What sx categorize eclampsia as severe?
blood pressure of 160/110 mm Hg or above on two occasions, 6 hours apart.
proteinuria above 5 g/24 hr,
thrombocytopenia with a platelet count <100,000/mm3,
liver enzyme abnormalities,
epigastric or right upper quadrant pain,
alteration of mental status.
Effect of advanced emergency contraception on population
No study showed that giving advance EC reduced pregnancy rates on a population level.
However, women who were provided with advance EC took the pills an average of approximately 15 hours sooner than women without advance access.
initial screening test for late-onset male hypogonadism
serum total testosterone
NOT free b/c high cost - only do if total is borderline
LH and FSH used to distinguish primary from secondary
Can you use ibuprofen in pregnancy?
Ibuprofen can also be used but should be avoided late in pregnancy because it is associated with premature closure of the ductus arteriosus and oligohydramnios.
When do US in pregnancy?
Eval uncertain gestational age Size discrepancies Vaginal bleeding Multiple gestations High risk situations
When is X-ray radiation concerning to baby?
> 5 rads
Dental rad is ok.
When screen for downs?
16-18 wk best
Screening tests for abnormal chromosomes
Tx vaginal candidiasis
Happens when overgrowth of aneaerobic bacteria + G. vaginalis
Not an STD but assoc w/ multiple sexual partners
Dx w/ 3/4:
1) thin homogeneous vaginal d/x
2) vaginal pH > 4.5 (most sensitive)
3) + KOH whiff test
4) Presence of clue cells in wet mount prep (most specific)
Tx bacterial vaginosis
1 cause of acute vaginitis
Need to tx preggers as can dec incidence of preterm delivery
ceftriaxone IM injection
doxycycline or azithromycin
The most common pharmacologic cause of galactorrhea is
metoclopramide, cimetidine, risperidone, methyldopa, codeine, morphine, verapamil, SSRIs, butyrophenones, dopamine-receptor blockers, tricyclics, phenothiazines, and thioxanthenes
Which one of the following fetal ultrasound measurements gives the most accurate estimate of gestational age in the first trimester (up to 14 weeks)?
Crown-rump length is the distance from the top of the head to the bottom of the fetal spine.
It is most accurate as a measure of gestational age at 7-14 weeks.
In the second trimester, biparietal diameter and femur length are used.
During the third trimester, biparietal diameter, abdominal circumference, and femur length are best for estimating gestational age.
Late decelerations are thought to be associated with
uteroplacental insufficiency and fetal hypoxia due to decreased blood flow in the placenta.
This pattern is a warning sign and is associated with increasing fetal compromise, worsening fetal acidosis, fetal central nervous system depression, and/or direct myocardial hypoxia.
Early decelerations are thought to result from
vagus nerve response to fetal head compression, and are not associated with increased fetal mortality or morbidity.
Variable decelerations are thought to be due to
acute, intermittent compression of the umbilical cord between fetal parts and the contracting uterus
In the symptomatic patient with uterine fibroids unresponsive to medical therapy, myomectomy is recommended over fibroid embolization for patients who
wish to become pregnant in the future.
SSRI NOT safe in preggers
Contraindications to breast feeding
following administration or use of radioactive isotopes, chemotherapeutic agents, “recreational” drugs, or certain prescription drugs
herpes lesions on breast
American Congress of Obstetricians and Gynecologists (ACOG) recommends consideration of cesarean delivery without a trial of labor if
the estimated fetal weight is 4500 g in a mother with diabetes mellitus, or 5000 g in the absence of diabetes.
The best initial imaging study for acute pelvic pain in women is
The initial evaluation for chronic pelvic pain should include a urinalysis and culture, cervical swabs for gonorrhea and Chlamydia, a CBC, an erythrocyte sedimentation rate, a β-hCG level, and pelvic ultrasonography
Which male condoms protect against STDs?
not natural skin
Absolute contraindications for IUD
abnormal uterus shape
current/recurrent endometritis, STD, PID
1st line postpartum depression
safe for breastfeeding@
When do you take emergency contraception after unprotected sex?
Within 72 hrs of sex
Mifepristone is ok for > 72 hrs
Contraindications to breastfeeding
Active hep B
mastitis is OK
RIsk of pregnancy with each sex encounter?
How long postpartum should you wait before starting birth control? IUD?
BReastfeeding = 6 weeks
Not breastfeeding = 3 weeks
- ok to use IUD 6 weeks postpartum regardless of breastfeeding status
how long lactation induced amenorrhea provide natural contraception?
6 mo postpartum
how to screen for gonorrhea / chlamydia in sex active men?
Urine leukocyte esterase
POstpartum fever is sign of…
usually endometritis UTI wound infection DVT mastitis
What is the effect of oxytocin on uterus?
increases uterine contraction
Vitamin D in newborns
recommended daily intake of vitamin D in infants, children, and adolescents to 400 IU/day
exclusive formula feeding probably provides adequate levels of vitamin D, but infants who consume less than 1 liter of formula per day need supplementation with 400 IU of vitamin D daily.
Vitamin D supplementation should be started within the first 2 months of birth
Most sensitive for determining if lesion is herpes
Viral polymerase chain reaction (PCR) testing
Pt has urethral d/c and had tx for gonorrhea/chlamydia but still persists with urethral d/c and has not had new partner - what do you do for tx? What do you suspect?
Mycoplasma or Ureaplasma and Trichomonas from the urethra or urine.
Treatment should include
azithromycin or doxycycline
bilateral nipple pain with and between feedings after initial soreness has resolved is usually due to .
Masitits is usually unilateral
he best management of localized, well-differentiated prostate cancer in men older than 65 is: (check one)
A. radiation implants
B. external beam radiation therapy
C. watchful waiting
D. primary androgen deprivation therapy
E. robot-assisted prostatectomy
For men older than 65 years of age with small-volume, low-grade disease and a 10- to 15-year life expectancy, the risk of complications from treatment outweighs any decreased risk of dying from prostate cancer
1st line tx hirsutism
First-line agents for ovulation induction and treatment of infertility in patients with polycystic ovary syndrome (PCOS) include
metformin + clomiphene, alone or in combination,
What is the accepted standard for evaluation of the acutely swollen scrotum
ultrasonography with color Doppler imaging
What has been shown to reduce the cumulative incidence of atopic dermatitis in the first 2 years of life for infants at high risk of developing atopic disease
Exclusive breastfeeding for the first 4 months of life
The identification of a new breast solid mass particularly in women older than 35 years should prompt
triple assessment, which includes
a clinical breast examination,
pathology assessment either by core biopsy or surgical excision.
For women with unrelenting breast pain in spite of modifications, what can you give?
danazol, an antigonadotropin,
is relatively expensive and has numerous side effects (hair loss, acne, weight gain, and irregular menses).
treatment of choice in most patients with hyperprolactinemic disorders.
Bromocriptine for tx of hyperprolactin-induced anovulatory infertilit
Causes of hyperprolactinemia
hypothalamus secretes GnRH, which stimulates the anterior pituitary to secrete FSH and LH.
As the FSH level rises, it causes an ovarian follicle to mature and it to release estrogen which induces endometrial proliferation.
A mid-cycle LH surge causes ovulation, and the follicle is transformed into the corpus luteum that secretes progesterone, which compacts and matures the endometrium.
If pregnancy does not occur, the production of progesterone abruptly decreases, resulting in sloughing of the endometrium and a menstrual bleed.
AMENORRHEA: Absence of menstrual bleeding for 6 or more months when a woman is not pregnant.
MENOMETRORRHAGIA: Heavy menstrual flow or prolonged duration of flow occurring at irregular intervals.
MENORRHAGIA: Excessive menstrual flow, or prolonged duration of flow (>7 days), occurring at regular intervals.
METRORRHAGIA: Bleeding occurring at irregular intervals.
a scarring within the uterine cavity caused by trauma from uterine curettage. It can result in reduction in the size of the uterus as the walls become scarred to each other
Eval of dysfunctional uterine bleeding (Abnormal Bleeding Associated with Irregular Menstrual Cycles)
In the period after menarche, watchful waiting is usually indicated, with correction of the problem usually occurring within 1 to 2 years.
In women younger than 35 years who are not at increased risk of endometrial cancer, treatment may be offered without workup beyond the history and physical examination.
When do you need further eval of dysfunctional uterine bleeding (Abnormal Bleeding Associated with Irregular Menstrual Cycles)?
- women with risk factors for endometrial cancer,
- women younger than age 35 years with continued symptoms in spite of treatment,
- postmenopausal women with uterine bleeding.
Transvaginal pelvic ultrasound
- endometrial biopsy
Or can do..
Hysteroscopy (endoscopic evaluation of the uterine cavity) can directly visu- alize endometrial masses, polyps, or other abnormalities, and can lead to directed biopsy. It is often performed with dilation and curettage (D&C), which sharply removes almost the entire endometrial lining for diagnostic and therapeutic purposes.
Risk factors for endometrial cancer include
anovulatory menstrual cycles, obesity, nulliparity, age greater than 35 years, use of tamoxifen or unopposed exogenous estrogen.
smoking is a negative risk factor for endometrial cancer.
What are the initial tests for the evaluation of menstrual irregularities?
a pregnancy test,
Pregestational diabetes vs gestational diabetes impact on baby
- associated with greater fetal malformations due to the higher serum glucose levels during organogenesis (5-10 weeks gestational age)
- associated with hyperglycemia after 20 weeks gestation, when the fetal organs have already formed (macrosomia and polyhydramnios).
1st line for N/V in preggers
Doxylamine (Unisom) and vitamin B6
Elevated early morning total testosterone is most often associated with
polycystic ovary syndrome
PCOS is a clinical dx and US has low sensitivity
intrahepatic cholestasis of pregnancy. - tx?
Ursodiol has been shown to be highly effective in controlling the pruritus and decreased liver function
is safe for mother and fetus
Tx infertility in woman w/ PCOS
Metformin and clomiphene alone or in combination are first-line agents for ovulation induction.
Clomiphene does not improve hirsutism, metformin does.
Tx hypothyroidism in pregnancy
often need to increase thyroid hormone dosage
Abnormal uterine bleeding in < 30 yo..workup
patient who is younger than 30 years of age will rarely be found to have a structural uterine defect.
Once pregnancy, hematologic disease, and renal impairment are excluded,
administration of intramuscular or oral progesterone will usually produce definitive flow and control the bleeding.
No further evaluation should be necessary unless the bleeding recurs.
clinically manifested as vaginal bleeding in the late second or third trimester, often after sexual intercourse.
The bleeding is typically painless, unless labor or placental abruption occurs
Placenta previa can happen early on but migrate
- do not change delivery until after US @ 36 weeks
NO bleeding –> repeat the US in the 3rd trimester
DO NOT do digital cervical exam
Bleeding –> steroids @ 24-34 wks
In patients with a history of previous cesarean delivery who have a placenta previa at the site of the previous incision, a color-flow Doppler study should be performed to evaluate for a potential placenta accreta.
–In such cases, MRI may be helpful to confirm the diagnosis.
Tx gestational diabetes
In addition to an appropriate diet and exercise regimen, pharmacologic therapy should be initiated in pregnant women with gestational diabetes mellitus whose fasting plasma glucose levels remain above 100 mg/dL despite diet and exercise.
- fasting plasma glucose levels below 95 mg/dL
- 1-hour postprandial levels below 140 mg/dL r
Insulin is best pharm tx
- intermediate insulin + short acting insulin BID
Polycystic ovary syndrome usually results in what levels of LH vs FSH.
How does this compare to hypothalamic amenorrhea?
normal to slightly elevated LH levels and tonically low FSH levels.
Hypothalamic amenorrhea - tonically low levels of LH and FSH.
Tx hirsuitism in premenopausal women
Antiandrogens such as spironolactone, along with oral contraceptives, are recommended for treatment of hirsutism in premenopausal women
What med has considerable efficacy in treating obstructive symptoms in men, but it unfortunately falsely depresses PSA levels.?
Type 2 DM preggers woman on oral DM meds - what do you do when she is now pregnant?
all oral agents cross the placenta (in contrast to insulin), leading to the potential for severe neonatal hypoglycemia.
Need exquisitely tight glucose control to reduce fetal macrosomia and organ dysgenesis,
Down’s screening in preggers
- Chorionic villus sampling is best
The recommended time to screen for gestational diabetes is
24–28 weeks gestation.
The patient may be given a 50-g oral glucose load followed by a glucose determination 1 hour later.
What is the highest rate of cancer for pap smear results that are dysplasia?
atypical glandular cells not otherwise specified (AGC-NOS)
Prepubertal labial adhesions
Tx if there is enough labial fusion to interfere with urination
Tx w/ topical estrogen
What is a red flag varicocele?
Usually on L
- on R
- in a child < 10 years of age
- may indicate an abdominal or retroperitoneal mass
HIGH BP w/o proteinuria after 20 weeks’ gestation
BP return to nl within 12 weeks of delivery.
- new onset of hypertension (systolic pressure >140 mm Hg or diastolic pressure >90 mm Hg) after 20 weeks’ gestation
- along with 300 mg protein in a 24-hour urine specimen.
hemolysis, elevated liver enzymes, and low platelets
HELLP syndrome is a form of severe preeclampsia.
If the patient has a favorable cervical examination, labor induction with oxytocin is appropriate.
If the cervix is unfavorable, cesarean delivery should be considered to expedite delivery
Acute fatty liver of pregnancy
is another rare condition occurring in the third trimester and is usually associated with preeclampsia (50%–100% of cases).
It presents with nausea and vomiting, anorexia, jaundice, abdominal pain, headache, and neurologic abnormalities.
Transaminase levels are moderately elevated, PT and PTT are prolonged, and profound hypoglycemia and renal failure are usually present
Which one of the following agents used for tocolysis has the unique adverse effect of respiratory depression? (check one) A. Magnesium sulfate B. Ritodrine (Yutopar) C. Terbutaline (Brethine, Bricanyl) D. Indomethacin (Indocin) E. Nifedipine (Adalat, Procardia)
Magnesium sulfate infusions must be carefully monitored because respiratory depression is a potential lethal side effect. Reflexes are usually lost first.
Intrahepatic cholestasis of pregnancy
is rare, occurring in 0.01% of pregnancies. It usually presents in the third trimester.
Approximately 80% of patients present with pruritus alone, and another 20% with jaundice and pruritus.
Laboratory results usually reveal normal or minimal elevation in transaminase levels, elevated bilirubin (usually <5 mg/dL), and occasional elevations in cholesterol and triglyceride levels.
It is important to recognize and diagnose this entity, as it is associated with prematurity, fetal distress, and increased perinatal mortality.
Biochem marker to indicate preggers at high risk for impending preterm delivery
fetal fibronectin in cervical or vaginal secretions.
In symptomatic women, this is most accurate in predicting spontaneous preterm delivery within 7–10 days.
Inevitable abortion vs completed abortion vs. threatened abortion vs. incomplete abortion vs. missed abortion
- open os
- no passage of products of conception (POCs).
- closed os
- complete passage of POCs
- closed os
- no passage of POCs
- open os
- POCs in os or vaginal vault
- no sx
- no embryo or fetus on US
- when to replace?
- when contraindicated?
A weight change of more than 15 lb, pregnancy, or pelvic surgery may necessitate refitting.
Diaphragm use is contraindicated in women with a history of toxic shock syndrome.
The diaphragm should remain in place for 6–24 hours after intercourse
2nd and 3rd stages of birth?
2nd stage = period from complete cervical dilation to complete delivery of the baby.
3rd stage = begins with the delivery of the baby and ends with the delivery of the placenta
Abruption of the placenta is the most common cause of intrapartum fetal death but is associated not only with brisk vaginal bleeding, but also with uterine tenderness that may be marked.
Delayed or interrupted puberty is defined as
- develop any secondary sex characteristics by age 13,
- to have menarche by age 16,
- to have menarche 5 or more years after the onset of pubertal development.
Tx Patients with PID and tubo-ovarian abscess and high fever
should be hospitalized and treated for at least 24 hours with intravenous antibiotics.
cefoxitin IM outpatient + probenecid
Ceftriaxone outpatient, no probenecid needed
When do Group B strep screening in preggers? From where?
Cx from the vaginal introitus and the rectum are the most sensitive for detecting colonization.
35-37 weeks’ gestation.
Culture-positive women are then treated during labor.
Tx genital warts during preggers
Cryotherapy (liquid nitrogen)
How does oral contraceptives improve acne?
Raise sex hormone binding globulin –> decrease free testosterone
Tx premenstrual dysphoria
Fluoxetine (Prozac, Serafem) for the last 2 weeks of the menstrual cycle