Step 2 OB/GYN Flashcards
(171 cards)
1
Q
What are some of the first physical signs of pregnancy and around what time do you see them? (Specifically, ‘named’ findings)
A
Goodell Sign = softening of the cervix [4 weeks]
Chadwick Sign = blue discoloration of the cervix and vagina [6 - 8 weeks]
Hegar Sign = softening and increased compressibility of the lower uterine segment [6 weeks]
Ladin Sign = softening and increased compressibility of the middle uterine segment [6 weeks]
Telangiectasia / Palmar Erythema = [1st Trimester]
Chloasma / Melasma = “the mask of pregnancy”, can worsen in the sun [2nd Trimester]
Linea Negra = hyper pigmentation of abdominal midline skin [2nd Trimester]
2
Q
Describe how the levels of B-HCG change throughout pregnancy per trimester
A
B-HCG initially doubles every 48 hrs for the first 4 weeks, peaking at 10 weeks
B-HCG falls a little during the 2nd Trimester
B-HCG rises again in the 3rd Trimester to 20,000 - 30,000
3
Q
At what level of B-HCG should a gestational sac be visualized per U/S? At what week GA should a gestational sac be visualized per U/S?
A
Gestational sac is visible at a B-HCG level of 1,500 and/or GA 5 weeks
4
Q
What hormones cause the nausea and vomiting experienced in early pregnancy?
A
Progesterone, Estrogen, and B-HCG
5
Q
Describe the physiologic renal changes in pregnancy. What are pregnant patients more at risk of in regards to renal infections?
A
Increased GFR 2/2 to plasma volume increase; decreased BUN & Creatinine levels (therefore, higher end of normal values would most likely indicate renal disease). Pyelonephritis is a greater risk 2/2 to enlarging uterus capable of impinging on ureters and obstructing system with elevated plasma filtrate. Mild gycosuria and proteinuria = NL.
6
Q
Describe the changes regarding PT/PTT/INR, fibrinogen, and venous levels in pregnancy
A
No change in PT/PTT/INR; increase in fibrinogen; increased venous stasis = Virchow’s Triad contributors, therefore more coagulable state
7
Q
Abnormal MSAFP levels can be 2/2 to…
A
1) Dating error (MCC)
2) NT Defect
3) Abdominal Wall Defect
4) Multiple Gestations
8
Q
What are spontaneous contractions that DO NOT result in cervical changes called? Should we worry about them?
A
They are called “Braxton-Hicks Contractions” and are not worrisome UNLESS they start becoming regular vs Normal contractions that are regular and q3min.
9
Q
What level of Hgb should you replace Fe orally? What else do you want to give to a pregnant patient regarding her Fe supplements?
A
Hgb < 11. Give stool softeners when prescribing oral Fe b/c it can exacerbate pregnancy’s already constipating state
10
Q
What are the RF’s for an ectopic pregnancy?
A
Previous ectopic pregnancy (MC), IUD, hx of PID/infxn
11
Q
How does Methotrexate (MTX) work in the medical treatment of ectopic pregnancies? What contraindications exist for Methotrexate prescription?
A
MTX is a folate-receptor antagonist. Contraindications include: immunodeficiency, unsure f/u, hepatotoxicity, large ectopic preg (>3.5 cm), or auscultated fetal heart sounds (b/c larger size increases likelihood of MTX failure)
12
Q
How do you treat an infected uterus with retained products of conception?
A
Treat a septic abortion with Methotrexate or Levofloxacin for antibiotic coverage and D/C to evacuate the products of conception
13
Q
What are the complications of a multiple gestation pregnancy?
A
1) Spontaneous abortion of one of the fetuses
2) Premature labor
3) Placenta previa
14
Q
Don’t stop a woman’s contractions that are regular, causing cervical dilation, and happening before 37 weeks if there is…
A
1) preeclampsia/eclampsia
2) maternal cardiac disease
3) cervical dilatation > 4cm
4) maternal hemorrhage
5) fetal death
6) chorio
With these situations, head straight to delivery (attempt vaginal if no contraindications)
15
Q
What are the side-effects of the following tocolytics: Mg Sulfate, CCB’s, and B-Adrenergic Agonists (Terbutaline)?
A
Mg Sulfate - (common) flushing, HA, diplopia, fatigue (serious) respiratory depression and cardiac arrest [CHECK DTR’s!!!]
CCB’s - dizziness, flushing, HA
Terbutaline - increased HR leading to palpitations, hypotension
16
Q
How do you treat the following types of abortions:
1) Complete Abortion
2) Incomplete Abortion
3) Inevitable Abortion
4) Threatened Abortion
5) Missed Abortion
6) Septic Abortion
A
1) Complete Abortion - f/u in office and check B-HCG serially to zero
2) Incomplete Abortion - D&C / Medical
3) Inevitable Abortion - D&C / Medical
4) Threatened Abortion - bed rest and pelvic rest
5) Missed Abortion - D&C < 14 wks, attempt labor induction if > 14 wks
6) Septic Abortion - D&C and IV Levofloxacin or Metronidazole
17
Q
What information do you need to manage preterm labor? How do you manage it?
A
Need to know the GA, the weight of the fetus, and the presenting part.
If GA 24 - 33 and Wt is 600 - 2,500 g = tocolytics and steroids
If GA 34 - 37 and Wt is >2,500 g = deliver
18
Q
What are the possible complications of PROM?
A
Cord prolapse, preterm labor, chorio, and placental abruption
19
Q
What three factors help you determine the management plan for PROM? How do you manage PROM?
A
Need to know: GA, Chorio +/-, and presence of PCN allergy
If Chorio is + = deliver now
If Chorio is - and GA is term = wait for spontaneous labor for 6-12 hours; if it doesn’t occur, induce
If Chorio is -, GA is preterm, and no PCN allergy = Betamethasone, Tocolytics, and Ampicillin and Azithromycin (use Cefazolin in place of Ampicillin for low risk of anaphylaxis if PCN allergy, or Clindamycin for high risk of anaphylaxis)
20
Q
What would you suspect a patient to have with painless bleeding? What do you NOT do with this pt?
A
Placenta Previa - DO NOT do a bimanual or transvaginal U/S, use transabdominal U/S instead
21
Q
If a patient has painless bleeding, you would head to immediate C-Section if…
A
[Placenta Previa}
Immediate C-Section if cervix > 4cm, severe hemorrhaging has occurred, or fetal distress
22
Q
What other placenta pathology is associated with placenta previa?
A
Placenta accreta
23
Q
What are the different types of placenta previa?
A
1) Complete - placenta covers the internal os totally
2) Partial - placenta covers some of the internal os
3) Marginal - placenta is adjacent to the internal os
4) Low-Lying - placenta is b/w 0 - 2 cm from the internal os
5) Vasa Previa - placenta vessels travel across the internal os
24
Q
What RF’s could lead someone to have painful vaginal bleeding? What could this condition cause?
A
[Placental Abruption]
RF’s = Hypertension, Previous Placental Abruption, Cocaine Use, External Trauma, Maternal Smoking, Polyhydramnios with rapid decompression 2/2 ROM, PROM
Complications = hypovolemic shock, uterine tetany, DIC, premature delivery
25
What type of placental abruption is most likely to cause a completely detached placenta and possibly postpartum hypopituitarism (Sheehan's Syndrome)?
Concealed Placental Abruption
26
When is it okay to attempt a vaginal delivery in the setting of a placental abruption?
If the FHR and tracing is okay, there is minimal detachment, or if there is extreme detachment and fetal death has already occurred
27
What are the RF's for a woman who experiences extreme pain during delivery?
[Uterine Rupture]
| RF's = myomectomy, trauma, overdistension of the uterus 2/2 to Polyhydramnios or Multiple Gestations
28
How do you deliver in the setting of a uterine rupture?
Via laparotomy, NOT C-Section…fetus could be "floating" in the abdomen
29
What are the indications for a C-Section in the setting of Placental Abruption?
Uncontrollable hemorrhage, rapidly expanding concealed hemorrhage, fetal distress, or rapid placental separation
30
Hemolytic disease of the newborn can cause _______ and ________. Hemolysis results in increased serum levels of ______ and ______. Why are we worried about this? What end-disease can occur due to the aforementioned?
1) Fetal Anemia
2) Extramedullary Production of RBC's (Liver/Spleen)
3) Heme
4) Bilirubin
Bilirubin can be neurotoxic; Erythroblastosis Fetalis is characterized by high CO and an end result 2/2 to hemolytic disease in the newborn.
31
What defines IUGR? What are the two different types and their respective etiologies?
IUGR = fetal weight in the bottom 10% for it's GA.
1) Symmetrical - (occurs before 20 wks) 2/2 congenital infections, drugs, or chromosomal abnormalities
2) Asymmetrical - (occurs after 20 wks) 2/2 placental insufficiency, poor maternal health, or multiple gestations
32
What weight defines fetal macrosomia? What do you expect to be off in the routine check-up? What's the next best test to confirm? And, how do you manage delivery?
Fetal macrosomia = 4500 g (about 10 lbs). Fundal height discrepancy relating GA (>3cm diff). Order an U/S to assess femur length, biparietal diameter, and abdominal circumference). Consider delivery of the fetus BEFORE it reaches 4500 g IF fetal lungs are mature. If it reaches 4500 g, do a C-Section
33
Define a "reactive" Non-Stress Test (NST). What do you do if it's "non-reactive"?
Within a period of 20 min, the fetus has two accelerations that are >15 beats above FHR baseline that lasts for >15 seconds.
If non-reactive, do vibroaccoustic stimulation of the fetus b/c it might just be sleeping =)
34
Define the Stages of Labor and the expected timeframe for Primips and Multips.
Stage 1 [encompasses both latent and active phase] (P = 6-20hrs and M = 2-14hrs)
1) Latent Phase = 0-4cm cervical dilation (P = 6-7hrs and M = 4-5hrs)
2) Active Phase = 4cm - full dilation (P = 1.2cm/hr and M = 1cm/hr)
Stage 2 [full dilation to delivery of the fetus] (P = 30min-3hrs and M = 5-30min)
Stage 3 [delivery of the fetus to delivery of the placenta] (Everyone = 30 min)
Stage 4 [delivery of placenta to maternal stabilization] (up to 48 hrs)
35
What are the Cardinal Movements during vaginal delivery?
Engagement - Descent - Flexion - Internal Rotation - Extension - External Rotation - Delivery of Anterior Shoulder
36
What if you have a woman who hasn't dilated beyond 4cm for more than 20 hrs as a Primip or 10 hrs as a multip, what is this called? What is it from? How to you manage these patients?
This is called "Prolonged Latent Phase". Likely 2/2 sedation, uterine dysfunction, unfavorable cervix, etc (check to see if the patient has had normal SVD before in the past!). Rest and hydrate = treatment.
37
What is it called when a Primip or Multip is taking more than 1 hour to dilate 1.2cm or 1cm, respectively, in the active stage of labor? What is the likely etiology?
Prolonged Cervical Dilation - thinks of the "3 P's" = Power, Passage, Passenger.
38
What is it called when the fetus fails to descend for more than 1 hr or when the cervix fails to dilate for more than 2 hrs? Was it it from most commonly?
Arrest of Fetal Descent and Cervical Arrest - likely 2/2 to CPD.
Mgmt: assess whether abnormal lie or CPD is present, if not labor augmentation is acceptable (oxytocin, prostaglandin), and continue with expectant management unless signs of fetal distress occur, then C-Section
39
At what GA can you consider doing external cephalic rotation with a malpresenting fetus?
GA 36
40
What are the risk factors for having a post partum hemorrhage >500 mL (SVD) or >1L (CS)?
Overdistension of the uterus (multiple gestation), anesthesia, prolonged labor, laceration, retained placenta, coagulopathy. MCC = uterine atony (within 24hrs of delivery)
41
How do you manage patients with PMS or PMDD? What are the diagnostic criteria? What if it's severe?
Tell them to chart their symptoms. Need to be symptom free in the first week of follicular phase, symptomatic in the last week of the luteal phase, have it occur for at least 2 cycles…dysfunction in life occurs with PMDD.
Treatment = decrease caffeine, alcohol, chocolate, and cigarettes. Add exercise. Can give SSRI's for severe cases
42
What is the diagnostic test of choice for menopause? What are contraindications for HRT?
FSH elevation. HRT is contraindicated in patients with previous DVT, if they smoke, PE, or estrogen dependent carcinoma of the breast or uterus.
43
What do you have to check for before diagnosing someone with Dysfunctional Uterine Bleeding (DUB)?
Since it's a diagnosis of exclusion, check for hypothyroidism and hyperprolactinemia.
44
What do OCP's decrease a woman's risk of? What do they increase their risk of?
Decrease risk of ovarian carcinoma, endometrial carcinoma, and ectopic pregnancy. Increased risk of thromboembolism and cervical cancer (possible confounding with increased # of sexual partners)
45
What should you obtain before placing an IUD?
Genital cultures b/c they're associated with PID
46
What is the MCC of labial fusion?
21-B Hydroxylase Deficiency causing an excess of androgens.
47
Which epithelial abnormality involving the vulva…
1) Is a risk for cancer?
2) Can involve other systemic parts of the body (mouth, arms, legs)?
3) Has a significant hx of pruritus with raised white plaques and is treated with Sitz Bathes or Lubricants?
1) Lichen Sclerosus - get punch bx - treat with steroids
2) Lichen Planus - violet patches - treat with steroids
3) Squamous Cell Hyperplasia
48
What are Amsel's Criteria? How do you treat for this vaginitis?
Amsel's Criteria:
1) pH > 4.5
2) Thin, watery grey discharge
3) Fishy, amine odor with KOH
4) Clue Cells (bacteria localized to border of squamous cells)
Treat with Metronidazole or Clindamycin
*FYI - Bacterial Vaginosis does not have "vaginitis" in the name so you rarely see inflammation or erythema in the vagina.
49
What is the most common non-viral STI that causes frothy green d/c and visible motile flagellates on wet mount?
Trichomonas Vaginitis - treat with Metronidazole and also treat the partner!
50
Which vaginitis has a normal pH?
Candidiasis - treat with Miconazole, Econazole, Clotrimazole, or Nystatin
51
What physical characteristics distinguishes Paget's Disease from Lichen Planus?
Paget's Disease has a red lesion, like LP, but it also has a white superficial covering of the lesion. Bx is needed regardless.
52
How do you diagnose Adenomyosis? What's the most accurate test? What's the only definitive treatment?
It's a clinical diagnosis! Large, globular, and boggy uterus. MRI is the most accurate test. Hysterectomy is the only definitive treatment.
53
How do you manage a patient with Endometriosis?
Mild symptoms = NSAIDS or OCP's
Moderate symptoms = Danazole (androgen) or Leuprolide (continuous GnRH agonist)
Severe = Surgical removal of implanted sites
54
Describe the relationship b/w FSH and LH on the Theca and Granulosa cells.
LH acts on the Theca cells to produce androgens while FSH acts on the Granulosa cells to use the androgens made and convert them to estrogen via aromatase
55
Describe the Pathophys of PCOS
Why LH is elevated is unknown. But hyperinsulinemia has been attributed to both genetic predisposition and DM RF's. The elevated levels on insulin cause a decrease in Sex Hormone Binding Hormone (SHBH) which contributes to elevated androgen levels and free Testosterone. These elevated hormones cause anovulation.
56
How can you treat PCOS patients who want children and don't want children?
Start off first with weight loss, and then can add OCP's for those not wanting children. You can use Clomiphene and Metformin for those wanting to become pregnant.
57
What is the diagnostic criteria for PCOS?
Rotterdam's Criteria: (need 2 of 3)
1) Clinical or lab evidence of hyperandrogenism (hirsutism, acne)
2) Oligo or Anovulation
3) Polycystic ovaries
* DO NOT have to be obese
* * Hyperinsulinemia can work on Insuling Like GF Receptors and cause epithelial growth and maturation resulting in Acanthosis Nigricans
58
What are two rare causes of postern pregnancy?
Placenta Sulfatase Deficiency (resulting in Icythiosis, cracked skin) and Anencephaly
59
When is MSAFP MOST accurate?
GA 15 - 20
60
What do you do initially if the MSAFP is abnormal? If it's still abnormal after step 1, what are the following steps?
1) Retest b/c 30% false positive rate
2) U/S
3) Amniocentesis (looking for elevated AFP in amniotic fluid or acetylcholinesterase)
61
When is the only time you consider giving Aspirin in pregnancy?
If they have Antiphospholipid Syndrome; sub-q heparin or LMWH can also help
62
What GA would you consider inducing labor with a potential post term pregnancy?
GA 41 wks
63
What are the two different types of Hydatiform moles? How are they characterized? How are they treated? What does their f/u consist of?
1) Complete = XX (soley from Dad) - no fetal parts
2) Incomplete/Partial = XXY - some fetal parts
Treatment = D&C for both kinds, and monitor B-HCG after until it trends to 0; if not, could be invasive mole or choriocarcinoma (treat with Methotrexate or Dactinomycin chemotherapy = good response)
64
What are some warning signs of molar pregnancy?
1) Preeclampsia before the 3rd Trimester
2) Rapidly rising B-HCG level or failure for it to zero-out s/p delivery
3) First or Second Trimester bleeding with the expulsion of grape-like from the vaginal introitus
65
What and when is the Triple Screen and Quadruple Screen used?
Triple Screen (NT, PAPP-A, and B-HCG) done during the first trimester (10-13 wks)
Quadruple Screen (AFP, B-HCG, uE3, inhibin A) done during second trimester (15-18 wks)
66
When do you offer CVS vs. Amniocentesis in a woman with a positive screening test?
Offer CVS in the first trimester and amniocentesis in the second. You want to basically get the karyotype. CVS>Amnio in terms of causing abortions.
67
What teratogenic agent can cause: phocomelia (absence of long bones and flipper like hands)
Thalidomide
68
What teratogenic agent can cause: yellow or browning of teeth
Tetracyclines
69
What teratogenic agent can cause: deafness
Aminoglycosides
70
What teratogenic agent can cause: Spina Bifida and hypospadias
Valproic Acid
71
What teratogenic agent can cause: IUGR, LBW, prematurity
Cigarettes
72
What teratogenic agent can cause: VACTERL (what does this stand for?)
Vertebral anomalies, Anal atresia, Cardiac defects, Tracheoesophageal fistula and/or Esophageal atresia, Renal & Radial anomalies and Limb defects
OCP's, Diabetes, Trisomy 18
73
What teratogenic agent can cause: Ebstein's Anomaly?
Lithium
74
What teratogenic agent can cause: IUGR, CNS defects, eye defects, malignancy (leukemia)
Radiation
75
What teratogenic agent can cause: fingernail hypoplasia, craniofacial defects
Carbamazepine
76
What teratogenic agent can cause: CNS, craniofacial, ear, and CV problems
Isotretinoin
77
What teratogenic agent can cause: Goiter, hypothyroidism
Iodine
78
What teratogenic agent can cause: Cerebral infarcts or mental retardation
Cocaine
79
What teratogenic agent can cause: cleft lip and/or palate
Diazepam
80
What teratogenic agent can cause: clear cell vaginal carcinoma, adenosis, cervical incompetence
DES
81
What would you screen for in a woman whose fetus had cardiac malformations, caudal regression, polyhydramnios, NT defects, left colon hypoplasia/immaturity, and macrosomia?
Diabetes Mellitus - get them under tight glucose control
* Can actually see microsomia if the diabetes is longstanding
82
What post-pregnancy problems can children of diabetic mothers suffer?
Hypoglycemia from beta islet cell hypertrophy 2/2 to mom's hyperglycemia during pregnancy. Increased risk of RDS
83
Why do you use insulin in pregnancy instead of oral hypoglycemic agents?
These agents can cross the placenta and cause fetal hypoglycemia
84
Define the differentiating features of TORCH Infections
Toxoplasmosis Gondii (look for cat/meat exposure) - chorioretinitis, and intracranial calcifications (near the cortex)
Other = Varicella Zoster can cause limb hypoplasia and scarring of the skin. Syphillis can cause saber shins, Hutchinson's Teeth, "snuffles" or rhinitis, interstitial keratinitis, and skin lesions.
Rubella - worse in the 1st trimester!!! Always check on first visit; look for micropthalmia, "Blueberry Muffin" purpura, deafness and cataracts!!!
CMV - most common of the TORCH infections; look for intracranial calcifications (periventricular), deafness, petechiae (NOT PURPURA), and micropthalmia
Herpes - look for vesicles and + Tzanck smear
85
When do you test an infant with a known HIV + mother? What type of HIV test do you use?
At birth, 1 month, 2 months, 1 year, 1.5 years. Use a direct HIV PCR DNA test b/c the fetus can have antibodies against HIV from the maternal serum.
86
When do you consider giving Varicella Zoster Immunoglobulin to an infant?
If the mother contracts chicken pox in the last five days before delivery or the first 2 days after delivery.
87
What do you give a child at birth with a mother who has known Hep B?
Hep B Vaccine and Immunoglobulin
88
How do you treat Gonorrhea and Chlamydia in pregnancy? When would child eye present with conjunctivitis for both of these respectively?
Gonorrhea is treated with Ceftriaxone since it's safe in pregnancy. Chlamydia is treated with azithromycin, erythromycin base (NOT erythromycin estolate), or amoxacillin instead of Doxycycline.
Gonorrhea presents first within 2 days of delivery while Chlamydia presents later!
89
Treat TB pregnant patient with...
Rifampin, Ethambutol, and Isoniazid. Pyrazinamide is suspect in the data in regards to its teratogenicity.
90
What type of C-Section is contraindicated for future VBAC?
Vertical incision methods
91
What are the contraindications to breastfeeding?
1) HIV
2) Drugs and Alcohol
3) Antineoplastic / Antimetabolites (Mercaptopurine, Cyclophosphamide)
4) Some anticonvulsants (topiramate)
5) Amiodarone
92
What are some side effects of the different types of anesthesia for pregnancy?
Spinal Anesthesia = more common to have hypotension vs. epidural and also interferes more with mom's ability to push during labor
General = increased risk of aspiration
93
When do you treat women who are + for GBS? What could it cause if untreated? What do you treat with?
Treat during the 3rd trimester b/c it has a high likelihood of returning. It can cause neonatal sepsis and endometritis. Treat with Penicillin G or Ampicillin
94
When do you treat mastitis? How do you treat mastitis? How would you treat a MRSA infxn?
For mild mastitis (induration, cracked nipples, erythematous breast) use analgesics, warm/cold compresses, and continued breastfeeding of affected side.
Moderate mastitis can have Dicloxacillin or Cephalexin for Staph Aureus trmt.; more than mild symptoms
I/D for fluctuant mass that's not responsive to antibiotics or supportive care
Give Trimethoprim/Sulfamethoxazole or Clindamycin for MRSA.
95
What are the main RF's for preeclampsia?
(Decreasing order) Chronic Renal Disease, Chronic hypertension, Fam Hx, multiple gestations, nulliparity, extremes of repro age, diabetes, and being black.
96
When is edema likely to be abnormal in pregnancy?
Mild edema in the feet = normal. Severe edema in the ankle or edema in the hands is likely abnormal
97
What are the top three causes of maternal mortality in Western World?
1) PE
2) Pregnancy - Induced Hypertension or Preeclampsia/Eclampsia
3) Hemorrhage
98
How do you treat an amniotic PE?
Supportive care!
99
Define Oligohydramnios and it's respective causes and possible complications.
Oligo = amniotic fluid < 500 mL or AFI < 5
Causes = IUGR, renal agenesis (Potter Syndrome), PROM, or postmaturity.
Complications = pulmonary hypoplasia, skeletal or cutaneous abnormalities 2/2 compression, and hypoxia 2/2 cord compression.
100
Define Polyhydramnios and discuss it's respective causes and possible complications.
Poly = AF > 2L or AFI > 25
Causes = Diabetes, multiple gestations, NT defects, abd wall defects, esophageal atresia, and hydrops fetalis.
Complications = postpartum uterine atony (PP hemorrhage) and maternal dyspnea from expanded uterus
101
What do you do if your patient, who recently received Oxytocin, starts having late decels, uterine rupture, or hyponatremia/water intoxication?
STOP THE OXYTOCIN and stabilize!!! The pt can develop hyper stimulated uterus with signs of overly painful contractions, overly frequent, and poorly coordinated contractions.
* The 1/2-life of Oxytocin = 10 min
* * Prostaglandin E2 can also cause this (Misoprostol or Dinoprostone)
102
What are the contraindication for SVD or induced vaginal delivery?
Vasa Previa, Placenta Previa, CPD, transverse lie, umbilical cord prolapse, "classic" C-section, active genital herpes, cervical cancer
103
Recurrent abortions (2-3 abortions) could be a sign of...
Infections: Listeria, Mycoplasma, Toxo, Syphilis
Inherited Thrombophilia: factor V Leiden, Antithrombin Def, Protein C/S Def, Gene 20210A gene mutation (causes hyperprothrombinemia)
Health Conditions: Diabetes, Hypothyroidism, SLE
Physical Problems: Cervical Incompetence (painless 2nd trimester abortions - cerclage in the future), Abnormal Female GU Tract, Fibroids
104
What factors determine how you treat ectopic pregnancy?
If the pt is stable and how large the tubal pregnancy is..
1) Stable, < 3 cm = salpingostomy with the tube being left open to heal and retain it's fertility or MTX
2) Unstable or > 3cm = salpingectomy
105
How do you manage a pt with variable decels?
First, turn her to lateral decubitous position, administer O2 via facial mask, and STOP oxytocin b/c likely 2/2 to cord compression. If not improving and severe bradycardia, consider checking fetal oxygen saturation or scalp pH
106
How do you manage a pt with late decels?
First, turn her to lateral decubitous position, administer O2 via facial mask, and STOP oxytocin. Next, give a tocolytic (B2 agonist) if she's not in active labor (ritodrine or Mg Sulfate). If not improving and severe bradycardia, consider checking fetal oxygen saturation or scalp pH
107
How do you manage a pt whose child's pH was < 7.2 or O2 sat was "low"?
C-Section immediately
108
When do bleeding d/o normally show themselves in relation to delivery? Before or after?
More commonly after delivery.
109
The biggest RF for Vasa Previa, or Vilamentous Insertion of the umbilical cord, is? How does it present? How can you test for it?
Biggest RF = multiple gestations. Bleeding (from the "fetus") is painless but the fetus shows decompensation with initial Tachy followed by Brady. An Apt test can differentiate maternal and fetal blood.
110
What's the management of 3rd Trim bleeding?
Start IVF, give blood if needed, start pt on O2 and set up maternal and fetal monitoring. Order drug screen if suspected, give RhoGAM if mother is Rh Neg. A Kleihauer-Betke test can quantify the AMOUNT of fetal blood (vs. Apt which just shows the presence) to determine how much RhoGAM to give.
111
What are some general contraindications for tocolytics?
Heart disease, hypertension, DM, hemorrhaging, ROM, cervical dilation > 4cm, IUGR, chorioamnionitis, fetal demise, or fetal anomalies incompatible with life.
112
What is Fetal Fibronectin test? When is it used?
Fetal Fibronectin can be found in vaginal fluids of some women presenting with PTL; it's an extracellular matrix protein that helps attach the amniotic membrane to the uterine lining. If it's negative with a woman presenting w/ S&S of PTL GA 22 - 34, VERY low likelihood of delivery within 2 weeks. If positive, high likelihood of delivery and management should be more aggressive with tocolysis and steroids for fetal lung maturity.
Use when NO cervical manipulation has been done and when there is NO advanced cervical changes
113
What tests and values are indicated to assess for fetal lung maturity?
Lecithin/Sphingomyelin Ratio > 2:1
| Phosphatidylglycerol > 0.3
114
What maternal antibody can cross the placenta?
IgG therefore any other Ig should raise concern. This is the same reason why ABO blood incompatibility can occur without previous sensitization b/c it's an IgG mediate response with O maternal blood and A, B, or AB fetal blood.
115
If you have a father and mother, one Rh + and one Rh -, what is the likelihood of having a Rh+ child?
50%
116
If you have an indication for Rh reactivity, when do you check maternal antibody titers and when do you give RhoGAM?
Check titers at 7 months and monthly thereafter and give RhoGAM at 7 mo's and within 72 hrs of delivery. If the antibodies come back positive on the initial screen, don't give RhoGAM, it's too late.
117
How much RhoGAM do you give in the setting of very high antibody levels?
It's worthless here b/c the immune response has already been mounted…
118
What does the fetus most likely have if there is pericardial or pleural effusions, edema, and ascites? How do you manage/treat?
Hydrops Fetalis - monitor with spectrophotometry and U/S to gauge severity. Deliver once fetal lung maturity has been confirmed and the fetus is at term. If not mature, intrauterine transfusion and treat with phenobarbital to help fetal liver break down bilirubin by inducing hepatic enzymes.
119
Treatment of woman with presenting fevers, tender uterus?
Ampicillin and Gentamicin while awaiting cultures for probable Chorioamnionitis
120
How do you treat a soft uterus s/p delivery?
Treat uterine atony with bimanual massage and diluted oxytocin infusion. If this fails, start ergonovine (contraindicated in hypertension), prostaglandin F2alpha, or misoprostol. If this fails, might need hysterectomy or uterine artery ligation if the patient want to retain fertility.
121
What is the MCC of delayed PP hemorrhaging? What defines "delayed" type of PP hemorrhaging?
Delayed type = > 24 hrs - 6 weeks. MCC = retained placenta.
122
Define Post Partum Fever and describe MCC.
PP fever = temp > 100.4 for more than 2 days and MCC = endometritis. Other etiologies include UTI, atelectasis, PNA (pulm etiology likely in C-Section pt), pelvic abscess, or thrombophlebitis
123
What are causes of refractory PP fevers?
No response to antibiotics makes pelvic abscess or thrombophlebitis much more likely. CT = best test to see a pelvic abscess. Thrombophlebitis will present with clean CT but persistent spiking fevers, and no response to Abx - give Heparin or LMWH for cure/dx.
124
What is on your ddx if a pt goes into shock without evident signs of bleeding?
Concealed hemorrhage into the abdomen/pelvis, Inverted Uterus, Amniotic Fluid Embolism
125
What two labs are markedly elevated in a normal pregnancy?
ESR and Alkaline Phosphatase
126
Underlying social stressors or psychiatric d/o predispose a woman to this d/o in their first pregnancy leading to electrolyte abnormalities and dehydration.
Hyperemesis Gravidarum - supportive care + small frequent meals + antiemetic meds
127
When does cholestasis of pregnancy normally present? What is definitive vs. symptomatic treatment?
Cholestasis of pregnant normally presents in the 2nd or 3rd trimester. Delivery is the only definitive treatment but Cholestyramine and Ursodeoxycholic Acid can help alleviate severe pruritus.
128
What causes acute fatty liver of pregnancy? How do you treat it? Why doesn't Vit K work? When does it normally present?
It is a mutation in the mitochondrial processing of long chain fatty acids. They eventually build up in the maternal circulation overwhelming the beta oxidation enzymes of the mother and cause acute hepatic failure. Treat aggressively with fluids, FFP, and glucose. Vitamin K doesn't work because the liver is in acute failure. Prognosis is good if treated aggressively, but is a much more serious disease overall w/ high untreated mortality rates. It presents in the third trimester or after delivery.
129
What fetal presentations are an absolute contraindication for vaginal delivery?
Transverse lie, shoulder presentation, and incomplete/footling.
130
What three things can help distinguish monozygotic from dizygotic twins 80% of the time?
1) Same blood type
2) Same sex
3) Monochorionic placenta (if dichorionic, must be dizygotic)
131
What twin presentations is safest for vaginal delivery?
Vertex-Vertex. If the first delivering twin is vertex, it might be safe to continue.
132
What three things have to be present to dx PID? What other objective findings would you look for in the lab work?
1) Abdominal Pain
2) Adnexal Tenderness
3) CMT
Look for elevated ESR, CRP, fever, leukocytosis, mucopurulent d/c from the cervix
133
For PID, what are your outpatient and inpatient treatment options? What causative organisms are you thinking about?
Inpatient = Cefotetan or Cefoxitin + Doxycycline
Outpatient = Ceftriaxone + Doxycycline
MCC = Gonorrhea and Chlamydia
Other offenders = E. Coli, Anaerobes, and with a hx of an IUD…Actinomyces Isralii
134
If you have a tuboovarian abscess, what factors of the abscess determine your management?
If it's non-ruptured, treat with antibiotics first to see if it responds to medical treatment alone. If it's ruptured and unilateral, proceed to surgery with unilateral salpingectomy. If ruptured and bilateral, proceed to surgery and preform a TAH with a bilateral salpingo-oophorectomy.
135
What would you be thinking about in a woman with tender adnexa who is afebrile? What are the 3 D's of this disease process? Typical PE findings? Classic sequela of the disease?
Endometriosis. Dyspareunia, Dyschezia, and Dysmenorrhea. You can find modularity of the uterosacral ligaments. Classically, a retroverted uterus results.
136
MCC of PREVENTABLE infertility in US? MCC of infertility in a woman 30 yo WITHOUT hx of PID? MCC of infertility in a woman
PID / PID / Endometriosis / PCOS
137
What might the squamous cells look like in a patient with HPV? What is the collection of these changes called (type of cell)?
1) Larger nuclei
2) Abnormal cellular borders
3) Hyperchromasia - darker nuceli
4) Perinuclear halo
These cells are called koilocytes
138
What do you consider when treating a patient with the most common STI and dysuria? Do you treat concomitantly for anything else?
Normally give Doxycycline but if the patient is pregnant, erythromycin. If adherence is questionable, give 1g of Azithromycin now. You DO NOT treat for Gonorrhea (you treat for presumed Chlamydia infxn if the patient has a Gonorrhea)
139
Explain the relation between fibroid and hormones.
Leiomyomas are estrogen-dependent and increase in size with OCP use, pregnancy and decrease after menopause.
*Anemia is an indication for hysterectomy
140
When does DUB most commonly present? How do you treat?
After menarche and immediately before menopause. Treat first with NSAIDs and OCP if the patient does not desire pregnancy. Monotherapy with progesterone is used for severe bleeding.
141
With no obvious direction, what is the first test to order in a couple with infertility? BONUS - what are the normal characteristics of semen?
Semen analysis.
Normal Characteristics:
1) Ejaculation Volume = > 1mL
2) Concentration = > 20mL
3) Initial forward motility = > 50% of sperm
4) Normal Morphology = > 60% of sperm
142
After a semen analysis comes back normal in a couple with infertility, what's the next best thing to do?
What test would you order to assess the uterus and fallopian tubes? What clues int he history might point you to fallopian tube/uterine pathology?
What's the last test in the work-up of infertility?
Document ovulation via basal body temp., luteal progesterone levels, and/or endometrial biopsy.
Order a hysterosalpinogram to look at the uterus and fallopian tubes. Tubal pathology might have a hx of PID or ectopic pregnancy. Uterine pathology might have a hx of previous D&C with subsequent synechiae, fibroids, or endometriosis.
Laparoscopy to visually assess. Lysis of adhesions and destruction of endometrial tissue can often restore fertility.
143
What are the medical treatments of infertility and what are their respective indications?
1) Clomiphene Citrate - for women who are producing sufficient estrogen (inhibits the negative inhibition estrogen has on the hypothalamus, therefore up regulating the HPA-gonadotropin axis)
2) Human Menopausal Gonadotropin - for hypoestrogenic women (it's a combo if FSH and LH)
144
What history would you expect to find in a patient with secondary amenorrhea 2/2 premature ovarian failure?
Chemotherapy exposure, Hx of Autoimmune d/o, or karyotype abnormalities.
145
How would you work up a patient without an obvious cause of secondary amenorrhea?
First - give progesterone to see if she bleeds within 2 wks, this means she has sufficient estrogen stores. If she does't bleed, check FSH - if elevated, premature ovarian failure. If FSH is normal, could be a brain tumor (craniopharyngioma), get an MRI.
Second - if she bleeds, order TSH and Prolactin levels; elevated TSH can cause Prolactin to be high. If Prolactin is elevated with normal TSH, get MRI to assess for pituitary adenoma. If TSH is the only abnormally high lab, it could be hypothyroidism.
Third - if everything is normal so far, assess GnRH levels. Low levels can be induced from drugs, stress, or exercise.
146
(1) What would you look for in a patient with primary amenorrhea and no secondary sexual characteristics?
(2) What if the female has normal breast development but no axillary or pubic hair? What else would be absent in this patient?
(3) If the female has normal breast development and has a uterus, what would you order?
(1) If the patient is 14 without any secondary sexual characteristics think congenital problems.
(2) Androgen Insensitivity Syndrome - absent uterus
(3) Order Prolactin, if high, assess for pituitary tumor with MRI. If normal, give progesterone and follow protocol for secondary amenorrhea.
147
What vaginal symptoms can occur with menopause? What would show up on microscopy? What would you see in labs?
Menopause (51 = avg age) can cause atrophy of vaginal with symptoms of dysuria, dyspareunia, incontinence, vaginal itching/burning/soreness. Increased parabasal cells and elevated FSH point towards menopause.
148
What things are important to assess with a patient presenting with nipple d/c?
Presence of blood, Uni/Bilateral, Hx of meds (OCP's, antipsychotics, HRT) or Hypothyroidism. Unilateral bloody d/c is the most worrisome for breast carcinoma. Bilateral non-bloody d/c is least worrisome, and likely 2/2 to a benign cause.
149
How would you treat someone with bilateral, multiple, cystic breast lesions that are tender right before menstruation?
Fibrocystic disease is MC in women < 35 yrs of age and can be treated with OCP's, progesterone, or danazole for symptomatic relief.
150
How would you manage a woman > 35 yo with presenting breast lesions?
If > 35 yo (and without obvious signs of premenstrual mastalgia or trauma w/ 2/2 fat necrosis) get a bx and baseline mammo.
If cystic, aspirate and assess for blood and see if it returns - those aforementioned factors = more likely cancer.
151
When is a breast lump considered cancer until otherwise proven?
In a 50 yo postmenopausal woman presenting with a new breast mass.
152
What is mammo best used for in terms of breast masses?
It's best used in patients > 30 yo b/c of breast density and is best for non-palpable breast masses.
153
Where would you expect to see vaginal bulging for prolapsed organs?
Upper Anterior Vaginal Wall = Cystocele
Lower Anterior Vaginal Wall = Urethrocele
Upper Posterior Vaginal Wall = Enterocele
Lower Posterior Vaginal Wall = Rectocele
154
What is the likely cause of ambiguous genitalia in an infant? How do girls and boys present differently? How do you treat these patients?
Adrenogenital Syndrome = Congenital Adrenal Hyperplasia. MCC = 21-hydroxylase deficiency.
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Girls = ambiguous genitalia b/c they can't make estrogen
Boys = salt wasting crises, hyperkalemia, hypotension, and elevated 17-hydroxyprogesterone
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Give steroids and IVF to prevent death
155
What are you suspecting with a pediatric patient with a "bunch of grapes" presenting in the vaginal introitus?
Sarcoma Botryoides - a malignant embryonal rhambdomyosarcoma tumor
156
What is the MCC of precocious puberty? What ages are considered precocious for boys and girls? What do you need to rule out in these patients? How do you treat the MCC of precocious puberty?
MCC = idiopathic. Defined as early puberty < 8 yo in girls and < 9 yo in boys. R/O hormone secreting tumor (like a Leydig Cell tumor) or CNS tumor (astrocytoma or hamartoma). Treat idiopathic precocious puberty with GnRH analogs to prevent early closure of epiphyseal plates.
157
What causes vaginitis in prepubescent girls? What are you concerned about if a STI is present? What are you concerned about if a white cottage cheese d/c is present?
Most are non-specific or physiologic - look for foreign objects! STI's are worrisome for sexual abuse. Candidiasis could be 2/2 underlying diabetes (check for glycosuria or serum glucose levels)
158
What are the MC SEfx's of Estrogen?
Endometrial bleeding, bloating, breast tenderness, HA's, and nausea.
159
What are the known risks/benefits of estrogen replacement therapy as seen by the Heart and Estrogen/Progesterone Replacement Study (HERS) and Women's Health Initiative (WHI)?
Risks = endometrial cancer, coronary heart disease, VTE, breast cancer, stroke, and gallbladder disease.
Benefits = decreased osteoporosis, reduced menopausal symptoms, and decreased risk of CRC
160
What are the ABSOLUTE contraindications for estrogen therapy?
Pregnancy, Active Liver Disease, CAD, Previous Thromboembolism, Hx of Endometrial/Breast Cancer, or Unexplained Vaginal Bleeding
161
What are the ABSOLUTE contraindications for OCP's?
Previous stroke, CAD, VTE, liver disease, DM w/ complications, breast cancer, pregnancy, lactation, HA with focal neural deficits, major sx w/ immobilization, > 35 w/ smoking hx of 15 cg/day, complicated valvular heart disease
162
What would you do with a patient presenting with hypertension who is taking OCP's?
Take them off for a month a recheck - OCPs are well known causes of secondary hypertension.
163
What are the common SEfxs of OCPs?
1) Glucose Intolerance (check for DM)
2) Depression
3) Edema
4) Wt Gain
5) Cholelithiasis
6) Benign liver adenomas
7) Melasma
8) N/V/HA
*Rifampin and anti epileptics can induce liver metabolism and decrease their effectiveness
164
How does hypothyroidism and hyperprolactinemia relate to each other? What classes of drugs could cause this too?
Dopamine inhibits Prolactin while Serotonin and TRH stimulate Prolaction, therefore hypothyroidism can cause hyperprolactinemia resulting in ammenorrhea and galactorrhea. Dopamine antagonists like antipsychotics, tricyclic antidepressants, and MAOI's.
165
What additional S/S would a pt with cocaine associated CP show? How would you initially treat the pt and what medication is contraindicated? What other arterial complications is a cocaine at risk for?
CP accompanied with atrophic nasal mucosa, agitation, dilated pupils, and general increased sympathetic system. Give oxygen and benzodiazepines. CCB's and nitro can help vasodilate, and aspirin retards thrombi formation. Beta-blockers are contraindicated because they can selectively cause alpha adrenergic stimulation (via beta blockade) and worsen coronary vasoconstriction 2/2 to cocaine's alpha and beta adrenergic effect. Risk for intracranial hemorrhage and aortic dissection.
166
Major source of estrogen in menopausal women is from _______?
Peripheral conversion of adrenal androgens by aromatase enzyme present in adipose tissue.
167
Dx for premature ovarian failure?
3 months of amennorhea with FSH in menopausal range in females < 40. Want to dx quickly to prevent osteoporosis in a young female.
Associated with chemo, irradiation, mumps, oophoritis, and autoimmune diseases.
168
When can isolated amenorrhea with well-developed secondary sexual characteristics be considered normal? When can amenorrhea + absent secondary sexual characteristics cause concern?
Age 16, and age 14 respectively
169
Women with primary vaginal cancer MC'ly have?
SCC - RF's = smoker, > 60, exposure to HPV (16/18), malodorous vaginal DC and baginal bleeding
*Adenocarcinoma = epi for age < 20
170
Serous cyst adenomas are the MCC cystic ovarian neoplasm, this % are bilateral?
50%
171
Endometrial hyperplasia WITHOUT atypia = management?
Progestin!
If atypia present and wants to retain child bearing, progestin. If not hysterectomy
