UWorld Flashcards
Serum markers for neural tube defect.
AFP up, all other markers normal
Serum markers for Trisomy 21 vs 18.
21 = betaHCG (up), Inhibin A (up), AFP (down), Estriol (down)
18 = betaHCG (down), Inhibin A (down), AFP (down), Estriol (normal)
Treatment of postpartum endometriris
Clindamycin and gentamicin
Next step in management for postpartum hemorrhage
Genital tract inspection (look for unrecognized laceration)
Infant with claw hand. Dx? Mechanism? Other symptoms?
Dx = Klumpke Palsy
Mechanism = shoulder dystocia causing traction on C8 T1
Other symptom = Horner’s
Prenatal testing at 10 weeks
Cell free DNA.
High sensitivity and specificity for aneuploidy
Timeline for chorionic villus sampling performed? Amniocentesis?
CVS = 10-13 wks Amnio = 15-20 wks
Chlamydia treatment
Azithromycin
* if resistant to azithromycin the use Doxycycline (but NOT in pregnancy)
At what gestational age do we perform the oral glucose challenge test?
24-28 wks
At what gestational age do we perform Group B Strep culture?
35-37 wks
Why does peripheral edema occur during pregnancy?
Plasma volume expansion
How often to administer shots of Depot Medroxyprogesterone Acetate (DMPA) intramuscularly?
Every 3 months
Cause of infertility after intrauterine surgery
Asherman syndrome (due to development of intrauterine synechiae = adhesions)
What is placenta previa
When the placenta covers the cervix
Differential of bleeding during pregnancy.
Placenta previa (placenta covers cervix) = Painless bleeding ad NORMAL fetal heart tracing
Placental abruption = YES fetal heart rate tracing abnormalities (e.g. decelerations, bradycardia)
Uterine rupture = Often occurs during labor, YES fetal heart tracing abnormalities (e.g. decelerations, bradycardia)
Vasa previa (fetal blood vessels cover cervix) = rapid deterioration of fetal heart tracings as the hemorrhage is primarily of fetal origin
What test is used to diagnose intrauterine fetal demise? Treatment and follow-up?
Test to diagnose = Transabdominal ultrasound must show absence of fetal cardiac activity (Doppler is NOT enough)
Tx = vaginal delivery
Follow-up =
- Fetal autopsy + karyotype
- Placental evaluation
- Maternal evaluation for antiphospholipid antibody syndriome and fetomaternal hemorrhage (KB test)
Pathophysiology of preeclampsia
Chronic uteroplacental insufficiency
What complication is likely to present in the neonate to a mother that has preeclampsia
Fetal growth restriction
Define late and post-term pregnancy
Late-term pregnancy > 41 wks
Post-term pregnancy > 42 wks
What is the risk to the mother and the fetus if pregnancy is prolonged beyond 42 wks?
Risk of Oligohydramnios (due to uretoplacental insufficiency)
What does a Fetal Heart Rate demonstrating sinusoidal pattern mean?
Sinusoidal pattern = severe fetal anemia
Fetal cord compression - What is the fetal heart rate monitor pattern?
Variable decelerations
Oligohydramnios - What is the fetal heart rate monitor pattern?
Variable decelerations
What is chorioamnionitis?
What is the fetal heart rate monitor pattern?
Chorioamnionitis = intraamniotic infection
FHR monitor = fetal tachycardia (>160 bpm)
What is uterine atony? Treatment?
Uterus fails to contract after delivery, causing heavy postpartum bleeding.
Tx = Bimanual uterine massage and/or oxytocin (uterotonic)
What does the physical exam of the uterus show in uterine atony?
Enlarged, boggy uterus
What do you see on bleeding labs of patients with vWF deficiency?
Normal PT and PTT
Prolonged bleeding time
How to treat acute bleeding caused by vWF deficiency?
Desmopressin
What is the exact definition of preeclampsia?
(1) High BP = SBP > 140 or DBP > 90
(2) Proteinuria or Signs of end-organ dysfunction
(3) Gestational age > 20 wks
What are the 6 severe features that define “Preeclampsia with severe features”?
(1) SBP > 160 or DBP > 110
(2) Thrombocytopenia
(3) High Creatinine
(4) High Transaminases
(5) Pulmonary edema
(6) Visual or Cerebral symptoms
What is the management of patients with preeclampsia?
Without severe features = deliver after 37 wks
With severe features = deliver after 34 weeks
+ MgSulfate + Antihypertensives
Preeclampsia definition (criteria) - exact numbers
(1) Hypertension (BP > 140/90)
(2) > 20 wks gestation
(3) Proteinuria OR organ damage
Define proteinuria of preeclampsia
Proteinuria =
> 300 mg protein /24 hrs
protein/Creatinine ratio > 0.3
Dipstick 1+ or higher
When is labetalol contraindicated in the treatment of hypertension in pregnancy
Labetalol is a beta blocker so it should not be used if patient’s pulse is less than 60 (bradycardia)
What oral medication is a choice to control hypertension of pregnancy and it what scenario should it NOT be used
Nefidipine (PO)
Do NOT use if pt has emesis
1st line treatment for magnesium toxicity
IV calcium gluconate
What kind of patients are at risk for magnesium toxicity?
Patients with renal disease
What is the mechanism and use of the drug Clomiphene?
Clomiphene is an estrogen receptor antagonist in the hypothalamus. Thus, it prevents feedback inhibition of GnRH. Therefore clomiphene leads to increased secretion of LH and FSH.
Clomiphene is used to treat infertility due to anovulation (e.g. PCOS)
Acne and male-pattern hair during pregnancy: Cause? Management?
Cause = elevated beta HCG leads to ovarian hyperstimulation causing development of bilateral luteoma (solid mass) or theca lutein cysts, which release androgens. Management = Will resolve after delivery
How to differentiate lactational mastitis and breast abcess.
Lactational mastitis and breast abscess both present with unilateral breast pain and flulike symptoms (fever, myalgias).
However Breast Abscess is a fluctuant (moveable) mass AND is associated with axillary lymphadenopathy.
How will galactocele present?
NO pain.
NO fever
Subareolar, mobile, well-circumscribed mass.
How will plugged breast duct present?
YES pain
NO fever
Focal tenderness and firmness.
Preterm labor is below how many weeks?
Below 37 weeks
How to manage preterm labor depending on the gestational age.
Less than 37 weeks, all preterm should receive Betamethasone + Penicilin if GBS status unknown.
Less than 34 weeks = Add Tocolytics
Less than 32 weeks = Add magnesium sulfate
What are tocolytics?
Examples?
Tocolytic = Inhibitor of active labor Examples = Indomethacin, Nifedipine, Terbutaline
Vulvar itchin and burning that leads to white vulvar plaques and loss of labia minora. Dx? Next step in management? Tx?
Dx = Vulvar lichen sclerosus
Next step = vulvar punch biopsy to rule out vulvar cancer
Tx = Superpotent topical steroids (clobetasol)
How to differentiate between vulvar lichen sclerosus and candida infection?
Vulvar lichen sclerosus and Candida intertigo both present with pruritis. However the lesions are different. In vulval lichen sclerosus the lesions are white and often localized perianaly. However, in candida the lesions are erythematous and associated with satellite lesions.
What makes someone predisposed to vulvar lichen sclerosus?
Diabetes
Post-menapausal
Risk factors for abruptio placentae
#1 = Previous abruptio placentae. Other: Preeclampsia Smoking Hypertension Trauma Advanced age
Complications after abruptio placentae
1 = Disseminated intravascular coagulation
- Severe hemorrhage
- Preterm delivery
- Fetal demise (20%) due to hypoxia
Where are Bartholin glands located?
Posterior vulvar vestibule (4 and 8 o’clock position)
Cauliflower-like lesion. Dx?
HPV
Tender anterior vaginal wall mass with dyspareunia and purulent discharge. Dx?
Urethral diverticulum
Tender posterior vulvar vaginal mass with dyspareunia and purulent discharge. Dx?
Bartholin gland abcess
Anterior vaginal bulge. Dx?
What physical exam test can be used to diagnose?
Cystocele
Physical exam = Valsalva maneuver will cause more bulging
Adnexal mass and virilization. Dx?
Dx = Sertoli-Leydig cell tumor
testosterone producing
Estrogen-secreting tumor
Granulosa cell tumor
Lactate-dehydrogenase secreting tumor
Dysgerminoma
Name the type of urinary incontinence: Dribbling
Overflow incontinence
Name the type of urinary incontinence: Sudden overwhelming need to void
Urgency incontinence
Name the type of urinary incontinence: Leakage with coughing.
What is the mechanism?
Stress incontinence
Mechanism = pelvic floor muscle weakness –> urethral hypermobility
Cervix that easily bleeds on contact and produces thick, yellow, malodorous discharge. Dx? Tx?
Dx = Acute cervicitis Tx = Azithromycin and Ceftriaxone (covering for chlamydia and gonnorhoeae)
Stillborn fetus with short, bent extremities. Dx?
Type 2 Osteogenesis Imperfecta
Potter sequence
Urinary tract abnormalities causing:
Oligohydramnios
-> Pulmonary hypoplasia
-> Limb deformities
Postmenapausal woman with vulvar pruritis and white plaque on labia. Dx? Next step? Tx?
Dx = Lichen sclerosus
Next step = punch biopsy to rule out vulvar squamous cell cancer
Tx = if just lichen sclerosus then – high potency topical corticosteroids (clobetasol, halobetasol)
How to differentiate between Leiomyoma and Adenyomyosis?
Leyomyoma (fibroids) = irregularly enlarged uterus, due to proliferation of myometrial smooth muscle cells
Adenomyosis = uniformly enlarged uterus, due to proliferation of endometrial glands inside the uterine myometrium
Fetal heart monitor: bottom peak of deceleration corresponds to peak of contraction. What is this called? What is the mechanism?
Early deceleration
Mechanism:
- occurs due to fetal head compression
- normal
Fetal heart monitor: bottom peak of deceleration occurs after the peak of contraction. What is this called? What is the mechanism?
Late deceleration
Mechanism:
- Uretoplacental insufficiency
Fetal heart monitor: bottom peak of deceleration occurs randomly and sometimes is a really short deceleration, less than 30 sec from start to peak. What is this called? What is the mechanism
Variable deceleration
Mechanism:
- Cord compression OR Cord prolapse
- Oligohydramnios
How to treat variable deceleration on fetal heart monitor.
Treatment for Variable decelerations
(#1) Maternal repositioning to reduce cord compression
(2) Amniofusion (instillation of saline into the intrauterine cavity)
Contraindication to using Raloxifene to treat osteoporosis or breast cancer.
Raloxifene is a selective estrogen receptor modulator. It increases the risk for venous thromboembolism. Therefore any history of previous venous thromboembolism is a contracindication to using raloxifene.
How to differentiate between lichen sclerosus and atrophic vaginitis?
Lichen sclerosus involves perianal thickening, white plaques and eventual obliteration of labia majora and minora. However, lichen sclerosus does NOT affect the internal part of vagina.
Atrophic vaginits - vaginal mucosa are pale, narrowed introitus
Severe acne and hirsutism. Dx?
Polycystic ovarian syndrome
Cessation of ovulation before age 40. Dx?
Dx = Primary Ovarian Insufficiency (POI)
First-line treatment for primary dysmenorrhea (painful menses). Mechanism of Tx.
Tx = NSAIDs or OCP Msm = NSAIDs Inhibit prostaglandin synthesis, OCPs (= progestin + estrogen)
What secretes beta-hCG? Function of beta-hCG?
Secretion = hCG is secreted by syncytiotrophoblast. Function = Preserving the corpus luteum. Corpus luteum secretes progesterone until the placenta is able to produce progesterone on it's own.
When does beta-hCG start to show, what is the trend and when does it peak?
Start hCG = 8 days after fertilization
Trend = Double every 2 days
Peak = 6-8 weeks gestation
(after 8-10 weeks placenta takes over from corpus luteum for progesterone production and hCG gradually decreases)
Treatment of irregular menstrual bleeding in the adolescent patient.
Progesterone
3 risk factors for ovarian torsion.
- Women of reproductive age
- Ovarian mass (e.g. ovarian cyst)
- Infertility treatment with ovulation induction
Typical presentation of patient with ovarian torsion.
- ** SUDDEN onset pelvic pain
- Nausea and vomiting
- +/- adnexal mass
What type of cancer is Mammary Paget Disease?
Adenocarcinoma
Painful genital ulcers. Differential and how to differentiate.
DDx =
- Herpes Simplex: Small vesicles, erythematous base
- Haemophilus ducreyi (chandroid): gray/yellow exudate, friable base
Painless genital ulcers. Differential and hot to differentiate.
DDx =
- Treponema pallidum (syphilis) (chancre) = single ulcer
- Chlamydia trachomatis L1-3 = lymphogranuloma venereum = small, shallow ulcers AND lymphadenopathy that can develop into buboes (painful inguinal lymph nodes that can ulcerate)
Pt with genital ulcers and sterile pyuria (urinanalysis shows WBCs but no bacteria)
Herpes simplex virus
What kind of contraceptive should be used by patients who have risk for thrombosis such as antiphospholipid antibody syndrome (APS)?
APS is a contraindication for combine (estrogen/progestin) hormonal contraceptives. Instead these patients should be offered a copper IUD or tubal ligation.
What vaginal pH level suggests genitourinary syndrome of menopause? What is the mechanism?
pH > 5 Low estrogen --> Low Glycogen Production --> Low Lactobacilli activity --> Decreased lactic acid production --> increased pH (=decreased acid)
Normal prolactin level
< 20
Normal TSH level
0.5 - 5
When is progesterone withdrawal test used? How to interpret results?
Used to evaluate secondary amenorrhea (no menses > 6 months in patients with previously irregular menses)
Interpretation:
No bleeding after progesterone implies low estrogen levels.
Continued bleeding on progesterone implies high estrogen levels (e.g. polycystic ovarian syndrome)
Why is obesity a major risk factor for endometrial hyperplasia and subsequent development of endometrial cancer.
Adipose tissue increases the peripheral conversion of androgens to estrone, thereby increasing estrogen levels and causing unopposed uterine estrogen exposure.
Endometrial hyperplasia is a precursor to endometrial cancer.
Fever, hypotension, diffuse macular rash involving palms and soles. Dx?
Toxic shock syndrome
Staphylococcus aureus infection due to prolonged tampon use.
What are the major risk factors for endometrial hyperplasia?
Obesity and PCOS
Fragile X premutation carriers (50-200 CAG repeats) have what gynecological issue?
Primary ovarian insufficiency (POI) due to accelerated ovarian follicle depletion in women age <40
2 out of 3 criteria must be met to diagnose PCOS. What are the 3 criteria?
1) Hypeandrogenism (acne / hirsutism / alopecia)
2) Irregular Menses
3) Ultrasound demonstrating PCOS
How to treat infertility in PCOS patient.
1) Weight loss
2) Clomiphene citrate (Induces ovulation, because it is a selective estrogen modulator at the hypothalamus, which allows the hypothalamus to restore regular pulsatile GnRH secretion to establish LH surge for ovulation)
Protein marker for Yolk-sac tumors of ovary.
alpha-fetoprotein
At what ages can HPV vaccine be given?
Women = 11-26
Men = 9 - 21
Men who have sex with men or HIV positive men = 9-26
Postpartum, normal pregnancy, woman has multiple infiltrates on chest x-ray, an enlarged uterus, irregular vaginal bleeding. Dx? Test to confirm diagnosis?
Dx = Choriocarcinoma Test = beta-HCG
Boggy uterus. Dx?
Dx = adenomyosis
Irregularly shaped uterus vs. Symmetrically enlarged uterus. What are the different diagnoses?
Irregular = Uterine leiomyomata (fibroids) Symmetrically = Adenomyosis
Vulvovaginal candidiasis treatment
Fluconazole
Right Upper Quadrant Pain
Occasional Spotting
Sexually active female
Dx?
Dx = Perihapatitis (Fitz-Hugh-Curtis disease)
- due to Pelvic Inflammatory Disease, due to
Exposure to the medication diethylsilbestrol (used to prevent spontaneous abortion) predisposes fetus to what?
Increased risk of vaginal clear cell adenocarcinoma
Infertility due to anatomic defects
What predisposes individuals to vaginal squamous cell carcinoma?
Smoking
HPV
Difference between presentation of:
Vulvar Lichen Planus
vs
Behcet disease
Vulvar Lichen Planus = Pruritic purple papules with border of white striae (Wickham striae), associated with oral ulcers
Behcet disease = Also associated with oral and genital lesions. However, No white striae
How to differentiate between Bartholyn gland abscess and Bartholyn gland cyst?
Bartholyn gland abscess will have tenderness and erythema.
Bartholyn gland cyst is non-tender.
How to differentiate between diagnosis of Vaginal candidiasis and Bacterial Vaginosis on PHYSICAL EXAM and HISTORY
Both have white discharge
Vaginal candidiasis is pruritic.
Vaginal candidiasis is associated with erythema and excoriations
Bacterial vaginosis does NOT have erythema and excoriations
Sinusoidal fetal heart rate
Placenta previa
also can present as fetal bradycardia
Late decelerations
Uteroplacental insufficiency
Biophysical profile. What is a normal Amniotic Fluid Index and Normal Single Fluid pocket
Amniotic Fluid Index > 5
Single Fluid Pocket > 2 x 1 cm
Biophysical profile: What is a normal number of:
Fetal movements
Fetal tone
Breathing movements
Within 30 min.
Fetal movement = 3 or more
Fetal tone = at least one flexion/extension
Fetal breathing movements = at least 1 for more than 30 sec.
What is the beta HCG level in hydatidiform mole?
Beta HCG more than 100,000
