Pregnancy & Child Birth Flashcards

Question

What is the management for Intrauterine Fetal Demise? - 2; What complication can arise from IUFD? *Main causes: Anencephaly, Potter sequence, etc.*

Answer 1

1. **If ≥24 WG = Induced Vaginal Delivery *_regardless of fetal lie_* when Mom's ready and before 28 WG if possible** 2. If 20-23WG = Dilate and Curettage * keeping fetus in there \> 28 WG can --\> coagulopathy* * \* fetal death \< 20WG = spontaneous abortion \**

Answer 2

DO THIS FOR ALL Rh NEGATIVE mothers 1. 50mcg 1st trimester **if uterine bleeding and/or spontaneous abortion occurs** 2. **300mcg at 28 WG** 3. **300 mcg within 3 days after delivery** **(*MUST* *adjust with Kleihauer-Betke if fetomaternal hemorrhage /abruptio placentae occurs)*** 4. give with each vaginal bleeding 5. give with External Cephalic Version 6. give with Hydatidiform Mole 7. give with Ectopic Pregnancy

Answer 3

35-37 WG ## Footnote *results are valid for 5 weeks*

Answer 4

25% of fetuses ≤28WG are naturally breeched, but will flip over into cephalic position by 37 WG \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ External Cephalic Version (**can** **only be done ≥37 WG**)

Answer 5

≥ 37 WG 1. There are vaginal delivery ctd and C/S (CSection) is indicated instead 2. Placental demise (previa or abruptio) 3. Oligohydraminos 4. Rupture Of Membrane 5. Hyperextended fetal head 6. Fetal/Uterine anomaly 7. Multiple Gestation

Answer 6

1. **PAINNNFFULLL antepartum vaginal bleeding (which can --\> hypovolemic shock, [DIC-from decidual bleeding releasing tissue factor 7] and fetal demise)** 2. Distended firm uterus 3. abd AND/OR back pain ## Footnote *etx: HTN of maternal decidual vessels --\> rupture --\> premature detachment of placenta from endometrium*

Answer 7

1. **SMOKING** intrapartum! (can also --\> *asymmetric* IUGR) 2. IUGR 3. abnormal fetal karyotype

Answer 8

[Fetal Yolk Sac]/GI/Liver \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 15-20WG \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ via Quad BUAD screen

Answer 9

1. Fetal Open Neural Tube Defects (open spina bifida, anencephaly) 2. Fetal Abd Wall defect (Gastroschisis, Omphalocele) 3. Multiple gestation (twins) *If ⬆︎AFP --\> GET ANATOMY US!*

Answer 10

Performed in twin deliveries to convert 2nd twin from transverse presentation --\> breech presentation for subsequent delivery

Answer 11

fetal vessels traverse the amniotic membranes over the internal cervical os --\> antepartum bleeding and FHR abnormalitites **after** ROM (rupture of membrane)

Answer 12

1. Tdap (27-36WG) 2. Flu inactivated 3. RhoD (28WG) 4. Hep A killed - if HepC positive 5. Hep B killed - if HepC positive

Answer 13

1. HPV 2. MMR 3. Varicella

Answer 14

**chromosomal abnormalities** 2. teratogen exposure 3. mullerian anomalies (uterine septum) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ *IUFD etx = mostly unknown*

Answer 15

1. **Expectant**: Watchful Waiting for products of conception to expel naturally in 2-6 weeks 2. **Surgical**: [Dilitation & Curettage (D&C) (cant be done during infection)] or [Manual Vacuum Aspiration] 3. **Medical**: 800mcg Vaginal Misoprostol - takes up to 2 weeks for expel ## Footnote *ALL REQUIRE 1 WEEK FOLLOW UP*

Answer 16

Pt has anemia during pregnancy ([hgb \< 11] + [MCV \< 80]) ## Footnote Non-Pregnant female normal hgb = 12-16

Answer 17

1. prior c/s (csection) 2. prior D&C (dilation and curettage) 3. Myomectomy 4. Maternal age \> 35 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Dx = Intraplacental villous lakes on antenatal US

Answer 18

1. Smooth mass protruding from cervix or vagina 2. postpartum hemorrrhage 3. severe abd pain ## Footnote *results from inversion/collapse and prolapse of uterine fundus thru cervix or vagina*

Answer 19

The 4 T's! **T**one (Uterine aTony) **T**rauma (Perineal vs Cervix lacerations vs Uterine inversion/prolapse) **T**issue (retinaed/invasive placental tissue) **T**hrombin (rare bleeding DO)

Answer 20

1. Placental abruptio (**PAINFUL** Anterpartum hemorrhaging) 2. Placental previa 3. Vasa Previa

Answer 21

Uterine rupture! ## Footnote * "Full thickness disruption of the uterine wall"* * biggest RF = pre-existing uterine scars (c/s, myomectomy)*

Answer 22

1. Nulliparity 2. LGA 3. Placenta Accreta (RF: prior c/s, myomectomy, D&C) 4. Precipitous (rapid) Labor & Delivery ## Footnote *results from inversion/collapse and prolapse of uterine fundus thru cervix or vagina when too much traction is applied to cord before placental separation*

Answer 23

1st: **Replace the Uterus first** 2nd: AND THEN remove placenta if still attached 3rd: Give Uterotonics (oxytocin/misoprstol) to ⬇︎ postpartum hemorrhage

Answer 24

2nd trimester **PAINLESS** Cervical Dilation that --\> Spontaneous abortion (\< 20WG) or IUFD ( ≥ 20WG)

Answer 25

1. Fever 2. malodorous purulent vaginal discharge 3. Large, Boggy tender uterus --\> lower abd pain ## Footnote *usually comes from unsterile/incomplete elective abortion*

Answer 26

irregularly thickened endometrial stripe with active blood flow

Answer 27

Using a suture or synthetic tape to reinforce the cervix in 2nd trimester pts who have cervical length ≤ 2cm per transVaginal US (or 2.5 if preterm hx present) or risk for PPROM

Answer 28

**NonStress Test** + [**US assessment** of Amniotic Fluid/Fetal mvmnt/Fetal tone/Fetal breathing - *each given 2 points if nml and 0 if not*] Normal= 8,10 (repeat BPP in 1 wk) / Equivocal=6 (repeat BPP in 24 hrs) / Abnml=0,2,4 *this (and alternative Contraction Stress Test) are performed in high risk fetal demise pregnancies to assess for fetal hypoxia*

Answer 29

evaluates for fetoplacental vascular insufficiency in IUGR pts (\< 10th%tile)

Answer 30

1. **"Snowstorm with grapes" on ultrasound** 2. **HHIIGH LEVELS OF bHCG (\> 100,000)** ## Footnote *Most of the time this is caused by sperm implanting an EMPTY ovum*

Answer 31

1. broad abx x 2 days 2. Dilation & Curettage 3. IVF

Answer 32

1. Ectopic pregnancy 2. Gestational Trophoblastic Neoplasia

Answer 33

when loop of umbilical cord wraps around fetus' neck --\> recurrent variable decelerations but **is not clinically significant**

Answer 34

1. IUGR 2. Intrauterine fetal demise 3. preeclampsia 4. Placenta abruptio 5. Preterm delivery 6. Maternal death!

Answer 35

1. DES intrauterine exposure--\> congenital abnormalities 2. cervical surgery

Answer 36

1st trimester use of **NSAIDs**

Answer 37

Fetal Anemia ## Footnote *Sinusoidal Fetal Heart Tracing*

Answer 38

1. Maternal DM - poorly controlled 2. swallowing fetal anomalieis (esophageal atresia)

Answer 39

*PreEclampsia --\> SEVERE PreEclampsia --\> HELLP and at anytime, Eclampsia is possible* Centrilobular necrosis, hematoma formation and portal capillary thrombi all --\> Distension of the [**Glisson's Hepatic Capsule**] --\> RUQ OR Epigastric abd pain = SEVERE PreEclampsia

Answer 40

35 lbs ([16kg])

Answer 41

by 20WG ## Footnote *BE SURE TO WATCH OUT FOR THIAMINE DEFICIENCY SX IN THESE PTS!*

Answer 42

1. IUGR asymmetrically 2. Preterm delivery 3. Oligohydraminos (AFI ≤5 cm) 4. Perinatal mortality 5. Placental Abruptio 6. Preeclampsia superimposed 7. c/s

Answer 43

1. c/s 2. Multiparity 3. Smoking ## Footnote ***PAINLESS** Antepartum Vaginal Bleeding with ONLY maternal vitals changing* *"previews are painless :-)"*

Answer 44

Physiological widening of pelvis by progesterone and relaxin to facilitate vaginal delivery ; **Postpartum** **suprapubic TTP pain that radiates to the Back and/or Hips** ## Footnote *worst with weight bearing, walking or position change and resolves by 4 weeks PostPartum*

Answer 45

Prolonged Hyperflexion at Hip for vaginal delivery (McRoberts maneuver) can --\> **Femoral n compression** --\> 1. Anterior & Medial thigh numbness 2. ⬇︎hip flexion 3. ⬇︎patellar reflexes

Answer 46

20 WG via routine US \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 1. Coitus 2. Digital examination 3. Vaginal delivery 4. External cephalic version *sometimes previa (and other malpresentations) spontaneously resolves by 3rd trimester due to growth of lower uterine segment and/or placental growth toward fundus. but other wise schedule c/s for 37 WG*

Answer 47

"Having Sciatica makes you break **LAWS**" * [**L**ower Back pain w/radiation down POST thigh --\> lateral foot] * **A**nkle jerk reflex ABSENT * **W**eak Hip Extension * [**S**1 n PosteroLateral compression at L4-5 or L5-S1]

Answer 48

upper uterine fundus ; implantation in outer "cornual" areas of uterus *dx = trans**Vaginal** US // tx = MTX or surgery if severe*

Answer 49

1. previous ectopic 2. previous Pelvic 3. previous Tubal surgery 4. PID 5. Bicornuate heart shaped uterus (causes cornual interstitial ectopic pregnancy) 6. In Vitro Fertilization (causes cornual intersitital ectopic pregnancy) ## Footnote *tx = MTX or surgery if severe*

Answer 50

1. Since Vasa Previa involves destruction of **fetal** blood vessels it --\> deterioration of FHT (bradycardia, decelerations), while Placenta Previa is all maternal bleeding only so FHT is NOT affected. 2. Vasa Previa occurs only after amniotomy is done

Answer 51

*Complications = Chorioamnionitis/Endometritis/Cord Prolapse/Placenta Abruptio*

Answer 52

**if baby not compromised, fetal surveillance until 34 WG and then deliver!** *Complications = Chorioamnionitis/Endometritis/Cord Prolapse/Placenta Abruptio*

Answer 53

1. Progesterone (vaginal or IM after 1st trimester) 2. Cerclage ## Footnote *Complications = Chorioamnionitis/Endometritis/Cord Prolapse/Placenta Abruptio*

Answer 54

At 9-13WG analyzes risk for Trisomy 21 or Edward's Trisomy 18 by measuring the **BUM** inside the pregnant woman 1. **β**HCG 2. **U**S analyzing fetal nuchal translucency 3. **M**aternal protein A serum if abnormal, f/u with 1st: Fetal Karyotyping obtained via **[amniocentesis if ≥ 14WG]** or [Chorionic Villus Sampling if ≤ 13WG] ALTERNATIVE IF MOTHER DECLIENS INVASIVE TESTING: [cell free fetal DNA screen (cffDNA)] (usually used as screen ≥ 10WG) *(this should come before First Trimester Combined Test if pt is high-risk for aneuploidy)*

Answer 55

[luteoma ovarian *mass*] or [theca luteal ovarian *cyst*(comes from ⬆︎⬆︎⬆︎βHCG Hydatidiform mole)]; Dx = US ; Tx = **Watchful Waiting** since it typically resolves after delivery (but watch for mass effect on the kidneys and inform pt that this ⬆︎virilizaiton risk)

Answer 56

**recession of fetal station** after sudden abd pain *any prior uterine scars* 1. prior c/s 2. prior myomectomy (usually for fibroids)

Answer 57

Maternal HTN, Maternal DM, Smoking (these cause IUGR in the 2nd & 3rd trimester); 1. **Congenital chromosome abnormality** 2. **Congenital infxns of 1st trimester (toxo, CMV) = RARE**

Answer 58

Delivery **within 3 hours** after contractions start \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Multipartiy *Precipitous labor is NOT affected by Oxytocin induction and is usually spontaneous. It may cause Uterine prolapse!*

Answer 59

1. **Usually none** 2. ⬆︎ risk for c/s 3. ⬆︎risk for NICU 4. ⬇︎umbilical cord pH due to hypoxemia

Answer 60

1. **hypOtension** (⬇︎ BP) 2. **hypOnatremia** (oxytocin cross reacts with POST pit ADH receptors) 3. Tachysystole ( ≥6 ctx in 10 min) ## Footnote *tx: 3% Hypertonic saline*

Answer 61

Determines the dose of [Rhogam Anti-D] needed after delivering an Rh+ fetus to an Rh- mother. Can confirm or exclude fetomaternal hemorrhage

Answer 62

***P**regnant **B**itches*

Answer 63

***P****regnant **B**itches **T**ake*

Answer 64

***P**regnant **B**itches **T**ake **M**oney*

Answer 65

1. Mg (⬇︎ Ca+ needed for uterine ctx) 2. Indomethacin (⬇︎Prostaglandin as a COX inhbiitor) 3. Nifedipine (Ca+ Channel Blocker) 4. Terbutaline (Relaxes Uterus as B2 agonist) 5. Atosiban (Uterus Oxytocin R Blocker)

Answer 66

1st best indicator: **PRIOR PRETERM DELIVERY = STRONGEST INDICATOR** 2nd best: Shortened cervix ≤ 2cm per transVaginal US (or 2.5 if preterm hx present) - hx of cold knife conization? 3rd best: + Fetal Fibronectin BUT ONLY BETWEEN 20-37WG 4th best: Circumstantial (Smoking, multiple gestation, IVF, obesity)

Answer 67

1. Diazepam 2. Phenytoin

Answer 68

1. Infxn chorioamnionitis (will include maternal fever) 2. Hypoxia 3. Anemia 4. Maternal Hyperthyroidism 5. Placenta Abruptio 6. Meds (terbutaline)

Answer 69

Blood Pressure! ; RULE OUT PREECLAMPSIA

Answer 70

1. prior Preterm delivery 2. \> 40 yo 3. multiple gestation 4. Gestational HTN 5. Amphetamine use 6. Cocaine ***P**regnant **B**itches **T**ake **M**oney*

Answer 71

1. **Neuro** depression (Somnolence, ⬇︎ Deep tendon reflexes, Visual disturbances, Paralysis) 2. **Respiratory** depression ## Footnote * Risk Factor = Renal Insufficiency since it's renal excreted!!* * Tx for Mg Toxicity = Ca+Gluconate*

Answer 72

1. limb defects 2. craniofacial defects 3. abd wall defects ## Footnote *NON-LETHAL :-)*

Answer 73

Accelerations ; 1. poor [fetal cerebral oxygenation] OR 2. fetal sleep (20 min duration) - be sure to extend NST to at least 40 min to catch this! ***Non**reactive NonStress test should be f/b BioPhysical Profiles to assess for necessary intervention*

Answer 74

PTU ; Methimazole

Answer 75

FALSE! Fetal heart accelerations are a sign of good [fetal cerebral perfusion] and therefore neuro development, and neuro development doesn't fully develop until 28 WG

Answer 76

damage to internal iLiac artery during delivery ; 1. Palpable mass 2. Hemodynamic instability 3. Fever

Answer 77

1. Multiple Gestation 2. GERD hx 3. Hydatidiform Mole (note: elevated βHCG can stimulate thyroid and --\> thyrotoxicosis of hyperemesis!) ## Footnote *HG is usually unresponsive to PO antiemetics, and can cause Thiamine Deficiency*

Answer 78

Umbilical **Cord** Compression (consider cord prolapse, oligohydramnios or nuchal cord as etx) ***VEAL CHOP***

Answer 79

**L lateral decubitius Maternal repositioning** --\> **amnioinfusion** if that doesn't work ## Footnote (⬇︎umbilical cord compression)

Answer 80

1. Contact sports (basketball/hockey/soccer) 2. High Fall Risk (skiing/gymnastics/horseback riding) 3. Scuba diving 4. Hot yoga ## Footnote *30 min of moderate exercise/day is actually recommended for pregnant pts unless ctd (see image)*

Answer 81

1. pt will have more classic s/s of SLE (RASH OR PAIN) 2. RBC cast = SLE 3. ⬆︎ ANA = SLE 4. ⬇︎Complement = SLE ## Footnote *Beware: SLE can look like Preeclampsia!*

Answer 82

1. preeclampsia (smh naturally) 2. preterm 3. c/s 4. IUGR 5. fetal demise ## Footnote *Beware: SLE can look like Preeclampsia!*

Answer 83

1. **STILLBIRTH** 2/2 UteroPlacental insufficiency 2. Oligohydramnios (UteroPlacenta insufficiency ⬇︎fetal urine output) 3. Macrosomia 4. Meconium aspiration 5. Convulsions ## Footnote *Maternal complications = infxn, postpartum hemorrhage, c/s*

Answer 84

analyzes risk for Trisomy 21 or [Edward's Trisomy 18] by measuring **BUS** 9-13WG

Answer 85

upper uterine fundus ; ## Footnote VAL had an ectopic the other day! 1. **V**aginal bleeding/spotting 2. **Adnexal Tenderness** **(if implanted in tube)** 3. **L**ower abd pain *dx = trans**V****aginal** US / tx = MTX or [surgery if severe]*

Answer 86

**UNKNOWN!!** ## Footnote *This commonly occurs in uncomplicated pregnancies and could be maternal/placental/fetal origin*

Answer 87

Endometriosis = endometrial glands and stroma outside the Endometrium 1. **Gun Powder burn lesions** 2. ADHESIONS --\> immobile uterus 3. Chocolate fluid 4. Nodules flesh or dark colored *# of implants does NOT correlate with sx intensity and these pts can be asx!* Dx = **Laparoscopy** to biopsy & remove endometriotic lesions

Answer 88

The 3 Ds and **A**ll 1. **D**ysmenorrhea 2. **D**yspareunia - implants in posterior cul-de-sac 3. **D**yschezia (painful defecation) - implants in posterior cul-de-sac OR **(4) A**SX (tx not indicated if so) - otherwise tx = NSAIDs --\> Contraceptives (combined OCP/IUD progesterone) (5) Infertility of unknown origin * Findings: Gun Powder Burn lesions, ADHESIONS--\>immobile uterus, Chocolate fluid* * Dx = Laparoscopy to biopsy & remove endometriotic lesions*

Answer 89

1. observation if asx 2. NSAIDs **1st** 3. Contraceptive (OCP/IUD progesterone) 4. Leuprolide (GnRH agonist that ⬇︎Endometrial gland estrogen stimulation) 5. Hysterectomy with oophorectomy ## Footnote * Findings: Gun Powder Burn lesions, Adhesions, Chocolate fluid* * Dx = Laparoscopy to biopsy endometriotic lesions*

Answer 90

determines fetal karyotyping via placental biopsy both CVS and amniocentesis can be used for fetal karyotyping **but only amniocentesis can be used in \> 13 WG pts**

Answer 91

***P**regnant **B**itches* Maternal hypOtension with reflex tachycardia

Answer 92

***P**regnant **B**itches* 1. Premature closure of ductus arteriosus 2. Oligohydramnios

Answer 93

***P**regnant **B**itches* It's a **weak tocolytic** so it doesn't actually help with slowing contractions down in preterm delivery

Answer 94

they are Metastasis from GI CA

Answer 95

1. C**5** --\> deltoid and infraspinatus muscle weakness 2. C**6** --\> bicep muscle weakness 3. C**7** --\> enables predominance of opposing muscles ## Footnote tx = 3 month self limited, but give massage and Physical Therapy to prevent contractures

Answer 96

18 **Maternal Fever** + ≥ 1 of: 1. Uterine tenderness 2. Tachycardia (maternal or fetal) 3. malodorous amniotic fluid 4. purulent vaginal discharge * Chorioamnionitis Tx = Abx --\> Delivery*

Answer 97

1st; cervical mucus and decidua seals off the uterus from pathogens during pregnancy

Answer 98

1. soft (it's lost its tone) 2. boggy 3. enlarged above the umbilicus ## Footnote *this also could indicate retained blood clots or septic abortion*

Answer 99

UteroTonic --\> 1. uterine contraction 2. vasoconstriction (ctd in HTN pts) 3. smooth m constriction Indication = When Uterine massage AND oxytocin have failed to stop postpartum hemorrhage 2/2 uterine atony

Answer 100

Hyperemesis Gravidarum = severe NV that --\> dehydration, wt loss from **hypoglycemia** and **thiamine deficiency/Wernicke Encephalopathy** which can --\> Spontaneous Abortion! ## Footnote *Tx = Glucose WITH Thiamine B1 supplement*

Answer 101

1. Give Oxytocin to induce contractions and watch fetal heart tracing OR 2. Nipple Stimulate until 3 contractions every 10 min occur CTX = any ctx to labor itself (as both of these can --\> active labor) - ex: placenta previa, prior myomectomy

Answer 102

*It's the same as PPROM!*

Answer 103

*It's the same as PPROM! Evaluate Fetal well-being first*

Answer 104

**3rd** trimester 1. NV 2. hypOglycemia 3. ⬆︎LFTs *linked to [fetal long chaing dehydrogenase fatty acid dysfunction] . Can look like Hyperemesis Gravidarum but occurs 3rd and not 1st!*

Answer 105

1. Maternal HIV 2. Herpes Simplex breast lesions 3. untreated TB 4. Varicella active 5. Substance use 6. Chemoradiation 7. Infants with galactosemia ## Footnote *Hep B pts can breastfeed as long as baby receives HepB Immunoglobulin and vaccination*

Answer 106

postpartum uterine/vaginal discharge **that's normal**

Answer 107

Regional anesthesia and [Pudendal n palsy 2/2 pelvic floor injury] ; if urinary retention is **\> 6 hours** after delivery then = Bladder Atony ## Footnote Tx = ambulation f/b catheterization until resolves spontaneously

Answer 108

1. **INCORRECT DATING** 2. Multiple gestation 3. Hydatidiform Mole 4. Leiomyomata uterine Fibroids (irregular contour) 5. Polyhydraminos (only in 2nd & 3rd trimester and is uniform)

Answer 109

⬆︎Stroke volume during *early* pregnancy --\> ⬆︎Cardiac Ouput AND ⬆︎HR during *late* pregnancy --\> even more ⬆︎Cardiac Output ## Footnote *Also, Volume expansion can --\> peripheral edema and their body compensates by ⬇︎BP*

Answer 110

Progesterone ⬆︎tidal volume for more O2 (pt takes deeper breaths) --\> physiologic hyperventilation and this --\> physiologic respiratory alkalosis (PaCO2 27-32) - eventually kidneys compensate by dumping HCO3 + enlarging uterus ⬇︎ functional residual capacity Both cause pregnancy dyspnea

Answer 111

**Head Compression** of Fetus ## Footnote *these occur WITH contractions and no tx is required*

Answer 112

Uterine Contractions... FALSE = irregular + weak + NO CERVICAL CHANGE True = [Regular with **increasing frequency**] + [**increasing in strength**] + cervical change

Answer 113

A: [Fetal **R**enal Agenesis bilaterally / Dysfunction] --\> Oligohydraminos (No Amniotic Fluid) B: **POTTER** **P**ulm hypOplasia **O**ligohydraminos **T**wisted Face **T**wisted and shortened Limbs **E**ars set low **R**enal agenesis = cause

Answer 114

Impingement (or avulsion) of 1. cervical fibers at **C8** and **T1 --\>** L hand paralysis (klumpke claw) 2. sympathetic fibers running along **C8** and **T1** --\> Horner Syndrome = poorer outcome if present

Answer 115

1. RhD type and antibody screen 2. Hemoglobin and Hematoctrit with MCV 3. HIV 4. RPR syphillis 5. Hep**BBBB** surface antigen 6. Rubella immunity 7. Varicella immunity 8. Chlamydia PCR 9. Urine cx CLEAN CATCH 10. Urine protein 11. Pap test (if indicated)

Answer 116

1. Hgb & Hct 2. Oral Glucose Challenge Test 1 hr - 50gram load (if positive confirm with 3 hr 100gm load) 3. Antibody screen if pt RhD negative ## Footnote *After 1st trimester, placenta secretes hormones that ⬆︎maternal physiologic insulin resistance so that baby gets more sugar. But if maternal pancreas cant overcome this resistance by secreting more insulin it can --\> gestational DM*

Answer 117

After 1st trimester, placenta secretes hormones that ⬆︎maternal physiologic insulin resistance so that baby gets more sugar. But if maternal pancreas cant overcome this resistance by secreting more insulin it can --\> gestational DM ## Footnote *Dx = Oral Glucose Tolerance Test*

Answer 118

1. 32-34WG in high risk pregnancies OR 2. ⬇︎fetal movements ## Footnote *the most common cause of NONreactive NST is fetal sleep cycle so be sure to allow at least 40 min testing and use vibroacoustic stimulation to wake them up!*

Answer 119

1. **Thoracic cavity hypOplasia** 2. Multiple fractures 3. Short femur 4. DOA (Lethal-Stillborn) AUTO DOM Type 1 Collagen Defect Type 1=mild / Type2=perinatal fatal / Type 3-9=mod

Answer 120

Pregnancy ⬆︎Renal blood flow AND Glomerular basement membrane permeability in 1st trimester --\> ⬆︎GFR --\> ⬇︎BUN and Creatinine levels. and then this plateaus by midpregnancy Important because renally excreted drugs will be excreted faster than usual

Answer 121

Hct ⬇︎ because Plasma volume ⬆︎ more than the RBC mass --\> mild ⬇︎in hgb concentration and = **dilutional anemia** Helpful because it protects Mom in case of Postpartum Hemorrhage (⬆︎hypercoaguability during pregnancy also helps with this)

Answer 122

1. ⬆︎fibrinogen (never should be nml in pregnancy. If so, could indicate DIC) 2. ⬆︎vWF (impt for platelet adhesion & stabilizes Factor 8) 3. ⬆︎**resistance** to [activated Protein **C**] (Protein **C** **C**uts [proteolysis] factors 5 and 8 in half but requires Protein S to do it) 4. ⬇︎Protein S (helps activated Protein C)

Answer 123

*Less than Stage 1* Systolic \< 140 Diastolic \< 90

Answer 124

**LAPORASCOPY** to biopsy & remove endometriotic lesions ## Footnote *1st, treat empirically with NSAIDs tho*

Answer 125

Fetal Macrosomia \> 4.5 kg ; 1. Brachial plexus injury 2. Fracture of clavicle or humerus (RESOLVES SPONTANEOUSLY) 3. hypoxic brain death tx = **BE CALM** mnemonic

Answer 126

Transabd US; NST uses same technology as doppler and just plots the fetal heart tones. If doppler was neg, so will NST ## Footnote *IUFD is confirmed by absence of cardiac activity **ON ULTRASOUND***

Answer 127

IUFD = fetal death ≥ 20WG BUT before onset of labor; 1. Autopsy 2. Placenta/Umbilical Cord/Amniotic Membranes exam 3. Karotype genetic studies

Answer 128

IUFD = fetal death ≥ 20WG BUT before onset of labor; 1. Kleihaurer Betke to assess for fetomaternal hemorrhage 2. Antiphospholipid Ab levels (causes recurrent pregnancy loss) 3. Coagulation studies

Answer 129

1. **Refractory to abx** postpartum Fever with no obvious source (blood, urine, spinal) 2. B/L lower quadrant TTP (since it usually occurs in deep pelvic or ovarian veins) ## Footnote *This is a dx of exclusion! Always consider Endometritis first in postpartum pts with fever*

Answer 130

phenytoin, carbamazepine 1. microcephaly --\> developmentally delay 2. midfacial hypoplasia 3. cleft lip and palate 4. digital hypoplasia 5. hirsutism

Answer 131

Measures 4 chemical markers for fetal anomalies and down syndrome- 81% accuracy (QUAD = **BUAD**): 1. **β**HCG⬆︎ 2. **U**nconjugated EsTriol⬇︎ 3. **A**FP⬇︎ 4. **D**imeric inhibin A⬆︎ - *only in QUAD screen* Performed 15 -20WG *Be sure to f/u abnml results with cell free fetal DNA test and US*

Answer 132

⬇︎βHCG ⬇︎**U**nconjugated EsTriol ⬇︎**A**FP NML **D**imeric inhibin A

Answer 133

1st: Diet change 2nd: Insulin or Metformin or Glyburide * Wt loss during pregnancy is **NOT** a good idea since it ⬆︎risk for IUGR*

Answer 134

**BE CALM** 1. **B**reathe, stop pushing and lower head of bed 2. **E**levate and flex hips against abd (McRoberts position) 3. **C**all for help (anesthesiologist/2nd physician/nurses) 4. **A**pply suprapubic pressure downward & laterally to release ANT shoulder 5. **L**argen's vaginal opening (episiotomy) 6. **M**aneuvers (see image)

Answer 135

\< 190 U/L

Answer 136

1. prolonged menstrual bleeding during 1st 6 months 2. weight gain! 3. breast tenderness 4. ⬇︎bone mineral density ## Footnote *50% of women have amenorrhea after using for a year*

Answer 137

Both hypO and HYPERthyroidism ⬆︎risk for infertility and recurrent pregnancy loss

Answer 138

1st: fetal presenting part is not palpable 2nd / **CONFIRMATION IS DONE BY TRANSABDOMINAL US**

Answer 139

1. Breech 2. Placenta Previa 3. Active HSV lesion 4. Prior **classical** c/s

Answer 140

≥ 24cm ## Footnote RF = Maternal DM, congenital swallowing malformation Polyhydramnios can --\> placenta Abruptio

Answer 141

ischemic necrosis of ANT Pituitary 2/2 massive postpartum hemorrhage ; FLAT PiG 1. FSH/LH ⬇︎ --\> **Amenorrhea** (remember, postpartum women should resume menses after 10 wks) 2. ACTH ⬇︎ --\> **⬇︎Na+ which causes ⬇︎BP** 3. TSH⬇︎ --\> **Fatigue/hypOthyroidism** 4. Prolactin⬇︎ --\> **LACTATION FAILURE (1ST SIGN OF SHEEHAN!)** 5. GH⬇︎ --\> **Anorexia**

Answer 142

1. Shivering (due to thermal imbalance) 2. Uterus contracts to become firm with fundus around umbilicus area 3. Bloody Lochia x 3 days postpartum eventually becoming white/yellow in 3 wks (comes from shedding of residual uterine decidua) 4. Breast Engorgement 5. Peripheral Edema

Answer 143

degenerates cervical connective tissue --\> softens and effaces cervix for induction ## Footnote *ex: misoprostol, dinoprostone*

Answer 144

1. **Palpable adnexal mass** 2. abrupt uL pelvic pain 3. NV

Answer 145

**ACUTE** uteroplacental insufficiency --\> fetal hypoxic brain injury vs **Chronic** uteroplacental insufficiency--\> asymmetric IUGR /SGA & oligohydramnios

Answer 146

Occurs once pt reaches *Active* Labor ( ≥6cm dilated) and... 1. No cervical dilation for ≥4 hours despite [adequate contractions: ≥200 MonteVideoUnit q10 min] OR 2. No cervical dilation for ≥6 hours despite inadequate contractions * Tx = c/s*

Answer 147

Occurs once pt reaches *Active* Labor ( ≥6cm dilated) and... 1. slower than 1-2 cm/hr dilation 2. +/- inadequate contractions *Tx = oxytocin*

Answer 148

10% ## Footnote Sympathetic nerve fibers are anesthetized --\> vasoDilation --\> venous pooling --\> ⬇︎venous return --\> ⬇︎Cardiac Output *Prevent this by giving IVF prior to epidural, L lateral decubits position and vasopressors if needed*

Answer 149

Ca+Gluconate ## Footnote *Risk Factor for Mg toxicity = Renal Insufficiency since it's renal excreted!!*

Answer 150

1. HA 2. Flushed 3. Nausea

Answer 151

**ENDOMETRITIS** ; \> 24 hours postpartum ; [Clindamycin + Gentamicin] ## Footnote *You do NOT need cx for this dx!*

Answer 152

Dicloxacillin ## Footnote *covers MSSA and GASP*

Answer 153

\>2 cm away from os

Answer 154

*Occurs once pt is **P**ushing and dilated to 10 cm but has **insufficient fetal descent after**:* 1. ≥ 3 hours if nulliparous OR 2. ≥ 2 hours if multiparous

Answer 155

1. **FETAL MALPOSITION** (occiput faces transverse or posterior instead of Anterior) --\> cephalopelvic disproportion 2. Cephalopelvic disproportion 3. Inadequate contractions (possibly from maternal exhaustion) ## Footnote RF: Maternal obesity, DM

Answer 156

Malpresentation = lowest part of the fetus in pelvis is NOT the vertex (i.e. face, breech) vs Malposition = relationship of the fetal presenting part to the pelvis (occiput anterior vs transverse vs posterior)

Answer 157

**FIRST** trimester US with crown to rump length (since there is minimal variability of fetuses when they first start off)

Answer 158

**FIRST trimester US is most accurate** 1. fundal height if \> 20WG 2. fetal abd cirucumference 3. fetal biparietal diameter 4. fetal femur length 5. fetal head circumference 6. LMP

Answer 159

**Pelvic US** revealing adnexal mass with absent Doppler flow

Answer 160

**PRE**menopausal ## Footnote *Untreated ovarian torsion --\> sepsis, chronic pelvic pain and infertility*

Answer 161

centesis of intraperitoneal fluid thru the cul-de-sac via vaginal aspiration ; No longer used and has been replaced by US for identifying pelvic free fluid

Answer 162

**Triple Antiretroviral therapy** (2 NRTI + 1 NNRTI or 1 PI) ## Footnote *Also, c/s if viral load is \> 1000 and Zidovudine given to neonate for ≥6 wks after birth are also good but not most important*

Answer 163

Mom's **Thyroid stimulating Ab** (anti-TSH R Ab) can cross the placenta and stimulate the baby's thyroid gland --\> Thyrotoxicosis ## Footnote Baby's tx = methimazole + Beta Blcoker

Answer 164

TRUE! - only the thyroid stimuating Ab can cross and that's only during 3rd trimester

Answer 165

Ig**G**; protects neonate for first 3 months of life

Answer 166

1. ARDS (intubate and ventilate them STAT!) 2. Cardiogenic shock 3. Seizures/Coma 4. DIC ## Footnote *RF = Multiparity, Advanced maternal age, Placental demise and c/s*

Answer 167

**Rapid** Heart Failure (SOB, cough, pedal edema) ; \> 36WG

Answer 168

X-linked recessive

Answer 169

*Labor = (LA)PD* ## Footnote **1A: L**atent phase = Strong Contractions q3-5 min **(should be ≤20 hrs for nulliparous pts and 14 hrs for multiparous pts)** **1B:** **A**CTIVE phase = Cervix is now 6 cm Dilated, [growing @ 1-2 cm/hr] and effacing **2** : **P**ushing Time! since Cervix is now 10 cm FULLY DILATED (should be ≤3 hrs for nulliparous and 2 hrs for multiparous) **3 : D**elivery of Baby! and then Deliver Placenta

Answer 170

*Labor = (LA)PD* ## Footnote **1A: L**atent phase = Strong Contractions q3-5 min (should be ≤20 hrs for nulliparous pts and 14 hrs for multiparous pts) **1B:** **A**CTIVE phase = Cervix is now 6 cm Dilated, [growing @ 1-2 cm/hr] and effacing **2** : **P**ushing Time! since Cervix is now 10 cm FULLY DILATED **(should be ≤3 hrs for nulliparous and 2 hrs for multiparous)** **3 : D**elivery of Baby! and then Deliver Placenta

Answer 171

*Labor = (LA)PD* ## Footnote **1A: L**atent phase = Strong Contractions q3-5 min (should be ≤20 hrs for nulliparous pts and 14 hrs for multiparous pts) **1B:** **A**CTIVE phase = Cervix is now 6 cm Dilated, [growing @ 1-2 cm/hr] and effacing **2** : **P**ushing Time! since Cervix is now 10 cm FULLY DILATED (≤3 hrs for nulliparous and 2 hrs for multiparous) **3 : D**elivery of Baby! and then Deliver Placenta **(≤30 min)**

Answer 172

*Labor = (LA)PD* **1A: L**atent phase = Strong Contractions q3-5 min (should be ≤20 hrs for nulliparous pts and 14 hrs for multiparous pts) **1B:** **A**CTIVE phase = Cervix is now 6 cm Dilated, [growing @ 1-2 cm/hr] and effacing **2** : **P**ushing Time! since Cervix is now 10 cm FULLY DILATED (≤3 hrs for nulliparous and 2 hrs for multiparous) **3 : D**elivery of Baby! and then Deliver Placenta **(≤30 min)** https://www.youtube.com/watch?annotation\_id=annotation\_563008&feature=iv&src\_vid=Xath6kOf0NE&v=ZDP\_ewMDxCo

Answer 173

D-dimer is already **naturally elevated** in pregnant woman due to their physiological ⬆︎ fibrinogen

Answer 174

You have to take it every day **DOWN TO THE EXACT HOUR** or it will fail! = compliance issues

Answer 175

1. **mass that becomes painful during menses** 2. firm mass 3. solitary mass 4. mobile 5. ~2 cm ## Footnote *most common cause of breast mass in teens*

Answer 176

microcalcifications

Answer 177

1. Peau d'orange appearance (superficial dimpling & pitting) 2. Diffuse breast erythema 3. breast edema 4. breast pain 5. nipple changes (retraction, flattening) 6. Axillary LAD 7. +/- nipple discharge ## Footnote *often confused with infectious process, **but difference is IBC has NO FEVER and DOESN'T RESPOND TO ABX***

Answer 178

Ductal **ADC** 1. **crusty eczematous or ulcerating nipple & areola** 2. +/- bloody nipple discharge 3. +/- nipple retraction *85% of Paget Disease of Breast is 2/2 underlying DCIS of glandular rissue which migrate thru mammary ducts to nipple surface. Dx = Mammogram and biopsy*

Answer 179

autoimmune chronic inflammatory condition of anogenital region that affects women **of any age** that --\> vulvar squamous cell carcinoma THIS DOES NOT AFFECT THE VAGINA! *dx = vulvar punch biopsy*

Answer 180

1. Pruritus SEVERE 2. Dyspareunia 3. White Grayish pale vulva (distinguishes from postmenopausal vaginal atrophitis) 4. Cigarette paper texture of vulva (**thin**, crinkled) 5. loss of vulvar anatomy (introitus, labia minora, clitoral hood) ## Footnote *dx = vulvar punch biopsy*

Answer 181

**PRE**menopausal 1. cyclical BILATERAL breast pain 2. diffuse nodularity *This cyclical BL breast pain is exacerbated with caffeine!*

Answer 182

do not confuse with Inflammatory Breast CA **inadequate milk duct drainage** allows Staph Aureus from infant's nasopharynx or mother's nipple skin to multiply in stagnant milk --\> 1. Breast Erythema in quadrants 2. Breast Pain in quadrants 3. LAD 4. **FEVER** Tx = **KEEP BREASTFEEDING** + Dicloxacillin + Ibuprofen

Answer 183

1. **EEE** - Excess Estrogen Exposure (HRT, neoplasm, [menstruation *outside* of 12-52], Nulliparity, Anovulation/PCOS) 2. **Tamoxifen** 3. **Obesity** (excess insulin--\> ⬆︎androgen release from ovarian theca --\> excess androgen is converted into estrone --\> EEE) ## Footnote *Smoking and Progestin OCP ⬇︎Endometrial CA Risk*

Answer 184

1. Intermenstrual bleeding (Dx= **BIOPSY** = goldstandard) 2. Postmenopausal bleeding (Dx = Pelvic US for postmenopausal) ## Footnote *Smoking and Progestin OCP ⬇︎Endometrial CA Risk. Progestin actually stimulates endometrial differentation and not uncontrolled proliferation*

Answer 185

1. **FIXED** palpable mass 2. Irregular borders 3. +/- Bilateral

Answer 186

Clobetasol ointment (high potency topical CTS) ## Footnote *dx = vulvar punch biopsy*

Answer 187

bladder injury during **pelvic surgery**, pelvic radiation or prolonged labor --\> Vesicovaginal fistula --\> **continuous painless vaginal urine leakeage** and possible cystitis (from bladder being exposed to vaginal flora) ## Footnote *Dx = cystourethroscopy*

Answer 188

N. Gonorrhea = non-exudative pharyngitis, and has PID lower abd pain vs. Mono = **exudative** pharyngitis and has fatigue *otherwise, presentation is similar*

Answer 189

1. Malodorous vaginal discharge 2. Vaginal irregularity aesthetically (mass, plaque, ulcer) 3. Postmenopausal bleeding 4. Postcoital bleeding Vaginal SQC = \> 60 yo Vaginal SQC = **POSTERIOR** Upper 1/3 of vaginal wall

Answer 190

1. Malodorous vaginal discharge 2. Vaginal irregularity aesthetically (mass, plaque, ulcer) 3. Postmenopausal bleeding 4. Postcoital bleeding Vaginal Clear cell ADC = \< 20 yo ; these pts usually have **difficulty conceiving and maintaining pregnancy** Vaginal SQC = **anterior** Upper 1/3 of vaginal wall

Answer 191

same as **Cervical CA risk factors** ## Footnote (*cervical CA migrates to vagina*)

Answer 192

1. Red patches 2. Flaky patches 3. Satellite lesions

Answer 193

DDx = CCAFF

Answer 194

posterior acoustic enhancement (indicates fluid is present) with no echogenic debris or solid components

Answer 195

1st: Drain breast cyst for sx relief 2nd: f/u in 6 mo 3rd: convert to f/u annually if no s/s of recurrence

Answer 196

**single** papule that turns into shallow, PAINLESS, **nonexudative ulcer** with indurated edges, accompanied with BL inguinal LAD ## Footnote THESE ARE EXTREMELY INFECTIOUS!

Answer 197

1. Multiple deep ulcers 2. Exudative Grayish yellow Base 3. **PAINFUL** inguinal coalesced bubo nodes ## Footnote Organisms clump in long strands like a "school of fish" **PAINFUL** *Haemophilus Ducreyi*

Answer 198

1. Multiple small shallow ulcers 2. Erythematous base 3. LAD ## Footnote **PAINFUL**

Answer 199

1. Multiple small shallow ulcers (similar to herpes) 2. Large PAINFUL coalesced inguinal lymph nodes = *Buboes* 3. Intracytoplasmic chlamydial inclusion bodies \*\* Initial lesion is NOT painful but Buboes are \*\* *Chlamydia Trachomatis*

Answer 200

1. Breast 2. Ovarian ## Footnote *Only do BRCA testing on women (or if they have 1st degree relatives) with breast CA \< 50 yo or women with ovarian CA at any age*

Answer 201

Mostly in India 1. Extensive ulcers WITH NO LAD 2. Granulation like base 3. Deeply staining gram neg intracytoplasmic cyst = Donovan bodies No, not painful *Klebsiella Granulomatis*

Answer 202

Empiric **PCN G IM**! ## Footnote *RPR false negatives are a thing so you should repeat serology in 2 weeks to see if tx reduced titers. Also, Treponemal Pallidum can NOT be cultured so don't do it!* THESE ARE EXTREMELY INFECTIOUS!

Answer 203

1. Whitish Gray vaginal discharge 2. Malodorous discharge

Answer 204

Painful Bladder Syndrome 1. Chronic pelvic pain 2. Urinary sx (dysuria, urgency, frequency) 3. Dyspareunia

Answer 205

Urethral diverticulum = distinct outpouching of urethra (with a separating border) into ANT vaginal wall --\> circumscribed cystic mass vs Urethrocele = urethral **prolapse** into vagina (continuous with the rest of the urethra) secondary to loss of ligamentous support *BOTH OF THESE CAUSE URINARY INCONTINENCE THRU THE UREHTRA*

Answer 206

1. **CLEAR** cervical mucus discharge (looks like uncooked egg white) - starts thin and then becomes thick after ovulation 2. ⬆︎temperature 3. Mittelschmerz mid-cycle (day 14) pelvic pain ## Footnote *order: LH surge --\> 36 hrs will pass --\> Ovulation*

Answer 207

yellowish brown thick cervical mucus shed right before labor that prevents asecending infxn during pregnancy

Answer 208

CA-125 can be elevated in younger women who have leiomyomata or endometriosis, so **elevated CA-125 is only associated w/ovarian CA in POSTmenopausal women**

Answer 209

*Postmenopausal women have ⬆︎risk of ovarian CA* 1. Monitors for recurrence after ovarian CA tx 2. used in initial w/u of an ovarian mass to determine if it is malignant or benign *DO NOT DO NEEDLE ASPIRATION ON OVARIAN MASS PTS SINCE CA STATUS IS UNKNOWN AND MAY BE IATROGENICALLY SPREAD DURING ASPIRATION*

Answer 210

Unopposed estrogen --\> uncontrolled endometrial proliferation (CA). Progesterone can regulate proper endometrial differentiation ## Footnote *just remember, estrogen replacement therapy can --\> postmenopausal bleeding on its own*

Answer 211

True dx = pathological exam of tissue after hysterectomy ## Footnote *etx: glands invade uterine myometrium --\> blood deposition inside myometrium during cycle --\> dysmenorrhea from irregular contractions and menorrhagia from extra deposited blood*

Answer 212

**PAINLESS** intermenstrual bleeding

Answer 213

1. Endometrial CA (ADC, hyperplasia) 2. Cervical CA 3. Vaginal CA (clear cell ADC, SQC) 4. Estrogen replacement therapy

Answer 214

1. Pelvic pressure --\> urinary incontinence/incomplete voiding/constipation 2. **irregularly enlarged NONTENDER uterus** 3. Menorrhagia (especially with submucosal) 4. Dysmenorrhea (especially with submucosal) 5. Progressively longer menses due to deformity of the uterus from fibroids ## Footnote *Submucosal and Pedunculated are the worst!*

Answer 215

1. Dense breast tissue in women \< 30 yo might impede assessment of breast masses 2. Breast radiation can --\> Breast CA in and of itself

Answer 216

1. **Core** = used for solid, acellular stroma masses 2. **Excisional** = used for LARGE masses 3. **Fine Needle** = used for cystic or very small masses ## Footnote *Again, use US first to determine what type of mass you're dealing with*

Answer 217

Vasculitis-mediated Recurrent Multiple Ulcers (aphthous and genital)

Answer 218

Colposcopy (**even if they're pregnant! - DO IT**) ; Cervical Conization (via cold knife conization or loop electrosurgical excision procedure) ## Footnote *conization inevitably --\> short cervix and cervical stenosis due to scar tissue*

Answer 219

**INTRAUTERINE ADHESIONS** (could be from infxn or uterine surgery) this can cause 2° Amenorrhea (normal ovulation and hormone levels but mechanical amenorrhea)

Answer 220

1. **4 or 8 oclock** position - base of labium majora 2. **egg shaped** 3. **CYSTIC mass** 4. Painless ; Duct obstruction *can develop into abscess which presents with flutuancy*

Answer 221

single or multiple submucosal cyst on the lateral aspects of the upper ANT vagina ; incomplete regression of Wolffian duct

Answer 222

**OBSERVATION** if asx since it will spontaneously drain :-) ## Footnote If symptoms are present --\> Incision and Drainage f/b word catheter ⬇︎ recurrence

Answer 223

**Mature dermoid cystic teratoma of ovary** mostly asx but sometimes with long standing lower abd/pelvic pain ; hyperechoic ovarian cyst with calcifications(from teeth and bone)

Answer 224

Detrusor hyperactivity 2/2 1. UTI 2. Estrogen deficiency (urethral closure --\> ⬆︎intrabladder pressure --\> urge) 3. Multiple Sclerosis 4. DM

Answer 225

1. DM neuropathy 2. mechanical obstruction ## Footnote *⬇︎Detrusor activity or mechanical outlet obstruction --\> Overdistended bladder --\> involuntary dribbling and incomplete empyting (⬆︎PVR)*

Answer 226

**OVARIAN ISCHEMIA 2/2 TORSION** mass on the ovary --\> ⬆︎risk for torsion around its support ligaments which contain ovarian blood supply *It is not common for Mature dermoid cystic teratoma to rupture*

Answer 227

Since the NAAT (Nucleic Acid Amplification Test) is now so specific and sensitive that there is little chance of false negatives, empiric tx of both infections is no longer required if there is only 1 that actually has a positive result

Answer 228

HPV 6 & 11 Could Either be: 1. multiple exophytic (cauliflower-like growth) skin-colored lesion +/- friability OR 2. multiple sessile (broad & flat) & smooth papules that's skin-colored +/- friability

Answer 229

1. **Copper IUD - useful for up to 5 days post intercourse [impairs implantation and MOST EFFECTIVE]** 2. Ulipristal PO - **5** days [delays ovulation] 3. Levonorgestrel progestin (Plan B) - **3** days [delays ovulation] 4. OCP progestin - 3 days [delays ovulation] - not as effective ## Footnote *these are NOT effective after implantation occurs and fertilization is possible 24 hours after ovulation*

Answer 230

*Functional hypOthalamic amenorrhea ; **these pts have low FSH** and therefore NO postmenopausal sx* 1. Excessive Exercise 2. Very low calorie diet/starvation 3. low BMI/Anorexia/Wt loss 4. Stress 5. Depression 6. Chronic illness ; Osteoporosis from lack of estrogen *note: these pts will NOT have normal mentrual cycles*

Answer 231

35 ; **FSH** would be higher in a ovarian reserve declining woman

Answer 232

high Androgen (such as PCOS) --\> ⬇︎GnRH release from feedback inhibition --\> ⬇︎FSH --\> ⬇︎ovarian maturation --\> 2°follicle atresia --\> 1. Anovulation chronically 2. Amenorrhea 3. Polycystic Ovaries

Answer 233

Failure to conceive after 1. **≥ 1 YEAR** of unprotected *timed* sexual intercourse (or 6 months if women is ≥35 yo) 2. pt ≤ 34 yo 3. pt is nulliparous *Dx = first order semen analysis then --\> **hysterosalpingogram** then --\> +/- Laparoscopy*

Answer 234

Hyperinsulinemia and Elevated LH --\> ⬆︎ Androgen release from Ovarian Theca which is converted to Estrone--\> **Elevated Estrone** which feedbacks on the hypothalamus --\> ⬇︎GnRH --\> ⬇︎**FSH imbalance** --\> failure of follicle maturation and anovulation --\> No progesterone --\> Endometrial CA ## Footnote * tx = weight loss and clomiphene citrate* * Note: if pt has high levels of sex hormone binding globulin, total testosterone may be low. so clinical dx may be necessary*

Answer 235

1st: **WEIGHT LOSS!** 2nd: Clomiphene citrate (GnRH agonist)

Answer 236

Glazed erythematous lesions on vulva with ulcerated areas

Answer 237

Leiomyomata uterine fibroids ## Footnote *Submucosal and Pedunculated are the worst!*

Answer 238

**FALSE** ## Footnote (this is a normal finding for preggos along with corpus luteum ovarian cyst UNLESS IT'S IN THE SETTING OF ECTOPIC. THEN IT MEANS HEMOPERITONEUM FROM RUPTURE OR OVARIAN CYST RUPTURE)

Answer 239

1. Normal pregnancy change 2. Ruptured Ectopic --\> hemoperitoneum 3. Ruptured Ovarian cyst

Answer 240

**girls with no menses by age 15** but who have normal growth and secondary sex characteristics ## Footnote w/u: If no breast --\> FSH --(if ⬇︎)--\> Pituitary MRI and (if FSH is ⬆︎) --\> karyotyping

Answer 241

they actually have functioning Testes that secrete **AntiMullerian Hormone** **& Testosterone** and this --\> regression of Mullerian ducts. Breast comes from the aromatization of testosterone into estrogen ## Footnote Wolffian ducts also degenerate and fetal urogenital sinus does not differentiate into a penis and scrotum --\> default of external female genitalia

Answer 242

ambiguous genitalia at birth 2/2 undervirilization ## Footnote *these pts can not convert Testosterone --\> DHT*

Answer 243

**AIS pts will have NO pubic or axillary hair** since they don't respond to testosterone (which is what causes axillary/pubic hair in both sexes!) but Mullerian agenesis pts have normal testosterone levels so will have pubic and axillary hair *Both obvi have no mullerian duct organs*

Answer 244

Combined OCPs ; NSAIDs ## Footnote *Combined OCPs treat dysmenorrhea by ⬇︎endometrial proliferation via atrophy which --\> ⬇︎prostaglandin release --\> ⬇︎painful uterine contractions*

Answer 245

its uterine inflammatory rxn actually --\> ⬆︎pain

Answer 246

1. it causes ⬇︎ of bone mineral density 2. it ⬆︎body fat and ⬇︎lean muscle mass ## Footnote *in addition to Breast tenderness and bleeding for 1st 6 months*

Answer 247

Intrauterine pregnancy is not detectable via transvaginal US until **1500-2000** bHCG. There should be SOMETHING on transvaginal US at that time (whether normal pregnancy or ectopic)

Answer 248

βhCG levels have to be **1500-2000** for conclusive pregnancy detection via transvaginal US and usually **\>5000** for transABDominal US to finally detect it A: Ectopic Preg/Miscarriage = low βhCG B: Molar Pregnancy = \> 100,000 βhCG!!! *βhCG should double every 2 days in normal pregnancy for first 7 weeks*

Answer 249

uterine infxn extends from fallopian tubes (salpingitis) --\> diffuse abd --\> Liver capsule--\> RUQ pain exacerbated with deep inspiration = **Fitz Hugh Curtis perihepatitis** ## Footnote PID causes salpingitis and cervicitis

Answer 250

\< 40 yo ## Footnote *these pts usually have autoimmune conditions and/or Turner's and present with oligomenorrhea--\> amenorrhea and infertility*

Answer 251

*these pts usually also have autoimmune conditions (i.e. hypothyroidism) or Turner*

Answer 252

1. proximal Colorectal 2. Ovarian 3. Endometrial 4. Skin ## Footnote *Germline mutation in mismatch repair protein*

Answer 253

1st: **XLap** to remove pelvic mass, dissect pelvic and paraAortic lymph nodes, inspect entire abd cavity 2nd: **Platinum based Chemotherapy** * this comes from ovarian, tubal or peritoneal abnormal proliferation*

Answer 254

aggressive form of gestational trophoblastic neoplasia;metastasizes to **LUNGS** --\> cp/dyspnea/hemoptysis ## Footnote occurs after ANY TYPE OF PREGNANCY

Answer 255

1. thickens cervical mucus 2. thins the endometrium when present outside of pregnancy which --\> implantation impairment AND ⬇︎menstrual bleeding 3. prevents withdrawal bleeding altogether --\> **amenorrhea**

Answer 256

**immaturity of hypothalamic-pituitary-gonadal axis** --\> inadequate amounts of GnRH --\> low FSH and LH --\> lack of ovulation --\> lack of Menses Menses normally occurs when corpus lutem (byproduct after ovulation) produces progesterone and this progesterone drops --\> Menses/shedding. **No ovulation --\> No menses** * Tx = Progestin-only or Combined OCPs* * this self-resovles 1-4 yrs after menarche*

Answer 257

1. **BL Salpingo-Oophorectomy** 2. OCP (only ⬇︎ovarian CA but actually ⬆︎breast CA risk) 3. 1st gestation \< 30 yo 4. Breastfeeding 5. Tubal ligation ## Footnote *Epithelial Ovarian Carcinoma comes from Ovarian, Tubal or Peritoneal abnormal proliferation*

Answer 258

1. **Breast tenderness** 2. HA

Answer 259

Mature dermoid cystic teratoma

Answer 260

Endometriosis of ovary (endometrioma)

Answer 261

Inpatient: 1. CeFOXitin IV + Doxy PO 2. Cefotetan IV + Doxy PO 3. Clindamycin + Gentamicin IV *Remember: PID is actually POLYmicrobial*

Answer 262

oil cyst +/- calcifications that may appear to be malignant ## Footnote *ruled out from malignancy based on bx revealing fat globules and foamy macrophages*

Answer 263

fat globules and foamy macrophages

Answer 264

CefTriaxone IM + Doxy PO ## Footnote *make sure these pts can tolerate and comply with PO abx*

Answer 265

1. Smoking (impairs immunity) 2. STI hx 3. Sexual activity early on or frequent (HPV 16/18 acquisition) 4. Immunosuppressed 5. Vaginal or Vulvar CA hx

Answer 266

1. Endometriosis 2. BRCA 1/2 mutation - **1st degree relatives** 3. repeated ovulation (from trauma to ovarian surface with each cycle)

Answer 267

1. Tampons 2. Surgery (**especially nasal/sinus**) 3. Burns/skin lesions

Answer 268

1. **Generalized macular rash INVOLVING palms & soles** 2. hypOtension 3. Fever 4. Vomiting 5. Diarrhea

Answer 269

HPV 6 & 11 1. **Trichloroacetic acid** 2. Cryotherapy c liquid nitrogen or cryoprobe 3. Podophyllin resin 4. Podofilox 0.5% gel - pt application 5. Imiquimod 5% cream - pt application

Answer 270

TRUE (**Colposcopy is indicated when pap is abnormal** **even if pt is pregnant! - DO IT**) ; So is Cervical bx if a lesion has high-grade features ## Footnote *Endocervical curettage is contraindicated*

Answer 271

Women 1. ALL Sexually active women \< 25 2. Sexually active women \> 25 **IF HIGH RISK** Men: Insufficient evidence :-( *ANNUAL GC/Chlamydia screening done via NAAT - vaginal or cervical swab*

Answer 272

1. [Age 21 - 65 every 3 years (cytology only)] ≥ 3x consecutively before stopping after 65 2. [Age 30-65 can alternatively get Co-HPV Testing every 5 years] ≥ 2x consecutively before stopping after 65 3. Risk Groups (immunocompro/CIN2, 3 or CA hx) **need more frequent screening and voids out #1 and 2 if present** ## Footnote *Immune system in under 21 yof clears HPV on its own within 1-2 years, thus \< 21 yo don't need testing*

Answer 273

**Mittel**schmerz = "**Middle** of the cycle" uL pelvic pain that occurs when blood released from rupture of follicle during ovulation irritates peritoneum ## Footnote *order: LH surge --\> 36 hrs will pass --\> Ovulation*

Answer 274

Treponema Pallidum **SECONDARY** syphillis 1. **FLAT** 2. **VELVETY**

Answer 275

Evaluate **F**LA**T** **P**iG for 2° Amenorrhea

Answer 276

syncytiotrophoblast ; **preserves corpus luteum** (which secretes progesterone) during early pregnancy until the placenta can take over ; 8 days after fertilization ## Footnote *hCG also stimulates maternal thyroid and promotes male sex differentiation*

Answer 277

**P**rogesterone **P**repares endometrium via decidualization

Answer 278

**E**strogen

Answer 279

**P**rogesterone

Answer 280

Lichen Sclerosus does **NOT** affect the vagina but only the Vulva Atrophic Vaginitis affects both and can be a result of menopause (2/2 natural, chemotherapy, radiation, surgical or lack of estrogen replacement therapy)

Answer 281

1. Women with Breast CA \< 50 yo 2. Women with Ovarian CA at any age 3. Women with first degree relatives with #1 or #2

Answer 282

1. early satiety (from ascities) 2. abd/pelvic pressure (from ascities) 3. GI sx (constipation/diarrhea/bloating/anorexia) - (from ascities)

Answer 283

FALSE ; **Combined** OCPs ⬇︎risk for Endometrial CA because the progestin differentiates endometrial cells

Answer 284

TRUE ; **Combined** OCPs ⬇︎risk for Ovarian CA because it suppresses chronic ovulation which causes chronic damage to surface

Answer 285

1. Amenorrhea for ≥ 1 year 2. Elevated **FSH** 3. **HAVOC** menopausal sx ## Footnote *Also be sure to measure TSH as menopause sx overlap with hyperthyroid sx*

Answer 286

PMS sx begin 1 week before menses (luteal phase) and resolves during week after menses (follicular phase) for ≥ 2 menstrual cycles ## Footnote Sx: - Bloating - Fatigue - HA - Hot Flashes - Breast Tenderness - **Irritability/Mood Swings** - ⬇︎Concentration

Answer 287

PMS sx begin 1 week before menses (luteal phase) and resolves during week after menses (follicular phase) ## Footnote 1st: **Sx Diary** reveal PMS sx timing occured over ≥ 2 menstrual cycles 2nd: Order **TSH** to r/o hypOthyroidism as cause 3rd: **Exercise w/NSAIDs** 4th: **SSRI** 5th: **Combined OCP** if SSRI don't work and there's no ctd

Answer 288

There is a rare but serious **RISK OF STROKE** with use of combined OCs in women with migraine/HA hx, especially if they smoke or are \> 35 yo

Answer 289

Between 11-26 yo regardless of anything ## Footnote \*they receive 3 doses spread out\* **\*\*this INCLUDES women with genital warts, positive HPV and abnormal cytology hx!!!!\*\***

Answer 290

Between 9-21 (or 26 if HIV+ and/or gay) yo ## Footnote \*they receive 3 doses spread out\*

Answer 291

Obesity --\> anovulation **without affecting LH/FSH levels** which--\> Amenorrhea

Answer 292

Granulosa cell ovarian tumors (occurs in postmenopausal and prepubertal girls) **secrete estrogen** and unopposed estrogen --\> Endometrial hyperplasia/ADC ## Footnote *Get an Endometrial biopsy to r/o ADC next!*

Answer 293

⬇︎estrogen --\> Vulvovaginal and **URETHRAL ATROPHY** --\> Urethral closure --\> ⬆︎bladder pressure --\> URGE incontinence and ⬇︎urethral compliance --\>STRESS incontinence and UTI + Bladder trigone, urethra and pelvic floor muscles are maintained by estrogen *UTI can also cause urge incontinence so be sure to rule this out*

Answer 294

1. Migraine with aura 2. Smokes ≥15 cig/day and ≥35 yo 3. HTN ≥160/100 4. Heart disease 5. DM with end organ damage 6. Breast CA (estrogen AND progesterone may have proliferative effects on breast tissue) 7. Liver Cirrhosis/CA 8. Thromboembolism hx 9. Prolonged immobilization 10. Antiphospholipid syndrome hx 11. ≤3 wks postpartum

Answer 295

pain with any vaginal penetration (penis, tampon, gyne exams) ## Footnote tx = Vaginal Dilators, Kegel exercises *this is AKA Vaginismus*

Answer 296

1. Vulva 2. Perineum 3. Rectum ## Footnote *these are the pudendal n distribution areas*

Answer 297

1. Adhesions (PID, surgery) 2. Tubal ligation

Answer 298

Ovarian, Tubal or Peritoneal 1. Solid 2. **Septated** 3. Ascities --\> bloating, early satiety and abd distension *this is different than Mature Dermoid Cystic Teratoma which is benign & derived of ectodermal cells!*

Answer 299

**WEIGHT LOSS** ; Combined OCPs ## Footnote HEY! HRT IS NO LONGER RECOMMENDED FOR CAD, DEMENTIA OR _OSTEOPOROSIS_ PX!!!!!!!

Answer 300

Menorrhagia

Answer 301

Weight Gain

Answer 302

**POST**menopausal; ⬆︎Theca cell activity --\> ⬆︎androgen and ⬆︎insulin resistance --\> virilization, hyperglycemia, acanthosis nigricans ## Footnote this does NOT affect LH and FSH and ovaries are enlarged but not cystic

Answer 303

*Pregnancy, Structural, NonStructural, Meds* 1. Pregnancy 2. Leiomyomata fibroids 3. Adenomyosis 4. Endometrial Polyps 5. Endometrial hyperplasia/ADC (get bx if risk factors present) 6. Cervical CA 7. Vaginal CA 8. Coagulopathy 9. Ovulatory dsfxn 10. Copper IUD

Answer 304

1. BRCA carrier 2. 1st degree reliative is BRCA carrier 3. eval of disease extent 4. eval of chemotherapy response 5. chest radiation exposure between 10-30 yo

Answer 305

diminished Ovarian reserve ## Footnote *oocytes are of number and quality*

Answer 306

sex cord-stromal tumor that secretes both but Estrogen \> testosterone

Answer 307

local trauma ; obstruction of sebaceous gland duct

Answer 308

**FAWN** 1. **F**atigue +/- insomnia 2. **A**menorrhea 3. **W**eight gain 4. **N**V *these sx can overlap with Perimenopausal sx so be careful not to quickly dismiss an older pt who's actually pregnant!*

Answer 309

TRUE - **after Colposcopy**, if lesion has high-grade features ## Footnote *Endocervical curettage is contraindicated*

Answer 310

cervical ; Endometrial (glands migrated to cervical area) 1. Colposcopy 2. Endocervical curettage 3. Endometrial biopsy *With AGC on Pap you need to evaluate Ectocervix, Endocervix and Endometrium*

Answer 311

Ovulation inducing medications --\> excessive follicle development --\> ovarian enlargement, ascities, SOB and abd pain

Answer 312

c/s ; Valacyclovir px at 36WG

Answer 313

**INCREASE** (with monitoring of T4); Estrogen from pregnancy usually ⬆︎Thyroid binding globulin AND bHCG stimulates thyroid which both --\> ⬆︎total thyroid hormone in mom for the baby. BUT hypOthyroid pts can't produce adequate thyroid hormone and this can --\> congenital hypOthyroidism. So **give them more Levothyroxine T4 when pregnant** *Levothyroxine = T4 / Liothyronine = T3*

Answer 314

**CAN** **F**arrah **C**ontrol her UTI?? 1. **C**iprofloxacin 2. **A**moxicillin-clavulanate 3. **N**itrofurantoin **F**osfomycin **C**efTriaxone *but also can use Fosfomycin and CefTriaxone*

Answer 315

bleeds "crumbles" ; N. Gonorrhea ## Footnote 1. Friable Cervix that 2. has cervical discharge 3. postcoital bleeding

Answer 316

ALPHA; 1. FSH 2. LH 3. TSH--\> Prenant woman naturally have more T3 and T4 (also because Estrogen ⬆︎thyroid binding globulin which ⬆︎total thyroid levels) - these pts are still *clinically* euthyroid

Answer 317

urinary catheterization ≥150 cc ## Footnote *Bladder can hold up to 400 cc*

Answer 318

1. **FAMILY HX OF PMS** 2. Vitamin B6 Pyrodixine deficiency 3. Ca+ deficiency 4. Mg deficiency 5. Age \> 30

Answer 319

self limited maternal withdrawal of estrogen

Answer 320

"elderly may need **DIAPERS**" 1. **D**iuretics 2. **I**nfection UTI 3. **A**trophic urethritis or Atrophic vaginitis 4. **P**scyh (delirium/depression) 5. **E**xcessive urine output (DM, CHF) 6. **R**estricted mobility 7. **S**tool impaction

Answer 321

DM candidiasis RF: DM, abx, immunosuppresion

Answer 322

cardiotoxicity

Answer 323

1. Webbed neck 2. Shield chest with widely spaced nipples 3. Short stature w/delayed maturation 4. Low ear placement 5. Coarctation of Aorta in 20% 6. Horseshoe kidney 7. Lymphdedema congenitally from abnormal lymphatic system development ## Footnote *Most turner syndrome fetuses miscarry within 1st trimester*

Answer 324

It normalizes menstruation by stabilizing unregulated endometrial proliferation

Answer 325

TuboOvarian Abscess ## Footnote These can have non-specific laboratory changes (including ⬆︎CA125)

Answer 326

ovarian dysgenesis from Turner Syndrome ## Footnote *Most turner syndrome fetuses miscarry within 1st trimester*

Answer 327

**BREAST** --(2.5 years later)--\> Menarche by 15 yo

Answer 328

1. smooth blue bulging vaginal mass 2. **primary amenorrhea** 3. hematocolpos (blood pooling behind the hymenal membrane) 4. cyclic lower abd pain

Answer 329

**girls with no menses by age 15** but who have normal growth and secondary sex characteristics ## Footnote If no breast --\> FSH (if FSH ⬇︎)--\> Pituitary MRI (if FSH ⬆︎) --\> karyotyping

Answer 330

GnRH stimulation test

Answer 331

1. LDH 2. bHCG

Answer 332

Maternal Estrogen exposure **NATURALLY**--\> 1. Mammary Gland Enlargement 2. leukorrhea 3. mild urterine bleeding in newborns. No w/u OR tx is necessary

Answer 333

pelvic cramping during the first few days of menses in the context of a normal pelvic exam; prostaglandin release from endometrial sloughing during menses

Answer 334

Endometriosis

Answer 335

Endometriosis = endometrial glands and stroma outside the Endometrium 1. **Gun Powder burn lesions** 2. ADHESIONS --\> immobile uterus 3. Chocolate fluid 4. Nodules flesh or dark colored *# of implants does NOT correlate with sx intensity and these pts can be asx!* Dx = **Laparoscopy** to biopsy & remove endometriotic lesions

Answer 336

*Purple = Pt has Risk Factors* **APPROVED FOR FEMALES AGE 9-26 yo**

Answer 337

**Enoxaparin** low molecular wt heparin for antiphosphoblipid syndrome *Beware: SLE can look like Preeclampsia!*

Answer 338

Gestational Trophoblastic Neoplasia ; 8 weeks (**BE SURE THEYRE ON CONTRACEPTION DURING FOR 6 MONTHS AS THIS IS HOW LONG THEIR βhCG SHOULD BE UNDETECTABLE**) *Most of the time this is caused by sperm implanting an EMPTY ovum*

Answer 339

Small for Gestational Age (SGA) *FYI: PreEclampsia can still occur superimposed on Chronic HTN*

Answer 340

≥3 mo idiopathic raw burning vulvar pain \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Tx = [pelvic floor physiotherapy] and CBT

Brainscape's Knowledge GenomeTM

Pregnancy & Child Birth Flashcards

Brainscape's Knowledge Genome^TM