Obstetrics & Gynaecology

Question 1

Both syst and diast ____ by 10-15mmHg in the first 2 trimesters but _____ 10mmHg in last trimester returning to baseline towards term thus chronic HTN can be masked in pregnancy

Answer 1

Decreases, increases

Question 2

What is defined as pre-existing/chronic hypertension?

Answer 2

BP >140/90 prior to 20 weeks GA, persisting >7 weeks post-partum

Question 3

What is defined as gestational hypertension?

Answer 3

sBP > 140 or dBP > 90 developing after 20th week GA in the absence of proteinuria in a women known to be normotensive before pregnancy

Question 4

Physical exam of mother with hypertensive disorders in pregnancy

Answer 4

Body weight, CNS (presence/severity of headache, visual disturbances – blurring, scotomata – loss of part of the visual field), tremulousness, irritability, somnolence, hyperreflexia), hematologic (bleeding, petechiae), hepatic (RUQ or epigastric pain, severe N/V), renal (decreased urine output), non-dependent edema (hands and face)

Question 5

Complications of Hypertensive Disorders in Pregnancy

Answer 5

Liver dysfunction (edema/subcapsular hematoma), renal dysfunction (hypoperfusion), seizure/eclampsia, abruptio, LV failure/pulmonary edema, DIC (release of placental thromboplastin consumptive coagulopathy), HELLP syndrome, hemorrhagic stroke (50% of deaths)

Question 6

Complications to fetus due to GHTN

Answer 6

Secondary to placental insufficiency – IUGR, prematurity, abruption, IUFD

Question 7

Labs/investigations of hypertensive disorders in pregnancy?

Answer 7

CBC (heme) + ALT/bilirubin/uric acid/LDH (hepatic) + Creatinine/Protein: Creatinine Ratio (renal) + PTT/INR/fibrinogen (if abnormal LFTs or bleeding, coagulopathy) + urate

Given that urine takes 1 day to come back, do urine dip (UA) – look for 2+ proteinuria (marker)

Question 8

Management for both Pre-existing + Gestational HTN

Answer 8

Labetalol, α-methyldopa. Ask patient to get BP cuff and parameters for when to come in. Hydralazine and nifedipine are short acting.
No ACEI, ARBs, diuretics, prazosin, or atenolol

Question 9

What is defined as pre-eclampsia?

Answer 9

New-onset hypertension (blood pressure [BP] > 140/90 mm Hg) plus new unexplained proteinuria (> 300 mg/24 hours after 20 weeks or a urine protein/creatinine ratio of >0.3)

Question 10

In the absence of proteinuria, preeclampsia is also diagnosed if pregnant women have new-onset hypertension plus new onset of any of the following

Answer 10

Platelets < 100,000, LFTs twice normal, severe RUQ/epigastric pain, renal insufficiency (Cr >1.1 or double serum Creatinine), pulmonary edema, new onset headache/visual disturbances, and could later see hyperreflexia/clonus

Question 11

What is the definitive treatment for PEC?

Answer 11

Delivery

Question 12

For management of PEC - Immediate delivery is recommended for:

Answer 12

Pregnancy of > 37 weeks, Eclampsia, Preeclampsia with severe features if pregnancy is >34 weeks, Deteriorating renal, pulmonary, cardiac, or hepatic function (eg, HELLP syndrome), Nonreassuring results of fetal monitoring or testing

Question 13

General management for PEC?

Answer 13

Hospitalized, Antenatal corticosteroids should be considered if GA <34wk, Delivery if >37weeks, Anti-HTN, MgSO4

Question 14

Who are considered high risk for PEC?

Answer 14

<18yo, muiltiprip, pre HTN, Hx preeclampsia

Question 15

What prevention should high risk women for PEC be on?

Answer 15

Low dose ASA AND Calcium if low Ca intake
ASA 162mg (2 tab) a night administered at bedtime starting pre-pregnancy or from diagnosis of pregnancy and continue until delivery starting at 12-16 weeks GA

Question 16

How do you define eclampsia?

Answer 16

The occurrence of =>1 grand mal seizures and/or coma in the setting of pre-eclampsia and the absence of other neurologic conditions occurring before/during/after labour (48-72 hr)

Question 17

What are the symptoms of eclampsia?

Answer 17

Tonic-clonic seizure lasting 60-75 seconds; symptoms that occur before seizure are persistent frontal or occipital headache, blurred vision, photophobia, RUQ pain, altered mental status, hyperreflexia

Question 18

Management of eclampsia

Answer 18

ABCs + roll patient in LLDP + supplement O2 to treat hypoxemia due to hypoventilation (while convulsing) + aggressive anti-HTN tx for sustained diastolic pressures > 105 or systolic > 160 + prevention of recurrent convulsions + MgSO4 and DELIVERY – doesn’t matter what age, it reduces the risk of maternal morbidity and mortality; mode of delivery depends on clinical situation/condition

Question 19

What is HELLP syndrome?

Answer 19

Hemolytic anemia + Elevated Liver enzymes + Low Platelet count

Question 20

Define primary and secondary infertility

Answer 20

Primary: no pregnancies ever
Secondary: has been pregnant before

Question 21

Causes of male infertility

Answer 21

• Sperm disorders - reduced sperm count, impaired motility, reduced ejaculate volume
• Testicular damage - scrotal injuries, testicular torsion, infections such as mumps, gonorrhea
• Cryptorchidism
• Scrotal hyperthermia (varicocele)
• Medication - anabolic steroids, spironolactone, corticosteroids, cimetidine
• Thyroid disorders
• Chronic diseases - liver cirrhosis, renal insufficiency, obesity
• Inherited disorders: Klinefelter syndrome, Kallmann syndrome
• Sexual dysfunction - impaired libido, anejaculation
• Pituitary and hypothalamic tumors
• Hyperprolactinemia

Question 22

List the main category of causes of female infertility

Answer 22

• Ovarian reserve dysfunction
• Ovarian dysfunction
• Outflow Tract Abnormalities
• Endometriosis

Question 23

Tx for hyperprolactinemia

Answer 23

Administer bromocriptine, a dopamine agonist, which suppresses prolactin.

Question 24

Tx for PCOS

Answer 24

Treat with clomiphene or letrozole +/- metformin, weight loss.

Question 25

Tx for pituitary insufficiency

Answer 25

Treat with intramuscular luteinizing hormone/follicle-stimulating hormone (LH/FSH) or clomiphene.

Question 26

What is the definition of infertility

Answer 26

Inability to conceive after 12 months of regular coitus under 35 years of age and after 6 months in women 35 years of age and over

Question 27

Investigations for male infertility?

Answer 27

- Semen analysis: sperm count + morphology + motility - Mixed antiglobulin reaction test for antisperm antibodies - TSH levels - Prolactin levels - Karyotype test (Kallmann syndrome, Klinefelter syndrome) - Scrotal/Testicular U/S: look for varicocele, obstruction, retrograde ejaculation into bladder

Question 28

Investigations for female infertility?

Answer 28

- Basal body temperature monitoring (biphasic pattern) - Hormone tests 3-5 day of the menstrual cycle - Midluteal serum progesterone levels (day 21-23): progesterone should increase shortly after ovulation - failure of progesterone levels to rise indicates anovulation - Endometrial bx - Imaging: Hysterosalpingogram, Hysteroscopy

Question 29

Which hormone tests should be done for female infertility

Answer 29

- Ovulation prediction test (detect LH levels) - Androgen levels – negative feedback on ovulation - TSH levels: elevated levels in hypothyroidism - Prolactin levels: hyperprolactinemia - Ovarian reserve: - Early follicular FSH levels: elevated in ovarian insufficiency and indicate reduced ovarian reserve - Early follicular estradiol levels - Anti-Mullerian hormone levels

Question 30

Causes of ovarian reserve dysfunction?

Answer 30

- <40 – Primary ovarian insufficiency | - >40 – menopause Tx: no treatment, adoption

Question 31

Causes of ovarian dysfunction?

Answer 31

- Pituitary insufficiency - Hyperprolactinemia - PCOS - Other causes: Hyper/hypothyroid, androgen excess, obesity/starvation, galactorrhea, stress.

Question 32

Causes of outflow tract abnormalities?

Answer 32

- Tubal Factors: PID, ligations/occlusion - Uterine Factors: congenital (bicornate/septate uterus), acquired: adhesions (Asherman’s Syndrome), fibroids/polyps, endometrial ablation - Cervical Factors: hostile/acidic cervical mucus, anti-sperm antibodies, structural defects

Question 33

What is letrozole

Answer 33

Aromatase inhibitor

Question 34

What is defined as acute pelvic pain?

Answer 34

Pain below the umbilicus lasting less than 6 months - occurs suddenly, sharply, and briefly

Question 35

What is defined as chronic pelvic pain?

Answer 35

6 months of pain below the umbilicus severe enough to cause functional disability or require tx

Question 36

Etiology for pelvic pain?

Answer 36

1. Pregnancy: ectopic pregnancy, spontaneous abortion, abruption placenta, uterine rupture, endometritis 2. Gynecological: - Ovary (e.g., ruptured cyst, torsion, neoplasia) - Tube (e.g., pelvic inflammatory disease, endometriosis) - Uterus (e.g., leiomyoma, endometriosis) - Other (dysmenorrhea, ovulation pain (Mittelschmerz), dyspareunia) 3. Systemic conditions: - Urologic (interstitial cystitis, renal colic) - Musculoskeletal (fibromyalgia, diastasis of the pubic symphysis due to previous vaginal deliveries) - Gastrointestinal (irritable bowel, diverticulitis, inflammatory bowel disease, hernias) - Neurologic: pudendal neuralgia, anterior abdo wall nerve entrapment - Vascular: pelvic congestion syndrome 4. Mental health issues - Depression, somatization - Sexual, physical, and psychological abuse/domestic violence

Question 37

Two emergencies to consider with acute pelvic pain?

Answer 37

- Ruptured ectopic pregnancy | - Ovarian torsion

Question 38

History for pelvic pain?

Answer 38

- HPI: First occurrence, PQRST. Relation to position changes (pudendal neuralgia) or menstruation (adenomyosis, endometriosis) - Obs history: MSK - pelvic floor myofascial pain syndromes, No prior pregnancies increase your risk of having endometriosis, PID, adhesions - Surgical history – nerve injury, adhesions - Last menstrual period (LMP) and menstrual history. - Gastrointestinal (GI) complaints such as nausea, vomiting, diarrhea, or constipation - Sexual history: Dyspareunia. - Social history (marital discourse, depression, stress, history of physical or sexual abuse)

Question 39

Physical exam for pelvic pain

Answer 39

- VS – elevated temp, tachy, hypo - Abdomen – palpated for tenderness, masses, and peritoneal signs. Rectal examination is done to check for tenderness, masses, and occult blood - Back – sacroiliac joints - Vulva – visual inspection, sensory exam to sharpness, dullness and light touch – rule out neuralgia - Pelvic examination: external genitals, speculum examination, bimanual examination. The cervix is inspected for discharge, uterine prolapse , and cervical stenosis or lesions. Bimanual examination should assess cervical motion tenderness, adnexal masses or tenderness, and uterine enlargement or tenderness.

Question 40

What is Carnett's test?

Answer 40

Carnett’s test - The patient voluntarily contracts her abdominal muscles by raising her head or legs. An increase in the pain indicates a myofascial origin (positive), whereas a decrease indicates an intraperitoneal disorder/visceral source.

Question 41

Red flags for pelvic pain?

Answer 41

- Syncope or hemorrhagic shock (eg, tachycardia, hypotension) - Peritoneal signs (rebound, rigidity, guarding) - Postmenopausal vaginal bleeding - Fever or chills - Sudden severe pain with nausea, vomiting, diaphoresis, or agitation

Question 42

Investigations for pelvic pain?

Answer 42

- Complete blood count (CBC) with differential: An elevated white blood cell count (WBC) may indicate an infection. - Pregnancy test. - RPR, if positive then a confirmatory test such as a VDRL or FTA-ABS, HIV, gonorrhea/chlamydia cultures. - Urinalysis (UA) and urine culture. - Fecal occult blood.

Question 43

Imaging studies for pelvic pain?

Answer 43

o Pelvic sonogram: Best to evaluate ovarian cyst/neoplasms or uterine fibroids. o For further evaluation: Computed tomography (CT)/magnetic resonance imaging (MRI)-best to evaluate for abdominopelvic masses or malignancies.

Question 44

What is endometriosis?

Answer 44

Endometrium outside of the endometrial cavity

Question 45

Pelvic pain that is not primary dysmenorrhea should be considered ____ until proven otherwise

Answer 45

Endometriosis

Question 46

What is the pathophysiology of endometriosis?

Answer 46

▪ The ectopic endometrial tissue is physiologically functional. It responds to hormones and goes through cyclic changes, such as menstrual bleeding. ▪ The result of this ectopic tissue is "ectopic menses," which causes bleeding, peritoneal inflammation, pain, fibrosis, and, eventually, adhesions.

Question 47

Presentation of endometriosis?

Answer 47

Pelvic pain (that is especially worse during menses, but can be chronic): - Secondary dysmenorrhea (pain begins up to 48 hr prior to menses). - Dyspareunia (painful intercourse) as a result of implants on pouch of Douglas; occurs commonly, with deep penetration. - Dyschezia (pain with defecation): Implants on rectosigmoid. - Dysuria Infertility, Intermenstrual bleeding, Cyclic bowel or bladder symptoms (hematuria). Up to one-third of women may be asymptomatic.

Question 48

Signs of endometriosis?

Answer 48

Retroverted uterus, uterosacral ligaments + rectovaginal nodules, adnexal masses (endometriomas).

Question 49

Diagnosis of endometriosis?

Answer 49

Laparoscopy or laparotomy: Ectopic tissue must be biopsied for definitive diagnosis. The gold standard for diagnosis is laparoscopy with biopsy proven hemosiderin laden macrophages.

Question 50

Medical and surgical treatments for endometriosis?

Answer 50

Medical (temporizing): - Mild-to-moderate: Empirical medical therapy with NSAIDs and continuous hormonal contraceptives - Severe sx: GnRH agonists (e.g., buserelin, goserelin) and estrogen-progestin OCPs Surgical: - Conservative (if reproductivity is to be preserved): Laparoscopic lysis and ablation of adhesions and implants. - Definitive: Total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH/BSO).

Question 51

What is adenomyosis?

Answer 51

Ectopic endometrial glands and stroma are found within the myometrium, resulting in a symmetrically enlarged and globular uterus.

Question 52

Presentation of adenomyosis?

Answer 52

Presentation: parous women in their 40’s to 50’s, uterus enlarged and boggy, pelvic pain (usually noncyclical), dysmenorrhea, and menorrhagia, dyspareunia

Question 53

Investigations for adenomyosis?

Answer 53

Transvaginal U/S or MRI to differentiate between adenomyosis and uterine fibroids

Question 54

Management of adenomyosis?

Answer 54

Management: No proven medical therapy for treatment. - GnRH agonist, NSAIDs, and OCPs may be used for pain and bleeding. - Hysterectomy: Definitive therapy if childbearing is complete. The diagnosis is usually confirmed after histologic examination of the hysterectomy specimen.

Question 55

What is Pelvic Inflammatory Disease?

Answer 55

A bacterial infection that spreads beyond the cervix to infect the upper female reproductive tract, including the uterus, fallopian tubes, ovaries, and surrounding tissue.

Question 56

Acute pain can occur with degeneration of these, torsion of pedunculated subserosal fibroids, or expulsion of pedunculated intracavitary myomas through the cervix.

Answer 56

Leiomyomas

Question 57

What is pelvic congestion?

Answer 57

Characterized by chronic pelvic discomfort exacerbated by prolonged standing and coitus in women who have periovarian varicosities on imaging studies

Question 58

Symptoms of pelvic congestion

Answer 58

Dull chronic ache, worsened at the end of the day, standing, premenstrual, or postcoital = pelvic varicosities.

Question 59

Treatment of pelvic congestion

Answer 59

Treatment: hormonal suppression, percutaneous embolotherapy, surgery.

Question 60

A tender hard band or nodule of the muscle associated with pelvic pain?

Answer 60

Myofascial trigger point

Question 61

What is dyspaurenia?

Answer 61

Genital pain before, during, or after sexual intercourse

Question 62

What are the risk factors for dyspaurenia?

Answer 62

Risk Factors: PID, peri/postmenopausal, anxiety, depression, prior sexual assault, female circumcision

Question 63

What is vestibulodynia?

Answer 63

Vulvar pain characterized by severe pain on touch/entry, tenderness to pressure within the vestibule, limited to erythema for physical findings

Question 64

What is vaginismus and how do you treat?

Answer 64

Involuntary spasm of perineal and levator muscles – psychological issues or conditioned response to pain

Question 65

What is vulvodynia and how do you treat?

Answer 65

Unprovoked stinging/burning/irritation/pain on vulva – treat with xylocaine 5% ointment PRN, or gabapentin

Question 66

How do you treat vulvovaginal atrophy?

Answer 66

Premarin cream 0.5g qhs x 4 weeks, estring, vagifem tablets, lubricants PRN

Question 67

Definition of menopause?

Answer 67

Menopause: permanent cessation of menses for >12 months

Question 68

Definition of premature ovarian failure?

Answer 68

Premature ovarian failure is defined as menopause occurring before age 40

Question 69

Describe the hypothalamic-pituitary-ovarian axis

Answer 69

GnRH is released in a pulsatile fashion. This pulsatility induces release of FSH. FSH then stimulates folliculogenesis of the ovaries and estrogen is released.

Question 70

What happens to the hormones in menopause?

Answer 70

Estrogen levels begin to decline from peak in mid-to-late 30’s, begins perimenopause. As women age, we see endocrine markers – high FSH and low estradiol - cycle variability increases

Question 71

Menopause is characterized by an elevated FSH due to

Answer 71

1. ↓ inhibin (inhibin inhibits FSH secretion; it is produced in smaller amounts by the fewer oocytes). 2. Resistant oocytes require more FSH to successfully mature, triggering greater FSH release.

Question 72

Why do women begin to ovulate less frequently?

Answer 72

This is due to a shortened follicular phase. The length of the luteal phase does not change. HPO: decrease in HPO sensitivity to estrogen (no LH surge = failure of estrogen(+) feedback)

Question 73

What are the autonomic symptoms of menopause?

Answer 73

- Increased sweating, hot flashes, and heat intolerance - Vertigo - Headache

Question 74

What is the most common cause of post-menopausal bleeding.

Answer 74

Vaginal atrophy resulting from lack of estrogen

Question 75

Treatment options for hot flashes?

Answer 75

SSRIs, specifically venlafaxine, can be used to control symptoms Lower temp of sleeping area, cold drink at the beginning of a flash

Question 76

What are the mental symptoms in menopause?

Answer 76

- Impaired sleep (insomnia and/or night sweats) - Depressed mood or mood swings - Anxiety/irritability - Loss of libido - Poor memory/concentration

Question 77

What are the atrophic symptoms of menopause?

Answer 77

- Breast tissue atrophy: breast tenderness and reduced breast size - Vulvovaginal atrophy: atrophy of the vulva, cervix, vagina leading to vaginal dryness, pruritus, and dyspareunia - Urinary atrophy: atrophy of the urinary tract leading to urinary incontinence, dysuria, urinary frequency, urgency, and increased urinary tract infections - Osteoporosis

Question 78

When should HRT be considered for menopause

Answer 78

If moderate or severe symptoms.

Question 79

Treatment for vaginal atrophy in menopause?

Answer 79

Local estrogen cream (Premarin) or Vaginal Suppository (VagiFem) or ring (Estring) or lubricant

Question 80

Prevention of osteoporosis in menopause?

Answer 80

1000-1500mg calcium + 800-1000IU VD3, weight exercise, no smoking, bisphosphonates (if diagnosed with osteoporosis)

Question 81

Treatment options for decreased libido in menopause?

Answer 81

Decreased Libido: vag lubrication, counselling, androgen replacement

Question 82

Treatment options for CVD in menopause?

Answer 82

CVD: manage risk factors with weight loss, BP control, etc.

Question 83

Contraindications to HRT in menopause

Answer 83

Contraindications (ABCD): acute liver disease, undiagnosed vaginal bleeding, cancer (breast or endo), cardiovascular disease, DVT

Question 84

Treatment if HRT is contraindicated in menopause?

Answer 84

If contraindicated: antidepressants + clonidine (alpha agonist) + gabapentin (start at 300mg at HS)

Question 85

When is ERT—estrogen alone indicated in menopause?

Answer 85

Indicated in women status post hysterectomy.

Question 86

Why do we use estrogen + progesterone for HRT?

Answer 86

The progesterone component is needed to protect the endometrium from constant stimulation and resultant increase in endometrial cancer. It is indicated for women who still have their uterus.

Question 87

At what point should a conversation be had to determine if therapy is still indicated for menopause symptoms?

Answer 87

Short-term therapy (< 5 yr) is acceptable for menopausal symptom relief – after 5 yrs need to have a conversation.

Question 88

Risks of HRT?

Answer 88

Risks: estro only ~ endometrial hyperplasia/carcinoma + thromboembolic +stroke/MI (1st year of treatment) + ^breast ca. risk (w/ combo) + gallbladder dx Breast Cancer Risk: increases after 5 years with combo use

Question 89

Side effects of HRT?

Answer 89

Side Effects: AUB, mastodynia, edema, bloating, nausea, heartburn, mood changes

Question 90

Definition of vulvovaginitis?

Answer 90

Vaginitis is a general term for a group of disorders affecting the vagina, caused by infection, inflammation, or changes in the normal flora.

Question 91

What is normal discharge?

Answer 91

Normal Discharge (pH 3.5-4.5): white/yellow, odorless, no associated vulvar or vaginal symptoms

Question 92

What should be asked on history for vulvovaginitis?

Answer 92

History: get full OBHx and GyneHx (pap smear hx, pelvic infection hx, procedures done to cervix, endometriosis/PCOS?)  Timeline/severity of all sx  Sexual: partners, practices, protection from STDs, past history of STDs, prevention from pregnancy  GI/GU: pelvic pain, urinary pain, vaginal pain, dyspareunia, ask about colour/amount/smell/blood, re: discharge  Consider: recent Abx use, pregnancy, OCP, immunosuppression, DM, vaginal douching (CANDIDIASIS), semen, drugs, chemicals

Question 93

Physical exam for vulvovaginitis?

Answer 93

Check for pruritis, burning, foul-smelling discharge, change in amount/consistency/colour, check abdo Ensure that you are doing a speculum and bimanual exam (to r/o ascending infection (PID)); assess discharge/pooling, assess cervix, tenderness, or signs of blood - smell?

Question 94

Signs/symptoms of reactive arthritis/syphillis?

Answer 94

Inspect eyes for conjunctivitis, uveitis, rash, mucosal ulcerations (syphilis)

Question 95

Signs/symptoms of candida vaginitis?

Answer 95

Itch + burn + white/curdy discharge + PLENTY of mucosal erythema + wet mount findings of hyphae KOH

Question 96

Signs/symptoms of bacterial vaginosis?

Answer 96

Fishy odour + gray discharge + NO mucosal erythema, CLUE CELL

Question 97

Signs/symptoms of trichomonas vaginitis?

Answer 97

Dyspareunia/dysuria, green and frothy discharge, pH 5-6, + variable erythema, wet mount finding of trich

Question 98

DDx for vulvovaginitis?

Answer 98

Infective/chemical/atrophic vaginitis (50+), cervicitis (STIs), malignancy, PID, foreign body, disrupted vag flora (BV)

Question 99

Workup for vulvovaginitis?

Answer 99

Serology (syphilis, HIV) + pH + Wet Mount + Whiff Test + Endocervical/Vag/Urethral Swab (HSV PCR + Syphilis PCR + Trich/BV/Yeast (+/- G&C)) + Urinalysis (NAAT first catch, culture/sensitivity for gonorrhea/chlamydia) + Biopsy

Question 100

What is bacterial vaginosis?

Answer 100

Overgrowth of Gardnerella vaginalis

Question 101

Treatment of bacterial vaginosis?

Answer 101

Metronidazole PO (500mg BID x 7d) or clindamycin (300mg PO BID x 7d) or topical

Question 102

Treatment of candida vaginitis?

Answer 102

Fluconazole PO (150mg) (watch liver) or OTC imidazole or polyene antifungals (1d - 7d doses)

Question 103

Treatment of gonorrhea and chlamydia?

Answer 103

G (Cefixime 800mg PO single dose + Azithromycin 1g PO, 1 dose), C (Azithromycin 1g PO, 1 dose)

Question 104

Treatment of trichomonas vaginitis?

Answer 104

``` metronidazole PO (2g x 1d) or topical metro/clotrimazole (BID x 5d) o TREAT SEXUAL PARTNER TOO + REPORT ```

Question 105

What are the notifiable STIs?

Answer 105

G / C / S / Chancroid / HIV / Trich / LGV / MPC / Granuloma Inguinale

Question 106

Treatment for HPV genital warts?

Answer 106

Patient applied (imiquimod cream) or provider applied (liquid nitrogen, several visits)

Question 107

MOA of progestin in hormonal contraception?

Answer 107

Progestin: prevents LH surge, suppresses ovulation, thickens cervical mucus, decreases tubal motility, decidualizes endometrium

Question 108

MOA of estrogen in hormonal contraception?

Answer 108

Estrogen: suppresses FSH and follicular development, causes endometrial proliferation

Question 109

Explain the feedback regulation of E2/progesterone on LH/FSH?

Answer 109

Feedback Regulation: E2/progesterone have positive feedback action on LH/FSH (unless E2 is there for a long time alone, then it can convert to positive feedback as it does in the menstrual cycle. Thus, a combination pill avoids positive feedback that leads to ovulation.

Question 110

What do combined oral contraceptive pills contain?

Answer 110

Most contain low dose ethinyl estradiol plus progestin

Question 111

What is the failure rate of OCPs?

Answer 111

Failure rate (0.3% to 8%) depending on compliance

Question 112

What do transdermal contraceptive patches contain?

Answer 112

Continuous release of 6mg norelgestrominn and 0.60mg ethinyl estradiol into bloodstream

Question 113

Where should you avoid placing the transdermal patch?

Answer 113

Can be placed on the buttocks, upper outer arms, lower abdomen, or upper torso (but not the breast)

Question 114

How often are transdermal patches changed?

Answer 114

Worn for 3 consecutive weeks (changed every wk) with 1wk off to allow for menstruation

Question 115

A population where transdermal patches may not be as effective?

Answer 115

Maybe less effective in women >90kg

Question 116

What is the failure rate of transdermal patches?

Answer 116

As effective as OCP in preventing pregnancy (>99% with perfect use)

Question 117

What is a contraceptive ring (Nuva Ring)?

Answer 117

Thin flexible plastic ring; releases etonogestrel and estradiol, works for 3wk then removed for 1wk to allow for menstruation

Question 118

What is the failure rate of the contraceptive ring?

Answer 118

As effective as OCP in preventing pregnancy (98%)

Question 119

Specific side effects of contraceptive ring?

Answer 119

Side effects: vaginal infections/irritation, vaginal discharge

Question 120

Before prescribing a hormonal contraceptive, what should you do, when should you see them in follow-up?

Answer 120

 Thorough history and physical exam, including blood pressure and breast exam  Can start at any time during cycle but ideal if within 5d of LMP  Follow-up visit 6wk after hormonal contraceptives prescribed  Pelvic exam not required as STI screening can be done by urine and pap smear screening does not start until >21 yr

Question 121

List advantages of combined estrogen and progestin methods

Answer 121

 Highly effective, does not interfere with intercourse  Reversible  Cycle regulation  Decreased dysmenorrhea and heavy menstrual bleeding (less anemia)  Decreased benign breast disease and ovarian cyst development  Decreased risk of ovarian and endometrial cancer Increased cervical mucus which may lower risk of STIs Decreased PMS symptoms  Improved acne  Osteoporosis protection (possibly)

Question 122

What are the estrogen-related side effects of hormonal contraceptives?

Answer 122

Estrogen-related: Nausea, Breast changes (tenderness, enlargement), Fluid retention/bloating/edema, Weight gain (rare), Migraine, headaches, Thromboembolic events, Liver adenoma (rare), Breakthrough bleeding (low estradiol levels) - Irregular breakthrough bleeding often occurs in the first few months after starting OCP; usually resolves after three cycles

Question 123

What are the progestin-related side effects of hormonal contraceptives?

Answer 123

Progestin-related: Amenorrhea/breakthrough bleeding, Headaches, Breast tenderness, Increased appetite, Decreased libido, Mood changes, HTN, Acne/oily skin* Hirsutism*

Question 124

What are the absolute contraindications for hormonal contraceptives?

Answer 124

- < 6 weeks post -partum & Breastfeeding (decreases milk production) - Smoker > 35 (> 15 cigarettes/day) - Hypertension (>160 />100) - Current/Past VTE - Ischemic Heart Disease - History of cerebrovascular accident - Migraine with focal neurological symptoms (risk of stroke) - Severe cirrhosis - Liver tumour (adenoma or hepatoma) - Breast cancer (current) - Diabetes with complications – neuropathy, nephropathy, retinopathy

Question 125

What are the relative contraindications for hormonal contraceptives?

Answer 125

- Smoker > 35 yr (<15 cigs/day - Controlled HTN, HPT (150 - 159/ 90 - 99) - Migraine over age 35 years old - Symptomatic GB disease (estrogen increases likelihood of stones) - Mild cirrhosis - History of OC-related cholestasis - Use of meds that interfere with OCP metabolism

Question 126

What are the drug Interactions/risks of hormonal contraceptives?

Answer 126

Rifampin, phenobarbital, phenytoin, griseofulvin, primidone, and St. John’s wort can decrease efficacy, requiring use of back-up method

Question 127

What are the indications for using a progestin-only method of contraception?

Answer 127

Indications: Suitable for postpartum women (does not affect breast milk supply), Women with contraindications to combined OCP (e.g. thromboembolic or myocardial disease), Women intolerant of estrogenic side effects of combined OCPs

Question 128

What does the progestin-only pill ("minipill") rely on for contraception

Answer 128

Relies on the progestin effects on the cervical mucous and endometrial lining

Question 129

To ensure reliable effect, what must you do with the progestin-only method?

Answer 129

Must be taken daily at same time of day to ensure reliable effect; no pill free interval

Question 130

The progestin-only method is highly effective for whom?

Answer 130

Highly effective if also post-partum breastfeeding, or if >35yr and smoke

Question 131

What is the failure rate of the progestin-only pill ("minipill")?

Answer 131

Higher failure rate (1.1-13% with typical use, 0.51% with perfect use) than other hormonal methods

Question 132

How often is ovulation inhibited by the progestin-only pill ("minipill")?

Answer 132

Ovulation inhibited only in 60% of women; most have regular cycles (but may cause oligo/amenorrhea)

Question 133

What is Depo-Provera?

Answer 133

Injectable depot medroxyprogesterone acetate given by a health-care professional in the upper arm or buttocks every 12 to 13 weeks (four times a year)

Question 134

When should you start Depo-Provera?

Answer 134

Initiate ideally within 5d of beginning of normal menses, immediately postpartum in breastfeeding and non-breastfeeding women. Can consider quick start

Question 135

What is the failure rate of Depo-Provera?

Answer 135

Highly effective 99%; failure rate 0.3%

Question 136

What is a disadvantage about Depo-Provera?

Answer 136

Disadvantage: restoration of fertility may take up to 9mo

Question 137

Specific side effect of Depo-Provera?

Answer 137

Side effect: decreased bone density (may be reversible) and weight gain

Question 138

Side effects of the progestin-only methods

Answer 138

Side effects: Irregular menstrual bleeding, Weight gain, Headache, Breast tenderness, Mood changes, Functional ovarian cysts, Acne/oily skin, Hirsutism

Question 139

What percentage of women have amenorrhea after 1-2 yrs use of Depo-Provera?

Answer 139

Irregular spotting progresses to complete amenorrhea in 70% of women (after 1-2yr of use)

Question 140

How long should the diaphragm and cervical cap remain in the vagina after intercourse?

Answer 140

Must be left in the vagina for 6 to 8 hours after intercourse. Spermicide should be reapplied in the vagina for each repeated act of intercourse (optional for the cervical cap)

Question 141

Disadvantage of the diaphragm and cervical cap?

Answer 141

Disadvantages: Must be available at time of intercourse, The use of spermicide may cause irritation of the vaginal and rectal walls and increase the risks of contracting human immunodeficiency virus (HIV), Diaphragm may increase the risk of persistent UTI, Cervical cap should not be used during menstruation and may cause vaginal odour and discharge, Does not protect against certain STIs

Question 142

What is the failure rate of the female condom?

Answer 142

Typical Use – 79%, Perfect Use – 95%

Question 143

What are sponge and spermicides?

Answer 143

- The sponge is a soft, disposable, polyurethane foam device impregnated with a spermicide - Sponge - Fits over the cervix, Traps and absorbs sperm to augment effect of spermicide - Spermicides - Ingredient that impairs sperm, Should be used with another form of contraception

Question 144

What is the calendar method for contraception?

Answer 144

A woman tracks the days of her menstrual cycle on a calendar for several months, to identify her fertility period – the period when a woman is most likely to become pregnant after having unprotected sexual intercourse. Avoid day 10-18

Question 145

Failure rate of the withdrawal method

Answer 145

Typical Use – 73%, Perfect Use – 96%

Question 146

What are the 2 types of intrauterine devices?

Answer 146

o Copper-Containing IUD (Nova-T®) | o Progesterone-Releasing IUS (Mirena, Kyleena®, Jaydess®)

Question 147

How does the copper-containing IUD (Nova-T®) work?

Answer 147

Mild foreign body reaction in endometrium; toxic to sperm and alters sperm motility - A T-shaped device with a copper wire around it, inserted into uterus

Question 148

How does the progesterone-releasing IUS (Mirena, Kyleena®, Jaydess®) work and what do they contain?

Answer 148

Decidualization of endometrium and thickening of cervical mucus; minimal effect on ovulation - Contains a hormone called levonorgestrel (a progestin) that is released slowly over time

Question 149

How effective are IUDs?

Answer 149

Highly effective (99.8%); failure rate 0-1.2%

Question 150

How quickly does endometrial pattern return after IUD is removed?

Answer 150

Contraceptive effects last 5 yr Reversible, private, convenient - Endometrial pattern returns to normal in 24hrs once removed

Question 151

What are the side effects of both Copper and Progesterone IUD?

Answer 151

Both Copper and Progesterone IUD: Breakthrough bleeding, Expulsion (5% in the 1st yr, greatest in 1st mo and in nulliparous women), Uterine wall perforation (1/1000) on insertion, If pregnancy occurs with an IUD, increased risk of ectopic, Increased risk of PID (within first 10 d of insertion only)

Question 152

What are the side effects of Copper IUD?

Answer 152

Copper IUD: increased blood loss and duration of menses, dysmenorrhea

Question 153

What are the side effects of Progesterone IUD?

Answer 153

Progesterone IUD: bloating, headache

Question 154

Contraindications to IUDs?

Answer 154

```  Pregnancy (bHCG prior to insertion)  PID/STI ACTIVE  Abnormal cavity  Post septic abortion  Unexplained PV bleed  Uterine/Cervical CA  Copper allergy (copper IUD)  Breast cancer? – PR positive  Malignant GTN – increased perforation ```

Question 155

What is the expulsion rate of postplacental IUD?

Answer 155

 Expulsion rate is higher (24%)

Question 156

When should the Kyleena be used for?

Answer 156

Kyleena is used for nulliparious women - Great option for menorrhagia

Question 157

Time period for the use of Yuzpe method?

Answer 157

Efficacy decreased with time (e.g. less effective at 72 h than 24 h)

Question 158

What is the follow up for after emergency postcoital contraception?

Answer 158

3-4wk post treatment to confirm efficacy (confirmed by spontaneous menses or pregnancy test)

Question 159

What is the expulsion rate of postplacental IUD?

Answer 159

Expulsion rate is higher (24%)

Question 160

Side effects of the Yuzpe method?

Answer 160

Side Effects: Nausea (due to estrogen; treat with Gravol), Irregular spotting

Question 161

What is 1st line emergency postcoital contraception if <24 hrs?

Answer 161

Plan B

Question 162

What is Plan B?

Answer 162

Consists of levonorgestrel 750 μg q12h for 2 doses (can also take 2 doses together); taken within 72 h of intercourse. Can be taken up to 5d

Question 163

In whom is Plan B less effective?

Answer 163

Less effective in overweight individuals (>75 kg less effective, >80 kg not recommended)

Question 164

Side effect of Plan B

Answer 164

No estrogen thus very few contraindications/side effects (less nausea)

Question 165

What is the most effective emergency postcoital contraception up to 7 days?

Answer 165

Postcoital IUD (Copper)

Question 166

For permanent contraception in women, the fallopian tubes may be

Answer 166

● Cut and a segment is excised ● Closed by ligation, fulguration, or various mechanical devices (plastic bands or rings, spring-loaded clips) ● Completely removed

Question 167

Women who become pregnant after sterilization procedure are at increased risk of?

Answer 167

Ectopic pregnancy

Question 168

Complications in women having transcervical (hysteroscopic) procedures?

Answer 168

In women having transcervical (hysteroscopic) procedures, complications may include tubal perforation (in 1%-3% of women), improper coil placement (in 0.5%-3% of women), expulsion of occlusion device (in 0.4%-2.2% of women), nickel hypersensitivity (in 0.01% of women)

Question 169

Complications in women having laparoscopy procedures?

Answer 169

In women having laparoscopy, complications may include mortality (rare, ~0.01%), usually due to anesthesia-related complications, minor or major morbidity (in about 0.9%-1.6% overall).

Question 170

What is the reversibility of tubal ligation?

Answer 170

Reversibility: cannot reverse clipping due to scarring/ligation, but can reverse by excising clip scar. If whole tube taken out, cannot reverse.

Question 171

Effectiveness of tubal ligation?

Answer 171

Effectiveness: 10-year cumulative failure rate about 1.9% for abdominal tubal sterilization procedures, reported to have similar efficacy as long-acting reversible contraceptive methods but may have increased morbidity compared with IUD

Question 172

What is a vasectomy?

Answer 172

For this procedure, the vasa deferentia are cut, and the cut ends are ligated or fulgurated.

Question 173

How long does sterility take after a vasectomy?

Answer 173

Sterility requires about 20 ejaculations after the operation and should be documented by 2 sperm-free ejaculates, usually obtained 3 months after the operation. A back-up contraceptive method should be used until that time.

Question 174

Complications of vasectomy

Answer 174

● Hematoma (5%) ● Sperm granulomas (inflammatory responses to sperm leakage) - surgery may be needed to remove the granuloma ● Spontaneous reanastomosis, which usually occurs shortly after the procedure ● Inflammation of the epididymis tubes (congestive epididymitis)

Question 175

Reversibility of vasectomy

Answer 175

Reversibility: can reverse, but not after 10 years (reversal not covered)

Question 176

Effectiveness of vasectomy

Answer 176

Effectiveness: very effective (99.85%) birth control method. 1-2 women/1,000 ~ unplanned pregnancy in 1st year after partners have had a vasectomy.

Question 177

At what GA should a pregnant women be screened for diabetes?

Answer 177

Due to hCS being highest at 24-28 weeks

Question 178

Explain the 2 step screening process for GDM?

Answer 178

``` Step 1: Random non-fasting 50g OGTT o > 11.1 mmol/L is GDM o If 1hr PG 7.8-11.1 mmol/L, proceed to step 2 Step 2: fasting (8hrs) 75g OGTT GDM if >1 of: ▪ FPG > 5.3 mmol/L ▪ 1hr PG > 10.6 mmol/L ▪ 2hr PG > 9.0 mmol/L ```

Question 179

Risk Factors for GDM

Answer 179

Prior GDM, prior delivery of macrosomia infant, high risk population (aboriginal/Hispanic/SouthAsian/Asian/African), age >35, BMI >30, acanthosis nigricans, corticosteroid use.

Question 180

Post-partum screening for pregnant women with GDM?

Answer 180

Women with GDM should undergo screening at six to 12 weeks postpartum with a fasting glucose measurement or 75-g two-hour glucose tolerance test

Question 181

When should women with multiple risk factors be screened for GDM

Answer 181

Women with multiple risk factors should be screened for T2DM in T1 w/ A1C

Question 182

Management of GDM?

Answer 182

Chemstrips (F/PP), urine ketones, dietary counselling, exercise/increasing activity, insulin up to 4 times daily, oral hypoglycemic agents in pregnancy are generally not safe except glyburide (does NOT cross the placenta) and metformin (DOES cross placenta)

Question 183

Preconception counselling recommendations?

Answer 183

- Folic acid supplementation (400 mcg daily) to reduce the risk of neural tube defects. 8-12 wks pre-conception until end of T1 to prevent NTDs - Iron supplementation, prenatal vitamins - BMI – achieve a healthy body weight before becoming pregnant - DM – good glycemic control - Teratogenic medications - ACE inhibitors, Accutane, statins, warfarin. - Screen for STIs - Update hepatitis B; influenza; measles, mumps, rubella; Tdap; and varicella immunizations - Social: smoking, alcohol, drug use, domestic violence

Question 184

When should 5 mg folic acid be recommended?

Answer 184

0.4-1 mg daily in all women; 5 mg if previous NTD, antiepileptic medications, DM, or BMI >35 kg/m2, ethnic group (Celtic, Sikh, N Chinese)

Question 185

What is Naegle's rule?

Answer 185

1st day of LMP + 1 year + 7days - 3months

Question 186

Initial history for new pregnancy?

Answer 186

- Desirability of pregnancy - Symptoms of pregnancy - Obstetrical: any previous complications (GDM, GHTN, delivery related – PTL, PPROM, operative delivery, C/S, or neonatal related – IUGR, IUFD), GTPAL - Gyne: any abnormal paps? Any pelvic infections of any kind? Cervical procedures (Colpo/LEEP)? Endo/PCOS, etc.? - Social: smoking (~IUGR), alcohol (FASD/GDD), cocaine (abruption, IUGR, PTL), SES, IPV, domestic violence - Prescription and non-prescription medications - Family: genetics (aneuploidy/ONTD/AR), maternal (GDM/GHTN/Multips), or obstetric - Review of Systems: headache, vision changes, swelling of hands/face, nausea, vomiting, UTI’s, trauma, SOB, bowel/bladder function, weight loss, etc.

Question 187

Initial physical exam for new pregnancy?

Answer 187

- Measure BMI - BP, HR, HEENT, breast, RESP, CV, abdo, reflexes, varicosities, pelvic exam - Pap smear (only if required according to patient history and provincial screening guidelines)

Question 188

What are the symptoms of pregnancy?

Answer 188

Amenorrhea, breast tenderness, N/V, fatigue, urinary frequency, bleeding

Question 189

What is gravidity (G)?

Answer 189

Gravidity (G): total number of pregnancies of any gestation (multiple gestation = one pregnancy) – includes pregnancy, abortions, ectopics, and hydatidiform moles

Question 190

What is parity (TPAL)?

Answer 190

Parity (TPAL): T is the number of term infants delivered (>37wk), P is number of premature infants delivered, (20-36+6wk), A is number of abortions (loss of intrauterine pregnancy prior to viability of fetus <20wk and/or <500g fetal weight) – induced (therapeutic or spontaneous (miscarriage), L is number of living children

Question 191

Initial investigations for new pregnancy?

Answer 191

1. Blood work - CBC (esp Hb and platelets, remember you can have physiologic anemia) - Blood group and Rh status + antibody screen (Rh/D – would be eligible for IgG for Rh even in 1st pregnancy!!!) Given at 28 weeks 2. Screening for STIs - HIV - Syphilis screening (Syphilis during pregnancy) - Hepatitis B surface antigen testing - Hepatitis C screening (Anti-HCV antibody testing) - Gonorrhea/Chlamydia testing 3. Cystic fibrosis screening recommended for 4. Glucose/HA1c 5. TSH 6. Urine dipstick protein testing: screening for proteinuria (baseline value is vital for comparison with results in later pregnancy to rule out preeclampsia); performed during every prenatal visit 7. Urine culture: screening for asymptomatic bacteriuria 8. Rubella and varicella antibody

Question 192

Categories of teratogens?

Answer 192

- A (controlled studies show no risk) - B (adverse in animals, but no risk in humans) - C (adverse in animal, unknown risk in humans) - D (evidence of risk in human, rare situations benefits > risk) - E (toxic, contraindicated)

Question 193

Complications of smoking during pregnancy?

Answer 193

Lower fertility, spontaneous abortion, preterm birth, placental insufficiency, placental abruption, ectopic pregnancy, SIDS, PPROM, low birth weight

Question 194

Complications of using cocaine during pregnancy?

Answer 194

Classic association with placenta abruption, low birth weight, prematurity, microcephaly, miscarriage

Question 195

Should you use NSAIDs or Tylenol during pregnancy?

Answer 195

CONTRAINDICATED - switch to Tylenol! Inhibit COX-1 and COX-2, which convert arachidonic acid into prostaglandins. risk of early closure of ductus arteriosus

Question 196

Which antibiotics are contraindicated in pregnancy?

Answer 196

Generally penicillin, cephalosporins, macrolides, azithromycin, erythromycin, clarithromycin, clindamycin (if penicillin allergic) are fine – but NOT metronidazole/sulfonamide (inhibits DNA synthesis), streomycin/gentamycin/kanamycin (ototoxicity/deafness), and tetracycline (bone/teeth staining)

Question 197

Counselling of the pregnant woman - nutrition?

Answer 197

- Calcium: 3-4 servings of milk products daily (greater if multiple gestation). 1200-1500 mg/d - Vitamin D: 1,000 IU - promotes calcium absorption - Iron: 0.8 mg/d in T1, 4-5 mg/d in T2, and >6 mg/d in T3 - supports maternal increase in blood cell mass, supports fetal and placental tissue; required amounts exceed normal body stores and typical intake, and therefore need supplemental iron - iron is the only known nutrient for which requirements during pregnancy cannot be met by diet - Essential Fatty Acids: supports fetal neural and visual development - contained in vegetable oils, margarines, peanuts, fatty fish - Daily caloric increase of ~100cal/d in the first trimester, and ~300cal/d in second/third, ~450cal/d in lactation

Question 198

Counselling of the pregnant woman - caffeine?

Answer 198

Diuretic and stimulant that readily crosses placenta – less than 300mg/d is not thought to contribute to miscarriage or preterm birth (ACOG) – relationship with IUGR is unknown; SOGC states 1-2cups/d are safe

Question 199

Counselling of the pregnant woman - food borne illnesses?

Answer 199

1. Listeriosis (Listeria monocytogenes) and toxoplasmosis (Toxoplasma gondii) concerning during pregnancy - Avoid consumption of raw meats, fish, shellfish poultry, hotdogs, raw eggs, unpasteurized dairy products - Avoid unpasteurized soft cheeses, deli meats, smoked salmon, and pates ~ potential sources of Listeria 2. Fish: limit consumption of top predator fish such as shark, swordfish, king mackerel, tilefish

Question 200

Counselling of the pregnant woman - exercise?

Answer 200

‘talk test’ – should be able to speak while exercising, avoid supine position after 20 weeks GA, should be low risk trauma sports

Question 201

Absolute contraindications of exercise in the pregnant woman?

Answer 201

Ruptured membranes, preterm labour, HTN disorders of pregnancy, incompetent cervix, IUGR, multiple gestation (>3)

Question 202

Counselling of the pregnant woman - optimal weight gain?

Answer 202

BMI 18-24.9: 25-35 pound weight gain normal BMI 25-29.9: 15-25 pound weight gain normal BMI >30: 15 pound weight gain normal

Question 203

Counselling of the pregnant woman - work?

Answer 203

Strenuous work, extended hours and shift work during pregnancy may be associated with greater risk of LBW, prematurity, and spontaneous abortion

Question 204

Counselling of the pregnant woman - air travel?

Answer 204

Is acceptable in second trimester, airline cut off for travel is 36-38 week gestation depending on airline, to avoid giving birth on the plane

Question 205

Counselling of the pregnant woman - sexual intercourse?

Answer 205

May continue, except in patients at risk for abortion, preterm labour, or previa – breast stimulation may induce uterine activity and is discouraged in high-risk patients near term

Question 206

Counselling of the pregnant woman - alcohol?

Answer 206

No amount of alcohol is safe in pregnancy, encourage abstinence from EtOH during pregnancy – increases risk of abortion, stillbirth, and congenital anomalies – fetal alcohol syndrome

Question 207

When is the dating ultrasound preformed?

Answer 207

7-13w

Question 208

What does the first trimester screening consist of?

Answer 208

Ultrasound (Nuchal Translucency) | PAPP-A + bHCG

Question 209

When is the first trimester screening performed?

Answer 209

11-13+6w

Question 210

What does the first trimester screen for?

Answer 210

Tri-21 + Tri-18 + Tri-13

Question 211

What is an abnormal amount of nuchal translucency and what is it suggestive of?

Answer 211

>3mm ~ congenital defects, aneuploidy, warrants further imaging (sees fluid at back of neck + nasal bone)

Question 212

First trimester invasive prenatal testing for extra/missing chromosomes

Answer 212

Chorionic Villi Sampling (11-13+6)

Question 213

When can NIPT be offered?

Answer 213

Offer beyond 10 weeks if (+). Accurate at detecting Down Syndrome, Turners, T18, T13

Question 214

What does the second trimester screening consist of?

Answer 214

AFP Maternal Serum Quad Screen (E2 + HCG + Inhibin A + AFP)

Question 215

When is the 2nd trimester screening performed?

Answer 215

15-20+6w

Question 216

If FTS is done, just add ___ to test for neural tube defects.

Answer 216

AFP

Question 217

When is the anatomic ultrasound preformed?

Answer 217

18-20w

Question 218

What does the 2nd trimester screen for?

Answer 218

Tri-21 + 18 + Neural Tube Defects + Spina bifida

Question 219

2nd trimester prenatal invasive testing for extra/missing chromosomes

Answer 219

Amniocentesis (16+)

Question 220

Indications for invasive testing?

Answer 220

- Age >40 - (+)FTS or Quad - Abnormal U/S (IUGR, soft mark’r, etc) - FHx or previous child w/ chromo abn

Question 221

Risk factors of post-partum depression?

Answer 221

PHx or FHx of depression (incl. PPD), prenatal dep/anxiety, stressful life situation, poor support system, unwanted pregnancy, colicky or sick infant

Question 222

What is post-partum depression?

Answer 222

Major depression occurring within 6 months of childbirth

Question 223

Symptoms of post-partum depression?

Answer 223

If blues last beyond 2 weeks, or severe symptoms in those 2 weeks (extreme disinterest in baby, suicidal/homicidal/infanticidal ideation) – use Edinburgh Postnatal Depression Scale

Question 224

Treatment of post-partum depression?

Answer 224

Antidepressants, psychotherapy, supportive care, ECT if refractory

Question 225

Cardiovascular changes during pregnancy?

Answer 225

- Increase blood/plasma volume by 40-50% - Increase CO (HR and SV) + RBC by 30-40% - BP decreases usually overall due to lower TPR, decreased response to vasopressors

Question 226

Respiratory changes during pregnancy?

Answer 226

- Progesterone increases medullary respiratory center sensitivity to CO2 = hyperventilation for more O2 to baby (normal!) = blow off more CO2 and the kidneys respond by lowering HCO3 = compensated respiratory alkalosis - Increased O2 consumption - Enlarged abdominal mass can affect breathing/diaphragm

Question 227

MSK/Derm changes during pregnancy?

Answer 227

- Increase BMI (10-15kg) - Stretch marks - Low back pain - Lordosis - Carpal tunnel syndrome - Sciatica - Increase skin pigmentation

Question 228

Gynaecological changes during pregnancy?

Answer 228

- Breast enlargement - Areolar pigmentation - Uterine hypertrophy and stretching (increases 10x) - Cervical gland hypertrophy (thick mucous plug) - Vagina – lactobacilli proliferation. Increase lactic acid – decreases pH

Question 229

Renal changes during pregnancy?

Answer 229

- Increased GFR (due to more blood, higher renal blood flow, no change to filtration fraction) - Glucosuria (secondary to increased GFR, normal but could be gestational diabetes too) - Increased vasopressor (RAAS) activity, but decreased vasopressor responsiveness

Question 230

Hematological changes during pregnancy?

Answer 230

- Increased RBC mass - Increased WBC count - Increased iron needs (50-60 elemental Fe daily, 1000mg overall) - Increased clotting (estrogen stimulates protein synthesis (clotting factors but NOT platelets) - 2/3 of Virchow’s triad – stasis, hypercoagulability

Question 231

Gastrointestinal changes during pregnancy?

Answer 231

- Decreased GI smooth muscle activity - Nausea/vomiting, GERD common (take ranitidine – Zantac) - Increased glucose tolerance (check at 24-28weeks due to high HCS at that point) - Weight gain (usually 2-4kg (4.5-8lbs) in first 20 weeks, then 0.5kg (~1lb) per week)

Question 232

How often should a pregnant women be seen during the pregnancy?

Answer 232

For uncomplicated pregnancies, SOGC recommends q4-6wk until 30wk, q2-3wk from 30wk, and q1-2wk from 36wk until delivery

Question 233

What should be asked in history for subsequent prenatal visits?

Answer 233

Fetal movements: Notice first movement (“quickening”) at 18-20 weeks in primigravidas and ~1-2 weeks earlier in; if the patient is concerned about decreased fetal movement, counsel them to choose a time when the fetus is normally active to count movements (usually recommended after 26 wk) Uterine bleeding: LMP? Which trimester is it? Cramping? Colour of blood? Clots/tissue? Painless or painful? Leaking, cramping (contractions), questions, concerns

Question 234

What should be done on physical exam for subsequent prenatal visits?

Answer 234

- Weight monitoring: to avoid fetal developmental problems (if weight gain is less than the recommended amount), fetal macrosomia, or maternal obesity (if weight gain is above normal) - Blood pressure monitoring: early detection of pregnancy-induced hypertension - SFH – pubic symphysis to uterine fundus. GA 20-40 wks - Fetal position (starting 28-32 wks): Leopold’s maneuvers for lie, position, and presentation of fetus - Determine FHR (starting at 12 wks) using Doppler US. Normal between 120-160 - Cervical exam at 37 weeks in case require IOL

Question 235

Most common symptoms of all 3 trimesters?

Answer 235

Urinary frequency + fatigue + poor sleep + back pain

Question 236

Investigations for subsequent prenatal visits?

Answer 236

- Urine dipstick for glucosuria and proteinuria in high risk women - Fetal heart rate starting at 10-12 wk using Doppler U/S - Prenatal screening for Group B streptococcus performed between 36 0/7 and 37 6/7 weeks of gestation (vaginal and rectal swab for culture and gram staining) because colonization by this bacteria may cause chorioamnionitis and neonatal infection. Treated w/ Pen G IV - Repeat Hb from the 24th week of pregnancy. - 50-g, one-hour oral glucose challenge test (initial screening) at 24-28 weeks gestation - Repeat rhesus screening: An unsensitized Rh(D)-negative women should receive anti(D)-immune globulin. Protective for 12 weeks only so may need another dose, also give for any other risk of maternal/fetal blood contact

Question 237

Management if GBS positive at delivery?

Answer 237

5mU Pen-G IV bolus, then 2.5 mU Pen-G IV q4h until delivery

Question 238

What is the test done if the 1 hr OGTT is positive?

Answer 238

100-g, three-hour oral glucose tolerance test (oGTT) to confirm diagnosis in case of positive initial screening

Question 239

What should you counsel pregnant women regarding fetal movement?

Answer 239

- If there is a subjective decrease in fetal movement, try drinking juice, eating, changing position, or moving to a quiet room and count for 2 h; ≥6 movements in 2 h expected - If there are <6 movement counts in 2 h, patient should present to labour and delivery triage

Question 240

When is the movement first noticed in pregnancy?

Answer 240

Notice first movement (“quickening”) at 18-20 weeks in primigravidas and can be 1-2 weeks earlier in multigravidas – can occur 1-2 weeks later if placenta is implanted on the anterior wall of the uterus

Question 241

DDx of decreased fetal movements?

Answer 241

DASH: - Death of fetus - Amniotic fluid decreased - Sleep cycle of fetus - Hunger/thirst

Question 242

What are the components of the biophysical profile?

Answer 242

- Limb extension + flexion = tone - AFV 2cm + 2cm – fluid pocket, most important - Movement (3 discrete) - Breathing (one episode x 30s) – usually not until 32 weeks

Question 243

Indications for biophysical profile

Answer 243

Post-term pregnancy, decreased fetal movement, IUGR, any other signs of fetal distress or uteroplacental insufficiency

Question 244

Indications for NST?

Answer 244

Run these if suggestion of uteroplacental insufficiency or suspected compromise in fetal well-being

Question 245

Normal NST findings?

Answer 245

Baseline: 110-160 bpm Variability: Moderate or Absent/Minimal (<40m) Decelerations: None / Occasional UV <30s Accelerations: 2, =>15bpm of >15s in <40m (>32w) 2, =>10bpm of >10s in <40m (<32w)

Question 246

Atypical NST findings?

Answer 246

Baseline: <110 or >160 for <30m, rising baseline Variability: Absent/Minimal (40-80m) Decelerations: UV 30-60s Accelerations: 2, =>15bpm of >15s in 40-80m (>32w) 2, =>10bpm of >10s in 40-80m (<32w)

Question 247

Abnormal NST findings?

Answer 247

Baseline: <110 or >160 for >30m, erratic baseline Variability: Absent/Minimal (>80m), Marked (>10m) Decelerations: UV >60s or Late Accelerations: 2, =>15bpm of >15s in >80m (>32w) 2, =>10bpm of >10s in >80m (<32w)

Question 248

What is menorrhagia?

Answer 248

Menses that are excessive (>80 mL) or prolonged (> 7 days)

Question 249

Bleeding that is unrelated to menses, occurring irregularly between

Answer 249

Metrorrhagia

Question 250

Bleeding that is excessive during menses and occurs irregularly between menses

Answer 250

Menometrorrhagia

Question 251

Etiology of excessive/irregular/abnormal vaginal bleeding?

Answer 251

PALM COEIN - Polyp: endometrial or cervical polyps - hyperplastic overgrowths of endometrial glands and stroma - Adenomyosis: painful, endometrial glands/stroma present in uterine musculature - Leiomyoma: fibroids, benign smooth muscle (or submucoasal) tumors. - Malignancy: endometrial adenocarcinoma - Coagulopathy: vWF most common or therapeutic anti-coagulation - heavy menstrual bleeding since menarche - Ovulatory Dysfunction: endocrine disorders preventing ovulation, causing deviation from normal cycle (PCOS, hypothyroidism, hyperprolactinemia, anorexia, cirrhosis) - Iatrogenic: Platelet arterial clots – Clopidogrel, ASA, NSAIDs. Venous factor thrombus – Warfarin, NOAC, warfarin Equipment – Cu-IUD - Not Yet Classified: causes of AUB that are not well-understood or not yet described

Question 252

Most common neoplasm in women with reproductive age.

Answer 252

Leiomyoma

Question 253

History for excessive/irregular/abnormal vaginal bleeding?

Answer 253

- History of present illness should include quantity (eg, by number of pads used per day or hour) and duration of bleeding, as well as the relationship of bleeding to menses and intercourse - Menstrual history, including date of last normal menstrual period, age at menarche and menopause (when appropriate), cycle length and regularity, and quantity and duration of typical menstrual bleeding - Previous episodes of abnormal bleeding, including frequency, duration, quantity, and pattern (cyclicity) of bleeding - Sexual history, including possible history of rape or sexual assault - ROS: - Missed menses, breast swelling, and nausea: Pregnancy-related bleeding - Abdominal pain, light-headedness, and syncope: Ectopic pregnancy or ruptured ovarian cyst - Chronic pain and weight loss: Cancer - Easy bruising and excessive bleeding due to toothbrushing, minor lacerations, or venipuncture: A bleeding disorder

Question 254

Physical exam findings for excessive/irregular/abnormal vaginal bleeding?

Answer 254

- Vital signs, BMI, thyroid exam, skin (pallor, bruising, petechiae, hirsutism, acanthosis nigricans), abdo exam (masses, distension) - Gynecologic examination is done unless abdominal examination suggests a late-stage pregnancy; then, digital pelvic examination is contraindicated until placental position is determined. In all other cases, speculum examination helps identify lesions of the urethra, vagina, and cervix. Bimanual examination is done to evaluate uterine size and ovarian enlargement.

Question 255

Red flags for excessive/irregular/abnormal vaginal bleeding?

Answer 255

- Hemorrhagic shock (tachycardia, hypotension) - Premenarchal and postmenopausal vaginal bleeding - Vaginal bleeding in pregnant patients - Excessive bleeding - In children, difficulty walking or sitting; bruises or tears around the genitals, anus, or mouth; and/or vaginal discharge or pruritus

Question 256

Investigations for excessive/irregular/abnormal vaginal bleeding?

Answer 256

- Heme: CBC, TSH, prolactin, vWF, PT and PTT - Urine: chlamydia, gonorrhea, pregnancy test - Imaging: pelvic U/S or MRI, saline-infusion sonohysterogram (polyps) and in other scenarios (fertility workup)

Question 257

Indications for endometrial biopsy?

Answer 257

Indications include age >35, risk factors (obese, PCOS, HNPCC), significant intermenstrual bleeding, post-menopausal bleeding, endometrial thickening > 4 mm

Question 258

Contraindications for combined hormonal contraceptives

Answer 258

Smoking > 35yo (15 cig/day), multiple risk factors for arterial cardiovascular disease (^age, smoking, DM, HTN), HTN (sBP>160 or dBP>100), venous thromboembolism, known thrombogenic mutations, known ischemic heart disease, Hx of stroke, complicated valvular heart disease, systemic lupus erythematosus, migraine with aura at any age, breast cancer, cirrhosis, hepatocellular adenoma or hepatoma

Question 259

Medical management of excessive/irregular/abnormal vaginal bleeding?

Answer 259

- NSAIDS: reduce PGs, promoting uterine vasoconstriction - Tranexamic Acid: anti-fibrinolytic; caution w/ risk for venous thromboemboli - Combined Hormonal Contraceptives: ESTROGEN/progesterone (pill, patch, ring), continuous, etc - IUD - Gonadotropin release hormone agonists

Question 260

Side effects of combined hormonal contraceptives?

Answer 260

Side effects: nausea, breast tenderness, bloating, spotting (break-through-bleeding)

Question 261

Side effects of progesterone only contraceptive?

Answer 261

Spotting, breast tenderness, bloating, weight gain, nausea.

Question 262

Surgical management of excessive/irregular/abnormal vaginal bleeding?

Answer 262

- Endometrial Ablation | - Hysterectomy

Question 263

Symptoms of uterine leiomyomas?

Answer 263

Majority asymptomatic. Heavy or prolonged menstrual bleeding (AUB), bulk-related symptoms (pelvic pressure, pain), and/or reproductive dysfunction (i.e. infertility or obstetric complications)

Question 264

Where do uterine leiomyomas typically arise from and how are they described?

Answer 264

Benign monoclonal tumors arising from the smooth muscle cells of the myometrium. Fibroids are typically described according to their location in the uterus (submucosal, intramural, subserosal, cervical).

Question 265

Diagnosis of uterine leiomyomas?

Answer 265

Clinical, based on pelvic imaging – likely a pelvic or trans-vaginal U/S (indications include pelvic pain/pressure/infertility or enlarged uterus on pelvic examination). Pathology confirmation not required to proceed with management, except in cases if another lesion suspected (i.e. uterine sarcoma). Saline Infusion Sonography (sonohysterography) improves characterization of protrusion extent/intracavitary lesions not seen on U/S.

Question 266

Medical management of uterine leiomyomas?

Answer 266

- NSAIDs + OCP/depo-provera - Selective Progesterone Receptor Modulators: ulipristal (Ella), will shrink fibroids (~20% smaller volume at 3 months) and decrease menstrual blood loss (90% reduction). Only approved for short duration (3-6 months). Can be useful pre-operatively. Smaller fibroids = easier surgery. Increased iron stores, hemoglobin.

Question 267

Surgical management of uterine leiomyomas?

Answer 267

Myomectomy: hysteroscopic, laparoscopic, abdominal or Uterine Artery Embolization

Question 268

What is adenomyosis?

Answer 268

Ectopic endometrial glands and stroma are found within the myometrium, resulting in a symmetrically enlarged and globular uterus.

Question 269

Presentation of adenomyosis?

Answer 269

Parous women in their 40’s to 50’s, uterus enlarged and boggy, pelvic pain (usually noncyclical), dysmenorrhea, and menorrhagia.

Question 270

Investigations for adenomyosis?

Answer 270

Transvaginal U/S or MRI to differentiate between adenomyosis and uterine fibroids

Question 271

Management of adenomyosis?

Answer 271

- No proven medical therapy for treatment. - GnRH agonist, NSAIDs, and OCPs may be used for pain and bleeding. - Hysterectomy: Definitive therapy if childbearing is complete. The diagnosis is usually confirmed after histologic examination of the hysterectomy specimen.

Question 272

Most common gyne malignancy?

Answer 272

Endometrial cancer

Question 273

Types of endometrial cancer?

Answer 273

- Type I (endometroid adenocarcinoma): MOST COMMON (75%). Estrogen-related. Slower growing, related to obesity. Comes from thinning of the uterus - Type II (nonendometroid carcinoma): non-estrogen related. MORE AGGRESSIVE. Thin patient - * can have hyperplasia with atypia (precursor for endometrial cancer, 40% have concurrent cancer).

Question 274

Risk factors for endometrial cancer?

Answer 274

- Metabolic syndrome (obesity, type II DM) - adipose tissue makes more estrogen than normal - Early menarche, Late menopause - PCOS - Nulliparity - Estrogen-only HRT - Lynch syndrome – FHx history of colon cancer - Personal history with breast cancer - Tamoxifen – estrogen-like effects on uterine tissue.

Question 275

Presentation/symptoms of endometrial cancer?

Answer 275

Abnormal vaginal bleeding either postmenopausally, abnormally heavy irregular bleeding in reproductive years. Later stages pelvic pain and palpable mass.

Question 276

Diagnosis of endometrial cancer?

Answer 276

- NEED TO SAMPLE/BIOPSY ENDOMETRIAL TISSUE. How? No anesthetic, go through cervix and get a quick biopsy through a pipelle (aspiration curettage). If negative biopsy and AUB persists, need D&C or hysteroscopy! Hysteroscopic view – look at lining of uterus, if its fluffy and thick – not normal. DON”T DO BIOPSY IN PREGNANT WOMEN - Can do a transvag U/S – but this is not diagnostic, just suggestive! Wall thickness in postmenopausal women <5mm = low risk, >10mm = high risk. - CXR/CT scan to rule out mets

Question 277

Surgical treatment for endometrial cancer?

Answer 277

Standard of care, early stage is hysterectomy, BSO (bilateral salpingo-oophorectomy) and staging - Traditional open laparotomy – longer recovery, more pain, risk of infection - MIS (lap) - shorter recovery, less bleeding, infection and post op pain - Lymph Nodes – helps determine spread of disease, upstages patients - ICG Infared Technology - Inject the tumour with ICG and it follows the lymphatics to the first/sentinel lymph node. Taking out sentinel nodes and not all their pelvic nodes decreases lymphedema

Question 278

Medical treatment for endometrial cancer?

Answer 278

Unfit for surgery – mirena IUD, oral high dose progesterone, letrozole (aromatase inhibitor)

Question 279

Radiation treatment for endometrial cancer?

Answer 279

Two types – vaginal vault or full pelvic RT. Decreases risk of recurrence in pelvis or vaginal vault. DOES NOT REDUCE RISK OF DISTANT RECURRENCE.

Question 280

Which syndrome is associated with endometrial cancer?

Answer 280

Lynch syndrome – includes higher incidence of colon cancer and some ovarian cancer

Question 281

Acute and chronic S/E of pelvic RT?

Answer 281

- Acute – fatigue, rashes, nausea | - Chronic – looser stools, radiation cystitis/hematuria, altered sexuality

Question 282

Indications for offering hormonal therapy for endometrial cancer?

Answer 282

- Medically and surgically unfit for OR. Frail elderly, too many surgical risks - Grade 1 – wanting to preserve fertility. Standard of care still TAH BSO. Do TAH BSO after childbearing finished - If counseled, compliant in follow up, understand risks, 6-12 month trial high dose progesterone - Need to follow, re sample endometrial biopsy

Question 283

Symptoms of ovarian cancer?

Answer 283

Symptoms: nonspecific symptoms – bloating, pain, bowel changes - U/S – ascites, large mass

Question 284

Treatment of ovarian cancer?

Answer 284

- If we can’t debulk, start chemo – one of the best solid tumors to see a response to. - Bevacizumab is ab against VEGF and is used commonly for bowel cancer. - Surgery might be an option after several rounds. - We offer all women with high grade serous cancer a BRCA1/2 test. - Olaparib may actually improve overall survival - biggest thing to happen in the last 30 years for women with these mutations

Question 285

Definition of preterm labour?

Answer 285

Regular painful contractions accompanied by cervical dilatation/effacement between 20-37wks.

Question 286

Etiology of preterm labour?

Answer 286

- Idiopathic (most common) - Maternal: infection (recurrent pyelonephritis, untreated bacteriuria, chorioamnionitis), HTN, DM, chronic illness, mechanical factors (previous obstetric, gynecological, and abdominal surgeries); socio-environmental (poor nutrition, smoking, drugs, alcohol, stress), pre-eclampsia - Maternal-fetal: PPROM (common), polyhydramnios, placenta previa, abruptio placentae, or placental insufficiency - Fetal: multiple gestation, congenital abnormalities, fetal hydrops - Uterine: excessive enlargement (hydramnios, multiple gestation), malformations (intracavitary leiomyomas, septate uterus, and Müllerian duct abnormalities

Question 287

Risk factors of preterm labour?

Answer 287

- Prior history of spontaneous PTL is the most important risk factor - Prior history of large or multiple cervical excisions (cone biopsy) or mechanical dilatation (D&C) - Cervical length: measured by transvaginal U/S (cervical length >30 mm has high negative predictive value for PTL before 34 wk) - Infection (uterine, placental, maternal) + bacteriuria - Shorter inter-pregnancy interval - Family history of preterm birth - Smoking - Late maternal age - Multiple gestation - Polyhydramnios – increased pressure - History of bleeding in 2nd or 3rd TM

Question 288

Signs and symptoms of preterm labour?

Answer 288

- Early Sx: menstrual-like cramps or mild/irregular contractions, lower back ache, vaginal pressure, bloody show - True Sx: regular uterine contractions (2 in 10 min, >6/h) accompanied by change in cervical dilatations and/or effacement (>1 cm dilated, >80% effaced, or length <2.5 cm)

Question 289

Diagnostic tests for preterm labour?

Answer 289

- Lab Testing: GBS swab, CBC, blood type and screen - FFN (Fetal Fibronectin) in vagina – a glycoprotein in amniotic fluid and placental tissue. Positive if >50 ng/mL - U/S: fetal position, placental position/abnormalities, AF volume, cervical length (20-30mm).

Question 290

Indications for FFN (Fetal Fibronectin)?

Answer 290

1 or more signs of preterm labour (regular contractions >6/h, pelvic pressure, low abdominal pain and/or cramps, low backache) + 24-34 weeks, intact membranes, <3 cm dilated, established fetal well being

Question 291

Contraindications for FFN (Fetal Fibronectin)?

Answer 291

Contraindicated as well if: cerclage, active vaginal bleeding, vaginal exam, or sex in last 24 h

Question 292

What are the methods used to prevent preterm labour?

Answer 292

- Cervical Cerclage - Progesterone - Lifestyle Modification

Question 293

Diagnosis of cervical incompetence?

Answer 293

- Obstetrical Hx: silent cervical dilation, recurrent T2 losses, cervical procedures such as loop excisions - Ability of cervix to hold an inflated Foley catheter during a hysterosonogram - Transvaginal U/S of cervical length is recommended only for high-risk pregnancies and only before 30 wk GA

Question 294

Definition of cervical cerclage?

Answer 294

Placement of cervical sutures at the level of the internal os, usually at the end of the T1 or in the T2 and removed in the T3

Question 295

Indications for cervical cerclage?

Answer 295

Cervical incompetence (i.e. cervical dilation and effacement in the absence of increased uterine contractility)

Question 296

Superior to cerclage in preventing preterm labour of singletons not due to cervical incompetence

Answer 296

Progesterone

Question 297

If previous PTL or short cervix?

Answer 297

- If previous PTL: 17-alphahydroxyprogesterone 250 mg IM weekly from 16+0 to 36 wk GA - If short cervix: 200 mg daily vaginally from time of diagnosis to 36 wk GA

Question 298

Lifestyle modification for the prevention of preterm labour?

Answer 298

Smoking cessation, substance use reduction, treatment of GU infections (including asymptomatic UTIs), and patient education regarding risk factors

Question 299

Management of preterm labour?

Answer 299

1. Tocolytics 2. Antenatal corticosteroids 3. Neuroprotection 4. Antibiotics

Question 300

What do tocolytics do?

Answer 300

Inhibit uterine contractions (for steroid benefit, fetal neuroprotection, transport to tertiary care)

Question 301

Requirements for tocolytics?

Answer 301

- Preterm labour - Live, immature fetus, intact membranes, cervical dilatation of <4 cm - Absence of maternal or fetal contraindications

Question 302

Contraindications to tocolytics?

Answer 302

- Maternal: bleeding (placenta previa or abruption), maternal disease (HTN, DM, heart disease), preeclampsia or eclampsia, chorioamnionitis - Fetal: erythroblastosis fetalis, severe congenital anomalies, fetal distress/demise, IUGR, multiple gestation (relative)

Question 303

Commonly used agents for tocolytics?

Answer 303

Most use Indocin (NSAID) or Nifedipine (Adelact)

Question 304

What are the benefits of antenatal corticosteroids for preterm labour?

Answer 304

Accelerate fetal lung maturation (reduce RDS, intraventricular hemorrhage, necrotizing enterocolitis, mortality)

Question 305

Dose and GA used for antenatal corticosteroids for preterm labour?

Answer 305

Betamethasone 12mg IM q24h x 2 doses <34 wks

Question 306

What does the GA need to be in order to use MgSO4 for neuroprotection in preterm labour?

Answer 306

If <32 weeks, then give MgSO4 if delivery is imminent!

Question 307

Use of antibiotics in preterm labour?

Answer 307

No benefits except for GBS prophylaxis – Pen G 5mU IM/IV then 2.5mU q4h until delivery

Question 308

What is defined as small for gestational age?

Answer 308

<10th%ile for gestational weight according to N American charts but not necessarily growth restricted (e.g. South Asian baby on N American curve). Not pathologic

Question 309

What is defined as intrauterine growth restriction?

Answer 309

<10th%ile fetus that has not reached its growth potential. Infant weight <10%ile for GA or <2500g or abdominal circumference <10%ile. Pathologic

Question 310

What are the 3 categories of etiology for IUGR?

Answer 310

Maternal (nutrient delivery), placental (nutrient transfer), or fetal (nutrient utilization) factors

Question 311

What are the maternal causes of IUGR?

Answer 311

Malnutrition, smoking, drug abuse, alcoholism, cyanotic heart disease, type 1 DM, SLE, pulmonary insufficiency, previous IUGR (25% risk, most important risk factor), and chronic HTN

Question 312

What are the placental causes of IUGR?

Answer 312

- Any disease that causes placental insufficiency | - Gross placental morphological abnormalities (infarction, hemangiomas, placenta previa, and abnormal cord insertion

Question 313

What are the fetal causes of IUGR?

Answer 313

Multiple gestation (why? inadequate placental reserve, occurs more in monozygotic), infection (5-10% of IUGR cases e.g. TORCH – toxo, other (varicella, syphilis), rubella, CMV, herpes), genetic disorders, congenital anomalies/malformations.

Question 314

What are the two types of IUGR?

Answer 314

- Symmetric IUGR – Type 1 - Asymmetric IUGR – Type 2 - Indeterminate IUGR - Type 3

Question 315

When does symmetric/type I IUGR occur and what are the causes?

Answer 315

Early onset, congenital anomalies or TORCH infections

Question 316

Clinical features of symmetric/type I IUGR

Answer 316

Reduced growth of both head and abdomen

Question 317

When does asymmetric/type II IUGR occur and what are the causes?

Answer 317

- Growth inhibition late in gestation affecting cell hypertrophy and growth, usually > 23 weeks! Later in pregnancy. - Placental insufficiency (redistribution of blood to critical organs: brain, heart, adrenals preserved, brain sparing effect) or external factor – brain/heart/adrenals spaced, ^MCA doppler =

Question 318

Clinical features of asymmetric/type II IUGR

Answer 318

- Fetal abdomen is disproportionately smaller than fetal head - Brain is spared; therefore head:abdomen ratio increased - loss of subcut fat, decreased muscle mass.

Question 319

What is symmetric IUGR – Type 1a vs Type 1b

Answer 319

1A: constitutional (small women) vs. 1B: intrinsic - growth inhibition early in gestation due to fetal abnormalities/insult. Inhibition of active mitosis, affecting cell hyperplasia.

Question 320

If mother at high risk for IUGR or SFH lags >2 cm behind GA, what should be done?

Answer 320

- U/S for biparietal diameter, head and abdominal circumference ratio, femur length, fetal weight, AFV (decrease associated with IUGR), and decrease in the rate of growth - ± BPP - Doppler analysis of umbilical cord blood flow

Question 321

Management of IUGR?

Answer 321

- Modify controllable factors: smoking, alcohol, nutrition, and treat maternal illness - Serial BPP (monitor fetal growth) and determine cause of IUGR, if possible - Delivery when extrauterine existence is less dangerous than continued intrauterine existence (abnormal function tests, absent growth, severe oligohydramnios) especially if GA >34 wk - As IUGR fetuses are less likely to withstand stresses of labour, they are more likely to be delivered by Cesarean section

Question 322

Complications of IUGR?

Answer 322

- Prone to meconium aspiration, asphyxia, polycythemia, hypoglycemia, hypocalcemia, hypophosphatemia, hyponatremia, and mental retardation - Greater risk of perinatal morbidity and mortality

Question 323

Etiology of breast discharge

Answer 323

- Intraductal papilloma - Mammary duct ectasia - Fibrocystic changes - Abscess/infection - Breast cancer - Intraductal carcinoma or invasive ductal carcinoma - Hyperprolactinemia (pituitary tumor, hypothyroidism) - Medications: Oral contraceptives, antihypertensive drugs (eg, methyldopa, reserpine, verapamil), H2-antagonists (eg, cimetidine, ranitidine), opioids, and dopamine D2 antagonists (eg, many psychoactive drugs, including phenothiazines and tricyclic antidepressants).

Question 324

Most common cause of breast discharge

Answer 324

Intraductal papilloma

Question 325

What should be asked on history for breast discharge?

Answer 325

- Characteristics of nipple discharge: Unilateral vs bilateral, Single vs multi duct, Bloody/OB vs watery, duration, Spontaneous vs induced (manipulation of breast) - Risk of breast cancer: Associated breast mass, nipple changes, skin retraction, axillary adenopathy, Risk factors for breast CA, Mammographic abnormality - Other breast pathology: Breast pain, cyclic (fibrocystic disease, cyclic mastopathy), Breast cysts, lumps, infections - R/o other causes, especially if bilateral or milky: pregnancy, psychiatric history (depression), visual fields (bitemporal hemianopsia in pituitary tumor), headaches, smoker, risk for lung CA

Question 326

Red flags of breast discharge?

Answer 326

Unilateral, localized to single duct, persistent, spontaneous, palpable mass, high volume, sanguineous (bloody), or serosanguinous (blood-tinged), male sex

Question 327

Physical exam for breast discharge?

Answer 327

- Symmetry/contour of breast, position of nipples, scars, skin retraction, dimpling, edema/erythema, ulceration, crusting of nipple, changes in skin color, elicit discharge and identify duct(s) involved, axillary/supraclavicular lymph nodes, delineate masses, localize tenderness

Question 328

Approach to diagnosis for bilateral breast discharge?

Answer 328

- Usually due to an endocrinological or physiologic process - Bloody nipple discharge, abnormal mammogram/US, or the presence of breast mass clinically REQUIRES surgical evaluation - Bilateral multiductal secretion that is non-bloody is usually benign (regardless of color) > medical evaluation and endocrine workup may be required, surgical consult is not indicated

Question 329

Approach to diagnosis for unilateral breast discharge?

Answer 329

- Uni-ductal: more likely to be pathological (papilloma, intraductal breast CA), whether or not the d/c is bloody - Multi-ductal: less likely to represent significant pathology and should be investigated as bilateral discharge

Question 330

Investigations for pathologic breast discharge

Answer 330

- Lesions that appear cystic are sometimes aspirated, and solid masses or any that remain after aspiration are evaluated with mammography followed by imaging-guided biopsy. - MRI if mammogram and US are negative - Surgical evaluation is required for dx and tx EVEN if imaging results are negative

Question 331

Indications for surgical evaluation (excisional bx) for breast discharge?

Answer 331

Breast mass, any imaging abnormality, d/c is spontaneous, uniductal, and/or bloody discharge.

Question 332

Investigations for non-pathologic breast discharge

Answer 332

PE/imaging is negative, d/c is multiductal + nonbloody > Lab tests, medical evaluation, galactorrhea workup

Question 333

Treatment for pathologic breast discharge

Answer 333

- Malignancy is r/o > Terminal duct excision with/without image guidance - Core needle biopsy demonstrates DCIS/invasive BCA > appropriate CA surgery

Question 334

Treatment for non-pathologic breast discharge

Answer 334

- Stop insulting medication (metoclopramide, SSRIs) | - Treat hyperprolactinemia

Question 335

What is intraductal papilloma

Answer 335

Papillary tumor growing from the lining of the breast duct

Question 336

Findings of intraductal papilloma associated with breast discharge?

Answer 336

Unilateral bloody (or guaiac-positive) or serosanguinous discharge. Should be excised whenever diagnosed by core needle biopsy

Question 337

Findings of duct ectasia associated with breast discharge?

Answer 337

Unilateral or often bilateral bloody, serosanguinous, or multicolored (purulent, gray, or milky) discharge

Question 338

Findings of fibrocystic changes associated with breast discharge?

Answer 338

A mass, often rubbery and tender, usually in premenopausal women. Possibly a serous, green, or white discharge. Possibly a history of other masses

Question 339

Findings of abscess/infection associated with breast discharge?

Answer 339

Acute onset with pain, tenderness, or erythema. Often fever. With abscess, a tender mass and possibly purulent discharge

Question 340

Most common malignancy associated with nipple discharge

Answer 340

DCIS

Question 341

Findings of breast cancer associated with breast discharge?

Answer 341

May have a palpable mass, skin changes, or lymphadenopathy. Spontaneous, unilateral, uniductal, blood discharge

Question 342

Clinical features of hyperprolactinema?

Answer 342

Galactorrhea (secretion of breast milk in women and, in rare cases, men), infertility, hypogonadism, amenorrhea, oligomenorrhea, erectile dysfunction

Question 343

Causes of hyperprolactinema?

Answer 343

- Prolactinoma: Most common pituitary adenoma (prolactin-secreting tumours may be induced by estrogens and grow during pregnancy) - Pituitary masses with pituitary stalk compression causing reduced dopamine inhibition of prolactin release - Primary hypothyroidism (low free T4, increase TRH, stimulate PRL) - Decreased clearance due to chronic renal failure or severe liver disease (prolactin is metabolized by both the kidney and liver) - Medications with anti-dopaminergic properties are a common cause of high prolactin levels: Antipsychotics (common), antidepressants, antihypertensives (verapamil/methyldopa), anti-migraine agents (triptans/ergotamines), bowel motility agents (metoclopramide/domperidone), H2-blockers (ranitidine) - Macroprolactinemia (high molecular weight prolactin also known as big-big prolactin) that has no action

Question 344

Investigations of hyperprolactinema?

Answer 344

- Serum PRL, TSH, liver enzyme tests, creatinine - Macroprolactin level in patients with hyperprolactinemia but no symptoms of prolactin excess - MRI of the sella turcica when a secondary cause is not identied or when prolactin levels suggest that there may be underlying tumoural hyperprolactinemia

Question 345

Findings in female patients with prolactinoma?

Answer 345

Female patients (pre-menopausal) - Most have small tumors (microadenomas), Galactorrhea 30-80%, Menstrual irregularity and infertility, Symptoms of large tumors (less common)

Question 346

Findings in male patients with prolactinoma?

Answer 346

Male patients - Usually large tumors (macroadenomas), Impotence and reduced libido (sex drive), galactorrhea not common, Symptoms of large tumors: visual field abnormalities, headache and hypopituitarism

Question 347

Treatment of hyperprolactinema?

Answer 347

- First line: long-acting dopamine agonist: bromocriptine, cabergoline, or quinagolide - Surgery ± radiation (rare) - Prolactin-secreting tumours are often slow-growing; treatment may not be necessary in the setting of small tumours associated with hyperprolactinemia that does not result in hypogonadism or bothersome galactorrhea - If medication-induced, consider stopping medication if possible - In certain cases if microprolactinoma and not planning on becoming pregnant, may consider OCP

Question 348

What increases physiologic discharge?

Answer 348

Increases with increased estrogen states: pregnancy, OCP, mid-cycle, PCOS, or premenarchal

Question 349

Signs and symptoms of physiologic discharge?

Answer 349

Clear, white, flocculent, odourless discharge; pH 3.8-4.2, no associated vulvar or vaginal symptoms

Question 350

Ddx for vulvar pruritius?

Answer 350

1. Physiologic discharge and cervical mucus production 2. Non-physiologic - genital tract infection - vulvovaginitis: candidiasis, trichomoniasis, BV, polymicrobial superficial infection - chlamydia, gonorrhea - pyosalpinx, salpingitis - genital tract inflammation (non-infectious) - local: chemical irritants, douches, sprays, foreign body, trauma, atrophic vaginitis, desquamative inflammatory vaginitis, focal vulvitis - neoplasia: vulvar, vaginal, cervical, endometrial - systemic: toxic shock syndrome, Crohn's disease, collagen disease, dermatologic (e.g. lichen sclerosis) - IUD, OCP (secondary to progesterone)

Question 351

Clinical findings of prepubertal vulvovaginitis?

Answer 351

Irritation, pruritus, discharge, vulvar erythema, vaginal bleeding (specifically due to Group A Streptococci and Shigella)

Question 352

Etiology of prepubertal vulvovaginitis?

Answer 352

- poor hygiene (proximity of anus to vagina) - foreign bodies (most commonly tissue paper) - irritation by perfumed soaps, chemicals, and tight clothing - localized skin disorders: lichen sclerosis, condyloma acuminata ■ trauma: accidental straddle injury, sexual abuse - infectious: pinworms, Candida (if using diapers or chronic antibiotics), Group A streptococcus, S. aureus and Shigella, discovery of STI should raise suspicion of sexual abuse

Question 353

Investigations of prepubertal vulvovaginitis?

Answer 353

- Vaginal swab for culture (specifically state that it is a pre-pubertal specimen) - pH, wet-mount, and KOH smear in prepubertal adults only

Question 354

Definition of vaginitis

Answer 354

Vaginitis is a general term for a group of disorders affecting the vagina, caused by infection, inflammation, or changes in the normal flora.

Question 355

Treatment of prepubertal vulvovaginitis?

Answer 355

- Enhanced hygiene and local measures (handwashing, white cotton underwear, no nylon tights, no tight fitting clothes, no sleeper pajamas, sitz baths, avoid bubble baths, use mild detergent, eliminate fabric softener, avoid prolonged exposure to wet bathing suits, urination with legs spread apart) - A&D* dermatological ointment (vitamin A/D) to protect vulvar skin - Infectious: treat with antibiotics for organism identified

Question 356

What should be asked on history for vulvovaginitis?

Answer 356

- Full OBHx and GyneHx (pap smear hx, pelvic infection hx, procedures done to cervix, endometriosis/PCOS?) - Timeline/severity of all sx - Sexual: partners, practices, protection from STDs, past history of STDs, prevention from pregnancy - GI/GU: pelvic pain, urinary pain, vaginal pain, dyspareunia, ask about colour/amount/smell/blood, re: discharge - Consider: recent Abx use, pregnancy, OCP, immunosuppression, DM, vaginal douching (CANDIDIASIS), semen, drugs, chemicals

Question 357

Physical exam for vulvovaginitis?

Answer 357

- Check for pruritis, burning, foul-smelling discharge, change in amount/consistency/colour, check abdo - STI’s: check external genitals for ulcerations, lesions, or signs of trauma - Reactive Arthritis/Syphillis: inspect eyes for conjunctivitis, uveitis, rash, mucosal ulcerations (syphilis) - Ensure that you are doing a speculum and bimanual exam (to r/o ascending infection (PID)); assess discharge/pooling, assess cervix, tenderness, or signs of blood - smell?

Question 358

Ddx for vulvovaginitis?

Answer 358

Infective/chemical/atrophic vaginitis (50+), cervicitis (STIs), malignancy, PID, foreign body, disrupted vag flora (BV)

Question 359

Investigations for vulvovaginitis?

Answer 359

- Serology: syphilis, HIV - Wet Mount: discharge on slide + 2cc of saline, place coverslip and examine under microscope (Trich/BV/Yeast) - Whiff Test: place discharge on a slide, add few drops of 10% KOH and ‘whiff’, fishy odour suggestive of BV - Endocervical(F)/Vaginal/Urethral(M) Swab: HSV PCR + Syphilis PCR + Trich/BV/Yeast (+/- G&C) - Urinalysis: NAAT first catch, culture/sensitivity for gonorrhea/chlamydia - Biopsy: suspicious lesions

Question 360

Pathophysiology of bacterial vaginosis

Answer 360

- Overgrowth of Gardnerella vaginalis | - Gram Stain: more *lactobacillus* (good score) more gardnerella (worse score)

Question 361

Signs and symptoms of bacterial vaginosis

Answer 361

Odour – fishy, grey thin discharge, absence of vulvar/vaginal irritation, ph >4.5 CLUE CELL

Question 362

Treatment of bacterial vaginosis

Answer 362

- No treatment if non-pregnant and asymptomatic, unless scheduled for pelvic surgery or procedure - Metronidazole PO (500mg BID x 7d) or clindamycin (300mg PO BID x 7d) or topical

Question 363

Pathophysiology of candida vaginitis

Answer 363

- YEAST HYPHAE (may need some KOH) - 90% C. Albicans - Patho: Predisposing factors include: Immunosuppressed host (DM, AIDS, etc.) Recent antibiotic use, Increased estrogen levels (e.g. pregnancy, OCP)

Question 364

Signs and symptoms of candida vaginitis

Answer 364

Pruritic/burning, white and curdy discharge, pH 4-4.5, + erythematous, dysuria, wet mount findings of hyphae KOH

Question 365

Treatment of candida vaginitis

Answer 365

Fluconazole PO (150mg) (watch liver) or OTC imidazole or polyene antifungals (1d - 7d doses)

Question 366

Parasite that causes trichomonas vaginitis

Answer 366

TRICHOMONAS PROTOZOAN (mobile flagellates)

Question 367

Treatment of trichomonas vaginitis

Answer 367

- Metronidazole PO (2g x 1d) or topical metro/clotrimazole (BID x 5d) - TREAT SEXUAL PARTNER TOO + REPORT

Question 368

Symptoms/signs of trichomonas vaginitis

Answer 368

Often asymptomatic (10-50%), Green and frothy discharge, pH 5-6, petechiae on vagina and cervix (strawberry), occasionally irritated, tender vulva, dysuria/dyspareunia, frequency, wet mount finding of trich

Question 369

Typical causes of vaginitis?

Answer 369

Vaginitis → trichomoniasis, bacterial vaginosis, or candida.

Question 370

Typical causes of cervicitis?

Answer 370

Cervicitis → chlamydia or gonorrhea, mucopurulent cervicitis. If + abd pain → PID.

Question 371

Testing for vaginal discharge?

Answer 371

- Gram stain not helpful but wet mount to look for candida, BV, trich useful if available - Collect specimens: vaginal swab (if doing speculum) or urine (G/C)

Question 372

Testing for urethral discharge?

Answer 372

- NAAT (+pharyngeal swab) for G/C - Urine for G/C - Blood tests for HIV antibody and syphilis

Question 373

Testing for genital ulcer?

Answer 373

- Darkfield microscopy, syphilis PCR, PCR for herpes simplex virus - Serologic tests for syphilis: EIA

Question 374

Typical causes of genital ulcer?

Answer 374

HSV, syphilis, chancroid, lymphogranuloma venereum (LGV)

Question 375

Typical causes of urethral discharge?

Answer 375

Gonorrhea, Non gonococcal urethritis (chlamydia, mycoplasma genitalium, trichomonas, herpes simplex (rare))

Question 376

Typical causes of genital warts?

Answer 376

HPV, syphilis

Question 377

Typical causes of testicular swelling?

Answer 377

Gonorrhea, chlamydia, tricomoniasis, GNBs

Question 378

Most common bacterial STI in Canada

Answer 378

Chlamydia

Question 379

Typical causes of genital rash?

Answer 379

Syphilis or disseminated gonorrhea or chlamydia

Question 380

Clinical features of chlamydia

Answer 380

- Often symptomatic, usually clear discharge, pelvic pain, post-coital/intermenstrual bleeding (esp. if on OCP + prior hx of good cycle control), symptomatic sexual partner - Urethral Syndrome: dysuria, frequency, pyruria, no bacteria on culture

Question 381

Transmission of chlamydia

Answer 381

Sexually + vertically

Question 382

Female manifestations of chlamydia

Answer 382

Most often asymptomatic, cervicitis, vaginal discharge, dysuria, lower abdo pain, dyspareunia, conjunctivitis, abnormal vaginal bleeding, proctitis

Question 383

Male manifestations of chlamydia

Answer 383

Often asymptomatic, urethral discharge, urethritis, dysuria, testicular pain, conjunctivitis, proctitis

Question 384

Sequelae of chlamydia

Answer 384

- Females: ectopic preg, infertility, chronic pelvic pain + PID (low grade salpingitis/adhesions = tubal obstruction) - Males: epididymo-orchitis, infertility - Both: Reiter’s syndrome, Fitz High Curtis syndrome (liver capsule inflammation)

Question 385

Investigations of chlamydia

Answer 385

Nucleic acid amplification test; first catch urine can also be used since obligate intracellular parasite – tissue culture is definitive standard…urine/self vaginal tests available (= or more effective than cerv swab)

Question 386

Treatment of chlamydia?

Answer 386

- Doxycycline 100mg PO BID (better for rectal) for 7 days or azithromycin 1g PO single dose (good for pregnancy) - Co-Infection: treat gonorrhea b/c high rate of co-infection - Partners: treat, report

Question 387

Who should be tested for cure for chlamydia?

Answer 387

Do it on everyone with high risk factors (pregnancy, pharyngeal/rectal infection, or potentially reduced susceptibility) – 4 days post-treatment or urine PCR 2 weeks post treatment; if no risk factors then rescreen 6-12 months post-treatment

Question 388

Male manifestations of gonorrhea

Answer 388

Males: urethritis, epididymitis

Question 389

Clinical features of gonorrhea

Answer 389

PURULENT URETHRAL DISCHARGE, dysuria, PID, however often asymptomatic (symptoms may present 7-21d after infection)

Question 390

Female manifestations of gonorrhea

Answer 390

Females: cervicitis, PID, urethritis

Question 391

Transmission of gonorrhea

Answer 391

Sexually + vertically

Question 392

Investigations of gonorrhea

Answer 392

Typically a NAAT (swab cervical, rectal, and throat (if indicated)). You could also do first catch urine sample. *Culture is the preferred method for sexual assault/tx failure/infection acquired overseas as it’s the only way to get antimicrobial susceptibility

Question 393

Male/female manifestations of gonorrhea

Answer 393

Both: pharyngeal infection, conjunctivitis, proctitis, disseminated gonococcal infection – rash, polytenosynovitis

Question 394

Treatment of gonorrhea

Answer 394

- Heterosexual or Pregnant: cefixime 800 mg PO + azithromycin 1g PO. Azithromycin only used as monotherapy if strong contraindication to cephalosporins - Pharyngeal infections or MSM: single dose of ceftriaxone 250mg IM + azithromycin 1g PO - Co-infection: treat chlamydia b/c high rate of co-infection - Partners: treat, report, abstain from sex for a week, screening the same as with chlamydia

Question 395

Etiology of mycoplasma genitalium?

Answer 395

Small facultative anaerobic bacteria without a cell wall

Question 396

Clinical manifestations of mycoplasma genitalium?

Answer 396

Asymptomatic, can cause similar presentation to G/C

Question 397

Investigations of mycoplasma genitalium?

Answer 397

- NAAT (not available in Alberta, need to send to National Microbiology lab) - Recommended in persistent or recurrent urethritis, cervicitis, or PID despite empiric treatment

Question 398

Treatment of mycoplasma genitalium?

Answer 398

Moxifloxacin

Question 399

Minimum criteria for PID?

Answer 399

Lower abdomen/pelvic pain, cervical motion or uterine/adnexal tenderness

Question 400

Additional criteria for PID?

Answer 400

Temperature >38.3C, mucopurulent cervical/vaginal discharge, WBCs on wetmount of discharge, high ESR/CRP

Question 401

Sequelae of PID?

Answer 401

Severity of clinical presentation corresponds poorly with damage, infertility, ectopic pregnancy, CPP, pelvic adhesions, tubo-ovarian abscess, pelvic thrombophlebitis

Question 402

When should someone with PID be hospitalized?

Answer 402

Hospitalization: severe illness, nausea/vomiting, fever, cannot exclude surgical emergency, pregnancy, poor response to PO abx, tubo ovarian abscess, imunodeficient

Question 403

Treatment of PID?

Answer 403

- Ceftriaxone 250mg IM + doxycycline 100mg PO BID x 14 days OR cefoxitin + doxycycline (Foxy Doxy) OR clindamycin + gentamycin until afebrile for 24h with clinical improvement - Other: remove IUDs, counsel, partner notification, STI reporting, re-evaluate in 38-72h and 7-10d

Question 404

Clinical features of herpes simplex virus?

Answer 404

- May be asymptomatic, vesicles on erythematous base, then painful blister with crust (syphilis is usually not painful), enlarged lymph nodes. Usually on external genitals, oral mucosa, cervix! - Primary episodes typically more severe than recurrent and tend to be bilateral - Recurrent disease usually associated with burning or tingling at site (24-48hr before lesions erupt)! Genital - Reactivation is usually unilateral but primary is bilateral! Can be subtle erythematous patches in boxer zone.

Question 405

Investigations of herpes simplex virus?

Answer 405

NAAT placed in universal transport media – swab the lesion

Question 406

Treatment of first episode of herpes simplex virus?

Answer 406

- Education regarding transmission (any shared contact with lesions at any stage, shedding is also common even when a person is asymptomatic), use barrier contraception, avoid contact from onset of prodrome until lesions have cleared - First Episode: acyclovir 400mg PO TID x 7-10 days or 200mg PO 5x/day x 7-10 days or valacyclovir 1g PO BID x 7-10 days or famciclovir 250mg PO TID x 7-10 days

Question 407

Recurrent episodes of herpes simplex virus?

Answer 407

Acyclovir 400mg PO TID x 5 days or 800mg PO x 5 days or valacyclovir 500g PO BID x 3 days or 1g OD x 5 days or famciclovir 125mg PO BID x 5 days or 1g PO BID x 1 day or 500mg PO x 1 day then 250mg PO BID x 2 days

Question 408

Daily suppressive therapy for herpes simplex virus?

Answer 408

Consider if >6 recurrences per year or one every 2 months; acyclovir 400mg PO BID or valacyclovir 500mg or 1g PO OD or famciclovir 250mg PO BID

Question 409

Severe disease for herpes simplex virus?

Answer 409

IV acyclovir 5-10mg/kg q8h x 2-7 days or until clinical improvement followed by PO thx to complete 10 days of therapy total

Question 410

When does primary syphilis present and what are the symptoms?

Answer 410

3-4 weeks post-exposure, painless chancre on vulva/vagina/cervix, serological tests usually negative – local infection only

Question 411

When does secondary syphilis present and what are the symptoms?

Answer 411

2-6 months post-exposure, non-specific sx like malaise, anorexia, headache, diffuse lymphadenopathy, generalized maculopapular rash (palms, soles (mostly these two), trunk, limbs), condylomata lata (anogenital, broad based fleshy grey lesions), serological tests usually positive

Question 412

When does latent syphilis occur and what are the symptoms?

Answer 412

No clinical manifestations, detected by serology only. Late >1year – non-infectious

Question 413

What are the symptoms and treatment of congenital syphilis?

Answer 413

fetal anomalies, stillbirths, or neonatal death, treat fetus with Pen G IV

Question 414

What are the symptoms of tertiary syphilis?

Answer 414

may involve any organ system, neurosyphilis (tabes dorsalis, general paresis, dementia), cardio (aortic aneurysm, dilated aortic root), vulvar gamma (nodules that enlarge, ulcerate, and necrotic)

Question 415

Best test for syphilis?

Answer 415

Darkfield microscopy

Question 416

What is the screening test for syphilis?

Answer 416

- EIA (measures IgM or IgG antibodies against Treponema pallidum) = SCREENING TEST. Arises during primary stage and persists for life

Question 417

What are the supplemental/confirmatory test for syphilis?

Answer 417

- When EIA +, TPPA needs to be done to verify. RPR tells us the stage - TPPA measures antibodies to Treponema pallidum = supplemental/confirmatory test

Question 418

What is the staging test for syphilis?

Answer 418

RPR titre tends to parallel disease activity, useful indicator of response to therapy by observing fall in titres over time. Used for STAGING

Question 419

Treatment of primary, secondary or latent <1yr duration syphilis?

Answer 419

Benzathine penicillin G 2.4 million units IM x 1dose

Question 420

Treatment of latent >1yr duration syphilis?

Answer 420

Benzathine penicillin G 2.4 million units IM q1week x 3 weeks

Question 421

Treatment of neurosyphilis

Answer 421

IV aqueous penicillin G 3-4 million units IM q4h x 10-14 days

Question 422

When is follow up needed for syphilis?

Answer 422

No follow up blood tests required if RPR non reactive at baseline or if low titre in late stage syphilis

Question 423

Most common viral STI?

Answer 423

Human Papillomavirus

Question 424

Transmission of human papillomavirus?

Answer 424

Transmission: sexually + vertically + perinatally

Question 425

HPV subtype classically associated with anogenital warts/condylomata acuminate?

Answer 425

HPV 6/11

Question 426

HPV subtype most oncogenic (classically associated with cervical HSIL)

Answer 426

HPV 16/18

Question 427

Clinical features of latent HPV infection?

Answer 427

No lesions, asymptomatic, only detected by hybridization tests

Question 428

Screening and prevention of HPV?

Answer 428

Gardasil 9 or Gardasil or Cervarix; condoms do not fully protect

Question 429

Treatment of HPV?

Answer 429

- Mechanical removal: cryotherapy - repeat q1-2 week, excision/laser - Topical treatments: antimitotics (podophyllin qweekly), caustics (eg, trichloroacetic acid - weekly for 4-6 weeks – good for pregnancy), interferon inducers (eg, imiquimod - 5% cream 3x per week qhs for 16 weeks)

Question 430

Investigations of HPV?

Answer 430

Biopsy of lesions at colposcopy + detection of HPV DNA subtype using nucleic acid probes (after abnormal pap)

Question 431

Treatment of HPV in pregnancy?

Answer 431

Pregnancy: warts tend to get bigger, treat early (excision), C-Section only if obstructing birth canal or risk of extensive bleed – do not use imiquimod, podophyllin, or podofilox

Question 432

Clinical features of subclinical HPV infection?

Answer 432

Visible lesions during colpo or pap – add acetic acid before test to whiten the warts

Question 433

Clinical features of clinical HPV infection?

Answer 433

Visible wart lesions w/o magnification, hyperkeratotic/verrucuous/flat/macular lesions, vulvar edema

Question 434

Screening test for HIV?

Answer 434

Enzyme-linked immunosorbent assay (ELISA).

Question 435

Confirmatory test for HIV?

Answer 435

Western blot and/or PCR.

Question 436

Ways to reduce vertical HIV transmission?

Answer 436

- Give maternal IV ZDV. - Reduce duration of ruptured membranes. - Recommend cesarean delivery before labor or rupture of membranes if viral load > 1000 copies. - Avoid breast-feeding. - Give ZDV syrup to newborn for 6 weeks

Question 437

HIV preferentially infects ____ + ____ resulting in progressive destruction of ____ + ____ populations

Answer 437

CD4 T-lymphocytes CD4 T-cell

Question 438

Transmission of HIV?

Answer 438

HIV does not cross the placenta, only blood to blood transmission – vertical transmission

Question 439

Treatment of HIV?

Answer 439

CART – Combination Antiretroviral Therapy – suppress HIV replication, prevent CD4 depletion (often increasing) – and track the viral load, ensuring it falls to < 1000 copies / mL. If she has an undetectable viral load she can deliver vaginally. If she hasn’t been on HAART, or her copies are > 1000, she delivers via C-Section.

Question 440

If HIV status was unknown at time of delivery?

Answer 440

AZT (zidovudine) at the time of delivery

Question 441

Prophylaxis/vaccines for HIV+ pregnant women?

Answer 441

Weekly azithromycin (if CD4 <100), Septra (CD4 <200), vaccinate for p-pneumonia, influenza, HBV/HAV

Question 442

Communicability of Hep B during pregnancy?

Answer 442

HBsAg+ state highly communicable, increased during 3-TM or early post-partum; increased risk of infectivity with increased levels of hepatitis B early antigen (HBeAg). DOES NOT increase risk of complications or congenital anomalies

Question 443

When should you screen for Hep B for pregnancy?

Answer 443

Screen for Hep B during the first trimester labs with hepatitis B surface antigen

Question 444

Treatment of hep B + during pregnancy?

Answer 444

- Vaccination against hepatitis viruses A, Abstain form alcohol use, avoid hepatotoxic drugs such as acetaminophen, ASA and sharing personal items - HBV DNA levels ≥106 IU/mL are an indication to initiate treatment during the last 3 months of pregnancy

Question 445

Treatment of hep B - and at risk during pregnancy?

Answer 445

Offer HBV vaccine; not contraindicated in pregnancy

Question 446

All infants born to HBsAg-positive mothers should receive?

Answer 446

One dose of HepB Ig and the initial dose of HBV vaccine within 12 hours of birth. 2nd and third at 1 and 6 months

Question 447

CDC Notifiable Diseases

Answer 447

Chancroid + Chlamydia + Gonorrhea + Hepatitis A/B/C + HIV + Syphilis

Question 448

Transmission of hep B?

Answer 448

Vertical

Question 449

Serology for Hep B?

Answer 449

- Hep B surface antibody: Exposed or vaccine - Hep B core antibody: Exposed - Hep B ANY antigen: Infected - Hep B s Ag: Infected - Hep B e Ag: Infectious

Question 450

Transmission of hep C?

Answer 450

Transmission via blood, IV drug use, perinatal transmission

Question 451

Investigations for hep C?

Answer 451

Serology – + for HCV-RNA or Anti-HCV (IgG, IgM)

Question 452

Is hep C an indication for C-section?

Answer 452

Pregnancy does not impact course of HCV or complications, fetal anomalies and is not an indication for C section

Question 453

Treatment of hep C?

Answer 453

- Don’t given Hep C treatment - Vaccinate against hepatitis A and B - Avoid sharing personal items –razors, toothbrush - Limit hepatotoxic drugs that may worsen liver damage - Liver enzymes and PCR at 1st prenatal visit and Q trimester


Question 454

Risk factors for STIs

Answer 454

History of previous STI, contact with an infected person, sexually active individual <25yo, multiple partners, new partner in the last 3 months, lack of barrier protection use, street involvement (homelessness or drug use)

Question 455

Definition of premenstrual syndrome (PMS)?

Answer 455

At least one symptom associated with "economic or social dysfunction" that occurs during the five days before the onset of menses and is present in at least three consecutive menstrual cycles. Symptoms may be affective (eg, angry outbursts, depression) or physical (eg, breast pain and bloating)

Question 456

Affective or behavioral symptoms of PMS

Answer 456

Mood swings (most common), irritability, anxiety/tension, sad or depressed mood, increased appetite/food cravings, sensitivity to rejection, and diminished interest in activities

Question 457

Core symptoms of PMS

Answer 457

The core symptoms include affective symptoms, such as depression, irritability, and anxiety, and somatic symptoms, such as breast pain, bloating and swelling, and headache

Question 458

Core feature of PMS?

Answer 458

The core feature is the recurrent onset of symptoms during the end of the luteal phase of the menstrual cycle with a symptom-free period shortly after menses has begun

Question 459

Physical symptoms of PMS

Answer 459

The most common physical manifestations of PMS are abdominal bloating and an extreme sense of fatigue. Other common symptoms include breast tenderness, headaches, hot flashes, and dizziness. Hot flashes in women who are neither postpartum nor peri-or postmenopausal are highly suggestive of PMS or PMDD.

Question 460

Etiology of PMS?

Answer 460

- Multifactorial: not completely understood; genetics likely play a role - CNS-mediated neurotransmitter (serotonin, dopamine, GABA) interactions with sex steroids (P, E, and T) - Serotonergic dysregulation – currently most plausible theory

Question 461

Diagnostic criteria for premenstrual syndrome

Answer 461

1. At least one affective and one somatic symptom during the 5d before menses in each of the three prior menstrual cycles - Affective: depression, angry outbursts, irritability, anxiety, confusion, social withdrawal - Somatic: breast tenderness or swelling, abdominal bloating, headache, swelling of extremities, joint or muscle pain, or weight gain 2. Symptoms relieved within 4 d of onset of menses and do not recur until at least day 13 of cycle 3. Symptoms present in the absence of any pharmacologic therapy, hormone ingestion, drug or alcohol use 4. Symptoms occur reproducibly during 2 cycles of prospective recording 5. Patient suffers from identifiable dysfunction in social or occupational performance

Question 462

Diagnostic criteria for premenstrual dysphoric disorder?

Answer 462

1. At least 5 of the following 11 symptoms during most menstrual cycles of the last year (with at least 1 of the first 4) - depressed mood or hopelessness - anxiety or tension - affective instability - anger or irritability - decreased interest in activities - difficulty concentrating - lethargy - change in appetite - hypersomnia or insomnia - feeling overwhelmed - physical symptoms: breast tenderness/swelling, headaches, joint/muscle pain, bloating, or weight gain 2. Symptoms cause significant distress and/or interfere with social or occupational functioning 3. Symptoms must be present during the week prior to menses and resolve within a few days after onset of menses 4. May be superimposed on other psychiatric disorders, provided it is not merely an exacerbation of another disorder

Question 463

1st line treatment of PMS?

Answer 463

- Exercise, cognitive behavioural therapy, vitamin B6 - Combined hormonal contraception - Continuous or luteal phase (day 15-28) low dose SSRIs (e.g. citalopram/escitalopram 10 mg)

Question 464

2nd line treatment of PMS?

Answer 464

- Estradiol patches (100 micrograms) + micronised progesterone (100 mg or 200 mg [day 17-28], orally or vaginally) or LNG-IUS 52 mg - Higher dose SSRIs continuously or luteal phase (e.g. citalopram/escitalopram 20-40 mg)

Question 465

3rd line treatment of PMS?

Answer 465

GnRH analogues + add-back HRT

Question 466

4th line treatment of PMS?

Answer 466

Surgical treatment ± HRT

Question 467

What is defined as PROM?

Answer 467

Pre-labor rupture of membranes at any GA

Question 468

Clinical features of PROM?

Answer 468

- Hx: fluid gush or continued leakage – colour, consistency, constancy (is it clear? Meconium? Bloody?), coughing - Ask around 4 Cardinal Q’s: bleeding, discharge, fetal movements, contractions/pain

Question 469

What is defined as prolonged ROM?

Answer 469

>24h elapsed b/w rupture of membranes and onset of labour

Question 470

What is defined as PPROM?

Answer 470

Preterm (<37w) + PROM

Question 471

Maternal risk factors for PROM?

Answer 471

Multiparity + cervical incompetence + infection (cervicitis, vaginitis, STI, UTI), FHx, low SES/poor nutrition, smoking, previous PPROM/PROM, placenta previa/abruption, trauma, low BMI, maternal age <18, >40, cervical surgery, sex

Question 472

Fetal risk factors for PROM?

Answer 472

Congenital anomaly + multiple gestation

Question 473

Physical/Investigations for PROM?

Answer 473

- Speculum Exam: check for pooling in posterior fornix + nitrazine (turns blue if basic) + ferning on microscope slide - Cervical Exam: dilation + effacement + length + consistency +/- station - Ultrasound: Assess amount of AF, rule out fetal anomalies + assess GA + presentation + BPP

Question 474

False (+) Nitrazine

Answer 474

Blood, semen, urine, BV – amniotic fluid pH of 7.1-7.3, vaginal pH 4.5-6.0

Question 475

False (-) Nitrazine

Answer 475

Not enough fluid or fluid is contaminated by other discharge

Question 476

Neonatal complications of PROM

Answer 476

Neonatal sepsis, long-term neurodevelopmental abnormalities, fetal asphyxia (most common), limb deformities, morbidities associated with preterm.

Question 477

Fetal complications of PROM

Answer 477

Intrauterine infection, cord compression, oligohydramnios – pulmonary hypoplasia, fetal malposition, umbilical cord prolapse, placental abruption, preterm birth

Question 478

Maternal complications of PROM

Answer 478

Chorioamnionitis (common etiology of PROM - Fever > 38C, leukocytosis, maternal/fetal tachycardia, uterine tenderness, malodorous vaginal discharge), endometritis, sepsis, postpartum endometritis.

Question 479

Management of PROM?

Answer 479

- Admit: for expectant mgmt + monitor vitals q4h + daily BPP + US + WBC count – delivery if fetal distress/chorioamnionitis - Imminent Delivery: cover for GBS and consult NICU - Screen: for UTI, STI, GBS (treat any of these is +) - Magnesium Sulfate: neuroprotection, if delivery <32 weeks is imminent (5g IV, then 1g q1h until delivery) - Tocolysis: only use if there is a need to delay for betamethasone (most use Indocin or Nifedipine) - Betamethasone: lung maturity, 12mg IV q24h x 2 dose for anyone <34w

Question 480

<24 week GA with PROM

Answer 480

Consider termination (poor outcome due to pulmonary hypoplasia)

Question 481

24-25 weeks GA with PROM

Answer 481

Individual consideration with counselling of parents regarding risks to preterm infants

Question 482

26-34 weeks GA with PROM

Answer 482

Expectant management (give steroids, prophylactic antibiotic, MgSO4), as prematurity complications are significant

Question 483

34-36 weeks GA with PROM

Answer 483

‘grey zone’ where risk of death from RDS and neonatal sepsis is the same. CONSIDER DELIVERY AT 34 WKS

Question 484

>37 weeks GA with PROM

Answer 484

Induction of labour since the risk of death from sepsis is greater than RDS

Question 485

What are the stages of labour?

Answer 485

1st (latent, active), 2nd (passive, active), 3rd (placenta), 4th (monitoring 1hr and repair)

Question 486

Stage 1 - Latent phase

Answer 486

Progressive effacement/dilatation of cervix usually until 4cm; contractions typically infrequent/irregular.

Question 487

Stage 1 - Active phase

Answer 487

Need to have regular contractions and cervix 4cm | Contractions: painful, regular contractions q2-3min, lasting 45-60s; strongest at fundus

Question 488

Slowest rates of stage 1 - active phase

Answer 488

Slowest rates: nulliparous (1.2cm/hour), multiparous (1.5cm/hour)

Question 489

Management of stage 1 - active phase

Answer 489

- Vital signs q4H, clear fluids in active labour, cervical exams q2-3H if uncomplicated, ambulation, fetal monitoring - ARM (Artificial Rupture of Membranes): no difference in length of 1st stage or Apgar scores

Question 490

Pain management of stage 1 - active phase?

Answer 490

Comes from T11, T12, L1 during first stage; morphine 5-10mg IM q4h (not within 4 hours of delivery, if close, then fentanyl) + gravol 50mg IM or epidural PRN or nitrous oxide PRN

Question 491

Stage 2 of labour

Answer 491

Starts at a cervix of 10 cm, ending in fetal delivery. Passive (no active pushing) + Active (active pushing).

Question 492

What is considered prolonged stage 2 active phase?

Answer 492

3h nulliparous, 1h multiparous

Question 493

Management of stage 2 of labour

Answer 493

Analgesia (no narcotics), fetal monitoring, assess progress (descent), when to push (when the urge is there), episiotomy (vacuum/forceps or shoulder dystocia), fetal head delivery, anterior shoulder (check nuchal cord), posterior shoulder, cord clamping (60 seconds of delayed clamping) – progress measured by descent

Question 494

Cardinal movements of the fetus during delivery?

Answer 494

Head floating/before engagement > engagement/descent/flexion > further descent/internal rotation > complete rotation/beginning extension > complete extension > restitution (external rotation) > delivery of anterior shoulder > delivery of posterior shoulder

Question 495

Stage 3 of labour

Answer 495

Separation of placenta, and ends with delivery of placenta – should last no more than 30minutes before intervention is indicated. Mean time: 8-10mins

Question 496

What are the signs of placental separation?

Answer 496

Uterus becomes globular/firm/rises in abdomen (place hand on the uterus just above the pelvis) + sudden gush of blood + umbilical cord lengthening

Question 497

Management of stage 3 of labour?

Answer 497

Bolus oxytocin, 5U IV or 10u IM with delivery of anterior shoulder, 20U in 1L normal saline (after shoulder delivered), gentle traction on umbilical cord WITH suprapubic support of uterus, early cord clamping – oxytocin can help to reduce risk of PPH by >40%. Inspect v/c/l for lacerations!

Question 498

Management of stage 4 of labour?

Answer 498

q15m for an hour, monitor vital signs/bleeding, repair lacerations, ensure uterus is contracted (palpate uterus and monitor uterine bleeding, examine placenta (make sure its intact)/umbilical cord (for 2 arteries + 1 vein), manage lacerations, monitor for PPH

Question 499

What is the expected progress of descent with delivery?

Answer 499

Expect at least 1cm descent per hour with primip and 2cm per hour with multip

Question 500

What is defined as abnormal progression of labour (Dystocia)?

Answer 500

Failure to progress – a slow or difficult delivery either due to lack of effacement/dilation or descent

Question 501

What is the difference between arrest and protraction?

Answer 501

Arrest (no progress) vs. protraction (slow progress)

Question 502

What is defined as arrest of labour?

Answer 502

Arrest in 1st stage means no cervical change in >4hrs despite adequate contractions but 2nd stage arrest is NO DESCENT in 2-4 hrs depending on epidural and para

Question 503

What is defined as protraction of labour?

Answer 503

1st stage – 4+ hrs of 0.5cm/hr OR no dilation in 2 hrs. 2nd stage – 1 hr of pushing with no descent

Question 504

Effect of epidural on the progression of labour?

Answer 504

No different in duration of 1st stage of labour. Increased duration of second stage of labour (13.6 min). Increased instrumental delivery. No difference in c-section rate.

Question 505

Etiology of failure to progress?

Answer 505

- Assess Power - Assess Passenger: size, lie and presentation, position (OA diameter 8.5cm, OP diameter 9cm), attitude (asynclitism – when head is tipped) - Assess Passage: pelvic types: gynecoid (transverse ellipse) = easiest/favourable for baby. Android (triangular shape) Anthropoid (AP ellipse) = narrow - Assess Psyche: stress increases epinephrine and other hormones which interfere with uterine contractility and interfere with progress and increase anxiety which increases stress

Question 506

What are satisfactory contractions for the assessment of power and how can you measure power?

Answer 506

Frequency (between 3-5 per 10 minutes), duration (60-90s), amplitude of contraction or pushings; intrauterine pressure catheter

Question 507

What are the abnormal contraction pattern?

Answer 507

- Too frequent: tachysystole - Too strong: hypertonus - Too sustained: tetanic - Abnormal contraction pattern + NRFHR = hyperstimulation

Question 508

Management of power as the cause of FTP?

Answer 508

Oxytocin, amniotomy (ARM), instrumental delivery or c-section delivery.

Question 509

Management of psyche as the cause of FTP?

Answer 509

Analgesia, labour support person – doula

Question 510

Management of passenger as the cause of FTP?

Answer 510

Manual rotation, instrumental delivery or c-section delivery.

Question 511

What is the shortest feat head diameter?

Answer 511

Shortest diameter: occiptobregmatic = well flexed head | Wider diameters = deflexed head: occipitofrontal (brow), occipitomental (face)

Question 512

Pain relief options for pregnancy?

Answer 512

- Non-pharmacologic: maternal movement and position change, ARM, immersion in water, TENS, hypnosis - Systemic: narcotics (always give with antiemetic), nitrous oxide (self administered), sedatives and hypnotics are INEFFECTIVE - Regional and Local: epidural (most effective pain relief, no effect on length of 1st stage, longer 2nd stage), pudendal (useful in 2nd stage for operative vaginal delivery

Question 513

Surrogate measure of pelvic inlet

Answer 513

Obstetrical pelvimetry: Diagonal conjugate = surrogate measure of pelvic inlet. Adequate if >11.5cm. True distance = DC – 1.5cm

Question 514

Typical baby size for non-diabetic and diabetic mothers?

Answer 514

>4500g in non-diabetic mom, >4000g in diabetic mom – heads and shoulders are usually larger

Question 515

Management of passage as the cause of FTP?

Answer 515

Instrumental delivery or c-section delivery

Question 516

Benign breast lesions categories?

Answer 516

- Nonproliferative - Proliferative without atypia - Atypical hyperplasia

Question 517

Ddx for nonproliferative benign breast lesions

Answer 517

- Simple breast cyst: - Papillary apocrine change - Galactocele - Apocrine metaplasia

Question 518

Ddx for proliferative benign breast lesions without atypia?

Answer 518

- Fibroadenomas - Intraductal papilloma - Usual ductal hyperplasia - Sclerosing adenosis

Question 519

High risk for malignancy on US

Answer 519

Ill-defined margins, hypoechogenicity, calcifications, shadowing, spiculations, taller-than-wider shape

Question 520

Clinical features and age of nonproliferative benign breast lesions

Answer 520

- Age 30 to menopause (and after if hormone replacement therapy (HRT) used) - Breast pain, focal areas of nodularity or cysts often in the upper outer quadrant, frequently bilateral, mobile, varies with menstrual cycle, and nipple discharge (straw-like, brown, or green)

Question 521

Investigations for nonproliferative benign breast lesions

Answer 521

- Evaluation of breast mass (U/S, mammography as indicated) - Observation thru menstrual cycle for resolution is an option. Fine needle aspiration to confirm diagnosis. Re-examine in 4-6 weeks. - Re-recurrence usually requires open biopsy

Question 522

What are nonproliferative benign breast lesions?

Answer 522

Benign breast condition characterized by fibrous and cystic changes in the breast (fibrocystic changes/disease)

Question 523

What are the features of breast cysts?

Answer 523

Breast cysts are fluid-filled, round, or ovoid masses derived from the terminal duct lobular unit. Most common nonproliferative lesion

Question 524

What is papillary apocrine change?

Answer 524

Papillary apocrine change is a proliferation of ductal epithelial cells showing apocrine features

Question 525

What are galactoceles and when do they occur?

Answer 525

Cystic collections of fluid, usually caused by an obstructed milk duct. Occurs after cessation of lactation or with decrease feeding frequency (up to 10 mo after).

Question 526

What is apocrine metaplasia?

Answer 526

Also referred to as a "benign epithelial alteration" is also a nonproliferative change that is secondary to some form of irritation, typically associated with a breast cyst.

Question 527

Classic triad of nonproliferation benign breast lesions?

Answer 527

Classic triad of breast pain, tenderness, nodularity in premenopausal women (30-50).

Question 528

Indications to send fluid for cytology for nonproliferation benign breast lesion?

Answer 528

- Residual mass after aspiration - Bloody fluid (no need to send clear fluid for cytology) - Recurrence > 3x

Question 529

Treatment of nonproliferative benign breast lesions

Answer 529

- Analgesia (ibuprofen, ASA) - Vitamin E, evening primrose oil - For severe symptoms: OCP, danazol, bromocriptine

Question 530

Most common breast tumour in women <30 yr

Answer 530

Fibroadenomas

Question 531

Clinical features of fibroadenomas

Answer 531

Nodules: firm, rubbery, discrete, well- circumscribed, non-tender, mobile, hormone- dependent (unlike cysts), needle aspiration yields no fluid

Question 532

Diagnosis of fibroadenomas?

Answer 532

- Core or excisional biopsy sometimes required if concerned about malignancy U/S and FNA alone cannot differentiate fibroadenoma from phyllodes tumour - US - solid, well-circumscribed avascular mass - Mammography may show well-circumscribed mass, or large, coarse calcifications in involuting FA is typical

Question 533

Treatment of fibroadenomas

Answer 533

- Generally conservative serial observation - Consider excision if size 2-3 cm and growing on serial U/S (q6mo x 2 yr is usual follow-up), if symptomatic, formed after age 35, patient preference or features on core biopsy suggestive of a phyllodes tumour

Question 534

What is a intraductal papilloma?

Answer 534

Solitary intraductal benign polyp

Question 535

Clinical features of intraductal papilloma?

Answer 535

Can present as nipple discharge (most common cause of spontaneous, unilateral, bloody nipple discharge = pathologic nipple discharge), breast mass, nodule on U/S

Question 536

Treatment of intraductal papilloma?

Answer 536

Surgical excision of involved duct to ensure no atypia

Question 537

What is a usual ductal hyperplasia

Answer 537

Increased number of cells within the ductal space

Question 538

Clinical features of usual ductal hyperplasia

Answer 538

Incidental finding on biopsy of mammographic abnormalities or breast masses

Question 539

Treatment of usual ductal hyperplasia and sclerosing adenosis?

Answer 539

None required

Question 540

What is sclerosing adenosis?

Answer 540

Lobular lesion with increased fibrous tissue and glandular cells

Question 541

Ddx for atypical hyperplasia benign breast lesions?

Answer 541

Atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), and lobular carcinoma in situ (LCIS)

Question 542

What are the features of lipomas of the breast?

Answer 542

Benign, usually solitary tumors composed of mature fat cells. Soft, nontender, well-circumscribed masses

Question 543

What are the features of fat necrosis of the breast

Answer 543

Commonly occurs as the result of breast trauma or surgical intervention. Fat necrosis can be confused with a malignancy on physical examination and may mimic malignancy on radiologic studies

Question 544

Treatment of fat necrosis?

Answer 544

Monitor, analgesia, warm compress, should self-resolve

Question 545

What is granulomatous mastitis and what is required in order to make the diagnosis?

Answer 545

An inflammatory mass in the breast. Biopsy is necessary to make a diagnosis

Question 546

What are the features of sarcoidosis of the breast and what is required in order to make the diagnosis?

Answer 546

Sarcoidosis of the breast presents as firm, hard masses, mimicking carcinoma. The mammographic appearance is also suspicious with irregular, ill-defined, spiculated masses that are solid on ultrasound. Biopsy is needed for confirmation of diagnosis

Question 547

Clinical features of sclerosing adenosis?

Answer 547

Mass or mammographic abnormality

Question 548

What are the features of breast abscess?

Answer 548

Localized collection of inflammatory exudate (i.e., pus), when mastitis/cellulitis does not respond to antibiotic treatment - localized, painful inflammation, associated with fever/malaise, fluctuant tender, palpable mass, dx = U/S showing fluid collection. Micro staph aureus most common

Question 549

What are the risk factors for breast abscess?

Answer 549

Obesity, smoking, age >30 years, first pregnancy, GA >41w

Question 550

Treatment of breast abscess?

Answer 550

Antibiotics (e.g., dicloxacillin), Needle or open drainage with cultures taken, Resection of involved ducts if recurrent, Breast pump if breastfeeding

Question 551

What should be asked on history for breast mass?

Answer 551

- Change in General Appearance of Breast: increase/decrease in size or change in symmetry, nipple rash, new nipple inversion/retraction (tumor involvement of Cooper’s ligaments and subsequent traction on ligaments pull skin inward), dimple - Nipple Discharge: bilateral, unilateral from one specific duct, timing, color, frequency, spontaneity of discharge) - Breast Pain: relationship with menstrual cycles (cyclic/noncyclic), location within the breast (or both), duration, whether it is aggravated/alleviated by any activities/medications - Evolution: how it was first noted, how long it has been present, whether it has changed in size - Location - Wax/Wanes during Menstrual Cycle: cysts may be more prominent premenstrual and regress in size during follicular phase

Question 552

Physical exam for breast mass?

Answer 552

- Determine whether a dominant mass, thickening or asymmetry is present – important in younger women (breast are more likely to be generally nodular than older) - Describing a breast mass, the texture (firm, soft, rubbery) should be noted, mobility (fixed, mobile), associated skin changes and location. - LN exam (supraclavicular, infraclavicular, axillary) - Characteristics: obvious/subtle, tender/nontender, soft/firm/hard, mobile/fixed to the chest wall, well-defined/non-discrete margins - Associations: ecchymosis, erythema, peau d’orange ulceration of the skin, nipple discharge or retraction, or none

Question 553

Ddx for malignant breast masses?

Answer 553

- Infiltrating Ductal Carcinoma - Infiltrating Lobular Carcinoma: diffuse thickening of the breast rather than discrete mass - Mixed Ductal/Lobular Carcinoma - Paget Disease: Scaly, raw, ulcerated lesion of the nipple and aerola. 75% have underlying Ca. Need punch biopsy of nipple

Question 554

Most common malignant breast mass?

Answer 554

Infiltrating Ductal Carcinoma: most common, 70-80% of invasive breast cancer

Question 555

Investigations for breast masses?

Answer 555

- Percutaneous core needle biopsy (palpation or U/S guided): Allows for diagnosis prior to surgery - Stereotactic core needle biopsy is required in lesion is only seen on mammogram - MRI guided core needle biopsy is needed is lesion is only seen by MRI

Question 556

Imaging for breast lesion?

Answer 556

- Mammogram: depicts mass as a soft tissue density, unable to make definitive diagnosis, cannot detect all (i.e., premenopausal women with dense breast tissue) - Ultrasound: Supplements mammography when dense tissue present, often in younger women. Initial imaging study in women <30 years old with breast pain or nipple discharge. Used as a follow up study from mammography - MRI: categorize breast lesions as mass/non-mass lesions, depict breast mass as enhancing/non-enhancing mass, rapid uptake of contrast = malignant mass characteristic, NOT necessary - high sensitivity, low specificity. Reserved for high risk patients

Question 557

High risk for malignancy on mammogram?

Answer 557

Poorly defined, spiculated border; microcalcifications; architectural distortion, interval mammographic changes

Question 558

What is the triple test for diagnosing breast cancer?

Answer 558

Triple Test: clinical breast exam + imaging (US for <30yr, mammography + US for >30yrs) + pathology (US/Mammography guided core needle biopsy or FNA - palpable cystic lesions)

Question 559

Preoperative staging workup for breast cancer?

Answer 559

- Bilateral mammogram (cancer in one breast is a risk factor for cancer in the contralateral breast!) - CXR (to check for lung metastasis) - LFTs (to check for liver metastasis) - Serum calcium level, alkaline phosphatase (if these tests indicate bone metastasis/“bone pain,” proceed to bone scan) - Other tests, depending on signs/symptoms (e.g., head CT scan if patient has focal neurologic deficit, to look for brain metastasis) - The Ls and Bs: liver, lung, bone and brain.

Question 560

Breast cancers are divided into ____ and ___

Answer 560

Carcinoma in situ and invasive cancer.

Question 561

What is carcinoma in situ of the breast?

Answer 561

Carcinoma in situ is proliferation of cancer cells within ducts or lobules and without invasion of stromal tissue.

Question 562

2 types of carcinoma in situ of the breast

Answer 562

- Ductal carcinoma in situ (DCIS): About 85% of carcinoma in situ are this type. DCIS is usually detected only by mammography. - Lobular carcinoma in situ (LCIS): LCIS is often multifocal and bilateral.

Question 563

What is the major risk with DCIS?

Answer 563

Subsequent development of infiltrating ductal carcinoma in the same breast

Question 564

Treatment of DCIS?

Answer 564

- Tumor <1 cm (low grade) = Remove with 1-cm margins and XRT - Tumor >1 cm = Perform lumpectomy with 1-cm margins and radiation or total mastectomy (no axillary dissection) - some perform a sentinel LN dissection for high-grade DCIS

Question 565

Features of DCIS?

Answer 565

It may involve a small or wide area of the breast; if a wide area is involved, microscopic invasive foci may develop over time. microcalcifications, rigid neolumen formation (cribriform architecture).

Question 566

Two types of LCIS?

Answer 566

There are 2 types: classic and pleomorphic.

Question 567

Features of classic LCIS?

Answer 567

Classic LCIS is not malignant but increases risk of developing invasive carcinoma in either breast. IT’S A HIGH RISK MARKER - 30% in the 20 years after diagnosis of LCIS! This nonpalpable lesion is usually detected via biopsy; it is rarely visualized with mammography

Question 568

Features + treatment of pleomorphic LCIS?

Answer 568

Pleomorphic LCIS behaves more like DCIS; it should be excised to negative margins.

Question 569

Invasive breast carcinoma is primarily ____

Answer 569

Adenocarcinoma

Question 570

Most common type of invasive breast carcinoma

Answer 570

About 80% is the infiltrating ductal type; most of the remaining cases are infiltrating lobular. Rare types include medullary, mucinous, metaplastic, and tubular carcinomas. Mucinous carcinoma tends to develop in older women and to be slow growing. Women with these rare types of breast cancer have a much better prognosis than women with other types of invasive breast cancer.

Question 571

Features of inflammatory breast cancer

Answer 571

A fast-growing, often fatal cancer. Cancer cells block the lymphatic vessels in breast skin; as a result, the breast appears inflamed, and the skin appears thickened, resembling orange peel (peau d’orange). Usually, inflammatory breast cancer spreads to the lymph nodes in the armpit. The lymph nodes feel like hard lumps. However, often no mass is felt in the breast itself because this cancer is dispersed throughout the breast.

Question 572

Treatment of inflammatory breast cancer?

Answer 572

Chemotherapy first! Then often followed by radiation, mastectomy, or both

Question 573

Features of Paget disease

Answer 573

Paget disease of the nipple (not to be confused with the metabolic bone disease also called Paget disease) is a form of ductal carcinoma in situ that extends into the skin over the nipple and areola, manifesting with a skin lesion (eg, an eczematous or a psoriaform lesion). Characteristic malignant cells called Paget cells are present in the epidermis. Women with Paget disease of the nipple often have underlying invasive or in situ cancer.

Question 574

What is are cystosarcoma phyllodes

Answer 574

Mesenchymal tumor arising from breast lobular tissue; most are benign (Note: “Sarcoma” is a misnomer, as the vast majority are benign; 1% of breast cancers)

Question 575

Signs and symptoms of cystosarcoma phyllodes

Answer 575

Mobile, smooth breast mass that resembles a fibroadenoma on exam, mammogram/ultrasound findings

Question 576

Treatment of cystosarcoma phyllodes

Answer 576

If benign, wide local excision; if malignant, simple total mastectomy. Consider chemotherapy if large tumor >5 cm and “stromal overgrowth”

Question 577

Diagnosis of cystosarcoma phyllodes

Answer 577

Core biopsy or excision

Question 578

Tumor markers for breast cancer?

Answer 578

Can test for estrogen, progesterone and her-2

Question 579

Consider genetic screening for BRCA1/2 if

Answer 579

Patient dx with BCA + ovarian CA, strong family hx of BCA+OCA, family hx of male breast cancer, young patient (<35yr), bilateral breast cancer patients <50yr

Question 580

For females with BRCA1/2 mutation, prevention approach?

Answer 580

Can offer risk-reducing bilateral salpingo-oophorectomy when child-bearing complete and offer risk-reducing bilateral mastectomy. Start age 25 annual breast MRI

Question 581

Indications of breast conserving surgery (BCS)?

Answer 581

Palpation, ultrasound guided or needle localized if mass only see on mammogram. Usually for stages I and II (tumors <5 cm), patient with stage IIIA cancer if they have to have NEOadjuvant chemotherapy

Question 582

Contraindications of breast conserving surgery (BCS)?

Answer 582

High risk of local recurrence (e.g. extensive malignant type calcifications on mammogram – extensive DCIS, and multifocal primary tumors), failure to obtain tumour free margins after re-excision, not suitable for radiation therapy (pregnancy, previous radiation, collagen vascular disease), large tumor size relative to breast

Question 583

Lumpectomy MUST be combined with ____ for survival equivalence to mastectomy

Answer 583

Radiation

Question 584

Reconstructive options after mastectomy?

Answer 584

TRAM flap, latissimus dorsi flap or implant reconstruction

Question 585

Indications for mastectomy?

Answer 585

Patient choice, contraindication to radiation, multicentric or unable to obtain negative margins

Question 586

When is sentinel lymph node dissection performed?

Answer 586

Perform in women with clinically node NEG BCA and those with extensive DCIS who are undergoing mastectomy. If SLNB is positive, completion ALND is indicated

Question 587

When is axillary lymph node dissection performed?

Answer 587

Perform in all patients with pathologic confirmation of nodal involvement (including POS SLNB as above). Removal of level 1 and 2 axillary nodes

Question 588

Risks of axillary lymph node dissection performed?

Answer 588

Arm lymphedema (10-15%) especially if getting radiation therapy, decreased arm sensation, motor nerve injury, post op seroma, wound infection, arm weakness or decrease range of motion

Question 589

Indications for radiation for breast cancer?

Answer 589

- Adjuvant treatment post-lumpectomy for all BCT - Post-mastectomy radiation indicated if advanced tumor (T3, T4, pN2 or pN3) - Inflammatory breast CA or tumor not responding to neoadjuvant chemo - Start 4-8 weeks post-op ideally, or after chemotherapy

Question 590

Indications for chemotherapy of breast cancer?

Answer 590

- Node positive - Node negative tumor with high risk features (e.g. high grade, Her2neu positive, age <35, hormone receptor negative, LVI) - Locally-advanced (T3, T4, N2, N3) - neoadjuvant chemo - Metastatic breast cancer - palliative chemo - For HER2+ BCA – add trastuzumab ± pertuzumab to the chemo regimen - May provide chemotherapy prior to surgery to decrease size

Question 591

Indications for hormone therapy for breast cancer?

Answer 591

- Estrogen receptor (ER) positive breast cancers - Tamoxifen is only agent used in premenopausal women, aromatase inhibitors if postmenopausal - Also indicated as chemoprevention for high risk women (strong family history, BRCA positive, LCIS, atypical hyperplasia)

Question 592

Common agents for hormone therapy for breast cancer?

Answer 592

Common agents: Tamoxifen (selective estrogen receptor modulator), aromatase inhibitors (Anastrazole, Letrozole), daily for 5-10 years postop

Question 593

Side effects of tamoxifien?

Answer 593

Endometrial cancer (2.5× relative risk), DVT, pulmonary embolus, cataracts, hot flashes, mood swings

Question 594

Therapeutic indications for excision of a breast mass?

Answer 594

Benign lumps (fibroadenoma, phyllodes), DCIS/invasive breast cancer that is amenable for BCS based on the size of the lesion

Question 595

Diagnostic indications for excision of a breast mass?

Answer 595

Equivocal pathology obtained on core biopsy or FNA cytology of a radiologically suspicious breast lump, lump classified as category 3 or 4 by the BIRAD system that is close to the pectoral muscle (which makes biopsy under radiological guidance difficult)

Question 596

Who is considered an average risk women in breast cancer screening guidelines?

Answer 596

50-74yo with no personal hx of BCA or hx of BCA in 1st degree relatives or known mutations of BRCA1/BRCA2 genes or previous exposures of the chest wall to radiation

Question 597

Are MRI, clinical breast exam or breast self-exam recommended for breast cancer screening?

Answer 597

No

Question 598

Who is considered a high risk women in breast cancer screening guidelines?

Answer 598

- One/Two 1st Degree Relatives with Invasive BCA: (but do not meet the criteria for referral to med genetics) - Breast Biopsy w/ Atypical Hyperplasia or LCIS or Following Surgical Management (r/o Invasive Carcinoma) - History of Chest Wall Radiation at Age 30 or Younger

Question 599

Breast cancer screening guidelines for: Average risk women age 40-49?

Answer 599

Routine screening with mammography NOT recommended

Question 600

Breast cancer screening guidelines for: Average risk women age 50-74?

Answer 600

Routine screening q2 years

Question 601

Breast cancer screening guidelines for: Average risk women age 75+?

Answer 601

Screen if benefits outweigh harm, must take overall health into account

Question 602

Breast cancer screening guidelines for: High risk women - One/Two 1st Degree Relatives with Invasive BCA

Answer 602

- Annual mammography starting 5-10 years younger than the youngest case in the family, but no earlier than age 25 and no later than age 40 - Annual CBEs starting at age 25

Question 603

Breast cancer screening guidelines for: High risk women - Breast Biopsy w/ Atypical Hyperplasia or LCIS or Following Surgical Management (r/o Invasive Carcinoma)?

Answer 603

- Annual mammography | - Annual CBEs

Question 604

Breast cancer screening guidelines for: High risk women - History of Chest Wall Radiation at Age 30 or Younger?

Answer 604

- Annual mammography + screening breast MRI starting 5-10 years after radiation give, but no earlier than 25 and no later than age 40 - Annual CBEs

Question 605

Risk Factors for Breast Cancer

Answer 605

- Gender (99% female) - Age (80% >40yr) - Personal Hx of bCA/Prior breast bx (regardless of pathology) - Family Hx of breast cancer (2 or more 1st degree relatives) - BRCA1 and BRCA2 gene mutations Relative risks: - Increased estrogen exposure: High breast density*/nulliparity, first pregnancy >30 years old, menarche <12 years old, menopause >55 years old - Decreased risk with lactation, early menopause, early childbirth - Radiation exposure (mantle radiation for Hodgkin’s disease) - >5 years of HRT use or >10 years of OCP use - Alcohol use, obesity, sedentary lifestyle

Question 606

Women requiring genetic referral for breast cancer?

Answer 606

Maternal or paternal family history of: - Multiple individuals with breast and/or ovarian cancer (e.g. 3 or more cases in 2 or more generations, at least one case onset before age 50), related to each other - Bilateral primary breast cancer, first onset age 50 or younger - Breast cancer at age 35 or younger - Breast cancer that is hormone receptor negative and HER2 negative (a.k.a. triple negative), age 60 or younger - Primary breast and primary ovarian cancer in the same individual - Male breast cancer, age 65 or younger, or at any age with close family history of breast cancer - Breast or ovarian cancer in a family with Ashkenazi Jewish heritage - BRCA1 or BRCA2 mutation in the family

Question 607

Definition of spontaneous abortion

Answer 607

Spontaneous abortion refers to pregnancy loss at less than 20 weeks’ gestation in the absence of elective medical or surgical measures to terminate the pregnancy. 80% occur before 12 wks

Question 608

What is defined as complete abortion?

Answer 608

All products of conception have been passed without the need for surgical or medical intervention + symptoms have resolved

Question 609

What is defined as incomplete abortion?

Answer 609

Bleeding/cramping with open cervical os, some, but not all, of the products of conception have been passed – usually presents with continued bleeding/pain (incomplete)

Question 610

What is defined as inevitable abortion?

Answer 610

The cervix has dilated, but the products of conception have not been expelled

Question 611

What is defined as missed abortion?

Answer 611

A pregnancy in which there is a fetal demise (usually for a number of weeks) but no uterine activity to expel the products of conception

Question 612

What is defined as recurrent spontaneous abortion?

Answer 612

Three or more consecutive pregnancy losses

Question 613

What is defined as septic abortion?

Answer 613

A spontaneous abortion that is complicated by intrauterine infection (fever/acute abdo/malaise/septic shock).

Question 614

What is defined as threatened abortion?

Answer 614

A pregnancy complicated by bleeding before 20 weeks’ gestation, closed cervical os

Question 615

Common bugs of septic abortion?

Answer 615

S. Aureus, Gram(-) bacilli, or Gram(+) cocci – if >20wks, then chorioamnionitis

Question 616

Differential diagnosis for first trimester bleeding

Answer 616

- Ectopic pregnancies - Spontaneous abortions (threatened, missed, inevitable, incomplete, complete, septic) - <20wks GA - Implantation bleed (usually occurs around time of the missed period) - Cervical/uterine etiology (tumors or polyps, infections – STIs or yeast, trauma – e.g. sex) - GTN (gestational trophoblastic neoplasm) - Other source (rectal or urinary)

Question 617

What should be asked on history for spontaneous abortion?

Answer 617

Duration, degree and severity of bleeding, PQRST, passage of tissue, associated symptoms, prior gyne history

Question 618

Physical exam for spontaneous abortion?

Answer 618

VS, temp, abdo exam, pelvic exam (cervical os (open vs closed), amount of bleeding) CAUTION – avoid aggressive or bimanual exams in suspected ectopic

Question 619

Symptoms of spontaneous abortion?

Answer 619

Crampy pelvic pain, bleeding, and eventually expulsion of tissue. Late spontaneous abortion may begin with a gush of fluid when the membranes rupture. Hemorrhage is rarely massive

Question 620

Investigations for spontaneous abortion?

Answer 620

- Potassium hydroxide and “wet prep” microscopy of any vaginal discharge - CBC - Blood type and screen (for all patients) → IgG for Rh-ve mums - Quantitative blood (not urine, since blood gives us a # to follow) hCG (normally hCG 2x every 2 days but not in spont abortion) - G/C testing - Determine if an intrauterine pregnancy can be reliably seen on ultrasound - 1500 - 2000 mIU - endovaginal scan - 4000 - 5000 mIU - abdominal U/S

Question 621

Etiology for spontaneous abortion?

Answer 621

- Embryonic causes (nondisjunction) like genetic issues – polyploidies, trisomies (30-60%) - Reproductive tract abnormalities - uterine anomalies - Prothrombotic factors - thrombophilia - Endocrinologic factors - polycystic ovary syndrome - Immunologic factors - antiphospholipid syndrome - Infection (lots of these cause 2nd trimester miscarriage) - most notably cytomegalovirus, herpesvirus, parvovirus, and rubella virus

Question 622

Rask factors for spontaneous abortion?

Answer 622

Age > 35, History of spontaneous abortion, Cigarette smoking, Use of certain drugs (eg, cocaine, alcohol, high doses of caffeine), A poorly controlled chronic disorder (eg, diabetes, hypertension, overt thyroid disorders) in the mother

Question 623

Treatment options for <12 weeks spontaneous abortion and subcategory used for?

Answer 623

- Conservative/Expectant: can wait for passage on its own, good for those already having symptoms and stable – threatened, incomplete, inevitable, complete. - Medical: Misoprostol (prostaglandin E1) 400-800mcg orally OR vaginally (1-2 doses, depending) to cause cramping/passage of tissue. Missed - Surgical: D&C (QUICKEST WAY!). Best for unstable/septic patients. Highest rate of completion but also complications – bleeding, perforation, cervical trauma, scarring.

Question 624

Side effects of misoprostol?

Answer 624

Cramp, diarrhea, severe bleeding, fever.

Question 625

Management of septic abortion?

Answer 625

D&C + IV broad spectrum antibiotics

Question 626

Treatment options for >12 weeks spontaneous abortion and subcategory used for?

Answer 626

- Medical: induction via repeated doses of Misoprostol! DONE IN HOSPITAL due to traumatic nature, risk of retained placenta. - Surgical: D&E (surgical removal of fetus, more difficult).

Question 627

What is defined as primary recurrent abortion?

Answer 627

No pregnancy >20wks.

Question 628

What is defined as secondary recurrent abortion?

Answer 628

At least 1, >20wks.

Question 629

Investigations for recurrent abortion?

Answer 629

- Hystero-salpingogram, karyotype (both partners) | - TSH + HbA1c + Prolactin + anti-thyroid antibodies + anti-phospholipid antibody screen + thrombophilia work-up

Question 630

Define primary amenorrhea?

Answer 630

- Failure to menstruate by 15 years old with secondary sex characteristics + linear growth - Failure to menstruate by 13 years old with no secondary sex characteristics and absence of growth

Question 631

Define secondary amenorrhea?

Answer 631

Previous regular menses, no periods for 3x the usual menstrual interval. If menses are irregular then 6 months

Question 632

Define oligomenorrhea?

Answer 632

Infrequent menstrual cycles, often longer than 35 days, i.e. 4-9 per year.

Question 633

Causes/differential diagnosis of amenorrhea

Answer 633

- Outflow Tract Causes - Primary ovarian insufficiency - Hypothalamic or pituitary disorders (Central): low FSH + low estradiol - Other endocrine gland disorders - Amenorrhea attributed to chronic disease - Physiologic or induced

Question 634

Most common causes of primary amenorrhea

Answer 634

1. Müllerian agenesis 2. Abnormal sex chromosomes (Turner’s syndrome) 3. Functional hypothalamic amenorrhea

Question 635

Outflow tract causes of amenorrhea?

Answer 635

- Acquired: cervical stenosis, intrauterine adhesions (Asherman’s Syndrome). - Congenital: Imperforate hymen, abnormal anatomy (Rokitansky-RKH syndrome (absent uterus)), Mullerian agenesis, transverse vaginal septum, 5alpha-reductase deficiency

Question 636

Primary ovarian insufficiency causes of amenorrhea?

Answer 636

- Acquired: autoimmune, chemotherapy or radiation | - Congenital: Turner syndrome (45 XO), gonadal dysgenesis

Question 637

Hypothalamic or pituitary disorders (central) causes of amenorrhea?

Answer 637

- Autoimmune disease - Brain radiation (panhypopituitarism - Constitutional delay of puberty - Empty sella syndrome - Functional (overall energy deficit or stress) - Eating disorder, Stress, Vigorous exercise, Weight loss - Gonadotropin deficiency (e.g., Kallmann syndrome) - Hyperprolactinemia - Adenoma (prolactinoma), Chronic kidney disease, Medications or illicit drugs (e.g., antipsychotics, opiates), Physiologic (pregnancy, stress, exercise) - Infarction (e.g., Sheehan syndrome) - Infiltrative disease (e.g., sarcoidosis) - Infection (e.g., meningitis, tuberculosis) - Medications or illicit drugs (e.g., cocaine) - Trauma or surgery - Tumor (primary or metastatic)

Question 638

What is Sheehan syndrome?

Answer 638

Postpartum w/ major bleed, infarction to pituitary

Question 639

Physiologic or induced causes of amenorrhea?

Answer 639

- Breastfeeding - Contraception - Exogenous androgens - Menopause - Pregnancy

Question 640

Amenorrhea attributed to chronic disease

Answer 640

- Celiac disease - Inflammatory bowel disease - Other chronic disease

Question 641

Other endocrine gland disorders that cause amenorrhea?

Answer 641

- Adrenal insufficiency - Androgen-secreting tumor (e.g., ovarian or adrenal) - Cushing syndrome - Diabetes mellitus, uncontrolled - Late-onset congenital adrenal hyperplasia - Polycystic ovary syndrome (multifactorial) - Thyroid disease

Question 642

What should be asked on history for amenorrhea

Answer 642

- Menstrual patterns (if any), pregnancy and breastfeeding history, eating and exercise habits, psychosocial stressors (e.g., perfectionist behaviors), changes in body weight, fractures, medication or substance use, chronic illness, and timing of breast and pubic hair development - Family history of early or delayed menarche - Hirsutism, acne - Chemotherapy or radiation

Question 643

Physical exam for amenorrhea?

Answer 643

- Thyroid examination (thyroid disease), Acanthosis nigricans or skin tags (Hyperinsulinemia (PCOS)) - Anthropomorphic measurements; growth charts (Turner syndrome, constitutional delay of puberty) - Body mass index (High: PCOS, Low: Functional hypothalamic amenorrhea) - Breast development (normal progression) - Presence of circulating estrogen - Dysmorphic features (e.g., webbed neck, short stature, low hairline) - Turner syndrome - Male pattern baldness, increased facial hair, acne - Hyperandrogenism, PCOS, ovarian or adrenal tumor, CAH, Cushing syndrome - Pelvic examination: Absence or abnormalities of cervix or uterus, Clitoromegaly, Presence of transverse septum or imperforate hymen, atrophic vaginal mucosae

Question 644

Investigations for amenorrhea?

Answer 644

- hCG + hormonal workup (TSH, serum LH and FSH, prolactin (MRI if abnormal), Testosterone/DHEA/Cortisol, E2), CBC, Anti-Müllerian hormone - Progesterone Challenge - Karyotype: if FSH is high in a patient under age 30 + short stature or absent uterus or virilization (usually 21-OH deficiency, Congenital Adrenal Hyperplasia). - U/S to confirm normal anatomy, identify PCOS

Question 645

What is the progesterone challenge?

Answer 645

- Give 10mg of medroxyprogesterone (Provera) for 10 days - Withdrawal bleeding may indicate estrogen exposure (e.g., polycystic ovary syndrome [PCOS]) and lack of bleeding may indicate a low estrogen condition (Central or ovarian cause)

Question 646

What is Müllerian agenesis?

Answer 646

Müllerian agenesis is caused by embryologic underdevelopment of the müllerian duct, with resultant agenesis or atresia of the vagina, uterus, or both

Question 647

Treatment of Müllerian agenesis?

Answer 647

Psychological counselling, Creation of neo-vagina with dilation

Question 648

Transverse septum and imperforate hymen may present with _____

Answer 648

Cyclic pelvic pain

Question 649

Transverse septum and imperforate hymen treatment?

Answer 649

Surgical management

Question 650

Intrauterine adhesions can occur after endometrial instrumentation and are corrected using

Answer 650

Hysteroscopy

Question 651

5α-reductase deficiency are phenotypic ____ that develop ___ secondary sex characteristics at puberty due to male level testosterone

Answer 651

Females | Male

Question 652

Those with 5α-reductase deficiency may require evaluation by a pediatric urologist based on malignancy risk and patient or guardian preferences. What procedure might be performed?

Answer 652

Prophylactic gonadectomy

Question 653

How is primary ovarian insufficiency diagnosed?

Answer 653

Diagnosed in patients younger than 40 years with two serum follicle-stimulating hormone levels in the menopausal range obtained at least one month apart (High FSH + LH/low estrogen)

Question 654

Treatment of primary ovarian insufficiency

Answer 654

- HRT - If no breast development, start low and go slow (do not use OCP @ the start since this can lead to tubular breasts), give estrogen alone first and in low doses THEN add cyclic progesterone after 12-18mo → once breast development occurred, use OCP or cyclic hormones - 1,200 mg of calcium daily and 1,000 IU of vitamin D daily with regular weight-bearing exercises to maintain bone mineral density

Question 655

What is functional hypothalamic amenorrhea and its causes?

Answer 655

Functional hypothalamic amenorrhea is a disorder of chronic anovulation caused by suppression of the hypothalamic-pituitary axis from body weight loss, excessive exercise, or stress and may result in infertility or bone density loss.

Question 656

Female Athletic Triad

Answer 656

Amenorrhea + osteopenia/porosis + eating disorder.

Question 657

Hormonal findings in functional hypothalamic amenorrhea

Answer 657

- Bone mineral density testing should be considered after six months of amenorrhea - Treatment should correct the underlying cause to restore ovulatory function through behavior change, nutritional repletion (e.g., caloric intake, vitamin D), stress reduction, and weight gai

Question 658

What is hyperprolactinemia and how can it cause amenorrhea?

Answer 658

Elevated serum prolactin may induce amenorrhea by inhibiting gonadotrophs.

Question 659

Imaging required for hyperprolactinemia

Answer 659

MRI

Question 660

Rotterdam Criteria (2003) for PCOS?

Answer 660

Need at least 2 of 3 criteria - Oligo/anovulation - Hyperandrogenism (clinical and/or biochemical) - Polycystic ovaries on ultrasound

Question 661

Hormonal findings in PCOS

Answer 661

Normal FSH/estro + low progesterone

Question 662

Treatment for PCOS?

Answer 662

- Patients should be screened for hypertension and an elevated body mass index at each visit, and should be screened for dyslipidemia and impaired glucose tolerance (i.e., two-hour oral glucose tolerance testing [preferred] or A1C level) every three to five years - Weight loss may restore regular menses and improve metabolic comorbidities in patients with an elevated body mass index - Combined hormonal contraceptives are first-line therapy for menstrual abnormalities, hirsutism, acne, and protection from endometrial cancer caused by unopposed estrogen secretion - For patients with PCOS and infertility, letrozole (Femara) is a first-line therapeutic option, because it confers higher ovulation, pregnancy, and live birth rates than clomiphene

Question 663

Etiology of dysmenorrhea

Answer 663

1. Primary/idiopathic (no pelvic abnormality) 2. Secondary(acquired) - Endometriosis - Adenomyosis - Uterine polyps - Uterine anomalies (e.g. non-communicating uterine horn) - Leiomyoma - Ovarian cysts - Cervical stenosis - Imperforate hymen, transverse vaginal septum - Pelvic inflammatory disease - IUD (copper) - Foreign body

Question 664

Definition of primary dysmenorrhea

Answer 664

Recurrent, crampy lower abdominal pain that occurs during menses in the absence of demonstrable disease

Question 665

Definition of secondary dysmenorrhea

Answer 665

Similar features as primary dysmenorrhea but with an underlying disorder that can account for the symptoms, such as endometriosis, adenomyosis or uterine fibroids

Question 666

Signs and symptoms of primary dysmenorrhea

Answer 666

- Spasmodic pain, is superimposed over constant lower abdominal pain, radiating to the lower back, labia, and inner thighs beginning hours before onset of bleeding and persisting for hours or days (48-72 h) - Associated symptoms: N/V, altered bowel habits, headaches, fatigue (prostaglandin-associated) - Symptoms begin soon after menarche or during adolescence

Question 667

Diagnosis of primary dysmenorrhea

Answer 667

- Assess for associated dyspareunia, abnormal bleeding, infertility (signs of 2o dysmenorrhea) Rule out underlying pelvic pathology and confirm cyclic nature of pain - Pelvic examination not required; indicated for patients not responding to therapy or with signs of organic pathology

Question 668

History that should be asked for dysmenorrhea

Answer 668

- History of present illness should cover complete menstrual history, including age at onset of menses, duration and amount of flow, time between menses, variability of timing, and relation of menses to symptoms. - The age at which symptoms began, Their nature and severity, Factors that relieve or worsen symptoms (including the effects of contraceptives), Degree of disruption of daily life, Effect on sexual activity, Presence of pelvic pain unrelated to menses, Response to acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) - Review of systems should include accompanying symptoms such as cyclic nausea, vomiting, bloating, diarrhea, and fatigue. - Past medical history should identify known causes, including endometriosis, uterine adenomyosis, or fibroids. Method of contraception should be ascertained, specifically asking about IUD use. - Past surgical history should identify procedures that increase risk of dysmenorrhea, such as cervical conization and endometrial ablation. - Sexual history should include prior or current history of sexual abuse or other traumatic events.

Question 669

Treatment of primary dysmenorrhea

Answer 669

- Regular exercise, local heat - NSAIDs: should be started before onset of pain Combined hormonal contraceptives with continuous or extended use: suppress ovulation/ reduce menstrual flow

Question 670

Physical exam for dysmenorrhea?

Answer 670

Pelvic examination focuses on detecting causes of secondary dysmenorrhea. The vagina, vulva, and cervix are inspected for lesions and for masses protruding through the cervical os. Structures are palpated to check for a tight cervical os, prolapsed polyp or fibroid, uterine masses, adnexal masses, thickening of the rectovaginal septum, induration of the cul-de-sac, and nodularity of the uterosacral ligament.

Question 671

Signs and symptoms of secondary dysmenorrhea

Answer 671

Associated dyspareunia, abnormal bleeding, infertility

Question 672

Diagnosis of secondary dysmenorrhea

Answer 672

- Bimanual exam: uterine or adnexal tenderness, fixed uterine retroflexion, uterosacral nodularity, pelvic mass, or enlarged irregular uterus (findings are rare in women <20 yr) - U/S, laparoscopy and hysteroscopy may be necessary to establish the diagnosis - Vaginal and cervical cultures may be required

Question 673

Treatment of secondary dysmenorrhea

Answer 673

Treat underlying cause

Question 674

Contraindications of oxytocin

Answer 674

Contraindications: prior classical/high risk C-section, prior uterine rupture, active genital herpes infection, previa/vasa previa, cord prolapse, transverse fetal lie, invasive cervical cancer, or abnormal fetal heart tracing

Question 675

Methods of induction of labour

Answer 675

1. Cervical Ripening (0-3cm Dilated): meds/other means to soften, efface, dilate cervix, ^likelihood of successful induction 2. Amniotomy/Artificial Rupture of Membranes (ARM): stimulate PG synthesis/secretion, may use this if cervix is open/soft and membranes can be felt, and if the head is present at the cervix + oxytocin = more women delivery vaginally at 24h than ARM alone and had fewer operative deliveries 3. Oxytocin (>3cm Dilated): 20U in 1L NS, run at 0.5-2 mU/min IV increasing by 1-2 mU/min q20-60min to a max of 36-48 mU/min. Dosage Recommendations: use the minimum dose to reach active labour and increase q30min as needed; reassessment should occur once a dose of 20 mU/min is reached

Question 676

Indications of cervical ripening

Answer 676

Indications: for Bishop score <6 prior to induction of labour

Question 677

Methods of cervical ripening?

Answer 677

- Prostin Gel: dinoprostone (prostaglandin E2) long/closed cervix, use this prostaglandin gel every 6-12h up to 3 doses - Cervidil: long/closed cervix, use if ROM – continuous release, can be removed if needed (controlled PGE2 release) - Cytotec/Misoprostol: long/closed cervix, more commonly used in 2nd trimester termination of pregnancy - Mechanical: use a foley catheter to mechanically dilate the cervix

Question 678

Complications of oxytocin?

Answer 678

Hyperstimulation/tetanic contraction (may cause fetal distress or rupture of uterus), uterine muscle fatigue, uterine atony (may result in PPH), vasopressin-like action causing anti-diuresis

Question 679

Risk factors for postpartum infection?

Answer 679

Patients of low socioeconomic status undergoing c-section who have had prolonged labor and rupture of membranes (ROM) incur 40-85% risk of endometritis. Multiple vaginal exams during labour!

Question 680

What is endometritis?

Answer 680

Affects endometrium and myometrium but can progress beyond the uterus to include abscess, peritonitis, and pelvic thrombophlebitis. It is historically referred to as puerperal fever and is divided into early (within 24–48 h) and late (>48 h) postpartum.

Question 681

Testing for ____ should be done when endometritis presents >7 days after delivery and in patients at high risk such as adolescents

Answer 681

Chlamydia

Question 682

Treatment of endometritis?

Answer 682

Empiric combination of clindamycin (900 mg q8 h IV or 600 mg q6 h IV) and an aminoglycoside (most commonly gentamicin 5 mg/kg q24 h or 1.5 mg/kg q8 h) remains the most effective regimen to treat postpartum endometritis; the addition of ampicillin or vancomycin as a third agent if enterococcus is suspected or isolated (pure culture or heavy growth from endometrial specimen)

Question 683

Postpartum fever and infection Ddx?

Answer 683

Consider UTI, wound infection, mastitis/breast abscess, endometritis or deep surgical infection, septic pelvic thrombophlebitis, drug reaction, clostridium difficile-associated diarrhea, complications related to anesthesia, PE/amniotic fluid embolism

Question 684

Antepartum risk factors of postpartum hemorrhage?

Answer 684

Personal Hx of PPH, overdistention (LGA, multiples, polyhydramnios), atony (fibroids), retained tissue (previa, uterine surgery, succenturiate lobes), coagulopathy (FHx, anticoagulated), distortion of uterus (placenta previa)

Question 685

Intrapartum risk factors of postpartum hemorrhage?

Answer 685

Atony (prolonged labour, induction/augment/chorioamnionitis), trauma (operative vag delivery, precipitous delivery, LGA).

Question 686

What is the active management of the 3rd stage of delivery?

Answer 686

- Oxytocin Bolus – 5 units IV push or 10 units IM (if no IV) with anterior shoulder, helps placental separation - Oxytocin Infusion – 20 units per 1000cc crystalloid, run @ 125cc/hr and titrate to flow - Uterine Massage – as soon as placenta delivered - Inspection of Placenta – missing cotyledons, edges for evidence of succenturiate lobes, and document! - Be Prepared: NPO during labour, early IV access, CBCd/T&S on admission, extra help, i.e. if known placenta previa/accrete/percreta…when dealing with blood loss, reestablishing intravascular volume > replacing RBCs (3L of crystalloid for 1L blood loss). Pay close attention to symptoms like pallor, pulse, and pulse pressure.

Question 687

What are the signs of placental separation?

Answer 687

Gush of blood, lengthening of the cord, anterior cephalad movement of the uterine fundus (which is firm and globular) – 30 min, gentle traction, prevent inversion with countertraction

Question 688

Pregnancy adaptations that are protective against blood loss during pregnancy

Answer 688

- Increase in Blood Volume – may lead to anemia - Preload leading to increase cardiac output – autotransfusion 500-750cc uteroplacental blood (if the uterus contracts appropriately), relief of compression of IVC

Question 689

Definition of postpartum hemorrhage?

Answer 689

- Definition: Loss of >500 mL of blood with VD or >1000 mL with C/S or >10% drop in Hgb (lab definition) - Early: within first 24 hours postpartum - Late: >24 hours but within first 6 weeks

Question 690

4 T’s of postpartum hemorrhage?

Answer 690

1. Abnormalities of Uterine Contraction: Tone - Primary mechanism is to stop bleeding at the placental insertion site 2. Products of Conception: Tissue 3. Trauma 4. Abnormalities of Coagulation: Thrombin

Question 691

Causes of abnormal uterine contraction causing postpartum hemorrhage?

Answer 691

- Overdistended uterus for polyhydramnios, multiple gestation, or macrosomia - Uterine muscle exhaustion for rapid/prolonged labour, high parity - Intra amniotic infection for fever, prolonged ROM - Functional anatomic distortion of the uterus from fibroids, previa (the tissue in the lower end has less ability to contract), or uterine anomalies (bifurcate/septum)

Question 692

Causes of trauma causing postpartum hemorrhage?

Answer 692

- Lacerations of the cervix, vagina, or perineum due to precipitous delivery and operative delivery - Extensions/lacerations of c-section - Uterine rupture - Uterine inversion

Question 693

Causes of products of conception causing postpartum hemorrhage?

Answer 693

- Retained products due to incomplete placenta delivery, uterine surgery, high parity, abnormal placenta (cotyledon/succinturiate) - Retained clots due to uterine atony

Question 694

Causes of abnormal coagulation causing postpartum hemorrhage?

Answer 694

- Hereditary: hemophilia A, vonWillebrand’s Disease (most common) - Acquired: liver disease, ITP, thrombocytopenia of preeclampsia, DIC (due to PEE), IUFD, infection, abruption, amniotic fluid embolus - Therapeutic anticoagulation

Question 695

Fluid resuscitation of class 1 = 500-1000cc (compensated) PPH?

Answer 695

Transfusion not usually necessary

Question 696

Fluid resuscitation of class 2 = 1000-1500cc PPH?

Answer 696

Crystalloid (transfuse 3L crystalloid per 1L of blood loss (3:1) +/- Colloid (e.g. Albumin ~ ^Oncotic Pressure to pull more fluid from interstitium)

Question 697

Symptoms of class 1 = 500-1000cc (compensated) PPH?

Answer 697

No symptoms

Question 698

Fluid resuscitation of class 3 = 1500-2000cc PPH?

Answer 698

- Crystalloid (transfuse 3L crystalloid per 1L of blood loss (3:1) +/- Colloid (e.g. Albumin ~ ^Oncotic Pressure to pull more fluid from interstitium) - Use P-RBCs if Hgb < 60. If 60-100 consider other factors like patient comorbidities

Question 699

Fluid resuscitation of class 4= >2000c PPH?

Answer 699

Transfusion protocol (+RBC transfusion)

Question 700

Symptoms of class 2 = 1000-1500cc PPH?

Answer 700

Diaphoresis/anxiety/weak/tachy-HR-RR/narrow PP

Question 701

Symptoms of class 3 = 1500-2000cc PPH?

Answer 701

Altered LOC, decreased systolic BP

Question 702

Symptoms of class 4= >2000c PPH?

Answer 702

All the symptoms found in class 3, but oliguria, anuria

Question 703

Management of postpartum hemorrhage?

Answer 703

1. initial assessment (ABCs) – vitals, establish IV access (large bore), oxygen, monitor BP/HR/RR/urine output/SP02 +/- insert a catheter – assess etiology! Blood Work: CBC, coagulation screen (LOW fibrinogen or low platelets ~ worry about DIC), Type & Cross Screen 2. STEP TWO: directed therapy

Question 704

Treatment of abnormal uterine contraction causing postpartum hemorrhage?

Answer 704

Assess fundal height/drain bladder…bimanual uterine massage + compress + - Syntocinon* 20 units in 1000cc crystalloid - Carboprost 250ug IM or I-myometrially q15m (max 2) - Misoprostol 400-800ug PO/SL, 800-1000ug rectal - Ergotamine 250ug IM or IV q5min up to 1.25mg

Question 705

Treatment of products of conception causing postpartum hemorrhage?

Answer 705

EUA/manual removal in OR (consider Abx) + curettage (done carefully)

Question 706

Treatment of trauma causing postpartum hemorrhage?

Answer 706

Explore vagina/cervix…correct inversion + repair lacerations + identify rupture

Question 707

Treatment of abnormal coagulation causing postpartum hemorrhage?

Answer 707

- Thrombin: reverse + anticoagulation + replace factors - Hematology Labs: CBCd + Type & Screen +/- Cross Match - Coagulation: PTT/PT-INR + Bleeding Time (Red top tube, if >7m to clot, consider coagulopathy)

Question 708

Management of intractable

Answer 708

3. STEP THREE: - Get Help: call anesthesia, book OR, prepare labs, ICU - Tamponade for Atony: Bakri Balloon OR Intrauterine Foley Catheter OR… - Manual Compression: pack uterus, vasopressin, embolization - Transfuse: either give crystalloid or blood products 4. STEP FOUR: surgery or B-Lynch/Cho sutures (if C/S): Repairs/Removals: repair lacerations, ligate vessels (uterines/internal iliac – just one side), uterine artery embolization, hysterectomy (can do elective if known placenta percreta) 5. STEP FIVE: post-hysterectomy bleeding Last Ditch: pack the abdomen, angiographic embolization

Question 709

Who receives continuous electronic FHR

Answer 709

Reserved for abnormal auscultation, prolonged labour, labour that is induced/augmented, meconium present, or multiple gestation/fetal complication – either doppler (external) or fetal scalp electrode (internal)

Question 710

Baseline FHR?

Answer 710

110-160bpm

Question 711

Non-pharmacologic pain relief techniques for labour?

Answer 711

- Reduction of painful stimuli (maternal movement, position change, counter-pressure, abdo compression) - Activation of peripheral sensory receptors (superficial heat/cold, immersion in water during labour, touch/massage, acupuncture/acupressure, TENS, intradermal injection of sterile water, aromatherapy) - Enhancement of descending inhibitory pathways (attention focusing and distraction, hypnosis, music/audio analgesia, biofeedback)

Question 712

Pharmacologic options for labour?

Answer 712

- Nitrous Oxide (e.g. self-administered Entonox) - Narcotics + Anti-emetic (Morphine if early in labour > 4 hours of delivery, Fentanyl if late in labour + Gravol) - Pudendal nerve block - Perineal infiltration with local anesthetic - Regional anesthesia (epidural block, combined spinal-epidural, spinal)

Question 713

Fetal indications of operative vaginal delivery?

Answer 713

Fetal Indications: atypical or abnormal FHR tracing, evidence of fetal compromise; consider if 2nd stage is prolonged, as this may be due to poor contractions or failure of fetal head to rotate

Question 714

Maternal indications of operative vaginal delivery?

Answer 714

Maternal Indications: need to avoid voluntary expulsive effort (e.g. CVD, CAD); exhaustion, lack of cooperation, and excessive analgesia may impair pushing effort

Question 715

Contraindications of operative vaginal delivery?

Answer 715

Non-vertex cephalic presentation, unengaged head, cervix incompletely dilated Contraindications for Vacuum: <34wk (<2500g), fetal head deflexed, fetus requires rotation, bleeding disorder

Question 716

Absolute contraindications of vaginal (scheduled) delivery?

Answer 716

Placenta previa, conjoined twins, previous classical (vertical T) c-section or full-thickness hysterotomy, malpresentation (transverse or footling types), absolute cephalopelvic disproportion (CPD), underlying maternal illness (eclampsia, HELLP, heart disease), fetal condition where labour is contraindicated (ONTD, thrombophilia, certain anomalies).

Question 717

Relative contraindications of vaginal (scheduled) delivery?

Answer 717

2 or more prev C-section, frank or complete breech, twins, evidence of fetal compromise/placental dysfunction before labour (IUGR, abnormal Doppler).

Question 718

Risks/Complications of C-Section delivery

Answer 718

Complications related to anesthesia, hemorrhage (avg loss 1000cc), infection (single dose antibiotic should be use), injury to surrounding structures, thromboembolism (DVT, PE), ^recovery time/hospital stay, maternal mortality (<0.1%). The more C/S you have, the higher the rate of accreta (placental attachment abnormally to myometrium) and previa

Question 719

Indications for emergent C-Section delivery

Answer 719

Known/suspected uterine rupture, dystocia or CPD, abnormal fetal heart rate, labour complications – cord prolapse, failed attempt at operative vaginal. Main ones are abnormal heart rate, arrest of labour process.

Question 720

Female treatment for infertility?

Answer 720

- Lifestyle modifications: cessation of alcohol, nicotine, and recreational drug use as they contribute to subfertility. - Treatment of underlying causes (e.g., levothyroxine for hypothyroidism, bromocriptine for hyperprolactinemia, metformin for PCOS) - Ovulation induction: ● Clomiphene citrate estrogen antagonist = ^FSH/LH = ovulation ● GnRH (pulsatile): stimulation of FSH and LH release - follicle maturation ● bHCG for simulation of ovum release - IVF - Oocyte/sperm donors - Surgery - tubuloplasty, lysis of adhesions