Block 8 OB/GYN Flashcards
(123 cards)
1
Q
Which Hep viruses are transferred fecal-oral?
A
A and E
2
Q
Who classically gets Hep A?
A
Travellers
Contamination from food handlers
3
Q
What is the classic means of transmission of Hep E?
A
Contaminated water or undercooked seafood
4
Q
Which Hep viruses have acute state only and no chronic state?
A
A and E
5
Q
Which Hep virus has a vaccine?
A
A
6
Q
What happens to pregnant women with Hep E infection?
A
Fulminant hepatitis with liver failure and massive liver necrosis
7
Q
How is Hep B transmitted?
A
Parenterally
This can be during childbirth, IV drug use, Sex
8
Q
Is hep B infection acute or chronic in most cases?
A
Most frequently acute, only 20% become chronic
9
Q
What is the first serological marker of HepB infection to rise and is also the marker of infection?
A
HBsAG (surface antigen)
10
Q
What serological marker defines the chronic state of HepB infection?
A
The presence of HBsAG for more than 6 months
11
Q
In the acute phase of HepB infection, what will be the serological status for the following: HBsAG HBeAG & HBV DNA HBcAB HBsAB
A
HBsAG: positive
HBeAG and HBV DNA: positive
HBcAB: IgM
HBsAB: negative
12
Q
In the window phase of HepB infection, what will be the serological status for the following: HBsAG HBeAG & HBV DNA HBcAB HBsAB
A
HBsAG: negative
HBeAG and HBV DNA: negative
HBcAB: IgM
HBsAB: negative
13
Q
In the resolved phase of HepB infection, what will be the serological status for the following: HBsAG HBeAG & HBV DNA HBcAB HBsAB
A
HBsAG: negative
HBeAG and HBV DNA: negative
HBcAB: IgG
HBsAB: IgG
14
Q
In the chronic phase of HepB infection, what will be the serological status for the following: HBsAG HBeAG & HBV DNA HBcAB HBsAB
A
HBsAG: positive more than 6 months
HBeAG and HBV DNA: +/– indicates infectivity
HBcAB: IgG
HBsAB: negative
15
Q
In the immunized phase of HepB infection, what will be the serological status for the following: HBsAG HBeAG & HBV DNA HBcAB HBsAB
A
HBsAG: negative
HBeAG and HBV DNA: negative
HBcAB: negative
HBsAB: IgG
16
Q
What is the serological sign of victory over Hep B?
A
Presence of IgG against the surface antigen
17
Q
How is HepC transmitted?
A
Parenterally through a break in the skin or mucus membranes: IV drugs, needle stick, sex, blood transfusion
18
Q
Does Hep C usually go acute or chronic?
A
Chronic is common
19
Q
What is the key serological marker for Hep C?
A
HCV-RNA
20
Q
What is unique about Hep D virus?
A
Requires infection with Hep B
Superinfection is more severe than coinfection with the two viruses
21
Q
What causes syphilis?
A
Treponema pallidum
A spirochete bacterium
22
Q
How is syphilis diagnosed?
A
Requires two types of tests:
Non-treponemal: VDRL or RPR as a screening and confirmed by
Treponemal: FTA-ABS, TP-PA, EIA’s (enzyme assays), or rapid treponemal assays
23
Q
What should be remembered when testing pregnant women for syphilis?
A
False-positives are common in pregnancy with non-treponemal tests such as RPR and should be followed up with treponemal tests to confirm syphilis
24
Q
What is the treatment for syphilis?
A
Parenteral Penicillin G (Bicillin-LA = benzathine penicillin G)
Oral and combination penicillins are not appropriate as syphilis can be latent in sequestered sites in the body that are poorly accessed by these forms and preparations of penicillin
25
When is gestational diabetes tested for?
24-28 weeks
26
Describe the testing process for gestational dibetes
Test done at 24-28 weeks even if previous tests earlier in pregnancy were negative as pt. can develop it later
1st test: 1hr glucose challenge test with 50mg glucose. Over 200 = DM, Over 140 = abnormal and requires 3hr test with 100mg glucose
2nd Test: 3hr glucose challenge with 100mg glucose. Measure blood 4 times at 1hr intervals. Abnormal values are above: 105 for fasting, 190 at 1hr, 165 at 2 hr, 145 at 3hr. An abnormal value at any 2 out of 4 = DM diagnosis
27
If a patient has gestation DM, do they need to be screened postpartum?
Yes, 6 weeks postpartum to check for resolution
28
What are the blood sugar goals when treating a patient with gestational diabetes?
Fasting less than 90
1hr postprandial less than 130
2hr postprandial less than 120
29
When is the earliest that a woman can be induced electively?
No earlier than 39 weeks
30
What are the two primary factors for determining when to screen for STD's?
Age and Risky Behavior
Risky Behavior = multiple sexual partners, new partners, (all summed up as not being married and monogamous)
Less than 25 and not being married = need for screening
31
What are the CDC guidelines for STD screening in pregnant women?
HIV, HBsAG, Syphilis in all pregnant women at first prenatal visit and again later in pregnancy if at increased risk
Chlamydia, Gonorrhea in all pregnant women less than 25 and in older women if they are at increased risk by not being married and having multiple partners
32
When is Rhogham administered if needed and why?
Administered at 28 weeks because it lasts for 12 weeks in the blood
33
Who should be tested for syphilis?
All pregnant women at 1st visit and if at high risk they are tested again at weeks 28-32 and at delivery.
Any women with stillborn after 20 weeks should be tested
34
What are the definitions of low birth weight and SGA?
Low birth weight = less than 2500 grams or 5lb 8oz
SGA = less than 10th percentile for weight
35
What are normal cardiac findings during pregnancy that are not found otherwise?
Wider splitting
S3
Systolic murmurs
36
What are normal skin findings in a pregnant woman?
Palmar erythema
Spider angiomata
Striae gravidarum
Linea nigra
37
When is Group B Strep screened for in pregnancy?
Weeks 35-37 because the flora can change every 6 weeks so this needs to be done early enough to catch before delivery and late enough that changes to the flora are unlikely before pregnancy
38
What is the treatment for GBS in a birthing mother? What are the next best medications if mother is allergic to first line agents?
IV penicillin from labor until birth
2nd option: clindamycin
3rd option: vancomycin
39
What are the general guidelines in terms of how to manage early rupture of membranes?
If greater than 34 weeks: deliver baby
If less than 34: monitor
No digital exam as this can increase risk of infection
40
What is the transmission rate for HIV to baby without intervention? Rate under best interventions?
Roughly 25%
With anti-retroviral therapy and c-section delivery about 1% transmission rate or less with appropriate postnatal care for the infant
41
What is the treatment strategy to prevent transmission of HIV to a baby through pregnancy and postpartum?
Viral therapy for the mother during pregnancy
C-section in some cases
Treatment of the newborn for 4-6 weeks after delivery
Bottle feeding infant instead of breastfeeding
Not pre-chewing food for infant
42
What are the most common symptoms of endometriosis?
Dysmenorrhea
Dyspareunia
Infertility
Less commonly, but characteristically, dyschezia
Premenstrual and postmenstrual spotting are also characteristic findings
Midcycle bleeding can occur, but heavy menstruation is uncommon and the amount of flow usually diminishes with endometriosis.
43
How is endometriosis diagnosed?
US and MRI can be screening tools, but the most definitive way is through laparoscopy looking in the abdomen for endometrial tissue
44
How are menstrual periods different between women with endometriosis and those without?
Endometriosis: tends to have shorter time between periods–less than 27 days, and they tend to have periods that last longer–more than 7 days (women with this longer time of flow are 2.5 times more likely to develop endometriosis)
45
What is the definition of endometriosis?
Presence of endometrial glands and stroma outside of the uterus.
46
What are the 3 leading theories for the cause of endometriosis?
Retrograde menstruation
Metaplasia of peritoneal mesothelium
Lymphatic spread
The leading theories favor retrograde menstruation combined with other factors that may include immunologic, genetic, and others that allow or promote the growth of endometrial tissue outside the uterus. Most if not all women have some degree of retrograde flow, so it is not known why only some women develop the disease while others do not.
47
What is adenomyosis?
The extension of endometrial glands and stroma into the uterine musculature more than 2.5mm below the basalis layer. The uterus becomes homogenously enlarged and often complicates fertility. Pt can be asymptomatic or have severe dysmenorrhea.
48
What is often the cause when endometriosis is seen earlier in life?
Generally, endometriosis is discovered in the 30's, but it can occur as early as infancy, childhood, and adolescence. These cases are generally caused by an obstructive anomaly such as a uterine or vaginal septum.
49
Where are endometriosis implants generally found?
Most commonly in the dependent portions of the pelvis. 2/3 of women with the disease have ovarian involvement.
50
What is an endometrioma?
An endometriosis implant of the ovary leading to the formation of a cyst filled with thick, chocolate-colored fluid. It is filled with hemolyzed blood and desquamated endometrium.
51
How do endometrial implants respond to hormones?
Cyclic hormones cause the growth and then sloughing of the tissue.
Persistent and constant hormone levels cause regression, especially with higher doses.
52
What is the purpose of the round ligaments of the uterus? From what do these ligaments originate?
Maintenance of the anteversion of the uterus during pregnancy. Stretching of this ligament during pregnancy can lead to pain and pulling in the labia majus. Outside of pregnancy, it is the cardinal ligament that maintains the uterine angle.
They originate from the gubernaculum.
53
What are some signs on PE of endometriosis?
Fixed firm tender mass felt in the adenexa
| Nodular tenderness in the cul-de-sac and in the uterosacral ligaments.
54
What are some of the most significant complications of endometriosis?
Involvement of the GI or GU leading to obstruction or perforation.
55
What are first-line and second-line treatments for endometriosis?
First: NSAIDS, Oral Contraceptives, and progestins and oral medroxyprogesterone acetate. (another option is an IUD that secretes levonorgestrel as this can treat dysmenorrhea caused by implants in the cul-de-sac without reducing circulating estrogen levels)
First-line treatments should be given 3-6 months trial before trying 2nd-line.
Second: GnRH agonist, higher dose progestins, danazol
2nd-line is usually started only after laparoscopic confirmation of the diagnosis
56
What is danazol and what considerations should be kept in mind with its use?
Androgenic derivative that may be used in a pseudomenopause regimen to suppress symptoms of endometriosis if fertility is not a present concern.
It works as a weak androgen that reduces circulating sex hormone-binding globulin resulting in increased testosterone which can lead to hirsutism and acne.
57
What are the cardinal movements of labor and delivery?
```
Engagement
Descent
Flexion
Internal Rotation
Extension
External Rotation
Expulsion
```
58
What disorder should be considered when maternal serum alpha fetal protein is elevated? What should be the next steps in management?
Elevated AFP is an indication for neural tube defects
Next step should be an US to rule out normal causes of this – multiple gestation, fetal demise, inaccurate GA
If above is normal, an amniocentesis is done to measure fetal AFP and AChE
AChE is only present if there is a neural tube defect
59
What are the options for Down's Syndrome screening and what is the preferred approach of Dr Le?
Options:
1) First trimester: maternal age, nuchal lucency, BHcG (elevated), PAPP-A (decreased) detection rate of 79%
Addition of nasal bone visualization increases to 93%
2) Second Trimester:
Triple screen: AFP (decreased), HcG (increased), Unconjugated Estriol 3 (decreased)at 16-20 wks, detection rate 70%
Quadruple screen: add inhibin-A (elevated) detection 81%
Integrated=1st and 2nd reported together – higher sensitivity and more cost effective
Sequential=report 1st in order to start care earlier
Non-invasive Prenatal Testing (NIPT): cell free fetal DNA, detection 99% for down's, quantifies the risk only, confirmatory test with CVS or amnio karyotyping
Dr Le: Quadruple screen at 15 weeks, if positive send for NIPT, if needed confirm with amnio or CVS (length of testing determined by situation, if need confirmation before abortion will go all the way)
60
What are the risk factors for vaginal candidiasis?
Pregnancy, antibiotic use, DM
61
Pt has vaginal soreness, dyspareunia, pruritus, discharge, burning, vaginal white plaques with underlying erythema. Likely dx? Workup? Tx?
Likely vaginal candidiasis
Dx best done by KOH
Tx with topical azoles or oral fluconazole 150mg x 1 dose
62
Pt has malodorous vaginal discharge with pruritus and vaginal patchy erythema. What is likely dx? Other physical findings? Tx?
Trichomoniasis
Strawberry cervix
Wet mount shows flagellated parasites in 50%, Nucleic acid amplification
Tx metronidazole 2mgx1 or 500mg BID x 7days
63
What 4 hormones of pregnancy contribute to gestational diabetes?
Prolactin, cortisol, progesterone, HPL
64
When is the time frame for down's screening?
15-21 weeks
65
What is the time cutoff for labor before c-section is chosen over vaginal delivery? Why is there a time cutoff?
Generally after 2 hours of active labor at a max for natural birth – epidural 3hrs
C-section will often be chosen earlier if no progress is being made
If uterus works to hard and fatigues it will not contract appropriately postpartum and hemorrhage is more likely
66
What is the basic process for delivering a baby?
Once head is graspable, rotate upper shoulder under the pubic symphysis, deliver anterior shoulder first, then do posterior shoulder, then pull straight out and hold baby head down and below the mother to drain fluids and cause blood infusion from the placenta
67
What are the causes of first trimester vaginal bleeding?
Different types of abortion
Molar pregnancy
Ectopic pregnancy
68
Significance of fetal fibronectin?
It is high in first 20 weeks and again at term when the uterus contracts and disrupts the layer between the dicidua and chorion.
Elevated levels in mid-second and third trimester are a marker for pre-term delivery
69
How are patients with a short cervix managed in order to prevent premature delivery?
W/ Hx of preterm delivery: IM injections of progesterone starting second trimester to keep uterus quiet and prevent rupture of membranes, serial measurements of cervix length until 24 weeks, if cervix is short then cerclage may also be necessary
W/O Hx preterm: vaginal progesterone
70
How is betamethasone used for a fetus?
Corticosteroid used to induce pneumocyte development in a fetus that has imminent delivery and is less than 37 weeks. It is not given to previable fetuses (less than 24weeks)
71
What are the absolute contraindications for combined contraceptive use?
```
Less than 3 weeks postpartum
More than 15 cigarettes and over 35yr
Hx of DVT, MI, Stroke
Any hypercoagulable state
Recent Breast cancer
Hypertension
Migraine with aura
Cirrhosis and liver cancer
Surgery with prolonged immobilization
```
72
Meaning of prolonged deceleration on FHR?
Associated with significant hypoxia
73
What is the purpose of FHR monitoring?
Indication of fetal hypoxia that can lead to CNS injury and death
74
How to interpret fetal tachycardia on FHR monitoring?
Can be caused by maternal fever or drugs
Also caused by hypoxia:
-Always preceded by decelerations (if contractions are present)
-In the absence of decelerations, it is almost never caused by hypoxia
75
If fetal tachycardia is seen on FHR monitoring, what is the next thing you should look for in order to confirm it is caused by hypoxia?
Look to see if it was preceded by decelerations. Without them, it is almost never caused by hypoxia.
76
What, if seen on FHR monitoring, reliably excludes severe hypoxia and acidosis?
Normal variability of heart rate
| This is between 6-25 beats per minute of variation
77
Definition of accelerations on FHR monitoring and their presence guarantees what?
Greater than 15 bpm for over 15 sec after 32 weeks (10 x 10 before 32 weeks)
Presence of accelerations guarantees pH above 7.20
78
Describe early decelerations and their meaning on FHR monitoring.
Decelerations line up with contractions
Head compression causes vagal response
Least common type of deceleration
Not a sign of fetal distress
79
Describe late decelerations and what they mean
Onset after uterine contraction with Nadir after the apex
Always indicates hypoxia (uteroplacental insufficiency)
The lag is caused by the time it takes for the fetal brain to sense a lack of oxygen and respond by increasing sympathetic discharge causing increased BP and a reflex decreased HR
80
Describe variable decelerations and their meaning
Most common type of deceleration
Abrupt onset with variable size, shape, and duration
Indicates umbilical cord compression, oligohydramnios, cord prolapse
Morphology tends to have a depression with shoulders
81
Define and explain causes of prolonged deceleration
Abrupt deceleration lasting more than 60-90 seconds
Causes: cord compression, abruption, rapid descent, TACHYSYSTOLE (more than 5 contractions per 10 minutes), severe uteroplacental insufficiency
82
What is the meaning of a sinusoidal pattern on FHR monitoring?
Fetal hypoxia, often due to fetal anemia
| May be associated with certain medications
83
Explain Human Chorionic Gonadotropin: source, purpose, use, levels during pregnancy, presence outside pregnancy
Hormone produced by the trophoblastic cells of the placenta
Has an alpha and beta subunit–alpha is shared by other hormones LH and TSH and is less specific
Maintains pregnancy by preserving the corpus luteum which produces the progesterone needed for pregnancy, also increases regulatory T cells that allow immune tolerance of the fetus from the mother
Used only early in pregnancy until the fetus can be visualized because levels are so variable.
First starts to rise 8 days after ovulation, peaks at 8-12 weeks and declines to a more constant level for the rest of the pregnancy
Outside pregnancy: from a tumor–mole, choriocarcinoma, embryonal carcinoma
84
What is the treatment choice for stage 1 endometrial cancer in women less than 40 years old with a desire to maintain fertility?
Endometrial cancer in younger patients is usually of early stage and low grade.
Tx with medroxyprogesterone acetate for 3-6 months will reverse changes in 75% of women but recurrences are common and therefore careful monitoring is essential.
Remember the fundamental concept that estrogen causes proliferation and progesterone shrinks the endometrial lining. Mirena IUD can be useful in these patients.
85
Lupron (Leuprolide)
| Category, MOA, Uses
Anti-neoplastic, GnRA agonist
Agonist analogue of LHRH leading to a decreased release of LH and FSH causing a decreased production of ovarian and testicular steroids
Used for prostate cancer, endometriosis, leiomyomata, breast cancer
86
What is the leading cause of cancer death in women world-wide? What has reduced the incidence of this is the US?
Cervical cancer
Screening has markedly reduced the incidence in the US and most new cases in the world are in under-developed countries where screening is not routine.
87
What are the risk factors for cervical cancer?
Anything that increases exposure to HPV
| Smoking
88
Age range fro cervical cancer
Younger female cervix is more susceptible to the disease because of the squamous metaplasia occurring in the transformation zone. However, the disease is relatively rare before 25 and is mean at age 47.
89
What is the false-negative rate for PAP smears with high-grade intraepithelial lesions?
20%
| This is higher for glandular lesions and invasive cancers!
90
Why should women continue to be screened for cervical cancer even if they have received the vaccine?
The vaccine does not protect against all of the high-risk types of the virus–only types 16 and 18
91
What are the findings on colposcopy consistent with CIN and which is the hallmark of CIN?
Hallmark=sharply delineated acetowhite epithelium (appears white after application of acetic acid)
Other findings are vascular and include punctation and mosaicism. The more abnormal the tissue, the more these features become apparent and irregular. The presence of abnormal vessels in comma and corkscrew shapes is a later and more significant finding.
92
How are patients with a PAP result of ASCUS managed? (Abnormal Squamous Cells of Undetermined Significance)
Can be re-screened in 6 months
Can have HPV test
Can have colposcopy
6-10% will have HSIL
93
Tx for cervical intraepithelial neoplasia
Remember that this is all pre-cancer at this point.
LSIL is not treated but observed
HSIL is treated and superficial ablative techniques are appropriate including LLETZ, Laser, Cryosurgery, Cervical Conization
94
What is the single most important prognostic factor in invasive cervical cancer?
The status of the paraaortic lymph nodes
95
What is a common kidney complication related to cervical cancer?
Invasive cancer leads to ureteric obstruction in up to 50% of cases and would therefore lead to increased levels of BUN and creatinine.
96
What is betamethasone?
Corticosteroid that can be administered IM to encourage fetal development.
97
5 most common complications of shoulder dystocia?
```
Fractured clavicle
Fractured humerus
Erb Duchenne palsy
Klumpke's palsy
Perinatal asphyxia
```
98
Describe Klumpke's palsy
Potential complication of shoulder dystocia
Pulling on arm causes damage to 8th cervical and 1st thoracic nerves (lowest portions of brachial plexus)
Paralysis of arm leading to claw hand deformity
Also causes ipsilateral Horner's syndrome
99
Describe lichen sclerosis
Chronic inflammatory condition thought to have an autoimmune component
Affects women at any age
Skin becomes like cigarette paper that is wrinkled, thin, white plaques
Can affect perianal region and other parts of the body in addition to the vulva, but spares the vagina and cervix
Sclerosis of the skin in the vulvar region leads to obliteration of the labia minora, shrinking of introitus, retraction of clitoral hood, dyspareunia, dyschezia, intense pruritus
It is a pre-malignant lesion to squamous cell carcinoma and therefore a punch biopsy must be done
100
How is lichen sclerosis treated?
High-potency topical steroids
101
What is atrophic vaginitis?
Complication of decreased estrogen levels post-menopause
Vulvovaginal dryness, loss of vaginal elasticity and rugae, thinning vulvar skin and loss of minora, diminished vaginal diameter
102
What is the definition of preeclampsia?
Onset of hypertension after 20 weeks gestation with either proteinuria or end-organ damage
103
What are the severe features of preeclampsia?
```
BP over 160/110
Elevated transaminases
Elevated creatinine
Thrombocytopenia
Pulmonary edema
Visual or cerebral symptoms
```
104
How is preeclampsia managed?
Delivery at 37 weeks if no severe features
Delivery at 34 weeks if severe features present
Magnesium sulfate for seizure prophylaxis and anti-hypertensive medications
105
Risk factors for preeclampsia
```
Previous preeclampsia
Pre-existing DM
Advanced maternal age
Multiple gestation
Nulliparity
CKD
```
106
What are the risks of complications with preeclampsia?
```
Eclamptic seizures
Placental abruption
Hepatic rupture
DIC
Cardiopulmonary arrest
```
107
Explain adenomyosis and disease features
Endometrial glands stuck in the myometrium that continue to shed during menses leading to dysmenorrhea and heavy menstrual bleeding
Usually multiparous women over 40
Leads to chronic pelvic pain
Uterus is boggy or soft and flaccid and globally enlarged and tender to palpation
Initial Dx through pelvic US or MRI, gold standard is histopathology post hysterectomy
Tx with hormones through contraceptives or hysterectomy
108
Work up for atypical glandular cells on PAP
Glandular cells can come from cervical or endometrial cancer and therefore must screen for both potential causes through colposcopy, endocervical curettage, endometrial biopsy
109
What is CA-125 a marker for?
Epithelial ovarian cancer
| It is used to evaluate this condition if other signs such as ascites and adnexal mass are present
110
Most common cause of fever within 24 hours after delivery?
Postpartum endometritis
111
Risk factors for postpartum endometritis?
```
Prolonged rupture of membranes
C-section
Surgical vaginal delivery
Prolonged labor
GBS infection
Chorioamionitis
```
112
Tx for postpartum endometritis?
Polymicrobial infection from vaginal flora
Clindamycin and gentamicin
Broad-spectrum required
113
Signs of postpartum endometritis?
Fever shortly after delivery
Purulent lochia
Uterine fundal tenderness
114
Tx choice for pyelonephritis in pregnancy?
Pyelo most commonly caused by E. coli
| Ceftriaxone is DOC
115
Medication used for treating lactational mastitis?
Dicloxacillin
116
Medication used to treat breast abscess?
Vancomycin
| Covers for MRSA
117
If magnesium sulfate is not effective for treatment of eclampsia seizures, what are the next agents in line for 2nd line use?
Diazepam
| Phenytoin
118
Most common cause of post partum hemorrhage and risk factors?
Uterine atony
Prolonged labor
Large baby (over 4kg) that over stretches the uterus
Oxytocin receptor insensitivity (labor induction)
Operative assisted vaginal delivery
Hypertensive disorders
Placental retention
Chorioamnionitis
119
What are second-line uterotonic agents that can be used for PPH if oxytocin is not fully effective? What are their contraindications?
Methylergonovine: causes smooth muscle vasoconstriction which can exacerbate HTN
Carboprost: synthetic prostaglandin, can cause bronchoconstriction and is therefore CI in asthmatics
120
What is the arm positioning common with anterior and posterior shoulder dislocation?
Anterior: arm abduction and external rotation
Posterior: arm adduction and internal rotation
121
What is Todd paralysis?
Unilateral paralysis post seizure that generally resolves on its own
122
What is gastroschisis associated with?
Use of NSAID's in the first trimester
123
What is polyhydramnios associated with?
Poorly controlled diabetes
| Fetal anomaly that inhibits swallowing
