Obstetrics

Question 1

Physiological Changes in Pregnancy - CVS (4)

Answer 1

Cardiac output and plasma volume: increased 50%
Systemic vascular resistance: decreased
MAP unchanged or slightly lower.
Pregnancy increases intravascular volume.

Question 2

Physiological Changes in Pregnancy - Respiratory (4)

Answer 2

Respiratory rate unchanged
Tidal volume increased
Minute ventilation increased
Ventilation exceeds needs

Question 3

Describe the characteristics of patients that present with lichen sclerosis, and the natural history of the disease.

Answer 3

Usually in the post-menopausal period. Can occur at any age.

Itching worse at night. - vaginal itching.

Skin classically described as “cigarette paper” as it appears crinkled and is fragile, thinned and atrophic.

Scratching can lead to scarring causing narrowing or complete closure of the vaginal introitus. Labia minora may fuse burying the clitoris behind the fused clitoral hood.

Question 4

Recognize the anatomical boundaries of the vulva and aspects of good vulvar
hygiene.

Answer 4

The anatomic boundaries of the vulva extend from the mons pubis superiorly to the anus inferiorly and the genitocrural folds laterally.

Avoid irritants such as soaps and bubble baths, cessation of scratching the lesions, and wearing all cotton, white underwear may help to alleviate symptoms.

Question 5

Identify current treatment regimes for lichen sclerosis (LS) and the followup
that is requisite.

Answer 5

Aimed at preventing relapses of intense pruritus and mainstay is corticosteroids. Initially a potent steroid ointment, Clobetasol, may be necessary to provide relief, and should be used daily until relief and then tapered.

Question 6

Biopsy of Lichen Sclerosis

Answer 6

Thinned epidermis, hyperkeratosis and elongation of the rete pegs.

Lichen planus usually involves vagina which LS does not.

Question 7

Bartholin Gland Abscess location and treatment

Answer 7

Located at the 5 and 7 o-clock locations of the labia majora.

Treatment include incision and placement of a small balloon catheter into the gland, or marsupialization (surgical fixation of the cyst wall everted against the mucosa of the vula. Biopsy if above 40 years of age.

Question 8

Definition of Lichen Sclerosis

Answer 8

Chronic, inflammatory dermatologic disease characterized by pruritus and pain, which mainly affects the anogenital region.

Question 9

Definition of Advanced maternal age

Answer 9

Pregnant woman who will be 35 years or beyond at the estimated date of delivery.

Question 10

Ramification of low hemoglobin (<10.5 g/dL) in pregnancy and its next steps

Answer 10

Preterm delivery
Low fetal iron stores
Identify thalassemia

Mild-therapeutic trial of iron
Moderate-ferritin and Hb
electrophoresis

Question 11

Ramification of negative rubella in pregnancy and its next steps

Answer 11

Nonimmune to rubella

Stay away from sick individuals, vaccinate postpartum
Live attenuated vaccine

Question 12

Ramification of negative Rh factor in pregnancy and its next steps

Answer 12

May be susceptible to Rh disease

If antibody screen negative, give Rhogam at 28 weeks, and if baby
is Rh positive, then also after delivery

Question 13

Ramification of positive antibody screen in pregnancy and its next steps

Answer 13

May indicate isoimmunization

Need to identify the antibody, and then titer

Lewis lives, Kell kills,Duffy
dies

Question 14

Ramification of positive HIV ELISA in pregnancy and its next steps

Answer 14

May indicate infection with HIV

Western blot or PCR, if positive then place patient on anti-HIV medicines, offer elective cesarean, or IV ZDV in labor

Intervention reduces Vertical transmission from 25% to 2%

Question 15

Ramification of positive RPR in pregnancy and its next steps

Answer 15

May indicate syphilis
Specific antibody such as MHA-TP, and if positive then stage disease

Less than 1 year, penicillin ×
1; > 1 year or unknown,
penicillin IM each week × 3

Question 16

Ramification of positive gonorrhea test in pregnancy and its next steps

Answer 16

May cause preterm labor , blindness

Ceftriaxone IM

Question 17

Ramification of positive Chlamydia in pregnancy and its next steps

Answer 17

May cause neonatal blindness, pneumonia

Azithromycin or amoxicillin orally

Question 18

Ramification of positive Hepatitis B surface antigen in pregnancy and its next steps

Answer 18

Patient is infectious

Check LFTs and hepatitis serology to determine if chronic carrier vs active hepatitis

Baby needs HBIG and hepatitis B vaccine

Question 19

Ramification of positive urine culture in pregnancy and its next steps

Answer 19

Asymptomatic bacteriuria may lead to pyelonephritis 25%

Treat with antibiotic and recheck urine culture

If GBS is organism, then give penicillin in labor

Question 20

Ramification of positive pap smear in pregnancy and its next steps

Answer 20

Only invasive cancer would alter management

ASC-US = re-Pap postpartum;
LGSIL, HSIL = colposcopy

Reflexive HPV not recommended with ASC-US

Question 21

Ramification of positive nuchal translucency (11-13 weeks) in pregnancy and its next steps

Answer 21

May indicate trisomy

Offer karyotype and follow-up ultrasounds

Increased NT means increased risk, not definitive diagnosis

Question 22

Ramification of positive Trisomy screen (16 - 20 weeks) in pregnancy and its next steps

Answer 22

At risk for trisomy or NTD

Basic ultrasound for dates; if dates confirmed, offer genetic amniocentesis

Most common reason for abnormal serum screening - wrong dates

Question 23

Ramification of elevated 1 h diabetic screen (26 - 28 weeks) in pregnancy and its next steps

Answer 23

May indicate gestational diabetes

Go to 3h GTT

About 15% of those screened will be positive

Question 24

Ramification of 2 abnormal 3h glucose tolerance test in pregnancy and its next steps

Answer 24

Gestational diabetes

Try ADA diet, monitor blood sugards, if elevated may need meds or insulin

About 15% of abnormal 1h GCT will have gestational diabetes

Question 25

Ramification of positive GBS culture (35 - 37 weeks) in pregnancy and its next steps

Answer 25

GBS colonizing genital tract Penicillin during labor Helps to prevent early GBS sepsis of newborn

Question 26

Implications of twin gestation for a pregnancy (both maternal and fetal effects)

Answer 26

A higher rate of congenital malformations, a two-time increased risk of preeclampsia and postpartum hemorrhage, and twin-twin transfusion (TTT) syndrome.

Question 27

Velamentous cord insertion

Answer 27

Umbilical vessels separate before reaching the placenta, protected only by a thin fold of amnion, instead of by the cord or the placenta itself; these vessels are susceptible to tearing after rupture of membranes.

Question 28

OCP and its effects on twin pregnancy

Answer 28

Oral contraceptives (OCPs) slow tubal motility, so it is important to know if a mother has used OCPs within 3 months of becoming pregnant. This is associated with an increased incidence of twinning.

Question 29

How does fertility treatments increase risk of twin gestations?

Answer 29

Clomiphene induces ovulation and promotes the maturation of multiple follicles, therefore increasing the number of eggs available for fertilization. In vitro fertilization involves the transfer of two to four embryos to the uterus. If more than one implants, a twin or higher order gestation occurs. All dizygotic twins are dichorionic/diamnionic.

Question 30

Treatment of TTT

Answer 30

Laser ablation of the shared anastomotic vessels at special centers, or serial amniocentesis for decompression.

Question 31

Differentiating fetal bleeding from maternal blood

Answer 31

Apt test and Kleihauer-Betke test

Question 32

Pelvic diaphragm muscles (3 important ones)

Answer 32

pubococcygeus, puborectalis, iliococcygeus

Question 33

Test for cystocele

Answer 33

Q-tip test. A positive Q-tip test of a 60-degree angle of excursion or greater indicates a hypermobile urethra.

Question 34

Diagnostic criteria of PCOS

Answer 34

oligomenorrhea, hyperandrogenism and multiple small cysts of the ovary on transvaginal ultrasound

Question 35

What does presence of acanthosis indicate in PCOS

Answer 35

Insulin resistance

Question 36

Management of PCOS based on fertility desires

Answer 36

Combination oral contraceptives have been the primary management of long-standing PCOS. They are effective in regulating dysfunctional bleeding and limiting unopposed estrogen (thus reducing endometrial cancer risk), increasing the sex hormone–binding globulin (decreases free androgen levels), and suppresses ovarian androgen production. Weight loss can reduce both the hyperinsulinemia and hyperandrogenism with as little as 5% weight loss from initial weight. Insulin-lowering agents, such as metformin, can be helpful in reducing the hyperinsulinism and thus limiting the risk of developing cardiovascular disease and diabetes mellitus. For patients desiring pregnancy, clomiphene citrate is the agent of choice, while metformin is only an adjunct.

Question 37

Lab studies to be considered in PCOS

Answer 37

TSH, prolactin, lipid profile, glucose-intolerance screening, endometrial biopsy (in patients with long-standing anovulation and unopposed estrogen exposure), 17-hydroxyprogesterone (congenital adrenal hyperplasia).

Question 38

Most common causes of abnormal serum screening

Answer 38

wrong dates and multiple gestations.

Question 39

Elevated maternal serum AFP

Answer 39

Open neural tube defect

Question 40

Low maternal serum AFP

Answer 40

fetal Down syndrome

Question 41

Ultrasound findings suspicious for having Down syndrome

Answer 41

Identification of a thickened nuchal fold, shortened femur length, or echogenic bowel.

Question 42

What is the triple test?

Answer 42

2 serum analyte: PAPP - A and free b-hCG | Nuchal translucency

Question 43

A 23-year-old G1 P0 woman at 20 weeks’ gestation undergoes an ultrasound examination for size greater than dates. The ultrasound reveals hydramnios with an amniotic fluid index of 30 cm. The fetal abdomen reveals a cystic mass in the right abdominal region, and a cystic mass in the left abdominal area. Which of the following is the most likely associated condition?

Answer 43

This baby has the “double bubble” of duodenal atresia. The hydramnios results from the inability of the baby to swallow. Duodenal atresia is strongly associated with fetal Down syndrome.

Question 44

window for serum screening for down syndrome?

Answer 44

15 - 21 weeks

Question 45

A 42-year-old woman with an 8-month history of increasing hirsutism and irregular menses. She denies the use of steroid medications, weight changes, or a family history of hirsutism. Pelvic examination shows an 8-cm, right adnexal mass. Most likely diagnosis?

Answer 45

An ovarian tumor, probable Sertoli–Leydig cell | tumor.

Question 46

Differential diagnosis of hirsutism

Answer 46

Cushing syndrome, Adrenal tumor, Congenital adrenal hyperplasia, PCOS, Sertoli-Leydig cell tumour

Question 47

Onset and duration of hirsutism and its differential diagnosis

Answer 47

(faster growth is associated with tumors of adrenal and ovary, whereas slow onset since menarche is more likely polycystic ovarian syndrome)

Question 48

A 6-year-old girl is noted to have breast development and vaginal spotting. No abnormal hair growth is noted. A 10-cm ovarian mass is palpated on rectal examination

Answer 48

Granulosa-theca cell tumour Isosexual (no virilization) precocious puberty with an adnexal mass usually is a granulosa cell tumor of the ovary.

Question 49

Normal LH:FSH ratio? | PCOS ratio?

Answer 49

Normal 1:1 | PCOS >2:1

Question 50

Microscopy of bacterial vaginosis

Answer 50

Clue cells

Question 51

Microscopy of trichomonal vaginitis

Answer 51

Trichomonads

Question 52

Microscopy of candidal vulvovaginitis

Answer 52

Pseudohyphae