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477 Cards in this Set

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Risk of shoulder dystocia with macrosomia
15%
definition macrosomia
4000g
Why isn't macrosomia an indication for induction?
No reduction in shoulder dystocia

CD rate rises
Misoprostol broken down in:
lung
Pulmonary edema

physiology
physical finding
lung exam
CXR finding
management
increased oncotic pressure

pink frothy sputum

auscultation rales

patchy infiltrates

sit pt upright
lasix up to 100mg
Clotting time
red top tube
should clot in 10 minutes
Nitro given how for uterine inversion?
IV or sublingual
seatbelt
how to wear in pregnancy
should strap b/w breasts
lap belt under protuberance and on ASIS b/l
High Brow presentation can deliver how?

diagnose brow how?
Possibly vaginally, will see how comes down.
Low brow must CD

feel anterior fontanelle and orbital bridge
PPH, Don't forget to examine placenta!
PPH, Don't forget to examine placenta!
after 6 units prbc, give
1 amp Calcium gluconate
after 4 units prbc, give
FFP if not in DIC
If in DIC give FFP until >100 or nl PT
treatment hypovolemia, don't forget can try as last resort
MAST Suit
Severe oliguria, must do this
CVP by PAC
Pulmonary artery catheter
Severe oliguria, don't forget meds!
Also give ephedrine and Dopamine.
renal dose/cardiac dose
vasopressors to gently squeeze flow to kidney.
Why fracture clavicle?
creates new bisacromial diameter
Try all maneuvers again.
# cervical vertebrae
# cranial nerves
7 vertebrae
8 cranial nerves
Complications of fracturing clavical
pneumothorax
hemothorax
subclavian vessel injury
A possible laparaomy last ditch in shoulder dystocia to:
give suprapubic pressure directly intraop
ECV contraindications
Multiple geststion
IUGR
Previa/abruption
maternal cardiac disease
Gest HTN
Uterine malformations
large submucosal fibroid
Marked oligo
PROM
Unexplained uterine bleeding
Prerequisites ECV
37 weeks
L&D, weekday
NPO since MN
notify anesthesia
T&S
informed consent
NST
u/s DVT PE PACU
SQT for which ECV candidates?
Nulliparous
What is only force to be give to breech?
Rotational force to keep sacrum anterior
head entrapped breech? What to do?
u/s, needle decompression if hydrocephaleus
Still entrapped?
symphysiotomy
Going to OR for vag breech, call for:
u/s
Deliver breech head by
Suprapubic pressure
Mariceau-Smellie-Veit
Pipers
Duhurssens
c/s under local, call for:
EKG
need continuous monitoring
CPR for mother, how much time to deliver fetus?
4 minutes
Postmortem?
17 minutes (20 minutes)
undocumented scar, mode of delivery
VD.
No increased rupture risk.
VBAC twins?
YES!
No increased rupture risk.
ECV if prior CD?
Yes, unless classical was prior.

Also, only if 1 prior c/s.
Gestational HTN - BP PP?
Normal BP
AFLP lab findings
low glucose
elevated serum ammonia
coagulopathy- hypofibrinogenemia
LFTs elevated

give D50
Superimposing?
Symptomatic OVER HIT
new onset proteinuria
worsening proteinuria
abrupt change BP
HELLP
Secondary causes HTN
Cushings
Pheo
Renal artery stenosis
Coarctation aorta
What to do with severe remote from term preeclampsia?
Transfer to tertiary care center. Needs delivery if term.
Mg toxic range based on symptoms:
increments of 6

reflex 10
cardiac arrest 22

repsiratory in between at 16
increments of 6
Seizure in Myasthenia? What to give?
Phenoarbital 250mg

Dilantin
valium
Dilantin needs what?
EKG
Valium needs what?
Bag mask
Pregestational DM without preexisting retinopathy needs how many exams?
One ophtho exam

preexisting needs q trimester
how to treat hypoglycemic episode
glucagon
milk
Creatnine level in ESRD
Creatnine > 1.5
Preconceptional DM counseling
D Document and classify/Whites
E Evaluate end organ ophtho, renal, cardiac
A Autoimmune/TSH and Adverse outcomes maternal/fetal
R Reinforce tight control/meds/diet/exercise/folate
insulin used for pump?
Glargine
24 hour duration
No peak, all basal
Pederson's Poor Prognostic signs.
An indication to regard DM pregnancy to be high risk
HTN/Preeclampsia
Pyelo
DKA
Self neglect
recurrence DM next preg?
50%
Which DM to deliver early
Poor control
Nephropathy
Vasculopathy
Prior Stillbirth
No need for 3 hour if GTT is:
185
u/s efw off either way by what %
15%
Which stage labor most risky time for cardiac patients?
Third stage
increased blood infused from retracted uterus
Besides TSH, how can PTU be monitored?
pulse rate
What happens to Total and free T3 T4 in pregnancy, and why?
Estrogen increases TBG, so increase in total T3 and T4

TSH, Free T3 and T4 stay same
(except for early pregnancy HCG effect)
Why do seizure med levels go up or down in pregnancy?
Decreased albumin - free drug up
increased RPF and GFR - total levels down
Not usual pharmacokinetics
Newborns of mothers on anticonvulsants should get what?
Vitamin K
Fetal Hydantoin syndrome:
Phalangeal hypoplasia
neonatal coagulopathy

microcephaly
MR
IUGR (sIp)
Management seizure disorder/meds in pregnancy
control - preconception
convert - to single agent
content - rest/sleep
adjust - levels
assess - NTD, IUGR
APS diagnosis
RAT and
LA/ACA

RPL
Autoimmune thrombocytopenia
Thrombosis
and
LA or ACA
RAT and
LAC/ACA
This antibody if present will have a prolonged PTT
anti La (SSA)

La La La La prolonged...
This antibody predisposes to congenital lupus
anti Ro (SSB)
This antibody predisposes to fetal wastage
anti La

To live and die in La
heart block for lupus
La (SSA)

Jenny from La block.
APS like seizure disorder risk how?
SIP

watch for preeclampsia/Gest HTN

Also IUGR and Stillbirth

aPS-I like SIP
Treat APS?
Low dose ASA
Heparin 5000 BID
Congenital lupus
cutaneous - temporary
anti- Ro
also partial heartblock
definition gestational thrombocytopenia in pregnancy:

Likely ITP if what platelet level?
<150,000

No strict clinical definition of gestational thrombocytopenia

ITP if < 70,000
ddx thrombocytopenia
ITP
FAIT
Gestational thromocytopenia
HELLP/Severe Preclampsia
Heparin/AZT/MTX
SLE/APS
DIC
Treatment ITP
Prednisone
Treatment FAIT
IVIG
Splenectomy
platelet transfusion if having surgery
Mode delivery ITP, FAIT?
obstetric principles
Intrapartum fetal platelet estimation helpful?
No
What is FAIT?
Platelet equivalent Rh disease.
What is mosaic
Two different cell lines with different karyotypes
More common twinning?
Dizygotic
Family history?
Dizygotic
AMA cutoff for twins
32 years old
Definition discordance

Usually in which type twins?
20%

Dizygotic
Diagnosis of discordance?
May have discordance in retrospect
difficulty with inaccuracy of u/s (15%)
What to look for in u/s twins?
intervening membrane
placentae
fluid
anomalies
cervical length/funneling shortening
Deliver twins when?
Deliver at 40, can aim for 38 if concerns/maternal symptoms.
TTT look at
bladders
fetal survival 24 weeks (viability)
15%
fetal survival 28 weeks
82%
When ANT per ACOG?
41 weeks
Hep A vax and IG okay in pregnancy?
yes
Hep B vax and IG okay in pregnancy?
Yes
Parvo findings in fetus
hydrops
anemia
heart failure

SAB first trimester
(TORCH IUFD)
Think of parvo as
Hydrops

mother makes antibodies to fetal rbcs and precursors.

virus replicates in bone marrow
What is treatment Parvo?
PUBS - blood transfusion
needs rbcs, and precursors were knocked out!
Parvo transmission?
30%
Mother presents with Parvo:
lacelike rash
flu
polyarthralgias peripheral - joint pain in adults
parvo dx:
Elisa/Western
Fetal survival with transfusion?
80%

(100-80 = 20%) without
Vertical transmission CMV?
30%
same as Parvo
What % fetuses die?
30%
Recurrent CMV disease?
negligible
Clinical features CMV?
Like Toxo

Chorioretinitis
Hydrops
HSM
IUGR
VENTRICULOMEGALY

Blueberry muffin rash/petechie from thrombocytopenia
MR
Most severe trimester for CMV?
First

Like toxo
Most common CMV trimester vertical transmission?
Third

Like toxo!

90/10 rule!
HIV, when should viral load be checked to determine mode delivery?
36 weeks
% transmission if HIV VL< 1000?
1%
When before c/s should ZDV be given?
3 hours prior
check HIV VL when?
36 weeks
risk transmission HIV if VL < 1000?
1%
ROM before c/s, what to do?
c/s within 4 hours.
increase transmission rate 2%/hr.
Give ZDV how long prior to scheduled c/s?
3 hours prior
Advanced HIV disease, increased risk transmission , what lab findings?
low CD4
high VL
p24 antigenemia on Western
side effects ZDV?
GI - lactic acidosis
hepatic steatosis - check LFTs
Thrombocytopenia
most predictable factor for HIV vertical transmission?
Viral Load
definition AIDS
CD4 <200
Identify how many bands on Blot?
2 out of 4 bands
Vertical transmission without ZDV
28%
Vertical transmission HIV with ZDV
8%
Vertical transmission HIV with ZDV + CD
2%
Vertical transmission HIV VD if VL<1000
1%
ACOG/CDC recommends opt in or out?
Opt out
sensitivity and specificity of Elisa and Western
99%
If positive what to check what labs?
VL CD4
CBC, LFT, Hep B, C, RPR,
If rapid HIV pos, what to do?
perform confirmatory test
CD if not in labor nor ROM
In pregnancy start ZDV 5x/day when?
14 weeks
until labor
CD performed when in HIV?
38 weeks
before onset labor
before ROM
If HIV and in labor, mode of delivery?
Individualize
discuss risks
check VL
Which twin higher transmission in HIV?
Twin A

At risk
AZT dose in labor
2 mg/kg then 1mg/kg/hr
can you VBAC if CD x 2 and but had a prior VD?
yes
no matter when it occurred in order.
Besdies MULIGI for IUFD/RPL, don't forget to check what?
Tox screen
Why does Lewis live?
It's an IgM/larger molecule

which does not cross the placenta.
Most common cause hydrops
Nonimmune

Parvo/CMV
Placenta AV malformations/chorioangioma
congenital heart defects
Poly amnio reduction for maternal comfort:
500cc/hr, total 1500cc
repeat every 2 weeks
% sensitivity DS for each test:
triple scree/first trimester anlytes only 65%
quad screen 75%
first trimester + sono 85%
combined FASTER 90%
can perform vag breech if:
26 weeks
750g
VBAC requisites:
on site anesthesia
can perform within 30 minutes
SBE prophylaxis is Recommended if bacteremia suspected in high and intermediate risk.
The following procedures - gynecologic
• Vaginal/abdominal hysterectomy (vagina involved)

• Vag delivery
• Urethral dilatation
• Cystoscopy
• Foley if infection



Endoscopic retrograde cholangiography with biliary obstruction

Biliary tract surgery

Surgical operations that involve intestinal mucosa
What are SBE Intermediate Risk cardiac lesion category?
Congenital heart malformations and unrepaired:
ASD
VSD
PDA


RHD with valvular dysfunction

HCM

MVP (regurg and/or thickened leaflets)
Contraindications to epidural
HSV on overying skin
coagulopathy
LMWH < 24 hours
local spinal anomaly
uncooperative pt
hypovolemia
SBE prophylaxis is Recommended if bacteremia suspected in high and intermediate risk.
The following proceudres - gynecologic
Vaginal/abdominal hysterectomy (vagina involved)
• Vag hysterectomy
• Vag delivery
• Urethral dilatation
• Cystoscopy
• Foley if infection



Endoscopic retrograde cholangiography with biliary obstruction

Biliary tract surgery

Surgical operations that involve intestinal mucosa
What are SBE Intermediate Risk cardiac lesion category?
Congenital heart malformations and unrepaired:
ASD
VSD
PDA


RHD with valvular dysfunction

HCM

MVP (regurg and/or thickened leaflets)
risk PP Depression
poor relationship with one's own mother
malformed infant
conceived <12 months after stillbirth
personal h/o depression
FH
lack of perceived emotional/financial support
single
had contemplated TOP
not breastfeeding
high number antepartum visits
h/o hyperemesis
not bonding with baby
Edinburgh PPD Scale

consider screening all new mothers before d/c home
10 item self-report quesitonnaire
max score 30
score 13 = identifies women with PPD
administration in first few days PP can predict mood for 1-2 months later PP
PPD treatment
Biopsychosocial support - new mom support group - reduces stress and depression

promote adequate sleep

pharmacotherapy

light therapy

ECT
f/u when after starting on PPD meds?
1-2 weeks
assess suicidal risk
Pharm therapy for PPD?
SSRI
SNRI venlafexine - monitor BP (SNRI)
Anxiolytic - 2 weeks, low dose/addictive potential
sides of SSRI and SNRI
GI (n/v/d)
HA
Insomnia
Sexual
Jittery
What if PPD needs help with sleep?
Benzodiazepine/alprazolam qhs
Trazodone qhs
risk PP Depression
poor relationship with one's own mother
malformed infant
conceived <12 months after stillbirth
personal h/o depression
FH
lack of perceived emotional/financial support
single
had contemplated TOP
not breastfeeding
high number antepartum visits
h/o hyperemesis
not bonding with baby
Edinburgh PPD Scale

consider screening all new mothers before d/c home
10 item self-report quesitonnaire
max score 30
score 13 = identifies women with PPD
administration in first few days PP can predict mood for 1-2 months later PP
PPD treatment
Biopsychosocial support - new mom support group - reduces stress and depression

promote adequate sleep

pharmacotherapy

light therapy

ECT
f/u when after starting on PPD meds?
1-2 weeks
assess suicidal risk
MOA of Trazodone?
unknown
Heterocyclic antidepressant used also as a sedative
antidepressant that alleviates sexual side sffects from SSRI
Bupropion - can cause seizures
Clinical response expected when from antidepressants?
4-6 weeks
refer when?
no response to meds
relapse
suicidal ideation
bipolar
ECT for which PPD patients?
risk for suicide or infanticide
psychotic symptoms
acute mania
Incidence factor 5 leiden
5%
Factor 5
inheritance factor 5 leiden
autosomal dominant
most common inherited cause thrombosis
Hereditary coagulopathies. Risk for thrombosis
Factor V Leiden
Antithrombin III deficiency
Protein C, S deficiency
HYPERHOMOCYSTENEMIA
Prothrombin G20210A gene mutation
Impedence plethysmography, what is sens and spec?
Highly sensitive, but not specific.
Factor 5 Leiden risk thrombosis if heterozygous:
5x
factor 5
Factor 5 Leiden risk thrombosis if homozygous:
50x
Which coagulopathies if tested while on heparin will have a false negative result? (falsely elevated)
Antithrombin III (hep potentiates ATIII)
Protein C,S (increased resistance in pregnancy)
How to test for hyperhomocystenemia?
fasting homocystine level
Why does LMWH have more bioavailaility?
due to reduced heparin binding
How do you act on neg V/Q scan results?
angiography if still have high suspicion
How do you act on intermed/high probability V/Q scan results?
start meds
PE work up
EKG
CXR
ABG
V/Q or Spiral CT
Angiography
ECAVA
Lung exam with PE?
Rales
Heart exam with PE?
Friction rub
CXR PE?
WNL or
Hampton's Hump- opaque triangular wedge points to hilum
Westermark sign - decreased vascularity
ABG finding on PE?
PaO2 < 90mmHg
EKG on PE?
sinus tachycardia
RAD - right axis deviation
S1Q3T3
Besides potentiating antithrombin III, what else does heparin do?
Increases inhibition of thrombin and Factor Xa

So can't cascade to clot
Why spatulate?
reduces stricture formation when it heals
"I would not do this, but an ultimate option would be to perform a ureteroneocystotomy by a specialist."
Good Quote
What suture for ureter repair?
4-0 chromic, full thickness
What suture to repair bladder?
3-vicryl
Which ureter anastomosis can always be done regardless of location as long as there is no tension?
end to end reanatomosis
When using vicryl layer on bowel repair, how is it closed?
interrupted

vicryl interrupted
bowel prep
Option #1
Golytely 1/hr q hour until clear
Cefoxitin 2g IV 30 minutes pre-op
Option#2
Neomycin 1g and Erythromycin 1g at 2,4,10p
Who gets mass closure?
obesity
Malignancy
Steroid therapy prolonged
poor nutrition
Poorly controlled DM
XRT
Monofilament suture, delayed absorbable
Maxon
PDS
Signs of drug fever
clinically better appearing than temp suggests

eosinophilia
When performing Vag Hyst, which is ligated first, cardinals or USL?
USL then Cardinals in VH.

In TAH alpha order on the way down, so in VH, it is the reverse.

So, USL then Cardinals in VH.
normal urinary frequency in voids/ day.
8/day
Nightime void normal frequency?
1 time/ night
PMH to ask about in eval incontinence?
DM
COPD
spinal cord injury
MS
PSH to ask about in eval incontinence?
Bladder
Back
Prior incontinence/prolapse surgery
XRT
continuous incontinence means
fistula
frequent dribble means
overflow incontinence
urolog how many days?
3 days
during work week
Normal bladder capacity
300-400 cc
Burch/sling success rate?
90%
sling for what?
SUI
ISD
Burch for what?
SUI
treatment kidney stone
IVF
analgesics
antibiotics
double pigtail stents
urteroscope/removal
percutaneous nephrostomy
lithotripsy
lithotripsy okay for pregnancy?
No
What's in TPN?
glucose
amino acids
lipids
if don't repair RVF right away, how long should you wait for inflammation to subside?
3-6 months
Culdocentesis, what gauge needle?
18 Gauge
Name 3 medical probs that are contraindicated for use of MTX in ectopic?
Active pulmonary disease
Liver disease
PUD
side effects MTX
stomatitis
thrombocytopenia
abdominal pain
leucopenia

elevated LFTs
MTX MOA
dihydrofolate reductase inhibitor
Two things to remind patients on MTX
No PNV/Folate
Reliable contraception

also avoid NSAIDS
Risk of ectopic if one prior and prior tubal surgery (not BTL)?

Think of it as whether had MTX treatment or salipingostomy/salpingectomy, will have same future risk
20%
Risk of ectopic if two prior ectopics or BTL?
50%
Risk of ectopic if ART?
5%
Vet or works on farm with positive serum BHCG. Could possibly mean what?
False positive.
Heterophile antibody
How to tell if false positive BHCG:
do urine BHCG
serially dilute serum
do a different assay

important when following BHCG s/p mole.
How do filshie clips compare to hulka?
Filshie's are longer, so can reach better.
Not studied in CREST study because came out afterwards.
Prog IUD failure rate
5%

Think of prog level = 5
Copper IUD failure rate
15%

like Bipolar
ectopic risk bands
7 %
lucky 7
failure rates higher for older women, ectopic rates higher for
younger women
pregnancy with IUD can cause
SAB
septic abortion
PTL
dose of rocephin for GC
125 mg IM
Does LVSI affect staging in Cervical CA?
No.

Only treatment.
Treatment of early stage breast CA with positive nodes varies depending on:
Menopausal status
Treatment of early stage breast CA with positive nodes
Premenopausal treatment
CAF

Cyclophosphamide (Breasts are cyclic)
Adriamycin
5-Fluoro-urocil
Treatment of early stage breast CA with positive nodes.
Postmenopausal treatment
Tamoxifen
most common cause solid breast mass
fibroadenoma
What % Pagets of breast are associated with underlying breast adenocarcinoma
20%
False positive rate mammo
10%

Same for false negative rate = 10%
Excisional breast bx if
bloody fluid - send for cytology/pos cytology
mass fails to resolve after attempted aspiration
clearing and subsequent reforming of mass
If pt HTN, what is their risk of UTERINE cancer?
5x risk!

think of estrogen and HTN
2nd trimester Cervical Ca.
What to do?
Terminate and treat!
1st trimester cervical cancer.
What to do?
No change. Usual treatment
Late 2nd and 3rd timester cervical cancer, what to do.
Individualize.
Consider risks/benefits.
Prematurity v. delayed treatment.
Point B represents location of what?
Obturator nodes
Point A represents location of what?
where uterine artery and ureter transect.
High risk HPV types:
16, 18, 31, 33, 35
External beam uses what element?
Cobalt

Tele = Tally = Talbot = Cobalt
Is Brenner solid or cystic?
Solid
serous cystadenoma bilaterality
10%
serous cystadenocarcinoma bilaterality
66%
germ cell tumors bilaterality

exception is gonadoblastoma =
15%

except gonadoblastoma 40%
mucinous ADENOMA b/l
virtually 0%
For mucinous, Think colon ca? order what marker?
CEA
think mucinous tumor? what marker?
CEA, CA 19.9
Criteria for borderline tumor (3)
PEN the Borderline

Papillations
Epithelial stratification
Nuclear atypia

No stromal invasion
PEN the Borderline
dysgerminoma b/L?
15%

b/l and bimodal
What tumor is exquisitely radiosensitive?
Dysgerminoma
How to treat dysgerminoma in young patient?
USO
washings
ipsi nodal dissection

follow HCG and LDH
How do you follow dysgerminoma up after surgery?
follow tumor markers
LDH
HCG
Dysgerminoma chemosensitive, too?
yes
Granulosa cell tumor histology
Call-Exner bodies
Coffee bean nuclei
organs involved in Lynch II
endometrium
ovary
breast
colon
According to WHO classification for metastatic GTN, which blood type is bad?
B is Bad.
theca lutein cysts are more common in which type of mole?
Complete
single agent treatment of metastatic GTN (low risk)
MTX 50 mg/m2 weekly
multi agent treatment of metastatic GTN (high risk)
EMACO

etoposide - inhibits microtubules
mtx - dihydrofolate reductase inhibitor
actinomycin - antibiotic, inhibits nucleic acid
cisplatin - inactivate nucleic acid CISPLACID!!!
oncovin (5FU) - inhibits DNA synthesis
follow up high risk disease need to follow titers for how long?
1 year
What is risk mole recurrence?
10x
What is risk of mole being CA?
5%
Cisplatin toxicity
Cis = piss
nephrotoxicity
Carboplatin toxicity
neurotoxicity
Taxol MOA
inhibits microtubule aggregation

TAXES the tubules so they're too tired to get together
vinco/etoposide alkaloid MOA
inhibits microtubule disassembly
most common cause cancer death in world
lung
most common gyn cancer death in world
breast
most common pelvic cancer in world
cervix
most common pelvic cancer death in USA
ovary
most common pelvic cancer in USA
uterine
most common pelvic tumor
fibroid
describe parakeratosis
nuclei in superficial layer
Describe secretory endometrium
subnuclear vacuolization
tortuous glands
luminal secretions
ovary has lymphocytes on histology, what is it?
dysgerminoma
krukenberg tumor on histo
signet ring cells
TB on histo
Langhans Giant Cell
When deciding b/w cone and leep, always discuss:
age
parity
desires
tubal status
Define CPP:
pain > 6 months
Name 3 musculoskeletal causes of CPP:
fibromyalgia
trigger point -represents center point of spasm in myofascial/myofascitis syndrome
arthritis

Pain posture - sacrum forward, legs hyperextended
Name 3 psych causes of CPP:
Depression
PTSD (rape)
Secondary gain
Name 2 unusual GI causes CPP:
mesenteric adenitis
meckel's diverticulum

Mesenteric & Meckel's
M&M's causes belly pain if eat too many
M&M's causes belly pain if eat too many
for CPP urinary, don't forget:
DI
Detrusor instability

do CMG
how do you work up pelvic pain?
"Quote"
"I take an extensive history.
I let my physical exam be guided by my history.
I let my lab work up be guided by my history and physical."
What is PQRST of CPP?
Precipitating
Quality
Radiating
Severity
Timing/aggravating/relieving
Osteoporosis when on lupron for how long?
2 years
options for conservative management of endometriosis
OCP/NSAIDs
GnRH
Depo provera
Danazol

DEPO-OSIS!!!
Preconceptional counseling
Food and Folate
Belts and Bikes/exercise
cats and rays/Xrays
smoke/drink/drugs(meds)
Vax (rubella/hep)and DV and vits
Preventive counseling
food and falls
belts and bikes
Vax and DV and vits/Ca
Smoke/drink/sex/drugs
kegels and continence
SBE
How many minutes of sunlight each day for adequate Vit D absorption?
30 minutes
how much Ca in glass of milk?
500mg Ca
What to tell patients to avoid while doing FOBT at home:
ASA
red meat
Vit C
Hep B household contacts should get what?
Hep B vax and HBIG if exposed
influenza starts when if low risk:
age 55
DEXA starts when if low risk
Age 65
every 5 years unless on meds, then every 2 years
when is meningococcal vax given?
15 years old
who gets pneumovax?
>65 once
every 5 years if:
sickle cell disease
immunocompromised
splenectomy
chronic medical illness
disadvantage of cone
bleeding
infertility - stenosis. Sperm can't get through
PTL
incompetence
SAB
Cone when
positive ECC
positive margins on leep
inadequate colpo
2 step difference

high parity
s/p tubal ligation
why bother doing colpo with AGC?
Still need to rule out 50% chance of concomitant squamous lesion.
AGC on pap, do what?
colpo (may have skip lesions past 3mm)
ECC
EMB
Do cone when for AGC if colpo/ECC/EMB okay?
If original pap was favor Neoplasia.
T score?
SD of mean of young adult peak BMD
osteopenia t score
T < -1.0
osteoporosis t score
T < -2.5
treat BMD with meds at what T score?
T = -1.5 with risk factors
T = -2.0 without risk factors
incidence BRCA I, II in population
1:800
not cost-effective to routine screen
inheritance of BRCA
autosomal dominant with high (likelihood) penetrance
lifetime risk of breast and ovarian cancer if BRCA pos and positive FH
50%
Meds that cause osteoporosis
Heparin
Anticonvulsants (Rickety)
Tamoxifen
Steroids

synthroid in super amounts
Depo Provera > 2 years
GnRH agonists
bone loss is mostly what type of bone?
trabecular
So your patient has BMD showing osteoporosis...

what is your work up of osteoporosis?
serum calcium
TSH if on synthroid
24 hour urine of Ca and Creatnine
PTH
Chem profile
How much vit D /day recommended?
400 IU/day
Fosamax contraindications
reflux
esophageal abnormalities
With HRT, how many fewer fractures per year? What % reduction?
5/10,000 fewer
33% reduction
Raloxifene reduces vertebral fractures by what %?
50%
Relax = Relox vertebrae
What are two other methods to reduce fractures (meds)
Salmon calcitonin nasal spray
PTH SQ
How is PTH SQ given?
Periodic injections

PTH continuously would actually increase osteoclasts, but intermittently given, it increases osteoblasts)
rape exam.
Five areas of body not to forget to collect samples
scalp
saliva
fingernails
pubic hair
rectum

clothes/fluid/woods lamp
percent co infection rate of GC/Chl
60%
Treat GC/Chl
Rocephin 125 mg IM
Doxy 100 mg BID x 7d
Treat PID outpatient
Ofloxacin/Flagyl

Ofloxacin,
400 mg PO BID X 14 days PLUS. Metronidazole, 500 mg PO BID X 14 days

or

Rocephin 250mg IM
Doxy 100 mg BID x 14 days


Outpatient PID: 14 day therapy
Oflaxacin/Flagyl
Mefoxitin with Probenecid, and Doxy with or without Flagyl
Ceftriaxone/Rocephin and doxy with or without Flagyl






Regimen A

Drug Regimen
Ofloxacin 400 mg PO BID X 14 days PLUS
Metronidazole 500 mg PO BID X 14 days

Regimen B

Drug Regimen
Ceftriaxone 250 mg IM X 1 OR


Cefoxitin 2 gm IM plus Probenecid 1 gm PO X 1 as a single dose OR
Other 3rd generation cephalosporin PLUS Doxycycline 100 mg BID X 14 days
Treat PID inpatient/TOA
Mefoxin 2g IV q 6 hours Me 2
Doxy 100mg IV q 12 hours


Cefotetan 1g IV q 12 hours
Gent
flagyl

amp/gent/flagyl
Treatment of Pyelonephritis?
Cephalosporins, first generation cefazolin (Ancef) PEcK (Gram neg)

Cephalosporins, 3rd generation ceftriaxone (Rocephin) PEcK & Ent (Enterobacter)

Ampicillin/gentamycin
how much PCN do you give for syphilis?
Benzathine PCN 2.4 mu IM
incubation primary syphilis
9-90 days
incubation secondary syphilis
6w-6 months (after primary chancre)
findings primary
painless chancre
findings secondary
lata rash
maculopapular
tertiary syphilis when?
years later
findings tertiary syphilis?
Gumma (granulomatous lesions)
Tabes Dorsalis (dorsal root ganglia)
Argyl-Robinson pupil
cardiac lesions
seroconversion syphilis
4-6 weeks
causes false pos RPR
SLE and small pox
malaria and mycoplasma
aging
Granula Inguinale findings
fistula
breakdown of tissue
what causes chancroid?
hemophilus ducreyi
If not pregnant and allergic to PCN, what can you give for treatment syphilis?
Tetracycline
Erythromycin
why not just give erythro to pregnant patient with PCN allergy instead of desensitization?
Erythro doesn't adequately treat fetus
Jarisch-Herxheimer can have what effect in pregnancy?
PTL

flu-like reaction from dying spirochetes
How do you diagnose chancroid?
culture

chancroid=culture
chancroid=culture
Whenever you find one STD what is very important to do?
Test for all STD!
Get a full STD panel.
TB CXR finding
Hilar LAN
apical cavitation
how is PPD administered?
INTRAdermally

0.1cc
purified protein derivative
Need to supplement TB meds with?
Pyridoxine (Vit B6)
Name 4 principles of medical ethics
Autonomy - right to choose
Beneficence - promote health and welfare
Non-Maleficence - do no harm
Justice
name of TB stain for AFB culture
Zeihl-Neilsen stain
What is found on Y chromosome?
SRY anitgen

Sex determining Region on Y chromosome
What does SRY do?
causes testes to produce seminiferous tubules
what do the seminiferous tubules do?
they produce 3 hormones
What 3 hormones do the seminiferous tubules produce?
Testosterone
MIF
5 alpha reductase
What does testosterone do?
promotes wollfian system
What does MIF do?
promotes ipsilateral mullerian duct regression
What does 5 alpha reductase do?
promotes male external genitalia
converts testosterone to DHT
where is SRY antigen receptor?
on testes
What is specifically needed for male external genitalia?
DHT
does ovary make testosterone?
yes
Name origin:
Clitoris
genital tubercle
Name origin:
Labia Majora
labioscrotal swelling
Name origin:
Labia minora
Urogenital fold
Name origin:
lower 1/3 vagina
urogenital sinus

sinovaginal bulb gets canalized
Name origin:
Hymen
mullerian tubercle
Name origin:
round ligament
mullerian duct
Name origin:
Gartner's duct
Wolffian duct
name congenital uterine fusion malformations in order of increasing severity
arcuate uterus
septate uterus
bicornuate unicollis
bicornuate bicollis
uterine didelphys - NO STRASSMAN REUNIFICATION
work up ambiguous genitalia
History

G
E
T
Genetic
Electrolytes (CAH)
Tumor


FH
Androgen ingestion
Androgen secreting tumor
work up ambiguous genitalia
Physical
Tanner
pelvic - vagina? cervix?
Breast development
work up ambiguous genitalia
Labs

GET
karyotype
testosterone
ELECTROLYTES
DHEAS
17-OHP
most common cause ambiguous genitalia
CAH
Why electrolytes deficient in 21 hydroylase deficiency?
No cortisol made
inadequate aldosterone made
shifts to making excess androgens

no neg feedback to ACTH - keeps seeing cortisol as being low.
causes congenital heart disease
multifactorial
chromosomal
lithium - Ebstein's - abnl Tricuspid, likely coincident ASD
DM
familial
Meds
TORCH
ddx hirtsuitism
Familial
Tumor
Drugs (androgens/danazol/dilantin)

PCOS/HAIR-AN
CAH/Sushings
to rule out adrenal tumor, should order what?
DHEAS
Testosterone
What do OCPs do to help hirsutism?
suppress androgens
decreases 5 alpha reductase
dec ILGF
increases SHBG
best way to dx if hypothalamic amenorrhea:
give premarin then provera


better than OCP (thins lining)- may have simply been ashermans.


or simply check FSH and estradiol. if both low then hypothalamic problem.
How should Premarin and provera be given?
PRIME with PREMARIN 5 mg x 21 days

Provera x 7days
Why is FSH high in menopause?
ovaries no longer secreting inhibin to inhibit B FSH levels.
What should you check with FSH?
Estradiol

low estradiol with high FSH means menopause. if both low, then hypothlamic. may not even need Premarin/provera.
Also remember that if no bleed with Premarin/provera, could be ashermans and not a hypothalamic disorder
Hypothalamic amenorrhea. How do you treat if fertility not desired?
OCP/replacement
to prevent fracture risk/bone loss
Hypothalamic amenorrhea. How do you induce ovulation if fertility is deisred?
Can't use clomid - need functioning hypothalamic-pituitary axis

Must use FSH and LH in hypothlamic amenorrhea.

Then add in HCG to trigger ovulation
definition secondary amenorrhea
no menses 6 months or missed equivalent to three usual cycles
don't forget LMP as physiologic reasons!
Lactation/menopause/pregnancy
side effects IV premarin
n/v
DVT
stroke
How does cortisol cause amenorrhea?
affects pulse generator of GnRh
what treatment is better for hypothalamic amenorrhea to treat fertility, FSH or recombinant LH?
recombinant LH
Can a prolactin level be done after a breast exam?
Yes, despite the fact that nipple stim can cause hyperprolactinemia, really need a lot of stim to affect levels.
Someone c/o PMS symptoms, what's the first thing they should do?
keep a PMS log for 2 months.
Then next for PMS per ACOG?
SANDS

support, aerobic exercise, nutrition, diet, spironolactone
Then next for PMS?
SSRI
Alprazolam
last for PMS?
OCP
GnRH
Danazol
Wat is prolactin under tonic inhibition by?
Dopamine
acts like PIF (prolactin inhibiting factor)
work up of galactorrhea, don't forget:
visual field testing
MRI of pituitary fossa
Why is MRI better than CT for adenoma?
MRI cuts will see if < 10mm.
CT will miss that.
Normal to produce milk how long after stopping BF or pregnancy?
1 year
meds that cause galactorrhea
TCA/Reglan and Haldol (anti DA)
to treat microadenoma how?
observe if reg menses
OCPs if amenorrhea - need replacement
Bromocriptine if symptomatic or desires fertility/ovulation
start thinking pituitary adenoma if PRL what levels?
70

>100 highly likely
follow adenoma PRL levels how often if micro (<10mm)
q 3-6 months
side effects bromocriptine
hypotension
dizziness
nausea
how to alleviate sides of bromocriptine
vaginal suppository
how often bromocriptine taken?
BID
how often Cabergoline/dostinex taken?
twice a week!

less severe sides than bromocriptine/dostinex
hormone units:
Prog
ng/ml
hormone units:
androgens
ng/ml
hormone units:
prolactin
ng/ml
hormone units:
estrogen
pg/ml
hormone units:
FSH/LH/HCG
mIU/ml
hormone units:
TSH
microU/ml
ONSET of LH surge to ovulation
36 hours
LH PEAK to ovulation
12 hours
Three things to check for infertility
uterine STOps


Mid luteal prog level - to see if ovulating
Semen anal
HSG
History Infertility
BBT - rough guide
Coital frequency
Cost/ multiple visits/no guarantee
Chronic disease
FH genetic abnormalities
Why remove hydrosalpinx?
only if going to do ART
only if have insurance to do it

d/w patient before going to OR

fluid is embryotoxic
when to try recombinant FSH/LH for infertility
after 3 ovulatory cycles with clomid
dose of injectables?
2 mg IM day 7-14
when to coitus after clomid?
5 days after last dose
when do they usally ovulate after clomid?
5 -10 days after last dose
how to treat precocious Puberty?
GnRH continuous
stops pulsatile release
What is used for GNRH addback?
Norethindrone - need after 6 months
can also use bisphosphonates
Why is GnRh needed for ART?
To take complete control of cycle
Can bromocriptine be given in pregnancy if needed for pituitary adenoma?
yes!

If macroadenoma with visual symptoms.
Inheritance:
Sickle cell
autosomal recessive
Inheritance:
CF
autosomal recessive
Inheritance:
Tay Sachs
autosomal recessive
Inheritance:
PKU
autosomal recessive
Inheritance:
Neurofibromatoosis
autosomal dominant
Inheritance:
marfans
autosomal dominant
Inheritance:
Huntingtons
autosomal dominant
Inheritance:
Osteogenesis imperfecta
autosomal dominant
Inheritance:
achondroplasia
autosomal dominant
Inheritance:
Hemophilia
X-linked recessive
Inheritance:
DMD
X-linked recessive
Inheritance:
cleft lip/palate
multifactorial
Define non disjunction
failure of chromatids to separate along metaphase plate during mitosis

one pole receives extra chromosome 24
other receives 22
Turners need what for treatment
HRT
Calcium
reurrence rate for NTD
3%
will folate prevent NTD for anticonvulsant use?
No
don't forget that patients with NTD may have this mutation:
Methyl Tetra Hydrofolate Reductase Mutation

MTHFR
is omphalocele ever normal?
yes.
In early embryo
9-10 weeks
what percent of omphalocele is associated with anencephaly
20%
What does GnRh do for ART?
synchronizes follicles
recurrence cleft lip
2%
recurrence cleft lip if sibling
5%
recurrence cleft lip if parent
5%
Why does clonidine help with hot flashes?
centrally acting alpha adrenegeric agonist.

acts on medulla oblongata for temp regulation
sides of clonidine?
clonidizzy
inclomnia
dry mouth
If need to give ERT, give what dose?

(Quote)
"Lowerst dose for shortest duration"

0.3 --> 0.45 --> 0.625
most effective clonidine dose
0.2 mg patch
daily or weekly
do you need to add progesterone if giving estrogen cream and have intact uterus?
If so, when?
Not if giving short term.

But if giving longterm (one year) should cycle q 3 months.
DES exposed should have paps/colpo beginning when?
age 14
consequences DES
cox comb cervix
incompetence
vaginal adenosis (glands in vagina)
T shaped uterus
ectropion
which local estrogen therapy has least absorption systemically?
estring
then
vagifem tabs, next best
VWD inherited how?
autosomal with varying penetrance
how to screen for VWD
Ristocetin factor
Factor 8
treat VWD
DDAVP - desmopressin acetate
VWF concentrates - cryoppt if bleeding
OCPs (increases VWF, just like pregnancy)
Tension HA can last how long?
Days!
Cluster HA worse when?
in AM
tearing
migraine HA follow aura in how long after aura?
within the hour

aura - hour
Can one take bromocriptine while breastfeeding?
No!

Will decrease prolactin.
therapeutic level dilantin
10-20 micrograms/ml
When are gent peaks done?
30 minutes after 3rd dose
when are gent troughs done?
30 minutes before next dose.

peak should be 8 mcg/ml
trough should be 2 mcg/ml
How many mg of protein should one have in their daily diet?
50mg
Aldara/imiquimod treatment for how long?
16 weeks

every other day
treatment for molluscum?
podophyllin
side effects fosamax
esophageal ulcerations
GERD
how long back up contraception for Essure?
3 months
need follow up HSG
bisphosphonate like fosamax but monthly.
Ibandronate
wait 60 minutes
what medication when used on vulva can mimic malignancy?
Podophyllin
which SERM decreases bone mass?
Tamoxifen
How do SERMS affect cholesterol?
reduces cholesterol
(think estrogen receptor)
b/w Tamox and Ralox, which reduces Breast Cancer in ER+ more?
Raloxifene
Which SERM is used to reduce osteoporosis and chemoprevention for Breast Ca and endometrial Ca
Raloxifene
which SERM increases risk uterine CA?
Tamoxifen
Which SERM causes vaginal estrogenization?
Tamoxifen
Which SERM reduces risk for pelvic floor relaxtion?
Raloxifene

Relax = Ralox!
how does monsels work?
denatures protein and occludes blood vessels
how does Silver Nitrate work?
precipitation of silver ions occlude blood vessels
coagulates cellular protein, removes granulation tissue
t 1/2 albumin
20 days
reflects longterm nutrition
t 1/2 prealbumin
2 days
t 1/2 transferrin?
10 days
indications for TPN
catabolic status lasting >7 days
XRT/ischemia - GI surgery
fistula/SBO leading to malnutrition
massive bowel resection
How many days of nutritional support does it take to catch up to one day of NPO?
3 days
complications TPN
line sepsis - pull line
thrombosis
GB disease
liver disease
ICP how to treat?
ursodeoxycholic acid (a bile salt that dissolves gallstones)
What can you give for ICP rash?
TAC (Acetonide cream 1%)
Ace Inhibitors usually exert their untoward effects on fetus in what trimesters?
2nd and 3rd trimesters
Pratt measured in what units?
French