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1

how is arrest of labor defined in nulliparous women? multiparous women?

what is the recommended course of action in these patients?

  • nulliparous women
    • ≥ 3hrs of pushing w/o epidural
    • ≥ 4 hours of pushing w/ epidural
  • multiparous women?
    • ≥ 2hrs of pushing w/o epidural
    • ≥ 3 hours of pushing w/ epidural

recommended course of action: c-section

2

How can you tell if contractions are of adequate strength?

place an intrauterine pressure monitor to accurately assess strength of contractions and calculate Montevideo units (MVUs)

Adequate labor is defined as ≥200-250 MVUs

3

work-up of down syndrome

integrated testing: 

  • at 10 weeks
    • US to measure nuchal translucency
    • serum markers PAPP-A
  • at 12 weeks
    • decreased AFP, HCG, unconjugated estriol, inhibin A
      • note: elevated AFP is present in spinal bifida, anencephaly, congenital nephrosis, ventral wall defects, improper fetal dating, multiple gestations

definitive diagnosis: amniocentesis and karyotyping

4

management of adnexal masses during pregnancy

>5 cm -> removal during 2nd trimester due to high risk of rupture, hemorrhage, and torsion, all of which may lead to preterm delivery

5

delivery of infant complicated by shoulder dystocia. infant demonstrates tachypnea, cyansois, and weak cry shortly after birth. How to determine if infant has diaphragmatic paralysis vs diaphragmatic hernia?

diaphragmatic paralysis - usually 2/2 phrenic nerve injury; typically associated w/ signs of brachial plexus injury (e.g. Erb's palsy)

diaphragmatic hernia - ipsilateral hypoplastic lung

6

management of retroverted uterus during pregnancy

uterus will usually reposition into anterior position between 12-16 weeks of pregnancy, but a small % will not. In these cases, the physicial has to manually reposition the uterus to avoid uterine incarceration in the sacral region, which may later jeopardize the lives of the mother/fetus, requiring urgent surgery.

7

Folic acid recommendations for general population

Folic acid recommendations for women on anticonvulsants or have had a child with neural tube defect

general population: 0.4mg/day for ≥1 month before conception through the first trimester

women on anticonvulsants or have had a child with neural tube defect: 4 mg/day for ≥1 month before conception through the first trimester

8

prognosis of Erb palsy in infant that sustained difficult delivery

prognosis is good, with an 80% chance of full or near-full recovery at 1 year of age

9

Tests that should be ordered at the first prenatal visit

Tests/parameters that should be measured on subsequent visit

first prenatal visit

  • blood: T&S, Rh, H/H
  • Infection: syphilis, chlamydia, HIV, HepB sAg, UA/UC
  • Pap smear

subsequent visits

  • BP, weight
  • fundal height
  • heart tones
  • fetal presentation
  • urine glucose and protein

10

mother presents w/ mildly low platelets in the third trimester and is asymptomatic.

what is the diagnosis?

management?

gestational thrombocytopenia, benign condition thought to be be of immune etiology

conservative management (follow-up)

 

note* thrombocytopenia can also be seen in HELLP syndrome, HIV, ITP (esp if the platelet count is particularly low or if the thrombocytopenia develops earlier in pregnancy), SLE (also presents w/ anemia and leukopenia) 

11

HELLP syndrome

FIRST thing you should do when patient is presenting with HELLP

hemolysis

elevated LFTs

low platelet #s

1st thing to do: give MgSO4

 

12

etiology of:

  1. abdominal pruritis in the setting of linear excorations and prominent abdominal striae
  2. abdomial pruritis in the setting of erythematous papules within the striae gravidarum, which may spread to involve the extremiteis
  3. abdominal pruritis in the setting of urticarial plaques, papules, and vesicles surrounding the umbilicus

management of all of these?

  1. physiologic changes of teh skin
  2. papular urticarial papules and plaques of pregnancy PUPPP
  3. herpes gestationis (autoimmune disorder)

management: topical/oral steroids + antihistamines to alleviate pruritic symptoms

13

treatment of pregnant lady who develops pruritic papules and vesicles surrounding the umbilicus

PO steroids, as herpes gestationis is an autoimmune disease of pregnancy

14

24F at 34wk GA undergoes US which shows fetus in complete breech presentation.

management?

most fetuses will assume cephalic presentation at 34-36 weeks, and most will spontaneously before delivery.

external cephalic version should not be attempted until after 37 week GA

15

elevated AFP level >2.5 MoM is indicative of...

what test should you order next?

open spina bifida

anencephaly

congenital nephrosis

ventral wall defect

dermatologic disorders

tumors

improper fetal dating

multiple gestations

 

get an US at 20 weeks gestation to get an anatomy survey

16

management of patient who is on an anti-epileptic drug (AED) during pregnancy

before pregnancy

can she breastfeed on AED?

continue current effective AED regimen if patient is already pregnant

if patient is on valproate and is considering a pregnancy, switch patient to an alternatel AED 6 months before a planned pregnancy

breastfeeding is generally NOT contraindicated

17

Management of patient w/ history of HSV infection during pregnancy

Management of patient w/ history of HSV exposure during pregnancy

HSV infection - begin antiviral therapy at 36 weeks, C-section if infection is active at time of birth

HSV exposure - get HSV serology, if positiive, then follow same regimen as above

18

25F w/ eisenmenger syndrome has a pregnant urine test. What is your recommendation and rationale?

elective termination in the first trimester due to high risk of mortality to mother and fetus

during pregnancy, there is an increase in intravascular volume, increase CO, and decreased SVR, all of which can exacerbate an existing R->L shunt (which is present in Eisenmenger syndrome 2/2 pulmonary HTN)

Maternal deaths can occur during the first week post-partum as there is a sudden drop in SVR after delivery, which will increase the R->L shunt and worsen hypoxemia

19

treatment of BV during pregnancy

PO metronidazole or PO clindamycin

metronidazole will cross the placenta, but does not have teratogenic effects

Untreated BV can result in increased risk of preterm birth, PROM, spontaneous abortion, and acquired infections (HIV, HSV II, gonorrhea, chlamydia, trichomonas)

20

mother is D(-) has significant intrapartum placental abrution (husband is known D(+)) develops anti-D antibody titers 1:34. Explanation?

dose of anti-D Ig after excessive feto-maternal hemorrhage (e.g. placental abruption) likely resulted in maternal alloimmunization

21

Is asymptomatic bacteriuria treated in pregnant women?

yes, as it can progress quickly to cystitis and pyelonephritis (conditions that are associated w/ preterm labor and premature birth)

22

Rx given to reduce risk of infant respiratory distress syndrome in preterm labor

when is it given?

INTRAMUSCULAR betamethasone or dexamethasone - stimulates surfactant production, accelerates lung development, and has shown to reduce risk of intraventricular hemorrhage in infants

given at 24-34 weeks of GA 

23

management of patient w/ severe pre-eclampsia

hydralazine (or labetalol) to lower blood pressure

MgSo4 to prevent progression to eclampsia

once stabilized, delivery should be carried out

24

36F in her 8th wk GA undergoes TVUS, which demonstrates a 1.8cm crescent shaped hypoechoic area suggestive of hematoma adjacent to gestational sac

next step?

treatment?

known complications?

repeat US in one week

no known therapeutic interventions

spontaneous abortion

25

Steps in management of shoulder dystocia

Breathe

Elevate legs (McRoberts)

Call for help

Apply suprapubic pressure

Lengthen vaginal opening w/ episiotomy

Manuevers

  • deliver posterior arm
  • apply pressure against baby's posterior shoulder, posterior/anterior rotation (woods corkscrew/rubin manuever) 
  • mother on all fours (gaskin manuever)
  • replace baby's head into vagina, followed by c-section delivery

26

indications for penicillin therapy in pregnant women

when to administer?

  1. prior deilvery complicated by neonatal GBS infection
  2. GBS bacteriuria
  3. GBS UTI
  4. GBS+ rectovaginal culture
  5. unknown GBS status + one of the following
    • <37 wk GA
    • intrapartum fever
    • ROM >18 hours

MUST BE GIVEN ≥4 HOURS BEFORE DELIVERY. If not given or not given within the appropriate time frame, infants should be observed for ≥48 hours to monitor for signs of infection (lethargy, poor feeding, temperature instability). CBC/BCx also indicated if infant was preterm (≤37 weeks) and had ROM ≥18 hours

27

managment of patients w/ hyperthyroidism during pregnancy

1st trimester: PTU (methimazole has teratogenic effects - scalp defects, tracheoesophageal fistula, choanal atresia)

2nd/3rd trimester: methimazole (due to potential liver failure w/ PTU intake)

28

Patient w/ Turner syndrome wants to get pregnant. Management?

weight reduction is associated w/ restoration of ovulation, decrease in androgen production, and pregnancy

if weight reduction fails to restore ovulation, can try metformin +/-clomiphene citrate

29

management in patient w/ evidence of venous sinus thrombosis and evidence of hemorrhagic foci

start heparin gtt, even if there is hemorrhagic infarction demonstrated on CT because the foci that occur are secondary to venous HTN

30

31

pregnant lady is febrile, tachy, hypotensive and is p/w bloody, purulent vaginal discharge and dilated cervix 

management?

Septic abortion

IVF, blood cultures, broad spetrum antibiotics (pip-tazo, imipenem, or triple therapy w/ clindamycin, gentamicin, and ampicillin)

once stabilized, evacuate uterus w/ suction curettage

Emergency hysterectomy if patient fails to respond to antibiotics and suction curettage, develops pelvic abscess or demonstrate signs of clostridial sepsis

32

Pt w/ hx of LEEP and pre-term birth is now pregnant w/ second child. Management?

cervical insufficiency - serial US evaluations of cervical length

cerclage placement during the second trimester is indicated if there is

  • a history of painless cervical dilation and second trimester loss.
  • a history of pre-term birth and a short cervix found on US btwn 16-24 weeks GA

33

Pregnant female who is Rh(D) negative and negative anti-D antibody screen does not know what the status of the father of child is. What should you do to prevent Rh(D) isoimmunization?

give anti-D immune globulin IM at 28wks GA 

34

Management of bipolar patients during pregnancy?

haloperidol

35

caput succedaneum vs cephalohematoma

management of both?

(A) caput succedaneum - swelling of scalp due to subcutaneous hemorrhage that crosses suture lines

(B) cephalohematoma - scalp hemorrhage that is limited by the periosteal attachments to a single cranial plate and therefore does not cross suture lines 

both result from birth trauma and do not require treatment unless hemorrhage is significant enough to cause hyperbilirubinemia.

A image thumb
36

Patient develops significant uterine tenderness after c-section and has foul-smelling discharge, elevated WBC w/ bandemia

diagnosis?

biggest risk factor for developing this?

management?

post-partum endometritis - polymicrobial infection (anaerobe, aerobe) of decidua --> clindamycin + gentamicin

risk factors: route of deliver (c-section vs vaginal)

37

management of patient in active labor at 38 wk GA  who presents with smooth, sessile flesh colored hyperkeratotic papules distributed all over the vaginal area.

expectant therapy - condyloma acuminata is a manifestation with HPV and is NOT considered a contraindication to vaginal delivery in pregnant women

Trichloroacetic acid is the preferred initial approach, followed by immunotherapy (e.g. topical interferon), or surgical excision

38

algorithm for palpable breast mass

< 30 yo - US (mammograms aren't as sensitive/specific for initial evaluation because the breast tissue is denser in this population)

  • if simple cyst -> needle aspiration if symptomatic
  • if solid, circumscribed -> repeat US/mammogram in 6 mo
  • if complex cyst/mass -> image-guided core needle biopsy

≥ 30 yo - mammogram + US (mammogram has low sensitivity for detecting small, non-calcified or intraductal lesions, whereas US is very sensitive for evaluating ductal pathology)

  • if suspicous for malignancy -> core biopsy

39

Patient w/ seizures really wants to take oral contraceptives. Which two OCPs do not decrease contracepive efficacy?

gabapentin

valproate

40

76F G4P4 c/o pelvic pressure, heaviness, lower back pain, constipation. PE demonstrates protrusion of the posterior vaginal wall. Diagnosis? Management?

Rectocele

if symptomatic (as in this patient): Pessary PLUS vaginal estrogen, as the pessary can cause chronic discharge and bleeding secondary to injury of the vaginal tissue

if asymptomatic: pelvic exercises, avoidance of exercises related to increased intraabdominal pressure, regular use of intravaginal estrogen to prevent tissue atrophy

41

25 AA female presents w/ dysmenorrhea, dyspareunia, dyschezia, and hematochezia that coincide with menses. Not relieved with anti-inflammatory medications. PE reveals nodularity of uterosacral ligaments.

Diagnosis? Next step in management? Treatment?

complications?

endometriosis - can involve ovaries, cul-de-sac, broad ligaments, uterosacral ligaments, uterus, fallopian tubes, sigmoid colon

Refer for laparoscopy for direct visualization of the endometrial implants/definitively establish the diagnosis of endometriosis before instituting treatment

Treatment: medical management (NSAIDs, GnRH analog, danazol (synthetic androgen), oral contraceptive)

complications: intestinal obstruction

42

management of uterine bleeding during the menopausal transition

endometrial biopsy is indicated for

  • ≥45 w/ suspected anovulatory bleeding
  • < 45 w/ risk factors for unopposed estrogen (obesity, POCS, failed medical management, persistent abnormal bleeding)

US is indicated in post-menopausal women presenting w/ vaginal bleeding; if the endometrial thickness is <4 mm, then the risk of endometrial cancer is very low and endometrial biopsy is not needed. 

HOWEVER, in peri-menopausal women, US is not as useful as hormonal activity is still present and endometrial thickness varies. 

43

what is ulipristal?

anti-progestin - prevents pregnancy by inhibiting or delaying ovulation

emergency contraception, effective for up to 5 days after unprotected intercourse and its efficacy does not decrease with time

even more effective than levonorgestrel (plan B, delays ovulation)

44

contraindications to OCPs

  • migraines w/ aura
  • smoking and ≥35 
  • BP >160/100
  • history of hypercoagulable state (stroke, MI, DVT)
  • breast cancer
  • cirrhosis, HCC
  • major surgery w/ prolonged immobolization 
  • <3 weeks post-partum

45

T/F patients on tamoxifen do not need additional screening for endometrial cancer

It depends if the patient is symptomatic

  • asymptomatic patients will just need an annual gynecologic exam w/ complete history and routin pap smears
  • Symptomatic patients will need TVUS or endometrial biospy

46

Aspiration of breast cyst yields grossly bloody fluid. 

Aspiration of breast cyst yields thin greenish fluid.

management?

grossly bloody fluid

  • -> mammogram + excision 

thin greenish fluid

  • -> if mass disappears -> f/u with US in 4-6 weeks
  • -> if mass persists -> mammogram + excision

47

management of ASCUS or LSIL in patients <25

management of ASCUS or LSIL in patients >25

Under 25

  • first repeat Pap smear at 12 months
    • if negative, or recurrent ASCUS/LSIL, repeat Pap in 12 months. If Pap negative two years in a row, then resume regular screening (3 year intervals)
    • if it becomes ASC-H, AGC, or HSIL, get colposcopy

Over 25

  • If ASCUS, get cytology + HPV testing

48

breast cancer screening recommendations

starting at age 50, get mammogram q2 years

genetic testing indicated if:

  • TWO 1st degree relatives 
  • THREE 1st or 2nd degree relatives
  • ONE 1st degree relative with breast AND ovarian cancer
  • ONE 1st degree relative with bilateral bresat cancer
  • Breast cancer in male relative
  • Ashkenazi Jewish women with any 1st or 2nd degree relative w/ breast or ovarian cancer

49

18F w/ history of irregular menstral periods p/w sudden onset of heavy vaginal bleeding

diagnoiss?

treatment?

dysfunctional uterine bleeding - usually due to anovulation, as there is no progesterone influence on the endometrium, so the unopposed estrogen causes endometrial growth that ultimately outgrows its blood supply resulting in irregular sloughing that may be significant (hemorrhage)

treatment: high dose steroids followed by progestin (combination pills)

50

management of lobular carcinoma in situ (LCIS)

excisional biopsy, as 38% of cases are upstaged to ductal carcinoma (DCIS) or invasive cancer when the entire lesion is removed

51

29F w/ suspected ectopic pregnancy has a TVUS that shows echogenic fluid consistent with blood in the posterior cul-de-sac, around adnexa, and in Morrison's pouch

next step?

surgery to ligate branches of the uterine and ovarian artery (supplying the fallopian tube)

posterior cul-de-sac (rectouterine space) is the most dependent part of the pelvis and is the primary place where the blood will accumulate.

Morrison's pouch is the hepatorenal space, and blood seen here on US suggests that there is >500cc of free blood present in the abdomen

52

management of septate uterus

Q image thumb

surgery/metroplasty - decreases the risk of future miscarriages 

53

management of CIN 1, 2, 3

CIN 2: observation  w/ cytology and colposcopy every 6 months for 1 year

CIN 3: ablation/excision of transformation zone

54

management of high grade squamous epithelial lesions on Pap smear

get colposcopy w/ biopsy

55

30F on OCP has an incidental finding of a well-demarcated hyperattenuated area that is 4cm in diameter in her liver. Diagnosis? Management?

hepatic adenoma

stop OCP

56

First line treatment for PMS/PMDD

Second line treatment

first line: SSRI

second line: SSRI