Ob-Gyn 3 Flashcards
1
Q
What is another name for atrophic vaginitis?
A
The genitourinary syndrome of menopause
2
Q
___ maintains the moisture, blood flow, and collagen content (eg, elasticity, turgor) of the vulvovaginal tissues (eg, vagina, vulva, urethra). Thus, patients with low ___ levels eventually develop dryness and decreased blood flow and elasticity in these tissues.
A
Estrogen
3
Q
What are the symptoms of atrophic vaginitis?
A
- Vulvovaginal dryness, irritation, pruritis
- Dyspareunia
- Vaginal bleeding
- Urinary incontinence, recurrent UTI
- Pelvic pressure
4
Q
What causes the symptoms of atrophic vaginitis?
A
Thinning of the vulvar skin -> irritation
Narrowing of the vaginal introitus -> dyspareunia
Loss of natural lubrication -> dryness
5
Q
Physical exam findings of atrophic vaginitis?
A
Narrowed introitus
Pale, easliy-denuded, retracted, atrophic vulvovaginal epithelium (eg, clitoral shrinkage), decreased elasticity, decreased rugae
Petechiae, fissures
Loss of labial volume
6
Q
First-line treatment of atrophic vaginitis?
A
OTC lubricants or moisturizers
7
Q
Treatment of persistent or severe atrophic vaginitis?
A
Vaginal estrogen
8
Q
___ is a chronic, inflammatory skin dystrophy that results in glazed, brightly erythematous, vulvar lesions with a purple hue that may be overlaid by white reticular lines known as ___.
A
Lichen planus; Wickham striae
9
Q
Patients with ___ have thin, wrinkled vulvar skin that can form into thickened white plaques that eventually obliterate the labia majora and minora, scarring the normal external landmarks. It does not affect the vagina.
A
Lichen sclerosus
10
Q
___ creates asymptomatic or pruritic vulvar lesions, particular in smokers. It appears as raised, multifocal vulvar lesions (eg, white, erythematous, hyperpigmented).
A
Vulvar intraepithelial neoplasia
11
Q
___ causes dyspareunia due to a sharp, burning pain on the vulvar vestibule often triggered by touch (eg, positive ___ test).
A
Vulvodynia; Q-tip
Patients may have vestibular erythema but no associated vaginal tissue narrowing or clitoral tissue shrinkage.
12
Q
___ is an insidious progressive disease, and physiologic and hemodynamic changes during pregnancy can precipitate symptoms in previously asymptomatic patients. The development of new ___ can further increase transmitral gradient and left atrial pressure, with dramatic worsening of pulmonary congestion and pulmonary edema.
A
Rheumatic mitral stenosis; atrial fibrillation
13
Q
___ causes rapid-onset systolic heart failure (fatigue, dyspnea, cough, pedal edema) at >36 weeks gestation or the early puerperium.
A
Peripartum cardiomyopathy
14
Q
Why is pregnancy contraindicated during breast cancer treatment?
A
Use of teratogenic agents such as chemotherapy and radiation
15
Q
Why are hormone-containing methods of contraception avoided in patients with breast cancer?
A
Estrogen and progesterone may have a proliferative effect on breast tissue
16
Q
True or false - BRCA2 carriers tend to have estrogen receptor-positive breast cancer.
A
True
17
Q
List absolute contraindications to combined hormonal contraceptives.
A
- Migraine with aura
- 15+ cigarettes/day + 35+ years of age
- HTN 160/100+ mmHg
- Heart disease
- DM with end-organ damage
- History of thromboembolic disease
- Antiphospholipid-Antibody syndrome
- History of stroke
- Breast cancer
- Cirrhosis and liver cancer
- Major surgery with prolonged immobilization
- Use <3 weeks postpartum
18
Q
True or false - combined OCs decrease the risk for ovarian cancer.
A
True (in the general population as well as in BRCA mutation carriers)
19
Q
Typical condom use is only ___% effective in preventing pregnancy.
A
80
20
Q
List 3 risk factors for ectopic pregnancies.
A
- Previous ectopic pregnancy
- Previous pelvic/tubal surgery
- PID
21
Q
List 2 risk factors for a cornual ectopic pregnancy?
A
- Uterine anomalies (eg, bicornuate, “heart-shaped” uterus)
2. IVF
22
Q
What is the first-line imaging for confirming the location of a gestational sac?
A
Transvaginal U/S
23
Q
___ is required in a patient with hemoperitoneum and unstable vital signs.
A
Emergency surgical exploration
24
Q
___ is used to remove uterine contents for spontaneous or incomplete abortion.
A
D&C
25
___ is used to treat a stable ectopic pregnancy. Ruptured ectopic pregnancy is a contraindication to its use.
MTX
26
___ is used to treat an incomplete or missed abortion. It causes cervical dilation and myometrial contraction to expel intrauterine contents.
Misoprostol
27
What is fetal growth restriction?
U/S estimated fetal weight <10th % for gestational age
28
List 4 risk factors for fetal growth restriction.
1. Maternal HTN
2. Pregestational DM
3. Genetic abnormalities
4. Congenital infection
29
List 5 physical exam features of an infant with fetal growth restriction.
1. Large anterior fontanel
2. Thin umbilical cord
3. Loose, peeling skin
4. Minimal subcutaneous fat
5. Meconium-stained amniotic fluid
30
Although the underlying cause of FGR can be of fetal, maternal, or placental origin, the results are usually ___ and ___.
Utero-placental insufficiency; poor fetal growth
31
How should fetal growth restriction be evaluated?
1. Placenta histopathology
| 2. Consider karyotype, urine toxicology, serology
32
Cranial ultrasonography evaluates for ___.
Intraventricular hemorrhage
33
Indications for cranial ultrasonography?
Gestational age of <30 weeks at delivery, respiratory distress (eg, tachypnea, grunting), and hypotension
34
List 4 risk factors for pubic symphysis diastasis.
1. Fetal macrosomia
2. Multiparity
3. Precipitous labor
4. Operative vaginal delivery
35
After a traumatic delivery, patients can develop a symptomatic pubic symphysis diastasis. How does it present?
1. Difficulty ambulating
2. Suprapubic pain radiating to the back, hips, thighs, or legs
3. Pubic symphysis tenderness
4. Intact neurologic examination
36
How is pubic symphysis diastasis managed? Most patients recover within the first ___ weeks PP.
Conservative with supportive care - NSAIDs, physical therapy, pelvic support; 4
37
Define primary dysmenorrhea.
Recurrent lower abdominal pain associated with menstruation
38
What is first-line treatment of primary dysmenorrhea in sexually active patients?
Combined estrogen-progestin OCPs
39
How do OCPs decrease pain symptoms in primary dysmenorrhea?
Thinning the endometrial lining, reducing prostaglandin release, and decreasing uterine contractions
40
List 9 side effects of OCPs.
1. Breakthrough bleeding
2. Breast tenderness, nausea, bloating
3. Amenorrhea
4. Hypertension
5. Venous thromboembolic disease
6. Decreased risk of ovarian and endometrial cancer
7. Increased risk of cervical cancer
8. Liver disorders (eg, hepatic adenoma)
9. Increased triglycerides (due to estrogen component)
41
What is the most common side effect of OCPs? It is usually associated with ___ estrogen doses.
Breakthrough bleeding; lower
42
What is the first-line treatment in primary dysmenorrhea in non-sexually active patients?
NSAIDs
43
Which contraceptive may increase body fat, decrease lean muscle mass, and cause weight gain?
Medroxyprogesterone
44
Why is medroxyprogesterone not recommended for adolescents or young women?
Significant loss of bone mineral density
45
DDx - acute abdominal/pelvic pain in women?
1. Mittelschmerz
2. Ectopic pregnancy
3. Ovarian torsion
4. Ruptured ovarian cyst
5. PID
46
How does Mittelschmerz present?
Recurrent mild and unilateral mid-cycle pain prior to ovulation; pain lasts hours to days
47
How does ectopic pregnancy present?
Amenorrhea, abdominal/pelvic pain, vaginal bleeding; positive beta-hcg
48
How does ovarian torsion present?
Sudden-onset, severe, unilateral lower abdominal pain; N/V; unilateral, tender adnexal mass on examination
49
How does ruptured ovarian cyst present?
Sudden-onset, severe, unilateral lower abdominal pain immediately following strenuous or sexual activity
50
How does PID present?
Fever/chills, vaginal discharge, lower abdominal pain, and cervical motion tenderness
51
Compare the U/S findings of the 5 DDx for acute abdominal/pelvic pain in women.
Mittelschmerz - not indicated
Ectopic pregnancy - no intrauterine pregnancy
Ovarian torsion - enlarged ovary with decreased or absent blood flow
Ruptured ovarian cyst - pelvic free fluid
PID - +/- tubo-ovarian abscess
52
How is an uncomplicated ovarian cyst rupture managed?
Conservatively with analgesics or on an outpatient basis
53
Define late-term and post-term pregnancy.
Late-term: 41+ weeks gestation
| Post-term: 42+ weeks gestation
54
List 5 risk factors for late- and post-term pregnancy.
1. Prior post-term pregnancy
2. Nuliparity
3. Obesity
4. 35+ y/o
5. Fetal anomalies (eg, anencephaly)
55
List 4 fetal/neonatal complications of late- and post-term pregnancy.
1. Macrosomia
2. Dysmaturity syndrome
3. Oligohydramnios
4. Demise
56
List 3 maternal complications of late- and post-term pregnancy.
1. Severe obstetric laceration
2. Cesarean delivery
3. PP hemorrhage
57
How is late- and post-term pregnancy managed?
Frequent fetal monitoring (eg, nonstress test) and delivery prior to 43 weeks
58
Why can oligohydramnios develop in the setting of late- and post-term pregnancy?
Decreased placental function due to age-related placenta changes -> increased placental vascular resistance and progressive dysfunction -> uteroplacental insufficiency and chronic fetal hypoxemia -> CNS system supression and intrauterine fetal demise or blood is distributed to the brain rather than peripheral tissue -> oligohydramnios (amniotic fluid is dependent on renal perfusion and urine production)
59
Define fetal macrosomia.
Weight >9.9 lb
60
Define low fetal birth weight.
Weight <5.5 lb
61
What happens to FSH and LH levels in pituitary dysfunction?
They are usually very low (<5 mIU/mL)
62
What is involved in the described abnormality of post-tubal ligation syndrome?
Dysmenorrhea, heavy bleeding or spotting, changes in the length or regularity of the menstrual cycle
63
What is the most common cause of generalized tonic-clonic seizure in pregnant patients with hypertension?
Eclampsia
64
What is the definition of eclampsia?
New-onset seizures in a patient with preeclampsia (new-onset HTN and proteinuria or end-organ damage at >20 weeks gestation).
65
What are the clinic features of eclampsia?
HTN, proteinuria, severe headaches, visual disturbances, RUQ or epigastric pain, 3-4 minutes of tonic-clonic seizure, usually self-limited
66
How is eclampsia managed?
1. Magnesium sulfate
2. Antihypertensive
3. Deliver the baby
67
Eclampsia is associated with maternal morbidity from ___, ___, and ___.
Abruptio placentae, DIC, and cardiopulmonary arrest
68
What is the only cure for eclampsia?
Expedient delivery
69
What is the antidote for magnesium toxicity?
Calcium gluconate
70
Define false labor.
Mild, irregular contractions that cause no cervical change
71
Define latent labor.
Regular contractions with increasing frequency and intensity that cause gradual cervical change
72
Define labor.
Regular, painful uterine contractions that cause cervical change
73
When should betamethasone be administered?
<37 weeks for patients at high risk for preterm delivery due to neonatal benefits
74
Indomethacin, a common tocolytic is contraindicated after 32 weeks - why? Mag sulfate is also administered for fetal neuroprotection before 32 weeks gestation.
Potential closure of the ductus arteriosus
75
How does abruptio placentae present?
Abdominal and/or back pain, FHR abnormalities, variable amount of vaginal bleeding.
76
Acute appendicitis of pregnancy may result in a ruptured appendix if the diagnosis is delayed beyond ___.
24-36 hours
77
What is the most common symptom of appendicitis in pregnancy?
RLQ pain
78
Why might the location of pain and tenderness in appendicitis of pregnancy be higher than expected?
Displacement of the appendix upward by the gravid uterus
79
What is the first diagnostic test used to confirm the diagnosis of appendicitis in pregnancy?
U/S with graded compression technique
80
If U/S is non-diagnostic of appendicitis in pregnant patients, what can be performed?
MRI
81
What are diagnostic findings of appendicitis on U/S?
Noncompression and dilation of the appendix
82
Where are the Bartholin glands and ducts located?
Bilaterally at the posterior vaginal introitus with ducts that drain into the vulvar vestibule at the 4 and 8 o'clock positions
83
How may a Bartholin duct cyst present?
Soft, mobile, nontender cystic mass, may be asymptomatic and found incidentally at the base of the labia majora
84
Condylomata acuminata result from ___, particularly types ___ and ___.
HPV; 6 and 11
85
What is a Gartner duct cyst?
Results from incomplete regression of the Wolffian duct during fetal development
86
Where do Gartner duct cysts appear?
Along the lateral aspects of the upper anterior vagina; do not involve the vulva
87
Where do Skene gland cysts appear?
Lateral to the urethral meatus
88
How are asymptomatic Bartholin duct cysts managed in young women?
Observation and expectant management - most drain spontaneously and resolve on their own
89
How are symptomatic Bartholin duct cysts or abscesses reated?
Incision and drainage, followed by the placement of a Word catheter to reduce the risk of recurrence
90
How is condylomata acuminata treated?
Cryotherapy and topical podophyllotoxin
91
List 2 risk factors for intrauterine adhesions.
1. Infection (eg, septic abortion, endometritis)
| 2. Intrauterine surgery (eg, curettage, myomectomy)
92
List 5 clinical features of intrauterine adhesions.
1. Abnormal uterine bleeding
2. Amenorrhea
3. Infertility
4. Cyclic pelvic pain
5. Recurrent pregnancy loss
93
How are intrauterine adhesions evaluated and treated?
Hysteroscopy + lysis of adhesions
94
Define infertility (<35 y/o, 35+ y/o).
Inability to conceive after 6 months of unprotected intercourse (35+ y/o) or 12 months (<35)
95
What is Asherman syndrome?
The development of symptomatic intrauterine synechiae
96
Describe the pathogenesis of Asherman syndrome.
Damage to the endometrial basalis layer of the uterus creates an inflamed, denuded endometrium that causes the uterus to adhere to itself, resulting in obliteration of the uterine cavity
97
What causes the secondary amenorrhea, infertility, and negative progesterone withdrawal test seen in Asherman syndrome?
Lack of endometrium
| Lack of implantation
98
What causes cyclic pelvic pain in Ashermansyndrome?
If the endometrial cavity is not totally obliterated due to small pockets of obstructed, proliferative endometrium
99
What is the strongest risk factor for preterm labor? Other important risk factors?
Preterm labor in a prior pregnancy; multiple gestation, history of cervical surgery (cold knife conization in particular)
100
The first step in evaluating the risk of preterm labor is TVUS to measure ___ in the second trimester.
Cervical length; short cervical length (=2cm with no history of preterm labor or =2.5 cm with a history) is a strong predictor of preterm labor
101
Elevated levels of ___ prior to term are used as indicators for increased risk of preterm labor in the mid-second and third trimesters.
Fetal fibronectin (FFN)
102
During pregnancy, ___ maintains uterine quiescence and protects the amniotic membranes against premature rupture. Thus, supplementation with exogenous ___ decreases the rate of preterm labor in patients with short cervices or a history of preterm birth.
Progesterone
103
Patients with short cervices and no history of preterm labor should be offered ___.
Vaginal progesterone
104
Patients with a history of preterm labor receive ___ starting in the second trimester, and undergo serial ___ for cervical length measurements. If it reveals a short cervix, ___ may be indicated.
IM progesterone; TVUS; cerclage
105
What are tocolytics such as CCBs and COX inhibitors used for?
To inhibit ACTIVE preterm labor by relaxing the myometrium (not to prevent preterm labor)
106
When are prenatal corticosteroids administered?
To patients at <37 weeks who are at imminent risk for preterm labor; generally not indicated for previable fetuses (<23-24 weeks gestation)
107
To prevent the maternal immune system from developing anti-D antibodies, anti-D immune globulin is first administered at __ and repeated within ___ of delivery.
28 weeks gestation; 72 hours of delivery
108
A standard dose of 300 micrograms at 28 weeks gestation can usually prevent alloimmunization. However, ~___% of Rh-negative women will need a higher dose after delivery, placental abruption, or procedures.
50
109
What test can be used to determine the appropriate dose of RhoGam for alloimmunization?
Kleihauer-Betke (KB) test - RBCs from the maternal circulation are fixed on a slide. The slide is exposed to an acidic solution and adult hemoglobin lyses, leaving "ghost" cells. The dose of anti-D immune globulin is calcualted from the percentage of remaining fetal hemoglobin.
110
Define intrauterine fetal demise.
Fetal death at 20+ weeks gestation and before the onset of labor
111
IUFD most commonly occurs in ___.
Uncomplicated pregnancies
112
What are risk factors for IUFD?
Fetal growth restriction, abnormal fetal karyotype, and tobacco use
113
How do patients with IUFD typically present?
Decreased or absent fetal movement
114
How is IUFD diagnosed?
Absence of fetal cardiac activity on U/S
115
What are the management options for IUFD?
At 20-23 weeks: Dilation and evacuation OR vaginal delivery (or C-section by maternal choice if history of prior classical cesarean/myomectomy)
At 24+ weeks: Vaginal delivery
116
Possible complication of IUFD?
Coagulopathy after several weeks of fetal retention
117
Risk factor for ABO hemolytic disease?
Infants with blood types A or B born to a mother with blood type O
118
5 clinical features of ABO hemolytic disease?
1. Jaundice within 24 hours of birth
2. Anemia
3. Increased reticulocyte count
4. Hyperbilirubinemia
5. Positive Coombs test
119
How is ABO hemolytic disease managed?
1. Serial bilirubin levels, oral hydration, and phototherapy for most neonates
2. Exchange transfusion for severe anemia/hyperbilirubinemia
120
Discuss the severity of hemolytic disease in the setting of ABO incompatibility.
Signs are typically mild and apparent only in ~1/3 of infants.
121
Why can ABO incompatibility affect a first pregnancy?
Patients with blood group O are exposed to A and B antigens early in life (from exposure to A- and B-like antigens in food, bacteria, and viruses) and produce antibodies to these antigens. By the time a woman with blood group O becomes pregnant, she already has anti-A and anti-B IgG Ab that cross the placenta.
122
Why is ABO incompatibility more mild?
Ab against A and B are hemolytic; however, in addition to RBCs, A and B antigens are present on the cells of all other fetal tissues. The reaction of the anti-A and anti-B antibodies with the antigens on these other cells neutralizes the Ab response.
123
List 5 modifiable risk factors for breast cancer.
1. HRT
2. Nulliparity
3. Increased age at first live birth
4. Alcohol consumption
5. Obesity
124
List 4 non-modifiable risk factors for breast cancer.
1. Genetic mutation or breast cancer in first-degree relatives
2. White race
3. Increasing age
4. Early menarche or late menopause
