Obstetrics And Gynecology Flashcards
Normal menstrual cycle:
Two phases?
Two hormones per phase?
Two potential outcomes?
Follicular: FSH and Estrogen -> proliferative phase of the endometrium
Luteal phase: LH and Progesterone -> secretory phase of the endometrium
Outcomes: pregnancy or menstruation
Physiologic cardiovascular changes during normal pregnancy
CO increases
SVR decreases more
Bloop pressure drops
Physiologic changes seen in the GI system in normal pregnancy
- Delayed gastric emptying
- Increased relaxation of the lower esophageal sphincter
- Decreased motility
Physiologic changes seen in the Renal system in normal pregnancy
GFR (CrCL) increases in pregnancy
Serum creatinine decreases
Physiologic changes seen in the endocrine system in normal pregnancy
Beta-hCG doubles every 48 hrs
hPL confers resistance to insulin
Hematopoietic changes during normal pregnancy
Hypercoagulable state
When to go for surgery instead of methotrexate in ectopic pregnancy
- ruptured ectopic pregnancy
- patient unlikely to follow up
- fetal heart sound
- beta hCG > 5000
- GS > 3.5cm
Define spontaneous abortion
Unprovoked fetal loss before 20 weeks gestation
Most common cause of spontaneous abortion
Chromosomal abnormalities
Complete abortion :
Vaginal bleeding
Cervix
Ultrasound
+/- vaginal bleeding
Closed cervix
Empty uterus
InComplete abortion :
Vaginal bleeding
Cervix
Ultrasound
Vaginal bleeding present
Open cervix
Product of conception present in the uterus
Inevitable abortion :
Vaginal bleeding
Cervix
Ultrasound
Vaginal bleeding
Open cervix
Live or dead product of conception
Threatened abortion :
Vaginal bleeding
Cervix
Ultrasound
Vaginal bleeding
Closed cervix
Live fetus on ultrasound
Missed abortion :
Vaginal bleeding
Cervix
Ultrasound
Vb hasn’t started yet
Closed cervix
Dead fetus
Risk factor for 1st time ectopic pregnancy
History of
- PID
- Salpingitis
- Prior surgery
- Endometriosis
Most common location of ectopic pregnancy
Ampulla
Quad screen consists of
Beta-hCG
Estriol
MSAFP
Inhibin A
Increase hCG and inhibin A, decrease estriol and AFP,
Trisomy 21
Increased MSAFP
Open neural tube defect, gastroschisis
When to screen for gestational diabetes
26- 28 weeks
How do you screen for gestational diabetes?
Start with 1hr GTT (50g glucose) If > 140, do 3hr 100 GTT Fasting : 95 1hr: 180 2hrs: 155 3hrs: 135
Or random > 200 + symptoms
Complications of pregestational diabetes mellitus
Caudal regression syndrome
Cardiac defects
Complications of gestational diabetes
Macrosomia,
Shoulder dystonia
Polydramnios
Neonatal hypoglycemia
Definition of oligohydramnios
Low amniotic fluid (< 5cm Amniotic Fluid Index)
Causes of oligohydramnios
Can’t pee or make urine: Renal agenesis GU obstruction ( posterior urethral valves in males) Uteroplacental insufficiency Ruptured membrane
Most common cause of oligohydramnios
Ruptured membranes
Definition of polyhydramnios
Increased amniotic fluid (>24 cm Amniotic Fluid Index on US)
Causes of polyhydramnios
Can’t absorb fluid to make urine or making too much urine:
- esophageal or duodenal atresia
- anencephaly
- maternal diabetes
Blood pressure criteria in pregnancy
- 4hrs apart
- systolic bp >/= 140mmHg or
- diastolic bp >/= 90mmHg
Gestational hypertension criteria
- bp criteria met
- after 20 weeks gestational age
- no features of preeclampsia
- no need for bp meds
- no need for aspirin
- deliver at 37 weeks
Chronic hypertension in pregnancy features
- bp criteria is met
- prior to 20 weeks gestational age
- no features of preeclampsia
- possibly need ongoing bp meds
- give aspirin at 12 weeks gestation
- deliver at 38 weeks if no meds and 37 weeks if on meds
Pre-eclampsia criteria
- blood pressure criteria met
- after 20 weeks gestation
- evidence of end-organ involvement: proteinuria or severe features
Organ systems that can be affected in preeclampsia
Renal Neurologic Pulmonary Hepatobiliary Hematopoietic
Proteinuria?
Protein/creatinine of 0.3mg/dL
300mg of protein in a 24 hour urine
Protein>/= 2+
Preeclampsia with severe features criteria
- Severe ranges of blood pressure:- >/= 160mmHg or >/= 110 mmHg
- Low platelet count (<100,000)
- Increased LFTs (> 2x the upper limit of normal conc)
- Pulmonary edema
- Creatinine >1.1 mg/dL or 2x baseline
- New onset headache and visual changes
- Right upper quadrant pain
Antihypertensives used in pregnancy
Labetalol
Hydralazine
Immediate release nifedipine
What is normal labor
Painful contractions that causes cervical changes
Explain the phases of the first stage of labor
Latent phase: prior - 6cm
Active phase: after 6cm
What is normal second stage of labor
10 cm(complete dilation) to delivery for = 2hrs for multiparous patients and = 3hrs for nulliparous patients
Third stage of labor?
From delivery of baby to delivery of placenta
What is arrest of active phase in labor
No change in >/= 4 hrs with adequate contraction
Or >/= 6hrs with inadequate contraction
Management of arrest of active phase of labor
Oxytocin
Cesarean delivery
Four aspects of interpretation of fetal heart rate monitoring
Baseline heart rate (110-160 bpm)
Beat to beat variability
Accelerations
Decelerations
Early decelerations is due to
Head compressions
Variable decelerations is due to
Cord Compression
Late decelerations is due to
Uteroplacental insufficiency
Category 1 FHR tracing features:
110-160 bp.
Moderate Variability
No variable or late decelerations
Category 3 of FHR tracing
Absent baseline variability plus any of
- Bradycardia
- Recurrent late or variable decelerations
- Sinusoidal pattern
Treatment of choice for prevention of intrapartum seizures in pre-eclamptic patient and/or eclamptic patients
Magnesium sulfate
First sign of magnesium toxicity
Decreased deep tendon reflexes
Signs of magnesium toxicity
Decreased DTRs
Respiratory paralysis
Arrhythmia
Magnesium antidote
Calcium gluconate
Which type of patients can’t get magnesium sulfate
Myasthenia gravis patients
Ulcerative painful STI
HSV
Chancroid
LGV
Painless ulcerative STI
Syphilis
Granuloma inguinale
Non-ulcerative STI
Chlamydia
Gonorrhea
Trichomonas
What is the most common STI
Human papilloma virus
Painful angry red ulcer(s) in genitals; painful lymphadenopathy that can rupture
Cause?
Haemophilus ducreyi
Painful angry red ulcer(s) in genitals; painful lymphadenopathy that can rupture
Treatment
Azithromycin, ceftriaxone or ciprofloxacin
Painless genital ulcers + painful lymphadenopathy
Diagnosis?
LGV
Treatment of LGV
Doxycycline
Painless ulcer+ painless lymphadenopathy
Syphilis
Management of a pregnant woman with syphilis and is allergic to Pencillin
Desensitize and treat with penicillin
Acute febrile reaction accompanied by headache and myalgia within 24 hrs of syphilis treatment initiation
Jarisch-Herxheimer reaction
Beefy red, velvety genital nodule that turns into a painless genital ulcers without lymphadenopathy
Organism?
Klebsiella granulomatis (granuloma inguinale)
Treatment for cervicitis
Ceftriaxone and azithromycin
Sexually actively female with chief complaint of lower abdominal or pelvic pain or tenderness in cervix raises suspicion for
PID
Outpatient treatment for PID
Ceftriaxone and doxycycline
Inpatient treatment for PID
Cefoxitin and doxycycline or clindamycin and gentamicin
How long to treat PID with antibiotics
10-14 days
Maternal fever+ purulent or foul smelling discharge; fetal tachycardia; maternal tachycardia; fundal tenderness
Most likely diagnosis?
Choriamnionitis
How does someone become GBS positive
Previous neonate with GBS disease (positive for life)
GBS asymptomatic bacteriuria or UTI anytime in pregnancy (positive for length of pregnancy)
GBD screening rectovaginal culture (positive for labor)
Treatment drug of choice for GBS chorioamnionitis
Penicillin
Treatment drug of choice for GBS chorioamnionitis with non anaphylactic penicillin allergy
Cefazolin
Treatment drug of choice for GBS chorioamnionitis with high risk anaphylaxis allergy
Require culture and susceptible testing for clindamycin
Sensitive to both: clindamycin
To non: Vancomycin
Painful dark vaginal blood in 3rd semester is suspicious of
Placenta abruption
Placenta blocks the exit (os) painless, bright red VB in third trimester
Placenta previa
Risk factors for placenta abruption
Previous abruption
HTN diseases
Cocaine
Management of placenta abruption
Emergent Delivery
Risk factors for placenta previa
Prior cesarean delivery
History of placenta previa
Management of placenta previa
Cesarean delivery
Define postpartum hemorrhage
Blood loss if >500cc during vaginal delivery or >1000cc during C.delivery or signs and symptoms of hypovolemia within 24hrs of delivery
Causes of postpartum hemorrhage
Uterine atony Genital trauma lacerations Uterine inversion Coagulopathies Retained placenta
Uterotonic drugs
Oxytocin
Methylergonovine
Misoprostol
Prostaglandin F2 alpha
A soft “boggy” uterus + postpartum hemorrhage
Uterine atony
1st line management of uterine atony
Massage
Meds that can be used for uterine atony
Oxytocin Methylergonovine Prostaglandins F2 Misoprostol Tranexamic acid
Postmenopausal female with dyspareunia, vulvar itching (or incidental findings of) and symmetric, whitish, thinning of the labia, perineum and perineum. Labia minora can stick together
Diagnosis?
Lichen sclerosis
Diagnostic test for lichen sclerosis
Punch biopsy
Treatment of lichen sclerosis
High potency Topical corticosteroid (clobetasol)
Normal pH for vaginal discharge
4 - 4.5
Which vaginitis has normal pH
Candidiasis
Malodorous discharge; off- white grayish homogeneous discharge
Diagnosis?
Bacterial vaginosis
What is seen on microscopy in bacterial vaginosis
Clue cells and less lactobacilli
Malodorous discharge, dyspareunia, dysuria; green-yellow discharge, vaginal erythema
Diagnosis?
Trichomoniasis
Treatment for bacterial vaginosis
Metronidazole
What is seen on microscopy in trichomoniasis
Mobile flagellated trichomonads
Pruritus, soreness, dyspareunia; vulvar erythema, clumpy white discharge
Diagnosis?
Candidiasis
What is seen on microscopy in candidiasis
Pseudohyphae- candida albicans
Budding yeast - non-albicans
Treatment of candidiasis
Azole antifungal
Painful grouped vesicles or ulcer with painful lymphadenopathy
Most likely Diagnosis?
HSV
Diagnostic test for HSV
PCR
Treatment for HSV
Acyclovir
Valacyclovir
Famciclovir
Management of a pregnant patient with history of HSV
Use suppressive medication around 36 weeks
Management of a pregnant patient who has prodromal symptoms or active lesions at time of labor
Cesarean delivery
Condyloma lata + maculopapular rash on palms and soles
Secondary Syphilis
PALM COEIN of AUB
Polyp Adenomyosis Leiomyoma Malignancy/ hyperplasia Coagulopathy Ovarian dysfunction Endometrial dysfunction Iatrogen Not otherwise classified
AUB -intermenstrual bleeding
Endometrial polyps
AUB - smooth, boggy uterus
Adenomyosis
AUB in post menopausal women is what until proven otherwise
Endometrial hyperplasia vs. cancer
AUB basic work up includes
Pregnancy test CBC TSH Cervical cancer screening STI screening
Work up for suspected ovarian cause of AUB
Pregnancy test
TSH
prolactin
Endometrial biopsy for high risk patients
Important indicators of unopposed estrogen exposure
Early menarche Late menopause No breast feeding Nulliparity Obesity Polycystic ovarian syndrome Hyperprolactinemia Thyroid disease
When should endometrial sampling be performed
Post menopausal bleeding AUB in women older than 45 AUB in women younger than 45 with unopposed estrogen exposure risk factors: Early menarche/ late menopause Nulliparity Chronic anovulation Obesity Diabetes Others: Lynch Syndrome, Family history, estrogen secreting tumor
Ultrasound features of potential malignancy that can make an adnexal mass be a big deal
Solid (hypoechoic) component
Septations
Doppler flow in the solid component
Ascites
Germ cell tumor is the most common ovarian malignancy in what age group of women
Women under 20
What is the treatment for germ cell tumor with the exception of dysgerminomas
Bleomycin
Cisplatin
Etoposide
Tumor marker for dysgerminoma
LDH
What is dysgerminoma very sensitive to
Radiation
Tumor marker for endodermal sinus
Increased AFP
Tumor marker for choriocarcinoma
Beta-hCG
Sertoli leydig celllz tumors presents with
Virilization
Oligo/amenorrhea
Elevated levels of testosterone or androstenedione
Meigs Syndrome triad
Fibroma
Right sided hydrothorax
Ascites
hiw do you Screen for ovarian cancer in a patient with BRCA mutations
Ultrasound and CA- 125
What hormone is responsible for the development of the external male genitalia
Dihydrotestosterone
What converts testosterone to dihydrotestosterone
5 alpha reductase
primary Amenorrhea + virilization+ internal male genitalia
Diagnosis?
5 alpha reductase deficiency
Normal appearing female with elevated testosterone, dihydrotestosterone and estrogen
Diagnosis?
Androgen insensitivity Syndrome
normal female external genitalia + Primary amenorrhea + absent sex characteristics + absent uterus
Androgen insensitivity Syndrome
Normal ovaries and female external genitalia + absent uterus, cervix and upper third of vagina
Mullerian agenesis
What hormone is increased in menopause
FSH
