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264 Cards in this Set

  • Front
  • Back
Which type of urinary incontinence is this? what is the mechanism?

- painless loss of urine concurrent with valsalva
- no urge to void
genuine stress incontinence (GSUI)
- incontinence through the urethra due to sudden increases in the intra-abdominal pressure, in the absence of bladder muscle spasm.
- weakness of pelvic floor diaphragm -> proximal urethra fall below diaphragm -> no pressure transmitted to urethra
- cough -> bladder pressure exceeds max -> urine flow
- diagnosis: physical exam (loss of bladder angle), cystometric exam.
- treatment: urethropexy, tension free vaginal tape procedures.
Which type of urinary incontinence is this?

- "have to go to the bathroom and can't make it there in time"
- several second delay urine loss with valsalva
urge incontinence (UUI)
- loss of urine due to an uninhibited and sudden bladder detrusor musle contraction.
- diagnosis: cystometric exam
- treatment: anticholinergic medication oxybutinin(ditropan)
Which type of urinary incontinence is this?

- loss of urine with valsalva
- dribbling
overflow incontinence
- loss of urine associated with an overdistended, hypotonic bladder in the absence of detrusor contractions.
- associated with diabetes, spinal cord injuries, lower motor neuropathies
- may be caused by urethral edema after pelvic surgery.
- diagnosis: postvoid residual cath
- treatment: intermittent self cath
Name the sympathetic control of the bladder.
hypogastric nerve (T10-L2)
- bladder neck contraction
- internal spincter contraction
Name the parasympathetic control of the bladder.
Pelvic nerve (S2-S4)
- contraction of detrusor muscle
Name the somatic nerve control of the bladder.
pudental nerve
- external sphincter, levator ani muscle contraction
Describe the nerve control process of micturition.
- stretch receptorsin the bladder wall signal CNS
- inhibition of sympathetic (bladder neck and internal sphinctor contraction) and pudental nerves (external and levator ani muscle contraction)
- activation of parasympathetic pelvic nerve (contraction of detrusor muscle)
- micturition
What physical exams should you do to evaluate someone with urinary incontinence?
- internal and external pelvic exam
- thorough neuro exam: deep tendon reflexes, anal reflex, pelvic floor contractions, bulbocavernosus reflex
What diagnostic tests can be done to evaluate patients with urinary incontinence?
- UA, urine culture: r/o UTI
- standing stress test
- cotton swab test: to diagnose hypermobile bladder neck
- cystometrogram: distinguish between SUI and detrusor instability
- uroflowmetry
What are some control
mechanisms of urinary conitinence.
- sympathetics (T10-L2): bladder neck and internal spincter
- pudental nerve: external spincter and levator ani
- mucosal copitation: estrogen sensitive
Risk factors for SUI.
- pelvic relaxation
- increased intra-abdominal pressure
- menopause (decreased estrogen)
Treatments of stress incontinence.
- pelvic exercises: Kegek exercises
- pessaries: elevate and support the bladder neck
- medication to enhance urethral sphincter closure (estrogen, propadrine)
- surgery to restpre urethral position (mainstay)
What are some common causes of urge incontinence?
Detrusor instability
- UTI
- urethral obstruction, compression
- bladder stones
- bladder cancer
- suburethral diverticula
- foreign bodies

Detrusor hyperreflexia
- cerebrovsascular accidents
- Alcheimer's
- MS
- Parkinson's
- diabetes
- peripheral neuropathies
- autonomic neuropathies
- cauda equina lesions
Treatment for UUI.
- anticholinergics: pro-banthine, oxybutinin
- smooth muscle relaxant: detrol, tolterodine
- TCA: tofranil (treats mixed UUI and SUI)
Name a drug that treats mixed SUI and UUI.
TCA (tofranil): both anticholinergic and alpha adrenergic
What type of urinary incontinence is this?

- painless continuous loss of urine
total urinary incontinence (fistula)
- associated with pelvic radiation and surgery
- diagnosis: methylene blue dye, indigo carmine, cystourethroscopy, IVP (intravenous pyelogram)
Treatment of total urinary incontinence (fistula).
surgery with antibiotics, steroids, estrogen (for postmenopausal women)
Treatment for overflow urinary incontinence.
- reduce urethral closing: prazosin, terazosin
- striated muscle relaxant: diazepam, dantrolene
- cholinergics: bethanechol
- intermittent self catheterization
What are the four signs of placental separation?
- gush of blood
- lengthening of the cord
- globular and firm shape of the uterus
- uterus rising up to the anterior abdominal wall
What is this?

- 31 y/o women has a normal vaginal delivery
- after slight lengthening of the cord, a reddish mass is noted bulging in the introitus
uterine inversion
- risk of massive hemorrhage
- prepare for rapid volume replacement: 2 large bore IV sites
- anesthesia assist: halothane terbulatine have uterine relaxation effect for uterine placement
- use cupped finger to replace the inverted uterus if placenta is already separated
- terbulatine or magnesium sulfate also relaxes uterus
- relaxation agents should be stopped after replacement of the inverted uterus and uterotonic agens oxytocin is given
What is the best method to avert a uterine inversion?
await spontaneous separation of the placenta from the uterus before placing traction on the umbilical cord
Risk factors for uterine inversion.
- atonic uterus
What is climacteric?
perimenopausal state
- hypoestrogenemia
- elevated serum FSH (decreased inhibin from ovaries) and LH levels
What is the pathophysiology of hot flashes of perimenopausal state?
failure of ovaries -> decreased estrogen -> vasomotor change -> skin temperature elevation and sweating -> hot flashes

decrease estrogen -> decrease vaginal epithelial thickness leading to vaginal atrophy and dryness
What is the best therapy for vasomotor symptoms and prevention of osteroporosis of menopause?
estrogen replacement therapy: small risk of breast cancer, heart disease, pulmonary embolism, stroke. But no adverse effects from short term of estrogen therapy (<6month)

* selective estrogen receptor modulator raloxifene can prevent osteoporosis, but dose not treat hot flashes
Can FSH be used to titrate estrogen replacement dose?
No.
FSH responds to inhibin (ovary), not estrogen.
What is this condition?

- 51 y/o female with oligomenorrhea and hot flashes
ovarian failure (menopause)
What is this condition?

- 22 y/o female with galactorrhea and hyperprolactinemia
hypothalamic dysfunction
What is this condition?

- 25 y/o female slightly obese, slightly hirsute
- long history of irregular menses
estrogen excess (PCOD)
What is this condition?

- 18 y/o female with infantile breast development has not started her menses
- webbing of neck
ovarian failure (Turner's syndrome)
- streaked ovaries
- elevated gonadotropin levels
What is this condition?

- 19 y/o female marathon runner with ammenorrhea
hypothalamic dysfunction caused by excessive exercise
What is this condition?

- 33 y/o female who has not started her menses since a vaginal delivery 1 yr previousely complicated by postpartum hemorrhage
- she was unable to breast feed
Sheehan's syndrome
- anterior pituitary hemorrhagic necrosis associated with postpartum hemorrhage
Where is the most common location of an osteroporosis-associated fracture?
compression type of fracture most commonly in the thoracic spine
Why shoud progestin be added to estrogen replacement therapy for women with uterus?
prevent endometrial cancer
What is the diagnosis? What is the next step?

- 28 y/o women presented to ER with fever of 102F, myalgia, nausea, vomiting
- BP 60/40, tachycardic, crackle at lung bases. Tender abdomen
- diffuse sunburn like skin rash
- lethargic, mental confusion
Toxic shock syndrome
- IVF
- IV nafcillin
- monitor urine output
- support BP with dopamine if needed
What is the minimum mean arterial pressure to perfuse vital organs?
65mmHg
MAP = (sBP + dBPx2)/3
What are some predisposing factors for TSS in menstruating women?
Risk factors
- barrier contraceptives
- tampons

TSS
- s aureus exotoxin 1 (dwell on mucosa, vagina most common)
- abx: nafcillin or methicillin. Add aminoglycosides when diagnosis is unclear.
- dopamine or dobutamine if IVF insufficient to maintain BP
What happens to the cervix during latent phase of labor?
latent phase of labor
- initial part of labor
- cervix mainly effaces rather than dilates (< 4cm)
What is considered protraction of active phase?
- cervical dilation in the active phase that is less than expected (1.2 cm/hr in nulliparus women, 1.5 cm/hr in multiparus women)
What is considered arrest of active phase of labor?
no progress in active phase of labor for 2 hours
Normal labor parameters:

latent phase
- nullupara: < 18-20 hrs
- multipara: < 14 hrs
Normal labor parameters:

active phase
- nullupara: > 1.2 cm/hr
- multipara: > 1.5 cm/hr
Normal labor parameters:

second stage
- nullupara: < 2 hrs, < 3 hrs if epidural
- multipara: < 1 hr, < 2 hrs if epidural
Normal labor parameters:

3rd stage
- < 30min
What 3Ps should you evaluate when a labor abnormality is diagnosed?
- power: need to give IV oxytocin via dilute titration. Adequate contraction: every 2-3min, firm on palpation, last at least 40-60s, montevideo unit > 200. Can use internal uterine cather to assess.
- passenger
- pelvis: c section if there is cephalopelvic disproportion
What do you do next for this women is labor?

- cervix is 3cm dilated
- contraction has been going on for > 24 hrs
prolonged latent phase labor
- assess 3ps
- oxytocin vs therapeutic rest
What should you do next in this women in labor?

- cervix is dilated at rate < 1.2cm/hr
protracted active phase
- assess 3ps
- observation vs oxytocin
- c-section for suspected cephalopelvic disproportion
What should you do next for this women is labor?

- no progress in the active phase for 2 hrs
arrest of active phase
- assess 3ps
- if power is adequate: c section
- if power is inadequate: oxytocin and reassess
What is cause of the bleeding?

- 24 y/o G2P1 at 39 wk gestation
- painful contraction
- dark vaginal blood mixed with some mucus
bloody show/loss of cervical mucus
- indicate impending labor
What fetal position is common with anthropoid pelvis?
anthropoid pelvis: anteriooposterior diameter < transverse diameter
- commonly see feral occiput posterior postion
What to do next?

- 18 y/o female 5wks gestation
- vaginal spotting and pelvic pain, not acutely symptomatic
- hCG 500
repear hCG in 48 hours
- if abnormal rise: probably nonviable pregnancy, proceed to uterine curettage. If chorionic villi present, the diagnosis is miscarriage. if not, diagnosis is ectopic pregnancy, and methotrexate should be given.
- if normal rise, but < 1500, oberve and repeat in 48 hrs
- if normal rise and > 1500: sonogram. If gestational sac seen, observe. If not, diagnosis may be ectopic, consider laparapscopy.
What to do next?

- 18 y/o female 5wks gestation
- vaginal spotting and severe pelvic pain, hypotensive, adenexial mass
- hCG 500
possible rupture of ectopic pregnancy
- laparoscopy or laparotomy
Risk factors for ectopic pregnancy.
high risks:
- prior ectopic pregnancy
- abnormal tubes
- maternal DES use
- endometriosis
- tubal ligation + currently pregnant
- IUD use

moderate risks:
- prior chlamydial cervical infection or PID or STI
- history of infertility
- multiple partners
- smoking

low risks:
- douching
- past abdominal surgeries
- old age
What is this disease?

- abnormal adherence of the placenta to the uterine wall due to an abnormality of the decidua basalis layer of the uterus
- placenta villi are attached to the myometrium
placenta accreta
What is this disease?

- abnormally implanted placenta penetrates into the myometrium
placenta increta
What is this disease?

- abnormally implanted placenta penetrates entirely through the myometrium to the serosa
placenta percreta
Risk factors for placenta accreta.
- placenta previa
- implantation over the lower uterine segment
- prior c section or other uterine scar
- uterine curretage
- Down syndrome
Management of placenta accreta.
- hysterectomy
- curettage usually not successful and may lead to hemorhage and exsanguination
Explain this phenomenon:

- transmigratiom of the placenta
low-lying placenta or placenta previa diagnosed in the 2nd trimester may resolve in the 3rd trimester
- lower uterine segment grows more rapidly
What is the diagnosis?

- 34 wk gestation and have placenta previa
- during c section, bluish tissue densely adherent between uterus and maternal bladder is noted
placenta percreta
What to do next?

- low lying or marginal placenta previa in 2nd tromester
repeat sonograph
- may resolve as a result of transmigration.
What is the diagnosis? how to treat it?

- 22 y/o female with purulent vaginal discharge and postcoital spotting
- gram stain: intracellular gram - diplococci
gonococcal cervicitis
- IM ceftriaxone for gonorrhea and azithromycin (or doxycyclin) for chlamydial infection for 7-10 days.
- conseling for STIs
What are some complications of gonococcal cervicitis?
- PID/salpigitis: which can lead to infertility or ectopic pregnancy
- infectious arthritis: large joints and migratory
- disseminated infection to skin: pustules
- conjuctivitis and blindness of newborn
- sexually transmitted pharyngitis
What is the organism?

- 34 y/o women with "fishy odor" vaginal discharge
trichomonas infection
What is the diagnosis? what to do next?

- 35 y/o woman at 8 wks gestation
- cramy lower abdominal pain and vaginal bleeding
- passed "liver" like material, pain relieved afterwards
- cervix is closed
completed spontaneous abortion
- next: follow hCG to zero, should half every 48 to 72 hrs. If level plateaus, there is retained tissue (incomplete abortion or ectopic pregnancy).
What is this type of abortion?

- pregnancy less than 20wks gestation
- cramping, bleeding, cervical dilation
- no passage of tissue
inevitable abortion
What type of abortion is this?

- pregnancy less than 20wks
- cramping, vaginal bleeding
- open cervix
- passage of tissue
incomplete abortion
- retained tissue
- continuing contractions
How to differentiate incomplete abortion from incompetent cervix?
presence of absence of uterine contractions
- cramping abdominal pain (due to uterine contractions) with a dilated cervix -> incomplete abortion
- painless, spontaneous cervical dilation -> incompetent cervix
What is the treatment?

- incomplete abortion
- D&C of the uterus
What is the diagnosis? how to treat it?

- painless vaginal spotting
- no fetal heart tones
- markedly elevated hCG
- u/s: "snowstorm"-like, grape like, "honeycone"-like pattern in the uterus
molar pregnancy
- trophoblastic tissue without a fetus
- treatment: uterine suction curettage
- complete molar pregnancy: no embryonic tissue (empty egg + sperm)
- partial molar pregnancy: fetal tissue present ( egg + 2 sperm)
- risk for choriocarcinoma
What is the treatment?

- missed abortion
- D&C vs expectant management
What is the diagnosis? what to do next?

- 25 y/o women at 42 wk gestation
- 4 hrs of first stage labor, 2 hr second stage labor
- fetal head is retracted toward maternal introitus, unable externally rotate ("turtle" sign)
shoulder dystocia
- McRoberts maneuver: flexion of maternal thigh toward abdomen to anteriorly rotate pubic symphysis
- suprapubic pressure: displaces fetal shoulder axis from anteroposterior to oblique
- Wood's corkscrew maneuver: progressively rotate the posterior shoulder in 180 degrees in a corkscrew fashion.
- deliver posterior arm
- Zavanelli maneuver: cephalic replacement with immediate c section.

* Avoid fundal pressure!
Complications of shouler dystocia.
- fetal hypoxia
- Erbs palsy (C5-6): weakness of deltoid, infraspinatus, flexors muscles of forearm.
- maternal postpartum hemorrhage
What is the diagnosis? What to do next?

- 45 y/o woman POD 2 of TAH for symptomatic endometriosis
- c/o R flank tenderness
- vitals stable, incision dry, intact
- abdomen slightly tender diffusely, R costovertebral angle tenderness
ureteral injury after hysterectomy
- next: IVP (intravenous pyelogram)

* if no h/o surgery, pyelonephritis would be likely, next step would be IV abx and urine culture.
Which ligament does uterine artery reside in?
cardinal ligament: attachment of the uterine cervix to pelvic side walls
Risk factors for ureteral injury as a complication of surgeries..
- cancer
- extensive adhesions
- endometriosis
- tubo-ovarian abscess
- residual ovaries
- interligamentous leiomyomata
What is the most common location for ureteral injury associated with surgery?
cardinal ligament where ureter is 2-3 cm lateral to the cervix.
- ureter is just under the uterine artery ("water under the bridge")

Less common is the pelvic brim which occur during the ligation of ovarian vessels (IP)

also at the point where ureters enter the bladder
Types of iatrogenic ureter injury.
- suture ligation
- transsection
- crushing with clamps
- ischemia from stripping the blood supply
Management of iatrogenic ureteral injury.
- IVP
- antibiotics
- cystoscopy to attempt retrograde stent passage
What should you do?

- bladder laceration on the dome (top) of the bladder
suture at the time of the surgery
What should you do?

- bladder laceration in the trigone area (lower part of the bladder)
ureteral stent placement to prevent ureteral stricture
T/F: The use of Panrose drain to ensure ureteral safety during surgery may lead to ischemic injury of the ureters due to overdissection.
True.
Risk factors for endometrial cancer.
- early menarche, late menopause
- obesity
- chronic anovulation
- estrogen secreting ovarian tumors
- ingestion of unopposed estrogen
- HTN
- DM
- personal/family history of breast or ovarian cancer
T/F: Endometrial cancer must be ruled out in any patient with postmenopausal bleeding.
True
What is the most common etiology of postmenopausal bleeding?
atrophic endometritis or vaginitis
Management of postmenopausal bleeding:

- when endometrial biopsy is unrevelaing and patient has persistent bleeding, what should you do?
hysteroscopy to further evaluate
List staging procedures for endometrial cancer.
- TAH, BSO
- omentectomy
- lymph node sampling
- peritoneal sampling
What is the biggest risk factor for development of endometrial cancer?
unopposed estrogen
What is the biggest prognostic factor for endometrial cancer?
histologic grade: degree of differentiation
What to do next?

30 y/o G5P4 ar 32 wk gestation with painless bleeding
- 4 wks prior had post coital vaginal spotting
- abdomen is soft, uterus nontender
placenta previa
- next: ultrasound exam (transabdominal or transvaginal) to assess placenta location.
- long term management: expectanct treatment as long as the bleeding is not excessive. C section at 36-37 wks.
Definition of antepartum hemorrhage.
significant vaginal bleeding after 20 wk gestation.
Give 2 most common cause of antepartum bleeding.
placenta abruption: painful uterine contraction with vaginal bleeding.

placenta previa: painless bleeding after mid second trimester
Risk factors for placenta previa.
grand multiparity
prior c section
prior uterune currettage
previous placenta previa
multiple gestation
Risk factors for placena abruption.
hypertension
cocaine use
short umbilical cord
trauma
uteroplacental insufficiency
submucous leiomyomata
sudden uterine decompression (hydramnios)
cigarette smoking
preterm premature rupture of membranes
Why is ultrasound a poor method for assessment of placenta abruption?
Because freshly developed blood clot behind the placenta has the same sonographic texture as the placenta itself.
What to do next?

- 22 y/o G2P1 cocaine user at 35 wk gestation with abdominal pain and vaginal bleeding
- exam: BP 150/90 HR 110. Fundal tenderness. Fetal heart tones 160-170
placenta abruption
- next: delivery (at 35 wks, risk of abruption outweighs the risk of prematurity)
Define: concealed abruption.
when the bleeding of the abruption occurs completely behind the placenta and no external bleeding is noted.

This condition is less common but more dangerous than abruption.
Define: couvelaire uterus (uteroplacental apoplexy).
bleeding into the myometrium of the uterus givinv a discolored appearance to uterine surface.

- a life threatening condition in which loosening of the placenta (abruptio placentae) causes bleeding that penetrates into the uterine myometrium forcing its way into the peritoneal cavity.
How to diagnose placenta abruption?
no one test is diagnostic of placental abruption, normal ultrasound does not r/o the condition.

clinical picture as a whole is diagnostic
Complications of placenta abruption.
hemorrhage
atony
fetomaternal bleeding: kleihauer-Betke test to determine.
coagulopathy secondary to hypofibtinigenemia (<100-150 mg/dl)
preterm delivery
What is the best management for this patient with placenta abruption?

- woman with premature fetus and diagnosis of "chronic abruption"
- no active bleeding, no fetal distress, mother is hemodynamically stable
expectant management
What is the best management for this patient with placenta abruption?

- fetal death and coagulopathy
vaginal delivery (safer for the mother)
- blood products and IVF should be given to maintain Hct above 25-30% and a urine output of at least 30 ml/hr.
What is the next step?

- cervical mass on speculum exam
- biopsy, not pap smear (fpr normal appearing cervix)
Risk factors for cervical cancer.
- early age of coitus
- STI
- early child bearing
- low socioeconomic status
- HPV
- HIV
- cigarette smoking
- multiple sexual partners
Define: radiation brachytherapy.
radioactive implants placed near the tumor bed.
Define: radiation teletherapy.
external beam radiation where the target is at some distance from the radiation source.
Colposcopy: what are the lesions you need to biopsy?
- acetowhite change
- vascular changes: punctations, atypical vessels.
How is cervical cancer staged?
clinically
- exam under anesthesia
- IV pyelogram
- chest xray
- barium enema or proctoscopy
- cystoscopy
Treatment for cervical cancer.
Early cervical cancer: radical hysterectomy or radiation

Advanced cervical cancer: radiotherapy (brachytherapy with teletherapy along with chemo (platinum based) to sensitize the tissue to the radiotherapy.
What is the most common cause of death in cervical cancer?
bilateral ureteral obstruction leading to uremia
- cancer spreads through the cardical ligaments toward pelvic sidewalls.
- flank tenderness or leg swelling
What are the two most common cause of secondary amenorrhea after postpartum hemorrhage?
- Sheehan syndrome: not able to lactate, anterior pituitary necrosis (hypothyroid, low FSH, LH, cortisol)

- Asherman syndrome (intrauterine adhesions): able to breast feed
Define: postpartum hemorrhage.
bleeding greater than 500ml for a vaginal delivery and greater than 1L for a c section.
T/F: in a nonlactating woman in whom menses does not return by 12 wks after delivery, pathology must be suspected.
True.
Next step assessment of postpartum amenorrhea.
1. pregnanct test
2. if postpartum hemorrhage: assess pituitary function to differentiate Sheehan syndrome from Asherman syndrome.
3. if no postrpartum hemorrhage and hypoestrogenic: FSH test to differentiate hypothalamic/pituitary cause from ovarian failure.
- if no postpartum hemorrhage and hyperestrogenic with obesity, hirsutism, glucose intolerance: think PSOD (LH/FSH >2)
What is the mechanism of Asherman syndrome?
intrauterine adhesion causing defective large patches of endometrium.
What is contraindicated in this case?

- 22 y/o G3P2 at term in labor with 5cm cervical dilation, vertex at -3 station.
artifical rupture of membrane is contraindicated because of the risk of cord prolapse that may lead to fetal bradycardia.

next:
- confirm fetal heart rate by internal scalp electrode or u/s
- vaginal exam to assess for cord prolapse
-postitional change: side position to move the uterus from great vessels this improve blood return to the heart
- IV bolus if volume depleted
- d/c oxytocin
- oxygen
List some causes of fetal bradycardia.
- hyperstimulation with oxytocin: treat with beta agonist terbutaline to relax uterine musculature
- epidural anesthetic: IV hydration, if not successful, ephedrine administration.
Management of cord prolapse with fetal bradycardia.
- digital exam to assess for the umbilical cord to confirm diagnosis
- elevation of presenting part: trendelenburg position
- emergent c section
What is the most common finding in a uterine rupture?
fetal heart rate abnormality
- fetal bradycardia
- deep variable deceleration
- late decelerations
What is the most common risk factor for uterine rupture?
uterine scar from previous c section
What is the initial step in management in this patient?

- 33 y/o G2P1 at 39 wk gestation in active labor
- 1 min episode of bradycardia in external fetal tracings
- cervix is closed
assess maternal pulse to differentiate fetal heart rate from maternal pulse
Risk factors for cord prolapse.
- artificial rupture of membranes
- transverse fetal lie
- footling breech position
List some causes of galactorrhea.
- pregnancy
- pituitary adenoma: MRI
- hypothalamic causes (craniopharyngioma, sarcoidosis, histiocytosis, leukemia): MRI
- chest wall trauma
- hypothyroidism: TSH and TRH, prolactin levels
- drugs: transquilizers, TCA, anti-HTN, narcotics, OCP
- empty sella syndrome
What is the cause of this women's problem?

- 30 y/o women with irregular periods and watery breast discharge of 6 months
- treated previousely with redioactive iodine for Grave's disease
galactorrhea secondary to primary hypothyroidism
- primary hypothyroid -> High TSH and TRH -> TRH act as prolactin releasing hormone -> inhibit hypothalamic GnRH -> oligomenorrhea
How to determine whether the breast discharge is truly galactorrhea?
multiple fat droplets under microsope
What is the most sensitive test for pituitary adenoma?
MRI

other symptoms: headache, peripheral vision disturbances (bitemporal hemianopsia)
What imaging should you order for this patient?

- oligomenorrhea
- galactorrhea
anteroposterior view and
lateral coned down view of the sella tursica
Treatment for pituitary adenoma causing hyperprolatinemia.
- bromocriptine: dopamine agonist, good for patient desiring fertility
- cabergoline: dopamine agonist
- estrogen
- surgery: transsphenoidal resection
Treatment for hyperprolatinemia caused by hypothyroidism.
thyroxine
T/F: A patient with galactorrhea but normal menses and a normal prolactin level can be observed.
True
T/F: Osteoporosis is a danger with hypoestrogenemia because of hyperprolactinemia.
True
What does this patient have and how to treat it?

- 24 y/o G1P0 at 28 wks gestation with generalized pruritis without rashes
- anicteric and normotensive
cholestasis in pregnancy
- associated with fetal morbidity: prematurity, fetal distress, fetal loss
- treat: antihistamines, cornstarch bath, cholestyramine (cause vitK deficiency), ursideoxycholic acid.
DDX for pruritis during pregnancy.
- cholestasis of pregnancy: itching without rashes. Fetal risks of prematurity and losses.
- pruritic urticatia papules and plaques of pregnancy (PUPPP): intense pruritis and erythematous papules on the abdomen and extremities. No adverse pregnancy outcomes.
- herpes gestationalis: intense itching and vesicles on abdomen and extremities. IgG autoantibodies directed at basement membrane. Transient neonatal lesions but will resolve. Risks of fetal growth retardation and stillbirth.
Treatment for herpes gestationalis.
oral corticosteroids.

herpes gestationalis: IgG against basement membrane. Not herpes simplex.
Treatment for PUPPP (pruritic urticarial papules and plaques of pregnancy).
topical steroids and antihistamines
What is this condition?

- abdominal tenderness
- cervical motion tenderness
- adnexal tenderness
- dyspareunia
PID (salpingitis)
- multiple organisms are responsible (Gonorrhea, chlamydia, anaerobes, gram negative rods), so need broad spectrum abx
- laparoscopy is the gold standard diagnosis
- long term sequelae: chronic pelvic pain, ectopic pregnancy, involuntary infertility.
What is Fitz-Hugh-Curtis syndrome?
seen with salpingitis (PID) when perihepatic adhesions are present.
- patients also have RUQ pain.
How to differentiate ovarian torsion and salpingitis clinically?
ovarian torsion: pain coliky pain.

salpingitis: abdominal tenderness, cervical motion tenderness,
Treatment for PID (salpingitis).
IM ceftriaxone (single injection) and oral doxycyclin (BID for 10-14 days)
What does this pregnant lady have?

- 20 wk gestation
- chest pain and severe dyspnea
- HR 120, RR 40
- lungs clear to auscultation
pulmomary embolism
What is the most common cause of maternal mortality?
embolism
How to confirm a pulmonary embolism in a pregnant lady?
- V/Q scan
- helical CT scan
Management of pulmonary embolism in pregnancy.
- diangosis based on clinical picture
- blood gas, chest xray
- if PO2 < 85mmHg or O2 sat < 95, provide oxygen
- initiate IV heparin
- confirm with V/Q scan or helical CT scan
- full heparin anticoagulation for 5-7 days
- switch to subcutaneous therapy to maintain ppt at 1.5 to 2.5 times control for 3 months
- full heparinization or prophylactic heparin till 6 wks postpartum
What is the management of this pregnant lady?

- 39 wk gestation
- ROM 2 hrs ago
- treated for herpes
- 1 day hx of tingling in perineal area
patient is with HSV outbreak, should offer c section
What is the most common cause of an infectious vulvar ulcer disease in the US?
herpes simplex virus
What is the management of this pregnant lady?

- 39 wk gestation
- ROM 2 hrs ago
- treated for herpes
- no prodromal symptoms of herpes: tingling, vesicles, ulcers
can proceed with vaginal delivery
Conditions that should be considered when patient presents with intermenstrual bleeding.
- fibroids
- endometrial hyperplasia
- endometrial polyp
- uterine cancer
Indication for hysterectomy in patients with fibroids.
anemia despite medical therapy (ex ibuprofen)
Name some types of fibroids.
- submucous
- intramural
- subserosal
- pedunculated
What is carneous degeneration of leimyoma (fibroids)?
Changes of the leiomyomata due to rapid growth, the center of the fibroid becomes red, causing pain.
What is a risk factor for rapid degeneration of leiomyomata into leiomyosarcoma?
history of radiation into the pelvis
Medical treatment for uterine fibroids (leiomyomata)
used as initial treatment
- NSAIDs
- progestin
- GnRH agonist: decrease fibroid size. reserved for tumor shrinkage or correction of anemia before operative treatment
Operative treatment for symptomatic leiomyomata (uterine fibroids).
- hysterectomy
- uterine artery embolization
- myomectomy for women who still desires pregnancy.
What is this problem?

- 39 wk gestation in 2nd stage labor
- hx of myomectomy for infertility
- fetal bradycardia associated with vaginal bleeding
- fetal head station changed form +2 to -3
uterine rupture
- extensive myomectomy is a risk factor, necessitates c section
Types of hypertensive disorders during pregnancy.
1. gestational hypertension
- increased BP without proteinuria
2. preeclampsia
- HTN + proteinuria
- severe: sBP > 160, dBP > 110, or >5g proteinuria
3. chronic hypertension
- pre-existing HTN or
- HTN that develops prior to 20 wks gestation
- at risk for pre-eclampsia
4. superimposed preeclampsia
5. eclampsia
- pre-eclampsia + convulsions/seizures
Pathophysiology of preeclampsia.
vasospasm and "leaky vessels" -> local hypoxia of tissue -> hypoxemia -> hemolysis, necrosis, end organ damage
Complications of preeclampsia.
- placenta abruption
- eclampsia (possible intracerebral hemorrhage)
- coagulopathies
- renal failure
- hepatic supcapsular hematoma
- hepatic rupture
- uteroplacental insufficiency
Risk factors for preeclampsia.
- nulliparity
- extreme of age
- African American race
- hx of preeclampsia
- chronic HTN
- chronic renal disease
- antiphospholipid syndrome
- diabetes
- multifetal gestation
Lab tests in evaluation of preeclampsia.
- CBC: hgb, platelet
- UA: 24 hr urine if possible
- LFTs
- lactate dehydrogenase: elevated with hemolysis)
- uric acid: increased with preeclampsia
- nonstress test to r/o uteroplacental insufficiency
- u/s to evaluate amniotic fluid volume
Management of preeclampsia.
- if term (>37wks): magnesium sulfate and deliver
- if preterm: evaluate severity. If mild: expectant treatment till term or severe. If severe: magnesium sulfate and deliver.
- when magnesium sulfate is used, need to monitor urine output (renal excretion), respiratory depression, dyspnea ( magnesium sulfate side effect is pulmonary edema), and abolition of the deep tendon reflex.
- magnesium sulfate is d/c 24 hrs after delivery.
- pt to f/u 1-2 wks to check BP and proteinuria.
What is the most common disease of this?

- 34 y/o women with unilateral serosanguineous nipple discharge from the breast, expressed from one duct.
intraductal papilloma
What is the most common disease of this?

- 27 y.o women with breast pain which increases with menses, breast has a lumpy bumpy sensation.
fibrocystic changes
What is the most common disease of this?

- 47 y/o women has a 1.5cm right breast mass with nipple retraction and skin dippling over the mass
breast cancer
What is the most common disease of this?

- 18 y/o women has an asymptomatic, 1cm, nontender, mobile, right breast mass.
fibroadenoma
Medical treatment for fibrocystic change of the breast.
- decrease caffeine intake, tight fitting bra
- NSAIDs
- OCP
- oral progestin therapy
- danazol (antiestrogen and antiandrongen) or mastectomy for severe cases
What to do for this woman with fibroadenoma?

- <35 y/o
- 3 dimensional dominant mass
FNA or core needle biopsy
What is the triple assessment of the breast?
usually evaluates a 3D dominant mass of the breast: ex. fibroadenoma
- clinical sxam
- imaging
- histology

*nonconcordance indicates the need to obtain more tissue
What is this condition and what should be done?

- 23 y/o G1P0 at 40 wks gestation
- incuded with pitocin
- cervix 6cm dilated for 3 hrs
- significant caput on cervical exam
arrest of active phase of labor
- next: consider 3Ps (pelvis, powers, passenger).
- if all adequate: consider c section
- if uterine contraction not adequate (<200 montevideos): give pitocin
What are the criteria for the diagnosis of arrest of active phase of labor?
- completed latent phase
- no cervical dilation for 2 hr or longer
Etiology of infertility.
1. Uterine: anomalies (septate uterus, bicornuate uterus), synechiae (Asherman syndrome), myomata.
2. ovulatory dysfunction: anovulation, irregular menses
3. tubal factor: peritubal adhesion, obstruction, GC infection
4. cervical factor: diminshed mucus production (leep procedure), sperm antibodies
5. peritoneal factor: endometriosis (3D: dysmenotthea, dyspareunia, dyschezia)
6. male factor: low sperm count, decreased motility and morphology, abnormal viscosity or agglutination.
How to evaluate ovulatory factor for infertility?
- basal body temperature chart: temp rise by 0.5F after ovulation for 10-12 days.
- LH surge
- luteal phase progesterone level: > 10ng/dl
How to evaluate uterine factor for infertility?
- hysterosalpingogram
How to evaluate tubal factor for infertility?
- hysterosalpingogram
How to evaluate peritoneal factor for infertility?
evaluate for endometriosis
- laparoscopy
- CA125
Treatment for this type of infertility:

- ovulatory dysfunction
clomiphene citrate:
- estrogen receptor modulator
Treatment for this type of infertility:

- endometriosis
- ablation of endometriosis
- medical therapy: NSAIDs, progesterone/progestin, OCP, danazol (suppress LH and FSH), GnRH agonist (lupron).
What is a typical normal sperm analysis?
- liquefaction: < 20 min
- volume: 1-6.5 ml
- pH: 7.2-7.9
- count: > 20 million
- % motile: > 60%
- % motile with FP: 75%
- morphology: >14%
What is this term?

- probability of achieving a pregnancy within one menstrual cycle.
fecundability
What is this disease during pregnancy?

- R lower quadrant pain, superior and lateral to McBurny's point
- NV
- anorexia
- fever
- leukocytosis
appendicitis
- surgical treatment: laparotomy + IV antibiotics
- may occur throughout pregnancy
What is this disease during pregnancy?

- first trimester
- right upper quadrant pain following meals
- nausea, vomiting
- bloated sensation
- no fever or leukocytosis
biliary colic
- due to increase in gallbladder volume and biliary sludge
- treatment: lowfat diet and observation till postpartum
What is this disease during pregnancy?

- first trimester
- right upper quadrant pain following meals
- nausea, vomiting
- bloated sensation
- fever
- leukocytosis
cholecystitis
- surgical treatment
What is this disease during pregnancy?

- 14 wk gestation
- unilateral abdomal or pelvic pain, colicky
- nausea, vomit
ovarian torsion
- surgical treatment: unwind the vascular pedicle to achieve reperfusion, if not viable, oophorectomy
What is this disease during pregnancy?

- thrid trimester bleeding, painful
- crampy midline uterine tenderness
- abnormal fetal heart tracings
placental abruption
- treatment: delivery via c section
Ectopic pregnancy is best evaluated by quantitative hCG and transvaginal u/s. U/s demostrating a gestational sac maybe misleading, demonstration of crown-rump length or yolk sac is reassuring of IUP. Why?
Ectopic pregnancy could be associated with fluid in the uterus , called "pseudogestational sac".
Treatment of ectopic pregnancy: when to use salpingectomy, salpingostomy, or medical therapy?
salpingectomy:
- gestations too large for conservative therapy
- rupture
- for women who do not wish future fertility

salpingostomy:
- for women who desire fertility
- unruptured tubal pregnancy

medical therapy: one shot methotrexate IM
- pregnancies less than 4 cm in diameter
What is this condition?

- 29 y/o G2P1 at 28 wk gestation
- 1 wk hx of fatigue
- treated with antibiotics for UTI 2 wks ago, now has dark-colored urine
- hgb: 7 g/dl
hemplytic anemia
- nitrofurantoin, a common prescribe abx for treating UTI during pregnancy is an oxidizing agent, may induce hemolysis in patients with G6PD deficiency.
- other possible meds that may cause this: sulfonamides, antimalarials.
What is the most common cause of anemia in pregnancy?
iron deficiency
- low ferritin
- high TIBC, transferritin, RDW
- low hgb (<10.5 g/dl for pregnant women)
Possible causes of hemolysis during pregnancy.
- HELLP syndrome
- autoimmune hemolytic anemia
- sickle cell crisis
- G6PD
Risk factors for preterm labor.
- preterm premature rupture of membranes
- multiple gestation
- previous preterm labor or birth
- hydramnios
- uterine anomaly
- history of cervical cone biopsy
- cocaine abuse
- african american race
- abdominal trauma
- pyelonephritis
- abdominal surgery in pregnancy
What is the cause of the symptoms?

- urinary urgency , frequency, and dysuria
- urine culture shows no organisms.
possible urethritis (often caused by chlamydia trachomatis)
- need urethral swabbing for chlamydial testing

could also be caused by candidal vulvovaginitis
What is the disease?

- urinary urgency and dysuria
- negative urine culture
- unkown etiology
urethral syndrome
- caused by urethral inflammation
Treatment of urethritis in pregnancy.
treat for chlamydia and gonorrhea infection
- cetriaxone
- should avoid doxycyclin during pregnancy
Treatment of pyelonephritis in nonpregnant and pregnant women.
In nonpregnant women
- trimethoprim/su;fa
- fluoroquinolone
- iv ampicillin or gentamicin if not tolerating po meds

in pregnant women
- hospitalize and treat with iv ampicillin or gentamicin
- suppressive antimicrobials (nitrofurantoin) for the remainder of the pregnancy
2 most common regimen of "morning after pills", ie emergency contraception.
1. Yuzpe regimen: 2 tablets of 0.1mg ethinyl estriadiol and 0.5mg levonorgestrel at time zero and 2 tablets after 12 hr.
- efficacy 75%
2. plan B (progestin only): 0.75 levonorgestrel in 2 doses taking 12 hrs apart
- greater efficacy (85%)
- fewer side effects

Side effects: n/v
Contraindication of emergency contraception.
- suspected pregnancy
- abnormal vaginal bleeding

women who do not have onset of menses within 21 days following emergency contraception should have a pregnancy test.
What are the 4 most common cause of death in the age group 13 to 19 yrs?
1. motor vehicle accidents
2. homicide
3. suicide
4. other unitentional injuries
What is the cause of symptoms?

- 20 y/o G1P0 at 29 wks gestation with acute pyelonephritis
- treated with iv ampicillin and gentamicin
- dyspnea, tachycardic
- right CVA tenderness
ARDS
- pulmonary injury due to endotoxin release (abx lyse the bacteria) -> leaky capillaries
- treatment: O2 supplement, fluid monitor

* endotoxin may damage capillaries, myocardium, liver, kidney and lungs
What is the most common cause of septic shock in pregnancy?
acute pyelonephritis
Asymptomatic bacteruria during pregnancy is best identified with what test?
urine culture on the first prenatal visit.
Management of DVT during pregnancy.
IV heparin 5-7 days then switch to subqutaneous therapy to maintain ppt at 1.5-2.5x control for at least 3 month after acute event. Then start full heparinization or prophylaxis for the remainder of the pregnancy.
What is this condition?

- 22 y/o female hx of wt loss, nervousness, sweating
- tachycardic
- thyroid gland normal to palpation, no proptosis or lid lag
- 9 cm mobile adnexial mass with cystic components.
Struma ovarii
- benign cystic teratoma (dermoid) containin thyroid tissue
- a type of germ cell tumors
- complication: torsion with severe acute abdominal pain
- treat surgically: cystectomy of oophorectomy
Types of epithelial ovarian tumors. Which type is most common?
- serous
- mucinous: most common, large size, may lead to pseudomyxoma peritonei if ruptured
- endometriod
- Brenner
- Clear cell

treatment
- surgical staging, optimal debulking
- then combination chemotherapy
For the following age group, what is the ovarian size that you should consider operate?

- prepubertal
ovarian size > 2cm
For the following age group, what is the ovarian size that you should consider operate?

- reproductive age
> 8cm: operate
5-8cm: sonogram, if septate or solid components, operate
For the following age group, what is the ovarian size that you should consider operate?

- postmenopausal
> 4-5 cm
What is the cause of her condition?

- 45 y/o diabetic woman
- postop day 7 of surgical staging of ovarian cancer
- profuse serosanguinous drainage from incision
fascial disruption
- surgical emergency
- immediate repair
- broadspetrum abx
What is this wound complication called?

- separation of part of the surgical incision but with an intact peritoneum
wound dehiscence
What is this wound complication called?

- separation of the fascial layer, usually leading to communication of the peritoneal cavity with the skin
fascial disruption
What is this wound complication called?

- a disruption of all layers of the incision with omentum or bowel protruding through the incision
evisceration
What is the most common reason for fascial disruption?
suture tear through fascia
What is the likely cause of this?

- 10 wk gestation
- severe abdominal pain, lightheadedness
- passed some tissue (frond pattern) and heavy vaginal bleeding
- BP 90/60, HR 120, temp 99
- abdomen diffusely tender, distended, rebound tenderness, fluid wave
- cervix closed
hemorrhagic shock due to hemoperitoneum caused by ruptured corpus luteum
- next step: laparoscopy or laparotomy
- if corpus luteum is removed prior to 10 wks gestation, exogenous progesterone is needed because placenta has not take over the function of maintaining hCG level yet.
- cysts tend to rupture more during pregnancy
-
DDX of hemorrhagic corpus luteum.
- ectopic pregnancy
- ruptured endometrioma
- adnexial torsion
- appendicitis
- splenic injury or rupture
What is the interpretation of this finding?

- culdocentesis done in a pregnant lady: 3 cc of clotted blood
blood probably come from vaginal blood vessel if it is clotted.
What is the cause of this condition?

- 33 y/o women with 7 month hx of amenorrhea s/p D&C for a spontaneous abortion
- no past hx of dysmenorrhea
- normal physical exam
- negative pregnancy test
Secondary amenorrhea due to itrauterine adhesions (Asherman syndrome)
- next step: hysterosalpingogram
- treatment: operative hysteroscopy + conjugated estrogens and progesterone
- need to re-evaluate uterine cavity prior to attemp conception.
What factors are important in pregnancy success rate after tubal reconstruction?
- severity of disease process that affected the pelvis
- extent of tubal disease prior to surgery
- length of the reconstructed tube
- other fertility factors
- surgical technique
What is this condition in infertility called?

- tubal epithelium penetrates into the muscularis or even the serosa
- associated with tubal infection
salpingitis isthmic nodosa
What is this condition?

- 17 y/o female has not started menses
- normal breast and genitalia development
- missing one kidney on xray
- normal physical exam
primary amenorrhea: mullarian agenesis
- next step: serum testosterone level or karyotype to distinguish this condition from androgen insensitivity: testosterone level should be normal in mullarian agenesis and elevated in androgen insensitivity. Karyotype should be XX for mullarian agenesis and XY for androgen insensitivity
How to differentiate mullarian agenesis from androgen insensitivity?
- scant or absent of axillary and pubic hair for androgen insensitivity
- XY karyotype for androgen insensitivity
- high testosterone level in androgen insensitivity
Complications of androgen insensitivity.
need gonadectomy because of risks of malignancy.
What is this diagnosis?

- 15 y/o female with no breast development and short stature
- karyotype is XY
gonadal dysgenesis
What is the diagnosis? what to do next?

- 23 y/o POD3 s/p D&C for incomplete abortion now presents with vaginal bleeding, lower abdominal cramping, fever, and chills.
- vitals: BP 90/40, HR 120, temp 102.5F
- exam: severe lower abdominal tenderness, cervix open, uterine tenderness
- labs: leukocytosis, normal urine analysis
septic abortion due to retained product of conception
- ascending infection from bacteria in the vaginal wall: strep, bacteroides, E coli, other gram negatives.
- next: broadspectrum abx and abx covering anaerobes (combo of clindamycin and gentamicin followed by D&C after at least 4 hrs.
What are the steps of teatment for septic abortion?
1. maitain BP: dopamine agonist, digitalis, steroids if needed
2. monitor BP, O2sat, UOP
3. start broadspetrum abx
4. uterine curettage
What is this? what to do next?

- 29 y/o female at 39 wks gestation with preeclampsia delivers vaginally
- after delivery of placenta, she has vaginal bleeding about 1000ml
postpartum hemorrhage most likely due to atony
- next: give dilute IV oxytocin, if not effective, give IM prostaglandin F2a
What are some causes of postpartum hemorrhage?
- urterine atony
- genital tract lacerations: suspected when uterus is firm
- uterine inversion
- placenta accreta or retained placenta
Treatment of postpartum hemmorhage due to uterine atony.
1. IV oxytocin
2. IM methergine: contraindicated in HTN patients
3. IM prostaglandin F2a: contraindicated in asthma patients
4. supposatorymisoprostal
5. uterine artery ligation, B-Lynch stitch, hysterectomy
Risk factors for uterine atony.
- magnesium sulfate
- oxytocin during labor
- rapid labor or delivery
- over-extension of uterus
- chorioamnionitis
- prolonged labor
- high parity
What are some causes of late postpartum hemorrhage?
bleeding after 24hrs postpartum
- subinvolution of placental site: treat with oral ergot alkaloid
- retained product of conception: treat with broadspectrum abx and uterine curettage
What is defined as delayed puberty?
lack of secondary sexual characteristics by age 14
What are the 4 stages of pubertal development?
1. thelarche: breast budding, age 10-11
2. pubarche/adrenarche: pubic and axillary hair, usually at age 11
3. growth spurt: 1 yr after thelarche
4. menarche: 2.3 years after thelarche
2 categories of causes of delayed puberty.
1. CNS: hypogonadotropic hypogonadism
- low FSH, low estrogen
- poor nutrition, eating disorder, chronic illness
- primary hypothyroidism, cushings, pituitary adenoma, craniopharyngiomas
2. ovarian: hypergonadotropic hypogonadism
- high FSH, low estrogen
- Turner's syndrome (most common), ovarian damage due to radiation, chemo, inflammation, torsion
Lab workup for delayed puberty.
- FSH, estrogen: to differentiate central and gonadal cause
- TSH
- karyotype
Management of delayed puberty.
goal is to initiate and sustain sexual maturation, prevent osteoporosis, and promote full height potential
- combine ocp: estrogem to promote growth and development, progestin protest against endometrial cancer
What is the condition and how to treat it?

- 3-4 wks postpartum breast pain, redness of the right breast, and fever
mastitis
- treat with dicloxacillin
- can still breast feed
What to do next?

- 22 y/o nulliparous with tender red right breast and enlarged axillary nodes
- no h/o trauma to the breast
- not lactating
biopsy
- suspect inflammatory breast carcinoma
What is the diagnosis?

- 18 y/o G2P1 at 35 wk gestation with h/o Grave's disease
- c/o nervousness, sweating, diarrhea, heart pounding
- vitals: BP 150/110, HR 140, RR 25, temp 110.8F.
- exam: thyroid mildly tender and enlarged. CV: tachycardic, systolic ejection murmur, tendon reflex +4
- lab: 20000 WBC
thyroid storm in pregnancy
- to treat: beta blockers (propranolol, corticosteroid, and PTU.
- PTU may cause bone marrow aplasia leading to leukopenia, and sepsis.
- for nonpregnant pt: saturated solution of potassium iodide
What is this condition?

- 24 y/o woman 2 month after SVD
- 1 wk h/o nervousness, tremulousness, feeling warm
- lab: TSH 0.01 mIU/ml
Destructive lymphocytic thyrotoxicosis
- postpartum steroid level is low and antimicrosomal antibodies are present.
Mangement of pregnant women with +chlamydial DNA assay only.
- oral erythromycin, azithromycin or amoxicillin
- erythromycin eye cream for new born prevents gonnococcal eye infection but no to chlamydial eye infection.
- oral erythromycin for newborn for 14 days to prevent eye infection
Management of intrapartum HIV.
- polytherapy antivirals
- goal is to maintain viral load < 1000 RNA copies per mL
- monthly monitor of viral load, liver function (drug toxicity).
- HIV serostatus at the time of delivery
- schedule c section or give IV ZDV for vaginal delivery
- neonate should also receive oral ZDV syrup
Outcome of B19 virus infection in pregnant women.
fetal abortion, stillbirth, hydrops
- mechanism: fetal anemia due to neonatal parvovirus infection which inhibits bone marrow RBC production
- gestation < 20 wks especially susceptible
- diagnosis: IgG and IgM seroplogy
List some causes of hydramnios.
- fetal CNS anomalies: anencephaly
- fetal GI malformations: duodenal atresia
- fetal chromosome abnormalities
- fetal nonimmune hydrops
- maternal diabetes
- isoimmunizations
- multiple gestation
- syphilis
What is the most sensitive method to diagnose genital herpes?
viral culture or PCR
List some differences between primary HSV2 and recurrent HSV2 infection.
Recurret infection:
- less infectious potential
- less symptoms
- lower viral load
- longer duration
What are the criteria for a HSV2 + women to delivery vaginally?
- no lesions
- no prodrome symptoms such as numbness, tingling sensations.
What is the most significant risk factors for postpartum endometritis?
most significant: c section
others
- numerous vaginal exams
- prolonged labor
- intrauterine pressure monitor
What bacteria is most commonly isolated in endometritis complicating patients who have undergone c section?
bacteroides (anaerobic)
What is the diagnosis? how to treat it?

- 22 y/o POD2 s/p c section
- persistent fever
- unresponsive to broadspectrum abx
- normal UA
- exam is normal
septic pelvic thrombophlebitis
- treat with IV heparin
What is this disease? What to do next?

- 31 y/o women with nontender, firm, 1cm ulcerated lesion of the vulva on an indurated base, raised border
- nontender bilateral palpable inguinal nodes
syphilic chancre
- next: RPR or VDRL, if negative, dark field microscopy, confirm with specific serology test (MHA-TP or FTA-ABS)
- treat with IM penicillin, if allergic, desensitize and then penicillin
Three most common infectious causes of vulvar ulcers in the US.
- HSV: painful vesicles
- syphilis: painless ulcer
- chancroid (haemophilus ducreyi): painless ulcer with ragged edges on a necrotic base, and tender lymph nodes. treat with oral azithromycin or IM cetriaxone. Need biopsy or culture to diagnose
List the clinical manfestations of primary, secondary, and tertiary syphilis.
Primary syphilis
- chancre

Secondary syphilis
- macular papular rash on palms and soles
- condyloma lata

Tertiary syphilis
- optic atrophy
- tabes dorsalis/neurosyphilis: treated with IV penicillin
- aortic aneurysm
What is the diagnosis? What to do next?

24 y/o woman at 30 wk gestation with PROM
- fever, mild uterine fundus tenderness
- persistent fetal tachycardia
chorioamnionitis
- next: IV abx (ampicillin and gentamicin) and induction of labor
- mechanism: ascending infection of vaginal organisms
Risk factors for PPROM.
- lower socioeconomic status
- STD
- smoking
- cervical conization
- emergency cerclage
- multiple gestation
- hydramnios
- placental abruption
Which bacteria may cause chorioamnionitis without ROM?
listeria
- mechanism: transplacental spread
Management of ROM in the following cases:

- after 34 wks
- before 32 wks
- before 32 wks with chorioamnionitis
- after 34 wks: induction of labor
- before 32 wks: expectant management
- before 32 wks with chorioamnionitis: IV broadspectrum abx (ampicillin and gentamicin)
What is the etiology of this vaginal infection?

- white discharge with a fishy odor, odor is worse after intercourse
- pH > 4.5
- whiff test positive
- clue cells on wet prep
bacterial vaginosis
- not a true infection: over clonization of anaerobic bacteria
- treat with metronidazole: should avoid alcohol to avoid a disulfiram reaction
What is the etiology of this vaginal infection?

- frothy yellow to green discharge with a fishy odor
- pH > 4.5
- strawberry cervix
- wet prep showed mobile flagellate organisms
trichomonal vaginitis
- true inflamation
- can survive up to 6 hrs
- treat with metroniodazole
What is the etiology of this vaginal infection?

- curdy or cottage cheeze like discharge
- intense vulvar or vaginal burning, irritation, swelling
- pH < 4.5
- wet prep: pseudohyphae
candidal vaginitis
- treat with fluconazole
DDX for hirsutism.
- cushing's syndrome: glucose intolerance, hypertension, buffalo hump, central obesity. Diagnosed by dexamethasone suppresion test. Treated surgically.
- adrenal tumor: rapid onset virilism, abdominal mass. Diagnosed by DHEA-S. Treated surgically.
- CAH: ambiguous genitalia, family hx, hypotension. Diagnosed by 17-hydroxyprogesterone. Treat with cortisol and mineralcorticoid.
- PCOS: onset since menarche, hirsutism, rarely virilization. Diagnosed by elevated LH-FSH ration. Treat with OCP.
- sertoli-leydig cell tumor: rapid onset, adnexal mass. Diagnosed by testerone level. Treated surgically.
What to do next?

- 20 y/o woman at 16 wk gestation with elevated msAFP (2.8x).
- hx: certain about LMP, regular menses
- fundal height midway between pubis and umbilicus.
next step: u/s to assess dates and multiple gestation
What is the diagnosis?

- low msAFP
- high human chorionic gonadotropin
Down syndrome
What is the diagnosis?

- low msAFP
- low hCG
- low inhibin
trisomy 18
What is the first trimester Down syndrome screen composed of and when is it usually performed?
1st trimester Down syndrome screen (between 10-13 wks):
- PAPP-A
- hCG
- nuchal translucency
What is the window for serum screening for aneuploidy?
between 15-21 wks
- triple screen: AFP, hCG, unconjugated estriol
- quad screen: AFP, hCG, unconjugated estriol, inhibin
Causes of low msAFP.
- overestimation of gestational age
- chromosome abnormalities
- molar pregnancy
- fetal death
- increased maternal weight
Causes of high msAFP.
- underestimated gestational age
- multiple gestation
- neural tube defect
- abdominal wall defect
- cystic hygroma
- fetal skin defect
- sacraococcygeal teratoma
- decreased maternal weight
- oligohydramnios