UWorld 3 Flashcards
intrauterine fetal demise (IUFD)
-fetal death at >20 weeks
-diagnosis: absence of fetal cardiac activity on US (dec or absent fetal movement)
-management:
20-23 weeks: dilation and evacuation or vaginal delivery
>24 weeks: vaginal delivery
complication: coagulopathy after several weeks of fetal retention
evaluation of fetal demise
fetal: autopsy, gross and microscopic exam of placenta (eval for signs of abruption or infection), membranes, cord; karyotpye/genetic studies
maternal: Kleihauer-Betke test for fetomaternal hemorrhage; antiphospholipis Ab; coagulation studies (for h/o recurrent pregnancy loss, fhx or personal h/o venous thrombosis, fetal growth restriction)
Primary infertility
- inability to conceive after a year of unportected sex in nulliparous pt <35yo
- hysterosalpingogram is used to diagnose an anatomic cause of infertility such as tubal obstruction from prior pelvic infection
congenital aromatase deficiency
- rare enzyme deficiency that prevents conversion of androgens to estrogens=undetectable estrogen levels
- causes virilization of female fetuses–>nml internal genitalia with ambiguous external genitalia
McCune-Albright syndrome
- triad: cafe au lait spots, polyostotic fibrous dysplasia, autonomous endocrine hyperfunction
- most common ft: gonadotropin-independent precocious puberty=early puberty
CAH (21) CP
- at birth: ambiguous external genitalia and nml internal female reproductive organs (uterus, ovaries)
- electrolyte abnormalities (hyponatremia)
Bartholin duct cyst
- common in women <30yo
- duct obstruction causes fluid accumulation, gland distension=cyst
- soft, mobile, nontender cystic mass is usually asymptomatic and found at base of labium majus
- if asymptomatic, observation is recommended
(symptomatic: treat like an abscess, with incision and drainage, followed by placement of a word catheter)
Mittelschmerz
- physiologic cause of unilat abdo pain in young women
- pain occurs in the middle of the menstrual cycle (days 10-14) corresponding with time of ovulation
- reassurance is indicated once acute path is excluded
Differential diagnosis of dysmenorrhea
- primary dysmenorrhea: crampy lower abdo and back pain during menses
- endometriosis: pain peaks before menses, dyspareunia, infertility
- fibroids: heavy menses with clots; constipation, urinary frequency, pelvic pain/heaviness; enlarged uterus on exam
- adenomyosis: dysmenorrhea, pelvic pain, menorrhagia, bulky globular and tender uterus
- pelvic congestion: dull and ill defined pelvic ache that worsens with standing
pubic symphysis diastasis
RF:
-fetal macrosomia, multiparity, precipitous (traumatic) labor, operative vag delivery
CP:
-difficulty ambulating/weight-bearing, radiating suprapubic pain, pubic symphysis tenderness, intact neuro exam
Management:
-conservative, NSAIDs, physical therapy, pelvic support
Hydatidiform mole
CP:
- abnml vaginal bleeding +/- hyropic tissues
- uterine enlargement>gestational age
- abnormally elevated beta-hcg levels
- theca lutein ovarian cysts
- hypermesis gravidum
- preeclampsia with severe features
- hyperthyroidism
RF:
- extremes of maternal age
- h/o hydatidiform mole
Diagnosis:
- snowstorm on US
- quantitative beta-hcg
- histologic eval of uterine contents
Management:
- dilation and suction curettage
- serial serum beta-hcg post evacuation
- contraception for 6 mo
Initial painful lesion
chancroid, genital herpes
chancroid
- haemophilus ducreyi
- multiple and deep ulcers
- base may have gray to ylw exudate
- organism clump: “school of fish”
genital herpes
- multiple small grouped ulcers
- shallow with erythematous base
- multinucleated giant cells and intranuclear inclusions (Cowdry type A)
granuloma inguinale (donocanosis)
- klebsiella granulomatis
- ectensive and progressive ulcerative lesions without LAD
- base may have granulation-like tissues
- deeply staining GN intracytoplasmic cysts (donovan bodies)
syphilis
- single indurated well circumscribed ulcer
- clean base
- thin, delicate, corkscrew shaped on dark field microscopy
lymphogranuloma venereum
- chlamydia trachomatis
- small and shallow ulcers
- large painful coalesced inguinal LN (buboes)
- intracytoplasmic chlamydial inclusion bodies in epithelial cells and leukocytes
syphilis diagnostic serology
- nontreponemal: Ab to cardiolipin-cholesterol-lecithin Ag
- –decrease in titers confirms treatment
- treponemal: Ab to treponemal Ag
- quantitative (reactive/nonreactive); greater sn in early infection, positive even after treatment
endometrial biopsy indications
- -Age >45: abnml uterine bleeding, postmenopausal bleeding
- -Age<45: abnml uterine bleeding PLUS: unopposed estrogen (obesity, anovulation); failed med management; Lynch syndrome (hereditary nonpolyposis CRC)
- -Age >35: atypical glandular cells on Pap test
Antiphospholipid syndrome
Diagnosis: vascular thrombosis (transient ischemic attack/stroke, DVT) and/or pregnancy complication (Recurrent miscarriage) PLUS >1 of the following Ab: -anti-cardiolipin Ab -lupus anticoagulant -anti-beta2-glycoprotein Ab
Wernicke encephalopathy
associated conditions: chronic alcoholism (m/c), malnutrition (anorexia nervosa), hyperemesis gravidarum
path: thiamine deficiency
CF: encephalopathy, oculumotor dysfunction (horizontal nystagmus, bilat abducens palsy), postural and gait ataxia
tx: iv thiamine followed by glucose infusion
RF for vulvovaginal candidiasis
- DM
- immunosuppression
- pregnancy
- OCPs
- antibiotic use
theca lutein cysts
CP: multilocular, bilateral, 10-15cm ovaries
Path: ovarian hyperstim d/t: gestational trophoblastic dz, multifetal gestation, infertility tx
clinical course: resolve with decreasing beta-hcg levels
management of preterm prelabor ROM
<34 weeks:
- sign of infection or fetal compromise?
yes: Abx, corticosteroids, mag if <32wks, delivery
no: Abx, corticosteroids, fetal surveillance
34 to <37 weeks
-Abx, +/- corticosteroids, delivery
PCOS
CF:
- androgen excess
- menstrual irregularities
- polycystic ovaries
Pathophys:
-INC T, INC estrogen, LH/FSH imbalance
Comorbidities:
-metabolic syndrome, OSA, NASH, endometrial hyperplasia/ca
Tx options:
-weight loss, OCP for menstrual regulation, clomiphene for ovulation induction
Late and post term pregnancy
-late term: >41 wk, post term: >42 wk
RF:
prior post term pregnancy, nulliparity, obesity, age >35, fetal anomolies
Complications: fetal/neonatal (macrosomia, dysmaturity syndrome, oligo, demise); maternal (severe obstetric laceration, cesarean, PPH)
Management:frequent fetal monitoring (nonstress test), delivery prior to 43 weeks gestation
types of miscarriages
Missed:
-no vaginal bleeding, closed cervical os, no fetal cardiac activity or empty sac
threatened:
-vaginal bleeding, closed cerv os, fetal cardiac activity
Inevitable:
-vag bleeding, dilated cerv os, products of conception may be seen or felt at or above the cerv os
Incomplete:
-vag bleeding, dilated cerv os, some products of conception expelled and some remain
complete:
-vag bleeding, closed cerv os, products of conception completely expelled
granulosa cell tumor
path: sex cord-stromal tumor, inc estradiol and inc inhibin
CF: complex ovarian mass, juvenile subtype-precocious puberty; adult subtype: breast tenderness, abnml uterine bleeding, postmenopausal bleeding
histo: call-exner bodies (Cells in rosette pattern)
management: endometrial bx (endometrial ca), surgery (tumor staging)
external cephalic version
procedure: manual rotation of fetus, dec cesarean delivery rate
indications: breech/transverse presentation, >37 weeks gestation
absolute contraindications ( to vaginal delivery): prior classical cesarean delivery, prior extensive uterine myomectomy, placenta previa
complications: abruptio placentae, intrauterine fetal demise
Sheehan syndrome
CF:
- lactation failure (dec prolactin)
- amenorrhea, hot flashes, vaginal atrophy (dec FSH, LH)
- fatigue, brady (dec TSH)
- anorexia, weight loss, hypoTN (Dec ACTH)
- dec lean body mass (dec growth hormone)
early decels
late decels
variable decel
VEAL CHOP
early: fetal head compression, can be nml, nadir of FHR coincides with peak of mom
late: uteroplacental insufficiency; nadir after peak of mom
variable: umbilical cord compression, oligo, cord prolapse
- intermittent are tolerated by fetus
- persistent may be alleviated by maternal repositioning; second line: amnionfusion
ocp and htn
ocp can cause htn, d/c ocp=relieve htn in most pts
maternal cardiopulm adaptation to pregnancy
maternal adaptations
- cardiac: inc CO, inc plasma volume, dec systemic vascular resistance
- resp: INC TV, dec FRC (elevation of diaphragm)
clinical manifestations:
- peripheral edema
- dec BP, inc HR
- systolic ejection murmur
- dyspnea
placental abruption=premature detachment of the placenta
RF: maternal HTN or preeclampsia/eclampsia
- abdo trauma
- prior placental abruption
- cocaine and tobacco use
CP: sudden-onset vaginal bleeding (80%)
- abdo or back pain
- high-freq low intensity contractions
- hypertonic tender uterus
diagnosis: primarily by CP
US to r/o placenta previa, may show retroplacental hematoma
placenta previa
RF: prior placenta previa, prior cesarean delivery, multiple gestation
CF: painless vaginal bleeding >20 wks gestation
diagnosis: transabdo followed by transvaginal sonogram
management: no intercourse, no digital cervical examination, inpt admission for bleeding episodes
Sjogren syndrome
exocrine features: keratoconjunctivitis sicca, dry mouth, salivary hypertrophy, xerosis of skin
extraglandular features: raynaud phenom, cutaneous vasculitis, arthralgia/arthritis, interstitial lung dz
diagnostic: objective signs of dec lacrimation, positive anti-Ro and/or anti-La
- salivary gland biopsy with focal lymphocytic sialoadenitis
- classification: primary if no associated CTD, secondary if comorbid CTD (eg SLE, RA, scleroderma)
indications for hospitalization for PID
- pregnancy
- failed outpt tx
- inability to tolerate po meds
- noncompliant
- severe CP (high fever, vomiting)
- complications (tubo-ovarian abscess, perihepatitis)
