Step 2 OB/GYN Flashcards
ACE-I –> what birth defects?
fetal renal tubular dysplasia and neonatal renal failure, oligohydraminos, IUGR, lack of cranial ossification
Alcohol–> what birth defects?
FAS (groweth restriction before and after birty, mental retardation, midfacial hypoplasia, renal and cardiac defects), consmption of >6 drinks/day is associated with a 40% risk of FAS
Androgens–> what birth defects?
Virilization of female fetuses, advanced genital development in male fetuses
Carbamazepine–> what birth defects?
Neural tube defects, fingernail hypoplasia, microcephaly, developmental delay, IUGR
Cocaine–> what birth defects?
Bowel atresia; congenital heart malformations, limbs face and GU tract malformations, microcephaly, IUGR, cerebral infarctions
DES–> what birth defects?
Clear cell adenocarcinoma of vagina or cervix, vaginal adenosis, abnormalities of the cervix and uterus or testes, possible infertility
Lead –> what birth defects?
SAB and stillbirths
lithium–> what birth defects?
Congenital heart disease (Ebstein anomaly)
Methotrexate –> what birth defects?
increased rate of spontaneous abortions
Organic Mercury –> what birth defects?
Cerebral atrophy, microcephaly, mental retardation, spasticity, seizures, blindness
Phenytoin –> what birth defects?
IUGR, mental retardation, microcephaly, dysmorphic craniofacial features, cardiac defects, fingernail hypoplasia
Radiation –> what birth defects?
Microcephaly, mental retardation, medical diagnostic radiation delivering < 0.05 Gy to the fetus has no teratogenic risk
Streptomycin and kanamycin
hearing loss; CN VIII damage
Tetracycline–> what birth defects?
Permanent yellow-brown discoloration of deciduous teeth; hypoplasia of tooth enamel
Thalidomide –> what birth defects?
Bilateral limb deficiencies; anotia and microtia, cardiac and GI abnormalities
Trimethadione and paramethadione
Cleft lip and palate, cardiac defects, microcephaly, mental retardation
Valproic acid
NTDs (spina bifida), minor craniofacial defects
Vitamin A and derivatives
Increased rate of spontaneous abortions, thymic agenesis, cardiovascualr defects, craniofacial dysmorphism, microphthalmia, cleft lip or cleft palate, mental retardation
Warfarin
Nasal hypoplasia and stippled bone epiphyses, developmental delay, IUGR, opthalmologic abnormalities
TORCHeS: “T” Transmission, Sx, Dx, Tx
Toxoplasmosis: Transmission: Primary transplacental infection via contact w cat poo or raw meat.
Sx: Hydrocephalus, intracranial calficications, chorioretinitis, ring-enhancing lesions on MRI
Dx: Serologic testing
Tx:Pyrimethamine + Sulfadiazine
Spiramycin ppx during third trimester
TORCHeS: “R” Transmission, Sx, Dx, Tx
Rubella: Transmission: Transplacental during first trimester
Sx: Purpuric “blueberry muffin” rash. Cataracts. Mental retardation. Hearing loss. PDA.
Dx: Serologic testing
Tx: symptomatic
If mother remains sero negative, vaccinate after delivery
TORCHeS: “C” Transmission, Sx, Dx, Tx
CMV: Transmission: Primarily transplacental.
Sx: periventricular calcifications and petechial rash.
Dx: Urine culture PCR of amniotic fluid
Tx: Postpartum ganciclovir
TORCHeS: HIV Transmission, Sx, Dx, Tx
HIV Transmission: in utero, at delivery or via breast milk
Sx: often asx. Neonate=FTT, frequent bacterial infections, increased incidence of upper and lower respiratory disease.
Dx: ELISA, Western blot
Tx: HAART
Notes: AZT or Nevirapine in pregnant HIV+ ppl
if viral load is >1000, perform C-section. Infants should receive prophylactic AZT
TORCHeS: HSV Transmission, Sx, Dx, Tx
HSV: Transmission: Intrapartum transmission if the mother has active lesions; transplacental transmission is rare.
Sx: skin, eye, and mucosal infections
Life-threatening CNS infxn
Dx: Serology
Tx: Acyclovir
If lesions present at delivery, perform C-section
TORCHeS: “S” Transmission, Sx, Dx, Tx
Syphilis: Transmission: Intrapartum; translplacental transmission is possible.
Sx: Maculopapular skin rash, lymphadenopathy, hepatomegaly, “snuffles” (mucopurulent rhinitis), osteitis. Late congenital syphilis includes: saber shins, saddle nose, CNS involvement, Hutchinsion triad (peg-shaped incisors, deafness, interstitial keratitis).
Dx: Darkfield microscopy. CDRL/RPR, FTA-ABS
Tx: PCN
OK to give PCN to pregnant women
What is a biophysical profile? What are the 5 parameters?
Test the Baby, woMAN! fetal TONE, Breathing, Movement, Amniotic fluid volume, & Nonstress test. all scored 0-2. with 8-10 being reassuring for fetal wellbeing, 0-4 is worrisome for fetal asphyxia. modified BPP is a NST + AFI with NL AFI>5.
What is the first step in the diagnosis of hyperemesis gravidarum?
rule out molar pregnancy w u/s +/- beta-hCG.
In a contraction stress test, is negative good or bad?
A negative CST is good. It is defined as no late or significant variable decels within 10 minutes and at least three contractions. A positive CST is defined by late decels following 50% or more of contractions in a 10 minute window.
What is screening test for GDM? What glucose value is considered abnormal
screening: 1 hour 50 g glucose challenge. abnl is >=140 mg/dL.
confirmatory is 3 hour 100 g glucose challenge. diagnosis is made if any 2 of following occur:
fasting > 95
1 hour > 180
2 hour > 155
3 hour > 140
Keys to the management of GDM?
1) ADA diet; 2) insulin if needed (fasting <95, 1 hr PP<140, 2 hr PP<120), 3) u/s for fetal growth, 4) NST beginning at 34 w if requiring insulin or an oral hypoglycemic
If patient has UA with glycosuria before 20 weeks, is it gestational DM?
No, think pregestational DM. Similarly, hyperglycemia in the the first trimester suggests preexisting DM and should be managed as such.
What is the classic triad of preeclampsia?
Hypertension, Proteinuria, Edema.
Mnemonic: believe the HyPE
What is HELLP syndrome?
HELLP is a variant of preeclampsia with a poor prognosis. It consistes of Hemolytic anemia, elevated Liver enzymes, Low Platelets. Risk factors: nulliparity, POC, extremes of age, multiple gestaiions, molar pregnancy, renal disease,
Is a + contraction stress test (CST) good or bad?
A + CST is bad. + is defined by late decels following 50% or more of contractions in a 10 minute
What is a BPP? What are the components?
A biophysical profile (BPP) uses u/s to test 5 fetal parameters (Test the Baby, MAN!): fetal heart Tones, Breathing, Movement, Amniotic fluid volume, and Nonstress test.
What is screening test for gestational DM and when do you do it?
1 hour 50 g. glucose challenge. values >=140 are abnormal. Confirm w 3 hour 100 g test.
What is a risk of pregestational diabetes and pregnancy? Especially if HbA1c is > 8?
Congenital malformations, fetal loss, and morbiitioy during L+D. If HbA1C>8, investigate!
If pregnant patient has glucosuria before 20 weeks, is it GDM or pregestational DM?
Likely pregestational DM. Hyperglycemia in first trimester suggests preexisting DM and should be managed as such
What are the four anatomical locations to consider during third trimester bleeding?
Vagina: bloody show, trauma
Cervix: cervical cancer, cervical/vaginal lesion
Placenta: placental abruption, placentia previa
Fetus: fetal beeding
Does Rh isoimmunization occur in Rh - or Rh + women? What titer results in close monitoring?
Rh - women are at risk for isimmunization (fetal RBCs leak into maternal circulation and maternail anti-Rh IgG ab’s can then cross placenta leading to hemolysis of feal Rh RBCs (=erythoblastosis fetalis). Dx with Ab titers > 1:16
Diagnostic criteria for postpartum endometritis?
Fever>38 within 36 hours of delivery, uterine tenderness, malodorous lochia
What are the 7 “W’s” of postpartum fever?
(for 10 days post-delivery) Womb - endometritis Wind - atelectasis, PNA Water - UTI Walk - DVT, PE Wound - incision, episiotomy Weaning - breast engorgement, abscess, mastitis Wonder drugs - drug fever
Most common causes of third trimester bleeding?
Placenta previa and placental abrubtion
Classic u/s and gross appearance of complete hydatiform mole?
snowstorm on u/s & cluster of grapes on gross exam
What is the chromosomal pattern of a complete mole
46, XX
What type of molar pregnancy is it if it contains fetal tissue?
partial mole
Symptoms of placental abruption?
Continuous & Painful vaginal bleeding
Symptoms of placenta previa?
self-limited painless vaginal bleeding
When should a vaginal exam be performed with suspected placenta previa?
Never
Antibiotics with teratogenic effects?
Tetracyclines, fluoroquinolones, aminoglycosides, sulfonamides
Medication given to accelerate fetal lung maturity?
betamethasone or dexamethasone x 48 hours
Tx for PPH?
Post partum hemorrhage tx = uterine massage 1st, then oxytocin
Typical abx for GBS ppx?
ampicillin or penicillin
A patient who fails to latate after an emergency C-section with marked blood loss. Dx?
Sheehan syndrome (postpartum pituitary necrosis)
Uterine bleeding at 18 weeks gestation, no products expelled, cervical os open
Inevitable abortion
Uterine bleeding at 18 weeks gestation, no products expelled, cervical os closed
Threatened abortion
First test to perform when a woman presents with amenorrhea?
Beta-hCG
What is the term for heavy bleeding during and between periods
Menometorrhagia
Cause of ameorrhea w/ normal prolactin, no response to estrogen-progesterone challenge and a history of D&C?
Asherman syndrome
Therapy for PCOS?
Weight loss, OCPs, Metformin
Medication used to induce ovulation
Comiphene citrate
Diagnostic step required in postmaenpausal woman who presents with vaginal bleeding
Endometrial bx
Indications or medical treatment of ectopic pregnancy?
Pt stable, unruptured ectopic pregnancy of < 3.5 cm at < 6 weeks gestation
Medical options for endometriosis
OCPs, danazol, GnRH agnoists
Most common location for ectopic?
Ampulla of the oviduct
How to diagnose fibroid?
U/s
A patient has increased vaginal disharge and petechial patches in the upper vagina and cervix. Dx?
Trichomonal vaginitis
Treatment for bacterial vagniosis?
oral metronidazole
Mst common cause of bloody nipple diacharge?
Intraductal papilloma
Contraceptive methods that protect against PID?
OCPs and barrier
Unopposed estrogen is contraindicated in which cancers?
Endometrial or ER + breast cancer
A patient presents with recent PID and RUQ pain. DX?
Consider Fitz-Hugh-Curtis syndrome
Breast malignancy presenting as itching, buring, and erosion of the nipple?
Paget disease
Annual screening for women with a strong fhx of ovarian cancer?
CA-125 and U/s
50 yo leaks urine when lauging. Tx?
Kegels, estrogen, pesary for stress incontinence
30 yo woman has unpredictable urine loss. Exam is nl. Tx?
This is urge incontinence. Tx includes nticholinergics (oxybutynin) or Beta-adrenergics (metaproterenol)
Lab values suggestive of menopause
Increase in FSH
Most common cause of infertility?
Endometriosis
If a patient has 2 consecutive findings of atypical squamous cell sof undertermined significance (ASCUS) on pap cmear, what’s next?
Colposcopy or endocervical curretage
What type of breast cancer increases the futre risk of invasive carcinoma of both breasts?
Lobular carcinoma in situ
What hormone do granulosa-theca tumors tend to secrete?
Estrogen
What hormone do sertoli-leydig tumors tend to secrete?
Testosterone
What are the severe features of preeclampsia?
Systolic >=160, Diastolic >=110, 2 times, 4 hours apart thrombocytopenia increased Cr increased LFTs Pulmonary edema Visual or cerebral changes
If nephropathy or HTN are present before 20 weeks, is it gestational?
NO, pre-gestational diseases exist prior to 20 weeks. LOOK AT DATES
Proliferation of smooth muscle cells within the myometrium? P/D?
Fibroids. Heavy periods, constipation, pelvic pain/heaviness, enlarged uterus (can be like 12 weeks size!)
Endometrial hyperplasia with atypia
progression to endometrial carcinoma. Occurs in postmenopausal women w bleeding. NORMAL size uterus/nontender. Risk factors: obesity, nullparity, chronic anovulation.
Granulosa Cell Tumor. pathogenesis, P/clinical features, histopath, management?
Pathogenesis: sex-cord stromal tumor
Increased Inhibin + Estradiol
P: complex ovarian mass. 2 subtypes: juvenile and adult:
-juvenile: precocious puberty
-adult: breast tenderness, abnl uterine bleeding, post menopausal bleeding
Histopath: Call-Exner Bodies (cells in rosette pattern)
Dx: Endometrial biopsy + surgery for tumor staging
Nl amt of amniotic fluid/AFI?
0.5-2L/AFI 5-25
4 classes of tocolytics and indications for each?
INNT Mag…
Indomethacin - first line, use in <32 weeks
Nifedipine - first line, use in 32-34
Terbutaline (beta-agonist) - short-term for inpt use
Mag
Pt w lupus. Major risk to fetus?
Complete AV Block
A 37 yo G4P4 requests BTL. She has a history of vaginal deliveries. PE shows no abnormalities. This pt is at the greatest risk for which of the following conditions related to BTL: Ectopic pregnancy, endometrial cancer, pulmonary embolus or abscess?
Ectopic pregnancy
Six Risk Factors for Preterm Labor
- Low maternal BMI
- Hx of preterm birth
- Short Interval pregnancy
- Vaginal Bleeding 2/2 Infection (UTI, Peridontal)
- short cervical length < 25 mm
- Prior cervical surgery
What is the threshold of anemia in pregnancy (based on Hb)?
In an iron-replete population, anemia defined as a value less than the fifth percentile is a hemoglobin level of 11 g/dL or less in the first trimester, 10.5 g/dL or less in the second trimester, and 11 g/dL or less in the third trimester.
Increased minute ventilation during pregnancy causes what acid-base change?
Compensated respiratory alkalosis
PFT changes in normal pregnancy?
Inspiratory capacity increases by 15% during 3rd trimester because of increases in tidal volume and inspiratory reserve volume. Respiratory rate does not change during pregnancy, but tidal volume is increased, therefore increasing minute ventilation, which is responsible for the respiratory alkalosis of pregnancy. Functional residual capacity is reduced to 80% of the non-pregnancy volume by term.
Breastfeeding is associated with a decreased risk of what two types of cancer?
Ovarian and breast cancer
What’s the worst type of contraceptives (of the “highly effective” ones) to give a pt who plans to breast feed?
combined OCPs. they decrease milk supply in first 30 days.
Late Decel caused by?
Uteroplacental insufficiency.
Variable decels caused by?
Umbilical cord compression. Oligo can increase the risk of cord compression.
Does prior + GBS necessitate a 35-37 week GBS swab in future pregnancy or do you just treat w intrapartum abx?
Just treat w Ampicillin.
You place an IUPC and 300 cc of frank blood and amniotic fluid flow out of the vagina. What do you do 1) crash c/s 2) remove IUPC, monitor fetus, if reasurring, replace IUPC or 3) keep IUPC in place and connect to tocometer
2) remove IUPC, monitor fetus, if reasurring, replace IUPC . If an IUPC is placed and there is significant vaginal bleeding, there is a possibility of placental separation or uterine perforation.
22 yo G1P0 at 39 w is at 6/90%/-1 and 4 hours later, found to be at 7/90%/-1. Strip is category I. What do you do?
This patient is in active labor but is protracted. she has made 1 cm change after 4 hours. Next step = place IUPC to determine if her contractions are adequate. Without determining adequacy of contractions, it is premature to d do a c/s. Pit augmentation would be indicated if the pt is protracted with documented insufficient power (generally (<240 MVUs) but this has not been determined. Expectant management is not sufficient as she is not making satisfactory progress.
HIV in pregnancy. What meds should mom be on? when?
HAART for antepartum (zidovudine, lamivudine, nevirapine, atazanivir). during delivery: IV zidovudine. Neonate gets zidovudine. C/S can reduce transmission rate in women with VL> 1,000 copies/mL
Among patients with cardiac disease, patients with what diagnosis are at highest risk for mortality during pregnancy?
Pulmonary HTN. 20-50% risk for death. Pts are at greatest risk when there is diminshed venous return and right ventricular filling. Similar mortality rates occur in pts with aortic coarctation w valve involvement and Marfans with aortic involvement.
24 yo G3P2 at 26 weeks found shivering and barely responsive. 2 day hx of cough and back pain, pt has recent dx of GDMA1, VS: 100.2, 160 BPM ,BP 68/32, RR 32/min, O2 82% on RA. On exam, no fundal tenderness, or vaginal bleeding, extremities are cool to the touch. Tenderness w percussion of R back. Fetal heart tones not audible. Lavs: ABCs: 24000, Hb 9.4. Dx?
This pt is in septic shock. The most common cause of sepsis in pregnancy is acute pyelonephritis. Her back pain, tenderness, elevated WBCs, and urinalysis all point to this dx. Given absence of bleeding, picture is not suggestive of placental abruption. Chorioamnionitis and PNA may both lead to sepsis but are not suggested by this clinical picture.
Acute treatment of thyroid storm in pregnancy
PTU (remember, methimazole is teratogenic), propanolol, sodium iodide, and dexamethasone.
DM risk factors? If present, when do you screen prenatally?
Risk factors for DM: BMI> 30, history of GDM in prior pregnancy, known impaired glucose metabolism. You can screen prenatal patitents with a 50 g OGTT at first prenatal visit, followed by diagnostic 100 g OGTT if screening test was positive. You can bypass these and just do a 75 g 2 hour OGTT if you wish to jump to diagnosis.
Infants born to diabetic mothers are at increased risk for what?
macrosomia, hypoglycemia, polycythemia, hyperbillirubinemia, hypocalcemia, and respiratory distress
If you get bloody fluid out from a breast FNA, what’s the next step?
Excisional bx
Twin-twin transfusion syndrome occurs in what type of twinning?
monochorionic. its characterized by an imbalance in blood flow through communicating vessels across a shared placenta leading to underperfusion of the donor twin, which becomes anemic, and often develops oligo and IUGR, while the recipient becomes polycytmeic and may experience volume overload and polyhydraminos that may lead to heart failure and hydrops.
Contraindications to expectant management in severe preE remote from term (<32 w)?
thrombocytopenia < 100,000, inability to control BP with 2 antihypertensives, non-reassuring fetal surveillance, LFTs>2x NL, eclampsia, CNS sx or oliguria.
MVP in pregnancy
MVP systolic ejection murmur w click. most are asx. if sx, use beta-blockers.
Which SSRI is class D in pregnancy?
Paxil/paroxetine b/c increased risk of fetal cardiac malformations and persistent pulmonary HTN.
Tx for uncomplicated varicella in pregnant women?
oral acyclovir 800 mg five times a day x 7 days.
Rh- mom and Rh + baby. What are the ways that mom could get sensitized?
Amniocentesis, CVS, spontaneous/threatened abortion, ectopic pregnancy, D&E, placental abruption, antepartum hemorrhage, preE, C/S, manual placental removal, and external version.
Risk of isoimmunization if Rh- mom and Rh + baby.
Risk of isoimmunization is 2% ante, 7% after full term delivery and 7% w subsequent pregnancy, therefore <20% overall. ~75% of pregnant ppl have e/o transplacental hemorrhage during pregnancy or immediately after delivery but is not usually enough to sensitize a patient.
PDT + Risk factors of intrahepatic cholestasis of pregnancy?
Clinical features: develops in third trimester, generalized pruritis - worse on hands and feet, no assc’d rash, RUQ PN.
Labs: Increased bile acids, LFTs, +/- increase in total and direct billi
OB Risks: IUFD, Preterm, Mec-amniotic fluid, Neonatal respiratory distress syndrome.
Man: Delivery @ 37w, Ursodeoxycholic acid, antihist.
Hep A Immunity conferred by what Ab?
Anti-HAV IgG
Continuous loss of urine (dribbling) due to incomplete bladder emptying (High PVRs). Type of incontinence?
Overflow
