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405 Cards in this Set

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What percent of couples (woman under 35 y/o) are considered "infertile" (eligible for treatment) after one year of unprotected sex?
10 to 15% (just remember 15)
What percent of couples will become pregnant in 1 year without a contraception method?
85% (15% are considered "infertile")
What percent of women having unprotected sex who
1) are less than 6 months post partum
2) remain ammenorrheic
will become pregnant? (Lactation Amenorrheic Method)
2%
Feared complication of prolonged diaphragm use for contraception.
toxic shock (e.g. like tampons)
Only contraception method known to prevent STDs.
condom
Failure rate with typical condom use (as the only means of contraception)?
20% become pregnant
What oral birth control can be recommended for a lactating woman?
Mini Pill (Progestin Only Pills aka POPs)
35 y/o patient who smokes wants birth control. What type is contraindicated? What is usually given instead?
Combined OCPs; give IUD
Wilson's Disease patient wants birth control. What type is contraindicated?
copper IUD
Increased risk of clotting (e.g. DVTs) with this type of contraception.
Combined OCPs
Common blood pressure change with OCPs.
HTN
Patient with h/o pulmonary embolism. What type of contraception is contraindicated?
Combined OCPs
Patient with h/o migraine. What type of contraception is contraindicated?
Combined OCPs
Feared disease when patient has IUD in place.
PID
SLE patient desires contraception. What to give?
Depo-Provera shots
Poorly compliant patient needs contraception. What to recommend.
Depo-Provera shots
Which is safer: Vasectomy or Tubal Ligation?
Vasectomy
Which is more effective: Vasectomy or Tubal Ligation?
Vasectomy
Woman on calendar based contraceptive method, and using it perfectly. What is the failure rate?
1-2%
Perfect condom use: what is the failure rate?
4-5%
Patient uses OCP with typical compliance and timing. What is the failure rate?
4-5%
What OCP requires consistent timing (i.e. same time each day)?
Mini Pill (Progestin Only Pills aka POPs)
Mechanism of Mini Pill (Progestin Only Pill)?
mostly barrier via increased cervical mucous
Mechanism of Combined OCP? (2)
Est decreases FSH = no follicle
Prog decreases LH = no ovulation
Post Partum: which comes first: ovulation or menses?
ovulation
Failure rate in IUD?
0.1%
Most effective contraceptive method in lactating women?
IUD
Definition of Premature Ovarian Failure (Premature Menopause)?
Less than 40 y/o
Definition of EARLY Menopause?
Less than 45 y/o
How long after LMP before you can you clinically diagnose menopause?
requires 6 months of amenorrhea
What in social history will be a risk factor for early menopause?
tobacco use
What endocrine disorder is associated with early menopause?
DM Type 1
2 risk factors in an OB/GYN specific history which are associated with early menopause?
1) short cycles
2) nulliparity
Usually the 1st sign of Ovarian Failure (Menopause).
Hot flashes
Confirmatory lab for Menopause diagnosis.
FSH increased (FSH/LH over 1)
Treatment of dyspareunia secondary to vaginal dryness (e.g. Menopause patient)?
lubrication (e.g. Crisco oil)
2 tests in work-up to follow comorbidities of Menopause.
DEXA scan (osteoporosis)
Lipid profile (HLD)
Menopause wreaks HAVOC mnemonic.
Hot flashes
Atrophy of the
Vagina
Osteoporosis
Coronary artery disease
2 cancers to think of in patient with HRT.
Endometrial and Breast
Why do post-hysterectomy patients not need progestin as a part of HRT?
unopposed estrogen causes increased risk of endometrial cancer, which does not apply to these patients
1st line treatment of Hot Flashes in Menopause (2)
1) Venlafaxine or 2) Clonidine
Supplements vital in Menopause patients.
Vit D and Calcium
Medical treatment options for osteoporosis. (2)
Bisphosphonates (e.g. Fosamax)
SERMs (e.g. Roloxifine)
Which patient is more likely to have Menopause symptoms: Obese or Thin? Why?
Thin patient will: obese patients have more estrogen produced by fat cells and endometrial hyperplasia
Vital lifestyle treatment for osteoporosis.
increase weight bearing exercise
Most common cause of amenorrhea?
pregnancy
Age definition of Primary Amenorrhea.
14 y/o without or 16 y/o with secondary sexual development
No menarche, breast development, or pubic hair in female: age definitions of delayed puberty vs. primary amenorrhea
13 y/o = Delayed Puberty
14 y/o = Delayed Puberty AND Primary Amenorrhea
Why get a hand XR in someone with Primary Amenorrhea?
check for lack of pubertal bone growth (Constitutional Growth Delay, which is the most common cause of primary amenorrhea)
1st lab to order in work-up for Amenorrhea (both primary and secondary).
beta-hCG
After ruling out pregnancy, what is the 1st test in work-up of primary amenorrhea?
hand XR (bone age test)
Normal bone growth in primary amenorrhea. Next step?
LH and FSH
High FSH and LH in patient with primary amenorrhea; no breasts. Your top 2 differential based on karyotype.
XX: premature ovarian failure
XO: turner's
3 Most common causes of Primary Amenorrhea (in order).
1) Constitutional Growth Delay
2) Tuner Syndrome
3) Mullerian Agenesis
LH and FSH levels in patient with Mullerian Agenesis.
normal
16 year old without menarche: normal breast development but no pubic hair. Diagnosis?
Androgen Insensitivity (XY)
16 year old without menarche, but has breast development. Next 2 steps in evaluation?
LH & FSH and get U/S abdomen
When to get karyotype in primary amenorrhea.
if abnormal uterus on u/s OR high LH&FSH
16 year obese female without menarche: normal breast development. Diagnosis?
PCOS
Primary Amenorrhea with normal LH and FSH and normal uterus on U/S. Most likely diagnosis?
Outflow Obstruction (Imperforate Hymen or Transvaginal Septum)
High FSH and LH in patient with primary amenorrhea; breasts present. Your top 2 differentials based on karyotype.
XX: PCOS
XY: androgen insensitivity
2 labs to check in primary amenorrhea if FSH and LH are low.
PRL and TSH (tumor or Hypothyroidism)
Low GnRH with normal PRL. What is causing the primary amenorrhea?
Kallman's Syndrome
16 year thin female without menarche: normal breast development. Diagnosis?
Anorexia Nervosa (low estrogen)
Patient with secondary amenorrhea is not pregnant. 1st step in work-up?
TSH and PRL
Secondary Amenorrhea with high PRL. What test to order?
MRI
Definition of Secondary Amenorrhea.
Discontinued menses for 6 months
How does hypothyroidism sometimes cause amenorrhea?
TRH stimulates PRL release which blocks GnRH release
Secondary Amenorrhea with normal PRL and TSH. Next 2 steps?
Do Progestin Challenge and order FSH and LH
Define a positive and negative Progestin Challenge?
Positive: withdrawal bleed after medroxyprogesterone bolus
Negative: no bleed
Secondary Amenorrhea: withdrawal bleed from progestin + high LH. Diagnosis?
PCOS
Medical Treatment for prolactinomas (2).
Bromocriptine or Cabergoline (Dopamine Agonists)
Medical Treatment for anovulation (2).
Clomid (SERM) +/- Leuprolide (GnRH analog)
Virulized patient with secondary amenorrhea. What 4 tests to order?
1) Dexamethasone suppression test or 24 hr Urine Cortisol
2) testosterone
3) DHEAS
4) 17-hydroxyprogesterone
3 Adrenal causes of secondary amenorrhea.
CAH
Addisons
Cushings
Scarring (e.g. D&C) caused secondary amenorrhea. What is this called?
Asherman's Syndrome
SEVERE virulization with secondary amenorrhea. Diagnosis?
Tumor (adrenal or ovarian)
Of the 15% of "infertile" couples, what percent will have a child with the help of treatment?
85% (2% of couples are truly infertile)
Of the 15% of "infertile" couples, what percent will have a child withOUT treatment?
50%
Rule out these 2 disorders in the Male when working up a couple for infertility.
Hypogonadism (check FSH, TSH, PRL) and Disordered Sperm (semen analysis)
Lab tests to order for female in work-up for infertility? (FEpRTL mnemonic) (6)
FSH
Estradiol
pRogesterone (midluteal)
pRolactin
TSH
LH
Why get a karytype in a male with infertility?
r/o Klinefelters (XXY)
Treatment for infertility 2/2 endometriosis.
Surgery: laparoscopic resection/ablation
How to check for tubal/pelvic factors as a source for infertility (e.g. PID, adhesions).
Hysterosalpingogram (HSG)
4 criteria for Bacterial Vaginosis
Gray discharge
pH over 4.5
+ whiff test (fishy)
Clue cells on KOH wet mount
3 causes of Vaginitis.
Bacterial Vaginosis
Trichomonas
Yeast (Candida)
3 causes of Vaginitis: treat partners?
Bacterial Vaginosis: no
Trichomonas: yes
Yeast (Candida): no
3 causes of Vaginitis: treatment?
Bacterial Vaginosis: Metronidazole TID x 7 days
Trichomonas: Metronidazolex1
Yeast (Candida): Fluconazole PO or topical
Pregnant patient with vaginal yeast infection. Oral or Topical treatment?
Topical
vaginal odor increases after sex. Diagnosis?
Bacterial Vaginosis (semen creates a positive wiff test)
pseudo hyphae on wet mount. Diagnosis?
Yeast Vaginitis
granular epithelial cells with indistinct cell margins. Diagnosis?
Bacterial Vaginosis (clue cells)
Painful Bleeding in the 1st Trimester. Diagnosis?
Ectopic Pregnancy
Painful Bleeding in the 3rd Trimester. Diagnosis?
Abruption
1st test to order in a woman with lower quadrant abdominal pain.
beta-hCG
AROPE mnemonic for acute pelvic pain ddx in a woman.
Appendicitis
Ruptured Ovarian Cyst
Ovarian Torsion
PID
Ectopic Pregnancy
Ectopic Pregnancy Treatment
methotrexate or surgery
Most common complication of Ectopic Pregnancy.
Rupture with internal hemorrhage (can cause hypovolemic shock)
When to get a CT scan of an unstable patient.
Never!
Test to rule out Ovarian Torsion in woman with lower quadrant abd pain.
U/S
Cervical Motion Tenderness (chandelier sign). Diagnosis?
PID
When to start antibiotics when suspecting PID.
should start empirically
2 most common causes of PID.
Gonorrhea and Chlamydia
Common history finding in patients with functional/chronic abdominal pain.
Sexual Abuse
Acute LRQ pain with negative beta hCG. Most likely diagnosis?
Appendicitis
Most common benign neoplasm in the female genital tract.
Uterine Leiomyoma (Fibroid)
Uterine Fibroids are benign, but are often removed. What 2 most common reasons?
Menorrhagia/dysmenorrhea
Infertility
Why do Uterine Fibroids increase in size during pregnacy and decrease in size after menopause?
they are sensitive to estrogen and progesterone
Prevelance of Uterine Fibroids in Black women.
50%
Classic physical exam description of a uterus with fibroids.
Lumpy Bumpy
Imaging of choice to r/o uterine fibroids.
U/S
Woman diagnosed with uterine fibroids, but they do not regress after menopause. What to do?
biopsy to r/o malignancy
Most common indication for surgery in women in the U.S.
Uterine Fibroids
Post -menopausal woman w/ vaginal bleeding. Diagnosis?
Cancer until proven otherwise even though:
Atrophy causes 80% of bleeds
Cancer causes 10% of bleeds
Most (97%) of Uterine Cancers are this type.
Endometrial Carcinoma (glandular)
Define the 4 stages of Uterine Cancer
1-Uterus only
2-to Cervix
3-to Vagina/Pelvis (3c=lymph nodes)
4-to Bladder or Bowel or other
Treatment for Uterine Cancer.
Hysterectomy
When to give radiation in Uterine Cancer. (What stage?)
If nodes are positive (stage greater than 3c)
How often to follow up on an asymptomatic Uterine Fibroid patient.
q6 months
At what age will oophorectomy automaticaly be recommended with hysterectomy?
over 45 y/o
Why luprolide (GnRH analog) for uterine fibroid?
supresses estrogen which sepresses fibroids (commonly used pre-op)
3 treatments of Fibroids are myomectomy, hysterectomy, or uterine artery embolization. What is the indication for each?
myomectomy: fertility desired
hysterectomy: fertility not desired
uterine artery embolization: good for patients near menopause
Pain and menorrhagia control in patient with Fibroids.
NSAIDS
Adnexal Mass is more commonly malignant in reproductive age or postmenopausal?
Postmenopausal (25% are malignant)
What is mittelschmirz?
brief midcycle pain (usually mild)
Adnexal Mass: with dyspareunia and dysmenorrhea. Diagnosis?
endometriosis
Adnexal Mass: with sudden severe pain and N/V. Diagnosis?
ovarian torsion
Adnexal Mass: amenorrheic, abd pain, vaginal bleeding. Diagnosis?
Ectopic Pregnancy
Adnexal Mass: with a large mobile uterus and menorrhagia/dysmenorrhea. Diagnosis?
Uterine Leiomyoma (Fibroid)
Adnexal Mass: with cervical motion tenderness and fever. Diagnosis?
PID
Adnexal Mass: in obese pt with hirsuitism and infertility. Diagnosis?
PCOS
Adnexal Mass: large, solid, irregular, non-mobile; ascites present. Diagnosis?
more likely malignancy
2 most common mutations known to be associated with Ovarian Cancer.
BRCA and HNPCC
Imaging for adnexal mass.
U/S
Imaging for adnexal mass which looks like Cancer on U/S.
CT scan (eval extent of disease)
4 types of ovarian tumors.
1) Epithelial
2) Germ cell
3) Stromal Tumors
4) Metastatic GI tumor
Most common type of ovarian tumor?
Epithelial (90%)
Most common ovarian tumor in woman under 20.
Germ cell tumor (e.g. teratoma)
Why remove a mature teratoma if it is benign?
risk of torsion
Define the 4 stages of Ovarian Cancer
1-only ovaries
2-to pelvis
3-to abdominal cavity
4-distant (e.g. omentum)
Why not get a fine needle aspirate to diagnose ovarian tumor?
can seed cancer along needle track
Palpable ovarian mass in post-menopausal. What to do?
laparotomy
When to do surgery on ovarian mass if pre-menopausal?
if large (over 8 cm) or symptomatic
When to give chemo (e.g. pacitaxel and carboplatin) for ovarian cancer.
for stage 2c or more
Age to start PAP smears.
21
Cause of cervical cancer
HPV
How often to do PAP smear on woman aged 21-29
every 2 years
When to test HPV DNA with PAP smear. (what age?)
at 30 y/o
At what age to recommendations for regular PAP smears stop.
stop at age 70
PAP shows LSIL (aka CIN1) or ASCUS. What to do (postmenopausal or premenopausal)?
Postmenopausal: HPV DNA test
Premenopausal: Colposcopy
Positive HPV DNA test. What to do? (even if PAP is negative)
Colposcopy
PAP shows HSIL (aka CIN2). What to do?
excision (LEEP) or ablation
Colposcopy shows CIN1. What to do?
PAP&HPV DNA in 1 year
Colposcopy shows CIN2 (aka HSIL). What to do?
excision (LEEP) or ablation
Colposcopy shows CIN3 (aka carcinoma in situ). What to do?
Hysterectomy, staging, radiation
Colposcopy shows Carcinoma. What to do?
Hysterectomy, staging, radiation
Which HPV viruses are covered in Gardasil? (4)
6, 11 (warts)
16, 18 (cervical dysplasia)
How often to get PAP smear on patient with HIV.
every year
Personal history of CIN2/3 or Cervical Carcinoma. How often to f/u with PAP smear?
every year for 20 years
How often to get PAP smear on patient who has been vaccinated with gardasil?
same as if she wasn't vaccinated
Atypical Glandular Cells (AGC) on PAP smear. What to do?
Endometrial biopsy
OCPs decrease the risk of this cancer
Ovarian
If you decide to screen a high risk woman for ovarian cancer, what do you do?
yearly CA-125 and Transvaginal U/S
Ovarian Tumor Marker: epithelial
CA-125
Ovarian Tumor Marker: endodermal sinus
AFP
Ovarian Tumor Markers: embryonal carcinoma
AFP, hCG
Ovarian Tumor Marker: Choriocarcinoma
hCG
Ovarian Tumor Marker: Dysgerminoma
LDH
Ovarian Tumor Marker: Granulsa Cell
Inhibin
Treatment for Gonorrhea
Ceftriaxone to pt and partners
Treatment for Chlaymida
Doxycycline to pt and partners
What portion of women have dysmenorrhea?
50%
2 part treatment for primary dysmenorrhea.
NSAIDS (scheduled 24 hr before menses)
OCP or Mirena
Most common cause of secondary dysmenorrhea.
Endometriosis
Endometriosis vs. Adenomyosis: cyclic or noncylic dysmenorrhea/pelvic pain?
Endometriosis: cyclic
Adenomyosis: non-cyclic
Medical treatment options for ENDOMetriosis.
Estrogen regulation (GnRH agonists e.g. Leuprolide)
NSAIDS
Danazol
OCP
Medroxyprogesterone
1st test to order in woman with pelvic pain.
beta-hCG
Leuprolide side effect to remember. What to do about it?
bone loss: needs vit D and calcium ("add back therapy")
Danazol side effect to remember (limiting treatment of endometriosis).
hirsuitism and voice chnages
Almost all Endometrial Cancer presents with this symptom.
vaginal bleeding
Test to evaluate concerning postmenopausal bleeding.
transvaginal u/s
When to biopsy endometrium in postmenopausal bleeding.
if transvaginal u/s shows stripe bigger than 5 mm
When to get u/s in patient with post-menopausal bleeding (2 reasons)?
if uterus enlarged on exam
if more than 6 months of sx
SPURT of urine with exertion or straining e.g. laughing. Defines what?
Stress incontinence
Sudden NEED TO PEE. What type of incontinence?
Urge incontinence (detrusor instability)
Continuous, uncontrolled urine loss, What type of incontinence?
Total Incontinence (e.g. fistula)
Urine DRIBBLES ocassionally. What type of incontinence?
Overflow incontinence
Chronic urine retention causes what type of incontinence?
Overflow incontinence
1st line treatment for Stress incontinence.
kegels
Treatment for total incontinence.
surgery
Treatment for urge incontinence.
Anticholinergics or TCA (e.g. Imipramine)
1st line medical treatment for overflow incontinence.
Prazosin or Terazosin (alpha1antagonists)
1st test in woman with incontinence. Why?
UA and Cx to r/o infection
Confirmatory test for stress incontinence.
standing stress test (stands over towel and coughs)
Test to r/o fistula and total incontinence.
cystogram
Treatment for urethrocele, cystocele, rectocele, or enterocele.
Surgery (colporrhaphy)
Bleeding between menses/periods is called.
Metrorrhagia
Bleeding too much or too long during menses is called.
Menorrhagia
Menstrual cycle longer than 35 days is called.
Oligomenorrhea
Menstrual cycle shorter than 21 days is called.
Polymenorrhea
Most common cause of abnormal uterine bleeding.
pregnancy
1st test to order in woman with abnormal uterine bleeding
beta-hCG
Work-up for metrorrhagia.
PAP smear
Treatment of Oligomenorrhea.
Progestin x 10 days to stimulate withdrawal bleed, then OCPs
Treatment of Polymenorrhea.
OCPs
Work-up for abnormal uterine bleeding. Rule out these 3 causes.
Anovulatory (TSH/PRL)
Bleeding disorder (PT/PTT)
Uterine Mass etc. (U/S)
1st line treatment for abnormal uterine bleeding.
NSAIDS
Treatment for HEAVY abnormal uterine bleeding.
High-dose Estrogen
When to do a D&C in patient with abnormal uterine bleeding.
if heavy bleeding despite estrogen
Work-up for menorrhagia: what imaging?
U/S
Most common complication of Menorrhagia.
Anemia
When to get hysterectomy in patient with abnormal uterine bleeding (2 criteria).
if 1) perimenopausal and 2) fail treatment (estrogen, D&C, and hormones)
Most common mechanism of abnormal uterine bleeding other than pregnancy.
anovulatory diseases (e.g. menarchal or menopausal)
When to get an endometrial biopsy in a premenopausal woman who has abnormal uterine bleeding. (3 rules)
if older than 35
or BMI over 35
or Diabetic
When to start antenatal checkups.
10 weeks is first visit
Review of Systems at each prenatal appointment. (ABCEDF mnemonic.)
Amniotic fluid per vag?
Bleeding per vag?
Contractions
Dysuria
Ecclampsia (HA, Edema, etc.)
FHTs
5 symptoms of pre-ecclampsia on review of systems.
HA
Edema
Vision changes
RUQ abd px
SOB
What week to listen to FHTs for the first time?
14 weeks
When do you see your prenatal patients every 4 weeks?
10-28 weeks
When do you see your prenatal patients every 2 weeks?
28-36 weeks
When do you see your prenatal patients every week?
36 weeks-birth (up to 42 weeks)
Weight gain expected in a pregnant woman with a normal BMI.
30 lbs
Weight gain expected in a pregnant woman with a BMI over 30
15 lbs
When to initiate Folate supplementation in pregancy?
3 months before conception
3 supplements for pregnant patients.
folic acid
Iron
Calcium
What week of pregancy to get the U/S?
20 weeks
When to get glucose tolerance test (GTT) during pregnancy?
28 weeks
When to get Rhogam (if needed)?
1) 28 weeks
2) under 72 hours post-partum
When to screen for Group B Strep (GBS) in pregnancy?
36 weeks
Treatment for pregnant patient at 42 weeks?
induction or C/S
Fundus at umbilicus. How many weeks?
20 weeks
Fundus half way to umbilicus. How many weeks?
16 weeks
Treatment of VDRL positive pregnant woman.
Penicillin shot before 16 weeks
When is Rogam needed?
in mom who has Rh- and fetus who may have Rh+ (just give to all Rh- moms)
When the triple or quad screen might be offered to pregnant patients?
at 18 weeks
All four tests in the quad screen are elevated. Diagnosis?
Edwards syndrome (trisomy 18)
2 supplements necessary in pregnant vegetarians.
Vit D and B12
Step 2 questions says failure to lactate after delivery. What is your diagnosis?
Sheehan's Syndrome
3 most common causes of Post-Partum Hemorrhage.
Uterine Atony
Lacerations/direct trauma
Retained products
Most common cause of Post-Partum Hemorrhage (90%).
Uterine Atony
Bleeding after delivery of the placenta; uterus is soft and "boggy." What is the diagnosis?
Uterine Atony
Mechanism of Uterine Atony.
fatigued myometrium
3 part treatment of Post-Partum Hemorrhage 2/2 Uterine Atony (MOM mnemonic)
Manual Massage
Oxytocin
Methergine or Misopristol
Contraindication of Methergine
HTN
Contraindication of Hemabate (prostaglandin).
asthma
Cheapest and most stable uterotonic for Uterine Atony.
Misopristol (Cytotec)
Post Partum Hemorrhage fails to respond to Atony treatment. What to do?
D&C
Post Partum Hemorrhage fails to respond to treatment or D&C. What to do?
Bakri Balloon
Last resort therapy for Post-Partum Hemorrhage.
Surgery: uterine aa ligation then hysterectomy
Iatrogenic risk factor for placenta previa and/or accreta.
previous C-Section
Placenta invades too far. Defines what?
Accreta
Placenta invades all the way through the uterine wall. Defines what?
Percreta
defined as being between Accreta and Percreta.
Placenta Increta
Active management of this stage of labor has decreased maternal mortality the most.
3rd stage (placenta)
Painless bleeding in the 3rd trimester. Diagnosis?
Placenta Previa
Woman pregnant with twins: 3 total pregnancies (including this one) and has 4 children: 1 baby the first pregnancy at 37 weeks, Triplets the second pregnancy at 30 weeks. G/P? and G/TPAL?
G3P2 and G3P1104
Vaginal bleeding before 20 weeks. What is this called?
Threatened Abortion
How to diagnose placenta previa
U/S
Rule about prenatal manual pelvic exam with vaginal bleeding.
Don't do it
Treatment of Complete Previa.
C-Section
Why does trauma in a pregnant woman often require immediate delivery.
Abruption often occurs with trauma
When to schedule delivery for a patient with complete previa?
Elective C-Section at 36 weeks.
What indicates delivery for a patient with placental abruption? (2)
if fetal or maternal distress
or if past 36 weeks
Fetal Bleeding from vagina with quick fetal demise. Cause?
Vasa Previa
Quickly rule these 2 causes of 3rd trimester out when taking the history.
Post-Coital bleeding
Hemorrhoids
Pain typical of placental abruption.
constant severe back pain
U/S shows macrosomia of fetus. At what estimated fetal weight (EFW) to consider elective C/S?
4000 g in Diabetic; 4500 g in others
Complications of macrosomia. (2)
shoulder distocia which can lead to Erb-duchenne palsy
HELPER mnemonic for shoulder dystocia treatment.
Help reposition
Epesiotomy
Leg elevation
Pressure (suprapubic)
Enter vagina to rotate
Reach for the fetal arm
What defines the beginning of active Stage 1 of normal labor?
4 cm dilated
What defines Stage 2 of normal labor?
completely dilated to delivery of baby
How many stages of labor are there?
3
What defines the end of stage 3 of normal labor?
delivery of placenta
What test will confirm the suspicion that active phase of Stage 1 of labor is protracted from insufficient contraction strength?
Intrauterine Pressure Catheter (IUPC)
Woman in labor is passed cut-off limit for Stage II of labor. How to decide to go to C/S?
If slowly but surely progressing, then wait. If COMPLETE ARREST, then C/S.
What to try for failure to progress before bringing to C/S in Stage 2 of labor?
vacuum and/or forceps
How to reduce mortality in Stage 3 of labor. (3)
ACTIVE MANAGEMENT:
cord traction
fundal massage
oxytocin
*manual evacuation and D&C if needed
3 rules that define adequate uterine contraction power.
q5 min or less
last at least 60 seconds
Over 200 MVU by IUPC
Pregnant woman at 37 weeks presents with irregular contractions and no cervical change over 4 hours. What to do?
send her home
Treatment for insufficient contraction power during labor.
oxytocin
C/S indication during Active phase of Stage 1 of labor is Arrest. Define Arrest (3)
NO change
for 3 hours
despite adequate contraction power
What is "protracted" active phase of Stage 1 of labor?
passed cut-off limit, but still progressing (not a c/s indication)
What is "prolonged" Stage 2 of labor?
passed cut-off limit, but still progressing (not a c/s indication)
Latent Phase of Stage 1 of labor: what is the cut-off time limit in Nulliparous? in Multiparous?
Nullip: 20 hours
Multip: 14 hours
What is the cut-off time limit for active phase of Stage 1 of labor in Nulliparous? in Multiparous?
Nullip: less than 1 cm/hr = protracted
Multip: less than 1.5 cm/hr = protracted
What is the cut-off time for Stage 2 of labor in Nulliparous? in Multiparous?
Nullip: over 2 hours (or 3 if epidural) = prolonged
Multip: over 1 hour (or 2 if epidural) = prolonged
Race which has multiple gestation more often?
Black
Why has the incidence of dizygotic twins increased, but monozygotic twin rate has not increased?
reproductive technology causes hyperovulation, but has little/no effect on embryonic division
cheapest way to confirm diangosis of twins.
separate heart beats
1 twin is small at birth and has anemia; the other has CHF and polycythemia. Diagnosis?
Twin-Twin Transfusion
When to start activity restrictions in a multiple gestation pregnancy to avoid preterm labor?
24 weeks
When can a multiple gestation pregnancy be delivered vaginally.
If 1st twin is cephalic presentation
How often to get U/S in a multiple gestation?
q4 wks after 20 wks
Embryonic division before 3 days. What form of monozygotic twin? (1/3 of twins)
diamniotic dichorionic (separate placentas)
Embryonic division 3-8 days. What form of monozygotic twin? (2/3s of twins)
diamniotic monochorionic
Embryonic division 8-13 days. What form of monozygotic twin? (1% of twins)
monoamnionic (50% die)
Embryonic division after 13 days. What form of monozygotic twin?
conjoined
hCG, MSAFP, and hPL are all high for gestational age. Suspect what?
multiple gestation
What antihypertensive for pregnant woman?
methyldopa
Why not ACEI or Diuretics for pregnant woman.
risk of uterine ischemia
Gestational Hypertension (aka Pregnancy Induced Hypertension) is defined as developing when?
after 20 weeks
Pre-Ecclampsia is diagnosed when a woman has PIH plus what?
proteinuria
What is HELLP syndrome?
Hemolysis
Elevated
Liver enzymes
Low
Platelets
Ecclampsia is Pre-Ecclampsia plus what?
new seizure
The only cure for Pre-Ecclampsia known.
delivery
When is delivery indicated in mild Pre-Ecclampsia?
at 37 weeks
When is delivery indicated in severe Pre-Ecclampsia? (2)
at 34 weeks
or if end-organ damage
Diet for a Pre-Ecclampsia patient.
low salt; protein restriction not shown to help
2 part medical treatment for Pre-Ecclampsia
Steroids
Mg
How to control HTN crisis in Pre-Ecclampsia: Short-term or Long-term?
Short-term: Labatelol or Hydralazine
Long-term: Nifedipine
Severe pre-ecclampsia diagnosed when . . . What lung problem?
SOB (pulmonary edema)
Severe pre-ecclampsia diagnosed when . . . What renal problems? (3)
Crt over 2
Proteinuria over 5 g
Oliguria
Severe pre-ecclampsia diagnosed when . . . What fetal problems? (2)
Oligohydramnios
IUGR
Severe pre-ecclampsia diagnosed when . . . What CNS changes? (3)
HA
vision changes
Seizure (Ecclampsia)
Severe pre-ecclampsia diagnosed when . . . What liver problems? (2)
RUQ pain (hepatic capsular swelling)
HELLP
Severe pre-ecclampsia diagnosed when BP reaches this threshold?
over 160/110
Ecclamptic seizure: prevention and treatment?
Prevention: Mg
Treatment: diazepam
What kind of decel indicates fetal hypoxemia (uteroplacental insufficiency)?
late (decel starts around the peak of contraction)
What is White DM Class A1?
GDM, diet controlled
What is White DM Class A2?
GDM, insulin controlled
What is White DM Class B?
onset >20 y/o or duration <10 yrs
What is White DM Class C?
onset 10-19 y/o or duration 10-19 yrs
What is White DM Class D?
onset <10 y/o or duration <20 yrs
What is White DM Class F?
diabetic neFropathy
What is White DM Class R?
Proliferative retinopathy
What is White DM Class RF?
Retinopathy and nephropathy
What is White DM Class H?
Ischemic heart disease
What is White DM Class T?
Prior renal transplant
2 numbers to remember after screening Glucose Tolerance Test (GTT) of 50g.
over 200 = GDM
over 140 = needs 3 day glucose tolerance test
What is the 3 day prep for the 100g Oral Glucose Tolerance Test (OGTT) as follow up for a high screening GTT?
3 day carbo diet
8 hr fast overnight
then 100 mg glucose load
4 numbers to remember after confirmatory 100g OGTT. (any 2 = GDM)
before glucose load: over 95
after 1 hr: over 180
after 2 hr: over 155
after 3 hr: over 140
Diabetic patient gets pregnant. What lab to run along with initial screening labs at first visit?
A1C
Treatment for Diabetes during pregnancy. (2)
Insulin and ADA diet
Biophysical Profile: 5 parts (Test the Baby MAN mnemonic)
Tones (FHTs)
Breathing
Movement
Amniotic fluid volume
Nonstress test
What is a "Reactive" (reassuring) nonstress test (NST)?
2 or more accelerations within 20 minutes in Fetal Heart Rate (increase in at least 15 bpm for at least 15 seconds)
Difference between a variable and a late decel. (2)
Late ones decelerate for over 30 seconds before coming back up AND have consistent onset points compared to contractions
Fetus should "kick" at least this many times per hour while it is awake.
6
Complication which can occur in baby if diabetic mom is not controlled on insulin drip during labor.
Mom's hyperglycemia will cause fetal hyperinsulinemia which will result in hypoglycemia after birth.
Most common identifiable cause of Preterm Premature Rupture of Membranes (PPROM).
UTI
What is Premature (or Prolonged) Rupture of Membranes (PROM)?
ROM for over 18 hours before birth (may or may not have contractions)
When to do a manual pelvic exam on a patient whose water has broken?
DON'T DO IT
Test to confirm amniotic fluid pooling (ROM)? (2)
Nitrazine positive
Ferning under microscope
When to deliever PPROM? (2)
if fetal or maternal distress
or if past 32 weeks (some say 34)
Most common complication of PROM.
chorioamnionitits
3 symptoms of Chorioamnionitis
tender fundus
fever
tachycardia (mom and fetus)
Most common neonatal complication after PROM.
ARDS
Treatment for fetus during PROM if fetal lung immaturity exists.
corticosteroids
Treatment of PROM if less than 32 weeks to prevent labor (2)
Tocolytics
Bedrest
Treatment of PROM to prevent infection.
Prophylactic Ampicillin and Erythromicin
Monitoring of PROM patient.
Inpatient and frequent NSTs
What to give for inadequate dilation during stage 1 of labor? (2)
Misopristol (Cytotec) and Oxytocin (Pitocin)
What is a Blighted ovum?
zygote attaches & sac may develop, but no embryo 2/2 chromosomal abnormalities
What is a Complete Abortion?
bleeding + passing tissue + NO retained products
What is a Incomplete Abortion?
bleeding + passing tissue + retained products
What is a Threatened Abortion?
bleeding + FHTs (happens in 25% of pregnancies: half of the 25% proceed to abort)
What is a Missed Abortion?
completely retained failed pregnancy
What is a Septic Abortion?
infection + bleeding + dilation etc.
What is a Inevitable Abortion?
ROM and dilation
What is a Induced Abortion?
elective: medical or surgical
Unknown blood type with vaginal bleeding in pregnant woman. Immediate treatment?
Rhogam!
What blood level to follow in an abortion?
quantative beta-hCG
What to do about a incomplete abortion?
most will resolve on their own; otherwise D&C
Does emotional/psychological stress cause spontaneous abortion?
NO
Can physical stress/trauma cause spontaneous abortion?
yes
Most common reason for abortion (other than elective murder)?
chromosomal abnormalities
Early multiple gestation pregnancies can have high hCG even when too small to see by U/S. How to rule out ectopic?
follow hCG (multiples will increase faster); if over 2000 re-ultrasound remains negative = ectopic
What is the doubling time for hCG in a normal pregnancy?
every 2 days (during 1st trimester)
race which has increased incidence of molar pregnancies.
asian
Chromosome count and source of a Complete Mole (90% of moles)?
46 XX (both sets from Dad)
Chromosome count and source of a Partial Mole (10% of moles)?
69 XXY (triploid: one from egg, 1 each from 2 different sperm)
Snow Storm uterus on ultrasound. Diagnosis?
Molar pregnancy
Multiple gestation pregnancies can have high hCG and large uterus for gestational age. How to rule out molar pregnancy?
U/S (will show multiple gestation or snow storm)
Preparation for D&C to remove a molar pregnancy.
get 4 units of blood ready (lots of bleeding usually)
Medicine treatment for molar pregnancy and malignant disease from molar pregnancy.
Methotrexate (100% cure rate)
What blood level to follow after treatment of a molar pregnancy (monthly for 1 year)? Why?
beta-hCG to rule out metastasis or missed invasive molar tissue
A1C greater than 8 in pregnant woman. What test? Why?
U/S to look for congenital defects
When to start U/S screening q 4 weeks for DM in pregnancy?
start at normal time (20 weeks)
Treatment for headache during pregnancy?
tylenol; watch for CNS signs of Pre-Ecclampsia
What is the BRAT diet for morning sickness?
Bananas
Rice
Applesauce
Toast and Tea
3 risk factors for hyperemesis gravidum.
Molar pregnancy
Multiple gestation
Nulliparous
2 treatments for more mild hyperemesis gravidum
B6
Doxylamine (antihistamine)
Treatment for severe hyperemesis gravidum.
antiemetics and IVF
Treatment of constipation in pregnancy.
Fiber and water! (can use stool softeners too)
2 supplements which have been shown to have some efficacy in morning sickness.
B6 and Ginger
Lifestyle change to manage morning sickness.
frequent small meals
Lifestlye treatment of GERD (e.g. during pregnancy).
no food before bed
elevate head of bed while sleeping
Vaginal discharge during pregnancy is probably normal. 2 things to r/o.
Ruptured Membranes (SROM)
and Vaginitis (infectious)
1st line antiemetic for morning sickness.
Phenergen (promethazine)
2nd line antiemetic for morning sickness.
Ondansetron (Zofran)
Mortality rate of hydrops fetalis from rhesus hemolytic disease if untreated?
100% die without treatment
Postnatal treatment of rhesus hemolytic disease.
Phototherapy (and exchange transfusion if severe)
What monitoring of Rh- pregnant woman who has history of Rh sensitization (previous pregnancy or otherwise)?
u/s q4 weeks
What do you check for on U/S for Rh hemolytic disease?
increased viscosity
If Rh hemolytic disease evidence found on U/S, what to do?
Umbilical Blood sample and transfuse if Hct less than 30.
When to deliver a fetus with Rh hemolytic disease?
at 32 weeks (some say 34)
What to test for in woman with h/o recurrent miscarriages: 2 things.
coagulation/bleeding disorders
uterine abnormalities
What is Fetal Fibronectin test?
Negative = 99% sensitive for NO deliver innext 7 days
Treatment for Preterm labor if mom and fetus are not distressed.
Tocolytics
Preterm labor without signs of infection. Why give antibiotics?
GBS prophylaxis
Why give steroids to mom with preterm labor?
helps with fetal lung development
3 general categories of causes of preterm labor
Infection
Uterine causes
Fetal causes
Treatment of uterine causes of preterm labor.
Bedrest and tocolytics
2 neonatal complications of prematurity to remember.
NEC and ARDS
what is complete breech?
bum down, knees flexed (feet at bum)
What is frank breech?
bum down, knees extended (feet at head)