OBGYN Flashcards
1
Q
GBS screening
A
Every woman should have vaginorectal GBS swab done at 35-37wks GA
2
Q
GBS prophylactic treatment indications
A
If no swab was done, tx based on following risk factors:
- Preterm labour <37wks
- Maternal temp >38C (suggests chorioamnionitis)
- Prolonged rupture of membranes >18h if symptomatic
- GBS bacteriuria in pregnancy
- Prev GBS w/ documented early onset GBS sepsis
3
Q
GBS antibiotic treatment
A
Penicillin G 5 million units IV x1 then Penicillin G 2.5million U IV q4h until delivery
If Pen allergic, but no risk of anaphylaxis –> Ancef 2g IV x1, then Ancef 1g IV q8h
If pen allergic and risk of anaphylaxis, clindamycin 900mg IV q8h
If resistant to clindamycin, use vancomycin
4
Q
Maternal fever intrapartum
A
> 38C
Suggests chorioamnionitis
Initial management: Rehydration, frequent temp checks, continuous fetal monitoring
5
Q
Gestational diabetes screen
A
Record date, gestational weeks, +ve or -ve result of screening test btwn 24-28wks gestation
6
Q
Stage 1 of labour
A
Onset of contractions - 10cm dilation
Latent: 0-4cm
Active: 4-10cm
7
Q
Stage 2 of labour
A
10cm dilation –> baby comes out
latent: 10cm dilation
Active: pushing
8
Q
Stage 3 of labour
A
Baby comes out –> placenta delivered
9
Q
Stage 4 of labour
A
Placenta delivered –> 1h post partum
10
Q
Cord blood samples taken at
A
2-3min post-birth, up to 20min max
11
Q
Normal values of fetal venous blood gas
A
Arterial pH: 7.21-7.35
Venous pH: 7.3-7.4
12
Q
When to get intrapartum fetal scalp blood sampling
A
Atypical/abnormal FH tracings
>34 wks GA when delivery not imminent
Cervix dilated at least 3cm, cephalic presentation, ruptured membranes
13
Q
Results of fetal scalp blood sampling
A
pH >/= 7.25 –> repeat if FHR abnormality persists
pH 7.21-7.24 –> repeat within 30mins or consider delivery if rapid fall since last sample
pH = 7.20 –> DELIVER
14
Q
Results of lactate scalp testing
A
<4.2 = normal 4.2-4.8 = Repeat within 30min >4.8 = DELIVER
15
Q
APGAR Scores
A
Appearance - colour Pulse Grimace Activity Respiration Max out of 10 (0, 1, 2 for each category)
16
Q
Normal IA
A
110-160bpm
Regular rhythm
Absence of decelerations
Presence of accelerations
17
Q
Abnormal IA
A
HR <110 or >160
Irregular rhythm
Presence of decelerations
Absence of accelerations over prolonged period
18
Q
Frequency of IA
A
Low risk pregnancy
Latent phase of stage 1: q1h
Active phase of stage 1: q15-30min
Stage 2: q5-15min
High risk pregnancy
Stage 1: q15min
Stage 2: q5min
19
Q
Grades of variability
A
Absent
Minimal (undetectable to = 5bpm)
Moderate/normal (6-25bpm)
Marked (>25bpm)
20
Q
Reasons for decreased variability
A
Benign: Fetal sleep, very premature (<28wks)
Concerning: Hypoxic acidosis, anemia (<70g/L), congenital anomalies
21
Q
Reasons for marked variability
A
Maternal stimulant ingestion, hypoxia
22
Q
Normal accelerations on EFM
A
Term: >/= 15bpm above baseline for >/= 15s
<32wks: >/=10bpm for = 10s
23
Q
Prolonged accelerations/decelerations
A
> /=2 min
24
Q
Late decelerations
A
Gradual, shallow decrease (onset to nadir is >/=30s) a/w contraction
25
Sinusoidal pattern on EFM
Smooth, rhythmic undulating wave-like pattern for >20min
May be a/w severe fetal anemia
If less smooth and accelerations present, more likely to be benign (narcotic admin, fetal thumb sucking)
26
Normal variation of contractions
no more than q2min (5 in 10min)
27
Fetal movements
Count up to 6 or at 2h
Call if <6 in 2h
Recommended to be aware of movement counting if healthy/no risk factors at 26-32wks
Daily counting recommended for women with risk factors at 26-32 wks
Daily counting for identified complication once fetus viable
28
Perform NST 2x weekly for
Post-date pregnancy
| Insulin-treated GDM
29
Contraction stress test
3 contractions of 60s each in 10min period to assess fetal heart rate
Via nipple stimulation or oxytocin IV
+ve result if late decelerations occur with >50% contractions --> proceed with delivery
30
Conditions a/w risk for placental insufficiency
HTN
Diabetes or other conditions predisposing to HTN
IUGR
Oligohydramnios
31
Kleihauer-Betke Test
Extent of fetomaternal hemorrhage by estimating volume of fetal blood that entered maternal circulation
32
Rhogam
Rh IgG
Give to Rh- mom at 28wks and within 72h of delivering Rh+ baby/+ve Kleihauer test/invasive procedure/ectopic preg/miscarriage/APH
33
Consequences of Rh antibody in fetus
Fetal hemolytic anemia -> heart failure --> fetal hydrous or erythroblastosis fetalis (immune-mediated hemolytic anemia)
34
IUPC readings
Contractions adequate if at 50-60mmHg above baseline
35
Tachysystole
>5 contractions over 10minutes
36
Keep infusing epidural until
End of 3rd stage
37
Bishop Score
Rates readiness of cervix for induction of labour (success of vaginal delivery)
1. Effacement (%)
2. Station (scale 1/5)
3. Consistency (soft, medium, firm)
4. Dilation
5. Position
= 5 --> labour unlikely to start without induction
>/= 9 --> labour likely to start spontaneously
38
Delayed cord clamping
30-60s recommended for term infants
Pro: Increases Fe stores in 6mo of age
Con: Increased risk of hyperbili, polycythemia in IUGR
39
Placental separation signs
1. Elongation of umbilical cord
2. Uterus contracts and rises
3. Gush of blood
40
Average blood loss at vaginal delivery
< 500mL
41
Cardinal movements of labour
```
Extension
Descent
Flexion
Internal rotation
Extension
Restitution and external rotation
Expulsion
```
42
Dystocia definition
Active first stage = >4h of <0.5cm/h dilation or no dilation over 2h
Active second stage: >1h of active using without descent of presenting part or no cervical dilation over 2h
43
Etiology of first stage dystocia
```
4 Ps:
Power
Passage
Passenger
Psyche
```
44
Etiology of second stage dystocia
Uterine inertia
Fetal malposition
Cephalopelvic disproportion
45
Maneuver used in shoulder dystocia
McRoberts maneuver - flex mom's thighs back against abdomen
46
GBS bacteriuria treatment
Bacteriuria >/= 10^4 CFU/mL --> amoxicillin, penicillin or cephalexin 3-7d (at time of dx PLUS abx during delivery)
Bacteriuria < 10^4 CFU/mL --> No tx required, abx during delivery
47
Maternal intrapartum fever tx
Ancef 2g IV q6h + Flagyl 500mg IV q8h until 24h afebrile
48
Major complication of PPROM at <18-20 weeks
Pulmonary hypoplasia secondary to severe oligohydramnios (disrupts canalicular phase of respiratory development)
49
Pre-term labour dx
>20wks but <37wks
Dx needs regular contractions (>/= 4/20min or 8/60min) PLUS at least 1 of:
Cervix >/= 2-3cm
>80% effacement
Progressive cervical change (cervical length <20mm on transvag US OR cervical length <30mm w/ +ve fetal fibronectin)
50
Fetal fibronectin
FIRST TEST to do on sterile speculum exam for premature labour work-up (can't have anything in vagina for prev 24h)
Protein used to help "glue" amniotic sac to lining of uterus
Detected in vaginal d/c toward end of pregnancy
If +ve btwn 22-34wks --> increased risk of preterm labour
If -ve --> not likely to deliver in next 2wks
51
Steroid use for lung maturity
Give if 24-34 wks GA
Starts working at 18h, full benefit at 48h, lasts 7d
Betamethasone 12mg IM q24h x 2 doses (preferred)
Or Dexamethasone 6mg IM q12h x 4 doses
52
Tocolytic
Prolongs delivery for ~48h to achieve full benefit of steroids in maturing lung, enable transfer, etc.
Indocid 100mg supp PR PR x 1 dose then 25mg PO q6h x 48h if <32wks
Adalat PA 10mg q20min max 4 doses then 4h later Adalat XL 30mg BID x 48h
53
Antibiotics given for PPROM
Increase latency and decrease risk of chorioamnionitis
Ampicillin 2g IV q6h x 48h AND erythromycin 250mg IV q6h x 48h THEN amoxicillin 500mg PO q8h x 5d AND erythromycin 333mg PO q8h x 5d
OR mono therapy Erythromycin 250mg PO q6h x 10d
If pt goes into labour and don't know GBS status --> switch to Pen G intralabour
54
Overall tx for preterm labour
```
Bed rest
Hydration - 500mL NS bolus, 125cc/h if dehydrated
Steroids
Tocolytics
MgSO4
GBS prophylaxis
```
55
Overall tx for PROM
Steroids if appropriate
| Abx to increase latency
56
Components of biophysical profile
```
BATMAN:
Breathing
Amniotic fluid volume
Tone
Movements
alright alright alright
NST
```
Score out of 10 based on 30min U/S
57
C/I to MTX tx for ectopic pregnancy
```
IUP
Ruptured
Renal/hepatic dysfunction
Immunodeficiency
Breastfeeding
```
58
MTX selection criteria for use in treating ectopic pregnancy
Hemodynamically stable
No C/I
hCG = 5000mIU/mL
No fetal cardiac activity detected on TVUS, size <3-4cm
59
Medical abortion up to 10wks GA
Mifepristone + Misoprostol
60
Medical abortion up to 7wks GA
Methotrexate + Misopristol
61
Medical abortion in 2nd trimester
Mifepristone + Misoprostol
62
Induction abortion
>16wks (usually >18wks)
Fetal demise induced by KCl or Digoxin
Misoprostol +/- Mifepristone for expulsion
63
Pre-existing HTN
BP > 140/90 BEFORE 20wks GA and persisting >7wks postpartum
64
Gestational HTN
Systolic >/= 140 OR diastolic >/= 90 in prev normotensive pt found >/= 20wks GA
65
Antihypertensives to avoid in pregnancy
ACEi, ARBs, Prazosin, Diuretics, Atenolol
66
Antenatal steroids for lung maturity considered in < ___ wks
34
67
Postpartum blood pressure
Increases by 3-4d PP, settles on its own
| if not back to normal by 12wks PP = chronic HTN
68
Goals for diabetes in pregnancy
Fasting glucose =5.3
Random glucose =7.8
2h post-prandial =6.7
69
Induce labour by... in pregnant diabetes patients
38 wks
70
Screening options for GDM
1 step Fasting 75gOGTT
| 2 step: Non-fasting 50g OGTT --> Fasting 75g OGTT
71
1 step 75g OGTT results
GDM if >/=1 of:
Fasting: 5.1
1h PG: 10.1
2h PG: 8.5
72
2 step 50g/75g OGTT results
```
Non-fasting 50g
1h PG: >/= 11.1 --> GDM
if 7.8-11 --> proceed to step 2
Fasting 75g: GDM if >/= 1 of
FPG >/= 5.3
1h PG >/= 10.6
2h PG >/= 9
```
73
Kleihauer Betke Test
Tests amount of maternal-fetal hemorrhage
| Used to help dose rhogam
74
L/S Ratio
Lecithin-Sphingomyelin ratio
Passes freely into amniotic fluid in last 3mo of pregnancy
Lecithin rises in amniotic fluid but sphingomyelin stays same --> L/S ratio increases = babies lungs are ready
75
Apt test
NaOH mixes with blood
Pink = fetal blood
Yellow = Maternal blood
To test for vasa previa
76
PPH
>500cc in vaginal delivery
>1000cc in CS
Within 24h after delivery
If >24h-12wks - delayed/late/secondary PPH
77
4Ts of postpartum hemorrhage
Tone
Tissue
Thrombin
Trauma
78
Drugs of choice for PPH management
Oxytocin 20-40U in 1L, wide open
Ergot 250mg mcg IM or IV q2-4h
hemabate 250mcgIM q15min to max of 8 doses
79
Ergot C/I
HIV meds or HTN hx
80
Hemabate C/I
Asthma
81
Uterus vascular supply
Uterine artery
| Utero-ovarian artery (from ovarian artery)
82
Factor V Leiden
Factor V mutation that affects its interaction with Protein C (natural anticoagulant)
83
Prothrombin gene mutation
Prothrombin = thrombin precursor -- cleaves fibrinogen to fibrin
84
Hemoglobin level that you start to worry about pathologic anemia
<105g/L
85
TSH targets
1st trimester: <2.5
| 2nd/3rd trimester: <3.0
86
Most common cause of hypothyroidism
Chronic AI thyroiditis
87
Most common cause of hyperthyroidism
Graves' dz
88
Gestational hyperthyroidism
Physiologic thyroid stimulation from hCG levels in early pregnancy
Generally no tx required
Possible tx: Propranolol - antithyroid activity
89
Graves' tx
Propylthiouracil during preconception and 1st trimester
| Methimazole after 1st trimester
90
Imaging test to tell you fallopian tubes open
Hysterosalpingogram
91
Endometriosis staging
```
I = minimal
II = mild
III = moderate
IV = severe
```
92
Most common type of cyst found in women age 20-40yo
Dermoid cyst/teratoma
93
Outpatient empiric abx tx for PID
Cefoxitin or Ceftriaxone IM x 1 + 14d doxy + metronidazole
3rd gen cephalosporin --> Gonorrhea
Doxy --> chlamydia
Metronidazole --> anaerobes
94
Inpatient abx tx for PID
Cefoxitin 2g IV q6h x 24h
Doxycycline 100mg PO q12h
Metronidazole 500mg IV q12h
95
Perimenopause
Period prior to menopause and first year after
96
Menopause
12 consecutive months of amenorrhea with no other pathologic or physiologic cause
<1000 oocytes
High FSH due to low Estrogen
97
Premature ovarian insufficiency
Menopause occurring 2SDs below mean (typically <40s)
Amenorrhea for >4mo preceded by duration of disordered menses
FSH >30mIU/mL x2 at least 1 mo apart
98
Infertility
* Inability to conceive within 20mo of
* Unprotected regular coitus
* Lack of contraception with risk for pregnancy
* OR 12mo of donor inseminations
99
Principle steroid of post-menopausal ovary
Androstenedione
100
Potency of estrogens
17-B estradiol > estrone > estriol
101
3 symptoms that vaginal estrogens are used for
Recurrent UTIs
Vaginal atrophy
Urge symptoms
102
C/I to estrogens
```
Unexplained vaginal bleeding
Active VTE
Stroke hx
E-dependent cancer
Coronary heart disease
Acute liver dysfunction
```
103
Normal vaginal discharge findings
Aymptomatic
pH 4-4.5
Wet mount - epithelial cell, lactobacilli
Amine/KOH test - negative
104
Candidiasis
Pruritus, tenderness, dyspareunia
Erythema, thick "cottage cheese-like" discharge
pH 4-4.5
Wet mount - pseudohyphae
Amine/KOH test - negative/pseudohyphae
Tx - fluconazole, boric acid (only if symptomatic)
If complicated/recurrent:
- Fluconazole 3 doses then weekly for 6 months
- Topical azoles for 14d
- Boric acid 300mg for 14d then 5d per month
105
Bacterial vaginosis
```
Malodourous thin grey discharge
Adherent discharge
pH > 4.5
Wet mount - clue cells, PMN
Amine/KOH - Positive
Tx:
Asymptomatic - treat only if pregnant, prior to IUD insertion or gene procedure
Symptomatic - flagyl PO, flagyl gel, clindamycin cream
```
106
Trichomoniasis vaginalis
Malodourous, white/yellow discharge
Strawberry cervix
pH > 5-6
Wet mount - Motile, flagellated protozoan
Amine/KOH test - negative
Tx - Metronidazole 500mg PO BID x 7d or Metronidazole 2g PO x 1
107
Cytolytic vaginosis
```
pH 3.5-4.5 (acidic)
Wet mount- no WBCs, false clue cells
Amine/KOH - negative
Tx - Sodium bicarb douching or sitz baths (1 tbsp in 2 cups warm water, 3x/wk)
Improves within 3 wks
```
108
Desquamative inflammatory vaginitis
```
Pain and diffuse discharge
Vaginal inflammation
pH > 4.5
Profuse WBCs
Tx: 2% clindamycin cream qhs for 14d or 25mg HC suppository ohs for 14d (may require tx for 4-6wks)
```
109
Lichen sclerosis
Childhood to elderly affected
Hypopigmentation, ivory white papules/plaques, thin skin, hour-glass figure affected (excludes vagina), can cause anatomical change (ie. loss of labia/clitoral anatomy)
Tx - bx to R/O cancer, barrier cream, clobetasol propionate 0.05% ointment
110
Lichen simplex chronics
Primary - chronic scratching
Secondary - incomplete tx of eczema, dermatitis, atopic dermatitis
Thickened, leathery and increased skin markings
Tx - remove irritants (most common = overwashing/medicating), restore barrier, topical steroids ointment (triamcinolone, clobetasol)
111
Lichen planus
Can cause loss of labia/normal clitoral anatomy
Very painful/burning/sig dyspareunia
Tx - high potency topical corticosteroid (ie. clobetasol), tacrolimus as 2nd line
112
Provoked vestibulodynia (PVD)
Allodynia of introitus and modest amount of pelvic muscle hypertonicity
Burning, ripping, tearing pain
Type of chronic pain syndrome (often comorbid with other pains ie. TMJ, IBS)
113
Vaginismus
Extreme form of pelvic muscle hypertonicity plus further reflexive peri-vaginal muscle tightening
NOT burning ripping, tearing pain
114
Rotterdam Criteria
```
Androgen excess (hirsutism and/or high serum free T levels)
Ovulatory dysfunction (mid-luteal phase serum progesterone)
PCOS
```
115
Oligomenorrhea
Infrequent menstrual cycles (>/=35d cycles)
116
Clomiphene citrate
SERM
Blocks E receptors at pituitary and hypothalamus --> blocks negative feedback --> increased FSH and LH secretion --> multiple follicular growth --> multiple ovulation
Take days 3-7 of cycle
117
Letrozole
Aromatase inhibitor
Take days 3-7 of cycle
Suppresses ovarian estradiol secretion --> reduces E negative feedback at pituitary and hypothalamus --> increased FSH --> multiple ovarian follicle stimulation
118
Primary amenorrhea
No menses by 14yo and absence of sex characteristics OR no menses by 16yo with presence of sex characteristics
119
Secondary amenorrhea
Previous hx of menstruation AND no menses for 3 cycles or 6months
120
Polyp treatment
```
Premenopausal and symptomatic --> remove
Premenopausal and asymptomative, remove if have risk factors for endometrial hyperplasia/CA OR IF :
- polyp >1.5cm in diameter
- multiple polyps
- infertility
- prolapsed through cervix
Postmenopausal --> remove ALL polyps
```
121
Types of uterine fibroids
Submucosal
Intramural
Subserosal
122
Conservative approach for uterine fibroids appropriate if:
Symptoms absent/minimal
Fibroids <6-8cm in size
Not submucosal (more likely to be symptomatic)
Pregnant
123
GnRH agonists
Leuprolide
Danazol
Used short term (6mo) pre-hysterectomy/myomectomy to reduce fibroid size and reduce bleeding
124
Ulipristal acetate
Partial progesterone receptor agonist
125
Tranexamic acid
Anti-fibrinolytic which helps with heavy menstrual bleeding
126
Ovarian tumour marker
CA 125
Protein expressed on membrane of normal ovarian tissue and ovarian carcinomas
<35 U/mL is normal
127
U/S criteria for spontaneous miscarriage/nonviable pregnancy
Intrauterine pregnancy
Mean sac diameter >25mm with no yolk sac or embryo
CRL >/= 7mm with no cardiac activity
Absence of embryo with heartbeat >/=2wks after scan that showed gestational sac w/o yolk sac
Absence of embryo with heartbeat >/= 11d after scan that showed gestational sac w/ yolk sac
Typically repeat U/S in 1-2 wks for F/U and official dx
128
Ovarian torsion treatment
Repro aged women: Lap ovarian detorsion +/- ovarian cystectomy (preferred 6-8wks later) +/- oophoropexy (teens with long suspensory ligaments)
Older women: Salpingo-oophorectomy
129
Endometriosis treatment
1st line - OCP & NSAID
2nd line - Progestin
3rd line - GnRH agonist (Lupron)
3rd line - Aromatase inhibitor (Letrazole)
130
Best imaging for PID
TVUS
| Abdo CT not helpful
131
Potential complications of PID
```
Recurrence
Ectopic pregnancy
Fitz-Hugh Curtis Syndrome
Infertility
CPP
Reiter's Syndrome
TOA
Hydrosalpinx (fallopian tube filled/blocked with sterile fluid)
Chronic salpingitis
```
132
Tubo-ovarian abscess tx
If hemo unstable --> surgical intervention
| If hemorrhage stable, <9cm abscess, adequate response, pre-menopause --> abx (cefoxitin and doxy)
133
Partner traceback for STI goes back...
60d
134
Chlamydia follow-up
Test of cure not needed, but can be done in 4wks
| Rescreen should be done in 6mo
135
Monozygotic twins that divide at day 3
Dichorionic diamniotic
136
Monozygotic twins that divide at days 4-7
Monochorionic diamniotic
137
Monozygotic twins that divide at days 8-13
Monochorionic monoamniotic
138
Hormone involved in gestational diabetes
Human placental lactogen (HPL)
139
Pulmonary TB xray finding
Hilar adenopathy
140
I:E ratio
Normally 1:1 or 1:2
| In obstructive disorders, expiration is PROLONGED and ratio is decreased
141
Levonorgestral IUD MOA
Thickens cervical mucous (primary)
| Endometrial thinning
142
Copper IUD MOA
Biochemical and morphological changes to endometrium
Affect sperm motility
Affects tubal transit
Toxic to sperm
143
Depo Provera (Progestin) MOA
Inhibits secretion of FSH and LH from pituitary
Increases thickness of cervical mucus
Thins endometrium
144
Combined OCPs MOA
Suppression of pituitary release of LH and FSH (inhibits ovulation)
Increased cervical mucous
145
1st trimester screening tests
Dating ultrasound
Chorionic villus sampling
1st trimester combined screen (NT U/S and hCG/PAPP-A blood test)
NIPT (starts at 10 wks)
146
Chorionic villus sampling
Chromosomal abnormalities
| No NTD data
147
2nd trimester screening tests
Detailed U/S
Amniocentesis
Quad
148
Quad screening tests
hCG, Inhibin A, AFP, Estriol
| Do if mom comes for screening for first time in 2nd trimester
149
Amniocentesis
```
Chromosomal abnormalities (more accurate than CVS)
AND NTD data
```
150
NIPT
Tests for cell-free fetal DNA circulating in maternal serum
Less invasive
Not covered by MSP yet
If positive, F/U with CVS or amniocentesis
151
SIPS
```
Blood tests taken at 10-13wks and 15-20 wks
Tests for chromosomal anomaly and NTD
1st blood test hCG, PAPP-A
2nd blood test is quad
Offered to all pregnant women
```
152
IPS
SIPS + Nuchal Translucency
153
Contraindications for labour induction
```
Prior CS
Uterine rupture
Any incision into uterus
Placenta or vasa previa
Active genital herpes
Cord prolapse
Invasive cervical CA
Already having regular uterine activity (>/= 2 contractions/10min)
```
154
Contraindications for mechanical/foley induction
Low lying placenta (relative C/I)
| GBS is NOT a C/I
155
Opioid use in labour
Latent stages --> IM morphine
| Active labour --> IV Fentanyl
156
Assessment for PPROM
- Sterile speculum exam - nitrizine, ferning, cervical/vaginal swabs for C&S, GS, chlamydia, vaginal/rectal swab for GBS (if not already done)
DO NOT DO VE b/c of increased risk of infection
Urinalysis
CBC
U/S
157
Assessment for preterm labour
```
Sterile speculum exam - fetal fibronectin, vag/cervical swab for C+S, GS, chlaydia, vaginal-rectal swab for GBS, nitrazine and ferning if suspect PPROM
If no PPROM --> do VE
CBC
Urinalysis
U/S
```
158
Functional cyst
Failure of follicle to rupture during ovulation
159
Corpus luteal cyst
Failure of corpus luteum involution
160
Theca lutein cyst
Hyperstimulation of luteinized follicles from high hCG
161
Types of ovarian cyst histology
Serous
Mucinous
Endometroid
Clear cell
162
Ovarian neoplasm that classically produces severe irritation from chemical peritonitis
Mature cystic teratoma
163
Contraindications to progesterone contraception
```
Pregnancy
Current PID
Progesterone receptor +ve breast CA (current or hx)
Uterine abnornality
AUB not yet investigated
Known endometrial CA
Pelvic TB
Severe liver dz
Postpartum >48h and <4wks
```
164
Depo Provera S/Es
```
Weight gain
Amenorrhea, irregular bleeding
Acne
Delayed return to fertility
Decreased BMD
```
165
Combined OCP C/I
```
<4wks postpartum if breastfeeding
<21d postpartum if not breastfeeding
Smoker >35
Vascular dz
HTN
Migraine with aura
Hx of stroke
Known thrombophilia
Current breast CA
Acute DVT
Liver dz, SLE with APLAs
```
166
Combined OCP reduces risk of certain types of cancer
Endometrial, ovarian and colorectal cancer
167
Plan B
Levonorgestrel high dose
Up to 5d after unprotected intercourse
Not for women BMI >25
Only works if taken before LH surge
168
Ulipristal Acetate
```
Selective progesterone receptor modulator
Up to 5d after unprotected intercourse
Works better for women BMI >25
Can interrupt ovulation
Rx only
```
169
Most effective emergency contraception
Copper IUD - within 7d
| Best if BMI > 30
170
4 signs associated with likely miscarriage
* Embryonic bradycardia (FH <100bpm after 6wks)
* Small gestational sac size
* Enlarged or abnormal yolk sac (>5mm)
* Subchorionic hemorrhage
171
Uterine findings for ectopics
* Thickened endometrial interface
* Fluid or blood in endometrial cavity
* Pseudosac
* Decidual cysts
* Peritoneal findings 40-80% of ectopic pregnancies will have free fluid in pelvis
172
Typical protocol for miscarriage management
Pre-medicate: Tylenol, NSAIDs, gravol
Misoprostol 800mcg PV, one repeat dose if no effect at 24h
F/U at 48h
Home pregnancy test at 3 wks, call if +ve
2% have excessive bleeding and need emerg D&C
173
Urge incontinence
1 or more of
Freq >8 voids/24h
Nocturia >1x/night
174
DIAPPERS mnemonic
```
Delirium
Infection or inflammation
Atrophy
Pharmaceuticals (ie. diuretic)
Psychological
Excessive UO
Restricted mobility
Stool impaction
```
175
Medication commonly used for urinary incontinence
Anticholinergics (mirabegron, oxybutynin, tolterodine)
176
3 ligaments that attach sacrum to rest of pelvis
Sacroiliac
Sacrospinous
Sacrotuberous
177
4 muscles that border pelvic cavity
Levator ani
Obturator internus
Coccygeus
Piriformis
178
3 muscles that make up urogenital triangle
Bulbocavernosus
Ischiocavernosus
Superficial transverse perineal
179
3 components of levator ani
Pubococcygeus
Ileococcygeus
Puborectalis
180
Ovarian CA type more common in <20yo
Germ cell
181
Ovarian CA type more common in >20yo
Epithelial tumours
182
3 clinical features of molar pregnancy
hCG >100 000
Symptoms suggestive of molar -- hyperemesis, hyperthyroid, abnormal bleeding, pelvic pressure/pain, uterine size greater than GA
TVUS features of complete/partial mole
183
TVUS features of complete mole
Absence of embyro/fetus, amniotic fluid
Central heterogenous mass with many anechoic spaces (snowstorm pattern)
Ovarian theca lutein cysts
184
TVUS features of partial mole
Fetus may be identified, viable but growth restricted
Amniotic fluid present but volume low
Placental abnormal
THeca lutein cysts absent
185
___% of molar pregnancies will become GTN
10-15
| At lifelong risk
186
Molar pregnancy management
Uterine evacuation
Weekly bhcg until negative x 2
Partial mole can then stop monitoring
Complete mole continue monthly x 6mo
187
Risk factors for developing GTN after molar pregnancy
Complete mole with signs of trophoblastic proliferation (uterine size > GA, serum hCG levels > 100 000)
Ovarian theca lutein cysts >6cm in diameter
Age >35-40yo
188
GTN includes
Choriocarcinoma
Placental site trophoblastic tumour
Epithelioid trophoblastic tumour
Invasive mole
189
GTN diagnosis
hCG level plateaus across 4 measurements over 3 wks
hCG level increases >10% across 3 readings over 2 wk duration
Persistence of detectable serum hCG for >6mo after molar evaucuation
190
Low risk GTN management
Low risk --> MTX;
If resistant to MTX --> actinomycin D mono agent chemotherapy
If resistant to both --> hysterectomy
191
High risk GTN management
Etoposide, MTX and actinomycin D multi agent chemo
| May require surgery
192
GTN remission status
hCG undetectable for 3 consecutive weeks
193
Misoprostol
Prostaglandin E1 analog
194
Mifepristone
Antiprogesterone agent
195
First visible sign on U/S of pregnancy
Gestational sac
| Visible at 4 wks GA via TVUS
196
Structure that confirms pregnancy is intrauterine
Yolk sac
Distinguishes from pseudo gestational sac or anembryonic pregame
Seen at 5 wks
# yolk sacs = # pregnancies
197
Rhombencephalon
Anatomic landmark that helps distinguish head from tail in embryo at 7-8 wks
198
4-5wk GA on U/S
Gestational sac visible
| FHR or embryo occasionally visible
199
7-8 wks GA on U/S
```
Embryo and cardiac activity always visible
Head, body and extremities identifiable
Midgut herniation at wk 7
Rhombencephalon visible
CRL measurable
```
200
9-12 wk GA on U/S
Human features more distinct
Nuchal translucency after 11 wks
Babe completely formed by 12 wks
201
Protective factors against ovarian CA
OCP
Pregnancy breast feeding
Prophylactic salpingectomy
Hysterectomy (without removal of ovaries)
202
Most common form of ovarian cancer
High grade serous epithelial cancer
203
3 sets of cells that give rise to ovarian CA
Ovarian epithelium
Germ cells
Ovarian stroma
204
CA-125
Ovarian CA tumour marker
205
CA 19-9
Upper GI
Pancreas
Mucinous ovarian CA
206
CA 15-3
Breast CA
207
CEA
Colon CA
208
Bloodwork to order for germ cell tumour workup
AFP, LDH bHCG
209
Risk of Malignancy Score
U/S features:
- Multilocular cyst
- Presence of solid areas
- Bilaterality of lesions
- Presence of ascites
- Presence of intra-abdominal metastasis
1 = no or one abnormality
4 = 2 or more abnormalities
Premenopausal: +1
Postmenopausal +4
Abnormality score x pre or post-menopausal score x CA125 level
210
Ovarian CA Staging
```
I = Limited to ovaries
Ia = 1 ovary
Ib = 2 ovaries
Ic = Rupture
II = Ovaries and pelvic extension
III = Mets to peritoneum/retroperitoneum/superficial liver mets
IV = distant mets beyond peritoneal cavity
```
211
Early decels associated with
Head squeeze
| Benign
212
Variable decels associated with
Cord compression
213
Late decels associated with
Uteroplacental insufficiency
214
Normal variations in contractions
No more than q2min (max 5/10min)
<90s duration
Coupling or tripling
Moderate-strong intensity on palpation (>25mHg but <75-80mmHg above baseline per contraction via IUPC)
Soft resting tone btwn contractions for at least 30s
215
Intrauterine resuscitation
```
Change maternal position
D/C oxytocin
O2 by mask
Hydrate
Vaginal exam to confirm dilatation and descent
Keep mom calm
```
216
Workup for abnormalities in fetal movement counts
U/S
NST
If NST normal --> resume daily fetal movement counts. If risk factor add AFI and umbilical artery doppler study as part of ongoing fetal surveillance.
If NST atypical --> Repeat NST later or next day, CST, AFI and umbilical artery doppler
If NST abnormal: Sonographic assessment (growth, AFI, UA doppler), BPP, CST, consider delivery
217
Normal NST
Strong negative predictive value of stillborn in 7d after
218
Umbilical artery doppler done at
3rd trimester
219
Absent end diastolic flow management
<32wks: Increase FHS. Consider steroids.
| >/=32 wks: Delivery may be indicated. Consider steroids first.
220
Reverse end diastolic flow management
Delivery indicated, regardless of GA
| If steroids required, increase FHS until delivery
221
Symphysis fundal height
12 weeks = symphysis
16 weeks = mid way to umbilicus
20 weeks = umbilicus
SFH +/- 3cm from GA
222
Folic acid for low risk woman
0.4-1mg daily from 8-12wks pre-conception until 10-12wks post-conception
223
Folic acid for high risk woman
5mg daily from 8-12wks pre-conception until 10-12wks post-conception
Then multivitamin with 0.4-1mg of folic acid until 4-6wks after birth
224
Ideal fetal positioning
Occiput anterior
225
Pre-eclampsia prophylaxis
Daily ASA 81mg
226
Primary issue associated with hypertension in pregnancy
Poor placentation
227
1st line meds for hypertension in pregnancy
```
Labetalol
Nifedipine (long-acting CCB)
Methyldopa
```
228
Induce delivery at ___ wks for uncomplicated pregnancies with only occasional BP elevations
38-39wks
229
Induce delivery ___ wks for pregnancies with frequent high BPs
37 wks
230
Postpartum BP
Peaks 3-5d postpartum
Almost always back to normal by 12 weeks
If >/=12wks PP --> chronic HTN
231
Pre-eclampsia
GTN HTN plus one or more of:
| 1) New proteinuria (>30mg/mmol or >/=0.3g/d
(2) one or more adverse conditions/severe complications
232
HELLP Syndrome
Hemolysis
Elevated liver enzymes
Low platelets
233
MgSO4 for HELLP syndrome
Usually started at labour onset and continued 12-24h post-delivery
234
Eclampsia
Gestational HTN with seizures
| >/=1 generalized convulsion and/or coma in setting of pre-eclampsia
235
Eclampsia management
Aggressive management once diastolic pressure >/= 106 or systolic >/= 160
Hydralazine or Labetalol IV
MgSO4 to prevent recurrence
Deliver (irrespective of GA)
236
Fetal monitoring in eclampsia
NST, AFI or BPP weekly starting at 32wks GA
237
Velamentous cord insertion
Umbilical cord inserts into fetal membranes then travels within membranes to placenta --> exposed vessels vulnerable to rupture in early labour
If vessels near cervix = vasa previa
238
HPV strains associated with genital warts
6 and 11
239
HPV strains associated with cervical CA
16 and 18
240
Pap smear results that you can follow with cytology in 6mo
LSIL
| ASCUS (If <30 or no HPV DNA testing available)
241
HELLP Syndrome management
Deliver baby! Regardless of GA week. May be able to prolong slightly for steroids if <34wks and otherwise stable, do not prolong for >48h
242
MgSO4 antidote
Calcium glutinate
243
Risk of seizure from pre-eclampsia highest during...
24h postpartum
| Continue MgSO4 for 12-24h after delivery
244
Pre-eclampsia management
```
If stable, may admit and follow +/- decide to deliver if 34-36wks
If severe, stabilize and deliver
Manage BP (Labetalol, Nifedipine)
MgSO4
```
245
Insulin resistance in pregnancy
Increased
246
Frequency of HbA1c testing in pregnancy
Monthly
247
GDM F/U
2g OGTT at 6wk PP
248
Extra antepartum surveillance in GDM
2nd trimester onwards: Fetal echo, repeat urinalysis each semester, NST weekly, U/S biweekly (then weekly after 32wks)
249
Placenta previa C/S vs SVD
>2cm from os --> SVD
1-2cm --> gray zone
<1cm --> C/S
Any degree of overlap after 35 wks --> C/S
250
Placenta previa clinical presentation
Painless bleeding at 30wk GA
Uterus soft and non-tender
FHR usually normal
251
Placenta previa management
<37 wks and hemo stable --> expectant management
| >37wks and/or hemo unstable --> C/S
252
Most common cause of DIC in pregnancy
Placental abruption
253
Placental abruption clinical presentation
Acute painful vaginal bleeding usually at ~20wks GA
Shock out of proportion to apparent blood loss
+/- fetal distress
254
Dx of placental abruption
Clinical
U/S not sensitive
Kleihauer
255
Vasa previa definition, dx and tx
Fetal vessels pass over cervical os (a/w cord insertion, accessory lobes)
Painless vaginal bleeding and fetal distress
Dx:
- Apt test
- Wright stain - nucleated RBCs (fetal)
Tx: emergency C/S
256
Water under the bridge
Ureter travels UNDER uterine artery
257
Twin to twin transfusion syndrome
Arterial blood from donor twins passes through placenta into vein of recipient twin
258
Monochorionic monoamniotic management
NSTs twice a day, starting at 26 wks
Weekly U/S
C-section at 32weeks if stable
259
Dichorionic sonographic findings
2 separate placental sites
Inter-twin membrane is thick (4 layers)
Lambda or twin peak sign -- chorionic villic visible going up in between amnions
260
Dichorionic diamniotic management
Lowest risk
Recommend routine scans q4wks
Usually deliver by 38wks
261
Monochorionic diamniotic management
Risk of TTTS, TAPS, TRAP, sIUGR
Recommend routine scans q2wks starting at 16wks
Deliver by 36-37wks
262
Twin monitoring
Up to 28 wks --> q2wks
| 28-36wks --> weekly
263
Normal prenatal screening visits
Up to 28wks --> q4wks
28-36wks --> q2wks
>36wks --> weekly
264
hCG secreted by...
syncytiotrophoblasts
265
Progesterone produced by...
Corpus luteum until 10wks
| Then placenta
266
Respiratory changes in pregnancy
Increase TV, minute ventilation, inspiratory capacity
Decreased residual volume, expiratory reserve volume, functional residual capacity
No change in in vital capacity, RR, FEV1
267
Hypothyroid meds changes in pregnancy
Increase meds due to increased TBG and decreased GI absorption (double dose on Sat and Sun)
268
When to refer women for infertility
<35yo: 12mo of trying
35-39: 6-12mo of trying
>40: Within 3mo of trying
Unless irregular menses, hx of PID, endometriosis, poor semen analysis, abnormal fertility test = refer right away
269
Most common causes of infertility in couples
Tubal and pelvic pathology
| Male problems
270
Infertility female work-up
```
Ovulatory function:
Mid-luteal phase progesterone
Ovulation kits detecting LH surge
If abnormal, test ovulatory reserve:
Day 3 FSH (normal if <10) PRL, TSH, PCOS work-up
AMH (higher the better)
Antral follicle count
```
271
Trichomonas Vaginalis management
Metronidazole 2g, even if asymptomatic
No sexual intercourse 7d after treatment
Re-screen 2wks-3mo after finishing tx
All sexual partners should be treated as well, don't need to be screened as well
272
Factors that affect menopause age
Smoking --> hastens by 2 years
BMI --> delays menopause
Ethnicity
Parity (lower parity goes into menopause earlier)
273
Chemo agent used in breast CA that ages ovaries by 10y
Cyclophosphamide
274
4 categories of patients who should receive transdermal E
At risk for VTE
Poor absorption
Spontaneous or estrogen-induced hypertriglyceridemia
Obese with metabolic syndrome
Consider also in: smokers, HTN, sexual dysfunction
275
Risks associated with hormone therapy from WHI trial
More strokes, VTE, less hip fracutre
More breast CA after >/=5yrs of use, risk back to baseline after stopping
E-only: More breast CA, less CRC
276
Amsel's criteria for BV
```
Need 3/4 of:
Characteristic of d/c (thick, white, malodours)
pH >4.5
Wet mount - Clue cells, PMN
Amine whiff test (+)
```
277
Pigmented lesion biopsy
Punch biopsy, completely excise
278
Blistering lesion biopsy
Suture, lift and cut technique
279
Ulcerated lesion biopsy
Incisional if large, excision if <1cm
280
Lichen sclerosus or lichen simplex chronicus or lichen planus that causes distortion of normal anatomy
Lichen sclerosus and lichen planus
| Lichen planus can extend into the vagina, possibly even causing it to close up
281
Lichen simplex chronicus AKA
Squamous cell hyperplasia
282
Medications a/w loss of vaginal lubrication
Antihistamine
| Anticholinergic
283
Polycystic ovaries
>12 astral follicles 2-9mm in one ovary
284
Test to R/O congenital adrenal hyperplasia
17-OHP
| Often ordered to test metabolic dysfunction as source of ovulatory dysfunction
285
Most common cause of primary amenorrhea
Hypergonadotropic Hypogonadism
286
AI diseases associate with hypergonadotropic hypogonadism
```
SLE
T1DM
Addison's
Thyroid
Myasthenia graves
```
287
5 alpha reductase deficiency
Can't convert T --> DHT
| Androgen synthesis disorder
288
Hypogonadotropic hypogonadism
```
Structural CNS (adenoma, prolactinoma, sheehan's)
Endo (hypothyroid, hyperprolactinemia)
Non-CNS (constitutional delay of puberty, functional hypothalamic amenorrhea, isolated GnRH deficiency)
```
289
If both thyroid and prolactin are off, which do you fix first?
Thyroid --> prolactin will flollow
| Hypothyroid -- TRH activates lactotrophs to secrete prolactin --> hyperprolactinemia
290
Velamentous cord insertion
Umbilical cord inserts into choriamniotic membranes then travels within membranes to placenta (btwn amnion and chorion)
Exposed vessels are not protected by Wharton's jelly
