UWorld 1 Flashcards
modifiable breast cancer RF
- hormone replacement therapy
- nulliparity
- inc age at first live birth
- alcohol consumption
non-modifiable breast cance RF
- genetic mutation of breast cancer in first degree relatives
- white race
- increasing age
- early menarche or later menopause
second stage arrest of labor-definition
insufficient fetal descent after pushing for
- > 3 hr if nulliparous
- > 2 hr is multiparous
second stage arrest of labor-RF
- maternal obesity
- excessive pregnancy weight gain
- DM
second stage arrest of labor-etiology
- cephalopelvic disproportion
- malposition
- inadequate contractions
- maternal exhaustion
second stage arrest of labor-management
- operative vaginal delivery
- cesarean delivery
pre-eclampsia definition
-new onset HTN (SBP >140 and/or DBP>90) at >20 weeks gestation
PLUS
-proteinuria and/or end-organ damage
pre-eclampsia severe features
- SBP >160 or DBP >110 (2x, >4hr apart)
- thrombocytopenia
- inc Cr
- inc transaminases
- pulmonary edema
- visual or cerebral s/s
pre-eclampsia management
- without severe features: delivery at >37 weeks
- WITH severe features: delivery at >34 weeks
- magnesium sulfate (sz ppx)-IV or IM
- antihypertensives (lower stroke risk): Hydralazine IV, Labetalol IV, or Nifedipine PO
RF for neonatal HSV infection
- primary maternal infection
- longer duration of ROM
- vaginal delivery with active lesions
- impaired skin barrier (eg fetal scalp electrode)
- preterm birth
What are the (5) hypertensive disorders of pregnancy
- chronic HTN
- gestational HTN
- preeclampsia
- eclampsia
- chronic HTN with superimposed preeclampsia
chronic HTN in pregnancy
-SBP: >140 and/or DBP >90 prior to conception or 20 weeks gestation
gestation HTN
-new onset elevated BP at >20 wk gestation
AND
-no proteinuria or signs of end-organ damage
eclampsia
preeclampsia AND new onset grand mal sz
chronic HTN with superimposed preeclampsia
chronic HTN AND one of the following:
- new onset proteinuria or worsening of existing proteinuria at >20 wks gestation
- sudden worsening of HTN
- signs of end organ damage
pregnancy-related risks due to HTN (maternal)
- superimposed preeclampsia
- postpartum hemorrhage
- gestational diabetes
- abruptio placentae
- cesarean delivery
pregnancy-related risks d/t HTN (Fetal)
- fetal growth restriction
- perinatal mortality
- preterm delivery
- oligohydramnios
(THREE) causes of abnml menstrual bleeding
- Fibroids: heavy menses, constipation, urinary frequency, pelvic pain/heaviness, enlarged uterus
- Adenomyosis: dysmennorhea, pelvic pain, heavy menses, bulky/globular/tender uterus
- Endometrial ca/hyperplasia: h/o obesity, nulliparity, or chronic anovulation; irregular/intermenstrual/postmenopausal bleeding; nontender uterus
causes of acute abdomen/pelvic pain in women
- mittelschmerz
- ectopic pregnancy
- ovarian torsion
- ruptured ovarian cyst
- PID
Mittelschmerz
- recurrent mild and unilat mid-cycle pain prior to ovulation
- pain lasts hours to days
- US not indicated
ectopic pregnancy
- amenorrhea, abdo/pelvic pain, vaginal bleeding
- positive beta-hCG
- US: no intrauterine pregnancy
ovarian torsion
- sudden-onset, severe, u/l lower abdo pain; n+v
- u/l, tendet adnexal mass on examination
- US: enlarged ovary with dec or absent blood flow
ruptured ovarian cyst
- sudden-onset, severe, u/l lower abdo pain immediately following strenuous or sexual activity
- US: pelvic free fluid
PID
- f/c, vaginal d/c, lower abdo pain and cervical motion tenderness
- US: sometimes tubo-ovarian abscess
Maternal thyroid testing in pregnancy, first trimester
- Total T4 INC and Free T4 unchanged/mildly INC
- –mech: beta hCG stimulates thyroid hormone production in 1T; estrogen stimulates TBG; thyroid INC hormone production to maintain steady free T4 levels
- TSH DEC
- –mech: INC beta-hCG and thyroid hormone suppress TSH secretion
complications of shoulder dystocia (FIVE)
- fractured clavicle
- fractured humerus
- Erb-Duchenne palsy
- Klumpke palsy
- perinatal asphyxia
fractured clavicle 2/2 shoulder dystocia
- clavicular crepitus/bony irregularity
- dec Moro reflex d/t pain on affected side
- intact biceps and grasp reflexes
fractured humerus 2/2 shoulder dystocia
- upper arm crepitus/bony irregularity
- dec Moro reflex d/t pain on the affected side
- intact biceps and grasp reflexes
Erb-Duchenne palsy 2/2 shoulder dystocia
- dec Moro and biceps reflexes on affected side
- waiter’s tip: extended elbow, pronated forearm, flexed wrist and fingers
- intact grasp reflex
Klumpke palsy 2/2 shoulder dystocia
- claw hand: extended wrist, hyperextended metacarpophalangeal joints, flexed interphalangeal joints, absent grasp reflex
- Horner syndrome (ptosis, miosis)
- intact Moro and biceps reflexes
Perinatal asphyxia 2/2 shoulder dystocia
- variable CP depending on duration of hypoxia
- AMS (irritability, lethargy), respiratory or feeding difficulties, poor tone, seizure
benign breast disease
breast cyst
-solitary, well-circumscribed, mobile mass, tenderness
fibrocystic changes
- multiple diffuse nodulocystic masses
- cyclic premenstrual tenderness
fibroadenoma
- solitary, well-circumscribed, mobile mass
- cyclic premenstrual tenderness
fat necrosis
- post-trauma/surgey
- firm, irregular mass
- +/- ecchymosis, skin/nipple retraction
Palpable breast mass
- <30 do ultrasonogram +/- mammo
- –>simple cyst then needle aspiration if pt desires
- –>complex cyst/(solid) mass then image-guided core biopsy
> 30 do mammo +/- ultrasonogram; if suspicious for malignancy do a core biopsy
obesity and amenorrhea
- obesity is a common cause of amenorrhea
- amenorrhea is a result of anovulation
- the FSH and LH levels are usually nml
- ovaries still producing estrogen, but progesterone is not being produced at the nml post-ovulation levels SO progesterone withdrawal menses at the end of the cycle doesnt occur
post partum hemorrhage (PPH)
- ob emergency, major cause of maternal mortality
- hemostasis after placental delivery is achieved by clotting and by compression of the placental site blood vessels by myometrial contraction (disruption of either of these can lead to PPH)
more PPH
- occurs <24hr s/p delivery and is most commonly caused by uterine atony
- atony occurs when uterus becomes fatigued (prolonged labor), over-distended (fetal weight >4000g/8.8lb, multiple gestation OR unresponsive to oxytocin from oxy receptor saturation
- other RF for atony: operative (forceps-assisted) vaginal delivery and hypertensive d/o
- uterus fails to contract and is soft “boggy” and enlarged (above the umbilicus) on PR
PPH definition
> 500 mL after vaginal delivery
>1000 mL after cesarean delivery
PPH RF
- prolonged or induced labor
- chorioamnionitis
- multiple gestation
- polyhydramnios
- grand multiparity
- operative delivery
PPH causes
- uterine atony (most common)
- retained placenta
- genital tract laceration
- uterine rupture
- coagulopathy
PPH treatment
- bimanual uterine massage, oxytocin
- IVF, oxygen
- uterotonics (methylergonovine, carboprost, misoprostol)
- intrauterine balloon tamponade
- uterine artery embolization
- hysterectomy
renal and urinary changes in nml pregnancy
Physiologic:
-inc renal blood flow, INC GFR, INC renal basement membrane permeability
Labs:
-DEC serum BUN, DEC serum Cr, INC renal protein excretion
What are the FOUR antepartum fetal surveillance tests
- nonstress test
- Biophysical profile
- contraction stress test
- doppler sonography of the umbilical artery
Nonstress test
- external FHR monitoring for 20-40 mins
- will see reactive >2 accels
- abnml would be nonrxv: <2 accels, recurrent variable, or late decels
BPP
nonstress test plus US assessment of:-amniotic fluid
-fetal breathing movement
-fetal tone
TWO points per category if nml and 0 points if abnml (max: 10/10)
nml results: 8 or 10 pts
equivocal: 6 pts
abnml: 0,2,4 pts; oligohydramnios
contraction stress test
external FHR monitoring during spontaneous or induced (eg oxytocin, nipple stim) uterine contractions
nml: no late or recurrent variable decels
abnml: late decels with >50% of contractions
Doppler sonography of the umbilical artery
eval of the umbilical artery flow in fetal IUGR only
- nml: high velocity diastolic flow in umbilical artery
- abnml: dec, absent, or reversed end-diastolic flow
HELLP
- complication of preeclampsia
- thrombocytopenia, microangiopathic hemolytic anemia, and inc liver enzymes
- path: hepatic and systemic inflammation, activation of coag cascade, and platelet consumption
HELLP clinical features
- preeclampsia
- n/v
- RUQ abdo pain
HELLP tx
- delivery
- magnesium for seizure ppx
- antihypertensive drugs
Osteoporosis nonmodifiable RF:
- advanced age
- postmenopausal
- low body weight
- white or asian ethnicity
- malabsorption disorders
- hypercortisolism, hyperthyroidism, hyperparathyroidism
- inflammatory d/o (RA)
- chronic liver or renal dz
Osteoporosis modifiable RF
- smoking
- excessive alcohol intake
- sedentary lifestyle
- meds (GC, anticonvulsants)
- VIt D deficiency, inadequate calcium intake
- estrogen deficiency (premature menopause, hysterectomy/oophorectomy)
risks for pre-term labor
- prior spontaneous preterm delivery
- multiple gestation
- short cervical length
- cervical surgery (cold knife conization)
- cigarette use
screening and prevention of preterm labor
- cervical length measured by TVUS
- progesterone administration
- cerclage placement
Adolescent cycles
- often anovulatory with irregular, heavy menstrual bleeding d/t an immature hypothalamic-pituitary axis
- progesterone normalized menstruation by stabilizing unregulated endometrial proliferation
What are the FOUR disorders of sexual development
- complete androgen insensitivity syndrome
- Mullerian agenesis (Mayer-Rokitansky-Kuster-Hauser syndrome)
- transverse vaginal septum
- turner syndrome
complete androgen insensitivity syndrome
cause: x-linked mutation of androgen R
- absent uterus and upper vagina; cryptorchid testes
- minimal to absent axillary and pubic hair
- 46 XY
Mullerian agenesis
cause: hypoplastic or absent mullerian ductal system
- absent or rudimentary uterus and upper vagina; nml ovaries
- nml axillary and pubic hair
- 46 XX
transverse vaginal septum
cause: malformation of urogenital sinus and mullerian ducts
- nml uterus, abnml vagina, nml ovaries
- nml axillary and pubic hair
- 46 XX
Turner syndrome
cause: complete/partial absence of 1 X chromosome
- variable breast development depending on ovarian function
- nml uterus and vagina, streak ovaries
- nml axillary and pubic hair
- 45X
Follicular phase and luteal phase
(F) primary follicle, secondary follicle, vesicular follicle
–day 14: ovulation–
(L) corpus luteum, regression, corpus albicans
cervical mucus
-just prior to ovulation is profuse, clear, thin, corresponds with an LH surge
post partum urinary retention RF
- primiparity
- regional anesthesia
- operative vaginal delivery
- perineal injury
- cesarean delivery
post partum urinary retention clinical features and management
CF:
- inability to void or small-volume voids
- incomplete bladder emptying
- dribbling of urine
Management:
- self-limited condition
- intermittent catheterization
Trial of labor is contraindicated for:
- classical cesarean delivery (vertical incision)
- abdominal myomectomy with uterine cavity entry
medically emancipated minors
- emergency care
- STI
- substance abuse
- pregnancy care
- contraception
emacipated minor
- homeless
- parent
- married
- military service
- financially independent
- high school graduate
Prenatal testing
first trimester combined test (9-13wk)
-early screening, not diagnostic
cell-free fetal DNA (>10wk)
-high sn and sp for aneuploidy, not diagnostic
chorionic villus sampling (10-13wk)
- definitive karyotype diagnosis
- invasive, r/o spontaneous abortion
second trimester quad screen (maternal serum AFP, estriol, beta-hcg, inhibin A) (15-22 wk)
- screends for NTD and aneuploidy
- not diagnostic
amniocentesis (15-20wk)
- definitive karyoptype diagnosis
- invasive, r/o membrane rupture, fetal injury and pregnancy loss
second trimester US (18-20)
- measures fetal growth, evaluates fetal anatomy, confirms placenta position
- cant id all abnormalities, some findings are of uncertain significance
imperforate hymen
- anatomic cause of primary amenorrhea
- pubertal pts typically present w/ cyclic lower abdo pain, amenorrhea, hematocolpos
- pelvic exam: smooth, blue, bulging vaginal mass that swells with inc intraabdominal pressure
transverse lie
- occurs when fetal longitudinal axis is perpendicular to the longitudinal axis of the uterus
- most fetuses in transverse lie spontaneously convert to vertex presentation prior to term.
- persistent malpresentation at term can be managed with external cephalic version or cesarean delivery
functional hypothalamic amenorrhea
-cause: excessive weight loss, strenuous exercise, chronic illness, eating disorder…leads to….dec adipose tissue/fat reserves, dec leptin production…leads to…hypothalamus (dec GnRH)…leads to…pituitary (dec LH, FSH)…leads to…ovaries (dec estrogen)
emergency contraception options
- copper IUD
- ulipristal pill
- levonorgestrel pill
- OCPs
copper IUD
- copper causes inflammatory rxn that is toxic to sperm and ova and impairs implantation
- 0-120 hours after intercourse
- 99% effective
Ulipristal pill
- antiprogestin; delays ovulation
- 0-120 hours after intercourse
- > 85% efficacy
Levonorgestrel pill
- progestin, delays ovulation
- 0-72 hours after intercourse
- 85% efficacy
OCPs
- progestin; delays ovulation
- 0-72 hr after intercourse
- 75% effective
LBP during pregnancy Etiology
- enlarged uterus–>exaggerated lordosis
- joint/ligament laxity from INC progesterone/relaxin
- weak abdo muscle–>dec lumbar support
LBP d/r pregnancy RF and management
RF: xs weight gain, chronic back pain, back pain in prior pregnancy, multiparity
management: behavioral modifications, heating pads, analgesics
suspected endometriosis
- chronic pelvic pain
- dysmenorrhea
- deep dyspareunia
- dyschezia (pain with defecation)
- infertility
manage with either laparoscopy or NSAIDS (ibuprofen, naproxen) +/- combined (estrogen and progestin) OCP.
- if yes to the following do laparoscopy:
- -contraindications to medical therapy
- -need for definitive diagnosis
- -h/o infertility
- -concern for malignancy or adnexal mass
Complications in DES daughters
- clear cell adenocarcinoma of the vagina and cervix
- structural anomalies of the reproductive tract: hooded cervix, T-shaped uterus, small uterine cavity, vaginal septae, vaginal adenosis
- pregnancy problems (ectopic pregnancy, pre-term delivery)
- infertility
Endometriosis Clinical Features
- immobile uterus
- cervical motion tenderness
- adnexal mass
- recto-vaginal septum, posterior cul-de-sac, uterosacral ligament nodules
(diagnosis with visualization and surgical biopsy)
fetal growth restriction
symmetric: 1T, chromosomal abnormalities, congenital infection, global growth lag
asymmetric: 2T/3T, utero-placental insufficiency or maternal malnutrition; head sparing growth lag
both: US estimated fetal weight <10th percentile for gestational age
management: weekly BPP, serial umbilical artery Doppler sonography, serial growth US
Management of hydatidiform mole
- suction currettage
- followed by serial beta-hcg levels until levels are undetectable for at least 6 months
- contraception is required during the surveillance period
Septic pelvic thrombophlebitis
RF:
- cesarean delivery
- pelvic surgery
- endometritis
- PID
- pregnancy
- malignancy
Path:
- hypercoagulability
- pelvic venous dilation
- vascular trauma
- infection
Presentation:
- fever unresponsive to ABx
- no localizing s/s
- negative infectious evaluation
- diagnosis of exclusion
tx: anticoagulation, broad-spectrum Abx
