Important Clinical Medicine Parameters

Question 1

Women ___ years of age or greater should receive annual mammograms.

Answer 1

40

Question 2

If a cyst reappears or does not resolve with fine needle aspiration, what should occur?

Answer 2

If cyst reappears or does not resolve with aspiration, diagnostic mammogram/ultrasound and perform biopsy.

Question 3

What are the guidelines for screening for cervical cancer in the following ages?

Under 21

21-29

30-65

65 and over

After Hysterectomy

Answer 3

Under 21 = NO SCREENING

21-29 = Cytology alone every 3 years

30-65 = HPV and cytology COTESTING every 5 years

65 and over = No screening folowing adequate negative prior screening

After Hysterectomy = NO screening

Question 4

You receive results of someone who has an ASC-US pap, how do you proceed?

Answer 4

-look for hpv (preferred method)
-if hpv negative, repeat co testing in 3 years
if hpv positive, send for colposcopy

or…
you can repeat cytology in one year

if you get asc again –> colp
if normal now –> go back to routine

Question 5

You receive results of someone who has a LSIL pap, how do you proceed?

Answer 5

low grade with neg HPV (almost never happens) –> cytology in one year

low grade with unknown hpv or positive hpv –> colp

Question 6

You receive results of someone who has a HSIL pap, how do you proceed?

Answer 6

culp or just go ahead and treat their cervix

wootton tends to colp so she can check the inside cells bc if those are bad she must do the cone

Question 7

Excisional techniques to the uterus are done when….

Answer 7

~Endocervical curettage positive (needs cold knife
cone)
~Unsatisfactory colposcopy (No SCJ)
~Substantial discrepancy between pap and biopsy
(i.e. High grade pap and negative colposcopy)

Question 8

If the endocervical curretage is positive, what is the next step?

Answer 8

Cold knife cone

Question 9

What are the guidelines for HPV testing?

Answer 9

Three injection series- first dose, second dose 2 months later, third dose 6 months from first (can still give doses if interval varies)

ACIP recommends a routine 2 dose HPV vaccine schedule in adolescents less than 15 years of age separated by 6-12 month intervals

Recommended routine vaccination for all girls and boys ages 9-26
( October 5, 2018 FDA approved for use in men and women ages 27-45)

Can receive if already have abnormal pap

Not for use in pregnancy but safe in breastfeeding

Question 10

What is the “discriminatory level” of hCG where a gestational sac be seen with transvaginal ultrasound (TVUS)?

Answer 10

1500-2000 mIU/L

Question 11

Which abnormal rise of hCG in 48 hours confirms a nonviable IUP or ectopic pregnancy?

Answer 11

Abnormal rise in hCG of <53% in 48 hrs

Question 12

Which weeks constitute the first, second, and third trimesters?

Answer 12

• First = first day of last menstrual period - 13 + 6 weeks
• Second = 14 weeks - 27 + 6 weeks
• Third = 28 weeks - 42 weeks

Question 13

Recurrent abortions are defined as what?

Answer 13

• Defined as 3 successive SAB

- Excluding (ectopic and molar pregnancies)

Question 14

How many cigarettes a day and alcoholic beverages a week are associated with a 4-fold increased risk for SAB?

Answer 14

• 20-cigs a day

- 7 alcoholic drinks/week

Question 15

Which fetal MCA value peak systolic velocity for gestational age is predictive of moderate to severe fetal anemia?

Answer 15

> 1.5 MOM

Question 16

Which Hct level is considered severe fetal anemia?

When are intrauterine transfusions done and with what?

Answer 16

• Hct is below 30% or 2 standard deviations below the mean Hct for the gestational age
• Intrauterine transfusions using fresh group O, Rh-negative packed RBC’s performed between 18-35 weeks

Question 17

What is the most valuable tool for detecting fetal anemia?

How often should it be performed?

Answer 17

• Doppler assessment of peak systolic velocity in the fetal MCA in cm/sec
• Should perform this test q 1-2 wks from 18-35 wks

Question 18

In addition to serial ultrasounds with MCA dopplers, what other 2 tests should be used in the management of Rh-isoimmunization?

Answer 18

• Antepartum testing: 2x weekly non-stress test or biophysical profiles
• Serial growth scans q 3-4 weeks

Question 19

How much should a baby move every 2 hours?

Answer 19

10 movements every 2 hours

Question 20

What scores on the components of the reassuring biophysical profile guidelines are:

~Reassuring

~Equivocal

~Nonreassuring

Answer 20

Reassuring = 8-10

Equivocal = 6

Nonreassuring = 4 or less

Question 21

What is the definition of labor?

Answer 21

Progressive cervical dilation resulting from regular uterine contractions that occur at least every 5 minutes and last 30-60 seconds

Question 22

What are the characteristics of a biophysical profile?

Answer 22

x

Question 23

What are parameters of a contraction stress test (CST)?

Answer 23

—Contraction stress test (CST)
—Give oxytocin to establish at least 3 contractions in a 10 min period.
If late decelerations are noted with the majority of contractions the test is positive and delivery is warranted

Question 24

What are the characteristics of a nonreactive stress test? What is considered reactive?

Answer 24

Nonstress test (NST)
—Reactive- 2 accelerations of at least 15 beats above baseline lasting at least 15 seconds during 20 minutes of monitoring
If this successfully occurs, called reactive
—If test is nonreactive further evaluation is warranted with a contraction stress test or biophysical profile

Question 25

what is the diagonal conjugate?

Answer 25

DIAGONAL CONJUGATE Is approximated by measuring from the inferior portion of the pubic symphysis to the sacral promontory If > 11.5 cm the anterioposterior (AP) diameter of pelvic inlet is adequate

Question 26

what is the obstetric conjugate?

Answer 26

OBSTETRIC CONJUGATE Is then estimated by subtracting 2.0 cm from the diagonal conjugate Is the narrowest fixed distance through which the fetal head must pass through during a vaginal delivery

Question 27

What occurs at the 20 weeks office visit, the 28 week office visit, and the 35 week office visit?

Answer 27

—20 weeks —Obtain fetal survey ultrasound Find out the gender! —28 weeks Screening for gestational diabetes & repeat hemoglobin and hematocrit —Rhogam injection to Rh negative patients —Tdap (Tetanus, diptheria, & acellular pertussis) give between 27-36 weeks —35 weeks —Screening for group B strep carrier with vaginal culture - treat in labor if positive

Question 28

What is the duration of the first stage of labor?

Answer 28

Duration of first stage: Primiparas- typically 6-18 hours Multiparas- typically 2-10 hours

Question 29

What is the rate of cervical dilation?

Answer 29

Rate of cervical dilation: Primiparas- 1.2 cm per hour Multiparas- 1.5 cm per hour

Question 30

What is the duration of the second stage of labor in primiparas vs multiparas?

Answer 30

``` Duration: Primapara without epidural- 2 hours Primapara with epidural- 3 hours Multipara without epidural- 1 hour Multipara with epidural- 2 hours ```

Question 31

What are the classic signs of placental separation?

Answer 31

``` Classic signs of placental separation Gush of blood from the vagina Lengthening of the umbilical cord Fundus of the uterus rises up A change in shape of the uterine fundus from discoid to globular ```

Question 32

what is the bishop score? what is the highest score? what is considered unfavorable?

Answer 32

x

Question 33

What is considered normal vs. tachysystole for uterine contractions when monitoring?

Answer 33

- Normal = 5 contractions or less in 10 minutes, averaged over 30 mins - Tachysystole = >5 contractions in 10 minutes, averaged over 30 mins

Question 34

What is considered an acceleration of FHR at ≥ 32 weeks and at <32 weeks gestation?

Answer 34

- ≥ 32 weeks: HR ≥ 15 bpm above baseline for 15 sec or more (but <2 mins) - <32 weeks: HR ≥ 10 bpm above baselines for 10 sec or more (but <2 mins)

Question 35

What is the normal amount of variability in amplitude with FHR?

Answer 35

Moderate (normal) = range of 6-25 bpm

Question 36

How do variable decelerations of FHR appear on monitor; what is the criteria?

Answer 36

- Abrupt ↓ in FHR ≥ 15 bpm lasting ≥ 15 sec and <2 min (looks like big 'V') - Can occur before, during, or after the contraction

Question 37

What seen on fetal heart rate tracing would be considered category III?

Answer 37

- Recurrent late decelerations or variable decels or bradycardia - Sinusoidal pattern

Question 38

When & How do we diagnose PTL? What symptoms are expected?

Answer 38

20-37 weeks w/ a CERVICAL EXAM, External Monitoring, FHR Must have: Uterine Contractions, Cervical Dilation of 2cm (80% effacement) ---------------------------- Menstraul like cramping, Backache, Pelvic Pressure, Discharge (bloody), Uterine Contractions

Question 39

What is the model is used to evaluate breast cancer risk? from woottons abn breast lecture

Answer 39

gail model

Question 40

In cases of potential invasive breast carcinoma, when would you order an MRI for your patient? from woottons abn breast lecture

Answer 40

Diagnostic in SUSPICIOUS MASSES Too expensive to use as a screening method. Use for women at high risk for breast cancer, like BRCA carriers

Question 41

a mammogram can be both screening and _____

Answer 41

diagnostic

Question 42

what are ultrasounds useful for in regards to the breast?

Answer 42

Useful in evaluating inconclusive mammogram findings Best for evaluating young women (age <40) and others with dense breast tissue Allows to differentiate between cystic versus solid lesions as well as show solid tissue within or adjacent to a cyst that may be malignant Used for guidance when performing core needle biopsies

Question 43

what occurs after a thin needle aspiration biopsy if the breast cyst DISAPPEARS? what is it REAPPEARS?

Answer 43

Return for clinical breast exam in 4-6 months if cyst completely disappears with aspiration If cyst reappears or does not resolve with aspiration diagnostic mammogram/ultrasound and perform biopsy

Question 44

what can be used for symptom relief in mastalgia?

Answer 44

Symptom relief: Properly fitting bra, weight reduction, exercise, decrease caffeine intake and vitamin E supplementation, evening of primrose oil

Question 45

what is the treatment follow up after getting officially diagnosed with breast cancer?

Answer 45

First 2 years after diagnosis- every 3-6 months Annually after first 2 years Most reoccurrences will happen within first 5 years after treatment

Question 46

what are the some of the epithelial cell abnormalities that can come back to you, the doc, on a path report after a pap smear?

Answer 46

Epithelial Cell Abnormalities that can come back to you, the doc, after a pap smear: - -Atypical squamous cells of undetermined significance (ASC-US) - -cannot exclude high grade (ASC-H) - -Low grade squamous intraepithelial lesion (LSIL) - -High grade squamous intraepithelial lesion (HSIL) - -Squamous cell carcinoma

Question 47

What are the risks of excisional procedures in treating the cervix?

Answer 47

Increased risk of cervical incompetence and resultant second trimester pregnancy loss Increased risk of preterm premature rupture of membranes (PPROM) cervical stenosis operative risks- bleeding, infection

Question 48

How do you characterize Mild Preeclampsia without severe features?

Answer 48

BP <140/90 (less than 160/110) Proteinuria >300mg over 24 hour urine collection (but less than 5 grams) ASYMPTOMATIC

Question 49

What are the main symptoms we see with Pre-eclampsia?

Answer 49

Scotoma -- vision disturbances Blurred Vision Epigastric/ RUQ pain Headache (that doesnt improve with ibuprofen)

Question 50

How do you characterize Severe Preeclampsia with Severe Features?

Answer 50

BP >160/>110 (must be 2 occasions) Proteinuria >5 grams per 24 hour Liver Enzymes -- 2x the upper limit / epigastric pain refractory to tx Pulmonary Edema Thrombocytopenia Cerebral/Visual Disturbances SYMPTOMATIC

Question 51

How do you assess for mom and baby in the case of chronic HTN?

Answer 51

Assess for maternal end-organ damage CBC, glucose, complete metabolic profile, 24 hour urine collection for total protein (or a spot urine protein to creatinine ratio) , EKG and possibly echocardiogram Assess for fetal well being -Initial ultrasound for accurate dating -Screening ultrasound -Growth ultrasounds monthly after 28 weeks gestation -Antepartum fetal testing to begin between 32-34 weeks gestation

Question 52

How is mild hypertension managed in pregnant mommas?

Answer 52

Mild hypertension (BP less than 160/110 mmHg) Begin aspirin therapy 81 mg daily at 12 weeks till delivery 􄡧 Initiate antihypertensive if reach threshold value 􄡧 Prenatal visits every 2-4 weeks until 34-36 weeks gestation and then weekly 􄡧 Antepartum fetal monitoring 􄡧 Delivery between 39-40 weeks gestation

Question 53

How is severe hypertension managed in pregnant mommas?

Answer 53

Severe hypertension (BP greater than 160/110) 􄡧 Antihypertensive therapy ▫ Methyldopa ▫ Labetalol* ▫ Nifedipine* ▫ Others (non-first line) metoprolol, prazosin, minoxidil, hydralizine, thiazide diuretics and clonidine Close prenatal monitoring for medication dosage change ! With associated renal disease- 24 hour urine collection every trimester ! Observation for signs of developing superimposed preeclampsia ! Antepartum fetal surveillance 􄡧 Growth ultrasounds every 3-4 weeks 􄡧 Non-stress tests and/or biophysical profiles ! Delivery after 38 weeks gestation

Question 54

when should gestational dm resolve?

Answer 54

12 weeks post partum

Question 55

bun:creatinine ratio of preeclampsia with mild features?

Answer 55

0.3

Question 56

bun:creatinine ratio of preeclampsia with severe features?

Answer 56

>1.1

Question 57

what labs are elevated in preeclampsia? what labs are low?

Answer 57

``` Laboratory findings Increased: ▫ Hematocrit ▫ Lactate dehydrogenase ▫ Transaminases (AST,ALT) ▫ Uric acid ``` Low: Thrombocytopenia (low platelets)

Question 58

what are the lab values associated with HELP syndrome?

Answer 58

Labs: LDH greater than 600 IU/L; AST/ALT elevated twice the upper limit of normal; platelets less than 100,000 ! Presence of hypertension and proteinuria are variable

Question 59

If pregnant patient w/ asthma has been using daily inhaled steroids or high potency oral for more than 3 weeks what is done during labor and delivery?

Answer 59

Stress dose of IV steroids to prevent adrenal crisis

Question 60

What is the most common HA during pregnancy; treated how?

Answer 60

tension - with acetaminophen

Question 61

Which serum creatinine level worsens the prognosis of chronic kidney failure during pregnancy?

Answer 61

Serum Cr. >1.5-2

Question 62

What drugs used in tx of thyroid storm during pregnancy?

Answer 62

- Propranolol - Sodium iodide (blocks secretion of thyroid hormone) - PTU - Dexamethasone (halts peripheral conversion of T4 --> T3)

Question 63

What are 6 fetal complications assoc. w/ gestational diabetes?

Answer 63

- Macrosomia - Neonatal hypoglycemia - Hyperbilirubinemia - Operative delivery - Shoulder dystocia - Birth trauma

Question 64

Intrahepatic cholestasis of pregnancy increase the risk of what complications?

Answer 64

Meconium stained amniotic fluid and fetal demise

Question 65

What is treatment for immune idiopathic thrombocytopenia during pregnancy?

Answer 65

All of this begin after platelets <50,000 - Give prednisone - IV immunoglobulin if severe - Platelet transfusion - Splenectomy

Question 66

what is the antepartum management of gdm?

Answer 66

● Diabetic teaching ● Blood glucose monitoring ● Fetal testing weekly (biophysical profiles and/ or non-stress tests) ● Ultrasound for estimated fetal weight ◦ If weight greater than 4500 gm-recommend cesarean delivery ● Can wait for spontaneous labor or estimated due date if all testing, growth and glycemic control are good

Question 67

what are the components of a fetal evaluation when the mother has PREEXISITING DM?

Answer 67

Fetal evaluation ◦ Early dating ultrasound ◦ Detailed fetal anatomy ultrasound including fetal echocardiogram ◦ Biochemical testing for congenital malformations in first trimester 11-13 weeks or quad screen at 16-21 weeks ◦ Fetal growth ultrasound every 2-4 weeks ◦ Fetal testing (NST/BPP) every week starting 32 weeks ● Delivery options depends on estimated fetal weight and glycemic control

Question 68

what medications should be taken by a pregnant mother if she has hyperthyroidism? how can hyperthyroidism affect the fetus?

Answer 68

Medications-Propylthiouracil (PTU)and methimazole ●Methimazole in 2nd and 3rd trimester (can cause aplasia cutis and choanal atresia in 1st trimester) ●propylthiouracil- increased risk of liver toxicity so only used in 1st trimester ●Monitor TSH levels throughout pregnancy ● Fetal effects ◦Medications cross placenta and fetal hypothyroidism and fetal goiter can develop ◦ Increased risk of prematurity, IUGR, preeclampsia and stillbirth

Question 69

Fetal complications of SLE

Answer 69

``` ◦ Fetal complications ●Preterm delivery ●Fetal growth restrictions ●Stillbirth ●Miscarriage ◦ 10% risk for neonatal lupus-passive transfer of anti- Ro/SSA or anti-La/SSB ```

Question 70

what are the fetal complications of post renal transplant?

Answer 70

● Post renal transplant ◦ Not recommended ●May lose graft function or experience rejection; best candidates are 1-2 years post transplant with stable creatinine and proteinuria without severe hypertension ●Fetal complications ◦ Steroid induced adrenal and hepatic insufficiency ◦ Prematurity ◦ Intrauterine growth restriction

Question 71

what can increase miscarriage risk if | disease is active at time of conception?

Answer 71

inflamm bowel disease

Question 72

what are the symptoms and lab findings of acute fatty liver of pregnancy?

Answer 72

``` Symptoms ●Abdominal pain ●Nausea and vomiting ●Jaundice ●Irritability ●Polydipsia/pseudodiabetes insipidus ●Hypertension/proteinuria in 50% of cases ``` ◦ Lab findings ●Increase protrombin time and partial thromboplastin time, elevated bilirubin, ammonia and uric acid, and elevation of liver transaminases

Question 73

Severe asthma in pregnancy is associated with increased...

Answer 73

``` ◦ Severe asthma associated with increased ●Miscarriage ●Preeclampsia ●Intrauterine fetal demise ●Intrauterine fetal growth restriction ●Preterm delivery ```

Question 74

what type of HA is most prevalent in childbearing years?

Answer 74

``` Migraines ●highest prevalence in childbearing years ●most often improve during pregnancy ●neurology can be helpful in treatment ```

Question 75

Women on anti-epileptics should be on anywhere | from 1 mg to 4 mg of....

Answer 75

Women on anti-epileptics should be on anywhere from 1 mg to 4 mg folic acid depending on which agent is used

Question 76

When would you never do a Vacuum assisted Vaginal Delivery?

Answer 76

<34 weeks Fetal Coag Disorder Fetal Macrosomia Breech presentation

Question 77

what are the time parameters of potential OVD in multiparous vs nulliparous?

Answer 77

• nulliparous: >2 hours without regional anesthesia or >3 hours with regional anesthesia • multiparous: >1 hour without regional anesthesia or > 2 hours with regional anesthesia

Question 78

What is Intrauterine Growth Restriction (IUGR)?

Answer 78

When the birth weight of a newborn is below the 10% for a given gestational age

Question 79

PUERPERAL SEPSIS

Answer 79

Febrile morbidity–is defined as temp> 100.4 (38oC) or higher that occurs for more then 2 consecutive days (exclusive of the first 24 hrs) during the first 10 postpartum days

Question 80

PUERPERAL SEPSIS

Answer 80

Febrile morbidity–is defined as temp> 100.4 (38oC) or higher that occurs for more then 2 consecutive days (exclusive of the first 24 hrs) during the first 10 postpartum days CLINICAL FEATURES: Postpartum fever & increasing uterine tenderness on postpartum day 2 to 3 are the key clinical findings Purulent lochia, chills, malaise& anorexia may also be noted

Question 81

Septic Pelvic Thrombophlebitis PATHOGENSIS

Answer 81

Physiologic conditions in setting of SPT fulfill Virchow’s triad for the pathogenesis of thrombosis Endothelial damage As a result of intrapartum trauma to vascular structures or a result of uterine infection Venous stasis As a result of pregnancy induced ovarian venous dilation Hypercoagulable state of pregnancy

Question 82

Ovarian Vein Thrombophlebitis

Answer 82

Fever & abdominal pain within 1 week after delivery or surgery Appear clinically ill Fever, abdominal pain, localized to the side of the affected vein 20% of the time thrombosis of ovarian vein is seen radiographically

Question 83

Deep Septic Pelvic Vein Thrombophlebitis

Answer 83

Usually have unlocalized fever in the first few days that is non responsive to antibiotics Do NOT appear clinically ill No radiographic evidence of thrombosis Diagnosis of exclusion