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1
Q

Basic principles of medical ethics?

A

Autonomy - right of choice
Beneficence: promote health/welfare
Nonmalficene: do no harm
Justice: equal service to everyone.

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2
Q

What are considerations for sterilization in women

A

respect for reproductive autonomy
- pre-sterilization counseling: include LARCs
- discuss male sterilization: safer and higher efficacy

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3
Q

What is transgender?

A

Someone’s gender identity aligns/differs from sex assigned to them at birth.

Gender dysphoria: distress/impairment associated w/ incongruence between internal sense of gender and primary/secondary sex characteristics.

preventative healthcare: cancer screening, contraception, family planning/fertility, routine screenings.

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4
Q

What are cancer screening recs in transgender patients?

A

TRANSMASCULINE:
- cervical, breast screening. NOT endometrium

TRANSFEMININE
- need breast after age 50 and 5+ yrs estrogen use. NEED prostate screen.

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5
Q

What is gender affirming hormone therapy?

A

Testosterone
- transmasculine. oral/IM/implant/transdermal
- contraindications: pregnancy, polycythemia, unstable CAD
- risks: incr triglycerides, low HDL

Estrogen: transfeminine
- oral/IM/transderma.
incr risk vTE, gallstones, incr triglycerides and lFTs.

Anti-androgen (spironolactone)
- transfeminine
-oral/IM/implant.
- avoid if: hyperkalemia, Addison’s disease.

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6
Q

How do you perform an oophoropexy?

A

Do it if you’ve had multiple torsions and lost ovary on other side.
Suture placed in utero-ovarian ligament and attach it to uterosacral ligament. It shortens the length of utero-ovarian ligament to decrease risk of torsion.

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7
Q

How would you manage a history of LE DVT in pregnancy?

A

If unprovoked -> treat.
If provoked, consider. If provoked was estrogen-related (OCP, pregnancy) -> prophylactic lovenox/UFH. If specific provoking factor (surgery, trauma immobility) -> don’t treat!

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8
Q

What is management of positive thrombophilia workup but no history of DVT in pregnancy?

A

High-risk thrombophilia: factor v leiden homozygote, protein G homozygote, antithrombin deficiency –> prophylaxis or intermediate dose LMWH/UFH

Low-risk thrombophilia; Factor 5 leiden heterozygote, prothrombin G heterozygote, protein CS or S deficiency, APL antibody: don’t treat!

Only prophylaxis if fam hx or prior DVT

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9
Q

What is management of hepatitis B in pregnancy?

A

Test for HCV, hepatitis A, hepatic function panel w/ LFTs. Inquire about immunization.

Could be chronic or acute.
Need core antibody. If positive, prior exposure. If neg, vaccination.
What would you see in chronic carrier state: +HBsAg and neg HBsAb. HBVcore is secondary to infection (NEVER IMMUNIZATION).
Prevalence of chronic HBV is 0.8% in pregnancy

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10
Q

What is workup of hep B in pregnancy?

A

HBV viral load in 3rd trimester. If >200K, need antiretroviral tx (Tenofovir 300mg/d until delivery. Lamivudine if used as single agent.

What precautions would you take during labor process? Avoid operative delivery and FSE.

Breastfeeding? Yes.

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11
Q

What is PMS/PMDD?

A

PMS occurs in 20-30%, PMDD in 2-5%
- pathophysiology unknown. 2/2 normal fluctuations in estrogen/progesteroen. ddx of exclusion.

PMS: physical/mood sx occur during gluteal phase and resolve shortly/yduring menstruation.
PMDD: type of depressive disorder.

ddx: pt report of symptoms most cycle of preceding year and 2 months of prospective symptom recording.
- sx present during luteal phase and 1st few days of menses. if sx present throughout cycle, consider mood disorder.

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12
Q

What is diagnosis of PMDD?

A

1+ of following:
- marked affective lability (mood swings)
- marked anger
- depressed mood
anxiety/tension

1+ or following to reach total of 5 sx:
- decreased interest in activities
concentration
nletheragy
changes in appetite
- hyeprsomnia/insomnia
- overwhelmed
- physical sx (breast tenderness)

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13
Q

What is treatment of PMDD?

A
  • SSRI: during luteal phase or continuousy
  • combined OCPs
  • GnRH agonist w/ add-back for severe sx
  • CBT
    -exercise
  • calcium supplementation 100-1200mg /day
  • Acupuncture
    NSAIDs
    -patient education
    -surgery w/ bilateral oophorectomy with/without hyst ONLY when me management failed.
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14
Q

What is hormone replacement therapy?
What are the risks?
When to use it?

A

Used for treatment of mod-severe vasomotor sx
- Low dose E: 0.025mg/q estradiol patch or 0.5mg oral E2
- transdermal estrogen (little to no VTE risk)
- oral estrogen (prothrombotic effect, incr VTE risk)
- oral progesterone (no incr VTE, no decrease in HDL)

  • VTE
  • breast cancer
  • no cardio protectiction (maybe if started close to menopause)

Use if :
- < 10 yrs from menopause
< age 60
- if symptomatic and no contraindications (Screen for CVD and breast cancer risk)
*don’t discontinue at age 65 IF pt still symptomatic).

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15
Q

What are contraindications to HRT?

A

Pregnancy
Breast cancer
estrogen sensitive tumor
undiagnosed vaginal bleeding
severe liver disease
hx DVT/thrombophilia
Coronary heart disease
- CVA/TIA

  • HTN, smoking, migraine w/ aura are NOT contraindications but transdermal estrogen preferred.
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16
Q

What are the benefits of HRT?

A
  • reduces osteoporosis progression/slows bone loss
  • alleviates VMS
  • improved memory and sleep
  • can improve urinary incontinence
  • less dyspareunia
  • NOT cardioprotective
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17
Q

What was WHI design?

A
  • enrolled 27K women into 3 arms: placebo, combination HT or continuous estrogen.
  • primary outcome: CHD | adverse outcome: invasive breast Ca
  • mean age 60
  • women <50 excluded, severe VMS excluded, avg BMI 28
  • 50% were smokers
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18
Q

What are takeaways from WHI?

A

-individualize therapy
- lowest dose for shortest duration possible
- DO NOT USE of prevention of heart disease, strokes or dementia
- use for tx menopausal VMS, vaginal dryness, prevent early osteoporosis bone loss.

  • localized estrogen: Premarin vaginal vream. not same contraindications as systemic HRT.
  • ## avoid in breast cancer pts on aromatase inhibitors
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19
Q

What were WHI results for combination HRT and estrogen-alone?

A

combination: + benefit for bone fracture reduction and colon cancer prevention
- no benefit for heart disease, breast cancer, stroke/PE prevention

ESTROGEN ALONE:
- CHD occurred less than in placebo
- more strokes
- less invasive breast cancer
- less fracture

20
Q

What are non-hormonal alternatives for VMS?

A

SSRI and SNRI (paroxetine- FDA approved), fluoxetine, venlafaxine.
- avoid proxetine/fluoxetine if on tamoxifen

Gabapentin
Clonidine
Progestins (incr breast Ca risk, use for endometrial protection only)
Vitamin E

21
Q

What is bioidentical hormone therapy?

A

plant-derived hormones.
- ONLY FDA approved ones should be used:
- micronized progesterone, estradiol, DHEA

22
Q

What is headache classification?

A
  1. Migraines w/o auras: unilateral, pulsatile, aggravated by routine activity, mod/severe pain. AND N/V, photophobia.
  2. Migraines w/ aura: reversible aura sx, HA follows aura w/ sx-free interval of < 60 min.
  3. Tension HA (most common): mild-mod dull aching, pressure across forehead, sides and back. tenderness in neck and shoulder muscles.
  4. Cluster hA: rare. intense pain around 1 eye/side. can lasts weeks-months.

Aura: visual, sensory (pins/needles), speech, motor (Weakness). last less than 1 hr.
- POSITIVE: visual, auditory, somatosensory, motor
- NEGATIVE: loss of vision, hearing, ability to move part of body.

23
Q

What is IBS?

A

functional disorder of GI tract assoc w/ chronic abdominal pain nd altered bowel habits. common cause of CPP.

Rome criteria: 2 or more at least 1/day week in last 3 months
- related to defecation
- associated w/ change in stool frequency
- associated with change in stool form.

24
Q

What is workup of IBS?

A
  • r/o other GI: diverticulosis/itis, H. Pylori, IBD, intestinal ameba

eval: H&P, CBC, fecal calprotectin or lactoferrin, stool test for giardia, serologic test for celiac, if constipation dependent Abdominal Xray

Management: dietary (fiber, low FODMAP diet, consider lactose intolerance, eat gluten-free foods).

25
Q

What are causes of infectious diarrhea?

A
  • Food poisoning: salmonella, norovirus, campylobacter, E. coli, listeria
  • Traveler’s diarrhea: E. coli. abx if sx severe or >10d (azithro)
  • Giardiasis: protozoa, watery diarrhea, malabsorption, bloating flatulence. ddx: fecal exam for trophozoites. tx=tinidazole
  • Bloody diarrhea: campylobacter jejune. Enterohemorrhagic E. coli 2/2 undercooked meats. Shigella. C. Diff.
26
Q

What are recommendations for obesity in pregnancy?

A
  • cfDNA assoc w/ lower fetal fraction/test failure. offer US and diagnostic testing.
  • incr Antenatal surveillance: weekly APT at 34w (BMI 40+), 37w for BMI 35-39.

Obesity class 1 30-35
class 2 35-40
class 3 >40

27
Q

What is counseling for obese pregnant patients?

A
  1. Preconception - weight reduction, maternal/fetal risk discussion
  2. Prenatal care - scree for OSA and DM at IPV, refer to sleep medicine if suspect OSA. nutrition consult, weight gain
    - 15-25lbs for BMI 25-29
    - 11-20 lb BMI 30+
    - nutrition deficiencies if bariatric surgery (B12, iron, folate, Ca)
    - delivery (anesthesia consult - intubation difficulty, epidurall failure risk), longer labor, higher VBAC failure, incr PPH, incr risk CS (wound breakdown, DVT
28
Q

If needle injury in OR, what is workup?

A

concern for HIV, Hepatitis B and C
Both the patient source and the surgeon need to be tested initially.
The affected surgeon should then be retested for HIV in 3 and 6 months.
He can be treated prophylactically with anti-retroviral agents.

29
Q

What is the most common cause of cancer death in US women?

A

descending order
- Lung
- Breast
- Colon
- Pancreas
- Ovary

30
Q

What are Schiller Duval bodies associated with?

A

Endodermal sinus tumor (yolk sac)

31
Q

What are components of a time out during surgery?

A

correct patient
correct side
correct anatomical location/procedure
consent signed, correct pt position
all necessary images
Antibiotics required yes/no
review of allergies

32
Q

What are absorbable sutures?

A

Vicryl, monocryl, PDS

33
Q

What are non-absorbable sutures?

A

Nylon, prolene, silk

34
Q

What are monofilament sutures?

A

PDS, monocryl, nylon, prolene

35
Q

What are multi-filament sutures?

A

Vicryl, silk

36
Q

What are considerations before going to OR for hyst?

A
  • know indication for procedure, anatomy (i.e. mass, malignancy), consider approach (TVH, TAH)
  • consider alternative options (medication) and discuss w/ pt
  • know pt’s age, BMI, comorbidities, medical hx, allergies. Optimize medications, diabetic control, hTN.
  • review pre-op labs and imaging
  • consider pre-op consults: anesthesia, gyn onc
  • review informed consent
  • arrange pre-op abx, DVT ppl, bowel prep.
37
Q

What is management after needle stick injury?

A
  • clean w/ soap, water and alcohol-based agent.
  • serologic test for HIV, HBV, HCV on both physician and patient
  • if pt hIV pos, determine VL, tx hx.
  • if pt HIV status unknown, start PEP while waiting results
  • PEP: start within 1-2hrs exposure. risk of contracting HIV is 3/1000 without ppx.

PEP: 3-drug HAART (tenofovir + emtricitabine + dolutegravir) or tenofovir + emtricitabine + raltegravir of childbearing bc dolutegravir incr risk NTD.
- tx for minimum 4 weeks.

HIV screening of physician with rat testing at 6 weeks and 4 moths post exposure.

38
Q

What is differential diagnosis for post-op profuse vaginal bleeding and hypotension after TVH/TAH?

A

Intra-peritoneal hemorrhage
Retro-peritoneal hemorrhage
Compression of IVC from expanding hematoma
- intra-op MI or PE

  • asses airway/breathing, VS, level of consciousness, degree of pain.
39
Q

Describe differential for post-op atelectasis vs pneumonia

A

Atelectasis: no sx or SOB. Can have fever, secretions. presents up to POD2

PNA: infix (F, WBC, purulent sputum, hypoxemia) and infiltrate on CXR

Differential:
- atelectasis
- peri-op intravascular fluid overload
- PNA
- exacerbation from existing URI
- unrecognized asthma/exacerbation
- peri-op MI
- CHF or fluid overload from renal dz
- PE or pneumothorax.

40
Q

What is standard deviation?

A

1 SD=68% of population (confidence limits)
2 SD=96% of population
3 SD=99% o population.

41
Q

What is sensitivity?

What is specificity?

A

ability to correctly diagnose disease: true pos/ (True pos + false neg)

ability to correctly exclude disease: true neg/ (true neg + false pos)

42
Q

What is positive and negative predictive values?

A

PPV: probability that a positive result is correct
= true pos (true pos + false pos)

NPV: probability that a negative result is correct
= true neg/ (true neg + false neg)

43
Q

What is incidence vs prevalence?

A

incidence=# new cases over specific period of time
prevalence=# cases at a given point in time

44
Q

What is management of Bartholin abscess?

A

small abscess <3cm, I&D, sits bath
large abscess, I&D with word catheter.

  • keep word catheter for 4-6wks to allow permanent opening to develop.
  • if word falls out, can do marsupialization.
  • if >40, can consider excision or biopsy to r/o adenocarcinoma.
45
Q

how to counsel trans masculine patient taking gender-affirming testosterone therapy for 6 mo who still has bleeding?

A
  • common concern
  • majority of pts have elimination of bleeding by 18 months
  • history: sexual activity
  • workup: transABDOMINAL US (anatomic causes), B-HCG
  • counseling: bleeding profiles can differ, confirm need for contraception (amenorrhea 2/2 testosterone is NOT reliable contraception), discuss fertility, family planning.

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