UWorld 2 Flashcards
28 yo G2P1 at 37 wks p/w hypotension and tachycardia
- h/o C-sxn
- PE: palpable, irregular protuberance in lower abdomen and moderate vaginal bleeding
- FHT: late decels
Rupture uterus
- increased risk given h/o C-sxn
- palpable fetal part
- late decels indicating uteroplacental insufficiency (b/c uterus is ruptured…)
Mechanism of acute postpartum urinary retention
Bladder atony 2/2 a decrease in detrusor tone
Screening test for ovarian cancer
There is none…
-so if person wants to be screened (concerned b/c friend has it etc) there is no good option
Best diagnostic test for primary syphilis
Dark field microscopy showing spirochetes
At the time of primary syphilis- often too early, antibodies aren’t made yet => RPR would give false negative
Differentiate the etiologies of symmetric vs. asymmetric fetal growth restriction
Symmetric (both head and body affected): 2/2 fetal factors
- chromosomal abnormalities
- early maternal infection (causing congenital infxns)
Asymmetric (only body affected, head intact), 2/2 fetal adaptation to suboptimal maternal factors
- ‘head sparing’ fetal growth restriction
- maternal HTN, DM, preeclampsia, smoking
78 yo w/ h/o Alzheimer’s p/w urinary incontinence x1 week
- less active
- afebrile
Next best step
UA and Cx-
UTI is a very common cause of acute urinary incontinence in the elderly
Clinical features of newborn clavicular fracture
Crepitus over the clavicle/palpable bony irregularity
-complication of macroscomia
36 yo F p/w lump in right breast found on self exam
- no other symptoms
- 1 cm firm, round mass in UOQ of right breast w/ no palpable LN
Next step?
Palpable breast mass, next step depends on age
Over 30: mammogram is first step
Under 30: Ultrasound in first step
So first use mammorgam (pt is 36) to further locate/characterize lump
45 yo G5P5 p/w involuntary loss of urine x5mo while jogging
- loses small amoung after coughing
- normal UA and low post-risidual volume
(a) Dx
(b) Mechanism
(a) Stress incontinence
(b) Urethral hypermobility
Define tachysystole
Tachysystole = abnormally frequent contractions defined as more than 5 contractions in 10 minutes averaged over 30 minutes
Main clinical feature of Sheehan syndrome
Sheehan syndrome = postpartum hypopituitarism 2/2 pituitary necrosis from hypovolemic shock/bloodloss after childbirth
Presents w/ lactation failure w/ hypotension and anorexia (2/2 adrenal insufficiency)
Clinical presentation of placental abruption
Biggest one = sudden-onset vaginal bleeding
- abdominal or back pain
- high-frequency (really close together), low-intensity contractions
ex: contractions q2 minutes - hypertonic, tender uterus
Diagnosed primarily by clinical presentation, then can use US to r/o placenta previa
Mechanism by which urinary incontinence risk increases in post-menopausal women
Estrogen deficiency
Hypoestrogenemia => atrophy of urethral mucosal epithelium and diminished urethral closure pressure => urinary frequency, urgency, UTI, incontinence
Tx = low-dose vaginal estrogen
23 yo F presents for infertility, irregular periods for past 2 yrs
- intense exerciser, lots of stress at work, BMI 18, negative pregnancy test
- labs: low FSH/LH, normal prolactin/TSH
(a) Dx
(b) Tx
(a) Hypogonadotropic hypogonadism
- problem is at the level of the hypothalamus not secreting proper GnRH
(b) Tx = pulsatile GnRH
Purpose if fetal fibronectin screening
Screening test for preterm labor-
-Best for negative predictive value (sensitive not specific): good predictor of spontaneous preterm labor before cervical dilation
-done as vaginal swab (preferably before manipulation by vaginal exam)
43 yo G6P5 at 39 wks w/ brief TC seizure
- BP 80/40, HR 110/min, RR 30, O2 75% on facemask
- PE: purpuric rash and bleeding from IV site
Dx
Mgmt
Respiratory failure 2/2 amniotic fluid embolism
-hypoxemia => seizures
Mgmt = intubation and mechanical ventilation
Common causes of fetal tachycardia
Maternal fever (ex: chorio)
Maternal hyperthyroid
Medication use (ex: terbutaline- tocolytic)
Placental aburption
Pt w/ hyperemesis gravidarum has pelvic US: enlarged ovaries w/ multilocular cystic appearance
Dx
Molar pregnancy
- b/l ovarian enlargement 2/2 hyperstimulation and ovarian cyst formation (theca lutein cysts)
- even more elevated beta-hCG puts these pts at higher risk for hyperemesis
When is external cephalic version performed
External cephalic version = convert breech into vertex for delivery
- performed btwn 37 weeks and onset of labor
- not before 37 wks: breech before can just move/convert to vertex
Thyroid hormone production during pregnancy
T4/T3/TSH
During pregnancy- total T4 is 1.5x greater than pre-pregnancy state, free T4 and T3 moderately increased
-slightly decreased TSH production b/c higher T3/T4 suppresses the TSH
beta-hCG stimulates thyroid hormone production, estrogen does increase TBG production but net effect is increase in T4
39 yo G4P0030 at 35 wks p/w intense constant lower abdominal pain
- h/o fibroids, s/p abdominal myomectomy where uterine cavity entered
- cervical dilation of 4cm, contractions q2-3 min
- FHR: persistent variable decels to the 90s
Next best step
Laparotomy and delivery
-aka C-section
Abdominal myomectomy- if uteirne cavity is entered then trial of labor is contraindicated 2/2 risk of uterine rupture
(if uterine cavity not entered you can do trial)
Cause of infertility:
37 yo w/ regular 28 day cycles, no other GU complaints
- no h/o STIs
- previous child w/ husband at age 31
- aeorbics instructor, normal vital
Decreased ovarian reserve
-significant drop in oocytes in 4th decade, one in 5 women are infertile btwn 35-39
What is hyperemesis gravidarum?
Such excessive/severe nausea/vomiting in pregnancy that it results in wt loss and dehydration
Causes of hypogonadotropic hypogonadism
Hypogonadotropic hypogonadism causes infertility 2/2 hypothalamic dysfunction: insufficient GnRH pulses from hypothalamus causes insufficient LH/FSH production
Causes: severe life stressors, eating d/o, excessive exercise
- anorexia
- marathon runners
2 maternal complications of abruptio placentae
2 maternal complications of placental abruption
- DIC
- hypovolemic shock
Increased risk w/ larger detachment
Which is a worse risk factor for osteoporosis: obesity or excessive EtOH
Ok so adipose tissue actually is protective from osteoporosis- inherent increase in wt bearing and adipose tissue acts as endogenous source of excess estrogen
2 hr old boy w/ minimal right arm movement after vacuum-assisted vaginal delivery at 37 wks gestation c/b shoulder dystocia
- birth wt 9 lbs
- RUE: adduction and internal rotation w/ elbow extended
- absent moro and biceps reflexes
Next step
Reassurance about prognosis
2/2 Erb-Duchenne palsy (brachail plexus injury to C5-7) => ‘waiter’s tip posture’
- up to 80% have spontaneous recovery
- surgical intervention only if no improvement by 3-6 mo
Function of MgSO4 when not used for seizure ppx
Give MgSO4 in under 32 weeks gestation when anticipating preterm birth for fetal neuroprotection, specifically CP (cerebral palsy)
28 yo G1P0 at 35 wks p/w N/V/epigastric and RUQ pain
- gestation HTN, BP 160/94, 2+ edema, 3+ protein on UA
- elevated AST/ALT, PT/PTT
(a) Dx
(b) Pathophys
(a) HELLP = hemolysis and elevated liver enzymes w/ low platelets
- complication/subtype of severe preclampsia
(b) Systemic inflammation and platelet consumption
- platets rapidly consumed and microangiopathic hemolytic anemia causes hepatocellular necrosis
Tx for urinary incontinence
(a) stress
(b) Urge
(c) Overflow
Treatment for urinary incontinence
(a) stress: kegels and urethral sling surgery
(b) Urge (sudden overwhelming need to empty bladder) tx w/ antimuscarinic
(c) tx overflow w/ cholinergic agents
- last line catheterization
What risk does tachysystole pose to the baby?
Tachysystole: insufficient time between contractions for uterus to relax => causes placental spiral artery constriction
Can => fetal hypoxia/acidemia
Risk of a complete molar pregnancy
Molar pregnancy = abnormal trophoblastic proliferation following abnormal fertilization, complete molar pregnancies have a 2.5% risk of developing into choriocarcinoma (malignant trophoblastic cancer)
First step in workup for palpable breast mass
First step depends on pt’s age
Under 30: do ultrasound +/- mammogram
30 or over: do mammogram +/- ultrasound
Differentiate the patterns of symmetric vs. asymmetric fetal growth restriction
Symmetric: growth lag begins at 1st-2nd trimester (before 28 wks)
-both head and body are affected
Asymmetric: head grows appropriately, fetus redistributes blood flow to vital organs
Clinical presentation of CAH
Oligo-ovulation (abnormal menses), hyperandrogenism (hirsuitism, acne), elevated 17-OH progesterone
How is a molar pregnancy created?
Complete molar pregnancy = either one or two sperms fertilize an egg lacking genetic material
Partial = haploid egg fertilized by one or two sperm which reduplicated causing too many chromosomes (ex: 69 XXY)
-basically abnormally fertilized egg allows for abnormal trophoblastic proliferation
Acid base disturbance seen in physiologic pregnancy
Direct effect of progesterone that stimulates the central respiratory center => relative hyperventilation => primary respiratory alkalosis due to hypocapnia
Typical inpatient abx regimens for PID
- Cefoxitin or cefotetan + doxy
- clindamycin + gentamycin
19 yo p/w sudden onset intensifying lower abdominal pain + vomiting
- diffuse tenderness, left greater than right, w/o guarding/rebound
- pelvic US: complex left adnexal mass w/o Dopller flow w/ small free fluid
(a) Dx
(b) Next step
(a) Ovarian torsion: sudden onset unilateral pelvic pain, N/V
- classic US finding = adnexal mass w/ absent doppler flow to ovary
(b) Laparoscopy
- laparoscopic cystectomy and detorsion w/ goal of saving ovary from irreversible necrosis
Workup for hyperemesis gravidarum
Ultrasound- r/o multifetal gestation and molar pregnancy (since both have increased placental mass => increased risk of HG)
-after do US, can turn to supportive tx
37 yo p/w severe abdominal pain x5 hrs, TTP w/ mild guarding, normal VS and labs
Next steps
- pregnancy test
- pelvic ultrasound to determine location of pregnancy test
-wouldn’t go straight to pelvic US before pregnancy test
What is Mittleschmerz?
Ovulation/midcycle pain
Tx of lichen sclerosus
High potency vaginal steroids
When do you do endometrial biopsy in women under 45
Persistent AUB or risk factors for endometrial cancer: obesity, diabetes, unopposed estrogen exposure, PCOS, early menarche/late menarche
Management of second pregnancy in mother w/ h/o preterm delivery
Can manage pts w/ h/o spontaneous preterm delivery w/ progesterone supplementation and serial cervical length measurements
60 yo G3P3 p/w SOB x6 mo
- sister w/ breast cancer, BRCA+
- distended abdomen w/ decreased bowel sounds, clear lungs
- firm, non-mobile mass palpated in the left adenexa
(a) Dx
(b) Next step
(a) Epithelial ovarian carcinoma
- give away if pelvic mass + ascites
(b) Next step = exploratory laparotomy
Objectively most accurate way of assessing gestational age
First trimester ultrasound
More accurate than date of LMP b/c LMP assumes normal 28 day cycles w/ ovulation on day 14 (that’s the average but not always the exact case)
Risk factors for placental abruption (besides previous C-section)
Maternal HTN, smoking, cocaine use, abdominal trauma
Name some meds that common cause urinary incontinence
- Alpha-adrenergic 2/2 urethral relaxation
- Anticholinergics, opiates, CCB 2/2 urinary retention and overflow
- Diuretics 2/2 excess urine production
Clinical presentation of degenerating fibroids
Fibroids degenerate in pregnancy when they outgrow their blood supply
- presents w/ intense constant abdominal pain
- no bleeding
Contraindications to external cephalic version
- placental abnormalities: previa or abruption
- oligohydramnios
- multiple gestations
Can cause fetal distress => so needs to be performed when arrangements have been made for back-up emergency C-section
16 yo runner p/w excessive facial hair
- irregular menses since age 12
- normal external genitalia
- elevated LH/FSH, testosterone, DHEA-S
Dx
Congenital adrenal hyperplasia- would expect elevated 17-hydroxyprogesterone
Lactation mastitis
(a) Most common bug
(b) Mechanism of infection
Lactation mastitis
(a) staph aureus- skin flora enters ducts thru nipple and multiples in stagnant milk
(b) stagnant milk 2/2 inadequate milk duct draining
- increased risk if miss nursing sessions
Clinical features differentiating endometriosis and adenomyosis
Both have dysmenorrhea, pelvic pain
Endometriosis associated w/ infertility
Adenomyosis: bulky, globular, tender uterus
Complications of the following during pregnancy
(a) Valproate
(b) Lithium
(a) Valproate => neural tube defects
(b) Lithium = cardiac defects: setpal defects and Ebstein’s anomaly
- specifically Ebstein’s anomaly: ASD, atrialized RV w/ malformed tricuspid valve
Indication for raloxifene
Raloxifene = SERM (selective estrogen receptor modulator)
-for prevention and tx of osteoporosis in postmenopausal F
17 yo sexually active F on OCPs p/w normal external genitalia w/o erythema or edema + copious, white, mucoid vaginal discharge w/ no odor
-microscopic: squamous cells w/ rare PMNs
(a) Dx
(b) Mgmt
(a) Physiologic leukorrhea = amount of normal vaginal discharge varies greatly. white/yellow, nonmalodorous, w/o symptoms or finding on exam = physiologic
(b) Mgmt = reassurance, no tx required
Management of uterine inversion
Manual replacement of the uterus
Then after uterus is replaced: remove placenta (if still in) and give uterotonic drugs
-don’t give uterotonics before replacing uterus
Birth plan for placenta previa
Planned C section at 36-37 weeks
FHT: moderate variability, recurrent variables
Next step?
Turn mother on side (decompress IVC), give fluid bolus, potentially amnioinfusion
-all to reduce cord compression
Don’t need to resort to C-sxn yet b/c moderate variability shows fetus is not acidemic
32 yo F w/ abdominal pain and nausea x2 days
- several blood clots vaginally
- BP 90/55, HR 120, guarding w/ decreased BS, + pregnancy test
- TVUS: gestational sac at upper left uterine cornu w/ free fluid in posterior col-de-sac
Next step
So this is totally an ruptured ectopic in a bicornate uterus
Next step = surgical exploration
-HDUS, hemoperitoneum
-Can’t use MTX here b/c pt is not HDS
Cornual ectopic pregnancy = gestation sac in the upper outer corner of bicornate uterine fundus
Tx of lactation mastitis
Dicloxacillin or cephalexin
- encourage breast feeding! even increased breast feeding since infxn is commonly 2/2 inadequate milk duct draining
- analgesia
25 yo G1P0 at 36 wks p/w sudden onset excruciating abdominal pain and vaginal bleeding x3h
- BP 160/110, HR 18
- PE: firm, distended and tender uterus
- FHT: 108 baseline w/ no variability
Dx
Dx = abruptio placentae = premature placental separation
-painful vaginal bleeding causing both fetal and maternal distress
Not vasa previa b/c that wouldn’t cause the hypertonic and tender uterus (it would be painless vaginal bleeding), and wouldn’t cause maternal HTN b/c blood loss is all fetal
Etiologies of premature ovarian failure
Multifactorial
- autoimmune component
- heritable factors
- exogenous factors: radiation
Distinguish visual manifestations of primary syphilis vs. chancroid
Syphilis- painless, non-exudative base, raised indurated margin
Chancroid- painful, lymphadenopathy, ulcer w/ deep purulent base
Basically painless (syphilis) vs. painful (chancroid)
36 yo G2P1 at 35 wks p/w vaginal bleeding and back pain
- h/o HTN controlled w/ HCTZ
- smooth, firm, distended uterus w/ fundal height of 38 cm
- cervix closed
- NST: minimal variability w/ 3 late decels
Dx
Dx = placental abruption
-painless vaginal bleeding
NOT placental previa = painLESS bleeding
Describe the change in management of hypothyroidism during pregnancy
Increase levothyroxine dose
Elevated estrogen stimulates TBG production => need more thyroid hormone
Criteria for diagnosis of chorioamnionitis
Maternal fever + 1:
- uterine tenderness
- maternal or fetal tachy
- malodorous amniotic fluid
- purulent vaginal discharge
Risk factors for hyperemesis gravidarum
Increased placental mass => higher beta-hCG
- multiple gestations
- molar pregnancy
Common clinical presentation of submucous fibroids
Heavy and prolonged menstrual bleeding 2/2 endometrial distortion
Pelvic mass + ascites
Buzzword for epithelial ovarian carcinoma
23 yo F w/ regular menses and no PMH, normal external genetalia w/ 27 yo husband present for infertility work up
First step…
Semen analysis- simple, noninvasive test
-male factor alone accounts for 35% of infertility
Tx of endometriosis
First things first is observation- you don’t need to tx unless pt is symptomatic
If symptomatic- then things to atrophy endometrial tissue: OCPs (first line), progestin only options, NSAIDs
Name 3 complications of using too high of a dose of uterotonic agents (ex: oxytocin overdose)
- Tachysystole
- Hyponatremia
- b/c oxytocin is similar in structure to ADH => causes water retention and hyponatremia - Hypotension
23 yo G1P0 at 39 wks p/w 1-day of abdominal pain and persistent wetness of underwear
- T 100.7, diffuse uterine tenderness, cervix 2cm dilated w/ positive nitrazine and ferning tests
- Hb 10.2, WBC 18k, plt 198k
Dx
Intraamniotic infection = chorioamnionitis
RF = prolonged rupture of membranes
-positive nitrazine/ferning = amniotic fluid
Step to take before starting trastuzumab therapy
Trastuzumab = Herceptin for HER2 positive breast cancer
Do echo before starting trastuzumab b/c of risk of cardiotoxicity, particularly if have low baseline EF
What is fetal fibronectin?
Biological glue that binds the fetal sac to the uterine lining
-produced by fetal cells, lies at the interface between the chorion and amnion
-swab used as screening test for preterm labor
20 yo G2P2 evlauted 8 hrs after vaginal delivery for bloody vaginal discharge and rigors/chills x30 mins during placental delivery
- T 100.2F, BP 120/80, HR 76
- uterine NT and firm
Next step
Reassurance and routine postpartum care
-transient rigors/chills, peripheral edema, lochia rubra, breast engorgement, uterine contraction and involuation are all normal findings in the postpartum period
What determines the first step in work up of nipple discharge?
Color of the discharge
Bloody or serous => do breast ultrasound/mammogram
If milky, nonbloody => serum prolactin, TSH, beta-hCG
31 yo F at 28 wks gestation p/w painful contractions
- no ROM/VB
- 3cm/90%, vertex w/ bulging bag
- BP 125/60 w/ contractions q5min
How to manage her?
- betamethasone
- MgSO4- used in under 32 wks for fetal neuroprotection
- indomethacin as tocolytic (not first line nifedipine b/c nifedipine + MgSO4 associated w/ respiratory depression)
45 yo p/w night sweats and insomnia
-irregular periods x6 mo
Mgmt
Can’t just chalk this up to estrogen withdrawal w/o ruling out hyperthyroidism first….
- Measure TSH and FSH
- Tx hyperthyroidism or tx menopause
Test for urethral hypermobility
Q-tip test: cotton swab in urethral orifice, if it moves more than a 30 degree angle w/ increased intrabdominal pressure (ex: coughing) that is diagnostic for urethral hypermobility
Urethral hypermobility => stress incontinence
Mechanism of polycythemia in fetal hyperglycemia
Fetal hyperglycemia (due to uncontrolled maternal diabetes) => fetal hyperinsulinemia => increased metabolic demand => fetal hypoxemia => increased erythropoiesis => polycythemia
Difference btwn raloxifene and tamoxifen
Tamoxifen has estrogen inhibitory effects on breast, but stimulates endometrial lining.
Raloxifene doesn’t have the effect on the endometrium => safe to give to postmenopausal women w/o increased risk of endometrial hyperplasia/cancer
Acid base disturbance seen in hyperemesis gravidarum
Excessive vomiting = loss of gastric acid => metabolic alkalosis
28 yo G3P2 at 30 wks gestation p/w vaginal bleeding after MVA
- BP 95/65, HR 116, RR 22
- minimally active bleeding from cervix
- O+
- contractions q5 min, no accel or decels
Dx
Mgmt
Placental abruption w/ hemorrhagic shock => need to give aggressive fluid resuscitation
So first step would be to stabilize mother (not assess fetus w/ BPP or anything) b/c baby complications would mainly be 2/2 insults to maternal circulation
Recommendations for reduction of ovarian cancer rate in BRCA-1 carrier
Premenopausal prophylactic b/l salpingo-oophorectomy (BSO) for mutation carriers once childbearing is complete
42 yo p/w left breast swelling and pain worsening x1 mo
- finished breastfeeding 2 mo ago, s/p abx for mastitis 1 mo ago
- VS normal
- left breast: diffusely warm and erythematous w/ some dimpling
Fx
Inflammatory breast cancer
-rapid-onset peau d’orange (superficial dimpling, fine pitting)
Less likely to be breast abscess given no fever and lack of improvement w/ abx
Clinical presentation of acute fatty liver of pregnancy
(a) Lab findings
Acute hepatic failure in the 3rd trimester or early postpartum
(a) prolonged PT/PTT, hypoglycemia, encephalopathy
What is contraindicated in placenta previa?
Intercourse, digital cervical exam, vaginal delivery all contraindicated
-recommend strict pelvic rest
Complications of untreated PID
- tubo-ovarian abscess
- abscess rupture
- pelvic peritonitis
- sepsis
Describe a complication of fibroids growing during pregnancy
Fibroids often grow during pregnancy 2/2 hormonal growth stimulation
-grow so much that they outgrow their blood supply, then undergo degeneration causing severe abdominal pain
Differentiate use of the following for workup of palpable breast mass:
FNA vs. core biopsy vs. excision biopsy
FNA for suspected cystic or small masses
Core biopsy for complex cyst or solid mass
-acellular (like stromal) masses
Excisional biopsy for large or suspicious masses
46 yo G3P3 p/w 2-yr heavy, dysmenorrhea and pelvic pain btwn periods
-PE: symmetrically enlarged uterus, boggy tender globular and freely mobile
Dx
Adenomyosis
Not endometriosis- usually has normal-sized, nontender uterus that is immobile (fixed)
54 yo G2P2 w/ involuntary urine loss whenever she “laughs, coughs, or sneezes”
(a) Dx
(b) Mechanism
(b) Tx
(a) Dx = stress incontinence
(b) Urethral hypermobility
(c) Tx
first line = Kegels (pelvic floor muscle exercises)
second line = uretethral sling surgery
What is lichen sclerosus? Clinical features
Lichen sclerosus = autoimmune skin disease causing intense pruritis and white atrophic plaques of the vulva, and sometimes perianal skin (but not the vagina)
Most common bugs that cause PID
Neisseria gonorrhea, chlamydia trachomatis, genital mycoplasmas
32 presents 2 days after her menstrual period ended w/ severe pelvic pain and what “feels like labor contractions”
- irregularly enlarged uterus
- h/o regular but heavy mentrual cycles
- 5cm dilated cervix w/ spherical mass visible thru the external os
Dx
Protruding leiomyoma uteri = aborting submucousal fibroid
- intramural fibroids can prolapse thru cervical os while hanging from a pedicle attached to the myometrium
- labor-like pain caused by expulsion of the fibroid
Further confirmed b/c fibroids can distort the endometrium causing heavy menses
Tx for gestational diabetes not responsive to dietary change
Insulin
-oral agents including metformin and glyburide
Why do we treat asymptomatic bactiuria in pregnant F?
B/c of the risk of pyelo…
Untreated asymptomatic bacteriuria can progress to pyelo in 20-40% of cases
Then pyelo => septicemia, preterm labor, low birth weight
34 yo 6 wks s/p vaginal delivery c/b severe postpartum hemorrhage requiring 5U pRBC p/w low energy, no milk production
- wt loss below pre-pregnancy wt
- BP 90/69
Dx
Dx = Sheehan syndrome = postpartum hypopituitarism from pituitary gland 2/2 blood loss and hypovolemic shock after childbirth
Infarcted pituitary => low prolactin release
-low ACTH => hypocortisolism => hypotension, wt loss, lethargy, loss of sexual hair
What is pseudocyesis?
Tx
False/phantom pregnancy- pt presents w/ actual clinical signs and symptoms of pregnancy (ex: morning sickness, amenorrhea, self-reported positive pregnancy test…) w/ negative in-office test
Form of conversion d/o => requires psych eval
What is internal podalic version?
When you literally reach into the uterus and grab the baby by its feet for vaginal delivery
-done for breech extraction of a malpresenting second twin
Fetal complications of maternal hyperglycemia
Fetal hyperglycemia => fetal hyperinsulinemia =>
- Polycythemia
- organomegaly
- shoulder dystocia => birth injuries
- neonatal hypoglycemia
29 yo w/ UC p/w syncope and right-sided abdominal pain w/ rebound tenderness and voluntary guarding
- vaginal bleeding
- LMP 8 wks ago
- cervical motion tenderness, right-sided adnexal tenderness, no palpable masses
Dx
Rupture ectopic: abdominal pain, vaginal bleeding, hypovolemic shock
-cervical motion, adnexal, abdominal tenderness, amenorrhea
25 yo F at 28 weeks presents in active labor
-US shows AFI of 4 and b/l renal agenesis
Mgmt
Mgmt = allow spontaneous vaginal delivery
-don’t administer corticostoierds/amniotransfusion/tocolysis b/c fetal anomaly of b/l renal agenesis is incompatible w/ life
34 yo w/ quad screen showing low MSAFP/estriol w/ elevated hCG/inhibin A
Next step?
Ultrasound- do US before amnio to evaluate fetal anatomy and measure growth (anomalies associated w/ trisomy 21)
FSH/LH levels seen in premature ovarian failure
Both FSH and LH are elevated (b/c hypoestrogen => loss of negative feedback)
FSH/LH > 1 (greater increase in FSH elevation) b/c of slower clearance of FSH from circulation
67 yo F p/w severe vulvar itching/burning x6mo
- dysparanuria
- h/o DM1
- thin, dry, white plaque-like vulvar skin w/ loss of labia minora, clitoral hood retraction, vulvar excoriation b/l
Dx
Mgmt
(a) Dx = lichen sclerosis
- autoimmune in etiology (associated w/ others like DM1)
- causes intense pruritis, dysparanuria, dysuria
- affects vulva and perianal region, not vagina
(b) Vulvar punch biopsy to r/o vulvar squamous cell carcinoma
- lichen sclerosis is considered a premalignancy of the vulva
25 yo G2P1 at 32 wks p/w acute-onset severe abdominal pain and diffuse vaginal bleeding
- h/o C-sxn for first pregnancy w/ vertical incision 2/2 anterior fibroids
- BP 160/95, HR 100
- firm, tender uterus
- FHT: baseline 150/min w/ no decels
- contractions q1-2m
Dx
Abruptio placentae = painful vaginal bleeding
- hypertonic/tender uterus
- tachysystole (frequent uterine contractions)
RF: h/o C-section w/ vertical incision
19 yo 3 days s/p D&C for abortion p/w 2 days of fever, foul-smelling yellowish discharge from cervical os
Dx
Mgmt
Dx = septic abortion
-infection of retained products of conception
Mgmt = suction curettage
Erbs vs. Klumpke’s palsy
(a) Nerves affected
(b) Clinical presentation
Erbs: C5/C5
-waiter’s tip: extended elbow, pronated forearm, flexed wrist and fingers
Klumpkes: C8/T1
- claw hand: extended wrist, flexed IP joints
- Horner’s = ipsilateral miosis and ptosis
So if baby has slight ptosis and anisocoria + arm abnormalities = Klumpke’s
-use the Horner’s stuff to easily differentiate
