UWise Flashcards
1
Q
Pt has a pap with ASUCS and + for high risk HPV. Now what?
A
Colposcopy is indicated
Repeat cytology in 1 year is acceptable with HPV testing was not done
2
Q
What are the criteria for discontinuing Pap smears?
A
- If pt had a hysterectomy, unless the indication was for cervical cancer or high grade dysplasia
- Age 65-70 with 3 consecutive NL pap smears, or 2 negative in the last 10 years + no hx of abn cells
Still need bimanual rectovaginal exam, mammograms
3
Q
How frequently should women get a Pap smear?
A
Every 5 years if w/ HPV screening (cotesting)
Every 3 years if cytology along
4
Q
Pap comes back with ASCUS. Now what?
A
Screen for HPV, or repeat cytology in a year
If + for high risk HPV -> colposcopy
5
Q
Pt has lower abdominal pain, adnexal masses, CMT, Vaginal dyscharge
A
Acute salpingitis (PID) Chlamydia, gonorrhea
6
Q
Pt with painless vaginal lesions and brown rash on palms needs a?
A
VDRL or RPR
Syphilis, confirm with treponemal testing
7
Q
Pt presents with painful lesions on the vulva. How should you manage?
A
Herpes likely, offer a full screening for STD’s
8
Q
Pt has a frothy yello-green vaginal discharge. PE erythematous patches on the cervix
A
Trichomonas
Strawberry cervix, protozoa on wet mount
9
Q
Pt has syx suspicious for herpes, but culture is negative. Why?
A
Test is specific but not sensitive
10-20% false negatives
10
Q
When is written Informed consent not required?
A
In a true emergency where the delay to consent could risk the pts life
11
Q
Can a PI own stock in the company they do research for?
A
Yes, as long as it is disclosed
12
Q
At what age should you start offering colonoscopies?
A
50
colonoscopy x 10 years
flex sigmoid x 5 years OR
FIT x 1 year
13
Q
When is a DEXA scan offered?
A
Pts with RF’s prior to age 65
14
Q
At what age should mammograms be offered?
A
40
Anual mammo
15
Q
When would you recommend a colonoscopy early?
A
If pt has a first degree relative <60 with colon cancer.
Begin screening at age 40, or 10 years before the age of the relative at diagnosis. Repeat x 5 years
16
Q
Which forms of contraception have <1% pregnancy rates?
A
Depo-Provera
Sterilization
Nexplanon
IUD
17
Q
What vaccination should be avoided if a pt may become preg?
A
MMR
Avoid within 4 weeks prior to conception
18
Q
Best way to prevent CVD in an otherwise healthy pt?
A
Start an aerobic exercise program
19
Q
What is the strongest risk factor for osteoperosis?
A
Family Hx, age>50
20
Q
Best way to lower risk of osteoperosis?
A
Weight bearing exercise 1-4x/wk
21
Q
What supplement should be recommended to all women of child bearing age?
A
Folic acid
22
Q
Preggo presents with dyspnea but no other findings
A
Physiologic dyspnea of pregnancy
23
Q
What metabolic change is seen in pregnancy due to chronic hypoventilation?
A
Compensated respiratory alkalosis
preggos have increased minute ventilatin
Exacerbated by URI
24
Q
What is the pathophys of preggo associated dyspnea
A
Inspiratory Capacity down by 15% due to decrease in TV and Inspiratory Reserve volume
FRC is reduced by 80%
Increased minute ventilation due to increased TV
25
Preggo presents with pulmonary edema. Why?
Decreased plasma osmolality, use of magnesium sulfate and nifedipine
26
Why do most women develop a diastolic murmur during pregnancy?
ABN
If Pulmonary vascular resistance > SVR causing R to L shunt if VSD is present
Develops cyanosis
27
Why do most women develop a systolic murmur during pregnancy?
Normal
| CO increases by 33% due to increased hr and SV
28
Why do many women have syx consistent with hydronephrosis during pregnancy?
R ureter dilation and ovarian v. dilation
29
What can happen to thyroid hormone levels during pregnancy?
TBG increases due to increased estrogen -> increases total T3 while free T4 and T3 remain canstant
30
What study is needed in a pt with a molar pregnancy?
CXR -> lungs are most common site for metastatic dz in pts with gestational trophoblastic dz
Weekly BhCG will be required after
31
How much weight should a preggo gain if her BMI is < 18.5
28-40lb
32
How much weight should a preggo gain if her BMI is < 18.5-24.9
25-35 lb
33
How much weight should a preggo gain if her BMI is 25-29.9
15-25lb
34
How much weight should a preggo gain if her BMI is >30
11-20lb
35
How do you figure out risk of sickle cell?
Risk of being carrier in unaffected family = 1/10
| Parent 1 chance of being carrier) x (parent 2 chance of being carrier) x (chance baby will be affected (1/4)
36
What screening would you recommend for a preggo AA woman?
CBC and Hgb electrophoresis
| Detects Sickle cell, Hgb C, and thalassemia
37
Which ar disease have increased incidence in Ashkenazi jews?
```
Fanconi Anemia
Tay-Sachs
Cystic Fibrosis
Niemann-Pick
Canavan
```
38
Valproic acid increases risk for?
Neural tube defects (hydrocephalus, craniofacial malformations)
39
Preggo with poorly controlled DM puts the fetus at increased risk of?
Structural anomalies - Neural tube defects, cardiovascular
| G/U and limb defects are also reported but less common
40
What can be identified on chorionic villous sampling?
Chromosomal abnormalities, biochemical, or DNA based studies
| CANNOT id neural tube defects
41
Which gestational screen is most sensitive for Trisomy 21 and trisomy 18
cell free DNA screen - 99%
42
What is the risk of miscarriage when a pt undergoes CVS?
Approx 1% regardless of previous hx of miscarriage
43
What is the most common form of inherited mental retardation?
Fragile X
| Down syndrome is genetic, but not considered inherited
44
Non hispanic whites are at increased risk of having children with?
Cystic Fibrosis
45
What should you do if a patients LMP and fundal height are significantly different?
Fetal ultrasound
| First trimester U/s is the most accurate estimate of gestational age
46
If a patient has multiple abn readings on a 3 hr glucose tolerance test, now what?
Educate on blood sugar monitoring and appropriate diet
47
Complications of gestational diabetes?
```
Shoulder dystocia
Metabolic disturbances
Preeclampsia
Polyhydramnios
Fetal macrosomia
```
48
What dose of folic acid is recommended for a woman with a previous pregnancy complicated by fetal neural tube defect?
4mg folic acid QD
| Recommended dose for a non-high risk pt is 0.6 mg/day
49
Pt has a negative cell free DNA screen but elevated alpha fetal protein. Why?
Most likely underestimation of gestation age
| Could also be: fetal demise, multiple gestation, ventral wall defects, tumor, liver disease
50
If a pt is concerned from chromosomal anomaly following an increased nuchal translucency on U/s, their best option is?
Amniocentesis
51
Preggos can take ibuprofen up until?
32 weeks gestation - first risk of premature PDA closure
52
Preggos can take warfarin up until?
Never. Teratogenic. Switch to LMWH
53
Irregular, short contractions causing discomfort in the lower abdomen/groin
Braxton Hicks contractions
| Less intense than true labor (strong regular contractions, cervical dilation, and effacement)
54
If a pt reports that her previous baby had neonatal sepsis, how do you manage her current preggo?
Do not culture
| Give intrapartum abx
55
When do you normally screen for GBS?
35-37 weeks
56
What should you do if fetal heart rate cannot be measured through external methods during deliver?
Fetal scalp electrode
| No epidural unless you can see the fetal hr
57
If a baby is at +2 station and heart tones drop to 60, what do you do?
Emergent outlet forceps or vacuum-assisted delivery
58
What should you do if frank blood is seen when inserting a intrauterine pressure catheter?
Placental seperation or uterine perforation
W/d cath, monitor for any signs of fetal compromise
If fetal status is reassuring - try to place cath again
59
What is the cause of late decels?
Uterine contractions, uteroplacental insufficiency
60
What is the cause of variable decels?
Umbilical cord compression
61
What is the cause of early decels?
Head compression
62
How do you manage umbilical cord prolapse in the setting of no fetal distress?
Elevate the fetal head to avoid compression of the cord and take to c-section
63
Is episiotomy ever the right answer?
No
64
Baby is born with flattened nasal bridge, small rotated ears, sandal gap toes, hypotonia, protruding tongue, simian creases, epicanthic folds, oblique palpebral fissures
Down syndrome
65
How do you manage a woman with meconium stained amniotic fluid?
intubate the trachea and suction meconium if the newborn is depressed
IF the newborn is vigorous
66
A T1DM mom is at risk of having a baby with?
Small and hypoglycemic
67
A mom with gestational diabetes is at risk of having a baby with?
Macrosomia, hypoglycemia, polycythemia, hyperbili, hypocalcemia, ARDS
68
Fetal tachycardia with minimal variability is a warning for?
Fetal spesis
Especially when mom is febrile (chorio)
Infant may be pale, lethargic, and febrile at birth
69
What is a common complication of twin-twin transfusion syndrome?
Plethoric twin - polycythemia, polyhydramnios, heart failure, hydrops
Donor twin - anemic, IUGR, oligohydramnios
Monochorionic pregnancy
70
How do you manage and infant born to a HIV + mom?
Start AZT immediately after delivery
test for HIV at 24 hours
Discourage breastfeeding
71
What are the recommendations for giving positive airway pressure in an infant?
Sniffing position
Secure mask
observe for initial chest rise
Oxygen flow at 10L/min
72
What is apgar scoring based on?
```
Heart rate
Respiratory rate
reflex
activity
color
each is worth 2 pts at max
```
73
What is the most common cause of postpartum hemorrhage?
Uterine atony
74
1 year s/p delivery pt has slow mental function, weight gain, fatigue, amenorrhea, hypotension, and no milk production
Sheehan Syndrome
Occurs after a pt has significant blood loss causing pituitary necrosis -> loss of TSH, ACTH
Tx - estrogen, progesterone, thyroid and adrenal hormones
75
What increases risk of endometritis?
postpartum infection
increased by c-section, prolonged vaginal labor, PROM, multiple vaginal exams, internal fetal monitoring, manual placental removal
76
Most common cause of postpartum fever?
Endometritis
| Commonly observed with fundal tenderness
77
Most common causative agent of endometritis?
polymicrobial, aerobes andanaerobes, Staph and Strep
78
Symptoms of post partum depression for less than two weeks?
Postpartum blues
79
What is a unique symptom in the post partum pt?
Ambivalence toward her infant
80
Strongest risk factor for postpartum depression?
Pt's history of depression
81
Safest way to suppress lactation?
Breast binding, ice packs, analgesics. Avoid breast stimulation or milk expression (helps to prevent prolactin secretion)
hormones increase risk of HTN and strokes
82
Breast feeding can decrease the incidence of which cancer?
Ovarian. Maybe breast
83
s/p delivery day 2 pt has bleeding and cracked nipples.
Poor positioning of infant
84
Hormone required for breast milk synthesis?
Prolactin
85
Why do women begin lactating after birth?
Rapid decline in progesterone and estrogen
These inhibt milk release
Can take up to two days
86
Breast feeding mom presents with burning pain during feeds, Nipples are pink and shiny with peeling at the periphery
Candida
Treat mom with TOP antifungal
Treat baby with oral nystatin
87
How do you determine if baby is getting enough milk?
3-4 stools QD
6 wet diapers QD
Weight gain
Sounds of swallowing
88
How do you advise a pt that is complaining of breast engorgement?
Frequent nursing (1.5-3 hours), warm compress, massage the breast, good bra, analgesic 20 minutes before BF
89
Which hormone is required for milk ejection?
Oxytocin
| Produced when the baby suckles (not as good with pumping)
90
How do you confirm an ectopic pregnancy when no fetal pole is visualized?
Repeat BhCG in 48 hours to see if the increase is consistent with pregnancy (usually >2000 before veing visualized on TVUS)
91
What is the greatest risk factor for ectopic pregnancy?
Previous ectopic,
| followed by age >35
92
What do you do in a pt with a suspected ruptured ectopic?
exploratory lap
93
If a BhCG doubles in 24 hours what type of pregnancy does the pt have?
Intrauterine
| BhCG should increase by at least 50% every 48 hours until the pregnancy reaches 48 hours
94
What is the diagnosis of ectopic pregnancy based on?
1. Fetal pole outside of the uterus
2. Bhcg > 2000 w/o intrauterine pregnancy on TVUS
3. BhCG does not increase by 50% every 48 hours and these do not decrease after D&C
95
What criteria must a pt have in order to receive methotrexate?
```
hemodynamically stable
non-ruptured mass <4cm w/o hr, or <3.5 with hr
Nl Liver enzymes
Nl renal fxn
Nl wBC
Ability for rapid follow up
```
96
What does endometrial stripe mean?
It excludes an intrauterine pregnancy
97
pt presents with cyclic midline abd cramping following a d&c. Scant bleeding. Dx?
Uterine perforation
98
Primary cause for 1st trimester spontaneous abortions?
genetic abnormalities
99
Most common karyotype causing spontaneous abortion?
Autosomal trisomy
100
What maternal RF's contribute to spontaneous abortions?
```
Chronic systemic dz (DM, CRD, SLE)
Genetic factors
Endocrine abnormalities
Reproductive tract abn
Immunologic factors
Environmental factors (cigarettes, EtOH)
```
101
How do you handle a 1st trimester mom that is profusely bleeding and H&H is dropping
Dilation and suction curettage
102
What do you do for a woman that has had two spontaneous abortions around 20 weeks and both fetuses were very normal?
Cervical cerclage at 14 weeks
| Mom likely has an incompetent cervix
103
How do you evaluate a woman with 3 1st trimester losses?
Rule out systemic disease
Karyotyping
Hysterography
104
Does voluntary pregnancy termination increase risk of spontaneous abortion or infertility?
No
105
Risks to fetus in a mom with T1DM?
Spontaneous abortion
Major congenital malformations
Fetal growth restriction
106
Which HTN medication should be d/c after the 1st trimester?
ACEI
| Oligohydramnios, growth retardation, neontal renal failure, hypotension, pulm hypoplasia, death
107
What should a HIV + preggo receive?
po zidoudine, IV zidovudine in labor and po z for baby
108
Most commone cause of sepsis during pergnancy?
Pyelonephritis
109
How do you manage asthma exacerbation in a preggo?
Continue beta agonists
Add INH corticosteroids or cromolyn sodium
SubQ terbutaline and corticosteroids in acute pts
110
What is thyroid storm?
Preggo in an acute life threatening hypermetabolic state.
Radioactive iodine is contra because it concentrates in the fetal thyroid and causes congenital hypothryoidism
Tx - PTU, propanolol, sodium iodide, dexamethasone
111
when do you do 50g OGTT in a preggo?
24-28 weeks
| If they fail the 50 g, do the 100 g
112
What is the risk of mortality for a preggo with PHTN?
25-50%
113
Preggo has a systolic murmur with a click
Mitral valve prolapse
| Tx - beta blockers (decrease sympathetic tone, relieve chest pain, palpitations)
114
Preggo has mild microcytic hypochromic anemia with a NL ferritin
Alpha thalassemia trait
115
What risks does a morbidly obese mom have?
```
Chronic HTN
gestation DM
Preeclampsia
Fetal macrosomia
higher rate of cesarean
```
116
Which chemo is contra?
Radiotherapy
117
Which SSRI is contra in preggo?
Paroxetine (Paxil)
118
Preggo develops jaundice and pruritis
Pruritus gravidarum
Caused by retention of bile salt
Tx - Ursodeoxycholic acid, naltrexon
119
What imaging do you use to confirm appendicitis in a preggo?
compression U/s
120
Pre-eclampsia pt is having respiratory depression. Why?
Mag toxicity
| d/c mag and give calcium gluconate
121
How do you manage preeclampsia in a pt at 39wks?
Just deliver the babe
122
Laboring preggo with preeclampsia, vag bleeding, and fetal hr is sinusoidal
Placental abruption
123
When preggo presents with preeclampsia, what is a goal diastolic pressure?
90-100 mmHg
| Low enough to prevent maternal stroke or abruption without compromising uterine perfusion
124
What is the risk of Rh isoimmunization w/o rhogam?
Approx 60%
125
What is a noninvasive way to assess fetal anemia?
Doppler U/s of the middle cerebral a. peak systolic velocity
126
What can be seen on fetal u/s in a mom that has anti-D Ab's
Fetal hydrops
Develops due to decreased hepatic protein production
Placental edema, pericardial effusion. and polyhydramnios on u/s
127
How do you decide how much rhogam to usse?
1:10. ie 30 cc of fetal blood requires 300 ug of Rhogam
128
When do you give Rho gam?
Give to Rh- women
Given after any event that could cause fetal-maternal hemorrhage
Give prophylactically at 28 weeks
129
Do Lewis Ab's cause isosensitization?
No, they are IgM and can't cross the placenta
130
If a preggo has evidence for hemolytic dz what would be found in the amnio?
Bilirubin
| Amniotic fluid will be yellow
131
Which finding in the amniotic fluid is associated with spontaneous preterm delivery
Ferritin
132
If a preggo has severe hemolytic disease what s the best action?
Delivery baby depending on gestational age
| Or fetal transfusion if the baby needs more time
133
Most likely reason a woman will be sensitized despite receiving Rhogam?
Underestimation of blood loss, therefore under dosed
134
Which u/s finding is suggestive a fraternal (dizygotic) twins?
2 placentas (dichorionic)
Dividing membrane >2mm
Twin peak (lambda sign)
Different fetal genders
135
What is a risk of having twins?
```
Twin infant death is 5x higher than single babies
Risk of CP is 5-6x increased
Higher incidence of IUGR
58% premature (avg 35 wks)
Increased risk of congenital anomaly
```
136
What do you recommend for a preggo with twins that is worried about preterm delivery?
Recommend adequate weight gain in the first 20-24 weeks
| Helps the placenta develop
137
Twin-twin transfusion syndrome involves which chorio amnio arrangement?
Monochorionic diamniotic twins
| Twins need separate sack but share a placenta
138
What do you do with a preggo laboring with twins, one vertex and one breech?
C-section
139
Most common karyotype in spontaneous abortions?
Autosomal trisomy
140
When is a fetus at greatest risk of developing IDD due to radiation exposure?
8-15 wks
141
Pt has a thrombosis leading to a still birth due to IUGR. What might mom have?
Factor V Leiden
142
What should be checked in all women that have vaginal bleeding during pregnancy?
Maternal blood type
| If Rh -, give Rhogam
143
What is the main reason that the C-section rate has been rising?
Rate of vaginal births after a c-section has decreased due to the risk of complications (esp uterine rupture)
Also fewer docs willing to do vaginal deliveries in a breech presentation
144
How to you start induction in a term patient with a closed cervix?
Give cytotec prior to pitocin
145
What are associated with breech presentations?
```
Prematurity
multiple gestations
genetic disorder
polyhydramnios
Hydrocephaly
anecephaly
placenta previa
uterine anomalies
uterine fibroids
```
146
Largest risk factor for shoulder dystocia?
Gestational DM
147
How do you manage secondary arrest of dilation (ie no dilation after starting and epidural)
amniotomy
| If still insufficient - add oxytocin
148
Fetus is at station 0 and category 3 heart tracing.
C-section
149
What is the most common type of breech?
Frank breech - presents with the buttocks
150
What is a RF for placental abruption?
Polyhydramnios
151
A pt with several previous C-sections is at risk of developing what in her future preggos?
Placenta accreta
| Placenta grows into the myometrium
152
What is in FFP?
Finbrinogen
Factor V, Factor VIII
NO platelets
153
What is in cryoprecipitate
Fribinogen, Factor VIII, Von Willebrand
154
RF's for placental abruption
```
Smoking
Cocaine
Chronic HTN
Trauma
Prolonged PROM
Prior abruption
```
155
Totally normal labor but preggo bleeds easily from the cervix
Bloody show
Cervix is extremely vascular and will bleed during dilation (small or large)
Not clinically significant, normal
156
Preggo has small vaginal bleeding during gestation but everything else is NL
Cervicitis. Caused by STD and cervix is vascular during preggo
157
Preggo has a small amount of bleeding and a hard mass on the posterior lip of the cervix
Cervical cancer
| Cervical polyps are soft
158
Most common cause of preterm labor?
idiopathic
159
What should be given to abort preterm labor?
Nifedipine - tocolytic
Betamethasone - promote pulmonary maturation
Ampicillin - if GBS status in unk
Terbutaline - no longer recommended due to AE's
160
How do you manage pre term labor in a febrile preggo?
Deliver since there is concern for intra-amniotic infection
161
Which tocolytics are contra in DM preggos?
Terbutaline
| Ritodrine
162
When is magnesium sulfate is contra in pts with?
Myasthinia gravis
163
Hoq does magnesium sulfate work?
Competes with Ca2+ for entry into the cells.
164
What is a side effect of terbutaline?
Tachycardia, hypotension, anxiety, chest tightening
| Beta-adrenergic agonist
165
What syx would a magnesium toxicity pt exhibit before respiratory depression?
Areflexia
12-15 mg - respiratory depression
>15 mg - cardiac depression
166
Treating a preterm fetus with betamethasone at 24-34 wks reduces RDS, but also associated with?
Decreased risk of intracerebral hemorrhage and necrotizing enterocolitis
Increased risk of infection or enhanced growth
167
What is the use of fibronectin testing?
NL in the vaginal secretions in the first 20 weeks
Later in pregnancy thought to indicate injury to the maternal-fetal interface
Strong Negative predictive value
168
How do you confirm ROM?
Test vaginal fluid for ferning and nitazine testing
| Do NOT test the cervical mucus, avoid digital exams
169
Why do you offer tocolytics to a preterm preggo with PROM?
Give time for steroids to have max benefit
| 48 hours of tocolytics
170
What is the main RF forpreterm ROM?
Genital tract infection, esp bacterial vaginosis
| Smoking , cervical length, and prior PROM do too
171
Why can PPROm cause variable decels in the fetus?
Cord is compressed due to lack of amniotic fluid
172
What is recommended in the setting of PPROM that can extend the pregnancy 5-7 days?
Ampicillin + erythromycin, increases latency period and reduces risk of infection
173
How can you prevent PPROM in a preggo with a known history?
17 alpha hydroxyprogesterone
Reduces risk of premature labor
Administer weekly starting at 16-20 wks and d/c at 36 wks
174
At which gestational age are tocolytics contra?
36 wks
175
How do you assess if contractions are adequate in a preggo that has arrest of labor?
Intrauterine pressure catheter
| Helps you decide if oxytocin augmentation is appropriate
176
When are prostaglandins given?
Cervical ripening
| Contra in pts with previous c-section due to risk of uterine rupture
177
How do you manage a fetus with persistant late decels?
c-section
178
What do you do if you see late decels but you are in the very early stages of labor?
Change maternal position to left lateral
| Increases perfusion to the uterus
179
During labor, fetus has minimal variability and no accelerations
Fetal scalp stimulation
If hr increases by >15bpm x 15 sec, reassuring that the acid-base status is NL
If not responsive enough - fetal scalp pH, vibracuoustic stimulation, allis clamp test
180
Which utertonics can you use in uterine atony
Methergine
Prostaglandins
Misoprostol
Oxytocin
181
What is contra in a woman with HTN and uterine atony?
Methylergonovine
Potent smooth m. constrictor
Exacerbates HTN and pre eclampsia
182
Which utertonic agent should be avoided in asthmatic pts?
Prostaglanding F2-alpha (Hemabate)
| Potent smooth muscle constriction with a bronchioconstrictive effect
183
Globular pale mass appears at the os during delivery of placenta
Uterine inversion
| RF - excessive traction on the umbilical cord
184
How is post partum hemorrhage defined?
Vaginal delivery - >500 cc
| C-section - >1000 cc
185
What is concerning for a woman with a low lying anterior placenta and hx of multiple c-sections?
Placenta accreta
186
What increases risk of retained placenta?
prior c-section
uterine leiomyoma
Prior uterine curettage
Succenturiate lobe of placenta
187
Uterine atony pt has already received all of the uterotonic agents. Now what?
Bakri balloon
Balloon placed into uterus with 500 cc of sterile fluid
Uterine a. ligation, B-lynch compression stitch, hysterectomy - laproscopic fixes
Uterine a. embolization - requiers IR
188
How do you tx endometritis after vaginal delivery?
Ampicillin (Gram +) + Gentamicin (Gram -)
189
Causes of acute cystitis after delivery?
```
E. coli
P. mirabilis
K. pneumoniae
S. faecalis
S. agalactiae
```
190
Febrile mom struggling to breast feed 2 days after delivery
Breast engorgement
| Low grade fever
191
How do you manage a pt having discharge from her c-section incision
Open the wound, check for fascial dehiscence, drain, assess the fluid.
Pack the wound
Give broad spectrum abx if you suspect cellulitis or abscess
192
Febrile patient 2 s/o c-section and you already ruled out endometritis, cystitis, and mastitis
Septic thrombophlebitis
thrombosis of the venous system of the pelvis
Diagnosis of exclusion
Tx- anticoags and abx
193
Most common source of fever on postpartum day 1?
lungs
| expecially if they received anesthesia (aspiration pneumonia_)
194
grade 4 lack is not healing well and necrotic. Now what?
Debridement of the necrotic areas to prevent spread
195
How do you treat endometritis following c-section
Gentamycin (Gram -) + Clindamycin (anaerobic)
196
Epidural pt has a raging HA now what?
Spinal HA, can have meningitis syx
Dx with LP
Requires aggressive tx with abx
197
Pt with a depression history is at greatest risk of developing?
post partum depression
| not blues
198
Most common AE of fluoxetine?
Insomnia
199
Can you breast feed while on SSRI?
yes, at the regular dose
| SSRI is secreted in the milk, but levels were not detected in the infant
200
What is the risk of third trimester use of SSRI's?
ABN muscle movements and w/d syx in the infant
agitation, inc/dec tone, tremor, sleepiness. difficulty breating/eating
Can subside in hours or days
201
What testing is needed starting at 41 wks?
Bi-weekly non-stress testing
| NL is two 15x15 accelerations over 20 min
202
What is associated with postterm pregnancy?
Placental sulfatase deficiency
fetal adrenal hypoplasia
anecephaly
inaccurate dates
203
What complications are associated with postterm?
```
Macrosomia
Oligohydramnios
Meconium aspiration
Uteroplacental insufficiency
Dysmaturity
```
204
What does amnioinfusion help to improve?
Tx of repetitive variable decels
205
How do you manage at 42 weeks?
Favorable cervix - induce
| Unfavorable cervix - biweekly stress tests
206
Infant is born - withered, meconium stained, long-nails, fragile, small placenta
Infant with dysmaturity
| Occurs in 10% of those when gestation age >43 wks
207
What helps with cervical ripening in a 42wker?
Prostaglandins
208
Greatest risk factor for a post term pregnancy?
```
Previous post term pregnancy (#1)
Nulliparity
Advanced maternal age
obesity
Male fetus
Caucasian mom
```
209
Most likely cause of IUGR in a woman with systemic disease?
Uteroplacental insufficiency
210
How do yo work up a preterm preggo with IUGR?
Non stress tests
AFI (oligo is a frequent cause)
Dopple U/s (Sys/dys ratio of the umbilical artery) - increased = vascular resistance
211
Once you detect IUGR, what do you do?
biweekly non stress testing
| Weekly AFI
212
Fetal growth restriction is a significant growth factor for?
Cardiovascular dz (HTN, stroke)
COPD
T2DM
Obesity
213
Preterm fetus with IUGR and abn unbiliacl arter doppler studies
Deliver
| Test is non reassuring so get baby out
214
Best way to estimate fetal weight?
OB U/s
215
Best way to estimate gestational age?
u/s measuring crown-rump length in the first trimester
216
What should be done if fatty tissue is seen during a D&C
Turn the suction off and remove the tissue
| Exp lap as this is most likely omental tissue and should look to see if there is bowel damage
217
You see a preggo with a fibroid protruding from the cervix. Now what?
C-section
| fribroid in the lower uterine segment can obstruct labor by preventing the fetal head to enter the pelvis
218
At what fetal head diamete is c-section indicated?
>12cm
219
What is an advantage of vacuum assisted birth?
Decreased rate of maternal lacerations
| Increased risk of fetal lateral rectus paralysis (transient)
220
Can you do a c-section on a baby at +2 station?
Yes, apparently it is possible
221
What is the most likely complication of a tubal ligation?
Future pregnancy
| approx 1% failure rate
222
Which type of cerclage is given to a woman that wants to get preg and has a hx of cervical insufficiency?
```
Transvaginal cerclage (McDonald procedure)
Purse-string permanent suture at the cervicovaginal junction
If they fail the transvag, try transabdominal
```
223
For how long do depo pts have unpredicatable bleeding?
2-3 months
| 50% amenorrhic at 1 yr
224
How do you manage a pt that had unprotected sex x 24hrs ago?
Offer emergency contraception (levonorgestrel pills)
| Start on OCP's
225
Indications for progesterone only OCP's
Hx of clots
Lactating
>35 smoker
Severe nausea with OCP's
226
Contraception that decreases risk for gyn cancers?
OCP's decrease risk of ovarian and endometrial cancer
227
What is the best method of permanent sterilization for a pt with a morbidly obese woman with hx of multiple abdominal surgeries?
Hysteroscopic tubal occlusion (Essure)
228
The number of yolk sacs corresponds to?
The number of placentas (chorios)
229
AA pt has microcytic anemia and gel eceltrophoresis is 95% Hgb A
Iron deficiency anemia
230
Amnio says the baby is 46XX, but the baby is male at birth. Why?
ACTH oversecretion
231
Pt has chronic dyspareunia and dysmenorrhea. PE nodularity over the uterosacral area, uterus is retroverted, adnexa NL. Now what?
Laparoscopy
232
Post menopausal woman with vulvar itching. Ulcerated lesion on the inner R labium majus surrounded by mild erythema. No adenopathy. Dx?
Vulvar carcinoma
233
Preggo has a hx of a 10lb baby. What is she at risk for during this pregnancy?
Gestational DM
234
What is the main RF for regretting sterilization in a female?
Age at time of procedure
235
What is the best option for sterilization in a woman with chronic medical problems and morbid obesity?
Vasectomy
236
What are the cons of the estrogen patch for contraception?
High failure rate in woman that weigh more than 198lb
| Otherwise comparable efficacy to OCPs
237
Febrile preggo presenting with vaginal bleeding and dilated cervix
Septic abortion
238
How do you manage a septic abortion?
Uterine evacuation and broad spectrum abx
239
What do you need to test in a woman with recurrent 1st trimester losses of karyotypically and anatomically normal fetuses
Antiphospholipid Ab's
| Cervical insuficiency are second trimester losses
240
How do you tx a mom with a hx of APL that wants to conceive again?
Aspirin + heparin
241
What is used to treat preterm delivery?
17-OH progesterone
242
What is a risk of medical abortion?
More blood loss than surgical abortion
Medical abortion offered if pregnancy <49 days
Mifepristone + misoprotol
243
Manual vacuum aspiration is an option for surgical abortion up until?
8 wks gestation
244
Least invasive way to manage a missed abortion (fetal demise)
Misoprostol (prostaglandin E1)
Effective up to 9 wks gestation
Risks - hemorrhage, failure
Invasive procedures (D&C, manual vacuum)
245
If pt has heavy bleeding after medical termination of preggo
D&C
| retained products of conception
246
Pt is febrile but not bleeding 2 days s/p D&C to terminate pregnancy
Post op endometritis - caused by bacteria that are introduced during the procedure
Start IV abx, u/s for retained products of conception
247
Tx for bacterial vaginosis
```
Metronidazole
Thin gray discharge with fishy odor
+ whiff test
clue cells
pH>4.5
```
248
Diffuse malodorous yellow green discharge
Trichomonas
Protozoa on wet prep
Tx - metronidazole
249
Derm condition involving the scalp, oral mucosa, and vulva
Lichen planus
| inflammatory dz with remissions and flares
250
Healthy pt has severe pain with vaginal penetration
Vestibulodynia
Tx - TCA, pelvic floor exercises, biofeedback, top anesthetics
Surgery if they fail
251
Healthy pt has chronic vulvar itching and scratching.
Lichen simplex chronicus
Common vulvar non-neoplastic disorder
Damaged skin due to scratching creates a protective barrier
Dx - bx
Tx - TOP corticosteroids + antihistamines
252
Pt has copious yellow discharge from the cervix but pH is 4
Mucopurulent cervicitis
Chlamydia and gonorrhea
Tx - azithro + ceftriaxone
253
Cause of recurrent genital herpes
HSV-2
| Primary infection - includes systemic syx
254
Pt has had a vulvar lesions x 1 yr
bx - suspicious for vulvar cancer
255
Sexually active female with vaginal itching after a cold
Herpes
256
Tx for a pt that had sex with a partner w/ acute Hep B
Initiate w/in 14 days of exposure
If unvax - HBIG + HBV vax series
If vax & responding - nothing
If vax & non resp - HBIG x 2
257
What causes acute salpingitis w/ b/l tubo-ovarian abscess?
Most often gonorrhea/chlamydia
| Also ascending infection from the GU or GI (polymicrobial)
258
IV tx for gonorrhea/chlamydia
Cefotetan or cefoxitin
Plus either:
1. Doxycycline
2. Clindamycin + gentamycin
259
Out pt tx for gonrrhea/chlamydia
Ceftriaxone or cefoxitin or 3rd gen cephalo
Plus doxycycline
w/ or w/o metronidazole
260
How does PID decrease fertility?
Tubal infertility
261
Main organism causing UTI in a young sexually active female
```
E. coli
#2 Staph sapro
```
262
Failure to empty the bladder adequately
Overflow incontinence
caused by underactive detrusor m. or obstruction
Post-void residual volume of 50-60cc is WNL
263
What are the RF's for pelvic organ proplapse?
```
Fam Hx
Increasing: parity, age
Obesity
Connective tissue disorders
Chronic constipation
```
264
Leakage of urine due to increased intra-abdominal pressure in the absence of a detrusor contraction
Genuine stress incontinence
Usually due to urethral hypermobility (angle >30)
Tx - if failed conservative measures, retropubic urethropexy (tape or sling procedure, 5 yr success rates for those with GSI due to hypermobility)
Urethral bulking for pts with intrinsic sphincteric deficiency
265
Loss of urine due to unopposed detrusor activity
Detrusor instability
| Tx - anticholinergics (oxybutynin)
266
Prolapse requiring repair of defects in the pubocervical fascia or attaching it to the sidewall
Central and lateral cystoceles
267
Defect in rectovaginal fascia
Rectocele
268
Urine leakage due to overactivity of the detrusor m.
Urge incontinence
Causes an increase int he bladder pressure over urethral pressure causing leakage
No association with activity
269
How do you manage asymptomatic prolapse?
Continue to monitor
| Surgically repair is syx develop
270
How do you manage a vaginal prolapse that is causing hydronephrosis?
Copocleisis
| Vagina is surgically obliterated, does not require general anesthesia
271
Initial tx for a symptomatic prolapse?
Pessary
272
Dysmenorrhea + dyspareunia
Endometriosis
Presence of endometrial glands/stroma outside of the uterus
Nodularity at uterosacral ligaments
273
Complex ovarian cyst in a endometriosis pt
Endometrioma (chocolate cyst)
274
Surgical tx for endometriosis
Laser ablation - younger pts
| Tots hys/BSO - older (done having babies)
275
Good initial tx for endometriosis?
OCP's
| Negative feedback to pituitary/hypo thal -> ovarian suppression -> decreased estrogen
276
Definitive way to dx endometriosis?
exp lap + bx's
277
Sudden onset of pain + nausea, ovarian cyst on u/s
Ovarian torsion
| Tx - surgical exploration
278
How do you manage a woman w/ endometriosis that is having difficult conceiving x 18 months
Clomiphene citrate
Stimulates the ovary
Can do w/ or w/o insemination
279
Young female has dysmenorrhea and PE and u/s are WNL.
Exp lap
| Ddx: endometriosis,
280
Pt has pelvic pain, dyspareunia and recurrent syx of urgency and grequency
```
Interstitial cystitis (IC)
Chronic inflammatory condition of the bladder
```
281
Pt w/ pelvic pain reports improvement of syx with BM's.
Irritable bowel syndrome
1. Relief w/ defecation
2. Associated with a change in stool frequency
3. Onset associated with change in stool consistency
282
How do GnRH agonists relieve endometriosis pain?
Down regulate the HPA production of LH and FSH -> decreases estradiol
Danazol - suppresses mid-cycle surges of LH:FSH
283
What is a significant RF for pelvic pain?
Physical and Sexual abuse (40-50% of women w/ pelvic pain)
284
Definitive tx for enometriosis in a multiparous woman?
Remove ovaries w/ or w/o hyserectomy
285
Older pt with nonspecific pelvic fullness and postmenopausal bleeding. How do you dx?
TVUS
| More sensitive that CT for gyn organs
286
Pt with prior hys complicated by abscess has significant pain and fullness over the pelvic cuff
Pelvic adhesive dz
| Adhesions on the tubes and ovaries that were retained
287
Pt has chronic pelvic pain and lots of vessels in the broad ligament on doppler
Pelvic congestion syndrome
Caused by pelvic variscosities
Cause is fairly UNK
288
Following surgery w/ a low transverse incision - pt has decreased sensation on medial thigh and across groin
Nerve entrapment of ilioinguinal
iliohypoastric would have loss of sensation in obliques
Nerve gets trapped in the suture during fascial closure
289
Pt has axillary tenderness but no mass, on exam her skin is shaved
Folliculitis
290
Woman with watery white nipple discharge has a mildly elevated prolactin immediately after PE. Now what?
Repeat prolactin
| Can be flasly elevated after stimulation. Test prolactin when breast has rested at least 24hr
291
What can aggrevate pain in fibrocystic breast disease
Caffeine
292
How do you manage a breast lump that returns bloody fluid on FNA
excisional bx
| If the mass had clear fluid and reduced - check back in 2 months
293
How do you manage breast pain in a pt being treated for mastitis?
Acetaminophen + ibu
294
Pt has a breast mass, -ve mammo and FNA and the mass persists
Reassure and observe
295
When is a breast MRI indicated?
Pts with an increased risk of breast cancer (BRCA, 1st degree relatives of BRCA, Li-Fraumeni, hx of radiation to the chest 10-30)
296
Find a solid breast mass on exam, -ve mammo, now what?
FNA
297
Pt w/ b/l breast implants has diffuse breast pruritis
Chemical irritation (can also be caused by soaps/perfumes
298
Colposcopy results show CNIII limited to the cervix
LEEP to remove the abn cells
299
What test should you do for unexplained vaginal bleeding?
Endometrial bx (can id endometritis, endometrial polyps, endometrial carcinoma)
300
What is a potential complication of LEEP?
Cervical stenosis
301
What is Asherman's syndrome?
Development of intrauterine adhesions
302
What do you do with a vulvar lesion that has not responded to treatment?
Biopsy
| This may be cancer, not a condyloma
303
During an IUD removal, the strings are not visible but IUD is in the uterine cavity on u/s
Hysteroscopy
| Can remove IUD under direct visualization
304
What do you do for a breast mass similar to fibroadenoma in a pt with a recent mammo?
FNA
| Gives definitive dx regardless of cystic or solid mass
305
adnexal mass noted on PE. Now what?
Pelvic u/s
306
What do you do w/ a cervical polyp?
Polypectomy
| Common in women 40-50
307
Definitive tx of endometriosis
Hysterectomy with b/l salpingo-oophorectomy
308
First sign of puberty in a female?
Thelarche (boobs)
309
What body weight is needed before menses can begin?
85-106lbs
| Sleep and optic exposure to sunlight can also delay menarche
310
How do you dx kallmann syndrome?
Olfactory challenge
Olfactory hypoplasia and the acrute nucleus do not secrete GnRH - females have no sense of smell or secondary sexual characteristics, including menstruation
311
8 y/o female is tall, menstruating and has other sex characteristics. Dx?
True precocious puberty
Sex steroids are increased due to HPA with increased GnRH secretion
Caused by cNS abnormalitis, hypothalamic hamartomas, surgery, trauma, radiation, congenital
312
Most likely cause of premature adenarche?
Congenital adrenal hyperplasia due to 21-hydroxylase deficiency
Insufficient cortisol -> accumulation of adrenal androgens -> precocious adenarche
Tx - steroid replacement
313
Amenorrhic teen with NL breast and pubic hair w/ small vaginal opening w/ blind pouch. U/s - NL ovaries but absence of uterus and cervix
```
Mullerian agenesis (46XX)
Do a renal u/s as anomalies are frequent
```
314
Amenorrhic female with abd pain that is worse one week out of the month. PE - bluish mass parting the labia
Imperforate hyman
| Tx - surgery
315
Amenorrhic female with a bluish cervix
Chadwick's sign
Increased blood flow to the cervix, indicative of pregnancy
Get a UPT
316
How does anorexia cause amenorrhea?
Hypothalamic-pituitary dysfunction -> lack of GnRH pulsations -> no FSH/LH
Get an FSH level
317
Tx for PCOS?
weight loss and OCPs
318
Healthy adult w/ amenorrhea and -ve UPT w/ dyspareunia
Premature ovarian failure
| dyspareunia due to vaginal dryness (hypoestrogen)
319
Pt w/ hx of endometritis following D&C and is now amenorrhic
Asherman's syndrome
| Adhesions of the endometrium
320
PCOS pts have a higher risk of which cancer?
endometrial
| Ovarian
321
Adult presents with hirsutism. NL testosterone but elevated DHEAS
adrenal tumor
322
What should you do if you suspect Chushing's?
Either:
24hr dexamethasone suppression test OR
24 hour urine for cortisol
323
Irregular menses, hirtuism and acanthosis nigricans
Elevated androgens and insulin (DM, PCOS)
| Get a fasting insulin
324
Dx criteria for PCOS
At least 2 of:
Chronic anovulation
Hyperandrogenism (clinical or measured)
Polycystic ovaries on u/s
325
Pt has syx of testosterone excess and enlarged adnexal mass
Sertoli-Leydig tumor
Secretes testosterone
Unilateral
Acne, hirsutism, amenorrhea, clitoral hypertrophy, voice deepening
326
Severe form of PCOS
Hyperthecosis
| Temporal balding, clitoral enlargment, deepening of the voice
327
PCOS pt has improvement in menorrhea w/ OCPs but hirsutism persists. Tx?
Add Spironolactone
| Aldosterone antagonist
328
How does medroxyprogesterone acetate (MPA) produce regular menses?
anovulatory pt's have endometrium proliferation due to unopposed estrogen
Progestin inhibits growth converting proliferative to secretory endometrium
329
workup for heavy menstrual bleeding?
Pelvic u/s
330
Most common cause of abn heavy bleeding in a teen?
Coag disorder
| Von willeberand is most common
331
At what size is polypectomy recommended?
>1.5 cm
332
ABN hormone levels in PCOS?
Testosterone - upper limit of NL or high
333
Best fertility sparing tx for submucosal leiomyomas
Hysteroscopic myomectomy
| Laproscopy can't access submucosa
334
Post transplant pt has post coital bleeding and a cervical mass
Colposcopy w/ cervical bx
| Immunosuppresed at higher risk of cervical dysplasia or cancer
335
Tx for dysmenorrhea
OCP's
| Supplemental progestin causes endometrial atrophy
336
When do you start chlamydia, gonorrhea testing?
Sexually active pts <25
| Can cause dysmenorrhea
337
If dysmenorrhea pt does not respond to OCP's?
Lap for endometriosis
338
Woman >40 with irregular bleeding
Get endometrial bx to rule out endometrial carcinoma
339
well-circumscribed, non-encapsulated myometrium
Fibroids
340
Hyperplastic overgrowth of endometrial glands/stroma
Endometrial polyps
341
How much calcium should post menopausal women take to maintain their bones (zero balance)
1200 mg
342
Management of post menopausal woman with recent hip fx that has healed
Start bisphosphanates
| Dexa (every 2 years)
343
Recommended tx for severe menopausal syx (hot flashes, night sweats, vag dryness)
HRT (estrogen) at the smallest effective dose for the shortest amount of time
344
Why can postmenopausal women have hotflashes after a hys w/ b/l SPO
Removing the post men ovaries causes an aburpt drop in circulating androgens -> w/o circulating androgens the periphral adipose cells cannot convert it to estrone and estradiol
345
What are the cancer pros/cons of combo HRT (estrogen + progesterone)?
Increases risk of breask cancer
Reduces risk of colon cancer
NO increased risk of endometrial cancer as is seen in estrogen only HRT
346
When is combo HRT recommended?
When the pt still has their uterus.
| Estrogen only is safe when the uterus is gone and there is no risk of endometrial cancer
347
How does HRT affect lipid profiles?
Reduces LDL
| Increases HDL
348
How is osteopenia defined?
-1 to -2.5 on DEXA plus RF's for fx (hx of falls, poor nutrition, smoking, low BMI, estrogen deficiency, alcoholism, insufficient exercise)
349
When is a couple considered infertile?
A year w/o contraception and not conceiving
350
You suspect infertility is due to PID.
Get a hysterosalpingogram
| Evaluates the uterus and tubes for adhesions
351
Pt being treated for bipolar and is infertile due to elevated prolactin
Switch bipolar meds
| Antidopaminergic effect of psychotropic medication (quetiapine)
352
What study do you order for infertiity in a heavy exerciser
```
estrogen level (low)
exercise-induced hypothalamic amenorrhea
tx - encourage decreased exercise and increased caloric intake
```
353
pt in her 40's still getting periods but infertile
Get an anti-mullerian hormone level to determine ovarian reserve
354
How do you counsel a woman w/ irregular cycles (26-30 days) of when is the best day to have sex?
Use an ovulation predictor kit
Most women ovulate on day 14 in a 28 day cycle, but hers vary.
Sperm can live up to 3 days
355
IF female has NL periods, TSH, and prolactin but no reason to be infertile
Order a semen analysis
| Cause of about 30% of infertility
356
Hypothyroidism can cause what other hormone abnormality?
Hyperprolactinemia
357
What condition can mimic PMS? (weight gain, fatigue, bloating)
Hypothyroidism
358
What is a last resort for women with severe PDD?
B/l oophorectomy
Risks - CVD, hot flashes, bone loss
Do a trial of GnRH agonist first, if syx improve she is likely to benefit from surgery
359
What can be effective in PMS that has not responded to other tx?
SSRI's
360
Why does exercise help PMS?
Endorphins
361
RF's for PMS?
Family Hx
| B6, Calcium, or Magnesium deficiency
362
What is a RF for molar pregnancy?
Being asian
| <20 or >40
363
Once a woman has a mole, what is the risk of having another?
1-2%
| 20x higher than other people
364
Characteristics of a partial mole?
69XXY, 69XXX, or 69XYY
Caused when egg is fertilized by dispermy
Can have fetal parts
365
Characteristics of a complete mole?
46XX (empty egg) or 46 (XY) empty egg fertilized by 2 sperm
| Usually presents with large uterus, preeclampsia, and higher risk of GTD
366
Molar pregnancy has a vaginal nodule. What needs to be done sTAT?
CT of the chest, andomen, and pelvis. Brain MRI also likely
| Evacuation is likely to be necessary but need to id if the nodule suggests metastasis
367
What confirms a dx of choriocarcinoma?
Beta-hcg
Pt presents with dyspnea months after delivery andno intrauterine preg
NEVER bx as these are highly vascular
368
Bx of a lichen sclerosis pt reveals SCC. Now what?
Radical vulvectomy and groin node dissection
369
Pigmented lesion on vulva
High grade vulvar intraepithelial neoplasia or
| Melanoma
370
Painless mass at the Bartholian gland
Bartholian gland malignancy
Needs excision/bx
Adenocarcinoma most common
371
How do you manage a Vulvar intraepithelial neoplasia III (VIN III)?
Local superficial excision
| Close surveillance
372
Pt with vulvar itching has a diffusely erythematous labia with a thin white film. Many focal flat whitish lesions
HPV related condition (condyloma or vulvar dysplasia)
Suspect this in the immunosuppressed
Get a bx
373
Pt has multifocal VIN II. Tx?
Laser ablation
374
Breast cancer survivor has vaginal pruritis. On exam - vulva fiery red mottled background with whitish hyperkaeratotic areas
Paget's disease of the vulva
375
RF's for cervical cancer
HPV exposure (early onset of sexual activity, multip partners, etc)
Smoking
Lack of pap smears
376
Female < 25 w/ ASCUS but NL HPV
Repeat Pap in 3 yrs
377
Female < 25 w/ ASCUS
Repeat pap in 1 year
378
Post coital bleeding in post menopausal?
Cervical bx
| Depending on result, may also need a CT
379
What should you do if you see a white plaque on the cervix?
Bx for leukoplakia regardless of pap status
380
What can make a cervical lesion more concerning?
Atypical vessels/angiogensis
381
Entire lesion cannot be seen on colposcopy and endocervical curettage is negative. Now what?
Cervical conization to obtain a pathologic specimen
382
Can you get cervical cancer w/o HPV exposure?
No
383
Cervical dysplasia extending below the basement membrane
Carinoma in situ (CIS)
abn cells involving the entrire epithelium to the basement membrane
Microinvasive cancer - invades <3mm
384
Major syx of fibroids
Heavy menstrual bleeding
385
Which type of fibroid can cause miscarriage?
Submucosal or intracavitary
Cause lower pregnancy and implantation rates
Tx - hysteroscopic resection
386
What do you do with a new dx of fibroids on PE/U/s
Endometrial sampling to rule out hyperplasia
especially if pt is post menopausal or late in reproductive age
Surgery not indicated unless pt is anemic
387
Anemic fibroid pt wants a little time to decide if she wants a hysterectomy, what can you offer for short term tx?
GnRH agonist
3-6 months max
can also decrease size of fibroid if trying to do a hysteroscopic removal
388
#1 RF for endometrial carcinoma?
Obesity
| Unless pt has complex atypical hyperplasia
389
Post menopausal with endometrial bx + for endometriod adenocarcinoma
TAH + BSO
390
Perimenopausal woman with intermenstrual bleeding, endometrial bx + and adnexal masses
Granulosa cell tumor
| Secretes estrogen
391
Elderly woman has spiral fx of the arm
Suspect abuse, spirals rarely occur w/o violence
392
Greatest FR for ovarian cancer
Family Hx
393
What can be protective for developing ovarian cancer
Long term suppression of ovulation (OCPs)
394
Healthy female has a unilocular simple cyst on pelvic u/s. Shes on day 21 of her menstrual cycle
Functional ovarian cyst
| NL part of ovulatory cycle
395
Post me female has abn vaginal bleeding, endometrial hyperplasia, and adnexal mass. Which ovarian tumor can cause this?
Granulosa cell tumor (sex-cord stromal tumor)
Fxnal tumor secreting high levels of estrogen
Can lead to endometrial cancer
396
Following debulking of a stage III ovarian tumor, all patients should receive?
Chemo
397
Most common ovarian tumor in women of all ages?
Dermoid (termatoma)
Mean age is 30
u/s - cystic and solid components
398
Vaginal atrophy can lead to which type of female sexual dysfunction
Insertional dyspareunia
| Women with regular sexual activity are less likely to develop this
399
Important source of lubrication during sexual arousal?
Vaginal mucosa/transudate
400
Define sexual behavior
How a person chooses to act sexually
| independent of orientation
401
Best therapy for vaginismus?
Vaginal dilators
402
At what age is a girl able to give consent?
16
| may not apply to relationships of similar age
403
What medications should be offered to rape victims?
Abx
Antiretroviral
plan B
404
Where is the best place to put fliers about a hotline for intimate partner violence?
Office restroom
405
Up until which gestational age is medical abortion approved?
Misprestone
63 days (9wks)
* recent data up until 10 wks
406
Mom is febrile during delivery. suspcious for?
Chorioamnionitis
Newborn at risk for sepsis
May appear pale lethargic and febrile at the time of birth
407
Babies born the GDM mothers are at risk of
```
Hypoglycemia
polycythemia
hyperbili
hypocalcemia
ARDS
```
408
What lab needs to be ordered in the event of fetal demise?
Maternal blood type
409
5 stages of grief
```
Denial
Anger
Bargaining
Depression
Acceptance
```
410
What is the primary reason for increasing rate of c sections?
Fewer women having trial of labor after a previous c section
411
What are RF's for breech presentation?
Prematurity
Multiple gestation
Polyhydramnios
Uterine anomalies/fibroids
412
Latent phase is <4cm dilated. When is a pt considered latent?
nullipapras >20hrs
| multi >14 hours
413
Fetal hr is category 3 racing
Get baby out stat
414
Preggo with vaginal bleeding has a a hard xcmass on their cervix that readily bleeds
cervical cancer
415
Variable decels
Cord compression
416
What indicates delivery in a PPROM?
signs of chorio (febrile, uterine tenderness)
417
In PPROM, which amnio finding would suggest chorioamnioitis?
Increased IL-6
418
At what time point does admin of steroids become controversial?
>32 wks
419
Most common source of fever on post partum day 1?
Lungs
| Especially if they had a c section
420
Baby is in breech at 2+ station
c-section
| All breech babies are at high risk of complication in vaginal delivery
421
Which contraceptive should be offered to a woman that is concerned about gyn cancer?
OCP's
| Decrease ovarian and endometrial
422
Failure to empty the bladder completely
Overflow incontinence
underactive detrusor m. (DM, MS) or obstruction (prolapse)
Residual volum >400cc
423
Tx of stress incontinence that fails conservative management
Retropubic urethrophexy (vaginal taping)
424
Tx for intrinsic sphincteric deficiency?
Urethral bulking
| "drain pipe" urethra on cystourethroscopy, q-tip test reveals fixed immobile urethra
425
Tx for detrusor instability
oxybutynin
| anticholinergics
426
Fixing defect in pubocervical fascia
Cystocele
427
Pt has frequency and nocturia but post voiding volume is 50cc
Urge incontinence
| Overactivity of detrusor m. causes no urge to pee
428
Why are colpocleisis preferred in older woman with multiple morbidities?
the vaginal ablation is done without general anesthesia
429
Pt about to start menses has b/l ovarain cysts (one complex, one simple)
Hemorrhagic cyst
| Repeat u/s in 2 months - most self resolve
430
post op hysterectomy pt had an abscess that was treated. Years later, non specific pelvic pain is suspicious for?
Pelvic adhesive dz. Infection likely involved her tubes and ovaries
431
What are 3 critical factors for starting menses?
>85 lbs
adequate sleep
Optic exposure to sunlight
432
Why do females with Kallmann syndrome have primary amenorrhea?
Their arcuate nucleus does not secrete GnRH
Do not develop secondary sexual characteristics
Dx: anosmia
Tx - pulsatile GnRH
433
Pt develops menses before breast and pubic hair development
McCune Albright
434
Pt having precocious puberty syx w/ LOW LH/FSH and high DHEA, DHEAS
Congenital adrenal hyperplasis
21-hydoxylase deficincy causes accumulation of adrenal androens
Tx - steroid replacement
435
Visibly female teen - NL ovaries, no uterus and cervix
Mullerian agenesis
Associated with renal anomalies
NL ovaries - 2ndary characteristics
436
For what ages should HPV vaccine be offered?
9-26
437
How do you manage a pt with a fx consistent with osteoperosis?
Get a DEXA and start bisphosphanates
| DEXA in 2 yr intervals
438
Mot effective tx for hot flashes?
Estrogen
| Only give if they dont have a uterus
439
Risk of initiating combo HRT?
Increased breast cancer
| This is not seen in estrogen only HRT
440
Pt with molar pregnancy has a vaginal lesion
Get CT of the chest/abdomen/pelvis
| CXR is not sufficient because she already has metastasis to the vagina
441
Untreated lichen sclerosus can progress to?
Squamous cell carcinoma
442
Abartholin mass in a post menopausaul woman is suspicious for?
Malignancy
| Needs bx/excision in any woman >40
443
Management of VIN III?
Local superficial excision
| Radical vulvectomy not appropriate since cancer has not been diagnosed
444
RF's for vulvar cancer
HPV
Smoking
Vulvar dystrophy (lichen sclerosis)
Immunocompromised (HIV, Autoimmune)
445
How far can micrinvasive cancer invade beyond the basement membrane
Up to 3mm
| Over this is carcinoma in situ
446
How do you manage a asymptomatic fibroid in pregnancy?
Just observe, unless it's lower in the uterus which would indicate a c-section
447
First step in a workup for a pelvic mass?
Pelvic u/s
448
Preggo w/ b/l ovarain cyst
theca lutein cyst
| seen in molar preg
449
Most helpful scoring to determine prognosis in a tumor?
Tumor stage
450
What is not associated with GDM?
Intrauterine growth restricition (this is associated with classic DM)
451
If quad screen is suspicious for trisomy 21 get a?
amnio
452
Baby is at 2+ and hr is dropping
Vacuum assisted vag delivery
453
T1 DM preggo has a fetus with IUGR. Now what?
NST 1 or 2/wk
454
How do you surgically remove a submucosal fibroid in a pt that wants to protect her fertility?
Hysteroscopic myomectomy
| Cant get a submucosal on lap
455
Best study for a woman w/ infertility suspicious for PCOS?
Testosterone
| LH:FSH also helpful
456
If a healthy preggo fails the 3hr OTT, what do you do?
Diet and blood sugar monitoring (90 fasting and <120 post prandial)
457
Fetal risk of being exposed to intrauterine valproic acid?
NTD
458
Most common reason for elevated alpha fetal protein?
Under estimation of gestational age
| NTD is possible, but not the most common
459
What is normal output for a baby?
3-4 stools
| 6 wet diapers
460
Suckling increases which hormone?
Oxytocin
| Actual suckling is better than a breast pump for stimulating the secretion of milk
461
Preggo with MVP should be treated with?
If asymptomatic - monitor
| IF symptomatic - Beta block - relieves chest pains, paliptations, anxiety
462
Mild microcytic hypochromic anemia, with NL ferritin and NL electrophoresis
Alpha thalassemia
463
Severe anemia with Hgb F and Hgb A2 on electrophoresis
Beta thalassemia
464
Obesity in pregnancy increases the risk of?
Preeclampsia and HTN
465
2 most common causes of anemia in pregnancy?
Iron deficiency
| Acute blood loss
466
SLE pt at 22 weeks has a flair.
NSAIDS
467
Why is Paxial contra in pregnancy?
Cat D drug
Risk of cardiac malformations and PHTN
Other SSRI's ok
468
Most common reasons for abdominal surgery during pregnancy?
Appendicitis
| Get a compression u/s if you're suspicious
469
What do you do if pt has mag toxicity during labor?
d/c mag and give calcium gluconate
470
How do you manage a preeclampsia pt at 39 weeks?
Induce her
471
Therapeutic range of magnesium?
4-7
| Over that areflexia> respiratory depression > cardiac arrest
472
Approximatre risk of isoimmunization w/o rhogam?
< 20%
473
How is fetal hydrops dx'd on u/s?
collection of fluid in two or more body cavities
474
Key complication of twin-twin transfusion syndrome
Neurologic sequelae of the surviving twin
Hydrops fetalis in either twin
Recipient - cardiomegaly, Tricuspid regurg, VH, plethoric, hypervolemic
Donor - anemic, hypovolemic, growth retarded
475
What makes fibronectin a good screening tool for preterm labor?
```
High NPV (99.2%)
- 99 of 100 women will not deliver w/in 10-14 days
```
476
PPROM + tender uterus
Deliver
| Chorioamnionitis
477
Other than elevated IL6 would suggest chorioamnioitis on an amnio?
Low amniotic glucose
478
Uterotonics
Methylergonovine, prostaglandins, oxytocin
