Obstetrics & Gynaecology Flashcards
1
Q
Treating Herpes Simplex, including pregnant and immunocompromised pts
A
Acyclovir 400mg TDS 7-10d first ep, 3-4 days recurrent episodes.
Fine in pregnancy.
Valcyclovir- more expensive. Both reduce viral shedding. Reduce symptoms. Also shorten viral excretion time and the duration of illness.
Immunocompromised pts require IV acyclovir
2
Q
Complications of PCOS
A
- NIDDM
- Endometrial cancer
- Nonalcoholic steatohepatitis
3
Q
Maternal and fetal complications of shoulder dystocia
A
Fetal
1) hypoxic ischaemic encephalopathy (chest compression by vagina or cord compression by pelvis can lead to hypoxia)
2) brachial plexus injury (Erb’s palsy: C5-C7; Klumpke’s palsy: C8-T1), 90% resolve within 6 mo
3) fracture (clavicle, humerus, and cervical spine)
4) death
Maternal
1) perineal injury
2) PPH (uterine atony)
4
Q
The window for antenatal treatment with corticosteroids
A
23-34 weeks
5
Q
Risk factors for ovarian torsion
A
- Women of repro age in 20s and 30s
- Pregnancy
- Anything involving induction of ovulation
- Ovarian tumours (benign) (usually dermoid cysts)
6
Q
Management of endometrial polyps
A
dx: pelvic ultrasound and treatment is d/c + bx to exclude cancer
7
Q
Risk factors for amniotic fluid embolus
A
placental abruption
rapid labour
multiparity
uterine rupture
uterine manipulation
induction medication and procedures
8
Q
Endometrial cancer risk factors
A
- Oestrogen exposure
- Nulliparity (2-3x increase)
- Early menarche Late menopause
- Unopposed menopausal oestrogen use
- PCOS (relative risk of 3)
- Diabetes
- Oestrogen producing ovarian tumours
- Obesity (2-3x increase in risk)
- High doses of tamoxifen
- Hypertension
- Thyroid disease
- Gallbladder disease
- Caucasian
9
Q
Management of placenta previa
A
Two categories of management: Not ready to deliver eg fetal immaturity. Stabilise the patient. Give a tocolytic to suppress labour. It buys time. Then give corticosteroids to promote fetal lung development. Deliver by caesarean if you have mature lungs. Fetal distress is a good reason.
10
Q
How to treat acute pyelonephritis in pregnancy
A
Acute pyelonephritis in pregnancy is treated in hospital with ivabx (Ceftriaxone) until the pt is afebrile for 24-48h and symptomatically improved
11
Q
Complications of uterine rupture
A
Maternal death 1-10%
1) maternal hemorrhage, shock, DIC
2) amniotic fluid embolus
3) hysterectomy if uncontrollable hemorrhage
4) fetal distress, associated with infant mortality as high as 15%
12
Q
Shoulder dystocia- risk to fetus of long term disability
A
1%
13
Q
Name a specific maternal contraindication to antenatal corticosteroids
A
Active TB
14
Q
atrophic vaginitis tx
A
topical estrogen
15
Q
Gardnerella vaginalis is the cause of what? And with which other organism is it commonly associated?
A
Bacterial vaginosis
Associated frequently with Mycoplasma Hominis
16
Q
Management of seizures in eclampsia
A
Loading dose of magnesium sulphate 4-6g followed by an infusion 2g/hr.
17
Q
Treatment of endometritis
A
Tx clindamycin + gentamicin
18
Q
Complications of bacterial vaginosis
A
- second and third trimester premature labour and birth
- Post natal endometritis
- Sometimes PID
19
Q
Risk factors for placental abruption
A
- Trauma
- Cocaine
- Polyhydramnios
- Chronic hypertension
- Pre-eclampsia Eclampsia
- PROM- prolonged
- Chorioamnionitis
- Previous ischaemic placental disease (IUGR)
- Maternal age
- Parity
- Smoking
- Male infant
20
Q
Name the condition:
Agalactorrhea, post-partum amenorrhea, secondary hypothyroidism, adrenalinsufficiency
A
Sheehan’s syndrome
21
Q
Definition of post partum haemorrhage
A
Blood loss >500mls after the third stage of labour
22
Q
Name the most common STI in Canada
A
Chlamydia
23
Q
Indications for the induction of labour
A
Pre-eclampsia
Bad fetal signs
Placental abruption
Preg is 42w or more
24
Q
Sites of endometriosis
A
Ovaries 60%
Broad ligament
Vesicoperitoneal fold
Cul de sac
Rectosigmoid colon + appendix
Also reported in liver, brain, lung & old scars
25
Physical examination in endometriosis
Physical exam: uterosacral nodularity on rectovaginal exam, fixed retroverted uterus
26
The drug of choice for chlamydia when a) not pregnant b) pregnant
a) Doxycycline b) Azithromycin
27
Definitive diagnosis of endometriosis
Laparoscopy
28
Drug of choice to reduce blood pressure in eclampsia
Labetolol
29
Defining characteristics of pre-term labour
Regular contractions (2 in 10 mins)
cervix \>2cm
\>80% effaced prior to term (20-37w)
30
What is colpitis macularis (strawberry cervix) associated with?
Trichomonas infection
31
Risk factors for placenta previa
* Mutiparity
* Prior caesarian
* Fibroids + uterine abnormalities
* Smoking + cocaine use
* Multifetal pregnancy
* Advanced maternal age
* Infertility Rx
* Previous uterine surgery
32
Management of uncomplicated UTI in pregnancy
First line: amoxicillin (250-500 mg PO q8h x 7 d)
alternatives: nitrofurantoin (100 mg PO bid x 7 d) or cephalosporins follow with monthly urine cultures
33
Treatment of syphilis
**Penicillin G** 2.4 million IU IM x 1 dose if early syphilis
(3 doses if late syphilis)
Monitor VDRL monthly
If penicillin G allergic: **clindamycin** 900 mg IV q8h
34
What is the significance of acanthosis nigricans?
It indicates insulin resistance
35
What's the drug of choice for trichomoniasis?
Metronidazole
36
Indications to hospitalise a patient with pelvic inflammatory disease
**Pregnant**
Lack of response or tolerance of oral meds
Can’t take oral meds/ vomiting
Severe illness
Pelvic abscess incl tubo-ovarian abscess
Non-compliance
37
Complications of placenta previa
_Placenta **a**ccreta_. It **a**ttaches to the myometrium.
_Placenta **i**ncreta_- **i**nvades the myometrium
_Placenta **p**ercreta_- **p**erforates the myometrium
Pre-term delivery
IUGR
Prem rupture of membranes
Congenital anomalies
38
Contraindications to medically managing an ectopic pregnancy
* Hemodynamically unstable
* Signs of impending or actual ectopic mass rupture
* Size larger than 3.5cm or fetal heart rate activity
* Immunodeficiency, active pulmonary disease, peptic ulcer disease
* Coexisting intrauterine pregnancy
* Non-compliance risk
* Breast-feeding
* Hypersensitivity to methotrexate
39
Chlamydia complications
* PID
* Infertility
* Ectopics
* Reactive arthritis
* Perinatal infection
40
Investigation of choice for suspected ovarian torsion
Do a transvaginal and abdominal US as a first measure Differentiate it from a ruptured ovarian cyst by the absence of peritoneal fluid on US
41
Chancroid organism
Haemophilus ducreyi
42
Causes of postpartum haemorrhage
**The four Ts**
Uterine **atony**- loss of strength of uterine muscle causes failure of contraction and retraction of the uterus. Caused by over distended uterus - fetal macrosomia, twins etc. Most common cause of PPH
**Tissue**- placenta not properly expelled after delivery
**Trauma**- during delivery. Incl uterine rupture
**Thrombosis**. Ay kind. Eg thrombocytopenia, low platelets
43
Ectopic pregnancy risk factors
* Age \>35
* Prev ectopic (15% chance of recurrence)
* Hx PID (scarring fallopian tube)
* Tubal pathology and surgery
* IUD
* Multiple sexual partners (dt risk of PID)
* Smoking due to impaired immunity in smokers
* Prior induced abortion
* In utero diethylstilbestrol exposure
* Infertility (tubal abnormalities)
44
Management of mild and moderate placental abruption at term
Mild- You can try a vaginal delivery if there is no fetal compromise Moderate- deliver urgently regardless of gestational age
45
Diagnosis of PCOS
_The Rotterdam criteria, 2/3_
Oligomenorrhoea/irreg periods for 6m
Hyperandrogenism
Polycystic ovaries on US
46
The AMSEL criteria for diagnosis of bacterial vaginosis
Whiff test (fishy odour KOH) and clue cells.
47
Cause of pain associated with fibroids
fibroid outgrows blood supply
48
Typical presentation of endometrial polyps
vaginal bleeding between periods
49
Definition of uterine hyperstimulation
Defined as contractions that are 2mins in length or less.
So **more than 5 in ten minutes**
50
Diagnosis and treatment of chancroid
Dx "school of fish" on Gram stain → Tx azithromycin or ceftriaxone
51
Breastfeeding contraindications
Active herpetic breast lesions
Active TB
Untreated brucellosis
After radioactive isotopes
Chemotherapy
Recreational drugs
52
Causes of vulvar/ vaginal itching
1. Bacterial vaginosis
2. Vaginal/vulvar candidiasis
3. Trichomonas vaginalis
4. Chemical vaginitis
53
Commonest sites of ectopic pregnancies
**ampullary (70%)**, isthmic (12%), fimbrial (11%)
54
Any woman presenting with abdominal pain, vaginal bleeding and amenorrhea is what until proven otherwise?
An ectopic pregnancy
55
Teratogenic antibiotics
Tetracyclines Fluoroquinolones Aminogylcasides Sulfonamides
56
A patient failing to lactate after a delivery with heavy blood loss
Sheehan syndrome
57
Uterine bleeding at 18 weeks. No products expelled. Os is open.
Inevitable abortion
58
Uterine bleeding at 18 weeks. No products expelled. Os is closed.
Threatened abortion
59
Most common cause of amenorrhea
Pregnancy
60
The term for heavy bleeding during and between menstrual periods
Menometrorrhagia
61
Therapy for PCOS
Weight Loss and OCPs. Consider metformin.
62
Laparoscopic findings in endometriosis
Powder burns and chocolate cysts
63
Most common location for an ectopic pregnancy
The AMPULLA of the oviduct
64
Patient has increased vaginal discharge and petechial patches in the upper vagina and cervix
Trichomonal vaginitis
65
Most common cause of bloody nipple discharge
intraductal papilloma
66
Breast malignancy presenting as itching, burning and erosion of the nipple
Paget disease
67
Annual screening for women with a strong family Hx of ovarian cancer
CA-125 and transvaginal ultrasonography
68
Non-surgical options for stress incontinence
Kegel exercises
Estrogen
Pessaries for stress incontinence
69
Lab values suggestive of menopause
Increased FSH
70
Most common cause of female infertility
1. Ovulation disorders
2. Endometriosis
71
Molar pregnancy containing fetal tissue
Partial mole
72
Typical Abx for GBS prophylaxis
IV penicillin or ampicillin
73
Investigation of choice in a woman w postmenopausal bleeding
Hysteroscopy. Not US
74
Difference between a total and a radical hysterectomy
A _total hysterectomy_ removes the whole uterus and cervix.
In a _radical hysterectomy_, a surgeon removes the whole uterus, tissue on the sides of the uterus, the cervix, and the top part of the vagina. Radical hysterectomy is generally only done when cancer is present.
75
Rx if endometrial cancer is confined to the uterus:
Total extrafascial abdominal hysterectomy w bilateral salpingo-oophorectomy + pelvic + para-aortic LN dissection, with CA-125 as a marker for F/U
76
Rx if endometrial cancer is beyond stage II
Hysterectomy, bilateral slapingo-oophorectomy, and if it’s stage II or greater do radiotherapy
77
Rx for a vaginal recurrence of endometrial cancer
Transvaginal brachytherapy
78
First line treatment abnormal uterine bleeding
Ibuprofen
Fibrinolytics
COCP (but not in a smoker \>35, thromboembolism). Note that oestrogen therapy on it’s own would make it worse
Progestins on days 10-14
Mirena coil
Danazil
79
Causes of post-coital bleeding
Cervical malignancy (squamous cell 95%, adeno 5%)
Polyps
Vaginal atrophy
80
Clinical examination findings in endometriosis
Fixed, retroverted uterus, nodular ligaments, firm adnexal mass (endometrioma)
81
Sites of endometriosis (in descending order)
1. **Ovaries 60%**
2. Broad ligament
3. Vesicoperitoneal fold
4. Cul de sac
5. Rectosigmoid colon + appendix
6. Also reported in liver, brain, lung + old scars
82
Treatment options for endometriosis
**NSAIDs** for mild sx
**OCPs** help the vast majority by preventing ovulation which leads to thinning of the endometrium
**GnRH agonist-** Leuprolide (US: Lupron), suppresses O production
Excision directly or by lasers to preserve fertility
Hysterectomy
83
Initial work up PCOS
Serum testosterone
Prolactin
17-OH progesterone
17 hydroxyprogesterone
17 OHP LH, FSH, oestradiol DHEAS TSH
84
Effect of pregnancy on thyroid hormones
Total T4 ↑bcs of ↑ THBG
85
Effect of pregnancy on creatinine
Creatinine ↓bcs of the increased GFR
86
Effect of pregnancy on GFR
GFR ↑ by 50%, this can lead to glycosuria which is not abnormal
87
The cure for eclampsia
Delivery
88
Risk of eclampsia in future pregnancies
Increased risk in future pregs, **25-50% increase in risk**
Higher future risk if you have it at less than 34w gestation, or another preg \<2 or \>10y
89
Should a woman with Hep B breastfeed
Yes apparently benefits outweigh risks
90
Rx for hot flashes of menopause
SSRIs. Fluoxetine, paroxetine, sertraline. Also SNRIs- venlafaxine
91
Herpes simplex- what kind of virus?
Large DNA virus
92
Painless red vaginal bleeding in pregnancy which stops spontaneously w a soft non tender uterus.
Placenta previa
93
Typical timing of placenta previa
After 20w, usu 29/30 weeks
94
Management of painless red vaginal bleeding in pregnancy which stops spontaneously w a soft non tender uterus, presenting at 20 weeks
If someone presents early arrange a US between 28-36w to determine placental location. In the absence of any other comps you don’t need to keep repeating the sonography.
95
Pregnant woman with Pain Vaginal bleeding (but bleeding might be concealed) Uterine hypertonus
Placental abruption
96
Placental abruption- diagnosis
Clinical
97
Management of placenta accreta
Hysterectomy
98
Lower abdo pain, adnexal tenderness, cervical motion tenderness, not pregnant
PID
99
Turner's syndrome abnormal lab tests
Gonadal dysgenesis will result in low oestrogen. FSH & LH increase oestrogen. These will both be high in Turner’s syndrome.
100
Treatment for Turner's syndrome to achieve adult height
Early Rx w GH is the DOC for helping pmts gain adult height. Giving oestrogen too early can lead to closure of epiphyseal plates so this starts at 12
101
80% of pyelonephritis is caused by which bug
E Coli
102
What's different about the pain from appendicitis vs ovarian torsion?
The latter is sudden onset
103
Diagnosis of gonorrhoea
Urethral discharge - culture + gram stain.
Characteristic gram - diplococci
Nucleic acid amplification test (NAAT)
104
Diagnosis of chlamydia
**Tissue culture**. You can't see it on a gram stain
105
Complications of shoulder dystocia
hypoxic ischemic encephalopathy (chest compression by vagina or cord compression by pelvis can lead to hypoxia)
brachial plexus injury (Erb’s palsy: C5-C7; Klumpke’s palsy: C8-T1), 90% resolve within 6 mo
fracture (clavicle, humerus, and cervical spine)
death
106
Antiretroviral triple therapy in pregnancy reduces HIV transmission to what?
reduces transmission to \<1%
107
First line Rx UTI of pregnancy
First line: **amoxicillin** (250-500 mg PO q8h x 7 d)
108
Pre-term labour- purpose of tocolytics
The primary purpose of tocolytic therapy is to delay delivery for 48 hours to allow the maximum benefit of glucocorticoids to decrease the incidence of RDS.
109
Do tocolytics delay delivery?
No
110
Maternal contraindications to tocolysis
* Bleeding (placenta previa or abruption)
* maternal disease (HTN, DM, heart disease)
* preeclampsia or eclampsia,
* chorioamnionitis
111
Fetal contraindications to tocolysis
* erythroblastosis fetalis
* severe congenital anomalies
* fetal distress/demise
* IUGR
* multiple gestation (relative)
112
Antenatal ultrasound (fetal biophysical profile)- what it looks at
_Fetal breathing:_ considered abnormal if there is absent breathing or no breathing episode for ≥20 seconds within a 30 minute lapse
_Fetal tone:_ considered abnormal if there is slow extension with return to partial flexion or absent fetal movement
_Fetal movement_ (gross body movement): considered abnormal if there is \<2 episodes of body/limb movements within a 30 minute lapse
_Amniotic fluid volume:_ considered abnormal if the largest pocket is **\<2 x 2 cm**
113
Absolute contras to the COCP
\< 6 wks postpartum
- smoker \> 35 (\>15 cigs day)
- hypertension
- current or past hx of venous thromboembolism (VTE)
- ischemic heart disease
- hx of cerebrovascular accident
- complicated valvular heart disease (pulmonary --hypertension, AF, hx subacute bact endocarditis)
- migraine headache w focal neurology
- breast cancer (current)
- diabetes with retinopathy/nephropathy/neuropathy
- severe cirrhosis
- liver tumour (adenoma or hepatoma)
114
Sacral backache with menses and deep dyspareunia
Endometriosis
115
Commonest cause of pregnancy loss in a) the first trimester b) the second trimester
a) chromosomal abnormality
b) cervical insufficiency, often secondary to a hx of cervical trauma
116
Natural history of genital warts
50% disappear in four months without Rx, and 75% in 2 years they recur with treatment
117
Rx for genital warts with the lowest rate of recurrence
Surgical excision
118
Causes of galactorrhea
* Hypothalamic or infundibular lesions
* Tumors Craniopharyngioma Germinoma Meningioma
* Infiltrative disorders Histiocytosis Sarcoidosis
* Rathke's cleft cysts
* Pituitary lesions Prolactinoma Acromegaly
* Breast surgery
* Burns
* Herpes zoster
* Spinal cord injury
* Trauma
* Hypothyroidism
* Renal insufficiency
* Medication-induced hyperprolactinemia
* Idiopathic hyperprolactinemia
119
The risk factor for endometrial cancer with the highest relative risk
**Postmenopausal estrogen** (2-10)
PCOS next (3)
120
What are the two types of hydatidiform mole and how do they differ?
_Complete_. Contains no fetal tissue, it is made of abnormal placental tissue. They are DIPLOID (androgenic 46XX or biparental 46XY)
_Incomplete,_ contains fetal tissue, the placenta grows abnormally into molar tissue. They are triploid 69XXX or 69XXY
121
Contraceptive effects of levonorgestrel IUD (Mirena)
- Mucous thickening preventing sperm entering uterus
- inhibits sperm motility
- sometimes prevents ovulation
122
The most likely cause of postpartum fever after caesarian delivery
Endometritis.
Usually day 2.
Fever, foul smelling discharge, leukocytosis
123
What is lochia?
The vaginal discharge in the puerperal period. Lasts 4-6 weeks, not offensive smelling.
124
Mechanism of action of a copper IUD
Spermicidal environment
125
Management of uterine inversion
1. The Johnson manœuvre- fist to reposition uterus
2. Hydrostatic reduction (following sublingual GTN)- with warm saline (the O'Sullivan technique)
126
Young woman with aysmptomatic small ovarian cyst \<5cm- management
Repeat US 12 weeks
127
Factors associated with poor outcome in TOLAC (trial of labour after caesarian)
High BMI \>40
Hx or 2 or more caesarians
\>35 years maternal age
Fetus \>4kg
Induction of labour
128
Preferred anticoagulant for venous thrombosis a) in pregnancy b) breastfeeding
a) LMW heparin b) Warfarin
129
Single most important risk factor for endometritis
Caesarian section
130
The Pap smear is better at detecting which type of cervical cancer?
Squamous \> adeno
131
When does the Canadian cervical screening programme start?
Age 25 for women with a hx of sexual activity, with three yearly smears
132
Higher rates of cervical metaplasia are associated with which types of HPV?
HPV 16 and 18
133
At risk groups for cervical cancer in Canada
immigrant Canadians
First Nations Canadians
geographically-isolated Canadians
sex-trade workers l
ow socioeconomic status Canadians
134
Low-grade squamous intraepithelial lesion (LSIL)- potential options
Colposcopy or repeat cytology in 6/12 (if negative, repeat again in 6/12, if negative for a second time revert to routine 3 yearly screening)
135
High-grade squamous intraepithelial lesion (HSIL)- potential options
Colposcopy
136
The Jarisch–Herxheimer reaction is traditionally associated with what?
Treatment of syphilis
137
What is The Jarisch–Herxheimer reaction?
It occurs after initiation of antibacterials when treating Gram-negative infections such as E coli, syphilis and louse- and tick-borne infections. It usually manifests 1–3 hours after the first dose of Abx as fever, chills, rigor, hypotension, headache, tachycardia, hyperventilation, vasodilation with flushing, myalgia (muscle pain), exacerbation of skin lesions and anxiety. The intensity of the reaction indicates the severity of inflammation. Reaction commonly occurs within two hours of drug administration, but is usually self-limiting.
138
Management of transverse lie in labour
Emergency caesarian section
139
Definition of prolonged PROM
24 hours
140
Definition of retained placenta
Failure to deliver the placenta **within 30 minutes** of birth
141
Management of molar pregnancy associated hyperthyroidism
It usually resolves with the treatment of the gestational trophoblastic disease. Some pts will require antithyroid medication. Tachycardia and hypertension can be managed with propranolol \*\*\*
142
Management options for missed, incomplete or inevitable abortion
**Expectant**- wait, F/U with US, serial beta-hcgs
**Medical**- mifeprostone followed by misoprostol or misoprostol alone
**Surgical**- D+C
\*\*\*
143
Sudden frop in fetal heart rate during premature labour after PROM at 32 weeks. Fetus is in transverse lie. What is most likely cause?
**Cord prolapse**.
## Footnote
Should be considered with any sudden drop in fetal heart rate or sudden change in the fetal trace. It is most common in _preterm pregnancies_ where there is _unstable lie_ and spontaneous _ROM_ has occurred.
\*\*\*
144
Breastfeeding when HIV+?
No
\*\*\*
145
Signs of magnesium sulphate toxicity
Loss of patellar tendon reflexes
Hot/ flushed
Muscular paralysis
Respiratory depression
Death
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