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401 Cards in this Set

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At what week gestation does B-HCG peak?
At 10 weeks - peaks at 100,000 mIU/mL
At what week gestation does an embryo start being called a fetus?
8 weeks gestation
How early might you start seeing fetal heart beats on US?
6 weeks
At what week gestational age might you first see the gestational sac in the uterus?
5 weeks
What is the Chadwick sign?
Bluish discoloration of the vagina and cervix indicating pregnancy
What is the difference between "Gestational age" and "Developmental age?"
Gestational age is the weeks since the LMP
Developmental age is the weeks since conception (usually two weeks less than GA)
At what week of gestation does the mother begin to be aware of fetal movements?
16-20 weeks
How much does plasma volume increase during pregnancy?
By 50%.
RBC volume increases by 20-30%, so hematocrit decreases
Which hormone affects smooth muscle in pregnancy and is responsible for many of the physiologic changes seen?
Progesterone causes smooth muscle relaxation
How much does the daily caloric intake requirement increase during pregnancy?
By 300kCal/day
If a patient begins to gain an unusually large amount of weight late in pregnancy, what pathology should you consider?
Pre-eclampsia - it could be a sign of fluid retention
Which three chemicals are assayed in the standard triple test for Down syndrome?
Alpha feto protein
B-HCG
estriol
At what week is AFP usually screened to check for Down syndrome?
15-18 weeks
At what week of pregnancy are women screened for Group B Streptococcal infection?
36 weeks
What is the treatment for women who test positive for GBS late in pregnancy?
IV penicillin
Name the common, benign cause of lower abdominal pain that often occurs late in the second trimester of pregnancy?
Round ligament pain - secondary to the rapid expansion of the uterus and stretching of the ligamentous attachments
What are the five components of the Biophysical Profile?
Amniotic fluid volume
Fetal tone
Fetal activity
Fetal breathing movements
NST
Which chemical is seen in higher concentrations in the amniotic fluid when the lung matures?
Lecithin increases as the lungs mature, while sphingomyelin decreases beyond about 32 weeks
What is a heterotropic pregnancy?
When there is an intrauterine and an extrauterine pregnancy simultaneously
詫び
/(n) apology/(P)/
[わび]
What is the treatment of choice for an unruptured ectopic pregnancy?
Methotrexate
What is the name for the death of an embryo or fetus before 20 weeks with complete retention of the POC?
Missed abortion
What is the most common cause of first trimester abortions?
Fetal chromosomal abnormalities
What are the most common causes (4) of second-trimester abortions?
Uterine or cervical abnormalties
Trauma
Systemic disease
Infection
What is the definition of recurrent/habitual abortions?
Three or more consecutive spontaneous abortions
What additional analyte is sometimes added to the triple test to make the "quad screen?"
Inhibin A
How many days after fertilization does the blastocyst typically implant into the endometrium?
7 days
In which weeks of development does organogenesis take place?
Weeks 3-8
What level of sensitivity does the triple-test have?
Only 60%
but 80% over the age of 35
With a Down syndrome fetus, which of the analytes in the triple test are elevated and which are decreased?
MSAFP - decreased
estriol - decreased
BHCG - increased
What percentage of amniocenteses have complications?
0.5%
Complications include ROM, premature labor, fetal injury
At which week gestation can CVS be performed?
9 weeks (six weeks earlier than amniocentesis)
What problems are associated with performing CVS before 9 weeks?
Limb abnormalities
What is fetal lie (what are the options/classifications)?
Either longitudinal or transverse in the uterus
What is fetal presentation (what are the options/classifications)?
Either breech or cephalic
What does the P in PROM stand for? What is the definition?
Premature Rupture of Membranes
Rupture 18 hours before labor
What do the P and P in PPROM stand for? What is the clinical definition?
Preterm Premature Rupture of Membranes
ROM before 37 weeks
How can leaks of amniotic fluid be differentiated from stress incontinence?
Nitrazine or fern tests of the fluid
How does the nitrazine test for amniotic fluid work?
Tests the pH of the vaginal fluid
Amniotic fluid is alkaline, while normal vaginal secretions are usually acidic
What are the five aspects of the Bishop score?
Cervical dilation
Cervical effacement
Fetal station
Cervical position
Cervical consistency
What does a high Bishop score indicate?
That the cervix is favorable for labor (either spontaneous or induced)
How is the station of the fetal head assessed?
The relation of the fetal head to the ischial spines. Positive is past the spines, negative is above the spines
How does the cervical position change throughout labor?
Advances its position from posterior to mid to anterior as labor progresses
What is the definition of Prodromal Labor or "false labor?"
Irregular contractions that vary in duration, intensity and intervals that yield little or no cervical change
Name five common indications for inducing labor?
Postterm pregnancy
Preeclampsia
Premature ROM
Nonreassuring fetal testing
IUGR
What is the normal range for the fetal heart rate?
110-160 bpm
What conditions are considered if the fetus has tachycardia >160?
Fetal distress secondary to
Infection
Hypoxia
Anemia
What is the definition of a formally reactive fetal heart tracing?
20 minute monitor
At least 2 accelerations of at least 15 beats per minute over the baseline that last at least 15 seconds
What causes early decelerations on the tocometer?
Increased vagal tone secondary to head compression during a contraction
What causes variable decelerations?
A result of umbilical cord compression
What causes late decelerations on a tocometer?
Uteroplacental insufficiency
What are the most worrisome - early, late, or variable decelerations?
Late decelerations - caused by uteroplacental insufficiency
The pH of fetal blood is nonreassuring if it is below what level?
<7.2
If you put a pulse oximeter on a fetus, what is a normal reading?
30%
What are the five cardinal movements of labor?
Engagement
Flexion
Internal rotation
Extension
External rotation
What marks the beginning and end of the second stage of labor?
Begins at full dilation of the cervix and ends at delivery of the infant
How long does the first stage of labor last?
10-12 hours in nulliparous woman
6-8 hours in a multiparous woman
What are signs of nonreassuring fetal status on a fetal heart monitor?
Repetitive late decelerations
Bradycardia
Loss of variability
What conditions are necessary for safe application of forceps during delivery?
Full dilation of cervix
Ruptured membranes
Head at at least +2 station
Experienced operator
What is the normal interval between the delivery of the infant and the placenta?
Usually 5-10 minutes
But up to 30 minutes is within normal limits
What is the current rate of cesarean delivery in the US (2007)?
29%
What is the risk of uterine rupture during TOLAC (trial of labor after cesarean)?
0.5-1%
In what percent of pregnancies does placenta previa occur?
0.5%
What are the associated sequelae of placenta previa?
Antepartum hemorrhage
Preterm delivery
PPROM
IUGR
Increased risk of puerperal hysterectomy
What is the classic presentation of placenta previa?
Painless third trimester bleeding
What is the most common factor associated with increased incidence of placental abruption?
Hypertension
What is the vascular volume of a term fetus?
About 250mL
What is the Apt test?
Examination of materanal blood for nucleated (fetal) red blood cells
What is a succenturiate placenta?
An accessory lobe of the placenta
What is the definition of low birth weight?
<2500g
What is the only medication approved by the FDA for tocolysis?
Ritrodine - a beta mimetic agent
How does good hydration decrease the number of contractions in preterm labor?
It decreases ADH which cross reacts with oxytocin receptors
What antibiotic(s) are used in the setting of PPROM?
Ampicillin with or without erythromycin
What is the "obstetric conjugate?"
The distance between the sacral promontory and the midpoint of the symphysis pubis - the shortest anteroposterior diameter of the pelvic inlet
What percentage of singleton deliveries present breech at delivery?
3-4%
How should a fetus with a shoulder presentation be managed?
Cesarean section
What is the antiseizure medication of choice in pregnancy?
Magnesium sulfate
What malignancies are LGA infants at a higher risk for?
Leukemia, Wilms tumor, osteosarcoma
Should obese patients be counselled to lose weight during pregnancy?
They shouldn't lose weight during pregnancy - but should gain less weight than other women
What is the normal maximum volume of amniotic fluid during pregnancy?
800 mL at ~28 weeks
500 mL at term
What are the common causes of polyhydramnios?
Maternal diabetes
Neural tube defects
Obstruction of alimentary canal
Hydrops
Which is a more ominous sign - polyhydramnios or oligohydramnios?
Oligohydramnios - umbilical cord often gets compressed leading to fetal asphyxia
What are the risks/complications for the fetus in a uterus with polyhydramnios?
Risk for malpresentation
Risk of cord prolapse
At what times in pregnancy should an Rh negative mother recieve RhoGAM when she has an Rh positive fetus?
At week 28 and postpartum
What is a good non-invasive test for fetal anemia?
Doppler measurement of blood flow in the middle cerebral artery
What are the dangers for the fetus of postterm pregnancies?
Increased risk of fetal demise
Macrosomia
Meconium aspiration
Oligohydramnios
What is the average gestational age for delivery of twins?
36-37 weeks
Which type of twins have the highest mortality rate?
-Monochorionic, diamniotic
-Monochorionic, monoamniotic
-Dichorionic, diamniotic
Monochorionic, monoamniotic due to cord accidents from entanglements
Which type of twins are at risk for Twin-to-twin transfusion syndrome?
-Monochorionic, diamniotic
-Monochorionic, monoamniotic
-Dichorionic, diamniotic
Monochorionic, diamnionic twins
What are the treatment options for Twin-to-twin transfusion syndrome?
Serial amniocenteses
Laser coagulation of vascular connections between the fetuses
Blood pressure typically decreases during pregnancy until which point?
About the middle of the second trimester
Is preeclampsia more common in primiparous or multiparous women?
Primiparous - 8x more common
What does HELLP syndrome stand for?
Hemolysis
Elevated Liver enzymes
Low Platelets
What are the typical medical treatments indicated in severe preeclampsia?
Magnesium sulfate for seizure prophylaxis
and Hydalazine for HTN
What is the recurrence rate for preeclamspia in subsequent pregnancies?
25-33%
What is the treatment for overdose with Magnesium sulfate during pregnancy?
10mL of calcium chloride or calcium gluconate
In eclamptic patients, do seizures typically occur before, during or after delivery?
25% before
50% during labor
25% after
What percentage of patients with chronic hypertension will develop superimposed preeclampsia during pregnancy?
33% or more
In which trimester is the onset of carbohydrate metabolism abnormalities in gestational diabetes most common?
Usually they do not occur until the third trimeseter
What blood glucose level qualifies as a positive glucose challenge test?
140mg/dL after 1 hour following a 50g dose of glucose
What are the cutoff blood glucose levels during the glucose tolerance test at
1 hour?
2 hours?
3 hours?
1 - 180mg/dL
2 - 155mg/dL
3 - 140mg/dL
What are the common signs of chorioamnionitis?
Maternal fever and high WBC
Uterine tenderness
Fetal tachycardia
How is chorioamnionitis treated?
Antibiotics and DELIVERY
Without treatment, what percentage of infants who are born to HIV infected mothers are born with infection?
About 25%
What is required to diagnose hyperemesis gravidarum in a pregnant woman?
Vomiting that leads to dehydration and possibly electrolyte disturbances
Does elevated estrogen increase or decrease the likelihood of developing seizures? What about progesterone?
Estrogen - increases seizures
Progesterone - decreases seizures
What is the drug of choice to control seizures for epileptic patients who become pregnant?
Phenytoin
Mg sulfate is good for seizures due to preeclampsia, but phenytoin is usually use for patients with known seizure disorder
Single drug treatment is optimal
What is the characteristic morphologic change to the heart in a patient with Peripartum Cardiomyopathy (PPCM)?
A dialated heart with an ejection fraction far below normal in the 20-40% range
What is the presentation of superficial vein thrombosis in pregnancy?
Painful, palpable venous cord with local erythema and edema
When Anticoagulant therapy is given what activities should be avoided
Shave With An Electric Razor instead of a disposable.

Use a Toothbrush With Soft Bristles

Any activities that could cause injuries
What is the treatment for DVT during pregnancy?
Heparin
Do SLE symptoms tend to get better or worse in pregnancy?
One-third rule:
1/3 get better
1/3 get worse
1/3 stay the same
What lab test helps to differentiate a lupus flare-up from preeclampsia?
There will be reduced C3 and C4 levels in a lupus flare-up
What is the treatment for alcohol withdrawal during pregnancy?
Barbituates, because benzodiazepines have a potential teratogenic effect
What are the major risk factors for the fetus if the mother smokes during pregnancy?
Spontaneous abortion
Preterm birth
Abruption
Decreased birth weight
SIDS
Respiratory illness in childhood
What is the definition of the puerperium?
The first six weeks after delivery
What are the top causes of postpartum bleeding?
Uterine atony (#1)
Retained POCs
Placenta accreta
Cervical/vaginal lacerations
What puts a woman at higher risk for uterine atony after birth?
Multiple gestations
Chorioamnionitis
Mg sulfate
Multiparity
Macrosomia
At what point in pregnancy is endomyometritis most likely to occur?
5-10 days after delivery
What treatment is commonly given for mastitis?
Dicloxacillin
Breast feeding can continue
How do you diagnose congenital adrenal hyperplasia?
Elevated 17-a-hydroxyprogesterone or urine 17-ketosteroid with decreased serum cortisol
How is imperforate hymen commonly diagnosed?
It is often diagnosed at puberty with primary amenorrhea in the setting of cyclic pelvic pain.
What is a synonym for testicular feminization?
Androgen insensitivity syndrome
What vaginal pathology presents in postmenopausal women with thin, white atrophic epithelium and labial fusion?
Lichen sclerosis
Where (on a clock face) on the vagina are Bartholin cysts and abscesses found?
4 o'clock and 8 o'clock
What is the surgical procedure used as treatment for Bartholin cysts and abscesses?
Marsupialization - the entire abscess or cyst is incised and the resulting space is sewn open. Epithelialization can then occur.
What is the name for cysts found on the cervix that are caused by blockage of an endocervical glands?
Nabothian cysts (or retention cysts)
How do fibroids behave during pregnancy?
They can grow quickly and to huge proportions due to estrogen sensitivity.
Is smoking a risk factor for fibroids?
No, smoking is protective.
Smoking suppresses estrogen and fibroids grow in response to estrogens.
Do fibroids appear darker or lighter than myometrium on US?
Fibroids are areas of hypoechogenicity - lighter than myometrium
What is the best medication to treat endometrial hyperplasia?
Progestin therapy
What abnormal lab value accompanies ovarian theca lutein cysts?
Beta HCG
What are the two most common sites for endometriosis?
Ovary and pelvic peritoneum
What percentage of women with infertility have endometriosis?
40%
What are medical treatment options for endometriosis?
NSAIDs
Oral contraceptives
Danazol
GnRH agonists
What are the common side effects of danazol?
Androgenic side effects -
Acne
Oily skin
Weight gain
Hirsutism
Where in the uterus is adenomyosis most commonly found?
Fundus and posterior wall
How is adenomyosis diagnosed?
It's a clinical diagnosis - menorrhagia and/or dysmenorrhea in parous women
Imaging studies are not useful/cost effective
What is the treatment of adenomyosis?
NSAIDs
OCPs
Progestins
What is the lifetime incidence of adenomyosis? (and in what age group does it most commonly occur)
15% of women
Usually in late 30's early 40's in parous women
What is the cause of malaise, fever, pharyngitis and/or rash after treatment for syphilis?
Jarisch-Herzheimer reaction
Caused by an immune reaction to the dead spirochetes
What is the initial test for syphilis?
RPR or VDRL nonspecific antibody testing. Darkfield microscopy can be used to investigate the primary genital lesions
Should patients with Herpes be treated medically?
Yes, treating with acyclovir reduces the length of primary infection and can suppress recurrances (but doesn't cure)
How is chancroid diagnosed?
Painful genital lesions with ragged/purulent edges are identified and herpes and syphilis chancre are ruled out with lab tests
What is the treatment for chancroid?
Single dose of PO azithromycin or IM ceftriaxone
What is the other name for genital warts?
Condyloma acuminata
Caused by HPV
What is the usual treatment for genital warts?
Cryotherapy or topical medications (trichloroacetic acid, podophyllin or 5-FU cream)
Large lesions can be treated with a CO2 laser
What is mostly responsible for the acidic pH of the vagina?
Lactobacillus sp. generally maintain the vaginal pH below 4
What is the most common complaint of bacterial vaginosis?
Amine odor
How is bacterial vaginosis diagnosed?
Adding KOH to a vaginal prep (whiff test)
or Clue cells
What are the predisposing factors for C. albicans overgrowth?
Use of broad-spectrum antibiotics
Diabetes mellitus
Decreased cellular immunity
Intercourse
Late luteal phase of the menstrual cycle
What percentage of patients suffering with genital candidiasis display the characteristic white plaques or cottage cheese-like discharge?
Only 20%
What is the recommended treatment for Neisseria gonorrhea?
Ceftriaxone 250mg IM once
Is incidence of gonorrhea increasing or decreasing in the US? What about chlamydia?
Gonorrhea decreasing
Chlamydia increasing (probably due to increased diagnosis)
When does endometritis or endomyometritis usually present?
Most commonly after C. section, vaginal deliveries, D&C or IUD placement
What patients should be hospitalized for treatment for PID?
Teenagers
Pregnant women
Noncompliant patients
Patients who can't tolerate oral treatment
How many cases of Toxic shock syndrome are generally seen each year in the US?
Fewer than 300 cases per year
What is the treatment for Toxic shock syndrome?
Hospitalization is always indicated
Treat hypotension with fluids and pressors
What percentage of AIDS patients in the US are women?
in the world?
US - 18%
World - 50%
How should HIV positive women be treated to reduce the risk of vertical transmission?
AZT treatment after the first trimester, during labor, and treating the neonate as well.
Cesarean section.
What are the risk factors for Pelvic Organ Prolapse (POP)?
Chronic cough
Straining
Ascites
Traumatic delivery
Aging and menopause
What are common presenting symptoms of pelvic organ prolapse?
Pelvic pressure/heaviness
Vaginal bulge
Urinary incontinence, frequency, urgency, or retention
How is first degree pelvic organ prolapse defined?
The herniated structure is confined to the upper 2/3 of the vagina
How is second degree pelvic organ prolapse defined?
The herniated structure decends to the level of the introitus
How is third degree pelvic organ prolapse defined?
The herniated structure protrudes through the introitus
What medical treatment might improve symptoms of pelvic organ prolapse in post-menopausal women?
Estrogen replacement can improve tissue tone and facilitate reversal of atrophic changes
What is the usual anatomic cause of stress incontinence?
Pelvic relaxation and displacement of the urethrovesical junction
What is total incontinence (what is the cause)?
Continuous leakage of urine due to urinary fistula resulting from pelvic surgery or radiation
What are the four primary types of incontinence?
Urge
Stress
Total
Overflow
For which type of incontinence are pessaries a therapeutic option?
Stress incontinence
What are medical therapeutic options for stress incontinence?
Alpha adrenergic agonists
Estrogen
What are some conditions known to cause detrusor instability (urge incontinence)?
UTIs
Bladder stones and cancer
Foreign bodies
Most are idiopathic
What is the most frequently used and effective medical treatment for urge incontinence?
Anticholinergics
What are common causes of overflow incontinence?
Medications - anticholinergics
Lower motor neuron disease
Spinal cord injuries
Diabetes mellitus
How is overflow incontinence treated?
Cholinergic agents (bethanachol)
Self-catheterization
What is the average length of time between thelarche and menstruation?
2.5 years
List the following in order of normal appearance in puberty:
1. Growth spurt (peak velocity)
2. Menarche
3. Pubarche
4. Thelarche
1. Thelarche
2. Pubarche
3. Growth spurt
4. Menarche
What is the role of the granulosa cells and theca cells in the production of estrogen?
Theca cells produce androstenedione
Granulosa cells convert this to estradiol
What is the physiologic role of B-HCG in the pregnant woman?
It is secreted by the trophoblast and maintains the corpus luteum so it can continue to support the endometrium with estrogen and progesterone production
What change in hormones is directly responsible for endometrium sloughing in the menstrual cycle?
Withdrawal of progesterone
How is the diagnosis of menopause confirmed?
Testing FSH levels - they should be elevated in menopause
What are the two major body systems that have an increased risk of disease in post menopausal women?
Cardiovascular - increased risk of coronary artery disease
Bones - bone resorption accelerates leading to osteoporosis
What are the two main indications for HRT?
Short-term treatment of postmenopausal symptoms
Prevention of bone loss
What are the contraindications for HRT (5)?
Chronic liver disease
Pregnancy
Known estrogen-dependent neoplasm
History of thromboembolic disease
Undiagnosed vaginal bleeding
What is Mayer-Rokitansky-Kuster-Hauser syndrome?
Mullerian agenesis or dysgenesis
What is Savage syndrome?
Failure of the ovaries to respond to FSH and LH due to a receptor defect - primary ovarian failure
What is the pathophysiology of testicular femininization?
Dysfunction or absence of testosterone receptors
What is Kallman syndrome?
Congenital absence of GnRH
Also associated with anosmia
What is the most common cause of cervical stenosis?
Scarring of the cervical os due to surgical or obstetric trauma
What chemical inhibits prolactin secretion and which 2 chemicals stimulate its secretion?
Dopamine inhibits
Serotonin and TRH stimulate
What are the first three chemicals that should be analyzed when investigating secondary amenorrhea?
B-HCG for pregnancy
TSH
Prolactin
What medical treatment might cause tumor regression in patients with pituitary micro or macroadenomas?
Bromocriptine
What type of drug is bromocriptime (mechanism)?
Dopamine agonist
What is primary vs. secondary dymenorrhea?
Primary - idiopathic
Secondary - due to a known underlying pathology
What are common causes of secondary dysmenorrhea (5)?
Endometriosis
Fibroids
Adenomyosis
PID
Cervical Stenosis
What is the first-line and second-line treatment for dysmenorrhea?
First - NSAIDs
Second - OCPs
Most patients who take OCPs for a year have reduced symptoms even after they are discontinued
What is laminaria?
A device made from seaweed that is placed in the cervix and absorbs water and dialates the cervical os. Its a treatment for cervical stenosis
Where in the menstrual cycle do PMS symptoms usually occur?
In the second half of the cycle
What is the normal amount of blood lost during menstruation?
30-50 mL
What are the most common causes of menorrhagia (6)?
Uterine fibroids
Adenomyosis
Endometrial hyperplasia
Endometrial polyps
Endometrial/cervical cancer
DUB
What is the definition of oligomenorrhea?
Periods greater than 35 days apart
What are the most common causes of oligomenorrhea (3)?
PCOS
Chronic anovulation
Pregnancy
How is a diagnosis of Dysfunctional Uterine Bleeding made?
A diagnosis of exclusion when no pathologic cause of abnormal uterine bleeding is identified
What medical treatment may be helpful if patients with DUB experience acute hemorrhage?
IV estrogens and high dose oral estrogens
What are the four most common causes of post menopausal bleeding?
Vaginal/endometrial atrophy (30%)
Exogenous estrogens (30%)
Endometrial cancer (15%)
Endometrial polyps (10%)
If a female patient has elevated androgens, what are the two possible sources?
Ovaries
Adrenal glands
How is Cushing syndrome diagnosed?
Overnight dexamethasone suppression test
In the overnight dexamethasone suppression test, if a patient has Cushing syndrome, what results do you suspect?
A cortisol level above 10ug/dL
What molecule is overproduced and builds up if a patient has 21-alpha-hydroxylase deficiency?
17-a-hydroxyprogesterone which is shunted to the androgen pathway
Name 5 primary causes of hirsutism and virilization-
PCOS
Ovarian tumors
Adrenal tumors
CAH
Cushing syndrome
What percentage of pregnancies in the US are unintended?
55%
What is the average effectiveness of periodic abstinence (the rhythm method) as a form of contraception?
55-80%
How long after pregnancy should breast feeding be relied on as an effective form of contraception?
Maximum of 6 months
What is the only form of contraception that offers protection against HIV?
Male Latex Condoms
What are nonoxynol-9 and octoxynol-9?
Spermicides
How do spermacide agents work (biologic mechanism)?
They disrupt the cell membranes of spermatazoa
What is believed to be the mechanism of IUDs?
Act primarily by killing sperm through a sterile inflammatory response
How long can the ParaGard IUD be left in place as a contraceptive? The Mirena IUD?
ParaGard - 10 years
Mirena - 5 years
Who is the ideal population for IUDs?
Monogamous multiparous women
Name 5 complications associated with OCPs-
DVT
PE
CVA
MI
HTN
What is the mechanism of the progestrone-only pill as a contraceptive?
Thickening of cervical mucosa
Thinning of endometrium
What is the active drug in Depo-Provera?
Medroxyprogesterone acetate (DMPA)
What is the advantage of the Depo-Provera birth control method?
It lasts for 3 months and is 99.7% effective over the year.
What are the Side Effects of the Depo-Provera birth control method?
Irregular menstrual bleeding
Bone demineralization
Significant delay in return of fertility after discontinuation
Describe the Essure procedure for sterilization-
Soft polyester fibers are introduced into the uterine portions of the fallopian tubes. Over ~12 weeks, sterilization is accomplished as in-growth of tissue around the coils results in a barrier in the tubes
What are the side effects of vasectomies?
Bascially, none
What is the mechanism of Mifepristone (RU-486)?
A synthetic progesterone receptor antagonist that binds to progesterone receptors and blocks the stimulatory effects on endometrial growth
How long after the LMP can mifepristone be used as an abortifactant?
49 days past the LMP
Typically given with a prostaglandin analogue
What is the success rate of abortions with mifepristone (RU 486) in early pregnancy?
65-85% when used alone
Up to 98% effective when combined with a prostaglandin analogue (misoprostol)
What medications are used for induction of labor as a method of terminating second-trimester pregnancies?
Cervical ripening agents
Amniotomy
IV Oxytocin
What is the fecundity rate per month for a couple with normal fertility?
20-25%
With modern technologies, what percent of infertile couples can have the cause of infertility identified?
About 90%
What endocrine factors can be a cause of male infertility?
Kallman (hypothalamic dysfunction)
Pituitary failure
Hyperprolactinemia
Exogenous androgens
Thyroid disease
Adrenal hyperplasia
What is the treatment for a couple who is infertile due to low semen volume?
Intrauterine insemination with washed sperm
If a couple is infertile due to endometriosis in the female, what is the treatment of choice?
Surgical removal of pelvic adhesions. There is no place for medical management.
IVF is another option
What are three effective management options for infertile women with PCOS?
Weight loss
Clomiphene
Metformin
What is the mechanism of clomiphene citrate (how does it promote ovulation)?
It binds to estrogen receptors in the hypothalamus stimulating pulsatile release of GnRH causing FSH and LH release from the pituitary
What are the two major options for medical ovulation induction?
Clomiphene citrate
Human menopausal gonadotropins
What are the symptoms of ovarian hyperstimulation syndrome?
Edema
Ascites
Pleural effusion
Hemoconcentration
Hypercoagulability
What are the two major complications of ovulation induction?
Ovarian hyperstimulation syndrome
Multiple gestation pregnancy
When should pruritic lesions of the vulva be biopsied?
When they do not respond to antifungal creams - especially in post menopausal women
What does VIN and VAIN stand for?
Vulvar Intraepithelial Neoplasia
Vaginal Intraepithelial Neoplasia
What is the cause of 80-90% of Vulvar Intraepithelial Neoplasia?
HPV infection
Other risk factors include cigarette smoking and an immunocompromised state
What percentage of women with Vulvar Intraepithelial Neoplasia have symptoms?
Only 50%
Vulvar pruritis or irritation are the common symptoms
What are the three most common types of vulvar neoplasms?
Squamous cell carcinoma (85-90%)
Malignant melanoma (5-10%)
Basal cell carcinoma (2%)
What is the most important prognostic factor in vulvar cancer?
Number of positive inguinal lymph nodes
What is the most common presentation of Vaginal Intraepithelial Neoplasia?
Almost always asymptomatic
But repeatedly positive Pap smears with negative cervical biopsies
Where in the vagina are most vaginal cancers located?
In the apex near the cervix
What are the common therapeutic options for vaginal cancer?
Local excision
Laser vaporization
Topical 5-FU
Which is the number one cancer killer of women in the developing world?
Cervical cancer
Besides HPV infection, which other risk factors predispose to cervical cancer?
Smoking
Long term OCP use
Depressed immune status
DES exposure
What is "reflex HPV testing"?
The principle that an ASC-US result should be immediately tested for HPV
Is HPV testing recommended for an LSIL or HSIL result from a Pap smear?
No, because nearly all will be positive
What are the four classic presentations of dysplasia on colposcopy?
Acetowhite changes
Mosaicism
Punctations
Atypical vessels
What is the management of CIN I? CIN II?
CIN I is followed with repeat Pap smears, because most will regress. CIN II (and III) is treated with LEEP
Which 4 strains of HPV are considered high risk types associated with cervical cancer?
16, 18, 31, 45
What is the most common presenting symptom of cervical cancer?
Post coital bleeding
also-- any other abnormal vaginal bleeding, watery discharge, pelvic pain or pressure, and rectal or urinary tract symptoms
What is the treatment for preinvasive (stage 0-1a) cervical cancer?
CKC biopsy or simple hysterectomy
What is the treatment for advanced cervical cancer (stages IIb-IV)
Chemoradiation (cisplatin based therapy)
What are the top four most common cancers in women (including non-gynecologic)?
Breast
Lung
Bowel
Endometrial
What is the average age of diagnosis for endometrial cancer?
61
What risk factor for endometrial cancer carries the highest relative risk?
Obesity >50lbs overweight carries a relative risk of 10
What is the most common presenting symptom with endometrial cancer?
Post menopausal bleeding -
irregular bleeding occurs in 90% of patients
What is the treatment for most stages of endometrial cancer?
TAHBSO with radiation therapy (especially for the higher stages)
What percentage of ovarian tumors are benign?
80%
What is the 5-year survival rate of ovarian carcinoma?
25-30%
What are the three distinct components of the ovary from which tumors can arise?
Epithelial cells
Stroma
Germ cells
What is the other name for HNPCC syndrome?
Lynch syndrome - also predisposes to ovarian cancer
Are OCPs a risk factor for ovarian cancer, or protective?
Protective
What is the name for ovarian cancer metastasizing to the umbilicus?
Sister Mary Joseph nodule
What tumor marker to dysgerminomas produce?
LDH
Why do germ cell tumors have better survival rates than epithelial tumors of the ovary?
They grow faster and produce symptoms like hemorrhage and pelvic pain. So they get diagnosed earlier.
Which ovarian tumors are especially sensitive to radiation therapy?
Dysgerminomas
What tumor marker do choriocarcinomas produce?
HCG
What is the name of an ovarian tumor with accompanying ascites and right hydrothorax?
Meig's syndrome
Which tumor type accounts for 70% of sex cord-stromal ovarian tumors?
Granulosa cell tumors
Which has a higher malignancy rate - complete or incomplete moles?
Complete moles
What is the common karyotype of complete moles?
46XX
What is the common karyotype of incomplete moles?
69XXY
What gynecologic pathology is associated with bilateral theca lutein cysts seen on US?
Complete moles
What are common symptoms associated with molar pregnancy?
Vaginal bleeding (97%)
Passage of molar vessicles (80%)
Theca lutein cysts (15-50%)
Symptoms related to BHCG - hyperemesis (10-25%)
Biologically, how is a complete mole formed?
Fertilization of an empty egg
Biologically, how is an incomplete mole formed?
When a normal egg is fertilized by two sperms
What is seen on ultrasound in incomplete mole?
May reveal a fetus with regular cardiac activity, congenital malformations and growth restrictions.
"Snowstorm" appearance is only in complete mole
How are invasive moles diagnosed?
Serial follow-up of HCG shows plateauing or elevated levels after removal of the mole.
What is the treatment of invasive mole?
Methotrexate or actinomycin single agent therapy, or multi-agent chemotherapy if metastases are present
What fraction of women will have breast cancer in their lifetime?
1 in 8 (12.5%)
What two arteries supply the breast?
Internal mammary artery
Lateral thoracic artery
What nerve, if damaged in breast surgery, can caused "winged scapula"?
Long thoracic nerve
When during the menstrual cycle is the best time for breast self-examination?
5 days after menses when the breast is least engorged and tender
What qualities typify malignant breast lesions on palpation?
Firm, nontender, poorly circumscribed and immobile
Which breast tumors are associated with bloody nipple discharge?
Intraductal papilloma
Invasive papillary cancer
What breast pathology is typified by painful breast masses that are often multiple and vary throughout the menstrual cycle?
Fibrocystic breast change - not associated with cancer risk
What is the prognosis for Phyllodes tumors of the breast?
Clinical course is unpredictable. 10% contain malignant cells and there is a high rate of recurrence after simple excision. Wide excision is recommended
In which quadrant do 50% of malignant breast lesions occur?
Upper Outer Quadrant
What breast tumor accounts for 70% of all malignant breast disease?
Infiltrating ductal carcinoma
What percent of breast cancer is related to genetic predisposition?
Only 5-10%
What is the rate of Down Syndrome in a 40 year old mother?
1 in 110
How long after conception does it take for the embryo to reach the uterus?
Day 3
Where is anti-mullerian hormone secreted in males?
Sertoli cells in testicle
What birth defect is Lithium associated with?
Ebstein's anomaly
What birth defects are associated with Warfarin?
Chondrodysplasia
Microcephaly
Mental retardation
Optic atrophy
How many days after fertilization does B-HCG appear in the maternal serum?
10 days after fertilization
What is the differential diagnosis of elevated hCG in early pregnancy?
Twin pregnancy
Hydatidiform mole
Choriocarcinoma
Embryonal carcinoma
What are the two sites of progesterone production during pregnancy?
Corpus luteum for the first 6-7 weeks
Placenta after 7 weeks
What is the function of progesterone during pregnancy?
Early - Keeps endometrium favorable
Late - Induces immune tolerance for pregnancy and prevents myometrial contractions
What is chloasma?
Blotchy pigmentation of the nose and face - a soft sign of pregnancy
What is the mean value of WBCs in the third trimester?
16,000
How do thyroid markers change during pregnancy?
TBG increases
T3 and T4 increases
but unbound T3 T4 is unchanged
At what week of pregnancy does the mother first report fetal quickening?
Multipara - 16-18 weeks
Primagravida - 18-20 weeks
What four measurements are used to estimate fetal age on 2nd and 3rd trimester ultrasounds?
Biparietal diameter
Head circumference
Abdominal circumference
Femur length
What is the difference between the birth rate and the fertility rate of a population?
Birth rate is number of live births per 1000 total population
Fertility rate is number of live births per 1000 women ages 15-45 yo
What is Bloody Show?
Vaginal passage of bloody endocervical mucus resulting from cervical dilation before labor
What is the differential diagnosis in a pregnant woman with elevated AFP?
Open neural tube defects
Gastroschisis
Twin pregnancy
Placental bleeding
Fetal renal disease
Which weeks are the window for triple testing?
15-20 weeks
What percent of women with an abnormal OGCT will be found to have gestational diabetes on OGTT?
Only 15%
What is the normal range for Amniotic Fluid Index (AFI)?
9-25cm
What is included in a modified BPP?
Only the NST and amniotic fluid volume. Its predictive value is almost as high as a complete BPP
In which fetuses is an elevated S/D ratio predictive of poor perinatal outcome?
Only in IUGR fetuses
What is the management of active genital HSV lesions during pregnancy?
Acyclovir and cesarean section
Are vaginal deliveries recommended in women with syphilis?
Yes, vaginal delivery is appropriate
Are vaginal deliveries recommended in women with HepB?
Yes, vaginal delivery is appropriate
What is the classic triad of vasa previa?
Painless vaginal bleeding
Rupture of membranes
Fetal bradycardia
What is the management of vasa previa?
Immediate cesarean delivery
What is the relative risk of uterine rupture with a vertical fundal cesarean section vs. a low transverse?
20x more common
What determines the chorionicity and amnionicity of monozygotic twins?
They vary according to the duration of time from fertilization to cleavage.
Up to 72 hrs - Di Di
Between 9-12 days - Mo Mo
What is the management of severe fetal anemia?
Intrauterine transfusion is <34 weeks
Delivery if >34 days
What is the most common risk factor for PROM?
Ascending infection from the lower genital tract
What is the management plan of a patient 24-35 weeks pregnant with PROM?
Bed rest
IM betamethasone
Prophylactic antibiotics
What is the management plan of a patient >35 weeks of pregnancy with PROM?
Prompt delivery
What is the most common risk factor for PROM?
Ascending infection from the lower genital tract
Name four classes of drugs that act as tocolytic agents-
Magnesium sulfate
Beta agonists
Ca channel blockers
Prostaglandin synthase inhibitors (indomethacin)
What is the management plan of a patient 24-35 weeks pregnant with PROM?
Bed rest
IM betamethasone
Prophylactic antibiotics
What is the definition of gestational hypertension?
BP>140/90 after 20 weeks of pregnancy without proteinuria
What is the management plan of a patient >35 weeks of pregnancy with PROM?
Prompt delivery
Name four classes of drugs that act as tocolytic agents-
Magnesium sulfate
Beta agonists
Ca channel blockers
Prostaglandin syndthase inhibitors (indomethacin)
What is the definition of gestational hypertension?
BP>140/90 after 20 weeks of pregnancy without proteinuria
What is the most common risk factor for PROM?
Ascending infection from the lower genital tract
What is the management plan of a patient 24-35 weeks pregnant with PROM?
Bed rest
IM betamethasone
Prophylactic antibiotics
What is the management plan of a patient >35 weeks of pregnancy with PROM?
Prompt delivery
Name four classes of drugs that act as tocolytic agents-
Magnesium sulfate
Beta agonists
Ca channel blockers
Prostaglandin syndthase inhibitors (indomethacin)
What is the definition of gestational hypertension?
BP>140/90 after 20 weeks of pregnancy without proteinuria
Any sustained blood pressure reading over what value would classify a pregnant woman as severe preeclampsia?
160/110
After what gestational age is prompt delivery recommended for a woman with severe preeclampsia?
Any gestational age if there is evidence of maternal or fetal jeopardy
What is the incidence of gestational diabetes in pregnancy?
2-3%
What is Class A1 and A2 gestational diabetes?
A1 - GDM with normal fasting blood sugar not requiring insulin
A2 - GDM with elevated FBS requiring insulin
What is Class C gestational diabetes?
Overt DM onset age 10-19 years or duration 10-19 years
What are the most common fetal anomalies in pregnant women with diabetes?
Neural tube defects
Congenital Heart Disease
What are the four bones of the pelvis?
Ileum
Ischium
Pubis
Sacrum
What is the most common position of the fetus at delivery?
Occiput anterior
What is the management of prolapsed umbilical cord?
Immediate cesarean delivery.
Put the patient in knee-chest position and avoid palpating the cord
What maneuvers help deliver shoulder dystocia?
Suprapubic pressure
Maternal thigh flexion
Internal rotation of the fetal shoulders
Delivery of the posterior arm
What are Piper forceps used for?
Used for the after-coming head of a vaginal breech baby
What is the most common indication for forceps delivery?
Prolonged second stage of delivery
What is the mean blood loss during a cesarean section?
1000 mL - twice that of normal vaginal delivery
What is the optimum time for external cephalic version of a fetus?
37 weeks gestation
Are oral contraceptive pills OK to use after pregnancy during lactation?
Combination pills should not be used because estrogen diminishes milk production
Progestin only pills are OK
What is the most common cause of fever postpartum day 1-2?
UTI
What is the most common cause of fever postpartum day 3-4?
Endometritis
What is the most common cause of fever postpartum day 4-5?
Wound infection
What is the most common cause of postpartum fever?
Endometritis
How is a Pap smear technically performed?
Two specimens are obtained - an ectocervical sample scraping the T-zone, and an endocervical sample obtained with a cytobrush
What must be visualized in order to declare a "satisfactory colposcopy?"
The entire transitional zone must be visualized with no lesions disappearing into the endocervical canal
What percentage of ASC-US Pap smears can represent a significant premalignant lesion?
10-15%
How thick is the endometrium normally in postmenopausal women on US examination?
Usually 2-3mm
Over 5mm is suspicious
What is the presumptive diagnosis of a woman with post-menopausal bleeding and a negative endometrial biopsy?
Atrophy of the endometrium
Can be treated with HRT
At what week of gestation does the uterus reach the umbilicus?
20 weeks
At what week in pregnancy does the pregnant uterus reach the symphysis pubis?
12 weeks
What is a good medication for shrinking leiomyomas?
GnRH analogs like leuprolide
What is the management of a simple ovarian cyst diagnosed on US?
It is probably benign - follow up exam in 6-8 weeks should show resolution
What are the three most common sites from which metastases to the ovaries are sent?
Endometrium
GI tract
Breast
Name 5 classifications of Epithelial ovarian tumors-
Serous
Mucinous
Brenner
Endometroid
Clear cell tumors
What is the most common cause of death in women with advanced ovarian carcinoma?
Bowel obstruction
What is the treatment for lichen sclerosis?
Testosterone cream
What is the most common site of distant metastasis from a gestational trophoblastic tumor?
Lungs
Why should patients with gestational trophoblastic disease be given effective contraception for 6-12 months following treatment of their disease?
So that B-hCG can be followed accurately to ensure there is no residual tumor
What three muscles make up the levator ani?
Puborectalis
Pubococcygeus
Ileococcygeus
What does stimulation of alpha and beta adrenergic receptors in the bladder cause?
Alpha - Contraction of urethra
Beta - Inhibition of fundal contraction
What are the two most common sites of endometriosis?
1 - Ovary
2 - Cul de sac
What are medical therapies for endometriosis?
Medroxyprogesterone
OCPs
Leuprolide
What is the differential diagnosis of first trimester bleeding -
Threatened abortion
Incomplete abortion
Ectopic pregnancy
Hydatidiform mole
What is the criteria for methotrexate use for an ectopic pregnancy?
Pregnancy mass <3.5cm
No fetal heart motion
B-hCG level <6000
What is the medical treatment for Tubo-ovarian abscess?
Inpatient IV clindamycin and gentamycin
Drainage may be required if there is no response
What is the most common complaint in women with bacterial vaginosis?
Fishy odor
What is the effect of OCPs on lipid profile?
Increases HDL
Lowers LDL
What protective effects are offered by taking OCPs besides contraception?
Endometrial and Ovarian cancer
PID, ectopic pregnancy
Benign breast disease
Anemia
Dysmenorrhea
What causes the decrease in progesterone and estradiol by day 23 of the normal menstrual cycle?
Involution of the corpus luteum
What is the differential diagnosis of premenarchal vaginal bleeding?
Foreign body (most common)
Ingesting estrogen medication
Cancer of vagina or cervix
Tumor of pituitary, adrenal gland or ovary
Sexual abuse
Idiopathic precocious puberty
What is the definition (age) of precocious puberty in males and females?
Secondary sexual characteristics
Before age 8 in girls
Before age 9 in boys
What percentage of precocious puberty in girls gets classified as constitutional or idiopathic?
80%
What is the DD of precocious puberty in girls?
Constitutional
CNS pathology
McCune Albright
Granulosa cell tumor
What is McCune Albright syndrome?
Autonomous stimulation of aromatase enzyme production of estrogen by the ovaries
Managed with aromatase inhibitors
What is the DD of primary amenorrhea if the uterus and breasts are present?
Constitutional delay
Imperforate hymen
Vaginal septum
Anorexia
Excessive exercise
Pregnancy before first menses
Which two conditions should be considered if there is primary amenorrhea in a patient with breasts but no uterus?
Mullerian agenesis
Complete androgen insensitivity
Is the LH to FSH ratio elevated or decreased in PCOS?
Elevated to 3:1
Normal is 1.5:1
What is the normal sperm count in a mL of semen?
20 million / mL
When in the menstural cycle is clomiphene citrate administered for ovulation induction?
Administered orally for 5 days beginning on day 5 of the menstrual cycle
What is the next step when investigating infertility if semen analysis is normal and ovulation is confirmed?
Assessment of fallopian tube abnormalities by HSG or laparoscopy
What is the mean age of menopause?
51
What is the most common anatomic site of injury due to osteoporosis?
Vertebral body crush fractures, kyphosis and loss of height

Hip and wrist fractures are the next most common.
What is the first line of treatment of postmenopausal osteoporosis?
Bisphosphonates and SERMs