Ob Gyn

Front 1

What is the MCC of preventable infertility in US?

Back 1

PID

Front 2

What is the most likely cause of infertility in a normal menstrating women under age of 30

Back 2

PID

Front 3

What is PID

Back 3

dt ascending STI of upper female genital tract that may involve endometrial cavity (endometritis), fallopian tubes (salingitis), ovaries (oophoritis), parametrial tissues/ligaments (parametritis), and.or peritoneal cavity( peritonitis)

Front 4

How to recognize PID on step 2

Back 4

female age 13-35 with following sx: 1. abdominal pain 2) adnexal tenderness AND 3) CERVICAL MOTION TENDERNESS

all three criteria must technically be present. in addition, one or more of hte following should be present: elevated ESR/C-reactive protein, leukocytosis, fever, or purulent cervical discharge

Front 5

HOw is PID treated

Back 5

Treat PID with more than one antibiotic (e.g., cefoxitin/ceftriaxone and doxycycline for outpatients; clindamycin and gentamicin for inpatients) to cover multiple organisms, especially Neisseria gonorrhoeae and Chlamydia trachomatis (the most common organisms). Also consider Escherichia coli, anaerobes, and, with a history of intrauterine device use, Actinomyces israelii.

Front 6

What are common sequelae?

Back 6

Common sequelae include infertility due to scarring of the fallopian tubes and progression to tuboovarian abscess (palpable on exam, may respond to antibiotics alone) that may rupture. Treat rupture with emergent laparotomy and excision of the affected tube (unilateral disease) or total abdominal hysterectomy and bilateral salpingo-oophorectomy for bilateral disease.

Front 7

Define endometritis. What are the symptoms and signs?

Back 7

Endometriosis is defined as endometrial glands outside the uterus (ectopic). Patients are usually nulliparous and over 30 with the following symptoms: DYSMENORRHEA (painful menstruation), DYSPAREUNIA (painful intercourse), DYSCHEZIA (painful defecation), and/or perimenstrual spotting. The most common site for the ectopic endometrial glands is the ovaries; look for tender adnexa in an afebrile patient. Other sites include the broad (uterosacral) ligament and peritoneal surface. Nodularities on the broad ligament are classic findings on physical exam; the classic sequela is a retroverted uterus.

Front 8

How is endometriosis diagnosed and treated?

Back 8

The gold standard of diagnosis is laparoscopy with visualization of the endometriosis. Treat first with birth control pills (if acceptable to patient); danazol and gonadotropin-releasing hormone agonists are second-line agents. Surgery and cautery can be used to destroy the endometriomas, a procedure that often improves fertility. In an older patient, consider hysterectomy and bilateral salpingo-oophorectomy for severe sympto

Front 9

What is the most likely cause of infertility in a menstruating woman over the age of 30 without a history of PID?

Back 9

Endometriosis.

Front 10

BUG

Back 10

FINDINGS

Hint 10

TREATMENT

Front 11

CANDIDA

Back 11

"Cottage cheese" pseudohyphae on KOH prep, hx of diabetes, antibiotic tx, or pregnancy

Hint 11

topical or oral antifungal

Front 12

T. Vaginalis

Back 12

Bugs seen swimming under microscope; pale green, frothy, watery discharge. "strawberry cervix"

Hint 12

Metronidazole

Front 13

G. vaginalis

Back 13

Malodorous discharge; fishy smell on KOH prep, clue cells

Hint 13

Metronidazole

Front 14

Human Papillomavirus

Back 14

Venereal warts, koilocytosis on Pap smear

Hint 14

Many (acid, cryotx, laser, podophyllin)

Front 15

Herpes virus

Back 15

Multiple shallow, painful ulcers; recurrence and resolution

Hint 15

Acyclovir

Front 16

Syphilis (stage I)

Back 16

Painless chancre, spirochete on dark-field microscopy

Hint 16

Penicillin

Front 17

Syphilis (stage II)

Back 17

Condyloma lata, maculopapular rash on palms, serology

Hint 17

Penicillin

Front 18

C. trachomatis

Back 18

Most common STD; dysuria, positive culture and antibody tests

Hint 18

Doxycycline or azithromycin*

Front 19

Neisseria gonorrhoeae

Back 19

Mucopurulent cervicitis; gram-negative bug on Gram stain

Hint 19

Ceftriaxone or fluoro quinolone*

Front 20

Molluscum

Back 20

Characteristic appearance of lesions, intracellular inclusions

Hint 20

Curette, cryotherapy, or electrocauterization/coagulation

Front 21

Pediculosis

Back 21

“Crabs;” look for itching; lice can be seen on pubic hairs

Hint 21

Permethrin cream (or malathion)

Front 22

True or false: With all of the infections listed in the previous table, you should seek out and treat the patient's sexual partners

Back 22

False. Candida and Gardnerella species are not typically sexually transmitted diseases; they are usually caused by disturbances in the normal vaginal flora. You should treat the patient's sexual partners and give counseling (e.g., condoms) for the other infections, which are sexually transmitted.

Front 23

True or false: Patients with gonorrhea usually are treated for presumed chlamydial infection

Back 23

True. A common current treatment strategy is to give both ceftriaxone (for gonorrhea) and doxycycline (for chlamydia) together to patients with gonorrhea. The reverse is not true; do not automatically give gonorrhea treatment to patients with chlamydial infection.

Front 24

Define adenomyosis. How does it classically present? What is the treatment?

Back 24

Adenomyosis is defined as endometrial glands within the uterine musculature Patients are usually over 40 with dysmenorrhea and menorrhagia and have a large, boggy uterus on physical exam. Do dilation and curettage first to rule out endometrial cancer. Consider hysterectomy to relieve severe symptoms; gonadotropin-releasing hormone agonists also may relieve symptoms.

Front 25

What are fibroids? How common are they? How often do they become malignant?

Back 25

Fibroids (i.e., leiomyomas) are benign uterine tumors (Fig. 16-2). They are the most common tumors in women and the most common indication for hysterectomy (when they grow too large or cause symptoms). Up to 40% of women have fibroids by age 40. Malignant transformation is quite rare (<1%).

Front 26

Explain the relationship between uterine leiomyomas and hormones. How do leiomyomas present? What is the treatment?

Back 26

Leiomyomas of the uterus are estrogen-dependent. Therefore, you may see rapid growth during pregnancy or use of oral contraceptive pills and regression after menopause. Leiomyomas may cause infertility, pain, and menorrhagia or metrorrhagia. Anemia due to leiomyoma is an indication for hysterectomy. Rare patients present with a polyp protruding through cervix. Dilation and curettage are needed to rule out endometrial cancer in women who present after the age of 35.

TX?

Hint 26

Treatment is usually surgical (the levonorgestrel-releasing intrauterine device is seeing more widespread use, though randomized trials are lacking). Myomectomy can sometimes maintain or even restore fertility; the alternative is hysterectomy.

Front 27

What is the first test to order in any woman of reproductive age with abnormal uterine bleeding?

Back 27

A pregnancy test.

Front 28

Define dysfunctional uterine bleeding (DUB). When is it physiologic?

Back 28

DUB is defined as abnormal uterine bleeding not associated with a tumor, inflammation, or pregnancy. It is the most common cause of abnormal uterine bleeding and is a diagnosis of exclusion. More than 70% of cases are associated with anovulatory cycles (unopposed estrogen). The age of the patient is important because after menarche and immediately before menopause, DUB is extremely common and, in fact, is considered physiologic. Most other women have polycystic ovary syndrome (PCOS), the most common nonphysiologic cause of DUB

Front 29

Why is dilation and curettage done in women over 35 with DUB? What other test should be ordered in all women with DUB (regardless of age)?

Back 29

To rule out endometrial cancer. Hemoglobin and hematocrit (or complete blood count) should be ordered on all women with DUB to make sure that the patient is not anemic from excessive blood loss.

Front 30

What causes DUB other than PCOS? How is DUB treated?

Back 30

Causes of DUB include infections, endocrine disorders (thyroid, adrenal, pituitary/prolactin), coagulation defects, and estrogen-producing neoplasms. In the absence of treatable pathology, treat first with nonsteroidal anti-inflammatory drugs (NSAIDs), which are first-line agents for DUB and dysmenorrhea. Oral contraceptive pills are also a first-line agent for menorrhagia and DUB if the patient does not desire pregnancy and menstrual cycles are irregular. Monotherapy with progesterone is used for severe bleeding.

Front 31

Define PCOS. How do you recognize it?

Back 31

PCOS is an endocrine imbalance characterized by androgen excess as well as a ratio of leuteinizing hormone (LH) to follicle-stimulating hormone (FSH) greater than 2:1. Patients also frequently develop enlarged ovaries with multiple peripherally-oriented cysts, which can be seen on ultrasound (Figs. 16-3 and 16-4). On the Step 2 exam, watch for an overweight woman who has hirsutism, amenorrhea, and/or infertility.

Front 32

What is the most likely cause for infertility in a woman under 30 with abnormal menstruation?

Back 32

PCOS.

Front 33

How is PCOS treated? With what risk is it associated?

Back 33

Treat with oral contraceptive pills or cyclic progesterone. If the patient desires pregnancy, you can use clomiphene to induce ovulation. Chronic unopposed estrogen (i.e., not enough progesterone; hence, infrequent menses) increases the risk of endometrial cancer in affected patients. Spironolactone can be used to treat hirsutism associated with PCOS. Metformin sometimes is used to treat the insulin resistance associated with PCOS and to help restore ovulation. However, metformin is not FDA-approved for this use, and oral contraceptive pills or cyclic progesterone are the preferred agents for endometrial protection.

Front 34

Is infertility usually a male or a female problem?

Back 34

Two-thirds of cases are due to a female problem, one-third to a male problem

Front 35

Assuming that the history and physical exam offer no clues, what is the first step in evaluating a couple for infertility?

Back 35

Semen analysis, which is cheap, easy, and noninvasive.

Front 36

List the relevant characteristics of normal semen

Back 36

Ejaculate volume> 1 mL

Sperm concentration> 20 million/mL

Initial forward motility> 50% of sperm

Normal morphology> 60% of sperm

Front 37

What is the next step after semen evaluation?

Back 37

Documentation of ovulation. The history may suggest an ovulatory problem (irregular menstrual cycle length, duration, or amount of flow; lack of premenstrual syndrome symptoms). Basal body temperature, luteal phase progesterone levels, and/or endometrial biopsy can be done to check for ovulation.

Front 38

What radiologic test is commonly used to examine the fallopian tubes and uterus? What points in the history may lead you to suspect a uterine or tube problem?

Back 38

he hysterosalpingogram is commonly used to examine the uterus and tubes. The history may suggest a tubal problem (PID, previous ectopic pregnancy) or a uterine problem (previous dilation and curettage that caused intrauterine synechiae, history of fibroids, or symptoms of endometriosis).

Front 39

What test is the last resort in the work-up for infertility?

Back 39

Laparoscopy can be done as a last resort or with a history suggestive of endometriosis. Lysis of adhesions and destruction of endometriosis lesions often restore fertility.

Front 40

Which two medications can be used to try to restore female fertility? In what situations are they effective?

Back 40

Medical therapy usually consists of clomiphene citrate to induce ovulation, but this approach requires adequate production of estrogen. If the woman is hypoestrogenic, use human menopausal gonadotropin (hMG), which is a combination of FSH and LH. If medications fail, in vitro fertilization can be attempted.

Front 41

What is the main risk associated with medical induction of ovulation?

Back 41

Multiple-gestation pregnancies.

Front 42

Distinguish between primary and secondary amenorrhea

Back 42

A patient with primary amenorrhea has never menstruated or had a menstrual period, whereas a patient with secondary amenorrhea used to menstruate but has stopped.

Front 43

Until proved otherwise, what is the cause of secondary amenorrhea in a previously menstruating woman of reproductive age

Back 43

Pregnancy. Always order a human chorionic gonadotropin (hCG) test to rule out pregnancy as the first step in your evaluation of secondary amenorrhea.

Front 44

True or false: Excessive exercise may cause amenorrhea

Back 44

True. It is not uncommon to find amenorrhea (or hypomenorrhea) in hard-training athletes. It results from an exercise-induced depression of gonadotropin-releasing hormone.

Front 45

What are other common causes of secondary amenorrhea?

Back 45

PCOS
▪ Anorexia (amenorrhea is required for diagnosis of anorexia)
▪ Endocrine disorders (headaches, galactorrhea, and visual field defects may indicate a pituitary tumor)
▪ Antipsychotics (due to increased prolactin)
▪ Previous chemotherapy (causes premature ovarian failure and menopause)

Although not considered secondary amenorrhea, menopause should be kept in mind as a cause for cessation of menstruation

Front 46

After ruling out pregnancy, if the cause of secondary amenorrhea is not obvious from the history and physical exam, what is the next step in your evaluation?

Back 46

Administer progesterone to assess the patient's estrogen status. If vaginal bleeding develops within 2 weeks of administering progesterone, the patient has sufficient estrogen. In this case, check the LH level. If it is high, consider PCOS. If it is low or normal, check the levels of prolactin and thyroid-stimulating hormone (TSH). The high TSH level in hypothyroidism causes high prolactin levels. If the prolactin is high with a normal TSH level, order a magnetic resonance (MR) scan of the brain to rule out pituitary prolactinoma. If the prolactin level is normal, look for low levels of gonadotropin-releasing hormone, which may be induced by drugs, stress, or exercise. In these patients, clomiphene can be used in an attempt to facilitate pregnancy.

Front 47

What if the patient fails to have vaginal bleeding after receiving progesterone?

Back 47

f the patient has no vaginal bleeding, estrogen levels are inadequate. Check the FSH level next. If it is elevated, premature ovarian failure is the problem; check for autoimmune disorders, karyotype abnormalities, and a history of chemotherapy. If the FSH level is low or normal, the problem may be a brain tumor (e.g., craniopharyngioma). Order an MR scan of the brain. Clomiphene is ineffective in these patients.

Front 48

True or false: Pregnancy can present as primary amenorrhea

Back 48

True. Always assess the hCG level in the evaluation of any type of amenorrhea.

Front 49

At what age can primary amenorrhea be diagnosed? What is the first step in evaluation?

Back 49

A diagnosis of primary amenorrhea is made when a girl has not menstruated by the age of 16. Patients also should be evaluated in the absence of secondary sexual characteristics by age 14 or in the absence of menstruation within 2 years of developing secondary sex characteristics. The first step is to rule out pregnancy.

Front 50

In a patient older than 14 with no secondary sexual characteristics or development, what is the most likely cause of amenorrhea?

Back 50

The most likely cause in this setting is a congenital problem. In a phenotypically normal female with normal breast development but no axillary or pubic hair, think of androgen insensitivity syndrome. In such patients the uterus is absent. In the presence of normal breast development and a uterus, the first step is to assess prolactin level to rule out pituitary adenoma. If the prolactin level is high, order an MRI. If it is normal, administer progesterone and follow the same procedure as in the evaluation of secondary amenorrhea.

Front 51

When in doubt, what is the best way to evaluate any type of amenorrhea?

Back 51

First, order a pregnancy test. If it is negative, administer progesterone. Further testing depends on the results of the progesterone challenge (bleeding or no bleeding). A TSH level and/or prolactin level should also be ordered, especially with symptoms of hypothyroidism or pituitary tumor.

Front 52

When does menopause occur? What are the symptoms and signs?

Back 52

The average age of menopause is around 51 years. Patients have irregular cycles or amenorrhea, hot flashes and mood swings, and an elevated FSH level. Patients also may complain of dysuria, dyspareunia, incontinence, and/or vaginal itching, burning, or soreness. Vaginal symptoms often are due to atrophic vaginitis; look for vaginal mucosa to be thin, dry, and atrophic with increased parabasal cells on cytology. Topical estrogen improves vaginal symptoms, but other symptoms require oral therapy.

Front 53

What is the current state of hormone replacement therapy?

Back 53

Hormone replacement therapy is currently recommended short-term for the management of moderate-to-severe vasomotor flushing. Long-term use for the prevention of disease (such as osteoporosis or cardiovascular disease) is no longer recommended based on the results of the Women's Health Initiative and the HERS trial.

Front 54

When a woman presents with a nipple discharge, what historical points are important?

Back 54

A history of using oral contraceptive pills, hormone therapies, antipsychotic medications or symptoms suggestive of hypothyroidism, which can all cause nipple discharge. The color of the discharge and whether the discharge is unilateral or bilateral is also very important. For example, if a nipple discharge is bilateral and non-bloody, it is not due to breast cancer, but it may be due a prolactinoma (check prolactin level) or endocrine disorder (check a thyroid stimulating hormone level). Alternatively, when a nipple discharge is unilateral and bloody (nipple discharge secondary to carcinoma generally contains hemoglobin), and/or associated with a mass, this should raise concern about possible breast cancer. Do a biopsy of any mass if present

Front 55

What are the most likely causes of a breast mass in a woman under the age of 35?

Back 55

Fibrocystic disease (Fig. 16-5): bilateral, multiple, cystic lesions that are tender to the touch, especially premenstrually. This is the most common of all breast diseases. Generally, no work-up is needed other than routine follow-up. Oral contraceptive pills, progesterone, or danazol may help to relieve symptom

Hint 55

Fibrocystic change of the breast. Typical features are shown in the micrograph, including cystic dilatation of ducts (C) with apocrine metaplasia (Ap) and areas of fibrosis (F). This fibrosis can give rise to clinically palpable masses that may have irregular outlines. This condition is benign and considered a physiological variant in the absence of atypical or significant hyperplasia.

Front 56

Fibroadenoma:

Back 56

Fibroadenoma: a painless, discrete, sharply circumscribed, unilateral, rubbery, mobile mass. This is the most common benign tumor of the female breast. Patients may be observed for one or more menstrual cycles in the absence of symptoms. Because tumors are estrogen-dependent, pregnancy and oral contraceptive pills may stimulate growth, whereas menopause causes regression. Excision is curative but not required except for cosmetic reasons

Front 57

Mastitis/abscess:

Back 57

Mastitis/abscess: typically in the first few months postpartum, lactating women may develop a painful, swollen, erythematous breast(s). The nipple may be cracked or fissured. The patient should be treated with analgesics (e.g., acetaminophen, ibuprofen) and instructed to continue breast feeding with the affected breast(s) even though it is painful (use a breast pump to empty the breast if needed) to prevent further milk duct blockage and abscess formation. An anti-staphylococcal antibiotic (e.g., dicloxacillin) should be given for more than mild symptoms. Methicillin resistant staphylococcus aureus (MRSA) is becoming an increasingly important pathogen in mastitis. Use trimethoprim-sulfamethoxazole or clindamycin if MRSA is a concern or is cultured. If a fluctuant mass develops or there is no response to antibiotics within a few days, an abscess is likely present and must be drained.

Front 58

Fat necrosis

Back 58

Fat necrosis: patients have a history of trauma in the area of the mass.

Front 59

True or false: Mammography should be done for any suspicious breast lesion in a woman under age 30

Back 59

False. Mammography is usually not done in women under age 30 because breast tissue is often too dense to discern a mass. If you are suspicious of breast cancer, which is very rare in this age group, proceed to ultrasound imaging or directly to biopsy.

Front 60

What are the likely causes of a breast mass in a woman over the age of 35?

Back 60

Fibrocystic disease: as mentioned previously, but aspiration of cyst fluid and baseline mammography are recommended. If the cyst fluid is non-bloody and the mass resolves after aspiration, the patient needs only reassurance and follow up (with a baseline mammogram). If the fluid is bloody or the cyst recurs quickly, do a biopsy to rule out cancer.

Fibroadenoma: get a baseline mammogram. Observe briefly if the mass is small and seems benign clinically and if the woman is premenopausal and has no risk factors for breast cancer. Otherwise, do a biopsy. Phyllodes tumors (minority are malignant) may masquerade as a fibroadenoma.

Fat necrosis: as mentioned previously.

Mastitis/abscess: as mentioned previously.

Breast cancer: on the Step 2 exam, you may not get the classic presentation of nipple retraction and/or peau d'orange in a nulliparous woman with a strong family history. In a woman 35 years old or over, you will never be faulted for doing a biopsy of any mass. In the absence of a classic benign presentation (e.g., trauma to the breast with fat necrosis or bilateral masses with premenstrual syndrome mastalgia), always consider biopsy. Also get a baseline mammography.

Front 61

Breast cancer: on the Step 2 exam,

Back 61

you may not get the classic presentation of nipple retraction and/or peau d'orange in a nulliparous woman with a strong family history. In a woman 35 years old or over, you will never be faulted for doing a biopsy of any mass. In the absence of a classic benign presentation (e.g., trauma to the breast with fat necrosis or bilateral masses with premenstrual syndrome mastalgia), always consider biopsy. Also get a baseline mammography.

Front 62

True or false: If a patient is postmenopausal or over age 50 and develops a new breast mass, you should assume cancer “until proven otherwise.”

Back 62

True. The risk of breast cancer begins to increase sharply, and the incidence of benign disorders begins to decrease sharply. Most benign disorders are caused by reproductive hormones that women in this age group lack.

Front 63

True or false: Mammography is best used as a tool to evaluate a palpable breast mass

Back 63

False. Mammography is best used as a tool to detect nonpalpable breast masses (as a screening tool). A suspicious lesion found on mammography should be biopsied, even if it seems benign or is inapparent on physical exam. Additionally, a clinically suspicious mass should be biopsied unless imaging demonstrates unequivocally benign findings (e.g., a cyst).

Front 64

What causes pelvic relaxation or vaginal prolapse? What are the symptoms and signs?

Back 64

Pelvic relaxation is due to a weakening of pelvic supporting ligaments. Look for a history of several vaginal deliveries, feeling of heaviness or fullness in the pelvis, backache, worsening of symptoms with standing, and resolution of symptoms with lying down.

Front 65

What types of pelvic relaxation are seen clinically? How are they treated?

Back 65

cystocele
rectocele
enterocele
urethrocele

Hint 65

tx
Conservative treatment for all types of pelvic relaxation involves pelvic strengthening exercises and/or a pessary (artificial device to provide support). Surgery is used for refractory or severe cases or patient desire.

Front 66

cystocele: what is it

Back 66

Cystocele: the bladder bulges into the upper anterior vaginal wall. Common symptoms include urinary urgency, frequency, and/or incontinence.

Front 67

Rectocele

Back 67

the rectum bulges into the lower posterior vaginal wall. Watch for difficulty with defecation.

Front 68

Enterocele:

Back 68

loops of bowel bulge into the upper posterior vaginal wall.

Front 69

Urethrocele

Back 69

the urethra bulges into the lower anterior vaginal wall. Common symptoms include urinary urgency, frequency, and/or incontinence.

Front 70

Other than abstinence, what are the most effective forms of birth control (when used properly)?

Back 70

The most effective forms of birth control are sterilization (e.g., tubal ligation or vasectomy), implants (etonogestrel implant) or an intrauterine device followed by injectable hormone depot preparations, then birth control pills/patch and a hormonal vaginal ring.

Front 71

Which forms of birth control prevent sexually transmitted diseases?

Back 71

Abstinence and condoms.

Front 72

What are the major problems with intrauterine devices?

Back 72

They increase the risk of ectopic pregnancies and PID (watch for Actinomyces species to be the cause). For these reasons, they are most appropriate for older, monogamous women.

Front 73

What is the classic cause of ambiguous genitalia on the Step 2 exam?

Back 73

Adrenogenital syndrome, also known as congenital adrenal hyperplasia. Ninety percent of cases are caused by 21-hydroxylase deficiency. Patients are female because affected males experience precocious sexual development. Patients with 21-hydroxylase deficiency have salt-wasting (low sodium), hyperkalemia, hypotension, and elevated 17-hydroxyprogesterone. Treat with steroids and intravenous fluids immediately to prevent death.

Front 74

What should you tell the parents of a child with ambiguous genitalia?

Back 74

Tell the parents the truth: you do not know the child's gender. No patient with ambiguous genitalia should be assigned a sex until the work-up is complete. A karyotype must be done.

Front 75

What is indicated by a “bunch of grapes” protruding from a pediatric vagina?

Back 75

Sarcoma botryoides, a malignant tumor (a type of embryonal rhabdomyosarcoma).

Front 76

Define precocious puberty. What causes it? How should it be treated?

Back 76

By definition, precocious puberty occurs in girls less than 8 years old or boys less than 9 years old. Premature or precocious puberty is usually idiopathic, but it may be caused by a hormone-secreting tumor or central nervous system disorder, both of which must be ruled out. Treat the underlying cause. If the condition is idiopathic, treat with a gonadotropin-releasing hormone analog to prevent premature epiphyseal closure and arrest or reverse puberty until an appropriate age.

Front 77

What causes vaginitis or discharge in prepubescent girls?

Back 77

Most cases are nonspecific or physiologic, but look for a vaginal foreign body, sexual abuse (especially if a sexually transmitted disease is present), or candidal infection. A candidal infection may be a presentation of diabetes; check the serum glucose level and/or the urine for glycosuria.

Front 78

How do you recognize and treat an imperforate hymen?

Back 78

Imperforate hymen classically presents at menarche with hematocolpos (blood in the vagina) that cannot escape; thus, the hymen bulges outward. Treatment is surgical opening of the hymen.

Front 79

What is the usual cause of vaginal bleeding in neonates? How is it treated?

Back 79

Vaginal bleeding in neonates is usually physiologic and due to maternal estrogen withdrawal. No treatment is needed because the bleeding resolves on its own.

Front 80

Which women are candidates for hormone replacement therapy?

Back 80

Hormone replacement therapy (i.e., estrogen with or without progesterone) is now controversial and probably best used only as a means of symptom relief. Observation during therapy is necessary, because estrogen and progesterone are not harmless. Every woman should make the decision on her own after weighing the risks and benefits.

Front 81

What are the known benefits of estrogen therapy?

Back 81

Decreased osteoporosis and decreased fractures
▪ Reduced hot flashes and genitourinary symptoms of menopause (dryness, urgency, atrophy-induced incontinence, frequency)
▪ Decreased risk of colorectal cancer (according to the Women's Health Initiative, when combined estrogen and progesterone therapy is used)

Front 82

What are the known risks of estrogen therapy?

Back 82

Increased risk of endometrial cancer (eliminated by coadministration of progesterone)
▪ Small increase in risk of coronary heart disease with combined estrogen and progesterone therapy, though the risk is not increased in women who are less than 10 years postmenopausal or 50 to 59 years of age
▪ Increased risk of venous thromboembolism
▪ Increased risk of breast cancer (according to the Women's Health Initiative when combined estrogen and progesterone therapy is used. There was a slightly decreased risk of breast cancer with estrogen only, though this decrease was not statistically significant)
▪ Increased risk of stroke (according to the Women's Health Initiative, with either estrogen only or combined estrogen and progesterone therapy)
▪ Increased risk of gallbladder disease

Front 83

What are the most common side effects of estrogen therapy?

Back 83

▪ Endometrial bleeding
▪ Bloating
▪ Breast tenderness
▪ Headaches
▪ Nausea

Front 84

What are the absolute contraindications to estrogen therapy?

Back 84

▪ Unexplained vaginal bleeding
▪ Active liver disease
▪ History of thromboembolism
▪ Coronary artery disease
▪ History of endometrial or
breast cancer
▪ Pregnancy

Front 85

What are the relative contraindications to estrogen therapy?

Back 85

▪ Seizure disorder
▪ Hypertension
▪ Uterine leiomyomas
▪ Familial hyperlipidemia
▪ Migraine headaches
▪ Thrombophlebitis
▪ Endometriosis
▪ Gallbladder disease

Front 86

What test is often done before starting estrogen therapy?

Back 86

Women classically get an endometrial biopsy, ultrasound or dilation and curettage at the onset of treatment to rule out hyperplasia and/or cancer and an evaluation of any unexplained bleeding, even while on therapy, unless they have had a normal evaluation within the past 6 months.

Front 87

True or false: Women without a uterus do not need to take progesterone with estrogen

Back 87

True. The main reason for giving progesterone with hormone replacement therapy is to eliminate the increased risk of endometrial cancer that accompanies unopposed estrogen therapy. If a woman has no uterus, then she has no need for progesterone.

Front 88

What are the absolute contraindications to oral contraceptive pills?

Back 88

▪ Venous thromboembolism, current or past (deep venous thrombosis or pulmonary embolism)
▪ Cerebrovascular disease (stroke)
▪ Coronary artery disease
▪ Complicated valvular heart disease
▪ Diabetes with complications
▪ Breast cancer
▪ Pregnancy
▪ Lactation (fewer than 6 weeks postpartum)
▪ Liver disease
▪ Headaches with focal neurologic symptoms
▪ Major surgery with prolonged immobilization
▪ Age greater than 35 years and smoking greater than or equal to 15 cigarettes per day
▪ Hypertension (blood pressure greater than 160/100 mm Hg or with concomitant vascular disease)

Front 89

What are the relative contraindications to oral contraceptive pills?

Back 89

▪ Postpartum fewer than 21 days
▪ Lactation (6 weeks to 6 months)
▪ Undiagnosed vaginal or uterine bleeding
▪ Age greater than 35 years and smoking less than 15 cigarettes per day
▪ History of breast cancer but no recurrence in past 5 years
▪ Interacting drugs (certain anticonvulsants, rifampin)
▪ Gallbladder disease
▪ Headaches without aura, age greater than or equal to 35 years
▪ Hypertension (well-controlled or blood pressure 140–159/90–99 mm Hg)

Front 90

What is the relationship between oral contraceptive pills and hypertension?

Back 90

Oral contraceptive pills are one of the most common causes of secondary hypertension. Any patient taking birth control pills who is noted have an increased blood pressure should discontinue the pills, then have their blood pressure rechecked at a later date.

Front 91

What do you need to know about oral contraceptive pills and surgery?

Back 91

Because of the risks of thromboembolism, oral contraceptive pills should be stopped 1 month before elective surgery and not restarted until 1 month after surgery.

Front 92

What are the side effects of oral contraceptive pills?

Back 92

The side effects include glucose intolerance (check for diabetes mellitus annually in women at high risk), depression, edema (bloating), weight gain, cholelithiasis, benign liver adenomas, melasma (“the mask of pregnancy”), nausea, vomiting, headache, hypertension, and drug interactions. Drugs such as rifampin and antiepileptics may induce metabolism of oral contraceptive pills and reduce their effectiveness.

Front 93

What is the relationship between oral contraceptive pills and breast and cervical cancer?

Back 93

Oral contraceptive pills have little, if any, effect on the risk of developing breast cancer. Cervical neoplasia may be increased in users of birth control pills, but this effect also may be due to the confounding factor of increased sexual relations or number of partners. Nonetheless, users of birth control pills should have regular Pap smears.

Front 94

What is the relationship between oral contraceptive pills and ovarian and endometrial cancer?

Back 94

Oral contraceptive pills have been shown to reduce the incidence of ovarian cancer by 50%; they also reduce the incidence of endometrial cancer.

Front 95

What are the other beneficial effects of oral contraceptive pills?

Back 95

They decrease the incidence of menorrhagia, dysmenorrhea, benign breast disease, functional ovarian cysts (often prescribed for the previous four effects), premenstrual tension, iron-deficiency anemia, ectopic pregnancy, and salpingitis.

Front 96

Define anemia

Back 96

Hemoglobin less than 12 mg/dL in women or less than 14 mg/dL in men.

Front 97

What are the symptoms and signs of anemia?

Back 97

Symptoms: fatigue, dyspnea on exertion, light-headedness, dizziness, syncope, palpitations, angina, and claudication.

Signs: tachycardia, pallor (especially of the sclera and mucous membranes), systolic ejection murmurs (from high flow), and signs of the underlying cause (e.g., jaundice and/or pigment gallstones (Fig. 17-1) in hemolytic anemia, positive stool guaiac with a gastrointestinal [GI] bleed).

Front 98

What are the important elements of the history when anemia is present?

Back 98

mportant points include medications, blood loss (e.g., trauma, surgery, melena, hematemesis, menorrhagia), chronic diseases (anemia of chronic disease), family history (e.g., hemophilia, thalassemia, sickle cell disease, glucose-6-phosphatase deficiency), and alcoholism (which may lead to iron, folate, and B12 deficiencies as well as GI bleeds).

Front 99

A patient who is taking birth control pills presents with amenorrhea. What is the likely cause?

Back 99

Pregnancy. No form of contraception is 100% effective (including tubal ligation), especially when patient compliance is required.

Front 100

List the symptoms and signs of pregnancy

Back 100

▪ Amenorrhea
▪ Morning sickness
▪ Weight gain
▪ Hegar sign (softening and compressibility of the lower uterine segment)
▪ Chadwick sign (dark discoloration of the vulva and vaginal walls)
▪ Linea nigra
▪ Melasma (also known as chloasma or the “mask of pregnancy”)
▪ Auscultation of fetal heart tones
▪ Gestational sac or fetus seen on ultrasound
▪ Uterine contractions
▪ Palpation/ballottement of fetus

Front 101

Which vitamin should all pregnant women take? Why?

Back 101

Give all pregnant patients folate to prevent neural tube defects. Ideally, all woman of reproductive age should take folate, because it is most effective in the first trimester, when most women do not know that they are pregnant. Iron supplements are given frequently to pregnant women to help prevent anemia.

Front 102

Define macrosomia. What is the likely cause?

Back 102

Macrosomia is defined as a newborn that weighs more than 4 kg (roughly 9 pounds). The cause is maternal diabetes mellitus until proven otherwise

Front 103

What routine tests should be obtained for all pregnant patients?

Back 103

▪ Pap smear: if the patient is due. Pregnancy does not change the frequency of screening.
▪ Urinalysis: at the first visit and every visit thereafter (to screen for proteinuria, preeclampsia, and bacteriuria; not a good screen for diabetes).
▪ Urine culture: obtained at 12 to 16 weeks to screen for asymptomatic bacteriuria.
▪ Hemoglobin and hematocrit: at the first visit to see if the patient is anemic (because pregnancy may aggravate anemia). Should be repeated in the third trimester.
▪ Blood type, rhesus (Rh) type, and antibody screen: at first visit (for identification of possible isoimmunization).
▪ Syphilis test: at first visit (mandated in most states) and subsequent visits (for high-risk patients).
▪ Rubella antibody screen: if the patient if found to be nonimmune, counsel her to get postpartum immunization.
▪ Glucose screen for gestational diabetes: at first visit in patients with risk factors for diabetes mellitus (obesity, positive family history, or age over 30 years old); otherwise, screen at 24 to 28 weeks. Use fasting serum glucose and serum glucose levels 1 or 2 hours after an oral glucose load.
▪ Serum alpha-fetoprotein: performed at 15 to 20 weeks, primarily to detect open spina bifida and anencephaly.
▪ Hepatitis B antigen testing: to prevent perinatal transmission.
▪ Varicella: all pregnant women should be tested for immunity to varicella.
▪ Thyroid function: maternal hypothyroidism may affect fetal neurologic development. Maternal hyperthyroidism can lead to fetal and maternal complications.
▪ HIV test: the American College of Obstetrics and Gynecology (ACOG) advocates an “opt-out” approach to screening rather than an “opt-in” approach to increase screening.
▪ Chlamydia screening: the Centers for Disease Control advocates testing all pregnant women while the ACOG recommends screening women at higher risk (e.g., age greater than 25 years, new sexual partner or more than one sexual partner, history of STD, drug use).
▪ Down syndrome screening: should be offered to all pregnant patients. There are multiple ways to screen. See questions 21 to 23.
▪ Group B beta-hemolytic streptococcus (GBS): screen at 35 to 37 weeks with a swab of the lower vagina and rectum.
▪ Others: tuberculosis skin test for women at higher risk. Testing for gonorrhea for women at higher risk of infection. Testing for toxoplasmosis is controversial. If asked, you should do chlamydia and gonorrhea cultures for any pregnant teenager. Testing for sexually transmitted diseases should be repeated in the third trimester for women who continue to be at risk or for women who acquire a risk factor during pregnancy.

Front 104

On every prenatal visit, listen to fetal heart tones and evaluate uterine size. When can these factors first be noticed? What constitutes a size/date discrepancy?

Back 104

Fetal heart tones can be heard with Doppler ultrasound at 10 to 12 weeks and with a normal stethoscope at 16 to 20 weeks. At 12 weeks of gestation, the uterus enters the abdomen and is palpable at the symphysis pubis; at roughly 20 weeks, it reaches the umbilicus. Uterine size is evaluated by measuring the distance from the symphysis pubis to the top of the fundus in centimeters. At roughly 20 to 35 weeks, the measurement in centimeters should equal the number of weeks of gestation. A discrepancy greater than 2 to 3 cm is called a size/date discrepancy. Ultrasound should be done for further evaluation (e.g., intrauterine growth retardation, multiple gestations).

Front 105

When is ultrasound most accurate at estimating the fetal age?

Back 105

At 16 to 20 weeks the biparietal diameter (measured on ultrasound) gives the most accurate estimate of fetal age.

Front 106

What is a hydatiform mole? What are the clues to its presence?

Back 106

A hydatiform mole is one form of gestational trophoblastic neoplasia, in which the products of conception basically become a tumor. Look for the following clues:
▪ Preeclampsia before the third trimester
▪ An hCG level that does not return to zero after delivery (or abortion/miscarriage) or one that rises rapidly during pregnancy
▪ First- or second-trimester bleeding with possible expulsion of “grapes” from the vagina (grossly, the tumor looks like a “bunch of grapes”) and excessive nausea/hyperemesis.
▪ Uterine size/date discrepancy
▪ “Snow-storm” pattern on ultrasound

Front 107

Distinguish between complete and partial moles. How are hydatiform moles treated?

Back 107

Complete moles have a karyotype of 46 XX (with all chromosomes from the father) and no fetal tissue. Incomplete moles usually have a karyotype of 69 XXY with fetal tissue in the tumor.

Treat hydatiform moles with uterine dilation and curettage. Then follow with serial measurements of hCG levels until they fall to zero. If the hCG level does not fall to zero or rises, the patient has either an invasive mole or a choriocarcinoma (increasingly aggressive forms of gestational trophoblastic neoplasia) and needs chemotherapy (usually methotrexate or dactinomycin, both of which are extremely effective).

Front 108

How is intrauterine growth retardation (IUGR) defined? What causes it?

Back 108

IUGR is defined as fetal size below the tenth percentile for age. Causes are best understood in broad terms as maternal (e.g., smoking, alcohol or drugs, lupus erythematosus), fetal (e.g., TORCH infections, congenital anomalies), or placental (e.g., hypertension, preeclampsia). For a discussion of TORCH infections, see question 33.

Front 109

When should ultrasound be used to evaluate the fetus?

Back 109

The indications for ultrasound are now quite liberal. Order ultrasound for all patients who have a size/date discrepancy greater than 2 to 3 cm or risk factors for pregnancy-related problems (e.g., hypertension, diabetes, renal disease, lupus erythematosus, smoking, alcohol or drug use, and history of previous pregnancy-related problems). Ultrasound also is used when fetal death, distress, or abortion or miscarriage is suspected (e.g., a baby that stops kicking, vaginal bleeding, or slow fetal heartbeat on auscultation).

Front 110

How is fetal well-being evaluated?

Back 110

A nonstress test is the easiest initial screen. It is performed with the mother at rest. A fetal heart rate tracing is obtained for 20 minutes. A normal strip has at least 2 accelerations of heart rate, each at least 15 beats per minute above baseline and lasting at least 15 seconds.

A biophysical profile is slightly more involved and includes a nonstress test as well as a measure of amniotic fluid (to determine whether oligo- or polyhydramnios is present; Fig. 25-1), a measure of fetal breathing movements, and a measure of general fetal movements.

Hint 110

If the fetus scores poorly on the biophysical profile, the next test is the contraction stress test, which looks for uteroplacental dysfunction. Oxytocin is given, and a fetal heart strip is monitored. If late decelerations are seen on the fetal heart strip with each contraction, the test is positive. In most cases of a positive contraction stress test, a cesarean section is performed.

Front 111

True or false: A biophysical profile often is used in high-risk pregnancies in the absence of obvious problems

Back 111

True. A biophysical profile may be done once or twice a week from the start of the third trimester until delivery to monitor for potential problems.

Front 112

True or false: Aspirin should be avoided during pregnancy

Back 112

True. Use acetaminophen instead. One important exception is patients with antiphospholipid syndrome, in whom aspirin may improve pregnancy outcome (subcutaneous unfractionated heparin or low molecular weight heparin also can be used to treat antiphospholipid syndrome in pregnancy).

Front 113

Define postterm pregnancy. Why is it a major concern? How is it treated?

Back 113

Postterm pregnancy is defined as more than 42 weeks of gestation. Both prematurity and postmaturity increase perinatal morbidity and mortality rates. With postmaturity, dystocia (or difficult delivery) becomes more common because of the increased size of the infant.

In general, if the gestational age is known to be accurate and the cervix is favorable, labor is induced (with oxytocin, for example). If the cervix is not favorable or the dates are uncertain, twice-weekly biophysical profiles are done. At 41 weeks, most obstetricians advise induction of labor.

Front 114

What two rare disorders are associated with prolonged gestation?

Back 114

Anencephaly and placental sulfatase deficiency.

Front 115

What are the normal changes and complaints in pregnancy?

Back 115

Normal changes in pregnancy include nausea or vomiting (morning sickness), amenorrhea, heavy (possibly even painful) feeling of the breasts, increased pigmentation of the nipples and areolae, Montgomery tubercles, backache, linea nigra, melasma (chloasma), striae gravidarum, and mild ankle edema. Heartburn and increased frequency of urination are also common problems.

Front 116

What test is used to screen for neural tube defects? At what time during pregnancy is it measured? Explain the significance of a low or high alpha-fetoprotein (AFP) level in maternal serum

Back 116

Maternal AFP is most accurate when measured between 15 and 20 weeks of gestation. A low AFP may represent Down syndrome, fetal demise, or inaccurate dates. A high AFP may represent neural tube defects (e.g., anencephaly, spina bifida), ventral wall defects (e.g., omphalocele, gastroschisis), multiple gestation, or inaccurate dates.

Front 117

What should be done if the AFP is elevated?

Back 117

Repeat the test. As many as 30% of elevated maternal serum AFP test results may be elevated but are normal upon repeat testing. The initial elevation is not associated with an increased risk of neural tube defects.

Front 118

What further testing should a patient undergo if the AFP remains elevated?

Back 118

If the AFP remains elevated the patient is advised first to undergo ultrasound to determine whether a neural tube defect or other anomaly is present. The ultrasound is also used to confirm gestational age, number of fetuses, and fetal viability. Further evaluation with amniocentesis may be required if the ultrasound findings are uncertain or there is a concern for nonvisualized neural tube defects (via elevated AFP level in amniotic fluid or detection of acetylcholinesterase in amniotic fluid). There is a small risk of miscarriage after amniocentesis.

Front 119

What prenatal tests are available to screen for Down syndrome?

Back 119

The first trimester combined test, integrated tests, and the quadruple test. The American College of Obstetricians and Gynecologists recommends that all women be offered screening before 20 weeks of gestation.

Front 120

What is the first trimester combined test? When is it performed?

Back 120

The first trimester combined test is performed at 11 to 13 weeks of gestation. The test involves determination of nuchal translucency (NT) by ultrasound, combined with serum pregnancy-associated plasma protein-A (PAPP-A) and serum human chorionic gonadotropin (hCG). Chorionic villus sampling (CVS) is used for women who have this first trimester screening and test positive.

Front 121

Describe the integrated tests

Back 121

The full integrated test includes an ultrasound measurement of nuchal translucency at 10 to 13 weeks of gestation, PAPP-A at 10 to 13 weeks of gestation, and alpha fetoprotein (AFP), unconjugated estradiol (uE3), hCG, and inhibin A at 15 to 18 weeks of gestation. Results of the full integrated test are not available until the second trimester.

The serum integrated test is the same as the full integrated test but without the ultrasound evaluation of nuchal translucency. This test is used in areas where expertise in the ultrasound measurement of nuchal translucency is not available. Results of the serum integrated test are not available until the second trimester.

Step-wise sequential testing has been developed to provide a risk estimate during the first trimester. The first trimester portion of the integrated screen is performed. If the tests indicate a very high risk of having an affected fetus, CVS is offered. Those women whose results do not place them at very high risk of having an affected fetus go on to have the second trimester portion of the screening.

Contingent testing is being evaluated in clinical trials, and concerns exist about the performance of this screening modality.

Front 122

What is the quadruple test? For whom is it typically used? When is it performed?

Back 122

The quadruple test includes the serum markers AFP, uE3, hCG, and inhibin A. The quadruple test is the best available test for women who present for prenatal care in the second trimester, but can be used for women who receive earlier prenatal care. It is performed at 15 to 18 weeks of gestation

Front 123

What is the next step if a woman has a positive screening test for Down syndrome?

Back 123

Offer fetal karyotype determination. This is done by chorionic villus sampling in the first trimester and by amniocentesis in the second trimester.

Front 124

Why is chorionic villus sampling done instead of amniocentesis in some cases?

Back 124

Chorionic villus sampling can be done at 9 to 12 weeks of gestation (earlier than amniocentesis) and generally is reserved for women with previously affected offspring or known genetic disease. It offers the advantage of a first-trimester abortion if the fetus is affected. Chorionic villus sampling is associated with a slightly higher miscarriage rate than amniocentesis.

Front 125

True or false: Chorionic villus sampling can detect neural tube defects but not genetic disorders

Back 125

False. Chorionic villus sampling can detect genetic or chromosomal disorders but not neural tube defects.

Front 126

Teratogen

Back 126

Defect caused: following cards

Front 127

Thalidomide

Back 127

Phocomelia (absence of long bones and flipper-like appearance of hands)

Front 128

Antineoplastics

Back 128

Many

Front 129

Tetracycline

Back 129

Yellow or brown teeth

Front 130

Aminoglycosides

Back 130

Deafness

Front 131

Valproic acid

Back 131

Spina bifida, hypospadias

Front 132

Progesterone

Back 132

Masculinization of female fetus

Front 133

Cigarettes

Back 133

Intrauterine growth retardation, low birth weight, prematurity

Front 134

Oral contraceptive pills

Back 134

VACTERL syndrome*

Front 135

Lithium

Back 135

Cardiac (Ebstein's) anomalies

Front 136

Radiation

Back 136

Intrauterine growth retardation, central nervous system defects, eye defects, malignancy (e.g., leukemia)

Front 137

Alcohol

Back 137

Fetal alcohol syndrome

Front 138

Phenytoin

Back 138

Craniofacial, limb, and cerebrovascular defect, mental retardation

Front 139

Warfarin

Back 139

Craniofacial defects, intrauterine growth retardation, central nervous system malformation, stillbirth

Front 140

Carbamazepine

Back 140

Fingernail hypoplasia, craniofacial defects

Front 141

Isotretinoin†

Back 141

Central nervous system, craniofacial, ear, and cardiovascular defects

Front 142

Iodine

Back 142

Goiter, cretinism

Front 143

Cocaine

Back 143

Cerebral infarcts, mental retardation

Front 144

Diazepam

Back 144

Cleft lip and/or palate

Front 145

Diethylstilbestrol

Back 145

Clear cell vaginal cancer, adenosis, cervical incompetence

Front 146

List the teratogenic effects of maternal diabetes mellitus. What is the best way to reduce these complications?

Back 146

▪ Cardiovascular malformations
▪ Cleft lip and/or palate
▪ Caudal regression (lower half of the body is incompletely formed)
▪ Neural tube defects
▪ Left colon hypoplasia/immaturity
▪ Macrosomia (most common and classic)
▪ Microsomia (can occur if the mother has long-standing diabetes)

Tight control of glucose during pregnancy dramatically reduces these complications.

Front 147

What other problems does maternal diabetes cause in pregnancy?

Back 147

In the mother, diabetes can result in polyhydramnios and preeclampsia (as well as the complications of diabetes). Problems in infants born to a diabetic mother (other than birth defects) include an increased risk of respiratory distress syndrome and postdelivery hypoglycemia (from fetal islet-cell hypertrophy due to maternal and thus fetal hyperglycemia). After birth, the infant is cut off from the mother's glucose and the hyperglycemia resolves, but the infant's islet cells still overproduce insulin and cause hypoglycemia. Treat with intravenous glucose.

Front 148

True or false: Oral hypoglycemic agents should not be used during pregnancy

Back 148

True. Use insulin to treat diabetes if diet and exercise cannot control glucose levels. Oral hypoglycemics, unlike insulin, may cross the placenta and cause fetal hypoglycemia.

Front 149

What commonly used drugs are generally considered safe in pregnancy?

Back 149

A short list of drugs that are generally safe in pregnancy includes acetaminophen, penicillins, cephalosporins, erythromycin, nitrofurantoin, histamine-2 receptor blockers, antacids, heparin, hydralazine, methyldopa, labetalol, insulin, and docusate.

Front 150

What are the TORCH syndromes? What do they cause?

Back 150

TORCH is an acronym for several maternal infections that can cross the placenta and can cause intrauterine fetal infections that may result in birth defects. Most TORCH infections can cause mental retardation, microcephaly, hydrocephalus, hepatosplenomegaly, jaundice, anemia, low birth weight, and IUGR.

T = Toxoplasma gondii: look for exposure to cats. Specific defects include intracranial calcifications and chorioretinitis.

O = Other: varicella-zoster causes limb hypoplasia and scarring of the skin. Syphilis causes rhinitis, saber shins, Hutchinson's teeth, interstitial keratitis, and skin lesions.

R = Rubella: worst in the first trimester (some recommend abortion if the mother has rubella in the first trimester). Always check antibody status on the first visit in patients with a poor immunization history. Look for cardiovascular defects, deafness, cataracts, and microphthalmia.

C = Cytomegalovirus: most common infection of the TORCH group. Look for deafness, cerebral calcifications, and microphthalmia.

H = Herpes: look for vesicular skin lesions (with positive Tzanck smears) and history of maternal herpes lesions.

Front 151

True or false: With most in utero infections that can cause birth defects, obvious clues are present in the mother and/or fetus at birth

Back 151

False. Although the USMLE probably will give clues, the mother may be asymptomatic (i.e., she may have a subclinical infection), and the infant may be asymptomatic at birth, developing only later such symptoms as learning disability, mental retardation, or autism.

Front 152

What do you need to know about HIV testing and transmission in mother and child?

Back 152

In untreated HIV-positive patients, HIV is transmitted to the fetus in roughly 25% of cases. When zidovudine is given to the mother prenatally and to the infant for 6 weeks after birth, HIV transmission is reduced to roughly 2%. A noninfected infant may still have a positive HIV antibody test at birth, because maternal antibodies can cross the placenta. Within 6-18 months, however, the test reverts to negative. This is why infants of infected mothers are tested using a direct HIV DNA PCR (polymerase chain reaction) test at birth, at 4-6 weeks of age, and 2 months after the second test. Babies who have these three negative tests should have an HIV antibody test at 12 and 18 months of age. Cesarean section may reduce HIV transmission to the child.

Front 153

What should you do if a pregnant woman has genital herpes?

Back 153

A decision is generally made when the mother goes into labor (not beforehand). If, at the time of true labor, the mother has active, visible genital herpes lesions, do a cesarean section to prevent transmission to the fetus. If, at the time of true labor, the mother has no visible genital herpes lesions, the child can be delivered vaginally.

Front 154

What should you do for the child if the mother has chronic hepatitis B or chickenpox?

Back 154

If the mother has chronic hepatitis B, give the infant the first hepatitis B vaccine shot and hepatitis B immunoglobulin at birth. If the mother contracts chickenpox in the last 5 days of pregnancy or the first 2 days after delivery, give the infant varicella-zoster immunoglobulin.

Front 155

How do you treat gonorrheal and chlamydial genital infections during pregnancy?

Back 155

The treatment for gonorrhea remains unchanged, because ceftriaxone is safe during pregnancy. For chlamydial infection, give azithromycin, amoxicillin, or erythromycin base instead of doxycycline or erythromycin estolate.

Front 156

How is tuberculosis treated in pregnancy?

Back 156

In a similar way as in a nonpregnant patient. Use isoniazid, rifampin, and ethambutol if the risk of a drug-resistant organism is low. Pyrazinamide should be used with caution because of a lack of data on the risk of teratogenicity. However, pyrazinamide should be added if a drug-resistant organism is suspected. Streptomycin, which is a rarely used second-line agent, should be avoided. Give vitamin B6 to pregnant patients treated with isoniazid to avoid a deficiency.

Front 157

What are the signs of placental separation during delivery?

Back 157

The signs of placental separation include a fresh show of blood from the vagina, lengthening of the umbilical cord, and a rising fundus that becomes firm and globular.

Front 158

True or false: After cesarean section, a patient may have a vaginal delivery in the future

Back 158

It depends. After a classic (vertical) uterine incision, patients must have cesarean sections for all future deliveries because of the increased rate of uterine rupture with vaginal delivery. After a lower (horizontal) uterine incision (the incision of choice), a patient may deliver future pregnancies vaginally with only a slightly increased (i.e., acceptable) risk of uterine rupture.

Front 159

Define lochia. When is it a problem?

Back 159

For the first several days after delivery, some vaginal discharge (known as lochia) is normal. It is red for the first few days and gradually turns white or yellowish-white by day 10. If the lochia is foul smelling, suspect endometritis

Front 160

What treatment may be given to a woman who does not want to breast-feed?

Back 160

Because the breasts can be become engorged with milk and thus quite painful, you may prescribe tight-fitting bras, ice packs, and analgesia to reduce symptoms. Medications for the suppression of lactation (e.g., bromocriptine and estrogens or oral contraceptive pills) are generally no longer recommended due to risks of thromboembolism and stroke.

Front 161

List the common contraindications for breast-feeding

Back 161

▪ Hepatitis
▪ Use of alcohol or illicit drugs
▪ HIV infection
▪ Scheduled substances

Front 162

What is the preferred method of anesthesia in obstetric patients? Why?

Back 162

Epidural anesthesia is the preferred method in obstetric patients. General anesthesia involves a higher risk of aspiration and its resulting pneumonia, because the gastroesophageal sphincter is relaxed in pregnancy and patients usually have not refrained from eating before going into labor. There also is concern about the effect of general anesthetic agents on the fetus. Spinal anesthesia can interfere with the mother's ability to push and is associated with a higher incidence of hypotension than epidural anesthesia.

Front 163

True or false: Asymptomatic bacteriuria, detected on routine urinalysis, should be treated during pregnancy

Back 163

True. Up to 20% of patients develop cystitis or pyelonephritis if untreated. This rate is much higher than in nonpregnant patients, who should not be treated for asymptomatic bacteriuria. In pregnancy, the gravid uterus can compress the ureters, and increased progesterone can decrease the tone of the ureters, increasing urinary stasis and the risk of urinary tract infection.

Front 164

What do you need to know about vaginal group B streptococcal colonization and pregnancy?

Back 164

Pregnant women should be tested for vaginal group B streptococci. Women who are carriers should be treated during labor and delivery with penicillin G or ampicillin. Earlier treatment (e.g., second trimester) is ineffective, because group B streptococci frequently return—and usually they are dangerous only during labor and delivery. The reason for treating asymptomatic carriers is to prevent neonatal sepsis and endometritis, both of which are commonly caused by group B streptococci.

Front 165

When does mastitis occur? How do you recognize and treat it?

Back 165

Mastitis (inflammation of the breast) usually develops in the first 2 months postpartum. Breasts are red, indurated, and painful, and nipple cracks or fissuring may be seen. Staphylococcus aureus is the usual cause. Treat with analgesics (e.g., acetaminophen, ibuprofen), warm and/or cold compresses, and continued breast feeding with the affected breast(s) even though it is painful (use breast pump to empty breast if needed) to prevent further milk duct blockage and abscess formation. Antistaphylococcal antibiotic (e.g., cephalexin, dicloxacillin) is usually given for more than mild symptoms. If a fluctuant mass develops or there is no response to antibiotics within a few days, an abscess is likely present and must be drained

Front 166

What are the diagnostic signs and symptoms of preeclampsia? When does it occur?

Back 166

Preeclampsia causes hypertension, defined as a greater than 30-point increase in systolic or a greater than 15-point increase in diastolic blood pressure over baseline. Other signs and symptoms include proteinuria (2+ or more protein on urinalysis), oliguria, edema of the hands or face, headache, visual disturbances, or the HELLP syndrome (hemolysis, elevated liver enzymes, low platelets, and right upper quadrant or epigastric pain). Preeclampsia usually occurs in the third trimester.

Front 167

What are the main risk factors for preeclampsia? How is it treated?

Back 167

The risk factors (in decreasing order of importance) include chronic renal disease, chronic hypertension, family history of preeclampsia, multiple gestations, nulliparity, extremes of reproductive age (the classic patient is a young woman with her first child), diabetes, and black race. The definitive treatment is delivery. This is the treatment of choice if the patient is at term. In a preterm patient with mild disease, the hypertension can be treated with hydralazine, labetalol or methyldopa. Advise bed rest and observe. If the patient has severe disease (defined as oliguria, mental status changes, headache, blurred vision, pulmonary edema, cyanosis, HELLP syndrome, blood pressure greater than 160/110 mmHg, or progression to eclampsia [seizures]), deliver the infant once the mother is stabilized. Otherwise, both mother and infant may die.

Front 168

True or false: The combination of hypertension and proteinuria during pregnancy means preeclampsia until proved otherwise

Back 168

True.

Front 169

When is edema normal during pregnancy? When is it not?

Back 169

Mild ankle edema is normal in pregnancy, but moderate-to-severe edema of the ankles or hands is likely to be preeclampsia.

Front 170

What should you consider if preeclampsia develops before the third trimester?

Back 170

The possibility of gestational trophoblastic disease (i.e., hydatiform mole or choriocarcinoma).

Front 171

Distinguish between preeclampsia and eclampsia. How can eclampsia be prevented?

Back 171

Preeclampsia plus seizures equals eclampsia. Eclampsia can be prevented by regular prenatal care so that you catch the disease in the preeclamptic stage and treat appropriately.

Front 172

What should you use to treat seizures in eclampsia? What are the toxic effects?

Back 172

Use magnesium sulfate for eclamptic seizures; it also lowers blood pressure. Toxic effects include hyporeflexia (first sign of toxicity), respiratory depression, central nervous system depression, coma, and death. If toxicity occurs, the first step is to stop the magnesium infusion.

Front 173

True or false: When eclampsia occurs, you must deliver the infant immediately, regardless of maternal status

Back 173

False. Do not try to deliver the infant until the mother is stable (e.g., do not perform a cesarean section while the mother is having seizures).

Front 174

Why are preeclampsia and eclampsia so important?

Back 174

Preeclampsia and eclampsia cause uteroplacental insufficiency, IUGR, fetal demise, and increased maternal morbidity and mortality rates.

Front 175

True or false: Preeclampsia and eclampsia are risk factors for development of hypertension in the future

Back 175

False.

Front 176

What are the major causes of maternal mortality associated with child birth?

Back 176

In decreasing order: pulmonary embolism, pregnancy-induced hypertension (preeclampsia/ eclampsia), and hemorrhage.

Front 177

How do you recognize an amniotic fluid pulmonary embolism?

Back 177

Look for a recently postpartum mother who develops sudden shortness of breath, tachypnea, chest pain, hypotension, and disseminated intravascular coagulation. Treatment is supportive.

Front 178

Define oligohydramnios. What causes it? Why is it worrisome?

Back 178

Oligohydramnios means a deficiency of amniotic fluid (less than 500 mL or an amniotic fluid index less than 5). Causes include IUGR, premature rupture of the membranes, postmaturity, and renal agenesis (Potter disease). Oligohydramnios may cause fetal problems, including pulmonary hypoplasia, cutaneous or skeletal abnormalities due to compression, and hypoxia due to cord compression.

Front 179

Define polyhydramnios. What causes it? Why is it worrisome?

Back 179

Polyhydramnios means an excess of amniotic fluid (greater than 2 L or an amniotic fluid index greater than 25). Causes include maternal diabetes, multiple gestation, neural tube defects (anencephaly, spina bifida), gastrointestinal anomalies (omphalocele, esophageal atresia), and hydrops fetalis. Polyhydramnios can cause maternal problems, including postpartum uterine atony (with resultant postpartum hemorrhage) and maternal dyspnea (an overdistended uterus compromises pulmonary function).

Front 180

When does a standard home pregnancy test become positive?

Back 180

Roughly 2 weeks after conception (about the time when the woman realizes that her period is late).

Front 181

First stage
Characteristics:
Latent phase, active phase, 2nd, 3rd, 4th stage

Back 181

Charac:Onset of true labor to full cervical dilation

Nulligravida: < 20 hrs

Multigravida: < 14 hrs

Front 182

Latent phase

Back 182

Charac:From 0 to 3–4 cm dilation (slow, irregular)

Nulligravida: highly variable

Multigravida: highly variable

Front 183

Active Phase

Back 183

Charac:From 3–4 cm to full dilation (rapid, regular)

Nulligravida: > 1 cm/hr dilation

Multigravida: > 1.2 cm/hr dilation

Front 184

Second Stage

Back 184

Charac:From full dilation to birth of baby

Nulligravida: 30 min–3 hr

Multigravida: 5–30 min

Front 185

Third Stage

Back 185

Charac:Delivery of baby to delivery of placenta

Nulligravida: 0- 30 min

Multigravida: 0-30 min

Front 186

Fourth Stage

Back 186

Charac:Placental delivery to maternal stabilization

Nulligravida: Up to 48 hr

Multigravida: Up to 48 hr

Front 187

Distinguish between a protraction disorder and an arrest disorder. What should you do when either occurs?

Back 187

A protraction disorder (dystocia) occurs once true labor has begun if the mother takes longer than the previous chart indicates, but labor nonetheless is progressing slowly. An arrest disorder (failure to progress) occurs once true labor has begun if no change in dilation is seen over 2 hours or no change in descent is seen over 1 hour.

In either situation, first rule out an abnormal lie and cephalopelvic disproportion. If neither is present, the mother can be treated with labor augmentation (e.g., oxytocin, prostaglandin). If these steps fail, manage expectantly and do a cesarean section at the first sign of trouble.

Front 188

What is the most common cause of protraction or arrest disorder?

Back 188

Cephalopelvic disproportion, defined as a disparity between the size of the infant's head and the mother's pelvis. Labor augmentation is contraindicated in this setting.

Front 189

Distinguish between true labor and false labor

Back 189

In true labor, normal contractions occur at least every 3 minutes, are fairly regular, and are associated with cervical changes (effacement and dilation). In false labor (Braxton-Hicks contractions), contractions are irregular and no cervical changes occur.

Front 190

What problems may be encountered when oxytocin is used to augment labor?

Back 190

On Step 2, watch for uterine hyperstimulation (painful, overly frequent, and poorly coordinated uterine contractions), uterine rupture, fetal heart rate decelerations, and water intoxication/hyponatremia (due to the antidiuretic hormone effect of oxytocin). Treat all of these complications first by discontinuing the oxytocin infusion; the half-life is less than 10 minutes.

Front 191

What problems are associated with the use of intravaginal prostaglandin and amniotomy?

Back 191

Prostaglandin E2 (dinoprostone) or misoprostol may be used locally to induce the cervix (a process sometimes called “ripening”) and is highly effective in combination with (or before) oxytocin. It also may cause uterine hyperstimulation. Amniotomy (creating a manual opening in the amniotic membrane) also hastens labor but exposes the fetus and uterine cavity to possible infection if labor does not occur promptly.

Front 192

What are the contraindications to labor induction or augmentation?

Back 192

The list is almost the same as the list of contraindications to vaginal delivery: placenta or vasa previa, umbilical cord prolapse, prior classic cesarean section, transverse fetal lie, active genital herpes, cephalopelvic disproportion, and cervical cancer.

Front 193

Define abortion

Back 193

Abortion is defined as the termination (intentional or not) of a pregnancy at less than 20 weeks of gestation or when the fetus weighs less than 500 grams. Miscarriage describes a spontaneous abortion.

Front 194

What are the different terms for an unintentional abortion?

Back 194

Threatened abortion: uterine bleeding without cervical dilation and no expulsion of tissue. Treat with bed rest and pelvic rest.

Inevitable abortion: uterine bleeding with cervical dilation and crampy abdominal pain and no tissue expulsion.

Incomplete abortion: passage of some products of conception through the cervix.

Complete abortion: expulsion of all products of conception from the uterus. Treat with serial testing of hCG level to make sure that it goes down to zero.

Missed abortion: fetal death with no expulsion of tissue (in some cases not for several weeks). Treat with dilation and curettage if less than 14 weeks of gestation, attempted delivery if more than 14 weeks of gestation.

All of the above terms imply less than 20 weeks of gestation. Treat all abortions with intravenous fluids (and blood transfusions if necessary) and consider dilation and curettage (once the fetus is confirmed as dead or expelled). Give the mother RhoGAM if she has an Rh-negative blood type.

Front 195

Define induced and recurrent abortions. What do recurrent abortions suggest?

Back 195

Induced abortion is an intentional termination of pregnancy at less than 20 weeks of gestation; it may be elective (requested by patient) or therapeutic (done to maintain the health of the mother).

Recurrent abortion is defined as two or three successive, unplanned abortions. History and physical exam may suggest the cause:
▪ Infection (Listeria, Mycoplasma, or Toxoplasma species, syphilis)
▪ Inherited thrombophilia (Factor V Leiden, G20210A gene mutation, antithrombin deficiency, deficiency of protein C or protein S)
▪ Environmental factors (alcohol, tobacco, drugs)
▪ Diabetes
▪ Hypothyroidism
▪ Systemic lupus erythematosus (especially with positive antiphospholipid/lupus anticoagulant antibodies, sometimes an isolated syndrome without coexisting lupus)
▪ Cervical incompetence (watch for a history of exposure to diethylstilbestrol [DES] in the patient's mother during pregnancy and/or a patient with recurrent painless second-trimester abortions; treat future pregnancies with cervical cerclage)
▪ Congenital female tract abnormalities (correct if possible to restore fertility)
▪ Fibroids (remove them)
▪ Chromosomal abnormalities (e.g., maternal or paternal translocations)

Front 196

True or false: hCG roughly doubles every 2 days in the first trimester

Back 196

True. An hCG level that stays the same or increases only slowly with serial testing indicates a fetus in trouble (e.g., threatened abortion, ectopic pregnancy) or fetal demise. A rapidly increasing hCG level or one that does not decrease after delivery may indicate hydatiform mole or choriocarcinoma.

Front 197

When can ultrasound detect an intrauterine gestational sac? Why do you need to know this information?

Back 197

At roughly 5 weeks after the last menstrual period (or when hCG is greater than 2000 mIU), evidence of intrauterine pregnancy can be detected by transvaginal sonography. A definite fetus and fetal heartbeat can be detected by transvaginal ultrasound at 5 to 6 weeks of gestation.

Use this information when trying to determine the possibility of an ectopic pregnancy. For example, if the patient's last menstrual period was 4 weeks ago and a pregnancy test is positive, you cannot rule out an ectopic pregnancy with ultrasound. If, however, the patient's last menstrual period was 10 weeks ago with a positive pregnancy test and an ultrasound of the uterus does not show a gestational sac, be suspicious of an ectopic pregnancy.

Front 198

What are the risk factors for developing an ectopic pregnancy?

Back 198

The major risk factor for ectopic pregnancy is a previous history of pelvic inflammatory disease (PID) (10-fold increase in ectopic pregnancy rate). Other risk factors include a previous ectopic pregnancy, history of tubal sterilization or tuboplasty, pregnancy that occurs with an intrauterine device in place, and a history of DES exposure, which can cause tubal abnormalities in women who were exposed in utero.

Front 199

What are the classic symptoms and signs of a ruptured ectopic pregnancy?

Back 199

A recent history of amenorrhea with current vaginal bleeding and abdominal pain. Patients also have a positive hCG pregnancy test. If you palpate an adnexal mass, it may be an ectopic pregnancy or a corpus luteum cyst.

Front 200

What should you do if you suspect an ectopic pregnancy?

Back 200

Order an ultrasound to look for a gestational sac or fetus. When the diagnosis is in doubt and the patient is doing poorly (e.g., hypovolemia, shock, severe abdominal pain, rebound tenderness), do a laparoscopy for definitive diagnosis and treatment, if necessary. Culdocentesis is rarely done in a stable patient to check for blood in the pouch of Douglas (with a ruptured ectopic pregnancy) because it has a high false-negative rate.

Front 201

How is symptomatic ectopic pregnancy managed?

Back 201

With surgery. A tubal pregnancy, if stable and less than 3 cm in diameter, can be treated with salpingostomy and removal of the products of conception. The tube is left open to heal on its own; this strategy retains normal tubal function and fertility. If the patient is unstable or the ectopic pregnancy has ruptured or is greater than 3 cm in diameter, a salpingectomy is required. In Rh-negative patients, give RhoGAM after treatment. Methotrexate (causes fetal demise) is an alternative treatment for small (less than 3 cm), unruptured tubal pregnancies.

Front 202

What are the problems with [preexisting] maternal hypertension in pregnancy?

Back 202

Preexisting hypertension (present before conception) increases the risk for IUGR and preeclampsia.

Front 203

What does a basic fetal heart monitoring strip contain?

Back 203

he fetal heart rate and the uterine contraction pattern over time.

Front 204

In fetal heart monitoring, what is the difference between early decelerations, late decelerations, and variable decelerations?

Back 204

In early decelerations (Fig. 25-2), the peaks match up (nadir of fetal heart deceleration and peak of uterine contraction). This pattern signifies head compression (probably a vagal response) and is normal.

Hint 204

Early decelerations are caused by compression of the fetal head. They are shallow, symmetric, uniform decelerations that begin early in the contraction, have their nadir coincident with the peak of the contraction, and return to the baseline by the time the contraction is over.

Front 205

Variable decelerations

Back 205

Variable decelerations (Fig. 25-3) are so-called because fetal heart rate deceleration varies in relation to uterine contractions. This is the most commonly encountered type of deceleration pattern and signifies cord compression. If it is seen, place the mother in the lateral decubitus position, administer oxygen by face mask, and stop any oxytocin infusion. If the fetal bradycardia is severe (less than 80 to 90 beats/min) or fails to resolve, check the fetal oxygen saturation or scalp pH.

Hint 205

These are typical variable decelerations. Variable decelerations are often recognized by the accelerations that precede and follow the decelerations.

Front 206

Late decelerations

Back 206

Late decelerations (Fig. 25-4) occur when fetal heart rate deceleration comes after uterine contraction. This pattern signifies uteroplacental insufficiency and is the most worrisome. If it is seen, first place the mother in the lateral decubitus position; then give oxygen by face mask and stop oxytocin, if applicable. Next, give a tocolytic (beta2 agonist such as ritodrine or magnesium sulfate) if the mother is not in active labor and intravenous fluids (if the mother is hypotensive). If the late decelerations persist, measure the fetal oxygen saturation or scalp pH. Consider preparing for operative delivery.

Hint 206

Late decelerations are seen in a case complicated by third-trimester bleeding. Note the presence of persistent late decelerations with only three contractions in 20 minutes as well as the apparent loss of variability of the fetal heart rate. The rise in baseline tone of the uterine activity channel cannot be evaluated with the external system.

Front 207

What other patterns of fetal distress may be seen on a fetal heart tracing? What is a normal fetal heart rate?

Back 207

Loss of short-term (beat-to-beat) variability, loss of long-term variability (or normal baseline changes in heart rate over 1 minute), and prolonged fetal tachycardia (greater than 160 beats/min). The normal fetal heart rate is 120 to 160 beats/min.

Front 208

What if the question gives you a value for fetal oxygen saturation or scalp pH?

Back 208

Any fetal scalp pH less than 7.2 or abnormally decreased oxygen saturation is an indication for immediate cesarean delivery. If the pH is greater than 7.2 or oxygenation is normal, you can generally continue to observe the mother and fetus.

Front 209

What should you do if shoulder dystocia or impaction occurs during vaginal delivery?

Back 209

The first step is to try the McRoberts maneuver. Have the mother sharply flex her thighs against her abdomen, which may free the impacted shoulder. Other maneuvers include applying suprapubic pressure, Woods screw maneuver (rotates the fetus so the anterior shoulder emerges from behind the maternal symphysis), delivery of the posterior arm, and fracture of the clavicle (risky). If these maneuvers fail, options are limited. A cesarean section is usually the procedure of choice (after pushing the infant's head back into the birth canal).

Front 210

What causes third-trimester bleeding?

Back 210

▪ Placenta previa
▪ Abruptio placentae
▪ Uterine rupture
▪ Fetal bleeding
▪ Cervical or vaginal infections (e.g., herpes simplex virus, gonorrhea, chlamydial or candidal infection)
▪ Cervical or vaginal trauma (usually from sexual intercourse)
▪ Bleeding disorders (rare before delivery; more common after delivery)
▪ Cervical cancer (which may occur in pregnant patients)
▪ “Bloody show”

Front 211

True or false: The initial work-up of third-trimester bleeding, like most conditions, requires a history and thorough physical exam, including a good pelvic exam

Back 211

False. You should do a history and partial physical exam, but always do an ultrasound before you do a pelvic exam.

Front 212

Why should you do ultrasound before you do a pelvic exam for third-trimester bleeding?

Back 212

In case placenta previa is present. Disturbing the placenta may make the bleeding worse and turn a worrisome case into an emergency.

Front 213

Define placenta previa. How does it present? How is it diagnosed and treated?

Back 213

True placenta previa occurs when the placenta implants in an area where it covers the cervical opening (os). Predisposing factors include multiparity, increasing maternal age, multiple gestation, and a history of prior placenta previa. Because of this condition you always do an ultrasound before a pelvic exam for third-trimester bleeding. The bleeding is painless and may be profuse. Ultrasound is 95% to 100% accurate in diagnosis. Mandatory cesarean section is required for delivery, but patients may be admitted to the hospital for bed and pelvic rest and tocolysis if they are preterm and stable and if the bleeding has stopped.

Front 214

Define abruptio placentae. How does it present? How is it treated?

Back 214

Abruptio placentae is premature detachment of a normally situated placenta. Predisposing factors include hypertension (with or without preeclampsia), trauma, polyhydramnios with rapid decompression after membrane rupture, cocaine or tobacco use, and preterm premature rupture of membranes. Patients can have this condition without visible vaginal bleeding; the blood may be contained behind the placenta. Usual symptoms include pain, uterine tenderness, increased uterine tone with a hyperactive contraction pattern, and fetal distress. Abruptio placentae also may cause disseminated intravascular coagulation if fetal products enter the maternal circulation. Ultrasound detects only a small percentage of cases. Treat with intravenous fluids (and blood if needed) and rapid delivery (vaginal preferred).

Front 215

What factors predispose to uterine rupture? How does it present? How is it treated?

Back 215

Predisposing factors include previous uterine surgery (especially prior caesarian section with vertical incision), trauma, oxytocin, grand multiparity (several previous deliveries), excessive uterine distention (e.g., multiple gestation, polyhydramnios), abnormal fetal lie, cephalopelvic disproportion, and shoulder dystocia. Uterine rupture is very painful, has a sudden and dramatic onset, and often is accompanied by maternal hypotension or shock. Other classic signs are the ability to feel fetal body parts on abdominal exam and a change in the abdominal contour. Maternal distress usually is more pronounced than fetal distress (unlike abruptio placentae, in which fetal distress is greater). Treat with immediate laparotomy and delivery. Hysterectomy usually is required after delivery.

Front 216

What causes fetal bleeding to present as third-trimester vaginal bleeding?

Back 216

Visible fetal bleeding usually is due to vasa previa or velamentous insertion of the cord, which occurs when umbilical vessels present in advance of the fetal head, usually traversing the membranes and crossing the cervical os. The biggest predisposing risk factor is multiple gestation (the higher the number of fetuses, the higher the risk). Bleeding is painless, and the mother is completely stable, whereas the fetus shows worsening distress (tachycardia initially, then bradycardia as the fetus decompensates). An Apt test performed on vaginal blood is positive for fetal blood (this test differentiates fetal from maternal blood). Treat with immediate cesarean section.

Front 217

Explain the term “bloody show.” How is it diagnosed?

Back 217

With cervical effacement, a blood-tinged mucous plug may be released from the cervical canal and heralds the onset of labor. This normal occurrence is a diagnosis of exclusion in the evaluation of third-trimester bleeding.

Front 218

Describe the initial management of third-trimester bleeding

Back 218

For all cases of third-trimester bleeding, start intravenous fluids, give blood if needed, start the patient on oxygen, and start fetal and maternal monitoring. Then order a complete blood count, coagulation profiles, ultrasound, and drug screen (if drug use is suspected, as cocaine causes placental abruption). Give RhoGAM if the mother is Rh-negative. A Kleihauer-Betke test can quantify fetal blood in maternal circulation and can be used to calculate the dose of RhoGAM.

Front 219

Define preterm labor. How is it treated?

Back 219

Preterm labor is defined as labor between 20 and 37 weeks of gestation. Put the mother in the lateral decubitus position, order bed and pelvic rest, and give oral or intravenous fluids and oxygen. In some cases these maneuvers stop the contractions. If they fail, you can give a tocolytic (beta2 agonist or magnesium sulfate) if no contraindications (heart disease, hypertension, diabetes, hemorrhage, ruptured membranes, cervix dilated more than 4 cm) are present. The mother can be managed as an outpatient with an oral tocolytic once she is stable.

Front 220

What are tocolytics? When is it not appropriate to give them?

Back 220

Tocolytics stop uterine contractions. Common examples are beta2 agonists (terbutaline, ritodrine) and magnesium sulfate. Do not give tocolytics to the mother in the presence of preeclampsia, severe hemorrhage, chorioamnionitis, IUGR, fetal demise, or fetal anomalies incompatible with survival.

Front 221

What is the role of steroids in preterm labor?

Back 221

Often steroids are given with tocolytics (at 24 to 34 weeks of gestation) to hasten fetal lung maturity and thus decrease the risk of respiratory distress syndrome in the neonatal period.

Front 222

Define quickening. When does it occur?

Back 222

Quickening is the term used to describe when the mother first detects fetal movements, usually at 18 to 20 weeks of gestation in a primigravida and 16 to 18 weeks of gestation in a multigravida.

Front 223

Give the order of fetal positions during normal labor and delivery

Back 223

1. Descent
2. Flexion
3. Internal rotation
4. Extension
5. External rotation
6. Expulsion

Front 224

What subtype of maternal antibody can cross the placenta?

Back 224

IgG is the only type of maternal antibody that crosses the placenta. This may be an important diagnostic point: an elevated neonatal IgM concentration is never normal, whereas an elevated neonatal IgG often represents maternal antibodies

Front 225

Explain Rh incompatibility. In what situations does it occur?

Back 225

Rh (or rhesus factor) blood-type incompatibility is of concern because it can lead to hemolytic disease of the newborn. Rh incompatibility occurs when the mother is Rh-negative and her infant is Rh-positive. The boards assume an understanding of inheritance of the Rh factor. If both the mother and the father are Rh-negative, there is nothing to worry about because their infant will be Rh negative. If the father is Rh-positive, the infant has a 50/50 chance of being Rh-positive.

Front 226

How do you detect and manage potential hemolytic disease of the newborn?

Back 226

If indicated by maternal and potential fetal blood type, check maternal titers of Rh antibody every month, starting in the seventh month of gestation. Give RhoGAM automatically at 28 weeks and within 72 hours after delivery as well as after any procedures that may cause transplacental hemorrhage

Front 227

True or false: The first child is usually the most severely affected by Rh incompatibility

Back 227

False. Previous maternal sensitization is required for disease to occur. In other words, if a nulliparous Rh-negative mother has never received blood products, her first Rh-positive infant will not be affected by hemolytic disease—except in the rare case of sensitization during the first pregnancy from undetected fetomaternal bleeding, which commonly occurs later in the pregnancy and in most instances can be prevented by RhoGAM administration at 28 weeks. The second Rh-positive infant, however, will be affected—unless you, the astute board taker, administer RhoGAM at 28 weeks and within 72 hours after delivery during the first pregnancy. Any history of blood transfusion, abortion, ectopic pregnancy, stillbirth, or delivery can cause sensitization.

Front 228

How much RhoGAM should you give if the maternal Rh antibody titer is extremely high?

Back 228

In this setting RhoGAM is worthless, because sensitization has already occurred. RhoGAM administration is a good example of primary prevention. Close fetal monitoring for hemolytic disease is required.

Front 229

How do you recognize, monitor, and treat hemolytic disease of the newborn?

Back 229

Hemolytic disease of the newborn in its most severe form causes fetal hydrops (edema, ascites, pleural and/or pericardial effusions) and death. Amniotic fluid spectrophotometry and ultrasound can help gauge the severity of fetal hemolysis. Treatment of hemolytic disease involves (1) delivery, if the fetus is mature (check lung maturity with a lecithin-to-sphingomyelin ratio); (2) intrauterine transfusion; and (3) phenobarbital, which helps the fetal liver break down bilirubin by inducing enzymes.

Front 230

True or false: ABO blood group incompatibility can cause hemolytic disease of the newborn

Back 230

True. ABO blood group incompatibility can cause hemolytic disease of the newborn when the mother is type O and the infant is type A, B, or AB. This condition does not require previous sensitization, because IgG antibodies (which can cross the placenta) occur naturally in mothers with blood type O—but not in mothers with other blood types. The hemolytic disease is usually less severe than with Rh incompatibility, but treatment is the same. In rare instances, other minor blood antigens also may cause a reaction

Front 231

When should RhoGAM be given?

Back 231

To reiterate, give RhoGAM only when the mother is Rh-negative and the father is Rh-positive or his blood type is unknown. During routine prenatal care, check for Rh antibodies at the first visit. If the test is positive, do not give RhoGAM—you are too late. Otherwise, give RhoGAM routinely at 28 weeks and immediately after delivery. Also give RhoGAM after an abortion, stillbirth, ectopic pregnancy, amniocentesis, chorionic villus sampling, and any other invasive procedure that may cause transplacental bleeding during pregnancy.

Front 232

Define premature rupture of membranes (PROM). How is it diagnosed?

Back 232

PROM is rupture of the amniotic sac before the onset of labor. Diagnosis of rupture of membranes (whether premature or not) is based on history, sterile speculum exam, and/or a positive nitrazine test. The sterile speculum exam shows pooling of amniotic fluid and a ferning pattern when the fluid is placed on a microscopic slide and allowed to dry. Nitrazine paper turns blue in the presence of amniotic fluid. Ultrasound should be done in cases of PROM to assess amniotic fluid volume as well as gestational age and any anomalies that may be present.

Front 233

What usually follows membrane rupture? What should you do if it does not occur?

Back 233

Spontaneous labor usually follows membrane rupture; for this reason, an amniotomy may be done in an attempt to induce labor if membranes do not rupture spontaneously. If labor does not occur within 6 to 8 hours of membrane rupture, and the mother is term, and if the cervix is favorable, labor should be induced.

Labor is induced because the main risk of PROM is infection, which may occur in the mother (chorioamnionitis) and/or the infant (neonatal sepsis, pneumonia, meningitis). The usual culprits are group B streptococci, Escherichia coli, or Listeria sp.

Front 234

Define preterm premature rupture of membranes (PPROM). How is it managed?

Back 234

PPROM is defined as premature rupture of membranes before 36 to 37 weeks of gestation. The risk of infection increases with the duration of ruptured membranes. Do a culture and Gram stain of the amniotic fluid. If it is negative, treatment simply involves pelvic and bed rest with frequent follow-up. If the culture is positive for group B streptococci, treat the mother with penicillin G or ampicillin, even if she is asymptomatic.

Front 235

How does chorioamnionitis present and how is it treated?

Back 235

Patients with chorioamnionitis present with fever and a tender, irritable uterus, usually after delivery. Antepartum chorioamnionitis may occur in patients with PROM. Do a culture and Gram stain of the cervix and amniotic fluid, and treat with antibiotics such as ampicillin plus gentamicin while awaiting culture results.

Front 236

Define postpartum hemorrhage. What are the common causes?

Back 236

Postpartum hemorrhage is defined as a blood loss greater than 500 mL during vaginal delivery or greater than 1 L during cesarean section. The most common cause is uterine atony (75% to 80% of cases). Other causes include lacerations, retained placental tissue, coagulation disorders, low placental implantation, and uterine inversion. Retained placental tissue results from placenta accreta (penetration of the placenta through the endometrium into the myometrium), increta (deeper penetration of the placenta into the myometrium), or percreta (penetration of the placenta through the myometrium to the uterine serosa); the placenta grows more deeply into the uterine wall than it should. The major risk factor for this condition is previous uterine surgery or cesarean section, and the usual treatment is hysterectomy.

Front 237

What causes uterine atony? How is it treated?

Back 237

Uterine atony is caused by overdistention of the uterus (due to multiple gestation, polyhydramnios, or macrosomia), prolonged labor, oxytocin usage, grand multiparity (a history of five or more deliveries), and precipitous labor (too fast or less than 3 hours). Treat with a dilute oxytocin infusion, and use bimanual compression to massage the uterus while the infusion is running. If this approach fails, use ergonovine (contraindicated with maternal hypertension), prostaglandin f2-alpha, or misoprostol. If these strategies also fail, the patient may need a hysterectomy; ligation of the uterine vessels can be attempted if the patient wants to retain fertility.

Front 238

What is the treatment for retained products of conception?

Back 238

With retained products of conception (which is probably the most common cause of a delayed postpartum hemorrhage), remove the placenta manually to stop the bleeding. Next try curettage in the operating room under anesthesia. If placenta accreta, increta, or percreta is present, hysterectomy is usually necessary to stop the bleeding.

Front 239

What causes uterine inversion? How is it treated?

Back 239

When the uterus inverts, it usually can be seen outside the vagina. It is usually iatrogenic, a result of pulling too hard on the cord. If it occurs, put the uterus back in place manually; you may need to use anesthesia because of pain. Give intravenous fluids and oxytocin

Front 240

Define postpartum fever. What are the common causes?

Back 240

Postpartum fever is defined as a temperature greater than 100.4° F (38° C) for at least 2 consecutive days and is classically due to endometritis. However, do not forget easy causes of postpartum fever, such as a urinary tract infection or atelectasis/pneumonia. Pulmonary problems are especially common after a cesarean section. Other causes include pelvic abscess and pelvic thrombophlebitis.

Front 241

What should you do if a patient has postpartum fever?

Back 241

Look for clues in the history and physical exam. For example, in a patient with a history of PROM and a tender uterus on exam, endometritis is almost certainly the cause of the fever. Next, get cultures of the endometrium, vagina, blood, and urine. Start empiric antibiotics if indicated. Clindamycin plus gentamicin is a good choice; add “big-gun” antibiotics if the patient is crashing.

Front 242

What should you do if postpartum fever does not improve with antibiotics?

Back 242

If a postpartum fever does not resolve with broad-spectrum antibiotics, there are two main possibilities: progression to pelvic abscess or pelvic thrombophlebitis. CT scan will show a pelvic abscess, which needs to be drained, and sometimes demonstrates thrombophlebitis. Pelvic thrombophlebitis presents with persistent spiking fevers, lack of response to antibiotics, and no abscess on CT. Give heparin or low molecular weight heparin for a cure (and diagnosis in retrospect).

Front 243

What should you consider if a postpartum patient goes into shock without evident bleeding?

Back 243

▪ Amniotic fluid embolism
▪ Uterine inversion
▪ Concealed hemorrhage (e.g., uterine rupture with bleeding into the peritoneal cavity)

Front 244

What normal lab changes of pregnancy may be encountered on the Step 2 exam?

Back 244

▪ The erythrocyte sedimentation test becomes markedly elevated; hence, this test is essentially worthless in pregnancy.
▪ Total thyroxine (T4) and thyroid-binding globulin increase, but free T4 remains normal.
▪ Hemoglobin increases, but plasma volume increases even more; thus the net result is a decrease in hemoglobin and hematocrit.
▪ Blood urea nitrogen (BUN) and creatinine decrease because of an increase in glomerular filtration rate. BUN and creatinine levels at the high end of normal indicate renal disease in pregnancy.
▪ Alkaline phosphatase increases markedly.
▪ Mild proteinuria and glycosuria are normal in pregnancy.
▪ Electrolytes and liver function tests remain normal.

Front 245

What cardiovascular and pulmonary changes occur in a normal pregnancy?

Back 245

Normal cardiovascular changes: blood pressure decreases slightly, heart rate increases by 10 to 20 beats/min, stroke volume increases, and cardiac output increases (by up to 50%).

Normal pulmonary changes: minute ventilation increases because of increased tidal volume, but respiratory rate remains the same or increases only slightly; residual volume and carbon dioxide decrease. Collectively these changes cause the physiologic hyperventilation/respiratory alkalosis of pregnancy.

Front 246

What is the average weight gain during pregnancy? What commonly causes weight gain to be more or less?

Back 246

The average weight gain in pregnancy is roughly 28 pounds (12.5 kg). A larger weight gain may mean maternal diabetes. A smaller weight gain may mean hyperemesis gravidarum or psychiatric or major systemic diseases.

Front 247

Define hyperemesis gravidarum. How do you recognize and treat it?

Back 247

Hyperemesis gravidarum is intractable nausea and vomiting leading to dehydration and possible electrolyte disturbances. It presents in the first trimester, usually in younger patients with their first pregnancy and underlying social stressors or psychiatric problems. Treat with supportive care as well as small, frequent meals and antiemetic medications such as doxylamine, promethazine, or dimenhydrinate (fairly safe in pregnancy). Patients may need intravenous fluids and correction of electrolyte abnormalities.

Front 248

Define cholestasis of pregnancy. How is it treated?

Back 248

Cholestasis of pregnancy presents with itching (often severe) and/or abnormal liver function tests, usually in the second and third trimester. In rare cases, jaundice may coexist. The only known definitive treatment is delivery, but ursodeoxycholic acid or cholestyramine may help with symptoms.

Front 249

What is acute fatty liver of pregnancy? How is it treated?

Back 249

Acute fatty liver of pregnancy is a more serious disorder than cholestasis. It presents in the third trimester or after delivery and usually progresses to hepatic coma. Treat with intravenous fluids, glucose, and fresh frozen plasma to correct coagulopathies. Vitamin K does not work, because the liver is in temporary failure. If the patient survives with supportive care, liver dysfunction usually resolves on its own with time.

Front 250

True or false: In terms of surgery, the usual rule of thumb is to treat the disease in a pregnant woman the same as you would treat it in a nonpregnant woman

Back 250

It depends. It definitely is true in the case of an acute surgical abdomen. Pregnant women can develop appendicitis, which may present with right upper quadrant pain due to displacement of the appendix by the pregnant uterus. Just as in nonpregnant patients, a laparotomy or laparoscopy is perfectly appropriate when the diagnosis is unsure and the patient has peritoneal signs.

For semiurgent conditions (e.g., ovarian neoplasm), it is best to wait until the second trimester to perform surgery (when the pregnancy is most stable). Purely elective cases are avoided during pregnancy.

Front 251

How do you manage fetal malpresentation?

Back 251

External cephalic version can be used to rotate the fetus from the breech to the cephalic position. If this fails, the decision must be made whether to attempt vaginal delivery or do a cesarean section. Although under specific guidelines some frank and complete breeches may be delivered vaginally, it is acceptable to do a cesarean section for any breech presentation. With shoulder presentation or incomplete/footling breech, cesarean section is mandatory. For face and brow presentations, watchful waiting is best, because most cases convert to vertex presentations. If they do not convert, do a cesarean section.

Front 252

What is the “poor man's way” to distinguish between monozygotic and dizygotic twins?

Back 252

If the sex or blood type is different, the twins are dizygotic (i.e., fraternal). If the placentas are monochorionic, the twins are monozygotic (i.e., identical). These three simple points differentiate monozygotic from dizygotic twins in 80% of cases. In the remaining 20%, human leukocyte antigen typing studies are required to determine the type of twins.

Front 253

What are the maternal and fetal complications of multiple gestations?

Back 253

Maternal complications include anemia, hypertension, premature labor, postpartum uterine atony, postpartum hemorrhage, and preeclampsia.

Fetal complications include polyhydramnios, malpresentation, placenta previa, abruptio placentae, velamentous cord insertion/vasa previa, premature rupture of the membranes, prematurity, umbilical cord prolapse, IUGR, congenital anomalies, and increased perinatal morbidity and mortality.

The higher the number of fetuses, the higher the risk of most of the conditions mentioned for both mother and offspring.

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How are multiple gestations delivered?

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With vertex–vertex presentations of twins (both infants are head first), you can try vaginal delivery for both infants, but with any other twin presentation combination or more than two infants, perform cesarean section.

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What is fetal fibronectin? When is a test for this substance useful? Is the test more helpful when positive or negative?

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Fetal fibronectin (an extracellular matrix protein that helps attach the amniotic membranes to the uterine lining) can be detected in the vaginal secretions of some women presenting with signs and symptoms of preterm labor. The test is most helpful when negative between 22 and 34 weeks of gestation, because it indicates a very low likelihood of delivery in the next 2 weeks. Thus, a more conservative, observational approach can be used. When fetal fibronectin is positive in this setting, the woman remains at a higher risk for delivery in the next 2 weeks and a more aggressive approach to tocolysis and fetal lung maturity hastening is typically employed.