Gyne Flashcards
1
Q
Which leg is more likely to have a DVT in pregnancy?
A
- Left iliac vein crosses over left iliac artery, leading to relative compression (left leg deep venous thrombosis is three times more likely than right in pregnant patients).
2
Q
COCP Contraindications
A
absolute:
- smoker (>15 cig/day) and >35 y old
- HTN (>160/100)
- Hx VTE, CAD, CVA, Afib, endocarditis, pulmonary HTN, migraine with aura, current breast ca, diabetes with micro complications, severe cirrhosis, liver tumor.
- migraine without aura and >35 y, or migraine without aura after starting COCP
relative:
- smoker (35 y old
- symptomatic gallbladder, mild cirrhosis, Hx COCP related cholestasis
- > 35 y with BMI >30
3
Q
Missed Pill Guidelines
A
COCP
- >48h and two or more missed pills: take one ASAP, take next at usual time. 7 days backup. Emergency contraception if necessary. *If missed dose is in last week of cycle (days 15-21 of a 28-day pill pack), omit hormone-free interval (discard rest of pack) and start next cycle.
Progestin Only Pill
- >3h past dose time or vx/dx within 3h of dose: take 1 pill ASAP, take next pill at usual time. Backup 2 days. Consider emergency contraception.
4
Q
Emergency Contraception
A
- copper IUD: most effective within 120h (~100%), up to 7 days post-coitus. Contraindicated in pregnancy, PID
- ulipristal acetate: most effective, especially 70-120h compared to levonorgestrel. 30 mg tab x 1.
-
Plan B (levonorgestrel): 1.5 mg x 1, 95% effective within 24h
- notes: will not cause abortion, make sure bleeding within 21 days otherwise preg test
- Can resume any contraceptive method after EC. Barrier method for 7 days post (14 days post Ella/ulipristal).
- Take pregnancy test if no withdrawal bleeding within 3 weeks. If vx within 3 hours, repeat dose of EC.
5
Q
Causes of AUB
A
-
Structural
- Polyp
- Adenomyosis
- Leiomyoma
- Malignancy/hyperplasia
-
Non-structural
- Coagulopathy
- Ovulatory dysfunction
- Endometrial
- Iatrogenic
- Not yet classified
6
Q
Causes of PVB/abdo pain after 20 wks preg
A
No speculum before ultrasound excludes placenta/vasa previa
-
abruptio placentatae
- from trauma or spontaneous
- peaks at 24-28 wks
- US specific but not sensitive
- dx is clinical
- pain +- tenderness +- PVB
- labs, RhoGAM + fetal NST
-
placenta previa & vasa previa
- painless PVB
- RhoGAM
- US, no pelvic
- OB
7
Q
Pre-Existing Hypertension in Pregnancy
A
Pre-existing hypertension
- BP > 140/90 starting before pregnancy or
- treat with labetalol, alpha-methyldopa, clonidine, nifedipine if BP >150/100 (140/90 if renal disease)
8
Q
Gestational Hypertension
A
Gestational Hypertension
- BP 140/90 starting in pregnancy beyond 20 wks
9
Q
Mild vs. Severe Preeclampsia
A
Mild Preeclampsia
- after 20 wks and
- SBP >= 140 or DBP >= 90 and
- proteinuria >0.3 g/24h collection
- no other systemic ssx
Severe Preeclampsia
- SBP >=160 or DBP >= 110 measured on two occasions at least 6h apart at rest and
- visual/mental status disturbance or
- pulmonary edema/cyanosis or
- epigastric/RUQ pain/abnormal LFT’s or
- thrombocytopenia or
- oliguria
- proteinuria >=5 g/24h collection or >= 3+ on two random urine samples at least 4 h apart or
- impaired fetal growth
10
Q
HELLP Syndrome
A
Hypertension
Elevated Liver enzymes
Low Platelets
- schistocytes, low plt, LFT’s, abnormal coags, high LDH
- manage like eclampsia
11
Q
Eclampsia
A
- eclampsia + seizures (sometimes seizures without HTN)
- tx: MgSO4 4-6 g IV over 20 min then 1-2 g/h, monitor levels Q1-2h if AKI/CKD, otherwise monitor presence of reflexes, u/o 100 mL/h, BP, RR
12
Q
Treatment of Gestational HTN, preeclampsia
A
- Labetalol: 100 mg PO BID, increase to 200-400 PO BID (usual)
- Methyldopa: 250 mg PO QID, increase to max 750 mg QID (3 g/day)
- Nifedipine XL (Adalat XL): 30 mg daily increase to 120 mg daily slowly
- Admit severe preeclampsia + HELLP and give MgSO4 as for eclampsia
13
Q
Vulvovaginal Candidiasis
A
- White, cottage-cheese d/c, no odour, can cause skin irritation
- Treatment
- Clotrimazole 1% cream QHS x 7d or 2% x 3 d or 100 mg supp QHS x 7d or 200 mg x 2 d or 500 mg x 1 dose
- Fluconazole 150 mg PO x 1
- Pregnant: topical azoles x 7d
- Complicated/recurrent: topical x 7-14d or fluconazole 150 mg day 1 and 3 or day 1, 4, 7
14
Q
Trichomonas Vaginitis/cervicitis
A
- 50% asymptomatic. Green/yellow, foul-smelling. Frothy. Stawberry (petechiae) cervix.
- Flagyl 2 g PO x 1 or 500 mg BID x 7d
- Treat partners also
15
Q
Bacterial Vaginosis
A
- Homogeneous, thin, grayish-white discharge that smoothly coats the vaginal walls
- Gold standard is Gram’s Stain
- Culture is +ve in most symptomatic women but is also +ve in 50-60% healthy asymptomatic women therefore DO NOT USE.
- Treatment:
- Flagyl 500 mg PO BID X 7d (safe preg)
- or
- Metronidazole gel 0.75% 5 g once daily X 5 days
- or
- Clindamycin 300 mg PO BID x 7d
- Flagyl 500 mg PO BID X 7d (safe preg)
- 30% relapse within 3 months, 50% within 12 months, consider prolonged oral Flagyl (14d)
- Partners: no testing/treatment needed
- Pregnancy: questionable benefit, do not test asymptomatic women; may treat with oral or vag Flagyl if +ve
16
Q
PID
A
- Polymicrobial, target GC/CT +- anaerobes (controversial)
- minimum for tx is CMT/adnexal tenderness and low AP
- better if NAAT +ve, discharge, bleeding, ESR/CRP or US thickening of tubes
- US check to TOA
- R/A in 72h for improvement if outpatient
- Ceftriaxone 250 mg IM + Doxy 100 mg BID x 14 d, + Flagyl 500 mg BID x 14d, consult ID/Gyne if anaphylaxis to penicillins
- treat partners without waiting for results
17
Q
Nausea/Vomiting in Pregnancy
A
Diclectin:
- 10 mg doxylamine/10 mg pyridoxine
- 1 tab QAM 1 tab QPM 2 tabs QHS
- studies show safety at higher doses (8 tabs/day)
Gravol
Maxeran
Zofran
Dex (risk of cleft lip before 10 weeks)
PPI’s
Hyperemesis Gravidarum:
- 5% pre-pregnancy weight loss, abnormal labs, ketonuria
- US
- beta
- CBC, lytes, TSH, Cr, LFT’s, U/A
18
Q
Endometriosis
A
Review Evernote “Dysmenorrhea”
19
Q
CMV Infection in Pregnancy
A
- heterophile -ve mono-like syndrome
- common ~1% all pregnancies
- 90% fetuses asymptomatic at birth –>15% of these develop late disabilities
- 10% symptomatic at birth –> severe neurologic complications
- transmission saliva, urine, sexual
- can be reactivation or new infection, often asymptomatic
- does not confer immunity
- 4x rise IgG over 14-21 days (IgM not as helpful)
20
Q
GTPAL
A
G: total preg any gestation T: # term (>37 wks) P: # premature (20-36+6 wk) A: # abortions (loss
