8
Q
[T or F] Posterior Cul-De-Sac fluid accumulation in a pregnant woman is an abnormal finding
A
FALSE
(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)
9
Q
Which CA does breastfeeding reduce - 2
A
- Breast
- Ovarian
10
Q
Breastfed infants have a Decreased risk of what conditions - 5
A
- SinoPulmonary infection (Ear, Lung, GI, UTI)
- Necrotizing Enterocolitis
- Type 1 DM
- CA
- Childhood Obesity
11
Q
For pts taking OCP
How does Estrogen affect Thyroid function?
A
Estrogen (OCP, Pregnancy) ⬆︎ T4 binding globulin –> mostly euthyroid state (slight HYPERthyroid sx) and normal TSH
12
Q
How does fetal hyperglycemia affect newborns? - 3
A
it –> macrosomia, hypOglycemia, birth malformations
13
Q
What are the 4 main inquries pts should be asked when coming in for L&D checks?
A
Can Mom Feel Baby?
Contractions?
Movement from Fetus?
Fluid leak vaginally?
Blood leak vaginally?
14
Q
Which 4 drugs can you give to treat HTN in pregnant patients?
A
Mothers Loathe Nefarious HTN
Methyldopa / Labetalol > Nifedipine / Hydralazine
15
Q
Explain what Pseudocyesis is
A
Somatization of stress –> activates [hypothalamic-pituitary-ovarian] axis –> early pregnancy sx without there actually being a baby in utero = nonpsychotic woman who mentally AND PHYSICALLY presents like she’s pregnant (may even misinterpret a pregnancy test!)
US and clinic pregnany test will be negative
16
Q
Risk factors for Pseudocyesis - 2
A
- infertility hx
- prior abortion
17
Q
Neonatal Abstinence Syndrome
Classic Signs-4 ; What drug usually causes this?
A
STTD
- Sneezes a lot
- Tremors w/sweating
- Tachypnea w/HIGH PITCHED CRY
- Diarrhea
From intrauterine exposure to Opiates (i.e. Heroin/Methadone)!
18
Q
s/s of intrauterine cocaine exposure - 3
A
- Excessive sucking
- Jitteriness
- Hyperactive Moro reflex
19
Q
Postpartum depression affects women during what time periods?
________________
What 2 methods are used to screen for this?
A
[within 1st year > first 3 mo]
________________
- [PHQ2 –(if both +)–> PHQ9]
- Edinburgh Postnatal Depression Scale
Screen prenatal, postnatal and well child
20
Q
Give brief descriptions that differentiate Postpartum
Blues vs Depression vs Psychosis
A
- Blues = onsets PPD1, peaking at PPD5 and subsiding PPD14, worst w/lactation
- Depression = can onset between [1 month - 12 months after birth] Traditional s/s. Previous Depression hx is RF
- Psychosis = RARE but onsets IMMEDIATELY after birth
21
Q
CP of [Edward’s Trisomy 18] - 8
A
- Prominent Occiput
- [Dysplastic malformed ears]
- Micrognathia (small jaw & mouth)
- VSD
- [shielded chest with wide nipples]
- Overlapping Fingers
- Absent Palmar creases
- Rocker-bottom feet
These pts die within 1st month of life
24
Q
What are 5 ways to determine if a pt truly has Leakage of Amniotic Fluid?
A
- Amnisure immunoassay (detects placental ⍺-microglublin1)
- POOL test (there’s pool of fluid in vaginal vault)
- NITRAZINE test (fluid turns blue when placed on nitrazine paper since amniotic fluid is alkaline)
- FERN test (fern-like estrogen crystals under microscopy)
- US to determine fluid quantity (Normal = 6-23 cm AFI)
25
Q
What are the 2 clinical features for diagnosing ACTIVE labor? -4
A
Labor = LAPD
- [Strong Contractions every 3-5 min]
- [Cervix Dilation > 6 cm]
- [Cervix growing at 1-2 cm/hr]
- [Cervix effaced]
Fetal Heart Tracing is IRRELEVANT to diagnosing active labor
26
Q
After the Rupture of Membranes, when is it safe for labor to begin?
A
[1 - 18 hours after ROM] (no sooner ; no later)
________________
labor starting ≥18H after ROM ➜ chorioamnionitis ➜ neonatal sepsis
________________
- Do not confuse this with PPROM (Preterm Premature Rupture Of Membrane)*
- Chorioamnionitis Tx = Abx –> Delivery*
27
Q
What constitutes an infant as “Full Term”?
A
37 - 42WG
30
Q
For Antepartum patients, their NST (Non Stress Test) should be reactive
What is the Fetal Heart Tracing criteria for this?-4 Does this happen in pts in labor?
A
reactive = appropriate [fetal cerebral oxygenation]
- within a 20 min period there are
- at least two HR acclerations that are
- 15 bpm over baseline
- 1.5 small boxes long (15 sec)
THIS IS NOT REQUIRED FOR PTS IN LABOR
31
Q
What is the normal Fetal Heart Rate and variability on a NST?
A
110 - 160/min (w/variability of 6-25)
Normal Fetus’ should have a reactive NST
32
Q
Criteria for PreEclampsia is Gestational HTN + [Proteinuria or End Organ Damage]
How do you clinically diagnose Gestational HTN? - 6
A
- NO previous HTN
- ≥ 20 WG (2nd trimester)
- Systolic > 140
- Diastolic > 90
- At least 2 readings taken > 6 hrs apart
- BP taken in seated or semi-reclined position
FYI: PreEclampsia can still occur superimposed on Chronic HTN
33
Q
Criteria for PreEclampsia is Gestational HTN + Proteinuria
Which demographic are at greater risk for this?
A
Af American Women
greater risk of having PreEclampsia, it being severe and suffering placental abruptio and Eclampsia
34
Q
What are the 4 major causes of Postpartum Hemorrhage? - 4
A
The 4 T’s!
Tone (Uterine aTony)
Trauma (Perineal vs Cervix lacerations vs Uterine inversion/prolapse)
Tissue (retinaed/invasive placental tissue)
Thrombin (rare bleeding DO)
35
Q
What is Intrauterine Fetal Demise (IUFD)?
________________
Dx?-3
A
fetal death ≥ 20WG BUT before onset of labor
________________
- No fetal cardiac activity on US
- No fetal heart tones on Doppler
- No/minimal subjective fetal mvmnt
This commonly occurs in uncomplicated pregnancies
36
What is the management for Intrauterine Fetal Demise? - 2;
What complication can arise from IUFD?
*Main causes: Anencephaly, Potter sequence, etc.*
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 \**
38
When is [RhoGam AntiRhD] administered to **Rh NEGATIVE** pregnant women? - 7
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
39
When are pts screened for Group B Strep via vaginal and rectal swab?
35-37 WG
## Footnote
*results are valid for 5 weeks*
40
Why is prematurity a risk factor for breech presentation?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What's a way to convert a breech into cephalic?
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**)
41
External Cephalic Version can only be done at ⬜ weeks gestation!!
What are the contraindications to External Cephalic Version? - 7
≥ 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
43
CP for Placental Abruptio - 3
## Footnote
*Risk factors = HTN, cocaine and smoking*
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*
45
What are the risk factors for Intrauterine Fetal Demise? - 3
1. **SMOKING** intrapartum! (can also --\> *asymmetric* IUGR)
2. IUGR
3. abnormal fetal karyotype
46
AFP is a protein made by the (⬜3) It is obtained in pregnant women at ⬜ weeks gestation via ⬜
[Fetal Yolk Sac]/GI/Liver
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
15-20WG
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
via Quad BUAD screen
47
*AFP is obtained in pregnant women at 15-20WG*
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What does an elevated AFP indicate in a pregnant woman?-3
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!*
48
What is an Internal Podalic Version?
Performed in twin deliveries to convert 2nd twin from transverse presentation --\> breech presentation for subsequent delivery
49
What is Vasa Previa MOD?
fetal vessels traverse the amniotic membranes over the internal cervical os --\> antepartum bleeding and FHR abnormalitites **after** ROM (rupture of membrane)
50
Which vaccines should be given to pregnant women **during their pregnancy**? - 5
1. Tdap (27-36WG)
2. Flu inactivated
3. RhoD (28WG)
4. Hep A killed - if HepC positive
5. Hep B killed - if HepC positive
51
Which vaccines can be given to pregnant women **AFTER delivery (since they're contraindicated for intrapartum)**? - 3
1. HPV
2. MMR
3. Varicella
52
Spontaneous abortions (unprovoked pregnancy loss \< 20 WG) are usually a result of ⬜
what are the other 2 less common causes?
**chromosomal abnormalities**
2. teratogen exposure
3. mullerian anomalies (uterine septum)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*IUFD etx = mostly unknown*
53
What are the options for Mngmt of Spontaneous Abortion - 4
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*
54
When is a hgb electrophoresis screen indicated in a pregnant woman?
Pt has anemia during pregnancy ([hgb \< 11] + [MCV \< 80])
## Footnote
Non-Pregnant female normal hgb = 12-16
55
What are the risk factors for Placenta Accreta - 4
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
dx?
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
57
CP for Uterine Inversion? - 3
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*
58
What are the 4 major causes of Postpartum Hemorrhage? - 4
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)
59
Major causes of Antepartum Hemorrhage - 3
## Footnote
*Antepartum = right before childbirth*
1. Placental abruptio (**PAINFUL** Anterpartum hemorrhaging)
2. Placental previa
3. Vasa Previa
60
A pregnant pt who looks like they're in [active labor stage 1B] but has a baby tht regressed from 0 station to -3 Station should concern you for ⬜
Uterine rupture!
## Footnote
* "Full thickness disruption of the uterine wall"*
* biggest RF = pre-existing uterine scars (c/s, myomectomy)*
63
What are the risk factors for Uterine Inversion? - 4
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*
64
A pt with precipitous vaginal delivery *(within 3 hours after contractions start )* has just had a uterine inversion with prolapse and postpartum hemorrhage
After giving fluids for loss of blood, what's the ultimate tx for [Uterine prolapse] ? - 3
1st: **Replace the Uterus first**
2nd: AND THEN remove placenta if still attached
3rd: Give Uterotonics (oxytocin/misoprstol) to ⬇︎ postpartum hemorrhage
68
What is Cervical insufficiency
2nd trimester **PAINLESS** Cervical Dilation that --\> Spontaneous abortion (\< 20WG) or IUFD ( ≥ 20WG)
69
CP for septic abortion - 3
1. Fever
2. malodorous purulent vaginal discharge
3. Large, Boggy tender uterus --\> lower abd pain
## Footnote
*usually comes from unsterile/incomplete elective abortion*
70
What would ultrasound reveal for septic abortion
irregularly thickened endometrial stripe with active blood flow
71
What is a Cerclage procedure?
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
72
What does the Biophysical Profile (BPP) consist of? - 2 ; What is the breakdown of the results?
**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*
73
What is Doppler US of the umbilical artery used for?
evaluates for fetoplacental vascular insufficiency in IUGR pts (\< 10th%tile)
74
What is the dx for Hydatidiform mole gestation? - 2
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*
75
Septic Abortion can --\> Peritonitis, Sepsis and Death
How do you manage it? - 3
1. broad abx x 2 days
2. Dilation & Curettage
3. IVF
76
In the context of Ob/Gyn, what is Methotrexate typically used for? - 2
1. Ectopic pregnancy
2. Gestational Trophoblastic Neoplasia
78
What is a Nuchal Cord
when loop of umbilical cord wraps around fetus' neck --\> recurrent variable decelerations but **is not clinically significant**
79
What are the effects of Amphetamine use during pregnancy? - 6
1. IUGR
2. Intrauterine fetal demise
3. preeclampsia
4. Placenta abruptio
5. Preterm delivery
6. Maternal death!
80
Risk factors for Cervical Insufficiency - 2
1. DES intrauterine exposure--\> congenital abnormalities
2. cervical surgery
81
Gastroschisis is associated with ⬜ trimester use of which drug?
1st trimester use of **NSAIDs**
82
Fetal Heart Tracing like this indicates what dx?
Fetal Anemia
## Footnote
*Sinusoidal Fetal Heart Tracing*
83
What are the risk factors for Polyhydraminos? - 2
## Footnote
*Polyhydraminos ( ≥24 cm AFI) is a risk factor for Placenta Abruptio*
1. Maternal DM - poorly controlled
2. swallowing fetal anomalieis (esophageal atresia)
84
*Criteria for PreEclampsia is **Gestational HTN** + [**Proteinuria or End Organ Damage]***
How does the Liver play a role in SEVERE PreEclampsia?
*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
85
How many pounds are pts underweight (BMI \< 18.5) advised to gain?
35 lbs ([16kg])
86
Hyperemesis Gravidarum is a normal part of pregnancy
When is it expected to resolve?
by 20WG
## Footnote
*BE SURE TO WATCH OUT FOR THIAMINE DEFICIENCY SX IN THESE PTS!*
87
name the possible sequelae of Gestational HTN? - 7
## Footnote
*Remember: can ONLY be diagnosed in ≥ 20 WG*
1. IUGR asymmetrically
2. Preterm delivery
3. Oligohydraminos (AFI ≤5 cm)
4. Perinatal mortality
5. Placental Abruptio
6. Preeclampsia superimposed
7. c/s
88
Risk factors for Placenta Previa - 3
## Footnote
***PAINLESS** Antepartum Vaginal Bleeding with unaffected FHT since bleeding is all maternal*
1. c/s
2. Multiparity
3. Smoking
## Footnote
***PAINLESS** Antepartum Vaginal Bleeding with ONLY maternal vitals changing*
*"previews are painless :-)"*
89
What is Pubic Symphsis Diastasis? ; What is the clinical presentation of this after a traumatic delivery?
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*
90
*After vaginal delivery, pt is now numb over her Anterior and Medial thigh*
What happened?
Prolonged Hyperflexion at Hip for vaginal delivery (McRoberts maneuver) can --\> **Femoral n compression** --\>
1. Anterior & Medial thigh numbness
2. ⬇︎hip flexion
3. ⬇︎patellar reflexes
91
When is Placenta Previa typically diagnosed?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What are the things that are contraindicated because of Placenta Previa? - 4
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*
92
Sciatica etx ; Clinical Presentation - 3
"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]
93
Gestational sacs normally implant in the \_\_\_\_\_
Describe a Cornual Interstitial ectopic pregnancy
upper uterine fundus ;
implantation in outer "cornual" areas of uterus
*dx = trans**Vaginal** US // tx = MTX or surgery if severe*
94
Name the major risk factors for Ectopic Pregnacy - 6
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*
95
Placenta Previa and Vasa Previa both present as **PAINLESS** Antepartum Vaginal bleeding
What is the differentiating factor? - 2
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
97
PPROM = Preterm Premature Rupture Of Membranes (which occurs **before** 37 WG)
How do you manage PPROM when it occurs ≥ 34WG?
*Complications = Chorioamnionitis/Endometritis/Cord Prolapse/Placenta Abruptio*
98
PPROM = Preterm Premature Rupture Of Membranes **before** 37 WG
How do you manage PPROM when it occurs
**if baby not compromised, fetal surveillance until 34 WG and then deliver!**
*Complications = Chorioamnionitis/Endometritis/Cord Prolapse/Placenta Abruptio*
99
PPROM = Preterm Premature Rupture Of Membranes **before** 37 WG
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What are 2 px therapies for PPROM?
1. Progesterone (vaginal or IM after 1st trimester)
2. Cerclage
## Footnote
*Complications = Chorioamnionitis/Endometritis/Cord Prolapse/Placenta Abruptio*
100
The First Trimester Combined Test analyzes risk for ____ and ___ by measuring what 3 things?
If abnormal, how should this test be followed up? - 2
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)*
102
Hyperandrogenism (Hirsutism/Acne) during pregnancy is a **benign** condition that is caused by \_\_\_\_\_-2 ; Dx? ; Tx?
[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)
104
What is the classic presentation for Uterine rupture? ; What are the risk factors? - 2
**recession of fetal station** after sudden abd pain
*any prior uterine scars*
1. prior c/s
2. prior myomectomy (usually for fibroids)
106
Asymmetric IUGR is typically caused by \_\_\_\_-3 while **Symmetric** IUGR is caused by \_\_\_-2
## Footnote
*Symmetric = Head AND Abd are growth restricted while in Asymmetric it's mostly just Abd*
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**
107
What is "Precipitous" labor?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What's the greatest risk factor for Precipitous labor?
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!*
108
What effects does Tachysystole have on the fetus - 4
## Footnote
*Tachysystole: ≥6 ctx in 10 min period*
1. **Usually none**
2. ⬆︎ risk for c/s
3. ⬆︎risk for NICU
4. ⬇︎umbilical cord pH due to hypoxemia
109
What are the effects of Oxytocin toxicity? - 3
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*
110
What is the Kleihauer Betke test
Determines the dose of [Rhogam Anti-D] needed after delivering an Rh+ fetus to an Rh- mother. Can confirm or exclude fetomaternal hemorrhage
111
Full term infant = 37- 42WG
How do you manage Preterm Labor 34 to 36+6 WG - 2
***P**regnant **B**itches*
112
Full term infant = 37 -42WG
How do you manage Preterm Labor 32 to 33+6 WG - 3
***P****regnant **B**itches **T**ake*
113
Full term infant = 37 - 42WG
How do you manage Preterm Labor \< 32WG - 4
***P**regnant **B**itches **T**ake **M**oney*
114
Name the main Toco**lytics** - 5
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)
115
What factors indicate ⬆︎ risk for possible Preterm labor? - 4
## Footnote
*Full Term delivery = 37 - 42WG*
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)
116
Mg Sulfate is 1st line for Eclampsia px
What are the alternatives for Eclampsia px? - 2
1. Diazepam
2. Phenytoin
117
Normal Fetal Heart Rate is 110-160 bpm
What could Fetal Tachycardia indicate? - 6
1. Infxn chorioamnionitis (will include maternal fever)
2. Hypoxia
3. Anemia
4. Maternal Hyperthyroidism
5. Placenta Abruptio
6. Meds (terbutaline)
119
What is the **FIRST** thing you should look at when seeing a pregnant patient? Why is this?
Blood Pressure! ; RULE OUT PREECLAMPSIA
121
Risk factors for pt having preterm delivery? - 6
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*
123
What are the major s/s of Magnesium Toxicity - 2
## Footnote
*Risk Factor = Renal Insufficiency*
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*
124
Amniotic Band Sequence CP - 3
1. limb defects
2. craniofacial defects
3. abd wall defects
## Footnote
*NON-LETHAL :-)*
125
A **Non**reactive NonStress test is one without \_\_\_\_\_. What does a **non**reative NonStress test indicate? - 2
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*
126
*A pregnant pt has Graves' disease*
What medication is recommended to treat this in the 1st trimester? What about the 2nd and 3rd trimester?
PTU ; Methimazole
127
[T or F] You should be alarmed if a fetus of 14 Weeks Gestation has no accelerations (**non**reactive stress test) on Fetal Heart Tracing
Why or Why not?
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
130
In the context of labor and delivery, how do retroperitoneal hematomas form? ; What is the CP?-3
damage to internal iLiac artery during delivery ;
1. Palpable mass
2. Hemodynamic instability
3. Fever
134
Hyperemesis Gravidarum is a normal part of pregnancy that resolves by **20 WG**
What are the risk factors for getting this? - 3
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*
136
Name the causes of Variable Decelerations on Fetal Heart Tracing
Umbilical **Cord**
Compression (consider cord prolapse, oligohydramnios or nuchal cord as etx)
***VEAL CHOP***
137
A pregnant pt is having recurrent Variable decelerations with more than 50% of her contractions
tx? - 2
**L lateral decubitius Maternal repositioning** --\> **amnioinfusion** if that doesn't work
## Footnote
(⬇︎umbilical cord compression)
140
What are the most common dangerous activities for pregnant women? - 4
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)*
142
Systemic Lupus Erythematosus in pregnant pts complicates the picture of diagnosing preeclampsia since they both present very similarly
How can you differentiate the two? - 4
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!*
143
Systemic Lupus Erythematosus in pregnant pts complicates the picture of diagnosing preeclampsia since they both present very similarly
What are the ⬆︎ risk associated with having SLE during pregnancy? - 5
1. preeclampsia (smh naturally)
2. preterm
3. c/s
4. IUGR
5. fetal demise
## Footnote
*Beware: SLE can look like Preeclampsia!*
144
Full term infant = 37- 42WG
What are the Fetal complications involved with Late term (41-42WG) and Post term ( \> 42WG) pregnancies? - 5
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*
146
When is the First Trimester Combined Test administered?
analyzes risk for Trisomy 21 or [Edward's Trisomy 18] by measuring **BUS**
9-13WG
147
Gestational sacs normally implant in the \_\_\_\_\_
What is the "typical" triad for Ectopic Pregnancy? - 3
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]*
148
IUFD = fetal death ≥ 20WG but before onset of labor
What is *usually* the cause of IntraUterine Fetal Demise?
**UNKNOWN!!**
## Footnote
*This commonly occurs in uncomplicated pregnancies and could be maternal/placental/fetal origin*
149
Endometriosis is defined as \_\_\_\_\_\_
What are the possible findings for Endometriosis? - 4
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
151
CP for Endometriosis - 5
## Footnote
*Homogenous cystic ovarian mass*
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*
152
tx for Endometriosis - 5
## Footnote
*Homogenous cystic ovarian mass*
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*
153
What is the purpose of Chorionic Villus Sampling? ; What is the differnece between this and amniocentesis?
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**
155
Full term infant = 37- 42WG
Most Tocolytics are not used in managing Preterm Labor 34 to 36+6 WG
Why specifically is Nifedipine not used?
***P**regnant **B**itches*
Maternal hypOtension with reflex tachycardia
156
Full term infant = 37- 42WG
Most Tocolytics are not used in managing Preterm Labor 34 to 36+6 WG
Why specifically is Indomethicin not used? - 2
***P**regnant **B**itches*
1. Premature closure of ductus arteriosus
2. Oligohydramnios
157
Full term infant = 37- 42WG
Most Tocolytics are not used in managing Preterm Labor 34 to 36+6 WG
Why specifically is Mg not used?
***P**regnant **B**itches*
It's a **weak tocolytic** so it doesn't actually help with slowing contractions down in preterm delivery
158
Krukenberg tumors present like Luteomas, in that they both cause Female Hirsutism
Where do Krukenberg tumors come from?
they are Metastasis from GI CA
160
Erby's palsy of an infant is a common complication of shoulder dystocia
Impingement of which nerves causes the *self-limited* Erb's Palsy? - 3
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
161
Prolonged Rupture of Membranes ≥ ___ hours is a risk factor IntraAmniotic Infection & neonatal sepsis
What is the dx criteria for IAI (IntraAmniotic Infection)? - 2
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*
162
Why is it rare for Women to get PID after the ___ trimester
1st; cervical mucus and decidua seals off the uterus from pathogens during pregnancy
163
Physically describe Uterine Atony - 3
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*
164
Methylergonovine MOA ; Indication?
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
165
Although most commonly associated with Alcoholism, why are pregnant pts also at risk for developing Wernicke Encephalopathy from Thiamine deficiency?
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*
166
Biophysical Profile and Contraction Stress Test can either or be used to assess for fetal hypoxia in high risk pregnancies
How do you perform a Contraction Stress Test?-2 ; What are the contraindications?
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
167
How do you manage SEVERE Preeclampsia when it occurs ≥ 34WG?
*It's the same as PPROM!*
168
How do you manage SEVERE Preeclampsia when it occurs
*It's the same as PPROM! Evaluate Fetal well-being first*
169
CP for Acute Fatty Liver of Pregnancy - 3 ; When does this occur?
**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!*
175
What are the absolute contraindications to breastfeeding? - 7
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*
176
What is lochia
postpartum uterine/vaginal discharge **that's normal**
177
Because of ____ and \_\_\_\_, immediate postpartum urinary retention is expected. When does this become pathologic (bladder atony)?
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
178
name the most common causes of uterine size-date discrepancy in pregnant patients - 5
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)
179
Why is it normal for pregnant patients to have a systolic ejection murmur
⬆︎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*
180
How does pregnancy affect the respiratory system? - 2
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
181
What is often the cause of Early Decelerations on Fetal Heart Tracing
**Head Compression** of Fetus
## Footnote
*these occur WITH contractions and no tx is required*
182
False labor occurs as a result of Braxton Hicks contractions and causes NO CERVICAL CHANGE
Compare the **Timing** / **Strength** / **Cervix status** of contractions occuring in False Labor to True Labor
Uterine Contractions...
FALSE = irregular + weak + NO CERVICAL CHANGE
True = [Regular with **increasing frequency**] + [**increasing in strength**] + cervical change
184
A: **Potters Sequence** etx
B: Clinical Presentation - 6
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
185
Shoulder Dystocia can cause multiple neonatal sequelae
What are they? - 5
186
Shoulder Dystocia can cause multiple neonatal sequelae. **Klumpe Palsy** is one of those possible sequelae
What is it caused by specifically? - 2
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
187
What all labs should be ordered for the Initial prenatal visit? - 11
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)
188
What all labs should be ordered for the 24-28WG prenatal visit? - 3
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*
189
Why are some women at risk for developing gestational DM after the 1st trimester?
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*
190
When is a NST indicated? - 2
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!*
191
CP for Type 2 Osteogenesis Imperfecta - 4 ; etx?
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
193
How does pregnancy affect Renal function? ; Why is this important?
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
194
What changes to Hematocrit occur during pregnancy? Why is this helpful?
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)
195
Pregnant Women are known to be hypercoagulable in order to decrease effects of PostPartum hemorrhage
What biochemical changes occur to make them hypercoagluable? - 4
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)
196
In a pregnant pt who has chronic HTN (HTN prior to 20 WG), what goals for blood pressure should be set?
*Less than Stage 1*
Systolic \< 140
Diastolic \< 90
197
How do you diagnose Endometriosis?
**LAPORASCOPY** to biopsy & remove endometriotic lesions
## Footnote
*1st, treat empirically with NSAIDs tho*
198
Shoulder Dystocia = inability to deliver neonatal shoulders
What is the biggest risk factor for Shoulder Dystocia? ; Why is Shoulder Dystocia so dangerous for newborns? - 3
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
199
In a pregnant pt who hasn't felt fetal mvmnt in 2 days, and dopper reveals no heart tones, what should be next step in management, **NST** or **Transabdominal Ultrasound**? Why?
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***
200
What is the work up for a Fetus that just underwent IntraUterine Fetal Demise? - 3
IUFD = fetal death ≥ 20WG BUT before onset of labor;
1. Autopsy
2. Placenta/Umbilical Cord/Amniotic Membranes exam
3. Karotype genetic studies
201
What is the work up for a Mother that just underwent IntraUterine Fetal Demise? - 3
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
202
Septic Pelvic Thrombophlebitis CP - 2
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*
203
Fetal Hydantoin Syndrome results from intrapartum usage of ____ or \_\_\_\_\_
Describe the CP of the baby for this - 5
phenytoin, carbamazepine
1. microcephaly --\> developmentally delay
2. midfacial hypoplasia
3. cleft lip and palate
4. digital hypoplasia
5. hirsutism
204
What is the Prenatal Maternal Quad Serum screening? When is this obtained?
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*
205
What are the Quad BUAD results (obtained 15-20WG) for Edward's Trisomy 18?
⬇︎βHCG
⬇︎**U**nconjugated EsTriol
⬇︎**A**FP
NML **D**imeric inhibin A
208
What is 1st line tx for gestational DM? ; What's used if this doesn't work? -3
1st: Diet change
2nd: Insulin or Metformin or Glyburide
* Wt loss during pregnancy is **NOT** a good idea since it ⬆︎risk for IUGR*
209
When should women be screened for Gestational DM?
24 - 28WG
210
Shoulder Dystocia = inability to deliver neonatal shoulders
What is the management for this? - 6
**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)
212
What is a normal Lactate DeHydrogenase (LDH)?
\< 190 U/L
216
What are the common side effects of the Medroxyprogesterone depot injection contraception? - 4
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*
221
How does thyroid dysfunction affect pregnancy? - 2
Both hypO and HYPERthyroidism ⬆︎risk for infertility and recurrent pregnancy loss
224
25% of fetuses ≤ 28WG are naturally breeched, but flip into cephalic/vertex position by 37WG
What are the 2 dx for disovering breech presentation?
1st: fetal presenting part is not palpable
2nd / **CONFIRMATION IS DONE BY TRANSABDOMINAL US**
225
Name the things that make vaginal delivery contraindicated - 4
1. Breech
2. Placenta Previa
3. Active HSV lesion
4. Prior **classical** c/s
229
Amniotic Fluid Index for Oligohydramnios
≤ 5cm
230
Amniotic Fluid Index for Polyhydramnios
≥ 24cm
## Footnote
RF = Maternal DM, congenital swallowing malformation
Polyhydramnios can --\> placenta Abruptio
232
Etx of Sheehan Syndrome ; What are the main signs and symptoms of Sheehan Syndrome?-5
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**
233
Early Postpartum period had several physiological processes that can be mistaken for pathology
Name them-5 (so you can avoid overdiagnosing!)
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
234
How do Prostaglandins "ripen" the cervix during induction?
degenerates cervical connective tissue --\> softens and effaces cervix for induction
## Footnote
*ex: misoprostol, dinoprostone*
238
CP for Ovarian Torsion - 3
1. **Palpable adnexal mass**
2. abrupt uL pelvic pain
3. NV
239
What are the complications for the fetus when exposed to acute uteroplacental insufficiency (i.e. abruptio placenta) and chronic uteroplacental inusufficinecy (i.e. preeclampsia)?
**ACUTE** uteroplacental insufficiency --\> fetal hypoxic brain injury
vs
**Chronic** uteroplacental insufficiency--\> asymmetric IUGR /SGA & oligohydramnios
240
Clinical criteria for Arrest of "Active Labor Stage 1B" - 2 ; Tx?
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*
241
Clinical criteria for "Labor Protraction" of Active Labor Stage 1B - 2
Occurs once pt reaches *Active* Labor ( ≥6cm dilated) and...
1. slower than 1-2 cm/hr dilation
2. +/- inadequate contractions
*Tx = oxytocin*
242
Epidural Anesthesia causes hypOtension in \_\_\_% of pregnant pts when given during Active Labor
What is the mechanism for this?
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*
243
What is the antidote for Magnesium Toxicity?
## Footnote
*Risk Factor for Mg toxicity = Renal Insufficiency*
Ca+Gluconate
## Footnote
*Risk Factor for Mg toxicity = Renal Insufficiency since it's renal excreted!!*
244
What are the **common** side effects of Magnesium administration? - 3
1. HA
2. Flushed
3. Nausea
245
What is the most common cause of postpartum fever? When does this fever usually present? Tx?
**ENDOMETRITIS** ; \> 24 hours postpartum ; [Clindamycin + Gentamicin]
## Footnote
*You do NOT need cx for this dx!*
246
Abx for Lactational mastitis?
Dicloxacillin
## Footnote
*covers MSSA and GASP*
247
A placenta is close to the internal cervical os
How far away does the placenta have to be from the cervical os to NOT be considered placenta previa
\>2 cm away from os
251
Clinical Criteria for Arrest of Labor Stage 2 - 2
*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
252
What are the causes of Labor Stage 2 ? - 3
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
253
What is the difference between fetal Malpresentation and Malposition?
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)
260
What is the most accurate method of determining gestational age?
**FIRST** trimester US with crown to rump length (since there is minimal variability of fetuses when they first start off)
261
After the ____ is used as the most accurate method to determine gestational age, what can be used as secondary? - 6
**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
262
Dx for Ovarian Torsion
**Pelvic US** revealing adnexal mass with absent Doppler flow
263
Ovarian Torsion is more common amongst \_\_\_\_\_[pre/post] menopausal women
**PRE**menopausal
## Footnote
*Untreated ovarian torsion --\> sepsis, chronic pelvic pain and infertility*
264
What is Culdocentesis? ; What is it used for?
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
266
What is the MOST IMPORTANT intervention for preventing vertical HIV transmission from Mom to baby? ; What are 2 other less important methods?
**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*
267
What is the precaution in a pregnant woman with Graves' disease?
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
268
[T or F] Thyroid hormones (T4 and T3) can NOT cross the placenta during pregnancy
TRUE! - only the thyroid stimuating Ab can cross and that's only during 3rd trimester
269
What's the only maternal Antibody that has the ability to cross the placenta? ; why does it do this?
Ig**G**; protects neonate for first 3 months of life
270
CP for Amniotic Fluid Embolism - 4
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*
272
How does Peripartum Cardiomyopathy present? ; When during the pregnancy does this present?
**Rapid** Heart Failure (SOB, cough, pedal edema) ; \> 36WG
273
What type of shoulder dislocation are Violent Muscle Contractions associated with
POSTERIOR
274
Mode of inheritance for Hemophilia A
X-linked recessive
275
What's the time limit for pregnant women in Latent labor Stage 1A if they're nulliparous? ; What about if they're multiparous?
*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
276
What's the time limit for pregnant women in Labor Stage 2 if they're nulliparous?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What about if they're multiparous?
*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
277
What's the time limit for pregnant women in Labor Stage 3?
*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)**
278
What are the stages of Labor?
*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
279
Why is there no use in getting a D-dimer in a pregant woman for DVT workup?
D-dimer is already **naturally elevated** in pregnant woman due to their physiological ⬆︎ fibrinogen
280
What is the disadvantage of using Progestin only OCP for contraceptive?
You have to take it every day **DOWN TO THE EXACT HOUR** or it will fail! = compliance issues
282
CP for Fibroadenoma - 5
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*
283
How does Ductal carcinoma in situ present on mammography?
microcalcifications
284
CP for Inflammatory Breast CA - 7
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***
286
Paget Disease of the Breast is a form of \_\_\_\_(*type of CA*) that presents how? - 3
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*
288
Describe Lichen Sclerosus MOD
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*
289
Signs and Symptoms of Lichen Sclerosus - 5
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*
290
Fibrocystic changes of the breast are common in \_\_\_\_(*pre/post*) menopausal women
How does this typically present? - 2
**PRE**menopausal
1. cyclical BILATERAL breast pain
2. diffuse nodularity
*This cyclical BL breast pain is exacerbated with caffeine!*
291
Etx of Lactational Mastitis?
What are the s/s?-4
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
292
Risk factors for Endometrial adenocarcinoma -3
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*
293
CP for Endometrial CA?-2
Dx for Endometrial CA?-2
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*
295
CP for Lobular breast carcinoma - 3
1. **FIXED** palpable mass
2. Irregular borders
3. +/- Bilateral
296
Tx for Lichen Sclerosus
Clobetasol ointment (high potency topical CTS)
## Footnote
*dx = vulvar punch biopsy*
297
Explain how women can develop urine leakage thru their vagina and NOT the urethra
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*
299
How do you discern pharyngitis 2/2 Neisseria Gonorrhea from pharyngitis 2/2 infectious mononucleosis?
N. Gonorrhea = non-exudative pharyngitis, and has PID lower abd pain
vs.
Mono = **exudative** pharyngitis and has fatigue
*otherwise, presentation is similar*
301
How does Vaginal CA (SQC or Clear cell ADC) present?-4
Who usually gets Vaginal SQC?
Where does Vaginal SQC occur in the vagina?
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
302
How does Vaginal CA (SQC or Clear cell ADC) present?-4
Who usually gets Vaginal Clear cell ADC and what's unique about them?
Where does Vaginal Clear cell ADC occur in the vagina?
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
303
What are the risk factors for Vaginal SQC?
same as **Cervical CA risk factors**
## Footnote
(*cervical CA migrates to vagina*)
305
CP for Vulvar yeast - 3
1. Red patches
2. Flaky patches
3. Satellite lesions
306
Pt comes in with Postmenopausal bleeding
How do you evaluate them?
309
Pt comes in with with Breast Mass
How do you evaluate them?
*DDx = CCAFF*
DDx = CCAFF
310
What is the classic ultrasound description of a **cyst**
posterior acoustic enhancement (indicates fluid is present) with no echogenic debris or solid components
311
Pt has just been diagnosed with **Simple** breast cyst and has tenderness in the area
How do you manage them? - 3
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
313
Describe the clinical progression of primary syphilis chancres
**single** papule that turns into shallow, PAINLESS, **nonexudative ulcer** with indurated edges, accompanied with BL inguinal LAD
## Footnote
THESE ARE EXTREMELY INFECTIOUS!
314
What are the features of a ChancROID?-3 ; Is it painful? ; What organism causes this?
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*
315
What are the features of a Genital Herpes?-3 ; Is it painful?
1. Multiple small shallow ulcers
2. Erythematous base
3. LAD
## Footnote
**PAINFUL**
316
What are the features of a Lymphogranuloma Venereum?-3 ; Is it painful? ; What organism causes this?
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*
317
The BRCA gene mutation puts women at risk for what 2 CA
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*
318
What are the features of Donovanosis granuloma inguinale?-3 ; Is it painful? ; What organism causes this?
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*
319
What do you do if a pt with clinical s/s of syphilis has a negative RPR?
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!
322
Describe the CP for Bacterial Vaginosis -2
1. Whitish Gray vaginal discharge
2. Malodorous discharge
323
Interstitial cystitis is AKA \_\_\_\_\_\_\_. How does it present?-3
Painful Bladder Syndrome
1. Chronic pelvic pain
2. Urinary sx (dysuria, urgency, frequency)
3. Dyspareunia
324
What is the difference between a Urethral diverticulum and a Urethrocele?
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*
328
What are bodily signs of ovulation - 3
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*
329
What is the cervical mucus plug?
yellowish brown thick cervical mucus shed right before labor that prevents asecending infxn during pregnancy
330
In Ovarian CA, why is the specificity for CA-125 much higher in older women?
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**
331
For ovarian CA, what can CA-125 be used for?
*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*
333
Why should pts taking estrogen for postmenopausal sx **also should be taking progesterone** if they have a uterus?
Unopposed estrogen --\> uncontrolled endometrial proliferation (CA). Progesterone can regulate proper endometrial differentiation
## Footnote
*just remember, estrogen replacement therapy can --\> postmenopausal bleeding on its own*
334
Adenomyosis dx
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*
335
What's the most common sign of Endometrial Polyps
**PAINLESS** intermenstrual bleeding
336
DDx for Postmenopausal bleeding - 4
1. Endometrial CA (ADC, hyperplasia)
2. Cervical CA
3. Vaginal CA (clear cell ADC, SQC)
4. Estrogen replacement therapy
337
Leiomyomata uterine Fibroids CP - 5
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!*
341
Why is mammography in women \< 30 y/o relatively not recommended? - 2
1. Dense breast tissue in women \< 30 yo might impede assessment of breast masses
2. Breast radiation can --\> Breast CA in and of itself
342
In women with breast mass, after using Ultrasound to determine the type of mass...
what are the different types of biopsies and when are they used? - 3
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*
347
Behcet Syndrome CP
Vasculitis-mediated Recurrent Multiple Ulcers (aphthous and genital)
348
What's the gold standard method to diagnose Cervical Intraepithelial Neoplasia? ; What's tx for this?
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*
349
What is Asherman syndrome
**INTRAUTERINE ADHESIONS** (could be from infxn or uterine surgery)
this can cause 2° Amenorrhea (normal ovulation and hormone levels but mechanical amenorrhea)
350
CP for Bartholin gland cyst-4 ; What causes this?
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*
351
Describe Gartner duct cyst ; Where do they come from?
single or multiple submucosal cyst on the lateral aspects of the upper ANT vagina ; incomplete regression of Wolffian duct
352
Tx for asx Bartholin duct cyst
**OBSERVATION** if asx since it will spontaneously drain :-)
## Footnote
If symptoms are present --\> Incision and Drainage f/b word catheter ⬇︎ recurrence
353
What would you expect symptom presentation for this to be? ; What would you expect pelvic US to reveal?
**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)
357
What is the DDx for Urge Incontinence - 4
## Footnote
*Sudden urge to urinate all the time*
Detrusor hyperactivity 2/2
1. UTI
2. Estrogen deficiency (urethral closure --\> ⬆︎intrabladder pressure --\> urge)
3. Multiple Sclerosis
4. DM
358
What is the DDx for Overflow incontinence - 2
1. DM neuropathy
2. mechanical obstruction
## Footnote
*⬇︎Detrusor activity or mechanical outlet obstruction --\> Overdistended bladder --\> involuntary dribbling and incomplete empyting (⬆︎PVR)*
359
What is the most common complication of an untreated Mature dermoid cystic teratoma?
**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*
360
Normal Post Void Residual for Women
\< 150 cc
361
Normal Post Void Residual for Men
\< 50 cc
362
Explain why clinicians no longer should empirically treat both Chlamydia and Gonorrhea if only one is positive
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
364
Condyloma Acuminata is caused by _____ & \_\_\_\_\_. Describe its appearance - 2
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
365
What are the Emergency Contraception options?-4 ; What is the time limit for which you can use each of them?
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*
366
What are the causes of Functional Hypothalamic Amenorrhea?-6 ; Explain how they cause amenorrhea ; What's the most common long term complication for these pts?
*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*
367
Ovarian reserve starts to decline in older woman around the age of \_\_\_\_\_. Which lab should you order to confirm this?
35 ; **FSH** would be higher in a ovarian reserve declining woman
368
How does high androgen levels affect fertility for Women?
high Androgen (such as PCOS) --\> ⬇︎GnRH release from feedback inhibition --\> ⬇︎FSH --\> ⬇︎ovarian maturation --\> 2°follicle atresia --\>
1. Anovulation chronically
2. Amenorrhea
3. Polycystic Ovaries
369
Clinical definition of Primary infertility - 3
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*
371
MOD for PCOS
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*
372
How should pts with PCOS go about restoring ovulatory cycles 1st? What's another option if that doesn't work?
1st: **WEIGHT LOSS!**
2nd: Clomiphene citrate (GnRH agonist)
375
Describe the appearance of Lichen Planus
Glazed erythematous lesions on vulva with ulcerated areas
377
What is the most common pelvic tumor in women?
Leiomyomata uterine fibroids
## Footnote
*Submucosal and Pedunculated are the worst!*
378
[T or F] Posterior Cul-De-Sac fluid accumulation in a pregnant woman is an abnormal finding
**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)
379
DDx for Free fluid in the pelvis of a woman - 3
1. Normal pregnancy change
2. Ruptured Ectopic --\> hemoperitoneum
3. Ruptured Ovarian cyst
380
Clinical definition of Primary Amenorhhea
**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
381
Why do pts with Androgen Insensitivity Syndrome have NO ovaries/fallopian tubes/uterus/cervix but DO have breast?
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
382
CP of congenital 5α reductase deficiency
ambiguous genitalia at birth 2/2 undervirilization
## Footnote
*these pts can not convert Testosterone --\> DHT*
383
Difference in CP between Androgen insenstivity syndrome and Mullerian agenesis pts
**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*
384
What is 1st line tx for Dysmenorrhea in sexually active pts? ; What about non-sexually active pts?
Combined OCPs ; NSAIDs
## Footnote
*Combined OCPs treat dysmenorrhea by ⬇︎endometrial proliferation via atrophy which --\> ⬇︎prostaglandin release --\> ⬇︎painful uterine contractions*
385
Why is Intrauterine Copper device relatively contraindicated in dysmenorrhea pts
its uterine inflammatory rxn actually --\> ⬆︎pain
386
Why is Medroxyprogesterone depot relatively contraindicated in young pts - 2
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*
387
In a +bHCG pt who comes in with RLQ pain, vaginal bleeding and a negative Transvaginal US
why would we wait and repeat the bHCG & transvaginal US in 2 days if at the time it was already 1000
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)
388
βhCG levels have to be ____ for pregnancy to be detected via trans*vaginal* US, and usually _____ when trans*abdominal* US can finally detect it
What are βhCG levels during:
A: Ectopic Preg/Miscarriage
B: Molar Pregnancy
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*
389
Why can pts with PID sometimes present with RUQ pain?
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
390
What age do women have to be in order to be diagnosed with Premature primary ovarian insufficiency?
\< 40 yo
## Footnote
*these pts usually have autoimmune conditions and/or Turner's and present with oligomenorrhea--\> amenorrhea and infertility*
393
What would you expect the following hormones to be in Hypothalamic hypogonadism (functional hypothalamic amenorrhea)?
GnRH
FSH
Estrogen
394
What would you expect the following hormones to be in Premature primary ovarian insufficiency?
GnRH
FSH
Estrogen
*these pts usually also have autoimmune conditions (i.e. hypothyroidism) or Turner*
395
What would you expect the following hormones to be in PCOS (polycystic ovarian syndrome)?
GnRH
FSH
Estrogen
396
What would you expect the following hormones to be in Exogenous estrogen use?
GnRH
FSH
Estrogen
401
What are the 4 CA associated with Lynch Syndrome
1. proximal Colorectal
2. Ovarian
3. Endometrial
4. Skin
## Footnote
*Germline mutation in mismatch repair protein*
402
Mngmt for Epithelial Ovarian Carcinoma (ovarian CA) - 2 steps
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*
403
What is Choriocarcinoma? ; What other organ does it involve? ; When does Choriocarcinoma occur?
aggressive form of gestational trophoblastic neoplasia;metastasizes to **LUNGS** --\> cp/dyspnea/hemoptysis
## Footnote
occurs after ANY TYPE OF PREGNANCY
404
How does the Levonorgestrel progestin IUD work as a contraceptive? - 3
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**
405
Why is it common for adolescents to have irregular and anovulatory menstruation
**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*
406
BRCA mutation is associated with Breast and Ovarian CA
How can pts reduce their risk of developing Epithelial Ovarian Carcinoma?-5
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*
407
What are the main side effects of Levonorgestrel progestin IUD - 2
1. **Breast tenderness**
2. HA
408
Pelvic US reveals Hyperechoic ovarian cyst with calcifications
Dx?
Mature dermoid cystic teratoma
409
Pelvic US reveals Homogenous cystic ovarian mass
Dx?
Endometriosis of ovary (endometrioma)
411
Pt has just been hospitalized for PID
Now that she's hospitalized, what are the **inpatient** abx options for PID?-3
Inpatient:
1. CeFOXitin IV + Doxy PO
2. Cefotetan IV + Doxy PO
3. Clindamycin + Gentamicin IV
*Remember: PID is actually POLYmicrobial*
412
What does Fat necrosis of breast show on mammography
oil cyst +/- calcifications that may appear to be malignant
## Footnote
*ruled out from malignancy based on bx revealing fat globules and foamy macrophages*
413
What does Fat necrosis of breast show on core biopsy - 2
fat globules and foamy macrophages
414
What is the **outpatient** abx regimen for treating PID
CefTriaxone IM + Doxy PO
## Footnote
*make sure these pts can tolerate and comply with PO abx*
415
What are the risk factors for Cervical CA? - 5
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
416
What are risk factors for Ovarian CA - 3
1. Endometriosis
2. BRCA 1/2 mutation - **1st degree relatives**
3. repeated ovulation (from trauma to ovarian surface with each cycle)
417
What are the risk factors for Toxic Shock Syndrome - 3
## Footnote
*organisms = Staph A and GASP*
1. Tampons
2. Surgery (**especially nasal/sinus**)
3. Burns/skin lesions
418
CP for Toxic Shock Syndrome - 5
## Footnote
*organisms = Staph A and GASP*
1. **Generalized macular rash INVOLVING palms & soles**
2. hypOtension
3. Fever
4. Vomiting
5. Diarrhea
419
Tx for Condyloma Acuminata - 5
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
420
[T Or F] It is absolutely Ok to perform a Colposcopy in a pregnant woman whose pap recently resulted abnormal
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*
421
What are the guidelines for ANNUAL GC/Chlamydia Screening (Women vs Men)
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*
422
Guidelines for **PAP Smear** Cervical CA Screening - 3
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*
423
What is Mittelschmerz?
**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*
425
Condyloma Lata is caused by \_\_\_\_\_\_. ; How would you describe these lesions?-2
Treponema Pallidum **SECONDARY** syphillis
1. **FLAT**
2. **VELVETY**
426
Secondary Amenorrhea occurs when women stop having menses for ≥6 months
What is the full workup for Secondary Amenorrhea?
Evaluate **F**LA**T** **P**iG for 2° Amenorrhea
428
hCG is secreted by _____ and responsible for what? ; When does hCG production begin?
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*
429
Which hormone prepares the endometrium for implantation of a fertilized egg?
**P**rogesterone **P**repares endometrium via decidualization
430
Which hormone induces prolactin production during pregnancy?
**E**strogen
431
Which hormone is responsible for myometrium relaxation during pregnancy?
**P**rogesterone
434
Lichen Sclerosus and Atrophic Vaginitis can present similarly
What is the major distinguishing feature?
*Both have thin & pale tissue*
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)
435
Dx for Functional Hypothalamic Amenorrhea?
⬇︎FSH
437
Who should be the only demographics to receive BRCA/HER2 testing - 3
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
438
CP of ovarian CA - 3
1. early satiety (from ascities)
2. abd/pelvic pressure (from ascities)
3. GI sx (constipation/diarrhea/bloating/anorexia) - (from ascities)
442
[T or F] Combined OCPs ⬆︎ risk for Endometrial CA ; Explain
FALSE ; **Combined** OCPs ⬇︎risk for Endometrial CA because the progestin differentiates endometrial cells
443
[T or F] Combined OCPs ⬇︎ risk for Ovarian CA ; Explain
TRUE ; **Combined** OCPs ⬇︎risk for Ovarian CA because it suppresses chronic ovulation which causes chronic damage to surface
444
Dx for Menopause - 3
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*
445
*Clinical criteria for diagnosing PMS (PreMenstrualSyndrome) relies on PMS sx*
What is the Clinical Criteria for PMS? ; Name some of the PMS sx
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
446
*Clinical criteria for diagnosing PMS (PreMenstrualSyndrome) relies on PMS sx*
What is the mngmt for PMS? - 5
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
447
Why are Combined OCPs **contraindicated in pts with [Migraine with aura] hx**?
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
448
When should the HPV **3 dose** vaccine be given to females?
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!!!!\*\***
449
When should the HPV **3 dose** vaccine be given to males?
Between 9-21 (or 26 if HIV+ and/or gay) yo
## Footnote
\*they receive 3 doses spread out\*
452
How does Obesity commonly cause amenorrhea?
Obesity --\> anovulation **without affecting LH/FSH levels** which--\> Amenorrhea
454
How do you rationalize a pt with a large ovarian mass and a thickened endometrium stripe on US
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!*
459
How does estrogen deficiency cause stress AND URGE incontinence?
⬇︎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*
461
List the numerous contraindications to Combined OCPs - 11
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
462
What is Penetration genitopelvic disorder ; tx?-2
pain with any vaginal penetration (penis, tampon, gyne exams)
## Footnote
tx = Vaginal Dilators, Kegel exercises
*this is AKA Vaginismus*
463
In pts with Pudendal neuralgia, where do they have superficial pain? - 3
1. Vulva
2. Perineum
3. Rectum
## Footnote
*these are the pudendal n distribution areas*
464
What are the causes of Hydrosalpinx (fluid accumulation in fallopian tubes) - 2
1. Adhesions (PID, surgery)
2. Tubal ligation
465
Epithelial Ovarian Carcinoma is caused by abnormal proliferation of \_\_\_\_\_\_-3
What are US features of a malignant mass? - 3
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!*
466
What is the 1st line tx for Postmenopausal hot flashes? ; What can you use if that doesn't work?
**WEIGHT LOSS** ; Combined OCPs
## Footnote
HEY! HRT IS NO LONGER RECOMMENDED FOR CAD, DEMENTIA OR _OSTEOPOROSIS_ PX!!!!!!!
468
What is the main side effect of Copper IUD
Menorrhagia
469
What is the main side effect of Medroxyprogesterone injections
Weight Gain
474
Ovarian hyperThecosis is usually diagnosed in \_\_\_\_[pre/post] menopausal women
What is it?
**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
475
DDx for Menorrhagia (abnormal uterine bleeding) - 10
*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
478
When is MRI of the breast indicated? - 5
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
479
In a woman with normal menstrual cycles, what is usually the cause of infertility if she is \> 35 yo?
diminished Ovarian reserve
## Footnote
*oocytes are of number and quality*
480
What is an ovarian Fibrothecoma
sex cord-stromal tumor that secretes both but Estrogen \> testosterone
481
Vulvar inclusion cyst usually result because of ______ whereas Vulvar epidermal cyst result from \_\_\_\_\_\_\_\_
local trauma ; obstruction of sebaceous gland duct
482
What are 4 major s/s of Pregnancy
**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!*
485
[T or F] It is ok to perform a Cervical biopsy on a pregnant woman whose pap recently resulted abnormal
TRUE - **after Colposcopy**, if lesion has high-grade features
## Footnote
*Endocervical curettage is contraindicated*
486
Atypical Glandular Cells on a Pap may be due to either ____ OR _____ CA
What should you do to work this up? - 3
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*
488
What is Ovarian hyperstimulation syndrome
Ovulation inducing medications --\> excessive follicle development --\> ovarian enlargement, ascities, SOB and abd pain
489
How do you manage an active HSV lesion in Pregnant Women who are in labor? ; How do you manage HSV in Pregnant Women remote to labor?
c/s ; Valacyclovir px at 36WG
491
In a pt with hypothyroidism, why do you need to \_\_\_\_\_[decrease/increase] her levothyroxine T4 when she becomes pregnant?
**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*
492
What are the 1st line abx for treating UTI/cystitis - 3
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What are the 2 alternatives?
**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*
493
A friable cervix is one that easily _____ when touched. This is usually a sign of acute **cervicitis** secondary to \_\_\_\_\_
What are the other 2 major symptoms?
bleeds "crumbles" ; N. Gonorrhea
## Footnote
1. Friable Cervix that
2. has cervical discharge
3. postcoital bleeding
494
bHCG shares an \_\_\_subunit with which other 3 hormones?
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
495
How do you confirm a pt has urinary retention
urinary catheterization ≥150 cc
## Footnote
*Bladder can hold up to 400 cc*
496
What are the major risk factors for PreMenstrual Syndrome? - 5
1. **FAMILY HX OF PMS**
2. Vitamin B6 Pyrodixine deficiency
3. Ca+ deficiency
4. Mg deficiency
5. Age \> 30
497
What is the most common cause of vaginal bleeding in neonates?
self limited maternal withdrawal of estrogen
498
What are the reversible causes of urinary incontinence in elderly? - 7
"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
499
recurrent vulvovaginal candidiasis warrants evaluation for what?
DM
candidiasis RF: DM, abx, immunosuppresion
500
major side effect of Trastuzumab
cardiotoxicity
501
Turner syndrome is the sex chromosoal disorder most likely associated with physical findings **at birth**
What are the classic findings? - 7
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*
502
What's the most important prognostic factor in pts with Breast Cancer
TNM
503
Why is Progesterone given to pts with irregular menses and/or heavy menses?
It normalizes menstruation by stabilizing unregulated endometrial proliferation
504
Pt with PID also has ⬆︎CA125 and multiloculated adnexal mass filled with debris
TuboOvarian Abscess or Ovarian Serous CystADC? Why?
TuboOvarian Abscess
## Footnote
These can have non-specific laboratory changes (including ⬆︎CA125)
505
A teenage female pt has short stature and primary amenorrhea
This should raise suspicions for what disorder?
ovarian dysgenesis from Turner Syndrome
## Footnote
*Most turner syndrome fetuses miscarry within 1st trimester*
506
What is the first manifestation of pubety for females?
**BREAST** --(2.5 years later)--\> Menarche by 15 yo
507
cp for Imperforate Hymen-4
1. smooth blue bulging vaginal mass
2. **primary amenorrhea**
3. hematocolpos (blood pooling behind the hymenal membrane)
4. cyclic lower abd pain
508
What is the workup for Primary Amenorhhea?-3
**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
509
What lab test is used to evaluate for precocious puberty?
GnRH stimulation test
510
What 2 things does Dysgerminoma ovarian tumors secrete?
these occur in women\<30yo
1. LDH
2. bHCG
511
Why should you not be alarmed when a newborn presents with Mammary Gland enlargement?
Maternal Estrogen exposure **NATURALLY**--\>
1. Mammary Gland Enlargement
2. leukorrhea
3. mild urterine bleeding
in newborns. No w/u OR tx is necessary
512
Diagnostic criteria for Primary Dysmenorrhea; etx
pelvic cramping during the first few days of menses in the context of a normal pelvic exam; prostaglandin release from endometrial sloughing during menses
513
Tenderness along the uterosacral ligament should make you suspicious for what disorder?
Endometriosis
514
Tenderness along the uterosacral ligaments should make you suspicious for what disorder?
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
515
For Adults, list immunization recommendations for **HPV**
*Purple = Pt has Risk Factors*
**APPROVED FOR FEMALES AGE 9-26 yo**
516
Systemic Lupus Erythematosus in pregnant pts complicates the picture of diagnosing preeclampsia since they both present very similarly
What medication should all pregnant Lupus pts be started on as as a complication of their Lupus?
**Enoxaparin** low molecular wt heparin for antiphosphoblipid syndrome
*Beware: SLE can look like Preeclampsia!*
517
Pts with Hydatidiform mole gestation are at risk of developing what type of neoplasia? ; After removal of the Hydatidiform mole, how long should it take for bHCG to be undetectable?
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*
518
*Criteria for PreEclampsia is **Gestational HTN** + [**Proteinuria or End Organ Damage]***
What is the major fetal complication from untreated Preeclampsia?
Small for Gestational Age (SGA)
*FYI: PreEclampsia can still occur superimposed on Chronic HTN*
519
520
Vulvodynia cp
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
tx
≥3 mo idiopathic raw burning vulvar pain
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Tx = [pelvic floor physiotherapy] and CBT
[2a] A ⼀ Step 2 OD USLME
flashcards
Decks in class (21)
# Cards
-
✅FACTIONLESS258
-
✅F1 (ID/RENAL/ENT/ALLERGY)85
-
✅F2 (GI / RHEUM-ORTHO / HEME-ONC/ENDOCRINE/ SURGERY)125
-
✅F3 (PEDS/PREGNANCY/REPRO/UROLOGY/BREAST)169
-
✅F4 (PSYCH/EYE/DERM/BIOSTAT/TOX/Rx)40
-
✅Surgery277
-
✅Infectious Disease151
-
Pulmonary135
-
renal112
-
CARDIOLOGY217
-
Gastrointestinal141
-
✅Hematology/Oncology166
-
psYchiatry223
-
Rheumatology / Orthopaedic141
-
DM & Endocrine105
-
✅NEUROLOGY371
-
✅Derm52
-
Biochem/Rx/Optho67
-
Pregnancy & Child Birth377
-
✅PEDS95
-
Tox7
