UWorld 1 Flashcards
35 yo F evaluated for fixed palpated breast mass s/p b/l reduction mammoplasty for mammary hyperplasia 2 yrs ago
- mammo shows spiculated 3x3 mass w/ calcifications
- US: hyperechoic mass
- Core biopsy: foamy macrophages and fat globules
(a) Dx
(b) Tx
(a) Fat necrosis = benign
- associated w/ prior breast surgery: reduction/reconstruction
- give away is the biopsy
(b) Tx = reassurance and f/u
Tx of uterine atony
First: bimanual massage and oxytocin
Then uterotonic meds
- methylergonovine (if no h/o HTN) b/c vasoconstricts
- carbopost (if no h/o asthma)
- misoprostol
Normal pH of vaginal secretions
3.8-4.5
Congenital rubella syndrome triad
Deafness, cataracts, cardiac defect = congenital rubella
When to give bethamethasone
Immature fetus can benefit from bethamethasone if given btwn 24-34 weeks
-also takes 24-48 hrs to take full effect => wouldn’t give to fetus that is urgently getting delivered
How finding of malignant features changes workup of an ovarian cyst
Changes workup if CA-125 is not elevated, if CA-125 is elevated you automatically do CT scan or met disease exploratory surgery anyway
CA-125 not elevated, if don’t have any malignant features, can observe w/ serial CA-125 and US
Mammary Paget disease
Mammary Paget disease = painful, ithcy, eczematous +/- ulcerating rash on nipple that spreads to areola
-85% have underlying malignancy (adenocarcinoma)
How to differenate fat necrosis vs. breast cancer
Need biopsy
Fat necrosis- will see fat globules and foamy histiocytes (macrophages).
25 yo nulligravid p/w pelvic and lower sacral back pain x1 yr, intensifies before menstruation
- unimproved w/ ibuprophen/OCPs
- PE: fornix tenderness, decreased uterine motility, thickening of uterosacral lig
Dx and Mgmt
Dx = endometriosis- chronic pelvic pain
Next step = laproscopy = direct visualization, biopsy, and removal of endometrial lesions
-indicated when conservative tx (NSAIDs/OCPs) fail
Contraindications to breast feeding
Active Tb, maternal HIV, herpetic lesions, varicella less than 5 days before or 2 days after delivery
- chemo/radiation
- active substance use (EtOH, drugs)**
-NOT HEP C
Describe the 5 parts of the BPP
- NST
- Amniotic fluid volume
- Fetal breathing movement
- fetal movement
- fetal tone
BPP: get 2 pts for each, 2 accels
(2) Amniotic fluid volume- single fluid pocket > 2x1cm or amniotic fluid index over 5
(3) 1+ breathing episode for 30+ seconds
(4) 3+ general body movements
(5) 1+ episodes of flexion/extension of fetal limbs or spine
Fetal US shows anterior placenta covering the cervical os and amniotic fluid index under 1.5 with single fluid pocket of 1.5x1cm
- 4 episodes of fetal mov’t
- 2 extension/flexion events
- nonreactive NST
- no fetal breathing
Calculate the BPP
BPP:
(1) 0 pts for nonreactive NST
(2) Oligohydramnios- want amniotic fluid index over 5 => 0 for amniotic fluid volume
(3) no breathing episodes => 0 for breathing episode (want 1+ for 30+ seconds)
(4) 2 pts for 3+ general body movements
(5) 2 pts for 1+ flexion/extension
= 4/10 = indicates fetal hypoxia 2/2 placental dysfunction/insufficiency
34 yo F at 32 weeks gestation p/w intense itching especially on soles of feet
- negative hepatitis panel
- elevated total bile acids, AST/ALT, D. bili
Dx
Intrahepatic cholestasis of pregnancy = functional d/o of bile formation
- presents w/ intense pruritis, 10% present w/ jaundice
- dx of exclusion
Clomiphene citrate
(a) Mechanism
(b) Indication
SERM = selective estrogen receptor modulator prescribed to induce ovulation
-pro-fertility agent to reverse anovaulation (ex: PCOS) or oligoovulation
Acts as estrogen analog to increase GnRH (and therefore FSH) release to stimulate ovulation
Presentation of HELLP syndrome
HELLP = Hemolytic anemia w/ Elevated Liver enzymes and Low Plts
-preeclampsia, nausea/vom, RUQ pain
Describe 3 changes in the BMP seen in pregnancy
- Decreased BUN
- Decrease creatinine
^both 2/2 increased GRD - Mild hyponatremia 2/2 increase in ADH release
Triad of congenital toxo
Chorioretinitis, hydrocephalus, intracranial calcifications
-big give away is intracranial calcifications = toxo
When is GBS testing performed
Test results are valid for about 5 weeks => perform at 35-37 weeks
-purpose is to identify mothers who need ppx abx to prevent transmission
Signs of IUFD
Signs of intrauterine fetal demise (death of fetus after 20 weeks)
- disappearance of fetal movement
- decrease or stagnation in uterine size
- fetal heart sounds no longer present
Not beta-hCG decline- b/c remains elevated as placenta is still in tact
Timeline for giving RhoGAM
Up to 72 hrs after delivery
-so if it’s an emergency and mother starts bleeding you can wait and deal w/ other stuff first
RF for vasa previa
Placenta previa in 2nd T that resolves in the 3rd- b/c possibly leaves vessels over the internal cervical os
Recall: vasa previa = fetal vessels transverse the membranes over the internal cervical os
Presenation of vasa previa
Painless vaginal bleeding w/ ROM
+
Fetal deterioration: sinusoidal waveform or bradycardia
Differentiate fibrocystic changes and fibroadenoma
Both are cyclic changes in breast tissue causing premenstrual tenderness
Fibrocystic changes = multiple diffuse nodulocystic masses
Firboadenoma = solitary nodule
Why do we screen for bacturia in pregnant ladies?
(a) When is the screening?
B/c pregnant F are more likely to have asymptomatic bacturia which can => cystitis, low fetal birth weight, pyelo, preterm birth, increased perinatal mortality
(a) Screen w/ clean-catch UA at 12-16 wks
How to prevent vertical transmission of HIV
Maternal combination (triple drug) tx + neonatal Zidovudine reduces perineal HIV transmission to under 1%
First step to work up a nonreactive fetal stress test
First thing is to let the test go on longer, test is only 20 minutes but fetal sleep cycle can be up to 40 mins => extend test to 40-120 minutes to ensure fetus is not sleepping
Most common symptom of neisseria gonorrhoeae
Usually asymptomatic (over 50%), if symptoms = cervicitis -mucopurulent discharge w/ friable and easily bleeding cervix
What a BPP of 2/10 tells you
BPP tells you about the FUNCTION of the placenta (not location)
BPP under 4/10 indicates fetal hypoxia 2/2 placental insufficiency/dysfunction
Explain why pregnancy is a prothrombic state
- decrease protein S activity
- increase in fibrinogen and cogulation factors
Describe management if pt presents at 37 and 5/7 w/ vaginal spotting
-on exam visualize placental tissue over the internal cervical os
Dx = placenta previa
Mgmt = C-section, vaginal delivery would require placenta to be delivered before the fetus => deprive fetus of O2
-first step would NOT be rhogam, you can give that later!
Describe a reactive fetal nonstress test
3 components for a fetal nonstress test (track HR for 20 mins) to be considered ‘reactive’- aka reassuring or good negative predictive value to r/o fetal hypoxia
- baseline HR 110-160
- moderate variability: 6-25/min
- 2 or more accels w/in 20 mins, each peaking about 15/min above baseline and lasting over 15 sec
NST on a premature fetus
-Describe and explain findings
Premature fetus will have no accels on NST b/c the fetal sympathetic nervous system doesn’t develop until 26-28 weeks
Presentation of placental abruption
Sudden onset bleeding, abdominal pain, hypertonic/tender uterus, tachysystole (frequent contractions)
Differentiate presentation of vasa previa and placenta previa
Vasa previa (fetal vessels transverse membranes overthe internal cervical os)- presents w/ painless vaginal bleeding and fetal deterioration -so see FHR decompensate (tachy --> brady or sinusoidal), while maternal VS remain stable
Placenta previa- bleeding is maternal in origin => you see maternal instead of fetal deterioration
Differentiate active vs. latent labor?
Labor split into 3 stages: dilation of cervix, delivery of baby, delivery of placenta
Dilation of cervix is split into
- latent = 0 to 6 cm
- active = 6 to 10 cm
Malignant features of an ovarian cyst
Solid mass, large size, thick septations, loculations
Describe vaginal discharge/inflammation seen in
(a) Bacterial vaginosis
(b) Trichomoniasis
(c) Candida vaginosis
Type of vaginal discharge/inflammation
(a) Bacterial vaginosis- thin, off white d/c w/ fishy odor
- no vaginal inflammation
(b) Trich- thin yellow/green malodorous frothy d/c
+vaginal inflammation
(c) Cadida- thick ‘cottage cheese’ d/c
+vaginal inflammation
62 yo nulligravid F w/ right adnexal enlargement
-US reveals 5cm r. ovarian cyst
First step in dx
Evaluating adenexal mass in postmeno F- first step is measure CA-125
-dont measure CA-125 in premenopausal b/c can be elevated for tons of other reasons (fibroids etc)
Then tx depends on CA-125
If elevated => CT scan or met disease exploratory surgery
CA-125 not elevated- see if malignant features of ultrasound
40 yo G5P0040 at 35 weeks p/w no fetal mov’t x24hr, NST for 1 hr shows no accels, US at 32 wks showed fetus in breech w/ placenta previa
Next step in management?
BPP (biophysical profile)
After nonreactive NST- do BPP or CST (contraction stimulation test) to determine if C-section is indicated
-in this case there is placenta previa => CST is contraindicated
How to differentiate fetal head compression vs. umbilical cord compression on fetal stress test
Fetal head compression causes fetal autonomic response to the alteration in ICP caused by contractions => get early decels
-shallow decrease in FHR that occurs w/ contractions
Cord compression causes variable decels
-abrupt drops in FHR ranging in depth/duration
23 yo at 38 weeks gestation presents w/ ROM at 2cm dilated, -1 station.
- 8cm dilation and 0 station over next 5 hrs
- over next 3 hrs: no change in cervical dilation or fetal descent
- contractions are adequate
- NST reactive
Next step?
Close observation for 1 more hour- by definition this pt is in protracted labor (slower than expected progress)
Not yet in arrested labor (after which you’d do C-section) b/c arrested labor = dilation over 6cm w/ ROM + either
- no cervical change for 6+ hrs w/ inadequate contractions
- no cervical change for 4+ despite adequate contractions
Clinical presentation of ruptured hepatic adenoma
Intraabdominal bleeding w/ peritoneal signs (rebound/guarding) and hypotension (2/2 acute blood loss)
Mother smokes- can she BF?
Not an absolute contraindication (EtOH and drug use is tho)
-but smoking and BF does increase risk of SCID and infant respiratory allergies
Tx for pt w/ PCOS who wants to get pregnant
Metformin- independently shown to improve ovulation
Clomiphene citrate = SERM (estrogen analogue) to induce ovulation
Contraindication to BF from infant
Only one is galactosemia
all others come from the mother- active infxn, substance use
When is C-section indicated in HIV+ mother
Only if viral load is under 1,000 copies
-so if mother is HIV+ w/ viral load under 1,000 there is no increased risk of transmission from vaginal delivery
Presentation of placenta previa
Painless vaginal bleeding
-confirm w/ US
27 yo w/ h/o PID p/w infertility
Key step in assessment
Assess fallopian tube patency w/ hysterosalpingogram
-assessing for tubar scarring/obstruction
When is RhoGAM given?
To Rh (-) mother first at 28-32 weeks, then again within 72 hrs of labor (or induced abortion, or abnormal vaginal bleeding etc) `
Mother w/ hep C- can she breast feed?
Yes! Never been demonstrated to be transmitted thru breast milk
- strongly encourage BF
- only stop if nipples are cracked or bleeding
Etiology of premature ovarian failure
Most commonly idiopathic
-mumps, oophoritis, irradiation, chemo
2/2 accelerated follicular atresia or low number of initial primordial follicles
5 parts of the biophysical profile
BPP: 8 out of 10 is considered normal and suggests fetus is not hypoxic (well oxygenated)
2 pts for each
- NST
- Amniotic fluid volume
- Fetal breathing movement
- fetal movement
- fetal tone
Pregnant mother w/ new onset hirsuitism and acne
-US: bilateral solid 7cm cysts in both ovaries
Dx
Mgmt
Pregnancy luteomas and theca luteum cysts are the most common causes of hyperandrogenism in pregnancy
Both benign, luteomas more likely than tehca luteum cysts to cause fetal virilization
Both likely to spontaneously regress, watch and wait
What is a bloody show?
Small amount of blood or blood-tinged mucus that comes out the vagina right before or at the beginning of labor
-freeing mucus and blood that occupied the cervical galnds or cervical os as the cervix changes shape
24 yo G2P1 p/w routine clean-catch UA with 120k colonies of E. Coli
Dx
Tx
Dx = Asymptomatic bacturia
-treat this in pregnant ladies b/c can => cystitis, pyelo, low birth wt, preterm bith, increased perinatal mortality
Tx:
Nitrofurantoin 5-7 days
Amox (or augmentin) 3-7 days
Fosfomycin single dose
Recall Batrim containdicated in pregnancy
Differentiate protracted from arrested labor
Differentiate management
Both describing the first stage of labor (0 to 10cm dilation of cervix)
Protracted = slower than expected progress, watch and wait, act if persists to arrested
Arrested = dilation over 6cm w/ ROM + either
-no cervical change for 4+ hrs despite adequate contractions
-no cervical change for 6+ hrs w/ inadequate contractions
Mgmt = C-section
Next step after NST is nonreactive for 90 minutes
Nonreactive stress test- high false positive rate => C-section is only indicated if BPP (biophysical profile) or CST (contraction stimulation test) is also abnormal)
Slide prep of
(a) BV
(b) Trich
(c) Candida vaginitis
Slide prep findings
(a) BV- Clue cells
+Whiff test- amine odor w/ KOH
(b) Trich- motile trichomonads
(c) Candida- pseudohyphae
Presentation of uterine rupture
Sudden onset vaginal bleeding w/ abdominal pain
- cessation of uterine contractions
- loss of fetal station
- fetal deterioriation
What is adenomyosis?
Ectopic endometrial tissue in the myometrium (endometrial galnds in the uterine muscle)
Changes in the following during pregnancy
(a) Cardiac output
(b) HR
Blood volume increases, SVR decreases => increase in HR and CO
When is the quad screen done?
15-20 wks
Ddx for abnormal pH of vaginal secretions
Bacterial vagnosis and trich have vaginal secretions over 4.5
Tx for
(a) BV
(b) Trich
(c) Candida vaginitis
Tx for
(a) BV- metronidazole or clindamycin
(b) Trich- metronidazole for pt and partner
(c) Fluconazole
26 yo G2P2 6 hrs s/p NSVD w/ epidural presents w/ continuous dribbling of urine and fullness/tenderness above the pubic symphysis on exam
Dx
Mgmt
Dx = pospartum urinary retention w/ overflow incontinence
-RF include nulliparity, prolonged labor, epidural anesthesia
Mgmt = insert urinary catheter (diagnostic and therapeutic)
-can’t watch and wait b/c don’t want to allow overdistention of the bladder
=> can damage detreusor or cause bladder wall ischemia
Tx of Graves’ disease during pregnancy
Preferred drug for hyperthryoid during 2nd/3rd T = Methimazole
Explain CBC changes seen in pregnancy
Diluational anemia 2/2 increase in plasma volume w/ smaller increase in RBC mass
Risk factors for placenta previa
Maternal age over 35, multiparity
Define premature ovarian failure
Amenorrhea (3+ mo), hypoestrogenism, elevated gonadotropic hormones in female under 40 yoa
How ultrasound can be used to differentiate uterine atony and retained placental parts as a cause of postpartum hemorrhage
Ultrasound to look at the endometrial stripe
-thin endometrial stripe suggests empty and normal uterine cavity
24 yo at 28 wks gestation presents for absence of fetal cardiac activity x2 wks
-low serum fibrinogen, thrombocytopenia, prolonged PT/PTT
(a) Dx
(b) Next best step
(a) IUFD = intrauterine fetal demise = death of fetus in utero after 20 wks
Retention of dead fetus can => chronic consumptive coagulopathy
(b) If any coagulation derangement is suspected- tx is delivery w/o delay
- dont need to give FFP transfusion first bc expected that abnormalities will resolve after birth of retained parts
RF for cervical insufficiency
Cervical LEEP or cone biopsy
DES exposure
Multiple gestation, h/o preterm birth, or 2nd trimester pregnancy loss
Pt p/w “closed cervix appearing shorter than normal”
Next step in management
Transvaginal ultrasound = gold standard diagnostic test for cervix incompetence
Why is early diagnosis of premature ovarian failure important?
Prevent osteoporosis at a young age
Early dx- why criteria is only 3 mo (instead of a year) of amenorrhea
27 yo G2P1 at 19 weeks gestation p/w N/V/RLQ pain
- febrile to 100.4, WBC 16k
- tenderness and guarding in RLQ
Dx and mgmt
Acute appendicitis- first step is abdominal ultrasound
NOT CT (umm pregnancy and radiation is a no no)
73 yo F p/w foul smelling bloody vaginal d/c for several mo, 40 pack yr smoker
PE: irregular lesion of the upper 1/3 of the posterior vaginal wall
Next step?
Dx w/ biopsy- most likely squamous cell carcinoma of the vagina
Vaginal cancers
- squamous cell: over age 60, associated w/ smoking, upper 1/3 of posterior vaginal wall
- Clear cell: under 20 yoa, inutero DES exposure, upper 1/3 of anterior vaginal wall
Etiologies of IUFD
Intrauterine fetal demise (death of fetus after 20 weeks)
- diabetes, hypertensive d/o of mother
- antiphospholipid syndrome
- luteal phase defect in mother
- infections: TORCH or listeriosis
What is vasa previa?
How does it present?
Vasa previa = fetal vessels transverse the membranes over the internal cervical os
=> p/w painless vaginal bleeding w/ ROM and fetal deterioriation (tachy then brady or sinusoidal) while mothers VS remain stable
27 yo G1P0 at 28 weeks p/w lack of fetal movement x48 hrs
Next step in management
Real-time sono
- to demonstrate absence of fetal movement and cardiac activity
- aka to rule in/out IUFD (intrauterine fetal demise)
Differentiate dermoid cyst from hydrosalpinx findings on US
Dermoid cyst on US = hyperechoic/calcified mass in ovary
Hydrosalpinx = mass separate from the ovary
Risk factors for impaired oocyte transport => infertility
Previous PID or endometriosis
Define dysparenuria
Painful or difficult sexual intercourse
25 yo w/ endometriosis is at greatest risk for developing what?
Infertility
-resection of endometriosis improves conception rate
40 yo G2P1 at 10 wks gestation
-cousin w/ Downs and wants to know her risk
Next best step
Order plasma cell-free fetal DNA testing = cffDNA can be ordered anytime 10+ wks gestation, graet sensitivity and specificity for trisomy (21, 18, 15)
If abnormal- confirm results w/ CVS (10-12 wks) or amniocentesis (15-20 wks)
What is tachysystole?
Abnormal or excessive uterine contractions that impair blood flow and oxygen delivery to the fetus
ex: if give oxytocin to already appropriately contracting mother
Why do we not use the following to tx UTI in pregnancy
(a) Fluoroquinolones
(b) Bactrim
(a) Fluoroquinolones increase risk of fetal cartilage abnormalities
(b) Bactrim relatively contraindicated in 1st and 3rd T b/c of increased risk of neonatal kernicterus
Describe ABG changes seen in pregnancy
Chronic respiratory alkalosis (low pCO2) w/ metabolic compensation (kidney excretes bicarb)
-due to progesterone’s direct stimulation of the central respiratory centers to increase TV and minute ventilation
Ultrasound appearance of a mature teratoma
Mature teratoma = Dermoid cyst
Calcification and hyperechoic nodule on ultrasound
When you can do amnio and CVS
Amnio 15-20 wks (same time when quad screen done)- second trimester
Chorionic villi sampling- earlier, 10-12 wks
Tx for HELLP
Microangiopathic hemolytic anemia and elevated liver enzymes w/ low plts
- Delivery the child
- Mg for seizure ppx
- Antihypertensive meds
Define IUFD
IUFD = intrauterine fetal demise = death of fetus after 20 weeks
23 yo at 38 wks gestation presents w/ ROM at 2cm dilated, 01 station
- next 5 hrs: 8cm dilated and 0 station
- next 3 hrs: no change in cervical dilation or fetal descent
- IUPC shows adequate contractions
- NST
Role of oxytocin in her management?
Wouldn’t help- she’s having normal contractions (IUPS showing contractions w/ montevideo units over 200)
-oxytocin would only put her at risk for tachysystole
27 yo nulliparious p/w intermittent l. pelvic pain x8 mo
- exacerbated by exercise
- stopped OCPs 2 yrs ago to have child w/ husband
- PE: normal sized uterus w/ enlarged left adnexa
- US: homogeneous cystic-appearing mass on left ovary
Dx
Endometriosis
- chronic (6+ mo) pelvic pain in reproductive age F
- noncyclic pain exacerbated by exercise
- fixed immobile uterus, adenexal mass
- cyst suggestive of ovarian endometrioma
- common consequence = inferility
53 yo G2P2 F p/w r. sided pelvic pain w/ bloating x3 mo, h/o chlamydia in 40s
-pelvic US: r. ovarian mass w/ thick septations and moderate periotneal fluid
Dx
Dx = ovarian carcinoma
-septations and ascites suggestive of malignancy
What is a dermoid cyst?
Dermoid cyst = mature cystic teratoma = benign ovarian tumor from ectodermal cells
-appears hyperechoic/calcified on US
Presentation of congenital syphilis in baby
Syphilis = intermittent fever, osteitis (bony inflammation), mucocutaneous lesions
Ultrasound findings of a uterine mass suggestive of cancer
- solid mass
- thick septations
- peritoneal free fluid (ascites)
What is a contraction stimulation test
Administer oxytocin or nipple stimulation until 3 contractions occur q10 min
Mechanism of consumptive coagulopathy in retention of dead fetus
Gradual release of tissue factor (thromboplastin) from the placenta into maternal circulation
