USMLE World Flashcards
(201 cards)
1
Q
A 28 y/o G2P2 at 26 wks comes in with 4 days of right flank pain that radiates to her groin. She has had an uncomplicated pregnancy thus far, has a PMHx significant for PID, and has moderate right flank percussion tenderness with microscopic hematuria without nitrites or leukocyte esterase in the urine. Next step?
A
Patient likely has renal colic - aka. stones. She needs a US of her kidneys and renal pelvis. Shockwave lithotripsy is CI’d in pregnancy. Can consider low-dose CT urography in second and third trimesters only.
2
Q
37 y/o with LMP -25days comes in with a BP 130/80, HR 110, RR25, T 36.8, and bilateral lower quadrant pain with mild guarding. She describes pain in the periumbilical area that localized to the lower abdomen. Her WC# is 10,9. What is the next step?
A
Even though it is unlikely, a B-HCG is necessary to rule out pregnancy. It can pick up a pregnancy within 4 days of implantation. She would need a US if the pregnancy test was positive, or an abdominal CT if it was negative.
3
Q
47 y/o with history of mastitis with her first child 20 years ago, comes in with left breast swelling and pain. She has a 7x6 cm area of edema and erythema, and a poorly localized mass without fluctuation. She has scant non-bloody discharge at the nipple and several large axillary LNs. What do we do next?
A
This patient likely has Peau d’ orange on her breast which is a sign of inflammatory breast carcinoma. It is often associated with axillary LAD, spontaneous nipple d/c. Do histology on a biopsy to exclude or confirm the diagnosis, then treat. 1/4 of patients have mets at presentation.
4
Q
Patient comes to you looking for emergency contraception options. What can you offer her?
A
Copper IUD (99% effective within 5d), Ulipristal pill (anti-progestin, delays ovulation, >85% effective within 5d), Levonorgestrel pill (progestin, delays ovulation, 85% effective within 3d), OCPs (75% effective within 3 d).
5
Q
What cancers does Tamoxifen increase the risk for?
A
Endometrial Cancer and Uterine Sarcoma.
6
Q
What are the options for prenatal testing for a female with a family history of Down syndrome to rule out aneuploidy?
A
If the Patient is >34, give Cell-free fetal DNA testing (cffDNA), ~99% for trisomy 21, ~92% for Trisomy 18, ~80% for Trisomy 13. If
7
Q
A 22 y/o G1P0 at 13 weeks comes in with vaginal bleeding without tissue passage. She has no history of trauma, tobacco, alcohol, or drugs. She has a closed cervix, a slightly tender uterus c/w gestational age, and free adnexae. US shows normal fetal heart motion. dx?
A
Threatened Abortion: term used to describe hemorrhage before 20 weeks, closed cervix, no passage of fetal tissue. Incomplete Abortion includes passage of some, but not all tissue. Inevitable abortion has vaginal bleeding, cramps that radiate to the back and perineum, dilated cervix, and US shows no fetal heart motion and a collapsed gestational sac. Follow this up Outpatient.
8
Q
A 49 y/o woman presents with a strange, itchy rash on her left nipple; an excezematous plaque. Biopsy shows halo-like areas invading the epidermis. Dx?
A
Adenocarcinoma. The skin finding is Paget Disease of the breast, which results from infiltration of a ductal carcinoma into a dermal lymphatic system.
9
Q
A woman with hypertension during pregnancy. What meds can you use?
A
Methyldopa, labetalol (B-blockers), Hydralazine, CCBs. Thiazides and Clonidine are second line.
10
Q
What is the most accurate way to measure gestational age in a pregnant woman?
A
First trimester ultrasound with crown-rump length. Ideally it should be done from 7-10 weeks (which gives accuracy of +/- 3 d).
11
Q
39 y/o primiparum comes in with 3 weeks of nausea and vomiting that have progressively worsened. She has had intermittent vaginal bleeding since her most recent period, 2 months ago, and has been having intercourse with her husband without protection in order to conceive. She is dehydrated and has a 10week uterus. What does she have?
A
Hyperemesis Gravidarum.
Risk Factors: HG in prior pregnancy, multiple gestation, molar pregancy.
Clinical: Severe, persistent vomiting, fluid/electrolyte abnormalities, ketonuria, >5% wt loss.
Workup: Orthostatic vitals, serum lytes, BUN, Cr, TSH, UA.
Trt: Diet, hydration, ginger, B6 +/- doxylamine.
12
Q
Patient with postpartum hemmorhage with passage of large blood clots. She had normal labor, normal placental pathology, and has a soft fundus at the umbilicus. What is the cause?
A
Atony of the uterus. 80% of PPH is caused by this. Next step is fundal massage, IV access, oxytocin. If still uncontrolled, uterine packing (ballooning) can be used.
13
Q
When should CVS be completed in order to give a definitive karyotype?
A
10-13 weeks
14
Q
Patient has abnormal values on a quad-screen. Whats the next step?
A
US. Then Amnio (15-20 weeks) or CVS (10-13 weeks).
15
Q
Neonate is born with a birth weight of 2080g, a temp of 37.2, and a HR of 190. Mother had a surgically resected thyroid for graves disease 6 months prior, and became hypothyroid post-surgery for which she took levothyroxine. What is the best treatment?
A
Methimazole PLUS B-blocker. Will self-resolve within 3 months; Neonatal Thyrotoxicosis from transplacental TSH-receptor Ab.
16
Q
A 22 y/o shows up after her first few experiences with intercourse stating that she had intense pain during sexual activity due to tensing of her vagina. Speculum exam is not possible due to tense perineal musculature. Dx and trt?
A
Vaginismus; prescribe kegel exercises and gradual dilatation. Most often caused by strict, negative upbringings towards sex, leading to involuntary contraction of the perineal musculature; psychological cause.
17
Q
A 28 y/o comes in for a pap smear and ASC-US is found. Next step?
A
> 25 y/o, HPV testing. Colposcopy if abnormal.21-24 should get repeat pap at 12 months.
18
Q
73 year old female presents with foul-smelling, bloody vaginal d/c for several months. She has a 40 year pack history of smoking, has not been sexually active for the past 10 years, and has an atrophic vagina with an irregular lesion of 1cm in the upper 1/3 of the posterior wall. Whats next?
A
She likely has a squamous cell carcinoma (HPV 16/18), which is caused by cig use, age >60, and often is found in the upper 1/3 of the posterior wall (vice upper 1/3 of anterior wall and history of DES in utero in a young woman for clear cell carcinoma). She should get a biopsy.
19
Q
Woman presents at 37th week with a breech fetus. What is a contraindication to external version?
A
Placental abnormalities, fetopelvic disporportion, hyperextended fetal head. Note that prior to 37th week, no intervention would be completed. Failure leads to C-S.
20
Q
Woman comes in with urinary frequency x2 days, suprapubic tenderness, and UA significant for nitrite, leukocyte esterase, and bacteria. Why do women get this problem more than men?
A
UTI: women> men due to shorter urethra. Other predisposing factors include altered normal flora by recent Abx, sexual intercourse, spermicide use, FHx.
21
Q
A 29 y/o nulligravida comes in with a contraceptive history of OCPs until 1 year ago, and >6months of amennorhea. She had irregular periods before OCPs, but got off them in an effort to conceive . She eats well, exercises regularly, has a BMI of 22, and is not pregnant (negative B-HCG). Next step?
A
Amenorrhea for >3 cycles or >6 months = secondary amenorrhea. If Negative Pregnancy test, check PRL, TSH, FSH to check for need for MRI, hypothyroid, Premature ovarian failure. Prior history of an intrauterine infection could indicate a need for a hysteroscopy.
22
Q
A 30 y/o G2P1 at 37wks comes in with sudden vaginal bleeding and painful uterine contractions. Her pregnancy was uncomplicated, though she has been trying to quit smoking. Her VS are wnl, PE shows a 3cm dilated cervix, vaginal bleeding, and a vertex presentation. Contractions are every 3 minutes. Fetal heart tracing is 140bpm, good variability, access no decels. Whats next?
A
Vaginal delivery. This patient has had a placental abruption, which can be caused by maternal HTN, abdominal trauma, cocaine + tobacco use. It presents with sudden-onset vaginal bleeding, abdominal/back pain, high frequency/low intensity contractions, hypertonic tender uterus. Treatment depends on mom’s stability - unstable - go to Cesarian (emergency), stable and >34wks - try vaginal birth.
23
Q
A 32 y/o nullip comes in for an epidural placement for pain control during delivery. After induction, she feels light-headed, has a pressure drop from 120/90 to 90/55, and her HR spikes to 120 with RR of 12. She has normal strength and sensation in her upper extremities. Whats the cause and treatment?
A
This patient has hypotension as a side effect of epidural anesthesia. It causes vasodilation and venous pooling, which can be combatted by good hydration (IV fluids) and left uterine displacement (position patient on their left) to improve venous return. Pressors can also be used.
24
Q
A 24 year old comes in with a self-palpated breast lump. She found it in the shower, and says that it is mildly tender. She has regular periods every 26 days, and her LMP was 3 weeks ago. She has no family history of breast cancer, has no LAD. Next step?
A
Have her come back after her menstrual period. The probability of benign disease is very high if the mass decreases in size, and therefore is a good first step before more invasive diagnostic techniques are done.
25
A 27 y/o at 10 weeks gestation comes to the ER with vaginal bleeding and cramping lower abdominal pain. She has normal vitals with an effaced and dilated cervix. Gestational tissue is visualized through the internal cervical os, and bimanual exam finds a soft and enlarged uterus. Dx?
Inevitable Abortion - vaginal bleeding and fluid discharge, cramps, and visualized conception products.
26
33 y/o at 35 weeks with di/di twins presents with high blood pressure (Stable at 160s/100s), 2+ pitting edema, and Cr. 1.4. DX?
Pre-Eclampsia with severe features. Conditions are New onset systolic >140 +/or Diastolic >90 after 20 weeks gestation AND Severe Features (>160/>110, TTP 1.1, 2xULN Transaminases, Pulmonary Edema, visual/cerebral symptoms).
27
29 y/o G3P2011 at 10 weeks comes in after not seeing a physician for many years for prenatal care. Her current pressures were 145/95. There are no signs of end-organ damage. Dx?
Chronic Hypertension. This is before 20 weeks = not caused by the baby.
28
Patient with pre-E comes in needing stat treatment. Options?
Hydralazine or Labetalol IV for BP lowering, IV Mag Sulfate for seizure prophylaxis. Methyldopa is great for long term, but is slow onset.
29
What causes a person with Hypothyroidism to start to lactate??
TRH stimulates prolactin stimulation (directly). The affects on PRL include stimulation of production by serotonin and TRH and inhibition of production by Dopamine.
30
25 y/o caucasian woman comes in with a history of anorexia nervosa. She is still moderately underweight, but has recovered from her previously very poor eating. She wants to know what affects this can have on her future pregnancies. Thoughts?
Can cause an SGA baby due to chronic nutrient deprivation (IUGR), a premature baby, and postpartum can have hyperemesis gravidarum, C/S, and postpartum depression. Children born to anorexic mothers often suffer from poor growth and intellectual impairment.
31
A patient comes in at 39weeks 0 days with nitrazine-positive clear fluid pooling in the vaginal fornix. Microscopy shows ferrying. Fetal heart monitoring shows a heart rate of 165/min, moderate variability, and no accels/decels. Fluid analysis shows 18.5k WBCs. Dx?
Intraamniotic infection (chiorioamnionitis). The patients FHT is c/w a Cat II tracing. Patients with increased risk include prolonged rupture of membranes (ROM). Maternal Fever + (uterine tenderness, maternal/fetal tachy, malodorous amniotic fluid, purulent vaginal d/c).
32
How do you manage a patient with chorio at 33 weeks?
Intravenous Broad-Spectrum Abx (Amp, Gent, Clinda), Corticosteroids for 24-34 weeks if likely to have baby.
33
24 y/o female comes in with increasing facial acne, recent menstrual irregularities. She weights 170#, and is 62in tall. What condition is she at risk of?
PCOS increases the risk of endometrial cancer. Excessive estrogens are converted to androgens.
34
Why should an Rh+, blood group O female and Rh+ blood group AB male not worry about alloimmunization in their first child?
Ab's to ABO antigens cause mild disease in most newborns, and specifically have a milder course than Rh incompatibility. Most have mild anemia and have jaundice fixed by phototherapy. Exposure in the first pregnancy is usually required before causing disease in subsequent pregnancies.
35
Primary Hypertension increases the risk of what in pregnancy?
Long-term CVD, Chronic Kidney disease, DM. Short-term, placental abruption.
36
Patient comes in with left lower quadrant pain that started 24 hours ago. It is a 5/10 in severity. She denies fevers, vomiting, dysuria, diarrhea, vaginal bleed. Last menstrual period was -2weeks. Dx?
Mittleschmerz (midcycle pain) in women not on OCPs. Timing and lack of systemic symptoms are the major clues; usually unilateral due to caused by release of egg.
37
62 y/o postmenopausal woman comes in with right adnexal enlargement on pelvic exam. No bleeding, no ascots, no other symptoms. Next step?
Ca-125 is 61-90% sensitive and 71-93% specific for malignancy in a adnexal mass.
38
A patient with eclampsia presenting after a grand-mal seizure comes in with her arm adducted and internal rotated. She has no sensory loss. What occurred?
She dislocated her shoulder - posterior. Caused by violent muscle contractions dislocating the glenohumeral joint. Exam shows a flattened shoulder, prominent coracoid process, and positioning as in the vignette with an inability to externally rotate the arm.
39
A 28 y/o G1P0 at 41weeks comes in for antepartum surveillance. She has an NST with baseline 140bpm, moderate variability, no accelerations, and 1 late decel. A BPP shows a score of 4. Most likely dx?
Uteroplacental Insufficiency. The order of BPP abnormalities in a metabolically compromised fetus are HR decelerations, absent fetal breathing movements, decreased body movements/tone, Oligohydramnios. Deliver at 4 or less.
40
Indications for anti-D IgG for an Rh-neg mom?
```
28-32 weeks
w/in 72 hrs of delivery of an Rh+ infant
Ectopic pregnancy
Hydatidiform mole
CVS/Amniocentesis
Abdominal Trauma
2/3rd trimester bleed.
External cephalic version.
```
41
When do we do routine GBS culture?
They are valid for 5 weeks - so at 35-37 weeks gestation.
42
Patient is 36 weeks with IUGR. After a NST, what other test is important for evaluation?
Umbilical artery dopper velocimetry; evaluates flow.
43
A follow-up for a patient with a nonreactive NST in the setting of decreased movement, who doesn't have a contraindication for labor (placenta previa) would be what test?
CST> BPP. BPP can always be done, but at CST is equivalent and can show distress when you give oxytocin or stimulate the patient.
44
Patient with a normal CST after a non-reactive NST. How long is the testing good for?
Liklihood of stillbirth is low for 1 week. Then follow-up testing is appropriate.
45
Pregnant 24 y/o lady needs STI screening without having risk factors. Name some risk factors and what she needs done.
GC/CL for for women
46
A 16 y/o female with a history of irregular menstruation since 12, comes in with hirsutism. She has normal external female genital and an otherwise normal exam. Labs show LH and FSH at slightly high levels, 17-OH-P at 100x normal, Testosterone at ULN, and DHEAS at ULN. What is her dx?
CAH; non-classic CAH shows up as oligo-ovulation, hyperandrgogenemia and increased 17-OH-P. Ddx is PCOS (not likely with this 17-OH-P), Ovarian/Adrenal tumor, hyper-PRL, cushings, Acromegaly.
47
a 38 y/o G0P0 African American woman with 6 months of chronic constipation, urinary frequency, abdominal fullness with irregular menses and a pelvic exam c/w a 14 week uterus that is irregular and mobile with a prominent posterior mass. UPT is negative. Family history of ovarian cancer in mother and GM. Most likely cause?
Leiomyoma >> Malignancy. Posterior masses often present with compression symptoms and heavy, prolonged menstrual bleeding.
48
Newborn with tonic-clonic siezures; CT shows hydrocephalus and intracranial calcifications. Dx?
Congenital toxoplasmosis.
| Congenital Rubella = deafness, cataracts, cardiac defects.
49
Patient with positive RPR and FTA-ABS comes in for treatment in the setting of a 25 week gestation pregnancy. She has a history of true allergy to Penicillin. Of Doxy, Erythromycin, Cipro, or Penicillin, which do you give?
You do penicillin desensitization by giving her increasing doses of oral Pen V. Tetracyclines are effective but are teratogenic. Erythromycin does not cross the placenta. Cipro does not work against syphillus and also causes teratogenicity.
50
24 y/o G2P1 comes in at 26 weeks' gestation with bilateral 2+ pitting edema and otherwise normal PE and Vitals. Management?
Reassurance and routine followup. The patient has engine edema of pregnancy - watch for DVT, but without fever, unilateral leg pain, redness, calf tenderness, its not likely.
51
A 17 y/o girl presents for an eval of vaginal d/c. It is copious, white, and mucoid vaginal d/c without odor. There is a predominance of squamous cells and rare PMNs on microscopic exam. She has been sexually active for 6 months. Dx?
Physiologic leukorrhea. Even if it is copious, white or yellow, non malodorous d/c without symptoms of pruritus, burning or fever are likely to be physiologic >> pathologic.
52
A 29 y/o with thin, gray-white vaginal d/c, Vaginal pH >4.5, an amine-like fishy smell with addition of KOH, and vaginal epithelial cells with adherent bacteria on wet mount. Dx?
Bacterial Vaginosis. bacteria are coccobacilli (Clue Cells).
53
Name some normal Renal changes in pregnant women.
Renal: Increase GFR and decreased BUN and Scr; due to increased CO, RBF, and excretion. Urinary frequency and nocturia; increased Uout and sodium excretion. Mild hyponatremia; hormones reset threshold due to increased ADH from pit.
54
Name some normal Heme changes in pregnant women.
Dilutional Anemia; Increased Plasma Volume and RBC mass. Prothrombotic state; Hormone mediated dec in protein S and increase in fibrinogen and coag factors.
55
Name some normal CV change in pregnant women.
Increased CO and HR due to increased Blood volume and decreased SVR.
56
Name some normal pulmonary changes in pregnant women.
Chronic resp. alkalosis with metabolic compensation (Increased PaO2 and decreased PaCO2); Progesterone and directly stimulates the central resp. centers to tidal volume minute ventilation.
57
A 43 y/o G6P5 female has a generalized tonic-clonic seizure in the delivery room 20 minutes after NSVD. She is disoriented, lightheaded, cyanotic. Her Vitals are T36.2, RR 30 and 75% on facemask, BP 80/30, Pulse 110. A generalized purpuric rash and bleeding from her IV site are noted. What next?
Inubation and mechanical ventilation; this patient has Amniotic fluid embolism and is in DIC. Risk Factors include AMA, Gravid 5+, C/s or instrument delivery, Placenta Previa/Abruption, Pre-E. Presentation is usually Cardiogenic Shock, Hypoxemic resp. failure, DIC, coma, and/or seizures. Treat with Resp. and hemodynamic support +/- transfusion.
58
38 y/o with inter menstrual bleeding, heavy menses, and occasional missed periods for the last year. She has a history of T2DM for 4 years, and is obese (BMI 35). PE shows nl vitals, slight pallor, and a normal uterus in size and shape. Hbg is 10.8, PT/PTTs are nl, she has a negative B-HCG. Whats next step?
Endometrial Biopsy.
Work up includes; B-HCG, blood counts, coags, TSH.
Next step: Risk factors for Endometrial Cancer (obesity, DM, periods of amennorhea) => biopsy.
59
Whats the DDx of Abnormal Uterine Bleeding?
PALM-COEIN
Structural = PALM; Polyps, Adenomyosis, Leiomyoma, Malignancy
Non-Structural = COEIN; Coagulopathy, Ovulatory dysfn (PCOS, PRL), Endometrial, Iatrogenic, Not- yet classified.
60
What are the risk factors for Endometrial Carcinoma?
Age >45, Obesity, DM, Unopposed estrogen (iatrogenic, Breast Cancer drugs, amennorhea), PCOS, early menarche, late menopause.
61
Indications for an Endometrial Biopsy in AUB?
Women >45 and all post menopausal women, Women
62
What are the complications (3), management (3), and prevention (4) strategies for Hep C patients during pregnancy?
Complications: GDM, cholestasis, preterm.
Mgmt: No Ribavirin, no need for condoms in serodiscordant monogamous couples, Vaccinate against Hep A&B.
Prevent vertical trans: Increased transmission with viral load and HIV+, CS doesn't prevent, scalp electrodes should not be used, encourage breastfeeding unless actively bleeding.
63
30 y/o G2P2 comes in with fatigue, mood swings, irritability, breast tenderness, bloating, and HA monthly. They are worse after her menses and resolve but the 3rd day of her cycle.
PMS - Premenstrual Syndrome. If she got angry/irritable = Premenstrual dysphoric disorder PMDD. Often 1-2 weeks prior to menses and resolve with flow. Ddx includes hypothyroidism.
64
Hyporeflexia in a Pre-E patient is indicative of what?
MgSO4 toxicity; stop Mg, give Calcium gluconate. Toxicity leads to hyporeflexia, then respiratory depression.
65
What is the normal pH of the vagina?
3.8-4.2
66
Patient with thin, yellow-green malodorous d/c and vaginal redness/irritation. pH is 5.3. Dx and management?
Will find motile trichomonads (highly motile pear-shaped organisms with 3-5 flagella) on wet mount = trichomoniasis. treat pt and partner with Metronidazole.
67
Thick, "cottage cheese" d/c and vaginal redness/irritation. pH is 3.9. Dx and management?
Will find psuedohyphae on wet-mount = candidiasis. Treat with fluconazole.
68
Thin, ivory colored d/c with fishy odor, no signs of irritation or redness in the vagina. pH is 5.3. Dx and management?
Will find Clue cells and have amine odor with KOH on wet mount = Gardarella vaginitis (BV). treat pt with Metronidazole/tindazole. Increased likelihood after sex.
69
Woman with 3 months of amenorrhea and 12 months of hot flashes, dyspareunia, and mood disturbances at 34 y/o. Studies show High FSH:LH, low E. What are is the dx, risk factors/causes, and how do you get them pregnant?
Premature Ovarian Failure: often idiopathic, but can be caused by Mumps, oophoritis, irradiation, chemo, Hashimoto's thyroiditis, Addison's, T1DM, and pernicious anemia. Give IVF with donor oocyte.
70
Patient with PCOS wants to get pregnant. What symptoms does she have and what do you give her?
PCOS symptoms: Infrequent/absent/missed periods, acne, dandruff, oily skin, hirsutism, infertility, ovarian cysts (non-painful), weight gain, male-pattern baldness. Give her clomiphene citrate (Estrogen analog = induces ovulation), pulsatile GnRH.
71
What are the indications for administration of prophylactic anti-D immune globulin (RhoGAM), for an unsensitized Rh- pregnant patient?
28-32 weeks gestation, within 72hrs of delivery in an Rh+ baby/ abortion (even threatened), Ectopic, Molar pregnancy, CVS/Amniocentesis, 2/3rd trimester bleeding, External cephalic version.
72
A patient presents with unpredictable periods for the last 2 years and 12 months of infertility with good effort. She works out for 2 hours 6 days a week and has a lot of stress at work. Her BMI is 20, her LH and FSH are low. What medication can treat her infertility?
This patient likely has acquitted hypogonadotropic hypogonadism due to stress and exercise. Her LH and FSH are both low. She should attempt lifestyle modifications and stress relief, then use pulsatile GnRH.
73
What are the contraindications to external cephalic version?
Indications for CS regardless of fetal lie (failure to progress, non-reassuring fetal heart tones), placenta previa/abruption, oligohydramnios, ruptured membranes, hyperextended fetal head, fetal/uterine anomaly, multiple gestation, prior to 37 weeks gestation.
74
20 y/o G0P0 complains of vaginal bleeding lower quadrant pain, and a missed period. her vitals are stable and her PE shows right lower quadrant tenderness without rebound or guarding. There is no active vaginal bleeding and the cervical os is closed. She is Rh+ and her B-HCG is 1000, and TVUS shows no intrauterine or extrauterine pregnancies. What is the next step, and at what level BHCG should you be able to see an IUP?
Wait 48hrs and do another B-HCG. You can't see an IUP until 1500-2000 B-HCG. In a viable IUP, B-HCG levels will double every 48hrs. If she was Rh -ve and this was an ectopic/threatened abortion, you might consider RhoGAM.
75
A baby is born to a mother with uncontrolled diabetes. If her diabetes was more uncontrolled in the first trimester, what is the likely outcome? If 2nd/3rd trimester, what four consequences often result?
1st Trimester = spontaneous abortion - often due to congenital anomalies, NTDs, small left colon syndrome.
2nd/3rd Trimester > LGA => Fetal hyperinsulinemia = polycythema, organomegaly, shoulder dystocia => injury, neonatal hyperglycemia.
Best control is good glucose control.
76
What should you do if a women gets rubella in the first trimester? Should you have given her the vaccine during the pregnancy? If you did without knowing, what should you do?
First trimester rubella often leads to congenital rubella syndrome - offer an abortion.
Don't give the vaccine during pregnancy; don't get pregnant within 28 days of vaccine (MMR).
If it happens without knowing, just reassure and do routine visits/prenatal care.
77
A patient from Bolivia comes into your office with a history of 1 prior NSVD and 1 prior classic (vertical) Cesarean section for breach in Bolivia. She is currently 36 weeks pregnant and 6/80%/0 on exam. She suddenly becomes tachycardic to 140 and tachypneic to 24, and seems agitated with intense diffuse abdominal pain. Bleeding is noted from the vagina. Fetal heart tracing shows variable decelerations and the fetus has changed from 0 to -2 station. What is the dx?
Uterine rupture; Trial of Labor after Cesarean (TOLAC) has a risk of rupture of less than 1%. If the uterine incision is a classic (vertical) incision, the chances can be as high as 9%. A Loss of Fetal Station is the key 'red flag' for uterine rupture. Other risk factors include multiparty, AMA, previous myomectomy.
78
What are the risk factors for cervical incompetence/ insufficiency? Definition of CI?
Prior gyne surgery (LEEP/ cone biopsy), prior obstetrical trauma, multiple gestation, mullerian anomalies, DES exposure, and a history of preterm birth/second trimester (>13week) pregnancy loss. Evaluate with TVUS (gold standard). Definition =
79
What are the risk factors for placental abruption?
Maternal trauma, chronic hypertension, maternal smoking, history of external cephalic version.
80
Risk factors for polyhydramnios are?
Fetal malformations and genetic disorders, maternal DM, multiple gestation, fetal anemia.
81
What are the risk factors for having an SGA baby?
Impaired placental perfusion, maternal smoking/etoh/drugs, maternal malnutrition, multiple gestation, infections, genetic disorders, teratogen exposure.
82
What is the definition of an IUFD, what are the top causes, and how should this be evaluated?
>20week loss of a fetus before onset of labor.
Cause: HTN disorders, DM, placental/cord complications, APA syndrome, congenital anomalies/fetal infections (TORCH, listeria); 50% are iatrogenic.
Evaluate: Autopsy of fetus/placenta.
83
Gram negative diplococci in the setting of vaginal pruritus, mucopurulent d/c and a friable cervix. How do we confirm Dx? Treatment?
Gonorrhea (gonococcal cervicitis). Confirm with NAATs (Nucleic Acid Amplification Testing. Treatment is 3rd gen cephalosporin PLUS azithromycin or doxycycline. Second drug is for resistant gonococci and simultaneous treatment of C. trachomatis.
84
What are the risk factors for osteoporosis? Always know #1!
Modifiable RFs: Low Estrogen levels, malnutrition, decreased calcium, decreased vitamin D, use of Glucocorticoids or anticonvulsants, immobility, cigarette smoking and excessive EtOH consumption (dose dependant >2 drinks).
Non-Modifiable RFs: female, advanced age, small size, late menarche/ early menopause, caucasian/asian race, family history.
Counselling: wt-bearing exercise, smoking cessation, decreased EtOH.
85
Patient complains of vaginal d/c, dyspareunia, and vulvar pruritus. She has a history of hypothyroidism and thyroid replacement. She smokes and drinks daily. She has a thin, grayish d/c and erythema/edema of the vulva and vagina. pH = 6.2, wet-mount shows pear-shaped motile organisms. What should be avoided during treatment for this disease?
Metronidazole is the treatment, it can cause a disulfiram reaction with EtOH. Avoid drinking.
86
A postpartum day 2 female complains of fever (101.3) and chills. She has a tender uterus and foul-smelling lochia. What are the risk factors for this disease? And how is it treated?
She has postpartum endometritis. Risk factors are: PROM (>24hrs), prolonged labor (>12hrs), CS and IUPC/Scalp Electrode use. Treatment is broad spectrum abx (IV clinda/gent) due to often polymicrobial (aerobic/anaerobic) nature.
87
32 y/o patient presents with infertility with her husband. Hormone workup is negative and her husbands semen is appropriately fertile. Patient complains of mild chronic pelvic pain and dyspareunia. She has a 27 day cycle with 4 days of bleeding each month. What is the most likely dx and what might be found on this patients ovaries?
Endometriosis - classic symptoms are pelvic pain, infertility, heavy/painful menses, dyspareunia. Likely ovarian findings are "chocolate cysts" which are endometriomas on the ovaries with old/dried blood inside them.
88
Patient presents with a painless genital ulcer in the setting of high risk sexual behaviors. The ulcer is indurated, red, and there is no associated lymphadenopathy in the inguinal nodes. What happens if this is untreated?
The patient has granuloma inguinale (donovanosis). This is likely not syphilis due to the lack of LAD. Syphilitic lesions often resolve on their own in 1-3 months, but this ulcer will remain without antibiotic treatment (TMX-SMX or Doxycycline).
89
A patient presents with a painless ulcer and is likely to have syphilis. What test would be best to confirm this diagnosis if the ulcer is only 2 weeks old?
Primary syphilis will often be VRDL/RPR/FTA-ABS negative because they still have not made an antibody response. Dark field microscopy demonstrating spirochetes is the best early diagnostic tool.
90
A 24 y/o primigravid at 34 weeks presents with contractions. They are in her lower abdomen, are irregular in timing and intensity, and have not changed since they began 3 hours ago. Fetal NST is reactive, and cervical exam is closed/thick/high with no change during a 2 hour visit. The patient feels better with mild sedation. What is the next step?
Reassure the patient and send her home. This is false labor - often last 4-8 weeks of pregnancy. It has no increased frequency/intensity over several hours, and has not caused progressive cervical changes, and is relieved by mild sedation. True labor is often in the back and upper abdomen, and is not relieved by sedation.
91
A 16 y/o presents with a primary complaint of amenorrhea. She is average height and weight for age, has tanner 4 breasts, and minimal axillary/pubic hair. She has normal external genitalia but absent uterus, cervix, and ovaries. What is the most likely karyotype in this patient?
Absent everything (no ovaries, uterus and cervix) = Androgen insensitivity syndrome = 46, XY male without the ability to use testosterone. Absent Uterus/cervix but present ovaries suggest Transverse septum or Mullerian agenesis, both of which would have 46, XX. Turner syndrome would have normal uterus/vagina but streak ovaries.
92
A 21 year old presents at 28 weeks gestation for a routine prenatal visit. Exam shows normal sized uterus for gestational age and fetal heart tones are normal. Routine urine culture shows 10^5 CFUs of E. Coli. Should you treat this patient's asymptomatic bacteriuria?
This patient has asymptomatic bacteriuria vs. contamination. Routine urine cultures during pregnancy are done with catheterization to avoid contaminants and should be treated to avoid pyelonephritis.
93
A 25 year old at 35 weeks gestation in an uncomplicated pregnancy has numbness, burning, tingling in her right palm that wakes her up from her sleep. What is the cause of this and what is the best treatment?
This patient likely has carpal tunnel syndrome (median nerve compression neuropathy). Since this is secondary to repetitive wrist flexion/extension, this patient should be splinted and given NSAIDs.
94
What is the name for/ pattern of inheritance for Coagulation factor VIII deficiency, and how does it affect the children of the daughter of an affected male?
Hemophilia A = X-linked recessive. If the father is affected, he passes the trait to all of his female children and any affected male children. Those females have a 25% chance of a male (affected) child, 25% of a male (unaffected) child, 25% chance of a female (carrier) child, and a 25% chance of a female (non-carrier) child.
95
What recommendations do we give for pregnant women with regards to exercise? What 8 things are absolute contraindications to exercise in pregnancy?
Normal exercise is great and encouraged to prevent excessive weight gain and overall fitness. >30minutes of moderate exercise 5-7 days a week is preferred. Unsafe activities include contact sports, high fall risk sports, skuba diving, and a hot yoga. Absolute contraindications to all exercise include Amniotic fluid leakage (PROM/PPROM), Cervical incompetence, Multiple gestation, Placental abruption/previa, premature labor, preE, Gestational HTN, Severe heart/lung disease. Note that there is increased ligamental laxity that increases the likelihood of women to injuries/falls.
96
A bipolar woman, well controlled on Lithium, presents to you at 22 weeks gestation without prior knowledge of the pregnancy. She asks if her disease will lead to problems with her pregnancy. An increase in the likelihood of what defect should be counseled to the patient?
Cardiac defects: Ebstein's anomaly is still 1:1000, but still higher, and cardiac defects in general are higher. Later stage exposure can cause neuromuscular dysfunction and pointer.
97
What are the causes of early, late, and variable decelerations?
```
Early = fetal head compressions
Variable = Cord compression
Late = placental insufficiency
```
98
Obese women are known to have higher amounts of estrogen - where is this created and where is it converted?
It is made in the adrenal gland and then peripherally converted to estrogens.
99
A patient presents with vaginal pH of 6.5, and a profuse, clear, thin mucous coming from the cervix. What stage is she in her cycle?
Ovulatory phase; during this phase, the d/c is profuse, clear, and thin and is associated with a higher pH than pre- and post-ovulatory phases, which are scant, opaque and thick. This mucous will stretch to ~ 6cm and will show ferning on wet-prep.
100
What are the risk factors of adenomyosis?
Multiparity, Age >40, early monarche, short menstrual cycles, prior uterine surgery, and preterm birth. Symptoms are often CPP, dysmenorrhea and menorrhagia with a boggy, globular, soft uterus. Endometriosis often occurs before 40s.
101
A 25 y/o obese female comes in for primary infertility. She has been trying to conceive with frequent intercourse for 12 months. She has sparse hair over her upper lip and uses acne medications over the counter. She has no galactorrhea, thyromegaly, or clitoromegaly. What is the best treatment?
This patient has PCOS. She has symptoms of androgen excess and infertility. She would likely benefit from Clomiphene citrate which would induce ovulation by improving GnRH release and FSH release and thus increase ovulation. She could also benefit from some metformin to increase her chance of fertility.
102
What are the benefits/protections of breastfeeding for children?
Decreased necrotizing enterocolitis, diarrheal illness, otitis media, URIs, and UTIs. Mom's also get decreased postpartum bleeding, more rapid uterine inflation, decreased blood loss, increased child spacing, earlier return to pre-pregnancy weight, and decreased breast and ovarian cancer.
103
What are the contraindications to breast feeding?
Active, untreated TB (moms can start 2 weeks after starting therapy), Maternal HIV, Herpetic breast lesions, varicella
104
What antibiotics should/ should not be used in pregnancy for treatment of a UTI?
Should = nitrofurantoin, amoxicillin +/- clav., cephalexin. Should not = Tetracyclines, Fluoroquinolones, TMP-SMX (relatively).
105
List common side effects and risks of Combination OCPs.
Breakthrough bleeding, breast tenderness, nausea, bloating, Amenorrhea, HTN, VTE, Decreased risk of ovarian and endometrial cancer, increased risk of cervical cancer, liver disease (hepatic adenoma), increased triglycerides (estrogen).
106
What is the diagnosis of Arrest of Labor in the first stage of labor?
Dilation >6cm with ruptured membranes and either no cervical change for >4 hrs despite adequate contractions, or >6 hours despite inadequate contractions. Adequacy = >299 Montevideo units for >2 hrs.
107
A 20 year old presents with 8 hrs of intense, intermittent RLQ pain. She has a history of a 4cm right-sided benign ovarian cysts, has tenderness on exam to deep palpation in the RLQ, and to deep palpation of the right addenda. UPT is negative, pulse is 100, T = 37.2. Dx?
Adnexal torsion. Risk factors include ovarian mass (esp. >5cm), reproductive age, pregnancy, infertility treatment with ovulation induction. It presents with pelvic pain (right side more often), unilateral and tender adnexal mass, n/v, low grade fever, +/- abnormal bleeding. R/u ectopic, pelvic color doppler for dx. Treat with surgery.
108
Patient with no family history of breast cancer comes in with a 4x5x6 cm firm, moveable, rubbery mass in her left breast. Ultrasound shows cyst, and aspiration yields clear fluid and the mass disappears. Next step?
This patient has fibrocystic disease. Observe for 4-6 weeks.
109
In the setting of an abortion, what two indications exist for prophylactic antibiotics?
Septic abortion and dilation and evacuation (decrease endometritis).
110
A patient presents with vaginal bleeding at 38 weeks of gestation. She has hypotension, tachycardia, fetal heart decelerations and fetal parts can be palpated on abdominal exam. Dx? Risk factors?
Uterine rupture. Risk factors = prior uterine surgery, induction of labor/ prolonged labor, congenital uterine anomalies, and fetal macrosomia.
111
What are the criteria for Genito-pelvic pain/penetration disorder?
At least 6 months, causing significant distress, not accounted for by other medical, mental, substance use, or relationship issues, and ongoing difficulties with at least 1 of : Vaginal penetration during intercourse, vaginal/pelvic pain during intercourse (or fear/anxiety about pain in anticipation thereof), and tenseness of pelvic floor muscles during attempted vaginal penetration.
112
Patient with urethral hyper mobility. What angle classifies as hyper mobility? What are the treatment options?
Anything greater than 30 degrees. Treatment = Kegel Exercises and Urethropexy.
113
33 y/o pregnant patient with Headaches, blurry vision, and epigastric pain presents after a tonic-clonic seizure. How do we manage her recurrent seizures, stroke, etc.
Stroke = labetalol/hydralazine.
Seizures = MgSO4
Prevent hypoxia/trauma to mom, evaluate for delivery with induction of labor.
114
Patient comes to the doctor complaining of > 1 week of mood swings, irritability, fatigue, bloating, breast tenderness, and decreased libido; diagnosis, and treatment?
This is PMS; bloating, fatigue, headaches, breast tenderness, anxiety, mood swings, difficulty concentrating, decreased libido, and irritability. Treatment should start with a menstrual diary to help understand severity and things that make symptoms worse. Caffeine is often a trigger.
115
If a patient has HELLP syndrome, what is the likely cause of RUQ pain?
Dissension of the hepatic capsule (Glisson's).
116
A patient begins to have shortness of breath with severe pre-eclampsia; what is the pathophysiology?
Pre-eclamptics have generalized arterial vasospasm, increased SVR, high cardiac after load, decreased renal function, decreased albumin, and increased capillary permeability.. Diuresis and fluid restriction should be started.
117
What is the timeframe of glucose testing in pregnancy?
24-28 weeks gestation, 1hr GTT (>140 = abnormal), then 3Hr GTT abnormal for 2+ values.
118
Classic SLE symptoms with 2 prior spontaneous abortions. Dx?
Lupus anticoagulant/ APA syndrome.
119
Painless vaginal bleeding directly following SROM on the L&D deck. Patient has no sensation, baby was tachycardic of a few minutes followed by bradycardia. Dx?
Vasa Previa - this will likely turn into a sinusoidal pattern, and 75% lead to exsanguination of the fetus.
120
A mother is 12 weeks postpartum and has still not had a menstrual cycle. She has a healthy three month old who is at home, breastfed, and doing well. What is the accuse of her lack of menses?
GnRH is inhibited by PRL due to breastfeeding. This is not reliable contraception; 50% of nursing mothers ovulate in the first 6-12 months.
121
A patient comes in for her first prenatal visit after a self-diagnosed positive pregnancy test several weeks prior. The patient strongly desires pregnancy, and is excited for the baby. She has a normal ultrasound with a normal endometrial stripe and a negative UPT. What is the likely diagnosis?
This is likely not a real pregnancy but a Pseudocyesis ( form of conversion disorder). She should see psych.
122
How do we suppress location in a patient who had an IUFD and needs to suppress her milk production?
Tight-fitting bra, avoid nipple stimulus, give analgesics for pain. Ice packs can be applied to breasts.
123
What are the risk factors for lactational mastitis?
Past History, Engorgement and inadequate milk drainage, sudden increased sleep, replaced nursing with formula/pumping, weaning, pressure on the duct, cracked or clogged nipple pore, and poor latch. Treat with breastfeeding/pumping and abx (dicloxacillin or cephalexin).
124
A patient with a history of ambiguous external genitalia at birth comes in with primary amenorrhea and sexual infantilism. She has known normal internal genitalia and karyotype, and upon serum testing has high testosterone, androstendeione, FSH and LH. What is the most likely diagnosis?
Aromatase deficiency. It is a rare enzyme deficiency, causes virilization due to increased male steroids.
125
Patient comes in with precocious puberty but delayed menarche, polyostotic fibrous dysplasia, and cafe-au-lait spots. Dx?
McCune-Albright syndrome.
126
The patient is obese, she has normal LH and FSH. She has been having irregular periods. Cause?
Anovulation,
127
HELLP = complication of pre-E. What is the cause of the condition?
Systemic Inflammation and platelet consumption. Half of HELLP Patients lead to DIC. Microangiopathic hemolytic anemia (MAHA) results. Treatment is delivery (>34wks), MgSO4, control HTN. Prior to 34wks use betamethasone.
128
Uterine Leiomyomas can be diagnosed with ? and treated with?
Ultrasound. Treat with contraception, embolization, and surgery.
129
A patient is taking Raloxifine. What are contraindications for this?
DVT history. It can help prevent osteoporosis, but it caries an increased risk of clotting. Tamoxifen is a different SERM which increases risk for endometrial hyperplasia, but not raloxifine.
130
A patient is diagnosed with breast cancer that is Her2 positive. You decide to give Trastuzumab. What should you check first?
Check cardiac function (Echo). If
131
A patient comes in with classic Premature Ovarian Failure. Should the LH/FSH be increased or decreased, and what should the FSH/LH ratio be?
Increased FSH and LH; overall FSH/LH >1.0.
| POF =
132
A nulliparous woman of 29 years comes in with ectopic endometrial tissue in her pelvis leading to chronic pain. What is the most definitive diagnostic test and what should treatment be?
Endometriosis - laparoscopy is the diagnosis, treatment is surgery (during lap) to remove or ablate ectopic tissue, as well as NSAIDs and hormonal contraceptives.
133
A patient on OCPs has high blood pressures on >2 separate occasions. What is the recommended management?
Stop OCPs; this is likely a patient who responds poorly and another method should be used. Without a family history of secondary etiology, no further workup is necessary.
134
A 37 y/o female G2P1 comes in for her routine prenatal visit after her quad screen. It showed Decreased AFP, increased B-hCG, Decreased Estriol, and Increased Inhibin A. Dx?
Chromosome 21 meiotic nondisjunction; i.e. Down Syndrome. Consider AMA. Quad test performed during 15-20 weeks. False Positive is ~5%. CffDNA should be offered (99% sens/spec), and a U/S for anomalies.
135
If there are differences in MSAFP, but a normal Inhibin A on Quad screen, what is the differential, and how can you tell them apart?
Normal Inhibin A with abnormal MSAFP = Trisomy 18 or NTD. 18 has low MSAFP like Tri21; NTDs have high MSAFP.
136
What are the side-effects for baby of Phenytoin use in pregnancy?
Craniofacial anomalies, fingernail hypoplasia, growth deficiency, developmental delay, cardiac defects, and clefts.
137
Patient with PPROM presents with an L/S ratio of 1.7. What is gestational age range is this patient, what medication is necessary, and what is the GA necessary to warrant that treatment?
L/S give Betamethasone. Patient can't be 34 weeks or more because then she would have PROM, not PPROM.
138
What is a normal Amniotic Fluid Index for pregnancy?
AFI >5,
139
G3P2 female with h/o cocaine abuse during pregnancy presents with contractions every 5-6 mins, after SROM 10 hours earlier. She is 3cm dilated, 80% effaced, and has pooling of clear "ferning" fluid in her vagina. Fetal Monitoring reveals repetitive late decelerations. What is the next step?
Emergent Cesarean Section due to Non-reassuring Fetal Heart Tones (NRFHT). Increased suspicion of inability to tolerate labor are drug use and SGA status of baby.
140
A patient with routine NAAT testing for GC/Cl come back negative for GC, positive for Cl. How do you treat?
Sensitivity for GC = 98-100%
Sensitivity for Cl = 92%, Specificity 99%.
If only Cl is positive, only treat for Cl (Azithromycin, 1000mg or 7 days Doxycycline). If only GC positive, treat for both (previous treatment plus Ceftriaxone). If a less reliable test is used and either is positive, treat for both.
141
A patient with a history of a rash in her first weeks of pregnancy comes in with her 3 day old with cloudy lenses and a PDA. The baby was SGA and failed her hearing screen. Dx?
Rubella (German Measles):
Sensorineural hearing oss, intellectual disability, cardiac anomalies (PDA), cataracts/glaucoma in infancy. Diagnose with PCR, prevent with vaccine, treat with supportive care.
142
What are the risk factors for spontaneous abortion?
Previous SAB, maternal smoking, AMA; these predispose to structural/chromosomal abnormalities.
143
A patient at 16 weeks with no reported symptoms has >100k colonies on routine clean catch urine. What is the diagnosis/treatment?
Asymptomatic bacteriuria of pregnancy - treat with nitrofurantoin for 7days, amox or amox-clav for 3-7 days, Fosfomycin as single dose. Screening done at 12-16 weeks normally. If symptoms, diagnosis cystitis.
144
What are the four main risks of Combined OCPs? What pills are contraindicated for >35 year old smokers?
VTE, HTN, Hepatic Adenoma, stroke/MI (very rare). Anything with estrogen is bad for smokers >35yrs. OCPs reduce endometrial and ovarian cancer.
145
What are the indications for GBS prophylaxis with penicillin? (four)
Prior birth with early-onset GBS disease.
GBS bactieriuria any time during pregnancy.
GBS positive within 5 weeks of labor.
Unknown GBS and either 18hrs. Penicillin should be given at least 4 hours before delivery for full effect.
146
What are the normal changes to Free and Total T4 and TSH during pregnancy?
Increased Total T4 x1.5, Increased Free T4, and decreased TSH. B-hCg stimulates thyroid hormone production, increased TBG binds extra T4, increasing total and free T4, and High T4 leads to low TSH.
147
Are Combined OCPs allowed after pregnancy for Birth Control?
Generally no - they decrease milk production and pass on to baby; not fully studied, so generally avoided.
148
What are the PID regimens?
Cefoxitin or Cefotetan PLUS Doxycycline PLUS Metronidazole.
Clindamycin PLUS gentamicin PLUS Metronidazole.
Don't give IV Doxy - it gives very bad local site reactions.
149
An ABG comes back with a PaCO2 of 56, an HCO3 of 44 and a pH of 7.49. Patient is 12 weeks pregnant. Likely diagnosis?
Hyperemesis Gravidarum. Volume depletion leads to loss of gastric acid and activation of RAAS. This patient has a metabolic alkalosis (high pH, high HCO3) with a respiratory acidosis attempting to compensate (high PaCO2). Expected PaCO2 is (0.9 x Bicarb) +16 +/-2. That makes this patient fully compensated (53-57). If this patient was acidotic, we could use winters formula (1.5x Bicarb +8 +/-2).
150
A patient comes in 2 months after her recent delivery without any menstrual periods. She has lethargy, weight gain, fatigue, decreased pubic hair, dry skin, and delayed DTRs. If this patient had a history of uterine atony, what is the cause of this patient's condition?
This patient has Sheehan's syndrome caused by ischemic necrosis of the pituitary. Uterine atony often causes postpartum hemorrhage, which can lead to severe blood loss and ischemic necrosis of watershed areas.
151
What is the role of hCG in pregnancy?
Maintaining the corpus luteum; it is secreted by syncytiotrophoblasts and maintains high levels of progesterone until the placenta can take over. Progesterone, then, prepares the endometrium for implantation.
152
How do we manage a threatened abortion?
Expectant management until one of the following:
| Symptom resolution, or progression to inevitable, incomplete, or missed ab.
153
How do we manage an inevitable, incomplete, or missed ab?
Hemodynamically stable, mild bleeding: expectant management, Prostoglandins, surgical.
Hemodynamically unstable, heavy bleeding: D+C (suction)
154
How do we manage a septic ab?
Blood and endometrial cultures, broad-spectrum antibiotics, and surgical evacuation of uterine contents.
155
A patient has an ultrasound-proven IUFD at 25 weeks. What is the workup?
Serum fibrinogen, platelets, PT, PTT. Fibrinogen is normally high in pregnancy, so low normal is abnormal and a sign of coagulation abnormalities and developing DIC. Patients with low fibrinogen should go to labor induction immediately, while those with normal values can be managed expectantly.
156
After a 39 week gestation fetus is delivered from a 25 year old G4P4 mother with blood type O-, blood is drawn from the maternal circulation and set on a slide. The slide is acidified and bright pink cells remain with some "ghost" cells. What are each type of cells, what is the name of this test, and what does it tell us?
This is the Kleihauer-Betke test; the acid destroys maternal RBCs (ghost cells) and leaves fetal RBCs behind. This helps determine the necessary amount of Rhogam to give to the mom after delivery. ~50% of Rh-neg women will need a higher dose than the standard 300ug dose at 28 weeks, especially those that have placental abruption or a procedure. Patients who alloimmunize should be suspicious for an insufficient dose.
157
A patient comes in with small teardrop-shaped growths on the vulva that resolve with application of trichloroacetic acid. Dx?
HPV; these are condyloma acuminata.
158
A patient with new onset abdominal pain after intercourse presents with an abdominal ultrasound showing a 4x5 mm cystic structure with free fluid on the left adnexa. What is the most likely diagnosis?
Ovarian Cyst rupture; it often occurs after strenuous or sexual activity.
159
What is the cause of low back pain in the 3rd trimester of pregnancy?
Increased lumbar lordosis and relaxation of the ligaments of the lower spine.
160
A patient presents with a brief episode of syncope this morning and associated nausea and lower abdominal pain. She has a history of of an abnormal pap and colposcopy 3 years ago, normal vitals except for a pulse of 125, and significant lower abdominal and cervical motion tenderness on exam. She also has diffuse uterine and adnexal tenderness. What is most likely causing her pain if she has not had a menstrual period for 6 weeks?
Ruptured ectopic. Risk factors include previous ectopic, previous pelvic/tubal surgery, in utero DES, infertility treatment, current IUD, PID, and multiple sexual partners.
161
A 25 year old 10 week pregnant female comes to clinic complaining of vaginal inflammation and thick d/c. She is diagnosed with Candidiasis. What first line drug is relatively contraindicated in this patient?
Oral fluconazole. This treatment is the first line normally, but is category C in pregnancy at the level necessary for treatment (150mg). In higher doses, it is category D, making this a risky decision, and vaginal treatment is better in this group.
162
A patient comes in with fetal heart tracing with 5 contractions in 20 minutes, 3 variable decelerations, no accels, and moderate variability. What do we do?
Reposition the patient to relieve cord clamping. Greater than 50% of contractions having a variable deceleration is worrisome and administering oxygen as well as maternal position changes should be used.
163
What is the workup for a palpable breast mass?
30, mammogram then u/s, core biopsy if suspicious for malignancy.
164
What are the indications for GBS prophylaxis with an unknown GBS status?
Delivery 18hrs, GBS bacteriuria in any concentration during pregnancy, prior history of delivery of an infant with GBS Sepsis.
165
A 45 year old comes in with classic symptoms of menopause. What do you do?
Check TSH and FSH levels.
166
What are the risk factors for placental abruption?
Maternal HTN, Pre-E, Eclampsia, Abdominal Trauma, prior abruption, Cocaine/Tobacco use.
167
How do we treat someone with sudden-onset vaginal bleeding at 36 weeks gestation associated with high frequency, low intensity contractions and abdominal pain?
If unstable/ non-reassuring NST, emergency Cesarean. If stable and >34weeks (w/o previa), trial of vaginal delivery.
168
A patient has urinary leakage hours after a spontaneous vaginal delivery without complications. What type of incontinence is most likely, and how would you treat it.
Overflow incontinence. Treat with 24 hours of catheterization in order to allow bladder decompression/rest.
169
Painful menses and crampy mid lower abdominal pain associated with stopping OCPs. PE is negative. dx?
Primary dysmenorrhea. Treatment is OCPS and NSAIDs.
170
What is the most effective treatment for decreasing transmission of HIV from mother to fetus?
Good 3 drug HAART therapy. If the mother has >1,000 viral load, then do cesarean, otherwise vaginal delivery.
171
A baby presents wit loss of grasp reflex on the right associated with an extended wrist, hyperextended MCPs, flexed IPs, left sided drooping, and intact Moro and biceps reflexes. Dx?
Klumpke Palsey from shoulder dystocia. This is a damage to the C8 and T1 nerve roots and is associated with a Horners syndrome (ptosis/miosis). Risk factors include LGA, maternal diabetes, maternal obesity.
172
Decreased Moro and biceps reflexes on a baby with an extended elbow, pronated forearm, and flexed wrist and fingers with an intact grasp reflex is diagnostic of?
Erb-Duchenne Palsy: CN 5-6.
173
What are the causes of fetal growth restriction in the first or second trimester that affects the baby's head and body size?
Symmetric (Fetal) factors: Genetic disorder, congenital heart disease, intrauterine infection.
174
What are the causes of fetal growth restriction that spares the head (i.e. body-only growth restriction)?
Head is specifically spared at the expense of the other organs. Asymmetric (Maternal) factors: Vascular disease (HTN, DM, Pre-E), APA syndrome, SLE, Cyanotic heart disease, substance abuse.
175
What are the causes of an increased MSAFP?
Open NTDs, Ventral wall defects, multiple gestation.
176
What is a normal NST? What is the normal follow up for a third trimester pregnancy requiring antenatal surveillance?
> 2 accels/ 20 mins is considered normal. It has a high NPV; and is good for 1 week, correlating to a low risk of fetal death.
177
A patient comes in with vaginal dryness, pruritus, dysuria, and urinary frequency. She has dry, pale, smooth vaginal epithelium and scarce pubic hair. She is post-menopausal. Treatment?
Atrophic Vaginitis is treated with estrogen cream.
178
A patient with an unknown history comes in and delivers. A SGA newborn boy has microcephaly, hypoplasia of the distal phalanges, excess hair, and a cleft palate. What is the most likely cause?
Phenytoin/ Carbemazepine use in pregnancy.
179
A patient with an IUP with bilateral renal agenesis is currently 4 cm dilated, 80% effaced at 28 weeks. What is then next step in management?
SVD; let is happen. The baby has an anomaly incompatible with life.
180
What are the earliest points that you can see a TVUS and an abdominal US based upon B-hCG.
TVUS: 1500. Abdominal ~5000, officially as high as 6500.
181
What are the maternal and fetal complications associated with late-term and post-term pregnancy complications?
Fetal: Oligohydramnios, meconium aspiration, stillbirth, Macrosomia, convulsions. Maternal: C/s, Infection, Postpartum hemorrhage, perineal trauma.
182
Patient at 18 weeks gestation begins to have symptoms of hyperandrogenism including hirsutism and acne. What are the causes and what is the management?
Luteoma and Theca luteum cysts are the most common reasons for maternal hyperandrogenism. Both show ovarian masses, though luteoma has solid masses, TLCs has cysts.
183
What are the definitions of infertility for a woman before and after 35 years?
>1 year of attempting 6 months attempting >35 years. 1/5 women 35-39 is no longer fertile; FSH and clomiphene challenge can diagnose decreased ovarian reserve.
184
If dietary restrictions in a woman with gestational diabetes fail, what is the next step. What constitutes failing?
GDM fail is >95 fasting, >140 for 1 hr postprandial, >120 for 2 hour postprandial. First line is Dietary, second line is insulin/ metformin/ glyburide.
185
What are the consequences of maternal hyperglycemia in the first, second, and third trimesters?
First = congenital anomalies (Congenital heart disease, NTDs, small left colon), and spontaneous Ab. 2/3: Polycythemia, organomegaly, birth injuries, and hypoglycemia as a neonate. Hypocalcemia is also a common complication due to PTH suppression.
186
A patient with multiple small, grouped ulcers with an erythematous base, shallow, tender LNs. What is the most likely dx?
HSV.
187
An athlete has amenorrhea. What is the cause?
Low LH leads to low GnRH, leading to Estrogen deficiency.
188
What is the definition of and risk factors for fetal macrosomia?
Weight >4kg. Maternal risks include AMA, DM, excessive weight gain or pre-existing obesity, multiparty. Fetal risks include African American/Hispanic race, Male baby, post-term.
189
A 35 y/o female comes in with an upper outer quadrant breast mass on palpation. It is fixed, and causing slight retraction of the nipple. Mammogram shows a 3x3cm speculated mass with coarse calcifications. US shows a hypo echoic mass, and biopsy shows foamy macrophages and fat globules. Dx?
This is fat necrosis. Differences from cancer? Cancer has micro calcifications vs coarse calcification. The pathology of fat globules and foamy histiocytes is diagnostic of fat necrosis. This will resolve with time.
190
A 76 y/o female has severe vulvar itching not relieved by OTC meds. Vulvar skin is thin, dry, and white. What is the next step, and what does she have?
In postmenopausal women with porcelain-white atrophy and anogenital pruritus, dyspareunia, dysuria, and painful defecation, considered Lichen Sclerosus et Atrophicus. A punch biopsy will confirm; increased risk of squamous cell carcinoma. Treat with steroids.
191
What is the normal constellation of lochia postpartum and when should you suspect endometritis?
Early, blood vaginal discharge is normal; lochia rubra. Next, lochia serosa occurs, which often appears as a pale d/c after 3-4 days. Finally, it becomes white or yellow and is called lochia alba. Endometritis should be suspected in high fever (low fever/ chills P/p is normal) and foul-smelling d/c.
192
Define stillbirth and give risk factors.
Fetal death at >20 weeks gestation. Risk factors are HTN, DM, smoking >10 cigs/day, AMA. Occurs in ~1/160 pregnancies. Treatment is delivery.
193
What are the risk factors for neonatal HSV and what is the treatment?
Risks: Primary maternal infection, longer ROM duratino, vaginal delivery with active lesions, impaired fetal skin barrier (fetal scalp electrode), preterm birth. Patients should be offered cesarean delivery if active lesions exist.
194
What is the cause of stress urinary incontinence/ what are non-surgical treatments?
Pelvic Floor muscle weakness, cystocele, uterine prolapse. Treatment is Kegel exercises, pessaries, and estrogen replacement.
195
A patient has nipple discharge and you want to know how to tell if it is malignant or physiologic. What do you need to know?
Unilateral = malignant, bilateral points towards physiological. Bloody/ serous d/c points towards malignant, milky/non-bloody towards physiologic. Palpable lump/skin change points toward malignant. Guiac positive points towards malignant. Contact surgery for likely malignant for a biopsy; test for Pregnancy, TSH, PRL, +/- Pituitary MRI if physiologic.
196
How does pregnancy affect levothyroxine/T3/T4 levels?
More Levo is likely necessary. T3/T4 usually need to increase to match higher levels of thyroid binding globulin.
197
A patient has an invasive ductal carcinoma that is resected. What do you want to know from pathology?
Oncogene amplification by FISH; does this have a Her2 mutation?
198
A mother is in preterm labor with heavy, frequent contractions at 30 weeks. She has no fetal indications for delivery and is 3cm dilated. What should you do?
MgSO4 for neuroprotection
199
If a patient comes in for decreased fetal movement, what is the next step?
NST.
200
A patient comes in for an infertility consult after 12 months of infertility with good effort. She has excessive chin and lower abdominal hair and states that she has had it for a long time. What is the most likely cause of her infertility?
Hyperandrogenism secondary to PCOS. She is likely not ovulating.
201
A patient with a category II NST presents with an episode of painless vaginal bleeding. What should be your next step?
u/s for placenta previa. This is your most dangerous diagnosis, as digital exam is contraindicated in that setting. Ddx includes vasa previa, though this is more rare and is associated with a worse NST.
