OB/GYN Flashcards
(315 cards)
1
Q
Mammography recs
A
- start offering at 40, begin between 40-50
- anually or biennially
- continue until 75
- shared decision making after 75
In very high risk women (>20% or BRCA), annual MRI
2
Q
Pap smear recs
A
<21: only if HIV+ or otherwise immunocompromised
21-29: every 3 yrs w/ cytology alone
30-65: every 5 yrs cotesting w/ cytology and HPV testing OR every 3 yrs w/ cytology alone
> 65: stop if
- 3 consecutive negative cytology reports w/in previous 10 yrs - 2 consecutive negative cotesting reports w/in past 10 yrs
Do not perform in women w/ TAH (removal of cervix)
If h/o CIN 2 or 3, continue screening for 20 yrs past resolution, even if that extends past 65
3
Q
Colorectal cancer screening
A
Starting at 50 or 45 for African-American; stopping at 75
Options:
- colonoscopy every 10 yrs
- annual FOBT or FIT
- flex sig every 5 yrs
- CT colonography every 5 yrs
- fecal DNA every 3? yrs
4
Q
Most common STD
A
Chlamydia
5
Q
GC screening recs
A
Screen for gonorrhea and chlamydia in women <25 who are sexually active and >25 at high risk
6
Q
Syphilis screening recs
A
Screen annually for women at increased risk
Screen all pregnant women
Nontreponemal testing (e.g., VDRL, RPR) followed by confirmatory testing (treoponemal)
7
Q
Osteoporosis screening recs
A
DEXA starting at 65, or younger if RFs
8
Q
DM screening
A
Fasting blood glucose every 3 yrs starting at 45, earlier if RFs
9
Q
Thyroid disease screening
A
TSH every 5 yrs starting at 50
10
Q
Lipid screening
A
Every 5 years starting at 45
11
Q
Differentiation of the gonads
A
The genetic sex of the embryo is determined by the sec chromosome (X or Y) carried by the sperm that fertilizes the oocyte.
Y has SRY that encodes a protein called testis-determining factor. When present –> MALE sex characteristics
Ovary-determining gene is WNT4; when present in the absence of SRY –> FEMALE sex characteristics
Gonads become structurally differentiated by 7th week of development, and external genitalia become differentiated by 12th week
12
Q
Oocyte development
A
Primordial germ cells (3rd wk) migrate to gonadal ridges –> oogonia, which divide via mitosis during fetal life.
10th wk: undifferentited gonad –> ovary
16 wks: primary follicles
-oocyte development is arrested until puberty, when one or more follicles are stimulated to continue development each month
13
Q
Development of the genital ducts
A
Begin in undifferentiated stage with both mesonephric (Wolffian) and paramesonephric (Müllerian) ducts present
In the female, the mesonephric (Wolffian) ducts disappear. The paramesonephric (Müllerian) ducts persist to form major parts of the F reproductive tract (fallopian tubes, uterus, and upper portion of the vagina).
14
Q
Development of the external genitalia
A
Cloaca –> urogenital sinus (anterior) and anorectal canal (poasterior), separated by urorectal septum
Genital tubercle develops (5-8 wks) at cranial end of cloacal membrane, while labioscrotal swellings and urogenital folds appear on each side.
In the presence of estrogens and the absence of androgens, external genitalia are feminized.
Genital tubercle –> clitoris
Unfused urogenital folds –> labia minora
Labioscrotal swellings –> labia majora
At approx. 15 wks of gestation, transabdominal US can often distinguish btwn the two sexes.
15
Q
Obstetric conjugate
A
Narrowest fixed distance through which the fetal head must pass during a vaginal delivery.
Cannot be measured directly clinically.
Instead, estimate w/ the diagonal conjugate [distance bwtn the lower border of the pubis anteriorly to the lower sacrum at the level of the ischial spines]
16
Q
Major blood supply to vagina
A
Vaginal artery, a branch of the hypogastric artery (aka the internal iliac and parallel veins)
17
Q
Order of pelvic organs
A
Ant –> post
Bladder, uterus/vagina, rectum
18
Q
Ligaments
A
Broad ligament: overlies the structures and CT immediately adjacent to uterus (contains uterine arteries and veins and ureters).
Infundibulopelvic ligament: connects ovary to post. abdominal wall
Uterosacral ligament: connects uterus at level of cervix to sacrum [primary support of uterus]
Cardinal ligament: attached to the side of the uterus immediately inferior to uterine artery
Sacrospinous ligament: connects sacrum to iliac spine (NOT attached to uterus)
19
Q
Layers of the uterine wall
A
Endometrium (simple columnar)- changes during menstrual cycle
Myometrium (smooth muscle)
Serosa (CT)
20
Q
Changes to the heart during pregnancy
A
Anatomy [on CXR can be confused w/ cardiac pathology]
- heart displaced upward and to the left
- ventricular muscle mass increases
- LA and LV increase in size
Physiology
- marked increase in cardiac output (30-50%)
- first 1/2 of pregnancy d/t increased SV, second 1/2 d/t increased HR (and SV returns to normal or near normal levels)
- increased circulating blood volume
- decreased SVR (d/t progesterone and vasodilators–PGs, NO, ANP)
- in late pregnancy, CO may decrease d/t vena caval obstruction d/t gravid uterus
- BP gradually decreases from wks 7-24/6. BP then gradually returns to nonpregnant values.
Symptoms
-Inferior vena cava syndrome: dizziness, lightheadedness, syncope
Physical exam findings
- increased S2 split w/ inspiration
- distended neck veins
- low-grade systolic ejection murmur
- S3 is common
- diastolic murmur is NOT normal
21
Q
Changes to the respiratory system during pregnancy
A
Anatomy
- diaphragm is elevated
- subcostal angle widens as chest diameter and circumference increase slightly
Physiology
- increase in total body oxygen consumption (20%)
- reduction in RV (20%), FRC (20%), total lung volume (5%)
- increase in tidal volume (30-40%) d/t 5% increase in inspiratory capacity
- increase (30-40%) in minute ventilation
- progesterone increases central chemoreceptor sensitivity to CO2 –> increased ventilation –> RESPIRATORY ALKALOSIS
- respiratory alkalosis compensated by increased renal excretion of bicarbonate, so pH is NORMAL
Symptoms
- dyspnea of pregnancy [d/t low arterial pCO2]
- allergy-like symptoms or chronic colds
22
Q
Changes to the hematologic system during pregnancy
A
Anatomy
- marked increase in plasma volume (50% in singleton pregnancies), red cell volume (35%0, and coagulation factors
- require additional 1,000 mg of iron (rec: 60mg daily, which is 300mg supplement ferrous sulfate)
- WBC slightly increase
- clotting factors I (fibrinogen), fibrin split products, VII, VIII, IX, X increase [II, V, XII stay unchanged]
- protein C and S decrease
- Avg. Hgb 12.5 [Hgb <11 is usually IDA]
Physiology
- increase in total oxygen carrying capacity
- Bohr effect (L shift of O2 dissociation curve) d/t compensated respiratory alkalosis: Hgb affinity for O2 increases in maternal lungs, while CO2 gradient in placenta btwn mother and fetus is increased, facilitating transfer of CO2 from fetus to mother
- hypercoagulable state: risk of thromboembolism doubles (increases to 5.5x risk during puerperium)
Symptoms
-edema
23
Q
Changes to the renal system during pregnancy
A
Anatomy
-enlargement and dilation of the kidneys and urinary collecting systems
Physiology
- increased renal plasma flow (75%)
- increased GFR (50%) and resultant increased urinary excretion of solutes (glucose, amino acids, B12 and other water-soluble vitamins, but NOT sodium)
- increased urinary glucose excretion
- NO proteinuria [any proteinuria should be considered ABNORMAL]
- all components of RAAS increase (but normal pregnant women are resistant to the hypertensive effects, while hypertensive women and women w/ hypertensive dz of pregnancy are not)
Symptoms
- urinary frequency
- 20% experience stress urinary incontinence
- increased incidence of pyelonephritis in pts w/ asymptomatic bacteriuria
Labs
- decreased serum creatinine and BUN
- increased creatinine clearance
- glucosuria
- NO proteinuria
24
Q
Changes to the gastrointestinal system during pregnancy
A
Anatomy
- displacement of stomach and intestines
- portal vein enlarges
Physiology
- progesterone (generalized SM relaxation) –> decreased LES tone (GERD), decreased GI motility (increased stomach and small bowel transit time), impaired gallbladder contractility (gallstones and cholestasis)
- estrogen also leads to cholestasis and gallstones
- estrogen stimulates hepatic biosynthesis of fibrinogen, ceruloplasmin, and binding proteins for corticosteroids, sex steroids, thyroid hormones, and vitamin D
Symptoms
-nausea and vomiting of pregnancy (morning sickness)
[d/t PG, hCG, and relaxation of SM of stomach). Severe NVP is hyperemesis gravidarum (can cause weight loss, ketonemia, and electrolyte imbalance)
-dietary cravings, pica (ice, starch, clay)
-olfactory aversions
-ptyalism (excessive salivation) [probably more d/t inability to swallow normally produced saliva]
-GERD
-constipation
-generalized prurutis
Physical exam findings
- gingival disease (bleeding gums)
- hemorrhoids
Labs
- LFTs may be elevated
- alka phos doubled
- cholesterol increases
- increased total albumin but decreased serum (hemodilution)
25
Changes to the endocrine system during pregnancy
Thyroid
- EUTHYROID
- thyroid gland enlarges (but does not produce thyromegaly or goiter)
- hCG in first trimester stimulates T4 secretion and produces transient rise in free T4
- estrogen induces hepatic synthesis of TBG, resulting in an increase in total T4 and total T3 levels [levels of free T4 and T3 are unchanged]
Adrenal
- estrogen induces hepatic synthesis of cortisol-binding globulin --> elevated levels of serum sortisol
- increased free plasma cortisol
- increased corticotropin
- increased aldosterone
26
Metabolism in pregnancy
Carbohydrate metabolism
- diabetogenic effect: reduced tissue response to insulin, hyperinsulinemia, and hyperglycemia
- insulin resistance d/t hPL (increases w/ pregnancy)
- postprandial hyperglycemia and fasting hypoglycemia
Lipid metabolism
-increase in circulating concentration of all lipids, lipoproteins, and apolipoproteins
27
Pregnancy effects on musculoskeletal system, skin, reproductive tract, breasts, eyes
MS
- lumbar lordosis
- unsteady gait, increased fall risk
Skin
- spider angiomata and palmar erythema (d/t estrogen)
- striae gravidarum
- hyperpigmentation (d/t increased MSH)
- linea alba --> linea negra
- melasma ("mask of pregnancy")
- transient telogen hair loss
Reproductive tract
- vulvar varicosities
- leukorrhea of pregnancy
Breasts
- size increases
- breast/nipple tenderness
- colostrum discharge
Ophthalmic
-blurred vision
28
Fetal and placental physiology
Placenta
- energy source is GLUCOSE
- produces estrogen, progesterone, hCG, and hPL
Fetal circulation
- oxygenation of fetal blood occurs in the placenta (rather than the fetal lungs)
- oxygenated blood is carried from placenta to fetus via the umbilical vein
- umbilical vein then becomes the origin of the ductus venosus
- blood from the pulmonary artery primarily flows through the ductus arteriosus into the aorta
- most of RV CO is shunted through the ductus arteriosus to the descending aorta
- umbilical arteries carry deoxygenated blood to the placenta
Hemoglobin and oxygenation
- Fetal hemoglobin- two alpha chains and two gamma chains
- HgbF: at any O2 tension, HgbF has a higher O2 affinity and O2 saturation than HgbA
- d/t less avid binding of 2,3-DPG to HgbF
- Bohr effect: maternal respiratory alkalosis facilitates transfer of O2 from fetal circulation to maternal circulation --> loss of CO2 causes rise in fetal blood pH --> L shift in Hgb dissociation curve (increase O2 binding affinity)
Kidney
-fetal urine becomes primary source of amniotic fluid
Liver
- slow to mature
- routine neonatal administration of vitamin K prevents newborn hemorrhagic disorders
Thyroid gland
- levels of fetal T3, T4, and TBG increase throughout gestation
- only moderate amounts of T3 and T4 cross placenta
29
Immunology of pregnancy
IgG is the only Ig that crosses the placenta, so maternal IgG comprises a major proportion of fetal Ig both in utero and in early neonatal period [passive immunity]
Fetal lymphocyte production begins ~6wks
By 12 wks of gestation, IgG, IgM, IgD, and IgE are present and continue to increase
30
Folic acid
0.4 mg daily while attempting pregnancy and during first trimester
If previous pregnancy w/ NTD or medication that affects folate metabolism, 4 mg daily
31
Before pregnancy all women should be tested for
HIV
32
Quickening
Perception of fetal movement
16-18 wks of gestation, up to 20
33
When should urine pregnancy tests be performed?
Morning
Highest concentration of hGC
34
Urine vs. serum pregnancy tests
Serum pregnancy test is more specific and sensitive because they test for the unique beta subunit of hCG (urine measures alpha, which is shared with LH).
Mean doubling time for hCG in viable pregnancy is 1.5-2d
35
Estimation of gestational age by fundal height
Fundal height (cm) represents gestational age from the time it is present (~20 wks) until about 36 wks
36
Gestational age
Number of weeks from first day of LMP [NOT presumed time of conception] and date of delivery
37
Estimated date of delivery
Naegele rule
Add 7d to the first day of the last normal menstrual flow and subtract 3 mo
38
Normal pregnancy duration
40 +/- 2 wks, calculated from the first day of the LMP
39
Normal fetal HR
110-160 bpm
40
Leopold maneuvers
1. Determination of what is in the fundus
2. Evaluation of the fetal back and extremities
3. Palpation of the presenting part above the symphysis
4. Determination of the direction and degree of flexion of the head
41
Optimal timing for single ultrasound
18-22 wks
42
Gestational diabetes screening
24-28 wks unless RFs
50g, 1hr oral glucose challenge. If positive (> 130, 135, 140), require 3hr glucose tolerance test using 100g glucose.
43
Common symptoms of pregnancy
```
Headaches
Edema
Nausea and vomiting
Heartburn
Constipation
Fatigue
Leg cramps
Back pain
Round ligament pain
Varicose veins and hemorrhoids
Vaginal discharge
```
44
Braxton-Hicks contractions
False labor
Not associated with dilation of the cervix
45
Bloody show
Passage of blood-tinged mucus late in pregnancy
Results as the cervix begins thinning
46
Fetal station
0 is "engaged"
| +5 is head visible at the introitus
47
Stages of labor
1. Onset of labor to full cervical dilation (10 cm)
1. Latent phase: cervical effacement and early dilation
2. Active phase: more rapid cervical dilation (usually begins at 5-6 cm)
2. Complete cervical dilation to delivery of infant
3. Delivery of infant to delivery of placenta
4. Post-partum to 2hrs after delivery of placent
48
Cardinal movements of labor
1. Engagement
2. Flexion
3. Descent
4. Internal rotation
5. Extension
6. External rotation
7. Expulsion
49
Options for labor induction
1. Oxytocin
2. Cervical ripening (misoprostol, CI in previous C-section or uterine surgery; or laminaria to dilate cervix)
3. Membrane manipulation
50
C-section risk of maternal mortality
2-4x higher than vaginal birth
[1 per 2,500, from 1 per 5,000-10,000]
51
Apgar score
Color [blue or pale || acyanotic || completely pink]
HR [absent || <100 || >100]
Reflex activity response to stimulation [no response || grimace || cry or active withdrawal]
Muscle tone [limp || some flexion || active motion]
Respirations [absent || weak cry; hypoventilation || good, crying]
0-2 for each w/ total 10
1 min, 5 min, then every 5 until 20
52
Contraindications to breast feeding
HIV, TB, chemo, antimetabolites, radioactive materials
53
Major causes of postpartum hemorrhage and management
1. Uterine atony
- caused when uterus does not contract to constrict spiral arteries
- clinical diagnosis: boggy uterus on palpation (normal is firm and contracted)
- prevent: active management of third stage of labor
- oxytocin immediately after delivery of infant, gentle cord traction, uterine massage
- bimanual uterine massage alone is often successful
- uterotonic agents
- oxytocin
- methylergonovine
- misoprostol
- 15-methyl prostaglandin F2alpha
- surgical management
- surgical compression techniques
2. Lacerations of the lower genital tract
3. Retained placenta
4. Other
- hematomas
- coagulation defects
- amniotic fluid embolism
- uterine inversion
- uterine rupture
54
Uterotonic agents
- oxytocin
- methylergonovine [IM; avoid in pts w/ hypertensive d/os]
- misoprostol
- 15-methyl prostaglandin F2alpha [avoid in pts w/ cardiac, pulmonary, or renal disease]
- dinoprostone [rectal]
55
Types of twins based on timing of division of zygote
1. Dizygotic twins: two separate ova fertilized by two separate sperms
2. Monozygotic twins
- w/in 3d: diamniotic/dichorionic [each fetus surrounded by an amnion and a chorion; may be two separate or a fused placenta]
- 4-8d: diamnionic/monochorionic [each fetus surrounded by an amnion but a single chorion]
- 9-12d: monoamniotic/monochorionic [1%; twins share a common sac]
- >12: conjoined twins
Monoamniotic twins: steroids and C-section at 32-34 wks
56
Most significant cause of twin neonatal morbidity
Preterm labor and delivery
6x more likely to be preterm, 13x more likely to give birth before 32 wks
5x risk of stillbirth
7x increase risk of neonatal death
57
Average age of delivery for twins
35 weeks (cf 39 for singletons)
Triplets: 32 wks
Quadruplets: 30 wks
58
Twin-twin transfusion syndrome
Monochorionic
Various vascular anastamoses between the fetuses can develop --> net blood flow from one twin to another
Donor twin: impaired growth, anemia, hypovolemia, oligohydramnios
Recipient twin: hypervolemia, HTN, polycythemia, CHF, polyhydramnios
Treatment:
- serial removal of amniotic fluid from the sac of the recipient twin
- endoscopic intrauterine laser ablation of the vascular anastamoses
59
Intrauterine growth restriction (IUGR) definition
fetus or infant w/ weight <10th percentile
[Small for gestational age (SGA) is typically used wrt infant, and IUGR to fetus]
60
Causes of IUGR
Maternal infections, substance abuse, FASD, maternal smoking, antiepileptics (valproic acid), warfarin, chemo, altitude, vascular disease
- F>M
- chromosomal abnormality
abnormalities in placentation
61
Macrosomia definition
>4,000-4,500 g
62
Large for gestational age (LGA) definition
>90th percentile for weight
63
Causes of macrosomia
- h/o macrosomia
- obesity
- weight gain during pregnancy
- M>F
- pre-existing DM
- GDM
- TGs and FAs
- increased parity
64
Management of macrosomia
C-section should be offered >5,000g in women w/o DM, and 4,500g in women w/ DM
65
Preterm birth and labor
Birth <37 wks
Regular uterine contractions <37 wks, associated w/ cervical changes
66
RFs for preterm labor
- multifetal gestation
- prior preterm birth
- cervical surgery
67
Four processes that lead to preterm labor
1. activation of maternal or fetal HPA axis d/t maternal or fetal stress
2. decidual-chorioamniotic on systemic inflammation caused by infection
3. decidual hemorrhage
4. pathologic uterine distension
68
Management of preterm labor
1. tocolytics
- calcium channel blockers (nifedipine)
- NSAIDs
- beta-adrenergic receptor agonists
- magnesium sulfate
2. corticosteroids
- betamethasone
- dexamethasone
69
Magnesium sulfate
Actually ineffective for tocolysis, but appears to be neuroprotective for fetus, lowering risk of developing cerebral palsy.
70
Third trimester bleeding: painful vs painless
Painful: placental abruption
Painless: placenta previa
71
Placenta previa
Placental location close to or over the internal cervical os.
Classified as:
-complete: placenta completely covers the os
-partial: placenta overlies part of but not all of the os
-marginal previa: placental edge w/in 2cm of the os
-low-lying placenta: placenta extends into the lower uterine segment but is more than 2cm from the os
Increased risk of preterm birth and perinatal morbidity and mortality.
Symptoms: PAINLESS BLEEDING in the third trimester.
Dx: transvaginal US
RFs: prior placenta previa, prior C/S or other uterine surgery, multiparity, AMA, cocaine, smoking
Management:
- if stable, C/S delivery between 36 0/7 - 37 6/7 wks.
- if complications, may be indication for immediate delivery
- single course of steroids (betamethasone) if at risk of preterm birth in next 7d
Complications:
-placenta accreta: placental tissue extends into the superficial layer of the myometrium
-placenta increta: placental tissue extends further into the
myometrium
-placenta percreta: placental tissue extends completely through the myometrium to the serosa, and sometimes into the adjacent organs such as the bladder
72
Key symptom of placenta previa
PAINLESS BLEEDING in the third trimester
73
Placenta accreta
placental tissue extends into the superficial layer of the myometrium
74
Placenta increta
placental tissue extends further into the
| myometrium
75
Placenta percreta
placental tissue extends completely through the myometrium to the serosa, and sometimes into the adjacent organs such as the bladder
76
Placental abruption
Abnormal premature separation of an otherwise normally implanted placenta. Occurs when bleeding in the decidua basalis causes separation of the placenta and further bleeding.
Classified as:
-complete abruption: entire placenta separates
-partial abruption: part of the placenta separates from the uterine wall
-marginal abruption: separation is limited to the edge of the placenta
Symptoms: VAGINAL BLEEDING w/ ABDOMINAL (and/or BACK) PAIN
-can also have a "concealed hemorrhage" w/ painful uterine contractions, significant fetal HR abnormalities, and fetal demise in severe cases
RFs:
-chronic HTN, preeclampsia, multiple gestation, AMA, multiparity, smoking, cocaine, chorioamnionitis, trauma
Dx: clinical
Management:
- delivery for severe hemorrhage
- fluids
Complications:
- Couvelaire uterus: blood penetrates uterus to such an extent that the serosa becomes blue or purple in color.
- coagulopathy
- DIC
77
Most common cause of coagulopathy in pregnancy
Placental abruption
78
Vasa previa
Passage of fetal blood vessels over the internal os below the presenting part of the fetus.
Can occur w/ a VELAMENTOUS INSERTION, in which the fetal blood vessels insert into the membranes between the amnion and the chorion instead of into the placenta and are not protected by Wharton jelly, or when there is a succenturiate lobe across the os from the main placenta.
Can lead to rupture of a fetal vessel, which can quickly lead to fetal death.
79
Apt test
Distinguishes fetal blood from maternal blood.
Hemolyze blood by putting in water, centrifuged, mixed w/ NaOH
Fetal: pink
Maternal: yellow-brown
80
Uterine rupture
Most commonly occurs at site of previous C/S
81
Premature rupture of membranes (PROM) and preterm premature rupture of membranes (PPROM)
Rupture of the chorioamniotic membrane before the onset of labor.
Generally followed by the onset of labor.
PPROM: PROM that occurs before 37 wks of gestation
Neonatal risks: NRDS, intraventricular hemorrhage, neonatal infection, necrotizing enterocolitis, neurologic and neuromuscular dysfunction, sepsis.
Most significant maternal risk is intrauterine infection.
RFs:
- chorioamnionitis
- h/o PPROM, short cervical length, 2nd and 3rd trimester bleeding, low BMI, low SES, smoking, drugs
Dx: fluid passing through the vagina must be presumed to be amniotic fluid until proven otherwise
- nitrazine test: amniotic fluid is ALKALINE. (Positive is BLUE)
- fern test: amniotic fluid causes arborization
- US w/ transabdominal dye injection [rare]
```
Management:
Term PROM (> 37 wks)
-labor induction at time of presentation w/ oxytocin which decreases risk of chorioamnionitis and endometritis
-but with informed consent, patient's choice, so can also do expectant management (may decrease C/S risk)
-GBS prophylaxis if +, RFs, or no cultures done
```
PPROM (< 37 wks)
- if infection, treat w/ IV abx and deliver immediately
- delivery recommended at or beyond 34 wks
- if very early (<22 wks), potentially not viable; expectant management
82
When is colposcopy indicated?
Any abnormal Pap results, including ASCUS when HPV is positive (if negative, then co-testing w/ cytology and HPV can be repeated in 3 yrs)
83
ASCUS in women 21-24
Repeat cytology alone in 12 months
84
If ovarian mass in a postmenopausal woman
US and CA-125
85
SERMs
Tamoxifen: adjuvant treatment of breast cancer in high-risk patients
Raloxifene: postmenopausal osteoporosis
MoA:
- competitive inhibitor of estrogen binding
- mixed agonist/antagonist action
AEs:
- hot flashes
- venous thromboembolism
- tamoxifen: endometrial hyperplasia and carcinoma
86
Asymptomatic bacteriuria
>100,000 CFU of a species w/o symptoms
Increased risk in pregnancy d/t progesterone which causes SM relaxation and ureteral dilatation
Increases risk of:
- acute pyelonephritis
- preterm labor
- low birth weight
ALL women are screened at initial prenatal visit
Must treat: cephalexin, amoxicillin-clavulanate, nitrofurantoin
87
Most common cause of second stage of labor arrest
Fetal malpositioning
88
Pathognomonic for uterine rupture
Loss of fetal station (retraction of presenting fetal part)
89
SE of epidural anesthesia
Hypotension
d/t blood redistribution to the lower extremities and venous pooling from sympathetic blockade
90
Sertoli-Leydig cell tumors
TESTOSTERONE
```
Rapid-onset virilization
-voice deepening
-male pattern balding
-increased muscle mass
-clitoromegaly
Oligomenorrhea
Unilateral, solid adnexal mass
```
Also get signs of ESTROGEN DEFICIENCY since testosterone inhibits GnRH release
- breast and vulvovaginal atrophy
- dyspaneunia
- oligomenorrhea
91
Management of hydatidiform mole
At risk for gestational trophoblastic neoplasia
Suction curretage, followed by serial beta-hCG levels until they are undetectable for at least 6 months
Since pregnancy makes it difficult to determine the significance of a rising beta-hCG level, contraception is required in the surveillance period
92
HELLP syndrome
Hemolysis (MAHA), elevated liver enzymes, low platelets
Complication of preeclampsia
Pathogenesis involves hepatic and systemic inflammation, activation of the coagulation cascade, and platelet consumption
Tx: DELIVER FETUS
93
Androgen insensitivity syndrome
X-linked mutation in androgen receptor
- Phenotypically female but genotypically male (46,XY)
- breast development
- absent or miminal axillary and pubic hair
- female external genitalia
- absent uterus, cervix, and upper 1/3 of vagina
- primary amenorrhea
- cryptorchid testes
Management
- gender identity/assignment counseling
- gonadectomy (malignancy prevention)
94
Post-term pregnancy
>42 wks
95
Most common cause of post-term pregnancy
Inaccurate dating
96
Consequences of post-term pregnancy
Maternal vaginal trauma, labor dysfunction, C-section (infection, bleeding, thromboembolism, visceral injury)
Macrosomia, shoulder dystocia, meconium aspiration syndrome, dysmaturity syndrome, oligohydramnios
97
Three outcomes in the course of a tubal pregnancy
1. tubal abortion: expulsion of the pregnancy through the fimbriated end. Tissue can either regress or reimplant in abdominal cavity.
2. Tubal rupture: associated w/ significant hemorrhage
3. Spontaneous resolution
98
Risk factors for ectopic pregnancy
- inflammation resulting in tubal damage (salpingitis, PID, chlamydia, gonorrhea)
- tubal sterilization
- prior ectopic pregnancy
- smoking
- prior tubal surgery
- AMA
- DES exposure
- ART
99
Symptoms of ectopic pregnancy
Amenorrhea followed by vaginal bleeding and abdominal pain on the affected side
100
Diagnosis of ectopic pregnancy
beta-hCG levels not rising appropriately
transvaginal US: absence of an intrauterine pregnancy
101
Management of ectopic pregnancy
If unstable (acute abdomen from hemoperitoneum), need emergency surgical exploration
Medical:
-methotrexate
Surgical:
- linear salpingostomy
- segmental resection
- salpingectomy
Rh- mothers should receive RhoGAM
102
Heterotopic pregnancy
Normal pregnancy + ectopic pregnancy
| methotrexate contraindicated
103
Causes of miscairrages
Majority: chromosomal abnormalities
Rarer:
- infections (chlamydia, listeria)
- thyroid disease
- type I DM
- smoking
- antiphospholipid syndrome
- uterine leimoyomata
- luteal phase defect
- Asherman syndrome
104
Threatened abortion
Bleeding in the first trimester w/o loss of fluid or tissue
~50% proceed to spontaneous abortion
105
Miscairrage symptoms
Persistent bleeding and cramping
106
Inevitable abortion
Vaginal bleeding and/or the gross rupture of the membranes in the presence of cervical dilation.
Typically, uterine contractions begin promptly, resulting in expulsion of the pregnancy.
Trying to prolong the pregnancy increases the risk of maternal infection
107
Incomplete abortion
Internal cervical os opens and allows passage of blood and some tissue
108
Complete abortion
Documented pregnancy that spontaneously passes all of the contents of the uterus
109
Missed abortion
Retention of a failed intrauterine pregnancy for an extended period (2 menstrual cycles).
Absence of uterine growth and may have lost some of the early symptoms of pregnancy. Many have no symptoms except amenorrhea.
110
Medical (induced) abortion
- mifepristone (antiprogestin)
- methotrexate (antimetabolite)
- misoprostol (prostaglandin)
Most common: combined misoprostol-methotrexate
111
Which hormone induces insulin resistance?
Human placental lactogen (hPL)
112
Management of gestational diabetes
1. diet
2. meds
- combo of NPH insulin and insulin lispro (or regular) at meals
- glyburide sometimes used
113
Treatment of hyperthyroidism in pregnancy
PTU and then methimazole
Methimazole should be avoided in first trimester (causes aplasia cutis and choanal atresia)
114
Management of nausea and vomiting of pregnancy
Monotherapy: vitamin B6
Add doxylamine
Add promethazine
Diphenhydramine
115
Most effective screening test for Down syndrome
Cell-free DNA
116
Chronic hypertension
Hypertension that began before pregnancy or that begins before 20 wks of gestation and persists after delivery
117
Gestational hypertension
HTN that develops for the first time after 20 wks gestation, in the absence of proteinuria
50% develop preeclampsia
118
Preeclampsia
Hypertension w/ proteinuria that develops after 20 wks of gestation
Edema typically present
Criteria:
- BP >140 systolic or >90 diastolic that occurs after 20 wks of gestation in a woman w/ previously normal BP
- proteinuria [urinary excretion of >0.3g protein/24h]
Severe preeclampsia is defined by one or more of the following:
- BP >160 systolic or >110 diastoilc on at least 2 occasions at least 4hrs apart while the patient is on bed rest
- progressive renal insufficiency (Cr >1.1 or doubling of Cr)
- pulmonary edema
- epigastric or RUQ pain
- evidence of hepatic dysfunction (aminotransferases >2x normal)
- thrombocytopenia (<100,000)
Delivery when diagnosed at term and beyond. If <37 weeks and no severe features, may be managed expectantly at home or the hospital.
If with severe features, need more intense surveillance. Stabilization with magnesium sulfate, antihypertensives, and monitoring of mother and fetus. Steroids if <37 wks. Delivery by induction or C-section. Expectant management if stable.
119
Severe preeclampsia
Severe preeclampsia is defined by one or more of the following:
- BP >160 systolic or >110 diastoilc on at least 2 occasions at least 4hrs apart while the patient is on bed rest
- progressive renal insufficiency (Cr >1.1 or doubling of Cr)
- pulmonary edema
- epigastric or RUQ pain
- evidence of hepatic dysfunction (aminotransferases >2x normal)
- thrombocytopenia (<100,000)
Indication for delivery, regardless of gestational age or maturity.
120
Eclampsia
Presence of convulsions (tonic-clonic seizures) in a woman w/ preeclampsia that is not explained by a neurologic disorder
Can also occur 2-10d postpartum
121
Treatment of chronic hypertension in pregnancy
- Labetalol
- CCBs (nifedipine, amlodipine)
- (methyldopa)
ACE inhibitors are contraindicated d/t causing fetal malformations
122
Treatment of preeclampsia
Delivery when diagnosed at term and beyond. If <37 weeks and no severe features, may be managed expectantly at home or the hospital.
If with severe features, need more intense surveillance. Stabilization with magnesium sulfate, antihypertensives, and monitoring of mother and fetus. Steroids if <37 wks. Delivery by induction or C-section. Expectant management if stable.
123
Treatment of eclampsia
Magnesium
Delivery once mother is stabilized
124
Treatment of HELLP syndrome
Delivery (w/ steroids if pre-term)
Transfuse platelets if <20,000
125
Granulosa cell tumor
ESTRADIOL and INHIBIN
Complex ovarian mass
Juvenile type
-precocious puberty
Adult type
- breast tenderness
- abnormal uterine bleeding
- postmenopausal bleeding
Histopathology: Call-Exner bodies
126
Diagnosis and management of chorioamnionitis
Maternal fever + one or more:
- fetal tachycardia (>160)
- maternal leukocytosis
- purulent amniotic fluid
Management: broad-spectrum abx and delivery
127
PPROM definition
Rupture of membranes <37 wks in the absence of uterine contractions
128
Bloody nipple discharge
Intraductal papilloma
129
Chorioninc villous sampling vs amniocentesis
Both are DIAGNOSTIC tests for aneuploidy
CVS: 10-13 wks
Amnio: 15 wks
130
Fetal heart tracing decelerations
Early
- symmetric to contraction
- nadir of deceleration corresponds to peak of contraction
- gradual (>30 sec from onset to nadir)
- d/t FETAL HEAD COMPRESSION
- can be normal
Late
- delayed compared to contraction
- nadir of deceleration occurs after peak of contraction
- gradual (>30 sec from onset to nadir)
- d/t UTEROPLACENTAL INSUFFICIENCY
Variable
- can be but not necessarily associated with contractions
- abrupt (<30 sec from onset to nadir)
- decrease >15 min; duration >15 sec but <2 min
- d/t CORD COMPRESSION, OLIGOHYDRAMNIOS, or CORD PROLAPSE
131
Condylomata acuminata vs lata
Condylomata acuminata: anogenital warts d/t HPV 6 and 11. Pink or skin colored verrucous lesions.
Condylomata lata: caused by secondary syphilis. Raised, gray-white lesions on mucosal surfaces. Broader base w/ smooth surface.
132
PCOS patients are at increased risk of
- metabolic syndrome (DM, HTN)
- OSA
- NASH
- endometrial hyperplasia/cancer
133
Anemia of pregnancy
Hb <10
| Hct <30
134
Management of GBS positive mothers
Screen for GBS between 35 and 37 wks
All GBS+ women should receive antibiotic prophylaxis in labor or w/ ROM.
If unknown status, prophylaxis for:
- preterm labor (<37 wks)
- PPROM (<37 wks)
- ROM >18 hrs
- maternal fever during labor
135
Management of HIV in pregnancy
ART reduces perinatal transmission to 1-2%
Avoid amniocentesis and chorionic villus sampling
Planned C/S at 38 wks if viral load >1,000
BREASTFEEDING IS CONTRAINDICATED
136
When should patients get a cervical cerclage for cervical insufficiency?
14 wks
137
Which SSRI is contraindicated in pregnancy?
Paroxetine (Paxil)
Fetal cardiac malformations and persistent pulmonary hypertension
138
LARCs
- implantable hormonal contraceptives
- progestin: thickens cervical mucus and inhibits ovulation
- IUDs
- levonorgestrel: thickens cervical mucus, thins uterine lining
- copper: spermicide
- may be used as emergency contraception (interferes w/ implantation)
- injectable hormonal contraceptives (depor medroxyprogesterone acetate)
- IM or SQ every 3 mo
139
Side effects of IUDs
Hormonal:
-decrease in menstrual blood loss and severity of dysmenorrhea (lighter periods or amenorrhea)
Copper:
-heavier periods and dysmenorrhea
140
Depot injection side effect
Loss of bone mineral density (d/t duppression of estradiol production)
Careful w/ adolescents
Do not use for >2 yrs (FDA says this, but ACOG doesn't since effects are reversible)
141
Adenomyosis
Abnormal endometrial tissue (glands + stroma) w/in the uterine myometrium
Sx:
- dysmenorrhea
- heavy menstrual bleeding (may have anemia)
- chronic pelvic pain
- diffuse uterine enlargement (e.g., globular uterus)
- +/- uterine tenderness
PE: symmetrically enlarged uterus
Dx:
- clinical
- MRI+US: thickened endometrium
- confirmation via pathology
Tx: hysterectomy
142
Do OCPs cause weight gain?
No
143
Emergency contraception
are not abortefactants
- progestin-only minipill (up to 72h)
- ulipristal (up to 120h)
- copper IUD
144
Bacterial vaginosis
Polymicrobial infection including G. vaginalis
Musty/fishy vaginal odor.
+KOH "whiff" test
Clue cells
Tx: po or topical metronidazole and topical clindamycin
145
Most common symptoms of leiomyomata uteri (fibroids)
Pelvic PRESSURE d/t mass effect (and other mass symptoms: urinary frequency, constipation)
Irregular uterine contour (globular abdominal mass)
Submucosal: dysmenorrhea
-Intracavitary, submucosal, intramural: recurrent pregnancy loss
146
Trichomoniasis
itching, burning, discharge w/ rancid odor, dysuria, dyspareunia, postcoital bleeding, frothy thin yellow-green color, strawberry cervix
Tx: po metronidazole
147
Pelvic inflammatory disease
Most often caused by C. trachomatis and N. gonorrheae
ceftriaxone and azithromycin
148
Sheehan syndrome
Obstetric hemorrhage complicated by hypotension --> ischemic necrosis of pituitary gland
Clinical features
- lactation failure (decreased prolactin)
- amenorrhea, hot flashes, vaginal atrophy (decreased FSH and LH)
- fatigue, bradycardia (decreased TSH)
- anorexia, weight loss, hypotension (decreased ACTH)
- decreased lean body mass (decreased growth hormone)
149
Magnesium toxicity
Muscle weakness, loss of DTRs, nausea, respiratory depression. Cardiac arrest can occur if medication is not stopped.
Tx: stop mag and give calcium gluconate
150
Gestational sac at the upper outer corner of the uterine fundus
Interstitial/cornual ectopic pregnancy
151
When should patients get a cervical cerclage for cervical insufficiency?
14 wks
152
Which SSRI is contraindicated in pregnancy?
Paroxetine (Paxil)
Fetal cardiac malformations and persistent pulmonary hypertension
153
Vulvar lichen sclerosus
- most common in postmenopausal women, esp. w/ autoimmune diseases
- early: vulva thins, causing hypopigmented (white) areas and causing hypersensitivity leading to intense itching and burning (and associated w/ erosions and excoriations)
- late: chronic irritation and scratching transform thinned skin to thickened, white vulvar plaques (lichenification) [classic figure eight pattern]
- normal anatomic structures may be atrophied or obliterated: loss of labia minora and clitoral hood retraction
- dyspareunia, urinary symptoms, painful defecation
dx: vulvar punch biopsy
tx: superpotent topical corticosteroids (clobetasol)
154
PCOS diagnosis
- Androgen excess
- menstrual irregularities (oligo/anovulation)
- polycystic ovaries on US
- obesity
high testosterone and estrogen levels; LH/FSH imbalance
155
Genitourinary syndrome of menopause
Sx:
- vulvovaginal dryness, irritation, pruritis
- dyspareunia
- vaginal bleeding
- urinary incontinence, dysuria, recurrent UTIs
- pelvic pressure
PE:
- narrowed introitus
- pale mucosa w/ decreased elasticity and decreased rugae
- petechiae, fissures
- loss of labial volume
Tx:
- topical moisturizer and lubricant
- topical vaginal estrogen
156
Adenomyosis
Abnormal endometrial tissue w/in the uterine endometrium
Sx:
- dysmenorrhea
- heavy menstrual bleeding
- chronic pelvic pain
- diffuse uterine enlargement (e.g., globular uterus)
- +/- uterine tenderness
Dx:
- clinical
- MRI+US: thickened endometrium
- confirmation via pathology
Tx: hysterectomy
157
Primary ovarian insufficiency
<40 y.o.
Absence of developing follicles
Hypergonadotropic hypogonadism:
decreased estrogen --> increased LH and FSH
Signs and symptoms of estrogen deficiency, including amenorrhea
Chemotherapy is RF
158
Stress vs urge vs overflow incontinence physiology
Stress:
- decreased urethral sphincter tone
- urethral hypermobility
Urge:
-detrusor hyperactivity
Overflow:
- impaired detrusor contractility
- bladder outlet obstruction
159
Mature cystic teratoma (dermoid cyst) risk
Ovarian torsion
See intermittent, colicky pelvic pain often triggered by physical activity. Persistent torsion is an emergency.
Tx:
-cyst removal via laparoscopic ovarian cystectomy OR oophorectomy to reduce risk of torsion
160
Vesicovaginal fistula
Painless, continuous urinary leakage from vagina
PE: pooling of clear watery fluid in vagina
Cystitis may be a complication (UA may show infection)
RFs
- pelvic surgery
- pelvic irradiation
- prolonged labor/childbirth trauma
- GU malignancy
161
Active stage of labor protraction vs arrest
Protraction
- cervical change slower than expected
- +/- inadequate contractions
- OXYTOCIN
Arrest
-no cervical change for >4h w/ adequate contractions
OR
-no cervical change for >6h w/ inadequate contractions
-C-SECTION
162
Sheehan syndrome
Obstetric hemorrhage complicated by hypotension --> ischemic necrosis of pituitary gland
Clinical features
- lactation failure (decreased prolactin)
- amenorrhea, hot flashes, vaginal atrophy (decreased FSH and LH)
- fatigue, bradycardia (decreased TSH)
- anorexia, weight loss, hypotension (decreased ACTH)
- decreased lean body mass (decreased growth hormone)
163
Magnesium toxicity
Muscle weakness, loss of DTRs, nausea, respiratory depression. Cardiac arrest can occur if medication is not stopped.
Tx: stop mag and give calcium gluconate
164
Assess for cervical insufficiency
transvaginal US (measure cervical length) in 2nd trimester
165
Treat patients w/ short cervix at risk for preterm labor
vaginal progesterone
166
Patients on valproate who want to get pregnant should be switched to
Lamotrigine
167
Obesity and anovulation
- obesity causes insulin resistance and hyperglycemia, hich decreases the production of sex hormone-binding globlulin, causing elevated free androgen levels
- increased free androgens are aromatized in adipose tissue to estrone, which leads to persistently elevated estrone levels
Get anovulation and AUB
168
PCOS diagnosis
- Androgen excess
- menstrual irregularities (oligo/anovulation)
- polycystic ovaries on US
- obesity
high testosterone and estrogen levels; LH/FSH imbalance
169
Presentation of molar pregnancy
- heavy bleeding
- "snowstorm" appearance on US
- beta-hCG > 100,000
170
Diagnosis of appendicitis in pregnancy
US w/ graded compression
Diagnostic: noncompression and dilation of the appendix
171
Symmetric vs asymmetric fetal growth restriction
Symmetric: d/t congenital disorders of 1st trimester infections
Asymmetric: d/t placental dysfunction during 2nd and 3rd trimesters– uteroplacental insuffieciency (HTN, pregestational DM) or maternal malnutrition
172
mono-di vs di-di on US
monochorionic, diamniotic: T sign [one placenta]
| dichorionic, diamniotic: lambda sign [two placentas]
173
If have a nonreactive nonstress test
Since high false positives, and low PPV, can't rule in fetal acidemia, so need biophysical profile or contraction stress test
174
Choose biophysical profile vs contraction stress test for lack of fetal movement w/ nonreactive nonstress test
Contraction stress test is contraindicated when there are contraindications to labor:
- placenta previa
- prior myomectomy
175
How to determine postpartum dose of RhoGAM
Kleihauer-Betke test
176
Which type of US is used in ectopic pregnancy
TVUS
177
Delivery planning for nonviable fetus
Focus on MATERNAL wellbeing– vaginal delivery has fewest risks
No fetal monitoring
Palliative care if not stillborn
Conditions:
- anencephaly
- bilateral renal agenesis
- holoprosencephaly
- acardia
- thanatophoric dwarfism
- intrauterine fetal demise
178
Best test to determine fetal anemia
Doppler US- middle cerebral artery peak systolic velocity (higher = less viscous = anemic)
179
What to do if positive maternal Lewis antibodies
Reassurance– anti-Lewis IgM does NOT cross placenta and thus does not cause isosensitization or hemolytic disease of the fetus
180
Physiology of lactational amenorrhea
Prolactin inhibits GnRH release, preventing LH and FSH production --> no ovulation --> amenorrhea
181
Treat chlamydia infection
Azithromycin or doxycycline
182
Inflammatory breast carcinoma
Peau d'orange, edema, erythema, retracted nipple, axillary lymphadenopathy
Aggressive form of breast cancer, often metastatic at presentation
183
Presentation of molar pregnancy
- heavy bleeding
- "snowstorm" appearance on US
- beta-hCG > 100,000
184
Septic abortion
Retained products of conception from elective abortion w/ nonsterile technique or missed or incomplete abortion (rare)
Clinical
- fevers, chills, abdominal pain
- sanguinopurulent vaginal discharge
- boggy, tender uterus; dilated cervix
Pelvic US: retained POC, thick endometrial stripe
Tx:
- IV fluids
- broad spectrum abx
- suction curettage
185
Management of hemodynamically unstable miscarriage patients
suction curettage
186
Indications for external cephalic version
Breech at >37 wks
187
Treatment of chorioamnionitis
Broad-spectrum abx (ampicillin, gentamicin, clindamycin) and immediate delivery via augmentation of labor (to remove source of infection)
188
Treatment of CIN III
If nonpregnant and >25: cervical conization
189
How to determine postpartum dose of RhoGAM
Kleihauer-Betke test
190
Primary dysmenorrhea is due to
Excessive prostaglandin production
Treat w/ NSAIDs and OCPs
191
Best contraception for patients w/ breast cancer
Copper IUD
192
If preeclampsia <20 wks, think
hydatidiform mole
193
PMS/PMDD
Physical: bloating, fatigue, headaches, hot flashes, breast tenderness
Behavioral: anxiety, irritability, mood swings, decreased interest
Eval: symptom/menstrual diary
Tx: SSRIs
194
Müllerian agenesis
Abnormal development of uterus, cervix, and upper 1/3 of vagina
- primary amenorrhea
- normal female external genitalia
- blind vaginal pouch
- absent or rudimentary uterus
- bilateral functioning ovaries (normal FSH)
195
Klumpke palsy
C8-T1
196
Erb palsy
C5-C6
197
Management of placenta previa
C-section at 36-37 wks
198
Pregnancy management of patients w/ HSV
Antiviral suppression (acyclovir, valacyclovir) beginning at 36 wks
If lesions or prodromal symptoms during labor, C-section. Otherwise, vaginal delivery.
199
Fibroids vs adenomyosis PE
Fibroids: irregularly enlarged uterus
Adenomyosis: symmetrically enlarged uterus
200
Theca lutein cysts
Result from overstimulation of the ovaries d/t:
- gestational trophoblastic disease
- multifetal gestation
- infertility treatment
Multilocular, bilateral
Resolve w/ decreasing beta-hCG levels
201
Choriocarcinoma
A form of gestational trophoblastic neoplasia
Most commonly follows from a complete hydatidiform mole, but can also occur after normal gestation or spontaneous abortion
RF:
- AMA
- prior complete hydatidiform mole
Presentation
- amenorrhea or AUB
- pelvic pain/pressure
- symptoms from metastases (lung [chest pain, hemoptysis, dyspnea], vagina)
- uterine mass
- elevated beta-hCG level
Tx: chemo
202
Imperforate hymen presentation
Cyclic lower abdominal pain in the absence of apparent vaginal bleeding
Hematocolpos --> increasing pressure/pain on surrounding organs --> lower back pain, pelvic pressure, defecatory rectal pain
Bulging vaginal mass or membrane that swells with increased intraabdominal pressure
203
Treat anovulatory cycles in adolescents
Progesterone
Normalizes menstruation by stabilizing unregulated endometrial proliferation
204
If palpable breast mass >30
Mammography +/- US
205
If palpable breast mass <30
US +/- mammography
206
Postpartum thyroiditis
Autoimmune disorder characterized by a possible brief hyperthyroid phase, a self-limited hypothyroid phase, and an ultimate return to a euthyroid state
Associated w/ anti-thyroid peroxidase antibodies
(basically the same a painless/silent thyroiditis but postpartum)
207
PMS/PMDD
Physical: bloating, fatigue, headaches, hot flashes, breast tenderness
Behavioral: anxiety, irritability, mood swings, decreased interest
Eval: symptom/menstrual diary
Tx: SSRIs
208
Management of uterine inversion
- aggressive fluid replacement
- manual replacement of the uterus
- placental removal and uterotonic agents AFTER uterine replacement
209
Fetal complications of late and post-term delivery
- macrosomia
- dysmaturity syndrome
- oligohydramnios
- demise
210
Treatment of postpartum endometritis
Clindamycin and gentamycin
| for polymicrobial infection
211
Management of Bartholin gland cysts
Asymptomatic: observation and expectant management (most resolve on their own)
Symptomatic: incision and drainage followed by placement of a Word catheter to reduce risk of recurrence
212
Pregnancy management of patients w/ HSV
Antiviral suppression (acyclovir, valacyclovir) beginning at 36 wks
If lesions or prodromal symptoms during labor, C-section. Otherwise, vaginal delivery.
213
Luteomas of pregnancy
Solid, bilateral ovarian masses
Elevated levels of beta-hCG stimulate the luteoma to release androgens, which may cause MATERNAL VIRILIZATION
High risk of delivering female fetus w/ virilization
Expectant management– masses spontaneously regress after delivery
214
Elevated vs decreased maternal serum alpha-fetoprotein
Elevated
- open NTDs (anencephaly, open spina bifida)
- ventral wall defects (omphalocele, gastroschisis)
- multiple gestation
Decreased
-aneuploidies (trisomies 18 and 21)
215
Distinguish hyperemesis gravidarum from nausea and vomiting of pregnancy
Ketones on UA, lab abnormalities, and changes in volume status
216
Contraindications to vaginal delivery
- prior CLASSICAL c-section
- prior extensive uterine myomectomy
- placenta previa
217
GnRH, FSH, and estrogen in primary ovarian insufficiency
Elevated GnRH
Elevated FSH
Decreased estrogen
218
Symptoms of primary ovarian insufficiency
oligo/amenorrhea w/ symptoms of decreased estrogen (e.g., hot flashes, fatigue)
Often w/ h/o autoimmunity
219
Altered mental status, oculomotor dysfunction, and gait ataxia in pregnancy
Wernicke encephalopathy (d/t thiamine deficiency) from hyperemesis gravidarum
220
Metabolic consequences of hyperemesis gravidarum
- hypochloremic metabolic alkalosis
- hypokalemia
- hypoglycemia
- elevated serum aminotranferases
- Wernicke encephalopathy
221
H. ducreyi vs HSV
HD has ONE painful genital ulcer w/ gray-yellow exudate and tender, suppurative lymphadenopathy
222
Tubo-ovarian abscess
A complication of PID
Fever, abdominal pain, complex multiloculated adnexal mass w/ thick walls and internal debris
Elevated WBC, CRP, CA-125
223
ABO hemolytic disease
Infants w/ blood types A or B born to a mother w/ blood type O
MILD hemolytic disease (can even be asymptomatic)
- jaundice w/in 24h of birth
- anemia
- reticulocytosis
- hyperbilirubinemia
- positive Coombs test
Treatment: phototherapy
224
Fetal hydantoin syndrome
d/t maternal antiepileptic use (phenytoin, carbamazepine, valproate)
- cleft lip and palate
- wide anterior fontanelle
- distal phalange hypoplasia
- cardiac anomalies (e.g., pulmonary stenosis, aortic stenosis)
- NTD
- microcephaly
225
Reactive nonstress test
2+ accelerations in 20 min
226
Treat infertility in PCOS
Clomiphine citrate (blocks estrogen receptors at hypothalamus)
Weight loss should be tried first
227
Antibiotics for PPROM
Ampicillin and erythromycin
228
Intrahepatic cholestasis of pregnancy
Clinical
- develops in 3rd trimester
- generalized pruritis
- pruritis worse on hands and feet
- no associated rash
- RUQ pain
Labs
- elevated total bile acids
- elevated transaminases
- +/- elevated total and direct bilirubin
Risks
- intrauterine fetal demise
- preterm delivery
- meconium-stained amniotic fluid
- NRDS
Management
- delivery at 37 wks
- ursodeoxycholic acid
- antihistamines
229
Septic pelvic thrombophlebitis
A complication of pelvic surgery or the postpartum period
Thrombosis of the deep pelvic or ovarian veins that becomes infected
Presentation
- fever unresponsive to antibiotics
- no localizing signs/symptoms
- negative infectious evaluation
- diagnosis of exclusion
Tx
- anticoagulation
- broad-spectrum abx
230
Which uterotonic agent is contraindicated in hypertension?
Methylergonovine
231
Which uterotonic agent is contraindicated in asthma?
Prostaglandin-F2-alpha (Hemabate)
Potent smooth muscle constrictor, so has bronchoconstrictive effect
232
Paget disease of the breast
Associated with ADENOCARCINOMA
Persistent, eczematous, ulcerating mass localized to the nipple and areola
233
Non-classical congenital adrenal hyperplasia
d/t partial deficiency of 21-hydroxylase
- hyperandrogenism
- elevated 17-hydroxyprogesterone
234
When is there the most cervical mucus in the menstrual cycle?
Just prior to ovulation, corresponding with the LH surge
It is profuse, clear, and thin
235
Fetal risk of preeclampsis
Chronic uteroplacental insufficiency --> fetal growth restriction/low birth weight (SGA)
Oligohydramnios
236
What do sinusoidal fetal heart tracings indicate?
Severe fetal anemia
Category III tracing
Requires immediate C/S
237
Uterus w/ irregular enlargement
fibroids
238
When should rubella-nonimmune pregnant patients get MMR?
Immediately postpartum
239
Oxytocin toxicity
- hyponatremia (and consequent seizures) [oxytocin has similar structure to ADH]
- hypotension
- tachysystole
Management: hypertonic (3%) saline
240
Aromatase deficiency
Normal internal female genitalia, external virilization (i.e., clitoromegaly), undetectable serum estrogen levels
Androgens cannot be converted to estrogens
Transient masculinization of the mother
Birth: ambiguous genitalia
Adolescent: delayed puberty, osteoporosis, undetectable estrogen levels (e.g., no breast development), high concentrations of gonadotropins (resulting in polycystic ovaries)
241
McCune-Albright syndrome
Café au lait spots, polyostotic fibrous dysplasia, autonomous endocrine hyperfunction
Gonadotropic-independent precocious puberty
242
Placentla sulfatase deficiency is associated with
post-term pregnancy
243
Uterine tachysystole
>5 contractions in 10 min
244
Urge incontinence
Detrusor overactivity
245
Stress incontinence
Increased intra-abdominal pressure
| Urethral hypermobility
246
Overflow incontinence
Bladder outlet obstruction or neurologic deficit
247
Normal post-void residual
50-60 cc
248
Complete vs partial moles
Complete: no fetal parts
- empty egg + sperm [45XX or 46XY]
- chromosomes completely of PATERNAL origin
- more likely to undergo malignant transformation
Partial: fetal parts
-egg + 2 sperm [69XXX or 69XXY]
"hydropic chorionic villi"
249
Fetal bradycardia after AROM and next steps
Cord prolapse (umbilical cord protrudes through cervical os)
Next step is VAGINAL EXAM
- if cord is palpated distal to os, immediate C-section
- if no cord palpated, fetal scalp stimulation
250
Most effective permanent contraception
Vasectomy
251
If suspect post-partum PE
Heparin first while pursue diagnostic confirmation
252
Mastitis antibiotics
Dicloxacillin, cephalexin
253
If postmenopausal bleeding, next step is
Endometrial biopsy
Endometrial carcinoma until proven otherwise
254
Options for treatment of menopause symptoms like hot flashes
1. SSRIs
2. Combo progesterone-estrogen therapy
- increases CV mortality, so only used in refractory vasomoteur symptoms
- contraindicated if h/o breast cancer or VTE
255
Can patients on warfarin breastfeed?
Yes
256
Which class of drugs can lead to hyperbilirubinemia in the newborn?
Sulfonamides (e.g., TMP/SMX for UTIs)
Displace bilirubin from albumin
257
Triple screen suggestive of trisomy 21
MSAF: decreased
Estriol: decreased
Beta-hCG: increased
258
For asymptomatic bacteriuria, in addition to antibiotics, patients need
Monthly urine cultures
259
If suspect PID, need to rule out
1. Ectopic pregnancy by hCG
| 2. Tubo-ovarian abscess by US
260
Polyhydramnios
AFI >24 cm
or
Deepest pocket >8 cm
261
Why is smoking a RF for placenta previa?
Placenta doesn’t get enough oxygen so needs to expand for larger surface area
262
Which emergency contraception is effective up to 120h (5d) after unprotected intercourse?
Ulipristal and copper IUD
263
Contraindications to expectant management for preeclampsia
- thrombocytopenia (<100,000)
- uncontrolled BP on max doses of two antihypertensives
- non-reassuring fetal surveillance
- >2x elevated LFTs
- eclampsia
- persistent CNS symptoms
- oliguria
264
Pharmacological intervention to decrease risk of preterm labor (including PPROM)
17 alpha-hydroxyprogesterone
265
Types of miscarriages
Missed abortion:
- no vaginal bleeding
- CLOSED cervical os
- no fetal cardiac activity or empty sac
Threatened abortion:
- vaginal bleeding
- CLOSED cervical os
- fetal cardiac activity
Inevitable abortion:
- vaginal bleeding
- DILATED cervical os
- products of conception may be seen or felt above cervical os
Incomplete abortion:
- vaginal bleeding
- DILATED cervical os
- some products of conception expelled and some remain
Complete abortion:
- vaginal bleeding
- CLOSED cervical os
- products of conception completely expelled
266
Missed abortion
- no vaginal bleeding
- CLOSED cervical os
- no fetal cardiac activity or empty sac
267
Threatened abortion
- vaginal bleeding
- CLOSED cervical os
- fetal cardiac activity
268
Inevitable abortion
- vaginal bleeding
- DILATED cervical os
- products of conception may be seen or felt above cervical os
269
Incomplete abortion
- vaginal bleeding
- DILATED cervical os
- some products of conception expelled and some remain
270
Complete abortion
- vaginal bleeding
- CLOSED cervical os
- products of conception completely expelled
271
Confirm intrauterine fetal demise (stillbirth)
Absence of fetal cardiac activity on ULTRASOUND
272
If breast mass
IMAGING first
<30: US
>30: mammography
Then get biopsy if positive
273
Preterm labor <32 wks
- betamethasone
- tocolytics
- magnesium
- penicillin if GBS positive or unknown
274
Management of preterm labor depending on timing
<32 wks
- betamethasone
- tocolytics
- magnesium
- penicillin if GBS positive or unknown
32 0/7 to 33 6/7
- betamethasone
- tocolytics
- penicillin if GBS positive or unknown
34 0/7 to 36 6/7
- +/- betamethasone
- penicillin if GSB positive or unknown
275
Types of miscarriages
Missed abortion:
- no vaginal bleeding
- CLOSED cervical os
- no fetal cardiac activity or empty sac
Threatened abortion:
- vaginal bleeding
- CLOSED cervical os
- fetal cardiac activity
Inevitable abortion:
- vaginal bleeding
- DILATED cervical os
- products of conception may be seen or felt above cervical os
Incomplete abortion:
- vaginal bleeding
- DILATED cervical os
- some products of conception expelled and some remain
Complete abortion:
- vaginal bleeding
- CLOSED cervical os
- products of conception completely expelled
276
Missed abortion
- no vaginal bleeding
- CLOSED cervical os
- no fetal cardiac activity or empty sac
277
Threatened abortion
- vaginal bleeding
- CLOSED cervical os
- fetal cardiac activity
278
Inevitable abortion
- vaginal bleeding
- DILATED cervical os
- products of conception may be seen or felt above cervical os
279
Incomplete abortion
- vaginal bleeding
- DILATED cervical os
- some products of conception expelled and some remain
280
Complete abortion
- vaginal bleeding
- CLOSED cervical os
- products of conception completely expelled
281
Confirm intrauterine fetal demise (stillbirth)
Absence of fetal cardiac activity on ULTRASOUND
282
If breast mass
IMAGING first
<30: US
>30: mammography
Then get biopsy if positive
283
Preterm labor <32 wks
- betamethasone
- tocolytics
- magnesium
- penicillin if GBS positive or unknown
284
Management of preterm labor depending on timing
<32 wks
- betamethasone
- tocolytics
- magnesium
- penicillin if GBS positive or unknown
32 0/7 to 33 6/7
- betamethasone
- tocolytics
- penicillin if GBS positive or unknown
34 0/7 to 36 6/7
- +/- betamethasone
- penicillin if GSB positive or unknown
285
Cystitis vs pyelonephritis
Cystitis
- afebrile
- dysuria, frequency
- WBC in urine (pyuria)
Pyelonephritis
- fever and chills
- flank pain, CVA tenderness
- WBC in urine and WBC casts
286
Pyelonephritis treatment in pregnancy
INPATIENT IV antibiotics
| -ceftriaxone
287
5-alpha-reductase reductase deficiency
46,XX genotype
Impaired testosterone to DHT conversion
Impaired virilization during embryogenesis
Normal male testosterone and estrogen levels
Features
- male internal genitalia (e.g., testes, vas deferens)
- female external genitalia (blind-ended vagina)
- phenotypically female at birth
- virlization at puberty (increased testosterone)
- clitoromegaly
- increased muscle mass
- male-pattern hair development
- nodulocystic acne
288
If can't feel presenting part during labor
US for transverse lie
289
In intrauterine fetal growth restriction, how to determine risk of intrauterine fetal demise
Doppler US of umbilical artery
290
Post-exposure prophylaxis for neonates born to mothers w/ symptomatic varicella at delivery
Varicella-zoster immune globulin
291
Clue to incisional seroma
Fluid pocket on palpation
292
Idiopathic hirsutism caused by
Increased 5-alpha-reductase activity
293
If anemia in pregnancy is not responding to iron, next step is
Hemoglobin electrophoresis
Pregnancy can worsen anemia from thalassemias
294
Biggest RF for placenta previa
Prior C/S or other uterine surgeries
295
When to perform amnioinfusion
Variable decels after membrane rupture not relieved by mom in left lateral decubitus position
296
Galactocele
Nonerythematous fluctuant mass on breast.
No fever or breast erythema or warmth.
297
Test to confirm Rh status
Indirect antiglobulin (Coombs) test
K-B test is to determine DOSE, not status
298
Candida vaginitis RFs
- immunosuppression
- diabetes
- OCP
- antibiotics
299
Pap in HIV patients
Annually
300
Transverse lie during active labor
C/S
301
Estrogen, FSH, and LH in functional amenorrhea
LOW FSH and LH --> low estrogen
302
How many doses of steroids in PPROM?
If <32 wks, TWO doses of steroids 24h apart
Also give Mg and Abx
303
Normal vaginal pH
<4.5-5
304
pH in vulvovaginal candidiasis
Normal (<4.5-5)
305
pH in bacterial vaginosis
>4.5
Remember: decrease in lactic-ACID producing lactobacilli
306
pH in trichomoniasis
>5-6
307
Low-risk HPV
6, 11
308
High-risk HPV
16, 18
309
Normal amount of weight gain in pregnancy
25-35 lbs total
1st trimester: 3-5 lbs
2nd trimester: 0.5 lbs/wk
3rd trimester: 1 lb/wk
310
Positive first trimester screen
- increased nuchal thickness
- decreased PAPP-A
- significantly increased beta-hCG
Indication fro CVS (10-12 wks) or amniocentesis (15-18 wks)
311
Positive quad screen for Down syndrome
- increased hCG
- increased Inhibin A
- decreased AFP
- decreased estriol
312
Positive quad screen for Edwards syndrome
- low hCG
- low estriol
- variable AFP
313
Drugs that cause fetal hydantoin syndrome
Phenytoin and carbamazepine
314
Treatment of lichen sclerosus
Clobetasol (superpotent steroid)
315
How long does post-pill amenorrhea last?
3 mo
