Part I Flashcards
Respiratory changes in pregnancy:
a) RR
b) Tidal volume
c) Expiratory reserve volume
d) Inspiratory reserve volume
e) FRC
f) Residual volume
g) Vital capacity
a) unchanged
b) Increase
c) Decreased
d) Unchanged
e) Decreased by 20-30%
f) Decreased
g) unchanged
Marfan’s syndrome:
A) Maternal Risks
B) Fetal risks
A) PPH, aortic rupture, uterine rupture, cervical insufficiency, operative delivery, death
b) inheritance (dominant), IUFD, IUGR, PTB
Key features of herpes gestationis? (aka pemphigoid)
Papules/vesicles everywhere
C3 +/- IgG deposition in basement membrane
Usually T2/3
Increased risk of recurrence (50-70%)
Fetal risk: SGA, PTB (30%), neonatal pemphigoid (10% risk)
Treatment: delivery by 37w + increased FHS + prednisone +/- IVIG
Causes of increased AFP on MSS? (6)
1) ONTD
2) Abdo wall defect
3) IUFD
4) Cystic hygroma
5) twins
6) wrong dates
Fetal risks of:
a) chloramphenicol
b) sulfa drugs
c) streptomycin
d) tetracycline
a) aplastic anemia
b) Inc Bili/kernicterus & skeletal abnormalities
c) ototoxicity
d) teeth hypoplasia and impaired skeletal growth
Cardiac conditions in which pregnancy is contraindicated (10):
1) Pulmonary arterial HTN
2) NYHA III/IV or EF < 30%
3) Severe (re)coarctation
4) Severe aortic root dilation: a) Marfan + aortic root >4.5cm, b) bicuspid or TOF + root >5cm, c) turner’s ASI > 25mm/m2
5) Eisenmenger’s syndrome
6) Previous peripartum cardiomyopathy & current EF <45%
7) Vascular Ehler Danlos
8) severe mitral stenosis
9) Fontan with any complication
10) severe symptomatic AS
Bad derm conditions in pregnancy with increased fetal risks: (2)
1) Pemphigoid (herpes gestationis)
2) Pustular psoriasis (impetigo herpetiformis)
Abnormal value for uterine artery doppler?
> 2.5 PI & bilateral !
Normal umbilical arterial blood gas for term infants:
pH = 7.2-7.34 pCO2 = 39-62 pO2 = 10-27 HCO3 = 18-26 BE = -5.5 to -0.1
Indications for infectious endocarditis PPx?
1) Prosthetic valve or material to repair valve
2) Previous infective endocarditis
3) Structural valvular regurgitation with prosthetic material in the setting of unrepaired/residual shunt, cyanotic heart disease or cardiac transplant
Risk factors for striae:
Increased Gestational weight gain
Multiples
Young women
Genetics
US findings of ONTD? (5)
- Lemon head sign
- Banana cerebellum
- Open defect along spine
- Ventriculomegaly
- Talipes
Others:
Relatively small head
obliterated posterior fossa
When to deliver IUGR with normal dopplers?
38-39wks (COGRP)
SOGC guideline says 37 wks
Hyperthyroidism:
A) Maternal risks
B) Fetal risks
A. Thyroid storm, tachycardia, sweating, heat intolerance, PET, CHF, PP flare
B. Hypothyroid, goiter, IUFD, hydrops, PTB, tachycardia
Criteria for APLS
- Clinical:
- Vascular thrombosis
- death of anatomically normal fetus >/ 10wks
- 3 or more consecutive loss <10wks
- placental insufficiency or severe PET with PTB <34w - Lab:
- Anticardiolipin IgG/IgM
- Anti B2 glycoprotein 1
- Lupus anticoagulant
Labs positive twice q12w apart
Classic triad for congenital rubella syndrome:
- Sensorineural hearing loss
- Ocular defects
- Cardiac defects
Most associated with BPP of 2?
Persistent Pulmonary HTN
Key features of pustular psoriasis (impetigo herpetiformis)?
Pustules on erythematous patches, flexural surfaces
Onset in 3rd trimester
Fetal risks = PTB IUGR IUFD
Tx = steroids, usually resolves postpartum
Components of a BPP:
- 3 movements
- 1 tone
- 30s breathing
- One 2x2 pocket
When to start kick counting?
26w
Most significant RF for PP depression?
Adolescent
Facial features of FAS?
Smooth filtrum Thin upper lip Epicanthal folds absent maxilla short palpebral fissures small eyes small head IUGR CNS abnormalities
2 risks of accutane? (retinoids)
Microtia
microopthalmia
(small ears and eyes)
Abnormal value for MCA doppler?
MoM > 1.5 => transfuse and investigate +/- steroids
Unsafe treatments of acne in pregnancy?
Tretanoin (accutane)
Tetracyclines
Safe treatment of psoriasis in pregnancy?
- steroids (topical or PO)
- UV light therapy
Rash on extensor surfaces?
Psoriasis
Rash on flexor surfaces?
eczema
How to monitor for Mg toxicity
In order of things lost:
1) Serial patellar reflexes
2) RR
3) Maintain U/O >30cc/hr
% melasma in pregnancy & treatment?
70%
Avoid sun, will resolve postpartum
Normal dermatological changes in pregnancy?
Hair loss PP
Transverse grooving in nails
More brittle nails
Nail bed coming off
spider angioma/palmar erythema/varicocities
Increased pigmentation - linea nigra, new nevi
Time post parvo infection when MOST hydrops occur?
What GA would the parvo infection would the worst?
- 2-4wks (4w) Post infection
2. Worst = 13-16wks GA
Which thyroid molecule is least likely to cross the placenta?
TSH
Biggest risk factor for failing a TOLAC
BMI
Least teratogenic anticonvulsant
Lamotrigine
Levatracetam (Keppra)
Think L’s
LR for:
A) Absent nasal bone
B) Inc nuchal fold
For T21
A) LR 6.6 if isolated/23.3 if in combination
B) LR 3.8 if isolated/23.3 if in combination
SOGC Table 3 Meta analysis 2017 values
Zika - when can you conceive?
Wait 3mo after last exposure/symptom onset prior to engaging in unprotected intercourse
(previously said 6mo but new guidance from CDC now says 3mo)
Tay-Sachs has a deficiency in which enzyme?
Hexosaminidase
Difference in presentation of clostridium & GAS?
Clostridium = TSS & No Fever GAS = Nec fasc & Fever
How to deliver brow presentation?
CS
RFs for ONTD? List 8
Low folic Acid Family hx of NTD Meds (schizo meds) Personal Hx Folic acid antagonist use GI malabsorption Obesity Ethnicity (celtic)
RCT evidence for wound closure with increased BMI?
With BMI >40, subQ stitch decreases wound complications
Obesity has the greatest effect on which stage of labour ?
Increased risk of CS in the first stage
Recommended delivery time for maternal obesity & why?
BMI 40 by 40w to decrease risk of SB (can also consider BMI >30)
High RFs where you can recommend ASA (i.e where you only need 1 of the RFs to start ASA) List all 6
Hx of PET Multiples Chronic HTN DM1/2 Renal Ds. Autoimmune Ds. (SLE or APLS)
Fetal surveillance with maternal obesity
Serial growth 28,32,36wks
BPP qWeekly 37w onwards
Recommended gestational weight gain if pre-preg BMI 30+?
Gain 5-9kg (11-20lbs) with most of it being in the 2nd half of the pregnancy
IOL at 39-40w for BMI 30+ has what benefits?
Decreased CS
Decreased macrosomia
Decreased neonatal Morbidity
Decreased maternal morbidity
How much ASA and when?
150mg (162mg) qHS (ASPRE trial dose n timing)
Start before 16wks (ASPRE started at 12w but can start before)
Stop at 36-37wks
How long to wait for pregnancy after bariatric surgery?
24mo
Who is at highest risk of uterine rupture:
a) low vertical incision
b) short interdelivery interval
Short interval (anything <18mo)
What is the rupture rate with a lower vertical scar?
Not significantly different than LTCS (~1-2%)
What is the rupture rate with a scar in the upper uterine segment (i.e classical)?
4-9% (some sources 12%)
Why is a low vertical incision a contraindication to TOLAC?
Because you don’t know if they cut into the upper segment
Rate of uterine rupture for TOLAC with IOL:
a) any GA
b) at term
c) 40w
a) 1%
b) 1.5%
c) 3.2%
IOL with cervical ripening:
a) PGE2
b) Misoprostol
What are the rupture rates?
a) 2%
b) 6%
Not recommended
Risk of uterine rupture with adding oxytocin (IOL or augmentation)?
~1% (double the risk of 0.5%)
TOLAC with 2 prior CS
a) Rate of success
b) rupture rate
c) Risks
a) similar to those with 1 CS
b) 1.6%
c) increased risk of blood transfusion and hysterectomy
ECV with prior CS
Not contraindicated
Multiples with TOLAC
a) success rate
b) rupture rate
a) similar to singleton
b) no increased rupture rate
Risk of uterine rupture with TOLAC vs Elective Repeat CS
0.47% vs 0.026%
Predictors of successful TOLAC (11)
- Age <30
- BMI <30
- Caucasian
- Previous vaginal birth
- Non recurrent indication for index CS (i.e breech)
- Previous GHTN
- Spont labour
- PV >4cm on admission to L&D
- Epidural use
- GA <40w
- Birth weight < 4000g
Factors that increase risk of uterine rupture?
Oxytocin use 2 or more CS IOL with ripening meds Pregnancy interval <18mo Thin LUS (no cutoff determined) Classical or low vertical CS
Contraindications to TOLAC (List 5)
Suspected or known Classical CS
Previous inverted T or low vertical incision
Prior history of rupture
Previous history of major uterine surgery (transmyometrial)
Pt chooses ERCS
Not technically contraindicated but needs to be informed of increased risk:
<18mo
2 or more
single layer closure
Interdelivery interval with TOLAC:
a) Success rate?
b) rupture rate? (<12mo and <15mo)
c) contraindicated
a) not affected by interval
b) <12mo = 4.8% <15mo=4.7%
c) <18mo
Risk of rupture with:
a) 1 layer unlocked
b) 1 layer locked
a) similar to 2 layers
b) Increased risk to 3%
Risk of neonatal death from uterine rupture?
6%!!!
Best 2 predictors of successful TOLAC
#1 = previous vaginal delivery (86%) #2 = spontaneous labour (80.6%)
Factors that decrease likelihood of TOLAC success
Age >/ 35 BMI >30 Previous dystocia IOL GA >40w Birth weight >4000g PET in this pregnancy
Neonatal risks vs benefits of ERCS vs TOLAC?
ERCS: increased RDS and TTN
TOLAC: Increased risk of death, seizures, permanent neurological deficits
Most common sign of uterine rupture
Abnormal FHR (complicated or late variables & bradycardia 30-60m prior to rupture)
Delayed cord clamping benefits?
decreased IVH
decreased anemia
ABx for PP D&C
Not indicated
Ascites at risk for what TORCH?
Syphilis
Trisomy ___ associated with Choroid plexus cysts?
T18
Fetal movements with respect to:
1) smoking
2) steroids
3) Temperature of food
1) Dec FM temporarily
2) Dec FM x3d after
3) Cold fluid Increases FM
Omphalocele - what decreases the risk of aneuploidy?
Liver herniation, giant omphalocele
Most likely cardiac defect with Eisenmenger syndrome?
VSD
Aortic stenosis is a ___ dependent lesion
Preload dependent (avoid PPH)
Fetal mortality rate in Canada
4.5/1000 total births
Only form of antenatal fetal surveillance with Level I evidence?
Umbilical artery doppler
Pregnant women with T1DM at increased risk of hypoglycemia?
First trimester or PP
Autonomic dysreflexia
- presentation
- triggers
- prevention
- headache, flushing, sweating, bradycardia, hypertension
- PVE, foley, Ctx, DRE, labour
- labour supine, topical anesthetic, early epidural
Gestational weight gain in
a) Normal weight
b) overweight
c) BMI >30
d) Underweight
a) 25-35lbs
b) 15-25lbs
c) 11-20lbs
d) 28-40lbs
Which cardiac defects are NOT preload dependent?
MR
MS
AR
10 investigations for hydrops fetalis?
- K-B
- CBC
- T&S
- TSH
- Parvo/Toxo/CMV/Rubella serologies
- LFTs, coags (mirror syndrome)
- Anti Ro/La
- HbElectrophoresis
- G6PD screen
- VDRL/RPR
4 diagnostic conditions for Peripartum cardiomyopathy?
- within last 1mo of pregnancy and 5mo PP (6mo window)
- R/O other causes
- No cardiac ds prior to onset
- LV dysfunction (EF<45%)
Maternal CAH
a) enzyme responsible
b) inheritance
c) prevention of virilization in female fetus
a) 21-hydroxylase deficiency
b) recessive
c) Dex 20mcg/kg/day until you can confirm male fetus or unaffected
Stress dose steroids dosing?
Hydrocortisone 100mg IV q8H
3 malignancies that can metastasize to the placenta?
Melanoma
Leukemia
lymphoma
What GA is physiologic herniation
9-11+6w
Why should blood glucose be kept between 4-7 during labour?
minimize risk of fetal hypoglycemia
Benefits of preconception A1C
Dec SA, anomalies, PET, progressive retinopathy
Single umbilical artery associated with and NOT associated with? (5/1)
A/W: Kidney defects (#1), IUGR, congenital heart, spinal defects, chromosomal abnormalities (1%)
No A/W: clefting
Management of pheo in pregnancy?
alpha blockade THEN beta-blockade
alpha blocker = phenoxybenzamine
<24wks consider surgery
>24wks consider medical treatment and CS
Ventriculomegaly associated with which syndrome?
T21/Down’s
Enzyme that protects fetus from maternal increase in cortisol?
Placental 11-beta-hydroxysteroid dehydrogenase
Maternal complications of Cushing’s in pregnancy? List 4
HDP
GDM
CHF
Maternal death
Pancytopenia (aplastic crisis) from what pregnancy conditions?
Parvovirus
Sickle cell
Definition of growth discordance in twins?
Difference of 20mm in AC
or
20% in EFW by discordance (bigger-smaller/bigger)
WinRho ___mcg cover ___mLs of fetal RBCs and ___mL of fetal blood
300mcg
15mLs RBCs
30mLs blood
Fetal monitoring >41w awaiting IOL?
Twice weekly:
BPP or
NST and Fluid assessment
What is true for Miso (PGE1) vs cervidil (PGE2)?
Miso has increased risk of tachysystole
Miso is MORE effective to achieve vaginal delivery
Miso a/w less epidural use
Misoprostol dosing PO and PV for IOL & disadvantages of each?
PO = 50mcg q4h disadvantages= need more Pit
PV = 25mcg q4h disadvantages = more tachysystole
How long after misoprostol can you start oxytocin?
4h
IOL for AMA at ___GA
40 by 40w (39-40wk)
Decreases rate of still birth
(biologically post term at 39wks)
When/how long after the following can you start oxytocin?
a) cervidil
b) PGE2 gel
a) 30m
b) 6h
Term PROM IOL vs expectant
less chorio less endometritis less NICU admission no difference in neonatal infections No difference in mode of delivery Women prefer pit *may increase CS?*
High priority reasons for IOL (6)?
PET Significant maternal disease not responding to treatment Significant but stable APH Chorio Suspected fetal compromise Term PROM GBS+ve
Unacceptable reasons for IOL?
Provider preference/convenience
Suspected macrosomia EFW>4kg in a non diabetic woman
Risks of IOL?
Failed IOL CS (only if cervix not ripe) Operative delivery Uterine rupture Preterm infant (incorrect dates) Cord prolapse Chorioamnionitis Tachysystole
Rank importance of components of Bishops score
- Dilatation
- Effacement
- Station/position
- Consistency
Factors that increase success of IOL? Name 6
- Bishop’s score >6
- BMI <40
- Parity (previous vaginal delivery)
- Non diabetic
- EFW <4kg
- Maternal age <35
NNT for sweeps at 38wks to prevent post dates pregnancy?
8
In appropriately selected women with well trained providers, the rates of perinatal mortality in breech vaginal delivery vs elective CS?
VBB = 0.8-1.7/1000 CS = 0-0.8/1000
Vaginal breech:
Short term vs long term neurological morbidity compared to CS?
Greater short term but no long term neonatal neuro morbidity with planned VBB
Rate of CP in breech?
1.5/1000 regardless of mode of delivery
How long for passive second stage for vaginal breech?
90m
How long for active (pushing) second stage with vaginal breech?
60m
Allowable length of time in second stage for: Passive: a) Nulliparous with epidural b) Nulliparous without epidural c) Multiparous with epidural d) Multiparous without epidural
Active
e) Nulliparous with epidural
f) Nulliparous without epidural
g) Multiparous with epidural
h) Multiparous without epidural
a) 2h
b) 2h
c) 2h
d) 1h
e) 2h
f) 2h
g) 2h
h) 2h
Total duration of 2nd stage: Nullip no epi = 3h Nullip with epi = 4h Multip no epi = 2h Multip with epi = 3h
Definitions of labour dystocia:
- Active first stage
- Active second stage
Definition of obstructed labour
- > 4h of <0.5cm/hr or no dilatation over 2h
- Greater than 1h of pushing without descent
No dilatation or descent over 2h despite evidence of strong ctxns (caput, molding, IUPC)
IUPC adequate ctxns?
each ctxns 50-60mmHg
or
MVU >200 (sum in 10m)
Frank vs complete breech?
Frank = hips flexed and knees extended Complete = hips and knees flexed
Can you use oxytocin with a breech?
Only for augmentation
IOL = limited data but does not appear to be associated with poorer outcomes than spontaneous labour
Selection criteria for planned vaginal breech?
Pre or early labour US:
- EFW 2800-4000g
- Flexed head
- Adequate maternal pelvis clinically
- No cord presentation
- Frank or complete (not footling)
- No fetal anomaly to interefere with delivery
- No contraindications to vaginal delivery
- Adequate counseling of risks and maternal consent
Adequate progress in 1st stage for a vaginal breech?
If no progress over 2h = CS
Maximum of 7h to go from 5cm to 10cm
Monitoring in labour for vaginal breech?
Continuous EFM
Definition of High assisted vaginal birth?
Fetal head not engaged (above station 0)
Not recommended
Definition of Mid AVB
0 to +2 (but not +2 –> thats low)
subcategory : > or < 45deg rotation from midline
Fetal head no more than 1/5 palpable above pubic brim
Definition of Low AVB
Leading bony point of the fetal head is at station 2+ or greater
Subdivided into > or < 45 deg rotation
Definition of outlet AVB
Fetal scalp visible without labial separation
Fetal skull at pelvic floor
Direct A or P or less than 45deg rotation
Prerequisites for AVB
- consent
- Good Exam - abdominal and pelvic
- Preparation of staff (NICU, anesthesia, nursing)
- Location of delivery - access to CS for unsuccessful TOF esp. with higher risk of failure (High BMI, EFW 4kg+, OP/OT, mid cavity)
- Analgesia
- Empty bladder
Contraindications to AVB
- Absolute (7)
- Relative (1)
Absolute:
- Unengaged head (>1/5th above pelvic brim)
- Fetal coagulopathy/ low plts/ skeletal dysplasia
- Non vertex
- Incomplete dilatation
- uncertain of head position
- Suspected CPD
- Inability to go quickly for a CS
Relative:
Vacuum <34w GA
Indications for AVB:
- Abnormal FHR in 2nd stage
- Labour dystocia in the 2nd stage
- Maternal conditions that preclude from valsava: NYHA III/IV, severe resp ds., cerebral AVM, proliferative retinopathy, myasthenia gravis, spinal cord injury at risk of autonomic dysreflexia
Documentation of AVB (18 things)
- Date/time
- Physician name
- Indication
- Anesthesia
- Consent
- Position/station
- Moulding/caput
- Adequate pelvis
- FHR and Ctxn pattern
- Instrument used
- Application and # of attempts
- Traction applied
- Pop offs or reapplication
- condition of newborn
- Neonatal/maternal injuries
- Position of chignon on head
- Initiation of monitoring
- Debrief with patients
Preferred episiotomy type?
RML at 60-70def starting 1cm lateral from the midline
Neonatal risks with forceps (6)
- Facial laceration
- Ocular injuries
- Facial nerve palsy
- Skull fracture
- brachial plexus injury
- Retinal hemorrhage
Neonatal risks with vacuum (6)
- Chignon (resolves in 24h)
- Bruise/laceration
- Cephalohematoma
- Subgaleal hemorrhage
- Shoulder dystocia
- Retinal hemorrhage
Describe Subgaleal hemorrhage:
Large emissary veins below the aponeurosis
Not limited to suture lines
large volume of blood
can lead to hypotension and shock
Describe a cephalohematoma
5% risk with vacuum
Bleeding between the bony skull and periosteum
Limited by suture lines
Can cause hyperBilirubinemia
Maternal risks of AVB (9)
- Lower genital laceration
- Vulvar/vaginal hematoma
- OASIS
- Urinary tract injuries
- Inc blood loss
- Inc pain
- Psych trauma (short term)
- Urinary incontinence
- POP (AVB >SVD>CS)
Also consider that 2nd stage CS has higher risk of PTB in subsequent pregnancy and Long term risks of a CS
Interventions that promote SVD (6)
- Dedicated support person
- IA for Low risk
- Delayed pushing with epidural
- Inc pushing time with epidural
- Manual rotation
- Augmentation with oxytocin
MOA of PTU?
Does it cross the placenta?
Is it safe for breastfeeding?
Congenital anomalies?
MOA: block organification of ioidine (dec thyroid hormone production) and blocks peripheral conversion of T4 to T3
It does cross the placenta
Safe for BF
No congenital anomalies - use in T1
Birth defects with methimazole?
Cutis aplasia Facial dysmorphism Choanal atresia Esophageal atresia Developmental delay
Which thyroid hormones cross/don’t cross placenta?
Cross: TRH, iodine, thyroid Ab’s, small amounts of T3/T4 in T1
Don’t cross: TSH
Medications for thyroid storm?
- Consult endocrinology
- First give PTU
- 1-2h after, give Lugol’s (iodine) = stops release of T3/4
- Dex
- Propanolol (HR <120 is the goal)
- Supportive treatment (cooling blankets, lytes)
Maternal side effects of:
PTU
Methimazole
PTU: transient leukopenia -> dont stop the med
Methimazole: Agranulocytosis; rare; stop drug and check CBC
When does the fetus start concentration iodine and start making thryoid hormone?
10-12w
Which thyroid hormones INCREASE and which are UNCHANGED or DECREASE in pregnancy?
Increase: Thyroid binding globulin, Total T3/T4
No change: TRH, Free T3/4
Decrease: TSH in early pregnancy but then unchanged
MOA of methimazole?
Does it cross the placenta?
Safe for BF?
Congenital anomalies?
MOA: blocks organification of iodine (Dec TH production) Placenta: crosses Safe for BF Associated with anomalies - do not use in T1 - cutis aplasia - facial dysmorphism - choanal/esophageal atresia - developmental delay
What is the risk with PTU and why do we change after T1?
Black box warning of severe liver injury
Triggers for thyroid storm?
Infection
Surgery
L&D
8 things that work to reduce risk of OHSS
1) antagonist protocol (can use agonist trigger)
2) metformin (with PCOS)
3) coasting (up to 3d)
4) freeze-all
5) single embryo transfer
6) progesterone for luteal phase support (instead of hCG)
7) cabergoline at time of hCG trigger
8) cycle cancellation (**most effective, but last line)
MOA of 5-alpha-reductase?
converts testosterone to DHT
MOA of mirabegron?
beta 3 adrenergic receptor agonist (relaxation of detrusor smooth muscle)
conditions or meds that decrease SHBG?
PCOS obesity insulin resistance excess androgens hypothyroid progestins glucocorticoids
conditions or meds that increase SHBG?
pregnancy
OCP / estrogen
hyperthyroid
pathophysiology of PCOS
- increased androgen sensitivity
- theca cells make more androgens
- insulin resistance
- altered GnRH pulsatility favouring LH - leads to increasing androgens
blood vessel to perineum?
inferior hemorrhoidal
risks / side effects of letrazole?
- multiples
- OHSS
- hot flashes
- headache
- fatigue
- dizziness
diagnostic criteria for metabolic syndrome
Need 3 of 5:
- waist circumference >88cm
- high TG’s (or on meds)
- low HDL
- high blood glucose (or on meds)
- HTN >130/85 (or on meds)
prenatal findings of Turners?
increased NT cystic hygroma abnormal MSS cardiac defects horseshoe kidney / other renal anomalies
Karyotype of Turners
45XO
MOA of letrazole
aromatase inhibitor - inhibits conversion from testosterone to estrogen (thereby decreasing negative feedback of estrogen on hypothalamus, allowing increased FSH/LH to stimulate ovulation)
daily dose of calcium?
1200 mg
what structure is the remnant of the mesonephric duct?
Gartner’s duct cyst
female equivalent to prostate?
Skene’s gland
postnatal findings of Turners
short stature scoliosis webbed neck shield chest hearing loss low set ears otitis media high palate delayed puberty / POI cardiac defects (coarctation of aorta, aortic stenosis) kidney stuff bone stuff (decreased BMD, congenital hip dysplasia, short 4th digit) wide carrying angle lymphedema DM, celiac, hypothyroid, HTN
RMI 2
menopause (4) x CA 125 x 4 if 2+ features on US US features (ABCDE): Ascites, Bilateral, multiloCulated Cyst, soliD areas, Extrapelvic disease, METS!
RF’s for cervical insufficiency
- maternal (7)
- in index pregnancy (4)
maternal: previous cervical insufficiency (<2.5cm <27wk), prior cervical trauma (LEEP, cone), recurrent mid-trimester losses, PPROM <32 wks, congenital uterine anomaly, connective tissue dz (ED)
index: cervical funneling, cervical shortening, overt cervical dilation, <2.5cm at <27 wks
indications for PV progesterone for prevention of PTB (3)
previous spontaneous PTB
cervix <25 mm in singleton 16-24 wk
cervix <25 mm in multiples 16-24 wk
indication for elective cerclage?
- 3 or more T2 losses (or extreme PTB) - 12-14wks
- History of PTB or cervical insufficiency AND cx <25mm <24 wks
indication for emergency/rescue cerclage?
- dilated cervix (<4cm) without contractions < 24 wks
- twins dilated > 1cm < 24 wks
dose of progesterone for prevention of PTB?
micronized
200 mg PV HS singleton
400 mg PV HS multiples (could split BID)
Contraindications to PV progesterone
allergy to soy/peanuts
liver disease
hx of VTE
2 regimens for PPROM antibiotics?
1) erythromycin 250mg po q6 hrs x 10 days
2) ampicillin 2g IV q6h + erythro 250mg IV q6h x 48 hrs
then amox 250 mg po q8 h + erythro 333mg po q8 hr x 5 days
how many susceptible Rh- women will become sensitized after
- Amnio
- CVS
2%
14%
how many Rh - women will become isoimmunized if not given prophylaxis, antepartum?
2%
investigations when presenting with PPROM?
BV
GBS
GC
urine culture
why treat PPROM with antibiotics?
*to prolong pregnancy and decrease maternal/neonatal morbidity
latency (by treating/preventing ascending infection)
prevent infection - may decrease fetal morbidity
WinRho after abdominal trauma, ECV, or FMH?
- do KB
- give 120-300 ug then more based on KB
- extra 10ug per 0.5ml fetal RBCs
when is the D antigen present on fetal RBCs?
7+3 GA - 38 days from conception
2 strategies for Rh prophylaxis
1) winrho 300 at 28 wks
2) winrho 120 at 28 + 34 wk
ideal time and latest time to give winrho after a sensitizing event?
72 hr
within 28 days
when/who to test for alloantibodies?
all pregnant women
at 1st PNV and at 28 wks
Does weak D (Du+) get Winrho?
no
How much Winrho after: SA, TA, ectopic, partial mole, amnio/CVS?
< 12wk - 120 ug
> 12wk - 300 ug
MOA of anti-D in preventing alloimmunization?
anti-D crosses placenta and masks or covers fetal RBCs with their antigens
when these fetal RBCs and antigen cross the placenta into maternal circulation, the maternal immune system and antibodies can’t “see” or attack the fetal antigens
risk of alloimmunization if no Winrho after delivery? (Rh- woman Rh+ fetus)
14%
Atypical and abnormal variability?
atypical: <5 bpm x 40-80 mins
abnormal: marked x 10 mins, minimal x 80mins, sinusoidal
atypical and abnormal FHR baseline?
atypical: 100-110, >160 x 30-80 mins, rising baseline, arrhythmia
abnormal: >160 x 80 mins, <100, erratic
continuous EFMis associated with? (3)
decreased neonatal seizures 50%
increased CS + operative delivery
no difference in mortality
abnormal FHR decelerations
repetitive (3 in a row) complicated variable
recurrent (>50% ctx in 20 min) late decels
single prolonged decel >3 min
atypical FHR decelerations
repetitive (3 in a row) uncomplicated variables
non-repetitive complicated variables
intermittent late decels
single decel >2 min <3 min
4 types of complicated variables
recovers after end of ctx
lasts longer than 60 s AND < 60bpm or 60 below baseline
variables with abnormal baseline or minimal/absent variability
overshoot (>20s >20bpm)
dose of IV nitro for uterine relaxation
50 mcg IV nitro
normal pH & lactate from FSBS?
pH: >7.24
lactate: <4.2
indications for IA?
low risk >37 wk, spontaneous labor
action required with abnormal EFM
DC/decrease oxytocin maternal resuscitation FSBS notify anesthesia/neonates expedite delivery - unless imminent, or evidence of normal FSBS
Target platelets for:
a) CS
b) SVD
c) epidural
a) 50
b) 20
c) 70
medical management of tone with PPH?
hemabate 0.25mg IM/IMM Q15min x max 8 doses (NOT in asthma)
ergot 0.25mg IM/IV Q2hrs (NOT in HTN or HIV proteases)
oxytocin 10 IU IM or 5 IU IV push or 20-40 IU in 250cc
misoprostol 400-800ug po/SL or 800-1000 PR
TXA 1g IV q30 min x 2
surgical management of tone and PPH?
1) uterine artery embolization
2) ligate uterines
3) ligate internal iliac (must be done BEFORE excessive blood loss)
4) B-Lynch/Cho sutures (must have HYSTEROTOMY to ensure no RPOC)
5) last option = hyst
Ro and La antibodies associated with?
Sjogrens
Lupus (fetal heart block!)
risk of recurrence of PP psychosis?
50%
pros and cons of delayed cord clamping?
pros: decreased blood transfusions, anemia; decreased IVH; increased Hb/iron stores at 6mo
cons: hyperbili, more phototherapy and jaundice
pros/cons of miso (PGE1) vs PGE2 for cervical ripening?
PGE1: MORE tachysystole, increased VD (compared to PGE2) therefore less CS, decreased epidural use
PGE2: decreased oxytocin use, ok in asthma, ok with ROM at term
classical CAH presentation at birth (5)
ambiguous genitalia salt wasting (hypo Na) hyperK hypotension shock
reasons to extend monitoring of FHR post 4 hrs of trauma?
- *admit for observation + intermittent auscultation + uterine activity monitoring x 24 hrs at least
- uterine tenderness
- sig abdo pain
- PVB
- sustained ctx (>1/10min)
- ROM
- atypical / ABN FHR
- high risk mechanism
- fibrinogen <2
warfarin embryopathy?
6-9 wk: midface hypoplasia, nasal hypoplasia, epiphysial stippling
T2-3 exposure: (due to fetal hemorrhage) CNS dysplasia, micropthalmia, blindness, MR
prophylactic oxytocin dose for ALL low risk women? (AMTSL)
10 IU IM with delivery of anterior shoulder
5 IU IV (only for VD, not CS!)
20-40 IU IV in 1 L at 150cc/hr
how does eGFR change in pregnancy?
increases max 50% in T2
increased 30% at term
medication for PPH prevention at elective CS?
carbetocin 100 ug IV bolus over 1-2 min
% of deliveries affected by PPH?
5%
Describe Pipingas technique
for retained placenta at 45 min:
1) syringe with miso 800 ug or pit 50 IV in 30 cc NS
2) push (with catheter) into umbilical vein
3) allow 30 min with cord clamped
degrees of shock
mild - <20% - diaphoresis, cool extremeties, increased cap refill
mod - 20-40% - tachycardia, tachypnea, postural BP drop, oliguria
severe - 40%+ - hypotension, agitation/confusion
% of major fetal anomalies identifiable prenatally?
% of live births with major anomalies?
% identified at birth?
3%
5%
2%
what % of SA are from chromosomal anomalies?
50%
risks of adolescent pregnancy? (6)
STI & BV - test at visit 1 & again in T3 IPV (30%) Mood d/o PTB/PPROM - increase visits in T2-3 LBW Congenital anomalies - US T1, T2, T3
causes of torsion in
a) adults
b) peds
c) pregnancy (highest risk time)
a) cystic teratoma (60%)
cystadenoma (30%)
22 % of postmenopausal torsions are malignant
b) long ovarian ligament/laxity (15-50%) benign teratomas (30%) functional cysts (25%)
c) up to 20% torsions are pregnant
T1 55% > T2 35% > T3 11%
ovulation induction
definition of primary and secondary dysmenorrhea and pathophys
1 - pain with menses w/o pathology
2 - pain with pathology (ie endo)
pathophys - ovulation –> uterine ctx; triggered by progesterone; withdrawal = uterine ischemia - made worse by prostaglandins
average age adnexal torsion?
more common side?
26yo right side (66%)
imaging findings for torsion (4)
- enlarged ovary
- absence of Doppler flow
- solid mass with peripheral cyst
- significant adnexal asymmetry (vol ratio >20 between 2 ovaries)
what to use for menstrual suppression for girls on chemo & when to start?
Lupron (or CHCs) - Lupron has most data
11.25mg 1 mo prior to chemo then Q3mo
Impact of WHO surgical safety checklist?
Decreased deaths by 50%
Treatment for primary syphilis?
Benzathine PenG 2.4M units IM x 1
2 non-albicans species of candida?
C. glabrata & C. tropicalis
Cut vs Coag?
Cut = low voltage + high frq + continuous current Coag = high voltage + intermittent current + more lateral spread
Minimum diagnostic criteria for PID?
lower abdominal tenderness
cervical motion tenderness
adnexal tenderness
Gold standard for dx PID?
Laparoscopy showing evidence of PID => tubal erythema &/or mucopurulent exudates in pelvis
3 antibiotics in pregnancy for chlamydia?
Amox 500mg PO BID x7d
Erythro 500mg QID x7d
Azithro 1g PO x1
Causative agent for Lymphogranuloma venereum?
C. trachomatis serovar L1, L2 or L3
Monopolar resectoscope
- Conductive vs Non Conductive solution?
- Tonicity of solution?
- Fluid deficit at which you want to finish quickly?
- Fluid deficit at which you want to stop procedure?
Repeat for Bipolar
- Non conductive
- Hypotonic (cystosol)
- 1000
- 1500
- Conductive solution
- isotonic (NS)
- 2000
- 2500
Absolute contraindications to medical management of ectopic?
- Unstable patient
- Allergy/sensitivty to MTX
- Severe liver or renal disease
- Breastfeeding
- Not dependable for FU
- Heterotopic pregnancy
Multiple ulcers with histo staining showing dark-staining Donovan bodies?
Klebsiella granulomatis
Histologic features of lichen sclerosis?
- Loss of rete pegs
- Thinning epidermis
- Edema of the dermis
- Lymphocytic infiltration
Treatment of non albicans VVC? (4 options)
- Boric acid 600mg PV x 14d
- Amphotericin B 50mg PV x 14d
- Flucytosine cream 5g PV x14d
- Flucytosine 1g + amphotericin B 100mg PV x 14d
What physical exam finding is required for diagnosis of provoked vestibulodynia?
+ Q tip test
MOA of heparin?
activates anti thrombin => inactivates Factor II/X
Circumvallate placenta associate with?
Abruption AbN FHR Oligo PTB SA
3 muscles that make up the levator ani?
- Pubococcygeus
- Puborectalis
- Ileococcygeus
PPI for the Ani
How many days after varicella are you most at risk for pneumonia?
4-6d
How many days after fertilization does implantation occur?
7-8d
How does HRT prevent bone loss in postmenopausal women?
Inhibition of osteoclast activity (decreased resorption and remodelling)
Mitral stenosis is ____ dependent
Afterload (keep them dry)
Tx for MgSO4 overdose?
Calcium gluconate
How to 1st investigate a breast mass in pregnancy?
US
Most likely maternal condition to cause neonatal thyrotoxicosis? and why?
Grave’s
TRAB’s cross placenta even if previoulsy treated
Tell tale sign of AFLP?
Dec glucose
Inc ammonia
Most common side effect of ergot?
HTN
Who is at more risk of aneuploidy: monozygotic vs dizygotic?
Per fetus: monozygotic
Per pregnancy: dizygotic
What is true about twin growth?
Same as singleton until ~32-35w after which it decreases slightly
What nerve conducts pain signal for labour?
Sympathetic afferents (afferent = ascending to CNS) from muscle to CNS
T10-L1 block for epidural
T4 for CS
Cherney vs Maylard incision?
Cherney = need to dissect the rectus off the pubic symphysis (good for space of retzius) Maylard = cut rectus laterally to create more space about 6-8cm above pubic symphysis
How to counsel about HRT and breast cancer?
HRT has ~ risk of Breast Cancer as Postmenopausal obese person
The combination of conjugated estrogens + MPA in WHI was shown to have the greatest risk of breast cancer
Estrogen alone (hx of hyst) was not associated with increased breast cancer risk
Progesterone seems to be the problem -> can avoid with new generation TSEC (only 2y of data so far)
PET CardioRespiratory complications: List 2 adverse conditions and 4 severe conditions
Adverse:
- O2 <97%
- CP or SOB
Severe:
- Uncontrolled severe HTN over 12h despite 3 agents
- O2 <90% or >/50% O2/intubation/pulmonary edema
- Pressors
- MI
PET Fetoplacental complications: List 4 adverse conditions and 3 severe conditions
Adverse:
- AbN FHR
- IUGR
- Oligo
- AEDF or REDF
Severe:
- Abruption with fetal/maternal compromise
- Reverse ductus venosus A wave
- Stillbirth
PET Renal complications: List 2 adverse and 2 severe conditions
Adverse:
- Elevated Cr
- Elevated UA
Severe:
- AKi (Cr >150)
- New indication for dialysis
PET Hematological complications: List 3 adverse and 2 severe complications
Adverse:
- Elevated WBC
- Elevated INR PTT
- Decreased plts
Severe:
- Plts <50
- Transfusion of any product
PET Hepatic complications: List 4 adverse and 2 severe conditions
Adverse:
- RUQ pain
- NV
- Elevated AST ALT LDH or Bili
- Dec Albumin
Severe:
- Hepatic dysfunction with INR >2 without DIC
- Hepatic hematoma or rupture
BP goal for non severe HTN with co-morbid conditions
<140/90
BP goal for non-severe HTN without comorbid conditions?
130-155/80-105
Agents and doses used for non severe HTN (149-159/90-105)
- Labetalol 100-400mg PO BID to TID (max 1200mg/day)
- Nifedipine XL 20-60mg PO daily (max 120mg)
- Methyldopa 250-500mg PO BID-QID (max 2g/day)
BP goal in L&D when Hypertensive
<160/110
PET CNS complications: List 1 adverse condition and 5 severe conditions
Adverse:
1. Headache, visual changes,
Severe:
- PRES
- Eclampsia
- TIA/Stroke
- GCS <13
- Cortical blindness or retinal detachment
Pathophysiology of PEt
Many factors that converge into INADEQUATE PLACENTATION Intervillous soup: -placental debris - immune reaction - cytokines - angiogenic imbalance Leads to endothelial cell activation
What korotkoff phase is used to desginate DBP?
Korotkoff V
High risk for PET (i.e indications for ASA) List 3
- Prior PET
- Pre existing HTN (or initial DBP >90), renal disease (or initial proteinuria) or DM
- APLAS
Goal of BP in severe HTN
<160/110
Drug for refractory HTN?
Sodium nitroprusside
1st line meds and doses for severe HTN?
- Nifedipine IR 5-10mg PO q30m
- Labetalol 20mg IV and repeat 20-80mg IV q30m (not to be used in asthma)
- Hydralazine 5mg IV and repeat 5-10mg IV q30m (max dose 20mg) (increased risk of hypotension)
When to deliver HELLP syndrome?
35+ weeks
if between 24-35w, consider delaying delivery long enough to give steroids
Delivery timing GHTN at term ?
within days
Timing for delivery of pre existing HTN and otherwise well?
38-40w
Dose of MgSO4
4g IV loading dose over 30m followed by 1g IV/hr
BP goal postpartum with and without comorbidities?
<140/90
BP goal postpartum with DM?
<130/80
Do not give NSAIDs PP if ____ (list 3)
- HTN difficult to control
- Kidney injury
- Plts <50
GHTN and PET are associated with _____ for the child later in life?
adverse pediatric neurodevelopmental effects (attention and externalizing behaviour (aggresive)
When to consider MgSO4 for non severe PET?
Severe HTN H/A vision changes RUQ/epigastric pain Plts <100 Elevated Cr Elevated LFTs
What are high risk thrombophilias? (3)
- antithrombin deficiency
- APLAS
- homozygous FVL
How long for VTEp with OHSS?
8-12w with LMWH
2 indications for therapeutic thromboprophylaxis in pregnancy
- Long term therapeutic ppx pre-pregnancy with persistent indication
- Personal hx of multiple previous VTE
How to long to give PP anticoagulation?
Persistent risk = 6w PP
Transient risk = until discharge or 2wk PP
Preferred test (SOGC) for dx of PE in pregnancy? & 2nd choice (a/w increased risk of?)
#1 choice - VQ scan #2 - CT PE (a/w breast cancer)
Why LMWH over UH/Warfarin/Xa Inhibtors in pregnancy?
UH = increased risk of HIT (use only if renal ds)
Warfarin = embryopathy (only superior for mechanical heart valves)
No data on Xa inhibitors in pregnancy
When to use a vena cava filter in pregnancy?
Acute DVT/PE and contraindication to anticoagulation (within 2w of delivery)
Who gets PP VTEp with LMWH -> Name 5 different indications
What does the risk of VTE need to be in order to qualify?
Risk needs to be >1%
- Hx of VTE
- High risk thrombophilias (APLAS, AT def, Homo FVL, prothrombin gene mutation)
- Bed rest prior to delivery x7d
- EBL >1L or transfusion AND and concurrent PP surgery
- Peripartum/PP infection
VTE in pregnancy more common in which leg?
Left
% concurrent PE with thrombophlebitis 5cm or more in pregnancy?
4%
When to treat superficial thrombophlebitis in pregnancy? (4) and what would you treat with/how long?
- Bilateral
- Symptomatic
- within 5cm of deep vein
- 5cm or longer in vein
Treat with PPx or Intermediate dose LMWH x 1-6wks
1 reason to give intermediate or therapeutic thrombophylaxis in pregnancy
Personal hx of VTE + high risk thrombophilias
9 reasons to give VTEp in pregnancy (VTE risk > ___ %)
VTE risk >1%
- Personal Hx of unprovoked VTE
- Personal Hx of estrogen or pregnancy provoked VTE
- Personal Hx of provoked VTE + low risk thrombophilia
- Asymptomatic homozygous FVL
- Asymptomatic combined thrombophilia
- Asymptomatic anti thrombin deficiency
- Non OB surgery in pregnancy
- Strict bed rest 7d+ and BMI >25
- Asymptomatic homozygous prothrombin gene mutation 20210A
Risk factors for ovarian vein thrombosis and which side is it more common?
R > L
RFs:
- CS
- Multiples
- Infection
Happens PP more commonly
When to screen for thrombophilia in pregnancy and what to screen for?
NO routine screening following 1 VTE in pregnancy
Only screen if VTE in pregnancy AND Family history
Screen for Protein C&S deficiency and AT deficiency (only test for APLAS if it would change duration of treatment)
Can get an epidural ___hours later with:
- LMWH PPx
- LMW Tx
- UH PPx
- UH IV infusion
- UH SC Tx
- LMWH PPx = 12h
- LMWH Tx = 24h
- UH PPx = No delay
- 4h later if PTT is normal
- When PTT is normal
Kallman syndrome:
- Breasts?
- Uterus?
- Presents with?
Breasts = no
Uterus = yes
Presents with 1’ amenorrhea + anosmia + hypo/hypo (GnRH deficiency)
Turner’s syndrome (45XO)
- Breasts?
- Uterus?
- Presents with?
Breasts = yes (min development) uterus = yes
Presents with short stature, shield chest (widened inter nipple distance), webbed neck, streak gonads, elevated FSH, posterior hairline, short 4th metacarpals, low set ears, increased carrying angle at the elbow (cubitus valgus)
What diet is associated with delayed puberty?
Vegetarian
How to treat:
- Central precocious puberty?
- Peripheral precocious puberty?
- Central = GnRH agonist
2. Peripheral = Aromatase inhibitor
Definition of delayed puberty?
a) without 2’ sexual characteristics = > 14yo
b) with 2’ sexual characteristics (presuming rest of puberty comes normally) => 16yo
Fecundability = ?
Fecundity = ?
Fertility rate = ?
Fecundability = ability to conceive a pregnancy per menstrual cycle
Fecundity = ability to achieve a live birth per cycle
Fertility rate = live births per 1000 women 15-44
Most common SE of miso?
Diarrhea
Evidence based treatment for vulvodynia?
Vestibulectomy
2 RCTs for TCA showed no difference but it continues to be used; off label use for pain
Main reason for Turner’s to be on OCP after menarche/puberty?
Bone protection
Most common causes (#1/#2) for 1’ amenorrhea?
- Gonadal dysgenesis
2. Mullerian anomaly
Reasons for mid cycle spotting?
Low estrogen
Savage Syndrome (FSH-R deficiency):
- Breasts?
- Uterus?
- Presents with?
Breasts = yes
Uterus = yes
Presents with 1’ or 2’ amenorrhea + elevated FSH + Normal AFC on US
DDx for precocious puberty?
Central: Idiopathic (80% - most common cause of Precocious Puberty) CNS tumors/anomaly/infection Head trauma iatrogenic (rads/chemo/sx) ischemia Hamartoma
Peripheral: Primary Hypothryoid Ovarian tumor Adrenal tumor Exogenous hormones McCune-Albright syndrome CAH
Swyer syndrome:
- Breasts?
- Uterus?
- Presents with?
Breasts = no
Uterus - yes
Presents with delayed puberty, XY + streak gonads + elevated FSH
McCune Albright syndrome?
Precocious puberty + Cafe au lait spots + polyostotic fibrous dysplasia
Isosexual, gonadotropin independent, form functional cysts producing E2
Definition of precocious puberty?
Puberty before age 7-8 in girls
How does BMI impact puberty and why?
Elevated BMI = earlier puberty
At a certain wt. the body thinks it can support a pregnancy = turns on HPO axis
MRKH/Mullerian agenesis :
- breasts?
- uterus?
- presents with?
Breasts = yes
Uterus = no
Presents with 1 amenorrhea and normal thelarche and adrenarche
Complete or partial AIS:
- Breasts?>
- Uterus?
- Presents with?
Breasts = yes
uterus = no
Presents with 1’ amenorrhea, XY, adrenarche, ambiguous genitalia
Stats you can get from a cohort study?
Incidence = # new cases in time / total population at risk (ie exposed)
RR = EER/CER = (a/a+b)/(c/c+d)
RR = how many times more likely are you to develop illness in those exposed vs those not exposed (derived from prospective cohort study)
Pros/Cons of a cohort study and explain a cohort study
Cohort study = group free of ds split into Exposed vs Unexposed and followed prospectively
Pros:
- good for rare exposures
- establish temporal relationship (case n effect)
- no recall bias
- can show an association
Cons:
- long follow up
- $$$
- not good for rare ds.
- confounding
What tests/plots for heterogeneity?
Forest plot I^2 stastistic L'Abbe-plot Tau^2 statistic Chi-squared statistic
Case control study: Pros/Cons and explain it
Case control study: Starts with those diagnosed and looks back for exposure
Pros:
- good for rare ds.
- fewer pts
- hypothesis generating
Cons:
- no causality
- easy to pick wrong controls
- recall bias
How to interpret I^2 tests?
It’s a test for heterogeneity in a meta analysis
0-25% = little to no heterogeneity = good 75-100% = too hetereogeneic = bad
Is heterogeneity good or bad in a meta analysis?
Bad - ideally studies should be conducted in a similar way
How can you assess for publication bias?
Funnel plot
What is the difference between a systematic review and meta analysis?
SR = compares different types of studies MA = combines similar types of studies (i.e all RCTs)
Prevalence?
AKA = pre test probability
Prevalence = total # cases / total population = a+c/a+b+c+d
Includes old and new cases
Snapshot in time of who has the disease
Pros/Cons of cross sectional study
Pros:
- describes a population at this point in time
- good for prevalence
- easy
- cheap
Cons:
- no associating
- not good for rare disease/short diseases/fatal diseases
- no F/U
Pros/cons of case report series?
Pros:
- easy
- cheap
Cons:
- generates hypothesis
- no associations
- selection bias
Pros/Cons of RCT
Pros:
- test hypothesis
- control for bias
- best to prove causation
- placebo arm = natural hx of ds
Cons:
- $$$
- hard for rare ds.
- long FU
- hard to selection proper study population
Stats you can get from RCT?
RR
RRR
ARR
NNT
What stat can you get from a case-control study and how to calculate it?
OR= (a/b)/(c/d)
treatment of dysmenorrhea (3)
1) NSAIDs (at onset of menses)
2) OCP/hormonal (continuous good option)
3) non-medical - exercise, heat, TENS, acupoint, ginger
indications for menstrual suppression? (8)
bleeding disorder anemia / AUB social choice severe dysmenorrhea (endo) hormonal withdrawal symptoms PMDD developmental disabilities cancer treatment at risk for low hgb and low platelets
risk factors for primary dysmenorrhea
young age nullip smoking or 2nd hand smoke frequent life changes / stress/ social low SES mood d/o
surgical treatment for primary dysmenorrhea that is evidence based
1) hysterectomy - effective with cyclic pain & normal pelvis on scope (complication rate 8%)
2) laparoscopic uterine nerve ablation - evidence for primary dysmenorrhea, NOT for endo
3) presacral neurectomy (PSN) - evidence for endo
4) endometrial ablation - evidence with HMB
age of consent for sexual activity?
18 for exploitive
16 for non-exploitive
exceptions - 14 or 15 is partner < 5 yrs older
12 or 13 - parter < 2 yrs older
what congenital anomalies are teens at increased risk for?
MSK - clefting, polydactyly, syndactyly
GI - gastroschisis, omphalocele
CNS - NTD, microcephaly, hydrocephalus
resectoscope ablation efficacy
2) % repeat surgery
3) %hysterectomy
20% repeat OR
10% subsequent hyst
advantage/disadvantage resectoscopic ablation?
advantages: can also treat polyps/fibroids or do biopsy, direct visualization, can be done if previous ablation or myomectomy
disadvantages: longer OR time, fluid absorption risks/increased complication rate, skill
advantages/disadvantages of non-resectoscopic ablation?
A: faster, safer (decreased perf, fluid overload, hematometria, cervix lac), quicker recovery, can do under local
D: increased N/V, increased cramping
how can you decrease risk of capacitive coupling with monopolar resectoscope?
keep out of cervical canal don't over dilate lower voltage (cut > coag) decrease activation time keep in contact with tissue when its activated use weighted speculum
what instruments can you use for repeat ablation
resectoscope or hydrotherm ablator
contraindications to non-resectoscopic ablation?
classical CS, transmural myomectomy
how to pre-op thin lining for endometrial ablation
GnRH agonists
danazol
progestins
time in cycle
predictors of failure for endometrial ablation
previous tubal
chronic pelvic pain / preop dysmenorrhea
age <40
non-resectoscopic ablation efficacy:
% re-intervention
% amenorrhea
- 20%
- 30-40%
most common genetic cause of MR
T21
timing of delivery of twins
DCDA - 37-38 wks
MCDA - 36-37 wks
MCMA - 32 wks
cell types in pituitary
a) ant
b) post
ant - FSH, LH (gonadotrophs), PRL (lactotrophs), ACTH (corticotrophs), TSH (thyrotropins), growth hormone (somatotropins)
post - oxytocin (magnocellular neurosecretory cells), ADH (special neurons)
Rank most common reasons for RPL
1) unknown - 50%
2) APLAS - 5-20%
3) anatomic 10-15% (septums account for majority)
4) reciprocal/balanced translocation - 3-5%
2 vitamins newborns need supplementation of
Vit D
Vit K
what components do you need for a sample size calculation?
power (1-B)
prevalence
(internet says confidence level, population size, and margin of error)
differential diagnosis for non-cardiogenic pulmonary edema
PET fluid overload sepsis/ARDS malignancy PE malnutrition
codeine to morphine
codeine is __ than morphine
6 x less potent
In PPROM - latency is ___
inversely proportional to GA
galactorrhea can be normal up to __ months post wean
6 mo
monozygotic can be __
DCDA
MCDA
MCMA
(1/3 dichorionic, 2/3 monochorionic)
monochorionic twins are always __
monozygotic
dizygotic are always __
dichorionic (DCDA)
how to tell chorionicity/amnionicty <10 wks GA
#GS = #placentas #yolk sacs = #sacs
how to tell chorionicty/amnionicty >10 wk GA
#placentas fetal genitalia (discordance = DCDA) lambda sign (DCDA) T sign (MCDA) characteristics of membrane
timing of egg splitting with multiples
monozygotic 1-3 - DCDA 4-8 - MCDA 8-13 - MCMA >13 days - conjoined
criteria to diagnose POI?
Rule of 4s:
- age < 40
- 4 mo amenorrhea
- FSH x 2 20-40 (4wks apart)
what % of pregnancies are affected by HG?
0.3 - 2%
RF’s for HG
- previous HG
- multiples
- molar pregnancy
- female fetus
- maternal inheritance
- low BMI
- mood d/o
risk of using ondansetron in pregnancy for NVP
<10 wks, may be risk of cardiac defects/clefting, use as last resort
>10 wks ok
what decreases your risk of ovarian cancer?
- opportunistic salpingectomy (or TL, but less)
- OCP
- BSO
- ASA?
what organism is NOT associated with BV?
actinomycin
definition of neonatal HSV
evidence of disease >48 hr after delivery
C/S by maternal request - risks
1) maternal death
2) risks of surgery
3) increased risk of hemorrhage
4) increased neonatal TTN (if <39 wk)
5) more pain at 6 mo
6) does not decrease lifetime risk of UI if >1 CS
risks during CS of
a) bladder injury
b) urethral injury
c) bowel injury
a) 2/1000
b) 0.3/1000
c) 1/1000
most common cause of non-immune fetal hydrops
a) overall
b) < 24 wk diagnosis
c) prenatal diagnosis
a) cardiac
b) chromosomal
c) chromosomal
mitral stenosis ?
afterload dependent
avoid increased HR and volume overload
keep dry
mitral regurg?
afterload dependent
avoid vol overload
keep dry
AS?
preload dependent
avoid hypotension / hypovolemia
keep wet
avoid PPH
how to do a risk reducing BSO
washings
inspect pelvis, appendix, upper abdo
cut tube in intramural portion of cornua and remnant cauterized
skeletonize IP and take 2cm distal to ovary
remove in bag
risk of occult malignancy with RR BSO?
2-9%
with BRCA, RRBSO decreases what?
reduced risk of ovarian cancer by 80-90%
reduced all cause mortality 60-77%
BRCA2 carriers - reduced risk breast ca 50%
daily fetal urine volume of term fetus?
1L
when does neural tube close?
38 - 40 days (5-6 wks)
best anticholinergic for elderly?
fesoteridine (toviaz)
benefits of breastfeeding with GDM
- decreased maternal metabolic syndrome, DM2
- decreased neonatal hypoglycemia, metabolic syndrome, development of DM2 and childhood obesity
most common chromosomal etiology of non immune hydrops?
turners 45XO
most common infectious etiology of non immune hydrops
parvo
correct placement of forceps
position of safety - lamboid sutures equidistant from blades, sagittal suture perpendicular to plane of shanks, fenestrations barely felt, posterior fontanelle is midway between blades and 1 FB above plane of shanks
when to deliver vasa previa
34-36 wks
examples of:
a) direct maternal death
b) indirect
c) non maternal death
a) direct - PPH, AFE, eclampsia
b) cardiac dz worsening in pregnancy (MS, AS)
c) MVA
risks of corticosteroids in T1?
clefting
definition of HG
varies depending on source - persistent & excessive vomiting starting before end of 22nd wk
NVP effects what % of pregnancies?
50-80%
what covers an omphalocele
2 layers - amnion, peritoneum
early surgical abortion
1) what GA?
2) what to do postop
3) ? bhcg trend post
<7 wks
direct exam of POC, and serial bhcg if POC not identified
beta should decrease by 50% within 24 hrs
typical use failure rate of OCP?
9%
rank reliability of tubal occlusive methods of contraception?
1) salpingectomy
2) filshie
3) bipolar cautery
4) Hulka clips
who to consider for a progesterone only pill?
breastfeeding recently postpartum endometriosis HMB/anemia/dysmenorrhea contraindications to estrogen (migraine, smokers >35, anticonvulsant meds)
MOA of OCP
- main one?
- 4 more
main: inhibits ovulation (suppresses HPO axis)
others: altered cervical mucus, altered tubal transport, stabilizes endometrium, impairs follicular development
medical abortion
1) Rh immunoglobulin?
2) FU beta?
3) rate of RPOC needing aspiration?
4) Tx/screening STI?
1) give it (recommended beyond 49 days from LMP, may be offered before that)
2) must fall >80% 7-14 days later
3) 3-5%
4) screen and treat method preferred
ways to decrease risk of perforation with IUD insertion (4)
- provider skill
- tenaculum
- sound
- bimanual
MOA for LNG-IUD
1) main
2) others
main: prevents fertilization by altered cervical mucus
others: foreign body rxn in endometrium, potential to decrease ovulation
ectopics and IUD?
overall lower risk than general population
if pregnancy - risk of ectopic is 15-50%
- Cu-IUD more likely ectopic overall (higher failure rate of copper)
- IF there is already a pregnancy with LNG-IUD, it’s more likely to be an ectopic that if it were a copper IUD
1) how to confirm GA before medical abortion?
2) medication regimen options for MA?
1) LMP, or US if uncertain LMP
2) MIFE200/miso800; MTX 50mg IM/po then miso 800mcg 3-5d later
how do you apply the patch/ring contraceptives?
patch: anywhere except breast; may be decreased efficacy >90kg; replace weekly x 3 then 1 patch free week
Ring: leave in for 3 weeks then remove for 1 wk (can remove up to 3hr for intercourse)
important for consent for permanent contraception?
CANNOT use a SDM
when are LNG EC vs UPA EC effective?
LNG UC NOT effective after LH rise or LH surge
UPC EC effective after LH rise but NOT after LH surge
contraception around time of permanent contraception?
need reliable contraception pre-procedure (because can have a luteal phase pregnancy even if preg test neg)
use back up 7 days post procedure
do preg test day of procedure
absolute contraindications to IUD insertion?
pregnancy active infection (PID, purulent cervicitis, post septic abortion) cervical cancer undiagnosed vaginal bleeding pelvic TB progestin receptor + breast ca molar pregnancy distorted uterine anatomy
max dose of lidocaine?
toxicity side effects?
with epi - 7mg/kg
without epi - 4-5 mg/kg
lightheaded, tinnitus, tingling, metalic taste in mouth
medical abortion approved up to?
MA and SA equally effective up until?
63 days past LMP as per guideline 70 days (10 wks) as per new evidence
49 days after LMP
when can you initiate hormonal contraception after using LNG EC vs UPA EC?
- initiate within 24 hrs of LNG EC, with back up x 7 days
- initiate 5 days after UPA, with back up for 14 days
contraindications to medical abortion?
unconfirmed GA signs/symptoms of ectopic ambiguity/uncertainty allergy chronic adrenal failure inherited porphyria uncontrolled asthma long term systemic steroids hemorrhagic d/o or anticoagulation
relative contraindications to IUD
hx within 5 years of progesterone + breast ca
severe liver stuff (LNG)
complicated solid organ transplant
PP > 48 hrs to < 4 wks
6 ways to make reasonably sure someone isn’t pregnant prior to IUD insertion?
<7 days from last menses
not sexually active since LMP
consistently using a good contraceptive
<7 days from abortion
within 4 wk PP
fully or nearly fully BFing and amenorrhea and <6mo PP
if not the above - do a preg test!
DMPA - absolute & relative contraindications
absolute: current breast cancer
relative: undiagnosed vaginal bleeding, severe cirrhosis, benign hepatocellular adenoma, malignant hepatoma, hx of breast ca with no disease x 5 yrs
routine BMD NOT recommended
what are and are NOT RF’s for IUD expulsion?
RF’s: postpartum, HMB, dysmenorrhea, young age, atypical uterine shape, fibroids, previous expulsion
NOT RF’s: nullip, length of cavity, use of menstrual cup/tampons
highest risk time in cycle to miss a pill? and what should you do?
1st or 3rd week of your cycle, or when hormone free interval >7 days
- take pill ASAP, or throw out sugar pills until next cycle (if in 2nd or 3rd wk) - if >3 pills missed, use backup x 7d
- if in 1st wk, use backup x7d
***always consider EC if UPI
first trimester surgical abortion
- what GA
- operative technique
- cervical priming
<14 wks
Pratt dilators - up to GA (9mm up to 9+6)
Analyze POC
If expected to be difficult - miso 400mcg PV or SL 3hrs preop
what BMI is EC less effective for (LNG and UPC)
- LNG EC less effective for BMI >25
- UPC EC less effective for BMI > 35
how long after UPI can you take - LNG EC, EPA EC, copper IUD?
LNG & UPA - within 5 days
CU-IUD - within 7 days
how long do you wait for placenta after 2nd trimester medical induced abortion
4 hours
how long to wait for menses post abortion before you investigate?
8 weeks
complications of abortion
perforation, cervical laceration, infection, bleeding, failed abortion/ongoing pregnancy, RPOC, repeat aspiration, DIC, seizures, asthma exacerbation, uterine rupture (miso and 1 CS is safe)
risk factors for uterine perforation with abortion (SA)
infection experience uterine anomaly uterine flexion cervical stenosis difficult evacuation
when is vasectomy effective
once 1 UNcentrifuged semen sample has <100 000 non-motile sperm/ml
do serum analysis 8-16wk post vasectomy, but may take 6 mo
fertile window?
5 days before ovulation, 1 day after
what is actinomycosis assoc with
management of actinomycosis on pap
assoc with Cu IUD (20%)
treat only if symptomatic (pen G, doxy, tetracycline)
preop for surgical abortion
screen for STIs
treat with antibiotics (doxycycline, flagyl, or beta lactams)
contraindications to MTX
for ectopic: BFing, unstable, IUP, hepatic/renal/heme/pulmonary dz, PUD, immunodeficiency
relative for ectopic: bhcg>5000, >3.5cm, FHR
for MA: ectopic, anemia, IUD, IBD, active liver/renal dz, bleeding d/o or anticoag, allergy, ambivalent to terminate
absolute contraindications to CHC
<4wk PP + BFing <21d PP (not BFing) smoker >35 + >15 cig/day vascular dz HTN acute DVT/PE hx VTE and risk of recurrence major sx or immobility known thrombophilia current/hx ischemic heart dz hx stroke complicated valvular dz lupus with APLA (or unknown APLA) migraine with aura peripartum cardiomyopathy with impaired function <6 mo current breast ca severe cirrhosis hepatocellular adenoma / hepatoma complicated solid organ transplant
absolute contraindications to hormonal EC, CuIUD
- pregnancy , allergy
- CuIUD - copper allergy, pregnancy
RF’s for regretting permanent contraception
**younger age (<30) - 20% risk! fewer children partner without children new partner post TL relationship distress not well informed subsequent death of a child
which meds change effectiveness of OCP and how?
carbemazapine (and most antiepileptics) reduce efficacy of OCP
OCP decreases efficacy of lamotragine
