Obstetrics and gynecology Flashcards

Question

Increased unchallenged translucency, want to rule out chromosomal abnormalities

Answer 1

Amniocentesis is a diagnostic test that may detect Down syndrome as well as other chromosomal abnormalities. Cell-free DNA testing detects over 99% of cases of Down syndrome. The first trimester screen, which consists of a nuchal translucency and maternal serum PAPP-A and beta-hCG, yields an 85% detection rate for Down syndrome. The NT is the measurement of the fluid collection at the back of the fetal neck in the first trimester. A thickened NT may be associated with fetal chromosomal and structural abnormalities as well as a number of genetic syndromes

Answer 2

Ibuprofen is safe to take until around 32 weeks gestation, when premature closure of the ductus arteriosis is a risk. While heparin is safe during pregnancy, warfarin has known teratogenic effects and should not be given. If continued anticoagulation is necessary, low molecular weight heparin is the drug of choice.

Answer 3

Braxton Hicks contractions are characterized as short in duration, less intense than true labor, and the discomfort as being in the lower abdomen and groin areas. True labor is defined by strong, regular uterine contractions that result in progressive cervical dilation and effacement.

Answer 4

Cultures for group B streptococcus are not required in women who have group B streptococcal bacteriuria during the current pregnancy or who have previously given birth to a neonate with early-onset group B streptococcal disease because these women should receive intrapartum antibiotic prophylaxis. Universal screening with a recto-vaginal culture at 35–37 weeks of gestation is recommended for all women who do not have an indication for intrapartum antibiotic prophylaxis. All women with positive cultures for group B streptococci should receive intrapartum antibiotic in labor unless a cesarean delivery is performed before onset of labor in a woman with intact amniotic membranes.

Answer 5

The initial evaluation of patients presenting to the hospital for labor includes a review of the prenatal records with special focus on the antenatal complications and dating criteria, a focused history and a targeted physical examination to include maternal vital signs and fetal heart rate, and abdominal and pelvic examination. A speculum exam with a nitrazine test to confirm rupture of membranes is indicated if the patient’s history suggests this, or if a patient is uncertain as to whether she has experienced leakage of amniotic fluid. Performing a fetal ultrasound is not a routine part of an assessment in a patient who may be in early labor. A prenatal ultrasound may be used in cases to determine fetal presentation, estimated fetal weight, placental location or amniotic fluid volume

Answer 6

If the fetal heart rate cannot be confirmed using external methods, then the most reliable way to document fetal well-being is to apply a fetal scalp electrode. Putting in an epidural without confirming fetal status might be dangerous. Although ultrasound will provide information regarding the fetal heart rate, it is not practical to use this to monitor the fetus continuously while the epidural is placed. An intrauterine pressure catheter will provide information about the strength and frequency of the patient’s contractions, but will not provide information regarding the fetal status.

Answer 7

If an intrauterine pressure catheter is placed, and a significant amount of vaginal bleeding is noted, the possibility of placenta separation or uterine perforation should be considered. Take it out and observe for fetal demise And then replace it if fetal tracing is reassuring

Answer 8

Variable decelerations are typically caused by cord compression and are the most common decelerations seen in labor. Placental insufficiency is usually associated with late decelerations ( oxygen deprivation). Head compression typically causes early decelerations.

Answer 9

Although fetal surveillance is reassuring, the most appropriate management is to continue to elevate the fetal head with a hand in the patient’s vagina and call for assistance to perform a Cesarean delivery. It is important to elevate the fetal head in an attempt to avoid compression of the umbilical cord. Once an umbilical cord prolapse is diagnosed, expeditious arrangements should be made to perform a cesarean section. It is not appropriate to replace the umbilical cord into the uterus or allow the patient to continue to labor or perform a forceps-assisted vaginal delivery.

Answer 10

A flattened nasal bridge, small size and small rotated, cup-shaped ears may be associated with Down syndrome and should prompt a survey looking specifically for other features seen with Down syndrome that include sandal gap toes, hypotonia, a protruding tongue, short broad hands, Simian creases, epicanthic folds, and oblique palpebral fissures.

Answer 11

Meconium aspiration syndrome occurs in up to 10% of infants who have been exposed to meconium-stained amniotic fluid. It is associated with significant morbidity and mortality. all infants with meconium-stained amniotic fluid should not routinely receive suctioning at the perineum. If meconium is present and the newborn is depressed, the clinician should intubate the trachea and suction meconium or other aspirated material from beneath the glottis. If the newborn is vigorous, defined as having strong respiratory efforts, good muscle tone, and a heart rate greater than 100 beats per minute, there is no evidence that tracheal suctioning is necessary. Injury to the vocal cords is more likely to occur when attempting to intubate a vigorous newborn. Routine prophylactic amnioinfusion for meconium-stained amniotic fluid is not recommended as there is no definitive benefit.

Answer 12

Small babies are more common with type 1 diabetes than with gestational diabetes, and the blood sugar level of all newborns of diabetic mothers should be monitored closely after delivery, as they are at increased risk for developing hypoglycemia. Macrosomic (large) infants are typically associated with gestational diabetes. Infants born to diabetic mothers are at increased risk for developing hypoglycemia, polycythemia, hyperbilirubinemia, hypocalcemia and respiratory distress. Thrombocytopenia is not a risk. Diabetics also have increased risk for polyhydramnios, congenital malformations (cardiovascular, neural tube defects, and caudal regression syndrome), preterm birth and hypertensive complications. Her diabetes does place her at an increased for twins.

Answer 13

fetal tachycardia may be in response to the maternal fever. Fetal tachycardia coupled with minimal variability is a warning sign that the infant may be septic. A septic infant will typically appear pale, lethargic and have a high temperature.

Answer 14

This case is suggestive of twin-twin transfusion syndrome (TTTS). Polycythemia is a common complication for the plethoric twin. TTTS is a complication of monochorionic pregnancies. It is characterized by an imbalance in the blood flow through communicating vessels across a shared placenta leading to under perfusion of the donor twin, which becomes anemic and over perfusion of the recipient, which becomes polycythemic. The donor twin often develops IUGR (intrauterine growth restriction)and oligohydramnios, and the recipient experiences volume overload and polyhydramnios that may lead to heart failure and hydrops.

Answer 15

You should give positive pressure ventilation and prepare to intubate the infant, if necessary. Any history of substance abuse may be a relative contraindication to the use of naloxone (Narcan) because the mother may have used narcotics during the pregnancy and administration of naloxone to the infant can cause life-threatening withdrawal. Stimulation may not be sufficient for this infant. Suction will not necessarily stimulate a respiratory effort.

Answer 16

A usual protocol is to start AZT (zidovudine) immediately after delivery. HIV testing begins at 24 hours. Breastfeeding not encouraged

Answer 17

The sniffing position (tilting the neonate’s head back and lifting the chin) is the correct position for application of positive pressure ventilation in a newborn infant. It is important to also secure the mask to the infant’s face and to observe an initial chest rise. A recommended rate of oxygen flow is 10 L/minute.

Answer 18

Heart rate, Respiratory rate, Reflex, Activity (muscle tone), Color 2,1,0; good score is 10

Answer 19

Postpartum hemorrhage (PPH) is an obstetrical emergency that can follow vaginal or Cesarean delivery. Uterine atony is the most common cause of PPH and occurs in one in every twenty deliveries. The most common definition of PPH is an estimated blood loss of greater than or equal to 500 ml after vaginal birth, or greater than or equal to 1000 ml after Cesarean delivery. Risk factors for uterine atony include precipitous (high risk) labor, multiparity, general anesthesia, oxytocin use in labor, prolonged labor, macrosomia, hydramnios, twins and chorioamnionitis. first steps in the management of postpartum hemorrhage are to make sure the uterus is well-contracted, there is no retained placental tissue and to look for lacerations Uterotonics (oxytocin, misoprostol etc), then uterine packing or Bakri balloon, then surgical treatment (uterine artery ligation, uterine artery embolization, hysterectomy)

Answer 20

Sheehan Syndrome is a rare occurrence. When a patient experiences a significant blood loss, this can result in anterior pituitary necrosis, which may lead to loss of gonadotropin, thyroid-stimulating hormone (TSH) and adrenocorticotropic hormone (ACTH) production, as they are all produced by the anterior pituitary. Signs and symptoms of Sheehan syndrome may include slow mental function, weight gain, fatigue, difficulty staying warm, no milk production, hypotension and amenorrhea. Sheehan’s syndrome frequently goes unnoticed for many years after the inciting delivery. Treatment includes estrogen and progesterone replacement and supplementation with thyroid and adrenal hormones.

Answer 21

Endometritis can be found in less than 3% of vaginal births and this is contrasted by a 5-10 times higher incidence after Cesarean deliveries. Factors related to increased rates of infection with a vaginal birth include prolonged labor, prolonged rupture of membranes, multiple vaginal examinations, internal fetal monitoring, removal of the placenta manually and low socioeconomic status.

Answer 22

The most common cause of postpartum fever is endometritis. The differential diagnosis includes urinary tract infection, lower genital tract infection, wound infections, pulmonary infections, thrombophlebitis, and mastitis. Uterine fundal tenderness is commonly observed in patients with endometritis.

Answer 23

Bacterial isolates related to postpartum endometritis are usually polymicrobial resulting in a mix of aerobes and anaerobes in the genital tract. The most causative agents are Staphylococcus aureus and Streptococcus.

Answer 24

Postpartum depression is a common condition estimated to affect approximately 10-15% of women and often begins within two weeks to six months after delivery. Signs and symptoms of depression which last for less than two weeks are called postpartum blues; it occurs in 40-85% of women in the immediate postpartum period. It is a mild disorder that is usually self-limited. In addition to the more common symptoms of depression, the postpartum patient may manifest a sense of incapability of loving her family and manifest ambivalence toward her infant--pp depression most significant risk factor for developing postpartum depression is the patient’s prior history of depression.

Answer 25

Benefits to the mother include increased uterine contraction due to oxytocin release during milk let down and decreased blood loss. Breastfeeding is associated with a decreased incidence of ovarian cancer. Some studies have reported a decreased incidence of breast cancer. Breast milk is a major source of Immunoglobulin A which is associated with a decrease of newborn’s gastrointestinal infections.

Answer 26

Although the side lying position is a good one for breastfeeding, it is important for mother and baby to be belly-to-belly in order for the infant to be in a good position to latch on appropriately, taking a large part of the areola into its mouth

Answer 27

Estrogen-mammary gland/lobule growth Progesterone- alveoli hyper trophy Prolactin-milk production (inhibited by estrogen and progesterone---inhibitory influence of progesterone on the production of alpha-lactalbumin by the rough endoplasmic reticulum. The increased alpha-lactalbumin serves to stimulate lactose synthase and ultimately to increase milk lactose.) Oxytocin - milk let down and uterine

Answer 28

classic picture of mastitis that is usually caused by streptococcus bacteria from the baby’s mouth. Mastitis is easily treated with antibiotics. The initial choice of antimicrobial is influenced by the current experience with staphylococcal infections at the institution. Most are community-acquired organisms, and even staphylococcal infections are usually sensitive to penicillin or a cephalosporin. If the infection persists, an abscess may ensue which would require incision and drainage. However, this patient’s presentation is that of simple mastitis. There is no need for the mother to stop breastfeeding because of the mastitis.

Answer 29

Hospital policies that promote breastfeeding include getting the baby on the breast within a half hour of delivery and rooming-in for the baby to ensure frequent breastfeeding on demand (i.e. unlimited access).

Answer 30

This presentation is classic for candidiasis and should prompt an inspection of the baby’s oral cavity. Candida of the nipple is associated with severe discomfort and pain. Localized candida of the nipple may be treated with an antifungal, topical medication such as clotrimazole or miconazole cream. The treatment plan may include a topical antibiotic ointment because nipple fissures can concurrently present with candida of the nipples, and S. aureus is significantly associated with nipple fissures. Either a triple antibiotic ointment or mupirocin can be prescribed. A topical steroid cream can be used to facilitate healing for cases in which the nipples that are very red and inflamed. Every treatment regimen must include the simultaneous treatment of the mother and baby. Oral nystatin is the most common treatment for the baby, followed by oral fluconazole.

Answer 31

3-4 stools in 24 hours, six wet diapers in 24 hours, weight gain and sounds of swallowing.

Answer 32

Engorgement commonly occurs when milk comes in. Strategies that may help include frequent nursing (every 1.5 -2 hours), taking a warm shower or warm compresses to enhance milk flow, massaging the breast and hand expressing some milk to soften the breast, wearing a good support bra and using an analgesic 20 minutes before breastfeeding.

Answer 33

Spontaneous abortion Viable, intrauterine pregnancy (nml implantation bleeding or sub chorionic hemorrhage) Ectopic pregnancy

Answer 34

Inappropriately rising Beta-hCG levels (less than 50% increase in 48 hours) or levels that either do not fall following diagnostic dilation and curettage would be consistent with the diagnosis of ectopic pregnancy. Alternatively, a fetal pole (thickening of margin of yolk sac) must be visualized outside the uterus on ultrasound. The patient would need a Beta-hCG level over the discriminatory zone (1500-2000, the level where an intrauterine pregnancy can be seen on ultrasound) with an empty uterus. The level commonly used is 2000 mIU/ml. progesterone level is within expected range for a normal pregnancy (>25 ng/ml suggests healthy pregnancy)

Answer 35

tenfold increase risk for ectopic pregnancy in women with a prior history of ectopic pregnancy. Age between 35 and 44 years old is associated with a threefold increase in ectopic pregnancy.

Answer 36

Her vital signs ( high p, high rr, low bp) , examination ( rebound and voluntary guarding, free fluid in the cup de sac )and anemia are consistent with an intra-abdominal bleed. Exploratory laparoscopy/laparotomy is indicated at this point. Conservative management with observation, serial examinations or repeat Beta-hCG testing could be dangerous in a patient suspected of having a ruptured ectopic pregnancy. Medical management (methotrexate) is not used in a patient with an acute surgical abdomen Signs of hypovolemia (tachycardia, hypotension) with peritoneal signs (rebound, guarding and severe abdominal tenderness) and a positive pregnancy test lead to the diagnosis of ruptured ectopic pregnancy.

Answer 37

Mifepristone is a progestin receptor antagonist and can be used as emergency contraception to prevent ovulation and blocks the action of progesterone which is needed to maintain pregnancy.

Answer 38

These include: hemodynamic stability; non-ruptured ectopic pregnancy; size of ectopic mass

Answer 39

Perforated uterus

Answer 40

approximately 50 to 60 percent of embryos and early fetuses that are spontaneously aborted contain form of chromosomal abnormalities. Environmental factors, such as smoking, alcohol and radiation are causes of spontaneous abortion

Answer 41

Autosomal trisomy is accounting for approximately 40-50% of cases.

Answer 42

Systemic diseases such as diabetes mellitus, chronic renal disease and lupus are associated with early pregnancy loss. In women with insulin-dependent diabetes, the rates of spontaneous abortion and major congenital malformations are both increased.

Answer 43

She, therefore, requires immediate surgical treatment consisting of dilation and suction curettage. Although clinicians increasingly utilize both expectant management and various drug regimens to treat spontaneous abortion, a prerequisite for either is that the patient is hemodynamically stable and reliable for follow-up care.

Answer 44

Patients experiencing early pregnancy loss can safely consider several different treatments, including expectant management, medical treatment to assist with expulsion of the pregnancy or surgical evacuation. Provided the patient is hemodynamically stable and reliable for follow-up, expectant management is appropriate therapy. At the gestational age described, expectant management portends no increase in risk of either hemorrhage or infection compared with surgical or medical evacuation. Regardless of method chosen, the patient’s blood type should be checked and rhogam administered as indicated.

Answer 45

incompetent cervix and should have a cervical cerclage at 14 weeks. A positive fetal fibronectin does not indicate incompetent cervix and is used later in pregnancy as a negative predictor of preterm delivery. Pregnancy loss in the late second trimester is not usually related to genetic abnormality of the conceptus and most clinicians delay placement of a cerclage until after the first trimester, given the high background prevalence of first trimester pregnancy wastage

Answer 46

Neither controlled trials nor surveillance data support the contention that a single, prior first trimester surgical abortion increases the risk of subsequent first trimester pregnancy loss.

Answer 47

angiotensin converting enzyme inhibitors, such as Lisinopril, beyond the first trimester of pregnancy has been associated with oligohydramnios, fetal growth retardation and neonatal renal failure, hypotension, pulmonary hypoplasia, joint contractures and death. Amitriptyline is used in pregnancy to treat migraine headaches.

Answer 48

The baseline transmission rate of HIV to newborns can be reduced from about 25% to 2% with the HAART (highly active antiretroviral therapy) protocol antepartum and continuing through delivery with intravenous zidovudine in labor and zidovudine treatment for the neonate. Cesarean section prior to labor can reduce this rate to 2% (although the benefit is less clear in women with viral loads).

Answer 49

Asthma generally worsens in 40% of pregnant patients. One of the indications for moving to the next line of treatment includes the need to use beta agonists more than twice a week. The appropriate choice for her treatment would be inhaled corticosteroids or cromolyn sodium. Theophylline would be used in more refractory patients. Subcutaneous terbutaline and systemic corticosteroids would be used in acute cases. Zafirlukast, a leukotriene receptor antagonist, is not effective for acute disease.

Answer 50

rapid plasma reagin test (RPR) positive (titer = 32); fluorescent treponemal antibody absorption test (FTA-ABS) is positive fluorescent treponemal antibody absorption test (FTA-ABS) confirms the diagnosis. The transmission rates for primary and secondary disease are approximately 50-80%. There are no proven alternatives to penicillin therapy during pregnancy and penicillin G is the therapy of choice to treat syphilis in pregnancy. Women with a history of penicillin allergy can be skin tested to confirm the risk of immunoglobulin E (IgE)-mediated anaphylaxis. If skin tests are reactive, penicillin desensitization is recommended and is followed by intramuscular benzathine penicillin G treatment.

Answer 51

Screening should be performed between 24 and 28 weeks in those women not known to have glucose intolerance earlier in pregnancy. This evaluation can be done in two steps: a 50-g oral glucose challenge test is followed by a diagnostic 100-g oral glucose tolerance test (OGTT) if initial results exceed a predetermined plasma glucose concentration. Patients at low risk are not routinely screened. For those patients of average risk screening is performed at 24-28 weeks while those at high risk (severe obesity and strong family history) screening should be done as soon as feasible.

Answer 52

Among women with cardiac disease, patients with pulmonary hypertension are among the highest risk for mortality during pregnancy, a 25-50% risk for death. Management of labor and delivery is particularly problematic. These women are at greatest risk when there is diminished venous return and right ventricular filling which is associated with most maternal deaths. Similar mortality rates are seen in aortic coarctation with valve involvement and Marfan syndrome with aortic involvement.

Answer 53

Most women with mitral valve prolapse are asymptomatic and diagnosed by routine physical examination or as an incidental finding at echocardiography. A small percentage of women with symptoms have anxiety, palpitations, atypical chest pain, and syncope. For women who are symptomatic, b-blocking drugs are given to decrease sympathetic tone, relieve chest pain and palpitations, and reduce the risk of life-threatening arrhythmias.

Answer 54

typical symptoms include cough, dyspnea, sputum production, and pleuritic chest pain. Mild upper respiratory symptoms and malaise usually precede these symptoms, and mild leukocytosis is usually present. Chest radiography is essential for diagnosis, although radiographic appearance does not accurately predict the etiology of the pneumonia

Answer 55

This patient has alpha thalassemia trait characterized by mild anemia, microcytic and hypochromic anemia and a normal hemoglobin electrophoresis. She denies blood loss therefore acute blood loss is unlikely and her serum ferritin is normal ruling out iron deficiency anemia. Hemoglobin H disease and beta thalassemia are characterized by moderate to severe anemia. Beta-thalassemia would have hemoglobin F as well as hemoglobin A2 on hemoglobin electrophoresis.

Answer 56

Increased maternal morbidity results from obesity and includes chronic hypertension, gestational diabetes, preeclampsia, fetal macrosomia, as well as higher rates of Cesarean delivery and postpartum complications. This patient’s BMI is approximately 38 so she is a class II and has over a 7-fold increase risk for preeclampsia and a 3-fold risk for hypertension.

Answer 57

Clinical manifestations include malaise, fever, arthritis, rash, pleuro-pericarditis, photosensitivity, anemia, and cognitive dysfunction. A significant number of patients have renal involvement. There is no cure and complete remissions are rare. Mild disease may be disabling because of pain and fatigue. Nonsteroidal anti-inflammatory drugs are used to treat arthralgia and serositis. Severe disease is best treated with corticosteroids.

Answer 58

most commonly used antidepressants are the selective serotonin reuptake inhibitors (SSRIs). One SSRI, paroxetine (Paxil) has been changed to a category D drug because of the increased risk of fetal cardiac malformations and persistent pulmonary hypertension. Other SSRI compounds, fluoxetine, sertraline, and citalopram have not been reported to cause early pregnancy loss or birth defects in animals or in human

Answer 59

pruritus gravidarum, a common pregnancy-related skin condition that is a mild variant of intrahepatic cholestasis of pregnancy. There is retention of bile salt, and as serum levels increase they are deposited in the dermis. This, in turn, causes pruritus. The skin lesions are secondary to scratching and excoriation. Antihistamines and topical emollients may provide some relief and should be used initially. Ursodeoxycholic acid relieves pruritus and lowers serum enzyme levels. Another agent reported to relieve the itching is the opioid antagonist naltrexone

Answer 60

The diagnosis is made based on clinical findings and graded compression ultrasonography that is sensitive and specific especially before 35 weeks gestation. This noninvasive procedure should be considered first in working up suspected acute appendicitis.

Answer 61

In addition to discontinuing the magnesium sulfate, she needs a dose of calcium gluconate to restore her respiratory function. The classic signs of magnesium toxicity include muscle weakness and loss of deep tendon reflexes, nausea, and respiratory depression. If magnesium is given in high doses, cardiac arrest is possible. At a magnesium level of 11 mEq/L, respiratory depression is most likely to occur. The therapeutic magnesium level is between 4-7 mEq/L. Seizures are prevented by the use of magnesium. Loss of deep tendon reflexes occurs at a level of 7-10 mEq/L. Cardiac arrest may occur at a level of 15 mEq/L. Used for eclampsia also

Answer 62

Regardless of disease severity, the only definitive therapy for preeclampsia is delivery of the fetus and placenta. This solution can occasionally be delayed in the setting of stable disease (mild or severe) when it occurs at an extremely early gestational age. Fluid management must be monitored closely in this person. Magnesium sulfate is the mainstay of therapy during labor and for 24 hours postpartum to lower the seizure threshold in women with severe disease. It is related to race, ethnicity and genetic predisposition. Environmental factors are also likely to play a role. Other risk factors for preeclampsia include a previous history of the disease, chronic hypertension, multifetal pregnancy and molar pregnancy. In addition, patients at extremes of maternal age or with diabetes, chronic renal disease, antiphospholipid antibody syndrome, vascular or connective tissue disease or triploidy are at increased risk for developing preeclampsia

Answer 63

Thrombocytopenia

Answer 64

HELLP syndrome is a disease process in the spectrum of severe preeclampsia. The acronym stands for “hemolysis, elevated liver enzymes, low platelets” and can lead to swelling of the liver capsule and possibly liver rupture. It may or may not be accompanied by right upper quadrant pain. It is possible to only have thrombocytopenia and elevated transaminases without clear hemolysis (elevated bilirubin and anemia), especially if a diagnosis is made early.

Answer 65

tachysystole on tocometer and evidence of fetal anemia (tachycardia and sinusoidal heart rate pattern) on the heart rate tracing. Hypertension and preeclampsia are risk factors for abruption

Answer 66

indicated for blood pressures persistently greater than 160 systolic and 105 diastolic. First-line agents include hydralazine (a direct vasodilator) 5 mg IV followed by 5-10 mg doses IV at 20-minute intervals (maximum dose = 40 mg); or labetalol (combined alpha & beta-adrenergic antagonist) 10-20 mg IV followed by 20 mg, then 40 mg, then 80 mg IV every 10 minutes (maximum dose = 220 mg). The goal is not a normal blood pressure, but to reduce the diastolic blood pressure into a safe range of 90-100 mmHg to prevent maternal stroke or abruption, without compromising uterine perfusion.

Answer 67

The risk of isoimmunization is 2% antepartum, 7% after full term delivery, and 7% with subsequent pregnancy so less than 20% total. While 75% of all gravidas have evidence of transplacental hemorrhage during pregnancy or immediately after delivery, 60% of these patients have

Answer 68

Noninvasive diagnosis of fetal anemia can be performed with Doppler ultrasonography. The use of middle cerebral artery peak systolic velocity in the management of fetuses at risk for anemia because of red cell alloimmunization (immune response to foreign antigens after exposure to genetically different cells or tissues) has emerged as the best test for the noninvasive diagnosis of fetal anemia. All the other listed tests are for assessment of fetal well-being and non-specific to detect fetal anemia.

Answer 69

Fetal hydrops is easily diagnosed on ultrasound. It develops in the presence of decreased hepatic protein production. It is defined as a collection of fluid in two or more body cavities, such as ascites, pericardial and/or pleural fluid and scalp edema. On occasion, when extramedullary hematopoiesis is extensive, there will be evidence of hepatosplenomegaly. Placentomegaly (placental edema) and polyhydramnios are also seen on ultrasound

Answer 70

Thirty (30) cc of fetal blood is neutralized by the 300 micrograms dose of RhoGAM. At 28-weeks gestation, 300 micrograms of Rh-immune globulin is routinely administered after testing for sensitization with an indirect Coombs’ test. Administration is given following amniocentesis at any gestational age. The current recommendations for Rh-negative women without evidence of Rh immunization is prophylactically at 28-weeks gestation (after an indirect Coombs’ test), and within 72 hours of delivering an Rh-positive baby, following spontaneous or induced abortion, following antepartum hemorrhage and following amniocentesis or chorionic villus sampling. If the father of the fetus is known to be Rh-negative, RhoGAM is not necessary since the fetus will be Rh-negative and not at risk for hemolytic disease.

Answer 71

Lewis antibodies are IgM antibodies and do not cross the placenta, therefore are not associated with isosensitization (Exposure to an alloantigen that induces immunologic memory cells.) or hemolytic disease of the fetus.

Answer 72

In the presence of a severely erythroblastotic fetus, the amniotic fluid is stained yellow. The yellow pigment is bilirubin, which can be quantified most accurately by spectrophotometric measurements of the optical density between 420 and 460nm, the wavelength absorbed by bilirubin. The deviation from linearity of the optical density reading at 450nm is due to the presence of heme pigment, an indicator of severe hemolysis. the delta OD450 (optical density deviation at 450 nm) results plot on the Liley curve in Zone 3; Values in Zone 3 of the Liley curve indicate the presence of severe hemolytic disease, with hydrops and fetal death likely within 7-10 days, thus demanding immediate delivery or fetal transfusion. At 30 weeks gestation, the fetus would benefit from more time in utero. An attempt should be made to correct the underlying anemia. Intravascular transfusion into the umbilical vein is the preferred method. Intraperitoneal transfusion is used when intravascular transfusion is technically impossible. If fetal hydrops is present, the reversal of the fetal anemia occurs much more slowly via intraperitoneal transfusion. Percutaneous umbilical blood sampling should not be used as a first-line method to evaluate fetal status. Maternal plasmapheresis is used in severe disease when intrauterine transfusions are not possible.

Answer 73

The protection afforded by a standard RhoGAM administration is dose-dependent. One dose will prevent Rh sensitization to an exposure of as much as 30 cc of Rh-positive red blood cells. With greater exposure, there is only partial protection and Rh sensitization may occur as a result of failure to diagnose massive transplacental hemorrhage. In addition, RhoGAM only confers protection against the D antigen, so despite administration of RhoGAM to Rh-negative patients, they may still become sensitized to other red blood cell antigens. Pregnancy spacing does not affect the presence of the antibody.

Answer 74

Alpha fetoprotein (AFP) levels in twin gestations are elevated and should be roughly twice that seen in singleton pregnancies. An additional clue to a possible diagnosis of twin gestation is the fundal height exceeding gestational age in weeks. Other causes of elevated maternal serum AFP include neural tube defects, pilonidal cysts, cystic hygroma, sacrococcygeal teratoma, fetal abdominal wall defects, and fetal death. Polyhydramnios is not by itself associated with abnormal MSAFP levels. Do a fetal sonogram/US to check on babies

Answer 75

Ultrasound markers suggestive of dizygotic (non-identical) twins include a dividing membrane thickness greater than 2 mm, twin peak (lambda) sign, different fetal genders and two separate placentas (anterior and posterior). The two different placental types in twin gestation are monochorionic and dichorionic. Dizygotic conceptions always have dichorionic placentas. Monozygotic conceptions may have either monochorionic or dichorionic placentation, depending upon the time of division of the zygote. Diamniotic dichorionic placentation occurs with division prior to the morula state (within three days post fertilization). Diamniotic monochorionic placentation occurs with division between days four and eight post-fertilization. Monoamniotic, monochorionic placentation occurs with division between days eight and 12 post fertilization. Division at or after day 13 results in conjoined twins.

Answer 76

The twin infant death rate is five times higher than that of singletons. The risk for development of cerebral palsy in twin infants is five to six times higher than that of singletons. twins had a higher incidence of IUGR (intrauterine growth restriction) than singletons. Fifty-eight percent of twins deliver prematurely, with an average gestational age at delivery of 35 weeks. Twelve percent of twins deliver very prematurely.

Answer 77

Although prematurity has been recognized as a major cause of morbidity and mortality among twin gestations, interventions for prevention of prematurity have, in general, been unsuccessful. Studies show that an adequate weight gain in the first 20 to 24 weeks of pregnancy is especially important for women carrying multiples and may help to reduce the risk of having preterm and low-birth weight babies. These pregnancies tend to be shorter than singleton pregnancies, and studies suggest that a good early weight gain aids in development of the placenta, possibly improving its ability to pass along nutrients to the babies.

Answer 78

Twin-twin transfusion syndrome is the result of an intrauterine blood transfusion from one twin to the other. It most commonly occurs in monochorionic, diamniotic twins. The donor twin is often smaller and anemic at birth. The recipient twin is usually larger and plethoric at birth. Clues to the presence of the twin-twin transfusion syndrome include the large weight discordance (although this is not necessary for diagnosis), polyhydramnios around the larger (recipient) twin, and oligohydramnios around the smaller (pump) twin Untreated severe twin-twin transfusion syndrome has a poor prognosis, with perinatal mortality rates of 70-100%. Death in utero of either twin is common. Surviving infants have increased rates of neurological morbidity, including an increased risk of cerebral palsy. Excessive volume can lead to cardiomegaly, tricuspid regurgitation, ventricular hypertrophy and hydrops fetalis for the recipient twin. Although the recipient twin is plethoric( swollen with blood), it is not macrosomic. The donor twin becomes anemic and hypovolemic, and growth is retarded. The recipient twin becomes plethoric and hypervolumic. Either twin can develop hydrops fetalis. The donor twin can become hydropic because of anemia and high-output heart failure.

Answer 79

Preterm delivery increases the risk of morbidity and mortality, increasing with higher orders of multiples. Preterm birth occurs in over 50% of twin pregnancies, 90% of triplet pregnancies, and almost all quadruplet pregnancies. While all the choices may occur with a multiple gestation, prematurity has the most significant consequences as it is associated with an increased risk of respiratory distress syndrome (RDS), intracranial hemorrhage, cerebral palsy, blindness, and low birth weight.

Answer 80

The optimal mode of delivery for twins in which the first twin is in the breech presentation is by Cesarean section. Similar to singletons, if the first twin is breech problems can occur including head entrapment and umbilical cord prolapse.

Answer 81

risk of developing microcephaly and severe intellectual disability is greatest between eight and 15 weeks gestation At 10 weeks: The embryo has become a fetus. vital organs – such as kidneys, intestines, brain, and liver – are starting to function.

Answer 82

patient is most likely to have the autosomal dominant Factor V Leiden (FVL) mutation based on her history. FVL is the most common inherited thrombophilic disorder affecting approximately 5% of Caucasian women in the United States. It is a point mutation which alters factor V making it resistant to inactivation by protein C. The thrombophilic effect of a FVL mutation has been clearly established. Heterozygosity for FVL is associated with a five- to ten-fold increased risk of thrombosis, while homozygosity is associated with an 80-fold increased risk. The FVL mutation is associated with obstetric complications including stillbirth, preeclampsia, placental abruption and IUGR. Fetuses with Trisomy 18 are likely to have congenital anomalies that are detectable on prenatal ultrasound. Over 90% of cases of trisomy 21 and 18 may be detected with the quad screen. A congenital parvovirus infection associated with a fetal demise would likely cause hydrops in the fetus which would be identified on ultrasound. Although poorly controlled diabetes mellitus are associated with fetal demise, they are not the most likely etiologies in this patient whose presentation is classic for the FVL mutation.

Answer 83

cervical incompetence or insufficiency. Preterm labor by definition does not occur until 24 weeks gestation

Answer 84

.maternal blood type should be checked on all women with vaginal bleeding during pregnancy, unless it was documented earlier in the pregnancy

Answer 85

usually associated with menstrual irregularities and infertility, and is a less likely cause

Answer 86

Ultrasound criteria for a missed abortion are a CRL(crown rump length) of > 7 mm with no cardiac activity. Medical induction using misoprostol has been shown to be efficacious and associated with less complications when compared to surgical evacuation

Answer 87

Denial, Anger, Bargaining, Depression, Acceptance.

Answer 88

Allow the parents to decide when to deliver. Keeping the patient adequately anesthetized during the labor and delivery as well as letting the parents hold the baby for as long as they desire also helps them grieve. Whether to have care on the maternity floor needs to be the parents’ decision as well. Offering an autopsy to determine the cause of death as well as having someone taking pictures and keeping mementos for the parents is helpful.

Answer 89

The rate of vaginal birth after Cesarean (VBAC) has decreased in recent years due to studies that showed an increased risk of complications, especially uterine rupture.

Answer 90

The patient has an arrest of dilatation in the active phase of labor. She is only having contractions every 5-6 minutes, so it is reasonable to start oxytocin to increase the frequency and strength of this patient’s contractions. If the patient does not have cervical change once she is having more frequent contractions on oxytocin, it would be reasonable to place an IUPC (intrauterine pressure catheter) to assess the strength of the contractions.

Answer 91

Her cervix is unfavorable; therefore, cytotec (misoprostol) administration is appropriate prior to pitocin induction. A foley bulb or artificial rupture of membranes cannot be achieved in a patient with a closed cervix

Answer 92

Prematurity, multiple gestation, genetic disorders, polyhydramnios, hydrocephaly, anencephaly, placenta previa, uterine anomalies and uterine fibroids are all associated with breech presentation.

Answer 93

The patient is in the latent phase of labor and has not yet reached the active phase (more than 4 cm). A prolonged latent phase is defined as >20 hours for nulliparas and >14 hours for multiparas, and may be treated with rest or augmentation of labor

Answer 94

secondary arrest of dilation, as she has not had any further cervical change in the active phase for over four hours. Amniotomy is often recommended in this situation. After it is performed, if the patient is still not in an adequate contraction pattern, augmentation with oxytocin can be attempted after careful evaluation

Answer 95

Her biggest risk factor is polyhydramnios with rapid decompression of the intrauterine cavity (3/75/-4 to 10/100/2 in a short time) presenting signs of an abruption include abdominal pain, bleeding, uterine hypertonus and fetal distress. Risk factors include smoking, cocaine use, chronic hypertension, trauma, prolonged premature rupture of membranes, and history of prior abruption. Treatment would involve an emergent Cesarean delivery with appropriate resuscitation, including intravenous fluids and blood products as needed

Answer 96

Placenta accreta occurs when the placenta grows into the myometrium. This patient is at risk for this condition due to her history of four previous Cesarean deliveries, and the low anterior placenta. The scar tissue from the previous surgery prevents proper implantation of the placenta and it subsequently grows into the muscle.

Answer 97

Fresh frozen plasma contains fibrinogen, as well as clotting factors V and VIII. Cryoprecipitate contains fibrinogen, factor VIII and von Willebrand’s factor.

Answer 98

Smoking increases the risk of several serious complications of pregnancy, including placental abruption, placenta previa, fetal growth restriction, preeclampsia and infection.

Answer 99

During pregnancy the cervix is extremely vascular, and with dilation a small amount of bleeding may occur. This bloody show is not of clinical significance and often occurs with normal labor.

Answer 100

Cervicitis caused by chlamydia, gonorrhea, trichomonas or other infections can present with vaginal bleeding. The cervix is much more vascular during pregnancy and inflammation can lead to bleeding.

Answer 101

Cervical polyps occur during pregnancy and can be a cause of bleeding, but are typically soft and not hard or nodular on examination. Nabothian cysts are very common, but do not typically cause bleeding. Smoking is a factor and hard consistency

Answer 102

In most cases, preterm labor is idiopathic (i.e. no cause can be identified). Dehydration and uterine distortion (from uterine fibroids or structural malformations) can be associated with preterm labor Ampicillin is indicated for this patient as her Group B Strep status is unknown and should be continued until a culture result is negative or her labor stops. Nifedipine is a tocolytic used to delay the progression of labor to allow for the benefit of betamethasone to hasten pulmonary maturation.

Answer 103

concerning for an intra-amniotic infection. Delivery is warranted and in the case of reassuring heart tones, there are no contraindications for labor induction and a Cesarean section is not indicated at this time

Answer 104

Terbutaline (tachycardia, hypotension, anxiety and chest tightening or pain are se) and ritodrine are contraindicated in diabetic patients. Magnesium sulfate is contraindicated in myasthenia gravis. Indomethacin is contraindicated at 33 weeks due to risk of premature ductus arteriosus closure. Magnesium sulfate works by competing with calcium entry into cells. Beta-adrenergic agents work by increasing cAMP in the cell, thereby decreasing free calcium. Prostaglandin synthetase inhibitors, such as Indomethacin, work by decreasing prostaglandin (PG) production by blocking conversion of free arachidonic acid to PG. Calcium channel blockers prevent calcium entry into muscle cells by inhibiting calcium transport

Answer 105

betamethasone from 24 to 34 weeks gestation has been shown to increase pulmonary maturity and reduce the incidence and severity of RDS (respiratory distress syndrome) in the newborn. It is also associated with decreased intracerebral hemorrhage and necrotizing enterocolitis (The wall of the intestine is invaded by bacteria) in the newborn.

Answer 106

Fibronectin is an extracellular matrix protein that is thought to act as an adhesive between the fetal membranes and underlying decidua. It is normally found in cervical secretions in the first half of pregnancy. Its presence in the cervical mucus between 22 and 34 weeks is thought to indicate a disruption or injury to the maternal-fetal interface. Fetal fibronectin is FDA approved for use in women with symptoms of preterm labor from 24 to 35 weeks and during routine screening of asymptomatic patients from 22 to 30 weeks gestation. Fetal fibronectin has a negative predictive value of 99.2% in symptomatic women — 99 out of every 100 patients with a single negative test result will not deliver in the next 14 days. The positive predictive value in symptomatic women is 16.7% — 17 out of 100 women with a positive test will deliver within 14 days. In asymptomatic women, a negative fetal fibronectin test has a negative predictive value of 96.7% for delivery before 35 weeks.

Answer 107

Methods to confirm rupture of membranes include testing the vaginal fluid for ferning and nitrazine testing. It is important to test the fluid from the vagina and not to test cervical mucus because of false positive ferning patterns

Answer 108

Tocolysis may be administered in an attempt to prolong the interval to delivery to gain time for steroids to obtain maximum benefit for the fetus. The risks of chorioamnionitis with continuing tocolytics beyond 48 hours outweighs the benefit of awaiting lung maturity. This may be reasonable in women without evidence of infection or advanced preterm labor. Admittedly, the likelihood of success in this setting is relatively poor, but the potential benefit to the fetus probably outweighs any maternal complication from tocolysis.

Answer 109

The primary risk factor for preterm rupture of membranes is genital tract infection, especially associated with bacterial vaginosis. Smoking and prior preterm premature rupture of membranes increases the likelihood of preterm rupture of membranes two-fold. A shortened cervical length is also a risk factor, but her cervical length is normal (at least 30 mm (3 cm)) Antibiotic therapy with ampicillin and erythromycin given to patients with preterm premature rupture of the membranes has been found to prolong the latency period by 5-7 days, as well as reduce the incidence of maternal amnionitis and neonatal sepsis. Clindamycin and gentamicin are not indicated for the management of PPROM. Tocolytics may also prolong the pregnancy for various lengths of time, but generally not seven days. 17 alpha-hydroxyprogesterone has been shown to reduce the risk of premature labor. 17 alpha-hydroxyprogesterone is administered weekly (starting between 16-20 weeks) until 36 weeks gestation.

Answer 110

Variable deceleration-cord compression (frequent cause of cord compression can be lack of amniotic fluid-amnioinfusion helps) Early deceleration- head compression (vagal stimulation and slowing of the heart rate) acceleration- ok Late deceleration- uteroplacental insufficiency (Common causes include chronic hypertension and postdate pregnancies;Initial measures to evaluate and treat fetal hypoperfusion include a change in maternal position to left lateral position which increases perfusion to the uterus, maternal supplemental oxygenation, treatment of maternal hypotension, discontinue oxytocin, consider intrauterine resuscitation with tocolytics and intravenous fluids, fetal acid-base assessment with fetal scalp capillary blood gas or pH measurement. Measures to improve blood flow should be attempted prior to proceeding with Cesarean delivery.

Answer 111

Maternal signs of chorioamnionitis or other evidence of intra-amniotic infection are indications for delivery. ruptured membranes and a tender fundus, which indicate chorioamnionitis. presence of amniotic leukocytes has the lowest predictive value for the diagnosis of chorioamnionitis. Interleukin-6 would be increased in the setting of chorioamnionitis. A low amniotic fluid glucose is an indication of intra-amniotic infection.

Answer 112

Neonatal survival when rupture occurs between 20 and 23 weeks is approximately 25%. Complications that may be found in the developing fetus include structural abnormalities that are primarily deformations (abnormalities that occur due to an insult after a structure has already formed) rather than malformations (abnormal development of the structure itself). Pulmonary hypoplasia is seen when rupture of membranes occurs before 25 weeks gestation because the lack of amniotic fluid interferes with the normal intrauterine breathing process. The result is failure of normal development and growth of the respiratory tree.

Answer 113

Augmentation of labor is needed. Expectant management at 36 weeks poses a large risk to the development of chorioamnionitis. The role of tocolytics in the setting of preterm premature rupture of membranes is controversial and is contraindicated at 36 weeks gestation. Steroid administration after 32 weeks is controversial.

Answer 114

While the patient is contracting every four minutes, it is not clear if her contractions are adequate. An intrauterine pressure catheter (IUPC) will help determine if her contractions are adequate and if oxytocin augmentation is appropriate. Prostaglandins are used for cervical ripening and are contraindicated in patients with history of previous Cesarean section.

Answer 115

baseline fetal heart rate is >160 with no accelerations or variability. Prolonged periods of fetal tachycardia are frequently found with maternal fever or chorioamnionitis.

Answer 116

Methylergonovine is an ergot alkaloid, which is a potent smooth muscle constrictor. It is also a vasoconstrictive agent and should be withheld from women with hypertension and/or preeclampsia. Prostaglandin F2-alpha (Hemabate) is a potent smooth muscle constrictor, which also has a bronchio-constrictive effect. As such, it should be used with caution in any patient with a reported history of asthma. It is absolutely contraindicated in patients with poorly controlled or severe asthma.

Answer 117

Globular pale mass Grand multiparity, multiple gestation, polyhydramnios and macrosomia are all risk factors. The most common risk factor, however, is excessive (iatrogenic) traction on the umbilical cord during the third stage of delivery.

Answer 118

Placental abruption and uterine atony are both common, but, in the presence of a low-lying anterior placenta in a patient with a history of multiple Cesarean births, the diagnosis of the placenta accreta must be entertained

Answer 119

Prior Cesarean delivery, uterine leiomyomas, prior uterine curettage and succenturiate lobe of placenta (a second or third placental lobe that is much smaller than the largest lobe)

Answer 120

uterine compression suture such as a B-Lynch has been shown to be effective in the management of unresponsive uterine atony. Ligation of a number of pelvic vessels can lead to reduction in the vascular pressure in the pelvis thus controlling hemorrhage. This is especially true with internal iliac artery (hypogastric artery) ligation.

Answer 121

Endomyometritis is a common complication of prolonged labor, prolonged rupture of membranes and multiple vaginal examinations. The infection is polymicrobial, mostly anaerobic and requires broad-spectrum antibiotics for treatment until the patient is afebrile for 24 hours. By adding Gentamicin, you are covering the spectrum of gram-negative organisms. Fever and maternal tachycardia and uterine tenderness

Answer 122

Acute cystitis is a common complication after vaginal delivery and the risk increases with the use of an indwelling catheter. The most common cause of acute cystitis infection is gram-negative bacteria. The major pathogens are E. coli (75%), P. mirabilis (8%), K. pneumoniae (20%), S. faecalis (

Answer 123

Postpartum fever differential includes endometritis, cystitis and mastitis

Answer 124

Mixed bacteria originating from the skin, uterus and vagina cause wound infections after a Cesarean section. Prior to establishing a diagnosis of surgical site infection, evaluation requires opening the wound, checking for fascial dehiscence, drainage and assessment of the fluid. Packing the wound until it has healed from the base of the wound facilitates the healing process. Broad spectrum antibiotics are indicated if you suspect cellulitis or abscess.

Answer 125

Classic symptoms include nausea, vomiting, dyspepsia and upper abdominal pain after eating fatty foods. Treatment would be dependent on the severity of symptoms, but often involves cholecystectomy that is usually performed laparoscopically.

Answer 126

involves thrombosis of the venous system of the pelvis. Diagnosis is often one of exclusion of other causes, but sometimes a CT scan will reveal thrombosed veins. Treatment requires addition of anticoagulation to antibiotics and resolution of fevers is rapid. Anticoagulation treatment is short-term.

Answer 127

The lungs are the most common source of fever on the first postpartum day, particularly if the patient had general anesthesia. Atelectasis may be associated with a postpartum fever. Aspiration pneumonia should be considered in patients who had general anesthesia.

Answer 128

Aggressive debridement of the necrotic areas is required to prevent further spread of the infection. Debridement should extend until vital tissue with good blood supply is encountered. Repair of the defect should be delayed until the infection has completely resolved

Answer 129

Postpartum depression

Answer 130

Inpatient psychiatric admission Always ask depressed person about suicide risk

Answer 131

With Category A drugs, there are adequate, well-controlled studies in pregnant women that have not shown an increased risk of fetal abnormalities to the fetus in any trimester of pregnancy. With Category B, animal studies have revealed no evidence of harm to the fetus; however, there are no adequate and well-controlled studies in pregnant women or animal studies that have shown an adverse effect, but adequate and well-controlled studies in pregnant women have failed to demonstrate a risk to the fetus in any trimester. Category C drugs have animal studies that show an adverse effect and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks. Category D drugs have adequate well-controlled or observational studies in pregnant women and are known risks to the fetus. Category X drugs should not be used in pregnancy, because adequate well-controlled or observational studies in animals or pregnant women have demonstrated positive evidence of fetal abnormalities or risks.

Answer 132

A patient’s history of a psychiatric illness is a risk factor for the development of a postpartum depression.

Answer 133

Insomnia and sexual dysfunction, such as decreased libido and delayed or absent orgasm, are common. Current recommendations state that SSRI medications can be safely used during lactation. Several studies show that SSRIs are secreted in breast milk, however no detectable levels of the drug were found in the infants’ serum Third trimester maternal use of SSRIs including Fluoxetine has been associated with abnormal muscle movements (extrapyramidal signs or EPS) and withdrawal symptoms which may include agitation, abnormally increased or decreased muscle tone, tremor, sleepiness, severe difficulty breathing, and difficulty in feeding.

Answer 134

Ascertaining the timing of her symptoms each month is an important first step in establishing the proper diagnosis. Symptoms of Premenstrual Dysphoric Disorder occur in the luteal phase and are absent in the beginning of the follicular phase. It is therefore important to document the timing of symptoms each month when considering a diagnosis of Premenstrual Dysphoric Disorder. Additionally, it is important to ascertain that these symptoms are not an exacerbation of an underlying psychiatric disorder before initiating therapy as this potentially can have more consequences during her pregnancy and postpartum period.

Answer 135

The patient is describing symptoms of postpartum blues that affects 40-80% women within two to three days postpartum and resolve within two weeks. Symptoms include insomnia, easy crying, depression, poor concentration, irritability or labile affect and anxiety. Symptoms often last a few hours per day and are mild and transient.

Answer 136

Postterm pregnancies should be followed with antepartum fetal surveillance because perinatal morbidity and mortality increases beginning at 41 weeks of gestation. Many practitioners use twice-weekly testing with some evaluation of amniotic fluid volume beginning at 41 weeks of gestation. A non-stress test and amniotic fluid volume assessment (a modified BPP) should be adequate. The non-stress test is an assessment of fetal well-being that measures the fetal heart rate response to fetal movemen

Answer 137

Sulfatase is a key enzymes of estrogen biosynthesis in the human placenta Postterm pregnancies are associated with placental sulfatase deficiency, fetal adrenal hypoplasia, anencephaly, inaccurate or unknown dates and extrauterine pregnancy Postterm pregnancies complications: macrosomia, oligohydramnios, meconium aspiration, uteroplacental insufficiency and dysmaturity (withered, meconium stained, long-nailed, fragile and have an associated small placenta). Although postterm infants are larger than term infants and have an increased incidence of fetal macrosomia, there is no evidence to support induction of labor as a preventive measure for macrosomia in these cases

Answer 138

Optimal management for the patient with a favorable cervix at greater than or equal to 41 weeks gestation is delivery. Her dilation and effacement make it likely her induction will be successful. Induction of labor in a patient with an unfavorable cervix increases the risk of Cesarean section significantly, compared to a patient who goes into spontaneous labor.

Answer 139

Prostaglandins applied locally are the most commonly-used cervical ripening agents.

Answer 140

Uteroplscental insufficiency due to vasculature issues

Answer 141

In growth-restricted pregnancies, oligohydramnios is frequently found. This finding is presumably due to reduced fetal blood volume, renal blood flow and urinary output. Chronic hypoxia is responsible for diverting blood flow from the kidney to organs that are more critical during fetal life. The significance of the amniotic fluid volume with respect to fetal outcome has been well documented. Ninety percent of patients with oligohydramnios delivered growth restricted infants. These infants experienced a high rate of fetal compromise. The systolic/diastolic (S/D) ratio of the umbilical artery is determined by Doppler ultrasound. An increase in the S/D ratio reflects increased vascular resistance. It is a common finding in IUGR fetuses. A normal S/D ratio indicates fetal well-being. As vascular resistance increases, the S/D ratio increases. With severe resistance, there is absence and ultimately reversal of end-diastolic flow. These findings are associated with an increased rate of perinatal morbidity and mortality, and a higher likelihood of a long-term poor neurologic outcome. Options for antenatal testing include the non-stress test, contraction stress test, and the biophysical profile. Any of these may be used in a growth-restricted fetus as a means of detecting possible or probable fetal asphyxia. While fetal kick counts may be of value, additional fetal testing such as twice weekly NST with AFI and weekly umbilical artery Doppler studies is indicated in monitoring fetuses with IUGR.

Answer 142

The crown-rump length can reliably date a pregnancy within five to seven days; good in any trimester

Answer 143

Uteroplacental insufficiency can lead to asymmetric growth restriction. Asymmetric growth restricted infants typically have a normal length, but their weight is below normal. On ultrasound, there is a head-sparing effect, meaning that the head/brain is spared of the reduced blood flow that is a result of uteroplacental insufficiency. Thus, the fetal abdomen measures below normal and the head remains very close to normal. There is an asymmetrical growth pattern that is usually detected during the third trimester and reflects uteroplacental insufficiency. Symmetric fetal growth restriction indicates that all fetal measurements are below normal. As a general rule, such a finding indicates an intrinsic growth failure or an “early event” secondary to one or more organ system anomalies, fetal aneuploidy or chronic intrauterine infection. Infectious diseases are known to cause IUGR, but the number of organisms is poorly defined. There is sufficient evidence to show a causal relationship between rubella and CMV infections and fetal growth restriction. Other viruses to consider are syphilis and varicella. The protozoan toxoplasmosis results in IUGR as well. There are no bacteria known to cause IUGR. Symmetrical growth restriction is usually detected in the mid-trimester of pregnancy.

Answer 144

Epidemiologic studies indicate that fetal growth restriction is a significant risk factor for the subsequent development of cardiovascular disease, chronic hypertension, chronic obstructive lung disease and diabetes.

Answer 145

4500=9.9 lbs | 5000 g = 11 lbs

Answer 146

Delivery is indicated in a fetus with IUGR at 36 weeks gestation with oligohydramnios and abnormal umbilical artery Doppler studies. Although there is an increased incidence of fetal intolerance of labor, induction of labor is generally preferred over elective Cesarean delivery. Delivery at term is indicated in fetuses with IUGR with reassuring fetal testing including a normal amniotic fluid volume.

Answer 147

CThe fetus with enhanced general growth or macrosomia is defined by a birth weight at or above the 90th percentile for gestational age. The condition can usually be ascribed to one of three etiologies: enhanced growth potential (50-60%); abnormal maternal glucose homeostasis (35-40%); or underestimation of fetal age (5%). Macrosomic newborns of diabetic mothers experience excessive rates of neonatal morbidity, including birth trauma such as shoulder dystocia and brachial plexus injury. These infants have significantly higher rates of severe hypoglycemia and neonatal jaundice. Neonatal acidosis occurs with poor glycemic control, thus increasing the incidence of fetal demise. While poorly controlled pre-existing diabetes is associated with an increased risk of congenital anomalies, gestational diabetes is not associated with increased risk of congenital anomalies.

Answer 148

The tissue is consistent with omental tissue and may include segments of bowel. The suction should be turned off and the tissue gently removed from the curette. Laparoscopy will allow closer examination and should bowel appear to be involved, the surgeon should consider laparotomy for closer evaluation of the bowel for damage. The other options would place the patient at increased risk of complications and delay diagnosis.

Answer 149

Uterine fibroids located in the lower uterine segment may obstruct labor by preventing the fetal head from entering the pelvis, so do a c section. A fetal head with measurements greater than 12 cm could benefit from delivery by Cesarean section

Answer 150

Forceps application requires complete cervical dilation, head engagement, vertex presentation, clinical assessment of fetal size and maternal pelvis, known position of the fetal head, adequate maternal pain control and rupture of membranes. Use forceps when prolonged 2nd stage, maternal exhaustion or to hasten delivery

Answer 151

Newer forms of vacuum extractors cause less maternal discomfort as they are applied to the vertex of the fetal head and do not take up additional space in the maternal pelvis. If properly applied, this leads to a decreased rate of maternal lacerations. Fetal and neonatal complications related to vacuum use include lacerations at the edges of the vacuum cup, particularly if torsion is applied. Torsion may also lead to separation of the fetal scalp from the underlying structures can cause a cephalohematoma and places the fetus at risk of jaundice. Transient neonatal lateral rectus paralysis has been found to occur more frequently in vacuum-assisted deliveries, but, because the paralysis resolves spontaneously, it is unlikely to be of clinical importance.

Answer 152

Post-term pregnancies, chorioamnionitis, oligohydramnios, and term premature rupture of membranes are all acceptable indications for induction of labor and delivery if the patient is a good candidate for initiation of labor

Answer 153

Most recent data suggests that breech infants delivered vaginally are at higher risk for neonatal complications. Therefore, it would be recommended that this patient undergo a Cesarean section, especially since this is her first pregnancy. External cephalic version and internal versions are contraindicated in active labor. Forceps are used in breech deliveries to assist in flexion of the head and vacuum applications on breech presentations are contraindicated.

Answer 154

Phases of labor: Labor= cervical change accompanied by regular uterine contractions Stage 1: Latent phase: 20hrs for nulliparas, >14hrs for multi Mgmt: counsel about latent phase, and rest Tx: rest or augmentation of labor ROM is not indicated as increases risk for infection; cervical dilation or laminaria placement is also not indicated Active phase: >4cm, dilation is more rapidly Typically progresses about 1.2 cm / hour, or 1.5-2 in multips Protraction of active phase when cervical dilation is less than expected Prolonged when no cervical change >4hrs Arrest when there is no progress of labor for 2 hours Tx: amniotomy if intact; if not intact or after and still not adequate contractions → augment with oxytocin after eval *it is the change in the cervix per time and note the uterine contraction pattern that dictates normalcy in labor Mgmt: observe course without intervention Stage 2: baby is being delivered to delivery of placenta ``` Stage 3: Placental Delivery: 4 signs of proper placental separation: 1) gush of blood 2) lengthening of the cord 3) globular and firm shape of the uterus 4) uterus rises up to the anterior abdominal wall Nl delivery is within 30 minutes Prolonged if it does not deliver within 30 mins.= → attempt manual extraction of the placenta Oxytocin should NOT be given until the uterine fundus is blacked back to its normal location Complication → hemorrhage Stage 4: 2 hours postpartums ```

Answer 155

Chorionic villus sampling (CVS) is a prenatal test that can detect genetic and chromosomal abnormalities of a fetus. The loss rate with amniocentesis is quoted as 0.5% vs. ~1 to 3% for chorionic villus sampling. CVS is performed between 10 and 12 weeks gestation, while amniocentesis is performed after 15 weeks. Early CVS (

Answer 156

initially after Depo-Provera injection there may be unpredictable bleeding. This usually resolves in 2-3 months. In general, after one year of using Depo-Provera, nearly 50% of users have amenorrhea. Not the best choice for someone overweight/high bmi

Answer 157

Provide emergency contraception, then begin oral contraceptives immediately

Answer 158

women who have contraindications to using combined oral contraceptives (estrogen and progestin containing). Contraindications to estrogen include a history of thromboembolic disease, women who are lactating, women over age 35 who smoke or women who develop severe nausea with combined oral contraceptive pills. Progestins should be used with caution in women with a history of depression.

Answer 159

Oral contraceptives will decrease a woman’s risk of developing ovarian and endometrial cance Htn is a contraindication for ocp

Answer 160

Hysteroscopic tubal occlusion (Essure®) can be performed in the office and places coils into the fallopian tubes that cause scarring that blocks the tubes. Patients are required to use a back up method of contraception for three months following the procedure until a hysterosalpingogram is performed confirming complete occlusion of the tubes. While tubal ligation, either by laparoscopy or mini-laparotomy, are common and effective forms of permanent sterilization, for this patient with her BMI and previous surgeries, this would carry more surgical risks. Hysterectomy is not an indicated procedure for sterilization. Endometrial ablation, or thermal destruction of the endometrial tissue, is an effective treatment for menorrhagia but is not reliable for permanent sterilization.

Answer 161

Approximately 10% of women who have been sterilized regret having had the procedure with the strongest predictor of regret being undergoing the procedure at a young age. The percentage expressing regret was 20% for women less than 30 years old at the time of sterilization. For those under age 25, the rate was as high as 40%. The regret rate was also high for women who were not married at the time of their tubal ligation, when tubal ligation was performed less than a year after delivery, and if there was conflict between the woman and her partner.

Answer 162

The patch has comparable efficiency to the pill in comparative clinical trials, although it has more consistent use. It has a significantly higher failure rate when used in women who weigh more than 198 pounds. The patch is a transdermal system that is placed on a woman’s upper arm or torso (except breasts). The patch (Ortho Evra®) slowly releases ethinyl estradiol and norelgestromin, which establishes steady serum levels for seven days. A woman should apply one patch in a different area each week for three weeks, then have a patch-free week, during which time she will have a withdrawal bleed.

Answer 163

The patient has a septic abortion. She has fever and bleeding with a dilated cervix which are findings seen with septic abortion. Threatened abortions clinically have vaginal bleeding, a positive pregnancy test and a cervical os closed or uneffaced. Missed abortions have retention of a nonviable intrauterine pregnancy for an extended period of time (i.e. dead embryo or blighted ovum) -- Misoprostol can be administered orally or vaginally and will induce uterine cramping with expulsion of products of conception. Potential risk factors of use include hemorrhage as well as failure.) A normal pregnancy would have a closed cervix. Ectopic pregnancy would likely present with bleeding, abdominal pain, possibly have an adnexal mass, and the cervix would typically be closed.

Answer 164

ncludes broad-spectrum antibiotics and uterine evacuation. Single agent antimicrobials do not provide adequate coverage for the array of organisms that may be involved and therefore are not indicated. A laparoscopy can be indicated if ectopic pregnancy is suspected, but it is unlikely in this case. Medical termination is not the best option since prompt evacuation of the uterus is indicated for septic abortion.

Answer 165

An(ntiphosphospholipid antibodies are associated with recurrent pregnancy loss. The workup for antiphospholipid syndrome includes assessment of anticardiolipin and beta-2 glycoprotein antibody status, PTT, and Russell viper venom time. Recurrent pregnancy loss is defined as > two consecutive or > three spontaneous losses before 20 weeks gestation. Etiologies include anatomic causes, endocrine abnormalities such as hyper- or hypothyroidism and luteal phase deficiency, parental chromosomal anomalies, immune factors such as lupus anticoagulant and idiopathic factors.

Answer 166

The prolonged dilute Russell viper venom time (detect lupus anticoagulant), history of three early pregnancy losses, and a history of venous thrombosis leads one to suspect that the etiology of recurrent pregnancy loss is due to antiphospholipid antibody syndrome. The treatment is aspirin plus heparin.

Answer 167

Medical abortion is associated with higher blood loss than surgical abortion. Early in pregnancy (less than 49 days) both medical and surgical procedures can be offered. Mifepristone (an antiprogestin) can be administered, followed by misoprostol (a prostaglandin) to induce uterine contractions to expel the products of conception. This approach has proven to be effective (96%) and safe. A surgical termination is required in the event of failure or excessive blood loss. Medical termination may be more desirable by some patients since they do not have to undergo a surgical procedure. It does not affect future fertility. Any termination of pregnancy, whether medical or surgical, can have psychological sequelae.

Answer 168

Manual vacuum aspiration is more than 99% effective in early pregnancy (less than eight weeks).

Answer 169

a progesterone receptor blocker, is used for pregnancy termination. It is recommended for use within 49 days of the last menstrual period, but there is data to show that it can be effective up to nine weeks

Answer 170

This patient is having heavy bleeding as a complication of medical termination of pregnancy. The most likely etiology for her bleeding is retained products of conception. This is managed best by performing a dilation and curettage. No need for transfusion if pt is asymptomatic for anemia

Answer 171

Bacterial vaginosis is the most common cause of vaginitis. The infection arises from a shift in the vaginal flora from hydrogen peroxide-producing lactobacilli to non-hydrogen peroxide-producing lactobacilli, which allows proliferation of anaerobic bacteria. The majority of women are asymptomatic; however, patients may experience a thin, gray discharge with a characteristic fishy odor that is often worse following menses and intercourse. Modified Amsel criteria for diagnosis include three out of four of the following: 1) thin, gray homogenous vaginal discharge; 2) positive whiff test (addition of potassium hydroxide releases characteristic amine odor); 3) presence of clue cells on saline microscopy; and 4) elevated vaginal pH >4.5. Treatment consists of Metronidazole 500 mg orally BID for seven days, or vaginal Metronidazole 0.75% gel QHS for five days.

Answer 172

Lichen sclerosus is a chronic inflammatory skin condition that most commonly affects Caucasian premenarchal girls and postmenopausal women. The exact etiology is unknown, but is most likely multifactorial. Patients typically present with extreme vulvar pruritus and may also present with vulvar burning, pain and introital dyspareunia. Early skin changes include polygonal ivory papules involving the vulva and perianal areas, waxy sheen on the labia minora and clitoris, and hypopigmentation. The vagina is not involved. More advanced skin changes may include fissures and erosions due to a chronic itch-scratch-itch cycle, mucosal edema and surface vascular changes. Ultimately, scarring with loss of normal architecture, such as introital stenosis and resorption of the clitoris (phimosis) and labia minora, may occur. Treatment involves use of high-potency topical steroids. There is less than a 5% risk of developing squamous cell cancer within a field of lichen sclerosus.

Answer 173

caused by the protozoan, T. vaginalis. Many infected women have symptoms characterized by a diffuse, malodorous, yellow-green discharge with vulvar irritation. However, some women have minimal or no symptoms. Diagnosis of vaginal trichomoniasis is performed by saline microscopy of vaginal secretions, but this method has a sensitivity of only 60% to 70%. The CDC recommended treatment is metronidazole 2 grams orally in a single dose. An alternate regimen is metronidazole 500mg orally twice daily for seven days. The patient’s sexual partner also should undergo treatment prior to resuming sexual relations.

Answer 174

Vulvovaginal candidiasis (VVC) usually is caused by C. albicans, but is occasionally caused by other Candida species or yeasts. Typical symptoms include pruritus and vaginal discharge. Other symptoms include vaginal soreness, vulvar burning, dyspareunia and external dysuria. None of these symptoms are specific for VVC. The diagnosis is suggested clinically by vulvovaginal pruritus and erythema with or without associated vaginal discharge. The diagnosis can be made in a woman who has signs and symptoms of vaginitis when either: a) a wet preparation (saline or 10% KOH) or Gram stain of vaginal discharge demonstrates yeasts or pseudohyphae; or b) a vaginal culture or other test yields a positive result for a yeast species. Microscopy may be negative in up to fifty percent of confirmed cases. Treatment for uncomplicated VVC consists of short-course topical Azole formulations (1-3 days), which results in relief of symptoms and negative cultures in 80%-90% of patients who complete therapy.

Answer 175

Lichen planus is a chronic dermatologic disorder involving the hair-bearing skin and scalp, nails, oral mucous membranes and vulva. This disease manifests as inflammatory mucocutaneous eruptions characterized by remissions and flares. The exact etiology is unknown, but is thought to be multifactorial. Vulvar symptoms include irritation, burning, pruritus, contact bleeding, pain and dyspareunia. Clinical findings vary with a lacy, reticulated pattern of the labia and perineum, with or without scarring and erosions as well. With progressive adhesion formation and loss of normal architecture, the vagina can become obliterated. Patients may also experience oral lesions, alopecia and extragenital rashes. Treatment is challenging, since no single agent is universally effective and consists of multiple supportive therapies and topical high potency corticosteroids.

Answer 176

Vestibulodynia (formally vulvar vestibulitis) syndrome consists of a constellation of symptoms and findings limited to the vulvar vestibule, which include severe pain on vestibular touch or attempted vaginal entry, tenderness to pressure and erythema of various degrees. Symptoms often have an abrupt onset and are described as a sharp, burning and rawness sensation. Women may experience pain with tampon insertion, biking or wearing tight pants, and avoid intercourse because of marked introital dyspareunia. Vestibular findings include exquisite tenderness to light touch of variable intensity with or without focal or diffuse erythematous macules. Often, a primary or inciting event cannot be determined. Treatment includes use of tricyclic antidepressants to block sympathetic afferent pain loops, pelvic floor rehabilitation, biofeedback, and topical anesthetics. Surgery with vestibulectomy is reserved for patients who do not respond to standard therapies and are unable to tolerate intercourse.

Answer 177

Lichen simplex chronicus, a common vulvar non-neoplastic disorder, results from chronic scratching and rubbing, which damages the skin and leads to loss of its protective barrier. Over time, a perpetual itch-scratch-itch cycle develops, and the result is susceptibility to infection, ease of irritation and more itching. Symptoms consist of severe vulvar pruritus, which can be worse at night. Clinical findings include thick, lichenified, enlarged and rugose labia, with or without edema. The skin changes can be localized or generalized. Diagnosis is based on clinical history and findings, as well as vulvar biopsy. Treatment involves a short-course of high-potency topical corticosteroids and antihistamines to control pruritus.

Answer 178

Mucopurulent cervicitis (MPC) is characterized by a mucopurulent exudate visible in the endocervical canal or in an endocervical swab specimen. MPC is typically asymptomatic, but some women have an abnormal discharge or abnormal vaginal bleeding. MPC can be caused by Chlamydia trachomatis or Neisseria gonorrhoeae; however, in most cases neither organism can be isolated. Patients with MPC should be tested for both of these organisms. The results of sensitive tests for C. trachomatis or N. gonorrhoeae (e.g. culture or nucleic acid amplification tests) should determine the need for treatment, unless the likelihood of infection with either organism is high or the patient is unlikely to return for treatment. Antimicrobial therapy should include coverage for both organisms, such as azithromycin or doxycycline for chlamydia and a cephalosporin or quinolone for gonorrhea. Uncomplicated cervicitis, as in this patient, would require only 125 mg of Ceftriaxone in a single dose. Ceftriaxone 250 mg is necessary for the treatment of upper genital tract infection or pelvic inflammatory disease (PID

Answer 179

Two serotypes of HSV have been identified: HSV-1 and HSV-2. Most cases of recurrent genital herpes are caused by HSV-2. Up to 30% of first-episode cases of genital herpes are caused by HSV-1, but recurrences are much less frequent for genital HSV-1 infection than genital HSV-2 infection. Genital HSV infections are classified as initial primary, initial nonprimary, recurrent and asymptomatic. Initial, or first-episode primary genital herpes is a true primary infection (i.e. no history of previous genital herpetic lesions, and seronegative for HSV antibodies). Systemic symptoms of a primary infection include fever, headache, malaise and myalgias, and usually precede the onset of genital lesions. Vulvar lesions begin as tender grouped vesicles that progress into exquisitely tender, superficial, small ulcerations on an erythematous base. Initial, nonprimary genital herpes is the first recognized episode of genital herpes in individuals who are seropositive for HSV antibodies. Prior HSV-1 infection confers partial immunity to HSV-2 infection and thereby lessens the severity of type 2 infection. The severity and duration of symptoms are intermediate between primary and recurrent disease, with individuals experiencing less pain, fewer lesions, more rapid resolution of clinical lesions and shorter duration of viral shedding. Systemic symptoms are rare. Recurrent episodes involve reactivation of latent genital infection, most commonly with HSV-2, and are marked by episodic prodromal symptoms and outbreaks of lesions at varying intervals and of variable severity. Clinical diagnosis of genital herpes should be confirmed by viral culture, antigen detection or serologic tests. Treatment consists of antiviral therapy with acyclovir, famciclovir or valacyclovir.

Answer 180

Overflow incontinence is characterized by failure to empty the bladder adequately. This is due to an underactive detrusor muscle (neurologic disorders, diabetes or multiple sclerosis) or obstruction (postoperative or severe prolapse-cystocele, rectocele). A normal post-void residual (PVR) is 50-60 cc. An elevated PVR, usually >300 cc, is found in overflow incontinence. pressure, fullness, and frequency, and is usually a small amount of continuous leaking. It is not associated with any positional changes or associated events.

Answer 181

Risk factors for the development of pelvic organ prolapse are increasing parity, increasing age, obesity, some connective tissue disorders (Ehlers-Danlos syndrome), and chronic constipation. Vaginal delivery is associated with a higher risk of POP than Cesarean delivery. It is unclear whether occupations that require heavy lifting increase the risk of POP. Women with a family history of POP have up to a 2.5 fold increase in prolapse.

Answer 182

Genuine stress incontinence (GSI) is the loss of urine due to increased intra-abdominal pressure in the absence of a detrusor contraction; urethra is intact. The majority of GSI is due to urethral hypermobility (straining Q-tip angle >30 degrees from horizon). Pt Transvaginal tape Sling

Answer 183

Here the urethra is scarred, fibrosed and remains patent without the ability to constrict This results in urinary stress incontinence It develops as a result of radiation therapy or Previous surgery for incontinence This is a classic example of intrinsic sphincteric deficiency- poor urethral closure function. Urethral bulking procedures are minimally invasive and have a success rate of 80% in these specific patients.

Answer 184

The patient has the diagnosis of detrusor instability. The parasympathetic system is involved in bladder emptying and acetylcholine is the transmitter that stimulates the bladder to contract through muscarinic receptors. Thus, anticholinergics are the mainstay of pharmacologic treatment. Oxybutynin is one example. Although the tricyclic antidepressant, amitriptyline, has anticholinergic properties, its side effects do not make it an ideal choice. Vaginal estrogen has been shown to help with urgency, but not urge incontinence. Pseudoephedrine has been shown to have alpha-adrenergic properties and may improve urethral tone in the treatment of stress incontinence. Kegel exercises or pelvic muscle training are used to strengthen the pelvic floor and decrease urethral hypermobility for the treatment of stress urinary incontinence.

Answer 185

Central and lateral cystoceles are repaired by fixing defects in the pubocervical fascia or reattaching it to the sidewall, if separated from the white line.

Answer 186

Because of the hydronephrosis due to obstruction, intervention is required. Colpocleisis is a procedure where the vagina is surgically obliterated and can be performed quickly without the need for general anesthesia. Anterior and posterior repairs provide no apical support of the vagina. She will be at high risk of recurrent prolapse. The sacrospinous fixation (cuff to sacrospinous-coccygeus complex) or sacrocolpopexy (cuff to sacral promontory using interposed mesh) require regional or general anesthesia and is not the best option for this patient with high surgical morbidity.

Answer 187

typical symptoms of endometriosis, including dysmenorrhea and dyspareunia. In addition, the nodularity along the back of the uterus along the uterosacral ligaments is suggestive of endometriosis. Endometrioma is a type of cyst formed when endometrial tissue (the mucous membrane that makes up the inner layer of the uterine wall) grows in the ovaries--chocolate cysts Surgery is the gold standard in the diagnosis of endometriosis, but often is not the initial treatment as suspected endometriosis is often managed medically- nsaids and OCP (provide negative feedback to the pituitary-hypothalamic axis which stops stimulation of the ovary resulting in ovarian suppression of sex hormone production, such as estrogen. Since estrogen stimulates endometrial tissue located outside of the endometrium and uterus, endometriosis can be suppressed by OCPs especially when prescribed in a continuous fashion (omit the week of placebo pills resulting in no withdrawal bleed).); A GnRH agonist is used to control pelvic pain in endometriosis patients unresponsive to other hormonal treatments; Numerous clinical trials show GnRH agonists are more effective than placebo and as effective as Danazol in relieving endometriosis-associated pelvic pain. Danazol, a 17-alpha-ethinyl testosterone derivative, suppresses the mid-cycle surges of LH and FSH. The role of surgery is often to manage the symptoms of endometriosis, often pelvic pain. As such, surgery may be conservative (laparoscopic ablation or excision of implants, excision of endometriomas) or definitive (total hysterectomy/BSO). Diagnostic laparoscopy

Answer 188

A repeat ultrasound is the most appropriate next step in an asymptomatic premenopausal woman; it will resolve on its own most likely

Answer 189

ovarian torsion Surgical exploration

Answer 190

benefits from ovarian stimulation with clomiphene citrate (cause ovulation), with or without intrauterine insemination.

Answer 191

Chronic pelvic pain is the indication for at least 40% of all gynecologic laparoscopies. Endometriosis and adhesions account for more than 90% of the diagnoses in women with discernible laparoscopic abnormalities, and laparoscopy is indicated in women thought to have either of these conditions. Often, adolescents are excluded from laparoscopic evaluation on the basis of their age, but several series show that endometriosis is as common in adolescents with chronic pelvic pain as in the general population. Therefore, laparoscopic evaluation of chronic pelvic pain in adolescents should not be deferred based on age. Laparoscopy can be both diagnostic and therapeutic in this patient in whom you suspect endometriosis. Most published evidence suggests a significant association of physical and sexual abuse with various chronic pelvic pain disorders.

Answer 192

Interstitial cystitis (IC) is a chronic inflammatory condition of the bladder, which is clinically characterized by recurrent irritative voiding symptoms of urgency and frequency, in the absence of objective evidence of another disease that could cause the symptoms. Pelvic pain is reported by up to 70% of women with IC and, occasionally, it is the presenting symptom or chief complaint. Women may also experience dyspareunia. The specific etiology is unknown, but IC may have an autoimmune and even hereditary component.

Answer 193

Irritable bowel syndrome (IBS) is a common functional bowel disorder of uncertain etiology. It is characterized by a chronic, relapsing pattern of abdominal and pelvic pain, and bowel dysfunction with constipation or diarrhea. IBS is one of the most common disorders associated with chronic pelvic pain. IBS appears to occur more commonly in women with chronic pelvic pain than in the general population. Diagnosis is based on the Rome II Criteria for IBS, which includes at least 12 weeks (need not be consecutive) in the preceding 12 months of abdominal discomfort or pain that has two of three features: 1) relief with defecation; 2) onset associated with a change in frequency of stool; or 3) onset associated with a change in stool form or appearance

Answer 194

pelvic adhesive disease as a result of her prior hysterectomy. The development of a postoperative pelvic infection likely has contributed to the further development of pelvic adhesions involving the tubes and ovaries that were retained.

Answer 195

Pelvic congestion syndrome is a cause of chronic pelvic pain occurring in the setting of pelvic varicosities. The unique characteristics of the pelvic veins make them vulnerable to chronic dilatation with stasis leading to vascular congestion. These veins are thin walled and unsupported, with relatively weak attachments between the supporting connective tissue. The cause of pelvic vein congestion is unknown. Hormonal factors contribute to vasodilatation when pelvic veins are exposed to high concentration of estradiol, which inhibits reflex vasoconstriction of vessels, induces uterine enlargement with selective dilatation of ovarian and uterine veins. This pain may be of variable intensity and duration, is worse premenstrually and during pregnancy, and is aggravated by standing, fatigue and coitus. The pain is often described as a pelvic “fullness” or “heaviness,” which may extend to the vulvar area and legs. Associated symptoms include vaginal discharge, backache and urinary frequency. Menstrual cycle defects and dysmenorrhea are common. No signs of pelvic floor relaxation were noted on exam.

Answer 196

The nerves at risk are the iliohypogastric nerve (T-12, L-1) and the ilioinguinal (T-12, L-1) nerve. These two nerves exit the spinal column at the 12th vertebral body and pass laterally through the psoas muscle before piercing the transversus abdominus muscle to the anterior abdominal wall. Once at the anterior superior iliac spine, the iliohypogastric nerve courses medially between the internal and external oblique muscles, becoming cutaneous 1 cm superior to the superficial inguinal ring. The iliohypogastric nerve provides cutaneous sensation to the groin and the skin overlying the pubis. The ilioinguinal nerve follows a similar, although slightly lower, course as the iliohypogastric nerve where it provides cutaneous sensation to the groin, symphysis, labium and upper inner thigh. These nerves may become susceptible to injury when a low transverse incision is extended beyond the lateral border of the rectus abdominus muscle, into the internal oblique muscle. Symptoms are attributed to suture incorporation of the nerve during fascial closure, direct nerve trauma with subsequent neuroma formation, or neural constriction due to normal scarring and healing. Damage to the obturator nerve, which can occur during lymph node dissection would result in the inability of the patient to adduct the thigh.

Answer 197

Age and gender are the greatest risk factors for developing breast cancer. Having one first-degree relative with breast cancer does increase the risk. A women’s risk of developing breast cancer before menopause is increased if she is BRCA-1 or BRCA-2 positive; however, these genetic mutations occur in a low percentage of the general population.

Answer 198

Folliculitis

Answer 199

Stimulation of the breast during the physical examination may give rise to an elevated prolactin level. Accurate prolactin levels are best obtained in the fasting state. If still elevated, then a TSH level and brain MRI would be indicated to rule out a pituitary tumor. Post partum women may continue to produce milk for up to two years after cessation of breastfeeding.

Answer 200

Any solid dominant breast mass on exam should be evaluated cytologically, with a fine needle aspiration (FNA), or histologically, with an excisional biopsy. Don't MRI something that you can feel.

Answer 201

Fibrocystic breast changes are the most common type of benign breast conditions and occur most often during the reproductive years. Fibrocystic disease is often associated with cyclic mastalgia, possibly related to a pronounced hormonal response. Caffeine intake can increase the pain associated with fibrocystic breast changes, so recommending that she decrease her caffeine intake may be helpful.

Answer 202

Breast cancer can also present with a spontaneous bloody nipple discharge. Even though the mass decreased in size after aspiration, the bloody discharge obtained obligates an excisional biopsy be performed to rule out breast cancer.

Answer 203

Nipple itch is a common symptom of allergies, dry skin, inflammation, or even physical irritation. The itch is characterized by tingling and/or uneasy sensation near the skin surface. Perhaps the most common cause is a chemical irritant such as laundry detergents, soaps, and even perfumes. Itching sensations are not associated with adenomas or ruptured breast implants

Answer 204

puerperal mastitis which most often occurs during the second to fourth week after delivery and the most appropriate next step in her management is to use ibuprofen in addition to acetaminophen for pain relief, give oral or iv antibiotics depending on the severity of the infection Most postpartum mastitis is caused by staphylococcus aureus, so a penicillin-type drug is the first line of treatment. Dicloxacillin is used due to the large prevalence of penicillin resistant staphylococci. Erythromycin may be used in penicillin allergic patients.

Answer 205

A specimen obtained on fine-needle aspiration (FNA) is examined both histologically and cytologically. An excisional biopsy should be performed when the results are negative, due to the possibility of a false-negative result. FNA can, however, prevent the need for other diagnostic testing and is the appropriate first step in the evaluation of a palpable breast mass.

Answer 206

The most recent consensus guidelines (ASCCP-2013) state that management of LSIL is initial colposcopic examination (unless the woman is pregnant, postmenopausal or an adolescent). An excisional procedure, such as cold knife biopsy or LEEP, is not warranted without a tissue diagnosis of dysplasia. Colposcopy is a way for your doctor to use a special magnifying device to look at your vulva, vagina , and cervix . If a problem is seen during colposcopy, a small sample of tissue (biopsy) may be taken from the cervix or from inside the opening of the cervix (endocervical canal).

Answer 207

cervical dysplasia (not invasive cancer) and therefore needs cervical conization by a LEEP procedure or cold knife cone. The procedure is usually done in the office under local intracervical anesthesia. It involves using an electrosurgical unit (similar to the Bovie in the operating room), along with a wire loop of varying sizes to remove the entire transformation zone and the dysplastic area(s) identified during colposcopy. This tissue is sent to pathology so that the area of dysplasia can be fully evaluated.

Answer 208

Endometrial biopsy is typically an office procedure which does not cause extreme discomfort for the patient. It results in information necessary to tailor the patient’s care, such as presence of endometritis, endometrial polyps or endometrial carcinoma.In a patient with significant risk factors for endometrial carcinoma, this should be done prior to a hysterectomy or ablation, if at all possible. With stable vital signs and a hematocrit of 29, erythropoietin and a blood transfusion would not be indicated at this time.

Answer 209

Complications from a LEEP include infection, bleeding, cervical stenosis, persistent disease, and possibly risk for preterm delivery.

Answer 210

The patient does not require treatment at this time. She requires follow up Pap smear in one year.

Answer 211

The best choice for this patient is to perform a hysteroscopy. This is easily performed either in the office or in the operating room, and the IUD could then be removed under direct visualization.