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122 Cards in this Set
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risk factors for cervical insufficiency
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most common: prior gyn surgery especially LEEP or cone bx of cervix
also prior trauma, multple gestation, mullerian anomalies, hx of preterm birth or second trimester pregnancy loss |
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risk factors for polyhydramnios
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fetal malformations and genetic disorders, maternal diabetes mellitus, multiple gestation, and fetal anemia
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on pelvic exam, cervix is closed but shorter than nl. most appropriate next step?
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transvaginal U/S: gold standard for evaluating cervix for cervical incompetence in pregnancy
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early, variable, late decelerations cause
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Early: fetal head compression
Variable: umbilical cord compression Late: uteroplacental insufficiency -> fetal hypoxia -> fetal acidosis |
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Stress incontinence tests and tx
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cotton swab test
pelvic muscle exercises and urethropexy are the recommended tx options |
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When to use steroids in prematurity?
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28-34 wks
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GBS PPx
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penicillin, ampicillin
alternatives: cefazolin, clinda, vanco |
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physiologic leukorrhea
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copious vaginal d/c that is white or yellow in appearance, nonmalodorous, and occurs in the absence of other sx or findings on vaginal exam is referred to as physiologic leukorrhea
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uterine rupture sx
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intense abdominal pain a/w vaginal bleeding. loss of fetal station = red flag
risk factors include pre-existing uterine scar or abdominal trauma |
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risk factors for increasing osteoporosis likelihood
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advanced age, thin body habitus, cigarette smoking, excessive alcohol consumption, corticosteroid use, menopause, malnutrition, family hx of osteoporosis, and asian/caucasian ethnicity
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IUFD (intrauterine fetal demise) is diagnosed with fibrinogen at 160 (nl 150-450). Next step?
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induction of labor
risk of DIC! fibrinogen normally elevated in pregnancy so |
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asymmetric intrauterine growth restriction: what causes this + typical causes?
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result of late exposure to a maternal fator that does not allow optimal fetal growth.
characterized by nl or almost nl head size and a reduced abdominal circumference. maternal factors: HTN, smoking, hypoxia, vascular dz, and preeclampsia |
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tx of choice for postpartum endometritis?
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polymicrobial infection -> tx with IV clinda and gent
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BP control in pregnancy
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ACEi and ARBs contraindicated in pregnancy. First line agents are labetolol and methyldopa
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Hallmark features of endometriosis
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dyspareunia, dysmenorrhea, and dyschezia
tx with OCPs. other possibilities include GnRH analogs (eg leuprolide) or danazol |
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UTI drugs in pregnancy
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recommended: nitrofurantoin, amoxillin, amoxillin-clavulanate, cephalexin
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metromenorrhagia at 14 yo
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most menstrual cycles in the first one to two years following menarche are anovulatory. these cycles are typically irregular and may be complicated by menorrhagia
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Kallmann's syndrome sx, karyotype, lab findings?
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primary amenorrhea and anosmia
nl female karyotype lab findings c/w GnRH deficiency (low FSH and LH |
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most common cause of abnl uterine bleeding?
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dysfunctional uterine bleeding (DUB) -> diagnosis of exclusion and is most often due to anovulation
Tx: high dose estrogen |
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Galactorrhea causes?
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presents as guaiac negative b/l nipple d/c
causes: prolactinoma, hypothyroidism, overstimulation of nipple, OCPs, medications which lower DA levels w/u includes r/o pregnancy, measuring serum prolactin and TSH levels, and possible MRI of brain to r/o prolactinoma |
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Trichomonas infxn
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inflamation, pruritis, and thin malodorous vaginal d/c
BV does NOT cause inflammation (erythema), candida causes thick/white d/c |
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PID tx
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INpatient tx with cefotetan and doxy
inability to take oral meds due to N/V is an indication for inpatient tx of PID |
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vaginal d/c from Candida. Tx?
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symptomatic patients can be treated with an azole antifungal, such as fluconazole.
(can't use oral nystatin). Sexual partners do not require tx |
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Syphilis diagnosis
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VDRL and RPR: high rate of false-negative results to serologic testing --> thus, in patients with recent painless ulcer formation, use darkfield microscopy if available.
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Confirmation of dx of IUFD
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ultrasonography to demonstrate absence of fetal movement and cardiac activity
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Most effective parameter for estimation of fetal weight in cases of suspected FGR.
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abdominal circumference (affected in both symmetric and asymmetric fetal growth restriction)
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Risks and benefits of OCPS
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risks; venous thromboembolism, cardiovascular events/stroke, triglyceride elevation, cholestasis or cholecystitis, DM, HTN
benefits: protective against ovarian cancer/cysts, endometrial CA, benign breast dz, dysmenorrhea (anemia) |
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Suppressing breast milk production
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no medications to be used. Patients advised to wear tight-fitting bra, avoid nipple manipulation and use ice packs and analgesics to relieve associated pain
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Idiopathic central precocious puberty management
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GnRH agonist therapy to prevent premature fusion of the epiphyseal plates, which would otherwise lead to short stature
all should undergo brain imaging to r/o underlying CNS lesion |
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Septic abortion management
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cervical + blood cx -> IV antibiotics -> gentle suction curretage
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Increase in BP that appears before 20 weeks. Reason?
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Chronic HTN or hydatiform mole
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Distinguishing adenomyosis vs fibroids on exam/clinical hx
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both with dysmenorrhea and menorrhagia
Adeno: PE reveals an enlarged and generally symmetrical uterus Fibroid: irregularly shaped |
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most common cause of abnl MSAFP level?
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gestational age error
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Preeclampsia RUQ pain. reason?
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Liver can be involved in preeclampsia by centrilobular necrosis, hematoma formation and the formation of thrombi int he portal capillary system -> swelling of the hepatic capsule and resultant RUQ pain
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mastitis vs breast engorgement
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mastitis: UNILATERAL breast pain with isolated firm, tender, erythematous area accompanied by fever greater than 38.3C. antistaphyloccal agents
breast engorgement: bilateral, breast tenderness and swelling. resolves spontaneously, --> use cool compresses, tylenol, and NSAIDs for sx control |
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mild preeclampsia management
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at term and/or fetal lung maturity ascertained -> delivery
not at term and/or fetal lungs are not yet mature, then pt is managed with bed rest and close observation. |
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arrest of dilatation/arrest of descent
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lack of change for 2 hrs in nulliparous and multiparous pts.
arrest of descent: lack of change for 2 hours in primigravid pts and 1 hr in multigravid pts, with an extra hr allowed if an epidural is in place. |
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asymptomatic women with pelvic masses on exam-> appropriate course of action?
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transvaginal U/S and then CA-125 level
if U/S suggests simple cyst and CA-125 level is not elevated, masses <10cm can be followed conservatively |
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exercise advice for pregnant women
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All healthy pregnant women with uncomplicated pregnancies are encouraged to exercise for 30min daily at a moderate intensity that allows the mother to carry on conversation while exercising
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External cephalic version indications
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can be attempted in women with breech pregnancies at greater than 37 wks GA if there are no contraindications to vaginal delivery and fetal well-being has been established
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thyroid changes in pregnancy
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increase in TBG, resulting in increased T4/T3, a normal free T4/T3, and a normal TSH
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Sheehan's syndrome following pregnancy
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look for severe postpartum bleeding followed by failure to lactate -> deficient prolactin from necrosis of anterior pituitary due to hemorrhagic shock -> failure to produce milk in this condition results from prolactin deficiency
prolactin gets increased during postpartum fall in estrogen and progesterone combined with nipple stimultion other complications include hypothyroidism, amenorrhea, genital atrophy, loss of pubic and axillary hair, and fatigue |
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gold standard for dx of endometriosis
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laparoscopy
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screening and diagnostic test for gestational diabetes
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screening: one hour 50gram oral glucose tolerance test (threshold 140)
if fail this test, then three hour oral glucose tolerance test (OGTT) is done next |
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Gestational diabetes carries what risks for fetus
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macrosomia, hypocalcemia, hypoglycemia, hyperviscosity due to polycythemia, respiratory dificulties, cardiomyopathy and CHF
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quad screen results that are predictive of down syndrome
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Increased beta-hCG and Inhibin A
Decreased MSAFP and estriol |
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morbid obese patient with amenorrhea. what's the cause?
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anovulation. In anovulation, FSH and LH levels are nl. Ovaries continue to produce estrogen, but progesterone is not being produced at the nl post ovulation levels.
Therefore, progesterone withdrawal menses at the end of the cycle does not occur (In premature ovarian failure, FSH/LH levels elevated) |
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Congenital aromatase deficiency
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prevents conversion of androgens to estrogens. causes gestational maternal virilization and virilization of XX fetuses. Thus, affected girls will have nl internal genitalia and ambiguous external genitalia
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Epidural anesthesia can cause what type of incontinence?
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overflow incontinence is transient (bladder denervation, blocking both afferents and efferents)
best treated with intermittent catheterization |
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Postterm pregnancies should be monitored for what problem?
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oligohydramnios twice weekly
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threatened abortion characteristics and management
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characterized by any hemorrhage occurring before the 20th week of gestation with a live fetus and a closed cervix
management: once confirmed via U/S, reassurance and performance of U/S one week later |
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Lichen sclerosis characteristics and next step in management of suspicious lesions
tx? |
most commonly affects postmenopausal women and manifests with vulvar pruritis and discomfort. Exam shows porcelain-white atrophy.
Bx should be considered to r/o vulvar SCC tx: topical corticosteroid (chronic inflammatory condition of hte anogenital region) --> pregmalignant lesion of vulva as vulvar SCC occurs with greater frequency in this population |
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first line med for tx of HTN in pregnancy?
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methyldopa (centrally acting alpha adrenergic agonist thereby decreasing sympathetic outflow and producing vasodilation)
also seen labetolol and hydralazine |
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Pregnant woman has pap smear that shows HSIL at 14 wks gestation. Test for HPV discloses strain with high oncogenic risk. Next best step?
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Colposcopy and bx after delivery (and during this time as well)
Any woman with a cytologic specimen suggesting HSIL should undergo colposcopy and directed bx. If the bx is negative, a second bx is recommended 6-wks after delivery |
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Reactive stress test
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20 min timeframe - at least 2 accel of the fetal heart rate of at least 15 beats/min above the baseline and lasting at least 15 sec each
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Missed abortion: when to suspect and how to dx
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missed abortion: form of spontaneous abortion (SAB) occurring before 20 weeks with complete retained POC and a closed cervix
pts typically present with loss of pregnancy sx and some brown vaginal d/c, and a transvaginal U/S is necessary to confirm dx |
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Ways to manage missed abortion with retained POCs
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removal of POC from uterus
surgical: D&C medical: vaginal misoprostol expectant: serial imaging to ensure complete natural expulsion of POC |
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Increased/Decreased MSAFP results
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NT defects, abdominal wall defects (gastroschisis, omphalocele), multiple gestation, and inaccurate gestational age.
low levels = chromosomal anomalies such as Down and trisomy 18, and inaccurate gestational dates U/S should be performed in patient FIRST to r/o inaccurate dates |
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Appropriate HIV tx for mother and fetus
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zidovudine throughout pregnancy and labor, and treating newborn for the first 6 wks of life -> risk of HIV transmission reduced by 70%
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Renal colic characteristics
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flank pain that radiates to the groin and hematuria are very characteristic of nephrolithiasis
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Pseudocyesis
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psychiatric condition in which woman presents with nearly all s/s of pregnancy; however, U/S reveals nl endometrial stripe and neg pregnancy test
proposed mechanism: depression causes hormonal changes mimicking that of pregnancy form of conversion d/o |
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Metronidazole should abstain from what?
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alcohol -> disulfiram-like reaction (flushing, N/V, and hypotension) --> basically a hangover
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With estrogen therapy, what should be expected in someone using synthroid?
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requirement increases -> monitor every month or so for dose adjustments
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BUN and creatinine changes during pregnancy
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both decreased due to increase in renal plasma flow and GFR
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tamoxifen agonist/antagonist
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decrease risk of osteo
increase risk of endometrial cancer no definitive data on ovarian CA |
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ovulatory phase of menstrual cycle: expectations on cervical exam
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cervical mucus is profuse, clear and then. Strech to approx 6cm (mucus) and exhibit ferning on microscope slide preparation
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One cause of irregular periods in 14yo
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hypothalamic pituitary gonadal axis immaturity -> insufficient gonadotropin secretion
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Obese woman with milder menopausal sx. Why?
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Conversion of adrenal androgens to estrogens by adipose tissue (which contains aromatase enzyme)
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Normal BPP results
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8-10 (five parameters - fetal tone, fetal movements, fetal breathing, AFI, NST)
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Preferred form of hormonal contraception for lactating mothers
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progestin-only contraceptives -> doesn't interfere with quantity and composition
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excessive stress, eating disorders, and excessive exercise can cause what type of amenorrhea?
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hypogonadotropic hypogonadism
use pulsatile GnRH therapy to induce ovulation |
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clinical suspicion of vasa previa in the setting of antepartum hemorrhage
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fetal heart changes progressing from tachy to brady and finally to a sinusoidal pattern occurring suddenly after rupture of membranes suggests dx
bleeding is fetal in origin so maternal vital signs will remain stable while fetus exsanguinates |
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To dx PMS, what should you have them do?
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menstrual diary to document 1-2 week prior to menses cycle of sx
SSRI are first line therapy for majority of patients |
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primary amenorrhea, bilateral inguinal masses, and breast development without pubic or axillary hair suggest what?
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androgen insensitivity syndrome.
blind vaginal pouch and karyotype of 46XY are other clues. gonadectomy should be performed after completion of puberty to avoid risk of testicular carcinoma |
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Most significant risk factor for CVS
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fetal loss, limb reduction (particularly if done before 9-10 wks GA)
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Elevated FSH in menopausal range. How long duration before you diagnose premature ovarian failure?
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3 mo
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Classic triad for hydatiform mole
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enlarged uterus, hyperemesis, and markedly elevated beta HCG (>100,000)
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Hyperemesis gravidarum sx
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KETONURIA, severe and persistent vomiting, weight loss
If sx begin after week 10 or do not resolve by week 20, then another etiology should be suspected |
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Most common cause of mucopurulent cervicitis
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Chlamydia trachomatis
(although gonorrhea is a less common cause, gonococcal infection should be carefully excluded by gram stain/cx |
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classic description of primary dysmenorrhea
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lower abdominal pain that radiates to the thighs and back and begin hours before menstruation
release of prostaglandins during breakdown of endometrium is believed to be the cause of sx -> can be reduced with NSAIDs |
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PCOS associated with what greater CA risk?
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endometrial carcinoma -> unbalanced estrogen secretion resulting from PCOS
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asymptomatic bacteriuria in pregnant patient
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>100,000 CFU
30-40% of untreated will develop pyelo--> may cause septicemia, preterm labor or low birth weight babies |
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Hypogonadotropic hypogonadism -> how does this result in decreased estrogen?
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As FSH and LH drop, so too do sex hormones like estrogen and testosterone --> predisposes pts to osteoporosis and decreased muscle bulk, also infertility
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Endometrial bx required in which patients to r/o endometrial hyperplasia/CA
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patients >35yo, obese, chronically hypertensive, diabetic
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S/S of false labor
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progressive cervical changes are absent, contractions are irregular (interval does not shorten and do not increase in intensity), felt in lower abdomen, and discomfort is readily relieved by sedation -> reassurance!
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Premenopausal women with simple or complex hyperplasia without atypia -> tx of choice
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cyclic progestins (OCP is not appropriate once endometrial hyperplasia has occurred)
simple atypical/complex atypical -> risk is 10% and 25%, respectively -> with complex atypia hysterectomy! |
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Placental abruption (as determined by uterine tenderness/hyperactivity and moderate vaginal bleeding) in a stable mother and fetus
next step in mgmt? |
vaginal delivery with augmentation of labor, if necessary
C/S only when there are obstetric indications, or when there is a rapid deterioration of the state of either the mother or the fetus and labor is in an early stage |
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Causes of precocious puberty (below 8 in girls, 9 in boys)
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central: increased FSH and LH -> get brain imaging with CT/MRI
peripheral: low FSH and LH -> gonadal or adrenal release of excess sex hormones tx: continuous GnRH analog |
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Immediate postpartum period, low grade fever, leukocytosis, and vaginal d/c. Is this nl?
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yes
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Pregnant woman has syphilis but is allergic to PCN. Next step?
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PCN desensitization -> incremental doses of oral penicillin V
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Treating HPV warts
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small lesions can be treated with trichloroacetic acid or podophyllin -> recurrence rate high, larger lesion requires excision or electric current
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Ways that maternal Rh (D) alloimmunization can happen
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most common: transplacental fetomaternal bleeding
also in miscarriage, abortion, ectopic pregnancy, fetal death, and maternal abdominal trauma |
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suspicious ectopic with transabdoinal U/S. next step?
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transvaginal U/S
though laparoscopy is extremely accurate, it is last resort in diagnosing ectopic -> reserve for ruptured one |
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S/S of sheehan's syndrome
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postpartum period with failure to lactate and other features of pituitary hormonal deficiency --> look for signs of hypopituitarism including hypothyroidism, hypogonadism
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When to suspect mother is sensitized to anti-D
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antibody titers > 1:6
administration of RhoGAM is not helpful in this setting and close fetal monitoring for hemolytic disease is required |
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Low back pain during third trimester of pregnancy due to what?
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believed to be caused by the increase in lumbar lordosis and the relaxation of the ligaments supporting the joints of the pelvic girdle (as a result of hormones)
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Infants born to patients with Graves disease treated with surgery are at risk for what? why?
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thyrotoxicosis because of the passage of thyroid stimulating immunoglobulin across the placenta.
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vaginal SCC tx options
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stage 1 and II less than 2 cm -> surgical
otherwise, radiation therapy also take into account age and comorbid conditions when deciding on surgery vs radiation |
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Which valve anomaly classically presents in pregnancy
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mitral stenosis -> most often due to rheumatic fever and occurs much more often in countries with limited access to antibiotics
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Hydatiform mole suspicions
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first trimester vaginal bleeding possibly a/w expulsion of villi
excessive N/V uterine size larger than expected for gestational age U/S showing "snow storm" appearance serum b-HCG increased |
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threatened abortion
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FETAL TONES STILL HEARD on U/S
any hemorrhage occurring before 20th week of gestation cervix closed and no passage of fetal tissue |
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Inevitable abortion
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vaginal bleeding, lower abdominal cramps that may radiate to the back and perineum and a dilated cervix
U/S demonstrates ruptured or collapsed gestational sac with absence of fetal cardiac motion |
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atypical squamous cells of undetermined significance (ASC-US) -> next step in mgmt?
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HPV DNA testing. If positive, colposcopy; if negative, repeat PAP and HPV test in 3 yrs
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painful third trimester vaginal bleeding with normal U/S most likely due to what?
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placental abruption
think HTN and cocaine! |
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role of U/S in the evaluation of antepartum hemorrhage is primarily what?
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r/o placenta previa and not to diagnose abruptio placentae
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Vaginismus def and tx
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vaginismus = involuntary contraction of the perineal musculature. underlying cause is psychological
tx: relaxation, kegel exercises to relax vaginal muscles, and insertion of dilators,fingers, etc to bring about desensitization |
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granulosa cell tumor
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fairly common and represent 10% of all solid malignant ovarian tumors -> secrete excessive estrogen -> precocious puberty!
with virilizing sx, think of excessive androgens |
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main role of hCG
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secreted by syncytiotrophoblast and is mainly responsible for the preservation of the corpus luteum during early pregnancy
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Primary amenorrhea with confirmed uterus - next step?
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last test - 8
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abdominal pain in a young female in the middle of her cycle
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most likely mittelschmerz (midcycle pain)
- often lateralizes to the ovary that produced a mature ovum, so it can be unilateral |
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DES exposure increases risk of what?
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clear cell adenocarcinoma of the vagina and cervix
cervical anomalies and uterine malformations |
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magnesium sulfate toxicity in the setting of pre-eclampsia -> alternative tx?
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calcium gluconate
toxicity: decreased deep tendon reflexes, followed by respiratory depression |
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epidural anesthesia can cause what side effect and through what mechanism?
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hypotension -> blood redistribution to the lower extremities and venous pooling due to sympathetic fiber block that results in vasodilation of the lower extremity vessels
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Plan B - medical name, ideal time frame
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Levonorgestrel -> given 120 hours after unprotected intercourse
this is a progestin only method effectiveness greater the earlier medication is administered prevents 7 out of 8 pregnancies |
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Fetal hydantoin syndrome
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exposure to anticonvulsant meds
small body size, microcephaly, digital hypoplasia, nail hypoplasia, midfacial hypoplasia, hirsutism, cleft palate, rib anomalies |
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First step in presence of nonreassuring heart rate?
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oxygen and change maternal position
uterotonic drugs need to be discontinued and maternal hypotension evluated and treated variable decelerations may require amnioinfusion, which consists of infusion of fluid into the amniotic cavity |
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fibroids
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most common pelvic tumor seen in women. usually present as pelvic masses with sx due to compression of adjacent organs (constipation, urinary frequency) and heavy, prolonged menstrual bleeding. bleeding between cycles nad postmenopausal bleeding are not typical for leiomyomas
diagnosed with ULTRASOUND (no need for CT) as it has a higher sensitivity than CT for both uterine and ovarian pathology. US also avoids putting pt at risk of radiation. |
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diagnosing acute appendicitis on a pregnant female
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US with graded compression technique: noncompression and dilation of the appendix are diagnostic of appendicitis.
if nondiagnostic, MRI can be performed |
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ruptured ectopic pregnancy
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typically with diffuse abdominal pain, cervical and adnexal tenderness, lightheadedness, and hemodynamic instability. mgmt includes urgent surgical evaluation.
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rubella vaccine for pregnancy
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women generally advised to avoid live vaccines immediately before and during a pregnancy. wild type rubella has been a/w significant adverse fetal effects, but hte vaccine strain has not.
women who are inadvertently given rubella vacination bbefore or during pregnancy do not require additional intervention and may proceed with routine prenatal care. |
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ruptured ovarian cyst
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p/w acute onset of unilateral pelvic pain immediatley after strenuous activity or sexual intercourse. Pelvic US can confirm the dx by showing free fluid in the pelvis.
supportive care (eg analgesics) is recommended for uncomplicated cyst rupture; complicated cyst rupture may require surgical intervention) |
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ovarian and adnexal torsion
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most commonly in women of reproductive age. primary risk factor is ovarian enlargement (pregnancy, tumors). pts develop sudden onset of unilateral lower abdominal pain (usually right sided), N/V.
dx confirmed with US using color DOppler. mgmt includes laparascopic surgery distinguished from ruptured ovarian cyst bc it has following features: usually after strenuous physical activity, accompanied by light bleeding, NO significant N/V. |
