Obstetrics and Gynecology Flashcards
(486 cards)
1
Q
What is the climacteric state?
A
Constellation of symptoms consistent with perimenopause including hot flashes, night sweats. Due to hypoestrogenemia. Occurs between ages of 40 and 51.
2
Q
Premature Ovarian Failure
A
Cessation of ovarian function due to atresia of follicles prior to age 40
3
Q
What were the findings of the Women’s Health Initiative Study?
A
HRT (continuous estrogen-progestin) treatment caused a small but significant increased risk of:
- breast cancer
- heart disease
- PE
- stroke
4
Q
Treatment for Hot Flashes
A
- estrogen therapy (no evidence of adverse effects for short term < 6 months use)
- antihypertensive agent Clonidine
- Raloxifene (SERM) helps prevent bone loss but does not alter hot flushes
5
Q
Effects of hypothyroidism and hyperprolactinemia on menstruation?
A
Cause hypothalamic dysfunction –> inhibits GNRH pulsations–> inhibits pituitary FSH and LH release –> hypoestrogenic amenorrhea
- Common cause of hyperprolactinemia in a younger girl is a prolactinoma
6
Q
Turner syndrome (45,X) effects on the ovary?
A
Ovarian failure.
- Have elevated gonadotropin levels and streaked ovaries
- Decreased E
7
Q
What is Sheehan syndrome?
A
Hemorrhagic necrosis of the anterior pituitary associated with PPH.
- Often unable to breastfeed due to inability to release prolactin from the anterior pituitary- - In hypoestrogenic state
- Tx: supplemental hormonal replacement
8
Q
Most common location of an osteoporosis-associated fracture?
A
Thoracic spine as a compression fracture
9
Q
If a woman still has her uterus what hormones should be used if HRT necessary?
A
- E and P
- Need progesterone to oppose estrogen to prevent endometrial cancer
10
Q
What is necrotizing fasciitis?
A
Serious infection of the muscle and fascia usually caused by multiple organisms or anaerobes
- Can involve surgical infections, traumatic injury or rarely Group A Streptococci (flesh-eating bacteria)
11
Q
What is group A Streptococcal Toxic Shock Syndrome?
A
Rapidly progressing infection of the episiotomy or Cesarean delivery incision (“flesh eating bacteria” syndrome)
12
Q
How do you calculate MAP?
A
MAP= [(2/ dBP) + (1 x sBP)]/3
13
Q
Management of a post C-section septic shock patient
A
1) IV fluids with close monitoring of urine output and BP
2) IV antibiotics (broad spectrum to include penicillin, gentamicin, and metrondiazole or other anaerobic agent)
3) Pressors (dopamine or dobutamine if IV fluids not enough to maintain BP)
4) Surgical debridement of wound infection
14
Q
Pathophysiology of Septic Shock
A
Vasodilation due to endotoxins (except for in the case of toxic shock syndrome- staphylococcus aureus is an exotoxin). Vasodilation leads to hypotension and is treated with IV fluids. Late stage can result in cardiac dysfunction.
15
Q
Classic sign of necrotizing fasciitis?
A
Gas in the muscle of fascia likely due to clostridial species.
16
Q
Toxic Shock Syndrome
A
- Commonly caused by S aureus
- Sunburn-like rash and/or desquamation is typical
- Initial abx: IV nafcillin or methicillin unless MRSA suspected, in which case vancomycin is used
17
Q
What is considered a term pregnancy?
A
Between 37 and 42 weeks from the LMP
18
Q
Rate of cervical dilation in active labour?
A
Average: Primip: ~1.2 cm/hr Mulltip: ~ 1.5 cm/hr Minimum: Primip: 0.5 cm/hr Multip: 1 cm/hr
19
Q
What to do if a pregnant woman is found not to be immune to rubella?
A
Immunize in postpartum period since it is a live-attenuated vaccine and contraindicated in pregnancy
20
Q
Definition of Labour
A
Cervical change accompanied by regular uterine contractions.
21
Q
Phases of Labour
A
1) Latent phase: initial part of labour where cervix mainly effaces rather than dilates (usually cervical dilation < 4cm)
- Usually takes < or = 18-20 h for a primip, and < or = 14 hours for a multip
2) Active phase: portion of labour where dilation occurs more rapidly (usually when cervix is > 4cm)
22
Q
What is protraction of the active phase of labour?
A
Cervical dilation in the active phase that is less than expected (less than average)
23
Q
What is arrest of the active phase of labour?
A
No progress in the active phase of labour for 2 hours
24
Q
Stages of Labour
A
1) Onset of labor until complete dilation of cervix
2) Complete cervical dilation to delivery of infant
- Should be < or = 2hr or 3hr (if epidural) for a primip, and < or = 1 hr or 2 hr (if epidural) for a multip
3) Delivery of infant to delivery of the placenta
- should be < 30 min
25
What is a normal FHR baseline?
Between 110-160 bpm
26
What are FHR Decelerations?
FHR changes below the baseline
- Three types:
1) Early (mirror image of uterine contraction)- often due to fetal head compression (benign)
2) Variable (abrupt jagged drips below the baseline- often due to cord compression
3) Late (offset following uterine contraction)- suggest fetal hypoxia and if persistent can indicate fetal acidemia
27
What are FHR Accelerations?
FHR that increases above the baseline for at least 15 bpm and at least 15 sec
28
What are clinically adequate uterine contractions?
Occurring every 2-3 minutes
Firm on palpation
Lasting 40-60 sec
- One way to assess is to examine a 10 min window and add each contraction's rise above baseline (> or = to 200 Montevideo units = adequate)
29
Three P's of Labour
1) Power
2) Pelvis
3) Passenger
30
How can you assess fetal acidemia during labour?
Fetal scalp pH monitor
31
What type of pelvis causes the fetal occiput posterior position?
Antropoid pelvis (AP diameter > transverse diameter with prominent ischial spines and a narrow anterior segment
32
What determines normalcy of labour- cervical change or contractions?
Cervical change
33
Lower abdo pain and vaginal spotting in a woman of childbearing potential is considered...
Ectopic pregnancy until proven otherwise
34
BhCG threshold for transvaginal sonography
1500-2000 mIU/L
35
Change in serial hCG levels suggesting a normal intrauterine gestation early on
66% in 48 hours (does not tell you if pregnancy is in the uterus or tube- if there is abnormal change and it is too early for U/S then can do uterine curettage- if chorionic villi present = miscarriage, if no chorionic villi = ectopic)
36
Ectopic Pregnancy
Pregnancy outside of the normal uterine implantation site (usually means a pregnancy in the fallopian tube)
37
Progesterone levels to determine viable vs. nonviable pregnancy?
> 25 ng/mL suggests normal intrauterine gestation
| < 5 ng/mL suggests nonviable gestation
38
Which ectopic pregnancies can be managed by IM methotrexate?
Asymptomatic and small (< 3.5 cm)
39
Best tx for a patient with early pregnancy, severe adnexal pain and is hemodynamically unstable
SURGERY
40
Usual management of placenta accreta
Hysterectomy because attempts to remove the firmly often lead to hemorrhage and/or maternal death
- If fertility is to be conserved, one can try to remove as much of the placenta as possible and pack the uterus or ligate the umbilical cord as high as possible and give IV methotrexate
41
Placenta Accreta
Abnormal adherence of the placenta to the uterine wall due to abnormality of the decidua basalis layer of the uterus
- Placental villi are attached to the myometrium
42
Placenta Increta
Abnormally implanted placenta penetrates into the myometrium
43
Placenta Percreta
Abnormally implanted placenta penetrates entirely through myometrium to the serosa
- Often invasion into the bladder is noted
44
RFs for placental adherence
- Low-lying placentation
- Previous placenta previa
- Prior c/s or uterine curettage
- Prior myomectomy
- Fetal down syndrome
45
What is transmigration of the placenta?
When a previous low-lying placenta or placenta previa diagnosed in the T2 because of the lower segment growing more rapidly in T3
46
Which is associated with a higher risk of placenta accreta- a posterior or anterior placenta?
Anterior placenta
47
Common treatment for gonococcal cervicitis
Ceftriaxone 125 to 250 mg IM
- Because Chlamydia often coexists with gonorrhea therapy with azithromycin 1g orally or doxycycline 100 mg BID for 7-10 days is also indicated
48
Most common organism implicated in mucopurulent cervical discharge
Chlamydia trachomatis
49
Complications of gonococcal cervicits
- Organisms can ascend and infect the fallopian tubes (acute salpingitis or PID)
- Predisposes patient to infertility and ectopic pregnancy (tubal occlusion and/or adhesions)
- Infectious arthritis usually involving the large joints and classically migratory
- Disseminated gonorrhea (individuals usually have eruptions or painful pustules with erythematous base on the skin)
50
What organism most commonly causes sexually-transmitted pharyngitis?
Neisseria gonorrhea because it has pili that allow it to adhere to the columnar epithelium at the back fo the throat
51
What can N. Gonorrhea and C. trachomatis cause in the baby of an infected pregnant woman?
- Blindness
| - C. Trachomatis can also cause infantile pneumonia generally between 1-3 months of age
52
What type of organis is N. Gonorrhea?
- Gram-negative intracellular diplococci
53
Clinical picture of a completed spontaneous abortion?
- Passage of tissue
- Resolution of cramping and bleeding
- Closed cervical os
54
How to determine if there is residual products of conception?
- Follow serum quantitative hCG levels (expected to halve every 48-72 hours- if they plateau instead of fall then there might be residual tissue left)
55
Most common cause identified with spontaneous abortion?
Chromosomal abnormality of the embryo
56
Threatened abortion
Pregnancy < 20 wks associated with vaginal bleeding generally without cervical dilation
57
Inevitable abortion
Pregnancy < 20 wks associated with cramping, bleeding and cervical dilation (no passage of tissue yet)
58
Incomplete abortion
Pregnancy < 20 wks associated with cramping, vaginal bleeding, open cervical os and some passage of tissue per vagina but some retained tissue in utero
- Cervix often remains open due to continued uterine contractions as it tries to expel the tissue
59
Completed abortion
Pregnancy < 20 wks in which all the products of conception have passed
- Cervix is generally closed (uterus is no longer contracting)
60
Missed abortion
Pregnancy < 20 wks with embryonic or fetal demise but no symptoms of bleeding or cramping
61
Molar pregnancy
Trophoblastic tissue or placental-like tissue usually without a fetus
- Clinical picture: vaginal spotting, absence of fetal heart tones, size greater than dates and markedly elevated hCG levels
- Diagnosis: U/S = snow storm pattern in uterus
- Tx: uterine suction & curettage
- Monitor weekly hCG levels because sometimes gestational trophoblastic disease persists and chemotherapy is needed
62
Incompetent cervix
Painless cervical dilation
- RFs: cervical conization, congenital malformations, trauma to cervix, prolonged 2nd stage of labor, uterine overdistention with multiple gestation pregnancy
- Tx: Cervical cerclage (stitch)
63
What is the "turtle sign"?
Retraction of the fetal head back toward the maternal introitus due to shoulder dystocia
64
What is shoulder dystocia?
Inability of the fetal shoulders to deliver spontaneously, usually due to the impaction of the anterior shoulder behind the maternal symphysis pubis
65
McRoberts Maneuver
Maternal thighs are sharply flexed against the maternal abdomen to straighten sacrum relative to L spine and rotate the symphysis pubis anteriorly toward maternal head
- Used to help treat shoulder dystocia
66
Erb Palsy
Brachial plexus injury involving C5- C6 nerve roots which may result from the downward traction of the anterior shoulder
- Baby usually has weakness of the deltoid, infraspinatus an flexor muscles of the forearm (arm usually hangs limp and is internally rotated)
67
RFs of Shoulder Dystocia
- Fetal macrosomia
- Maternal obesity
- Prolonged 2nd stage of labour
- Gestational DM
68
Signs of shoulder dystocia?
- Turtle sign
- No restitution of fetal head
- Failure to deliver with expulsive effort and usual maneuvers
69
ALARMER acronym
```
- Tx of shoulder dystocia
A – ask for help
L – lift/hyperflex legs (McRobertson maneuver)
A – anterior shoulder disimpaction
R – rotation of the posterior shoulder
M – manual removal of the posterior arm
E – episiotomy
R – roll over onto all fours
```
70
Last resorts to tx of shoulder dystocia?
- Clavicular fracture
- Zavanelli maneuver (push fetal head back in for c/s)
- Symphisiotomy
71
What gynecologic procedure is most likely to result in ureteral injury?
Hysterectomy
72
Where is the most common location for ureteral injury?
At the cardinal ligament where the ureter is only 2-3 cm lateral to the cervix
73
What is the "water under the bridge"?
The ureters travel under the uterine arteries
74
If IV pyelogram shows possible obstruction with hydronephrosis what is the tx?
- IV abx and cystoscopy to attempt retrograde stent passage (in the hopes that the ureter is kinked and not occluded)
75
Vesicovaginal fistula
Constant connection between the bladder and vagina
- Predisposed to this after any pelvic surgery or vaginal birth
- Causes constant urinary leakage
- Surgery necessary to remove fistula
76
Flank pain and fever after pelvic surgery suggests what?
Ureteral injury
77
Post-menopausal bleeding is what until proven otherwise?
Endometrial CA
| * Other etiologies: endometrial polyps or atrophic endometrium
78
RFs for endometrial CA?
- Obesity
- DM
- HTN
- Prior irregular menstruation
- Late menopause
- Nulliparity
- Unopposed E in HRT
- Early menarche
- E-secreting ovarian tumors
- Personal fam hx of breast of ovarian CA
79
Initial test of choice for endometrial CA?
Endometrial biopsy
80
Endometrial Stripe
Transvaginal sonographic assessment of the endometrial thickness (> 5cm is abnormal in post-menopausal women)
81
Most common female genital tract malignancy
Endometrial CA
82
Does smoking increase or decrease risk of endometrial CA?
Decrease because it promotes a lower estrogenic state
83
Atypical glandular cells on Pap smear suggest?
```
Endocervical or endometrial CA
Next steps:
- colposcopic examination of the cervix
- curretage of the endocervix
- endometrial sampling
```
84
CA125 is most associated with what type of tumor?
Epithelial tumors of the ovary
85
Painless vaginal antepartum bleeding (>20 wks)
Placenta previa
86
Antepartum vaginal bleeding (>20 wks) with painful uterine contractions/ increased uterine tone?
Placental abruption
87
Tx of placenta previa
Expectant management as long as the bleeding is not excessive with c/s at 36- 37 wks GA
88
Placental abruption
Premature separation of a normally implanted placenta
89
Vasa Previa
Umbilical cord vessels that insert into the membranes with the vessels overlying the internal cervical os (fetus is vulnerable to exsanguination upon rupture of membranes)
90
Two most common causes of significant antepartum bleeding?
Placenta previa
| Placental abruption
91
Define antepartum vaginal bleeding
Vaginal bleeding occurring after 20 weeks GA
92
First step to diagnose placenta previa?
U/S - avoid speculum or digital exam until placenta previa r/o since it may induce bleeding
93
Why may placenta previa lead to PPH?
Lower uterine segment is poorly contractile
94
What other placental abnormality is associated with placenta previa?
Placental accreta (particularly if there is a previous uterine scar)
95
RFs of placental previa?
- Grand multiparity
- Prior c/s
- Prior uterine currettage
- Previous placenta previa
- Multiple gestation
96
Is U/S good at assessment of abruption?
No, because the freshly developed blood clot behind the placenta has the same sonographic texture as the placenta itself
97
RFs for Placental Abruption?
- HTN
- Cocaine use (causes maternal HTN and vasoconstriction)
- Short umbilical cord
- Trauma
- Uteroplacental insufficiency
- Submucous leiomyomata
- Sudden uterine decompression (hydramnios)
- Cigarette smoking
- PPROM
98
Couvelaire Uterus
Bleeding into the myometrium of the uterus giving it a discolored appearance to the uterine surface
- Increases risk of PPH due to decreased contractibility of the myometrium
99
Complications of Placental Abruption
- PPH
- Preterm delivery
- Coagulopathy (secondary to hypofibrinogenemia)
- Fetal to maternal bleeding
100
Management of Placental Abruption
- Usually delivery
- If fetus immature, expectant management can be exercised if the patient is stable with no active bleeding or signs of fetal compromise
101
Best diagnostic procedure when a cervical lesion is seen?
Cervical biopsy
102
Most common presenting symptom of invasive cervical CA?
Post-coital bleeding
103
RFs for cervical CA?
- Multiparity
- Cigarette smoking
- Hx of sexually transmitted disease (syphilis)
- Early age of coitus
- Multiple sexual partners
- HIV infection
- HPV
104
Cervical Intraepithelial Neoplasia
Preinvasive lesions of the cervix with abnormal cellular maturation, nuclear enlargement and atypia
105
HPV
Circular, dsDNA virus that can become incorporated into cervical squamous epithelium, predisposing the cells for dysplasia and/or CA
106
Radical Hysterectomy
Removal of uterus, cervix, supportive ligaments, and proximal vagina
107
Radiation Brachytherapy
Radioactive implants placed near tumor bed
108
Radiation Teletherapy
External beam radiation where the target is at some distance from radiation source
109
HPV Vaccine
- Killed virus vaccine
- FDA approved for females 9-26
- Quadrivalent vaccine (gardasil) contains antigens of HPV types 16 and 18 (associated with 50% of cervical CA and dysplasia) and 6 and 11 (which cause venereal warts)
110
Where do the majority of cervical dysplasia and cancers arise?
Squamocolumnar junction of the cervix
111
Most common cause of death due to cervical CA?
Bilateral ureteral obstruction leading to uremia
112
When do women with a total hysterectomy need pap smears of the vaginal cuff?
If there is a history of abnormal pap smears indicating cervical dysplasia
113
What is the most common type of cervical CA?
Squamous cell carcinoma
114
Two causes of secondary amenorrhea after PPH?
- Sheehan syndrome
| - Asherman's syndrome
115
Sheehan Syndrome
Anterior pituitary hemorrhagic necrosis caused by hypertrophy of the prolactin-secreting cells in conjunction with a hypotensive episode usually in the setting of PPH (bleeding in ant. pit --> pressure necrosis)
- Usually will see other abnormal ant. pit function (low thyroid hormones, low gonadotropins, low cortisol levels, low prolactin)
- Will have a monophasic basal body temp chart due to lack of progesterone
- Tx: replacement of hormones
116
Asherman's Syndrome
Caused by uterine curettage that damages the decidua basalis layer rendering the endometrium unresponsive
- Tx: hysteroscopic resection of scar tissue
117
PPH
Classically defined as bleeding > 500 mL for a vaginal delivery or > 1000 mL for a c/s
- Clinically = amount of bleeding that results in or threatens to result in hemodynamic instability
118
Most common cause of amenorrhea in the reproductive years?
Pregnancy
119
How long does amenorrhea ensure normally after a term delivery?
2-3 months, breast feeding may prolong this
120
Findings consistent with PCOS
- Positive progesterone withdrawal bleed
- Estrogen excess without progesterone
- Obesity
- Hirsuitism
- Glucose intolerance
- Elevated LH:FSH ratio of 2:1
- Small ovarian cysts on U/S
121
Two broad categories of hypoestrogenic amenorrhea?
- Hypothalamic/pituitary diseases
- Ovarian failure
* Distinguish between the two by FSH level (high FSH = ovarian failure)
122
When should artificial ROM be avoided?
With an unengaged presenting part- predisposes to cord prolapse
123
Treatment of cord prolapse?
Immediate c/s
- Place patient in trandelenberg position and keep his/her hand in the vagina to elevate the presenting part to keep it off of the cord
124
How can oxytocin lead to fetal bradycardia?
Hyperstimulation with oxytocin can cause the uterus to be tetanic or frequent and thus not allow for adequate blood flow through the placenta to the fetus
- Terbutaline given IV can help to relax the uterine musculature
125
Steps to Take With Fetal Bradycardia
1) Confirm FHR (vs maternal HR- scalp electrode or U/S)
2) Vaginal exam for cord prolapse
3) Positional changes (move to LLD)
4) Oxygen
5) IV fluid bolus
6) D/c oxytocin
126
Most common finding in uterine rupture?
FHR abnormality such as fetal bradycardia, deep variable decelerations or late decelerations
127
Treatment of uterine rupture?
Immediate c/s
128
Definition of uterine hyperstimulation?
> 5 uterine contractions in 10 minute window
129
How does hypothyroidism lead to galactorrhea?
Hypothyroidism is associated with elevated thyroid releasing hormone levels which acts as a prolactin-releasing hormone
130
Causes of galactorrhea?
- Pregnancy
- Pituitary adenoma
- Breast stimulation
- Chest wall trauma
- Hypothyroidism
131
Pituitary Secreting Adenoma
Tumor in the pituitary gland that produces prolactin
| - Symptoms: galactorrhea, h/a, peripheral vision defect (bitemporal hemianopsia)
132
Two drugs that can be used for hyperprolactinemia
- Bromocriptine
- Cabergolamine
* Both are dopamine agonists
133
What 2 hormones are released by the POSTERIOR pituitary?
- ADH
| - Oxytocin
134
What does oxytocin due in a pregnant woman?
- Causes uterine contractions
| - Stimulates ejection of the milk in a lactating woman
135
Cholestasis in Pregnancy
Intrahepatic cholestasis of unknown etiology in pregnancy whereby the patient usually complains of pruritus with or without jaundice and no skin rash
- Usually begins in T3 at night and gradually increases in severity
- Itching more severe on extremities than on trunk
- May occur in subsequent pregnancies and with the ingestion of OCPs - suggest hormone-related pathogenesis
- Diagnosis confirmed by elevated circulating bile acids (liver enzymes usually normal)
- Associated with increased incidence of prematurity, fetal distress and fetal loss (especially if associated jaundice)
- Increased incidence of gallstones
- Tx: antihistamines and cornstarch baths, can try bile salt binders- cholestyramine or ursodeoxycholic
136
Prurtitc Utricarial Papules and Plaques of Pregnancy (PUPPP)
Common skin condition of unknown etiology unique to pregnancy characterized by intense pruritus and erythematous papules on abdomen and extremities
- Begin on abdomen and spread to the thighs and sometimes buttocks and arms
- No negative effect on fetal/maternal outcomes
- Tx: topical steroids and antihistamines
137
Herpes Gestationis
Rare skin condition only seen in pregnancy
- Characterized by intense itching and vesicles on the abdomen and extremities
- Begins in T2
- Thought to be autoimmune related
- Limbs affected more than trunk
- May cause fetal growth retardation and stillbirth, as well as transmission to baby that resolves on its own
- Tx: oral corticosteroids
138
Why are pregnant women at risk of PE?
- Venous stasis due to compression of the IVC by the uterus
| - High estrogen state induces a hypercoagulable state due to the increase in clotting factors, particularly fibrinogen
139
Clinical Criteria of Salpingitis (PID)
- Lower abdominal pain
- Adenexal tenderness
- Cervical motion tenderness
- Fever
140
What is Fitz-Hugh and Curtis syndrome?
Perihepatic lesions that result following PID
141
How to confirm diagnosis of PID?
Laparoscopy that reveals purulent discharge from fimbria of the tubes
142
Criteria for Outpatient Management of PID
- Low grade fever
- Tolerance of oral medication
- Absence of peritoneal signs
- Compliance
143
Candidates for Inpatient Tx of PID?
- If patient fails outpatient tx
- If patient is pregnant
- At extremes of age
- Cannot tolerate oral medication
144
Tubo-ovarian Abscess
Sequelae of PID that generally has an anaerobic predominance and necessitates antibiotics (clindamycin or metrondiazole)
- Complication = rupture (surgical emergency)
- Treated with abx therapy not surgical drainage
145
Long-term Complications of PID
- Chronic pelvic pain
- Involuntary infertility
- Ectopic pregnancy
146
What increases the risk of PID?
IUD
147
What decreases the risk of PID?
OCPs (progestin thickens the cervical mucous)
148
Ideal Scan for a Pregnant Woman Suspected of Having a PE
- CT scan
- Originally it was thought that a V/Q scan was better but it actually exposes the fetus to slightly more radiation and has a higher rate of indeterminate cases
149
What are the physiologic changes to the respiratory system in pregnancy?
Increased TV --> Increased Minute Ventilation --> Higher O2 level, lower Co2 --> respiratory alkalosis --> renal excretion of bicarb --> low serum bicarb --> increased risk of metabolic acidosis
- Common values: pH= 7.45, PO2 = 95-105, PCO2 = 28, HCO3 = 19
150
What Other Tests Should You Run if a Pregnant Woman has a PE?
- Protein S
- Protein C
- Antithrombin III
- Factor V Leiden
- Hyperhomocysteinemia
- Antiphospholipid syndrome
151
Common Signs and Symptoms of PE?
- Dyspnea
- Tachypnea
- Pleuritic chest pain
152
Most Common Cause of Maternal Mortality?
Thromboembolism and amniotic fluid embolism
153
What is the most common ECG finding associated with PE?
Tachycardia
154
Risk to Baby of Maternal HSV?
Encephalitis that can lead to severe permanent CNS compromise
155
Herpes Simplex Prodromal Symptoms
Prior to outbreak of classical vesicles, patient may complain of burning, itching or tingling
156
When Should You Perform a C/S on a Pregnant Woman with HSV?
Any prodromal symptoms or genital lesions suspicious for HSV
157
Acyclovir
Activity against HSV1 and HSV2
- In primary herpes outbreaks, it reduces viral shedding, pain symptoms and is associated with faster healing of the lesions
- Usually required for frequent outbreaks or if a woman has her first outbreak during pregnancy
158
Distribution of HSV1 vs HSV2
HSV 1 = above the waist
| HSV2 = below the waist
159
Most Common Cause of Infectious Vulvar Ulcers?
HSV
160
Most Common Reason for Hysterectomy
Symptomatic Uterine Fibroids
161
Most Common Symptom of Uterine Fibroids?
Menorrhagia
162
Classic Physical Exam Finding of a Uterine Fibroids
Enlarged midline mass that is irregular and contiguous with the cervix
163
Six treatments for uterine fibroids?
1) NSAIDs
2) Provera if uterus is small
3) GnRH agonist to shrink fibroids (maximum shrinkage is seen after 3 months of therapy and will regrow when therapy stopped- therefore usually used to shrink them before surgery)
4) Uterine artery ligation
5) Myomectomy (procedure of choice if wishing to maintain fertility)
6) Hysterectomy
164
Leiomyomata
Benign,smooth muscle tumors, usually of the uterus
165
Leiomyosarcoma
Malignant, smooth muscle tumor with numerous mitoses
166
Submucous Fibroid
Primarily on the endometrial side of the uterus and impinge on the uterine cavity
- Associated with recurrent abortions
167
Intramural Fibroid
Primarily in the uterine muscle
168
Subserosal Fibroid
Primarily on the outside of the uterus on the serosal surface
- Can obstruct the ureters
169
Carneous/Red Degeneration
Changes of the fibroids due to rapid growth
| - Centre of fibroid becomes red causing pain
170
Most common tumor of the pelvis?
Uterine Leiomyomata (occur in 25% of women)
171
Signs of a Leiomyomata degenerating into a leiomyosarcoma?
- Rapid growth (increase of more than 6 weeks' gestational size in 1 year)
- Hx of radiation to the pelvis
* Need surgical evaluation
172
Pre-existing HTN
BP of 140/90 before pregnancy or less than 20 wks GA
173
Gestational HTN
HTN (140/90 or +) without proteinuria at > 20 weeks GA
174
Preeclampsia
HTN with proteinuria (> 300 mg/24 hr) at a GA > 20 weeks, caused by vasospasm
- Commonly also see nondependent edema
- Severe: systolic BP > 160, diastolic > 110 or urine protein level > 5g (or 3+ to 4+ on dipstick) OR symptoms such as h/a, RUQ pain or vision changes
175
Eclampsia
Seizure disorder associated with preeclampsia
176
Pathophysiology of Preeclampsia
Vasospasm and endothelial damage result in leakage of serum between the endothelial cells and cause local hypoxemia of tissue --> hemolysis, necrosis and other end-organ damage
177
Complications of preeclampsia
- Placental abruption
- Eclampsia (with possible intracerebral hemorrhage)
- Coagulopathies
- Renal failure
- Hepatic subcapsular hematoma
- Hepatic rupture
- Uteroplacental insufficiency
178
RFs of Preeclampsia
- Nulliparity
- Extremes of age
- African American
- Personal hx of severe preeclampsia
- Fam hx of preeclampsia
- Chronic HTN
- Chronic renal disease
- Antiphospholipid syndrome
- DM
- Multifetal gestation
179
Tests to Run for Preeclampsia
- CBC (platelets and hemoconcentration)
- Urinalysis and 24 urine collection (proteinuria)
- LFTs
- LDH
- Uric acid test
- BPP
180
Definitive tx of Preeclampsia?
DELIVERY
181
Greatest risk for occurrence of eclampsia?
Just prior to delivery, during labour and within the first 24 hours postpartum
182
What should you start the preeclamptic patient on while in labour and what should you monitor?
- Magnesium sulfate
* Need to monitor urine output, respiratory depression, dyspnea (side effect of mag sulf is pulmonary edema) and abolition of deep tendon reflexes (first sign of toxic effects)
183
What 2 main antihypertensives are used in preeclampsia?
- Hydralazine
| - Labetalol
184
Fibroadenoma
Benign, smooth muscle tumor of the breast, usually occurring in young women
- Firm, rubbery, mobile and solid in consistency
- Do not respond to ovarian hormones and do not vary during menstrual cycle
- Tx: careful f/u or excision of mass
185
Fibrocystic Breast Changes
- Multiple, irregular, "lumpiness of the breast"
- Clinical presentation: cyclic, painful, engorged breasts more pronounced before menstruation and occasionally with serous or green breast discharge
- Usually FNA is required to ensure mass is not cancer
- Tx: decrease caffeine, adding NSAIDs, tight-fitting bra, OCPS or oral progestin therapy (severe cases can use danazol or masectomy)
186
Bloody (Serosanguinous) nipple discharge when only one duct is involved and the absence of a breast mass
Intraductal papilloma
- Small benign tumors that grow in the milk ducts
- Second most common cause is breast malignancy
187
Galactocele
Mammary gland tumors that are cystic in nature and contain milk or milky fluid
- Occur when there is any sort of obstruction of milk flow in lactating breast
188
Signs Suggestive of Breast Malignancy
- Nipple retraction
| - Skin dimpling over a mass
189
Best way to image the breast of a woman < 30 years
- U/S due to dense fibrocystic changes that interfere with mammogram
190
Five Factors to Examine in Infertility
1) Ovulatory
2) Uterine
3) Tubal
4) Male Factor
5) Peritoneal Factor (Endometriosis)
191
Three D's of Endometriosis
- Dysmenorrhea
- Dyspareunia
- Dyschezia (difficulty defecating)
192
Fecundability
Probability of achieving pregnancy within one menstrual cycle (20-25%) for a normal couple
193
5 Ways to Document Ovulation
1) Basal body temperature (increase of 0.5 F that occurs after ovulation)
2) Midluteal P
3) LH surge
4) Endometrial biopsy showing secretory tissue
5) U/S documenting a decrease in follicle size and presence of fluid in the cul-de-sac
194
How to Test for the Uterine and Tubal factors of Fertility
Hysterosalpingogram done between day 6 and 10 of the cycle
195
Gold standard for diagnosing tubal and peritoneal disease
Laproscopy
196
Parameters of Semen Analysis
1) Volume (nl > 2.0 mL)
2) Sperm concentration (nl > 20 million/mL)
3) Motility (nl >50%)
4) Morphology (nl > 30% normal forms)
197
Treatment to 5 Factors of Fertility
1) Ovulatory dysfunction - Clomiphene citrate
2) Uterine disorder- hysteroscopic procedure
3) Male factor - Repair of hernia or varicocele, IVF
4) Tubal disorder - Laparoscopy, IVF
5) Ablation of endometriosis, medical therapy
198
Ovarian Torsion (Definition)
Twisting of ovarian vessels leading to ischemia
| - Most frequent and serious complication of benign ovarian cyst
199
Symptoms of ovarian torsion
- Colicky lower abdo pain
| - Nausea and vomiting
200
Treatment of Ovarian Torsion
Surgical
- Can untwist ovarian pedicle to lead to reprofusion of the ovary
- Ovarian cystectomy (remove only the cyst and leave remainder of normal tissue intact- best tx)
- Oophorectomy
201
Typical Timing of Presentation of Ovarian Torsion in Pregnancy
- Either at 14 wks when the uterus rises above the pelvic brim
- Immediately postpartum when uterus rapidly involutes
202
Presentation of acute appendicitis in the pregnant woman
- Abdominal pain not right in the RLQ but instead superior and lateral to McBurney point because the enlarged uterus pushes appendix to move it upward and outward towards flank
- Also present with nausea, emesis, fever and anorexia
- Tx: surgery regardless of GA and IV abx
203
Presentation of gallstones in pregnant woman
- RUQ pain following a meal
- "Bloated sensation"
- Possibly emesis
- Diagnose with U/S
- Tx: low-fat diet and observed until postpartum
204
Presentation of cholecystitis
- Severe and unrelenting pain
- Jaundice
- Fever
- Leukocytosis
- Diagnose: U/S
- Tx: surgery and supportive management
205
Most common cause of pancreatitis in pregnancy?
Gallstones
206
Two Key Tests to Diagnose Ectopic Pregnancy
- HCG
| - Transvaginal U/S
207
Threshold of Transvaginal U/S
HCG = 1500 IU/mL
208
Classic Triad of Ectopic Pregnancy
- Amenorrhea
- Abdominal pain
- Irregular vaginal spotting
- * IF it ruptures, pain becomes more severe, can have shoulder tup pain from blood irritating the diaphragm
209
Treatment of ectopic
Surgical: salpingostomy if ectopic small, wish to preserve fertility, and if ectopic not ruptured (otherwise salpingectomy)
Medical: Methotrexate - usually 1 IM dose if ectopic < 4cm (85-90% successful)
- may experience pain between 3-7 days after indicating tubal abortion
210
Levels of Progesterone that Suggest Viable Pregnancy
> 25 ng/mL
| Abnormal: <5 ng/mL
211
What do levels of HCG that plateau in the first 8 weeks of pregnancy indicate?
Abnormal pregnancy
212
Most common cause of microcytic anemia in pregnancy?
Iron deficiency
213
Anemia in a pregnant woman
Hb < 10.5 g/dL
214
Most common cause of macrocytic anemia in pregnancy?
Folate deficiency
215
Side effect of nitrofurantoin to treat UTI in someone with G6PD deficiency?
Hemolytic anemia
216
Diagnosis of Preterm Labour in a Nulliparous Woman?
2 cm dilation and 80% effacement
217
Fetal Fibronectin
- Basement membrane protein that helps bind placental membranes to the decidua of the uterus
- Can swab the posterior vaginal fornix for this, and if positive may indicate risk of preterm birth
- negative test is strongly associated with no delivery within 1 week
218
When should antenatal steroids be given?
Risk of preterm labour < 34 wks gestation
219
Tocolysis
```
Pharmacologic agents used to delay delivery once preterm labor is diagnosed if < 34-35 wks
Most commonly used agents:
- Indomethacin (NSAID)
- Nifedipine (Ca2+ channel blocker)
- Terbutaline (B agonist)
- Ritodrine (B-agonist)
```
220
Cervical Length Assessment
Can be used to determine risk of preterm delivery (< 25 mm or funneling = increased risk)
221
What infection is strongly associated with preterm delivery?
Gonococcal Cervicitis
- C. Trachomatis is less common
- UTIs and BV can also cause it
222
What is a relative contraindication for tocolysis?
Suspected abruption
223
Variable decelerations after tocolysis- what is the culprit?
Indomethacin- causes oligohydramnios which can lead to cord compression and variable decels
224
Common side effect of B-agonists for tocolysis?
Pulmonary Edema
225
Tx of preterm labour (3 steps) ?
- Identify the cause
- Give antenatal steroids if needed
- Tocolysis if needed
226
Most common cause of neonatal morbidity in a preterm infant?
Respiratory distress syndrome
227
Most common etiologic agent of bladder infections?
E. Coli
| Tx: sulfa agents, cephalosporins, quinolones or nitrofurantoin are all acceptable
228
Define Urethritis
Infection of the urethra commonly caused by C trachomatis
229
Define Urethral syndrome
Urgency and dysuria caused by urethral inflammation of unknown etiology
- Urine cultures negative
230
Order of common causes of bacterial cystitis?
- E coli
- Enterobacter
- Klebsiella
- Pseudomonas
- Proteus
- GBS
- Staphylococcos saprophyticus
- Chlamydia
231
Should you treat asymptomatic bacteriuria in pregnant women?
YES- 25% of untreated women go on to develop acute infection
232
Definition of Cystitis
Bacterial infection of the bladder with > 100,000 cfu/mL in midstream-voided specimen
233
Plan B
Levonorgestrel 0.75 mg taken orally at time 0 and the same dose after 12 hours
234
Main Effects of Progesterone in OCP
- Inhibit Ovulation
| - Cause cervical mucous thickening
235
Main Effects of Estrogen in OCP
- Mainain the endometrium
- Prevent unscheduled bleeding
- Inhibit follicle development
236
Side Effects of OCPS
- Nausea
- Breast tenderness
- Fluid retention
- Weight gain
237
RIsks of combined OCPs
- Mainly due to estrogen component
- Venous thromboembolism
- Strokes
- MI
- Increased risk of cholelithiasis
- Benign hepatic tumors
238
Positive Effects of combined OCPs
- Decreases the risk of developing ovarian or endometrial CA
- Shortens duration of menses
- Decreases blood loss during menses
- Improves pain from dysmenorrhea and endometriosis
- Decreases dysufunctional uterine bleeding and menorrhagia
- Improves acne
239
Contraindications to combined OCPs
- Thrombogenic mutations
- Prior thromboembolic event
- Cerebrovascular or CAD
- Uncontrolled HTN
- Migraines with aura
- DM
- PVD
- Smoking and age > 35
- Suspected/known breast CA
- E-dependent neoplasia
- Active liver disease
- Known or suspected pregnancy
240
How does the Levonorgestrel-releasing IUD work?
- Thickens cervical mucous
| - Creates atrophic endometrium
241
Contraindications to IUD insertion
- Current pregnancy
- Current STI
- Current or PID in the past 3 months
- Unexplained vaginal bleeding
- Malignant gestational trophoblastic disease
- Untreated cervical CA
- Untreated endometrial CA
- Uterine fibroids
- Current beast CA
242
Two regimens of emergency contraception
- Yuzpe method: combined OCP method- 0.1 mg of ethinyl estradiol and 0.5 mg of levonorgestrel in 2 doses 12 hours apart beginning within 72 hours of unprotected intercourse
- Progestin only method (plan B)
243
Side Effect of Depo-Provera?
Loss of BMD especially in adolescents
244
What is the down side to the contraceptive patch?
Greater risk of DVT
245
Complication of Abx therapy for Pyelonephritis?
ARDS with pulmonary injury due to endotoxin release after the abx begin to lyse the bacteria and lead to endotoxemia --> leads to leaky pulmonary capillaries
- Endotoxins can lead to damage to the myocardium, liver and kidneys
- May induce preterm labour
246
Common organism causing Pyelonephritis?
E. Coli
247
Most Common Cause of Sepsis in Pregnancy
Pyelonephritis
248
Tx of Pyelonephritis in Pregnancy?
Hospitalization and IV abx (cephalosporins- cefotetan or ceftriaxone or the combination of ampicillin and gentamicin)
- Tx until fever and flank tenderness have substantially improved and then switched to oral antimicrobial therapy and then suppressive therapy for the remainder of the pregnancy (1/3 of women will develop a recurrent UTI if suppressive therapy not utilized)
249
What would be suspected if clinical improvement has not occurred after 48-72 hours of appropriate abx therapy for pyelonephritis?
Urinary tract obstruction or perinephric absecess
250
What is the most common organism responsible for mastitis?
S aureus typically acquired from the back of the baby's throat during breast feeding
251
What is the Homans sign
Dorsiflexion of the foot to attempt to elicit tenderness in the patient
- Poor test
- Theoretically may cause embolization of clots
252
Ideal noninvasive test for DVT?
Doppler flow study of the venous system of the affected lower extremity
253
Symptoms of DVT
- Muscle pain
- Deep linear cords of the calf
- Tenderness and swelling of the lower extremity
- 2cm difference in leg circumferences
254
Management of DVT
Anticoagulation with bed rest and extremity elevation
| - Heparin preferred over Coumadin (coumadin can cause congenital abnormalities and is more difficult to reverse)
255
Side Effect of Heparin
Osteoporosis (propensity to inhibit vit K which is involved in bone metabolism) and thrombocytopenia
256
What types of CA do the BRCA gene mutations put a person at increased risk of?
- Breast
| - Ovarian
257
What is the most common CA in women?
Breast
| - It is the 2nd most common cause of female cancer deaths (secondary to lung CA)
258
What is the most important RF for breast CA?
Age (1/30 women will develop breast CA at age 60)
259
When should annual mammography be initiated?
Age 50
| - Age 35 years if positive family history
260
What should you do for any palpable dominant mass in the breast?
Biopsy it regardless of mammographic findings
261
Who is a candidate for genetic testing for the BRCA genes?
- First-degree relatives with breast CA
| - Patients of Ashkenazi Jewish ancestry
262
What inheritance pattern is the BRCA mutations?
Autosomal dominant
263
Most common histiological receptor status of breast CA?
Infiltrating intraductal carcinoma
264
What is the most significant factor in determining a patient's prognosis once diagnosed with breast CA?
Lymph node status
265
Most common ovarian tumors in women < 30
Dermoid cysts (benign cystic teratomas)
266
What is a common side effect of a dermoid cyst?
Hyperthyroidism (sometimes they contain thyroid tissue)- called struma ovarii
267
What is a cystic teratoma?
Benign germ cell tumor that may contain all three germ cell layers
268
Most common type of ovarian tumor in older women
Epithelial ovarian tumor (neoplasm from the outer layer of the ovary that can imitate the other epithelium of the gynecologic or urologic system)
269
Functional Ovarian Cyst
Physiologic cysts of the ovary which occur in reproductive-aged women, of follicular, corpus luteal or theca lutein in origin
270
Treatment of a dermoid cyst?
Cystectomy or unilateral oophorectomy with inspection of the contralateral ovary
271
What is the most common subtype of epithelial tumors?
Serous subtype
| - Typically bilateral
272
Character of mucinous tumors?
Large size
273
What type of tumors have an elevated CA125?
Most epithelial ovarian tumors
| - More specific in postmenopausal women since a variety of disease during the reproductive years can elevate CA125
274
What size of an adnexal mass is likely to be a tumor?
> 8 cm
275
What would you think of an adnexal mass < 5cm?
Functional cyst
276
What do you do if there is an adnexal cyst between 5 and 8 cm?
Sonographic features may help distinguish functional vs neoplas
- Some wait to see if there is a change if the cyst is between 5 and 8 cm and then operate if persistent
277
Common estrogen-secreting ovarian tumor
Granulosa-theca cell tumor (stromal sex chord tumors)
278
What is found inside immature teratomas?
All three germ layers as well as immature or embryonal structures
279
What is found inside malignant teratomas?
Immature neural elements
280
What is pseudomyxoma peritonei?
When a mucinous tumor ruptures intra-abdominally and the contents spill into the peritoneum leading to repeated bouts of bowel obstruction
281
What is a common sign of ovarian malignancy?
Ascites
282
Wound dehiscence
Separation of part of the surgical incision, but with an intact peritoneum
- Red, tender, indurated incision and fever 4-10 days postop
- Open wound and drain
- Broad spectrum antimicrobial
- Wet-to-dry dressing changes
- Can close on its own or approximated
283
Fascial disruption
Separation of the fascial layer usually leading to a communication of the peritoneal cavity with the skin
- Often caused by the suture tearing through the fascia
- Profuse drainage 5-14 days postop
- Needs repair
- Initiate broad-spectrum abx
284
RFs for Fascial Disruptions
- Vertical incisions
- Obesity
- Intra-abdominal distention
- DM
- Exposure to radiation
- Corticosteroid use
- Infection
- Coughing
- Malnutrition
285
Evisceration
Protrusion of bowel or omentum through incision indicating complete separation of all layers
- Surgical emergency
- Significant mortality due to sepsis
- Start abx stat
286
Most common cause of a hemoperitoneum in a pregnant woman
Ruptured ectopic pregnancy
287
What does the float test test for?
Tissue passed vaginally which floats in a frond pattern when placed in saline is good evidence of products of conception (95% accurate for the presence of chorionic villi)
288
What diagnostic test confirms a ruptured corpus luteal cyst?
Laparoscopy
289
Management of a ruptured corpus luteal cyst
1) secure hemostasis
| 2) if bleeding does not stop - cystectomy
290
What is the function of the corpus luteum in pregnancy?
Produces progesterone until about 10 weeks GA, after this there is a shared function between the placenta and corpus luteum
- Maintained by hCG
291
If you have to surgically remove the corpus luteum prior to 10-12 weeks what must you do?
Supplement progesterone
292
What can happen to a corpus luteum?
- Intrafollicular bleeding
| - When bleeding is excessive, cyst can enlarge = increased risk of rupture
293
What is most likely to happen to fibroids during pregnancy?
Estrogen causes rapid growth of the fibroid which can cause it to outgrow its blood supply --> ischemia/pain (red or carneous degeneration during pregnancy)
294
What is the earliest sign of hypovolemia?
Decreased urine output
295
What can mimic an ectopic pregnancy?
Ruptured corpus luteum
296
In a young, healthy patient how much of their blood volume have they lost when they are hypotensive?
30-40%
297
Define secondary amenorrhea
6 months of no menses with previously normal menses
298
What is Uterine Sounding?
Assessing the depth and direction of the cervical and uterine cavity with a thin blunt probe
299
What are two factors associated with extensive scar formation?
- Postpartum curettage performed between the 2nd and 4th weeks after delivery
+
- Hypoestrogenic states (breast-feeding or hypogonadotropic hypogonadism)
300
Would a woman with Asherman's have withdrawal bleeding after a progesterone challenge?
No
301
What is the most common method of diagnosing Ashermans?
Hysterosalpingogram
302
What is the gold standard test for Asherman's (IUA)?
Hysteroscopy
303
Treatment of IUA?
Operative hysteroscopy
- After can insert an IUD or a pediatric Foley catheter to prevent recently lysed adhesions from reforming
- Administration of conjugated estrogens and progesterone should be considered
- Re-evaluate the uterine cavity prior to attempting conception
304
Which is associated with crampy abdominal pain- cervical stenosis or IUA?
Cervical stenosis
305
Someone with POF is at risk of?
Osteoporosis
306
What is the hormonal status of a woman with IUA?
Normal
307
2 suspicious findings of breast CA on mammography?
- Small cluster of calcifications around a small mass
| - Small masses with ill-defined borders
308
What should you do if there is a palpable breast mass and a normal mammography?
Biopsy
309
What may identify early breast cancers missed by mammography?
MRI
310
What may result in mammographic findings identical to breast CA?
Fat necrosis resulting from trauma to the breast
| - Biopsy should still be done to confirm
311
Two main types of biopsy used for suspicious breast CA from mammography
- Core biopsy
| - Stereotactic guidance and needle-localization excision
312
Two most common causes of primary amenorrhea when there is normal breast development
- Mullerian agenesis
| - Androgen insensitivity
313
A distinguishing characteristic of androgen insensitivity?
Scant axillary and pubic hair (due to defective androgen R)
| - Can be confirmed by serum T which would be elevated (male range) and karyotype (XY)
314
Amenorrhea + absence of breast development is what kind of estrogenic state?
Hypoestrogenic (Ex. Turner syndrome)
315
Define primary amenorrhea?
- No menses by 14 years without secondary sex characteristics
- No menses by 16 years with secondary sex characteristics
316
Mullerian Agenesis
Congenital absence of development of the uterus, cervix, and fallopian tubes in a 46,XX female --> primary amenorrhea
- 1/3 also have a urinary tract abnormality
317
How is a person with AIS able to have breast development?
Because of the small amounts of circulating levels of estrogen secreted by the gonads and adrenals and produced by peripheral conversion of androstenedione (contributes the most)
318
What must be done to the gonads of a person with AIS and why?
Gonadectomy because they are at increased risk for malignancy (rarely occurs before puberty)
- Therefore, usually done after puberty to allow full breast development and linear growth to occur
319
Physically, what distinguishes a person with AIS from one with Mullerian Agenesis?
Those with AIS do not have pubic hair because sensitivity to androgens are needed for this
320
Most common karyotype of gonadal dysgenesis
45, XO (Turner syndrome)
321
First test with any woman that presents with amenorrhea
Pregnancy test
322
Septic Abortion
Any type of abortion associated with a uterine infection
| - <1% of spontaneous and ~ 0.5% of induced abortions
323
Source of infection leading to septic abortion?
Ascending infections from the vagina --> cervix --> endometirum --> myometrium --> parametrium --> peritoneum
- Retained POC often become a nidus for infection to develop
- Usually polymicrobial particularly anerobes (favourable response with combination gentamicin and clindamycin)
324
Four general components to tx of septic shock?
1) Maintain BP
2) Monitor BP, O2 and urine output
3) Start broad spectrum abx
4) Perform uterine curettage (~ 4 hours after abx started)
325
Pockets of gas on CT scan noted after diagnosis and abx for septic abortion?
Necrotizing metritis with gas forming bacteria such as Clostridial species
- Tx: urgent hysterectomy
326
What type of infection can be caused by unpasteurized milk products such as soft goat cheese?
Listeria monocytogenes
- Amniotic fluid usually meconium stained and may also see Gram +ve rods
- Tx: IV ampicillin
- Can cause miscarriage and septic abortion
327
Most common cause of PPH
Uterine atony
328
Steps to manage uterine atony --> PPH
1) Uterine massage
2) Dilute oxytocin
3) Prostaglandin F2-alpha (contraindicated in asthmatic patients) or rectal misoprostol or methergine
4) Surgical: exploratory laparotomy with interruption of blood vessels to the uterus
5) B-lynch stitch
329
If after birth the uterus is palpated and found to be firm, but bleeding continues what should be suspected?
Genital tract laceration (most common cause), uterine inversion, placental causes (accreta or retained placenta) or coagulopathy
330
Methylergonovine maleate (methergine)
An ergot alkyloid agent that induces myometrial contraction as a treatment of uterine atony
- Contraindicated in HTN
331
RFs for Uterine Atony
- Mg Sulf
- Oxytocin use during labor
- Rapid labor and/or delivery
- Overdistention of the uterus (macrosomia, multifetal pregnancy, hydramnios)
- Intra-amniotic infection (chorioamnionitis)
- Prolonged labor
- High parity
332
What can cause late PPH (occurring after fist 24 hours)?
Subinvolution of the placental site
- Usually occurring at 10-14 days after delivery
Tx: oral ergot & careful f/u
333
Definition of delayed puberty?
Absence of secondary sexual characteristics by age 14
334
Gonadal Dysgenesis
Failure of development of the ovaries usually associated with karyotypic abnormality (ex. 45, X) and often associated with streaked gonads
335
Four stages of puberty
1) Thelarche (~10.8 yrs)
2) Pubarche (~11 yrs)
3) Growth spurt (1 yr after thelarche)
4) Menarche (2.3 years after thelarche)
336
What causes hypergonadotropic hypogonadism?
```
Gonadal deficiency (most commonly Turner's)
- High FSH, low E
```
337
Features of Turner's Syndrome
- Streaked gonads
- No secondary sex characteristics
- Internal and external genitalia = female
- Short stature
- Webbed neck
- Shield chest
- Increased carrying angle
338
What causes hypogonadotropic hypogonadism?
A central defect
- Low FSH, low E
- Ex: poor nutrition/eating disorders, extreme exercise, chronic illness, stress, primary hypothyroidism, Cushing's, pituitary adenomas, craniopharyngiomas
339
Goals for management of delayed puberty
- Initiate and sustain sexual maturation
- Prevent osteoporosis from hypoestrogenemia
- Promote full height potential
*Therefore can treat with combined OCPs
340
What predisposes intra-abdominal gonads to malignancy?
Y chromosome
341
Treatment of Mastitis
Dicloxacillin unless MRSA suspected
| - Breast feeding should be continued to prevent abscess development
342
Persistent fever after 48 hours of abx for mastitis or presence of fluctuant mass?
Breast abscess
- Can be confirmed by U/S
Tx: surgical drainage or U/S guided aspiration
343
Contraindications to breast feeding
- infants with classic galactosemia
- mothers with active untreated TB or HIV
- mothers receiving diagnostic or therapeutic radioactive isotopes or exposure to radioactive materials
- mothers receiving antimetabolites or chemo
- mothers abusing drugs
- mothers with herpes simplex lesion on a breast
344
What should be supplemented that baby cannot get from breast milk?
Vit D at 2 months of age
345
Benefits to baby of breastfeeding
- Less infections (meningitis, UTIs and sepsis)
- better neurodevelopmental outcomes
- decreased risk of DM and childhood obesity later in life
- decreased GI infections (due to lactoferrin which inhibits certain iron-dependent bacteria of the GI tract and lysozyme that protects against E.coli and other bacteria)
346
Hallmark of Thyroid Storm
Autonomic instability
347
Thyroid Storm
Extreme thyrotoxicosis leading to CNS dysfunction (coma or delirium) and autonomic instability (hyperthermia, HTN and hypotension)
348
Most common cause of hyperthyroidism in pregnancy?
Graves disease (autoimmune disorder where antibodies are produced that mimic the function of TSH)
349
Drug of choice to treat hyperthyroidism in pregnancy?
Propylthiouracil (inhibits peripheral conversion of T4 to T3)
- Alternate: methimazole (but can cause skin/scalp defects)
- Both cross the placenta somewhat and can lead to transient neonatal hypothyroidism
350
Symptoms suggestive of thyroid storm
- Altered mental status
- Hyperthermia
- HTN
- Diarrhea
351
Management of Thyroid Storm
1) PTU
2) B-blockers for tachycardia (but becareful in those with CHF)
3) Acetaminophen or cooling blankets for hyperthermia
4) Corticosteroids to prevent peripheral conversion of t4 to t3
352
What does estrogen do to thyroid hormones in pregnancy?
- Increased thyroid binding globulin
- Increased total T4
- NO change to active or free T4 or TSH
- GENERALLY PREGNANCY IS A EUTHYROID STATE
353
What is the most common cause of hyperthyroidism in the postpartum state?
Destructive lymphocytic thyroiditis
- This is because the high corticosteroid levels in pregnancy suppress autoimmune antibodies (antimicrosomal antibodies) and a flare occurs postpartum
354
What are the levels of TSH and free T4 in hypothyroidism?
- High TSH
| - Low T4
355
What are the levels of TSH and free T4 in hyperthyroidism?
- Low TSH
| - High T4
356
What is given to babies born with chlamydial opthalmic infections?
Oral erythromycin for 14 days
357
What is given to babies prophylactically for gonococcal eye infection at birth?
Erythromycin eye ointment
358
Most common cause of conjunctivitis in the first month of life?
Chlamydial conjunctivitis
359
Treatment for chlamydia in pregnancy?
- Amoxicillin
- Azithromycin
* Tetracycline is contraindicated in pregnancy because of the possibility of the staining of the neonatal teeth, erythromycin can lead to liver dysfunction in pregnancy and ciprofloxacin can lead to neonatal MSK problems
360
Most common mode of transmission of HIV in women?
Heterosexual spread
361
Ways in which a fetus can develop HIV from the mother?
- Vertical transmission through placenta
- Transmission during delivery
- Through breast milk
362
When are HIV antibodies detectable?
- Usually 1 month after infection and almost always at 3 months
363
What should be monitored monthly in a pregnant woman with HIV?
Viral load
- Should be monitored monthly until no longer detectable (Reduces transmission to fetus to almost nothing)
- Try and maintain viral load < 1000 RNA
364
What is the optimal mode of delivery for the baby of a mother with HIV?
- C/S
| - If vaginal delivery they should receive IV zidovudine during labour
365
What would the infant born to an HIV positive mother receive after birth?
Oral zidovudine syrup
366
What cells does Chlamydia have a propensity for?
- Columnar and transitional epithelium
367
Difference in presentation of parvovirus infection between children and adults?
Adults: malaise, arthralgias, myalgias and a reticular (lacy) faint rash that comes and goes (sometimes asymptomatic
Children: "slapped cheek" appearance and high fever- "fifth disease"
368
What does parvovirus infection do in pregnancy?
May cause fetal infection that may lead to suppression of erythrocyte precursors
- Severe fetal anemia (Aplastic anemia) may result leading to fetal hydrops (one of the earliest signs is hydramnios)
369
Early signs of Hydramnios?
- Uterine size bigger than dates
| - Fetal parts difficult to palpate
370
How do you diagnose parvovirus?
Serology of IgM and IgG
- Negative IgM and positive IgG = prior infection, immune
- Negative, Negative (if < 20 days from exposure it could be early infection, if > 20 days not infected)
- Positive, Negative (probable acute infection but possible false positive IgM)
371
Sinusoidal HR pattern
FHR pattern that resembles a sine wave with cycles of 3-5 minutes
- Indicative of severe fetal anemia or fetal asphyxia
372
What kind of virus is parvovirus?
- small, single-stranded DNA virus
373
How to follow pregnant women infected with parvovirus?
- Weekly fetal U/S for 10 weeks assessing for fetal hydrops
| - If found, referral for possible intrauterine transfusion
374
Mechanism of action of hydrops fetalis
Severe anemia may cause heart failure or induction of the hematopoietic centers in the liver to replace normal liver tissue --> low serum protein
375
What happens with ITP in Pregnancy?
Antiplatelet antibodies may cross the placenta and cause fetal thrombocytopenia
376
Differential for hydramnios
- Gestational DM
- Isoimmunization
- Syphilis
- Fetal cardiac arrhythmias
- Fetal intestinal atresia
377
Most common cause of fever for a woman who has undergone c/s?
Endomyometritis
378
Differential for a fever in a woman who had a c/s?
- Endomyometritis
- Mastitis
- Wound infection
- Pyelonephritis
- Atelectasis (if had GA)
379
Febrile Morbidity
Temperature after c/s > 100.4 (38C) taken on two occasions at least 6 hours apart, exclusive of the first 24 hours
380
Septic Pelvic Thrombophlebitis
Bacterial infection of pelvic venous thrombi, usually involving the ovarian vein
- Tx: abx + heparin
381
Mechanism of Endomyometritis
Ascension of bacteria (mixture of organisms) from normal vaginal flora
- Uterine incision site is commonly the site for infection
382
Symptoms of Endomyometritis
- Fever that occurs on postop day 2
- Abdominal tenderness
- Foul-smelling lochia
383
Tx of Endomyometritis
- Broad-spectrum antimicrobial therapy especially with anaerobic coverage (usually IV gentamicin and clindamycin)
384
What would you do if fever persists after 48 hours of therapy for endomyometritis?
Add ampicillin because it is likely an enterococcal infection
- If fever still persists, than a CT scan of abdo and pelvis may reveal an abscess or infected hematoma
385
Most common organisms responsible for postcesarean endomyometritis?
Anaerobic bacteria (most commonly bacteroides species)
386
Classic lesion of primary syphilis?
Painless chancre
387
When does primary syphilis usually manifest itself?
2- 6 weeks after inoculation
388
Nontreponemal tests
Nonspecific antitreponemal antibody test such as VDRL or RPR tests
- These titers will fall with effective treatment
389
Specific Serologic Tests for Syphillis
Antibody tests that are directed against trepnemal organism such as MHA-TP and FTA-ABS
- Remain positive for life after infection
390
Two most common infectious causes of vulvar ulcers?
- HSV
| - Syphilis
391
What bacteria causes Syphilis?
T palidum
392
What do you do if a nontreponemal test is negative but there is the appearance of a chancre?
Darkfield microscopy or biopsy of the lesion
393
What is seen with secondary syphilis?
- Occurs about 9 weeks after the primary chancre
- Macular papular rash anywhere on the body (usually palms and soles of feet)
- Flat moist lesion of the condylomata lata on vulva (high concentration of spirochetes)
394
What is the latency period of syphilis?
- Subdivided in to late latent (>1 year) and early latent (<1 year)
- If untreated 1/3 go on to tertiary syphilis
395
What is seen with tertiary syphilis?
Cardiovascular or CNS effects (optic atrophy, tabes dorsalis, and aortic aneurysms)
396
What is the treatment of choice for syphilis?
Long-acting penicillin (benzathine penicillin G)
- One IM injection of 2.4 million units unless late latency (1 dose every week for 3 weeks)
- If allergic to penicillin, use oral erythromcin or doxycycline
- In pregnancy, penicillin is the only known effective tx to prevent congenital syphilis
397
What would you follow after therapy for syphilis?
Nontreponemal titres
- Appropriate response: 4 fold fall in titres in 3 months and a negative titre in 1 year ( if this does not occur, possible etiology is neurosyphilis diagnosed by LP and treated with IV penicillin x 4-6 doses)
398
What is Chancroid
STI
- Usually manifests as a soft, tender ulcer of the vulva (ragged edges on a necrotic base)
- More common in males than females
- May have tender lymphadenopathy as well
- Etiologic organism = Haemophilus ducreyi (gram-neg rod)
399
What is seen on gram stain of a chancroid?
School of fish
400
Treatment of chancroid?
Oral azithromycin or IM ceftriaxone
401
What other condition may show positive RPR besides syphilis?
SLE
402
Classic Examination of Neurosyphilis?
- Unsteady balance
| - Argyll robertson pupils (small pupils that accomodate but do not react to light)
403
Premature Rupture of Membranes
Rupture of membranes prior to onset of labor
404
Preterm Premature Rupture of Membranes
Rupture of membranes in a gestation < 37 wks, prior to onset of labor
405
What is an early sign of chorioamnionitis?
Fetal tachycardia
406
Treatment of PPROM?
- If < 32 weeks antenatal steroids may be given to enhance fetal lung maturity
- Broad-spectrum abx therapy (usually gent and amp)
- Expectant mgmt is undertaken when the risk of infection is < risk of prematurity
- After 34-35 weeks, tx is usually delivery
407
How do you diagnose chorioamnionitis?
Amniocentesis-revealing organisms on Gram stain
408
What can cause chorioamnionitis without rupture of membranes
Listeria from unpasteurized milk products can spread transplacentally
409
What does vaginal amniotic fluid with phosphatidyl glycerol suggest?
Fetal maturity
410
What is a contraindication of corticosteroid use for fetal lung maturity?
Clinical infection (corticosteroids suppress the immune system)
411
Three common causes of vaginitis or vaginosis?
BV
Trichomoniasis
Candida vulvovaginitis
412
What is BV?
Condition of excessive anaerobic bacteria in the vagina leading to discharge that is alkaline
413
What is candida vulvovaginits?
Vaginal and/or vulvar infection caused by Candida species usually with heterogenous discharge and inflammation
414
What is trichomonas vaginits
Infection of the vagin caused by protozoa Trichomonas vaginalis
- Usually associated with frothy green discharge and intense inflammatory response
415
What is the most common symptom of BV?
- Fishy or "musty" odor exacerbated by menses or intercourse since both of these introduce an alkaline substance
416
What is the vaginal pH in BV?
Alkaline (elevated above normal)
417
Out of BV, Trichomonous and Candida which has an acidic pH?
Candida
418
Is there an inflammatory reaction with BV?
No, therefore patient wont complain of swelling or irritation
419
What are three things BV is associated with?
- Genital tract infection (ex. endometritis)
- PID
- Pregnancy complications (preterm delivery and PPROM)
420
How do you treat BV?
Oral or vaginal metronidazole
421
How do you treat Trichomonas?
Metrondiazole (2g one dose) and partner treated
422
How do you treat Candida?
Fluconazole or imidazole cream
423
What should you avoid while taking metronidazole?
Alcohol- to avoid a disulfiram reaction
424
Symptoms of Trichomonas?
- Profuse "frothy" yellow-green to gray vaginal discharge
- Vaginal irritation
- Strawberry cervix
- Fishy odor
425
How does Candida develop?
Normally lactobaciili in the vagina inhibit fungal growth
- Therefore, abx therapy can decrease the lactobacilli concentration --> Candida overgrowth
- Also seen in patients with DM
426
Most common cause of hyperandrogenism
PCOS
427
Most sensitive marker of excess androgen production
Hirsuitism
428
Differential diagnosis for hirsuitism
- Anovulation
- Late-onset adrenal hyperplasia
- Androgen-secreting tumors
- Cushings
- Medications
- Thyroid disease
- Hyperprolactinemia
429
What is the most common enzymatic genetic defect causing CAH?
21-hydroxylase
430
Tests to run to determine source of hirsuitism
- Dexamethasone suppression test (cushings)
- DHEA-S (adrenal tumor)
- 17 hydroxyprogesterone (CAH)
- LH:FSH (PCOS)
- Testosterone (Sertoli-Leydig cell tumor)
431
What affect does hyperandrogenism have on SHBG?
Decreases it = more free T
432
What is characteristic of a sertoli-leydig cell tumor?
Fast onset of androgenic symptoms
433
Treatment of hirsuitism?
Depends on etiology but generally decrease DHT
434
Most common cause of ambiguous genitalia in the newborn?
CAH
435
What is the most common cause of hirsuitism and irregular menses?
PCOS
436
How do you treat PCOS?
Spironolactone and OCPs
437
Two most common locations of androgen production and secretion in a female?
Ovary and adrenal gland
438
Normal cut off value for msAFP?
2.0 to 2.5 MOM
439
Alpha-fetoprotein
Glycoprotein made by the fetal liver, analogous to the adult albumin
440
Neural Tube Defect
Failure of closure of the embryonic neural folds leading to an absent cranium and cerebral hemispheres (anencephaly) or nonclosure of the vertebral arches (spina bifida)
- If it is not covered by skin = open NTD
441
What are the most common causes of an elevated vs a low msAFP suggest?
- Elevated msAFP: oNTD
| - Low msAFP: DS
442
What is involved in IPS?
Part 1: NT, PAPP-A, BHCG
| Part 2: msAFP, Ue3, BHCG, Inhibin A
443
What is the first step in the management of an abnormal triple screen result?
U/S for correct GA and to determine multiple gestations
444
Diagnostic tests for abnormal baby?
Amniocentesis
| CVS
445
On neonatal U/S what is the "double bubble" finding?
Doudenal atresia (cystic mass in the right and left abdominal area)
- Can lead to hydramnios resulting from the baby being unable to swallow
- Strongly associated with fetal DS
446
Most common cause of abnormal triple screening?
Wrong dates
447
What are the 5 complications of PCOS?
- DM
- Endometrial CA
- Hyperlipidemia
- Metabolic syndrome
- CVD
448
What are the 6 diagnostic tests for PCOS?
- TSH
- Prolactin
- Serum T
- DHEAS
- 17 hydroxyprogesterone
- U/S
449
Diagnostic criteria for PCOS
2 of:
- Oligomenorrhea
- Hyperandrogenism
- Multiple cysts of the ovary on U/S
450
What is the LH:FSH ratio in PCOS?
2:1
451
Treatment of PCOS
If pregnancy not desired:
- OCPs
- Diet and exercise
- Assess for metabolic abnormalities leading to DM and CVD
- Metformin if necessary
If pregnancy desired:
- Metformin
- Clomiphene citrate
452
What provides anatomical support of the pelvic organs?
Pelvic diaphragm
| Endopelvic fascia
453
Define cystocele
Defect of the pelvic muscular support of the bladder allowing the bladder to fall down into the vagina
- Often urethra is hypermobile
- Anterior POP
454
Define enterocele
Defect of the pelvic muscular support of the uterus and cervix or the vaginal cuff (if hysterectomy)
- Small bowel and omentum push organs into vagina
- Central POP
455
Define rectocele
Defect of pelvic muscular support of the rectum allowing the rectum to impinge into the vagina
- May have constipation or difficulty evacuating stool
- Posterior POP
456
Paravaginal Defect
Defect in the levator ani attachment to the lateral pelvic side wall leading to lack of support of the vagina
- Lateral pelvic defect
457
RFs for POP
- Multiple vaginal births
- Coughing
- Lifting
- Connective tissue disorders
- Genetic predisposition
- Lack of E
- Obesity
458
Muscles that make up pelvic diaphragm
- Pubococcygeus
- Puborectalis
- Levator ani
459
Q-tip test
Place a cotton Q-tip in the urethra and observe the degree of movement upon a Valsalva
- Positive test = >60 degree angle of excursion (hypermobile urethra)
460
Procidentia
When a woman's entire uterus is prolapsed out of the introitus
461
Tx of POP
- Pelvic floor strengthening exercises
- Pessary devices
- Surgery (colporrhaphy)
462
Velamentous Cord Insertion
Umbilical vessels separate before reaching the placenta protected by only a thing fold of amnion instead of by the cord or the placenta itself
- These vessels are susceptible to tearing after ROM
463
Vasa Previa
Umbilical vessels that are not protected by cord or membranes which cross the internal cervical os in front of the fetal presenting part
- Most commonly occurs with velamentous cord insertion or a placenta with one or more accessory lobes
464
How are monozygotic twins formed?
Fertilization of one egg by one sperm, and then the egg splits
465
How are dizygotic twins formed?
Fertilization of 2 eggs by 2 sperm
466
What is chorionicity?
Number of placentas in a twin or higher order gestation
- In monozygotic twins it can be monochorionic or dichorionic
- In dizygotic twins it is always diamniotic
467
What is amnionicity?
Number of amniotic sacs in a twin or higher order gestation
- Monozygotic twins may be monoamniotic or diamniotic
- Dizygotic twins are always diamniotic
468
Complications of twin pregnancies
- Higher rate of preterm delivery
- Higher rate of congenital malformations
- 2x increased risk of preeclampsia
- PPH
- twin to twin transfusion syndrome
469
What determines the chronicity and amnionicity of monozygotic twins?
Timing of the division of embryos:
- First 72 hours: dichorionic/diamniotic
- Day 4-8: Monochorionic/diamniotic
- Day 8: Mono/mono
- After day 8: conjoined
470
What type of twins are influenced by race, heredity, maternal age, parity and fertility drugs?
Dizygotic twins
471
What is twin-to-twin transfusion syndrome?
One twin is the donor and the other the recipient such that one twin is larger with more amniontic fluid
-Tx: laser ablation of the shared anastomotic vessels at special centers or serial amniocentesis for decompression
472
What is the danger in mono/mono twins?
Cord entanglement
473
When can twin pregnancy be delivered vaginally?
When both twins are presenting vertex
474
What should be done if vasa previa is identified?
Planned c/s before ROM around 35-36 weeks of GA
| - Digital vaginal exams are CONTRAINDICATED
475
Apt Test
Test to distinguish if vaginal bleeding is maternal or fetal (as in vasa previa)
- Blood is mixed with NaOH will denatures only adult blood and turns sample YELLOW
- If sample stays PINK, it is fetal blood
476
Kleihauer- Betke (Neirhaus)
Quantitative test of fetal blood cells in maternal circulation
477
What are the maternal effects of a twin pregnancy?
They are enhanced
- Increase nausea and vomiting
- Greater "physiologic" anemia
- Greater increase in BP after 20 weeks
- Greater increase in size and weight of uterus
478
What type of murmur is normal in pregnant women?
Early SEM
479
What is Rh Isoimmunization?
RH negative woman develops anti-D (Rh Factor) antibodies in response to exposure to Rh (D) antigen
480
What would cause vaginal bleeding in < 20 weeks?
Threatened abortion
Completed abortion
Ectopic pregnancy
Septic Abortion
481
WHat would cause vaginal bleeding at > 20 weeks
Placenta previa
| Placenta abruption
482
Lichen Sclerosis
Chronic, inflammatory dermatologic disease characterized by pruritus and pain which mainly affects the anogenital region
- No cure
483
Presentation of Lichen Sclerosis
Itching worse at night localized to vulva
- "Cigarette paper" appearance
- Tears may develop from scratching or attempted intercourse and scarring may cause narrowing or complete closure of vaginal introitus
484
Differential diagnosis to lichen sclerosis
Lichen planus
Psoriasis
Vulvar intraepithelial neoplasia
Vitiligo
485
Treatment of Bartholin Gland Abscess
Incision and placement of small balloon catheter into the gland
Marsupialization (surgical fixation of the cyst wall everted against the mucosa of the vulva)
- If over 40 need biopsy to ensure it is not CA
486
What greatly increases the risk of Hep B vertical transmission?
Presence of hep E antigen
