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Flashcards in OB/GYN UWorld Deck (436):
1

which contraceptive devices are contraindications in pts with breast cancer

hormone-containing methods of contraception should be avoided in pts with breast cancer,
as estrogen and progesterone may have a proliferative effect on breast tissue

esp concern hormone receptor-postivie breast cancer

2

what is the most effective non-hormonal contraceptive

copper IUD

3

what are absolute contraindications for combined hormonal contraceptives

migraine with aura
>=15 cigarettes/day PLUS age >35
HTN >160/100
heart disease
DM with end-organ damage
h/o thromboembolic disease
antiphospholipid-antibody syndrome
h/o stroke
breast cancer
cirrhosis and liver cancer
major surgery with prolonged immobilization
use <3 weeks postpartum

4

what are you required to do if a pt is HIV positive

report positive HIV tests to the local health department

the local health department usually contacts the pt's contacts (anonymously)

5

what is dx in pt with "3 D's":
dysmenorrhea, dyspareunia, and dyschezia

endometriosis

6

what is empiric tx for endometriosis

NSAIDs and/or combined oral contraceptives

OCPs are thought to reduce pain by ovulation suppression, which may result in atrophy of endometrial tissue

laparoscopy if treatment fails, adnexal mass, or acute symptoms

7

what is dx in female >20 weeks gestation with new-onset BP >140/90 + proteinuria and/or end-organ damage

preeclampsia

8

what are the 6 severe features of preeclampsia

systolic BP >160 or diastolic BP >110
(2x at least 4hrs apart)

thrombocytopenia

high Creatinine

high transaminases

pulmonary edema

visual or cerebral symptoms

9

how do you manage preeclampsia, depending on whether severe features are present

Magnesium sulfate (seizure prophylaxis)
Antihypertensives

w/o severe features: delivery at >=37 weeks

w/ severe features: delivery at >= 34 weeks

10

what are 6 risk factors for preeclampsia

multiple gestation
nulliparity
preexisting DM
advanced maternal age
CKD
prior preeclampsia

11

what are 3 treatment options for preeclampsia in a hypertensive crisis

IV labetalol (beta blocker w/ alpha-blocking activity)
--avoid in bradycardia

IV hydralazine (vasodilator)

oral Nifedipine (CCB)
--avoid with emesis

12

which drug prevents/treats eclamptic seizures

IV or IM Magnesium sulfate

13

what are 2 indications for oxytocin use

induction or augmentation of labor

prevention and management of postpartum hemorrhage

14

what are 3 adverse effects in excessive oxytocin administration

hyponatremia (water intoxication)
--can cause generalized tonic-clonic seizure

hypotension

tachysystole

15

what has a similar structure to oxytocin that explains some of its action

ADH

prolonged doses of oxytocin can cause water retention and hyponatremia

16

how do you treat acute hyponatremia / water intoxication

hypertonic saline (3% saline) to normalize the Na levels

17

what are nl Mg levels, how does magnesium toxicity present and what serum level does it become toxic

normal serum levels: 1.5-2
therapeutic levels for pregnancy seizure prevention: 5-8
toxic Mg: >8

toxicity presents:
hyporeflexia
lethargy
headache
respiratory failure
ultimately cardiac arrest
(no seizures)

18

run through the 5 portions of the biophysical profile during pregnancy; and their normal findings

1. Nonstress test:
--reactive fetal heart rate monitoring

2. Amniotic fluid volume
--single fluid pocket >2x1 cm or amniotic fluid index >5

3. Fetal movements
-- >= 3 general body movements

4. Fetal Tone
-- >= 1 episode of flexion/extension of fetal limbs or spine

5. Fetal breathing movements
-- >= 1 breathing episode for >= 30 seconds

0 - 2 for each; max score of 10
8-10 is normal
6 is equivocal
<= 4 is an indication for delivery to prevent intrauterine fetal demise (fetal hypoxia 2/2 placental insufficiency)

19

what are late and post-term pregnancies at risk for

41-42 weeks' gestation are at risk for
uteroplacental insufficiency

20

how long is the fetal sleep cycle, and how is it disrupted

fetal sleep cycle lasts for 20 minutes

usually disrupted by vibroacoustic stimulation

21

what is dx in pregnant F who presents with fetal tachycardia (>160), maternal fever, and uterine tenderness

intraamniotic infection
(chorioamnionitis)

22

what is dx in female with unilateral bloody nipple discharge w/o associated mass or Lymphadenopathy

intraductal papilloma

23

what is dx in female with well demarcated, round, firm, and mobile breast mass

fibroadenoma

24

what is dx in female with nipple discharge and mass / Lymphadenopathy

infiltrating ductal carcinoma

25

what does imaging show for infiltrating ductal carcinoa

a lesion with micro calcifications

26

what marks the second stage of labor

start:
when the cervix is dilated to 10cm

progression:
evaluated via fetal station, which measures the descent of the presenting part through the pelvis

ends:
fetal delivery

27

how is progression during the second stage of labor evalutated

by determining fetal station

28

what does fetal station measure

descent of the presenting part through the pelvis during the second stage of labor

29

what defines an arrested second stage

when there's no fetal descent after pushing:
> 3 hrs if nulliparous
> 2 hrs if multiparous

30

what is optimal fetal position during second stage labor

occiput anterior ("occipital" part of head is anterior)

it facilitates the cardinal movements of labor

31

what are breech presentation types x 5

frank:
butt going through pelvis; both feet up by head

incomplete:
butt going through pelvis; 1 foot up by head

complete:
butt going through pelvis; no feet up by head

single footing:
1 leg through pelvis

double footing:
both legs through pelvis

32

what is the most common cause of second-stage arrest

fetal malposition

33

what is dx in pt with thin, off-white discharge with fishy odor; no inflammation

bacterial vaginosis
(Gardnerella vaginalis)

34

what are lab findings in gardnerella vaginalis

pH >4.5
clue cells
positive whiff test

35

what is tx for bacterial vaginosis

metronidazole or clindamycin

36

what is dx in pt with thin, yellow-green, malodorous, frothy discharge with vaginal inflammation

trichomoniasis

37

what are lab findings in trichomoniasis

pH >4.5
motile trichomonads (pear-shaped)

38

what is tx for trichomoniasis

metronidazole for pt and sexual partner

39

what is dx in pt with thick, cottage-cheese discharge and vaginal inflammation

candida vaginitis

40

what are lab findings in vaginal candidiasis

normal pH (3.8 - 4.5)
pseudohyphae

41

what is tx for candida vaginitis

fluconazole

42

what is dx in pt with low FSH and estradiol

hypogonadotropic hypogonadism

43

what causes hypogonadotropic hypogonadism

excessive weight loss
strenuous exercise
chronic illness
eating disorder

44

what sequence of labs occurs in hypogonadotropic hypogonadism

decrease in amplitude and frequency of GnRH pulses secreted by the hypothalamus,
decreasing LH and FSH production,
which also reduces ovarian estrogen production

45

what are lab values in PCOS

FSH and estradiol levels are normal to increased

high LH/FSH ratio

insulin resistance

elevated testosterone

46

what are possible fetal complications of late-term and post-term pregnancy

oligohydramnios** (common)
meconium aspiration
stillbirth
macrosomia
convulsions

47

what are possible maternal complications of late-term and post-term pregnancy

Cesarean delivery
infection
postpartum hemorrhage
perineal trauma

48

why does oligohydramnios happen in late and post-term pregnancies

an aging placenta may have decreased fetal perfusion,
resulting in decreased renal perfusion,
and decreased urinary output from fetus

49

which trimester is the inactivated influenza vaccine safe during pregnancy

inactivated influenza vaccine is safe during every trimester,
and during breastfeeding

it should be given during the initial prenatal visit

50

which 3 routine prenatal lab tests should be done at the 24-28 week visit

Hemoglobin/Hct

Antibody screen if Rh(D) negative

50-g 1 hour Glucose challenge test (GCT)

51

which 1 routine prenatal lab test should be done at 35-37week visit

group B streptococcus culture

52

contrast symmetric vs asymmetric fetal growth restriction:
onset
etiology
clinical features

symmetric:
1st trimester onset
chromosome abnormality or congenital infection etiology
global growth lag

asymmetric:
2nd/3rd trimester onset
utero-placental insufficiency or maternal malnutrition etiology
"head sparing" growth lag

53

what is the definition of fetal growth restriction

ultrasound estimated fetal weight <10th percentile for gestational age

54

how do you manage fetal growth delay

weekly biophysical profiles

serial umbilical artery doppler sonography

serial growth ultrasounds

55

how can you treat atrophic vaginitis

topical vaginal estrogen therapy for moderate-severe cases

moisturizers and lubricants for mild cases

56

what signs and symptoms are indicative of menopause

symptoms:
vulvovaginal dryness, irritation, pruritus
dyspareunia
vaginal bleeding
urinary incontinence, recent UTI
pelvic pressure

PE:
narrowed introitus
pale mucosa, decreased elasticity and rugae
petechiae, fissures
loss of labial volume

57

what is dx in pt with vulvar white plaque formation, "cigarette paper" skin changes, and loss of normal anatomical markers (obliteration of clitoris or labia minora, figure of 8 appearance)

lichen sclerosis

58

how do you treat lichen sclerosis

high-potency corticosteroid ointment
--clobetasol

59

what is the recommended initial treatment for dyspareunia

vaginal oil-based lubricants

60

what is dx in pt with fever, lower abdominal pain, purulent cervical discharge, cervical motion and adnexal tenderness

PID

61

what are possibilities if PID is left untreated

infection can progress to tube-ovarian abscess
abscess rupture
perihepatitis
sepsis

62

what two organisms usually precede PID

Neisseria gonorrhoeae and Chlamydia trachomatis

63

what is management for PID, depending on severity

indications for hospitalization:
pregnancy
failed outpatient tx
inability to tolerate oral medications
noncompliant with therapy
severe presentation (high fever, vomiting)
complications (tube-ovarian abscess, perihepatitis)
(also adolescents w/ risk of non-compliance)

inpatient:
these pts will receive IV cefoxitin or cefotetan plus oral doxycycline

outpatient:
intramuscular ceftriaxone plus oral doxycycline

64

what is dx in pt with chronic pelvic pain > 6 months, dysmenorrhea, non cyclical pain that can be exacerbated by exercise, and adnexal mass

endometriosis

65

what is the finding of a homogenous cystic ovarian mass highly suggestive of

endometrioma in endometriosis

66

what is dx in pt with endometrial glands in the myometrium;
typically F >40 w/ secondary dysmenorrhea and menorrhagia; symmetrically enlarged uterine size

adenomyosis

67

what does epithelial ovarian carcinoma look like

septated mass with solid components

68

what would give an ultrasound appearance of calcifications and hyper echoic nodules

mature teratoma (dermoid cyst)

69

what appears on ultrasound as a complex, thick-walled mass with air-fluid levels

tubo-ovarin abscess

70

what refers to rupture of membranes at <37 weeks gestation prior to onset of labor

preterm premature rupture of membranes PPROM

71

what is dx in pregnant pt with increased leakage frequency, nitrazine-positive vaginal fluid, and decreased amniotic fluid index

preterm premature rupture of membranes PPROM

72

how do you manage PPROM 34-37 weeks

Antibiotics
+/- corticosteroids
delivery (and intrapartum Penicillin for Strep B coverage)

73

how do you manage PPROM <34 weeks

signs of infection or fetal compromise:
antibiotics
corticosteroids
Magnesium if <32 weeks
delivery

no signs:
antibiotics
corticosteroids
fetal surveillance

74

how do you treat recurrent variable decelerations due to umbilical compression during labor

amniotransfusion

75

which exercises are unsafe in pregnancy

contact sports (basketball, hockey, soccer)

high fall risk (skiing, gymnastics, horseback riding)

scuba diving

hot yoga

76

what exercise regimen is recommended in pregancy

20-30min of moderate-intensity exercise on most/all days is recommended

77

how do thyroid values change in the first trimester of pregnancy

total T4 increases

free T4 unchanged or mild increase

TSH decreased

78

what is the mechanism of changing thyroid values in first trimester pregnancy

beta-hCG stimulates thyroid hormone production in first trimester

estrogen stimulates TBG

thyroid increases hormone production to maintain steady free T4 levels

increased beta-hCG and thyroid hormone suppress TSH secretion
(hCG has structural similarity to TSH and can directly stimulate TSH receptors)

79

what is dx in pt with low total and free T3 with a normal T4 and TSH

euthyroid sick syndrome

alteration in biochemical thyroid function tests in the setting of severe non thyroid illness

80

what is dx in pt with increased total and free thyroid hormone levels
proptosis
diffuse goiter
HTN
tachycardia

graves disease

81

what is dx in pt with hyperthyroidism with suppressed TSH
following an acute viral illness
painful, tender goiter

subacute thyroiditis (granulomatous or De Quervain)

82

what is definition of spontaneous abortion

pregnancy loss <20 weeks

83

how do you manage a spontaneous abortion

expectant
medical induction (misoprostol)

suction curettage if infection or hemodynamic instability

84

what signs/symptoms should raise suspicion for spontaneous abortion

<20 weeks gestation
heavy vaginal bleeding
cramping
dilated cervix
ultrasound that shows nonviable fetus (no heartbeat)
intrauterine gestation in the lower uterine segment

85

why is oxytocin not effective in stimulating uterine contractions or expelling retained products of conception during first or second trimesters

there are few oxytocin receptors in the uterus during early pregnancy

86

what is next step once Lichen Sclerosis is identified

vulvar punch biopsy

LS is pre-malignant lesion for squamous cell carcinoma

87

what commonly treats genital warts

cryotherapy

88

what treats genital herpes

acyclovir

89

what is dx in pt with an enlarged, irregular, firm uterus
pregnancy difficulties
heavy, prolonged menses with clots
urinary frequency, constipation, pelvic pressure/pain (compressive symptoms)

uterine leiomyomas (fibroids)

90

what is the workup when a uterine fibroid is suspected on H&E

pelvic ultrasound

higher sensitivity than CT for both uterine and ovarian pathology

91

what is treatment for uterine fibroids

observation if no significant symptoms

hormonal contraception, embolization, or surgery if symptomatic (usually the large fibroids causing compressive symptoms)

92

what is the most common pelvic tumor in reproductive-age women

uterine leiomyoma / fibroid

93

what is the next step when there's clinical suspicion of endometrial hyperplasia or carcinoma

endometrial biopsy

94

what is dx in pt with cyclic lower abdominal pain in absence of menarche, with PE showing a blue bulging vaginal mass that swells with increased intraabdominal pressure (valsalva), and increasing pressure on surrounding pelvic organs (lower back pain, pelvic pressure, defecatory rectal pain)

imperforate hymen

95

what is treatment for imperforate hymen

incision of the hymen and drainage of the hematocolpos

96

what is dx in pt with amenorrhea and blind vaginal pouch

complete mullerian agenesis

97

what organs are missing in mullerian agenesis

uterus and cervix

98

what is dx in pt with pelvic pressure and vaginal bulge that increases with Valsalva, typically in postmenopausal Females

pelvic organ prolapse

99

what is dx in infant pt with polypoid or "grape like" mass protruding from the vagina with associated vaginal discharge and bleeding

sarcoma botryoides

100

when is a core biopsy indicated in a female pt <30yo

evidence of a complex cyst or complicated cyst (echogenic debris, thick septa, solid components)

or if mass recurs / does not disappear after aspiration

101

what are GnRH, FSH, and estrogen levels in:

hypothalamic hypogonadism:
low GnRH
low FSH
low estrogen

Primary ovarian insufficiency:
high GnRH
high FSH
low estrogen

PCOS:
high GnRH
normal FSH (LH/FSH ratio imbalance)
high estrogen

normal ovulation:
normal GnRH
normal FSH
normal estrogen

exogenous estrogen use:

102

what is the definition of primary ovarian insufficiency

cessation of ovarian function <40 yo

it's a form of hypergonadotropic hypogonadism

103

what is pathogenesis of Sheehan syndrome

heavy permpartum blood loss complicated by hypotension and/or blood transfusion

postpartum pituitary infarction

104

what is dx in pt recently postpartum with lactation failure, hypotension, weight loss, fatigue, and postpartum hemorrhage

Sheehan syndrome-
ischemic necrosis of pituitary

105

what is dx in pregnant pt with HTN, thrombocytopenia, and proteinuria

HELLP syndrome
hemolysis
elevated liver enzymes
low plt count

106

what is dx in pt with acute renal injury, thrombocytopenia, and microangiopathic hemolytic anemia frequently 2/2 Gastroenteritis

HUS

107

how does SLE with nephritis present in pregnancy

pre-eclampsia + SLE signs (malar rash, etc)

108

what are appropriate maternal cardiopulmonary adaptations to pregnancy and their clinical manifestations

cardiac:
--increase cardiac output (inc SV early; inc HR late)
--increase plasma vol
--decrease SVR

respiratory:
--increase TV
--decrease FRC (elevation of diaphragm)

clinical manifestations:
--peripheral edema (plasma vol expansion)
--low BP
--high HR
--systolic ejection murmur (inc CO)
--dyspnea

--nocturnal leg pain (lactic and pyruvic acid)

109

what is RhoGAM

anti-D immune globulin

110

when is anti-D immune globulin (RhoGAM) indicated

unsensitized, Rh- females at 28 weeks gestation
or within 72 hours of any procedure/incident in which there is any possibility of feto-maternal blood mixing (incl delivery, abortion, ectopic, mole, villus sampling, trauma)

111

what is dx in pregnant pt with:
low alpha-fetoprotein
low beta-hCG
low estriol
normal Inhibin A

Trisomy 18

112

what is dx in pregnant pt with:
low alpha-fetoprotein
high beta-hCG
low estriol
high Inhibin A

Trisomy 21

113

what is dx in pregnant pt with:
high alpha-fetoprotein
normal beta-hCG
normal estriol
normal Inhibin A

neural tube or abdominal wall defect

114

what are the 4 values included in quadruple screening

alpha-fetoprotein
beta-hCG
estriol
inhibin A

115

when is the quadruple screening test performed

second trimester 15-20 weeks

116

what is the next step after an abnormal quadruple screening

pts are offered cell-free fetal DNA testing

ultrasound

117

what is term for failure of primary neurulation

myelomeningocele

118

what is a paraumbilical bowel evisceration with no covering membrane

gastroischisis

119

what is a peritoneum-covered sac at the umbilicus

omphalocele

120

what is the most important direct role of hCG in pregnancy

maintenance of the corpus luteum

(maintain progesterone secretion until the placenta is able to produce progesterone on its own)

121

what is the timing of hCG levels during pregnancy

hCG production/secretion by the syncytiotrophoblast begins ~8 days after fertilization

hCG levels double every 48 hours until they peak at 6-8 weeks gestation

122

what is the structure of hCG

alpha subunit: common to hCG, TSH, LH, and FSH

beta subunit: unique to hCG, and is used as the basis of virtually pregnancy tests

123

what hormone inhibits uterine contractions

progesterone

124

which hormone is responsible for induction of prolactin production during pregnancy

estrogen

125

which hormone is responsible for preparing the endometrium for implantation of a fertilized ovum

progesterone

126

what is definition of preterm labor

regular contractions at <37 weeks gestation that cause cervical dilation and/or effaceent

127

which drugs postpone delivery

tocolytics:

indomethacin
nifedipine (CCB)

128

what drugs decrease risk of neonatal RDS in preterm delivery

corticosteroids (betamethasone)

129

which drug is administered <32 weeks gestation to lower the risk of neonatal neurological morbidities like cerebral palsy in pts who are expected to deliver within the next 24 horus

Magnesium sulfate

130

what does a positive fetal fibronectin test or a shortened cervix mean for pt

increased risk of preterm delivery

131

what is administered to pts with a h/o prior preterm delivery or a shortened cervix to prevent preterm delivery

progesterone

132

what is the medical management for preterm labor, depending on gestational age

<32 weeks:
betamethasone
tocolytics
magnesium sulfate
Penicillin if GBS positive or unknown

32 - 33 weeks:
betamethasone
tocolytics
Penicillin if GBS positive or unknown

34 - 36 weeks:
+/- betamethasone
Penicillin if GBS positive or unknown

133

what is dx in female pt with normal internal genitalia, external virilization, and undetectable serum estrogen levels

aromatase deficiency

unable to convert androgens to estrogens

134

what may happen to mother if fetus has aromatase deficiency

transient masculinization of the mother that resolves after delivery

(inability of placental to convert androgens to estrogens)

135

what happens to patients with aromatase deficiency in adolesence

delayed puberty
osteoporosis
undetectable estrogen levels (no breast development)
high concentrations of gonadotropins, resulting in polycystic ovaries

136

what is generic dx in female pt with ambiguous external genitalia, normal uterus and ovaries, and electrolyte abnormalities

congenital adrenal hyperplasia

137

what is dx in pt with hypogonadotropic hypogonadism with anosmia, delayed puberty, and low/absent LH/FSH

Kallman syndrome

X-linked

138

what is dx in pt with triad of:
cafe au lait spots
polycystic fibrous dysplasia
autonomous endocrine hyperfunction

McCune-Albright syndrome

139

what is the most common endocrine feature of McCune-Albright syndrome

precocious puberty

140

what is dx in pts with:
virilization
insulin resistance
low/normal LH and FSH
post-menopausal
ultrasound with solid-spearing, enlarged ovaries

ovarian hyperthecosis

141

what is the first-line management step in assessing a palpable breast mass in females >30yo

mammography

142

what is the "scenario" that puts one at risk for ABO incompatibility

infants with blood types A or B born to a mother with blood type O

143

what is the response when a type O mother is worried about ABO incompatibility

signs of hemolytic disease are typically mild and apparent only in ~1/3 infants

possible mild anemia at birth, may have jaundice

144

why can ABO incompatibility affect a first pregnancy

by the time a type O female becomes pregnant, she likely already has anti-A and anti-B IgG antibodies that can cross the placenta
--early A and B antigen exposure early in life from things like food, bacteria, and viruses

145

what is the next step if fetal movement decreases or becomes imperceptible by the mother

non-stress test NST

146

how is an NST test performed and what are possible results

record fetal HR while monitoring for spontaneous perceived fetal movements

reactive/normal if there are at least 2 accelerations of the fetal HR of at least 15 beats/min above baseline lasting at least 15 seconds each in 20 minutes

nonreactive/abnormal if <2 accelerations are noted in 20 min

147

what is the most common cause of a nonreactive NST and how is it managed

fetal sleep schedule

use vibroacoustic stimulation to awaken the fetus and allow a timely test

148

what is inheritance pattern for Hemophilia A

X linked recessive

149

what are the 2 etiologies of early decelerations of fetal HR

fetal head compression (stimulating vagal response which slows HR)

or can be normal fetal tracing

150

what are early deceleration findings

Nadir of deceleration corresponds to peak of contraction

gradual (>30 sec from onset to Nadir)

symmetric to contraction

151

what are late deceleration findings

Nadir of deceleration occurs after peak of contraction

gradual (>30 sec from onset to nadir)

delayed compared to contraction

152

what is the etiology of a late deceleration

uteroplacental insufficiency

153

what are variable deceleration findings

can be but not necessarily associated with contractions

abrupt (<30sec from onset to nadir)

decrease >15/min; duration >15 sec but <2 min

154

what are 3 etiologies of variable decelerations

cord compression

oligohydramnios

cord prolapse

155

which types o fetal HR decelerations are normal and which ones indicate fetal hypoxemia and acidosis

early decelerations do not indicate fetal distress

late and variable decelerations indicate risk for fetal hypoxemia and acidosis

156

at what beta-hCG level can a Transvaginal ultrasound be able to visualize an intrauterine pregnancy

hCG >1500

if hCG is lower than this, wait ~2 days, remeasure, and repeat TVUS
--hCG levels increase quickly

157

what is dx in pt with fever, firm, red, tender, swollen quadrant of 1 breast; +/- myalgia, chills, and malaise

mastitis

158

what is the most common cause of mastitis

staph aureus

159

how do you manage mastitis

continue breastfeeding
analgesics
Abx targeting staph aureus

160

what causes menopausal genitourinary syndrome

hypoestrogenism
--the bladder trigone, urethra, pelvic floor muscles, and endopelvic fascia possess estrogen receptors and are maintained by adequate estrogen levels
--hypoestrogenism results in atrophy of superficial and intermediate layers of the vagina and urethral mucosal epithelium
--diminished urethral closure pressure and loss of urethral compliance contribute to urgency, frequency, UTIs, and incontinence

161

what are 4 first-line treatment options in asymptomatic bacteriuria

cephalexin

amoxicillin-clavulanate

nitrofurantoin

fosfomycin

162

what is dx in pt with soft, mobile, well-circumscribed mass at base of labia majora; usually asymptomatic; <30 yo

bartholin duct cyst

163

what skin involvement results from infection by HPV 6 and 11

condylomata acuminata

exophytic or sessile growths that may be solitary or multiple but do not form cystic masses

164

what cyst results from incomplete regression of the Wolffian duct during fetal development

Gartner duct cyst

165

what cyst is described as single or multiple and are submucosal along the lateral (parallel) aspects of the upper anterior vagina; do not involve vulva

Gartner duct cyst

166

what presents as small, firm, painless bumps with central pits; usually asymptomatic or local itching

molluscum contagiosum

167

what presents with a chancre (round, painless ulcer)

primary syphillis

168

what is dx in pt with a raised and fleshy, often ulcerated, vulvar lump or mass; with long-standing vulvar pruritis

vulvar cancer
most are squamous cell carcinomas

169

how do you tx asymptomatic vs symptomatic Bartholin duct cyst

asymptomatic: observation

symptomatic: I&D, followed by placement of a Word catheter

170

what is dx in pt with prolonged menstruation, dysmenorrhea, miscarriages, and PE showing irregular uterine contour that may be palpable in the abdomen as a globular mass

uterine leiomyomata (fibroids)
--most common pelvic tumor in females

171

what is dx when pt presents with dysmenorrhea, menorrhagia, and soft, boggy, uniformly enlarged uterus

adenomyosis

172

what is inter menstrual spotting without uterine enlargement hallmark for

endometrial polyps

173

what is dx in pt with adnexal mass and nonspecific GI symptoms (early satiety, constipation/diarrhea, anorexia, bloating, increased abdominal girth)

ovarian cancer

174

what is hallmark dx in painful, itchy, eczematous, and/or ulcerating rash on nipple that spreads to areola

Paget disease of the breast

175

what do 85% of pts with mammary Paget disease have

underlying breast adenocarcinoma

176

what is dx in reproductive-age pt with acute lower abdominal pain, N/V, usually in setting of known adnexal mass

ovarian torison

177

what is gold standard for dx of ovarian torsion

pelvic ultrasound showing an ovarian mass with absent Doppler flow

178

what is the management of ovarian torsion

emergency laparoscopic detorsion and surgical restoration of anatomy with cystectomy

179

what is the most common etiology of intrauterine fetal demise

can be maternal, placental, or fetal, but etiology is most often unknown

180

what is most common cause of congenital adrenal hyperplasia

21-hydroxylase deficiency

181

what is dx in female pt with hyperandrogenism (hirsutism, acne), elevated 17-hydroxyprogesterone, +/- hyponatremia, menstrual irregularities in adolescence/adulthood

non classic congenital adrenal hyperplasia

182

what are normal renal changes during pregnancy and the mechanisms

increase GFR and renal size, decrease BUN and serum Cr
--increase cardiac output and RBF 2/2 progesterone, with increase in renal excretion

urinary frequency, nocturia
--high urine output and Na excretion

mild hyponatremia
--hormones reset threshold to increase ADH release from pituitary

183

what are normal heme changes during pregnancy and the mechanisms

dilutional anemia
--increased plasma volume and RBC mass

prothrombotic state
--hormone-mediated decrease in total protein S antigen activity; increase in fibrinogen and coagulation factors

184

what are normal CVS changes during pregnancy and the mechanisms

increase cardiac output and HR
--increase blood volume, decrease SVR

185

what are normal pulmonary changes during pregnancy and the mechanisms

chronic respiratory alkalosis with metabolic compensation
high PaO2 and low PaCO2
--progesterone directly stimulates central respiratory centers to increase Tidal Volume and minute ventilation

186

what's the strongest risk factor for a fragility fracture

prior history of a fragility fracture

187

what is dx in pt with presence of maternal fever and >= 1 of the following:
uterine tenderness
maternal or fetal tachy
malodorous amniotic fluid
purulent vaginal discharge

chorioamnionitis (intra-amniotic infection)

188

what is an important risk factor for chorioamnionitis

prolonged rupture of the membranes PROM

189

what is the most appropriate treatment of chorioamnionitis

prompt administration of broad-spectrum Abx followed by delivery to reduce the risk of life-threatening neonatal infection and maternal complications
--oxytocin accelerates labor

190

what is dx in pregnant pt with sudden onset abdominal pain, recession of the presenting part during active labor, and fetal heart rate abnormalities

uterine rupture

191

what is a major risk factor for uterine rupture

prior uterine surgery, such as a scar of prior cesarean delivery

192

what is loss of fetal station pathognomonic for

rupture

193

what is dx in pt with fever, abdominal pain, and complex multiloculated adnexal mass with thick walls and internal debris on ultrasound with h/o PID

tubo-ovarian abscess (TOA)

194

what is the abdominal pain in HELLP syndrome due to

liver swelling with distension of the hepatic (Glisson's) capsule

195

what is dx in pt with secondary amenorrhea, negative pregnancy test, normal prolactin and normal TSH

functional hypothalamic amenorrhea (hypoestrogenemia)

196

what does a challenge with medroxyprogesterone acetate do

it's a progestin challenge test that can confirm low estrogen levels

the presence of estrogen causes proliferation the endometrium, with
sloughing after the progesterone is withdrawn
--pts with low estrogen will have little/no bleeding after progesterone withdrawal as there is no endometrial lining to shed

197

what is a significant concern in pts with functional hypothalamic amenorrhea

decreased bone mineral density 2/2 estrogen deficiency

198

what is the immediate management of uterine inversion

replacement of uterus

if placenta is still attached, wait to remove it until the uterus is replaced to reduce risk of massive hemorrhage

199

what is first line imaging to assess fallopian tube patency

hysterosalpingogram

200

what is gold standard for evaluating risk of preterm delivery

transvaginal ultrasound measurement of cervical length

201

what hormone maintains uterine quiescence and protects amniotic membranes against premature rupture

progesterone

202

what is the only way to definitively diagnose endometriosis

laparoscopy with visualization and biopsy of endometrial implants

indicated after NSAIDs and hormonal contraceptives have failed

203

what is a major risk of endometriosis

infertility

cyclic accumulation of ectopic foci of hemorrhage and adhesions can distort pelvic anatomy and impair fertility by obstructing oocyte release or sperm entry

204

what are first 2 steps when ovarian malignancy is suspected

pelvic ultrasound and CA-125

205

what is dx in pt when uterine villi attach to the myometrium presenting w/ placental adherence and hemorrhage at time of attempted placental delivery

placenta accreta

206

what is dx in pt with ultrasound showing irregularity or absence of the placental-myometrial interface and intraplacental villous lakes

placenta accreta

207

what is dx in pt with premature detachment of placenta from uterus; presents w/ vaginal bleeding, sudden abdominal or back pain, tense distended uterus, and fetal HR abnormalities

placental abruption

208

what is dx in pt whose placenta implants over the internal cervical os

placenta previa

209

what is dx when uterus fails to contract after placental delivery

uterine atony

210

what is dx when fetal vessels traverse the amniotic membranes over the internal cervical os; presents w/ painless antepartum bleeding and fetal HR abnormalities just after the rupture of membranes

vasa previa

211

how do levothyroxine requirements change during pregnancy

increase

pts with hypothyroidism should increase their thyroid meds

212

why are thyroid hormone requirements increased during pregnancy

estrogen induces an increase in serum TBG levels, requiring an increase in the amount of thyroid hormone needed to saturate the binding sites

213

what are the vaccine indications for HPV

all females 11-26yo

males 9-21 yo (9-26 for those who have sex w/ men or have HIV)

214

when does pap testing begin

pap testing begins at age 21 in immunocompetent pts regardless of age of onset of sexual activity or number of sexual partners

215

what is dx in pt with proliferation of SM cells within the myometrium and irregular uterine enlargement

leiomyomata uteri (fibroids)

216

what is dx in pt with cyclic bleeding of ectopic endometrial glands; presents as pelvic pain, heavy bleeding (no anemia), or an irregularly enlarged uterus

endometriosis

217

what is dx in proliferation of endometrial glands inside the uterine myometrium; presents w/ bulky/boggy, tender uterus that is uniformly enlarged

adenomyosis

218

what is concern in postmenopausal females with bleeding and normal-sized uterus

endometrial hyperplasia w/ atypia, progressing to endometrial carcinoma

219

what is dx in pt with fever >24 hrs postpartum, uterine fundal tenderness, and purulent lochia

postpartum endometritis

220

what is treatment for postpartum endometritis

clindamycin and gentamycin

polymicrobial infection requiring broad-spectrum Abx

221

what are 3 liver disorders unique to pregnancy

intrahepatic cholestasis of pregnancy

HELLP

acute fatty liver of pregnancy

222

what is dx in pregnant pt with intense pruritus;
diagnosis of exclusion w/ labs:
high bile acids
high aminotransferases

intrahepatic cholestasis of pregnancy

223

what is dx in pregnant pt with malaise, RUQ pain, N/V, sequelae of liver failure; labs:
hypoglycemia
mildly elevated liver aminotransferases
elevated bilirubin
possible DIC

acute fatty liver of pregnancy

224

what is commonly prescribed in intrahepatic cholestasis of pregnancy for treatment, and its MOA

Ursodeoxycholic acid

increase bile acid flow and relieve itching

225

what are maternal and fetal risk factors for fetal macrosomia

maternal:
advanced age
DM
excessive weight gain during pregnancy, or pre-existing obesity
multiparity

fetal:
african american or Hispanic ethnicity
male
post-term pregnancy

226

what is the most common type of brachial plexus injury during delivery, and what does it involve

Erg-Duchenne palsy

involves 5th, 6th, and sometimes 7th cervical nerves

227

what is dx in pt with weakness of deltoid and infraspinatus muscles (C5), biceps (C6), and wrist/finger extensors (C7), leading to predominance of the opposing muscles

Erb-Duchenne palsy

"waiter's tip" posture

228

what is treatment for Erb Duchenne palsy

gentle massage and PT to prevent contractures

up to 80% pts have spontaneous recovery within 3 months; otherwise, surgical intervention is considered

229

what is next step when evaluating renal colic in pregnant pts

ultrasound of kidneys and pelvis

low-dose CT urography may be considered only in 2nd and 3rd trimesters

230

what is the HIV management protocol during pregnancy

antepartum:
--testing of HIV-1 viral load months until undetectable; then every 3 months
--CD4 cell count every 3 months
--Resistance testing if not previously performed
--Initiation or continuation of HAART
--Avoidance of amniocentesis if viral load is detectable

Intrapartum:
--avoidance of artificial ROM, fetal scalp electrode and operative delivery
--Viral load <1000 copies: continuation of HAART and vaginal delivery
--Viral load >1000 copies: Zidovudine and cesarean delivery

Postpartum:
--Mother: continuation of HAART
--Infant: Zidovudine for >6 weeks plus serial HIV testing

231

what is recommended in pts at >37 weeks gestation with breech presentation

offer external cephalic version

Cesarean delivery is necessary if ECV fails

vaginal delivery of a singleton breech fetus is generally contraindicated due to increased his for birth asphyxia and trauma

232

what is dx when fetal Doppler sonography fails to detect a fetal heart rate in pts with decreased or absent fetal movement >20 weeks

Intrauterine fetal demise

233

what is management when intrauterine fetal demise is suspected

absence of fetal cardiac activity on ultrasound is necessary to confirm diagnosis

234

what is gold standard method of diagnosing Cervical Intraepithelial Neoplasia (CIN)

colposcopy

235

what is the recommendation for CIN 3

cervical conization (excision of the intact transformation zone)

CIN 3 is premalignant with high risk of progressing to SCC

236

what are 3 potential complications of a cervical conization

cervical stenosis (scar tissue)
cervical impotence
preterm delivery

237

what is dx in pt with formation of intrauterine adhesions from infection or intrauterine surgical interventions (involving endometrium)

Asherman syndrome

238

what are the 2 methods of cervical conization

cold knife conization

loop electrosurgical excision procedure (LEEP)

239

what test is highly sensitive and specific screening for fetal aneuploidy, can be ordered at >=10 weeks gestation

plasma cell-free fetal DNA testing

240

how can you confirm abnormal cell-free fetal DNA testing

confirmed by chorionic villus sampling at 10-12 weeks or amniocentesis at 15-20 weeks

241

what is dx in pt with bilateral, symmetric fullness, tenderness and warmth of breasts 3-5 days after delivery

breast engorgement

242

what causes breast engorgement

colostrum is replaced by milk

243

what is dx in newborn with small body size, microcephaly, digital hypoplasia, nail hypoplasia, mid facial hypoplasia, hirsutism, cleft palate, and rib anomalies

fetal hydantoin syndrome

(exposure to anticonvulsant meds during fetal development)

244

what 2 medications commonly cause fetal hydantoin syndrome

anticonvulsants, most notably phenytoin and carbamazepine

245

what is dx in newborn with rhinitis, HSM, and skin lesions; later findings of interstitial keratitis, Hutchinson teeth, saddle nose, saber shins, deafness, and CNS involvement

congenital syphilis

246

what is dx in newborn with mid facial hypoplasia, microcephaly, and stunted growth; also CNS damage (hyperactivity, intellectual disability, learning disability) is typical

fetal alcohol syndrome

247

what are your 4 emergency contraception options, MOA, time after intercourse to use, and efficacy

copper IUD:
--copper causes inflammatory reaction that is toxic to sperm and ova; impairs implantation
--0-5 days
--99% efficacy

Ulipristal pill:
--antiprogestin; delays ovulation
--0-5 days
-->85% efficacy

Levonorgestrel pill:
--progestin; delays ovulation
--0-3 days
--85% efficacy

OCPs:
--Progestin; delays ovulation
--0-3 days
--75% efficacy

248

what is dx in non psychotic F who present with signs and symptoms of early pregnancy (amenorrhea, morning sickness, abdominal distension, breast enlargement) and belief that she is pregnant, but evaluation excludes pregnancy (neg pregnancy test and ultrasound)

Pseudocyesis

249

what is the management for pseudocyesis

pseudocyesis is a form of somatization, so management requires psych evaluation and tx

250

what is dx in pt with androgen excess, oligo- or an-ovulation, obesity, and polycystic ovaries

PCOS

251

what malignancy is associated with PCOS

endometrial hyperplasia/cancer

due to unregulated endometrial proliferation from unopposed estrogen stimulation

252

what is the treatment option for PCOS pt who wants to conceive

clomiphene citrate for ovulation induction

253

how do you treat treponema pallidum

penicillin

254

how do you screen and confirm syphilis

screen with either a nontreponemal test (VDRL) or a treponemal-specific test (fluorescent treponemal antibody absorption)

confirm with the other test type, as there's a high false positive rate

255

when should you screen for syphilis in a pregnant pt

first prenatal visit

256

how do you treat syphilis in pregnant pt w/ penicillin allergy

penicillin skin test to evaluate for the presence of an IgE-mediated response

positive test = pts are desensitized to penicillin prior to receiving treatment with intramuscular penicillin G benzathine

257

how do you manage chronic Hepatitis C in pregnancy

Hepatitis A and B vaccination with inactivated/killed vaccines

--Ribavirin is teratogenic and should be avoided
--no indication for barrier protection in serodiscordinant, monogamous couples

258

how do you prevent vertical transmission of Hepatitis C in pregnancy

vertical transmission strongly associated with maternal viral load

Cesarean delivery is not protective

scalp electrodes should be avoided

breastfeeding should be encouraged unless maternal blood is present (nipple injury)

259

how do you manage chronic hepatitis C in non-pregnant pts

combination of Interferon-alpha and Ribivirin

260

what does primary HTN increase the risk of in pregnancy for mom and fetus?

maternal:
--superimposed preeclampsia
--postpartum hemorrhage
--gestational diabetes
--abruptio placentae
--Cesarean delivery

fetal:
--fetal growth restriction/small for gestational age
--perinatal mortality
--preterm delivery (not PPROM)
--oligohydramnios

261

what is the initial management of blunt abdominal trauma (MVC) in pregnant pt (30 weeks)

aggressive fluid resuscitation and uterine displacement to optimize maternal circulation
--leave pt in LL decubitus position to displace uterus off aortocaval vessels to maximize CO

--BAT/MVC is a significant risk factor for severe hemorrhage from abrupt placenta

262

what is the first-line treatment and second best long-term outcome treatment for stress urinary incontinence

pelvic floor exercises are first-line

urethral sling surgery provides the best long-term outcome

263

what is stress incontinence due to

urethral hypermobility

264

how do you diagnose urethral hypermobility

place pt in dorsal lithotomy position
insert cotton swab into urethral orifice
>=30 degree angle from horizontal to increase intraabdominal pressure (coughing) signifies urethral hypermobility

265

what is treatment for urinary retention due to neurogenic bladder

intermittent self-catheterization

266

what are alpha-blockers and cholinergics helpful in treating for urinary symptoms

help with bladder contraction

alpha blockers: urgency incontinence associated w/ BPH

bethanechol: tx overflow incontinence due to diabetic neuropathy

267

what are antimuscarinics used for in urinary symptoms

treat urge incontinence
--sudden urge to urinate at any time

268

what is dx in pt with crampy lower abdomen and/or back during menses; normal examination

primary dysmenorrhea

269

how do you manage primary dysmenorrhea

NSAIDs and hormonal contraceptions for pain relief

270

which dx has pain that peaks before menses

endometriosis

271

what is the most accurate way to determine estimated gestational age (EGA)

ultrasound dating with fetal crown-rump measurement in the first trimester is most accurate
--accuracy varies from +/- 3 to 5 days between 7 - 14 weeks gestation
--EGA should not be changed based on measurement discrepancies on a 2nd/3rd trimester ultrasound; growth problems should be considered in this case

272

what are daughters of mothers who took Diethylstilbestrol (DES) at risk for

40-fold increase clear cell adenocarcinoma of vagina and cervix

structural anomalies of the reproductive tract (hooded cervix, T-shaped cervix, small uterine cavity, vaginal septae, vaginal adenosis)

pregnancy problems (ectopic pregnancy, pre-term delivery)

infertility

273

what is Diethylstilbestrol (DES)

synthetic estrogen used widely 1938-1971 for prevention of spontaneous abortion, premature delivery, and postpartum lactation suppression

banned in US due to adverse effects

274

what is the major risk factor for CCA vs SCC in the vagina and cervix

CCA: daughter of DES mother

SCC: HPV and tobacco

275

when are rectovaginal cultures obtained for GBS screening

35-37 weeks gestation

276

who should receive GBS prophylaxis without testing

pregnant pts with a history of
GBS bacteriuria
UTI
infant w/ early-onset GBS disease

277

how do you manage GBS prophylaxis

give Penicillin 4 hours before delivery

278

what is dx in pt with diffuse breast erythema, warmth, pain, and edema w/ peau d'orange appearance

inflammatory breast carcinoma

279

what does condylomata acuminata come from

HPV 6, 11

(genital warts)

280

what is dx in pt with single or multiple pink or skin-colored lesions; lesions range from smooth, flattened papule to exophytic/cauliflower-like growth

genital warts
condylomata acuminata
HPV 6, 11

281

how do you treat condyloma acuminata

small lesions may be treated with applications of trichloroacetic acid
or podophyllin resin

excisional therapy may be considered for larger lesions

recurrence rate is high, regardless of tx modality

282

what is dx in pt with flat, velvety lesions; broad base and flat surface; lobulated and plaque-like

condyloma lata
secondary syphilis

283

what is dx in pt with single/clustered blisters or superficial, tender ulcers

HSV

284

what is dx in pt with pruritic, glassy, bright red erosions and ulceration involving the vulva and vagina

genital lichen planus

285

what is dx in pt with poxvirus and single or multiple "pearly" (smooth, firm) painless nodules with central dimples/pits; no bleeding on contact

molluscum contagiosum

286

what is the only current indication for hormone replacement therapy

vasomotor symptoms (severe hot flashes) in women <60 yo who have undergone menopause within the last 10 yrs

287

what are contraindications to hormone replacement therapy

history of:
CAD
thromboembolism
TIA/stroke
breast cancer
endometrial cancer

288

how do you manage pts with severe vasomotor symptoms (hot flashes) with a contraindication to systemic HRT

SSRIs

289

what is the concern with HRT in treating menopause symptoms

the estrogen component treats menopausal symptoms
but if unopposed (no progesterone),
can cause endometrial proliferation and hyperplasia

therefore, in pts with a uterus- HRT must contain a progestin component for endometrial protection

290

what is dx in pt with h/o pelvic surgery and painless continuous loss of clear, watery fluid from the vagina

vesicovaginal fistula (urine leak)

291

how can you diagnose a vesicovaginal fistula

PE
dye test
cystourethroscopy

292

how can you prevent vesicovaginal fistula

bladder catheterization in the immediate postoperative period allows a small fistula to heal

otherwise, surgical correction is indicated

293

what is the first sing of puberty in girls

breast development (thelarche)
age 8-12
in response to rising estrogen levels

294

when is menarche expected during puberty

~Tanner stage 4
approximately 2-2.5 yrs after initial breast bud development
avg age 12.5

295

what are contraindications to external cephalic version

indications for Cesarean delivery regardless of fetal lie (failure to progress during labor, non-reassuring fetal status)

placental abnormalities (placenta previa or abruption)

oligohydramnios

ruptured membranes

hyperextended fetal head

fetal or uterine anomaly

multiple gestation

296

what is the most common cause of postpartum hemorrhage

uterine atony (failure to contract)

297

what is initial management of postpartum hemorrhage 2/2 uterine atony

bimanual uterine massage and uterotonic agents
--oxytocin (first line)
--methylergonovine (risk of vasoconstriction/HTN)
--Carboprost (risk of bronchoconstriction/asthma)

298

what is dx in pt with skin/nipple retraction, calcifications on mammography, and biopsy showing fat globules and foamy histiocytes

fat necrosis of the breast
--can mimic breast cancer; associated with breast surgery and trauma

299

what ultrasound finding often correlates with benign breast etiology

hyperechoic mass

300

how do pts with androgen insensitivity present

male karyotype
male testosterone levels
breast development (testosterone is aromatized into estrogen)
primary amenorrhea (absent ovaries, uterus, and cervix)
minimal pubic and axillary hair

301

what is pathogenesis s of androgen insensitivity syndrome

end-organ resistance to androgens 2/2 mutated androgen receptor

pts have functioning testes and secrete AMH and testosterone
--AMH stimulates regression of Mullerian ducts (no uterus, cervix, or upper vagina)

no masculization 2/2 androgen resistance
--Wolffian duct degeneration
--fetal urogenital sinus does not differentiate into a penis and scrotum
--male 2ndary sex characteristics are minimal/absent (hair, voice)

302

what is best next step in management with a high-grade squamous intraepithelial lesion Pap test result vs low-grade

high grade:
immediate colposcopic examination and biopsy of cervical abnormalities due to high risk of progression to cervical cancer

low grade or undetermined significance:
HPV co-testing

303

what dx in pathogenesis that involves systemic inflammation, activation of the coagulation cascade, and platelet consumption

HELLP syndrome

304

what are 2 maternal complications from abruptio placentae

hypovolemic shock

DIC

305

what is the pathophysiology of neonatal thyrotoxicosis

transplacental passage of maternal anti-TSH receptor antibodies

antibodies bind to infant's TSH receptors and cause excessive thyroid hormone release

306

what is dx in newborn with warm, moist skin, tachy, poor feeding, irritability, poor weight gain, and low birth weight/preterm birth

neonatal thyrotoxicosis

307

how do you dx neonatal thyrotoxicosis

maternal anti-TSH receptor antibodies >= 500% normal

308

how do you treat neonatal thyrotoxicosis

self-resolves within 3 months (disappearance of maternal antibody)

methimazole PLUS beta-blocker

309

when do you want to use Tamoxifen vs Raloxifene

Tamoxifen: adjuvant treatment of breast cancer
--endometrial hyperplasia and endometrial carcinoma

Raloxifene: postmenopausal osteoporosis

310

what is management for placenta previa

Cesarean delivery

NO intercourse or digital vaginal examination

vaginal delivery is contraindicated

311

who should be screened for chlamydia and gonorrhea

all sexually active women <25 yo should undergo annual screening for Chlamydia and gonorrhea due to high rates of asymptomatic infection that can lead to infertility

312

what is the gold standard for screening/diagnosis of chlamydia and gonorrhea

nucleic acid amplification testing

313

what is dx in pt with pain with vaginal penetration, distress/anxiety over symptoms, and no other medical cause

genitor-pelvic pain/penetration disorder

previously vaginismus

314

what is dx in pt with insomnia, fatigue, weight gain, amenorrhea, and an enlarged uterus

pregnancy

315

what are concerns for lithium exposure in pregnant women for fetuses?

first trimester: cardiac malformations
--septal defects; and possibly Epstein's anomaly

2nd and 3rd:
goiter, transient neonatal neuromuscular dysfunction

316

what is dx in pt in active phase of labor with cervical change slower than expected; +/- inadequate contractions

protraction to help with contraction strength

317

how do you treat protraction during active phase of labor

oxytocin

318

what is dx in pt in active phase of labor with no cervical change for >4hrs with adequate contractions
OR
no cervical change for >6hrs with inadequate contractions

arrest

319

how do you treat arrest of the active phase of labor

cesarean delivery

320

what is dx in post-op pelvic pt with persistent fever unresponsive to Abx and bilateral lower abdominal pain; no localizing signs/symptoms

septic pelvic thrombophlebitis

post-op/postpartum infected thrombosis of the deep pelvic or ovarian veins

321

what is medroxyprogesterone's MOA

Depot medroxyprogesterone acetate (DMPA) is administered intramuscularly every 3 months to prevent pregnancy by inhibiting the release of GnRH form the hypothalamus and suppressing ovulation

322

what is dx in pt with postmenopausal bleeding, thickened endometrium, breast tenderness, and large pelvic/adnexal mass

granulosa cell tumor
--secretes estrogen and causes hormonal effects

323

what is the major risk factor for shoulder dystocia

fetal macrosomia

post-term pregnancy
maternal obesity
gestational DM
excessive maternal weight gain during pregnancy

324

when do you stop pap testing

Age 65 or hysterectomy
PLUS
no h/o CIN 2 or higher
AND
3 consecutive negative Pap tests
OR
2 consecutive negative co-testing results

325

what is dx in pt with recurrent sudden mild and unilateral mid-cycle pain prior to ovulation lasting hours-days; may mimic appendicitis

Mittelscherz

326

what is dx in pt with sudden-onset, severe, unilateral lower abdominal pain immediately following strenuous or sexual activity; ultrasound shows pelvic free fluid

ruptured ovarian cyst

327

what is dx in pt with sudden-onset, severe, unilateral lower abdominal pain; N/V; unilateral, tender adnexal mass on examination; ultrasound shows enlarged ovary with decreased or absent flow

ovarian torsion

328

what is the most significant risk factor for spontaneous preterm delivery

h/o spontaneous preterm delivery in a prior pregnancy

329

what is dx in pt with Keratoconjunctivitis sicca, dry mouth, salivary hypertrophy, xerosis of skin, Raynaud phenomenon, cutaneous vasculitis, arthralgias/arthritis, interstitial lung disease

Sjogren syndrome

330

what are diagnostic findings of Sjogren syndrome

objective signs of decreased lacrimation (Schirmer test)

postive anti-Ro (SSA) and/or anti-La (SSB)

salivary gland biopsy with focal lymphocytic sialoadenitis

331

what is dx in pt with pain to superficial touch of the vaginal vestibule rather than dryness

vulvodynia
formerly vestibulodynia

332

what is dx in pt with amenorrhea, lactational failure, and persistent hypotension

Sheehan syndrome,
a complication of massive obstetrical hemorrhage

333

what is used for dx and treatment of postpartum urinary retention

urethral catheterization

334

which 3 vaccines are recommended during pregnancy

Trap
Inactivated influenza
Rho(D) immunoglobulin

335

which 6 vaccines are indicated for high-risk pts

Hepatitis B
Hepatitis A
Pneumococcus
Haemophilus influenzae
Meningococcus
Varicella-zoster immunoglobulin

336

which 4 vaccines are contraindicated in pregnancy

HPV
MMR
live attenuated influenza
Varicella

337

what 4 labs/tests should you get to evaluate galactorrhea

serum pregnancy test
serum prolactin
TSH
possible MRI of brain

338

what is dx in pt with PID complicated by perihepatitis

Fitz-Hugh-Curtis disease

339

what is dx in pt with fever, lower abdominal tenderness, mucopurulent cervical discharge, and cervical motion and uterine tenderness; possible inter menstrual spotting,

PID

340

what are the 2 painful types of infectious genital ulcers

HSV (small vesicles or ulcers)

Haemophilus ducreyi (chancroid; larger, deep ulcers w/ gray/yellow exudate)

341

what is the most sensitive test for HSV

PCR

(viral culture can be used, but less sensitive)

342

what is the recurrence pattern of genital herpes if left untreated

it will resolve, with decreasingly frequent recurrences

343

what is the management of shoulder dystocia

BE CALM

Breathe; do not push
Elevate hips against abdomen (McRoberts position)
Call for help
Apply suprapubic pressure
enLarge vaginal opening w/ episiotomy
Maneuvers:
--deliver posterior arm
--rotate 180 degrees (Woods corkscrew)
--collapse anterior shoulder (Rubin maneuver)
--replace fetal head into pelvis for cesarean delivery (Zavanelli maneuver)

344

what causes the genitourinary syndrome of menopause (atrophic vaginitis)

due to loss of vaginal wall elasticity from lack of estrogen

345

what is the best option for managing intrauterine fetal demise depending on weeks gestation?

20-23 weeks:
Dilation and evacuation
OR
vaginal delivery

>= 24 weeks:
induction of labor for vaginal delivery
--it can be delayed to allow time for parental acceptance of dx
--retention of fetus for several weeks can lead to coagulopathy

346

what is dx in an immigrant pt with h/o recurrent sore throats and new onset AF w/ RVR

rheumatic mitral stenosis

may be brought on by pregnancy 2/2 physiologic increases in HR and blood volume that raise the transmittal gradient and LA pressure

347

what causes infertility in PCOS pts

anovulation from failed follicular maturation and oocyte release

persistently elevate estrone levels due to peripheral androgen conversion in adipose tissue and decreased levels of SHBG.
--high estrone levels provide negative feedback to hypothalamus, which inhibits GnRH secretion
--imbalance in LH and FSH release from anterior pituitary
--LH/FSH imbalance results in a lack of LH surge
--failure of follicle maturation

348

what are 4 benefits and 4 risks of Combined estrogen-progestin contraceptives

Benefits:
--pregnancy prevention
--endometrial and ovarian cancer risk reduction
--menstrual regulation with reduction in iron deficiency anemia
--reduction in risk of benign disease

Risks:
--Venous thromboembolism
--HTN
--Hepatic adenoma
--Very rarely, stroke and MI

349

what test is used to determine appropriate dose of anti-D immune globulin

Kleihauer-Betke (KB) test

maternal RBCs fixed on a slide
slide is exposed to acidic soln
adult Hb lyses
leaves "ghost" cells
dose of anti-D immune globulin is calculated from the % of remaining fetal hemoglobin

350

what is the standard dose of anti-D immune globulin given, and when?

300 micrograms at 28 weeks gestation usually prevents alloimmunization

--~50% of Rh- women will need higher dose after delivery, placental abruption, or procedures
--do KB test to determine dosage

351

what is helpful to dx PMS

symptom diary

352

what is an effective tx option for PMS

SSRIs

353

when do PMS symptoms typically occur

1-2 weeks prior to menses during the luteal phase
--resolve with menses

354

what is management for pts with active genital herpes lesions at the time of delivery

Cesarean delivery to reduce risk for neonatal HSV

355

what should management be for pregnant women w/ h/o genital HSV infection

prophylactic acyclovir or valacyclovir beginning at 36 weeks gestation

356

distinguish between placenta previa and placental abruption

placenta previa:
--placenta implants over internal cervical os
--painless antepartum vaginal bleeding
--normal fetal HR tracings

placental abruption:
--premature separation of placenta from uterus
--vaginal bleeding
--distended and very tender uterus
--fetal HR tracing abnormalities

357

what is the work-up process of secondary amenorrhea

amenorrhea for >=3 cycles or >=6 months:

beta-hCG
--positive = pregnancy

prior uterine procedure/infection?
--hysteroscopy

check prolactin, TSH, FSH
--high prolactin = brain MRI
--high TSH = hypothyroidism
--high FSH = premature ovarian failure

358

how should you manage pts with uncomplicated preterm premature rupture of membranes (PROM) at <34 weeks gestation?

manage conservatively with antenatal corticosteroids and antibiotics (betamethasone) to decrease risk of neonatal RDS

delivery should occur at 34 weeks or in the setting of intrauterine infection or deteriorating fetal/maternal status

359

what is the next step in pregnancy management if first-trimester screen is abnormal

diagnostic testing with either:

amniocentesis
--15-20 weeks
--definitive karyotype dx
--invasive; risk of membrane rupture, fetal injury, and pregnancy loss

chorionic villus sampling
--10-13 weeks
--definitive karyotype dx
--invasive; risk of spontaneous abortion

(quadruple test is not indicated if the first-trimester screen is already abnormal, as they have similar sensitivity/specificity)

360

what are indications for endometrial biopsy, depending on age of pt
>=35
<45
>= 45

>= 35:
atypical glandular cells on Pap test

<45:
abnormal uterine bleeding PLUS:
--unopposed estrogen (obesity, anovulation)
--failed medical management
--lynch syndrome (HNPCC)

>=45:
abnormal uterine bleeding
postmenopausal bleeding

361

how do you manage persistent variable decelerations (occurring with >50% of contractions)

may be alleviated by maternal repositioning

362

how do you manage intermittent variable decelerations (occurring with <50% of contractions)

well-tolerated by fetus

363

what is fetal scalp stimulation used for

an attempt to induce accelerations when they are absent
--does not treat variable decelerations and could exacerbate decelerations if parasympathetic tone increases in response to the stimulus

364

what are the 2 indications for oxytocin and 3 adverse effects

indications:
--induction or augmentation of labor
--prevention and management of postpartum hemorrhage

adverse effects:
--hyponatremia
--hypotension
--tachysystole

365

what is the most significant risk factor for precipitous labor

multiparity

366

what is likely dx in pt with preeclampsia at <20 weeks gestation, and what causes the preeclampsia

hydatidiform mole

preeclampsia is likely due to abnormal placental spiral artery development,
which causes placental hypo perfusion, placental ischemia, and maternal hypertension

367

what are 5 modifications that can be done ro reduce risk of ovarian cancer in a pt with BRCA mutation

bilateral salpingo-oophrectomy
(recommended as soon as child-bearing is complete)

oral contraceptive use

age <30 at first live birth

breastfeeding

tubal ligation

368

what does the workup for a pt with decreased fetal movement

pt should undergo antenatal fetal testing with a non stress test (NST)
followed by a biophysical profile or contraction stress test if the NST is nonreactive

369

which lab value is helpful for monitoring growth-restricted fetuses (estimated fetal weight <10th percentile)

umbilical artery flow velocimetry

370

what is the screening test for ovarian cancer in an asymptomatic, average-risk pt without an adnexal mass?

no screening test for these pts

ovarian cancer is most commonly dx in advanced stages and therefore has high mortality rates

371

what is the cause of initial irregular and anovulatory cycles in adolescents, aka "abnormal uterine bleeding" following menarche

hypothalamic-pituitary-gonadal axis immaturity and insufficient secretion of GnRH

372

what is dx in pt with painless lesion that begins as a papule and converts to a nonexudative ulcer with indurated borders; may have mild-moderate bilateral lymphadenopathy

primary syphilis

373

what is dx in intrauterine fetal demise associated with growth restriction, multiple limb fractures, and a hypo plastic thoracic cavity

type 2 osteogenesis imperfecta
--auto dominant
--defective type 1 collagen synthesis
--decreased bone density and increased fragility

374

what is dx in intrauterine fatality that presents with pulmonary hypoplasia, limb deformities (clubfoot, hip dislocation, but not limb fractures) and oligohydramnios

potter sequence

375

what is the most common cause of Potter sequence

urinary tract abnormalities (bilateral urinary agenesis, PKD)

376

what causes amenorrhea in a breastfeeding female

elevated prolactin levels inhibit GnRH release, thereby suppressing LH and FSH production
--anovulation and amenorrhea

377

what is hypotension 2/2 epidural anesthesia caused by

blood redistribution to the LE and venous pooling from sympathetic blockade of nerves responsible for vascular tone
--decreased venous return to the R heart
--decreasded cardiac output

378

how can you prevent hypotension 2/2 epidural anesthesia? treat it?

prevent:
aggressive IV volume expansion prior to epidural placenta

treat:
--left uterine displacement (pt positioning) to improve venous return from the IVC
--additional IV fluid bolus
--vasopressor administration

379

what is dx in post-abortion pt with fever, chills, abdominal pain, sanguinopurulent vaginal discharge, boggy, tender uterus w/ dilated cervix, and pelvic ultrasound showing retained parts of conception, thick endometrial stripe

septic abortion

380

what are the 3 things to manage septic abortion

IV fluids
broad-spectrum Abx
suction curettage

381

what should you do after dx and removal (suction curettage) of hydatidiform mole

serial beta-hCG monitoring to ensure it's decreasing/undetectable for at least 6 months
--this also means contraception for 6 months so a pregnancy does not interfere with beta-hCG levels

you need to monitor the pt because they're at risk for gestational trophoblastic neoplasia

382

what is the term for the longitudinal axis of the fetus is perpendicular to the longitudinal axis of the uterus

transverse lie
--can be either back up (with the spine toward the maternal head) or back down (with the spine toward the cervix)

383

what is the management of a transverse lie

it's typically transient prior to term
--most fetuses spontaneously convert to breech or vertex presentation
--ultrasound at 37 weeks to determine delivery management

384

how close does the placenta have to be to the cervical os to be considered placenta previa

<2 cm from the cervical os

>2cm from the cervical os is not considered placenta previa and does not require Cesarean delivery

385

what is dx in postpartum pt with difficulty ambulating, radiating suprapubic pain, pubic symphysis tenderness, and intact neuro exam with a traumatic delivery

pubic symphysis diastasis

386

what is management for pubic symphysis diastasis

conservative:
NSAIDs
physical therapy
pelvic support

--most pts recover within 4 weeks postpartum

387

what is dx in pt with adhesions and powder-burn lesions/nodules

endometriosis (AKA "chocolate cysts")

388

what is management of asymptomatic vs symptomatic endometriosis (incidental finding)

asymptomatic:
observation

symptomatic:
--conservative management includes NSADs, OCPs, a progesterone IUD
--definitive tx includes surgical resection and hysterectomy with oophorectomy

389

what is MOA of leuprolide

GnRH agonist
--suppresses estrogen stimulation of endometrial tissue
--poorly tolerated due to menopausal symptoms

390

what is dx in pt with amenorrhea, diffuse abdominal pain, and hemodynamic instability, possible bleeding

ruptured ectopic pregnancy

391

what symptoms accompany blood in abdomen and pelvis (ex ruptured ectopic pregnancy)

syncope, hypotension, tatty

irritation of nearby structures:
--diffuse abdominal pain
--cervical motion tenderness
--shoulder pain (referred from diaphragm)
--urge to defecate (blood in posterior cul-de-sac)

392

what 5 conditions can minors (<18yo) be medically emancipated for

emergency care

STD

substance abuse (most states)

pregnancy care (most states)

contraception

393

what are 4 first-line, 2 second-line, and 5 contraindicated antihypertensives in pregnancy

First line (safe):
--methyldopa (alpha-2 agonist)
--beta blocker (labetalol)
--Hydralazine (arterial vasodilator)
--CCB (nifedipine)

Second line:
--Thiazide diuretics
--Clonidine

Contraindicated:
--ACE inhibitors
--ARBs
--Aldosterone blockers
--Direct renin inhibitors
--Furosemide

394

describe the contractions in a false labor vs latent labor in terms of timing, strength, pain, and cervical change

false labor:
--irregular, infrequent timing
--weak strength
--no/mild pain
--no cervical change

latent labor:
--regular, increasing frequency timing
--increasing intensity strength
--painful
--cervical change

395

what is dx in pt postpartum (mole, normal pregnancy, or spontaneous abortion) with enlarged uterus, irregular vaginal bleeding, pulmonary symptoms, and multiple pulmonary infiltrates on CXR

choriocarcinoma
--metastatic form of gestational trophoblastic neoplasia
--dx confirmed w/ elevated beta-hCG

396

what is dx in pt with rapid cessation of breastfeeding, bilateral fullness and tenderness, no erythema, and afebrile

engorgement
--milk production exceeds release

397

how do you manage a pt's desire for lactation suppression 2/2 engorgement

NSAIDs, supportive bra, avoid nipple stimulation/manipulation, and ice packs

--Dopamine agonists (bromocriptine) inhibits prolactin secretion from anterior pituitary to suppress lactation, but is no longer approved by the USFDA for lactation suppression due to side effects

398

what is dx in pt with recurrent pregnancy loss, prior TIA

thrombophilia/hypercoagulability

--Antiphospholipid syndrome is an autoimmune disorder that presents w/ pregnancy complications or VTE/arterial thrombosis due to membrane antiphospholipid antibodies

399

what is the next step in management after pt presents with signs/symptoms of ectopic pregnancy

dx is made by a positive pregnancy test and transvaginal ultrasound showing the gestational sac at an ectopic site

400

when do you use laparoscopy vs laparotomy

laparoscopy:
gold standard tx for ruptured ectopic pregnancy which presents with diffuse abdominal pain and eventually hemodynamic instability

laparotomy:
may be considered in pts with acute bleeding

401

what is the first-line treatment for Candida vaginitis

oral azole (fluconazole)
--intravaginal agents are equally efficacious, but pts prefer oral over intravaginal

(oral nystatin is only used for oral candidiasis; intravaginal nystatin would treat Candida vaginitis though)

402

what is the best way to diagnose uterine fibroids

ultrasound of pelvis

403

what is best management for uterine procidentia (a form of pelvic organ prolapse) in a poor surgical candidate

pessary

404

what are 3 causes of hyperandrogegism in pregnancy

luteoma

theca luteum cyst

Krukenberg tumro

405

what is dx in pregnant pt wth hyerandrogenism, bilateral solid ovarian masses on ultrasound, and metastasis from primary GI tract cancer; fetal virilization risk?

Krukenberg tumor
--high fetal virilization risk

406

what is dx in pregnant pt with hyperandrogegism, bilateral solid ovarian cysts on ultrasound; associated with molar pregnancy and multiple gestation; and regress spontaneously after delivery; fetal virilization risk?

Theca luteum cyst
--low fetal virilization risk

407

what is dx in pregnant pt with hyperandrogegism, yellow-yellow/brown masses (often w/ areas of hemorrhage) of large lutein cells; solid ovarian masses on ultrasound (50% bilateral); and regress spontaneously after delivery; fetal virilization risk?

Luteoma
--high fetal virilization risk

408

what is proper tx for asymptomatic pt who tests positive for chlamydia but negative for gonorrhea using nucleic acid amplification testing?
gonorrhea only?

Chlamydia only:
Azithromycin only

Gonorrhea only:
Azithromycin + ceftriaxone

409

how should a pt deliver if they have a history of a classical Cesarean delivery or extensive myomectomy for leiomyoma removal

delivery requires laparotomy and delivery

--labor and vaginal delivery are contraindicated due to significant risk of uterine rupture

410

what is dx in pt with decreased urethral sphincter tone; urethral hypermobility

stress incontinence

411

what is dx in pt with detrusor hyperactivity

urge incontinence

412

what is dx in pt with impaired detrusor contractility (bladder atony); bladder outlet obstruction

overflow incontinence

413

distinguish between vaginal squamous cell carcinoma vs clear cell adenocarcinoma with:
epidemiology
risk factors
location
clinical features
dx

Squamous cell:
-->60yo
--Risk factors: HPV 16 or 18; h/o cervical dysplasia or cancer; smoking
--Located: upper 1/3 of posterior vaginal wall

Clear cell adenocarcinoma:
--<20yo
--Risk factors: in utero exposure to diethylstilbestrol
--LocateD: upper 1/3 of anterior vaginal wall

clinical features are the same:
--malodorous vaginal discharge
--postmenopausal or postcoital vaginal bleeding
--irregular mass, plaque, or ulcer in vagina

Dx:
--biopsy

414

what is the rule for pregnant women making decisions for their unborn children

a woman who has mental capacity has the right to refuse treatment, even if it places her unborn child at risk
--maternal autonomy supersedes the rights of the unborn child while it is still physically attached to her

415

what is the best way to evaluate proteinuria when testing for preeclampsia

urine protein-to-creatinine ratio or a 24-hour urine collection for total protein (gold standard)

416

what is dx in pt with ultrasound findings of a solid mass with thick sepations, ascites/peritoneal fluid

epithelial ovarian carcinoma
--presents with bloating and pelvic pain

417

what is dx in pt with confusion/encephalopathy, ataxia, and horizontal nystagmus and bilateral abducens palsy

Wernicke Encephalopathy

418

what is the etiology and 3 associated conditions of wernicke encephalopathy

Thiamine deficiency

chronic alcoholism (most common)
malnutrition (anorexia nervosa)
Hyperemesis gravidarum

419

what is dx in pt with hyperemesis gravidarum, enlarged uterus, and bilaterally enlarged ovaries

complete hydatidiform mole, a type of gestational trophoblastic disease

420

what causes the enlarged ovaries in a hydatidiform mole

the gestation is composed of proliferative trophoblastic tissue that secretes high levels of beta-hCG

the markedly elevated beta-hCG levels cause hyper stimulation of the ovaries and formation of theca lutein cysts, which are large, bilateral, multilocular ovarian cysts

421

what is dx in pt with pharyngitis with fever and lower abdominal pain in a young, sexually active female

gonococcal pharyngitis with PID
--Neisseria gonorrhea is common STD that can cause cervicitis leading to PID; and pharyngitis occurs during urogenital contact

422

what is dx in newborn with large anterior fontanel, thin umbilical cord, loose skin, and minimal subcutaneous fat

fetal growth restriction

423

what evaluation step is included when a growth-restricted fetus is born

evaluation includes histopathologic examination of the placenta to asses for infection and/or infarction

424

what dx should you consider/suspect in a pt with recurrent candidiasis in an otherwise "normal" pt

diabetes mellitus

--candidiasis risk factors are DM, immunosuppression, and Abx

425

what is dx in pt with a pregnancy loss at <20 weeks gestation prior to expulsion of products of conception; typically asymptomatic, or light vaginal bleeding; findings of closed cervix, decreasing beta-hCG; no fetal cardiac activity or empty sac

missed abortion

426

what is dx in pregnant pt with pain, bleeding, dilated cervix, and passage of some products of conception and some remain

incomplete abortion

427

what is dx in pregnant pt with vaginal bleeding, closed cervical os, and fetal cardiac activity

threatened abortion

428

what is dx in pregnant pt with vaginal bleeding, dilated cervical os, products of conception may be seen or felt at/above cervical os

inevitable abortion

429

what is surgical removal of uterine fibroids called

myomectomy

430

how do you manage epithelial ovarian carcinoma

exploratory laparotomy and resection of cancer with inspection of entire abdominal cavity

--a biopsy of the pelvic mass is contraindicated due to risk of spreading cancerous cells throughout the abdomen

431

what is smoking a cancer risk factor for

cervical cancer

432

what is dx in shoulder dystocia pt with:
clavicular crepitus/bony irregularity
decreased Moro reflex due to pain on affected side
intact biceps and grasp reflexes

Fractured clavicle

433


upper-arm crepitus/bony irregularity
decreased Moro reflex due to pain on affected side
intact biceps and grasp reflexes

Fractured humerus

434


decreased Moro and biceps reflexes on affected side
"waiter's tip" w/ extended elbow, pronated forearm, and fleeced wrist and fingers
intact grasp reflex

Erg-Duchenne palsy

damage to nerves C5-C6

435


"claw hand" with extended wrist, hyperextended metacarpophalangeal joints, flexed interphalangeal joints, and absent grasp reflex
Ipsilateral Horner syndrome (ptosis, miosis)
intact Moro and biceps reflexes

Klumpke palsy


damage to nerves C8 and T1 (hand paralysis and IL Horner syndrome)

436


variable presentation depending on duration of hypoxia
altered mental status (irritability, lethargy)
respiratory or feeding difficulties
poor tone
seizure

perinatal asphyxia