Step 2 OB/GYN Flashcards
What are some of the first physical signs of pregnancy and around what time do you see them? (Specifically, ‘named’ findings)
Goodell Sign = softening of the cervix [4 weeks]
Chadwick Sign = blue discoloration of the cervix and vagina [6 - 8 weeks]
Hegar Sign = softening and increased compressibility of the lower uterine segment [6 weeks]
Ladin Sign = softening and increased compressibility of the middle uterine segment [6 weeks]
Telangiectasia / Palmar Erythema = [1st Trimester]
Chloasma / Melasma = “the mask of pregnancy”, can worsen in the sun [2nd Trimester]
Linea Negra = hyper pigmentation of abdominal midline skin [2nd Trimester]
Describe how the levels of B-HCG change throughout pregnancy per trimester
B-HCG initially doubles every 48 hrs for the first 4 weeks, peaking at 10 weeks
B-HCG falls a little during the 2nd Trimester
B-HCG rises again in the 3rd Trimester to 20,000 - 30,000
At what level of B-HCG should a gestational sac be visualized per U/S? At what week GA should a gestational sac be visualized per U/S?
Gestational sac is visible at a B-HCG level of 1,500 and/or GA 5 weeks
What hormones cause the nausea and vomiting experienced in early pregnancy?
Progesterone, Estrogen, and B-HCG
Describe the physiologic renal changes in pregnancy. What are pregnant patients more at risk of in regards to renal infections?
Increased GFR 2/2 to plasma volume increase; decreased BUN & Creatinine levels (therefore, higher end of normal values would most likely indicate renal disease). Pyelonephritis is a greater risk 2/2 to enlarging uterus capable of impinging on ureters and obstructing system with elevated plasma filtrate. Mild gycosuria and proteinuria = NL.
Describe the changes regarding PT/PTT/INR, fibrinogen, and venous levels in pregnancy
No change in PT/PTT/INR; increase in fibrinogen; increased venous stasis = Virchow’s Triad contributors, therefore more coagulable state
Abnormal MSAFP levels can be 2/2 to…
1) Dating error (MCC)
2) NT Defect
3) Abdominal Wall Defect
4) Multiple Gestations
What are spontaneous contractions that DO NOT result in cervical changes called? Should we worry about them?
They are called “Braxton-Hicks Contractions” and are not worrisome UNLESS they start becoming regular vs Normal contractions that are regular and q3min.
What level of Hgb should you replace Fe orally? What else do you want to give to a pregnant patient regarding her Fe supplements?
Hgb < 11. Give stool softeners when prescribing oral Fe b/c it can exacerbate pregnancy’s already constipating state
What are the RF’s for an ectopic pregnancy?
Previous ectopic pregnancy (MC), IUD, hx of PID/infxn
How does Methotrexate (MTX) work in the medical treatment of ectopic pregnancies? What contraindications exist for Methotrexate prescription?
MTX is a folate-receptor antagonist. Contraindications include: immunodeficiency, unsure f/u, hepatotoxicity, large ectopic preg (>3.5 cm), or auscultated fetal heart sounds (b/c larger size increases likelihood of MTX failure)
How do you treat an infected uterus with retained products of conception?
Treat a septic abortion with Methotrexate or Levofloxacin for antibiotic coverage and D/C to evacuate the products of conception
What are the complications of a multiple gestation pregnancy?
1) Spontaneous abortion of one of the fetuses
2) Premature labor
3) Placenta previa
Don’t stop a woman’s contractions that are regular, causing cervical dilation, and happening before 37 weeks if there is…
1) preeclampsia/eclampsia
2) maternal cardiac disease
3) cervical dilatation > 4cm
4) maternal hemorrhage
5) fetal death
6) chorio
With these situations, head straight to delivery (attempt vaginal if no contraindications)
What are the side-effects of the following tocolytics: Mg Sulfate, CCB’s, and B-Adrenergic Agonists (Terbutaline)?
Mg Sulfate - (common) flushing, HA, diplopia, fatigue (serious) respiratory depression and cardiac arrest [CHECK DTR’s!!!]
CCB’s - dizziness, flushing, HA
Terbutaline - increased HR leading to palpitations, hypotension
How do you treat the following types of abortions:
1) Complete Abortion
2) Incomplete Abortion
3) Inevitable Abortion
4) Threatened Abortion
5) Missed Abortion
6) Septic Abortion
1) Complete Abortion - f/u in office and check B-HCG serially to zero
2) Incomplete Abortion - D&C / Medical
3) Inevitable Abortion - D&C / Medical
4) Threatened Abortion - bed rest and pelvic rest
5) Missed Abortion - D&C < 14 wks, attempt labor induction if > 14 wks
6) Septic Abortion - D&C and IV Levofloxacin or Metronidazole
What information do you need to manage preterm labor? How do you manage it?
Need to know the GA, the weight of the fetus, and the presenting part.
If GA 24 - 33 and Wt is 600 - 2,500 g = tocolytics and steroids
If GA 34 - 37 and Wt is >2,500 g = deliver
What are the possible complications of PROM?
Cord prolapse, preterm labor, chorio, and placental abruption
What three factors help you determine the management plan for PROM? How do you manage PROM?
Need to know: GA, Chorio +/-, and presence of PCN allergy
If Chorio is + = deliver now
If Chorio is - and GA is term = wait for spontaneous labor for 6-12 hours; if it doesn’t occur, induce
If Chorio is -, GA is preterm, and no PCN allergy = Betamethasone, Tocolytics, and Ampicillin and Azithromycin (use Cefazolin in place of Ampicillin for low risk of anaphylaxis if PCN allergy, or Clindamycin for high risk of anaphylaxis)
What would you suspect a patient to have with painless bleeding? What do you NOT do with this pt?
Placenta Previa - DO NOT do a bimanual or transvaginal U/S, use transabdominal U/S instead
If a patient has painless bleeding, you would head to immediate C-Section if…
[Placenta Previa}
Immediate C-Section if cervix > 4cm, severe hemorrhaging has occurred, or fetal distress
What other placenta pathology is associated with placenta previa?
Placenta accreta
What are the different types of placenta previa?
1) Complete - placenta covers the internal os totally
2) Partial - placenta covers some of the internal os
3) Marginal - placenta is adjacent to the internal os
4) Low-Lying - placenta is b/w 0 - 2 cm from the internal os
5) Vasa Previa - placenta vessels travel across the internal os
What RF’s could lead someone to have painful vaginal bleeding? What could this condition cause?
[Placental Abruption]
RF’s = Hypertension, Previous Placental Abruption, Cocaine Use, External Trauma, Maternal Smoking, Polyhydramnios with rapid decompression 2/2 ROM, PROM
Complications = hypovolemic shock, uterine tetany, DIC, premature delivery
What type of placental abruption is most likely to cause a completely detached placenta and possibly postpartum hypopituitarism (Sheehan’s Syndrome)?
Concealed Placental Abruption
When is it okay to attempt a vaginal delivery in the setting of a placental abruption?
If the FHR and tracing is okay, there is minimal detachment, or if there is extreme detachment and fetal death has already occurred
What are the RF’s for a woman who experiences extreme pain during delivery?
[Uterine Rupture]
RF’s = myomectomy, trauma, overdistension of the uterus 2/2 to Polyhydramnios or Multiple Gestations
How do you deliver in the setting of a uterine rupture?
Via laparotomy, NOT C-Section…fetus could be “floating” in the abdomen
What are the indications for a C-Section in the setting of Placental Abruption?
Uncontrollable hemorrhage, rapidly expanding concealed hemorrhage, fetal distress, or rapid placental separation
Hemolytic disease of the newborn can cause _______ and ________. Hemolysis results in increased serum levels of ______ and ______. Why are we worried about this? What end-disease can occur due to the aforementioned?
1) Fetal Anemia
2) Extramedullary Production of RBC’s (Liver/Spleen)
3) Heme
4) Bilirubin
Bilirubin can be neurotoxic; Erythroblastosis Fetalis is characterized by high CO and an end result 2/2 to hemolytic disease in the newborn.
What defines IUGR? What are the two different types and their respective etiologies?
IUGR = fetal weight in the bottom 10% for it’s GA.
1) Symmetrical - (occurs before 20 wks) 2/2 congenital infections, drugs, or chromosomal abnormalities
2) Asymmetrical - (occurs after 20 wks) 2/2 placental insufficiency, poor maternal health, or multiple gestations
What weight defines fetal macrosomia? What do you expect to be off in the routine check-up? What’s the next best test to confirm? And, how do you manage delivery?
Fetal macrosomia = 4500 g (about 10 lbs). Fundal height discrepancy relating GA (>3cm diff). Order an U/S to assess femur length, biparietal diameter, and abdominal circumference). Consider delivery of the fetus BEFORE it reaches 4500 g IF fetal lungs are mature. If it reaches 4500 g, do a C-Section
Define a “reactive” Non-Stress Test (NST). What do you do if it’s “non-reactive”?
Within a period of 20 min, the fetus has two accelerations that are >15 beats above FHR baseline that lasts for >15 seconds.
If non-reactive, do vibroaccoustic stimulation of the fetus b/c it might just be sleeping =)
Define the Stages of Labor and the expected timeframe for Primips and Multips.
Stage 1 [encompasses both latent and active phase] (P = 6-20hrs and M = 2-14hrs)
1) Latent Phase = 0-4cm cervical dilation (P = 6-7hrs and M = 4-5hrs)
2) Active Phase = 4cm - full dilation (P = 1.2cm/hr and M = 1cm/hr)
Stage 2 [full dilation to delivery of the fetus] (P = 30min-3hrs and M = 5-30min)
Stage 3 [delivery of the fetus to delivery of the placenta] (Everyone = 30 min)
Stage 4 [delivery of placenta to maternal stabilization] (up to 48 hrs)
What are the Cardinal Movements during vaginal delivery?
Engagement - Descent - Flexion - Internal Rotation - Extension - External Rotation - Delivery of Anterior Shoulder
What if you have a woman who hasn’t dilated beyond 4cm for more than 20 hrs as a Primip or 10 hrs as a multip, what is this called? What is it from? How to you manage these patients?
This is called “Prolonged Latent Phase”. Likely 2/2 sedation, uterine dysfunction, unfavorable cervix, etc (check to see if the patient has had normal SVD before in the past!). Rest and hydrate = treatment.
What is it called when a Primip or Multip is taking more than 1 hour to dilate 1.2cm or 1cm, respectively, in the active stage of labor? What is the likely etiology?
Prolonged Cervical Dilation - thinks of the “3 P’s” = Power, Passage, Passenger.
What is it called when the fetus fails to descend for more than 1 hr or when the cervix fails to dilate for more than 2 hrs? Was it it from most commonly?
Arrest of Fetal Descent and Cervical Arrest - likely 2/2 to CPD.
Mgmt: assess whether abnormal lie or CPD is present, if not labor augmentation is acceptable (oxytocin, prostaglandin), and continue with expectant management unless signs of fetal distress occur, then C-Section
At what GA can you consider doing external cephalic rotation with a malpresenting fetus?
GA 36
What are the risk factors for having a post partum hemorrhage >500 mL (SVD) or >1L (CS)?
Overdistension of the uterus (multiple gestation), anesthesia, prolonged labor, laceration, retained placenta, coagulopathy. MCC = uterine atony (within 24hrs of delivery)
How do you manage patients with PMS or PMDD? What are the diagnostic criteria? What if it’s severe?
Tell them to chart their symptoms. Need to be symptom free in the first week of follicular phase, symptomatic in the last week of the luteal phase, have it occur for at least 2 cycles…dysfunction in life occurs with PMDD.
Treatment = decrease caffeine, alcohol, chocolate, and cigarettes. Add exercise. Can give SSRI’s for severe cases
What is the diagnostic test of choice for menopause? What are contraindications for HRT?
FSH elevation. HRT is contraindicated in patients with previous DVT, if they smoke, PE, or estrogen dependent carcinoma of the breast or uterus.
What do you have to check for before diagnosing someone with Dysfunctional Uterine Bleeding (DUB)?
Since it’s a diagnosis of exclusion, check for hypothyroidism and hyperprolactinemia.
What do OCP’s decrease a woman’s risk of? What do they increase their risk of?
Decrease risk of ovarian carcinoma, endometrial carcinoma, and ectopic pregnancy. Increased risk of thromboembolism and cervical cancer (possible confounding with increased # of sexual partners)
What should you obtain before placing an IUD?
Genital cultures b/c they’re associated with PID
What is the MCC of labial fusion?
21-B Hydroxylase Deficiency causing an excess of androgens.
Which epithelial abnormality involving the vulva…
1) Is a risk for cancer?
2) Can involve other systemic parts of the body (mouth, arms, legs)?
3) Has a significant hx of pruritus with raised white plaques and is treated with Sitz Bathes or Lubricants?
1) Lichen Sclerosus - get punch bx - treat with steroids
2) Lichen Planus - violet patches - treat with steroids
3) Squamous Cell Hyperplasia
What are Amsel’s Criteria? How do you treat for this vaginitis?
Amsel’s Criteria:
1) pH > 4.5
2) Thin, watery grey discharge
3) Fishy, amine odor with KOH
4) Clue Cells (bacteria localized to border of squamous cells)
Treat with Metronidazole or Clindamycin
*FYI - Bacterial Vaginosis does not have “vaginitis” in the name so you rarely see inflammation or erythema in the vagina.
What is the most common non-viral STI that causes frothy green d/c and visible motile flagellates on wet mount?
Trichomonas Vaginitis - treat with Metronidazole and also treat the partner!
Which vaginitis has a normal pH?
Candidiasis - treat with Miconazole, Econazole, Clotrimazole, or Nystatin
What physical characteristics distinguishes Paget’s Disease from Lichen Planus?
Paget’s Disease has a red lesion, like LP, but it also has a white superficial covering of the lesion. Bx is needed regardless.
How do you diagnose Adenomyosis? What’s the most accurate test? What’s the only definitive treatment?
It’s a clinical diagnosis! Large, globular, and boggy uterus. MRI is the most accurate test. Hysterectomy is the only definitive treatment.
How do you manage a patient with Endometriosis?
Mild symptoms = NSAIDS or OCP’s
Moderate symptoms = Danazole (androgen) or Leuprolide (continuous GnRH agonist)
Severe = Surgical removal of implanted sites
Describe the relationship b/w FSH and LH on the Theca and Granulosa cells.
LH acts on the Theca cells to produce androgens while FSH acts on the Granulosa cells to use the androgens made and convert them to estrogen via aromatase
Describe the Pathophys of PCOS
Why LH is elevated is unknown. But hyperinsulinemia has been attributed to both genetic predisposition and DM RF’s. The elevated levels on insulin cause a decrease in Sex Hormone Binding Hormone (SHBH) which contributes to elevated androgen levels and free Testosterone. These elevated hormones cause anovulation.
How can you treat PCOS patients who want children and don’t want children?
Start off first with weight loss, and then can add OCP’s for those not wanting children. You can use Clomiphene and Metformin for those wanting to become pregnant.
What is the diagnostic criteria for PCOS?
Rotterdam’s Criteria: (need 2 of 3)
1) Clinical or lab evidence of hyperandrogenism (hirsutism, acne)
2) Oligo or Anovulation
3) Polycystic ovaries
* DO NOT have to be obese
* * Hyperinsulinemia can work on Insuling Like GF Receptors and cause epithelial growth and maturation resulting in Acanthosis Nigricans
What are two rare causes of postern pregnancy?
Placenta Sulfatase Deficiency (resulting in Icythiosis, cracked skin) and Anencephaly
When is MSAFP MOST accurate?
GA 15 - 20
What do you do initially if the MSAFP is abnormal? If it’s still abnormal after step 1, what are the following steps?
1) Retest b/c 30% false positive rate
2) U/S
3) Amniocentesis (looking for elevated AFP in amniotic fluid or acetylcholinesterase)
When is the only time you consider giving Aspirin in pregnancy?
If they have Antiphospholipid Syndrome; sub-q heparin or LMWH can also help
What GA would you consider inducing labor with a potential post term pregnancy?
GA 41 wks
What are the two different types of Hydatiform moles? How are they characterized? How are they treated? What does their f/u consist of?
1) Complete = XX (soley from Dad) - no fetal parts
2) Incomplete/Partial = XXY - some fetal parts
Treatment = D&C for both kinds, and monitor B-HCG after until it trends to 0; if not, could be invasive mole or choriocarcinoma (treat with Methotrexate or Dactinomycin chemotherapy = good response)
What are some warning signs of molar pregnancy?
1) Preeclampsia before the 3rd Trimester
2) Rapidly rising B-HCG level or failure for it to zero-out s/p delivery
3) First or Second Trimester bleeding with the expulsion of grape-like from the vaginal introitus
What and when is the Triple Screen and Quadruple Screen used?
Triple Screen (NT, PAPP-A, and B-HCG) done during the first trimester (10-13 wks)
Quadruple Screen (AFP, B-HCG, uE3, inhibin A) done during second trimester (15-18 wks)
When do you offer CVS vs. Amniocentesis in a woman with a positive screening test?
Offer CVS in the first trimester and amniocentesis in the second. You want to basically get the karyotype. CVS>Amnio in terms of causing abortions.
What teratogenic agent can cause: phocomelia (absence of long bones and flipper like hands)
Thalidomide
What teratogenic agent can cause: yellow or browning of teeth
Tetracyclines
