Obstetrics/Gynecology Flashcards
How do you suspect septic pelvic thrombophlebitis?
Persistent fever unresponsive to broad-spectrum antibiotic therapy and a negative infectious evaluation (blood, urine cultures, etc)→Diagnosis of exclusion
Treatment of septic pelvic thrombophlebitis
- Anticoagulation
- Broad-spectrum antibiotics
Fetal complications of preeclampsia and the mechanism
Chronic uteroplacental insufficiency→Oligohydramnios and fetal growth restriction/small for gestational age
Why estrogen agonists (tamoxifen, raloxifene, oral contraceptives) increase the risk of venous thromboembolism?
Increase protein C resistance
Treatment for candida vaginitis. How do you identify it?
- Oral or intravaginal antifungals
- Oral fluconazole (first line treatment)
- Topical azole intravaginal
- Thick cottage cheese discharge, vaginal inflammation, pseudohyphae, normal pH (3,8-4,5)
How do you identify an acute cervicitis and differentiate it from pelvic inflammatory disease at the physical exam?
- Acute cervicitis→mucopurulent discharge and a red, inflamed, friable cervix (easily bleeds on contact with a swab)
- Pelvic inflammatory disease→pain on pelvic bimanual examination. Cervical motion (chandelier sign), uterine or adnexal tenderness
Difference between Bartholin cyst and Gartner duct cyst.
- Batholin cyst→soft, mobile, nontender, cystic mass, at 4 or 8 o’clock position at the base of the labium majus (vulva)
- Duct obstruction
- Gartner duct cyst→single o multiple cysts, submucosal along the lateral (parallel) aspect of the upper anterior vagina (DON’T involve vulva)
- Incomplete regression of the Wolffian duct during fetal development
Treatment of Bartholin cyst according to the symptoms
- Asymptomatic→Observation
- Symptomatic (same as Bartholin Abscess)→incision and drainage. Word catheter placement►↓risk of recurrence
- Antibiotics→Bartholin abscess only if cellulitis (erythema, fever)
Difference between vulvar Lichen sclerosus and menopausal atrophy.
- Lichen sclerosus→perianal thickening with fissures
- Menopausal atrophy→No perianal skin involvement
Most common cause of puerperal fever. Treatment
- Postpartum Endometritis
- Clindamycin + Gentamicin
Gold standard diagnostic test for acute cervicitis
Nucleic acid amplification test (NAAT)
What do you want to rule out with the Biophysical profile test? What mean each rank of score?
- Fetal hypoxia
- 0-4→fetal hypoxia (urgent delivery), 6→equivocal (repeat in 24 hours), 8-10→rule out fetal hypoxia
What is a fetal heart rate acceleration?
> 15 beats/min above base line and >15 seconds long within a 20-minute period in a nonstress test (NST)
*can last up to 40 minutes for 20 minute fetal sleep cycle
How do you define a growth restriction fetus?
<10th percentile weight for gestational age
What is the external cephalic version? Reason to do it.
- Maneuvers to convert a breech into a vertex presentation for delivery
- Between 37 wks and onset of labor, ↓rate of cesarean deliveries
What do you have to rule out first to do external cephalic version?
Contraindications to a vaginal delivery
*Fetal well being must be documented (NST)
What is the internal podalic version?
Perform in twin delivery to convert the second twin from a transverse/oblique to a breech presentation for subsequent delivery
What is a variable deceleration?
Abrupt ↓FHR <30 seconds from onset to nadir, followed by a rapid return to baseline, ↓≥15/min below de baseline, duration ≥15 seconds but <2 min.
*Can be but not necessarily associated with contractions. Onset, depth, and duration of each deceleration may vary.
Etiologies that may suggest a variable deceleration
- Cord compression
- Oligohydramnios
- Cord prolapse (prolonged deceleration and bradycardia)
*Common after rupture of membranes
What may suggest a late deceleration?
Uteroplacental insufficiency→Fetal hypoxia
*Placental abruption, post-term pregnancies
What may suggest a early deceleration?
Head compression
*Can be normal fetal tracing
What is the difference and the implication between intermittent and recurrent variable decelerations?
- Intermittent variable decelerations→associated with <50% of contractions►well tolerated by fetus, typically not cause fetal hypoxia, close observation
- Recurrent variable decelerations→occur with >50% of contractions►↑ risk fetal acidosis (as ↑frequency and severity of decelerations), treat
Treatment for recurrent variable decelerations when cord compression is suspected
- Maternal repositioning (ex, left lateral)→first line►↓cord compression and improve blood flow to the placenta
- Amnioinfusion→second line→instillation of saline into the amniotic sac (if ↓amniotic fluid after rupture membranes)
When do you suspect fetal acidemia and what is the best next step?
- Recurrent variable decelerations + loss of fetal heart rate variability
- Cesarean
Possible adverse effects and manifestations of prolonged administration of high doses of oxytocin
- Hyponatremia→headaches, abdominal pain, vomiting, nausea, lethargy and tonic-clonic seizures
- Hypotension
- Tachysystole
Which options do you think when report an enlarged uterus?
- Pregnancy (first to discard - ask for B-hcg)
- Leiomyoma (Asymmetric and nontender uterus)
- Adenomyosis (diffusely enlarged uterus, Symmetric and tender uterus)
Which disease correspond to postmenopauseal bleeding until proven otherwise? What test do you do?
- Endometrial cancer
- Endometrial biopsy
Which type of tumor do you expect to find in a postmenopausal woman with vaginal bleeding and ovarian mass? Important fact at the uterus and why does it happen?
Granulosa-theca cell tumor→Estrogen secretor→Endometrial hyperplasia
Most common cause of second stage prolonged or arrested labor
Fetal malposition→deviation from occiput anterior (occiput transverse, occiput posterior)→cause cephalopelvic disproportion
Optimal fetal position
Occiput anterior→facilitated cardinal movements of labor
Diagnosis of choriamnionitis
Maternal fever plus at least one of these:
- Fetal tachycardia >160/min for at least 10 min
- Maternal leukocytosis
- Maternal tachycardia
- Purulent amniotic fluid
Main risk factor for chorioamnionitis
Premature or Prolonged (>18 hours) rupture of the membranes
Treatment of Chorioamnionitis
- Antibiotics: Ampicilin + Gentamycin for vaginal delivery, add Clindamycin for C-section
- Expedited Delivery: labor augmentation; cesarean delivery is reserved for standard obstetric indications
Which medication is contraindicated in chorioamnionitis?
Tocolytics regardless gestational age
Common renal abnormalities in Mayer-Rokitansky-Küster-Hauser syndrome, why?
Unilateral renal agenesis, pelvic kidneys, duplication of the collecting system►Internal genitalia and primitive kidney have common embryologic source
*Müllerian (paramesonephric) agenesis
Structures derived from Müllerian (paramesonephric) ducts
1/3 upper vagina, cervix, uterus, fallopian tubes
Best management for recurrent late decelerations
- Intrauterine resuscitative interventions→O2, IV fluids, discontinuing uterotonics►Improve uteroplacental blood flow and fetal oxygenation
- If remote for delivery (not 10 cm dilated) and no improvement with initial management→Cesarean
What are recurrent late decelerations?
- Late decelerations→gradual ↓FHR with nadir after the peak of uterine contraction, no return baseline until contraction ends
- Recurrent→with =>50% of contractions
When do you suspect an androgen-secreting neoplasm of the ovaries or adrenal glands?
- Rapid onset hirsutism (<1 year)
- Virilization→temporal balding, excessive muscular development, enlarged clitoris
How do you evaluate the patients with suspected androgen-secreting neoplasm? Why?
- ↑Testosterone and ↓DHEAS►ovarian source, more common
- ↑Dehydroepiandrosterone sulfate (DHEAS)→adrenal tumor, far less common
Secondary amenorrhea, negative pregnancy test, normal prolactin and TSH levels, progestin challenge test confirming low estrogen levels
Functional hypothalamic amenorrhea
Patients with functional hypothalamic amenorrhea have a great risk to develop which condition?
Decreased bone mineral density
Hyperandrogenism signs and symptoms in polycystic ovary syndrome
Male pattern hair loss, hirsutism, severe acne (nodulocystic, on the back)
*Laboratory: ⬆serum testosterone
Which diseases must be screening in PCOS patients?
Metabolic syndrome→Hypertension, DM, dyslipidemia
Gold standard test for DM screening in PCOS
Two-hour oral glucose tolerance test→more sensitive in detecting intolerance than fasting glucose and HbA1C
Indication for BRCA mutation testing
Family history ovarian cancer at any age or personal/family history of breast cancer <=50 in first degree relative
How do you distinguish typical nausea and vomiting of pregnancy from hyperemesis gravidarum?
- Ketones on urianalysis (due prolonged hypoglycemia)
- Hypochloremic metabolic alkalosis, Hypokalemia
- ↑Aminotransferases
- Change volume status→dehydration, orthostatic hypotension
Clinical manifestations of hyperemesis gravidarum
- Severe and persistent vomiting
- > 5% loss weight or 6 lb compared with pregnancy weight
- Dehydration→hypotension, dry mucous membranes, decreased skin turgor
Causes of Abnormal uterine bleeding
PALM (structural causes)-COEIN (nonstructural causes)
- Polyp
- Adenomyosis
- Leiomyoma
- Malignancy/Hyperplasia
- Coagulopathy
- Ovulatory dysfunction
- Endometrial
- Iatrogenic (anticoagulants, OCPs, IUD) or Infection/Inflammation
- Not yet classified
When do you suspect AUB secondary to ovulatory dysfunction?
Heavy bleeding menses in adolescents
Cause of ovulatory dysfunction
Immature hypothalamic-pituitary-ovarian axis
Treatment of AUB secondary to ovulatory dysfunction
Intravenous estrogen (conjugated equine estrogen) or high-dose oral estrogen/progestin contraceptive pills
*High dose progestin in case contraindications of estrogen (history of throboembolism) - Not as effective as estrogen
What is the combined test, when you may run it?
- B-hcg, Maternal PAPP-A, nuchal translucency
- 9-13 weeks to assess for Down syndrome
What is the triple and quad screen and when do you run it?
- Maternal serum alpha fetoprotein (MSAFP), B-hcg, Estriol + Inhibin A (quad)
- 15-20 weeks to screen congenital problems
Quad screen profile in trisomy 18 vs trisomy 21
- Trisomy 18→↓MSAFP, ↓Estriol, ↓ or normal Inhibin A, ↓B-hcg
- Trisomy 21→↓MSAFP, ↓Estriol, ↑Inhibin A, ↑B-hcg
What would an increase MSAFP elevation suggest?
- Open neural tube defects (anencephaly, spina bifida)
- Abdominal wall defects (gastroschisis, omphalocele)
- Multiple gestation
- Incorrect gestational dating
- Fetal death
- Placental abnormalities (eg, placental abruption)
Why do you use tocolytics?
Preterm labor management
- Allow time for steroids to work➡⬇risk of neonatal respiratory distress syndrome
- Transportation to another medical center
Best initial test when suspect placenta previa
Transabdominal ultrasound and then Transvaginal ultrasound
Post-cesarean patient with shock, no signs of uterine atony, no incisional bleeding and minimal abdominal pain. Management.
- Postpartum hemorrhage►intrapartum uterine artery injury→intraabdominal bleeding→retroperitoneal hematoma
- Rapid and massive blood loss→Hemodinacally unstable→Emergency laparotomy
Which contraceptive method is contraindicated in hypertension and why?
- Combined estrogen-progestin oral contraceptives, estrogen-progestin vaginal ring
- Estrogen-induced angiotensinogen synthesis
*Use copper-containing uterine devices
Clinical presentation of Vasa previa
- Painless vaginal bleeding with ROM or contractions (tear unprotected fetal vessels)
- Fetal heart abnormalities (bradycardia, sinusoidal pattern)
- Fetal exsanguination and demise
Pathognomonic sign of uterine rupture
Loss of fetal station→presenting fetal part may retract
Indications for endometrial biopsy in women with AUB under 45
- Failed medical management (combined oral contraceptives)
- Persisten >6 months AUB
- Tamoxifen therapy
- Obesity
*Rule out endometrial hyperplasia/cancer (Risk: Unregulated excess of estrogen)
Use of Progesterone withdrawal test
- Evaluate secondary amenorrhea (no menses >6 mo with previous irregular menses)
- Determine if amenorrhea is from low estrogen levels→no bleeding after progesterone
What is an early deceleration?
A visually apparent, gradual (onset to nadir in >30 seconds) ↓FHR, with return to baseline that mirrors the uterine contraction.
*Onset, nadir, and recovery of the deceleration are coincident with the beginning, peak, and ending of the contraction respectively (“mirror image”)
What is a late deceleration?
A visually apparent, gradual (onset to nadir in >30 seconds) ↓FHR, nadir occurs after peak of contraction
What is the Fitz Hugh Curtis Syndrome?
Gonococcal perihepatitis or perihepatitis syndrome
*Complication of pelvic inflammatory disease: Neisseria gonorrhoeae and Chlamydia trachomatis
Etiology of primary dysmenorrhea
↑Endometrial prostaglandin production→uterine hypercontractility, hypertonicity→ischemia
Most accurate test for Pelvic Inflammatory Disease
Laparoscopy➡Only if diagnostic is unclear, symptoms persist despite therapy, recurrent episodes of unclear reasons
Findings on intrapartum fetal heart rate monitoring during cord prolapse
May present with variable decelerations, but typically: Abrupt, prolonged deceleration or bradycardia
*Umbilical compressed with no subsequent decompression
Use of fetal scalp stimulation
Evaluate fetal acidosis in patients without accelerations on FHR monitoring
*Do NOT perform in patients with prolonged decelerations or bradycardia
Which benign condition might mimic breast cancer in the clinical and mammography findings? How do you distinguish them?
- Fat necrosis of the breast➡associated with breast surgery (reduction/reconstruction) and trauma (Ex, seatbelt injury)
- Clinical examination: Fixed, firm irregular mass, skin or nipple retraction
- Mammography: Calcifications
- Distinguish
- Ultrasonography: hyperechoic mass (suggest benign etiology)
- Biopsy: Fat globules, foamy histiocytes
Management of CIN 3 (cervical intraepithelial neoplasia 3)
High grade dysplastic lesion of squamous epithelium; In nonpregnant >25 yrs:
- Excision of the transformation zone➡cervical conization▶LEEP, cold knife conization, cryoablation
*Risk progression to invasive squamous cell cervical carcinoma
Treatment of hyperemesis gravidarum
- Dietary changes
- Antihistamines: doxylamine or diphenhydramine, adding pyridoxine
- If no response, discontinue doxylamine-pyridoxine and add metoclopramide, promethazine, or prochlorperazine (dopamine antagonist)
- No response, 5HT antagonist (Ondansetron)
What is the arrest of cervical dilation?
No dilation of the cervix for more than 2 hours
What is a prolonged latent stage?
- Primipara: more than 20 hours to reach 6 cm of dilation (reach active phase)
- Multipara: more than 14 hours to reach 6 cm of dilation
What is protracted cervical dilation?
Less than 1.2 cm of dilation per hour (primipara) and 1.5 cm (multipara), during the active phase of stage 1 labor
Causes and treatment for protracted cervical dilation
- Cephalopelvic disproportion: Cesarean delivery
- Weak uterine contraction: Oxytocin
Treatment of simple breast cyst
Aspirate IF patient is in severe pain
Best initial test for probable breast mass
- Mammogram
- Regardless when was the last mammogram, even under age of 30 - MTB source
- Ultrasonography to differentiate a mass from fluid-filled vs solid➡Fine-needle aspiration (FNA) [alleviate pain and confirm that is cystic]➡Excisional biopsy if no fluid is obtained or if the fluid is bloody on aspiration
- FA source
What is the Paget disease of the vulva? Clinical presentation
Intraepithelial neoplasia➡vulvar soreness and
pruritus; red lesion with a superficial white coating
Management in pregnants to prevent neonatal group B Streptococcus infection. Indications of treatment.
- GBS bacteriuria or GBS urinary tract infection in current pregnancy
- GBS-positive rectovaginal culture (screen at 35-37 wks)
- unknown GBS status + any: <37 wks, intrapartum fever, ROM >18 hrs
- Prior infant with early-onset neonatal GBS infection
- Intravenous Penicilin
Management of normal labor during intrapartum in an HIV positive pregnant
- Based upon the viral load at delivery:
- <=1.000 copies➡ART, vaginal delivery
- > 1.000 copies➡ART, Zidovudine, cesarean delivery
What is gestational thrombocytopenia and how do you assess it?
- Thrombocytopenia during second half of pregnancy
- Peripheral blood smear➡paucity of platelets
*Most common cause of thrombocytopenia during pregnancy. Mild, without fetal or maternal morbidity.
What is primary amenorrhea?
Absence of menarche age≥13 with no secondary sexual characteristics; or age≥15 with secondary sexual characteristics (Ex, axillary/pubic hair)
Laboratory markers of primary ovary insufficiency. Usual clinical presentation.
- ⬇Estradiol▶⬆FSH
- Oligomenorrhea, amenorrhea, infertility, menopausal symptoms (hot flashes)
Etiology and risk factor for vaginal squamous cell carcinoma
- Persistent HPV infection (types 16, 18)
- Chronic tobacco use➡⬇Immune response➡❌viral clearing
Which type of cancer is associated with Diethylstilbestrol (DES) in-utero exposure?
Vaginal clear cell adenocarcinoma
Most common cause of vesicovaginal fistula
Obstructed labor➡injury and necrosis to the maternal vagina, rectum and bladder▶erosion, fistula
*Associated with resource-limited areas, young maternal age (small pelvis), lack prenatal care
How do you identify or suspect vesicovaginal fistula?
- Continuous ⬆pH vaginal discharge (due urine, malodorous due necrotic tissue)
- Pelvic examination: vaginal pool of urine, visible defect or area of raised, red granulation tissue in anterior vaginal wall
How do you confirm the diagnosis of vesicovaginal fistula?
Bladder dye testing
*Particularly in whom have small fistulas not visualized on pelvic examination
Most common brain complications of preeclampsia
Endothelial cell damage▶Acute stroke
- ➕Coagulation system + platelet aggregation➡microthrombi formation▶Ischemic stroke
- Dysregulated cerebral blood flow➡inappropriate cerebral vasospasm➡⬆⬆perfusion pressure➡ruptured intracerebral vessels▶Hemorrhagic stroke
Fetal heart rate tracing of uterine rupture
Might be the first sign
- Bradycardia
- Late decelerations
- Variable decelerations
*Palpable fetal parts➡irregular protuberance in lower abdomen
Management of a pregnant patient with history of genital HSV infection and no recent outbreaks
Beginning at 36 weeks gestation until delivery➡antiviral prophylaxis (acyclovir, valacyclovir) regardless of symptoms
When do you suspect a Sertoli-Leydig cell tumor in a woman?
- Rapid-onset virilization➡voice deepening, male-pattern balding, ⬆muscle mass, clitoromegaly
- Oligomenorrhea
- Unilateral, solid adnexal mass
Anemia in pregnancy
- Hb<11 g/dL in 1st and 3rd trimester
- Hb<10.5 g/dL in 2nd trimester
Teratogenic effects of ACEI and ARBs
- Fetal renal hypoplasia: bilateral small, underdeveloped fetal kidneys, small fetal bladder with minimal urine
- Oligohydramnios: AFI≤5cm▶⬆Risk of pulmonary hypoplasia and facial and limb defects (Potter sequence)
*Angiotensin II required for fetal renal development and maintenance of fetal GFR
First-line test for a patient with primary infertility and a history of PID
Hysterosalpingogram➡assess fallopian tube patency
*PID is an important cause of infertility due to tubal scarring and obstruction
Prophylaxis for preeclampsia and in which patients may we use it?
- Daily low-dose aspirin at 12 weeks gestation (12-28 wks, optimally before 16 wks)
- High-risk patients: DM, HTN, multiple gestations, prior preeclampsia, CKD, autoimmune disease
Indication of indomethacin for preterm labor management
Tocolysis at <32 weeks
Best next step in a young woman (<25) with dysuria and sterile pyuria
Common presentation of Chlamydia trachomatis-associated urethritis➡nucleic acid amplification testing for chlamydia (also gonorrhea because common co-infection)
*Urine or vaginal/cervical swab
Best next step when identifying mixed urinary incontinence (stress and urgency symptoms)
Urodynamic testing➡tracks fluid intake, urine output, leaking episodes➡ classifies predominant type to determine appropriate treatment
What is Mittelschmerz and what are the symptoms?
Ovulation (in the middle of menstrual cycle)➡unilateral sudden lower quadrant pain and enlarged anexa
*May mimick appendicitis
Does the cesarean decrease the risk of having late-onset GBS neonatal sepsis and/or meningitis from a positive screened mother?
- No, horizontal transmission (late-onset) may happen.
- Intrapartum antibiotics ⬇risk of early-onset GBS disease, but are not needed in cesarean. Nevertheless, cesarean nor antibiotics do not eliminate colonization▶horizontal transmission
Risk factors for placenta previa
- Prior cesarean delivery
- Prior placenta previa
- Multiple gestation
- Advance maternal age (≥35)
How do you identify the acute fatty liver of pregnancy?
- 3rd trimester RUQ pain, ⬆risk multiple gestation
- Hepatic inflammation (leukocytosis, ⬆aminotransferases)➡Liver failure (⬆ bilirubin, profound hypoglycemia)➡Multiorgan system failure (CID, AKI)
- Placenta hypoperfusion➡Fetal hypoxemia, acidosis, death
*Defective maternal-fetal fatty acid metabolism
High risk of sexually transmitted infection during pregnancy
- Age <25
- Prior STI
- High-risk sexual activity (multiple partners, commercial sex work)
Screening for high-risk STI during pregnancy
At the initial prenatal visit and 3rd trimester
- HIV
- Syphilis
- Gonorrhea
- Hepatitis B virus
- Chlamydia
Therapy to induce ovulation in polycystic ovary syndrome
- if Obese→weight loss►↓peripheral estrogen conversion
- Letrozole (aromatase inhibitor)→inhibits the conversion of androgens to estrogens► normalizing FSH, LH levels→surge of LH►Ovulation (higher live birth rate than clomiphene citrate)
Diagnosis of cervical insufficiency
Any one of the following criteria:
- Examination-based: Painless cervical dilation in the current pregnancy
- Ultrasound-based: Second-trimester cervical length ≤2.5 cm plus a prior preterm delivery
- History-based: ≥2 prior consecutive, painless, second-trimester losses
When do you use Fetal fibronectin (fFN) testing?
Distinguish between preterm and false labor in patients with preterm contractions between 22 and 35 weeks gestation
*Extracellular matrix protein located between the maternal decidua and fetal chorion
How do you distinguish vasa previa vs placenta previa?
Both present with painless vaginal bleeding:
- Placenta previa: early stage of bleeding is primarily maternal in origin→reactive (normal) fetal heart rate tracing
- Vasa previa: bleeding is primarily fetal in origin→rapid deterioration of the fetal heart rate tracing
Potential vitamin deficiency as a complication of hyperemesis gravidarum
Thiamine deficiency➡Wernicke encephalopathy
- Altered mental status (encephalopathy)
- Oculomotor dysfunction (horizontal nystagmus, bilateral abducens palsy)
- Postural and gait ataxia
Best next step in a postmenopausal woman with a benign-appearance adnexal mass (eg, ovarian cyst)
CA-125 level➡malignancy risk stratification
How do you distinguish the source of severe hyperandrogenism in females?
Suggestive androgen-secreting tumor:
- Ovarian androgen-secreting tumor➡⬆⬆Testosterone (>150 ng/dL)
- Adrenal tumor➡⬆Dehydroepiandrostenedione (DHEAS) (>700 mcg/dL)
Complication of ovulation induction for infertility treatment
Ovarian hyperstimulation syndrome:
- 1-2 weeks after injection
- Abdominal pain, ascites
- Bilateral enlarged, cystic ovaries
- Third spacing➡intravascular volume depletion (hemoconcentration), thromboembolism, multiorgan failure, death
How do you evaluate Atypical glandular cells (AGC) result on Pap testing?
- Colposcopy
- Endocervical curettage
- Endometrial biopsy (ectocervix, endocervix, endometrium)
*Could be Cervical or Endometrial adenocarcinoma
Most probable diagnosis in an HIV patient with postcoital bleeding and ulcerative lesion on the cervix that bleeds with contact
Cervical cancer (AIDS-defining illness)
*HPV 16 & 18
Best next step when resection of corpus luteus (e.g. oophorectomy by ovarian torsion) is done during pregnancy before week 10?
Progesterone supplementation until week 10➡prevent pregnancy loss
*Corpus luteus provides progesterone until week 10, then placenta takes over
Which test should be done in patients with a high risk of preeclampsia at the beginning of the pregnancy?
24-hour urine collection for total protein
*Baseline and help determine if patient develop gestational hypertension (HTN without proteinuria or organ damage) vs. preeclampsia (HTN + worsening proteinuria)
Most important negative prognostic factor for breast cancer
Tumor stage➡includes lymph node involvement
*Estrogen and progesterone receptor expression➡improved outcomes
Treatment of menopause vasomotor symptoms when HRT (estrogens) are contraindicated
Non-hormonal therapy: SSRI
Contraindications of systemic hormone replacement therapy
CAD, thromboembolism, TIA, stroke, breast cancer, endometrial cancer
Most common cause of heavy, regular menses in adolescents
Von Willebrand disease
Pre-gestational diabetes mellitus screening indication
Early screening with 1-hr glucose challenge test at the first prenatal visit if high risk➡obesity (or BMI≥25 kg/m2 - NBME) + ≥1:
- Prior Gestational diabetes mellitus
- Prior macrosomic infant (≥4kg at birth)
- Family history of DM (first-degree relative)
- PCOS
- Maternal age≥40
- Hypertension
Most important risk factors for placenta acreta
- Prior cesarean delivery
- Placenta previa
Most common risk factor for endometrial hyperplasia/cancer
Obesity➡⬆⬆estrogen➡unopposed estrogen exposure
Treatment for labial adhesion. Which are the typical physical findings found?
- Topical estrogen cream (partial symptomatic or complete)
- Adhesive ridge fusing the posterior labia minora in the midline
Clinical presentation of Labia adhesion
- Partial➡asymptomatic or pain/prutitus, escoriations➡⬆adhesion development
- Complete➡small orifice for urine to come out, covering urethral meatus➡⬆recurrent UTI
Tocolytics indicated by gestational age
- <32 weeks➡Indomethacin
- 32-34 weeks➡Nifedipine
Role of Magnesium sulfate in preterm labor management
Fetal Neuroprotection➡⬇Risk of cerebral palsy at <32 weeks
Treatment for new-onset severe-range hypertension* in preeclampsia
- IV Labetalol: do not use if bradycardia
- IV Hydralazine: can cause tachycardia
- Oral Nifedipine: if tolerate oral intake
*SBP≥160 mmHg or DBP≥110 mmHg
Most common cause of unilateral bloody nipple discharge without a coexisting breast mass or lymphadenopathy
Intraductal papilloma
Most common mechanism of peripartum urinary retention
- Pudendal nerve injury➡external urethral sphincter dysfunction
- Regional neuraxial anesthesia➡bladder atony
Side effects of indomethacin on the fetus
⬇Prostaglandins➡fetal vasoconstriction
- Premature closure of ductus arteriosus
- ⬇Renal perfusion➡fetal oliguria➡oligohydramnios
- Give for up to 48 hours as tocolysis (preterm labor) between 24-32 weeks
- Side effects increase if given 32-34 weeks
Management of a patient with preterm labor at 35 weeks with no contraindication of vaginal delivery
- Expectant management
- No tocolytics indicated after 34 weeks➡⬆risk of tocolytics side effects
*Penicillin prophylaxis if GBS (+) or unknown
Risks of complications for short interpregnancy interval
<6-28 months from delivery to next pregnancy
- Maternal anemia
- Preterm prelabor rupture of membranes (PPROM)
- Preterm delivery
- Low birth weight
Best next step in management in a 12 years old female with one week of suprapubic pain, history of cyclic lower abdominal pain, suprapubic mass on examination a blue-tinged bulge between the labia (hematocolpos)
Imperforate hymen
- Hymenal incision and drainage
- Laparoscopy is wrong because drainage should be done first. If pain and chronic pain do not resolve, consider laparoscopy
Management of second-stage arrest
Operative vaginal delivery (eg, vacuum-assisted)
Best next step in a patient with a firm, immobile mass in the left or right adnexa and rectovaginal nodularity, confirmed by a CT scan, with elevated CA-125
- Highly suggestive of epithelial ovarian carcinona➡Exploratory laparotomy
- Do not do guided biopsy because it can lead to rupture of the mass and spreading of cancerous cells throughout the abdomen
