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1
Q

Immunizations to avoid in pregnancy

A

Typhoid, HPV, Yellow Fever, Chicken Pox, MMR, Influenza (Nasal)
“The Happy Yellow Chicken Might Fly”

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2
Q

Medication options for urinary urgency, frequency, and PAIN

A

Interstitial Cystitis / Painfull Bladder Syndrome –> Can use Pentosan and any combination of the other meds

  • Pentosan Polysulfate (Elmiron) works in 3-6 mo’s
  • PFT
  • TCA’s
  • Antidepressants
  • Dimethyl Sulfoxide (DMSO) = bladder instillation FDA approved
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3
Q

Dose for add-back therapy

A

Norethindrone 5mg = progestin

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4
Q

Topics to address during wellness visits

A

ABCDEFGHI / L / VOS
Abuse, BCM, Cancer, Diet, Exercise, F*cking/Sexual health, Grief, Hot (menopause), Incontinence / Labs / Vaccinations, Osteoporosis, Safety

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5
Q

Bisphosphonate Therapy and Recommendations

A

Alendronate (Fosfamax) 70mg PO x1/week
- Consider drug holiday after 3-5 years (holiday up to 5 years). Take first thing in the morning, empty stomach with 8 oz water, remain upright for 30 min. Contraindications = can’t take as instructed, esophageal disease, renal failure

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6
Q

Zolendronic Acid Therapy and Concern

A

Zolendronic Acid (Reclast) 5mg IV x1/yr. Risk of osteonecrosis

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7
Q

Only vaginitis without an elevated pH

A

Vulvovaginal candidiasis

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8
Q

Criteria for recurrent BV and treatment regimen

A

3 separate infections/year. Treat acutely (metro gel 0.75%, 5g daily for 5d) and then suppressive therapy with Metro gel twice weekly for 4 months

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9
Q

Different criteria for complicated vulvovaginal candidiasis and different treatment reigmens - additional testing?

A

Complicated (severe features, immunocompromised, HIV, DM, Steroid use, recurrent, or C. Glabrata)

  • Recurrent (4x/year) = Fluconazole 150mg first + weekly doses for 6 months
  • Severe Features = Fluconazole 150mg for Day 1/4/7 or extended vaginal therapy for 14 days
  • Non-C. Albicans culture (e.g.: C. Glabrata) = Boric Acid 600mg for 14 days counsel about fatal if orally taken, keep away from children, need contraception
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10
Q

NRT (patch) counseling and dosing

A 
Easy to use on clean upper extremity or torso, long-acting, well-tolerated, increased risk of local irritation, insomnia, vivid dreams. Stop smoking at time of trmt initiation.
Dosing :
-21mg/patch/day x 4 weeks 
-14mg/patch/day x 4 weeks
-7mg/patch/day x 4 weeks
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11
Q

Estrogen formulations for menopausal vaginal-only treatment

A
  • Estradiol vaginal tablet 10mcg tab/day
  • Estradiol ring 0.05 mg/d
  • Conjugated estrogen cream 0.5-2g/d
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12
Q

Systemic HRT formulations for menopausal vasomotor symptoms

A

• Low-dose = Conjugated Estrogen 0.3 mg/d
- Prempro (Conjugated Estrogen 0.3 mg + MPA 1.5mg)
• Standard dose = Conjugated Estrogen = 0.6 mg/d
- Prempro (Conjugated Estrogen 0.6 + MPA 2.5mg)

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13
Q

Absolute contraindications for MTX

A

Sensitivity, breastfeeding, blood dyscrasia (anemia/leukopenia/thrombocytopenia), liver or renal disease, immunodeficiency, peptic ulcer disease, active pulmonary disease (not asthma), unstable, concern for ruptured, can’t follow-up

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14
Q

Different fluid distention mediums for hysteroscopy, their differences, and allowable fluid deficit [healthy/unhealthy]

A
  • Normal Saline = isotonic, electrolytes present, low viscosity [2.5L / 750mL] - use with bipolar electrocautery; risk of fluid overload
  • Hypotonic agents:
    • 1.5 Glycine / 3% Sorbitol = viscous, hypotonic, no electrolytes [1L/750mL] good for monipolar; increased risk of hypo-osmolar and hyponatremia complications
    • 5% Mannitol = viscous, isotonic, no electrolytes [1L/750mL] good for monipolar; less risk of hyponatremia
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15
Q

Definition of Migraine

A

A migraine is a headache lasting 4 to 72 hours and must have nausea, vomiting, or photophobia/phonophobia, as well as at least two of the following: unilateral location, pulsating quality, moderate to severe pain, and aggravation by routine physical activity.

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16
Q

Women with DM who can NOT have CHC’s

A
  • Any -opathy (retinopathy, nephropathy, opthalmopathy)
  • H/o 20+ years of DM
  • Any other CVD RF’s (tobacco, HTN, etc. )

Good population to recommend endometrial protection with Progesterone

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17
Q

What BCM concerns exist for those with SLE

A

There are special considerations for women with antiphospholipid antibodies (CHC), nephritis (CHC), vascular disease (CHC), or severe thrombocytopenia (new progesterone or Cu-IUD).

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18
Q

Describe borders of peri-rectal avascular space

A

Bounded medially by ureter, laterally by the internal iliac artery, and the cardinal ligament at the apex

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19
Q

What thrombophilias likely have multiple mutations?

A

Protein S (30%), Protein C (15%), Factor V Leiden (15%)

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20
Q

Name thrombophilias and their risk of thrombosis

A 
Antithrombin III (30-50%!!!!!) 
Prothrombin G20210A 
Factor V Leiden 
Protein C
Protein S
Anti-Phospholipid Syndrome 
All others can quote 5% risk!
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21
Q

Work up consideration for non-pregnant patient for PE

A

If likely PE (modified Wells criteria), can consider going straight to CTA. If unclear, can get a D-Dimer and if > 500, then can get CTA

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22
Q

How does Heparin work? Lovenox?

A

Heparin binds to AT III, which prevent Factor X going to Xa…which now doesn’t allow prothrombin to become thrombin

Lovenox is a FactorXa inhibitor, doing the same which now doesn’t allow prothrombin to become thrombin

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23
Q

Heparin and Lovenox treatment regimens for PE and DVT. Treatment timeframe? How to monitor Coumadin?

A

Heparin - Load with 5k-10k [more specifically, 100u/kg (DVT) 150u/kg (PE)], transition 1200u/hr for 5 days or when stable, then transition to Coumadin OR Heparin 10k BID for pregnancy AFTER establishing PTT 1.5-2.5x

Lovenox - 1mg/kg BID (or once daily dosing with 1.5mg/kg) SC QD for 3 days –> switch to Coumadin

Treat DVT for 3 months and PE for 6 mo’s. Monitor Coumadin with PT >2.5 (need to go to a clinic for this)

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24
Q

Risk of Coumadin and Heparin - how to reverse?

A

Coumadin risks = fetal limb and nasal hypoplasia, stippled epiphyses –> reverse with Vitamin K

Heparin = thrombocytopenia and osteoporosis (long-term) –> reverse with protamine sulfate

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25
Layers of the abdominal wall
Skin/Epidermis Subcutaneous fat Superficial Fascia (Campers / Scarpas) Abdominal muscle and fascia complex (EO/IO/TA) -Midline ~Above the arcuate line (IO splits above and below rectus abdominus) ~Below the arcuate line (all aponeurosis go above the rectus abdominus) - Transversalis Fascia - Pre-peritoneal fat - Peritoneum
26
Screening for ovarian cancer consider for BRCA
Can consider CA-125 and TVUS from 30-35yo with BRCA until they choose to do risk-reducing BSO
27
Screening for endometrial cancer consideration for Lynch - when discuss Hyst/BSO?
Consider EMB every 1-2yrs starting at 30-35yo. Hyst/BSO discussion at age 40yo
28
Risk-reducing BSO in BRCA reduces ovarian and breast cancer risk by?
80% reduction in ovarian cancer / 30-100% reduction in breast cancer
29
Medication dosing for fibroid management (bleeding only specifically)
GnRH Agonist --> Elagolix 300mg BID with add-back (ethinyl estradiol 1mg / 0.5 norethindrone); can use up to two years
30
Medication dosing for fibroid bridging medication to menopause, procedure, or surgery
GnRH Agonist --> Lupron 3.75mg IM (1mo) or 11.25mg IM (3mo) with add-back (conjugated estradiol 0.625 mg + 5mg norethindrone); can use 6mo (w/o add-back) or 1yr (w/ add-back)
31
MCC of solid breast mass
Fibroadenoma
32
MCC of bloody nipple discharge
Intraductal papilloma (benign)
33
False positive rate of mammogram and age to start (general pop.)
10% - start at age 40yo (annual)
34
MC types of cancer DEATH for women
Lung > Breast > Colon > Pancreas > Ovary
35
Types of epithelial ovarian cancers
Mucinous, Serous, Clear-cell, Endometrioid
36
Types of Germ Cell Tumors
Choriocarcinoma, Dysgerminoma, Endodermal Sinus Tumor/Yolk-sac tumor, Teratoma
37
Types of Sex-Cord/Stromal tumors
Fibroma, Thecoma, granulosa cell, sertoli-leydig,
38
What tumor markers reasonable for adnexal masses and: - young age? - bleeding, thickened ES? - hirsutism or androgen signs? - really large mass?
BhCG / LDH / AFP / - young age Estrogen and Inhibin - bleeding, thickened ES Androgen - hirsutism or androgen signs CEA - really large mass
39
Tumor marker associations: - BhCG - LDH - AFP - Estrogen and Inhibin - Androgen - CEA
- BhCG = choriocarcinoma - LDH = Dysgerminoma - AFP = Endodermal sinus tumor/Yolk-sac - Estrogen and Inhibin = Granulosa Cell tumor - Androgen = Sertoli-Leydig, Thecoma, Fibroma - CEA = Mucinous cystadenoma
40
Management of Dysgerminoma
USO for young patients, continue to follow with LDH and HCG
41
Endodermal Sinus Tumor/Yolk Sac tumor marker and path
AFP and Schiller-Duval Bodies
42
Granulosa cell tumor marker and path
Inhibin + estrogen and Coffee-bean nuclei + Call-Exner Bodies (starry sky)
43
Brenner Tumor path
Coffee-bean nuceli
44
Krukenburg tumor path
Signet-ring cells
45
Dysgerminoma tumor marker and path
LDH/HCG and "fried egg" appearance (lymphocytes)
46
LMP tumors and Serous Tumor path
Psammoma Bodies
47
Causes of false positive RPR
Malaria, Debilitation, Mycoplasma Pneumonia, SLE, Smallpox vaccination, HIV, Thrombocytopenia, Pregnancy
48
Treatment goal of Syphilis for titers over one year
4-fold decrease by 3 months; 8-fold decrease by 6 months; undetectable by one year
49
DDX for vulvo-vaginal ulcer - how to differentiate?
Syphilis, Chancroid, HSV, Lymphogranuloma Venereum, Granuloma Inguinale, Vulvar Cancer Painful ulcer: - Yes = HSV (multiple vesicles) / Chancroid (multiple) [=Hemophilus Ducreyi] - No = Syphilis / LGV / GI ~Painful LAD? -Yes = LGV [=Chlamydia] -No = Syphilis (singular chancre) / GI (multiple) [= Klebsiella]
50
When to excise or biopsy bartholin gland?
Age > 40yo or with multiple infections to rule out adenocarcinoma
51
Conditions needed for testing Prolactin?
Early morning, fasting, before exercise/intercourse
52
Medications for Prolactinoma
Cabergoline (preferred) and Bromocriptine = Dopamine agonist
53
Tests/evals for Galactorrhea
TSH, PRL, visual field test, ask about medications (metoclopromide, antipsychotics, antidepressants), nipple stimulation
54
What symptoms to stop Clomid for
Headache, blurry vision, eye pain
55
Listeria treatment
- If asymptomatic, just observe - If mild symptoms (afebrile), can expectantly manage or treat - If severe symptoms and/or febrile, IV Ampicillin (if PCN allergic, can give Bactrim)
56
Workup for Recurrent Pregnancy Loss
"ULIGI" Uterine (septate) = 3D US, MRI, HSG Lifestyle/PMH = EtOH, smoking, substance abuse Infectious (TORCH) Genetic (couple karyotype) = Robertsonian translocation, Fragile X Immune (APLS labs) = APLS, Thyroid dysfunction
57
Risks associated with Complete Molar Pregnancy
- 15-25% risk of GTN - 5% metastatic GTN - 10x fold increase risk for future pregnancy
58
Factors used in FIGO system to assess low-risk vs high-risk GTN
Age, time since last pregnancy, last type of pregnancy (term vs SAB), pretreatment BhCG, evidence of mets, size of mets, number of mets, previously failed treatment
59
Indications for screening for underlying bleeding disorders
- HMB since menarche - One of the following: (1) PPH (2) bleeding with surgery (3) bleeding with dental work - Two of the following: ~Bruising 1-2x/month ~Epistaxis 1-2x/month ~Gum bleeding 1-2x/month ~Family hx of bleeding symptoms
60
Supplements associated with bleeding
Ginko, Ginseng, Motherwort
61
Contraindications to BF'ing
Active HIV, active breast lesions of HSV, TB, Lithium use, substance abuse, chemo use
62
Newborn effects associated with SSRI's
Jitteriness, TTN, admission to NICU, persistent pulmonary HTN
63
Recommendations for weight gain in pregnancy
- BMI < 18.5 (underweight) = 30-40lbs / 1lb per week in 2nd/3rd trimester - BMI 18-25 (normal) = 25-35lbs / 1lb per week in 2nd/3rd trimester - BMI 25-29.9 (Overweight) = 15-25lbs / 0.6 lb per week in 2nd/3rd trimester - BMI 30 (Class I) and above = 10-20lbs / 0.5lb per week in 2nd/3rd trimester
64
Treatment for MRSA
Vancomycin IV or Bactrim (Trimethoprim/Sulfamethoxazole)
65
Wound with pain out of proportion, crepitus on exam, loss of sensation, maybe with sepsis/DIC...diagnosis, pathogen, and treatment
- Necrotizing Fasciitis - Typically polymicrobial (gram Pos/Neg and anaerobes) > Group A Strep is a big offender > Clostridium - Surgical debridement + broad spectrum antibiotics + sepsis resuscitation - -> Clindamycin (helps shut down toxin production with Group A Strp) + Zosyn [Pipperacillin/Tazobactim] is good broad spectrum beta-lactam (or can use Meropenem) + Linezolid (better than Vanco because it stops toxin productin, is not nephrotoxic, and better availability - but Vancomycin still is an option).
66
Differential for concerning wounds (specific types)
- Toxic Shock Syndrome (diffuse erythroderma, prominent gastrointestinal symptoms) --> streptococcal infexn (Group A Strp) - Necrotizing Fasciitis - Fournier's gangrene is a necrotizing soft tissue infection of the perineum
67
Treatment recommendations for cervical cancer staging
- Stage IA1 = Cone / Simple Hysterectomy - Stage IA2 = Rad Hyst + Nodes - Stage IB - IIA = Rad Hyst + Nodes OR Radiation + Cisplatin - Stage IIB and Up = Radiation + Cisplatin
68
When do to an ECC?
- Unsatisfactory (can't see all of TZ; can see all of lesion) - If considering ablative procedure - If pap shows ASC-H, HSIL, AGC, or AIS - Discrepant pap smear and colpo
69
Overall principle of pap smear management (broad theme)
For women 25 yrs+, consider the immediate risk of CIN 3+ and the 5-year risk of CIN3+: - If the risk for CIN3+ is >= 4%, going to Colpo or Treat - If the risk is <4%, consider 5-year risk to help determine if retest in 1 / 3 / or 5 years
70
Surveillance timeframe after treatment of HSIL/ CIN2/3, or AIS
3 years
71
When to consider CKC over LEEP
If patient is s/p BTL, completed childbearing, inadequate colposcopy, discrepancy between cytology and histology, or results of CIS/AIS, +ECC, + margins on prior LEEP or if can't redo LEEP because too little cervix left
72
Expedited partner therapy for if they won't come in for Gonorrhea treatment?
Cefixime 800mg (if they won't come for Ceftriaxone 500mg IM x1); can also offer Azithromycin 1g for Chlamydia too
73
Fecundity at ages: < 31, 31-35, >35
75%, 65%, 55%
74
Treatment options of hirsutism
1. OCP --> increases SHB-globulin which binds androgens 2. Cosmetic Laser therapy - (dark hair light skin = best candidates) the melanin absorbs the laser wavelength of light which selectively damages the follicle without harming surrounding tissue 3. Antiandrogen Therapy: (need contraception with antiandrogens) •Eflornithine - blocks ornithine decarboxylase -SE: stinging burning at site of application •Finasteride - 5-alpha reductase inhibitor (blocks testosterone --> DHT) -1mg QD •Flutamide - androgen receptor blocker -125mg QD •Spironolactone: diuretic, aldosterone antagonist, binds androgen receptor, slight effect on 5-alpha reductase too (cautious to use in those with renal problems because can exacerbate hyperkalemia) -25-100mg BID -SE: orthostatic hypotension
75
Medications for acute bleeding
- IV conjugated estrogen 25mg every 6hrs for 24hrs - Oral OCP with 35mcg of ethinyl estradiol TID x7days - Medroxyprogesterone acetate 20mg PO TID x7days - TXA 1.3mg PO TID x5 days
76
Clostridium Difficile RF's and Abx treament
- Extremes of age, nursing home, prolonged hospitalization, recent surgery or antibiotic use (Clindamycin, Ampicillin, Cephalosporin, Fluoroquinolones) - Treatment •Firstline: -Oral Vancomycin (IV doesn’t achieve colonic penetration) 125mg q6hrs x10 days -Fidaxomicin 200mg BID x10 days •Second line = Metronidazole 500mg TID x10days
77
Vulvar hematoma likely from what blood supply?
Pudendal artery or contributing branch
78
Levator ani muscles
Puborectalis / Pubococcygeus / Iliococcygeus
79
When to treat hyperlipidemia?
- LDL > 190 - Present CVD - All Diabetics 45-75yo • If 10-yr CVD risk score > 7.5% = high-intensity, < 7.5% = moderate intensity statins o High-intensity statin = goal reduction of > 50% LDL decrease o Moderate-intensity statin = goal reduction of 30-50% LDL decrease o Atorvastatin start 40mg for mod-high intensity, otherwise 20mg PO  SE’s: myalgia, temporary increase in LFT’s  10-yr CVD risk > 7.5%  Pooled Cohort Equation from the ACC – looks at age, race, gender, age, lipid levels, BP, and medical history to assess 10-yr risk for CVD
80
Cardinal movements
Engagement, Descent, Flexion, Internal Rotation, Extension, External Rotation and Restitution, and Expulsion
81
% of NST that are non-reactive 24-28 weeks vs 28-32weeks
24-28 weeks = 50% | 28-32 weeks = 15%
82
Etiologies of secondary PPH and definition
PPH 24hrs - 12 weeks - placental site subinvolution - infection - coagulopathy - retained POC
83
What is methergine
Ergot alkaloid
84
What minor RBC antigens are concerning for hemolytic disease of the newborn if antibodies develop
Anti-Kell, anti-Rh c, anti-Rh E, and anti-Duffy and anti-Kidd antibodies are worrisome
85
RF's for Breast Cancer
- Fam history of ovary, breast cancer and other syndrome-associated cancers (pancreatic, prostate) - Early menarche / late menopause - Not breastfeeding - Nulliparity - Increase Age and BMI - Alcohol and smoking - HRT with estrogen AND progesterone - Breast biopsy with: 1. Atypical hyperplasia 2. Lobular carcinoma in-situ
86
When to do work-up for hematuria
RBC count is > 25 per high-power field
87
When to start transgender hormonal manipulation? Risks of treatment?
Start after Tanner Stage 2 with Testosterone (for F to M vs Spironolactone for M to F); risk of testosterone = hyperlipidemia, hypertension, hepatitis, polycythemia
88
Type of surgical prep for abdomen and vagina
Skin: chlorhexidene-alcohol scrub for 2 min / drytime = 3 min ~ If use providone-iodine, scrub for 5 min, then paint abdomen with same soln and let dry for 3 min Vagina: 4% Chlorhexidine gluconate or providine-iodine
89
ERAS talking points:
- PreOp counseling - Early ambulation the same day of surgery (sitting in chair to standing) - Stepwise pain control: ~ scheduled NSAIDs -> if can't take NSAID, use Toradol) ~ scheduled Tylenol unless hepatic failure ~ Gabapentin ~ Opioids only for breakthrough - Foley and drains removed within 24 hrs - Allow diet and PO intake as tolerated
90
Non-pregnant BP stages:
Normal: SBP < 120 DBP < 80 Elevated: SBP 120-129 DBP 80 Stage 1: SBP 130-139 DBP 80-89 Stage 2: SBP >140 DBP >90 Chronic HTN = > 12 weeks postpartum
91
When to cosnider secondary HTN eval?
If HTN before the age of 30yo, HTN resistant to treatment, more sudden onset

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