UWorld Flashcards
SERMs are a class on nonsteroidal compounds that exhibit estrogen agonist and antagonist properties in a tissue-specific fashion. The 2 most frequently used SERMs are raloxifene and tamoxifen. Raloxifene exhibits estrogen agonist activity on the bone and decreases post-menopausal osteoporosis. Although less effective than aldendronate, raloxifene is frequently used for osteoporosis management in postmenopausal women who cannot tolerate bisphosphonates or are at high risk for invasive breast cancer. All medicines with estrogen agonist activity increase risk for what
VTE
Shoulder dystocia frequently occurs in patients with no risk factors and can be difficult to predict. What are the warning signs of an impending dystocia
- Prolonged first or second stage of labor
- retraction of the fetal head into the perineum after delivery (turtle sign)
ilateral inguinal lymphadenopathy and a painless genital chancre
Classic symptoms of primary syphilis
Describe the lesion of primary syphilis
-single papule that turns into a shallow, painless, NONexudative ulcer with indurated edges
initial RPR result in early primary syphilis
Can be negative
Patients with negative screening serology and strong clinical evidence of primary syphilis should be treated how
impirically with Intramuscular benzathine penicillin G
-repeat nontreponemal serology should be done in 2-4 weeks to establish baseline titers
Clinical presentation of epithelial ovarian carcinoma?
- Acute: shortness of breath, obstipation/constipation with vomiting, abdominal distention
- Subacute: pelvic abdominal pain, bloating, early satiety
- Asymptomatic adnexal mass
US findings in epithelial ovarian carcinoma?
- Solid mass
- Thick septations
- Ascites
Management of epithelial ovarian carcinoma
-Exploratory Laparotomy
Ascites from epithelial ovarian carcinoma is likely due to what
-peritoneal spread of cancer causing increased capillary permeability and decreased intravascular oncotic pressure
What is the use of CA-125 in epithelial ovarian carcinoma
-to correlate with clinical finding and to monitor treatment in the future
In an RH- woman in second pregnancy having RH+ baby will need anti-D immune globulin. A standard dose of 300 ug at 28 weeks gestation can usually prevent alloimmunization. However, about 50% of Rh-negative women will need a higher dose after delivery, placental abruption, or procedures. What is commonly used to determine the dose
KB test
Antenatally diagnosed placenta accreta is delivered how
planned Cesarean hysterectomy
Risk factors for placenta accreta
- prior C section
- History of D and C
- Advanced maternal age
correlation of OCPs and HTN
- OCPs can cause mild elevations in BP and sometimes lead to overt HTN.
- Discontinuing OCPs can reduce the BP over a 2 t o12 month period and can often correct the problem
Depot Medroxyprogesterone acetate (DMPA) is administered IM how often to prevent pregnancy by inhibiting the release of GRH from the hypothalamus and suppressing ovulation
every 3 months
Treatment of confirmed Chlamydia but Negative Gonorrhea? . . . If using NAAT
Just Azithromycin
-If culture or microscopy used then always treat both
Treatment of confirmed Gonorrhea but negative chlamydia? . . . If using NAAT
BOTH Azithromycin and ceftriaxone
Fat necrosis is a benign condition associated with what
-breast surgery and trauma
Fat necrosis can mimic breast cancer in its clinical and radiographic presentation because it commonly presents as what?
-a fixed mass with skin or nipple retraction and gives the appearance of calcifications on mammography
Biopsy is diagnostic of fat necrosis and typically shows what
Fat globules and foamy histiocytes
once fat necrosis is diagnosed, what is the most appropriate course of action in management
Reassurance and routine follow up
Complications of inadequate pregnancy weight on the fetus
- Fetal growth restriction
- Preterm delivery
- unilateral bloody nipple discharge
- No associated mass or lymphadenopathy
Intraductal papilloma
Management of intraductal papilloma
- Mammography and US
- Biopsy +/- excision
- Patient with abortion history presents at 35 weeks with decreased fetal movement and placenta previa
- NST done and fetus has heart tones at 130 but no accels (nonreactive)
- NExt step?
BPP or Contraction stress test (CST)
-CST is contraindicated in placenta previa or prior myomectomy
Normal Nonstress test finding in BPP?
Reactive fetal heart rate monitoring
Normal Amniotic fluid volume finding in BPP
- Single fluid pocket > 2x1 cm
- or amniotic fluid index >5
Normal fetal movement finding in BPP
-3 or more general body movements
Normal fetal tone finding in BPP
1 or more episodes of flexion/extension of fetal limbs or spine
Normal fetal breathing movements finding in BPP
1 or more breathing episode for at least 30 sec
An abnormal BPP score of 0/10 to 4/10 indicates what?
fetal hypoxia due to placental dysfunction
-Prompt delivery is indicated due to the high probability of fetal demise
Normal ovulation can cause pain in the middle of the menstrual cycle called what ?
What is the pathophys of the pain?
Mettelschmerz
-Rupture of the follicle releases the egg. The concomitant release of a small amount of blood during this process irritates the peritoneum
Advice regarding alcohol to patients getting treated for trich
refrain from alcohol consumption after treatment due to risk of a disulfiram-like reaction
Chorionic villus sampling is a diagnostic genetic test performed at what weeks?
-10-13
Amniocentesis is a diagnostic genetic test performed at what weeks
15-20
This results from incomplete regression of the Wolffian duct during fetal development. These cysts may be single or multiple and are submucosal along the lateral (parallel) aspects of the upper anterior vagina
Gartner duct cyst
management of an asymptomatic Bartholin cyst in a young woman
- no intervention
- Observation is recommended as spontaneous drainage and resolution may occur
management of symptomatic Bartholin cyst
- I and D
- Placement of a word catheter after drainage reduces the risk of recurrence
US differentiates ovarian torsion from other acute gynecologic conditions by the presence of what?
- adnexal mass
- lack of Doppler flow . . .pathognomonic finding
next step in management of ovarian torsion
surgery . laparoscopic cystectomy and detorsion
A patient with gestational HTN needs BPPs how often and starting when
- every week
- starting at 32 weeks
Patient comes in at 37 weeks with severe preeclampsia and delivers. What complications can newborn have
- pathophys likely involves abnormal placental development and function, which puts the fetus at risk for chronic uteroplacental insufficiency
- This can leads to fetal growth restriction/low birth weight even if the neonate is delivered at term
Describe the pathophysiology of HELLP syndrome
- thought to result from abnormal placentation, triggering systemic inflammation and activation of the coagulation system and complement cascade
- circulating platelets are rapidly consumed, and microangiopathic hemolytic anemia is particularly detrimental to the liver
- The resulting hepatocellular necrosis and thrombi in the portal system cause elevated liver enzymes, liver swelling, and distension of the hepatic (Glisson) capsule
Treatment of HELLP
- Delivery
- Mag for seizure prophylaxis
- Antihypertensive drugs
Adolescent Pts with an imperforate hymen typically present with what
- cyclic lower abdominal pain in the absence of apparent vaginal bleeding
- When menstruation occurs, blood collects in the vagina behind the hymenal membrane (hemocolpos)
- The enlarging blood collection with each menstrual period causes increasing pressure on the surrounding pelvic organs, resulting in lower back pain, pelvic pressure, or defactory rectal pain
The strongest risk factor for preterm delivery is preterm delivery. What are other important risk factos
- Multiple gestation
- Hx of cervical surgery. In particular, removal of part of the cervix by cold knife conization for cervical intraepithelial neoplasia can cause cervical scarring/stenosis and incompetence
What is the first step in evaluating the risk of preterm delivery?
-Transvaginal US measurement of cervical length in the second trimester
When are Fetal fibronectin levels normally high and when can they be used as an indicator for increased risk of preterm delivery?
- FFN levels are high until 20 weeks
- Low during the mid-second and third trimesters and increase again at term when contraction disrupt the decidual-chorionic interface
- Elevated levels prior to term but after 20 weeks can indicate risk of preterm
If evaluated by transvaginal US and determined to have a short cervic then what can be given?
- Progesterone maintains uterine quiescence and protects the amniotic membranes against premature rupture
- Pts with short cervices and NO Hx of preterm delivery should be offered VAGINAL progesterone
- Pts with a Hx of preterm delivery receive IM progesterone
Hyperandrogenism during pregnancy is usually caused by ovarian masses. A luteoma is a benign condition that occurs more frequently in African American. Describe presentation and management
- hirsutism and acne
- US shows large solid ovarian masses and half are bilateral
- Management involves clinical monitoring and US evaluation as the mass and symptoms regress spontaneously after delivery
Patients with Luteomas in pregnancy have increased risk of what?
puts a female fetus at high risk of virilization
What is the first line therapy for ovulation induction in PCOS
Clomiphene
electrolyte abnormality that can be caused by oxytocin
Hyponatremia
Seizures and Oxytocin?
- patient with new onset generalized tonic clonic seizure in setting of severe hyponatremia.
- Seizure probably due to water intoxication from excessive oxytocin administration during the postpartum hemorrhage after a prolonged induction of labor
- similar in structure to ADH
- Management involves gradual administration of hypertonic saline
Therapeutic Magnesium range
5 to 8
A tender, mobile breast mass in a young patient is most likely benign. In a patient < 30 with a clinically benign mass, breast US is the first line imaging study. if consistent with simple breast cyst what would be the management?
- aspiration, which should yield clear fluid and result in disappearance of the mass and thereby confirm Dx
- As cystic fluid can reaccumulate, the patient should return in 2-4 months for a follow up clinical breast exam
What are the symptoms and Physical exam findings of gentiourinary syndrome of menopause?
- Vulvovaginal dryness, irritation, pruritus
- Dyspareunia
- Vaginal bleeding
- Urinary incontinence, recurrent UTI
- pelvic pressure
- Narrowed introitus
- Pale mucosa, low elasticity, low rugae
- petechiae, fissures
- Loss of labial volume
Treatment of genitourinary syndrome of menopause
- Vaginal moisturizer and lubricant
- Topical vaginal estrogen
The diagnosis of intrauterine fetal demise must be confirmed by what
absence of fetal cardiac activity on US
Describe the evaluation after fetal demise
Fetal: Autopsy, Gross and microscopic exam of placenta, membranes and cord, Karyotype/genetic studies
Maternal: KB test for fetomaternal hemorrhage, antiphospholipid antibodies, coagulation studies
Describe Lactational amenorrhea
- result of high levels of prolactin, which has an inhibitory effect on the production of GnRH
- natural form of contraception for the first 6 months postpartum if the mother is breastfeeding exclusively
risk factors for ovarian torsion
- ovulation induction (infertility treatment)
- preexisting ovarian masses, especially those that are large
Management of ectopic pregnancy?
- stable: methotrexate
- Unstable or ruptured: surgery
The presence of fluid in the posterior cul-de-sac in the setting of an ectopic pregnancy suggests what
blood in the pelvis
pregnant patient with postcoital bleeding and a thick, mucopurulent discharge and friable cervix
acute cervicitis
Describe the presentation of an inevitable abortion
- Vaginal bleeding
- cramping
- dilated cervix
- often with products of conception visualized at the os
Small genital warts (condyloma acuminata) may be treated how?
- Trichloracetic acid or podophylin resin
- excisional therapy may be considered for larger lesions
On pap smear, High-grade squamous intraepithelial lesions (HSILs) on pap testing are concerning for underlying severe neoplasia or invasive cervical cancer , and all patient require what
evaluation with immediate colposcopy
-Can be treated with immediate loop electrosurgical excision but pregnant patients first undergo colposcopy and then cervical excision only if evidence of invasive cancer is found
if HSIL found on pap and then on colposcopy the transformation zone of SC junction are not visualized then what?
- endocervical curettage to evaluate endocervical canal
- This is deferred during pregnancy due to risk of miscarriage and preterm delivery
An athletic patient with secondary amenorrhea, a negative pregnancy test, and normal prolactin and TSH levels has a clinical pictures consistent with what diagnosis?
Functional hypothalamic amenorrhea
What can confirm functional hypothalamic amenorrhea
- A progestin challenge test confirms low estrogen levels
- The presence of estrogen causes proliferation of the endometrium, with subsequent sloughing after the withdrawal of progesterone
- Patients without adequate estrogen will have no or minimal bleeding as there is no endometrial lining to shed
Functional hypothalamic amenorrhea and bone density?
-Will have decreased bone mineral density despite physical training due to the low estrogen levels offsetting the bone-building effects of exercise
In functional hypothalamic amenorrhea, what can offset and increase bone density
- Estrogen repletion
- Increasing caloric intake and/or decreasing exercise is a more effective means
What is the most common cause of prolonged or arrested second stage of labor
fetal malposition
What is the optimal fetal position
-Occiput anterior
What is the most common cause of a protracted first stage of labor
inadequate contractions (,3 in 10 minutes, soft to palpation)
In genitourinary syndrome of menopause, the diagnosis can be made clinically, but laboratory testing such as what confirms the hypoestrogenic state
-elevated vaginal pH >5
Next step in a patient who has arrest of active labor as she has had no cervical change in 4 hours despite adequate contractions
C section
What are the Fetal Late-term and postterm pregnancy complications
- Oligohydramnios
- Meconium aspiration
- Stillbirth
- macrosomia
- convulsions
What are the Maternal Late-term and postterm pregnancy complications
- C section
- infection
- postpartum hemorrhage
- Perineal trauma
US showing a thin endometrial stripe suggests what
an empty and normal uterine cavity
First line treatments for Asymptomatic bacteriuria?
- Cephalexin
- Amoxicilli-clavulanate
- Nitrofurantioin
- Fosfomycin
Describe the use of Trimethoprim-Sulfamethoxazole during pregnancy?
- Safe during second trimester
- contraindicated during the first trimester due to interference with folic acid metabolism
- Should be avoided during the third trimester due to increased risk of neonatal kernicterus
most effective emergency contraceptive
copper IUD
Postpartum endometritis typically presents with fever >24 hours postpartum and what else
- purulent lochia
- uterine tenderness
What is calcium gluconate used for
- used for calcium repletion in patients with hypocalcemia
- it is also an antidote for magnesium toxicity
Adolescents often have anovulatory cycles with irregular, heavy menstrual bleeding due to an immature hypothalamic-pituitary axis. How can this be managed
Progesterone normalizes mentruation by stabilizing unregulated endometrial proliferation
How does Pelvic inflammatory disease typically present
- fever
- lower abdominal tenderness
- mucopurulent cervical discharge
- cervical motion and uterine tenderness
- Intermenstrual spotting can occur
- Infection can extend from the upper genital tract to spread throughout the abdomen and cause liver capsule inflammation (e.g. perihepatitis or Fitz-Hugh-Curtis disease) . . RUQ pain
Most appropriate management advice for a patient with fetal demise at 28 weeks gestation
Labor can be induced in the hospital when you feel ready
What time frame is Dilation and evacuation indicated for intrauterine fetal demise
<24 weeks
Adnexal mass or fullness should be confirmed by US, and the finding of a homogeneous cystic ovarian mass is highly suggestive of what
an ovarian endometrioma
what is a common consequence of endometriosis, especially with the presence of endometrioma
infertility
Type of abortion: -No vaginal bleeding
- closed cervical os
- No fetal cardiac activity or empty sac
Missed abortion
Type of abortion: -vaginal bleeding
- Closed cervical os
- Fetal cardiac activity
Threatened
Type of abortion: -Vaginal bleeding
- Dilated cervical os
- Products of conception may be seen or fest at or above cervical os
Inevitable
Type of abortion: Vaginal bleeding
- Dilated cervical os
- Some products of conception expelled and some remain
-Incomplete
Type of abortion: -vaginal bleeding
- close cervical os
- Products of conception completely expelled
complete abortion
this presents with painless vaginal bleeding and fetal heart rate abnormalities after amniotomy
-vasa previa
Palpable breast mass. what imaging is indicated next in women >30?
How about <30?
what confirms diagnosis?
- Mammography and targeted US can further characterize
- US is preferred for women <30, although mammography can be used for further characterization if an abnormality is seen
- Tissue biopsy is required to confirm
Clinical features of hyperemesis gravidarum
- Severe, persistent vomiting
- > 5% loss of prepregnancy weight
- dehydration
- Orthostatic hypotension
Hyperemesis gravidarum can be differentiated from typical nausea and vomiting of pregnancy by the presence of what
- ketones on UA
- lab abnormalities
- changes in volume status
Treatment and management of chorioamnioitis
- broad spectrum IV antibiotics (Amp, Gent, Clinda)
- Immediate delivery via INduction of labor
What are the indications for hospitalization for PID
- Pregnancy
- Failed outpatient treatment
- Inability to tolerate oral meds
- Noncompliant with therapy
- Severe presentation (e.g. high fever, vomiting)
- Complications (e.g. tubo-ovarian abscess, perihepatitis)
- Recommended for adolescents due to the risk of noncompliance
Antibiotic regimen for hospitalized PID patients
- IV cefoxitin or cefotetan plus
- oral doxycycline .
-or can use IV clinda plus gent
When is metronidazole added to PID treatment
when it’s complicated by tubo-ovarian abscess due to required additional anaerobic coverage
What is the pathophysiology of neonatal thyrotoxicosis
- Transplacental passage of maternal anti-TSH receptor antibodies
- Antibodies bind to infant’s TSH receptors and cause excessive thyroid hormone release
Treatment of Neonatal thyrotoxicosis
- Self-resolves within 3 months (disappearance of maternal antibody)
- Methimazole PLUS Beta blocker
Daughters of women who used diethylstilbestrol are at increased risk for developing what kind of cancer
- clear cell adenocarcinoma of the vagina and cervix
- Many of these women have cervical or uterine malformations as well as difficulty conceiving and maintaining pregnancy
Clinical features of vulvar lichen sclerosus
- Thin, white, wrinkled skin over the labia majora/minor; atrophic changes that may extend over the perineum and around the anus
- Excoriations, erosions, fissures from severe pruritus
- Dysuria, dyspareunia, painful defacation
Workup of vulvar lichen slerosus
-punch biopsy of adult-onset lesions to exclude malignancy
treatment of vulvar lichen sclerosus
superpotent corticosteroid ointment
Hypotension is a possible side effect of epidural anesthesia. If persistent and untreated it can result in decreased placental perfusion and can lead to fetal acidosis. What is the pathophysiology of the hypotension?
-sympathetic nerve fibers responsible for vascular tone are blocked, resulting in vasodilation (venous pooling), decreased venous return to the right side of the heart, and decreased cardiac output
Hypotension is a possible side effect of epidural anesthesia. If persistent and untreated it can result in decreased placental perfusion and can lead to fetal acidosis. How can it be prevented?
-aggressive IV fluid volume expansion prior to epidural placement
Hypotension is a possible side effect of epidural anesthesia. If persistent and untreated it can result in decreased placental perfusion and can lead to fetal acidosis. How can it be treated?
- Left uterine displacement (Positioning patient on the left side) to improve venous return
- Additional IV fluid bolus
- Vasopressor administration
Depression of cervical spinal cord and brainstem activity occurs when local anesthesia ascends toward the head, also known as a “high spinal” or “total spinal”, a dangerous complication of epidural anesthesia. It may happen with intrathecal injection or overdose of the anesthesia. What are the signs?
- First signs: Hypotension, bradycardia, and respiratory difficulty
- Later: diaphragmatic paralysis and possibly cardiopulmonary arrest
Leakage of cerebral spinal fluid may occur if the dura is inadvertently punctured during epidural placement. This results in leakage of spinal fluid and is known as a “wet tap”. Patients may experience what symptoms
-postural headaches that are worse with sitting up and improved with lying down after delivery
Does cervical laser ablation increase the risk of preterm delivery
No
Management of PPROM at 34-37 weeks with inknowne GBS status
- antibiotics
- deliver
What is amnioinfusion used for
-for treatment of recurrent variable decels due to umbilical cord compression during labor
Bilateral, gray, nonbloody nipple discharge, guaiac negative is consistent with what ?
-Initial evaluation?
physiologic galactorrhea
-should focus on identifying etiology and includes serum prolactin, THS, and pregnancy test
what is measured in conjunction with pelvic US finding to categorize ovarian mass as likely malignant or benign
CA-125 levels
In a postmenopausal patient, an elevated CA-125 level in the context of an adnexal mass is highly suspicious for what
malignancy
Endometrial biopsy is performed to investigate for endometrial carcinoma and is indicated in patients with what symptoms
- postmenopasual bleeding
- abnormal uterine bleeding over age 45
- or thickened endometrial stripe with an ovarian mass
Why is needle aspiration contraindicated in postmenopausal women with an adnexal mass
risk of spreading potentially malignant cells should the mass prove to be cancerous
- Sudden-onset, severe unilateral lower abdominal pain immediately following strenuous or sexual activity
- Pelvic free fluid
-Ruptures ovarian cyst
Elevated maternal serum alpha-fetoprotein in pregnancy is associated with what defects?
- Open neural tube defects (e.g. anencephaly, open spina bifida)
- Ventral wall defects (e.g. omphalocele, gastroschisis)
- multiple gestation
Decreased Maternal serum alpha-fetoprotein in pregnancy is associated with what
-Aneuploidies (e.g. trisomy 18 and 21)
Elevated maternal serum alpha-fetoprotein in pregnancy warrants what further test
careful US evaluation of the fetal anatomy
- in addition, number of fetuses should be clarified
- Gestational age is also confirmed as interpretation of AFP level depends on an accurate gestational age
What is recommended to all women who are in labor with active genital HSV lesions or prodromal symptoms
C section
Pregnancy women with a history of genital HSV infection should receive prophylactic acyclovir or valacyclovir beginning when
36 weeks
When is testing for toxoplasmosis indicated
only when patients have symptoms of potential infection (e.g. fever, malaise, lymphadenopathy)
Describe the maternal management of Hepatitis C infection in pregnancy?
- Ribavirin is TERATOGENIC and should be avoided
- No indication for barrier protection in serodiscordant, monogamous couples
- Hepatitis A and B vaccination
Is C section protective of vertical transmission of Hep C
No
Hep C and breast feeding
- Breastfeeding does NOT increase the risk of HCV transmission to the neonate
- Should be suspended only if the nipple area is actively bleeding
Scraping of a vulvar lesion for potassium hydroxide testing is performed when dermal candidiasis is suspected. How does vulvar yeast present
as red and flaky patches with satellite lesions and possible extension to the inner thighs and groin
What is the ultrapotent topical corticosteroid ointment that is the first line treatment for relief of itching and other symptoms of lichen sclerosus
Clobetasol
What is the most important direct role of hCG in pregnancy
- Secreted by the syncytiotrophoblast and is responsible for Maintenance of the corpus luteum during early pregnancy in order to maintain progesterone secretion until the placenta is able to produce progesterone on its own
role of progesterone in pregnancy
inhibits uterine contractions
what hormone is responsible for preparing the endometrium for implantation of a fertilized ovum
progesterone
The diagnosis of ectopic pregnancy is made by a pregnancy test combined with what?
- TransVAGINAL US
- Transabdominal US cannot reliably visualize a gestational sac super early in pregnancy
Mother has blood group O and a husband with blood group AB . . they will have a child with either blood group A or B. In these situations of ABO incompatibility, describe the risk of hemolysis?
- Signs of hemolytic disease are typically mild and apparent only in about 1/3 of infants
- Affected infants are usually asymptomatic or mildly anemia at birth
- Within the first 24 hours of life they may develop jaundice (e.g. hyperbilirubinemia), which typically resons to phototherapy
Can ABO incompatibility affect first pregnancy?
yes because patients with blood group O are exposed to A and B antigens early in life (from exposure to A- and B- like antigens present in food, bacteria, and viruses) and produce IgG
Presentation of Theca Lutein cysts
- Multilocular
- Bilateral
- 10-15 cm ovaries
Pathogenesis of theca lutein cysts
- Ovarian hyperstimulation due to:
- Gestational trophoblastic disease
- Multifetal gestation
- Infertility treatment
Clinical course of theca lutein cysts?
-Resolve with decrasing beta-hCG levels
Hyperemesis gravidarum, an enlarged uterus, and bilarerally enlarged ovaries is a presentation concerning for what
hydatidiform mole
Pathogenesis of theca lutein cysts from hydatidiform mole
ovarian hyperstimulation from abnormal trophoblastic proliferation
Target blood glucose levels in Gestational DM
- Fasting <95
- 1 hour postprandial: <140
- 2 hour postprandial <120
Atypical glandular cells on Pap testing may be due to what/
either cervical or endometrial adenocarcinoma
Atypical glandular cells on Pap testing is further investigated how?
- Colposcopy
- endocervical curettage
- endometrial biopsy
baby with klumpke palsy and horner syndrome after shoulder dystocia and forceps delivery. What nerves affected
-C8 and T1
Erb-Duchenne palsy involves what nerves
C5 and C6
Describe the course of genital herpes if untreated
Resolution then DECREASINGLY frequent recurrences
Rectovaginal fistula presents with incontinence of flatus or fecal material through the vagina, causing a malodorous brown/tan discharge. Diagnosis is usually confirmed by visual examination showing what?
-Dark red, velvety rectal mucosa on the posterior vaginal wall
Risk factors for pubic symphysis diastasis
- Fetal macrosomia
- Multiparity
- Precipitous labor
- Operative vaginal delivery
Presentation of Pubic symphysis diastasis
- Difficulty ambulating
- Radiating suprapubic pain
- Pubic symphysis tenderness
- Intact neurologic exam
Femoral nerve damage can occur during delivery as a result of hyperflexion of the thigh (McRoberts Maneuver). How does it present
- numbness over the anterior and medial thigh
- inability to extend the leg or flex the thigh
- diminished patellar reflexes
Patient with Amniotomy at +1 station at 7 cm dilation went from intermittent variable decels to recurrent. What would first line intervention be
- Maternal repositioning (Left lateral) which may reduce cord compression and improve blood flow to the placenta
- Should these fail, amnioinfusion is a reasonable second-line intrauterine resuscitation option
- If fully dilated then instrumental vaginal delivery would be indicated
Unilateral bloddy nipple discharge is the hallmark of what? . . no associated mass or lymphadenopathy
-intraductal papilloma
management of breast abscess
- Needle aspiration under US guidance and antibiotics (Dicloxacillin, cephalexin)
- Incision and drainage with packing are recommended for abscesses not responsive to needle aspiration and antibiotics, suspected necrotic material, and Large (>5cm) pus collections
- Male karyotype
- male testosterone levels
- Breast development
- Primary amenorrhea (absent ovaries, uterus, cervix)
- Minimal pubic and axillary hair
Androgen insensitivity syndrome
-mutated androgen receptor
This occurs in 46,XX females and consists of no upper vagina, cervix, or uterus, but otherwis normal femal development
-Should have normal pubic and axillary hair and female testosterone levels
Mullerian agenesis (Mayer-Rokitansky-Kuster-Hauser syndrome)
This occurs close to ovulation (late follicular phase) and can be perceived by patients as vaginal discharge. The mucus is clear, elastic, thin in consistency and described similar in appearance to an uncooked egg white
Cervical mucus
A palpable, well-circumscribed, mobile breast mass in women age <30 suggest what
a benign process, most commonly a fibroadenoma
This presents as multiple, small, cyclically tender masses (diffuse breast nodularity) on physical examination
Fibrocystic breast changes
Clinical presentation of a septic abortion
- Fever, chills, abdominal pain
- Sanguinopurulent vaginal discharge
- Boggy, tender uterus; dilated cervix
- Pelvic US: retained POC, thick endometrial stripe
Management of a septic abortion
- IV fluids
- Broad spectrum antibiotics
- Suction currettage
Patient at 35 weeks gestation with irregular contractions and a closed cervix is consistent with what
False labor
When does tocolysis for preterm labor become contraindicated
34 weeks
management of patient in false labor
- can resume routine prenatal care
- reassure patient and discharge home
Patient presents with amenorrhea, breast fullness, morning sickness, and abdominal distension - symptoms of early pregnancy - and believes she is pregnant. However, her office exam (thin endometrial stripe, negative urine pregnancy) excludes pregnancy. This is consistent with what
Pseudocyesis
risk factors for pseudocyesis
- Hx of infertility
- Prior pregnancy loss
Management of inevitable abortion
- Expectant or medial (e.g. misoprostol) management is appropriate in hemodynamically stable patients with minimal bleeding
- Surgical (suction currettage) indicated for hemodynamically unstable patients
At what Beta-hCG level is fetus usually visible by transvaginal US
1500
-If the level is <1500 then repeat in 2 days
Anti-D immune globulin is indicated when
in unsensitezed, Rh-negative women at 28 weeks gestation or within 72 hours of any procedure or incident in which there is any possibility of feto-meternal blood mixing
What is considered a nonreactive (abnormal) NST
,2 accelerations in 20 minutes
Most common cause of a nonreactive NST and what should be done?
- Fetal sleep cycle
- Vibroacoustic stimulation to awaken fetus and allow timely test
Patient presents with menstrual irregularities (e.g. anovulation), infertility, and enlarged ovaries. In addition, the presence of acanthosis nicricans indicates insulin resistance. These are clinical manifestations of what?
polycystic ovarian syndrome
describe management of PCOS in patient wanting to get pregnant
- Weight loss to reestablish ovulation by decreasing the peripheral estrogen conversion
- if unsuccessful then clomiphene citrate, a selective estrogen modulator that primarily blocks estrogen receptors at the levels of the hypothalamus and inhibits the negative feedback
Breast cancer and Combined hormonal contraceptives?
ABSOLUTE CONTRAINDICATION . . . actually all hormonal containing contraception would be so copper IUD would be best
What 2 uterine surgeries makes a trial of labor contraindicated
- Classical C section (Vertical incision)
- Abdominal myomectomy with uterine cavity entry
Patient with previous myomectomy, intense constant abdominal pain, and persistent variable decelerations are concerning for what
uterine rupture . . . so urgent laparotomy and delivery
Amnioinfusion and Hx of uterine surgery
contraindicated
Blunt abdominal trauma is a significant risk factor for severe hemorrhage from placenta abruption. Initial management involves what?
-Aggressive fluid resuscitation and uterine displacement to optimize maternal circulation
Engorgement results when milk production exceeds release, and this patient has engorged breasts due to rapid cessation of breastfeeding. How is lactation suppression accomplished?
- by wearing a comfortable, supportive bra
- avoidance of nipple stimulation and manipulation
- application of ice packs to the breasts
- NSAIDs
- Heavy menses
- Constipation, urinary frequency, pelvic pain/heaviness
- enlarged uterus
Fibroids
- Dysmenorrhea, pelvic pain
- Heavy menses
- Bulky, globular, and tender uterus
Adenomyosis
- History of obesity, nulliparity, or chronic anovulation
- Irregular, intermenstrual, or postmenopausal bleeding
- Nontender uterus
Endometrial cancer/hyperplasia
How does obesity cause endometrial hyperplasia
-increases circulating estrogen levels through increased peripheral conversion of androgens to estrogens and aromatization of androstenedione to estrone
Hallmarks of endometriosis . . . “the 3 D’s”
- Dysmenorrhea
- DEEP dyspareunia
- dyschezia (pain with defacation)
- Other features include pelvic pain and infertility
What are the first line empiric treatment for endometriosis without definitive surgical diagnosis, such as in this patient without plans for immediate conception
-NSAIDs and or combined oral contraceptives
Primary infertility is defined as failure to conceive after a year of unprotected, times sexual intercourse in a nulliparous patient age <35 (after age 35, infertility investigation can begin after 6 months). If patient has history of PID what would be next step
-Hysterosalpingogram to assess fallopian tube patency
A woman has a 1 in 8 lifetime risk of breast cancer. What is a dose dependent risk factor and reduced intake will decrease the risk of breast cancer?
- Alcohol consumption
- Protective lifestyle aspects include exercise and breastfeeding
In obstetrical ethical decisions who has the ultimate rights?
The mother is considered to have ultimate rights over her unborn child, assuming she has capacity
Violent muscle contractions, as seen in a seizure or electrocution injury (maybe eclampsia), are a common cause of what shoulder pathology
posterior shoulder dislocation
Describe the shoulder in a posterior shoulder dislocation
-The shoulder is typically held in adduction and internal rotation, with visible flattening of the anterior aspect of the shoulder and prominence of the caracoid process
IN anterior shoulder dislocations, the patient holds the arm how
slightly abducted and externally rotated
Describe Todd paralysis
transient unilateral weakness following a tonic clonic seizure that usually spontaneously resolves
Wernicke encephalopathy is a neurological disease due to a thiamine deficiency. Although most commonly associated with alcoholsim, it can occurs with what disorder associated with pregnancy?
Hyperemesis gravidarum, a severe, persistent nausea and comiting of pregnancy that results in weight loss and dehydration
Lab values associated with hyperemesis gravidarum
- Hypochloremic metabolic alkalosis
- hypokalemia
- hypoglycemia
- elevated serum aminotransferases
- All of these are the result of protracted vomiting
treatment of asymptomatic endometriosis found incidentally during a different surgery
just observation
What is the only current indication for hormonal replacement therapy
-vasomotor symptoms in women <60 who have undergone menopause within the past 10 years
Describe advice to pregnant patients on lithium
-In patients who have stable bipolar disease, slow tapering of lithium should be considered
Active labor and external cephalic version
relative contraindication
Hx of recurrent pregnancy loss and prior transient eschemic attack is concerning for what?
- Thrombophilia
- Antiphospholipid syndrome is an autoimmune disorder that presents with pregnancy complication or venous or arterial thrombis
What should be the first diagnostic test used to confirm the diagnosis of appendicitis in pregnancy and can also be helpful to rule oute other potential diagnoses?
US
Universal screening for GBS in pregnancy
rectovaginal culture at 35-37 weeks gestation
Women who miss screening for GBS (status unknown) should be treated in labor under what circumstances?
- ,37 weeks gestation
- Develop intrapartum fever
- have ROM for >18 hours
Typical presentation is dysmenorrhea with heavy menstrual bleeding (soaking a pad or tampon more often than every 2 hours) that starts later in reproductive years with progression to chronic pelvic pain.
Classic physical exam findings are a boggy tender, uniformly enlarged uterus
Adenomyosis
Lab abnormalities in intrahepatic cholestasis of pregnancy
- Elevated bile acids
- Elevated levels of liver enzymes
Red papules within striae with sparing around the umbilicus sometimes extending to the extremities
PUPPP
Adverse effects of SERMs (Tamoxifen and Raloxifene)
- Hot flashes
- VTE
- Endometrial hyperplasia and carcinoma (Tamoxifen only)
Lack of menses is considered normal until what age if development of secondary sex characteristics has been appropriate?
-15
In PCOS, what is the mechanism behind anovulation or infertility
failure of follicle maturation
The initial menstrual cycles in adolescents are irregular and anovulatory due to what?
hypothalamic-pituitary-gonadal axis immaturity and insufficient secretion of gonadotropin-releasing hormone
Secondary Amenorrhea is absence of menses for 6 months. If Beta-hCG is negative and the is no prior uterine procedure or infection then what is the further workup
- Prolactin
- TSH
- FSH
What should be considered in a patient with no history of skin disease who develops a breast rash?
Breast cancer . . most commonly adenocarcinoma
Sudden onset of abdominal pain, recession of the presenting part during active labor, and fetal heart rate abnormalities are red flags for what?
-uterine rupture
Clinical presentation of amniotic fluid embolism
- Cardiogenic shock
- Hypoxemic respiratory failure
- DIC
- Coma or seizures
Treatment of amniotic fluid embolism
-Respiratory and hemodynamic support
This is a form of gestational trophoblstic neoplasia, a malignancy that arises from placental trophoblastic tissue and secretes Beta-hCG
choriocarcinoma
Choriocarcinoma typically presents when
< 6 months after a pregnancy
Presenting symptoms of choriocarcinoma
- Irregular vaginal bleeding
- Enlarged uterus
- pelvic pain
Choriocarcinoma is an aggressive type of gestational trophoblastic neoplasia. The most common site of metastases is where
lungs
What is commonly the sole presenting symptom of endometriosis
infertility
Pharyngitis with fever and lower abdominal pain in a young, sexually active patient is suggestive of what
-May present as pharyngeal edema and NONtender cervical lymphadenopathy
-Gonococcal pharyngitis with PID
Marijuana use while breastfeeding is condraindicated and has been associated with what effects on the baby
- decreased muscle tone
- poor suckling
- sedation
- Delayed motor development at age 1
What is the most accurate method of determining gestational age
First trimester US with crown-rump length
Newborn with: Large anterior fonatanel
- thin umbilical cord
- Loose, peeling skin
- Minimal subcutaneous fat
Fetal growth restriction
Evaluation of newborn with fetal growth restriction
- Placenta histopathology (usually due to utero-placental insufficiency)
- Consider karyotype, urine tox, serology
Neonatal complications in newborn with fetal growth restriction
- Polycythemia
- Hypoglycemia
- Hypocalcemia
- Poor thermoregulation
In fetal growth restriction, the placental histopatholgy is looking for what
Infarction and/or infection (e.g. spirochetes)
What are nonviable fetal diagnoses?
- Anencephaly
- Bilateral renal agenesis
- Holoprosencephaly
- Acardia
- Thanatophoric dwarfism
- INtrauterine fetal demise
Management of nonviable fetus
- Vaginal delivery
- No fetal monitoring
US findings of ovary with Adnexal fullness on routine PE in otherwise asymptomatic patient that shows hyperechoic nodules and calcifications
Dermoid ovarian cyst (mature cystic teratoma)
What type of cysts have higher likelihood of ovarian torsion
Dermoid (mature cystic teratoma)
- Midfacial hypoplasia
- microcephaly
- cleft lip and palate
- digital hypoplasia
- hirsutism
- developmental delay
Fetal hydantoin syndrome
What features of fetal hydantoin syndrome are ABSENT in fetal alcohol syndrome
- Cleft palate
- excess hair
Normal internal genitalia, external virilization (e.g. clitoromegly), and undetectable serum estrogen levels in a female patients are consistent with what Dx?
aromatase deficiency
Describe the findings in adolescents of patients with aromatase deficiency
- delayed puberty
- osteoporosis
- undetectable estrogen levels (e.g. no breast development)
- high concentrations of gonadotropins that results in polycystic ovaries
This is an X-linked abnormality characterized by hypogonadotropic hypogonadism with anosmia. Patients have delayed puberty but LH and FSH levels are low or absent
Kallman syndrome
this is marked by the triad of cafe au lait spots, polyostotic fibrous dysplasia, and autonomous endocrine hyperfunction
McCune-Albright syndrome
Most common endocrine features of McCune-Albright syndrome
Gonadotropin-independent precocious pubery
When can external cephalic version be performed
-between 37 weeks gestation and the onset of labor and has been shown to reduce the rate of C section
This is performed in twin delivery to convert the second twin from a transverse/oblique presentation to a breech presentation for subsequent delivery
Internal podalic version
Describe anovulation secondary to morbid obesity
- FSH and LH levels are normal
- Ovaries are still producing estrogen
- Progesterone is not being produced at the normal post ovulation levels
- Progesterone withdrawal menses at the end of the cycle does not occur
Thin, yellow green, malodorous, frothy discharge
-Vaginal inflammation
Trichomoniasis
Thin, off-white discharge with fishy odor
-NO inflammation
BV (Gardnerella vaginalis)
What are the indications for Cervical conization
-CIN grades 2 and 3
Complications from cervical conization
- Cervical stenosis
- Preterm birth
- PPROM
- Second trimester pregnancy loss
This refers to the formation of intrauterine adhesions from infection (e.g. severe endometritis) or intrauterine surgical interventions (e.g. Dilation and currettage, endometrial ablation, endometrial resection)
Asherman syndrome
If a patient has a history of CIN 2 or higher, describe the pap screening guidelines
-for another 20 years after detection and past 65 if indicated
A small vaginal pool of clear fluid seen on speculum examination can be due to urine or amniotic fluid. What makes SROM Less likely and Stress urinary incontinentce more likely?
- No fluid emerges from the cervix on valsalva
- Nitrazine and fern tests are negative
Weight gain and OCPs?
-Although weight gain as a side effect is a common perception, several studies have shown no significant weight gain, particularly with low dose formulations
Copper IUD and dysmenorrhea?
Not recommeneded as its inflammatory reaction on the uterus may increase pain symptoms
Risks of combined OCPs
- VTE
- HTN
- Hepatic adenoma
- very rarely stroke and MI
during surgical removal of a mature dermoid cyst, intraperitoneal spillage of cyst contents should be avoided as it can cause what
chemical peritonitis
Which vaccines are CONTRAINDICATED during pregnancy
- HPV
- MMR
- Live attenuated influenza
- Varicella
- Dull and ill defined pelvic ache that worsens with standing
- Dyspareunia
Pelvic congestion
IN patients known to have SLE prior to conception, the appearance of proteinuria during pregnancy may represent an SLE flare complicated by nephritis, preeclampsia, or both. Distinguishing b/t lupus nephritis and preeclampsia can be difficult as both present with edema, HTN, and proteinuria. what additions signs point to SLE
- Joints pain
- Malar rash
- presence of RBC casts on UA
- decreased complement levels
- Increasing ANA
Infertility in 37 year old female with normal exam and normal menses
- Infertility can occur due to diminished ovarian reserve, characterized by decrease oocyte number and quality.
- Regular menstrual periods still occur due to continuing ovulation, but fecundability (conception rate) decreases due to diminished oocyte quality
Describe the etiology of low back pain during pregnancy
- Enlarged uterus –> exaggerated lordosis
- Joint/ligament laxity from Increased progesterone/relaxin
- Weak abdominal muscles –> decreased lumbar support
Imaging in low back pain during pregnancy
Not indicated
management of low back pain during pregnancy
- Behavioral modifications
- Heating pads
- Analgesics
Beta-hCG levels in a hydatidiform mole
> 100,000
Clinical features of PMS
- Physical: Bloating, fatigue, HA, hot flashes, breast tenderness
- Behavioral: Anxiety, irritability, mood swings, decreased interest
Evaluation of PMS
symptoms/Menstrual diary over 2 mentrual cycles
-Should demonstrate recurrence of symptoms during the luteal phase (1-2 weeks prior to menses)
Treatment of PMS
SSRI
what is the more severe variant of PMS
-PMDD (premenstrual dysphoric disorder)
This is an estrogen secreting ovarian tumor which leads to estrogenic symptoms like breast tenderness, postmenopausal bleeding, precocious puberty
Granulosa cell tumor
Describe the PE and imaging findings in Granulosa cell tumor
- Large pelvic/adnexal mass
- endometrial hyperplasia or carcinoma, which presents as postmenopausal bleeding and appears on US as a thickened endometrium
What situations make a medically emancipated minor?
- Emergency care
- STI
- Substance abuse (most states
- Pregnancy care (most states)
- Contraception
What are unsafe exercise activities in pregnancy
- Contact sports (e.g. BBall, hockey, soccer)
- High fall risk (e.g. downhill skiing, Gymnastics, horseback riding)
- Scuba diving
- hot yoga
fetal gastroschisis is associated with use of what in the first trimester
NSAIDs
All sexually active women age <25 are advised to undergo what annual gynecologic screening annually in addition to routine Pap testing
Chlamydia and Gonorrhoeae
Pathophysiology of type II osteogenesis imperecta
- Autosomal dominant
- Type 1 collagen defect
US findings of type II osteogenesis imperfecta
- multiple fractures
- short femur
- hypoplastic thoracic cavity
- fetal growth restriction
- intrauterine demise
Prognosis of type II osteogenesis imperfecta
lethal
This is a non lethal autosomal dominant bone dysplasia that presents with macrocephaly, frontal bossing, midface hypoplasia, genu varum, and limb shortening
Achondroplasia
This is a lethal fetal anomaly that presents with pulmonary hypoplasia, limb deformities (e.g. clubfoot, hip dislocation), and oligohydramnios. The sequence is most commonly due to urinary tract abnormalities (e.g. bilateral renal agenesis, Polycystic kidney disease
Potter sequence
Describe the management of a patient who had suction curettage after a hydatidiform mole
- beta-hCG levels are followed weekly until undetectable
- A plateau or increase in the levels is diagnositc of gestational trophoblastic neoplasia (GTN)
- Once hCH is undetectable, monthly monitoring continues for 6 months, newly detectable level means GTN
- During the surveillance period, contraception is prescribed, as pregnancy would make it hard to determine the significance of a rising Beta-hCG level
- GTN rarely develops >6months after suciton curettage so after 6 months of undetectable levels, patients can attempt conception
What is first line treatment of gestational trophoblastic neoplasia
-methotrexate and hysterectomy
Describe the levonorgestrel containing IUD
- long acting, reversible, contraceptive
- releases a progestin, which creates a physical barrier by thickening cervical muus and impairing implantation through decidualization of the endometrium
- Common side effect is amenorrhea, which can be used to improve anemia and abnormal uterine bleeding
Copper IUD and heavy bleeding/anemia
-Can cause heavy menstrual bleeding and should not be placesin women with hypermenorrhea or anemia
Medroxyprogesterone injections and weight gain?
-weight gain is a common side effect
This typically presents with high fever, hypotension, and a diffuse red macular rash involving palms and soles
Toxic shock syndrome
This is a complication of PID and presents with fever, abdominal pain, and a complex multiloculated adnexal mass with thick walls and internal debris
Tubo-ovarian abscess
Lab findings in tubo-ovarian abscess
- increases in nonspecific indices (e.g. leukocytosis, CRP, CA-125)
- fever
- Female Precocious puberty
- Large Adnexal mass
Granulosa cell tumor, a type of ovarian sex cord-stromal tumor
what hormones are elevated in Granulosa cell tumor
- Estradiol
- Inhibin
Call-Exner Bodies (cells in rosette pattern) on histopathology
Granulosa cell tumor
Patients with Granulosa cell tumor before puberty present with what
- Early-onset breast development
- Vaginal bleeding due to endometrial proliferation
- Advanced bone age (> 2 standard deviations of chronologic age)
These are germ cell tumors that contain cells that differentiate into syncytiotrophoblast cells of the placenta. They can secrete lactate dehydrogenase or beta-hCG but they do NOT cause precocious puberty
Dysgerminomas
These are benign germ cell tumors composed of endodermal, mesodermal, and ectodermal tissue. They may secrete thyroid hormone (ie, struma ovarii)
Mature teratoma
These are ovarian sex cord-stromal tumors that produce androgens (eg, testosterone, androstenedione); patients with these tumors typically have virilization (eg, amenorrhea, deepening voice, cliorormegaly)
Sertoli-Leydig cell tumors
What are clinical features of a Granulosa cell tumor in Adulthood?
- Breast tenderness
- Abnormal uterine bleeding
- Postmenopausal bleeding
- Chronic unopposed estrogen can result in endometrial hyperplasia or cancer
