OBSTETRICS and GYNECOLOGY Flashcards
Premenopause
Dysmenorrhea
Dyschezia
Dyspareunia
Dx?
EnDometriosis
Metromeorrhagia
Colicky dysmenorrhea
Dyspareunia
Pelvic pain
Dx?
Adenomyosis
Tender, soften premenstrual uterus
Halban sign
Exophytic mass projecting into endometrial cavity
Endometrial polyps
Snowstorm pattern
H. Mole
Levator ani muscles (3)
PuboRectalis
PuboCoccygeous
IlioCoccygeous
Blood supply of posterior vaginal wall
Middle Rectal Artery
The labia minora is invested by which structure?
Sebaceous gland
Artery frequently encountered when Pfamnensteil skin incision is performed during cesarean delivery
Superficial Epigastric artery
Artery should be fpund and ligated prior to performace of Maylard incision
Inferior Epigastric artery
Chronic pain may develop in the area of Pfannentwil skin incision if this nerve is severed or entrapped
IlioHypogastric nerve
Structures that provide support for fecal continence
Internal and external anal sphincter
Landmark used when performing nerve block
Ischial spine
Blue tint of the cervix that is due to increased cervical vascularity in pregnancy
Chadwick sign
Relationship between ureter and uterine artery near the insertion to the uterus
Ureter is 2cm LATERAL to the cervix and crosses UNDER the uterine artery
Vascular supply of uterus from?
Uterine artery
Artery, that comes off the posterior division of the internal iliac artery
Superior Gluteal Artery
Mobility of this joint aids in the delivery of the obstructed shoulder in the case of shoulder dystocia
Sacroiliac
Plane of LEAST pelvic dimensions
The plane of midpelvis
Pelvic inlet boundaries
Posterior - Promontory
Lateral - Linea terminalis
Anterior - horizontal pubic rami
The LEAST clinically important diameter of pelvic inlet
CANNOT be directly measured
SHORTEST distance from sacral promontory and symphisis pubis
Measures 10.5cm
Obstetric conjugate
Contains the SMALLEST pelvic diameter
Serves as the point to measure station
Marked by interspinous diameter
Midpelvis
Most common Caldwell-Moloyanatomical pelvis
Gynecoid
Structure arises from the urogenital sinus
HUGE-V
Hymen
Urethra
Glands - Skene and bartholin
Epithelium of vagina
Distal Vagina/ lower 2/3
Uterine anomaly LEAST likely associated with renal abnormality
Arcuate uterus
Remnant of mesonephric tissue
Gartner duct cyst
Gestational age where differentiation between male and female external genitalia can be seen
12 weeks gestation
Fetal antimüllerian hormone produced
Sertoli cells
Imaging modality that has the highest accuracy for the diagnosis of uterine anomaly
MRI
Which anomaly would a surgical procedure be recommended prior to attempting pregnancy
Unicornuate uterus with communicating horn
Uterine anomaly arises from a complete lack of fusion of the mullerian ducts
Uterine didelphys
Septate uterus in 3D sonography
Intrafundal downward cleft measuring <1cm
Uterine anomaly associated with highest risk of obstetrical complication
Unicornuate non-communicating
Female metanephros will ultimately form..
Kidney
Most common uterine anomaly
Bicornuate uterus
Local production of this hormone is necessary for virilization of male genitalia in the fetus
Dihydrotestosterone
Hormone that prevents the formationof the uterus, fallopian tube, and upper vagina
Antimüllerian hormone
Non-rhythmic, usual intensity of 5-24mmHg and can be detected by bimanual examination
Braxton hicks contractions
A soluble receptor attenuates vascular endothelial and placental growth factor in vivo
sFlt-1
According to WHO, protein deposition is highest per day in what trimester?
3rd trimester
Fetus gains the most weight proportionately during this period of pregnancy
10-20 weeks gestation
When are maternal iron stores used in pregnancy?
Latter half of pregnancy
Unchanged coagulation factor level in pregnancy
Antithrombin III
Hepatic enzyme increased in normal pregnancy
Alkaline phosphatase
After ___ weeks’ gestation, the placenta is the main source of placental growth hormone
20 weeks
Hormones secreted by the posterior pituitary gland
Oxytocin
ADH
Pregnancy related memory decline is limited to which period in pregnancy?
3rd trimester
The average ovulatory menstrual cycle ranges from 25 to 32 days. Which phase of the cycle is most consistent in length?
Luteal
When does LH secretion peak in reference to ovulation
10-12 hours after
Hormone rescues the corpus luteum during early pregnancy
Human chorionuc gonadotropin
Following ovulation, when is the latest time fertilization can occur for a successful pregnancy to ensue?
24 hours
This gives rise to the chorionic structures that transport oxygen and nutrients between the fetur and mother
Villous trophoblast
Provides tensile strength of the fetal membranes
Amnion
The phenomenon that describes how fetal cells can become engrafted in the mother during pregnancy and then be identified decades later is called
Microchimerism
At term, what is the average amniotic fluid volume?
Normal volume?
Average - 1000mL
Normal vol. - 750-800mL
What gestational age are peak maternal B-hCG levels reached?
10 weeks
Half-life of human placental lactogen
10-30mins
What is the source of the precursor for progesterone production by syncytiotrophoblast
Maternal cholesterol
Maternal surface of placenta
Basal plate
Fetal surface of placenta
Chorionic plate
Placental measurements
Weight - 500g at term
2 to 4 cm thick
Normal placenta increases in thickness at a rate of approximately 1mm per week
In what situation is the submission of placenta for patho examination most informative and cost effective?
Oligohydramnios complicating the 3rd trimester
Percentage of placental villi can be lost without resulting in adverse impact to the fetus
30%
On pathology:
“Massive perivillous fibrin deposition”
Recommend antiphospholipid antibody lab panel
Retroplacental hematoma noted during a 28 week ultrasound performed for lagging fundal height
Indication for what?
Screen fetal-maternal bleed
Maternal malugnancy least likely to metastasize to the placenta
Cervical cancer
Average length of a full term umbilical cord
50-60cm
A single umbilical cord cyst is found during a first trimester utz performed for assessment of vaginal bleeding. Next step?
Schedule follow-up utz at 16-18weeks gestation
A true knot in the umbilical cord is associated with?
Stillbirth
Polyhydtamnios
Monoamniotic twin gestation
What is assumed when using the first day of the last menstrual period for dating?
Patient ovulated approximately 2 weeks later
Approximately how long is each trimester of pregnancy?
14 weeks
When is a conceptus termed an embryo?
Third week from the last menstrual period
Neural tube closes at?
6 weeks gestation
*start folic before 6weeks for it to be efficacious
How does oxygen content of the blood coming to the heart from the inferior vena cava compared to oxygen contents of blood leaving the placenta?
Lower
After birth, the intraabdominal remnants of the umbilical vein become?
Ligamentum teres
Anemia in the fetus
30%
Approximately what percentage of the total hemoglobin is hemoglobin F in a term fetus?
75%
This is the last stage of fetal lung development that starts late in the fetal period and continues into childhood
Alveolar stage
Biosynthesis of surfactant takes place in the?
Type II pneumocytes
Starting at what gestational age does the fetus engage in respiratory movements that are intense enough to move amniotic fluid in and out of the respiratory tract?
4 months
At what gestational age does swallowing begin?
10 - 12 weeks gestation
How much amniotic fluid do term fetuses swallow per day?
200 - 760 mL per day
This gives meconium its greenish black color
Biliverdin
Fetal kidney starts producing urine at?
12 weeks gestation
How much urine does a fetus make at term?
650mL per day
When does the fetal thyroid concentrate iodide more avidly than the maternal thyroid?
12 weeks gestation
Where is fetal immunoglobulin M (IgM) produced?
Fetus
Immunoglobulin in colostrum provides mucosal protection against enteric infections
IgA
What is uteroplacental blood flow at term?
700 - 900 mL/min
How does IgG cross the placenta?
Trophoblast receptor-mediated transfer
Average oxygen saturation of intervillous blood
65-75%
At term, what is the average PCO2 in the umbilical arteries?
50mmHg
Set of interventions that aim to identify and modify biomedical, behavioral, and social risks to a woman’s health or pregnancy outcome through prevention and management
Preconceptional care
Preconceptional folic acid can reduce the recurrence risk of having a child with neural tube defect by what percentage?
72%
CNS development at embryonic period
Birth defects are responsible for what percentage of infant mortality?
20%
Recommended daily dose of folic acid for all women who may become pregnant
400mg
Fetal tissues most susceptible to damage by high blood phenylalanine levels
Cardiac and neural
Worldwide, what is the most common single-gene disorder?
Hemoglobinopathies
Best way to identify a genetic abnormality in a stillborn fetus
Chromosomal microarray analysis
When do B-hCG levels peak in pregnancy?
60-70 days after last menstrual period
Alcoholic mom
Baby with facial abnormality, fetal growth restriction, and CNS dysfunction
Most complete source of nutrients for pregnant woman
Dairy
Mineral least likely to be supplied in quantities sufficient for pregnancy when ingesting a normal diet
Iron
Which vitamin, when ingested in large quantities, causes a well-described constellation of birth defects
Vitamin A
Which type of fish contains a level of methylmercury LOW enough to be safe for consumption during pregnancy?
Salmon
At least how much elemental iron should be given as a supplement daily to a pregnant woman?
27mg
Maternal vit D deficiency associated with?
Congenital rickets
Air travel is not recommended after which gestational age?
36 weeks
Only vaccine with proven fetal harm
Smallpox
Recommended amount of caffeine consumption in pregnancy according to ACOG
<200mg per day
Standard error for ultrasound estimates of fetal weight after the first trimester
20%
Minimum mean sac diameter measurement necessary to diagnose an anembryonic pregnancy with certainty
25mm
Additional utz measurement should be taken in the same image that the cerebellum and cisterna magna are evaluated?
Nuchal fold
“Tear drop shape” lateral ventricle on prenatal sonography
Agenesis of corpus callosum
Caudal regression sequence is increased in what maternal medical complication?
Diabetes mellitus
Most common class of congenital anomalies
Cardiac
Primary source of amniotic fluid in late 2nd trimester
1st trimester?
2nd trimester - Fetal urine production
1st trimester - fetal skin, flow across amnion and flow across fetal vessel
Normal volume of blood flow to the gravid uterus at term
500ml/min
Tonicity:
Fetal urine is ___tonic in amniotic fluid
Fetal urine is ___tonic to maternal plasma
Isotonic ro amniotic fluid
Hypotonic to maternal plasma
Polyhydramnios in utz
Amniotic fluid index >25cm
Single deepest vertical pocket >8cm
Amniotic fluid index >97th percentile for gestational age
Fetal growth restriction with polyhydramnios is most classically associated with?
Trisomy 18
Anhydramnios or severe oligohydramnios prior to what gestational age is most likely to be associated with lethal pulmonary hypoplasia?
Before 20 weeks
Approximately how many medications do women take while pregnant?
2-3
An agent that acts during embronic or fetal development to produce a permanent alteration of form or function
Teratogen
Aminoglycoside side effect
Ototoxicity
Chloramphenicol side effect
Ashen-gray skin
Tetracycline side effect
Decidious teeth discoloration
antiviral agent associated with skull, palate, eye, skeleton, and gastrointestinal abnormalities
Ribavirin
Effects of diethylstibesterol exposure in utero
Hypospadias
Vaginal clear cell adenocarcinoma
Hypoplastic, T-shaped uterine cavity
Primary source of mercury
Consumption of large fish
First trimester warfarin exposure
Nasal hypoplasia
In what phase of cell division are oocytes arrested between birth and ovulation?
Prophase I
Fetus with multiple anomalies including hypertelorism, syndactyly, VSD and a cleft lip and palate
Placneta is small and with asymmetric growth restriction
Digynic triploidy
45,X/ 46,XX
Turner syndrome
Term that describes whether or not a dominant gene is phenotypically expressed
Penetrance
Cytogenetic karyotype is performed on chromosomes arrested in what phase of replication?
Metaphase
Elevated maternal serum alpha fetoprotein has been associated with?
Preeclampsia
Omphalocele
Maternal hepatoma
Low levels of maternal serum Estriol as part of quadruple screen —-> investigate for?
Smith Lemli Opitz syndrome
Femur ratio of <= 0.90
Suggest?
Increase risk for trisomy 21
Appropriate screening test for hemoglobinopathies in patients of African descent
Hemoglobin electrophoresis
Ashkenazi jews should be checked for?
Canavan disease
Familial dysautonomia
Tay sachs disease
Immunoglobulin subtype that may contribute to fetal hemolytic anemia
IgG
Amount of fetal erythrocytes required to sensitize a D-negative woman
0.1 mL
26yo pregnant
New onset severe headache
Generalized edema
Fetal hygroma and dx of trisomy 18
Fetal hydrops
Hypertension
4+ proteinuria
Elevated serum crea
Fetal demise - severe pokyhydramnion and placentomegaly
Mirror syndrome
Why does ABO incompatibility manifest in first-born neonates, despite the lack of prior maternal exposures?
Most group O women have previously been exposed to bacteria possessing A- or B-like antigens
Fetus with premature atrial contractions can later be found to have which arrhthmia?
Supraventricular tachycardia
Sustained fetal tachyarrythmias can lead to?
Hydrops
Agents commonly administered to women to treat fetal tachyarrythmias
Sotalol
Digoxin
Flecainide
Congenital adrenal hyperplasia is caused by what enzyme deficiency?
21-hydroxylase deficiency
Before what gestational age does maternal treatment with dexamethasone need to commence to prevent virilization of a female fetus with congenital adrenal hyperplasia?
9 weeks’ gestation
The neural damage in myelomeningocele is the result of?
Exposure to amniotic fluid
Main concern in an isolated congenital diaphragmatic hernia
Low lung volumes
Female fetus with lower urinary tract obstruction is associated with?
Increased likelihood for complex malformations
Contrainidications to vesicoamniotic shunt placement in fetus with bladder outlet obstruction
Female sex
Aneuploidy
Presence of renal cyst
Indication for in utero fetal cardiac intervention
Critical aortic stenosis
Goal of fetal aortic valvuloplasty
Preserve left ventricular function and prevent left hypoplastic heart syndrome
Goal of antepartum fetal surveillance
Avoid unnecessary intervention
Contraction stress test is for?
Identify uteroplacental insufficiency
Nonstress test is for?
Assess fetal condition rather than uteroplacental function
Similar ability to predict fetal well-being as contraction stress test
Time to perform a nonstress test is much shorter than a contraction stress test
This can assess fetal breathing
Cervical exam
% of spontaneous abortions occur within the first 12 weeks of gestation
80%
Most common chromosomal abnormality in the setting of first-trimester spontaneous abortion
Monosomy X (Turner syndrome)
Septic abortion
41c temp
78/42mmHg
Cervical motion tenderness
Generalized malaise
Tx?
Antibiotic against Group A streptococcus
Cervical insufficiency
Cerclage
Short cervix
Daily vaginal progesterone
Woman without hx of prior CS, removal of prophylactic transvaginal cerclage is recommended at
37 weeks gestation
Indication for transabdominal cerclage
Hx of transvaginal cerclage
Known risks of prophylactic cerclage
Bleeding
Infection
Membrane rupture
Medical abortion risk of failure
2 -17%
Suction curettage efficacy rate
96%-100%
Least effective route of Misoprostol as a drug for cervical ripening
Oral
Prophylaxis for postabortive infection
100mg doxycycline 1 hour prior and 200mg doxycycline after the procedure
Risk of mifepristone exposure in pregnancy which include?
5% risk of fetal malformations
Side effects of misoprostol
Fever and chills
Risk of uterine rupture with medical termination of a 2nd trimester pregnancy in a setting of prior CS delivery
0.4%
Among women who become pregnant while using contraception, relative number of ectopic pregnancies increased with
Progestin-releasing intrauterine device
In ectopic pregnancy, the absence of which tubal tissue layer facilitates rapid invasion of proliferating trophoblasts into the muscularis
Submucosa
Classic triad of clinical symptoms of an ectopic pregnancy
Delayed menstruation
Pain
Vaginal bleeding
Neck and shoulder pain experienced in an ectopic pregnancy is due to
Diaphragmatic irritation due to hemoperitoneum
Minimum rise of B-hCG expected in 48hr from an early progressing intrauterine pregnancy
53%
What % of ectopic pregnancies demonstrate appropriately rising B-hCG levels
33%
Progesterone value threshold most helpful to exclude ectopic pregnancy
> 25 ng/mL
Expected findings on tv utz if the date is correct and the pregnancy is viable
Gestationa sac
Yolk sac
Fetal pole with cardiac motion
Purpose of performing a dilatation and curettage prior to administering methotrexate
To confirm the absence of trophoblastic tissue
MOA of methotrexate
Impedance of DNA and RNA synthesis
Ectopic resolution rate following methotrexate administration
90%
Single best predictor of successful treatment with single dose methotrexate
B-hCG
41 yo G5P3 6-7 weeks AOG
Lower abdominal pain
Hx tubal ligation 2 years ago during her 3rd CS
Risk of this pregnancy continues
Placanta accreta
Adjunctive treatment can be employed to decrease or manage complications associated with a cervical ectopic pregnancy
Uterine artery embolization
This hormone is pivotal in diagnosis, management, and surveillance of gestational trophoblastic disease
Human Chorionic Gonadotropin
H moles as a group are differentiated histologically from non-molar neoplasms by the presence of
Vili
Pathogenesis of complete H mole
Androgenesis
Dispermic fertilization
Maternal chromosome inactivation
Criteria for diagnosis of gestational trophoblastic neoplasia
Rise in B-hCG
Plateau of B-hCG levels
Persistence of B-hCG for 6 months or more
Gestational trophoblastic neoplasia may develop after?
Evacuation of partial mole
Delivery of normal term pregnancy
Ectopic pregnancy in fallopian tube
The most consistent finding with gestational trophoblastic neoplasia
Uterine bleeding
Most characteristic feature of invasive mole
Penetrates deeply into myometrium
Most characteristic of gestational choriocarcinoma
Commonly accompanied by ovarian theca-lutein cysts
Most characteristic of placnetal site trophoblastic tumor
High proportion of free B-hCG is considered diagnostic
Best treated by hysterectomy due to chemotherapy resistance
Arise from intermediate trophoblasts at the placental site
Clinical features of epithelioid trophoblastic tumor are most similar to?
Placental-site trophoblastic tumor
Metastatic spread of choriocarcinoma thru?
Distant mets at?
Hematogenous
Lung
Characteristic of amnion
Provides tensile strength to resist rupture of membranes
Phase 2 of parturition
Uterine activation, cervical ripening
Clinical stages of labor is which phase of parturition?
Phase 3
Stage of labor where the fetus is delivered
Stage 2
Cervical softening in phase 1 of parturition results in part from?
Increase stromal vascularity
Primary source of corticotropin-releasing hormone in pregnancy
Placental
Uterine contraction pain causes
Myometrial hypoxia
Uterine peritoneum stretch
Compression of nerve ganglia in yhe cervix
After cervix is fully dilated, what is the most important force in fetal expulsion
Intraabdominal pressure
Most important component of pelvic floor
Levator ani muscle
What is the initial step that leads to placental separation following delivery of the infant?
Tension pulls it away from the implantation site
Mechanism of placental delivery when the placenta leave the body BEFORE the retroplacental hematoma
Schultze mechanism
NSAIDs (Indomethacin) targets which enzyme in prostaglandin priduction?
Cyclooxygenase 1
Administering Terbutaline, a B2 adrenergic receptor agonist, causes uterine relaxation by?
Increased cyclic adenosine monophosphate levels
Ovulation returns _ to _ weeks after birth
4 to 6 weeks
Uterotonins in phase 3 parturition
Emdothelin 1
Angiotensin II
Prostaglandins
Most common fetal lie
Longitudinal
Fetus lies with the long axis transversely, what is the presenting part?
Shoulder
Neck is only partly flexed with the anterior fontanel is presenting
What is the fetal attitude?
Sinciput
What composes the cephalic pole?
Head
Reason for high incidence of breech among hydrocephalic fetuses
Cephalic pole needs more room
Incidence of breech at term
3%
Leopold maneuver determines degree of fetal descent
4
The term engagement refers to?
Biparietal diameter passing through the pelvic inlet
Lateral deflection of the sagittal suture toward the sacral promontory
Anterior asynclitism
Which portion of labor does the cervix dilate very little but the connective tissue component change considerably
Preparatory division
Stage of labor where the patient reaches complete cervical dilatation through delivery of the fetus
Stage 2
Prolonged 2nd stage of labor causes
Sedation
Macrosomia
Contracted maternal pelvis
When the cervix becomes as thin as the adjacent lower uterine segment, what is the effacement?
100%
Majority of labor dystocia is due to?
Asynclitism
Lowest contraction pressure necessary to cause cervical dilatation
15 mmHg
Protraction is defined as ___cm/hr cervical dilatation for a minimum of ___ hours
1 cm/hr
4hours
Treshold for adequate uterine contractions
180 montevideo units
Maternal risk associated with precipitous labor
Uterine atony
The infant delivered with a precipitous labor is at risk of?
Brachial plexus palsy
Contracted pelvic inlet
Transverse diameter <12cm
Interischial tuberous diameter measurement serves as the threshold to define pelvic outlet contraction
8cm
Most mentum posterior presentation will convert to mentum anterior
True or false?
True
Cause of foot drop and pain after vaginal delivery
Prolonged 2nd stage of labor
Most reliable portion of fetal electrocardiogram
R-wave peaks
Current fetal monitors can detect
Separate heart rates from a twin gestation
Fetal heart rates defines fetal bradycardia and fetal tachycardia
<110 and >160
Most common cause of fetal tachycardia
Chorioamnionitis
Single most reliable sign of fetal compromise
Reduced variability
Frequency cycle of 2-5cycles/min
Sinusoidal fetal heart rate pattern
Occuring with >=50% of conrractions in a 20min period
Recurrent fetal heart rate decelerations
Deceleration that begins after the peak of contraction and returns to baseline after the contraction ends
Late
Physiologic event results in compensatory rise in fetal heart rate during a variable deceleration
Occlusion of the umbilical vein
Itching and incisional discomfort post CS
Give?
Nalbuphine
Primary and most important reason for administering epidural test dose
Rule out intravenous catheter placement
Local anesthetic associated with both neurotoxicity and cardiotoxicity at similar serum drug levels
Bupivacaine
Level of blockade desired with spinal anesthesia for cesarean delivery
T4
Vassopressor associated with fetal acidemia when used in OB anesthesia setting
Ephedrine
Most common complication associated with epidural anesthesia
Hypotension
Which pulmonary lobe most often onvolved in aspirationas a complication of general anesthesia
Right lower lobe
Nerve primarily involved with pain associated with perineal stretching
Pudendal
Direct cause of most maternal deaths involving regional anesthesia
High spinal blockade
FDA approved peptic ulcer prevention
Misoprostol
Half-life of oxytocin
Onset of action?
3 minutes
Onset is 1min
Oxytocin’s similarity to arginine vasopressin accounts for which unwanted side effect?
Water intoxication
Benefit of membrane stripping at term
Reduced incidence of postterm pregnancy
Most common position for vaginal delivery is?
Knee-chest
Benefits of delayed cord clamping in preterm infants
Decrese IVH
Decrease NEC
Decrease need for blood transfusion
Risk of delayed cord clamping
Increased hyperbilirubinemia
Occiput transverse position of the fetal head in the maternal pelvis
Easiest way to rotate is manually
Can be rotated with Kielland forceps
Seen with android pelvises
Persistent occiput posterior
2-10% of cephalic fetuses deliver in the OP position
Increased blood loss compared to occiput anterior
More 3rd or 4th degree lacerations compared to occiput anterior position
Most common maneuver used to reduce a shoulder dystocia
Suprapubic pressure
Water birth
Lower rate of anesthesia block!
Genital mutilation types
Type 1 - partial or total removal of clitoris and/or prepuce
Type 2 - partial or total removal of clitoris AND LABIA MINORA
Type 3 - partial or total removal of LABIA MINORA and/or MAJORA and INFIBULATION W/ or W/O clitoridectomy
Indication for episiotomy
Breech
Shoulder dystocia
Persistent occiput posterior position
Uterine atony
Tx?
Intramuscular methylergonovine
Among singleton pregnancies, breech presentation persists in what percentage at term?
3-5%
Risk factors for breech presentation
Prior breech fetus
Best indicator of pelvic adequacy for vaginal breech delivery
Steady cervical dilatationand progressive descent of station with contractions
The index and middle fibger of one hand are applied over the maxilla to flex the head while the fetal body rests on the palm of the same hand with legs straddling the forearm
Mariceau maneuver
Process by which a frank breech fetus is manually converted to a footling breech presentation within the uterus during a cesarean or vaginal delivery
Decomposition
Most adequate method of pain management for planned vaginal delivery of a breech fetus
Epidural anesthesia
External cephalic version (breech to cephalic)
Recommended if possible
MOXIBUSTION is an alternative medicine technique that she could consider
Absolute contrainidication of externa cephalic version
Twin gestation
External cephalic version success is improved with
Acute tocolysis
Internal podalic version
Manipulation within the uterus to yield a breech presentation, typically reserved for delivery of a second twin
Risk factor for urinary retention
Episiotomy
Interventions which may reduce maternal perineal wall laceration during a forceps assisted vaginal delivery
Early disartuculation
Mediolateral episiotomy
Cessation of pushing during disarticulation
Subgaleal henorrhage is seen more frequently with what delivery route?
Vacuum extraction
In the setting of an occiput posterior position, correctly placed blades are equidistant from what landmark?
Midline of face and brow
How is asynclitism resolved after placement of forceps?
Pulling and/or pushing each branch along the long axis
Forces produced by a forceps-assisted vaginal delivery
Friction
Traction
Compression
Action necessary to rotate a fetus from an occiput posterior to an occiput anterior position
Flexion of fetal head
Pelvic type generally associated with persistent occipuy posterior position
Anthropoid
Best forceps used to attempt rotation from occiput anterior to occiput posterior
Piper
Least common indication of primary cesarean delivery
Placenta previa
Most inappropriate indication for primary cesarean delivery
Early-onset severe preeclampsia
Vertical midline incision compared to transverse skin incision
Decreased risk of neuropathy
Greater ease with wound care
Decreased risk of subfascial hematoma
Usual tolerated blood loss volume without hemodynamic compromise
2000 mL
Emergent repeat cesarean delivery has these risks/ complications compared to planned procedure
Bladder injury
Ureteral injury
Blood transfusion
Potential indication for a classical hysterotomy
Maternal morbid obesity
Densely adherent bladder
Back-down transverse fetal lie
Benefit of using monofilament suture vs braided suture (vicryl)
Decreased risk of infection
Potential advantage of closure of of parietal peritoneum prior to closure of fascia at the time of cesarean delivery
Avoidance of distended bowel at the time of fascial closure
Intervention most likely to decrease adhesion formation at the time of cesarean delivery
Achieving hemostasis
Disadvantage of uterine exteriorization for repair of hysterotomy
Increased nausea and vomiting
Compared to manual extraction, spontaneous delivery of the placenta with fundal massage has shown to reduce the risk of?
Postpartum infection
During CS, a hysterotomy is made in the lower uterine segment. What setting should the incision be made relatively higher on the uterus to avoid uterine vessel laceration or unintended entry into the vagina
A completely dilated cervix
Use of scissors for sharp extension instead of blunt extension has been associated with
Blood loss
Operative time
Unintended extensions
Failure to recognize dextrorotation of uterus prior to hysterotomy increases the risk of damage to?
Left uterine artery
Benefits of low transverse uterine incision compared to classical incision
Ease of closure
Less likely to rupture in subsequent pregnancies
Lower risk of incisional adhesions to bowel or omentum
The first fascial layer incised in Pfannensteil incision
External oblique
Benefits of pfannenstiel incision vs vertical midline incision
Less operative pain
Improved cosmetic result
Less risk of incisional hernia
When performing Pfannentiel skin incision, which vessel should be anticipated halfway between the skin and fascia, several cm from the midline?
Superficial epigastrics
To reduce postop morbidity, ACOG recommends antibiotic prophylaxis to be given within how many mins prior to skin incicsion?
60mins
Recommendation for antibiotic prophylaxis at cesarean delivery for women with significant penicillin allergu include a single dose of which agent?
Gentamycin + Clindamycin
Although not recommended by ACOG, elective CS on maternal request should only be considered when?
The pregnancy has reached at least 39 completed weeks
Ridk factor for urinary retention after cesarean delivery
Postoperative narcotic analgesia
Suture most appropriate for repair of bladder mucosa and muscularis layer
3.0 vicryl
Circumstances with increased risk of unintentional cystostomy
Hx of prior CS delivery
Need for emergent CS delivery
CS delivery in the 2nd stage of labor
Most closely approximates the risk of ureteral injury at the time of cesarean delivery
1 in 3000
Cesarean hysterectomy increases the risk of?
Urinary tract damage
Benefits of Vertical midline incision compared to transverse skin incision
Decreased risk of neuropathy
Greater ease with wound care
Decreased risk of subfascial hematoma
No prenatal visit
In active labor
Refuse all blood products due to religion
What will you do?
Proactive administration of uterotonics if atony occurs
Maternal obstetrical complication increased in cesarean delivery compared to vaginal delivery
Infection
Hemorrhage
The
Thromboembolism
Adverse neonatal outcome that may occur in CS delivery
Respiratory distress syndrome
Pelvic shape predisposed to occiput transverse position
Platypelloid and Android
Maneuver that involves replacement of the fetal head into the pelvis folled by cesarean delivery
Zavanelli maneuver
Cutting the clavicle with scissors or other sharp instrument. Done for dead fetus
Cleidotomy
Major function of human placental lactogen
To induce lipolysis and protein synthesis leading to a constant nutrient supply to the fetus
Elevated maternal serum Alpha fetoprotein suggests?
Neural tube defects
Spina bifida
Meningomyelocele
Anencephaly
Gastroschisis or omphalocele
Previa or accreta
Increased incidence of myelomeningocele is associated with which medication?
Valproic acid
Risks of amniocentesis
Pregnancy loss
Chorioamnionitis
Fetal injury with needle
Maternal infection
Alloimmunization of an Rh-negative woman carrying an Rh-positive fetus
Premature rupture of membrane
Classic findings of Down syndrome on obstetric ultrasound are?
AV canal and Pyloric stenosis
Paternal nondysjunction sex chromosomal abnormalities are
Turner syndrome 45,XO
Klinefeltet syndrome 47,XXY
Decreased level of maternal serum alpha fetoprotein may be seen in
Down syndrome
Lithium in pregnancy
Ebstein anomaly - displacement of tricuspid valve
Fluxetine ond several other SSRIs
Increase in fetal cardiac anomaly
Low dose aspirin
Slightly reduce the risk of preeclampsia
Most favorable fetal presentation and position to achieve a vaginal delivery
Vertex with occiput anterior
2nd degree laceration
Extends ito the perineal body, but does not involve the anal sphincter
First degree laceration
Mucosa or skin only
4th degree laceration
Can be button-hole
Rectal mucosa is torn but sphincter is intact
Used to ripen cervix if Bishop score is greater than 5
Oxytocin
Used to ripen the cervix if the Bishop score is less than 5
Prostaglandin E2 gel or
PGE2 pessary (cervidil) or
PGE1M (misoprostol)
Maternal contraindications for the use of prostaglandins
Asthma
Glaucoma
Obstetric contraindications for the use of prostaglandins
Prior cesarean section
Non reassuring fetal testing
A device to measure the pressure changes during contractions and can evaluate the adequacy of contractions
Intrauterine pressure catheter (IUPC)
Device that can directly monitor fetal heart rate and variability
Fetal scalp electrode
Absolute contraindication of TOLAC (trial of labor after cesarean)
Prior classical hysterotomy or other vertical uterine incision —–> uterine rupture
MOA of Magnesium sulfate
Antagonizes calcium and stabilizes cell membranes
MOA of terbutaline
Increase conversion of ATP to cAMP, which results i. Decrease levels of free calcium ions through sequestration in the sarcoplasmic reticulum
MOA of Indomethacin
Blocks cyclooxigenase and decreases levels of prostaglandins
Side effects of Magnesium sulfate
Flushing
Diplopia
Headache
Most effective test to monitor patients for magnesium toxicity
Serial deep tendon reflex (DTR) exam
Mg <10mg/dL –lost DTR
Mg >10mg/dL – respiratory depression, hypoxia and cardiac arrest
Maneuver that involves pressure on either fetal shoulder to diminish the biacromial diameter in effort to free the anterior shoulder and allow delivery of fetus
Rubin maneuver
Least invasive maneuver where the maternal hips is flexed increasing the size of pelvic outlet
Mcrobert maneuver
Placing a hand behind either the anterior or posterior fetal shoulder and rotating the fetus in 180deg to lead to descent and delivery of shoulders
Wood’s cork maneuver
Involves replacement of the fetal head by reversing the cardinal movements of labor
Zavanelli maneuver
Sequela to toxoplasmosis infection
IUGR
Microcephaly
Choriretinitis
Intracranial calcification
Hearing loss
Mental retardation
Hepatosplenomegaly
Ascites
Periventricular calcification
Ventriculomegaly
Seizures
Sequela of rubella infection
Fetal growth retardation
Sensorineural hearing loss
Cardiac lesions
Eye defects
= seen in first 12 weeks of gestation
Effects of CMV infection in fetus
Mental retardation
Microcephaly
Chorioretinits
Cerebral calcifications
MOST COMMON CONGENITAL INFECTION IN PREGNANCY
Congenital herpes results to
Growth restrictions
Eye disease
Microcephaly
Hydraencephaly
Tobacco abuse causes
IUGR
Cleavage between 3 and 8 days and occurs after placental differentiation occured but prior to amnion formation
Monochorionic - diamniotic twinning
Cleavage during the first 2 to 3 days and occurs before cells are differentiated to form throphoblast
Dichorionic-diamniotic twins
Embryo cleavage between days 8 and 13 again occurs after differentiation of trophoblast but after formation of amnion
Monochorionic - monoamniotic gestation
After day 15 of development
Singleton pregnancy
Hypertension that is present before pregnancy, sustained hypertension before 20 weeks’ gestation, ot hypertension persisting fpr more than 6 weeks postpartum
Chronic hypertension
Mayernal blood screening test that looks at levels of AFP, B-hCG, estradiol and Inhibin A to assess the probability of potential genetic abnormalities
Done in 2nd trim (bet 15 and 18 weeks)
Quad screen
Severe criteria pre eclampsia blood pressure
SBP >160 mmHg or DBP > 110mmHg
Asymptomatic bacteriuria may cause?
Pre-term birth
Low birth weight infant
Side effect of CIPROFLOXACIN in pregnancy
Renal anomalies in fetus (1st trim exposure)
Factors that may lead to oligohydramnios
Chromosomal abnormalities
Uteroplacental insufficiency
Hypertension
Postterm pregnancy
Twin-twin transfusion syndrome
DOC for asymptomatic bacteriuria
Cephalosporin (cefazolin, cedotetan, or ceftri)
Or
Ampicillin and gentamicin
10 tp 14 days of combine IV and oral
Criteria of Chorioamnionitis
Maternal fever >38deg C
And at least 2:
- elevated wbc
- maternal tachycardia
- uterine tenderness
- fetal tachycardia
- foul smelling amniotic fluid
Gold standard of dx of chorioamnionitis
Culture of amniotic fluid (amniocentesis)
Most common cause of chorioamnionitis
Polymicrobial infection of rectovaginal organism
Most concerning complications of pyelonephritis
Acute respiratory distress syndrome (ARDS)
Most common precursor of neonatal sepsis which has a high rate of fetal mortality
Chorioamnionitis
1st trimester infection of parvovirus b19
Miscarriage
Midtrimester infection of parvovirus B19
Fetal anemia and hydrops
How do parvovirus cause fetal anemia?
Bone marrow suppression
When to start antiretroviral (HAART) Therapy in pregnant women with HIV
2nd trimester
—– ideally, CS
—– no breastfeeding!
Most common cause of bloody nipple discharge
(-) mass
Benign intraductal papilloma
Solitary, mobile, non painful, rubbery breast mass
Dx?
Fibroadenoma
Multiple, painful, bilateral, and fluctuate throughout the menstrual cycle
Fibrocystic breast change
Firm, fixed breast mass
Invasive breast cancer
Breast mass
Epithelial and stromal proliferation
Fibroadenoma
With scattered maligmamt cells
Cystosarcoma phyllodes
2nd most common cause of bloody nipple discharge
Invasive papillary carcinoma
ER+ PR+
Tx?
Aromatase inhibitor (LETROZOLE) with hormone receptor positive cancers
First line hormone therapy for premenopausal women
Tamoxifen
Monoclonal antibody for adjuvant treatment in tumors that are HER2/neu positive
Trastuzumab
Most reliable predictor of all breast cancer survival is
Stage of breast cancer at the time of diagnosis
+ PT
Vaginal bleeding
Closed cervix
B-hcg = 1,000,000 mIU/mL
Dx? Next step? Tx of choice?
Gestational trophoblastic disease
Complete pelvic utz
Suction curettage
Intrauterine fetus
Marked thickening and cystic formation within the plancenta
Significant increased serum B-hcg
Incomplete (partial) molar pregnancy
Profuse vaginal bleeding
Solid intrauterine mass
Serum B-hCG = 220mlU/mL
Dx?
Placantal site Trophoblastic tumor
Serum marker = human placental lactogen
Tx of choice = hysterectomy
FIGO staging
Stage 1 - persistently elevated serum B-hcg with tumor confined to the uterus
Stage 2 - tunor outside uterus but limited to vaginal and or pelvis
Stage 3 - pulmo mets with or without uterine, vaginal or pelvic tumor mets
Stage 4 - all other mets (brain, liver, kidney and GI tract)
Ascites
Hydrothorax
Ovarian fibromas and other pelvic tumor
Meigs syndrome
Profuse watery discharge (hydrops tubar profluens)
Pelvic pain
Pelvic mass
Latzko’s triad
Spontaneous or pressure induced release of watery or blood-tinged vaginal discharge resulting in shrinkage of pelvic mass
Fallopian tube tumors
Hydrops tubae profluens
Hypertension
Obesity
Insulin resistance or NIDDM
Hypertriglyceridemia
Increased peripheral vascular disease
Elevated catecholamines
Syndrome X or metabolic syndrome
Pathognemonic of granulosa cell tumors
Call-exner bodies (microcluster arrangement)
Most common type of germ cell tumor
Dysgerminoma
Most common chemotherapeutic regime following treatment for epithelial ovarian cancer
Carboplatin and Taxol
Most common mullerian anomaly due to malfusion of paramesonephric (mullerian) ducts
Septate uterus
Patients with septate uterus high risk of?
Recurrent first trimester pregnancy loss
Typical pubertal sequence
Accelerated growth
Thelarche
Pubarche
Menarche
Blood test that would confirm diagnosis of menopause
FSH
Only indication for Hormone Replacement Therapy (HRT)
Cardiovascular disease prevention
Hallmarks of adenomyosis
Menorrhagia and dysmenorrhea
Risk factor of endometrial CA
Obesity
Nulliparity
Early menarche
Late menopause
Family hx
Lynch syndrome II
Exogenous estrogen or Tamoxifen use
Protective: hx of oral contraceptives and multiparity
Risk factors of Ovarian CA
BRCA 1 mutation
Early menarche
Late menopause
Nulliparity
Family hx
Protective: OCP use (also protective in breast CA)
Most common presenting symptom of patient w/ cervical cancer
Abnormal vaginal bleeding
MC clinical condition associated with development of endometrial hyperplasia
Polycystic ovarian syndrome
Hereditary predisposition to the development of colon, breast and endometrial cancer
Type II Lynch syndrome
Benign inclusion cyst created in fallopian tube by invagination of tubal serosa
Walthard nest
Tumor marker useful in follow up of tubal serous carcinomas
CA-125
MC primary malignant neoplasm of fallopian tubes
Papillary serous adenocarcinoma
Standartd tx for tubal carcinoma
TAH/BSO - aggressive cytoreductive surgery and chemotherapy
Lymphatic drainage of fallopian tube
Para-aortic lymph nodes
MC location on the vulva to find adenoid cystic carcinoma
Bartholin’s gland
Single most important prognostic factor in woman with vulvar cancer
Lymph node metastasis
Vaginal tumor presents as mass of grape-like nodules most commonly in first 2 years of life
Embryonal rhabdomyosarcoma (sarcoma botryoides)
MC location of primary vaginal carcinoma (squamous cell) lesion
Upper 3rd and posterior wall of vagina
Risk factor of PID
Age <20yo
Multiple sex partner
Nulliparity
Prev hx of PID
Risk factor of PID
Age <20yo
Multiple sex partner
Nulliparity
Prev hx of PID
Pt with uterus larger than expected from hx of gestation
Vaginal bleeding
Passes grape-like tissue from the vagina
Dx?
Hydatifldiform mole
Chocolate cysts
Endometriomas (cystic form of endometriosis on the ovary)
Risk factor of vulvar carcinoma
Older age
Smoking
Prev Squamous cell CA of cervix/vagina
Chronic vulvar dystrophy
Immunocompromised
MC organism causes pelvic inflammatory disease
N. gonorrhea and chlamydia
