U-World: OB/GYN Flashcards
What does it mean when you palpate the vertex of the fetus at the fundus?
How do you deal with this? (2)
Fetus is in breech presentation
If 37 weeks, consider cephalic version, and if that fails, c-section
How would you work up an adnexal mass in a postmenopausal woman?
First transvag U/S
-then-
CA-125 to monitor
What happens to BUN/Cr in pregnancy and why?
Decrease; increased renal plasma flow and increased GFR 2/2 progesterone
Main role of hCG in pregnancy?
Maintain corpus leuteum
Which screening tests are recommended prenatally under all circumstances (across entities, etc.)
HIV, Hep B, Syphillis (RPR/VDRL/Fluroescent treponemal antibody absorption test if RPR or VDRL +),
Abx choice for bacteruria during pregnancy?
Which ones are contraindicated?
Amoxicillin, cephalexin, fosfomycin, NITROFURANTOIN,
tetracyclines (doxycycline), fluoroquinolones (ciprofloxacin), and TMP-SMX are CONTRAINDICATED (teratogenic)
Who should get HPV vaccine?
Who should get the rubella vaccine?
All non-pregnant women 9-26
All dudes 9-21
MMR vaccine CONTRAINDICATED IN PREGNANCY
ALL LIVE-ATTENUATED VACCINES ARE BAD IN PREGNANCY!
Target blood sugars for gestational diabetes and lines of treatment.
Diagnostic levels?
When, who, and with what to screen?
first line: dietary modification
second line: insulin, metformin, glyburide
NOT THIAZOLIDINEDIONES (pioglitazone, rosiglitazone) OR SULFONYLUREAS (chlropropamide, tolbutamide)
target fasting less than 95, dx 95
target one hour tolerance less than 140, dx 180
target two hour tolerance less than 120, dx 155
ALL pregnant women at 24-28 weeks with oral glucose tolerance
Does insulin cross the placenta?
Does levothyroixine cross the placenta?
NO!
NO!
Indications for galactorrhea workup
If
1) UNILATERAL
2) BLOODY/SEROUS
3) PALPABLE LUMP/SKIN CHANGES
then workup with mammography +/- breast U/S, surgical evaluation
If bilateral, nonbloody, no skin changes, no lumps,
then workup with Prolactin, TSH, MRI pituitary, pregnancy test etc.
What is the recommendation for suppression of lactation (say if an infant dies of sepsis and milk is no longer needed)
1) tight fitting bra
2) ice-packs
3) analgesia
Criteria for chorioamnionitis (intra-amnionic infection)
maternal fever and 1 or more of the following:
- maternal or fetal tachycardia
- uterine tenderness
- malodorous amniotic fluid
- purulent vaginal discharge
(prolonged >18 hours rupture of membranes is an important risk factor)
Two categories of etiologies for IUGR and examples of each
[<10th percentile]
1) Asymmetric [maternal factors], “head sparing”***
2) Symmetric [fetal factors], both head and body affected
1)
a) vascular (HTN, DM, pre-E)
b) autoimmune
c) substance abuse (cocaine, tobacco, alcohol)
2)
a) intrauterine infection (toxo, rubella, CMV, malaria)
b) genetic (aneuploidy)
c) congenital heart disease
***BABY REDIRECTS BLOOD TO BRAIN AWAY FROM OTHER ORGANS
Mother has vaginal vessicles and is going into labor. What is the dx? What is the best way to reduce mortality for this neonate?
HSV
c-section (avoid contact on from vaginal delivery)
When is endometrial biopsy indicated
cases with abnormal uterine bleeding
in all women >45 years
women <45 with high risk/concerning features
With labs; treatment, distinguish:
HELLP
Intrahepatic Cholestasis of Pregnancy
Acute Fatty Liver of Pregnancy
HELLP - hemolysis, proteinuria, increased LDH; delivery w/mag to prevent convulsions
ICoP - NORMAL PT/PTT; ursodeoxycholic acid
AFLP - increased PT/PTT, increased creatinine/uric acid, hypoglycemia; delivery
13 things that ALL patients should get when pregnant
5 things that SOME (at-risk) patients should get
offer Down’s screen, offer Cystic Fibrosis screen, rhesus testing, FLU VACCINE [!!!!!INACTIVATED! NOT LIVE-ATTENUATED], Pap as routine, H&H/MCV, varicella, rubella, syphillis, chlamydia, HepB, HIV, urine culture,
thyroid function/diabetes (family history), TB (at-risk), toxo (at risk), Hb electrophoresis (ethnic, MCV<80), lead (history)
What is associated with prolonged gestation, polyhydramnios or oligohydramnios?
OLIGO!!!!! (poly in diabetes, etc.)
Overview of approach to woman in preterm labor <34 weeks.
Def of preterm labor?
Painful contractions at <34 weeks and regular contractions [aka 4 in 20 min or 8 in 1 hr]
1) MAG (neuroprotection)
2) STEROIDS (fetal lung maturation)
3) TOCOLYTICS (CCB, beta-agonist, NSAID.)
OLD lady with vulvar excoriations, thin white lesion, refractory pruritis
dx?
initial step?
tx?
[1ddx]
Pink, smooth, teardrop lesions on vulva that resolve following (insert 1st line tx here)
dx?
tx?
organism?
[1ddx]
- lichen SCLEROSUS
- punch biopsy (r/o SSC)
- tx. corticosteroids (autoimmune etiology)
[lichen PLANUS - MIDDLE AGED WOMEN, papulosquamous/hyperkeratotic appearance, vaginal discharge, pruritis, soreness]
- condyloma ACUMINATA
- acetic acid/podophyllin; treat large lesions with excision or fulguration (electric current)
- HPV
[condyloma LATA: secondary syphilis, flat/velvety lesions, responds to penicillin]
GBS screen
when? tx with what?
35-37 week, penicillin
Gold standard for evaluation of cervix
Transvaginal ultrasound
In a patient presenting with menopause-like symptoms, what should you check as part of workup.
FSH (bc estrogen decreases during menopause)
and
TSH!!!!! (bc hypothyroidism presents very similarly to menopause)
Easy way to think of premature ovarian failure?
Tx?
Labs and explain this finding
Basically menopause1)
This is because FSH is cleared more slowly from circulation
NBS if quad screen is pos? When to do a quad screen?
2nd trimester (15-20 weeks); do cell-free fetal DNA test +/- U/S
False Labor
a) definition
b) characteristics unique to false labor (2)
c) tx
a) 4-8 weeks prior to delivery, contractions felt in the lower abdomen, irregular interval that does not shorten nor increase in intensity,
b)
- not accompanied by cervical changes
- usually relieved by sedation
c) discharge and reassurance
Breast cancer (invasive ductal CA?) receptor?
How to detect?
Either immunohistochemical staining or FISH
Tx for HER2 receptor positive breast adenoCA?
Side effect with this?
What to do before starting this therapy to address potential side effect?
Trastuzumab
Cardiotoxicity (esp in low EF patients)
Echocardiogram
General management strategy for threatened abortions?
Default to expectant management unless progression to inevitable, incomplete, missed, septic
a) hemodynamically unstable (then D&C)
b) septic abortion (blood/endometrial cultures, broad spectrum abx, then D&C)
Vaginismus definition and treatment
Involuntary psychosocial contractions of perineal musculature leading to dyspareunia
tx kegel exercises and gradual dilation
You find on pap smear: atypical squamous cells of undetermined significance.
NBS in >25 years?
NBS in <25 years?
a) >25 years: FIRST do HPV DNA testing…
if positive, do colposcopy
if negative, repeat HPV test and Pap in 3 years
b) 21-24 years: repeat cytology in 1 year
Explain the phenomenon of why fat people might have extra estrogen
Peripheral adipose tissue CONVERTS ANDROGENS TO ESTROGENS VIA AROMATASE!!!!!
THE PERIPHERAL ADIPOSE DOES NOT PRODUCE ESTROGEN DIRECTLY
Discuss the physiologic changes with the following systems during pregnancy:
a) Renal/Urinary (3)
b) Hematologic (2)
c) Cardiovascular (2)
d) Pulmonologic (1)
a)
- mild hyponatremia (ADH)
- decreased BUN/Cr (decreased RPF and GFR 2/2 progesterone)
- urinary output/nocturia
b)
- dilutional anemia (increased plasma volume and RBC mass)
- hypercoagulability (increased fibrinogen & coag. factors; decrease in protein S antigen) [all hormone mediated]
c)
- increased blood volume (increased CO)
- DECREASED systemic vascular resistance (increased HR)
d)
- chronic respiratory alkalosis (progesterone stimulates hyperventilation centrally)
- increased tidal volume and minute ventilation
- increased pO2, decreased pCO2
Are inhaled corticosteroids safe in pregnancy?
YES
What are the first and second signs of Magnesium Sulfate toxicity? MOA of each? NBS?
First - loss of DTRs (interference at the neuromuscular junction)
Second - respiratory depression (CNS depressant)
d/c Magnesium and replace with Calcium Gluconate
Mittelschmerz:
definition
epidemiology
px
path
- midcycle pain
- young ovulating females
- 2 weeks following LMP, lower quadrant pain, often unilateral, with no other clinical findings
- result of ovulation itself
Cervicitis:
dx
1st MC causative agent, features, tx
2nd MC, features, tx
3rd, tx, buzzword
-can gram stain but nucleic acid amplification can distinguish
- Chlamydia D-K, 1 day azithromycin -or- 7 day doxycycline, mucopurulent dcg/friable cervix
- Gonorrhea, azithromycin/doxycycline + ceftriaxone, mucopurulent dcg/friable cervix
-Trichomonas can cause strawberry cervix (usually vaginitis though?) tx metronidazole + partner
Postpartum woman, pulmonary symptoms, multiple nodules on CXR.
Dx?
Best confirmatory test?
Choriocarcinoma
b-HCG
What is the triad of gestational trophoblastic disease in general. Examples of GTD?
vaginal bleeding, enlarged uterus, pelvic pain
choriocarcinoma
Abnormal Uterine Bleeding (AUB)
- MC cause in adolescents?
- 1st line tx
- anovulatory 2/2 immature hypothalamic-pituitary axis
- estrogen (to regenerate endometrium that has sloughed off from bleeding)
Androgen insensitivity syndrome vs mullerian agenesis
Cryptorchid testes, [absent uterus], absent upper vagina, breasts (androgens converted to estrogens),
vs
normal ovaries, [absent uterus], absent upper vagina, external genitalia normal
False positive VDRL (syphilis), thrombocytopenia, prolonged PTT
dx?
tx?
[false positive VDRL would be confirmed with a negative fluorescent treponemal antibody (FTA) test result]
anti-phospholipid antibody syndrome
LMWHeparin
OB/GYN select abx regimens: List regimen and which diseases get them (2)
(avoid teratogens, aka TMP-SMX, tetracyclines, fluroquinolones)
a) Clindamycin + Gentamycin
- endometritis
- PID/tubo-ovarian abscess
b) Azithromycin/Doxycycline + ceftriaxone
- chlamydial cervicitis unconfirmed by PCR
- all gonococcal cervicitis
c) 1 day Azithromycin/7 day doxycycline
- chlamydial cervicitis confirmed by PCR
d) metronidazole
- gardnerella vaginalis
- trichomonas vaginitis (+partner tx)
e) fluconazole/clotrimazole/miconazole/nystatin
- vaginal candidiasis
f) penicillin G
- syphillis
g) acyclovir
- herpes
h) cephalexin/nitrofurantoin/amoxicillin
- bacteruria/UTI
i) amoxicillin
- GBS ppx
Menstrual cycle:a) Which phase is variable in time?b) hormone dominated by the phase in (a)? Function?c) Which phase is NON-variable?d) hormone dominated by the phase in (c)? Function?e) How to determine what day someone ovulated?
a) follicular phaseb) estrogen; endometrial PROLIFERATIONc) luteal phase (ALWAYS 14 DAYS)d) progesterone; endometrial SECRETION e) [Total cycle length]-14= day of ovulation (LH surge)
