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My CCFP > Obstetrics and Gynecology > Flashcards

Obstetrics and Gynecology Flashcards

1
Q

Spontaneous abortion : definition (timeline) ?
types (6) ?

A

pregnancy loss <20 weeks

threatened
inevitable
incomplete
complete
missed
septic

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2
Q

DDx of spontaneous abortion (5)

A

Cervical abnormality
Ectopic
Infection
Molar Pregnancy
Subchorionic hemorrhage

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3
Q

When and how much Anti-D (WinRho) to give?

A

In SA :
120IM if <12wks
300IM if >12wks

N Pregnancy :
at 28 weeks
+ 72h PP if BB is Rh+

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4
Q

Risk factors for spontaneous abortions

A

Advanced maternal age
Thrombophilia, lupus (antiphosphilipid antibody syn)
Infections (TORCH)
Previous SA
Conception before 6mo after last
IUD
Uterine abnormalities
Misoprostol, retinoids, MTX, NSAIDs
Habits

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5
Q

Medication for spontaneous abortion? For medical abortion?

A

Spontaneous : Misoprostol 800mcg vaginally + 24-72h if no bleeding

Medical : Mifepristone 200mg PO then Misoprostol 800mcg PO in 24-48h

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6
Q

Differentiate threatened, inevitable, incomplete, complete, missed and septic abortions

A

threatened : soft and closed cervix
inevitable: open and dilated cervix
incomplete : open cervix
complete : open and dilated cervix
missed : closed cervix, fetal demise w/o uterine activity (no bleed)
septic abortions : SA + uterine infx (SIRS)

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7
Q

What antibiotics to give in a septic abortion?

A

Gentamicin + Clindamycin

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8
Q

Prescribe a medical abortion.

A

Day 1 : Mifepristone 200mg PO
- progesterone receptor antagonist = decr proga action and cessation of pregnancy

Day 2 or 3: Misoprostol 800mcg + 2nd dose 3-6h later if 9+0 - 12+0 weeks
- synthetic prostaglandin causing expulsion

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9
Q

Give 4 obstetrical DDx for 3rd trimester vaginal bleeding

A

Placenta Previa (accreta, increta or percreta) : low lying placenta <2cm from os) : PP is POORLY POSITIONED PLACENTA and is PAINLESS (can bleed spontaneously or w/ cervical change)

Placenta Abruption (total vs partial) : separation of maternal vessels : PA is AWFUL (PAINFUL)

Bloody Show : effaced+dialated cervix = mucus plug passes

Vasa Previa : fetal vessels run along os (70% mortality) : VP is VESSELS are POORLY POSITIONED and is PAINLESS (bleeds after membrane rupture)

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10
Q

Placenta previa definition, presentation and risk factors

A

Definition: placenta is positioned low in the uterus and partially or completely covers the internal cervical os (the opening to the cervix).

Bleeding: painless vaginal bleeding and can occur in the third trimester as the cervix starts to thin and dilate, disrupting placental attachment.

Risk Factors: prior C-sections, advanced maternal age, multiple pregnancies, or uterine scarring.

Mnemonic: PP is POOR POSITIONED PLACENTA and is PAINLESS

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11
Q

Vasa Previa definition, presentation, risk factors and management

A

Definition: fetal blood vessels run through the membranes covering the internal cervical os, without being protected by the umbilical cord or placenta.

Bleeding: Can lead to significant, life-threatening bleeding for the fetus if vessels rupture. Typically associated with a sudden onset of painless vaginal bleeding right AFTER membrane rupture.

Risk Factors: velamentous cord insertion or succenturiate lobes of the placenta.

Mnemonic: Think “Vasa” for “Vessels” (fetal vessels lying unprotected).

Management : Apt test (pink=+=fetal blood=bad=urgent c/s)

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12
Q

Placental Abruption definition, presentation, risk factors and management

A

Definition : separation of maternal vessels (partial or complete)

Bleeding : painful bleeding, abdo/pack pain, incr uterine tone, non-reassuring FHR

Risk Factors : PPROM, multiparity, previous abruption, HTN, DM2, thrombophilia, drugs, fibroids

Management : Kleihauer-Betke test, ABC, IVF, monitor for DIC, monitor preterms, induce VD in stable terms, and c/s in unstable pts

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13
Q

Definite Antiphospholipid Antibody Syndrome (APLA/APS)

A

APS is an autoimmune disorder where the immune system produces antiphospholipid antibodies (aPL) that mistakenly target proteins associated with phospholipids (fat molecules) in cell membranes, especially on blood vessel walls. This immune reaction increases the tendency for abnormal blood clotting (thrombosis).

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14
Q

APS diagnostic criteria

A

Need 1 Clinical Criteria:
* Vascular Thrombosis: Documented episodes of blood clots, either venous (e.g., deep vein thrombosis or DVT) or arterial (e.g., stroke, myocardial infarction).

  • Pregnancy Complications:
    – ≥1 unexplained fetal deaths >10wks
    – Premature birth >34wks due to preeclampsia, eclampsia, or placental insufficiency
    – ≥3 unexplained, consecutive miscarriages >10wks

Need 1 Laboratory Criteria (+ x 2 at least 12 weeks apart):
- Presence of lupus anticoagulant.
- Elevated anticardiolipin antibodies (IgG or IgM).
- Elevated anti-β2-glycoprotein I antibodies (IgG or IgM).

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15
Q

Treatment of APS patients (non-pregnant and pregnant).

A

Pregnant : LMWH + ASA

Non-pregnant : Warfarin + ASA

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16
Q

APS causes low or high platelettes?

A

Low (paradoxically as APS causes clots!)

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17
Q

Describe physiological discharge. When does it increase?

A

1-4mL fluid/24hrs, white / transparent, thick, odourless

increases with pregnancy, ovulation, OCPs

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18
Q

Provide DDx for vaginitis

A
  • Bacterial vaginosis**most common
  • Trichomoniasis
  • Candidiasis
  • Chlamydia
  • Gonorrhea
  • Lichen Sclerosis
  • Vulvar Cancer
  • Vaginal Atrophy
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19
Q

PROM vs PPROM

A

Premature rupture (after 37wks, before labor)
Preterm Premature rupture (before 37wks)

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20
Q

Vaginosis vs Trichomoniasis vs Candidiasis presentation

A

Vaginosis (BV) : asx vs fishy, white/grey thin d/c

Trich : pruritis, dysuria, white/yellow frothy d/c, straberry cervix, erythema of the vulva

Candidiasis : asx vs pruritis, dysuria, dyspareunia, white clumpy curdy d/c, erythema + edema of vagina

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21
Q

Treatments for BV, Trich, Candida

A

BV : Metronidazole 500mg PO BID x 7d (ok in 3rd trimester otherwise use 0.75% 5g PV cream x5d) or Clinda 2%cream 5g PV HS x7d
or Metro 2gx1
or Clinda 300mg BID

Trich : Metronidazole 500mg PO BID x 7d
AND TX MALES : 2g x 1

Candida : Clotrimazole 200mg PV x 3d or 2% cream x3d
or Miconazole 400mg PV x 3d or 4% x 3d
or Fluconazole 150mg PO x 1
**if reccurent ≥4x/y : Fluco 150mg PO q3d x 3 doses, topical azole x 10-14d then treat for 3-6mo w/ Fluc 150mg PO q1wk

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22
Q

Chlamydia vs Gono Treatment

A

Chalm : Azithro 1gx1 (ok if pregnant) or Doxy 100mg BIDx7d or Erythro 2g/dx7d or Amox 500mg TIDx7d (ok if preg)
** no test of cure unless prepubertal 3-4wks, but repeat screen in 3-6mo

Gono : Azithro 1gx1 AND Ceftriaxone 250mg IMx1
if allergic to cephalos : Axithro 2gx1
if tx failure : Azithro 2gx1 and Ceftri 1g IM x1
**think CEFtri for SAFEsex

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23
Q

Treatment for vaginal lichen sclerosis

A

Clobetasol

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24
Q

Treatment for vaginal atrophy

A

Lifestyle : no smoking, regular sex
Topical : Replens, lubes
Estrogen :
- Premarin cream 0.625mg qHS x 2wks then q2-3d x6mo
- Estring q3mo
- Vagifem tablets 1tab PV HS x 2wks then 2/wk

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25
Q

What are common non-pharmacologic treatments for dysmenorrhea?

A

Heat application, regular exercise, dietary adjustments (such as reducing caffeine ortaking ginger 750-2000mgdays 1-4 of menses), and acupuncture.

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26
Q

Name two classes of medications commonly used to manage dysmenorrhea.

A

NSAIDs (e.g., ibuprofen) and hormonal contraceptives (e.g., oral contraceptive pills).

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27
Q

Why are NSAIDs effective for primary dysmenorrhea?

A

NSAIDs reduce prostaglandin production, which helps decrease uterine contractions and pain.

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28
Q

How do combined oral contraceptives help in managing dysmenorrhea?

A

They reduce the volume of menstrual flow and lower endometrial prostaglandin production, decreasing pain.

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29
Q

Name (at least) 3 causes of secondary dysmenorrhea?

A

Endometriosis, adenomyosis, fibroids, pelvic inflammatory disease, and intrauterine devices (IUDs).

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30
Q

When should you suspect secondary dysmenorrhea?

A

When menstrual pain begins later in life, worsens over time, or is associated with other symptoms like heavy bleeding or pain outside of menstruation.

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31
Q

How much blood loss defines menorrhagia?

A

Menorrhagia is defined as menstrual blood loss of more than 80 mL per cycle or periods lasting more than 7 days.

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32
Q

List some common causes of menorrhagia.

A

Causes include hormonal imbalances, uterine fibroids, polyps, adenomyosis, bleeding disorders, thyroid disorders, and malignancies.

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33
Q

What surgical options exist for menorrhagia or dysmenorrhea if conservative treatments fail?

A

Options include endometrial ablation, uterine artery embolization, and hysterectomy.

If fertility is wanted for dysmenorrhea, consider : uterine nerve ablation or presacral neurectomy

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34
Q

What are common symptoms of endometriosis?

A

Symptoms include chronic pelvic pain, dysmenorrhea, dyspareunia (pain during intercourse), dyschezia (painful bowel movements), and infertility.

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35
Q

Which sites are most commonly affected by endometriosis?

A

Common sites include the ovaries, fallopian tubes, pelvic peritoneum, and, less frequently, the bladder, intestines, and rectum.

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36
Q

What is the leading theory for the cause of endometriosis?

A

The retrograde menstruation theory suggests that menstrual blood flows backward through the fallopian tubes into the pelvis, depositing endometrial cells that implant and grow.

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37
Q

How is endometriosis diagnosed?
GOLD STANDARD

A

Definitive diagnosis requires laparoscopy with biopsy, but it can be suspected based on symptoms and imaging, especially transvaginal ultrasound.

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38
Q

What are the main goals of treatment for endometriosis?

A

The goals are to relieve pain, manage symptoms, and improve fertility if desired.

39
Q

List some hormonal treatments used for endometriosis.

A

Combined oral contraceptives (COCs), progestins (depo-provera, nexplanon, Mirena), GnRH agonists (e.g., leuprolide), GnRH antagonists (Elagolix), and aromatase inhibitors (Letrozole).

40
Q

How can endometriosis affect fertility?

A

Endometriosis can cause scarring, adhesions, and inflammation that may interfere with ovulation, fertilization, or implantation, thus impacting fertility.

41
Q

What are side effects of GnRH agonist and antagonist treatments? Name an example of both.

A

Both classes can cause menopausal-like side effects (hot flashes, decreased bone density, vaginal dryness) due to low estrogen levels. They are typically used short-term or combined with “add-back” therapy (small doses of estrogen or progestin) to mitigate these effects.

Agonist : Leuprolide, goserelin
Antagonist : Elagolix

42
Q

What are the risk factors for fibroids?

A

Risk factors include age (30s-40s), family history, African descent, early menarche, obesity, and high estrogen exposure.

43
Q

What are the types of fibroids based on location?

A

The types are submucosal (within uterine lining), intramural (within uterine wall), subserosal (outer uterine surface), and pedunculated (attached by a stalk inside or outside the uterus).

44
Q

Describe common symptoms of fibroids.

A

Symptoms include heavy or prolonged menstrual bleeding, pelvic pressure or pain, bloating, urinary frequency, and reproductive issues (e.g., infertility or pregnancy complications).

45
Q

How are fibroids diagnosed?

A

Diagnosis is primarily through pelvic ultrasound. MRI may be used for complex cases or pre-surgical planning.

46
Q

What is the role of combined oral contraceptives (COCs) in fibroid management?

A

COCs can help manage heavy menstrual bleeding associated with fibroids but do not reduce fibroid size.

47
Q

How do GnRH agonists help manage fibroids?

A

GnRH agonists reduce estrogen levels, leading to fibroid shrinkage and symptom relief, typically used short-term or pre-surgery.

48
Q

What are the main non-surgical treatment options for fibroids?

A

Options include GnRH agonists, progestin-releasing IUDs (for bleeding), and NSAIDs for pain management.

49
Q

What are the main surgical options for fibroid removal?

A

Options include myomectomy (fibroid removal), hysterectomy (uterus removal), and uterine artery embolization (UAE), which reduces blood flow to fibroids.

50
Q

What are potential complications of untreated fibroids?

A

Complications include severe anemia, infertility, urinary obstruction, and pregnancy complications like miscarriage and preterm birth.

51
Q

What is a major side effect of GnRH agonist therapy?

A

The hypoestrogenic state from GnRH agonists can cause menopausal-like symptoms (e.g., hot flashes, bone density loss), which limits long-term use.

52
Q

Why might fibroids impact fertility?

A

Fibroids can distort the uterine cavity, block fallopian tubes, or interfere with implantation and embryo growth, leading to infertility or pregnancy complications.

53
Q

List the contraindications for systemic estrogen (eg for use in menopause)

A

Pregnancy
Abn vaginal bleeding
Breast/ovarian/endometrial cancer
CAD
CVA/VTE
Liver dz

**DM, HTN and migraine with aura are NOT absolute CI

54
Q

Provide pharmacotherapy options to breast cancer survivors with vasomotor sx of menopause.

A

Venlafaxine
Gabapentine
Oxybutynin
Clonidine
Paced Breathing
Acupuncture
CBT

55
Q

What are the criteria for starting HRT in menopausal women that do not have any contraindication?

A

<60 years old
<10 years postmenopausal

56
Q

What is the female viagra? How does it work? What is it used for?

A

Flibanserin (Addyi)

Effects dopamine and serotonin in the prefrontal cortex to cause relaxation and decreased BP

HSDD : hypoactive sexual desire disorder

57
Q

What symptoms should you screen for in menopause?

A

hot flashes, changes in libido, vaginal dryness, incontinence, and psychological changes

58
Q

Do you need tests to diagnose menopause?

A

Not if they have typical sx

if atypical sx (weight loss, BRBPR) then obviously order tests

59
Q

What laboratory levels help diagnose menopause?

Can you rule out menopause simply based on hormone level blood tests?

A

FSH > 30 (day 3 of cycle, not on OCPs)
Estradiol < 20 (if on OCP needs to be off x 7d)

No

60
Q

What screening should you consider in (peri)menopausal women?

A

OP screening (FRAX +/-BMD)

Breast cancer screening (mammography)

61
Q

What is the most appropriate first-line treatment for menopausal symptoms in women who prefer non-hormonal options?

A

SSRIs

62
Q

What is the most common cause of infertility in women?

A

Ovulatory disorders, including conditions like polycystic ovary syndrome (PCOS)

63
Q

What is the primary investigation for assessing ovulation in a woman? (eg assessing infertility)

A

Luteal phase serum progesterone testing (usually around day 21 of the cycle) to confirm ovulation

64
Q

Which test is the gold standard for evaluating tubal patency in women?

A

Laparoscopy with chromopertubation is the gold standard for evaluating tubal patency, allowing direct visualization of the pelvic organs and assessment of the fallopian tubes.

65
Q

What is the most common male factor contributing to infertility?

A

Sperm abnormalities, such as low sperm count (oligospermia) and reduced motility (asthenozoospermia)

66
Q

Which hormonal abnormality is commonly associated with polycystic ovary syndrome (PCOS)?

A

Women with PCOS often exhibit increased LH levels relative to FSH, contributing to anovulation and menstrual irregularities.

67
Q

What is the primary mechanism of action for clomiphene citrate in treating infertility?

A

By blocking estrogen receptors in the hypothalamus, leading to increased secretion of gonadotropins (LH and FSH) and promoting ovulation.

68
Q

Give DDx for PCOS

A

Late onset congenital hyperplasia
Cushing syndrome
ovarian + adrenal neoplasm
hyperprolactinaemia
thyroid disfunction
exogenous use of steroid hormones/androgens

69
Q

How do you diagnose PCOS

A

ROTTERDAM Criteria 2 /3 :
1. Hyperandrogenism (clinical or biochemical elevated total/free testoterone)
2. Oligomenorrhea
3. Polycystic ovaries on US

70
Q

What investigations do you do in suspected PCOS?
Are the increased or decreased?

A

↑Total testosterone, DHEAS, androstenedione
↓SHBG
LH:FSH > 2:1 (↑↑LH)

FBG:insulin <4.5(insulin resistance)
OGTT/A1c/FPG, lipids

Others for ddx :
TSH, prolactin

Imaging: transvaginal U/S

71
Q

Whats the pharmacological management of hyperprolactinemia?

How does this medication work?

A

Bromocriptine

Dopamine agonist (inhibits prolactin secretion from the anterior pituitary)

72
Q

What is the role of spironolactone in the management of PCOS?

Name two other anti-androgens that can be considered for hirsutism in PCOS.

A

Spironolactone is an anti-androgen that helps manage hirsutism by blocking androgen receptors and reducing testosterone production.

Finasteride and flutamide.

73
Q

What is the first-line pharmacological treatment for managing menstrual irregularities in women with PCOS?

A

Combined oral contraceptives (COCs) to regulate menstrual cycles and reduce androgen levels.

74
Q

What medication can be used off-label to induce ovulation in women with PCOS?

How does it work?

A

Clomiphene citrate.

Decreases estrogen levels causing an increase in FSH

75
Q

What medication (and dose) should woman take pre-conception?
What about vaccines?

A

Folic acid 0.4mg/d

Rubella + varicella if not immune

76
Q

What risks increase with increasing maternal age?
Paternal age?

A

SA, chromosomal abnormailities
SA, AD conditions, ASD, SCZ

77
Q

Name the DDx for female infertility

A
  1. Ovulatory dysfunction : PCOS, POF, prolactinoma, TSH, Cushings
  2. Uterine/tubal factors : PID, adhesions, previous ectopic, uterine anomaly, IUD, fibroids
  3. Cervical factors : structural, hostile mucous
  4. Peritoneal : endometriosis
78
Q

Name the DDx for male infertility

A
  1. Testicular: variocele, post-infectious, Klinefelter’s, torsion
  2. Iatrogenic : radiation, drugs (THC)
  3. Structural : vasectomy, hernia repair
79
Q

What labworks should you investigate for infertility in women? Men?

A

Day 3 LH, FSH, Prolactin, TSH, estradiol, testosterone
Day 21 progesterone (post-ovulatory)
Rubella and varicella status

Men : if abn semen analysis, consider LH, FSH, prolactin and estradiol

80
Q

List DDx of menopause

A

Vasomotorsx : stress/panic, EtOH, TSH, infx, carcinoid syndrome, pheochromocytoma, leukemia, neo

Menstural irregularity

TSH, pregnancy, pathology, OCP, hyperPRL, virilizing tumour, ↑androgens

81
Q

How does insulin affect testosterone?

A

Insulin increases testosterone by increasing LH centrally AND decreasing SHBG hepatically

82
Q

Name the main absolute contraindications of combined hormonal contraception.

What are the postpartum rules?

A

History of thromboembolism.
Migraine with aura.
Uncontrolled hypertension.
Smoking >15cpd and age >35.
Active breast cancer, liver disease.

Absolute CI : <4w PP breastfeeding or <21d PP not BF
Relative CI : 4-6wPP w/ other VTE risk factors

83
Q

Name side effects of birth control.

A

Irregular bleeding
N
Weight gain
Mood changes
Breast tenderness
HA

84
Q

Name risks of birth control.

A

VTE
MI+CVAif >50mcg estrogen
Breast Ca

85
Q

Name benefits of birth control.

A

↓ : flow, anemia, dysmenorrhea, pelvic pain, PMSx, acne, hirtuism, endometrial/ovarian/colorectal Ca, fibroids, ovarian cysts, benign breast dz, salpingitis
↑ : BMD

86
Q

Prescribe combined contraceptives.

A

COC : start first sunday of period of start whenever but use protection for 7days

Patch (Evra) : 1 patch/3wks, 1wk off (less effective if >90kg)

NuvaRing : 1 ring/3weeks, 1wk off

87
Q

Prescribe emergency contraception.

What are the CI?

A
  1. Copper IUD up to 7d post coitus (most effective withing 120h)
    – CI : pregnancy, PID, STI
  2. Ilipristal 30mgx1, hormonal contraception 5d later + backup x 14d
    – CI : pregnancy
  3. Plan B:levonorgestrel 1.5mg x 1 within 24-72h, hormonal contraception 1d later + backup x 7d
    – CI : pregnancy

**If no bleed within 21 days –> pregnancy test
**2 : not effective if taken day of ovulation

88
Q

Name the main absolute contraindications of progestin contraceptives.

A

Absolute: pregnancy, unexplained vaginal bleed, recurrent breast Ca

Relative : cirrhosis, active viral hep, hepatic adenoma, breast Ca5y ago

To consider in >35yo smokers, migraines, BF, endometriosis, sickle cells and pts on anti-convulsants

89
Q

What are the risks of progestin contraceptives?

A

Delayed fertility (9mo)
↓BMD (reversible)

Menstural disterbance

90
Q

Prescribe progestin contraceptives.

A

Oral : start on day 1 of cycle, take within 3h, backupx7dif started >7d after LMP **NO PILL FREE DAYS

Injection (Depo-provera) : 150mg IM q12-13wks, start 1st 5d of period

Implants (Nexplanon) : 5d after T1 abortion or 28PP

IUD (Mirena)

91
Q
A
92
Q

What are common PID etiologies?

List 3 complications of PID.

What sign do you need to diagnose it?

A

Chlamydia, gonorrhea, HSV, Trichomoniasis

I FACE PID : Infertility Fitz-Hugh-Curitis syndrome. Abscesses Chronic pelvic pain. Ectopic pregnancy. Peritonitis Intestinal obstruction

Uterine/adnexal/cerical motion tenderness

93
Q

What’s the treatment for PID?

A
  1. Ceftri 500mg IM + Doxy 100mg BID x14d
  2. Cefixime 800mg x1 + Doxy 100mg BID x14d
  3. Moxifloxacin 400mg OD x14d
  4. Levofloxacin 500mg OD x 14d

ADD Metronidazole if adnexal mass, abscess, peritonitis or BV

My CCFP (8 decks)

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