OB-Gyn

Question 1

Options if pap smear reveals ASCUS?

Answer 1

1. Repeat pap in 4-6mo and 1yr (no HPV testing)
2. HPV testing
3. Colposcopy

• -> If HPV+ then get colposcopy
• ->If HPV- then repeat pap in 1yr

Question 2

What is colposcopy?

Answer 2

If pap smear was weird (ASCUS/HSIL+):

1. apply acetic acid to highlight areas of nuclear density
2. biopsy highlighted areas
3. follow with endocervical curettage

Question 3

Special consideration for ASCUS in post-menopausal woman

Answer 3

treat with vaginal estrogen, then repeat pap

Question 4

Benign breast nodules

Answer 4

Fibrocystic changes - small mobile and tender w/ cycle
Fibroadenomas - small mobile and non-tender
*Don’t get a mammogram in women <30yo

Question 5

What to do with a palpable breast mass

Answer 5

1. diagnostic mammogram
   
   • if neg, then image by U/S
   • if pos, radiologist to grade: benign vs needs bx
2. if not determined benign, then get sample:
   
   • aspirate if cystic appearing
   • biopsy if solid appearing
3. definitely biopsy if: still palpable after aspiration, or aspirate is bloody

*15% of brca can be mammographically silent

Question 6

Bi-RADS scale

Answer 6

0 = need more info
1 = negative
2 = benign
3 = probably benign (0-2% chance of malig)
4 = suspicious for malignancy (a-10/b-50/c-95)
5 = 95%+ it's malignant
6 = bx-proven malignant

Question 7

4 symptoms that point to acute bacterial cystitis

Answer 7

1. frequency
2. dysuria (acute onset)
3. hematuria
4. back pain
   In contrast - absence of dysuria and back pain r/o UTI

Question 8

How often do men get cystitis and/or pyelonephritis?

Answer 8

uncommonly - if they have urinary sx and are ill (and have a normal urinary tract) then think prostatitis

Question 9

What is the work-up for post-menopausal vaginal bleeding?

Answer 9

1. pelvic exam
2. r/o STIs and anatomic abnormalities
3. endometrial biopsy
   * don’t perform bx if pregnant, has PID or a bleeding diathesis

Question 10

Explain hormones of menstrual cycle.

Answer 10

Follicular Phase:
1. GnRH –> FSH (lots) and LH (small)
2. FSH –> follicle to produce estrogen
3. Low dose estrogen –I LH
Surge:
1. FSH builds and causes build of Estrogen
2. High dose estrogen –> LH
3. LH surge –> ovulation
Luteal Phase:
1. Corpus luteum –> progesterone, inhibin, and some estrogen
2. Inhibin –I FSH (stall before next follicle)
3. Progesterone –I GnRH (stall before next FSH/LH)
*Then when corpus luteum dies, progesterone withdrawal causes endometrial shedding

Question 11

What to do for heavy AUB?

Answer 11

1. High dose estrogen - to switch back to proliferative phase
2. OCPs with estrogen and progesterone
   - -> Surgery if needed

Question 12

Mnemonic for causes of AUB

Answer 12

PALM (structural) COIEN (functional)
P-polyps
A-adenomyosis
L-leiomyoma
M-malignancy
C-coagulopathy
O-ovarian dysfunction
E-endometrium
I-iatrogenic (IUD)
N-not otherwise classified

Question 13

Anti-depressant that’s ok for pregnancy

Answer 13

Fluoxetine

DON’T give paroxetine, lithium, BZDs

Question 14

Big side effects of vacuum assisted delivery

Answer 14

1. cephalohematoma
2. retinal hemorrhage
3. increased risk of shoulder dystocia
   BUT it has less maternal soft tissue trauma than forceps

Question 15

Work up and treatment of hyperemesis gravidarum

Answer 15

1. it’s N/V past first trimester, along with weight loss and ketonuria
2. r/o molar pregnancy with BhCG and U/S
3. evaluate lytes, LFTs, and amylase/lipase
4. treat with: B6, doxylamine, promethazine;
   +if dehydrated: IVF, nutrition, dymenhydrinate
   +if severe: reglan, zofran, prochlorperazine, promethazine

Question 16

Gestational diabetes

Answer 16

• dx by 1hr OGTT >140, then 3hr OGTT >140
• start with ADA diet, exercise, add insulin for tight glucose control, monitor baby regularly
• > 50% will go on to develop DM later

Question 17

Pregestational diabetes in pregnancy

Answer 17

pre-gestational = mother already had DM; may be found by hyperglycemia or glucosuria in 1st trimester

• insulin requirements may increase up to 3 fold
• monitor mom for DM complications
• strict glucose control
• close eye on fetus during later term and delivery; C/S if EFW>4500g

Question 18

Pre-E, E, and HELLP

Answer 18

Pre-E = HTN, proteinuria, edema
E = seizures
HELLP = Hemolytic anemia, elevated LFTs, Low Plt; this is a variant of Pre-E with poor prognosis; physio is vasospasm leading to hemorrhage and organ necrosis

Control BP with labetalol and/or hydralazine, prevent sz with Mg drip, treat sz with diazepam

Question 19

Complete vs. Incomplete Mole

Answer 19

Complete: sperm + empty egg = 46,XX; no fetal tissue

Incomplete: 2 sperm + normal egg = 69,XXY; contains fetal tissue

Question 20

Gestational trophoblastic disease

Answer 20

Benign = complete/incomplete moles
Malignant = molar pregnancy that progresses to GTD, meaning invasive mole or choriocarcinoma

Question 21

What to do for preterm labor

Answer 21

1. sterile spec to r/o PROM
2. U/S to evaluate baby
3. tocolytics (Mg, CCB, PGIs), steroids (beta or dex), and PCN/Amp for GBS ppx

Question 22

Risks of external version

Answer 22

cord compression or placental abruption; be prepared for C-section

Question 23

Triad of postpartum endometritis; treatment; and complication

Answer 23

1. fever >38 w/in 36hrs
2. uterine tenderness
3. malodorous lochia
   Tx: Clinda+Gent until AFx48hrs
   Watch out for septic pelvic thrombophlebitis (picket fence fevers; get CT pelvis; broad-spec abx and heparin x7-10d)

Question 24

How to diagnose Sheehan syndrome?

Answer 24

provocative hormonal testing and MRI brain to r/o pituitary tumor

Question 25

Hypergonadotropic hypogonadism

Answer 25

no secondary sex characteristics because gonads are not responding to the HIGH amounts of gonadotropic hormones (FSH/LH); check karyotype and/or work up for no ovaries

Question 26

Hypogonadotropic hypogonadism

Answer 26

no secondary sex characteristics because no gonadotropic hormones (FSH/LH); check all the other hormones that could be throwing these off, as well as chronic disease (CBC/LFT/ESR) and MRI for compressive pituitary tumor *If that's all negative then it's constitutional growth delay and just wait

Question 27

Work-up for Primary amenorrhea

Answer 27

Think about HPO Axis and Anatomy: +axis, +anatomy = anorexia, pregnancy, imperforate hymen +axis, - anatomy = Mullerian agenesis, AIS -axis, +anatomy = Kallman, Craniopharyngioma, Turner's

Question 28

How to differentiate Kallmans, Craniopharyngioma, and Turner's syndrome in w-u for 1˚ amenorrhea

Answer 28

- only Turner's will have super high FSH/LH, because it's a normal axis trying to talk to absent ovaries - Kallman and CP will have low FSH/LH because something is wrong with the central axis - MRI brain will show mass in CP, show nothing in Kallman's

Question 29

Work-up for secondary amenorrhea

Answer 29

1. Pregnancy - check UPT 2. Hypothyroidism - check TSH, FT4 3. High prolactin - check Prl level 4. Low DA - check meds list for antipsychotics 5. Another problem with the HPO axis - work backwards from the EM: progesterone challenge, E+P, FSH/LH, U/S ovaries, MRI brain; hypothalamus problem would be dx of exclusion

Question 30

When evaluating virilization: testosterone - think? DHEA-S - think?

Answer 30

testosterone - think ovaries; PCOS or Sertoli-Leydig cell tumor DHEA-S - think adrenals; CAH or adrenal tumor

Question 31

Buzz words for uterine rupture

Answer 31

- palpable irregular abdominal protuberance - loss of fetal station, "no fetal presenting part" or retraction of fetal part (pathognomonic) - late decels and loss of intrauterine pressure - mother will also have HOTN, vaginal bleeding, and sudden onset pain