Part 2 Flashcards
Pelvic floor exercises strengthen which muscles?
- Levator ani
- External anal sphincter
- Urethral sphincter striated muscle
Cystometry measures all phases of micturition except?
Emptying
Define types of vaginal/perineal tears, including OASIS grading system
1: perineal skin only
2: perineal muscle
3A: <50% EAS
3B: >50% EAS
3C: EAS + IAS
4: EAS, IAS, anal epithelium
Button hole injuries do not belong to this classification - they are their own entity
Risk factors for OASIS?
Previous OASIS Primiparous (*highest risk) AMA Diabetes Infundibulation Assisted vaginal delivery (forceps > vacuum) Midline episiotomy Prolonged second stage (>1 h) TOLAC/VBAC (effectively a primip) Augmentation of labour Macrosomia (EFW > 4000 g) Post-dates OP presentation Abnormal FHR
Protective factor for OASIS?
Obesity
Overall incidence of OASIS?
4 - 6.6%
Risk of recurrent OASIS?
4 - 8%
Complications of OASIS (7)?
- Pain
- Infection
- Wound breakdown
- Urinary retention
- Dyspareunia
- Flatal/fecal incontinence or urgency
- Fistula (rectovaginal)
List regimens for UTI prophylaxis in pregnancy
Cephalexin 250 mg PO daily
Nitrofurantoin 50 mg PO daily (avoid last 4 weeks of pregnancy)
Define recurrent UTI
2 uncomplicated UTIs in 6 months OR 3 culture-proven UTIs in 12 months
List complications of pessary use
- Erosions (9%)
- Can lead to fistulas, cancer if chronic and untreated
- Tx with removal and estrogen - Infection (2.5%)
- Discharge
- BV: remove more frequently + flagyl or replens
- Candida: can keep pessary, tx as usual - Dislodged/malpositioned
- Can lead to constipation
Which pessary has not been shown to prevent PTB?
Arabin
Complications of mesh?
- Bladder injury
- Infection
- EBL >500 mL/hematoma
- Mesh erosion/exposure (4% risk TVT, 12% other procedures)
- Dyspareunia
- Pain
- De novo SUI
What type of mesh has the lowest associated complication rates?
Polypropylene type 1 monofilament macroporous synthetic mesh
Risk factors for mesh exposure post-op?
Concomitant hysterectomy
Smoking
**Post-op tx with estrogen does not prevent
Predictors of pessary discontinuation?
Posterior wall prolapse
Young age (<65)
Urinary incontinence
Discomfort
Predictors of unsuccessful pessary fitting?
Short vagina (<6 cm) Wide introitus (>4 cm) Rectocele Previous vaginal surgery Co-existing SUI
Anal sphincter complex - list muscles and innervation
External anal sphincter (EAS) - inferior branch of pudendal nerve
Internal anal sphincter (IAS) - autonomic nervous system
Puborectalis - S3/4; responsible for 50% of resting tone
Strongest evidence for vaginal estrogen with incontinence?
Urge incontinence
List 5 causes of persistent SUI after surgery
- Treatment failure
- Wrong treatment
- De novo urge incontinence
- UTI
- Fistula
Symptom most likely to improve with pessary?
SUI (up to 21%)
Symptoms most likely to worsen with pessary?
Voiding difficulties (up to 53%)
Findings (2) on UDS that suggests intrinsic sphincter deficiency?
Maximal urethral closure pressure <20 cm H2O
Leak point pressure < 60 cm H2O
4 types of enterocele
- Congenital
- Pulsion (increased intrabdominal pressures)
- Iatrogenic
- Traction (aka POP; “natural” pulling)
What must be done as part of office assessment for SUI pre-op?
PVR
Would also do:
Urinalysis/culture
UVJ hypermobility
Objective evidence of SUI
Most common cause of fistula globally?
Obstructed labour
Most common cause of fistula in developed nations?
Hysterectomy
Strongest indication for vaginal estrogen?
Recurrent UTIs in postmenopausal women
Which 3 urinary conditions are their evidence for improvement with estrogen?
- Recurrent UTIs (postmenopausal)
- Urge incontinence
- OAB (decreased frequency, dysuria, nocturia)
For what urinary condition is there NO evidence for improvement with estrogen?
SUI
What nerve is injured with an expanding hematoma following a Burch?
Obturator
Define OAB
Constellation of bladder symptoms:
Frequency
Urgency
Nocturia
(Not consistent with a UTI)
Route of hysterectomy associated with LEAST risk of ureteric injury?
Vaginal
Route of hysterectomy associated with HIGHEST risk of ureteric injury?
Radical hysterectomy > TLH > TAH
Mechanism of action for OAB anticholinergics?
Inhibit M2/M3 receptors in bladder wall to increase storage capacity
Absolute and relative contraindications to anticholinergics?
Absolute: allergy, acute uncontrolled narrow angle glaucoma, urinary and gastric retention
Relative: myasthenia gravis, controlled glaucoma, delayed gastric emptying, cognitive impairment
What 2 anticholinergics have fewer cognitive side effects and are better for use in the cognitively impaired?
Fesoterodine (Toviaz)
Trospium (Trosec)
In what compartment is risk of recurrence high for:
A) SSVF
B) Burch
A) Anterior
B) Posterior
Indications for UTI prophylaxis in pregnancy?
- Pre-pregnancy history of recurrent UTI
- Two failed treatments of UTI
- 1 UTI with risk factors (sickle cell, DM)
What is the Hodge pessary for?
Incarcerated uterus
Generally left in situ for 2 weeks until uterus grows and is out of the pelvis (~19 weeks)
How do incontinence pessaries work?
Stabilize the urethra and create a backboard to increase urethral resistance
If someone has recurrent UTIs with anything other than e. coli, what should you do?
Upper tract imaging + cystoscopy
Most common place for a ureteric injury:
A) During gynecologic surgery
B) During hysterectomy
A) At the level of the IP
B) At the level of the uterine artery
Nerve roots for:
A) Anal wink reflex
B) Bulbocavernosus reflex
A) S 2-5
B) S2/4 (“keeps the shit off the floor”)
7 causes of rectovaginal fistula?
- Surgery
- OASIS
- Radiation
- IBD
- Endometriosis
- Infection
- Malignancy
Classic symptom triad associated with urethral diverticulum?
- Post-void dribble
- Dyspareunia
- Dysuria
Craniosynostosis (premature fusion of fetal skull bones) is caused by?
Methotrexate in first trimester
Hyperthyroidism
Warfarin use
Valproic acid
Risks of methotrexate in first trimester?
ONTD (if taken before neural tube closes)
Microcephaly
TOF
Pulmonary valve atresia
Limb reduction
Syndactyly
Craniosynostosis (premature fusion of fetal skull bones)
Benefits of Delayed Cord Clamping?
Reduced IVH
Decreased anemia/transfusions
Increased iron stores at 6 months
Decreased NEC
Collaterals to uterus after bilateral internal iliac artery ligation?
Lumbar artery
Recurrence risk for stillbirth?
5-fold
Tocolytic that can cause pulmonary edema?
Nifedipine
Calcium-channel blocker that decreases cardiac inotrope = increased cardiac preload
Symptoms of fibrocystic breast disease?
Cyclic breast pain (hormonally responsive)
Most common complication of a D&E?
Hemorrhage
secondary to RPOC and cervical lacerations
Highest risk exposure time for limb defects with varicella?
Second trimester
Name the nerve: A) Sensory to labia + medial/upper thigh B) Motor to labia + medial/upper thigh (adduction) C) Sensory to mons and labia D) Hip pain
A) Genitofemoral
B) Obturator
C) Ilioinguinal
D) Iliohypogastric
Why is AC the most sensitive for detection of IUGR?
Contains the liver –> glucose storage
Most likely cause of vulvovaginitis in a 6 yo?
Non-specific
How long must someone be on testosterone before gender-affirming hysterectomy?
1 year
What has the most significant impact on
A) recurrence
B) persistence
following LEEP for HSIL?
A) High risk HPV
B) Positive margins
treatment for vulvodynia?
Topical xylocaine
Vestibulectomy (**has best evidence)
No evidence for TCAs
How do you treat genital warts in pregnancy?
Trichloroacetic acid (TCA) Cryotherapy
Podophyllin (Imiquimod) is contraindicated
Most significant risk factor for PP depression?
Adolescent
Risk of misoprostol exposure in first trimester?
Mobius syndrome - congenital facial paralysis
Most common nerves/vessel to be injured with SSVF?
Nerves: pudendal and sciatic
Vessels: inferior gluteal
The WHI quotes a 26% risk of breast cancer because this measure was used?
Relative risk
Definition of PMS
Symptoms must start within 5 days of menses and end within 4 days of menses
Euglycemia in GDM reduces the risk of?
Macrosomia
Shoulder dystocia
PET
5 goals of treating GDM?
Reduced risk of:
- Macrosomia
- IUFD
- PET
- C/S
- Neonatal complications (shoulder dystocia, birth trauma, hypoglycemia)
Risks (4) to babies born from diabetic mothers?
- Polycythemia
- Hypoglycemia
- Hypocalcemia
- Hyperbilirubinemia
Targets for glycemic control in pregnancy?
Fasting <5.3
1 h post-prandial <7.8
2 h post-prandial <6.7
Cut-offs for 1h 50g GCT?
Normal <7.8
7.8 - 11.0 –> 75 g OGTT
≥ 11.1 = GDM
Diagnostic cut-offs for 2h 75g OGTT?
Any 1 of:
Fasting ≥ 5.3
1 h ≥ 10.6
2 h ≥ 9.0
Timing of delivery for:
A) PGDM or GDM on insulin
B) PGDM or GDM diet
A) 38 - 39 weeks
B) No later than 40 weeks (38 - 40)
Fetal surveillance for GDM or PGDM?
Serial growth + fluid assessment Q2-4 weeks beginning at 28 weeks
Weekly fetal well-being assessment beginning at 36 weeks (any 1 of):
BPP
NST
NST + fluid assessment
Risks of GDM?
LGA Shoulder dystocia C/S PET PTB Stillbirth (begins to increase at 36 weeks) Congenital anomalies Risk of T2DM/obesity in future Perinatal mortality
Benefits of preconception A1c ≤ 7.0% with PGDM?
Reduced risk of congenital anomalies (NTD, cardiac)
Decreased SA
Decreased retinopathy
Decreased preeclampsia
Preconception recommendations for PGDM (10)?
- Usual PNC: stop smoking/EtoH/PNV/immunizations
- Folic acid 1 mg 3 months pre-conception + T1
- Stop ACE/ARBs, statins, fibrates, all oral anti-hyperglycemics except metformin
- A1c ≤ 7.0% (ideally ≤6.5)
- BP < 135/85
- Eye exam
- BMI <30
- TSH
- ACR + eGFR
- ECG if >40
Risk factors for underlying T2DM?
>35 Obesity (BMI >30) Ethnicity (Aboriginial, African, Asian, Hispanic, South-East Asian) FHx of DM PCOS Acanthosis nigricans Steroid use Hx GDM Hx macrosomic infant Bariatric surgery
TTP vs. HUS?
TTP: decreased platelets, fever, neurologic abnormalities, renal impairment, hemolytic anemia
HUS: more profound renal impairment, fever, neuro abnormalities
Etiologies of infertility?
30-40% Tubal
30-40% male factor
15% anovulation
15% unexplained
(From Speroff)
Chancroid is most consistent with?
Travel to endemic areas
Most actively reabsorbed electrolyte in kidney in pregnancy?
Sodium
Most common aneuploidy in first trimester losses?
- Trisomies (T16 most common)
- Autosomal trisomy (22-32%) - Monosomy X (5-20%)
How do you get a hypo/hypo pregnant?
If Kallman’s = pulse GnRH
Otherwise = exogenous gonadotropins
“Best” = IVF
Where is oxytocin produced?
Hypothalamus
Secreted by posterior pituitary
List the hormones that come from the anterior and posterior pituitary
Anterior: ACTH, FSH/LH, PRL, GH, TSH
Posterior: ADH, oxytocin
What helps differentiate TTTS and growth discordance?
Presence of 2 placentas
Most common cause of perinatal mortality with PGDM?
Congenital anomalies
Comparable effectiveness to dienogest (Visanne) for endometriosis?
Leuprolide acetate (GnRH agonists)
Buprenorphine has decreased risks of what vs. methadone?
Overdose
Best determination of GA by U/S?
Earliest U/S with CRL > 10 mm
Indications for adjuvant treatment in serous ovarian cancer?
Greater than stage IA (must be full staged IA to observe)
Mechanism of action of tamoxifen?
SERM
Selective estrogen receptor modulator
Chromosome and risk of ovarian cancer in BRCA1?
Chromosome 17
30-60%
Chromosome and risk of ovarian cancer in BRCA2?
Chromosome 13
10-30%
First line tx for endo?
Combined hormonal contraceptives or progestins
Second line tx for endo?
IUD or GnRH agonsit/antagonist
Third line tx for endo?
Danazol
Then aromatase inhibitors
Biggest contributor to anovulation in PCOS?
Ovarian androgen production
Recurrence risk PTB?
20-30%
Risk of FAS with EtOH consumption in second trimester?
50%
Common reasons for each of the nerve injuries below: A) Femoral B) Ilioinguinal/iliohypogastric C) Genitofemoral D) Obturator E) Peroneal
A) Deep retractor or overflexion of hips
B) Pfannenstiel extension
C) Dissection in pelvic side wall (external iliac nodes)
D) Pelvic node dissection, excision of endometriosis, TVT-O, Burch, paravaginal surgery
E) Lithotomy boot compression
1 and #2 complications of PET that lead to maternal mortality?
1) Stroke
2) Pulmonary edema
Most androgenic progestin?
Norethindrone acetate
Inheritance of complete AIS?
X-linked recessive
Tamoxifen increases the risk of?
Endometrial cancer
Uterine sarcoma
Risk factors for late radiation enteritis?
Diabetes
Histologic changes with GUSM?
Increased parabasal/intermediated cells
Decreased superficial cells
Decreased collagen and elastin
Histologic changes with vaginal estrogen for tx for GUSM?
Increased superficial cells
Proliferation of intermediate cells
NNT for MgSO4 to prevent:
A) CP or death
B) CP alone
A) 43
B) 63
Planned PTB - how long before C/S must MgSO4 be given?
4h
Contraindications to MgSO4?
Myasthenia gravis
Hepatic coma
Hypersensitivity
GA that qualifies for MgSO4?
Viability to 33+6 weeks
MgSO4 has evidence for decreased?
CP and death
Indications for MgSO4?
Imminent PTB
Planned PTB
Define imminent PTB (for the purposes of MgSO4 administration)?
Active labour with cervix ≥ 4 cm
OR planned PTB
Tocolysis + MgSO4
NO!
Tocolysis should be stopped if giving MgSO4
Delivery should not be delayed for MgSO4
When can you consider repeating course of MgSO4?
> 12-24 h from last dose
Risks of endometrial sampling?
Pain Bleeding Infection False passage Uterine perforation Bowel/bladder/vascular injury Anesthetic risks False negative/positive result
Risk factors that should make you consider polypectomy when patient asymptomatic?
Age > 60 Polyp size > 4 cm BMI > 30 DM Menopausal HTN
When to sample asymptomatic thickened lining on U/S?
> 11 mm
Increased vascularity
Heterogeneous
Particulate fluid
Screening for endometrial cancer?
No - no role for TVUS or endometrial biopsy in asymptomatic women
Definition of asymptomatic endometrial thickening?
> 5 mm in postmenopausal woman
Benefits of:
A) Betamethasone
B) Dexamethasone
A) Decreased rates of chorio, RDS, chronic lung disease
B) Greater reduction in IVH, NEC, shorter NICU stay
NOT indications for ACS?
Transfer with dx of PTL Short cervix with no dilatation \+FFN alone Repeat courses Term >37 weeks elective C/S
Risks of ACS? (and multiple courses)
Decreased head circumference
Decreased birth weight
Possible long-term neurodevelopmental outcomes
ACS has been shown to improve?
Perinatal death
RDS
IVH
NEC
Indications for ACS?
24 - 34+6 weeks GA when delivery is expected within 7 days
Types of ACS and doses?
Betamethasone 12 mg IM Q24 H x 2 doses
Dexamethasone 6 mg IM Q12 H x 4 doses
Other than PTL, what are other indications for ACS?
PPROM (24 - 34+6 weeks)
Significant APH (if delivery anticipated within 7 days)
Vasa previa/placenta previa (if delivery anticipated within 7 days)
MCMA twins
What conditions do NOT change timing or dose of steroids?
Obesity
DM
Multiples
IUGR
When should GDM testing be done following ACS administration?
7 days
Effect of ACS on fetal movement?
Transient decrease in FM x 3 days
Does only a few hours of ACS still provide fetal benefit?
Yes
How should insulin doses be adjusted following ACS?
Day 1: Increase QHS dose 25% Day 2 & 3: Increase all 40% Day 4: Increase all 20% Day 5: Increase all 10-20% Day 6: Begin gradual taper to pre-ACS doses
Ferriman-Gallway Score for: A) Excessive hair growth B) Mild hirsutism C) Moderate hirsutism D) Severe hirsutism
A) ≥8
B) <15
C) 16-25
D) >25
Investigations for moderate to severe hirsutism?
- Total testosterone (not free testosterone)
If testosterone is increased:
- DHEAS
- SHBG
- 17-OHP
- TSH
Criteria for dx of PCOS?
Rotterdam (2/3):
- Oligomenorrhea/anovulation
- Clinical or biochemical evidence of hyperandrogenism
- Polycystic ovaries (≥12 follicles of at least 10 cc in size)
Must be diagnosis of exclusion (r/o other causes)
1 and #2 causes of hirsutism?
1) PCOS
2) Idiopathic
First line tx for hirsutism?
OCP
Duration of tx for hirsutism to see effects?
4 - 6 months
First line treatment for infertility related to PCOS (anovulation)?
Weight loss
5-10% total body weight
Target BMI <35
2nd, 3rd, 4th , 5th line tx for infertility related to PCOS?
#2 - Letrozole 2.5 mg days 3-7 (can increase to 7.5 mg) #3 - Add metformin to Letrozole #4 - Gonadotropins #5 - IVF
*Consideration for ovarian drilling
Pre-op criteria that must be met before endometrial ablation (6)?
- Completed childbearing
- Contraception discussion
- r/o malignancy - pap, endometrial biopsy
- Set expectations (decreased bleeding, NOT amenorrhea)
- Risk of hysterectomy in future if recurrent PVB and unable to sample
- Assess cavity
Risk factors for fibroids (8)?
- Nulliparity
- Ethnicity (African)
- Early menarche
- Frequent menses
- Dysmenorrhea
- FHx
- Obesity
- Age (peak incidence 40-50s; 80% by menopause)
Indications for endometrial biopsy with AUB (ie. risk factors for endometrial cancer)?
- Age > 40
- Obesity (BMI >30)
- Nulliparity
- PCOS
- DM
- Lynch syndrome
- Failed medical tx
- IMB
- Anovulatory cycles
Step-wise MEDICAL tx for AUB?
- NSAIDs (start day before menses)
- TXA
- OCP
- Oral progestins (norethindrone, provera)
- Injectable progestins (DMPA)
- IUD
- Danazol
- GnRH agonists/antagonists –> need add-back
Medical management of acute AUB?
Options include:
- IV estrogen 25 mg Q6H
- OCP 2 pills x 5 days, then 1 pill
- TXA 1 g IV Q6H
- Provera (MPA) 10-20 mg BID or Megace 20-60 mg BID
Risk of LMS in a fibroid?
1/400
Pathophysiology of fibroids?
Monoclonal tumours that arise from benign myometrium
Myofibroblasts undergo disordered proliferation, which is dependent on estrogen and progestin
Indications for surgical tx of AUB?
- Failed medical management
- Contraindications to medical management
- Significant anemia
- QoL impact
- Concomitant uterine pathology (ie. large fibroids, hyperplasia, dysplasia, etc.)
What is hemoglobin target before gyne surgery?
≥120 g/L
How is flare from GnRH avoided?
Letrozole x 5 days
OCP x 10 days
Describe FIGO classification of fibroids
0: pedunculated intracavitary
1: <50% intramural
2: >50% intramural
3: 100% intramural, but contacts endometrium
4: intramural
5: subserosal with ≥50% intramural
6: subserosal with <50% intramural
7: subserosal pedunculated
8: combination or other (parasitic, cervical, etc.)
Investigations for AUB?
CBC Ferritin (if CBC abnormal) BhCG TSH (only if syptoms of hypothyroidism) Coags (only if HMB since menarche or FHx bleeding disorder)
There is NO evidence for FSH, LH, estrogen, progestin, prolactin
Medical treatment for BLEEDING symptoms secondary to fibroids (7)?
- OCP
- Progestins
- LNG-IUD
- Lupron (GnRH agonist)
- Elagolix (GnRH antagonist)
- Danazol
- Mifepristone
Medical treatment for BULK symptoms from fibroids (2)?
- Lupron (GnRH agonist)
2. Mifepristone
Risk factors for BV?
Black women
Smoking
Sexual activity
Vaginal douching
How do you treat vulvovaginal candidiasis in pregnancy?
What must be avoided?
Topical azoles (ie. clotrimazole)
Cannot use fluconazole (TOF), boric acid (2x risk of birth defects in 1st 4 months of pregnancy)
Recurrent vulvovaginal candidiasis treatment:
A) 4 induction treatment options and duration?
B) 3 maintenance treatment options and duration?
A) Imidazole PV x 10-14 days
Fluconazole 150 mg PO Q72h x 3 doses
Boric acid 300-600 mg daily x 14 days
Clotrimazole 500 mg PV Q monthly x 6 months
B) Fluconazole 150 mg PO weekly
Boric acid 300 mg PV daily x 5 days with each
menses
Ketoconazole 100 mg PO daily
All maintenance treatment should be continued for at least 6 months
2 treatments for uncomplicated vulvovaginal candidiasis (PO and PV)?
Fluconazole 150 mg PO x1
Clotrimazole 1% cream PV daily x7 days OR clotrimazole 10% cream x 1 OR clotrimazole 500 mg suppository PV x 1
2 ways to diagnose BV?
- Gram stain with Nugent score
Normal = 0-3
Intermediate = 4-6
Positive ≥ 7
2. Amsel's Test (3/4): Adherent or homogenous discharge Vaginal pH > 4.5 Clue cells on wet mount \+ Whiff test
Treatment of BV:
A) Uncomplicated
B) Recurrent
C) Pregnancy
A) Flagyl 500 mg PO BID x 7 days
Clindamycin 300 mg PO BID x 7 days
Flagyl gel 0.75% 5 g (1 applicator) PV x 5 days
Clindamycin cream 2% 5 g (1 applicator) PV x 7 days
B) Flagyl 500 mg PO BID x 10-14 days
If extended PO course ineffective: Flagyl gel 0.75% 5 g (1 applicator) daily x 10 days
C) Oral treatment in pregnancy with Flagyl or Clinda as above in A
Treatment of non-albicans candida (ie. glabrata)?
- Boric acid insert
- Flucytosine cream
- Amphotericin B suppository
- Nystatin suppository
Why are vaginal preparations of clinda/flagyl not used in pregnancy for BV?
They are safe, but have not been shown to decrease the risk of PTB
Diagnosis of vulvovaginal candidiasis:
A) pH ____
B) Wet mount _____
C) Whiff test ______
D) Gram stain _____
A) pH < 4.5
B) Budding yeast and pseudohyphae
C) Whiff test negative
D) Polymorphonuclear cells with budding yeast and pseudohyphae
Risks of BV:
A) Pregnancy (6)?
B) Gynecologic (2)?
A) PTB PPROM SA Chorio Endometritis (PP) Wound infection (post C/S)
B) Post-surgical infection
Subclinical PID
Define recurrent vulvovaginal candidiasis?
4 or more episodes in 1 year
When should a test of cure for BV be done in pregnancy?
1 month post completion of treatment
Risk factors for ureteric injury at the time of hysterectomy?
Large uterus endometriosis Adhesions Additional procedures (BSO, POP) Surgeon skill level/experience
Low threshold for cystoscopy
Opportunistic salpingectomy principles?
Reduced risk of ovarian ca
No increase in complication rate or long-term side effects
No decrease to ovarian reserve
Slight increase in OR time
Surgical approach should not be changed solely for the purpose of salpingectomy
Does hysterectomy affect ovarian reserve?
Yes
Risks of BSO in age <45?
Increased all-cause mortality Cardiac events Osteoporosis Cognitive decline/dementia Sexual dysfunction
Preferred route of hysterectomy?
Minimally-invasive
Vag hyst (as per SOGC guideline) --> shorter OR time and less cost TLH comparable and appropriate alternative
Falsehoods about supracervical hysterectomy?
Improved sexual function
Decreased POP
Decreased rate of ureteric injury
Levels of pelvic support?
Level 1: cardinal and uterosacral ligaments (apical supports)
Level 2: arcus tendineus fascia pelvis and fascia of levator ani
Level 3: urogenital diaphragm and perineal body
Rates of urologic injury by route of hysterectomy?
Same regardless of route
What are the 5 most common reasons for hysterectomy (in order)?
- Fibroids
- AUB
- Endometriosis
- POP
- Chronic pelvic pain
Possible increased risks of folic acid?
Increased risk of:
Colon ca
Multiples
Respiratory wheeze/reactive airway disease in children
Recurrence rate for NTD?
1% (with folic acid supplementation); 2-4% if no supplementation
When does the neural tube close?
3rd - 4th embryologic week (days 26-28) or 5th-6th week by LMP
List medications that inhibit folate (and are risk factors for NTD)?
Anti-convulsants Metformin Methotrexate Sulfasalazine Triamterene Trimethoprim
Who needs 1 mg of folic acid?
- History of folate-sensitive anomaly (cardiac, cleft lip/palate, GU, hydrocephalus)
- FHx NTD
- PGDM –> measure RBC folate
- Dialysis
- Medications (antiepileptics)
- Anti-folate medications (MTX)
- GI malabsorption (gastric bypass, IBD)
- Severe liver disease
If on higher dose folic acid, what is the duration of treatment?
3 months pre-conception through to 12 weeks
Then reduce to 0.4 mg daily until 4-6 weeks PP or done BF
If pregnancy does not occur by 6-8 months, reduce to 0.4 mg daily x 6 months
If still no pregnancy –> REI
Criteria for high-dose folic acid?
4-5 mg folic acid
- Woman or partner with personal hx of ONTD
- Previous pregnancy affected with ONTD
How does each of the following cross the placenta?
A) Oxygen
B) Glucose
A) Simple diffusion
B) Facilitated diffusion
Which coagulation factors decrease in pregnancy?
Free protein S
Describe the order in which oxygenated blood flows through the fetal circulation
- Umbilical vein
- ductus venosus
- Foramen ovale
- Fetal brain + ductus arteriosus
- Umbilical artery
1 and #2 risk factors for SUI?
1) Vaginal delivery
2) Obesity
Benefits of breastfeeding with GDM?
Decreased neonatal hypoglycemia
Decreased incidence of metabolic syndrome in future for mother and baby
Mullerian anomaly that is most associated with unilateral renal agnesis?
1) Unicornuate
2) Didelphys
*Think MAJOR anomalies
List common X-linked disorders
Hemophilia
Duchenne muscular dystrophy
Fragile X
Describe cardiac physiology principles that worsen pulmonary hypertension
- Decreased preload
2. Increased afterload
Copious malodorous discharge and pH <5.0?
Trichomonas
Positive Whiff test?
BV and trichomonas
What factors are most predictive of successful ECV?
- Complete breech
- Posterior placenta
- AFI > 10
List (in order) the anomalies most associated with RPL
- Septate (highest risk of RPL)
- Unicornuate
- Bicornuate
- Didelphys (least associated with RPL)
What are 2 benefits of smoking (that we tell no one)?
1) Decreased endometrial cancer
2) Decreased risk of preeclampsia (however increased risk of PTB/low birth weight)
Investigations that must be completed for ALL stillbirths?
CBC T&S Kleihauer-Betke HbA1c Karyotype/microarray Placental pathology Must be offered autopsy (but need consent)
What is gonorrhea resistant to?
Quinolones
What has NOT been shown to decrease the risk of infection at the time of IUD insertion?
Screening for BV
1 risk factor for SUI?
Previous vaginal delivery
First line treatment for SUI?
Pelvic floor physiotherapy
NOT weight loss and no role for estrogen
List GA at which the following are indicated in the management of pregnancy with hx of stillbirth:
A) Kick counts beginning at ____ weeks
B) Fetal growth at ___ weeks
C) Antenatal fetal surveillance at _____ weeks OR ____ weeks prior to GA of previous SB
A) 28 weeks
B) 28 weeks
C) 32 weeks OR 1-2 weeks earlier than GA of previous SB
SSRIs are associated with what (3) things in pregnancy?
- Cardiac anomalies
- Withdrawal
- Persistent pulmonary hypertension
What are SSRIs NOT associated with in pregnancy?
NTDs
What muscles and nerve roots are involved with Erb’s palsy?
C5-6
Infraspinatus
Deltoid
Forearm flexors
“Waiter’s tip”
What muscles and nerve roots are involved with Klumpke’s palsy?
C8-T1
Intrinsic muscles of the hand
“Claw hand”
Indications for classical C/S (7)?
- Bladder adhesions in lower segment
- Transverse back down
- Invasive (macro) cervical cancer
- Invasive placenta
- Premature delivery (no lower segment developed)
- Premature breech
- Distorted lower segment (ie. large fibroids)
What is the classic triad of congenital rubella syndrome?
“Eyes, ears, heart”
- Cataracts
- Deafness (SNHL)
- Cardiac anomalies
What are features associated with congenital varicella?
- Chorioretinitis
- Cutaneous scarring (cicatricial scarring)
- Bony defects/limb defects
What does not generally affect the teratogenicity of a substance?
Route of administration
What organism is NOT associated with PPROM?
Trichomonas
At what age does birth rate start to decline?
35
1 and #2 most likely organisms cultured in the setting of PPROM?
1) GBS
2) E. coli
First line treatment for cervical ectopic?
Multi-dose methotrexate
+/- hysteroscopy and laparoscopy
A woman seizes PP and BP is found to be 160/100
Next steps?
- Treat seizure with Mg
2. Control BP
Disposable trocars require what amount of force for insertion (with pneumoperitoneum)?
4-6 kg
Disposable trocars require ____ force than reusable trocars?
Half
1 cause of BENIGN adnexal mass in:
A) Pregnant?
B) Non-pregnant
1) Dermoid
2) Cystadenoma
How does hyperprolactinemia cause amenorrhea?
Suppresses GnRH secretion thereby inhibiting ovarian estrogen production
How do you manage a high grade SBO with advanced ovarian cancer? What about LBO?
SBO - NG first
LBO - consider diversion with ostomy
What would you expect to see with hemolytic disease of the newborn on:
A) Coomb’s test
B) CBC
A) Weakly positive or negative
B) Mild anemia
Most common side effect of misoprostol?
Diarrhea
What is NOT associated with second trimester loss?
Intrauterine adhesions
