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Paradoxical Bradycardia

In a patient w/ a ruptured ectopic pregnancy, you would expect the patient to be tachycardia and hypotensive (blood loss into peritoneal cavity). BUT instead the blood irritates the peritoneum, causing a vagal response (bradycardia).


Common symptoms of pre-eclampsia?

Headaches, visual changes, dyspnea, epigastric pain, face/hand swelling, hyper-reflexes

Caused by endothelial defects in the placenta leading to increased blood pressure


Bartholin gland cyst/abscess

Vulvar mass at 5:00 or 7:00 positions


Prenatal testing at 16-20 weeks?

Neural tube defects, Down syndrome, trisomies (PAPP-A), bHCG, nuchal translucency

PAPP-A = pregnancy-associated plasma protein A


Prenatal testing at 26-28 weeks?

Gestational diabetes


Prenatal testing 35-37 weeks?

Group B strep


Most common cause of postpartum hemorrhage?

....if the uterus is firm?

Uterine atony (normally, contraction of the uterus compresses the vasculature and stops bleeding) --> first step in assessment is uterine massage to check if the uterus is boggy

Genital tract laceration, usually involving the cervix


Symptoms of uterine fibroids?

Lower abdominal pain
Dysuria/decreased frequency (obstruction of ureters via fibroids)
Problems deficating (obstruction of bowel from fibroids)
Irregular vaginal bleeding (metorrhagia)

Cause of post-menopausal bleeding


Most common cause of vaginal discharge in pre-menarche child/adolescent?

Foreign object in vagina

Diagnose: nasal speculum while child is asleep/anesthesia (they won't comply if awake)


Uses for Magnesium in pregnancy?

1) In severe pre-eclampsia as seizure prophylaxis
2) In preterm premature labor/deliveries, it can help aid in neurodevelopment in the fetus to prevent cerebral palsy


HPV types for Genital Herpes?

6, 11


HPV types for cervical cancer?

16, 18


Why gestational diabetes (uncontrolled) results in big baby?

Physiologic changes in pregnancy cause mom to be insulin-insensitive --> increased blood glucose levels in mom & cross placenta to baby --> baby produces more insulin to deal w/ high sugars --> insulin similar in structure to GH --> essentially increased GH and baby grows too much


How OCP's treat acne?

Acne caused by increased testosterone in females

Estrogen in OCP's increase production of Sex Hormone Binding Globulin (SHBG) --> SHBG binds any free hormones in circulation (testosterone) --> there is now DECREASED FREE testosterone levels --> free testosterone is what causes acne & hair thinning


Signs of cholestasis in pregnancy?

ITCHING in hands

Check bile acids


Adolescent w/ very heavy periods & also has bleeding in gums when brushing her teeth?

von Willebrands disease


First sign of chorioamnionitis?

Fetal tachycardia


Fetal infection causing conjunctivits & pneumonia?



2 vitamins lacking in breast milk?

Vitamin D & K


Cause of 1st trimester abortions?

Chromosomal abnormalities


Fetal structural complication of uncontrolled gestational diabetes?

Sacral agenesis & LE malformations (Caudal Regression Syndrome)


Obese woman presents w/ shortness of breathe and crampy abdominal pain. All prior exams have been normal. Her appetite has been decreasing w/ early satiety. On physical exam, she gets dyspneic after prolonged talking. She has crackles at the lower R lung base. Pelvic & abd exams are normal. CXR shows R pleural effusion. Labs showed low Hgb, low Albumin, Na, & K. An abdominal CT showed ascites in the abdomen and a 7-cm right pelvic mass. What are you thinking?

Ovarian cancer - Meigs Syndrome!!!

Meigs Syndrome is a triad of:
1) Ascites
2) Pleural effusion
3) Ovarian mass


Treatment for placental abruption?

Emergent C-section!


Woman w/ placental abruption has emergent C-section, but continues to drop her BP (60/40). She was already given 2 L LR. What is next best step in management?

Transfuse w/ PRBC

Class 4 hemorrhagic shock: persistent hypotension + tachycardia

Secondary to intrauterine blood loss and resultant hypovolemic shock --> stop bleeding and replace blood

Crystalloids are always temporary measure to improve BP; only 1/3 of volume remains in intravascular space (not indicated for advanced shock)


7 month pregnant woman suddenly develops intra-abdominal bleeding and her pressures rapidly drop. What is most common cause of her intra-abdominal bleeding?

Visceral artery aneurysm involving SPLENIC artery --> tend to rupture during pregnancy

May see "signet ring sign" on plain film when the calcified aneurysm is seen as radio-opaque in RUQ


Pregnant woman in 10 week's gestation has occasional nausea, but has no other symptoms. Urine dipstick is (+) for nitrites & leukocyte esterase and urine culture shows 100,000 cfu of E. coli. What is appropriate treatment?

Association b/w asymptomatic bacteriuria & preterm delivery/low birth wt

*All pregnant women w/ asymptomatic bacteriuria should be treated w/ Abx:
- Nitrofurantoin
- Cefalexin
- Amoxicillin


What hormone is abnormal in Turner syndrome?

What cardiac anomaly is associated w/ Turner syndrome?

HIGH FSH --> ovarian dysgenesis causes low estrogen levels --> lack of negative feedback on FSH from pituitary --> high FSH

Coarctation of aorta (high BP in UE; low BP in LE)


14 yo with heavy periods that are often irregular and prolonged when they do occur. Menarche at age 13. Most common cause for this menorrhagia?

Anovulatory cycles


What are symptoms pointing to PCOS?

What is best screening test?

Menstrual irregularities
Male-pattern baldness

*Oral glucose tolerance test --> increased risk of insulin resistance and T2DM


S/S of uterine fibroids?

Surgical treatment?

Firm, enlarged, irregularly shaped uterus
Heavy periods (anemia)

Tx: still wanting children = myomectomy
done with children = hysterectomy


In HELLP syndrome, what is best treatment?

Stabilize patient with anti-HTN & Mg (seizure prophylaxis)
Plan for induction w/ vaginal delivery


Person with preeclampsia is given mag sulfate ad hydralazine for treatment. Afterwards, she develops hyporeflexia and slowed respirations. Why?

Toxicity of Magnesium Sulfate --> decreased reflexes and resp depression


Exposure to what is associated with clear cell adenocarcinoma of the vagina and cervix?

DES exposure


Women with normal BMI should gain how much wt during pregnancy?

15-25 lbs


Sudden onset of unilateral lower abdominal pain immediately after strenuous activity or sex?

What will pelvic ultrasound show?

Ruptured ovarian cyst

Free fluid in pelvis


1) Complete abortion
2) Incomplete abortion
3) Missed abortion
4) Threatened abortion
5) Inevitable abortion

1) complete expulsion of ALL products of conception BEFORE 20 weeks gestation

2) partial expulsion of SOME but not all products of conception before 20 weeks gestation

3) death of a fetus before 20 weeks w/ complete retention of products of conception

4) Intrauterine bleeding before 20 weeks gestation WITHOUT dilation of cervix or expulsion of any products of conception

5) Retained products of conception (can be visualized) but bleeding and 2cm dilated cervix


Most effective post-coital contraceptive, but it's dependent on a certain condition?

Copper IUD ONLY if placed within 5 days of sex


What tests are indicated in the initial prenatal visit?

ABO & Rh status
Hepatitis B


What medications are advised for HTN control in pregnancy?



What is pseudocyesis?

Woman with signs/symptoms of pregnancy (amenorrhea, enlargement of breasts and abdomen, morning sickness, wt gain, sensation of fetal movement) and reported pregnancy test as (+).

On Ultrasound --> normal endometrial stripe and office pregnancy test is (-)


Vulvar lesions with pink color and teardrop shape that completely resolve with the use of trichloroacetic acid - what are they?

HPV warts (condoloma acuminata)

Tx with tricholoacetic acid or podophyllin


In primary amenorrhea what is assumed when breast development has NOT occurred?

What is the best INITIAL test?

What is the hormone to be tested? Why?

Estrogen is decreased

*Pelvic ultrasound --> see if internal female organs present

If high = peripheral cause
If low = central cause


28 yo woman has Pap smear and results showed ASCUS. What is next best step? After that?

HPV testing

If HPV (+) --> colposcopy
If HPV (-) --> repeat cytology and HPV in 3 years


Woman has premature ovarian failure from chemotherapy of non-Hodgkin lymphoma. What would her FSH, LH and FSH/LH ratio be?

FOLLICLES in ovary are woman's main source of ESTROGEN --> if ovaries are "failing" they are not producing follicles and estrogen --> estrogen normal inhibits FSH and LH

*Both FSH and LH are HIGH b/c of no (-) feedback
**FSH is higher (remains in blood longer)


Woman is 28 weeks gestation with her first child. She recently developed coarse facial hair above her lip and on her chest and gained 5 lbs over the last 2 months. What is it?
What is best test to confirm?
Risks to fetus and mom?

Luteoma of pregnancy (benign)

*New-onset hirsutism and acne in pregnant woman*

Ultrasound is gold standard --> B/L ovarian masses

Usually regress after delivery
*High risk of virilization to FEMALE fetus*

Monitor and US evaluation


Person has oligomenorrhea (every 2-3 months) and hyperandrogenism (high testosterone, hirsutism). What are you thinking?

What is best initial treatment? Why?


Wt loss
Estrogen/progesterone (OCP) contraceptives
- Regulate menses
- Prevent pregnancy
**Lower serum androgens --> OCPs INCREASE production of SHBG = binds extra free testosterone and DECREASES overall free testosterone level (active form)
- Block adrenal androgen production, LH secretion, and LH-dependent ovarian androgen production --> reduce hirsutism


Post-menopausal woman is shown to have R adnexal mass on physical exam. What 2 tests should be done regardless?

1) Transvaginal ultrasound
2) Cancer antigen 125 (CA-125) level

If CA-125 increased = ? ovarian cancer
If US shows simple cyst and CA-125 normal = follow conservatively


What are 3 important side effects of OCPs?

What commonly thought s/e if NOT true?

1) Breakthrough bleeding (decreased levels of estrogen in some pills)
2) HTN
3) Risk of venous thromboembolism

*Wt gain NOT a s/e!


How does PCOS lead to anovulation?

Abnormal GnRH secretion = HIGH LH and low FSH
- High LH = excess testosterone production --> hirsutism, acne, virilizaiton
- Low FSH = no development of follicles/ovulation


When is Rhogam (anti-Rh factor) given in pregnancy?

Only to Rh(-) moms

1) 28-32 weeks gestation
2) Within 72 hours of delivery


What findings indicate severe pre-eclampsia?

*Elevated BP (>140/90) in previously normotensive pt & proteinuria
end-organ injury
- Low platelets
- Elevated creatinine (renal insuff)
- Elevated LFTs
- Neurologic s/s (reflexes, altered mental status)
- Pulmonary edema


What 2 areas must be addressed in treatment of severe preeclampsia?

1) HTN --> hydralazine or labetalol
2) Seizure risk --> magnesium sulfate


All sexually active women under 24 yo should be screened for what disease(s)?
What test is used?

Chlamydia & Gonorrhea --> can cause cervicitis, which may be asymptomatic & eventually lead to PID

Nucleic acid amplification test (NAAT)


2 features of Kallmann syndrome?

Low/no GnRH secretion (low LH & FSH)


3 months after delivery of her child, woman still has frequent episodes of dark bloody vaginal discharge. She also has enlarged uterus. CXR shows multiple b/l infiltrates of varying sizes. What is the best next test?

b-HCG --> r/o choriocarcinoma!

*Irregular vaginal bleeding beyond 8 weeks postpartum = suspicious for Gestational Trophoblastic disease

Choriocarcinoma is highly metastatic, esp lungs!


What should be suspected in any postpartum woman with pulmonary symptoms and multiple nodules on CXR?

How to confirm?


Elevated B-HCG


What is the cutoff for gestational HTN and preeclampsia?

More than 20 weeks gestation


Most important risk factor for abruptio placentae?



In severe pre-eclampsia, what is the best treatment in regards to delivery?

Augment labor --> ONLY do C-section if originally indicated


Mammary gland enlargement, whitish vaginal discharge, and mild vaginal bleeding are seen in a newborn. What is this from and what tx is needed?

Physiologic response to transplacental maternal estrogen exposure

Normal response


How is blood pressure affected by OCPs?

Their effect on endometrial and ovarian cancer?

Cause HTN!

REDUCE endometrial cancer --> due to progestin in OCPs
REDUCE ovarian cancer --> due to ovulation suppression


What disorder is characterized by increased Inhibin A? What else is increased?

What condition had low b-HCG and Inhibin A?

What condition has high aFP?

Trisomy 21 - also have high b-HCG

Trisomy 18

Neural tube defects


Woman with no prior skin conditions has an eczematous rash over nipple/areola that has not improved with topical treatments. What is it?

What associated finding is present?

Paget disease of the breast

Underlying ADENOCARCINOMA that has spread via lymphatics and mammary glands to skin surface


In secondary amenorrhea (had menarche), after a b-HCG, what is the appropriate test to perform?

After pregnancy, need to r/o other causes of amenorrhea:

**Prolactin, TSH, FSH levels


3 maternal conditions responsible for neonatal polycythemia at birth?

Pre-eclampsia (in-utero hypoxia)
Smoking (in-utero hypoxia)
Maternal diabetes (poor placental gas exchange)


Is leukocytosis and shaking chills normal during and immediately following delivery?

Yes - these and vaginal discharge (lochia) are normal findings


Frequency of mammography?

Every 2 years starting age 50 up to age 75


Is there a risk in giving or recently having the rubella vaccine (or MMR) if you recently discovered you are pregnant?

NO - the rubella vaccine has not been found to cause significant fetal harm

The wild-type rubella is dangerous


Why do obese women have less menopausal s/s than normal wt women?

During childbearing years, estrogen production is mainly in the OVARIES

During menopause, ovaries stop making estrogen --> there is aromatase in peripheral fat and this causes additional estrogen formation during these years and lessens the side effects of menopause


Any woman over 35 yo should be offered what testing?


Cell-free fetal DNA testing of maternal plasma

>10 wks


35 yo woman w/ history of breast surgery has retracted R nipple with fixed mass on upper quadrant of breast. Mammogram shows coarse calcifications and FNA reveals foamy macrophages with fat globules. What is this?

Fat necrosis of the breast

*Fat globules and foamy histiocytes

No treatment needed --> self-limited condition


Role of hCG in early pregnancy?

Maintain corpus luteum in order to continue progesterone secretion until placenta can take over


27 yo woman comes in with 1yr history of infertility and mild chronic pelvic pain. Exam shows enlarged L adnexa and ultrasound shows homogeneous cystic-appearing mass on L ovary. What is the diagnosis?


**Infertility with chronic pelvic pain and ovarian mass**

Infertility because of inflammation and adhesions in fallopian tubes and uterus


What type of decelerations are SYMMETRIC to contractions and the nadir of the deceleration corresponds to the peak of the contraction?

What are causes?

Early decelerations

Fetal head compression


Type of deceleration whose onset is delayed compared to the contraction. The nadir of the deceleration occurs after peak of the contraction?


Late decelerations

Uteroplacental insufficiency
Fetal hypoxia
Fetal acidosis


Type of deceleration that can be (but not necessarily) associated with contractions. They are usually abrupt (

Variable decelerations

Umbilical cord compression
Cord prolapse out of uterus (into vagina)


Tamoxifen has 2 dangerous complications?

1) Increased risk of endometrial cancer
2) Increased risk of venous thrombosis


How does pregnancy effect thyroid levels?

*b-HCG stimulates thyroid hormone production --> increased T4 and T3
b-HCG shares common a-subunit with TSH

*Increased estrogen levels --> increased levels of SHBG and TBG --> binds more thyroid hormone in the blood --> have slight increase in T4 & T3 levels

*The increased T4/T3 causes DECREASED TSH levels


What is a common cause for IUGR?

Maternal HTN


What characterizes arrest of labor?

No cervical change for:
>4hrs with adequate contractions
>6hrs with inadequate contractions


How does epidural anesthesia affect the bladder?


Impairs afferents and efferents from bladder --> can't sense bladder fullness and contract the bladder voluntarily

Results in urinary retention and overflow incontinence

Tx: short-term indwelling catheter


Post-menopausal woman has vulvar itching and the vulvar skin is thin, dry, and white in color. What is it?


What complication must you r/o?

Lichen sclerosus

Tx: corticosteroid cream (inflammatory condition)

SCC (biopsy)


Woman with hirsutism and amenorrhea also has enlarged clitoris and temporal balding. What is the best way to differentiate b/w ovarian or adrenal cause of excess androgen synthesis?

Testosterone, DHEAS

**DHEAS = sulfated form of DHEA that is ONLY made from adrenals**

High testosterone, normal DHEAS = ovary
High DHEAS, normal testosterone = adrenal


Best option for post-coital contraception?

Levonorgestrel/ulipristal --> delays ovulation


Adolescent with acute abnormal uterine bleeding - what is the best initial treatment?

High-dose estrogen (moderate-severe bleeding)


If mom has hx of Hep C, what should be given during the prenatal hx?

Hep A + Hep B vaccines (inactivated) if not already received

*NEVER give ribivarin for Hep C if pregnant = teratogenic


In a NST, what is "normal"?

2+ FHR accelerations w/in a 20-minute period


In women with suspected PID, what other tests should be performed?

Syphilis (RPR)
Hep B
Pap smear


Sign of placenta previa?

Risk factors?

PAINLESS 3rd trimester vaginal bleeding

*Prior C-section


When should you suspect antiphospholipid antibody syndrome?

What findings are present on labs?


*Hx multiple spontaneous abortions

Labs: low platelets, prolonged PTT



Postpartum mom who fails to lactate and has history a excessive blood loss during delivery?

Sheehan syndrome
*Also may have signs of hypothyroidism/hypogonadism


Best test for suspected intra-uterine fetal demise?

Real-time ultrasonography --> demonstrate absence of fetal movement and cardiac activity


If IUFD occurs, and it is the first time occurring, what is the best course of action?

Autopsy of fetus and placenta to determine the cause


15 yo girl has not had her first period yet. She has a short vagina, no uterus, and 2 normal sized ovaries on US. What is the cause?

Mullerian agenesis --> congenitally absent uterus, cervix, upper vagina


Maternal C/I to breastfeeding?

Only neonate C/I to breastfeeding?

Untreated TB
Maternal HIV infection
Herpetic breast lesions
Varicella infection


What must be checked in someone with PPROM?

Check GBS status --> give penicillin to prevent transmission


Women with PCOS have what 2 common symptoms?

At risk for what cancer?

Menstrual irregularities + hyperandrogenism

*Endometrial cancer --> constant and excessive estrogen causes mitogenic stimulation of endometrium


Woman with previous C-section is in labor and suddenly develops diffuse abdominal pain, fetal HR decelerations, and the fetus moves from station 0 to station -2. What is the cause?

Uterine rupture

*Loss of fetal station = suspect uterine rupture