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747 Cards in this Set
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What percent of all pregnancies are aborted in first semester spontaneously?
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15%
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Fertility rate in women with multiple spontaneous abortions?
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50%
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Most common cause of spontaneous abortions in
1st trimester? 2nd trimester? |
1st - chromosomal abnormalities
2nd - uterine or environmental issues (cervical incompetence or toxins) |
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Age of father when risk for aneuploidy begins?
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55
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Multiple spontaneous 1stT abortions increase risk for what?
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Subsequent pregnancy and child to have c'somal abnormalities.
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Teratogenic effect of alcohol?
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Fetal alcohol syndrome
1) IUGR 2) craniofacial abnormalities 3) Mental retardation |
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Teratogenic effect of tetracycline?
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Bone development and stained teeth
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Teratogenic effect of phenytoin (dilantin)?
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Digital hypoplasia and craniofacial abnormalities
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Radiation during pregnancy has what cutoff, and if breeched has what effects in
1stT 2ndT |
1) 50 rad
1stT - lungs, heart, limbs 2ndT - CNS |
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Recs for exercise for pregnant women (4)
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1) Exercise is good, no cutoff for hr
2) Non-weight bearing ideal 3) Avoid supine position 4) 4-6 weeks post pregnancy to return to prepreggers ex regimen |
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Nuchal translucency is a risk factor for what?
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C'somal abnormalities specifically Down's.
Also, greater the luceny the greater the risk for other abnormalities even with nl karyotype |
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Cystic hygromas on US risk for what?
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Turner's sx
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Inheritance of achondroplasia
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Autosomal dominant
but 90% of cases are de novo! |
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How fertile are people with balanced translocations?
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Translocated individuals have normal phenotypes, but they cannot produce nl gametes. Non-disjunction ALWAYS happens in meiosis so all fertilizations are either trisomies or monosomies of that c'some. All but 45,X are lethal for monosomies.
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Indication for MSAFP
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If greater than 4.0 MOM then risk for neural tube defect increases (not diagnostic!)
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Safest cytology by semester?
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1st - CSV
2nd - Amniocentesis 3rd - Amniocentesis |
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Vaccines
Give IVIG: Give Inactivated Bac: Contraindicated: Contraindicated except with exposure: |
Give IVIG: Hep A, Hep B, Rabies, Tetanus, Varicella
Give Inactivated Bac: Cholera, plague, Thyphoid Contraindicated: Measles, Mumps Contraindicated except with exposure: Rubella |
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Which infection can spread from a recently vaccinated person to a new host?
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Polio
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Abx causes kernicterus (bilirubin induced brain damage)
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Bactrim (Trimethoprim/sulfamethaxazole)
All SULFA drugs |
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Abx causes gray baby sx (vomiting, SOB, hypothermia, cardiovascular collapse)
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Chloramphenicol
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Safe Abx in pregnancy
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Cephalosporins and Penicillins
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Environmental stress that increases risk for neural tube defect
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Maternal hyperthermia
Suanas and hot tubs |
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Low MSAFP
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Dowm's Sx
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Mgmt
Elevated MSAFP |
Ultrasound for confirmation of GA and to screen for fetal abnormalities
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How much weight should women gain during pregnancy?
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nl - 25-35 lbs
Obese - 5-10 lbs Really obese - no weight gain at all All should avoid restricted diet or weight loss |
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Mgmt of
Epileptic pregnant woman |
1) Attempt to wean off anti-epileptic
2) Reduce or use only 1 anti-epileptic 3) Avoid VPA *All epileptic women have increased risk for structural abnormalities |
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When to get MMR and Flu vaccine during pregnancy
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MMR - 3 months before conception
Flu - after 1st T |
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Screenings by ethnicity
Jews: Northern Europe: Mediterranean: |
Jews: Tay-Sachs, Canavan
Northern Europe: CF Mediterranean: Beta thalassemia |
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Vegetarian deficiencies in pregnant mothers
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Need animal protein (for essential a. acids)
Need B12 Vit A supplementation can cause abnormalities |
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Drugs that are teratogenic
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Tobacco
Alcohol Cocaine |
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Dx
Hemolytic anemia in setting of sulfonamide abx tx |
G6PDase deficiency
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Inheritance of G6PDase deficiency
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X-linked recessive
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Dx
Dome shaped papules on body, with cafe au lait lesion on back |
Neurofibromatosis
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Inheritance of neurofibromatosis
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Autosomal dominant
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Inheritance of CF
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Autosomal recessive
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Dx
Bone fractures and deformities on prenatal ultrasound in fetus |
Osteogenesis imperfecta
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Dx
Nuchal translucency (cystic hygroma) |
Turner's syndrome if later
The earlier it's seen in GA the more likely it is to be 21, 18, or 13 |
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Dx
Blocked ureter with enlarged bladder and oligohydramnios |
Prune belly syndrome
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Dx
Lemon sign |
Spina bifida
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Dx
Double bubble of dudodenal atresia |
Trisomy 21
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Dx
Fetal hearing loss from abx during pregnancy |
Streptomycin
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Dx
Hemolytic anemia in fetus and mother from abx during pregnancy |
Nitrofurantoin
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Recs for Flu vaccine for pregnant women
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If underlying disease is serious
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Recs for Typhoid vaccine for pregnant women
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If traveling to endemic country
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Recs for Hep A vaccine for pregnant women
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After exposure or if traveling to endemic country
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Recs for Cholera vaccine for pregnant women
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Only if traveling to endemic country
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Recs for TDap vaccine for pregnant women
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If never given before or if more than 10 years since last
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Recs for polio vaccine for pregnant women
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During epidemic is mandatory, but otherwise contraindicated
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Recs for Yellow Fever vaccine for pregnant women
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If traveling to endemic country
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Recs for Rabies vaccine for pregnant women
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Always given
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Division after formation of embryonic disc
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Siamese twins
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In Mono-Di twins which can be mono
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The chorion
(the amnion- the inner layer-) can be single or double, but the amnion cannot be less than the chorion |
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Having a single umbilical artery is a risk for what?
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18% rate of congenital malformation
(more common in diabetic mothers) |
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Vasa previa (vilamentous insertion of cord that traverses internal os) can lead to what?
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Fetal exsanguination when membranes rupture (causing the umbilical vessels to rupture as well)
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Dx
Pt has presyncope when in supine position |
Compression of vena cava by gravid uterus. No mgmt needed.
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Dx
Spider angiomas |
Hyperestrogenism of pregnancy
No mgmt needed |
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Dx
Colikcy abdominal pain, nausea, emesis, decreased bowel sounds |
Bowel obstruction during pregnancy (adhesions from intestine to uterus strangulate the bowel)
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Mgmt
Colikcy abdominal pain, nausea, emesis, decreased bowel sounds |
Upright or lateral decubitus abdominal x-ray
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Tx
Colikcy abdominal pain, nausea, emesis, decreased bowel sounds |
Bowel rest, IV fluids, nasogastric suction.
If conservative tx resistant, surgery. |
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Iron needs of pregnant women
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Iron supplementation mandatory for all women
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Dx
Bilateral hydronephrosis with right ureter more dilated than left |
Normal physiologic response to pregnancy
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Dx
Positive urine glucose during pregnancy |
Normal during pregnancy due to increased GFR and less resorption.
GTT for suspected diabetes |
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Dx
Dyspnea during pregnancy |
Normal during pregnancy, increased tidal volume and minutre ventilation
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Dx
After delivery placenta is removed in pieces with hemorrhage |
Placenta accreta
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Dx
After delivery intact placenta is delivered, hemorrhage, US shows more placental tissue |
Succenturiate placenta
(placenta in two pieces connected by vessels through amnion) |
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Dx
Painless hemorrhage in antepartum |
Placental Previa
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Dx
Thin, tachycardic with frequent irregular menses, temperature instability, and anxiety and sleep disturbance. |
Hyperthyroidism
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Mgmt
Thin, tachycardic with frequent irregular menses, temperature instability, and anxiety and sleep disturbance |
TSH level
and Pregnancy test (always get with spotting/pain in reproductive age women) |
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Mgmt
ASCUS on pap smear |
Get HPV typing,
or Repeat pap in 6 months and 12. |
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Mgmt
ASCUS with high risk HPV |
Colposcopy
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Dx study for
Multiple ulcers and erosions of variable size of vulva, the lesions are eroded, some with a purulent eschar. |
This is herpes, but a complete STI panel is warranted
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Mgmt
Multiple ulcers and erosions of variable size of vulva, the lesions are eroded, some with a purulent eschar. (3) |
1) This is herpes, cannot do speculum exam for endocervical sampling for G/C. If high risk for G/C empiric tx.
2) Hep B vaccine 3) Valtrex for herpes |
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Dx
Copper penny lesions on palms and soles of feet. |
Syphilis
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Dx study for
Copper penny lesions on palms and soles of feet. |
PRP or VDRL
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Dx study for suspected herpes lesion
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Culture of base of lesion
or PCR for HSV-2 |
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Dx
Lower abdominal pain, adnexal tenderness, fever, cervical motion tenderness, vaginal discharge |
PID (acute salpingitis)
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Dx
Mucopurulent cervicitis with exacerbation during and after menses |
Gonorrhea
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Dx
Thick, white, cottage cheese discharge |
Candida (albicans)
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Pap smears in old people
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STOP between 65-70:
1) If hysterectomy not done for cervical cancer or precursor 2) If 3 consecutive pap smears normal and no hx of ever high grade CIN Keep doing if: 1) Have ever had cervical cancer 2) Have ever had CIN III or higher 3) Are less than 65 |
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Frequency of pap smears
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q3 years:
1) No hx of CIN 2) Not high risk sexual acitivity q1 year: 1) Ever cancer 2) Ever CIN 3) High risk sex |
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Recs for rectovaginal exam in women
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Annually
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Dx study for
Fixation of uterus, thickening of rectovaginal septum, friable cervix |
Cervical biopsy
(cervical ca diagnosis must be made by biospy) |
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Dx
Erythematous patches on cervix, frothy yellow-green discharge |
Trichomoniasis
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Dx
Clue cells |
BV
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Dx
Positive KOH test |
BV
(sometimes trichomoniasis) |
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Tx for
Trichomoniasis |
Oral metronidazole
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Tx for
Cadidiasis |
Oral, topical, or suppository Imidazole
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Tx for
BV |
Oral or topical metronidazole
or Topical clindamycin |
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Recs for
G/C testing |
Screening for
1) Sexually active women under 24 2) All women over 25 at increased risk |
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ACOG recs for Pap smears
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1) All women at age 21
2) Biannually until 3 consecutive negatives --> Then every 3 years |
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Which immunization contraindicated in even possibility of pregnancy?
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MMR
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Indications for breast MRI or US
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When mammogram is inconclusive
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When to offer BRCA testing?
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After counseling if breast or ovarian cancer in family
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Screening recs for DXA scan
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1) All women over 65
2) All postmenopausal women with early menopause, steroid tx, hyperthyroid, hyperparathyroid, vit D defciency, chronic liver or renal disease 3) All postmenopausal women with fractures 4) Women under 50 if surgically menopausal |
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When to start pap smears
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At 21 for ALL women (independent of coitarche)
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When to start mammograms
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Acog - 40, biannually, then annually after 50
USPSTF - Biannually at 50 |
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Lower cutoff for Hgb during pregnancy
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10-11ish
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Thyroid levels in pregnancy
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T3/T4 go up, but so does thyroglobulin so total free Thyroxine stay the same
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Respiratory changes in pregnancy
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Tidal volume goes up
RR stays the same So minute ventilation goes up |
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Dx study for
Snowstorm pattern on uterine US |
CXR for lung mets from the gestational trophoblastic disease (molar pregnancy)
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Dx
Snowstorm pattern US, beta hCG 1 million |
Molar pregnancy
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Dx
Bibasilar crackles in pre-term mother |
Terbutaline induced pulmonary edema
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Diastolic murmurs are always abnormal in pregnancy.
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!
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Dx
Macrocytic anemia in pregnancy |
Folate deficiency
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ACOG Guidelines on weight gain during pregnancy
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Underweight: 28-40
Normal: 25-35 Overweight: 15-25 Obese: 11-20 |
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Teratogenic effect of
VPA |
Neural tube defect
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Most common cause of inherited mental retardation
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Fragile X
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Dx study for
Preconception counseling for African american couple |
Hgb electrophoresis and CBC
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Triple screen has what component's and is screening for what?
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1) Alpha fetal protein (!FP)
2) Beta hCG 3) Unconjugated estriol For: Trisomy 21, Trisomy 18, and neural tube defect |
Add Inhibin A for quad screen to increase seitivity
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Quad 4 screen has what added to increase sensitivity for what
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Inhibin A
for Down's sx sensitivity |
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Risk of SAB with CVS with 2 prior SABs
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1% (all CVS has this risk) not effected by prior SABs
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Jew panel for preceonception
(4) |
1) Tay-Sachs
2) CF 3) Niemann-Pick 4) Fanconia Anemia |
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Most common fetal strucutral abnormality in diabetic mothers
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Cardiac abnormality
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Teratogenic effects of Gestational diabetes
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1) Polyhydramnios
2) Neonatal hypoglycemia 3) Preeclampsia 4) Fetal macrosomia |
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Teratogenic effects of
Pre-existing diabetes |
IUGR
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Most common fetal side effect of VPA
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Neural tube defect
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Screening tests for Down's by trimester
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1st T: Combined test = Nuchal translucency, serum PAPP-A, and Beta hCG
2nd T: Triple or Quad Screen = Serum FAP, unconjugated estriol, beta hCG, (Inhibin A) |
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Folate recommendations for preventing spina bifida
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Non high risk: .4 mg per day
High risk: 4 mg/day |
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Dx study for
Unsure GA by conflict between hx and physical exam (uterine size) |
Ultrasound
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BG cutoffs for 3 hour GTT
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Fasting: 95
1 hr: 180 2 hr: 155 3 gr: 140 |
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Dx
Vaginal discharge and itching in 3 yo after abx tx |
Yeast infxn
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Contraindication for oral estrogen tx for atrophic vaginitis
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An intact uterus
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Of molar pregnancies which is more likely to be persistent?
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Complete molar more likely than partial molar
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Mgmt of
Pt post molar pregnancy D&C |
Follow beta hCG for 6 months following procedure, using OCPs the entire time
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Tx for
Recurrent molar pregnancies |
Folic acid supplemenatation
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Dx
Vaginal bleeding, uterine size greater than GA from LMP, |
Molar pregnancy
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Dx
Snowstorm pattern, beta hCG of a million |
Molar pregnancy
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Initial Tx for
Molar pregnancy |
D&C
(may need methotrexate later if she develops post molar GTD) |
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Dx
Older woman, lower beta hCG levels, longer gestations, incorrectly diagnosed as missed abortions, marked villi swelling |
Partial molar pregnancy
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Dx
Trophoblastic proliferation with hydropic degeneration, large uteri, preeclampsia |
Complete molar pregnancy
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Dx study for
Mets in liver, lungs, suspicion for choriocarcinoma |
Beta hCG
(Do NOT get biposy, bc lesions are very vascular) |
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Asian increases risk for what
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Molar pregnancy
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Dx study for
Uterus larger than LMP would indicate |
Ultrasound
(Beta hCG only diagnostic if over a million) |
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Tx for
Squamous cell carcinoma of vulva |
Radical vulvectomy and groin node dissection
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Tx for
SCC of vulva if less than 2 cm and invasion less than 1 mm |
Excisional biopsy
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Dx
Multi-focal, flat, whitish lesions on vulva, in setting of immunosuppression, negative wet prep |
HPV related condyloma or vulvar dysplasia
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Dx study for
Multi-focal, flat, whitish lesions on vulva, in setting of immunosuppression, negative wet prep |
Colposcopy with directed biopsies
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Dx
Post menopausal, fiery red vuvla with mottled whitish hyperkeratotic areas, non-tender |
Paget's disease of the vulva
(i.e. in situ carcinoma of the vulva, a non-invasive adenocarcinoma of breast tissue in the vulva) |
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Risk factors for Vulvar Intraepithelial Lesion (VIN)
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HPV and smoking
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Tx for
Diffuse, whitish raised 0.5-1.5 cm papules throuhgout large portions of external vaginal orifice |
Laser ablation
(Excision not ideal given diffuse nature) |
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Dx
Elevated, firm, erythematous, ulcerated lesion on left labia 2.5 cm in diameter |
SCC of vulva
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Dx
Crinkled tissue paper, white inelastic skin |
Lichen sclerorsus
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Dx
White, plaquelike lesions, not a discrete mass on vulva |
Paget's disease of the vulva
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Tx for
VIN III |
Wide local excision
(Only do radical vulvectomy for full blown carcinoma) |
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Dx
Pigmented, flat lesion, 1.5 cm in diameter on vulva |
Melanoma in situ
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Dx
Multicentric brown pigemented papupes on vulva, no induration |
Vulvar Intraepithelial Lesion (VIN) due to HPV
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Tx for
Lichen sclerosus of vulva |
Steroid cream
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Worst prognostic sign in cervical dysplasia
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Atypical vessles and mosaicism
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Mgmt of
HSIL on Pap with nl biopsies and ECC |
Cervical conization
(significant discrepancy between pap smear and biopsies) |
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Mgmt
Inability to visualize the entire squamocolumnar junction |
Cervical conization
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Indications for cervical conization
(3) |
1) Severe dysplasia on biopsy
2) Carcinoma in situ 3) Positive ECC |
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Distinction between CIN, microinvasive cancer, and carcinoma in situ
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CIN 3: Atypical cells through entire depth to basement membrane
Microinvasive: Less than 3 mm past basement membrane Carcinoma in situ: More than 3 mm beyond basement membrane |
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Mgmt
Endocervical speculum cannot visualize entire lesion, ECC is negative |
Colposcopy
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Pap smear recs for chicks with the hivy
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Twice in the first year of HIV diagnosis. If both normal, back to annually
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Mgmt
Normal pap smear in recently diagnosed HIV pt |
Repeat in 6 moths, then can go to annually
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Mgmt
Small white lesion on speculum exam for pap smear |
Biopsy under colposcopy
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Tx for
Young fertile woman with leiomyomas |
Myomectomy
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Tx for
Near menopausal or infertile women with leiomyomas (3) |
1) GnRH agonists to shrink before surgery
2) Surgery 3) Uterine artery embolization |
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Uterine fibroids grow in response to what?
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Estrogen
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Why can you only give GnRH for 6 months?
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The constant (not pulsatile) GnRH causes negative feedback on estrogen which causes bone loss
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Dx
Postmenopausal, bleeding, pelvic pain, uterine enlargement, vaginal discharge |
Uterine leiomyosarcoma
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Dx
Heavier and longer periods in premenopausal woman, irregularly shaped enlarged uterus |
Uterine fibroids
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Dx
Menorrhagia, dysmenorrhia, boggy uterus |
Adenomyosis
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Tx for
Subserosal fibroid during pregnancy |
If asymptomatic - nothing
If symptomatic - follow, no myomectomy which is contraindicated If blocks lower uterine segment --> C-section |
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Tx
Menorrhagia in fertile woman due to fibroids |
GnRH +/- Myomectomy
(Ablation would cause infertility) |
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Tx
Perimenopausal woman with menorrhagia |
Endometrial biopsy
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Risk factors for
Endometrial Ca |
1) Late menopause (and early menarche)
2) Unopposed estrogen tx 3) nulliparity 4) Obesity 5) Tamoxifen tx 6) Diabetes |
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Tx
Grade 2 Endometrial Ca |
1) Total abdominal hysterectomy
2) Bilateal salpingo-oophrectomy 3) Pelvic and para-aortic lymphadenectomy 4) Pelvic and abdominal washings |
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Tx for
Well differentiated endometriod adenocarcinoma in women who can't tolerate abdominal surgery |
Total vaginal hysterectomy +/- BSO
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Mgmt
Nulliparous woman, obese, diabetic, HTN, irregular menses throughout life, presenting with heavy irregular bleeding |
Endometrial biopsy
(D&C if cant' tolerate speculum exam) |
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Dx study for
Diagnosed stage I endometrial ca |
CXR
possibly CA-125 |
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Dx study for
Vaginal bleeding in any postmenopausal woman |
Endometrial biopsy
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Mgmt
Postmenopausal woman with hx of tamoxifen use |
Annual visits (no special mgmt of her increased risk for endometrial ca)
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Dx study for
Postmenopausal woman with vaginal bleeding but only rare atypical cells on endometrial biopsy |
D&C
(the endometrial biopsy may have missed the big kahuna) |
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Risk factors for ovarian ca
(4) |
1) Low parity
2) Delayed child bearing 3) Early menarche and late menopause 4) FHx |
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Protective against ovarian ca
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OCPs
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Prognostic factors in ovarian ca
|
Most to least important
1) Tumor stage 2) Volume of residual dz s/p cytoreductive surgery 3) Grade of tumor |
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Dx
Adnexal maxx with cystic and solid components in 30 yo, possibly echogenic |
Dermoid tumor
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Tx for
Stage III Ovarian ca |
Surgery and subsequent chemotherapy
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Dx
Unilocular simple cyst on ovary |
(Functional) Ovarian cyst
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Dx
Increasing abdominal girth |
Serous cystadenoma of ovary
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Dx
Multilocular and large cyst on ovary |
Mucinous cystadenoma of ovary
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Dx study for
Positive FHx of ovarian and breast ca |
BRCA1 and BRCA2 in proband (i.e. mother below the first afflicted)
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Dx study for
Large pelvic mass on transvaginal US with elevated CA-125 |
Pelvic and abdominal CT scan
(most importantly to look for omental caking) |
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Normal puberty development schedule
|
Thelarche - 10.5
Adrenarche - 11.5 Growth Spurt Menarche - 12.5 |
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Normal range of menarche
|
9-17
|
|
|
|
Dx study
15 yo Tanner stage II breasts, normal genital anatomy, no menarche |
Reassurance
|
|
|
|
Dx
4 yo with pubic hair but no breast development, low LH and FSH, but high DHEA and DHEAS |
Congenital Adrenal Hyperplasia
|
|
|
|
Dx
17 yo Primary Amenorrheic, normal pubic hair and breast development, blind vagina without cervix or uterus. Normal ovaries. |
Mullerian Agenesis
|
|
|
|
Dx study in
Mullerian Agenesis |
Renal US
(25-35% have renal anomalies) |
|
|
|
3 Things girls need to develop secondary sex characteristics
|
1) Adequate body weight (85-106 lbs)
2) Sleep 3) Optic exposure to sunlight |
|
|
|
Dx study for
Normal appearing 16 yo with primary amenorrhea, adequate weight, no secondary sexual characteristics |
Olfactory challenge for Kallman's
|
|
|
|
Dx
Normal appearing 16 yo with primary amenorrhea, adequate weight, no secondary sexual characteristics |
Kallman's
|
|
|
|
Dx
Short, lack of secondary sex characteristics, palpebral fissure growth, shield chest, cubitus valgus |
Turner Sx
|
|
|
|
Pathophys of
True Precocious Puberty |
Premature secretion of GnRH in a pulsatile manner.
|
|
|
|
Tx for
True precocious puberty |
GnRH agonist
(when constant and not pulsatile will turn off FSH and LH which are producing the estrogen that is the problem) |
|
|
|
First line test for secondary amenorrhea in 20 something yo
|
Prolactin level
|
|
|
|
Dx
Secondary amenorrhea s/p D&C |
Asherman's syndrome
|
|
|
|
Dx
33 yo with Secondary amenorrhea Dyspareunia TSH and Prolactin nl Not pregnant |
Premature ovarian failure
|
|
|
|
Dx
Stressed out girl with secondary amenorrhea |
Hypothalamic pituitary dysfunction
(Hypothalamus doesn't pulse GnRH bc she aint fertile now anyway) |
|
|
|
Dx
Primary amenorrhea Nl development Cyclical abdominal pain |
Genital outflow tract obstruction
(structural problem) |
|
|
|
1st Line Tx for
PCOS |
OCPs
and weight loss |
|
|
|
Most common cause of secondary amenorrhea
|
Pregnancy
|
|
|
|
Dx study
Secondary amenorrhea Thin, suspect HP axis dysfunction |
FSH and LH
(not GnRH) |
|
|
|
Main causes of
Hypothalamic Pituitary Dysfunction (4) |
1) Functional: Weight loss, obesity, exercise
2) Drugs: MJ and tranquilizers 3) Pituitary adenomas 4) Psych: Anxiety or eating disorder |
|
|
|
Dx
Hair loss post pregnancy |
Totally normal
(High Estrogen during pregnancy) High estrogen levels in pregnancy cause many hairs to grow in the same cycle, so they all fall out together too. |
|
|
|
Dx
Hirsutism, mildly elevated testosterone |
PCOS
|
|
|
|
Dx
Hirsutism, irregular menses, obesity Weight gain Stretch marks purplish in color |
Cushing's Sx
|
|
|
|
Dx study for
Suspected Cushing's |
Dexamethasone suppression test
|
|
|
|
Dx study for
Hirsutism, acne TSH, prolactin, testosterone, DHEAS nL |
17-Hydroxyprogesterone
(for late onset 21-hydroxylase deficiency) |
|
|
|
Dx
Elevated DHEAS, recent onset hirsutism in middle age |
Adrenal tumor
(more common in Asians) |
|
|
|
Dx
Hirsutism NL TSH, prolactin, testosterone, DHEAS, 17-Hydroxyprogesterone NL menstrual cycles |
Idiopathic hirsutism
|
|
|
|
Tx for
PCOS hirsutism |
1st - OCPs
2nd - Spironolactone (Or Lupron or Depo) |
|
|
|
Dx
Rapid onset of hirsutism, virilization, 20-40 yo |
Sertoli-Leydig tumor (produces testosterone)
Usually with high FSH and LH and an adnexal mass |
|
|
|
Dx study for
Abnormal bleeding |
Endometrial biopsy (if over 35)
|
|
|
|
Tx for
Longterm control abnormal uterine bleeding |
Endometrial ablation
|
|
|
|
Dx study for
Intermenstrual bleeding |
Pelvic ultrasound
(most likely causes are myoma, polyp, malignancy) |
|
|
|
Most common causes of intermenstrual bleeding?
(3) |
1) Myomsa
2) Polyps 3) Malignancy |
|
|
|
Dx
Recent menarche, heavy bleeding every time |
Coagulation disorder
(most likely von willebrand) |
|
|
|
Most likely bleeding disorder to present at menarche?
|
Von Willebrand's
|
|
|
|
Dx study for
Heavy bleeding happening cyclically |
Pelvic US
|
|
|
|
Complete work up of Abnormal uterine bleeding (5)
|
1) TSH
2) Prolactin 3) Pelvic US 4) Endometrial biopsy 5) Beta hCG |
|
|
|
Dx
Complete work up for abnormal uterine bleeding negative |
Dysfunctional uterine bleeding (catch all term of exlcusion)
|
|
|
|
Strongest predictor of PMS
|
Mother with PMS
|
|
|
|
Dx study for
suspected PMS/PMDD |
Prospective symptom calendar
|
OC
|
|
|
Tx for
PMS |
OCPs
|
|
|
|
Vitamin deficiencies associated with PMS
|
A
E B6 |
|
|
|
Tx for
PMDD (and PMS) |
SSRIs
|
|
|
|
Pathophys of PMS
|
Hypothalamic-Pituitary-Ovary axis
Only removal or death of ovaries will cause resolution |
|
|
|
Dx
Fatigue, irritability, bloating, breast tenderness ALL the time |
Hypothyroid
(PMS has to be cyclical) |
|
|
|
What does exercise due to help PMS?
|
Release Endorphins
|
|
|
|
Tx for (Definitive)
Adenomyosis |
Hysterectomy
|
|
|
|
Tx for
Adenomyosis if desire future pregnancy |
1) IUD
2) Ablation (less so) |
|
|
|
Dx study for
Dysmenorrhea causing functional loss, refractory to Ibuprofen and OCPs and Depo |
Laparoscopy for Endometriosis
|
|
|
|
Dx
Dysmenorrhea causing functional loss, refractory to Ibuprofen and OCPs and Depo |
Endometriosis
|
|
|
|
Screening recs for G/C
|
All sexually active women 25 and younger
|
|
|
|
Tx for
Dysmenorrhea refractory to NSAIDs |
OCPs
|
|
|
|
Pathophys of
Dysmenorrhea |
The endometrium produces prostaglandins that hurt
|
|
|
|
Dx
Soft, boggy uterus |
Adenomyosis
|
|
|
|
What can exclude endometrial ca?
|
Regularly regular periods (irrespective of length of bleeding)
|
|
|
|
Dx
Hemosiderin-laden macrophages and blue black powder lesions |
Endometriosis
|
|
|
|
Calcium requirements of postmenopausal women
|
1200-1500
|
|
|
|
Tx for
Postmenopausal symptoms |
COMBINED OCPs
only the estrogen is therapeutic but the progesterone prevents the estrogen from being unopposed |
|
|
|
Why do fat women have fewer menopausal symptoms?
|
Fat cells aromatize testosterone to estrogen
|
|
|
|
Cutoff for Premature Ovarian Failure
|
Before age of 35
|
|
|
|
Main side effect of estrogen replacement therapy
|
Vaginal bleeding
|
|
|
|
How to do clomiphene challenge?
What does it show? |
Give Clomiphene on days 5-9 and compare FSH on days 3 and 10
Normally acting hypo/pit will churn out FSH due to high GnRH pulses from blinded hypothalamus |
|
|
|
What is clomiphene
(Clomid) |
A Selective Estrogen Receptor Modulator
Mostly used as an ovulation inducer as it can produce estrogen levels that can cause the LH surge Increases gonadotropins by preventing negative feedback on hypothalamus |
|
|
|
Infertility test for older women
|
1) Clomiphene challenge
2) AMH |
|
|
|
Dx
Hyperprolactinemia with lack of conception, irregular menses, high TSH |
Hypothyroid
(it causes hyperprolactinemia) |
|
|
|
Infertility Tx for
PCOS |
1) Weight loss
2) Metformin 3) Clomid (ovulation inducers) |
|
|
|
S/e of Imipramine
|
Hyperprolactinemia
|
|
|
|
Cutoff for infertility
|
12 months of unprotected sex
|
|
|
|
Labs in exercise-induced hypothalamic amennorrhea
|
Normal FSH and low estrogen levels
|
|
|
|
Tx for
Exercise-induced hypothalamic amennorrhea |
Exogenous FSH and LH
(ovulation inducers don't work as well) |
|
|
|
Window of conception
|
4 days
(days 12-15) Sperm can live for 3, egg only 1 |
|
|
|
PCOS lab anormalities
(2) |
1) Elevated LH/FSH
2) Elevated testosterone 3) |
|
|
|
Pathophys of PCOS
|
1) Excess LH is made by anterior pituitary; High insulin contributes as well
2) They both cause hi levels of testosterone to be made by Theca cells |
|
|
|
OCPs are protective against which types of Cancer?
Increases? |
1) Endometrial
2) Ovarian (The longer they were ever used the more protective) Increases risk of breast cancer, but that risk normalizes after 10 years of non use |
|
|
|
Contraindications for Estrogen in combined OCPs
(4) |
1) Previous clot
2) Smoker and over 35 3) Chronic HTN 4) Breast feeding |
|
|
|
BTL magically lowers risk for what?
|
Ovarian Cancer
|
|
|
|
Fat married woman wants sterilization, what do you offer?
|
Vasectomize her husband
|
|
|
|
Contraindication to patch birth control
|
Fat chicks
|
|
|
|
Dx
Recurrent SABs and hx of clot |
Antiphospholipid antibody syndrome
|
|
|
|
Dx
Vaginal bleeding, positive beta, uterus large and tender, slightly dilated cervix, fever |
Septic abortion
|
|
|
|
Dx
Vaginal bleeding, positive beta, closed cervix |
Threatened abortion
or Incomplete abortion |
|
|
|
Dx
Vaginal bleeding, abdominal pain, adnexal mass, cervix closed |
Ectopic Tubal pregnancy
|
|
|
|
Cutoffs for Abortions
1) Medical 2) Surgical |
1) 7.0 weeks
2) 24.0 weeks |
|
|
|
Mgmt
Girl wants abortion, US shows no gestational sac |
Beta hCG
|
|
|
|
Dx
Elective abortion 2 days prior, vaginal bleeding, abdominal and pelvic pain, fever |
Endometritis
|
|
|
|
Mgmt
Suspected endometritis |
1) IV Abx
2) US for retained products of conception --> If gestational sac --> D&C |
|
|
|
Tx for
Pregnancy in APLS |
Aspirin + Heparin
|
|
|
|
Method of abortion in surgical cases when autopsy necessary
|
Induction with intravaginal prostaglandins
|
|
|
|
D&C cutoff
|
16 weeks
16.1 weeks and more must get D&E |
|
|
|
Tx for
Septic abortion |
Uterine evacuation + Abx
|
|
|
|
Tx for
Heavy bleeding after medical abortion |
D&C
|
|
|
|
Cutoff for MVA (Manual vacuum aspiration)
|
8.0 weeks
|
|
|
|
Dx
Chronic, relapsing and remitting, irritated, burning pruritis, contact bleeding, dyspareunia Lacy reticulated pattern on labia and perineum, rash on wrists |
Lichen planus
|
|
|
|
Dx
Lacy reticulated pattern on labia and perineum, rash on wrists |
Lichen planus
|
|
|
|
Dx
Pruritis, vaginal discharge of thick white curds |
Yeast infection
|
|
|
|
Tx for
Yeast infection |
Azole creams
|
|
|
|
Dx
Frothy yellow green discharge, petechiae on cervix |
Trichomoniasis
|
|
|
|
Tx for
Trichomoniasis |
Metronidazole
|
|
|
|
HSV-1
HSV-2 Which is genital |
HSV-1 is cold sores
HSV-2 is genital herpes |
|
|
|
Dx
Fever, HA, malaise, myalgias, genital lesions, HSV ab negative |
HSV-2 primary infection
|
|
|
|
Tx for
Genital herpes |
Valcyclovir
|
|
|
|
Dx
Thick, scaly, enlarged labia, with or without edema. Hx of scratching and rubbing for a long time |
Lichen simplex chronicus
|
|
|
|
Dx
Mucopurulent discharge |
Gonorrhe or chlamydia
(Both difficult to culture) |
|
|
|
Tx
Mucopurulent discharge but pending G/C |
Treat for both G and C with
Chlamydia - Doxycycline or Azithromycin Gonorrhea - Any ceph or quinolone |
|
|
|
Dx
Very bad dyspareunia, inability to insert tampons, exquisite tenderness to touching labia |
Vulvar vestibulitis
|
|
|
|
Tx for
Vulvar Vestibulitis |
TCAs and topical anesthetics (with biofeedback and pelvic relaxation)
|
|
|
|
Txd for
Vulvar vestibulitis refractory to TCAs and topical anesthetics |
Vestibulectomy
|
|
|
|
Dx
Extreme vulvar pruritis with burning, pain, intraoital dyspareunia, ivory papules, hypopigmentation, resorption of clitoris and labia minora due to scarring |
Lichen sclerosus
|
|
|
|
Dx
Ivory papules, hypopigmentation, of external genitalia |
Lichen sclerosus
|
|
|
|
Dx
Thing grey dischare, elevated vaginal pH |
Bacterial vaginosis
|
|
|
|
Requirements to diagnose BV
|
Need 3 of 4
1) Thing grey discharge 2) Positive whiff test 3) Presence of clue cells 4) Elevated vaginal pH (over 4.5) |
|
|
|
Tx for
Bacterial Vaginosis |
Metronidazole orally BID for 7 days
or Vaginal Metronidazole gel for 5 days |
|
|
|
Most common pathogen in uncomplicated UTI
|
E Coli
|
|
|
|
Dx
Fever, bilateral 1 inch complex masses |
Salpingitis
|
|
|
|
Dx study for
Low pelvic pain, urinary frequency, new incontinence |
UA
|
|
|
|
Mgmt
Lower abdominal pain bilaterally, no contraception, fever, purulent cervical discharge with cervical motion tenderness |
Acute Salpingitis --> Requires IV Abx to prevent long term sequelae of PID
|
|
|
|
Long term sequelae of salpingitis (PID)
|
1) Chronic pelvic pain
2) Hydrosalpinx 3) Tubal scarring 4) Ectopic pregnancy |
|
|
|
Mgmt
Pelvic pain that started today, bp 100/60, pulse 100, tempm 102.0, foul smelling mucopurulent discharge, uterine tenderness |
Probably G/C --> Needs IV Abx given high fever
|
|
|
|
Dx
Abdominal pain, adnexal tenderness bilaterally, guarding |
Acute salpingitis
|
|
|
|
Dx
Cold like illness 1-2 weeks ago, vulvar burning or irritation |
Primary herpes simplex (right before lesions break out)
|
|
|
|
Dx
Painless papule with ulceration |
Syphilis (primary)
*will become the chancre during primary too |
|
|
|
Dx
Low grade fever, malaise, HA, generalize lympadenopathy, rash, anorexia, weight loss, myalgias |
Secondary Syphilis
|
|
|
|
Dx
Clue cells |
Bacterial vaginosis
|
|
|
|
Tx for
Urinary stress incontinence |
Retropubic urethropexy
(Sling) |
|
|
|
Tx for
Cystocele |
Pubocervical fascia plication to arcus tendineus fascia
|
|
|
|
Tx for
Rectocele |
Rectovaginal fascia repair
|
|
|
|
Tx for
Uterine prolapse |
Vaginal hysterectomy
|
|
|
|
Tx for
Vaginal vault prolpase (3) |
Plication of vaginal cuff to
1) Uterosacral ligament 2) Sacrospinous ligament 3) Sacrocolpoplexy |
|
|
|
Tx for
Hypermobile urethra |
Sling
|
|
|
|
1st Line Tx for
Intrinsic sphincteric deficiency |
Urethral bulking procedure
|
|
|
|
Dx
Incontinence, drain pipe urethra, fixed immobile urethra |
Intrinsic sphincteric deficiency
|
|
|
|
Tx for
Vaginal prolapse, not candidate for general (or regional) anesthesia |
Colpocleisis
|
|
|
|
Used to increase urethral tone
|
Pseudoephedrine (alpha agonist causes sympathetic constriction of urethral sphincters)
|
|
|
|
Tx for
Detrusor instability |
Oxybutynin
(Anti-Cholinergic) |
|
|
|
Dx
High post void residual |
Atonic bladder (overflow incontinence)
|
|
|
|
What is mixed in
Mixed Incontinence |
Both
Urge Incontinence and Stress Incontinence |
|
|
|
Dx
Incontinence in which small amount is continuously leaked |
Overflow incontinence (Atonic bladder)
|
|
|
|
Dx
Random, large volumes in incontinence |
Urge incontinence
|
|
|
|
Dx
Dysmenorrhea, dyspareunia, nodularity on back of uterus |
Endometriosis
|
|
|
|
Dx
Complex cyst on ovary, no hx of dysmenorrhea or dyspareunia, non echogenic |
Hemorrhagic cyst
(If echogenic, consider teratoma) |
|
|
|
Dx
Sudden onset pain, right lower quadrant pain, nausea, nl WBCs |
Ovarian torsion
|
|
|
|
Tx for
Infertility due to endometriosis |
Ovarian stimulation with clomiphene
|
|
|
|
Tx for
Endometriosis |
1) Nsaids and OCPs
2) If mild or trying to get pregnant --> Observation 3) If fail medical therapy or planning pregnancy soon --> Laparoscopy |
|
|
|
Dx study for
Complex ovarian cyst in postmenopausal woman |
Exploratory surgery for suspected Ovarian Cancer
|
|
|
|
Mgmt for
Premenopausal 40 year old with 4 cm complex ovarian cyst, fhx of endometriosis |
Repeat ultrasound in 2 months
(can't give OCPs, in premenopasual not high enough suspicion for ovarian cancer) |
|
|
|
Mgmt
Severe sudden right lower quadrant pain, right ovarian mass, young woman |
Exploratory laparoscopy for suspected Ovarian Torsion
|
|
|
|
Dx
Dysnmenorrhea, dyspareunia, complex ovarian cyst |
Endometrioma
|
|
|
|
Dx study for
Pelvic pain and pressure with light vaginal bleeding several months ago, postmenopausal |
US
(for vague sx not yet concerning for anything in particular) Although this pt needs a endometrial biopsy too |
|
|
|
Dx
Chronic, lower abdominal pain, with constipation or diarrhea, relief with defecation |
IBS
|
|
|
|
Dx criteria for
IBS |
1) 12 weeks of pain w/in last 12 months
2) Onset coincides with defecation frequency 3) Change in stool consistency |
|
|
|
Dx
Post LTCS radiating pain and sensory loss to inguinal area and medial thigh exacerbated by adduction |
Ilioinguinal nerve entrapment
|
|
|
|
Dx
Inability to adduct thigh |
Obturator nerve damage
|
|
|
|
Dx
Long term chronic pelvic pain, dysmenorrhea, other idiopathic pain |
Abuse
|
|
|
|
Tx for
Hydrosalpinx and adhesions for woman who wants children |
Salpingectomy and lysis of adhesions
|
|
|
|
Mgmt
Adolescent with severe dysmenorrhea and heavy flow |
Diagnostic laparosocpy
(most likely etiologies even in adolescents are endometriosis and adhesions) |
|
|
|
Mgmt
Non-cyclical pain in 48 yo with endometriosis, wants definitive tx |
Oophrectomy (+/- hysterectomy)
(once you take ovaries, not enough estrogen to stimulate endometrium) |
|
|
|
Dx
Dilated vessles on doppler feeding uterus in broad ligament, dysmenorrhea with menorrhagia |
Pelvic congestion
|
|
|
|
Dx
Chronic recurrent urgency and frequency of urination, dyspareunia |
Interstitial cystitis
|
|
|
|
How do GnRH agonists (lupron) work?
|
They negatively feedback on the hypothalamus and pituitary to decrease FSH and LH production leading to much decreased estrogen levels
|
|
|
|
How does danazol work?
|
1) Supresses GnRH release
2) Suppresses the mid-cycle LH and FSH surges |
|
|
|
Dx
Tender, mobile, axillary lymph node |
Infection
|
|
|
|
Dx
Firm, non-tender, fixed axillary lymph node |
Breast cancer
|
|
|
|
Tx for
Fibrocystic changes causing cyclic mastalgia |
Caffeine reduction
|
|
|
|
Tx for
Mastitis of breastfeeding (2) |
1) Abx
2) Ibuprofen or Acetaminophen |
|
|
|
Dx study for
White, watery discharge from nipple with manual extraction, borderline high prolactin |
Fasting prolactin
(your breast exam elevates the prolactin) If was fasted, then brain MRI |
|
|
|
Dx study
Solid, dominant, breast mass with normal mammogram |
Fine needle aspiration
|
|
|
|
Dx study
Fine needle aspiration of lump yields clear fluid and reduction of lump |
Return in 2 month for exam
|
|
|
|
Dx study
Fine needle aspiration of lump yields bloody fluid and reduction of lump |
Excisional biopsy
(always mandatory if blood, including bloody discharge from nipple) |
|
|
|
Abx for Mastitis of breastfeeding
|
Dicloxacillin
(or erythromycin if penicillin resistant) |
|
|
|
Dx study for
2 cm dominant breast mass, FNA is negative, mass persisted |
Excisional biopsy
(If mass doesn't reduce, FNA could be false negative so you get a biopsy) |
|
|
|
Mgmt
CIN III/ HGSIL |
LEEP
|
|
|
|
Recs for Breast Cancer
|
Starting at 40 biannually
Starting at 50 annually |
|
|
|
Mgmt for
CIN I/ LGSIL |
F/u pap in 6 months
|
|
|
|
Mgmt
Failed IUD removal |
Hysterosocopy for visualization and remove IUD in office
|
|
|
|
Mgmt
LGSIL |
Colposcopy
|
|
|
|
Comparison of CIN to Bethesda
1) Normal 2) Atypical cells 3) CIN I - mild dysplasia 4) CIN II - moderate dysplasia 5) CIN III - severe dysplasia 6) Squamous cell carcinoma 7) Atypical glandular cells |
Bethesda
1) Normal 2) ASCUS 3) LGSIL (60% regress) 4) HGSIL (43% regress) 5) None (HGSIL still?) (33% regress, 12% become cancer) 6) Squamous cell carcinoma 7) Atypical glandular cells of undetermined significance (AGCUS) |
|
|
|
Mgmt for
CIN I - CIN II - CIN III - |
CIN I - f/u pap in 6 months or high risk hpv screen in 1 year. If persists x2 years --> LEEP
CIN II - LEEP CIN III - LEEP |
|
|
|
Mgmt for
ASCUS high risk HPV negative - ASCUS high risk HPV positive - ASC-H cannot exclude HSIL - LGSIL - HGSIL - SCC - AGC - |
ASCUS high risk HPV negative - Pap in 1 year
ASCUS high risk HPV positive - Colposcopy w. cervical biopsies ASC-H cannot exclude HSIL - Colposcopy w. cervical biopsies LGSIL - Colposcopy w. cervical biopsies HGSIL - Colposcopy w. cervical biopsies SCC - Colposcopy w. cervical biopsies, Consider cold kife conization AGC - Colposcopy w. cervical biopsies, endometrial biopsy |
|
|
|
Mgmt for
Cervical lesion confined to ectocervix |
LEEP
|
|
|
|
Mgmt for
Cervical lesion involving endocervix |
2 stage LEEP
or Cold knife conization |
|
|
|
Mgmt for
Large cervical lesion (other indications?) (2) |
Laser conization
1) Teenage patient 2) Upper vagina involved |
|
|
|
Dx study
Tender 4 cm adnexal mass, 38 yo, urinary frequency |
Transvaginal US
|
|
|
|
Mgmt
New rubbery, mobile, breast mass slightly tender in woman who drinks lots of caffeine |
Fine needle aspiration
|
|
|
|
Dx
Dyspnea, cough, frothy sputum, on terbutaline, high RR |
Terbutaline induced Pulmonary Edema
|
|
|
|
Why does minute ventilation go up in pregnancy?
|
Increased tidal volume
(not RR) |
|
|
|
Mgmt
Loss of external fetal monitoring, pt requesting epidural, active labor |
Put on scalp electrode
(can only do epidural with fetal heart tones reassuring) |
|
|
|
Dx
Irregular contractions with pain in lower abdomen and groin |
Braxton Hicks contractions
|
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Stages of Labor
|
Stage 1) Onset of strong regular contractions until full cervical effacement
Stage 2) Till delivery of infant Stage 3) Till delivery of placenta Stage 4) 2 hours after delivery of placenta |
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Mgmt
Placing of IUPC causes blood loss |
Withdraw and monitor fetus
If non-reassuring --> C-section |
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Indications for Antepartum woman to come to hospital to deliver
(4) |
1) Contractions every 5 minutes
2) Rupture of membranes 3) Fetal movement less than 10 per 2 hours 4) Vaginal bleeding |
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Tradeoffs of Midline episiotomy
|
Less pain, easier repair, and less blood loss
BUT Higher risk of 3rd and 4th degree lacerations |
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Mgmt
Pt arrives at 2+ station with fetal heart rate in 60s |
Assisted operative vaginal delivery
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When do late decels start, nadir, and recover
|
After the start of a contraction
At the peak of contraction At the end of contraction |
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Appearance of baby in chorioamnionitis
(3) |
1) Lethargic
2) Pale 3) High temp |
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Dx
Flattened nasal bridge, small size, small rotated cup shaped ears, sandal gap toes, hypotonia, protruding tongue, short broad hands, simian creases, epicanthic folds, oblique palpebral fissure |
Down Sx
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Position for infant positive pressure ventilation
|
Sniffing position
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Mgmt of
Infant with HIV+ mother |
1) Immediate AZT tx
2) HIV test 24 hrs post delivery |
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Dx
Twins are vastly different sizes and one is ruddy while the other is pale |
TTTS
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Complication of TTTS (hematologic) in plethoric twin
|
Polycythemia
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Tx
For unresponsive infant in opiate addicted mother |
Give positive pressure and prepare to intubate
(Do not give naloxone as baby can die from withdrawal) |
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Most likely complication in infant of mother with preeclampsia that required Magnesium
|
Respiratory distress
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What kind of babies do uncontrolled Type I diabetic mothers have
|
Small and hypoglycemic
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What constitutes APGAR score?
|
1) Heart rate: Absent, less than 100, more than 100
2) Respiratory rate: Absent, weak irregular gasping, crying 3) Muscle tone: None, some flexion, flexed arms and legs that can resist 4) Reflex irritability: None, grimace feeble cry to stimulation, cry or pull away when stimulated 5) Skin tone: Blue or pale, blue extremities pink body, all pink |
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Risks in infants born to gestationally diabetic mothers
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1) Hypoglycemia
2) Polythycemia 3) Hyperbilirubinemia 4) Hypocalcemia 5) Respiratory distress |
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Most common cause of infection post partum, and risk factors
|
Endometritis
2% of SVDs 10-15% of C/Ss Risk: Prolonged labor or ROM, manual removal of fetus |
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Mgmt for
Breast milk suppression in not breast feeding mothers |
Breast binding, ice packs and analgesics
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Dx
Postpartum hemmorhage after SVD in a woman with prior C/S |
Most likely Uterine Atony
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Blood loss cutoffs for postpartum hemorrhage
|
SVD - 500 cc
C/S - 1000 cc |
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Best predictor of Postpartum depression vs regular postpartum blues
|
Ambivalence toward baby moves needle toward full blown depression
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Dx
Hypovolemic shock after delivery, at f/u cannot breast feed, breast atrophy and amenorrhea |
Sheehan's syndrome
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Dx
Slow mental fxn, weight gain, fatigue, coldness, no milk production, hypotension, amenorrhea |
Sheehan's
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Microbe implicated in endometritis
|
Polymicrobial aerobic and anaerobic
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Dx criteria for
Postpartum depression |
Two week period of depressed or anhedonia nearly every day within 3-6 months of delivery with 1 of:
1) S - Insomnia or hypersomnia 2) I - Interest/anhedonia 3) G - Feelings of guilt/worthlessness 4) E - Energy low 5) C - Concentration decrease 6) A - appetite changes 7) P - PMR/PMA 8) S - SI/HI |
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Dx criteria for
Postpartum blues (2) |
1) Begins within 1 week of delivery
2) Lasts no longer than 10 days |
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Which hormones do what in breast feeding?
|
Prolactin makes milk
Oxytocin ejects milk (created by suckling) |
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Dx
Wedge shaped tender area on breast, breastfeeding mother, fever |
Mastitis
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Dx
Breastfeeding, sore nipples, burning in breasts, nipples pink and shiny with peeling at periphery |
Candidiasis
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Indication infant is feed enough milk
(2) |
1) 3-4 stools/day
2) 6 wet diapers/day |
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Milk production is spurred by what
|
Precipitous drops in Estrogen and Progesterone
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Indications to use forceps
(6) |
1) Complete cervical dilation
2) Head engagement 3) Vertex position 4) Baby head and mother's pelvis compatible 5) Known position of baby head 6) ROM |
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Active labor cutoffs for nulliparous and multiparous women
|
Nulliparous:
1) 3 hours with epidural 2) 2 hours w/o epidural Multiparous: 1) 2 hours with epidural 2) 1 hour w/o epidural |
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Lacerations by degree
|
First) Vaginal mucosa
Second) Vaginal fascia and perineum Third) Partial or complete transection of rectal sphincter Fourth) External anal sphincter, internal anal sphincter, and rectal mucosa |
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Best predictor of due date if LMP unknown in first trimester
|
Ultrasound crown-rump length
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Definition of macrosomia
|
1) More than 4000 grams in normal woman
2) More than 4500 grams in a diabetic mother |
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Fetal head size indicated for primary C/S
|
12 cm or more
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Contraindication for SVD
|
Uterine fibroid in lower uterine segment
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When can you not do external cephalic version?
|
In active labor
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Mgmt
+2 station, baby in breech position |
C/S
(breeched babies delivered vaginally have higher rates of complication) |
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When to use CVS vs. Amniocentesis
|
Weeks 10-12: CVS
(b/c can be performed earlier) Weeks 15 to term: Amniocentesis (Lower death rate, fewer attempts, more likely to get enough sample, can be used to follow isoimmunization by bilirubin levels) |
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Dx
Symmetric fetal growth restriction with polyhydramnios |
Trisomy 18
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Dx study for
Symmetric fetal growth restriction with polyhydramnios |
Amniocentesis for Trisomy 18
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Dx
Beta hCGs not increasing by 53% every 48 hours |
Abnormal pregnancy
IUP or Ectopic |
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Mgmt
Abnormal 48 hour beta hCG (rose but not enough), with something in the uterus |
D&C and check beta hCG again
If didn't decrease by 15% consider ectopic |
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Mgmt
Abnormal 48 hour beta hCG (rose but not enough), with nothing in uterus |
Methotrexate for assumed ectopic pregnancy
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Indications for medical termination of ectopic pregnancy
(6) |
1) Hemodynamically stable
2) Non-ruptured 3) Beta less than 5000 4) Mass less than 4 cm w/o fetal heart rate or less than 3.5 w/ fetal heart rate 5) Good follow up in pt 6) Normal WBS and LFTs |
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Dx criteria for
Ectopic Pregnancy |
1) Fetal pole outside uterus
2) Beta hCG over 2000 w/ nothing in uterus 3) Slowly rising beta hCG even after D&C |
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Dx
Tachycardia, hypotension, rebound tenderness, severe abdominal tenderness, positive beta hCG |
Ruptured ectopic pregnancy
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Mgmt
Beta 1000, hemodynamically stable, not febrile |
Repeat beta in 48 hours
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Cutoff by which you should see IUP by US
|
Transvaginal - 2000
Abdominal - 5000 |
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When to check for causes of recurrent abortion
|
3 first trimester losses
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Workup of recurrent abortion
(4) |
1) Lupus anticoagulant
2) Diabetes 3) Thyroid disease 4) Maternal and paternal karyotype |
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Tx for
Incompetent cervix, currently pregnant |
Prophylatic cervical cerclage at 14 weeks
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Tx for
First trimester confirmed missed abortion |
Expectant management if hemodynamically stable
(or drugs to help dispel uterine contents, up to patient) |
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Dx
Vaginal bleeding before 20 weeks with viable fetus and no passage of any products |
Threatened abortion
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Tx for
Spontaneous abortion, actively bleeding, anemic |
Dilitation and suction curettage
(SAB can be medically managed (misoporostol) if pt is hemodynamically stable) |
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Recs for
Gestational diabetes testing |
1) For average risk: 50g OGTT at 24-28 weeks, then f/u with 100 g OGTT if hi
2) For high risk: ASAP (obese or family history) |
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Tx for
Asthma in pregnancy |
1st Line: Beta agonists
2nd Line: Add inhaled corticosteroids if using rescue inhaler more than 2x/week 3rd: Add terbutaline or oral steroids if refractory to above |
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Dx
Cold pregnant woman, back pain, hypotensive, tachycardic |
Septic shock from pyelonephritis
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Tx for
Syphilis in pregnancy If allergic? |
Penicillin
If allergic - Desensitization and then penicillin |
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Most common complication in Type I diabetics
|
Fetal growth restriction
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Tx for
Thyroid storm in pregnant woman |
1) Propylthiouracil
2) Propanolol 3) Inorganic iodide *Cannot use radioactive iodine |
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Mgmt for
Bacterial vaginosis in pregnant woman |
Treat with metronidazole now
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Dx study for
In pregnant woman, fever, n/v, mid-abdominal pain, no anorexia, decreased bowel sounds |
Graded compression ultrasound
(for suspected appendicitis) |
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Contraindicated tx for breast cancer in pregnant woman
|
Radiation
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Dx
Pregnant women with intense itching and scratching over arms, legs, soles of feet. slightly icteric, scattered excoriations |
Pruritis gravidarum
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Tx for
Pregnant women with intense itching and scratching over arms, legs, soles of feet. slightly icteric, scattered excoriations (3) |
1) Antihistamines and lotions
2) Cholestyramine 3) Urodeoxycholic acid for suspected pruritis gravidarum |
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Dx
Systolic ejection murmur with click, palpitations, CP, syncope, in pregnancy |
Mitral valve prolapse
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Dx
Hypochromia and microcytic RBCs What are the ferittin levels |
Iron deficiency anemia
Serum ferritin is low |
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Dx
In pregnant woman: cough, dyspnea, sputum production, pleuritic chest pain |
Pneumonia
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Dx study for
In pregnant woman: cough, dyspnea, sputum production, pleuritic chest pain |
CXR for pneumonia
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Contraindicated antidepressant
|
Paroxetine (paxil)
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Tx for
Back pain, chills, and fever in pregnant woman, refractory to abx |
Double-J ureteral stent
(abx with aggressive hydration failed already) |
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Symptoms of mag toxicity by level
|
4-7 = Therapeutic
7-10 = Lose DTRs 12+ = Respiratory depression 15+ = Cardiac arrest |
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Tx for
Hypertension in preeclampsia (2) |
Hydralazine
or Labetalol |
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Indication to treat HTN in preeclampsia, and what pressure is goal
|
If systolic over 160
or Diastolic over 105 Goal" Diastolics 90-100 |
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Dx
Sinusoidal fetal heart tracing |
Placental abruption
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Mild and severe preeclampsia cutoffs
|
Mild: More than 300 mg protein or 140/90
Severe: More than 5000 mg protein or 160/110 |
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Dx
High bilirubin, hi liver enzymes, low platelets |
HELLP
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Mgmt for
Pregnant woman 27.2 weeks with severe preeclampsia, hemoconcentration, platelets 97,000 |
Immediate delivery bc platelets under 100,000 even in remote from term (<32 weeks)
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Dx study for
Suspected allimmunization in fetus |
Middle cerebral artery peak systolic blood flow
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What causes fetal hydrops?
|
Anemia in the fetus requires more cardiac output to achieve equal oxygenation, which causes heart failure which causes fluid retention (edema)
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Tx
Liley curve zone 3 in anti-D positive mother |
Intraumbilical tranfusion
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What is the Kleihauer-Betke test?
|
A quantitative test for the amount fetal blood that has gotten into maternal circulation
(ghosts are mom's RBC, pink RBCs are fetuses bc they resist acid wash) |
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Indications for Rhogam administration
|
1) Women at 28 weeks and at delivery
2) After abortion 3) After any type of hemorrhage 4) Amniocentesis or CVS |
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Rhogam confers resistance against how much fetal blood?
|
30 cc
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Chorio amnio requiements for TTTS
|
Monochorionic Diamnionic
or Monochorionic Monoamnionic |
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Monozygotic splitting dates
|
0-3 days) Di Di
4-8 days) Monochorionic Diamniotic 8-12 days) Mono Mono 13+ days) Conjoined twins |
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How to deliver twins if first baby is breech
|
C/S
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|
Fundal height should equal GA in weeks
|
!
|
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Dx
Elevated MSAFP with larger than expected uterus |
Twins
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How do twins in TTTS get hydrops?
|
Plethoric - Excess bloody supply, volume overload, heart failure, edema
Donor - Anemia from donating blood, increased CO, heart failure, edema, |
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Tx to prevent preterm delivery in twins
|
Early and good weight gain
|
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Dx
Late term fetal demise, hx of clot on OCPs |
Factor V Leiden
(most common coagulopathy) |
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Highest risk period for mental retardation
|
8-15 weeks
|
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Chorio amnio requiements for TTTS
|
Monochorionic Diamnionic
or Monochorionic Monoamnionic |
|
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Dx
Twins, polyhydramnios around A, no bladder fluid in B, |
TTTS
|
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|
|
Monozygotic splitting dates
|
0-3 days) Di Di
4-8 days) Monochorionic Diamniotic 8-12 days) Mono Mono 13+ days) Conjoined twins |
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|
How to deliver twins if first baby is breech
|
C/S
|
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|
|
Fundal height should equal GA in weeks
|
!
|
|
|
|
Dx
Elevated MSAFP with larger than expected uterus |
Twins
|
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|
|
How do twins in TTTS get hydrops?
|
Plethoric - Excess bloody supply, volume overload, heart failure, edema
Donor - Anemia from donating blood, increased CO, heart failure, edema, |
|
|
|
Tx to prevent preterm delivery in twins
|
Early and good weight gain
|
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|
|
Dx
Late term fetal demise, hx of clot on OCPs |
Factor V Leiden
(most common coagulopathy) |
|
|
|
Highest risk period for mental retardation
|
8-15 weeks
|
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Mgmt
Fatty tissue on D&C |
Laparascopy
|
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|
Mgmt for
Pregnant mom with thinner blood and one dead twin |
Check fibrinogen for coagulopathy
|
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Dx
Dead fetus with open neural tube defect, macrosomia, polyhydramnios, nonreactive NST |
Uncontrolled diabetes
|
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Most likely caused of fetal demise
|
Uncontrolled diabetes
|
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|
Mgmt
Active labor, intact membranes, full dilation but cervical dilation unchanged for 2 hours |
Amniotomy
(then oxytocin if still no change) |
|
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|
Mgmt
Mutliparous woman pushing for 2 hours with strong contractions q3 minutes |
Nothing
(oxytocin if contractions were weak) |
|
|
|
Order of induction of labor
(4) |
1) If cervix closed: Cytotec to ripen cervix
2) If cervix not dilated enough: Foley bulb 3) If no SROM: AROM 4) If not enough contractile force: Oxytocin |
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Delivery mode if 2 prior C/S
|
Has to be repeat C/S
|
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|
Phase 1 of labor time scales
|
Latent phase (0-4 cm)
Nullip: <20 hrs Multip: <16 hrs Active phase (4-10 cm) Nullip: 1.2 cm/hr Multip: 1.5 cm/hr |
|
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Mgmt
3rd Trimester vaginal bleeding with placental previa, 36 weeks |
C/S
|
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Dx
3rd Trimester bleeding in smoking mother with abdominal pain |
Placental abruption
|
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|
Dx
3rd Trimester bleeding with bright red blood from cervix for last 30 minutes, 36 weeks, cervix slightly dilated |
Bloody show
(normal) |
|
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|
Dx
3rd Trimester bleeding, hx of 4 C/Ss, current placenta is low and partial previa |
Placenta accreta
|
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|
Dx
3rd Trimester bleeding with bright red blood from cervix, 24 weeks, cervix closed |
Cervicitis
|
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|
Dx
45 yo, 2nd Trimester bleeding, cervix which bleeds with palpation and is hard in consistency |
Cervical cancer
|
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|
Dx
3rd Trimester bleeding, abdominal pain, uterus very tense, non-reassuring fetal heart rate tracing, cocaine user |
Placental abruption
|
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|
|
Dx study
24 weeks, vaginal bleeding for last hour, earlier intercourse, no pain, baby doing well |
Pelvic US to rule out abnormal placentation.
*Cannot do vaginal exam until placenta previa has been ruled out |
|
|
|
What is in Fresh Frozen Plasma?
|
Fibrinogen, factor V and factor VIII
in Cryoprecpitate: Fibrinogen, Factor VIII, and von wille |
|
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|
Dx
Premature constriction of ductus arteriosus in fetus |
Indomethacin side effect
|
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|
|
Benefits of Betamethasone in premature infants
(2) |
1) Improves lung maturity
2) Decreased intracerebral hemorrhage |
|
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S/e
Fetal bradycardia Fetal tachycardia |
Fetal bradycardia - Indomethacin
Fetal tachycardia - Maternal infx or high temperature |
|
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S/e
Terbutamine |
Tachycardia
|
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|
|
Tx
Contractions q4 minutes at 32 weeks gestation |
Observation
(most spontaneously resolve) |
|
|
|
Method of action of Magnesium sulfate
|
Competes with Ca for entry into cells
|
|
|
|
Method of action Terbutamine
|
Beta adrenergic increases cAMP decreasing free Ca in cells
|
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|
Mgmt
Preterm labor at 32 weeks, contractions q4, febrile, tachycardic |
Amniocentesis for possible infection
|
|
|
|
Contraindications for tocolytics
1) Terbutaline - 2) Magnesium - 3) Indomethacin - |
1) Terbutaline - Diabetics
2) Magnesium - Myasthenia gravis 3) Indomethacin - after 33 weeks |
|
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|
What does fibrinonectin tell us?
|
If negative - 99.2% will not deliver in next 2 weeks
If positive - 16% chance will deliver in next two weeks All in asymptomatic women |
|
|
|
Dx study for
Suspected chorioamnionitis |
Amneocentesis for low glucose and hi IL-6
|
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|
|
Mgmt
Preterm labor at 32 weeks or less |
Tocolytics but only if no evidence of infection
|
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|
|
Tx
PPROM in 36 weeks |
Induction of labor
|
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|
|
Dx study for
Large release of fluid from vagina at 31 weeks |
Microscopic exam for ferning or nitrazine test from vagina (cervix will screw up result)
|
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Dx
Tender fundus with PPROM |
Chorio
|
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Tx for
Tender fundus with PPROM |
Deliver if after 34 weeks
|
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|
|
Main risk factor for
PPROM |
Bacterial vaginosis
|
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|
|
Tx for
29 week PPROM |
Abx
(prolong gestation by 5-7 days!) |
|
|
|
Dx
Fetal tachycardia with poor variability |
Maternal fever, infection +/- chorio
|
|
|
|
How to interpret fetal heart tracing tests
|
NST) Look for 15x15 accels
(looks at fetal well being) CST) Look for persistent late decels that indicate uteroplacental insufficiency |
|
|
|
Definitions of decels:
1) Early 2) Variable 3) Late |
1) Early - start with beginning of contraction, end with end of contraction (mirror contraction)
2) Variable - Fall faster and return faster 3) Late - Begin after peak of contraction, return to baseline gradually after end of contraction |
|
|
|
Tx for
Occasional late decels in term mother |
1) On L side
2) Oxygen 3) Hydralazine if HTN 4) Discontinue oxytocin 5) Fetal pH |
|
|
|
Tx for
Atonic postpartum hemorrhage refractory to medical management |
Hypogastric artery ligation
|
|
|
|
Mgmt
Postpartum hemorrhage with intact placenta and firm uterus |
Look for lacerations
|
|
|
|
Mgmt
Postpartum hemorrhage with boggy uterus and no lacerations |
Intramuscular (IM) Prostaglandin F2
(Dinoprost) |
|
|
|
Which uterotonic cannot be used with asthmatics (debatable with mild asthma)
|
Prostaglandin F2 (potent bronchoconstrictor)
|
|
|
|
Dx
Postpartum hemorrhage with fibroids |
Retained placenta
|
|
|
|
Dx
Postpartum hemorrhage, globular pale mass before delivery of placenta |
Uterine inversion
|
|
|
|
Uterotonic contraindicated in hypertensives
|
Methergine (smooth muscle constrictor and vasoconstrictive agent)
|
|
|
|
Dx
Heavy postpartum hemorrhage with prior C/Ss |
Placenta accreta
|
|
|
|
Tx
4th degree laceration, febrile, infected with dead tissue and dehiscence of repair |
Debridement
(never repair while infection ongoing) |
|
|
|
Tx for
Endomyometritis after prolonged labor |
Penicillin + Gentamycin
|
|
|
|
Dx
Prolonged labor, prolonged ROM, tender uterus, blood in urine |
Endomyometritis
|
|
|
|
Dx
Postpartum fever with nl urine, uterus, breasts, and abdomen, refractory to broad spectrum abx |
Septic thrombophlebitis
|
|
|
|
Dx
Mild fever, no other reason for it in postpartum mother, breasts not red, but tender |
Breast engorgement
|
|
|
|
Dx
N/v, right upper abdominal pain |
Cholecystitis
|
|
|
|
Tx
Refractory fever to broad spectrum abx without known source of infection |
Heparin
for suspected septic thrombophlebitis |
|
|
|
Dx
Insomnia, easy crying, depression, poor concentration, irritability, labile affect |
Postpartum blues
|
|
|
|
Mgmt
Pt with prior hx of depression during pregnancy |
Close f/u bc high risk for postpartum depression
|
|
|
|
Can you breastfeed on SSRIs?
|
Yes
|
|
|
|
Mgmt
42 weeks with 4 cm cervix with effacement |
Induction of labor
|
|
|
|
Tx for
Repetitive variable decels |
Amnioinfusion
(only use of amnioinfusion) |
1
|
|
|
ACOG recs for postterm management:
(4) |
1) Record fetal kicks
2) Fetal surveilance starting at 42 weeks (w/ NST, CSTM or BPP) 3) Induce at 42 weeks 4) If cervix not ripe, give misoprostol (or prostaglandin E1) |
|
|
|
Mgmt
41 week or more mother but with uncertainty concerning GA |
Perform bi-weekly CST, NST, or BPP and also AFT and deliver if anything is non-reassuring
|
|
|
|
Mgmt
Baby decreasing rapidly in growth percentile but with reactive NST |
Continue weekly fetal monitoring
|
|
|
|
Ways to determine GA
|
1) Fetal heart tones recorded for 20 weeks
2) Positive hCG more than 36 weeks ago 3) Crown rump length between 6-12 weeks 4) US at 13-20 weeks |
|
|
|
Dx study
IUGR less than 10% (3) |
1) AFI
2) Umbilical artery doppler 3) Non-stress test |
|
|
|
Dx
Fetus is appropriate length but weight is disproportionately below normal |
Uteroplacental insufficiency
|
|
|
|
Dx
Pruritis including palms and soles of feet, elevated total bile acids |
Intrahepatic cholestasis of pregnancy
(normal pregnancy has mildly elevated alk phos, but other enzymes should be normal) |
|
|
|
Abx classes contraindicated in pregnancy (3)
and Permissible (3) |
Contraindicated
1) Tetracyclines 2) Fluoroquinolones 3) Bactrim Permissible: 1) Penicillins 2) Cephalosporins 3) Nitrofurantoins |
|
|
|
Tx for
UTI in pregnant woman (3) |
1) Amoxicillin
2) Nitrofurantoin 3) Cephalexin |
|
|
|
Dx
Sudden onset dyspnea, inability to lie flat, EKG changes |
Mitral stenosis
(rheumatic fever) |
|
|
|
Dx study
Guiac negative, bilateral nipple discharge |
TSH and Prolactin
(r/o pregnancy too!) |
|
|
|
When to test for Rh status
|
24-28 weeks
|
|
|
|
Who should get an RPR
|
All pregnant women regardless of risk
|
|
|
|
Screeening tests for all pregnant women (10)
Screening for pregnant women sometimes (5) |
1) Rh status
2) CBC 3) Rubella immunity 4) Varicella immunity 5) Urine cx 6) RPR 7) Hep B 8) Chlamydia 9) HIV 10) Flu vaccine if flu season Sometimes: 1) Thyroid if symptomatic 2) TB for risk 3) Toxo for risk 4) Hemoglobinopathies for african americans or mcv<80 5) Lead if risk |
|
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Dx
Pregnant woman passes something in blood, uterus is empty with closed cervix |
Complete abortion (SAB)
|
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|
Pathophys
Neonate with thyrotoxicosis to mother with surgically corrected grave's disease on thyroid therapy |
Mother's thyroid stimulating antibody affected the fetus
|
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Dx study
Amenorrhea, abdominal pain, vaginal bleeding |
hCG and US for ectopic pregnancy
|
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|
Dx
Fever, uterine tenderness, foul smelling loschia, prolonged ROM/operative vaginal delivery/C-section |
Endometritis
|
|
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|
Pathogen in postpartum endometritis
|
Polymicrobial bacteria
|
|
|
|
Tx for
Postpartum endometritis |
IV Clindamycin + Gentamicin
|
|
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|
Dx
Dysmenorrhea, heavy menses, enlarged uterus, dull pelvic sensation |
Uterine fibroids
|
|
|
|
Exercise recs during pregnancy
|
30 minutes of aerobic exercise daily that is mild enough to allow conversation
|
|
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|
Dx criteria for
Fetal demise |
After 20 weeks but before onset of labor
|
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|
Mgmt
Mother with IUFD and low normal coag panel If coag panel is abnormal |
Induction of labor
If coag panel abnormal: FFP then induction of labor |
|
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|
Mgmt
Asymptomatic pregnant woman with positive urine cx |
Nitrofurantoin or amoxicillin or 1st generation ceph (cefalexin, cefazolin)
|
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|
Indications for BPP
(3) |
1) High risk pregnancy
2) Decreased fetal movement 3) Non-reactive NST |
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Mgmt algorithm for BPP scores of
8 or 10) 8 w/ oligo) 6) 4 or 2) |
8 or 10) Normal
8 w/ oligo) Consider delivery 6) w/o oligo - consider delivery if over 37 weeks, repeat BPP in 24 hrs if less than 37 weeks w/oligo - Deliver if over 32 weeks 4 or 2) Deliver IMMEDIATELY (fetal asphyxiation) |
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Dx
Hypotension from epidural |
Blood venous poolingn in lower extremities
|
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Dx
Cessation of fetal movements |
IUFD
|
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|
Dx study for
Suspected IUFD |
Ultrasound for absence of fetal movement and cardiac activity
|
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|
Dx study
First time IUFD |
Autopsy of fetus and placenta
(even after first IUFD, to prevent recurrence) |
|
|
|
Dx study for
PPROM |
AFI for fetal lung indices
|
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|
Tx
PPROM less than 34 weeks |
Betamethasone
|
|
|
|
Most likely complication of PPROM
|
Lung hypoplasia (immaturity)
|
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|
Dx
Copious white vaginal discharge, without odor, pruritis, pain, or erythema |
Physiologic leukorrhea
|
|
|
|
Dx criteria for BV
(4) |
1) Thin, grey-white discharge
2) Vaginal pH greater than 4.5 3) Positive whiff test 4) Clue cells |
|
|
|
Dx
High blood pressure in upper extremities, low blood pressure in lower extremities |
Aortic coarctation
(Turner's) |
|
|
|
Pathophys in Turner's
|
Poor ovarian function and hi FSH
|
|
|
|
Dx
Precocious puberty in girl, adnexal mass, elevated estrogen, no male characteristics |
Granulosa cell tumor
(Estrogen producing tumor) |
|
|
|
Tx for
Genital herpes outbreak intrapartum |
C/S
|
|
|
|
Tx for
Infertility due to PCOS |
Clomiphene
|
|
|
|
Tx for
Chlamydia |
Single dose Azithromycin
|
|
|
|
Tx for
Gonorrhea |
Ceftriaxone
|
|
|
|
Tx for both
G and C or if PCR not available for one |
Azithromycin + Ceftriaxone
|
|
|
|
Dx
Acne, monomorphous erythematous follicular papules without comedones |
Systemic or topical steroid s/e
|
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|
|
Dx
Polymorphous acne with open and closed comedones |
Adolescent acne
|
|
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Dx
Pelvic pain worsened by intercourse or exercise or spicy foods, relieved by urinating, with frequency, urgency and nocturia, negative urinalysis |
Interstitial cystitis
|
|
|
|
Mgmt
Bright red vaginal bleeding, complete placental previa, non-reassuring FHT |
Emergent C/S
|
|
|
|
Tx for
Vaginismus |
Kegels, relaxation techniques, and desensitization with big objects
|
|
|
|
Feedback on Prolactin production
Serotonin TRH Dopamine |
Serotonin - stimulates
TRH - stimulates Dopamine - inhibits |
|
|
|
Tx for
Term chorioamnionitis |
Broad spectrum abx and delivery
|
|
|
|
Indications for prophylactic GBS penicillin administration
|
1) Term delivery
2) ROM longer than 18 hrs 3) GBS positive at any point in pregnancy 4) Hx of GBS in any pregnancy |
|
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Dx
Pregnant, vaginal bleeding before 20 weeks, closed cervix, live fetus |
Threatened abortion
|
|
|
|
Tx
Threatened abortion |
Reassurance and f/u
|
|
|
|
Tx for
Missed abortion |
You have to expel contents, but choice is up to you:
1) D&C or 2) Misoprostol or 3) Expectant management |
|
|
|
Dx
Chronic pelvic pain, worse premenstrually, tender vaginal fornix or with movement of uterus |
Endometriosis
|
|
|
|
Risk factors for
Endometrial Carcinoma (6) |
1) Age
2) Unopposed estrogen 3) Tamoxifen 4) Obesity 5) Nulliparity 6) PCOS |
|
|
|
Risk factors for
Breast Cancer (5) |
1) FHx
2) BRCA 1/2, or p53 3) Early menarche with late menopause 4) Prolonged HRT 5) Nulliparity |
|
|
|
Risk factors for placental abruption
(5) |
1) HTN
2) Cocaine 3) Smoking 4) Preeclampsia 5) Age |
|
|
|
Initial workup of amenorrhea
(3) |
FSH
TSH Prolactin |
|
|
|
Dx
Small volume incontinence with activity with cystocele |
Stress incontinence
|
|
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|
Dx
Morning sickness, distended abdomen, really happy about being pregnant |
Pseudocyesis
|
|
|
|
BG goal for gestational diabetes fasting
|
75-90
|
|
|
|
Complications of gestational diabetes
(5) |
1) Macrosomia
2) Hypocalcemia 3) Hypglycemia 4) Hyperviscosity (due to polycythemia) 5) Heart failure |
|
|
|
Tx
Febrile, high WBCs, purulent cervical discharge, adnexal tenderness, cervical motion tenderness |
Inpatient with IV Cef + doxy If: high fever, n/v, pregnant, risk of non-compliance
Outpatient PO Cef + Doxy if otherwise |
|
|
|
Dx
Pregnant, vaginal bleeding, dilated cervix with visualization of gestational contents |
Inevitable abortion
|
|
|
|
Mgmt
36 yo intermenstrual bleeding and heavy menses |
Endometrial biopsy
|
|
|
|
Dx study for
Primary syphilis |
Darkfield microscopy
(RPR and FTA-ABS not as sensitive in primary) |
|
|
|
In varsity amenorrhea what is pathophys?
What is tx for infertility? |
Hypothalamus doesn't send GnRH pulses
Exogenous GnRH pulses |
|
|
|
Best test for fetal chromosomal abnormalities in 1st Trimester
|
CVS
(MSAFP is 2nd Trimester and isn't as sensitive as CVS) |
|
|
|
Biggest risk for limb reduction and fetal loss in CVS
|
Early GA
|
|
|
|
Dx
Amenorrhea, normal breasts, absent pubic and axillary hair, absent internal reproductive organs, XY |
Androgen insensitivity
(Testes present and release mullerian inhibiting hormone) |
|
|
|
Dx study
Decreased fetal movement in low risk mother |
NST
|
|
|
|
Dx or Dx study
Hirsutism and virilization during prenancy 1) No ovarian mass 2) Bilateral cyst 3) Bilateral solid 4) Unilateral solid |
1) No ovarian mass - Abdominal CT to rule out adrenal mass
2) Bilateral cyst - Theca lutein cust 3) Bilateral solid - Luteoma 4) Unilateral solid - Laparscopy for r/o malignancy |
|
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Tx
Vaginal bleeding with complete placental previa but with stabilization and reassuring FHT |
Scheduled C/S
|
|
|
|
Tx for
HTN and proteinuria in preeclampsia |
Methyldopa
(alpha adrenergic agonist on CNS to reduce sympathetic outflow) |
|
|
|
PCOS predisposes to what cancer
|
Endometrial carcinoma
|
|
|
|
Used to estimate fetal weight
|
Abdominal circumference
|
|
|
|
Dx study
Pregnant, bloody urine, considerable flank pain |
Ultrasound of abdomen for kidney stones
|
|
|
|
Dx
Antepartum hemorrhage with brief tachycardia of fetus followed by bradycardia and then repetitive decels. Mother's vitals stable |
Ruptured vilamentous umbilical vessel
If mother was unstable, more likely placental abruption |
|
|
|
Dx
Mother used diethlystilbestrol |
Adenocarcinoma of vagina
|
|
|
|
Tx
Mild preeclampsia with mild edema, preterm |
Bed rest and f/u
|
|
|
|
Quadruple screen results for down syndrome or other aneuploidy
|
Beta high
MSAFP low Estriol low Inhibin A high |
|
|
|
Tx
Frank breech fetus, with reassurance, term |
External cephalic version
|
|
|
|
Dx study
LSIL in high risk woman |
Colposcopy
|
|
|
|
Dx study
BPP of 8 w/o oligohydramnios |
Repeat BPP in 1 week
|
|
|
|
Dx
Painless 3rd Trimester vaginal bleeding, no contractions |
Placental previa
|
|
|
|
Dx study
Painless 3rd Trimester vaginal bleeding, no contractions |
US for location of placenta
(concern for previa) |
|
|
|
Breech position management
|
37 or less weeks) Nothing
38+ weeks) External cephalic version If fail external version) C/S |
|
|
|
Dx
Teenager with irregular periods in first two years after menarche |
Insufficient gonadotropin secretion
causing anovulation |
|
|
|
Tx for
HTN in pregnancy |
ACEs and ARBs contraindicated
Use labetalol or methyldopa |
|
|
|
Tx for
HPV papules on genitals |
Trichloroacetic acid
or Podophyllin |
|
|
|
Dx
Thin, malodorous discharge, vulvar and vaginal erythema |
Trichomonis
(BV is an osis not an itis so doesn't cause inflammation or erythema) |
|
|
|
Tx
Intense uterine contractions, vaginal bleeding, uterine tenderness and hyperactivity, stabilized bleeding and FHT reassuring, preeclampsia |
SVD +/- augmentation
|
|
|
|
Dx
Intense uterine contractions, vaginal bleeding, uterine tenderness and hyperactivity, stabilized bleeding and FHT reassuring, preeclampsia |
Placental abruption
|
|
|
|
OCPs increase risk of what?
Protect against what? |
Risk: DVT, HTN, DM, CAD, cholestasis, breast cancer
Protect: Endometrial cancer, ovarian cancer, benign breast disease |
|
|
|
Tx for
Infertility in premature ovarian failure |
IVF
|
|
|
|
Late decels indicate what?
(3) |
Uteroplacental insufficiency
Hypoxia Acidosis |
|
|
|
Dx
Pregnant, hx of second trimester abortion, preterm fetal loss, HX of LEEP |
Cervical insufficiency
|
|
|
|
Dx study for
Cervical incompetence |
Transvaginal US for funneling or short cervix
|
|
|
|
Tx for
Stress incontinence |
Kegels first
Then Urethropexy |
|
|
|
Tx
Incompetent cervix in 1st trimester |
Cervical cerclage
|
|
|
|
Tx
Preterm labor before 37 weeks |
Tocolysis and bed rest
|
|
|
|
Tx
Androgen insensitivity |
Gonadectomy after puberty (the undescended testes are at high risk for cancer)
|
|
|
|
Dx criteria for
Somatization disorder |
Four pain symptoms, two GI sx, one sexual sx, and neurologic sx
|
|
|
|
Tx
Decels with non-repetitive depths and durations |
(Variable decels)
Maternal lateral decubitus position and oxygen |
|
|
|
Dx
HTN before 20 weeks HTN after 20 weeks No protein in urine |
before 20 - chronic HTN
after 20 - transient HTN of pregnancy |
|
|
|
Tx
Active labor woman with hyporefelxia, respiratory depression |
Mag toxicity
Stop mag and give Ca gluconate |
|
|
|
Mgmt
HSIL on pap during pregnancy |
1) Colpo with goal of r/o invasive cancer
So, if biopsy negative --> repeat colpo after delivery |
|
|
|
Tx
DVT postpartum |
Heparin
|
|
|
|
Most common cause of mucopurulent cervical discharge
|
Chlamydia
(gonorrhea is next most common) |
|
|
|
Dx
Painful 3rd trimester bleeding with normal ultrasound |
Placental abruption
|
|
|
|
Thyroid levels in pregnancy
|
Increased TBG --> Increased total T4 and T3
But normal, free T4/T3 and TSH |
|
|
|
What happens to thyroid hormones when woman gets HRT
|
Estrogen increases thyroxine metabolism, so she needs more thyroxine
|
|
|
|
What happens to BUN and Cr during pregnancy
|
They both go down bc GFR goes up
|
|
|
|
Tx
Gram negative diplococci in sexually active woman |
Gonorrhea (chlamydia is hard to culture)
So give both Ceftriaxone and Azithromycin |
|
|
|
Tx for
Squamous cell carcinoma of vagina that is non metastatic |
Radiation
|
|
|
|
How does preeclampsia cause RUQ pain
|
Stretching of hepatic capsule
|
|
|
|
Dx
XX, blind vaginal pouch, no uterus |
Mullerian agenesis
|
|
|
|
Vaginal pH 6.5, clear cervical secretion that is stringy
|
Normal ovulatory phase
|
|
|
|
Dx
Asymmetrical fetal growth (aka head is bigger than abdomen) |
Late exposure to maternal factor e.g. HTN, preeclampsia,
smoking, hypoxia, vascular diseas |
|
|
|
Tx
Thin malodorous vaginal discharge, vulvar pruritis, erythema of vulva and vaginal mucosa (strawberry cervix) |
Metronidazole for pt and partner
for Trich |
|
|
|
Tx for
Positive urine cx in pregnant woman |
Abx
TO PREVENT progression to PYELONEPHRITIS |
|
|
|
Dx
Amniocentesis, sudden respiratory failure, cardiogenic shock, seizure |
Amniotic Fluid TEmbolism
|
|
|
|
Dx
Purpuric rash with bad vitals |
DIC presenting in Amniotic fluid embolism
|
|
|
|
Tx
Amniocentesis, sudden respiratory failure, cardiogenic shock, seizure |
Intubation and mechanical ventilation for Amniotic fluid embolism
|
|
|
|
Tamoxifen increases risk for which cancer?
|
Endometrial cancer
(so is contraindicated) |
|
|
|
Contraindication for Raloxifene
|
Hx of coagulopathy or DVT
(it increases risk) |
|
|
|
Tx for
Osteoperosis (3) |
1) Bisphosphonatess
2) Estrogen 3) Raloxifene |
|
|
|
Do OCPs cause weight gain
|
No!
|
|
|
|
How does breastfeeding cause amenorrhea
|
Prolactin inhibits GnRH secretion
|
|
|
|
Dx
Incontinence with high PVR after delivery with epidural |
Overflow incontinence from epidural block
|
|
|
|
Tx
Incontinence with high PVR after delivery with epidural |
Intermittent cath for transient overflow incontinence
|
|
|
|
Tx for
Menorrhagia and intermenstrual bleeding in woman who doesn't want more pregnancy and has complex hyperplasia without atypia |
Cyclic progestin
(Do not ablate bc can obscure progression to endometrial cancer, hysterectomy not indicated, and OCPs not strong enough) |
|
|
|
Dx
Trauma, antepartum vaginal bleeding, repetitive late decels, irregularly contoured abdomen |
Uterine rupture 2/2 trauma
|
|
|
|
Dx
Postpartum chills, bloody vaginal discharge, stable vitlas, low grade fever 100.4 |
Normal postpartum
(chills nl, loschia is first bloody then white then yellow for a few days) |
|
|
|
Dx
Vaginal dryness and dysuria, pale dry vaginal mucosa, scarce pubic hair |
Atrophic vaginitis
|
|
|
|
Tx
Vaginal dryness and dysuria, pale dry vaginal mucosa, scarce pubic hair |
Estrogen cream
for Atrophic vaginitis |
|
|
|
Tx
3 days post abortion, hypotonic, 103 fever, tachy, RR26 |
Cervical and blood cx's,
Abx Gentle suction curretage for Septic abortion NOT vigorous curretage which can perf uterus |
|
|
|
Tx
24 yo with breast lump in luteal phase of menstrual cycle, no obvious signs of malignancy |
Return after period to see if lump decreased
(mammography of limited utility in young women bc they have dense breasts) |
|
|
|
What is the main concern for postterm pregnancy in a healthy woman
|
Oligohydramnios
|
|
|
|
Dx
Clitoromegaly and virilization of external genitalia, but normal internal genitalia Labs High testosterone and androgens Undetectable Estradiol and Estrogen High FSH and LH |
Aromatase deficiency
|
|
|
|
Dx
Female virilization, salt wasting, normal estrogen, internal genitalia normal |
21-hydroxlyase deficiency
|
|
|
|
Dx
Cafe au lait spots, gonadotropin independent precocious puberty with normal genitalia |
McCune-Albright syndrome
|
|
|
|
Dx
Delayed puberty, low FSH and LH, anosmia |
Kallman's syndrome
|
|
|
|
Dx
1) Precocious puberty with LH response to GnRH 2) Precocious puberty with no LH response to GnRH |
1) Idiopathic central precocious puberty (premature activation of normal HPA axis)
2) Peripheral precocious puberty (ovarian tumor etc.) |
|
|
|
Tx
Central precocious puberty |
GnRH agonist
to prevent short stature |
|
|
|
Diabetes screening recs in pregnant women
|
Between 24-28 weeks
1 hr 50 gram GTT If over 140, 3 hr GTT performed |
|
|
|
Dx
Bilateral breast tenderness few days postpartum, mild fever |
Breast engorgement
|
|
|
|
Dx study
Perimenopausal symptoms |
TSH and FSH
(must rule out hyperthyroid which presents similarly) |
|
|
|
Tx
Hemodynamically hypotnic with uterine atony |
Pitocin with uterine massage
then, D&C Then hysterectomy |
|
|
|
1st Line Tx for
BV |
PO Metronidazole
cream is 2nd |
|
|
|
Most common cause of increased MSAFP
|
Incorrect dating
|
|
|
|
Dx
Fetus has small body, microcephaly, digital hypoplasia, nail hypoplasia, cleft palate, hirsutism |
Phenytoin use during prengnacy
|
|
|
|
What do you need to avoid with PO metronidazole
|
Alcohol
(get asian glow) |
|
|
|
Dx
Lower abdominal pain that radiates to thighs and back hours before menstruation Tx? |
Primary dysmenorrhea (increased prostaglandins)
NSAIDs |
|
|
|
Dx study for
Suspected central precocious puberty (you already know hormone levels) |
Head CT or MRI
|
|
|
|
Why doesn't ABO mistyping in pregnancy cause any problems?
|
Mothers do mount an immune response, but neonate is only mildly afected
|
|
|
|
Dx
Pregnant woman, HTN, massive proteinuria, malar rash, positive ANA titer, |
Lupus
causes the Glomerulonephritis |
|
|
|
Hormone levels in menopause (or premature ovarian failure)
|
Ovaries die, so low estrogen
Also High FSH and LH (FSH/LH ratio greater than 1) because no negative feedback on hypothalamus |
|
|
|
Tx for
Emergency contraception |
Levonorgestrel (plan B progesterone) up to 120 hours after intercourse
|
|
|
|
Dx
Extreme nausea and vomiting that persists in pregnant woman |
Hyperemesis gravidarum
Cause is idiopathic or Gestational trophoblastic disease |
|
|
|
Dx study for
Suspected hyperemesis gravidarum |
Beta hCG to check for gestational trophoblastic disease, or to see if just idiopathic
|
|
|
|
Recs for GBS screening pregnancy
|
1) Screening at 35-37 weeks and abx prohphylaxis at delivery if positive
2) If ever GBS in past pregnancy get abx right off the bat |
|
|
|
Risks and benefits of Tamoxifen
|
1) Antagonist at breast so decreases breast cancer
2) Agonist at endometrium so increases endometrial cancer risk 3) Helps osteoperosis |
|
|
|
Dx study
Low MSAFP |
US to confirm GA and detect multiple gestations or defects
|
|
|
|
Dx
Pain around day 14 of cycle with no bleeding or GI/GU sx on exam |
Mittelschmerz
|
|
|
|
Dx
Pruritis of vulva, vulvar skin is thin, dry, white |
Lichen sclerosus
|
|
|
|
Tx for
Pruritis of vulva, vulvar skin is thin, dry, white |
Topical steroids for Lichen sclerosus
|
|
|
|
Dx
Pregnant, abdominal pain, hypotensive, cold and diaphoretic, closed os and no vaginal bleeding |
Placental abruption
(don't rule out even though no vaginal bleeding) |
|
|
|
Tx for
Lactation suppression |
Tight fitting bra and ice packs
|
|
|
|
Tx for
HIV positive mother |
Ziduvudine throughout prenancy and labor, and in neonate for 6 weeks
|
|
|
|
Tx for
Adolescent with active vaginal bleeding and no other symptoms, volume is moderate |
High dose estrogen tx to induce ovulation (cause is anovulation in adolescent for DUB)
If low volume, tx with iron supplementation |
|
|
|
Dx
Smooth philtrum, thin upper lip in neonate |
Fetal alcohol syndrome
|
|
|
|
Dx study for
Insulin resistance in suspected PCOS |
2 hr OGTT
|
|
|
|
Dx
Ebstein's anomaly |
Lithium use in pregnancy
|
|
|
|
Mgmt
Pregnant woman on Li |
Wean if stable bipolar d/o
|
|
|
|
Mgmt
Vaginal bleeding and right abdominal pain with Beta hCG of 1000, nothing in uterus on TV US |
Repeat beta hCG in 2 days
Why? Can't see anything in uterus with TVUS until 1500-2000 beta or <5000 with transabdominal |
|
|
|
Dx study for
Infertility with irregular and upper limit of normal cycle lengths |
Mid luteal progesterone levels
(Cause is most likely anovulation, so check if corpus luteum is present which indicates ovulation with progesterone level) |
|
|
|
Dx
Full term mother, intense onset of abdominal pain, FHT has sudden variable decels, and station has gone in reverse |
Uterine rupture
|
|
|
|
Tx for
Inevitable abortion |
D&C, rhogam if necessary, IV fluids
|
|
|
|
Dx
Vaginal bleeding, 10 weeks, gestational sac present but ruptured and no fetal heart tones |
Inevitable abortion
|
|
|
|
Dx study
Primary amenorrhea in 16 yo without pubic hair or breast development |
FSH
No breast development means no estrogen, so cause is either gonads or central. Do FSH to figure out which. |
|
|
|
Dx and Dx study
Primary amenorrhea in 16 yo without pubic hair or breast development. Present uterus Increased FSH |
Hypogonadism
Get Karyotype for Turner's |
|
|
|
Dx and Dx study
Primary amenorrhea in 16 yo without pubic hair or breast development. Present uterus. FSH low |
Central (hypothal or pituitary lack of hormone production)
Cranial MRI |
|
|
|
Dx
Primary amenorrhea, uterus absent, karyotype 46 XX |
Mullerian agenesis
|
|
|
|
Dx
Primary amenorrhea, uterus absent, karyotype 46 XY, normal male testosterone levels |
Androgen insensitivity
|
|
|
|
Dx
Hyperemesis, enlarged uterus, markedly elevated beta hCG |
Hydatidiform mole
|
|
|
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Causes of symmetrical IUGR
(3) |
1) Chromosomal abnormalities
2) Congenital anomalies 3) TORCH |
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Causes of assymetrical IUGR
(6) |
1) HTN
2) Preeclampsia 3) Uterine anomalies 4) APLS 5) Collagen vascular disease 6) Cigarettes |
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Dx
Myalgias, fever, ulcers on mouth and labia, exudative pharyngitis |
Herpes simplex
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Tx
Severe preeclampsia with no prior C/Ss |
Induction of labor (SVD preferred, C/S if not)
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Type I Diabetic mothers need what antepartum
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An NST to rule out anomalies and make sure no IUGR
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Dx
Moth-eaten alopecia, white patches on togue |
Syphilis
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Tx
Breat cancer patient with sudden back pain and lower neuroglic sx |
Steroids for mets to spine that is compressing spinal cord
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Dx study for
Bloody discharge from nipple with palpable mass in postmenopausal woman |
Mammography with fine needle cytology
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Mgmt
Pregnant woman with unknown varicella immunity with known exposure |
IgG varicella serology
(give IVIG against zoster if negative) |
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Myometcomy and previous C/S increase risk for what?
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Uterine rupture
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Tx
Birth control in slutty girl with lots of STIs |
CANNOT get IUD, so give OCPs and use jimmy caps
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What is methyl-prostaglandin F2 and who can't get it?
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It's hemabate and you can't give it to asthmatics
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when shoud abx be given in surgery
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30 minutes prior to surgery
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Risk of miscarriage in 1st trimester bleeding
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20-25%
or 10% if fetal heart tones seen |
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Dx study for
SOB, afebrile, tachypepnic, tachycardic, CXR normal |
VQ scan for PE
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Screening recs for Gestational diabetes postpartum
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at 6 weeks postpartum 75 g 2 hr OGTT
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Tx
Snowstorm pattern |
D&C of complete hydatidiform mole
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Tx
Adolescent with bleeding from anovluation |
If severe IV high dose estrogens
If hemodynamically stable then OCPs |
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When to place cerclage
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10-14 weeks
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BC option for someone with lots of STI risk
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Condoms
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