorionic villous sampling be performed
after 9 weeks gestation
mccune-albright syndrome
females, pseudo-precocious puberty, cafe-au-lait macules, fibrous dysplasia of the bone
estrogen generated by ovaries
estradiol
estrogen generated by placenta
estriol
estrogen generated by fat tissue
estrone
nonhormonal options for menopausal hot flashes
desvenlafaxine, venlafaxine, clinidine, gabapentin, placebo, or just wait (most hot flashes resolve within 4-5 years)
what lab findings distinguish true precocious puberty from pseudoprecocious puberty
elevations of LH, FSH in central/true precocious puberty, further increased by GnRH stimulation
definition of precocious puberty
< 8 in girls
< 9 in boys
some causes of pseudoprecocious puberty
exogenous hormones, adrenal tumor, congenital adrenal hyperplasia, ovarian tumor, mccune-albright syndrome
definition of premature ovarian failure
> 1 year amenorrhea in women < 40
hormone associated with increase in basal body temperature
progesterone
how is body basal temperature increase associated with ovulation
1 degree increase occurs 1 day before ovulation
4 different options for emergency contraception
combination pill, progestin pill, copper IUD, anti-progestin
contraindications to OCP use
DVTs, smokers, breast/endometrial cancer, pregnancy, hepatic disease, migraine with aura
medications known for reducing effectiveness of OCPs
rifampin, griseofulvin, anti-epileptics, st. john’s wort
definition of primary amenorrhea
no menses by 16 w/secondary sexual characteristics or no menses by 13 w/o secondary sexual characteristics
first step in any work-up of amenorrhea
beta-hCG
basic components of work-up for secondary amenorrhea
beta-hCG, LH, FSH, TSH, testosterone, DHEAS, progestin withdrawal test
diagnosis: primary amenorrhea, absent secondary sex characteristics, anosmia
kalmann’s syndrome XXY, congenital absence of GnRH secretion
initial management of a woman presenting with secondary amenorrhea and new galactorrhea when beta-hCG is negative
TSH, free T4
positive beta-hCG, intrauterine pregnancy, closed os
threatened abortion
enlarged uterus, menometrorrhagia for months
uterine fibroids
bleeding associated with severe menstrual pelvic pain
endometriosis
menorrhagia, perimenopausal
endometrial hyperplasia until proven otherwise
abnormal uterine bleeding started with menarche
hereditary bleeding disorder
positive beta-hCG, severe pain, no fetus in uterus on US
ectopic pregnancy
metrorrhagia after intercourse, no pain, normal sized uterus
endometrial or cervical polyp
depression, constipation, abnormal uterine bleeding
hypothyroidism
outpatient treatment for abnormal uterine bleeding
estrogen 21-25 days
progesterone 10 days
heavy withdrawal bleed will occur
inpatient treatment for abnormal uterine bleeding with hemodynamic instability
2-4 L normal saline, transfuse PRBC
introduce tamponade transcervically and inflate to stop bleeding
IV premarin to stabilize and regrow endometrium
IV /phenergan to prevent N/V a/w high dose estrogen
medications used for PMS and PMDD
exercise, B6, NSAIDs, OCPs, progestins, SSRIs +/- alprazolam
treatment of choice for primary dysmenorrhea
OCPs, NSAIDs
most common cause of hirsutism in the US
PCOS
lab findings to diagnose PCOS
elevated LH, elevated total testosterone
medications used for syphillis
penicillin G, doxycycline, tetracycline
diagnosis of pelvic inflammatory disease
clinical diagnosis, abdominal/pelvic pain in the absence of other pathologies, cervical motion tenderness, leukocytosis, vagina/cervical discharge, elevated ESR/CRP
medications used for PCOS
exercise/weight loss
OCPs, clomiphene to induce pregnancy, metformin, sprionolactone
progestin withdrawal if cannot tolerate OCPs
which STD can be mistaked for IBD due to fistula formation
lymphogranuloma venereum due to L1, 2, L3 serotypes of chlamidya trachomatis
ASCUS on pap smear
surveillance, repeat pap smear 3-6 months
perform HPV screening
ASCUS x 2 on pap smear
colposcopy
ASCH on pap smear
atypical squamous cells, cannot exclude HSIL
colposcopy + ECC
AGUS on pap smear
atypical glandular cells
colposcopy + ECC
if age > 35, also perform endometrial biopsy
CIN1 on pap smear
surveillance, repeat pap smear 3-6 months
alternatively, go straight to colposcopy
CIN1 x 2 on pap smear
colposcopy
HSIL with precancerous lesion on pap smear
colposcopy + LEEP or conization
repeat cervical cytology every 6 months
management: squamous cell carcinoma of the cervix
surgical resection +/- chemotherapy
most important prognostic factor in endometrial cancer
histologic grade is more important than depth of invasion
management: squamous cell carcinoma of the vagina
< 2 cm, resection or internal radiation
> 2 cm, external beam radiation
generally, no chemotherapy
lichen sclerosis diagnosis and management
chronic inflammatory condition of anogenital region, most commonly affecting women
ivory/porcelain white macules and plaques with pruritis
treatment: low threshold for punch biopsy to r/o squamous cell carcinoma, steroids (clobetasol), or pimecrolimus
differential diagnosis for gynecomastia
puberty medications (spironolactone, cimetidine, amiodarone, ketoconazole, haloperidol, HAART therapy, digoxin herbal agents (tea tree oil, lavender oil), cirrhosis, hypogonadism, testicular germ cell tumor, hyperthyroidism, hemodialysis patients
herbal causes of gynecomastia
tea tree oil, lavender oil
most likely cause of bloody nipple discharge
intraductal papilloma
most common breast cancer
invasive ductal carcinoma
breast cancer often presents with serous or bloody nipple discharge
intraductal papilloma
most common breast mass in patients 35-50
fibrocystic changes of the breast
most common breast tumor in teen and young women
fibroadenoma
breast mass accompanied by redness, pain, and heat
inflammatory breast carcinoma
risk factors for endometrial cancer
unopposed estrogen, PCOS, obesity, nulliparity, diabetes, hypertension, family history, high fat diet, HNPCC
risk factors for ovarian cancer
ovulation, nulliparity, family history, BRCA1, BRCA2
serum marker elevated in endometrial cancer
CA-125 sometimes
serum marker elevated in ovarian cancer
CA-125 frequently
next step in management of CIN 2 cervical lesion identified on biopsy
excise with LEEP or conization or laser
next step in management of ASCUS pap smear
repeat pap smear 3-6 months
next step in management of AGUS pap smear
colposcopy with ECC
> 35, also endometrial biopsy
ovarian tumor associated with psammoma bodies
serous cyst adenocaricnoma
ovarian tumor associated with estrogen excess
granulosa cell tumor
ovarian tumor associated with androgen secretion
leydig cell tumor
treatment for DCIS
lumpectomy, possible radiation
consider mastectomy in high-risk individuals
treatment for LCIS
observation, possible treatment with tamoxifen/raloxifene
normal reactive nonstress test
two or more 15 bpm accelerations lasting at least 15 seconds within 20 minutes
fetal tachycardia
> 160 bpm
caused by maternal infection, dehydration, chorioaminionitis, fetal anemia, maternal thyrotoxicosis, fetal tachyarrhythmias, tertbutaline (beta-agonist), fetal hypoxia
fetal bradycardia
< 110
what causes a fetal heart rate with a sinusoidal pattern
fetal anemia
normal fetal variability
x6-25 bpm
what is the definition of PROM
premature rupture of membranes before the onset of labor, increased risk with vaginal/cervical infection or cervical incompetence, prior to 37 weeks
when to suspect chorioamnionitis in a patient with PROM
if fever present with maternal or fetal tachycardia, maternal leukocytosis, or uterine tenderness or foul smelling discharge
at what gestational age is labor managed actively instead of expectantly in preterm labor
34 weeks or if there is proven fetal lung maturity in younger fetuses
what are the risk factors for placental abruption
trauma, cocaine, smoking, chronic HTN, preeclampsia, PROM, multiple gestations, multiparity
drugs used for tocolysis
tertbutaline, ritodrine, magnesium sulfate, or less commonly indomethacin, nifedipine
reversal agent in cases of magnesium toxicity
calcium gluconate
components of biophysical profile for assessment of fetal well being
amniotic fluid index, fetal tone, fetal breathing, fetal movement, non-stress test
early decelerations
fetal head compression, no treatment necessary
variable decelerations
cord compression, reposition mother
late decelerations
uteroplacental insufficiency, fluid resuscitation, address underlying problem if posisble
definition of oligohydramnios
AFI < 5
definition of polyhydramnios
AFI > 25
classic signs and symptoms of magnesium toxicity
decreased DTRs, respiratory arrest, cardiovascular arrest
infertility work-up
semen analysis, LH/FSH, HSP, endometrial biopsy
ideal fetal presenting position
occiput anterior
maternal indications for induction
preeclampsia, diabetes, chorioamnionitis, greater than 40-42 weeks
how should breech presentation be managed after 36 weeks
external cephalic rotation
definition of postpartum hemorrhage
> 500cc in vaginal delivery
> 1000cc in c-section
treatment for woman who does not wish to breastfeed postpartum
ice packs, tight fitting bra, analgesics
second line: OCPs, bromocriptine
diagnosis: postpartum female presents with pain in breast localized to one region, no redness or warm
galactocele
when can OCPs be initiated in women who do not wish to breast feed
wait 6 weeks due to risk of DVT
diagnosis: postpartum woman develops sudden onset of hypoxia, cardiogenic shock, and DIC
amniotic fluid embolism
diagnosis: patient loses 500cc of blood postpartum and now has anemia, attempts at breast feeding have been unsuccessful as she is unable to secrete milk
sheehan syndrome
medications used to control postpartum hemorrhage
uterine massage, oxytocin
second line: methergen, hemabate, surgical options
definition of prolonged latent phase in labor
> 20 hours in nulliparous
> 14 hours in multiparous
definition of prolonged active phase in labor
< 1.2 cm/hr in nulliparous
< 1.5 cm/hr in multiparous
definition of arrest of descent in labor
> 2 hours in nulliparous
1 hour in multiparous
add 1 hour for epidural injection
first steps in management of uterine hyperstimulation, nonreassuring fetal heart tones
remove stimulating agent, maternal oxygen, turn the mom to the left lateral decubitus position, may need to adminster tertbutaline to stop contractions, place fetal scalp electrode and IUPC
treatment for lichen planus
high dose steroids (clobetasol)
biopsy to rule out malignancy
sinusoidal fetal heart changes (tachycardia to bradycardia)
ruptured fetal umbilical vessel
condition where fetal blood vessels traverse fetal membranes across lower segment of uterus between baby and internal cervical os
vasa previa
most significant risk factor for distal limb reduction defects associated with chorionic villi sampling
< 9-10 weeks associated with greater risk of limb defects
BPP: score 8-10
normal
BPP: score 6 without oligohydramnios
> 37 weeks: deliver
< 37 weeks: repeat BPP in 24 hours and deliver if unimproved
BPP: score 6 with oligohydramnios
> 32 weeks: deliver
< 30 weeks: daily monitoring
BPP: score 4
> 26 weeks: deliver
high FSH/LH with low estrogen
ambiguous genitalia at birth
polycystic ovaries later in life
aromatase deficiency
cafe-au-lait macules, fibrous dysplasia of bone, precocious puberty
mccune-albright syndrome
pseudohermaphroditism, salt wasting, virilization
congenital adrenal hyperplasia
etiology of lower abdominal pain during periods that radiates to the thighs
prostaglandins
management of fetal demise < 24 weeks
dilation and evacuation
management of fetal demise < 28 weeks
prostaglandin E2
management of fetal demise > 28 weeks
misoprostol or oxytocin
PROM < 32 weeks
steroids, antibiotics
induce when amniotic fluid indicates fetal lung maturity
PROM 32-34 weeks
aminotic fluid analysis to determine lung maturity dictates management
PROM > 34 weeks
antibiotics and delivery is induced
painless genital ulcer with beefy red base
granuloma inguinale (donovania/klebsiella granulomatis)
painless ulcer with subsequence inguinal buboes, associated with fistula formation
lymphogranuloma venereum (c. trachomatis)
painful ulcer from tropical regions, gray base and foul odor, possible inguinal lymphadenopathy
chancroid (haemophilus ducreyi: gram-positive rod)
induces ovulation midcycle
LH surge
stimulates development of ovarian follicle
FSH
stimulates endometrial proliferation
estrogen
stimulates endometrial gland development
progesterone
decrease in levels leads to menstruation
progesterone
increases basal body temperature
progesterone
inhibits uterine contractions
progesterone
increases thickness of cervical mucus
progesterone
inhibits LH and FSH secretion
progesterone
inhibits FSH secretion
estrogen
induces LH surge
estrogen
maintains corpus luteum
hCG
benign ovarian cyst in beginning of cycle
follicular cyst
benign ovarian cyst in later weeks of cycle
corpus luteum cyst of theca cells
