OBGYN Shelf Flashcards
(164 cards)
1
Q
which uterogenic drug do you not use on someone who is HTN and/or Pre-eclampsia
A
Methylergonovine – ergot alkaloid – potent smooth muscle constrictor
2
Q
when is a B-lynch suture used?
A
post-partum hemorrhage; at time of laprotomy due to uterine atony
3
Q
What are causes/ risk factors for a retained placenta (3)
A
- prior C section
- uterine leiomyoma
- prior uterine currettage and succenturiate lobe of placenta.
4
Q
Immediately postpartum, there is excessive bleeding greater than 2000 cc. She has an IV in place. There are no lacerations and the uterus is found to be boggy. Which is the most appropriate next step?
A
Prostaglandin F2-alpha IM
It could also be injected directly into the uterine muscle. Prostaglandin F2-alpha should not be administered IV, as it can lead to severe bronchoconstriction. Oxytocin is administered as a short time, rapid infusion of a dilute solution (20-80 units in a liter) and not as an IV bolus/push. Misoprostol (800 to 1000 mcg) can be administered orally or rectally and is not administered IV or IM.
5
Q
contradictions to estrogen/ candidates for progesterone- only pills (4)
use cation with progestins in patients suffering from what?
A
- history of thromboembolic disease
- women who are lactating
- women over age 35 who smoke
- women who develop severe nausea with combined oral contraceptive pills.
Progestins should be used with caution in women with a history of depression.
6
Q
A person with exercised-induced amenorrhea has characteristicly what type of levels of FSH and estrogen?
A
Normal FSH
Low estrogen
7
Q
Amenorrhea associated with exercise falls under what category of amenorrhea?
A
Hypothalamic amenorrhea
8
Q
What STI presents as a viral-like symptom preceding the appearance of vesicular genital lesions?
How is it described?
A
HSV – DNA virus
Burning or itching may occur before the lesions appear.
With primary infections, dysuria due to vulvar lesions can cause significant urinary retention requiring catheter drainage.
9
Q
Time line for post-exposure prophylaxis for Hepatitis B
A
- no later than 7 days after blood contact
- No later than 14 days after sexual contact
In unvaccinated: HBIG (hep B immune globullin) + HBV series.
If source is HBsAG negative or unknown then HBV series only.
If person is vaccinated and is a responder then no further tx is necessary. IF exposed person is vaccinated and a non-responder, then HBIG + HBV or HBIG times two doses is used.
Because incubation period for the virus is six weeks to six months, checking liver function and immunologic status at this time is not indicated.
10
Q
treatment of PID in patient with fever, abdominal pain, nausea and vomiting
A
IV cefotetan or cefoxitin plus doxycycline
or
IV clindamycin plus gentamicin
11
Q
Outpatient treatment for PID
A
ceftriaxone, cefoxitin, or other 3rd generation cephalosprins PLUS doxycyclin with or without metronidazole.
12
Q
What must be considered in a patient who presents with low pelvic pain, urinary frequency, urinary urgency, hematuria or new issues with incontinence? What test can you do?
A
Urinary tract infection
Perform a urine analysis.
13
Q
Nodularity in the back of the uterus is suggestive of what?
A
endometriosis
14
Q
what are the two requirements to rule out endometrial cancer:
A
- tissue diagnosis consistent with normal endometrium
2. Pelvic U/S with endometrial stripe of
15
Q
at what age can you consider premature ovarian failure?
What are FSH, LH, and FSH/LH?
A
before 40 yo
Increase in FSH, LH and FSH/LH >1 because FSH elevates more than LH
16
Q
How much calcium must post-menopausal women intake in order to remain in zero calcium balance?
A
- 1200mg of elemental calcium
Calcium absorption decreases with age because of a decrease in biologically active vit D. A positive calcium balance is necessary to prevent osteoporosis. Calcium supplementation reduces bone loss and decreases fractures in individuals with low dietary intakes.
17
Q
Effect of estrogen on lipid profiles
A
- increases TGs
- Increases LDL catabolism + Lipoprotein receptor = decreases LDL levels
- prevents conversion of HDL2 to HDL3 = increase HDL levels
18
Q
why do postmenopausal women undergoing hysterectomy and bilateral salpingo-oophorectomy reexperience menopause.
A
menopausal ovaries are known to continue production of androgens, surgical removal of postmenopausal ovaries may result in resurgence of menopausal symptoms from the abrupt drop in circulation androgens.
19
Q
Hypothalamic amenorrhea
A
Anorexia
Exercise induced
Stress: starvation, depression, chronic illness, stress
Marijuana use
20
Q
Amenorrhea due to disorders of annovulation
A
- CAH (non classic)
- Cushing’s syndrome
- PCOS
21
Q
Diagnostic criteria of PCOS (3)
A
- Oligo-anovulation
- Hyperandrogenism ( clinical and biochemical)– check total testosterone (>60ng/dL), free testosterone (more sensitive but more expensive) DHEA-S (when androgen-secreting tumor)
- Polycystic ovaries on ultrasound
- only require 2 out of 3
22
Q
Health concerns of PCOS (7)
A
- diabetes (10%)
- Obesity
- Metabolic syndrome
- Cardiovascular disease
- Endometrial hyperplasia
- Infertility
- Depression
23
Q
what is a normal post void residual volume (urine)
what is an elevated PVR?
A
50-60cc
> 300cc —> overflow incontinence: small amoumt of continuous leaking. Not associated with any positional changes or associated events.
24
Q
what causes urge incontinence?
What is (genuine) stress incontinence?
What is mixed incontinence?
A
detrusor instability – contractions of detrusor muscle while bladder is filling.
loss of urine due to increased abdominal pressure in the absence of detrusor contraction. Usually due to urethral hypermobility
Increased intra-abdominal pressure causes the urethral-vesical junction to descend causing the detrusor muscle to contract.
25
in a patient that has vaginal prolapse what is the course of action?
Colpocleisis: procedure where the vagina is surgically obliterated and can be performed quickly without the need for general anesthesia.
Anterior and posterior repairs provide no apical support of the vagina. She will be at risk of recurrent prolapse.
26
She describes severe pain with penile insertion. On further questioning, she reports an inability to use tampons because of painful insertion. She also notes a remote history of frequent yeast infections while she was on antibiotics for recurrent sinusitis that occurred years ago. Her medical history is unremarkable, and she is on no medications. Pelvic examination is remarkable for normal appearing external genitalia. Palpation of the vestibule with a Q-tip elicits marked tenderness and slight erythema. A normal-appearing discharge is noted. Saline wet prep shows only a few white blood cells, and potassium hydroxide testing is negative. Vaginal pH is 4.0. The cervix and uterus are unremarkable. Which of the following is the most likely diagnosis in this patient?
Vulvar vestibulitis = severe pain on vestibular touch or attempted vaginal entry. Symptoms are abrupt onset and are described as sharp, burning, and rawness sensation.
TX: tricyclic antidepressents to block sympathetic afferent pain loops, pelvic floor rehabilitation, biofeedback, and topical anesthetics.
Surgery with vestibulectomy is recommended for patients who do not respond to standard therapies and are unable to tolerate intercourse.
27
What vulvar disorder has a perpetual itch-scratch-itch cycle? symptoms?
Lichen Simplex chronicus
| symptoms: severe vulvar pruritis which can be worse at night.
28
Mucopurulent cervicitis (MPC)
- PE
- Causes
- Tx
mucopurulent exudate visible in endocervical canal or endocervical swab specimen.
caused by chlamydia trachomatis or Neisseria gonorrheae -- however in most cases neither oragnism can be isolated.
Patient should be treated for both G/C. 125mg Ceftriaxone; Azithromycin.
Tx: azithromycin (1 dose) or doxycycline (7 days course) for chlamydia and cephalosporin or quinolone for gonorrhea.
29
Common findings seen in an anorexic patient: (6)
1. osteoporosis
2. Elevated cholesterol and carotene levels
3. Cardiac arrhythmias (prolonged QT interval)
4. Euthyroid sick syndrome
5. Hypothalamic-pituitary axis dysfunction resulting in anovulation, amenorrhea, and estrogen deficiency
6. Hyponatremia secondary to excess water drinking is often the only electrolyte abnormality, but the presence of other electrolyte abnormalities indicates purging behavior.
30
risk factors for cervical insufficiency? (5)
- prior gynecological surgery--LEEP or cone biopsy, elective abortions
- history of maternal obstetrical trauma
- DES exposure
- Multiple gestations
- hx of preterm birth or second trimester pregnancy loss are also risk factors
31
risk factors for abruptio placentae (4):
hx of maternal trauma
Chronic HTN
Maternal smoking
History of external cephalic version
32
risk factors for uterine rupture (4)
- multiparity
- advanced maternal age
- previous C/S
- myomectomy operations
33
risk factors for polyhydraminos
- fetal malformations/ genetic disroders
- maternal diabetes
- multiple gestation
- fetal anemia
34
what is the gold standard for evaluating the cervix for cervical incompetence in pregnancy?
What is the qualification for a short cervix?
What is the length of a short cervix at 23-28 wks?
Transvaginal ultrasound
cervical length below 10th percentile
Less than 25mm at gestational age 23-28wks
35
first line treamtnet for lichen sclerosus?
High potency topical steroids
- BID for 4wks
then swich to a less potent topical steroid or topical calcineurin inhibitor for maintenance therapy.
36
Treatment for genital warts
Cryotherapy
37
risk factors for uterine atony
- uterine overdistention: multiple gestations, polyhydramnios, macrosomia, increased parity.
- uterine fatigue (prolonged labor)
38
steps in managing of postpartum hemorrhage (4)
1. fundal or bimanual massage -- stimulates utuerus to contract and resolves hemorrage.
2. Intravenous access
3. Crystalloid infusion to keep systolic blood pressure > 90mmHG
4. notification of blood bank for packed RBCs
39
Gonococcal Cervicitis
- clinical features
- Diagnosis
- Empiric treatment
Clinical features:
- Purulent or mucopurulent discharge
- Friable cervix with easy bleeding (friable -- intramenstrual or postcoital bleeding)
- can lead to uveitis and PID
Diagnosis: nucleic acid amplification testing
Empiric tx: 3rd generation cephalosporin + azithromycin/ doxycycline
40
Chorioamnionitis (intraamniotic infection IAI)
- RF
- Diagnosis
risk factors: prolonged rupture of membranes >18 hrs.
```
Diagnosis:
maternal fever and >/1 of the following:
- uterine tenderness
- Maternal or fetal tachycardia
- Malodorous amniotic fluid
- Purulent vaginal discharge
```
* amniotic fluid does not need to be purulent or malodorous to make the IAI diagnosis.
41
What test is used to measure the amount of fetal hemoglobin transferred into the maternal bloodstream?
When should it be used?
Kleihauer-Betke test
Perform on an RH negative woman with an RH positive fetus to determine the dose of RH immune globulin to prevent RH sensitization.
IF the patient's blood type is RH + then the kleihauer-betke test is not indicated.
42
What is the beta- hCG level needed for ultrasound?
Above discriminatory zone: 2000mIU/mL
43
What is the progesterone level for a normal pregnancy?
> 25ng/mL
Progesterone level
44
criteria for diagnosis of ectopic pregnancy (3)
1. fetal pole is visulaized outside of the uterus on ultrasound
2. patient has a beta-hCG level over the discriminatory zone (level at which an intrauterine pregnancy should be seen on ultrasound-- 2000) and No intrauterine pregnancy (IUP) seen on ultrasound
3. Patient has inappropiately rising b-hcg
45
What is the most concerning complication for the baby of a type 1 diabetic mother?
Overt diabetic patients are at an increased risk for fetal growth restriction (although, macrosomia may also occur). This is true especially if patient has vascular complications (retinopathy).
46
Complications during pregnancy for a diabetic mother>
1. polyhydramnios
2. congenital malformations (cardiovascular, neural tube, caudal regression syndrome)
3. preterm birth
4. hypertensive complications
47
how do you treat thyroid storm in pregnancy? (4 main ones plus 4 others)
1. thioamides (PTU)
2. Propanolol
3. Sodium iodide
4. dexomethasone
O2
digitalis
antipyretics
fluid replacement
48
screening for gestational diabetes is done when and how for a normal risk patient?
How about for a high risk patient?
24-28 wks
50g oral glucose challenge followed by 100g oral glucose tolerance est.
asap (severe obesity and strong family history)
49
risks with mothers that have pulmonary hypertension? (2)
mortality > 25%
diminished venous return and RV filling
note: baby is not at increased risk of pulmonary hypoplasia or Marfan's due to mother's condition
50
What is the definition of intrauterine fetal demise (IUFD) (3) and what are some conditions that can cause it?
death of fetus in utero that occurs after 20 weeks gestation and before onset of labor.
- decrease fetal movements
- absent fetal heart sound
- a decrease in stagnation in uterine size.
* B-HCG levels may continue to be elevated.
1. HTN disorders
2. DM
3. Placental and cord complications
4. Antiphospholipid syndrome
5. Congenital anomalies
6. Fetal infections (TORCHE)
51
What test differentiates maternal from fetal blood in patients with vaginal bleeding?
Apt Test or Kleihauer-Betke test
52
Remedy for magnesium sulfate toxicity?
Stop magnesium sulfate infusion
| Administer calcium gluconate
53
False labor (4) vs true labor (4)
False labor: 4-8 wks of pregnancy.
- absence of cervical change
- contractions are irregular and nonprogressive
- discomfort is in lower abdomen
- Discomfort relieved by sedation
True labor:
- Cervical change
- contractions are regular intervals that are progressive
- pain felt in back and upper abdomen and
- not relieved by sedation.
54
Severe features of preeclampsia (6)
```
BP >/ 160/110mmhg
Thrombocytopenia ( 1.1mg/dL
Elevated transaminases
Pulmonary Edema
New onset visual or cerebral symptoms
```
55
47 year old women, afebrile, with 7x6 cm area of edema and erythema without fluctuation is palpable. Scant non-bloody discharge is noted and several large axillary nodes are palpable. What is the next step in management?
Inflammatory breast carcinoma:
- brawny edematous cutaneous plaque with "peau d'orange" appearance overlying a breast mass.
- Aggressive tumor- lymph node involvement
- spontaneous nipple discharge in poste menopausal women
Tx: biopsy for histology and treatment depending on teh findings of histology
(hard to distinguish between breast abscess)
56
What is the diagnosis of a rubbery, firm, mobile and painful mass in a young patient who experience more tenderness during her menses?
What is the best approach in management after needle aspiration yields clear fluid?
Fibrocystic disease
Aspiration yields clear fluid and results in the disappearance of mass. Afterwards, patients are typically observed for 4-6 wks.
57
Risk factors for placenta abruption? (4)
HTN
trauma
Cocaine
smoking (poor placental perfusion)
58
lactation suppression (3)
- tight fitting bra
- avoidance of nipple stimulation or manipulation
- application of ice packs to the breasts and analgesics to manage pain.
There is no role for medications in the suppression of breast milk production
59
clinical diagnosis for endometritis (4)?
RF (4):
Treatment?
Fever
Uterine tenderness
Foul smelling lochia
Leukocytes
RF:
- prolonged ROM
- Prolonged labor
- Operative vaginal delivery (forceps)
- CS
Tx: broadspectrum b/c polymicrobial : clindamycin combined with IV aminoglycoside such as gentamicin
60
What are dysmorphic feature associated with maternal phenytoin/ carbamazepine use?
Fetal hydantoin syndrome
Fetal hydantoin syndrome is characterized by midfacial hypoplasia, microcephaly, cleft lip and palate, digital hypoplasia, hirsutism and developmental delay.
61
Signs of congenital syphilis?
- rhinitis (snuffles)
- Hepatosplenomegaly
- Skin lesions
- Hutchinson teeth
- Saddle nose
- Saber shins
- Deafness
- CNS involvement
62
What do you do if you have a finding of atypical squamous cells of undetermined significance on cytology (2)?
- women 21-24: repeat cytology in 1 year
- Women >/25: HPV DNA test
(+): Colposcopy
(-): followed with repeat Pap and HPV test in 3 years
** colposcopy is not usually performed unless the patient demonstrates ASC on 3 consecutive Paps, but colposcopy is recommended for atpical glandular cells, or high-grade squamous intraepithelial lesions.
63
Contraindications to external cephalic version (7)
When is it usually performed?
- indications for C/S (failure to progress during labor, non-reassuring fetal status)
- Placental abnormalities ( Placenta previa, abruption)
- Oligohydramnios
- ROM
- Hyperextended fetal head
- Fetal or uterine anomaly
- Multiple gestations
Performed at 37 wks getation and the onset of labor
64
Indications for prophylactic anti-D immune globulin administration for an unsensitized Rh negative pregnant patient?
- 28-32 wks gestation
- W/in 72 hrs of delivery of an RH-positive infant or a spontaneous, threatened, or induced abortion.
- Ectopic pregnancy
- Hydatidiform molar pregnancy
- Chronic villus sampling, amniocentesis
- 2nd or 3rd trimester beleding
- External cephalic version
* antepartum prophylaxis is not needed if the father is known to be Rh negative
65
GBS prophylaxis indications? (4)
Tx?
- Delivery at / 18hrs
- GBS bacteriuria in any concentration during current pregnancy
- Prior history of delivery of an infant with GBS sepsis.
Tx: first line: penicillin
- ampicillin, cefazolin, clindamycin, or vancomycin
66
Amsel criteria for diagnosis of bacterial vaginosis (BV) (4)
- thin, gray-white vaginal discharge
- Vaginal pH > 4.5
- Positive "whiff" test upon addition of KOH to the vaginal discharge
- Clue cells (vaginal epithelial cells adherent to coccobacilli) on wet mount.
* need at least 3
67
HELLP syndrome:
Symptoms:
Timing:
Labs:
Treatment:
Symptoms: nausea, vomiting, epigastric & RUQ abdominal pain, hypertension
Timing: usually late 2nd and 3rd trimester and postpartum
Labs:
- Proteinuria, high AST and ALT, high bilirubin
- Platelets 600
- Schistocytes on blood smear
Treatment:
- Prompt delivery: warranted at >/ 34 wks gestation or with deteriorating maternal or fetal status. Vaginal delivery is perferred if the cervix is favorable, if the woman is in labor, the fetus is vertex and the overall clinical status is otherwise stable.
- Magnesium sulfate to prevent convulsions
- control of HTN
68
Intrahepatic cholestasis of Pregnancy (pruritus gravidarum)
Symptoms:
Timing:
Labs:
Treatment:
Symptoms: Pruritis, jaundice
Timing: usually late second/third trimester
Labs: high AST ALT, high bilirubin, normal INR and GGT
Treatment: Ursodeoxycholic acid, Early delivery at 37-38 weeks of
69
Acute fatty liver of pregnancy
Symptoms
Timing
Labs
Treatment
Symptoms:
- Nausea, vomiting,abdominal pain, anorexia, jaundice.
- 50% have HTN and proteinuria
Timing: usually 3rd trimester
Labs:
- Increase in ALT AST Bilirubin and PT/INR
- Increase in WBC
- DECREASE in platelets
- Increase creatinine
- Decrease Glucose, Decrease uric acid
Treatment: prompt delivery
70
Gestational diabetes mellitus
1. Target blood glucose levels
2. Treatment:
- Fasting /
71
Modifiable risk factors that lead increase risk of osteoporosis? (6)
- hormonal factors (low estrogen)
- Malnutrition: decreased Ca, decreased vit D
- use of medication: glucocorticoids or antivonculsants
- Immobility
- Cigarette smoking
- Excessive alcohol consuption
72
Non-modifiable risk factors for increase risk of osteoporosis? (6)
- Female gender
- Advanced age
- Small body size
- Late menarche/ early menopause
- Caucasian/ Asian ethnicity
- Family history
73
What should you do before adding trastuzumab to a chemotherapy regiment?
Echocardiogram because trastuzumab with chemotherapy can lead to cardiac toxicity.
Recommended for a baseline and to consider other treatments in patients with poor baseline heart function. Patients with borderline or low ejection fractions (less than 55%) are thought to be at higher risk for cardiotoxicity secondary to trastuzumab.
74
Ovulation can be induced in PCOS patients via:
Clomiphene citrate or metformin
75
What preventative measure can you give a pregnant women with a hx of HSV infection? and When do you give it?
Prophylactic acyclovir or valacyclovir begining at 36 weeks of pregnancy.
CS is recommended to all women who are in labor with active genital HSV lesions or prodromal symtoms (buring, pain)
76
```
A 19 year-old G1P0 woman at 18 weeks gestation presents with a 3-month history of palpitations and intermittent chest pain. Physical examination reveals a pulse of 96 and grade II/VI systolic ejection murmur with a click. The ECG shows normal rate and rhythm and an echocardiogram is ordered. Which of the following is the best treatment in the management of this patient?
A. Anxiolytics
B. β-blockers
C. Calcium-channel blockers
D. Digitalis
E. No treatment needed at this time
```
B. Beta- blockers
decrease sympathetic tone, relieve chest pain and palpitations, and reduce the risk of life-threatening arrhythmias. Because she is symptomatic, the option of no treatment is not correct.
77
If a pregnant women shows sign of pyelonephritis: backpain, chills, and fevers and medical treatment is not helping -- recurrent fevers of 102.0; then further investigation by sono is warranted. If a calci is found, what is the next step?
Steps:
1. Obstruction can be relieved by cystoscopic placement of a double-J ureteral stent
2. unless long-term stenting is foreseen, then percutaneous nephrostomy is indicated.
3. Surgical exploration is required in up to 2% of women if other conservative therapies are not successful.
78
Categorization of obesity:
```
class I (BMI: 30 to 34.9 kg/m2)
class II (BMI: 35 to 39.9 kg/m2)
class III (BMI: 40-plus kg/m2)
```
Increased maternal morbidity results from obesity and includes: chronic hypertension, gestational diabetes, preeclampsia, fetal macrosomia, as well as higher rates of Cesarean delivery and postpartum complications.
This patient’s BMI is over 38 so she is a class II and has over a 7-fold increase risk for preeclampsia and a 3-fold risk for hypertension.
79
A 27 year-old G1P0 at 22 weeks gestation with systemic lupus erythematosus (SLE) presents complaining of malaise, joint aches, and fever. Physical examination reveals the following: pulse 88, temperature 98.6°F (37.0°C), respiratory rate of 22, and BP 150/110 (baseline is 100/70.) Laboratory analysis reveals 1 + proteinuria, AST 35, and ALT 28. Which of the following is the most appropriate initial therapy for the treatment of this patient?
A. steroids
B. nonsteroidal anti-inflammatory drugs (NSAIDs)
C. azathioprine
D. cyclophosphamide
E. magnesium sulfate
Steroids!!!
80
A 34 year-old G2P1 at 18 weeks gestation presents with a newly discovered lump in her left breast. Fine needle aspiration reveals adenocarcinoma. Which of the following is NOT a recommended therapy for breast cancer during pregnancy?
```
A. Wide local excision biopsy
B. Modified radical mastectomy
C. Total mastectomy and node dissection
D. Chemotherapy
E. Radiotherapy
```
E. Radiotherapy
Non-pregnant women receive adjunctive radiotherapy with breast-conserving surgery. However, this is not recommended during pregnancy due to sizeable abdominal scatter placing the fetus at significant risk for excessive radiation.
81
```
Which of the following antidepressants is contraindicated in pregnancy?
Fluoxetine (Prozac)
Nortriptyline (Norpress)
Paroxetine (Paxil)
Sertraline (Zoloft)
Bupropion (Wellbutrin)
```
Paroxetine (Paxil)
category D drug because of the increased risk of fetal cardiac malformations and persistent pulmonary hypertension.
older SSRI compounds, fluoxetine and sertraline, have not been reported to cause early pregnancy loss or birth defects in animals or in humans. Because these agents have few side effects compared with other antidepressants, they are a good choice for pregnant women.
Tricyclic antidepressants have a long record of use in pregnancy and there is no increase in the rate of fetal malformation.
Bupropion is not an MAO inhibitor, nor is it an SSRI and a report by the Bupropion Pregnancy Registry reports no unusual effects in 90 exposed pregnancies.
82
What is the imaging that you use one a pregnant woman that you suspect of appendicitis?
Graded compression ultrasound
| --- high sensitive and specific especially before 35 weeks gestation.
83
24 yo Patient suffering from deep thrust dyspareunia, two year history of dysmenorrhea despite use of contraceptives, urinary frequency, urgency, and nocturia w/ hx of endometriosis due to lap + CO2 ablation. What is the most likely diagnosis?
Interstitial cystitis
Chronic inflammatory condition of the bladder -- symptoms are pelvic pain, dysparenia (sometimes), urgency and frequency in urination.
Autoimmune and even hereditary component
84
Diagnosis of irritable bowel sydnrome (IBS)
12 weeks in the preceding 12 months of abdominal discomfort or pain with 2/3 features:
1. relief with defication
2. onset associated with a change in frequency of stool
3. Onset associated with a change in stool form or appearance.
Hx does not support any other pathological cause.
85
Pelvic congestion syndrome
Associated symptoms (5)
Pelvic varicosities -- cause unknown
Pain is worse premenstrually and during pregnancy, and is aggrevated by standing, fatigue, and coitus.
Often described as "fullness" or "heaviness" which may extend to the vulvar area and legs.
Associated symptoms: vaginal discharge, backache, urinary frequency, menstrual cycle defects and dysmenorrhea are common.
86
Nerve entrapment syndrome
Who are the nerves in risk? (2)
Cutaneous sensation?
During what surgery are they susceptible?
1. iliohypogastric nerve ( T-12 -- L-1)
- courses medially btwn internal and external oblique muscles, cutaneous 1cm superior to the superficial inguinal ring : sensation to groin and skin overlying the pubis.
2. ilioinguinal (T-12-- L1)
- cutaneous to groin, symphysis, labium, and upper inner thigh.
Susceptible: low transverse incision extends beyond the lateral border of the rectus abdominus muscle, into the internal oblique muscle.
87
At what age should women get mammograms annually?
Starting age 40 and older
88
Contraceptive methods that have
- Deop-Provera
- IUD
- Sterilization (male or female)
- Implanon
89
When do you give women a DEXA scan?
What are some risk factors associated with warranting an earlier screening? (11)
65 yo unless they warrant an earlier screening
Risk Factors:
- early menopause
- Glucocorticoid therapy
- Sedentary lifestyle
- Alcohol consumption
- Hyperthyroidism
- Hyperparathyroidism
- Anticonvulsant therapy
- Vit D deficiency
- Family history of early or severe osteoporosis
- Chronic liver
- Renal disease
90
Diagnosis (3) of Premenstrual Dysphoric disorder (PMDD)
Diagnosis:
- 5/11 clearly defined symptoms
- functional impairment
- symptoms present during last week of the luteal phase that begin to resolve with the beginning of the follicular phase.
PMDD is associated with severe symptoms that seriously impair usual daily functioning and personal relationshipes.
91
What vitamin deficiencies have been associated with an increase in PMS (premenstrual syndrome)
- Vitamin A
- Vitamine E
- Vitamin B6
92
What can you give someone with PMS to help their symptoms?
Mild symptoms of PMS often improve by suppressing the Hypothalamic-pituitary-ovarian axis with oral contraceptive pills.
SSRIs -- Fluoxetine -- take medication everyday or for 10 days during the luteal phase. (both PMS and PDD)
93
What disease can mimic PMS symptoms?
Hypothyroidism
94
A patient with PMS (37 yp G3P3) wants a hysterectomy to help with her symptoms. The doctor says no. Why does he say no?
- Hysterectomy (or endometrial ablation) only resolve the menstrual bleeding component of this patient's symptoms. They have no effect on the hormonal production of the ovaries.
removal of her ovaries may imporve her symptoms but would increase her risk for future problems: osteoporosis and menopausal symptoms.
A bilateral oophorectomy would be the last option for this patient.
95
A 32-year-old G1P0 woman at 10 weeks gestation presents to your office after an ultrasound evaluation has revealed a diamniotic, dichorionic twin gestation. She is very concerned about the risk for preterm delivery. Which intervention would you recommend as a possible means to reduce the risk of a preterm, low-birthweight infant?
```
A. Bed rest
B. Cervical cerclage
C. Tocolytics starting at 24 weeks
D. Home uterine monitoring
E. Early, good weight gain
```
E. Early, good weight gain
Adequate weight gain in 20-24 wks helps reduce risk of preterm/low birth weight babies.
Good early weight gain aids in development of the placenta
96
In what type of twins does the Twin- twin transfusion syndrome occur?
Monochorionic, diamniotic twins.
The donor twin is smaller and anemic at birth, growth retarded.
The recipient is larger and plethoric (polycythemia), hypervolemic, and macrosomic at birth -- high volume = cardiomegaly, tricuspid regurgitation, ventricular hypertrophy and hydrops fetalis
97
What are the clues to the presence of twin-twin transfusion syndrome?
- large weight discordance
- polyhydramnios around larger twin
- Oligohydramnios around smaller twin
98
Administratin of prostaglandins to a pregnant woman is used for what? When is it contraindicated?
- Cervical ripening
| - Contraindicated in patients with history of previous CS
99
If a patient remains 5cm dilated/ 80% effaced/ -1 position for 4 hours and she continues to contract every 4 minutes with reassuring fetal status
What is the next step in management?
Placement of an intrauterine pressure catheter ( IUPC) to help determine if her contractions are adequate and if oxytocin augmentation is appropriate
100
Gestational Hypertension
Raise in BP after 20 wks gestation in the absence of:
| proteinuria or other findings associated with preeclampsia
101
Diagnosis of preeclampsia: (2) vs (6 others)
BP >/ 140/90 (at least 4 hrs apart)
Protein uria > 0.3 g/ 24hr
OR
in the absence of proteinuria new onset of:
- thrombocytopenia ( 1.1)
- Impaird liver function ( 2x increase in transamniases)
- Pulomary edema
- Cerebral or visual symptoms
102
In a woman with preeclampsia, when is it okay to deliver her?
Delivery is recommended for women with gestational HTN or Preeclampsi without severe features AT OR BEYOND 37 0/7 weeks of gestation.
103
What is the treatment of choice for someone with eclampsia?
Magnesium sulfate
104
at what magnesium level is it theraputic against preeclampsia?
at what level is it toxic?
dangerous side effects?
4-6 mEq/L -- prevent seizures
7-10 mEq/L -- areflexia
11 mEq/L -- respiratory depression
15 mEq/L -- Cardiac arrest
Pulmonary edema can occur with magnesium therapy but it is not related to toxicity from the drug.
105
Of which of the following possible findings would necessitate delivery of a preeclampsic patient at 27 weeks gestation?
```
A. Elevated uric acid
B. Thrombocytopenia
C. Proteinuria
D. Poorly controlled blood pressures
E. Hemoconcentration
```
B. Thrombocytopenia
106
What are additional contraindications to expectant management prior to 34weeks gestation in severe preeclampsia (7)
- Pulmonary edema
- Renal failure
- Abruption-placentae
- DIC
- Persistent cerebral symptoms
- NOn reassuring fetal testing
- Fetal demise
107
A 27-year-old G2P1 woman at 36 weeks gestation is admitted with severe preeclampsia. Her blood pressure is 200/105. She has received two doses of IV hydralazine to lower her blood pressure. What diastolic blood pressure should you aim for in this patient?
```
A. 50-55 mm Hg
B. 60-65 mm Hg
C. 70-75 mm Hg
D. 80-85 mm Hg
E. 90-95 mm Hg
```
E. 90- 95
Goal is not a normal blood pressure, but to reduce the diastolic blood pressure intoa safe range of 90-100mmHG to prevent maternal stroke or abruption
108
An 18-year-old G1P0 woman at 12 weeks gestation reports nausea, vomiting, scant vaginal bleeding and a “racing heart.” These symptoms have been present on and off for the past four weeks. The patient has no significant past medical, surgical or family history. Vital signs are: temperature 98.6°F (37°C); heart rate 120 beats/minute; blood pressure 128/78. On physical examination: uterine fundus is 4 cm below the umbilicus; no fetal heart tones obtained by fetal Doppler device; cervix is 1 cm dilated with pinkish/purple “fleshy” tissue protruding through the os. Labs show: hemoglobin 8.2 gm/dL, quantitative Beta-hCG 1.0 Million IU/mL; thyroid-stimulating hormone (TSH) undetectable; free T4 3.2 (normal 0.7 – 2.5). An ultrasound reveals heterogeneous cystic tissue in the uterus (snowstorm pattern). Which of the following is the most appropriate next step in the management of this patient?
```
A. Repeat quantitative Beta-hCG
B. Repeat transvaginal ultrasound
C. PET scan
D. Chest x-ray
E. CBC
```
D. chest x-ray
Patient with molar pregnany.
CXR indicated because lungs are the most common site ofmetastatic disease in patients with gestational trophoblastic disease.
109
Weight gain recommended for the following BMIs?
BMI 30
BMI 30 --- 11- 20lbs
110
What are pap smear and HPV testing recommendations for women 30- 65yo that have had normal paps all their life?
Screening cytology (pap smear) and HPV testing every 5 years or cytology alone every 3 years.
111
A 28-year-old G0 woman has a pap test which is reported as high-grade squamous intraepithelial lesion (HSIL). She is currently sexually active. She has had six sexual partners and has been in a monogamous relationship with her fiancé for the last year. What is the next most appropriate next step in the management of this patient?
```
A. Colposcopy
B. Cryotherapy
C. Reflex HPV testing
D. Repeat Pap test in one month
E. Repeat Pap test in six month
```
Coloscopy
recommend immediate LEEP or colposcopy for women with HSIL cytology test results.
Cryotherapy is inadequate because it does not provide a tissue specimen
112
acute salpingitis is also known as what?
pelvic inflammatory disease
113
A 30 year old G1P0 10wks gestation. HbA1c = 9.7
What structural anomaly is the fetus at highest risk of developing?
```
A. Cardiac anomalies
B. Caudal regression syndrome
C. Hydrocephalus
D. Microphaly
E. Lim reductions
```
Cardiac anomalies
Majority of women with poorly controlled diabetes -- lesions involve CNS (neural tube defects) and Cardiovascular anomalies.
114
A 34 year old G2P1 17 wks gestation. What is the most sensitive test for screening of Down syndrome?
A. Nucal translucency measurement with serum PAPP-A
B. Cell-free DNA
C. Triple screen
D. Quadruple screen
E. Maternal serum alpha fetoprotein level
Cell free DNA is most effective.
| Performed as early as 9 weeks
115
32 year old G1 woman with IVF, 12 wks gestation.
Increase in fetal nuchal translucency ( 3.0mm).
What is the next best step to rule out a chromosomal abnormality in this patient?
Amniocentesis
116
Up to what gestational age can you take ibuprofen and why must you stop it then?
32 weeks; premature closure of ductus arteriosis
117
Characteristics of Braxton Hicks contractions?
Contractions are:
- short in duration
- less intense
- lower abdomen and groin area
118
32 year old G2P1 20wks gestation.
Prior pregnancy son dianosed with neonatal sepsis due to GBS infection.
What is the management regarding GBS in this patient?
DO not perform recto-vaginal cultures.
Treat with antibiotics during labor
GBS cultures not required if bacteriuria during current pregnancy or who have previously given birth to neonate with early-onset GBS disease.
- Women receive intrapartum antibiotics
119
What is the most appropriate management of a patient noted to have meconium-stained amniotic fluid after amniotomy was performed?
If newborn is depressed, the clinician should intubate the trachea and suction meconium or other aspirated material from beneath glottis.
If newborn is vigorous, there is no evidence that states tracheal suctioning is necessary. Injury to vocal cords is more likely to occur when attempting to intubate a vigorous newborn
120
Who has the smaller babies: Type 1 diabetes vs. gestational diabetes?
Type 1 diabetes
121
Patient is suspected to have chorioamnionitis ( fever, tachycardia of fetus); what will baby look like on delivery
Lethargic, pale with high temperature
122
If mother is suspected of substance abuse, what is the most appropriate step in management of the neonate?
What is contraindicated?
Give positive pressure ventilation and prepare to intubate.
Do not give naloxone (Narcan) because it can cause life-threatening withdrawal in infant.
123
What tends to be the most likely causative agents of endometritis in this patient?
Polybacterial : Staph aureus and streptococcus
124
Postpartum depression vs post partum blues
Postpartum depression: beginins within 2 weeks to 6 months after delivery.
* * Sense of incapability of loving her family and manifest ambivalence toward her infant.
* most significant risk factor: hx of depression
Blues: Signs and symptoms of depression which last for less than two weeks.
125
Breastfeeding decreases risk of what type of cancer?
ovarian cancer
126
22yo G2P1 , 3 month old daughter. Two weeks ago began to experience sore nipples. Very sensitive, burning pain in breast that worsens with feeding. The nipples are pink and shiny with peeling at the periphery. What is the diagnosis?
```
A. Group A strep
B. Group B strep
C. Staph aureus
D. Staph epidermidis
E. Candida
```
Candida
Must check baby's oral cavity
127
Which of the following is the most likely cause of a spontaneous abortion?
```
A. Autosomal trisomy
B. Triploidy
C. Tetraploidy
D. Monosomy X ( 45, XO)
E. Fragile X mutation
```
Autosomal trisomy
128
Pregnancy loss in late 2nd trimester is not due to genetics. If patient continues to have 2nd trimester abortions (19 or 18wks) then placement of what is beneficial?
Cervical cerclage after 1st trimester
129
What is the risk of an RH negative mother of isoimmunization if she does not recieve Rhogram?
60%
130
How can one diagnose fetal anemia using non-invasive tests?
Doppler ultrasound.
| - Middle cerebral artery peak systolic velocity
131
What are the steps in Grief?
- Denial
- Anger
- Barganing
- Depression
- Acceptance
132
Fresh Frozen Plasma (FFP) is given to replace which cofactor?
Fibrinogen
133
What is a side-effect of SSRIs in a mother?
Can they be safely used during lactation?
What are the side-effects of Fluoxetine in a neonate (3rd trimester)?
Insomnia -- sleep disturbance
Current recommendations state that yes
FLuoxetine -- abnormal muscle movements (extrapyramidal signs) and withdrawal symptoms which may include agitation, abnormally increased or decreased muscle tone, tremor, sleepiness, severe difficulty breathing, and difficulty in feeding.
134
Postterm pregnancies are associated with what conditions? (5)
- Placental sulfatase deficiency
- Fetal adrenal hypoplasia
- Anencephaly
- Inaccurate or unknown dates
- Extrauterine pregnancy
135
A patient is diagnosed with low- grade squamous intraepithelial lesion (LSIL). What is the next step in management?
Colposcopy
136
If you are doing a suction and curettage abortion and you see fatty tissue, what do you do?
Stop suction and do a laparoscopy because you hit the omentum tissue and you may have damaged bowel. So you need to go in and see what happened.
137
A 30-year-old G2P1 woman has an ultrasound at 42 weeks for size greater than dates. The fetus had an isolated enlarged head measurement with a BPD of 11 cm, but otherwise appeared to have normal femur length and abdominal circumference. Polyhydramnios is noted. The estimated fetal weight is 3900 g. There is a 10 cm lower uterine segment fibroid protruding into the uterine cavity. The fetus is in the vertex presentation and the fetal head is above the level of the uterine fibroid. Which of the following is an indication for primary Cesarean section in this patient?
```
A. Uterine fibroid
B. Fetal hydrocephalus
C. Polyhydramnios
D. Macrosomia
E. 42 weeks gestation
```
Uterine Fibroid
If located in the lower uterine segment it may obstruct labor by preventing the fetal head from entering the pelvis
138
A 22-year-old G1P0 woman at 38 weeks gestation has been pushing for four hours. You recommend an operative vaginal delivery. In obtaining informed consent, which of the following is less likely to occur during a vacuum delivery vs. forceps assisted delivery?
```
A. Maternal lacerations
B. Fetal cephalohematoma
C. Neonatal lateral rectus paralysis
D. Neonatal hyperbilirubinemia
E. Neonatal retinal hemorrhage
```
Maternal lacerations because vacuum does not take up additional space in the maternal pelvis.
139
A 32-year-old G0 woman presents with irregular menses occurring every six to eight weeks for the past eight months. The bleeding alternates between light and heavy. Her irregular menses were treated successfully with medroxyprogesterone acetate (MPA), 10 mg every day, taken for 10 days each month. By which mechanism does the MPA control her periods?
Progestins inhibit further endometrial growth, converting the proliferative to secretory endometrium. Withdrawal of the progestin then mimics the effect of the involution of the corpus luteum, creating a normal sloughing of the endometrium.
140
An 18-year-old G0 woman comes to the office due to vaginal spotting for the last two weeks. Her menstrual periods were regular until last month, occurring every 28-32 days. Menarche was at age 13. She started oral contraceptives three months ago. On pelvic examination, the uterus is normal in size, slightly tender with a mass palpable in the right adnexal region. No adnexal tenderness is noted. Which of the following tests is the most appropriate next step in the management of this patient?
```
A. Endometrial biopsy
B. Pelvic MRI
C. Pelvic ultrasound
D. Abdominal CT Scan
E. Urine pregnancy test
```
Urine Pregnancy test-- vitally important to rule out pregnancy in the evaluation of abnormal uterine bleeding.
Pelvic ultrasound can be considered as a next step if the pregnancy test is negative.
141
```
An obese 30-year-old G3P1 Asian woman undergoes an uncomplicated dilation and curettage for a first-trimester miscarriage. Pathology reveals a molar pregnancy. The patient’s medical history is significant for chronic hypertension. She has a history of a previous uncomplicated term pregnancy, and termination of a pregnancy at 16 weeks gestation for trisomy 18. What aspect of the patient’s history places her at increased risk for a molar pregnancy?
A. Obesity
B. Previous history of fetal aneuploidy
C. Asian race
D. Chronic hypertension
E. Prior term pregnancy
```
Asian race
Incidence is also higher in areas wher epeople consume less beta- carotene and folic acid
142
What is the recurrent risk for a molar pregnancy after 1 molar pregnancy?
How about after 2 molar pregnancies?
1-2% (20 fold increase from background risk).
After two molar pregnancies = 10%
143
Complete mole
```
Genotype:
b-hcG
Imaging
Uterine size
Post-molar GTD
```
Genotype: 46 XX or XY
Very High b-hCG
Imaging: snowstorm/ clusters of grapes
Uterine size is greater than gestational age
Higher risk than partial mole for developing post-molar GTD
Low risk overall for developing a post-moalr GTD
GTD: Gestational trophoblastic neoplasm-- due to persistent retained or invasive disease in the uterus or metastatic disease (lungs)
144
How long must a patient who underwent D&C for molar pregnancy wait before getting pregnant again?
Six months after negative b-hCG levels
145
A 38-year-old G3P3 woman presents to the office because she has noted dark spots on her vulva. She states that the lesions have been present for at least two years and are occasionally itchy. She has a history of laser therapy for cervical intraepithelial neoplasia ten years ago, and has not had a pelvic exam since then. She has had multiple partners and uses condoms. Her menses are regular and she had a tubal ligation. She has a history of genital herpes, but has only one or two recurrences a year. She has smoked since age 14. On examination, multicentric brown-pigmented papules are noted on the perineum, perianal region and labia minora. No induration or groin adenopathy is noted. The vagina and cervix are normal in appearance. Which of the following is the most likely diagnosis?
```
A. Hidradenitis suppurativa
B. Molluscum contagiosum
C. Vulvar intraepithelial neoplasia
D. Melanoma
E. Paget’s disease
```
C. Vulvar intraepithelial neoplasia
- presentation is classic for human papilloma virus related to vulvar intraepithelial neoplasia.
Hidradenitis is a chronic, unrelenting skin infection causing deep, painful scars and foul discharge.
146
A 45-year-old G3P3 woman presents to the office because of a large dark spot on her vulva. She states that the lesion has been present for at least two years and is occasionally itchy. She has smoked since age 20. She has a history of genital herpes, but only has one or two recurrences a year. On examination, a 2.5 cm lesion is noted. No induration or groin lymphadenopathy is noted. The vagina and cervix appear normal. There are no additional lesions noted on colposcopic examination of the vulva. A biopsy of the lesion returns as vulvar intraepithelial neoplasia grade 3 (VIN 3). What is the most appropriate next step in the management of this patient?
```
A. Imiquimod (Aldara) treatment
B. Trichloroacetic acid (TCA) treatment
C. Wide local excision
D. Cryotherapy
E. Radical vulvectomy
```
Wide local incision
VIN III should be treated with local superficial excision. Even with complete removal of all gross disease, recurrence is still possible. Patient will need close surveillance.
It is inappropriate to do radical surgery in the setting as cancer has not been diagnosed.
Treatment with TCA and Aldara are reserved for condyloma, although studies have shown utility in the use of Aldara in treating low grade VIN.
Cryotherapy is primarily used to treat cervical dysplasia.
147
What are the indications for cervical conization when evaluating a HSIL? (5)
1. unsatisfactory colposcopy, including inability to visualize the entire transformation zone
2. Positive endocervical currettage
3. Pap smear indicating adenocarcinoma in situ
4. Cervical biopsies that cannot rule out invasive cancer
5. A substancial discrepancy between Pap smear and biopsy results.
148
Cervical Cancer screening (5)
Cervical cancer screening should start at age 21 years.
· Women aged 21 – 29 years should have a Pap test every three years.
· Women aged 30 – 65 years should have a Pap test and an HPV test (co-testing) every five years (preferred). It is acceptable to have a Pap test alone every three years.
· Women should stop having cervical cancer screening after age 65 years if they do not have a history of moderate or severe dysplasia or cancer and they have had either three negative Pap test results in a row, or two negative co-test results in a row within the past 10 years, with the most recent test performed within the past five years.
· Women who have a history of cervical cancer, are infected with HIV, have a weakened immune system, or who were exposed to DES before birth should not follow these routine guidelines.
149
A 28-year-old G2P0020 experienced her second miscarriage within 14 months. A recent ultrasound was notable for two uterine fibroids. The patient is worried that the fibroids may have caused her early pregnancy losses. She is otherwise healthy and has no previous surgeries. She presents to you for further consultation. Which type of fibroid is the most likely explanation of her miscarriages?
```
A. Submucosal
B. Intramural
C. Subserosal
D. Pedunculated
E. Cervical
```
Submucosal
Submucosal or intracavity myomas are the most likely to cause lower pregnancy and implantation rates.
Reasons:
1. focal endometrial vascular disturbacne
2. Endometrial inflammation
3. Secretion of vasoactive substances.
Submucosal fibroids are best treated by hysteroscopic resection.
150
A patient is interested in the medical options for treating symptomatic uterine fibroids, but has tried NSAIDs which did not seem to help much. What is the next best step in the management of this patient?
```
A. Aspirin
B. Methotrexate
C. Estrogen
D. Gonadotropin-releasing hormone agonists
E. Indomethacin
```
Gonadotropin-releasing hormone agonist
- uterine fibroids are stimulated by estrogen.
GrHn agonists inhibit endogenous estrogen
= 40-60% reduction in uterine size.
* therapy may be most useful for women who are close to menopause because once a person comes off this therapy, then the uterine fibroids will continue to grow.
151
A 62-year-old G0 postmenopausal woman is being referred to your gynecologic oncology colleague after an office endometrial sample demonstrated a FIGO grade 1 endometrioid adenocarcinoma. The patient has no significant medical, surgical or other gynecologic history. She does not smoke and drinks only occasionally at social events. She takes a multivitamin. Her physical exam is unremarkable. Which of the following additional tests is indicated for this patient?
```
A. Pelvic ultrasound
B. Chest x-ray
C. Pelvic MRI
D. CA-125
E. Serum estrogen level
```
Chest X-ray
Once pathologic diagnosis is confirmed by biopsy, CXR is the next step becasue lungs are the most common site of distant spread.
Pelvic sono is not indicated once a pathologic diagnosis has been established.
152
most common causes of postmenopausal bleeding (5):
- Atrophy of endometrium (80-90%)
- Hormone replacement therapy (15-25%)
- Endometrial cancer (10-15%)
- Polyps (2-12%)
- Hyperplasia (5-10%)
153
You suspect a patient has a large pelvic mass on transvaginal ultrasound and an elevated CA-125. What image type is the most helpful in assessing the extend of the disease
CT scan-- can view entire peritoneal cavity and retroperitoneum
154
post operative check following tumor debulking for stage IIIB endometrioid adenocarcinoma of the ovary. Her medical history is significant for diabetes, hypertension, obesity, hypercholesterolemia and major depression. Which of the following is the most appropriate next step in the management of this patient?
In all patients with advanced ovarian cancer, post-operative chemotherapy with a combination of a taxane and platinum adjunct is considered standard of care in the United States.
Women who undergo surgical cytoreduction, followed by chemotherapy, have a better overall survival rate than those who undergo surgery alone.
155
A 30-year-old G1P1 woman presents to the emergency department with left-sided abdominal pain. Physical examination is notable for a 5 x 6 cm mobile left adnexal mass. An ultrasound is performed, which shows a left ovarian mass with cystic and solid components. Which of the following is the most likely diagnosis in this patient?
```
A. Serous cystadenoma
B. Mucinous cystadenoma
C. Endometrioid tumor
D. Dermoid tumor
E. Brenner tumor
```
Dermoid tumor --
the most common tumor foudn in women of all ages. Median age of occurrence is 30 years and 80% occur during the reproductive years.
Dermoids contain differential tissue from all three embryonic germ layers.
Dermoid tissues can contain teeth, hair, sweat, and sebaceous glands, cartilage, bone and fat.
156
A 38-year-old G1P0 woman presents to the hospital at 39 weeks in early labor. She has had routine prenatal care and no antepartum complications to date. She reports good fetal movement and denies vaginal bleeding and leakage of fluid. What is the next best step in the initial assessment of this patient?
```
A. Physical examination
B. Nitrazine test
C. Fetal ultrasound
D. Biophysical profile
E. Contraction stress test
```
PHysical exam:
The initial evaluation of patients: maternal vital signs and fetal heart rate, abdominal and pelvic examination. Then a speculum exam with a nitrazine test to confirm rupture of membranes is indicated if the patient's history is suggestive.
157
A healthy 63-year-old G0 woman comes to the office for a health maintenance exam. She has no history of abnormal Pap smears or sexually transmitted infections. She has a history of endometriosis and infertility in the past. She has been postmenopausal for 10 years and is not taking any medications. She is 5 feet 4 inches tall and weighs 130 pounds. On pelvic examination, the patient has a palpable left adnexal mass. An ultrasound shows a 5 cm complex left ovarian cyst. What is the most appropriate next step in the management of this patient?
```
A. Observation
B. Repeat ultrasound in three months
C. CT scan of the abdomen and pelvis
D. MRI of the pelvis
E. Exploratory surgery
```
Explorative surgery
A complex ovarian mass in a post-menopausal patient needs to be surgically explored. Although this could be an old endometrioma which never resolved, this cannot be assumed.
A CT or MRI will not add more information and ultrasounds are typically the best imagining studies for the uterus and adnexa.
158
IN terms of contraception, what is a draw back to using a patch?
significanlty higher failure rates in women who weight more than 198lbs.
159
A 33-year-old G2P1 woman at 29 weeks gestation presents with confirmed preterm premature rupture of membranes. She denies labor. She takes prenatal vitamins and iron. She denies substance abuse, smoking or alcohol use. Her prior pregnancy was delivered vaginally at 41 weeks after spontaneous rupture of membranes. Her blood pressure is 110/70; pulse 84; temperature 98.6°F (37.0°C). Which of the following is the best medication to delay the onset of labor?
```
A. Antibiotics
B. Betamethasone
C. Calcium channel blocker
D. Beta mimetics
E. Magnesium sulfate
```
Antibiotics.
| Increase latency period by 5-7 days as well as reduce the incidence of maternal amnionitis and neonatal sepsis.
160
A 26-year-old G1P0 woman with last menstrual period 13 weeks ago presents to your office for her first prenatal visit. She reports vaginal spotting for the last two days. You perform an ultrasound that shows an intrauterine pregnancy consistent with 11 weeks gestation with no cardiac activity. She denies cramping or abdominal pain. What is the most important laboratory test to check for this patient?
```
A. Quantitative Beta-hCG
B. Maternal blood type
C. Hemoglobin and hematocrit
D. Platelet count
E. Progesterone
```
Maternal blood type
If she is RH-negative RhoGAM would be indicated to prevent RH sensitization.
161
```
A 70-year-old G3P3 woman presents with a four-year history of constant leakage of urine. Her history is significant for abdominal hysterectomy and bilateral salpingo-oophorectomy for endometriosis. She had four anterior repairs in the past for recurrent cystocele. The leakage started six months after her last anterior repair. Pelvic exam showed no evidence of pelvic relaxation. The vagina was well-estrogenized. Q-tip test revealed a fixed, immobile urethra. Cystometrogram showed no evidence of detrusor instability. Cystourethroscopy showed no evidence of any fistula and revealed a “drain pipe” urethra. Which of the following is the best first treatment for this patient?
A. Retropubic urethropexy
B. Needle suspension
C. Artificial urethral sphincter
D. Urethral bulking procedure
E. Sling procedure
```
Urethral bulking
procedures are minimally invasive and have a success rate of 80% in these specific patients. The success rates for retropubic urethropexies, needle suspension and slings are less than 50%.
An “obstructive or tight” sling can be performed to increase the success rate, but the voiding difficulties are significant, even requiring prolonged or lifelong self-catheterization.
Artificial sphincters should be used in patients as a last resort.
162
A 24-year old G1P1 woman had an uncomplicated Cesarean section 20 hours ago under general anesthesia secondary to an umbilical cord prolapse. You are called to evaluate her because her temperature is 102.0° F (38.9° C). The patient does not have any specific complaints. She has experienced intermittent chills. Her exam is non-focal. There is no uterine tenderness. A urine analysis shows no WBCS and is nitrate and leukocyte estrase negative. What is the next appropriate step in the management of this patient?
```
A. Endometrial cultures
B. Chest X-ray
C. Treatment with intravenous broad spectrum antibiotics
D. Pelvic ultrasound
E. Culture of the incision
```
Chest X-ray
Lungs are the most common source of fever on the first postpartum day, particularly if the patient had general anesthesia
Atelectasis may be assocaited with a post-partum fever.
Aspiration pneumonia is also on the differential
163
A 25-year-old G1 woman at 41 weeks gestation presents to labor and delivery with painful contractions every four minutes. Her cervix is 5 cm dilated, 90% effaced. On cervical exam, you are able to feel a fetal body part but it is not the head. Which of the following is the most likely body part you were palplating?
```
A. Foot
B. Hand
C. Buttocks
D. Back
E. Shoulder
```
Buttock
Breech presentation occurs in approximately 3-4% of women in labor overall, and occurs more frequently in preterm deliveries. Frank breech is the most common type, occurring in 48-73% of cases and the buttocks are the presenting part. Complete breech is found in approximately 5-12% of cases and incomplete breech (footling breech) occurs in approximately 12-38% of cases.
164
A 38-year-old G2P0 woman at 28 weeks gestation has been diagnosed with preterm labor and is currently stable on nifedipine. Her cervical exam has remained unchanged at 2 cm dilated, 75% effaced and -2 station. Her vital signs are stable and fetal heart tracing is category I. You recommend treatment with betamethasone (a steroid). Which of the following is associated with betamethasone therapy in the newborn?
A. Enhancement of fetal growth
B. Increased risk of infection
C. Increased incidence of necrotizing enterocolitis
D. Increased incidence of intracerebral hemorrhage
E. Decreased incidence of intracerebral hemorrhage
E. Decreased incidence of intracerebral hemorrhage.
Treatment with betamethasone from 24-34 weeks gestation has been shown to increase pulmonary maturity and reduce the incidence and severity of RDS in a new born. Also associated with decreased intracerebral hemorrhage, necrotizing enterocolitis in newborn. It has not been associated with increased infection or enhanced growth.
