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Royal College - OBGYN > Part 2 > Flashcards

Part 2 Flashcards

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1
Q

Pelvic floor exercises strengthen which muscles?

A
  1. Levator ani
  2. External anal sphincter
  3. Urethral sphincter striated muscle
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2
Q

Cystometry measures all phases of micturition except?

A

Emptying

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3
Q

Define types of vaginal/perineal tears, including OASIS grading system

A

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

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4
Q

Risk factors for OASIS?

A 
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
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5
Q

Protective factor for OASIS?

A

Obesity

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6
Q

Overall incidence of OASIS?

A

4 - 6.6%

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7
Q

Risk of recurrent OASIS?

A

4 - 8%

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8
Q

Complications of OASIS (7)?

A
  1. Pain
  2. Infection
  3. Wound breakdown
  4. Urinary retention
  5. Dyspareunia
  6. Flatal/fecal incontinence or urgency
  7. Fistula (rectovaginal)
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9
Q

List regimens for UTI prophylaxis in pregnancy

A

Cephalexin 250 mg PO daily

Nitrofurantoin 50 mg PO daily (avoid last 4 weeks of pregnancy)

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10
Q

Define recurrent UTI

A

2 uncomplicated UTIs in 6 months OR 3 culture-proven UTIs in 12 months

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11
Q

List complications of pessary use

A
  1. Erosions (9%)
    - Can lead to fistulas, cancer if chronic and untreated
    - Tx with removal and estrogen
  2. Infection (2.5%)
  3. Discharge
    - BV: remove more frequently + flagyl or replens
    - Candida: can keep pessary, tx as usual
  4. Dislodged/malpositioned
    - Can lead to constipation
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12
Q

Which pessary has not been shown to prevent PTB?

A

Arabin

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13
Q

Complications of mesh?

A
  • Bladder injury
  • Infection
  • EBL >500 mL/hematoma
  • Mesh erosion/exposure (4% risk TVT, 12% other procedures)
  • Dyspareunia
  • Pain
  • De novo SUI
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14
Q

What type of mesh has the lowest associated complication rates?

A

Polypropylene type 1 monofilament macroporous synthetic mesh

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15
Q

Risk factors for mesh exposure post-op?

A

Concomitant hysterectomy
Smoking

**Post-op tx with estrogen does not prevent

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16
Q

Predictors of pessary discontinuation?

A

Posterior wall prolapse
Young age (<65)
Urinary incontinence
Discomfort

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17
Q

Predictors of unsuccessful pessary fitting?

A 
Short vagina (<6 cm)
Wide introitus (>4 cm)
Rectocele
Previous vaginal surgery
Co-existing SUI
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18
Q

Anal sphincter complex - list muscles and innervation

A

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

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19
Q

Strongest evidence for vaginal estrogen with incontinence?

A

Urge incontinence

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20
Q

List 5 causes of persistent SUI after surgery

A
  1. Treatment failure
  2. Wrong treatment
  3. De novo urge incontinence
  4. UTI
  5. Fistula
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21
Q

Symptom most likely to improve with pessary?

A

SUI (up to 21%)

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22
Q

Symptoms most likely to worsen with pessary?

A

Voiding difficulties (up to 53%)

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23
Q

Findings (2) on UDS that suggests intrinsic sphincter deficiency?

A

Maximal urethral closure pressure <20 cm H2O

Leak point pressure < 60 cm H2O

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24
Q

4 types of enterocele

A
  1. Congenital
  2. Pulsion (increased intrabdominal pressures)
  3. Iatrogenic
  4. Traction (aka POP; “natural” pulling)
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25
Q

What must be done as part of office assessment for SUI pre-op?

A

PVR

Would also do:
Urinalysis/culture
UVJ hypermobility
Objective evidence of SUI

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26
Q

Most common cause of fistula globally?

A

Obstructed labour

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27
Q

Most common cause of fistula in developed nations?

A

Hysterectomy

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28
Q

Strongest indication for vaginal estrogen?

A

Recurrent UTIs in postmenopausal women

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29
Q

Which 3 urinary conditions are their evidence for improvement with estrogen?

A
  1. Recurrent UTIs (postmenopausal)
  2. Urge incontinence
  3. OAB (decreased frequency, dysuria, nocturia)
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30
Q

For what urinary condition is there NO evidence for improvement with estrogen?

A

SUI

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31
Q

What nerve is injured with an expanding hematoma following a Burch?

A

Obturator

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32
Q

Define OAB

A

Constellation of bladder symptoms:
Frequency
Urgency
Nocturia

(Not consistent with a UTI)

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33
Q

Route of hysterectomy associated with LEAST risk of ureteric injury?

A

Vaginal

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34
Q

Route of hysterectomy associated with HIGHEST risk of ureteric injury?

A

Radical hysterectomy > TLH > TAH

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35
Q

Mechanism of action for OAB anticholinergics?

A

Inhibit M2/M3 receptors in bladder wall to increase storage capacity

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36
Q

Absolute and relative contraindications to anticholinergics?

A

Absolute: allergy, acute uncontrolled narrow angle glaucoma, urinary and gastric retention

Relative: myasthenia gravis, controlled glaucoma, delayed gastric emptying, cognitive impairment

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37
Q

What 2 anticholinergics have fewer cognitive side effects and are better for use in the cognitively impaired?

A

Fesoterodine (Toviaz)

Trospium (Trosec)

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38
Q

In what compartment is risk of recurrence high for:

A) SSVF
B) Burch

A

A) Anterior

B) Posterior

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39
Q

Indications for UTI prophylaxis in pregnancy?

A
  1. Pre-pregnancy history of recurrent UTI
  2. Two failed treatments of UTI
  3. 1 UTI with risk factors (sickle cell, DM)
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40
Q

What is the Hodge pessary for?

A

Incarcerated uterus

Generally left in situ for 2 weeks until uterus grows and is out of the pelvis (~19 weeks)

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41
Q

How do incontinence pessaries work?

A

Stabilize the urethra and create a backboard to increase urethral resistance

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42
Q

If someone has recurrent UTIs with anything other than e. coli, what should you do?

A

Upper tract imaging + cystoscopy

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43
Q

Most common place for a ureteric injury:

A) During gynecologic surgery
B) During hysterectomy

A

A) At the level of the IP

B) At the level of the uterine artery

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44
Q

Nerve roots for:

A) Anal wink reflex
B) Bulbocavernosus reflex

A

A) S 2-5

B) S2/4 (“keeps the shit off the floor”)

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45
Q

7 causes of rectovaginal fistula?

A
  1. Surgery
  2. OASIS
  3. Radiation
  4. IBD
  5. Endometriosis
  6. Infection
  7. Malignancy
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46
Q

Classic symptom triad associated with urethral diverticulum?

A
  1. Post-void dribble
  2. Dyspareunia
  3. Dysuria
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47
Q

Craniosynostosis (premature fusion of fetal skull bones) is caused by?

A

Methotrexate in first trimester
Hyperthyroidism
Warfarin use
Valproic acid

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48
Q

Risks of methotrexate in first trimester?

A

ONTD (if taken before neural tube closes)
Microcephaly
TOF
Pulmonary valve atresia
Limb reduction
Syndactyly
Craniosynostosis (premature fusion of fetal skull bones)

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49
Q

Benefits of Delayed Cord Clamping?

A

Reduced IVH
Decreased anemia/transfusions
Increased iron stores at 6 months
Decreased NEC

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50
Q

Collaterals to uterus after bilateral internal iliac artery ligation?

A

Lumbar artery

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51
Q

Recurrence risk for stillbirth?

A

5-fold

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52
Q

Tocolytic that can cause pulmonary edema?

A

Nifedipine

Calcium-channel blocker that decreases cardiac inotrope = increased cardiac preload

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53
Q

Symptoms of fibrocystic breast disease?

A

Cyclic breast pain (hormonally responsive)

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54
Q

Most common complication of a D&E?

A

Hemorrhage

secondary to RPOC and cervical lacerations

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55
Q

Highest risk exposure time for limb defects with varicella?

A

Second trimester

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56
Q 
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

A) Genitofemoral
B) Obturator
C) Ilioinguinal
D) Iliohypogastric

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57
Q

Why is AC the most sensitive for detection of IUGR?

A

Contains the liver –> glucose storage

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58
Q

Most likely cause of vulvovaginitis in a 6 yo?

A

Non-specific

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59
Q

How long must someone be on testosterone before gender-affirming hysterectomy?

A

1 year

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60
Q

What has the most significant impact on
A) recurrence
B) persistence
following LEEP for HSIL?

A

A) High risk HPV

B) Positive margins

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61
Q

treatment for vulvodynia?

A

Topical xylocaine

Vestibulectomy (**has best evidence)

No evidence for TCAs

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62
Q

How do you treat genital warts in pregnancy?

A 
Trichloroacetic acid (TCA)
Cryotherapy

Podophyllin (Imiquimod) is contraindicated

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63
Q

Most significant risk factor for PP depression?

A

Adolescent

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64
Q

Risk of misoprostol exposure in first trimester?

A

Mobius syndrome - congenital facial paralysis

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65
Q

Most common nerves/vessel to be injured with SSVF?

A

Nerves: pudendal and sciatic

Vessels: inferior gluteal

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66
Q

The WHI quotes a 26% risk of breast cancer because this measure was used?

A

Relative risk

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67
Q

Definition of PMS

A

Symptoms must start within 5 days of menses and end within 4 days of menses

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68
Q

Euglycemia in GDM reduces the risk of?

A

Macrosomia
Shoulder dystocia
PET

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69
Q

5 goals of treating GDM?

A

Reduced risk of:

  1. Macrosomia
  2. IUFD
  3. PET
  4. C/S
  5. Neonatal complications (shoulder dystocia, birth trauma, hypoglycemia)
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70
Q

Risks (4) to babies born from diabetic mothers?

A
  1. Polycythemia
  2. Hypoglycemia
  3. Hypocalcemia
  4. Hyperbilirubinemia
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71
Q

Targets for glycemic control in pregnancy?

A

Fasting <5.3
1 h post-prandial <7.8
2 h post-prandial <6.7

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72
Q

Cut-offs for 1h 50g GCT?

A

Normal <7.8

7.8 - 11.0 –> 75 g OGTT

≥ 11.1 = GDM

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73
Q

Diagnostic cut-offs for 2h 75g OGTT?

A

Any 1 of:

Fasting ≥ 5.3
1 h ≥ 10.6
2 h ≥ 9.0

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74
Q

Timing of delivery for:

A) PGDM or GDM on insulin
B) PGDM or GDM diet

A

A) 38 - 39 weeks

B) No later than 40 weeks (38 - 40)

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75
Q

Fetal surveillance for GDM or PGDM?

A

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

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76
Q

Risks of GDM?

A 
LGA
Shoulder dystocia
C/S
PET
PTB
Stillbirth (begins to increase at 36 weeks)
Congenital anomalies
Risk of T2DM/obesity in future
Perinatal mortality
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77
Q

Benefits of preconception A1c ≤ 7.0% with PGDM?

A

Reduced risk of congenital anomalies (NTD, cardiac)
Decreased SA
Decreased retinopathy
Decreased preeclampsia

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78
Q

Preconception recommendations for PGDM (10)?

A
  1. Usual PNC: stop smoking/EtoH/PNV/immunizations
  2. Folic acid 1 mg 3 months pre-conception + T1
  3. Stop ACE/ARBs, statins, fibrates, all oral anti-hyperglycemics except metformin
  4. A1c ≤ 7.0% (ideally ≤6.5)
  5. BP < 135/85
  6. Eye exam
  7. BMI <30
  8. TSH
  9. ACR + eGFR
  10. ECG if >40
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79
Q

Risk factors for underlying T2DM?

A 
>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
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80
Q

TTP vs. HUS?

A

TTP: decreased platelets, fever, neurologic abnormalities, renal impairment, hemolytic anemia

HUS: more profound renal impairment, fever, neuro abnormalities

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81
Q

Etiologies of infertility?

A

30-40% Tubal
30-40% male factor
15% anovulation
15% unexplained

(From Speroff)

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82
Q

Chancroid is most consistent with?

A

Travel to endemic areas

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83
Q

Most actively reabsorbed electrolyte in kidney in pregnancy?

A

Sodium

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84
Q

Most common aneuploidy in first trimester losses?

A
  1. Trisomies (T16 most common)
    - Autosomal trisomy (22-32%)
  2. Monosomy X (5-20%)
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85
Q

How do you get a hypo/hypo pregnant?

A

If Kallman’s = pulse GnRH

Otherwise = exogenous gonadotropins

“Best” = IVF

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86
Q

Where is oxytocin produced?

A

Hypothalamus

Secreted by posterior pituitary

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87
Q

List the hormones that come from the anterior and posterior pituitary

A

Anterior: ACTH, FSH/LH, PRL, GH, TSH
Posterior: ADH, oxytocin

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88
Q

What helps differentiate TTTS and growth discordance?

A

Presence of 2 placentas

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89
Q

Most common cause of perinatal mortality with PGDM?

A

Congenital anomalies

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90
Q

Comparable effectiveness to dienogest (Visanne) for endometriosis?

A

Leuprolide acetate (GnRH agonists)

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91
Q

Buprenorphine has decreased risks of what vs. methadone?

A

Overdose

92
Q

Best determination of GA by U/S?

A

Earliest U/S with CRL > 10 mm

93
Q

Indications for adjuvant treatment in serous ovarian cancer?

A

Greater than stage IA (must be full staged IA to observe)

94
Q

Mechanism of action of tamoxifen?

A

SERM

Selective estrogen receptor modulator

95
Q

Chromosome and risk of ovarian cancer in BRCA1?

A

Chromosome 17

30-60%

96
Q

Chromosome and risk of ovarian cancer in BRCA2?

A

Chromosome 13

10-30%

97
Q

First line tx for endo?

A

Combined hormonal contraceptives or progestins

98
Q

Second line tx for endo?

A

IUD or GnRH agonsit/antagonist

99
Q

Third line tx for endo?

A

Danazol

Then aromatase inhibitors

100
Q

Biggest contributor to anovulation in PCOS?

A

Ovarian androgen production

101
Q

Recurrence risk PTB?

A

20-30%

102
Q

Risk of FAS with EtOH consumption in second trimester?

A

50%

103
Q 
Common reasons for each of the nerve injuries below:
A) Femoral
B) Ilioinguinal/iliohypogastric
C) Genitofemoral
D) Obturator
E) Peroneal
A

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

104
Q

1 and #2 complications of PET that lead to maternal mortality?

A

1) Stroke

2) Pulmonary edema

105
Q

Most androgenic progestin?

A

Norethindrone acetate

106
Q

Inheritance of complete AIS?

A

X-linked recessive

107
Q

Tamoxifen increases the risk of?

A

Endometrial cancer

Uterine sarcoma

108
Q

Risk factors for late radiation enteritis?

A

Diabetes

109
Q

Histologic changes with GUSM?

A

Increased parabasal/intermediated cells
Decreased superficial cells
Decreased collagen and elastin

110
Q

Histologic changes with vaginal estrogen for tx for GUSM?

A

Increased superficial cells

Proliferation of intermediate cells

111
Q

NNT for MgSO4 to prevent:
A) CP or death
B) CP alone

A

A) 43

B) 63

112
Q

Planned PTB - how long before C/S must MgSO4 be given?

A

4h

113
Q

Contraindications to MgSO4?

A

Myasthenia gravis
Hepatic coma
Hypersensitivity

114
Q

GA that qualifies for MgSO4?

A

Viability to 33+6 weeks

115
Q

MgSO4 has evidence for decreased?

A

CP and death

116
Q

Indications for MgSO4?

A

Imminent PTB

Planned PTB

117
Q

Define imminent PTB (for the purposes of MgSO4 administration)?

A

Active labour with cervix ≥ 4 cm

OR planned PTB

118
Q

Tocolysis + MgSO4

A

NO!

Tocolysis should be stopped if giving MgSO4
Delivery should not be delayed for MgSO4

119
Q

When can you consider repeating course of MgSO4?

A

> 12-24 h from last dose

120
Q

Risks of endometrial sampling?

A 
Pain
Bleeding
Infection
False passage
Uterine perforation
Bowel/bladder/vascular injury
Anesthetic risks 
False negative/positive result
121
Q

Risk factors that should make you consider polypectomy when patient asymptomatic?

A 
Age > 60
Polyp size > 4 cm
BMI > 30
DM
Menopausal
HTN
122
Q

When to sample asymptomatic thickened lining on U/S?

A

> 11 mm
Increased vascularity
Heterogeneous
Particulate fluid

123
Q

Screening for endometrial cancer?

A

No - no role for TVUS or endometrial biopsy in asymptomatic women

124
Q

Definition of asymptomatic endometrial thickening?

A

> 5 mm in postmenopausal woman

125
Q

Benefits of:
A) Betamethasone
B) Dexamethasone

A

A) Decreased rates of chorio, RDS, chronic lung disease

B) Greater reduction in IVH, NEC, shorter NICU stay

126
Q

NOT indications for ACS?

A 
Transfer with dx of PTL
Short cervix with no dilatation
\+FFN alone
Repeat courses
Term >37 weeks elective C/S
127
Q

Risks of ACS? (and multiple courses)

A

Decreased head circumference
Decreased birth weight
Possible long-term neurodevelopmental outcomes

128
Q

ACS has been shown to improve?

A

Perinatal death
RDS
IVH
NEC

129
Q

Indications for ACS?

A

24 - 34+6 weeks GA when delivery is expected within 7 days

130
Q

Types of ACS and doses?

A

Betamethasone 12 mg IM Q24 H x 2 doses

Dexamethasone 6 mg IM Q12 H x 4 doses

131
Q

Other than PTL, what are other indications for ACS?

A

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

132
Q

What conditions do NOT change timing or dose of steroids?

A

Obesity
DM
Multiples
IUGR

133
Q

When should GDM testing be done following ACS administration?

A

7 days

134
Q

Effect of ACS on fetal movement?

A

Transient decrease in FM x 3 days

135
Q

Does only a few hours of ACS still provide fetal benefit?

A

Yes

136
Q

How should insulin doses be adjusted following ACS?

A 
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
137
Q 
Ferriman-Gallway Score for:
A) Excessive hair growth
B) Mild hirsutism
C) Moderate hirsutism
D) Severe hirsutism
A

A) ≥8
B) <15
C) 16-25
D) >25

138
Q

Investigations for moderate to severe hirsutism?

A
  1. Total testosterone (not free testosterone)

If testosterone is increased:

  1. DHEAS
  2. SHBG
  3. 17-OHP
  4. TSH
139
Q

Criteria for dx of PCOS?

A

Rotterdam (2/3):

  1. Oligomenorrhea/anovulation
  2. Clinical or biochemical evidence of hyperandrogenism
  3. Polycystic ovaries (≥12 follicles of at least 10 cc in size)

Must be diagnosis of exclusion (r/o other causes)

140
Q

1 and #2 causes of hirsutism?

A

1) PCOS

2) Idiopathic

141
Q

First line tx for hirsutism?

A

OCP

142
Q

Duration of tx for hirsutism to see effects?

A

4 - 6 months

143
Q

First line treatment for infertility related to PCOS (anovulation)?

A

Weight loss
5-10% total body weight
Target BMI <35

144
Q

2nd, 3rd, 4th , 5th line tx for infertility related to PCOS?

A 
#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

145
Q

Pre-op criteria that must be met before endometrial ablation (6)?

A
  1. Completed childbearing
  2. Contraception discussion
  3. r/o malignancy - pap, endometrial biopsy
  4. Set expectations (decreased bleeding, NOT amenorrhea)
  5. Risk of hysterectomy in future if recurrent PVB and unable to sample
  6. Assess cavity
146
Q

Risk factors for fibroids (8)?

A
  1. Nulliparity
  2. Ethnicity (African)
  3. Early menarche
  4. Frequent menses
  5. Dysmenorrhea
  6. FHx
  7. Obesity
  8. Age (peak incidence 40-50s; 80% by menopause)
147
Q

Indications for endometrial biopsy with AUB (ie. risk factors for endometrial cancer)?

A
  1. Age > 40
  2. Obesity (BMI >30)
  3. Nulliparity
  4. PCOS
  5. DM
  6. Lynch syndrome
  7. Failed medical tx
  8. IMB
  9. Anovulatory cycles
148
Q

Step-wise MEDICAL tx for AUB?

A
  1. NSAIDs (start day before menses)
  2. TXA
  3. OCP
  4. Oral progestins (norethindrone, provera)
  5. Injectable progestins (DMPA)
  6. IUD
  7. Danazol
  8. GnRH agonists/antagonists –> need add-back
149
Q

Medical management of acute AUB?

A

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
150
Q

Risk of LMS in a fibroid?

A

1/400

151
Q

Pathophysiology of fibroids?

A

Monoclonal tumours that arise from benign myometrium

Myofibroblasts undergo disordered proliferation, which is dependent on estrogen and progestin

152
Q

Indications for surgical tx of AUB?

A
  1. Failed medical management
  2. Contraindications to medical management
  3. Significant anemia
  4. QoL impact
  5. Concomitant uterine pathology (ie. large fibroids, hyperplasia, dysplasia, etc.)
153
Q

What is hemoglobin target before gyne surgery?

A

≥120 g/L

154
Q

How is flare from GnRH avoided?

A

Letrozole x 5 days

OCP x 10 days

155
Q

Describe FIGO classification of fibroids

A

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.)

156
Q

Investigations for AUB?

A 
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

157
Q

Medical treatment for BLEEDING symptoms secondary to fibroids (7)?

A
  1. OCP
  2. Progestins
  3. LNG-IUD
  4. Lupron (GnRH agonist)
  5. Elagolix (GnRH antagonist)
  6. Danazol
  7. Mifepristone
158
Q

Medical treatment for BULK symptoms from fibroids (2)?

A
  1. Lupron (GnRH agonist)

2. Mifepristone

159
Q

Risk factors for BV?

A

Black women
Smoking
Sexual activity
Vaginal douching

160
Q

How do you treat vulvovaginal candidiasis in pregnancy?

What must be avoided?

A

Topical azoles (ie. clotrimazole)

Cannot use fluconazole (TOF), boric acid (2x risk of birth defects in 1st 4 months of pregnancy)

161
Q

Recurrent vulvovaginal candidiasis treatment:

A) 4 induction treatment options and duration?

B) 3 maintenance treatment options and duration?

A

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

162
Q

2 treatments for uncomplicated vulvovaginal candidiasis (PO and PV)?

A

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

163
Q

2 ways to diagnose BV?

A
  1. 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
164
Q

Treatment of BV:

A) Uncomplicated
B) Recurrent
C) Pregnancy

A

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

165
Q

Treatment of non-albicans candida (ie. glabrata)?

A
  1. Boric acid insert
  2. Flucytosine cream
  3. Amphotericin B suppository
  4. Nystatin suppository
166
Q

Why are vaginal preparations of clinda/flagyl not used in pregnancy for BV?

A

They are safe, but have not been shown to decrease the risk of PTB

167
Q

Diagnosis of vulvovaginal candidiasis:

A) pH ____
B) Wet mount _____
C) Whiff test ______
D) Gram stain _____

A

A) pH < 4.5
B) Budding yeast and pseudohyphae
C) Whiff test negative
D) Polymorphonuclear cells with budding yeast and pseudohyphae

168
Q

Risks of BV:

A) Pregnancy (6)?

B) Gynecologic (2)?

A 
A) PTB
PPROM
SA
Chorio
Endometritis (PP)
Wound infection (post C/S)

B) Post-surgical infection
Subclinical PID

169
Q

Define recurrent vulvovaginal candidiasis?

A

4 or more episodes in 1 year

170
Q

When should a test of cure for BV be done in pregnancy?

A

1 month post completion of treatment

171
Q

Risk factors for ureteric injury at the time of hysterectomy?

A 
Large uterus
endometriosis
Adhesions
Additional procedures (BSO, POP)
Surgeon skill level/experience

Low threshold for cystoscopy

172
Q

Opportunistic salpingectomy principles?

A

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

173
Q

Does hysterectomy affect ovarian reserve?

A

Yes

174
Q

Risks of BSO in age <45?

A 
Increased all-cause mortality
Cardiac events
Osteoporosis
Cognitive decline/dementia
Sexual dysfunction
175
Q

Preferred route of hysterectomy?

A

Minimally-invasive

Vag hyst (as per SOGC guideline) --> shorter OR time and less cost
TLH comparable and appropriate alternative
176
Q

Falsehoods about supracervical hysterectomy?

A

Improved sexual function
Decreased POP
Decreased rate of ureteric injury

177
Q

Levels of pelvic support?

A

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

178
Q

Rates of urologic injury by route of hysterectomy?

A

Same regardless of route

179
Q

What are the 5 most common reasons for hysterectomy (in order)?

A
  1. Fibroids
  2. AUB
  3. Endometriosis
  4. POP
  5. Chronic pelvic pain
180
Q

Possible increased risks of folic acid?

A

Increased risk of:
Colon ca
Multiples
Respiratory wheeze/reactive airway disease in children

181
Q

Recurrence rate for NTD?

A

1% (with folic acid supplementation); 2-4% if no supplementation

182
Q

When does the neural tube close?

A

3rd - 4th embryologic week (days 26-28) or 5th-6th week by LMP

183
Q

List medications that inhibit folate (and are risk factors for NTD)?

A 
Anti-convulsants
Metformin
Methotrexate
Sulfasalazine
Triamterene
Trimethoprim
184
Q

Who needs 1 mg of folic acid?

A
  1. History of folate-sensitive anomaly (cardiac, cleft lip/palate, GU, hydrocephalus)
  2. FHx NTD
  3. PGDM –> measure RBC folate
  4. Dialysis
  5. Medications (antiepileptics)
  6. Anti-folate medications (MTX)
  7. GI malabsorption (gastric bypass, IBD)
  8. Severe liver disease
185
Q

If on higher dose folic acid, what is the duration of treatment?

A

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

186
Q

Criteria for high-dose folic acid?

A

4-5 mg folic acid

  1. Woman or partner with personal hx of ONTD
  2. Previous pregnancy affected with ONTD
187
Q

How does each of the following cross the placenta?

A) Oxygen
B) Glucose

A

A) Simple diffusion

B) Facilitated diffusion

188
Q

Which coagulation factors decrease in pregnancy?

A

Free protein S

189
Q

Describe the order in which oxygenated blood flows through the fetal circulation

A
  1. Umbilical vein
  2. ductus venosus
  3. Foramen ovale
  4. Fetal brain + ductus arteriosus
  5. Umbilical artery
190
Q

1 and #2 risk factors for SUI?

A

1) Vaginal delivery

2) Obesity

191
Q

Benefits of breastfeeding with GDM?

A

Decreased neonatal hypoglycemia

Decreased incidence of metabolic syndrome in future for mother and baby

192
Q

Mullerian anomaly that is most associated with unilateral renal agnesis?

A

1) Unicornuate
2) Didelphys

*Think MAJOR anomalies

193
Q

List common X-linked disorders

A

Hemophilia
Duchenne muscular dystrophy
Fragile X

194
Q

Describe cardiac physiology principles that worsen pulmonary hypertension

A
  1. Decreased preload

2. Increased afterload

195
Q

Copious malodorous discharge and pH <5.0?

A

Trichomonas

196
Q

Positive Whiff test?

A

BV and trichomonas

197
Q

What factors are most predictive of successful ECV?

A
  1. Complete breech
  2. Posterior placenta
  3. AFI > 10
198
Q

List (in order) the anomalies most associated with RPL

A
  1. Septate (highest risk of RPL)
  2. Unicornuate
  3. Bicornuate
  4. Didelphys (least associated with RPL)
199
Q

What are 2 benefits of smoking (that we tell no one)?

A

1) Decreased endometrial cancer

2) Decreased risk of preeclampsia (however increased risk of PTB/low birth weight)

200
Q

Investigations that must be completed for ALL stillbirths?

A 
CBC
T&S
Kleihauer-Betke
HbA1c
Karyotype/microarray
Placental pathology
Must be offered autopsy (but need consent)
201
Q

What is gonorrhea resistant to?

A

Quinolones

202
Q

What has NOT been shown to decrease the risk of infection at the time of IUD insertion?

A

Screening for BV

203
Q

1 risk factor for SUI?

A

Previous vaginal delivery

204
Q

First line treatment for SUI?

A

Pelvic floor physiotherapy

NOT weight loss and no role for estrogen

205
Q

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

A) 28 weeks
B) 28 weeks
C) 32 weeks OR 1-2 weeks earlier than GA of previous SB

206
Q

SSRIs are associated with what (3) things in pregnancy?

A
  1. Cardiac anomalies
  2. Withdrawal
  3. Persistent pulmonary hypertension
207
Q

What are SSRIs NOT associated with in pregnancy?

A

NTDs

208
Q

What muscles and nerve roots are involved with Erb’s palsy?

A

C5-6
Infraspinatus
Deltoid
Forearm flexors

“Waiter’s tip”

209
Q

What muscles and nerve roots are involved with Klumpke’s palsy?

A

C8-T1
Intrinsic muscles of the hand

“Claw hand”

210
Q

Indications for classical C/S (7)?

A
  1. Bladder adhesions in lower segment
  2. Transverse back down
  3. Invasive (macro) cervical cancer
  4. Invasive placenta
  5. Premature delivery (no lower segment developed)
  6. Premature breech
  7. Distorted lower segment (ie. large fibroids)
211
Q

What is the classic triad of congenital rubella syndrome?

A

“Eyes, ears, heart”

  1. Cataracts
  2. Deafness (SNHL)
  3. Cardiac anomalies
212
Q

What are features associated with congenital varicella?

A
  1. Chorioretinitis
  2. Cutaneous scarring (cicatricial scarring)
  3. Bony defects/limb defects
213
Q

What does not generally affect the teratogenicity of a substance?

A

Route of administration

214
Q

What organism is NOT associated with PPROM?

A

Trichomonas

215
Q

At what age does birth rate start to decline?

A

35

216
Q

1 and #2 most likely organisms cultured in the setting of PPROM?

A

1) GBS

2) E. coli

217
Q

First line treatment for cervical ectopic?

A

Multi-dose methotrexate

+/- hysteroscopy and laparoscopy

218
Q

A woman seizes PP and BP is found to be 160/100

Next steps?

A
  1. Treat seizure with Mg

2. Control BP

219
Q

Disposable trocars require what amount of force for insertion (with pneumoperitoneum)?

A

4-6 kg

220
Q

Disposable trocars require ____ force than reusable trocars?

A

Half

221
Q

1 cause of BENIGN adnexal mass in:

A) Pregnant?
B) Non-pregnant

A

1) Dermoid

2) Cystadenoma

222
Q

How does hyperprolactinemia cause amenorrhea?

A

Suppresses GnRH secretion thereby inhibiting ovarian estrogen production

223
Q

How do you manage a high grade SBO with advanced ovarian cancer? What about LBO?

A

SBO - NG first

LBO - consider diversion with ostomy

224
Q

What would you expect to see with hemolytic disease of the newborn on:

A) Coomb’s test
B) CBC

A

A) Weakly positive or negative

B) Mild anemia

225
Q

Most common side effect of misoprostol?

A

Diarrhea

226
Q

What is NOT associated with second trimester loss?

A

Intrauterine adhesions

Royal College - OBGYN (3 decks)

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