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Obstetrics and Gynecology > Obstetrics and Gynecology > Flashcards

Obstetrics and Gynecology Flashcards

1
Q

What is the climacteric state?

A

Constellation of symptoms consistent with perimenopause including hot flashes, night sweats. Due to hypoestrogenemia. Occurs between ages of 40 and 51.

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2
Q

Premature Ovarian Failure

A

Cessation of ovarian function due to atresia of follicles prior to age 40

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3
Q

What were the findings of the Women’s Health Initiative Study?

A

HRT (continuous estrogen-progestin) treatment caused a small but significant increased risk of:

  • breast cancer
  • heart disease
  • PE
  • stroke
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4
Q

Treatment for Hot Flashes

A
  • estrogen therapy (no evidence of adverse effects for short term < 6 months use)
  • antihypertensive agent Clonidine
    • Raloxifene (SERM) helps prevent bone loss but does not alter hot flushes
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5
Q

Effects of hypothyroidism and hyperprolactinemia on menstruation?

A

Cause hypothalamic dysfunction –> inhibits GNRH pulsations–> inhibits pituitary FSH and LH release –> hypoestrogenic amenorrhea
- Common cause of hyperprolactinemia in a younger girl is a prolactinoma

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6
Q

Turner syndrome (45,X) effects on the ovary?

A

Ovarian failure.

  • Have elevated gonadotropin levels and streaked ovaries
  • Decreased E
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7
Q

What is Sheehan syndrome?

A

Hemorrhagic necrosis of the anterior pituitary associated with PPH.

  • Often unable to breastfeed due to inability to release prolactin from the anterior pituitary- - In hypoestrogenic state
  • Tx: supplemental hormonal replacement
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8
Q

Most common location of an osteoporosis-associated fracture?

A

Thoracic spine as a compression fracture

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9
Q

If a woman still has her uterus what hormones should be used if HRT necessary?

A
  • E and P

- Need progesterone to oppose estrogen to prevent endometrial cancer

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10
Q

What is necrotizing fasciitis?

A

Serious infection of the muscle and fascia usually caused by multiple organisms or anaerobes
- Can involve surgical infections, traumatic injury or rarely Group A Streptococci (flesh-eating bacteria)

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11
Q

What is group A Streptococcal Toxic Shock Syndrome?

A

Rapidly progressing infection of the episiotomy or Cesarean delivery incision (“flesh eating bacteria” syndrome)

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12
Q

How do you calculate MAP?

A

MAP= [(2/ dBP) + (1 x sBP)]/3

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13
Q

Management of a post C-section septic shock patient

A

1) IV fluids with close monitoring of urine output and BP
2) IV antibiotics (broad spectrum to include penicillin, gentamicin, and metrondiazole or other anaerobic agent)
3) Pressors (dopamine or dobutamine if IV fluids not enough to maintain BP)
4) Surgical debridement of wound infection

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14
Q

Pathophysiology of Septic Shock

A

Vasodilation due to endotoxins (except for in the case of toxic shock syndrome- staphylococcus aureus is an exotoxin). Vasodilation leads to hypotension and is treated with IV fluids. Late stage can result in cardiac dysfunction.

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15
Q

Classic sign of necrotizing fasciitis?

A

Gas in the muscle of fascia likely due to clostridial species.

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16
Q

Toxic Shock Syndrome

A
  • Commonly caused by S aureus
  • Sunburn-like rash and/or desquamation is typical
  • Initial abx: IV nafcillin or methicillin unless MRSA suspected, in which case vancomycin is used
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17
Q

What is considered a term pregnancy?

A

Between 37 and 42 weeks from the LMP

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18
Q

Rate of cervical dilation in active labour?

A 
Average:
Primip: ~1.2 cm/hr
Mulltip: ~ 1.5 cm/hr
Minimum: 
Primip: 0.5 cm/hr
Multip: 1 cm/hr
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19
Q

What to do if a pregnant woman is found not to be immune to rubella?

A

Immunize in postpartum period since it is a live-attenuated vaccine and contraindicated in pregnancy

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20
Q

Definition of Labour

A

Cervical change accompanied by regular uterine contractions.

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21
Q

Phases of Labour

A

1) Latent phase: initial part of labour where cervix mainly effaces rather than dilates (usually cervical dilation < 4cm)
- Usually takes < or = 18-20 h for a primip, and < or = 14 hours for a multip
2) Active phase: portion of labour where dilation occurs more rapidly (usually when cervix is > 4cm)

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22
Q

What is protraction of the active phase of labour?

A

Cervical dilation in the active phase that is less than expected (less than average)

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23
Q

What is arrest of the active phase of labour?

A

No progress in the active phase of labour for 2 hours

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24
Q

Stages of Labour

A

1) Onset of labor until complete dilation of cervix
2) Complete cervical dilation to delivery of infant
- Should be < or = 2hr or 3hr (if epidural) for a primip, and < or = 1 hr or 2 hr (if epidural) for a multip
3) Delivery of infant to delivery of the placenta
- should be < 30 min

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25
Q

What is a normal FHR baseline?

A

Between 110-160 bpm

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26
Q

What are FHR Decelerations?

A

FHR changes below the baseline

  • Three types:
    1) Early (mirror image of uterine contraction)- often due to fetal head compression (benign)
    2) Variable (abrupt jagged drips below the baseline- often due to cord compression
    3) Late (offset following uterine contraction)- suggest fetal hypoxia and if persistent can indicate fetal acidemia
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27
Q

What are FHR Accelerations?

A

FHR that increases above the baseline for at least 15 bpm and at least 15 sec

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28
Q

What are clinically adequate uterine contractions?

A

Occurring every 2-3 minutes
Firm on palpation
Lasting 40-60 sec
- One way to assess is to examine a 10 min window and add each contraction’s rise above baseline (> or = to 200 Montevideo units = adequate)

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29
Q

Three P’s of Labour

A

1) Power
2) Pelvis
3) Passenger

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30
Q

How can you assess fetal acidemia during labour?

A

Fetal scalp pH monitor

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31
Q

What type of pelvis causes the fetal occiput posterior position?

A

Antropoid pelvis (AP diameter > transverse diameter with prominent ischial spines and a narrow anterior segment

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32
Q

What determines normalcy of labour- cervical change or contractions?

A

Cervical change

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33
Q

Lower abdo pain and vaginal spotting in a woman of childbearing potential is considered…

A

Ectopic pregnancy until proven otherwise

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34
Q

BhCG threshold for transvaginal sonography

A

1500-2000 mIU/L

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35
Q

Change in serial hCG levels suggesting a normal intrauterine gestation early on

A

66% in 48 hours (does not tell you if pregnancy is in the uterus or tube- if there is abnormal change and it is too early for U/S then can do uterine curettage- if chorionic villi present = miscarriage, if no chorionic villi = ectopic)

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36
Q

Ectopic Pregnancy

A

Pregnancy outside of the normal uterine implantation site (usually means a pregnancy in the fallopian tube)

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37
Q

Progesterone levels to determine viable vs. nonviable pregnancy?

A

> 25 ng/mL suggests normal intrauterine gestation

< 5 ng/mL suggests nonviable gestation

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38
Q

Which ectopic pregnancies can be managed by IM methotrexate?

A

Asymptomatic and small (< 3.5 cm)

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39
Q

Best tx for a patient with early pregnancy, severe adnexal pain and is hemodynamically unstable

A

SURGERY

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40
Q

Usual management of placenta accreta

A

Hysterectomy because attempts to remove the firmly often lead to hemorrhage and/or maternal death
- If fertility is to be conserved, one can try to remove as much of the placenta as possible and pack the uterus or ligate the umbilical cord as high as possible and give IV methotrexate

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41
Q

Placenta Accreta

A

Abnormal adherence of the placenta to the uterine wall due to abnormality of the decidua basalis layer of the uterus
- Placental villi are attached to the myometrium

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42
Q

Placenta Increta

A

Abnormally implanted placenta penetrates into the myometrium

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43
Q

Placenta Percreta

A

Abnormally implanted placenta penetrates entirely through myometrium to the serosa
- Often invasion into the bladder is noted

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44
Q

RFs for placental adherence

A
  • Low-lying placentation
  • Previous placenta previa
  • Prior c/s or uterine curettage
  • Prior myomectomy
  • Fetal down syndrome
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45
Q

What is transmigration of the placenta?

A

When a previous low-lying placenta or placenta previa diagnosed in the T2 because of the lower segment growing more rapidly in T3

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46
Q

Which is associated with a higher risk of placenta accreta- a posterior or anterior placenta?

A

Anterior placenta

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47
Q

Common treatment for gonococcal cervicitis

A

Ceftriaxone 125 to 250 mg IM
- Because Chlamydia often coexists with gonorrhea therapy with azithromycin 1g orally or doxycycline 100 mg BID for 7-10 days is also indicated

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48
Q

Most common organism implicated in mucopurulent cervical discharge

A

Chlamydia trachomatis

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49
Q

Complications of gonococcal cervicits

A
  • Organisms can ascend and infect the fallopian tubes (acute salpingitis or PID)
  • Predisposes patient to infertility and ectopic pregnancy (tubal occlusion and/or adhesions)
  • Infectious arthritis usually involving the large joints and classically migratory
  • Disseminated gonorrhea (individuals usually have eruptions or painful pustules with erythematous base on the skin)
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50
Q

What organism most commonly causes sexually-transmitted pharyngitis?

A

Neisseria gonorrhea because it has pili that allow it to adhere to the columnar epithelium at the back fo the throat

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51
Q

What can N. Gonorrhea and C. trachomatis cause in the baby of an infected pregnant woman?

A
  • Blindness

- C. Trachomatis can also cause infantile pneumonia generally between 1-3 months of age

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52
Q

What type of organis is N. Gonorrhea?

A
  • Gram-negative intracellular diplococci
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53
Q

Clinical picture of a completed spontaneous abortion?

A
  • Passage of tissue
  • Resolution of cramping and bleeding
  • Closed cervical os
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54
Q

How to determine if there is residual products of conception?

A
  • Follow serum quantitative hCG levels (expected to halve every 48-72 hours- if they plateau instead of fall then there might be residual tissue left)
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55
Q

Most common cause identified with spontaneous abortion?

A

Chromosomal abnormality of the embryo

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56
Q

Threatened abortion

A

Pregnancy < 20 wks associated with vaginal bleeding generally without cervical dilation

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57
Q

Inevitable abortion

A

Pregnancy < 20 wks associated with cramping, bleeding and cervical dilation (no passage of tissue yet)

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58
Q

Incomplete abortion

A

Pregnancy < 20 wks associated with cramping, vaginal bleeding, open cervical os and some passage of tissue per vagina but some retained tissue in utero
- Cervix often remains open due to continued uterine contractions as it tries to expel the tissue

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59
Q

Completed abortion

A

Pregnancy < 20 wks in which all the products of conception have passed
- Cervix is generally closed (uterus is no longer contracting)

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60
Q

Missed abortion

A

Pregnancy < 20 wks with embryonic or fetal demise but no symptoms of bleeding or cramping

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61
Q

Molar pregnancy

A

Trophoblastic tissue or placental-like tissue usually without a fetus

  • Clinical picture: vaginal spotting, absence of fetal heart tones, size greater than dates and markedly elevated hCG levels
  • Diagnosis: U/S = snow storm pattern in uterus
  • Tx: uterine suction & curettage
  • Monitor weekly hCG levels because sometimes gestational trophoblastic disease persists and chemotherapy is needed
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62
Q

Incompetent cervix

A

Painless cervical dilation

  • RFs: cervical conization, congenital malformations, trauma to cervix, prolonged 2nd stage of labor, uterine overdistention with multiple gestation pregnancy
  • Tx: Cervical cerclage (stitch)
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63
Q

What is the “turtle sign”?

A

Retraction of the fetal head back toward the maternal introitus due to shoulder dystocia

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64
Q

What is shoulder dystocia?

A

Inability of the fetal shoulders to deliver spontaneously, usually due to the impaction of the anterior shoulder behind the maternal symphysis pubis

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65
Q

McRoberts Maneuver

A

Maternal thighs are sharply flexed against the maternal abdomen to straighten sacrum relative to L spine and rotate the symphysis pubis anteriorly toward maternal head
- Used to help treat shoulder dystocia

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66
Q

Erb Palsy

A

Brachial plexus injury involving C5- C6 nerve roots which may result from the downward traction of the anterior shoulder
- Baby usually has weakness of the deltoid, infraspinatus an flexor muscles of the forearm (arm usually hangs limp and is internally rotated)

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67
Q

RFs of Shoulder Dystocia

A
  • Fetal macrosomia
  • Maternal obesity
  • Prolonged 2nd stage of labour
  • Gestational DM
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68
Q

Signs of shoulder dystocia?

A
  • Turtle sign
  • No restitution of fetal head
  • Failure to deliver with expulsive effort and usual maneuvers
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69
Q

ALARMER acronym

A 
- Tx of shoulder dystocia
A – ask for help
L – lift/hyperflex legs (McRobertson maneuver)
A – anterior shoulder disimpaction
R – rotation of the posterior shoulder
M – manual removal of the posterior arm
E – episiotomy
R – roll over onto all fours
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70
Q

Last resorts to tx of shoulder dystocia?

A
  • Clavicular fracture
  • Zavanelli maneuver (push fetal head back in for c/s)
  • Symphisiotomy
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71
Q

What gynecologic procedure is most likely to result in ureteral injury?

A

Hysterectomy

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72
Q

Where is the most common location for ureteral injury?

A

At the cardinal ligament where the ureter is only 2-3 cm lateral to the cervix

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73
Q

What is the “water under the bridge”?

A

The ureters travel under the uterine arteries

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74
Q

If IV pyelogram shows possible obstruction with hydronephrosis what is the tx?

A
  • IV abx and cystoscopy to attempt retrograde stent passage (in the hopes that the ureter is kinked and not occluded)
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75
Q

Vesicovaginal fistula

A

Constant connection between the bladder and vagina

  • Predisposed to this after any pelvic surgery or vaginal birth
  • Causes constant urinary leakage
  • Surgery necessary to remove fistula
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76
Q

Flank pain and fever after pelvic surgery suggests what?

A

Ureteral injury

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77
Q

Post-menopausal bleeding is what until proven otherwise?

A

Endometrial CA

* Other etiologies: endometrial polyps or atrophic endometrium

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78
Q

RFs for endometrial CA?

A
  • Obesity
  • DM
  • HTN
  • Prior irregular menstruation
  • Late menopause
  • Nulliparity
  • Unopposed E in HRT
  • Early menarche
  • E-secreting ovarian tumors
  • Personal fam hx of breast of ovarian CA
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79
Q

Initial test of choice for endometrial CA?

A

Endometrial biopsy

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80
Q

Endometrial Stripe

A

Transvaginal sonographic assessment of the endometrial thickness (> 5cm is abnormal in post-menopausal women)

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81
Q

Most common female genital tract malignancy

A

Endometrial CA

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82
Q

Does smoking increase or decrease risk of endometrial CA?

A

Decrease because it promotes a lower estrogenic state

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83
Q

Atypical glandular cells on Pap smear suggest?

A 
Endocervical or endometrial CA
Next steps:
- colposcopic examination of the cervix 
- curretage of the endocervix 
- endometrial sampling
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84
Q

CA125 is most associated with what type of tumor?

A

Epithelial tumors of the ovary

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85
Q

Painless vaginal antepartum bleeding (>20 wks)

A

Placenta previa

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86
Q

Antepartum vaginal bleeding (>20 wks) with painful uterine contractions/ increased uterine tone?

A

Placental abruption

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87
Q

Tx of placenta previa

A

Expectant management as long as the bleeding is not excessive with c/s at 36- 37 wks GA

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88
Q

Placental abruption

A

Premature separation of a normally implanted placenta

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89
Q

Vasa Previa

A

Umbilical cord vessels that insert into the membranes with the vessels overlying the internal cervical os (fetus is vulnerable to exsanguination upon rupture of membranes)

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90
Q

Two most common causes of significant antepartum bleeding?

A

Placenta previa

Placental abruption

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91
Q

Define antepartum vaginal bleeding

A

Vaginal bleeding occurring after 20 weeks GA

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92
Q

First step to diagnose placenta previa?

A

U/S - avoid speculum or digital exam until placenta previa r/o since it may induce bleeding

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93
Q

Why may placenta previa lead to PPH?

A

Lower uterine segment is poorly contractile

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94
Q

What other placental abnormality is associated with placenta previa?

A

Placental accreta (particularly if there is a previous uterine scar)

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95
Q

RFs of placental previa?

A
  • Grand multiparity
  • Prior c/s
  • Prior uterine currettage
  • Previous placenta previa
  • Multiple gestation
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96
Q

Is U/S good at assessment of abruption?

A

No, because the freshly developed blood clot behind the placenta has the same sonographic texture as the placenta itself

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97
Q

RFs for Placental Abruption?

A
  • HTN
  • Cocaine use (causes maternal HTN and vasoconstriction)
  • Short umbilical cord
  • Trauma
  • Uteroplacental insufficiency
  • Submucous leiomyomata
  • Sudden uterine decompression (hydramnios)
  • Cigarette smoking
  • PPROM
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98
Q

Couvelaire Uterus

A

Bleeding into the myometrium of the uterus giving it a discolored appearance to the uterine surface
- Increases risk of PPH due to decreased contractibility of the myometrium

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99
Q

Complications of Placental Abruption

A
  • PPH
  • Preterm delivery
  • Coagulopathy (secondary to hypofibrinogenemia)
  • Fetal to maternal bleeding
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100
Q

Management of Placental Abruption

A
  • Usually delivery
  • If fetus immature, expectant management can be exercised if the patient is stable with no active bleeding or signs of fetal compromise
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101
Q

Best diagnostic procedure when a cervical lesion is seen?

A

Cervical biopsy

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102
Q

Most common presenting symptom of invasive cervical CA?

A

Post-coital bleeding

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103
Q

RFs for cervical CA?

A
  • Multiparity
  • Cigarette smoking
  • Hx of sexually transmitted disease (syphilis)
  • Early age of coitus
  • Multiple sexual partners
  • HIV infection
  • HPV
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104
Q

Cervical Intraepithelial Neoplasia

A

Preinvasive lesions of the cervix with abnormal cellular maturation, nuclear enlargement and atypia

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105
Q

HPV

A

Circular, dsDNA virus that can become incorporated into cervical squamous epithelium, predisposing the cells for dysplasia and/or CA

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106
Q

Radical Hysterectomy

A

Removal of uterus, cervix, supportive ligaments, and proximal vagina

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107
Q

Radiation Brachytherapy

A

Radioactive implants placed near tumor bed

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108
Q

Radiation Teletherapy

A

External beam radiation where the target is at some distance from radiation source

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109
Q

HPV Vaccine

A
  • Killed virus vaccine
  • FDA approved for females 9-26
  • Quadrivalent vaccine (gardasil) contains antigens of HPV types 16 and 18 (associated with 50% of cervical CA and dysplasia) and 6 and 11 (which cause venereal warts)
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110
Q

Where do the majority of cervical dysplasia and cancers arise?

A

Squamocolumnar junction of the cervix

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111
Q

Most common cause of death due to cervical CA?

A

Bilateral ureteral obstruction leading to uremia

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112
Q

When do women with a total hysterectomy need pap smears of the vaginal cuff?

A

If there is a history of abnormal pap smears indicating cervical dysplasia

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113
Q

What is the most common type of cervical CA?

A

Squamous cell carcinoma

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114
Q

Two causes of secondary amenorrhea after PPH?

A
  • Sheehan syndrome

- Asherman’s syndrome

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115
Q

Sheehan Syndrome

A

Anterior pituitary hemorrhagic necrosis caused by hypertrophy of the prolactin-secreting cells in conjunction with a hypotensive episode usually in the setting of PPH (bleeding in ant. pit –> pressure necrosis)

  • Usually will see other abnormal ant. pit function (low thyroid hormones, low gonadotropins, low cortisol levels, low prolactin)
  • Will have a monophasic basal body temp chart due to lack of progesterone
  • Tx: replacement of hormones
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116
Q

Asherman’s Syndrome

A

Caused by uterine curettage that damages the decidua basalis layer rendering the endometrium unresponsive
- Tx: hysteroscopic resection of scar tissue

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117
Q

PPH

A

Classically defined as bleeding > 500 mL for a vaginal delivery or > 1000 mL for a c/s
- Clinically = amount of bleeding that results in or threatens to result in hemodynamic instability

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118
Q

Most common cause of amenorrhea in the reproductive years?

A

Pregnancy

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119
Q

How long does amenorrhea ensure normally after a term delivery?

A

2-3 months, breast feeding may prolong this

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120
Q

Findings consistent with PCOS

A
  • Positive progesterone withdrawal bleed
  • Estrogen excess without progesterone
  • Obesity
  • Hirsuitism
  • Glucose intolerance
  • Elevated LH:FSH ratio of 2:1
  • Small ovarian cysts on U/S
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121
Q

Two broad categories of hypoestrogenic amenorrhea?

A
  • Hypothalamic/pituitary diseases
  • Ovarian failure
  • Distinguish between the two by FSH level (high FSH = ovarian failure)
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122
Q

When should artificial ROM be avoided?

A

With an unengaged presenting part- predisposes to cord prolapse

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123
Q

Treatment of cord prolapse?

A

Immediate c/s
- Place patient in trandelenberg position and keep his/her hand in the vagina to elevate the presenting part to keep it off of the cord

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124
Q

How can oxytocin lead to fetal bradycardia?

A

Hyperstimulation with oxytocin can cause the uterus to be tetanic or frequent and thus not allow for adequate blood flow through the placenta to the fetus
- Terbutaline given IV can help to relax the uterine musculature

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125
Q

Steps to Take With Fetal Bradycardia

A

1) Confirm FHR (vs maternal HR- scalp electrode or U/S)
2) Vaginal exam for cord prolapse
3) Positional changes (move to LLD)
4) Oxygen
5) IV fluid bolus
6) D/c oxytocin

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126
Q

Most common finding in uterine rupture?

A

FHR abnormality such as fetal bradycardia, deep variable decelerations or late decelerations

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127
Q

Treatment of uterine rupture?

A

Immediate c/s

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128
Q

Definition of uterine hyperstimulation?

A

> 5 uterine contractions in 10 minute window

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129
Q

How does hypothyroidism lead to galactorrhea?

A

Hypothyroidism is associated with elevated thyroid releasing hormone levels which acts as a prolactin-releasing hormone

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130
Q

Causes of galactorrhea?

A
  • Pregnancy
  • Pituitary adenoma
  • Breast stimulation
  • Chest wall trauma
  • Hypothyroidism
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131
Q

Pituitary Secreting Adenoma

A

Tumor in the pituitary gland that produces prolactin

- Symptoms: galactorrhea, h/a, peripheral vision defect (bitemporal hemianopsia)

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132
Q

Two drugs that can be used for hyperprolactinemia

A
  • Bromocriptine
  • Cabergolamine
  • Both are dopamine agonists
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133
Q

What 2 hormones are released by the POSTERIOR pituitary?

A
  • ADH

- Oxytocin

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134
Q

What does oxytocin due in a pregnant woman?

A
  • Causes uterine contractions

- Stimulates ejection of the milk in a lactating woman

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135
Q

Cholestasis in Pregnancy

A

Intrahepatic cholestasis of unknown etiology in pregnancy whereby the patient usually complains of pruritus with or without jaundice and no skin rash

  • Usually begins in T3 at night and gradually increases in severity
  • Itching more severe on extremities than on trunk
  • May occur in subsequent pregnancies and with the ingestion of OCPs - suggest hormone-related pathogenesis
  • Diagnosis confirmed by elevated circulating bile acids (liver enzymes usually normal)
  • Associated with increased incidence of prematurity, fetal distress and fetal loss (especially if associated jaundice)
  • Increased incidence of gallstones
  • Tx: antihistamines and cornstarch baths, can try bile salt binders- cholestyramine or ursodeoxycholic
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136
Q

Prurtitc Utricarial Papules and Plaques of Pregnancy (PUPPP)

A

Common skin condition of unknown etiology unique to pregnancy characterized by intense pruritus and erythematous papules on abdomen and extremities

  • Begin on abdomen and spread to the thighs and sometimes buttocks and arms
  • No negative effect on fetal/maternal outcomes
  • Tx: topical steroids and antihistamines
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137
Q

Herpes Gestationis

A

Rare skin condition only seen in pregnancy

  • Characterized by intense itching and vesicles on the abdomen and extremities
  • Begins in T2
  • Thought to be autoimmune related
  • Limbs affected more than trunk
  • May cause fetal growth retardation and stillbirth, as well as transmission to baby that resolves on its own
  • Tx: oral corticosteroids
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138
Q

Why are pregnant women at risk of PE?

A
  • Venous stasis due to compression of the IVC by the uterus

- High estrogen state induces a hypercoagulable state due to the increase in clotting factors, particularly fibrinogen

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139
Q

Clinical Criteria of Salpingitis (PID)

A
  • Lower abdominal pain
  • Adenexal tenderness
  • Cervical motion tenderness
  • Fever
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140
Q

What is Fitz-Hugh and Curtis syndrome?

A

Perihepatic lesions that result following PID

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141
Q

How to confirm diagnosis of PID?

A

Laparoscopy that reveals purulent discharge from fimbria of the tubes

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142
Q

Criteria for Outpatient Management of PID

A
  • Low grade fever
  • Tolerance of oral medication
  • Absence of peritoneal signs
  • Compliance
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143
Q

Candidates for Inpatient Tx of PID?

A
  • If patient fails outpatient tx
  • If patient is pregnant
  • At extremes of age
  • Cannot tolerate oral medication
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144
Q

Tubo-ovarian Abscess

A

Sequelae of PID that generally has an anaerobic predominance and necessitates antibiotics (clindamycin or metrondiazole)

  • Complication = rupture (surgical emergency)
  • Treated with abx therapy not surgical drainage
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145
Q

Long-term Complications of PID

A
  • Chronic pelvic pain
  • Involuntary infertility
  • Ectopic pregnancy
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146
Q

What increases the risk of PID?

A

IUD

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147
Q

What decreases the risk of PID?

A

OCPs (progestin thickens the cervical mucous)

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148
Q

Ideal Scan for a Pregnant Woman Suspected of Having a PE

A
  • CT scan
  • Originally it was thought that a V/Q scan was better but it actually exposes the fetus to slightly more radiation and has a higher rate of indeterminate cases
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149
Q

What are the physiologic changes to the respiratory system in pregnancy?

A

Increased TV –> Increased Minute Ventilation –> Higher O2 level, lower Co2 –> respiratory alkalosis –> renal excretion of bicarb –> low serum bicarb –> increased risk of metabolic acidosis
- Common values: pH= 7.45, PO2 = 95-105, PCO2 = 28, HCO3 = 19

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150
Q

What Other Tests Should You Run if a Pregnant Woman has a PE?

A
  • Protein S
  • Protein C
  • Antithrombin III
  • Factor V Leiden
  • Hyperhomocysteinemia
  • Antiphospholipid syndrome
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151
Q

Common Signs and Symptoms of PE?

A
  • Dyspnea
  • Tachypnea
  • Pleuritic chest pain
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152
Q

Most Common Cause of Maternal Mortality?

A

Thromboembolism and amniotic fluid embolism

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153
Q

What is the most common ECG finding associated with PE?

A

Tachycardia

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154
Q

Risk to Baby of Maternal HSV?

A

Encephalitis that can lead to severe permanent CNS compromise

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155
Q

Herpes Simplex Prodromal Symptoms

A

Prior to outbreak of classical vesicles, patient may complain of burning, itching or tingling

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156
Q

When Should You Perform a C/S on a Pregnant Woman with HSV?

A

Any prodromal symptoms or genital lesions suspicious for HSV

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157
Q

Acyclovir

A

Activity against HSV1 and HSV2

  • In primary herpes outbreaks, it reduces viral shedding, pain symptoms and is associated with faster healing of the lesions
  • Usually required for frequent outbreaks or if a woman has her first outbreak during pregnancy
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158
Q

Distribution of HSV1 vs HSV2

A

HSV 1 = above the waist

HSV2 = below the waist

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159
Q

Most Common Cause of Infectious Vulvar Ulcers?

A

HSV

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160
Q

Most Common Reason for Hysterectomy

A

Symptomatic Uterine Fibroids

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161
Q

Most Common Symptom of Uterine Fibroids?

A

Menorrhagia

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162
Q

Classic Physical Exam Finding of a Uterine Fibroids

A

Enlarged midline mass that is irregular and contiguous with the cervix

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163
Q

Six treatments for uterine fibroids?

A

1) NSAIDs
2) Provera if uterus is small
3) GnRH agonist to shrink fibroids (maximum shrinkage is seen after 3 months of therapy and will regrow when therapy stopped- therefore usually used to shrink them before surgery)
4) Uterine artery ligation
5) Myomectomy (procedure of choice if wishing to maintain fertility)
6) Hysterectomy

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164
Q

Leiomyomata

A

Benign,smooth muscle tumors, usually of the uterus

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165
Q

Leiomyosarcoma

A

Malignant, smooth muscle tumor with numerous mitoses

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166
Q

Submucous Fibroid

A

Primarily on the endometrial side of the uterus and impinge on the uterine cavity
- Associated with recurrent abortions

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167
Q

Intramural Fibroid

A

Primarily in the uterine muscle

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168
Q

Subserosal Fibroid

A

Primarily on the outside of the uterus on the serosal surface
- Can obstruct the ureters

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169
Q

Carneous/Red Degeneration

A

Changes of the fibroids due to rapid growth

- Centre of fibroid becomes red causing pain

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170
Q

Most common tumor of the pelvis?

A

Uterine Leiomyomata (occur in 25% of women)

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171
Q

Signs of a Leiomyomata degenerating into a leiomyosarcoma?

A
  • Rapid growth (increase of more than 6 weeks’ gestational size in 1 year)
  • Hx of radiation to the pelvis
  • Need surgical evaluation
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172
Q

Pre-existing HTN

A

BP of 140/90 before pregnancy or less than 20 wks GA

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173
Q

Gestational HTN

A

HTN (140/90 or +) without proteinuria at > 20 weeks GA

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174
Q

Preeclampsia

A

HTN with proteinuria (> 300 mg/24 hr) at a GA > 20 weeks, caused by vasospasm

  • Commonly also see nondependent edema
  • Severe: systolic BP > 160, diastolic > 110 or urine protein level > 5g (or 3+ to 4+ on dipstick) OR symptoms such as h/a, RUQ pain or vision changes
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175
Q

Eclampsia

A

Seizure disorder associated with preeclampsia

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176
Q

Pathophysiology of Preeclampsia

A

Vasospasm and endothelial damage result in leakage of serum between the endothelial cells and cause local hypoxemia of tissue –> hemolysis, necrosis and other end-organ damage

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177
Q

Complications of preeclampsia

A
  • Placental abruption
  • Eclampsia (with possible intracerebral hemorrhage)
  • Coagulopathies
  • Renal failure
  • Hepatic subcapsular hematoma
  • Hepatic rupture
  • Uteroplacental insufficiency
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178
Q

RFs of Preeclampsia

A
  • Nulliparity
  • Extremes of age
  • African American
  • Personal hx of severe preeclampsia
  • Fam hx of preeclampsia
  • Chronic HTN
  • Chronic renal disease
  • Antiphospholipid syndrome
  • DM
  • Multifetal gestation
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179
Q

Tests to Run for Preeclampsia

A
  • CBC (platelets and hemoconcentration)
  • Urinalysis and 24 urine collection (proteinuria)
  • LFTs
  • LDH
  • Uric acid test
  • BPP
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180
Q

Definitive tx of Preeclampsia?

A

DELIVERY

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181
Q

Greatest risk for occurrence of eclampsia?

A

Just prior to delivery, during labour and within the first 24 hours postpartum

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182
Q

What should you start the preeclamptic patient on while in labour and what should you monitor?

A
  • Magnesium sulfate
  • Need to monitor urine output, respiratory depression, dyspnea (side effect of mag sulf is pulmonary edema) and abolition of deep tendon reflexes (first sign of toxic effects)
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183
Q

What 2 main antihypertensives are used in preeclampsia?

A
  • Hydralazine

- Labetalol

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184
Q

Fibroadenoma

A

Benign, smooth muscle tumor of the breast, usually occurring in young women

  • Firm, rubbery, mobile and solid in consistency
  • Do not respond to ovarian hormones and do not vary during menstrual cycle
  • Tx: careful f/u or excision of mass
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185
Q

Fibrocystic Breast Changes

A
  • Multiple, irregular, “lumpiness of the breast”
  • Clinical presentation: cyclic, painful, engorged breasts more pronounced before menstruation and occasionally with serous or green breast discharge
  • Usually FNA is required to ensure mass is not cancer
  • Tx: decrease caffeine, adding NSAIDs, tight-fitting bra, OCPS or oral progestin therapy (severe cases can use danazol or masectomy)
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186
Q

Bloody (Serosanguinous) nipple discharge when only one duct is involved and the absence of a breast mass

A

Intraductal papilloma

  • Small benign tumors that grow in the milk ducts
  • Second most common cause is breast malignancy
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187
Q

Galactocele

A

Mammary gland tumors that are cystic in nature and contain milk or milky fluid
- Occur when there is any sort of obstruction of milk flow in lactating breast

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188
Q

Signs Suggestive of Breast Malignancy

A
  • Nipple retraction

- Skin dimpling over a mass

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189
Q

Best way to image the breast of a woman < 30 years

A
  • U/S due to dense fibrocystic changes that interfere with mammogram
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190
Q

Five Factors to Examine in Infertility

A

1) Ovulatory
2) Uterine
3) Tubal
4) Male Factor
5) Peritoneal Factor (Endometriosis)

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191
Q

Three D’s of Endometriosis

A
  • Dysmenorrhea
  • Dyspareunia
  • Dyschezia (difficulty defecating)
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192
Q

Fecundability

A

Probability of achieving pregnancy within one menstrual cycle (20-25%) for a normal couple

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193
Q

5 Ways to Document Ovulation

A

1) Basal body temperature (increase of 0.5 F that occurs after ovulation)
2) Midluteal P
3) LH surge
4) Endometrial biopsy showing secretory tissue
5) U/S documenting a decrease in follicle size and presence of fluid in the cul-de-sac

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194
Q

How to Test for the Uterine and Tubal factors of Fertility

A

Hysterosalpingogram done between day 6 and 10 of the cycle

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195
Q

Gold standard for diagnosing tubal and peritoneal disease

A

Laproscopy

196
Q

Parameters of Semen Analysis

A

1) Volume (nl > 2.0 mL)
2) Sperm concentration (nl > 20 million/mL)
3) Motility (nl >50%)
4) Morphology (nl > 30% normal forms)

197
Q

Treatment to 5 Factors of Fertility

A

1) Ovulatory dysfunction - Clomiphene citrate
2) Uterine disorder- hysteroscopic procedure
3) Male factor - Repair of hernia or varicocele, IVF
4) Tubal disorder - Laparoscopy, IVF
5) Ablation of endometriosis, medical therapy

198
Q

Ovarian Torsion (Definition)

A

Twisting of ovarian vessels leading to ischemia

- Most frequent and serious complication of benign ovarian cyst

199
Q

Symptoms of ovarian torsion

A
  • Colicky lower abdo pain

- Nausea and vomiting

200
Q

Treatment of Ovarian Torsion

A

Surgical

  • Can untwist ovarian pedicle to lead to reprofusion of the ovary
  • Ovarian cystectomy (remove only the cyst and leave remainder of normal tissue intact- best tx)
  • Oophorectomy
201
Q

Typical Timing of Presentation of Ovarian Torsion in Pregnancy

A
  • Either at 14 wks when the uterus rises above the pelvic brim
  • Immediately postpartum when uterus rapidly involutes
202
Q

Presentation of acute appendicitis in the pregnant woman

A
  • Abdominal pain not right in the RLQ but instead superior and lateral to McBurney point because the enlarged uterus pushes appendix to move it upward and outward towards flank
  • Also present with nausea, emesis, fever and anorexia
  • Tx: surgery regardless of GA and IV abx
203
Q

Presentation of gallstones in pregnant woman

A
  • RUQ pain following a meal
  • “Bloated sensation”
  • Possibly emesis
  • Diagnose with U/S
  • Tx: low-fat diet and observed until postpartum
204
Q

Presentation of cholecystitis

A
  • Severe and unrelenting pain
  • Jaundice
  • Fever
  • Leukocytosis
  • Diagnose: U/S
  • Tx: surgery and supportive management
205
Q

Most common cause of pancreatitis in pregnancy?

A

Gallstones

206
Q

Two Key Tests to Diagnose Ectopic Pregnancy

A
  • HCG

- Transvaginal U/S

207
Q

Threshold of Transvaginal U/S

A

HCG = 1500 IU/mL

208
Q

Classic Triad of Ectopic Pregnancy

A
  • Amenorrhea
  • Abdominal pain
  • Irregular vaginal spotting
    • IF it ruptures, pain becomes more severe, can have shoulder tup pain from blood irritating the diaphragm
209
Q

Treatment of ectopic

A

Surgical: salpingostomy if ectopic small, wish to preserve fertility, and if ectopic not ruptured (otherwise salpingectomy)
Medical: Methotrexate - usually 1 IM dose if ectopic < 4cm (85-90% successful)
- may experience pain between 3-7 days after indicating tubal abortion

210
Q

Levels of Progesterone that Suggest Viable Pregnancy

A

> 25 ng/mL

Abnormal: <5 ng/mL

211
Q

What do levels of HCG that plateau in the first 8 weeks of pregnancy indicate?

A

Abnormal pregnancy

212
Q

Most common cause of microcytic anemia in pregnancy?

A

Iron deficiency

213
Q

Anemia in a pregnant woman

A

Hb < 10.5 g/dL

214
Q

Most common cause of macrocytic anemia in pregnancy?

A

Folate deficiency

215
Q

Side effect of nitrofurantoin to treat UTI in someone with G6PD deficiency?

A

Hemolytic anemia

216
Q

Diagnosis of Preterm Labour in a Nulliparous Woman?

A

2 cm dilation and 80% effacement

217
Q

Fetal Fibronectin

A
  • Basement membrane protein that helps bind placental membranes to the decidua of the uterus
  • Can swab the posterior vaginal fornix for this, and if positive may indicate risk of preterm birth
  • negative test is strongly associated with no delivery within 1 week
218
Q

When should antenatal steroids be given?

A

Risk of preterm labour < 34 wks gestation

219
Q

Tocolysis

A 
Pharmacologic agents used to delay delivery once preterm labor is diagnosed if < 34-35 wks
Most commonly used agents:
- Indomethacin (NSAID)
- Nifedipine (Ca2+ channel blocker)
- Terbutaline (B agonist)
- Ritodrine (B-agonist)
220
Q

Cervical Length Assessment

A

Can be used to determine risk of preterm delivery (< 25 mm or funneling = increased risk)

221
Q

What infection is strongly associated with preterm delivery?

A

Gonococcal Cervicitis

  • C. Trachomatis is less common
  • UTIs and BV can also cause it
222
Q

What is a relative contraindication for tocolysis?

A

Suspected abruption

223
Q

Variable decelerations after tocolysis- what is the culprit?

A

Indomethacin- causes oligohydramnios which can lead to cord compression and variable decels

224
Q

Common side effect of B-agonists for tocolysis?

A

Pulmonary Edema

225
Q

Tx of preterm labour (3 steps) ?

A
  • Identify the cause
  • Give antenatal steroids if needed
  • Tocolysis if needed
226
Q

Most common cause of neonatal morbidity in a preterm infant?

A

Respiratory distress syndrome

227
Q

Most common etiologic agent of bladder infections?

A

E. Coli

Tx: sulfa agents, cephalosporins, quinolones or nitrofurantoin are all acceptable

228
Q

Define Urethritis

A

Infection of the urethra commonly caused by C trachomatis

229
Q

Define Urethral syndrome

A

Urgency and dysuria caused by urethral inflammation of unknown etiology
- Urine cultures negative

230
Q

Order of common causes of bacterial cystitis?

A
  • E coli
  • Enterobacter
  • Klebsiella
  • Pseudomonas
  • Proteus
  • GBS
  • Staphylococcos saprophyticus
  • Chlamydia
231
Q

Should you treat asymptomatic bacteriuria in pregnant women?

A

YES- 25% of untreated women go on to develop acute infection

232
Q

Definition of Cystitis

A

Bacterial infection of the bladder with > 100,000 cfu/mL in midstream-voided specimen

233
Q

Plan B

A

Levonorgestrel 0.75 mg taken orally at time 0 and the same dose after 12 hours

234
Q

Main Effects of Progesterone in OCP

A
  • Inhibit Ovulation

- Cause cervical mucous thickening

235
Q

Main Effects of Estrogen in OCP

A
  • Mainain the endometrium
  • Prevent unscheduled bleeding
  • Inhibit follicle development
236
Q

Side Effects of OCPS

A
  • Nausea
  • Breast tenderness
  • Fluid retention
  • Weight gain
237
Q

RIsks of combined OCPs

A
  • Mainly due to estrogen component
  • Venous thromboembolism
  • Strokes
  • MI
  • Increased risk of cholelithiasis
  • Benign hepatic tumors
238
Q

Positive Effects of combined OCPs

A
  • Decreases the risk of developing ovarian or endometrial CA
  • Shortens duration of menses
  • Decreases blood loss during menses
  • Improves pain from dysmenorrhea and endometriosis
  • Decreases dysufunctional uterine bleeding and menorrhagia
  • Improves acne
239
Q

Contraindications to combined OCPs

A
  • Thrombogenic mutations
  • Prior thromboembolic event
  • Cerebrovascular or CAD
  • Uncontrolled HTN
  • Migraines with aura
  • DM
  • PVD
  • Smoking and age > 35
  • Suspected/known breast CA
  • E-dependent neoplasia
  • Active liver disease
  • Known or suspected pregnancy
240
Q

How does the Levonorgestrel-releasing IUD work?

A
  • Thickens cervical mucous

- Creates atrophic endometrium

241
Q

Contraindications to IUD insertion

A
  • Current pregnancy
  • Current STI
  • Current or PID in the past 3 months
  • Unexplained vaginal bleeding
  • Malignant gestational trophoblastic disease
  • Untreated cervical CA
  • Untreated endometrial CA
  • Uterine fibroids
  • Current beast CA
242
Q

Two regimens of emergency contraception

A
  • Yuzpe method: combined OCP method- 0.1 mg of ethinyl estradiol and 0.5 mg of levonorgestrel in 2 doses 12 hours apart beginning within 72 hours of unprotected intercourse
  • Progestin only method (plan B)
243
Q

Side Effect of Depo-Provera?

A

Loss of BMD especially in adolescents

244
Q

What is the down side to the contraceptive patch?

A

Greater risk of DVT

245
Q

Complication of Abx therapy for Pyelonephritis?

A

ARDS with pulmonary injury due to endotoxin release after the abx begin to lyse the bacteria and lead to endotoxemia –> leads to leaky pulmonary capillaries

  • Endotoxins can lead to damage to the myocardium, liver and kidneys
  • May induce preterm labour
246
Q

Common organism causing Pyelonephritis?

A

E. Coli

247
Q

Most Common Cause of Sepsis in Pregnancy

A

Pyelonephritis

248
Q

Tx of Pyelonephritis in Pregnancy?

A

Hospitalization and IV abx (cephalosporins- cefotetan or ceftriaxone or the combination of ampicillin and gentamicin)
- Tx until fever and flank tenderness have substantially improved and then switched to oral antimicrobial therapy and then suppressive therapy for the remainder of the pregnancy (1/3 of women will develop a recurrent UTI if suppressive therapy not utilized)

249
Q

What would be suspected if clinical improvement has not occurred after 48-72 hours of appropriate abx therapy for pyelonephritis?

A

Urinary tract obstruction or perinephric absecess

250
Q

What is the most common organism responsible for mastitis?

A

S aureus typically acquired from the back of the baby’s throat during breast feeding

251
Q

What is the Homans sign

A

Dorsiflexion of the foot to attempt to elicit tenderness in the patient

  • Poor test
  • Theoretically may cause embolization of clots
252
Q

Ideal noninvasive test for DVT?

A

Doppler flow study of the venous system of the affected lower extremity

253
Q

Symptoms of DVT

A
  • Muscle pain
  • Deep linear cords of the calf
  • Tenderness and swelling of the lower extremity
  • 2cm difference in leg circumferences
254
Q

Management of DVT

A

Anticoagulation with bed rest and extremity elevation

- Heparin preferred over Coumadin (coumadin can cause congenital abnormalities and is more difficult to reverse)

255
Q

Side Effect of Heparin

A

Osteoporosis (propensity to inhibit vit K which is involved in bone metabolism) and thrombocytopenia

256
Q

What types of CA do the BRCA gene mutations put a person at increased risk of?

A
  • Breast

- Ovarian

257
Q

What is the most common CA in women?

A

Breast

- It is the 2nd most common cause of female cancer deaths (secondary to lung CA)

258
Q

What is the most important RF for breast CA?

A

Age (1/30 women will develop breast CA at age 60)

259
Q

When should annual mammography be initiated?

A

Age 50

- Age 35 years if positive family history

260
Q

What should you do for any palpable dominant mass in the breast?

A

Biopsy it regardless of mammographic findings

261
Q

Who is a candidate for genetic testing for the BRCA genes?

A
  • First-degree relatives with breast CA

- Patients of Ashkenazi Jewish ancestry

262
Q

What inheritance pattern is the BRCA mutations?

A

Autosomal dominant

263
Q

Most common histiological receptor status of breast CA?

A

Infiltrating intraductal carcinoma

264
Q

What is the most significant factor in determining a patient’s prognosis once diagnosed with breast CA?

A

Lymph node status

265
Q

Most common ovarian tumors in women < 30

A

Dermoid cysts (benign cystic teratomas)

266
Q

What is a common side effect of a dermoid cyst?

A

Hyperthyroidism (sometimes they contain thyroid tissue)- called struma ovarii

267
Q

What is a cystic teratoma?

A

Benign germ cell tumor that may contain all three germ cell layers

268
Q

Most common type of ovarian tumor in older women

A

Epithelial ovarian tumor (neoplasm from the outer layer of the ovary that can imitate the other epithelium of the gynecologic or urologic system)

269
Q

Functional Ovarian Cyst

A

Physiologic cysts of the ovary which occur in reproductive-aged women, of follicular, corpus luteal or theca lutein in origin

270
Q

Treatment of a dermoid cyst?

A

Cystectomy or unilateral oophorectomy with inspection of the contralateral ovary

271
Q

What is the most common subtype of epithelial tumors?

A

Serous subtype

- Typically bilateral

272
Q

Character of mucinous tumors?

A

Large size

273
Q

What type of tumors have an elevated CA125?

A

Most epithelial ovarian tumors

- More specific in postmenopausal women since a variety of disease during the reproductive years can elevate CA125

274
Q

What size of an adnexal mass is likely to be a tumor?

A

> 8 cm

275
Q

What would you think of an adnexal mass < 5cm?

A

Functional cyst

276
Q

What do you do if there is an adnexal cyst between 5 and 8 cm?

A

Sonographic features may help distinguish functional vs neoplas
- Some wait to see if there is a change if the cyst is between 5 and 8 cm and then operate if persistent

277
Q

Common estrogen-secreting ovarian tumor

A

Granulosa-theca cell tumor (stromal sex chord tumors)

278
Q

What is found inside immature teratomas?

A

All three germ layers as well as immature or embryonal structures

279
Q

What is found inside malignant teratomas?

A

Immature neural elements

280
Q

What is pseudomyxoma peritonei?

A

When a mucinous tumor ruptures intra-abdominally and the contents spill into the peritoneum leading to repeated bouts of bowel obstruction

281
Q

What is a common sign of ovarian malignancy?

A

Ascites

282
Q

Wound dehiscence

A

Separation of part of the surgical incision, but with an intact peritoneum

  • Red, tender, indurated incision and fever 4-10 days postop
  • Open wound and drain
  • Broad spectrum antimicrobial
  • Wet-to-dry dressing changes
  • Can close on its own or approximated
283
Q

Fascial disruption

A

Separation of the fascial layer usually leading to a communication of the peritoneal cavity with the skin

  • Often caused by the suture tearing through the fascia
  • Profuse drainage 5-14 days postop
  • Needs repair
  • Initiate broad-spectrum abx
284
Q

RFs for Fascial Disruptions

A
  • Vertical incisions
  • Obesity
  • Intra-abdominal distention
  • DM
  • Exposure to radiation
  • Corticosteroid use
  • Infection
  • Coughing
  • Malnutrition
285
Q

Evisceration

A

Protrusion of bowel or omentum through incision indicating complete separation of all layers

  • Surgical emergency
  • Significant mortality due to sepsis
  • Start abx stat
286
Q

Most common cause of a hemoperitoneum in a pregnant woman

A

Ruptured ectopic pregnancy

287
Q

What does the float test test for?

A

Tissue passed vaginally which floats in a frond pattern when placed in saline is good evidence of products of conception (95% accurate for the presence of chorionic villi)

288
Q

What diagnostic test confirms a ruptured corpus luteal cyst?

A

Laparoscopy

289
Q

Management of a ruptured corpus luteal cyst

A

1) secure hemostasis

2) if bleeding does not stop - cystectomy

290
Q

What is the function of the corpus luteum in pregnancy?

A

Produces progesterone until about 10 weeks GA, after this there is a shared function between the placenta and corpus luteum
- Maintained by hCG

291
Q

If you have to surgically remove the corpus luteum prior to 10-12 weeks what must you do?

A

Supplement progesterone

292
Q

What can happen to a corpus luteum?

A
  • Intrafollicular bleeding

- When bleeding is excessive, cyst can enlarge = increased risk of rupture

293
Q

What is most likely to happen to fibroids during pregnancy?

A

Estrogen causes rapid growth of the fibroid which can cause it to outgrow its blood supply –> ischemia/pain (red or carneous degeneration during pregnancy)

294
Q

What is the earliest sign of hypovolemia?

A

Decreased urine output

295
Q

What can mimic an ectopic pregnancy?

A

Ruptured corpus luteum

296
Q

In a young, healthy patient how much of their blood volume have they lost when they are hypotensive?

A

30-40%

297
Q

Define secondary amenorrhea

A

6 months of no menses with previously normal menses

298
Q

What is Uterine Sounding?

A

Assessing the depth and direction of the cervical and uterine cavity with a thin blunt probe

299
Q

What are two factors associated with extensive scar formation?

A
  • Postpartum curettage performed between the 2nd and 4th weeks after delivery
    +
  • Hypoestrogenic states (breast-feeding or hypogonadotropic hypogonadism)
300
Q

Would a woman with Asherman’s have withdrawal bleeding after a progesterone challenge?

A

No

301
Q

What is the most common method of diagnosing Ashermans?

A

Hysterosalpingogram

302
Q

What is the gold standard test for Asherman’s (IUA)?

A

Hysteroscopy

303
Q

Treatment of IUA?

A

Operative hysteroscopy

  • After can insert an IUD or a pediatric Foley catheter to prevent recently lysed adhesions from reforming
  • Administration of conjugated estrogens and progesterone should be considered
  • Re-evaluate the uterine cavity prior to attempting conception
304
Q

Which is associated with crampy abdominal pain- cervical stenosis or IUA?

A

Cervical stenosis

305
Q

Someone with POF is at risk of?

A

Osteoporosis

306
Q

What is the hormonal status of a woman with IUA?

A

Normal

307
Q

2 suspicious findings of breast CA on mammography?

A
  • Small cluster of calcifications around a small mass

- Small masses with ill-defined borders

308
Q

What should you do if there is a palpable breast mass and a normal mammography?

A

Biopsy

309
Q

What may identify early breast cancers missed by mammography?

A

MRI

310
Q

What may result in mammographic findings identical to breast CA?

A

Fat necrosis resulting from trauma to the breast

- Biopsy should still be done to confirm

311
Q

Two main types of biopsy used for suspicious breast CA from mammography

A
  • Core biopsy

- Stereotactic guidance and needle-localization excision

312
Q

Two most common causes of primary amenorrhea when there is normal breast development

A
  • Mullerian agenesis

- Androgen insensitivity

313
Q

A distinguishing characteristic of androgen insensitivity?

A

Scant axillary and pubic hair (due to defective androgen R)

- Can be confirmed by serum T which would be elevated (male range) and karyotype (XY)

314
Q

Amenorrhea + absence of breast development is what kind of estrogenic state?

A

Hypoestrogenic (Ex. Turner syndrome)

315
Q

Define primary amenorrhea?

A
  • No menses by 14 years without secondary sex characteristics
  • No menses by 16 years with secondary sex characteristics
316
Q

Mullerian Agenesis

A

Congenital absence of development of the uterus, cervix, and fallopian tubes in a 46,XX female –> primary amenorrhea
- 1/3 also have a urinary tract abnormality

317
Q

How is a person with AIS able to have breast development?

A

Because of the small amounts of circulating levels of estrogen secreted by the gonads and adrenals and produced by peripheral conversion of androstenedione (contributes the most)

318
Q

What must be done to the gonads of a person with AIS and why?

A

Gonadectomy because they are at increased risk for malignancy (rarely occurs before puberty)
- Therefore, usually done after puberty to allow full breast development and linear growth to occur

319
Q

Physically, what distinguishes a person with AIS from one with Mullerian Agenesis?

A

Those with AIS do not have pubic hair because sensitivity to androgens are needed for this

320
Q

Most common karyotype of gonadal dysgenesis

A

45, XO (Turner syndrome)

321
Q

First test with any woman that presents with amenorrhea

A

Pregnancy test

322
Q

Septic Abortion

A

Any type of abortion associated with a uterine infection

- <1% of spontaneous and ~ 0.5% of induced abortions

323
Q

Source of infection leading to septic abortion?

A

Ascending infections from the vagina –> cervix –> endometirum –> myometrium –> parametrium –> peritoneum

  • Retained POC often become a nidus for infection to develop
  • Usually polymicrobial particularly anerobes (favourable response with combination gentamicin and clindamycin)
324
Q

Four general components to tx of septic shock?

A

1) Maintain BP
2) Monitor BP, O2 and urine output
3) Start broad spectrum abx
4) Perform uterine curettage (~ 4 hours after abx started)

325
Q

Pockets of gas on CT scan noted after diagnosis and abx for septic abortion?

A

Necrotizing metritis with gas forming bacteria such as Clostridial species
- Tx: urgent hysterectomy

326
Q

What type of infection can be caused by unpasteurized milk products such as soft goat cheese?

A

Listeria monocytogenes

  • Amniotic fluid usually meconium stained and may also see Gram +ve rods
  • Tx: IV ampicillin
  • Can cause miscarriage and septic abortion
327
Q

Most common cause of PPH

A

Uterine atony

328
Q

Steps to manage uterine atony –> PPH

A

1) Uterine massage
2) Dilute oxytocin
3) Prostaglandin F2-alpha (contraindicated in asthmatic patients) or rectal misoprostol or methergine
4) Surgical: exploratory laparotomy with interruption of blood vessels to the uterus
5) B-lynch stitch

329
Q

If after birth the uterus is palpated and found to be firm, but bleeding continues what should be suspected?

A

Genital tract laceration (most common cause), uterine inversion, placental causes (accreta or retained placenta) or coagulopathy

330
Q

Methylergonovine maleate (methergine)

A

An ergot alkyloid agent that induces myometrial contraction as a treatment of uterine atony
- Contraindicated in HTN

331
Q

RFs for Uterine Atony

A
  • Mg Sulf
  • Oxytocin use during labor
  • Rapid labor and/or delivery
  • Overdistention of the uterus (macrosomia, multifetal pregnancy, hydramnios)
  • Intra-amniotic infection (chorioamnionitis)
  • Prolonged labor
  • High parity
332
Q

What can cause late PPH (occurring after fist 24 hours)?

A

Subinvolution of the placental site
- Usually occurring at 10-14 days after delivery
Tx: oral ergot & careful f/u

333
Q

Definition of delayed puberty?

A

Absence of secondary sexual characteristics by age 14

334
Q

Gonadal Dysgenesis

A

Failure of development of the ovaries usually associated with karyotypic abnormality (ex. 45, X) and often associated with streaked gonads

335
Q

Four stages of puberty

A

1) Thelarche (~10.8 yrs)
2) Pubarche (~11 yrs)
3) Growth spurt (1 yr after thelarche)
4) Menarche (2.3 years after thelarche)

336
Q

What causes hypergonadotropic hypogonadism?

A 
Gonadal deficiency (most commonly Turner's)
- High FSH, low E
337
Q

Features of Turner’s Syndrome

A
  • Streaked gonads
  • No secondary sex characteristics
  • Internal and external genitalia = female
  • Short stature
  • Webbed neck
  • Shield chest
  • Increased carrying angle
338
Q

What causes hypogonadotropic hypogonadism?

A

A central defect

  • Low FSH, low E
  • Ex: poor nutrition/eating disorders, extreme exercise, chronic illness, stress, primary hypothyroidism, Cushing’s, pituitary adenomas, craniopharyngiomas
339
Q

Goals for management of delayed puberty

A
  • Initiate and sustain sexual maturation
  • Prevent osteoporosis from hypoestrogenemia
  • Promote full height potential

*Therefore can treat with combined OCPs

340
Q

What predisposes intra-abdominal gonads to malignancy?

A

Y chromosome

341
Q

Treatment of Mastitis

A

Dicloxacillin unless MRSA suspected

- Breast feeding should be continued to prevent abscess development

342
Q

Persistent fever after 48 hours of abx for mastitis or presence of fluctuant mass?

A

Breast abscess
- Can be confirmed by U/S
Tx: surgical drainage or U/S guided aspiration

343
Q

Contraindications to breast feeding

A
  • infants with classic galactosemia
  • mothers with active untreated TB or HIV
  • mothers receiving diagnostic or therapeutic radioactive isotopes or exposure to radioactive materials
  • mothers receiving antimetabolites or chemo
  • mothers abusing drugs
  • mothers with herpes simplex lesion on a breast
344
Q

What should be supplemented that baby cannot get from breast milk?

A

Vit D at 2 months of age

345
Q

Benefits to baby of breastfeeding

A
  • Less infections (meningitis, UTIs and sepsis)
  • better neurodevelopmental outcomes
  • decreased risk of DM and childhood obesity later in life
  • decreased GI infections (due to lactoferrin which inhibits certain iron-dependent bacteria of the GI tract and lysozyme that protects against E.coli and other bacteria)
346
Q

Hallmark of Thyroid Storm

A

Autonomic instability

347
Q

Thyroid Storm

A

Extreme thyrotoxicosis leading to CNS dysfunction (coma or delirium) and autonomic instability (hyperthermia, HTN and hypotension)

348
Q

Most common cause of hyperthyroidism in pregnancy?

A

Graves disease (autoimmune disorder where antibodies are produced that mimic the function of TSH)

349
Q

Drug of choice to treat hyperthyroidism in pregnancy?

A

Propylthiouracil (inhibits peripheral conversion of T4 to T3)

  • Alternate: methimazole (but can cause skin/scalp defects)
  • Both cross the placenta somewhat and can lead to transient neonatal hypothyroidism
350
Q

Symptoms suggestive of thyroid storm

A
  • Altered mental status
  • Hyperthermia
  • HTN
  • Diarrhea
351
Q

Management of Thyroid Storm

A

1) PTU
2) B-blockers for tachycardia (but becareful in those with CHF)
3) Acetaminophen or cooling blankets for hyperthermia
4) Corticosteroids to prevent peripheral conversion of t4 to t3

352
Q

What does estrogen do to thyroid hormones in pregnancy?

A
  • Increased thyroid binding globulin
  • Increased total T4
  • NO change to active or free T4 or TSH
  • GENERALLY PREGNANCY IS A EUTHYROID STATE
353
Q

What is the most common cause of hyperthyroidism in the postpartum state?

A

Destructive lymphocytic thyroiditis
- This is because the high corticosteroid levels in pregnancy suppress autoimmune antibodies (antimicrosomal antibodies) and a flare occurs postpartum

354
Q

What are the levels of TSH and free T4 in hypothyroidism?

A
  • High TSH

- Low T4

355
Q

What are the levels of TSH and free T4 in hyperthyroidism?

A
  • Low TSH

- High T4

356
Q

What is given to babies born with chlamydial opthalmic infections?

A

Oral erythromycin for 14 days

357
Q

What is given to babies prophylactically for gonococcal eye infection at birth?

A

Erythromycin eye ointment

358
Q

Most common cause of conjunctivitis in the first month of life?

A

Chlamydial conjunctivitis

359
Q

Treatment for chlamydia in pregnancy?

A
  • Amoxicillin
  • Azithromycin
  • Tetracycline is contraindicated in pregnancy because of the possibility of the staining of the neonatal teeth, erythromycin can lead to liver dysfunction in pregnancy and ciprofloxacin can lead to neonatal MSK problems
360
Q

Most common mode of transmission of HIV in women?

A

Heterosexual spread

361
Q

Ways in which a fetus can develop HIV from the mother?

A
  • Vertical transmission through placenta
  • Transmission during delivery
  • Through breast milk
362
Q

When are HIV antibodies detectable?

A
  • Usually 1 month after infection and almost always at 3 months
363
Q

What should be monitored monthly in a pregnant woman with HIV?

A

Viral load

  • Should be monitored monthly until no longer detectable (Reduces transmission to fetus to almost nothing)
  • Try and maintain viral load < 1000 RNA
364
Q

What is the optimal mode of delivery for the baby of a mother with HIV?

A
  • C/S

- If vaginal delivery they should receive IV zidovudine during labour

365
Q

What would the infant born to an HIV positive mother receive after birth?

A

Oral zidovudine syrup

366
Q

What cells does Chlamydia have a propensity for?

A
  • Columnar and transitional epithelium
367
Q

Difference in presentation of parvovirus infection between children and adults?

A

Adults: malaise, arthralgias, myalgias and a reticular (lacy) faint rash that comes and goes (sometimes asymptomatic
Children: “slapped cheek” appearance and high fever- “fifth disease”

368
Q

What does parvovirus infection do in pregnancy?

A

May cause fetal infection that may lead to suppression of erythrocyte precursors
- Severe fetal anemia (Aplastic anemia) may result leading to fetal hydrops (one of the earliest signs is hydramnios)

369
Q

Early signs of Hydramnios?

A
  • Uterine size bigger than dates

- Fetal parts difficult to palpate

370
Q

How do you diagnose parvovirus?

A

Serology of IgM and IgG

  • Negative IgM and positive IgG = prior infection, immune
  • Negative, Negative (if < 20 days from exposure it could be early infection, if > 20 days not infected)
  • Positive, Negative (probable acute infection but possible false positive IgM)
371
Q

Sinusoidal HR pattern

A

FHR pattern that resembles a sine wave with cycles of 3-5 minutes
- Indicative of severe fetal anemia or fetal asphyxia

372
Q

What kind of virus is parvovirus?

A
  • small, single-stranded DNA virus
373
Q

How to follow pregnant women infected with parvovirus?

A
  • Weekly fetal U/S for 10 weeks assessing for fetal hydrops

- If found, referral for possible intrauterine transfusion

374
Q

Mechanism of action of hydrops fetalis

A

Severe anemia may cause heart failure or induction of the hematopoietic centers in the liver to replace normal liver tissue –> low serum protein

375
Q

What happens with ITP in Pregnancy?

A

Antiplatelet antibodies may cross the placenta and cause fetal thrombocytopenia

376
Q

Differential for hydramnios

A
  • Gestational DM
  • Isoimmunization
  • Syphilis
  • Fetal cardiac arrhythmias
  • Fetal intestinal atresia
377
Q

Most common cause of fever for a woman who has undergone c/s?

A

Endomyometritis

378
Q

Differential for a fever in a woman who had a c/s?

A
  • Endomyometritis
  • Mastitis
  • Wound infection
  • Pyelonephritis
  • Atelectasis (if had GA)
379
Q

Febrile Morbidity

A

Temperature after c/s > 100.4 (38C) taken on two occasions at least 6 hours apart, exclusive of the first 24 hours

380
Q

Septic Pelvic Thrombophlebitis

A

Bacterial infection of pelvic venous thrombi, usually involving the ovarian vein
- Tx: abx + heparin

381
Q

Mechanism of Endomyometritis

A

Ascension of bacteria (mixture of organisms) from normal vaginal flora
- Uterine incision site is commonly the site for infection

382
Q

Symptoms of Endomyometritis

A
  • Fever that occurs on postop day 2
  • Abdominal tenderness
  • Foul-smelling lochia
383
Q

Tx of Endomyometritis

A
  • Broad-spectrum antimicrobial therapy especially with anaerobic coverage (usually IV gentamicin and clindamycin)
384
Q

What would you do if fever persists after 48 hours of therapy for endomyometritis?

A

Add ampicillin because it is likely an enterococcal infection
- If fever still persists, than a CT scan of abdo and pelvis may reveal an abscess or infected hematoma

385
Q

Most common organisms responsible for postcesarean endomyometritis?

A

Anaerobic bacteria (most commonly bacteroides species)

386
Q

Classic lesion of primary syphilis?

A

Painless chancre

387
Q

When does primary syphilis usually manifest itself?

A

2- 6 weeks after inoculation

388
Q

Nontreponemal tests

A

Nonspecific antitreponemal antibody test such as VDRL or RPR tests
- These titers will fall with effective treatment

389
Q

Specific Serologic Tests for Syphillis

A

Antibody tests that are directed against trepnemal organism such as MHA-TP and FTA-ABS
- Remain positive for life after infection

390
Q

Two most common infectious causes of vulvar ulcers?

A
  • HSV

- Syphilis

391
Q

What bacteria causes Syphilis?

A

T palidum

392
Q

What do you do if a nontreponemal test is negative but there is the appearance of a chancre?

A

Darkfield microscopy or biopsy of the lesion

393
Q

What is seen with secondary syphilis?

A
  • Occurs about 9 weeks after the primary chancre
  • Macular papular rash anywhere on the body (usually palms and soles of feet)
  • Flat moist lesion of the condylomata lata on vulva (high concentration of spirochetes)
394
Q

What is the latency period of syphilis?

A
  • Subdivided in to late latent (>1 year) and early latent (<1 year)
  • If untreated 1/3 go on to tertiary syphilis
395
Q

What is seen with tertiary syphilis?

A

Cardiovascular or CNS effects (optic atrophy, tabes dorsalis, and aortic aneurysms)

396
Q

What is the treatment of choice for syphilis?

A

Long-acting penicillin (benzathine penicillin G)

  • One IM injection of 2.4 million units unless late latency (1 dose every week for 3 weeks)
  • If allergic to penicillin, use oral erythromcin or doxycycline
  • In pregnancy, penicillin is the only known effective tx to prevent congenital syphilis
397
Q

What would you follow after therapy for syphilis?

A

Nontreponemal titres
- Appropriate response: 4 fold fall in titres in 3 months and a negative titre in 1 year ( if this does not occur, possible etiology is neurosyphilis diagnosed by LP and treated with IV penicillin x 4-6 doses)

398
Q

What is Chancroid

A

STI

  • Usually manifests as a soft, tender ulcer of the vulva (ragged edges on a necrotic base)
  • More common in males than females
  • May have tender lymphadenopathy as well
  • Etiologic organism = Haemophilus ducreyi (gram-neg rod)
399
Q

What is seen on gram stain of a chancroid?

A

School of fish

400
Q

Treatment of chancroid?

A

Oral azithromycin or IM ceftriaxone

401
Q

What other condition may show positive RPR besides syphilis?

A

SLE

402
Q

Classic Examination of Neurosyphilis?

A
  • Unsteady balance

- Argyll robertson pupils (small pupils that accomodate but do not react to light)

403
Q

Premature Rupture of Membranes

A

Rupture of membranes prior to onset of labor

404
Q

Preterm Premature Rupture of Membranes

A

Rupture of membranes in a gestation < 37 wks, prior to onset of labor

405
Q

What is an early sign of chorioamnionitis?

A

Fetal tachycardia

406
Q

Treatment of PPROM?

A
  • If < 32 weeks antenatal steroids may be given to enhance fetal lung maturity
  • Broad-spectrum abx therapy (usually gent and amp)
  • Expectant mgmt is undertaken when the risk of infection is < risk of prematurity
  • After 34-35 weeks, tx is usually delivery
407
Q

How do you diagnose chorioamnionitis?

A

Amniocentesis-revealing organisms on Gram stain

408
Q

What can cause chorioamnionitis without rupture of membranes

A

Listeria from unpasteurized milk products can spread transplacentally

409
Q

What does vaginal amniotic fluid with phosphatidyl glycerol suggest?

A

Fetal maturity

410
Q

What is a contraindication of corticosteroid use for fetal lung maturity?

A

Clinical infection (corticosteroids suppress the immune system)

411
Q

Three common causes of vaginitis or vaginosis?

A

BV
Trichomoniasis
Candida vulvovaginitis

412
Q

What is BV?

A

Condition of excessive anaerobic bacteria in the vagina leading to discharge that is alkaline

413
Q

What is candida vulvovaginits?

A

Vaginal and/or vulvar infection caused by Candida species usually with heterogenous discharge and inflammation

414
Q

What is trichomonas vaginits

A

Infection of the vagin caused by protozoa Trichomonas vaginalis
- Usually associated with frothy green discharge and intense inflammatory response

415
Q

What is the most common symptom of BV?

A
  • Fishy or “musty” odor exacerbated by menses or intercourse since both of these introduce an alkaline substance
416
Q

What is the vaginal pH in BV?

A

Alkaline (elevated above normal)

417
Q

Out of BV, Trichomonous and Candida which has an acidic pH?

A

Candida

418
Q

Is there an inflammatory reaction with BV?

A

No, therefore patient wont complain of swelling or irritation

419
Q

What are three things BV is associated with?

A
  • Genital tract infection (ex. endometritis)
  • PID
  • Pregnancy complications (preterm delivery and PPROM)
420
Q

How do you treat BV?

A

Oral or vaginal metronidazole

421
Q

How do you treat Trichomonas?

A

Metrondiazole (2g one dose) and partner treated

422
Q

How do you treat Candida?

A

Fluconazole or imidazole cream

423
Q

What should you avoid while taking metronidazole?

A

Alcohol- to avoid a disulfiram reaction

424
Q

Symptoms of Trichomonas?

A
  • Profuse “frothy” yellow-green to gray vaginal discharge
  • Vaginal irritation
  • Strawberry cervix
  • Fishy odor
425
Q

How does Candida develop?

A

Normally lactobaciili in the vagina inhibit fungal growth

  • Therefore, abx therapy can decrease the lactobacilli concentration –> Candida overgrowth
  • Also seen in patients with DM
426
Q

Most common cause of hyperandrogenism

A

PCOS

427
Q

Most sensitive marker of excess androgen production

A

Hirsuitism

428
Q

Differential diagnosis for hirsuitism

A
  • Anovulation
  • Late-onset adrenal hyperplasia
  • Androgen-secreting tumors
  • Cushings
  • Medications
  • Thyroid disease
  • Hyperprolactinemia
429
Q

What is the most common enzymatic genetic defect causing CAH?

A

21-hydroxylase

430
Q

Tests to run to determine source of hirsuitism

A
  • Dexamethasone suppression test (cushings)
  • DHEA-S (adrenal tumor)
  • 17 hydroxyprogesterone (CAH)
  • LH:FSH (PCOS)
  • Testosterone (Sertoli-Leydig cell tumor)
431
Q

What affect does hyperandrogenism have on SHBG?

A

Decreases it = more free T

432
Q

What is characteristic of a sertoli-leydig cell tumor?

A

Fast onset of androgenic symptoms

433
Q

Treatment of hirsuitism?

A

Depends on etiology but generally decrease DHT

434
Q

Most common cause of ambiguous genitalia in the newborn?

A

CAH

435
Q

What is the most common cause of hirsuitism and irregular menses?

A

PCOS

436
Q

How do you treat PCOS?

A

Spironolactone and OCPs

437
Q

Two most common locations of androgen production and secretion in a female?

A

Ovary and adrenal gland

438
Q

Normal cut off value for msAFP?

A

2.0 to 2.5 MOM

439
Q

Alpha-fetoprotein

A

Glycoprotein made by the fetal liver, analogous to the adult albumin

440
Q

Neural Tube Defect

A

Failure of closure of the embryonic neural folds leading to an absent cranium and cerebral hemispheres (anencephaly) or nonclosure of the vertebral arches (spina bifida)
- If it is not covered by skin = open NTD

441
Q

What are the most common causes of an elevated vs a low msAFP suggest?

A
  • Elevated msAFP: oNTD

- Low msAFP: DS

442
Q

What is involved in IPS?

A

Part 1: NT, PAPP-A, BHCG

Part 2: msAFP, Ue3, BHCG, Inhibin A

443
Q

What is the first step in the management of an abnormal triple screen result?

A

U/S for correct GA and to determine multiple gestations

444
Q

Diagnostic tests for abnormal baby?

A

Amniocentesis

CVS

445
Q

On neonatal U/S what is the “double bubble” finding?

A

Doudenal atresia (cystic mass in the right and left abdominal area)

  • Can lead to hydramnios resulting from the baby being unable to swallow
  • Strongly associated with fetal DS
446
Q

Most common cause of abnormal triple screening?

A

Wrong dates

447
Q

What are the 5 complications of PCOS?

A
  • DM
  • Endometrial CA
  • Hyperlipidemia
  • Metabolic syndrome
  • CVD
448
Q

What are the 6 diagnostic tests for PCOS?

A
  • TSH
  • Prolactin
  • Serum T
  • DHEAS
  • 17 hydroxyprogesterone
  • U/S
449
Q

Diagnostic criteria for PCOS

A

2 of:

  • Oligomenorrhea
  • Hyperandrogenism
  • Multiple cysts of the ovary on U/S
450
Q

What is the LH:FSH ratio in PCOS?

A

2:1

451
Q

Treatment of PCOS

A

If pregnancy not desired:

  • OCPs
  • Diet and exercise
  • Assess for metabolic abnormalities leading to DM and CVD
  • Metformin if necessary

If pregnancy desired:

  • Metformin
  • Clomiphene citrate
452
Q

What provides anatomical support of the pelvic organs?

A

Pelvic diaphragm

Endopelvic fascia

453
Q

Define cystocele

A

Defect of the pelvic muscular support of the bladder allowing the bladder to fall down into the vagina

  • Often urethra is hypermobile
  • Anterior POP
454
Q

Define enterocele

A

Defect of the pelvic muscular support of the uterus and cervix or the vaginal cuff (if hysterectomy)

  • Small bowel and omentum push organs into vagina
  • Central POP
455
Q

Define rectocele

A

Defect of pelvic muscular support of the rectum allowing the rectum to impinge into the vagina

  • May have constipation or difficulty evacuating stool
  • Posterior POP
456
Q

Paravaginal Defect

A

Defect in the levator ani attachment to the lateral pelvic side wall leading to lack of support of the vagina
- Lateral pelvic defect

457
Q

RFs for POP

A
  • Multiple vaginal births
  • Coughing
  • Lifting
  • Connective tissue disorders
  • Genetic predisposition
  • Lack of E
  • Obesity
458
Q

Muscles that make up pelvic diaphragm

A
  • Pubococcygeus
  • Puborectalis
  • Levator ani
459
Q

Q-tip test

A

Place a cotton Q-tip in the urethra and observe the degree of movement upon a Valsalva
- Positive test = >60 degree angle of excursion (hypermobile urethra)

460
Q

Procidentia

A

When a woman’s entire uterus is prolapsed out of the introitus

461
Q

Tx of POP

A
  • Pelvic floor strengthening exercises
  • Pessary devices
  • Surgery (colporrhaphy)
462
Q

Velamentous Cord Insertion

A

Umbilical vessels separate before reaching the placenta protected by only a thing fold of amnion instead of by the cord or the placenta itself
- These vessels are susceptible to tearing after ROM

463
Q

Vasa Previa

A

Umbilical vessels that are not protected by cord or membranes which cross the internal cervical os in front of the fetal presenting part
- Most commonly occurs with velamentous cord insertion or a placenta with one or more accessory lobes

464
Q

How are monozygotic twins formed?

A

Fertilization of one egg by one sperm, and then the egg splits

465
Q

How are dizygotic twins formed?

A

Fertilization of 2 eggs by 2 sperm

466
Q

What is chorionicity?

A

Number of placentas in a twin or higher order gestation

  • In monozygotic twins it can be monochorionic or dichorionic
  • In dizygotic twins it is always diamniotic
467
Q

What is amnionicity?

A

Number of amniotic sacs in a twin or higher order gestation

  • Monozygotic twins may be monoamniotic or diamniotic
  • Dizygotic twins are always diamniotic
468
Q

Complications of twin pregnancies

A
  • Higher rate of preterm delivery
  • Higher rate of congenital malformations
  • 2x increased risk of preeclampsia
  • PPH
  • twin to twin transfusion syndrome
469
Q

What determines the chronicity and amnionicity of monozygotic twins?

A

Timing of the division of embryos:

  • First 72 hours: dichorionic/diamniotic
  • Day 4-8: Monochorionic/diamniotic
  • Day 8: Mono/mono
  • After day 8: conjoined
470
Q

What type of twins are influenced by race, heredity, maternal age, parity and fertility drugs?

A

Dizygotic twins

471
Q

What is twin-to-twin transfusion syndrome?

A

One twin is the donor and the other the recipient such that one twin is larger with more amniontic fluid
-Tx: laser ablation of the shared anastomotic vessels at special centers or serial amniocentesis for decompression

472
Q

What is the danger in mono/mono twins?

A

Cord entanglement

473
Q

When can twin pregnancy be delivered vaginally?

A

When both twins are presenting vertex

474
Q

What should be done if vasa previa is identified?

A

Planned c/s before ROM around 35-36 weeks of GA

- Digital vaginal exams are CONTRAINDICATED

475
Q

Apt Test

A

Test to distinguish if vaginal bleeding is maternal or fetal (as in vasa previa)

  • Blood is mixed with NaOH will denatures only adult blood and turns sample YELLOW
  • If sample stays PINK, it is fetal blood
476
Q

Kleihauer- Betke (Neirhaus)

A

Quantitative test of fetal blood cells in maternal circulation

477
Q

What are the maternal effects of a twin pregnancy?

A

They are enhanced

  • Increase nausea and vomiting
  • Greater “physiologic” anemia
  • Greater increase in BP after 20 weeks
  • Greater increase in size and weight of uterus
478
Q

What type of murmur is normal in pregnant women?

A

Early SEM

479
Q

What is Rh Isoimmunization?

A

RH negative woman develops anti-D (Rh Factor) antibodies in response to exposure to Rh (D) antigen

480
Q

What would cause vaginal bleeding in < 20 weeks?

A

Threatened abortion
Completed abortion
Ectopic pregnancy
Septic Abortion

481
Q

WHat would cause vaginal bleeding at > 20 weeks

A

Placenta previa

Placenta abruption

482
Q

Lichen Sclerosis

A

Chronic, inflammatory dermatologic disease characterized by pruritus and pain which mainly affects the anogenital region
- No cure

483
Q

Presentation of Lichen Sclerosis

A

Itching worse at night localized to vulva

  • “Cigarette paper” appearance
  • Tears may develop from scratching or attempted intercourse and scarring may cause narrowing or complete closure of vaginal introitus
484
Q

Differential diagnosis to lichen sclerosis

A

Lichen planus
Psoriasis
Vulvar intraepithelial neoplasia
Vitiligo

485
Q

Treatment of Bartholin Gland Abscess

A

Incision and placement of small balloon catheter into the gland
Marsupialization (surgical fixation of the cyst wall everted against the mucosa of the vulva)
- If over 40 need biopsy to ensure it is not CA

486
Q

What greatly increases the risk of Hep B vertical transmission?

A

Presence of hep E antigen

Obstetrics and Gynecology (1 decks)

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