OB GYN Flashcards Preview

OSCE > OB GYN > Flashcards

Flashcards in OB GYN Deck (157)
Loading flashcards...
1

Physiologically, what is responsible for dysmenorrhea?

Prostaglandin release from the endometrium

2

What contraceptive therapies can reduce dysmenorrhea? (3)

- Combined OCPs
- Intravaginal ring
- Progesterone implant
- Mirena IUD

3

What contraceptive therapies can reduce dysmenorrhea A/W ENDOMETRIOSIS? (4)

- Combined OCPs
- Progesterone implant
- Mirena IUD
- Depot provera

4

How long before combined OCPs control the (name this symptom) a/w menstrual irregularities?

Spotting
3-6 months

5

How effective (%) is the progesterone-only OCP for controlling menstrual irregularities?

50%

6

Besides OCPs, what are 2 other methods of controlling menstrual irregularities?

- Depot provera
- Mirena IUD

(but they both have initial irregular bleeding)

7

Can women on OCPs still have PMS sx?

Yes
- May benefit from a longer interval

8

What are some alternatives to surgery for menorrhagia?

- OCPs (reduce blood loss 40-50%)
- Mirena IUD, implanon (a/w initial bleeding, but good outcomes)
-

9

Which of the following is the best for treating menorrhagia?
- OCPs
- Endometrial ablation
- Mirena IUD

Mirena IUD

10

What are the 2 most cost-effective treatments for menorrhagia?

- Combined OCPs
- Mirena IUD

11

What is the only therapy proven to improve pre-menstrual dysphoric disorder?

OCPs containing Drospirenone

12

What therapy can also be helpful in suppressing menstruation, therefore limiting PMS?

Extended-cycle combined OCPs

13

What types of contraceptive therapies can reduce or eliminate migraines?

Extended cycle contraceptives (OCPs, depot-provera, patch)
- Due to fluctuation in hormones

14

For women who experience migraines w/ focal neurologic signs, smoke, or are > 35, what contraceptive therapies should they use?

Progesterone only, barrier, or IUD contraception

15

What contraceptives are effective in reducing hirsutism and acne?
- How?

*All combined oral contraceptives
- ^ SHBG, suppress LH-driven hormone production, thereby reducing free androgen levels

16

Although all combined contraceptives can reduce hirsutism and acne, how can this effect be enhanced?

Combined OCPs containing anti-androgen preparations (drospirenone, cyproterone acetate) were superior in some comparative trials
- Drospirone also reduces PMS sx in combined OC's

17

What is a possible explanation for why the patch and vaginal ring are less effective in controlling hirsutism and acne?

They bypass the first-pass effect of the liver and may be less effective as a result

18

How effective are progesterone-only preparations for treating acne?

Not effective

19

What contraceptive techniques can be used to treat endometrial cancer?

- Combined OCs (reduce risk 50%, short or long-term)
- Depot provera (similar reduction)
- Mirena IUD (can be used to treat hyperplasia w/o atypia, although regular surveillance is still essential)

20

What contraceptive form is effective for reducing the risk of ovarian cancer?

Combined OCs (reduce risk 27%)
- Length of use increases risk reduction

21

What contraceptive form is effective for reducing the risk of colorectal cancer?

Combined OCs (reduce risk 18%)

22

How do OCPs alter ovarian cysts?

They do not change regression

23

How can OCPs affect bone mass in premenopausal women?
Postmenopausal?

- Premenopausal: may decrease bone mass (take adequate calcium)
- Postmenopausal: may increase bone mass

24

Do OCPs reduce fx risk?

No good studies

25

How do depot provera and implanon affect bone mineral density?

May decrease, but resolves s/p discontinuation

26

How do OCPs affect leiomyoma size?
- Mirena?

Mixed results
- Mirena: no effect

27

Distinguish:
- Asx bacteruria
- Cystitis
- Acute pyelonephritis

o Asymptomatic bacteriuria – considerable bacteriuria in a pt w/o symptoms
o Cystitis – infection limited to the lower urinary tract (dysuria, frequency, urgency)
o Acute pyelonephritis – infection of the renal parenchyma usually w/ fever and flank pain

28

Define UTI "relapse".

Define UTI "reinfection".

Relapse – recurrent UTI w/ same organism after adequate therapy

Reinfection – recurrent UTI by same organism after intervening negative UCx, or recurrent UTI w/ different organism

29

More than __% of women will get a UTI in their lifetime.

50%

30

________ (organism) causes most UTIs.

E. coli
(has virulence factors that help it chill in bladder)

31

What are some UTI r/f's for school-aged girls?

- New onset sex
- Congenital abnormalities

32

What are some UTI r/f's for premenopausal women?

- History of UTIs
- Frequent sex
- Diaphragm use
- Frequent spermicide use
- Diabetes
- Obesity
- Renal stones
- Urinary retention (MS, paraplegia, etc.)

33

What are some UTI r/f's for postmenopausal women?

- Vaginal atrophy
- Urinary retention
- Poor hygiene
- Pelvic organ prolapse
- Type 1 diabetes
- History of UTI

34

Recall: sx of cystitis? (dx of UTI)

- Frequency
- Urgency
- Dysuria
- Suprapubic tenderness

35

If you see cystitis sx, what must you r/o?

- Urethritis from GC-chlamydia or HSV can be similar
- Pyelonephritis: fever and chills, flank pain, varying degrees of other sx

36

How could a UTI appear in an older woman?

Older women may be asymptomatic, have sepsis, urinary continence, or any other sx above (frequency, urgency, dysuria, suprapubic tenderness)

37

Diagnosis of significant bacteriuria is > ________ colonies, but ________ to _________ in a symptomatic woman may be acceptable.

100,000

1,000-10,000

38

If you see leukocyte esterase or nitrites on a UA, are you done with w/u for UTI dx?

Fast but false negatives happen so you should get a UCx and UA anyways

39

UTI abx resistance rates > __ to __ % necessitate a change in antibiotic class.

15-20%

40

List 5 tx regiments for uncomplicated acute bacterial cystitis, starting w/ the preferred tx.

- bactrim 1 tablet BID 3 days (preferred therapy)
- trimethoprim 100 mg BID 3 days
- cipro 250 mg BID 3 days
- Nitrofurantoin monohydrate 100 mg BID 7 days
- fosfomycin 3 g single dose

41

Is outpatient treatment ever okay for pyelonephritis?

Okay in stable patients who can take PO meds

42

Generally, how long is abx tx for cysitis vs. peylonephritis?

3 days (cystitis) vs. 14 days (pyelo)

43

What are some good antibiotic mgmt strategies for pyelonephritis?

IV or PO:
• Gram positive organism on stain – amoxicillin or ampicillin
• cipro (bactrim if resistance patterns are known and low)
• for septic pts, amp + gent, zosyn, fluoroquinolones, or 3rd gen
cephalosporins alone or in combination

44

Recurrent UTI occurs to __ to __% of women within 1 year of UTI.

25-50%

45

Women have a __ to __% change of frequent UTIs over "many years"

3-5%

46

Discuss how you'd treat recurrent UTIs.

- What if they have FREQUENT recurrence?
- What if they have a known post-coital risk?

- *Risk assessment and behavioral change are important
- Nl tx as above ok, w/ test of cure after 1-2 weeks
- For frequent recurrence: once daily tx for 6-12 months w/ reassessment after
- Women w/ known post-coital risk: post-coital prohylaxis w/ single dose of agents above is effective

47

Which UTI medication is less effective in post-menopausal women?

Fosfomycin (should not be used)

48

For pts w/recurrent UTIs, after they take their 3-day therapy, they should return if sx don't improve after how long?

48 hrs

49

In UTI, when is a UCx helpful?

UCx can be helpful in pt’s w/ persistent sx for 48 hrs on treatment or in recurrences

50

Is imaging useful during UTI tx?

Imaging not cost-effective or useful unless no response to therapy or clinical worsening on tx w/ other tests (UCx) already done

51

Which antibiotic can cause hemolytic anemia in G6PD deficiency?

Nitrofurantoin (so ask for OSCE)

52

Which of the following have been shown to be effective in reducing UTI recurrence?
Postcoital voiding, aggressive hydration, douching, yogurt to the vagina, and wiping techniques.

None

53

How is cranberry juice useful in the UTI world?

Cranberry juice/tablets are effective in reducing recurrences, but ideal dosing and duration not known

54

Are methenamine salts useful in preventing UTI recurrences?

No

55

Is estrogen tx useful in preventing UTIs in women?

Estrogen therapy may be beneficial in preventing recurrence in postmenopausal women, but more evidence is needed

56

Is screening and treating asymptomatic bateriuria in nonpregnant women recommended or supported by evidence?

No

57

What are some HPI questions to ask w/r/t vaginitis?

- Change in discharge
- Malodor, itching
- Irritation
- Dysuria
- Swelling
- Dyspareunia
- Location (vulva, vagina, anus)
- Duration
- Relation to menstrual cycle
- Sexual history
- Response to prior treatment including self-treatment and douching

58

If sx of vaginitis, samples should be taken for the following tests during speculum exam:

pH
Amine "whiff" test
Wet mount (saline)
(10%) KOH microscopy

59

In vaginitis pts, samples for pH should be taken from the _________________.

Mid-vaginal side wall

60

Dx of candidiasis requires 1/2 of the following:

(1) visualization of blastospores or pseudohyphae
(2) positive culture in a symptomatic woman

61

What differentiates uncomplicated from complicated vulvovaginal candidiasis?

Uncomplicated
- Sporadic or infrequent episodes
- Mild-mod sx or findings
- Suspected Candida albicans infxn
- Nonpregnant woman w/o medical complications

Complicated
- Recurrent episodes (4+ / yr)
- Severe sx or findings
- Suspected or proved non-albicans Candida infxn
- Women w/ DM, severe medical illness, immunosuppression, other vulvovaginal conditions
- Pregnancy

62

What are 2 routes that uncomplicated vaginal candidiasis can be treated?

Topically or orally

63

Can vaginal candidiasis in pregnancy be treated with topical, oral, both, or neither abx?

Topical only
(oral dose may be a/w birth defects)

64

Describe the tx regimen for uncomplicated candidiasis? How does it differ for complicated candidiasis?

Oral fluconazole 150 mg then 150 mg (+ another dose 3 days later for complicated candidiasis)

65

How long should RECURRENT vulvovaginal candidiasis be treated for? (give interval and med name)

Weekly fluconazole for 6 months

66

How is bacterial vaginosis dx'd?

Wet mount, culture, or POC rapid antigen test

67

Describe the 2 medication regimen options for trichomoniasis.

Describe the 2 medication regimen options for BV.

1) Metronidazole 2,000 x 1, 500 BID x 7
2) Tinidazole 2,000 x 1

1) Metronidazole
2) Clindamycin

68

In bacterial vaginosis, does partner need to be treated?

Yes

69

What should be avoided with metronidazole?
- For how long w/metro?
- For how long w/ tinidazole?

ETOH
- No alcohol for 24 hrs after metro
- No alcohol for 72 hrs after tinidazole

70

Name some organisms that can overgrown in BV.

- Gardernerella vaginalis
- Mycoplasma hominis
- Bacteroides
- Peptostreptococcus sp.
- Fusobacterium sp.
- Provatella sp.
- Atopobium vaginae
- Other anaerobes (due to lack of KOH-producing lactobacilli)

71

What are some adverse sequelae to BV infxn in pregnancy?

- PROM
- Pre-term labor
- Low birth weight

72

Does tx of BV during pregnancy prevent adverse outcomes?

No

73

How does pH change w/atrophic vaginitis?

What cells might you see on microscopy?

Elevated pH w/ parabasal or intermediate cells on microscopy

- Tx: E cream

74

In rare desquamative inflammatory vaginitis, what would you see on microscopy?
How is it treated?

- Lots of PMNs w/ parabasal cells
- Clindamycin cream for 14 days can help, but relapse is common

75

Here are some things to tell pts w/r/t vaginitis:

- Trich is an STD, but can carry for long periods of time, so doesn’t mean current
partner gave it to you
- BV and candida are not STD’s
- Douching is not a tx for and may exacerbate vaginitis
- Tampon use is not a/w vaginitis

76

Where are 97% of ectopics located?

Fallopian tune

77

What are some causes of ectopic pregnancy?

- Tubal surgery
- PID
- Previous ectopic pregnancy
- Exposure to DES in-utero

Other r/f's: infertility, use of reproductive tech, previous pelvic/abd surgery, smoking

78

What proportion of those with ectopic pregnancy have no r/f's?

1/2

79

Every reproductive aged woman w/ either of these 2 sx should be screened for pregnancy:

- Abd pain
- Vag bleed

80

When suspecting ectopic, what are 3 possible outcomes of transvaginal US?

- Intrauterine gestation
- Extrauterine gestation
- Non-diagnostic

81

During ectopic dx, if US is non-diagnostic, which is better for determining whether an intrauterine gestation should be visible, known gestational age or hCG?

known gestational age

82

At what hCG level (range) should an intrauterine gestation be able to be seen on US?

1,500-2,000 mIU/mL

83

If someone is using IVF, need to rule out _______________________ even if you see an intrauterine gestation.

heterotopic pregnancy

84

Serum PROGESTERONE < __ ng/mL signifies an abnormal pregnancy; > __ ng/mL is nl; __-__ is equivocal.

5
20
6-19

85

If hCG fails to increase by __% in 48 hrs, the pregnancy is abnormal.

53% (~50%)

86

What is the mechanism of methotrexate?

Inhibits dihydrofolate reductase, prevents synthesis of purines, serine and methionine.

87

Overall success in treating ectopic is __to__%

71-92% (don't memorize)

88

If hCG > ______ mIU/mL, MULTIPLE doses of methotrexate may be needed to treat ectopic pregnancy.

5,000

(or if gestational sac >3.5cm)

89

When is methotrexate contraindicated?

- Liver disease
- Kidney disease
- Bone marrow issues
- GI issues
(toxic to liver, cleared by kidney, effects rapidly dividing cells)

90

What are some dosing strategies for methotrexate? (not actual doses, but amounts of doses per tx)

Can use single dose, two dose, or fixed multi-dose (two dose is successful and well-
tolerated)

91

If surgery for ectopic fails, can you use methotrexate?

Yes, single dose (monitor serial hCG's)

92

After using methotrexate for ectopic pregnancy, how do you expect the serial hCG's to change?

May increase at first, then decrease (*by at least 15% from day 4 to day 7)
- If it doesn't, repeat dose or consider surgery

93

Discuss the side effects of methotrexate. (what 2 meds should be avoided?)

o Dose and duration dependent
o N/V, and stomatitis are most common (don’t use NSAIDs or alcohol)
o Abdominal pain 2-3 days post-tx

94

After ectopic tx, what's an additional risk that you should warn pts about?

Rupture

95

What is contraindicated s/p methotrexate tx?

Don’t use folate supplements, no NSAIDs, no alcohol, no sex or vigorous activities, avoid sunlight exposure

96

Does methotrexate use affect future offspring/pregnancies?

No

97

Who can get expectant mgmt for ectopic pregnancies?

Only stable pts who accept risk of rupture and hemorrhage

98

In pts w/ectopic pregnancy, pts w/ hCG below _____ have higher rates of spontaneous resolution.

200

99

Are the main determinants of bone mass genetic or environmental?

Genetic

100

Rank the following races in terms of fx rates:
mexican-americans, AAs, whites

whites > mexican-americans > AAs

101

Chinese Americans have (lower/higher) bone-mineral density than whites and (lower/higher) fx rates.

lower
lower

(but in geneal, fx rates correlate w/BMD)

102

Peak bone mass achieved by age __ in females.

19

103

What is the preferred method for diagnosing osteoporosis?

Dual-energy X-ray absorptiometry (DXA) scan of the lumbar spine and hip

104

What is T-score and what is the threshold for dx of osteoporosis?

BMD of pt is compared to cohort of young, healthy females; T-score of less than -2.5
establishes the diagnosis

105

When is the fx risk assessment (FRAX) tool useful? (2)

Women over 40 w/ DXA scores between
-1 and -2.5

(may be helpful to decide when to initiate tx)

106

List 6 meds used for osteoporosis.

- Bisphosphonates
- Raloxifene
- Denosumab
- Calcitonin
- PTH
- Hormone therapy

107

Bisphosphonates: MoA?

Prevent resorption of bone by inhibiting osteoclast function

108

Bisphosphonates: adverse effects?

Muscle aches and pains, GI upset, esophageal ulcers

109

Review some other notable facts about bisphosphonates.

- Discontinuation can continue effects for years depending on the drug
- Zalendronate can’t be used in kidney dysfunction

110

What are 2 major conditions that raloxifene is used for?

SERM
Prevents osteoporosis (vertebral fracture) and invasive breast cancer

111

Raloxifene: adverse effects?

VTE, leg cramps, stroke
Women close to menopause may experience hot flashes

112

Is Raloxifene better for older or younger postmenopausal women?

Risk-benefit profile makes this drug better for younger post-menopausal pts

113

What is the MoA of denosumab and how is it administered?

- Anti-RANK-L antibody
- Administered sub-q every 6 months

114

What are some adverse effects of calcitonin?

Nausea, flushing

115

Is calcitonin more effective in older or younger postmenopausal women?

Not effective in women w/ early menopause; must be 5 years out to be treated

116

Review these facts about PTH (teriparatide)
- What a nice benefit/upside of this drug?

- Improves bone microarchitecture, geometry
- Effects disappear after discontinuation
- 1 subQ injection every 6 months (nice benefit)
- Tx duration limited to 2 years (osteosarcoma in rats)

117

Alcohol > __ units per day leads to dose dependent increase in fracture risk

3

118

How much Ca2+ should someone w/osteoporosis consume per day?

1,000 mg – 1,300 mg / day

119

How much vit D should someone w/osteoporosis consume per day?

Vit D intake should be 600-800 IU / day
o Upper limit is 4,000 IU / day

120

In treating osteoporosis, calcium supplementation may increase risk for ___________ and _____________.

CVD and renal stones

121

Does soy increase bone mineral density?

Not proven to

122

How old should a woman be before starting screening DXA scans?

65

123

What are some things that a pt w/osteoporosis should be counseled on?

- Weight-bearing exercise (reduce risk of falls and fractures)
- take appropriate amounts of Vit D and calcium
- stop smoking and avoid 2nd hand smoke
- reduce alcohol intake
- Adopt fall-prevention strategies

124

How long can bisphosphonates be used for?

5-10 years

125

How long can combined HRT be used to prevent osteoporosis?
Estrogen only?

Combined for 5 years (then ^ risk breast cancer)
Estrogen only for longer

126

List DXA screening interval for T score:
> -1.5 (towards 0)
-1.5 to -2.0
-2.0 to -2.5

! 15 yrs for T-score > -1.5
! 5 yrs for T-score < -1.5 and > -2.0
! 1 yr for T-score < -2.0 and > -2.5

127

1 in __ women aged 12+ have HSV-2 antibodies.

4

128

Are most genital herpes recurrences due to HSV-1 or HSV-2?

HSV-2

129

Is HSV-1 or 2 a/w genital herpes?

Both/either

130

True or false:
Shedding of HSV can occur w/o symptoms and can still spread disease.

True

131

What tests can be used to make the dx of HSV?

- Viral culture
- Antigen testing (doesn’t differentiate 1 vs 2)
- PCR
- AB testing (takes 2-12 wks to make AB's)

132

How long after infxn until you can see AB's vs. HSV?

22 days (can do ELISA)

133

True or false:
Can give prophylaxis after high risk HSV exposure.

True

134

Describe med tx's for HSV and what affects that can have.

Medications (acyclovir 400 TID then 400 BID, valacyclovir 1,000 BID then 1,000 daily, famcyclovir 250 TID then 250 BID) decrease shedding, symptoms, and lesions, but don’t affect long-term outcomes.
- Tx can be suppressive or episodic

135

How do you decide whether to do suppressive or episodic tx for HSV flairs?

Episodic works best for people w/ fewer episodes who take the meds when they feel an outbreak coming

136

Are herpes flairs more severe or milder than the initial outbreak?

Milder

137

In terms of pregnancy, is HSV transmission to fetus a risk? When?

Risk of transmission to a baby is low as long as infection is acquired before or during the
1st half of pregnancy
- Acquiring the virus late in pregnancy carries a 50% risk of transmission

138

Should ppl with HSV be counseled to tell their partner?

Yes
(vaccine in development)

139

If suspicious of ectopic pregnancy, what test should you order?

What if this test is inconclusive?

- Transvaginal US

- hCG (would see < 53% increase over 48 hrs)

(Progesterone may be helpful, as is abnl if less than 5, but in most ectopics it's 10-20, so not that useful)

140

Failure to detect a gestational sac by this many days (if EDC is known) is a sign of abnormal pregnancy?

24 days

141

What is the dose of MTX usually given?

50 mg/m^2 IM (give day 1, sometimes day 4 also, and check for 15% decrease hCG b/w days 4-7.

142

Which has better outcomes for the following in tx of ectopic pregnancy: MTX or salpingostomy:
- Tubal preservation
- Tubal patency
- Repeat ectopic pregnancy
- Future pregnancies

They are equal

143

Is topical antiviral therapy helpful for HSV genital infxns?

No, just PO

144

About what % of bone is lost in women w/in 3 years after menopause?

6-7%

145

Can osteoporosis be dx'd in a women in the absence of imaging?

Yes, clinically in women w/ hx of low-trauma fx in at-risk woman.

146

What labs should you order to find the cause of osteoporosis?

CBC
CMP
24 hr urinary calcium
25-hydroxy vit D level
TSH

147

More than __ drinks of ETOH / day is a/w a dose-dependent increased fx risk in women.

3

148

If awoman is < 65 but is post-menopausal already or has high fx risk (skinny, alcoholic, smoker, RA...), what is the first thing to do?

FRAX
- If fx risk > 9.3%, refer for DXA

149

If someone has T score < -2.5 on DXA, do you need to do FRAX?

No, just treat

150

How do you generally treat osteoporosis medically?
- What if they're younger and have breast cancer fam hx?

First line: bisphosphonates
- If younger, consider starting w/ raloxifene and transitioning to bisphosphonates later

151

Name 3 not uncommon 2ndary causes of bone loss.

- Vit D insufficiency
- Idiopathic hypercalciuria
- Celiacl dz

152

Women who have a T score -1 to -2.5 (low bone mass) and a FRAX > __% for risk of hip fx or > __% for risk of major osteoporotic fx should be treated with medications.

3%
20%

153

First step in treating pyelo?

IV fluids
- Then UCx, Susceptibility testing. While waiting: empiric abx

154

Does the initial tx of symptomatic lower UTI w/ pyruria or bacteruria or both require UCx?

No

155

How is BV dx'd clinically?

3/4 Amsel's criteria:
- Abnl gray d/c
- pH > 4.5
- Positive amine (whiff) test
- >20% epithelial cells being clue cells

156

How can trichomoniasis be dx'd?

- Saline microscopy (motile trichomonads)
- *Trich cx (better)
- OSOM Trich Rapid test (POC)

157

Is self-dx of vaginitis reliable or unreliable?

Unreliable (seek clinical eval)