Peds and OB Flashcards
(216 cards)
1
Q
Peds Vitals (new borns)
A
RR = 40-60 normal HR = 120-160 = normal
2
Q
APGAR
A
Color :
blue = 0 points
pink with blue extremities = 1
pink = 2
Pulse:
<60 = 0
60-110 = 1
>110 = 2
RR:
none =0
weak =1
crying =2
Grimace:
none=0
weak = 1
crying =2
activity:
none = 0
flexion =1
complete movement.. flailing arms and legs = 2 ponts
1st min apgar tells you inutero score
5min apgar tells you currently how baby is
most common apgar = 9,9
3
Q
What do you do as soon as baby is born and you are in the deliver room?
A
- Eyes - Erythromycin drops
- Vitamin K injection –> to prevent hemolytic disease of newborn.. (babies have no E.coli in their intestines.. meaning they cant make vita k.. which means they cant make vita k dependent clotting factors - 2,7,9,10 or protein C and S
- New Born Screenings must do:
- G6PD testing (x-linked recessive)
- PKU testing (Autosomal recessive)
- Galactossemia testing
- Congenital Adrenal Hyperplasia testing
- Hypothyroidism in baby testing
- Cystic Fibrosis testing (BIT = sweat chlroide, most accurate = genetic testing)
- Hearing Screen
- HEP B vaccine! must do before they leave (if mom is HEP B surface antigen.. then the baby MUST get Hep B IG before leaving! If the mom is HEP B surface antibody Positive then the baby must get vaccine before leaving)
4
Q
conjunctivitis in new born
A
day 1 = chemical
day 2-7 = gohnnerhea –> treat with IM ceftriaxone one dose
Day 8-14 = chlamydia –> treat with ORAL Erythromycin
3 weeks + = Herpes – > tx with Acyclovir
5
Q
If mom of newborn is HEP B antibody or antigen positive.. what must be done for the baby before DC
A
HEP B vaccine! must do before they leave (if mom is HEP B surface antigen.. then the baby MUST get Hep B IG before leaving! If the mom is HEP B surface antibody Positive then the baby must get vaccine before leaving)
6
Q
Polycythemia of newborn
A
transient condition – goes away itself.
Hypoxia inutero causes polycythemia.. It goes away once the baby is born and breathing air
7
Q
Is splenomegally normal in new born?
A
yes. Normal in new born
8
Q
Transient tachypnea of newborn
A
normal vag delivered patients.. squeeze through birthing canal and get rid of the fluid in the lungs - these babies usually will not get transient thacypnea
babies with c-section.. dont get to have all the fluid squeezed out of their lungs –> transient tachypnea
9
Q
hyperbilirubinemia in newborns
A
normal and transient
Spleen is removing all the HbF and making normal HbA.
Removing HbF –> hyperblilrubinemia
10
Q
Caput Secumdarium vs Cephalo Hematoma
A
Caput Secundarium - Crosses suture lines
Cephalo Hematoma - does NOT cross suture lines.
11
Q
Brachial plexus injury durring birth
A
Waiters tip
C5-C6
Treatment = immobilization and wait
12
Q
Klumpke paralysis
A
Claw hand
C6-C8
Treatment = Immobilization and wait
13
Q
Facial nerve paralysis during birth (using forceps to pull baby out)
A
Immobilize and wait.
14
Q
New Born eye screening
A
Eyes - check RED reflex
15
Q
WAGR
A
Willms tumor
Aniridia
GU tumor
Mental RETArdation
16
Q
New born abnormal findings in the abdomen
A
Abdomen:
1. DIaphragmatic Hernia - Hole in diaphragm.. causes intestines to develop in chest.. This takes up space in the chest and results in HYPOpulmonary development –> Respiratroy distress in the nuewborn –> only way to fix is with SURGERY.
- Omphalocele –> INcreased alpha feto protein!!! Intestines in sac
- Gastrochisis –> NO sac covering –> must do surgery.. but first make sure you cover with something moist.
- Willms Tumor = most common palpable ABDOMINAL mass. Caused by HEMIhypertrophy of ONE kidney!! Assoicated with WAGR
- Neuroblastoma - tumor in the adrenal Medulla –> test with urinary VMA (just like a pheochromocytoma)
17
Q
New born abnormal findings in the GU system
A
Hydrocele - Reminant of the TUnica vaginalis, TRANSiluminates, PAINLESS swelling.
Treatment - Resolves on its own in 6 months
Varicocele - heaviness in scrotum.. BIT = physical exam – feel bag of veins
MAT = ultrasound or CT
Cryptoorchidism - Undescended testi.. If it doesnt descend in one year you must do surgery otherwise it can cause cancer.
Hypospadias = ventral surface opening
Episapdias = Dorsal surface of penis
18
Q
Reflex testing in new borns
A
sucking
grasping
rooting - touch cheek they move face towards touching (shows baby is hungry)
Moro = make baby feel like they are falling they will put arms and legs out
Stepping reflex - hold baby up and they lift their feet
Babinski - Fanning of toes when touching the foot.. NORMAL in babies!!
19
Q
What time frame defines prolonged labor?
A
First time mom - over 20 hours
Multigravid - over 14 hours
What are some causes?
- CLosed cervix
- Anesthesia
Treatment = wait.
20
Q
Prolonged Dialation
A
1st time moms = dilating less than 1.2 CM / hour
Multi = dilating less than 1.5 Cm / Hour
Causes = 3 Ps
Power - Not enough uterine contractions –> treat with OXYTOCIN
Passenger - baby too big.. –> must do C-section
Passage - Birth canal too narrow, –> must do C-section
21
Q
Known breech positioning of baby.. what do you do?
A
C-section
22
Q
Post partum hemmhorage
A
More than 500mL blood after delivery
Treatment:
- Bi-manual exam (massaging uterus from inside and outside) this will cause blood vessels to constrict
- Oxytocin - This will cause contractions - constriction of vessels.
23
Q
Mom had a postpartum hemmhorage.. and now she is having trouble breastfeeding.. what is the diagnosis?
A
sheehan syndrome –> atrophy of the pituitary because it didnt get enough blood –> endocrine abnormalities –> including Prolactin and Oxytocin
24
Q
when can you do external cephalicversion?
A
AFTER 36 weeks.
meaning if baby is in breech position on ultrasound.. you can try and manuver the baby by pressing on the moms stomach into the right position.. but ONLY after 36 weeks.
25
What is the most common pediatric cyanotic lesion?
Tetralogy of fallot
1. overriding aorta
2. Pulmonary stenosis
3. RVH
4. VSD
Tet spells (squatting.. increases venous return) = Tetralogy
Causes: Genetic --> chromosome 22
Diagnosis =
BIT = CXR
MAT = ECHO
Treatment = surgery
26
In Transposition of Great Vessels what drugs are CONTRAINDICTED?
NSAIDS and INDOmethacin
In Transposition.. the aorta comes out of right heart and pulmonary vessels come out of left heart.. the ONLY WAY a baby survives if there is a VSD, ASD or PDA.. These MUST stay open.
To keep open - PGE1 analogues
Nsaids and indomethacin close these openings and are thus CONTRAINDICATED.
BIT = CXR --> Egg on string apperance.
MAT = ECHO!
Treatment = surgery
27
Hypoplastic Left Heart Syndrome
Tiny Left heart.
NO PULSE!!
single S2 sound
Right Ventricular HYPERTROPHy --> on PE you can feel the right side impulse NOT the left
CXR = GLobular heart (because right is bigger than the left)
These babies actually appear grey (not blue)
MAT = ECHO!!
Tx = Surgery
28
Truncus Arteriosis
only ONE vessele comming out of heart.. this one vessel supplies both the lungs and heart
THey will have SEVERE hypoxia and Dyspnea.
SINGLE S1
BOUNDING PULSES@!
MAT = ECHO
TX = SUrgery
29
VSD in infancy
a large VSD will result in pulmonary HTN.
Blood from normal route is already in lungs.. however in VSD extra blood is going from left to right heart pushing even more blood into the lungs--> pulmon HTN
This results in Dypnea.
If its little it will close on its own.
If its big --> pulmon HTN
VSD murmur = HIGH PITCHED HOLOsystolic Murmur
CXR = Increased pulmonary VASCULAR markings
30
ASD in Infancy
more common in females than males
Murmur = FIXED wide SPLIT S2
BIT and MAT = ECHO
Definitive diagnosis with CATH
Paradoxical EMboli --> these patients will have a DVT that becomes a STROKE. --> because in an ASD blood is going from Right atrium to Left atrium--> Left Ventricle and directly into circulation.. lots of the circulation goes to the brain directly.. this DVT goes straight to Brain rather than going from Right atrium to right ventricle to lungs and causing a PE.
Large ASD --> surgery
Small ASD = spontaneous closure
31
PDA is a connection between what vessels?
Pulmonary artery and AOrta
PDAs are normal part of embryo.. When baby is born and you breath oxygen and pO2 is above 50.. then the PDA shuts by itself.
Murmur = Continuous MACHINERY!
DIagnosis = BIT and MAT = Echo
and CATH = definitive
Treatment = INDOMETHACIN = closes PDA
32
Aortic Coarctation
associated strongly with turners
Narrowing of the AORTA after the DUCTUS
Low BP in legs
HIGH BP in arms
Notching of RIbs on CXR
33
Pathalogical Jaundice
1. If it occurs in 1st day of life
2. If it raises more than 5mg d/l in one day
3. if its ever above 19.5
4. If Direct is > 2 mg/dl
5. If its elevated for more than 2 weeks.
34
What is kernicturus?
Deposition of Bilirubin in the BASAL GANGLIA!
Symptoms:
1. Hypotonia
2. Seizures
3. Hearing loss
4. CHOREOathetosis
Kernictursu is IRREVERSABLE.. once its there you always have it!
DIagnosis =
Type and screen (looking for ABO incompatiblity)
Bilirubin levels
Pathological jaundice is treated how?
Photo-therapy
if its not working then do EXCHANGE TRANSFUSION!
35
Esophageal Atresia
Presents one of 3 ways in infants:
1. Vomiting on first feeding
2. choking when feeding
3. recurrent aspiration pneumo
Prenatal history will show --> POLYHYDraminos
CXR --> esophageal bubble
Tx --> IVF, ABX (if there is pneumo) and surgery to fix atresia.
36
Pyloric Stenosis
Olive sign on CXR
NON-Billious Vomiting!!
PROJECTILE
Hypochloremic, hypokalemic, metabolic ALKAlosis
Diagnosis:
BIT = Abdominal US
MAT = Upper GI Series
Treatment = IV fluids, electrolytes
then do MYOtomey (cut the pylorus where there is hypertrophy)
37
Choanal Atresia
A MEMBRATE between NOSTRILS and PHARYNGEAL space.
Cant breathe while eating (drink milk) because of this membrane.
When they EAT = BLUE
CRY = PINK
Associated with CHARGE Syndrome
```
Diagnosis = CT
TX = Surgery
```
38
Hirshsprungs
NO nerves to DISTAL bowel
THis results in the muscle being CONTRACTED All the time.
THis causes no passage of feces.
NO MECONIUM Passage (or takes more than 48hrs) after birth.
Diagnosis:
Abdominal X-ray --> DIlated bowel.. and then very thin bowel (look up pic)
MAT = BIOPSY --> no nerves in distal bowel.
Tx = SURGERY
39
Imperforate ANUS
NO anal opening
related to Down Syndrome and VACTREL syndrome
No stool .. obviously
Diagnosis = clinical.. no anal opening on PE
Tx = Surgery
40
Duodenal Atreisa
Lack of APOPTOSIS --> thus lack of CANNALizatoin (no hole for everything to go through).. food will get THROUGH the duodenum.. but cant go PAST that.
Associated with: ANNULAR pancreas!
Symptoms: BILLIOUS vomiting within 12 hrs of life
CXR = DOuble Bubble sign
Tx = IVF / Electrolytes
then do SURGERY
41
Volvulus
Intestine twisted on itself --> vomiting, abdominal pain (colicky)
Abdominal X-ray --> FLuid AIR levels
Treatment - Try ENDOSCOPY if that doesn't work then surgery
42
INtusucception
Telescoping of bowel
Colicky abodominal pain, vomiting
CURRANT JELLY stools
kids go into FETAL position.. because it feels better
```
PE = SAUSAGE like mass
US = Target lesion
```
Treatment = BARIUM ENEMA (diagnostic and treatment)
All of these can cause intussuception:
1. meckels
2. lymphomas
3. hard stool
4. viruses
43
Meckles Diverticulum
the ONLY true DIVerticulum
Caused by persistence of Viteline duct --> Ectopic (pancreatic or gastric) tissue!
PAINLESS rectal BLeeding (due to pancreatic or gastric enzymes)
Diagnosis: Tech 99 scan!
Treatment - SURGERY (remove diverticulum)
RUle of 2s:
1. 2% of population
2. 2 feet from illeocecal valve
3. 2% of people that have it are symptomatic
4. Usually at age 2
44
whats the diff between diarrhea and gastro?
Gastro also causes INFLAMMATION in addition to the diarrhea.
Inflammatory - fever, pain, possible blood in stool
Non-inflammatory - watery, crapming pain, vomiting
45
GI Viruses
Rota = Seen more in winter, Watery, lasts less than 7 days.. no treatment. Patients are vaccinated by 6 months for this!
Adeno - Seen all year round, lasts less than 7 days
Norwalk - cruise ships, EXPLOSIVE diarrhea.. only lasts 1-2 days.
46
Necrotizing ENterocolitis
assoicatd with PREMATURE and LOW birthweight babies.
Basically causes BOWEL NECROSIS.
Fever, vomiting, abdominal distention
Diagnosis - ABdominal X-RAY --> will see PNEUMATOSIS INTESTINALIS (air in bowel wall) this is pathagnomonic!
Treatment = Stop feeding (to reduce blood flow.. and thus prevent further necrosis), Put in NG tube to decompress bowel, IVF fluids , maybe ABX
May need surgery to remove dead bowel.
47
Infants of Diabetic mothers
Macrosomia - organs are enlarged.. happens to all organs EXCEPT the BRAIN.
Patients also have increase in bone marrow --> polycythemia --> hyperbilirubinemia (when RBCs break down) --> can lead to kernictururs--> look out for that
Small left colon --> distention from constipation.. treat this with Small Frequent meals
Asymmetric Septal Hypertrophy (most common cardiac defect in diabetic mother infants) -- Diagnose with EKG / ECHO
Treat with BB and IVF.
HYPOglycemia - Babies in utero are surrounded by all the glucose in the moms blood so they make tons of insulin.. then when they are born.. they have all the insulin.. but no sugar --> hypoglycemia --> leads to seizures
Hypocalcemia --> tetany.. lethargy
Hypomagnesemia --> tetany and Decreased PTH
48
Rickets
Rickets can be caused by a deficiency in any of the 3 components of bone:
1. Vita D
2. Calcium
3. Phosphorous
Weak bones / softening of bones
1. Vitamin D deficient --> replace vitamin D
2. Vitamin D dependent (cant make active form of vitamin D2) --> replace with vitamin D2
3. X-Linked Hypophosphatemia --> body cant retain phosphorous --> cant mineralize bones --> soft bones.
Symptoms:
Bowing of bones
Diagnostic test:
x-ray - Rosary like appearance and BOWING of bones on xray
49
If Mom is ONLY breastfeeding what must you supplement?
VITAMIN D!!!
starting at 2 months of age.
50
Neonatal sepsis
Two categories: Early and Late.
Early:
1. E.coli
2. GBS
3. Listeria
Late:
1. Staph
2. E. coli
3. GBS
Workup and treatment:
1. IVF
2. Cultures (urine and blood)
3. LP if considering meni
51
Scarlet Fever
Usually caused by StreP. PYOgenes
1. Sand paper rash
2. Fever
3. STRAWBERRY tongue
4. Cervical LYmph.
DIagnosis:
Clinical but labs will show: Elevated ASO, ESR, and CRP
Treatment:
Penicililin (just like any other strep infection), If allergic to penicillin --> azithromycin or cephalosporin
52
TORCH infections
Toxoplasmosis - Chorioretinitis, hydrocephalus and RING enhancing lesions on CT
BIT = IGM
MAT = PCR
SUlfadiazine and Pyridoximine = treatment
```
Syphilis = hutchinson teeth, rash, sniffling
BIT = VDRL
MAT = FTABS / Darkfield or PCR
Treatment = Penicillin.. if allergic desensitize them
```
Rubella = Blueberry Muffin spots, Cataracts and Deafness
BIT = IgM titers
MAT- PCR
Treatment - supportive.. cant do much else.
CMV - Periventricular CALCIFICAtions, microcephally, HEARINg loss, ChorioRETinitis
BIT = TItiers
MAT = PCR
Treatment = Gancyclovir
```
Herpes= Shock / DIC, Vesicular lesions, Encephalitis
BIT = Tzanck smear
Treatment = Acyclovir
```
53
Croup
Caused by Parainfluenza virus
Can also be caused by RSV (especially in winter)
URI symptoms -- caused by severe inflammation
BARKY cough with INSPIRATORY Stridor
COryza = inflammation of mucous membranes lining the nasal cavity
CXR - STEEPLE sign (narrowing trachea)
Mild Croup - steroids
Moderate to severe = RACEMIC EPINepherine
54
Epiglottiis
Caused by HIB!
Severe inflammation of the EPIglottis
HIB is normally vaccinated.. so kids that get this will have no vaccination or delayed vaccines.
TRIPOD positions, drooling, MUFFLED voice.
CXR = THumb Print Sign
INTUBATE these kids in the OR
Treatment - CEFTRIAXONE for 7-10 days
FOr close contacts --> RIfampin
55
Whooping Cough
caused by B. Pertussis.
TdaP and Dtap contain this vaccine.
There is 3 stages to whooping cough:
1. Catthareal stage - Nasal congestion and cough --> lasts 14 days. This is the ONLY TREATABLE stage.. the rest are NOT.
Treat with Azithromycin or Eryhtromycin!
2. Paroxysmal Stage -- With "whoop" at the end of it.. this stage lasts 14-30 days.. no treatment at this stage.
3. Convalescent stage --> resolution with decreased cough
Make sure to ISOLATE the patient and give MACrolides to any close contacts!
56
whats the differenece between Tdap and DTAP?
Nothing. ITs the same thing.
TdaP given to ADULTS
Dtap = given to children!
57
Bronchitis
Inflammation of airways - caused by bacteria or viruses --> productive COUGH.. lasts 7-10 days.
CLINCAL diagnosis!
Treatment = supportive.
58
Pharyngitis
Inflammation of the NasoPharynx - caused by bacteria or viruses.--> sore throat, petechiae, FEVER, Cervical lymphadenopathy, URI symptoms.
MOST common cause = Group A strep
If this goes untreated what can it lead to?
GLomerulonephritis and Rheumatic fever
How do you diagnose?
1. BIT = Rapid DNAase ANTIGEN testing!
2. MAT = culture
Treatment = Penicillin (just like treatment for all strep).. if allergic to penicilin use MACROLIDES
59
Diphtheria
Corneobacterium DIphtherium
MEMBraneous Inflammation - Grey Pseudomembrane in the pharynx --> very VASCULAR so DO NOT SCRAPE!!!!!
No antibiotics for this
Must treat with ANti - toxin.
60
Congential Dysplasia of the HIP
found on NEWborn Exam (found in newborns.. age is big clue on exam)
Bortelani and Bartelow tests -- Clicking or cluncking on exam --> positive for congentical dysplasia of hip.
Xray of HIP
Teatment = PAVILIC HArness
61
Legg - calve - perthes
Avascular Necrosis of Femoral Head.
Happens to kids 2-8 years old (BIG CLUE..on test is age bracet)
X-ray - Widening of Joint space, Painful Limb.
RX = Surgery of BOTH hips!! Not only the HIP with issues!!!... must do both!
Then do Rest and NSAIDS
62
Slipped Capital Femoral EPiphysis
OBESE ADOlescents (happens in adolescents.. age is big clue on exam)
Painful LIMP
X-ray = Widening of JOINT
Treatment - INTernal FIXATION with surgical PINNINg
63
Vitamin A deficiency or toxicity
Deficiency:
1. poor NIGHt vision
2. HYPOparathyroidism
Toxicity:
1. HYPERparathyroidism
2. PSeudotumor cerebri
64
Vitamin B1 deficency or toxicity (thiamine)
Deficent:
1. Berri Berri Syndrome
2. Wernicke Encepholpathy
Toxicity:
its Water soluble.. no toxicity
65
B2 = Riboflavin
Deficency:
1. Angular Chelosis
2. Stomatitis
3. Glossitis
66
B3 = Niacin
Pellagra
4 Ds.
DIarrhea, Dermatitis, Dementia, Death
67
B5 = Penthonic acid
Burning in FEET
68
B6 = Pyridoximine
Peripheral NEURO!
Must give with INH..
69
B9 = Folate
Deficency - Megaloblastic anemia
Hyper segmented neutrophils
No Periphreal neuro with this alone
70
B12
Megalobalstic anemia
Peripheral Neuro
71
Vitamin C deficency
Scurvy
Bleeding, petechiae, echymosis
72
Vita D
Rickets
Toxicicity -- Increased Calcium --> polyuria and polydipsia
73
Vita K deficency
Bleeding, increased PT, PTT, INR
Give vita K in warfarin toxicity
Toxicity
74
PMS / PMDD
occurs in 20-30 y/o women
1. headache
2. moody
3. breast tenderness
4. pelvic pain
5. cramping / bloating
Occurs in last 2 weeks of mesturation.
To get the diagnosis the patient must have charted these symptoms for 2 CONSECUTIVE cycles!!
PMDD = The above symptoms cause dysfunction in the patients life.
Treatment = Take away caffiene and chocolate.. decrease smoking and alcohol
Increase exercise
If severe + PMDD then give SSRI
75
Menopause
48-52 y/o
when it first starts - irrecular periods (because oocytes decrease estrogen and progesterone)
Lasts about 12 months.. symptoms are:
1. Menstural irregularity
2. irritability
3. hot flashes
4. DYSPARINURIA (caused by low estrogen leading to vaginal dryness and atrophy)
5. decreased breast size
6. atrophy of cervix
INCREASED risk of OSTEOperosis.
HRT = used to control the symptoms of Menopause and ONLY done for 1 year..
HRT is linked to Endometrial cancer and breast cancer... thus its used in limited amounts.
76
Menhorragia
HEavy and PROLONGed bleeding.
Causes:
1. Fibroids = MCC
2. Dysfuncitonal uterine bleeding
3. Hyperplasia
4. IUD
77
HYPOmenhoragia
loss of bleeding
OCPs, Obstruction (present Hymen),
78
Metohoragia
irregular bleeding
1. Endometrial polyps
2. Cancers
79
METOMENOhragia
Irregular + Prolonged:
Cancers and polyps
80
Postcoital bleeding is a sign of what?
Cervical Cancer until proven otherwise!
also seen in atrophic vaginitis and cervical polyps
81
Dysfunctional Uterine bleeding
unexplained abnormal bleeding - MCC = anovulation
THe endometrium outgrows the blood supply and sheds --> bleeding
Diagnositc tests:
TSH levels
Prolactin Levels
Treatment = Combination OCPs (estrogen and progesterone pills)
Hysterectomy or endometrial ablation if very severe
82
Post Menopausal bleeding
AFTER all periods have stopped.. the patient comes in (6 months.. year later) with bleeding.
This is CANCER until proven otherwise
83
Simple Cysts
2 kinds - Luteal and Follicular cyts
These are the most common cysts in repo years.
Asymptomatic unless they become very large and compress adjacent tissues and burst.
B-hCG is negative
US will show fluid filled cystic Mass
Management - Follow up in 6-8 weeks.. generally resolve on their own.
Once they resolve give the patient STEROID Contraception to prevent new cysts from forming.
Laparoscopic removal must be done if the cyst is > 7cm Diameter.. or if STeroid contraception fails to resolve the cyst
84
Compelx Cysts
Benign Cystic Teratoma (DERMOID cyst)
COntains Cellular tissue from all 3 GERM LAYERS.
Rarely - SQUAMOUS CELL CARCINOMA develops.
US = COmplex MASS
Management = Laparascopic removal done in two ways:
1. Cystectomy - just remove cyst and keep ovary
2. OOPheroectomy - remove entire tube.. if fertility is no longer desired.
85
31 yo woman in ED with severe, SUDDEN lower abdoinal pain that started 3 hours ago.
Exam = Abdomen tender, with no rebound tenderness present
Adnexal mass in the cul-de-sac area.
US 8cm left adnexal mass
beta-HcG negative!
What is next step?
b HcG is negative --> not ectopic.. and sign of a SIMPLE cyst.
However this is above 7cm.. and thus we must do a LAparascopic EVALUATION of the ovaries.
86
9 yo girl, right adnexal pain, complex cysts on US.
What is the most likely cause?
GERM CELL TUMOR!
Most common in young women
Most common malignant epithelial cell type is DYSGERMINOMA
Tumor Markers: LDH, B-hcG, AFP
87
67 yo woman with progressive weight loss, distended abdomen and left adnexal mass.. what is the most liekly cause?
Epithelial TUMOR
Most common ovarian cancer in post menopausal women.
Most commong malignant sub-type = SEROUS tumor.
Tumor Markers = CA-125, CEA
88
58 yo Postmenopausal bleeding. Endometrial BIOPSy shows ENDOMETRIAL HYPERplasia. Pelvic US reveals RIGHT OVARIAN MASS
what is the most likely cause
Endometrial hyperplasia indicates an ESTROGEN secreting tumor.
Most likely mass = GRANULOSA - THECA cell tumor (STROMAL TUMOR)
Secretes estrogen and can cause ENDOMETRIAL hyperplasia
89
48 yo woman with increased FACIAL hair and DEEPening voice. has ADNEXAL mass on exam..
what is most likely casue
Facial hair and deepining voice --> indicates TESTOSterone.
SERTOLI - LEYDIG cell TUMORs (STROMAL TUMOR) secrete Testosterone
Tumor marker = testosterone
90
64 yo woman with Gastric ulcer and dyspepsia with WEIGHT loss and ABDominal pain. Adnexal mass on exam.
What is most likely cause?
gastric ulcers and dyspepsia is associated with the KRUKENBERG tumor.. which metastasizes from gastric cancer to the ovary.
MUCIN - producing ADENOcarcinoma
Metastasis from GAstriC Cancer.
Tumor Markers = CEA
91
Management for ALL prepubertal or postmenopasual ovarian masses?
Management:
Sonogram
CT scan for postmenopausal women
Biopsy via laparoscopy for simple cysts
No septations or Solid Components
92
Labial fusion
Fused Labia... caused by excess androgens
MCC = 21 B Hydroxylase Deficency
Treatment = Reconstructive surgery
93
What are the 3 epidermal problems in OBgyn?
1. Lichen Sclerosis
2. Lichen Planus
3. Squamous cell Hyperplasia
94
Lichen Sclerosis
White, thin streak on the LABIA -- In post menopausal women lichen sclerosis is a precursor to cancer
Treatment = TOpical steroids
95
Lichen Planus
Purples flat lesions in the VULVA
Seen between 30-60 years of age
Treatment = Topical Steroids
96
Squamous cell Hyperplasia
Chornic itchiness of vagina..excessive itching causes hyperKERATOSIS (thickenign and whitening of skin)
Treatment - Stiz Bath to stop the itchyness
97
Bartholin Gland Cyst
Fluctuant mass in Vagina.
On the lateral sides of the vagina.
Normally they secret mucus.. if they got blocked or clogged --> now it starts forming a cyst / abscess --> pain, pain during sex, pain during walking
Treatment = Incision and Drainage. Make sure to culture the puss.. to see if it was ghonorrhea or chlamydia that caused the gland to clog.
98
Vaginitis
Risk factors are anything that changes the pH balance of the vag --> ABX, diabetes.
Bacterial vaginosis - Gardenerella overgrowth (usually normal flora) --> fishy odor and copious vag discharge.
Wet mount - clue cells
Treatment = Metro
Candida - white thick cheese like vag discharge -- > extreme itchyness / puritis... If you keep getting yeast infections check the patient for diabetes.
KOH prep - pseudo hyphate
Treatment - Fluconazole
Trichamonas - caused by T. Vaginalis
Green, forthy, copious amounts of vag discharge
Saline wet mount - motile organisms
Treatment - Metro.. MAKE SURE TO TREAT PARTNER!!!!
99
Pagets disease
an INTRAepithelial lesion and is MALIGNANT
Occurs in POSTmenopasual women
SOre and itchiness of vagina
Redlesion with white on top
Definitive diagnosis --> biopsy
Treatment = vulvectomy
100
Squamous Cell carcinoma of vagina
most common type of MALIGNANT cancer in vulva
Itchy, bloody vaginal discharge.
stage it with biopsy.
treatment - VULVectomy.. and if lymph nodes are involved.. do lymphectomy.
101
Adenomyosis
Endometrial Glands inside the MYOmetrium - Occurs in patients between 35-50 years old
Pain
Menhoragia
Dysparenia
Risk factors - Endometreosis and Fibroids
Diagnosis -- Clinical Diangosnis!.. when you do bimanual exam.. you will feel large, globular uterus.
MAT = MRI.
Treatment = Hysterectomy (only treatment)
102
EndoMEtreosis
Endometrial tissue outside the Endometrium.
causes pain.. infertility
Pain occurs 1-2 weeks BEFORE menstruration and RESOLVES during menstruation.
Diagnosis - Laparoscopy --> choclate cyst on ovaries
On Ultra Sound - Ground Glass Appearance.
Treatment - NSAIDS for pain, OCPs to decrease ovulation.. Danazole = androgen analogue, Leupron = GNRH agonist.
103
Fibroids
Benign Tumor in MYOmetrium.
They cause pain and menhoragia.
Diagnosis = US
Treatment = OCPs to decrease bleeding.
Can do Hysterectomy.
104
Endometrial Cancer
Post menopausal women who suddenly have bleeding = endo ca until proven otherwise.
MUST DO BIOPSY in these patients!!!!
105
PCOS
Amenhorrea, Irregular menstruation, Hirsutism, Acne, Diabetes
Bilateral ovarian cysts - "string of pearls"
Diagnosis - Pelvic US.. (if you dont see cysts that doesnt mean patient doesnt have PCOS)
Look at LH / FSH and TEstosterone (PCOS has elevated testosterone).
Treatment - Weight loss, OCPs,
Clompiphene and Metformin for women that want to coneive and PCOS
106
Preterm Labor Risk factors and workup
The strongest risk factor for preterm labor = a PREVIOUS PREGNANCY with preterm labor.
Other risk factors are:
1. Multiple gestation
2. Cervical Surgery - in particular removal of part of the cervix by COLD KNIFE CONIZATION.
First step in evaluating the risk of preterm labor = TRANSVAGINAL ULTRASOUND for measurement of CERVICAL LENGTH.
A short cervical length is a strong predictor of PRETERM labor
107
If on evaluation a pregnant patient is found to have a short cervix (less than 2cm).. then what is the next step?
Short cervix found on transvag US is a strong predictor of PRETERM LABOR.
Progesterone maintains UTERINE QUIESCENCE and protects the amniotic membranes against PREMATUre rupture.
Patients with short cervix and NO HISTORY OF preterm labor --> VAGINAL progesterone.
Patinets with a history of preterm labor --. INTRA MUSCULAR progesterone
May need to have CERCLAGE done in some patients to maintain cervix.
108
Fetal Decelerations
Early Decelerations - Fetal Head Compression. Early decelerations are a benign physciologic finding and do not indicate fetal Hypoxia... These declerations DO NOT require intervention. NADIR at peak of contraction.
Late Declerations - Placental abruption and UTEROplacental insufficiency cuase FETAL HYPOXIA --> Late deceleration.
NADIR occurs AFTER peak of contraction.
Variable Deceleration - UMBILICAL CORD COMPRESSION.
109
Tubo-Ovarian Abscess causes and workup
COmplication of PID - presents with:
1. Fever
2. Abdominal pain
3. COMPLEX multiLOCULATED ADNEXal Mass with THICk walls and INTERNAL DEBRIS.
4. Caused by a Polymicrobial infection of the upper Genital tract.
Infection Extends to fallopian tubes and creates an inflammatory exudate, purulent fluid and wall thinkening which conglomerate into a complex mass.
Lab findings:
1. Leukocytosis
2. C- Reactive Protein
3. CA-125
these 3 along with fever suggest infection rather than malignancy.
TOA is diagnosed by imaging - Pelvic US or CT.
Treat with Broad spectrum ABx
110
Abruptio Placentae
Placental seperation from the uterine wall
PAINFUL vaginal bleeding
Late decelerations! (uteroplacental insufficency)
HTN = Most common risk factor
COcaine / Tobacco use and trauma are other large risk factors.
Presents with ABDOMINAL and or BACK pain and Vaginal bleeding.
This is a clinical diagnosis.. US is not needed.. but is done to rule out Placenta Previa.
Associated with DIC and HYPOvolemic SHOCK.
Fetal complications include - Hypoxia and Preterm Delivery.
111
Uterine Rupture symptoms
Abdominal PAIN, Vag bleeding, Fetal heart rate tracing abnormalities.
WIll present with LOSS of FETAL STATION, DIminishing CONTRACtions, and PALPABLE fetal parts
ABNORMAL CONTRACTION PATTERN.. (helps distinguish from placental abruption (which has normal contraction patterns)
will NOT have a smooth uterus.
Associated with INTRABDOMINAL HEMORRHAGE
Fetal parts may RETRACT upwards back into uterus.
Next step - EMERGENT LAPAROTOMY to confirm diagnosis and expedite delivery
112
What is the most common complication with TWIN pregnancies?
PRETERM labor!
Uterine overdistension --> overstretching of the MYOmetrium --> increased PROSTAglandin production, number of OXYToCIN receptors, and CONTRACTILITY within the uterus --> PRETERM delivery.
over 50% of twin pregnancies occur before 37 weeks gestation
113
Fetal DYsmaturity syndrome occurs in who?
POST term babies.. babies more than 42 weeks gestation!
Placental changes, loose skin, thin body, small for gestational age babies.
114
Vaccines DURING pregnancy
Recommended:
1. Tdap
2. Inactivated Influenza
3. Rho(D) Immunoglobulin
HIgh RIsk patients only:
1. HEP B
2. HEP A
3. Pneumococcus
4. H. Influenzae
5. MEningococcus
6. Varicella zoster Immunoglobulin
Contraindicated:
1. HPV
2. MMR - Give post partum if patients are not immune when testing during pregnancy.
3. Live attenuated Influenza
4. Varicella - Give POST PARTUM (if patients are not immune when testing durring pregnancy)
115
What should you do for a mom who is NOT immune for Rubella and is pregnant?
Give MMR POST partum.
116
When do you give RHOGAM (Rho(D) Immunoglobulin)
When Mom is Rh - and Baby is Rh +!
In these cases give Rho Immunoglobulin at 28 weeks gestation!!!
The ONLY TIME Rho Immunoglobulin is recommended in the 1st trimester is in the setting of UTERINE BLEEDING.
117
Mullerian Agenesis
The Mullerian AKA PARAMESONEPHRIC Duct does not develop and thus patients dont have:
1. Cervix
2. Uterus
3. Upper 1/3 of vagina (ends in blind pouch).
Primary Amenorrhea.. they will have ovaries bilaterally and normal secondary sexual characteristics (breast, normal stature, hair)
Must Do RENAL US --> paramesonephric duct has a lot of kidney organs the develop with it.. thus these patients need to be screened for any structural renal abnormaliteis via Ultra SOUND.
Treatment - dilate the vag for sexual intercourse.
118
Androgen Insensitivity Syndrome
Genotypically MALE (46, XY)
DEFECTIVE androgen RECEPTOR function.
Appear PHENOTYPICALLY FEMALE and have Primary AMENORRHEA, tall stature, and an ABSENT UTERUS.
Minimal pubic / axillary hair (no peripheral effect of testosterone) and have MALE INTERNAL genitalia (testes)
119
DIagnosis and treatment of chlamydia and ghonnerhea
ANNUAL SCREENING for CHlamydia and Ghonnerhea is recommended in all SEXUALLY ACTIVE WOMEN AGE 25 and OLDER!!
GOLD STAdARD = NAAT (nucleic acid amplification test) for both chlamydia and ghonnerhea.
the old testing method - culture and microscopy.. and had a high false negative rate.. thus if either chlamyida or gonnherea were positive you would have to treat for both.. that is NO LONGER THE CASE.
Treatment for CHlaymida = Azithromycin or DOXY
Treatment for Ghonnerea = BOTH Ceftiraxone and Azithromycin (need both drugs to fight gonnherea now because of resistance)
a positive NAAT test for either organism requires treatment REGARDLESS of if the patient doesnt have symptoms
120
FOr a patient entering menopause.. how do you confirm the diagnosis?
get a SERUM TSH level and SERUM FSH level.
HYPERthryoidism has many features that overlap with menopasue.. and we must first rule out hyper thyroid.
Durring menopasue..the ciruclating estrogen decreases --> decreased in the feedback inhibition on the hypothalmaic-pituitary axis --> ELEVATED FSH --> helps confirm the diagnosis of MENOPAUSE.
121
How can you tell the differnece between a lupus flare and preeclampisa in a prego patient?
BOTH will have:
1. Proteinuria
2. Edema
3. HTN
However SLE flare will have other SLE findings:
1. joint pain
2. malar rash
3. RBC casts on UA
4. Decreased complement levels
5. Increasing antinuclear antibody titers
122
Gestational HTN definition
HTN at >20 weeks gestation with NO EVIDENCE of PRoteinuria or end organ damage..
If there is proteinuria or end organ damage --> Preeclampsia.
123
HELLP syndrome
Hemolysis
Elevated Liver Enzymes
Low Platelet count
Patients will have:
1. HTN
2. Thrombocytopenia
3. Proteinuria
124
Oral COntraceptive Pills - types and side effects
1. Combination (Estrogen - Progestin) OCPs.
Most common side effect = BREAKTHROUGH BLEEDING (associated with lower estrogen doses).
other side effects include nausea, bloating and breast tenderness --> improve with continued use.
Adverse effects - HTN, Increased risk of cervical cancer and VENOUS thromboembolisms.
Weight gain is NOT a side effect of Combo OCPs.
2. MEDROxyPROGESTERONE - Increases body fat, decreases lean muscle and Causes WEIGHT GAIN. Not recommended for adolescents or young women due to significant risk of BONE Mineral density loss... only used if there is no other acceptable options.
3. Progesterone ONLY pills - The side effects of comobination OCPs is mainly due to estrogen.. and thus this has much less side effects.. however its also less effective against contraception and dysmenorrhea treatment because it DOES Not inhibit ovulation.
125
What is first line treatment for Primary Dysmenorrhea?
Primary Dysmenorrhea - defined as RECURRENT lower abdomonal pain associated with MENSTURATION.
FIRST line treatment = COMBINATION OCPs (estrogen - progestin).
They DECREASE PAIN by THINNING the ENDOMETRIAL LINING, REDUCING PROSTAGLANDIN RELEASE, and DECREASING uterine contractions.
126
Granulosa Cell Tumor
Estradiol and Inhibin secreting tumor.
Inhibin suppreses pintuitary FSH release via negative feedback
Malignant proliferation of granulsa cells can cause high estradiol levels resulting in the following symptoms:
1. Breast Tenderness and enlargment
2. Endometrial proliferation (unopposed proliferatoin)
3. Enlarged Uterus with thickened endometrial stripe on ultra sound.
manage surgically by removing tumor.
127
what tumors secrete LACTATE DEHYDROGENASE?
DYSGERMINOMAS -- these are malignant tumors that present as RAPIDLY ENLARGING, PAINFUL masses.
no breast tenderness or thickened endometrium
128
Which tumors secrete TESTOSTERONE??
SERTOLI- LEYDIG cell tumors
they are sex cord-stromal ovarian tumors.
Patients have
1. VIRILIZATION - Acne, Clitoromegaly
2. HYPOESTROGENISM - Breast atrophy, Thin ENdometrium.
129
IF there is a neonatal clavicular fracture durring birth what is the treatment?
X-ray to confirm the fracture.
Neonatal clavicular fractures HEAL RAPIDLY (7-10 days) and thus nothing is needed.
REASSURANCE and GENTLE HANDLING is given to parents.
130
Uterine Inversion
Uncommon but Potentially FATAL cause of POSTPARTUM HEMORRHAGE.
Excessive FUNDAL PRESSURE and TRACTION ON THE UMBLICAL CORD before placental seperation can cause it.
SMOOTH, ROUND MASS, PROTRUDING through the CERVIX or VAG.
Uterine inversion is typically accompanies by HEMORRHAGIC SHOCK (BP drops) and LOWER AB PAIN.
Treatment =
1. Aggressive fluid replacement
2. MANUAL replacement of the UTERUS
3. PLACENTAL removal and UTEROTONIC drugs AFTER uterine replacement.
131
Pubic Symphysis Diastasis
Suprapubic pain that radiates to back, hips, thighs or legs and is EXACERBATED BY WALKING, weight bearing or position changes.
CLINICAL DIAGNOSIS.
POINT TENDERNESS TO PALPATION over the PUBIC SYMPHYSis, and sometimes have WADDLING GAIT.
Treatment - conservative management with supportive care
132
When is quadruple screening done and what is included in it?
Done in the second trimester (15-20 weeks)
Includes 4 things:
1. MSAFP
2. B-hCG
3. Estriol
4. Inhibin A
Trisomy 18:
1. decreased MSAFP, B-hCH, Estriol and
2. NORMAL inhibin A
Trisomy 21:
1. Decreased MSAFP and Estrol
2. ELEVATED B-hCG and Inhibin A
NTDs or Abdominal Wall Defects:
1. Increased MSAFP
2. Normal everything else (b-hcg, inhibin a and Estriol.)
133
Late decelerations are a sign of uteroplacental insufficiency and impending fetal hypoxemia.
What is the only other event that can mimic late deceleration?
Uterine TACHYSYSTOLE = more than 5 UTERINE CONTRACTIONS / 10 mins.
For these patients.. DISCONTINUE all UTEROTONIC AGENTS (Oxytocin) untill the excessive uterine activity and resulting fetal decelerations resolve.
134
Late Decelerations require what intervetion?
EMERGENT C-section.!!
If the late decelerations are not due to uterine tachysystole.. must do emergency c section.
In uterine tachysystole.. if discontinuation of uterotonic agents does not resolve the issue then must do emergency c sectoin.
135
CMV in pregnancy - how is it diagnosed?
In mother via SEROLOGY
In baby via AMniocentesis.
INTRAcrainal and INTRAHEPATIC calcifications
There is no therapy.. if mom has it.. we dont give antiviral.. because it doesnt help prevent fetal infection.
Pregancy termination may be considred for fetuses that have severe congenital CMV identified early in prego.
136
babies of mothers infected with ZIKA
transmited by Aedes mosquito bite
1. SEVERE Microcephally
2. THIN cerebral cortices
3. MULTIPLE INTRACRANIAL Calcifications (due to tissue necrosis)
4. Closed anterior fontanelle.
5. Multiple contracctures and hypertonicity.
Diagnosis - Reverse transcriptase PCR
No treatment - avoid tropical areas with mosquitos when prego.
137
acute cervicitis cause and symptoms
MCC - Chlaymd and gonorrhoeae
Presentation:
1. Bleed after sex
2. thick MUCOPURULENT Discharge
3. Dysuria
4. Dysparenuia
Diagnosed clinically - Pelvic exam --> MUCOPURURLENT DISCHARGE and a FRIABLE CERVIX (bleeds easy on contact).
Treatment = Empiric treatment with AZITHROMYCIN and CEFTRIAXONE
Do Nucleic Acid Amplification Testing to confirm. But start emperic treatment before confirming.. because if the infection ascends it can cause complications.
138
Fetal Growth Restriction causes
Defined as UltraSOUND estimated fetal weight below 10th percentile for gestational age
```
Two Types:
Symmetric -
1. Chormosomal abnormalities
2. Congenital infection
3. Global growth lag.. head is small with everything else
```
```
Asymmetric -
1. Utero-placental insufficiency
2 Maternal Malnutrition
3. Maternal HTN and Tobacco use
4. HEAD- SPARRING growth lag.. head will be normal.
```
Management for both:
1. Weekly BIophysical profiles
2. Serial Umbilical artery Doppler US
3. Serial Growth USs
139
HOw can Oxytocin cause a seizure?
Oxytocin is used to induce or augment labor. And also prevention and management of postpartum hemorrhage.
Adverse effects:
1. HYPOnatremia
2. HYPOtension
3. Tachysystole - more than 5 contractions in 10 mins
The severe HYPOnatremia will cause seizures!
The severe hyponatremia is caused by Oxytocin.. oxytocin is similar in structure to ADH.. and thus causes water retention --> hyponatremia
140
False Labor vs Latent Labor vs Labor
False Labor: Irregular, INFREQUENT, weak contractions with no pain. THey result in NO CERVICAL CHANGES - braxton hicks contractions.
In these cases reassure the patient and send them home.
Latent Labor: Regular contractions with INCREASING FREQUENCY and INTENSITY, and cause GRADUAL changes in CERVIX.
Labor: Regular, PAINFUL uterine contractions that cause CERVICAL CHANGES (dialtion and effacement)
141
When do you give Penicillin for GBS prophylaxis?
DURING LABOR!!
if GBS culture comes back positive at ANY prentatal visit. Dont give pencilin UNTIL LABOR!!
if laboring before 37 weeks and patient GBS status is unknown --> give PENICILIIN to prevent vertical transmission.!!
It doesnt help to treat GBS before labor.. because of quick bacterial re-growth.. the mom woul dhave to get penicliin all over again during labor regardless.. so its pointless to give before.
142
When is tocolysis contraindicated?
You DO NOT want to do TOcoysis AFTER 34 weeks gestation!
The risks of the therapies exceed those of preterm delivery.
Common tocolytics = Indomethacin and Mag sulfate --> both of these are actually contraindicated after 32 weeks (before 34 weeks).
143
What kind of patients should be screened for illicit drug use at the initial prenatal visit?
all patients.
144
Complications of Amphetamine abuse durring pregnancy
Fetal Growth Restriction
Preeclamisa
Abruptio Placentae
Preterm delivery
Intrauterine fetal demise
increased risk of maternal mortality
145
Gastroschisis is associated with first trimester use of what substance?
NSAIDS
146
NTDs are associated with deficiency of what?
FOLIC acid
147
POLYhydraminos is associated with what?
Poorly controlled MATERNAL DIABETES
and anything preventing the fetus from swallowing (Esophageal Atresia)
148
Vasa Previa is associated with what?
Low lying placenta or MUltiple Gestations
149
What are the most common masses causing HYPERANDROGENISM in pregnancy?
Luteomas and Theca Lutein Cysts are the most common benging ovarian tumors causing hyperandrogenism.
Lutemoas - Solid, Bilateral or Unilateral masses on US. ELEVATED b-hcg levels stimulate the LUTEOMA (composed of large lutein ells) to rlease androgens, which may cause maternal VIRILIZATION.
Management = Observation and expectant management, as the masses and symptoms resolve spontaneously after delivery, due to falling of b-hcg levels.
150
what is the 2 step approach for screening and diagnosing gestational diabetes?
Step 1: At 24-28 weeks administer 50g ORAL glucose load.. and check Glucose 1 hour later.
If it is <140.. no diabeetes.. no further testing
If it is >140 Must administer 100g ORal GLUcose load and check fasting serum glucose each hour after for 3 hours.
If there are 2 or more abnormal values you now have the diagnosis of gestational diabetes.
151
What causes gestational diabetes?
INCREASed insulin RESISTANCE
hPL (Human placental lactogen) increases in production in the 3rd trimester resulting in Pancreatic B-cell Hyperplasia --> increased insulin resistance.
Gestational diabetes occurs when peripheral insulin resistance exceeds pancreatic insulin secretion.
152
Which type of c-section incisions are a contraindication for vaginal delivery in the future?
Classic (vertical incision) - Contraindicated vaginal delivery due to high risk of uterine rupture
Low Transverse Cesarean - This has a low risk of rupture.. and thus patients who had this type of incision CAN HAVE A VAGINAL DELIVERY for subsequent pregos.
153
pain that in lower pelvic area moves to legs and subsides within 2-3 days of menses.
includes nausea vomiting diarrhea
Primary dysmenorrhea.
Non sexyally active - NSAIDs
sexually active - Combination OCPS
154
PMS / PMDD treatment?
SSRI is first line
155
Child with lmitied upward gaze, upper eye lide retraction, pupils non-reactive to light, reactive to accomomdation.
Papilledema, headache, vmoiting, ataxia (all sysmtoms of obstructive hydrocephalus because the tuor blocks movement of CSF)
Pineal gland tumor
156
suprasellar mass that can compress the optic chiasm and result in visual field deficits
Craniopharyngioma
157
child (pediatric tumor) with ataxia, truncal instability (from hydrocephalus causing mass effect) and tumor in CEREBELLAR VERMIS
Medulloblastoma
158
where is inhibin A released from and what would its level be in turners?
Low.
Released from ovaris.. turners dont have ovaries.
Decreased estrogen, inhibin and progesterone.
Increased FSH and LH
Turners patients require estorgne replacement therapy to induce sexual development, improve growth/ height and increase bone mineral density.
159
what if you find High grade squamous intraepithelial lesions on pap testing (CIN2 or CIN3) in a pregnant patient?
what is next step?
IMMEDIATE COLPOSCOPY.
this is concernitng for cervical cancer sand shoudl be done rigta way.
COlposcopy evaluates the CERVIX and VAGINA under maginfication after application of acedtic acid to contrast and identify abnormal ACETO - WHITE changes from normal cells.
Cervical neoplasia typically occurs at the TRANSFORMSTION ZONE (squamo-columnar junction).
If a high grade lesion is found.. do a CERVICAL BIOPSY.. even in pregnancy.!
Endocervical curettage is an invasive procedure.. and is differed to after pregnancy...due to risks of miscarage and preterm delivery.
Cervical incision via LOOP electrosurgical cexcision procedure is ONLY done AFTER confirming high grade neoplasia in the pregnant female.
160
if mom had varicella zoster 2 days before or 5 dfays after delivery what should the post exposure prophylaxis be for the neonate?
VZIG. (passive immunity.. Varicella zoster immunoglobulin).
VZIG is given to neonates, pregnant women and immunocompromised patients.
Varicella live faccine (VZV vaccine) is given to all immunocopentent indivisuals for post exposure prophylaxis.
161
What sould be done for someone who has a uterine prolapse thorugh vag.. and is a poor surgical candidate?
Pessary fiting.
For good surgical candidates - do surgery.
Pelvic floor muscle exercises can be done for mild prolapse. For complete prolapse must do a pessary or surgery.
162
retraction of the superior portion of the TM and a pearly white mass in a patient with chornic middle ear infectiosn is what?
Cholesteatoma.
Tympanic membrane epithelium and KERATIN debris accumulation.
163
what is the most common potential side effect of the first line medication to prevent sickle cell flares?
Hydroxyurea.
Myelosupression is the most common potential side effect.
164
severe nodulocystic acne on the arms and upper back of a woman is a sign of what?
Hyperandrogenism.
A common cause of hyperandrogenism in young women, particularly in conjunciton with obesity is PCOS!
PCOS - high testosterone (hirstuitsm), Polycisystic ovaris on ULTRA SOUND, and a history of IRREGULSR MENSES.
165
Androstenedione produced by the adrenal glands and Ovaries goes to the Fat cells and is converted to ESTERONE by which enzyme?
AROMATASE
166
what increases the chance of endometrial cancer more? obesity or OCPS?
OBESITY.
unapposed estrogen creation leading to endometrial hyperplasia.
OCPS actually reduce the risk of endometrial cancer by causing cyclic shedding of the endometrium (never hyperplasias).
167
Bilateral hydronephrosis, oligohydramions inuntero, flattened facies, abdominal distension and club feet.
what is the diagnosis. and what is causing the bilateralhydronephrosis?
Potters syndrome.
Posterior urethral valves are causing the bilateral hydronephrosis.
168
what is the role of hCG in pregnancy?
maintainece of the corpus luteum.
secreted by the synctiotrophoblast its responsible for preserving the copus luteum durring pregnancy in order to maintiant progesterone secreion until the placenta is able to produce progesterone on its own.
169
when is GBS screening done?
35-37 weeks gestation.
results are valid for 5 weeks after the screening.
170
Unifocal, firm, white vulvar plaque is concenring for what?
Vulvar Squamous Cell Canccer.
Diagnosis is done via biopsy.
Chronic inflammation from lichen sclerousus, and persistent HPV infection are risk factors.
171
When should PAP and HPV testing begin?
what if a woman is sexually active before 21?
Done starting age 21 in women.
REGARDLESS Of when sexual activity began or number of partners.
172
Who should receive the HPV vaccine?
what if the patient already had HPV?
Even if they had previous HPV you MUST GIVE the vaccination if they are in the age group.
All girls and women age 11-26
All boys and men 9-21 or (9-26 for gays)
173
Sudden onset unilateral pelvic pain, nausea and vomiting, palpable adnexal mass and Absent doppler flow to ovary (first line imaging modality is US).
Ovarian torsion.
Treatment - LAPAROSCOPY with DETORSION.
Do oophorectomy if there is necrosis or malignancy.
untreated torsion will lead to infertility, hemorrhage or periotnitis and spesis.
174
what is treatment for scabies?
Topical 5% permethrin or Oral Ivermectin
175
what is seen in primary ovarian insufficiency and what is the treatment?
Amenorrhea at age less than 40.
Hypoestrogenic symptoms (hot flashes)
Decreased estrogen and INCREASED FSH.
Major causes - turners, Fragile x, Autoimmune oophoritis, cancer drugs, pelvic ratiation, glactosemia.
Treatment - estrogen therapy.
176
Heavy menses, abnormal menstrual bleeding, constipation, urinary frequency, pelvic pain / heaveness and enlarged uterus are all signs of what?
UTERINE FIBROIDS
177
Dysmenorrhea, pelvic pain, heavy menses, bulky, globular and tender uterus.
Adenomyosis
178
what is the gold standard for diagnosis of endometrial hyperplasia and malignancy?
Endometrial biopsy.
179
how do you treat patients with bartholin duct cysts?
Asymptomatic patients are treated with expected managment and observation.
symptomatic or patients with an absces are treated via Incision and drainage with either a WORD catheter or MARSUPIALZATION procedure
180
Stridor, barky cough, Para influenza is caused by what?
and what causes the inspiratory stridor?
edema and narrowing of the proximal trachea?
Treatment - corticosteroids and nebulized epinephrine
181
what is the mOA of HIB causing epiglottitis?
Inflamation of the epiglottis and aryepiglottic folds.
these patients will also have stridor amontst all the other symptoms
182
Child with thromobocytopenia (bleeding, brusing gums), leukpenia (infections), Anemia (fatigue), Short stature, Hyper or Hypopigmentation, and Absent or HYPOplastic THUMBS.
Fanconi syndrome.
This is the most common cause of congenital APLASTIC ANEMIA (bone marrow failure, pancytopenia).
Caused by a DNA repair defect.
Treatment - Hematopoietic stem cell transplant.
183
women with multiple candidal infections and nocturia / urinary frequency should be screened for what?
diabetees.
check the HbA1c
184
Scarlet fever vs Kawasaki disease.
Kawasaki disease: - medium vesel vasuclits
Fever for 5 or more days plus 4 of the following:
1. conjunctivitis - bilateral, nonexudative
2. Mucositis - Erythematous, fissured lips (strawberry tongue)
3. Rash - Polymorphous
4. Extremity changes - erythema, edema, desquamation of the HANDS and FEET
5. Cervical Lymphadenopathy - >1.5 cm
treatment - aspirin
```
Scarlet fever (caused by strep pyogenes)
pharyngitis, fever and sandpaper like rash that usually desquamates. Strawberry toungque and cervical lymphadeonopathy. However, the rash in scarlet fever is most prominent ofver SKIN FOLDS and patients DO NOT have CONJUNCTIVAL INJECTION or EXTREMITY swelling.
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185
fine pink, maculopapular rash that spreads cephalocudally. Low grade fever and lymphadeonopahty
rubella - german measels
186
Fever, cough, coryza, conjunctivitis, Koplik spots.
pink rash that spreads cephalocaudally
Rubeola ( measels)
187
Nitrazine positive vaginal fluid (amniotic fluid) before 37 weeks is called what?
Premature rupture of membranes.. is rupture of membranes before 37 weeks.
If after 34 weeks DELIVER THE BABY! there is increased morbidity and mortality associated with prmeature delivery decrease and the incidence of chorioaminiotis is decreased after 34 weeks so deliver.
Patients with PROM at less than 34 weeks with signs of infection (maternal fever, fetal tachyshould also be delivered.
ALL patients, beofre or afer 34 weeks with PROM should receive IV ANTIBIOTICS!
188
How can hypothyroidism cause abnormal uterine bleeding?
In hypothyrodism the increased release of TRH (thyrotropin releasing hormone) from the hypothalamus causes increased PROLACTIN levels.
Elevated prolactin level INHIBITS FSH and LH release from the pitutiary ---> ANOVULATION and ABNORMAL uterine bleeding.
189
WHy is C3 decreased in PSGN
Because PSGN causes a Type 3 Hypersensitivity reaction.
Immune complexes deposit in the GBM and MESANGIUM. This causes Complement system activation and ACCUMULATION of C3 in the glomerular deposits. This resltuls in Decreased C3 with elevation in creatinine.
190
Child with Microscopic or gross hematuria + Sensorinueural hearing loss + occular defects.
Alports syndrome.
X linked inherited disorder of type 4 COLLAGEN
191
Hematuria / Proteinuria + Dyspnea, cough, Hempotysis.
Good pastures.
Renal and pulmonary disease.
IgG autoantibodies against the GLOMERULAR and ALVEOLAR basement membranes.
192
Sudden onset unilateral pelvic pain, Nausea and vomiting +/- adnexal mass?
Ovarian torsion.
Caused by partial or complete rotation of the ovary aroudn the infundibulopelvic (suspensory ligament of the ovary) and/or utero ovarian ligaments --> these cause obstructed blood supply.
Diagnosis --> US will show absent doppler flow to ovary and a pelvic mass.
RIsk factors = Ovarian Mass, Women of repro age, Women receiving Infertility treatment with ovulation induction
Treatment - Laparoscopy with DETORSION, Ovarian cystectomy or oopherectomy if necrosis or malignancy.
193
Athlete with Low BMI develops amenorrhea.
This is called HYPOTHALAMIC amenorrhea --> secondary amenorrhea.
Low GnRH --> Low FSH / LH --> Low estrogen
Long term consequences --> Low bone mineral density, Increased cholesterol and triglycerides.
They also will get vag and breast atrophy and infertility (all signs of decreased estrogen)
Treatment = Increase caloric intake, ESTROGEN and Calcium and Vita D.
194
Patient under 30 years old comes in with a single, unilateral, mobile, well-circumscribed mass. What is next step?
This is likely a fibroadenoma.
breast cancer is VERY RARE in patients under 30. This patients mass should be checked again after the next menstrual cycle.
Fibroadenomas increase in size during menses (due to elevated estrogen and progesterone) and go away after that. They are usually rubbery and mobile.
If the mass is still there after do a US.
If the patient is above 30 do an US
Mammogram is not helpful in patients under 30 due to dense breast tissue.
195
An adolescent had unprotected sex. What do you give them for abortion?
Most steates allow you to give contraception, pregnancy care and STD treatment confidentially to adolescents (dont need to notify parents)
Plan B - Oral Levonorgesterl --> works by DELAYING OVULATION. Can be take upto 72 hours after.
Ulipristal --> Antiprogestin --> DELAYS FOLLICULAR RUPTURE, inhibits ovulation and IMPAIRS IMPLANTATION --> can be taken up to 5 days after.
Copper IUD --> the MOST EFFECTIVE emergency contraception --> creates an inflammatory response that is TOXIC TO SPERM AND OVA --> no fertilization.
196
what is the most readily available form of emergency contraception?
what is the most effective form of emergency contraception?
Readily available - Plan B (oral Levonorgestrel).
Most Effective - Copper IUD
197
Phenotypically female + Breast development + minaimal or absent axillary and pubic hair + Female external genitalia + absent uterus, cervix and upper 1/3 of vag (blind pouch).
What is diagnosis and what should be done next?
Androgen insensitivity syndrome (x-linked mutaiton in androgen receptor)
Genotpyically male 46xy
Must treat with:
1. Gender identity / assignment counseling
2. Elective Gonadectomy --> the testis inside aere normal but are CRYPTORCHID / UNDESCENDed (testicular descent is an androgen dependent process).
These testies need to be removed because they are a risk for testicular cancer (elevated intrabodominal pressures --> abnormal spermatogenesis and aberrant germ cell differentiation)
ELECTIVE GONADECTOMY.
198
Is SPF 100 better than SPF 50?
no.
SPF 50 filters 98% of UVB.
SPF 100 does 99%.. a NEGLIGBLE AMount.
199
what is the best method of photo protection to prevent sunburn?
SUN AVOIDANCE!!!
If its not possible to avoid the sun use SPF 15-30 or higher and apply it 15-30 minutes BEFORE sun exposure.
Make sure to REAPPLY ATLEAST EVERY 2 HOURS.
Cloud coverage does NOT block UVB rays.
200
which bleeding disorder is the most common cause of heavy menstural bleeding in adolescents?
Von Willebrand disease.
Deficency of VwF --> IMPAIRED PLATELED ADHESION --> vWF acts as a bridging glycoprotein between platelets and endothelial factors at site of injury.
Platelet count and PT are NORMAL.
PTT can be normal in mild disease.. or elevated in severe disease.
Confimr diagnosis with Ristocetin cofactor activity.
Treatment - Desmopressin or vWF replacement therapy.
201
heavy painful menses + IMMOBILE UTERUS
endometriosis.
MUST HAVE IMMOBILE UTERUS.
202
Cows milk vs breast milk
cows milk - low iron. Give iron. Can cuase IDA.
breast milk - low vitamin D supplement with vita d
203
What are treatments for primary nocturnal enuresis?
Urinary incontinece after age 5.
Do UA to rule out secondary causes.
1st. Lifestyle mods
2nd. Enuresis alarm
3rd. DESMOPRESSIN (ADH analogue)
Imipramien used if desmopressin fails
if desmopressin used as monotherapy.. it has a high rate of relapse after stopping.
204
what is usually the first sign in infant botulism?
constipation from bowel hypoactivity.
Inhibits presynaptic AcH release
Treatment = Botulism immune globulin
Diagnosis =
resp - spores from dust
Honey - toxin in stool
205
9 year old boy with oozing skin lesions on his leg. Causing pain an puritis. lesions appear wet and others have thin, crusted coating. VESICLES in a LINEAR ARRANGEMENT. what is the diagnosis?
Poison Ivy.
This is ALLERGIC CONTACT DEMRATITIS - Type 4 Hypersensitivity. Cell mediated.
Treatment.. reduce exposure.. remove clothes and if needed topical / oral glucocorticoids.
206
Neonate with vaginal bleeding and discharge. what is the most likely cause?
Maternal withdrawal of estrogen.
Maternal estrogen crosses the placenta during pregnancy and causes growth of the fetal endometrial lining (just like the follicular phase of menstruation).
Following delivery the neonatal endometrium may slough off --> mucoid vaginal bleeding.
Usually occurs in the first 2 weeks of life.
The maternal hormones may also cause breast bud and genitalia engorgement during the first month of life.
Neither of these require any treatment.
207
what are risk factors for hyperemesis gravidarum?
Twin pregnancies (multiple gestational)
previous prego with hyperemeis
Hydatiform mole
The elevated bHCG in these conditions causes the emesis.
208
Miosis + Ptosis + claw hand --> injury to what nerves?
C8-T1
209
pink / flesh colored, verrucous papules and plaques. puritic and friable lesions in a child. what is the next step?
this is HPV.
they can be asymptomatic (not bleeding) or bleed.
If seen in a child - do a sexual abuse investigation.
210
Persistent, ECZEMATOUS, and / or ulcerating RASH, localized to the NIPPLE and spreads to the areola.
Pages disease of breast.
Patients can have vesicles, scales, bloody discharge and nipple retraction. Patients experience pain, itching, and burning of the affected nipple and NO resolution with topical steroids.
85% of patients with Pagets disease of breast will have an underlying breast cancer.
Adenocarcinoma is the most common type of breast cancer.
211
How do you diagnose wilms tumor?
after palpating an abdominal mass the first step is Abdominal US.
that should be followed up with CT with contrast of the abdomen. also CT with contrast of chest to identify any pulmonary mets.
212
what is the imaging study in a patient below 30 with a breast mass?
US.
If US shows simple cyst then do an FNA (if the patient wants).
"Posterior acoustic enhancement" on US means its FLUID and no debris / solid components --> simple breast mass
If the US shows a solid mass (complex cyst / mass) then do an Image guided CORE BIOPSY
213
What is the imaging study in a patient 30 or older with breast mass?
Mammogram.
If its suspicious for malignancy do a CORE BIOPSY.
214
after removal (drainage) of a simple cyst in breast (clear fluid).. when should the patient come back next?
the follow up breast exam shold be done in 2 months.
If this is normal then the patient can move to annual screening.
215
variable decelerations are a sign of cord compression. what is something that can be done to reduce cord compression?
AMNIO INFUSION!
216
12 weeks Post delivery patient has amenorrhea. what is teh cause?
Lactational Amenorrhea.
The high prolactin inhibits the production of Hypothalamic GnRH.
Low GnRH = Low FSH and LH.
Thus lactation prevents ovulation --> natural form of contraception for the first 6 months postpartum.
after 6 months over 50% of women resume ovulation and another form of contraception should be considered.
